Plabable With Answers-1

PLAB DOABLE
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Questions
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Answers
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Subject wise
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CONTENTS
Subjects Page Number

Front Cover 1
Contents 2
1 Anatomy 3
2 Cardiology 35
3 Dermatology 125
4 Emergency Medicine 148
5 Endocrinology 232
6 ENT 324
7 Epidemiology 385
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8 Ethics 394
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9 GIT 421
10 General Surgery 511
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11 Genetics 550
12 Haematology 569
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13 Infectious Diseases 698

14 Nephrology 769
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15 Neurology 802
16 Obstetrics & Gynaecology 930
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17 Ophthalmology 1100
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18 Orthopaedics 1148
19 Paediatrics 1179
20 Pharmacology 1264
21 Psychiatry 1281
22 Respiratory 1399
23 Rheumatology 1489
24 Urology 1522
25 Vascular Surgery 1565
2
ANATOMY
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Questions
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Answers
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3
Anatomy
1. A 37-year-old man has a non-healing ulcer on the skin of the right medial malleolus. Which SINGLE
lymph node is likely to be involved?
A.
Axillary lymph nodes
B.
Pre-aortic lymph node
C.
Aortic lymph node
D.
Inguinal lymph node
E.
External iliac lymph nodes
2. A 35-year-old man sat cross-legged for 30 minutes after which he found himself unable to dorsiflex
his left foot and had loss of sensation in the web space between the big toe and the second toe.
What is the SINGLE most likely anatomical structure to be affected?
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A.
Femoral nerve
B.
C
Sural nerve
C.
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Sciatic nerve
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D.
Deep peroneal nerve
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E.
Superficial peroneal nerve
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3. Which anatomical structure is located at the level of the first lumbar vertebra (L1)?
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A.
Mcburney’s point
B.
Stellate ganglion
C.
Deep inguinal ring
D.
Xiphoid process
E.
Transpyloric plane
4. A 23-year-old man is having difficulty in speaking following a stab wound to the right of his neck.
On tongue protrusion test, the tip of tongue is deviated to the right. Which of the following nerve
is the SINGLE most likely to be affected in this patient?
4
Anatomy
A.
Facial nerve
B.
Hypoglossal nerve
C.
Vagus nerve
D.
Trigeminal nerve
E.
Glossopharyngeal nerve
5. A 32-year-old woman has weakness of both her hands after a fall down a flight of stairs. An X-ray
was ordered. Which is the SINGLE lowest vertebrae that needs to be seen in the cervical X-ray to
help diagnose the injury?
A.
C4/C5
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B.
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C5/C6
C.
C6/C7
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D.
C7/T1
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E.
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C8/T1
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6. Which artery descends into the anterior interventricular groove?

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A.
Acute marginal branch
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B.
Left anterior descending artery
C.
Septal branches
D.
Circumflex artery
E.
Right coronary artery
7. What important landmark is placed at the 5th intercostal space at the anterior axillary line?
A.
Apex beat
B.
Chest drain insertion
C.
5
Anatomy
Stellate ganglion
D.
Transpyloric plane
E.
Vena cava opening into the diaphragm
8. A 73-year-old woman with rheumatoid arthritis is unable to extend the fingers of her right hand at
the metacarpophalangeal joint and interphalangeal joints following a fall. What is the SINGLE most
likely tendon to have been damaged?
A.
Extensor carpi radialis
B.
Extensor carpi ulnaris
C.
Extensor digitorum
D.
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Extensor indicis
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E.
Flexor digitorum profundus
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9. A 24-year-old man is hit by a baton just above the knee on his right leg. This is followed by loss of
motor control of the leg. His foot drops and is unable to dorsiflex his foot. There is loss of sensation
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over the front and outer half of the leg and dorsum of the foot. What is the SINGLE most likely
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anatomical structure to be affected?

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A.
Sural nerve
B.
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Common peroneal nerve

C.
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Tibia nerve
D.
Lateral plantar nerve
E.
Medial plantar nerve
10. A 55-year-old man with rheumatoid arthritis struck his hand against a door. On examination, he
could extend the interphalangeal joint of his right thumb but the metacarpophalangeal joint of the
thumb remained flex. What is the SINGLE most likely tendon to have been damaged?
A.
B.
Extensor digitorum
C.
Extensor indicis
6
Anatomy
D.
Extensor pollicis brevis
E.
Extensor pollicis longus
11. A 63-year-old lady with a BMI of 32 has pigmentation on her legs. Dilated veins could be seen on
the lateral aspect of her ankle. Which SINGLE structure would be involved?
A.
Short saphenous vein
B.
Long saphenous vein
C.
Deep venous system
D.
Popliteal veins
E.
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Sapheno-femoral junction
12.
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A 24-year-old patient was lying down on the operating table in a position with his arms hanging
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down for 3 hours. Soon after he woke up, he complains of numbness and weakness on his left
hand and has a wrist drop. There is a loss of sensation over a small area between the dorsal aspect
of 1st and 2nd metacarpals. What is the SINGLE most likely structure to be damaged?
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A.
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Radial nerve
B.
Median nerve
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C.
Ulnar nerve
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D.
Axillary nerve
E.
Suprascapular nerve
13. A 55-year-old man presents with an ulcer of the scrotum. Which is the SINGLE most likely lymph
node involved in its lymphatic drainage?
A.
External iliac lymph node
B.
C.
Aortic lymph node
D.
Inguinal lymph node
7
Anatomy
E.
Cervical lymph node
14. What is the SINGLE most likely anatomical structure to be pierced when inserting a drain in the
mid-axillary line?
A.
External iliac muscle
B.
Linea alba
C.
Rectus sheath muscle
D.
Conjoined tendon
E.
Intercostal muscles
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15. A 32-year-old patient presents to Accident & Emergency with a deep cut on the surface of her
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palm and the surface of the back of her wrist. She has an inability to extend the distal phalanx of
her ring finger. What is the SINGLE most likely structure affected?
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A.
Extensor digitorum
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B.
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Branch of ulnar nerve

C.
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D.
Palmaris brevis
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E.
Branch of median nerve
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16. A 55-year-old man with a history of a stroke a year ago has severe difficulty remembering events in
his life. This includes important events like the year he married his wife. Along with the long-term
memory impairment, he has altered sexual behaviour which has been seen after the stroke. He is
also noted to have a visual defect after the stroke. What is the SINGLE most likely visual defect?
A.
Homonymous hemianopia
B.
Upper homonymous quadrantanopias
C.
Lower homonymous quadrantanopias
D.
Binasal hemianopia
E.
Bitemporal hemianopia
8
Anatomy
17. What SINGLE anatomical landmark correlates to the tip of the 9th costal cartilage?
A.
Fundus of the gallbladder
B.
Deep inguinal ring
C.
Termination of the spinal cord
D.
Stellate ganglion
E.
Inferior vena cava passing through the caval opening
18. A 34-year-old man has a white patch on the margin of the mid-third of his tongue. Which is the
SINGLE most likely lymph node involved?
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A.
C
B.
Submandibular lymph node
C.
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Submental lymph node

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D.
Deep cervical lymph node
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E.
Aortic lymph node
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19. A 12-year-old boy presents with a painful swollen knee after a sudden fall on his right knee. The
pain is localized below the knee cap. Which SINGLE anatomical structure is most likely to be
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affected?
A.
Semimembranosus bursa
B.
Prepatellar bursa
C.
Pretibial bursa
D.
Suprapatellar bursa
E.
Pes anserine bursa
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Anatomy
20. A 60-year-old man screwing his cupboard to the wall when he suddenly felt a rupture at the cubital
fossa resulting in a swollen elbow with weakness on flexion and supination. A lump in the forearm
is seen. What is the SINGLE most likely diagnosis?
A.
Hand flexor tendon rupture
B.
De Quervain's disease
C.
Biceps tendon rupture
D.
Tennis elbow
E.
Golfer's elbow
21. A 33-year-old man complains of double vision when he looks to the right. Which is the SINGLE
most likely nerve to be involved?
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A.
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Left abducens
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B.
Right abducens
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C.
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Left trochlear
D.
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Right trochlear
E.
Right oculomotor
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22. Which anatomical structure is located halfway between the suprasternal notch and pubic
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symphysis?
A.
B.
Mcburney’s point
C.
Stellate ganglion
D.
Deep inguinal ring
E.
Transpyloric plane
23. A 32-year man presents to A&E with a fracture dislocation of his right elbow. He complains of loss
of sensation in his little finger and ring finger. Which is the SINGLE most likely nerve to be
involved?
10
Anatomy
A.
Median nerve
B.
Ulnar nerve
C.
Radial nerve
D.
Superficial branch of radial nerve
E.
Axillary nerve
24. A 36-year-old male involved in a street fight presents with bruises and deformity of his upper part
of leg. X-ray shows a fracture of the neck of fibula. What is the single most associated nerve injury?
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A.
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Sciatic nerve
B.
Femoral nerve
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C.
Musculocutaneous nerve
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D.
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E.
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Tibial nerve
25. A 15-year-old boy complaining of double vision when climbing down the stairs aftering being hit on
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the face. The images appear above one another. He also notices double vision when he looks to
the right. Which is the SINGLE most likely nerve to be affected?
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A.
Left Abducens nerve
B.
Left Trochlear nerve
C.
Left Oculomotor nerve
D.
Right Trochlear nerve
E.
Right Abducens nerve
26. A 64-year-old woman has difficulty in moving her right shoulder on recovering from surgery of the
posterior triangle of her neck. What is the SINGLE most likely anatomical structure to be affected?
A.
11
Anatomy
Accessory nerve
B.
C.
Hypoglossal nerve
D.
Vagus nerve
E.
Brachial plexus
27. A camel rider sustained an injury to the lateral side of his right leg just below the knee caused by
the camel stick. The site is slightly bruised and tender to touch. He is unable to either dorsiflex or
evert the foot. There is loss of sensation over the front and outer half of the leg and dorsum of the
foot. What is the SINGLE most likely anatomical structure to be affected?
A.
Sural nerve
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B.
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C.
Tibia nerve
C
D.
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E.
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28. A 68-year-old woman is unable to extend the interphalangeal joint of her right thumb six weeks
following a fracture of the right radius. The other fingers and thumb movements are unaffected.
What is the SINGLE most likely tendon to be damaged?
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A.
Ev
Abductor pollicis longus

B.
C.
D.
E.
Flexor pollicis longus
29. A 62-year-old male comes to the GP complaining of double vision when climbing down the stairs.
Which is the SINGLE most likely nerve to be affected?
A.
Abducens nerve
B.
12
Anatomy
Trochlear nerve
C.
Oculomotor nerve
D.
Optic nerve
E.
Trigeminal nerve
30. A 35-year-old man is due for a surgery to attempt to removal of a glioma. What is the SINGLE most
likely anatomical structure to be opened during the surgery?
A.
Cricoid cartilage
B.
C.
Dura Mater
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D.
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Conjoined tendon
E.
Intercostal muscles
C
31. What anatomical structure or landmark lies just above the midpoint of the inguinal ligament?
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A.
Femoral artery pulse felt
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B.
C.
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Stellate ganglion
D.
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Deep inguinal ring

E.
Transpyloric plane
32. A 33-year-old man presents with outward gaze and ptosis of his right eye. He also complains of
seeing double. Which is the SINGLE most likely nerve to be affected?
A.
Left trochlear
B.
Left oculomotor
C.
Right trochlear
D.
Right abducens
E.
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Anatomy
Right oculomotor
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14
Anatomy
1) A 37-year-old man has a non-healing ulcer on the skin of the right medial malleolus. Which SINGLE
lymph node is likely to be involved?
A.
Axillary lymph nodes
B.
C.
Aortic lymph node
D.
Inguinal lymph node
E.
External iliac lymph nodes
The skin at the medial malleolus drains into inguinal lymph nodes.
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2) A 35-year-old man sat cross-legged for 30 minutes after which he found himself unable to dorsiflex
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his left foot and had loss of sensation in the web space between the big toe and the second toe.
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A.
Femoral nerve
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B.
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Sural nerve
C.
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Sciatic nerve
D.
Deep peroneal nerve
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E.
Superficial peroneal nerve
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Deep peroneal nerve (Deep fibular nerve)
Motor functions:
The deep peroneal nerve innervates the muscles in the anterior compartment of the leg which are
responsible for dorsiflexion of the foot at the ankle joint.
Sensory functions:
The deep peroneal nerve innervates the webbed space of skin between the great toe (hallux) and the
second toe.
Clinical relevance:
The deep peroneal nerve can become entrapped or compressed during its course through the anterior
compartment of the leg. This causes paralysis of the muscles in the anterior compartment of the leg,
and so a patient loses the ability to dorsiflex the foot. With unopposed plantarflexion, their foot
drops.
15
Anatomy
There are two main reasons why the deep fibular nerve could be compressed.
- The first is that the anterior leg muscles have been excessively used and so are compressing the
nerve within the anterior compartment. The patient will experience pain in the anterior leg.
- The other common cause is tight-fitting shoes, compressing the nerve beneath the extensor
retinaculum. This commonly occurs with wearing tight ski boots (referred to as ski boot syndrome).
The patient will experience pain in the dorsum of the foot.
3) Which anatomical structure is located at the level of the first lumbar vertebra (L1)?
A.
Mcburney’s point
B.
Stellate ganglion
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C.
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Deep inguinal ring
D.
Xiphoid process
C
E.
Transpyloric plane
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The first lumbar vertebra is level with the anterior end of the ninth rib. This level is also called the
important transpyloric plane, since the pylorus of the stomach is at this level. Other important
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structures are also located at this level, they include; fundus of the gall bladder, coeliac trunk,
superior mesenteric artery, termination of spinal cord, and hilla of kidneys.
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The Transpyloric plane, also known as Addison's Plane, is an upper transverse line, located halfway
between the jugular notch and the upper border of the pubic symphysis. The plane in most cases cuts
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through the pylorus of the stomach, the tips of the ninth costal cartilages and the lower border of the
first lumbar vertebra.
4) A 23-year-old man is having difficulty in speaking following a stab wound to the right of his neck. On
tongue protrusion test, the tip of tongue is deviated to the right. Which of the following nerve is the
SINGLE most likely to be affected in this patient?
A.
Facial nerve
B.
Hypoglossal nerve
C.
Vagus nerve
D.
Trigeminal nerve
E.
16
Anatomy
The hypoglossal nerve is the twelfth cranial nerve XII, and innervates muscles of the tongue. The
following are the common causes of this nerve injury:
a. Lower motor neuron lesions- Polio, syringomyelia.

b. Stroke
c. Bulbar Palsy
d. Neck trauma.
e. Surgery- Carotid endarterectomy.
Symptoms often show deviation of the tongue towards the paralyzed side when it is stuck out. This is
because of the weaker genioglossal muscle.
Other lesions:
Facial nerve lesion lead to facial weakness and loss of taste sensation of anterior two third of tongue.
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Vagus nerve lesion results in weak cough, vocal cord paralysis with dysphonia. There is also
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parasympathetic loss of innervation to respiratory, Gastrointestinal and Cardiovascular systems.
C
Trigeminal nerve lesion presents with signs depending upon the level of lesion. Usually there is
weakness of muscles of mastication, Jaw deviates to side of weak pterygoid muscle and there is also
loss sensation on the face.
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Glossopharyngeal nerve lesion presents with loss of gag reflex, loss of taste sensation from posterior
third of the tongue, loss of general sensation from posterior pharynx, tonsils and soft palate.
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5) A 32-year-old woman has weakness of both her hands after a fall down a flight of stairs. An X-ray
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was ordered. Which is the SINGLE lowest vertebrae that needs to be seen in the cervical X-ray to
help diagnose the injury?
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A.
C4/C5
B.
C5/C6
C.
C6/C7
D.
C7/T1
E.
C8/T1
Hand weakness involves either median nerve which has contributions from roots C5-T1 or ulnar nerve
which originates from the C8-T1 nerve roots.
Remember, a C8 vertebrae does not exist and so the option for C8/T1 is clearly wrong.
17
Anatomy
There are seven cervical vertebrae (C1-C7) and a total of eight cervical nerves C1- C8. All cervical
nerves except C8 emerge above their corresponding vertebrae, while the C8 nerve emerges below the
C7 vertebra that is between C7 and T1 vertebrae.
When you request for a cervical X-ray, you would like the film to extend up to C7/T1 as so you would
be able to see the cervical vertebrae (C1-C7) and all the cervical nerves (C1-C8).
6) Which artery descends into the anterior interventricular groove?
A.
Acute marginal branch
B.
C.
Septal branches
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D.
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Circumflex artery
E.
C
The left anterior descending (LAD, interventricular) artery appears to be a direct continuation of the
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left coronary artery which descends into the anterior interventricular groove.
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7) What important landmark is placed at the 5th intercostal space at the anterior axillary line?
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A.
Apex beat
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B.
Chest drain insertion
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C.
Stellate ganglion
D.
Transpyloric plane
E.
Vena cava opening into the diaphragm
Chest drain Insertion Technique
Chest insertion should be performed ideally within “safe triangle”
‘Safe triangle’ for chest drain insertion, bounded anteriorly by pectoralis major, posteriorly by
latissimus dorsi, inferiorly by the fifth intercostal space, and superiorly by the axilla.
More specifically, the tube is inserted into the 5th intercostal space slightly anterior to the mid
axillary line.
18
Anatomy
By inserting at the safe triangle, we avoid major vessels and muscles.
It is important to note that the intercostal vessels and nerves run below the inferior border of the ribs.
Thus, the drain track should be directed over the top of the lower rib to avoid the intercostal vessels
lying below each rib.
8) A 73-year-old woman with rheumatoid arthritis is unable to extend the fingers of her right hand at
the metacarpophalangeal joint and interphalangeal joints following a fall. What is the SINGLE most
likely tendon to have been damaged?
A.
Extensor carpi radialis
B.
C.
Extensor digitorum
y
D.
op
Extensor indicis
E.
C
The extensor digitorum communis extends the phalanges, then the wrist, and finally the elbow. It
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tends to separate the fingers as it extends them.

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9) A 24-year-old man is hit by a baton just above the knee on his right leg. This is followed by loss of
t
ua
motor control of the leg. His foot drops and is unable to dorsiflex his foot. There is loss of sensation
over the front and outer half of the leg and dorsum of the foot. What is the SINGLE most likely
anatomical structure to be affected?
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A.
Ev
Sural nerve
B.
C.
Tibia nerve
D.
E.
This is actually called a peroneal strike. A peroneal strike is a temporarily disabling blow to the
common peroneal nerve of the leg, just above the knee which causes a temporary loss of motor
control of the leg, accompanied by numbness and a painful tingling sensation from the point of
impact all the way down the leg, usually lasting anywhere from 30 seconds to 5 minutes in duration.
19
Anatomy
The common peroneal nerve innervates the short head of the biceps femoris muscle (part of the
hamstring muscles, which flex at the knee). In addition, its terminal branches also provide innervation
to muscles:
Motor Functions:
Superficial fibular nerve: Innervates the muscles of the lateral compartment of the leg. These muscles
act to evert the foot.
Deep fibular nerve: Innervates the muscles of the anterior compartment of the leg. These muscles act
to dorsiflex the foot, and extend the digits. It also innervates some intrinsic muscles of the foot.
If the common fibular nerve is damaged, the patient may lose the ability to dorsiflex and evert the
foot, and extend the digits.
Sensory Functions:
There are two cutaneous branches that arise directly from the common fibular nerve as it moves over
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the lateral head of the gastrocnemius.
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Sural communicating nerve: This nerve combines with a branch of the tibial nerve to form the sural
C
nerve. The sural nerve innervates the skin over the lower posterolateral leg.
Lateral sural cutaneous nerve: Innervates the skin over the upper lateral leg.
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In addition to these nerves, the terminal branches of the common fibular nerve also have a cutaneous
function:
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Superficial fibular nerve: Innervates the skin of the anterolateral leg, and dorsum of the foot (except
the skin between the first and second toes).
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Deep fibular nerve: Innervates the skin between the first and second toes.
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Tip: It may be hard to remember all the sensory and motor functions of the peroneal nerve. So just
remember this keyword “foot drop”. Whenever you see the word “foot drop” or “unable to dorsiflex”
pick peroneal nerve.
10) A 55-year-old man with rheumatoid arthritis struck his hand against a door. On examination, he
could extend the interphalangeal joint of his right thumb but the metacarpophalangeal joint of the
thumb remained flex. What is the SINGLE most likely tendon to have been damaged?
A.
B.
Extensor digitorum
C.
Extensor indicis
D.
20
Anatomy

E.
The extensor pollicis brevis extends the thumb at the metacarpophalangeal joint.
11) A 63-year-old lady with a BMI of 32 has pigmentation on her legs. Dilated veins could be seen on the
lateral aspect of her ankle. Which SINGLE structure would be involved?
A.
Short saphenous vein
B.
Long saphenous vein
C.
Deep venous system
D.
Popliteal veins
y
E.
op
Sapheno-femoral junction C
The short saphenous vein is the only one which travels on the lateral aspect of the ankle.
Note that the great or long saphenous vein travels on the medial aspect of the ankle.
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12) A 24-year-old patient was lying down on the operating table in a position with his arms hanging
down for 3 hours. Soon after he woke up, he complains of numbness and weakness on his left hand
t
ua
and has a wrist drop. There is a loss of sensation over a small area between the dorsal aspect of 1st
and 2nd metacarpals. What is the SINGLE most likely structure to be damaged?
al
A.
Ev
Radial nerve
B.
Median nerve
C.
Ulnar nerve
D.
Axillary nerve
E.
Suprascapular nerve
Radial nerve (C5–T1)
Motor to
• Extensor muscles (forearm, wrist, fingers, thumb)
• If damaged → leads to wrist drop
21
Anatomy
Sensory to
• If damaged → Sensory loss is variable, but always includes the dorsal aspect of the root of the
thumb. Usually leads to loss to small area between the dorsal aspect of 1st and 2nd
metacarpals
It is important to remember the key phrases for nerve damage during PLAB. There are certain
phrases you need to memorise to relate it to a specific nerve damages.
Examples:
Wrist drop → Radial nerve
Foot drop → Either common peroneal nerve or sciatic nerve
y
op
Claw hand → Ulnar nerve C
Paraesthesia of thumb, index and middle finger → Median nerve
Numbness on superior aspect of upper arm just below shoulder joint → Axillary nerve
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Fibular neck fracture → Common peroneal nerve

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Femur neck fracture or Acetabular fractures → Sciatic nerve
Fracture of humeral shaft → Likely Radial nerve

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Fracture of humeral neck → Likely Axillary nerve

Ev
Monteggia fracture → Radial nerve
Paraesthesia and impaired sensation in both hands (glove distribution) → Peripheral neuropathy
Features
• Abdominal pain
• Polyuria, polydipsia, dehydration
• Kussmaul respiration (deep hyperventilation)
• Acetone-smelling breath ('pear drops' smell)
13) A 55-year-old man presents with an ulcer of the scrotum. Which is the SINGLE most likely lymph
node involved in its lymphatic drainage?
A.
22
Anatomy

B.
C.
Aortic lymph node
D.
Inguinal lymph node
E.
Cervical lymph node
The superficial inguinal lymph nodes receive afferents lymphatic vessels from the scrotum.
14) What is the SINGLE most likely anatomical structure to be pierced when inserting a drain in the mid-
axillary line?
A.
External iliac muscle
y
B.
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Linea alba
C.
C
D.
Conjoined tendon
n
E.
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Intercostal muscles
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ua
Chest drain Insertion technique

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‘Safe triangle’ for chest drain insertion, bounded anteriorly by pectoralis major, posteriorly by
Ev
latissimus dorsi, inferiorly by the fifth intercostal space, and superiorly by the axilla.
More specifically, the tube is inserted into the 5th intercostal space slightly anterior to the mid
axillary line
By inserting at the safe triangle, we avoid major vessels and muscles
It is important to note that the intercostal vessels and nerves run below the inferior border of the ribs.
Thus, the drain track should be directed over the top of the lower rib to avoid the intercostal vessels
lying below each rib.
15) A 32-year-old patient presents to Accident & Emergency with a deep cut on the surface of her palm
and the surface of the back of her wrist. She has an inability to extend the distal phalanx of her ring
finger. What is the SINGLE most likely structure affected?
A.
Extensor digitorum
23
Anatomy
B.
Branch of ulnar nerve
C.
D.
Palmaris brevis
E.
Branch of median nerve
16) A 55-year-old man with a history of a stroke a year ago has severe difficulty remembering events in
his life. This includes important events like the year he married his wife. Along with the long-term
memory impairment, he has altered sexual behaviour which has been seen after the stroke. He is
also noted to have a visual defect after the stroke. What is the SINGLE most likely visual defect?
A.
Homonymous hemianopia
B.
y
Upper homonymous quadrantanopias
op
C.
Lower homonymous quadrantanopias
D.
C
Binasal hemianopia
E.
n
Bitemporal hemianopia
io
This man has had a stroke affecting his temporal lobe. It is important to note that the most common
t
ua
cause of temporal lobe lesions is a cerebrovascular event (CVE). Several neural structures found in the
temporal lobe are proposed to be involved in memory. This also include structures closely related to it
such as the amygdala, the hippocampus, and the rhinal cortex in the temporal lobe.
al
Once you know that the temporal lobe is affected, you would be able to answer the question. The
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optic radiation passes through the temporal lobes. Damage to this can cause an upper homonymous
quadrantanopias.
17) What SINGLE anatomical landmark correlates to the tip of the 9th costal cartilage?
A.
B.
Deep inguinal ring
C.
Termination of the spinal cord
D.
Stellate ganglion
E.
Inferior vena cava passing through the caval opening
24
Anatomy
The fundus of the gall-bladder approaches the surface behind the anterior end of the ninth right
costal cartilage close to the lateral margin of the Rectus abdominis.
18) A 34-year-old man has a white patch on the margin of the mid-third of his tongue. Which is the
SINGLE most likely lymph node involved?
A.
B.
Submandibular lymph node
C.
Submental lymph node
D.
Deep cervical lymph node
E.
Aortic lymph node
y
The tip of the tongue drains bilaterally to the submental nodes.
op
The anterior two-thirds of the tongue drain unilaterally to the submandibular nodes.
The posterior one-thirds of the tongue drains bilaterally to the jugulo-omohyoid nodes.
C
The posterior most part of the tongue drains bilaterally into the upper deep cervical lymph nodes.
n
t io
ua
al
Ev
25
Anatomy
19) A 12-year-old boy presents with a painful swollen knee after a sudden fall on his right knee. The pain
is localized below the knee cap. Which SINGLE anatomical structure is most likely to be affected?
A.
Semimembranosus bursa
B.
Prepatellar bursa
C.
Pretibial bursa
D.
Suprapatellar bursa
E.
Pes anserine bursa
The prepatellar bursa is a frontal bursa of the knee joint. It is a superficial bursa with a thin synovial
lining located between the skin and the patella.
y
Prepatellar bursitis classically occurred in housemaids, hence the nickname ‘housemaid’s knee’. It is
op
commonly seen in people who kneel such as plumbers. Friction caused by repeated kneeling can
cause it. It is a common cause of swelling and pain above the patella (kneecap), and is due to
inflammation of the prepatellar bursa.
C
Symptoms:
n
- Redness Inability to flex the knee.
io
- Pain and swelling is localized over site of bursa (e.g. below patella)
t
ua
Rest usually relieves symptoms.
20) A 60-year-old man screwing his cupboard to the wall when he suddenly felt a rupture at the cubital
al
fossa resulting in a swollen elbow with weakness on flexion and supination. A lump in the forearm is
seen. What is the SINGLE most likely diagnosis?
Ev
A.
Hand flexor tendon rupture
B.
De Quervain's disease
C.
Biceps tendon rupture
D.
Tennis elbow
E.
Golfer's elbow
The weakness and lump at forearm are characteristic for a biceps tendon rupture.
There are two types of biceps tendon rupture which are proximal and distal. Thankfully, this question
does not require you to differentiate the two.
26
Anatomy
Proximal biceps tendon rupture:
- Ruptures of the proximal biceps tendon make up nearly all biceps ruptures.
- Presents with the biceps muscle bunches up in the distal arm, causing the characteristic 'Popeye
muscle' appearance. There is minimal loss of function.
Distal biceps tendon rupture:
- Distal biceps tendon rupture is usually caused by a single traumatic event involving flexion against
resistance, with the elbow at a right angle.
- Presents with a sudden sharp tearing sensation resulting in a painful swollen elbow with weakness
of flexion and supination.
21) A 33-year-old man complains of double vision when he looks to the right. Which is the SINGLE most
likely nerve to be involved?
y
A.
op
Left abducens
B.
Right abducens
C
C.
Left trochlear
n
D.
io
Right trochlear
E.
t
ua
Right oculomotor
His right eye is unable to abduct thus he sees double. The nerve involved here would be the right
al
abducens nerve.
Ev
Nerves involving the eye:
CN III - Oculomotor nerve:

- Controls most of eye muscle
- Constriction of pupil
- Levator palpebrae superioris
CN IV - Trochlear nerve:
- Innervates a single muscle - Superior oblique
CN VI - Abducens nerve:
- Lateral rectus muscle
The simple method to remember this for the exam is:

CN III - Oculomotor nerve:
- Will have features of either ptosis and/or a dilated pupil on the nerve on the same side as the
27
Anatomy
affected eye
- Mnemonic: Letter “O” for oculomotor which with good imagination can represents a dilated pupil.
CN IV - Trochlear nerve:
- Diplopia on downward gaze
- If looks right and sees double, then lesion is on the left. (Opposite to gaze)
CN VI - Abducens nerve:
- If looks left and sees double, then lesion is on the left. (Same side as gaze)
Another Mnemonic is:
LR6(SO4)O3
Lateral rectus - 6th Nerve

Superior oblique - 4th Nerve
Others - 3rd Nerve
y
op
22) Which anatomical structure is located halfway between the suprasternal notch and pubic
symphysis?
C
A.
n
B.
io
Mcburney’s point
C.
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ua
Stellate ganglion
D.
Deep inguinal ring
al
E.
Transpyloric plane
Ev
The suprasternal notch (fossa jugularis sternalis) is also known as the jugular notch
The Transpyloric plane, also known as Addison's Plane, is an upper transverse line, located halfway
between the jugular notch and the upper border of the pubic symphysis. The plane in most cases cuts
through the pylorus of the stomach, the tips of the ninth costal cartilages and the lower border of the
first lumbar vertebra.
23) A 32-year man presents to A&E with a fracture dislocation of his right elbow. He complains of loss of
sensation in his little finger and ring finger. Which is the SINGLE most likely nerve to be involved?
A.
Median nerve
B.
Ulnar nerve
28
Anatomy
C.
Radial nerve
D.
Superficial branch of radial nerve
E.
Axillary nerve
Ulnar nerve (C8–T1) Sensory loss is over the little finger and a variable area of the ring finger (palmar
& dorsal)
This is the nerve of finger abduction and adduction. Injury level determines severity of the claw
deformity. In a distal lesion of the ulnar nerve, there will be more clawing of the 4th and 5th fingers
compared with a proximal, more complete lesion at the elbow.
24) A 36-year-old male involved in a street fight presents with bruises and deformity of his upper part of
leg. X-ray shows a fracture of the neck of fibula. What is the single most associated nerve injury?
y
op
A.
Sciatic nerve
B.
C
Femoral nerve
C.
n
Musculocutaneous nerve
io
D.
t
ua
E.
Tibial nerve
al
Peroneal nerve injury:

- The common peroneal nerve crosses the fibular neck and is susceptible to injury from a fibular neck
Ev
fracture, the pressure of a splint or during surgical repair.

- Peroneal nerve injury may result in foot drop and sensation abnormalities.
It is important to remember the key phrases for nerve damage during PLAB. There are certain
phrases you need to memorise to relate it to a specific nerve damages.
Examples:
Claw hand → Ulnar nerve
29
Anatomy

Paraesthesia and impaired sensation in both hands (glove distribution) → Peripheral neuropathy
25) A 15-year-old boy complaining of double vision when climbing down the stairs aftering being hit on
the face. The images appear above one another. He also notices double vision when he looks to the
right. Which is the SINGLE most likely nerve to be affected?
A.
Left Abducens nerve
B.
Left Trochlear nerve
C.
Left Oculomotor nerve
D.
Right Trochlear nerve
E.
Right Abducens nerve
y
op
Trochlear nerve innervates the superior oblique muscle. It only causes diplopia on downgaze like
looking downwards to walk. It is a trochlear nerve lesion on the left side because he sees double
when looking on the right side.
C
26) A 64-year-old woman has difficulty in moving her right shoulder on recovering from surgery of the
n
posterior triangle of her neck. What is the SINGLE most likely anatomical structure to be affected?
io
A.
t
ua
Accessory nerve
B.
al
C.
Hypoglossal nerve
Ev
D.
Vagus nerve
E.
Brachial plexus
The accessory nerve is a cranial nerve that controls the sternocleidomastoid and trapezius muscles.
Injury to the spinal accessory nerve can cause an accessory nerve disorder or spinal accessory nerve
palsy, which results in diminished or absent function of the sternocleidomastoid muscle and upper
portion of the trapezius muscle.
27) A camel rider sustained an injury to the lateral side of his right leg just below the knee caused by the
camel stick. The site is slightly bruised and tender to touch. He is unable to either dorsiflex or evert
the foot. There is loss of sensation over the front and outer half of the leg and dorsum of the foot.
30
Anatomy
A.
Sural nerve
B.
C.
Tibia nerve
D.
E.
This is actually called a peroneal strike. A peroneal strike is a temporarily disabling blow to the
common peroneal nerve of the leg, just above the knee which causes a temporary loss of motor
control of the leg, accompanied by numbness and a painful tingling sensation from the point of
impact all the way down the leg, usually lasting anywhere from 30 seconds to 5 minutes in duration.
y
op
The common peroneal nerve innervates the short head of the biceps femoris muscle (part of the
hamstring muscles, which flex at the knee). In addition, its terminal branches also provide innervation
to muscles:
C
Motor Functions
n
io
Superficial fibular nerve: Innervates the muscles of the lateral compartment of the leg. These muscles
act to evert the foot.
t
ua
Deep fibular nerve: Innervates the muscles of the anterior compartment of the leg. These muscles act
to dorsiflex the foot, and extend the digits. It also innervates some intrinsic muscles of the foot.
al
If the common fibular nerve is damaged, the patient may lose the ability to dorsiflex and evert the
Ev
foot, and extend the digits.
Sensory Functions
There are two cutaneous branches that arise directly from the common fibular nerve as it moves
over the lateral head of the gastrocnemius.
Sural communicating nerve: This nerve combines with a branch of the tibial nerve to form the sural
nerve. The sural nerve innervates the skin over the lower posterolateral leg.
Lateral sural cutaneous nerve: Innervates the skin over the upper lateral leg.
In addition to these nerves, the terminal branches of the common fibular nerve also have a
cutaneous function:
31
Anatomy
Superficial fibular nerve: Innervates the skin of the anterolateral leg, and dorsum of the foot (except
the skin between the first and second toes).
Deep fibular nerve: Innervates the skin between the first and second toes.
Tip: It may be hard to remember all the sensory and motor functions of the peroneal nerve. So just
remember this keyword “foot drop”. Whenever you see the word “foot drop” or “unable to dorsiflex”
pick peroneal nerve.
28) A 68-year-old woman is unable to extend the interphalangeal joint of her right thumb six weeks
following a fracture of the right radius. The other fingers and thumb movements are unaffected.
What is the SINGLE most likely tendon to be damaged?
A.
Abductor pollicis longus
B.
y
C.
op
D.
C
E.
Flexor pollicis longus
n
io
Full extension of right thumb is achieved by extensor pollicis longus.

t
ua
29) A 62-year-old male comes to the GP complaining of double vision when climbing down the stairs.
Which is the SINGLE most likely nerve to be affected?
al
A.
Abducens nerve
Ev
B.
Trochlear nerve
C.
Oculomotor nerve
D.
Optic nerve
E.
Trigeminal nerve
Trochlear nerve innervates the superior oblique muscle. It only causes diplopia on downgaze like
looking downwards to walk.
This is a high yield question in PLAB. Please remember the nerves involving the eye and how they
present.
Nerves involving the eye
32
Anatomy
CN III - Oculomotor nerve

Controls most of eye muscle
Constriction of pupil
Levator palpebrae superioris
CN IV - Trochlear nerve
Innervates a single muscle - Superior oblique
CN VI - Abducens nerve
Lateral rectus muscle
30) A 35-year-old man is due for a surgery to attempt to removal of a glioma. What is the SINGLE most
likely anatomical structure to be opened during the surgery?
A.
Cricoid cartilage
y
B.
op
C.
Dura Mater
C
D.
Conjoined tendon
n
E.
io
Intercostal muscles
t
ua
Gliomas are tumours arising from glial cells and may occur in the spinal cord or the brain.
The dura mater, which is a thick membrane of the outermost three layers of the meninges that
al
surround the brain and spinal cord would need to be opened for the surgery to take place.
31) What anatomical structure or landmark lies just above the midpoint of the inguinal ligament?
Ev
A.
B.
C.
Stellate ganglion
D.
Deep inguinal ring
E.
Transpyloric plane
The deep Inguinal ring is located about 2.5 cm above the midpoint of the inguinal ligament.
32) A 33-year-old man presents with outward gaze and ptosis of his right eye. He also complains of
seeing double. Which is the SINGLE most likely nerve to be affected?
33
Anatomy
A.
Left trochlear
B.
Left oculomotor
C.
Right trochlear
D.
Right abducens
E.
Right oculomotor
The nerve involved here would be the right oculomotor nerve. This is a high yield question in PLAB.
Please remember the nerves involving the eye and how they present.
Nerves involving the eye
y
op
Controls most of eye muscle
Constriction of pupil
Levator palpebrae superioris
C
CN IV - Trochlear nerve
n
Innervates a single muscle - Superior oblique
io
CN VI - Abducens nerve
t
ua
Lateral rectus muscle

al
Ev
34
CARDIOLOGY
y
op
C
Questions
n
io
&
t
ua
Answers
al
Ev
35
Cardiology
1) A 50-year-old female presents with shortness of breath and palpitations which has been on-going for the
past few hours. She has ankle swelling which has been present for more than a year and feels difficulty
in breathing while lying down. She is a known alcoholic. A chest radiograph shows evidence of cardiac
enlargement. What is the SINGLE most likely cause of her worsening condition?
A.
Ventricular tachycardia
B.
Paroxysmal supraventricular tachycardia
C.
Ventricular fibrillation
D.
Atrial fibrillation
E.
Ventricular ectopic
2) A 55-year-old man who suffered a myocardial infarction a few days ago is now ready for discharge. His
y
medical history remains insignificant other than the myocardial infarction he had. He has no drug
op
allergies. He has already been put on aspirin and clopidogrel. What is the SINGLE most appropriate
medication(s) to be given to him on discharge?
C
A.
Statin only
n
B.
io
Statin and Warfarin

C.
t
ua
Statin and ACE inhibitor

D.
Warfarin only
al
E.
Heparin only
Ev
3) A 43-year-old lady is admitted with pyrexia, breathlessness and history of syncope. She was recently
diagnosis with a pulmonary embolus. There is an early diastolic sound and a mid-diastolic rumble. Her
jugular venous pressure is elevated with prominent a-waves. What is the SINGLE most likely diagnosis?
A.
Mitral regurgitation
B.
Ventricular ectopics
C.
Pulmonary regurgitation
D.
Atrial myxoma
E.
Complete heart block
36
Cardiology
4) A 48-year-old man has continuous anterior chest pain which is worse on inspiration. 4 weeks ago, he had
a myocardial infarction. He has a temperature of 37.5°C. His blood results show an ESR of 82 mm/h.
What is the SINGLE most likely explanation for the abnormal investigation?
A.
Pulmonary embolism
B.
Cardiac tamponade
C.
Atrial thrombus
D.
Left ventricular aneurysm
E.
Dressler syndrome
5) A 55-year-old man had a myocardial infarction 3 days ago. He now complains of a shortness of breath
and a sharp pain in the chest. The pain increases when he breathes and is relieved when sitting forward.
y
His respiratory rate is 22 breath’s/minute and his heart rate is 95 beats/minute. What is the SINGLE most
op
likely diagnosis? C
A.
Myocardial infarction
B.
n
Pericarditis
io
C.
Aortic dissection
t
ua
D.
Pulmonary embolism
E.
al
Cardiac tamponade
Ev
6) A 28-year-old man complains of heart racing. He is completely conscious throughout. He has a pulse of
132 beats/minute, a blood pressure of 120/80 mmHg and a respiratory rate of 20 breaths/minute. An
ECG was taken which shows supraventricular tachycardia. What is the SINGLE most appropriate initial
management?
A.
Amiodarone
B.
Adenosine
C.
Radio-frequency ablation
D.
Carotid massage
E.
Metoprolol
37
Cardiology
7) A 44-year-old man who presently has acute renal failure has an ECG that shows tall tented T waves, flat
P waves and a wide QRS complex. What is the SINGLE most likely electrolyte abnormality?
A.
Hypophosphataemia
B.
Hyperkalaemia
C.
Hypokalaemia
D.
Hypercalcaemia
E.
Hypocalcaemia
8) A 69-year-old man was successfully thrombolysed for an inferior myocardial infarction 15 days ago and
was discharged 5 days after the thrombolysis. He is now re-admitted as he is hypotensive, tachycardic
and with pulmonary oedema. What is the most SINGLE most likely diagnosis?
y
op
A.
Aortic regurgitation
B.
C
Acute mitral regurgitation
C.
n
Mitral valve prolapse

io
D.
Pulmonary stenosis
t
ua
E.
Rheumatic mitral valve stenosis
al
9) A 6-week-old baby has a pansystolic murmur at sternal border. He feeds poorly and has poor weight
gain. The baby is acyanotic. What is the SINGLE most likely diagnosis?
Ev
A.
Tetralogy of Fallot
B.
Atrial septal defect
C.
Ventricular septal defect
D.
Patent ductus arteriosus
E.
Transposition of the great arteries
10) A 55-year-old man with a history of a myocardial infarction has progressive dyspnoea. He has had
previous admissions with heart failure in the past year. He has a respiratory rate of 31 breaths/minute
and a systolic blood pressure of 90 mmHg. His oxygen saturation is 90% on room air. On examination, he
38
Cardiology
looks pale and sweaty, and has widespread crepitations over both lung fields. Oxygen by face mask was
commenced. What is the SINGLE most appropriate investigation?
A.
Chest X-ray
B.
Computed tomography scan of the chest
C.
Electrocardiogram
D.
Full blood count
E.
D-dimer test
11) A 65-year-old man presents with recurrent light-headedness for one month especially when he gets up
from bed in the morning. He also has occasional episodes of light-headedness when standing for
prolonged periods of time. He suffers from hypertension and type 2 diabetes. His regular medications
y
include atenolol, amlodipine, bendroflumethiazide and metformin. On physical examination, his blood
op
pressure was 125/85 mmHg taken when he was supine and 101/69 mmHg when standing. What is the
SINGLE most likely diagnosis?
C
A.
Acute hypotension
n
B.
io
Vasovagal faints
C.
t
ua
Postural hypotension
D.
Postprandial hypotension
al
E.
Aortic stenosis
Ev
12) A 74-year-old man started having chest pain. He has a blood pressure of 70/50 mmHg. He is conscious
and a radial pulse is felt. An ECG shows the following rhythm. What is the SINGLE most likely diagnosis?
A.
Supraventricular tachycardia
39
Cardiology
B.
C.
D.
Atrial fibrillation
E.
Atrial flutter
13) A 75-year-old man is found to be unresponsive. The ward doctor is called to the patient’s bedside. He is
not breathing and has no detectable pulse. Which is the SINGLE most appropriate next step?
A.
Get a defibrillator
B.
Give two rescue breaths immediately
C.
y
Check notes for a Do Not Attempt Resuscitation (DNAR) order
op
D.
Insert two wide-bore cannulas into each antecubital fossa
E.
C
Start chest compressions at a rate of 30:2
n
14) A 43-year-old man was brought into the A&E after being stabbed in the chest with a knife. His chest is
io
bilaterally clear. He has muffled heart sounds and his neck veins look distended. His systolic blood
pressure is 60 mmHg and pulse is 120 bpm. What is the SINGLE most likely diagnosis?
t
ua
A.
Pulmonary embolism
al
B.
Pericardial effusion
Ev
C.
Cardiac tamponade
D.
Hemothorax
E.
Pneumothorax
15) A 60-year-old lady has severe chest pain. ECG shows changes of inferior wall myocardial infarction. The
ECG also shows progressive prolongation of PR interval until a QRS complex is dropped. What is the
A.
Atrial fibrillation
B.
C.
40
Cardiology
D.
Mobitz type I AV block
E.
Mobitz type II AV block
16) A 62-year-old women who had stroke a year ago now reports having increased dyspnoea on exertion. An
ECG was performed which showed an atrial fibrillation. Chest X-ray shows a straight left heart border.
What is the SINGLE most likely diagnosis?
A.
B.
C.
D.
y
Pulmonary stenosis
op
E.
Mitral valve stenosis
C
17) A preterm neonate has a continuous murmur that disappeared at the time of discharge from the
paediatric intensive care unit. What is the SINGLE most likely diagnosis?
n
io
A.
t
ua
B.
Tetralogy of fallot
C.
al
Transposition of great arteries

D.
Ev

E.
18) A 74-year-old man started having chest pain. He has a blood pressure of 70/50 mmHg. His level of
consciousness is decreased. A radial pulse is felt. An ECG shows the following rhythm. What is the
SINGLE most appropriate management?
41
Cardiology
A.
Cardioversion
B.
Carotid sinus massage
C.
Adenosine
y
D.
op
Amiodarone
E.
Lidocaine
C
19) A 44-year-old woman in the postnatal ward develops sudden onset chest pain and shortness of breath.
n
She had an emergency C-section for fetal distress two days ago. She feels the breathlessness worsen
io
when she lies down. She has a respiratory rate of 32 breaths/minute and a blood pressure of 100/60
mmHg. Her oxygen saturation is 89% on room air and temperature is 36.9°C. On examination, she looks
t
ua
pale and sweaty. Auscultation reveals widespread crepitations over both lung fields. An ECG was
performed which shows sinus tachycardia. Oxygen by face mask was commenced. A chest X-ray confirms
the diagnosis. Which SINGLE medication is used as part of the management?
al
A.
Ev
Co-amoxiclav
B.
Aspirin
C.
Furosemide
D.
Low molecular weight heparin
E.
Alteplase
20) A 60-year-old woman with a history of ischaemic heart disease presents to A&E with progressive
dyspnoea. She has had previous admissions with heart failure in the past year. She has a respiratory rate
of 34 breaths/minute and a systolic blood pressure of 90 mmHg. Her oxygen saturation is 88% on room
air. On examination, she looks pale and sweaty, and has widespread crepitations over both lung fields.
Oxygen by face mask was commenced. What is the SINGLE most appropriate next step in management?
42
Cardiology
A.
Bendroflumethiazide
B.
Furosemide
C.
Aspirin
D.
Carvedilol
E.
Spironolactone
21) A 28-year-old man complains of heart racing. He is completely conscious throughout. He has a pulse of
132 beats/minute, a blood pressure of 120/70 mmHg and a respiratory rate of 21 breaths/minute. An
ECG was taken which shows supraventricular tachycardia. What is the SINGLE most appropriate
immediate management?
A.
y
Amiodarone
op
B.
Adenosine
C.
C
Lidocaine
D.
n
Verapamil
io
E.
Metoprolol
t
ua
22) A 68-year-old man is found collapsed at a shopping mall. An ECG reveals no connection between P waves
and QRS complexes with a rate of 35 beats/minute. What is the SINGLE most likely diagnosis?
al
A.
Ev
Third degree heart block

B.
C.
First degree heart block
D.
E.
23) A 46 year old man was brought into the A&E after being stabbed in the chest with a knife. His chest is
bilaterally clear. He has muffled heart sounds and his neck veins look distended. His blood pressure is
84/40 mmHg and pulse is 110 bpm. What is the SINGLE most appropriate investigation that can lead to a
diagnosis?
A.
43
Cardiology
Echocardiogram
B.
Chest X-ray
C.
CTPA
D.
Spirometry
E.
Blood cultures
24) A 72-year-old woman had sudden chest pain and shortness of breath 1 hour ago. There is ST elevation in
the II, III and aVF on ECG. Oxygen has been started. She was given GTN and diamorphine which has
improved her chest pain. Her heart rate is 90 bpm and respiratory rate is 18/min. What is the SINGLE
most appropriate next step in management?
A.
y
B.
op
Percutaneous intervention (PCI)
C.
Warfarin
C
D.
Streptokinase
n
E.
io
Alteplase
t
ua
25) A 52-year-old man underwent a hemicolectomy. A few days after his operation he develops chest pain
and a temperature of 38.8°C. He is having rigors and night sweats. On auscultation, a systolic murmur is
heard. What is the next SINGLE most appropriate investigation?
al
A.
Ev

B.
Abdominal ultrasound
C.
Chest X-ray
D.
Blood culture
E.
Liver function test
26) A 33-year-old man complaints of occasional left sided chest pain that lasts less than 30 minutes following
exercise. The pain is relieved once he takes a rest. What is the SINGLE most likely diagnosis?
A.
Unstable angina
B.
44
Cardiology
Decubitus angina
C.
Stable angina
D.
Coronary spasm
E.
27) A 71-year-old woman had sudden chest pain and shortness of breath 2 hours ago. The pain radiates to
her left arm. There is ST elevation in the II, III and aVF on ECG. Oxygen has been started and she was
given GTN which has improved her chest pain. Her heart rate is 80 bpm and respiratory rate is 18/min.
What is the SINGLE most appropriate next step in management?
A.
B.
Alteplase
y
C.
op
Warfarin
D.
Proton pump inhibitors
C
E.
Continue current management
n
io
28) A 2-week-old baby has oxygen saturation of 70% on air. He is cyanosed and has an ejection systolic
murmur. What is the SINGLE most likely diagnosis?
t
ua
A.
Tetralogy of Fallot
al
B.
Ev
C.
D.
E.
29) A 58-year-old man suddenly becomes shocked several days after suffering an acute myocardial
infarction. His chest X-ray shows a large globular shaped heart and clear lung fields. His neck veins look
distended. What is the SINGLE most likely diagnosis?
A.
Acute pericarditis
B.
Atrial thrombus
C.
45
Cardiology
Cardiac tamponade
D.
Heart block
E.
30) A 60-year-old man had a myocardial infarction 2 weeks ago. He now presents with dyspnoea and chest
pain. A pericardial friction rub was noticed on examination. ECG shows widespread ST elevation. A Chest
X-ray shows an enlarged, globular heart. His pulse rate is 95 bpm and his respiratory rate is 24/min.
What is the SINGLE most likely cause of his symptoms?
A.
Cardiac tamponade
B.
C.
Dressler’s syndrome
y
D.
op
Atrial fibrillation
E.
Pulmonary Embolism
C
31) A 58-year-old man with a history of type 1 diabetes mellitus and hypertension for 13 years develops
n
sudden central chest pain for 45 minutes. The pain started while he was driving and it was associated
io
with cold sweating and dyspnoea. He describes the pain as a burning pain. What is the SINGLE most
likely diagnosis?
t
ua
A.
Myocardial Infarction
al
B.
Pericarditis
Ev
C.
Pulmonary embolism
D.
Costochondritis
E.
Pneumothorax
32) A 54-year-old man has a temperature of 39°C, a new murmur and cardiac failure. He had a dental
extraction several of days ago. What is the SINGLE most likely reason for his symptoms?
A.
Atheroma
B.
Congenital
C.
Regeneration of tissue
46
Cardiology
D.
Infection
E.
Neoplasm
33) A 50-year-old man with diabetes mellitus suddenly develops persistent crushing central chest pain
radiating to the neck and arm when he was driving. He has a pulse of 122 beats/minute, a blood
pressure of 110/70 mmHg and a respiratory rate of 34 breaths/minute. What is the SINGLE most likely
diagnosis?
A.
Angina
B.
Costochondritis
C.
Dissecting aneurysm
D.
y
op
E.
Pulmonary embolism
C
34) A 46-year-old African-Caribbean man is found to have blood pressure of 160/90 mmHg on 3 separate
occasions. What is the SINGLE most appropriate initial treatment?
n
io
A.
ACE inhibitors
t
ua
B.
Beta-blockers
C.
al
Angiotensin II receptor blockers

D.
Ev
Thiazide diuretics
E.
Calcium channel blockers
35) A 66-year-old man with a history of hypertension presents to A&E with sudden, severe lower abdominal
pain and back pain. A tender pulsatile abdominal mass is palpated lateral and superior to the umbilicus.
His heart rate is 110/min and blood pressure is 80/50 mmHg. What is the SINGLE most appropriate
investigation?
Plab Lab Values
A.
Laparoscopy
B.
X-ray KUB
C.
47
Cardiology
Ultrasound pelvis
D.
Sigmoidoscopy
E.
Ultrasound abdomen
36) A 69-year-old woman had sudden chest pain and shortness of breath 2 hours ago. ECG shows ST
elevation in leads I, II, III. Oxygen has been started and she was given GTN which has improved her chest
pain. Her heart rate is 70 bpm and respiratory rate is 18/min. What is the SINGLE most appropriate next
step in management?
A.
B.
Streptokinase
C.
Warfarin
y
D.
op
E.
C
37) A 57-year-old woman who is suffering from hypertension, presents to the hospital with complaints of
recurrent falls when trying to get out of bed or getting up from sitting. She is on antihypertensive
n
therapy with no other medical problems. What is the SINGLE most likely cause of her falls?
io
A.
t
ua

B.
Vertebrobasilar insufficiency
al
C.
Thiazide
Ev
D.
Hypoglycemia
E.
Pneumonia
38) A 55-year-old woman was found collapsed at home. The paramedics revived her but in the ambulance
she had a cardiac arrest and could not be saved. The paramedic’s report states that the woman was
immobile lately due to hip pain and that they found ulcers on the medial side of ankle. She has a history
of diabetes mellitus and was on anti-diabetics. What is the likely cause of her death?
A.
Acute Myocardial infarction
B.
Diabetic ketoacidosis
C.
Pulmonary embolism
48
Cardiology
D.
Acute pericarditis
E.
Cardiac tamponade
39) A 58-year-old women with a history of type 1 diabetes mellitus suddenly develops chest and abdominal
pain. The pain started when she was watching television. It was associated with nausea, vomiting,
dyspnoea, and palpitations. She describes the pain as dull and burning. What is the SINGLE most likely
diagnosis?
A.
B.
Pericarditis
C.
Pulmonary embolism
D.
y
Costochondritis
op
E.
Pneumothorax
C
40) A 58-year-old woman presents to A&E with a fall. From her records, you noticed that she has a few
attendances to A&E in the last few months resulting from recurrent falls. On examination, she looks
n
slightly pale and she jokes that she is clumsier nowadays. Her medical history included asthma,
io
hypertension and a previous myocardial infarction. She regularly takes Salbutamol inhaler, QVAR inhaler,
Amlodipine, Aspirin, Atenolol, and Bendroflumethiazide. What is the SINGLE most appropriate
t
ua
investigation to be carried out?
A.
al
24 hours ECG
B.
Ev
Blood pressure monitoring

C.
Peak flow meter
D.
Echo
E.
Computed tomography head
41) A 72-year-old man is found to be unresponsive. The ward doctor is called to the patient’s bedside. He is
not breathing and has no detectable pulse. Which is the SINGLE most appropriate next step?
A.
Get a defibrillator
B.
C.
49
Cardiology
Call resuscitation team

D.
E.
42) A 55-year-old man was brought to the emergency department from a shopping mall after collapsing 2
hours ago. He is now fully conscious and answering questions. His ECG shows an irregular rhythm. His
blood pressure is 120/80 mmHg. What is the SINGLE most appropriate investigation to carry out?
A.
CT
B.
MRI
C.
24 hours ECG
D.
y
Echocardiogram
op
E.
Exercise testing
C
43) A 69-year-old man has the following ECG. What is the SINGLE most appropriate next step in
n
t io
ua
al
Ev
management?
A.
Metoprolol
B.
Digoxin
C.
D.
Adenosine
E.
Amiodarone
44) A 66-year-old man has presented to the emergency department with a stroke. CT shows no
haemorrhage. ECG shows atrial fibrillation. He has been thrombolysed and he is awaiting discharge. He
has no other medical conditions. What is the SINGLE best prophylactic regimen for him?
50
Cardiology
A.
Warfarin
B.
Heparin
C.
Aspirin
D.
Statins
E.
Beta blockers
45) A 65-year-old man has chest pain. On initial assessment, he is noted to be pale. An ECG reveals no
connection between P waves and QRS complexes with a rate of 42 beats/minute. What is the SINGLE
most likely diagnosis?
A.
y
op
B.
C.
C
D.
n

io
E.
t
ua
46) A 6-week-old baby presents with the following features of progressive cyanosis, poor feeding,
tachypnoea during the first two weeks of life. A holosystolic murmur is heard. What is the SINGLE most
al
likely diagnosis?
Ev
A.
B.
C.
Tricuspid atresia
D.
E.
Tetralogy of Fallot
47) A 50-year-old smoker and heavy drinker presents with complaints of a racing heart. He has no chest
pain. The palpitations usually occur when he drinks alcohol or when he exercises. He has no significant
past medical history. A 24 hours ECG is shown to be normal. What is the SINGLE most appropriate
action?
51
Cardiology
A.
Echocardiogram
B.
Reassure
C.
Exercise stress test
D.
24 hour BP monitoring
E.
Fasting blood glucose
48) A 65-year-old man continues to experience chest pain 2 days after an acute myocardial infarction. He
has a temperature of 37.8°C. His ECG shows widespread ST elevation with upward concavity. What is the
A.
Acute pericarditis
y
B.
op
Cardiac tamponade
C.
Atrial thrombus
C
D.
n
E.
io
Dressler syndrome
t
ua
49) A 42-year-old man collapsed and died at home. The GP’s report states that he has type 2 diabetes and
has a BMI of 35. What is the SINGLE most likely cause of death?
al
A.
Ev
B.
Hyperglycaemia
C.
Heart Failure
D.
Pulmonary Embolism
E.
Renal failure
50) A 76-year-old diabetic man was recently admitted after being found to be in atrial fibrillation. This was
his second episode of atrial fibrillation. He has no other medical problems. What is the SINGLE most
appropriate management?
A.
Aspirin
B.
52
Cardiology
Warfarin
C.
Clopidogrel
D.
Heparin
E.
Statins
51) A 60-year-old man presents with a history of sudden chest pain which radiates to his jaw accompanied
by shortness of breath which started 2 hours ago. An ECG was done which shows a normal sinus rhythm
without ST elevation. What is the SINGLE most appropriate investigation?
A.
Cardiac troponins
B.
Chest X-ray
C.
y
Echocardiogram
op
D.
Holter ECG
E.
C
n
52) A 47-year-old man with history of a myocardial infarction complains of chest pain with shortness of
io
breath on exertion over the past few days. ECG was shown to be normal. Echocardiogram shows
decreased ejection fraction and decreased septal wall thickness. What is the SINGLE most likely
t
ua
diagnosis?
A.
al
Dilated cardiomyopathy
B.
Ev
Constrictive pericarditis
C.
Amyloidosis
D.
Subacute endocarditis
E.
Pericarditis
53) An 18-year-old man complains of fatigue and dyspnoea. On examination, he has a left parasternal heave
and systolic thrill with a harsh pan-systolic murmur at left parasternal edge. What is the SINGLE most
likely diagnosis?
A.
Tetralogy of Fallot
B.
53
Cardiology
C.
D.
E.
54) A 42-year-old lady had corrective surgery for cyanotic congenital heart disease at the age of 3 after
having a palliative operation during infancy. On examination, a parasternal heave and a diastolic murmur
at the left upper sternal age is noted. What is the SINGLE most likely diagnosis?
A.
B.
C.
Aortic stenosis
y
D.
op
Pulmonary stenosis
E.
C
55) A 45-year-old man has shortness of breath and palpitations. He has a pulse of 142 beats/minute, a blood
n
pressure of 110/80 mmHg and a respiratory rate of 20 breaths/minute. Carotid sinus massage was
io
attempted but he is still tachycardic. What is the SINGLE most appropriate next management?
t
ua
A.
Adenosine
B.
al
Amlodipine
C.
Ev
DC cardioversion
D.
Lidocaine
E.
Beta blocker
56) A 69-year-old hypertensive white british man is currently on Indapamide 2.5mg daily but his blood
pressure is still high. Which of the following is the SINGLE best choice to add in order to control his blood
pressure?
A.
Increase dose of diuretic to 5mg daily
B.
Enalapril (ACE inhibitor)
C.
Atenolol (Beta blocker)
54
Cardiology
D.
Amlodipine (Calcium channel blocker)
E.
Prazosin (Alpha blocker)
57) A 56-year-old man presents to the emergency department with chest pain. The following ECG was taken.
y
op
C
n
io

t
ua
A.
Anteroseptal myocardial infarction
B.
al
Inferior myocardial infarction

Ev
C.
Lateral myocardial infarction
D.
Posterior myocardial infarction
E.
Non-ST-elevation myocardial infarction
58) A 45-year-old lady who was previously fit and well is admitted with breathlessness, palpitations and a
history of syncope. Her symptoms change with position. On examination, a loud S1 is noted at the apex.
A.
B.
C.
55
Cardiology
D.
Atrial myxoma
E.
59) Which is the SINGLE most likely artery that has artery dominance in 85% of the general population?
A.
B.
Coronary sinus
C.
Circumflex artery
D.
Posterior descending artery
E.
y
op
60) A 59 years old man returns for routine follow up 6 weeks following a myocardial infarction. He complains
of breathlessness when walking uphill. His ECG shows ST elevation in leads V1, V2, V3, V4 and V5. What
C
is the SINGLE most likely explanation for the abnormal findings?
A.
n
Heart block
io
B.
Right ventricular strain
t
ua
C.
Atrial thrombus
D.
al

E.
Ev
61) A 52-year-old man with history of anterior myocardial infarction 3 weeks ago developed a sudden onset
of dyspnoea. He has a blood pressure of 100/60 mmHg, pulse rate of 100 beats/minute, SaO2 = 88%,
and his chest is audible for bilateral crackles. What is the SINGLE best investigation to determine the
underlying cause?
A.
Chest X-ray
B.
Echocardiogram
C.
D-dimer
D.
Ventilation/perfusion scan
E.
56
Cardiology
Troponin
62) A 59-year-old man who is on multiple medications for ischaemic heart disease, hypertension and
diabetes finds it difficult to mobilize as he feels dizzy when trying to stand up. What is the SINGLE most
appropriate investigation for him?
A.
B.
ECG
C.
Magnetic resonance imaging
D.
Chest X-ray
E.
Computed tomography scan
y
op
63) A 57-year-old man presents to A&E with central abdominal and lower back pain associated with feeling
faint and sweaty. The pain started very suddenly and it is very severe. His heart rate is 105 bpm and
C
blood pressure is 88/50 mmHg. On physical examination, there is a tender pulsatile abdominal mass and
his left femoral pulse is absent. What is the SINGLE most appropriate initial investigation?
n
A.
io
Ultrasound
B.
t
ua
Sigmoidoscopy
C.
Barium enema
al
D.
X-ray of the abdomen
Ev
E.
Magnetic resonance imaging of the abdomen
64) A 62-year-old woman with longstanding anxiety is seen in the outpatient department. She complains of
her heart skipping a beat quite often. This particularly occurs when she is trying to get to sleep. The
palpitations are never sustained. What is the SINGLE most likely rhythm disturbance?
A.
B.
C.
D.
Atrial fibrillation
E.
57
Cardiology
Ventricular ectopic
65) A 65-year-old man presents with fatigue and dyspnoea 3 days after having a myocardial infarction. On
auscultation, he has a pansystolic murmur at the apex radiating to the axilla. What is the SINGLE most
likely diagnosis?
A.
Papillary muscle rupture
B.
Ventricular aneurysm
C.
Pericarditis
D.
E.
y
66) A 60-year-old man with a history of ischaemic heart disease starts having chest pain. He has a heart rate
op
of 170 beats/minute and a blood pressure of 70/450 mmHg. An ECG reveals a broad complex
tachycardia with absence of atrial activity. He feels unwell and is now semi-conscious. What is the
C
A.
n
Stokes-Adams syndrome
io
B.
t
ua
C.
D.
al

E.
Ev
Atrial fibrillation
67) A 28-year-old man presents with a 2 hours history of rapid palpitations. He feels light headed but is
otherwise well. On examination, he has a pulse of 170 beats/minute, regular. His blood pressure is
100/68 mmHg. He had 2 similar episodes of feeling palpitations in the past 3 months. What is the SINGLE
most likely rhythm disturbance?
A.
B.
C.
D.
Ectopic beats
E.
58
Cardiology
Atrial fibrillation
68) A 72-year-old man is found not breathing in the CCU with the following rhythm. His pulse can not be felt.
A.
B.
y
C.
op
D.
Atrial fibrillation
C
E.
Atrial flutter
n
io
69) 52-year-old man presents with increased breathlessness at rest. He is currently taking furosemide which
he finds gives him some relief. His medical history is significant for diabetes mellitus. On examination,
t
bilateral pedal oedema and bibasal crepitation’s are noted. What is the SINGLE most appropriate next
ua
step in management?
al
A.
Ramipril
Ev
B.
Bendroflumethiazide
C.
Atenolol
D.
Amlodipine
E.
Carvedilol
70) A 79-year-old man with a past history of ischemic heart disease presents with yellow haloes, nausea and
vomiting. His ECG reveals an arrhythmia. Which of the following medication is most likely responsible for
his symptoms?
A.
Digoxin
B.
59
Cardiology
Amlodipine
C.
Aminophylline
D.
Propranolol
E.
Diltiazem
71) A 50-year-old man presents with a stab wound to his left anterior chest at the level of the 4th intercostal
space. On physical examination, his neck veins are dilated, heart sounds are faint and trachea is central.
He has a systolic blood pressure of 80 mmHg and a pulse rate of 130 bpm. What is the SINGLE most likely
diagnosis?
A.
Cardiac tamponade
B.
Diaphragmatic rupture
y
C.
op
Fractured ribs
D.
Tension pneumothorax
C
E.
Traumatic rupture of aorta
n
io
72) A 40-year-old man was brought into the A&E after being hit by a vehicle. He sustained trauma to the
chest. His neck veins look distended and his heart sounds are faint. He has a blood pressure of 80/45
t
ua
mmHg and pulse is 120 bpm. His trachea is central. What is the SINGLE most appropriate management?
A.
al
Chest drain
B.
Ev
IV fluids
C.
Pericardiocentesis
D.
Large-bore cannula into second intercostal space in midclavicular line
E.
Blood transfusion
73) A 55-year-old man has central chest pain that radiates to his shoulders and arm. It is relieved by sitting
up and leaning forward. Pericardial friction rub is heard. A widespread 'saddle-shaped' ST elevation is
seen on an ECG. The cardiac shadow is not enlarged on a chest X-ray. What is the SINGLE most likely
diagnosis?
A.
Acute pericarditis
B.
60
Cardiology
Cardiac tamponade
C.
Pericardial Effusion
D.
E.
Pleural effusion
74) A 45-year-old carpenter presents with a 2 hour history of chest pain radiating to his left arm. His ECG is
normal. What is the SINGLE most appropriate investigation?
A.
Cardiac enzymes
B.
Chest X-ray
C.
Chest CT
y
D.
op
Holter ECG
E.
V/Q scan
C
75) A 72-year-old woman presents to the emergency department with chest pain. The following ECG was
n
taken.
t io
ua
al
Ev
A.
B.
61
Cardiology

C.
D.
E.
76) A 38-year-old man presents to the emergency department feeling unwell and dizzy. He has a heart rate
of around 35 beats/minute. What is the SINGLE most appropriate first line treatment?
A.
Atropine
B.
Adenosine
C.
Dopamine
D.
y
Epinephrine
op
E.
Supplemental oxygen
C
77) A 63-year-old man presents with sudden severe chest pain that radiates through to his back. He is
sweaty and nauseated. On examination, his BP is 176/96 in his right arm and 143/78 in his left arm. On
n
auscultation, you can hear an early diastolic murmur.

t io
ua
A.
al
Aortic valve perforation

B.
Ev
Thoracic outlet syndrome

C.
Aortic aneurysm
D.
E.
Aortic dissection
62
Cardiology
1) A 50-year-old female presents with shortness of breath and palpitations which has been on-going for the
past few hours. She has ankle swelling which has been present for more than a year and feels difficulty in
breathing while lying down. She is a known alcoholic. A chest radiograph shows evidence of cardiac
enlargement. What is the SINGLE most likely cause of her worsening condition?
A.
B.
Paroxysmal supraventricular tachycardia
C.
D.
Atrial fibrillation
E.
Ventricular ectopic
Ankle swelling and orthopnoea are features of heart failure. These features in combination with the history
y
of alcoholism gives us the hints of an alcoholic cardiomyopathy which is a type of dilated cardiomyopathy.
op
Atrial fibrillation is the most common arrhythmia that develops in patients with dilated cardiomyopathy.
Acute decompensations can occur especially in patients with asymptomatic LV dysfunction who develop
atrial fibrillation.
C
In some scenarios, there is a setting of acute alcohol use or intoxication followed by palpitations, dizziness,
n
and syncope which can be attributed to arrhythmias such as atrial fibrillation or flutters. This is known as
io
holiday heart syndrome because the incidence is increased following weekends and during holiday seasons.
t
ua
Atrial fibrillation presentation:

al
- Dyspnoea
- Palpitation
Ev
- Syncope or dizziness
- Chest discomfort or pain
- Stroke or transient ischaemic attack
- An irregularly irregular pulse
2) A 55-year-old man who suffered a myocardial infarction a few days ago is now ready for discharge. His
medical history remains insignificant other than the myocardial infarction he had. He has no drug allergies.
He has already been put on aspirin and clopidogrel. What is the SINGLE most appropriate medication(s) to
be given to him on discharge?
A.
Statin only
B.
Statin and Warfarin
C.
Statin and ACE inhibitor
63
Cardiology
D.
Warfarin only
E.
Heparin only
All patients with MI on discharge:
Dual antiplatelet therapy: Aspirin + Clopidogrel

Note: Aspirin is continued life long
Clopidogrel for 12 months
Beta Blockers
Offer BB to people who present acutely with MI as soon as they are hemodynamically stable
Continue a beta-blocker for at least 12 months after an MI in people without heart failure. Continue
a beta-blocker indefinitely in people with HF
ACEi
Offer ACEi to people who present acutely with MI as soon as they are hemodynamically stable
If intolerant to ACEi → use ARB
y
STATINS
op
Mnemonic: Once the patient is discharged, he can take the CAB or BAS (BUS) home.
C - Clopidogrel
C
A - Aspirin
B - Beta Blockers
n
A - ACEi
io
S – Statin
t
ua
3) A 43-year-old lady is admitted with pyrexia, breathlessness and history of syncope. She was recently
diagnosis with a pulmonary embolus. There is an early diastolic sound and a mid-diastolic rumble. Her
jugular venous pressure is elevated with prominent a-waves. What is the SINGLE most likely diagnosis?
al
A.
Ev
B.
C.
D.
Atrial myxoma
E.
Atrial myxomas are benign tumours.
Around three quarters of atrial myxomas occur in the left atria, and tend to grow on the wall (septum).
64
Cardiology
Sometimes small pieces of the tumor can break off and fall into the bloodstream. If this happens, they can
block an artery elsewhere in the body such as the brain, which could cause a stroke, or in the lungs causing
a pulmonary embolus.
Around 10% of myxomas seem to be inherited (passed down through families). These are known as familial
myxomas.
The symptoms occur due to obstruction of the mitral valve which result in syncope and heart failure.
Features:
Symptoms of haemodynamic obstruction, embolisation, or constitutional symptoms such as fever,
malaise, tachycardia and tachypnoea
Symptoms and signs of ischaemia or infarction in the peripheries, due to embolisation of adherent
thrombus
Atrial fibrillation
Large myxomas may impair intracardiac blood flow, causing dyspnoea, syncope or symptoms and
signs of congestive cardiac failure
y
Echo: pedunculated heterogeneous mass typically attached to the fossa ovalis region of the
op
interatrial septum C
4) A 48-year-old man has continuous anterior chest pain which is worse on inspiration. 4 weeks ago, he had a
myocardial infarction. He has a temperature of 37.5°C. His blood results show an ESR of 82 mm/h. What is
the SINGLE most likely explanation for the abnormal investigation?
n
io
A.
Pulmonary embolism
t
ua
B.
Cardiac tamponade
C.
al
Atrial thrombus
D.
Ev

E.
Dressler syndrome
Dressler's syndrome tends to occur around 2-6 weeks following a MI. The underlying pathophysiology is
thought to be an autoimmune reaction against antigenic proteins formed as the myocardium recovers. It is
characterised by a combination of fever, pleuritic pain, pericardial effusion and a raised ESR. It is treated
with NSAIDs.
5) A 55-year-old man had a myocardial infarction 3 days ago. He now complains of a shortness of breath and
a sharp pain in the chest. The pain increases when he breathes and is relieved when sitting forward. His
respiratory rate is 22 breath’s/minute and his heart rate is 95 beats/minute. What is the SINGLE most likely
diagnosis?
A.
65
Cardiology
B.
Pericarditis
C.
Aortic dissection
D.
Pulmonary embolism
E.
Cardiac tamponade
Pericarditis is one of the differentials of any patient presenting with chest pain. Pericarditis presents as
sharp, pleuritic, and positional chest pain, usually 1 to 3 days’ post infarct.
The pain that is relieved when sitting forward is a clincher for pericarditis.
Acute pericarditis
Features:
y
- Chest pain is described as sharp, stabbing, central chest pain, with radiation to the shoulders and
op
upper arm
- Chest pain may be pleuritic and is often relieved by sitting forwards
C
- Chest pain may be made worse by inspiration, cough, swallowing, or movement of the trunk
- Other symptoms include non-productive cough and dyspnoea
- Pericardial friction rub on auscultation (Clinically, the presence of a pericardial friction rub is
n
pathognomonic - often a rub can be heard even when a pericardial effusion is present)
io
Causes:
t
ua
- Viral infections (Coxsackie)

- Tuberculosis
- Uraemia (causes 'fibrinous' pericarditis)
al
- Trauma
- Post-myocardial infarction, Dressler's syndrome
Ev
- Connective tissue disease
Post myocardial infarction is an extremely important cause to remember for the exam.
ECG changes:
- Widespread 'saddle-shaped' ST elevation (Saddle-shaped meaning concavity directed upwards)
- PR segment depression
Comparing common features of Acute Pericarditis, Pericardial Effusion, Cardiac Tamponade that are often
asked in PLAB
66
Cardiology
Acute Pericarditis Pericardial Effusion Cardiac Tamponade
Cause e.g. Viruses (Coxsackie) Any cause of Any cause of pericarditis

Uraemia pericarditis (see left)
Myocardial infarction,
dressler’s Trauma
Clinical Central chest pain worse Dyspnoea, raised JVP Pulse ↑

Features on inspiration or lying BP↓
flat ± relief by sitting muffled heart sounds
forward. ↑ JVP
Pericardial friction rub Beck’s triad: falling BP; rising JVP;
y
muffled heart sounds.
op
Test ECG classically shows CXR shows enlarged, Echo is diagnostic
concave (saddle-shaped) globular heart
ST segment elevation
C
ECG shows low-
n
(NB: troponin may be voltage QRS

io
raised), complexes
and alternating
t
ua
Treatment NSAIDS Pericardiocentesis Urgent Pericardiocentesis

al
6) A 28-year-old man complains of heart racing. He is completely conscious throughout. He has a pulse of 132
Ev
beats/minute, a blood pressure of 120/80 mmHg and a respiratory rate of 20 breaths/minute. An ECG was
taken which shows supraventricular tachycardia. What is the SINGLE most appropriate initial
management?
A.
Amiodarone
B.
Adenosine
C.
Radio-frequency ablation
D.
Carotid massage
E.
Metoprolol
Carotid massage should be attempted before giving IV adenosine.
67
Cardiology
Paroxysmal supraventricular tachycardia is manifested as an absolutely regular rhythm at a rate between

130 and 220 beats/min.
Acute management should be done in the following sequence.
1st. Valsalva manoeuvre, carotid massage

2nd Adenosine IV
3rd. Electrical Cardioversion
Prevention of episodes:
- beta-blockers
- radio-frequency ablation
7) A 44-year-old man who presently has acute renal failure has an ECG that shows tall tented T waves, flat P
y
waves and a wide QRS complex. What is the SINGLE most likely electrolyte abnormality?
A.
op
Hypophosphataemia
C
B.
Hyperkalaemia
n
C.
io
Hypokalaemia
D.
t
ua
Hypercalcaemia
E.
Hypocalcaemia
al
Acute renal failure is one of the causes of hyperkalaemia. Together with the ECG findings points towards
Ev
hyperkalaemia as the answer.
ECG characteristics in electrolyte disbalance
Hyperkalaemia:
- Tall-tented T waves, small P waves, widened QRS leading to a sinusoidal pattern and asystole.
Hypokalemia:
- Flat T waves, ST depression and prominent U waves
Hypercalcaemia:
- Shortened QT intervals
Hypocalcaemia:
- Prolonged QT intervals
68
Cardiology
8) A 69-year-old man was successfully thrombolysed for an inferior myocardial infarction 15 days ago and was
discharged 5 days after the thrombolysis. He is now re-admitted as he is hypotensive, tachycardic and with
pulmonary oedema. What is the most SINGLE most likely diagnosis?
A.
B.
C.
D.
Pulmonary stenosis
E.
Rheumatic mitral valve stenosis
Acute mitral regurgitation post-MI
y
This is a mitral regurgitation due to ischaemic papillary muscle dysfunction or partial rupture. It is usually
op
seen 2-10 days post myocardial infarction. It is more commonly associated with inferior myocardial
infarction than anterior myocardial infarction.
C
‘Silent MR’ is quite frequent and must be suspected in any post-MI patient with unexplained haemodynamic
deterioration.
n
io
Diagnosis:
Echocardiogram
t
ua
Treatment:
This is unlikely to be asked in PLAB but for your own knowledge:
al
Acute MR is treated with vasodilator therapy but often require emergency surgical repair.
Ev
9) A 6-week-old baby has a pansystolic murmur at sternal border. He feeds poorly and has poor weight gain.
The baby is acyanotic. What is the SINGLE most likely diagnosis?
A.
Tetralogy of Fallot
B.
C.
D.
E.
A key mnemonic that can help you get through PLAB part 1 cardio questions is:
69
Cardiology
Pan-systolic → MR, TR, VSD
Hence, when you see the words pan-systolic murmur in the question, straight away, you can cut out any
options that ARE NOT mitral regurgitation, tricuspid regurgitation and ventricular septal defect.
In this question, the phrase pan-systolic murmur already gives you the answer which is VSD.
Ventricular septal defect:

- Basically, a hole connecting the ventricles
Causes:
- Congenital
- Acquired (post-MI)
Symptoms:
- May present with severe heart failure in infancy, or remain asymptomatic and be detected
incidentally in later life.
y
op
Signs:
These depend on size and site:
A. Small holes
C
- Infant or child is asymptomatic with normal feeding and weight gain
- May be detected when a murmur is heard on routine examination
n
- Give louder murmurs
io
- Classically, a harsh pan-systolic murmur heard at the left sternal edge, with a systolic thrill, and a
left parasternal heave
t
ua
Most importantly is to remember the term “pan-systolic murmur” as often that alone can give you the
answer provided mitral regurgitation and tricuspid regurgitation are not one of the options.
al
B. Large holes
Ev
- Associated with signs of pulmonary hypertension

- These babies may develop a right to left shunt with cyanosis or Eisenmenger's syndrome
The diagnosis and management → Not so important for the exam
A memory flow chart to help you easily differentiate murmurs
70
Cardiology
y
op
C
n
10) A 55-year-old man with a history of a myocardial infarction has progressive dyspnoea. He has had previous
io
admissions with heart failure in the past year. He has a respiratory rate of 31 breaths/minute and a systolic
blood pressure of 90 mmHg. His oxygen saturation is 90% on room air. On examination, he looks pale and
t
sweaty, and has widespread crepitations over both lung fields. Oxygen by face mask was commenced.
ua
What is the SINGLE most appropriate investigation?

al
A.
Chest X-ray
Ev
B.
C.
Electrocardiogram
D.
Full blood count
E.
D-dimer test
This patient is suffering from acute pulmonary oedema brought upon by heart failure. While it is true that
an ECG is important to look for arrhythmia, a chest-X ray would be a better answer given that it would be
able to confirm pulmonary oedema. This question is very debatable but the clinical picture here fits
pulmonary oedema slightly better than a myocardial infarction. In reality, both will be performed.
11) A 65-year-old man presents with recurrent light-headedness for one month especially when he gets up
from bed in the morning. He also has occasional episodes of light-headedness when standing for prolonged
71
Cardiology
periods of time. He suffers from hypertension and type 2 diabetes. His regular medications include
atenolol, amlodipine, bendroflumethiazide and metformin. On physical examination, his blood pressure
was 125/85 mmHg taken when he was supine and 101/69 mmHg when standing. What is the SINGLE most
likely diagnosis?
A.
Acute hypotension
B.
Vasovagal faints
C.
Postural hypotension
D.
Postprandial hypotension
E.
Aortic stenosis
Postural hypotension (Orthostatic hypotension)
y
op
Postural hypotension should always be considered in an elderly patient especially if he is on multiple
medications and presents with dizziness. The baroreflex mechanisms which control heart rate and vascular
C
resistance decline with age (particularly in patients with hypertension) who thus display lability in BP. They
are particularly prone to postural hypotension and to the effects of drugs.
n
It may present with dizziness or sudden loss of consciousness after getting up from chair, with recovery
io
within a minute
t
ua
Diagnosis:
- Blood pressure taken when lying down and standing up
al
Postural hypotension is defined as a drop-in BP of more than 20 mmHg after 3 minutes of standing.
Ev
12) A 74-year-old man started having chest pain. He has a blood pressure of 70/50 mmHg. He is conscious and
a radial pulse is felt. An ECG shows the following rhythm. What is the SINGLE most likely diagnosis?
A.
B.
C.
72
Cardiology
D.
Atrial fibrillation
E.
Atrial flutter
For junior doctors, the ECG pattern between ventricular tachycardia and ventricular fibrillation can be
rather hard to distinguish. But here as the patient is still conscious, it cannot be ventricular fibrillation as v.
fib would present without a pulse and the patient would not be conscious. Thus, ventricular tachycardia is
the answer here.
Ventricular tachycardia:
Ventricular tachycardia may impair cardiac output with consequent hypotension, collapse, and acute
cardiac failure. This is due to extreme heart rates and lack of coordinated atrial contraction (loss of “atrial
kick”).
The rate of V. Tach is from about 100-250 bpm. P Waves may be present or absent. P waves are usually not
y
seen if the rate is increased. If present, the P Waves have no relation to the QRS complexes of the V. Tach.
V. tach can present in two ways:

op
1. With Pulse
C
a) Haemodynamically stable or
b) Haemodynamically unstable — e.g hypotension, chest pain, cardiac failure, decreased conscious level.
n
io
2. Without Pulse
t
ua
Management depends on how the patient presents:
With Pulse:
al
a) Haemodynamically stable → antiarrhythmics e.g. amiodarone, lidocaine, procainamide

b) Haemodynamically unstable — e.g hypotension, chest pain, cardiac failure, decreased conscious level. →
Ev
immediate electrical cardioversion is indicated
Without Pulse → immediate electrical cardioversion is indicated
13) A 75-year-old man is found to be unresponsive. The ward doctor is called to the patient’s bedside. He is not
breathing and has no detectable pulse. Which is the SINGLE most appropriate next step?
A.
Get a defibrillator
B.
C.
Check notes for a Do Not Attempt Resuscitation (DNAR) order
D.
E.
73
Cardiology
bilaterally clear. He has muffled heart sounds and his neck veins look distended. His systolic blood pressure
is 60 mmHg and pulse is 120 bpm. What is the SINGLE most likely diagnosis?
A.
Pulmonary embolism
B.
C.
Cardiac tamponade
D.
Hemothorax
E.
Pneumothorax
y
This question clearly points towards cardiac tamponade. His chest is bilaterally clear thus we can therefore
op
exclude pneumothorax or pleural effusion. Muffled heart sounds, distended neck veins, hypotension are
called Beck’s triad and it is a classical finding in cardiac tamponade.
C
Cardiac tamponade:
A life-threatening condition in which a pericardial effusion has developed so rapidly or has become so large
n
that it compresses the heart.

io
Aetiology:
t
ua
Usually penetrating or blunt chest trauma
Features:
al
- Dyspnoea
- Raised JVP - seen by having neck veins which are distended
Ev
- Tachycardia
- Hypotension
- Muffled heart sounds
- Pulsus paradoxus
Remember → Beck’s triad: Muffled heart sounds, distended neck veins, and hypotension
Diagnosis:
Echocardiography
Treatment:
Pericardiocentesis
15) A 60-year-old lady has severe chest pain. ECG shows changes of inferior wall myocardial infarction. The
ECG also shows progressive prolongation of PR interval until a QRS complex is dropped. What is the SINGLE
74
Cardiology
A.
Atrial fibrillation
B.
C.
D.
E.
Inferior myocardial infarction is frequently associated with conduction defects.
Mobitz type I AV block (also known as Wenckebach's block/phenomenon)

There is progressive prolongation of the P-R interval following each atrial impulse, until an atrial impulse
fails to be conducted to the ventricles causing a 'dropped' beat’.
y
op
Heart block C
First degree • PR interval > 0.2 seconds
heart block
n
Second degree Mobitz type I AV block (Wenckebach block/phenomenon)
io
heart block • Progressive prolongation of the PR interval until a dropped beat occurs
t
ua

• PR interval is constant but the P wave is often not followed by a QRS complex (dropped
al
beat)
Ev
Third degree • P waves will occur regularly, usually at a rate of around 75 beats per minute but are
(complete) completely unconnected to the rhythm of the QRS complexes.
heart block
16) A 62-year-old women who had stroke a year ago now reports having increased dyspnoea on exertion. An
ECG was performed which showed an atrial fibrillation. Chest X-ray shows a straight left heart border.
A.
B.
C.
D.
Pulmonary stenosis
75
Cardiology
E.
Mitral valve stenosis
The clincher here is the chest X-ray that shows a straight left heart border. This is classic for mitral stenosis
where the left atrium enlarges. The rest of the symptoms also match the diagnosis of mitral stenosis. The
history of stroke given in this question is a clue that she has had atrial fibrillation for a while and had a
systemic embolism (due to stagnation of blood in an enlarged left atrium).
Mitral Valve Stenosis:

- Most commonly due to rheumatic fever
- Results in right ventricular failure
Aetiology:
- Most cases are secondary to rheumatic fever → This is extremely important to remember for the
exam
Pathogenesis:
y
- Mitral valve stenosis impedes left ventricular filling
op
- Increased left atrial pressure is referred to the lungs, causing pulmonary congestion
- Forward cardiac output becomes reduced, secondary pulmonary vasoconstriction occurs, and
eventually right ventricular failure results
C
Clinical symptoms: Usually manifest slowly over years
n
- Dyspnoea
io
- Orthopnoea
- Paroxysmal nocturnal dyspnoea
t
ua
- Right-sided heart failure

- Hepatomegaly
- Ascites
al
- Peripheral oedema
Ev
The following are presentations which are rare and unlikely to be asked:
- Haemoptysis (due to rupture of pulmonary vessels due to raised atrial pressure)
- Systemic embolism (due to stagnation of blood in an enlarged left atrium)
Physical signs:
- Malar flush on the cheeks
- Atrial fibrillation
- Pulmonary rales
- Loud S1 → This is particularly important to note for the exam
- Diastolic rumble (low-pitched apical murmur)
Diagnosis:
1. ECG
- May show signs of right ventricular hypertrophy
- Atrial fibrillation may be seen
- P mitrale → bifid P wave
76
Cardiology
2. Chest x-ray
- Large left atrium → straightening of the left heart border
- Pulmonary hypertension, including Kerley B lines and increased vascular markings
y
op
C
3. Echocardiography
- Thickening of mitral valve leaflets
n
io
17) A preterm neonate has a continuous murmur that disappeared at the time of discharge from the paediatric
intensive care unit. What is the SINGLE most likely diagnosis?
t
ua
A.
al
B.
Tetralogy of fallot
Ev
C.
D.
E.
PDAs are very common in preterm babies and it also may close may close spontaneously.
Patent ductus arteriosus in preterm neonates:

- PDAs are very common in preterm babies and can have significant physiological effects
- The continuous murmur (rarely heard)
- There may be a rough systolic murmur along the left sternal border
- Bounding peripheral pulses
- The diagnosis is confirmed by echocardiography which not only allows the PDA to be visualised but
also assesses the haemodynamic significance of the PDA
77
Cardiology
- PDAs may close may close spontaneously

- Indomethacin closes the connection in the majority of cases
18) A 74-year-old man started having chest pain. He has a blood pressure of 70/50 mmHg. His level of
consciousness is decreased. A radial pulse is felt. An ECG shows the following rhythm. What is the SINGLE
most appropriate management?
y
A.
op
Cardioversion
B.
C
C.
Adenosine
n
D.
io
Amiodarone
E.
t
ua
Lidocaine
For junior doctors, the ECG pattern between ventricular tachycardia and ventricular fibrillation can be
al
rather hard to distinguish. But here as the patient is still conscious, it cannot be ventricular fibrillation as v.
fib would present without a pulse and the patient would not be conscious. Thus, ventricular tachycardia is
Ev
the answer here.
Since the patient is hemodynamically unstable, cardioversion would be the answer.
Ventricular tachycardia:
kick”).
V. tach can present in two ways:

1. With Pulse
78
Cardiology
2. Without Pulse
With Pulse:
Without Pulse → immediate electrical cardioversion is indicated
19) A 44-year-old woman in the postnatal ward develops sudden onset chest pain and shortness of breath. She
had an emergency C-section for fetal distress two days ago. She feels the breathlessness worsen when she
lies down. She has a respiratory rate of 32 breaths/minute and a blood pressure of 100/60 mmHg. Her
oxygen saturation is 89% on room air and temperature is 36.9°C. On examination, she looks pale and
sweaty. Auscultation reveals widespread crepitations over both lung fields. An ECG was performed which
y
shows sinus tachycardia. Oxygen by face mask was commenced. A chest X-ray confirms the diagnosis.
op
Which SINGLE medication is used as part of the management?
C
A.
Co-amoxiclav
B.
n
Aspirin
io
C.
Furosemide
t
ua
D.
E.
al
Alteplase
Ev
This patient is suffering from acute pulmonary oedema brought upon by heart failure. It is worth noting
that this stem is a little tricky as there were no risk factors of heart failure mentioned and the information
that the women had a recent C-section makes physicians (especially if you have worked in an obstetric
unit), think of a pulmonary embolism. However, it is important to be aware that cardiac causes of
breathlessness do occur in pregnancy and post-delivery as well. This stem gives the history of orthopnoea
which clearly points towards heart failure as the reason for the shortness of breath.
In terms of management of acute pulmonary oedema, 4 important steps need to be done:

1. Sit patient up, and give oxygen - aim for saturations ≥95% (>90% in those with COPD)
2. Glyceryl trinitrate (GTN) spray two puffs sublingual
3. Furosemide 40 mg intravenously (slowly) produces transient venodilation and subsequent diuresis
4. Diamorphine 2.5-5 mg intravenously slowly (or morphine 5-10 mg intravenously slowly) can be used
to relieve anxiety, pain and distress.
20) A 60-year-old woman with a history of ischaemic heart disease presents to A&E with progressive dyspnoea.
She has had previous admissions with heart failure in the past year. She has a respiratory rate of 34
79
Cardiology
breaths/minute and a systolic blood pressure of 90 mmHg. Her oxygen saturation is 88% on room air. On
examination, she looks pale and sweaty, and has widespread crepitations over both lung fields. Oxygen by
face mask was commenced. What is the SINGLE most appropriate next step in management?
A.
Bendroflumethiazide
B.
Furosemide
C.
Aspirin
D.
Carvedilol
E.
Spironolactone
This patient is suffering from acute pulmonary oedema brought upon by heart failure.
y
In terms of management of acute pulmonary oedema, 4 important steps need to be done:
op
1. Sit patient up, and give oxygen - aim for saturations ≥95% (>90% in those with COPD)
2. Glyceryl trinitrate (GTN) spray two puffs sublingual
C
3. Furosemide 40 mg intravenously (slowly) produces transient venodilation and subsequent diuresis
Diamorphine 2.5-5 mg intravenously slowly (or morphine 5-10 mg intravenously slowly) can be used to
relieve anxiety, pain and distress.
n
t io
ua
21) A 28-year-old man complains of heart racing. He is completely conscious throughout. He has a pulse of 132
beats/minute, a blood pressure of 120/70 mmHg and a respiratory rate of 21 breaths/minute. An ECG was
taken which shows supraventricular tachycardia. What is the SINGLE most appropriate immediate
al
management?
Ev
A.
Amiodarone
B.
Adenosine
C.
Lidocaine
D.
Verapamil
E.
Metoprolol

80
Cardiology
Acute management should be done in the following sequence:
1st. Valsalva manoeuvre, carotid massage

2nd. Adenosine IV
3rd. Electrical Cardioversion
Prevention of episodes:
- beta-blockers
- radio-frequency ablation
22) A 68-year-old man is found collapsed at a shopping mall. An ECG reveals no connection between P waves
and QRS complexes with a rate of 35 beats/minute. What is the SINGLE most likely diagnosis?
A.
Third degree heart block
B.
y
C.
op
D.
C
E.
n
io
bilaterally clear. He has muffled heart sounds and his neck veins look distended. His blood pressure is
t
ua
84/40 mmHg and pulse is 110 bpm. What is the SINGLE most appropriate investigation that can lead to a
diagnosis?
al
A.
Echocardiogram
Ev
B.
Chest X-ray
C.
CTPA
D.
Spirometry
E.
Blood cultures
This question clearly points towards cardiac tamponade. His chest is bilaterally clear thus we can therefore
exclude pneumothorax or pleural effusion. Muffled heart sounds, distended neck veins, hypotension are
called Beck’s triad and it is a classical finding in cardiac tamponade.
Cardiac tamponade:
A life-threatening condition in which a pericardial effusion has developed so rapidly or has become so large
that it compresses the heart.
81
Cardiology
Aetiology:
Usually penetrating or blunt chest trauma
Features:
- Dyspnoea
- Raised JVP - seen by having neck veins which are distended
- Tachycardia
- Hypotension
- Muffled heart sounds
- Pulsus paradoxus
Remember → Beck’s triad: Muffled heart sounds, distended neck veins, and hypotension
Diagnosis:
Echocardiography
y
Treatment:
op
Pericardiocentesis C
24) A 72-year-old woman had sudden chest pain and shortness of breath 1 hour ago. There is ST elevation in
the II, III and aVF on ECG. Oxygen has been started. She was given GTN and diamorphine which has
improved her chest pain. Her heart rate is 90 bpm and respiratory rate is 18/min. What is the SINGLE most
n
appropriate next step in management?

io
A.
t
ua

B.
Percutaneous intervention (PCI)
al
C.
Warfarin
Ev
D.
Streptokinase
E.
Alteplase
Percutaneous intervention (PCI) would be the best management for myocardial infarction.
Myocardial infarction Summary:

- If patient presents to hospital less than 90 minutes → Perform PCI
- If PCI not available within 90 minutes → Thrombolysis (Alteplase) is indicated
- Thrombolysis can only be done within 12 hours of symptom onset
- If thrombolysis is contraindicated → transfer to another hospital for PCI
- If PCI fails → Perform CABG within 12 hours of symptom onset
Myocardial infarction:
82
Cardiology
Immediate and prompt revascularisation with percutaneous coronary intervention (PCI) within 90 minutes
of first presentation, or thrombolysis within 12 hours of symptom onset
Primary PCI should be considered in patients presenting within 12 hours of symptom onset or in patients
presenting after 12 hours but with ongoing ischaemia.
Thrombolysis is indicated if PCI is not available within 90 minutes of first medical contact and the patient
has no contra-indications to thrombolytic therapy
Many hospitals have 24-hour PCI capacity; however, in facilities without catheterisation laboratories,
routine transfer to a PCI facility should be considered for all patients within 30 minutes of presentation, and
ideally within 30 minutes of symptom onset
Radial approach is preferable to femoral approach to minimise bleeding complications, if the operator is
experienced in radial access
Emergency revascularisation with CABG should be strongly considered in patients who fail PCI, and should
y
be performed within 12 hours of symptom onset, ideally within 6 hours
op
In patients with contraindications to thrombolysis, PCI is indicated even if it cannot occur within 90 minutes.
C
Patients should be transferred for PCI as soon as possible.
n
25) A 52-year-old man underwent a hemicolectomy. A few days after his operation he develops chest pain and
io
a temperature of 38.8°C. He is having rigors and night sweats. On auscultation, a systolic murmur is heard.
What is the next SINGLE most appropriate investigation?
t
ua
A.
al
B.
Ev
C.
Chest X-ray
D.
Blood culture
E.
Liver function test
This is a case of infective endocarditis. The most appropriate investigation is blood cultures or
echocardiogram. Since echocardiogram is not one of the options, blood cultures should be picked.
Infective endocarditis:
- Fever + new murmur = endocarditis until proven otherwise
Diagnosis: Infective endocarditis is diagnosed if:

- 2 major criteria present, or
- 1 major and 3 minor criteria present, or
83
Cardiology
- 5 minor criteria present
Major criteria:
- Positive blood cultures
- Positive echocardiogram - showing abscess formation, new valvular regurgitation
Minor criteria:
- IV Drug user, predisposing heart condition
- Fever >38°C
- Vascular phenomena: e.g. major emboli, clubbing, splinter haemorrhages, Janeway lesions
- Immunological phenomena: glomerulonephritis, Osler's nodes, Roth spots
- Microbiological evidence does not meet major criteria
26) A 33-year-old man complaints of occasional left sided chest pain that lasts less than 30 minutes following
exercise. The pain is relieved once he takes a rest. What is the SINGLE most likely diagnosis?
y
A.
op
Unstable angina
B.
Decubitus angina
C
C.
Stable angina
n
D.
io
Coronary spasm
E.
t
ua
Angina is chest pain or discomfort that is caused when heart muscle does not get enough blood. In, stable
al
angina, the pain is precipitated by predictable factors like exercise. This is relieved by rest.
Ev
27) A 71-year-old woman had sudden chest pain and shortness of breath 2 hours ago. The pain radiates to her
left arm. There is ST elevation in the II, III and aVF on ECG. Oxygen has been started and she was given GTN
which has improved her chest pain. Her heart rate is 80 bpm and respiratory rate is 18/min. What is the
SINGLE most appropriate next step in management?
A.
B.
Alteplase
C.
Warfarin
D.
E.
84
Cardiology
Percutaneous intervention (PCI) would be the best management for myocardial infarction. As PCI not given
in the options. Thrombolysis would be the next best step. In terms of thrombolysis, alteplase is preferred
over streptokinase in the NHS.
Myocardial infarction Summary

y
op
C
n
io
t
ua
al

Ev
28) A 2-week-old baby has oxygen saturation of 70% on air. He is cyanosed and has an ejection systolic
murmur. What is the SINGLE most likely diagnosis?
A.
Tetralogy of Fallot
B.
C.
D.
E.
85
Cardiology
Tetralogy of Fallot is the most likely diagnosis here. It usually presents with an ejection systolic murmur. The
low oxygen saturation and cyanosis are consistent with Tetralogy of Fallot.
Tetralogy of Fallot (TOF)

- The most common cause of cyanotic congenital heart disease.
- Typically presents at around 1-2 months, although may not be picked up until the baby is 6 months
old
The four characteristic features are:

- Ventricular septal defect (VSD)
- Right ventricular hypertrophy
- Pulmonary stenosis
- Overriding aorta
Other features:
y
- Cyanosis
op
- Causes a right-to-left shunt
- Ejection systolic murmur due to pulmonary stenosis (the VSD does not usually cause a murmur)
C
- A right-sided aortic arch is seen in 25% of patients
- Chest x-ray shows a 'boot-shaped' heart, ECG shows right ventricular hypertrophy
n
29) A 58-year-old man suddenly becomes shocked several days after suffering an acute myocardial infarction.
io
His chest X-ray shows a large globular shaped heart and clear lung fields. His neck veins look distended.
t
ua
A.
Acute pericarditis
al
B.
Atrial thrombus
Ev
C.
Cardiac tamponade
D.
Heart block
E.
A myocardial infarction can cause acute pericarditis which can lead to pericardial effusion. A chest X-ray
shows an enlarged globular heart at this stage. A pericardial effusion of significant amount can cause
cardiac tamponade which shows up as signs of shock. One can expect his blood pressure to be low and his
JVP to be high.
30) A 60-year-old man had a myocardial infarction 2 weeks ago. He now presents with dyspnoea and chest
pain. A pericardial friction rub was noticed on examination. ECG shows widespread ST elevation. A Chest X-
ray shows an enlarged, globular heart. His pulse rate is 95 bpm and his respiratory rate is 24/min. What is
the SINGLE most likely cause of his symptoms?
86
Cardiology
A.
Cardiac tamponade
B.
C.
D.
Atrial fibrillation
E.
Pulmonary Embolism
The widespread ST elevation and pericardial friction rub is seen in pericarditis. The Chest X-ray showing an
enlarged, globular heart points towards pericardial effusion. Dressler’s syndrome would explain all the
findings.
Dressler's syndrome tends to occur around 2-6 weeks following a MI. The underlying pathophysiology is
thought to be an autoimmune reaction against antigenic proteins formed as the myocardium recovers. It is
y
characterised by a combination of fever, pleuritic pain, pericardial effusion and a raised ESR. It is treated
op
with NSAIDs. C
31) A 58-year-old man with a history of type 1 diabetes mellitus and hypertension for 13 years develops
sudden central chest pain for 45 minutes. The pain started while he was driving and it was associated with
cold sweating and dyspnoea. He describes the pain as a burning pain. What is the SINGLE most likely
n
diagnosis?
io
A.
t
ua
B.
Pericarditis
al
C.
Pulmonary embolism
Ev
D.
Costochondritis
E.
Pneumothorax
This is clear that this is a myocardial infarction.
- In pericarditis, the pain is aggravated by inspiration or lying flat and relieved by leaning forward.
Pericardial rub may present and there may be fever.
- In pulmonary embolism, patients would present with dyspnoea and pleuritic chest pain. The writers
of the exam would also give other hints like having a history of immobilization or a long travel.
- In costochondritis, the pain is localized at the costochondral junction which is enhanced by motion,
coughing, or sneezing. The writers would usually give a history of repeated minor chest injury or
activities that one is unused to - perhaps decorating or moving furniture.
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Cardiology
- In pneumothorax, the pain is not central but pleuritic and there are no signs that indicate that this is
pneumothorax in the given question
The given picture of central chest pain for 45 minutes (more than 30 minutes), sweating and dyspnoea with
major risk factor of diabetes mellitus and hypertension suggest the diagnosis of myocardial infarction.
Acute Myocardial Infarction
Presentation: Chest pain (central chest pain may not be the main symptom):
- Three quarters of patients present with characteristic central or epigastric chest pain radiating to
the arms, shoulders, neck, or jaw.
- The pain is described as substernal pressure, squeezing, aching, burning, or even sharp pain.
- Radiation to the left arm or neck is common.
- Chest pain may be associated with sweating, nausea, vomiting, dyspnoea, fatigue and/or
palpitations.
- Shortness of breath: may be the patient's anginal equivalent or a symptom of heart failure.
y
- Atypical presentations are common and tend to be seen in women, older men, people with diabetes
op
and people from ethnic minorities. Atypical symptoms include abdominal discomfort or jaw pain;
elderly patients may present with altered mental state.
C
32) A 54-year-old man has a temperature of 39°C, a new murmur and cardiac failure. He had a dental
n
extraction several of days ago. What is the SINGLE most likely reason for his symptoms?
io
A.
t
ua
Atheroma
B.
Congenital
al
C.
Regeneration of tissue
Ev
D.
Infection
E.
Neoplasm
Signs and consistent with infective endocarditis. Dental extraction is a known source of infection causing
bacteraemia.
Infective endocarditis:
- Fever + new murmur = endocarditis until proven otherwise
Risk factors:
- Valve replacement
- Recreational drug abuse and invasive vascular procedures
Note: Dentistry interventions are a common cause of bacteraemia leading to infective endocarditis
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Cardiology
Cause:
- Strep viridans is a common cause (more than 35%)
Presentation:
- Septic signs: Fever, rigors, night sweats, malaise
- Cardiac lesion: New murmur
- Immune complex deposition: Roth spots (boat-shaped retinal haemorrhage with pale centre);
splinter haemorrhages, Osler’s nodes (painful pulp infarcts in fingers or toes)
- Embolic phenomena: e.g. Janeway lesions (painless palmar or plantar macules)
Some patients may present with congestive cardiac failure
33) A 50-year-old man with diabetes mellitus suddenly develops persistent crushing central chest pain
radiating to the neck and arm when he was driving. He has a pulse of 122 beats/minute, a blood pressure
of 110/70 mmHg and a respiratory rate of 34 breaths/minute. What is the SINGLE most likely diagnosis?
y
A.
op
Angina
B.
Costochondritis
C
C.
Dissecting aneurysm
n
D.
io
E.
t
ua
Pulmonary embolism
Presentation: Chest pain (central chest pain may not be the main symptom):
al
Ev
palpitations.
- Atypical presentations are common and tend to be seen in women, older men, people with
diabetes and people from ethnic minorities. Atypical symptoms include abdominal discomfort or
jaw pain; elderly patients may present with altered mental state.
34) A 46-year-old African-Caribbean man is found to have blood pressure of 160/90 mmHg on 3 separate
occasions. What is the SINGLE most appropriate initial treatment?
A.
ACE inhibitors
B.
Beta-blockers
89
Cardiology
C.
Angiotensin II receptor blockers
D.
Thiazide diuretics
E.
Since patient has Afro-Caribbean origins calcium channel blockers would be the best antihypertensive
medication to start.
Afro-Caribbean’s tend to develop low-renin, salt sensitive type hypertension. Monotherapy for hypertension
with beta-blockers or ACE inhibitors are less effective than calcium channel blockers in this particular
ethnicity.
Main simplified points on Hypertension Management
Classification:
y
1. Stage 1 hypertension
op
- Clinic BP >= 140/90 mmHg and subsequent ambulatory blood pressure monitoring (ABPM) daytime
average or home blood pressure monitoring (HBPM) average BP >= 135/85 mmHg
C
2. Stage 2 hypertension
- Clinic BP >= 160/100 mmHg and subsequent ambulatory blood pressure monitoring (ABPM) daytime
n
average or home blood pressure monitoring (HBPM) average BP >= 150/95 mmHg
io
3. Severe hypertension
t
ua
- Clinic systolic BP >= 180 mmHg, or clinic diastolic BP >= 110 mmHg
Management:
al
1. For Stage 1 hypertension

- Treat if < 80 years of age and has target organ damage
Ev
2. For Stage 2 hypertension

- Treat
3. If hypertensive patient less than 55 years old

- Treat with ACE inhibitor
4. If hypertensive patient more than 55 years old OR of Afro-Caribbean origin

- Treat with calcium channel blocker
Drug treatment of essential hypertension can be summarised as follows:

Step 1; Age <55 - ACE inhibitor. Age >55 or of black African or Caribbean origin - calcium channel blocker
Step 2; ACE inhibitor + calcium channel blocker
Step 3; ACE inhibitor + calcium channel blocker + thiazide-like diuretic
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Cardiology
35) A 66-year-old man with a history of hypertension presents to A&E with sudden, severe lower abdominal
pain and back pain. A tender pulsatile abdominal mass is palpated lateral and superior to the umbilicus. His
heart rate is 110/min and blood pressure is 80/50 mmHg. What is the SINGLE most appropriate
investigation?
Plab Lab Values
A.
Laparoscopy
B.
X-ray KUB
C.
Ultrasound pelvis
D.
Sigmoidoscopy
E.
Ultrasound abdomen
y
op
This is a classic picture of a ruptured abdominal aneurysm.
C
An ultrasound scan is the only appropriate investigation given the options.
Questions would usually have either an ultrasound or CT abdomen as one of the choices for a ruptured
n
aortic aneurysm. Both choices are correct. It is important to note that both USS or CT scan can be
io
performed. Although, it may be safer and quicker to perform USS in the ED, rather than transfer the patient
for CT scan.
t
ua
36) A 69-year-old woman had sudden chest pain and shortness of breath 2 hours ago. ECG shows ST elevation
in leads I, II, III. Oxygen has been started and she was given GTN which has improved her chest pain. Her
al
heart rate is 70 bpm and respiratory rate is 18/min. What is the SINGLE most appropriate next step in
management?
Ev
A.
B.
Streptokinase
C.
Warfarin
D.
E.
Percutaneous intervention (PCI) would be the best management for myocardial infarction. As PCI not given
in the options. Thrombolysis would be the next best step. In terms of thrombolysis, Alteplase is preferred
over streptokinase in the NHS. However, alteplase is not given in the options thus the best option would be
option B. (streptokinase).
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Cardiology
Myocardial infarction Summary:

y
op
C
n
io
t
ua
al

Ev
37) A 57-year-old woman who is suffering from hypertension, presents to the hospital with complaints of
recurrent falls when trying to get out of bed or getting up from sitting. She is on antihypertensive therapy
with no other medical problems. What is the SINGLE most likely cause of her falls?
A.
B.
Vertebrobasilar insufficiency
C.
Thiazide
D.
Hypoglycemia
E.
Pneumonia
One of the many known adverse effects of thiazides is postural hypotension.
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Cardiology
Common adverse effects of thiazides worth remembering include:

- Postural hypotension
- Hyponatraemia, hypokalaemia
- Gout

within a minute
Diagnosis:
y
op
C
38) A 55-year-old woman was found collapsed at home. The paramedics revived her but in the ambulance, she
had a cardiac arrest and could not be saved. The paramedic’s report states that the woman was immobile
lately due to hip pain and that they found ulcers on the medial side of ankle. She has a history of diabetes
n
mellitus and was on anti-diabetics. What is the likely cause of her death?
io
A.
t
ua
Acute Myocardial infarction

B.
al
C.
Pulmonary embolism
Ev
D.
Acute pericarditis
E.
Cardiac tamponade
This is a very debatable question. The two top choices here are acute myocardial infarction (a silent MI) or
pulmonary embolism due to immobilization which may resulted in deep vein thrombosis. Acute myocardial
infarction fits well because a silent myocardial infarction is seen in diabetics. It can be painless as the
patient can develop autonomic neuropathy. If one does not feel pain, she might not call for help. As this
progress, she collapses and dies. We call this a “silent MI”. Given the history of immobilization, pulmonary
embolism can be suspected as well. However, given the two choices, a silent MI (acute myocardial
infarction) is more likely the answer, as if she were to develop PE, she would have shortness of breath and
would have called the ambulance instead.
39) A 58-year-old women with a history of type 1 diabetes mellitus suddenly develops chest and abdominal
pain. The pain started when she was watching television. It was associated with nausea, vomiting,
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Cardiology
dyspnoea, and palpitations. She describes the pain as dull and burning. What is the SINGLE most likely
diagnosis?
A.
B.
Pericarditis
C.
Pulmonary embolism
D.
Costochondritis
E.
Pneumothorax
Atypical presentations of myocardial infarction are common. They may present with abdominal pain like in
the question above. The reason the question gives a female with diabetes is because atypical presentations
tend to be seen more commonly in women or people with diabetes. Atypical symptoms include abdominal
y
discomfort or jaw pain. The remaining symptoms are quite characteristic of myocardial infarction.
-
op
In pericarditis, the pain is aggravated by inspiration or lying flat and relieved by leaning forward.
C
Pericardial rub may present and there may be fever.
- In pulmonary embolism, patients would present with dyspnoea and pleuritic chest pain. The writers
n
of the exam would also give other hints like having a history of immobilization or a long travel.
io
- In costochondritis, the pain is localized at the costochondral junction which is enhanced by motion,
t
ua
coughing, or sneezing. The writers would usually give a history of repeated minor chest injury or
activities that one is unused to - perhaps decorating or moving furniture.
al
- There are no signs that indicate that this is pneumothorax

Ev
Acute Myocardial Infarction: Presentation: Chest pain (central chest pain may not be the main symptom):
palpitations.
- Atypical presentations are common and tend to be seen in women, older men, people with diabetes
and people from ethnic minorities. Atypical symptoms include abdominal discomfort or jaw pain;
elderly patients may present with altered mental state.
40) A 58-year-old woman presents to A&E with a fall. From her records, you noticed that she has a few
attendances to A&E in the last few months resulting from recurrent falls. On examination, she looks slightly
pale and she jokes that she is clumsier nowadays. Her medical history included asthma, hypertension and a
94
Cardiology
previous myocardial infarction. She regularly takes Salbutamol inhaler, QVAR inhaler, Amlodipine, Aspirin,
Atenolol, and Bendroflumethiazide. What is the SINGLE most appropriate investigation to be carried out?
A.
24 hours ECG
B.
C.
Peak flow meter
D.
Echo
E.
Computed tomography head
Her regular medications include multiple blood pressure lowering agents (amlodipine, atenolol,
bendroflumethiazide) which are known to cause postural hypotension. Blood pressure monitoring would be
most appropriate in this scenario to assess and review her medication therapy.
y
op
C
n
io
within a minute
t
ua
Diagnosis:
al
Ev
41) A 72-year-old man is found to be unresponsive. The ward doctor is called to the patient’s bedside. He is not
breathing and has no detectable pulse. Which is the SINGLE most appropriate next step?
A.
Get a defibrillator
B.
C.
Call resuscitation team
D.
E.
95
Cardiology
This man has had a cardiac arrest. The resuscitation guidelines state that if there are no signs of life, call
the resuscitation team.
Basic life support is an important topic for PLAB part 1. Be sure to know the sequence of management's.
Resus.org.uk have very good simplified algorithm. Memorize those.
The other choices in this question are less appropriate
Get a defibrillator → The guidelines mention start CPR and send for a defibrillator as soon as possible. But
given the choice, calling the resuscitation team would come first.
Give two rescue breaths immediately → will always be the wrong answer as it was part of the old
guidelines.
Insert two wide-bore cannulas into each antecubital fossa → The man has no cardiac output and, although
inserting wide-bore cannulas into each antecubital fossa is indicated, this should not be the first thing to do.
y
Start chest compressions at a rate of 30:2 → Would be started immediately once the resuscitation team has
op
been called. C
42) A 55-year-old man was brought to the emergency department from a shopping mall after collapsing 2
hours ago. He is now fully conscious and answering questions. His ECG shows an irregular rhythm. His
blood pressure is 120/80 mmHg. What is the SINGLE most appropriate investigation to carry out?
n
io
A.
CT
t
ua
B.
MRI
C.
al
24 hours ECG
D.
Ev
Echocardiogram
E.
Exercise testing
Echocardiogram would be the best option here. It is used to identify structural cardiac abnormalities and
assess left ventricular function. It may show a clot in the atrial appendage responsible for syncope which
could be due to a transient ischaemic attack secondary to atrial fibrillation.
The most common valvular cause for a syncope is aortic stenosis which needs an echocardiogram to
diagnose it.
A holter ECG (24-hour ECG) is not needed as the ECG is already said to have an irregular rhythm. If they did
not state that the rhythm was irregular, then 24-hour ECG would be an option.
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Cardiology
CT and MRI may be performed in selected cases (eg, aortic dissection and haematoma, pulmonary
embolism, cardiac masses, pericardial and myocardial diseases, congenital anomalies of coronary arteries).
However, as he has recovered fully. It is unlikely to be any of the causes requiring a CT or MRI.
Exercise testing is for patients who have experienced episodes of syncope during or shortly after exertion.
There was no mention of exertion in this question.
43) A 69-year-old man has the following ECG. What is the SINGLE most appropriate next step in management?
y
A.
op
C
Metoprolol
B.
n
Digoxin
C.
io

D.
t
ua
Adenosine
E.
Amiodarone
al
The diagnosis here is atrial fibrillation. This man is an elderly man and thus rate control should be the first
Ev
option (beta blockers, calcium channel blockers or digoxin). Digoxin should be reserved for when patient is
having atrial fibrillation and heart failure together thus it is not the first option here.
These are the general rules for atrial fibrillation
Rate control: BB or CCB or Digoxin
Rhythm control: Amiodarone OR electrical
Rate control: BB or CCB or Digoxin ---> if symptoms are not well controlled ---> use combination therapy:
BB, CCB (diltiazem), Digoxin.
Rhythm control is preferred in paroxysmal atrial fibrillation, young patients, symptomatic, younger patients
presenting for first time.
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Cardiology
If new onset atrial fibrillation + haemodynamic unstable → Emergency Electrical Cardioversion.
44) A 66-year-old man has presented to the emergency department with a stroke. CT shows no haemorrhage.
ECG shows atrial fibrillation. He has been thrombolysed and he is awaiting discharge. He has no other
medical conditions. What is the SINGLE best prophylactic regimen for him?
A.
Warfarin
B.
Heparin
C.
Aspirin
D.
Statins
E.
Beta blockers
y
Warfarin would be the best choice in this case given that he has atrial fibrillation which could cause another
op
stroke. If atrial fibrillation was not included in this question, then the answer would be aspirin for 2 weeks
and clopidogrel long term for stroke prevention.
C
NICE updated their guidelines on the management of atrial fibrillation (AF) in 2014. They suggest using the
CHA2DS2-VASc score to determine the most appropriate anticoagulation strategy. This scoring system
n
superseded the CHADS2 score.

io
As this patient has had a stroke and his age is between 65-74 years, this gives him a CHA2DS2-VASc score of
t
ua
3. In general, we offer anticoagulation if the CHA2DS2-VASc score is 2 or more.

al
45) A 65-year-old man has chest pain. On initial assessment, he is noted to be pale. An ECG reveals no
connection between P waves and QRS complexes with a rate of 42 beats/minute. What is the SINGLE most
Ev
likely diagnosis?
A.
B.
C.
D.
E.
46) A 6-week-old baby presents with the following features of progressive cyanosis, poor feeding, tachypnoea
during the first two weeks of life. A holosystolic murmur is heard. What is the SINGLE most likely diagnosis?
98
Cardiology
A.
B.
C.
Tricuspid atresia
D.
E.
Tetralogy of Fallot
The most common cyanotic heart conditions presenting in the neonatal period are referred to as “The five
T’s”
1. Tetralogy of Fallot (TOF)

2. Transposition of the Great Arteries (TGA)
3. Truncus Arteriosus
y
4. Tricuspid Atresia
op
5. Total Anomalous Pulmonary Venous Connection (TAPVC)C
By using the above mnemonic, we are down to 2 options: Tricuspid atresia or Tetralogy of Fallot.
Tricuspid atresia → manifests early in life with severe cyanosis. Holosytolic murmurs is found along the left
n
sternal border (Most have VSD)
io
Tetralogy of Fallot → Can also happen at birth but the symptoms depends on the severity. Ejection systolic
t
ua
murmur due to pulmonary stenosis is the common murmur to be heard.
47) A 50-year-old smoker and heavy drinker presents with complaints of a racing heart. He has no chest pain.
al
The palpitations usually occur when he drinks alcohol or when he exercises. He has no significant past
medical history. A 24 hours ECG is shown to be normal. What is the SINGLE most appropriate action?
Ev
A.
Echocardiogram
B.
Reassure
C.
D.
24 hour BP monitoring
E.
Fasting blood glucose
A racing heart or palpitation is a common phenomenon in alcoholics which is not serious or harmful. So
reassure the patient.
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Cardiology
48) A 65-year-old man continues to experience chest pain 2 days after an acute myocardial infarction. He has a
temperature of 37.8°C. His ECG shows widespread ST elevation with upward concavity. What is the SINGLE
A.
Acute pericarditis
B.
Cardiac tamponade
C.
Atrial thrombus
D.
E.
Dressler syndrome
Chest pain and ECG findings of widespread ST elevation with an upwards concavity is diagnostic of acute
pericarditis. The history of a myocardial infarction supports this as one of the causes of acute pericarditis is
y
a recent myocardial infarction.
op
Fever, night sweats, and other constitutional symptoms may be present, depending on
the underlying cause.
C
Acute pericarditis
n
io
Features:
- Chest pain is described as sharp, stabbing, central chest pain, with radiation to the shoulders and
t
ua
upper arm
- Chest pain may be pleuritic and is often relieved by sitting forwards
- Chest pain may be made worse by inspiration, cough, swallowing, or movement of the trunk
al
- Other symptoms include non-productive cough and dyspnoea

- Pericardial friction rub on auscultation (Clinically, the presence of a pericardial friction rub is
Ev
pathognomonic - often a rub can be heard even when a pericardial effusion is present)
Causes:
- Viral infections (Coxsackie)
- Tuberculosis
- Uraemia (causes 'fibrinous' pericarditis)
- Trauma
- Post-myocardial infarction, Dressler's syndrome
- Connective tissue disease
Post myocardial infarction is an extremely important cause to remember for the exam.
ECG changes:
- Widespread 'saddle-shaped' ST elevation (Saddle-shaped meaning concavity directed upwards)
- PR segment depression.
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Cardiology
49) A 42-year-old man collapsed and died at home. The GP’s report states that he has type 2 diabetes and has
a BMI of 35. What is the SINGLE most likely cause of death?
A.
B.
Hyperglycaemia
C.
Heart Failure
D.
Pulmonary Embolism
E.
Renal failure
Although there are risk factors for myocardial infarction and pulmonary embolism, it is more likely a
myocardial infarction that killed this man because in diabetics, myocardial infarction can be painless as the
patient can develop autonomic neuropathy. We call this a “silent MI”. If one does not feel pain, he might
y
not call for help. As this progress, he collapses and dies.
op
50) A 76-year-old diabetic man was recently admitted after being found to be in atrial fibrillation. This was his
C
second episode of atrial fibrillation. He has no other medical problems. What is the SINGLE most
n
A.
io
Aspirin
B.
t
ua
Warfarin
C.
Clopidogrel
al
D.
Heparin
Ev
E.
Statins
Anticoagulation using warfarin is the most appropriate. He has a high risk of stroke.
NICE suggest using the CHA2DS2-VASc score to determine the most appropriate anticoagulation strategy
for atrial fibrillation. The CHA2DS2VASc score tool is used to assess a person's stroke risk. Offer
anticoagulation treatment to all people with a CHA2DS2VASc score of 2 or above, and consider offering it
to men with a CHA2DS2VASc score of 1.
Risk factor Points
C Congestive heart failure 1
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Cardiology
H Hypertension (or treated hypertension) 1
A2 Age >= 75 years 2
Age 65-74 years 1
D Diabetes 1
S2 Prior Stroke or TIA 2
V Vascular disease (including ischaemic heart disease and peripheral arterial disease) 1
S Sex (female) 1
51) A 60-year-old man presents with a history of sudden chest pain which radiates to his jaw accompanied by
shortness of breath which started 2 hours ago. An ECG was done which shows a normal sinus rhythm
y
without ST elevation. What is the SINGLE most appropriate investigation?
A.
op
C
Cardiac troponins
B.
Chest X-ray
n
C.
io
Echocardiogram
D.
t
ua
Holter ECG
E.
al
We are suspecting a myocardial infarction in this patient. Cardiac enzymes would need to be ordered.
Ev
Measurement of cardiac troponins helps to predict which patients are at risk of a cardiac event, and who
can be safely discharged early.
The risk of death from an ACS is directly related to troponin level and patients with no detectable troponins
have a good short-term prognosis. Serum levels increase within 3-12 hours from the onset of chest pain,
peak at 24-48 hours, and return to baseline over 5-14 days. Troponin levels may therefore be normal
initially and should be repeated.
Myocardial muscle creatine kinase (CK-MB) is found mainly in the heart. CK-MB levels increase within 3-12
hours of onset of chest pain, reach peak values within 24 hours and return to baseline after 48-72 hours.
Sensitivity and specificity are not as high as for troponin levels.
52) A 47-year-old man with history of a myocardial infarction complains of chest pain with shortness of breath
on exertion over the past few days. ECG was shown to be normal. Echocardiogram shows decreased
ejection fraction and decreased septal wall thickness. What is the SINGLE most likely diagnosis?
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Cardiology
A.
B.
Constrictive pericarditis
C.
Amyloidosis
D.
Subacute endocarditis
E.
Pericarditis
Although in many cases no cause is apparent, dilated cardiomyopathy is probably the result of damage to
the myocardium. In this case, it was due to the fibrous change of the myocardium from a previous
myocardial infarction. This is supported by the decreased ejection fraction and thinning of the septal walls
seen on an echocardiogram.
y
op
- A disorder of heart muscle characterized by left ventricular and/or right ventricular dilation and
impairment of systolic function
C
Presentation:
- Presents as congestive heart failure:
n
- Dyspnoea
io
- Oedema
- Raised JVP
t
ua
- Pulmonary congestion
- Cardiomegaly
al
53) An 18-year-old man complains of fatigue and dyspnoea. On examination, he has a left parasternal heave
and systolic thrill with a harsh pan-systolic murmur at left parasternal edge. What is the SINGLE most likely
Ev
diagnosis?
A.
Tetralogy of Fallot
B.
C.
D.
E.
A key mnemonic that can help you get through PLAB part 1 cardio questions is:
Pan-systolic → MR, TR, VSD
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Cardiology
Hence, when you see the words pan-systolic murmur in the question, straight away, you can cut out any
options that ARE NOT mitral regurgitation, tricuspid regurgitation and ventricular septal defect.
In this question, the phrase pan-systolic murmur already gives you the answer which is VSD.
- Basically, a hole connecting the ventricles
Causes:
- Congenital
- Acquired (post-MI)
Symptoms:
- May present with severe heart failure in infancy, or remain asymptomatic and be detected
incidentally in later life.
y
op
Signs: These depend on size and site: C
1. Small holes
- Infant or child is asymptomatic with normal feeding and weight gain
- May be detected when a murmur is heard on routine examination
n
- Give louder murmurs
io
- Classically, a harsh pan-systolic murmur heard at the left sternal edge, with a systolic thrill, and a
left parasternal heave
t
ua
Most importantly is to remember the term “pan-systolic murmur” as often that alone can give you the
answer provided mitral regurgitation and tricuspid regurgitation are not one of the options.
al
2. Large holes
Ev
- Associated with signs of pulmonary hypertension

- These babies may develop a right to left shunt with cyanosis or Eisenmenger's syndrome
The diagnosis and management → Not so important for the exam
A memory flow chart to help you easily differentiate murmurs
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Cardiology
54) A 42-year-old lady had corrective surgery for cyanotic congenital heart disease at the age of 3 after having
y
a palliative operation during infancy. On examination, a parasternal heave and a diastolic murmur at the
op
left upper sternal age is noted. What is the SINGLE most likely diagnosis?
C
A.
B.
n
io
C.
Aortic stenosis
t
ua
D.
Pulmonary stenosis
E.
al
Ev
Pulmonary regurgitation is a common complication after surgical or percutaneous relief of pulmonary

stenosis and following repair of Fallot's tetralogy. Pulmonary regurgitation is usually asymptomatic unless
severe, when it may lead to signs of right heart failure. It is possible for patients to live for many decades
following surgical repair of tetralogy of Fallot but a major problem encountered is the development of
pulmonary regurgitation which may require pulmonary valve replacement.
55) A 45-year-old man has shortness of breath and palpitations. He has a pulse of 142 beats/minute, a blood
pressure of 110/80 mmHg and a respiratory rate of 20 breaths/minute. Carotid sinus massage was
attempted but he is still tachycardic. What is the SINGLE most appropriate next management?
A.
Adenosine
B.
Amlodipine
C.
DC cardioversion
105
Cardiology
D.
Lidocaine
E.
Beta blocker
56) A 69-year-old hypertensive white british man is currently on Indapamide 2.5mg daily but his blood
pressure is still high. Which of the following is the SINGLE best choice to add in order to control his blood
pressure?
A.
Increase dose of diuretic to 5mg daily
B.
Enalapril (ACE inhibitor)
C.
Atenolol (Beta blocker)
D.
Amlodipine (Calcium channel blocker)
y
E.
op
Prazosin (Alpha blocker) C
You should be able to recognise that the patient is currently on Step 1 of the NICE hypertension treatment
pathway - Persons aged over 55 OR black person of African or Caribbean family origin of any age with
hypertension, offer antihypertensive treatment with a CCB. If a CCB is not suitable, for example because of
n
oedema or intolerance, or if there is evidence of heart failure or a high risk of heart failure, offer a thiazide-
io
like diuretic.
t
ua
He should therefore be commenced with Step 2 by adding an ACE inhibitor or an angiotensin-II receptor
blocker.
al
Ev
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Cardiology
An increase his Indapamide dose is not recommended as doses larger than 2.5mg daily showed no
appreciable antihypertensive effect but a diuretic effect may become apparent.
y
op
C
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t io
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Ev
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Cardiology
57) A 56-year-old man presents to the emergency department with chest pain. The following ECG was taken.
y
op
What is the SINGLE most likely diagnosis? C
A.
B.
n

io
C.
t
ua
D.
E.
al

Ev
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Cardiology
We can note that there is ST elevation in lead V2, V3, V4 (circled in red). This ECG shows a classical example
of an anterior myocardial infarction.
Those ECG findings are more than enough to answer the questions in the exam and it is highly unlikely that
you would need to know more than that.
For those who want to go into more details (probably not needed for the exam), one can notice the
following on this ECG:
Q waves are present in the septal leads (V1-2)
Note the subtle ST elevation in I, aVL and V5, with reciprocal ST depression in lead III
There are hyperacute (peaked) T waves in V2, V3 and V4
These features indicate an anteroseptal STEMI
ECG changes in myocardial infarction and coronary territories
y
Area of ECG changes Coronary artery
op
infarct
Most Anteroseptal V1-V4 Left anterior descending (LAD)
commonly
C
asked Inferior II, III, aVF Right coronary (RCA)
n
Lateral I, aVL +/- V5-6 Left circumflex
io
Less Anterolateral I, aVL, V4-6 Left anterior descending (LAD) or left circumflex
commonly
t
asked Posterior Tall R waves V1-2 Usually left circumflex, also right coronary
ua
al
Also note the

reciprocal ST-
Ev
segment depression
in the anterior chest
leads
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t
110
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Cardiology
n
C
op
y
Cardiology
58) A 45-year-old lady who was previously fit and well is admitted with breathlessness, palpitations and a
history of syncope. Her symptoms change with position. On examination, a loud S1 is noted at the apex.
A.
B.
C.
D.
Atrial myxoma
E.
Atrial myxomas are benign tumours.
y
Around three quarters of atrial myxomas occur in the left atria, and tend to grow on the wall (septum).
op
Sometimes small pieces of the tumor can break off and fall into the bloodstream. If this happens, they can
C
block an artery elsewhere in the body such as the brain, which could cause a stroke, or in the lungs causing
a pulmonary embolus.
n
Around 10% of myxomas seem to be inherited (passed down through families). These are known as familial
io
myxomas.
t
ua
The symptoms occur due to obstruction of the mitral valve which result in syncope and heart failure.
Features:
al
- Symptoms of haemodynamic obstruction, embolisation, or constitutional symptoms such as fever,

malaise, tachycardia and tachypnoea
Ev
- Symptoms and signs of ischaemia or infarction in the peripheries, due to embolisation of adherent
thrombus
- Atrial fibrillation
c Large myxomas may impair intracardiac blood flow, causing dyspnoea, syncope or symptoms and
signs of congestive cardiac failure
- Echo: pedunculated heterogeneous mass typically attached to the fossa ovalis region of the
interatrial septum
59) Which is the SINGLE most likely artery that has artery dominance in 85% of the general population?
A.
B.
Coronary sinus
C.
Circumflex artery
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Cardiology
D.
Posterior descending artery
E.
Coronary artery dominance
The artery that supplies the posterior descending artery (PDA) determines the coronary dominance.
If the posterior descending artery is supplied by the right coronary artery (RCA), then the coronary
circulation can be classified as "right-dominant".
If the posterior descending artery is supplied by the circumflex artery (CX), a branch of the left artery, then
the coronary circulation can be classified as "left-dominant".
If the posterior descending artery is supplied by both the right coronary artery and the circumflex artery,
then the coronary circulation can be classified as "co-dominant".
y
op
Approximately 85% of the general population are right-dominant
C
In 85% of patients (Right Dominant), the RCA gives off the posterior descending artery (PDA). In the other
15% of cases (Left Dominant), the PDA is given off by the left circumflex artery. The PDA supplies the
inferior wall, ventricular septum, and the posteromedial papillary muscle.
n
io
60) A 59 years old man returns for routine follow up 6 weeks following a myocardial infarction. He complains
of breathlessness when walking uphill. His ECG shows ST elevation in leads V1, V2, V3, V4 and V5. What is
t
ua
the SINGLE most likely explanation for the abnormal findings?
A.
al
Heart block
B.
Ev
Right ventricular strain

C.
Atrial thrombus
D.
E.
Ventricular aneurysms
- Usually complications resulting from a myocardial infarction. When the cardiac muscle partially dies
during a myocardial infarction, a layer of muscle may survive, and being severely weakened, start to
become an aneurysm.
ECG:
- Persistently raised ST segments on ECG and left ventricular failure
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Cardiology
CXR:
- Cardiomegaly with an abnormal bulge at the left heart border
Echo:
- Paradoxical movement of ventricular wall
Thrombus may form within the aneurysm increasing the risk of stroke.
61) A 52-year-old man with history of anterior myocardial infarction 3 weeks ago developed a sudden onset of
dyspnoea. He has a blood pressure of 100/60 mmHg, pulse rate of 100 beats/minute, SaO2 = 88%, and his
chest is audible for bilateral crackles. What is the SINGLE best investigation to determine the underlying
cause?
A.
Chest X-ray
B.
y
Echocardiogram
op
C.
D-dimer
D.
C
Ventilation/perfusion scan
E.
n
Troponin
io
The key word here to look out for is “investigation to determine the underlying cause”. A chest X-ray might
t
ua
show features of pulmonary oedema but will not show the underlying cause. An echocardiogram is more
likely to identify the underlying cause whether it be a post myocardial infarction complication such as
ventricular aneurysm, infarct expansion, acute mitral regurgitation from papillary muscle rupture or
al
ventricular septal rupture.

Ev
62) A 59-year-old man who is on multiple medications for ischaemic heart disease, hypertension and diabetes
finds it difficult to mobilize as he feels dizzy when trying to stand up. What is the SINGLE most appropriate
investigation for him?
A.
B.
ECG
C.
Magnetic resonance imaging
D.
Chest X-ray
E.
Computed tomography scan
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Cardiology

within a minute
Diagnosis:
63) A 57-year-old man presents to A&E with central abdominal and lower back pain associated with feeling
faint and sweaty. The pain started very suddenly and it is very severe. His heart rate is 105 bpm and blood
pressure is 88/50 mmHg. On physical examination, there is a tender pulsatile abdominal mass and his left
femoral pulse is absent. What is the SINGLE most appropriate initial investigation?
y
op
A.
Ultrasound
B.
C
Sigmoidoscopy
C.
n
Barium enema
io
D.
X-ray of the abdomen
t
ua
E.
Magnetic resonance imaging of the abdomen
al
This is a classic picture of a ruptured abdominal aneurysm.

Ev
An ultrasound scan is the only appropriate investigation given the options.
Questions would usually have either an ultrasound or CT abdomen as one of the choices for a ruptured
aortic aneurysm. Both choices are correct. It is important to note that both USS or CT scan can be
performed. Although, it may be safer and quicker to perform USS in the ED, rather than transfer the patient
for CT scan.
64) A 62-year-old woman with longstanding anxiety is seen in the outpatient department. She complains of her
heart skipping a beat quite often. This particularly occurs when she is trying to get to sleep. The
palpitations are never sustained. What is the SINGLE most likely rhythm disturbance?
A.
B.
C.
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Cardiology
D.
Atrial fibrillation
E.
Ventricular ectopic
From the given options, the most likely answer is ventricular ectopics. This is a classic scenario where the
patient would complain of having “missed beats”. They are usually otherwise asymptomatic. If ventricular
ectopics occurs in a normal heart (i.e. no cardiomyopathy or ischaemic heart disease) though symptomatic,
it is benign and are of no clinical significance.
Ventricular ectopics:
- Caused by the premature discharge of a ventricular ectopic focus which produces an early and
broad QRS complex
Aetiology:
- Ischaemic heart disease
y
- Cardiomyopathy
op
- Stress, alcohol, caffeine, medication, cocaine, or amphetamines
- Occurs naturally
C
Patients may be symptomatic with palpitations often described as "skipped or missed beats" but they may
also have symptoms of dyspnoea or dizziness. Over half the population have silent, or asymptomatic,
n
ventricular ectopics which are discovered incidentally on a routine ECG.
io
In clinical practice, it is important to identify the presence of an underlying cardiomyopathy or ischaemic

t
ua
heart disease. If neither of these are present then it is likely that these ventricular ectopics are benign.
Patients with no ischaemic heart disease or cardiomyopathy have an excellent prognosis however, if
ventricular ectopics are secondary to heart disease like myocardial infarction, it may precipitate to more
al
life-threatening arrhythmias like ventricular fibrillation.

Ev
65) A 65-year-old man presents with fatigue and dyspnoea 3 days after having a myocardial infarction. On
auscultation, he has a pansystolic murmur at the apex radiating to the axilla. What is the SINGLE most
likely diagnosis?
A.
Papillary muscle rupture
B.
Ventricular aneurysm
C.
Pericarditis
D.
E.
Rupture of a papillary muscle is a rare but well known complication of myocardial infarction. Papillary
115
Cardiology
muscle rupture may lead to worsening of mitral regurgitation of which features include having a
pansystolic apical murmur radiating to the axilla which is seen in this stem.
66) A 60-year-old man with a history of ischaemic heart disease starts having chest pain. He has a heart rate of
170 beats/minute and a blood pressure of 70/450 mmHg. An ECG reveals a broad complex tachycardia
with absence of atrial activity. He feels unwell and is now semi-conscious. What is the SINGLE most likely
diagnosis?
A.
Stokes-Adams syndrome
B.
C.
D.
E.
y
Atrial fibrillation
op
The ECG revealing a broad complex tachycardia with absence of atrial activity in a conscious person can
C
only be ventricular tachycardia. The hypotension seen here supports this. Cardiac arrhythmias are more
common in patients with Ischaemic heart disease hence the given history.
n
Occasionally, in the exam, they may include a picture of an ECG showing a broad complex tachycardia.
io
Again, pick ventricular tachycardia if the patient is still a wake as it is impossible to see a ventricular
fibrillation in an awake patient.
t
ua
al
kick”).
Ev
V. tach can present in two ways.

1. With Pulse
2. Without Pulse
1. With Pulse
116
Cardiology
2. Without Pulse → immediate electrical cardioversion is indicated
67) A 28-year-old man presents with a 2 hours’ history of rapid palpitations. He feels light headed but is
otherwise well. On examination, he has a pulse of 170 beats/minute, regular. His blood pressure is 100/68
mmHg. He had 2 similar episodes of feeling palpitations in the past 3 months. What is the SINGLE most
likely rhythm disturbance?
A.
B.
C.
D.
y
Ectopic beats
op
E.
Atrial fibrillation
C
The given history of palpitation, light-headedness with tachycardia plus a history that this has occurred
before, gives the likely diagnosis of supraventricular tachycardia
n
io
t
ua
68) A 72-year-old man is found not breathing in the CCU with the following rhythm. His pulse can not be felt.
al

Ev
A.
B.
C.
D.
Atrial fibrillation
E.
117
Cardiology
Atrial flutter
Ventricular fibrillation (VF)

Ventricular Fibrillation means “sudden death”. The blood pressure drops immediately to zero and so does
the cardiac output. Ventricular fibrillation (VF) is the most important shockable cardiac arrest rhythm. The
ventricles suddenly attempt to contract at rates of up to 500 bpm. This rapid and irregular electrical
activity renders the ventricles unable to contract in a synchronised manner, resulting in immediate loss of
cardiac output. Unless advanced life support is rapidly instituted, this rhythm is invariably fatal. Prolonged
ventricular fibrillation results in decreasing waveform amplitude, from initial coarse VF to fine VF and
ultimately moving on to asystole due to progressive depletion of myocardial energy stores.
ECG Findings for V. Fib:

- Chaotic irregular deflections of varying amplitude
- No identifiable P waves, QRS complexes, or T waves
- Rate 150 to 500 per minute
- There is no specific pattern to the discharge. There are different types of wavering baseline
patterns
y
op
69) 52-year-old man presents with increased breathlessness at rest. He is currently taking furosemide which he
finds gives him some relief. His medical history is significant for diabetes mellitus. On examination, bilateral
C
pedal oedema and bibasal crepitation’s are noted. What is the SINGLE most appropriate next step in
management?
n
A.
io
Ramipril
B.
t
ua
Bendroflumethiazide
C.
Atenolol
al
D.
Amlodipine
Ev
E.
Carvedilol
This patient is suffering from chronic heart failure. Given that this patient has diabetes mellitus, an ACE-
inhibitor like Ramipril would be more appropriate when compared to a beta blocker.
Management of chronic heart failure
The general management of chronic heart failure can be summarized below:
- ACE-inhibitor and a beta-blocker (e.g. Carvedilol) → 1st line

- Spironolactone → 2nd line
- Digoxin → Only if heart failure is in combination with atrial fibrillation
Both an angiotensin-converting enzyme (ACE) inhibitor and a beta-blocker licensed to treat heart failure but
it is good practice to only start one drug at a time.
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Cardiology
Clinical judgement is used when deciding which drug to start first. For example, the preferred initial
treatment might be:
- An ACE-inhibitor if the person has diabetes mellitus or has signs of fluid overload
- A beta-blocker, if the person has angina
70) A 79-year-old man with a past history of ischemic heart disease presents with yellow haloes, nausea and
vomiting. His ECG reveals an arrhythmia. Which of the following medication is most likely responsible for
his symptoms?
A.
Digoxin
B.
Amlodipine
C.
Aminophylline
D.
y
Propranolol
op
E.
Diltiazem
C
The words “yellow haloes” are a clincher for digoxin toxicity.
n
For PLAB, if you see any question with yellow-green colour vision with arrhythmia, it is most likely digoxin
io
toxicity.
t
ua
Digoxin is now mainly used for rate control in the management of atrial fibrillation. As it has positive
inotropic properties it is sometimes used for improving symptoms (but not mortality) in patients with heart
failure.
al
Also remember, hypokalaemia predisposes to toxicity because potassium and digoxin bind to the same site
Ev
on the sodium-potassium ATPase pump, leading to increased intracellular calcium leading to increased
cardiac contractility.
Features of digoxin toxicity

- Gastrointestinal symptoms are most common. These are nausea, vomiting, diarrhoea, and anorexia
- Neurologic and visual symptoms include blurred vision, yellow-green vision, hallucinations, and
confusion.
- Arrhythmias - Bradycardia, premature contractions, ventricular tachycardia, and any other type of
arrhythmias may be seen.
A serum digoxin level should be ordered in patients you suspect of being toxic (history, etc.).
Management of digoxin toxicity
- Digibind
- Correct arrhythmias
119
Cardiology
- Monitor potassium
71) A 50-year-old man presents with a stab wound to his left anterior chest at the level of the 4th intercostal
space. On physical examination, his neck veins are dilated, heart sounds are faint and trachea is central. He
has a systolic blood pressure of 80 mmHg and a pulse rate of 130 bpm. What is the SINGLE most likely
diagnosis?
A.
Cardiac tamponade
B.
Diaphragmatic rupture
C.
Fractured ribs
D.
E.
Traumatic rupture of aorta
y
op
72) A 40-year-old man was brought into the A&E after being hit by a vehicle. He sustained trauma to the chest.
His neck veins look distended and his heart sounds are faint. He has a blood pressure of 80/45 mmHg and
C
pulse is 120 bpm. His trachea is central. What is the SINGLE most appropriate management?
A.
n
Chest drain
io
B.
IV fluids
t
ua
C.
Pericardiocentesis
D.
al
Large-bore cannula into second intercostal space in midclavicular line

E.
Ev
Blood transfusion
73) A 55-year-old man has central chest pain that radiates to his shoulders and arm. It is relieved by sitting up
and leaning forward. Pericardial friction rub is heard. A widespread 'saddle-shaped' ST elevation is seen on
an ECG. The cardiac shadow is not enlarged on a chest X-ray. What is the SINGLE most likely diagnosis?
A.
Acute pericarditis
B.
Cardiac tamponade
C.
Pericardial Effusion
D.
E.
Pleural effusion
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Cardiology
74) A 45-year-old carpenter presents with a 2-hour history of chest pain radiating to his left arm. His ECG is
A.
Cardiac enzymes
B.
Chest X-ray
C.
Chest CT
D.
Holter ECG
E.
V/Q scan
75) A 72-year-old woman presents to the emergency department with chest pain. The following ECG was
taken. What is the SINGLE most likely diagnosis?
y
op
C
n
t io
ua
al
Ev
A.
B.
C.
D.
E.
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Cardiology
y
op
There is obvious ST elevation in leads II, III and aVF.
ECG changes in myocardial infarction and coronary territories

C
Area of ECG changes Coronary artery
infarct
n
Most Anteroseptal V1-V4 Left anterior descending (LAD)
io
commonly
asked Inferior II, III, aVF Right coronary (RCA)
t
ua
Lateral I, aVL +/- V5-6 Left circumflex

Less Anterolateral I, aVL, V4-6 Left anterior descending (LAD) or left circumflex
al
commonly
asked Posterior Tall R waves Usually left circumflex, also right coronary
V1-2
Ev
Also note the

reciprocal ST-
segment
depression in
the anterior
chest leads
76) A 38-year-old man presents to the emergency department feeling unwell and dizzy. He has a heart rate of
around 35 beats/minute. What is the SINGLE most appropriate first line treatment?
A.
Atropine
B.
122
Cardiology
Adenosine
C.
Dopamine
D.
Epinephrine
E.
Supplemental oxygen
Atropine is the first drug of choice for symptomatic bradycardia.
The dose in the bradycardia ACLS algorithm is 0.5mg intravenous push and may repeat up to a total dose of
3mg.
77) A 63-year-old man presents with sudden severe chest pain that radiates through to his back. He is sweaty
and nauseated. On examination, his BP is 176/96 in his right arm and 143/78 in his left arm. On
auscultation, you can hear an early diastolic murmur.
y
op
A.
Aortic valve perforation
B.
n
Thoracic outlet syndrome

io
C.
Aortic aneurysm
t
ua
D.
E.
al
Aortic dissection
Ev
Acute aortic dissection is defined as the rapid development of a false, blood-filled channel within the
tunica media of the aorta. It has an estimated incidence of 3 per 100,000 persons per year
Patients with aortic dissection typically present with severe central chest pain that radiates through to the
interscapular area. The pain is often described as being tearing or ripping in nature and may also radiate
onto the neck. Sweating, pallor and tachycardia are all also commonly seen at presentation. Other features
that may be present include focal neurological deficits, pulse deficits, syncope and end organ ischaemia.
An inter-arm blood pressure differential of greater than 20 mmHg is a highly sensitive predictor.
Retrograde extension can involve the aortic valve resulting in the appearance of the early diastolic murmur
of aortic regurgitation.
Risk factors include:
- Hypertension
- Atherosclerosis
123
Cardiology
- Aortic coarctation
- Sympathomimetic drug use e.g. cocaine
- Marfan syndrome
- Ehlers-Danlos syndrome
- Turner’s syndrome
- Tertiary syphilis
- Pre-existing aortic aneurysm
Aortic dissection can be classified using the Stanford classification:
• Type A – affects the ascending aorta and the arch and accounts for 60% of dissections. These are
generally managed surgically and may result in coronary artery occlusion and aortic regurgitation.
• Type B – dissection commences distal to the left subclavian artery and accounts for approximately
40% of dissections. These are generally managed medically with blood pressure control.
y
op
C
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Ev
124
DERMATOLOGY
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op
C
Questions
n
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&
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Answers
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Ev
125
1. A 35 year old woman has a butterfly rash on her face and suffers from symmetrical joint pains in the knee and
elbow, Recent laboratory results show an elevated ESR and normal CRP. What is the SINGLE most discriminative
investigations?
A. Anti-dsDNA
B. Anti-histone
C. Antinuclear antibodies
D. Anti-Jo-1
E. Anti-Scl-70
2. A 19 year old girl has developed an itchy well-demarcated bright red elevated lesions over the extensor surface of
her body. She also complains of a dry itchy scalp. Her mother suffers from a similar rash that often comes and
goes. What is the SINGLE most likely diagnosis?
A. Eczema
B. Seborrheic dermatitis
y
C. Impetigo
op
D. Lichen planus
E. Psoriasis C
3. A 29 year old man has developed a red, raised rash on his trunk after playing football. The rash is becoming
increasingly itchy over the past few hours and has now spread to his arms. His past medical history includes
asthma which was diagnosed when he was 7 years old. What is the SINGLE most appropriate management?
n
io
A. Oral chlorpheniramine
B. Oral amoxicillin
t
C. IM adrenaline
ua
D. Nebulized salbutamol
E. No treatment necessary
al
4. A 19 year old boy complains of severe itching at the site of an insect bite which he noticed earlier today while
camping. What is the SINGLE most appropriate management?
Ev
A. Oral antihistamine
B. Doxycycline
C. IM adrenaline
D. Oral ciprofloxacin
E. Reassurance
5. A 34 year old woman has fatigue, oral ulcers and a facial rash that is worse in the summer. She complains of
having joint pains and stiffness especially in the morning. Urea and creatinine are slightly elevated with urinalysis
demonstrating red cell casts. What is the SINGLE most appropriate investigations?
A. Ultrasound of the Kidneys, Ureters & Bladder

B. Joint aspiration
C. Autoantibodies
D. Intravenous urogram
E. Schirmer test
126
6. A 33 year old woman who recently came from India has a nodular patch on both her shins which is reddish
brown. The nodules are slightly raised above the surrounding skin. She also has a fever and feels unwell. What is
the SINGLE most probable diagnosis?
A. Lupus vulgaris
B. Erythema nodosum
C. Pyoderma gangrenosum
D. Erythema marginatum
E. Solar keratosis
7. An 8 year old child presented to her GP with eczema. She was given emollient and topical steroids by the GP.
What SINGLE most appropriate advice should be given to her regarding application of the ointments and cream?
A. Use steroids only when itchy

B. Apply emollient first, then steroids 30 minutes later
C. Apply steroids first, then emollient 30 minutes late
D. Mix emollient & steroid before use
E. Apply emollient at night together with steroids
y
op
8. A 22 year old woman complains of recent onset of severe itching and weals which followed a viral infection. On
inspection, numerous weals of all sizes are noticed on his skin. The weals tend to come and go within hours. What
is the SINGLE most likely diagnosis?
C
A. Primary sclerosing cholangitis
B. Urticaria
n
C. Psychogenic itching
io
D. Atopic eczema
E. Primary biliary cirrhosis
t
ua
9. A 24 year old woman complains of recent onset of severe itching and weals which followed a viral infection. She
is unable to sleep at night due to the itch. On inspection, numerous weals of all sizes are noticed on his skin. The
weals tend to come and go within hours. Eyelids, lips and tongue appear normal with no swelling. What is the
al

Ev
A. Antihistamines
B. Adrenaline
C. Ursodeoxycholic acid
D. Ganciclovir
E. Benzodiazepine
10. A 29 year old woman has developed an itchy scaly rash particularly over her wrist with fine white streaks
overlying the lesion. Her nails have ridges and her buccal mucosa is lined with a lacy white pattern. What is the
A. Psoriasis
B. Scabies
C. Lichen planus
D. Dermatitis herpetiformis
E. Candida infection
127
11. A 44 year old man complains of a solitary, shiny, red nodule which has been growing on his nose for several
months. It is firm with a central depression. It is 0.6 cm in size. What is the SINGLE most likely diagnosis?
A. Basal cell carcinoma

B. Squamous cell carcinoma
C. Molluscum contagiosum
D. Keratoacanthoma
E. Kaposi’s sarcoma
12. A 7 year old girl has been treated with penicillin for a sore throat, fever and cough. A few hours later she develops
a skin rash and complains of pruritus. What is the SINGLE most probable diagnosis?
A. Erythema nodosum
B. Erythema multiforme
C. Steven Johnson Syndrome
E. Erythema gangrenosum
y
13. A 55 year old woman has fatigue and arthralgia. She has been feeling increasingly tired over the last few months
op
with aches and pains especially in the morning. On examination, a ring-shaped, raised scaly lesions are noticed on
sun-exposed areas. Her past medical history includes chronic heart failure which is treated with isosorbide
dinitrate and hydralazine. What is the SINGLE most likely positive antibody?
C
A. Anti-dsDNA
B. Anti-histone
n
C. Anti-Smith
io
D. Anti-Jo-1
E. Anti-La
t
ua
14. A 72 year old woman admitted for community acquired pneumonia was given Amoxicillin. 90 minutes after
treatment, she developed a generalised rash with a necrotic base sparing the oral mucosa and genital area. What
al
A. Erythema multiforme
Ev
B. Erythema nodosum
C. Erythema migrans
E. Urticaria
15. A 58 year old man complains of nose disfigurement. He has a history of facial erythema particularly of the cheeks
and nose. Red papules and pustules have been erupting at intervals over the last 10 years. He notices that his
face becomes flushed commonly after consumption of alcohol. On examination, he is noted to have rhinophyma.
A. Eczema
B. Acne rosacea
C. Pemphigus vulgaris
D. Dermatomyositis
E. Tinea versicolor
16. A 32 year old woman has malaise, fatigue, weight loss and fever. On examination, a
128
Malar rash with sparing of nasolabial fold can be seen. She also complains of joint stiffness and pain. What is the
SINGLE most appropriate investigation?
A. Anti-dsDNA
B. Anti-histone
C. Anti-centromere
D. Anti-Jo-1
E. Anti-Scl-70
17. A 19 year old man complains of shortness of breath, wheeze, and cough. He also has dry scaly skin with rashes
that are itchy. His brother suffers from similar symptoms. What is the single SINGLE most likely diagnosis?
A. Scabies
B. Eczema
C. Rheumatism
D. Dermatitis
E. Psoriasis
y
18. A 25 year old woman presents with pruritic purple papules on the flexor surface of her wrist. A white lacy pattern
op
is identified on her buccal mucosa. What is the SINGLE most likely diagnosis?
A. Leukoplakia
C
B. Candida infection
C. Lichen simplex
D. Lichen sclerosus
n
E. Lichen planus
io
19. A 14 year old girl has developed an itchy, scaly patch on her scalp. She had a similar patch that cleared
t
spontaneously 2 years ago. Her aunt has a similar undiagnosed rash on the extensor aspects of her elbows and
ua
knees. What is the SINGLE most likely diagnosis?
A. Eczema
al
B. Fungal infection
C. Impetigo
Ev
D. Lichen planus
E. Psoriasis
20. A 38 year old man presents with an acute infection of the skin on his the leg. A diagnosis of cellulitis has been
made. He has no known allergies. What is the SINGLE best choice of antibiotic to be prescribed?
A. Flucloxacillin
B. Metronidazole
C. Vancomycin
D. Ceftriaxone
E. Clindamycin
21. A 35 year old woman has tiredness and joint pain. She has been undergoing treatment for tuberculosis. On
examination, erythematous macules and papules are seen on face, upper chest, and arms in photodistribution.
What is the SINGLE most likely positive antibody?
A. Anti-dsDNA
129
B. Anti-histone
C. Anti-Smith
D. Anti-Jo-1
E. Anti-La
22. A 4 year old child is brought to your GP practice by her mother. She has painful crusted lesions on her face and
neck, mostly localized around her mouth. Her face feels hot to the touch. She is otherwise well. What is the
A. Contact dermatitis
B. Impetigo
C. Measles
D. Chicken pox
E. Eczema
23. A 22 year old man presents to the Accident and Emergency department with pain on his left leg. On examination,
the area is tender, slightly swollen and inflamed. He has a temperature of 38.6°C. His blood results show:
y
Haemoglobin 138 g/L
op
White cell count 23 x 109/L
CRP 58 C
The patient has no known allergies and takes no other regular medications. What is the SINGLE most appropriate
first line antibiotic to be prescribed?
n
A. Flucloxacillin
io
B. Metronidazole
C. Vancomycin
t
D. Gentamicin
ua
E. Terbinafine
24. A 67 year old builder has a persistent nodular lesion on upper part of his right pinna. On examination, there is a
al
central depression and raised areas with telangiectasia around the lesion. It is 0.5 cm in size. What is the SINGLE
most likely diagnosis
Ev

C. Keratoacanthoma
D. Actinic keratosis
E. Bowen's disease
25. A 12 year old boy presents with pruritus especially around the wrists and palms of his hands. On examination, his
skin is dry and red. His mother is asthmatic and older brother has hay fever. What is the SINGLE most likely
diagnosis?
A. Dermatitis herpetiformis
B. Scabies
C. Eczema
D. Hand foot disease
E. Systemic lupus erythematosus
130
26. A 34 year old cab driver presents with an urticarial rash that is very pruritic. Due to his job, he has requested for
any medication to help with the itch which will not make him drowsy. What is the SINGLE most appropriate
medication to prescribe?
B. Oral prednisolone
C. Oral cetirizine
D. Emollients
E. Hydrocortisone ointment
y
op
C
n
t io
ua
al
Ev
131
Dermatology Answers
1. A 35 year old woman has a butterfly rash on her face and suffers from symmetrical joint
pains in the knee and elbow, Recent laboratory results show an elevated ESR and
normal CRP. What is the SINGLE most discriminative investigations?
A. Anti-dsDNA
B. Anti-histone
C. Antinuclear antibodies
D. Anti-Jo-1
E. Anti-Scl-70
The signs and symptoms here point towards systemic lupus erythematosus (SLE). The 3
best initial test to order are anti-dsDNA titre, complement (C3 and C4) and ESR.
ESR may be raised but CRP may be normal unless there is intercurrent infection or
serositis.
y
Systemic lupus erythematosus (SLE)
op
Important must know features for the PLAB exam
- Remitting and relapsing illness
C
- Mouth ulcers → large, multiple and painful
- Lymphadenopathy
- Malar (butterfly) rash: spares nasolabial folds
n
- Discoid rash: scaly, erythematous, well demarcated rash in sun-exposed areas
io
- Photosensitivity
- Arthralgia
t
- Raynaud's phenomenon occurs in about one fifth of patients but is often mild
ua
- Cardiovascular: pericarditis
- Respiratory: pleurisy, fibrosing alveolitis
- Renal: Glomerulonephritis (nephritis is often asymptomatic and is detected by
al
proteinuria, haematuria, hypertension or a raised serum urea or creatinine)

- Neuropsychiatric: anxiety and depression are common
Ev
Investigation
FBC and ESR:
- Mild normochromic normocytic anaemia is common
- ESR is raised
Autoantibodies:
- Antinuclear antibody (ANA)
o Screening test with a sensitivity of 95% but not diagnostic in the
absence of clinical features. It is a nonspecific antibody that is also
present in many patients with systemic autoimmune conditions
- Anti-dsDNA
o Highly specific (> 99%), but less sensitive (70%)
- Anti-Smith
o Most specific (> 99%), but even less sensitive (30%-40%)
- Anti-histone: drug-induced lupus ANA antibodies are often this type
- 20% are rheumatoid factor positive
132
Complement levels (C3, C4) are low during active disease (formation of complexes leads
to consumption of complement)
2. A 19 year old girl has developed an itchy well-demarcated bright red elevated lesions
over the extensor surface of her body. She also complains of a dry itchy scalp. Her
mother suffers from a similar rash that often comes and goes. What is the SINGLE most
likely diagnosis?
A. Eczema
B. Seborrheic dermatitis
C. Impetigo
D. Lichen planus
E. Psoriasis
Psoriasis
The level of PLAB is rather superficial and it would be unlikely that they would ask you
about types of psoriasis. However, you do need to know how it presents.
y
op
Presentation:
- Itchy, well-demarcated circular-to-oval bright red/pink elevated lesions
(plaques) with overlying white or silvery scale, distributed symmetrically over
C
extensor body surfaces and the scalp
- Nail changes: pitting, onycholysis
- Relapses
n
- May have a family history
io
3. A 29 year old man has developed a red, raised rash on his trunk after playing football.
t
The rash is becoming increasingly itchy over the past few hours and has now spread to
ua
his arms. His past medical history includes asthma which was diagnosed when he was 7
years old. What is the SINGLE most appropriate management?
al
B. Oral amoxicillin
Ev
C. IM adrenaline
This man is suffering from urticaria. Oral antihistamines would be indicated.
Since this is an allergic reaction, the only two reasonable options are A and C in this
question. However, in the context of allergic reactions, IM adrenaline should only be
used in anaphylactic shock whereby the patient would have breathing difficulties.
The followings are the indications of adrenaline in anaphylaxis:

1. Hoarseness of voice
2. Wheeze
3. Shortness of breath
4. Shock
5. Stridor
6. Swelling of the tongue and cheek
133
7. Facial swelling
If you see an urticaria like allergic reaction, with none of the following indications
stated above for adrenaline, then pick the oral antihistamine as the answer.
4. A 19 year old boy complains of severe itching at the site of an insect bite which he
noticed earlier today while camping. What is the SINGLE most appropriate
management?
A. Oral antihistamine
B. Doxycycline
C. IM adrenaline
D. Oral ciprofloxacin
E. Reassurance
The question here is quite straightforward. Itching without signs or symptoms of

anaphylaxis. Manage with oral antihistamines.
y
5. A 34 year old woman has fatigue, oral ulcers and a facial rash that is worse in the
op
summer. She complains of having joint pains and stiffness especially in the morning.
Urea and creatinine are slightly elevated with urinalysis demonstrating red cell casts.
What is the SINGLE most appropriate investigations?
C
A. Ultrasound of the Kidneys, Ureters & Bladder
B. Joint aspiration
n
C. Autoantibodies
io
D. Intravenous urogram
E. Schirmer test
t
ua
best initial test to order are anti-dsDNA titre, complement (C3 and C4) and ESR. Given
in the options are autoantibodies which include anti-dsDNA titres.
al

Ev

- Lymphadenopathy
- Photosensitivity
- Arthralgia
Investigation
134
FBC and ESR:
- ESR is raised
Autoantibodies:
- Anti-dsDNA
- Anti-Smith
y
op
6. A 33 year old woman who recently came from India has a nodular patch on both her
shins which is reddish brown. The nodules are slightly raised above the surrounding
skin. She also has a fever and feels unwell. What is the SINGLE most probable
C
diagnosis?
A. Lupus vulgaris
n
B. Erythema nodosum
io
t
E. Solar keratosis
ua
Erythema nodosum is the most likely diagnosis here. The reason they give a history of
coming from India with fever and feeling of being unwell is to point you towards the
al
direction of tuberculosis. Erythema nodosum can occur with the primary infection of
TB.
Ev
Erythema Multiforme Erythema Nodosum

- Target lesions - Tender, erythematous, nodular
- If symptoms are severe and lesions
involve blistering → Think Steven - Usually over shins
Johnson Syndrome - May also occur elsewhere e.g.
- Causes: forearms, thighs
o Mycoplasma - Causes:
o Penicillin o IBD
o Sarcoidosis
o Drugs e.g. Penicillins
Erythema Marginatum Erythema Chronicum Migrans
- Pink rings on torso or inner - Target lesions
surface of limbs - Causes:
- Barely raised and are non-itchy o Only Lyme disease
- Causes:
135
o Rheumatic fever
(considered in major
Jone’s criteria)
Erythema Infectiosum (fifth disease) Erythema Ab Igne
- Caused by parvovirus B19 - Reaction caused by chronic
- Childhood infection causing a exposure to infrared radiation in
slapped cheek appearance and a the form of heat
rash - Usually an elderly who sits too
- Appears a few days later with close to an open fire or electric
firm red cheeks space heater
- Lasts 2 to 4 days, and is followed
by a pink rash on the limbs and
occasionally the trunk
7. An 8 year old child presented to her GP with eczema. She was given emollient and
topical steroids by the GP. What SINGLE most appropriate advice should be given to her
regarding application of the ointments and cream?
A. Use steroids only when itchy
y
B. Apply emollient first, then steroids 30 minutes later
op
C. Apply steroids first, then emollient 30 minutes late
D. Mix emollient & steroid before use
E. Apply emollient at night together with steroids
C
If a topical steroid is also being used with an emollient, the emollient should be applied
n
first followed by waiting at least 30 minutes before applying the topical steroid. Creams
soak into the skin faster than ointments.
io
8. A 22 year old woman complains of recent onset of severe itching and weals which
t
followed a viral infection. On inspection, numerous weals of all sizes are noticed on his
ua
skin. The weals tend to come and go within hours. What is the SINGLE most likely
diagnosis?
al

B. Urticaria
Ev
C. Psychogenic itching
D. Atopic eczema
E. Primary biliary cirrhosis
Urticaria
The typical lesion is a central itchy white papule or plaque due to swelling of the surface
of the skin (weals). This is surrounded by an erythematous flare. The lesions are
variable in size and shape and may be associated with swelling of the soft tissues of the
eyelids, lips and tongue
Individual lesions are typically transient. They come and go within a few minutes to
hours.
Management
- Where possible, identify and treat the cause. Nonspecific aggravating factors
should be minimised, such as overheating, stress, alcohol, and caffeine
136
- Antihistamines: Non-sedating H1 antihistamines are the mainstay of treatment.
In pregnancy chlorphenamine is often the first choice of antihistamine
9. A 24 year old woman complains of recent onset of severe itching and weals which
followed a viral infection. She is unable to sleep at night due to the itch. On inspection,
numerous weals of all sizes are noticed on his skin. The weals tend to come and go
within hours. Eyelids, lips and tongue appear normal with no swelling. What is the
A. Antihistamines
B. Adrenaline
C. Ursodeoxycholic acid
D. Ganciclovir
E. Benzodiazepine
Urticaria
The typical lesion is a central itchy white papule or plaque due to swelling of the surface
y
of the skin (weals). This is surrounded by an erythematous flare. The lesions are
op
variable in size and shape and may be associated with swelling of the soft tissues of the
eyelids, lips and tongue C
Individual lesions are typically transient. They come and go within a few minutes to
hours.
n
Management
io
- Where possible, identify and treat the cause. Nonspecific aggravating factors
should be minimised, such as overheating, stress, alcohol, and caffeine
t
- Antihistamines: Non-sedating H1 antihistamines are the mainstay of treatment.

ua
In pregnancy chlorphenamine is often the first choice of antihistamine
10. A 29 year old woman has developed an itchy scaly rash particularly over her wrist with
al
fine white streaks overlying the lesion. Her nails have ridges and her buccal mucosa is
lined with a lacy white pattern. What is the SINGLE most likely diagnosis?
Ev
A. Psoriasis
B. Scabies
C. Lichen planus
D. Dermatitis herpetiformis
E. Candida infection
Lichen planus
Lichen planus is a skin disorder of unknown aetiology, most probably being immune
mediated.
Features
- Purple, pruritic, papular, polygonal rash on flexor surfaces
- Lacy white pattern on buccal mucosa
Mnemonic: 4P
Purple
137
Pruritic
Papular
Polygonal rash
11. A 44 year old man complains of a solitary, shiny, red nodule which has been growing on
his nose for several months. It is firm with a central depression. It is 0.6 cm in size.

D. Keratoacanthoma
E. Kaposi’s sarcoma
The clues for basal cell carcinoma in the exam are descriptions of a pearly white
umbilicated ulcer with central depression anywhere in the face with rolled edges or
inverted edge. These are hints pointing towards the diagnosis of basal cell carcinoma.
Ulcers presenting above the neck in the PLAB exam are almost inevitably basal cell
y
carcinoma.
Basal cell carcinoma
op
Basal cell carcinomas (BCCs) are slow-growing, locally invasive malignant epidermal skin
C
tumours
Risk factors:
n
- Genetic predisposition
io
- Exposure to ultraviolet (UV) radiation

t
Presentation:
ua
- The sun-exposed areas of the head and neck are the most commonly involved
sites
- Early lesions are often small, translucent or pearly and have raised areas with
al
telangiectasia
- Indurated edge and ulcerated centre
Ev
12. A 7 year old girl has been treated with penicillin for a sore throat, fever and cough. A
few hours later she develops a skin rash and complains of pruritus. What is the SINGLE
most probable diagnosis?
A. Erythema nodosum
B. Erythema multiforme
C. Steven Johnson Syndrome
E. Erythema gangrenosum
138
Erythema Multiforme Erythema Nodosum
- Target lesions - Tender, erythematous, nodular
o Penicillin o IBD
o Sarcoidosis
- Causes:
o Rheumatic fever
Jone’s criteria)
y
op
C
n
io

t
13. A 55 year old woman has fatigue and arthralgia. She has been feeling increasingly tired
ua
over the last few months with aches and pains especially in the morning. On
examination, a ring-shaped, raised scaly lesions are noticed on sun-exposed areas. Her
past medical history includes chronic heart failure which is treated with isosorbide
al
dinitrate and hydralazine. What is the SINGLE most likely positive antibody?
Ev
A. Anti-dsDNA
B. Anti-histone
C. Anti-Smith
D. Anti-Jo-1
E. Anti-La
Hydralazine can cause drug-induced lupus in which anti-histone antibodies are found in
95% of cases.
Drug-induced lupus
In drug-induced lupus not all the typical features of systemic lupus erythematosus are
seen, with renal and nervous system involvement being unusual. It usually resolves on
stopping the drug.
Features
- Arthralgia
- Myalgia, fatigue
139
- Skin (e.g. malar rash) and pulmonary involvement (e.g. pleurisy) are common
- Anti-histone antibodies are found in 95% of cases
While these symptoms are similar to those of systemic lupus erythematosus, they are
generally not as severe unless they are ignored which leads to more harsh symptoms.
Symptoms of drug-induced lupus erythematosus generally disappear days to weeks

after medication use is discontinued.
14. A 72 year old woman admitted for community acquired pneumonia was given
Amoxicillin. 90 minutes after treatment, she developed a generalised rash with a
necrotic base sparing the oral mucosa and genital area. What is the SINGLE most likely
diagnosis?
A. Erythema multiforme
B. Erythema nodosum
C. Erythema migrans
y
E. Urticaria
Erythema Multiforme
- Target lesions
op
Erythema Nodosum
- Tender, erythematous, nodular
C
n
io
o Penicillin o IBD
t
o Sarcoidosis
ua

al

Ev
- Causes:
o Rheumatic fever
Jone’s criteria)
15. A 58 year old man complains of nose disfigurement. He has a history of facial erythema
particularly of the cheeks and nose. Red papules and pustules have been erupting at
intervals over the last 10 years. He notices that his face becomes flushed commonly
140
after consumption of alcohol. On examination, he is noted to have rhinophyma. What is
the SINGLE most likely diagnosis?
A. Eczema
B. Acne rosacea
C. Pemphigus vulgaris
D. Dermatomyositis
E. Tinea versicolor
Acne rosacea
Rosacea is a common rash, usually occurring on the face, which predominantly affects
middle-aged (age range 40 to 60 years old) and fair skinned people.
Clinical features:
- Red papules and pustules on the nose, forehead, cheeks and chin
- Frequent blushing or flushing
- Red face due to persistent redness and/or prominent blood vessels -
telangiectasia
y
- Aggravation by sun exposure and hot and spicy food
op
- Fibrous thickening causing rhinophyma → Rhinophyma is an enlarged nose
associated with rosacea which occurs almost exclusively in men
C
For a diagnosis to be confirmed the erythema should have been present for at least
three months
n
Note: Flushing after alcohol or spicy food is a hint usually put in exams
io
16. A 32 year old woman has malaise, fatigue, weight loss and fever. On examination, a
t
Malar rash with sparing of nasolabial fold can be seen. She also complains of joint
ua
stiffness and pain. What is the SINGLE most appropriate investigation?
A. Anti-dsDNA
al
B. Anti-histone
C. Anti-centromere
Ev
D. Anti-Jo-1
E. Anti-Scl-70
best initial test to order are anti-dsDNA titre, complement (C3 and C4) and ESR.

- Lymphadenopathy
- Photosensitivity
- Arthralgia
141
Investigation
FBC and ESR:
- ESR is raised
Autoantibodies:
- Anti-dsDNA
y
- Anti-Smith
op
C
n
io
17. A 19 year old man complains of shortness of breath, wheeze, and cough. He also has
dry scaly skin with rashes that are itchy. His brother suffers from similar symptoms.
t
What is the single SINGLE most likely diagnosis?

ua
A. Scabies
B. Eczema
al
C. Rheumatism
D. Dermatitis
Ev
E. Psoriasis
The shortness of breath, wheeze and cough is probably due to asthma. Eczema fits the
symptoms perfectly as atopic eczema has a family history and also is associated with
asthma.
18. A 25 year old woman presents with pruritic purple papules on the flexor surface of her
wrist. A white lacy pattern is identified on her buccal mucosa. What is the SINGLE most
likely diagnosis?
A. Leukoplakia
C. Lichen simplex
D. Lichen sclerosus
E. Lichen planus
Lichen planus
142
Lichen planus is a skin disorder of unknown aetiology, most probably being immune
mediated.
Features
- Purple, pruritic, papular, polygonal rash on flexor surfaces
- Lacy white pattern on buccal mucosa
Mnemonic: 4P
Purple
Pruritic
Papular
Polygonal rash
19. A 14 year old girl has developed an itchy, scaly patch on her scalp. She had a similar
patch that cleared spontaneously 2 years ago. Her aunt has a similar undiagnosed rash
on the extensor aspects of her elbows and knees. What is the SINGLE most likely
diagnosis?
y
A. Eczema
op
B. Fungal infection
C. Impetigo
D. Lichen planus
C
E. Psoriasis
The fact that she has an itchy, scaly patch on scalp are classic presentation of scalp
n
psoriasis. Her aunt’s presentations with a similar rash on extensor aspects of her elbow
io
and knees are suggestive of psoriasis.

t
Psoriasis
ua
The level of PLAB is rather superficial and it would be unlikely that they would ask you
about types of psoriasis. However, you do need to know how it presents.
al
Presentation:
Ev
- Itchy, well-demarcated circular-to-oval bright red/pink elevated lesions

(plaques) with overlying white or silvery scale, distributed symmetrically over
extensor body surfaces and the scalp
- Nail changes: pitting, onycholysis
- Relapses
- May have a family history
20. A 38 year old man presents with an acute infection of the skin on his the leg. A
diagnosis of cellulitis has been made. He has no known allergies. What is the SINGLE
best choice of antibiotic to be prescribed?
A. Flucloxacillin
B. Metronidazole
C. Vancomycin
D. Ceftriaxone
E. Clindamycin
143
Cellulitis is an infection of the dermis and subcutaneous tissue.The most common
causative organisms are Streptococcus or Staphylococcus spp. but they can be caused
by a wide range of both aerobic and anaerobic bacteria.
Flucloxacillin in adults is usually given as first-line in uncomplicated infection. In

sufficient doses, this covers both beta-haemolytic streptococci and penicillinase-
resistant staphylococci.
Erythromycin or Clindamycin can be used if the patient is penicillin-allergic.
21. A 35 year old woman has tiredness and joint pain. She has been undergoing treatment
for tuberculosis. On examination, erythematous macules and papules are seen on face,
upper chest, and arms in photodistribution. What is the SINGLE most likely positive
antibody?
A. Anti-dsDNA
B. Anti-histone
C. Anti-Smith
y
D. Anti-Jo-1
op
E. Anti-La
Tuberculosis treatments such as isoniazid can cause drug-induced lupus in which anti-
C
histone antibodies are found in 95% of cases.
Drug-induced lupus
n
In drug-induced lupus not all the typical features of systemic lupus erythematosus are
io
seen, with renal and nervous system involvement being unusual. It usually resolves on
stopping the drug.
t
ua
Features
- Arthralgia
- Myalgia, fatigue
al
- Skin (e.g. malar rash) and pulmonary involvement (e.g. pleurisy) are common
- Anti-histone antibodies are found in 95% of cases
Ev
While these symptoms are similar to those of systemic lupus erythematosus, they are
generally not as severe unless they are ignored which leads to more harsh symptoms.
Symptoms of drug-induced lupus erythematosus generally disappear days to weeks

after medication use is discontinued.
22. A 4 year old child is brought to your GP practice by her mother. She has painful crusted
lesions on her face and neck, mostly localized around her mouth. Her face feels hot to
the touch. She is otherwise well. What is the SINGLE most likely diagnosis?
A. Contact dermatitis
B. Impetigo
C. Measles
D. Chicken pox
E. Eczema
Contact Dermatitis: usually presents with itching and redness of a single affected area.
144
Chicken pox: presents with systemic symptoms such as pyrexia, malaise. Vesicles
present on the face, neck and trunk
Measles: Hard K sounds → Koplik spots, Cough, Conjunctivitis, Coryza
Impetigo:
Impetigo is a common condition. It most often affects children although it can occur at
any age. Risk factors include poor hygiene and skin conditions that lead to a break in
the protective layers
Types and presentation:
- Non-bullous impetigo
o Non-bullous lesions usually start as tiny pustules or vesicles that evolve
rapidly into honey-coloured crusted plaques that tend to be under 2 cm
in diameter. It is usually on the face (particularly around the mouth and
nose)
- Bullous impetigo
o Bullous lesions have a thin roof and tend to rupture spontaneously.
y
They are usually on the face, trunk, extremities, buttocks, or perineal
op
regions. They are more likely to occur on top of other disease like
atopic eczema.
- Ecthyma
C
o This begins as a non-bullous impetigo but ulcerates and becomes
necrotic. It is deeper and may occur with lymphadenitis.
n
Treatment:
io
The National Institute for Health and Care Excellence (NICE) Clinical Knowledge
Summary on impetigo advises that fusidic acid is used first-line in localised infections,
t
three times a day for seven days. Mupirocin should be reserved for cases where MRSA
ua
is the causative organism, to avoid resistance.
Flucloxacillin is recommended as first-line treatment when oral antibiotics are required.

al
Clarithromycin or erythromycin are recommended as second-line for those who are

allergic to penicillin, with clarithromycin being preferred, as side-effects are less
Ev
common.
Treatment summary:
1. Topical fusidic acid
2. Topical Mupirocin if MRSA is involved
3. Systemic antibiotics namely flucloxacillin (or clarithromycin) in resistance to
topical treatmen
23. A 22 year old man presents to the Accident and Emergency department with pain on
his left leg. On examination, the area is tender, slightly swollen and inflamed. He has a
temperature of 38.6°C. His blood results show:
Haemoglobin 138 g/L

CRP 58
145
The patient has no known allergies and takes no other regular medications. What is the
SINGLE most appropriate first line antibiotic to be prescribed?
A. Flucloxacillin
B. Metronidazole
C. Vancomycin
D. Gentamicin
E. Terbinafine
Cellulitis is usually caused by gram positive bacteria such as staphylococci or

streptococci which are commonly present on the skin. Flucloxacillin is a narrow-
spectrum beta lactam antibiotic which covers susceptible Gram positive bacteria and
should therefore be given.
24. A 67 year old builder has a persistent nodular lesion on upper part of his right pinna. On
examination, there is a central depression and raised areas with telangiectasia around
the lesion. It is 0.5 cm in size. What is the SINGLE most likely diagnosis
y
op
C. Keratoacanthoma
D. Actinic keratosis
C
E. Bowen's disease
The clues for basal cell carcinoma in the exam are descriptions of a pearly white
n
umbilicated ulcer with central depression anywhere in the face with rolled edges or
io
inverted edge. These are hints pointing towards the diagnosis of basal cell carcinoma.
Ulcers presenting above the neck in the PLAB exam are almost inevitably basal cell
t
carcinoma.
ua
Basal cell carcinoma

Basal cell carcinomas (BCCs) are slow-growing, locally invasive malignant epidermal skin
al
tumours
Ev
Risk factors:
- Genetic predisposition
- Exposure to ultraviolet (UV) radiation
Presentation:
- The sun-exposed areas of the head and neck are the most commonly involved
sites
- Early lesions are often small, translucent or pearly and have raised areas with
telangiectasia
- Indurated edge and ulcerated centre
25. A 12 year old boy presents with pruritus especially around the wrists and palms of his
hands. On examination, his skin is dry and red. His mother is asthmatic and older
brother has hay fever. What is the SINGLE most likely diagnosis?
A. Dermatitis herpetiformis
B. Scabies
146
C. Eczema
D. Hand foot disease
The findings are consistent with eczema. Having atopic disease in a first-degree relative
favours the diagnosis of eczema.
26. A 34 year old cab driver presents with an urticarial rash that is very pruritic. Due to his
job, he has requested for any medication to help with the itch which will not make him
drowsy. What is the SINGLE most appropriate medication to prescribe?
C. Oral cetirizine
D. Emollients
E. Hydrocortisone ointment
Cetirizine is a second generation antihistamine. It’s use will help reduce the symptoms
y
of the pruritus. Second generation antihistamines like cetirizine are less able to cross
op
the blood–brain barrier and therefore have diminished effects on the central nervous
system and thus less likely to cause drowsiness when compared to first-generation
antihistamines like chlorpheniramine.
C
Corticosteroids have very little use in urticarial rashes. There may be times when
steroids are used but it usually involves severe cases and the suspicion of rarer forms of
n
urticaria such as urticarial vasculitis.
t io
ua
al
Ev
147
EM
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Questions
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Answers
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1. A 17-year-old girl has taken an overdose of 30 paracetamol tablets 3 hours ago. She is extremely anxious
but otherwise asymptomatic. She has no past medical history. She weighs 50kg. BP 120/70 mmHg, heart
rate is 100 bpm, SaO2 98% on air. Which is the SINGLE most appropriate next step?
A.
Activated charcoal
B.
Gastric lavage
C.
N-acetylcysteine infusion
D.
Paracetamol plasma level 4 hours after overdose
E.
Urgent liver function tests + clotting screen
2. A 24-year-old man presents with acute respiratory distress after being stabbed in the back. The trachea
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is not deviated, but he has engorged neck veins and no breath sounds on his right chest. He has a blood
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pressure of 80/50 mmHg, a pulse of 135 beats/minute, and a respiratory rate of 35 breaths/minute.
C
A.
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B.
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Cardiac tamponade
C.
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Simple pneumothorax
D.
Haemothorax
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E.
Pleural effusion
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3. A 33-year-old man was admitted to the emergency department after a head injury. On arrival, he has a
Glasgow Coma Scale score of 15. A few hours later, his Glasgow Coma Scale score drops to 12. What is
the SINGLE most appropriate immediate action?
A.
Computed tomography head scan
B.
X-ray skull
C.
Intravenous mannitol
D.
Emergency burr hole
E.
Shift to operating room
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4. A 32-year-old man presents to the emergency department after a motorcycle crash. The patient has
bruises around the left orbital area. GCS is 13. On examination, an alcoholic breath is noticed. Shortly
afterwards, his GCS drops to 8. What is the SINGLE most important initial investigation?
A.
MRI head
B.
CT head
C.
Chest X-ray
D.
CT angio brain
E.
Head X-ray
5. A 33-year-old lady who is an opiate drug addict wants to quit her drug abuse problem. She is supported
by her friends and family. What is the SINGLE most appropriate treatment to combat withdrawal
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symptoms?
A.
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Benzodiazepines
C
B.
Chlordiazepoxide
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C.
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Naloxone
D.
t
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Methadone
E.
Disulfiram
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6. A 9-year-old child was admitted following a road traffic accident. On admission, his initial GCS was 15.
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His GCS dropped to 13 during the night. What is the SINGLE most appropriate management?
A.
Refer to neuro-surgeon
B.
IV fluids
C.
Intubation
D.
CT head
E.
Skull X-ray
7. A 25-year-old man has been stabbed in the right-hand side of his abdomen with a small knife. He
presents with severe pain in his right upper quadrant with guarding. IV fluids are being administered. He
is very anxious and agitated. His temperature is 36.5°C, heart rate 120 bpm, BP 85/55 mmHg, SaO2 97%
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on 10L oxygen. The A&E doctor thinks his liver might have been damaged in the attack and calls the
surgeons to assess him. Which is the SINGLE most appropriate initial management?
A.
Cross-match for packed red cells
B.
Fresh frozen plasma
C.
Liver enzymes
D.
Immediate laparotomy
E.
Urgent CT scan of the abdomen
8. A 6-month-old boy has been brought A&E following an apnoeic episode at home. He is now completely
well but his parents are very anxious as they family friend’s child died of sudden infant death syndrome
at a similar age. The parents would like to know how to perform CPR on a baby of his age. What is the
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SINGLE most recommended technique for cardiac compressions?
A.
op
All fingers of both hands
C
B.
All fingers of one hand
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C.
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Palm of one hand

D.
t
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Thumb of one hand

E.
Index and middle fingertips of one hand
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9. A 33-year-old man is stabbed with a knife in his thigh. He has tried to use a towel to stop the bleeding
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but has bled so much that the towel is now soaked with blood. His blood pressure is 85/50 mmHg, pulse
rate is 132 beats/minute and respiratory rate is 31 breaths/minute. What percentage of circulatory
blood did he lose?
A.
<15%
B.
15-30%
C.
30-40%
D.
40-50%
E.
>50%
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10. A 12-year-old comes into the emergency department with severe burns all over his body from a house
fire. There is oropharyngeal swelling and soot in the mouth. He is in severe pain. What is the SINGLE
A.
Refer to burn unit
B.
IV Fluids
C.
IV Antibiotic
D.
IV Analgesia
E.
Call a senior anaesthetist
11. A 55-year-old lady comes in with severe haematemesis. She is anxious and aggressive. Her medical
history includes liver disease. Her INR is 9; heart rate is 110 bpm; Systolic BP is 110 mmHg; SpO2 is 94%.
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What is the SINGLE most appropriate management?
A.
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Oxygen
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B.
IV Steroids
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C.
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Whole blood
D.
t
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IV fluids
E.
Fresh frozen plasma (FFP)
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12. A 24-year-old woman has been brought to the emergency department having taken 36 tablets of
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paracetamol following an argument with her partner. She weighs 60 kg. She has no previous psychiatric
history and is physically well. What is the SINGLE most appropriate management?
A.
Refer to social worker
B.
Admit to psychiatric ward
C.
Discharge home with advice
D.
Refer to clinical psychologist
E.
Admit to medical ward
13. A 14-year-old girl has been brought to the emergency department having taken an unknown amount of
paracetamol 2 hours ago. She has no previous psychiatric history and is physically well. When would be
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the SINGLE most appropriate time to attain plasma paracetamol concentration levels following her
presentation to A&E?
A.
Immediately
B.
In 2 hours’ time
C.
In 4 hours’ time
D.
In 8 hours’ time
E.
In 22 hours’ time
14. A 35-year-old man with a known peanut allergy presents to Accident & Emergency after having
unknowingly ingested a cupcake with nuts. He has widespread wheezes bilaterally on auscultation and
he is experiencing stridor and dyspnoea. His lips have also started to swell. IV access has been
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established. What is the SINGLE most appropriate immediate treatment for him?
A.
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Intramuscular adrenaline 1:1000
C
B.
Intravenous adrenaline 1:1000
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C.
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Intravenous hydrocortisone
D.
t
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Intravenous diphenhydramine
E.
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15. An 18-year-old, previously well student in his first year at university, was brought in to the emergency
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department in an agitated, deluded and disoriented state. What is the SINGLE most probable reason for
his condition?
A.
Drug toxicity
B.
Delirium tremens
C.
Infection toxicity
D.
Electrolyte imbalance
E.
Head injury
16. A 60 year old woman with history of a urinary tract infection, hypertension and gallstones presents to
the emergency department. She complains of upper right abdominal pain, rigors and feeling unwell. Her
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urine dipstick is negative for white cell and nitrates. She has a temperature of 38.9°C. Her blood pressure
is 88/55 mmHg, oxygen saturation of 92% on room air, pulse rate of 130 beats/minute and respiratory
rate of 24 breaths/minute. What is the SINGLE most likely diagnosis?
A.
Sepsis
B.
Urinary tract infection
C.
Pre-eclampsia
D.
Septic shock
E.
Cirrhosis
17. A 31-year-old man was knocked down during a fight in the waiting room of the emergency department.
He is now unconscious and unresponsive. What is the SINGLE most important first action?
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op
A.
Turn patient and put in recovery position
B.
C
Airway management
C.
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Blood pressure measurement

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D.
Assess Glasgow Coma Scale
t
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E.
Initiate cardiac compressions
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18. A 15-year-old girl is admitted in the medical ward after taking 28 tablets of paracetamol with a large
amount of alcohol. Her plasma paracetamol concentration taken 4 hours’ post ingestion is just below
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the concentration that would suggest treatment with N-acetylcysteine. What is the SINGLE most
appropriate next course of action?
A.
Refer to psychiatric team
B.
Discharge home
C.
Start N-acetylcysteine
D.
Activated charcoal
E.
Liver transplant
19. A 70-year-old male presents with a 2 day history of productive cough and shortness of breath. He
complains of chills and rigors. He is ill-looking. He has a temperature of 38.5ºC, respiratory rate of 26
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breaths/minute, and a pulse rate of 125 beats/min. His blood pressure is 88/45 mmHg and oxygen
saturation is 90% on room air. On auscultation, bronchial breath sounds are heard in the periphery. He is
given a fluid challenge of 1L normal saline. His blood pressure post fluid challenge is 90/40 mmHg. What
is the SINGLE best term to use in his condition?
A.
Sepsis
B.
Severe sepsis
C.
Septic shock
D.
Systemic inflammatory response syndrome (SIRS)
E.
Infection
20. A 9-year-old girl is brought by her mother to the A&E with stridor, wheezing and a rash. Her lips are
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beginning to swell. The young girl came from visiting her friend at her farm house. What is the SINGLE
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most appropriate treatment? C
A.
0.15 ml adrenaline intramuscularly
B.
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C.
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D.
0.3 ml adrenaline orally
E.
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Intravenous chlorpheniramine
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21. A 12-year-old girl when playing in the garden accidentally stepped on a hive and was bitten several
times. She has numerous wheals on her body and complains of severe itching which is worsening in the
last few hours. What is the SINGLE most appropriate management?
A.
Oral antihistamine
B.
IV antihistamine
C.
IM adrenaline
D.
Oral ciprofloxacin
E.
Reassurance
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22. Parents of an 11-month-old baby want to know the steps for CPR for their child as they have recently
attended a funeral of their neighbour’s child who died very suddenly after an episode of apnoea. They
want to know what they can do if an event like this occurs. What is the SINGLE most appropriate advice
in regards to CPR for their child?
A.
Index and middle finger compression
B.
Compression with heel of one hand
C.
Compression with heel of two hands with fingers interlocked
D.
Compression with rescue breaths 30:2
E.
Give 2 rescue breaths before starting compression
23. A 21-year-old lady after a heavy bout of drinking last night comes to the emergency department with
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vomiting blood, feeling dizzy, and having intense abdominal pain. On examination, her limbs feel cold.
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After initial resuscitation with oxygen and fluids, she still continues to bleed and continues to vomit
blood. She has a pulse of 130 beats/minute and blood pressure of 85/58 mmHg. What is the SINGLE next
best step?
C
A.
n
Clotting screen
io
B.
Ultrasound
t
ua
C.
Computed tomography
D.
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Endoscopy
E.
Ev
Intravenous omeprazole
24. A 10-year-old boy is rushed to Accident & Emergency after his parents found him unconscious on the
kitchen floor. It is revealed that he ingested some medication belonging to his grandmother. His
grandmother was unable to identify which medications are missing. On examination, the child is
hypotensive with dilated pupils and dryness in the mouth. His ECG showed prolongation of the PR, QRS
and QT intervals. Which SINGLE most likely medication has he taken in excess?
A.
Amitriptyline
B.
Carbamazepine
C.
Digoxin
D.
Metoprolol
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E.
Thiazide
25. A 30-year-old patient is brought to the emergency department after a road traffic accident. He has
multiple bruises on his chest and paradoxical breathing is observed. A chest X-ray shows a widened
mediastinum and right-sided pulmonary contusion. He has a pulse of 129 beats/minute, a blood
pressure of 100/70 mmHg and a respiratory rate of 38 breaths/minute. He has severe chest pain and is
dyspnoeic. What is the SINGLE best management for his condition?
A.
16-gauge needle into the 2nd intercostal space on the left
B.
Intercostal block anaesthesia
C.
Endotracheal intubation and positive-pressure ventilation
D.
16-gauge needle into the 4th intercostal space on the right
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E.
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Consent the patient for surgery C
26. A 47-year-old man was involved in a road traffic accident and was brought to the emergency
department by ambulance. He has signs of respiratory distress and has abdominal and chest pain. On
physical examination, no breath sounds are heard over the entire left lung field. A nasogastric tube is
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seen curled into the left chest on a chest X-ray. What is the SINGLE most likely diagnosis?
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A.
t
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Diaphragm rupture
B.
Pneumothorax
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C.
Splenic rupture
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D.
Bowel perforation
E.
Gastric perforation
27. A 9-month-old child aspirated a foreign object which was removed at the hospital. The child is now fine.
His parents would like to know what they should do should this occur again. What is the SINGLE most
appropriate advice to give them?
A.
Heimlich maneuver
B.
Turn the infant into a supine position and give chest trust
C.
Turn the infant on his back and give five thrust to the middle of the back
D.
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Place a clenched fist between the umbilicus and xiphisternum and give abdominal thrusts
E.
Turn infant into recovery position and open infant’s mouth
28. A 32-year-old man rescued from a building on fire presents unconscious without any evidence of burns
and external injury. What is the SINGLE most appropriate management?
A.
Tight-fitting mask with 100% oxygen
B.
24% oxygen by face mask
C.
Hyperbaric oxygen in a hyperbaric chamber
D.
Intubate and provide IPPV on 100% oxygen
E.
Refer to specialist unit
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29. A 21-year-old man, who was heavily drinking a few hours ago at an evening party presents to A&E with a
history of vomiting repeatedly during the night. He vomited fresh blood an hour ago. His vitals are stable
C
and his Hb is 15.3 g/dl. He has no further bleeding. What is the SINGLE most appropriate management?
A.
n
Admit and observe

io
B.
Discharge with advice
t
ua
C.
Endoscopy
D.
al
Cross match 2 units of blood

E.
Ev
Administer vasopressin analogue
30. An 18-year-old girl has taken an unknown dose of paracetamol yesterday. She cannot remember the
exact time she took the tablets. She is extremely anxious but otherwise asymptomatic. She has no past
medical history. She weighs 55kg. BP 120/75 mmHg, heart rate is 100 bpm, SaO2 99% on air. Which is
the SINGLE most appropriate next step?
A.
Activated charcoal
B.
Gastric lavage
C.
D.
Discharge home
E.
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Psychiatric review
31. A 21-year-old man has been found unconscious in an alleyway with a respiratory rate of 5
breaths/minute and a pulse of 55 beats/minute. His pupils are constricted. What is SINGLE most
A.
Methadone
B.
Naloxone
C.
Flumazenil
D.
Thiamine
E.
Dextrose
y
32. A 24-year-old male presents to A&E with 40% partial thickness burns. His pulse rate is 105 bpm and
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respiratory rate is 25 breaths per minute. His systolic blood pressure is 80 mmHg. What is the SINGLE
C
A.
IV fluids calculated from the time of hospital arrival
n
B.
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IV fluids calculated from the time of burn

C.
t
ua
Oral rehydration
D.
IV dextrose stat
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E.
Ointments
Ev
33. A 35-year-old man had a fight in a bar which involved blunt trauma to his head. Since the injury, he has
developed bleeding from the auditory meatus associated with ringing and hearing loss in his ear. Clear
fluid is seen coming from his nose. What is the SINGLE most appropriate investigations of choice?
A.
Computed tomography scan of brain
B.
X-ray skull
C.
Otoscopy
D.
Magnetic resonance imaging of head
E.
Coagulation study
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34. A 24-year-old man was under the custody of police when he was punched. He is now cyanosed and
unresponsive. What is the SINGLE most appropriate initial action?
A.
IV fluids
B.
Clear airway
C.
D.
Give 100% oxygen
E.
Analgesia
35. An 8-year-old boy is rushed into A&E coughing, cyanosed and with a urticaria rash. His mother tells the
staff that he began to cough after eating a cookie at a garden party. What is the SINGLE most likely
diagnosis?
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op
A.
Aspiration of food
B.
C
Allergic reaction
C.
n
Diffuse Esophageal Spasm

io
D.
Tracheoesophageal fistula
t
ua
E.
Achalasia
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36. A 33-year-old woman has recurring tightness in her chest accompanied by palpitations and sweating.
These episodes occur several times a week and are associated with increased respiratory rate and
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tingling and numbness around the mouth and fingers. What is the SINGLE most likely diagnosis?
A.
Pericarditis
B.
Stable angina
C.
Panic attack
D.
Gastro-oesophageal reflux disease
E.
Aortic aneurysm
37. A 16-year-old girl has taken an overdose of 34 paracetamol tablets earlier this morning. She is extremely
anxious but otherwise asymptomatic. She has no past medical history. Paracetamol plasma levels were
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taken at 4 hours from time of overdose and is above the treatment line. She weighs 55kg. BP 120/75
mmHg, heart rate is 100 bpm, SaO2 99% on air. Which is the SINGLE most appropriate next step?
A.
Activated charcoal
B.
Gastric lavage
C.
D.
Discharge home
E.
38. A 34-year-old man had a car crash and is being observed in the emergency department. He is slowly
deteriorating and his GCS has fallen from 13 to 7. What is the SINGLE most appropriate next step in
management?
y
op
A.
CT
B.
C
Burr hole
C.
n
MRI
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D.
Intubation
t
ua
E.
IV fluids
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39. A 31-year-old man was involved in a road traffic accident and has severe pain at the right outer upper
thigh and groin. There is clear deformity of the hip and shortening of the right leg. A femoral shaft
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fracture is suspected. His blood pressure is 100/70 mmHg. He has a heart rate of 90 beats/minute and a
respiratory rate of 19 breaths/minute. He is saturating at 97% at room air. What is the SINGLE most
appropriate next action?
A.
Anteroposterior pelvic and lateral hip X-rays
B.
Intravenous fluids
C.
Thomas' splint
D.
Full blood count and cross match
E.
Magnetic resonance imaging (MRI)
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40. A 23-year-old woman has been found unconscious by her partner. There are several packets of
paracetamol and an empty bottle of vodka alongside her. When she comes to in the Emergency
Department, she is confused and unable to estimate when she took the tablets. Her Glasgow Coma Scale
(GCS) score is 14/15. Which is the SINGLE most appropriate next step?
A.
CT Head
B.
Haemodialysis
C.
Start N-acetylcysteine immediately
D.
Start N-acetylcysteine 4 hours after presentation
E.
Take paracetamol levels and treat if raised
41. A 27-year-old man presents to the emergency department after a road traffic accident where his right
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foot was stuck under a truck for several hours. On examination, his right foot is swollen and tender.
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Sensation is reduced between the space of the 3rd metatarsal and big toe. His dorsalis pedis pulse is not
felt. What is the SINGLE most likely diagnosis?
C
A.
Compartment syndrome
n
B.
io
Artery rupture
C.
t
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Arterial embolism
D.
Deep vein thrombosis
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E.
Fibular fracture
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42. A 32-year-old woman starts bleeding profusely in theatre during an elective caesarean section. She had
a spinal block and was awake throughout the procedure. She is now found to be unconscious. Her BP
has dropped to 70/40 mmHg. What is the SINGLE most likely diagnosis?
A.
Primary haemorrhage
B.
Reactionary haemorrhage
C.
Secondary haemorrhage
D.
Pulmonary embolism
E.
Septic shock
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43. A 35-year-old patient is brought to the emergency department after having a road traffic accident. He
has bruises on his chest. A chest X-ray shows a widened mediastinum. He has a pulse of 129
beats/minute, a blood pressure of 80/40 mmHg and a respiratory rate of 34 breaths/minute. What is the
A.
B.
Abdominal aortic aneurysm
C.
Thoracic aortic rupture
D.
Flail chest
E.
Pleural effusion
44. A 55-year-old women recovering from a surgery for a toxic goitre is found to be cyanosed in the
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recovery room. Her neck is tense and her BP is 85/45 mmHg. There is blood oozing from the drain. What
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is the SINGLE most likely diagnosis? C
A.
Primary haemorrhage
B.
n
io
C.
t
ua
D.
Thyroid storm
E.
al
Tracheomalacia
Ev
45. A 5-year-old boy with a febrile convulsion lasting eight minutes. He has been given IV lorazepam to
control his seizures. What is the SINGLE most likely side effect of IV lorazepam that is potentially life
threatening?
A.
Amnesia
B.
Anaphylactic shock
C.
Apnoea
D.
Bronchospasm
E.
Cardiac arrhythmia
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46. A 34-year-old man was involved in a road traffic accident. Whilst in the ambulance his Glasgow Coma
Scale deteriorates from a score of 13 to 9. His respiratory rate increases from 30 to 48 breaths/minute.
A.
Intravenous fluids
B.
Needle thoracentesis
C.
100% oxygen
D.
Portable X-ray
E.
47. A 47-year-old man had a road traffic accident and has presented to A&E with multiple injuries. On
physical examination, perineal bruising was noticed. A pelvic fracture has been confirmed. He has not
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passed urine since the accident which was 7 hours ago. What is the SINGLE most appropriate next
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course of action? C
A.
Urethral catheterization
B.
n
Suprapubic catheterization
io
C.
IV fluids
t
ua
D.
IV furosemide
E.
al
Insulin
Ev
48. A 76-year-old woman has become tired and confused following an influenza like illness. She is vomiting
and with abdominal pain. She is also breathless with signs of consolidation of the left lung base. Her
temperature is 39.0 °C. She has a blood pressure of 80/60 mmHg A blood count showed:
Haemoglobin 120 g/L

White cell count 19.1 x 109/L
Platelets 90 x 109/L.
A.
Drug toxicity
B.
Delirium tremens
C.
Toxic shock syndrome
164
D.
Hypoglycaemia
E.
49. A 19-year-old man is rushed into A&E by his friends who left him immediately before they could be
interviewed by the medical staff. He is semiconscious. His respiratory rate is 7/min, blood pressure is
120/75 mmHg, and pulse rate is 60 bpm. He is noted to have needle track marks on his arms and he has
pinpoint pupils. What is the SINGLE most appropriate management?
A.
Insulin
B.
Naloxone
C.
Methadone
D.
y
Gastric lavage
op
E.
Flumazenil
C
50. A 13-year-old boy presents with recurrent episodes of facial and tongue swelling. He also complains of
abdominal pain which occurs occasionally. His father has had similar episodes. What is the SINGLE most
n
likely diagnosis?
io
A.
t
ua
C1 esterase inhibitor deficiency

B.
Nephrotic syndrome
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C.
Acute urticaria
Ev
D.
Anaphylaxis
E.
Sjogren’s syndrome
51. A 25-year-old male with a history of frequent binge drinking presents 4 hours after having had a
takeaway meal following a night's heavy drinking. He complains of nausea and has vomited on several
occasions. After the last vomiting episode, he vomited approximately a cupful of blood. On admission,
he smells of alcohol, pulse of 100 beats/minute, blood pressure of 140/80 mmHg. He has some
tenderness in the epigastrium. What is the SINGLE most likely diagnosis?
A.
Gastric carcinoma
B.
Mallory-weiss tear
C.
165
Oesophageal carcinoma
D.
Oesophageal varices
E.
Peptic ulcer
52. A 14-year-old boy fell and hit his head in the playground school. He did not lose consciousness but has
swelling and tenderness of the right cheek with a subconjunctival haemorrhage on his right eye. What is
the SINGLE most appropriate initial investigation?
A.
Head CT
B.
Electroencephalogram
C.
Head MRI
D.
y
Skull X-ray
op
E.
Facial X-ray
C
53. An 18-month-old boy pulled over a cup of hot tea that was on a high table. The hot liquid splashed over
him and he now presents with a 6% partial thickness burn on his chest. What is SINGLE best treatment
n
for him?
io
A.
t
ua
IV crystalloids
B.
IV colloids
al
C.
No need for IV treatment
Ev
D.
IV dextrose bolus
E.
IV albumin infusion
54. Parents of a 3-year-old child have recently attended a funeral of their neighbour’s son who died
following a cardiorespiratory arrest. They want to know the algorithm for paediatric basic life support
should their 3-year-old child has an arrest. What is the SINGLE most accurate advice would you give?
A.
Ratio of 5 compression to 1 breath
B.
Ratio of 5 compression to 2 breaths
C.
Ratio of 15 compressions to 2 breaths with nose pinched
D.
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Ratio of 15 compressions to 2 breaths without nose pinched
E.
Ratio of 30 compressions to 2 breaths
55. A 78-year-old woman presents to A&E with severe epigastric pain and vomiting. The pain is referred to
her right shoulder. Generalised rigidity is noted when examining. She has a temperature of 37.2°C and a
pulse of 102 beats/minute. Her medical history is significant for rheumatoid arthritis. What is the SINGLE
most appropriate investigation?
A.
Ultrasound Abdomen
B.
Sigmoidoscopy
C.
Colonoscopy
D.
Erect chest X-ray
y
E.
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Upper GI endoscopy C
56. A 23-year-old girl presented with perioral paraesthesia and carpopedal spasm 20 minutes after a huge
argument with her boyfriend. What is the SINGLE most appropriate next course of action?
n
A.
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SSRI
B.
t
ua
Diazepam
C.
Rebreathe into a paper bag
al
D.
Propranolol
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E.
Alprazolam
57. Which of the following formulas is used for calculating fluids for burn patients?
Plab Lab Values
A.
4 x weight(lbs) x area of burn (in ml of fluids)
B.
4 x weight(kgs) x area of burn (in L of fluids)
C.
4 x weight(kgs) x area of burn (in ml of fluids)
D.
4 x weight(lbs) x area of burn (in L of fluids)
E.
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4.5 x weight(kgs) x area of burn (in dL of fluids)
58. A butcher comes to the emergency department after accidentally stabbing his groin with a knife. He
tried to use a towel to stop the bleeding but has bled so much that the towel is now soaked with blood.
His blood pressure is 80/50 mmHg and pulse is 130 beats/minute. What percentage of circulatory blood
did he lose?
A.
<15%
B.
15-30%
C.
30-40%
D.
40-50%
E.
>50%
y
op
59. A 4-year-old child playing with toys unattended suddenly develops breathlessness and stridor and is
rushed into the hospital by his father. The child is drooling and unable to swallow. What is the SINGLE
C
best investigation likely to lead to a diagnosis?
A.
n
Laryngoscopy
io
B.
Chest X-ray
t
ua
C.
Peak flow meter
D.
al
Arterial blood gas

E.
Ev
Pulse oximeter
60. A 24-year-old male presents to A&E with 40% partial thickness burns after having been in a house fire.
His pulse rate is 115 bpm and respiratory rate is 29 breaths per minute. His systolic blood pressure is 80
mmHg. What is the SINGLE most appropriate management?
A.
B.
C.
Oral rehydration
D.
IV dextrose stat
E.
168
IV morphine
61. An 18-year-old female was brought into the ED after ingestion of 28 paracetamol tablets after breaking
up with her boyfriend. She came in confused and unwell. She was admitted in the medical ward and N-
Acetylcysteine was given. 24 hours later, her laboratory results show a normal FBC, an arterial pH of 7.1,
Prothrombin time of 17 seconds and creatinine of 255μmol/L. She is still confused and lethargic. What is
the SINGLE most appropriate management?
Normal Lab values:

Creatinine 70–150μmol/L
pH 7.35–7.45
Prothrombin time (PT): 11-14 sec
A.
Observe for another 24 hours
B.
y
C.
op
Intravenous fluids
D.
Administer charcoal
C
E.
Liver transplantation
n
io
62. A 34-year-old man was brought to the ED after a road traffic accident. His blood pressure is 50/0 mmHg
and respiratory rate is 34 breaths/minute. His chest wall is not moving symmetrically. What is the
t
ua
SINGLE most appropriate initial action?
A.
al
IV fluid infusion
B.
Ev
Intubation and ventilation

C.
Analgesia
D.
Transfer to ITU
E.
Chest X-ray
63. A 24-year-old man comes into the emergency department with partial thickness burns all over his body
from a house fire. He has persistent cough and stridor. There are deep neck burns, carbonaceous
sputum and soot in the mouth and oedema of the oropharynx. What is the SINGLE most appropriate
management?
A.
Topical antibiotics
B.
169
Fluid resuscitation
C.
Immediate burn care and cooling
D.
Intravenous analgesia
E.
Tracheal intubation
64. A 25-year-old woman has been feeling anxious and nervous for the last few months. She also complains
of palpitations and tremors. Her symptoms develop rapidly and last for a few minutes. She mentions
that taking alcohol initially helped her relieve her symptoms but now this effect is wearing off and she
has palpitations and tremors even after drinking alcohol. What is the SINGLE most likely diagnosis?
A.
Panic attacks
B.
Depression
y
C.
op
Obsessive-compulsive disorder (OCD)
D.
Alcohol addiction
C
E.
Generalised Anxiety Disorder (GAD)
n
io
65. A butcher comes into A&E after accidentally stabbing his groin with a knife. He tried to use a towel to
stop the bleeding but has bled so much that the towel is now soaked with blood. His
t
ua
Blood pressure is 75/40 mmHg and pulse is 120 beats/minute. What is the SINGLE most appropriate
initial management?
al
A.
Ev
Blood transfusion
B.
IV fluids
C.
Fresh frozen plasma
D.
Refer to surgeon
E.
Oral rehydration
66. A 49-year-old woman presents to the Emergency Department with a productive cough of green sputum.
She feels unwell, feverish and lethargic. On examination, bronchial breathing is heard at her right base.
She has a respiratory rate of 27 breaths/minute, oxygen saturation of 90% on room air, pulse rate of 130
beats/minute and a blood pressure of 85/40 mmHg. What is the SINGLE next most appropriate action?
A.
170
Intravenous fluids
B.
Oral antibiotics
C.
Chest X-ray
D.
Intramuscular adrenaline
E.
Sputum culture
67. A 36-year-old man rescued from a building on fire presents headache, vertigo, nausea, confusion and
vomiting. He complains of feeling weak. He is without any evidence of burns or external injury. What is
A.
B.
y
op
C.
D.
C
E.
n

io
68. A 20-year-old man presents to A&E after having severe injuries from a road traffic accident. On
t
ua
presentation, he is breathless and has severe chest pain. His systolic blood pressure is 70 bpm and his
pulse rate is 130/min What is the SINGLE most appropriate initial action?
al
A.
Antibiotics
Ev
B.
Analgesia
C.
High flow oxygen
D.
Secure venous access
E.
Refer to surgeon
69. A 16-year-old female teenager was brought to the emergency department after being stabbed on the
upper right side of his back 2 hours ago. An erect Chest X-ray revealed homogenous opacity on the lower
right lung. The trachea is centrally placed. She has a blood pressure of 80/60 mmHg, a pulse of 122
beats/minute, and a respiratory rate of 34 breaths/minute. What is the SINGLE most likely diagnosis?
A.
Pneumothorax
171
B.
Haemothorax
C.
Pneumonia
D.
E.
Empyema
70. A 32-year-old man is brought to A&E by his wife with symptoms of chest pain, abdominal pain,
palpitations, nausea and altered mental status. His wife says that she found a bottle of empty
medication on the toilet floor and it is likely that he consumed the whole bottle. He has a respiratory
rate of 34 breaths/minute. His arterial blood gas shows the following:
pH 7.21
pCO2 3.0 kPa
P02 13
y
Bicarbonate 18 mmol/L
op
What is the SINGLE most likely medication that he could have taken?
C
A.
Paracetamol
n
B.
io
Aspirin
C.
t
ua
Diclofenac
D.
Enalapril
al
E.
Gentamicin
Ev
71. A 33-year-old man was involved in a road traffic accident. He has acute abdominal pain. On abdominal
examination, there is bruising along the site of the portion of the seat belt. His abdomen is very tender.
A computerised tomography scan of his abdomen shows a subcapsular splenic haematoma. He has a
pulse rate of 90 beats/minute, respiratory rate of 24 breaths/minute, and a blood pressure of 120/80
mmHg. What is the SINGLE most appropriate action?
A.
B.
Refer to surgical team for observation
C.
Out patient department referral
D.
Routine referral for ultrasound scan
E.
172
Laparoscopy
72. A 10-year-old comes is brought in by ambulance after having been rescued from a house fire. There is
soot in his mouth and he has difficulty breathing. What is the SINGLE most appropriate management?
A.
Refer to burn unit
B.
Tracheal intubation
C.
Cricothyroidotomy
D.
Intermittent positive-pressure ventilation
E.
Administer 100% oxygen by face mask
73. A 44-year-old man with a history of alcohol dependency presents with confusion. He responds poorly to
y
questions and is seen to be irritable. He is unsteady and has unco-ordinated walking. His blood glucose is
op
3.5 mmol/L. He has no other relevant medical history. What is the SINGLE most appropriate immediate
action?
C
A.
Intravenous thiamine
n
B.
io
Bolus of 50% glucose

C.
t
ua
Intravenous 5% dextrose
D.
Normal saline
al
E.
Computed tomography of head
Ev
173
EM
1. A 17-year-old girl has taken an overdose of 30 paracetamol tablets 3 hours ago. She is extremely anxious
but otherwise asymptomatic. She has no past medical history. She weighs 50kg. BP 120/70 mmHg, heart
rate is 100 bpm, SaO2 98% on air. Which is the SINGLE most appropriate next step?
A.
Activated charcoal
B.
Gastric lavage
C.
D.
Paracetamol plasma level 4 hours after overdose
E.
Blood taken before 4 hours is unreliable because the drug is still being absorbed and distributed. The N-
y
acetylcysteine infusion does not need to be started unless the time of the overdose is unknown or has
op
been staggered over a few hours. Initial symptoms are often limited to nausea and vomiting.
C
The other options are incorrect:
Activated charcoal → should be considered if the overdose has been taken within 1 hour
n
Gastric lavage → Would always be the wrong answer when dealing with paracetamol poisoning. The
io
British Poisons Centres only recommend the use of gastric lavage cases where medications have been
ingested that activated charcoal would absorb poorly (eg iron, lithium) and for sustained-release
t
ua
formulations or enteric-coated tablets.
N-acetylcysteine infusion → Should not be started until the blood test has been taken at 4 hours and
al
results are above a single treatment line. Administration of N-acetylcysteine can be rather confusing but
it is important to know exactly what criteria is needed to start acetylcysteine especially as PLAB questions
Ev
often ask this.
Urgent liver function tests + clotting screen → often no change in these values acutely.
Paracetamol (acetaminophen) poisoning:
Initial features → Nausea, vomiting, pallor

After 24 hours → Hepatic enzymes rise
After 48 hours → Jaundice, an enlarged, tender liver
Hypoglycaemia, hypotension, encephalopathy, coagulopathy, coma may also occur.
When to discharge home?

- If ingestion of paracetamol is < 150mg/kg in a child/adult with no hepatic risk factors
When to admit?
174
EM
- Admit those presenting within 8h of ingesting >150mg/kg (or an unknown amount)
(For the exam, it can be quite time consuming to multiply 150mg with the weight of the patient. So, we
would advise you to use the number 24 as a benchmark whereby if the patient consumes more than 24
tablets (12 g) of paracetamol, then you admit him/her)
When to do a serum paracetamol concentration?

- At ≥4h post ingestion if consumed >150mg/kg (or an unknown amount)
When to give activated charcoal?

- If presenting < 1h, and >150mg/kg of tablets ingested
When to give N-acetylcysteine?

- If there is a staggered overdose (Note: a staggered overdose is if all the tablets were not taken
within 1 hour); or
- If there is doubt over the time of paracetamol ingestion, regardless of the plasma paracetamol
concentration; or
y
- If plasma paracetamol concentration (taken 4 hours’ post ingestion) is above the appropriate line
op
- If patients present late (>8h) and ingested dose is >150mg/kg, (or dose is unknown)
C
2. A 24-year-old man presents with acute respiratory distress after being stabbed in the back. The trachea
is not deviated, but he has engorged neck veins and no breath sounds on his right chest. He has a blood
pressure of 80/50 mmHg, a pulse of 135 beats/minute, and a respiratory rate of 35 breaths/minute.
n

io
A.
t
ua
B.
Cardiac tamponade
al
C.
Simple pneumothorax
Ev
D.
Haemothorax
E.
Pleural effusion
Haemothorax:
- Blood accumulates in the pleural cavity
Clinical features:
Similar to that seen in traumatic pneumothorax, except the following:
- Dullness to percussion over the affected lung
- Signs and symptoms of hypovolaemia if massive haemothorax
Investigations:
- Chest X-ray shows an increased shadowing on a supine X-ray, with no visible fluid level
175
EM
Treatment:
- Oxygen
- Insert 2 large venous cannula and send blood for cross matching
- Evacuation of blood may be necessary to prevent development of empyema; thus, chest tube is
needed and is often placed low. Usually the lung will expand and the bleeding will stop after a
chest tube is inserted.
- Surgery to stop the bleeding is seldom required. The lung is the usual the source of bleeding.
Since it is a low-pressure system, the bleeding usually would stop by itself.
3. A 33-year-old man was admitted to the emergency department after a head injury. On arrival, he has a
Glasgow Coma Scale score of 15. A few hours later, his Glasgow Coma Scale score drops to 12. What is
the SINGLE most appropriate immediate action?
A.
Computed tomography head scan
B.
X-ray skull
y
C.
op
Intravenous mannitol
D.
Emergency burr hole
C
E.
Shift to operating room
n
io
A CT head would be appropriate. The initial GCS of 15 followed by a later GCS 12 are suggestive of
intracranial haemorrhage.
t
ua
Criteria for performing a CT head scan in Adults (NICE guidelines)

al
For adults who have sustained a head injury and have any of the following risk factors, perform a CT
head scan:
Ev
- GCS less than 13 on initial assessment in the emergency department.

- GCS less than 15 at 2 hours after the injury on assessment in the emergency department.
- Suspected open or depressed skull fracture.
- Any sign of basal skull fracture (haemotympanum, 'panda' eyes, cerebrospinal fluid leakage from
the ear or nose, Battle's sign).
- Post-traumatic seizure.
- Focal neurological deficit.
- More than 1 episode of vomiting.
For adults with any of the following risk factors who have experienced some loss of consciousness or
amnesia since the injury, perform a CT head scan within 8 hours of the head injury:
- 65 years or older.
- Any history of bleeding or clotting disorders.
- Dangerous mechanism of injury (a pedestrian or cyclist struck by a motor vehicle, an occupant
ejected from a motor vehicle or a fall from a height of greater than 1 metre or 5 stairs).
176
EM
- More than 30 minutes' retrograde amnesia of events immediately before the head injury.
4. A 32-year-old man presents to the emergency department after a motorcycle crash. The patient has
bruises around the left orbital area. GCS is 13. On examination, an alcoholic breath is noticed. Shortly
afterwards, his GCS drops to 8. What is the SINGLE most important initial investigation?
A.
MRI head
B.
CT head
C.
Chest X-ray
D.
CT angio brain
E.
Head X-ray
y
5. A 33-year-old lady who is an opiate drug addict wants to quit her drug abuse problem. She is supported
op
by her friends and family. What is the SINGLE most appropriate treatment to combat withdrawal
symptoms?
C
A.
Benzodiazepines
n
B.
io
Chlordiazepoxide
C.
t
ua
Naloxone
D.
Methadone
al
E.
Disulfiram
Ev
Methadone is used to help combat withdrawal effects for opiate misusers. Methadone is an opioid
medication and it reduces withdrawal symptoms in people addicted to heroin. It does not cause the
"high" associated with the drug addiction and thus it is especially helpful for opiate addicts to help them
quit the drug addiction problem.
6. A 9-year-old child was admitted following a road traffic accident. On admission, his initial GCS was 15.
His GCS dropped to 13 during the night. What is the SINGLE most appropriate management?
A.
Refer to neuro-surgeon
B.
IV fluids
C.
Intubation
D.
177
EM
CT head
E.
Skull X-ray
A CT head scan should be performed if GCS < 15 at 2 hours’ post-injury in children
Criteria for performing a CT head scan in Children (NICE guidelines)
For children who have sustained a head injury and have any of the following risk factors, perform a CT
head scan:
- Post-traumatic seizure but no history of epilepsy.

- On initial emergency department assessment, GCS less than 14, or for children under 1 year GCS
(paediatric) less than 15.
- At 2 hours after the injury, GCS less than 15.
- Suspected open or depressed skull fracture or tense fontanelle.
- Any sign of basal skull fracture (haemotympanum, 'panda' eyes, cerebrospinal fluid leakage from
y
the ear or nose, Battle's sign).
op
- Focal neurological deficit. C
For children who have sustained a head injury and have more than 1 of the following risk factors (and
none of those stated above), perform a CT head scan:
n
- Loss of consciousness lasting more than 5 minutes (witnessed).
io
- Abnormal drowsiness.
- Three or more discrete episodes of vomiting.
t
ua
- Dangerous mechanism of injury (high-speed road traffic accident either as pedestrian, cyclist or
vehicle occupant, fall from a height of greater than 3 metres, high-speed injury from a projectile
or other object).
al
- Amnesia (ante-grade or retrograde) lasting more than 5 minutes

Ev
7. A 25-year-old man has been stabbed in the right-hand side of his abdomen with a small knife. He
presents with severe pain in his right upper quadrant with guarding. IV fluids are being administered. He
is very anxious and agitated. His temperature is 36.5°C, heart rate 120 bpm, BP 85/55 mmHg, SaO2 97%
on 10L oxygen. The A&E doctor thinks his liver might have been damaged in the attack and calls the
surgeons to assess him. Which is the SINGLE most appropriate initial management?
A.
Cross-match for packed red cells
B.
Fresh frozen plasma
C.
Liver enzymes
D.
E.
178
EM
Urgent CT scan of the abdomen
Cross-match is the most appropriate as he may need a blood transfusion. If IV fluids have not been
started and the option for IV fluids is given in this question, then pick IV fluids. This would be the first
initial step together with oxygen.
The other options given in this question are less likely:
- Fresh Frozen plasma → are used in replacement of isolated factor deficiency, reversal of warfarin
effect, massive blood transfusion (>1 blood volume within several hours), treatment of thrombotic
thrombocytopenic purpura and are not indicated here in this question
- Liver enzymes → Have no role in the acute management
- Immediate laparotomy → This may well be the last step after all investigations are carried out.
- Urgent CT scan of the abdomen → The patient must be resuscitated and stabilized before sending
y
to the CT scanner.
8.
op
A 6-month-old boy has been brought A&E following an apnoeic episode at home. He is now completely
C
well but his parents are very anxious as they family friend’s child died of sudden infant death syndrome
at a similar age. The parents would like to know how to perform CPR on a baby of his age. What is the
SINGLE most recommended technique for cardiac compressions?
n
io
A.
All fingers of both hands
t
ua
B.
All fingers of one hand
C.
al
Palm of one hand

D.
Ev
Thumb of one hand

E.
Index and middle fingertips of one hand
There are two options here. Either index and middle finger of one hand or grip the chest in both hands in
such a way that two thumbs can press on the lower third of the sternum.
Chest compression in infants:

- The lone rescuer should compress the sternum with the tips of two fingers.
- If there are two or more rescuers, use the encircling technique:
a. Place both thumbs flat, side-by-side, on the lower half of the sternum (as above), with the tips
pointing towards the infant’s head.
b. Spread the rest of both hands, with the fingers together, to encircle the lower part of the infant’s
rib cage with the tips of the fingers supporting the infant’s back.
c. Press down on the lower sternum with your two thumbs to depress it at least one-third of the
depth of the infant’s chest, approximately 4 cm.
179
EM
Chest compression (only to be started after successful lung inflation). Aim for a rate of 100/min
9. A 33-year-old man is stabbed with a knife in his thigh. He has tried to use a towel to stop the bleeding
but has bled so much that the towel is now soaked with blood. His blood pressure is 85/50 mmHg, pulse
rate is 132 beats/minute and respiratory rate is 31 breaths/minute. What percentage of circulatory
blood did he lose?
A.
<15%
B.
15-30%
C.
30-40%
D.
40-50%
E.
y
>50%
Stages of hypovolaemic shock

op
C
For adults, the clinical staging relating to loss of blood volume can be classified as:
n
io
Stage 1 Stage 2 Stage 3 Stage 4

t
ua
Blood loss 10- 15-30% 30-40% Over 40%

15%
al
Blood Normal Postural Hypotension Marked hypotension

pressure hypotension
Ev
Heart rate Normal Slight tachycardia Tachycardia Extreme tachycardia

(> 100 bpm) (> 120 bpm) (>140 bpm)
Respiratory Normal Increased Tachypnoea Extreme tachypnoea

rate (> 20) (> 30)
Mental status Normal Slight anxiety, Altered, confused Decreased consciousness,
restless lethargy, or coma
Urine output Normal 20-30 mL/hour Less than 20 No urine output

ml/hour
It may be difficult to remember all these values and features of stages of hypovolemic shock. The best
suggestion is to just memorise the heart rate and base your answer on that. The examination questions
usually would give a history of blood loss and the patient’s heart rate. With the heart rate alone, you
180
EM
should be able to tell which clinical stage he is in. You would also need to memorize the amount of blood
loss in each stage e.g. 30-40% in stage 3.
10. A 12-year-old comes into the emergency department with severe burns all over his body from a house
fire. There is oropharyngeal swelling and soot in the mouth. He is in severe pain. What is the SINGLE
A.
Refer to burn unit
B.
IV Fluids
C.
IV Antibiotic
D.
IV Analgesia
E.
Call a senior anaesthetist
y
op
After major burns, if there is any evidence of impending airway obstruction (stridor, oropharyngeal
swelling, call for senior ED help and a senior anaesthetist immediately. Urgent general anaesthesia and
tracheal intubation may be life-saving.
C
Airway, breathing, and circulation → always in this order.
n
io
Smoke inhalation injury is a common cause of death in burn victims. Initial assessment may reveal no
evidence of injury, but laryngeal oedema can develop suddenly and unexpectedly thus early intubation is
t
ua
warranted if there is evidence of inhalation injury.
Signs and symptoms of smoke inhalation injury:

al
- Persistent cough
- Stridor
Ev
- Wheezing
- Black sputum suggests excessive exposure to soot
- Use of accessory muscles of respiration
- Blistering or oedema of the oropharynx
- Hypoxia or hypercapnia
11. A 55-year-old lady comes in with severe haematemesis. She is anxious and aggressive. Her medical
history includes liver disease. Her INR is 9; heart rate is 110 bpm; Systolic BP is 110 mmHg; SpO2 is 94%.
A.
Oxygen
B.
IV Steroids
C.
Whole blood
181
EM
D.
IV fluids
E.
Fresh frozen plasma (FFP)
The most appropriate management here would be FFP as she has a history of liver disease and a high
INR. IV fluids is a must as well but you need to read the PLAB questions very carefully. If the question had
said “What is the SINGLE most initial management?”, then IV fluids would be your choice. However, in
this question they are asking for the “SINGLE most appropriate management”. In this case, FFP would be
the most appropriate.
Oxygen should be administered as well but since the Sp02 is 94% this answer is less appropriate.
Blood would be eventually needed if she bleeds too much. We give packed red blood cells and not whole
blood.
This lady is anxious and aggressive which are initial symptoms of hypovolaemic shock. As the
y
hypovolaemic shock worsens, she would get drowsy, confused and later unconscious.
Upper gastrointestinal bleeding

op
C
Start IV fluids followed by blood as necessary. Shocked patients should receive prompt volume
replacement. Red cell transfusion should be considered after loss of 30% of the circulating
n
volume.
io
If the patient is anticoagulated, or has a clotting disorder (eg due to liver disease), give vitamin K/clotting
t
ua
factors/fresh frozen plasma (FFP) accordingly.
12. A 24-year-old woman has been brought to the emergency department having taken 36 tablets of
al
paracetamol following an argument with her partner. She weighs 60 kg. She has no previous psychiatric
history and is physically well. What is the SINGLE most appropriate management?
Ev
A.
Refer to social worker
B.
C.
Discharge home with advice
D.
Refer to clinical psychologist
E.
Admit to medical ward
13. A 14-year-old girl has been brought to the emergency department having taken an unknown amount of
paracetamol 2 hours ago. She has no previous psychiatric history and is physically well. When would be
the SINGLE most appropriate time to attain plasma paracetamol concentration levels following her
presentation to A&E?
182
EM
A.
Immediately
B.
In 2 hours’ time
C.
In 4 hours’ time
D.
In 8 hours’ time
E.
In 22 hours’ time
14. A 35-year-old man with a known peanut allergy presents to Accident & Emergency after having
unknowingly ingested a cupcake with nuts. He has widespread wheezes bilaterally on auscultation and
he is experiencing stridor and dyspnoea. His lips have also started to swell. IV access has been
established. What is the SINGLE most appropriate immediate treatment for him?
y
A.
op
B.
Intravenous adrenaline 1:1000
C
C.
n
D.
io
Intravenous diphenhydramine
E.
t
ua
Even though IV access has been established, the best treatment to resolve his hypersensitivity reaction is
al
STILL intramuscular adrenaline.

Ev
Anaphylaxis algorithm:
1. ABC
2. Give high-flow oxygen
3. Lay the patient flat:
4. Adrenaline (epinephrine) intramuscularly (IM) in the anterolateral aspect of the middle third of
the thigh (safe, easy, effective).
The recommended doses for adrenaline are as follows:
Adrenaline
< 6 months 150 micrograms (0.15ml 1 in 1,000)

6 months - 6 years 150 micrograms (0.15ml 1 in 1,000)
6-12 years 300 micrograms (0.3ml 1 in 1,000)
Adult and child > 12 years 500 micrograms (0.5ml 1 in 1,000)
183
EM
Adrenaline is the most important drug in anaphylaxis and should be given intramuscularly as soon as
possible. Once adrenaline is administered, hydrocortisone and chlorpheniramine should follow.
15. An 18-year-old, previously well student in his first year at university, was brought in to the emergency
department in an agitated, deluded and disoriented state. What is the SINGLE most probable reason for
his condition?
A.
Drug toxicity
B.
Delirium tremens
C.
Infection toxicity
D.
E.
y
Head injury
op
Young age and first year in university is likely to point towards drug toxicity.
C
16. A 60-year-old woman with history of a urinary tract infection, hypertension and gallstones presents to
the emergency department. She complains of upper right abdominal pain, rigors and feeling unwell. Her
n
urine dipstick is negative for white cell and nitrates. She has a temperature of 38.9°C. Her blood pressure
io
is 88/55 mmHg, oxygen saturation of 92% on room air, pulse rate of 130 beats/minute and respiratory
rate of 24 breaths/minute. What is the SINGLE most likely diagnosis?
t
ua
A.
Sepsis
al
B.
Urinary tract infection
Ev
C.
Pre-eclampsia
D.
Septic shock
E.
Cirrhosis
This elderly woman has biliary sepsis probably due to a bile duct obstruction hence the upper right
abdominal pain. As the urine dipstick is negative, it is unlikely that she has a UTI.
As she was never given IV fluids, we are unable to say that she has septic shock given that the term
“septic shock” is defined as persistently low blood pressure which has failed to respond to the
administration of intravenous fluids.
The very important term to note in this stem is “rigors”. Rigors are episode of shaking or exaggerated
shivering and is classically seen in 2 scenarios:
184
EM
- Bacteraemia such as seen in biliary sepsis or sepsis from pyelonephritis

- Malaria
17. A 31-year-old man was knocked down during a fight in the waiting room of the emergency department.
He is now unconscious and unresponsive. What is the SINGLE most important first action?
A.
B.
Airway management
C.
Blood pressure measurement
D.
Assess Glasgow Coma Scale
E.
Initiate cardiac compressions
y
In this question, the examiners want you to know the basics of life-threatening emergencies. ABC -
op
airway, breathing, circulation should always be addressed first.
C
18. A 15-year-old girl is admitted in the medical ward after taking 28 tablets of paracetamol with a large
amount of alcohol. Her plasma paracetamol concentration taken 4 hours’ post ingestion is just below
the concentration that would suggest treatment with N-acetylcysteine. What is the SINGLE most
n

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A.
t
ua
Refer to psychiatric team

B.
Discharge home
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C.
Start N-acetylcysteine
Ev
D.
Activated charcoal
E.
Liver transplant
Referral to psychiatric team would be the most accurate option here. Acute alcohol consumption is an
inhibitor of P-450 enzyme system. Since she has consumed a large amount of alcohol acutely, the risk of
fatal effects of paracetamol poisoning would be reduced. Not to mention that her plasma paracetamol
concentration is below the treatment line thus she does not need to start N-acetylcysteine.
She does however need a psychiatric evaluation before she leaves the hospital as she was clearly trying
to harm herself.
Paracetamol (acetaminophen) poisoning
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EM


When to admit?
(For the exam, it can be quite time consuming to multiply 150mg with the weight of the patient. So we

y
op
C
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within 1 hour); or
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concentration; or
t
ua
al
19. A 70-year-old male presents with a 2-day history of productive cough and shortness of breath. He
complains of chills and rigors. He is ill-looking. He has a temperature of 38.5ºC, respiratory rate of 26
Ev
breaths/minute, and a pulse rate of 125 beats/min. His blood pressure is 88/45 mmHg and oxygen
saturation is 90% on room air. On auscultation, bronchial breath sounds are heard in the periphery. He is
given a fluid challenge of 1L normal saline. His blood pressure post fluid challenge is 90/40 mmHg. What
is the SINGLE best term to use in his condition?
A.
Sepsis
B.
Severe sepsis
C.
Septic shock
D.
Systemic inflammatory response syndrome (SIRS)
E.
Infection
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EM
Although, infection, sepsis, severe sepsis and SIRS are correct terms to use, the best term in this case is
septic shock.
Septic shock is defined as severe sepsis with persistently low blood pressure which has failed to respond
to the administration of intravenous fluids.
Sepsis vs SIRS
Sepsis SIRS - Systemic inflammatory response syndrome

Sepsis is defined as a life-threatening organ SIRS may occur as a result of an infection
dysfunction caused by a dysregulated host (bacterial, viral or fungal) or in response to a non-
response to infection infective inflammatory cause, for example burns or
pancreatitis
Septic shock is defined as:
• Persistently low blood pressure which Requires 2 of the following:
has failed to respond to the • Body temperature less than 36°C or greater
administration of intravenous fluids than 38.3°C
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• Heart rate greater than 90 beats/minute
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Evaluation for 'Red Flag' sepsis • Respiratory rate greater than 20
• Systolic blood pressure < 90 mmHg (or breaths/minute
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>40 mm Hg fall from baseline) • Blood glucose > 7.7mmol/L in the absence
• Heart rate >130 beats/minute of known diabetes
• Oxygen saturations < 91% (< 88% in • White cell count less than 4 or greater than
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COPD) 12
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• Respiratory rate >25 breaths/minute

• Responds only to voice or
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ua
pain/unresponsive
• Lactate >2.0 mmol
• Urine output < 0.5 ml/kg/hr for ≥ 2
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hours
Ev
Sepsis Six → Take 3, Give 3

Take 3
• Blood cultures
• FBC, urea and electrolytes, clotting,
lactate
• Start monitoring urine output
Give 3
• High flow oxygen
• Intravenous fluid challenge
• Intravenous antibiotics
Sepsis has always been hard to define and many diagnostic criterias has been proposed. There are a few
terms of which definitions will help you understand the topic of sepsis.
How is organ dysfunction identified?
187
EM
At the bedside, organ dysfunction is identified by an increase in the Sequential (Sepsis-related) Organ
Failure Assessment (SOFA) score of 2 points or more.
What is qSOFA?
In emergency department, or general hospital ward settings, adult patients with suspected infection can
be rapidly identified as being more likely to have poor outcomes typical of sepsis if they have at least 2 of
the following clinical criteria that together constitute a new bedside clinical score termed quickSOFA
(qSOFA):
- Respiratory rate of >=22/min
- Altered mentation
- Systolic blood pressure < =100 mmHg
qSOFA is becoming increasingly popular in UK hospitals to screen for sepsis and in future, may be more
important than NEWS score.
OLD TERMS
“Severe sepsis” are terms of the past that are no longer in use
y
“SIRS” is also a term that is no longer used clinically
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C
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t io
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al
Ev
20. A 9-year-old girl is brought by her mother to the A&E with stridor, wheezing and a rash. Her lips are
beginning to swell. The young girl came from visiting her friend at her farm house. What is the SINGLE
most appropriate treatment?
A.
B.
188
EM
C.
D.
0.3 ml adrenaline orally
E.
Intravenous chlorpheniramine
Adrenaline is by far the most important drug in anaphylaxis and should be given as soon as possible. This
girl is 9 years old hence 0.3ml of adrenaline is appropriate for her age (6 to 12 years old).
21. A 12-year-old girl when playing in the garden accidentally stepped on a hive and was bitten several
times. She has numerous wheals on her body and complains of severe itching which is worsening in the
last few hours. What is the SINGLE most appropriate management?
A.
Oral antihistamine
B.
y
IV antihistamine
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C.
IM adrenaline
D.
C
Oral ciprofloxacin
E.
n
Reassurance
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This girl is suffering from urticaria. Oral antihistamines would be indicated.

t
ua
Since this is an allergic reaction, the only two reasonable options are A and C in this question. However,
in the context of allergic reactions, IM adrenaline should only be used in anaphylactic shock whereby the
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patient would have breathing difficulties.

Ev
The followings are the indications of adrenaline in anaphylaxis:

1. Hoarseness of voice
2. Wheeze
3. Shortness of breath
4. Shock
5. Stridor
6. Swelling of the tongue and cheek
7. Facial swelling
If you see an urticaria like allergic reaction, with none of the following indications stated above for
adrenaline, then pick the oral antihistamine as the answer.
22. Parents of an 11-month-old baby want to know the steps for CPR for their child as they have recently
attended a funeral of their neighbour’s child who died very suddenly after an episode of apnoea. They
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EM
want to know what they can do if an event like this occurs. What is the SINGLE most appropriate advice
in regards to CPR for their child?
A.
Index and middle finger compression
B.
Compression with heel of one hand
C.
Compression with heel of two hands with fingers interlocked
D.
Compression with rescue breaths 30:2
E.
Give 2 rescue breaths before starting compression
This is a rare scenario in PLAB that you may encounter where both the answers are correct. Both A and D
are appropriate advice to give to the parents of the child. The doctors that write the PLAB test questions
may have written them prior to publishing new guidelines and this may be overlooked by the organizers.
y
When this occurs, the organizers for the PLAB test will award marks for both answers when evaluating
op
the papers. This is a very rare event but may still occur. Thus, do not spend too much time trying to
decide which is the right or wrong option between the two.
C
For health care provider and layperson
CPR should be started with the C:V ratio that is familiar and for most, this will be 30:2. The paediatric
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modifications to adult CPR should be taught to those who care for children but are unlikely to have to
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resuscitate them. The specific paediatric sequence incorporating the 15:2 ratio is primarily intended for
those who have the potential to resuscitate children as part of their role.
t
ua
In the case above, the parents are unlikely to need to resuscitate their child and a CPR C:V ratio that is
familiar which is 30:2 is appropriate. Note: that if you were a paediatrician you should be doing a C:V
al
ratio of 15:2 as you potentially need to resuscitate children as part of your role.
Ev
Note there are two options for chest compression. Either index and middle finger of one hand or grip the
chest in both hands in such a way that two thumbs can press on the lower third of the sternum.
Chest compression in infants:

- The lone rescuer should compress the sternum with the tips of two fingers.
- If there are two or more rescuers, use the encircling technique:
a. Place both thumbs flat, side-by-side, on the lower half of the sternum (as above), with the tips
pointing towards the infant’s head.
b. Spread the rest of both hands, with the fingers together, to encircle the lower part of the infant’s
rib cage with the tips of the fingers supporting the infant’s back.
c. Press down on the lower sternum with your two thumbs to depress it at least one-third of the
depth of the infant’s chest, approximately 4 cm.
Chest compression (only to be started after successful lung inflation). Aim for a rate of 100/min.
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EM
23. A 21-year-old lady after a heavy bout of drinking last night comes to the emergency department with
vomiting blood, feeling dizzy, and having intense abdominal pain. On examination, her limbs feel cold.
After initial resuscitation with oxygen and fluids, she still continues to bleed and continues to vomit
blood. She has a pulse of 130 beats/minute and blood pressure of 85/58 mmHg. What is the SINGLE next
best step?
A.
Clotting screen
B.
Ultrasound
C.
Computed tomography
D.
Endoscopy
E.
Intravenous omeprazole
y
This is a classic presentation of Mallory-Weiss syndrome (MWS). It is characterised by upper
op
gastrointestinal bleeding (UGIB) from mucosal lacerations in the upper gastrointestinal tract, usually at
the gastro-oesophageal junction or gastric cardia. Excessive alcohol ingestion is one of the main causes
C
as prolonged or forceful bout of vomiting can cause a tear in the upper gastrointestinal tract.
Light-headedness and dizziness and features associated with the initial cause of the vomiting - eg,
n
abdominal pain may be seen and are seen in this stem.
io
Resuscitation is a priority - maintain airway, provide high-flow oxygen, correct fluid losses by giving IV
t
ua
fluids. Intravenous blood can also be given in severe cases.
Haemodynamically unstable patients like in this stem should have endoscopy immediately after
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resuscitation. It is the primary diagnostic investigation and can be used to stop the bleeding.
Ev
Note proton pump inhibitor (PPI) use is not recommended prior to diagnosis by endoscopy. A Cochrane
review found PPI use at this stage was not associated with a reduction in re-bleeding, need for surgery or
mortality.
24. A 10-year-old boy is rushed to Accident & Emergency after his parents found him unconscious on the
kitchen floor. It is revealed that he ingested some medication belonging to his grandmother. His
grandmother was unable to identify which medications are missing. On examination, the child is
hypotensive with dilated pupils and dryness in the mouth. His ECG showed prolongation of the PR, QRS
and QT intervals. Which SINGLE most likely medication has he taken in excess?
A.
Amitriptyline
B.
Carbamazepine
C.
Digoxin
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EM
D.
Metoprolol
E.
Thiazide
The key to this question is trying to figure out what medication this child has taken and try to tie it in with
his signs and symptoms
Amitriptyline: causes drowsiness, hypothermia, hypotension, tachycardia, dry mouth, ECG shows
arrhythmias, particularly changes in the QRS width, dilated pupils
Carbamazepine: causes mydriasis and nystagmus, tachycardia, hypotension
Digoxin: The classic features of digoxin toxicity are nausea, vomiting, diarrhoea, abdominal pain,
headache, dizziness, confusion, delirium, vision disturbance (blurred or yellow vision). It is also associated
with cardiac disturbances including irregular heartbeat, ventricular tachycardia, ventricular fibrillation,
sinoatrial block and AV block
y
op
Metoprolol: bradycardia, hypotension, hypothermia, hypoglycaemia (especially in children), and seizures.
Myocardial conduction delays with decreased contractility typify the acute beta-blocker ingestion.
C
Thiazide: hypotension, fever, frequent urination, hypotension, muscle cramps and twitching
n
The two best contenders are amitriptyline and carbamazepine. However, the single best choice would be
io
Amitriptyline because of the ECG changes.

t
ua
25. A 30-year-old patient is brought to the emergency department after a road traffic accident. He has
multiple bruises on his chest and paradoxical breathing is observed. A chest X-ray shows a widened
mediastinum and right-sided pulmonary contusion. He has a pulse of 129 beats/minute, a blood
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pressure of 100/70 mmHg and a respiratory rate of 38 breaths/minute. He has severe chest pain and is
dyspnoeic. What is the SINGLE best management for his condition?
Ev
A.
16-gauge needle into the 2nd intercostal space on the left
B.
Intercostal block anaesthesia
C.
Endotracheal intubation and positive-pressure ventilation
D.
16-gauge needle into the 4th intercostal space on the right
E.
Consent the patient for surgery
To know the correct management, we first have to know what injury this patient is suffering from. This
patient has a flail chest.
Flail Chest:
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EM
A flail chest occurs as a result of a trauma to the chest, leading to at least 3 ribs becoming fractured or
broken, close together, with pieces of bone detaching from the chest wall. These segments of bone start
to move independently of the chest wall and in the opposite direction because of lung pressure. The
result is a “paradoxical respiration”
Cause:
- Fall (for example, off a bicycle or a horse)
- Blunt trauma to the chest
- Car accident
- Bone disease in the elderly.
Diagnosis:
Paradoxical respiration with shortness of breath and chest pain in a patient who has just had blunt chest
trauma raises the suspicion of a flail chest. Diagnosis is made on chest X-ray
Management:
a. Humidified oxygen
y
b. Analgesia - paracetamol / NSAIDS / Opiates / intercostal block / thoracic epidural (up to T4) +
op
splinting of injury
c. Intubation / mechanical ventilation - if worsening fatigue and RR
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26. A 47-year-old man was involved in a road traffic accident and was brought to the emergency
department by ambulance. He has signs of respiratory distress and has abdominal and chest pain. On
n
physical examination, no breath sounds are heard over the entire left lung field. A nasogastric tube is
io
seen curled into the left chest on a chest X-ray. What is the SINGLE most likely diagnosis?
t
ua
A.
Diaphragm rupture
B.
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Pneumothorax
C.
Ev
Splenic rupture
D.
Bowel perforation
E.
Gastric perforation
Diaphragmatic rupture (also called diaphragmatic injury or tear) is a tear of the diaphragm. It is usually
secondary to blunt trauma. The usual case would be someone in a car passenger seat involved in a car
accident where the seat belt compression causes a burst injury directed to the diaphragm. The pressure
within the abdomen raises so quickly with a sudden blow to the abdomen causing a burst in the
diaphragm. It is commonly on the left side.
Signs and symptoms include chest and abdominal pain, and respiratory distress. Breath sounds on the
side of the rupture may be diminished. Bowel sounds may be heard in the chest.
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EM
For your own knowledge, it is important to remember that chest X-ray to diagnose diaphragmatic
rupture is actually quite unreliable and has low sensitivity and low specificity. However, there are specific
signs detectable on X-ray which should raise suspicion. Diaphragmatic rupture is suspected in any patient
with a blunt trauma and a raised left hemi diaphragm on a chest X-ray. Air fluid levels in the chest may
also be seen. A nasogastric tube from the stomach may appear on the film in the chest cavity. This
particular sign with the NG tube curled into the left chest is pathognomonic for diaphragmatic rupture,
but it is rare.
Thoracoabdominal CT scan is usually diagnostic.
27. A 9-month-old child aspirated a foreign object which was removed at the hospital. The child is now fine.
His parents would like to know what they should do should this occur again. What is the SINGLE most
appropriate advice to give them?
A.
Heimlich manoeuvre
B.
y
Turn the infant into a supine position and give chest trust
op
C.
Turn the infant on his back and give five thrust to the middle of the back
D.
C
Place a clenched fist between the umbilicus and xiphisternum and give abdominal thrusts
E.
n
Turn infant into recovery position and open infant’s mouth

io
Choking and Foreign Body Airway Obstruction (FBAO) in Infants

t
ua
For infants:
- In a seated position, support the infant in a head-downwards, prone position to let gravity aid
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removal of the foreign body;

- Deliver up to five sharp blows with the heel of your hand to the middle of the back (between the
Ev
shoulder blades);
- After five unsuccessful back blows, use chest thrusts: turn the infant into a supine position and
deliver five chest thrusts. These are similar to chest compressions for CPR, but sharper in nature
and delivered at a slower rate.
28. A 32-year-old man rescued from a building on fire presents unconscious without any evidence of burns
and external injury. What is the SINGLE most appropriate management?
A.
B.
C.
D.
194
EM
E.
As this patient is unconscious, we need to intubate and provide IPPV on 100 % O2. For a conscious
patient use a tight-fitting mask with an O2 reservoir.
The decision for hyperbaric oxygen therapy (HBOT) is a difficult one and there are many debates about
the added value provided by hyperbaric oxygen. As this patient is unconscious one might suggest a
transfer to a hyperbaric chamber but even so, this will take time as you would need to call the Poisons
Information Service and find the nearest locations of hyperbaric chambers. In the current NICE guidelines,
treatment with hyperbaric oxygen is not currently recommended, because there is insufficient evidence
that hyperbaric oxygen therapy improves long-term outcomes of people with severe carbon monoxide
poisoning, compared with standard oxygen therapy. Thus, based on NICE guidelines, for any question
with CO2 poisoning, hyperbaric oxygen therapy will NOT be the answer.
If this question was rewritten and asked for “What is the SINGLE most appropriate INITIAL
management?”, then mask with 100% oxygen would be a valid answer because one would give 100%
y
oxygen by mask first while preparing for intubation.
op
Carbon monoxide poisoning: Carbon monoxide (CO) is a tasteless and odourless gas produced by
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incomplete combustion. Poisoning may occur from car exhausts, fires and faulty gas heaters. CO is also
produced by metabolism of methylene chloride (used in paint strippers and as an industrial solvent).
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CO decreases the oxygen-carrying capacity of the blood by binding haemoglobin (Hb) to form
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carboxyhaemoglobin (COHb). This impairs O2 delivery from blood to the tissues thus causing severe
tissue hypoxia.
t
ua
Clinical features - Early features are:

- Headache
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- Malaise
- Nausea and vomiting
Ev
In severe toxicity:
- 'Pink' skin and mucosae
- Hyperpyrexia
- Arrhythmias
- Coma with hyperventilation
Management:
Note: The elimination half-life of CO is about 4 hours on breathing air, 1 hour on 100% O2, and 23
minutes on O2 at 3 atmospheres pressure.
- Clear the airway
- Maintain ventilation with high concentration of O2
- For a conscious patient use a tight-fitting mask with an O2 reservoir, but if unconscious intubate
and provide IPPV on 100% O2
Indications for hyperbaric oxygen therapy (HBOT)
195
EM
There is debate about the added value provided by hyperbaric oxygen. Hyperbaric O2 therapy is logical,
but of no proven benefit for CO poisoning. Transfer to a hyperbaric chamber and pressurization may take
hours and so hyperbaric treatment may be no more effective than ventilation on 100 % normobaric O2.
Caring for a critically ill patient in a small pressure chamber may be impracticable.
A COHb concentration of >20% should be an indication to CONSIDER hyperbaric oxygen and the decision
should be taken on the basis of the indicators listed below:
Loss of consciousness at any stage
Neurological signs other than headache
Myocardial ischaemia/arrhythmia diagnosed by ECG
The patient is pregnant.
If there are any of the indications stated above, discuss with a Poisons Information Service and consider
hyperbaric treatment. The Poisons Information Service can advise on the location of hyperbaric
chambers. But note currently, the treatment with hyperbaric oxygen is not currently recommended by
NICE guidelines, because there is insufficient evidence that hyperbaric oxygen therapy improves long-
term outcomes of people with severe carbon monoxide poisoning, compared with standard oxygen
y
therapy.
29.
op
A 21-year-old man, who was heavily drinking a few hours ago at an evening party presents to A&E with a
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history of vomiting repeatedly during the night. He vomited fresh blood an hour ago. His vitals are stable
and his Hb is 15.3 g/dl. He has no further bleeding. What is the SINGLE most appropriate management?
n
A.
io
Admit and observe

B.
t
ua
Discharge with advice

C.
Endoscopy
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D.
Cross match 2 units of blood
Ev
E.
Administer vasopressin analogue
This patient has Mallory-Weiss tears from drinking too much alcohol.
As he is vitally stable, and haemoglobin count is high. The best plan is to discharge him home with
advice.
This is a very high yield question. Occasionally, the option of “discharge with advice” is not there, in
which case they would provide other correct options such as:
- Repeat FBC
- Observe vital signs for deterioration
30. An 18-year-old girl has taken an unknown dose of paracetamol yesterday. She cannot remember the
exact time she took the tablets. She is extremely anxious but otherwise asymptomatic. She has no past
196
EM
medical history. She weighs 55kg. BP 120/75 mmHg, heart rate is 100 bpm, SaO2 99% on air. Which is
A.
Activated charcoal
B.
Gastric lavage
C.
D.
Discharge home
E.
Psychiatric review
N-acetylcysteine infusion should be started if there is doubt over the time of paracetamol ingestion,
regardless of the plasma paracetamol concentration
y
The other options are incorrect:
op
Activated charcoal → should be considered if the overdose has been taken within 1 hour
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Gastric lavage → Would always be the wrong answer when dealing with paracetamol poisoning. The
British Poisons Centres only recommend the use of gastric lavage cases where medications have been
ingested that activated charcoal would absorb poorly (eg iron, lithium) and for sustained-release
n
formulations or enteric-coated tablets.
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Discharge home → Only If ingestion of paracetamol is < 150mg/kg in a child/adult with no hepatic risk
t
ua
factors
Urgent liver function tests + clotting screen → often no change in these values acutely.
al
Psychiatric review → would be needed eventually but much later in the management
Ev


When to admit?
197
EM
(For the exam, it can be quite time consuming to multiply 150mg with the weight of the patient. So we



within 1 hour); or
concentration; or
y
op
31. A 21-year-old man has been found unconscious in an alleyway with a respiratory rate of 5
breaths/minute and a pulse of 55 beats/minute. His pupils are constricted. What is SINGLE most
C
A.
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Methadone
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B.
Naloxone
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ua
C.
Flumazenil
D.
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Thiamine
E.
Ev
Dextrose
This is a classic case of opioid overdose. The word “alleyway” already gives the answer away. Respiratory
depression, bradycardia and miotic pupils support the clinical picture. Naloxone is used to block the
effects of opioids, especially in overdose.
32. A 24-year-old male presents to A&E with 40% partial thickness burns. His pulse rate is 105 bpm and
respiratory rate is 25 breaths per minute. His systolic blood pressure is 80 mmHg. What is the SINGLE
A.
B.
C.
Oral rehydration
198
EM
D.
IV dextrose stat
E.
Ointments
We use the Parkland formula to count the fluids required after burns. This is calculated from the time of
the burn rather than the time of presentation. If the presentation is delayed, fluid may need to be given
more rapidly
PARKLAND FORMULA:
Fluid Requirements = Body area burnt (%) x Wt (kg) x 4mL. (use Hartmann’s).
Give 1/2 of total requirements in 1st 8 hours, then give 2nd half over next 16 hours.
The area of body burn is calculated by adding the percentage of burns in each area using the rule of 9’s:
9% head and neck, 9% each upper limb, 18% each lower limb, 18% front of trunk, 18% back of trunk, 1%
Palmar surface of the hand, including fingers, 1% Perineum
y
op
33. A 35-year-old man had a fight in a bar which involved blunt trauma to his head. Since the injury, he has
developed bleeding from the auditory meatus associated with ringing and hearing loss in his ear. Clear
C
fluid is seen coming from his nose. What is the SINGLE most appropriate investigations of choice?
A.
n
Computed tomography scan of brain

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B.
X-ray skull
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ua
C.
Otoscopy
D.
al
Magnetic resonance imaging of head

E.
Ev
Coagulation study
Any suspicion of a base of skull fracture should prompt a CT scan of the brain. The bleeding from ear
from auditory meatus and rhinorrhoea are signs of basilar skull fracture.
Signs of base of skull fracture - Often a clinical diagnosis. One or more of the following may be seen:
- Bilateral orbital bruising confined to the orbital margin (‘Raccoon eyes’)
- Subconjunctival haemorrhage
- Haemotympanum or bleeding from the auditory meatus
- CSF otorrhoea or rhinorrhoea (sometimes with anosmia)
- Battle’s sign: bruising over the mastoid process without local direct trauma follows petrous
temporal bone fracture, this can sometimes take several days to appear
CT scan for adults if:

- Glasgow Coma Scale (GCS) < 13 when first assessed or GCS < 15 two hours after injury
- Suspected open or depressed skull fracture
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EM
- Signs of base of skull fracture

- Post-traumatic seizure
- Focal neurological deficit
- More than 1 episode of vomiting
- Coagulopathy or on oral anticoagulants
34. A 24-year-old man was under the custody of police when he was punched. He is now cyanosed and
unresponsive. What is the SINGLE most appropriate initial action?
A.
IV fluids
B.
Clear airway
C.
D.
Give 100% oxygen
y
E.
op
Analgesia C
n
35. An 8-year-old boy is rushed into A&E coughing, cyanosed and with a urticaria rash. His mother tells the
io
staff that he began to cough after eating a cookie at a garden party. What is the SINGLE most likely
diagnosis?
t
ua
A.
Aspiration of food
al
B.
Allergic reaction
Ev
C.
Diffuse Esophageal Spasm
D.
Tracheoesophageal fistula
E.
Achalasia
This boy is having anaphylaxis which is a type of allergic reaction.
The other options are far less likely:
Aspiration of food → Although this makes sense and many will choose this, aspiration of food will not
account for the urticarial rash seen on this boy.
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EM
Diffuse Esophageal Spasm → usually presents with intermittent chest pain and dysphagia. The pain can
simulate that of a myocardial infarction, but it bears no relationship with exertion. There is no
relationship with eating, ruling out odynophagia. The pain can be precipitated by drinking cold liquids.
Tracheoesophageal fistula → is suggested in a newborn by copious salivation associated with choking,

coughing, vomiting, and cyanosis coincident with the onset of feeding.
Achalasia → presents with slowly progressive dysphagia. Initially worse for liquids than solids. Frequent
regurgitation of undigested food is common in late disease. Secondary recurrent respiratory infections
can occur due to aspiration. Achalasia cannot present suddenly like in this scenario.
Anaphylaxis
Clinical features: The speed of onset and severity vary with the nature and amount of the stimulus, but
the onset is usually in minutes/hours.
Respiratory: Swelling of lips, tongue, pharynx, and epiglottis may lead to complete upper airway
occlusion. Lower airway involvement is similar to acute severe asthma e.g. dyspnoea, wheeze, chest
y
tightness, hypoxia, and hypercapnia.
Skin: Pruritus, erythema, urticaria, and angio-oedema.

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Cardiovascular: Peripheral vasodilation and increased vascular permeability cause plasma leakage from
the circulation, thus causing hypotension, and shock.
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36. A 33-year-old woman has recurring tightness in her chest accompanied by palpitations and sweating.
These episodes occur several times a week and are associated with increased respiratory rate and
t
ua
tingling and numbness around the mouth and fingers. What is the SINGLE most likely diagnosis?
A.
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Pericarditis
B.
Ev
Stable angina
C.
Panic attack
D.
Gastro-oesophageal reflux disease
E.
Aortic aneurysm
In panic attacks, perioral paresthesia, tingling and numbness in the hands can occur due to
hyperventilation and CO2 washout leading to low ionic calcium. The description of tightening with
palpitations fits with panic attacks.
Panic attacks
Period of intense fear characterized by a constellation of symptoms that develop rapidly, reach a peak of
intensity in about 10min, and generally do not last longer than 20–30min (rarely over 1 hour). Attacks
201
EM
may be either spontaneous (‘out of the blue’) or situational (usually where attacks have occurred
previously).
Symptoms/signs
- Tremor
- Tachycardia
- Tachypnoea,
- Sweating
- Concerns of death from cardiac or respiratory problems
They may complain of dizziness, circumoral paraesthesia, carpopedal spasm, and occasionally sharp or
stabbing chest pain. Initial examination would reveal tachypnoea with equal air entry over both lung
fields, and no wheeze or evidence of airway obstruction. It is important to consider secondary causes
(such as PE or DKA). Therefore, perform the following investigations:
• SpO2
• ECG
y
• ABG if SpO 2 ↓, or if symptoms do not completely settle in a few minutes
op
• BMG C
If symptoms do not completely settle in a few minutes, obtain:
• CXR
• U&E, blood glucose, FBC
n
io
Treatment
Do not sedate a patient who is hyperventilating. Once serious diagnoses have been excluded, use this
t
ua
information to help reassure the patient with primary hyperventilation. Often this is all that is required,
but it may be helpful to try simple breathing exercises (e.g. breathe in through nose)
al
37. A 16-year-old girl has taken an overdose of 34 paracetamol tablets earlier this morning. She is extremely
anxious but otherwise asymptomatic. She has no past medical history. Paracetamol plasma levels were
Ev
taken at 4 hours from time of overdose and is above the treatment line. She weighs 55kg. BP 120/75
mmHg, heart rate is 100 bpm, SaO2 99% on air. Which is the SINGLE most appropriate next step?
A.
Activated charcoal
B.
Gastric lavage
C.
D.
Discharge home
E.
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EM
38. A 34-year-old man had a car crash and is being observed in the emergency department. He is slowly
deteriorating and his GCS has fallen from 13 to 7. What is the SINGLE most appropriate next step in
management?
A.
CT
B.
Burr hole
C.
MRI
D.
Intubation
E.
IV fluids
Intubate and ventilate all patients with GCS 8 or less. This should be done first before anything else. (ABC
protocol)
y
op
39. A 31-year-old man was involved in a road traffic accident and has severe pain at the right outer upper
thigh and groin. There is clear deformity of the hip and shortening of the right leg. A femoral shaft
C
fracture is suspected. His blood pressure is 100/70 mmHg. He has a heart rate of 90 beats/minute and a
respiratory rate of 19 breaths/minute. He is saturating at 97% at room air. What is the SINGLE most
appropriate next action?
n
io
A.
Anteroposterior pelvic and lateral hip X-rays
t
ua
B.
Intravenous fluids
C.
al
Thomas' splint
D.
Ev
Full blood count and cross match

E.
Magnetic resonance imaging (MRI)
In any trauma associated emergency, including fractures of the shaft of the femur, we should apply
Advanced Trauma Life Support principles and attend to the femur only once we are happy with our
ABCDEs. As this patient is clinically stable, we should move on to attend the femur by by splinting it.
Intravenous fluids, full blood count and cross match would also be performed but since in this question,
he is clinically stable, we should perform a Thomas’ splint first. Putting a splint will improve alignment
and reduce ongoing blood loss. Blood loss in a femur shaft fracture is alarming as blood loss is significant.
In reality, you would have more than one doctor and health care professional in this scene, thus one
would be putting an IV cannula and sending bloods while the others would be splinting the leg.
Imaging is important but can be done at a later time.
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EM
40. A 23-year-old woman has been found unconscious by her partner. There are several packets of
paracetamol and an empty bottle of vodka alongside her. When she comes to in the Emergency
Department, she is confused and unable to estimate when she took the tablets. Her Glasgow Coma Scale
(GCS) score is 14/15. Which is the SINGLE most appropriate next step?
A.
CT Head
B.
Haemodialysis
C.
Start N-acetylcysteine immediately
D.
Start N-acetylcysteine 4 hours after presentation
E.
Take paracetamol levels and treat if raised
In cases like this where a serious overdose is suspected, give paracetamol antidote N-acetylcysteine
y
immediately. The amount of paracetamol taken is known in this question. N-acetylcysteine infusion
op
should be started if there is doubt over the time of paracetamol ingestion, regardless of the plasma
paracetamol concentration.
C
The 4-hour figure refers to the time after ingestion at which plasma levels can be interpreted. If levels
turn out to be below the treatment line, N-acetylcysteine can be stopped.
n
io
Paracetamol (acetaminophen) poisoning:

t
ua
- Initial features → Nausea, vomiting, pallor

- After 24 hours → Hepatic enzymes rise
- After 48 hours → Jaundice, an enlarged, tender liver
al

Ev

When to admit?
(For the exam, it can be quite time consuming to multiply 150mg with the weight of the patient.
So, we would advise you to use the number 24 as a benchmark whereby if the patient consumes
more than 24 tablets (12 g) of paracetamol, then you admit him/her)


204
EM

within 1 hour); or
concentration; or
41. A 27-year-old man presents to the emergency department after a road traffic accident where his right
foot was stuck under a truck for several hours. On examination, his right foot is swollen and tender.
Sensation is reduced between the space of the 3rd metatarsal and big toe. His dorsalis pedis pulse is not
felt. What is the SINGLE most likely diagnosis?
A.
B.
y
Artery rupture
op
C.
Arterial embolism
D.
C
E.
n
Fibular fracture
io
The diagnosis here is clearly compartment syndrome given the history of the prolonged limb
t
ua
compression. The reason the dorsalis pedis pulse is not felt is because arterial blood inflow is reduced
when pressure exceeds systolic blood pressure. Note that sensory deficit may occur in the distribution of
nerves passing through the compartment which explains the reduced sensation in this stem. Muscle
al
tenderness and swelling are also a part of the clinical features seen in compartment syndrome.
Ev
Compartment syndrome is a painful and potentially serious condition caused by bleeding or swelling
within an enclosed bundle of muscles (a muscle 'compartment').
Acute compartment syndrome occurs after a traumatic injury such as a car crash. The trauma causes a
severe high pressure in the compartment which results in insufficient blood supply to muscles and nerves.
Acute compartment syndrome is a medical emergency that requires surgery to correct. If untreated, the
lack of blood supply leads to permanent muscle and nerve damage and can result in the loss of function
of the limb.
42. A 32-year-old woman starts bleeding profusely in theatre during an elective caesarean section. She had
a spinal block and was awake throughout the procedure. She is now found to be unconscious. Her BP
has dropped to 70/40 mmHg. What is the SINGLE most likely diagnosis?
A.
205
EM
Primary haemorrhage
B.
C.
D.
Pulmonary embolism
E.
Septic shock
Primary Haemorrhage occurs at the time of surgery. It is due to inadequate haemostasis at the time of
surgery or the displacement of a tie from the inferior pedicle. Treatment involves replacing blood. If
severe, return to theatre for adequate haemostasis.
It is actually quite unlikely that a pregnant lady bleeds heavily during a caesarean section as pregnancy
by itself is a thrombogenic state.
y
The other options given are less likely:
op
Reactionary Haemorrhage → occurs within the first 24 hours following trauma/surgery. It is usually
C
caused by slipping of ligatures, dislodgement of clots, patient warming up after surgery causing
vasodilation, on top of normalization of blood pressure. Haemostasis appears secure until BP rises and
bleeding starts. Treatment usually involves replacing blood and re-exploring the wound.
n
io
Secondary Haemorrhage → Usually caused by necrosis of an area of blood vessel, related to previous
repair and is often precipitated by wound infection. It occurs 1–2 weeks post-op.
t
ua
Pulmonary embolism → There are no signs or symptoms here to indicate that this is pulmonary embolism
al
Septic shock → There are no signs or symptoms of infection to indicate sepsis

Ev
43. A 35-year-old patient is brought to the emergency department after having a road traffic accident. He
has bruises on his chest. A chest X-ray shows a widened mediastinum. He has a pulse of 129
beats/minute, a blood pressure of 80/40 mmHg and a respiratory rate of 34 breaths/minute. What is the
A.
B.
Abdominal aortic aneurysm
C.
Thoracic aortic rupture
D.
Flail chest
E.
Pleural effusion
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EM
The condition is frequently fatal due to the profuse bleeding that results from the rupture. By far the
most common site for tearing in traumatic aortic rupture is the proximal descending aorta.
The classical findings on a chest X-ray of a aortic rupture will be widened mediastinum and displacement
of the trachea. A widened mediastinum occurs when a traumatic pseudo aneurysm changes the contour
of the mediastinum or more commonly when mediastinal haemorrhage or haematoma occurs.
44. A 55-year-old women recovering from a surgery for a toxic goitre is found to be cyanosed in the
recovery room. Her neck is tense and her BP is 85/45 mmHg. There is blood oozing from the drain. What
A.
Primary haemorrhage
B.
C.
y
D.
op
Thyroid storm
E.
Tracheomalacia
C
Reactionary Haemorrhage occurs within the first 24 hours following trauma/surgery. It is usually caused
n
by slipping of ligatures, dislodgement of clots, patient warming up after surgery causing vasodilation, on
io
top of normalization of blood pressure. Haemostasis appears secure until BP rises and bleeding starts.
Treatment usually involves replacing blood and re-exploring the wound.
t
ua
Hypotension, tense neck and blood oozing from drain tells us that the patient is probably bleeding. As the
patient is still in recovery room, it is likely that the surgery is recent (less than 24 hours) thus the
al
diagnosis of reactionary haemorrhage.

Ev
The other options given are less likely:
Primary Haemorrhage → Occurs at the time of surgery. It is due to inadequate haemostasis at the time
of surgery or the displacement of a tie from the inferior pedicle. Treatment involves replacing blood. If
severe, return to theatre for adequate haemostasis.
Secondary Haemorrhage → Usually caused by necrosis of an area of blood vessel, related to previous
repair and is often precipitated by wound infection. It occurs 1–2 weeks post-op.
Thyroid storm → is an extreme form of thyrotoxicosis. This is an endocrine emergency. It is precipitated

by stress, infection, surgery, or trauma. It is manifested by extreme irritability, delirium, coma,
tachycardia, restlessness, vomiting, jaundice, diarrhea, hypotension, dehydration, and high fever.
Tracheomalacia → refers to tracheal weakness. It is an abnormal collapse of the tracheal walls.

Tracheostomy or endotracheal intubation can damage the tracheal cartilage at the stoma or inflatable
207
EM
cuff site, respectively, which weakens the tracheal wall. The major symptoms and signs of TM in adults
are dyspnea, cough, and sputum retention. Wheezing or stridor may also exist.
45. A 5-year-old boy with a febrile convulsion lasting eight minutes. He has been given IV lorazepam to
control his seizures. What is the SINGLE most likely side effect of IV lorazepam that is potentially life
threatening?
A.
Amnesia
B.
Anaphylactic shock
C.
Apnoea
D.
Bronchospasm
E.
Cardiac arrhythmia
y
op
Lorazepam is a benzodiazepine. Respiratory depression is a known effect of benzodiazepine overdose.
Amnesia can occur as well, but it will not be life threatening.
C
Side effects of benzodiazepines include:
n
- sedation
io
- cognitive impairment
- respiratory depression
t
ua
- hypotension
- anterograde amnesia
al
46. A 34-year-old man was involved in a road traffic accident. Whilst in the ambulance his Glasgow Coma
Ev
Scale deteriorates from a score of 13 to 9. His respiratory rate increases from 30 to 48 breaths/minute.
A.
Intravenous fluids
B.
Needle thoracentesis
C.
100% oxygen
D.
Portable X-ray
E.
He is in the ambulance. It is obvious that his demand for oxygen has increased due to an increased
respiratory rate. 100% oxygen would be a suitable option as part of the initial management. One would
208
EM
not do a needle thoracentesis unless there were clinical features of a tension pneumothorax like a
deviated trachea.
47. A 47-year-old man had a road traffic accident and has presented to A&E with multiple injuries. On
physical examination, perineal bruising was noticed. A pelvic fracture has been confirmed. He has not
passed urine since the accident which was 7 hours ago. What is the SINGLE most appropriate next
course of action?
A.
Urethral catheterization
B.
Suprapubic catheterization
C.
IV fluids
D.
IV furosemide
E.
y
Insulin
op
The pelvic fracture and perineal bruising indicate that there may be a urethral injury. If you suspect a
C
urethral injury, do not attempt to perform urethral catheterization. In PLAB part 1, the option of
suprapubic catheterization is usually given. Pick that.
n
Urethral injuries
io
Posterior urethral tears are often associated with pelvic fractures. Urethral injury may also result from
blows to the perineum. Look for perineal bruising and blood at the external urethral meatus and perform
t
ua
a rectal examination (an abnormally high-riding prostate or inability to palpate the prostate imply
urethral injury).
al
If urethral injury is suspected, do not attempt urethral catheterization, but refer urgently to the urology
team. Some urologists perform a retrograde urethrogram to assess urethral injury, but many prefer
Ev
suprapubic catheterization and subsequent imaging.
48. A 76-year-old woman has become tired and confused following an influenza like illness. She is vomiting
and with abdominal pain. She is also breathless with signs of consolidation of the left lung base. Her
temperature is 39.0 °C. She has a blood pressure of 80/60 mmHg A blood count showed:
Haemoglobin 120 g/L

A.
Drug toxicity
B.
Delirium tremens
209
EM
C.
D.
Hypoglycaemia
E.
Symptoms of toxic shock syndrome vary depending on the underlying cause. Toxic shock syndrome
resulting from infection with the bacterium Staphylococcus aureus typically manifests in otherwise
healthy individuals with high fever, accompanied by low blood pressure, malaise and confusion, which
can rapidly progress to stupor, coma, and multiple organ failure.
The characteristic rash, often seen early in the course of illness, resembles a sunburn, and can involve any
region of the body, including the lips, mouth, eyes, palms and soles.
y
In patients who survive the initial phase of the infection, the rash desquamates, or peels off, after 10–14
op
days. C
WBC is usually increased and platelets are decreased (platelet count < 100,000 / mm³)
Signs and symptoms of toxic shock syndrome:

n
- Body temperature > 38.9 °C
io
- Systolic blood pressure < 90 mmHg

- Diffuse macular erythroderma
t
ua
- Desquamation (especially of the palms and soles) 1–2 weeks after onset.
Involvement of three or more organ systems:

al
- Gastrointestinal (vomiting, diarrhea)

- Muscular: severe myalgia or creatine phosphokinase level elevation
Ev
- Mucous membrane hyperemia

- Kidney failure
- Liver inflammation
49. A 19-year-old man is rushed into A&E by his friends who left him immediately before they could be
interviewed by the medical staff. He is semiconscious. His respiratory rate is 7/min, blood pressure is
120/75 mmHg, and pulse rate is 60 bpm. He is noted to have needle track marks on his arms and he has
pinpoint pupils. What is the SINGLE most appropriate management?
A.
Insulin
B.
Naloxone
C.
Methadone
D.
210
EM
Gastric lavage
E.
Flumazenil
Coma with slow respiration and pinpoint pupils is typical of opioid poisoning, give naloxone
The other points that point towards an opioid overdose in this question are:
- Friends who did not want to be interviewed by medical staff
- Reduced consciousness
- Low respiratory rate
- Needle track marks on his arm
50. A 13-year-old boy presents with recurrent episodes of facial and tongue swelling. He also complains of
abdominal pain which occurs occasionally. His father has had similar episodes. What is the SINGLE most
likely diagnosis?
A.
y
C1 esterase inhibitor deficiency
op
B.
Nephrotic syndrome
C.
C
Acute urticaria
D.
n
Anaphylaxis
io
E.
Sjogren’s syndrome
t
ua
Hereditary angioedema (C1 esterase inhibitor deficiency)

- Rare genetic condition causing episodes of angioedema which includes life-threatening laryngeal
al
oedema
Ev
The stem would usually include

- A positive family history
- Onset from childhood of episodes of angioedema affecting the larynx
Sometimes impairing respiration and GI system, causing abdominal pain, and vomiting.
Confirmed by:
- Low levels of C-esterase inhibitor and complement studies during the acute episode
51. A 25-year-old male with a history of frequent binge drinking presents 4 hours after having had a
takeaway meal following a night's heavy drinking. He complains of nausea and has vomited on several
occasions. After the last vomiting episode, he vomited approximately a cupful of blood. On admission,
he smells of alcohol, pulse of 100 beats/minute, blood pressure of 140/80 mmHg. He has some
tenderness in the epigastrium. What is the SINGLE most likely diagnosis?
A.
211
EM
Gastric carcinoma
B.
Mallory-weiss tear
C.
Oesophageal carcinoma
D.
Oesophageal varices
E.
Peptic ulcer
This is a classic presentation of Mallory-Weiss syndrome (MWS). It is characterised by upper

gastrointestinal bleeding (UGIB) from mucosal lacerations in the upper gastrointestinal tract, usually at
the gastro-oesophageal junction or gastric cardia. Excessive alcohol ingestion is one of the main causes
as prolonged or forceful bout of vomiting can cause a tear in the upper gastrointestinal tract.
Resuscitation is a priority - maintain airway, provide high-flow oxygen, correct fluid losses by giving IV
fluids. Intravenous blood can also be given in severe cases.
y
op
Haemodynamically unstable patients like in this stem should have endoscopy immediately after
resuscitation. It is the primary diagnostic investigation and can be used to stop the bleeding.
C
Note, proton pump inhibitor (PPI) use is not recommended prior to diagnosis by endoscopy. A Cochrane
review found PPI use at this stage was not associated with a reduction in re-bleeding, need for surgery or
n
mortality
io
52. A 14-year-old boy fell and hit his head in the playground school. He did not lose consciousness but has
t
ua
swelling and tenderness of the right cheek with a subconjunctival haemorrhage on his right eye. What is
the SINGLE most appropriate initial investigation?
al
A.
Head CT
Ev
B.
Electroencephalogram
C.
Head MRI
D.
Skull X-ray
E.
Facial X-ray
There is no feature of intracranial haemorrhage but the swelling and tenderness of right cheek are likely
to indicate a facial injury. So, the most appropriate initial investigation is a facial x-ray.
53. An 18-month-old boy pulled over a cup of hot tea that was on a high table. The hot liquid splashed over
him and he now presents with a 6% partial thickness burn on his chest. What is SINGLE best treatment
for him?
212
EM
A.
IV crystalloids
B.
IV colloids
C.
No need for IV treatment
D.
IV dextrose bolus
E.
IV albumin infusion
Any child with more than 10% of the total body surface area burned requires fluid replacement. Here
there is only 6% partial thickness burns.
54. Parents of a 3-year-old child have recently attended a funeral of their neighbour’s son who died
following a cardiorespiratory arrest. They want to know the algorithm for paediatric basic life support
should their 3-year-old child has an arrest. What is the SINGLE most accurate advice would you give?
y
op
A.
Ratio of 5 compression to 1 breath
B.
C
Ratio of 5 compression to 2 breaths
C.
n
Ratio of 15 compressions to 2 breaths with nose pinched

io
D.
Ratio of 15 compressions to 2 breaths without nose pinched
t
ua
E.
Ratio of 30 compressions to 2 breaths
al
15 compressions to 2 breaths with nose pinched is the answer. For a child over 1 year old, pinch the soft
part of his nose closed with the index finger and thumb of your hand on his forehead when giving rescue
Ev
breaths.
213
EM
y
op
C
n
t io
ua
al
Ev
55. A 78-year-old woman presents to A&E with severe epigastric pain and vomiting. The pain is referred to
her right shoulder. Generalised rigidity is noted when examining. She has a temperature of 37.2°C and a
pulse of 102 beats/minute. Her medical history is significant for rheumatoid arthritis. What is the SINGLE
A.
Ultrasound Abdomen
B.
Sigmoidoscopy
C.
Colonoscopy
D.
Erect chest X-ray
E.
214
EM
Upper GI endoscopy
The history of rheumatoid arthritis tells you that she is more than likely to be taking NSAIDS to manage
with the pain. This is a risk factor for peptic ulcer which if perforates gives the signs and symptoms that
she is describing...
Perforation of a peptic ulcer causes an acute abdomen with epigastric pain that may progress to
generalised rigidity. Shoulder tip pain suggest is seen in perforation.
A diagnosis is made by taking an erect abdominal/chest X-ray. Air under the diaphragm gives the
diagnosis of a perforation.
56. A 23-year-old girl presented with perioral paraesthesia and carpopedal spasm 20 minutes after a huge
argument with her boyfriend. What is the SINGLE most appropriate next course of action?
A.
SSRI
y
B.
op
Diazepam
C.
Rebreathe into a paper bag
C
D.
Propranolol
n
E.
io
Alprazolam
t
ua
In panic attacks, perioral paresthesia, tingling and numbness in the hands can occur due to
hyperventilation and CO2 washout leading to low ionic calcium. The history of argument with her
boyfriend could have elicit a panic attack. Rebreath into a paper bag will help to increase CO2 levels and
al
resolve symptoms.
Ev
Panic attacks
previously).
Symptoms/signs:
- Tremor
- Tachycardia
- Tachypnoea,
- Sweating
215
EM
• SpO2
• ECG
• ABG if SpO 2 ↓, or if symptoms do not completely settle in a few minutes
• BMG

• CXR
Treatment:
y
op
57. Which of the following formulas is used for calculating fluids for burn patients?
Plab Lab Values
C
A.
4 x weight(lbs) x area of burn (in ml of fluids)
n
B.
io
4 x weight(kgs) x area of burn (in L of fluids)

C.
t
ua
4 x weight(kgs) x area of burn (in ml of fluids)

D.
4 x weight(lbs) x area of burn (in L of fluids)
al
E.
4.5 x weight(kgs) x area of burn (in dL of fluids)
Ev
more rapidly.
PARKLAND FORMULA
Fluid Requirements = Body area burned (%) x Wt (kg) x 4mL. (use Hartmann’s).
216
EM
58. A butcher comes to the emergency department after accidentally stabbing his groin with a knife. He
tried to use a towel to stop the bleeding but has bled so much that the towel is now soaked with blood.
His blood pressure is 80/50 mmHg and pulse is 130 beats/minute. What percentage of circulatory blood
did he lose?
A.
<15%
B.
15-30%
C.
30-40%
D.
40-50%
E.
>50%
Stages of hypovolemic shock
y
op
For adults, the clinical staging relating to loss of blood volume can be classified as:
C
Stage 1 Stage 2 Stage 3 Stage 4
n
Blood loss 10- 15-30% 30-40% Over 40%
15%
io
Blood Normal Postural Hypotension Marked hypotension

t
pressure hypotension
ua
Heart rate Normal Slight tachycardia Tachycardia Extreme tachycardia

(> 100 bpm) (> 120 bpm) (>140 bpm)
al
Ev
Respiratory Normal Increased Tachypnoea Extreme tachypnoea

rate (> 20) (> 30)
Mental status Normal Slight anxiety, Altered, Decreased consciousness,
restless confused lethargy, or coma
Urine output Normal 20-30 mL/hour Less than 20 No urine output

ml/hour
It may be difficult to remember all these values and features of stages of hypovolemic shock. The best
suggestions are to just memorise the heart rate and base your answer on that. The examination
questions usually would give a history of blood loss and the patient’s heart rate. With the heart rate
alone, you should be able to tell which clinical stage he is in. You would also need to memorize the
amount of blood loss in each stage e.g. 30-40% in stage 3.
217
EM
59. A 4-year-old child playing with toys unattended suddenly develops breathlessness and stridor and is
rushed into the hospital by his father. The child is drooling and unable to swallow. What is the SINGLE
best investigation likely to lead to a diagnosis?
A.
Laryngoscopy
B.
Chest X-ray
C.
Peak flow meter
D.
Arterial blood gas
E.
Pulse oximeter
Breathlessness and stridor in a child playing with toys is most likely due to aspiration of a foreign body
(e.g. a part of the toy) for which indirect laryngoscopy and/or fibre-optic examination of the pharynx
y
would provide a diagnosis.
op
Remember, the ingestion of foreign bodies is most commonly a problem in young children aged 6
months to 5 years.
C
60. A 24-year-old male presents to A&E with 40% partial thickness burns after having been in a house fire.
n
His pulse rate is 115 bpm and respiratory rate is 29 breaths per minute. His systolic blood pressure is 80
io
mmHg. What is the SINGLE most appropriate management?

t
ua
A.
B.
al

C.
Ev
Oral rehydration
D.
IV dextrose stat
E.
IV morphine
These are the steps that you need to know for the treatment of burns for PLAB 1. Note the order.
- Large-calibre intravenous lines must be established immediately in a peripheral vein. Any adult
with burns affecting more than 15% of the total body surface area burned or a child with more
than 10% of the total body surface area burned requires fluid replacement calculated from the
time of the burn.
- Ensure adequate analgesia: strong opiates should be used.
- Prevent hypothermia.
218
EM
more rapidly.
PARKLAND FORMULA
Fluid Requirements = Body area burned (%) x Wt (kg) x 4mL. (use Hartmann’s).
61. An 18-year-old female was brought into the ED after ingestion of 28 paracetamol tablets after breaking
up with her boyfriend. She came in confused and unwell. She was admitted in the medical ward and N-
Acetylcysteine was given. 24 hours later, her laboratory results show a normal FBC, an arterial pH of 7.1,
Prothrombin time of 17 seconds and creatinine of 255μmol/L. She is still confused and lethargic. What is
y
Normal Lab values:

op
C
pH 7.35–7.45
Prothrombin time (PT): 11-14 sec
n
io
A.
Observe for another 24 hours
t
ua
B.
C.
al
Intravenous fluids
D.
Ev
Administer charcoal
E.
Liver transplantation
Her arterial pH is 7.1 which is an indication for liver transplantation.
King's College Hospital criteria for liver transplantation (paracetamol liver failure)
Arterial pH < 7.3, 24 hours after ingestion or all of the following:
- prothrombin time > 100 seconds
- creatinine > 300 µmol/l
- grade III or IV encephalopathy
Generally, if one takes more than 24 tablets (12g), we admit.
Paracetamol poisoning is always dealt in the medical ward (not psychiatry ward). Only once treated and
stable can they move to a psychiatric ward for evaluation.
219
EM


If ingestion of paracetamol is < 150mg/kg in a child/adult with no hepatic risk factors
When to admit?
- (For the exam, it can be quite time consuming to multiply 150mg with the weight of the patient.
So, we would advise you to use the number 24 as a benchmark whereby if the patient consumes
more than 24 tablets (12 g) of paracetamol, then you admit him/her)
y
op
C
n
io

t
ua
within 1 hour); or
concentration; or
al
Ev
62. A 34-year-old man was brought to the ED after a road traffic accident. His blood pressure is 50/0 mmHg
and respiratory rate is 34 breaths/minute. His chest wall is not moving symmetrically. What is the
SINGLE most appropriate initial action?
A.
IV fluid infusion
B.
Intubation and ventilation
C.
Analgesia
D.
Transfer to ITU
E.
Chest X-ray
220
EM
This patient is in shock. In reality, high flow oxygen, securing venous access and analgesia would all be
done simultaneously. But for the purpose of this exam, we should know the steps according to NHS
guidelines and British references. Thus, securing airways and giving oxygen would come before anything
else.
Management of Shock
- Investigation and treatment should occur simultaneously.
- Address the priorities → ABC
- High flow O2 by mask
- Secure adequate venous access and take necessary bloods for investigation
- Resuscitation is usually started with crystalloid, such as normal saline or Hartmann's solution →
20 mL/kg as bolus
63. A 24-year-old man comes into the emergency department with partial thickness burns all over his body
y
from a house fire. He has persistent cough and stridor. There are deep neck burns, carbonaceous
op
sputum and soot in the mouth and oedema of the oropharynx. What is the SINGLE most appropriate
management?
C
A.
Topical antibiotics
n
B.
io
Fluid resuscitation
C.
t
ua
Immediate burn care and cooling

D.
Intravenous analgesia
al
E.
Tracheal intubation
Ev
swelling, call for senior ED help and a senior anaesthetist immediately. Urgent general anaesthesia and
tracheal intubation may be life-saving.
Signs and symptoms of smoke inhalation injury

- Persistent cough
- Stridor
- Wheezing
221
EM

64. A 25-year-old woman has been feeling anxious and nervous for the last few months. She also complains
of palpitations and tremors. Her symptoms develop rapidly and last for a few minutes. She mentions
that taking alcohol initially helped her relieve her symptoms but now this effect is wearing off and she
has palpitations and tremors even after drinking alcohol. What is the SINGLE most likely diagnosis?
A.
Panic attacks
B.
Depression
C.
D.
Alcohol addiction
y
E.
op
Generalised Anxiety Disorder (GAD) C
There is a fine line between Generalised Anxiety Disorder (GAD) and Panic attacks. They both can present
similarly. However, in this question, her symptoms develop rapidly and only last for a few minutes. This is
the key phrase that you should look out for that tells you this is Panic attacks rather than GAD.
n
io
Panic attacks
t
ua
al
previously).
Ev
Symptoms/signs
- Tremor
- Tachycardia
- Tachypnoea
- Sweating
• SpO2
• ECG
• ABG if SpO 2 ↓, or if symptoms do not completely settle in a few minutes.
222
EM
• BMG

• CXR
Treatment:
65. A butcher comes into A&E after accidentally stabbing his groin with a knife. He tried to use a towel to
stop the bleeding but has bled so much that the towel is now soaked with blood. His
Blood pressure is 75/40 mmHg and pulse is 120 beats/minute. What is the SINGLE most appropriate
initial management?
y
A.
op
Blood transfusion
B.
IV fluids
C
C.
Fresh frozen plasma
n
D.
io
Refer to surgeon
E.
t
ua
Oral rehydration
In reality, we would obviously start IV fluids as soon as possible and get a crossmatch for a blood
al
transfusion. Thus, many argue that the option A. Blood transfusion would be correct. Although
debatable, the question here does ask for the most appropriate initial management. IV fluids would be
Ev
more appropriate given that he is hypotensive and IV normal saline is readily available in the A&E
departments. Packed RBC take time as staff would need to call the blood transfusion lab and order blood.
66. A 49-year-old woman presents to the Emergency Department with a productive cough of green sputum.
She feels unwell, feverish and lethargic. On examination, bronchial breathing is heard at her right base.
She has a respiratory rate of 27 breaths/minute, oxygen saturation of 90% on room air, pulse rate of 130
beats/minute and a blood pressure of 85/40 mmHg. What is the SINGLE next most appropriate action?
A.
Intravenous fluids
B.
Oral antibiotics
C.
Chest X-ray
D.
Intramuscular adrenaline
223
EM
E.
Sputum culture
Her observations are extremely alarming and would raise red flags. She is clearly septic from a
pneumonia. Sepsis six would need to be performed urgently within the hour. Among the sepsis six is to
give intravenous fluids.
Oral antibiotics would be inappropriate. We need a broad-spectrum antibiotic in the blood stream as
soon as possible thus it needs to be given intravenously.
Chest X-ray would need to be perform but can be done after performing the sepsis six and stabilising the
patient.
Sepsis
A life-threatening organ dysfunction caused by a dysregulated host response to infection
There are a few questions you need to ask when dealing with sepsis:
y
op
- Is the patient acutely unwell or is there any clinical concern?
- Is the total NEWS score 5 or more?
- Is there a single NEWS score indicator of 3?
C
Note: NEWS score stands for National Early Warning Score. It is a score introduced by the Royal College
n
of Physicians in 2012 and it is used across the NHS to assess patient's vitals and observations.
io
If any of the above questions were yes, then ask yourself, could this be an infection?
t
ua
If yes, look for any RED FLAGS
➢ Evaluation for 'Red Flag' sepsis

al
➢ Systolic blood pressure < 90 mmHg (or >40 mm Hg fall from baseline)
➢ Heart rate >130 beats/minute
Ev
➢ Oxygen saturations < 91% (< 88% in COPD)

➢ Respiratory rate >25 breaths/minute
➢ Responds only to voice or pain/unresponsive
➢ Lactate >2.0 mmol
➢ Urine output < 0.5 ml/kg/hr for ≥ 2 hours
If 1 or more RED FLAGS present → Complete the SEPSIS SIX within 60 minutes
Sepsis Six → Take 3, Give 3

➢ Take 3
- Blood cultures
- FBC, urea and electrolytes, clotting, lactate
- Start monitoring urine output
➢ Give 3
- High flow oxygen
- Intravenous fluid challenge
224
EM
- Intravenous antibiotics
67. A 36-year-old man rescued from a building on fire presents headache, vertigo, nausea, confusion and
vomiting. He complains of feeling weak. He is without any evidence of burns or external injury. What is
A.
B.
C.
D.
E.
y
As this patient is conscious, we just need a tight-fitting mask with 100% oxygen for an unconscious
op
patient intubate and provide IPPV on 100% oxygen C
The decision for hyperbaric oxygen therapy (HBOT) is a difficult one and there are many debates about
the added value provided by hyperbaric oxygen. As this patient is conscious, the decision is easy here as
there are no indications for HBOT.
n
io
In the current NICE guidelines, treatment with hyperbaric oxygen is not currently recommended, because
there is insufficient evidence that hyperbaric oxygen therapy improves long-term outcomes of people
t
ua
with severe carbon monoxide poisoning, compared with standard oxygen therapy. Thus, based on NICE
guidelines, for any question in PLAB with CO2 poisoning, hyperbaric oxygen therapy will NOT be the
answer.
al
Carbon monoxide poisoning

Ev
Carbon monoxide (CO) is a tasteless and odourless gas produced by incomplete combustion. Poisoning
may occur from car exhausts, fires and faulty gas heaters. CO is also produced by metabolism of
methylene chloride (used in paint strippers and as an industrial solvent).
CO decreases the oxygen-carrying capacity of the blood by binding haemoglobin (Hb) to form
carboxyhaemoglobin (COHb). This impairs O2 delivery from blood to the tissues thus causing severe
tissue hypoxia.
Clinical features:
- Early features are:
- Headache
- Malaise
- Nausea and vomiting
In severe toxicity:
- 'Pink' skin and mucosae
225
EM
- Hyperpyrexia
- Arrhythmias
- Coma with hyperventilation
Management
Note: The elimination half-life of CO is about 4 hours on breathing air, 1 hour on 100%
O2, and 23 minutes on O2 at 3 atmospheres pressure.
- Clear the airway
- Maintain ventilation with high concentration of O2
- For a conscious patient use a tight-fitting mask with an O2 reservoir, but if unconscious intubates
and provide IPPV on 100% O2
Indications for hyperbaric oxygen therapy (HBOT):

There is debate about the added value provided by hyperbaric oxygen. Hyperbaric O2 therapy is logical,
but of no proven benefit for CO poisoning. Transfer to a hyperbaric chamber and pressurization may take
hours and so hyperbaric treatment may be no more effective than ventilation on 100 % normobaric O2.
Caring for a critically ill patient in a small pressure chamber may be impracticable.
y
op
A COHb concentration of >20% should be an indication to CONSIDER hyperbaric oxygen and the decision
should be taken on the basis of the indicators listed below:
- Loss of consciousness at any stage
C
- Neurological signs other than headache
- Myocardial ischaemia/arrhythmia diagnosed by ECG
n
- The patient is pregnant.
io
If there are any of the indications stated above, discuss with a Poisons Information Service and consider
t
ua
hyperbaric treatment. The Poisons Information Service can advise on the location of hyperbaric
chambers. But note currently, the treatment with hyperbaric oxygen is not currently recommended by
NICE guidelines, because there is insufficient evidence that hyperbaric oxygen therapy improves long-
al
term outcomes of people with severe carbon monoxide poisoning, compared with standard oxygen
therapy.
Ev
68. A 20-year-old man presents to A&E after having severe injuries from a road traffic accident. On
presentation, he is breathless and has severe chest pain. His systolic blood pressure is 70 bpm and his
pulse rate is 130/min What is the SINGLE most appropriate initial action?
A.
Antibiotics
B.
Analgesia
C.
High flow oxygen
D.
Secure venous access
E.
Refer to surgeon
226
EM
Another very debatable question.
This patient is in shock. In reality, high flow oxygen, securing venous access and analgesia would all be
done simultaneously. But for the purpose of this exam, we should know the steps according to NHS
guidelines and British references. Thus, securing airways and giving oxygen would come before anything
else.
Management of Shock
Investigation and treatment should occur simultaneously.
- Get senior help immediately.

- Address the priorities → ABC.
- Give high flow O2 by mask
y
- Secure adequate venous access and take necessary bloods investigation
op
- Monitor vital signs, including pulse, BP, SpO2, respiratory rate
- Insert a urinary catheter and monitor urine output hourly.
-
C
For shock associated with effective circulating blood volume, give IV crystalloid (0.9 % saline)
20mL/kg as bolus.
n
69. A 16-year-old female teenager was brought to the emergency department after being stabbed on the
io
upper right side of his back 2 hours ago. An erect Chest X-ray revealed homogenous opacity on the lower
right lung. The trachea is centrally placed. She has a blood pressure of 80/60 mmHg, a pulse of 122
t
ua
beats/minute, and a respiratory rate of 34 breaths/minute. What is the SINGLE most likely diagnosis?
A.
al
Pneumothorax
B.
Ev
Haemothorax
C.
Pneumonia
D.
E.
Empyema
Haemothorax
Blood accumulates in the pleural cavity
Clinical features
Similar to that seen in traumatic pneumothorax, except the following
- Dullness to percussion over the affected lung
- Signs and symptoms of hypovolaemia if massive haemothorax
227
EM
Investigations
- Chest X-ray shows an increased shadowing on a supine X-ray, with no visible fluid level
Treatment
- Oxygen
- Insert 2 large venous cannulae and send blood for cross matching
- Evacuation of blood may be necessary to prevent development of empyema; thus, chest tube is
needed and is often placed low. Usually the lung will expand and the bleeding will stop after a
chest tube is inserted.
- Surgery to stop the bleeding is seldom required. The lung is the usual the source of bleeding. Since
it is a low-pressure system, the bleeding usually would stop by itself.
70. A 32-year-old man is brought to A&E by his wife with symptoms of chest pain, abdominal pain,
palpitations, nausea and altered mental status. His wife says that she found a bottle of empty
medication on the toilet floor and it is likely that he consumed the whole bottle. He has a respiratory
rate of 34 breaths/minute. His arterial blood gas shows the following:
y
pH 7.21
op
pCO2 3.0 kPa
P02 13
Bicarbonate 18 mmol/L
C
What is the SINGLE most likely medication that he could have taken?
n
io
A.
Paracetamol
t
ua
B.
Aspirin
C.
al
Diclofenac
D.
Ev
Enalapril
E.
Gentamicin
The clinical picture here represents metabolic acidosis. This is likely from aspirin poisoning. With aspirin
overdose, they initially hyperventilate leading to respiratory alkalosis initially. The initial phase could last
up to 12 hours. Following that, progressive metabolic acidosis occurs. This usually occurs around the 24-
hour mark after ingestion for adults.
Paracetamol overdose may also cause metabolic acidosis in the early and late course of poisoning and
thus paracetamol as an answer is not completely wrong. However, aspirin overdose is a more recognised
cause of metabolic acidosis compared to paracetamol.
Overdose of Enalapril (ACE inhibitor), Diclofenac (NSAIDs) or Gentamicin (aminoglycoside) is likely to

cause metabolic alkalosis and not acidosis.
228
EM
If suspecting metabolic acidosis do a blood gas. A metabolic acidosis picture with an increased anion gap
can be due to several drugs. Common ones are listed here:
- Metformin
- Alcohol
- Isoniazid
- Iron
- Aspirin
- Digoxin
71. A 33-year-old man was involved in a road traffic accident. He has acute abdominal pain. On abdominal
examination, there is bruising along the site of the portion of the seat belt. His abdomen is very tender.
A computerised tomography scan of his abdomen shows a subscapular splenic haematoma. He has a
pulse rate of 90 beats/minute, respiratory rate of 24 breaths/minute, and a blood pressure of 120/80
mmHg. What is the SINGLE most appropriate action?
A.
y
B.
op
Refer to surgical team for observation
C.
Outpatient department referral
C
D.
Routine referral for ultrasound scan
n
E.
io
Laparoscopy
t
ua
A subscapular splenic haematoma as diagnosed by the preoperative CT scan is neither a predictor for
delayed splenic rupture, nor by itself an indication for operative management of the injured spleen in a
haemodynamically stable patient.
al
Observation would be the most appropriate action. Focused abdominal sonography (ultrasound) for
Ev
trauma (FAST) is regarded as the investigation of choice for early diagnostic investigations in patients
with suspected blunt abdominal trauma and it is regarded as the investigation of choice for unstable
patients. Free fluid in a haemodynamically unstable patient indicates the need for emergency
laparotomy. However, this patient is stable and does not warrant an immediate laparotomy. The FAST
scans are typically used to enhance the speed of trauma assessment, reduce the number of CT scans and
cut cost. However, this patient has already had a CT scan, thus an ultrasound scan would not give any
added information in regards to an acute abdomen.
Solid organ injury in haemodynamically stable patients can often be managed without surgery but would
require observation for a while before discharge.
72. A 10-year-old comes is brought in by ambulance after having been rescued from a house fire. There is
soot in his mouth and he has difficulty breathing. What is the SINGLE most appropriate management?
A.
Refer to burn unit
229
EM
B.
Tracheal intubation
C.
Cricothyroidotomy
D.
Intermittent positive-pressure ventilation
E.
Administer 100% oxygen by face mask
swelling, a tracheal intubation would need to be performed as it is live-saving.
y
op
Signs and symptoms of smoke inhalation injury:
- Persistent cough
- Stridor
C
- Wheezing
n
io

t
ua
73. A 44-year-old man with a history of alcohol dependency presents with confusion. He responds poorly to
al
questions and is seen to be irritable. He is unsteady and has unco-ordinated walking. His blood glucose is
3.5 mmol/L. He has no other relevant medical history. What is the SINGLE most appropriate immediate
Ev
action?
A.
Intravenous thiamine
B.
Bolus of 50% glucose
C.
Intravenous 5% dextrose
D.
Normal saline
E.
Computed tomography of head
It is well known that chronic alcoholics are at high risk for being deficient in vitamin B1 (thiamine), which
is known to put the patient at an increased risk for Wernicke-Korsakoff Syndrome and cerebellar
degeneration. Thiamine should be given as priority in this stem before administering glucose. Firstly, it is
230
EM
unlikely that his deterioration of cognitive function is the result of hypoglycaemia as this is usually seen
at glucose levels less than 3.0mmol/L.
Secondly, if you were to administer glucose first, you will be feeding the cells more glucose without giving
the needed thiamine to allow for the forward movement of cellular reactions for complete ATP
generation. This would lead to an increase in amount of lactic acid produced and consequently leading to
acidosis. Remember, in the context of Wernicke-Korsakoff syndrome, thiamine should be given first so
that when the glucose is given, glucose will be utilized to form ATP and prevent the acceleration of cell
death in structures of the brain.
y
op
C
n
t io
ua
al
Ev
231
ENDOCRINE
y
op
C
Questions
n
io
&
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ua
Answers
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Ev
232
Endocrinology Questions
1. A 30 year old man has frequent episodic headaches with palpitations. He suffers from
anxiety and has the occasional tremor on both his hands. His blood pressure was found
to be 160/110 mmHg. What is the SINGLE most likely diagnosis?
A. Hyperthyroidism
B. Panic attacks
C. Phaeochromocytoma
D. Cushing’s disease
E. Generalized anxiety disorder
2. A 46 year old woman who lives in UK complains of weight gain, constipation and
sensitivity to cold. Her pulse is regular at 50 beats/minute. What is the SINGLE most
likely underlying mechanism for her condition?
A. Autoimmune
B. Degenerative
y
C. Congenital
op
D. Infective
E. Nutritional C
3. A 39 year old man has 7 kg unintentional weight loss in the last two months despite
having good appetite. He also complains of palpitations, sweating and diarrhoea. He
has a lump in front of his neck which moves on swallowing. What is the SINGLE most
n
appropriate diagnosis?
io
A. Lymphoma
t
B. Tuberculous lymphadenitis
ua
C. Thyroid Cancer
D. Goiter
E. Thyroid cyst
al
4. A 56 year old man has noticed a strange tingling around his mouth for the past few
Ev
weeks. It was very subtle at first but has become increasingly apparent. On
examination, twitching facial muscles were noticed. His past medical history includes
type 1 diabetes. What is the SINGLE most likely biochemical finding?
A. Hyponatraemia
B. Hypocalcaemia
C. Hypercalcaemia
D. Hypokalaemia
E. Hyperkalaemia
5. A 23 year old woman presents to the female health clinic with secondary amenorrhoea
for a duration of 10 months. Her BMI is 30. She has dark pigmentation on her neck and
severe acne on her face. She complains of feeling weak and lethargic. Blood test reveals
a serum potassium level of 2.5mmol/L. What is the SINGLE most likely diagnosis?
A. Acquired hypothyroidism
B. Primary hyperaldosteronism
C. Cushing’s syndrome
233
D. Polycystic ovarian syndrome
E. Addison’s disease
6. A 67 year old male is urinating more than usual, particularly at night. He recently is
feeling tired most of the time. He has a BMI of 33. His urine dipstick tested negative for
nitrates but was positive for glucose. What is the SINGLE most appropriate next
investigation?
A. Prostate-specific antigen
B. Urea, creatinine and electrolytes
C. MSU culture and sensitivity
D. Acid fast urine test
E. Blood sugar
7. A 40 year old male with pre-existing glomerulonephritis deteriorates and presents with
oliguria.
Lab results show the following:
y
Serum K+ = 7.8mmol/L
op
Urea = 13 mmol/L
Creatinine = 342 mmol/L
GFR = 19mL/h.
C
What is the SINGLE most appropriate initial management?
n
A. Calcium supplement
io
B. Calcium resonate enema 30g

C. Urgent haemodialysis
t
D. Loop diuretics
ua
E. IV Calcium gluconate
8. A 24 year old schizophrenic has been under antipsychotic treatment for the last year.
al
He has been experiencing headaches and erectile dysfunction. Which medication is

most likely to have caused this?
Ev
A. Fluoxetine
B. Citalopram
C. Clozapine
D. Haloperidol
E. Risperidone
9. A 50 year old lady presents with tiredness and weight gain over the last 6 months. She
has glucose in her urine and has recently been diagnosed with hypertension.
Investigations were performed and a diagnosis of Cushing’s disease was made. Which
of the following findings is NOT found in Cushing’s disease?
A. A high adrenocorticotropic hormone (ACTH) level

B. Failure to suppress morning cortisol with dexamethasone
C. Hypertension requiring more than 2 antihypertensive agents
D. Cortisol suppression with a high dose of dexamethasone
E. Unilateral adrenal enlargement
234
10. A 29 year old lady comes to the emergency department with complaints of palpitations,
and excessive sweating that has been present for the past 4 days. She also feels warmer
than usual. Her heart rate is 154 bpm and has an irregular rhythm. Her temperature is
38.7°C. What is the SINGLE most appropriate management?
A. Amiodarone
B. Beta blockers
C. Adenosine
D. Verapamil
E. Flecainide
11. A 44 year old man with acute renal failure presents with palpitations. His ECG shows tall
tented T waves and a wide QRS complex. What is the SINGLE most appropriate next
step?
A. Dialysis
B. IV calcium chloride
y
C. IV insulin with dextrose
op
D. Calcium resonium
E. Nebulized salbutamol C
12. A 39 year old lady presents with gradually worsening headaches, visual disturbance,
and lack of energy. MRI shows a 15mm tumour in the pituitary fossa. She has been on
cabergoline for treatment of her prolactinoma but has not had any response. What is
n
io
A. Radiotherapy
t
B. Octreotide
ua
C. Craniotomy
D. Transsphenoidal surgery
E. Chemotherapy
al
13. A 45 year old woman has lost weight 12 kg over the past half year. She has also noticed
Ev
episodes where she feels her heart beat beating rapidly. She has a regular pulse rate of
90 bpm. Her ECG shows sinus rhythm. What is the SINGLE most appropriate
investigation to be performed?
A. Thyroid antibodies
B. Thyroid function test
C. Adrenocorticotropic hormone stimulation (Synacthen®) test
D. Echocardiogram
E. Plasma glucose
14. A 9 year old boy during operation and immediately after showed glycosuria. A day later
his urinalysis was normal. What is the SINGLE most likely diagnosis?
P
A. Pre-diabetic state
B. Normal finding
C. Type 1 diabetes mellitus
D. Type 2 diabetes mellitus
235
E. Maturity Onset Diabetes of the Young
15. A 42 year old lady has unexplained milk secretion from her nipples. Her last menstrual
period was 6 months ago. She says she has been experiencing a loss of libido. What is
A. Hyperprolactinaemia
B. Cushing’s syndrome
C. Pheochromocytoma
D. Hyperthyroidism
E. Hypoparathyroidism
16. A 32 year old man has been repeatedly admitted to the hospital for what was described
as anxiety or panic attacks associated with palpitations. On occasions he is found to be
hypertensive and tremulous. What is the SINGLE most likely diagnosis?
A. Hyperthyroidism
B. Panic attacks
y
op
E. Generalized anxiety disorder C
17. A 32 year old woman with headaches and lethargy has hypertension. A recent blood
test shows a serum potassium of 2.9 mmol/l. What is the SINGLE most appropriate
hormone test to order?
n
io
A. Aldosterone
B. Cortisol
t
C. Thyroxine
ua
D. Renin
E. Testosterone
al
18. A 52 year old woman diagnosed with breast cancer presents with urinary frequency.
Which part of the brain is the metastasis spread to?
Ev
A. Brain stem
B. Pons
C. Medulla
D. Diencephalon
E. Cerebral cortex
19. A 45 year old lady presents with diarrhea, vomiting, and severe abdominal pain.
Examination reveals that her skin is hyperpigmented. Her blood pressure is 70/55
mmHg. What is the SINGLE most likely electrolyte abnormality to be found?
A. Sodium 130 mmol/L, potassium 6.2 mmol/L

B. Sodium 125 mmol/L, potassium 2.9 mmol/L
C. Sodium 140 mmol/L, potassium 4.5 mmol/L
D. Sodium 150 mmol/L, potassium 3.5 mmol/L
E. Sodium 150 mmol/L, potassium 5.6 mmol/L
236
20. A 40 year old man complains of thirst and lethargy. He has a blood pressure of 145/95
mmHg. His blood tests show:
Serum calcium 3.5 mmol/l

Serum potassium 4.5 mmol/l
Serum sodium 149 mmol/l
A. IV fluids
B. Calcitonin
C. IV hydrocortisone
D. Furosemide
E. Cinacalcet hydrochloride
21. A 27 year old woman presents with tremors, anxiety. She has a history of significant
weight loss over the last 6 months.She has a heart rate of 112 beats/minute. Mild
proptosis was seen on examination. What is the SINGLE most likely mechanism that
y
accounts for her symptoms?
A. Deficiency in thyroid hormone

B. Increased level of calcitonin
op
C
C. Increased metabolic rate
D. Insulin resistance
E. Reduced caloric intake
n
io
22. A 32 year old man has paroxysmal hypertension. He has frequent headaches and
complains of profuse sweating. His blood pressure remains high despite having started
t
on an ACE inhibitor. What is the SINGLE most likely diagnosis?

ua
A. Hyperthyroidism
B. Panic attacks
al
C. Essential hypertension
D. Phaeochromocytoma
Ev
23. An 8 month old infant presents with failure to thrive and constipation. On examination,
a protruding tongue and widely set eyes are observed. His father and older sister has a
history of prolonged neonatal jaundice. What is the SINGLE most likely diagnosis?
A. Down's syndrome
B. Fragile X syndrome
C. Prader Willi syndrome
D. DiGeorge syndrome
E. Congenital hypothyroidism
24. A 44 year old woman has menstrual irregularities and unexplained milk discharge from
her nipples. An MRI reveals a pituitary tumour. What is the SINGLE most likely visual
abnormality associated with a pituitary tumour?
A. Homonymous hemianopia
237
B. Homonymous upper quadrantanopia
C. Bitemporal hemianopia
D. Cortical blindness
E. Homonymous lower quadrantanopia
25. A 35 year old man who a known type 1 diabetic has abdominal pain with deep
breathing and drowsiness. The nurse has said that his breath has a fruity smell. His
mucous membranes look dry. A urine dipstick testing shows marked glycosuria and
ketonuria. Plasma glucose was elevated. What is the SINGLE most appropriate
A. Intravenous fluids followed by insulin

B. Intravenous dextrose
C. Oral rehydration
D. Subcutaneous insulin immediately
E. Intravenous antibiotics
26. A 43 year old man complains of thirst, lethargy and frequent urination. He was
y
diagnosed with multiple myeloma. What is the SINGLE most likely biochemical
op
abnormality to be associated with this condition?
A. Hypercalcaemia
C
B. Hyperkalaemia
C. Hypernatraemia
D. Hypocalcaemia
n
E. Hypomagnesemia
io
27. A 9 year old girl who is known to have type 1 diabetes mellitus presents with
t
drowsiness and deep breathing. Her blood glucose is 18 mmol/L. She has a blood
ua
pressure of 120/80 mmHg and her mucous membranes are dry. What is the SINGLE
most appropriate next step?
al
A. Serum urea
B. Blood culture
Ev
C. Computed tomography
D. HbA1c
E. Arterial blood gas
28. An 8 year old boy with a body mass index is 25 kg/m2 was admitted to a surgical ward
following a road traffic accident. He was found to have glycosuria. When he recovered
from his injury the glycosuria resolved. What is the SINGLE most appropriate follow-up
investigation?
A. Fasting blood glucose

B. Glycated haemoglobin (HbA1c)
C. 24 hour urine cortisol
D. Random blood glucose
E. Serum cortisol levels
29. A 55 year old man has weight loss, dyspnoea and syncope. He smokes 20
cigarettes/day. Investigations confirm squamous cell carcinoma in the left bronchus.
238
What is the SINGLE most likely biochemical abnormality to be associated with this
condition?
A. Hypercalcaemia
B. Hyperkalaemia
C. Hypernatraemia
D. Hypocalcaemia
E. Hypomagnesemia
30. A 55 year old man with a 4 year history feeling thirsty and urinating more often than
usual presents with a deep painless ulcer on the heel. He also has a history of
unexplained weight loss and feels tired all the time. What is the SINGLE most
appropriate investigation?
A. Arteriography
B. Venography
C. Blood sugar
D. Biopsy for malignant melanoma
y
E. Biopsy for pyoderma
31.
op
A 45 year old lady complains of galactorrhoea, decreased libido, amenorrhoea, weight
gain, depression and fatigue. She also gives a history of constipation in the last 3
C
months. Her serum prolactin levels are 856 mU/L. What is the SINGLE most likely cause
of her hyperprolactinaemia?
n
A. Hypothyroidism
io
B. Stress
C. Pregnancy
t
D. Prolactin secreting pituitary tumor

ua
E. Polycystic ovary syndrome
32. A 35 year old man is feeling unwell after a recent myocardial infarction. A recent ECG of
al
the patient shows widening of the QRS complex and tall-tented T wave. His recent
blood results show:
Ev
Sodium 136 mmol/L

Potassium 6.2 mmol/L
Urea 5 mmol/L
Creatinine 90 μmol/L
A. Intravenous calcium gluconate

B. Oral calcium resonium
C. Oral calcium with vitamin D
D. Intravenous sodium chloride
E. Intravenous glucose
33. A 55 year old woman has recently been diagnosed with type 2 diabetes mellitus. Her
body mass index is 23 kg/m2. Her last two random blood sugars that were taken were 8
and 7 mmol/l. Her blood pressure is 140/86 mmHg. Her total cholesterol is 4.7mmol/l.
239
She has no symptoms but has microalbuminuria. What is the SINGLE most appropriate
drug management?
A. ACE inhibitors
B. Calcium channel blockers
C. Statin
D. Statin and glibenclamide
E. Beta-blockers
34. An 18 year old man has extreme thirst and polyuria. 6 months ago he had a significant
head injury as the result of a road traffic accident. A diagnosis of diabetes insipidus is
suspected. What is the SINGLE most likely laboratory findings after fluid deprivation
before the administration of desmopressin?
(normal plasma osmolality 275-295 mosmol/kg and normal urine osmolality is 300-900
mosmol/kg)
A. Plasma osmolality of 280 mosmol/kg and urine osmolality of 250 mosmol/kg
y
B. Plasma osmolality of 300 mosmol/kg and urine osmolality of 350 mosmol/kg
op
C. Plasma osmolality of 335 mosmol/kg and urine osmolality of 700 mosmol/kg
D. Plasma osmolality of 280 mosmol/kg and urine osmolality of 700 mosmol/kg
E. Plasma osmolality of 335 mosmol/kg and urine osmolality of 200 mosmol/kg
C
35. A type 2 diabetes mellitus is undergoing a major surgery. He is on long acting insulin
and gliclazide. What is the SINGLE most appropriate pre-op management?
n
io
A. Start him in IV insulin and glucose and K+ just before surgery

B. Stop his oral hypoglycaemics on the day of the procedure
t
C. Continue regular oral hypoglycaemic

ua
D. Stop oral hypoglycaemic the night before surgery and start IV insulin sliding scale
with glucose and K+ before surgery
E. Change to short acting oral hypoglycaemic
al
36. A 33 year old woman complains of tiredness, lethargy and constipation. On inspection,
Ev
she has a dry coarse skin, hair loss and cold peripheries. What is the SINGLE most likely
diagnosis?
A. Hypothyroidism
B. Hyperthyroidism
C. Crohn’s disease
D. Addison’s disease
E. Irritable bowel syndrome
37. A 36 year old male diagnosed with glioblastoma has been receiving dexamethasone for
several months to treat cerebral oedema. He started having diarrhoea and vomiting for
the last 3 days. He complains of abdominal pain. He feels dizzy when he gets up from
bed or stands up from a chair. What is the SINGLE most likely reason for his symptoms?
A. Adrenal insufficiency
B. Dehydration
C. Steroids side effects
240
D. Raised intracranial pressure
E. Cushing’s disease
38. A 31 year old man has profuse sweating, palpitations, headaches, flushing and
hypertension. He was diagnosed with phaeochromocytoma and is to have a surgical
removal of the tumour in a week. What is the SINGLE most appropriate initial
A. Tricyclic antidepressant
B. Diazepam
C. Diuretics
D. Alpha-blocker
E. Beta-blocker
39. A 24 year old man is admitted to the emergency department with abdominal pain and
vomiting. He is discovered to have diabetic ketoacidosis. What is the SINGLE most
appropriate immediate management?
y
A. Intravenous fluids and insulin infused continuously
op
C. Bolus of intravenous insulin
C
40. A 34 year old woman presents with truncal obesity, easy bruising, hyperglycemia and
n
depression. She has a blood pressure of 165/95 mmHg. Which of the following
io
investigations will be most helpful in localizing the cause of Cushing’s syndrome?

t
A. Serum cortisol
ua
B. 24-hour urinary free cortisol

C. Low dose dexamethasone suppression test
D. High dose dexamethasone suppression test
al
E. Overnight dexamethasone suppression test

Ev
41. A 12 year old boy is clinically obese and is the shortest in his class. His medical history
includes having a renal transplant 2 years ago. There are purple striae noticed on his
skin. What is the SINGLE most likely diagnosis?
A. Cushing’s syndrome
B. Congenital hypothyroidism
C. Pseudo-Cushing's syndrome
D. Laurence–Moon syndrome
E. Down syndrome
42. A 9 year old boy had glycosuria following an appendectomy. He has no history of
diabetes mellitus. A few days later, his glycosuria resolved. What is the SINGLE most
appropriate follow-up investigation?

241
43. A 44 year old woman has recently undergone surgery for a fractured left hip. Her blood
tests show a low serum calcium level, low serum phosphate level and raised alkaline
phosphatase. What is the SINGLE most likely diagnosis?
A. Paget’s disease
B. Osteoporosis
C. Multiple myeloma
D. Osteomalacia
E. Rickets
44. A 26 year old woman with diagnosed carcinoma of the bronchus has been receiving
steroid treatment for the last several months. She started vomiting and having severe
abdominal pain for the past 2 days. She also complains of sudden dizziness in the
morning. What is the SINGLE most likely reason for her symptoms?
y
A. Steroids side effects
op
B. Metastasis of cancer
C. Adrenal insufficiency
D. Conn’s disease
C
45. A 54 year old woman has presented with episodes of abdominal ache, vomiting and
n
postural hypotension. She also has a dark pigmentation of her skin. A diagnosis of
io
Addison’s disease was made. What is the SINGLE most likely electrolyte abnormality
expected in this patient?
t
ua
A. High sodium, Low potassium

B. Low sodium, High potassium
C. Low sodium, Low potassium
al
D. High sodium, High potassium

E. Low sodium, Normal potassium
Ev
46. A 42 year old woman complains of tingling, numbness, paraesthesia, and involuntary
spasm of the upper extremities. She has undergone a thyroidectomy for thyroid
carcinoma a week ago. What is SINGLE most likely diagnosis?
A. Thyroid storm
B. Hyperparathyroidism
C. Unilateral recurrent laryngeal nerve injury
D. Hypokalaemia
E. Hypocalcaemia
47. A 35 year old woman presents with visual problems and amenorrhoea. An MRI reveals
a pituitary tumour. What is the SINGLE most likely visual abnormality?
B. Tunnel vision
242
D. Glares and halos
48. A 39 year old woman has been feeling lethargic and tired. She has a blood pressure of
160/90 mmHg despite being on enalapril. Her blood test show:
Haemoglobin 130 g/L

Serum sodium 144 mmol/L
Serum potassium 3.1 mmol/L
B. Conn’s syndrome
C. Hyperparathyroidism
D. Renal disease
E. Phaeochromocytoma
y
49. A 64 year old man with multiple myeloma has been vomiting for the past 2 days. His
op
blood tests show:

C
Serum potassium 5 mmol/l
Packed cell volume 55%
n
io
What is the SINGLE most appropriate next step?

t
A. IV insulin
ua
B. IV calcium gluconate
C. IV fluids
D. IV bisphosphonates
al
E. Oral bisphosphonates
Ev
50. A 45 year old man presents with bitemporal hemianopia and swelling of his hands. He
says that his nose has become larger and his voice has become more hoarse. On
examination, spade-like hands are seen. What is the SINGLE most definitive test to
confirm the diagnosis?
A. Early morning growth hormone

B. Prolactin level
C. Oral glucose tolerance (OGTT) with serial growth hormone measurements
D. Random insulin-like growth factor (IGF-1)
E. Short synacthen test
51. A 63 year old man who takes spironolactone and ramipril for hypertension and was
found to have elevated potassium of 5.8mmol/L on routine blood test while on a day
ward. He is otherwise well and has no allergies. An ECG is carried out which is normal.
What is the SINGLE best initial treatment in light of his potassium levels?
Normal Lab values
243
Potassium 3.5–5 mmol/L
A. Calcium gluconate IV
B. Renal dialysis
C. Stop spironolactone and ramipril
D. Recheck potassium level
E. IV insulin and glucose
52. A 26 year old woman comes to the emergency department with vomiting, abdominal
pain and tachypnoea. Her breath has a fruity smell. She has a heart rate of 99
beats/minute and a respiratory rate of 30 breaths/minute. Her blood pressure is
110/70 mmHg. Her blood and urine results show:
Blood Ketones 3.3 mmol/L (high)

Urine Ketones +++
Venous pH 7.2 (low)
Blood Glucose 22 mmol/L (high)
y
op
What is the SINGLE most appropriate immediate management?

C
C. Oral rehydration
n
io
53. A 19 year old man presents with weight loss, increasing thirst and increasing frequency
t
of going to the washroom. His father, grandfather and his 2 sisters have been
ua
diagnosed with diabetes mellitus. What is the SINGLE most likely type of diabetes this
man suffers from?
al
A. Wolfram Syndrome
B. Diabetes mellitus type 2
Ev
C. Latent autoimmune diabetes of adults (LADA)

D. Maturity onset diabetes of the young
E. Diabetic ketoacidosis
54. A 58 year old woman has tiredness and diarrhoea for the last few weeks. She has
noticed that her skin looks tanned. She describes dizziness on standing up and recently
started feeling nauseous. What is the SINGLE most likely electrolyte abnormality to be
found?

55. A 45 year old man with diagnosed colon cancer develops increased thirst, and frequent
urination. He is also noted to have been losing weight in the last couple of months. His
244
blood test shows a fasting blood glucose of 9 mmol/L. He has a pulse of 70
beats/minute, a blood pressure of 125/80 mmHg and a respiratory rate of 18
breaths/minute. What is the SINGLE most appropriate management?
A. Oral hypoglycaemic
B. Long acting insulin
C. Short acting insulin before meals
D. IV insulin
E. Subcutaneous insulin
56. A newborn has congenital hypothyroidism. What feature might develop if no treatment
is given?
A. Microglossia
B. Physiological jaundice
C. Undescended testis
D. Anal tags
E. Left soft palate
y
op
57. A 33 year old woman has amenorrhoea and galactorrhoea. An MRI shows a 9mm
tumour in the pituitary fossa. What is SINGLE most appropriate management?
C
A. Radiotherapy
B. Cabergoline
C. Craniotomy
n
io
E. Chemotherapy
t
58. A 30 year old woman complains of decreased appetite and weight gain. She has been
ua
having irregular, infrequent periods in the last 10 months. She also feels tired and
lethargic majority of the day. On inspection, she has a dry coarse skin. What is the
al
A. Hypothyroidism
Ev
B. Hyperthyroidism
C. Polycystic ovary syndrome
E. Premature ovary failure
59. A 33 year old man has erectile dysfunction, decreased libido and galactorrhoea. What is
C. Pheochromocytoma
D. Hyperthyroidism
60. A 44 year old man is extremely thirsty despite excessive drinking. Diabetes mellitus and
renal failure has been ruled out and a diagnosis of diabetes insipidus is suspected. Fluid
deprivation test and an assessment of response to vasopressin was done which was
245
consistent with central diabetes insipidus. What is the SINGLE most likely laboratory
finding that lead to the conclusion?
A. An increase in urine osmolality after administration of vasopressin

B. A decrease in urine osmolality after administration of vasopressin
C. An increase in plasma osmolality after administration of vasopressin
D. A decrease in plasma osmolality during fluid deprivation
E. An increase in urine osmolality during fluid deprivation
61. A 38 year old lady was admitted with severe abdominal pain and diarrhoea. On
examination, hyperpigmentation is noticed at the palmar creases and buccal mucosa.
She has muscle cramps and joint pain. Her blood pressure is 79/50 mmHg. What is the
A. Addison’s disease
B. Cushing syndrome
D. Hyperthyroidism
y
62.
op
A 46 year old woman complains of tiredness and lethargy. She has noticed a 8 kg
weight gain in the last 3 months and is feeling more sensitivity to cold. She has a pulse
C
rate of 55 beats/minute. What is the SINGLE most likely diagnosis?
A. Hypothyroidism
n
B. Hyperthyroidism
io
t
ua
63. A 49 year old man with a diagnosis of squamous cell carcinoma of the lung is confused
and lethargic. He is continuously thirsty and urinates frequently. His blood tests show:
al

Ev

What is the SINGLE most appropriate initial step?
A. Calcitonin
C. IV 0.9% saline
E. Steroids
64. A 34 year old woman is referred to the endocrine clinic with a history of thyrotoxicosis.
At her first appointment she is found to have a smooth goiter, lid lag and bilateral
exophthalmos with puffy eyelids. She wants to discuss the treatment of her thyroid
problem as she is keen to become pregnant. What is the SINGLE most likely treatment
to be given to her?
246
A. Carbimazole alone
B. Propylthiouracil alone
C. A combination of carbimazole and thyroxine
D. Radioactive iodine
E. Thyroidectomy
65. A 28 year old woman complains of tiredness, lethargy, and intolerance to cold. She has
a history of Addison’s disease. Her skin looks dry on examination. She has been having
infrequent periods in the one year and her last menstrual period was 3 months ago.
A. Polycystic ovary syndrome

B. Hyperthyroidism
C. Hypothyroidism
66. A 31 year old man has tremors, profuse sweating and palpitations. His blood pressure
y
was measured at 160/115 mmHg but dropped to 139/92 on standing. What is the
op
A. Hyperthyroidism
C
B. Panic attacks
n
io
67. A 56 year old man was recently started on antihypertensive medication. His recent
t
blood results show:

ua
Sodium 134 mmol/L

al
Urea 7 mmol/L
Ev
What is the SINGLE most likely medication responsible for the abnormal results?
A. Amlodipine
B. Bendroflumethiazide
C. Doxazosin
D. Atenolol
E. Ramipril
68. A 39 year old man has galactorrhoea. On examination of his visual fields, a bitemporal
hemianopia was noted. What is the SINGLE most likely diagnosis?
C. Pheochromocytoma
D. Hyperthyroidism
247
69. A 29 year old male comes to clinic with a swollen, painful right wrist joints. On further
questioning, he gives a history of noticing a change in his shoe size. His other complains
also include constipation, feeling cold and needing more warm clothes to keep him
warm. On examination, his skin is found to be dry and his right wrist is erythematous
and tender to touch. What is the SINGLE most likely diagnosis?
A. Chondrosarcoma
B. Liposarcoma
C. Gout
D. Pseudogout
E. Ankylosing spondylitis
70. A 33 year old man comes to clinic to have an oral glucose tolerance test. What is the
plasma glucose level two-hours after glucose intake which indicates an impaired
glucose tolerance?
A. >11.1 mmol/L
y
B. >11.0 mmol/L
op
C. Between 8.0-10.9 mmol/L
D. Between 7.8-11.1 mmol/L
E. Between 7.1-11.1 mmol/L
C
71. A 35 year old man with a medical history of type 1 diabetes mellitus presents to the
hospital with reduced conscious level and feeling unwell. He has dry mucous
n
membranes and a slow capillary refill. He has a blood pressure of 80/50 mmHg and a
io
pulse rate of 105 beats/minute. What is the SINGLE most appropriate initial
investigation?
t
ua
A. Arterial blood gas

B. Full blood count
C. HbA1c
al
D. Liver function tests

E. Serum urea
Ev
72. A 29 year old known diabetic man comes to A&E after falling down the stairs. While
waiting in the waiting room, he becomes unconscious and collapses. What is the
SINGLE most appropriate initial investigation?
A. Computed tomography scan

B. Random blood sugar
C. Magnetic resonance imaging
D. Electrocardiogram
73. A 68 year old woman was diagnosed with Type 2 Diabetes Mellitus. Diet and lifestyle
modifications have failed to control his blood sugar over the last three months. She has
no known allergies and takes Ramipril 5mg daily. She has a body mass index is 35
kg/m2. Her blood results are as follows:
Serum urea 13.2 mmol/L
248
Creatinine 390 mmol/L
eGFR 25 ml/min
What is the SINGLE most appropriate pharmacological management?
A. Biguanide
B. Sulfonylurea
C. Insulin
D. Glitazone
E. Sodium glucose co-transporter 2 (SGLT2) inhibitors
74. A 65 year old man with a body mass index is 33 kg/m2 has been diagnosed with Type 2
diabetes mellitus. Diet and lifestyle modifications have failed to control his blood sugar
over the last three months. He has no known allergies and does not take any regular
medications. His blood results are as follows:
Serum urea 3.6mmol/L

y
eGFR 79 ml/min
op
C
A. Biguanide
B. Sulfonylurea
C. Sodium glucose co-transporter 2 (SGLT2) inhibitors
n
D. Glitazone
io
E. Incretin mimetics
t
75. A 75 year old man with a recent diagnosis of prostate cancer has confusion, thirst,
ua
lower back pain and abdominal pain. An ECG was performed which showed shortening
of QT interval. What is the SINGLE most appropriate investigation?
al
A. Magnetic resonance imaging spine

B. Radionuclide bone scan
Ev
C. DEXA scan
D. Serum alkaline phosphatase
E. Serum calcium
76. A 79 year old man has a diagnosis of lung cancer. He has a sodium level of 122 mmol/l
but remains asymptomatic for hyponatraemia. What is the SINGLE most appropriate
management?
A. Demeclocycline
B. Vasopressin
C. Fluid restriction
D. Reassure
E. Tolvaptan
77. A 32 year old man has recently had an appendectomy performed. His post-op blood
results return with the following values:
249
Glucose 4.5 mmol/L
Sodium 129 mmol/L
A. Sodium chloride 0.9% intravenous infusion

B. Sodium chloride 0.45% intravenous infusion
C. Insulin-glucose intravenous infusion
D. Nebulised salbutamol
E. Sodium bicarbonate
78. A 41 year old obese women has recently undergone a blood test. Her results show:
Fasting blood sugar 6 mmol/l

Oral glucose tolerance test 10.1 mmol/l.
y
op
A. Impaired glucose tolerance
B. Diabetes insipidus
C
E. Maturity onset diabetes of the young
n
79. A 21 year old man is brought into A&E semi-conscious by his friends. They were at a
io
party and have been drinking alcohol when they found him unconscious in a corner. He
is groaning and unable to give any information to the doctors. During the initial
t
evaluation, his respiratory rate is 17/min and pulse rate is 88 bpm, BP is110/70 mmHg,
ua
pupils are responsive. His Glasgow Coma Scale (GCS) score is 11/15. What is the SINGLE
most appropriate next course of action?
al
A. Computed tomography of head

B. Magnetic resonance imaging of head
Ev
C. Check blood glucose

D. Check Body temperature
E. Intravenous fluids
80. A 22 year old footballer collapses during a game and is brought into A&E by ambulance.
During the initial evaluation, his respiratory rate is 14/min and pulse rate is 84 bpm, BP
is115/80 mmHg. He is sweating profusely and muttering incomprehensible words.
What is the SINGLE most appropriate next course of action?

D. Intravenous insulin
81. A 58 year old man who is known to have diabetes mellitus presents to the hospital with
drowsiness, blurred vision, tremors, fatigue and confusion. On examination, he is
250
excessive sweaty. Which SINGLE investigations should be done initially to help with
further management?
A. Fasting blood sugar

B. Blood glucose
C. Standing and lying blood pressure
E. Computed tomography of head
82. A 29 year old smoker presents with dry eyes and diplopia. On examination, she has lid
lag and lid retraction bilaterally. What is the SINGLE most appropriate next step?
A. Thyroid Function Tests

B. Tensilon test
C. Fundoscopy
D. Autoantibodies
E. Electromyography
y
83. A 44 year old lady has just recovered from an upper respiratory tract infection. She
op
feels her heart racing and has increased perspiration. Her blood tests show:
Free thyroxine (T4) 48 pmol/L

C
Free triiodothyronine (T3) 15 pmol/L
Thyroid stimulating hormone (TSH) 0.1 mU/L
Thyroid antibodies negative
n
io

t
A. Hashimoto's thyroiditis
ua
B. Graves' disease
C. Subacute thyroiditis
D. Toxic nodular goitre
al
E. Sick euthyroid syndrome

Ev
84. A 4 year old child is brought to the emergency department by his mother with
complains of vomiting for the past 4 days. On examination, he has clinical signs of mild
to moderate dehydration. What is his arterial blood gas profile likely to show?
A. A low pH and low PCO2

B. A low pH and high PCO2
C. A high pH and low PCO2
D. A high pH and high PCO2
E. A high pH and normal PCO2
85. A 62 year old man had a bowel resection 3 days ago for colorectal cancer. His urine
output has been low since the procedure and he is now becoming breathless. He has a
blood pressure of 130/95 mmHg. On auscultation, he has crackles at both lung bases
and on palpation, he has sacral oedema. His blood tests show:
Haemoglobin 109 g/L

251
Serum creatinine 603 μmol/L
A. Bolus of 20 units of insulin

B. Calcium resonium
C. Sodium bicarbonate
D. Intravenous fluid
E. 10 units of insulin and 50 ml of 50% glucose infusion
y
op
C
n
t io
ua
al
Ev
252
Endocrinology Answers
1. A 30 year old man has frequent episodic headaches with palpitations. He suffers from
anxiety and has the occasional tremor on both his hands. His blood pressure was found
to be 160/110 mmHg. What is the SINGLE most likely diagnosis?
A. Hyperthyroidism
B. Panic attacks
Phaeochromocytoma
Phaeochromocytoma is a rare catecholamine secreting tumour.
Rule of 10
• bilateral in 10%
• malignant in 10%
y
• extra-adrenal in 10% (most common site = organ of Zuckerkandl, adjacent to
op
the bifurcation of the aorta)
• 10% are familial and may be associated with MEN type II, neurofibromatosis
and von Hippel-Lindau syndrome
C
• 10% not associated with hypertension
Features are typically episodic

n
• Hypertension (around 90% of cases and may be sustained)
io
• Headaches
• Palpitations
t
• Profuse sweating
ua
• Anxiety
• Tremor
al
Mnemonic
PHaeochromocytoma
Ev
P → Palpitations
H→ Headaches
PH → PHlushings (flushing)
Tests
• 24 hr urinary collection of metanephrines (sensitivity 97%), Note: this has
replaced a 24 hr urinary collection of catecholamines (sensitivity 86%)
Management
Surgical resection of the tumour is the treatment of choice and usually results in cure of
the hypertension. However, the patient must first be stabilized with medical
management:
• alpha-blocker (e.g. phenoxybenzamine)
• beta-blocker (e.g. propranolol) Note: Alpha blocker must be given before a beta
blocker
253
The reason behind medical management with alpha-blockers and beta-blockers is it is
required to control blood pressure to prevent intraoperative hypertensive crises.
Alpha blockade with phenoxybenzamine is started at least 7 to 10 days before

operation to allow for expansion of blood volume. Only once this is achieved is beta
blockade considered. If beta blockade is started too soon, unopposed alpha stimulation
can precipitate a hypertensive crisis.
2. A 46 year old woman who lives in UK complains of weight gain, constipation and
sensitivity to cold. Her pulse is regular at 50 beats/minute. What is the SINGLE most
likely underlying mechanism for her condition?
A. Autoimmune
B. Degenerative
C. Congenital
D. Infective
E. Nutritional
y
She is suffering from hypothyroidism.
op
Note that Iodine deficiency (nutritional causes) is the most common cause of
hypothyroidism worldwide but in developed countries like UK, autoimmune
C
hypothyroidism is more prevalent.
Hypothyroidism
n
io
Primary hypothyroidism
• Autoimmune hypothyroidism - Hashimoto's thyroiditis (associated with a
t
goitre) and atrophic thyroiditis.

ua
• Iatrogenic - radioiodine treatment, surgery, radiotherapy to the neck

• Iodine deficiency - the most common cause worldwide and goitre is present
(uncommon in UK)
al
• Drugs - amiodarone, contrast media, iodides, lithium and antithyroid

medication.
Ev
• Congenital defects - e.g. absence of thyroid gland
Secondary hypothyroidism
• Isolated TSH deficiency
• Hypopituitarism - neoplasm, infiltrative, infection and radiotherapy
• Hypothalamic disorders - neoplasms and trauma
Symptoms
• Tiredness, lethargy, intolerance to cold
• Dry skin and hair loss
• Slowing of intellectual activity - eg, poor memory and difficulty concentrating.
• Constipation
• Decreased appetite with weight gain.
• Menorrhagia and later oligomenorrhoea or amenorrhoea
Signs
• Dry coarse skin, hair loss and cold peripheries
254
• Puffy face, hands and feet (myxoedema)
• Bradycardia
In autoimmune hypothyroidism, patients may have features of other autoimmune

diseases, such as, vitiligo, pernicious anaemia, Addison's disease and diabetes mellitus.
3. A 39 year old man has 7 kg unintentional weight loss in the last two months despite
having good appetite. He also complains of palpitations, sweating and diarrhoea. He
has a lump in front of his neck which moves on swallowing. What is the SINGLE most
A. Lymphoma
C. Thyroid Cancer
D. Goiter
E. Thyroid cyst
He has signs and symptoms of hyperthyroidism. The mass is likely to be a goitre rather
y
than thyroid cancer as thyroid cancers usually do not manifest with symptoms of
op
hyperthyroidism.
Manifestations of hyperthyroidism (all forms)

C
Symptoms
• Hyperactivity, irritability, altered mood, insomnia
n
• Heat intolerance, sweating
• Palpitations
io
• Fatigue, weakness
• Dyspnoea
t
• Weight loss with increased appetite

ua
• Pruritus
• Increase stool frequency
al
• Thirst and polyuria

• Oligomenorrhoea or amenorrhoea, loss of libido, erectile dysfunction
Ev
Signs
• Sinus tachycardia, atrial fibrillation
• Fine tremor, hyperreflexia
• Warm, moist skin
• Palmar erythema
• Hair loss
• Muscle weakness and wasting
4. A 56 year old man has noticed a strange tingling around his mouth for the past few
weeks. It was very subtle at first but has become increasingly apparent. On
examination, twitching facial muscles were noticed. His past medical history includes
type 1 diabetes. What is the SINGLE most likely biochemical finding?
A. Hyponatraemia
B. Hypocalcaemia
C. Hypercalcaemia
D. Hypokalaemia
255
E. Hyperkalaemia
This question is rather straightforward. The tingling around his mouth is perioral
paraesthesia, which, in combination the findings of twitching facial muscles leads us to
think that this is hypocalcaemia. The history of diabetes was given as another hint for
the diagnosis. He most likely has a degree of chronic renal impairment due to diabetes
which supports the findings of hypocalcaemia.
Hypocalcaemia
Common causes
• vitamin D deficiency (osteomalacia)
• chronic renal failure
• hypoparathyroidism (e.g. post thyroid/parathyroid surgery)
• Hyperphosphatemia
• Hypomagnesemia
The clinical history combined with parathyroid hormone levels will reveal the cause of
y
hypocalcaemia in the majority of cases
Clinical Findings
op
Hypocalcaemia results in increased neural hyperexcitability such as seizures, tetany,
C
circumoral numbness, and tingling of the extremities. Arrhythmias may develop
because of a prolonged QT.
n
A mnemonic to help is with clinical signs and symptoms is: “SPASMODIC”

io
S → Spasm (carpopedal spasms = Trousseau's sign)

P → Perioral paraesthesiae
t
A → Anxious, irritable, irrational

ua
S → Seizures
M → Muscle tone increased in smooth muscles
O → Orientation impaired (time, place and person) and confusion
al
D → Dermatitis
I → Impetigo herpetiformis (rare and serious)
Ev
C → Chvostek’s sign, Cardiomyopathy (long QT interval on ECG)
The examination findings that illustrate this deficit are:

1. Trousseau’s sign in which the wrist flexes and the fingers are drawn together in
response to occlusion of the brachial artery.
2. Chvostek’s sign in which facial muscles twitch in response to tapping over the
parotid, revealing neuromuscular excitability due to the low calcium.
Management
• acute management of severe hypocalcaemia is with intravenous replacement.
The preferred method is with intravenous calcium gluconate,
• intravenous calcium chloride is more likely to cause local irritation
• further management depends on the underlying cause
5. A 23 year old woman presents to the female health clinic with secondary amenorrhoea
for a duration of 10 months. Her BMI is 30. She has dark pigmentation on her neck and
256
severe acne on her face. She complains of feeling weak and lethargic. Blood test reveals
a serum potassium level of 2.5mmol/L. What is the SINGLE most likely diagnosis?
A. Acquired hypothyroidism
B. Primary hyperaldosteronism
This is a seemingly difficult question because there are lots of conditions that fit this
patient's signs and symptoms. However, in a question like this where you have doubts,
look at the clincher in the stem that offers a definitive result. In this question, it is the
potassium level.
There are many causes of a low potassium level but the two that we are considering in
this question are Cushing’s syndrome and hyperaldosteronism.
Patients with hyperaldosteronism often present with the complaint of polyuria and
y
polydipsia in addition to headaches and lethargy. Upon further investigation,
op
hypertension and hypokalaemia will be discovered. Hyperaldosteronism does not
present with menstrual abnormalities or an increase in BMI therefore it is not the
answer.
C
Cushing’s syndrome:
n
Please note that Cushing’s syndrome merely implies exposure to high levels of
io
glucocorticoids. When an endogenous source of glucocorticoids are found after

investigation, it is termed Cushing’s Disease.
t
ua
Cushing’s syndrome presents with a myriad of signs and symptoms. The most
important thing for PLAB 1 is knowing how to evaluate Cushing’s syndrome and
determine the source of the glucocorticoid exposure.
al
6. A 67 year old male is urinating more than usual, particularly at night. He recently is
Ev
feeling tired most of the time. He has a BMI of 33. His urine dipstick tested negative for
nitrates but was positive for glucose. What is the SINGLE most appropriate next
investigation?
A. Prostate-specific antigen
B. Urea, creatinine and electrolytes
C. MSU culture and sensitivity
D. Acid fast urine test
E. Blood sugar
Given his age, high BMI, positive glucose on urine dipstick, along with the symptoms of
polyuria and nocturia, the preliminary diagnosis here is diabetes mellitus type 2.
Diabetes mellitus (type 2)
257
The diagnosis of type 2 diabetes mellitus can be made by either a plasma glucose or a
HbA1c sample. Diagnostic criteria vary according to whether the patient is symptomatic
(polyuria, polydipsia etc) or not.
7. A 40 year old male with pre-existing glomerulonephritis deteriorates and presents with
oliguria.
Lab results show the following:

Serum K+ = 7.8mmol/L
Urea = 13 mmol/L
Creatinine = 342 mmol/L
GFR = 19mL/h.
A. Calcium supplement
B. Calcium resonate enema 30g
C. Urgent haemodialysis
y
D. Loop diuretics
op
E. IV Calcium gluconate
Calcium gluconate is the most appropriate initial management as it is used to prevent

C
cardiac arrhythmia. It prevents cardiac arrest or life threatening cardiac arrhythmia to
buy time till definitive measures are taken.
n
Hyperkalaemia
io
Untreated hyperkalaemia may cause life-threatening arrhythmias. ECG changes seen in

t
hyperkalaemia include tall-tented T waves, small P waves, widened QRS leading to a

ua
sinusoidal pattern and asystole
Causes of hyperkalaemia that are important for PLAB:

al
• Acute renal failure

• Potassium sparing diuretics, ACE inhibitors, angiotensin 2 receptor blockers,
Ev
spironolactone
• Metabolic acidosis
• Addison's
Management
1. Stop drugs that cause hyperkalaemia

2. If ECG changes of hyperkalaemia are seen → IV calcium gluconate
• IV calcium gluconate is used to stabilise the cardiac membrane

• Note that ECG changes are more accurate in identifying cardiac toxicity than
plasma K+ levels
3. If severely hyperkalemic and short-term shift in K+ from extracellular to
intracellular fluid compartment is needed → Insulin and dextrose infusion
Other methods to remove K+ from the body

• Calcium resonium → lowers potassium very slowly by binding it in the gut
258
• Loop diuretics
• Dialysis
8. A 24 year old schizophrenic has been under antipsychotic treatment for the last year.
He has been experiencing headaches and erectile dysfunction. Which medication is
most likely to have caused this?
A. Fluoxetine
B. Citalopram
C. Clozapine
D. Haloperidol
E. Risperidone
Haloperidol can raise prolactin levels causing hyperprolactinaemia which can cause
erectile dysfunction.
Hyperprolactinaemia
y
Excess prolactin secretion is a common clinical problem in women and causes the
op
syndrome of galactorrhoea-amenorrhoea. The amenorrhoea appears to be caused by
inhibition of hypothalamic release of luteinizing hormone releasing hormone (LHRH)
with a decrease in luteinizing hormone (LH) and follicle-stimulating hormone (FSH)
C
secretion.
Prolactin inhibits the LH surge that causes ovulation.

n
io
Although hyperprolactinaemia is also seen in men, gynecomastia and especially

galactorrhoea are very rare.
t
ua
Etiology
• hyperprolactinaemia can be seen in natural physiologic states such as
pregnancy, nipple stimulation/suckling, stress
al
• Pituitary tumours such as prolactinomas

• Hypothalamic disease → mass compressing stalk (craniopharyngioma,
Ev
meningioma)
• Hyperprolactinaemia can also occur with decreased inhibitory action of
dopamine. (e.g. Antipsychotic agents)
• Hypothyroidism →TRH increases prolactin
Clinical of Hyperprolactinaemia
• Galactorrhoea → usually in women. Man rarely get galactorrhoea
• Menstrual abnormalities → amenorrhoea or oligomenorrhoea,
• Disturbed gonadal function in men → erectile dysfunction, decreased libido,
gynecomastia in men, reduced fertility
Clinical features of Mass effects (macroadenomas only)

• Headaches and visual field defects (uni- or bitemporal field defects)
• Hypopituitarism
Diagnosis
259
• Always exclude states such as pregnancy, lactation, hypothyroidism and
medications before starting the work-up of hyperprolactinaemia
• Serum prolactin <2,000mU/L is suggestive of a tumour → either a
microprolactinoma or a non-functioning macroadenoma compressing the
pituitary stalk
• Serum prolactin >4,000mU/L is diagnostic of a macroprolactinoma.
• Imaging: MRI
For the purpose of PLAB:

The normal level of prolactin is less than 400 mU/L. A very high prolactin level (>5000
mU/L) usually means that a prolactinoma is present. Levels in between may be due to a
prolactinoma, or to other causes
9. A 50 year old lady presents with tiredness and weight gain over the last 6 months. She
has glucose in her urine and has recently been diagnosed with hypertension.
Investigations were performed and a diagnosis of Cushing’s disease was made. Which
of the following findings is NOT found in Cushing’s disease?
y
A. A high adrenocorticotropic hormone (ACTH) level
op
B. Failure to suppress morning cortisol with dexamethasone
C. Hypertension requiring more than 2 antihypertensive agents
D. Cortisol suppression with a high dose of dexamethasone
C
E. Unilateral adrenal enlargement
n
One must remember that Cushing’s disease is not the same as Cushing’s syndrome.
Cushing’s syndrome are clinical signs and symptoms of excess cortisol. Cushing’s
io
disease is a pituitary adenoma that causes Cushing’s syndrome. Note however,

Cushing’s syndrome could be cause by many other aetiologies besides a pituitary
t
adenoma.
ua
In this stem, they are asking about Cushing’s disease (pituitary adenoma causing
cushing’s syndrome).
al
In Cushing’s disease, the pituitary adenoma produces massive amounts of ACTH which
Ev
travels through the bloodstream and causes the normal adrenal glands to make
excessive amounts of cortisol. This can lead to hyperactivity of both adrenal glands
called bilateral adrenal hyperplasia. Remember that both adrenals would respond to
ACTH equally causing bilateral adrenal hyperplasia rather than unilateral adrenal
enlargement.
Cushing’s syndrome
• A clinical state caused by prolonged exposure to elevated levels of either
endogenous or exogenous glucocorticoids
Causes can be divided into 2 groups:

• Adrenocorticotropic hormone (ACTH)-dependent disease:
o Excessive ACTH from the pituitary (Cushing's disease)
o Ectopic ACTH-producing tumours (Especially small cell lung cancer and
carcinoid tumours)
• Non-ACTH-dependent:
o Adrenal adenomas
260
o Adrenal carcinomas
o Excess glucocorticoid administration → This is the chief cause
Investigations:
Outpatient tests
• 24-hour urinary free cortisol → as an outpatient screening tool
• Overnight dexamethasone suppression test → Administration of 1mg
dexamethasone at midnight is followed by a serum cortisol measurement at 9
a.m. Cortisol < 50 nmol/L makes Cushing’s unlikely. The 1 mg overnight
dexamethasone suppression test is the best initial diagnostic test to establish a
diagnosis of Cushing syndrome.
Inpatient tests
• ACTH levels → This is the next test to do once the diagnosis of Cushing’s
syndrome is confirmed. We do this test to differentiate between ACTH-
dependent and ACTH-independent aetiologies. ACTH levels are elevated with
either a pituitary source of ACTH such as an adenoma or with an ectopic
source.
y
• High-dose dexamethasone suppression test → This test is done to differentiate
op
between a pituitary adenoma and an ectopic source. The output of a pituitary
adenoma will suppress with high-dose dexamethasone (i.e. cortisol
suppressed). The output of an ectopic source will not suppress with high-dose
C
dexamethasone (i.e. cortisol not suppressed).
n
The reason that cortisol is suppressed in pituitary adenoma is because the adenoma is
semi-autonomous. A low dose dexamethasone will not suppress it but a high dose
io
dexamethasone will. Whereas, ectopic ACTH producing tumours are fully autonomous
and will not respond to a high dose dexamethasone suppression test.
t
ua
Investigations for Cushing’s syndrome is a must know especially when to use a high dose
dexamethasone suppression test. It is a commonly asked question.
al
Ev
10. A 29 year old lady comes to the emergency department with complaints of palpitations,
and excessive sweating that has been present for the past 4 days. She also feels warmer
261
than usual. Her heart rate is 154 bpm and has an irregular rhythm. Her temperature is
38.7°C. What is the SINGLE most appropriate management?
A. Amiodarone
B. Beta blockers
C. Adenosine
D. Verapamil
E. Flecainide
From the symptoms, this patient is likely having a thyroid storm. She is having atrial
fibrillation secondary to thyrotoxicosis. Thyroid crisis represents a rare, but life-
threatening, exacerbation of the manifestations of thyrotoxicosis.
B-adrenergic blocking agents are essential in the management to control tachycardia,

tremor, and other adrenergic manifestations:
→Propranolol in divided doses or as an infusion would be given
Manifestations of hyperthyroidism (all forms)
y
Symptoms
op
• Hyperactivity, irritability, altered mood, insomnia
• Heat intolerance, sweating
• Palpitations
C
• Fatigue, weakness
• Dyspnoea
n
• Weight loss with increased appetite
• Pruritus
io
• Increase stool frequency

• Thirst and polyuria
t
ua
• Oligomenorrhoea or amenorrhoea, loss of libido, erectile dysfunction
Signs
al
• Sinus tachycardia, atrial fibrillation

• Fine tremor, hyperreflexia
Ev
• Warm, moist skin

• Palmar erythema
• Hair loss
• Muscle weakness and wasting
11. A 44 year old man with acute renal failure presents with palpitations. His ECG shows tall
tented T waves and a wide QRS complex. What is the SINGLE most appropriate next
step?
A. Dialysis
B. IV calcium chloride
C. IV insulin with dextrose
D. Calcium resonium
E. Nebulized salbutamol
262
The likely diagnosis here is hyperkalaemia. Both IV calcium gluconate or IV calcium
chloride can be used when there is ECG changes in hyperkalaemia. We use it to stabilise
the cardiac membrane.
Hyperkalaemia


spironolactone
• Addison's
Management
y
op
C
n
plasma K+ levels
io

t

ua

• Loop diuretics
al
• Dialysis
Ev
12. A 39 year old lady presents with gradually worsening headaches, visual disturbance,
and lack of energy. MRI shows a 15mm tumour in the pituitary fossa. She has been on
cabergoline for treatment of her prolactinoma but has not had any response. What is
A. Radiotherapy
B. Octreotide
C. Craniotomy
E. Chemotherapy
Since dopamine agonists here have been shown to be ineffective. Transsphenoidal

surgery is appropriate.
Prolactinoma Management
Drug therapy - dopamine agonists
263
• Suppresses prolactin in most patients, with secondary effects of normalization
of gonadal function and terminates galactorrhoea
• Shrinks tumours → by shrinking the tumour, restoration of other hormonal
axes may occur
• Corrects visual field defect by chiasmal decompression thus immediate surgical
decompression is not necessary
• Note: Cabergoline is more effective in normalization of prolactin in
microprolactinoma compared to bromocriptine. It is also associated with fewer
side effects than bromocriptine
Surgery
• Since the introduction of dopamine agonist treatment, transsphenoidal surgery
is indicated only for patients who are resistant to, or intolerant of, dopamine
agonist treatment
Radiotherapy
• Reduce the chance of recurrence (rarely needed)
y
13. A 45 year old woman has lost weight 12 kg over the past half year. She has also noticed
op
episodes where she feels her heart beat beating rapidly. She has a regular pulse rate of
90 bpm. Her ECG shows sinus rhythm. What is the SINGLE most appropriate
investigation to be performed?
C
A. Thyroid antibodies
n
B. Thyroid function test
C. Adrenocorticotropic hormone stimulation (Synacthen®) test
io
D. Echocardiogram
E. Plasma glucose
t
ua
Hyperthyroidism
Symptoms:
al
Weight loss, tachycardia, diarrhoea, oligomenorrhoea, irritability, heat intolerance,

tremors, sweating and weight loss despite increased appetite, atrial fibrillation/sinus
Ev
tachycardia
The most sensitive test in thyroid diseases is the TSH. If the TSH is normal, then the
patient is euthyroid.
14. A 9 year old boy during operation and immediately after showed glycosuria. A day later
his urinalysis was normal. What is the SINGLE most likely diagnosis?
A. Pre-diabetic state
B. Normal finding
E. Maturity Onset Diabetes of the Young
Glycosuria fairly common after an operation. Stress during operation can cause
transient hyperglycaemia causing glycosuria secondary to stress induced rise of cortisol
which becomes normal after some time.
264
15. A 42 year old lady has unexplained milk secretion from her nipples. Her last menstrual
period was 6 months ago. She says she has been experiencing a loss of libido. What is
C. Pheochromocytoma
D. Hyperthyroidism
Hyperprolactinaemia
secretion.
y
op

C
Etiology
n
io

t

ua
meningioma)
al

Ev

• Hypopituitarism
Diagnosis
pituitary stalk
265
• Imaging: MRI

16. A 32 year old man has been repeatedly admitted to the hospital for what was described
as anxiety or panic attacks associated with palpitations. On occasions he is found to be
hypertensive and tremulous. What is the SINGLE most likely diagnosis?
A. Hyperthyroidism
B. Panic attacks
Phaeochromocytoma
y
Rule of 10
op
C
n
io

t
ua

al
• Headaches
• Palpitations
Ev
• Anxiety
• Tremor
Mnemonic
PHaeochromocytoma
P → Palpitations
H→ Headaches
Tests
Management
management:
266
blocker


17. A 32 year old woman with headaches and lethargy has hypertension. A recent blood
test shows a serum potassium of 2.9 mmol/l. What is the SINGLE most appropriate
hormone test to order?
A. Aldosterone
B. Cortisol
y
C. Thyroxine
op
D. Renin
E. Testosterone C
Hypertension and hypokalemia is seen in hyperaldosteronism. Aldosterone would be
the most appropriate hormone test.
n
io
Conn’s syndrome (Adrenal adenoma)

t
Think of Conn’s in these contexts:

ua
• Hypertension associated with hypokalaemia

• Refractory hypertension, eg despite ≥3 antihypertensive drugs
• Hypertension occurring before age 40
al
Classic features include:

Ev
• Hypertension
• Hypokalaemia (usually < 3.5 mmol/L, although 70% of patients may be
normokalaemic)
• Metabolic alkalosis
• Sodium may be normal or at the high end of normal
• Weakness may be present from hypokalaemia.
• Headaches and lethargy may also be present.
Management
Medical management is used in the period prior to surgery. Medical management
involves the use of aldosterone antagonists - eg, spironolactone.
Surgery is the definitive treatment. Surgical treatment involves adrenalectomy.

Laparoscopic surgery is safe and effective and may be better than open surgery.
18. A 52 year old woman diagnosed with breast cancer presents with urinary frequency.
Which part of the brain is the metastasis spread to?
267
A. Brain stem
B. Pons
C. Medulla
D. Diencephalon
E. Cerebral cortex
The topic to be discussed here is Diabetes Insipidus which accounts for her urinary
frequency. In this question, cranial diabetes insipidus is described. It is due to deficiency
of circulating arginine vasopressin (antidiuretic hormone). The pathophysiology behind
this is pituitary infiltration by metastases originating from breast. A little anatomy
knowledge is needed in this question. Among all of the answers, diencephalon would fit
as it gives rise to the posterior forebrain structures including the thalamus,
hypothalamus, posterior portion of the pituitary gland, and pineal gland.
19. A 45 year old lady presents with diarrhea, vomiting, and severe abdominal pain.
Examination reveals that her skin is hyperpigmented. Her blood pressure is 70/55
mmHg. What is the SINGLE most likely electrolyte abnormality to be found?
y
op
C
n
Diarrhoea, vomiting, severe abdominal pain, tanned skin (hyperpigmentation) and
io
hypotension points towards Addison’s disease where hyponatraemia and

hyperkalaemia are seen.
t
ua
Addison's disease
Associated electrolyte abnormalities:

al
• Hyperkalaemia
• Hyponatraemia
Ev
• Hypoglycaemia
It may be easier to think of the hormones that are involved:
ACTH ↑ → hyperpigmentation
Aldosterone ↓ → Na↓ → Hypotension

→ K↑
→ H↑ → Metabolic acidosis
Cortisol ↓ → Arterial hypotension

→ Hypoglycaemia
20. A 40 year old man complains of thirst and lethargy. He has a blood pressure of 145/95
mmHg. His blood tests show:
268
A. IV fluids
B. Calcitonin
C. IV hydrocortisone
D. Furosemide
E. Cinacalcet hydrochloride
The first step in management in hypercalcaemia is always rehydration with IV fluids.
The given scenario has a slightly high BP. This can be found in hypercalcaemia as well.
Hypercalcaemia
y
Aetiology
op
• Primary Hyperparathyroidism → This is the main cause of hypercalcaemia. It is
the most common cause of hypercalcaemia but it is usually mild most of the
time so most patient have no symptoms at all
C
• Malignancy → i.e. multiple myeloma, production of PTH like molecule
(Squamous cell carcinoma of the lung). This is a common cause of
hypercalcaemia that requires hospital admission
n
• Familial Hypocalciuric hypercalcaemia
io
• Immobilization
• Sarcoidosis
t
ua
Clinical features
Mnemonic: "moans, stones, groans, and bones".

al
• Neuro and psych: Hypercalcemia results in decreased mental activity leading to

Ev
lethargy, confusion and depression (Groans)

• Gastrointestinal: Hypercalcemia results in decreased bowel activity such as
constipation (Moans)
• Renal: Hypercalcemia results in polyuria and polydipsia because of the
induction of nephrogenic diabetes insipidus. Calcium also precipitates in the
kidney, resulting in both kidney stones as well as nephrolithiasis. (Stones)
• Bone pain is only seen when it is hyperparathyroidism which is causing
hypercalcaemia (Bones)
• Cardiovascular: The ECG shows a short QT
Hypercalcaemia: management
• The initial management of hypercalcaemia is rehydration with normal saline,
typically 3-4 litres/day. Increasing the circulating volume with 0.9% saline, helps
to increase the urinary output of calcium
• Following rehydration bisphosphonates may be administered intravenously.
Other less used options include:
269
• Calcitonin → It has fewer side-effects than bisphosphonates but is less effective
in reducing hypercalcaemia.
• Steroids in sarcoidosis
• Cinacalcet hydrochloride is a calcimimetic agent that effectively reduces
parathyroid levels in patients with secondary hyperparathyroidism
• Haemodialysis or peritoneal dialysis may be relevant in patients with severe
hypercalcaemia secondary to renal failure
• Furosemide has a limited role → It is occasionally used where there is fluid
overload but it does not reduce serum calcium
21. A 27 year old woman presents with tremors, anxiety. She has a history of significant
weight loss over the last 6 months.She has a heart rate of 112 beats/minute. Mild
proptosis was seen on examination. What is the SINGLE most likely mechanism that
accounts for her symptoms?
A. Deficiency in thyroid hormone

B. Increased level of calcitonin
y
C. Increased metabolic rate
D. Insulin resistance
op
E. Reduced caloric intake
The given features are of thyrotoxicosis in which increased metabolism causes tremors,
C
anxiety, weight loss and an increased heart rate.
n
22. A 32 year old man has paroxysmal hypertension. He has frequent headaches and
complains of profuse sweating. His blood pressure remains high despite having started
io
on an ACE inhibitor. What is the SINGLE most likely diagnosis?

t
A. Hyperthyroidism
ua
B. Panic attacks
al

Ev
Phaeochromocytoma
Rule of 10

• Headaches
• Palpitations
270
• Anxiety
• Tremor
Mnemonic
PHaeochromocytoma
P → Palpitations
H→ Headaches
Tests
Management
management:
y
op
blocker

C
n
io
t
ua
23. An 8 month old infant presents with failure to thrive and constipation. On examination,
a protruding tongue and widely set eyes are observed. His father and older sister has a
history of prolonged neonatal jaundice. What is the SINGLE most likely diagnosis?
al
A. Down's syndrome
Ev
E. Congenital hypothyroidism
Failure to thrive, constipation, protruding tongue, widely set eyes are consistent with
congenital hypothyroidism.
This questions is purely a theoretical one and is probably rare to see in real life
especially in the UK.
Firstly, routine screening for congenital hypothyroidism is available throughout the UK.
Thyroid stimulating hormone (TSH) analysis is performed on a single spot from the
initial dried blood sample. Screening for congenital hypothyroidism is part of the
newborn blood spot test which is offered when baby is 6 to 8 weeks old. So it would be
unlikely that a congenital hypothyroidism would go undiagnosed until the 8 month of
life.
271
The reason for the family history of prolonged neonatal jaundice is because 15% of
congenital hypothyroidism is caused by thyroid dyshormonogenesis defects
transmitted by an autosomal recessive mode of inheritance. Thyroid hormone
dysgenesis is caused by inborn errors of thyroid metabolism.
Congenital hypothyroidism
Clinical features
• Physiological jaundice
• Goitre
• Feeding problems, constipation
• Delay in reaching normal milestones of development, short stature
• Coarse features with protruding tongue, broad flat nose, widely set eyes
• Sparse hair and dry skin
• Impaired mental development
y
24. A 44 year old woman has menstrual irregularities and unexplained milk discharge from
her nipples. An MRI reveals a pituitary tumour. What is the SINGLE most likely visual
op
abnormality associated with a pituitary tumour?
C
B. Homonymous upper quadrantanopia
n
D. Cortical blindness
io
Pituitary tumour by pressing optic chiasma causes bitemporal hemianopia

t
ua
Hyperprolactinaemia
al
Ev

secretion.

Etiology
meningioma)
272

• Hypopituitarism
Diagnosis
pituitary stalk
y
• Imaging: MRI

op
C
n
io

t
ua

al

Ev

• Hypertension
normokalaemic)
Management

25. A 35 year old man who a known type 1 diabetic has abdominal pain with deep
breathing and drowsiness. The nurse has said that his breath has a fruity smell. His
273
mucous membranes look dry. A urine dipstick testing shows marked glycosuria and
ketonuria. Plasma glucose was elevated. What is the SINGLE most appropriate

C. Oral rehydration
It is clear in this question that this man is suffering from diabetic ketoacidosis. Most
DKA patients have a depletion of around 5 litres thus initial intravenous normal saline is
so important. 0.9% saline is the replacement fluid of choice. Insulin should be infused
continuously at 0.1u/kg/h.
Characterised by hyperglycaemia, acidosis and ketonaemia
May be a complication existing type 1 diabetes mellitus or be the first presentation
y
op
Precipitating factors
The most common are:
• Infection
C
• Missed insulin doses
• Cardiovascular disease (e.g. stroke or myocardial infarction)
n
Features
io
• Polyuria, polydipsia, dehydration, vomiting

• Abdominal pain
t

ua

• If severe → altered mental state, including coma
al
Diagnosis
• Glucose > 11 or known diabetic
Ev
• pH < 7.3
• Bicarb < 15
• Ketones > 3 or urine dipstick ketones ++
Management
• The most important initial intervention is appropriate fluid replacement
followed by insulin administration.
• When plasma glucose is below 12 mmol/L then replace normal saline with 5%
dextrose to prevent over-rapid correction of blood glucose and hypoglycaemia.
• Hypokalaemia may need to be corrected with KCL
26. A 43 year old man complains of thirst, lethargy and frequent urination. He was
diagnosed with multiple myeloma. What is the SINGLE most likely biochemical
abnormality to be associated with this condition?
A. Hypercalcaemia
B. Hyperkalaemia
274
C. Hypernatraemia
D. Hypocalcaemia
E. Hypomagnesemia
Hypercalcaemia
Aetiology
• Immobilization
• Sarcoidosis
Clinical features
y
op

C
n
io

t
•
ua
Bone pain is only seen when it is hyperparathyroidism which is causing

al
Ev


27. A 9 year old girl who is known to have type 1 diabetes mellitus presents with
drowsiness and deep breathing. Her blood glucose is 18 mmol/L. She has a blood
275
pressure of 120/80 mmHg and her mucous membranes are dry. What is the SINGLE
A. Serum urea
B. Blood culture
C. Computed tomography
D. HbA1c
This child is likely suffering from diabetic ketoacidosis. An arterial blood gas at this time
would be a good investigation of choice to determine the severity.
y
• Infection
op
C
Features
n
• Abdominal pain
io

t
ua
Diagnosis
al
• pH < 7.3
• Bicarb < 15
Ev
Management
28. An 8 year old boy with a body mass index is 25 kg/m2 was admitted to a surgical ward
following a road traffic accident. He was found to have glycosuria. When he recovered
from his injury the glycosuria resolved. What is the SINGLE most appropriate follow-up
investigation?

276
Glycosuria can be seen during any event that contains stress to the body. Stress related
cortisol release can elevate blood glucose and in the severely ill patients they may
elevate glucose beyond the renal threshold leading to glycosuria. Once the patient
recovers, it glycosuria resolves. Nonetheless, a fasting blood glucose concentration
should be performed in his follow up visits to exclude diabetes.
29. A 55 year old man has weight loss, dyspnoea and syncope. He smokes 20
cigarettes/day. Investigations confirm squamous cell carcinoma in the left bronchus.
What is the SINGLE most likely biochemical abnormality to be associated with this
condition?
A. Hypercalcaemia
B. Hyperkalaemia
C. Hypernatraemia
D. Hypocalcaemia
E. Hypomagnesemia
y
op
Hypercalcaemia
Aetiology
C
n
io

t

ua
• Immobilization
• Sarcoidosis
al
Clinical features
Ev

277

30. A 55 year old man with a 4 year history feeling thirsty and urinating more often than
usual presents with a deep painless ulcer on the heel. He also has a history of
unexplained weight loss and feels tired all the time. What is the SINGLE most
y
A. Arteriography
op
B. Venography
C. Blood sugar
D. Biopsy for malignant melanoma
C
E. Biopsy for pyoderma
n
This patient has diabetic foot. Polydipsia, polyuria, fatigue and unexplained weight loss
are symptoms of diabetes. Blood sugars would be the best investigation of choice.
io
The main symptoms, which are common in diabetes are:

t
• urinating more often than usual, particularly at night

ua
• feeling very thirsty

• feeling very tired
al
• unexplained weight loss

• itching around the penis or vagina, or frequent episodes of thrush
Ev
• cuts or wounds that heal slowly

• blurred vision (caused by the lens of the eye becoming dry)
31. A 45 year old lady complains of galactorrhoea, decreased libido, amenorrhoea, weight
gain, depression and fatigue. She also gives a history of constipation in the last 3
months. Her serum prolactin levels are 856 mU/L. What is the SINGLE most likely cause
of her hyperprolactinaemia?
A. Hypothyroidism
B. Stress
C. Pregnancy
D. Prolactin secreting pituitary tumor
E. Polycystic ovary syndrome
Hypothyroidism can cause hyperprolactinaemia and would be the cause here as there
are symptoms of weight gain, depression and constipation.
Hyperprolactinaemia
278
secretion.

Etiology
meningioma)
y
op
C
n
io

t

ua

• Hypopituitarism
al
Diagnosis
Ev

pituitary stalk
• Imaging: MRI

32. A 35 year old man is feeling unwell after a recent myocardial infarction. A recent ECG of
the patient shows widening of the QRS complex and tall-tented T wave. His recent
blood results show:
Sodium 136 mmol/L
279
Urea 5 mmol/L

B. Oral calcium resonium
C. Oral calcium with vitamin D
D. Intravenous sodium chloride
E. Intravenous glucose
The ECG changes point towards hyperkalaemia. The need for urgent intravenous
calcium gluconate is live saving as this patient could have a cardiac arrest.
Hyperkalaemia
y
op

C
spironolactone
n
io
• Addison's
t
Management
ua

al

Ev
plasma K+ levels

• Loop diuretics
• Dialysis
33. A 55 year old woman has recently been diagnosed with type 2 diabetes mellitus. Her
body mass index is 23 kg/m2. Her last two random blood sugars that were taken were 8
and 7 mmol/l. Her blood pressure is 140/86 mmHg. Her total cholesterol is 4.7mmol/l.
She has no symptoms but has microalbuminuria. What is the SINGLE most appropriate
drug management?
A. ACE inhibitors
280
B. Calcium channel blockers
C. Statin
D. Statin and glibenclamide
E. Beta-blockers
Patients with type 2 diabetes mellitus have a considerably higher risk of cardiovascular
morbidity and mortality and are disproportionately affected by cardiovascular disease.
Thus they have a different set of rules when it comes to managing their hypertension.
Provide lifestyle advice if blood pressure is confirmed as being consistently above

140/80 mmHg (or above 130/80 mmHg if there is nephropathy, retinopathy, or
cerebrovascular damage). If lifestyle advice does not reduce blood pressure to below
these targets, add a drug treatment
First-line antihypertensive drug treatment should be a once-daily ACE inhibitor. This

applies to most people.
34. An 18 year old man has extreme thirst and polyuria. 6 months ago he had a significant
y
head injury as the result of a road traffic accident. A diagnosis of diabetes insipidus is
op
suspected. What is the SINGLE most likely laboratory findings after fluid deprivation
before the administration of desmopressin? C
(normal plasma osmolality 275-295 mosmol/kg and normal urine osmolality is 300-900
mosmol/kg)
n
A. Plasma osmolality of 280 mosmol/kg and urine osmolality of 250 mosmol/kg
io
B. Plasma osmolality of 300 mosmol/kg and urine osmolality of 350 mosmol/kg

C. Plasma osmolality of 335 mosmol/kg and urine osmolality of 700 mosmol/kg
t
D. Plasma osmolality of 280 mosmol/kg and urine osmolality of 700 mosmol/kg

ua
E. Plasma osmolality of 335 mosmol/kg and urine osmolality of 200 mosmol/kg
In diabetes Insipidus, one can expect excess fluid loss with urine. Urine osmolality
al
would be low and plasma osmolality would be high.

Ev
Diabetes Insipidus
Fluid deprivation test and assessment of response to vasopressin:

1. Patient is then deprived of fluids
2. Plasma osmolality is measured 4 hourly and urine volume and osmolality every
2 hours
3. The patient is then given IM desmopressin with urine volume and urine and
plasma osmolality measured over the next 4 hours.
Understanding the results
Normal patient Diabetes insipidus

Fluid restriction causes a decrease in Despite fluid restriction, urine volume
urine volume and an increase in urine remains high and urine osmolality is
osmolality decreased
281
Central Diabetes Nephrogenic
insipidus Diabetes insipidus
Urine volume There is no change
decreases and after administering
urine osmolality desmopressin
increases after
administering
desmopressin
Plasma osmolality (mOsm/kg)

After fluid deprivation, If plasma osmolality >305, the patient has diabetes insipidus
Urine osmolality (mOsm/kg)
Central Diabetes insipidus Nephrogenic Diabetes

insipidus
After fluid deprivation <300 <300
After desmopressin >800 <300
y
35.
op
A type 2 diabetes mellitus is undergoing a major surgery. He is on long acting insulin
and gliclazide. What is the SINGLE most appropriate pre-op management?
C
A. Start him in IV insulin and glucose and K+ just before surgery
n
B. Stop his oral hypoglycaemics on the day of the procedure
C. Continue regular oral hypoglycaemic
io
D. Stop oral hypoglycaemic the night before surgery and start IV insulin sliding scale
with glucose and K+ before surgery
t
E. Change to short acting oral hypoglycaemic

ua
Management of the diabetic patient pre-op

al
• Clarify if the patient is oral-controlled, insulin-dependent or brittle insulin-

dependent
Ev
• Diabetics should be first on operating lists to ensure timings can be as

predictable as possible for blood sugar management.
Minor surgery
• Oral-controlled: Give normal regimen.
• Insulin-controlled: Omit preoperative insulin on day of surgery; monitor blood
sugar (BS) every 4 hours; restart normal insulin once oral diet is established.
Major surgery
• Oral-controlled: Omit long-acting hypoglycaemics preoperatively. Monitor BS
every 4 hours.
• Insulin-controlled: Commence on IV insulin sliding scale preoperatively once nil
by mouth (NBM) and continue until normal diet is re-established. Check BS
every 4 hours.
282
she has a dry coarse skin, hair loss and cold peripheries. What is the SINGLE most likely
diagnosis?
A. Hypothyroidism
B. Hyperthyroidism
Hypothyroidism
(uncommon in UK)
y
op
medication.
C
n
io
Symptoms
t

ua

al
• Constipation
Ev
Signs
• Bradycardia

37. A 36 year old male diagnosed with glioblastoma has been receiving dexamethasone for
several months to treat cerebral oedema. He started having diarrhoea and vomiting for
the last 3 days. He complains of abdominal pain. He feels dizzy when he gets up from
bed or stands up from a chair. What is the SINGLE most likely reason for his symptoms?
A. Adrenal insufficiency
B. Dehydration
C. Steroids side effects
283
D. Raised intracranial pressure
The symptoms here are consistent with adrenal insufficiency. The pathogenesis in this
question is not clear. But it is most likely due to cessation of steroids causing addisonian
crisis.
Bare in mind that, the commonest cause of secondary adrenal insufficiency is

iatrogenic. This is due to long term steroid therapy leading to suppression of the
pituitary-adrenal axis. This only becomes apparent on withdrawal of the steroids. Other
causes are rare and include hypothalamic-pituitary disease leading to decreased ACTH
production.
Steroids side effect is not the right answer because side effects of steroids do not
produce these symptoms. It is the cessation of the steroids that cause the symptoms of
vomiting, abdominal pain and the sudden dizziness on standing which is evidence of
postural hypotension.
y
Adrenal Insufficiency
Primary insufficiency (Addison's disease)
op
• An inability of the adrenal glands to produce enough steroid hormones. The
C
most common cause for this in the developed world is autoimmune disease.
Secondary insufficiency
n
• Inadequate pituitary or hypothalamic stimulation of the adrenal glands.
io
Features
t
• Nausea/vomiting
ua
• Abdominal pain
• Diarrhoea/constipation
• Weakness
al
• Postural hypotension, dizzy

• Hyperpigmentation (only for Addison’s disease)
Ev
Think of adrenal insufficiency in all with unexplained abdominal pain or vomiting
It is especially important to note for the exam that in secondary insufficiency, there is
no hyperpigmentation of the skin as ACTH is decreased. Hyperpigmentation would only
happen in primary insufficiency (Addison's disease) as the ACTH is extremely high.
38. A 31 year old man has profuse sweating, palpitations, headaches, flushing and
hypertension. He was diagnosed with phaeochromocytoma and is to have a surgical
removal of the tumour in a week. What is the SINGLE most appropriate initial
A. Tricyclic antidepressant
B. Diazepam
C. Diuretics
D. Alpha-blocker
E. Beta-blocker
284
Phaeochromocytoma
Rule of 10

• Headaches
• Palpitations
y
• Anxiety
op
• Tremor
Mnemonic
C
PHaeochromocytoma
P → Palpitations
n
H→ Headaches
io
Tests
t
ua

al
Management
Ev
management:
blocker


39. A 24 year old man is admitted to the emergency department with abdominal pain and
vomiting. He is discovered to have diabetic ketoacidosis. What is the SINGLE most
appropriate immediate management?
285
A. Intravenous fluids and insulin infused continuously
C. Bolus of intravenous insulin
Only give a stat dose of insulin if there is a delay in starting the insulin infusion.
y
op
• Infection
C
Features
n
• Abdominal pain
io

t

ua
Diagnosis
al

• pH < 7.3
Ev
• Bicarb < 15
Management
40. A 34 year old woman presents with truncal obesity, easy bruising, hyperglycemia and
depression. She has a blood pressure of 165/95 mmHg. Which of the following
investigations will be most helpful in localizing the cause of Cushing’s syndrome?
A. Serum cortisol
B. 24-hour urinary free cortisol
C. Low dose dexamethasone suppression test
D. High dose dexamethasone suppression test
286
E. Overnight dexamethasone suppression test
The features are representative of Cushing’s syndrome. A high dose dexamethasone

suppression test to differentiate between a pituitary adenoma and an ectopic source
which is producing ACTH.
Cushing’s syndrome
• A clinical state caused by prolonged exposure to elevated levels of either
endogenous or exogenous glucocorticoids
Causes can be divided into 2 groups:

• Adrenocorticotropic hormone (ACTH)-dependent disease:
o Excessive ACTH from the pituitary (Cushing's disease)
o Ectopic ACTH-producing tumours (Especially small cell lung cancer and
carcinoid tumours)
• Non-ACTH-dependent:
o Adrenal adenomas
o Adrenal carcinomas
y
o Excess glucocorticoid administration → This is the chief cause
Investigations:
Outpatient tests
op
C
• 24-hour urinary free cortisol → as an outpatient screening tool
• Overnight dexamethasone suppression test → Administration of 1mg
n
dexamethasone at midnight is followed by a serum cortisol measurement at 9
a.m. Cortisol < 50 nmol/L makes Cushing’s unlikely. The 1 mg overnight
io
dexamethasone suppression test is the best initial diagnostic test to establish a

diagnosis of Cushing syndrome.
t
ua
Inpatient tests
• ACTH levels → This is the next test to do once the diagnosis of Cushing’s
syndrome is confirmed. We do this test to differentiate between ACTH-
al
dependent and ACTH-independent aetiologies. ACTH levels are elevated with

either a pituitary source of ACTH such as an adenoma or with an ectopic
Ev
source.
• High-dose dexamethasone suppression test → This test is done to differentiate
between a pituitary adenoma and an ectopic source. The output of a pituitary
adenoma will suppress with high-dose dexamethasone (i.e. cortisol
suppressed). The output of an ectopic source will not suppress with high-dose
dexamethasone (i.e. cortisol not suppressed).
The reason that cortisol is suppressed in pituitary adenoma is because the adenoma is
semi-autonomous. A low dose dexamethasone will not suppress it but a high dose
dexamethasone will. Whereas, ectopic ACTH producing tumours are fully autonomous
and will not respond to a high dose dexamethasone suppression test.
Investigations for Cushing’s syndrome is a must know especially when to use a high dose
dexamethasone suppression test. It is a commonly asked question.
287
41. A 12 year old boy is clinically obese and is the shortest in his class. His medical history
includes having a renal transplant 2 years ago. There are purple striae noticed on his
y
skin. What is the SINGLE most likely diagnosis?
op
C
C. Pseudo-Cushing's syndrome
D. Laurence–Moon syndrome
E. Down syndrome
n
io
Cushing’s syndrome is the most likely diagnosis here. The history of a renal transplant
means that he is probably taking exogenous steroids which are causing his syndrome.
t
ua
42. A 9 year old boy had glycosuria following an appendectomy. He has no history of
diabetes mellitus. A few days later, his glycosuria resolved. What is the SINGLE most
appropriate follow-up investigation?
al

Ev

Glycosuria can be seen during any event that contains stress to the body. Stress related
cortisol release can elevate blood glucose and in the severely ill patients they may
elevate glucose beyond the renal threshold leading to glycosuria. Once the patient
recovers, it glycosuria resolves. Nonetheless, a fasting blood glucose concentration
should be performed in his follow up visits to exclude diabetes.
43. A 44 year old woman has recently undergone surgery for a fractured left hip. Her blood
tests show a low serum calcium level, low serum phosphate level and raised alkaline
phosphatase. What is the SINGLE most likely diagnosis?
B. Osteoporosis
288
C. Multiple myeloma
D. Osteomalacia
E. Rickets
Remember the bone profile differences:
Osteoporosis Paget’s Disease Osteomalicia

Serum Calcium Normal Normal Low
Serum phosphate Normal Normal Low
Alkaline Normal High High
phosphate
Osteomalacia
• Normal bony tissue but decreased mineral content
We use the term rickets the epiphysis has not fused (in younger people)
Commonly asked causes
y
• Vitamin D deficiency e.g. malabsorption, lack of sunlight, diet
op
• Renal failure
• Drug induced e.g. anticonvulsants
C
Presentation:
• Bone pain
n
• Fractures
• Muscle tenderness
io
44. A 26 year old woman with diagnosed carcinoma of the bronchus has been receiving
t
ua
steroid treatment for the last several months. She started vomiting and having severe
abdominal pain for the past 2 days. She also complains of sudden dizziness in the
morning. What is the SINGLE most likely reason for her symptoms?
al
A. Steroids side effects

Ev
B. Metastasis of cancer
C. Adrenal insufficiency
D. Conn’s disease
The symptoms here are consistent with adrenal insufficiency. The pathogenesis in this
question is not clear. But it is most likely due to cessation of steroids causing addisonian
crisis.
Bare in mind that, the commonest cause of secondary adrenal insufficiency is

iatrogenic. This is due to long term steroid therapy leading to suppression of the
pituitary-adrenal axis. This only becomes apparent on withdrawal of the steroids. Other
causes are rare and include hypothalamic-pituitary disease leading to decreased ACTH
production.
Steroids side effect is not the right answer because side effects of steroids do not
produce these symptoms. It is the cessation of the steroids that cause the symptoms of
289
vomiting, abdominal pain and the sudden dizziness in the morning which is evidence of
postural hypotension.

Features
• Nausea/vomiting
• Abdominal pain
• Weakness
y
op
C
n
io
45. A 54 year old woman has presented with episodes of abdominal ache, vomiting and
postural hypotension. She also has a dark pigmentation of her skin. A diagnosis of
t
Addison’s disease was made. What is the SINGLE most likely electrolyte abnormality
ua
expected in this patient?

al

Ev

Addison's disease

• Hyperkalaemia
• Hyponatraemia
• Hypoglycaemia

→ K↑
290

→ Hypoglycaemia
46. A 42 year old woman complains of tingling, numbness, paraesthesia, and involuntary
spasm of the upper extremities. She has undergone a thyroidectomy for thyroid
carcinoma a week ago. What is SINGLE most likely diagnosis?
A. Thyroid storm
B. Hyperparathyroidism
C. Unilateral recurrent laryngeal nerve injury
D. Hypokalaemia
E. Hypocalcaemia
Hypoparathyroidism is one of the well known causes of hypocalcaemia. It is seen

especially after thyroid surgeries where the surgeon has to work in close proximity to
the parathyroid gland.
y
op
Hypocalcaemia
Common causes
C
• vitamin D deficiency (osteomalacia)
• chronic renal failure
• hypoparathyroidism (e.g. post thyroid/parathyroid surgery)
n
• Hyperphosphatemia
io
• Hypomagnesemia
t
The clinical history combined with parathyroid hormone levels will reveal the cause of
ua
hypocalcaemia in the majority of cases
Clinical Findings
al
Hypocalcaemia results in increased neural hyperexcitability such as seizures, tetany,

circumoral numbness, and tingling of the extremities. Arrhythmias may develop
Ev
because of a prolonged QT.
A mnemonic to help is with clinical signs and symptoms is: “SPASMODIC”

S → Spasm (carpopedal spasms = Trousseau's sign)
P → Perioral paraesthesiae
A → Anxious, irritable, irrational
S → Seizures
M → Muscle tone increased in smooth muscles
O → Orientation impaired (time, place and person) and confusion
D → Dermatitis
I → Impetigo herpetiformis (rare and serious)
C → Chvostek’s sign, Cardiomyopathy (long QT interval on ECG)
The examination findings that illustrate this deficit are:

3. Trousseau’s sign in which the wrist flexes and the fingers are drawn together in
response to occlusion of the brachial artery.
291
4. Chvostek’s sign in which facial muscles twitch in response to tapping over the
parotid, revealing neuromuscular excitability due to the low calcium.
Management
• acute management of severe hypocalcaemia is with intravenous replacement.
The preferred method is with intravenous calcium gluconate,
• intravenous calcium chloride is more likely to cause local irritation
• further management depends on the underlying cause
47. A 35 year old woman presents with visual problems and amenorrhoea. An MRI reveals
a pituitary tumour. What is the SINGLE most likely visual abnormality?
B. Tunnel vision
D. Glares and halos
y
Pituitary tumour by pressing optic chiasma causes bitemporal hemianopia
Hyperprolactinaemia
op
C
n
io
secretion.
t

ua

al
Etiology
Ev

meningioma)

292
• Hypopituitarism
Diagnosis
pituitary stalk
• Imaging: MRI

y
48. A 39 year old woman has been feeling lethargic and tired. She has a blood pressure of
160/90 mmHg despite being on enalapril. Her blood test show:
Haemoglobin 130 g/L

op
C
Serum potassium 3.1 mmol/L
n
io
B. Conn’s syndrome
t
C. Hyperparathyroidism
ua
D. Renal disease
al

Ev


• Hypertension
normokalaemic)
Management
293
49. A 64 year old man with multiple myeloma has been vomiting for the past 2 days. His
blood tests show:

Serum potassium 5 mmol/l
Packed cell volume 55%
A. IV insulin
C. IV fluids
y
E. Oral bisphosphonates
op
Multiple myeloma itself is a cause of vomiting and is also associated with
hypercalcaemia which can cause sickness. As the patient has been vomiting for 2 days
C
there may be considerable dehydration. He also has hypercalcaemia which needs to be
treatment with IV fluid.
n
Hypercalcaemia
io
Aetiology
t

ua
al

Ev

• Immobilization
• Sarcoidosis
Clinical features

294

y
op
50. A 45 year old man presents with bitemporal hemianopia and swelling of his hands. He
says that his nose has become larger and his voice has become more hoarse. On
examination, spade-like hands are seen. What is the SINGLE most definitive test to
C
confirm the diagnosis?
n
A. Early morning growth hormone
B. Prolactin level
io
C. Oral glucose tolerance (OGTT) with serial growth hormone measurements

D. Random insulin-like growth factor (IGF-1)
t
E. Short synacthen test

ua
The clinical symptoms along with the spare-like hands give the suspicion of acromegaly.
al
Acromegaly investigations
Ev
Growth hormone (GH) levels tend to vary during the day and are therefore unreliable
and not recommended.
The best initial test → Insulin like growth factor

• It is used as a screening test and occasionally used to monitor disease
The most definitive test → Oral glucose tolerance (OGTT) with serial growth hormone
measurements
• In normal patients, growth hormone is usually suppressed with glucose
• In acromegaly, there is no suppression of growth hormone with glucose
MRI scan of pituitary may show a tumour. MRI scan of pituitary is more sensitive than
CT scan.
51. A 63 year old man who takes spironolactone and ramipril for hypertension and was
found to have elevated potassium of 5.8mmol/L on routine blood test while on a day
295
ward. He is otherwise well and has no allergies. An ECG is carried out which is normal.
What is the SINGLE best initial treatment in light of his potassium levels?
Normal Lab values
Potassium 3.5–5 mmol/L
A. Calcium gluconate IV
B. Renal dialysis
C. Stop spironolactone and ramipril
D. Recheck potassium level
E. IV insulin and glucose
Spironolactone is a potassium sparing diuretics and ramipril is an ACEi. Both can cause
hyperkalaemia.
The K+ is only slightly elevated, so stopping medication would suffice. We can expect
potassium levels to fall. It is important to check for symptoms and do an ECG, but at
y
this levels it is unlikely that patient is symptomatic or an ECG is abnormal.
op
In this question, the patient has a normal ECG with no symptoms so calcium gluconate
is not indicated. This man is certainly not a candidate for dialysis.
C
Hyperkalaemia
n
io

t
ua

al
spironolactone
Ev
• Addison's
Management


plasma K+ levels

• Loop diuretics
• Dialysis
296
52. A 26 year old woman comes to the emergency department with vomiting, abdominal
pain and tachypnoea. Her breath has a fruity smell. She has a heart rate of 99
beats/minute and a respiratory rate of 30 breaths/minute. Her blood pressure is
110/70 mmHg. Her blood and urine results show:
Blood Ketones 3.3 mmol/L (high)

Urine Ketones +++
Venous pH 7.2 (low)
Blood Glucose 22 mmol/L (high)

C. Oral rehydration
y
op
C
n
io

t
ua

• Infection
al

Ev
Features
• Abdominal pain
Diagnosis
• pH < 7.3
• Bicarb < 15
Management
297
53. A 19 year old man presents with weight loss, increasing thirst and increasing frequency
of going to the washroom. His father, grandfather and his 2 sisters have been
diagnosed with diabetes mellitus. What is the SINGLE most likely type of diabetes this
man suffers from?
A. Wolfram Syndrome
B. Diabetes mellitus type 2
C. Latent autoimmune diabetes of adults (LADA)
D. Maturity onset diabetes of the young
E. Diabetic ketoacidosis
MODY is a rare form of diabetes which is different from both Type 1 and Type 2
diabetes, and runs strongly in families. Maturity onset diabetes of the young is
estimated to be the underlying cause in 0.5–1% of all patients with diabetes. A typical
y
‘MODY patient’ has young age of onset (
op
The need to know so much detail for MODY is not necessary in PLAB. But there are
three key features which one needs to know.
C
1. Being young - diagnosed with diabetes under the age of 25
2. Having a strong family history. E.g. a parent with diabetes, with diabetes in two
or more generations
n
3. Manifest as mild hyperglycaemia
io
54. A 58 year old woman has tiredness and diarrhoea for the last few weeks. She has
t
noticed that her skin looks tanned. She describes dizziness on standing up and recently
ua
started feeling nauseous. What is the SINGLE most likely electrolyte abnormality to be
found?
al

Ev

Diarrhoea, nausea, tanned skin (hyperpigmentation) and postural hypotension in a

tired women points towards Addison’s disease where hyponatraemia and
hyperkalaemia are seen.
Addison's disease

• Hyperkalaemia
• Hyponatraemia
• Hypoglycaemia
298

→ K↑

→ Hypoglycaemia
55. A 45 year old man with diagnosed colon cancer develops increased thirst, and frequent
urination. He is also noted to have been losing weight in the last couple of months. His
blood test shows a fasting blood glucose of 9 mmol/L. He has a pulse of 70
breaths/minute. What is the SINGLE most appropriate management?
A. Oral hypoglycaemic
B. Long acting insulin
y
C. Short acting insulin before meals
op
D. IV insulin
E. Subcutaneous insulin C
The diagnosis of diabetes is very clear here. An increased thirst and increased frequency
in urination along with weight loss is suggestive of diabetes mellitus. The fasting blood
glucose of 9 mmol/L supports the diagnosis of diabetes. At the age of 45, the most
n
likely type of diabetes is type 2 diabetes mellitus. This is treated with oral hypoglycemic
io
agents. The first line is usually metformin but this again depends on other factors such
as the weight of the patient.
t
ua
Insulin can be used in type 2 diabetes as well. But it is used in combination with
metformin or it is used in very sick patients with a high blood glucose (hyperosmolar
hyperglycaemic state) often having a blood glucose level more than 40 mmol/L.
al
Type 2 Diabetes Management

Ev
• Offer standard-release metformin as the initial drug treatment for adults with
type 2 diabetes
• If metformin is contra-indicated or not tolerated, consider initial drug
treatment with a dipeptidyl peptidase-4 (DPP-4) inhibitor or pioglitazone or a
sulfonylurea
56. A newborn has congenital hypothyroidism. What feature might develop if no treatment
is given?
A. Microglossia
B. Physiological jaundice
C. Undescended testis
D. Anal tags
E. Left soft palate
299
Clinical features
The following features are late sequelae of congenital hypothyroidism and, with routine
screening now available, should never be seen nowadays.
• Physiological jaundice
• Goitre
• Delay in reaching normal milestones of development, short stature
• Coarse features with protruding tongue, broad flat nose, widely set eyes
• Sparse hair and dry skin
• Impaired mental development
• Epiphyseal dysgenesis, delayed dentition
57. A 33 year old woman has amenorrhoea and galactorrhoea. An MRI shows a 9mm
tumour in the pituitary fossa. What is SINGLE most appropriate management?
A. Radiotherapy
B. Cabergoline
y
C. Craniotomy
op
E. Chemotherapy
Drug treatment should always be tried first. Cabergoline is a dopamine agonist used in
C
treatment of prolactinoma.
n
Prolactinoma Management
io
Drug therapy - dopamine agonists

• Suppresses prolactin in most patients, with secondary effects of normalization
t
of gonadal function and terminates galactorrhoea

ua
• Shrinks tumours → by shrinking the tumour, restoration of other hormonal

axes may occur
al
• Corrects visual field defect by chiasmal decompression thus immediate surgical

decompression is not necessary
Ev
• Note: Cabergoline is more effective in normalization of prolactin in

microprolactinoma compared to bromocriptine. It is also associated with fewer
side effects than bromocriptine
Surgery
• Since the introduction of dopamine agonist treatment, transsphenoidal surgery
is indicated only for patients who are resistant to, or intolerant of, dopamine
agonist treatment
Radiotherapy
• Reduce the chance of recurrence (rarely needed)
58. A 30 year old woman complains of decreased appetite and weight gain. She has been
having irregular, infrequent periods in the last 10 months. She also feels tired and
lethargic majority of the day. On inspection, she has a dry coarse skin. What is the
A. Hypothyroidism
300
B. Hyperthyroidism
C. Polycystic ovary syndrome
Hypothyroidism
(uncommon in UK)
medication.
y
op
C
Symptoms
n
io
• Constipation
t
ua
Signs
al

Ev
• Bradycardia

59. A 33 year old man has erectile dysfunction, decreased libido and galactorrhoea. What is
C. Pheochromocytoma
D. Hyperthyroidism
Hyperprolactinaemia
301
secretion.

Etiology
meningioma)
y
op
C
n

io

• Hypopituitarism
t
ua
Diagnosis
al

Ev

pituitary stalk
• Imaging: MRI

60. A 44 year old man is extremely thirsty despite excessive drinking. Diabetes mellitus and
renal failure has been ruled out and a diagnosis of diabetes insipidus is suspected. Fluid
deprivation test and an assessment of response to vasopressin was done which was
consistent with central diabetes insipidus. What is the SINGLE most likely laboratory
finding that lead to the conclusion?
A. An increase in urine osmolality after administration of vasopressin

B. A decrease in urine osmolality after administration of vasopressin
302
C. An increase in plasma osmolality after administration of vasopressin
D. A decrease in plasma osmolality during fluid deprivation
E. An increase in urine osmolality during fluid deprivation
In diabetes Insipidus, one can expect excess fluid loss with urine. Urine osmolality
would be low and plasma osmolality would be high.
After administration of vasopressin (desmopressin), an increase in urine osmolality is

diagnostic for central (cranial) diabetes insipidus.
Diabetes Insipidus
Fluid deprivation test and assessment of response to vasopressin:

1. Patient is then deprived of fluids
2. Plasma osmolality is measured 4 hourly and urine volume and osmolality every
2 hours
3. The patient is then given IM desmopressin with urine volume and urine and
plasma osmolality measured over the next 4 hours.
y
op
Understanding the results
C
Normal patient Diabetes insipidus
Fluid restriction causes a decrease in Despite fluid restriction, urine volume
urine volume and an increase in urine remains high and urine osmolality is
n
osmolality decreased
io
Central Diabetes Nephrogenic

insipidus Diabetes insipidus
t
Urine volume There is no change

ua
decreases and after administering

urine osmolality desmopressin
increases after
al
administering
desmopressin
Ev

After fluid deprivation, If plasma osmolality >305, the patient has diabetes insipidus
Central Diabetes insipidus Nephrogenic Diabetes

insipidus
61. A 38 year old lady was admitted with severe abdominal pain and diarrhoea. On
examination, hyperpigmentation is noticed at the palmar creases and buccal mucosa.
She has muscle cramps and joint pain. Her blood pressure is 79/50 mmHg. What is the
A. Addison’s disease
B. Cushing syndrome
303
D. Hyperthyroidism
The signs and symptoms are classic for Addison’s disease. The hyperpigmentation alone
should prompt you to pick addison’s disease. This is supported by the symptoms of
abdominal pain and diarrhoea. Muscle pain, joint pain and hypotension is also seen in
Addison’s disease. Sometimes they would give you a history of postural hypotension
instead of hypotension.
Note that hyperpigmentation is especially noticeable in buccal mucosa, lips, palmar

creases.

y
op
C
Features
• Nausea/vomiting
• Abdominal pain
n
io
• Weakness
t

ua

al
Ev
62. A 46 year old woman complains of tiredness and lethargy. She has noticed a 8 kg
weight gain in the last 3 months and is feeling more sensitivity to cold. She has a pulse
rate of 55 beats/minute. What is the SINGLE most likely diagnosis?
A. Hypothyroidism
B. Hyperthyroidism
Hypothyroidism
304
(uncommon in UK)
medication.
Symptoms
• Constipation
y
Signs
op
•
C
Dry coarse skin, hair loss and cold peripheries
• Bradycardia
n
io

t
ua
63. A 49 year old man with a diagnosis of squamous cell carcinoma of the lung is confused
and lethargic. He is continuously thirsty and urinates frequently. His blood tests show:
al

Ev
What is the SINGLE most appropriate initial step?
A. Calcitonin
C. IV 0.9% saline
E. Steroids
This patient is suffering from hypercalcaemia due to production of PTH like molecule
(Squamous cell carcinoma of the lung). The first step in management is always
rehydration with IV fluids.
Hypercalcaemia
Aetiology
305
• Immobilization
• Sarcoidosis
Clinical features

y
op
C
n
io

t
ua

al

Ev
64. A 34 year old woman is referred to the endocrine clinic with a history of thyrotoxicosis.
At her first appointment she is found to have a smooth goiter, lid lag and bilateral
exophthalmos with puffy eyelids. She wants to discuss the treatment of her thyroid
problem as she is keen to become pregnant. What is the SINGLE most likely treatment
to be given to her?
A. Carbimazole alone
B. Propylthiouracil alone
C. A combination of carbimazole and thyroxine
306
E. Thyroidectomy
Of the three recognised treatment options for hyperthyroidism (radioiodine therapy,

antithyroid drug therapy and surgery), generally only drug therapy (preferably
propylthiouracil) is considered for treating pregnant women. As this patient is not yet
pregnant but trying to conceive, there are no consensus on the treatment option.
However, it is likely that propylthiouracil would be the preferred treatment as she has
not attempted any anti-thyroid drug therapy in the past.
Both propylthiouracil (PTU) and carbimazole are effective in controlling the disease in
pregnancy. Historically, propylthiouracil has been preferred in pregnancy because it is
not associated with aplasia cutis and omphalocele, which may be the case for
carbimazole. However, recent concern regarding hepatotoxicity of PTU, particularly in
children, has led to recommendations that it should only be prescribed in the first
trimester. Nonetheless, PTU is the drug of choice when trying to conceive
(preconception) and also in the first three months of pregnancy. If PTU is not available,
carbimazole can be used.
y
op
Surgical management is also something to consider and in a number of women
planning to become pregnant, it is the therapy of choice. As stated above, there are no
consensus to which management pathway should be used but it is likely that
C
propylthiouracil would be attempted first before considerations of surgery. While
subtotal or near total thyroidectomy achieves a 98% cure rate, it is indicated if there is
suboptimal response to anti-thyroid medication or radio-iodine.
n
io
Anti-thyroid medication has a slight increased risk of baby developing structural

abnormalities, so it is common for physicians to encourage patients to choose to have
t
definitive treatment of Grave’s disease with radioactive iodine or surgery before

ua
considering a pregnancy. But then again, a trial of anti-thyroid medication is likely to be

attempted first.
al
It is also important to note that the patient has symptoms of Graves’s ophthalmopathy
of which radioactive iodine should not be used as part of the management. There is
Ev
evidence that Graves’s ophthalmopathy worsens after administration of radioactive

iodine.
Pre-pregnancy counselling is also important. It should include informing the patient of

the importance of euthyroidism before conception since uncontrolled hyperthyroidism
is associated with an increased risk of congenital abnormalities.
If the patient was already pregnant, the decision to pick propylthiouracil becomes more
clear. Also, points to note if the patient is pregnant are as follows:
• The use of iodides and radioiodine is contraindicated in pregnancy
• Patient still needs to continue taking anti-thyroid medication during pregnancy
o As anti-thyroid medication is able to cross the placenta, the lowest
possible dose should be prescribed
• If already on carbimazole, change carbimazole to propylthiouracil
• Thyroidectomy is rarely performed in pregnancy
o It is reserved for patients not responding to anti-thyroid medication
307
o If necessary, it is preferable to perform thyroidectomy in the second
trimester
65. A 28 year old woman complains of tiredness, lethargy, and intolerance to cold. She has
a history of Addison’s disease. Her skin looks dry on examination. She has been having
infrequent periods in the one year and her last menstrual period was 3 months ago.

B. Hyperthyroidism
C. Hypothyroidism
Hypothyroidism
y
op
(uncommon in UK)
C
medication.
n
io
t

ua

al
Symptoms
Ev

• Constipation
Signs
• Bradycardia

66. A 31 year old man has tremors, profuse sweating and palpitations. His blood pressure
was measured at 160/115 mmHg but dropped to 139/92 on standing. What is the
308
A. Hyperthyroidism
B. Panic attacks
Postural hypotension is defined as a reduction in systolic blood pressure of 20mmHg or

more after standing for at least one minute. Postural hypotension can be seen in
phaechromocytoma.
Phaeochromocytoma
Rule of 10
y
op
• 10% not associated with hypertension C
n
• Headaches
• Palpitations
io
• Anxiety
t
ua
• Tremor
Mnemonic
al
PHaeochromocytoma
P → Palpitations
Ev
H→ Headaches
Tests
Management
management:
blocker

309
67. A 56 year old man was recently started on antihypertensive medication. His recent
blood results show:
Sodium 134 mmol/L

Urea 7 mmol/L
What is the SINGLE most likely medication responsible for the abnormal results?
A. Amlodipine
C. Doxazosin
y
D. Atenolol
op
E. Ramipril
Ramipril is an ACE inhibitor. ACE inhibitors are known for their effects of
C
hyperkalaemia.
Hyperkalaemia
n
io

t

ua

al

spironolactone
Ev
• Addison's
Management


plasma K+ levels

• Loop diuretics
310
• Dialysis
68. A 39 year old man has galactorrhoea. On examination of his visual fields, a bitemporal
hemianopia was noted. What is the SINGLE most likely diagnosis?
C. Pheochromocytoma
D. Hyperthyroidism
Hyperprolactinaemia
secretion.
y
op

C
Etiology
n
io

t

ua
meningioma)
al

Ev

• Hypopituitarism
Diagnosis
pituitary stalk
311
• Imaging: MRI



• Hypertension
y
normokalaemic)
op
C
n
Management
io

t
ua

al
69. A 29 year old male comes to clinic with a swollen, painful right wrist joints. On further
questioning, he gives a history of noticing a change in his shoe size. His other complains
Ev
also include constipation, feeling cold and needing more warm clothes to keep him
warm. On examination, his skin is found to be dry and his right wrist is erythematous
and tender to touch. What is the SINGLE most likely diagnosis?
A. Chondrosarcoma
B. Liposarcoma
C. Gout
D. Pseudogout
This is a two part question.
The first part is recognising the symptoms of hypothyroidism. The change of shoe size is
probably due to myxoedema. The other features given like constipation, cold
intolerance and dry skin are features seen in hypothyroidism.
The second part is recognising that pseudogout may be precipitated by hypothyroidism.

This explains the swollen wrist joint.
312
Pseudogout may have an acute presentation like gout. It may also present in an
asymptomatic and chronic form. The knee is the most commonly affected joint. The
other joints commonly affected are the wrist, shoulder, and ankle. Presentation is
similar (but usually milder) to acute gout, with acute joint pain and swelling. Attacks
may be associated with fever and a raised white cell count.
Positive birefringent crystals in synovial fluid evaluation are pathognomonic for acute
pseudogout.
70. A 33 year old man comes to clinic to have an oral glucose tolerance test. What is the
plasma glucose level two-hours after glucose intake which indicates an impaired
glucose tolerance?
A. >11.1 mmol/L
B. >11.0 mmol/L
C. Between 8.0-10.9 mmol/L
D. Between 7.8-11.1 mmol/L
y
E. Between 7.1-11.1 mmol/L
op
Impaired glucose tolerance is defined as a fasting plasma glucose concentration of less
than 7.0 mmol/L with a two-hour oral glucose tolerance test value of 7.8 to 11.1
C
mmol/L
71. A 35 year old man with a medical history of type 1 diabetes mellitus presents to the
n
hospital with reduced conscious level and feeling unwell. He has dry mucous
io
membranes and a slow capillary refill. He has a blood pressure of 80/50 mmHg and a
pulse rate of 105 beats/minute. What is the SINGLE most appropriate initial
t
investigation?
ua

B. Full blood count
al
C. HbA1c
D. Liver function tests
Ev
E. Serum urea
Signs of dehydration, hypotension, tachycardia with a medical history of type 1

diabetes mellitus points towards a likely diagnosis of diabetic ketoacidosis. In reality,
diabetic ketoacidosis should be part of the differential in anyone with diabetes who is
unwell.
From the given options, arterial blood gas is the best response as it would help the
medics know the severity of the DKA. If capillary blood glucose was in the options, this
would take priority over the other investigations as it is quick and helps us with the
differential.
313
• Infection
Features
• Abdominal pain
Diagnosis
• pH < 7.3
• Bicarb < 15
y
Management
op
C
n
io
72. A 29 year old known diabetic man comes to A&E after falling down the stairs. While
waiting in the waiting room, he becomes unconscious and collapses. What is the
t

ua
A. Computed tomography scan

B. Random blood sugar
al

Ev
A random blood sugar is the first investigation to do. In an unconsciousness patient

especially a diabetic, ruling out hypoglycaemia has to be treated as priority. It is easy
and fast to perform.
73. A 68 year old woman was diagnosed with Type 2 Diabetes Mellitus. Diet and lifestyle
modifications have failed to control his blood sugar over the last three months. She has
no known allergies and takes Ramipril 5mg daily. She has a body mass index is 35
kg/m2. Her blood results are as follows:

eGFR 25 ml/min
A. Biguanide
314
B. Sulfonylurea
C. Insulin
D. Glitazone
E. Sodium glucose co-transporter 2 (SGLT2) inhibitors
NICE recommends biguanide (such as Metformin) as first line treatment for patients
with type 2 diabetes unless this is contraindicated. This patient is obese and has poor
renal function, hence biguanides, sulfonylurea and sodium glucose co-transporter 2
inhibitors are contraindicated. Pioglitazone causes weight gain so this is not an
appropriate option as well.
74. A 65 year old man with a body mass index is 33 kg/m2 has been diagnosed with Type 2
diabetes mellitus. Diet and lifestyle modifications have failed to control his blood sugar
over the last three months. He has no known allergies and does not take any regular
medications. His blood results are as follows:
Serum urea 3.6mmol/L

y
eGFR 79 ml/min
op
C
A. Biguanide
B. Sulfonylurea
C. Sodium glucose co-transporter 2 (SGLT2) inhibitors
n
D. Glitazone
io
E. Incretin mimetics
t
NICE recommends biguanide (such as Metformin) as first line treatment for patients
ua
with type 2 diabetes unless this is contraindicated. Contraindications to Metformin

include eGFR less than 30 ml/min, severe infection, shock, hepatic insufficiency, and
alcohol addiction - all of which predisposes a risk to developing lactic acidosis The
al
patient is also obese hence sulphonylureas is not suitable as it can cause weight gain.
Ev
75. A 75 year old man with a recent diagnosis of prostate cancer has confusion, thirst,
lower back pain and abdominal pain. An ECG was performed which showed shortening
of QT interval. What is the SINGLE most appropriate investigation?
A. Magnetic resonance imaging spine

C. DEXA scan
D. Serum alkaline phosphatase
E. Serum calcium
It is clear from the clinical features that this man is suffering from hypercalcaemia.
Prostate cancer is typically associated with metastatic osteoblastic lesions,
hypocalcemia and hypophosphatemia. Although, hypercalcemia is sometimes
encountered like in this case.
Prostate cancer cells in a bone may make extra calcium pass out of the damaged bone
and into the blood. Hypercalcaemia explains the symptoms in this stem of confusion,
315
thirst because of polyuria and abdominal pain. The back pain seen in this stem is due to
metastatic bone disease.
As there are no symptoms of tingling or numbness in the legs in this stem, there is no
rush to perform a magnetic resonance imaging of the spine to investigate for malignant
spinal cord compression. Obtaining a serum calcium would be the most appropriate
since ECG changes are already seen and hypercalcaemia would need to be treated as
soon as possible.
Remember the clinical features of hypercalcemia:
Clinical features

y
op
C
n
io
76. A 79 year old man has a diagnosis of lung cancer. He has a sodium level of 122 mmol/l
but remains asymptomatic for hyponatraemia. What is the SINGLE most appropriate
t
management?
ua
A. Demeclocycline
B. Vasopressin
al
C. Fluid restriction
D. Reassure
Ev
E. Tolvaptan
This man is suffering from effects of syndrome of inappropriate antidiuretic hormone

secretion (SIADH) which is leading to his hyponatraemia. One of the causes of SIADH is
small cell lung cancer.
Treat the cause of SIADH and restriction of fluid is the mainstay management for
majority of cases of SIADH. Consider Tolvaptan or demeclocycline if poor response after
fluid restriction.
77. A 32 year old man has recently had an appendectomy performed. His post-op blood
results return with the following values:
Glucose 4.5 mmol/L

Sodium 129 mmol/L
316
A. Sodium chloride 0.9% intravenous infusion

B. Sodium chloride 0.45% intravenous infusion
C. Insulin-glucose intravenous infusion
D. Nebulised salbutamol
E. Sodium bicarbonate
There is mild hyponatremia with normal to mild hyperkalaemia. Glucose is within

normal levels. The range for “normal” potassium differs among laboratories but they
are usually between 3.5-5.0 mmol/l. There is no universal definition of hyperkalemia
but a serum potassium above 5.5mmol/l is widely used.
It is worth knowing the contents of sodium chloride 0.9%. One litre of sodium chloride
0.9% contains:
• 154 mEq of sodium ion = 154 mmol/L
• 154 mEq of chloride ion = 154 mmol/L
y
Thus, sodium chloride 0.9% intravenous infusion can be used to treat sodium depletion
op
and in this case it will correct the electrolyte disbalance. Potassium levels will also be
brought down slightly with sodium chloride 0.9% intravenous infusion.
C
Nebulised salbutamol, insulin-glucose intravenous infusion and sodium bicarbonate are
used in the management of moderate to severe hyperkalaemia (usually with potassium
values ranging from above 6 mmol/L)
n
io
78. A 41 year old obese women has recently undergone a blood test. Her results show:
t
Fasting blood sugar 6 mmol/l

ua
Oral glucose tolerance test 10.1 mmol/l.

al
A. Impaired glucose tolerance

Ev
B. Diabetes insipidus
E. Maturity onset diabetes of the young
Impaired glucose tolerance is defined as a fasting plasma glucose concentration of less

than 7.0 mmol/L with a two-hour oral glucose tolerance test value of 7.8 to 11.1
mmol/L.
79. A 21 year old man is brought into A&E semi-conscious by his friends. They were at a
party and have been drinking alcohol when they found him unconscious in a corner. He
is groaning and unable to give any information to the doctors. During the initial
evaluation, his respiratory rate is 17/min and pulse rate is 88 bpm, BP is110/70 mmHg,
pupils are responsive. His Glasgow Coma Scale (GCS) score is 11/15. What is the SINGLE
317
D. Check Body temperature
Alcohol intoxication can cause hypoglycaemia which presentations include a coma.

Check venous or capillary blood with glucose oxidase strip would be an appropriate first
step before taking him for a CT scan or any other investigation. It is fast, easy and if
hypoglycaemia is the cause, it can be quickly reversible.
Hypoglycaemia
Always exclude hypoglycaemia in any patient with coma, altered behaviour,

neurological symptoms, or signs.
Causes
• Commonest cause is a relative imbalance of administered versus required
insulin or oral hypoglycaemic drug. This results from:
y
• Exercise
op
• Insufficient or delayed food intake
• Excessive insulin administration C
Other causes are:
• Alcohol (in addition to alcohol directly causing hypoglycaemia, the features of
n
hypoglycaemia may be mistaken for alcohol intoxication or withdrawal)
• Addison’s disease
io
• Insulinomas
• Liver failure
t
• Malaria
ua
Common features:
al
Plasma glucose is normally maintained at 3.6-5.8mmol/L. Cognitive function

deteriorates at levels < 3.0mmol/L, but symptoms are uncommon >2.5mmol/L.
Ev
• Sweating
• Pallor
• Tachycardia
• Palpitations
• Hunger
• Trembling
• Altered or loss of consciousness
• Fitting
• Coma
Diagnosis:
• Venous or capillary blood with glucose oxidase strip (BMG)
• If < 3.0mmol/L, take a venous sample for a formal blood glucose level, but do
not delay treatment
80. A 22 year old footballer collapses during a game and is brought into A&E by ambulance.
During the initial evaluation, his respiratory rate is 14/min and pulse rate is 84 bpm, BP
318
is115/80 mmHg. He is sweating profusely and muttering incomprehensible words.

D. Intravenous insulin
The collapse could be due to hypoglycaemia. Check venous or capillary blood with
glucose oxidase strip would be an appropriate first step before taking him for a CT scan
or any other investigation. It is fast, easy and if hypoglycaemia is the cause, it can be
quickly reversible.
Hypoglycaemia
Always exclude hypoglycaemia in any patient with coma, altered behaviour,

neurological symptoms, or signs.
y
op
Causes
• Commonest cause is a relative imbalance of administered versus required
insulin or oral hypoglycaemic drug. This results from:
C
• Exercise
• Insufficient or delayed food intake
• Excessive insulin administration
n
io
Other causes are:

• Alcohol (in addition to alcohol directly causing hypoglycaemia, the features of
t
hypoglycaemia may be mistaken for alcohol intoxication or withdrawal)

ua
• Addison’s disease
• Insulinomas
• Liver failure
al
• Malaria
Ev
Common features:
Plasma glucose is normally maintained at 3.6-5.8mmol/L. Cognitive function
deteriorates at levels < 3.0mmol/L, but symptoms are uncommon >2.5mmol/L.
• Sweating
• Pallor
• Tachycardia
• Palpitations
• Hunger
• Trembling
• Altered or loss of consciousness
• Fitting
• Coma
Diagnosis:
• Venous or capillary blood with glucose oxidase strip (BMG)
• If < 3.0mmol/L, take a venous sample for a formal blood glucose level, but do
not delay treatment
319
81. A 58 year old man who is known to have diabetes mellitus presents to the hospital with
drowsiness, blurred vision, tremors, fatigue and confusion. On examination, he is
excessive sweaty. Which SINGLE investigations should be done initially to help with
further management?
A. Fasting blood sugar

B. Blood glucose
C. Standing and lying blood pressure
E. Computed tomography of head
It is clear in this question that this man is having a hypoglycaemic episode. This could be
caused by a missed meal or increased activity. The first step should be attaining blood
sugars. This does not need to be fasting blood sugars.
82. A 29 year old smoker presents with dry eyes and diplopia. On examination, she has lid
lag and lid retraction bilaterally. What is the SINGLE most appropriate next step?
y
A. Thyroid Function Tests
op
B. Tensilon test
C. Fundoscopy
D. Autoantibodies
C
E. Electromyography
Although there is no mention of a goitre or symptoms of hyperthyroidism, it is clear

n
that she has eye manifestations of Grave’s disease. Thyroid function test would be the
io
most appropriate next step.

t
Autoantibodies would generally be ordered when taking blood for the thyroid function
ua
test in reality when suspecting Grave’s disease. But if you were to pick a thyroid
function test or autoantibodies, you would pick a thyroid function test as it is more
sensitive and can guide you with your management.
al
83. A 44 year old lady has just recovered from an upper respiratory tract infection. She
Ev
feels her heart racing and has increased perspiration. Her blood tests show:
Free thyroxine (T4) 48 pmol/L

Free triiodothyronine (T3) 15 pmol/L
Thyroid stimulating hormone (TSH) 0.1 mU/L
Thyroid antibodies negative
A. Hashimoto's thyroiditis
B. Graves' disease
C. Subacute thyroiditis
D. Toxic nodular goitre
E. Sick euthyroid syndrome
The patient has features of hyperthyroidism. Her T3 and T4 levels are high and her TSH
levels are low.
320
In subacute thyroiditis, patients will experience a hyperthyroid period which is typically
followed by a hypothyroid phase as the pituitary reduces TSH production before
resolving to euthyroid. Hence, the symptoms are those of hyperthyroidism and
hypothyroidism.
There will be an initial elevation in T3 and T4 in serum which is caused by leak of

hormones from the thyroid gland, followed by hypothyroidism as the it gets depleted.
This stem includes having a history of upper respiratory tract infections because
subacute thyroiditis are usually viral in origin, usually preceding an upper respiratory
tract infection.
Subacute thyroiditis is usually self-limited and is not treated with radioiodine.
84. A 4 year old child is brought to the emergency department by his mother with
complains of vomiting for the past 4 days. On examination, he has clinical signs of mild
to moderate dehydration. What is his arterial blood gas profile likely to show?
y
op
A. A low pH and low PCO2
B. A low pH and high PCO2
C. A high pH and low PCO2
C
D. A high pH and high PCO2
E. A high pH and normal PCO2
n
Prolonged vomiting causes loss of H+ from the body resulting in metabolic alkalosis.
io
Thus, pH will be higher than usual. To compensate for metabolic alkalosis, the
respiratory system will retain carbon dioxide through slower breathing or alveolar
t
hypoventilation in attempts to diminish the change in pH that would otherwise occur.

ua
This would result in a higher PCO2.
85. A 62 year old man had a bowel resection 3 days ago for colorectal cancer. His urine
al
output has been low since the procedure and he is now becoming breathless. He has a
blood pressure of 130/95 mmHg. On auscultation, he has crackles at both lung bases
Ev
and on palpation, he has sacral oedema. His blood tests show:
Haemoglobin 109 g/L

A. Bolus of 20 units of insulin

B. Calcium resonium
C. Sodium bicarbonate
D. Intravenous fluid
E. 10 units of insulin and 50 ml of 50% glucose infusion
The most significant point to highlight in this case is his potassium levels. His potassium
levels are high enough to cause a life-threatening arrhythmia. The high levels of
321
potassium could be due to many reasons but it is likely that he is suffering from acute
kidney injury due to heart failure causing low blood volumes.
The hyperkalaemia needs to be addressed first to prevent cardiac arrest.
Shifting potassium intracellularly is a useful holding measure in life threatening

hyperkalaemia. This can be done quickly by administering Insulin Actrapid® 10 units in
50 mL of Glucose 50% intravenously over 30 minutes via a volumetric pump. Insulin
stimulates cellular uptake of potassium, so it drops serum potassium levels rapidly, and
glucose is given with insulin to prevent hypoglycemia. This would reduce serum
potassium levels by 0.65 - 1.0mmol/L but the reduction only last for about an hour. This
is usually followed by monitoring blood glucose after 15 minutes, 30 minutes and then
hourly for up to 6 hours as there is a risk of late hypoglycaemia. Again this regimen
would differ depending on your local hospital guideline for hyperkalaemia. Just
remember that capillary blood glucose needs to be checked before, during and after
insulin-glucose infusion.
Other methods that can be used to treat life threatening hyperkalaemia include:
y
• 10-20 mg nebulised salbutamol - this reduces serum potassium (0.5-1.0
op
mmol/L) in 15-30 minutes and lasts for two hours
It is also important to check potassium 30 minutes afterwards and if there is a good

C
response, check U&E 1-2 hours later.
It is important to remember that shifting potassium intracellularly to treat life
threatening hyperkalaemia does not reduce total body potassium, and after two to six
n
hours, there is an efflux of potassium back out into the extracellular space resulting in
io
serum levels as high or sometimes even higher than at the outset.

t
Therefore, any of the steps mentioned must be combined with attempting to reduce
ua
total body potassium. This can be done by:

• Avoiding medications which can raise potassium
• Promote urinary potassium loss
al
o Intravenous normal saline as long as the patient is not significantly

overloaded (In this stem, you would not be giving IV fluids as he has
Ev
heart failure and is clearly fluid overloaded given his clinical features of
crackles at both lung bases and sacral oedema on palpation)
o If well hydrated consider starting or increasing the dose of a loop
diuretic.
• Remove excess potassium
o Calcium Resonium® has a slow onset of action (at least 2-6 hours) (This
is the reason it is not the answer in this question. The action to correct
hyperkalaemia is too slow. Calcium Resonium® has no role in an acute
situation)
• Dialysis
o This is useful if all the above measures have been done and the patient
still has high serum potassium
o Note: Dialysis is also likely to be needed if potassium is very high ( >7.5
mmol/L) or patient is oligo or anuric. In this question, if dialysis was
present, it would be a better option to pick rather than insulin-glucose
infusion because this patient is having acute renal failure and is anuric.
If haemodialysis is performed within 15-30 minutes then treatments to
322
move potassium into cells are unlikely to be helpful and may make
potassium removal on dialysis more difficult.
Sodium bicarbonate may be useful in the setting of resistant hyperkalaemia with

acidosis. It should only be considered if pH is < 7.2. The use of sodium bicarbonate is
controversial in patients with acidosis and there is still insufficient evidence to justify
routine use. It is therefore likely to always be the WRONG answer in the PLAB part 1 test
in the context of hyperkalaemia.
If intravenous calcium gluconate was in one of the options, that would also be a correct
answer because it is needed to stabilise the cardiac membrane to prevent arrhythmias.
Intravenous calcium has rapid effects, resulting in improvement of ECG abnormalities
within minutes of administration.
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323
ENT
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Questions
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Answers
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324
ENT Questions
1. A 25 year old woman complains of dizziness, nausea, and anxiety which keeps coming
from time to time. She notices that the attacks are associated with sudden change in
posture and these episodes last only a few seconds. What is the SINGLE most likely
diagnosis?
A. Panic disorder
B. Carotid sinus syncope
C. Benign paroxysmal positional vertigo
D. Vertebrobasilar insufficiency
E. Postural hypotension
2. A 29 year old teacher had a respiratory infection for which she was prescribed
antibiotics. A few days after she finished the antibiotic course, she rejoins school but
she has a weak, altered voice which was not present previously. What is the SINGLE
most appropriate diagnosis?
y
A. Recurrent laryngeal nerve palsy
op
B. Angioedema
C. Laryngeal obstruction
D. Laryngitis
E. Functional dysphonia
C
3. A 45 year old man presents with progressive hoarseness. He has swollen vocal cords.
n
He has a body mass index is 34 kg/m2 and he smokes 20 cigarettes a day. He also drinks
io
2 pints of beer a day. He has been suffering from heartburn since he was mid twenties.
His diet involves eating large amounts of red meat. Investigations reveal that he has
t
laryngeal cancer. What is the SINGLE most likely cause of his cancer?
ua
A. Diet
B. High BMI
al
C. Alcohol abuse
D. Gastro-oesophageal reflux disease
Ev
E. Smoking
4. A 26 year old woman has become aware of an increasing right sided hearing loss since
her last pregnancy. On otoscopy, her eardrums look normal. Her hearing tests shows
bone conduction (BC) is better than air conduction (AC) in the right ear. Weber’s test
lateralizes to the right ear. What is the SINGLE most likely diagnosis?
A. Encephalopathy
B. Functional hearing loss
C. Tympanosclerosis
D. Otosclerosis
E. Sensorineural deafness
5. A 47 year old man has difficulty hearing on his right ear. Air conduction (AC) is better
than bone conduction in both ears. The sound was localised towards the left side on
Weber’s test. What is the SINGLE most likely diagnosis?
A. Right sensorineural deafness
325
B. Left sensorineural deafness
C. Right conductive deafness
D. Left conductive deafness
E. Bilateral sensorineural deafness
6. A 15 year old boy injured his right ear during a rugby match. He reports pain around the
right pinna. On examination, the pinna of the right ear is red and tender. The tympanic
membrane was found to be normal. What is the SINGLE most appropriate next step?
A. Topical gentamicin
B. Oral flucloxacillin
C. Intravenous flucloxacillin
D. Refer to ENT specialist
E. No further intervention needed
7. A 30 year old woman presents with sudden onset of severe vertigo. She has a 4 week
history of intermittent dizziness. These episodes typically occur when she suddenly
moves her head or roles in bed and are characterised by the sensation that the room is
y
'spinning'. Most attacks last a few seconds. Neurological examination is unremarkable.
op
A. Benign paroxysmal positional vertigo

C
B. Meniere disease
C. Postural hypotension
D. Psychogenic vertigo
n
E. Viral labyrinthitis
io
8. A 37 year old man has unilateral hearing loss on the right with tinnitus and balance
t
disturbances. He complains of a feeling that his ear is plugged. He is also noted to have
ua
impaired facial sensation on that same side, What is the SINGLE most appropriate
investigations to perform?
al
A. Audiometry
B. Computed tomography of brain
Ev
C. Magnetic resonance imaging of brain

D. Tympanometry
E. Weber’s test
9. A 4 year old girl has a painful right ear. She is irritable and has been crying and
coughing. She has a temperature of 38.8°C. Otoscopy reveals bulging of the tympanic
membrane which appears red. What is the SINGLE most likely diagnosis?
A. Acute otitis media

B. Herpetic infection of the ear
C. Referred pain from teeth
D. Perforation of the eardrum
E. Otitis externa
10. A 41 year old man presents with longstanding foul smelling brown ear discharge and
progressive hearing loss of his right ear. The discharge has persisted despite three
courses of antibiotic ear drops. Otoscopy shows perforation of the pars flaccida. A
326
pearly white soft matter is seen at the posterior margin of the perforation. What is the
A. Acute Suppurative Otitis Media

B. Chronic Suppurative Otitis Media
C. Acquired cholesteatoma
D. Congenital cholesteatoma
E. Barotrauma
11. A 4 year old boy presents with fever, severe ear ache, and vomiting. Tonsillitis was
noted on examination. Otoscopy reveals a red bulging tympanic membrane. What is
A. Otitis externa
B. Acute otitis media
D. Chronic suppurative otitis media
E. Mastoiditis
y
op
12. A 11 year old girl presents to the clinic with hoarseness of voice. She is a known case of
bronchial asthma and has been on oral steroids for half a year. What is the SINGLE most
likely cause of her hoarseness of voice?
C
A. Laryngeal candidiasis
B. Infective tonsillitis
n
C. Laryngeal edema
io
D. Allergic drug reaction

E. Ludwigs angina
t
ua
13. A 7 year old boy is brought to clinic by his mother. She says that he is always turning up
the TV volume and she has to shout to get his attention. There has been recurrent ear
infections in the past which was resolved by medication. On examination: a bulging
al
drum is noticed. There is no pain or fever. What is the SINGLE most appropriate
management?
Ev
A. Grommet insertion
B. Reassure and review in 3 months
C. Hearing aids
D. Adenoidectomy
E. Antibiotics
14. A 33 year old man comes to the clinic complaining of hearing loss in one ear. There is
no earache, fever, vertigo or tinnitus. On inspection, a buildup of earwax is observed.
A. Olive oil ear drops

B. ear irrigation
C. Refer to an Ear Nose and Throat specialist for removal of wax
D. Advise to keep ear dry
E. Removal by cotton bud
327
15. A 66 year old male presents with painful swallowing. He describes it as a burning
sensation that radiates to the back everytime he swallows fluid or food. What is the
SINGLE most likely causative organism?
A. Neisseria meningitidis
B. Cryptococcus neoformans
C. Candida albicans
D. Isospora belli
E. Mycobacterium avium
16. A 34 year old man presents with right sided facial pain felt as upper jaw pain and
located at the skin of the right cheek. He gives a history of having a cold 3 days ago. He
feels tenderness at the anterior wall below the inferior orbital margin. What is the
A. Ethmoid sinusitis
B. Maxillary sinusitis
C. Septal haematoma
y
D. Adenoiditis
op
E. Allergic rhinitis
17. A 6 year old girl has a left earache for 4 days. The earache then subsided 2 hours ago
C
with the onset of a purulent discharge which relieved the pain. Her temperature is
39.2°C. What is the SINGLE most appropriate antibiotic to prescribe?
n
A. Amoxicillin
io
B. Ciprofloxacin
C. Clindamycin
t
D. Erythromycin
ua
E. Flucloxacillin
18. A 5 year old child complains of sore throat and earache. He has a temperature of
al
38.6°C. Examination shows enlarged, hyperemic tonsils with pus. He is not on any
medication. What is the SINGLE most likely diagnosis?
Ev
A. Infectious mononucleosis
B. Acute tonsillitis
C. Scarlet fever
D. Acute Epiglottitis
E. Acute Otitis Media
19. A 39 year old man has a history of swelling in the region of the submandibular region,
which became more prominent and painful on chewing. He also gives a history of sour
taste in the mouth and having a dry mouth. On palpation, the area is tender. What is
the SINGLE most likely underlying diagnosis?
A. Chronic sialadenitis
B. Adenolymphoma
C. Mikulicz’s disease
D. Adenoid cystic carcinoma
E. Submandibular abscess
328
20. A 30 year old lady has epistaxis for 30 minutes. Blood results shows:
Haemoglobin 122 g/L

Platelets 200 x 109/L
Prothrombin time (PT), Activated partial thromboplastin time (APTT) and bleeding time
is normal
What is the SINGLE most likely cause of the bleed?
A. Platelet disorder
B. Clotting factor deficiency
C. Sepsis
D. Anatomical defect
E. Warfarin use
21. A 17 year old woman with no previous history of ear complains, presents with a one
y
day history of severe pain in the right ear which is extremely tender to examine. There
op
is pain with movement of the tragus. What is the SINGLE most likely diagnosis?
A. Chondromalacia
C
B. Furuncle
C. Myringitis
D. Otitis externa
n
E. Otitis media
io
22. A 5 year old girl has been reported by her parents to be increasing the volume of the
t
television to an excessive level. A hearing test conducted at school shows a symmetric

ua
loss of 40db. A grey bulging drum is seen on otoscopy on both ears. What is the SINGLE
al
A. Otitis media with effusion

B. Otitis externa
Ev
C. Cholesteatoma
D. Otosclerosis
E. Congenital sensorineural deficit
23. A 45 year old male presents with a whitish-grey opaque areas with red inflamed
patches on his tongue. These patches are unable to be scraped off. What is the SINGLE
A. Kaposi’s sarcoma
B. Basal cell carcinoma
C. Aphthous ulcer
D. Oral thrush
E. Leukoplakia
24. A 48 year old man has a lump on his mandible. It has rapidly increased in size over the
past 8 months. On examination, there is an induration of the skin overlying the mass.
The mass is free and mobile. What is the SINGLE most appropriate investigations?
329
A. Fine needle aspiration (FNA) cytology
B. Computed tomography
C. Salivary immunoglobulin M (IgM)
D. Magnetic resonance imaging
E. Erythrocyte sedimentation rate (ESR)
25. An 8 year old boy was brought by his mother complaining that her child seems to be
watching the television at very high volumes. He lacks concentration and is socially
withdrawn. He would prefer to read books indoors rather than play outdoors. What is
the SINGLE most likely finding to be expected on an otoscopy?
A. Flamingo pink tympanic membrane

B. Attic perforation
C. A bluish grey tympanic membrane with an air fluid level
D. Inflamed tympanic membrane with cart wheel appearance of vessels
E. Red and inflamed tympanic membrane
y
26. A 15 year old boy presents to A&E with a nose bleed. The bleeding started 3 hours ago
op
and has not stopped. His blood pressure is 115/70 mmHg, heart rate is 80 bpm and
respiratory rate is 18/min. What is the SINGLE most appropriate next course of action?
C
A. IV fluids
B. Lean forward, open mouth and pinch cartilaginous part of nose firmly
C. Lean backwards, ice packs and pinch base of nose firmly
n
D. Start IV tranexamic acid
io
E. Radiological arterial embolization

t
27. A 52 year old woman has intermittent vertigo, tinnitus and fluctuating hearing loss. She
ua
complains of a sensation of ear pressure. The attacks can last for 2 to 3 hours. A MRI
brain scan was reported as normal. What is the SINGLE most appropriate treatment?
Plab Lab Values
al
A. Prochlorperazine
Ev
B. Fluphenazine
C. Vitamin A
D. Gentamicin drops
E. Aspirin
28. An 8 year old boy who has recently returned from Spain complains of severe pain in
one ear. On examination, pus is seen in the auditory canal. The tympanic membrane
looks normal. What is the SINGLE most appropriate treatment?
B. Amoxicillin PO
C. Analgesia
D. Amoxicillin IV
E. Microsuction
29. A 46 year old man has a long history of chronic sinusitis. He feels that his nose is
blocked and it does not clear and he occasionally sees blood when he blows his nose.
330
He now presents with pressure in his upper teeth, recent cheek swelling, and double
vision. On examination, left maxillary tenderness is noted along with epiphora of the
left eye. What is the SINGLE most likely diagnosis?
A. Nasopharyngeal carcinoma
B. Pharyngeal carcinoma
C. Paranasal sinus carcinoma
D. Laryngeal carcinoma
E. Hypopharyngeal tumour
30. A 29 year old man with a medical history that includes late onset asthma attends clinic
with rhinorrhoea and bilateral painless nasal obstruction. He complains of reduce sense
of smell. What is the SINGLE most likely diagnosis?
A. Septal abscess
B. Septal haematoma
C. Nasal polyp
D. Atrophic rhinitis
y
31.
op
A 17 year old man presents with sore throat for several days and dysphagia.
Examination reveals a unilateral bulge, above and lateral to his left tonsil. The bulge
C
was noted to be red and inflamed. The examination of the oral cavity was proven to be
difficult as he had mild trismus. Drooling of the saliva was seen. What is the SINGLE
n
io
A. Lymph node biopsy

B. Intravenous antibiotic and analgesics
t
C. Intravenous antibiotics, incision and drainage

ua
D. Excision biopsy of bulge

E. Tonsillectomy
al
32. A 10 year old boy presents to clinic with poor grades in school and difficulty in hearing.
There has been recurrent ear infections in the past which was resolved by medication.
Ev
On examination: bone conduction is normal, air conduction is reduced bilaterally, and

there is no lateralization in the Weber’s test. There is no pain. What is the SINGLE most
likely diagnosis?

B. Perforation of tympanic membrane
C. Otitis media with effusion
D. Congenital sensorineural deficit
E. Otosclerosis
33. A 5 year old girl has had an upper respiratory tract infection for 3 days and has been
treated with paracetamol by her mother. In the last 12 hours, she has been irritable and
with severe pain in her right ear. She has a temperature of 38.3°C. What is the SINGLE
A. Herpes zoster infection

B. Impacted ear wax
331
C. Mumps
D. Acute otitis media
E. Perforation of eardrum
34. A 40 year old man with a 25 year history of smoking presents with progressive
hoarseness of voice, difficulty swallowing and episodes of haemoptysis. He mentioned
that he used to be a regular cannabis user. What is the SINGLE most likely diagnosis?
A. Nasopharyngeal cancer
C. Sinus cancer
D. Laryngeal cancer
35. A 6 year old boy presents with a fever, sore throat and lymphadenopathy. The diagnosis
of tonsillitis has been made. He had 3 similar episodes last year which were self limiting.
What is the SINGLE most appropriate management for this child?
y
A. Tonsillectomy
op
B. Paracetamol
C. Oral penicillin
D. Oral amoxicillin
C
E. Prophylactic low dose penicillin
36. A 38 year old man was slapped over his right ear during a fight. There is blood coming
n
from his right external auditory canal. He describes the pain as intense and he also has
io
ringing in his ears. He is also noted to have decreased hearing on that ear. What is the
t
ua
A. Computed tomography
B. Magnetic resonance imaging
C. Otoscopy
al
D. Skull X-ray
E. Facial X-ray
Ev
37. A 30 year old man was camping and an insect got stuck in his ear which he has been
unable to remove. He complains that he can still hear the buzzing in the ear. On
inspection, the insect is clearly visible in the ear canal. What is the SINGLE most
appropriate initial management?
A. 2% lidocaine
B. Ear irrigation
C. Refer to an Ear Nose and Throat specialist
D. Reassure
38. A 6 year old child fell on his nose 3 days ago. His parents have now brought him to the
hospital as he is having difficulty in breathing and feeling unwell. He has general
malaise and complains of nasal pain. On examination, nasal bones are seen to be
straight however there is tenderness over the dorsum of the nose. He has a
temperature of 38.9°C. What is the SINGLE most likely diagnosis?
332
A. Nasal polyp
B. Nasal septal haematoma
C. Nasal septal abscess
D. Deviated nasal septum
E. Fractured nose
39. A mentally retarded 8 year old child puts a green pea in his ear while eating. Otoscopy
shows a green coloured object in the ear canal. What is the SINGLE most appropriate
approach to remove the green pea?
A. By magnet
B. Syringing
C. Removal under general anaesthesia
D. By hook
E. By instilling olive oil
40. A 33 year old patient has sensorineural hearing loss and loss of corneal reflex on the left
y
side. He is noted to have reduced facial sensation on that same side. He also complains
op
of tinnitus and vertigo. What is the SINGLE most definitive investigation?
A. Computed tomography of internal auditory meatus

C
B. Nuclear imaging of brain
C. Magnetic resonance imaging of internal auditory meatus
D. Radioisotope scan
n
E. X-ray skull
io
41. A 28 year old man has a headache that worsens on bending his head forward. He has
t
no nausea or vomiting. The headache tends to be at its worst first thing in the morning
ua
and improves by the afternoon. What is the SINGLE most likely diagnosis?
A. Chronic sinusitis
al
B. Trigeminal neuralgia
C. Migraine
Ev
D. Cluster headache
E. Tension headache
42. A 45 year old man presents with hearing loss and tinnitus in the right ear. A 512 Hz
tuning fork is used which highlights Rinne’s test having AC > BC bilaterally. Weber test
lateralizes to the left. What is the SINGLE next best investigation?
C. Angiogram
D. Otoscopy
E. Oto-acoustic emissions
43. A 2 year old child is brought by his mother. The mother had hearing impairment in her
early childhood and is now concerned about the child having a similar condition. What
is the SINGLE best investigation to be done for the child?
333
A. Conditioned response audiometry
B. Distraction testing
C. Scratch test
D. Tuning fork
E. Otoacoustic emissions
44. A 33 year old tennis player has to stop playing tennis competitively because she has
recurrent vertigo attacks every time she plays tennis. The vertigo attacks started after a
history of runny nose, cough and fever. Her hearing is not affected. What is the SINGLE
A. Acoustic neuroma
B. Meniere’s disease
C. Labyrinthitis
D. Benign paroxysmal positional vertigo
E. Vestibular neuritis
45. A 44 year old man presents with muffled hearing and tinnitus. He also complains of the
y
feeling of pressure in ear and vertigo. He has double vision when looking to the right.
op
A. Meniere’s disease
C
B. Acoustic neuroma
C. Acute labyrinthitis
D. Meningioma
n
E. Otosclerosis
io
46. A 7 year old boy is brought to clinic by his mother. His mother complains that he has
t
been getting in trouble in school because he is inattentive in class. The mother also
ua
mentions that he sits close to the television at home. These problems have been going
on for more than 12 months. There is no pain or fever. A tympanogram highlights
conductive hearing loss at 30-dB. What is the SINGLE most appropriate management?
al
Ev

C. Hearing aids
D. Adenoidectomy
E. Refer to child psychologist
47. A 6 year old boy was was playing in the playground when he stuck a seed into his ear.
He has been unable to remove it. On inspection, the seed is clearly visible in the ear
canal. What is the SINGLE most appropriate management?
A. 2% lidocaine
B. Ear irrigation
D. Suction with a small catheter
48. A 62 year old man with a long history of smoking and alcohol presents with nasal
obstruction, and on and off nose bleeds. He has a noticeable lump on his upper neck.
334
He is having difficulty hearing with his left ear and has had worsening ear pain in that
ear. Examination reveals conductive hearing loss in the left ear. What is the SINGLE
B. Paranasal sinus carcinoma
C. Oesophageal carcinoma
D. Oropharyngeal carcinomas
E. Hypopharyngeal carcinoma
49. A 9 year old girl has been increasing the volume of the television to an excessive level.
Her parents complain that she needs them to repeat themselves constantly. On
examination: bone conduction is normal, air conduction is reduced bilaterally. What is
A. Perforation of tympanic membrane

B. Otitis media with effusion
C. Congenital sensorineural deficit
y
D. Otosclerosis
op
E. Presbycusis
50. A 10 year old boy presents to his GP with a nose bleed. The bleeding started 1 hour ago
C
and has not stopped. He is haemodynamically stable. What is the SINGLE most
n
A. Press the base of the nose
io
B. Press the soft parts of the nose

C. Ice packs and lean backwards
t
D. Start oral tranexamic acid

ua
E. Send to A&E
51. A 45 year old woman presents with rotational vertigo, nausea and vomiting which is
al
worst when moving her head. She also had a similar episode 2 years ago. These
episodes typically follow an event of runny nose, cough and fever. What is the SINGLE
Ev
A. Acoustic neuroma
C. Labyrinthitis
E. Vestibular neuronitis
52. A 9 year old girl has been referred for assessment of hearing as she is finding difficulty
in hearing her teacher in the class. Her hearing tests show that bone conduction is
normal and symmetrical air conduction threshold is reduced bilaterally. Weber test
does not lateralize. What is the SINGLE most likely diagnosis?

D. Otosclerosis
335
E. Presbycusis
53. A 28 year old woman complains of vertigo and nausea that last around 30 minutes
several times a year. She has mild hearing loss in the left ear. A diagnosis of Meniere’s
disease is made. What is the SINGLE most appropriate treatment?
A. Aspirin
B. Metoclopramide
C. Cyclizine
D. Clotrimazole
E. Ondansetron
54. A 16 year old female presents with a midline lump on her neck. It is painless and
smooth. The swelling tends to move upwards when she protrudes her tongue. What is
A. Thyroglossal cyst
B. Goitre
y
C. Pharyngeal Pouch
op
D. Thyroid cancer
E. Lipoma C
55. A 75 year old man presents with symptoms of progressive sensorineural hearing loss on
the right. He also complains of dizziness and tinnitus. What is the SINGLE most
n
io

t

ua
D. Ultrasound scan and fine needle aspiration

E. X-ray skull
al
56. A 6 year old boy was was playing at home alone when he stuck super glue into his ear.
His mother has brought him to A&E and is extremely concerned. On inspection, the
Ev
adhesive is in contact with the tympanic membrane. What is the SINGLE most
A. Reassure
B. Ear irrigation
E. Manual removal immediately
57. A 12 year old boy presents with right sided hearing loss and facial drooping on the right
side. He has a headache and feels dizzy. On examination, both ears appear normal with
an intact eardrum. Rinne’s test was found to be normal. Weber test lateralized to the
left. What is the SINGLE most likely diagnosis?
A. Bell’s palsy
B. Lyme disease
C. Acoustic neuroma
336
D. Pituitary adenoma
E. Glioma
58. A 35 year old woman has dull pain in her right ear which has been present for several
weeks. The pain is located in front of the tragus of the right ear and spreads along the
cheek and mandible. Chewing increases the pain. Her husband has mentioned that she
grinds her teeth when she sleeps at night. The eardrum appears normal and there is no
discharge. What is the SINGLE most likely diagnosis?
A. Dental caries
B. Mumps
C. Otitis media
D. Temporomandibular joint disorder
E. Trigeminal neuralgia
59. A 44 year old man has difficulty hearing on his right ear. Rinne’s test was done and it
was normal in both ears however Weber’s test lateralized to the left ear. What is the
y
op
C
n
60. A 48 year old man has difficulty hearing. Bone conduction is better than air conduction
io
in the left ear. The sound was localised towards the left side on Weber’s test. What is
t
ua

al

E. Bilateral conductive deafness
Ev
61. A 45 year old man has noticed difficulty hearing over the telephone. His hearing has
been progressively getting worse over the last few years. He is concerned because his
father has had similar problems around his age. Rine’s and Weber’s test demonstrate
conductive hearing loss. An audiogram shows moderate hearing loss in both ears across
all frequencies. What is the SINGLE most likely diagnosis?
A. Acoustic neuroma
B. Meniere's’ disease
C. Glue ear
D. Otosclerosis
E. Presbycusis
62. A 10 year old child developed fever, severe earache and tonsillitis following an upper
respiratory tract infection. On otoscopy, the tympanic membrane is distinctly red. What
is the most likely diagnosis?
337
A. Acute Otitis Media
B. Otitis Externa
C. Glue Ear
D. Meningitis
E. Vestibular Neuritis
63. A 6 year old down syndrome boy was was playing at home alone when he stuck a small
piece of toy into his ear. His mother has brought him to a GP clinic and is extremely
concerned. On inspection, a small foreign object is visible. The child is uncooperative
and does not understand why his mother has brought him here. What is the SINGLE

B. Ear irrigation
E. Manual removal immediately using forceps
y
64. A 25 year old man presents with a history of pain and swelling in the submandibular
op
region that has been present for weeks. The pain is unilateral and more prominent
during eating. The area is tender on palpation. What is the SINGLE most likely
diagnosis?
C
B. Adenolymphoma
n
io

E. Salivary gland neoplasm
t
ua
65. A 27 year old man had a fly enter his ear. He is anxious to get the fly removed. What is
the SINGLE best method for removal of the fly from his ear?
al
A. Removal with forceps

B. Removal under general anaesthesia
Ev
C. Instill mineral oil into his ear

D. Instill alcohol ear drops
E. Syringe his ear with normal saline
66. A 52 year old patient is complaining of vertigo whenever she moves sideways on the
bed while lying supine. She would feel as if the room is spinning and she would feel
nauseous. This goes away after a few minutes but returns when she moves her head.
A. Hallpike's Manoeuvre
B. Reassure
C. Advice on posture
D. Carotid Doppler
E. CT head
338
67. A 55 year old man presents with swelling at the angle of the mandible which is
progressively increasing in size over the past 6 months. It is painless, firm and mobile.
A. Benign parotid tumour

B. Mandible tumour
C. Tonsillar carcinoma
D. Parotitis
E. Sjögren's syndrome
68. A 52 year old male with poorly controlled diabetes mellitus presents to his GP with
severe pain in the ear and an intense headache. On examination, his skin around the
ear is black in colour and there is a foul smelling discharge coming from the ear. He is
also noted to have conductive hearing loss. What is the SINGLE most likely diagnosis?
A. Carbuncle
B. Folliculitis
C. Malignant otitis externa
y
D. Cholesteatoma
op
E. Furuncle
C
n
t io
ua
al
Ev
339
ENT Answers
1. A 25 year old woman complains of dizziness, nausea, and anxiety which keeps coming
from time to time. She notices that the attacks are associated with sudden change in
posture and these episodes last only a few seconds. What is the SINGLE most likely
diagnosis?
A. Panic disorder
B. Carotid sinus syncope
C. Benign paroxysmal positional vertigo
D. Vertebrobasilar insufficiency
E. Postural hypotension
Benign paroxysmal positional vertigo is one of the most common causes of vertigo
encountered. It is characterised by the sudden onset of dizziness and vertigo triggered
by changes in head position.
Presentation:
y
• Can be preceded by infections
op
• Vertigo on turning over in bed, lying down, or sitting up from supine position
• each episode typically lasts 10-20 seconds
C
Diagnosis:
• Hallpike's Manoeuvre positive
n
Treatment:
io
• Mostly spontaneous resolution with exacerbations

t
ua
2. A 29 year old teacher had a respiratory infection for which she was prescribed
antibiotics. A few days after she finished the antibiotic course, she rejoins school but
she has a weak, altered voice which was not present previously. What is the SINGLE
al
most appropriate diagnosis?

Ev
A. Recurrent laryngeal nerve palsy

B. Angioedema
C. Laryngeal obstruction
D. Laryngitis
E. Functional dysphonia
Functional dysphonia refers to a voice disturbance that occurs in the absence of any
structural abnormality of the larynx or any cord paralysis. It is a diagnosis of exclusion.
Symptoms include vocal fatigue (voice becoming worse with use) and laryngeal
discomfort. There may be various interacting causes, such as heavy demands on the
voice, poor vocal technique and stress.
The case given above gives a history of voice overuse. This is a common problem in
some occupations such as acting and teaching. It may also follow unaccustomed voice
use, such as shouting at a football match. Vocal strain may be exacerbated when
attempting to compensate for an acute respiratory infection. Given that there is no
340
option to pick voice overuse and since there is no structural or neurological pathology,
functional dysphonia is the best option.
Recurrent laryngeal nerve palsy mainly presents with voice changes as well but there is
usually an obvious cause like trauma during surgery (especially thyroid surgery), tumour
spread, bulbar palsy, or penetrating wounds none of which was mentioned in this stem.
Angioedema in severe cases can cause hoarseness but it also presents with difficulty in
breathing which is not the case here.
Laryngeal obstruction like angioedema would have difficulty in breathing.
Laryngitis would have been the best option provided that the hoarseness of voice
occurred during the respiratory infection prior to treatment. Since the hoarseness of
voice occurred post treatment, it is unlikely to be laryngitis.
3. A 45 year old man presents with progressive hoarseness. He has swollen vocal cords.
He has a body mass index is 34 kg/m2 and he smokes 20 cigarettes a day. He also drinks
y
2 pints of beer a day. He has been suffering from heartburn since he was mid twenties.
op
His diet involves eating large amounts of red meat. Investigations reveal that he has
laryngeal cancer. What is the SINGLE most likely cause of his cancer?
C
A. Diet
B. High BMI
C. Alcohol abuse
n
io
E. Smoking
t
Chronic hoarseness is the most common early symptom of laryngeal cancer. The typical
ua
patient would be an elderly male patient who smokes and presents with progressive
hoarseness, then stridor, difficulty or pain on swallowing. Later with haemoptysis and
ear pain if the pharynx is involved.
al
While it is true that alcohol is a risk factor for laryngeal cancer, smoking is the main
Ev
avoidable risk factor and is known to be the number one cause of laryngeal cancers in
the UK.
Risk factors
• Smoking is the main avoidable risk factor for laryngeal cancer, linked to an
estimated 79% of laryngeal cancer cases in the UK.
• Certain occupational exposures (asbestos, formaldehyde, nickel, isopropyl
alcohol and sulphuric acid mist) can also cause laryngeal cancer.
• Insufficient fruit and vegetables intake is linked to an estimated 45% of
laryngeal cancer cases in the UK.
• Human papillomavirus type 16 (HPV16) seropositivity is associated with an
increased risk of oral, pharyngeal and laryngeal cancer.
4. A 26 year old woman has become aware of an increasing right sided hearing loss since
her last pregnancy. On otoscopy, her eardrums look normal. Her hearing tests shows
bone conduction (BC) is better than air conduction (AC) in the right ear. Weber’s test
lateralizes to the right ear. What is the SINGLE most likely diagnosis?
341
A. Encephalopathy
B. Functional hearing loss
C. Tympanosclerosis
D. Otosclerosis
E. Sensorineural deafness
Weber’s test lateralized to the right and bone conduction is better than air conduction
on the right. This clearly shows a conductive deafness on the right. There are no
features of encephalopathy. Tympanosclerosis has characteristic chalky white patches
seen on inspection of the eardrum. Since the eardrum here was viewed as normal, it is
unlikely to be tympanosclerosis.
The only answer left would be otosclerosis. Bone and air conduction must be tested
and in otosclerosis it typically reveals a purely conductive, predominantly low-tone loss.
Rinne's and Weber's test
y
Performing both Rinne's and Weber's test allows differentiation of conductive and
op
sensorineural deafness.
Rinne's test
C
A tuning fork is placed over the mastoid process until the sound is no longer heard,
followed by repositioning just over external acoustic meatus
• Note that air conduction (AC) is normally better than bone conduction (BC)
n
(Positive Rinne's test)
io
• If BC > AC, then the patient has conductive deafness (Negative Rinne’s test)
(Abnormal Rinne’s test)
t
ua
Note that the words positive and negative are used in a somewhat confusing fashion
here, as compared to their normal use in medical tests. Positive or negative in this case
means that a certain parameter that was evaluated was present or not. In this case,
al
that parameter is whether air conduction (AC) is better than bone conduction (BC).
Thus, a "positive" result indicates the healthy state, in contrast to many other medical
Ev
tests. Therefore, some prefer to avoid using the term 'positive' or 'negative', and simply
state if the test was normal or abnormal e.g. 'Rinne's test was abnormal in the right ear,
with bone conduction greater than air conduction'.
Weber's test
A tuning fork is placed in the middle of the forehead equidistant from the patient's
ears. The patient is then asked which side is loudest
• If sound is localised to the unaffected side, then this is unilateral sensorineural
deafness
• If sound is localised to the affected side, then this is unilateral conductive
deafness
Example
If Weber’s test localises to the right side. It can either be right conductive deafness OR
left sensorineural deafness. A Rinne’s test would be able to confirm if it is a right
conductive deafness.
342
5. A 47 year old man has difficulty hearing on his right ear. Air conduction (AC) is better
than bone conduction in both ears. The sound was localised towards the left side on
Weber’s test. What is the SINGLE most likely diagnosis?

Rinne's test
y
op
C
n
io
t
ua
al
Weber's test
Ev

deafness
deafness
Example
6. A 15 year old boy injured his right ear during a rugby match. He reports pain around the
right pinna. On examination, the pinna of the right ear is red and tender. The tympanic
membrane was found to be normal. What is the SINGLE most appropriate next step?
B. Oral flucloxacillin
343
C. Intravenous flucloxacillin
D. Refer to ENT specialist
E. No further intervention needed
No further intervention is needed as the tympanic membrane is normal. This is a

transient inflammation of the pinna from an injury during a hit in a rugby match. It is
self limiting and of no worry.
7. A 30 year old woman presents with sudden onset of severe vertigo. She has a 4 week
history of intermittent dizziness. These episodes typically occur when she suddenly
moves her head or roles in bed and are characterised by the sensation that the room is
'spinning'. Most attacks last a few seconds. Neurological examination is unremarkable.

B. Meniere disease
C. Postural hypotension
D. Psychogenic vertigo
y
E. Viral labyrinthitis
Benign paroxysmal positional vertigo (BPPV)
op
Benign paroxysmal positional vertigo (BPPV) is the most common cause of vertigo
C
which is experienced as the illusion of movement. The symptoms of vertigo only last a
few seconds or minutes. It is often related to head movements.
n
Note that there are no associated symptoms.
io
The Dix-Hallpike test is used to confirm posterior canal BPPV. It is a simple test which
t
can recreate the symptoms.

ua
Management
• Epley's manoeuvre is the most widely used repositioning manoeuvre for BPPV.
al
The idea is to attempt to reposition the crystals in the semicircular canals

• The natural history for BPPV is for spontaneous remission
Ev
8. A 37 year old man has unilateral hearing loss on the right with tinnitus and balance
disturbances. He complains of a feeling that his ear is plugged. He is also noted to have
impaired facial sensation on that same side, What is the SINGLE most appropriate
investigations to perform?
A. Audiometry
B. Computed tomography of brain
C. Magnetic resonance imaging of brain
D. Tympanometry
E. Weber’s test
Hearing loss, tinnitus, vertigo points towards an affected Vestibulocochlear nerve.

Numbness of the face points towards a trigeminal nerve involvement. Acoustic
neuroma could account for these set of symptoms in which case MRI would be the
investigation of choice.
344
Acoustic neuroma
Acoustic neuromas (more correctly called vestibular schwannomas) account for
approximately five percent of intracranial tumours and 90 percent of cerebellopontine
angle. It causes problems by having local pressure and behaving as a space-occupying
lesion.
Features can be predicted by the affected cranial nerves

• Cranial nerve VIII: hearing loss (sensorineural deafness), vertigo, tinnitus
• Cranial nerve V: absent corneal reflex
• Cranial nerve VII: facial palsy
Bilateral acoustic neuromas are seen in neurofibromatosis type 2
Investigation
• MRI of the cerebellopontine angle is the investigation of choice
9. A 4 year old girl has a painful right ear. She is irritable and has been crying and
coughing. She has a temperature of 38.8°C. Otoscopy reveals bulging of the tympanic
y
membrane which appears red. What is the SINGLE most likely diagnosis?

B. Herpetic infection of the ear
op
C
D. Perforation of the eardrum
n
E. Otitis externa
io
Acute otitis media in children

Acute otitis media is acute inflammation of the middle ear and may be caused by
t
bacteria or viruses.
ua
Features
• Rapid onset of pain (younger children may pull at the ear)
al
• Fever
• Irritability
Ev
• Coryza
• Vomiting
• Often after a viral upper respiratory infection
• A red, yellow or cloudy tympanic membrane or bulging of the tympanic
membrane.
• An air-fluid level behind the tympanic membrane
• Discharge in the auditory canal secondary to perforation of the tympanic
membrane
• Perforation of the eardrum often relieves pain. This is because bulging of the
tympanic membrane causes the pain.
10. A 41 year old man presents with longstanding foul smelling brown ear discharge and
progressive hearing loss of his right ear. The discharge has persisted despite three
courses of antibiotic ear drops. Otoscopy shows perforation of the pars flaccida. A
pearly white soft matter is seen at the posterior margin of the perforation. What is the
345
A. Acute Suppurative Otitis Media
B. Chronic Suppurative Otitis Media
C. Acquired cholesteatoma
D. Congenital cholesteatoma
E. Barotrauma
Cholesteatoma
The term cholesteatoma is a misnomer as it is actually neither cholesterol nor a
tumour. Cholesteatoma is a destructive and expanding growth consisting of keratinizing
squamous epithelium in the middle ear and/or mastoid process. Think of
cholesteatoma as an uncommon abnormal collection of skin cells inside your ear that
left untreated can continue to grow and damage the bones of the middle ear (ossicles).
Small lesions are associated with a progressive conductive hearing loss but, as the
lesion grows and erodes into adjacent structures, there may be additional features such
as vertigo, headache and facial nerve palsy
It can be either congenital or acquired.
y
op
Acquired cholesteatoma
• Occurs following repeated ear infections. Note they are usually poorly
responsive to antibiotic treatment
C
• Frequent painless otorrhoea which may be foul-smelling
• Progressive, unilateral conductive hearing loss
• Tympanic membrane perforation is seen in around 90% of cases or retracted
n
tympanum
io
Congenital cholesteatomas
t
• Presents in childhood (6 months to 5 years) but may occasionally present much

ua
later, in adulthood
• Often no history of recurrent suppurative ear disease, previous ear surgery or
tympanic membrane perforation
al
• May be an incidental finding on routine otoscopy of an asymptomatic child

• Seen as a pearly white mass behind an intact tympanic membrane
Ev
Remember: Cholesteatoma is suggested by the following:

• Foul discharge
• Deafness
• Headache
• Ear pain
• Facial paralysis
• Vertigo
11. A 4 year old boy presents with fever, severe ear ache, and vomiting. Tonsillitis was
noted on examination. Otoscopy reveals a red bulging tympanic membrane. What is
A. Otitis externa
B. Acute otitis media
D. Chronic suppurative otitis media
346
E. Mastoiditis
Acute otitis media may occur after a viral upper respiratory tract infections which in this
case is the tonsillitis.

Features
• Fever
• Irritability
• Coryza
• Vomiting
y
membrane.
op
membrane
C
n
12. A 11 year old girl presents to the clinic with hoarseness of voice. She is a known case of
bronchial asthma and has been on oral steroids for half a year. What is the SINGLE most
io
likely cause of her hoarseness of voice?

t
ua
A. Laryngeal candidiasis
B. Infective tonsillitis
C. Laryngeal edema
al
D. Allergic drug reaction

E. Ludwigs angina
Ev
Steroids predispose to fungal infection and can cause laryngeal candidiasis which
results in hoarseness.
13. A 7 year old boy is brought to clinic by his mother. She says that he is always turning up
the TV volume and she has to shout to get his attention. There has been recurrent ear
infections in the past which was resolved by medication. On examination: a bulging
drum is noticed. There is no pain or fever. What is the SINGLE most appropriate
management?
C. Hearing aids
D. Adenoidectomy
E. Antibiotics
In PLAB 1, paediatrics ENT questions would come up occasionally. The ones to focus on
would be acute otitis media, otitis media with effusion and cholesteatoma. When PLAB
347
1 has case scenarios where mothers notice their children “turning up the TV volume” or
“doing badly in school”, before thinking of behavioral / developmental problems, go
with physical problems (i.e. hearing).
This is usually the presentation of otitis media with effusion. As this is his first visit,
reassurance and review in 3 months would be the most appropriate.
Otitis media with effusion
Also known as glue ear is common with the majority of children having at least one
episode during childhood
An important risk factor for otitis media with effusion is parental smoking. This is
extremely important to note as PLAB questions sometimes ask which would be the
SINGLE best management and then provide an option of “tell parents to stop smoking”.
One might not think this is the answer as it sounds silly, but in actual fact this is the
correct answer.
y
Presentation:
op
Hearing loss is usually the presenting feature (glue ear is the commonest cause
of conductive hearing loss in childhood). May present as
C
o Listening to the TV at excessively high volumes or needing things to be
repeated.
o Lack of concentration, withdrawal especially in school
n
• Secondary problems such as speech and language delay, behavioural or balance
io
problems may also be seen

• Rarely complains of ear pain
t
• May have prior history of infections (especially upper respiratory tract) or

ua
oversized adenoids
Signs:
al
• Variable, eg retracted or bulging drum. It can look dull, grey, or yellow. There
Ev
may be bubbles or a fluid level
Diagnosis:
• Audiograms: conductive defects.

• Impedance audiometry: flat tympanogram
Treatment:
• Observation first because may resolve, monitor every 3 months.

• (thus if a scenario is given with a recent diagnosis of otitis media with effusion,
and the question is asking for the SINGLE best management → “Reassure and
review in 3 months” would be the best choice.
• Surgery: If persistent bilateral OME over 3 months → insert grommets
• Hearing aids: Reserve for persistent bilateral OME and hearing loss if surgery is
not accepted.
348
14. A 33 year old man comes to the clinic complaining of hearing loss in one ear. There is
no earache, fever, vertigo or tinnitus. On inspection, a buildup of earwax is observed.

B. ear irrigation
C. Refer to an Ear Nose and Throat specialist for removal of wax
D. Advise to keep ear dry
Ear wax softening drops are the first thing to try for a buildup of earwax. Prescribe ear
drops for 3–5 days initially, to soften wax and aid removal. Sodium bicarbonate 5%,
sodium chloride 0.9%, olive oil, or almond oil drops can be used
If symptoms persist, consider ear irrigation
If irrigation is unsuccessful, there are three options:
y
• Advise the person to use ear drops for a further 3–5 days and then return for
op
further irrigation.
• Instill water into the ear. After 15 minutes irrigate the ear again.
• Refer to an Ear Nose and Throat specialist for removal of wax.
C
NICE CKS have not recommended irrigation without prior use of a softening agent
because expert opinion stated that extra force may be needed which is more likely to
n
cause trauma.
io
Advise people against inserting anything in the ear. Cotton buds, matchsticks, and hair
t
pins can cause the wax to become impacted by pushing it further into the canal.
ua
15. A 66 year old male presents with painful swallowing. He describes it as a burning
sensation that radiates to the back everytime he swallows fluid or food. What is the
al

Ev
B. Cryptococcus neoformans
C. Candida albicans
D. Isospora belli
E. Mycobacterium avium
Given the options, Candida albicans would be the only culprit that would cause
odynophagia.
Oesophageal candidiasis
Presentation:
• Dysphagia
• Odynophagia (pain on on swallowing) food or fluids
16. A 34 year old man presents with right sided facial pain felt as upper jaw pain and
located at the skin of the right cheek. He gives a history of having a cold 3 days ago. He
349
feels tenderness at the anterior wall below the inferior orbital margin. What is the
A. Ethmoid sinusitis
B. Maxillary sinusitis
C. Septal haematoma
D. Adenoiditis
The likely diagnosis here is an acute sinusitis which is an inflammation of the

membranous lining of one or more of the sinuses. Upper respiratory tract infections are
one of the predisposing factors to sinusitis which explains the history in the stem of the
cold 3 days ago.
Tenderness at the anterior wall below the inferior orbital margin can be found in
maxillary sinusitis.
The maxillary sinus is innervated by the infraorbital nerve and anterior, middle and
y
posterior superior alveolar nerves. Hence, pathology here may be felt as referred pain
op
and described as upper jaw pain, toothache or pain directly at the skin of the cheek.
17. A 6 year old girl has a left earache for 4 days. The earache then subsided 2 hours ago
C
with the onset of a purulent discharge which relieved the pain. Her temperature is
39.2°C. What is the SINGLE most appropriate antibiotic to prescribe?
n
A. Amoxicillin
io
B. Ciprofloxacin
C. Clindamycin
t
D. Erythromycin
ua
E. Flucloxacillin
This is the picture of Acute Otitis Media which has led to tympanic membrane
al
perforation.
Ev
Sometimes a child may report that the pain suddenly settles. This is followed by
discharge. The reason that the pain suddenly settles is that the tympanic membrane
has perforated, releasing the pressure immediately.
Otitis media can be bacterial or viral but most are self limiting and do not require
antibiotics. If an antibiotic is required, prescribe a five-day course of amoxicillin. For
children who are allergic to penicillin, prescribe a five-day course of erythromycin or
clarithromycin. The most common bacterial pathogens are Haemophilus influenzae,
Streptococcus pneumoniae, Moraxella catarrhalis and Streptococcus pyogenes of which
amoxicillin would be suitable. The most common viral pathogens are respiratory
syncytial virus (RSV) and rhinovirus.

Features
350
• Fever
• Irritability
• Coryza
• Vomiting
membrane.
membrane
18. A 5 year old child complains of sore throat and earache. He has a temperature of
38.6°C. Examination shows enlarged, hyperemic tonsils with pus. He is not on any
medication. What is the SINGLE most likely diagnosis?
y
op
B. Acute tonsillitis
C. Scarlet fever
D. Acute Epiglottitis
C
E. Acute Otitis Media
n
Tonsillitis is usually caused by a viral infection or, less commonly, a bacterial infection.
The given case is a bacterial tonsillitis (probably caused a streptococcal infection). Note
io
that the pain for tonsillitis may be referred to the ears.

t
ua
If the sore throat is due to a viral infection the symptoms are usually milder and often
related to the common cold.
al
In streptococcal infection the tonsils often swell and become coated and the throat is
sore. The patient has a temperature, foul-smelling breath and may feel quite ill. The
Ev
differences are variable and it is impossible to tell on inspection if the infection is viral
or bacterial in real life. However in PLAB, look for these main four signs that point
towards tonsillitis being caused by a bacterial infection rather than a viral infection.
4 signs:
• a high temperature
• white pus-filled spots on the tonsils
• no cough
• swollen and tender lymph nodes (glands)
Note: In this question it is unlikely to be Infectious mononucleosis (glandular fever) as it

affects teenagers most often. They may be quite unwell with very large and purulent
tonsils and a long-lasting lethargy. An enlarged spleen is classically described.
Tonsillitis
Symptoms
351
• Pain in the throat is sometimes severe and may last more than 48 hours, along
with pain on swallowing.
• Pain may be referred to the ears.
Signs
• The throat is reddened, the tonsils are swollen and may be coated or have
white flecks of pus on them.
• Possibly a high temperature.
• Swollen regional lymph glands.
• Classical streptococcal tonsillitis has an acute onset, headache, abdominal pain
and dysphagia.
• Examination shows intense erythema of tonsils and pharynx, yellow exudate
and tender, enlarged anterior cervical glands.
19. A 39 year old man has a history of swelling in the region of the submandibular region,
which became more prominent and painful on chewing. He also gives a history of sour
taste in the mouth and having a dry mouth. On palpation, the area is tender. What is
y
op
B. Adenolymphoma
C
E. Submandibular abscess
n
Sialadenitis refers to inflammation of a salivary gland and may be acute or chronic,

io
infective or autoimmune.
t
The patients suffering from sialadenitis generally experience redness, swelling and pain
ua
in the affected side of the mouth. This occurs due to the enlargement of gland as a
result of inflammation caused by bacteria or virus infection. The swelling may become
al
enormously enlarged, sometimes even reaching the size of an orange, with overlying
inflamed reddened skin and edema. Mild pain and swelling are usually common before
and during meals. Fluctuation test may be positive in the swelling if it is filled with fluid.
Ev
Other symptoms of sialadenitis include a foul taste in the mouth, decreased mobility in
the jaw, dry mouth, skin changes, weight loss, shortness of breath, keratitis, dental
pain, skin discharge and lymphadenopathy. The patient may run fever with rigors and
chills along with malaise and generalized weakness as a result of septicemia. In severe
cases, pus can often be secreted from the duct by compressing the affected gland. The
duct orifice is reddened with reduced flow. There may or may not be a visible or
palpable stone.
20. A 30 year old lady has epistaxis for 30 minutes. Blood results shows:
Haemoglobin 122 g/L

Prothrombin time (PT), Activated partial thromboplastin time (APTT) and bleeding time
is normal
What is the SINGLE most likely cause of the bleed?
352
A. Platelet disorder
B. Clotting factor deficiency
C. Sepsis
D. Anatomical defect
E. Warfarin use
All her blood work is normal. This is likely a anatomical defect.
Trauma to the nose is the most common cause. Nose picking, insertion of foreign
bodies and excessive nose blowing may also be seen as trauma.
21. A 17 year old woman with no previous history of ear complains, presents with a one
day history of severe pain in the right ear which is extremely tender to examine. There
is pain with movement of the tragus. What is the SINGLE most likely diagnosis?
A. Chondromalacia
B. Furuncle
y
C. Myringitis
op
D. Otitis externa
E. Otitis media C
Otitis externa is difficult to examine because of tenderness. Typically there is pain when
moving the tragus.
n
Other features that one may see in the stem is discharge, hearing loss and fever.
io
22. A 5 year old girl has been reported by her parents to be increasing the volume of the
t
television to an excessive level. A hearing test conducted at school shows a symmetric

ua
loss of 40db. A grey bulging drum is seen on otoscopy on both ears. What is the SINGLE
al
A. Otitis media with effusion

B. Otitis externa
Ev
C. Cholesteatoma
D. Otosclerosis
E. Congenital sensorineural deficit
The child's hearing loss and increasing the TV volume suggests that she has otitis media
with effusion. This is supported by the otoscopy findings.
correct answer.
353
Presentation:
• Hearing loss is usually the presenting feature (glue ear is the commonest cause
repeated.
oversized adenoids
Signs:
y
op
Diagnosis:

C
n
Treatment:
io

t
ua
al
not accepted.
Ev
23. A 45 year old male presents with a whitish-grey opaque areas with red inflamed
patches on his tongue. These patches are unable to be scraped off. What is the SINGLE
B. Basal cell carcinoma
C. Aphthous ulcer
D. Oral thrush
E. Leukoplakia
Leukoplakia
• Seen as white thickening of the oral mucosa
• The key word that question writers would have to give is that “the white patch
that adheres to oral mucosa cannot be removed by rubbing”
• These should be biopsied as it is premalignant
354
24. A 48 year old man has a lump on his mandible. It has rapidly increased in size over the
past 8 months. On examination, there is an induration of the skin overlying the mass.
The mass is free and mobile. What is the SINGLE most appropriate investigations?
A. Fine needle aspiration (FNA) cytology

C. Salivary immunoglobulin M (IgM)
Submandibular neoplasms often appear with diffuse enlargement of the gland. Any
masses of this sort need to be investigated. In fact, any salivary gland swelling that is
present for more than 1 month needs to be investigated or removed. Ultrasound-
guided fine needle aspiration (FNA) cytology is used to obtain cytological confirmation.
25. An 8 year old boy was brought by his mother complaining that her child seems to be
watching the television at very high volumes. He lacks concentration and is socially
withdrawn. He would prefer to read books indoors rather than play outdoors. What is
y
the SINGLE most likely finding to be expected on an otoscopy?
A. Flamingo pink tympanic membrane

B. Attic perforation
op
C
C. A bluish grey tympanic membrane with an air fluid level
D. Inflamed tympanic membrane with cart wheel appearance of vessels
E. Red and inflamed tympanic membrane
n
io

t
ua
al
Ev
correct answer.
Presentation:
repeated.
oversized adenoids
355
Signs:
Diagnosis:

Treatment:

y
op
not accepted. C
26. A 15 year old boy presents to A&E with a nose bleed. The bleeding started 3 hours ago
and has not stopped. His blood pressure is 115/70 mmHg, heart rate is 80 bpm and
n
io
A. IV fluids
t
B. Lean forward, open mouth and pinch cartilaginous part of nose firmly
ua
C. Lean backwards, ice packs and pinch base of nose firmly

D. Start IV tranexamic acid
E. Radiological arterial embolization
al
Epistaxis
Ev
Treatment of epistaxis varies with different literature. Thus, it is important to use the
NHS guidelines for this question.
If haemodynamically compromised
• arrange immediate transfer to A and E. Use first aid measures to control

bleeding e.g. Lean forward, open mouth. Pinch cartilaginous (soft) part of nose
firmly and hold for 10 to 15 minutes without releasing the pressure, whilst
breathing through their mouth.
If haemodynamically stable
• just use first aid measures to control bleeding

• If bleeding does not stop after 10 - 15 minutes of nasal pressure, (and still
haemodynamically stable), then do NASAL CAUTERY (using silver nitrate). If
cautery is ineffective or bleeding point cannot be seen, then NASAL PACKING.
356
27. A 52 year old woman has intermittent vertigo, tinnitus and fluctuating hearing loss. She
complains of a sensation of ear pressure. The attacks can last for 2 to 3 hours. A MRI
brain scan was reported as normal. What is the SINGLE most appropriate treatment?
Plab Lab Values
A. Prochlorperazine
B. Fluphenazine
C. Vitamin A
D. Gentamicin drops
E. Aspirin
This is a classic case of Meniere’s disease. All four clues are present: dizziness, tinnitus,
deafness, and increased feeling of pressure in the ear. Treatment is prochlorperazine.
Meniere’s disease
Presentation:
• Dizziness, tinnitus, deafness, increased feeling of pressure in the ear. Note:
y
Vertigo is usually the prominent symptom
op
• Episodes last minutes to hours
• MRI is normal
• Usually a female >> male ; 20-60 years old
C
• Typically symptoms are unilateral but bilateral symptoms may develop after a
number of years
n
Treatment:
• Acute attacks: buccal or intramuscular prochlorperazine. Admission is
io
sometimes required
Note that vertigo and nausea can be alleviated by prochlorperazine, cinnarizine,
t
cyclizine, or promethazine.
ua
28. An 8 year old boy who has recently returned from Spain complains of severe pain in
al
one ear. On examination, pus is seen in the auditory canal. The tympanic membrane
looks normal. What is the SINGLE most appropriate treatment?
Ev
B. Amoxicillin PO
C. Analgesia
D. Amoxicillin IV
E. Microsuction
The diagnosis here is otitis externa.
Symptoms of otitis externa include minimal discharge, itch, pain and tragal tenderness
due to an acute inflammation of the skin of the meatus
This is a frequent question and the treatment options include: Topical gentamicin or
Topical gentamicin with hydrocortisone. Both are correct.
29. A 46 year old man has a long history of chronic sinusitis. He feels that his nose is
blocked and it does not clear and he occasionally sees blood when he blows his nose.
He now presents with pressure in his upper teeth, recent cheek swelling, and double
357
vision. On examination, left maxillary tenderness is noted along with epiphora of the
left eye. What is the SINGLE most likely diagnosis?
C. Paranasal sinus carcinoma
D. Laryngeal carcinoma
Paranasal sinus tumours (maxillary, ethmoid, frontal, sphenoid) are commonly well-
differentiated squamous cell carcinoma. They present with signs and symptoms similar
to this stem which include with local swelling, pain, and ocular symptoms if the orbit is
involved. Pain particularly in the upper cheek, nasal obstruction, blood in nasal
discharge point towards a likely diagnosis of paranasal sinus carcinoma.
30. A 29 year old man with a medical history that includes late onset asthma attends clinic
with rhinorrhoea and bilateral painless nasal obstruction. He complains of reduce sense
of smell. What is the SINGLE most likely diagnosis?
y
op
A. Septal abscess
B. Septal haematoma
C. Nasal polyp
C
D. Atrophic rhinitis
n
Nasal polyps
io
• Lesions arising from the nasal mucosa, occurring at any site in the nasal cavity
or paranasal sinuses
t
ua
Note that nasal polyps tend to be bilateral
• Associations
al
• Asthma
• Aspirin sensitivity
Ev
It is particularly important to remember the association with asthma.
Note: The association of asthma, aspirin sensitivity and nasal polyps is known as
Samter's triad.
Presentation
• Nasal obstruction
• Rhinorrhoea
• Anosmia (loss of smell)
31. A 17 year old man presents with sore throat for several days and dysphagia.
Examination reveals a unilateral bulge, above and lateral to his left tonsil. The bulge
was noted to be red and inflamed. The examination of the oral cavity was proven to be
difficult as he had mild trismus. Drooling of the saliva was seen. What is the SINGLE
358
A. Lymph node biopsy
B. Intravenous antibiotic and analgesics
C. Intravenous antibiotics, incision and drainage
D. Excision biopsy of bulge
E. Tonsillectomy
The stem here gives a typical presentation of peritonsillar abscess. Difficulty in

swallowing can result in drooling.
The changes in microbiology of the causative organism and their resistance is the
primary reason antibiotics alone is not sufficient as treatment. Incision and drainage or
aspiration in combination with intravenous antibiotics is the preferred option. Needle
aspiration, incision and drainage and quinsy tonsillectomy are all considered acceptable
surgical management for acute peritonsillar abscess.
Peritonsillar abscess (quinsy)

• A complication of acute tonsillitis
• Pus is trapped between the tonsillar capsule and the lateral pharyngeal wall
y
• Typically preceded by a sore throat for several days
Presentation
• Sore throat
op
C
• Dysphagia
• Pain localized to one side of the throat
n
• Peritonsillar bulge
• Uvular deviation → Bulging tonsil pushes the uvula away from the affected side
io
• Fever
• Trismus (difficulty opening the mouth)
t
ua
• Altered voice quality ('hot potato voice') due to pharyngeal oedema and
trismus
al
32. A 10 year old boy presents to clinic with poor grades in school and difficulty in hearing.
There has been recurrent ear infections in the past which was resolved by medication.
Ev
On examination: bone conduction is normal, air conduction is reduced bilaterally, and

there is no lateralization in the Weber’s test. There is no pain. What is the SINGLE most
likely diagnosis?

B. Perforation of tympanic membrane
C. Otitis media with effusion
D. Congenital sensorineural deficit
E. Otosclerosis
359
correct answer.
Presentation:
repeated.
y
op
oversized adenoids
C
Signs:
n
•
io
Variable, eg retracted or bulging drum. It can look dull, grey, or yellow. There
t
ua
Diagnosis:
al

Ev
Treatment:

not accepted.
33. A 5 year old girl has had an upper respiratory tract infection for 3 days and has been
treated with paracetamol by her mother. In the last 12 hours, she has been irritable and
with severe pain in her right ear. She has a temperature of 38.3°C. What is the SINGLE
360
A. Herpes zoster infection
B. Impacted ear wax
C. Mumps
D. Acute otitis media
E. Perforation of eardrum

Features
• Fever
• Irritability
• Coryza
• Vomiting
y
membrane.
op
membrane
C
n
34. A 40 year old man with a 25 year history of smoking presents with progressive
io
hoarseness of voice, difficulty swallowing and episodes of haemoptysis. He mentioned

that he used to be a regular cannabis user. What is the SINGLE most likely diagnosis?
t
ua
A. Nasopharyngeal cancer
al
C. Sinus cancer
D. Laryngeal cancer
Ev
The history of cannabis here is of no value. It has no relation to laryngeal cancer or any
of the above cancers.
Given the history of smoking, hoarseness of voice, dysphagia, and haemoptysis, the
likely diagnosis is laryngeal cancer.
Laryngeal Cancer
Risk factors
• Smoking is the main avoidable risk factor for laryngeal cancer
Presentation
• Chronic hoarseness is the most common early symptom.
• Other symptoms of laryngeal cancer include pain, dysphagia, a lump in the
neck, sore throat, earache or a persistent cough.
• Patients may also describe breathlessness, aspiration, haemoptysis, fatigue and
weakness, or weight loss.
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35. A 6 year old boy presents with a fever, sore throat and lymphadenopathy. The diagnosis
of tonsillitis has been made. He had 3 similar episodes last year which were self limiting.
What is the SINGLE most appropriate management for this child?
A. Tonsillectomy
B. Paracetamol
C. Oral penicillin
D. Oral amoxicillin
E. Prophylactic low dose penicillin
This question examines your knowledge of the indications of antibiotic use in tonsillitis
and also the indications of tonsillectomy.
Antipyretic analgesics such as paracetamol and ibuprofen are of proven benefit and
recommended for relief of fever, headache and throat pain in patients with sore throat
This child neither falls in the category for use of antibiotics or for a tonsillectomy.
y
op
Tonsillitis and antibiotics
For most patients, antibiotics have little effect on the duration of the condition or the
severity of symptoms and therefore treatment with antibiotics is not routinely
C
recommended.
NICE suggests prescribing antibiotics for those with:

n
• Features of marked systemic upset
io
• Increased risk of serious complications (e.g. diabetes or immunocompromised)

• Valvular heart disease
t
• A history of rheumatic fever

ua
Tonsillectomy
al
Surgery is not a treatment for the acute condition but aimed at reducing the incidence
of recurrent infections. The indications for tonsillectomy are controversial.
Ev
According to NICE, consider referral for tonsillectomy in children if all of the following
criteria are met:
• 5 or more episodes of acute sore throat per year, documented by the parent or
clinician
• Symptoms have been occurring for at least a year
• The episodes of sore throat have been severe enough to disrupt the child's
normal behaviour or day to day functioning
The following are recommended as per SIGN guidelines as indications for consideration
of tonsillectomy:
• Sore throats are due to acute tonsillitis (i.e. not recurrent upper respiratory
tract infections)
• Episodes of sore throat are disabling and prevent normal functioning
• 7 or more adequately treated sore throats in the preceding year or
• 5 or more such episodes in each of the preceding two years or
• 3 or more such episodes in each of the preceding three years
362
36. A 38 year old man was slapped over his right ear during a fight. There is blood coming
from his right external auditory canal. He describes the pain as intense and he also has
ringing in his ears. He is also noted to have decreased hearing on that ear. What is the
C. Otoscopy
D. Skull X-ray
E. Facial X-ray
It is quite clear here that the first examination should be an otoscopy to look for the
source of bleeding. One would not jump right away to a computed tomography as an
initial investigation for blood in the external auditory canal.
37. A 30 year old man was camping and an insect got stuck in his ear which he has been
unable to remove. He complains that he can still hear the buzzing in the ear. On
y
inspection, the insect is clearly visible in the ear canal. What is the SINGLE most
op
A. 2% lidocaine
C
B. Ear irrigation
D. Reassure
n
io
Insects should be killed prior to removal, using 2% lidocaine.

t
ua
Olive oil can also be used to float the insect out by pouring olive oil into the ear.
38. A 6 year old child fell on his nose 3 days ago. His parents have now brought him to the
al
hospital as he is having difficulty in breathing and feeling unwell. He has general

malaise and complains of nasal pain. On examination, nasal bones are seen to be
Ev
straight however there is tenderness over the dorsum of the nose. He has a
temperature of 38.9°C. What is the SINGLE most likely diagnosis?
A. Nasal polyp
B. Nasal septal haematoma
C. Nasal septal abscess
D. Deviated nasal septum
E. Fractured nose
Nasal septal abscess is the likely diagnosis here given the temperature and general
malaise. Nasal septal abscess is where there is a collection of pus between the
mucoperichondrium and septal cartilage. It results from a bacterial infection of a nasal
septal haematoma. This is why it is particularly important to incise and drain a septal
haematoma as to prevent an abscess from forming.
363
39. A mentally retarded 8 year old child puts a green pea in his ear while eating. Otoscopy
shows a green coloured object in the ear canal. What is the SINGLE most appropriate
approach to remove the green pea?
A. By magnet
B. Syringing
C. Removal under general anaesthesia
D. By hook
E. By instilling olive oil
The pea is not a magnetic material and hence it cannot be removed by a magnet.
It will swell up if syringing is attempted. Irrigation with water is contra-indicated for soft
objects, organic matter or seeds (which may swell and increase the level of pain and
difficulty to remove if exposed to water).
Removal by hook is not suitable in a mentally retarded child.
y
Olive oil only works for ear wax or used to float an insect out by pouring olive oil into
op
the ear.
General anaesthesia to remove the foreign object is usually needed in this sort of
C
scenario. This is to avoid injury.
For the purpose of PLAB, whenever you see a mentally retarded child with a foreign
n
object in the ear, the answer would be removal under general anaesthesia. (Consider a
io
mentally retarded child to be unco-operative)

t
Referral to an ear, nose and throat specialist

ua
Referral is indicated in the following:

al
• If the patient requires sedation.

• If there is any difficulty in removing the foreign body.
Ev
• If the patient is unco-operative.

• If the tympanic membrane has been perforated.
• If an adhesive is in contact with the tympanic membrane.
Foreign objects in the ear is a very commonly asked question in PLAB. You need to
know the management of these specific scenarios which include super glue in ear, seed
in ear, insect in ear, wax buildup, and a foreign body in ear with an uncooperative child.
40. A 33 year old patient has sensorineural hearing loss and loss of corneal reflex on the left
side. He is noted to have reduced facial sensation on that same side. He also complains
of tinnitus and vertigo. What is the SINGLE most definitive investigation?

D. Radioisotope scan
E. X-ray skull
364
Hearing loss, tinnitus, vertigo points towards an affected vestibulocochlear nerve.
Absent corneal reflex and reduced facial sensation is due to the trigeminal nerve being
affected.
Acoustic neuroma could account for these set of symptoms in which case MRI would be
the investigation of choice.
Acoustic neuroma
lesion.

y
op
Investigation
C
n
41. A 28 year old man has a headache that worsens on bending his head forward. He has
no nausea or vomiting. The headache tends to be at its worst first thing in the morning
io
and improves by the afternoon. What is the SINGLE most likely diagnosis?
t
A. Chronic sinusitis
ua
B. Trigeminal neuralgia
C. Migraine
D. Cluster headache
al
E. Tension headache
Ev
The key word here is “a headache that worsens on bending his head forward”. There
are two types of headaches which can worsen on bending. Sinus headaches and
migraines. Sinusitis, however, usually is not associated with nausea or vomiting.
Migraines, depending on severity, are often accompanied by nausea, vomiting and
sensitivity to light.
Sinus headaches are an uncommon type of headache caused by inflamed sinuses. It

happens when there is a build-up of pressure inside the sinuses and the small opening
from the sinuses to the nose becomes blocked. The pressure builds up and causes pain
behind the face and head. They are felt as a dull, throbbing pain in the upper face
especially in the area of the cheeks (maxillary sinus), bridge of the nose (ethmoid sinus),
or above the eyes (frontal sinus). It is usually on one side and tends to be worse first
thing in the morning. The pain may get worse when you move your head, strain or bend
forward. It is usually accompanied by a stuffy nose. Examination of the facial area may
reveal local tenderness, redness, swelling, and the presence of clear or discolored nasal
discharge.
365
Remember: Both sinus headaches and migraine headache pain often gets worse when
you bend forward. However. migraines are more severe than sinus headaches and
symptoms may include nausea and vomiting
42. A 45 year old man presents with hearing loss and tinnitus in the right ear. A 512 Hz
tuning fork is used which highlights Rinne’s test having AC > BC bilaterally. Weber test
lateralizes to the left. What is the SINGLE next best investigation?
C. Angiogram
D. Otoscopy
E. Oto-acoustic emissions
AC > BC indicates Rinne positive (i.e. deafness is not conductive). It is important to note
that the hearing loss is on right side. Weber lateralized to left. Weber lateralizes to the
same side if there is conductive deafness and to opposite if there is sensorineural
deafness. It is quite obvious that the deafness of right ear is sensorineural deafness for
y
which magnetic resonance imaging brain is the next best investigation.
op
Sensorineural hearing loss refers to problems occurring in the cochlea, cochlear nerve
or brain stem, resulting in abnormal or absent neurosensory impulses. MRI scan can be
C
used to identify gross structural causes of hearing loss. They are useful in cases where a
tumour is suspected or to determine the degree of damage in a hearing loss caused by
bacterial infection or auto-immune disease.
n
io

t
ua
Rinne's test
al
Ev
Weber's test
366
deafness
deafness
Example
43. A 2 year old child is brought by his mother. The mother had hearing impairment in her
early childhood and is now concerned about the child having a similar condition. What
is the SINGLE best investigation to be done for the child?
A. Conditioned response audiometry

B. Distraction testing
C. Scratch test
D. Tuning fork
y
E. Otoacoustic emissions
Hearing tests in the children:

• < 6 months
op
C
o Otoacoustic emissions (OAE):
▪ Vibration of the hair cells in response to noise generates
n
acoustic energy which is detected by a microphone in the
external meatus.
io
o Audiological brainstem responses (ABR):

▪ The ears are covered with earphones that emit a series of soft
t
clicks. Electrodes on the infant’s forehead and neck measure

ua
brain wave activity in response to the clicks.

• 6-18 months:
o Distraction testing:
al
▪ As the child sits on parent’s lap, an assistant in front attracts

the child’s attention while a tester attempts to distract by
Ev
making noises behind and beside child, eg with a rattle,

conversational voice.
• 2-4 years:
o Conditioned response audiometry:
▪ The child is trained to put pegs into holes or give toys to a
parent on a particular auditory cue.
o Speech discrimination:
▪ The child touches selected objects cued by acoustically similar
phrases, eg key/tree.
• 5 years:
o Pure tone audiogram
▪ Each ear is tested individually. The child presses a button when
he hears a tone.
44. A 33 year old tennis player has to stop playing tennis competitively because she has
recurrent vertigo attacks every time she plays tennis. The vertigo attacks started after a
367
history of runny nose, cough and fever. Her hearing is not affected. What is the SINGLE
A. Acoustic neuroma
C. Labyrinthitis
E. Vestibular neuritis
This may sound like benign paroxysmal positional vertigo but because of the history of
runny nose, cough and fever, it is more likely to be vestibular neuritis. Vestibular
neuritis follows a viral infection and can cause vertigo, nausea and vomiting on
movement of the head.
Vestibular neuritis
Develops over hours and resolves in days. Usually followed by a viral infection. Strictly
speaking the term means inflammation of the vestibular nerve but the aetiology is
thought to be a vestibular neuropathy.
y
op
Presentation
• Onset is usually very abrupt
• Recurrent vertigo attacks lasting hours or days
C
• Unsteadiness, nausea and vomiting (feel as if the room is rotating)
• Moving the head aggravates symptoms
n
Note: Labyrinthitis is a similar syndrome to vestibular neuritis, but with the addition of
io
hearing symptoms (sensory type hearing loss or tinnitus). There is no hearing loss with
vestibular neuritis.
t
ua
45. A 44 year old man presents with muffled hearing and tinnitus. He also complains of the
feeling of pressure in ear and vertigo. He has double vision when looking to the right.
al
A. Meniere’s disease
Ev
B. Acoustic neuroma
C. Acute labyrinthitis
D. Meningioma
E. Otosclerosis
Hearing loss, feeling of pressure in the ear with tinnitus, vertigo and involvement of
cranial nerve i.e. right abducens nerve are suggestive of acoustic neuroma
Acoustic neuroma
lesion.

368
Investigation
46. A 7 year old boy is brought to clinic by his mother. His mother complains that he has
been getting in trouble in school because he is inattentive in class. The mother also
mentions that he sits close to the television at home. These problems have been going
on for more than 12 months. There is no pain or fever. A tympanogram highlights
conductive hearing loss at 30-dB. What is the SINGLE most appropriate management?
C. Hearing aids
D. Adenoidectomy
E. Refer to child psychologist
y
op
C
n
This is usually the presentation of otitis media with effusion. A tympanogram would
io
show a hearing loss between 20 to 40 dB. If this was his first visit, reassurance and
review in 3 months would be the most appropriate. But as this problem has been
t
persisting for more than 12 months, a referral for a grommet insertion would be the
ua
more appropriate choice.

al
Ev
correct answer.
Presentation:
repeated.
369
oversized adenoids
Signs:
Diagnosis:

Treatment:
y
•
op
Observation first because may resolve, monitor every 3 months.
C
n
not accepted.
t io
47. A 6 year old boy was was playing in the playground when he stuck a seed into his ear.
ua
He has been unable to remove it. On inspection, the seed is clearly visible in the ear
canal. What is the SINGLE most appropriate management?
al
A. 2% lidocaine
B. Ear irrigation
Ev

Irrigation with water is contra-indicated for soft objects, organic matter or seeds (which
may swell and increase the level of pain and difficulty to remove if exposed to water).
Suction with a small catheter held in contact with the object may be effective.
48. A 62 year old man with a long history of smoking and alcohol presents with nasal
obstruction, and on and off nose bleeds. He has a noticeable lump on his upper neck.
He is having difficulty hearing with his left ear and has had worsening ear pain in that
ear. Examination reveals conductive hearing loss in the left ear. What is the SINGLE
B. Paranasal sinus carcinoma
370
D. Oropharyngeal carcinomas
E. Hypopharyngeal carcinoma
The first symptom of nasopharyngeal carcinoma is often a painless swelling or lump in

the upper neck. This is often due to a swollen lymph node. Other symptoms include
nasal obstruction, epistaxis and otitis media from eustachian tube obstruction. Hearing
loss (conductive deafness) in one ear and tinnitus are also symptoms seen in
nasopharyngeal carcinoma.
Smoking and alcohol can increase the risk of nasopharyngeal carcinoma but then again,
they increase risk in many other types of cancers. One specific risk factor for
nasopharyngeal carcinoma is an infection with the Epstein-Barr virus.
49. A 9 year old girl has been increasing the volume of the television to an excessive level.
Her parents complain that she needs them to repeat themselves constantly. On
examination: bone conduction is normal, air conduction is reduced bilaterally. What is
y
op
C
D. Otosclerosis
E. Presbycusis
n
The diagnosis here is otitis media with effusion. The hearing tests would typically show
io
a mild conductive hearing loss.

t

ua
al
Ev
correct answer.
Presentation:
repeated.
371
oversized adenoids
Signs:
Diagnosis:

Treatment:
y
•
op
(thus if a scenario is given with a recent diagnosis of otitis media with effusion,
C
not accepted.
n
io
50. A 10 year old boy presents to his GP with a nose bleed. The bleeding started 1 hour ago
t
and has not stopped. He is haemodynamically stable. What is the SINGLE most
ua
A. Press the base of the nose

al
B. Press the soft parts of the nose

C. Ice packs and lean backwards
Ev
D. Start oral tranexamic acid

E. Send to A&E
Epistaxis
Treatment of epistaxis varies with different literature. Thus, it is important to use the
NHS guidelines for this question.
If haemodynamically compromised
• arrange immediate transfer to A and E. Use first aid measures to control

bleeding e.g. Lean forward, open mouth. Pinch cartilaginous (soft) part of nose
firmly and hold for 10 to 15 minutes without releasing the pressure, whilst
breathing through their mouth.
If haemodynamically stable
• just use first aid measures to control bleeding
372
• If bleeding does not stop after 10 - 15 minutes of nasal pressure, (and still
haemodynamically stable), then do NASAL CAUTERY (using silver nitrate). If
cautery is ineffective or bleeding point cannot be seen, then NASAL PACKING.
51. A 45 year old woman presents with rotational vertigo, nausea and vomiting which is
worst when moving her head. She also had a similar episode 2 years ago. These
episodes typically follow an event of runny nose, cough and fever. What is the SINGLE
A. Acoustic neuroma
C. Labyrinthitis
E. Vestibular neuronitis
This may sound like benign paroxysmal positional vertigo but because of the history of
runny nose, cough and fever, it is more likely to be vestibular neuritis. Vestibular
neuritis follows a viral infection and can cause vertigo, nausea and vomiting on
y
movement of the head.
Vestibular neuritis
op
Develops over hours and resolves in days. Usually followed by a viral infection. Strictly
C
speaking the term means inflammation of the vestibular nerve but the aetiology is
thought to be a vestibular neuropathy.
n
Presentation
io
• Onset is usually very abrupt

• Recurrent vertigo attacks lasting hours or days
t
• Unsteadiness, nausea and vomiting (feel as if the room is rotating)

ua
• Moving the head aggravates symptoms
Note there is no hearing loss with vestibular neuritis

al
52. A 9 year old girl has been referred for assessment of hearing as she is finding difficulty
Ev
in hearing her teacher in the class. Her hearing tests show that bone conduction is
normal and symmetrical air conduction threshold is reduced bilaterally. Weber test
does not lateralize. What is the SINGLE most likely diagnosis?

D. Otosclerosis
E. Presbycusis
The diagnosis here is otitis media with effusion. The hearing tests would typically show
a mild conductive hearing loss.
373
correct answer.
Presentation:
repeated.
y
op
oversized adenoids
Signs:
C
n
io
Diagnosis:
t
ua

al
Treatment:
Ev

not accepted.
53. A 28 year old woman complains of vertigo and nausea that last around 30 minutes
several times a year. She has mild hearing loss in the left ear. A diagnosis of Meniere’s
disease is made. What is the SINGLE most appropriate treatment?
A. Aspirin
B. Metoclopramide
C. Cyclizine
374
D. Clotrimazole
E. Ondansetron
There are a number of medications that can be used to treat Meniere’s disease. These
are prochlorperazine, cinnarizine, cyclizine, or promethazine. They help with the
vertigo.
Meniere’s disease
Presentation:
• Dizziness, tinnitus, deafness, increased feeling of pressure in the ear. Note:
Vertigo is usually the prominent symptom
• MRI is normal
• Typically symptoms are unilateral but bilateral symptoms may develop after a
number of years
Treatment:
y
op
sometimes required
Note that vertigo and nausea can be alleviated by prochlorperazine, cinnarizine,

C
cyclizine, or promethazine.
n
54. A 16 year old female presents with a midline lump on her neck. It is painless and
smooth. The swelling tends to move upwards when she protrudes her tongue. What is
io

t
A. Thyroglossal cyst
ua
B. Goitre
C. Pharyngeal Pouch
D. Thyroid cancer
al
E. Lipoma
Ev
Thyroglossal cysts
Thyroglossal cysts represent the most common congenital anomaly of the neck and
account for 2-4% of all neck masses. They form along the embryological tract of the
thyroid. They usually present as fluctuant swellings in the midline of the neck along the
line of thyroid descent. These cyst tend to move upwards on tongue protrusion because
they are attached to the thyroglossal tract which attaches to the larynx by the
peritracheal fascia. They are painless and mobile but can become painful if infected.
55. A 75 year old man presents with symptoms of progressive sensorineural hearing loss on
the right. He also complains of dizziness and tinnitus. What is the SINGLE most

D. Ultrasound scan and fine needle aspiration
E. X-ray skull
375
Hearing loss, tinnitus, vertigo points towards an affected vestibulocochlear nerve. An
acoustic neuroma would be up on the list of differentials. An MRI of the internal
auditory meatus will show a benign tumour in the cerebellopontine angle.
Sometimes, in the stem, they would include facial palsy as a feature.
Acoustic neuroma
lesion.

y
Investigation
op
C
56. A 6 year old boy was was playing at home alone when he stuck super glue into his ear.
n
His mother has brought him to A&E and is extremely concerned. On inspection, the
adhesive is in contact with the tympanic membrane. What is the SINGLE most
io
t
A. Reassure
ua
B. Ear irrigation
al
E. Manual removal immediately

Ev
Adhesives (eg, Super Glue®) may be removed manually within 1-2 days once
desquamation has occurred. Referral to an ear, nose and throat specialist is required if
an adhesive is in contact with the tympanic membrane.
57. A 12 year old boy presents with right sided hearing loss and facial drooping on the right
side. He has a headache and feels dizzy. On examination, both ears appear normal with
an intact eardrum. Rinne’s test was found to be normal. Weber test lateralized to the
left. What is the SINGLE most likely diagnosis?
A. Bell’s palsy
B. Lyme disease
C. Acoustic neuroma
D. Pituitary adenoma
376
E. Glioma
Acoustic neuroma
lesion.

Investigation
y
58. A 35 year old woman has dull pain in her right ear which has been present for several
op
weeks. The pain is located in front of the tragus of the right ear and spreads along the
cheek and mandible. Chewing increases the pain. Her husband has mentioned that she
grinds her teeth when she sleeps at night. The eardrum appears normal and there is no
C
discharge. What is the SINGLE most likely diagnosis?
n
A. Dental caries
B. Mumps
io
C. Otitis media
D. Temporomandibular joint disorder
t
E. Trigeminal neuralgia
ua
The term temporomandibular disorders (TMDs) refers to a group of disorders affecting

the temporomandibular joint (TMJ), masticatory muscles and the associated structures.
al
One of the contributing factors is muscle overactivity which include bruxism (grinding of
Ev
teeth) which is seen in this stem.
Symptoms of temporomandibular disorders include facial pain, restricted jaw function

and joint noise. The pain is around the temporomandibular joint but is often referred to
the head, neck and ear.
59. A 44 year old man has difficulty hearing on his right ear. Rinne’s test was done and it
was normal in both ears however Weber’s test lateralized to the left ear. What is the

377
Rinne's test
y
op
Weber's test
C
n
deafness
io

deafness
t
ua
Example
al
Ev
60. A 48 year old man has difficulty hearing. Bone conduction is better than air conduction
in the left ear. The sound was localised towards the left side on Weber’s test. What is

E. Bilateral conductive deafness
Rinne's test
378
Weber's test
y
op
deafness
C
deafness
n
Example
io

t
ua
61. A 45 year old man has noticed difficulty hearing over the telephone. His hearing has
been progressively getting worse over the last few years. He is concerned because his
father has had similar problems around his age. Rine’s and Weber’s test demonstrate
al
conductive hearing loss. An audiogram shows moderate hearing loss in both ears across
all frequencies. What is the SINGLE most likely diagnosis?
Ev
A. Acoustic neuroma
B. Meniere's’ disease
C. Glue ear
D. Otosclerosis
E. Presbycusis
This patient has conductive hearing loss. With that information, we are able to rule out
a few options here. Acoustic neuroma, and presbycusis present with sensorineural
hearing loss, so we can cross those out right away. Meniere’s disease classically has
four clues which are present in the stem: dizziness, tinnitus, deafness, and increased
feeling of pressure in the ear (Note: Vertigo being the prominent symptom). Glue ear
(Otitis media with effusion) is more common in children. WIth the given family history,
otosclerosis fits the best.
Otosclerosis
379
In otosclerosis, there is a pathological increased bony turnover leading to sclerosis and
failure of the sound conduction mechanism. This is due to ankylosis of the stapes
footplate in the fenestra ovalis of the cochlea. This reduces normal sound transmission
resulting in a conductive deafness.
Otosclerosis is the commonest cause of progressive deafness in young adults although

the numbers of incidences seems to be reducing. It usually presents between teen
years and middle age (typically between the ages of 15 and 35).
Genetic factors are involved, so the condition often (but not always) runs in families.
The family history is especially important to note as it is commonly given in the stem if
the question writers want you to pick otosclerosis.
Both ears may be affected, although it is not uncommon for one ear to be worse than
the other.
Untreated, the deafness gradually worsens and in a small percentage of people it can
cause profound hearing loss. Other symptoms of otosclerosis can include tinnitus and
y
vertigo.
op
It is progressive and there is no curative treatment at the moment. Management
usually involves either surgery or bilateral hearing aids.
C
Key features for otosclerosis:
• Conductive hearing loss (Where the cochlea is involved there may be a mixed
n
conductive/sensory pattern of hearing loss)
io
• Family history of hearing loss

t
62. A 10 year old child developed fever, severe earache and tonsillitis following an upper
ua
respiratory tract infection. On otoscopy, the tympanic membrane is distinctly red. What
is the most likely diagnosis?
al
A. Acute Otitis Media

B. Otitis Externa
Ev
C. Glue Ear
D. Meningitis
E. Vestibular Neuritis
In older children and adults, AOM usually presents with earache. If the child was
younger, he may pull or rub his ear, or may have nonspecific symptoms such as fever,
irritability, crying, poor feeding, restlessness at night, cough, or rhinorrhoea.

Features
• Fever
• Irritability
• Coryza
380
• Vomiting
membrane.
membrane
63. A 6 year old down syndrome boy was was playing at home alone when he stuck a small
piece of toy into his ear. His mother has brought him to a GP clinic and is extremely
concerned. On inspection, a small foreign object is visible. The child is uncooperative
and does not understand why his mother has brought him here. What is the SINGLE
y
B. Ear irrigation
op
E. Manual removal immediately using forceps C
This patient is uncooperative and needs an ENT referral. General anaesthesia to remove
the foreign object is usually needed in this sort of scenario.
n
Referral to an ear, nose and throat specialist

io
Referral is indicated in the following:

t
ua
• If the patient requires sedation.

• If there is any difficulty in removing the foreign body.
al
• If the patient is unco-operative.

• If the tympanic membrane has been perforated.
Ev
• If an adhesive is in contact with the tympanic membrane.
64. A 25 year old man presents with a history of pain and swelling in the submandibular
region that has been present for weeks. The pain is unilateral and more prominent
during eating. The area is tender on palpation. What is the SINGLE most likely
diagnosis?
B. Adenolymphoma
E. Salivary gland neoplasm
381
Pain, swelling, more pain on chewing, tenderness, suggests diagnosis of submandibular
chronic sialadenitis. Chronic sialadenitis is usually secondary to sialolithiasis (salivary
stone).
Sialadenitis
Refers to inflammation of a salivary gland and may be acute or chronic.
Acute sialadenitis
Acute sialadenitis is an acute inflammation of a salivary gland. Patients typically present
acutely in A and E with erythema over the area, pain, tenderness upon palpation, and
swelling. The infection is often the result of dehydration with overgrowth of the oral
flora. A common scenario would be postoperative dehydration. Purulent material may
be observed.
Chronic sialadenitis
Chronic sialadenitis, in contrast, is typically less painful and is associated with recurrent
enlargement of the gland (often following meals) typically without erythema. The
chronic form of the disease is associated with conditions linked to decreased salivary
y
flow, rather than dehydration. These conditions include calculi (sialolithiasis).
65.
op
A 27 year old man had a fly enter his ear. He is anxious to get the fly removed. What is
the SINGLE best method for removal of the fly from his ear?
C
A. Removal with forceps
B. Removal under general anaesthesia
n
C. Instill mineral oil into his ear
io
D. Instill alcohol ear drops

E. Syringe his ear with normal saline
t
ua
Points to remember for foreign bodies in the ear:
• Referral to an ear, nose and throat specialist is indicated in the following:

al
o If the patient requires sedation.

o If there is any difficulty in removing the foreign body.
Ev
o If the patient is uncooperative.

o If the tympanic membrane has been perforated.
o If an adhesive is in contact with the tympanic membrane.
• After removal the tympanic membrane must be checked - there may be a
perforation which must be treated.
• The following should be avoided:
o use of a rigid instrument to remove a foreign body from an
uncooperative patient's ear
o removal of a large insect without killing it first
o irrigating a seed from an ear canal. Water causes the seed to swell.
o removal of a large or hard object with forceps which may push them
farther into the canal
• Removal of the foreign body by syringing is not usually successful.
• Organic foreign bodies are more likely to cause infection.
• Spherical objects need to be hooked out. They cannot be grasped with forceps.
• Live insects cause great distress. Drown the insect in olive oil and if necessary
then syringe it out.
382
66. A 52 year old patient is complaining of vertigo whenever she moves sideways on the
bed while lying supine. She would feel as if the room is spinning and she would feel
nauseous. This goes away after a few minutes but returns when she moves her head.
A. Hallpike's Manoeuvre
B. Reassure
C. Advice on posture
D. Carotid Doppler
E. CT head
Benign paroxysmal positional vertigo is one of the most common causes of vertigo
encountered. It is characterised by the sudden onset of dizziness and vertigo triggered
by changes in head position.
Presentation:
• Can be preceded by infections
y
• Vertigo on turning over in bed, lying down, or sitting up from supine position
op
• each episode typically lasts 10-20 seconds
Diagnosis:
C
• Hallpike's Manoeuvre positive
n
Treatment:
• Mostly spontaneous resolution with exacerbations
t io
67. A 55 year old man presents with swelling at the angle of the mandible which is
ua
progressively increasing in size over the past 6 months. It is painless, firm and mobile.
al
A. Benign parotid tumour

B. Mandible tumour
Ev
C. Tonsillar carcinoma
D. Parotitis
E. Sjögren's syndrome
The description of a mobile mass fits a benign parotid tumour such as pleomorphic
adenoma. A mandibular tumour or tonsillar carcinoma would not be described as
mobile. Parotitis is unlikely as parotitis is described as a painful and tender mass at the
angle of the jaw. Sjögren's syndrome does involve parotid gland enlargement and
occasional tenderness but no other features of Sjögren's syndrome were given in this
stem such as dryness in the eyes or mouth. Therefore benign parotid tumour is still
more likely than Sjögren's syndrome.
Pleomorphic adenoma
• Also called benign mixed tumour
• It is the most common tumour of the parotid gland and causes over a third of
submandibular tumours
383
Features
• Presents around middle age
• Slow-growing and asymptomatic
• Solitory
• Painless
• Usually mobile
• Firm single nodular mass
Though it is classified as a benign tumor, pleomorphic adenomas have the capacity to

undergo malignant transformation.
Treatment involves removing by superficial parotidectomy or enucleation
68. A 52 year old male with poorly controlled diabetes mellitus presents to his GP with
severe pain in the ear and an intense headache. On examination, his skin around the
ear is black in colour and there is a foul smelling discharge coming from the ear. He is
also noted to have conductive hearing loss. What is the SINGLE most likely diagnosis?
y
A. Carbuncle
op
B. Folliculitis
C. Malignant otitis externa
D. Cholesteatoma
C
E. Furuncle
n
Malignant otitis externa is an aggressive infection rather than a malignancy, or cancer.
It is rare. In some cases, the infection can spread to the outer ear and surrounding
io
tissue, including the bones of the jaw and face. Despite the term “malignant” being
used, it is NOT cancerous.
t
ua
Conductive hearing loss and foul-smelling purulent otorrhoea is also one of the features
in malignant otitis externa.
al
Risk factors for malignant otitis externa include diabetes and a weakened immune
system.
Ev
Without treatment, malignant otitis externa can be fatal.
384
EPIDEMIOLOGY
y
op
C
Questions
n
io
&
t
ua
Answers
al
Ev
385
Epidemiology Questions
1. A study was conducted to evaluate the risk for blindness in a patient with diabetes over
a 5-year period. 4 people became blind in Group A which consist of 100 people. 3
people became blind in group B which consisted of 100 people. All participants in group
B were given a trial of a new drug whereas group A did not receive any treatment.
Given the data above, which statement is correct?
A. Absolute risk is 1
B. Relative risk is 3
C. Relative risk is 0.75
D. Absolute risk is 0.75
E. Relative risk is 1
2. A random study on pulmonary embolism shows 10 patients out of 100 died who did not
get treatment and 10 patients out of 100 died who got proper treatment. What is the
SINGLE most likely absolute risk?
y
A. Absolute risk 5%
op
B. Absolute risk 2%
C. Absolute risk 100%
D. Absolute risk 10%
E. Absolute risk 0.1%
C
3. A group of patients with atherosclerosis are followed forward over a period of time to
n
investigate the outcome according to exposure to different factors. It started with 2
io
groups free of disease and followed forward for a period of time. What is the SINGLE
most likely study design?
t
ua
A. Prospective cohort study

B. Retrospective cohort study
C. Case control study
al
D. Randomized controlled study

E. Prevalence
Ev
4. A town has a population of 500 000. In a 5 year period, 1250 cases of lung cancer were
registered by death certification. It was also found in the same town, 500 people were
diagnosed with lung cancer from the community hospital. The 1 year survival rate is 0%.
What is the SINGLE most likely annual prevalence of lung cancer per million in this
population?
A. 200
B. 400
C. 500
D. 700
E. 1250
5. Half of a group of observations lies above this level and it is particularly important if the
distributions are not normal. What is the SINGLE most likely term?
A. Chi-square test
B. Linear regression
386
C. Mean
D. Median
E. Mode
6. This is the likelihood of a test reporting positive when the condition being tested is
actually present. What is the SINGLE most likely term?
A. Null hypothesis
B. Prevalence
C. Probability
D. Sensitivity
E. Specificity
7. Each year 950 000 people develop myocardial infarction in a population of 250 000 000.
Out of these, 215 000 die and 112 500 in the first hour. Which of the following is the
SINGLE most likely value for the incidence of myocardial infarction?
A. 112 500 in 250 000 000
y
B. 112 500 in 215 000 000
op
C. 215 000 in 250 000 000
D. 215 000 in 950 000
E. 950 000 in 250 000 000
C
8. A study was carried out in which 10 000 women participated. All the women underwent
a cervical smear. 1000 of 10 000 women had a positive smear. Of these, 100 developed
n
cervical cancer. 10 women who had negative smear developed cancer. What is the
io
SINGLE most likely terminology used to describe the 10 women with negative results
who developed cervical cancer?
t
ua
A. Case control study

B. False positive
C. Chance incidence
al
D. False negative
E. Randomized controlled trial
Ev
9. A small town has a population of 250,000. In a five year period there was 1,000 cases of
lung cancer diagnosed in that town. The neighbouring town also has a population of
250,000 but only 400 people were diagnosed with lung cancer during the five year
period. What is the annual incidence per million of lung cancer in the population of
both of these towns?
A. 2800
B. 1400
C. 700
D. 560
E. 1800
10. This is the measure of dispersion of a set of values. What is the SINGLE most likely
term?
A. Null hypothesis
387
B. Prevalence
C. Probability
D. Sensitivity
E. Standard deviation
11. A new screening test has been devised to detect early stages of prostate cancer. The
test has been found to be positive in a high number of patients who are later
discovered not to have the cancer on other more definitive testing methods. What is
the correct term to describe this test?
A. High true positive rate

B. High false positive rate
C. High true negative rate
D. High false negative rate
E. High specificity
y
op
C
n
t io
ua
al
Ev
388
Epidemiology Answers
1. A study was conducted to evaluate the risk for blindness in a patient with diabetes over
a 5-year period. 4 people became blind in Group A which consist of 100 people. 3
people became blind in group B which consisted of 100 people. All participants in group
B were given a trial of a new drug whereas group A did not receive any treatment.
Given the data above, which statement is correct?
A. Absolute risk is 1
B. Relative risk is 3
C. Relative risk is 0.75
D. Absolute risk is 0.75
E. Relative risk is 1
Risk ratios are an important topic in PLAB as it is one of the main epidemiologic
questions asked.
y
Absolute risk (AR) of a disease is your risk of developing the disease over a time period.
op
The same absolute risk can be expressed in different ways. For example, say you have a
1 in 10 risk of developing a certain disease in your life. This can also be said to be a 10%
risk, or a 0.1 risk - depending on whether you use percentages or decimals.
C
Relative risk (RR) is used to compare the risk in two different groups of people. For
n
example, consider the risk for blindness in a patient with diabetes over a 5-year period.
If the risk for blindness is 4 in 100 (4%) in a group of patients treated conventionally
io
(control group) and 3 in 100 (3%) in patients treated with a new drug (experimental
group), the relative risk is the ratio of the two risks. Given the data above, the relative
t
risk is:
ua
3% ÷ 4% = 75% (or 0.75)

al
Expressed as a relative difference, the new drug reduces the risk for blindness by a
quarter.
Ev
An RR of < 1 means the event is less likely to occur in the experimental group than in
the control group.
An RR of > 1 means the event is more likely to occur in the experimental group than in
the control group.
A good formula to remember for PLAB part 1 is:
RR = risk of disease in exposed / risk of disease in unexposed
In this scenario, it would be:
RR = risk of blindness in diabetics taking new drug / risk of blindness in diabetics with
no drug
389
2. A random study on pulmonary embolism shows 10 patients out of 100 died who did not
get treatment and 10 patients out of 100 died who got proper treatment. What is the
SINGLE most likely absolute risk?
A. Absolute risk 5%
B. Absolute risk 2%
C. Absolute risk 100%
D. Absolute risk 10%
E. Absolute risk 0.1%
Absolute risk by definition is the percentage of people within a particular group

affected by a certain event. Therefore, for both sets of patients who got treatment and
those who did not, the absolute risk of death (the event) would be: 10 / 100 = 1/10 =
0.1 = 10%.
3. A group of patients with atherosclerosis are followed forward over a period of time to
investigate the outcome according to exposure to different factors. It started with 2
groups free of disease and followed forward for a period of time. What is the SINGLE
most likely study design?
y
op
A. Prospective cohort study
B. Retrospective cohort study
C. Case control study
C
D. Randomized controlled study
E. Prevalence
n
A prospective cohort study assembles participants and follows them into the future.
io
4. A town has a population of 500 000. In a 5 year period, 1250 cases of lung cancer were
t
registered by death certification. It was also found in the same town, 500 people were
ua
diagnosed with lung cancer from the community hospital. The 1 year survival rate is 0%.
What is the SINGLE most likely annual prevalence of lung cancer per million in this
population?
al
A. 200
Ev
B. 400
C. 500
D. 700
E. 1250
In this question, we must figure out the total amount of people affected with lung
cancer within the 5 year period first: 1250 + 500 = 1750. Therefore, annually there are
1750 / 5 = 350 deaths from lung cancer. This is based on the assumption that the 1 year
survival rate is 0% therefore all cases should be accounted for. Since 350 deaths/year is
from a population of 500 000, to find out the annual prevalence per million, would be
(350 x 1 000 000) / 500 000 = 700 [cross multiply].
5. Half of a group of observations lies above this level and it is particularly important if the
distributions are not normal. What is the SINGLE most likely term?
A. Chi-square test
B. Linear regression
390
C. Mean
D. Median
E. Mode
Median is the value of the observation that comes half way when the observations are
ranked in order.
6. This is the likelihood of a test reporting positive when the condition being tested is
actually present. What is the SINGLE most likely term?
A. Null hypothesis
B. Prevalence
C. Probability
D. Sensitivity
E. Specificity
Sensitivity is a measure of a test’s ability to correctly detect people with the disease. It
is the proportion of diseased cases that are correctly identified by the test. It is
y
calculated as follows:
op
Sensitivity = Number with disease who have a positive test/Number with disease.
C
7. Each year 950 000 people develop myocardial infarction in a population of 250 000 000.
Out of these, 215 000 die and 112 500 in the first hour. Which of the following is the
SINGLE most likely value for the incidence of myocardial infarction?
n
io
A. 112 500 in 250 000 000

B. 112 500 in 215 000 000
t
C. 215 000 in 250 000 000

ua
D. 215 000 in 950 000

E. 950 000 in 250 000 000
al
The definition of incidence is the number of new cases of a disease occurring within a
population during a specific time. Therefore, in this question 950 000 people (number
Ev
of new cases) develop myocardial infarction within a population during a specific time
period.
8. A study was carried out in which 10 000 women participated. All the women underwent
a cervical smear. 1000 of 10 000 women had a positive smear. Of these, 100 developed
cervical cancer. 10 women who had negative smear developed cancer. What is the
SINGLE most likely terminology used to describe the 10 women with negative results
who developed cervical cancer?
A. Case control study

B. False positive
C. Chance incidence
D. False negative
E. Randomized controlled trial
A falsely drawn negative conclusion. A conclusion that a person does not have the
disease or condition being tested, when they actually do.
391
9. A small town has a population of 250,000. In a five year period there was 1,000 cases of
lung cancer diagnosed in that town. The neighbouring town also has a population of
250,000 but only 400 people were diagnosed with lung cancer during the five year
period. What is the annual incidence per million of lung cancer in the population of
both of these towns?
A. 2800
B. 1400
C. 700
D. 560
E. 1800
Incidence in epidemiology is a measure of the probability of occurrence of a given

medical condition in a population within a specified period of time.
As the question specifically asked for annual incidence per million, the calculation
should be as below:
y
op
1000 + 400 = 1400
250 000 + 250 000 = 500 000

C
There are 1400 people diagnosed with lung cancer in a population of 500 000 in 5
years.
n
io
1 000 000 / 500 000 = 2

t
Incidence per million in 5 years = 2 x 1400 = 2800

ua
Incidence per million in 1 year = 2800 / 5 = 560

al
10. This is the measure of dispersion of a set of values. What is the SINGLE most likely
term?
Ev
A. Null hypothesis
B. Prevalence
C. Probability
D. Sensitivity
E. Standard deviation
Standard deviation is a measure of the spread or dispersion of a set of observations,

calculated as the average difference from the mean value in the sample.
11. A new screening test has been devised to detect early stages of prostate cancer. The
test has been found to be positive in a high number of patients who are later
discovered not to have the cancer on other more definitive testing methods. What is
the correct term to describe this test?
A. High true positive rate

B. High false positive rate
392
C. High true negative rate
D. High false negative rate
E. High specificity
The easiest way to remember this is using the following definitions.
True positive is the amount of sick people correctly identified as sick

False positives is the amount of healthy people incorrectly identified as sick
True negative is the healthy people correctly identified as healthy
False negative is the sick people incorrectly identified as healthy
High sensitivity means few false negatives

Low sensitivity means many false negatives
High specificity means few false positives
Low specificity means many false positives
y
op
C
n
t io
ua
al
Ev
393
ETHICS
y
op
C
Questions
n
io
&
t
ua
Answers
al
Ev
394
Ethics Questions
1. A 15 year old girl comes requesting the oral contraceptive pill (OCP). She is sexually
active and her sexual partner is also 15 years old. She does not want her parents to
know about her sexual relationship with this boy. What is the SINGLE most appropriate
action?
A. Breach confidentiality and inform her parents

B. Advise her about safe sex and prescribe OCP
C. Inform her that it is illegal for her to have a sexual relationship with a 15 year old boy
D. Contact the police and local safeguarding officer
E. Inform her that it is illegal to prescribe the pill for her
2. A 15 year old girl is requesting for oral contraceptive pills (OCP) as she is sexually active.
She refuses to tell her parents about her sexual activity and mentions that her partner
is a 38 year old man. What is the SINGLE most appropriate action?
A. Breach confidentiality and inform authorities
y
B. Advise them about safe sex and prescribe the pill
op
C. Perform an STI screen
D. Inform her that she can only be prescribed the pill after the age of 16
E. Inform her that she can only be prescribed the pill after the age of 18
C
3. A 15 year old boy in London is brought to the hospital by his parents complaining of
lower abdominal pains for the past three days. A clinical suspicion of appendicitis and
n
the decision to admit was made. The young boy refuses to be admitted as he has plans
io
to go out with his friends tonight. He is unable to understand the serious nature of an
untreated appendicitis. His parents would like to overrule his wishes and to admit him.
t
What is the SINGLE most appropriate course of action?

ua
A. Contact the local safeguarding officer

B. Respect his wishes and do not admit
al
C. Involve social services

D. Refer for a psychiatric evaluation before admission
Ev
E. Admit him under parental consent
4. A 15 year old girl attends the emergency department with mild vaginal bleeding. A
pregnancy test is positive. She does not want her parents to know about her pregnancy
and she refuses to disclose any information regarding her sexual partner to the
healthcare professionals. What is the SINGLE most appropriate management?
A. Assess child's competency to make decisions

B. Inform her parents
D. Inform patient that she is lawfully obliged to provide her partner's name and age
E. Contact the police
5. A 34 year old woman requests for sterilization. Her last born child has cerebral palsy.
Her husband strongly objects to the procedure. What is the SINGLE most appropriate
action?
A. Provide advice for other modes of contraception
395
B. Proceed with patient wishes and carry out sterilization
C. Seek judicial review instructions
D. Referral to social services
E. No action taken
6. A 13 year old girl presents to the clinic requesting morning pills. She says the condom
she used with her 13 year old boyfriend split into two while having intercourse. What is
the SINGLE most appropriate action?
A. Inform the police and then give patient contraception

B. Inform patient’s General Practitioner
C. Inform patient’s mother and the police immediately
D. Give contraception
E. Refer patient to another doctor to handle the case
7. A healthy 19 year old female, gestational age of 27 weeks, presents to Obstetrics and
Gynecology clinic requesting a termination. She says her boyfriend has just left her and
that she would not want the baby to remind her of him. The boyfriend, who is currently
y
in jail, has reportedly been assaulting her during their stormy 2 year relationship. What
op
is the SINGLE most appropriate action?
A. Terminate fetus via conservative management

C
B. Terminate fetus via dilation and curettage
C. Inform police and terminate fetus
D. Refusal of termination
n
E. Refusal of termination and inform police
io
8. A 30 year old female is brought into the Emergency Department by her husband
t
drifting in and out of consciousness following a road traffic accident. She is in shock and
ua
requires immediate blood transfusion. Her husband objects saying they are devout
Jehovah’s Witnesses and are against blood transfusion. Her condition is deteriorating.
What is the SINGLE most appropriate action?
al
A. Do not transfuse blood because there is no consent

Ev
B. Transfuse blood without consent

C. Inform health authorities as situation is complicated
D. Seek judicial review instructions
E. Consult social services
9. A 31 year old Jehovah’s Witness was in a car accident and brought into the emergency
department. He has lost a massive amount of blood. He is given IV fluids. He is in critical
condition and blood products are needed but he refuses any form of blood products
due to his religious beliefs. What is the SINGLE most appropriate next step?
A. Transfuse blood against his will

B. Respect his decision and do not transfuse blood
C. Contact the police
D. Involve social services
E. Seek legal advice
396
10. A 17 year old boy is brought into the Emergency Department unconscious following a
road traffic accident. What is the SINGLE most appropriate action?
A. Resuscitate without consent

B. Wait for relatives to consent before beginning resuscitation
E. No action taken
11. A 16 year old boy has lower abdominal pain. A clinical suspicion of acute appendicitis
was made and the surgical team has decided to go ahead with an appendectomy. The
patient is happy to go ahead with the surgery but his parents refuse to sign the consent
form as they are opposed to any form of surgery. The procedure has been explained
clearly to the patient and his parents and they understand the risk of not going for
surgery. What is the SINGLE most appropriate action?
A. Cancel the surgery once proper documentation by parents are filled

B. Obtain a consent from patient and proceed with surgery
y
C. Contact the local safeguarding officer
op
E. Contact the police C
12. A 30 year old man is found to be HIV positive and is against condom use. After
discussing with him, he is still refusing to accept the need to tell his wife of his
diagnosis. What is the SINGLE most appropriate action
n
io
A. Inform the police

B. Do not inform the police
t
C. Inform health authorities

ua
D. Consult with social services

E. Notify wife via partner notification programme
al
13. You are treating a general surgeon for Hepatitis B. You ask him to inform the NHS trust
where he is currently working and he refuses. What is the SINGLE most appropriate
Ev
action?
A. Respect the patient’s confidentiality and do not inform the health authorities
B. Inform the health minister
C. Inform the relevant health authorities
E. Try to convince patient and ask for consent again
14. A 37 year old female who was recently diagnosed with multiple sclerosis took 100
tricyclic antidepressant tablets. She is now refusing all treatment. What is the SINGLE
most appropriate action?
A. Immediate arterial-blood gas analysis

B. Observe
C. Activated charcoal
D. IV sodium bicarbonate
E. Refer to psychiatrist to evaluate capacity
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15. A 45 year old man is found to be HIV positive in a Genitourinary Medicine clinic. He is
not sexually active. He does not want his GP informed about his diagnosis as he has
witnessed a friend who suffered discrimination following accidental disclosure of his
HIV status. What is the SINGLE most appropriate action?
A. Accept patient’s decision not to inform GP

B. Explain the legal and ethical duties of confidentiality to the patient and inform his GP
C. Explain to the patient that it is the patient’s duty by law to inform his GP
D. Inform his GP when his viral load is below 500 copies/mL
E. Inform his GP only when anti-viral medications are started
16. A 15 year old girl comes in with her 15 year old boyfriend requesting for oral
contraceptive pills (OCP). They are sexually active. They could not be persuaded to
inform their patients about their sexual relationship or that contraceptive advice was
being sought. What is the SINGLE most appropriate action?
A. Breach confidentiality and inform parents
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C. Contact the police and local safeguarding officer
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17. An armed robber is injured during an exchange of gunfire with the police and comes to
the Emergency Department. He requests your silence. What is the SINGLE most
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appropriate action?
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A. Inform the police without revealing patient’s personal information

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C. Consult with seniors of the NHS trust

E. Inform the health minister
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18. A 34 year old man with multiple sclerosis has taken an overdose of more than 50
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tablets of paracetamol with the intent to end his life. He has been brought to the
emergency department by his wife. He is refusing all interventions. What is the SINGLE
A. Assess his glasgow coma scale

B. Evaluate his mental capacity to refuse treatment
C. Establish if patient has any previous mental illness
D. Attain consent from his wife to give treatment
E. Admit but do not provide any intervention
19. A 15 year old girl is brought to the hospital by her parents with mild lower abdominal
pain. An ultrasound scan reveals a large ovarian cyst. The decision for a laparoscopic
ovarian cystectomy has been made but she refuses treatment. She understands the
consequences of not having the surgery and is deemed competent. Her parents ask if
they can override her decision and sign the consent form on her behalf. What is the
SINGLE most appropriate action?
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A. Seek legal advice
B. Obtain a consent from parents and carry out the surgery
C. Obtain a consent from two consultant gynaecologist and carry out the surgery
D. Contact social services
E. Cancel the surgery and respect patient’s wishes
20. An 85 year old woman with Alzheimer’s disease wants to change her will. Her
granddaughter is refusing as she says that her grandmother does not know what she is
saying since she is suffering from dementia. What is the SINGLE best action for you to
take?
A. Allow her to change her will

B. Refuse her as she has no capacity
C. Refer for assessment of capacity
D. Her granddaughter is her caretaker and therefore can consent for her
E. Allow her to change her will after 3 months
21. A 49 year old HIV positive man has been responding well to Highly Active Antiretroviral
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Therapy (HAART) which he obtains from the Genitourinary Medicine clinic. He is due for
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an elective orthopaedic surgery. He has not disclosed his HIV status to the orthopaedic
surgeon and wishes that his HIV status remains disclosed. What is the SINGLE most
appropriate action in regards to his HIV status?
C
A. Accept patient’s decision not to inform the orthopaedic surgeon about his HIV status
B. Inform the orthopaedic surgeon about his HIV status
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C. Inform the orthopaedic surgeon that a patient with a blood blood-borne virus is
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booked in for surgery on the day, without disclosing patient’s identity

D. Inform his orthopaedic surgeon if his viral load is below 500 copies/mL
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E. Explain to the patient that it is the patient’s duty by law to inform his surgeon
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22. A mother brings her 12 year old son to you requesting surgery for his sticking out ears.
She says that he is constantly teased in school because of his ears and wants him to
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undergo cosmetic surgery for it. The boy says he does not want surgery. What is the
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A. Refer to private practice

B. Schedule surgery as his consent is not needed
C. Contact social services and explore their concerns
D. Explain to mother that surgery is not possible without her son’s consent
E. Discuss the situation with your colleagues
23. You are a junior doctor working in the NHS. You suspect one of your colleagues to be
under the influence of recreational drugs. What is the SINGLE most appropriate action
to be taken?
A. Inform police
B. Confront your colleague directly
C. Inform the senior consultant
D. Seek for more evidence first
E. Report to the trust manager
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24. You are the SHO in psychiatry. Your consultant is having a sexual relationship with a
widowed patient that is currently being treated for depression. The lady’s condition is
much improved and is awaiting discharge next week. What is the SINGLE most
appropriate action?
A. Inform health minister as situation is complicated

B. Inform police and then give her contraception
C. Report him to trust manager as per hospital protocol
D. Inform the patient’s family members
E. Do not take action
25. A 55 year old woman has recently been diagnosed with multiple sclerosis and has been
started on oral steroids. She is brought to the hospital after having ingested more than
40 tablets of paracetamol 3 hours ago. She is refusing all medical treatment as she
wants to end her life. What is the SINGLE most appropriate action?
A. Admit and observe but do not provide any intervention

B. Refer to psychiatrist to assess patients ability to refuse treatment
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C. Gastric lavage
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D. Activated charcoal
E. Refer to social worker C
26. A man with dementia has an ulcerative lesion on his forehead. He wants it removed so
‘it can help improve his memory’. His wife says he is not fit to give consent. What is the
n
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A. Remove the lesion after obtaining written consent from the patient
B. Document finding but do not remove lesion
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C. Refer to GP for further assessment of lesion

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D. Refer to psychiatrist to assess the mental capacity to give consent

E. Review in 6 weeks
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27. A 15 year old girl had unprotected sex with her 38 year old boyfriend and is now
requesting for the morning pill. What is the SINGLE most appropriate action?
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A. Inform the police and give contraception

B. Do not inform police and give contraception
C. Inform parents and give contraception with their consent
D. Do not inform parents and give contraception
E. Consult with social services
28. A 33 year old pregnant woman is in labour at 40 weeks gestation. The emergency bell
was rung by the midwife in the labour room as the cardiotocograph shows fetal
bradycardia for the past 5 minutes that has not recovered. A quick decision to go for an
emergency C-section is made however she is unable to consent as she speaks only
Tigrinya and cannot understand English. Her partner is not in the hospital with her.
Attempts have been made to contact the language line but at present they are unable
to obtain a Tigrinya translator. What is the SINGLE most appropriate action?
A. Wait until a translator becomes available before performing the C-section

B. Proceed to perform a C-section
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C. Seek legal advice
D. Contact next of kin by telephone
E. Do not proceed with C-section until patient can fully understand and signs consent
form written in Tigrinya language
29. A 32 year old woman is brought in unconscious by the ambulance after receiving the
news that she has terminal breast cancer earlier in the day. She is suspected of having
taken an overdose of benzodiazepines. She was found by her boyfriend with an empty
bottle of tablets beside her with a note declaring that she wishes to end her life. The
note specifically says that she does not want any treatment. What is the SINGLE most
appropriate action?
A. Respect her wishes and do not treat

B. Wait for consciousness to obtain consent for treatment
C. Obtain verbal consent from her boyfriend regarding the decision to treat
D. Treat her with attempts to save her live despite not having a consent
E. Contact her parents to obtain consent to treat
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30. A 33 year old man is brought into the Emergency Department having been involved in a
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fight outside a local pub. During the fight, he was hit on the head by a metal chair. On
examination, there is a open laceration on his head and he has sustained cuts and
bruises on his arms and legs. He also smells of alcohol. He was initially uncooperative
C
before losing consciousness. What is the SINGLE most appropriate action?
A. Proceed to investigate and treat the patient without his consent

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B. Wait till he regains consciousness to obtain consent
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C. Investigate only without treating the patient

D. Treat only if his observations are unstable
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31. A 33 year old man is extremely thankful for your service and for assisting in his
laparoscopic appendicectomy. He offers you a valuable clock as a gift. What is the
al

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A. Accept it with gratitude

B. Accept it with a condition that it will be sold and money used on improvements of
services in the ward
C. Ask him to donate it to the ward
D. Refuse the gift and inform him that doctors are unable to accept valuable gifts from
patients
E. Accept it and donate it to charity
32. A 48 year old man recently had a transient ischaemic attack. What advice on driving
would you give him?
A. Continue to drive only when accompanied by another person

B. Continue to drive without any restrictions
C. Drive on the familiar roads and avoid busy roads
D. Stop driving completely
E. Do not drive for at least one month
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33. A 14 year old girl presents to the clinic requesting oral contraceptives. She is sexually
active with her 15 year old partner. What is the SINGLE most appropriate action?

B. Refer to social services
C. Consult another doctor as you need a second opinion to prescribe oral
contraceptives
D. Prescribe oral contraceptive pills and advise her to involve her parents in her
decision
E. Assess both her mental capacity and her partner's mental capacity
34. You are a junior doctor eating with a few friends in a restaurant. On leaving the
restaurant, you notice an empty table with patient's medical notes. The table has been
unattended for a while. What is the SINGLE most appropriate action?
A. Request that the restaurant manager call the hospital

B. Look through the medical notes and attempt to phone the patient
C. Look through the medical notes for a general practitioners contact and inform the
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practice
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D. Take the medical notes to the hospital
E. Ignore the incident and walk out of the restaurant
C
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Ethics Answers
1. A 15 year old girl comes requesting the oral contraceptive pill (OCP). She is sexually
active and her sexual partner is also 15 years old. She does not want her parents to
know about her sexual relationship with this boy. What is the SINGLE most appropriate
action?
A. Breach confidentiality and inform her parents

B. Advise her about safe sex and prescribe OCP
C. Inform her that it is illegal for her to have a sexual relationship with a 15 year old boy
D. Contact the police and local safeguarding officer
E. Inform her that it is illegal to prescribe the pill for her
This question is testing your knowledge on the Fraser Criteria.
For the under-16s
GMC guidance states that the duty of confidentiality is the same for children and young
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people as it is for adults.
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Confidentiality may only be breached in order to protect the adolescent or others from
serious harm - for example, where issues such as child abuse and child protection are
C
involved, or where required by law. In this situation the adolescent should be informed
of the disclosure and the reasons for it.
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Guidance also states that 'any competent young person, regardless of age, can
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independently seek medical advice and give valid consent to treatment'. Note that the
ability to consent changes if you are under 13. By law children under 13 are considered
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unable to consent.
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Contraceptive advice or treatment can be provided to a competent young person aged

under 16 years, without parental consent or knowledge, using the Fraser criteria. A
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health professional needs to be satisfied that:

- The young person could understand the advice and have sufficient maturity to
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understand what was involved in terms of the moral, social and emotional
implications.
- They could neither persuade the young person to inform the parents, nor to
allow the health professional to inform them, that contraceptive advice was
being sought.
- The young person would be very likely to begin or to continue having sexual
intercourse with or without contraceptive treatment.
- Without contraceptive advice or treatment, the young person's physical or
mental health or both would be likely to suffer.
- The young person's best interests required the health professional to give
contraceptive advice or treatment or both without parental consent.
2. A 15 year old girl is requesting for oral contraceptive pills (OCP) as she is sexually active.
She refuses to tell her parents about her sexual activity and mentions that her partner
is a 38 year old man. What is the SINGLE most appropriate action?
A. Breach confidentiality and inform authorities
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C. Perform an STI screen
Under the Fraser guidelines, a competent young person may be given advice on
contraception. However, this man is much older than her. Thus, you would need to
share information regarding this and breach confidentiality.
If her sexual partner was of similar age, example 15 years old, and she had the maturity
to understand the advice and its implications, you should then advise them about safe
sex, prescribe the COCP and do not breach confidentiality.
Breaching confidentiality in sexually active young person
Under the Fraser guidelines, you can provide contraceptive, abortion and STI advice
and treatment, without parental knowledge or consent, to young people under 16
provided that:
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- They understand all aspects of the advice and its implications
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- You cannot persuade the young person to tell their parents or to allow you to
tell them
- In relation to contraception and STIs, the young person is very likely to have sex
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with or without such treatment
- Their physical or mental health is likely to suffer unless they receive such advice
or treatment, and
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- It is in the best interests of the young person to receive the advice and
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treatment without parental knowledge or consent

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However, you should share information about abusive or seriously harmful sexual
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activity involving any child or young person, including that which involves:
- A young person too immature to understand or consent
- Big differences in age, maturity or power between sexual partners
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- A young person’s sexual partner having a position of trust

- Force or the threat of force, emotional or psychological pressure,
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- Bribery or payment, either to engage in sexual activity or to keep it secret

- Drugs or alcohol used to influence a young person to engage in sexual activity
when they otherwise would not
- A person known to the police or child protection agencies as having had
abusive relationships with children or young people.
3. A 15 year old boy in London is brought to the hospital by his parents complaining of
lower abdominal pains for the past three days. A clinical suspicion of appendicitis and
the decision to admit was made. The young boy refuses to be admitted as he has plans
to go out with his friends tonight. He is unable to understand the serious nature of an
untreated appendicitis. His parents would like to overrule his wishes and to admit him.
A. Contact the local safeguarding officer

B. Respect his wishes and do not admit
D. Refer for a psychiatric evaluation before admission
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E. Admit him under parental consent
This young boy is under 16. He lacks maturity and is unable to understand the
seriousness of his condition. You therefore can rely on parental consent.
Capacity to consent
The capacity to consent depends more on young people’s ability to understand and
weigh up options than on age. When assessing a young person’s capacity to consent,
you should bear in mind that:
- At 16 a young person can be presumed to have the capacity to consent

- A young person under 16 may have the capacity to consent, depending on their
maturity and ability to understand what is involved.
Respect for young people’s views is important in making decisions about their care. If
they refuse treatment, particularly treatment that could save their life or prevent
serious deterioration in their health, this presents a challenge that you need to consider
y
carefully
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Parents cannot override the competent consent of a young person to treatment that
you consider is in their best interests. But you can rely on parental consent when a child
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lacks the capacity to consent. In Scotland parents cannot authorise treatment a
competent young person has refused. In England, Wales and Northern Ireland, the law
on parents overriding young people’s competent refusal is complex. You should seek
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legal advice if you think treatment is in the best interests of a competent young person
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who refuses.
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Note that the ability to consent changes if you are under 13. By law children under 13
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are considered unable to consent.
4. A 15 year old girl attends the emergency department with mild vaginal bleeding. A
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pregnancy test is positive. She does not want her parents to know about her pregnancy
and she refuses to disclose any information regarding her sexual partner to the
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healthcare professionals. What is the SINGLE most appropriate management?
A. Assess child's competency to make decisions

B. Inform her parents
D. Inform patient that she is lawfully obliged to provide her partner's name and age
Confidentiality under 16
A young person under 16 has the right to advice and treatment without parental
knowledge and consent provided that she is competent and understands all aspects of
advice and its implications, and cannot be persuaded to tell her parents or to allow you
to tell them
There are only certain circumstances in which you may disclose information that a
young person does not agree to disclose. These are:
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- When there is an overriding public interest in the disclosure
- When you judge that the disclosure is in the best interests of the young person
who does not have the maturity or understanding to make a decision about
disclosure
- When disclosure is required by law
Note that this only applies to children 13 and older. Sexual activity with a child under 13
is a criminal offence and should always result in a child protection referral. You should
usually share information about sexual activity involving children under 13, who are
considered in law to be unable to consent
5. A 34 year old woman requests for sterilization. Her last born child has cerebral palsy.
Her husband strongly objects to the procedure. What is the SINGLE most appropriate
action?
A. Provide advice for other modes of contraception

B. Proceed with patient wishes and carry out sterilization
C. Seek judicial review instructions
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D. Referral to social services
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E. No action taken
In this case stem, there is no indication that the patient’s mental capacity is impaired.
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Under GMC consent guidelines, “no one else can make a decision on behalf of an adult
who has capacity”. In addition, it is up to the patient’s choice whether to involve their
family members or carer in their decision making process. Therefore, you would
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proceed with the patient’s wishes assuming that you have thoroughly explained the
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procedure, its outcomes and risks and the patient has been fully informed to her full
satisfaction.
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6. A 13 year old girl presents to the clinic requesting morning pills. She says the condom
she used with her 13 year old boyfriend split into two while having intercourse. What is
the SINGLE most appropriate action?
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A. Inform the police and then give patient contraception

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B. Inform patient’s General Practitioner

C. Inform patient’s mother and the police immediately
D. Give contraception
E. Refer patient to another doctor to handle the case
In this case both the girl and her boyfriend are the same age. Under the GMC, there is
no need to inform the police about their sexual activity as they are the same age. If the
boyfriend was much older, and thereby have a greater disparity in age to the girl, then
informing the police and/or social services would be considered. In this case, you are
permitted to provide contraception to the girl without parental knowledge or consent
as it is most likely in her best interests to do so according to the GMC.
7. A healthy 19 year old female, gestational age of 27 weeks, presents to Obstetrics and
Gynecology clinic requesting a termination. She says her boyfriend has just left her and
that she would not want the baby to remind her of him. The boyfriend, who is currently
in jail, has reportedly been assaulting her during their stormy 2 year relationship. What
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A. Terminate fetus via conservative management
B. Terminate fetus via dilation and curettage
C. Inform police and terminate fetus
D. Refusal of termination
E. Refusal of termination and inform police
Under UK law, the Abortion Act 1967 (amended in 1990) states that termination of
pregnancy is legal up to 24 weeks of gestation. Termination over 24 weeks can only be
done under special circumstances (i.e. where the continuation of pregnancy would
jeopardize the well-being of the mother and/or the birth of the child would result in
his/her being seriously handicapped). In this case, the patient is healthy and there is no
indication that her current pregnancy is jeopardizing her life nor is the fetus having any
serious abnormalities. As such, termination of pregnancy needs to be refused.
8. A 30 year old female is brought into the Emergency Department by her husband
drifting in and out of consciousness following a road traffic accident. She is in shock and
requires immediate blood transfusion. Her husband objects saying they are devout
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Jehovah’s Witnesses and are against blood transfusion. Her condition is deteriorating.
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A. Do not transfuse blood because there is no consent

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B. Transfuse blood without consent
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E. Consult social services
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In this emergency situation, there are a few reasons why a doctor should be transfusing
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blood without consent. Firstly, the patient is not conscious enough to make an
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informed decision pertaining to blood transfusion. Her husband in this case is not
permitted to make that decision for her as there is no indication in the case stem that
there is an advance directive allowing her husband to do so. Under normal
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circumstances, most Jehovah’s Witnesses would carry a blood refusal card which states
that they would refuse blood products under emergency situations. In this case, there is
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no mention of a blood refusal card. Therefore, you would treat this patient just like any
other unconscious patient that has entered the Emergency Department until she is able
to have capacity to make an informed decision.
9. A 31 year old Jehovah’s Witness was in a car accident and brought into the emergency
department. He has lost a massive amount of blood. He is given IV fluids. He is in critical
condition and blood products are needed but he refuses any form of blood products
due to his religious beliefs. What is the SINGLE most appropriate next step?
A. Transfuse blood against his will

B. Respect his decision and do not transfuse blood
C. Contact the police
Jehovah's Witnesses and Blood transfusion
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You must respect a competent patient’s decision to refuse an investigation or
treatment, even if you think their decision is wrong or irrational. You may advise the
patient of your clinical opinion, but you must not put pressure on them to accept your
advice. You must be careful that your words and actions do not imply judgement of the
patient or their beliefs and values.
Many Jehovah's Witnesses have strong objections to the use of blood and blood
products, and may refuse them even if they may die as a result. Hospital liaison
committees established by the Watch Tower Society (the governing body of Jehovah's
Witnesses) can advise on current Society policy. They also keep details of hospitals and
doctors who are experienced in ‘bloodless’ medical procedures.
10. A 17 year old boy is brought into the Emergency Department unconscious following a
road traffic accident. What is the SINGLE most appropriate action?
A. Resuscitate without consent

B. Wait for relatives to consent before beginning resuscitation
y
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E. No action taken
As per GMC’s ethics guidelines, this case is an emergency. Therefore, we can begin
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immediately treating the patient without their consent as it is necessary to save their
life. Once they have regained capacity within your care, you can inform them of what
you have done and ask for them to make ongoing treatment decisions.
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11. A 16 year old boy has lower abdominal pain. A clinical suspicion of acute appendicitis
was made and the surgical team has decided to go ahead with an appendectomy. The
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patient is happy to go ahead with the surgery but his parents refuse to sign the consent
ua
form as they are opposed to any form of surgery. The procedure has been explained
clearly to the patient and his parents and they understand the risk of not going for
surgery. What is the SINGLE most appropriate action?
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A. Cancel the surgery once proper documentation by parents are filled

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B. Obtain a consent from patient and proceed with surgery

C. Contact the local safeguarding officer
At 16 it is legally presumed that young people have the ability to make decisions about
their own care. Note that even children under 16 may have the capacity to consent
provided they have the maturity to do so. In this case, the parents are refusing
treatment that is clearly in the best interests of a child. It is clear that the child has the
maturity and ability to understand what is involved and he is of good age to give
consent.
Capacity to consent
408
carefully
who refuses.
y
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12. A 30 year old man is found to be HIV positive and is against condom use. After
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discussing with him, he is still refusing to accept the need to tell his wife of his
diagnosis. What is the SINGLE most appropriate action
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C. Inform health authorities
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E. Notify wife via partner notification programme
In the UK, there are partner notification services for those diagnosed with sexually
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transmitted infections (STI) and/or HIV. This service’s main aim is to inform
unsuspecting partners of those infected of the possibility of being infected with STI/HIV
Ev
and to seek medical care. Under normal circumstances, the patient affected is offered a
choice: to inform their partner(s) themselves or to provide details of those partner(s) to
the healthcare worker to contact them anonymously. Usually, it is a mix of the above
where the patient is given a time frame to inform their partner(s) and if not done by
that set date, the healthcare worker will be the one to inform. In this case, the man
refuses to tell his wife the diagnosis. As this is a communicable disease, the wife needs
to be informed as she will need to be tested. Therefore, you would contact her via
protocols of the partner notification programme.
13. You are treating a general surgeon for Hepatitis B. You ask him to inform the NHS trust
where he is currently working and he refuses. What is the SINGLE most appropriate
action?
A. Respect the patient’s confidentiality and do not inform the health authorities
B. Inform the health minister
C. Inform the relevant health authorities
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E. Try to convince patient and ask for consent again
Under GMC guidelines, it is the duty of a healthcare worker to report whether he or she
has a serious communicable disease. If they do not, then you as their doctor must
report it to the relevant health authorities as they can put the patients they are treating
at risk.
14. A 37 year old female who was recently diagnosed with multiple sclerosis took 100
tricyclic antidepressant tablets. She is now refusing all treatment. What is the SINGLE
A. Immediate arterial-blood gas analysis

B. Observe
C. Activated charcoal
D. IV sodium bicarbonate
E. Refer to psychiatrist to evaluate capacity
The GMC framework’s guidance on capacity seeks to preserve patient autonomy above
all else. Some important points include:
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- You must assess a patient’s capacity to make a particular decision at the time it
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needs to be made. You must not assume that because a patient lacks capacity
to make a decision on a particular occasion, they lack capacity to make any
decisions at all, or will not be able to make similar decisions in the future.
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- If your assessment leaves you in doubt about the patient’s capacity to make a
decision, you should seek advice from:
o nursing staff or others involved in the patient’s care, or those close to
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the patient, who may be aware of the patient’s usual ability to make
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decisions and their particular communication needs

o colleagues with relevant specialist experience, such as psychiatrists,
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neurologists, or speech and language therapists.

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- If you are still unsure about the patient’s capacity to make a decision, you must
seek legal advice with a view to asking a court to determine capacity.
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15. A 45 year old man is found to be HIV positive in a Genitourinary Medicine clinic. He is
not sexually active. He does not want his GP informed about his diagnosis as he has
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witnessed a friend who suffered discrimination following accidental disclosure of his

HIV status. What is the SINGLE most appropriate action?
A. Accept patient’s decision not to inform GP

B. Explain the legal and ethical duties of confidentiality to the patient and inform his GP
C. Explain to the patient that it is the patient’s duty by law to inform his GP
D. Inform his GP when his viral load is below 500 copies/mL
E. Inform his GP only when anti-viral medications are started
The patient’s decision must be respected unless there is an overriding public interest in
disclosing the information without his consent. A HIV positive patient may not need to
reveal his diagnosis to the GP. He may obtain his anti-viral treatments from the GUM
clinic.
One may strongly encourage the patient to consent, explaining the clear benefits of
informing his GP of his status, and seek to reassure him about his GP’s legal and ethical
410
duty of confidentiality but you are not able to inform the GP unless the patient gives
you permission to.
16. A 15 year old girl comes in with her 15 year old boyfriend requesting for oral
contraceptive pills (OCP). They are sexually active. They could not be persuaded to
inform their patients about their sexual relationship or that contraceptive advice was
being sought. What is the SINGLE most appropriate action?
A. Breach confidentiality and inform parents

C. Contact the police and local safeguarding officer
This question is testing your knowledge on the Fraser Criteria.
For the under-16s
y
GMC guidance states that the duty of confidentiality is the same for children and young
op
people as it is for adults.
Confidentiality may only be breached in order to protect the adolescent or others from
C
serious harm - for example, where issues such as child abuse and child protection are
involved, or where required by law. In this situation the adolescent should be informed
of the disclosure and the reasons for it.
n
io
Guidance also states that 'any competent young person, regardless of age, can
independently seek medical advice and give valid consent to treatment'. Note that the
t
ability to consent changes if you are under 13. By law children under 13 are considered
ua
unable to consent.
Contraceptive advice or treatment can be provided to a competent young person aged

al
under 16 years, without parental consent or knowledge, using the Fraser criteria. A
health professional needs to be satisfied that:
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- The young person could understand the advice and have sufficient maturity to
understand what was involved in terms of the moral, social and emotional
implications.
- They could neither persuade the young person to inform the parents, nor to
allow the health professional to inform them, that contraceptive advice was
being sought.
- The young person would be very likely to begin or to continue having sexual
intercourse with or without contraceptive treatment.
- Without contraceptive advice or treatment, the young person's physical or
mental health or both would be likely to suffer.
- The young person's best interests required the health professional to give
contraceptive advice or treatment or both without parental consent.
17. An armed robber is injured during an exchange of gunfire with the police and comes to
the Emergency Department. He requests your silence. What is the SINGLE most
appropriate action?
411
A. Inform the police without revealing patient’s personal information
C. Consult with seniors of the NHS trust
E. Inform the health minister
Under GMC guidelines, any person arriving into the hospital with a gunshot wound
needs to be reported to the police. The reasoning behind this is to ensure the safety of
the patient, the medical staff, the patients and visitors within the hospital, as well as to
prevent another attack. It is important to note that the incident of the gunshot wound
is to be reported initially and not necessarily the personal details of the armed robber.
Personal information, such as the patient’s name and address, should not usually be
disclosed in the initial contact with the police. The police will respond even if the
patient’s identity is not disclosed. The police need to be informed quickly in order to
respond to the risk to patients, staff and the public. They also need statistical
information about the number of gunshot and knife injuries, and when and where they
occur, to inform their own and their crime reduction partners’ operational and strategic
y
priorities.
18.
op
A 34 year old man with multiple sclerosis has taken an overdose of more than 50
tablets of paracetamol with the intent to end his life. He has been brought to the
C
emergency department by his wife. He is refusing all interventions. What is the SINGLE
n
A. Assess his glasgow coma scale
io
B. Evaluate his mental capacity to refuse treatment

C. Establish if patient has any previous mental illness
t
D. Attain consent from his wife to give treatment

ua
E. Admit but do not provide any intervention
This patient has multiple sclerosis. The first thing to do if he is refusing treatment is to
al
evaluate his mental capacity to do so.

Ev
19. A 15 year old girl is brought to the hospital by her parents with mild lower abdominal
pain. An ultrasound scan reveals a large ovarian cyst. The decision for a laparoscopic
ovarian cystectomy has been made but she refuses treatment. She understands the
consequences of not having the surgery and is deemed competent. Her parents ask if
they can override her decision and sign the consent form on her behalf. What is the
A. Seek legal advice

B. Obtain a consent from parents and carry out the surgery
C. Obtain a consent from two consultant gynaecologist and carry out the surgery
D. Contact social services
E. Cancel the surgery and respect patient’s wishes
Remember to note these few points in the stem that would help you answer your
question
1. The case above is not an emergency and you have time to seek legal advice
412
2. She is deemed competent even though she is below 16 years old
Capacity to consent

carefully
y
op
C
who refuses.
n
io

t
20. An 85 year old woman with Alzheimer’s disease wants to change her will. Her
ua
granddaughter is refusing as she says that her grandmother does not know what she is
saying since she is suffering from dementia. What is the SINGLE best action for you to
take?
al
A. Allow her to change her will

Ev
B. Refuse her as she has no capacity

C. Refer for assessment of capacity
D. Her granddaughter is her caretaker and therefore can consent for her
E. Allow her to change her will after 3 months
Referring the patient for assessment of her capacity is the best possible choice out of
the given choices. A safe answer for PLAB 1 exam ethics questions is always discussing
and exploring patient concerns.
Allowing her to change her will would be the correct choice if she wasn’t diagnosed
with Alzheimer’s disease. Patient autonomy is the founding principal of U.K medical
practice and we should always endeavor to maintain patient autonomy at all times.
Refusing her to change her will is the incorrect choice because without an evaluation of
whether she has capacity or not, this would be a violation of the U.K code of ethics.
413
There was no mention in the stem that her granddaughter is indeed her caretaker, and
even if her granddaughter was her caretaker, important decisions that impact on the
patient cannot be undertaken by a caretaker without a power of attorney document
(which also was not mentioned in the stem).
The Mental Capacity Act of 2005 seeks to empower and protect people who may not
be able to make some decisions for themselves. It also enables people to plan ahead in
case they are unable to make important decisions for themselves in the future. The law
works on the principle that everyone is assumed to have capacity to make decisions for
themselves if they are given enough information, support and time. It protects their
right to make their own decisions and to be involved in any decisions that affect them.
A person's capacity must be judged according to the specific decision that need to be
made, and not solely because of their illness, disability, age, appearance or behaviour.
An important principle in the law is that just because someone is making what seems to
be an unwise decision (even if they have an illness or disability) this does not
necessarily mean they lack capacity.
21. A 49 year old HIV positive man has been responding well to Highly Active Antiretroviral
y
Therapy (HAART) which he obtains from the Genitourinary Medicine clinic. He is due for
op
an elective orthopaedic surgery. He has not disclosed his HIV status to the orthopaedic
surgeon and wishes that his HIV status remains disclosed. What is the SINGLE most
appropriate action in regards to his HIV status?
C
A. Accept patient’s decision not to inform the orthopaedic surgeon about his HIV
status
n
B. Inform the orthopaedic surgeon about his HIV status
io
C. Inform the orthopaedic surgeon that a patient with a blood blood-borne virus is
booked in for surgery on the day, without disclosing patient’s identity
t
D. Inform his orthopaedic surgeon if his viral load is below 500 copies/mL
ua
E. Explain to the patient that it is the patient’s duty by law to inform his surgeon
This is a difficult question and a very debatable one but one should know about
al
confidentiality for PLAB. Majority of physicians would either answer A or E. However,

after much debate and much research, we believe the answer would still remain as A.
Ev
The patient’s decision must be respected unless it would put the health care workers at
risk of infection. For example, in the event of a needlestick or similar injury to a
healthcare worker, disclosure of his status is needed.
Contacting the surgeon to say a patient with a blood-borne virus is booked in on the
day for which patient’s operation is planned would not necessarily be a breach of
confidence, but it would not be a sensible course of action. It might lead to disclosure
of the patient’s status. If for example, he was the only person booked in for surgery on
that day, or if he changed the date of his operation.
22. A mother brings her 12 year old son to you requesting surgery for his sticking out ears.
She says that he is constantly teased in school because of his ears and wants him to
undergo cosmetic surgery for it. The boy says he does not want surgery. What is the
A. Refer to private practice
414
B. Schedule surgery as his consent is not needed
C. Contact social services and explore their concerns
D. Explain to mother that surgery is not possible without her son’s consent
E. Discuss the situation with your colleagues
The topic of consent is extremely important for the PLAB exam as well as practice in the
NHS. In terms of U.K law, a person aged 16 and upward is generally considered to have
capacity and is able to consent for their own medical procedures. A child is also able to
consent provided they are competent in understanding the situation. This is called
Gillick competence. In the above situation, the best choice is to contact social services
and assess the boy’s capacity to make his own decision. Surgery is a major procedure
and this child should not be subject to undergo a potentially life-threatening procedure
that he doesn’t need just because his caregiver wishes him to.
Scheduling the surgery as his consent is not needed would be the correct answer IF this
was an emergency procedure that the child needed in order to survive. In those
conditions, parental consent would overrule the child’s wishes as the procedure would
be in the best interests of the child.
y
op
Not performing the surgery since the boy has not given consent cannot be chosen
blindly without exploring whether the child has capacity or not. A safe answer for PLAB
exam ethics questions is always discussing and exploring patient concerns.
C
23. You are a junior doctor working in the NHS. You suspect one of your colleagues to be
under the influence of recreational drugs. What is the SINGLE most appropriate action
to be taken?
n
io
A. Inform police
B. Confront your colleague directly
t
C. Inform the senior consultant

ua
D. Seek for more evidence first

E. Report to the trust manager
al
This is the best choice out of the given choices. In PLAB 1 ethics questions, it is always
safe to discuss and explore concerns.
Ev
The GMC’s ethical guidance outlines state that:
- You should understand the difference between a personal grievance, that is a

complaint about your own employment situation, and a concern about a risk,
malpractice or wrongdoing that affects others. This is particularly important if
patients or members of the public are at risk of harm
- You should be aware that poorly performing colleagues may have health
problems and respond constructively where this is the case.
- You should encourage such colleagues to seek and follow professional advice
and offer them appropriate help and support.
- You must not unfairly discriminate against colleagues because of an issue
related to their health or a disability.
- You should, as far as possible, support colleagues who are experiencing
performance problems. But, in all cases, you should remember your duty to
raise concerns where you believe a colleague may not be fit to practise or may
otherwise pose a risk of serious harm to patients.
415
24. You are the SHO in psychiatry. Your consultant is having a sexual relationship with a
widowed patient that is currently being treated for depression. The lady’s condition is
much improved and is awaiting discharge next week. What is the SINGLE most
appropriate action?
A. Inform health minister as situation is complicated

B. Inform police and then give her contraception
C. Report him to trust manager as per hospital protocol
D. Inform the patient’s family members
E. Do not take action
As per GMC ethical guidance, as a medical professional, one must not “pursue a sexual
or improper emotional relationship with a patient or someone close to them”. In this
instance, you must report the incident to the appropriate seniors in your hospital as per
hospital protocol to investigate the allegation. Police would only be involved if you
suspect that the consultant has committed sexual assault or other criminal activity
towards the patient.
y
25. A 55 year old woman has recently been diagnosed with multiple sclerosis and has been
op
started on oral steroids. She is brought to the hospital after having ingested more than
40 tablets of paracetamol 3 hours ago. She is refusing all medical treatment as she
wants to end her life. What is the SINGLE most appropriate action?
C
A. Admit and observe but do not provide any intervention
B. Refer to psychiatrist to assess patients ability to refuse treatment
n
C. Gastric lavage
io
D. Activated charcoal
E. Refer to social worker
t
ua
This patient has multiple sclerosis. The first thing to do if he is refusing treatment is to
evaluate her mental capacity to do so.
al
26. A man with dementia has an ulcerative lesion on his forehead. He wants it removed so
‘it can help improve his memory’. His wife says he is not fit to give consent. What is the
Ev
A. Remove the lesion after obtaining written consent from the patient
B. Document finding but do not remove lesion
C. Refer to GP for further assessment of lesion
D. Refer to psychiatrist to assess the mental capacity to give consent
E. Review in 6 weeks
This question is very straightforward. He is in no position to give consent and so a

psychiatrist should review his mental capacity.
27. A 15 year old girl had unprotected sex with her 38 year old boyfriend and is now
requesting for the morning pill. What is the SINGLE most appropriate action?
A. Inform the police and give contraception

B. Do not inform police and give contraception
C. Inform parents and give contraception with their consent
416
D. Do not inform parents and give contraception
E. Consult with social services
The age discrepancy between the girl and her boyfriend, under GMC guidelines, is seen
as the boyfriend being able to be of greater influence and power over the girl. As such,
this would be considered a case of sexual abuse and needs to be reported to the police.
Consultation from social services would also be considered; however, the priority here
is to inform the police first. You would also provide contraception as requested by the
girl as she is of mental capacity to make an informed decision over treatment and
under GMC guidelines, you would not be obligated to inform or gain consent from her
parents for doing so. However, you would advise the girl that it would be in her best
interests to discuss with her parents.
28. A 33 year old pregnant woman is in labour at 40 weeks gestation. The emergency bell
was rung by the midwife in the labour room as the cardiotocograph shows fetal
bradycardia for the past 5 minutes that has not recovered. A quick decision to go for an
emergency C-section is made however she is unable to consent as she speaks only
Tigrinya and cannot understand English. Her partner is not in the hospital with her.
y
Attempts have been made to contact the language line but at present they are unable
op
to obtain a Tigrinya translator. What is the SINGLE most appropriate action?
A. Wait until a translator becomes available before performing the C-section

C
B. Proceed to perform a C-section
C. Seek legal advice
D. Contact next of kin by telephone
n
E. Do not proceed with C-section until patient can fully understand and signs consent
io
form written in Tigrinya language

t
GMC is clear that doctors must have consent before carrying out any treatment.
ua
However, in an acute emergency like in this stem, the importance of saving the fetus’
life outweighs this. It would be considered wrong not to act on a fetal bradycardia on
the basis that the mother is unable to understand the language. Waiting for a translator
al
may put the fetus’ life at risk. Fetal bradycardia is an acute emergency and obstetricians
are trained to get baby out by C-section within 60 seconds of skin incision. No time
Ev
should be wasted trying to seek legal advice or contacting the next of kin.
Furthermore, the mother has not refused a C-section, she is merely unable to
understand the language. In the absence of a clear expression of her wishes, you may
act and provide appropriate treatment and prevent serious detriment to the baby.
29. A 32 year old woman is brought in unconscious by the ambulance after receiving the
news that she has terminal breast cancer earlier in the day. She is suspected of having
taken an overdose of benzodiazepines. She was found by her boyfriend with an empty
bottle of tablets beside her with a note declaring that she wishes to end her life. The
note specifically says that she does not want any treatment. What is the SINGLE most
appropriate action?
A. Respect her wishes and do not treat

B. Wait for consciousness to obtain consent for treatment
C. Obtain verbal consent from her boyfriend regarding the decision to treat
D. Treat her with attempts to save her live despite not having a consent
417
E. Contact her parents to obtain consent to treat
The question here is how binding is the note that states she is refusing treatment. To be
valid and legally binding under the Mental Capacity Act 2005 (England and Wales), an
advance decision refusing treatment must state exactly what treatment is being
refused and in what circumstances. A suicide note in most situations is NOT a valid
advance decision.
Decisions refusing life-sustaining treatment must be in writing and include a clear and
specific statement that it applies even if the patient’s life is at risk. It is unlikely that the
note fulfills all these criteria. The document must also be signed and witnessed which in
this stem is not.
30. A 33 year old man is brought into the Emergency Department having been involved in a
fight outside a local pub. During the fight, he was hit on the head by a metal chair. On
examination, there is a open laceration on his head and he has sustained cuts and
bruises on his arms and legs. He also smells of alcohol. He was initially uncooperative
before losing consciousness. What is the SINGLE most appropriate action?
y
op
A. Proceed to investigate and treat the patient without his consent
B. Wait till he regains consciousness to obtain consent
C. Investigate only without treating the patient
C
D. Treat only if his observations are unstable
n
GMC is clear that doctors must have consent before carrying out any examination,
io
investigation, or providing treatment. However, it is likely that the patient initially

refusal was due to his condition rather than the fact that he was refusing consent for
t
investigations and treatment. As the patient has sustained a head injury it is not
ua
practical to wait until he is sober before obtaining a consent as his life could be at risk.
Neither is it appropriate to seek legal advice in an acute situation like this. Remember,
he could be acutely deteriorating and early detection is vital. In the absence of a clear
al
expression of his wishes, you may act and provide appropriate treatment and prevent a
serious deterioration of his condition.
Ev
31. A 33 year old man is extremely thankful for your service and for assisting in his
laparoscopic appendicectomy. He offers you a valuable clock as a gift. What is the
A. Accept it with gratitude

B. Accept it with a condition that it will be sold and money used on improvements of
services in the ward
C. Ask him to donate it to the ward
D. Refuse the gift and inform him that doctors are unable to accept valuable gifts
from patients
E. Accept it and donate it to charity
It may be entirely reasonable to accept a small token of appreciation from a patient. In

fact, refusing it may cause embarrassment that could unnecessarily harm the
relationship between a doctor and a patient. But gifts of money or items of high
financial value raise contractual and ethical issues that doctors need to consider.
418
The GMC states that doctors must not accept gifts from patients, or colleagues, if it is
an inducement, gift or hospitality that may affect or be seen to affect the way that
person is treated. Gifts with considerable value may alter the dynamic between the
doctor and patient such that the patient may receive or expect to receive preferential
treatment.
What is considered valuable? A gift that is valued £100 or more.
The Social Care Bill (2000) legislated that gifts over £100 in value should be declared.
Explaining to the patient that receiving such an expensive gift would not be in keeping
with the guidance set by the General Medical Council,
The first action should always be refusing the gift. If this fails and the patient insist on
giving, then you can suggest other options like giving it to charity or to the ward fund.
32. A 48 year old man recently had a transient ischaemic attack. What advice on driving
y
would you give him?
op
A. Continue to drive only when accompanied by another person
B. Continue to drive without any restrictions
C
C. Drive on the familiar roads and avoid busy roads
D. Stop driving completely
E. Do not drive for at least one month
n
io
You must stop driving for at least 1 month after a transient ischaemic attack (TIA). You
can be fined up to £1,000 if you do not tell DVLA about a medical condition that affects
t
your driving.
ua
33. A 14 year old girl presents to the clinic requesting oral contraceptives. She is sexually
active with her 15 year old partner. What is the SINGLE most appropriate action?
al

B. Refer to social services
Ev
C. Consult another doctor as you need a second opinion to prescribe oral

contraceptives
D. Prescribe oral contraceptive pills and advise her to involve her parents in her
decision
E. Assess both her mental capacity and her partner's mental capacity
In this case both the girl and her boyfriend are roughly the same age. Under the GMC,
there is no need to inform the police about their sexual activity as they are of similar
age. If the boyfriend was much older, and thereby have a greater disparity in age to the
girl, then informing the police and/or social services would be considered. In this case,
you are permitted to provide contraception to the girl without parental knowledge or
consent as it is most likely in her best interests to do so according to the GMC.
Encouraging her to inform her parents is another point that a good practitioner would
do.
419
34. You are a junior doctor eating with a few friends in a restaurant. On leaving the
restaurant, you notice an empty table with patient's medical notes. The table has been
unattended for a while. What is the SINGLE most appropriate action?
A. Request that the restaurant manager call the hospital

B. Look through the medical notes and attempt to phone the patient
C. Look through the medical notes for a general practitioners contact and inform the
practice
D. Take the medical notes to the hospital
E. Ignore the incident and walk out of the restaurant
Informing the GP practice would be the most practical option. The GP surgery would
have all the records of the patient and they would be able to advise you what you need
to do with the notes. It may be possible that the GP surgery would ask you to bring the
notes into the practice and they will keep it securely or scan a copy to the hospital if
needed.
The second most appropriate option is to bring the notes to the hospital. This is
y
inconvenient as great efforts and time would be needed to find the department that
op
this patient attended.
C
n
t io
ua
al
Ev
420
GIT
y
op
C
Questions
n
io
&
t
ua
Answers
al
Ev
421
Gastroenterology Questions
1. A 23 year old female presents with an 8 week history of bloody diarrhoea. She says her
bowels have not been right for the past few months and she frequently has to run to
the toilet. A diagnosis of ulcerative colitis is made. What is the SINGLE most likely sign
to be seen on a barium enema?
A. Loss of haustral markings

B. Kantor's string sign
C. Cobblestone appearance
D. Rose thorn ulcers
E. Fistula
2. A 42 year old man with type 2 diabetes presents with fatigue and shortness of breath.
He is noted to have a bronze tinge to his skin. Abdominal examination reveals
hepatomegaly. His blood test show a high ferritin level. A diagnosis has been made but
he is refusing all treatment. Which organ is the most likely to be at risk of developing
cancer?
y
op
A. Testes
B. Adrenal gland
C. Liver
D. Pancreas
C
E. Heart
n
3. A 28 year old female presents with 1 week history of jaundice, fever and malaise. She
io
was diagnosed with hypothyroidism for which she is receiving levothyroxine. Her blood
tests show:
t
ua
Serum bilirubin 40 μmol/L

Alanine transferase (ALT) 120 iu/L
Aspartate transaminase (AST) 90 iu/L
al
Alkaline phosphatase (ALP) 200 iu/L

Prothrombin time (PT) 25 sec
Ev
A. Acute on chronic liver failure

B. Hyperacute liver failure
C. Autoimmune hepatitis
D. Acute liver failure
E. Drug induced hepatitis
4. A 35 year old female presents with secondary amenorrhoea. Her blood test show the
following:

422
B. Autoimmune hepatitis
C. Primary biliary cirrhosis
E. Gilbert’s syndrome
5. A 42 year old obese female has severe upper abdominal pain. She vomited several
times today. She has a temperature of 37.8°C. She is married and has 5 living children.
She has no previous surgeries. Her blood count shows:
Haemoglobin 123 g/L

A. Ectopic pregnancy
y
B. Ovarian torsion
op
C. Hepatitis
D. Endometriosis
E. Cholecystitis
C
6. A 48 year old woman has become increasingly fatigued over the past 10 months.
Vitiligo of the hand was noted. Her blood tests show:
n
io
Haemoglobin 88 g/L
t

ua
Mean cell volume 130 fL

al
A. Folate Deficiency
Ev
B. Thalassaemia minor
C. Pernicious anaemia
D. Anaemia of chronic disease
E. Sickle cell anaemia
7. A 60 year old man presents with a lump in the left supraclavicular region. He complains
that he does not eat as much anymore because he does not have the appetite. He has
also lost 10kg in the last 3 months. What is the SINGLE most probable diagnosis?
A. Gastric cancer
B. Lymphoma
C. Pancoast tumor
D. Thyroid cancer
E. Laryngeal cancer
8. A 50 year old man has severe pain on defecation. On examination, a tender, reddish
blue swelling is seen near the anal verge. What is the SINGLE most likely diagnosis?
423
A. Perianal abscess
B. Perianal haematoma
C. Pilonidal cyst
D. Haemorrhoids
E. Anal fistula
9. A 49 year old female presents with right hypochondrial pain. An ultrasound shows a
large gallstone. Her BP is 120/85 mmHg; respiratory rate 18/min; Heart rate 90 bpm;
Temperature 37.6°C; WBC 15 x 109/L. What is the SINGLE most appropriate
management?
A. Laparoscopic cholecystectomy
B. Reassure
C. Low fat diet
D. Ursodeoxycholic acid
E. Emergency laparotomy
y
10. 42 year old obese woman presents to the emergency department with a 12 hour
op
history of severe epigastric pain. The pain started suddenly and and radiates to her
back. It is relieved when sitting forward. She is nauseous and has vomited twice in since
the pains started. She drinks one and a half glasses of wine per day. She has no
C
significant past medical history. She has a pulse rate of 110 beats/minute and is tender
in the epigastric region. What is the SINGLE most appropriate investigation?
n
A. Chest X-ray
io
B. Abdominal ultrasound
C. Serum lipase
t
D. Abdominal X-ray
ua
E. Liver function test
11. A 52 year old alcoholic man complains of epigastric and back pain associated with loose
al
pale, offensive stools. He feels nauseous and has lost weight over the last couple of
months. What is the SINGLE most likely diagnosis?
Ev
A. Acute pancreatitis
B. Chronic pancreatitis
C. Gastro-oesophageal reflux disease
D. Oesophagitis
E. Carcinoma of the head of pancreas
12. A 41 year old man has had a liver biopsy as part of investigations for abnormal liver
function test. The pathology report states: special stains demonstrate the presence of a
very large amount of iron pigment within hepatocytes. What SINGLE condition is
identified by the pathology report?
A. Alpha-1-antitrypsin deficiency
B. Haemangioma
C. Haemochromatosis
D. Haemosiderosis
E. Wilson’s disease
424
13. A 25 year old woman complains of diarrhoea, and abdominal cramps for the past 8
months. She says that her diarrhoea has recently become bloody. A biopsy was
performed and the colonic mucosa shows crypt abscesses. What is the SINGLE most
likely diagnosis?
A. Ulcerative colitis
B. Crohn's disease
C. Infective diarrhoea
D. Colorectal cancer
14. A 28 year old man has intermittent diarrhoea, fatigue and weight loss over the last 6
months. He has excluded gluten from his diet in the last 2 months and his symptoms
have resolved. He wants to be tested to confirm the diagnosis of coeliac disease. What
is the SINGLE most appropriate next step in action?
A. Jejunal biopsy
y
B. Reintroduce gluten prior to testing
op
C. Sweat test
D. Tissue transglutaminase antibodies
E. Stool sample
C
15. A 45 year old man had his head of pancreas removed due to malignancy. He now has a
rigid abdomen which is tender, a temperature of 37.5°C, a blood pressure of 90/55
n
mmHg and pulse rate of 125 bpm. His past medical history includes peptic ulcer
io
disease. What is the SINGLE most appropriate next action?

t
A. CT abdomen
ua
B. X-ray abdomen
C. MRI abdomen
D. US abdomen
al
E. Endoscopy
Ev
16. A 56 year old woman has had severe abdominal pain for 24 hours radiating to her back
and is accompanied by nausea and vomiting. She denies any diarrhoea or fever. She
appears to be tachycardic and in shock. She has a history of gallstones. What is the
SINGLE most likely investigations to confirm the diagnosis?
A. Ultrasound abdomen
B. Abdominal X-ray
C. Serum lipase
D. Urea and electrolytes
17. A 54 year old man presents with a worsening history of intermittent dysphagia over a
period of 3 months. He has not experienced any weight loss and complains of
sometimes regurgitating food, after which he says he experiences a feeling of great
relief. What is the SINGLE most likely diagnosis?
A. Achalasia
425
B. Oesophageal carcinoma
C. Scleroderma
D. Plummer-Vinson syndrome
E. Barrett's Oesophagus
18. A 26 year old young man presents with history of passing loose stools for the past 2
months. He says his stools contain blood and mucous and are associated with
abdominal pain. He had a colonoscopy after which he was started on treatment. What
is the SINGLE most appropriate treatment for his condition?
A. Mesalazine
B. Corticosteroids
C. Mebeverine
D. Cyclosporine
E. Peppermint oil
19. A 58 year old man has been having frequent episodes of secretory diarrhea for the past
2 weeks. His diarrhoea is extremely watery with large amounts of mucus. A diagnosis of
y
villous adenoma was made after performing an endoscopy. What is the SINGLE most
op
likely electrolyte abnormality?
A. Hyperkalemia
C
B. Hypernatremia
C. Hyponatremia
D. Hypokalemia
n
E. Hypercalcemia
io
20. A 55 year old man develops fatigue and palpitations. He had a gastrectomy a years ago.
t
Recent blood test were ordered which shows:

ua
Haemoglobin 98 g/L
Mean cell volume (MCV) 110 fL
al
On neurological examination, loss of proprioception and vibration sense were noted.

Ev
A. Iron deficiency
B. Folate deficiency
C. Vitamin B12 deficiency
D. Haemolytic anemia
E. Sickle cell disease
21. A 36 year old lady has diarrhoea for the last 2 months. She has lost 8 kg in that time
period. A colonoscopy was performed which showed fistulas. Perianal fistulas are also
noticed. What is the SINGLE most likely diagnosis?
A. Crohn's disease
B. Irritable bowel syndrome
C. Coeliac disease
D. Diverticulitis
E. Ulcerative colitis
426
22. A 35 year old man presents with history of dyspepsia. Serum antibodies for H.Pylori are
negative. No improvement is seen after 1 month of treatment. What is the SINGLE most
appropriate next step?
A. Urea breath test

B. Repeat serum antibodies
C. CT
D. MRI
E. Endoscopy
23. A 38 year old man has just returned from Kenya a few days ago. Since his return, he has
developed watery diarrhoea with crampy abdominal pain. What is the SINGLE most
likely causative organism?
A. Giardia
B. Entamoeba
C. Shigella
y
D. Salmonella
op
E. Escherichia coli
24. A 25 year old woman with longstanding constipation has severe anorectal pain on
C
defecation. She notices streaks of blood that covers her stool. Rectal examination is
impossible to perform as she is in such great pain. What is the SINGLE most likely
diagnosis?
n
io
A. Anal haematoma
B. Anal fissure
t
C. Anal abscess
ua
D. Proctalgia fugax
E. Haemorrhoids
al
25. A 28 year type 1 diabetic has intermittent diarrhoea and abdominal bloating over the
last 6 months. He also complains of feeling tired all the time. Tissue transglutaminase
Ev
antibodies was found to be positive. What is the SINGLE most appropriate next step in
action?
A. Jejunal biopsy
B. Upper gastrointestinal endoscopy
C. Sweat test
D. Thyroid function test
E. Stool culture
26. A 48 year old female presents with tiredness and painless dysphagia. She complains of a
feeling of something stuck in her throat. A full blood count shows microcytic,
hypochromic anaemia. On examination, glossitis is noted. An oesophageal web is found
at the post cricoid region. What is the SINGLE most likely diagnosis?
A. Coeliac disease
B. Plummer vinson syndrome
C. Pharyngeal carcinoma
427
D. Barrett's oesophagus
E. Oesophageal carcinoma
27. A 69 year old smoker has had increasing dysphagia when eating solid food which has
been on going for the past 3 months. He has notice a drop of 8 kg in weight in the past
few months. What SINGLE investigations is most likely to lead to a diagnosis?
A. Barium swallow
B. Chest X-ray
C. Computed tomography chest
D. Endoscopy and biopsy
E. Videofluoroscopy
28. While performing an appendectomy, a surgeon found a mass in the caecum of a

patient. The mass was removed and sent for analysis. Analysis revealed a transmural
infiltration with lymphocytes and granulomas without necrosis. What is the SINGLE
y
A. Caecal Cancer
op
B. Lymphoma
C. Tuberculosis
D. Crohn’s Disease
C
E. Ulcerative Colitis
29. A 44 year old woman had a total abdominal hysterectomy and bilateral salpingo-
n
oophorectomy 5 days ago. She now has increasing abdominal discomfort and is now
io
bloating. She was encourage to stay well hydrated but she is still unable to pass gas. No
bowel sounds are heard. What is the SINGLE most appropriate next step?
t
ua
A. X-Ray abdomen
B. Exploratory laparoscopy
C. CT abdomen
al
D. Ultrasound abdomen
E. Barium enema
Ev
30. A 32 year old woman complains of brief episodes of severe shooting pain in the rectum
that usually occur at night. Rectal examination and flexible sigmoidoscopy detect no
abnormalities. What is the SINGLE most probable diagnosis?
A. Anal haematoma
B. Anal fissure
C. Rectal carcinoma
D. Proctalgia fugax
E. Piles
31. A 42 year old female presents to her GP following a staging CT for her recently
diagnosed renal cell carcinoma. On the CT scan, gallstones were noticed in the
gallbladder. She has no history of abdominal pain or jaundice and is otherwise well. A
left sided nephrectomy for her renal cell carcinoma has been scheduled. What is the
SINGLE most appropriate course of action?
428
B. ERCP (Endoscopic Retrograde cholangiopancreatography)
C. MRCP (Magnetic resonance cholangiopancreatography)
D. Reassurance
E. Laparoscopic cholecystectomy
32. A 60 year old man presents with weight loss and complains of mild abdominal pain,
bloating and diarrhoea for the past 6 months. A recent blood test shows a haemoglobin
of 7 g/dl. What is the SINGLE most appropriate investigation?
A. Barium enema
B. Colonoscopy
C. Sigmoidoscopy
D. Computed tomographic (CT) colonography
E. Carcinoembryonic Antigen (CEA)
33. A 38 year old man complains of "crushing" chest discomfort for 1 hour that started
when he drank a cold drink. He has no significant medical history. ECG shows sinus
y
rhythm. He is given sublingual nitroglycerin in the emergency room that improves his
op
chest pain almost immediately. He has a pulse of 70 beats/minute, a blood pressure of
130/80 mmHg and a respiratory rate of 18 breaths/minute. Cardiac enzymes came back
negative. What is the SINGLE most likely diagnosis?
C
A. Myocardial Infarction
B. Pericarditis
n
C. Oesophageal spasm
io
D. Pulmonary embolism
E. Pneumothorax
t
ua
34. A 58 year old man presents with a lump in the left supraclavicular fossa. It has been
present for the last 6 months. He also complains of dyspepsia and loss weight which he
accounts for due to his reduced appetite. What is the SINGLE most likely term for the
al
lump?
Ev
A. Virchow’s node
B. Lymphoma
C. Pancoast tumor
D. Thyroglossal cyst
E. Reactive lymph nodes
35. A 12 year old child complains of right iliac fossa pain and diarrhoea. On colonoscopy, a
transmural, cobblestone appearance mucosa is seen near the ileo-caecal junction.
A. Mesalazine
B. Paracetamol
C. Ibuprofen
D. Metronidazole
E. Mercaptopurine
429
36. A 40 year old woman complains of dysphagia when eating solids and drinking liquids.
She sometimes suffers from severe retrosternal chest pain. Barium swallow reveals a
dilated oesophagus which tapers to a fine distal end. What is the SINGLE most
A. Reassurance
B. Antispasmodics
C. Dilatation of the lower oesophageal sphincter
D. Endoscopic diverticulectomy
E. Calcium channel blocker
37. A 55 year old man with no past medical history comes to your office for the evaluation
of "difficulty swallowing" foods. He has had this problem for almost a year, and finds it
difficult for him to swallow both solids and liquids. A barium meal shows gross
dilatation of the esophagus with a smooth narrowing at the lower end of the
esophagus. What is the SINGLE most likely diagnosis?
A. Achalasia
y
B. Myasthenia gravis
op
D. Oesophageal web
E. Systemic sclerosis
C
38. What is the pathological change in Barrett's esophagus?
n
A. Replacement of squamous epithelium to columnar epithelium
io
B. Replacement of columnar epithelium to squamous epithelium

C. Replacement of squamous epithelium to cuboidal epithelium
t
D. Dysplasia
ua
E. Hyperplasia
39. A 25 year old woman has diarrhoea and abdominal bloating over the last 4 months. On
al
examination, she has blistering rash over her elbows. Her blood test show:
Ev
Haemoglobin 105 g/L

On jejunal biopsy, there is shortening of the villi and lymphocytosis. What is the SINGLE
A. Coeliac disease
B. Whipple’s disease
D. Tropical sprue
E. Giardiasis
40. A 28 year old female presents with a 4 month history of diarrhoea, lethargy and weight
loss. She complains of abdominal discomfort and passing stools more than 6 times a
day. An endoscopy was performed which shows cobblestone mucosa. What is the
430
A. Amoeba
B. Colon Cancer
D. Crohn's disease
41. A 33 year old woman has severe upper abdominal pain with radiation to the back
within 24 hours of removing gallstones by endoscopic retrograde
cholangiopancreatography (ERCP). The pain is eased when she leans forward. She
reports some nausea and vomiting but denies any diarrhoea. Jaundice is noted and the
epigastric region is tender on palpation. Her blood pressure is 120/80 mmHg, and
temperature is 37.3°C. What is the SINGLE most likely reason for his signs and
symptoms?
A. Ascending cholangitis
B. Acute pancreatitis
C. Perforated duodenal ulcer
D. Chronic pancreatitis
y
E. Bleeding
42.
op
A 48 year old woman is admitted to A&E with a productive cough and a moderate
fever. She complains of central chest pain and regurgitation of undigested food. She
C
finds it difficult to swallow both food and liquids. These symptoms of swallowing have
been present for the last 4 months. A chest X-rays shows megaesophagus. What is the
n
io
A. Pharyngeal pouch
B. Hiatus hernia
t
C. Bulbar palsy
ua
D. Achalasia
E. Tuberculosis
al
43. A 44 year old male is admitted with repeated attacks of pancreatitis. He has peripheral
paresthesia and loss of proprioception in the legs. He is having memory loss and
Ev
difficulties with thinking. What is the SINGLE most appropriate management?
A. Thiamine
B. Pyridoxine
C. Hydroxocobalamin
D. Lipase
E. Antibiotics
44. A 36 year old bodybuilder presents with sudden onset of severe abdominal pain. He
was previously fit and well and only suffers from indigestion occasionally. He has been
taking ibuprofen for a long term knee injury. On examination, he has a rigid abdomen,
lies motionless on the bed and has no bowel sounds. His pulse rate is 115 bpm and
blood pressure is 100/60 mmHg. What is the SINGLE most likely diagnosis?
A. Biliary peritonitis
B. Ischemic colon
C. Pancreatic necrosis
431
D. Perforated diverticulum
E. Perforated peptic ulcer
45. A 43 year old male alcoholic presents after a large haematemesis. He has some spider
naevi on his chest. His blood pressure is 100/76 mmHg and pulse rate is 110
beats/minute. On examination. a swollen abdomen with shifting dullness is seen. What
A. Peptic ulcer
B. Mallory-weiss tear
C. Oesophageal cancer
D. Oesophageal varices
E. Oesophagitis
46. A 70 year old man had a right hemicolectomy for caecal carcinoma 4 days ago. He now
has abdominal distension and recurrent vomiting. He has not opened his bowels since
the surgery. On auscultation, no bowel sounds were heard. He has a temperature of
37.3°C. FBC was done. Results show:
y
WBC - 9 x 109/L
op
Hb - 12g/dl
What is the SINGLE most appropriate next management?

C
A. IV Antibiotics
B. Glycerine suppository
n
C. Laparotomy
io
D. NG tube suction and IV fluids

E. Total parenteral nutrition
t
ua
47. An 65 year old lady had a urinary tract infection which was treated with broad
spectrum antibiotics. A few days later she developed bloody diarrhoea and abdominal
pain. She has a temperature of 38.6°C. Her blood tests show:
al
Haemoglobin 119 g/L

Ev
White blood cells 18 x 109/L

CRP 180 mg/l
What is the SINGLE most likely management?
A. Co-amoxiclav
B. Piperacillin + tazobactam
C. Ceftriaxone
D. Vancomycin
E. Amoxicillin
48. A 54 year old woman, known case of pernicious anaemia refuses to take
hydroxocobalamin IM as she is needle shy. She is asking for oral medication. What is
the SINGLE best reason that describes why oral medications will not be effective?
A. Intrinsic factor deficiency

B. Increased gastric acidity
432
C. Lack of gastric acidity
D. Irritated gastric mucosa
E. abundance of ileal binding sites
49. A 44 year old female presents with right upper quadrant pain radiating to the right
shoulder. On examination, her sclera appear yellow. Her BP is 120/85 mmHg;
respiratory rate 15/min; Heart rate 85 bpm; Temperature 37.3°C; WBC 9 x 109/L. She
has no relevant past medical history and is not on any medications. What is the SINGLE
B. Urinary bilirubin
C. Alkaline phosphatase
D. Serum cholesterol
E. X-ray abdomen
50. An 8 year old child presents with recurrent abdominal pain. He has three episodes of
abdominal pain within the last 3 months and it is severe enough to affect his activity in
y
school. The abdominal pain is intense and located periumbilically lasting for a few hours
op
and is associated with nausea and episodic headaches. He maintains a good appetite
and is an appropriate weight for his age. On examination, there were no significant
findings. Full blood count, urea and electrolytes are found to be normal. What is the
C
n
B. Computed tomography abdomen
io
C. Reassure
D. Prescribe omeprazole
t
E. Admit and administer intravenous fluids

ua
51. A 44 year old male was admitted to the medical ward with complaint of diarrhoea,
abdominal pain and weight loss for the last few months. The examination notes finger
al
clubbing, perianal skin tags and abdominal tenderness. A colonoscopy reveals

transmural granulomatous inflammation involving the ileocaecal junction. What is the
Ev
A. Crohn's disease
C. Bowel cancer
D. Diverticulitis
52. A 55 year old woman complains of retrosternal chest pain and difficulty swallowing
which is intermittent and unpredictable. She says that food gets stuck in the middle of
the chest and she has to clear it with a drink of water. She is then able to finish the
meal without any further problem. A barium meal shows a ‘corkscrew patterned
oesophagus’. What is the SINGLE most likely cause of the dysphagia?
A. Oesophageal candidiasis
433
D. Pharyngeal pouch
E. Plummer-vinson syndrome
53. A 51 year old man has become increasingly fatigued over the past 10 months. His
medical history includes having a gastrectomy a year ago. His physical examination is
unremarkable. His blood tests show:
Haemoglobin 85 g/L
What is the SINGLE most likely finding on a blood smear?
A. Hypersegmented neutrophils
B. Nucleated RBC
C. Blasts
D. Hypochromic, microcytic RBC
y
E. Schistocytes
54.
op
A 41 year old lady attends the clinic complaining of a long history of mild pruritus and
fatigue. She looks jaundiced. Alkaline phosphatase was raised on routine liver function
C
test. She was diagnosed with Sjögren syndrome a few years back. What is the SINGLE
most appropriate test to perform to help make a diagnosis?
n
A. Rheumatoid factor
io
B. Anti-nuclear antibodies
C. Anti Smooth Antibodies
t
D. Antimitochondrial antibodies
ua
E. Antineutrophil cytoplasmic antibodies
55. A 39 year old patient was recently diagnosed with coeliac disease and has been treated
al
with a gluten free diet for 2 years. He now has an exacerbation of the classic symptoms
of coeliac disease such as abdominal pain, diarrhoea, and has loss significant weight.
Ev
The biopsy of the small intestine shows lymphomatous infiltrates. What is the SINGLE
A. Lymphoma
B. Diverticular disease
C. Lynch syndrome
D. Gastric tuberculosis
E. Peritoneal tumor
56. A 39 year old woman is admitted with central abdominal pain radiating through to the
back. She has vomited several times in the last 24 hours. She denies any diarrhoea or
fever. Bending forward helps alleviate the pain. Her blood test show:
Amylase 1335 U/mL (Elevated)
434
A. Cirrhosis
D. Dissecting aortic aneurysm
E. Mesenteric ischaemia
shoulder. An ultrasound establishes the diagnosis of gallstones. Her BP is 120/85
mmHg; respiratory rate 15/min; Heart rate 85 bpm; Temperature 37.3°C; WBC 9 x
109/L. What is the SINGLE most appropriate management?
A. Elective laparoscopic cholecystectomy

B. Reassure
C. Low fat diet
58. A 50 year old man comes to A&E with abdominal pain that began suddenly about 1
y
hour ago. The pain is now generalized, constant, and extremely severe. He lies
op
motionless on the stretcher, is diaphoretic, and has shallow, rapid breathing. His
abdomen is rigid, very tender to deep palpation, and has guarding. X-ray shows free air
under the diaphragm. What is the SINGLE most likely diagnosis?
C
B. Ischemic colon
n
io
t
ua
59. A 52 year old man who underwent a partial gastrectomy 10 months ago presents with
increasing fatigue. A yellow tinge is noted on his skin and he has a red sore tongue.
al
A. B12 deficiency
Ev
B. Cancer of the colon

C. Alcoholism
D. Coeliac disease
E. Crohn’s disease
60. An 83 year old woman who is a resident in a nursing home is admitted to a hospital
with a 4 day history of chronic constipation. She has had no weight loss or change in
appetite. She has been on analgesics for 3 weeks for her back pain. She is in obvious
discomfort. Rectal examination reveals faecal impaction with hard stools. What is the
SINGLE most appropriate immediate management?
A. Codeine phosphate for pain relief

B. High fiber diet
C. IV fluids
D. Phosphate enemas
E. Urinary catheterisation
435
61. A 17 year old boy has abdominal pain and diarrhoea for the last 3 months. He has lost 7
kg in the last 2 months. On colonoscopy, deep ulcers and skip lesions are noticed on the
mucosa. Perianal skin tags were seen on examination. What is the SINGLE most likely
diagnosis?
A. Crohn's disease
C. Coeliac disease
D. Diverticulitis
62. A 70 year old woman is reviewed following a course of oral clindamycin for a right
lower limb cellulitis. She recently developed bloody diarrhoea and abdominal pain. She
has a temperature of 38.8°C. Her blood tests show:
Haemoglobin 125 g/L

CRP 140 mg/l
y
op
A. Oral co-amoxiclav
C
B. IV piperacillin + tazobactam
C. IV ceftriaxone
D. Oral metronidazole
n
E. Continue oral clindamycin
io
63. A 61 year old man presents with fatigue and palpitations. His past surgical history
t
includes an ileal resection which was performed one year ago. An FBC was requested
ua
and the results are as follows:
Haemoglobin 93 g/L
al

Ev
A. Anaemia of chronic disease

B. Iron deficiency
C. Folate deficiency
E. Vitamin B12 deficiency
64. A 46 year old woman presents with sudden episode of abdominal pain which started
about 5 hours ago. The pain is located in the epigastrium and radiates to her back. She
has vomited twice since the onset of attack. The pain is made worse by lying flat on her
back and she is more comfortable sitting up and bending forwards. She was informed of
the presence of gallstones in her gall bladder four weeks earlier when she reported pain
in the right hypochondrium. Her temperature is 38.4°C, blood pressure is 120/85
mmHg, and pulse rate is 115 beats/minute. There is no presence of jaundice but there
436
is marked tenderness in the epigastrium. What is the SINGLE most appropriate
investigation?
A. Abdominal X-ray
B. Serum amylase
C. Serum bilirubin
D. Barium swallow
E. Urea and electrolytes
65. A 24 year old female presents with a 4 month history of bloody diarrhoea, lethargy and
weight loss. She complains of abdominal discomfort and passing stools more than 8
times a day. An endoscopy was performed which shows deep ulcers, and skip lesions.
A. Diverticulitis
B. Colon Cancer
D. Crohn's disease
y
66.
op
A 43 year old lady presents with jaundice. Skin excoriations were seen on physical
examination. Blood test reveal a raised alkaline phosphatase with mildly raised alanine
C
transaminase. Antimitochondrial antibodies are found to be positive. What is the
SINGLE most likely diagnosis
n
A. Hepatitis B
io
B. Hepatitis C
t
D. Primary sclerosing cholangitis

ua
E. Obstetric cholestasis
67. A 30 year old lady complains of intermittent diarrhoea, chronic abdominal pain and
al
tenesmus. Sometimes she notices blood in her stool. What is the SINGLE most likely
cause of her symptoms?
Ev
A. Inflammatory bowel disease

B. Diverticulosis
C. Irritable bowel disease
D. Adenomyosis
E. Endometriosis
68. A 22 year old man presents with a 2 month history of diarrhoea. He says his bowels
have not been right for the past few months and he frequently has to run to the toilet.
These symptoms seemed to be improving up until two weeks ago and for the past
week, he notices the presence of blood when he passes stool. On examination, there
are aphthous oral ulcers. He has not lost any weight and has a good appetite.
Examination of his abdomen demonstrates mild tenderness in the left lower quadrant
but no guarding. What is the SINGLE most likely diagnosis?
B. Crohn's disease
437
E. Anal Fissure
69. A 23 year old woman has abdominal bloating, weight loss and intermittent diarrhoea.
She describes her stools as “frothy” and difficult to flush down the toilet. Her blood test
show:
Haemoglobin 105 g/L

Platelets 350 x 10 9/L
Ferritin 11 ng/ml
Vitamin B12 225 ng/L
Folate 1.9 mcg/L
Endomysial antibodies were tested positive. What is the SINGLE most likely diagnosis?
A. Coeliac disease
y
B. Ulcerative colitis
op
D. Irritable bowel syndrome
E. Giardiasis
C
70. A 34 year old man presents with slow progressive dysphagia. He has been using H2
blockers for the last year because of retrosternal discomfort. He has not notice any
n
weight loss. A haemoglobin level was done a month ago which reads 13.3g/dL. What is
io

t
A. Foreign body
ua

C. Pharyngeal pouch
D. Peptic stricture
al
E. Esophageal Cancer
Ev
months. She says that her diarrhoea has recently become bloody. A rectal biopsy was
performed and histology was reported as “decreased amounts of goblet cells”. What is
B. Crohn's disease
72. A 15 year old child complains of right iliac fossa pain and diarrhoea. He has lost 7 kg in
the last 2 months. On colonoscopy, skip lesions are noticed on the mucosa. What is the
A. Prednisolone
B. Mebeverine
438
C. Peppermint oil
D. Metronidazole
E. Vancomycin
73. A 59 year old man has multiple liver metastasis with the primary tumour originating
from the large bowel. He has abdominal pain, and jaundice. On general inspection, he
looks cachexic and drowsy. He has significant ascites and oedema seen on both ankles.
His family have concerns that he is not having sufficient fluids orally. His urine output is
low. He currently takes regular haloperidol 1.5 mg three times a day and lactulose 10ml
twice a day. His blood test show:

Sodium 129 mmol/L
Calcium 2.42 mmol/l
Potassium 3.6 mmol/l
Albumin 18 g/L
Bilirubin 105 μmol/L
y
Alkaline phosphatase (ALP) 411 U/L
op
C
A. Albumin infusion
B. Crystalloids intravenously
C. Furosemide intravenous
n
D. Fluids via nasogastric tube
io
E. Cease haloperidol
t
74. A 56 year old man comes for a routine check up. He is noted to have increased skin
ua
pigmentation, spider angioma and a heart murmur. He has mild joint pain particularly
in those of the hands. He rarely drinks alcohol. On examination, his liver is firm and has
a span of 10 cm. On further investigations of the heart murmur, he was given the
al
diagnosis of restrictive cardiomyopathy. What is the SINGLE condition that he is most

likely at risk of?
Ev
A. Cerebellar degeneration
B. Gallstones
C. Renal failure
D. Hepatoma
E. Hepatic vein thrombosis
75. A 35 year old woman has sudden onset epigastric pain, chills and nausea. She gave birth
to a health baby 2 days ago. Her blood pressure was normal throughout pregnancy. Her
temperature is 37.3°C and her blood pressure is 139/90 mmHg. Urinalysis reveals no
proteins. Her blood test show:

Alanine transferase (ALT) 650 U/L
International normalized ratio (INR) 1.0
Haemoglobin 101 g/L
439
White cell count (WCC) 13.5 x 109/L
A. Acute cholecystitis
B. Pre-eclampsia
C. Obstetric cholestasis
D. Acute fatty liver of pregnancy
E. HELLP syndrome
76. A 33 year old pregnant woman develops severe epigastric pain, nausea and vomiting at
35 weeks gestation. She was diagnosed with pre-eclampsia 2 weeks ago. On
examination, she has yellow sclerae. Laboratory investigations show a deranged liver
function, low platelets, low serum glucose, raised serum ammonia. What is the SINGLE
A. Acute fatty liver of pregnancy
y
B. Hyperemesis gravidarum
op
C. Biliary colic
D. HELLP syndrome
E. Autoimmune hepatitis
C
77. A 41 year old pregnant woman presents to A&E with right upper quadrant pain that
started in the last 12 hours and is gradually worsening. She has dark urine and pale
n
stools for the last 2 days. She is noted to have a yellow sclera on examination. Her
io
blood pressure is 145/95 mmHg. What is the SINGLE most appropriate investigation?
t
A. Ultrasound of abdomen
ua
B. Urine protein: creatinine ratio

C. Urinary bilirubin
D. Urinary urobilinogen
al
E. Alkaline phosphatase
Ev
78. A 33 year old lady who has been traveling around Europe for a few months now returns
to the United Kingdom with lethargy, abdominal pain, loose watery diarrhoea and
bloating. She has lost a few kilograms since coming back from the trip. Her physical
examination remains unremarkable with abdominal examination having mild
generalised tenderness. What is the SINGLE most likely organism causing her
symptoms?
A. Campylobacter jejuni
B. Salmonella enterica
C. Shigella dysentery
D. Staphylococcus aureus
E. Giardia lamblia
79. A 21 year old man has been brought to A&E by his friends as he is having a yellow sclera
and yellowing of the skin. He has recently been having flu-like symptoms and a non-
productive cough. A urine dipstick was performed and was normal. His blood results
show:
440
Haemoglobin 129 g/dl
Reticulocytes 1.2%
Alkaline phosphatase (ALP) 88
Alanine transferase (ALT) 24
Albumin 42
A. Acute hepatitis
B. Gilbert’s syndrome
C. Dubin Johnson Syndrome
D. Glucose-6-phosphate dehydrogenase
E. Infectious mononucleosis
80. A 17 year old boy presents to A&E after his mother has noticed that his sclera has a
yellowish tint. He has been taking over the counter medication for an upper respiratory
y
tract infection for the past few days. He is otherwise well and has no significant past
op
medical history. What is the SINGLE most likely diagnosis?
A. Acute hepatitis
C
C. Drug induced haemolysis
n
E. Acute cholecystitis
io
81. A 47 year old women diagnosed with coeliac at the age of three has recently developed
t
diarrhea and weight loss for the past three months. What is the SINGLE most likely
ua
reason for this?
A. Tapeworm infection
al
B. Lymphoma of the small intestine

C. Tuberculosis
Ev
D. Giardia
82. A 31 year old female presented with complains of chest pain and difficulty in
swallowing liquids and solids. She has also been suffering from recurrent chest infection
for the past few months. What is the SINGLE most likely diagnosis?
A. Schatzki ring
B. Plummer-Vinson syndrome
C. Achalasia cardia
D. Peptic stricture
83. A 33 year old female has intermittent diarrhoea and abdominal bloating which is
usually exacerbated by consumption of wheat and eggs. She has been feeling more
tired in the past few months. She has no significant weight loss. What is the SINGLE
441
A. Coeliac disease
C. Crohn's disease
D. Gastroenteritis
E. Malabsorption
y
op
C
n
t io
ua
al
Ev
442
Gastroenterology Answers
1. A 23 year old female presents with an 8 week history of bloody diarrhoea. She says her
bowels have not been right for the past few months and she frequently has to run to
the toilet. A diagnosis of ulcerative colitis is made. What is the SINGLE most likely sign
to be seen on a barium enema?
A. Loss of haustral markings

B. Kantor's string sign
C. Cobblestone appearance
D. Rose thorn ulcers
E. Fistula
Loss of haustration is pathognomonic for Ulcerative Colitis. Cobblestone appearance is

seen on an endoscopy in Crohn’s disease. Kantor's string sign, rose thorn ulcers, and
fistulae are seen on a small bowel enema in Crohn’s disease.
It is important to know the differences of ulcerative colitis and crohn’s disease for PLAB
y
as it is very commonly asked.
op
These are some key differences that will help you with your exam:
C
Crohn’s disease Ulcerative colitis
Usually non bloody Bloody diarrhoea more common
n
Abdominal mass palpable in right iliac Abdominal pain in left lower quadrant
io
fossa
Decreased goblet cells on histology
t
Increased goblet cells on histology

ua
Granulomas are infrequent on histology

Granulomas seen on histology
Primary sclerosing cholangitis more
al
Weight loss more prominent common

Ev
Transmural, skip lesions, cobble stone Aphthous oral ulcers

appearance on endoscopy
Loss of haustration, drain pipe collon
seen on barium enema
2. A 42 year old man with type 2 diabetes presents with fatigue and shortness of breath.
He is noted to have a bronze tinge to his skin. Abdominal examination reveals
hepatomegaly. His blood test show a high ferritin level. A diagnosis has been made but
he is refusing all treatment. Which organ is the most likely to be at risk of developing
cancer?
A. Testes
B. Adrenal gland
C. Liver
D. Pancreas
E. Heart
443
The diagnosis here is haemochromatosis. The liver is a primary storage area for iron and
will naturally accumulate excess iron. Over time the liver is likely to be damaged by iron
overload causing cirrhosis. Cirrhosis and haemochromatosis together will increase the
risk of hepatocellular carcinoma.
Haemochromatosis
Hereditary haemochromatosis (HHC) is an autosomal recessive genetic disease in which
increased intestinal absorption of iron causes accumulation in tissues, especially the
liver, which may lead to organ damage. Other organs that may be affected by iron
deposits include the pancreas, joints, heart, skin and gonads.
Presentation
• Early diagnosis is difficult because HHC is often asymptomatic until the late
stages of disease. Symptoms usually start between ages 40-60
• Initial symptoms are usually vague and nonspecific - eg, fatigue, weakness and
heart problems
• HHC may be diagnosed incidentally - eg, following abnormal serum ferritin or
LFTs
y
• Symptoms of advanced disease include:
op
o Diabetes
o Bronzing of the skin
o Hepatomegaly
C
o Cirrhosis
o Arthropathy
n
o Cardiac disease - arrhythmias or cardiomyopathy
o Neurological or psychiatric symptoms - impaired memory, mood
io
swings, irritability, depression

t
Remember the triad of diabetes, hepatomegaly and bronze pigmentation. This is seen in
ua
30% of patients with haemochromatosis and is a common presentation given in the

questions.
al
3. A 28 year old female presents with 1 week history of jaundice, fever and malaise. She
was diagnosed with hypothyroidism for which she is receiving levothyroxine. Her blood
Ev
tests show:

Prothrombin time (PT) 25 sec
A. Acute on chronic liver failure

B. Hyperacute liver failure
C. Autoimmune hepatitis
E. Drug induced hepatitis
444
In autoimmune hepatitis, serum aminotransferases: aspartate aminotransferase (AST)
and alanine aminotransferase (ALT) are usually elevated at initial presentation. Serum
alkaline phosphatase is normal or only mildly raised. A more than two-fold elevation
suggests an alternative or additional diagnosis. Hypoalbuminaemia and prolongation of
prothrombin time are markers of severe hepatic synthetic dysfunction.
These lab test do not rule out other liver diseases but given the combination of the
presence of another autoimmune disease like hypothyroidism, the most likely diagnosis
here is autoimmune hepatitis.
Autoimmune hepatitis
Autoimmune hepatitis (AIH) is a chronic disease of unknown cause, characterised by
continuing hepatocellular inflammation and necrosis, which tends to progress to
cirrhosis.
• Predominantly affects young or middle-aged women
y
• Up to 40% present with acute hepatitis and signs of autoimmune disease, eg
op
fever, malaise, urticarial rash, polyarthritis, pleurisy, pulmonary infiltration, or
glomerulonephritis. The remainder present with gradual jaundice or are
asymptomatic and diagnosed incidentally with signs of chronic liver disease.
C
Amenorrhoea is common and disease tends to attenuate during pregnancy.
Investigations:
n
The diagnosis rests on a combination of compatible biochemical, immunological and
io
histological features together with exclusion of other liver diseases.

t
ua
Associated diseases
Concurrent autoimmune disorders occur in approximately 40% of patients, particularly
autoimmune thyroid disorder.
al
4. A 35 year old female presents with secondary amenorrhoea. Her blood test show the
Ev
following:


B. Autoimmune hepatitis
E. Gilbert’s syndrome
The combination of deranged LFTs combined with secondary amenorrhoea in a young

female strongly suggest autoimmune hepatitis.
445
In autoimmune hepatitis, serum aminotransferases: aspartate aminotransferase (AST)
and alanine aminotransferase (ALT) are usually elevated at initial presentation. Serum
alkaline phosphatase is normal or only mildly raised. A more than two-fold elevation
suggests an alternative or additional diagnosis.
Occasionally, the stem would include a form of another autoimmune disease such as
addison’s disease, vitiligo, or an autoimmune thyroid disorder as this may be present
with autoimmine hepatitis.
Autoimmune hepatitis
Autoimmune hepatitis (AIH) is a chronic disease of unknown cause, characterised by
continuing hepatocellular inflammation and necrosis, which tends to progress to
cirrhosis.
• Predominantly affects young or middle-aged women

• Up to 40% present with acute hepatitis and signs of autoimmune disease, eg
y
fever, malaise, urticarial rash, polyarthritis, pleurisy, pulmonary infiltration, or
op
glomerulonephritis. The remainder present with gradual jaundice or are
asymptomatic and diagnosed incidentally with signs of chronic liver disease.
Amenorrhoea is common and disease tends to attenuate during pregnancy.
C
Investigations:
The diagnosis rests on a combination of compatible biochemical, immunological and
n
histological features together with exclusion of other liver diseases.
t io
Associated diseases
ua
Concurrent autoimmune disorders occur in approximately 40% of patients, particularly

autoimmune thyroid disorder.
al
5. A 42 year old obese female has severe upper abdominal pain. She vomited several
times today. She has a temperature of 37.8°C. She is married and has 5 living children.
Ev
She has no previous surgeries. Her blood count shows:
Haemoglobin 123 g/L

B. Ovarian torsion
C. Hepatitis
D. Endometriosis
E. Cholecystitis
Remember the mnemonic for gallstones: 5Fs: Female, Forties, Fair, Fertile, Fat
Acute cholecystitis
446
Acute cholecystitis follows stone or sludge impaction in the neck of the gallbladder,
which may cause continuous epigastric or RUQ pain (referred to the right shoulder),
vomiting, fever, local peritonism, or a gallbladder mass.
The main difference from biliary colic is the inflammatory component (local peritonism,
fever, and elevated WCC).
If the stone moves to the common bile duct (CBD), obstructive jaundice and cholangitis
may occur
Murphy’s sign is positive when you lay 2 fingers over the RUQ and ask patient to
breathe in which causes pain & arrest of inspiration as an inflamed gallbladder impinges
on your fingers. It is only positive if the same test in the LUQ does not cause pain.
Tests:
WCC would be elevated
Ultrasound shows a thick-walled, shrunken gallbladder
y
op
Management:
Nil by mouth, pain relief, IV fluids, and antibiotics.
C
Once symptoms settle, do a laparoscopic cholecystectomy. Laparoscopic
cholecystectomy is the treatment of choice for all patients fit for general anaesthesia.
Open surgery is required if there is gall bladder perforation.
n
io
6. A 48 year old woman has become increasingly fatigued over the past 10 months.
Vitiligo of the hand was noted. Her blood tests show:
t
ua
Haemoglobin 88 g/L
al

Ev
The mean cell volume is increased. This points towards either a B12 deficiency or folate
deficiency.
Pernicious anaemia is one of the causes of a B12 deficiency and it may coexist with
other autoimmune disease such as vitiligo. Note that hypothyroidism is also another
coexisting autoimmune disease to look out for.
B12 deficiency
447
Vitamin B12 is found in meat, fish, and dairy products, but not in plants. Body stores are
sufficient for 4 years.
B12 then binds to intrinsic factor in the stomach, and this complex is absorbed in the
terminal ileum.
Clinical presentation
• Symptoms are those of chronic anaemia, i.e. fatigue, dyspnoea on effort
• Neurological symptoms may also be present → classically peripheral
paresthesia and disturbances of position and vibration sense
• If uncorrected, the patient may develop subacute combined degeneration of
the spinal cord leading to permanently ataxia
Causes of B12 deficiency:

• Pernicious anaemia →Commonest cause. It is due to autoimmune gastric
atrophy resulting in loss of intrinsic factor production required for absorption of
y
B12. It is usually associated with other autoimmune problems e.g.
op
hypothyroidism
• Dietary (e.g. vegans)
• Following total gastrectomy
C
• Ileal disease → Resection of ileum, Crohn’s disease
• Malabsorption disorders → Coeliac disease, tropical sprue
n
In PLAB, one distinction that may help you choose between B12 and folate deficiency is
io
the diet. Good food sources of folate include broccoli, brussels sprouts, asparagus, peas
(basically vegetables). Thus if the given scenario is a vegetarian, it is unlikely that he is
t
suffering from folate deficiency. In that case, pick B12 deficiency.

ua
Haematological abnormalities of B12 deficiency

al
• Macrocytic anaemia and the MCV is usually >110fL

• Hypersegmented neutrophils
Ev
• Serum B12 is low
Management:
Hydroxocobalamin IM
that he does not eat as much anymore because he does not have the appetite. He has
also lost 10kg in the last 3 months. What is the SINGLE most probable diagnosis?
A. Gastric cancer
B. Lymphoma
C. Pancoast tumor
D. Thyroid cancer
E. Laryngeal cancer
448
The lump in the left supraclavicular region is known as a Virchow’s node it is indicative
of carcinoma of the stomach. The weight loss and decrease appetite supports the
diagnosis of gastric cancer.
8. A 50 year old man has severe pain on defecation. On examination, a tender, reddish
blue swelling is seen near the anal verge. What is the SINGLE most likely diagnosis?
A. Perianal abscess
B. Perianal haematoma
C. Pilonidal cyst
D. Haemorrhoids
E. Anal fistula
Perianal haematoma
Strictly speaking, it is actually a clotted venous saccule. It appears as a 2-4mm ‘dark

blueberry’ (purple colour) under the skin at the anal margin. It is seen as swollen and
acutely tender perianal lumps.
y
op
Management:
It may be evacuated under local anaesthesia or left to resolve spontaneously.
• Incision and drainage of the clot relieve pain but the thrombosis often recurs
C
and there may be persistent bleeding.
• Conservative treatment includes analgesia, ice packs and stool softeners. A
topical calcium antagonist may help to relieve pain. If managed conservatively,
n
symptoms usually settle within 10-14 days
io
9. A 49 year old female presents with right hypochondrial pain. An ultrasound shows a
t
large gallstone. Her BP is 120/85 mmHg; respiratory rate 18/min; Heart rate 90 bpm;
ua
Temperature 37.6°C; WBC 15 x 109/L. What is the SINGLE most appropriate

management?
al
A. Laparoscopic cholecystectomy
B. Reassure
Ev
C. Low fat diet

As she is symptomatic, reassurance is out of the question. The two remaining options
are laparoscopic cholecystectomy or emergency laparotomy. Laparoscopic
cholecystectomy is the prefered option here as there are no signs of gallbladder
perforation. Laparotomy has higher risk as it is much more invasive.
Acute cholecystitis
Acute cholecystitis follows stone or sludge impaction in the neck of the gallbladder,
which may cause continuous epigastric or RUQ pain (referred to the right shoulder),
vomiting, fever, local peritonism, or a gallbladder mass.
The main difference from biliary colic is the inflammatory component (local peritonism,
fever, and elevated WCC).
449
If the stone moves to the common bile duct (CBD), obstructive jaundice and cholangitis
may occur
Murphy’s sign is positive when you lay 2 fingers over the RUQ and ask patient to
breathe in which causes pain & arrest of inspiration as an inflamed gallbladder impinges
on your fingers. It is only positive if the same test in the LUQ does not cause pain.
Tests:
WCC would be elevated
Ultrasound shows a thick-walled, shrunken gallbladder
Management:
Nil by mouth, pain relief, IV fluids, and antibiotics.
Once symptoms settle, do a laparoscopic cholecystectomy. Laparoscopic

cholecystectomy is the treatment of choice for all patients fit for general anaesthesia.
Open surgery is required if there is gall bladder perforation.
y
op
10. 42 year old obese woman presents to the emergency department with a 12 hour
history of severe epigastric pain. The pain started suddenly and and radiates to her
back. It is relieved when sitting forward. She is nauseous and has vomited twice in since
C
the pains started. She drinks one and a half glasses of wine per day. She has no
significant past medical history. She has a pulse rate of 110 beats/minute and is tender
in the epigastric region. What is the SINGLE most appropriate investigation?
n
io
A. Chest X-ray
B. Abdominal ultrasound
t
C. Serum lipase
ua
D. Abdominal X-ray
al
The likely diagnosis is acute pancreatitis. The most useful investigation is a serum
lipase, looking for an elevation of more than 3 times the upper limit of normal.
Ev
While abdominal x-rays are not useful in the diagnosis of pancreatitis, they are
routinely ordered to exclude other potential causes of abdominal pain such as
perforation or bowel obstruction.
Ultrasound is useful to detect the presence of gallstones but it is not a good diagnostic
test for acute pancreatitis. The pancreas is poorly visualised in 25-50% of cases.
Urea and electrolytes and liver function test do not directly aid the diagnosis of
pancreatitis however, they are helpful in assessing the severity of the disease (e.g. by
showing the degree of leucocytosis or of hypovolaemia) or give clues of the aetiology of
pancreatitis (e.g. gallstone pancreatitis).
Acute pancreatitis
450
Aetiology
The vast majority of cases in the UK are caused by gallstones and alcohol.
A popular mnemonic to remember is GET SMASHED

• Gallstones
• Ethanol
• Trauma
• Steroids
• Mumps (other viruses include Coxsackie B)
• Autoimmune (e.g. polyarteritis nodosa), Ascaris infection
• Scorpion venom
• Hypertriglyceridaemia, Hyperchylomicronaemia, Hypercalcaemia, Hypothermia
• ERCP
• Drugs (azathioprine, mesalazine*, didanosine, bendroflumethiazide,
furosemide, pentamidine, steroids, sodium valproate)
Clinical features
• Gradual or sudden severe epigastric or central abdominal pain (radiates to
y
back, sitting forward may relieve it)
op
• Vomiting is prominent
• Tachycardia
• Fever,
C
• Jaundice
• Shock
• Rigid abdomen with local or general tenderness
n
• Periumbilical bruising (Cullen’s sign)
io
Investigation
t
• Raised serum amylase (>1000U/mL or around 3-fold upper limit of normal).

ua
However, lipase levels are more sensitive and more specific.

• CT scan with contrast enhancement may be diagnostic where clinical and
biochemical results are equivocal on admission
al
11. A 52 year old alcoholic man complains of epigastric and back pain associated with loose
Ev
pale, offensive stools. He feels nauseous and has lost weight over the last couple of
months. What is the SINGLE most likely diagnosis?
A. Acute pancreatitis
B. Chronic pancreatitis
C. Gastro-oesophageal reflux disease
D. Oesophagitis
E. Carcinoma of the head of pancreas
Chronic pancreatitis can present with abdominal pain. Classically, epigastric pain
radiating into the back. Nausea and vomiting is also another clinical feature.
Steatorrhoea occurs due to malabsorption of fats from the lack of pancreatic lipase
secretion. This subsequently causes weight loss. Occasionally, the question writers may
use words like “offensive stools which are difficult to flush” which in other words
represent the term steatorrhoea.
451
Endocrine dysfunction such as diabetes mellitus may be part of the stem as well.
One might consider “Carcinoma of the head of pancreas” as the answer given the
similar symptoms of weight loss, epigastric pain and history of alcohol. The reason that
the answer for this question is not “Carcinoma of the head of pancreas” is because the
stem would include obstructive jaundice as part of the features.
12. A 41 year old man has had a liver biopsy as part of investigations for abnormal liver
function test. The pathology report states: special stains demonstrate the presence of a
very large amount of iron pigment within hepatocytes. What SINGLE condition is
identified by the pathology report?
A. Alpha-1-antitrypsin deficiency
B. Haemangioma
C. Haemochromatosis
D. Haemosiderosis
y
In haemochromatosis, characteristically, the iron is found predominantly in a periportal
op
distribution (acinar zone 1) within the hepatic lobule, with virtually all iron deposited in
parenchymal hepatocytes and none in Kupffer cells.
C
By contrast iron overload in haemosiderosis causes to accumulation of iron granules
predominantly in kupffer cells and more in central area rather than peripheral
hepatocyte.
n
io
Since the question gives a pathology report of large amount of iron pigment in
hepatocytes rather than Kupffer cells, the diagnosis is haemochromatosis.
t
ua
Haemochromatosis
al
Ev
Presentation
heart problems
LFTs
o Diabetes
o Hepatomegaly
o Cirrhosis
o Arthropathy
452
questions.
months. She says that her diarrhoea has recently become bloody. A biopsy was
performed and the colonic mucosa shows crypt abscesses. What is the SINGLE most
likely diagnosis?
B. Crohn's disease
Crypt abscesses (Crypts of Lieberkühn) are typical of ulcerative colitis, though not
diagnostic. They are mucosal crevices that are seen in the normal gastrointestinal tract.
y
In ulcerative colitis, these get clogged up with neutrophilic exudates, forming “crypt
op
abscesses.” These are not “real” abscesses and do not require surgical drainage.
C
n
io

t
ua
fossa
al

Ev


14. A 28 year old man has intermittent diarrhoea, fatigue and weight loss over the last 6
months. He has excluded gluten from his diet in the last 2 months and his symptoms
have resolved. He wants to be tested to confirm the diagnosis of coeliac disease. What
is the SINGLE most appropriate next step in action?
A. Jejunal biopsy
453
B. Reintroduce gluten prior to testing
C. Sweat test
D. Tissue transglutaminase antibodies
E. Stool sample
If patients are already taking a gluten-free diet they should be asked, if possible, to
reintroduce gluten for at least 6 weeks prior to testing. Serology test and jejunal
biopsies may come back negative if patient is currently on a gluten-free diet.
Coeliac disease
Coeliac disease is caused by sensitivity to the protein gluten. Repeated exposure leads
to villous atrophy which in turn causes malabsorption.
Signs and symptoms

• Chronic or intermittent diarrhoea
• Stinking stools/steatorrhoea
• Persistent or unexplained gastrointestinal symptoms including bloating, nausea
and vomiting
y
• Fatigue
op
• Recurrent abdominal pain, cramping or distension
• Sudden or unexpected weight loss
• Unexplained iron, vitamin B12 or folate deficiency. Note that the one of the
C
most common presentation of coeliac disease is iron deficiency anaemia. Also,
folate deficiency is more common than vitamin B12 deficiency in coeliac
disease
n
io
Complications
• osteoporosis
t
• T-cell lymphoma of small intestine (rare)

ua
Investigation
Diagnosis is made by a combination of immunology and jejunal biopsy. Any test for
al
coeliac disease is accurate only if a gluten-containing diet is eaten during the diagnostic
process. The person should not start a gluten-free diet until diagnosis is confirmed.
Ev
NICE issued guidelines on the investigation of coeliac disease in 2009. If patients are
already taking a gluten-free diet they should be asked, if possible, to reintroduce gluten
for at least 6 weeks prior to testing.
Specific auto-antibodies
• Tissue transglutaminase (TTG) antibodies (IgA) are first-choice according to
NICE
• Endomysial antibody (IgA)
Jejunal biopsy
A biopsy is still needed to diagnose coeliac disease even if antibody test confirm the
diagnosis of coeliac disease.
• Villous atrophy
• Crypt hyperplasia
• Increase in intraepithelial lymphocytes
454
Management
• Gluten-free diet
15. A 45 year old man had his head of pancreas removed due to malignancy. He now has a
rigid abdomen which is tender, a temperature of 37.5°C, a blood pressure of 90/55
mmHg and pulse rate of 125 bpm. His past medical history includes peptic ulcer
disease. What is the SINGLE most appropriate next action?
A. CT abdomen
B. X-ray abdomen
C. MRI abdomen
D. US abdomen
E. Endoscopy
This is a case of perforated peptic ulcer with the features of shock, abdominal rigidity
and raised temperature. Perforation of a peptic ulcer causes an acute abdomen with
epigastric pain that may progress to generalised rigidity.
y
The stress an operation may cause the body to produce higher amounts of acid, which
op
can irritate preexisting ulcers leading to easy perforation. A diagnosis is made by taking
an erect abdominal/chest X-ray (seeking air under the diaphragm).
C
16. A 56 year old woman has had severe abdominal pain for 24 hours radiating to her back
and is accompanied by nausea and vomiting. She denies any diarrhoea or fever. She
appears to be tachycardic and in shock. She has a history of gallstones. What is the
n
SINGLE most likely investigations to confirm the diagnosis?
io
t
B. Abdominal X-ray
ua
C. Serum lipase
al
The likely diagnosis is acute pancreatitis. The most useful investigation is a serum
Ev
lipase, looking for an elevation of more than 3 times the upper limit of normal.
pancreatitis (e.g. gallstone pancreatitis).
Acute pancreatitis
Aetiology
455

• Gallstones
• Ethanol
• Trauma
• Steroids
• Scorpion venom
• ERCP
Clinical features
y
op
• Tachycardia
• Fever,
• Jaundice
C
• Shock
n
io
Investigation
t

ua

al
17. A 54 year old man presents with a worsening history of intermittent dysphagia over a
period of 3 months. He has not experienced any weight loss and complains of
Ev
sometimes regurgitating food, after which he says he experiences a feeling of great

relief. What is the SINGLE most likely diagnosis?
A. Achalasia
C. Scleroderma
D. Plummer-Vinson syndrome
E. Barrett's Oesophagus
Achalasia
• Achalasia is the idiopathic loss of the normal neural structure of the lower
oesophageal sphincter. The lower oesophageal sphincter is usually contracted
to prevent the acidic gastric contents from refluxing backward into the
oesophagus. For swallowing to occur, there is normally a relaxation process of
the lower oesophageal sphincter in order to allow food to pass into the
stomach. Inhibitory neurons are stimulated, blocking the impulses that cause
456
constriction. In achalasia, these inhibitory neurons have been lost, as well as
the ability to relax the lower oesophageal sphincter.
Presentation:
• Progressive dysphagia to both solids and liquids simultaneously and can have
regurgitation several hours after eating
• There can also be weight loss
• Achalasia has no relationship with alcohol or tobacco use
• Note: This is different from oesophageal cancer, which not only usually
presents with dysphagia to solid foods that progresses to difficulty swallowing
liquids, but also is more common in older patients with a long history of alcohol
and tobacco use.
Investigations:
• Barium swallow shows dilation of the esophagus, which narrows into a "bird's
beak" at the distal end
• The most accurate test overall is esophageal manometry. Manometry shows
increased lower oesophageal resting pressure
y
op
Management:
• Dilatation of the lower oesophageal sphincter
C
18. A 26 year old young man presents with history of passing loose stools for the past 2
months. He says his stools contain blood and mucous and are associated with
abdominal pain. He had a colonoscopy after which he was started on treatment. What
n
is the SINGLE most appropriate treatment for his condition?
io
A. Mesalazine
t
B. Corticosteroids
ua
C. Mebeverine
D. Cyclosporine
E. Peppermint oil
al
The clinical features and treatment after colonoscopy suggests diagnosis of ulcerative
Ev
colitis for which initial treatment option is mesalazine.
Ulcerative Colitis Management

Inducing remission
Topical → Rectal Mesalazine better than rectal steroids
1st line → 5-ASA (e.g. oral mesalazine)
2nd line → Oral Prednisolone
If severe colitis, treat in hospital with IV steroids as first line.
Maintaining remission
oral aminosalicylates e.g. mesalazine
19. A 58 year old man has been having frequent episodes of secretory diarrhea for the past
2 weeks. His diarrhoea is extremely watery with large amounts of mucus. A diagnosis of
villous adenoma was made after performing an endoscopy. What is the SINGLE most
likely electrolyte abnormality?
457
A. Hyperkalemia
B. Hypernatremia
C. Hyponatremia
D. Hypokalemia
E. Hypercalcemia
This is a very high yield question and you need to remember that villous adenoma is
one of the causes of hypokalaemia.
20. A 55 year old man develops fatigue and palpitations. He had a gastrectomy a years ago.
Recent blood test were ordered which shows:
Haemoglobin 98 g/L
On neurological examination, loss of proprioception and vibration sense were noted.

y
op
A. Iron deficiency
C. Vitamin B12 deficiency
C
E. Sickle cell disease
n
High MCV and low Hb → Macrocytic anaemia
io
These findings together with a history of a gastric resection whereby malabsorption of

t
B12 could occur, points towards the diagnosis of B12 deficiency.

ua
B12 deficiency
al
Ev
terminal ileum.

hypothyroidism
458

Management:
Hydroxocobalamin IM
21. A 36 year old lady has diarrhoea for the last 2 months. She has lost 8 kg in that time
y
period. A colonoscopy was performed which showed fistulas. Perianal fistulas are also
op
noticed. What is the SINGLE most likely diagnosis?
A. Crohn's disease
C
C. Coeliac disease
D. Diverticulitis
n
io
The diagnosis of Crohn’s disease is quite clear here. Fistulas help differentiate between
t
ulcerative colitis and crohn’s. Since fistulas are present, it can only be crohn’s disease.
ua
al
Ev

fossa

459
22. A 35 year old man presents with history of dyspepsia. Serum antibodies for H.Pylori are
negative. No improvement is seen after 1 month of treatment. What is the SINGLE most
A. Urea breath test

B. Repeat serum antibodies
C. CT
D. MRI
E. Endoscopy
This patient is less than 55 years old and does not have any red flags.
This is the general management for dyspepsia for patients less than 55 with no red
flags:
y
op
C
n
t io
ua
23. A 38 year old man has just returned from Kenya a few days ago. Since his return, he has
developed watery diarrhoea with crampy abdominal pain. What is the SINGLE most
al
likely causative organism?

Ev
A. Giardia
B. Entamoeba
C. Shigella
D. Salmonella
E. Escherichia coli
The most common organism that causes traveller’s diarrhoea is E. coli. It will usually
cause a mild self-limiting diarrhoea for less than 72 hours.
24. A 25 year old woman with longstanding constipation has severe anorectal pain on
defecation. She notices streaks of blood that covers her stool. Rectal examination is
impossible to perform as she is in such great pain. What is the SINGLE most likely
diagnosis?
A. Anal haematoma
B. Anal fissure
C. Anal abscess
460
D. Proctalgia fugax
E. Haemorrhoids
Anal fissure
• exquisite pain with defecation and blood streaks covering the stools
• The fear of pain is so intense that they avoid bowel movements (and get
constipated)
• refuse proper examination of area → thus exam needs to be done under
anaesthesia
Anal fissures are longitudinal or elliptical tears of the squamous lining of the distal anal
canal.
If present for less than 6 weeks → defined as acute

If present for more than 6 weeks → defined as chronic
25. A 28 year type 1 diabetic has intermittent diarrhoea and abdominal bloating over the
y
last 6 months. He also complains of feeling tired all the time. Tissue transglutaminase
op
antibodies was found to be positive. What is the SINGLE most appropriate next step in
action? C
A. Jejunal biopsy
B. Upper gastrointestinal endoscopy
C. Sweat test
n
D. Thyroid function test
io
E. Stool culture
t
There is an association between type 1 diabetes and coeliac disease. The gold standard
ua
to diagnose coeliac is a jejunal biopsy.
Coeliac disease
al
Ev
Signs and symptoms

and vomiting
• Fatigue
disease
Complications
• osteoporosis
461
Investigation
NICE
Jejunal biopsy
y
• Villous atrophy
op
C
Management
n
26. A 48 year old female presents with tiredness and painless dysphagia. She complains of a
io
feeling of something stuck in her throat. A full blood count shows microcytic,
hypochromic anaemia. On examination, glossitis is noted. An oesophageal web is found
t
at the post cricoid region. What is the SINGLE most likely diagnosis?
ua
A. Coeliac disease
al
C. Pharyngeal carcinoma
D. Barrett's oesophagus
Ev
When someone presents with dysphagia, glossitis and iron deficiency anaemia,
Plummer vinson syndrome is your answer.
Plummer Vinson syndrome

• A condition where iron deficiency is associated with a postcricoid oesophageal
web
The syndrome most often affects middle-aged women.
Presentation:
• Painless, intermittent dysphagia → due to oesophageal webs
• Symptoms of iron-deficiency anaemia
Management:
• Iron supplements
462
• Dilation of the webs
27. A 69 year old smoker has had increasing dysphagia when eating solid food which has
been on going for the past 3 months. He has notice a drop of 8 kg in weight in the past
few months. What SINGLE investigations is most likely to lead to a diagnosis?
A. Barium swallow
B. Chest X-ray
C. Computed tomography chest
D. Endoscopy and biopsy
E. Videofluoroscopy
The likely cause is oesophageal cancer where a malignant stricture or mass has resulted
in difficulty in swallowing. An endoscopic biopsy is the definitive investigation.
Oesophageal cancer
Adenocarcinoma has now overtaken squamous cell carcinoma as the most common
type of oesophageal cancer
y
op
Risk factors
• Smoking → risk factor for both adenocarcinoma and squamous cell carcinoma,
but associated with a much higher risk for squamous cell carcinoma than
C
adenocarcinoma.
• Alcohol
• GORD
n
• Barrett's oesophagus → which is a precursor of adenocarcinoma
io
• Achalasia → Chronic inflammation and stasis from any cause increase the risk of
oesophageal squamous cell carcinoma
t
ua
Very often in the stem, there would be a patient with a history of gastro-oesophageal
reflux disease (GORD) or Barrett's oesophagus. Sometimes, they would give a history of
increasing dysphagia and weight loss.
al
Diagnosis
Ev
• Upper GI endoscopy with brushings and biopsy of any lesion seen is the first
line test
• CT or MRI scan of the chest and upper abdomen is performed for staging
purposes
28. While performing an appendectomy, a surgeon found a mass in the caecum of a

patient. The mass was removed and sent for analysis. Analysis revealed a transmural
infiltration with lymphocytes and granulomas without necrosis. What is the SINGLE
A. Caecal Cancer
B. Lymphoma
C. Tuberculosis
D. Crohn’s Disease
E. Ulcerative Colitis
463
This is a difficult question to answer as there is not much background information in
terms of patient history or signs and symptoms in terms of patient presentation. Based
on the histology, we would be tempted to choose Crohn’s disease as a diagnosis as
Crohn’s disease is known to have histopathology of:
· Abdominal mass palpable in right iliac fossa
· Increased goblet cells on histology
· Granulomas seen on histology
· Transmural, skip lesions, cobble stone appearance on endoscopy
· Kantor's string sign, rose thorn ulcers and fistulae are seen on a small bowel
enema
Based on the histopathology ALONE the correct answer is D. In reality, the patient
would present with the classical signs and symptoms of Crohn’s disease i.e:
· diarrhoea (which may be bloody and become chronic - ie present for more than six
weeks)
· abdominal pain and/or weight loss
· periods of acute exacerbation, interspersed with remissions or less active disease.
· Systemic symptoms of malaise, anorexia, or fever
y
· Abdominal tenderness or distension, palpable masses.
op
· Anal and perianal lesions (pendulous skin tags, abscesses, fistulae) are
characteristic.
· Mouth ulcers.
C
Some additional points to remember
n
To diagnose UC or CD:
io
1. Fecal calprotectin
2. AXR - to exclude colonic dilatation
t
3. Stool exam
ua
4. Barium fluoroscopy
5. Sigmoidoscopy/colonoscopy + biopsy
al
Ulcerative Colitis Management

Inducing remission
Ev
Topical → Rectal Mesalazine better than rectal steroids

1st line → 5-ASA (e.g. oral mesalazine)
2nd line → Oral Prednisolone
If severe colitis, treat in hospital with IV steroids as first line.
oral aminosalicylates e.g. mesalazine
Management of Crohn’s disease

Inducing remission
1st line → Oral Prednisolone
2nd line → 5-ASA drugs (e.g. mesalazine)
azathioprine or mercaptopurine may be used as an add-on medication to induce
remission but is not used as monotherapy
metronidazole is often used for isolated perianal disease
1st line → azathioprine or mercaptopurine
464
29. A 44 year old woman had a total abdominal hysterectomy and bilateral salpingo-
oophorectomy 5 days ago. She now has increasing abdominal discomfort and is now
bloating. She was encourage to stay well hydrated but she is still unable to pass gas. No
bowel sounds are heard. What is the SINGLE most appropriate next step?
A. X-Ray abdomen
B. Exploratory laparoscopy
C. CT abdomen
E. Barium enema
The likely diagnosis here is paralytic ileus and an X-ray can help with the diagnosis
Prolonged surgery is one of the major causes of paralytic ileus and it occurs due to over
handling of the bowel.
Paralytic ileus is to be expected in the first few days after abdominal surgery. Bowel
sounds are absent and there is no passage of gas. There may be mild distension, but
y
there is no pain.
Clinical features
op
• Abdominal distension, tympanic or dull on percussion.
C
• Abdominal X-ray → Shows air/fluid-filled loops of small and/or large bowel
• Intestinal ileus usually settles with appropriate treatment.
n
Treatment
io
• Pass an NGT to empty the stomach of fluid and gas if the patient is nauseated
or vomiting. Small volumes of tolerated oral intake may help mild ileus to
t
resolve.
ua
• Ensure adequate hydration by IV infusion (‘drip and suck’).

• Reduce opiate analgesia and encourage the patient to mobilize.
al
30. A 32 year old woman complains of brief episodes of severe shooting pain in the rectum
that usually occur at night. Rectal examination and flexible sigmoidoscopy detect no
Ev
abnormalities. What is the SINGLE most probable diagnosis?
A. Anal haematoma
B. Anal fissure
C. Rectal carcinoma
D. Proctalgia fugax
E. Piles
A normal rectal examination and flexible sigmoidoscopy excludes the other options.
Only proctalgia fugax is left.
Proctalgia fugax
Severe recurrent rectal pain in the absence of any organic disease. Attacks may occur at
night, after bowel actions, or following ejaculation. Anxiety is said to be an associated
feature.
465
31. A 42 year old female presents to her GP following a staging CT for her recently
diagnosed renal cell carcinoma. On the CT scan, gallstones were noticed in the
gallbladder. She has no history of abdominal pain or jaundice and is otherwise well. A
left sided nephrectomy for her renal cell carcinoma has been scheduled. What is the
B. ERCP (Endoscopic Retrograde cholangiopancreatography)
C. MRCP (Magnetic resonance cholangiopancreatography)
D. Reassurance
E. Laparoscopic cholecystectomy
Reassurance is the correct option here. It is reserved for patients who are
asymptomatic and have stones in their gallbladder. Stones that are found incidentally,
as a result of imaging investigations unrelated to gallstone disease in patients who are
asymptomatic do not require any intervention. But be aware that if the gallstones were
found in the common bile duct instead of the gallbladder, then a laparoscopic
cholecystectomy may be needed regardless if they are symptom free or have
y
symptoms.
32.
op
A 60 year old man presents with weight loss and complains of mild abdominal pain,
bloating and diarrhoea for the past 6 months. A recent blood test shows a haemoglobin
C
of 7 g/dl. What is the SINGLE most appropriate investigation?
A. Barium enema
n
B. Colonoscopy
io
C. Sigmoidoscopy
D. Computed tomographic (CT) colonography
t
E. Carcinoembryonic Antigen (CEA)

ua
Colonoscopy would be able to diagnose majority of the causes of change of bowel habit
and weight loss. The likely diagnosis here is colorectal cancer although inflammatory
al
bowel disease could also present with similar features (e.g. weight loss, abdominal
pain, and anaemia). Whatever the cause, a colonoscopy and biopsy is the gold standard
Ev
to give us a diagnosis.
Colorectal carcinoma diagnosis

Colonoscopy is still the preferred diagnostic investigation. Alternatives to colonoscopy
include barium enema and CT colonography.
If a patient is without major comorbidities, colonoscopy should be offered to diagnose

colorectal cancer. If a lesion suspicious of cancer is detected, a biopsy sample should be
sent for histology.
Flexible sigmoidoscopy, then barium enema can be used as an alternative to

colonoscopy for patients with major comorbidity. Barium enema may also be used if
colonoscopy fails to visualise the caecum or if the patient is unable to tolerate the
colonoscopy procedure.
Computed tomographic (CT) colonography can also be used as an alternative if the local
radiology service can demonstrate competency in this technique. If a lesion suspicious
466
of cancer is detected on CT colonography, a colonoscopy with biopsy to confirm the
diagnosis should be performed.
The tumour marker Carcinoembryonic Antigen (CEA) is of no use for diagnosis or

staging, but can be used to monitor disease relapse if raised at diagnosis and falls to
normal after resection.
33. A 38 year old man complains of "crushing" chest discomfort for 1 hour that started
when he drank a cold drink. He has no significant medical history. ECG shows sinus
rhythm. He is given sublingual nitroglycerin in the emergency room that improves his
chest pain almost immediately. He has a pulse of 70 beats/minute, a blood pressure of
130/80 mmHg and a respiratory rate of 18 breaths/minute. Cardiac enzymes came back
negative. What is the SINGLE most likely diagnosis?
A. Myocardial Infarction
B. Pericarditis
y
E. Pneumothorax
op
The pain started when he drank a cold drink. The most likely answer here is oesphageal
spasm.
C
Diffuse Esophageal Spasm (DES)
n
Clinical Presentation
io
These patients present with intermittent chest pain and dysphagia. The pain can
simulate that of a myocardial infarction, but it bears no relationship with exertion. The
t
pain can be precipitated by drinking cold liquids.

ua
Diagnosis
Barium studies may show a "corkscrew" pattern at the time of the spasm. The most
al
accurate test is manometric studies, which will show high-intensity, disorganized

contractions
Ev
Because the contractions are disorganized, they do not lead to the forward flow of food
and peristalsis.
Treatment
Calcium-channel blockers, such as nifedipine, and nitrates.
34. A 58 year old man presents with a lump in the left supraclavicular fossa. It has been
present for the last 6 months. He also complains of dyspepsia and loss weight which he
accounts for due to his reduced appetite. What is the SINGLE most likely term for the
lump?
A. Virchow’s node
B. Lymphoma
C. Pancoast tumor
D. Thyroglossal cyst
E. Reactive lymph nodes
467
The lump in the left supraclavicular region is known as a Virchow’s node it is indicative
of carcinoma of the stomach. The weight loss and decrease appetite supports the
diagnosis of gastric cancer.
35. A 12 year old child complains of right iliac fossa pain and diarrhoea. On colonoscopy, a
transmural, cobblestone appearance mucosa is seen near the ileo-caecal junction.
A. Mesalazine
B. Paracetamol
C. Ibuprofen
D. Metronidazole
E. Mercaptopurine
The diagnosis of Crohn’s disease is quite clear here. A transmural, cobblestone

appearance mucosa is a give away that this is Crohn’s disease.
y
Inducing remission
op
C
• azathioprine or mercaptopurine may be used as an add-on medication to
induce remission but is not used as monotherapy
n
• metronidazole is often used for isolated perianal disease
io
t

ua
al
Ev

fossa

468
36. A 40 year old woman complains of dysphagia when eating solids and drinking liquids.
She sometimes suffers from severe retrosternal chest pain. Barium swallow reveals a
dilated oesophagus which tapers to a fine distal end. What is the SINGLE most
A. Reassurance
B. Antispasmodics
C. Dilatation of the lower oesophageal sphincter
D. Endoscopic diverticulectomy
E. Calcium channel blocker
Achalasia
y
op
Presentation:
C
n
io
t
ua
and tobacco use.
Investigations:
al
Ev

Management:
37. A 55 year old man with no past medical history comes to your office for the evaluation
of "difficulty swallowing" foods. He has had this problem for almost a year, and finds it
difficult for him to swallow both solids and liquids. A barium meal shows gross
dilatation of the esophagus with a smooth narrowing at the lower end of the
esophagus. What is the SINGLE most likely diagnosis?
A. Achalasia
D. Oesophageal web
469
Achalasia
Presentation:
y
op
and tobacco use.
Investigations:
C
n
io
Management:
t

ua
38. What is the pathological change in Barrett's esophagus?

al
A. Replacement of squamous epithelium to columnar epithelium

Ev
B. Replacement of columnar epithelium to squamous epithelium

C. Replacement of squamous epithelium to cuboidal epithelium
D. Dysplasia
E. Hyperplasia
Barrett’s oesophagus
Barrett’s oesophagus results from prolonged exposure of normal oesophageal

squamous epithelium to the refluxate of GORD. This causes mucosal inflammation and
erosion, leading to replacement of the mucosa with metaplastic columnar epithelium.
The most significant associated morbidity is oesophageal adenocarcinoma.
39. A 25 year old woman has diarrhoea and abdominal bloating over the last 4 months. On
examination, she has blistering rash over her elbows. Her blood test show:
Haemoglobin 105 g/L
470
On jejunal biopsy, there is shortening of the villi and lymphocytosis. What is the SINGLE
A. Coeliac disease
B. Whipple’s disease
D. Tropical sprue
E. Giardiasis
The blistering rash over her elbows is called dermatitis herpetiformis. Dermatitis
herpetiformis, is a skin condition linked to coeliac disease. Typical symptoms of
dermatitis herpetiformis are red, raised patches, often with blisters and severe itching.
The low haemoglobin is another clue towards coeliac as one of the most common
presentation of coeliac disease is iron deficiency anaemia. Folate and B12 deficiency
can also occur.
y
op
The shortening of villi (villous atrophy) and lymphocytosis on jejunal biopsy is provides
us with the diagnosis of coeliac disease. C
One may be thinking of tropical sprue as a diagnosis as it also has villous atrophy on
jejunal biopsy and has similar presentation. But tropical sprue does not present with
dermatitis herpetiformis and it is also much rarer as compared to coeliac disease.
n
io
Coeliac disease
t

ua
Signs and symptoms

al
Ev
and vomiting
• Fatigue
disease
Complications
• osteoporosis
Investigation
471
NICE
Jejunal biopsy
• Villous atrophy
Management
y
40.
op
A 28 year old female presents with a 4 month history of diarrhoea, lethargy and weight
C
loss. She complains of abdominal discomfort and passing stools more than 6 times a
day. An endoscopy was performed which shows cobblestone mucosa. What is the
n
io
A. Amoeba
B. Colon Cancer
t
ua
D. Crohn's disease
al
The diagnosis of Crohn’s disease is quite clear here. Lethargy and weight loss are non
specific signs that can occur in Crohn’s disease. The give away here is the cobblestone
Ev
mucosa that is seen on endoscopy which is pathognomonic for Crohn’s disease.

fossa
472
41. A 33 year old woman has severe upper abdominal pain with radiation to the back
within 24 hours of removing gallstones by endoscopic retrograde
cholangiopancreatography (ERCP). The pain is eased when she leans forward. She
reports some nausea and vomiting but denies any diarrhoea. Jaundice is noted and the
epigastric region is tender on palpation. Her blood pressure is 120/80 mmHg, and
temperature is 37.3°C. What is the SINGLE most likely reason for his signs and
symptoms?
A. Ascending cholangitis
y
op
D. Chronic pancreatitis
E. Bleeding C
The likely cause is acute pancreatitis. Pancreatitis is one of the most frequent post-ERCP
complications. The incidence of this is around 20%.
n
Ascending cholangitis may have similar presentation but given that she is apyrexial, the
io
likely cause is acute pancreatitis. Note that even in acute pancreatitis, mild pyrexia is
common.
t
ua
Comparison between acute pancreatitis and acute cholangitis
Acute pancreatitis Acute cholangitis

al
Suggested by: Suggested by:

• Pain radiating straight through to • Fever, RUQ abdominal pain, and
Ev
the back which is better on jaundice (Charcot’s triad)

sitting up or leaning forward • Hypotension
• General abdominal tenderness • Leucocytosis
with reduced bowel sounds
Confirmed by:
Confirmed by: • Ultrasound scan of gallbladder
• Elevated serum lipase and and biliary ducts, and blood
amylase, CT pancreas cultures
Acute pancreatitis
Aetiology

• Gallstones
473
• Ethanol
• Trauma
• Steroids
• Scorpion venom
• ERCP
Clinical features
• Tachycardia
• Fever,
• Jaundice
y
• Shock
op
C
Investigation
n
io

t
ua
42. A 48 year old woman is admitted to A&E with a productive cough and a moderate
fever. She complains of central chest pain and regurgitation of undigested food. She
finds it difficult to swallow both food and liquids. These symptoms of swallowing have
al
been present for the last 4 months. A chest X-rays shows megaesophagus. What is the
Ev
A. Pharyngeal pouch
B. Hiatus hernia
C. Bulbar palsy
D. Achalasia
E. Tuberculosis
The diagnosis here is Achalasia. It can sometimes present as chest pain. The productive
cough in this question points towards aspiration pneumonia secondary to retained food
and fluid in the oesophagus. Regurgitation of undigested food, and difficulty swallowing
both food and liquids are classic for achalasia. A chest X-ray would also show a large
oesophagus in Achalasia.
While some might argue that the answer here could potentially be pharyngeal pouch
due to the regurgitation of undigested food and the aspiration pneumonia. The writers
of the PLAB test would provide other hints if pharyngeal pouch was the answer such as
474
halitosis which may occasionally be seen in a pharyngeal pouch. Furthermore,
megaesophagus points towards achalasia as being the answer for this question.
Achalasia
Presentation:
y
op
and tobacco use.
C
Investigations:
n
io

t
ua
Management:
al
43. A 44 year old male is admitted with repeated attacks of pancreatitis. He has peripheral
paresthesia and loss of proprioception in the legs. He is having memory loss and
Ev
difficulties with thinking. What is the SINGLE most appropriate management?
A. Thiamine
B. Pyridoxine
C. Hydroxocobalamin
D. Lipase
E. Antibiotics
Inadequate vitamin B12 absorption can be due to chronic pancreatitis.
Neuropsychiatric features of B12 deficiency include dementia which is why he is having

memory loss and difficulties with thinking.
Peripheral paresthesia and disturbances of position and vibration sense are classically
seen in B12 deficiency.
Treat with hydroxocobalamin.
475
B12 deficiency
terminal ileum.

y
op
hypothyroidism
C
n
io
t

ua

al

Ev
Management:
Hydroxocobalamin IM
44. A 36 year old bodybuilder presents with sudden onset of severe abdominal pain. He
was previously fit and well and only suffers from indigestion occasionally. He has been
taking ibuprofen for a long term knee injury. On examination, he has a rigid abdomen,
lies motionless on the bed and has no bowel sounds. His pulse rate is 115 bpm and
blood pressure is 100/60 mmHg. What is the SINGLE most likely diagnosis?
B. Ischemic colon
476
The diagnosis here is perforated peptic ulcer induced by NSAIDs. The sudden onset,
rigid abdomen, lying motionless and no bowel sounds are all hints that point towards
perforated peptic ulcer.
Perforated peptic ulcer
Perforation of a gastric or duodenal ulcer is usually a severely painful sudden event. It

may occur in those without known peptic ulcer disease, as well as those with previously
diagnosed problems. However, close questioning may reveal recent symptoms
attributed to ‘indigestion’.
Sudden localized epigastric pain spreads to the remainder of the abdomen the pain is
worse on coughing or moving and may radiate to the shoulder tip
Examination
Although distressed, the patient often prefers to lie still, rather than roll about. Absent
bowel sounds, shock, generalized peritonitis and fever develop as time passes.
y
Investigations
op
An erect chest X-ray will demonstrate free gas under the diaphragm
In those cases where the diagnosis is suspected, but not proven by X-ray, a contrast CT
C
scan may help.
Treatment
n
• Provide IV analgesia
io
• Give an antiemetic (eg IV metoclopramide 10mg).

• Resuscitate with IV 0.9 % saline.
t
• Refer to the surgeon and give IV antibiotics

ua
45. A 43 year old male alcoholic presents after a large haematemesis. He has some spider
naevi on his chest. His blood pressure is 100/76 mmHg and pulse rate is 110
al
beats/minute. On examination. a swollen abdomen with shifting dullness is seen. What

Ev
A. Peptic ulcer
B. Mallory-weiss tear
C. Oesophageal cancer
D. Oesophageal varices
E. Oesophagitis
Spider naevi and ascites are suggestive of liver disease. It is likely that with the history
of alcohol, and his signs and symptoms, he has a diagnosis of chronic liver disease
which has resulted in portal hypertension and bleeding from oesophageal varices.
Oesophageal varices
• Dilated sub-mucosal veins in the lower third of the oesophagus
This can lead to variceal haemorrhage which occurs from the dilated veins (varices) at
the junction between the portal and systemic venous systems. The bleeding is often
477
severe and life-threatening. Majority of the patients would have a history of chronic
liver disease.
Presentation:
• Haematemesis (most commonly), melaena
• Signs of chronic liver disease
Investigation:
• Endoscopy at early stage
Acute management of variceal bleeding

• Always start with ABC
• Correct clotting: FFP, vitamin K
• Vasoactive agents like terlipressin → Terlipressin should be offered to patients
with suspected variceal bleeding at presentation
• Antibiotic prophylaxis → reduces mortality in patients with acute upper GI
bleeding in association with chronic liver disease
• Endoscopic variceal band ligation → If band ligation not available, use
y
emergency sclerotherapy as first line
op
• Sengstaken-Blakemore tube if uncontrolled haemorrhage
• Transjugular Intrahepatic Portosystemic Shunt (TIPSS) if still unable to control
bleeding
C
Prophylaxis of variceal haemorrhage
• Propranolol often given at discharge to reduce portal pressure in order to
n
decrease the risk of repeat bleeding
t io
46. A 70 year old man had a right hemicolectomy for caecal carcinoma 4 days ago. He now
ua
has abdominal distension and recurrent vomiting. He has not opened his bowels since
the surgery. On auscultation, no bowel sounds were heard. He has a temperature of
37.3°C. FBC was done. Results show:
al
WBC - 9 x 109/L
Hb - 12g/dl
Ev
What is the SINGLE most appropriate next management?
A. IV Antibiotics
B. Glycerine suppository
C. Laparotomy
D. NG tube suction and IV fluids
E. Total parenteral nutrition
The diagnosis here is paralytic ileus which is seen commonly after a prolonged surgery.
It should be treated conservatively. ‘Drip and suck’ method would be the best option
here. “Drip” meaning IV fluids. “Suck” meaning pass an NGT to empty the stomach of
fluid and gas. Intestinal ileus usually settles with appropriate treatment.
Paralytic ileus
is the cessation of GI tract motility.
478
Causes
• Prolonged surgery, exposure and handling of the bowel
• Peritonitis and abdominal trauma
• Electrolyte disturbances
• Anticholinergics or opiates
• Immobilization
Clinical features
• Nausea, vomiting
• Abdominal distension
• Air-/fluid-filled loops of small and/or large bowel on abdominal X-ray
Treatment
• Pass an NGT to empty the stomach of fluid and gas if the patient is nauseated or
vomiting. Small volumes of tolerated oral intake may help mild ileus to resolve
• Ensure adequate hydration by IV infusion (‘drip and suck’)
• Maintain the electrolyte balance
• Reduce opiate analgesia and encourage the patient to mobilize
y
op
47. An 65 year old lady had a urinary tract infection which was treated with broad
spectrum antibiotics. A few days later she developed bloody diarrhoea and abdominal
pain. She has a temperature of 38.6°C. Her blood tests show:
C
Haemoglobin 119 g/L
n
CRP 180 mg/l
io

t
ua
A. Co-amoxiclav
B. Piperacillin + tazobactam
C. Ceftriaxone
al
D. Vancomycin
E. Amoxicillin
Ev
Clostridium difficile
Clostridium difficile is a Gram positive rod often encountered in hospital practice. It

produces an exotoxin which causes intestinal damage leading to a syndrome called
pseudomembranous colitis. Clostridium difficile develops when the normal gut flora are
suppressed by broad-spectrum antibiotics.
Features
• diarrhoea - may be mild diarrhoea or serious bloody diarrhoea with systemic
upset
• abdominal pain
• a raised white blood cell count is characteristic
Diagnosis
Clostridium difficile toxin (CDT) detected in the stool
479
Management
• Stop the causative antibiotic (if possible)
• first-line therapy is oral metronidazole
• if severe or not responding to metronidazole then oral vancomycin may be
used
Note: Treatment is not usually needed if patient is asymptomatic
48. A 54 year old woman, known case of pernicious anaemia refuses to take
hydroxocobalamin IM as she is needle shy. She is asking for oral medication. What is
the SINGLE best reason that describes why oral medications will not be effective?
A. Intrinsic factor deficiency

B. Increased gastric acidity
C. Lack of gastric acidity
D. Irritated gastric mucosa
E. abundance of ileal binding sites
y
Pernicious anaemia is caused by an autoimmune atrophic gastritis, leading to
op
achlorhydria and lack of gastric intrinsic factor secretion. Injections are required.
Note: if the cause of B12 deficiency is not due to pernicious anaemia (e.g. dietary), then
C
oral B12 can be given after the initial acute course. In the UK, the usual regimen for b12
deficiency that is NOT caused by pernicious anaemia is regular (eg 3-monthly) IM
hydroxocobalamin (1mg). Elsewhere, high-dose oral B12 regimen (cyanocobalamin 1
n
mg/day) is standard, less costly, and obviates the need for repeat visits to nurses.
io
B12 deficiency
t
ua
al
terminal ileum.
Ev

hypothyroidism
480
shoulder. On examination, her sclera appear yellow. Her BP is 120/85 mmHg;
respiratory rate 15/min; Heart rate 85 bpm; Temperature 37.3°C; WBC 9 x 109/L. She
has no relevant past medical history and is not on any medications. What is the SINGLE
B. Urinary bilirubin
C. Alkaline phosphatase
D. Serum cholesterol
E. X-ray abdomen
Ultrasound of abdomen is the best answer, as this will most likely show the cause (i.e.
gallstones present or not). The diagnosis here is likely to be biliary colic which presents
in this manner. As gallstones obstruct the common bile duct, it may present with
jaundice.
y
Urinary bilirubin will merely confirm an obstructive jaundice picture.
op
Alkaline phosphatase can also confirms a cholestatic picture.
C
Testing serum cholesterol will only show increased cholesterol levels, which is not very
specific and does not address the cause
n
Plain Abdominal X-ray only shows around 10% of gallstones.
io
Biliary colic
t
ua
Occurs when a stone temporarily occludes the cystic duct. There is a colicky pain in the
right upper quadrant radiating to right shoulder. The episode is usually self limiting.
Ultrasound establishes diagnosis of gallstones.
al
The main difference of biliary colic and acute cholecystitis is the inflammatory
Ev
component. In acute cholecystitis there is local peritonism, fever, and elevated WCC.
Management includes:
Analgesia, rehydrate, nil by mouth.
Elective laparoscopic cholecystectomy is usually indicated
50. An 8 year old child presents with recurrent abdominal pain. He has three episodes of
abdominal pain within the last 3 months and it is severe enough to affect his activity in
school. The abdominal pain is intense and located periumbilically lasting for a few hours
and is associated with nausea and episodic headaches. He maintains a good appetite
and is an appropriate weight for his age. On examination, there were no significant
findings. Full blood count, urea and electrolytes are found to be normal. What is the
B. Computed tomography abdomen
481
C. Reassure
D. Prescribe omeprazole
E. Admit and administer intravenous fluids
Recurrent abdominal pain with episodic headaches in a child with no abnormal finding
on examination and investigation, points towards a diagnosis of Abdominal Migraine.
Abdominal migraines are a type of functional pain. It is usually characterised by having:

• Paroxysmal episodes of intense, acute periumbilical pain lasting for one or
more hours
• Pain is dull or "just sore" quality
• Intervening periods of usual health, lasting weeks to months
• The pain interferes with normal activities
• The pain is associated with two or more of the following: anorexia, nausea,
vomiting
• Not attributed to another disorder
Reassurance is all that is needed.
y
op
51. A 44 year old male was admitted to the medical ward with complaint of diarrhoea,
abdominal pain and weight loss for the last few months. The examination notes finger
clubbing, perianal skin tags and abdominal tenderness. A colonoscopy reveals
C
transmural granulomatous inflammation involving the ileocaecal junction. What is the
n
A. Crohn's disease
io

C. Bowel cancer
t
D. Diverticulitis
ua
al

Ev

fossa

482
52. A 55 year old woman complains of retrosternal chest pain and difficulty swallowing
which is intermittent and unpredictable. She says that food gets stuck in the middle of
the chest and she has to clear it with a drink of water. She is then able to finish the
meal without any further problem. A barium meal shows a ‘corkscrew patterned
oesophagus’. What is the SINGLE most likely cause of the dysphagia?
A. Oesophageal candidiasis
D. Pharyngeal pouch
E. Plummer-vinson syndrome
The corkscrew pattern gives it away. This can only be oesphageal spasm.
Diffuse Esophageal Spasm (DES)
y
op
These patients present with intermittent chest pain and dysphagia. The pain can
simulate that of a myocardial infarction, but it bears no relationship with exertion. The
C
pain can be precipitated by drinking cold liquids.
Diagnosis
n
Barium studies may show a "corkscrew" pattern at the time of the spasm. The most
io
accurate test is manometric studies, which will show high-intensity, disorganized

contractions
t
ua
Because the contractions are disorganized, they do not lead to the forward flow of food
and peristalsis.
al
Treatment
Calcium-channel blockers, such as nifedipine, and nitrates.
Ev
53. A 51 year old man has become increasingly fatigued over the past 10 months. His
medical history includes having a gastrectomy a year ago. His physical examination is
unremarkable. His blood tests show:
Haemoglobin 85 g/L
What is the SINGLE most likely finding on a blood smear?
A. Hypersegmented neutrophils
B. Nucleated RBC
C. Blasts
D. Hypochromic, microcytic RBC
E. Schistocytes
483
B12 could occur, points towards the diagnosis of B12 deficiency. Mean cell volume is
also increased which supports that diagnosis. Hypersegmented neutrophils are seen on
blood smear in megaloblastic anaemias.
B12 deficiency
terminal ileum.
y
op

C
n
hypothyroidism
io

t

ua
al
Ev

Management:
Hydroxocobalamin IM
54. A 41 year old lady attends the clinic complaining of a long history of mild pruritus and
fatigue. She looks jaundiced. Alkaline phosphatase was raised on routine liver function
test. She was diagnosed with Sjögren syndrome a few years back. What is the SINGLE
most appropriate test to perform to help make a diagnosis?
A. Rheumatoid factor
484
B. Anti-nuclear antibodies
C. Anti Smooth Antibodies
D. Antimitochondrial antibodies
E. Antineutrophil cytoplasmic antibodies
The diagnosis here is primary biliary cirrhosis
The classic presentation is itching in a middle-aged woman as we see here.
Often asymptomatic and diagnosed after finding alkaline phosphatase on routine LFT.
Lethargy, sleepiness, and pruritus may precede jaundice.
There is an association with Sjögren syndrome.
Antimitochondrial antibodies (AMA) are the hallmark for this disease
To help remember: Think of the M rule for Primary biliary cirrhosis

• IgM
y
• anti-Mitochondrial antibodies
op
• Middle aged females
55. A 39 year old patient was recently diagnosed with coeliac disease and has been treated
C
with a gluten free diet for 2 years. He now has an exacerbation of the classic symptoms
of coeliac disease such as abdominal pain, diarrhoea, and has loss significant weight.
The biopsy of the small intestine shows lymphomatous infiltrates. What is the SINGLE
n
io
A. Lymphoma
t
B. Diverticular disease
ua
C. Lynch syndrome
D. Gastric tuberculosis
E. Peritoneal tumor
al
Enteropathy-associated T-cell lymphoma (EATL) is a complication of celiac disease (CD).

Ev
This tumor derives from the neoplastic transformation of aberrant intraepithelial T

lymphocytes emerging in coeliac patients unresponsive to a gluten-free diet.
Biopsy may show lymphomatous infiltrates accompanied by a prominent mixed

inflammatory infiltrate composed of histiocytes, small lymphocytes, plasma cells, and
eosinophils, which may obscure the neoplastic cells.
Just keep in mind that lymphoma should be at the top of the list of answers when you
see a patient with coeliac disease in the PLAB exam.
Coeliac disease
Signs and symptoms

485
and vomiting
• Fatigue
disease
Complications
• osteoporosis
Investigation
y
op
C
n
NICE
io

t
Jejunal biopsy
ua
• Villous atrophy
al
Ev
Management
56. A 39 year old woman is admitted with central abdominal pain radiating through to the
back. She has vomited several times in the last 24 hours. She denies any diarrhoea or
fever. Bending forward helps alleviate the pain. Her blood test show:
Amylase 1335 U/mL (Elevated)
A. Cirrhosis
D. Dissecting aortic aneurysm
E. Mesenteric ischaemia
486
The likely diagnosis is acute pancreatitis given the elevated amylase.
Acute pancreatitis
Aetiology

• Gallstones
• Ethanol
• Trauma
• Steroids
• Scorpion venom
• ERCP
y
op
Clinical features
C
n
• Tachycardia
io
• Fever,
• Jaundice
t
• Shock
ua

al
Investigation
Ev

shoulder. An ultrasound establishes the diagnosis of gallstones. Her BP is 120/85
mmHg; respiratory rate 15/min; Heart rate 85 bpm; Temperature 37.3°C; WBC 9 x
109/L. What is the SINGLE most appropriate management?
A. Elective laparoscopic cholecystectomy

B. Reassure
C. Low fat diet
As she is symptomatic, reassurance is out of the question. The two remaining options
are elective laparoscopic cholecystectomy or emergency laparotomy. Laparoscopic
487
cholecystectomy is the prefered option here as there are no signs of gallbladder
perforation. Laparotomy has higher risk as it is much more invasive.
Biliary colic
58. A 50 year old man comes to A&E with abdominal pain that began suddenly about 1
y
hour ago. The pain is now generalized, constant, and extremely severe. He lies
op
motionless on the stretcher, is diaphoretic, and has shallow, rapid breathing. His
abdomen is rigid, very tender to deep palpation, and has guarding. X-ray shows free air
under the diaphragm. What is the SINGLE most likely diagnosis?
C
B. Ischemic colon
n
io
t
ua
Definitely an acute abdomen. The X-ray which shows free air under the diaphragm is
classical for a perforation. Lying motionless and having a rigid, tender abdomen with
signs of guarding is typical for a perforated peptic ulcer.
al
Perforated peptic ulcer

Ev
Perforation of a gastric or duodenal ulcer is usually a severely painful sudden event. It

may occur in those without known peptic ulcer disease, as well as those with previously
diagnosed problems. However, close questioning may reveal recent symptoms
attributed to ‘indigestion’.
Sudden localized epigastric pain spreads to the remainder of the abdomen the pain is
worse on coughing or moving and may radiate to the shoulder tip
Examination
Although distressed, the patient often prefers to lie still, rather than roll about. Absent
bowel sounds, shock, generalized peritonitis and fever develop as time passes.
Investigations
An erect chest X-ray will demonstrate free gas under the diaphragm
In those cases where the diagnosis is suspected, but not proven by X-ray, a contrast CT
scan may help.
488
.
Treatment
• Provide IV analgesia
• Give an antiemetic (eg IV metoclopramide 10mg).
• Resuscitate with IV 0.9 % saline.
• Refer to the surgeon and give IV antibiotics
59. A 52 year old man who underwent a partial gastrectomy 10 months ago presents with
increasing fatigue. A yellow tinge is noted on his skin and he has a red sore tongue.
A. B12 deficiency
B. Cancer of the colon
C. Alcoholism
D. Coeliac disease
E. Crohn’s disease
Findings on examination for B12 deficiency may include lemon tinge to the skin and
y
glossitis.
op
B12 could occur, points towards the diagnosis of B12 deficiency.
C
B12 deficiency
n
io
t
terminal ileum.
ua
al

Ev


hypothyroidism
489
Management:
Hydroxocobalamin IM
60. An 83 year old woman who is a resident in a nursing home is admitted to a hospital
with a 4 day history of chronic constipation. She has had no weight loss or change in
appetite. She has been on analgesics for 3 weeks for her back pain. She is in obvious
discomfort. Rectal examination reveals faecal impaction with hard stools. What is the
A. Codeine phosphate for pain relief

B. High fiber diet
y
C. IV fluids
op
D. Phosphate enemas
E. Urinary catheterisation C
Medications such as opioid pain relievers reduce intestinal movement and may cause
faecal matter to become too large, hard and dry making it difficult to expel.
n
Codeine can reduce motility of the colon, increasing the likelihood of faecal impactions.
io
Thus, it is not the right answer here.

t
Enemas can be used to soften the stool by increasing the water content until it is soft
ua
enough to be expelled. Phosphate enema is the clear answer here as the question is
addressing the immediate management.
al
Faecal impaction
If the patient has faecal impaction, try:
Ev
• Bisacodyl suppositories
• Arachis oil retention enema to soften
• Phosphate enema
• An alternative is polyethylene glycol, Movicol taken for three days
• Manual removal (with midazolam, morphine, or caudal anaesthesia)
• Once successful it is imperative to start regular oral measures to prevent
recurrence of the problem
To be more specific in managing faecal impaction:

These are quite specific and are unlikely to be asked in the PLAB exam but nonetheless
good for your practice.
• For hard stools, consider using a high dose of an oral macrogol
• For soft stools, or for hard stools after a few days treatment with a macrogol,
consider starting or adding an oral stimulant laxative.
• If the response to oral laxatives is insufficient or not fast enough, consider:
• Using a suppository: bisacodyl for soft stools; glycerol alone, or glycerol
plus bisacodyl for hard stools.
490
• Using a mini enema
The final choice of laxative will depend on individual preference and what has
previously been tried.
61. A 17 year old boy has abdominal pain and diarrhoea for the last 3 months. He has lost 7
kg in the last 2 months. On colonoscopy, deep ulcers and skip lesions are noticed on the
mucosa. Perianal skin tags were seen on examination. What is the SINGLE most likely
diagnosis?
A. Crohn's disease
C. Coeliac disease
D. Diverticulitis
The diagnosis of Crohn’s disease is quite clear here. Skip lesions is a give away that this
y
is Crohn’s disease. This is supported by the weight loss and the perianal skin tags.
op
C

n
io
t
fossa
ua

al

Ev

62. A 70 year old woman is reviewed following a course of oral clindamycin for a right
lower limb cellulitis. She recently developed bloody diarrhoea and abdominal pain. She
has a temperature of 38.8°C. Her blood tests show:
Haemoglobin 125 g/L

CRP 140 mg/l
491
A. Oral co-amoxiclav
B. IV piperacillin + tazobactam
C. IV ceftriaxone
D. Oral metronidazole
E. Continue oral clindamycin
Clostridium difficile
Clostridium difficile is a Gram positive rod often encountered in hospital practice. It

produces an exotoxin which causes intestinal damage leading to a syndrome called
pseudomembranous colitis. Clostridium difficile develops when the normal gut flora are
suppressed by broad-spectrum antibiotics.
Features
• diarrhoea - may be mild diarrhoea or serious bloody diarrhoea with systemic
upset
y
• abdominal pain
op
• a raised white blood cell count is characteristic
Diagnosis
C
Clostridium difficile toxin (CDT) detected in the stool
Management
n
• Stop the causative antibiotic (if possible)
io
• first-line therapy is oral metronidazole

• if severe or not responding to metronidazole then oral vancomycin may be
t
used
ua
Note: Treatment is not usually needed if patient is asymptomatic

al
63. A 61 year old man presents with fatigue and palpitations. His past surgical history
Ev
includes an ileal resection which was performed one year ago. An FBC was requested
and the results are as follows:
Haemoglobin 93 g/L
A. Anaemia of chronic disease

B. Iron deficiency
C. Folate deficiency
E. Vitamin B12 deficiency
High MCV and low Hb → Macrocytic anaemia
492
These findings together with a history of ileal resection whereby malabsorption of B12
could occur, points towards the diagnosis of B12 deficiency.
B12 deficiency
terminal ileum.
y
op
C
hypothyroidism
n
io

t
ua
al
Ev

Management:
Hydroxocobalamin IM
64. A 46 year old woman presents with sudden episode of abdominal pain which started
about 5 hours ago. The pain is located in the epigastrium and radiates to her back. She
has vomited twice since the onset of attack. The pain is made worse by lying flat on her
back and she is more comfortable sitting up and bending forwards. She was informed of
the presence of gallstones in her gall bladder four weeks earlier when she reported pain
in the right hypochondrium. Her temperature is 38.4°C, blood pressure is 120/85
mmHg, and pulse rate is 115 beats/minute. There is no presence of jaundice but there
is marked tenderness in the epigastrium. What is the SINGLE most appropriate
investigation?
493
A. Abdominal X-ray
B. Serum amylase
C. Serum bilirubin
D. Barium swallow
E. Urea and electrolytes
The likely diagnosis is acute pancreatitis. Serum amylase and lipase are appropriate
investigations, looking for an elevation of more than 3 times the upper limit of normal.
y
op
pancreatitis (e.g. gallstone pancreatitis). C
Acute pancreatitis
Aetiology
n
io

t
• Gallstones
ua
• Ethanol
• Trauma
• Steroids
al

Ev
• Scorpion venom
• ERCP
Clinical features
• Tachycardia
• Fever,
• Jaundice
• Shock
494
Investigation
65. A 24 year old female presents with a 4 month history of bloody diarrhoea, lethargy and
weight loss. She complains of abdominal discomfort and passing stools more than 8
times a day. An endoscopy was performed which shows deep ulcers, and skip lesions.
A. Diverticulitis
B. Colon Cancer
D. Crohn's disease
y
The diagnosis of Crohn’s disease is quite clear here. Lethargy and weight loss are non
op
specific signs that can occur in Crohn’s disease. The give away here is the deep ulcers,
and skip lesions that is seen on endoscopy which is pathognomonic for Crohn’s disease.
C
Note that although Crohn’s disease usually has non bloody diarrhoea, it occasionally
may present with bloody diarrhoea.
n
io
t

ua
al
fossa
Ev


66. A 43 year old lady presents with jaundice. Skin excoriations were seen on physical
examination. Blood test reveal a raised alkaline phosphatase with mildly raised alanine
transaminase. Antimitochondrial antibodies are found to be positive. What is the
SINGLE most likely diagnosis
495
A. Hepatitis B
B. Hepatitis C
D. Primary sclerosing cholangitis
The diagnosis here is primary biliary cirrhosis
The classic presentation is itching in a middle-aged woman as we see here.
Often asymptomatic and diagnosed after finding alkaline phosphatase on routine LFT.
Lethargy, sleepiness, and pruritus may precede jaundice.
There is an association with Sjögren syndrome.
Antimitochondrial antibodies (AMA) are the hallmark for this disease
y
To help remember: Think of the M rule for primary biliary cirrhosis
op
• IgM
• anti-Mitochondrial antibodies
• Middle aged females
C
If one compares Primary Biliary Cirrhosis and Primary Sclerosing Cholangitis
n
Primary Biliary Cirrhosis Primary Sclerosing Cholangitis
io
• Autoimmune, idiopathic • Autoimmune, idiopathic

• Association → Sjogren • Association → IBD (especially UC)
t
• Pruritus, ↑ALP • Pruritus, ↑ALP

ua
• Antimitochondrial antibody • ERPC is the most specific test

(AMA) positive • Management involves
• Management involves ursodeoxycholic acid,
al
ursodeoxycholic acid, cholestyramine

cholestyramine
Ev
67. A 30 year old lady complains of intermittent diarrhoea, chronic abdominal pain and
tenesmus. Sometimes she notices blood in her stool. What is the SINGLE most likely
cause of her symptoms?
A. Inflammatory bowel disease

B. Diverticulosis
C. Irritable bowel disease
D. Adenomyosis
E. Endometriosis
Inflammatory bowel disease remains the best choice among the rest. All the symptoms
stated in the question including tenesmus can occur in inflammatory bowel disease.
The answer is unlikely to be diverticulosis as diverticulosis is defined as the presence of

diverticula which are asymptomatic. This patient has symptoms.
496
Blood in stools is not seen in irritable bowel disease. Remember, passing blood is not a
symptom of IBS.
The symptoms are not at all consistent with adenomyosis or endometriosis
68. A 22 year old man presents with a 2 month history of diarrhoea. He says his bowels
have not been right for the past few months and he frequently has to run to the toilet.
These symptoms seemed to be improving up until two weeks ago and for the past
week, he notices the presence of blood when he passes stool. On examination, there
are aphthous oral ulcers. He has not lost any weight and has a good appetite.
Examination of his abdomen demonstrates mild tenderness in the left lower quadrant
but no guarding. What is the SINGLE most likely diagnosis?
B. Crohn's disease
y
E. Anal Fissure
op
The diagnosis of Ulcerative colitis is quite clear here.
C
n
io

t
ua
fossa
al

Ev


69. A 23 year old woman has abdominal bloating, weight loss and intermittent diarrhoea.
She describes her stools as “frothy” and difficult to flush down the toilet. Her blood test
show:
Haemoglobin 105 g/L

497
Platelets 350 x 10 9/L
Ferritin 11 ng/ml
Vitamin B12 225 ng/L
Folate 1.9 mcg/L
Endomysial antibodies were tested positive. What is the SINGLE most likely diagnosis?
A. Coeliac disease
D. Irritable bowel syndrome
E. Giardiasis
The anaemia and low ferritin and folate levels are characteristic of coeliac disease. This
is in combination with the endomysial antibodies. A jejunal biopsy should be done to
confirm this diagnosis.
Coeliac disease
y
op
Signs and symptoms

C
n
and vomiting
io
• Fatigue
t

ua
al
disease
Ev
Complications
• osteoporosis
Investigation
NICE
498
Jejunal biopsy
• Villous atrophy
Management
70. A 34 year old man presents with slow progressive dysphagia. He has been using H2
blockers for the last year because of retrosternal discomfort. He has not notice any
weight loss. A haemoglobin level was done a month ago which reads 13.3g/dL. What is
A. Foreign body
y
C. Pharyngeal pouch
op
D. Peptic stricture
E. Esophageal Cancer C
Peptic strictures have an association with gastro-oesophageal reflux disease and can
cause dysphagia.
n
The fact that there is no weight loss and haemoglobin is normal points towards a
io
benign cause. Esophageal cancer at this age group is also uncommon.

t
months. She says that her diarrhoea has recently become bloody. A rectal biopsy was
ua
performed and histology was reported as “decreased amounts of goblet cells”. What is
al
B. Crohn's disease
Ev
The diagnosis of Ulcerative colitis is quite clear here. Decreased goblet cells on
histology points towards ulcerative colitis.

fossa
499

72. A 15 year old child complains of right iliac fossa pain and diarrhoea. He has lost 7 kg in
the last 2 months. On colonoscopy, skip lesions are noticed on the mucosa. What is the
y
A. Prednisolone
op
B. Mebeverine
C. Peppermint oil
D. Metronidazole
C
E. Vancomycin
The diagnosis of Crohn’s disease is quite clear here. Skip lesions is a give away that this
n
is Crohn’s disease.
io

t
ua
Inducing remission
al
• azathioprine or mercaptopurine may be used as an add-on medication to

induce remission but is not used as monotherapy
Ev
• metronidazole is often used for isolated perianal disease

fossa
500

73. A 59 year old man has multiple liver metastasis with the primary tumour originating
from the large bowel. He has abdominal pain, and jaundice. On general inspection, he
looks cachexic and drowsy. He has significant ascites and oedema seen on both ankles.
His family have concerns that he is not having sufficient fluids orally. His urine output is
low. He currently takes regular haloperidol 1.5 mg three times a day and lactulose 10ml
twice a day. His blood test show:
y
op
Sodium 129 mmol/L
Calcium 2.42 mmol/l
C
Potassium 3.6 mmol/l
Albumin 18 g/L
n
io

t
ua
A. Albumin infusion
B. Crystalloids intravenously
C. Furosemide intravenous
al
D. Fluids via nasogastric tube

E. Cease haloperidol
Ev
This patient has hypoalbuminaemia. When plasma proteins, especially albumin, no

longer sustain sufficient colloid osmotic pressure to counterbalance hydrostatic
pressure, oedema and ascites develops.
Intravenous albumin may be used to increase a colloid osmotic pressure to draw fluid
back into the intravascular compartment to reduce the oedema and ascites. It restores
intravascular plasma volume with less exacerbation of salt and water overload than
isotonic solutions. Albumin infusion produces only a transient effect but it is useful in
cases like this where surgery may not be an option and treatment of intravascular fluid
deficit and oedema is required. It is also useful to obtain a diuresis in
hypoalbuminaemic patients.
Haloperidol has no role in causing hypoalbuminaemia.
74. A 56 year old man comes for a routine check up. He is noted to have increased skin
pigmentation, spider angioma and a heart murmur. He has mild joint pain particularly
501
in those of the hands. He rarely drinks alcohol. On examination, his liver is firm and has
a span of 10 cm. On further investigations of the heart murmur, he was given the
diagnosis of restrictive cardiomyopathy. What is the SINGLE condition that he is most
likely at risk of?
A. Cerebellar degeneration
B. Gallstones
C. Renal failure
D. Hepatoma
E. Hepatic vein thrombosis
Hepatoma (more often called hepatocellular carcinoma) is a primary malignancy of the

liver. The given scenario has features of haemochromatosis of which is among the
causes of restrictive cardiomyopathy. It is a very well known fact that. patients with
haemochromatosis have an increased risk of developing hepatocellular carcinoma.
The liver is a primary storage area for iron and will naturally accumulate excess iron.
Over time the liver is likely to be damaged by iron overload causing cirrhosis. Cirrhosis
y
and haemochromatosis together will increase the risk of hepatocellular carcinoma.
Haemochromatosis
op
C
n
io
Presentation
t

ua
heart problems
al
LFTs
Ev
o Diabetes
o Hepatomegaly
o Cirrhosis
o Arthropathy
questions.
75. A 35 year old woman has sudden onset epigastric pain, chills and nausea. She gave birth
to a health baby 2 days ago. Her blood pressure was normal throughout pregnancy. Her
temperature is 37.3°C and her blood pressure is 139/90 mmHg. Urinalysis reveals no
proteins. Her blood test show:
502
International normalized ratio (INR) 1.0
Haemoglobin 101 g/L
White cell count (WCC) 13.5 x 109/L
A. Acute cholecystitis
B. Pre-eclampsia
C. Obstetric cholestasis
D. Acute fatty liver of pregnancy
E. HELLP syndrome
The history of sudden onset epigastric pain, chills, and nausea in the postpartum period
y
with a likely history of an uneventful pregnancy makes cholecystitis the most likely
op
diagnosis.
Symptomatic gallstone disease is the second most common abdominal emergency in

C
pregnant women. Pregnancy alters bile composition and gallbladder emptying slows in
the second trimester, increasing the risk of gallstones.
n
The raised ALT is of something to note. The causes of raised liver enzymes in
io
postpartum period is endless. They include:

• Pregnancy-related liver diseases such as:
t
o Obstetric cholestasis
ua
o Pre-eclampsia, eclampsia,
o HELLP syndrome
o Acute fatty liver of pregnancy
al
• Liver diseases unrelated to pregnancy

o Viral hepatitis
Ev
o Autoimmune liver disease

o Wilson’s disease
o Budd-Chiari syndrome
o Acute cholecystitis
o Drug-induced hepatotoxicity
As there is no protein in the urine and blood pressure has been normal throughout
pregnancy, pre-eclampsia is unlikely. As haemoglobin levels and platelet levels are
within a normal range for someone who has just delivered a baby, HELLP syndrome is
unlikely. Obstetric cholecystitis may have aminotransferase levels as high as 20 times
the normal limit, but the raised bile acids would cause significant pruritus which would
be the main presenting feature rather than epigastric pain.
Biliary colic occurs when a stone temporarily occludes the cystic duct. There is a colicky
pain in the right upper quadrant radiating to right shoulder. The episode is usually self
limiting. Ultrasound establishes diagnosis of gallstones. The diagnostic accuracy of
ultrasound for detecting gallstones is 95%.
503
76. A 33 year old pregnant woman develops severe epigastric pain, nausea and vomiting at
35 weeks gestation. She was diagnosed with pre-eclampsia 2 weeks ago. On
examination, she has yellow sclerae. Laboratory investigations show a deranged liver
function, low platelets, low serum glucose, raised serum ammonia. What is the SINGLE

B. Hyperemesis gravidarum
C. Biliary colic
D. HELLP syndrome
E. Autoimmune hepatitis
Acute fatty liver of pregnancy (AFLP) and HELLP (Haemolysis, Elevated Liver enzymes,
Low Platelets) syndrome both have low platelets and deranged liver function as part of
y
the clinical picture. However, low serum glucose and/or raised serum ammonia are
op
more suggestive of AFLP. Vomiting is also more commonly seen in AFLP than HELLP
syndrome. C
Acute fatty liver of pregnancy
Acute fatty liver of pregnancy (AFLP) is a rare form of jaundice in pregnancy. It occurs
n
late in pregnancy and may be life-threatening. The aetiology of AFLP is unknown. It is
io
part of the spectrum of disorders related to pre-eclampsia. Differentiation from HELLP

(Haemolysis, Elevated Liver enzymes, Low Platelets) syndrome can be difficult as signs
t
and symptoms can overlap.

ua
Risk factors
• Pre-eclampsia → There is associated pre-eclampsia in 30–60% of AFLP
al
• First pregnancies
• Multiple pregnancy
Ev
Presentation
• Presents acutely with:
o Nausea
o Vomiting
o Abdominal pain
o Fevers
o Headache
o Pruritus
o Jaundice
• Begins typically after 30 weeks of gestation
• It also may also appear immediately after delivery
Severe hypoglycaemia and clotting disorder may develop causing coma and death
Investigations
• Liver transaminases are elevated (ALT is typically elevated more than 500 U/L)
504
• Raised serum bilirubin
• Hypoglycaemia
• Abnormal clotting with coagulopathy (prolongation of prothrombin and partial
thromboplastin times)
• Biopsy would be diagnostic
Management (Unlikely to be asked in detail for the level of PLAB exam)

• Treat hypoglycaemia
• Correct clotting disorders
• N-acetylcysteine (NAC) (Unlicensed use)
• Consider early delivery
77. A 41 year old pregnant woman presents to A&E with right upper quadrant pain that
started in the last 12 hours and is gradually worsening. She has dark urine and pale
stools for the last 2 days. She is noted to have a yellow sclera on examination. Her
blood pressure is 145/95 mmHg. What is the SINGLE most appropriate investigation?
A. Ultrasound of abdomen
y
B. Urine protein: creatinine ratio
op
C. Urinary bilirubin
D. Urinary urobilinogen
E. Alkaline phosphatase
C
Symptomatic gallstone disease is the second most common abdominal emergency in
pregnant women. Pregnancy alters bile composition and gallbladder emptying slows in
n
the second trimester, increasing the risk of gallstones.
io
Do not be mislead into thinking this is pre-eclampsia due to the high blood pressure
t
and RUQ pain. Blood pressure will be raised in any patient who is in pain. Furthermore,
ua
pre-eclampsia does not present with symptoms of jaundice.
Ultrasound of abdomen is the best option here as an ultrasound will most likely show
al
the cause which is likely gallstones in this stem.

Ev
Raised urinary bilirubin with absent or reduced urobilinogen is suggestive of obstructive

jaundice and will merely confirm an obstructive jaundice picture.
Alkaline phosphatase will also be raised with gallstones causing bile duct obstruction
but also can be seen raised in pregnancy. Alkaline phosphatase is not a useful test in
pregnancy because of elevated levels from the placenta.
Biliary colic
505
78. A 33 year old lady who has been traveling around Europe for a few months now returns
to the United Kingdom with lethargy, abdominal pain, loose watery diarrhoea and
bloating. She has lost a few kilograms since coming back from the trip. Her physical
examination remains unremarkable with abdominal examination having mild
generalised tenderness. What is the SINGLE most likely organism causing her
symptoms?
A. Campylobacter jejuni
B. Salmonella enterica
C. Shigella dysentery
D. Staphylococcus aureus
E. Giardia lamblia
The two top choices for the cause of the diarrhoea in this stem are Campylobacter and
y
Giardia. As the patient has watery diarrhoea instead of bloody diarrhoea, giardiasis fits
op
best.
In the UK, many cases of giardiasis are associated with recent foreign travel. Giardiasis
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can present as traveller's diarrhoea with symptoms lasting more than ten days.
Symptoms of giardiasis include bloating, flatulence, abdominal pain, loose stool and
explosive diarrhoea. The symptoms may begin after returning from travel, and may be
n
associated with weight loss. Giardiasis can cause both acute and chronic diarrhoea. In
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this stem, it is likely chronic diarrhoea as there is a history of weight loss.

t
The clinical features of giardiasis are slightly different compared to campylobacter

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enteritis. In campylobacteriosis, clinical features usually include a prodromal illness of

headache and myalgia with fevers as high as 40°C. This is followed by abdominal pains
and profuse diarrhoea. The stool is often bloody. The reason many choose
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campylobacter as the answer is because campylobacter is the commonest bacterial

cause of infectious intestinal disease in the UK. But this is incorrect for this stem.
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Important key notes:

• Campylobacter, Shigella, Salmonella usually cause bloody diarrhoea.
• Giardiasis causes non-bloody diarrhoea
• Giardiasis can cause chronic diarrhoea associated with weight loss
• Campylobacter has a prodrome of headache, myalgia and fever
79. A 21 year old man has been brought to A&E by his friends as he is having a yellow sclera
and yellowing of the skin. He has recently been having flu-like symptoms and a non-
productive cough. A urine dipstick was performed and was normal. His blood results
show:
Haemoglobin 129 g/dl

Reticulocytes 1.2%
Alkaline phosphatase (ALP) 88
Alanine transferase (ALT) 24
506
Albumin 42
A. Acute hepatitis
C. Dubin Johnson Syndrome
Gilbert's syndrome is usually an autosomal recessive disorder and is a common cause of

unconjugated hyperbilirubinaemia due to decreased UGT-1 activity which is the enzyme
that conjugates bilirubin with glucuronic acid.
It may go unnoticed for many years and usually presents in adolescence with
intermittent jaundice occurring during illness, physical exertion, stress or fasting. In this
stem, the jaundice was precipitated by infection.
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Investigations usually show a mildly raised serum bilirubin but the other LFTs remain
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within normal ranges as seen in this stem. FBC would show normal reticulocyte count -
this helps distinguish Gilbert’s syndrome from other types of haemolysis. Urine
dipsticks would be seen as normal as it is the unconjugated bilirubin that is high (not
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the conjugated bilirubin as would be seen in Dubin Johnson syndrome).
Remember, viral infections are common triggers for a rise in the bilirubin in patients
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with Gilbert's syndrome.
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80. A 17 year old boy presents to A&E after his mother has noticed that his sclera has a
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yellowish tint. He has been taking over the counter medication for an upper respiratory
ua
tract infection for the past few days. He is otherwise well and has no significant past
medical history. What is the SINGLE most likely diagnosis?
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A. Acute hepatitis
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C. Drug induced haemolysis

E. Acute cholecystitis
Gilbert's syndrome is usually an autosomal recessive disorder and is a common cause of

unconjugated hyperbilirubinaemia due to decreased UGT-1 activity which is the enzyme
that conjugates bilirubin with glucuronic acid.
It may go unnoticed for many years and usually presents in adolescence with
intermittent jaundice occurring during illness, physical exertion, stress or fasting. In this
stem, the jaundice was precipitated by infection.
Remember, viral infections are common triggers for a rise in the bilirubin in patients
with Gilbert's syndrome.
507
81. A 47 year old women diagnosed with coeliac at the age of three has recently developed
diarrhea and weight loss for the past three months. What is the SINGLE most likely
reason for this?
A. Tapeworm infection
B. Lymphoma of the small intestine
C. Tuberculosis
D. Giardia
One must remember the cancer risk associated with coeliac disease. Intestinal
lymphoma is one of them.
82. A 31 year old female presented with complains of chest pain and difficulty in
swallowing liquids and solids. She has also been suffering from recurrent chest infection
for the past few months. What is the SINGLE most likely diagnosis?
A. Schatzki ring
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B. Plummer-Vinson syndrome
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C. Achalasia cardia
D. Peptic stricture
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The diagnosis here is achalasia. In achalasia, dysphagia is often with both fluids and
solid and in fact solids are affected more than soft food or liquids.
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It can sometimes present as chest pain or with recurrent chest infections. The chest
infections or aspiration pneumonia results from untreated achalasia that leads to
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nocturnal inhalation of material lodged in the oesophagus and aspiration pneumonia.

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Achalasia
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Presentation:
and tobacco use.
Investigations:
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•
Management:
83. A 33 year old female has intermittent diarrhoea and abdominal bloating which is
usually exacerbated by consumption of wheat and eggs. She has been feeling more
tired in the past few months. She has no significant weight loss. What is the SINGLE
A. Coeliac disease
C. Crohn's disease
D. Gastroenteritis
E. Malabsorption
y
op
The best answer here is Coeliac disease. Whilst it is true that coeliac disease causes
malabsorption which accounts for the intermittent diarrhoea and abdominal bloating,
the more specific answer is still Coeliac disease since there is a history of wheat in the
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diet.
Eggs actually do not exacerbate coeliac disease as it is not gluten however her meals
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which contain wheat is likely the cause of her malabsorption symptoms.
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Coeliac disease
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Signs and symptoms

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and vomiting
• Fatigue
disease
Complications
• Osteoporosis
Investigation
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NICE
Jejunal biopsy
• Villous atrophy
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Management
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GENERAL SURGERY
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Questions
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&
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Answers
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General Surgery Questions
1. A 24 year old woman presents with a 1 cm small smooth, firm, mobile mass in her left
breast. She is very anxious and wants a form of investigation. What is the SINGLE most
appropriate investigation to perform?
A. Mammography
B. Ultrasound scan of breast
C. Fine needle aspiration cytology
D. Magnetic resonance imaging scan of breast
E. Computerised tomography scan of breast
2. A 39 year old woman has been having tingling and numbness of her thumb, index and
middle fingers for a while. She has been treated with local steroids but there was no
improvement. She has planned to undergo a surgical procedure. What is the SINGLE
most likely structure to be incised?
A. Flexor digitorum profundus
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B. Transverse carpal ligament
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C. Palmar aponeurosis
D. Extensor retinaculum
E. Antebrachial fascia
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3. What anatomical structure is pierced during a midline port insertion during a
laparoscopic cholecystectomy?
n
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A. External iliac muscle

B. Linea alba
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C. Rectus abdominis
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D. Conjoined tendon
E. Intercostal muscles
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4. A 52 year old man has hoarseness of voice following a thyroid surgery a week ago. There
has been no signs of improvement. What is the SINGLE most likely anatomical
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structure(s) involved?
A. Bilateral recurrent laryngeal nerve

B. Unilateral recurrent laryngeal nerve
C. Unilateral external laryngeal nerve
D. Bilateral external laryngeal nerve
E. Vocal cords
5. A 55 year old man has been admitted for an elective herniorrhaphy. Which among the
following is the SINGLE most likely reason to postpone his surgery?
A. History of asthma
B. BMI > 30
C. Deep venous thrombosis 2 years ago
D. Diastolic BP of 90 mmHg
E. Myocardial infarction 2 months ago
512
6. A 55 year old man with cirrhosis of the liver complains of tiredness and right upper
quadrant pain over the last few months. He has lost 8 kg in the last 2 months. The liver is
palpable on abdominal examination. What is the SINGLE most appropriate investigation?
A. CA 125
B. CA 15-3
C. CA 19-9
D. Carcinoembryonic antigen (CEA)
E. Alpha-fetoprotein (AFP)
7. A 60 year old woman has lower abdominal discomfort and mild abdominal distention.
On pelvic examination, a nontender, sold irregular right adnexal mass is felt. Her pap
smear done a year ago was normal. What is the SINGLE most appropriate tumour
marker to request for?
A. CA 125
B. CA 15-3
C. CA 19-9
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D. CA 15-3
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8. A 50 year old man is admitted for an elective herniorrhaphy. Which SINGLE best criteria
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would lead to his elective procedure being postponed?
A. Systolic blood pressure of 110 mmHg

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B. Myocardial infarction 2 months ago
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C. Haemoglobin of 12 g/dL
D. Pain around the hernia
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E. Abdominal distention
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9. A 57 year old man complains of symptoms of vomiting, tiredness, and palpitations. He

has lost 8 kg in the last 3 months. On examination, hepatomegaly and ascites is noted.
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He has a palpable left supraclavicular mass. Records show that he is blood group A.
What is the SINGLE most likely diagnosis given the symptoms and risk factors?
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A. Gastric carcinoma
B. Colorectal carcinoma
C. Peptic ulcer disease
D. Atrophic gastritis
E. Krukenberg tumor
10. A 68 year old male presents with swelling in the lower pole of the parotid gland. This
swelling has been slow growing for the past 7 years. On examination, the parotid gland is
firm in consistency. What is the SINGLE most probable diagnosis?
A. Pleomorphic adenoma
B. Adenolymphoma
D. Parotiditis
E. Frey’s syndrome
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11. A 62 year old has per rectal bleeding and painful defecation. In the last 2 months, he has
noticed a change in bowel habit. A full blood count shows slight anaemia. What is the
A. Colorectal carcinoma
B. Coeliac disease
C. Crohn's disease
D. Ulcerative colitis
12. A 32 year old man is about to undergo an elective inguinal hernia surgery. His blood
tests show:
Haemoglobin 82 g/L
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What is the SINGLE most appropriate next action?
A. Investigate and postpone the surgery

B. Blood transfusion and proceed with surgery
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C
C. Blood transfusion and defer surgery
D. Continue with surgery with 2 units cross matched blood on stand by
E. Platelet transfusion and proceed with surgery
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13. A 55 year old male presents with longstanding gastric reflux, dysphagia and chest pain.
He says it came on gradually and initially only noticed it with solid food but more
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recently has been having symptoms with soft foods also. Barium swallow shows irregular
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narrowing of the mid-thoracic oesophagus with proximal shouldering. What is the

SINGLE most appropriate diagnosis?
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A. Achalasia
B. Oesophageal spasm
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C. Gastro-oesophageal reflux disease (GORD)

D. Barrett’s oesophagus
14. A 57 year old male presents with sudden onset of severe abdominal pain and rigidity.
The pain initially started as left lower quadrant pain but is now generalized. He has a
fever and a pulse of 135 beats/minute. He has no past medical or surgical history of note
and he is not taking any regular medications. What is the SINGLE most likely diagnosis?
A. Intussusception
B. Bowel ischaemia
C. Sigmoid volvulus
E. Zenker’s diverticulum
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15. A 28 year old pregnant woman with polyhydramnios comes for an anomaly scan at 31
weeks. On ultrasound scan, there was no gastric bubble seen. What is the SINGLE most
likely diagnosis?
A. Duodenal atresia
B. Oesophageal atresia
C. Gastroschisis
D. Exomphalos
E. Diaphragmatic hernia
16. A 58 year old patient presents with altered bowel habits and bleeding per rectum. A full
blood count shows the presence of mild anaemia. A sigmoidoscopy shows an ulcer.
B. Coeliac disease
C. Crohn's disease
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17. A 55 year old man has a history of weight loss and tenesmus. He is diagnosed with rectal
carcinoma. Which SINGLE risk factor is not associated with rectal carcinoma?
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A. Smoking
B. Family history
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C. Polyposis syndromes
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D. Inflammatory bowel disease

E. High fibre diet
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ua
18. A 62 year old lady with family history of ovarian carcinoma. A pelvis ultrasound scan
reveals a complex mass that is 7 cm by 5 cm in the left adnexa. What is the SINGLE most
appropriate tumour marker to request for?
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A. CA 125
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B. CA 15-3
C. CA 19-9
D. CA 15-3
19. A 67 year old woman presents with a firm, round, painless 5cm lump in her right breast.
She has a bruise on the surface and there is no discharge. What is the SINGLE most likely
diagnosis?
A. Fat necrosis
B. Fibroadenoma
C. Fibroadenosis
D. Duct ectasia
E. Breast cancer
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20. A 22 year old man presents with haemoptysis. He had a tonsillectomy done 7 days ago.
His blood pressure is 120/80 mmHg, pulse rate is 70 beats/minute and respiratory rate is
18 breaths/minute. What is the SINGLE most appropriate next step?
A. Blood transfusion
B. Oral antibiotics and discharge
C. Admit and administer intravenous antibiotics
D. Return to theatre and explore
E. Intubate
of reduced appetite and he has lost 7 kg in the last two months. What is the SINGLE
A. Thyroid carcinoma
B. Gastric carcinoma
C. Bronchial carcinoma
D. Mesothelioma
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E. Laryngeal carcinoma
22.
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A 49 year old lady had a colostomy closure 4 days ago. She now comes with fluctuating
small swelling in the stoma. Her temperature is 37.9°C, respiratory rate is 18/min, pulse
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rate is 80 bpm. What is the SINGLE most appropriate management?
A. Local exploration
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B. Exploratory laparotomy
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C. CT abdomen
D. Ice packs
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E. Analgesia and rest

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23. A 44 year old alcoholic presents with painless jaundice. He has lost 9 kg in the last 4
months. His stools are pale and he has dark urine. What is the SINGLE most likely
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diagnosis?
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A. Cancer of the head of pancreas

B. Cancer in the tail of pancreas
C. Chronic pancreatitis
D. Biliary colic
E. Common duct stone
24. A 44 year old man has just had a hemi-colectomy for colorectal cancer. He is now post-
op and has been put on 100% facemask oxygen. An arterial-blood gas analysis reveals:
pH is 7.54
PaO2 = 28.8kPa
PaCO2 = 3.8kPa
He is breathless and dyspneic. What is the SINGLE best management for this patient?
A. Physiotherapy
B. Ventilate and intubate
C. Immediate laparotomy
D. IV antibiotics
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E. Reduce oxygen
25. A 35 year old construction worker is diagnosed with indirect inguinal hernia. Which
statement below best describes indirect inguinal hernias?
A. Passes through the superficial inguinal ring only

B. Lies above and lateral to the pubic tubercle
C. Does not pass through the superficial inguinal ring
D. Passes through the deep inguinal ring
E. Passes medial to the inferior epigastric vessels
26. A 60 year old man has difficulty in swallowing, regurgitation of food and bad breath. He
has been coughing a lot lately. He has loss some weight recently in the last couple of
months and is concerned about oesophageal cancer. What is the SINGLE most
appropriate initial investigation?
A. Barium swallow
B. Computed tomography scan of chest
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C. Manometry
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D. Skeletal survey
E. Endoscopy C
27. A 72 year old man presents with intermittent difficulty in swallowing with regurgitation
of stale food materials. Lately, he has been having chronic cough. What is the SINGLE
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A. Benign stricture
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D. Pharyngeal pouch
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28. A 65 year old woman has been losing weight and feels lethargic. Three years ago, she
had a right hemicolectomy for cancer of the ascending colon. She looks pale on
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examination but there were no abdominal findings. What is the SINGLE most
A. CA 125
B. CA 15-3
C. CA 19-9
29. A 75 year old man has left-sided earache and discomfort when he swallows. There is
ulceration at the back of his tongue and he has a palpable non-tender cervical mass.
A. Acute mastoiditis
B. Dental abscess
C. Herpes zoster infection
D. Oropharyngeal carcinoma
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E. Tonsillitis
30. A 60 year old man has right upper quadrant discomfort. He has lost 10 kg in the last 4
months. On examination, a palpable liver with nodularities was found. Three years ago,
he had a right hemicolectomy for a colorectal cancer. What is the SINGLE most
appropriate tumour marker to investigate?
A. CA 125
B. CA 15-3
C. CA 19-9
31. A 35 year old day 1 post caesarean section complains of inability to void. She denies
dysuria but complains of fullness. She was given an epidural for analgesia. What is the
A. Midstream specimen of urine
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B. Intravenous urogram (IVU)
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C. Ultrasound of the kidneys, ureters & bladder
D. Serum calcium
E. Bladder scan
C
32. An 8 year old child has oral burns is found not to be breathing well. Intubation has failed.
His oxygen saturations are low. What SINGLE anatomical structure is likely to be pierced
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to help this child recover?
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A. Cricothyroid membrane
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B. Dura Mater
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C. Thyroid gland
D. Conjoint tendon
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33. A 67 year old female underwent a radical mastectomy. She now comes with the
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complaint of swelling and redness in her right upper limb. Which of the following
structions are responsible for these symptoms?
A. Epitrochlear lymph node

B. Cephalic vein
C. Subclavian artery
D. Axillary lymph node
E. Long thoracic nerve
34. A 53 year old man has become increasingly short of breath in the 3 hours since returning
to the ward after a thyroidectomy. He has a temperature of 37.5°C, heart rate of 110
beats/minute, blood pressure of 90/60 mmHg, respiratory rate of 35 breaths/minute,
and SaO2 of 89% on air. There are harsh inspiratory upper airway sounds and reduced
air entry bilaterally. What is the SINGLE most appropriate course of action?
A. Cut SC sutures
B. Adrenaline
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C. Low molecular weight heparin
D. Oxygen 15L via non-rebreather mask
E. Salbutamol Nebulizer
35. A 31 year old woman has an injury to the right external branch of superior laryngeal
nerve during a thyroid surgery. What is the SINGLE most likely symptom in this patient?
A. Stridor
B. Hoarseness
C. Aphonia
D. Dysphonia
E. Aphasia
36. A 28 year old woman who is 8 weeks pregnant has central abdominal pain for the last 36
hours. The pain is now colicky. She reports no vaginal bleeding. She has vomited once
and has had an episode of loose stools earlier in the day. She has a temperature of
37.9°C. On examination, she looks ill, and has rebound tenderness in the right iliac fossa.
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A. Salpingitis
B. Appendicitis
C. Ectopic pregnancy
C
D. Ovarian torsion
E. Uterine fibroid
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37. A 40 year old manual worker presents with a swelling in the groin. He says he noticed
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the appearance earlier today and it is accompanied by pain. On examination, a mass is

found to be just above and lateral to the pubic tubercle. On examination, the mass is
t
reducible and impulse on coughing is seen. What is the SINGLE most likely diagnosis?
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A. Inguinal hernia
B. Femoral artery aneurysm
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C. Femoral hernia
D. Incarcerated hernia
Ev
E. Strangulated hernia
38. A 58 year old lady with a medical history of type 1 diabetes mellitus has a tender lump
near the anal opening which has been increasing in size for the last 3 weeks. She
complains of constipation and throbbing pain when she sits down. She has a
temperature of 38.1°C. The mass is seen to be swollen, erythematous and tender at the
edge of the anus. What is the SINGLE most appropriate management?
A. Incision, drainage and antibiotics

B. Intravenous antibiotics only
C. Rubber band ligation
D. Sclerotherapy
E. Glycerol suppositories
39. A 39 year old man has a painful palpable mass for the past 6 weeks near his anus. On
examination, the lump is warm, erythematous, and tender. He has a history of diabetes.
519
A. Anal fissure
B. Perianal abscess
C. Perianal haematoma
D. Anogenital warts
E. External haemorrhoids
40. 2 hours after an appendectomy, a 33 year old man complains of feeling unwell, having
abdominal pain. He has a pulse of 128 beats/minute, a blood pressure of 88/55 mmHg
and a respiratory rate of 32 breaths/minute. What is the SINGLE most likely reason for
his observations?
A. Intra-abdominal bleed
B. Anastomotic leak
C. Sepsis
D. Intestinal obstruction
E. Pulmonary embolism
y
41. A 32 year old man was involved in a road traffic accident and was operated for
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abdominal trauma where a splenectomy was performed. On the second day post-op, his
abdomen becomes gradually distended and tender and he complains of epigastric
fullness. He feels nauseous and vomited twice in the morning. His blood pressure has
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now dropped to 70/40 mmHg and he has a pulse rate of 140 beats/minute. A
nasogastric tube was inserted and the patient was almost immediately relieved. What is
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A. Acute gastric dilatation

B. Primary haemorrhage
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C. Reactionary haemorrhage
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D. Secondary haemorrhage
E. Subphrenic abscess
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42. An 66 year old woman is found to be anaemic. As part of her exam, she had a barium
enema which reveals a mass lesion in the right side of the large intestine. What is the
Ev
A. Sigmoid volvulus
B. Anal fissure
C. Sigmoid carcinoma
D. Diverticular disease
E. Caecal carcinoma
43. A 35 year old diabetic man on insulin is booked in for an elective hernia operation. What
is the SINGLE most appropriate management plan for his diabetes on the day of the
surgery?
A. Stop insulin and start metformin on the day of surgery

B. Administer insulin and saline pre-operatively
C. Administer Intravenous insulin, dextrose and saline pre-operatively
D. Administer insulin as usual
E. Stop insulin for the duration of the operation
520
44. A 29 year old woman presents with a single 2 cm by 2 cm lump in the breast. The lump is
mobile and hard in consistency. On examination, the mass is painless and there is also a
palpable lymph node in the axilla. An ultrasound was performed which shows a mass
with hypoechoic, ill-defined, spiculated, and microlobulated margins. A mammogram
shows ill-defined, spiculate borders. A fine needle aspiration cytology was performed
which results came back as normal. What is the SINGLE most appropriate investigations
to confirm the diagnosis?
A. Repeat fine needle aspiration cytology

C. Punch biopsy
D. Genetic testing and counselling
E. Core biopsy
45. A 43 year old diabetic, who takes regular sitagliptin, has a planned elective hernia repair
surgery. What is the SINGLE most appropriate advice to give regarding the perioperative
management of his diabetic medication?
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A. Start normal saline infusion and dextrose at time of admission
B. Start subcutaneous insulin
C. Omit sitagliptin 3 days prior to the procedure
C
D. Continue medication with no change
E. Omit sitagliptin on the day of the procedure
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46. A 45 year old man is scheduled to have an elective anterior resection of the rectum.
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What is the SINGLE most appropriate antibiotic prophylaxis regimen?

t
A. Oral antibiotics a week before surgery

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B. Oral antibiotic 2 days before surgery and continue for 5 days after surgery
C. Intravenous antibiotics the night before surgery
D. Intravenous antibiotics 3 days before surgery
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E. Intravenous antibiotics at the induction of anaesthesia

Ev
47. A 48 year old man complains of rectal bleeding and loss of weight. He has a mass in left
iliac fossa. What is the SINGLE most likely diagnosis?
A. Caecal carcinoma
B. Carcinoma of sigmoid colon
C. Carcinoma of transverse colon
E. Volvulus
48. A 32 year old man has undergone an open appendectomy earlier today. In theatre, a
gangrenous appendix was found. What is the SINGLE most appropriate pain relief to
administer post operatively?
A. Patient controlled analgesia with morphine

B. Oral tramadol
C. Oral morphine
D. Rectal diclofenac
521
E. Intramuscular morphine
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522
General Surgery Answers
1. A 24 year old woman presents with a 1 cm small smooth, firm, mobile mass in her left
breast. She is very anxious and wants a form of investigation. What is the SINGLE most
appropriate investigation to perform?
A. Mammography
B. Ultrasound scan of breast
C. Fine needle aspiration cytology
D. Magnetic resonance imaging scan of breast
E. Computerised tomography scan of breast
Generally for a women younger than 35 years old, an ultrasound scan is the prefered
radiological assessment. This is because young women have increased tissue density
which reduces sensitivity and specificity of a mammography.
2. A 39 year old woman has been having tingling and numbness of her thumb, index and
middle fingers for a while. She has been treated with local steroids but there was no
y
improvement. She has planned to undergo a surgical procedure. What is the SINGLE
op
most likely structure to be incised?
A. Flexor digitorum profundus

B. Transverse carpal ligament
C
C. Palmar aponeurosis
D. Extensor retinaculum
n
E. Antebrachial fascia
io
During open carpal tunnel release surgery, the transverse carpal ligament is cut, which
t
releases pressure on the median nerve and relieves the symptoms of carpal tunnel
ua
syndrome.
3. What anatomical structure is pierced during a midline port insertion during a

al
laparoscopic cholecystectomy?
Ev
A. External iliac muscle

B. Linea alba
C. Rectus abdominis
D. Conjoined tendon
The linea alba is the correct answer here. As this is a midline port insertion, the linea
alba is the main structure that would be pierced.
The exposure of the linea alba is usually performed by sharp dissection. After which
insertion of a trocar can be done.
4. A 52 year old man has hoarseness of voice following a thyroid surgery a week ago. There
has been no signs of improvement. What is the SINGLE most likely anatomical
structure(s) involved?
A. Bilateral recurrent laryngeal nerve

B. Unilateral recurrent laryngeal nerve
C. Unilateral external laryngeal nerve
523
D. Bilateral external laryngeal nerve
E. Vocal cords
There is a risk of recurrent laryngeal nerve injury post thyroidectomy. If it is unilateral, it

results in hoarseness. If it is bilateral, it results in aphonia and airway obstruction.
Unilateral damage is more common than bilateral laryngeal nerve injury.
5. A 55 year old man has been admitted for an elective herniorrhaphy. Which among the
following is the SINGLE most likely reason to postpone his surgery?
A. History of asthma
B. BMI > 30
C. Deep venous thrombosis 2 years ago
D. Diastolic BP of 90 mmHg
E. Myocardial infarction 2 months ago
After a myocardial infarction, elective surgery should not be performed for the next 6
months as there is an increased risk of mortality for this specific group.
y
op
6. A 55 year old man with cirrhosis of the liver complains of tiredness and right upper
quadrant pain over the last few months. He has lost 8 kg in the last 2 months. The liver is
palpable on abdominal examination. What is the SINGLE most appropriate investigation?
C
A. CA 125
B. CA 15-3
n
C. CA 19-9
io

t
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The signs and symptoms and history of cirrhosis are indicative of hepatocellular
carcinoma. Alpha-fetoprotein (AFP) us a good screening test for hepatocellular
carcinoma.
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Common tumour markers

Ev
Tumour marker Association

CA 125 Ovarian cancer
CA 19-9 Pancreatic cancer
CA 15-3 Breast cancer
Prostate specific antigen (PSA) Prostatic carcinoma
Carcinoembryonic antigen (CEA) Colorectal cancer
Alpha-fetoprotein (AFP) Hepatocellular carcinoma, teratoma
7. A 60 year old woman has lower abdominal discomfort and mild abdominal distention.
On pelvic examination, a nontender, sold irregular right adnexal mass is felt. Her pap
smear done a year ago was normal. What is the SINGLE most appropriate tumour
marker to request for?
A. CA 125
B. CA 15-3
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C. CA 19-9
D. CA 15-3
A pelvic mass that is identified after menopause should raise the suspicion of ovarian
cancer. Remember that in postmenopausal women, the ovaries should normally be
atrophic so if they are felt, think of ovarian carcinoma.
Among the above options, CA 125 should be taken for the possibility of an ovarian
epithelial cancer.

y
op
C
8. A 50 year old man is admitted for an elective herniorrhaphy. Which SINGLE best criteria
would lead to his elective procedure being postponed?
n
A. Systolic blood pressure of 110 mmHg

io
B. Myocardial infarction 2 months ago

C. Haemoglobin of 12 g/dL
t
D. Pain around the hernia

ua
E. Abdominal distention
al
After a myocardial infarction, elective surgery should not be performed for the next 6
months as there is an increased risk of mortality for this specific group.
Ev
9. A 57 year old man complains of symptoms of vomiting, tiredness, and palpitations. He

has lost 8 kg in the last 3 months. On examination, hepatomegaly and ascites is noted.
He has a palpable left supraclavicular mass. Records show that he is blood group A.
What is the SINGLE most likely diagnosis given the symptoms and risk factors?
A. Gastric carcinoma
B. Colorectal carcinoma
C. Peptic ulcer disease
D. Atrophic gastritis
E. Krukenberg tumor
It is clear that this is gastric carcinoma. The vomiting, tiredness, weight loss are general
features of gastric cancer. In addition, the palpitation are a symptom of anaemia.
Hepatomegaly and ascites are late features of gastric cancer. The lump at the left
supraclavicular region known as a Troisier's sign (an enlarged left supraclavicular node -
Virchow's node), It is indicative of gastric cancer. People with blood group A are at a
higher risk of gastric cancer.
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Gastric cancer
Risk factors and Associations
- Increasing age
- H. pylori infection
- blood group A
- gastric adenomatous polyps
- pernicious anaemia
- Smoking
- diet: salty, spicy, nitrates
Presentation
- Nonspecific with dyspepsia, weight loss, vomiting, dysphagia and anaemia.
- The majority of patients present with advanced disease and alarm symptoms
such as weight loss, vomiting, anorexia, abdominal pain and anaemia.
- Signs suggesting incurable disease - eg, epigastric mass, hepatomegaly, jaundice,
y
ascites, Troisier's sign (an enlarged left supraclavicular node - Virchow's node).
op
10. A 68 year old male presents with swelling in the lower pole of the parotid gland. This
swelling has been slow growing for the past 7 years. On examination, the parotid gland is
C
firm in consistency. What is the SINGLE most probable diagnosis?
A. Pleomorphic adenoma
n
B. Adenolymphoma
io
D. Parotiditis
t
E. Frey’s syndrome
ua
Pleomorphic adenoma
- Also called benign mixed tumour
al
- It is the most common tumour of the parotid gland and causes over a third of
submandibular tumours
Ev
- Features
- Presents around middle age
- Slow-growing and asymptomatic
- Solitory
- Painless
- Usually mobile
- Firm single nodular mass
Though it is classified as a benign tumor, pleomorphic adenomas have the capacity to

undergo malignant transformation.
Treatment involves removing by superficial parotidectomy or enucleation
11. A 62 year old has per rectal bleeding and painful defecation. In the last 2 months, he has
noticed a change in bowel habit. A full blood count shows slight anaemia. What is the
526
B. Coeliac disease
C. Crohn's disease
Colorectal cancer
Clinical features
Rectal location
- PR bleeding. Deep red on the surface of stools.
- Change in bowel habit. Difficulty with defecation, sensation of incomplete
evacuation, and painful defecation (tenesmus)
Descending-sigmoid location
- PR bleeding. Typically dark red
y
- Change in bowel habit
Right-sided location
op
- Iron deficiency anaemia may be the only elective presentation
C
- Weight loss
- Mass in right iliac fossa
- Disease more likely to be advanced at presentation
n
io
Emergency presentations
Up to 40% of colorectal carcinomas will present as emergencies.
t
- Large bowel obstruction (colicky pain, bloating, bowels not open)

ua
- Perforation with peritonitis

- Acute PR bleeding
al
12. A 32 year old man is about to undergo an elective inguinal hernia surgery. His blood
tests show:
Ev
Haemoglobin 82 g/L
A. Investigate and postpone the surgery

B. Blood transfusion and proceed with surgery
C. Blood transfusion and defer surgery
D. Continue with surgery with 2 units cross matched blood on stand by
E. Platelet transfusion and proceed with surgery
For elective procedures, proceed only if haemoglobin is above 100 g/L (10 g/dL). If
haemoglobin is lower than that, defer the operation and investigate first. If haemoglobin
was below 80 g/L (8 g/dL) and patient was symptomatic, then transfuse with blood.
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13. A 55 year old male presents with longstanding gastric reflux, dysphagia and chest pain.
He says it came on gradually and initially only noticed it with solid food but more
recently has been having symptoms with soft foods also. Barium swallow shows irregular
narrowing of the mid-thoracic oesophagus with proximal shouldering. What is the
A. Achalasia
B. Oesophageal spasm
C. Gastro-oesophageal reflux disease (GORD)
D. Barrett’s oesophagus
The progressive nature of symptoms (first solids and now liquids) suggests a growing
obstruction and points to a diagnosis of oesophageal malignancy. Achalasia would
present with inability to swallow both liquids and solids from the outset.
Oesophageal cancer
y
Adenocarcinoma has now overtaken squamous cell carcinoma as the most common type
op
of oesophageal cancer
Risk factors
C
- Smoking → risk factor for both adenocarcinoma and squamous cell carcinoma,
but associated with a much higher risk for squamous cell carcinoma than
adenocarcinoma.
n
- Alcohol
io
- GORD
- Barrett's oesophagus → which is a precursor of adenocarcinoma
t
- Achalasia → Chronic inflammation and stasis from any cause increase the risk of
ua
oesophageal squamous cell carcinoma
Very often in the stem, there would be a patient with a history of gastro-oesophageal
al
reflux disease (GORD) or Barrett's oesophagus. Sometimes, they would give a history of
increasing dysphagia and weight loss.
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Diagnosis
- Upper GI endoscopy with brushings and biopsy of any lesion seen is the first line
test
- CT or MRI scan of the chest and upper abdomen is performed for staging
purposes
14. A 57 year old male presents with sudden onset of severe abdominal pain and rigidity.
The pain initially started as left lower quadrant pain but is now generalized. He has a
fever and a pulse of 135 beats/minute. He has no past medical or surgical history of note
and he is not taking any regular medications. What is the SINGLE most likely diagnosis?
A. Intussusception
B. Bowel ischaemia
C. Sigmoid volvulus
E. Zenker’s diverticulum
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Sudden onset of severe abdominal pain, rigidity, left iliac fossa pain in combination with
tachycardia and fever are in favour of a perforated diverticulum.
A perforated diverticulum is a very rare complication of diverticulitis.
Intussusception → is unlikely as it presents with nonspecific abdominal pain which is

recurrent. Occasionally, they present with nausea and vomiting as well.
Bowel ischaemia → also unlikely as it usually presents with moderate-to-severe colicky

or constant and poorly localised pain. A striking feature is that the physical findings are
out of proportion to the degree of pain and, in the early stages, there may be minimal or
no tenderness and no signs of peritonitis. In the later stages typical symptoms of
peritonism develop, with rebound guarding and tenderness. In the stem they would also
likely give some clues if they would like you to pick bowel ischaemia. Example, they may
include atrial fibrillation in part of the history.
Sigmoid Volvulus → Another unlikely answer. Most often it presents with sudden-onset
y
colicky lower abdominal pain associated with severe abdominal distension. Patients
op
would also be unable to pass either flatus or stool. Vomiting would occur later. Note that
hypotension and an elevated temperature may be present if there is colonic perforation.
However, given that there was another choice in the question of a perforation
C
(perforated diverticulum), that would be a better answer.
Zenker’s diverticulum → Is definitely incorrect as Zenker’s diverticulum represents a

n
pharyngeal pouch and does not present with abdominal pain. The usual presenting
io
features are dysphagia, regurgitation, aspiration, chronic cough and weight loss.
t
15. A 28 year old pregnant woman with polyhydramnios comes for an anomaly scan at 31
ua
weeks. On ultrasound scan, there was no gastric bubble seen. What is the SINGLE most
likely diagnosis?
al
A. Duodenal atresia
B. Oesophageal atresia
Ev
C. Gastroschisis
D. Exomphalos
E. Diaphragmatic hernia
Diagnosis of oesophageal atresia may be suspected antenatally because of

polyhydramnios and an absent fetal stomach bubble detected on ultrasound.
Oesophageal atresia
Prenatal signs: Polyhydramnios; small stomach, absent fetal stomach bubble detected
on ultrasound
Postnatal: Cough, airway obstruction, secretions, blowing bubbles, distended abdomen,

cyanosis, aspiration. Inability to pass a catheter into the stomach. X-rays show it coiled in
the oesophagus.
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16. A 58 year old patient presents with altered bowel habits and bleeding per rectum. A full
blood count shows the presence of mild anaemia. A sigmoidoscopy shows an ulcer.
B. Coeliac disease
C. Crohn's disease
Colorectal cancer
Clinical features
Rectal location
- PR bleeding. Deep red on the surface of stools.
- Change in bowel habit. Difficulty with defecation, sensation of incomplete
evacuation, and painful defecation (tenesmus)
y
op
Descending-sigmoid location
- PR bleeding. Typically dark red
- Change in bowel habit
C
Right-sided location
- Iron deficiency anaemia may be the only elective presentation
n
- Weight loss
io
- Mass in right iliac fossa

- Disease more likely to be advanced at presentation
t
ua
Emergency presentations
Up to 40% of colorectal carcinomas will present as emergencies.
- Large bowel obstruction (colicky pain, bloating, bowels not open)
al
- Perforation with peritonitis

- Acute PR bleeding
Ev
17. A 55 year old man has a history of weight loss and tenesmus. He is diagnosed with rectal
carcinoma. Which SINGLE risk factor is not associated with rectal carcinoma?
A. Smoking
B. Family history
C. Polyposis syndromes
D. Inflammatory bowel disease
E. High fibre diet
It is quite the opposite. A low fibre diet is a risk factor for colorectal cancers.
Risk factors of colorectal cancer

- Family history of colorectal neoplasia: carcinoma; adenoma under the age of 60
years
- Past history of colorectal neoplasm: carcinoma, adenoma
- Inflammatory bowel disease: ulcerative colitis, Crohn's colitis
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- Polyposis syndromes: familial adenomatous polyposis (Gardner's syndrome),
Turcot's syndrome, attenuated adenomatous polyposis coli, flat adenoma
syndrome, hamartomatous polyposis syndromes (Peutz-Jeghers syndrome,
juvenile polyposis syndrome, Cowden's syndrome)
- Hereditary non-polyposis colorectal cancer (HNPCC)
- Diet: rich in meat and fat; poor in fibre, folate and calcium
- Sedentary lifestyle, obesity, smoking, high alcohol intake
- History of small bowel cancer, endometrial cancer, breast cancer or ovarian
cancer
18. A 62 year old lady with family history of ovarian carcinoma. A pelvis ultrasound scan
reveals a complex mass that is 7 cm by 5 cm in the left adnexa. What is the SINGLE most
appropriate tumour marker to request for?
A. CA 125
B. CA 15-3
C. CA 19-9
D. CA 15-3
y
op
A pelvic mass that is identified after menopause should raise the suspicion of ovarian
cancer. Remember that in postmenopausal women, the ovaries should normally be
C
atrophic so if they are felt, think of ovarian carcinoma.
Among the above options, CA 125 should be taken for the possibility of an ovarian
n
epithelial cancer.
io

t
ua

al

Ev

19. A 67 year old woman presents with a firm, round, painless 5cm lump in her right breast.
She has a bruise on the surface and there is no discharge. What is the SINGLE most likely
diagnosis?
A. Fat necrosis
B. Fibroadenoma
C. Fibroadenosis
D. Duct ectasia
E. Breast cancer
Fat necrosis feels like a firm, round lump (or lumps) and is usually painless, but in some
people it may feel tender or even painful. The skin around the lump may look red,
bruised or occasionally dimpled. Like in this question, there was a bruise noticed on the
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surface. Occasionally fat necrosis can cause the nipple to be pulled in (retracted).
Sometimes within an area of fat necrosis cysts containing an oily fluid can occur.
Fat necrosis or sclerosing adenosis → is suggested by a firm, solitary localized lump.

Confirmed by: appearance on mammogram and benign histology after excision.
Fibroadenoma → is suggested by a smooth and mobile lump (‘breast mouse’), usually in

ages 15–30 years old. They are sometimes described as "breast mice" because they can
easily move around within the breast.
Fibroadenosis (or fibrocystic disease) → is the most common cause of breast lumps in
women of reproductive age. The peak incidence is between 35 and 50 years of age. It is
a term used to describe a group of benign conditions that affect the breast. The
symptoms of fibroadenosis include breast pain (mastalgia or mastodynia), increase in
breast size and lumpiness of the breast (nodularity), particularly just before or during a
period
Duct Ectasia → is suggested by a green or brown nipple discharge.
y
op
Breast Cancer → is suggested by fixed, irregular, hard, painless lump, nipple
retraction, fixed to skin (peau d’orange) or muscle, and local, hard or firm, fixed nodes in
axilla.
C
20. A 22 year old man presents with haemoptysis. He had a tonsillectomy done 7 days ago.
His blood pressure is 120/80 mmHg, pulse rate is 70 beats/minute and respiratory rate is
n
18 breaths/minute. What is the SINGLE most appropriate next step?
io
A. Blood transfusion
t
B. Oral antibiotics and discharge

ua
C. Admit and administer intravenous antibiotics

D. Return to theatre and explore
E. Intubate
al
Admission and IV antibiotics would be the most appropriate step. The patient should be
Ev
admitted and the course of bleeding should be observed. Not every patient needs to go
to theatre right away. Secondary Haemorrhage are caused by necrosis of an area of
blood vessel, related to previous repair and is often precipitated by wound infection.
Complications of tonsillectomy
Intraoperative
- Haemorrhage
- Dental trauma due to displacement of the mouth gag
Immediate postoperative
Haemorrhage; either primary or secondary. The overall bleeding rate is 2.3–3.4% of
cases
- Primary haemorrhage happens within the first 24 hours, due to inadequate
haemostasis at the time of surgery or the displacement of a tie from the inferior
pedicle. It would require return to theatre in up to 1% of patients, although the
majority of cases can be managed conservatively.
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- Secondary, or reactive, haemorrhage occurs after discharge (1–10 days) and is
due to separation of the slough in the tonsillar bed. The readmission rate is
approximately 5%, of which less than 1% are returned to theatre
- Temporary dysphagia
of reduced appetite and he has lost 7 kg in the last two months. What is the SINGLE
A. Thyroid carcinoma
B. Gastric carcinoma
D. Mesothelioma
E. Laryngeal carcinoma
The lump at the left supraclavicular region known as a Troisier's sign (an enlarged left
supraclavicular node - Virchow's node), It is indicative of gastric cancer.
y
22. A 49 year old lady had a colostomy closure 4 days ago. She now comes with fluctuating
op
small swelling in the stoma. Her temperature is 37.9°C, respiratory rate is 18/min, pulse
rate is 80 bpm. What is the SINGLE most appropriate management?
C
A. Local exploration
B. Exploratory laparotomy
C. CT abdomen
n
D. Ice packs
io

t
Fluctuating small swelling indicates an abscess has formed. Local exploration would be
ua
beneficial in this scenario. Stomal abscess is a collection of pus (infection) occurring just
under the skin around the site of the stoma. Antibiotics and drainage of the pus is
sometimes required
al
23. A 44 year old alcoholic presents with painless jaundice. He has lost 9 kg in the last 4
Ev
months. His stools are pale and he has dark urine. What is the SINGLE most likely
diagnosis?
A. Cancer of the head of pancreas

B. Cancer in the tail of pancreas
C. Chronic pancreatitis
D. Biliary colic
E. Common duct stone
It is important to note that alcohol does not appear to be an independent risk factor but
alcohol is a risk factor towards chronic pancreatitis which may lead to pancreatic cancer.
The obstructive jaundice is because the tumour on the head of pancreas blocks the
biliary tract.
Pancreatic cancer
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60% of pancreatic tumours are adenocarcinomas which typically occur at the head of the
pancreas.
Associations
- Smoking
- Diabetes
- Chronic pancreatitis
Features
Tumours in the head of pancreas

- Classically painless jaundice (obstructive jaundice → dark urine, pale stools and
pruritus)
Tumours in body or tail of pancreas

- Epigastric pain which radiates to the back and relieved by sitting forward
Either tumour in head or body/tail may cause:
y
- Anorexia, weight loss
op
- Atypical abdominal pain
Investigation
C
- CA 19-9 is non specific but helps assess prognosis
- Ultrasound has a sensitivity of around 60-90%
- High resolution CT scanning is the investigation of choice
n
io
Management
- Whipple's resection (pancreaticoduodenectomy) is considered in fit patients
t
with no metastasis
ua
- ERCP with stenting is often used for palliation
24. A 44 year old man has just had a hemi-colectomy for colorectal cancer. He is now post-
al
op and has been put on 100% facemask oxygen. An arterial-blood gas analysis reveals:
pH is 7.54
Ev
PaO2 = 28.8kPa
PaCO2 = 3.8kPa
He is breathless and dyspneic. What is the SINGLE best management for this patient?
A. Physiotherapy
B. Ventilate and intubate
C. Immediate laparotomy
D. IV antibiotics
E. Reduce oxygen
Physiotherapy is the incorrect answer. If you chose this, you might be thinking of
atelectasis as the diagnosis. Atelectasis presents with much of the same signs and
symptoms EXCEPT it presents with hypoxia, and here we can see that the PaO2 is
greater than normal.
There was no mention of a fever so IV antibiotics is the incorrect answer as well.
534
The diagnosis here is hyperoxaemia or hyperoxia.
Hyperoxaemia/Hyperoxia
Hyperoxemia or hyperoxia is defined as a PaO2 > 16kPa (120mmHg). This kind of
hyperoxia can lead to oxygen toxicity, caused from the harmful effects of breathing
molecular oxygen at elevated partial pressures. Hyperoxia differs from hypoxia in that
hyperoxia refers to a state in which oxygen supply is too much, whereas hypoxia refers
to the state in which oxygen supply is insufficient.
Atelectasis
Atelectasis is also known as alveolar collapse. This is caused when airways become
obstructed, usually by bronchial secretions. Most cases are mild and may go unnoticed.
Symptoms are slow recovery from operations, poor colour, mild tachypnoea and
tachycardia. Prevention is by pre-operative and postoperative physiotherapy. In severe
cases, positive pressure ventilation may be required.
25. A 35 year old construction worker is diagnosed with indirect inguinal hernia. Which
statement below best describes indirect inguinal hernias?
y
op
A. Passes through the superficial inguinal ring only
B. Lies above and lateral to the pubic tubercle
C. Does not pass through the superficial inguinal ring
C
D. Passes through the deep inguinal ring
E. Passes medial to the inferior epigastric vessels
n
Indirect inguinal hernias occur when abdominal contents protrude through the deep
io
inguinal ring, lateral to the inferior epigastric vessels; this may be caused by failure of
embryonic closure of the processus vaginalis. An indirect inguinal hernia like other
t
inguinal hernias protrudes through the superficial inguinal ring. It is the most common
ua
cause of groin hernia.
In an indirect inguinal hernia, the protrusion passes through the deep inguinal ring and is
al
located lateral to the inferior epigastric artery.

Ev
26. A 60 year old man has difficulty in swallowing, regurgitation of food and bad breath. He
has been coughing a lot lately. He has loss some weight recently in the last couple of
months and is concerned about oesophageal cancer. What is the SINGLE most
A. Barium swallow
535
B. Computed tomography scan of chest
C. Manometry
D. Skeletal survey
E. Endoscopy
The bad breath and regurgitation of food points towards a pharyngeal pouch. Loss of
weight can also occur in pharyngeal pouch. The first step in investigation would be a
barium swallow and not an endoscopy. Performing an endoscopy in a patient with a
pharyngeal pouch could lead to a perforation.
Pharyngeal pouch (Zenker's diverticulum)
It is a herniation between the thyropharyngeus and cricopharyngeus muscles that are

both part of the inferior constrictor of the pharynx.
Presentation
- Dysphagia
- History of food sticking and regurgitation
y
- Aspiration (Aspiration pneumonia can also occur)
op
- Chronic cough
- Some may present with progressive weight loss
- Usually there are no clinical signs but there may be a lump in the neck that
C
gurgles on palpation
- Halitosis (bad breath) from food decaying in the pouch.
n
Investigations
io
- Endoscopy should be avoided as an initial investigation for fear of perforating

the lesion. A barium swallow may show a residual pool of contrast within the
t
pouch.
ua
27. A 72 year old man presents with intermittent difficulty in swallowing with regurgitation
of stale food materials. Lately, he has been having chronic cough. What is the SINGLE
al

Ev
A. Benign stricture
D. Pharyngeal pouch
The stale food material can only point to one diagnosis which is pharyngeal pouch. The
remaining options may have regurgitation but none with stale food.
Sometimes, question writers may also give a history of bad breath.
Pharyngeal pouch (Zenker's diverticulum)
It is a herniation between the thyropharyngeus and cricopharyngeus muscles that are

both part of the inferior constrictor of the pharynx.
Presentation
536
- Dysphagia
- History of food sticking and regurgitation
- Aspiration (Aspiration pneumonia can also occur)
- Chronic cough
- Some may present with progressive weight loss
- Usually there are no clinical signs but there may be a lump in the neck that
gurgles on palpation
- Halitosis (bad breath) from food decaying in the pouch.
Investigations
- Endoscopy should be avoided as an initial investigation for fear of perforating
the lesion. A barium swallow may show a residual pool of contrast within the
pouch.
28. A 65 year old woman has been losing weight and feels lethargic. Three years ago, she
had a right hemicolectomy for cancer of the ascending colon. She looks pale on
examination but there were no abdominal findings. What is the SINGLE most
y
op
A. CA 125
B. CA 15-3
C. CA 19-9
C
n
Carcinoembryonic antigen (CEA) is especially important to monitor response to
io
treatment and identify relapse in tumours showing raised CEA at diagnosis (e.g.
colorectal cancers)
t
ua
The history of the right upper quadrant discomfort and the examinations of a palpable
liver are descriptions of tumour metastasis to the liver. CEA raises with a metastatic
tumours from colon whereas alpha-fetoprotein (AFP) is elevated in primary
al
hepatocellular carcinoma. So do not get confused and pick AFP where there is a clear
history of colorectal carcinoma.
Ev

29. A 75 year old man has left-sided earache and discomfort when he swallows. There is
ulceration at the back of his tongue and he has a palpable non-tender cervical mass.
537
B. Dental abscess
D. Oropharyngeal carcinoma
E. Tonsillitis
Oropharyngeal carcinoma is the most probable diagnosis here.
Acute mastoiditis may have ear pain but does not have discomfort when swallowing and
does not present with an ulcer at the back of tongue.
Herpes zoster infection has a different presentation where patients complain of burning,
itching or paraesthesia in one dermatome. Although in Ramsay Hunt Syndrome the
presenting feature is often pain deep within the ear, there is usually a rash or herpetic
blisters in the distribution of the nervus intermedius.
A dental abscess would present with worsening pain which may radiate to the ipsilateral
ear, jaw and neck with a bad taste in the mouth, fever, malaise and trismus (inability to
open the mouth). The ulceration of the tongue does not fit in this case.
y
op
Tonsillitis pain may be referred to ears but on examination, reddened and swollen
tonsils would definitely be seen. There would also be presence of a fever and again it
would not account for the ulceration at the base of the tongue
C
Oropharyngeal carcinoma
n
Features
io
- Typical old patient, smoker

- Persistent sore throat
t
- A lump in the mouth or throat

ua
- Referred otalgia
- Difficulty swallowing or moving your mouth and jaw
- Unexplained weight loss
al
30. A 60 year old man has right upper quadrant discomfort. He has lost 10 kg in the last 4
Ev
months. On examination, a palpable liver with nodularities was found. Three years ago,
he had a right hemicolectomy for a colorectal cancer. What is the SINGLE most
appropriate tumour marker to investigate?
A. CA 125
B. CA 15-3
C. CA 19-9
Carcinoembryonic antigen (CEA) is especially important to monitor response to

treatment and identify relapse in tumours showing raised CEA at diagnosis (e.g.
colorectal cancers)
The history of the right upper quadrant discomfort and the examinations of a palpable
liver are descriptions of tumour metastasis to the liver. CEA raises with a metastatic
tumours from colon whereas alpha-fetoprotein (AFP) is elevated in primary
538
hepatocellular carcinoma. So do not get confused and pick AFP where there is a clear
history of colorectal carcinoma.

31. A 35 year old day 1 post caesarean section complains of inability to void. She denies
dysuria but complains of fullness. She was given an epidural for analgesia. What is the
y
A. Midstream specimen of urine
op
B. Intravenous urogram (IVU)
C. Ultrasound of the kidneys, ureters & bladder
D. Serum calcium
C
E. Bladder scan
n
Bladder scan is the correct answer here.
io
Women would be catheterised during the C-section. Infection control and continence
guidelines specify that newly inserted urinary catheters should be removed within 48
t
hours to reduce urinary sepsis and restore normal bladder function as quickly as
ua
possible. In a routine elective C-section, this would usually be on the same day or the
next day. Most catheters can be removed promptly using a trial without catheter
al
(TWOC) procedure.
Postoperative urinary retention occurs due to the effects of the epidural during a C-
Ev
section. In practice, after taking out the catheter, doctors or nurses would ensure the
patient is aware of symptoms of urinary retention such as passing small volumes,
hesitancy or having the feeling of a full bladder that is unable to empty.
If postvoid residual volumes on bladder scan (PVRVs) are 300-500ml and patient unable
to void or uncomfortable, or if PVRV >500ml the usual management would be to reinsert
catheter. The actual postvoid residual volumes for catheterisation differ amongst
hospitals in the UK but are around similar figures.
32. An 8 year old child has oral burns is found not to be breathing well. Intubation has failed.
His oxygen saturations are low. What SINGLE anatomical structure is likely to be pierced
to help this child recover?
A. Cricothyroid membrane
B. Dura Mater
C. Thyroid gland
D. Conjoint tendon
539
A cricothyroidotomy wound be indicated here and it involves a 2 cm transverse incision

through the skin overlying the cricothyroid membrane and then straight through the
cricothyroid membrane.
33. A 67 year old female underwent a radical mastectomy. She now comes with the
complaint of swelling and redness in her right upper limb. Which of the following
structions are responsible for these symptoms?
A. Epitrochlear lymph node

B. Cephalic vein
C. Subclavian artery
D. Axillary lymph node
E. Long thoracic nerve
Axillary node clearance

Increases risk of lymphoedema greatly.
y
The extent of axillary node clearance performed in invasive breast cancer is dependent
op
on the likelihood of finding involved lymph nodes.
34. A 53 year old man has become increasingly short of breath in the 3 hours since returning
C
to the ward after a thyroidectomy. He has a temperature of 37.5°C, heart rate of 110
beats/minute, blood pressure of 90/60 mmHg, respiratory rate of 35 breaths/minute,
and SaO2 of 89% on air. There are harsh inspiratory upper airway sounds and reduced
n
air entry bilaterally. What is the SINGLE most appropriate course of action?
io
A. Cut SC sutures
t
B. Adrenaline
ua

D. Oxygen 15L via non-rebreather mask
E. Salbutamol Nebulizer
al
This is a very common question in PLAB part 1. Once you do a few of these questions,
Ev
you would soon realise that you would be able to answer this question after reading the
first sentence. Anyone with shortness of breath and stridor after a very recent
thyroidectomy needs their sutures cut.
A rare complication of thyroidectomy is upper airway obstruction secondary to

haematoma. To prevent the airway from being totally occluded, it is necessary to release
the pressure this haematoma is causing by loosening the tightness of the compartment
in which it is building up. If this does not improve his breathing, this man will very soon
need intubation. Whilst this is a rare scenario and not important per se , it is still
commonly asked in exams.
Adrenaline → is used in anaphylaxis, which is a reasonable differential in stridor (due to

laryngoedema), but is less likely here than the local effects of the surgery.
Low molecular weight heparin → is the treatment for a pulmonary embolus, which does
cause sudden breathlessness, but not due to upper airway compromise.
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Oxygen → is a reasonable response to dropping SaO2 in someone with healthy lungs
but is not the treatment that is going to arrest this man’s upper airway occlusion.
Salbutamol Nebulizer → is useful to open smaller constricting airways (e.g. in asthma or

COPD) but will not reduce the pressure effect of a haematoma on the trachea.
35. A 31 year old woman has an injury to the right external branch of superior laryngeal
nerve during a thyroid surgery. What is the SINGLE most likely symptom in this patient?
A. Stridor
B. Hoarseness
C. Aphonia
D. Dysphonia
E. Aphasia
The two most important complications of nerve damages you would need to know
during a thyroidectomy is:
1. Recurrent laryngeal nerve damage
y
2. Superior laryngeal nerve damage
op
A unilateral recurrent laryngeal nerve damage damage results in hoarseness and for
bilateral damage symptoms include aphonia and airway obstruction.
C
The external branch of the superior laryngeal nerve is one of the nerves commonly
injured in thyroid surgery. Injury to this nerve results in the inability to lengthen a vocal
n
fold and, thus, inability to create a high-pitched sound (dysphonia). They would have a
io
mono toned voice. This would be detrimental to a person who is a a professional singer.
So in this stem, injury to the external branch of superior laryngeal nerve is likely to
t
produce symptoms of dysphonia.

ua
36. A 28 year old woman who is 8 weeks pregnant has central abdominal pain for the last 36
hours. The pain is now colicky. She reports no vaginal bleeding. She has vomited once
al
and has had an episode of loose stools earlier in the day. She has a temperature of
37.9°C. On examination, she looks ill, and has rebound tenderness in the right iliac fossa.
Ev
A. Salpingitis
B. Appendicitis
D. Ovarian torsion
E. Uterine fibroid
The pain that has shifted towards the right iliac fossa and the fact there is a positive
McBurney's sign and loose stools makes the diagnosis of appendicitis more likely. One
cannot rule out ectopic pregnancy and so ideally an ultrasound scan would take place to
confirm that the pregnancy is in utero. However, the clinical features in the above stem
clearly show evidence of an acute appendicitis.
37. A 40 year old manual worker presents with a swelling in the groin. He says he noticed
the appearance earlier today and it is accompanied by pain. On examination, a mass is
541
found to be just above and lateral to the pubic tubercle. On examination, the mass is
reducible and impulse on coughing is seen. What is the SINGLE most likely diagnosis?
A. Inguinal hernia
B. Femoral artery aneurysm
C. Femoral hernia
D. Incarcerated hernia
The first hint here is his sex (male) and his occupation (manual worker). In adults, male
sex and heavy lifting are risk factors for inguinal hernias
Traditionally it is taught that an inguinal hernia will lie above and medially to the pubic
tubercle whereas a femoral hernia lies laterally and below. This is not strictly true, as the
internal ring is always lateral to the femoral canal and a small indirect inguinal hernia will
therefore be lateral to the pubic tubercle. A better test to differentiate the two might be
to place the finger over the femoral canal for reducible hernias and then ask the patient
to cough. When the patient coughs, a femoral hernia should remain reduced while an
y
inguinal hernia will reappear as an obvious swelling.
op
Remember, inguinal hernias has impulse on coughing or bearing down. Femoral hernias
are usually irreducible (due to the narrow femoral canal) and cough impulse rarely
C
detectable.
Incarcerated hernia cannot be pushed back into the abdomen by applying manual
n
pressure and hence are irreducible.
io
Strangulated hernia are also irreducible. They are tense and red and usually followed by
t
symptoms and signs of bowel obstruction.

ua
Discrimination between direct and indirect inguinal hernia by physical examination is not
very accurate. In an indirect inguinal hernia, the protrusion passes through the deep
al
inguinal ring and is located lateral to the inferior epigastric artery. Whilst traditional
textbooks describe the anatomical differences between indirect (hernia through the
Ev
inguinal canal) and direct hernias (through the posterior wall of the inguinal canal), this
is of no clinical relevance as the management still remains the same. The type of inguinal
hernia in adults is usually confirmed at the operation.
542
38. A 58 year old lady with a medical history of type 1 diabetes mellitus has a tender lump
near the anal opening which has been increasing in size for the last 3 weeks. She
complains of constipation and throbbing pain when she sits down. She has a
temperature of 38.1°C. The mass is seen to be swollen, erythematous and tender at the
edge of the anus. What is the SINGLE most appropriate management?
A. Incision, drainage and antibiotics

B. Intravenous antibiotics only
C. Rubber band ligation
D. Sclerotherapy
E. Glycerol suppositories
This is a case of anorectal abscess. Diabetes, immunocompromised patients or patients

with crohn’s disease are likely candidates for an anorectal abscess. Fever and pain are
typical for an anorectal abscess. The perianal pain is sometimes worse when sitting and
can be associated with constipation.
Management would include surgical drainage. Antibiotic use is necessary if there is a
y
history of diabetes or immunosuppression.
op
39. A 39 year old man has a painful palpable mass for the past 6 weeks near his anus. On
examination, the lump is warm, erythematous, and tender. He has a history of diabetes.
C
A. Anal fissure
B. Perianal abscess
n
C. Perianal haematoma
io
D. Anogenital warts
E. External haemorrhoids
t
ua
This is a very straightforward question. Although many of the options could be very well
correct, the history of diabetes should point you towards an infective cause. Hence,
perianal abscess as the answer.
al
40. 2 hours after an appendectomy, a 33 year old man complains of feeling unwell, having
Ev
abdominal pain. He has a pulse of 128 beats/minute, a blood pressure of 88/55 mmHg
and a respiratory rate of 32 breaths/minute. What is the SINGLE most likely reason for
his observations?
A. Intra-abdominal bleed
B. Anastomotic leak
C. Sepsis
D. Intestinal obstruction
The most likely answer here would be an intra-abdominal bleed. Given the time of 2
hours post-op, bleeding is the most likely reason for his observations deteriorating.
It is also important to note that there is no anastomosis in an appendectomy hence

anastomotic leak is clearly wrong. Bowel perforation (if given) would be a potential
answer however the timing of 2 hours does not quite fit.
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41. A 32 year old man was involved in a road traffic accident and was operated for
abdominal trauma where a splenectomy was performed. On the second day post-op, his
abdomen becomes gradually distended and tender and he complains of epigastric
fullness. He feels nauseous and vomited twice in the morning. His blood pressure has
now dropped to 70/40 mmHg and he has a pulse rate of 140 beats/minute. A
nasogastric tube was inserted and the patient was almost immediately relieved. What is
A. Acute gastric dilatation

B. Primary haemorrhage
C. Reactionary haemorrhage
D. Secondary haemorrhage
E. Subphrenic abscess
Patients can develop acute gastric dilatation as a postoperative complication of

splenectomy and abdominal surgery. This is due to disruption of blood supply to the
stomach which predisposes to acute gastric dilatation. One of the causes of acute gastric
dilatation is If the patient drinks too soon after an abdominal surgery when the stomach
y
is still in ileus. The accumulation of fluid in the stomach may induce hypovolaemic shock.
op
In addition, patients with acute gastric dilatation may proceed to have a gastric rupture.
This will lead to the development of peritonitis.
C
Signs and symptoms of acute gastric dilatation include a distended and tender abdomen,
epigastric fullness, nausea, vomiting and heartburn.
n
Insertion of a nasogastric tube would allow decompression of the stomach and
io
immediately improve patients condition.

t
Given that the nasogastric tube relieved his symptoms, it is unlike that this is a bleed.
ua
The other options are less likely

Primary haemorrhage → Occurs immediately after surgery or as a continuation of an
al
intraoperative bleeding. This is usually due to an unsecured blood vessel.

Ev
Reactionary haemorrhage → Occurs within the first 24 hours and it is usually due to
venous bleeding and is commonly thought to be due to improved post-operative
circulation and fluid volume, which results in rolling or slipping of ligature. It is important
to remember that postoperatively, the blood pressure would rise due to refilling of the
venous system and thus exposing unsecured vessels that bleed.
Secondary haemorrhage → Develops 24 hours or more after the surgery. It occurs up to

10 days post-operatively. It is usually due to infection of an operative wound or raw
surfaces causing clot disintegration and bleeding from exposed tissue.
42. An 66 year old woman is found to be anaemic. As part of her exam, she had a barium
enema which reveals a mass lesion in the right side of the large intestine. What is the
A. Sigmoid volvulus
B. Anal fissure
C. Sigmoid carcinoma
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D. Diverticular disease
E. Caecal carcinoma
A mass in right side of the large intestine and anaemia makes cecal carcinoma the likely
diagnosis from the given options.
Usually the patient presents with unexplained pain in the right iliac fossa with or without
general symptoms such as anaemia, malaise and weakness. However it is important to
note that abdominal pain often develops late in the disease. Cancers arising on the right
side of the large intestine (ascending colon and cecum) tend to be exophytic. For that
reason, it very rarely causes obstruction of faeces, and presents with symptoms such as
anaemia.
43. A 35 year old diabetic man on insulin is booked in for an elective hernia operation. What
is the SINGLE most appropriate management plan for his diabetes on the day of the
surgery?
A. Stop insulin and start metformin on the day of surgery
y
B. Administer insulin and saline pre-operatively
op
C. Administer Intravenous insulin, dextrose and saline pre-operatively
D. Administer insulin as usual
E. Stop insulin for the duration of the operation
C
The patient needs to be on a sliding scale pre-operatively to maintain optimal glucose
control.
n
io
In the sliding-scale method, insulin dose is based on your blood glucose level. The higher
your blood glucose, the higher the insulin dose is adjusted to.
t
ua
Every hospital has slightly different guidelines for a sliding scale. But the general key idea
is to maintain a hourly monitoring of capillary blood glucose target between 4 - 9
mmol/L. This is done by administering insulin, dextrose and saline to keep the glucose
al
levels between 4 - 9 mmol/L.

Ev
44. A 29 year old woman presents with a single 2 cm by 2 cm lump in the breast. The lump is
mobile and hard in consistency. On examination, the mass is painless and there is also a
palpable lymph node in the axilla. An ultrasound was performed which shows a mass
with hypoechoic, ill-defined, spiculated, and microlobulated margins. A mammogram
shows ill-defined, spiculate borders. A fine needle aspiration cytology was performed
which results came back as normal. What is the SINGLE most appropriate investigations
to confirm the diagnosis?
A. Repeat fine needle aspiration cytology

C. Punch biopsy
D. Genetic testing and counselling
E. Core biopsy
Breast fine needle aspirations are not 100% accurate. The lump is definitely suspicious.
The most appropriate investigation to confirm the diagnosis is core biopsy. A core biopsy
uses a hollow needle to take one or more samples of breast tissue from the area of
545
concern. Because tissue is taken rather than cells, it gives more detailed information
compared to a fine needle aspiration.
A fine needle aspiration (FNA) involves taking one or more samples of breast cells using
a fine needle and syringe. The sample of fluid or cells is smeared on a glass slide and sent
to a pathology laboratory to be examined. It is usually done under ultrasound guidance
or occasionally mammogram guidance. Fine needle aspirations only take a small amount
of cells and thus they cannot be used to definitely rule out cancer as sometimes the cells
that are taken may have arisen from normal tissue.
A punch biopsy may be done when there is a change to the skin of the breast or nipple.
It involves taking a very small cylindrical piece of tissue from the changed area.
45. A 43 year old diabetic, who takes regular sitagliptin, has a planned elective hernia repair
surgery. What is the SINGLE most appropriate advice to give regarding the perioperative
management of his diabetic medication?
A. Start normal saline infusion and dextrose at time of admission
y
B. Start subcutaneous insulin
op
C. Omit sitagliptin 3 days prior to the procedure
D. Continue medication with no change
E. Omit sitagliptin on the day of the procedure
C
Perioperative management of diabetes is often quite confusing. Below are guidelines
that give you an idea of which medications need to be stopped and when they can be
n
restarted. It is not an exhaustive list and different hospitals have different protocols for
io
diabetic medications but the general concept is still there.

t
The highlighted boxes represent frequently asked topics which you should memorize
ua
Insulin type and Day prior to Day of surgery After Surgery

frequency admission
al
Long-acting insulin, Take as usual See 'after surgery' Restart once eating
taken once a day box and drinking
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in the evening
Long-acting insulin, Take as usual Reduce usual dose Restart once eating
taken once a day by approximately and drinking
in the morning 1/3 for each
expected omitted
meal
Twice daily insulins Take as usual Half usual morning Restart once eating
eg mixed or dose and drinking
intermediate acting
Three times a day Take as usual Omit doses on Restart once eating
(mealtime) insulin meals that are to and drinking
be missed
546
Types of non- Day prior to Day of surgery After Surgery
insulin anti- admission
diabetic
medicines
Acarbose Take as normal Omit dose if Restart once
missing meal eating and
drinking
Meglitinide Take as normal Omit dose if Restart once
(e.g. gliclazide, missing meal eating and
glipizide) drinking
Short acting Take as normal Omit dose if Restart once
sulphonylureas missing meal eating and
(e.g. drinking
glibenclamide)
Long acting Take as normal Omit dose if Restart once
sulphonylureas missing meal eating and
(e.g. drinking
y
glibenclamide)
Metformin Take as normal Take as normal Take as normal
op
(including (unless surgery (unless surgery (unless surgery
Glucophage with contrast with contrast with contrast
SR) dye - needs to
C
dye - miss all dye - restart
be stopped doses) two days after
two days surgery)
n
before
surgery)
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Pioglitazone Take as normal Take as normal Restart once

eating and
t
ua
drinking
DPP IV Take as normal Omit morning Restart once
inhibitor (e.g. dose eating and
al
sitagliptin, drinking
vildagliptin,
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saxagliptin)
Short-acting Take as normal Omit morning Restart once
GLP-1 dose eating and
analogue (e.g. drinking
exenatide,
liraglutide)
Long-acting Take as normal Take as normal Take as normal

GLP-1
analogue (e.g.
exenatide)
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y
op
C
n
t io
ua
al
Ev
Blood glucose should be checked regularly before, during and after the operation. If at
any point the blood glucose level is higher than 11 mmol/L, consider starting an insulin
infusion intravenously.
46. A 45 year old man is scheduled to have an elective anterior resection of the rectum.
What is the SINGLE most appropriate antibiotic prophylaxis regimen?
A. Oral antibiotics a week before surgery

B. Oral antibiotic 2 days before surgery and continue for 5 days after surgery
C. Intravenous antibiotics the night before surgery
D. Intravenous antibiotics 3 days before surgery
E. Intravenous antibiotics at the induction of anaesthesia
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Surgical antibiotic prophylaxis is defined as the use of antibiotics to prevent infections at
the surgical site. It needs to be given at the correct time and for most parenteral
antibiotics that would be at the time of induction of anaesthesia.
47. A 48 year old man complains of rectal bleeding and loss of weight. He has a mass in left
iliac fossa. What is the SINGLE most likely diagnosis?
A. Caecal carcinoma
B. Carcinoma of sigmoid colon
C. Carcinoma of transverse colon
E. Volvulus
The position of the mass in combination of the symptoms of change of bowel habit and
weight loss can only be from a carcinoma of sigmoid colon.
48. A 32 year old man has undergone an open appendectomy earlier today. In theatre, a
y
gangrenous appendix was found. What is the SINGLE most appropriate pain relief to
op
administer post operatively?
A. Patient controlled analgesia with morphine

C
B. Oral tramadol
C. Oral morphine
D. Rectal diclofenac
n
E. Intramuscular morphine
io
This is a case of an open surgery. Patient controlled analgesia with morphine would be
t
the best to start off and this could be weaned off when the patient is in less pain.
ua
al
Ev
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GENETICS
y
op
C
Questions
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io
&
t
ua
Answers
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Ev
550
Genetics Questions
1. A 4 year old child has progressive muscle weakness and frequent falls. He has a
waddling gait when he attempts to run. He is unable to hop or jump. His motor
milestones seemed to be delayed. What is the SINGLE most likely diagnosis?
A. Duchenne muscular dystrophy

B. Becker’s muscular dystrophy
C. Polymyositis
D. Lambert-Eaton syndrome
E. Polymyalgia rheumatic
2. A 7 year old boy is brought by his mother to the GP clinic with another chest infection.
He has had multiple respiratory infections in the past. On examination, he is noted to
be below the 5th percentile for weight and height. He is also noted to have greasy
stools. What is the SINGLE most likely diagnosis?
A. Cystic Fibrosis
y
B. Severe combined immunodeficiency
op
C. Primary T cell immunodeficiency
D. Primary B cell immunodeficiency
E. Malabsorption
C
3. An 8 year old boy is clinically obese. As a baby he was floppy and difficult to feed. He
now has learning difficulties and is constantly eating despite measures by his parents to
n
hide food out of his reach. What is the SINGLE most likely diagnosis?
io
t
ua

D. Laurence moon biedl syndrom
E. Down’s syndrome
al
4. A 11 year old has increased laxity of joints and hyperelastic skin. He is noted to have
Ev
mild spinal curvature and a blue sclera. What is the SINGLE most likely diagnosis?
A. Fragile X syndrome
B. Prader-willi syndrome
C. DiGeorge syndrome
D. Marfan's syndrome
E. Ehlers-Danlos syndrome
5. A 44 year old woman presents with memory loss, poor concentration and inability to
recognize household objects. She has right-handed involuntary writhing movement
which has just recently started. She reports occasional difficulty in walking. There is a
strong family history with similar symptoms. What is the SINGLE most likely diagnosis?
A. Friedreich’s ataxia
B. Wilson’s disease
C. Huntington’s disease
D. Motor neuron disease
E. Charcot-Marie-Tooth disease
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6. A 59 year old man has shown a change in his mood and personality over a 9 month
period. He has subsequently developed difficulty with memory and concentration, and
then progressive fidgety movements of his limbs and facial musculature. By the time of
medical assessment he has frank choreiform movements and a mini-mental state exam
of 21/30. He was adopted and therefore no information on his family history is
available. He has 3 adult children (27, 30, 33) of whom the 2 youngest are
asymptomatic. However, the oldest son has recently been investigated by the
neurology department for slightly erratic behavior and fidgety restless movements of
both legs. Based on the likely clinical diagnosis, what is the SINGLE most likely mode of
inheritance?
A. Autosomal dominant inheritance with anticipation

B. Autosomal dominant with variable penetrance
C. Autosomal recessive
D. X-linked
E. Mitochondrial disorder
y
7. A 30 year old man and wife presents to the reproductive endocrine clinic as they have
op
been trying to conceive for the last 3 years. They have intercourse 3 times a week and
do not use contraception. The man is tall and has bilateral gynecomastia. Examination
of the testes reveals bilateral small, firm testes. Which is the SINGLE best investigation
C
that could lead to a diagnosis?
A. Computed tomography scan of the pituitary gland

n
B. Chromosomal analysis
io
C. Serum gonadotropin levels

D. Serum testosterone levels
t
E. Follicle-stimulating hormone (FSH) and luteinising hormone (LH) levels

ua
8. A 5 year old boy has recurrent chest infections and offensive stool. On physical
examination, he has finger clubbing. What is the SINGLE most appropriate initial
al
investigation?
Ev
A. Endomysial antibody (IgA)

B. Sweat test
C. Barium meal
D. anti-gliadin antibody (IgA or IgG)
E. Glucose tolerance test
9. A 4 year old boy presents to clinic after an incidental finding of elevated creatine
kinase. The mother gives a history of the boy walking at 18 months and sluggish when
he runs, climbs stairs, rising from a sitting position, or riding his tricycle. Compared to
his older sister at the same age, he has difficulty holding onto small objects. What is the

C. Myotonic muscular dystrophy
D. Spinal muscular atrophy type 1
E. Lambert-Eaton syndrome
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10. A mother has a child with 17-alpha-hydroxylase deficiency. She is now pregnant for the
second time. What are the risks of her unborn child having congenital adrenal
hyperplasia?
A. 1:1
B. 1:2
C. 1:4
D. 1:8
E. 2:3
11. A 3 year old boy presents with rectal prolapse. He is noted to be below the 5th
percentile for weight and height. His mother is also concerned because he has a foul-
smelling bulky stool that "floats." She also state that the child has developed a
repetitive cough over the last few months. What is the SINGLE most appropriate initial
investigation?
y
B. Sweat test
op
C. Barium meal
C
12. A 33 year old mother of a child with cystic fibrosis is concerned of her next baby also
having cystic fibrosis. She is with the same partner and they both are completely
n
healthy. What is the SINGLE most likely probability of their future child having cystic
io
fibrosis?
t
A. 1:2
ua
B. 1:4
C. 1:8
D. 1:1
al
E. No risk
Ev
13. A 7 year old male child is brought to the paediatricians office by his concerned mother.
She states that he is unable to climb stairs and that he is being bullied in school as he
cannot run with his classmates on the playground. Upon examination, it is noted that
he has diminished deep tendon reflexes and hypertrophy of his calf muscles bilaterally.

B. Guillain Barre Syndrome
C. Becker’s muscular dystrophy
D. Polymyositis
E. Motor neurone disease
14. A 32 year old female has café au lait spots seen at birth. Axillary freckles started to
appear in her childhood. What is the probability of her child having the same condition
as she has?
A. 1:2
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B. 1:4
C. 1:16
D. 3:4
E. No genetic link
15. A 44 year old lady who has polycystic kidney disease is concerned because her 38 year
old brother recently died of an intracranial insult. She knows he was not hypertensive.
What was the SINGLE most likely cause of her brother’s death?
A. Subdural haematoma
B. Subarachnoid haemorrhage
C. Cerebral infarct
D. Epidural haematoma
E. Dehydration
16. A 15 year old girl presents with primary amenorrhoea. She has a short stature and a
broad chest with widely spaced nipples. What is the SINGLE most likely diagnosis?
y
A. Down’s syndrome
op
B. Klinefelter's syndrome
C. Fragile X syndrome
D. Turner syndrome
C
E. Normal physiological findings
17. A 42 year old woman is 16 week pregnant. She was late in booking her antenatal
n
appointments and missed her first trimester scan. She is extremely worried about an
io
abnormal chromosomal anomaly in her unborn baby as her first child was born with
Down Syndrome. What is the SINGLE most definitive investigations at this stage?
t
ua
A. Amniocentesis
B. Chorionic Villous Sampling
C. Parents karyotyping
al
D. Transvaginal ultrasound
E. Preimplantation genetic testing
Ev
18. The parents of two children would like to try for another child. Their first child was
diagnosed with cystic fibrosis and their second child is healthy. Both the parents are
healthy. What is the chances of their next child being a carrier?
A. 1:4
B. 1:2
C. 2:3
D. 1:8
E. 1:16
19. A 28 year old lady with a family history of cystic fibrosis comes for genetic counselling
and wants the earliest possible diagnostic test for cystic fibrosis for the baby she is
planning. She is planning to get pregnant in the near future and she is not in favor of
termination. What is the SINGLE most appropriate test to recommend?
A. Chorionic villous sampling
554
B. Amniocentesis
C. Preimplantation genetic diagnosis
D. Chromosomal karyotyping
E. Non-invasive prenatal testing
20. A 26 year old tall and slender man and his wife has been trying to conceive for the past
3 years. He has been investigated for primary infertility and his recent semen analysis is
consistent with azoospermia. What is the SINGLE most appropriate investigations to be
performed?
A. Testosterone
B. Luteinising hormone (LH)
C. Follicle-stimulating hormone (FSH)
D. Estradiol
E. Karyotyping
21. A patient who presents with bilateral cerebellopontine tumors, bilateral sensorineural
hearing loss and café au lait spots is pregnant. What are the chances of her child having
y
the same condition?
A. 1:1
B. 1:2
op
C
C. 1:4
D. 3:4
E. 1:8
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t io
ua
al
Ev
555
Genetics Answers
1. A 4 year old child has progressive muscle weakness and frequent falls. He has a
waddling gait when he attempts to run. He is unable to hop or jump. His motor
milestones seemed to be delayed. What is the SINGLE most likely diagnosis?

C. Polymyositis
D. Lambert-Eaton syndrome
E. Polymyalgia rheumatic
Duchenne muscular dystrophy is an X-linked recessive condition which presents in early

childhood and inevitably progresses. Some carriers also have symptoms. New
mutations are common in DMD; this means that female relatives of a child with DMD
are not necessarily carriers of the gene.
Becker's muscular dystrophy (BMD) is similar to the more common muscular dystrophy
y
- Duchenne muscular dystrophy (DMD) - but the clinical course is milder. As with DMD,
op
there is muscle wasting and weakness which is mainly proximal. Generally, walking
difficulties begin after the age of 16 in Becker's muscular dystrophy. Thus the most
appropriate answer here is Duchenne’s muscular dystrophy.
C
Duchenne muscular dystrophy
Presentation:
n
- PLAB 1 setting: boy comes into clinic by age 4-5 years
io
- Delayed motor milestone: walking at > 18 months, can’t hold objects

- Inability to run - waddling gait when attempting to do so.
t
- Gower’s sign, proximal muscle weakness

ua
- +/- Respiratory or cardiac signs/symptoms

- Elevated creatine kinase, AST, ALT
al
Diagnosis:
- Creatine kinase - initial → (CK levels are very high (10-100 x normal from birth).
Ev
- Blood sample and muscle biopsy → genetic testing for dystrophin mutations →
PCR
- Neuromuscular assessment → diagnosis severity and determine management
- Genetic testing after a positive biopsy diagnosis of DMD is mandatory
2. A 7 year old boy is brought by his mother to the GP clinic with another chest infection.
He has had multiple respiratory infections in the past. On examination, he is noted to
be below the 5th percentile for weight and height. He is also noted to have greasy
stools. What is the SINGLE most likely diagnosis?
A. Cystic Fibrosis
B. Severe combined immunodeficiency
C. Primary T cell immunodeficiency
D. Primary B cell immunodeficiency
E. Malabsorption
Cystic fibrosis
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- Recurrent chest infections (Cough and chronic sputum production)
- Malabsorption → Leading to:
o Frequent, bulky, greasy stools (Steatorrhoea)
o Failure to thrive
- Pancreas → increased incidence of diabetes mellitus
- Delayed sexual development
- Male infertility, female subfertility
- Salty taste of skin
- Short stature
- Meconium ileus (in neonatal period)
Diagnosis
- Usually diagnosed with CF as neonates or as children
- Diagnosis involves:
o Sweat test positive
o Molecular genetic testing for CFTR gene
y
3. An 8 year old boy is clinically obese. As a baby he was floppy and difficult to feed. He
op
now has learning difficulties and is constantly eating despite measures by his parents to
hide food out of his reach. What is the SINGLE most likely diagnosis?
C
n
D. Laurence moon biedl syndrom
io
t
Prader Willi syndrome rare congenital disorder characterized by learning difficulties,

ua
growth abnormalities, and obsessive eating, caused mostly by deletion of the paternally
inherited chromosomal 15q11.2-q13 region.
al
Prader-Willi syndrome (PWS)

Ev
- The striking feature of PWS is massive hyperphagia with associated compulsive

food-seeking, and consequent marked obesity.
Clinical features
- Neonates: hypotonia, sleepiness, unresponsiveness, narrow bifrontal diameter,
triangular mouth (feeding difficulties and swallowing problems), strabismus,
acromicria (shortness of extremities)
- Childhood/adolescence: short stature, hypogenitalism, behavioural disorders
(overeating and obesity, self-injurious behaviour).
- Associated features: Small hands and feet, cleft palate, almond-shaped eyes,
strabismus, clubfoot, scoliosis.
4. A 11 year old has increased laxity of joints and hyperelastic skin. He is noted to have
mild spinal curvature and a blue sclera. What is the SINGLE most likely diagnosis?
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Ehlers-Danlos syndrome
There are many types of EDS based on different gene mutations affecting the structure
or assembly of different collagens. Many syndromes overlap and it may be difficult to
differentiate one from the other. But not however, they all share common features of:
- Hyperelasticity of skin
- Joint hypermobility
Those are the only two signs you need to know for your exam for Ehlers-Danlos
syndrome
5. A 44 year old woman presents with memory loss, poor concentration and inability to
recognize household objects. She has right-handed involuntary writhing movement
which has just recently started. She reports occasional difficulty in walking. There is a
strong family history with similar symptoms. What is the SINGLE most likely diagnosis?
y
op
A. Friedreich’s ataxia
B. Wilson’s disease
C. Huntington’s disease
C
E. Charcot-Marie-Tooth disease
n
The right-handed involuntary writhing movements are called chorea. These are
io
uncontrollable limb movements. Cognitive abilities are progressively impaired in

Huntington’s which explains the memory loss, poor concentration and the inability to
t
recognize household objects. A general lack of coordination and an unsteady gait often
ua
follow. The final clue is the strong family history. Huntington’s disease is an autosomal-
dominant disorder. One can imagine either her father or mother with this disorder.
al
Huntington’s disease
- Huntington's disease (HD) is an autosomal-dominant, progressive
Ev
neurodegenerative disorder with a distinct phenotype
Presentation
- Typically, onset of symptoms at middle age
- Early signs may be personality change, self-neglect and clumsiness
- Incoordination
- Cognitive decline
- Behavioural difficulties
- Later → Chorea, dystonia, rigidity and dementia
6. A 59 year old man has shown a change in his mood and personality over a 9 month
period. He has subsequently developed difficulty with memory and concentration, and
then progressive fidgety movements of his limbs and facial musculature. By the time of
medical assessment he has frank choreiform movements and a mini-mental state exam
of 21/30. He was adopted and therefore no information on his family history is
available. He has 3 adult children (27, 30, 33) of whom the 2 youngest are
asymptomatic. However, the oldest son has recently been investigated by the
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neurology department for slightly erratic behavior and fidgety restless movements of
both legs. Based on the likely clinical diagnosis, what is the SINGLE most likely mode of
inheritance?
A. Autosomal dominant inheritance with anticipation

B. Autosomal dominant with variable penetrance
D. X-linked
E. Mitochondrial disorder
This patient is suffering from Huntington's disease. It is an autosomal dominant

disorder with anticipation. The term “anticipation” is a phenomenon whereby as the
genetic disorder is passed on to the next generation, the symptoms of the genetic
disorder become apparent at an earlier age. This occurs in each generation whereby
the symptoms would appear earlier and earlier.
Huntington’s disease
- Huntington's disease (HD) is an autosomal-dominant, progressive
y
neurodegenerative disorder with a distinct phenotype
Presentation
- Typically, onset of symptoms at middle age
op
C
- Early signs may be personality change, self-neglect and clumsiness
- Incoordination
- Cognitive decline
n
- Behavioural difficulties
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- Later → Chorea, dystonia, rigidity and dementia

t
7. A 30 year old man and wife presents to the reproductive endocrine clinic as they have
ua
been trying to conceive for the last 3 years. They have intercourse 3 times a week and
do not use contraception. The man is tall and has bilateral gynecomastia. Examination
of the testes reveals bilateral small, firm testes. Which is the SINGLE best investigation
al
that could lead to a diagnosis?

Ev
A. Computed tomography scan of the pituitary gland

B. Chromosomal analysis
C. Serum gonadotropin levels
D. Serum testosterone levels
E. Follicle-stimulating hormone (FSH) and luteinising hormone (LH) levels
Many with known Klinefelter's syndrome are not diagnosed until they are adults. The
SINGLE best test that confirms diagnosis is a chromosomal analysis. In this question,
attending a reproductive endocrine clinic and trying to concieve for the last 3 years is a
hint telling you about his infertility.
Klinefelter’s syndrome (XXY)
Findings
- Mental retardation (average IQ 85-90)
- Behavioral problems
- Long limbs ( decreased upper:lower segment ratio)
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- Tall and slim
- Hypogonadism
- Infertility
- Gynecomastia
8. A 5 year old boy has recurrent chest infections and offensive stool. On physical
examination, he has finger clubbing. What is the SINGLE most appropriate initial
investigation?

B. Sweat test
C. Barium meal
Sweat testing confirms the diagnosis and is 98% sensitive.
Cystic fibrosis
y
op
C
o Failure to thrive
n
io

t
- Short stature
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Diagnosis
al

Ev

9. A 4 year old boy presents to clinic after an incidental finding of elevated creatine
kinase. The mother gives a history of the boy walking at 18 months and sluggish when
he runs, climbs stairs, rising from a sitting position, or riding his tricycle. Compared to
his older sister at the same age, he has difficulty holding onto small objects. What is the

C. Myotonic muscular dystrophy
D. Spinal muscular atrophy type 1
E. Lambert-Eaton syndrome
This is a classic presentation of Duchenne muscular dystrophy. The stem would usually
present with a pre-school boy and a history of abnormal gait. Clues: “rising from a
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sitting position” (Gower’s sign), hypertrophic calf muscles, and elevated creatine kinase.
The presentation of Becker’s has an onset of around 10 years old or presenting with a
young man who is unable to walk. Myotonic muscular dystrophy presents at birth with
multi-system complications as with spinal muscular atrophy type 1. With option E,
symptoms would be similar to Duchenne’s but the proximal muscle weakness would
improve with exercise and usually is associated with a tumour of the lung.

Presentation:
Diagnosis:
y
op
PCR
C
10. A mother has a child with 17-alpha-hydroxylase deficiency. She is now pregnant for the
second time. What are the risks of her unborn child having congenital adrenal
n
hyperplasia?
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A. 1:1
t
B. 1:2
ua
C. 1:4
D. 1:8
E. 2:3
al
Unfortunately this is not the type of question that you can figure out using logic. You
Ev
need to learn that Congenital Adrenal Hyperplasia is an autosomal recessive genetic

disorder. This means that in order for a child to have the condition, both parents need
to have the recessive gene. This would result in 25% of offspring being normal, 50% of
offspring being carriers and 25% of offspring having the disease in its active form
Congenital Adrenal Hyperplasia
Congenital adrenal hyperplasia (CAH) describes a group of autosomal recessive

disorders of cortisol biosynthesis.
21-hydroxylase deficiency is the most common and is characterized by cortisol
deficiency (with or without aldosterone deficiency) and androgen excess.
11-beta-hydroxylase deficiency is the second most common and is characterized by
aldosterone deficiency which causes salt-wasting) in early infancy and excess
hypertension in childhood and adult life
17-alpha-hydroxylase deficiency is extremely rare and is characterized by hypertrophy
of the adrenal cortex. It presents in much the same way as 11-beta-hydroxylase
deficiency.
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It is not really important to know the specifics of the subtypes or the biosynthesis
pathways. Just know that CAH is an autosomal recessive disorder.
11. A 3 year old boy presents with rectal prolapse. He is noted to be below the 5th
percentile for weight and height. His mother is also concerned because he has a foul-
smelling bulky stool that "floats." She also state that the child has developed a
repetitive cough over the last few months. What is the SINGLE most appropriate initial
investigation?

B. Sweat test
C. Barium meal
Sweat testing confirms the diagnosis and is 98% sensitive. The rectal prolapse is due to
bulky stools which is seen in CF.
y
op
Cystic fibrosis
C
n
o Failure to thrive
io

t

ua

- Short stature
al
Diagnosis
Ev

12. A 33 year old mother of a child with cystic fibrosis is concerned of her next baby also
having cystic fibrosis. She is with the same partner and they both are completely
healthy. What is the SINGLE most likely probability of their future child having cystic
fibrosis?
A. 1:2
B. 1:4
C. 1:8
D. 1:1
E. No risk
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Cystic fibrosis (CF) is an autosomal recessive disorder. This means that the parents of
the cystic fibrosis child are carriers.
If a child is born to parents who carry the same autosomal recessive change (mutation),
the child has a 1 in 4 chance of inheriting the abnormal gene from both parents and
developing the disease. The child would have a 50% (1 in 2) chance of inheriting one
abnormal gene. This would make him/her a carrier.
13. A 7 year old male child is brought to the paediatrician’s office by his concerned mother.
She states that he is unable to climb stairs and that he is being bullied in school as he
cannot run with his classmates on the playground. Upon examination, it is noted that
he has diminished deep tendon reflexes and hypertrophy of his calf muscles bilaterally.

B. Guillain Barre Syndrome
C. Becker’s muscular dystrophy
D. Polymyositis
y
E. Motor neurone disease

Presentation:
op
C
n
io

t
ua
Diagnosis:
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PCR
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Becker's muscular dystrophy (BMD)

- Is similar to the more common muscular dystrophy - Duchenne muscular
dystrophy (DMD) - but the clinical course is milder.
- As with DMD, there is muscle wasting and weakness which is mainly proximal.
- Generally, walking difficulties begin after the age of 16 in Becker's muscular
dystrophy.
14. A 32 year old female has café au lait spots seen at birth. Axillary freckles started to
appear in her childhood. What is the probability of her child having the same condition
as she has?
A. 1:2
B. 1:4
C. 1:16
D. 3:4
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E. No genetic link
This lady has neurofibromatosis. The risk of an affected individual with

neurofibromatosis type 1 or 2 transmitting the disease to their child is 50%.
Neurofibromatosis
There are two types of neurofibromatosis, NF1 and NF2. Both are inherited in an
autosomal dominant fashion
Type 1 Type 2
More common form A central form with CNS tumours rather
- Café-au-lait spots than skin lesions
- Axillary/groin freckles - Bilateral acoustic neuromas
- Peripheral neurofibromas - Multiple intracranial
- Iris hamartomas (Lisch nodules) schwannomas, meningiomas and
- Scoliosis ependymomas
- Association with
phaeochromocytomas
y
15. A 44 year old lady who has polycystic kidney disease is concerned because her 38 year
op
old brother recently died of an intracranial insult. She knows he was not hypertensive.
What was the SINGLE most likely cause of her brother’s death?
C
A. Subdural haematoma
n
C. Cerebral infarct
D. Epidural haematoma
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E. Dehydration
t
The key to answer this question is to look for associations. Cerebral aneurysms are
ua
recognized association of polycystic kidney disease. Since polycystic kidney disease has
a genetic component, it is safe to assume that the question writers are trying to hint
that the brother also has polycystic kidney disease. The most serious possible
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complication of polycystic kidney disease is a cerebral aneurysm that ruptures. This

causes a subarachnoid haemorrhage.
Ev
16. A 15 year old girl presents with primary amenorrhoea. She has a short stature and a
broad chest with widely spaced nipples. What is the SINGLE most likely diagnosis?
A. Down’s syndrome
B. Klinefelter's syndrome
C. Fragile X syndrome
D. Turner syndrome
E. Normal physiological findings
Primary amenorrhoea, short stature and a broad chest with widely spaced nipples are
features of Turner syndrome.
Down’s syndrome and Fragile X syndrome do not present with primary amenorrhoea.
Klinefelter's syndrome affects males.
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17. A 42 year old woman is 16 week pregnant. She was late in booking her antenatal
appointments and missed her first trimester scan. She is extremely worried about an
abnormal chromosomal anomaly in her unborn baby as her first child was born with
Down Syndrome. What is the SINGLE most definitive investigations at this stage?
A. Amniocentesis
B. Chorionic Villous Sampling
C. Parents karyotyping
E. Preimplantation genetic testing
The most appropriate test at this gestation would be an amniocentesis.
Amniocentesis
Amniocentesis is an invasive, diagnostic antenatal test. It involves taking a sample of

amniotic fluid in order to examine fetal cells found in this fluid.
y
Amniocentesis is an invasive procedure, diagnostic antenatal test involving taking a 20
op
ml sample of amniotic fluid using a transabdominal needle under ultrasound guidance
in order to examine fetal cells found in this fluid. It is offered after screening tests have
indicated a high risk of fetal abnormality or in women considered to be at high risk, for
C
example if above 35 years old.
Amniocentesis is usually performed at 16 weeks and the risk of fetal loss is 0.5-1%. The
n
karyotype results typically take 3 weeks.
io
Conditions which may be diagnosed

t
- Neural tube defects (raised AFP levels in the amniotic fluid)

ua
- Chromosomal disorders
- Inborn errors of metabolism
al
Timing of amniocentesis
- Early (between 12 and 14+6 weeks of gestation):
Ev
o This is not recommended, as it is associated with an increased risk of

miscarriage
- Mid-trimester (between 15 and 18 weeks of gestation):
o This is the most common time for the procedure.
- Third trimester
o May be undertaken for late karyotyping
18. The parents of two children would like to try for another child. Their first child was
diagnosed with cystic fibrosis and their second child is healthy. Both the parents are
healthy. What is the chances of their next child being a carrier?
A. 1:4
B. 1:2
C. 2:3
D. 1:8
E. 1:16
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Pay special attention to the final line of the question. In this question they are
specifically asking for chances that this boy is a carrier (not an affected child with cystic
fibrosis). In other stems and questions, they may ask for the chance that this boy will
have the disease.
Both parents here would have to be carriers in order to produce a child with cystic
fibrosis as it is an autosomal recessive disease.
Therefore, the chances of having:

- An unaffected child is 1:4
- An unaffected ‘carrier’ child is
1:2
- An affected child is 1:4
y
op
19. A 28 year old lady with a family history of cystic fibrosis comes for genetic counselling
and wants the earliest possible diagnostic test for cystic fibrosis for the baby she is
planning. She is planning to get pregnant in the near future and she is not in favor of
C
termination. What is the SINGLE most appropriate test to recommend?
A. Chorionic villous sampling

n
B. Amniocentesis
io
C. Preimplantation genetic diagnosis

D. Chromosomal karyotyping
t
E. Non-invasive prenatal testing

ua
This women is not yet pregnant but planning for pregnancy. The earliest possible
diagnostic test for cystic fibrosis is a pre-implantation genetic diagnosis (PGD).
al
Preimplantation genetic diagnosis (PGD) is a procedure used prior to implantation to

help identify genetic defects within embryos created through in vitro fertilization to
Ev
prevent certain diseases or disorders from being passed on to the child. The process
helps potential parents prevent the birth of a child with a serious genetic condition.
Specialist occasionally recommend these test if a woman has a family history of a
serious genetic condition (e.g. cystic fibrosis).
20. A 26 year old tall and slender man and his wife has been trying to conceive for the past
3 years. He has been investigated for primary infertility and his recent semen analysis is
consistent with azoospermia. What is the SINGLE most appropriate investigations to be
performed?
A. Testosterone
B. Luteinising hormone (LH)
C. Follicle-stimulating hormone (FSH)
D. Estradiol
E. Karyotyping
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The likely diagnosis is Klinefelter’s syndrome. While it is true that serum testosterone is
low or low normal and FSH and LH are elevated (FSH >LH) in Klinefelter’s syndrome, the
diagnosis is confirmed by chromosomal analysis. The most common indications for
karyotyping are hypogonadism and infertility.
Many with known Klinefelter's syndrome are not diagnosed until they are adults. The
SINGLE best test that confirms diagnosis is a chromosomal analysis.
Klinefelter’s syndrome (XXY)
Findings
- Mental retardation (average IQ 85-90)
- Long limbs ( decreased upper:lower segment ratio)
- Tall and slim
- Hypogonadism
- Infertility
- Gynecomastia
y
op
21. A patient who presents with bilateral cerebellopontine tumors, bilateral sensorineural
hearing loss and café au lait spots is pregnant. What are the chances of her child having
the same condition?
C
A. 1:1
B. 1:2
n
C. 1:4
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D. 3:4
E. 1:8
t
ua
In order to work out probability of inheritance, you need to know the disease in
question. This woman has neurofibromatosis. Neurofibromatosis is an autosomal
dominant condition therefore the chances of this woman’s child having the condition is
al
50% or 1:2.
Ev
Neurofibromatosis
NF is a genetic disorder causing lesions in the skin, nervous system and skeleton. The
neurofibromatoses are autosomal dominant genetic disorders that encompass the rare
diseases NF1, NF2, and schwannomatosis
Type 1 is the more common form

Type 2 is a central form with CNS tumours rather than skin lesions:
Schwannomatosis is a recently recognized form of neurofibromatosis, characterized by
multiple non-cutaneous schwannomas, which is a histologically benign nerve sheath
tumour:
UNAFFECTED AFFECTED PARENT (Mother)
PARENT
(Father)
H H
H Hh hh
H Hh hh
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Diagnostic criteria for NF1
The diagnostic criteria for NF1 require at least two of seven criteria:
1. At least six café-au-lait spots or hyperpigmented macules
2. Axillary or inguinal freckles.
3. Two or more typical neurofibromas or one plexiform neurofibroma.
4. Optic nerve glioma.
5. Two or more iris hamartomas. They are called Lisch nodules and are seen by
slit-lamp examination.
6. Sphenoid dysplasia or typical long-bone abnormalities such as arthrosis.
7. Having a first-degree relative with NF1.
Knowing that neurofibromatosis is an autosomal dominant condition is important for

PLAB, as is knowing the difference between NF1 and NF2.
y
op
C
n
t io
ua
al
Ev
568
HAEMATOLOGY
y
op
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Questions
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&
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Answers
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Ev
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Haematology Questions
1. A 67 year old man with history of weight loss complains of hoarseness of voice. Chest X-
ray reveals opacity in the right upper mediastinum. He denies any history of difficulty
breathing. What is the SINGLE most appropriate investigation?
A. Laryngoscopy
B. Bronchoscopy
C. Lymph node biopsy
D. Bronchoalveolar lavage
E. Barium swallow
2. A 75 year old male presents with enlarged cervical nodes. He has several recurrent
infections over the last year. His conjunctiva is pale and he feels weak. What is the
SINGLE most likely cell type to be found on a blood smear of this patient?
A. Granulocyte without blast cells

B. Myofibroblasts
y
C. Plasma cells
op
D. Mature lymphocytes
E. Sickling of cells C
3. A 29 year old woman at 28 weeks gestation comes in for an antenatal visit. Her blood
tests reveal:
n
Hb: 11.0g/dL
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MCHC: normal range

MHC: normal
t
ua
What is the SINGLE best explanation for these blood results?
A. Iron deficiency anaemia

al
B. Folate deficiency anaemia

C. Anaemia of chronic disease
Ev
D. Normal physiological phenomenon

E. Autoimmune anaemia
4. A 50 year old woman is investigated for anaemia. She has no past medical history of
note. Clinical examination reveals massive splenomegaly associated with pale
conjunctivae. A full blood count was requested and results show:
Haemoglobin 105 g/L

A. Chronic lymphocytic leukaemia

B. Chronic myeloid leukaemia
C. Myeloma
D. Acute myeloid leukaemia
E. Malaria
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5. A 51 year old man complains of headache and pruritus. He had a deep vein thrombosis
recently. Recent blood report shows the following:
Haemoglobin 192 g/L

Erythropoietin was found to be low. What is the SINGLE most likely diagnosis?
A. Myelofibrosis
B. Polycythaemia rubra vera (PRV)
C. Essential thrombocythemia
D. Chronic myeloid leukaemia (CML)
E. Chronic lymphocytic leukaemia (CLL)
6. A 14 year old child has recurrent throat infections. He feels tired and lethargic all the
time. Blood results show:
y
op
Hb 7.2g/dl
WCC 6 x 109/L
C
Blood film shows blast cells. What is the SINGLE most likely diagnosis?
n
A. Acute lymphoblastic leukaemia (ALL)
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B. Acute myeloid leukaemia (AML)

C. Chronic myeloid leukaemia (CML)
t
D. Chronic lymphocytic leukaemia (CLL)

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E. Hodgkin’s lymphoma
7. A 53 year old lady has been suffering from chronic rheumatoid arthritis and is on
al
methotrexate. Blood results show:

Ev
Haemoglobin 83 g/L
What is the SINGLE most likely cause?
A. Haemorrhoids
B. Anaemia of chronic disease
C. Menorrhagia
D. Folate deficiency
E. B12 deficiency
8. A 17 year old girl has prolonged bleeding after a routine dental extraction. Her father
and paternal grandmother have experience similar problems. What is the SINGLE most
likely mode of inheritance?
A. Autosomal co-dominant
B. Autosomal dominant
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D. X-linked
E. Mitochondrial gene defect
9. A 51 year old vegan presents with complaints of peripheral paresthesia, mild shortness
of breath and fatigue. Examination reveals that she has angular stomatitis and a sore
red tongue. What is the SINGLE most likely cell type to be seen on a blood film?
A. Numerous blast cells

B. Oval macrocytic red cells
C. Spherocytes
D. Microcytic hypochromic red cells
E. Heinz bodies
10. A 51 year old man complains of lethargy tiredness and pruritus. The pruritus is worse
after he takes a hot shower. He also says that he feels a burning sensation in his fingers
and toes. Splenomegaly was found during an abdominal examination. His medical
history is significant for gout. What is the SINGLE most likely diagnosis?
y
op
A. Polycythaemia rubra vera (PRV)
B. Myelofibrosis
C. Rheumatoid arthritis
C
D. Scleroderma
n
11. A 63 year old man presents with extreme thirst that despite drinking fluids he still feels
io
thirsty. He has been having a back ache for the last 4 weeks that is getting worse and
feels tired all the time. His serum calcium was found to be elevated. A blood film was
t
taken. What is the SINGLE most likely finding to be seen on a blood film?
ua
A. Basophilic stippling
B. Howell Jolly bodies
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C. Heinz bodies
D. Trophozoites
Ev
E. Rouleaux formation
12. A 5 year old boy has swelling at the knee after falling on the ground with rashes on his
buttocks. His blood tests show:
Haemoglobin 119 g/L

Prothrombin time 12 seconds
Activated partial thromboplastin time 61 seconds
A. Haemolytic uraemic syndrome

B. Haemophilia
C. Henoch-Schönlein purpura
D. Osler weber rendu syndrome
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E. Von-Willebrand disease
13. A 54 year old woman is diagnosed with deep vein thrombosis after taking a long haul
flight. She is started on warfarin. What is the target INR for her?
A. <1
B. 1 - 2
C. 2 - 3
D. 3 - 4
E. 2 – 5
14. A 13 year old girl has has mucosal bleeding and petechial rashes. She has been feeling
tired lately. She looks pale. A blood count shows:
Haemoglobin 74 g/L
Neutrophils 0.1 x 109/L
y
op
Blood film morphology was unremarkable. Reticulocytes are absent. A bone marrow
aspirate shows a gross reduction in all haemopoietic tissue that is replaced by fat
spaces. What is the SINGLE most likely underlying diagnosis?
C
A. Pernicious anaemia
n
C. Aplastic anaemia
io

E. Acute lymphoblastic leukaemia
t
ua
15. A 51 year old male presents with malaise and tiredness. On physical exam, his spleen is
noted to be approaching his right iliac fossa. No lymphadenopathy was noticed. What is
the SINGLE most likely cell type to be seen on a blood smear?
al
A. Helmet shaped cell

Ev
B. Sickle cell
C. Granulocyte without blast cells
D. Blast cells
E. Target red cells
16. A 25 year old Greek man presents with dark red urine hours after eating fava beans. He
is now very ill and has signs of shock. Spherocytes and RBC fragments are seen on blood
film. What is the SINGLE most likely diagnosis?
A. Hereditary spherocytosis
B. Glucose-6-phosphate dehydrogenase (G6PD) deficiency
C. Alpha thalassemia
D. Beta thalassemia
E. Hereditary sideroblastic anaemia
17. A 63 year old man presents with back pain, polydipsia and polyuria which have been
present for the last couple of weeks. He complains of being tired lately. His previous full
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blood count shows a normochromic, normocytic anaemia. What is the SINGLE most
appropriate test that would lead to a diagnosis?
A. Bone marrow biopsy

B. Vitamin D levels
C. Liver function test
D. CT scan
E. Renal biopsy
18. A 36 year old female presents with a petechial rash and menorrhagia. Her physical
examination is completely normal and she has no other complaints. A full blood count
was done and reveals:
Hb: 13.3g/dL
WBC: 9 x 109/L
Platelets: 90 x 109/L
y
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A. Polycythaemia rubra vera
B. Thrombocytopaenia
C. Thrombocytosis
C
D. Chronic myeloid leukaemia
E. Hyposplenism
n
19. A 26 year old man has recently returned from new york. He has noticed weight loss,
io
and has been having night sweats that is usually drenching. He has a temperature of
37.6°C and cervical lymphadenopathy. An enlarged spleen was seen on abdominal
t
examination. What is SINGLE most likely the diagnosis?

ua
A. Tuberculosis
B. Lymphoma
al
D. Bronchitis
Ev
E. plaMycoplasma pneumonia
20. A 50 year old man has dizziness after exercising. He also complains of itching after a hot
shower and says that he feels burning around his fingers. Abdominal examination is
significant for splenomegaly. What is the SINGLE most likely diagnosis?
A. Scleroderma
B. Lymphoma
C. Polycythemia
D. Scabies
E. Eczema
21. A 4 year old boy has a cough and arthritis followed by rash on legs which are non-
blanching on glass test. He has no history of a fever. His blood tests show:
Haemoglobin 120 g/L

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A. Meningitis septicemia
B. Haemophilia
D. Idiopathic thrombocytopenic purpura
E. Thrombotic thrombocytopenic purpura
she has dry coarse skin, hair loss and cold peripheries. On examination, a diffuse and
lobulated goitre can be palpated on her anterior neck. A full blood count and peripheral
smear is done which shows a macrocytic anaemia. What is the SINGLE most likely
diagnosis?
y
A. Cushing’s Syndrome
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B. Hyperthyroidism
C
E. Pernicious anaemia
23. A 21 year old man presents with mild jaundice.

n
io
Haemoglobin 75 g/L
Reticulocytes 7%
t
ua
There are spherocytes seen on the blood film. He has no past medical history of any
significance. What is the SINGLE most appropriate investigation?
al
A. G6PD enzyme assay

B. Direct coombs test
Ev
C. Indirect coombs test

D. Bone marrow biopsy
E. Sickle solubility test
24. A 40 year old female, chronic heavy smoker has a haemoglobin of 189 g/L. What is the
SINGLE most useful hormone level to test for to help establish a diagnosis?
A. Aldosterone
B. Cortisol
C. Erythropoietin
D. T4
E. TSH
25. A 6 year old boy is brought to the hospital by his mother with bleeding from his gums
and nose. His mother complains that he has been having recurrent sore throats that
come and go in last couple of months.. Pale conjunctivae is noticed on examination.
What is the SINGLE most likely single cell type associated with his diagnosis?
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A. Clumped platelets
B. Microcytes
D. Blast cells
E. Mature lymphocytes
26. A 55 year old man complains of headache and visual disturbances. He has a history of
hypertension. He also reports itching after a hot bath and burning sensation in his
finger and toes. He is noted to have mass in the left upper quadrant. Blood report
shows the following:
Haemoglobin 202 g/L

Erythropoietin is normal
y
op
A. Myelofibrosis
C
n
27. A 42 year old woman with septicaemia suddenly develops purpura all over her legs and
io
arms. Her blood tests show:

t
Haemoglobin 118 g/L

ua

al
Prothrombin time, and activated partial thromboplastin time are prolonged. D-dimers
were elevated. What is the SINGLE most likely diagnosis?
Ev
A. Pulmonary embolism
B. Disseminated intravascular coagulation
C. Deep vein thrombosis
D. Factor V Leiden mutation
E. Warfarin interaction
28. A 7 year old boy has recurrent episodes of spontaneous bleeding into his knee and
elbow joints. Mild joint deformity us noted. His father has a similar illness. Factor VIII/XI
assay results show a decrease in factor VIII. What is the SINGLE most appropriate
management?
A. Desmopressin
B. Recombinant factor IX
C. Heparin
D. Infusion of platelet concentrates
E. Vitamin K
576
29. A 22 year old man is admitted to the hospital with lethargy. His medical history includes
hereditary spherocytosis. His blood tests show:
Haemoglobin 51 g/L
Reticulocytes 0.4%
What is the SINGLE most likely cause of his low haemoglobin and low reticulocytes?
A. Parvovirus B19 infection

B. Autoimmune haemolytic anaemia
C. Splenic sequestration crisis
D. Haemolytic transfusion reactions
E. Recent antibiotic treatment
30. A 33 year old man complains of lethargy tiredness and pruritus. A diagnosis of
polycythaemia vera was made. What is the SINGLE most appropriate management?
y
A. Phlebotomy
op
B. Splenectomy
C. Indomethacin
D. Heparin
C
E. Warfarin
31. A 75 year old man presents with back pain and lethargy. Investigations were carried
n
out. A bone marrow biopsy reports as having abundance of plasma cells. What is the
io

t
A. Multiple myeloma
ua
B. Ankylosing spondylitis
C. Amyloidosis
D. Leukaemia
al
E. Myelofibrosis
Ev
32. A 22 year old Greek man presents with rapid symptoms of anaemia and jaundice
following treatment of malaria. He is noted to have Heinz bodies on a blood film. What
A. Glucose-6-phosphate dehydrogenase (G6PD) deficiency

D. Thalassaemia trait
33. A 35 year old man has fatigue, night sweats and a mild fever for the last month.
Examination reveals painless cervical lymphadenopathy. Splenomegaly is noted on
abdominal examination. He has significant weight loss. What is the SINGLE most likely
diagnosis?
A. Non-Hodgkin lymphoma
B. Polycythemia
577
C. Iron deficiency anaemia
D. Toxoplasmosis
E. Cytomegalovirus infection
34. A 26 year old Greek man has recently recovered from a haemolytic episode 6 weeks
ago. The haemolytic episode occurred a day after he ate a traditional Greek dish.
Glucose-6-phosphate dehydrogenase deficiency is suspected. What is the SINGLE most
definitive diagnostic test?
A. Osmotic fragility test

B. G6PD enzyme assay
C. Heinz bodies seen on blood film
D. Bite cells seen on blood film
E. Decreased haptoglobins and increased reticulocytes
35. A 29 year old man has back pain and abdominal pain following treatment of malaria.
His urine has become dark and his eyes have a yellowish tinge. He has had gallstones in
the past. His past medical history includes jaundice when he was a neonate. What is the
y
op
B. Allergy to antimalaria medication
C
C. Steven-Johnson syndrome
D. Peptic ulcer disease
E. Beta thalassemia
n
io
36. A 10 year old boy is brought to the hospital with a rash over his buttocks associated
with abdominal pain and vomiting. He is accompanied by his mother and stepfather.
t
His mother had left him for the weekend with the stepfather and she was called to
ua
come back from holiday as he started to have blood in his urine with the rash. Social
services have been notified. What is the most likely diagnosis?
al
A. Non accidental injury

B. Idiopathic thrombocytopenic purpura
Ev
D. Acute lymphoblastic leukaemia (ALL)
E. Haemolytic uraemic syndrome
37. A 6 year old boy has recurrent episodes of spontaneous bleeding into his knee joints.
His father has a similar illness. Factor VIII was found to be decreased on a blood test.
A. Haemophilia A
B. Haemophilia B
C. Von willebrand’s disease
D. Sickle cell anaemia
E. Thalassaemia
38. A 11 year old boy has an upper respiratory tract infection followed by a low grade fever
with erythematous macular rash, especially on the back of the legs. A few hours later,
578
the macules evolve into purpuric lesions that are slightly raised and do not blanch on a
glass test. He also complains of a headache and joint stiffness. His blood tests show:
Haemoglobin 123 g/L

A. Meningitis
B. Sepsis
39. A 65 year old man presents with back pain. Abdominal examination reveals
splenomegaly
y
Blood report shows the following:
Haemoglobin 102 g/L

op
C
ESR 25
n
He has been found to have Philadelphia chromosome on cytogenetic analysis. What is
io

t

ua

al
E. Lymphoma
Ev
40. A 20 year old man presents with develops low back pain, shortness of breath and
dizziness 3 days after taking primaquine to treat malaria. His past medical history is
significant for neonatal jaundice. What is the SINGLE most likely diagnosis?
A. Haemolytic anaemia
B. Pulmonary embolism
C. Allergy to primaquine
41. A 4 year old boy is presents with haemarthrosis following a minor fall. His father and
uncle have similar bleeding problems throughout their lives. What is the SINGLE most
likely mode of inheritance?
579
D. X-linked
42. A 50 year old man presents fatigue, weight loss and complains of abdominal fullness.
An abdominal examination reveals splenomegaly extending towards the right iliac
fossa.
Haemoglobin 82 g/L
Philadelphia chromosome was positive on cytogenetic analysis. What is the SINGLE


y
op
E. Lymphoma C
43. A 30 year old woman presents with complaints of lethargy and frequent infections.
Upon examination, massive splenomegaly with no associated lymphadenopathy is
observed. A full blood count reveals the following:
n
io
Hb: 10.2g/dL
WBC: 2 x 109/L
t
ua
What tissue biopsy will you do to prove the diagnosis?

al
A. Liver
B. Lymph node
Ev
C. Spleen
D. Bone marrow
E. Lung
44. A 15 year old boy is investigated after he bled excessively following a tooth extraction.
He has always noted that he bruises easily with minimal trauma. His blood tests show:
Haemoglobin 120 g/L

Bleeding time within normal ranges
A. Haemophilia A
580
B. Haemophilia B
D. Thrombotic thrombocytopenic purpura
E. Idiopathic thrombocytopenic purpura
45. A 15 year old boy has marked pallor and jaundice. He has to receive regular blood
transfusions to maintain his haemoglobin above a certain level. His medical history
includes diabetes. He has obvious skull bossing and hepatosplenomegaly. What is the
C. Alpha thalassemia trait
D. Beta thalassemia major
46. A 52 year old female has loss a few litres of blood during a hysterectomy. She is due for
a blood transfusion. What is the SINGLE most likely test involved in the preparation of
y
blood transfusion?
A. Indirect Coombs test

B. Direct Coombs test
op
C
C. Sickle solubility test
D. G6PD enzyme assay
E. Osmotic fragility test
n
io
47. A 7 year old boy presents with epistaxis of 2 hour duration. The bleeding has been
controlled. His blood tests show:
t
ua

al
Bleeding time is normal

Ev
A. Haemophilia
B. Von willebrand disease
C. Idiopathic thrombocytopenic purpura
D. Vitamin K deficiency
E. Anatomical defect
48. A 20 year old woman has had bruising and petechiae for a week. She also reports
frequent nose bleeds and menorrhagia but is otherwise well. A blood count showed:
Haemoglobin 111 g/L

581
A. Acute leukaemia
B. Aplastic anaemia
C. HIV infection
49. A 5 year old child has bleeding gums and sore throat for the last 3 months. He feels
tired and lethargic all the time. On examination, splenomegaly was noted. Blood results
show:
Hb 7.8g/dl
WCC 3 x 109/L

y
op
E. Hodgkin’s lymphoma C
50. A 55 year old man presents with significant weight loss, fever and night sweats.
Hodgkin’s lymphoma was later diagnosed. What type of cell is associated with
Hodgkin’s lymphoma?
n
io
A. T-cells
B. Reed-Sternberg cells
t
C. B-cells
ua
D. Macrophages
E. Auer rods
al
51. A 12 year old boy has sudden development of purpura 2 weeks after an upper
respiratory tract infection. A blood count showed:
Ev
Haemoglobin 119 g/L

Bleeding time 10 minutes
A. Idiopathic thrombocytopenic purpura

B. Thrombotic thrombocytopenic purpura
C. Von Willebrand’s disease
D. Haemophilia A
E. Haemophilia B
582
52. A 33 year old woman complains of tiredness for the last 3 months, On routine blood
test, she is found to have a haemoglobin of 85 g/L, low mean cell volume, and low
ferritin. What is the SINGLE most likely diagnosis?
A. Iron deficiency
C. Thalassaemia
E. Sideroblastic anaemia
53. A 36 year old woman has massive bleeding from a venipuncture site. Petechiae was
noticed on her skin. Her blood tests show:
Haemoglobin 113 g/L

Prothrombin time, activated partial thromboplastin time and bleeding time are
y
prolonged. Fibrin degradation products were elevated. What is the SINGLE most likely
op
diagnosis?
A. Haemophilia
C
n
E. Warfarin overdose
io
54. A 62 year old man presents with bone pain at his ribs which have been present for the
t
last couple of weeks. He has been feeling tired lately and finds himself always thirsty.
ua
His previous FBC shows a haemoglobin of 9 g/dL. Biochemistry shows calcium levels of
4.0mmol/L and ALP of 118 iu/L. What cell type is most likely to be found in abundance
in the bone marrow?
al
A. Plasma cell
Ev
B. Myeloid cell
C. Bence-jones protein
D. Megakaryocytes
E. Reticulocytes
55. A 67 year old woman with a history of rheumatoid arthritis presents to her GP’s office
with complaints of epigastric discomfort, especially after eating. She has been on long
term methotrexate and NSAID therapy for her condition. On examination, she appears
pale but seems otherwise well. A full blood count reveals the following:
Hb: 10.5g/dL
MCV, MCH and MCHC are all decreased
A. Folate deficiency anaemia

B. Vitamin B12 deficiency anaemia
583
C. Haemolytic anaemia
D. Aplastic anaemia
E. Chronic gastrointestinal bleeding
56. A 25 year old lady has a chest infection in which she is receiving antibiotics for. She has
shortness of breath, feels tired and weak. On examination she looks pale and purpura is
seen on her legs. Blood results show the following:
Haemoglobin 76 g/L
Reticulocytes 1%
Blood film morphology was unremarkable. A bone marrow aspirate shows a reduction
in haemopoietic cells. What is the SINGLE most likely underlying diagnosis?
y
op
C. Aplastic anaemia
C
57. A 53 year old man presents complaining of weight loss, lethargy, increasing abdominal
discomfort and gout for the past year. On examination, spleen is palpated 5 cm below
n
the left costal margin. His blood tests show:
io
Haemoglobin 105 g/L

t

ua

85% neutrophils
al

Sodium 140 mmol/L
Ev
Potassium 4 mmol/L
Philadelphia chromosome positive
A. Chronic myeloid leukaemia

B. Chronic lymphocytic leukaemia
C. Acute myeloid leukaemia
D. Malaria
E. Lymphoma
58. A 90 year old woman is brought to the hospital complaining of back pain and has been
referred to the surgeon. She has been saying that her mother is due to visit her today
and that somebody must have broken her lower back as she is in agony. Her blood tests
show:
Haemoglobin 109 g/L
584
What SINGLE investigations is most likely to lead to a diagnosis?
A. Ultrasound KUB
B. X-ray Spine
C. Intravenous urogram
D. Urine protein electrophoresis to look for Bence-Jones Protein
E. Mental state exam
59. A 15 year old girl was admitted with chest infection. She was treated and her symptoms
had regressed. She was brought again with fever and the same symptoms a few days
later. It was found that all her blood works done in the hospital showed a mild anaemia
and thrombocytopenia. What is the SINGLE most likely diagnosis?
A. Acute myeloid leukaemia (AML)
y
B. Acute lymphoblastic leukaemia (ALL)
op
C. Aplastic anaemia
C
60. A 34 year old woman developed a purpuric rash on the back of her legs. She also
reports frequent nose bleeds and menorrhagia. A blood count shows:
n
io
Haemoglobin 119 g/L

t
ua

al

Ev

D. Antiphospholipid syndrome
E. Henoch-Schönlein purpura
61. A 21 year old man has episodic right upper quadrant pain. An abdominal ultrasound
reveals gallstones. His father had a splenectomy when he was young. His blood tests
show:
Haemoglobin 91 g/L
Mean cell haemoglobin concentration 369 g/L
585
D. Beta thalassemia
62. A 7 year old boy has recurrent episodes of spontaneous bleeding into his knee joints
and muscles. Factor IX was found deficient. What is the SINGLE most likely diagnosis?
A. Haemophilia A
B. Christmas disease
E. Thalassaemia
63. A 66 year old woman is confused, and lethargic. Her son reports gradual confusion over
the last 4 months. On examination, she looks pale. Blood test have been done which
shows a megaloblastic anaemia. Both B12 deficiency and folate deficiency was
diagnosed on further investigation. What is the SINGLE most likely treatment for her
anaemia?
y
op
A. Oral folic acid and start Intramuscular vitamin B12 when folic acid levels are normal
B. Intramuscular vitamin B12 and start oral folic acid when vitamin B12 levels are
normal
C
C. Oral folic acid only
D. Intramuscular vitamin B12 only
E. Iron tablets
n
io
64. A 4 year old boy has a history of epistaxis. Prothrombin time, bleeding time, fibrinogen
levels and von Willebrand factor are normal. Activated partial thromboplastin time
t
(APTT) was found to be prolonged. His blood tests show:

ua
Haemoglobin 112 g/L

al

Ev
A. Haemophilia
C. Sickle cell anaemia
D. Haemolytic uraemic syndrome
E. Thalassaemia
65. A 41 year old man has fatigue and palpitations. Physical examination reveals a red sore
tongue, angular stomatitis and koilonychia. His blood tests show:
Haemoglobin 85 g/L
A. Folate deficiency
586
B. Vitamin B12 deficiency
C. Iron deficiency
D. Vitamin E deficiency
E. Haemolytic anemia
66. A 52 year old lady has been suffering from chronic rheumatoid arthritis and is on
methotrexate and naproxen. Blood results show:
Haemoglobin 83 g/L
A. Haemorrhoids
B. Gastrointestinal haemorrhage
C. Menorrhagia
E. B12 deficiency
y
op
67. A 6 year old child has a history of recurrent mild jaundice that occurs a fews days after
the onset of a fever. Between the episodes he is well. 3 days ago, he had a chest
infection and his blood results show:
C
Haemoglobin 106 g/L
n
io
Bite cells are seen on blood film. What is the SINGLE most likely diagnosis?
t
ua

C. Thalassemia
D. Sickle cell disease
al
E. Congenital storage disorder

Ev
68. A 45 year old woman who is taking medication for the treatment of rheumatoid
arthritis presents with dizziness, fatigability and lack of energy. Blood results show:
Haemoglobin 80 g/L
What is the SINGLE most likely cause of her anaemia?
A. Steroids
B. Chronic disease
C. NSAIDs
D. Methotrexate
E. Leflunomide
69. A 4 year old boy presents with recurrent episodes of self limiting spontaneous bleeding
into his arms and legs that occurs with minimal trauma. His blood tests show:
587
His father and uncle suffer from a similar illness. What is the SINGLE most likely
diagnosis?
A. Haemophilia
B. Thalassaemia
70. A 22 year old man with sickle cell anaemia has shortness of breath, pallor, headache
and lethargy. Infection with parvovirus is suspected. His blood tests show:
Haemoglobin 53 g/L
y
A. Aplastic crises
B. Haemolytic crisis
op
C
D. Vaso-occlusive crises
E. Acute chest syndrome
n
io
71. A 49 year old lady complains of headaches, dizziness and pruritus. She says that the
pruritus is worsen after taking a hot bath. A recent FBC revealed that she has a
t
haemoglobin of 192 g/L. What is the SINGLE most useful test to establish the diagnosis
ua
of polycythaemia rubra vera?
A. JAK mutation screen

al
B. Leukocyte alkaline phosphatase

C. Serum erythropoietin
Ev
D. Oxygen saturation with arterial blood gas greater than 92%

E. Bone marrow aspiration
72. A 26 year old man develops mild anaemia following a chest infection. A blood film
shows Heinz bodies. What is the SINGLE most likely diagnosis?
D. Beta thalassemia
73. A 10 year old girl presents with pallor and features of renal failure. She has haematuria
as well as proteinuria. The serum urea and creat are elevated. These symptoms started
after an episode of bloody diarrhoea 4 days ago. What is the SINGLE most likely
diagnosis?
588
A. Thrombotic thrombocytopenic purpura
B. Haemolytic uraemic syndrome
D. Henoch-Schönlein purpura
E. Acute renal failure
74. A 55 year old man complains of fatigue. A blood test shows:
Haemoglobin 82 g/L
y
op
75. A 55 year old HIV positive man presents with painless peripheral lymphadenopathy,
fever, night sweats and weight loss. Abdominal examination reveals a enlarged spleen.
C
A. Hodgkin’s lymphoma
B. Non-Hodgkin lymphoma
n
C. Acute lymphoblastic leukaemia (ALL)
io
D. Acute myeloid leukaemia (AML)

E. Chronic myeloid leukaemia (CML)
t
ua
76. A 47 year old man who is on warfarin therapy is due for a hemicolectomy. He is on
warfarin for recurrent pulmonary embolism. What advice would you give him prior to
his surgery?
al
A. Continue with warfarin

Ev
B. Continue with warfarin and add heparin

C. Stop warfarin and start aspirin
D. Stop warfarin and start heparin
E. Stop warfarin
77. A 45 year old man presents with a lump in the posterior triangle of his neck. It has been
growing for the past few months. He also complains of having drenching night sweats,
unexplained fever and weight loss. Lymph nodes are palpable at the supraclavicular
region. What is the SINGLE most likely diagnosis?
A. Tuberculosis
B. Lymphoma
C. Lipoma
D. Reactive lymph nodes
E. Virchow’s nodes
589
78. A 40 year old man has a mild fever and feels generally tired. He has marked weight loss
over the last 6 months and has a bilateral white, vertically corrugated lesion on the
lateral surfaces of the tongue. What is the SINGLE most likely diagnosis?
A. C1 esterase deficiency
B. Crohn's disease
C. HIV disease
D. Sarcoidosis
E. Sjogren’s syndrome
79. A 51 year old man complains of pruritus and fatigue. A full blood count was done and
the following was reported:
Haemoglobin 197 g/L

JAK2 mutation was found to be positive. What is the SINGLE most likely diagnosis?
y
op
B. Myelofibrosis
C. Acute myeloid leukaemia (AML)
C
n
80. A 39 year old pregnant woman who is 36 week gestation has acute abdominal pain and
io
is rushed for immediate C-section. Her blood pressure was reported to be 110/60
mmHg. Her blood tests show:
t
ua
Haemoglobin 101 g/L

al

Ev
Fibrinogen 0.6 g/L

A. Pregnancy induced hypertension

C. HELLP syndrome
D. Acute fatty liver
81. A 26 year old businessman travelled from New York to the U.K. He presented to A&E
three weeks later complaining of drenching night sweats, fever and lymphadenopathy
in the neck since returning from his business trip. What is the SINGLE most likely
diagnosis?
A. Tuberculosis
590
B. Lymphoma
C. Aplastic anaemia
D. Hereditary Spherocytosis
82. A 32 year old man presents with fatigue, weakness, weight loss. On examination,
cervical lymphadenopathy and splenomegaly is noted. What is the SINGLE most likely
diagnosis?
A. Haemophilus influenzae infection

B. Streptococcal infection
C. Toxoplasmosis
D. Non-Hodgkin lymphoma
E. Pneumocystis infection
83. A 16 year old boy presents with rash on his buttocks and extensor surface following a
sore throat. He complains of joint stiffness and pain. What is the SINGLE most probable
diagnosis?
y
op
A. Measles
B. Bullous-pemphigoid
C. Rubella
C
D. Idiopathic thrombocytopenic purpura (ITP)
E. Henoch-Schönlein purpura (HSP)
n
84. A 45 year old man presents fatigue. He is otherwise asymptomatic. Blood report shows
io
the following:
t
Haemoglobin 82 g/L
ua

al
There was an increased number of neutrophils, basophils, eosinophils. Peripheral blood

smear shows all stages of maturation. What is the SINGLE most likely diagnosis?
Ev

E. Lymphoma
85. A 5 year old child presents with fever and pallor. His parents say he always feels tired
and is not as active as the other children around his age. On examination, splenomegaly
was noted. Blood results show:
Hb 7 g/dl
WCC 2 x 109/L
591
A. Acute myeloid leukaemia
B. Acute lymphoblastic leukaemia
C. Chronic myeloid leukaemia
D. Chronic lymphocytic leukaemia
86. A 54 year old man has fatigue. A recent blood report shows the following:
Haemoglobin 90 g/L
Serum ferritin 9 μg/L
Total iron-binding capacity 75 μmol/L
A. Thalassaemia trait
B. Hypoparathyroidism
y
C. Hereditary sideroblastic anaemia
op
E. Iron deficiency anaemia C
87. A 59 year old smoker who recently underwent a hip replacement surgery 2 days ago,
has a swollen and tender left leg. The diameter of his left calf is higher than the right
calf. Passive movements cause pain. The calf is tender to touch. What is the SINGLE
n
io
A. Deep vein thrombosis

t
B. Lymphoedema
ua
C. Peripheral vascular disease

D. Cellulitis
E. Superficial thrombophlebitis
al
88. A 28 year old man has sudden onset of bone pain. He also begins experiencing bleeding
Ev
from his gums. Looking retrospectively, he notes a decreased energy level over past
weeks. He feels dizzy and has dyspnoea on exertion. He looks pale and has numerous
ecchymoses is seen over his body. Hepatosplenomegaly is noted. A full blood count
shows WBC of 102 x 109/L. A bone marrow biopsy shows numerous blasts. What is the
A. Mantle cell lymphoma

B. Infectious lymphocytosis
C. Waldenstrom’s macroglobulinemia
E. Acute lymphoblastic leukaemia (ALL)
592
Haematology Answers
1. A 67 year old man with history of weight loss complains of hoarseness of

voice. Chest X-ray reveals opacity in the right upper mediastinum. He denies
any history of difficulty breathing. What is the SINGLE most appropriate
investigation?
A. Laryngoscopy
B. Bronchoscopy
C. Lymph node biopsy
D. Bronchoalveolar lavage
E. Barium swallow
Mediastinal masses are frequent and are sometimes discovered on a

routine CXR in lymphoma.
Tissue diagnosis is the best way to diagnose lymphoma. Lymph node

excision biopsy is what is usually done.
y
op
2. A 75 year old male presents with enlarged cervical nodes. He has several
recurrent infections over the last year. His conjunctiva is pale and he feels
weak. What is the SINGLE most likely cell type to be found on a blood smear
of this patient?
C
A. Granulocyte without blast cells
n
B. Myofibroblasts
io
C. Plasma cells
D. Mature lymphocytes
t
E. Sickling of cells
ua
The diagnosis here is Chronic lymphocytic leukaemia (CLL) which has

mature lymphocytes on the blood film.
al
Factors that support the diagnosis of CLL in this question:

Ev
• His age (75 years old) - In the PLAB test, if you see an elderly patient
(usually more than 65 years old) with symptoms of leukaemia, it is
most likely CLL. However, read the whole question before you make
a decision on the answer.
• Cervical lymphadenopathy
• Recurrent infections → dysfunctional WBC
• Pale conjunctiva → Anaemia
On blood film, B cell lymphocytosis will be seen often with smudge cells.
They are mature but functionally impaired lymphocytes as they escape
apoptosis.
Chronic lymphocytic leukaemia (CLL)
CLL can often present as an asymptomatic elevation of white cells found on

routine evaluation of patients during investigations for other health
problems. These patients are exclusively older (majority over 50 years old).
593
When patients do have signs and symptoms they are usually non-specific:
• Fatigue
• Lethargy
• Enlargement of lymph nodes
When should you suspect CLL?

When an older patient has marked elevation in white cell count with
marked lymphocytic predominance. The marrow is often infiltrated with
leukemic lymphocytes. “Smudge cells” are seen on smear.
3. A 29 year old woman at 28 weeks gestation comes in for an antenatal visit.

Her blood tests reveal:
Hb: 11.0g/dL
MCHC: normal range
MHC: normal
What is the SINGLE best explanation for these blood results?
y
op
A. Iron deficiency anaemia
B. Folate deficiency anaemia
C. Anaemia of chronic disease
C
D. Normal physiological phenomenon
E. Autoimmune anaemia
n
The British Committee for Standards in Haematology has defined anaemia
io
in pregnancy as the following values

Hb levels of:
t
• < 11.0g/dl in the first trimester

ua
• < 10.5 g/dl in the second and third trimesters

• < 10.0 g/dl in the postpartum period.
al
Normal physiological changes in pregnancy

Ev
Haematological changes
• Plasma volume increases over the course of pregnancy by about

50%. Dilutional anaemia is caused by the rise in plasma volume.
Elevated erythropoietin levels increase the total red cell mass by
the end of the second trimester but haemoglobin concentrations
never reach pre-pregnancy levels.
• Usually mean corpuscular volume (MCV) and mean corpuscular
haemoglobin concentration (MCHC) are unaffected.
• Serum iron falls during pregnancy whilst transferrin and total iron
binding capacity rise.
Knowing the new British criteria for diagnosing anaemia in pregnancy is

extremely important for the PLAB 1 exam as is knowing the normal
physiological changes in pregnancy. Many people get caught out with some
of these physiological changes and class them as pathological whereas in
fact, they are completely normal in pregnancy.
594
4. A 50 year old woman is investigated for anaemia. She has no past medical
history of note. Clinical examination reveals massive splenomegaly
associated with pale conjunctivae. A full blood count was requested and
results show:
Haemoglobin 105 g/L

A. Chronic lymphocytic leukaemia

C. Myeloma
E. Malaria
y
The clincher here is the massive spleen. Although there are many causes of
op
massive spleen, for the purpose of PLAB, massive spleen can only be caused
by Chronic myeloid leukaemia (CML) or Malaria
C
If you see a middle aged man/woman with a huge spleen → likely to be
Chronic myeloid leukaemia (CML). Malaria would likely have a travel history
of some sort.
n
io
Mnemonic:CML → Crazy Massive Large Spleen

t
The blood picture fits perfectly for CML in this question. Slight anaemia and
ua
high WBC. Raised platelets can also be seen in CML

Chronic myeloid leukaemia (CML)
CML is a clonal bone marrow stem cell disorder in which a proliferation
al
of mature granulocytes (neutrophils, eosinophils and basophils) and their

precursors is found.
Ev
CML typically progresses through three stages:
• Chronic phase
The immune system is competent and patients are asymptomatic
for prolonged periods - (typically 4-5 years) More than 90% of
patients are diagnosed in the initial chronic phase.
• Accelerated phase
In about two thirds of patients, the chronic phase transforms into
an accelerated phase characterised by a moderate increase in blast
cells, increasing anaemia or thrombocytopenia.
• Blast crisis or blastic phase
After a variable amount of time (usually months) the accelerated
phase progresses to acute blastic transformation. Features of
blastic phase include bone marrow or peripheral blasts ≥30%,
severe constitutional symptoms due to tumour burden (weight loss,
fever, night sweats, bone pain), infection and bleeding
595
Usually presents at age 40 to 50 years old (middle-age)
85-90% of patients are diagnosed in the chronic phase and in recent years
about 40% of patients have been diagnosed before any symptoms
developed, with incidental abnormalities spotted on a blood test.
• Fatigue (due to anaemia)

• Weight loss
• Night sweats
• Abdominal discomfort → from massive enlargement of spleen (this
is common)
• Splenomegaly → this is the most common physical finding, which
may extend towards the right iliac fossa (Seen in >75%)
• Hepatomegaly
• Enlarged lymph nodes (rare)
• Low grade fever
• Gout due to rapid cell turnover
y
op
Note: Enlarged lymph nodes are rare and infection are uncommon because
these white cells retain the majority of their function
C
Investigations at presentation
• FBC:
o Leukocytosis is common (often >100 x 109/L)
n
o Differential shows granulocytes at all stages of
io
development (increased numbers of neutrophils,

myelocytes, basophils, eosinophils)
t
o Platelets may be elevated, decreased or normal levels

ua
o A mild-to-moderate, usually normochromic and normocytic,

anaemia is common
• Peripheral blood smear - all stages of maturation seen
al
• Biochemistry - U&Es are usually normal at presentation, lactate

dehydrogenase is usually raised, serum urate may be raised.
Ev
• Bone marrow aspiration and biopsy are essential to quantify the

percentage of blasts and basophils, to assess the degree of fibrosis
and to obtain material for cytogenetic-molecular analyses.
• Cytogenetics - the characteristic feature in CML is the Ph
chromosome, found in about 90% of cases. (oxford says > 80%).
This can be found on cytogenetic analysis of blood or bone marrow.
Take home notes:
• The main feature of the disease is an elevated white blood cell count
consisting predominantly of neutrophils. Blasts are either absent or
present in very small amounts.
• The Philadelphia chromosome is present in more than 90% of
patients with chronic myeloid leukaemia (CML).
• In PLAB, look for the massive enlargement of spleen
596
5. A 51 year old man complains of headache and pruritus. He had a deep vein
thrombosis recently. Recent blood report shows the following:
Haemoglobin 192 g/L

Erythropoietin was found to be low. What is the SINGLE most likely

diagnosis?
A. Myelofibrosis
The signs and symptoms are consistent with polycythaemia rubra vera
(PRV)
y
op
About a third of patients with PRV present with symptoms due to
thrombosis. This includes DVT like in this question.
C
PCV is usually associated with a low serum level of the hormone
erythropoietin (EPO).
n
Polycythaemia rubra vera (PRV)
io
Polycythaemia rubra vera (PRV) is the most common form of primary

t
polycythaemia. It is a malignant proliferation of a clone derived from one

ua
pluripotent marrow stem cell.

al
• There is excess proliferation of RBCs, WBCs, and platelets, leading

to hyperviscosity and thrombosis
Ev
• More commonly found in patients who are more than 60 years old
• A mutation in JAK2 is present in >90%
Presentation
• It may be discovered on routine blood count in a person with no
related symptoms or there may be nonspecific complaints of
lethargy and tiredness
• About a third present with symptoms due to thrombosis. Features
include stroke, myocardial infarction, deep vein thrombosis and
pulmonary embolism
• Headaches, dizziness, sweating, and tinnitus
• Bleeding from gums or easy bruising is usually mild but
gastrointestinal haemorrhage can be more severe. This is secondary
to abnormal platelet function
• Pruritus which is typically worse after a hot shower or bath
• Splenomegaly is present in about 75% of patients (oxford says 60%)
• Hypertension is common
597
• Erythema, warmth, pain, and even sometimes infarction of the
distal extremities. Burning sensation in fingers and toes, are
characteristic but not very common
• Facial plethora
• Gout from increased cell turnover
Note:
• There is usually an abnormally low serum erythropoietin
Management
• Venesection
• Chemotherapy options include:
• Younger than 40 years of age: first-line is interferon
• Older than 40 years of age: first-line is hydroxycarbamide
(hydroxyurea)
• Low dose aspirin 75mg OD → To reduce thrombotic events
y
op
6. A 14 year old child has recurrent throat infections. He feels tired and
lethargic all the time. Blood results show:
C
Hb 7.2g/dl
WCC 6 x 109/L
n
io
Blood film shows blast cells. What is the SINGLE most likely diagnosis?
t

ua

al
Ev
Acute lymphoblastic leukaemia (ALL)
Aetiology
Most cases of acute leukaemia arise with no apparent cause. There are
several well known associations with the development of acute leukaemia
that are sometimes present. These include radiation exposure,
chemotherapeutic agents, as well as some retroviruses.
The most common presentation results from the effects of the leukaemic
blast cells crowding out the normal marrow cells, resulting in symptoms of
pancytopenia even if the total white blood cell count is normal.
• Fatigue from anaemia is the most common presenting complaint.

• Bleeding, petechiae, purpura or ecchymoses (due to
thrombocytopenia)
598
• Recurrent and severe infections (oral, throat, skin, perianal
infections commonly). This is because of the underproduction or
abnormal function of white blood cells.
• Left upper quadrant fullness and early satiety due to splenomegaly
(10-20%)
Acute lymphocytic leukaemia (ALL) is more common in children, and acute

myelogenous leukaemia (AML) is more common in adults, but they are
indistinguishable clinically. This means you cannot determine the diagnosis
only from the clinical presentation.
ALL is more often associated with infiltration of other organs, but AML can
do it as well. Enlargement of the liver, spleen, and lymph nodes and bone
pain are common at presentation.
Diagnosis
The FBC is the first clue to the diagnosis. Depression of all three cell lines is
common at presentation.
y
op
FBC
• Anaemia is usual and Hb may be below 5 g/L
• The white cell count can be low, normal, or elevated
C
• Thrombocytopenia
Many other disorders can present as pancytopenia similar to leukaemia

n
such as aplastic anaemia, infections involving the marrow, metastatic
io
cancer involving the marrow, vitamin B12 deficiency, SLE, hypersplenism,

and myelofibrosis. However, none of these will have leukaemic blasts
t
circulating in the peripheral blood. Although pancytopenia can cause all of

ua
the above, in PLAB, when pancytopenia is in the options, it is usually

leukaemia, or aplastic anaemia.
al
A bone marrow biopsy showing numerous blasts confirms the diagnosis of

acute leukaemia.
Ev
It is very unlikely that the PLAB questions would ask you to differentiate the
AML from ALL using specific test. However, if a child (young age) is given
with signs and symptoms of pancytopenia, ALL would be the most likely as
it is the commonest childhood leukaemia.
Note:
• ALL is the commonest childhood leukaemia. Peak age is 2–4 years
old.
• The Philadelphia chromosome occurs in 15–30% (mostly adults) and
is associated with a poor prognosis.
7. A 53 year old lady has been suffering from chronic rheumatoid arthritis and
is on methotrexate. Blood results show:
Haemoglobin 83 g/L
599
A. Haemorrhoids
C. Menorrhagia
E. B12 deficiency
The patient has microcytic anaemia which can fit with the diagnosis of
anaemia of chronic disease. In anaemia of chronic disease, red cells are
often normochromic, normocytic, but may be hypochromic, microcytic (as
frequently seen in rheumatoid arthritis and Crohn's disease)
Folate and B12 deficiency are in the category of macrocytic anaemias.
There should be no reason for menorrhagia. Besides, the patient is 53 years

old. The average age of menopause in UK is 51.
y
op
There is also no relation with haemorrhoids.
8. A 17 year old girl has prolonged bleeding after a routine dental extraction.
C
Her father and paternal grandmother have experience similar problems.
What is the SINGLE most likely mode of inheritance?
n
io
t
D. X-linked
ua
Although type 3 Von Willebrand disease is actually autosomal recessive,

al
majority of Von willebrand’s disease is autosomal dominant.

Ev
Von Willebrand disease
The 3 most important points you need to know in Von Willebrand disease
in PLAB is:
1. It presents with mucosal bleeding → Epistaxis, menorrhagia
(behaves like a platelet disorder)
2. Autosomal dominant (type 3 is recessive)
3. Role of Von Willebrand's factor is:
a. Promotes platelet aggregation
b. Carrier molecule for factor VIII
Investigation
• Bleeding time → prolonged
• APTT → prolonged
• Factor VIII levels may be moderately reduced
• Defective platelet aggregation with ristocetin
600
Management
• Tranexamic acid for mild bleeding
• Desmopressin (DDAVP): raises levels of vWF by inducing release of
vWF
• Factor VIII concentrate
Comparing the 3 important bleeding disorders in PLAB

Von Willebrand Haemophilia Disseminated
disease intravascular
coagulation (DIC)
Platelet type bleeding Factor type bleeding Bleeding everywhere:
(mucosal bleeding) (deep bleeding into • Venepuncture
muscles and joints) sites
• GI tract
• Ear nose throat
• Skin: Purpura
aPTT prolonged aPTT is prolonged aPTT prolonged
y
Bleeding time Bleeding time
op
prolonged prolonged
C PT prolonged
9. A 51 year old vegan presents with complaints of peripheral paresthesia,

n
mild shortness of breath and fatigue. Examination reveals that she has
angular stomatitis and a sore red tongue. What is the SINGLE most likely cell
io
type to be seen on a blood film?

t
A. Numerous blast cells

ua
B. Oval macrocytic red cells

C. Spherocytes
D. Microcytic hypochromic red cells
al
E. Heinz bodies
Ev
Angular stomatitis is a known sign for iron deficiency anaemia however

vitamin B12 deficiency is sometimes responsible for angular stomatitis, and
commonly occurs together with folate deficiency
The appearance of the tongue in vitamin B12 deficiency is described as

"beefy" or "fiery red and sore".
Peripheral paresthesia is also a known symptom of vitamin B12.
Vitamin B12 deficiency has RBC changes which include oval macrocytosis
10. A 51 year old man complains of lethargy tiredness and pruritus. The pruritus
is worse after he takes a hot shower. He also says that he feels a burning
sensation in his fingers and toes. Splenomegaly was found during an
abdominal examination. His medical history is significant for gout. What is
601
B. Myelofibrosis
C. Rheumatoid arthritis
D. Scleroderma
(PRV)
Gout can be seen in PRV. This is due to an increased cell turnover.

y
op
C
Presentation
n
io

t
pulmonary embolism
ua

al

Ev

• Facial plethora
Note:
Management
• Venesection
(hydroxyurea)
602
11. A 63 year old man presents with extreme thirst that despite drinking fluids
he still feels thirsty. He has been having a back ache for the last 4 weeks
that is getting worse and feels tired all the time. His serum calcium was
found to be elevated. A blood film was taken. What is the SINGLE most
likely finding to be seen on a blood film?
A. Basophilic stippling
B. Howell Jolly bodies
C. Heinz bodies
D. Trophozoites
E. Rouleaux formation
The signs and symptoms along with the hypercalcaemia point towards
multiple myeloma. Rouleaux formation can be seen on the blood film in
multiple myeloma.
y
Multiple Myeloma
op
A clonal abnormality of plasma cells resulting in their overproduction
replacing the bone marrow as well as the production of large quantities of
C
functionless immunoglobulins.
n
• Bone disease → Bone pain is the most common clinical
io
manifestation. This is most commonly in the back and the ribs,

secondary to pathologic fractures.
t
• Recurrent bacterial infection

ua
• Renal failure
• Anaemia → may present with weakness, fatigue, and pallor
• Hypercalcaemia → may present with polyuria, polydipsia, and
al
altered mental status

Ev
Rarely, symptoms of a hyperviscosity syndrome such as blurry vision, and

confusion, may occur.
Diagnosis
• Although a normochromic, normocytic anaemia is the most
common laboratory finding, this is not specific for myeloma.
• A serum protein electrophoresis with a markedly elevated
monoclonal immunoglobulin spike is present in almost all cases
• Urine protein electrophoresis: looks for the presence of Bence
Jones' protein.
• Plain x-ray of the skeletal system and skull will reveal the punched
out lytic lesion caused by the overproduction of osteoclast
activating factor from the plasma cells.
• Hypercalcaemia from the destruction of bone. Note that the
hypercalcaemia is associated with normal alkaline phosphatase.
• Elevation in the BUN and creatinine from the damage to the kidney
from the immunoglobulins
603
• A bone marrow biopsy with abundance of plasma cells confirms a
diagnosis of multiple myeloma
• Rouleaux formation can be seen on blood film (rouleaux means a
cylindrical packet of coins)
Management
This is beyond what will be asked in PLAB part 1
12. A 5 year old boy has swelling at the knee after falling on the ground with
rashes on his buttocks. His blood tests show:
Haemoglobin 119 g/L

y
op
A. Haemolytic uraemic syndrome
B. Haemophilia
C
D. Osler weber rendu syndrome
E. Von-Willebrand disease
n
As a general rule, platelet deficiency causes petechial haemorrhages and
io
ecchymoses (bruising) whilst clotting factor deficiency produces

haematomas and haemarthroses. This question gives a mixed picture where
t
there are descriptions of both platelet deficiency (petechial haemorrhages

ua
seen on his buttocks) and factor deficiency (bleeding/swelling at his knee).

However, the prolonged aPTT supports the diagnosis of haemophilia thus
that is the answer. We can only hope that in PLAB, these mixed picture
al
questions are low in number for you exam.

Ev
Haemophilia A and B
• Are congenital bleeding disorders with low levels of factor VIII
(haemophilia A, classical haemophilia) or IX (haemophilia B,
Christmas disease).
• Sex-linked inheritance.
• Males are typically affected
• Female carriers are rarely symptomatic
• Haemophilia A and B are clinically indistinguishable
• Symptoms depend on the factor level.
• History of spontaneous bleeding into joints, especially the knees,
ankles and elbows, without a history of significant trauma.
Spontaneous haemarthrosis are virtually pathognomonic
• Intramuscular haemorrhage may also occur. Spontaneous bleeding
into arms, legs, or any site. The bleeding may lead to nerve
compression, or compartment syndrome
604
Investigations
• Prothrombin time, bleeding time, fibrinogen levels and von
Willebrand factor are normal
• Activated partial thromboplastin time (APTT) is usually prolonged
but can be normal in mild disease
• Factor VIII/XI assay to diagnose
Remember these test to distinguish haemophilia from Von Willebrand

disease
• Haemophilia
• Only aPTT is prolonged
• Has factor type bleeding (deep bleeding into muscles and
joints)
• Von willebrand disease
• aPTT and bleeding time are prolonged
• Has platelet type bleeding (mucosal bleeding)
y
Haemophilia A-specific treatment
op
• Desmopressin raises factor VIII levels, and may be sufficient to treat
Haemophilia type A
• Major bleeds (eg haemarthrosis): May need treatment with
C
recombinant factor VIII
• Do not give IM injections when factor is low
n
Haemophilia B-specific treatment
io
• Recombinant factor IX is the treatment of choice

• Note: Desmopressin has no value in treatment of haemophilia B
t
ua
Avoid NSAIDS and IM injections!

Questions may arise with this topic. In PLAB, in whichever scenario, avoid
NSAIDS and IM injection as the answer in Haemophilia. NSAIDs must not be
al
employed for the fear of gastrointestinal haemorrhage. If needed, give

opiates for pain relief and if given parenterally, pick intravenously (IV) or
Ev
possibly subcutaneously (SC) but not intramuscularly (IM). IM injection will

produce a large and painful haematoma.
13. A 54 year old woman is diagnosed with deep vein thrombosis after taking a
long haul flight. She is started on warfarin. What is the target INR for her?
A. <1
B. 1 - 2
C. 2 - 3
D. 3 - 4
E. 2 – 5
INR is derived from the PT ratio and is a standardized method of reporting

which permits comparability between laboratories.
The INR range of 2 to 3 is appropriate for:

• Prophylaxis or treatment of venous thromboembolism
605
• Reduction of the risk of systemic embolism for people with atrial
fibrillation and valvular heart disease
For the purpose of PLAB, just remember that INR of 2 to 3 is the answer for
majority of cases. The only cases where a higher INR is required, is in the
cases of a mechanical heart valve replacement. Patients with metallic valves
require lifelong anticoagulation with a target INR of 3 to 4.
14. A 13 year old girl has has mucosal bleeding and petechial rashes. She has
been feeling tired lately. She looks pale. A blood count shows:
Haemoglobin 74 g/L
Blood film morphology was unremarkable. Reticulocytes are absent. A bone

marrow aspirate shows a gross reduction in all haemopoietic tissue that is
y
replaced by fat spaces. What is the SINGLE most likely underlying diagnosis?
op
C
C. Aplastic anaemia
n
io
She has a signs and symptoms of anaemia. The blood picture shows
pancytopenia which rules out pernicious anaemia as an underlying cause.
t
ua
Normal morphology rules out the possibility of acute myeloid leukaemia,

and acute lymphoblastic leukaemia.
al
From the age alone we can exclude chronic myeloid leukaemia as it usually
presents at age 40 to 50 years old (middle-age)
Ev
A bone marrow aspirate that shows a gross reduction in all haemopoietic

tissue that is replaced by fat spaces is seen classically in aplastic anaemia.
Absent reticulocytes support the diagnosis.
Aplastic anaemia
Aplastic anaemia is a rare, potentially life-threatening failure of
haemopoiesis characterised by pancytopenia and hypoplastic marrow (the
marrow stops making cells).
Causes
Most cases are autoimmune, triggered by drugs (viruses, eg parvovirus,
hepatitis) or irradiation.
Presentation
Aplastic anaemia can present abruptly over, or insidiously over, weeks to
months.
606
Clinical manifestations are proportional to the peripheral-blood cytopenias
and include:
• Symptoms of anaemia (pallor, headache, palpitations, dyspnoea,
fatigue, or ankle oedema) Note: Anaemic symptoms are usually less
severe due to the chronic onset
• Symptoms of thrombocytopenia (skin or mucosal haemorrhage,
visual disturbance due to retinal haemorrhage, petechial rashes)
• Infection (a less common presentation) particularly upper and lower
respiratory tracts, skin, mouth, and peri-anal
• There is no lymphadenopathy or hepatosplenomegaly (in the
absence of infection).
Diagnostic tests:
Marrow examination is needed for the diagnosis
Note: To define aplastic anaemia based on FBC and bone marrow findings,
at least two of the following must be present:
y
• Haemoglobin <10 g/dL
op
• Platelet count < 50 x 109/L
• Neutrophil count <1.5 x 109/L
C
It is also important to note that the blood film morphology is unremarkable
which differentiates it from some other types of leukaemias.
n
15. A 51 year old male presents with malaise and tiredness. On physical exam,
io
his spleen is noted to be approaching his right iliac fossa. No

lymphadenopathy was noticed. What is the SINGLE most likely cell type to
t
be seen on a blood smear?

ua
A. Helmet shaped cell

B. Sickle cell
al

D. Blast cells
Ev
E. Target red cells
The clincher here is the massive spleen that approaches the right iliac fossa.
Although there are many causes of massive spleen, for the purpose of PLAB,
massive spleen can only be caused by chronic myeloid leukaemia (CML) or
Malaria

of some sort.
Mnemonic: CML → Crazy Massive Large Spleen

CML is a clonal bone marrow stem cell disorder in which a proliferation
of mature granulocytes (neutrophils, eosinophils and basophils) and their
607
• Chronic phase
• Accelerated phase
• Blast crisis or blastic phase
y
op
C
• Weight loss
n
• Night sweats
io

is common)
t

ua

• Hepatomegaly
al
• Low grade fever

Ev
• FBC:
o Leukocytosis is common (often >100 x 109/L)
o Differential shows granulocytes at all stages of
o Platelets may be elevated, decreased or normal levels
o A mild-to-moderate, usually normochromic and normocytic,
anaemia is common
608
Take home notes:
16. A 25 year old Greek man presents with dark red urine hours after eating
fava beans. He is now very ill and has signs of shock. Spherocytes and RBC
y
fragments are seen on blood film. What is the SINGLE most likely diagnosis?
op
C
D. Beta thalassemia
n
io
Spherocytes are usually seen in hereditary spherocytosis and autoimmune

haemolytic anaemias. However, they may be seen in G6PD deficiency as
t
well in severe haemolysis. The history of consumption of fava beans

ua
followed by rapid deterioration points towards G6PD deficiency.
Otherwise, in the exam, if you see spherocytes, it is almost always either

al
hereditary spherocytosis or autoimmune haemolytic anaemias.

Ev
Glucose-6-phosphate dehydrogenase (G6PD) deficiency
Glucose-6-phosphate dehydrogenase (G6PD) deficiency is X-linked and

clinically important cause of oxidant haemolysis. It affects all races but is
most common in those of African, Asian or Mediterranean descent.
Deficiency of the G6PD enzyme results in reduced glutathione making the

red cells vulnerable to oxidative damage and thus liable to haemolysis.
↓ G6PD enzyme → ↓ glutathione → ↑ red cell susceptibility to oxidative

stress
• Being X-linked, the disease affects mainly men but in areas of high
frequency it is not uncommon to find homozygous women. (In the
exam, it is usually always male patient)
• Most individuals with the G6PD defect are asymptomatic and
unaware of their status
609
• Haemolysis occurs after exposure to oxidants or infection.
• Acute episodes of haemolysis with fava beans (termed favism)
There are many drugs that can elicit haemolysis in patients with G6PD
deficiency. One drug that you would definitely need to look out for in the
exam is → antimalarials: primaquine
Presentation:
• Most are asymptomatic
• May be a history of neonatal jaundice, severe enough to require
exchange transfusion
• May have history of drug-induced haemolysis
• Gallstones are common
• Pallor from anaemia
• During a crisis jaundice occurs
• Back or abdominal pain (usually occurs when >50% haemolysis
occurs)
• Splenomegaly may occur
y
op
There are typically 4 ways the patient might present in PLAB. Below are
the specifics: C
Drug-induced haemolysis in G6PD deficiency
• Begins 1-3 days after ingestion of drug
• Anaemia most severe 7-10 days after ingestion
n
• Associated with low back and abdominal pain
io
• Urine becomes dark (black sometimes)

• Red cells develop Heinz body inclusions
t
• Haemolysis is typically self-limiting

ua
Haemolysis due to infection and fever

• 1-2 days after onset of fever
al
• Mild anaemia develops

• Commonly seen in pneumonic illnesses
Ev
Favism
• Hours/days after ingestion of fava beans (broad beans)
• Urine becomes red or very dark
• Shock may develop and it may be fatal
Neonatal jaundice
• May develop kernicterus (possible permanent brain damage)
Laboratory investigation (Important for exam)

• In steady state (i.e. no haemolysis) the RBCs appear normal
• Heinz bodies is seen on blood film in drug-induced haemolysis. Bite
cells are also seen. Bite cells are cells with Heinz bodies that pass
through the spleen and have part of the membrane removed
Laboratory investigations (Less important for exam)
610
• Spherocytes and RBC fragments on blood film is seen if there is
severe haemolysis
• Increased reticulocytes
• Increased unconjugated bilirubin
• decreased haptoglobins
Diagnosis
G6PD enzyme activity - is the definitive test
Diagnosis should not be done during the haemolytic episode but be done
during the steady state which is around 6 weeks after the episode of
haemolysis. The reason behind this is the diagnosis is difficult during
haemolytic episode since reticulocytes have increased levels of enzyme and
may get abnormal result.
Management
• Avoidance of precipitating drugs, and broad (fava) beans
• Transfuse in severe haemolysis or symptomatic anaemia
y
• IV fluids to maintain good urine output
op
• In infants, exchange transfusion may be required
• Splenectomy may be of value in severe recurrent haemolysis
C
17. A 63 year old man presents with back pain, polydipsia and polyuria which
have been present for the last couple of weeks. He complains of being tired
lately. His previous full blood count shows a normochromic, normocytic
n
anaemia. What is the SINGLE most appropriate test that would lead to a
io
diagnosis?
t
A. Bone marrow biopsy

ua
B. Vitamin D levels
D. CT scan
al
E. Renal biopsy
Ev
The signs and symptoms together with the normochromic, normocytic

anaemia are indicative of multiple myeloma. A bone marrow biopsy would
show an increased amount of plasma cells.
Multiple Myeloma

• Renal failure
611

Diagnosis
Jones' protein.
y
op
C
n
Management
io

t
18. A 36 year old female presents with a petechial rash and menorrhagia. Her
ua
physical examination is completely normal and she has no other complaints.

A full blood count was done and reveals:
al
Hb: 13.3g/dL
WBC: 9 x 109/L
Ev
A. Polycythaemia rubra vera

B. Thrombocytopaenia
C. Thrombocytosis
D. Chronic myeloid leukaemia
E. Hyposplenism
This woman has an isolated decrease in platelets with no other complaints

(other than menorrhagia). The presence of petechiae is an additional clue to
thrombocytopaenia.
Idiopathic thrombocytopenic purpura in adults
612
Unlike ITP in children, adult ITP does not normally follow an infection and
usually has an insidious onset. It is more likely to follow a chronic course in
affected adults than in children.
Presentation:
Adults with ITP may demonstrate a range of symptoms from none at all
through to severe haemorrhage
For the purpose of PLAB 1, the presentation is likely to be either:
• Bleeding
• Purpura
• Epistaxis
• Menorrhagia
Laboratory diagnosis
Isolated thrombocytopenia; blood count otherwise normal
Management:
1. Prednisolone
y
2. IV immunoglobulin
op
3. Emergency platelet transfusion only in life threatening
haemorrhage. (usually platelet less than 20 x 109/L)
C
19. A 26 year old man has recently returned from new york. He has noticed
weight loss, and has been having night sweats that is usually drenching. He
has a temperature of 37.6°C and cervical lymphadenopathy. An enlarged
n
spleen was seen on abdominal examination. What is SINGLE most likely the
io
diagnosis?
t
A. Tuberculosis
ua
B. Lymphoma
D. Bronchitis
al
E. plaMycoplasma pneumonia
Ev
The signs and symptoms are classical for lymphoma. In this question, you do
not need to differentiate between Hodgkin’s and non-Hodgkin’s.
The travel history is irrelevant and was probably put in to throw you off.
20. A 50 year old man has dizziness after exercising. He also complains of
itching after a hot shower and says that he feels burning around his fingers.
Abdominal examination is significant for splenomegaly. What is the SINGLE
A. Scleroderma
B. Lymphoma
C. Polycythemia
D. Scabies
E. Eczema
613
The signs and symptoms are consistent with polycythaemia.


Presentation
y
op
pulmonary embolism
C
n
io
t

ua

• Facial plethora
al
Ev
Note:
Management
• Venesection
(hydroxyurea)
21. A 4 year old boy has a cough and arthritis followed by rash on legs which
are non-blanching on glass test. He has no history of a fever. His blood tests
show:
Haemoglobin 120 g/L

614
A. Meningitis septicemia
B. Haemophilia
The blood results are all normal. The rash in the legs that are non blanching
and the arthritis are hints towards Henoch-Schönlein purpura.
The disease occurs mostly in the winter months. About 50-90% of patients
have a preceding upper respiratory tract infection (URTI) which explains the
cough in the given question.
y
op
The stem here gives a no history of fever. Generally, patients with Henoch-
Schönlein purpura appear to be mildly ill, with low-grade fever. But having
no fever does not exclude the diagnosis.
C
Henoch-Schönlein purpura (HSP)
n
Presentation:
io
• Purpura (non-blanching) over buttocks and extensor surfaces

• Arthralgia (especially in the knees and ankles)
t
• Abdominal pain
ua
Diagnosis:
• Mainly a clinical diagnosis
al
• Look for elevated ESR, IgA

• Raised creatinine ; labs consistent with nephropathy
Ev
Treatment:
• Self-limiting; conservative management
• NSAIDs for arthralgic pain → beware of choosing this option if case
stem has impaired renal involvement!
• Corticosteroids can improve associated arthralgia and the
symptoms associated with gastrointestinal dysfunction
22. A 30 year old woman complains of tiredness, lethargy and constipation. On

inspection, she has dry coarse skin, hair loss and cold peripheries. On
examination, a diffuse and lobulated goitre can be palpated on her anterior
neck. A full blood count and peripheral smear is done which shows a
macrocytic anaemia. What is the SINGLE most likely diagnosis?
A. Cushing’s Syndrome
B. Hyperthyroidism
615
E. Pernicious anaemia
This is a multi-part question. Her symptoms are indicative of

hypothyroidism. Her signs are indicative of Hashimoto’s Thyroiditis (an
autoimmune thyroid disorder). Since Hashimoto’s is an autoimmune
disease and her blood smear shows a macrocytic anaemia, a logical
conclusion would be that she is suffering from pernicious anaemia (also an
autoimmune disease).
Some points to remember for the PLAB 1 exam:
Growth patterns of goitres
• Iodine deficiency (rare in the developed world): diffuse

• Hashimoto’s Thyroiditis: diffuse and lobulated
• Pituitary disease: diffuse
• Grave’s Disease: diffuse
y
• Thyroid cancer and benign thyroid growths: uninodular
op
If you have difficulty remembering this long list just remember: all goitres
grow diffuse except Hashimoto’s (diffuse AND lobulated) and
C
benign/malignant thyroid growths (uninodular).
Associations of hypothyroidism
n
io
• Obstructive sleep apnoea

• Carpal tunnel syndrome
t
• Galactorrhoea/hyperprolactinaemia
ua
23. A 21 year old man presents with mild jaundice.

al
Haemoglobin 75 g/L
Reticulocytes 7%
Ev
There are spherocytes seen on the blood film. He has no past medical
history of any significance. What is the SINGLE most appropriate
investigation?
A. G6PD enzyme assay

B. Direct coombs test
C. Indirect coombs test
D. Bone marrow biopsy
E. Sickle solubility test
The likely diagnosis here is the warm antibody induced haemolysis type of
autoimmune haemolytic anaemia. Most cases are idiopathic with no
underlying pathology. The low haemoglobin and high reticulocytes fit the
picture. Mild jaundice and spherocytes can also be seen.
616
Direct Coombs test is the investigation of choice.
Autoimmune haemolytic anaemia
This occurs when RBCs react with autoantibody with or without a

complement which leads to premature destruction of RBCs by
reticuloendothelial system.
Types of autoimmune haemolytic anaemia

• Warm antibody type:
• Idiopathic
• Secondary to other autoimmune diseases e.g. Systemic
lupus erythematosus (SLE)
• Secondary to lymphoproliferative diseases e.g. Lymphoma,
Chronic lymphatic leukaemia (CLL)
• Cold antibody type:
• Idiopathic
y
• Mycoplasma pneumoniae
op
• Infectious mononucleosis
Warm antibody induced haemolysis

C
• Most cases are idiopathic with no underlying pathology
• Affects predominantly individuals >50 years of age
• Clinical features
n
o Highly variable symptoms, asymptomatic or severely
io
anaemic
o Mild jaundice
t
o Splenomegaly
ua
• Diagnosis
o Anaemia
o Spherocytes on peripheral blood film
al
o Increased reticulocytes
o Detect on direct Coombs test
Ev
Cold haemagglutinin disease (CHAD)

• Describes syndrome associated with acrocyanosis in cold weather
due to RBC agglutinates in blood vessels of skin. Caused by RBC
antibody that reacts most strongly at temperatures below 32°C.
• May be idiopathic or secondary to infection with Mycoplasma or
EBV (infectious mononucleosis)
• Clinical features
o Acrocyanosis (blue discoloration of extremities e.g. fingers,
toes) in cold conditions
o Splenomegaly
• Diagnosis
o Anaemia
o Increased reticulocytes
o Positive direct Coombs test
617
24. A 40 year old female, chronic heavy smoker has a haemoglobin of 189 g/L.
What is the SINGLE most useful hormone level to test for to help establish a
diagnosis?
A. Aldosterone
B. Cortisol
C. Erythropoietin
D. T4
E. TSH
Since this patient is a chronic smoker, we can assume that the haemoglobin
levels are increased due to hypoxia.
Erythropoietin levels are important to establish the cause of the high

haemoglobin level.
Secondary polycythaemia is where an underlying condition causes more

erythropoietin to be produced. This is a hormone produced by the kidneys
y
that stimulates the bone marrow cells to produce red blood cells.
op
Secondary polycythaemia can be due to hypoxia (e.g. high altitudes, chronic
lung disease, cyanotic congenital heart disease, heavy smoking). These can
C
cause an increase in erythropoietin, due to not enough oxygen reaching the
body's tissues.
n
25. A 6 year old boy is brought to the hospital by his mother with bleeding from
io
his gums and nose. His mother complains that he has been having recurrent
sore throats that come and go in last couple of months.. Pale conjunctivae is
t
noticed on examination. What is the SINGLE most likely single cell type
ua
associated with his diagnosis?
A. Clumped platelets
al
B. Microcytes
Ev
D. Blast cells
E. Mature lymphocytes
Before looking at the cell types, think of the diagnosis. The most likely
diagnosis here is Acute lymphoblastic leukaemia (ALL) as he young,
suffering recurrent infections (due to abnormal WBC), and having pale
conjunctiva (anaemia). The bleeding gums and nosebleeds tell you that he
has thrombocytopenia.
Acute lymphoblastic leukaemia (ALL) and Acute myeloid leukaemia (AML)

both have numerous blast cells.
Aetiology
618

thrombocytopenia)
(10-20%)
y
op
C
n
io

t
Diagnosis
ua
al
FBC
Ev



acute leukaemia.
619
Note:
old.
26. A 55 year old man complains of headache and visual disturbances. He has a
history of hypertension. He also reports itching after a hot bath and burning
sensation in his finger and toes. He is noted to have mass in the left upper
quadrant. Blood report shows the following:
Haemoglobin 202 g/L

Erythropoietin is normal
y
op
A. Myelofibrosis
C
n
io
t
(PRV)
ua
Hypertension is found in 30% of patients with PRV. Splenomegaly is found

in 75% of patients at the time of diagnosis.
al
The mass in the left upper quadrant represents the spleen (splenomegaly)
Ev
Burning sensation in fingers and toes, are characteristic.

erythropoietin (EPO). However, everything else in this question points
towards PRV.


620
Presentation
pulmonary embolism
y
• Facial plethora
op
Note:
C
Management
n
• Venesection
io

t

ua
(hydroxyurea)
al
27. A 42 year old woman with septicaemia suddenly develops purpura all over
her legs and arms. Her blood tests show:
Ev
Haemoglobin 118 g/L

Prothrombin time, and activated partial thromboplastin time are prolonged.

D-dimers were elevated. What is the SINGLE most likely diagnosis?
C. Deep vein thrombosis
E. Warfarin interaction
Disseminated intravascular coagulation (DIC)
Presentation
621
• Ecchymoses or spontaneous bleeding at venepuncture sites, and
the site of trauma
• Bleeding from ears, nose and throat, gastrointestinal tract
• Petechiae, purpura
Diagnosis
No single laboratory test that can establish or rule out the diagnosis of DIC,
therefore assess the whole clinical picture, taking into account the clinical
condition of the patient, and all available laboratory results.
• Thrombocytopenia (in up to 98% of cases) → around 50% of them

would have a platelets count less than 50 x 109/L
• Fibrin degradation products (inc. D-dimer) is elevated
• Prothrombin time (PT) is elevated
• Activated partial thromboplastin time (aPTT) is elevated
• Fibrinogen level low
y
Remember, everything is elevated except platelets and fibrinogen.
Treatment
• Treat the underlying condition
op
C
• Transfusion of platelets or plasma (components) for patients with
severe bleeds
• In bleeding patients with DIC and prolonged PT and aPTT,
n
administer fresh frozen plasma (FFP)
io
28. A 7 year old boy has recurrent episodes of spontaneous bleeding into his
t
knee and elbow joints. Mild joint deformity us noted. His father has a
ua
similar illness. Factor VIII/XI assay results show a decrease in factor VIII.
al
A. Desmopressin
B. Recombinant factor IX
Ev
C. Heparin
D. Infusion of platelet concentrates
E. Vitamin K
Factor VIII deficiency is evidence of haemophilia A. Desmopressin is one of

the treatment choices.
Haemophilia A and B
Christmas disease).
622
Investigations

disease
• Haemophilia
y
op
joints)
C
n
io

Haemophilia type A
t

ua

al

Ev

29. A 22 year old man is admitted to the hospital with lethargy. His medical
history includes hereditary spherocytosis. His blood tests show:
Haemoglobin 51 g/L
Reticulocytes 0.4%
623
What is the SINGLE most likely cause of his low haemoglobin and low
reticulocytes?
A. Parvovirus B19 infection

B. Autoimmune haemolytic anaemia
D. Haemolytic transfusion reactions
E. Recent antibiotic treatment
Parvovirus B19 infection can cause an aplastic crises in patients with

hereditary spherocytosis. This can be life-threatening and often requires
blood transfusion.
Splenic sequestration crisis is a wrong answer. A patient with a

sequestration crisis is also severely anaemic , but the reticulocyte count will
be high, in contrast to the aplastic crisis where the reticulocyte count is low
or zero. Splenic sequestration crisis is also usually seen in sickle cell.
y
op
Hereditary Spherocytosis
Hereditary Spherocytosis is the most common inherited RBC membrane
defect characterized by variable degrees of haemolysis, spherocytic RBCs
C
with increased osmotic fragility.
n
Approximately 75% of cases display an autosomal dominant pattern of
io
inheritance; the rest are recessive forms and de novo mutations.

t
ua
Clinical features
• Patients may present at any age with haemolytic anaemia, jaundice
(either from haemolysis or gallstones) and splenomegaly
al
• 20-30% of patients have mild disease with an increased red cell

turnover compensated with adequate replacement. They are
Ev
neither symptomatic nor anaemic, but may have mild

splenomegaly, slight reticulocytosis and minimal spherocytes
visible.
• 60-70% of patients have moderate disease and half of these present
in childhood with anaemia.
• Neonates with severe hereditary disease do not always present at
birth with anaemia, but haemoglobin may fall dramatically over the
first few weeks of life and may be severe enough to require
exchange transfusion.
• Occasional aplastic crises occur, e.g. with parvovirus B19 infection.
Diagnosis
(These are the 3 most important test that you need to know in the exam for
Hereditary Spherocytosis)
• Blood film shows spherocytes and increased reticulocytes
• MCHC would be elevated
624
• Osmotic fragility test → confirms presence of spherocytes but does
not permit hereditary spherocytosis to be distinguished from other
spherocytic haemolytic disorders such as autoimmune haemolytic
anaemia. This is not reliable until six months of age.
Some authors mention that osmotic fragility test is unreliable and is

no longer recommended. However, it is still considered the gold
standard despite missing up to 20% of cases. In the PLAB exam,
osmotic fragility test may be given as a choice for a diagnostic test
for Hereditary Spherocytosis. Pick it if it is.
Note:
Spherocytosis almost always refers to hereditary spherocytosis but note
that spherocytes are found in hereditary spherocytosis and also
autoimmune haemolytic anaemias. The test to distinguish the two would be
a direct Coombs test. Hereditary spherocytosis has a negative direct
Coombs test but autoimmune haemolytic anaemias have a positive direct
Coombs test
y
op
C
n
t io
ua
Management
al
Steroid therapy
Ev
• effective in augmenting haemoglobin levels during haemolytic

crises in patients with moderate disease
Folate supplementation
Splenectomy
• eliminates anaemia and hyperbilirubinaemia and lowers the high
reticulocyte number to nearly normal levels
• Splenectomy is curative in most patients but increased recognition
of the long-term risks of splenectomy has led to re-evaluation of the
role of splenectomy.
Mild cases do not usually require folate supplements or splenectomy
Complications
625
• Rapid haemolysis can be triggered by viral infections and produce
jaundice, anaemia and occasionally abdominal pain and tender
splenomegaly. Supportive treatment is usually all that is needed.
• Aplastic crises (aplastic anaemia). They are most commonly caused
by infection with parvovirus B19 and usually last 10-14 days. This
can be life-threatening.
When you see parvovirus B19 in the exam, immediately think of sickle cell
anaemia or hereditary spherocytosis
Parvovirus and anaemia

Although most patients have a decrease of erythropoiesis (production of
red blood cells) during parvovirus infection, it is most dangerous in patients
with sickle cell anaemia or hereditary spherocytosis, as they are heavily
dependent on erythropoiesis due to the reduced lifespan of the red cells.
30. A 33 year old man complains of lethargy tiredness and pruritus. A diagnosis
of polycythaemia vera was made. What is the SINGLE most appropriate
y
management?
A. Phlebotomy
B. Splenectomy
op
C
C. Indomethacin
D. Heparin
E. Warfarin
n
io
Venesection is the most appropriate.

t
Splenectomy is something to consider in the management of PCV. But it is

ua
usually down the line when there is painful splenomegaly or there are
repeated episodes of splenic infarction.
al

Ev


Presentation
pulmonary embolism
626
• Facial plethora
Note:
Management
• Venesection
y
op
(hydroxyurea)
C
31. A 75 year old man presents with back pain and lethargy. Investigations were
n
carried out. A bone marrow biopsy reports as having abundance of plasma
io
cells. What is the SINGLE most likely diagnosis?

t
A. Multiple myeloma
ua
B. Ankylosing spondylitis
C. Amyloidosis
D. Leukaemia
al
E. Myelofibrosis
Ev
A bone marrow biopsy with abundance of plasma cells is diagnostic for

multiple myeloma.
Multiple Myeloma

• Renal failure
627

Diagnosis
Jones' protein.
y
op
C
n
io
Management
t
ua
32. A 22 year old Greek man presents with rapid symptoms of anaemia and
jaundice following treatment of malaria. He is noted to have Heinz bodies
on a blood film. What is the SINGLE most likely diagnosis?
al

Ev

Heinz bodies are pathognomonic for G6PD deficiency. In PLAB, if you see a
question that has Heinz bodies on a blood film, you can almost be certain
that this is G6PD deficiency.
Haemolysis in this case was elicited by treatment of malaria. Usually

primaquine is the culprit.
628


stress
y
op
C
Presentation:
n
io

t

ua

occurs)
al

Ev
the specifics:


629
Favism
Neonatal jaundice


severe haemolysis
y
op
Diagnosis
C
n
io

t

ua
Management
al

Ev

33. A 35 year old man has fatigue, night sweats and a mild fever for the last
month. Examination reveals painless cervical lymphadenopathy.
Splenomegaly is noted on abdominal examination. He has significant weight
loss. What is the SINGLE most likely diagnosis?
A. Non-Hodgkin lymphoma
B. Polycythemia
D. Toxoplasmosis
E. Cytomegalovirus infection
There are two major points mentioned here: cervical lymphadenopathy and
splenomegaly.
630
This combination makes Non-Hodgkin lymphoma as the most likely cause
Toxoplasmosis although uncommon, may have cervical lymphadenopathy

and splenomegaly as well. But weight loss is not seen in toxoplasmosis
hence non-hodgkin's lymphoma remains the top choice.
Non-Hodgkin lymphoma
This includes all lymphomas without Reed-Sternberg cells
Most are derived from B-cell lines; diffuse large B-cell lymphoma (DLBCL) is
commonest.
Common Signs and Symptoms

• Painless, slowly progressive peripheral lymphadenopathy is the
most common clinical presentation
• Primary extranodal involvement and systemic symptoms (fatigue,
weakness, fever, night sweats, weight loss) are not common at
y
presentation but are common in patients with advanced or end-
op
stage disease.
Note: fever, night sweats, weight loss are less common than in
Hodgkin’s lymphoma, and indicates disseminated disease
C
• Bone marrow is frequently involved and may be associated with
pancytopenia - anaemia, infection, bleeding (platelets).
• Splenomegaly
n
• Hepatomegaly
io
34. A 26 year old Greek man has recently recovered from a haemolytic episode
t
6 weeks ago. The haemolytic episode occurred a day after he ate a

ua
traditional Greek dish. Glucose-6-phosphate dehydrogenase deficiency is

suspected. What is the SINGLE most definitive diagnostic test?
al
A. Osmotic fragility test

B. G6PD enzyme assay
Ev
C. Heinz bodies seen on blood film

D. Bite cells seen on blood film
E. Decreased haptoglobins and increased reticulocytes
G6PD enzyme activity is the definitive test
Osmotic fragility test is to diagnose Hereditary spherocytosis. Heinz bodies

and bite cells seen on blood film are important investigations that point
towards G6PD but are not the definitive diagnostic test.

631

stress
y
Presentation:
op
C
n
io

occurs)
t

ua
the specifics:
al

Ev


Favism
632
Neonatal jaundice


severe haemolysis
Diagnosis
y
op
C
n
Management
io

t

ua

al
35. A 29 year old man has back pain and abdominal pain following treatment of
malaria. His urine has become dark and his eyes have a yellowish tinge. He
Ev
has had gallstones in the past. His past medical history includes jaundice
when he was a neonate. What is the SINGLE most likely diagnosis?

B. Allergy to antimalaria medication
C. Steven-Johnson syndrome
D. Peptic ulcer disease
E. Beta thalassemia
Haemolysis in G6PD deficiency patients can be elicited by treatment of

malaria. Back pain and abdominal pain can be seen in severe haemolysis
occurring in G6PD deficiency.
History of gallstones and neonatal jaundice support the diagnosis of G6PD

deficiency.
633


stress
y
op
C
Presentation:
n
io
t

ua

al
occurs)
Ev
the specifics:


634
Favism
Neonatal jaundice


severe haemolysis
y
op
Diagnosis
C
n
io

t

ua
Management
al

Ev

36. A 10 year old boy is brought to the hospital with a rash over his buttocks
associated with abdominal pain and vomiting. He is accompanied by his
mother and stepfather. His mother had left him for the weekend with the
stepfather and she was called to come back from holiday as he started to
have blood in his urine with the rash. Social services have been notified.
What is the most likely diagnosis?

D. Acute lymphoblastic leukaemia (ALL)
635
Rash over buttock, abdominal pain and vomiting, blood in urine or stool
suggest Henoch-Schönlein purpura.
A mixed picture question like this can be sometimes confusing as in this

question there are some features of a non accidental injury (stepfather). Be
sure to evaluate all the signs and symptoms before jumping to the
conclusion that this is a non accidental injury.
Presentation:
• Abdominal pain
Diagnosis:
y
Treatment:
op
C
n
io
t
knee joints. His father has a similar illness. Factor VIII was found to be
ua
decreased on a blood test. What is the SINGLE most likely diagnosis?
A. Haemophilia A
al
B. Haemophilia B
Ev

E. Thalassaemia
Factor VIII deficiency is evidence of haemophilia A.
Haemophilia A and B
Christmas disease).
636
Investigations

disease
• Haemophilia
y
op
joints)
C

n
io
Haemophilia type A
t

ua

al

Ev

38. A 11 year old boy has an upper respiratory tract infection followed by a low
grade fever with erythematous macular rash, especially on the back of the
legs. A few hours later, the macules evolve into purpuric lesions that are
slightly raised and do not blanch on a glass test. He also complains of a
headache and joint stiffness. His blood tests show:
Haemoglobin 123 g/L

637
A. Meningitis
B. Sepsis
The blood results are all normal. The rash in the legs that are non blanching
and the joint stiffness are hints towards Henoch-Schönlein purpura.
About 50-90% of patients have a preceding upper respiratory tract infection

(URTI) which explains the boy’s history in the given question.
Patients with Henoch-Schönlein purpura may appear to be mildly ill, with

low-grade fever.
y
op
Given that his WBC are not raised and he has no other symptoms of
meningitis, HSP would be the the better option. Headaches may also occur
in HSP.
C
n
Presentation:
io

t
• Abdominal pain
ua
Diagnosis:
al

Ev
Treatment:
39. A 65 year old man presents with back pain. Abdominal examination reveals
splenomegaly
Haemoglobin 102 g/L

ESR 25
638
He has been found to have Philadelphia chromosome on cytogenetic
analysis. What is the SINGLE most likely diagnosis?

E. Lymphoma
Anaemia, raised WBC count, low platelet (platelet may be variable) are
known features of Chronic myeloid leukaemia (CML)
Splenomegaly (particularly if massive) is very suggestive of Chronic myeloid

leukaemia (CML) and Philadelphia chromosome is diagnostic of Chronic
myeloid leukaemia (CML).
y
CML is a clonal bone marrow stem cell disorder in which a proliferation of
op
mature granulocytes (neutrophils, eosinophils and basophils) and their
precursors is found. C
1. Chronic phase
n
io

2. Accelerated phase
t

ua

3. Blast crisis or blastic phase
al

Ev


• Weight loss
• Night sweats
is common)
639
• Hepatomegaly
• Low grade fever
• FBC:
• Leukocytosis is common (often >100 x 109/L)
• Differential shows granulocytes at all stages of
• Platelets may be elevated, decreased or normal levels
• A mild-to-moderate, usually normochromic and normocytic,
anaemia is common
y
op
C
n
io
Take home notes:

t
ua

al

Ev
40. A 20 year old man presents with develops low back pain, shortness of
breath and dizziness 3 days after taking primaquine to treat malaria. His
past medical history is significant for neonatal jaundice. What is the SINGLE
A. Haemolytic anaemia
C. Allergy to primaquine
Haemolysis in this case was elicited by the treatment of malaria using

primaquine. This patient has G6PD deficiency.
640


stress
y
op
C
Presentation:
n
io

t

ua

occurs)
al

Ev
the specifics:


Favism
641
Neonatal jaundice


severe haemolysis
y
Diagnosis
op
C
n
io

t
ua
Management
al

Ev
41. A 4 year old boy is presents with haemarthrosis following a minor fall. His
father and uncle have similar bleeding problems throughout their lives.
What is the SINGLE most likely mode of inheritance?
D. X-linked
Haemophilia A and B
Christmas disease).
642
Investigations
y
op
disease
C
• Haemophilia
n
joints)
io
• Von Willebrand disease

t

ua

al
Haemophilia type A
Ev



643
42. A 50 year old man presents fatigue, weight loss and complains of abdominal
fullness. An abdominal examination reveals splenomegaly extending
towards the right iliac fossa.
Haemoglobin 82 g/L
Philadelphia chromosome was positive on cytogenetic analysis. What is the


E. Lymphoma
y
op
Anaemia, raised WBC count are known features of Chronic myeloid
leukaemia (CML). Splenomegaly (particularly if massive) is very suggestive
of Chronic myeloid leukaemia (CML) and Philadelphia chromosome is
C
diagnostic of Chronic myeloid leukaemia (CML)
Note that platelets can be normal in CML.

n
io

t

ua

al
1. Chronic phase
Ev

644

• Weight loss
• Night sweats
is common)
• Hepatomegaly
• Low grade fever
y
op
• FBC:
C
n
io

anaemia is common
t

ua

al

Ev

Take home notes:

43. A 30 year old woman presents with complaints of lethargy and frequent
infections. Upon examination, massive splenomegaly with no associated
lymphadenopathy is observed. A full blood count reveals the following:
Hb: 10.2g/dL
645
WBC: 2 x 109/L
What tissue biopsy will you do to prove the diagnosis?
A. Liver
B. Lymph node
C. Spleen
D. Bone marrow
E. Lung
According to her lab results, this woman appears to have a pancytopenia

(reduction in all three haematopoietic cell lines). In order to prove a
diagnosis of aplastic anaemia, a bone marrow biopsy must be done.
Please note that pancytopenia and aplastic anaemia are NOT

interchangeable terms.
y
• Pancytopenia is a decrease in all three haematopoietic cell lines.
op
Pancytopenia can be suspected from a full blood count with or
without a peripheral blood smear.
C
• Aplastic anaemia is pancytopenia AND histological evidence of a
hypoplastic bone marrow. It is a diagnosis of exclusion and can only
be made by a bone marrow biopsy.
n
io
44. A 15 year old boy is investigated after he bled excessively following a tooth
extraction. He has always noted that he bruises easily with minimal trauma.
t
His blood tests show:

ua
Haemoglobin 120 g/L

al

Ev

Bleeding time within normal ranges
A. Haemophilia A
B. Haemophilia B
The prolonged aPTT supports the diagnosis of haemophilia.
Between both haemophilia A and B. Haemophilia A is more common and it

accounts for 90% of cases of haemophilia.
Haemophilia A and B
646
Christmas disease).
Investigations
y
op
C

n
disease
io
• Haemophilia
t

ua
joints)
al

Ev

Haemophilia type A


647
45. A 15 year old boy has marked pallor and jaundice. He has to receive regular
blood transfusions to maintain his haemoglobin above a certain level. His
medical history includes diabetes. He has obvious skull bossing and
hepatosplenomegaly. What is the SINGLE most likely diagnosis?
C. Alpha thalassemia trait
D. Beta thalassemia major
The signs and symptoms point towards a beta thalassaemia major.
Alpha thalassemia trait have mild anaemia and are usually clinically
asymptomatic.
y
op
Thalassaemias
Thalassaemia is not a very commonly asked topic. You should only go

C
through this if you have time to spare. We have only included the important
points of thalassaemia.
n
Important points to know:
io
• α thalassaemia major → is usually lethal in utero. It should be

considered when hydrops fetalis is diagnosed
t
• β thalassaemia major → Presents in infancy often includes failure to

ua
thrive, vomiting feeds, sleepiness, stunted growth and irritability. In

severe, untreated cases there may be:
• Hepatosplenomegaly
al
• Bony deformities (frontal bossing). The extra medullary

haemopoiesis occurs in response to anaemia.
Ev
• Marked pallor and slight to moderate jaundice

• Iron overload can cause endocrinopathy with diabetes,
thyroid, adrenal and pituitary disorders
• β-thalassaemia carrier status is often confused with iron deficiency
due to reduced MCV and MCH. But note that in iron deficiency,
serum ferritin and iron is low while in thalassaemia they are usually
high.
Management for thalassaemia major:

• Lifelong blood transfusions are needed to maintain a haemoglobin
level higher than 9.5 g/dL (or some authors say 9.0 g/dL)
• Iron chelation to prevent overload syndrome (Oral deferiprone +
desferrioxamine SC twice weekly)
• A histocompatible marrow transplant can offer the chance of a cure
648
46. A 52 year old female has loss a few litres of blood during a hysterectomy.
She is due for a blood transfusion. What is the SINGLE most likely test
involved in the preparation of blood transfusion?
A. Indirect Coombs test

B. Direct Coombs test
C. Sickle solubility test
D. G6PD enzyme assay
E. Osmotic fragility test
Coombs test
There are two Coombs tests:

1. The direct Coombs test (DCT, also known as direct antiglobulin test
or DAT)
2. The indirect Coombs test (also known as indirect antiglobulin test or
IAT)
y
Direct Coombs test
op
• Used to test for autoimmune haemolytic anaemia
• It is used to detect these antibodies or complement
proteins that are bound to the surface of red blood cells.
C
Basically, it is used to test patients RED BLOOD CELLS.
• A positive Coombs test indicates that an immune
mechanism is attacking the patient's own RBCs. Examples:
n
• Common examples of alloimmune haemolysis
io
o Haemolytic disease of the newborn (also

known as HDN or erythroblastosis fetalis)
t
o Rh D haemolytic disease of the newborn

ua
(also known as Rh disease)

o ABO haemolytic disease of the newborn
o Alloimmune haemolytic transfusion
al
reactions
• Common examples of autoimmune haemolysis
Ev
o Cold agglutinin disease : Infectious

mononucleosis
• Drug-induced immune-mediated hemolysis
o Penicillins, Cephalosporins
Indirect Coombs test

• Used in prenatal testing of pregnant women and in testing blood
prior to a blood transfusion.
• It detects antibodies against RBCs that are present unbound
in the patient's serum. In this case, serum is extracted from
the blood sample taken from the patient and tested.
Basically, it is used to test patients SERUM (not red blood
cells)
• If agglutination occurs, the indirect Coombs test is positive.
• Examples of use:
o Blood transfusion preparation : Antibody
screening, cross matching
649
o Antenatal antibody screening: to screen
pregnant women for IgG antibodies that
are likely to pass through the placenta into
the fetal blood and cause haemolytic
disease of the newborn
47. A 7 year old boy presents with epistaxis of 2 hour duration. The bleeding
has been controlled. His blood tests show:

A. Haemophilia
B. Von willebrand disease
y
op
D. Vitamin K deficiency
E. Anatomical defect C
All his blood results are normal. Anatomical defect is the only possibility.
48. A 20 year old woman has had bruising and petechiae for a week. She also
n
reports frequent nose bleeds and menorrhagia but is otherwise well. A
io
blood count showed:

t
Haemoglobin 111 g/L

ua

al

Ev
A. Acute leukaemia
B. Aplastic anaemia
C. HIV infection
Idiopathic thrombocytopenic purpura is usually seen in children but that

does not mean it can’t happen in adults.
As the patient is otherwise well, acute leukaemia, HIV and SLE are unlikely.
A normal WBC count excludes aplastic anaemia. Thus the likely diagnosis is
ITP. Idiopathic thrombocytopenic purpura fits with her symptoms of
bruising and petechiae. Older girls may have menorrhagia. Some experience
nosebleeds.
The isolated thrombocytopenia in a well patient points to a diagnosis of

idiopathic thrombocytopenic purpura.
650
Presentation:
• As in children, adults with ITP may demonstrate a range of
symptoms from none at all through to severe haemorrhage
• Bleeding, purpura, epistaxis and menorrhagia
• Isolated thrombocytopenia; blood count otherwise normal
Management:
• Prednisolone
• IV immunoglobulin
y
• Emergency platelet transfusion
op
• Only in life threatening haemorrhage. (usually platelet less
than 20 x 109/L) C
49. A 5 year old child has bleeding gums and sore throat for the last 3 months.
He feels tired and lethargic all the time. On examination, splenomegaly was
noted. Blood results show:
n
io
Hb 7.8g/dl
WCC 3 x 109/L
t
ua

al

Ev

The commonest leukaemia in children is Acute lymphoblastic leukaemia

(ALL)
Bleeding gums (low platelet), feeling tired and lethargic, sore throat,
splenomegaly are all well known features of Acute lymphoblastic leukaemia
(ALL)
Aetiology
651

thrombocytopenia)
(10-20%)
y
op
C
n
io
Diagnosis
t
ua
FBC
al

Ev


acute leukaemia.
652
Note:
old.
50. A 55 year old man presents with significant weight loss, fever and night
sweats. Hodgkin’s lymphoma was later diagnosed. What type of cell is
associated with Hodgkin’s lymphoma?
A. T-cells
B. Reed-Sternberg cells
C. B-cells
D. Macrophages
E. Auer rods
y
op
A very easy and direct question. The diagnostic cells in Hodgkin’s lymphoma
are Reed-sternberg cells. C
Hodgkin's lymphoma
Hodgkin's lymphoma is a malignant tumour of the lymphatic system that is

n
characterised histologically by the presence of multinucleated giant cells
io
(Reed-Sternberg cells)
t
There are subtypes of Hodgkin's lymphoma but these are not commonly
ua
asked.
Presentation
al
• Most patients present with an enlarged but otherwise

asymptomatic lymph node, typically in the lower neck or
Ev
supraclavicular region. They are painless, non-tender, ‘rubbery’

superficial lymph nodes. They also can be axillary or inguinal nodes
• Mediastinal masses are frequent and are sometimes discovered on
a routine CXR.
• Systemic symptoms of drenching night sweats, unexplained fever
>38°C, and weight loss of >10% over six months are termed B
symptoms and are identified in approximately 25% of patients.
• Pruritus and lethargy
• Besides the lymphadenopathy. findings on examination include
hepatomegaly, splenomegaly, and superior vena cava syndrome
(SVC syndrome is due to an obstruction from mediastinal lymph
node involvement causing features of a mass effect)
Diagnosis
• Tissue diagnosis: Lymph node excision biopsy if possible
653
51. A 12 year old boy has sudden development of purpura 2 weeks after an
upper respiratory tract infection. A blood count showed:
Haemoglobin 119 g/L

Bleeding time 10 minutes

D. Haemophilia A
E. Haemophilia B
y
The isolated thrombocytopenia and history of an upper respiratory tract
op
infection with the development of purpura suggest idiopathic
thrombocytopenic purpura. C
In idiopathic thrombocytopenic purpura, bleeding time may be increased
like the above.
n
Idiopathic thrombocytopenic purpura
io
Presentation:
t
• Follows viral infection or immunisation

ua
• The most common presentation is petechiae or bruising. Petechiae

mainly in arms and legs - sudden onset
• Up to a quarter present with nosebleeds
al
• Haematuria and gastrointestinal bleeds are less common.

• Older girls may have menorrhagia
Ev
• Otherwise the patient is well and physical examination is normal
Management:
• Prednisolone
than 20 x 109/L)
52. A 33 year old woman complains of tiredness for the last 3 months, On
routine blood test, she is found to have a haemoglobin of 85 g/L, low mean
cell volume, and low ferritin. What is the SINGLE most likely diagnosis?
A. Iron deficiency
654
C. Thalassaemia
E. Sideroblastic anaemia
The table below is a short summary of common findings given in the exam
to help you differentiate between the cause of the anaemia.
Microcytic Macrocytic
Iron Deficiency Megaloblastic
• Fe ↓ → Hypersegmented neutrophils
• Ferritin ↓
• TIBC↑
B12 deficiency
• Neurological problems
Thalassemia • Subacute combined
• Normal iron studies degeneration of the cord
• Electrophoresis to see type • Serum B12 ↓
y
Anaemia of chronic disease
• Fe ↓
op Folate deficiency
• Serum folate ↓
C
• Ferritin ↑ Normoblastic (Non megaloblastic)
• TIBC↓ • Alcohol
• Liver disease
n
• Hypothyroidism
io
Sideroblastic anaemia • Pregnancy

• Fe ↑ • Reticulocytosis
t
• Ferritin ↑ • Myelodysplasia
ua
• In sideroblastic anaemia, • Drugs: cytotoxics

the body has iron available
but cannot incorporate it
al
into haemoglobin
Ev
Normocytic (normal MCV)

• Haemolytic anaemias: Bloods in general show ↑LDH , ↑
unconjugated bilirubin, ↓ Haptoglobin, ↑ Reticulocytes
Sickle Cell
• Blood smear → Sickle cells
• Sickle solubility test → This test detects the presence of
haemoglobin S but does not distinguish between sickle cell disease
and trait
• Hb Electrophoresis → For asymptomatic patients to see if patient
has trait
• Treatment: Acute → IV fluids, morphine, O2, antibiotics
• Prophylaxis → Hydroxyurea. Also needs pneumococcal vaccines
Autoimmune haemolysis
• COOMBS test
655
• Treat with steroids
Hereditary spherocytosis
• Blood film → spherocytes
• Osmotic fragility test
• Treatment: Splenectomy
G6PD deficiency
• Blood film → Heinz bodies
• Check G6PD levels
• Treatment: stop offending drugs
53. A 36 year old woman has massive bleeding from a venipuncture site.
Petechiae was noticed on her skin. Her blood tests show:
y
Haemoglobin 113 g/L
op
Platelets 48 x 109/L C
Prothrombin time, activated partial thromboplastin time and bleeding time
are prolonged. Fibrin degradation products were elevated. What is the
n
io
A. Haemophilia
t

ua

E. Warfarin overdose
al

Ev
Presentation
the site of trauma
• Petechiae, purpura
Diagnosis

656
Treatment
severe bleeds
54. A 62 year old man presents with bone pain at his ribs which have been
present for the last couple of weeks. He has been feeling tired lately and
finds himself always thirsty. His previous FBC shows a haemoglobin of 9
g/dL. Biochemistry shows calcium levels of 4.0mmol/L and ALP of 118 iu/L.
What cell type is most likely to be found in abundance in the bone marrow?
A. Plasma cell
B. Myeloid cell
y
C. Bence-jones protein
op
D. Megakaryocytes
E. Reticulocytes C
Multiple Myeloma

n
io
t
ua

al

• Renal failure
Ev


Diagnosis
Jones' protein.
657
Management
55. A 67 year old woman with a history of rheumatoid arthritis presents to her
GP’s office with complaints of epigastric discomfort, especially after eating.
She has been on long term methotrexate and NSAID therapy for her
condition. On examination, she appears pale but seems otherwise well. A
full blood count reveals the following:
y
Hb: 10.5g/dL
op
MCV, MCH and MCHC are all decreased

C
A. Folate deficiency anaemia
B. Vitamin B12 deficiency anaemia
n
C. Haemolytic anaemia
io
D. Aplastic anaemia
E. Chronic gastrointestinal bleeding
t
ua
The blood values are indicative of a microcytic anaemia. It is true that

methotrexate can cause a folic acid deficiency anaemia but since the blood
results clearly show a microcytic anaemia (and folic acid deficiency anaemia
al
is a macrocytic anaemia) the only correct conclusion that we can reach is

that the long term NSAID therapy is the culprit for her anaemia.
Ev
56. A 25 year old lady has a chest infection in which she is receiving antibiotics
for. She has shortness of breath, feels tired and weak. On examination she
looks pale and purpura is seen on her legs. Blood results show the
following:
Haemoglobin 76 g/L
Reticulocytes 1%
Blood film morphology was unremarkable. A bone marrow aspirate shows a

reduction in haemopoietic cells. What is the SINGLE most likely underlying
diagnosis?
658
C. Aplastic anaemia
She has a signs and symptoms of anaemia. The blood picture shows
pancytopenia which rules out pernicious anaemia as an underlying cause.
Normal morphology rules out the possibility of acute myeloid leukaemia,

and acute lymphoblastic leukaemia.
Chronic myeloid leukaemia usually has leucocytosis.
A bone marrow aspirate that shows a gross reduction in all haemopoietic

tissue is seen classically in aplastic anaemia. Decrease reticulocytes support
the diagnosis.
Aplastic anaemia
y
Aplastic anaemia is a rare, potentially life-threatening failure of
op
haemopoiesis characterised by pancytopenia and hypoplastic marrow (the
marrow stops making cells). C
Causes
Most cases are autoimmune, triggered by drugs (viruses, eg parvovirus,
hepatitis) or irradiation.
n
io
Presentation
Aplastic anaemia can present abruptly over, or insidiously over, weeks to
t
months.
ua
Clinical manifestations are proportional to the peripheral-blood cytopenias

and include:
al
• Symptoms of anaemia (pallor, headache, palpitations, dyspnoea,

fatigue, or ankle oedema) Note: Anaemic symptoms are usually less
Ev
severe due to the chronic onset

• Symptoms of thrombocytopenia (skin or mucosal haemorrhage,
visual disturbance due to retinal haemorrhage, petechial rashes)
• Infection (a less common presentation) particularly upper and lower
respiratory tracts, skin, mouth, and peri-anal
• There is no lymphadenopathy or hepatosplenomegaly (in the
absence of infection).
Diagnostic tests:
Marrow examination is needed for the diagnosis
Note: To define aplastic anaemia based on FBC and bone marrow findings,
at least two of the following must be present:
• Haemoglobin <10 g/dL
• Platelet count < 50 x 109/L
• Neutrophil count <1.5 x 109/L
659
It is also important to note that the blood film morphology is unremarkable
which differentiates it from some other types of leukaemias.
57. A 53 year old man presents complaining of weight loss, lethargy, increasing
abdominal discomfort and gout for the past year. On examination, spleen is
palpated 5 cm below the left costal margin. His blood tests show:
Haemoglobin 105 g/L

85% neutrophils
Sodium 140 mmol/L
Potassium 4 mmol/L
Philadelphia chromosome positive
y
op
A. Chronic myeloid leukaemia
B. Chronic lymphocytic leukaemia
C. Acute myeloid leukaemia
C
D. Malaria
E. Lymphoma
n
The clincher here is the massive spleen. Although there are many causes of
io
massive spleen, for the purpose of PLAB, massive spleen can only be caused
by Chronic Myeloid Leukaemia (CML) or Malaria
t
ua
Weight loss, lethargy, increasing abdominal discomfort support the

diagnosis of CML
al

Ev
of some sort.
Mnemonic:CML → Crazy Massive Large Spleen
The blood picture fits perfectly for CML in this question. Slight anaemia,
high WBC and high neutrophils. Philadelphia chromosome also helps with
the diagnosis.
Gout in this question is because of the rapid cell turnover seen in CML.

660
1. Chronic phase
y
op

C
• Weight loss
• Night sweats
n
is common)
io

t
• Hepatomegaly
ua

• Low grade fever
al
Ev
• FBC:
anaemia is common
661
Take home notes:

58. A 90 year old woman is brought to the hospital complaining of back pain
and has been referred to the surgeon. She has been saying that her mother
is due to visit her today and that somebody must have broken her lower
back as she is in agony. Her blood tests show:
Haemoglobin 109 g/L
y
op
Serum calcium 3.02 mmol/l C
What SINGLE investigations is most likely to lead to a diagnosis?
A. Ultrasound KUB
n
B. X-ray Spine
io
D. Urine protein electrophoresis to look for Bence-Jones Protein
t
E. Mental state exam

ua
Multiple myeloma is the suspected diagnosis here.

al
Elevation in the BUN and creatinine is seen due to the damage to the kidney
Ev
Anaemia is the most common laboratory finding in multiple myeloma
She is 90 years old. It is unlikely that her mother is still alive. The statement
that she thinks her mother is going to visit her today points to some sort of
confusion. This confusion can be seen in multiple myeloma due to
hyperviscosity and also hypercalcaemia.
Multiple Myeloma

662
• Renal failure

Diagnosis
y
Jones' protein.
op
C
n
io

t

ua
59. A 15 year old girl was admitted with chest infection. She was treated and
al
her symptoms had regressed. She was brought again with fever and the
same symptoms a few days later. It was found that all her blood works done
Ev
in the hospital showed a mild anaemia and thrombocytopenia. What is the

A. Acute myeloid leukaemia (AML)

B. Acute lymphoblastic leukaemia (ALL)
C. Aplastic anaemia
The age is the only factor that support the diagnosis of acute lymphoblastic
leukaemia (ALL) along with the given picture. The same picture can happen
in aplastic anaemia but there is not a single factor mentioned in favour of it.
So acute lymphoblastic leukaemia (ALL) can be taken as best option in the
given scenario.
663
Aetiology

thrombocytopenia)
y
(10-20%)
op
C
n
io
t
ua
Diagnosis
al
FBC
Ev



acute leukaemia.
664
Note:
old.
60. A 34 year old woman developed a purpuric rash on the back of her legs. She
also reports frequent nose bleeds and menorrhagia. A blood count shows:
Haemoglobin 119 g/L

y
op
D. Antiphospholipid syndrome
C
E. Henoch-Schönlein purpura
Idiopathic thrombocytopenic purpura is usually seen in children but that

n
does not mean it can’t happen in adults.
io
Chronic ITP which is mainly seen in women can run a fluctuating course of
t
bleeding, purpura, epistaxis and menorrhagia.

ua
The isolated thrombocytopenia in a well patient points to a diagnosis of

idiopathic thrombocytopenic purpura.
al

Ev
Presentation:
• As in children, adults with ITP may demonstrate a range of
symptoms from none at all through to severe haemorrhage
• Bleeding, purpura, epistaxis and menorrhagia
Management:
• Prednisolone
665
than 20 x 109/L)
61. A 21 year old man has episodic right upper quadrant pain. An abdominal
ultrasound reveals gallstones. His father had a splenectomy when he was
young. His blood tests show:
Haemoglobin 91 g/L
D. Beta thalassemia
y
op
The evidence of increased MCHC, gallstones and family history points
towards hereditary spherocytosis.
C
Hereditary Spherocytosis
Hereditary Spherocytosis is the most common inherited RBC membrane
n
defect characterized by variable degrees of haemolysis, spherocytic RBCs
io
with increased osmotic fragility.

t
Approximately 75% of cases display an autosomal dominant pattern of

ua
inheritance; the rest are recessive forms and de novo mutations.
Clinical features
al
• Patients may present at any age with haemolytic anaemia, jaundice

(either from haemolysis or gallstones) and splenomegaly
Ev
• 20-30% of patients have mild disease with an increased red cell

turnover compensated with adequate replacement. They are
neither symptomatic nor anaemic, but may have mild
splenomegaly, slight reticulocytosis and minimal spherocytes
visible.
• 60-70% of patients have moderate disease and half of these present
in childhood with anaemia.
• Neonates with severe hereditary disease do not always present at
birth with anaemia, but haemoglobin may fall dramatically over the
first few weeks of life and may be severe enough to require
exchange transfusion.
• Occasional aplastic crises occur, e.g. with parvovirus B19 infection.
Diagnosis
(These are the 3 most important test that you need to know in the exam for
Hereditary Spherocytosis)
666
• Blood film shows spherocytes and increased reticulocytes
• MCHC would be elevated
• Osmotic fragility test → confirms presence of spherocytes but does
not permit hereditary spherocytosis to be distinguished from other
spherocytic haemolytic disorders such as autoimmune haemolytic
anaemia. This is not reliable until six months of age.
Some authors mention that osmotic fragility test is unreliable and is

no longer recommended. However, it is still considered the gold
standard despite missing up to 20% of cases. In the PLAB exam,
osmotic fragility test may be given as a choice for a diagnostic test
for Hereditary Spherocytosis. Pick it if it is.
Note:
Spherocytosis almost always refers to hereditary spherocytosis but note
that spherocytes are found in hereditary spherocytosis and also
autoimmune haemolytic anaemias. The test to distinguish the two would be
a direct Coombs test. Hereditary spherocytosis has a negative direct
y
Coombs test but autoimmune haemolytic anaemias have a positive direct
op
Coombs test
C
n
t io
ua
al
Management
Ev
Steroid therapy
• effective in augmenting haemoglobin levels during haemolytic
crises in patients with moderate disease
Folate supplementation
Splenectomy
• eliminates anaemia and hyperbilirubinaemia and lowers the high
reticulocyte number to nearly normal levels
• Splenectomy is curative in most patients but increased recognition
of the long-term risks of splenectomy has led to re-evaluation of the
role of splenectomy.
Mild cases do not usually require folate supplements or splenectomy
Complications
667
• Rapid haemolysis can be triggered by viral infections and produce
jaundice, anaemia and occasionally abdominal pain and tender
splenomegaly. Supportive treatment is usually all that is needed.
• Aplastic crises (aplastic anaemia). They are most commonly caused
by infection with parvovirus B19 and usually last 10-14 days. This
can be life-threatening.
anaemia or hereditary spherocytosis
Parvovirus and anaemia

Although most patients have a decrease of erythropoiesis (production of
red blood cells) during parvovirus infection, it is most dangerous in patients
with sickle cell anaemia or hereditary spherocytosis, as they are heavily
dependent on erythropoiesis due to the reduced lifespan of the red cells.
knee joints and muscles. Factor IX was found deficient. What is the SINGLE
y
A. Haemophilia A
B. Christmas disease
op
C
E. Thalassaemia
n
io
Factor IX deficiency is evidence of haemophilia B (Christmas disease).

t
Haemophilia A and B
ua

Christmas disease).
al
Ev
Investigations
668

disease
• Haemophilia
joints)

Haemophilia type A
y
op
C
n
io

t

ua
63. A 66 year old woman is confused, and lethargic. Her son reports gradual
al
confusion over the last 4 months. On examination, she looks pale. Blood
test have been done which shows a megaloblastic anaemia. Both B12
Ev
deficiency and folate deficiency was diagnosed on further investigation.

What is the SINGLE most likely treatment for her anaemia?
A. Oral folic acid and start Intramuscular vitamin B12 when folic acid levels
are normal
B. Intramuscular vitamin B12 and start oral folic acid when vitamin B12
levels are normal
C. Oral folic acid only
D. Intramuscular vitamin B12 only
E. Iron tablets
It is important in a patient who is also deficient in both vitamin B12 and folic
acid to treat the B12 deficiency first to avoid precipitating subacute
combined degeneration of the cord. Once the vitamin B12 levels are
normal, then start oral folic acid.
669
64. A 4 year old boy has a history of epistaxis. Prothrombin time, bleeding time,
fibrinogen levels and von Willebrand factor are normal. Activated partial
thromboplastin time (APTT) was found to be prolonged. His blood tests
show:
Haemoglobin 112 g/L

A. Haemophilia
C. Sickle cell anaemia
E. Thalassaemia
Despite the fact that many people remember haemophilia presenting with
y
bleeding into joints and muscles, you would need to know that epistaxis
op
may occur in haemophilia
Activated partial thromboplastin time (APTT) that is prolonged with

C
everything else being normal points towards haemophilia.
Factor VIII and IX levels should be offered to confirm the diagnosis.

n
io
Haemophilia A and B
t

ua
Christmas disease).
al

Ev
Investigations
670
disease
• Haemophilia
joints)

Haemophilia type A
y
op

C
n
io

t
ua
65. A 41 year old man has fatigue and palpitations. Physical examination reveals
a red sore tongue, angular stomatitis and koilonychia. His blood tests show:
al
Haemoglobin 85 g/L
Ev
A. Folate deficiency
B. Vitamin B12 deficiency
C. Iron deficiency
D. Vitamin E deficiency
E. Haemolytic anemia
Angular stomatitis, sore red tongue can ben seen in both B12 deficiency and
iron deficiency although angular stomatitis is more of a sign of iron
deficiency. Koilonychia is usually seen in iron deficiency.
But the key to the question is the mean cell volume. As this is decreased, it
cannot be B12 deficiency or folate deficiency. Iron deficiency leads to
microcytic anaemia so we would expect the MCV to be low.
671
Iron-deficiency anaemia
Aetiology
• Blood loss from the gastrointestinal (GI) tract is the most common
cause of iron-deficiency anaemia in adult men and postmenopausal
women
• Blood loss due to menorrhagia is the most common cause of iron
deficiency in premenopausal women
• In tropical countries, infestation of the gut may cause iron-
deficiency anaemia , especially with hookworm and schistosomiasis
• Common causes of blood loss include:
• Non-steroidal anti-inflammatory drug (NSAID) use
• Colonic carcinoma
• Gastric carcinoma
• Gastric or duodenal ulceration
• Dietary inadequacy
• Failure of iron absorption: Malabsorption conditions such as coeliac
disease
y
• Excessive requirements for iron: Pregnancy
Laboratory tests
• Low Haemoglobin
op
C
• Low Mean cell volume (MCV)
• Low Mean cell haemoglobin concentration (MCHC)
• High Red cell distribution width (RDW)
n
• Low serum ferritin
io
• High Total iron-binding capacity

t
The above laboratory test are important to remember for PLAB as they may
ua
be asked
66. A 52 year old lady has been suffering from chronic rheumatoid arthritis and
al
is on methotrexate and naproxen. Blood results show:

Ev
Haemoglobin 83 g/L
A. Haemorrhoids
B. Gastrointestinal haemorrhage
C. Menorrhagia
E. B12 deficiency
Gastrointestinal haemorrhage would be a cause of microcytic anaemia like

in the given scenario and it fits with the history of prolonged use of NSAIDS.
Folate and B12 deficiency are in the category of macrocytic anaemias.
672
There should be no reason for menorrhagia. Besides, the patient is 52 years
old. The average age of menopause in UK is 51. Blood loss from the
gastrointestinal (GI) tract is the most common cause of iron deficiency
anaemia in postmenopausal women.
There is also no relation with haemorrhoids
67. A 6 year old child has a history of recurrent mild jaundice that occurs a fews
days after the onset of a fever. Between the episodes he is well. 3 days ago,
he had a chest infection and his blood results show:
Haemoglobin 106 g/L

Bite cells are seen on blood film. What is the SINGLE most likely diagnosis?
y
C. Thalassemia
op
D. Sickle cell disease
E. Congenital storage disorder C
There are some precipitating factors of haemolysis causing jaundice in
patients with G6PD deficiency. Among then include infection.
n
Bite cells point towards the diagnosis of G6PD.
io

t
ua

al

Ev

stress
673
Presentation:
occurs)
the specifics:

y
op
C
n
io

t
Favism
ua

al
Neonatal jaundice
Ev


severe haemolysis
Diagnosis
674
Management
68. A 45 year old woman who is taking medication for the treatment of
rheumatoid arthritis presents with dizziness, fatigability and lack of energy.
Blood results show:
y
Haemoglobin 80 g/L
op
What is the SINGLE most likely cause of her anaemia?

C
A. Steroids
B. Chronic disease
n
C. NSAIDs
io
D. Methotrexate
E. Leflunomide
t
ua
Methotrexate is a folate antagonist. It causes folate deficiency which is

shown as a macrocytic anaemia like in the case above.
al
Anaemia of chronic disease would be considered as a cause if the MCV was

normal or low. Rheumatoid arthritis leading to anaemia of chronic disease
Ev
has red cells that are usually hypochromic, microcytic or normochromic,

normocytic.
Folate Deficiency
Folate deficiency represents the other main deficiency cause of
megaloblastic anaemia. (The other main deficiency is B12 deficiency).
Megaloblastic anaemias are a heterogeneous group of disorders sharing

common morphological characteristics. Erythrocytes are larger and have
higher nuclear-to-cytoplasmic ratios compared to normoblastic cells.
Neutrophils can be hypersegmented and megakaryocytes are abnormal.
Causes:
Dietary deficiency
• Malabsorption (eg, coeliac disease, jejunal resection, inflammatory
bowel disease).
• Poor intake
675
• Alcohol excess (also causes impaired utilisation)
Antifolate drugs
Example: Sulfasalazine, methotrexate
Diagnosis:
The haematological features indistinguishable from those of B12 deficiency
(macrocytic,
megaloblastic anaemia). Distinction is on basis of demonstration of reduced
red cell and serum folate. Vitamin B12 levels should be assessed at the
same time due to the close relationship in metabolism.
In PLAB, one distinction that may help you choose between B12 and folate
deficiency is the diet. Good food sources of folate include broccoli, brussels
sprouts, asparagus, peas (basically vegetables). Thus if the given scenario is
a vegetarian, it is unlikely that he is suffering from folate deficiency. In that
case, pick B12 deficiency.
y
Management:
op
Folic acid 5 mg/d PO for 4 months.
Note: It is important in a patient who is also deficient in both vitamin B12

C
and folic acid to treat the B12 deficiency first to avoid precipitating
subacute combined degeneration of the cord. Once the vitamin B12 levels
are normal, then start oral folic acid.
n
io
69. A 4 year old boy presents with recurrent episodes of self limiting
spontaneous bleeding into his arms and legs that occurs with minimal
t
trauma. His blood tests show:

ua

al

Ev
His father and uncle suffer from a similar illness. What is the SINGLE most
likely diagnosis?
A. Haemophilia
B. Thalassaemia
Activated partial thromboplastin time (APTT) that is prolonged with

everything else being normal points towards haemophilia.
Factor VIII and IX levels should be offered to confirm the diagnosis.
Haemophilia A and B
676
Christmas disease).
Investigations
y
op
C

n
disease
io
• Haemophilia
t

ua
joints)
al

Ev

Haemophilia type A


677
70. A 22 year old man with sickle cell anaemia has shortness of breath, pallor,
headache and lethargy. Infection with parvovirus is suspected. His blood
tests show:
Haemoglobin 53 g/L
A. Aplastic crises
B. Haemolytic crisis
D. Vaso-occlusive crises
E. Acute chest syndrome
y
anaemia or hereditary spherocytosis with the diagnosis of aplastic crisis at
op
hand.
Sickle cell crisis

C
Sickle cell anaemia is characterised by periods of good health with
intervening crises
n
io
There are four main types of crises:

t
Thrombotic crises (Vaso-occlusive crises)

ua
• This is the most common type of crisis. It is the obstruction of the

microcirculation by sickled red blood cells, causing ischaemia
• Precipitated by by cold, infection, or dehydration
al
• Occlusion causes pain which may be severe

• Infarcts occur in various organs
Ev
Commonly presenting scenarios in exams are

• Occlusion causing mesenteric ischaemia, mimicking an
acute abdomen
• Avascular necrosis e.g. femoral head
Sequestration crises
• Is the sudden enlargement of the spleen, causing a decrease in
haemoglobin concentration, circulatory collapse and hypovolaemic
shock
• Occurs mainly in babies and young children
• The severity is variable but can present with shock and anaemia
• Acute splenic sequestration has been defined as an acute fall of
haemoglobin and markedly elevated reticulocyte count, together
with an acute increase in spleen size
• Recurrent splenic sequestration is an indication for splenectomy
Aplastic crises
678
• Is the temporary cessation of erythropoiesis, causing severe
anaemia
• Caused by infection with parvovirus B19
• Most patients have a decrease of erythropoiesis (production of red
blood cells) during parvovirus infection, however it is most
dangerous in patients with sickle cell anaemia or hereditary
spherocytosis, as they are heavily dependent on erythropoiesis due
to the reduced lifespan of the red cells.
Haemolytic crises
• Rare thus uncommon to be asked in PLAB
• During painful crises there may be a marked increase in the rate of
haemolysis with a fall in the haemoglobin level
71. A 49 year old lady complains of headaches, dizziness and pruritus. She says
that the pruritus is worsen after taking a hot bath. A recent FBC revealed
that she has a haemoglobin of 192 g/L. What is the SINGLE most useful test
y
to establish the diagnosis of polycythaemia rubra vera?
A. JAK mutation screen

B. Leukocyte alkaline phosphatase
op
C
C. Serum erythropoietin
D. Oxygen saturation with arterial blood gas greater than 92%
E. Bone marrow aspiration
n
io
It has recently been established that a mutation in JAK2 is present in

approximately 95% of patients with PRV. JAK2 mutation is now a major
t
criteria in the diagnosis of polycythaemia rubra vera.

ua

al

Ev

Presentation
pulmonary embolism
679
• Facial plethora
Note:
Management
• Venesection
y
op
(hydroxyurea)
C
72. A 26 year old man develops mild anaemia following a chest infection. A
blood film shows Heinz bodies. What is the SINGLE most likely diagnosis?
n
io
t
ua
D. Beta thalassemia
al
Heinz bodies are pathognomonic for G6PD deficiency. In PLAB, if you see a
question that has Heinz bodies on a blood film, you can almost be certain
Ev
that this is G6PD deficiency.



stress
680
Presentation:
y
occurs)
op
C
the specifics:

n
io

t

ua

al

Ev

Favism
Neonatal jaundice

681
severe haemolysis
Diagnosis
Management
y
op
C
73. A 10 year old girl presents with pallor and features of renal failure. She has
n
haematuria as well as proteinuria. The serum urea and creat are elevated.
io
These symptoms started after an episode of bloody diarrhoea 4 days ago.

t
ua
A. Thrombotic thrombocytopenic purpura

B. Haemolytic uraemic syndrome
al
D. Henoch-Schönlein purpura
E. Acute renal failure
Ev
Most cases of haemolytic uremic syndrome develop in children after 2 to 14

days of diarrhoea often bloody, due to infection with a certain strain of E.
coli. Common features include abdominal pain, fever, features of renal
failure like nausea/vomiting can also occur.
Renal function and electrolytes would show a rise in urea and creatinine.
This is due to dehydration but, if associated with haemolysis and
thrombocytopenia, then it would indicate the onset of HUS.
A brief description:
Henoch-Schönlein purpura (HSP) Vs Haemolytic uraemic syndrome (HUS) Vs
Thrombotic thrombocytopenic purpura (TTP)
Henoch-Schönlein Haemolytic Uraemic Thrombotic

Purpura Syndrome Thrombocytopenic
Purpura
682
Purpura Triad Pentad (Triad of HUS)
Abdo pain 1. Acute renal +
Arthritis failure 4. Neurological
Glomerulonephritis 2. Microangiopat manifestation
Periarticular oedema hic haemolytic 5. Fever
anaemia
Features of IgA (MAHA)
nephropathy may 3. Thrombocytop
occur enia
E.g. Haematuria, renal
failure
Seen in Children Seen in Children

Usually follows an Associated with E.Coli Inhibition of ADAMTS
Upper respiratory tract 13
infection • ADAMTS 13 is
responsible for
breakdown of
y
VWF. Without
op
ADAMTS13,
coagulation
occurs.
C
Haemolytic uraemic syndrome (HUS)
n
HUS consists of a triad of haemolytic anaemia, uraemia, and

io
thrombocytopenia.
t
The anaemia will be intravascular in nature and will have an abnormal blood
ua
smear showing schistocytes, helmet cells, and fragmented red cells.
LDH and reticulocyte count will be elevated and the haptoglobin decreased.
al
90% are caused by E. coli strain O157. This produces a verotoxin that
Ev
attacks endothelial cells. Occurs after eating undercooked contaminated

meat.
Signs and Symptoms:
The classical presenting feature is profuse diarrhoea that turns bloody 1 to 3

days later. It is rare for the diarrhoea to have been bloody from the outset.
About 80-90% of children from whom the organism is isolated will develop
blood in the stool. It is usually at this stage that they are admitted to
hospital.
Most adults infected with E. coli O157 remain asymptomatic.
There is often fever, abdominal pain and vomiting
Management
683
• Treatment is supportive e.g. Fluids, blood transfusion and dialysis if
required
• Do not give antibiotics to those with possible HUS. The organism
may release more toxins as it dies if antibiotics are given and may
worsen the disease.
• The indications for plasma exchange in HUS are complicated. As a
general rule plasma exchange is reserved for severe cases of HUS
not associated with diarrhoea
74. A 55 year old man complains of fatigue. A blood test shows:
Haemoglobin 82 g/L
y
op
E. Sickle cell anaemia C
The best option above is folate deficiency as it is a macrocytic anaemia.
(High MCV).
n
Folate Deficiency
io
Folate deficiency represents the other main deficiency cause of

megaloblastic anaemia. (The other main deficiency is B12 deficiency).
t
ua
Megaloblastic anaemias are a heterogeneous group of disorders sharing

common morphological characteristics. Erythrocytes are larger and have
higher nuclear-to-cytoplasmic ratios compared to normoblastic cells.
al
Neutrophils can be hypersegmented and megakaryocytes are abnormal.

Ev
Causes:
Dietary deficiency
• Malabsorption (eg, coeliac disease, jejunal resection, inflammatory
bowel disease).
• Poor intake
• Alcohol excess (also causes impaired utilisation)
Antifolate drugs
Example: Sulfasalazine, methotrexate
Diagnosis:
The haematological features indistinguishable from those of B12 deficiency
(macrocytic,
megaloblastic anaemia). Distinction is on basis of demonstration of reduced
red cell and serum folate. Vitamin B12 levels should be assessed at the
same time due to the close relationship in metabolism.
684
In PLAB, one distinction that may help you choose between B12 and folate
deficiency is the diet. Good food sources of folate include broccoli, brussels
sprouts, asparagus, peas (basically vegetables). Thus if the given scenario is
a vegetarian, it is unlikely that he is suffering from folate deficiency. In that
case, pick B12 deficiency.
Management:
Folic acid 5 mg/d PO for 4 months.
Note: It is important in a patient who is also deficient in both vitamin B12

and folic acid to treat the B12 deficiency first to avoid precipitating
subacute combined degeneration of the cord. Once the vitamin B12 levels
are normal, then start oral folic acid.
75. A 55 year old HIV positive man presents with painless peripheral
lymphadenopathy, fever, night sweats and weight loss. Abdominal
examination reveals a enlarged spleen. What is the SINGLE most likely
diagnosis?
y
op
A. Hodgkin’s lymphoma
B. Non-Hodgkin lymphoma
C. Acute lymphoblastic leukaemia (ALL)
C
E. Chronic myeloid leukaemia (CML)
n
Although both Hodgkin’s and Non-Hodgkin’s lymphoma present in similar
io
ways with lymphadenopathy, night sweats, fever, weight loss, non-

Hodgkin’s is more associated with HIV than hodgkin’s disease. Non-
t
Hodgkin's lymphoma (NHL) is known as AIDS-related lymphoma.

ua
The most prevalent of the HIV-related lymphomas is diffuse large B-cell

non-Hodgkin's lymphoma, followed by Burkitt's lymphoma.
al
Although not considered an AIDS-defining illness, Hodgkin's lymphoma is

Ev
increasing in incidence in those with HIV infection and would be considered

an answer to this question if NHL was not present as one of the answers.
There is a with a clear correlation between the degree of

immunosuppression and the risk of developing NHL. The pathogenesis is
rather the immunosuppression rather than the HIV itself.
76. A 47 year old man who is on warfarin therapy is due for a hemicolectomy.
He is on warfarin for recurrent pulmonary embolism. What advice would
you give him prior to his surgery?
A. Continue with warfarin

B. Continue with warfarin and add heparin
C. Stop warfarin and start aspirin
D. Stop warfarin and start heparin
E. Stop warfarin
685
Warfarin should always be stopped 5 days before planned surgery. Heparin
is used instead of warfarin prior to surgery in patients with intermediate to
high risk of thromboembolism, recent TIA or patients with mechanical
cardiac valves.
Surgery and Warfarin
If the person needs to have surgery or any other invasive procedure, they
may need to temporarily stop taking warfarin.
Surgery — in general, warfarin is usually stopped 5 days before planned

surgery, and once the person's international normalized ratio (INR) is less
than 1.5 surgery can go ahead.
Warfarin is usually resumed at the normal dose on the evening of surgery or

the next day if haemostasis is adequate.
(In practice, you would need to adhere to local guidelines in Perioperative
y
Bridging of Warfarin in Adult Patients Undergoing Elective Surgery). See
op
example of local guidelines of guys and st thomas.)
77. A 45 year old man presents with a lump in the posterior triangle of his neck.
C
It has been growing for the past few months. He also complains of having
drenching night sweats, unexplained fever and weight loss. Lymph nodes
are palpable at the supraclavicular region. What is the SINGLE most likely
n
diagnosis?
io
A. Tuberculosis
t
B. Lymphoma
ua
C. Lipoma
D. Reactive lymph nodes
E. Virchow’s nodes
al
This is quite the classical presentation of lymphoma.

Ev
• Drenching night sweats, fever, weight loss

• Enlarged but otherwise asymptomatic lymph node, typically in the
lower neck or supraclavicular region
• Occasionally, findings on examination may reveal hepatomegaly or
splenomegaly.
In this question thankfully you do not need to differentiate between

Hodgkin’s and non-Hodgkin’s.
78. A 40 year old man has a mild fever and feels generally tired. He has marked
weight loss over the last 6 months and has a bilateral white, vertically
corrugated lesion on the lateral surfaces of the tongue. What is the SINGLE
B. Crohn's disease
C. HIV disease
686
D. Sarcoidosis
E. Sjogren’s syndrome
The white, vertical lesion described is called hairy leukoplakia which occurs
primarily in HIV-positive individuals.
Hairy leukoplakia
Hairy leukoplakia is a condition that is characterised by irregular white
patches on the side of the tongue and occasionally elsewhere on the tongue
or in the mouth. It is a form of leukoplakia, which refers to white patches on
the mucous membranes of the mouth often arising in response to chronic
irritation. Hairy leukoplakia occurs primarily in HIV-positive individuals.
This white lesion cannot be scraped off. The lesion itself is benign and does
not require any treatment.
79. A 51 year old man complains of pruritus and fatigue. A full blood count was
done and the following was reported:
y
op
Haemoglobin 197 g/L
C
JAK2 mutation was found to be positive. What is the SINGLE most likely
diagnosis?
n
io

B. Myelofibrosis
t
C. Acute myeloid leukaemia (AML)

ua

al
(PRV)
Ev
About a third of patients with PRV present with symptoms due to

thrombosis. This includes DVT like in this question.

erythropoietin (EPO).


687
Presentation
pulmonary embolism
y
• Facial plethora
op
Note:
C
Management
n
• Venesection
io

t

ua
(hydroxyurea)
al
80. A 39 year old pregnant woman who is 36 week gestation has acute
abdominal pain and is rushed for immediate C-section. Her blood pressure
Ev
was reported to be 110/60 mmHg. Her blood tests show:
Haemoglobin 101 g/L

Fibrinogen 0.6 g/L
A. Pregnancy induced hypertension

C. HELLP syndrome
D. Acute fatty liver
688
Acute abdominal pain may indicate concealed abruptio placentae which
may be a cause of disseminated intravascular coagulation.
The two top choices here are HELLP syndrome and disseminated
intravascular coagulation (DIC). It is important to understand that HELLP
syndrome may lead to disseminated intravascular coagulation. But the
more specific answer in this question is DIC because in HELLP syndrome, the
prothrombin time, activated partial thromboplastin time and serum
fibrinogen levels are normal but are prolonged in DIC.
Bilirubin levels may be higher than normal due to bilirubin production

secondary to haemolysis.
Presentation
y
the site of trauma
op
• Petechiae, purpura C
Diagnosis
n
io

t

ua

al

Ev
Treatment
severe bleeds
81. A 26 year old businessman travelled from New York to the U.K. He
presented to A&E three weeks later complaining of drenching night sweats,
fever and lymphadenopathy in the neck since returning from his business
trip. What is the SINGLE most likely diagnosis?
A. Tuberculosis
B. Lymphoma
C. Aplastic anaemia
689
D. Hereditary Spherocytosis
The two main contenders for an answer to this question are tuberculosis
and lymphoma.
Tuberculosis is improbable because New York City (USA) is not a

tuberculosis prone area. The main TB prone areas that you have to take
note of for the PLAB exam is a patient travelling to or from South Asia or
sub-Saharan Africa.
While it is true that the signs and symptoms of tuberculosis and lymphoma
are very similar, the following table makes is easy to differentiate between
tuberculosis and lymphoma if you are having difficulty choosing either as an
answer:
Tuberculosis Lymphoma
Fatigue, malaise, fever, weight loss, Drenching night sweats, fever,
y
anorexia weight loss
op
Hilar, paratracheal or superficial Enlarged but otherwise
node involvement. Palpable nodes asymptomatic lymph node, typically
may be initially tender, firm and in the lower neck or supraclavicular
C
discrete region
Chronic, productive cough with Patients might complain of chest
n
purulent ± bloodstained sputum discomfort with a cough or
dyspnoea
io
May result in lobar collapse, Mediastinal masses are frequent

bronchiectasis, pleural effusion and and are sometimes discovered on a
t
pneumonia routine CXR

ua
Erythema nodosum Findings on examination include

lymphadenopathy, hepatomegaly,
splenomegaly, and superior vena
al
cava syndrome
Ev
82. A 32 year old man presents with fatigue, weakness, weight loss. On
examination, cervical lymphadenopathy and splenomegaly is noted. What is
A. Haemophilus influenzae infection

B. Streptococcal infection
C. Toxoplasmosis
D. Non-Hodgkin lymphoma
E. Pneumocystis infection
There are two major points mentioned here: cervical lymphadenopathy and
splenomegaly.
This combination makes Non-Hodgkin lymphoma as the most likely cause.
Toxoplasmosis although uncommon, may have cervical lymphadenopathy
690
and splenomegaly as well. But weight loss is not seen in toxoplasmosis
hence non-hodgkin's lymphoma remains the top choice.
Non-Hodgkin lymphoma
This includes all lymphomas without Reed-Sternberg cells
Most are derived from B-cell lines; diffuse large B-cell lymphoma (DLBCL) is
commonest.
Common Signs and Symptoms

• Painless, slowly progressive peripheral lymphadenopathy is the
most common clinical presentation
• Primary extranodal involvement and systemic symptoms (fatigue,
weakness, fever, night sweats, weight loss) are not common at
presentation but are common in patients with advanced or end-
stage disease.
Note: fever, night sweats, weight loss are less common than in
y
Hodgkin’s lymphoma, and indicates disseminated disease
op
• Bone marrow is frequently involved and may be associated with
pancytopenia - anaemia, infection, bleeding (platelets).
• Splenomegaly
C
• Hepatomegaly
83. A 16 year old boy presents with rash on his buttocks and extensor surface
n
following a sore throat. He complains of joint stiffness and pain. What is the
io
SINGLE most probable diagnosis?

t
A. Measles
ua
B. Bullous-pemphigoid
C. Rubella
D. Idiopathic thrombocytopenic purpura (ITP)
al
E. Henoch-Schönlein purpura (HSP)

Ev
In HSP, the purpuric rash is typically found over buttocks and extensor
surfaces of arms and legs.
Presentation:
• Abdominal pain
Diagnosis:
Treatment:
691
84. A 45 year old man presents fatigue. He is otherwise asymptomatic. Blood

report shows the following:
Haemoglobin 82 g/L
There was an increased number of neutrophils, basophils, eosinophils.

Peripheral blood smear shows all stages of maturation. What is the SINGLE

y
op
E. Lymphoma C
Anaemia, raised WBC count are known features of Chronic myeloid
leukaemia (CML).
n
Myeloid cells include neutrophils, basophils, eosinophils, erythrocytes, and
io
platelets. An increased number of neutrophils, basophils, eosinophils are

consistent with CML.
t
ua
Note that platelets can be low, normal or raised in CML.

al

Ev

1. Chronic phase
692

• Weight loss
• Night sweats
is common)
• Hepatomegaly
• Low grade fever
y
op
C
• FBC:
n
io

t

ua

anaemia is common
al

Ev

Take home notes:

693
85. A 5 year old child presents with fever and pallor. His parents say he always
feels tired and is not as active as the other children around his age. On
examination, splenomegaly was noted. Blood results show:
Hb 7 g/dl
WCC 2 x 109/L

y
Aetiology
op
C
n
io
t
ua

thrombocytopenia)
al

Ev

(10-20%)

Diagnosis
694
FBC


acute leukaemia.
y
op
Note:
C
old.
n
io
86. A 54 year old man has fatigue. A recent blood report shows the following:
t
ua
Haemoglobin 90 g/L
al
Serum ferritin 9 μg/L

Total iron-binding capacity 75 μmol/L
Ev
A. Thalassaemia trait
B. Hypoparathyroidism
C. Hereditary sideroblastic anaemia
E. Iron deficiency anaemia
Iron-deficiency anaemia
Aetiology
• Blood loss from the gastrointestinal (GI) tract is the most common
cause of iron-deficiency anaemia in adult men and postmenopausal
women
• Blood loss due to menorrhagia is the most common cause of iron
deficiency in premenopausal women
695
• In tropical countries, infestation of the gut may cause iron-
deficiency anaemia , especially with hookworm and schistosomiasis
• Common causes of blood loss include:
• Non-steroidal anti-inflammatory drug (NSAID) use
• Colonic carcinoma
• Gastric carcinoma
• Gastric or duodenal ulceration
• Dietary inadequacy
• Failure of iron absorption: Malabsorption conditions such as coeliac
disease
• Excessive requirements for iron: Pregnancy
Laboratory tests
• Low Haemoglobin
• Low Mean cell volume (MCV)
• Low Mean cell haemoglobin concentration (MCHC)
• High Red cell distribution width (RDW)
• Low serum ferritin
y
• High Total iron-binding capacity
op
The above laboratory test are important to remember for PLAB as they may
C
be asked
87. A 59 year old smoker who recently underwent a hip replacement surgery 2
n
days ago, has a swollen and tender left leg. The diameter of his left calf is
io
higher than the right calf. Passive movements cause pain. The calf is tender
to touch. What is the SINGLE most likely diagnosis?
t
ua
A. Deep vein thrombosis

B. Lymphoedema
C. Peripheral vascular disease
al
D. Cellulitis
E. Superficial thrombophlebitis
Ev
One calf having a larger diameter than the other is one one of the known
signs of a DVT. The risk factors (smoker, immobile, major surgery) that are
given also point clearly towards the likely diagnosis of deep vein
thrombosis.
88. A 28 year old man has sudden onset of bone pain. He also begins
experiencing bleeding from his gums. Looking retrospectively, he notes a
decreased energy level over past weeks. He feels dizzy and has dyspnoea on
exertion. He looks pale and has numerous ecchymoses is seen over his
body. Hepatosplenomegaly is noted. A full blood count shows WBC of 102 x
109/L. A bone marrow biopsy shows numerous blasts. What is the SINGLE
A. Mantle cell lymphoma

B. Infectious lymphocytosis
C. Waldenstrom’s macroglobulinemia
696
E. Acute lymphoblastic leukaemia (ALL)
This is actually an acute emergency. The leucocytosis is causing the bone

pain. Bleeding from the gum is commonly seen in acute myeloid leukaemia
(AML). Note that gum bleeding can also be seen in ALL.
AML is the most common acute leukaemia in adults. Thus, majority of the
acute leukaemia in children questions asked in the PLAB test would be
acute lymphoblastic leukaemia (ALL) and not acute myeloid leukaemia
(AML).
One needs to be careful with picking AML or ALL as there are often
questions with a very similar stem. In reality, it is difficult to diagnose them
clinically as well. Flow cytometry (immunophenotyping) is used to help
distinguish AML from acute lymphocytic leukemia (ALL).
Acute myeloid leukaemia (AML)
y
op
This neoplastic proliferation of blast cells is derived from marrow myeloid
elements. It progresses rapidly (death in about 2 months if untreated)
C
Children or young adults may present with acute symptoms over a few days
to a few weeks.
n
Most AML subtypes show more than 30% blasts of a myeloid lineage in the
io
blood, bone marrow, or both.

t
Presentation:
ua
• Fatigue, pallor, dizziness and shortness of breath on exertion

(symptoms of anaemia)
• Bleeding caused by thrombocytopenia. Thrombocytopenia often
al
causes petechiae on the lower limbs. DIC may aggravate the

situation and cause larger lesions
Ev
• Infection
• Gingivitis is common, with swollen, bleeding gums
• There can also be bone pain
• Hepatomegaly and splenomegaly may be found. Lymphadenopathy
is less common.
Investigations
• FBC:
• Total WBC count is often high. However, it may also be
normal or even low
• Neutrophils are usually depleted and blast cells are seen in
their place
• Bone marrow aspiration is the diagnostic procedure. (The WHO
classification requires more than 20% blasts in the peripheral blood,
to make a diagnosis of AML)
697
INFECTIOUS DISEASE
y
op
C
Questions
n
io
&
t
ua
Answers
al
Ev
698
Infectious Diseases Questions
1. A 3 year old child was treated for bacterial meningitis and has recovered from it. She is
now afebrile. What is the SINGLE most appropriate investigation to perform?
A. CT scan
B. EEG
C. Blood culture
D. Repeat lumbar puncture
E. Hearing test
2. A 7 year old school boy has been diagnosed with meningococcal meningitis. What is the
SINGLE most appropriate prophylactic management?
A. Prophylactic rifampicin for the family

B. Prophylactic IV cefotaxime for family
C. Meningococcal vaccine for the family
D. Prophylactic benzylpenicillin for family
y
E. No prophylaxis needed
op
3. A 35 year old woman has numerous painful blisters and sores on her vulva. She also
complains of a flu-like illness with mild fever. What is the SINGLE most appropriate
treatment?
C
A. Doxycycline
n
B. Gentamicin
io
C. Penicillin
D. Aciclovir
t
E. Interferon
ua
4. A 36 year old lady with Hodgkin’s lymphoma has chemotherapy 8 days ago. She
presents with a temperature of 39.5°C and left sided abdominal pain. Her pulse rate is
al
96 beats/minute. Full blood count was sent and bloods were taken for culture. What is
the SINGLE most appropriate next action?
Ev
A. Wait for results of culture and sensitivity to confirm antibiotic choice

B. Wait for results of full blood count to determine further management
C. Start oral antibiotics immediately
D. Start broad spectrum IV antibiotics immediately
E. Start IV fluids only
5. A 24 year old man presents with a deep penetrating wound on his foot after having
stepped on a nail in a field. The wound is deep. He does not remember if he had
tetanus vaccines when he he was a child. What is the SINGLE most appropriate
management to be given?
A. Tetanus immunoglobulins only

B. Tetanus immunoglobulins and tetanus vaccine
C. Complete course of tetanus vaccine
D. Tetanus booster vaccine only
E. Antibiotic
699
6. A 68 year old woman has a sudden onset of pain and loss of hearing in her left ear and
unsteadiness when walking. There are small lesions visible on her palate and left
external auditory meatus. What is the SINGLE most likely diagnosis?
B. Cholesteatoma
D. Oropharyngeal malignancy
E. Otitis media with effusion
7. A 34 year old man from Zimbabwe is admitted with abdominal pain to the emergency
department. An abdominal X-ray reveals bladder calcification and evidence of
obstructive uropathy. What is the SINGLE most likely causative organism?
A. Schistosoma mansoni
B. Sarcoidosis
C. Leishmaniasis
D. Tuberculosis
y
E. Schistosoma haematobium
8.
op
A 73 year old woman living in a nursing home, presents with rashes on her finger webs
and also at her axillary folds. She complaints of itching which is more severe at night.
C
A. 0.5% permethrin
n
B. Doxycycline
io
C. 5% permethrin
D. Aciclovir
t
E. Malathion 0.5%
ua
9. A 78 year old nursing home resident has intensely itchy rash. White linear lesions are
seen on the wrists and elbows, and red papules are present on his penis. What is the
al

Ev
A. Topical permethrin
B. Referral to GUM clinic
C. Topical betnovate
D. Topical ketoconazole
E. Topical selenium sulfide hyoscine
10. A 33 year old lady who works at a nursing home presents with itching. On examination,
linear tracks on the wrist are seen. She says that 2 days ago she had come in contact
with a nursing home resident with similar symptoms. What is the SINGLE most likely
mechanism of itching?
A. Infection
B. Destruction of keratinocytes
C. Allergic reaction
D. Intolerance
E. Decreased histamine
700
11. A 14 year old boy has pain and swelling at the angles of the jaw bilaterally. He has a
temperature of 38.4°C. He has been complaining of dry mouth and sore ears and he
finds it difficult to talk. On examination, his scrotum is also swollen and oedematous
and the testes are impalpable. What is the SINGLE most likely diagnosis?
B. Epididymo-orchitis
C. Acute otitis media
D. Mumps
E. Measles
12. A 16 year old girl has a sore throat. She feels tired and weak. Oropharyngeal
examination shows tonsillar enlargement which is exudative. Her GP prescribed her
amoxicillin after which she developed a pruritic rash. What is the SINGLE most likely
diagnosis?
B. Kawasaki disease
y
C. Lymphoma
op
D. Cytomegalovirus
E. Group A streptococcal pharyngitis C
13. A 33 year old man comes from India with cough, fever and enlarged cervical lymph
nodes. Histology reveals caseating granulomas found in the lymph nodes. What is the
n
io
A. Lymphoma
t
C. Thyroid carcinoma
ua
D. Goiter
E. Thyroid cyst
al
14. A 24 year old man develops itching worse at night and following a bath. Examination
reveals a greyish white linear rash that can be seen on the flexor surface of the wrist
Ev
and axillary folds. What is the SINGLE most likely diagnosis?
A. Scabies
B. Polycythaemia
C. Urticaria vasculitis
D. Atopic eczema
E. Lichen planus
15. A 4 year old child is brought by his parents with a clean wound. He has never been
immunised as his parents are worried about the side effects of the immunisations.
There are no contraindications to immunisation. What is the SINGLE most appropriate
management?
A. Full course of diphtheria, pertussis, tetanus (DTP) vaccine

B. Rabies vaccination
C. 1 single injection diphtheria, pertussis, tetanus (DTP) vaccine
D. Intramuscular tetanus immunoglobulins
701
E. Antibiotic
16. A 22 year old lady comes to the hospital with complaints of fever, vertigo and pain in
her right ear. On physical examination, there are vesicles visible in her left ear. What is
A. Meniere's disease
B. Ramsay Hunt syndrome
C. Chicken pox
D. Acoustic neuroma
E. Cellulitis
17. A 28 year old man presents with a widespread maculopapular rash over his soles and
palms. He also has mouth ulcers. He had a penile ulcer which healed six weeks ago.
What is the SINGLE most likely organism responsible?
A. Mycoplasma genitalium
B. Treponema pertenue
y
C. Treponema pallidum
op
D. Lymphogranuloma venereum
E. Herpes simplex virus type 2 C
18. A 44 year old HIV positive man complains of a two week history of worsening headache,
facial weakness and visual hallucinations. He also reports new onset of eye pain. An
MRI head reveals multiple ring shaped contrast enhancing lesions. What is the SINGLE
n
most likely causative organism?
io
A. Cytomegalovirus
t
B. Streptococcus
ua
C. Toxoplasma gondii
D. Herpes Simplex Virus
E. Pneumocystis jirovecii
al
19. A 49 year old man with known HIV presents with history of cough and shortness of
Ev
breath. His CD4 count is measured at 350mm³. A chest X-ray was performed and shows
lobar consolidation. He has a temperature of 38.1°C, a respiratory rate of 30
breaths/minute and a heart rate of 90 beats/minute. What is the SINGLE most likely
causative organism?
A. Mycobacterium avium intracellulare

B. Cytomegalovirus
C. Streptococcus pneumoniae
D. Toxoplasmosis
E. Pneumocystis jiroveci
20. A 55 year old immunocompromised patient presents with dysphagia and pain on
swallowing. He has a redness, fissuring and soreness at the angle of his mouth. What is
the SINGLE causative organism?
A. Human herpesvirus 8
B. Molluscum contagiosum
702
C. Cytomegalovirus
D. Candida
E. Toxoplasma gondii
21. A 17 year old man has acute pain and earache on the right side of his face. He has a
temperature of 39.4°C and has extensive pre-auricular swelling that is tender on
palpation bilaterally. He also complains of headache, malaise, and dry mouth. What is
B. Acute otitis externa
D. Mumps
22. A 16 year old girl attends clinic with a sore throat and palatal petechiae. A full blood
count was done which shows:
y
Haemoglobin 109 g/L
op
platelets 88 x 109/L C
A Paul Bunnell test was shown to be positive. What is the SINGLE most likely diagnosis?
A. Glandular fever
n
B. Idiopathic thrombocytopenic purpura (ITP)
io
C. Measles
D. Rubella
t
E. Thrombotic thrombocytopenic purpura (TTP)

ua
23. A 35 year old lady presents with recurrent extremely painful ulcers on her vulva. Viral
culture and DNA detection using polymerase chain reaction (PCR) of a swab from the
al
ulcer has come back as negative. What is the SINGLE most appropriate investigations
which will lead to the diagnosis?
Ev
A. Anti-HSV antibodies
B. Dark ground microscopy of the ulcer
C. Treponema pallidum antibody test
D. Rapid plasma reagin test
E. Venereal Disease Research Laboratory test (VDRL)
24. A 16 year old girl has had an enlarging mass in the right side of her neck for the past 2
weeks with a sore throat. She feels tired and weak. She has several smaller associated
lymph nodes that are palpable at her axilla. Oropharyngeal examination shows tonsillar
enlargement which is exudative. What is the SINGLE most likely diagnosis?
B. Leukaemia
C. Lymphoma
D. Mumps
E. Tuberculosis
703
25. A 75 year old woman has weakness of the left side of her face and pain deep within the
left ear. The ear pain was paroxysmal at first but after a day it became constant and
radiates into the pinna. Now she has hears ringing in her left ear. A mild left hearing
loss was noted. There are blisters on the skin of the ear canal and auricle. What is the
A. Chronic serous otitis media

B. Herpes zoster oticus
C. Herpes simplex infection
D. Viral labyrinthitis
E. Bell’s palsy
26. A 74 year old female presents with headache and neck stiffness to the emergency
department. Following a lumbar puncture, the patient was started on IV ceftriaxone.
CSF culture reports as having listeria monocytogenes. What is the SINGLE most
appropriate treatment?
y
A. Add IV amoxicillin
op
B. Change to IV ampicillin + gentamicin
C. Add IV ciprofloxacin
D. Add vancomycin
C
E. Continue IV ceftriaxone as monotherapy
27. An 8 year old boy has red, itchy rash on his abdomen, face, arms and legs that has
n
turned into fluid-filled blisters. A few days later they crusted over. What is the main
io
mode of transmission of this condition?

t
A. Airborne
ua
B. Direct contact
C. Bloodborne
D. Vectorborne
al
E. Waterborne
Ev
28. A 3 year old girl presents with a history of fever for 2 days. She is drowsy and had a
seizure causing twitching of the right side of the body for 4 minutes. Her respiratory
rate is 30 beats/minute, oxygen saturation is 90%, temperature is 38.9°C, and capillary
refill time is 2 seconds. A urine dipstick was reported as negative. What is the SINGLE
A. Blood culture
B. Blood glucose
C. Chest X-ray
D. Urine culture and sensitivity
E. CSF analysis
29. A 40 year old man who recently traveled to Sudan 5 weeks ago presents with dark
urine, rigors and a fever. On examination, a tender hepatomegaly was noted. What is
A. Malaria
704
B. Brucellosis
C. Leptospirosis
D. Schistosomiasis
E. Ebola
30. A 46 year old man is being investigated for indigestion. A jejunal biopsy shows
deposition of macrophages in the lamina propria-containing granules which stain
positive for Periodic Acid-Schiff (PAS). What is the SINGLE most likely diagnosis?
A. Bacterial overgrowth
B. Coeliac disease
C. Tropical sprue
D. Whipple’s disease
E. Small bowel lymphoma
31. A 33 year old man presents with an erythematous patch on his thigh, which has been
enlarging in the last few days. He went for a camping trip a week ago. He has no
allergies to any known medication. He is otherwise asymptomatic. What is the SINGLE
y
A. Erythromycin
B. Doxycycline
op
C
C. Penicillin
D. Amoxicillin
E. Ceftriaxone
n
io
32. A 36 year old Jewish man presents with multiple purple papular lesions on his face and
upper trunk measuring 1-2 cm across. It has been slowly growing over the last couple of
t
years. It is not painful or itchy. What is the SINGLE most likely diagnosis?
ua
B. Hairy leukoplakia
al
C. Cryptosporidium
D. Cytomegalovirus infection
Ev
E. Cryptococcal infection
33. A 5 year old boy has a sudden onset of fever and bilateral swelling at the angles of the
jaw. He has ear pain when he chews. The GP saw him yesterday for bilateral parotid
pain and prescribed him paracetamol. He currently has a temperature of 38.8°C. What
is the SINGLE most appropriate next step?
A. Corticosteroids
B. Antibiotic
C. Biopsy
D. Immediate surgery
E. Reassurance
34. A 20 year old lady is suffering from fever and loss of appetite. She has been diagnosed
with toxoplasmosis. What is the SINGLE most appropriate treatment?
A. Pyrimethamine
705
B. Pyrimethamine + sulfadiazine
C. Clindamycin
D. Spiramycin
E. Trimethoprim + sulfamethoxazole
stepped on a nail in a field. He said he had the full course of tetanus vaccine when he
was in school and again at 18 years old. What is the SINGLE most appropriate

E. Antibiotic
36. A 36 year old homosexual man has multiple purple nodular lesions on his face and
upper trunk measuring 1-2 cm across. It is not painful or itchy. What is the SINGLE most
y
likely diagnosis?
op
C
C. Basal cell carcinoma
D. Melanoma
n
io
37. A 30 year old man is seen in the emergency department with vomiting, muscle pain,
rash at his axilla and sensitivity to light. He has a temperature of 38.9°C. The medical
t
staff are suspecting he is suffering from meningitis. Which is the SINGLE most
ua
appropriate empirical antibiotic to be started immediately?
A. IM Benzylpenicillin
al
B. IV Cefotaxime
C. IV Gentamicin
Ev
D. IV Aciclovir
E. IV Amoxicillin
38. A 55 year old man has auricular pain and tinnitus on his left ear. On inspection, a
painful vesicular rash around the auditory canal is noted. He also has decreased hearing
on the left ear. What is the SINGLE most likely diagnosis?
B. Cholesteatoma
C. Ramsay Hunt syndrome
D. Herpes zoster ophthalmicus
39. A 20 year old man with a known diagnosis of otitis media presents with a severe
headache, and sensitivity to light. He is shivering, sweating and has a temperature of
38.9°C. What is the SINGLE most likely complication?
706
A. Giant cell arteritis
B. Meningitis
C. Myringitis
D. Trigeminal neuralgia
E. Labyrinthitis
40. A 62 year old IV drug abuser is brought into the emergency department with complaint
of fever, shivering, malaise, shortness of breath and productive cough. Around 8 days
ago he developed symptoms consistent with a flu-like illness. Initially there was an
improvement in his condition but deteriorated over the past three days. He now has a
temperature of 39°C, a pulse of 110 beats/minute, a blood pressure of 100/70 mmHg
and a respiratory rate of 22 breaths/minute. A Chest X-ray shows bilateral cavitations.
What is the SINGLE most likely causative organism?
A. Mycoplasma pneumoniae
B. Staphylococcus aureus
C. Chlamydia pneumoniae
D. Escherichia coli
y
E. Klebsiella pneumoniae
41.
op
A 30 year old man presents to the emergency department with difficulty breathing. He
has returned from India 5 days ago. On examination, his throat reveals grey membranes
C
on the tonsils and uvula. He has a fever, and enlarged anterior cervical lymph nodes.
n
A. Diphtheria
io
B. Infectious mononucleosis
C. Acute follicular tonsillitis
t
D. Scarlet fever
ua
E. Agranulocytosis
42. A 33 year old male patient presents with a white patches in the mouth that can be
al
wiped off and is easily removed leaving behind a red base which is painless. He has
cracks at the corners of his mouth. What is the SINGLE most likely diagnosis?
Ev
C. Cytomegalovirus infection
D. Oral thrush
E. Leukoplakia
43. A 33 year old man with Hodgkin's lymphoma has chemotherapy 9 days ago. He
develops a temperature of 39.0°C and signs of a chest infection. Blood count shows:
Haemoglobin 113 g/L

707
A. Co-amoxiclav
B. Piperacillin+tazobactam
C. Erythromycin
D. Piperacillin+Co-amoxiclav
E. Clarithromycin
44. A 67 year old man who is currently on chemotherapy treatment for a malignancy
suddenly develops febrile neutropenia. He has been commenced on tazocin and
gentamicin. He has recently commenced meropenem but his fever still remains at 39°C
on the 3rd day. Two blood tests and urine cultures have come back negative.
Investigation done this morning show:
Haemoglobin 104 g/L

What is the SINGLE best management?
y
A. Continue IV antibiotics and add oral antifungals
op
B. Continue IV antibiotics and add IV antifungals
C. Stop antibiotics
D. Continue present antibiotics
C
E. Repeat blood culture
45. A 69 year old woman lives in a nursing home following a stroke. She recently developed
n
a reddish scaly rash on her trunk. She has many scratch marks on her limbs and trunk
io
with linear burrows seen on her hands and feet. What is the SINGLE most appropriate
treatment?
t
ua
A. Aqueous cream
B. Chlorpheniramine
C. Coal tar
al
D. Hydrocortisone ointment
E. Permethrin
Ev
46. An 82 year old man was brought into the emergency department with a low level of
consciousness. His wife mentions that he had a severe headache for the last 20 hours
and was very sensitive to light. He has a temperature of 39.0°C, a pulse of 118
breaths/minute. He is conscious but confused. Kernig’s sign was positive. High flow
oxygen and IV fluids was immediately started. What is the SINGLE most appropriate
A. Intravenous antibiotic
B. Lumbar puncture
C. Computed tomography brain scan
D. Head magnetic resonance imaging
E. Blood culture
708
47. A 33 year old woman has numerous painful ulcers on her vulva. She is sexually active
and has multiple partners in the past. What is the SINGLE most likely cause of her
ulcers?
A. Chlamydia
B. Trichomonas vaginalis
C. Gardenella
D. Herpes simplex virus
E. Epstein barr virus
48. A 15 year old boy had a patchy rash over his body following antibiotic treatment for
sore throat. On examination, he has cervical lymph node enlargement and mild
splenomegaly which is tender on palpation. What is the SINGLE most likely antibiotic
that would have caused the rash?
A. Ampicillin
B. Erythromycin
C. Cefuroxime
y
D. Metronidazole
op
E. Tetracycline
49. A 38 year old female, 32 weeks pregnant presents with thick white marks on the inside
C
of her mouth for 3 weeks. Her mouth including her tongue appears inflamed on
examination. She smokes 20 cigarettes a day despite advice to quit. What is the SINGLE
n
io
A. Lichen planus
B. Aphthous ulcer
t
ua
D. Candidiasis
E. Leukoplakia
al
50. A 38 year old woman recently returned from Bangkok. She did not have any malaria
prophylaxis before leaving the UK on her trip. She presents with a high fever,
Ev
generalised macular blanching rash, tender and swollen cervical lymphadenopathy and
generalised myalgia. What is the SINGLE most likely diagnosis?
A. Cerebral Malaria
B. Dengue Fever
C. Typhoid
D. Diphtheria
E. Lymphoma
51. A 5 year old child started having a fever two days ago associated with neck stiffness,
chills, impaired consciousness and vomiting. He has a history of travel with his parents
to Ghana and returned 6 weeks ago. Before he left to Ghana, he was started on malaria
prophylaxis. A full blood count shows that the young child is anaemic. What is the
A. Cerebral abscess
B. Cerebral malaria
709
C. Meningococcal meningitis
D. Subarachnoid haemorrhage
E. Cerebral tumour
52. A 15 year old girl presents to A&E with headache, vomiting, neck stiffness and
photophobia. No rash was seen on examination. Her temperature is 38.3°C, heart rate
is 90 bpm and respiratory rate is 18/min. What is the SINGLE most appropriate
investigation?
A. Blood culture
B. Blood glucose
C. Lumbar puncture
D. Chest X-ray
E. CT head
53. A 32 year old man has recently been to Thailand and returned with cervical
lymphadenopathy, malaise and a mild fever. What is the SINGLE most likely infectious
agent causing his symptoms?
y
op
A. Human immunodeficiency virus (HIV)
B. Treponema pallidum
C. Salmonella typhi
C
D. Measles
E. Epstein-Barr virus
n
54. A 33 year old African woman presents with episodes of fever with rigors and chills for
io
the past year. Blood film shows ring form plasmodium with schuffner's dots in red
blood cells. What is the SINGLE most appropriate drug to eradicate this infection?
t
ua
A. Mefloquine
B. Doxycycline
C. Proguanil
al
D. Quinine
E. Primaquine
Ev
55. A 13 year old girl complains of a 3 day history of hoarseness of voice associated with
dry cough. She presents with a fever and malaise. On direct laryngoscopy, her vocal
cords are seen to be grossly oedematous. What is the SINGLE next most appropriate
investigation?
A. None required
B. Sputum for acid-fast bacilli
C. Blood culture
D. Cervical spine X-ray
E. Bronchoscopy
56. A 3 year old boy presents with a 2 day history of being unwell. He has a 2 hour old rash
made up of urticarial and purpuric spots. His conscious level is decreased. He has a
blood pressure of 80/50 mmhg, a respiratory rate of 30 breaths/minute, oxygen
saturations of 94%, a temperature of 39°C, and a capillary refill time of 3 second. Urine
710
dipstick was found to be negative. What is the SINGLE investigations most likely to lead
to diagnosis?
A. Blood culture and sensitivity

B. Erythrocyte sedimentation rate (ESR)
C. Chest X-ray
D. Urine for culture and sensitivity
E. Cerebrospinal fluid analysis
57. A 35 week pregnant woman presents to the Antenatal Day Unit with productive cough
and rigors. This is her first pregnancy and there have been no issues to date. She
returned from Uganda two weeks ago from a family visit. She is suspected to have
respiratory tuberculosis. What is the SINGLE most likely medication that should NOT be
used in pregnancy?
A. Ethambutol
B. Pyrazinamide
C. Streptomycin
y
D. Isoniazid
op
E. Rifampicin
58. A 32 year old breast feeding mother has a painful, swollen, hard lump in her right
C
breast which developed 2 weeks after having a normal vaginal delivery. She has a
temperature of 38.1°C. A breast abscess is suspected. What is the SINGLE most likely
organism?
n
io
A. Staphylococcus aureus
B. Staphylococcus albus
t
C. Streptococcus agalactiae
ua
D. Streptococcus pyogenes
E. Staphylococcus epidermidis
al
59. A 38 year old woman presents with dysphagia and a lump on her neck. On examination,
there is a 5 cm by 4 cm erythematous neck swelling lateral to the thyroid cartilage. She
Ev
has a temperature of 38.9°C, a respiratory rate of 28 breaths/minute and a heart rate of

110 beats/minute. What is the SINGLE most appropriate action?
A. Thyroid function test

B. Paracetamol, Ibuprofen and broad spectrum antibiotics orally
C. X-ray of neck
D. Endoscopic diverticulotomy
E. Intravenous antibiotics, incision and drainage
60. A 45 year old man has developed an annular rash with a scaly edge on his thigh. The
rash has been spreading over the last 3 weeks. He also complains of general aches and
pains. What is the SINGLE most appropriate investigation?
A. Antinuclear antibodies
B. Biopsy of lesion
C. Skin scrap for mycology
D. Antibodies to Borrelia recurrentis
711
E. Antibodies to Borrelia burgdorferi
61. A 33 year old known drug abuser has swelling and erythema in his arm where he
injects. He has a fever and appears sick. He is asking for morphine as the pain is severe
and seems to be disproportionate to the clinical appearance. Bullae is seen on the skin
of his arm. He was started on intravenous flucloxacillin but the infection has not
responded to antibiotics and seems to be worsening. What is the SINGLE most likely
diagnosis?
A. Cellulitis
B. Erysipelas
D. Penicillin allergic reaction
E. Necrotising fasciitis
62. A 34 year old man who has a new diagnosis of haematological malignancy presents in
the emergency department with bruises all over his abdomen. He has a temperature of
38.6°C. His respiratory rate is 25 breaths/minute, heart rate is 102 beats/minute and
y
blood pressure is 80/50 mmHg. His blood results show:

op
C
He is commenced on meropenem. What is the SINGLE most likely diagnosis?
n
A. Septic shock
io
B. Neutropenic sepsis
C. Hepatitis
t
D. Cytomegalovirus
ua
E. HIV
63. A 7 year old child is being investigations for active respiratory tuberculosis. He has dry
al
cough and is unable to produce sputum. His parents have been informed about the
possibility of a bronchoalveolar lavage which can be useful in diagnosis tuberculosis
Ev
however the parents decline this invasive test. What is the SINGLE next method to
acquire a sample to diagnose tuberculosis?
A. Venipuncture
B. Throat swab
C. Gastric lavage
D. Liver biopsy
E. Lumbar puncture
64. A 30 year old homeless lady has cough, sputum and a fever. She complains of night
sweats and has lost 13 kg in the past 6 months. A chest X-ray was performed which
showed apical involvement with infiltrates and cavitation in the upper lobe of the right
lung. What is the next SINGLE most appropriate test to perform?
A. Acid-Fast Bacilli smear

B. Mantoux test
C. Interferon Gamma test
712
D. Bronchoscopy
E. Computed tomography
65. A 23 year old homeless smoker has an ongoing productive cough. She takes
recreational drugs and looks malnourished. She has lost 15 kg in the past year. There
are several nontender swellings on both sides of her neck. On examination, she has
crackles in her right upper lobe but is otherwise well and stable. A chest X-ray reveals
upper lobe infiltrates with cavitation on the right lung. What is the SINGLE most likely
diagnosis?
A. Aspergillosis
B. Klebsiella pneumoniae
C. Pneumococcal pneumonia
D. Bronchogenic Carcinoma
E. Tuberculosis
66. A 6 week infant has been diagnosed as HIV positive. What is the SINGLE most
appropriate immunization plan for the infant?
y
op
A. Avoid MMR vaccinations and tetanus vaccinations
B. Administer all vaccines as scheduled except live attenuated vaccines
C. Administer only BCG vaccine
C
D. Administer all vaccines as scheduled except BCG vaccine
E. Avoid influenza vaccinations
n
67. A 12 month old child who is HIV positive is due for his measles, mumps, and rubella
io
(MMR) vaccine. His CD4 count is more than 200 cells/mL. What is the SINGLE most
appropriate action?
t
ua
A. Defer immunization for 2 weeks

B. Advise not to have MMR vaccine
C. Administer half dose of MMR vaccine
al
D. Administer paracetamol with MMR vaccine

E. Proceed with administration of MMR vaccination
Ev
68. A 70 year old diabetic woman has a red swelling over her right foot. Her foot is
erythematous, glossy, warm and tender to touch. She is a heavy smoker. What SINGLE
complication is this woman likely to develop?
A. Osteomyelitis
B. Septicaemia
C. Ulcers
D. Gangrene
69. A 58 year old woman attends clinic for advice as her grandson who lives with her has
developed chicken pox with the rash appearing 2 days ago. She is currently undergoing
chemotherapy for breast cancer and has been using long term corticosteroids to
manage her inflammatory bowel disease. She has never had chicken pox before. On
examination, there is no evidence of any rash. What is the SINGLE most appropriate
management?
713
A. Intravenous aciclovir
B. Oral aciclovir
C. Immunisation against varicella zoster
D. Varicella zoster immunoglobulin
E. Reassurance
70. A 5 year old boy was brought to his GP with a temperature of 38.8°C and numerous
pruritic vesicles on his chest and back. What is the SINGLE most appropriate
management?
B. Oral aciclovir
C. Oral antibiotics
D. Topical steroids
E. Reassurance
71. A 24 year old male has a history of urethral discharge and dysuria. He is sexually active
y
with other men and has had four sexual partners in the last year. He does not practice
op
safe sex. Urethral swabs were taken which results came back positive for chlamydia.
What is the SINGLE most likely complication if left untreated?
C
A. Orchitis
B. Balanitis
C. Epididymo-orchitis
n
D. Acute abdomen
io
E. Erectile dysfunction
t
72. A 30 year old man from Australia returned from a business trip to Indonesia 6 days ago
ua
presenting with complaints of fever, headache, vomiting, joint and muscle ache. His
headache is felt behind the eyes and has been present for the past 2 days. What is the
al
A. Malaria
Ev
B. Chicken pox
C. Diphtheria
D. Typhoid fever
E. Dengue
73. A 20 week pregnant lady presents with intermittent fever, coughs, headaches, myalgia,
gastric upset and mild confusion. She arrived from Ghana 12 days ago. She travelled
there to visit her family. Before she left, she was prescribed chloroquine and proguanil
and she took it as prescribed starting 1 week before entering Ghana. She is still taking
chloroquine and proguanil as her doctor had asked her to continue it for 4 weeks after
arriving in the United Kingdom. On examination, she has a yellowish tinge on her skin.
A. Malaria
B. Hepatitis
C. Dengue
D. Influenza
714
E. Side effects of medication
74. A 7 year old boy presented 10 hours after having a foot injury while playing football in
the garden. A metal spike had gone through his shoes and pierced the bottom of his
foot. His immunisations are up to date. What is the SINGLE most appropriate
management?
A. Administer antibiotics and immunoglobulins

B. Administer antibiotics, immunoglobulins and vaccine
C. Administer antibiotics and vaccine
D. Administer immunoglobulins and vaccine
E. Administer antibiotics only
75. A 21 year old man has generalized skin lesions. The skin lesions consist of macular,
papular and vesicles and concentrated more on his back and chest. Pinkish fluid is seen
secreted from a few of the lesions. He has a temperature of 39.1°C. What is the SINGLE
most appropriate medication to prescribe?
y
A. Topical antibiotics
op
B. Topical steroids
C. Oral antibiotics
D. Oral steroids
C
E. Topical steroid and antibiotic gel
76. A 33 year old man has complains of dysuria and three tender penile ulcers. He is
n
sexually active and does not use any protection. What is the SINGLE most likely
io
diagnosis?
t
A. Chlamydia infection
ua
B. Gonorrhea infection
C. Primary syphilis
D. Trichomoniasis
al
E. Herpes infection
Ev
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Infectious Diseases Answers
1. A 3 year old child was treated for bacterial meningitis and has recovered from it. She is
now afebrile. What is the SINGLE most appropriate investigation to perform?
A. CT scan
B. EEG
C. Blood culture
D. Repeat lumbar puncture
E. Hearing test
One of the delayed complications of meningitis is decreased hearing, or deafness.

Hearing loss may be partial or total. People who have had meningitis will usually have a
hearing test after a few weeks to check for any problems
2. A 7 year old school boy has been diagnosed with meningococcal meningitis. What is the
SINGLE most appropriate prophylactic management?
y
A. Prophylactic rifampicin for the family
op
B. Prophylactic IV cefotaxime for family
C. Meningococcal vaccine for the family
D. Prophylactic benzylpenicillin for family
E. No prophylaxis needed
C
Meningococcal Prophylaxis
n
Prevention of secondary case of meningococcal meningitis is with rifampicin or
io
ciprofloxacin. It is usually given to all intimate, household or daycare contacts who have
been exposed to the patient within 10 days of onset.
t
ua
3. A 35 year old woman has numerous painful blisters and sores on her vulva. She also
complains of a flu-like illness with mild fever. What is the SINGLE most appropriate
treatment?
al
A. Doxycycline
Ev
B. Gentamicin
C. Penicillin
D. Aciclovir
E. Interferon
The probable diagnosis here is genital herpes. This should be treated with aciclovir.
Genital Herpes
• may be asymptomatic or may remain dormant for months or even years. When
symptoms occur soon after a person is infected, they tend to be severe. They
may start as multiple small blisters that eventually break open and produce
raw, painful sores that scab and heal over within a few weeks. The blisters and
sores may be accompanied by flu-like symptoms with fever and swollen lymph
nodes.
• Genital herpes can be a chronic, lifelong infection. Majority of cases are caused
by HSV-2 (HSV-1 is taking over).
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Signs: Flu-like prodrome, then grouped vesicles/papules develop around genitals. These
burst, and form shallow ulcers.
Management:
Oral aciclovir. Some patients with frequent exacerbations may benefit from longer term
acyclovir
4. A 36 year old lady with Hodgkin’s lymphoma has chemotherapy 8 days ago. She
presents with a temperature of 39.5°C and left sided abdominal pain. Her pulse rate is
96 beats/minute. Full blood count was sent and bloods were taken for culture. What is
A. Wait for results of culture and sensitivity to confirm antibiotic choice

B. Wait for results of full blood count to determine further management
C. Start oral antibiotics immediately
D. Start broad spectrum IV antibiotics immediately
E. Start IV fluids only
y
There are clear signs of infection with risk that the patient could be having neutropenic
op
sepsis thus broad spectrum IV antibiotic should be started empirically while waiting for
blood reports. C
There are 2 main reasons neutropenia is seen in lymphoma:
1. Lymphoma in the bone marrow

n
• If lymphoma cells are in the bone marrow, they take up space that is normally
io
used to produce healthy blood cells which can lead to neutropenia.

t
2. Side effects of treatment

ua
• Although the aim of treatment is to kill the lymphoma cells, a side effect of
many types of chemotherapy, and some radiotherapy treatments (eg
radiotherapy to the pelvis), is that some healthy cells are also destroyed. This
al
may include blood cells that are developing in the bone marrow.
• Depending on the strength of your chemotherapy regimen, neutropenia is most
Ev
commonly seen 10 to14 days after chemotherapy
Neutropenic sepsis is a potentially fatal complication of anticancer treatment

(particularly chemotherapy).
Febrile neutropenia is defined as:

• An oral temperature ≥38.5°C or two consecutive readings of ≥38.0°C for two
hours and
• An absolute neutrophil count ≤0.5 x 109/L
Febrile neutropenia should also be suspected in:

• Recipients of chemotherapy within the last 4 weeks
• Recipients of bone marrow transplant within the last year who are febrile
• Treat these patients, pending confirmation of neutrophil count, to avoid any
delays in antibiotic administration.
General Management for Neutropenic Sepsis
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• Antibiotics must be started immediately (do not wait for the WBC)
• NICE recommend starting empirical antibiotic therapy with piperacillin with
tazobactam (Tazocin) immediately
• If patient is still febrile and unwell after 48 hours → an alternative antibiotic
such as meropenem is often prescribed +/- vancomycin
• If patient is not responding after 4-6 days → order investigations for fungal
infections, rather than just starting antifungal therapy blindly
stepped on a nail in a field. The wound is deep. He does not remember if he had
tetanus vaccines when he he was a child. What is the SINGLE most appropriate

E. Antibiotic
y
op
If uncertain history of previous vaccination and high risk wound (like in this case): Give
vaccine and tetanus immunoglobulin (TIG) C
Tetanus vaccine is currently given in the UK as part of the routine immunisation
schedule at:
n
• 2 months
• 3 months
io
• 4 months
• 3-5 years
t
ua
• 13-18 years
If high-risk wound → Give intramuscular human tetanus immunoglobulin irrespective

al
of whether 5 doses of tetanus vaccine have previously been given

Ev
If incomplete or unknown vaccination → Give complete course of tetanus vaccine
What is considered a high risk wound?

• Wounds contaminated with soil
• Compound fractures
• Wounds containing foreign bodies
• Wounds or burns in people with systemic sepsis
6. A 68 year old woman has a sudden onset of pain and loss of hearing in her left ear and
unsteadiness when walking. There are small lesions visible on her palate and left
external auditory meatus. What is the SINGLE most likely diagnosis?
B. Cholesteatoma
D. Oropharyngeal malignancy
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Ramsay Hunt syndrome
Ramsay Hunt syndrome (herpes zoster oticus) is caused by the reactivation of the
varicella zoster virus in the geniculate ganglion of the seventh cranial nerve.
Features
• Auricular pain is often the first feature
• Facial nerve palsy (ipsilateral facial palsy, loss of taste)
• Painful vesicular rash around the ear on the auditory canal
• Vertigo and tinnitus
• Ipsilateral hearing loss
Management
• Oral acyclovir and corticosteroids are usually given
• For herpetic neuralgia, give amitriptyline for the pain
7. A 34 year old man from Zimbabwe is admitted with abdominal pain to the emergency
department. An abdominal X-ray reveals bladder calcification and evidence of
y
obstructive uropathy. What is the SINGLE most likely causative organism?
op
A. Schistosoma mansoni
B. Sarcoidosis
C. Leishmaniasis
C
D. Tuberculosis
E. Schistosoma haematobium
n
Bladder involvement is caused by Schistosoma haematobium while Schistosoma

io
mansoni is mainly responsible for intestinal forms of disease.

t
Urinary schistosomiasis (bilharzia)

ua
This is caused by the parasitic trematode (or flatworm) called Schistosoma

al
haematobium. It occurs in Africa (Egypt) and the Middle East.
An X-ray may show a calcified, contracted bladder and evidence of obstructive

Ev
uropathy. An ultrasound in established disease may show hydronephrosis and a

thickened bladder wall.
Complications
The two most important complications needed to know for the PLAB exam is
• Squamous cell carcinoma of the bladder → there can be a lag period of around
20 years between infection and the development of malignancy
• Bladder calcification, and ulceration
8. A 73 year old woman living in a nursing home, presents with rashes on her finger webs
and also at her axillary folds. She complaints of itching which is more severe at night.
A. 0.5% permethrin
B. Doxycycline
C. 5% permethrin
D. Aciclovir
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E. Malathion 0.5%
In PLAB, when you see an elderly living in a nursing home with rashes, think of scabies
Permethrin 5% is probably the only treatment that would be asked in PLAB for scabies
Scabies
Scabies is a parasitic skin infection characterized by superficial burrows, intense

pruritus, and secondary infections
Aetiology
Sarcoptes scabiei. Transmitted by skin-to-skin contact.
Clinical Findings
• Pruritus, burrows, papules, commonly found on flexor surfaces of wrists, finger
y
webs, elbows, axillary folds, areola of the breast in women, and genitals of the
op
males. Scabies digs into the skin at the skin folds.
• Patients who are immunocompromised or debilitated may develop a severe
form of scabies called Norwegian scabies (crusted scabies). These patients
C
present with diffuse cutaneous involvement with crusting and malodorous
discharge.
n
Treatment
io
• Scabies treatment is with permethrin 5% which is first-line

t
• (malathion 0.5% is second-line)

ua
• Note: all household and close physical contacts should be treated at the same
time, even if asymptomatic
al
9. A 78 year old nursing home resident has intensely itchy rash. White linear lesions are
Ev
seen on the wrists and elbows, and red papules are present on his penis. What is the
A. Topical permethrin
B. Referral to GUM clinic
C. Topical betnovate
D. Topical ketoconazole
E. Topical selenium sulfide hyoscine
Permethrin 5% is probably the only treatment that would be asked in PLAB for scabies
Scabies

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Aetiology
Clinical Findings

discharge.
Treatment
y
op
time, even if asymptomatic C
10. A 33 year old lady who works at a nursing home presents with itching. On examination,
linear tracks on the wrist are seen. She says that 2 days ago she had come in contact
n
with a nursing home resident with similar symptoms. What is the SINGLE most likely
mechanism of itching?
io
A. Infection
t
B. Destruction of keratinocytes
ua
C. Allergic reaction
D. Intolerance
E. Decreased histamine
al
In scabies, pruritus develops as an allergic reaction to infection, around 4-6 weeks after
Ev
infestation.
Most of the symptoms of scabies are due to your immune system's response to the
mites, or to their saliva, their eggs or their poo (faeces). In other words, the rash and
the itching are mostly caused by your body's allergic-like reaction to the mites, rather
than the mites themselves.
Scabies

Aetiology
Clinical Findings
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discharge.
Treatment

11. A 14 year old boy has pain and swelling at the angles of the jaw bilaterally. He has a
y
temperature of 38.4°C. He has been complaining of dry mouth and sore ears and he
finds it difficult to talk. On examination, his scrotum is also swollen and oedematous
op
and the testes are impalpable. What is the SINGLE most likely diagnosis?
C
B. Epididymo-orchitis
n
D. Mumps
E. Measles
io
Mumps
t
ua
• Mumps is an acute, generalised infection caused by a paramyxovirus, usually in

children and young adults
•
al
It can infect any organ but usually affects the salivary glands
• The virus is highly infectious with transmission by droplets spread in saliva via
Ev
close personal contact

• Infected persons excrete the virus for several days before symptoms appear
and for several days afterwards
Presentation
• Mumps can be asymptomatic
• Nonspecific symptoms lasting a few days, such as fever, headache, malaise,
myalgia and anorexia, can precede parotitis
• Parotitis is usually bilateral although it can be unilateral
• Typically, there is pain at or near the angle of the jaw
• Fever may be as high as 39.5°C without rigors in small children
• Swelling causes distortion of the face and neck with skin over the gland hot and
flushed but there is no rash
• With severe swelling, the mouth cannot be opened and is dry because the
salivary ducts are blocked.
• Discomfort lasts for three or four days but may be prolonged when one side
clears and the other side swells.
722
• Usually just the parotid glands are involved but, rarely, the submaxillary and
sublingual salivary glands are affected
Orchitis
Orchitis may occur four or five days after the start of parotitis but it often appears
without it. This can sometimes lead to the diagnosis being missed. Orchitis presents
with chills, sweats, headache and backache with swinging temperature and severe local
testicular pain and tenderness. The scrotum is swollen and oedematous so that the
testes are impalpable.
Orchitis is usually unilateral but may be bilateral.
12. A 16 year old girl has a sore throat. She feels tired and weak. Oropharyngeal
examination shows tonsillar enlargement which is exudative. Her GP prescribed her
amoxicillin after which she developed a pruritic rash. What is the SINGLE most likely
diagnosis?
B. Kawasaki disease
y
C. Lymphoma
op
D. Cytomegalovirus
E. Group A streptococcal pharyngitis C
A maculopapular, pruritic rash develops in around 99% of patients who take
ampicillin/amoxicillin whilst they have infectious mononucleosis.
n
Infectious Mononucleosis
io
Infectious mononucleosis (glandular fever) is caused by the Epstein-Barr virus (also

t
known as human herpesvirus 4, HHV-4). It is most common in adolescents and young

ua
adults.
Features
al
• Sore throat; tonsillar enlargement is common, classically exudative and may be

massive
Ev
• Palatal petechiae
• Lymphadenopathy, especially neck glands
• Pyrexia
• Malaise
• Splenomegaly - may rarely predispose to splenic rupture
• A maculopapular, pruritic rash develops in around 99% of patients who take
ampicillin/amoxicillin whilst they have infectious mononucleosis. Thus, they
should not be given in any patient who might have infectious mononucleosis.
Diagnosis
• heterophil antibody test (Monospot test) (Paul Bunnell)
Other investigations:
• FBC
• raised white cell count with lymphocytosis and a relative atypical lymphocyte
count greater than 20%
• ESR is elevated
723
Management is supportive
Simple analgesia for any aches or pains
13. A 33 year old man comes from India with cough, fever and enlarged cervical lymph
nodes. Histology reveals caseating granulomas found in the lymph nodes. What is the
A. Lymphoma
C. Thyroid carcinoma
D. Goiter
E. Thyroid cyst
Tuberculous lymphadenitis (or tuberculous adenitis) is a chronic specific granulomatous

inflammation of the lymph node with caseation necrosis, caused by infection with
Mycobacterium tuberculosis or Mycobacterium bovis.
y
Tuberculosis is responsible for up to 43 percent of peripheral lymphadenopathy in the
op
developing world. In rural India, the prevalence of tuberculous lymphadenitis is
significantly higher. C
14. A 24 year old man develops itching worse at night and following a bath. Examination
reveals a greyish white linear rash that can be seen on the flexor surface of the wrist
and axillary folds. What is the SINGLE most likely diagnosis?
n
io
A. Scabies
B. Polycythaemia
t
C. Urticaria vasculitis
ua
D. Atopic eczema
E. Lichen planus
al
Do not get fooled by the itch that is worse at night following a bath. Although we see
that commonly in polycythaemia, the greyish white linear rash on the wrist points
Ev
towards scabies.
Scabies

Aetiology
Clinical Findings

724
discharge.
Treatment

15. A 4 year old child is brought by his parents with a clean wound. He has never been
immunised as his parents are worried about the side effects of the immunisations.
There are no contraindications to immunisation. What is the SINGLE most appropriate
management?
A. Full course of diphtheria, pertussis, tetanus (DTP) vaccine
y
B. Rabies vaccination
op
C. 1 single injection diphtheria, pertussis, tetanus (DTP) vaccine
D. Intramuscular tetanus immunoglobulins
E. Antibiotic
C
n
schedule at:
• 2 months
io
• 3 months
• 4 months
t
• 3-5 years
ua
• 13-18 years
al

Ev

16. A 22 year old lady comes to the hospital with complaints of fever, vertigo and pain in
her right ear. On physical examination, there are vesicles visible in her left ear. What is
A. Meniere's disease
B. Ramsay Hunt syndrome
C. Chicken pox
D. Acoustic neuroma
E. Cellulitis
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Features
• painful vesicular rash on the auditory canal

• ipsilateral facial palsy
• other features include loss of taste, vertigo, tinnitus
Management
• oral acyclovir and corticosteroids
17. A 28 year old man presents with a widespread maculopapular rash over his soles and
palms. He also has mouth ulcers. He had a penile ulcer which healed six weeks ago.
What is the SINGLE most likely organism responsible?
y
A. Mycoplasma genitalium
op
B. Treponema pertenue
C. Treponema pallidum
D. Lymphogranuloma venereum
C
E. Herpes simplex virus type 2
n
Syphilis
Syphilis is a sexually transmitted infection caused by the spirochaete Treponema
io
pallidum. Acquired syphilis is characterised by primary, secondary and tertiary stages.

The incubation period is around 3 weeks.
t
ua
Acquired syphilis
Primary features
• Chancre - painless ulcer at the site of sexual contact
al
• Local non-tender lymphadenopathy

• In women, they are found on the vulva, labia and, much less frequently, on the
Ev
cervix.
Secondary features
• Secondary syphilis often appears 6 weeks after the beginning of the primary
lesion but may overlap or not appear for several months.
• Systemic symptoms: fevers, lymphadenopathy, headaches, malaise.
• A generalised polymorphic rash often affects the palms, soles and face
• Papules enlarge into condylomata lata (pink or grey discs) in moist warm areas.
Tertiary features
• Gummas (granulomatous lesions → can occur in any organ but most commonly
affect bone and skin)
• Cardiovascular syphilis → ascending aortic aneurysms, aortic regurgitation
• Neurological syphilis → tabes dorsalis, dementia
18. A 44 year old HIV positive man complains of a two week history of worsening headache,
facial weakness and visual hallucinations. He also reports new onset of eye pain. An
726
MRI head reveals multiple ring shaped contrast enhancing lesions. What is the SINGLE
A. Cytomegalovirus
B. Streptococcus
C. Toxoplasma gondii
D. Herpes Simplex Virus
E. Pneumocystis jirovecii
The symptoms and MRI findings here are highly suggestive of toxoplasmosis, a disease
caused by the protozoan Toxoplasma gondii.
The reason behind the HIV history is that toxoplasmosis can reactivate in those with
severe HIV disease when their CD4 counts are very low ( <50-100/μL).
Principle Manifestations usually include a brain mass lesion, headache, confusion,

seizures, and focal neurologic deficits. Symptoms and signs of increased ICP.
y
CT or MRI scan of the head would show a "ring" (contrast) enhancing lesion with
op
oedema
Toxoplasmosis
C
Toxoplasma gondii is a protozoa which infects the body via the GI tract, lung or broken
skin. It's oocysts release trophozoites which migrate widely around the body including
to the eye, brain and muscle. The usual animal reservoir is the cat, although other
n
animals such as rats carry the disease.
io
Most infections are asymptomatic. Symptomatic patients usually have a self-limiting

t
infection, often having clinical features resembling infectious mononucleosis (fever,

ua
malaise, lymphadenopathy). Other less common manifestations include

meningoencephalitis and myocarditis.
al
Treatment: pyrimethamine plus sulphadiazine

Ev
19. A 49 year old man with known HIV presents with history of cough and shortness of
breath. His CD4 count is measured at 350mm³. A chest X-ray was performed and shows
lobar consolidation. He has a temperature of 38.1°C, a respiratory rate of 30
breaths/minute and a heart rate of 90 beats/minute. What is the SINGLE most likely
causative organism?
A. Mycobacterium avium intracellulare

B. Cytomegalovirus
C. Streptococcus pneumoniae
D. Toxoplasmosis
This is another debatable topic. At first, the impression that is given in the stem points
towards Pneumocystis jiroveci given the history of cough and a HIV-positive patient.
Pneumocystis jiroveci is obviously the most common opportunistic infection in HIV
positive patients. However, one must remember that Pneumocystis jiroveci tends to
affect HIV-positive patients who have a CD4 count below 200 cells/mm³. For this
727
reason, all patients with a CD4 count < 200/mm³ should receive Pneumocystis jiroveci
prophylaxis. While it is true that Pneumocystis jiroveci can also infect a HIV positive
patient with a CD4 count above 200 cells/mm³, it is less likely compared to
Streptococcus pneumoniae.
The chest X-ray findings also point more towards Streptococcus pneumoniae as the
causative organism. Remember that Streptococcus pneumoniae is the most common
causative organism of lobar pneumonia and it accounts for around 80% of cases of
community acquired pneumonia (CAP). Note that, HIV infection is also a risk factor for
Streptococcus pneumoniae infections.
20. A 55 year old immunocompromised patient presents with dysphagia and pain on
swallowing. He has a redness, fissuring and soreness at the angle of his mouth. What is
the SINGLE causative organism?
A. Human herpesvirus 8
C. Cytomegalovirus
y
D. Candida
op
E. Toxoplasma gondii
Angular cheilitis
C
• Redness, fissuring and soreness at the angle of the mouth.
• It can be due either to Candida spp. or to bacterial infection (mainly
Staphylococcus aureus)
n
• Contributing factors are older age, ill-fitting dentures, immunocompromised,
io
vitamin B12 deficiency or iron-deficiency anaemia

t
21. A 17 year old man has acute pain and earache on the right side of his face. He has a
ua
temperature of 39.4°C and has extensive pre-auricular swelling that is tender on

palpation bilaterally. He also complains of headache, malaise, and dry mouth. What is
al
Ev
B. Acute otitis externa

D. Mumps
Mumps

• It can infect any organ but usually affects the salivary glands
Presentation
728
Orchitis
y
op
C
22. A 16 year old girl attends clinic with a sore throat and palatal petechiae. A full blood
count was done which shows:
n
Haemoglobin 109 g/L

io

platelets 88 x 109/L
t
ua
A Paul Bunnell test was shown to be positive. What is the SINGLE most likely diagnosis?
al
A. Glandular fever
B. Idiopathic thrombocytopenic purpura (ITP)
Ev
C. Measles
D. Rubella
E. Thrombotic thrombocytopenic purpura (TTP)
The clincher here is the positive Paul Bunnell test which is only seen in infectious
mononucleosis (Glandular fever). The rest of the symptoms fit perfectly as well. Palatal
petechiae and sore throat can occur with infectious mononucleosis. WBCs are
classically high and the anaemia is secondary to cold agglutinins (IgM).

adults.
Features
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massive
• Lymphadenopathy, especially neck glands.
• Pyrexia
• Malaise
23. A 35 year old lady presents with recurrent extremely painful ulcers on her vulva. Viral
culture and DNA detection using polymerase chain reaction (PCR) of a swab from the
ulcer has come back as negative. What is the SINGLE most appropriate investigations
which will lead to the diagnosis?
A. Anti-HSV antibodies
B. Dark ground microscopy of the ulcer
C. Treponema pallidum antibody test
D. Rapid plasma reagin test
y
E. Venereal Disease Research Laboratory test (VDRL)
op
The probable diagnosis here is Genital Herpes Simplex. Usually Viral culture and
DNA detection using polymerase chain reaction (PCR) of a swab from the base of an
ulcer are used to diagnose genital herpes.
C
Anti-HSV antibodies are only used in certain scenarios. One of them is if there are
n
recurrent/atypical genital ulcers with negative culture or PCR results.
io
Genital Herpes
t
ua
al
nodes.
Ev
Management:
acyclovir
24. A 16 year old girl has had an enlarging mass in the right side of her neck for the past 2
weeks with a sore throat. She feels tired and weak. She has several smaller associated
lymph nodes that are palpable at her axilla. Oropharyngeal examination shows tonsillar
enlargement which is exudative. What is the SINGLE most likely diagnosis?
B. Leukaemia
730
C. Lymphoma
D. Mumps
E. Tuberculosis

adults.
Features

massive
• Lymphadenopathy, especially neck glands.
• Pyrexia
• Malaise
y
25.
op
A 75 year old woman has weakness of the left side of her face and pain deep within the
left ear. The ear pain was paroxysmal at first but after a day it became constant and
C
radiates into the pinna. Now she has hears ringing in her left ear. A mild left hearing
loss was noted. There are blisters on the skin of the ear canal and auricle. What is the
n
io
A. Chronic serous otitis media

B. Herpes zoster oticus
t
C. Herpes simplex infection

ua
D. Viral labyrinthitis
E. Bell’s palsy
al

Ev
Features
Management
26. A 74 year old female presents with headache and neck stiffness to the emergency
department. Following a lumbar puncture, the patient was started on IV ceftriaxone.
CSF culture reports as having listeria monocytogenes. What is the SINGLE most
appropriate treatment?
731
A. Add IV amoxicillin
B. Change to IV ampicillin + gentamicin
C. Add IV ciprofloxacin
D. Add vancomycin
E. Continue IV ceftriaxone as monotherapy
The therapy after identification of Listeria monocytogenes in CSF is ampicillin 2g 4

hourly + gentamicin 5 mg/kg divided into 8-hourly doses
27. An 8 year old boy has red, itchy rash on his abdomen, face, arms and legs that has
turned into fluid-filled blisters. A few days later they crusted over. What is the main
mode of transmission of this condition?
A. Airborne
B. Direct contact
C. Bloodborne
D. Vectorborne
y
E. Waterborne
op
The diagnosis here is chicken pox. It is caused by varicella-zoster virus. The mode of
transmission of varicella zoster virus is mainly person-to-person by airborne respiratory
C
droplets, but also occurs by direct contact with vesicle fluid of chickenpox cases or
contact with the vesicle fluid of patients with herpes zoster.
n
28. A 3 year old girl presents with a history of fever for 2 days. She is drowsy and had a
io
seizure causing twitching of the right side of the body for 4 minutes. Her respiratory
rate is 30 beats/minute, oxygen saturation is 90%, temperature is 38.9°C, and capillary
t
refill time is 2 seconds. A urine dipstick was reported as negative. What is the SINGLE
ua
A. Blood culture
al
B. Blood glucose
C. Chest X-ray
Ev

E. CSF analysis
The fever and drowsiness are nonspecific but given there is no history of a urinary tract
infection, or cough indicating a respiratory infection, we should consider CNS
involvement.
In meningitis, some children will present with mostly nonspecific symptoms or signs.
In meningitis, If the patient has got a rash, then perform blood culture as the diagnosis
is most likely meningococcal septicaemia. The causative organism is Neisseria
meningitides.
If there is no rash then a lumbar puncture would be a better answer, but this can only
be done if there are no signs of raised intracranial pressure.
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Generally, treatment for meningitis should be started before doing any investigations
due to the seriousness of the disease.
29. A 40 year old man who recently traveled to Sudan 5 weeks ago presents with dark
urine, rigors and a fever. On examination, a tender hepatomegaly was noted. What is
A. Malaria
B. Brucellosis
C. Leptospirosis
D. Schistosomiasis
E. Ebola
This is a very interesting question with a huge debate between Malaria and
Schistosomiasis.
Initially, one may pick Schistosomiasis as Schistosomiasis is widely distributed in in

Sudan with more than 5 million people, mostly children, requiring treatment. 5 weeks
y
here fits the timeline of schistosomiasis as symptoms usually takes from four to six
op
weeks from the time of infection. They may feel generally unwell at this point however
in majority of cases blood in the urine only occurs somewhere between 10 to 12 weeks
after the infection. The blood in urine is due to the worms of Schistosoma
C
haematobium migrating to the veins around the bladder and ureters.
Furthermore, one must remember that bladder involvement is caused by Schistosoma

n
haematobium while Schistosoma mansoni is mainly responsible for intestinal forms of
io
disease. Hepatomegaly is not a clinical feature of infection with Schistosoma

haematobium (which causes the bloody urine). It can be seen in infections with
t
Schistosoma mansoni but again these are two different infections. Infections with
ua
Schistosoma mansoni does not cause bloody urine.
In short, a patient suffering from urinary schistosomiasis (caused by Schistosoma

al
haematobium) will develop terminal haematuria, while another patient infected with
Schistosoma mansoni may develop hepatomegaly but ultimately these symptoms are
Ev
caused by different species.
Considering the clinical features, the best answer is Malaria. Blackwater fever is a
complication of malaria infection in which red blood cells burst in the bloodstream
(haemolysis), releasing hemoglobin directly into the blood vessels and into the urine.
This accounts for the dark urine. Malaria is also known to cause hepatomegaly.
30. A 46 year old man is being investigated for indigestion. A jejunal biopsy shows
deposition of macrophages in the lamina propria-containing granules which stain
positive for Periodic Acid-Schiff (PAS). What is the SINGLE most likely diagnosis?
A. Bacterial overgrowth
B. Coeliac disease
C. Tropical sprue
D. Whipple’s disease
E. Small bowel lymphoma
733
A jejunal biopsy shows deposition of macrophages in the lamina propria-containing
granules which stain positive for Periodic Acid-Schiff (PAS) are diagnostic for Whipple’s
disease.
Whipple’s disease
Whipple’s disease is a rare disease featuring GI malabsorption which usually occurs in

middle-aged white males, most commonly in Europe. It is fatal if untreated and is
caused by Tropheryma whippelii, which, combined with defective cell-mediated
immunity, produces a systemic disease.
Features:
• Often starts insidiously with arthralgia (mainly peripheral joints)
• GI symptoms commonly include colicky abdominal pain, weight loss,
steatorrhea/diarrhoea, which leads to malabsorption.
• Systemic symptoms such as chronic cough, fever, sweats, lymphadenopathy
and skin hyperpigmentation also occur
• Cardiac involvement may lead to endocarditis
y
• CNS features include a reversible dementia, ophthalmoplegia, and facial
op
myoclonus
Tests:
C
• Diagnosis requires a high level of clinical suspicion
• Jejunal biopsy shows stunted villi. There is deposition of macrophages in the
n
lamina propria-containing granules which stain positive for Periodic Acid-Schiff
(PAS).
io
31. A 33 year old man presents with an erythematous patch on his thigh, which has been
t
enlarging in the last few days. He went for a camping trip a week ago. He has no
ua
allergies to any known medication. He is otherwise asymptomatic. What is the SINGLE

al
A. Erythromycin
B. Doxycycline
Ev
C. Penicillin
D. Amoxicillin
E. Ceftriaxone
Lyme disease
Lyme disease is caused by the spirochaete Borrelia burgdorferi and is spread by ticks
(Ixodes scapularis tick)
Tick needs at least 24 hours of attachment to transmit the Borrelia burgdorferi

organism.
Symptoms begin 3-30 days after the bite of the tick. Eighty percent of patients develop
the
734
erythema migrans rash at the site of the bite. (An erythematous patch, which may
enlarge in the first few days) Even without treatment, the rash resolves in several
weeks. A flu like illness with fever, chills, and myalgias occurs in half of patients.
Neurologic symptoms develop several weeks later. This is most commonly paralysis of
the seventh cranial nerve (facial paralysis) and may be bilateral. Meningitis, and
encephalitis may develop as well.
Cardiac symptoms develop a minority of people and is most commonly an AV heart

block or Myocarditis
Joint involvement may develop but this is months to years later
Investigation
Serology: antibodies to Borrelia burgdorferi
Management
• Doxycycline if early disease. Amoxicillin is an alternative if doxycycline is
y
contraindicated (e.g. pregnancy)
op
• Ceftriaxone if disseminated disease
32. A 36 year old Jewish man presents with multiple purple papular lesions on his face and
C
upper trunk measuring 1-2 cm across. It has been slowly growing over the last couple of
years. It is not painful or itchy. What is the SINGLE most likely diagnosis?
n
io
B. Hairy leukoplakia
C. Cryptosporidium
t
D. Cytomegalovirus infection
ua
Kaposi's sarcoma
al
Kaposi's sarcoma (KS) is a connective tissue cancer caused by human herpesvirus 8 -

Ev
now called Kaposi's sarcoma-associated herpesvirus (KSHV). The malignant lesion is

characterised by neoplastic cells and abnormally growing blood vessels. KS is different
to other neoplasms by virtue of the fact that lesions may begin in more than one place
at the same time.
Types of Kaposi's sarcoma:

1. Classic: especially elderly Jewish or Mediterranean man. It is rare and
progresses slowly over years.
2. Endemic or African KS: affects young adult men who live near the African
equator and have a normal immune system.
3. KS in immunosuppression: Aggressive course with visceral involvement.
4. AIDS related: May be life-threatening with many skin, gut and lung lesions. It
affects mostly homo- or bisexual men
Presentation
• Skin lesions may be nodular, papular or blotchy; they may be red, purple,
brown or black.
735
• Lesions can also be seen under or on mucous membranes, with similar
characteristics.
• The most common sites include the mouth, nose and throat.
• Usually painless but may become painful if inflamed or swollen.
• Lesions may also involve internal organs - eg, lungs (leading to dyspnoea),
gastrointestinal tract (it can cause fatal bleeding) and lymphatics, resulting in
lymphoedema
33. A 5 year old boy has a sudden onset of fever and bilateral swelling at the angles of the
jaw. He has ear pain when he chews. The GP saw him yesterday for bilateral parotid
pain and prescribed him paracetamol. He currently has a temperature of 38.8°C. What
A. Corticosteroids
B. Antibiotic
C. Biopsy
E. Reassurance
y
op
Remember that there is no specific treatment for mumps but drugs such as
paracetamol and ibuprofen may give symptomatic relief. In this case, reassurance is all
that is needed. Mumps is a self limiting condition.
C
Mumps
n

io

• It can infect any organ but usually affects the salivary glands
t
ua

al

Ev
Presentation
Orchitis
736
34. A 20 year old lady is suffering from fever and loss of appetite. She has been diagnosed
with toxoplasmosis. What is the SINGLE most appropriate treatment?
A. Pyrimethamine
B. Pyrimethamine + sulfadiazine
C. Clindamycin
D. Spiramycin
E. Trimethoprim + sulfamethoxazole
Toxoplasmosis
Toxoplasma gondii is a protozoa which infects the body via the GI tract, lung or broken
y
skin. It's oocysts release trophozoites which migrate widely around the body including
op
to the eye, brain and muscle. The usual animal reservoir is the cat, although other
animals such as rats carry the disease. C
Most infections are asymptomatic. Symptomatic patients usually have a self-limiting
infection, often having clinical features resembling infectious mononucleosis (fever,
malaise, lymphadenopathy). Other less common manifestations include
n
meningoencephalitis and myocarditis.
io
Treatment: pyrimethamine plus sulfadiazine

t
ua
stepped on a nail in a field. He said he had the full course of tetanus vaccine when he
was in school and again at 18 years old. What is the SINGLE most appropriate
al
Ev

E. Antibiotic

schedule at:
• 2 months
• 3 months
• 4 months
• 3-5 years
• 13-18 years

737

36. A 36 year old homosexual man has multiple purple nodular lesions on his face and
upper trunk measuring 1-2 cm across. It is not painful or itchy. What is the SINGLE most
likely diagnosis?
C. Basal cell carcinoma
D. Melanoma
y
Kaposi's sarcoma
op
Kaposi's sarcoma (KS) is a connective tissue cancer caused by human herpesvirus 8 -
now called Kaposi's sarcoma-associated herpesvirus (KSHV). The malignant lesion is
C
characterised by neoplastic cells and abnormally growing blood vessels. KS is different
to other neoplasms by virtue of the fact that lesions may begin in more than one place
n
at the same time.
io
Types of Kaposi's sarcoma:

5. Classic: especially elderly Jewish or Mediterranean man. It is rare and
t
progresses slowly over years.

ua
6. Endemic or African KS: affects young adult men who live near the African
equator and have a normal immune system.
7. KS in immunosuppression: Aggressive course with visceral involvement.
al
8. AIDS related: May be life-threatening with many skin, gut and lung lesions. It
affects mostly homo- or bisexual men
Ev
Presentation
• Skin lesions may be nodular, papular or blotchy; they may be red, purple,
brown or black.
• Lesions can also be seen under or on mucous membranes, with similar
characteristics.
• The most common sites include the mouth, nose and throat.
• Usually painless but may become painful if inflamed or swollen.
• Lesions may also involve internal organs - eg, lungs (leading to dyspnoea),
gastrointestinal tract (it can cause fatal bleeding) and lymphatics, resulting in
lymphoedema
37. A 30 year old man is seen in the emergency department with vomiting, muscle pain,
rash at his axilla and sensitivity to light. He has a temperature of 38.9°C. The medical
staff are suspecting he is suffering from meningitis. Which is the SINGLE most
appropriate empirical antibiotic to be started immediately?
738
A. IM Benzylpenicillin
B. IV Cefotaxime
C. IV Gentamicin
D. IV Aciclovir
E. IV Amoxicillin
In a hospital setting, give intravenous third generation cephalosporin antibiotics

(ceftriaxone or cefotaxime)
If this exact same questions was given but she presented to her GP (or was found
outside the hospital), then benzylpenicillin IM or IV would be the correct answer. If you
suspect meningitis and patient is not yet in the hospital give IM/IV benzylpenicillin and
send patient to the hospital.
If this exact same question was given, but there was a diagnosis of Listeria, then IV
amoxicillin and gentamicin would be the correct answer
If this exact same question was given, but she is penicillin or cephalosporin allergic,
y
then chloramphenicol would be the answer. If the patient has a history of immediate
op
hypersensitivity reaction to penicillin or to cephalosporins the BNF recommends using
chloramphenicol. C
Investigations
n
io
Rash
If patient has got a rash, then perform blood culture as the diagnosis is most likely
t
meningococcal septicaemia. The causative organism is Neisseria meningitides.

ua
be done if there are no signs of raised intracranial pressure
al
Management of contacts
Ev
Prophylaxis (oral ciprofloxacin or rifampicin) needs to be offered to household and

close contacts of patients affected with meningococcal meningitis
Summary
Pre-hospital setting + Suspect meningococcal disease → IM benzylpenicillin
Hospital setting + Suspect meningococcal disease →IV cefotaxime
Meningitis caused by listeria → IV amoxicillin and gentamicin
Hypersensitivity reaction to penicillin or cephalosporins → chloramphenicol
Prophylaxis to close contact (meningococcal meningitis) → oral ciprofloxacin or
rifampicin
38. A 55 year old man has auricular pain and tinnitus on his left ear. On inspection, a
painful vesicular rash around the auditory canal is noted. He also has decreased hearing
on the left ear. What is the SINGLE most likely diagnosis?
B. Cholesteatoma
739
D. Herpes zoster ophthalmicus

Features
Management
y
op
39. A 20 year old man with a known diagnosis of otitis media presents with a severe
headache, and sensitivity to light. He is shivering, sweating and has a temperature of
38.9°C. What is the SINGLE most likely complication?
C
n
B. Meningitis
C. Myringitis
io
D. Trigeminal neuralgia
E. Labyrinthitis
t
ua
One of the very serious but rare complications of otitis media is meningitis. This patient
has clear signs that resemble meningitis.
al
40. A 62 year old IV drug abuser is brought into the emergency department with complaint
Ev
of fever, shivering, malaise, shortness of breath and productive cough. Around 8 days
ago he developed symptoms consistent with a flu-like illness. Initially there was an
improvement in his condition but deteriorated over the past three days. He now has a
temperature of 39°C, a pulse of 110 beats/minute, a blood pressure of 100/70 mmHg
and a respiratory rate of 22 breaths/minute. A Chest X-ray shows bilateral cavitations.
What is the SINGLE most likely causative organism?
A. Mycoplasma pneumoniae
C. Chlamydia pneumoniae
D. Escherichia coli
Staphylococcus aureus may complicate influenza infection and is seen most frequently
in the elderly and in intravenous drug users or patients with underlying disease. Chest
X-ray shows bilateral cavitations. Remember, there is a high incidence of
Staphylococcus aureus pneumonia in patients following influenza so in PLAB if you see
740
a patient with a flu-like illness which symptoms are now of pneumonia, the likely
causative organism is Staphylococcus aureus.
41. A 30 year old man presents to the emergency department with difficulty breathing. He
has returned from India 5 days ago. On examination, his throat reveals grey membranes
on the tonsils and uvula. He has a fever, and enlarged anterior cervical lymph nodes.
A. Diphtheria
B. Infectious mononucleosis
C. Acute follicular tonsillitis
D. Scarlet fever
E. Agranulocytosis
History of travel to India with grey membrane in tonsil and uvula, and a low grade
fever, supports the diagnosis of diphtheria. Note that the pseudomembrane may cause
respiratory obstruction as seen in this question.
y
Diphtheria
op
Risk factors
• In countries where hygiene is poor, cutaneous diphtheria is the predominant
clinical manifestation and source of infection.
C
• Poor living conditions and lack of immunisation, especially where there is not
an immunisation programme, increase risk
n
Presentation
io
• Very early symptoms may be similar to the common cold.

• Often diphtheria presents with a nasal discharge that is initially watery and
t
becomes purulent and blood-stained. The nostril can be sore or crusted with
ua
the pseudomembrane sometimes visible within the nostril.

• Incubation period is usually 2-5 days, but may be up to 10 days.
• In diphtheria of the upper respiratory tract, there is a membranous pharyngitis
al
(often referred to as a pseudomembrane) with fever, enlarged anterior cervical

lymph nodes and oedema of soft tissues giving a 'bull neck' appearance.
Ev
• The pseudomembrane may cause respiratory obstruction.

• Swallowing may be made difficult by unilateral or bilateral paralysis of the
muscles of the palate.
• The exotoxin also affects other parts of the body, including the heart and
nervous systems. It may cause paralysis and cardiac failure.
42. A 33 year old male patient presents with a white patches in the mouth that can be
wiped off and is easily removed leaving behind a red base which is painless. He has
cracks at the corners of his mouth. What is the SINGLE most likely diagnosis?
C. Cytomegalovirus infection
D. Oral thrush
E. Leukoplakia
Pseudomembranous oral candidiasis (oral thrush)
741
• Curd-like white patches in the mouth. The white pseudomembrane can be
easily removed, leaving an underlying red base that is usually painless (in
contrast with leukoplakia, which cannot be rubbed off)
• Cracks can occasionally be seen at the corners of the mouth
Candida Vs Lichen Planus Vs Leukoplakia
Oral Candidiasis Oral Lichen Planus Leukoplakia
y
History of
immunosuppression or
Lace like appearance
op Also history of smoking
C
smoking Raised edges/ bright white
e.g. taking oral/inhaled patches and sharply defined
n
steroids and cannot be rubbed out like
a candida patch.
io
Thick white marks

Treatment
t
Treatment
ua
If using inhaled Stop smoking

steroids, good inhaler
technique, spacer
al
device, rinse mouth

with water after use.
Ev
Stop smoking
Oral fluconazole 50
mg/day for 7 days.
43. A 33 year old man with Hodgkin's lymphoma has chemotherapy 9 days ago. He
develops a temperature of 39.0°C and signs of a chest infection. Blood count shows:
Haemoglobin 113 g/L

742
A. Co-amoxiclav
B. Piperacillin+tazobactam
C. Erythromycin
D. Piperacillin+Co-amoxiclav
E. Clarithromycin
Piperacillin-Tazobactam may be used in the management of neutropenic patients with

fever suspected to be due to a bacterial infection as in patient with post-chemotherapy
neutropenia.
There are 2 main reasons neutropenia is seen in lymphoma:
3. Lymphoma in the bone marrow

• If lymphoma cells are in the bone marrow, they take up space that is normally
used to produce healthy blood cells which can lead to neutropenia.
4. Side effects of treatment
y
• Although the aim of treatment is to kill the lymphoma cells, a side effect of
op
many types of chemotherapy, and some radiotherapy treatments (eg
radiotherapy to the pelvis), is that some healthy cells are also destroyed. This
may include blood cells that are developing in the bone marrow.
C
• Depending on the strength of your chemotherapy regimen, neutropenia is most
commonly seen 10 to14 days after chemotherapy
n
io
t

ua

hours and
al

Ev

• Treat these patients, pending confirmation of neutrophil count, to avoid any
delays in antibiotic administration.

• If patient is still febrile and unwell after 48 hours → an alternative antibiotic
• If patient is not responding after 4-6 days → order investigations for fungal
44. A 67 year old man who is currently on chemotherapy treatment for a malignancy
suddenly develops febrile neutropenia. He has been commenced on tazocin and
gentamicin. He has recently commenced meropenem but his fever still remains at 39°C
743
on the 3rd day. Two blood tests and urine cultures have come back negative.
Investigation done this morning show:
Haemoglobin 104 g/L

What is the SINGLE best management?
A. Continue IV antibiotics and add oral antifungals

B. Continue IV antibiotics and add IV antifungals
C. Stop antibiotics
D. Continue present antibiotics
E. Repeat blood culture
Continue inpatient empiric antibiotic therapy in all patients who have unresponsive
fever unless an alternative cause of fever is likely. It is quite the norm to add on IV
antifungals for neutropenic sepsis as well.
y
op
If there was an option to order investigations for fungal infections in this question, that
would be correct as well. C
• antibiotics must be started immediately (do not wait for the WBC)
n
io

• if patient is still febrile and unwell after 48 hours → an alternative antibiotic
t

ua
• if patient is not responding after 4-6 days → order investigations for fungal
al
45. A 69 year old woman lives in a nursing home following a stroke. She recently developed
a reddish scaly rash on her trunk. She has many scratch marks on her limbs and trunk
Ev
with linear burrows seen on her hands and feet. What is the SINGLE most appropriate
treatment?
A. Aqueous cream
B. Chlorpheniramine
C. Coal tar
D. Hydrocortisone ointment
E. Permethrin
Permethrin 5% is probably the only treatment that would be asked in PLAB for scabies.
Scabies

744
Aetiology
Clinical Findings

discharge.
Treatment
y
op
time, even if asymptomatic C
46. An 82 year old man was brought into the emergency department with a low level of
consciousness. His wife mentions that he had a severe headache for the last 20 hours
n
and was very sensitive to light. He has a temperature of 39.0°C, a pulse of 118
io
breaths/minute. He is conscious but confused. Kernig’s sign was positive. High flow
oxygen and IV fluids was immediately started. What is the SINGLE most appropriate
t
ua
A. Intravenous antibiotic
B. Lumbar puncture
al

D. Head magnetic resonance imaging
Ev
E. Blood culture
This man is having meningitis. Treatment for meningitis should be started before doing
any investigations due to the seriousness of the disease.

47. A 33 year old woman has numerous painful ulcers on her vulva. She is sexually active
and has multiple partners in the past. What is the SINGLE most likely cause of her
ulcers?
A. Chlamydia
C. Gardenella
D. Herpes simplex virus
E. Epstein barr virus
745
The probable diagnosis here is genital herpes.
Genital Herpes
nodes.
Management:
y
op
acyclovir
48. A 15 year old boy had a patchy rash over his body following antibiotic treatment for
C
sore throat. On examination, he has cervical lymph node enlargement and mild
splenomegaly which is tender on palpation. What is the SINGLE most likely antibiotic
that would have caused the rash?
n
io
A. Ampicillin
B. Erythromycin
t
C. Cefuroxime
ua
D. Metronidazole
E. Tetracycline
al
A maculopapular, pruritic rash develops in around 99% of patients who take

ampicillin/amoxicillin whilst they have infectious mononucleosis.
Ev

adults.
Features
massive
• Pyrexia
• Malaise
746
Diagnosis
• FBC
• ESR is elevated
y
49. A 38 year old female, 32 weeks pregnant presents with thick white marks on the inside
of her mouth for 3 weeks. Her mouth including her tongue appears inflamed on
op
examination. She smokes 20 cigarettes a day despite advice to quit. What is the SINGLE
most likely diagnosis? C
A. Lichen planus
B. Aphthous ulcer
n
D. Candidiasis
io
E. Leukoplakia
t
Smokers are more likely to develop oral thrush. The history of pregnancy is not too
ua
relevant. But the idea that the question writers want to portray is that in pregnancy,
the immune system is weakened. Thus candidiasis is more likely.
al
Lichen planus may have lace like appearance and not thick white mark like in this case.
Ev
Aphthous ulcer is typically round or oval sores or ulcers inside the mouth.
Molluscum contagiosum present as firm, smooth, umbilicated papules on the trunk or

extremities and not in the mouth like in the given stem.
Leukoplakia is an option but it is less likely that oral candidiasis. They may sometimes
give a history of a white lesion in the mouth that cannot be rubbed off.
Pseudomembranous oral candidiasis (oral thrush)

• Curd-like white patches in the mouth. The white pseudomembrane can be
easily removed, leaving an underlying red base that is usually painless (in
contrast with leukoplakia, which cannot be rubbed off)
• Cracks can occasionally be seen at the corners of the mouth
Candida Vs Lichen Planus Vs Leukoplakia
Oral Candidiasis Oral Lichen Planus Leukoplakia
747
History of Lace like appearance Also history of smoking
immunosuppression or
smoking Raised edges/ bright white
e.g. taking oral/inhaled patches and sharply defined
steroids and cannot be rubbed out like
a candida patch.
y
Thick white marks
op
Treatment
Treatment
If using inhaled Stop smoking
C
steroids, good inhaler
technique, spacer
device, rinse mouth
n
with water after use.
io
Stop smoking
t
ua
Oral fluconazole 50
mg/day for 7 days.
al
50. A 38 year old woman recently returned from Bangkok. She did not have any malaria
Ev
prophylaxis before leaving the UK on her trip. She presents with a high fever,
generalised macular blanching rash, tender and swollen cervical lymphadenopathy and
generalised myalgia. What is the SINGLE most likely diagnosis?
A. Cerebral Malaria
B. Dengue Fever
C. Typhoid
D. Diphtheria
E. Lymphoma
In PLAB 1, these are the most important epidemiology points that you need to know for
infectious diseases
• Malaria: Africa
• Dengue fever: Far East Asia
• Typhoid: South America
• Diphtheria: India
748
Even if you did not know this, the signs and symptoms point toward dengue fever. Here
is a summarised list of the presentation of these diseases. Remember to tie in the signs
and symptoms with the travel history:
• Malaria: fever, chills, rigors

• Dengue Fever: generalised rash, biphasic fever, retro-orbital pain
• Typhoid: severe headache, patients adopt a crouching position
• Diphtheria: presents with flu-like symptoms initially, enlarged anterior cervical
lymph nodes
51. A 5 year old child started having a fever two days ago associated with neck stiffness,
chills, impaired consciousness and vomiting. He has a history of travel with his parents
to Ghana and returned 6 weeks ago. Before he left to Ghana, he was started on malaria
prophylaxis. A full blood count shows that the young child is anaemic. What is the
A. Cerebral abscess
y
B. Cerebral malaria
op
C. Meningococcal meningitis
E. Cerebral tumour
C
Malaria prophylaxis does not provide full protection against all subtypes of malarial
n
parasites.
io
The two top choices given here is cerebral malaria and meningococcal meningitis. The
full blood count showing anaemia points towards cerebral malaria as the diagnosis
t
rather than meningococcal meningitis.

ua
Impaired consciousness is one of the signs of cerebral malaria. There are no specific
symptoms of malaria so it is critical to consider the possibility of the diagnosis. Most
al
missed malarial infections are wrongly diagnosed as nonspecific viral infections,

influenza, gastroenteritis or hepatitis. Children, in particular, are more likely to present
Ev
with nonspecific symptoms (fever, lethargy, malaise, somnolence) and to have

gastrointestinal symptoms.
It is important to consider malaria in every febrile patient returning from a malaria-

endemic area within the last year, especially in the previous three months, regardless
of whether they have taken chemoprophylaxis, as prompt recognition and appropriate
treatment will improve prognosis and prevent deaths.
52. A 15 year old girl presents to A&E with headache, vomiting, neck stiffness and
photophobia. No rash was seen on examination. Her temperature is 38.3°C, heart rate
is 90 bpm and respiratory rate is 18/min. What is the SINGLE most appropriate
investigation?
A. Blood culture
B. Blood glucose
C. Lumbar puncture
D. Chest X-ray
749
E. CT head
She has signs of meningitis.
If the patient has got a rash, then perform blood culture as the diagnosis is most likely
meningococcal septicaemia. The causative organism is Neisseria meningitides.
be done if there are no signs of raised intracranial pressure.
53. A 32 year old man has recently been to Thailand and returned with cervical
lymphadenopathy, malaise and a mild fever. What is the SINGLE most likely infectious
agent causing his symptoms?
A. Human immunodeficiency virus (HIV)
y
B. Treponema pallidum
op
C. Salmonella typhi
D. Measles
E. Epstein-Barr virus
C
Cervical lymphadenopathy is one of the main features of infectious mononucleosis.
n
If this was a HIV infection, there would be more of a generalized lymphadenopathy.
io
t
ua

adults.
al
Features
Ev

massive
• Pyrexia
• Malaise
Diagnosis
• FBC
750
• ESR is elevated
54. A 33 year old African woman presents with episodes of fever with rigors and chills for
the past year. Blood film shows ring form plasmodium with schuffner's dots in red
blood cells. What is the SINGLE most appropriate drug to eradicate this infection?
A. Mefloquine
B. Doxycycline
C. Proguanil
D. Quinine
E. Primaquine
Schuffner’s dots are exclusively found in Plasmodium ovale and Plasmodium vivax. Thus
y
primaquine should be used to eradicate them. The fact that they gave you the ethnicity,
op
is another clue. Plasmodium ovale typically comes from Africa.
Plasmodium vivax → Fever spikes every 48 hours.

C
Plasmodium ovale → Similar to P. vivax, except untreated infection lasts less long.
n
Both may produce true relapses by new invasion of the blood from latent hypnozoites
io
in the liver, up to a few years after complete clearance of parasites from the blood.
t
Ovale and vivax malaria have a hypnozoite stage and may therefore relapse following
ua
treatment.
Treatment of non-falciparum malaria

al
• Almost always chloroquine sensitive thus chloroquine is the drug of choice

• If chloroquine fails, resistant P. vivax can be treated with quinine
Ev
• Primaquine is used to destroy liver stage parasites and prevent relapse
55. A 13 year old girl complains of a 3 day history of hoarseness of voice associated with
dry cough. She presents with a fever and malaise. On direct laryngoscopy, her vocal
cords are seen to be grossly oedematous. What is the SINGLE next most appropriate
investigation?
A. None required
B. Sputum for acid-fast bacilli
C. Blood culture
D. Cervical spine X-ray
E. Bronchoscopy
This is a likely case of a common cold. No further investigations or management is

required.
751
56. A 3 year old boy presents with a 2 day history of being unwell. He has a 2 hour old rash
made up of urticarial and purpuric spots. His conscious level is decreased. He has a
blood pressure of 80/50 mmhg, a respiratory rate of 30 breaths/minute, oxygen
saturations of 94%, a temperature of 39°C, and a capillary refill time of 3 second. Urine
to diagnosis?

C. Chest X-ray
D. Urine for culture and sensitivity
A very straight forward question. The child is clearly septic with the likely diagnosis of
meningococcal septicaemia. Blood culture is the investigation of choice.
57. A 35 week pregnant woman presents to the Antenatal Day Unit with productive cough
and rigors. This is her first pregnancy and there have been no issues to date. She
y
returned from Uganda two weeks ago from a family visit. She is suspected to have
op
respiratory tuberculosis. What is the SINGLE most likely medication that should NOT be
used in pregnancy? C
A. Ethambutol
B. Pyrazinamide
C. Streptomycin
n
D. Isoniazid
io
E. Rifampicin
t
The standard unsupervised six month treatment regimen may be used during
ua
pregnancy. Streptomycin should not be used in pregnancy because it has been shown
to have harmful effects on the fetus.
al
This patient should be treated as the risks of untreated tuberculosis are greater to
pregnancy than the medication. The risk towards the pregnancy are perinatal infection,
Ev
low birth weight or growth retardation, and premature delivery. Treatment for
tuberculosis is the same for pregnant and non-pregnant status: 4 drug therapy
(Isoniazid, Rifampicin, Pyrazinamide, Ethambutol).
58. A 32 year old breast feeding mother has a painful, swollen, hard lump in her right
breast which developed 2 weeks after having a normal vaginal delivery. She has a
temperature of 38.1°C. A breast abscess is suspected. What is the SINGLE most likely
organism?
B. Staphylococcus albus
C. Streptococcus agalactiae
D. Streptococcus pyogenes
E. Staphylococcus epidermidis
Infectious mastitis occurs when accumulated milk allows bacteria to grow. It typically
develops within the first few weeks of breastfeeding. If treatment is delayed it may
752
result in a breast abscess like in this case. The usual infecting organism is
Staphylococcus aureus, although it may also be caused by Staphylococcus albus and
streptococci.
If a breast abscess forms, advise the patient to discard the milk if it is pus-like.
Flucloxacillin
is usually the treatment of choice. It is safe for baby. Incision and drainage of abscess
with cavity packed open with gauze is recommended if the underlying skin is thin or
necrotic.
If the patient has mastitis, we would still encourage the patient to breastfeed as the
blocked milk ducts may clear more quickly by breastfeeding as it keeps milk flowing.
However, if the patient has an abscess, in some cases, breast-feeding may have to
cease until the abscess is successfully treated.
59. A 38 year old woman presents with dysphagia and a lump on her neck. On examination,
there is a 5 cm by 4 cm erythematous neck swelling lateral to the thyroid cartilage. She
has a temperature of 38.9°C, a respiratory rate of 28 breaths/minute and a heart rate of
y
110 beats/minute. What is the SINGLE most appropriate action?
A. Thyroid function test
op
B. Paracetamol, Ibuprofen and broad spectrum antibiotics orally
C
C. X-ray of neck
D. Endoscopic diverticulotomy
E. Intravenous antibiotics, incision and drainage
n
io
Superficial neck abscesses are usually the result of an infection in a lymph node in the
neck (lymphadenitis) turning into an abscess. Staphylococcus aureus is usually the
t
culprit. Antibiotics can initially be given and if the abscess does not resolve then it may
ua
need to be drained. However, given this stem, it is clear that she is unwell and possibly
septic and thus oral antibiotics would not be a good option here. Antibiotics need to be
given intravenously, and the abscess needs to be drained.
al
Most cases of neck abscess require patients to be hospitalized and intravenous

Ev
antibiotics to be given. Analgesia is also important to relieve pain from the abscess but
the option to give oral antibiotics in combination with pain relief is an incorrect one in a
scenario where the patient is potentially septic.
Draining of a superficial neck abscess is a simple procedure and is done under general
anesthesia. Incision and drainage is important as the pus sample collected from the
drainage is sent to the laboratory for culture and sensitivity. After the organism is
identified, specific antibiotics can be used accordingly.
60. A 45 year old man has developed an annular rash with a scaly edge on his thigh. The
rash has been spreading over the last 3 weeks. He also complains of general aches and
pains. What is the SINGLE most appropriate investigation?
A. Antinuclear antibodies
B. Biopsy of lesion
C. Skin scrap for mycology
D. Antibodies to Borrelia recurrentis
753
E. Antibodies to Borrelia burgdorferi
The rash described is one of Lyme disease.
Lyme disease
Lyme disease is caused by the spirochaete Borrelia burgdorferi and is spread by ticks
(Ixodes scapularis tick)
Tick needs at least 24 hours of attachment to transmit the Borrelia burgdorferi

organism.
Symptoms begin 3-30 days after the bite of the tick. Eighty percent of patients develop
the
erythema migrans rash at the site of the bite. (An erythematous patch, which may
enlarge in the first few days) Even without treatment, the rash resolves in several
weeks. A flu like illness with fever, chills, and myalgias occurs in half of patients.
y
op
Neurologic symptoms develop several weeks later. This is most commonly paralysis of
the seventh cranial nerve (facial paralysis) and may be bilateral. Meningitis, and
encephalitis may develop as well.
C
Cardiac symptoms develop a minority of people and is most commonly an AV heart
block or Myocarditis
n
io
Joint involvement may develop but this is months to years later

t
Investigation
ua
Serology: antibodies to Borrelia burgdorferi
Management
al
• Doxycycline if early disease. Amoxicillin is an alternative if doxycycline is

contraindicated (e.g. pregnancy)
Ev
• Ceftriaxone if disseminated disease
61. A 33 year old known drug abuser has swelling and erythema in his arm where he
injects. He has a fever and appears sick. He is asking for morphine as the pain is severe
and seems to be disproportionate to the clinical appearance. Bullae is seen on the skin
of his arm. He was started on intravenous flucloxacillin but the infection has not
responded to antibiotics and seems to be worsening. What is the SINGLE most likely
diagnosis?
A. Cellulitis
B. Erysipelas
D. Penicillin allergic reaction
Necrotising fasciitis
754
Necrotising fasciitis is a life-threatening infection which rapidly spreads caused
predominantly by group A β-haemolytic Streptococci,. It is defined as necrotising
infection involving any layer of the deep soft tissue compartment (dermis,
subcutaneous tissue, fascia or muscle).
Risk factors
• Intramuscular or subcutaneous drug injection
• Diabetes
• Immunosuppression
Presentation → According to days

• Day 1 to 2
o Swelling, erythema, pain over affected area (mimics cellulitis)
o Margins of infection are poorly defined, with tenderness extending
beyond the apparent area of involvement (unlike cellulitis)
o No response to antibiotics (unlike cellulitis)
y
• Day 2 to 4
op
o Bullae, indicating skin ischaemia (unlike cellulitis)
o Skin progresses to grey colour due to necrosis (unlike cellulitis)
o Subcutaneous tissues have a wooden-hard feel (unlike cellulitis)
C
o From intense pain to anaesthesia like pain → due to nerves being
destroyed
• Day 4 to 5
n
o Septic shock develops
t io
As necrotising infection is deep within the skin and is not visible it is often difficult to
ua
diagnose. One important notable feature is if the pain is severe, and disproportionate to
the physical signs, think necrotising fasciitis.
al
Ev
62. A 34 year old man who has a new diagnosis of haematological malignancy presents in
the emergency department with bruises all over his abdomen. He has a temperature of
38.6°C. His respiratory rate is 25 breaths/minute, heart rate is 102 beats/minute and
blood pressure is 80/50 mmHg. His blood results show:

He is commenced on meropenem. What is the SINGLE most likely diagnosis?
A. Septic shock
B. Neutropenic sepsis
C. Hepatitis
D. Cytomegalovirus
E. HIV
755

hours and

Treat these patients, pending confirmation of neutrophil count, to avoid any delays in
antibiotic administration.

y
• if patient is still febrile and unwell after 48 hours → an alternative antibiotic
op
• if patient is not responding after 4-6 days → order investigations for fungal
C
n
63. A 7 year old child is being investigations for active respiratory tuberculosis. He has dry
io
cough and is unable to produce sputum. His parents have been informed about the
possibility of a bronchoalveolar lavage which can be useful in diagnosis tuberculosis
t
however the parents decline this invasive test. What is the SINGLE next method to
ua
acquire a sample to diagnose tuberculosis?
A. Venipuncture
al
B. Throat swab
C. Gastric lavage
Ev
D. Liver biopsy
E. Lumbar puncture
The diagnosis of tuberculosis is usually made in one of three ways:

1. Smear of sputum → Staining with Ziehl-Neelsen (ZN) stain and microscopy for
acid-fast bacilli
2. Culture of sputum → Takes 4-8 weeks due to slow bacterial growth
3. Histology with caseating granulomas on biopsy
This young child is unable to cough up sputum and thus there is no sample to perform a
stain for Acid-Fast Bacilli (AFB). Bronchoalveolar lavage would be the next step to
attempt to acquire a sample given the high index of suspicion for tuberculosis. As the
parents of the child have declined this procedure, gastric lavage would be able to
acquire a sample. Some patients with tuberculosis do not raise any sputum but instead
swallow small amounts of sputum. Gastric washings reflect TB swallowed overnight. It
is rarely performed if bronchoscopy is readily available but it is commonly used in
children.
756
Tuberculosis
Tuberculosis (TB) is an infection caused by Mycobacterium tuberculosis that most

commonly affects the lungs.
Primary tuberculosis
• Primary infection of the lungs
• A small lung lesion known as a Ghon focus develops
• Primary infection is usually asymptomatic
Secondary (post-primary) tuberculosis

• Occurs if the host becomes immunocompromised the initial infection may
become reactivated
• Presentation of secondary infection is variable and often nonspecific
Presentation
• Fatigue, malaise
y
• Chronic, productive cough
op
• Night sweats
• Weight loss C
Diagnosis
• X-ray
o Upper lobe infiltrates with cavitation
n
• Stain for Acid-Fast Bacilli (AFB)
io
• Culture is most specific but may take weeks

t
Do not use Mantoux test to diagnose acute cases of TB

ua
Screening
• Mantoux testing → to diagnose latent tuberculosis infection
al
o Used in people who are either household contacts, co-workers, or

school contacts of patients with active tuberculosis
Ev
• Interferon Gamma testing

o Used in patients who have had a bacillus Calmette-Guérin (BCG)
vaccine. This is because Mantoux test may be positive in patients who
have had a BCG vaccine.
Management of active tuberculosis

• Initial phase - first 2 months → Mnemonic (RIPE)
o Rifampicin
o Isoniazid
o Pyrazinamide
o Ethambutol
o
• Continuation phase - next 4 months
o Rifampicin
o Isoniazid
Mnemonic: I saw a red pyre
757
• I SAw - ISOniazid
• Red - Rifampicin
• PyrE - Pyrazinamide, Ethambutol
64. A 30 year old homeless lady has cough, sputum and a fever. She complains of night
sweats and has lost 13 kg in the past 6 months. A chest X-ray was performed which
showed apical involvement with infiltrates and cavitation in the upper lobe of the right
lung. What is the next SINGLE most appropriate test to perform?
A. Acid-Fast Bacilli smear

B. Mantoux test
C. Interferon Gamma test
D. Bronchoscopy
It is important to remember the risk factors of tuberculosis as well as how it presents.
y
Weight loss is common because of the chronicity of the infection. Night sweats also
op
occurs with TB.
Homeless people are at higher risk of TB as they often live in overcrowded areas and
C
have poor housing which encourage the spread of TB. It is estimated that homeless are
at 150 times at risk of TB than the UK average.
n
Stain for Acid-Fast Bacilli (AFB) is the most appropriate next test.
io
Mantoux test and interferon gamma test are used to diagnose latent tuberculosis
t
infection and not acute cases of tuberculosis.

ua
Bronchoscopy is sometimes used when there is a need to obtain bronchoalveolar

lavage or lymph node samples. It is used if a patient has non-productive cough or an
al
unhelpful sputum culture but the physicians still have a high index of clinical suspicion
for tuberculosis.
Ev
Tuberculosis


become reactivated
Presentation
758
• Night sweats
• Weight loss
Diagnosis
• X-ray
Screening
y
op
have had a BCG vaccine. C
o Rifampicin
n
o Isoniazid
io
o Pyrazinamide
o Ethambutol
t
o
ua

o Rifampicin
o Isoniazid
al

Ev
65. A 23 year old homeless smoker has an ongoing productive cough. She takes
recreational drugs and looks malnourished. She has lost 15 kg in the past year. There
are several nontender swellings on both sides of her neck. On examination, she has
crackles in her right upper lobe but is otherwise well and stable. A chest X-ray reveals
upper lobe infiltrates with cavitation on the right lung. What is the SINGLE most likely
diagnosis?
A. Aspergillosis
B. Klebsiella pneumoniae
C. Pneumococcal pneumonia
D. Bronchogenic Carcinoma
E. Tuberculosis
759
It is important to remember the risk factors of tuberculosis as well as how it presents.
Weight loss is seen in tuberculosis. One of the signs in tuberculosis is lymphadenopathy

particularly cervical which is seen in this stem.
The examination findings and chest X-ray are consistent with almost every option given
in the question. But only tuberculosis and lung cancer would have the associated
weight loss. Given the age of only being 23, tuberculosis is the likely answer.
Risk factors for TB which are included in this stem are:

• Homeless
• Drug abuser
• Smoker
The reason for homeless and drug abusers being at risk of TB is that they often live in
overcrowded areas and have poor housing which encourage the spread of TB. It is
estimated that homeless are at 150 times at risk of TB than the UK average.
y
Tuberculosis
op
C
n
io

t

ua

become reactivated
al
Presentation
Ev
• Night sweats
• Weight loss
Diagnosis
• X-ray
Screening
760
have had a BCG vaccine.

o Rifampicin
o Isoniazid
o Pyrazinamide
o Ethambutol
o
o Rifampicin
o Isoniazid

y
op
66. A 6 week infant has been diagnosed as HIV positive. What is the SINGLE most
C
appropriate immunization plan for the infant?
A. Avoid MMR vaccinations and tetanus vaccinations

n
B. Administer all vaccines as scheduled except live attenuated vaccines
io
C. Administer only BCG vaccine

D. Administer all vaccines as scheduled except BCG vaccine
t
E. Avoid influenza vaccinations

ua
BCG should not be given to HIV positive patients. All other vaccinations can be given.
MMR vaccinations should not be given if the CD4 count is below 200 cells/mL.
al
67. A 12 month old child who is HIV positive is due for his measles, mumps, and rubella
Ev
(MMR) vaccine. His CD4 count is more than 200 cells/mL. What is the SINGLE most
appropriate action?
A. Defer immunization for 2 weeks

B. Advise not to have MMR vaccine
C. Administer half dose of MMR vaccine
D. Administer paracetamol with MMR vaccine
E. Proceed with administration of MMR vaccination
Even though measles, mumps, and rubella (MMR) vaccine contains live attenuated
viruses, it is sometimes recommended for people with HIV/AIDS. It is contraindicated if
the patient is severely immunocompromised including a HIV-infected patient with CD4
counts less than 200 cells/mL.
68. A 70 year old diabetic woman has a red swelling over her right foot. Her foot is
erythematous, glossy, warm and tender to touch. She is a heavy smoker. What SINGLE
complication is this woman likely to develop?
761
A. Osteomyelitis
B. Septicaemia
C. Ulcers
D. Gangrene
This patient has clinical features of cellulitis. One of the complications is gangrene.
Others like necrotising fasciitis, septicaemia and osteomyelitis can also occur but are
less common.
Gangrene occurs when there is insufficient blood supply resulting in necrosis. It is most
common in the lower limbs. There are two broad types of gangrene - Dry and Wet. One
of the well known causes of the dry gangrene is peripheral arterial disease and it is
especially seen in smokers and patients with diabetes mellitus.
69. A 58 year old woman attends clinic for advice as her grandson who lives with her has
y
developed chicken pox with the rash appearing 2 days ago. She is currently undergoing
op
chemotherapy for breast cancer and has been using long term corticosteroids to
manage her inflammatory bowel disease. She has never had chicken pox before. On
examination, there is no evidence of any rash. What is the SINGLE most appropriate
C
management?
n
B. Oral aciclovir
io
C. Immunisation against varicella zoster

D. Varicella zoster immunoglobulin
t
E. Reassurance
ua
This patient is clearly immunocompromised. She is on chemotherapy AND she is taking

long term steroids. She is at a high risk of developing severe complications from
al
varicella infection. As she is currently asymptomatic, the best management would be

immunoglobulins. If she had developed the infection, then we would administer
Ev
aciclovir.
Chickenpox
• Caused by primary infection with varicella-zoster virus. Reactivation of the
dormant virus after a bout of chickenpox leads to herpes zoster (shingles)
• Highly infectious and its spread is via the respiratory route. Most chickenpox is
mild to moderate and self-limiting but serious complications can occur in
immunocompromised patients.
Infectivity → 4 days before rash and until 5 days after the rash first appeared
Incubation period → 10 to 21 days
Clinical features
• Pyrexia → Often the first feature
• Itchy, rash starting on head, chest and back before spreading
762
• Lesions are usually most concentrated on the chest and back
• Initially rash is macular → then papular → then vesicular → then dry crust
Clinical features tend to be more severe in adults
Management
• Pruritus → managed by sedating antihistamines and emollients. While some
sources mention that calamine lotion is no longer recommended, as when it
dries it ceases to be effective, it is still used and the advice that is given is to
reapply it regularly
• Administer varicella zoster immunoglobulin (VZIG) to:
o Immunocompromised with exposure or
o Newborn with peripartum exposure or
o Pregnant women with exposure and with no varicella antibodies
• Administer aciclovir to:
o Pregnant women who develop chicken pox
o Immunocompromised who develop chicken pox
y
70. A 5 year old boy was brought to his GP with a temperature of 38.8°C and numerous
op
pruritic vesicles on his chest and back. What is the SINGLE most appropriate
management? C
B. Oral aciclovir
C. Oral antibiotics
n
D. Topical steroids
io
E. Reassurance
t
The diagnosis here is chicken pox. The management here would involve reassurance,
ua
and supportive management like paracetamol for the fever, antihistamine and
calamine lotion for the pruritus.
al
Chickenpox
Ev

Clinical features
Management
763
71. A 24 year old male has a history of urethral discharge and dysuria. He is sexually active
with other men and has had four sexual partners in the last year. He does not practice
safe sex. Urethral swabs were taken which results came back positive for chlamydia.
What is the SINGLE most likely complication if left untreated?
A. Orchitis
y
B. Balanitis
op
C. Epididymo-orchitis
D. Acute abdomen
E. Erectile dysfunction
C
Chlamydia is the most prevalent sexually transmitted infection in the UK and is caused
by Chlamydia Trachomatis.
n
io
Males tend to have either:

• Classical urethritis with dysuria and urethral discharge or
t
• Epididymo-orchitis presenting as unilateral testicular pain

ua
Fever may also be a presenting feature in males

al
72. A 30 year old man from Australia returned from a business trip to Indonesia 6 days ago
presenting with complaints of fever, headache, vomiting, joint and muscle ache. His
Ev
headache is felt behind the eyes and has been present for the past 2 days. What is the
A. Malaria
B. Chicken pox
C. Diphtheria
D. Typhoid fever
E. Dengue
Dengue is characterised by an abrupt onset of fever often accompanied by severe

headache and retro-orbital pain, myalgia, arthralgia, nausea, vomiting, and abdominal
pain
Retro-orbital pain is a well recognized feature of dengue fever.
In PLAB 1, these are the most important epidemiology points that you need to know for
infectious diseases
764
• Malaria: Africa
• Dengue fever: Far East Asia
• Typhoid: South America
• Diphtheria: India
Even if you did not know this, the signs and symptoms point toward dengue fever. Here
is a summarised list of the presentation of these diseases. Remember to tie in the signs
and symptoms with the travel history:
• Malaria: fever, chills, rigors

• Dengue Fever: generalised rash, biphasic fever, retro-orbital pain
• Typhoid: severe headache, patients adopt a crouching position
• Diphtheria: presents with flu-like symptoms initially, enlarged anterior cervical
lymph nodes
73. A 20 week pregnant lady presents with intermittent fever, coughs, headaches, myalgia,
gastric upset and mild confusion. She arrived from Ghana 12 days ago. She travelled
y
there to visit her family. Before she left, she was prescribed chloroquine and proguanil
op
and she took it as prescribed starting 1 week before entering Ghana. She is still taking
chloroquine and proguanil as her doctor had asked her to continue it for 4 weeks after
arriving in the United Kingdom. On examination, she has a yellowish tinge on her skin.
C
A. Malaria
n
B. Hepatitis
io
C. Dengue
D. Influenza
t
E. Side effects of medication

ua
This lady has been taking malaria chemoprophylaxis but it is important to note that
Malaria can still occur in people even though they take Malaria chemoprophylaxis.
al
Chloroquine and proguanil can be used in pregnancy but these drugs are not
appropriate for most areas because their effectiveness has declined, particularly in Sub-
Ev
Saharan Africa.
Evidence also suggests that pregnant women are twice as likely as non-pregnant
women to be bitten by anopheline mosquitoes.
Clinical features that are seen with Malaria include:

• Intermittent fevers
• Chills
• Rigors
• Headache
• Cough
• Myalgia
• Gastrointestinal upset
• Splenomegaly
• Hepatomegaly
• Jaundice
765
74. A 7 year old boy presented 10 hours after having a foot injury while playing football in
the garden. A metal spike had gone through his shoes and pierced the bottom of his
foot. His immunisations are up to date. What is the SINGLE most appropriate
management?
A. Administer antibiotics and immunoglobulins

B. Administer antibiotics, immunoglobulins and vaccine
C. Administer antibiotics and vaccine
D. Administer immunoglobulins and vaccine
E. Administer antibiotics only
It is clear that this injury is to be considered a high risk wound. Intramuscular human
tetanus immunoglobulin need to be administered. Antibiotics would also be a useful to
add on here to prevent wound infection.

schedule at:
• 2 months
y
• 3 months
op
• 4 months
• 3-5 years
• 13-18 years
C
n
io

t

ua

al

Ev
75. A 21 year old man has generalized skin lesions. The skin lesions consist of macular,
papular and vesicles and concentrated more on his back and chest. Pinkish fluid is seen
secreted from a few of the lesions. He has a temperature of 39.1°C. What is the SINGLE
most appropriate medication to prescribe?
A. Topical antibiotics
B. Topical steroids
C. Oral antibiotics
D. Oral steroids
E. Topical steroid and antibiotic gel
The skin lesions seen in different stages are quite classical for chicken pox. As this man
has a temperature of 39.1°C, it is likely that there is a secondary infection that requires
oral antibiotics. Usually cases of chicken pox only require symptomatic treatment but if
chicken pox blisters become infected with bacteria, they would require antibiotic
treatment. With a temperature of 39.1°C, oral antibiotics is more suitable than topical.
766
Chickenpox
Clinical features
y
Management
op
C
n
io

t

ua
76. A 33 year old man has complains of dysuria and three tender penile ulcers. He is
al
sexually active and does not use any protection. What is the SINGLE most likely
diagnosis?
Ev
A. Chlamydia infection
B. Gonorrhea infection
C. Primary syphilis
D. Trichomoniasis
E. Herpes infection
Genital herpes simplex which is caused by herpes simplex virus may present with
painful multiple ulcers and also dysuria.
Syphilis ulcers are usually painless and thus is not the correct answer.
Genital Herpes
767
nodes.
Management:
acyclovir
y
op
C
n
t io
ua
al
Ev
768
NEPHROLOGY
y
op
C
Questions
n
io
&
t
ua
Answers
al
Ev
769
Nephrology Questions
1. A 34 year old woman with diabetes mellitus is undergoing a contrast radiography. What
is the SINGLE most appropriate measure that should be taken to prevent renal damage
with contrast dye?
A. Reduce contrast dye

B. Plenty of fluids
C. NSAIDS
D. ACE inhibitors
E. IV dextrose
2. A 32 year old woman of 38 weeks gestation complains of feeling unwell with fever,
rigors and abdominal pains. The pain was initially located in the abdomen and was
associated with urinary frequency and dysuria. The pain has now become more
generalized specifically radiating to the right loin. She says that she has felt occasional
uterine tightening. CTG is reassuring. What is the SINGLE most likely diagnosis?
y
op
B. Acute pyelonephritis
C. Round ligament stretching
D. Cholecystitis
E. Cystitis
C
3. A 26 year old mountain biker was rescued after being trapped under heavy rocks for
n
almost 12 hours. His urine is dark and urine is positive for blood on dipstick. His heart
io
rate is 120 bpm and systolic blood pressure is 100 mmHg. Lab results show a creatinine
of 350 μmol/L and urea of 15 mmol/L. What is the SINGLE most appropriate
t
management?
ua
Normal Lab values:

al
Ev
Urea 2.5–6.7mmol/L
A. Dialysis
B. IV Normal saline
C. IV dextrose
D. IV KCl
E. Pain relief
4. A 45 year old known hypertensive man presents with tiredness, lethargy, fluid retention
and proteinuria. His albumin levels are low. What is the SINGLE most definitive
diagnostic test?
A. Mid stream urine for culture

B. Renal biopsy
C. Renal function test
D. Urine microscopy
E. Serum protein
770
5. A 31 year old lady has urinary frequency, pain on voiding and back pain. The urine is
cloudy with an offensive smell. She has a temperature of 38.6°C. What is the SINGLE
A. Klebsiella
B. Escherichia coli
C. Proteus
D. Staphylococci
E. Pseudomonas
6. A 27 year old lady was admitted with fever, rigors, and loin pain. A dipstick urinalysis
was positive for blood, leukocyte esterase and nitrites. A midstream specimen of urine
(MSU) was sent for culture. What is the SINGLE appropriate action?
A. Start antibiotics immediately

B. Wait for culture results to start antibiotics
C. Spiral CT
D. Intravenous pyelogram (IVP)
y
E. Ultrasound and KUB X-ray
7.
op
In chronic renal failure, what is the main cause of vitamin D deficiency?
C
A. Decreased vitamin D absorption in intestines
B. Deficiency of 25 alpha-hydroxyvitamin D
C. Excess Vitamin D loss in urine
n
D. Reduced activity of 1-alpha hydroxylation
io
E. Unavailability of Vit D precursors

t
8. A 24 year old male was trying to move his wardrobe when it fell on his thigh. His two
ua
legs were trapped underneath it for several hours before someone was able to help
him get out. When he was seen in the ED his urine was dark and dipstick was positive
for blood. His heart rate is 115 bpm and systolic blood pressure is 100 mmHg. Lab
al
results show a creatinine of 320 μmol/L and urea of 13 mmol/L. What is the SINGLE
most likely cause of his renal failure?
Ev
Plab Lab Values
A. Acetylcholine
B. Drug toxicity
C. Troponin
D. Acetoacetate
E. Myoglobin
9. An 18 year old man reports having several episodes of visible haematuria over the last
24 hours. There is no history of abdominal or loin pain. These typically seem to occur
within a day or two of developing an upper respiratory tract infection. Urine testing by
dipstick shows albumin and blood. What is the SINGLE most likely diagnosis?
771
A. IgA nephropathy
B. Henoch-Schönlein purpura
C. Minimal change nephropathy
D. Wilson’s disease
E. Post-streptococcal glomerulonephritis
10. A 50 year old women newly diagnosed with hypertension complains of urinary
frequency and dysuria for the past 2 weeks. Urinalysis reveals presence of white cells
and protein. What is the SINGLE most appropriate management?
A. Imipramine
B. Furosemide
C. Vaginal oestrogen cream
D. Trimethoprim
E. Clotrimazole
11. A 44 year old man presents with periorbital and pedal edema. 24h urine shows 8 g of
y
protein and his serum cholesterol is 7 mmol/L. Renal biopsy results have not come back
op
yet. What would be the SINGLE most likely diagnosis?
A. Minimal change disease

C
B. Membranous glomerulonephropathy
C. Focal segmental glomerulosclerosis (FSGS)
D. IgA nephropathy
n
E. Mesangiocapillary
io
12. A 26 year old man presents to hospital complaining that his urine has been very dark
t
recently resembling tea. He had recently been under “the weather” 2 weeks back and
ua
had taken a few days off work with a sore throat and coryzal symptoms. A urine dipstick
returns highly positive for blood and protein. He is admitted for supportive
management. What is the SINGLE most likely diagnosis?
al
A. Membranous glomerulonephropathy
Ev
B. Systemic Lupus Erythematosus

C. Wegener’s granulomatosis
D. Post-streptococcal glomerulonephritis
E. IgA nephropathy
13. A 29 year old lady was admitted with fever, rigors, loin pain and vomiting. A dipstick
urinalysis was positive for blood, leukocyte esterase and nitrites. She has a history of
repeated urinary tract infections but this time she has blood in her urine. What is the
A. Acute pyelonephritis
B. Chronic pyelonephritis
C. Urinary tract infection
D. Bladder stone
E. Urethritis
772
14. A 32 year old miner was rescued after being trapped under a fallen rock for 4 hours.
After applying a bladder catheter, 15-20 ml of reddish brown urine was obtained. He
has a systolic blood pressure of 100 mmHg and a pulse rate of 130 beats/minute. What
is the SINGLE most appropriate next management?
A. Dopamine intravenously
B. Intravenous fluids
C. Furosemide intravenously
D. 20% Mannitol intravenously
15. A 3 year old child presents to A&E with history of bloody diarrhea and decreased
urination. The mother states that the child's developed fever, vomiting, abdominal
pain, and diarrhea that started 5 days ago. On physical examination, the patient
appears ill. He is pale and lethargic. Laboratory results show platelets 80 x 10^9/L,
haemoglobin 9 mg/dL,. There was fragmented red cells on blood film. What is the
y
op
B. Hemolytic uremic syndrome
C. Thrombotic thrombocytopenic purpura (TTP)
D. Hepatorenal syndrome
C
E. Sepsis
16. A 65 year old diabetic woman is undergoing a coronary angiography. What is the
n
SINGLE most appropriate measure to prevent contrast induced nephropathy?
io
A. Administer furosemide
t
B. Administer dextrose
ua
C. Administer 0.45% saline

D. Administer 0.9% saline
E. Administer corticosteroids
al
17. A 6 year old boy is brought to the emergency department by his mother because of
Ev
swelling on his legs the has been worsening in the last two days. The swelling is also
present in the scrotum and around his eyes. He is generally tired and his urine is noted
to be frothy. Renal biopsy report states no abnormalities can be seen on light
microscopy, however, electron microscopy reveals abnormal podocytes (fused). What is
A. Thrombotic thrombocytopenic purpura (TTP)

B. Myelodysplastic disease
C. Henoch–Schönlein purpura (HSP)
D. Membranous glomerulonephritis
E. Minimal change disease
18. A 24 year old man has just completed a long-distance running event. He becomes very
weak afterward and is brought to the emergency department with painful muscles and
red-brown urine. Urine is positive for blood on dipstick but without RBC on microscopy.
ECG shows a tall T waves, small P waves, and a widened QRS complex. What is the
SINGLE most appropriate initial management?
773
B. IV normal saline
C. IV Magnesium sulphate
D. Pain relief
E. Oral rehydration
19. A 34 year old primigravida who is now 16 week gestation attends the antenatal clinic
for a routine check up. She has a blood pressure of 160/100 mmHg. She has a history of
repeated childhood urinary tract infections. What is the SINGLE most likely cause of her
high blood pressure?
A. Essential hypertension
C. Acute pyelonephritis
D. Pre-eclampsia
E. Perinephric abscess
y
20. A 35 year old lady presents with a 12 day history of haemoptysis, and 24 hour history of
op
haematuria. In last 24 hours she has become increasingly breathless and oliguric. A
chest X-ray shows patchy interstitial infiltration predominantly affecting both lower
zones. Her blood tests show:
C
Haemoglobin 98 g/L
n
io
Sodium 136 mmol/L

t
ua
A. Anti-glomerular basement membrane antibodies

al
B. Abdominal X-ray
C. Urine protein electrophoresis
Ev
E. Computed tomography abdomen and chest
21. A 4 year old child presents with swelling. Periorbital oedema, lower limb oedema and
oedema of the genitals were noted on examination. A urine dipstick shows proteinuria.
He has a normal renal function, normal blood pressure, normal complement levels.
A. Post-streptococcal glomerulonephritis
C. Minimal change disease
D. Rapidly progressive glomerulonephritis
E. IgA nephropathy
22. A 32 year old man presents with painless haematuria and flank pain. His blood pressure
is 155/98 mmHg. The rest of the physical examination was otherwise unremarkable.
774
A. Bladder cancer
B. Adult polycystic kidney disease
D. Prostate cancer
E. Haemolytic uraemic syndrome (HUS)
23. A 42 year old woman with a past medical history of severe headache treated in the
emergency department presents with signs and symptoms of renal failure. She has
been seen by her GP for hypertension and loin pain with outpatient investigation
pending. What SINGLE investigations is most likely to lead to a diagnosis?
Plab Lab Values
A. Ultrasound of the kidneys, ureters & bladder

B. Computed tomography brain scan
D. Renal artery doppler
E. Renal biopsy
y
op
24. A 65 year old woman with diabetes, and hypertension underwent a total right hip
replacement. She had massive haemorrhage during the operation and was given 8 units
of packed red blood cells. The blood pressure dropped to 60/40 mmHg for about two
C
hours before it was corrected with intravenous fluids and blood transfusions. Two days
after the surgery, her blood results show:
n
Serum creatinine level rose to 255 μmol/L
io

t
She had a normal kidney function prior to the surgery. What is the SINGLE most likely
ua
diagnosis?
A. Diabetic nephropathy
al
B. Malignant hypertension
C. Rhabdomyolysis
Ev
D. Interstitial nephritis
E. Acute tubular necrosis
25. A 58 year old man complains of tiredness, lethargy, nausea and severe itching which is
worse after a hot bath and at night. His skin appears pale and dry with increased skin
pigmentation and numerous scratch marks. Peripheral oedema is noted on
examination. What is the SINGLE most likely diagnosis?
Plab Lab Values
A. Hyperthyroidism
B. Polycythaemia vera
C. Chronic renal failure
D. Eczema
E. Liver failure
26. A 35 year old man has recently been diagnosed as having asthma. He has attended
clinic with complains of having deep and aching pains in his lower back especially at
775
night. On examination, there are skin lesions present in the form of tender
subcutaneous nodules on his legs. Investigations were performed and he was started
on corticosteroids. What is the SINGLE most likely diagnosis?
A. Ankylosing spondylitis
B. Churg-strauss syndrome
C. Cryptogenic fibrosing alveolitis
D. Polyarteritis nodosa
E. Tropical eosinophilia
27. A 2 year old boy has gradual swelling of his face, feet and legs. He feeds poorly but is
noted to have gained weight. There is a foamy appearance of the urine. He feels
fatigue. What is the SINGLE most appropriate investigation?
A. Ultrasound kidneys
B. 24 hour urinary protein
C. Serum calcium
y
E. Serum glucose
28.
op
A 52 year old man known diabetes mellitus presents to emergency department with
sudden onset of pain in the left loin and haematuria. An ultrasound scan shows a 7mm
C
stone in left lower ureter. Diclofenac was administered for the renal colic pain and
nifedipine and prednisolone was prescribed as initial treatment as part of an expulsive
therapy. He returns to the emergency department the following day with worsening
n
pain, vomiting and a history of having passed two stones. A repeat ultrasound scan
io
reveals hydronephrosis in the left ureter and the presence of stones. His renal function
test indicate an acute kidney injury. What is the SINGLE most appropriate
t
management?
ua
A. Repeat a similar regimen

B. Administer an alpha blocker
al
C. Extracorporeal shock wave lithotripsy

D. Open surgery
Ev
E. Percutaneous nephrostomy
29. A 2 year old boy is brought to the hospital by his mother with diarrhoea and vomiting.
He was previously fit and well until a few days ago where he was treated with
antibiotics by his general practitioner for an upper respiratory tract infection. He no
longer has a cough but feels extremely unwell. His recent blood test show:
Na 124
Potassium 5.9
Urea 10.1
A. Renal failure
B. Adrenal insufficiency
C. Gastroenteritis
D. Pyloric stenosis
776
E. Hypopituitarism
y
op
C
n
t io
ua
al
Ev
777
Nephrology Answers
1. A 34 year old woman with diabetes mellitus is undergoing a contrast radiography. What
is the SINGLE most appropriate measure that should be taken to prevent renal damage
with contrast dye?
A. Reduce contrast dye

B. Plenty of fluids
C. NSAIDS
D. ACE inhibitors
E. IV dextrose
Contrast induced nephropathy
Prevention
Dehydration can increase your risk of contrast induced nephropathy. Thus, drink fluids
to prevent dehydration. IV normal saline can help prevent dehydration as well. The
evidence supporting their use is strong. In practice, 0.9% NaCl 1mL/kg/h for 12h pre-
y
and 12h post-procedure is given to patients.
op
There are some studies that show that N-acetylcysteine (NAC) may be of some use to
prevent contrast induced nephropathy but it is unlikely to be asked in a basic exam like
PLAB part 1.
C
2. A 32 year old woman of 38 weeks gestation complains of feeling unwell with fever,
n
rigors and abdominal pains. The pain was initially located in the abdomen and was
io
associated with urinary frequency and dysuria. The pain has now become more
generalized specifically radiating to the right loin. She says that she has felt occasional
t
uterine tightening. CTG is reassuring. What is the SINGLE most likely diagnosis?
ua

al
C. Round ligament stretching

D. Cholecystitis
Ev
E. Cystitis
Fever, rigor, abdominal pain associated with frequency and dysuria and radiation to the
right loin suggests right sided pyelonephritis.
Acute pyelonephritis
Pyelonephritis is an inflammation of the kidney and renal pelvis.
Risk factors
- Structural renal abnormalities, including vesicoureteric reflux (VUR)
- Calculi and urinary tract catheterisation
- Stents or drainage procedures
- Pregnancy
- Diabetes
- Primary biliary cirrhosis
- Neuropathic bladder
- Prostate enlargement
778
Presentation
- Onset is rapid with symptoms appearing over a day or two
- Unilateral or bilateral loin pain, suprapubic pain or back pain
- Fever is variable but can be high enough to produce rigors
- Nausea, vomiting
- There are usually accompanying symptoms suggestive of a lower UTI
(frequency, urgency, suprapubic pain, urethral burning or pain on voiding)
Investigations
- Urinalysis: urine may be cloudy with an offensive smell. Positive on dipstick
urinalysis for blood, protein, leukocyte esterase and nitrite
- A midstream specimen of urine (MSU) should always be sent off for microscopy
and culture. A catheter specimen will be acceptable if a catheter is in situ.
- Special arrangements may be needed for collecting a sample from a child.
(Clean catch, catheter or suprapubic aspiration are methods used which reduce
the risk of contamination
- Microscopy of urine shows pyuria
y
Management
op
- Support: rest, adequate fluid intake and analgesia
- Antibiotics: start empirical antibiotic treatment whilst awaiting culture and
sensitivity. Antibiotics are usually given according to your local antibiotic policy.
C
In general, for adults, current UK protocols recommend that the first-line
antibiotic should be either ciprofloxacin or co-amoxiclav. Trimethoprim may be
used if culture confirms sensitivity
n
- For children co-amoxiclav is recommended as first-line treatment, with cefixime
io
second-line
t
Note:
ua
- Eighty percent of infections are secondary to E. coli
3. A 26 year old mountain biker was rescued after being trapped under heavy rocks for
al
almost 12 hours. His urine is dark and urine is positive for blood on dipstick. His heart
rate is 120 bpm and systolic blood pressure is 100 mmHg. Lab results show a creatinine
Ev
of 350 μmol/L and urea of 15 mmol/L. What is the SINGLE most appropriate
management?
Normal Lab values:
A. Dialysis
B. IV Normal saline
C. IV dextrose
D. IV KCl
E. Pain relief
This patient here has attained severe crush injuries which has lead to rhabdomyolysis
Rhabdomyolysis results from skeletal muscle breakdown, with release of its contents
779
into the circulation, including myoglobin, K+, phosphate, urate and creatine kinase
(CK). Rhabdomyolysis is caused by sudden, severe crush injury, seizures, and severe
exertion. This disorders result in enough pigment release in the bloodstream to cause
nephrotoxicity. The toxicity is because the pigment is directly toxic to the tubular cells
as well as from precipitation of the pigment in the tubules. The degree of toxicity is
related to the duration of contact of the tubular cells with myoglobin.
This toxicity is compounded by dehydration. Hence, a person who has run a marathon
has both myoglobin release as well as poor kidney perfusion. This is cumulative in the
risk of renal failure.
Laboratory testing.
The most important test when there has been a severe crush injury and the
rhabdomyolysis is potentially life threatening is an ECG or potassium level.
This implies that you know how a patient with rhabdomyolysis will die. Acidosis and
y
hyperkalemia can lead to an arrhythmia. If there are peaked T-waves on the ECG, you
op
will give calcium chloride or calcium gluconate.
The best initial test that is specific for rhabdomyolysis is a urinalysis in which you find a
C
dipstick that is positive for blood but in which no red cells are seen. This is a False +ve
dipstick haematuria. This is because myoglobin can react with the reagent on the
dipstick and come out as if there were red cells present. Hemoglobin will do the same
n
thing. The dipstick of the urinalysis cannot distinguish among hemoglobin, myoglobin,
io
and red blood cells. This is because myoglobin has heme in it.
t
Rhabdomyolysis is confirmed with a markedly elevated serum CPK level. Elevated

ua
serum
CPK is a biochemical marker of skeletal muscle neurosis.

al
Rhabdomyolysis is associated with a very rapidly rising creatinine level. This is because
of both renal failure as well as the massive release of muscle products.
Ev
Treatment
If there are ECG abnormalities from the hyperkalemia the best initial therapy is calcium
chloride or gluconate.
IV fluid rehydration is a priority to prevent AKI. This decreases the duration of contact
between the nephrotoxic myoglobin and the kidney tubule.
IV sodium bicarbonate is used to alkalinize urine to pH >6.5, to stabilize a less toxic form
of myoglobin. Alkalinizing the urine with bicarbonate may help prevent the
precipitation of the pigment in the tubule
Dialysis may be needed. Ideally manage patient in HDU/ICU setting to allow early
detection of deterioration and regular bloods and monitoring. Prognosis is good if
treated early.
780
4. A 45 year old known hypertensive man presents with tiredness, lethargy, fluid retention
and proteinuria. His albumin levels are low. What is the SINGLE most definitive
diagnostic test?
A. Mid stream urine for culture

B. Renal biopsy
C. Renal function test
D. Urine microscopy
E. Serum protein
This patient is presenting with nephrotic syndrome. The definitive test to do is a renal
biopsy as this would provide us with the aetiology.
Nephrotic syndrome
Triad of:
1. Proteinuria (> 3g/24hr) causing
2. Hypoalbuminaemia (< 30g/L) and
y
3. Oedema
Causes
op
Primary glomerulonephritis accounts for around 80% of cases
C
- minimal change glomerulonephritis (causes 80% in children, 30% in adults)
- membranous glomerulonephritis
- focal segmental glomerulosclerosis
n
- membranoproliferative glomerulonephritis
io
Systemic disease
t
- diabetes mellitus
ua
- systemic lupus erythematosus

- amyloidosis
al
5. A 31 year old lady has urinary frequency, pain on voiding and back pain. The urine is
cloudy with an offensive smell. She has a temperature of 38.6°C. What is the SINGLE
Ev
A. Klebsiella
B. Escherichia coli
C. Proteus
D. Staphylococci
E. Pseudomonas
Risk factors
- Pregnancy
- Diabetes
781
Presentation
- Nausea, vomiting
Investigations
y
op
- Microscopy of urine shows pyuria C
Management
n
io

t

ua

second-line
al
Note:
Ev
6. A 27 year old lady was admitted with fever, rigors, and loin pain. A dipstick urinalysis
was positive for blood, leukocyte esterase and nitrites. A midstream specimen of urine
(MSU) was sent for culture. What is the SINGLE appropriate action?
A. Start antibiotics immediately

B. Wait for culture results to start antibiotics
C. Spiral CT
D. Intravenous pyelogram (IVP)
E. Ultrasound and KUB X-ray
Risk factors
782
- Pregnancy
- Diabetes
Presentation
- Nausea, vomiting
Investigations
y
op
C
n
Management
io

t
ua

al

second-line
Ev
Note:
7. In chronic renal failure, what is the main cause of vitamin D deficiency?
A. Decreased vitamin D absorption in intestines

B. Deficiency of 25 alpha-hydroxyvitamin D
C. Excess Vitamin D loss in urine
D. Reduced activity of 1-alpha hydroxylation
E. Unavailability of Vit D precursors
Patients with kidney disease have reduced activity of the enzyme 1-α hydroxylase in the
kidneys, which converts 25-hydroxyvitamin D to its more active form, 1,25-
dihydroxyvitamin D, and thus patients with kidney disease have traditionally been given
vitamin D replacement with active, 1,25-dihydroxyvitamin D or a related analog.
783
8. A 24 year old male was trying to move his wardrobe when it fell on his thigh. His two
legs were trapped underneath it for several hours before someone was able to help
him get out. When he was seen in the ED his urine was dark and dipstick was positive
for blood. His heart rate is 115 bpm and systolic blood pressure is 100 mmHg. Lab
results show a creatinine of 320 μmol/L and urea of 13 mmol/L. What is the SINGLE
most likely cause of his renal failure?
Plab Lab Values
A. Acetylcholine
B. Drug toxicity
C. Troponin
D. Acetoacetate
E. Myoglobin
y
op
C
n
io

t
ua
al
Laboratory testing.
Ev

serum
784
Treatment
treated early.
y
op
9. An 18 year old man reports having several episodes of visible haematuria over the last
24 hours. There is no history of abdominal or loin pain. These typically seem to occur
within a day or two of developing an upper respiratory tract infection. Urine testing by
C
dipstick shows albumin and blood. What is the SINGLE most likely diagnosis?
n
A. IgA nephropathy
B. Henoch-Schönlein purpura
io
C. Minimal change nephropathy

t
E. Post-streptococcal glomerulonephritis
ua
IgA nephropathy (Berger's disease)

al
Features
- Young male, recurrent episodes of macroscopic haematuria
Ev
- Typically usually with an upper respiratory tract infection or, less often,
gastroenteritis. Most patients have a history of an upper respiratory tract
infection and, either at the onset or within the first 24-48 hours, there is gross
haematuria that lasts for less than three days. The urine is red or brown and
there may also be loin pain.
- Alternatively, there may be no symptoms but urine shows erythrocytes, casts
and proteinuria.
- It is associated with a number of other diseases, including Henoch-Schönlein
purpura.
- Of those that do not remit, there is a slow progression to ESKD.
Differentiating between IgA nephropathy and post-streptococcal glomerulonephritis
IgA nephropathy Post-streptococcal glomerulonephritis

- Develops 1-2 days after URTI - Develops 1-2 weeks after URTI
- Main symptom → Haematuria - Main symptom → Proteinuria
- Young males
785
- Associated with low complement
levels
10. A 50 year old women newly diagnosed with hypertension complains of urinary
frequency and dysuria for the past 2 weeks. Urinalysis reveals presence of white cells
and protein. What is the SINGLE most appropriate management?
A. Imipramine
B. Furosemide
C. Vaginal oestrogen cream
D. Trimethoprim
E. Clotrimazole
This lady has a urinary tract infection. The hypertension given in this stem has no
relationship to the management and it is given to throw you off. Trimethoprim would
be the most appropriate choice given that it is an antibiotic used to treat UTI.
11. A 44 year old man presents with periorbital and pedal edema. 24h urine shows 8 g of
protein and his serum cholesterol is 7 mmol/L. Renal biopsy results have not come back
y
yet. What would be the SINGLE most likely diagnosis?
A. Minimal change disease

op
C
C. Focal segmental glomerulosclerosis (FSGS)
D. IgA nephropathy
n
E. Mesangiocapillary
io
Membranous nephropathy
t
- This is the most common form of idiopathic nephrotic syndrome in adults. It is

ua
also associated with cancer such as lymphoma or breast cancer, and infections
such as endocarditis or chronic hepatitis B or C. Other etiologies are lupus,
penicillamine, gold salts, and NSAIDs.
al
- Accounts for 20–30% of nephrotic syndrome in adults; 2–5% in children.

- Mostly idiopathic
Ev
Treatment:
Secondary involves treating the underlying cause
In idiopathic membranous, treatment involves general measures such as ACE/ARB and

diuretics. Spontaneous complete remission occurs in up to 30% and partial remission in
24–40% by 5 years.
12. A 26 year old man presents to hospital complaining that his urine has been very dark
recently resembling tea. He had recently been under “the weather” 2 weeks back and
had taken a few days off work with a sore throat and coryzal symptoms. A urine dipstick
returns highly positive for blood and protein. He is admitted for supportive
management. What is the SINGLE most likely diagnosis?
A. Membranous glomerulonephropathy
B. Systemic Lupus Erythematosus
C. Wegener’s granulomatosis
786
D. Post-streptococcal glomerulonephritis
E. IgA nephropathy
Post-streptococcal glomerulonephritis
Post-streptococcal glomerulonephritis typically occurs 7-14 days following a group A
beta-haemolytic Streptococcus infection (usually Streptococcus pyogenes). It classically
follows a streptococcal sore throat but often occurs after infection elsewhere, e.g.
tonsillitis, pharyngitis (commonly), impetigo, otitis media, and cellulitis.
It is caused by immune complex (IgG, IgM and C3) deposition in the glomeruli. Young
children most commonly affected usually below age 7.
Varies from asymptomatic microscopic haematuria through to an acute nephritic
syndrome, with frank haematuria, oliguria, proteinuria, oedema, increased blood
pressure and AKI.
Very commonly patients would describe their urine as smoky, cola, or tea-colored
y
urine. This abnormal urine color is from hematuria, red cell casts, and proteinuria.
Investigations
- Low C3
op
C
- Raised anti-streptolysin O titre
- The most accurate test is the renal biopsy showing "humps" on electron
microscopy. IgG and C3 will be deposited in the mesangium as subepithelial
n
humps. However, biopsy is rarely needed as treatment is largely supportive
io
with the vast majority resolving spontaneously.

t
Differentiating between IgA nephropathy and post-streptococcal glomerulonephritis

ua
IgA nephropathy Post-streptococcal glomerulonephritis

- Develops 1-2 days after URTI - Develops 1-2 weeks after URTI
al
- Main symptom → Haematuria - Main symptom → Proteinuria

- Young males - Associated with low complement
Ev
levels
13. A 29 year old lady was admitted with fever, rigors, loin pain and vomiting. A dipstick
urinalysis was positive for blood, leukocyte esterase and nitrites. She has a history of
repeated urinary tract infections but this time she has blood in her urine. What is the
A. Acute pyelonephritis
C. Urinary tract infection
D. Bladder stone
E. Urethritis
The loin pain is suggestive of acute pyelonephritis. Urinary tract infection is not wrong
as acute pyelonephritis is under the category of a urinary tract infection but the more
specific answer would be acute pyelonephritis.
787
Many doctors would have answered chronic pyelonephritis because of the history of
repeated urinary tract infections. However, chronic pyelonephritis usually has no active
infection. They may present with symptoms secondary to renal failure. Diagnosis is
often from incidental findings during general investigation.
Risk factors
- Pregnancy
- Diabetes
y
Presentation
op
C
- Nausea, vomiting
n
io
Investigations
t

ua
al
Ev
Management
second-line
Note:
14. A 32 year old miner was rescued after being trapped under a fallen rock for 4 hours.
After applying a bladder catheter, 15-20 ml of reddish brown urine was obtained. He
788
has a systolic blood pressure of 100 mmHg and a pulse rate of 130 beats/minute. What
is the SINGLE most appropriate next management?
A. Dopamine intravenously
B. Intravenous fluids
C. Furosemide intravenously
D. 20% Mannitol intravenously
The patient has developed rhabdomyolysis as he was trapped under a fallen rock for
several hours. The reddish brown sometimes referred to as ‘tea-coloured’ urine is due
to myoglobin in the urine. Due to the danger of acute renal failure, intravenous fluids
would be an appropriate option to avoid further renal compromise.
y
op
C
n
io
Laboratory testing.
t
ua
al
Ev

serum

Treatment
789
treated early.
15. A 3 year old child presents to A&E with history of bloody diarrhea and decreased
urination. The mother states that the child's developed fever, vomiting, abdominal
pain, and diarrhea that started 5 days ago. On physical examination, the patient
appears ill. He is pale and lethargic. Laboratory results show platelets 80 x 10^9/L,
y
haemoglobin 9 mg/dL,. There was fragmented red cells on blood film. What is the
op
C
B. Hemolytic uremic syndrome
n
D. Hepatorenal syndrome
E. Sepsis
io
Haemolytic uraemic syndrome (HUS)

t
ua
HUS consists of a triad of haemolytic anaemia, uraemia, and thrombocytopenia.
The anaemia will be intravascular in nature and will have an abnormal blood smear
al
showing schistocytes, helmet cells, and fragmented red cells.

Ev
LDH and reticulocyte count will be elevated and the haptoglobin decreased.
90% are caused by E. coli strain O157. This produces a verotoxin that attacks
endothelial cells. Occurs after eating undercooked contaminated meat.
Signs: Abdominal pain, bloody diarrhoea, and AKI.
Management
- Treatment is supportive e.g. Fluids, blood transfusion and dialysis if required

- Do not give antibiotics to those with possible HUS. The organism may release
more toxins as it dies if antibiotics are given and may worsen the disease.
- The indications for plasma exchange in HUS are complicated. As a general rule
plasma exchange is reserved for severe cases of HUS not associated with
diarrhoea
790
16. A 65 year old diabetic woman is undergoing a coronary angiography. What is the
SINGLE most appropriate measure to prevent contrast induced nephropathy?
A. Administer furosemide
B. Administer dextrose
C. Administer 0.45% saline
D. Administer 0.9% saline
E. Administer corticosteroids
Contrast induced nephropathy
Prevention
Dehydration can increase your risk of contrast induced nephropathy. Thus, drink fluids
to prevent dehydration. IV normal saline can help prevent dehydration as well. The
evidence supporting their use is strong. In practice, 0.9% NaCl 1mL/kg/h for 12h pre-
and 12h post-procedure is given to patients.
There are some studies that show that N-acetylcysteine (NAC) may be of some use to
y
prevent contrast induced nephropathy but it is unlikely to be asked in a basic exam like
op
PLAB part 1.
17. A 6 year old boy is brought to the emergency department by his mother because of
C
swelling on his legs the has been worsening in the last two days. The swelling is also
present in the scrotum and around his eyes. He is generally tired and his urine is noted
to be frothy. Renal biopsy report states no abnormalities can be seen on light
n
microscopy, however, electron microscopy reveals abnormal podocytes (fused). What is
io

t
A. Thrombotic thrombocytopenic purpura (TTP)

ua
B. Myelodysplastic disease
C. Henoch–Schönlein purpura (HSP)
D. Membranous glomerulonephritis
al
E. Minimal change disease

Ev
The phrase “electron microscopy shows fusion of podocytes“ is key. This tells you that it
can be nothing else but minimal change disease. PLAB questions would likely give a
scenario similar to this where a child is having symptoms of swelling or proteinuria and
a renal biopsy shows fusion of podocytes on electron microscopy.
Minimal change disease
Minimal change disease nearly always presents as nephrotic syndrome, accounting for
75% of cases in children and 25% in adults.
The majority of cases are idiopathic
Features
- Nephrotic syndrome
- Normotension - hypertension is rare
- Renal biopsy: electron microscopy shows fusion of podocytes
791
Management
- Majority of cases (80%) are steroid responsive

- Cyclophosphamide is the next step for steroid resistant cases
18. A 24 year old man has just completed a long-distance running event. He becomes very
weak afterward and is brought to the emergency department with painful muscles and
red-brown urine. Urine is positive for blood on dipstick but without RBC on microscopy.
ECG shows a tall T waves, small P waves, and a widened QRS complex. What is the

B. IV normal saline
C. IV Magnesium sulphate
D. Pain relief
E. Oral rehydration
y
This man has just finished a long-distance run of which he was severely exerted. The
op
skeletal muscle breakdown has resulted in Rhabdomyolysis and thus hyperkalaemia. IV
calcium gluconate needs to be administered first for cardio protection.
C
n
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al
Ev
Laboratory testing.
792
serum

Treatment
y
op
treated early. C
19. A 34 year old primigravida who is now 16 week gestation attends the antenatal clinic
for a routine check up. She has a blood pressure of 160/100 mmHg. She has a history of
n
repeated childhood urinary tract infections. What is the SINGLE most likely cause of her
high blood pressure?
io
t
ua
C. Acute pyelonephritis
D. Pre-eclampsia
E. Perinephric abscess
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Repeated urinary tract infection in childhood can lead to renal scarring and chronic
Ev
pyelonephritis which results in hypertension.
Chronic pyelonephritis
This describes renal scarring which may or may not be related to previous UTI. It is a
radiological, functional, or pathological diagnosis or description.
Causes
- Renal scarring due to previous infection
- Long-term effects of VUR, with or without superimposed infection
- A child with VUR, particularly where there is reflux of infected urine, will
develop reflux nephropathy (which, if bilateral, may cause renal impairment or
renal failure). If the child’s kidneys are examined radiologically, the radiologist
will describe the appearances as those of ‘chronic pyelonephritis’.
- An adult may also develop radiological features of chronic pyelonephritis due to
the presence of reflux combined with high bladder pressures, again particularly
where the urine is infected.
793
Presentation
- Patients may be asymptomatic or present with symptoms secondary to renal
failure.
- Diagnosis is often from incidental findings during general investigation.
- There is usually no active infection.
Appearances on imaging
- Renal ultrasound may show small kidneys with a thin cortex
- Intravenous pyelogram (IVP) may show small kidneys, ureteric and caliceal
dilatation/blunting with cortical scarring
- Micturating cystourethrogram (MCUG) may help to identify reflux.
- Technetium-99m Tc-DMSA scan is the most sensitive for demonstration of
renal scars.
Management
- Aim to investigate and treat any infection, prevent further UTI, and monitor
and optimize renal function
- Blood pressure should be controlled to slow the progression of chronic kidney
y
disease. Ideally using angiotensin-converting enzyme (ACE) inhibitors
op
- Severe underlying VUR diagnosed in children may require antibiotics
prophylactically until puberty or until the reflux resolves
C
20. A 35 year old lady presents with a 12 day history of haemoptysis, and 24 hour history of
haematuria. In last 24 hours she has become increasingly breathless and oliguric. A
chest X-ray shows patchy interstitial infiltration predominantly affecting both lower
n
zones. Her blood tests show:
io
Haemoglobin 98 g/L
t

ua

Sodium 136 mmol/L
al

Ev
A. Anti-glomerular basement membrane antibodies

B. Abdominal X-ray
C. Urine protein electrophoresis
E. Computed tomography abdomen and chest
The likely diagnosis here is Goodpasture syndrome. The bloods reflect a acute kidney
injury. The slightly lower haemoglobin levels can be explained by the persistent
intrapulmonary bleeding.
Anti-GBM antibodies are diagnostic:
Goodpasture syndrome
- Goodpasture's syndrome is the coexistence of acute glomerulonephritis and
pulmonary alveolar haemorrhage
794
Presentation
- Typically presents as acute kidney injury caused by a rapidly progressive
glomerulonephritis, accompanied by pulmonary haemorrhage that may be life-
threatening
- Lung involvement is characterized by haemoptysis, cough, and shortness of
breath
Anti-glomerular basement membrane antibodies antibodies are diagnostic
Remember: The best initial test to confirm the diagnosis is anti-GBM antibodies. The
SINGLE most accurate test is a lung or kidney biopsy
Management
Management for Goodpasture syndrome is highly unlikely to be asked given that
Goodpasture's syndrome is an uncommon disease. But one should remember the
principles of management:
- Plasmapheresis (plasma exchange) to remove circulating antibodies
- Treat with immunosuppressant medications to prevent further production of
y
antibodies
21.
op
A 4 year old child presents with swelling. Periorbital oedema, lower limb oedema and
oedema of the genitals were noted on examination. A urine dipstick shows proteinuria.
C
He has a normal renal function, normal blood pressure, normal complement levels.
n
A. Post-streptococcal glomerulonephritis
io
C. Minimal change disease
t
D. Rapidly progressive glomerulonephritis

ua
E. IgA nephropathy
Minimal change disease

al
Minimal change disease nearly always presents as nephrotic syndrome, accounting for
Ev
75% of cases in children and 25% in adults.
The majority of cases are idiopathic
Features
- Normotension - hypertension is rare
- Renal biopsy: electron microscopy shows fusion of podocytes
Management
- Majority of cases (80%) are steroid responsive

- Cyclophosphamide is the next step for steroid resistant cases
795
22. A 32 year old man presents with painless haematuria and flank pain. His blood pressure
is 155/98 mmHg. The rest of the physical examination was otherwise unremarkable.
A. Bladder cancer
B. Adult polycystic kidney disease
D. Prostate cancer
E. Haemolytic uraemic syndrome (HUS)
For the purpose of the examination, scenarios with haematuria + hypertension are
almost always polycystic kidney disease (PKD).
Questions often ask about screening test for PKD and give you an option between
genetic testing for PKD1 or an ultrasound scan. The answer should always be an
ultrasound scan. Genetic testing for PKD1 is difficult as the gene is large and there are
hundreds of described mutations. USS screening offers good sensitivity and specificity.
y
Autosomal dominant polycystic kidney disease
Presentation
- Flank pain
op
C
- Haematuria (micro and gross)
- Urinary tract infections (UTIs) and calculi
- Hypertension
n
- Bilateral kidney enlargement - abdominal examination may reveal enlarged and
io
palpable kidneys
t
Other points:
ua
- Gross haematuria following trauma is a classic presenting feature of ADPKD

- Sometimes present with kidney failure (usually in the fourth to sixth decade of
life)
al
- May also present as asymptomatic on screening of family members

- Intracranial aneurysm is an important extrarenal manifestation (an important
Ev
point that is commonly asked)
Note: The other extra-renal manifestation are less commonly asked
Diagnosis:
Ultrasound
Treatment
Nonspecific; management of hypertension
23. A 42 year old woman with a past medical history of severe headache treated in the
emergency department presents with signs and symptoms of renal failure. She has
been seen by her GP for hypertension and loin pain with outpatient investigation
pending. What SINGLE investigations is most likely to lead to a diagnosis?
Plab Lab Values
A. Ultrasound of the kidneys, ureters & bladder
796
B. Computed tomography brain scan
D. Renal artery doppler
E. Renal biopsy
The initial symptoms of headache and hypertension in this scenario would make you
consider a renal artery stenosis. However, in addition to the loin pain and features of
renal failure, the diagnosis of autosomal dominant polycystic kidney disease is more
likely. This is best diagnosed using ultrasound of the kidneys, ureters & bladder.
Questions often ask about screening test for PKD and give you an option between
genetic testing for PKD1 or an ultrasound scan. The answer should always be an
ultrasound scan. Genetic testing for PKD1 is difficult as the gene is large and there are
hundreds of described mutations. USS screening offers good sensitivity and specificity.
Autosomal dominant polycystic kidney disease
Presentation
y
- Flank pain
op
- Haematuria (micro and gross)
- Urinary tract infections (UTIs) and calculi
- Hypertension
C
- Bilateral kidney enlargement - abdominal examination may reveal enlarged and
palpable kidneys
n
Other points:
io
- Gross haematuria following trauma is a classic presenting feature of ADPKD

- Sometimes present with kidney failure (usually in the fourth to sixth decade of
t
life)
ua
- May also present as asymptomatic on screening of family members

- Intracranial aneurysm is an important extrarenal manifestation (an important
point that is commonly asked)
al
Note: The other extra-renal manifestation are less commonly asked

Ev
Diagnosis:
Ultrasound
Treatment
Nonspecific; management of hypertension
24. A 65 year old woman with diabetes, and hypertension underwent a total right hip
replacement. She had massive haemorrhage during the operation and was given 8 units
of packed red blood cells. The blood pressure dropped to 60/40 mmHg for about two
hours before it was corrected with intravenous fluids and blood transfusions. Two days
after the surgery, her blood results show:
Serum creatinine level rose to 255 μmol/L

797
She had a normal kidney function prior to the surgery. What is the SINGLE most likely
diagnosis?
A. Diabetic nephropathy
B. Malignant hypertension
C. Rhabdomyolysis
D. Interstitial nephritis
E. Acute tubular necrosis
Acute tubular necrosis (ATN) can occur after a prolonged ischaemic event which likely
took place here as there was a massive haemorrhage and a hypotensive shock. This is
supported by the increased creatinine.
Acute tubular necrosis is the commonest renal cause of an acute kidney injury. Other
stems may include a history of nephrotoxins such as aminoglycosides, radiological
contrast, and myoglobinuria in rhabdomyolysis.
25. A 58 year old man complains of tiredness, lethargy, nausea and severe itching which is
y
worse after a hot bath and at night. His skin appears pale and dry with increased skin
op
pigmentation and numerous scratch marks. Peripheral oedema is noted on
Plab Lab Values
C
A. Hyperthyroidism
B. Polycythaemia vera
n
C. Chronic renal failure
io
D. Eczema
E. Liver failure
t
ua
The signs and symptoms points towards chronic renal failure. Uraemic pruritus also
known as chronic kidney disease associated pruritus refers to excessive urea in the
blood and occurs when both kidneys fail to work sufficiently. It is a common feature of
al
end stage renal disease and has been seen to affect one-third of patients on dialysis.
Ev
26. A 35 year old man has recently been diagnosed as having asthma. He has attended
clinic with complains of having deep and aching pains in his lower back especially at
night. On examination, there are skin lesions present in the form of tender
subcutaneous nodules on his legs. Investigations were performed and he was started
on corticosteroids. What is the SINGLE most likely diagnosis?
A. Ankylosing spondylitis
C. Cryptogenic fibrosing alveolitis
E. Tropical eosinophilia
Churg-Strauss syndrome
The cardinal manifestations of Churg-Strauss syndrome are asthma, eosinophilia, and
lung involvement
Presentation
798
Depends on which systems are involved
The most prominent symptoms and signs include:
- Pulmonary: Asthma, haemoptysis
- Upper respiratory tract: Nasal polyposis, allergic rhinitis
- Cardiac: Heart failure, myocarditis and myocardial infarction
- Skin: Purpura, skin nodules, urticaria
- Renal: Glomerulonephritis, hypertension
- Peripheral neuropathy: mononeuritis multiplex
The typical patient with Churg-Strauss is a middle aged individual with new-onset
asthma. Other symptoms that may be included in the stem are mononeuropathy,
transient pulmonary infiltrates seen on chest X-ray, nasal polyps, and allergic rhinitis.
Diagnosis
- Peripheral eosinophilia is the most common finding
- p-ANCA may be positive
- Biopsy involved tissue
y
Management
op
- Corticosteroids
27. A 2 year old boy has gradual swelling of his face, feet and legs. He feeds poorly but is
C
noted to have gained weight. There is a foamy appearance of the urine. He feels
fatigue. What is the SINGLE most appropriate investigation?
n
A. Ultrasound kidneys
io
B. 24 hour urinary protein

C. Serum calcium
t

ua
E. Serum glucose
This is a case of nephrotic syndrome which is likely caused by minimal change disease.
al
Minimal change disease has a peak incidence at 2 to 3 years of age. Almost all cases are
idiopathic but a small percentage of cases have identifiable causes like NSAIDs, toxins,
Ev
and infections.
Children with minimal change disease often gain weight, as they are excreting less
water in the urine.
Testing the renal function is important however in most cases it would be normal
(hyponatremia is often observed due to water retention). A 24-hour urine
measurement for protein and creatinine clearance is a better answer.
Nephrotic syndrome
Triad of:
1. Proteinuria (> 3g/24hr) causing
2. Hypoalbuminaemia (< 30g/L) and
3. Oedema
799
28. A 52 year old man known diabetes mellitus presents to emergency department with
sudden onset of pain in the left loin and haematuria. An ultrasound scan shows a 7mm
stone in left lower ureter. Diclofenac was administered for the renal colic pain and
nifedipine and prednisolone was prescribed as initial treatment as part of an expulsive
therapy. He returns to the emergency department the following day with worsening
pain, vomiting and a history of having passed two stones. A repeat ultrasound scan
reveals hydronephrosis in the left ureter and the presence of stones. His renal function
test indicate an acute kidney injury. What is the SINGLE most appropriate
management?
A. Repeat a similar regimen

B. Administer an alpha blocker
C. Extracorporeal shock wave lithotripsy
D. Open surgery
E. Percutaneous nephrostomy
This acute kidney injury and hydronephrosis are indicative of an obstructive uropathy.
Percutaneous nephrostomy would be the best intervention to temporary decompress
y
the renal collecting system.
Percutaneous nephrostomy
op
C
This is used as a temporary relief of ureteric obstruction where ureteric stones fail to
respond to analgesics and where renal function is impaired due to the stone. It is an
intervention that decompresses the renal collecting system by placing a catheter,
n
through the skin, into the kidney, under local anaesthetic. This catheter allows the urine
io
to drain from the kidney into a collecting bag, outside the body. Another method that is
often used to relieve ureteric obstruction is an insertion of a JJ stent.
t
ua
The function of a percutaneous nephrostomy is to bypass the ureteric obstruction and

therefore relieve the pain associated with the obstruction.
al
The percutaneous nephrostomy tube can restore efficient peristalsis to the ureteric
wall and in some cases this allows the stone to pass down and out of the ureter with
Ev
the nephrostomy in situ, however in many instances, it simply sits where it is and
subsequent definitive management to remove the stone is still required.
29. A 2 year old boy is brought to the hospital by his mother with diarrhoea and vomiting.
He was previously fit and well until a few days ago where he was treated with
antibiotics by his general practitioner for an upper respiratory tract infection. He no
longer has a cough but feels extremely unwell. His recent blood test show:
Na 124
Potassium 5.9
Urea 10.1
A. Renal failure
B. Adrenal insufficiency
C. Gastroenteritis
800
D. Pyloric stenosis
E. Hypopituitarism
This is a stem that is missing a number of vital information. However, with the bloods
alone, one can say that this patient has a form of acute kidney injury. Whether the
aetiology is due to sepsis or drugs (antibiotics), it remains unknown.
Acute kidney injury (AKI), formerly referred to as acute renal failure (ARF), is seen as an
acute reduction in kidney function that results in a decline in glomerular filtration rate
(GFR) leading to retention of urea and other nitrogenous waste products. The urea
would be seen as high and high levels of urea in the blood can result in vomiting or
diarrhea (or both). Hyperkalaemia is seen as the kidneys are not able to filter out
potassium. Failure of kidneys to remove excess fluid results in hyponatraemia.
Clinical feature of acute kidney injury include fatigue, malaise, nausea, vomiting, chest
pain, palpitations, shortness of breath, fluid overload, abdominal pain, oliguria.
y
op
C
n
t io
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al
Ev
801
NEUROLOGY
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op
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Questions
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&
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Answers
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Ev
802
Neurology Questions
1. A 72 year old woman is seen to collapse by her son. He calls the paramedics
when she is unable to stand and seems weak down her right side. On arrival to
the A&E her GCS is 13/15 with a right hemiparesis. She is increasingly agitated
and within an hour her GCS is 8/15. Which is the SINGLE most appropriate next
course of action?
A. Urgent anaesthetic review

B. Start thrombolysis treatment
C. Give aspirin
D. Give lorazepam
E. Urgent CT head
2. A 50 year old man presents to the emergency department with right leg pain
and back pain. There is greater pain when he is lying supine with his leg raised.
y
A. MRI
op
B. CT spine
C. Plain X-ray
D. Dual energy X-ray absorptiometry
E. Doppler ultrasound
C
3. A 65 year old woman with difficulty in swallowing presents with an aspiration
n
pneumonia. She has a bovine cough. Her tongue looks wasted and sits in the
io
mouth with fasciculations. It is very difficult for her to articulate certain words.
Sometimes as she swallows food, it comes back through her nose. What is the
t
SINGLE most likely cause of her dysphagia?

ua
A. Bulbar palsy
al
C. Pharyngeal pouch
D. Pseudobulbar palsy
Ev
4. A 45 year old man has acute back pain radiating down to his legs and faecal
incontinence. On examination, perineal sensory loss is noted. What is the
A. Multiple sclerosis
B. Lumbosacral disc herniation
C. Degenerative disc disease
D. Thoracic disc herniation
E. Cauda equina syndrome
5. A 35 year old woman complains of dizziness. She awoke in the morning with a
mild headache and the dizziness started when she sat up in bed. She felt that
the room was spinning for a few minutes. If she is at rest the spinning stops but
is aggravated again by movement. There are no other neurological symptoms.
What is the SINGLE most likely diagnosis
803
A. Brainstem stroke
B. Benign paroxysmal positional vertigo
C. Meniere’s disease
D. Vestibular neuronitis
E. Acoustic neuroma
6. A 33 year old patient presents with gradual onset of headache, neck stiffness,
photophobia and fluctuating lost of consciousness. Cerebral spinal fluid shows
lymphocytosis and decrease glucose but no organism on gram stain. A CT head
was read as normal. What is the SINGLE most likely causative organism?
B. Mycobacterium tuberculosis
C. Cytomegalovirus
D. Listeria monocytogenes
E. Streptococcus pneumoniae
7. An 18 year old female presents to the Emergency Department with a
y
generalized tonic-clonic seizure. Her seizure had lasted 20 minutes according to
op
eyewitness accounts. Her SpO2 is currently 97% and she has already been given
2 doses of rectal diazepam but the seizures have not stopped. What is the
C
A. IV Lorazepam
B. IV Phenobarbital
n
C. IV Phenytoin
io
D. Refer to ICU
E. Immediate intubation
t
ua
8. A 50 year old lady presents with a sudden onset of severe occipital headache
associated with neck pain and vomiting. CT brain was inconclusive and a lumbar
puncture was performed which revealed xanthochromia. What is the SINGLE
al

Ev
A. Bacterial meningitis
B. Viral meningitis
C. Migraine
E. Subdural haemorrhage
9. A 70 year old woman was brought into the Emergency Department by her son
for increasing confusion and slurred speech. On examination, she was oriented
to time, place and person. Neurological examination was positive for bilateral
past pointing and truncal ataxia but no nystagmus. Blood tests were within
normal limits. Where is the SINGLE most likely location of her lesion?
A. Bilateral basal ganglia

B. Left temporo-parietal lobe
C. Cerebellar vermis
D. Left cerebellar lobe
E. Left-sided frontal lobe
804
10. A 26 year old woman complains of headache of 1 day duration that has been
intensifying in severity over the last few hours. There is discomfort while
turning her head and cannot tolerate bright lights. On examination, there is no
papilloedema nor rashes. Kernig’s sign is negative. Lumbar puncture results
reveal: elevated protein, normal glucose, and lymphocytosis. She is generally
unwell but haemodynamically stable. What is the single most likely diagnosis?
A. Viral meningitis
B. Migraine
C. Aseptic meningitis
D. Bacterial meningitis
E. TB meningitis
11. A 72 year old man with a history of hypertension and an ex-smoker presents to
the clinic with his wife due to change in behavior. For the past year and a half,
he has slowly become socially withdrawn with a decrease interest in his usual
hobbies. There are times where he forgets to groom himself and there was an
y
incident once where his wife found him urinating on the sofa. Over the past few
op
months there has been a gradual struggle with finding the right word choice
while talking. What is the SINGLE most likely diagnosis?
C
A. Depression
B. Frontotemporal dementia
C. Alzheimer’s disease
n
D. Vascular dementia
io
E. Lewy body disease

t
12. A 36 year old woman presents to clinic with intermittent episodes of dizziness
ua
that lasts 1 day each time for the past 6 months. Recently, she has experienced
ringing and increased pressure in her ears. Her husband noticed that she has
had to increase the volume of her television. MRI head is normal. What is the
al

Ev

B. Vestibular schwannoma
C. Vestibular neuronitis
D. Cervical spondylosis
E. Meniere’s disease
13. A 50 year old woman presents with facial asymmetry. She noted in the morning
that the right hand corner of her mouth was drooping. She had some pain
behind her right ear yesterday and complains of dryness in her right eye. On
examination, she is unable to move her right side of her face. What is the
A. Ramsey-Hunt syndrome
B. Bell's palsy
C. Multiple sclerosis
D. Stroke
E. Parotid tumour
805
14. A 5 year old girl is brought to the hospital by her mother with complaints of
sudden right facial weakness, numbness and pain around her ear. She reports
no other symptoms. On examination, her right eyebrow is unable to raise and
the right hand corner of her mouth is drooping. What is the SINGLE most likely
diagnosis?
A. Subarachnoid haemorrhage
B. Bell’s palsy
C. Stroke
D. Transient ischaemic attack
15. A 55 year old man presents to clinic with shortness of breath and increased
daytime sleepiness. He drinks 25 units of alcohol weekly. On examination, his
BMI is 35 kg/m2, blood pressure is 150/70 mmHg, and respiratory exam was
normal. His wife complains that he snores loudly at night. What is the SINGLE
most appropriate initial investigation likely to confirm his diagnosis?
y
op
A. Polysomnography
B. Pulse oximetry
C. EEG
C
D. Multiple sleep latency test
E. Epworth sleepiness scale
n
16. A 55 year old male had a recent transient ischaemic attack which he recovered
io
from. He had a stroke 4 years ago. ECG shows a heart rate of 80 bpm in sinus
rhythm. He is already on aspirin 75 mg and antihypertensive drugs. What
t
SINGLE medication(s) should be offered?

ua
A. Clopidogrel only
B. Aspirin 300 mg
al
C. Warfarin
D. Clopidogrel and statins
Ev
E. Add statin only
17. A 24 year old college student presents to A&E with nausea, vomiting, headache,
neck stiffness and a fever of 38.4°C. What is the SINGLE most appropriate
empirical antibiotic to be started immediately?
A. Intravenous Ceftriaxone
B. Intramuscular Benzylpenicillin
C. Intravenous Gentamicin
D. Intravenous Tazobactam
E. Intravenous Amoxicillin
18. A 55 year old man presents to clinic for gradual weakness of his arms bilaterally
over the past year. He is now unable to lift heavy loads above his head and has
difficulty breathing while going up the stairs. In the past month, he has noticed
hoarseness and difficulty in swallowing liquids. On examination, there were
muscle atrophy and weakness in the trunk, neck, back and both proximal upper
806
limbs for lower motor signs. Deep tendon reflexes the upper and lower limbs
were positive for upper motor signs with atrophy of the tongue. Hoffman’s sign
was positive and autoimmune panel is normal. What is the SINGLE most likely
diagnosis?
A. Myasthenia gravis
B. Guillain-Barre syndrome
D. Amyotrophic lateral sclerosis
E. Polymyositis
19. A 41 year old woman presents to clinic with vertigo, vomiting and a feeling of
aural fullness. The attacks of vertigo can last for several hours. She also states
that she has difficulty hearing. She had a similar attack last year. Recently, she
has experienced ringing in her ears. MRI scan was done and was found to be
normal. What is the SINGLE most likely diagnosis?
y
op
C
20. A 19 year old female with previous history of repeated pain over the medial
canthus and chronic use of nasal decongestants, presents with abrupt onset of
n
a severe headache, fever with chills and rigor, diplopia on lateral gaze,
io
moderate proptosis and chemosis. On examination optic disc is congested.

Which of the following is the SINGLE most likely diagnosis?
t
ua
A. Cavernous sinus thrombosis

B. Orbital cellulitis
C. Acute ethmoidal sinusitis
al
D. Orbital apex syndrome

E. Migraine
Ev
21. A 22 year old female was hit on the side of her head with a cricket ball during a
match. She initially lost consciousness but spontaneously recovered but is now
experiencing increasing headache with one episode of vomiting. Her roommate
has noticed that there is a slowing of responses. What is the SINGLE most likely
diagnosis?
B. Subdural haemorrhage
C. Epidural haemorrhage
D. Simple seizure
E. None of the above
22. A 26 year old man complains of pins and needles in his feet. He feels his legs
getting weaker in the past 2 days. He gives a history of feeling unwell and
having diarrhoea last week which has resolved. On examination, he has mild
807
bilateral facial weakness, reflexes are diminished and has impaired sensation in
his legs. What is the SINGLE most likely diagnosis?
A. Polymyositis
B. Multiple sclerosis
C. Guillain-Barré syndrome
D. Myasthenia Gravis
E. Motor neuron disease
23. A 64 year old man presents with a history of left sided hemiparesis and slurred
speech. His symptoms resolved and he was absolutely fine 6 hours after the
episode. What is the SINGLE most appropriate prophylactic regimen?
A. Aspirin 300mg for 2 weeks followed by aspirin 75 mg

B. Aspirin 300mg for 2 weeks followed by aspirin 75 mg and dipyridamole
200mg
C. Clopidogrel 75mg
D. Dipyridamole 200mg
y
E. Aspirin 300mg for 2 weeks
24.
op
A 2 year old child fell from his bicycle and immediately ceased breathing and
became pale. This was accompanied by a stiffening, clonic jerks of the limbs
C
and loss of consciousness. He regains full consciousness a few seconds later.
n
A. Reflex anoxic seizures
io
B. Epilepsy
C. Cardiac arrhythmia
t
D. Postural orthostatic tachycardia syndrome

ua
E. Pure autonomic failure
25. A 69 year old man presented to clinic with worsening balance and difficulty
al
walking over the past year. Recently, he has been prone to falling more
frequently and his wife notes he forgets to turn off the stove or water taps. He
Ev
has also started to have urinary urgency and incontinence. On examination he

is walking with a cane and has difficulty turning. What is the SINGLE most likely
diagnosis?
A. Parkinson’s disease
B. Normal pressure hydrocephalus
D. Dementia with Lewy bodies
E. Frontotemporal dementia (Pick’s disease)
26. A 32 year old female who is 18 months pregnant presents to the Emergency
Department. She has a history of epilepsy and is on medication for it however
she was non-compliant and did not take her medication for the past 5 days. She
had a tonic-clonic seizure earlier in the morning lasting for 5 minutes and was
brought in by ambulance. She has IV access. While waiting for a doctor, she
starts to have another generalized tonic-clonic seizure. What is the SINGLE
808
A. IV Lorazepam
B. IV Phenobarbital
C. IV Phenytoin
D. Refer to ICU
E. Rectal Diazepam
27. An 8 year old girl is brought to the clinic due to abnormal behavior noticed by
her teacher. She would stare blankly towards the wall, sometimes with an
upturning of the eyes for around 15 seconds, then blinks. This would occur
several times during the day. The teacher notes that while she would resume
her activity after these events she would be tired and unable to concentrate.
A. Simple partial seizure

B. Complex partial seizure
C. Absence seizure
D. Generalized seizure
y
E. Febrile seizure
28.
op
A 50 year old man, known case of hypertension and deep vein thrombosis,
presents to the Emergency Department with a sudden onset of vision loss in his
C
right eye. It is painless and lasted for approximately 5 minutes. He describes the
vision loss as a ‘black curtain coming down’. On examination, there is a bruit on
his neck. What is the SINGLE most likely diagnosis?
n
io
A. Retinal vein thrombosis

B. Retinal artery occlusion
t
C. Amaurosis Fugax
ua
D. Optic neuritis
E. Acute angle glaucoma
al
29. A previously healthy 20 year old woman presents to the Emergency

Department with the complaint of “falling out.” She was with her friends at a
Ev
restaurant when she felt faint and, according to friends, lost consciousness for
about a minute. There was no seizure activity noted, but the friends did notice
her arms twitching irregularly. She is now acting normally. She denies chest
pain or palpitations, and her electrocardiogram is normal. What is the SINGLE
A. Hypoglycaemia
B. Vertigo
C. Prolonged QT syndrome
D. Vasovagal syncope
E. Paroxysmal supraventricular tachycardia
30. A 50 year old woman presents following a fall. She reports pain and weakness
in her hands for several months, swallowing difficulties, and has bilateral
wasting of the small muscles of her hands. Her back and shoulders feel stiff.
The reflexes in her upper limbs are absent. Both legs show increased tone and
hyperreflexia. Pain and temperature sensation are impaired in the upper limbs.
809
She is also noted to have a facial palsy. What is the SINGLE most likely
diagnosis?
B. Motor neuron disease
C. Syringobulbia
D. Syringomyelia
E. Myasthenia gravis
31. A 55 year old chronic alcoholic who lives alone, brought in the emergency
department having been found confused at home after a fall. He complains of a
headache and gradually worsening confusion. What is the SINGLE most likely
diagnosis?
A. Vascular dementia
B. Hypoglycemia
C. Extradural haematoma
D. Subdural haematoma
y
E. Pick’s dementia
32.
op
A 45 year old man has been admitted for an elective surgery. 2 days later he
develops agitation, sweating and complains of seeing snakes on the hospital
C
wall. A history of chronic alcoholic abuse is revealed and chlordiazepoxide has
been started. What is the SINGLE most appropriate next course of action?
n
A. Add Diazepam
io
B. Add Acamprosate
C. Add Disulfiram
t
D. Add Thiamine
ua
E. Add Naloxone
33. An 82 year old lady had an ischaemic stroke that was confirmed with brain
al
imaging. She has no drug allergies and no other comorbidities. She was put on
aspirin 300mg daily for two weeks. What is the SINGLE most appropriate
Ev
medication to be given after the course of Aspirin is completed?
A. Clopidogrel
B. Ticagrelor
C. Combination of modified-release dipyridamole and low dose aspirin
D. Abciximab
E. No additional medication needed long term
34. A 24 year old woman complains of progressive left leg stiffness and clumsiness
over the few weeks. There has also been a history of intermittent blurry vision
that spontaneously resolves each time. On examination, there is increased
tone, left leg power of 3/5, and upward plantars. A pale disc was seen in
ophthalmoscopy. All other neurological examinations were normal. What is the
A. Non-steroidal anti-inflammatory drug

B. Methotrexate
810
C. Interferon-beta
D. Methylprednisolone
E. Bed rest
35. A 60 year old man presents to Emergency with dizziness. The onset was sudden
and described as “the room spinning around”. He also is bumping into things on
his right side. On examination, his blood pressure is 159/91 mmHg, heart rate is
72 bpm. He is positive for nystagmus and dysdiadochokinesia. CT brain
confirms ischaemic stroke. Where is the SINGLE most likely location of his
stroke?
A. Temporal lobe
B. Left parietal lobe
C. Right parietal lobe
D. Anterior circulation
E. Posterior circulation
36. A 34 year old man is hit by a car. He loses consciousness but is found to be fine
y
by the paramedics. When awaiting doctors review in the Emergency
op
Department he suddenly becomes unconscious. What is the SINGLE most likely
diagnosis? C
B. Subdural haematoma
C. Intracerebral haemorrhage
n
D. Extradural (epidural) haematoma
io
E. Whiplash
t
37. A 58 year old man has visual hallucinations of animals walking around his room.
ua
He is amused by them but is conscious that they are not real. He is noted to
have fluctuating levels of awareness and attention and a decline in problem
solving ability. Signs of mild parkinsonism are also seen. What is the SINGLE
al

Ev
A. Frontotemporal dementia
B. Lewy body dementia
C. Delirium tremens
D. Alzheimer’s disease
E. Huntington’s disease
38. A 54 year old chronic alcoholic man was admitted in the hospital for a fractured
femur 2 days ago. He now has tremors, is profusely sweating, apprehensive and
fearful. What is the SINGLE most appropriate treatment?
A. Acamprosate
B. Chlordiazepoxide
C. Lorazepam
D. Lofexidine
E. Procyclidine
811
39. A 26 year old woman who is a known epileptic wants to start a family. She
takes sodium valproate for her epilepsy which has been well controlled and has
been seizure free for the past year. She and her husband have been using
condoms as contraception till present. She attends clinic seeking advice
regarding her antiepileptic medication as she would like to get pregnant. What
is the SINGLE most appropriate advice to give?
A. Add ferrous sulphate

B. Change sodium valproate to carbamazepine
C. Advise to stop antiepileptic medication and start folic acid
D. Reduce dose of sodium valproate
E. No change in medication
40. A 52 year old lady has weak limbs when examined. She was found to have burn
marks on finger tips. Her hands looked wasted and with diminished reflexes.
She also has weak spastic legs and dissociated sensory loss. What is the SINGLE
y
op
B. Syringomyelia
C. Motor neuron disease
D. Guillain-barre
C
E. Friedreich's ataxia
41. A 75 year old woman has been admitted from a nursing home with sudden
n
onset of right hemiplegia and homonymous hemianopia. She is dysphasic. She
io
remains conscious throughout and on examination, brisk reflexes and several

beats of clonus are noted. What is the SINGLE most likely artery to be
t
occluded?
ua
A. Right middle cerebral artery

B. Left middle cerebral artery
al
C. Right posterior cerebral artery

D. Right posterior cerebral artery
Ev
E. Left basilar artery
42. A 32 year old female presents with a history of recurring headaches. They are
usually unilateral, last for 24–48 hours, have a pulsatile quality, and are
associated with nausea and photophobia.The patient describes the headaches
as intense, usually requiring her to limit her activities. She has tried several
over-the-counter medications with no relief. Which of the following is the
SINGLE most appropriate choice for first-line management of her condition?
A. Paracetamol oral
B. Prednisone oral
C. Sumatriptan oral
D. Sumatriptan nasal
E. Oxycodone oral
43. 79 year old stumbled at home and sustained a minor head injury 2 weeks ago.
He did not become unconscious and was well after the fall. His son has brought
812
him to clinic because he has become increasingly confused, drowsy and
unsteady over the past few days. He has a GCS of 13. His past medical history
includes atrial fibrillation in which he takes warfarin for. What is the SINGLE
A. Alzheimers
B. Delirium
C. Chronic Subdural haemorrhage
44. A 45 year old man presents to the emergency department with acute back pain
radiating down to his legs, urinary retention and incontinence. On examination,
perineal sensory loss is noted. What is the SINGLE most appropriate
investigation?
A. MRI
B. CT spine
y
C. Plain X-rays
op
E. PET CT C
45. A 33 year old woman previously in good health presents with sudden onset of
severe occipital headache and vomiting a few hours ago. Her only physical sign
on examination is a stiff neck. What is the SINGLE most likely diagnosis?
n
io
t
C. Cerebellar haemorrhage
ua
D. Migraine
E. Cerebral embolism
al
46. A 39 year old chronic alcoholic stopped drinking alcohol for the last 2 days. He
is now anxious, has tremors and is sweating profusely. His heart rate is 103
Ev
beats/minute. What is the SINGLE most appropriate treatment?
A. Naloxone
B. Benzodiazepines
C. Acamprosate
D. Disulfiram
E. Haloperidol
47. A 45 year old chronic alcoholic presents to A&E with an ataxic gait,
hallucinations and is confused. He is given chlordiazepoxide. What is the SINGLE
most appropriate medication to be given with chlordiazepoxide?
A. Acamprosate
B. Thiamine
C. Diazepam
D. Disulfiram
E. Haloperidol
813
radiating down to his right leg. The pain is relieved when lying down and
exacerbated by long walks and prolonged sitting. What is the SINGLE most
A. MRI
B. CT spine
C. X-ray spine
E. Serum paraprotein electrophoresis
49. A 44 year old man presents to Emergency after falling from a third floor
building. His Glasgow Coma Scale is 4/15. He is intubated and ventilated on
arrival. Neurological examination reveals unequal pupils. CT head and neck
reveals midline shift and a left-sided convex enhancing area. What is the
y
A. Intravenous mannitol to reduce intracranial pressure
op
B. Intravenous thiopentone to reduce intracranial pressure
C. Conservative management with 30 degree head-up
D. Urgent craniotomy
C
E. Endovascular coiling under neuroradiological guidance
50. A 64 year old housewife, known case of uncontrolled hypertension, presents to

n
emergency with dysphagia, right sided hemi-paresis and ataxia. There is also
io
loss of sensation on the left side of the face. Which of the following is the
SINGLE most likely area in the brain to be affected?
t
ua
A. Frontal lobe
B. Parietal lobe
C. Temporal lobe
al
D. Lateral medulla
E. Occipital lobe
Ev
51. A 26 year old man was found on the street to be unsteady and drunk by police.
On admission to Emergency, he had a sudden onset of headache with severe
intensity. The headache is localized to his occipital area and is continuous. On
examination, his GCS is 15/15, afebrile and no focal neurological signs. What is
the SINGLE most likely diagnosis
A. Subdural haemorrhage
D. Cluster headache
E. Viral meningitis
52. A 62 year old man has recently had a flu-like illness. He woke up with difficult
and unclear articulation of speech. Movement of his eyelids and lips are weak
on the right side. What is the SINGLE most likely anatomical site affected?
814
A. Facial nerve
B. Hypoglossal nerve
C. Oculomotor nerve
D. Trigeminal nerve
E. Glossopharyngeal nerve
53. A 78 year old male presents with a history of urinary incontinence and change
in behavior. On examination, he has a waddling gait. What is the SINGLE most
likely diagnosis?
A. Subdural hemorrhage
B. Brain tumor
C. Parkinson's disease
D. Psychotic depression
E. Normal pressure hydrocephalus
54. A 49 year old man first presented with increasing difficulty in swallowing.
y
Several months later he developed weakness in his right foot. Now he can no
op
longer feed himself, he chokes on food and has become confined to a
wheelchair. What is SINGLE most likely diagnosis?
C
A. Cerebral tumor
C. Lambert-Eaton syndrome
n
io
E. Cerebrovascular disease
t
55. A 66 year old man, known case of uncontrolled hypertension, presents to clinic
ua
with confusion. He has a past history of transient ischaemic attack where he

temporarily suffered from left arm paralysis. Throughout the year, his wife has
noticed a decline in his memory, along with clumsy gait which has made him
al
prone to falls, as well as progressive urinary incontinence. On examination, his

BMI is 31 kg/m2 and has irritable mood. MRI brain showed multiple subcortical
Ev
lacunar old infarcts. What is the SINGLE most likely diagnosis?
C. Fronto-temporal (Pick’s) dementia
56. A 26 year old woman presents to her GP with a headache, photophobia and a
fever. On examination, a generalized rash that does not blanch on pressure was
observed. What is the SINGLE most appropriate initial management?
A. IM benzylpenicillin
B. Isolate the patient
C. Blood culture
D. IV Gentamicin
E. IV Ceftriaxone
815
57. A 44 year old woman presents with a severe throbbing unilateral right sided
headache and photophobia 20 minutes after an episode of tingling and
numbness of her left hand. What is the SINGLE most likely diagnosis?
A. Transient Ischemic Attack

B. Migraine
C. Meningitis
D. Stroke
E. Subarachnoid haemorrhage
58. A 50 year old man complains of being pursued by the police for a crime he
denies committing however on further investigation, this was found to be
untrue. He has poor concentration and impaired short-term memory. He
admits to drinking large amounts of alcohol for the last 20 years. He is able to
carry on a coherent conversation, but moments later he is unable to recall that
the conversation took place. What is the SINGLE most likely diagnosis?
y
A. Cotard syndrome
op
B. Alcohol withdrawal
C. Wernicke’s encephalopathy
D. Schizophrenia
C
E. Korsakoff psychosis
59. A 69 year old woman is brought to A&E by ambulance with no significant past
n
medical history or allergies. She presents with speech disturbance and
io
asymmetric facial and arm weakness. The symptoms began 3 hours ago. Brain
imaging shows an ischaemic stroke. Which is the SINGLE most appropriate next
t
course of action?
ua
A. Anticoagulation
B. Administer alteplase
al
C. Administer streptokinase
D. Start statins
Ev
E. Review in 24 hours
60. A 46 year old chronic alcoholic man is brought to the emergency department in
a drowsy state. He is responding vaguely to questions. He denies any alcohol
intake today. He walks with an ataxic gait. Examination reveals nystagmus and
hyperreflexia.
Haemoglobin 128 g/L

What is the SINGLE most likely cause for his cognitive impairment?
A. B1 deficiency
B. B6 deficiency
C. B12 deficiency
E. Liver disease
816
61. A 43 year old woman presented with blurred vision and intermittent clumsiness
for 3 months. Reflexes are brisk in her arm and optic disc is pale. What is the
SINGLE most appropriate test to confirm diagnosis?
A. CSF analysis
B. CT
C. MRI
D. EEG
E. EMG
62. A 33 year old man was working late in his office when he had a sudden onset of
excruciating headache localized to his right side and associated with right eye
pain. He has had similar episodes 2 months ago. On examination, his right eye
is swollen and red with lacrimation. What is the SINGLE most likely diagnosis?
A. Migraine with aura

B. Temporal arteritis
y
C. Conjunctivitis
op
D. Cluster headache
E. Tension headache C
63. A 31 year old woman, no known case of medical illnesses, presents to clinic
with numbness and tingling of her hands and fingers followed by a severe
throbbing headache localized to her left side. At home she tried to relieve her
n
headache with cold packs, paracetamol, and ibuprofen but there was no relief.
io
She has had similar episodes in the past. Currently, she is nauseated. On
examination, she required the lights to be dimmed. What is the SINGLE most
t
appropriate next step pharmacological management?

ua
A. Perfalgan IV
B. Ketoprofen oral
al
C. Sumatriptan oral
D. Gabapentin oral
Ev
E. Topiramate oral
64. A 68 year old lady complains of falls to the ground without any warning. She
maintains consciousness throughout and remembers the event. There is no
confusion after the fall. What is the SINGLE most likely diagnosis?
A. Stokes Adams attack

B. Hypoglycaemia
C. Vasovagal syncope
D. Drop attacks
E. Epilepsy
65. A 65 year old man has been recently diagnosed with atrial fibrillation. He has
suffered from a transient ischaemic attack 3 years ago. His medical history is
significant for diabetes mellitus type 2. What is the SINGLE best scoring method
to assess the need for anticoagulation?
817
A. ABCD2
B. CHA2DS2-VASc
C. Well’s Score
D. CURB-65
E. NYHA Score
66. A 78 year old woman admitted for a urinary tract infection for the last 10 days
has become increasingly confused. Her son has noted her level of
consciousness has been fluctuating and is disoriented to time and place. She is
more withdrawn but intermittently becomes very noisy and agitated. What is
A. Dementia
B. Delirium
C. Schizophrenia
D. Depression
E. Cerebral mass
y
67. A 30 year old primigravid woman of 32 weeks gestation presents to clinic with
op
left facial droop of 2 days duration. On examination, there is no rash. The
nasolabial fold is flattened, there is a drooping of the left corner of her mouth
when asked to smile, and eye closure is weaker on the left side. She is unable to
C
puff her cheeks but is able to wrinkle her forehead. What is the SINGLE most
likely cause to these clinical findings?
n
A. Ramsay-Hunt syndrome
io
B. Parotid gland tumour

C. Bell’s palsy
t
D. Internal capsule stroke

ua
E. Lyme disease
68. A 56 year old woman with multiple sclerosis presents with drooping her lips on
al
the left side. She also has loss of sensation over her face, and hearing
impairment. She has lack of voluntary coordination of muscle movements.
Ev
What is the SINGLE most likely anatomical site affected?
A. Cerebellum
B. Cerebrum
C. Spinal cord
D. Brain stem
E. Optic nerve
69. A 40 year old woman suddenly collapsed and died. At the post-mortem
autopsy, it was found that there was a bleed from a berry aneurysm from the
circle of Willis. Which is the most likely space that the bleeding occurred in?
A. Subarachnoid
B. Subdural
C. Extradural
D. Subparietal
E. Brain ventricles
818
70. A 7 year old child is brought to the hospital by his teacher. The child was playing
with other children and sudden fell down and hit the table and went
unconscious for a few seconds before returning to his normal self. On probing
further, the diagnosis of absence seizure was made. What is the SINGLE most
likely reason that could have led to this diagnosis?
A. The child had not eaten since morning

B. The child suddenly stared blankly into space and there was up-rolling of eyes
C. The child started moving his fingers uncontrollably before he fell
D. The child’s body became rigid and then started to jerk
E. The child has a fever and feels unwell
71. A 41 year old male with hypertension and recurrent kidney stones presents to
the Emergency Department with a headache of intense severity. He is also
noted to have neck stiffness and pain. Labs were done and revealed a serum
sodium of 131 mmol/L. What is the SINGLE most likely mechanism behind his
serum sodium results?
y
op
A. Decreased intake of food
B. Polyuria
C. Syndrome of inappropriate anti-diuretic hormone
C
D. None of the above
E. All of the above
n
72. A 49 year old patient has Parkinson’s disease. What is the SINGLE most useful
io
medication in the management of his tremor and dystonia?

t
A. Apomorphine
ua
B. Cabergoline
C. Selegiline
D. Amantadine
al
E. Benzhexol
Ev
73. A 53 year old man presents to clinic with complains of urinary incontinence and
erectile dysfunction. He is seen to have ataxia, rigidity and a pill rolling tremor
of the hands. On examination, postural hypotension is also noted. What is the
B. Creutzfeldt-Jakob disease
C. Shy-drager syndrome
D. Huntington’s disease
E. Lewy body dementia
74. A 26 year old female presents with bladder incontinence, clumsiness when
walking, shooting lower back pain, and blurry vision, and sensory loss. These
symptoms have occurred all at once or in different combinations approximately
every few months and each event lasts 3-4 days. There is swelling of the optic
disc on fundoscopy, inability to walk heel to toe, and weakness at the hip
girdles. What is the SINGLE most appropriate diagnostic test?
819
A. CT head and spinal cord
B. MRI brain and spinal cord
C. Serum Vitamin B12 levels
D. EMG
75. A 73 year old male presents with a history of falls over the past 12 month. His
relatives have also noticed a rather strange behavior lately and more recently
he has had episodes of enuresis. Examination reveals that he is disorientation
to time and place, with a broad-based, clumsy gait. What is the SINGLE most
likely diagnosis?
B. Pituitary adenoma
C. Cardiovascular disease
D. Syringomyelia
y
op
76. A 54 year old man had a recent stroke. He now presents with ataxia, intentional
tremors and dysarthria. Which part of the brain is most likely affected by the
stroke?
C
A. Inner ear
B. Brain stem
n
C. Diencephalon
io
D. Cerebrum
E. Cerebellum
t
ua
77. A 22 year old female presents with progressive difficulty in walking due to
lower back pain. There is tingling and numbness in her hands that has radiated
towards her elbows. On examination, cranial nerves are intact. There is no
al
sensation of vibration or pin prick in her upper limbs to elbows and from lower
limbs to hips. There are absent reflexes and mute plantars. Blood pressure is
Ev
124/85 mmHg and heart rate is 68 beats/minute. The patient had an episode of
food poisoning two months ago. What is the SINGLE most likely diagnosis?
C. Myasthenia gravis
D. Diabetic neuropathy
E. Infective neuropathy
78. A 55 year old was admitted to the hospital for investigations of haemoptysis.
Two days after admission he develops alternating state of consciousness,
sweating, and tremors. His temperature is 37.3°C. He gives a history drinking
alcohol every day for the past year. What is the SINGLE most appropriate
management?
A. Acamprosate
B. Chlordiazepoxide
820
C. Antibiotics
D. High potency vitamin B complex
E. Disulfiram
79. A 28 year old woman complains of double vision. She tires easily especially as
the day progresses. There is difficulty climbing stairs, reaching for items on
shelves, and brushing her hair. As she speaks, her speech fades gradually. Over
the last week, she has had difficulty chewing and swallowing. On examination,
there were no significant findings. She has a family history of thyroid disease.
A. Polymyositis
80. A 63 year old man presents after having a seizure. He is alert and orientated.
y
On examination, inattention on the left side is noticed with hyperreflexia of the
op
arm. What is the SINGLE most likely diagnosis?
A. Cerebral tumour
C
C. Cerebellar abscess
D. Huntington's chorea
n
E. Parkinsonism
io
81. A 63 year old man, known case of hypertension and smoker, presents to clinic
t
with a sudden onset of weakness in the right arm and changes in speech which
ua
had resolved within a 24 hour period. On examination, there were no residual

neurological findings and cardiology examination was normal. What is the
al
A. MRI brain
Ev
B. CT brain
C. Echocardiogram
E. Carotid doppler scanning
82. A 58 year old man has a progressively worsening headache and confusion. He
had a fall three days ago after slipping and hitting his head in the garden. He
has a history of alcohol abuse. What is the SINGLE most appropriate
investigation?
A. X-ray skull
B. Electrocardiogram
D. Magnetic resonance imaging brain scan
E. Electroencephalogram
821
83. A 67 year old man with a known case of diabetes mellitus type II and prostate
carcinoma presents to clinic with back pain, groin numbness, and inability to
initiate voiding. Which of the following is the SINGLE most likely mechanism to
explain for these symptoms?
A. Cauda Equina syndrome

B. Urinary outlet obstruction secondary to prostate carcinoma
C. Hydronephrosis secondary to urolithiasis
D. Neurogenic bladder from long-standing diabetes mellitus type II
84. A 56 year old male has increased thirst and increased micturition. He is found
to have an intracranial tumour. Where is the SINGLE most likely location for the
tumour?
A. Diencephalon
B. Midbrain
C. Medulla
y
D. Pons
op
E. Cerebrum
85. A 75 year old lady on warfarin for atrial fibrillation is brought into clinic by her
C
daughter. Her daughter is concerned as her mother is progressively getting
more confused over the last couple of weeks. On physical examination,the lady
was noticed to have bruises on her arms. She has an INR of 7. What is the
n
io
A. Alzheimers
t
B. Delirium
ua

al
86. The daughter of a 69 year old male found her father alone in his apartment
Ev
with confusion, bruising on his left arm and an unsteady gait. CT brain reveals a
midline shift away from the side of a clot. What is the SINGLE most likely
diagnosis?
B. Intracerebral bleed
C. Subdural haemorrhage
D. Epidural haemorrhage
E. Complex partial seizure
87. A 67 year old woman with a history of atrial fibrillation with presents to
emergency with slurred speech, asymmetric facial weakness, left sided hemi-
paresis and ataxia. On arrival to the A&E her GCS is 14/15. She is increasingly
agitated. Which is the SINGLE most appropriate next course of action?
A. Anticoagulation
822
C. Give aspirin
D. Give lorazepam
E. Urgent CT head
88. A 34 year old housemaid presents with severe headaches in the back of her
head for several days and pain on flexing her neck. The pain is worsened by
movements. On examination, there is limited range of movement of the neck.
B. Cervical spondylosis
C. Subarachnoid haemorrhage
D. Meningitis
E. Cluster headache
89. A 75 year old nursing home resident complains of worsening headache, and
impaired vision for 4 days. Her daughter says she is getting more and more
confused day by day. She has multiple bruises on her head. What is the SINGLE
y
most likely cause of her confusion?
A. Alcohol intoxication
B. Infection
op
C
C. Subdural haematoma
D. Hypoglycaemia
E. Hyponatraemia
n
io
90. A previously healthy 2 year old girl is brought to the Emergency Department by
her mother after having witnessed the child’s body suddenly going stiff
t
followed by uncontrolled twitching of the arms and legs for about 5 minutes.
ua
There was frothing at the mouth and on examination now the child is drowsy.
Temperature on admission was 38oC. This was a first time event. What is the
SINGLE next appropriate management?
al
A. Paracetamol and observation

Ev
B. Diazepam per rectal

C. Lumbar puncture
D. CT brain
E. EEG
91. A 45 year old man, with no known medical illnesses, presents to the clinic with
left facial pain for the past month. It is a sharp shooting pain that radiates
around his left cheek while chewing. It would last a few seconds repeatedly
throughout the day. He has taken ibuprofen but with no relief. On examination:
blood pressure is 120/70 mmHg, neurological exam is normal, palpation to the
left jaw and cheek elicits pain although jaw muscles are of full strength. What is
the SINGLE most appropriate management for this condition?
A. Amitriptyline
B. Patient controlled analgesia
C. Gabapentin
D. Carbamazepine
823
E. Microvascular decompression
92. A 70 year old man with a known case of ischaemic heart disease presents to
emergency with paralysis of his left arm, sensory loss on the left side of his
face, right sided gaze preference and homonymous hemianopsia. Which of the
following is the SINGLE most likely artery to be affected?

B. Right posterior cerebral artery
C. Left posterior cerebral artery
D. Right anterior cerebral artery
E. Basilar artery
93. A 52 year old man presents with visual hallucinations and features of cognitive
impairment including memory loss. He has a tremor and a festinating gait.
y
op
C. Delirium tremens
C
94. A 45 year old man presents to clinic for his routine diabetic check-up. The
patient has normal tone, 5/5 power, normal plantars and proprioception. There
n
is sensory stimulus on the medial side of the right lower leg. Which of the
io
following is the SINGLE most likely dermatome to be affected?

t
A. L1
ua
B. L2
C. L3
D. L4
al
E. L5
Ev
95. A 49 year old chronic alcoholic with established liver damage is brought to the
hospital after an episode of heavy drinking. His is not able to walk straight and
is complaining of double vision. He is shouting obscenities and expletives. What
A. Korsakoff psychosis
B. Delirium tremens
C. Wernicke's encephalopathy
D. Tourettes syndrome
E. Alcohol dependence
96. A 72 year old man becomes confused over a period of 2 weeks. He used to be
active and goes for long walks. Now he stares at the wall, barely talks to
anyone, and sleeps majority of the day. His daughter recalls that he fell down
the stairs about a week before the mental changes began. What is the SINGLE
824
A. Chronic Subdural haemorrhage
B. Epidural haematoma
C. Alzheimers
97. An 50 year old man presents to the clinic with his wife. She states that her
husband has had a noticeable change in personality. He is impulsive and
occasionally demonstrates inappropriate behavior. On examination, he has
difficulty naming objects, but his memory, ability to calculate, and his
visuospatial skills are intact. What is the SINGLE most likely diagnosis?
A. Alzheimer’s disease
B. Frontotemporal dementia (Pick’s disease)
C. Parkinson’s disease
y
98. A 44 year old man with a history of chronic alcohol abuse attends A&E. He is
op
unkempt, drowsy, walks with an ataxic gait and has poor memory. it is believed
he has not eaten in forty eight hours. A decision to commence chlordiazepoxide
and IV Pabrinex is made. Which vitamin, present in Pabrinex, can prevent the
C
progression of his symptoms?
A. Vitamin B1
n
B. Vitamin B6
io
C. Vitamin B12
D. Vitamin C
t
E. Vitamin D
ua
99. A 53 year old chronic alcoholic was brought to the emergency department with
an alternating state of consciousness, nausea and vomiting. He has unsteady,
al
uncoordinated walking and complains of double vision. On examination of his

face, his eyelids seem to be drooping and nystagmus is seen. He denies having
Ev
taken alcohol in the last 12 hours. What is the SINGLE most appropriate
management?
A. Acamprosate
B. Chlordiazepoxide
C. Diazepam
E. Disulfiram
100. A 31 year old man with no past medical history complains of severe headache
since 2 hours ago during work. The headache is mainly localized to the left side
and is associated with photophobia. A similar episode had occurred a few
months ago which had lasted over 2 weeks and resolved spontaneously. During
the examination, he is unable to sit still with obvious agitation and anxiety.
825
B. Epidural haemorrhage
C. Tension headache
D. Cluster headache
E. Migraine
101. A 45 year old man has back pain radiating down to his legs. He has motor
weakness with knee extension and foot dorsiflexion. On examination, perineal
sensory loss is noted. What is the SINGLE most appropriate action?
A. Analgesia, rest and review in 6 weeks

B. Administer benzodiazepine
C. Encourage to keep active and referral to physiotherapist
D. Advise on correct sitting position and posture
E. Immediate referral to orthopaedic surgeon
102. A 60 year old woman presents with acute onset of bone and back pain
following a rough journey in a car. On examination, tenderness at the mid-
thoracic vertebra was noted. The pain is goes away when she bends forward.
y
A. Osteoporotic fracture of vertebra

B. Myofascial pain syndrome
op
C
C. Whiplash injury
D. Multiple myeloma
E. Bone metastasis
n
io
103. A 40 year old woman with a history of epilepsy presents to clinic with multiple
fleshy nodules and several light brown, round macules with a smooth border on
t
her back, arms and legs. There are also freckles under her arms. What is the
ua
A. Neurofibromatosis type I
al
B. Neurofibromatosis type II
C. Tuberous sclerosis
Ev
D. Hereditary haemorrhagic telangiectasia

E. Sturge–Weber syndrome
104. A 31 year old man, known case of alcohol abuse, is brought into Emergency by
his friend from a night club. The friend saw the patient suddenly collapse on the
dance floor where his body went stiff then there was twitching of his legs
followed by involuntary voiding. What is the SINGLE most likely diagnosis?
A. Complex partial seizure

B. Generalised myoclonic seizure
C. Generalised clonic seizure
D. Generalised tonic seizure
E. Generalised tonic-clonic seizure
105. An 80 year old man has had an ischaemic stroke and was brought to the A&E
department 6 hours after the onset of symptoms by his concerned daughter
who found him lying on the floor at home. A CT brain has already been done
826
and has confirmed the diagnosis. The patient has no drug allergies and no other
comorbidities. What is the SINGLE most appropriate medication to be given to
this patient upon discharge?
A. Clopidogrel 75 mg daily
B. Statin
C. Combination of modified-release dipyridamole (200 mg) and low dose aspirin
(75 mg) daily
D. Warfarin
E. Aspirin 300 mg daily for 3 months
106. A 56 year old lady has developed severe right sided headache which worsens
whenever she goes under bright light. This has been occurring for the last 3
days. She feels nauseated, but has not vomited. She does not take any
medication and has no relevant medical history. What is the SINGLE most likely
diagnosis?
y
B. Chronic subdural haemorrhage
op
C. Intracranial neoplasm
D. Cluster headache
E. Migraine
C
107. A 62 year old male is brought to the emergency department by his daughter as
he is confused, and has an unsteady, uncoordinated walking. He is a known
n
alcoholic and has been admitted recently with delirium tremens. On
io
questioning, he denies any problem with his memory. He knows his name and
address and convincingly states that he was at a betting shop in the morning.
t
His daughter interjects saying that, that is untrue as he was at home. What is
ua
A. Ganser syndrome
al
B. Cotard syndrome
Ev
D. Korsakoff psychosis
E. Alcohol withdrawal
108. An 81 year old man is brought into clinic by his son who is concerned that his
father doesn’t seem to be himself. His wife died 3 years ago and has been
depressed since. The son notes that his father has become increasingly
forgetful, leaving taps running or the stove on when not in use. At times, he
cannot articulate what he wants to say and is easily confused. CT brain reveals
mild, diffuse cortical atrophy. Which of the following is the SINGLE most likely
medication to be started first?
A. Donepezil
B. Memantine
C. Haloperidol
D. Olanzapine
E. Amitriptyline
827
109. A 65 year old known alcoholic is brought into hospital with confusion,
aggressiveness and ophthalmoplegia. He is treated with chlordiazepoxide.
What is the SINGLE most appropriate medication to give alongside
chlordiazepoxide?
A. IV Antibiotics
B. Glucose
C. Acamprosate
D. Disulfiram
E. Vitamin B complex
110. A 73 year old woman presents to clinic accompanied by her son with a 6 month
history of anorexia and altered bowel habits. She has no significant past
medical history and is on aspirin. On examination, the patient has an
expressionless face, she takes many steps to turn, has resting tremor in
predominantly in her right hand, and cogwheel rigidity. Cognition is intact.
y
A. Malignancy
op
D. Progressive supranuclear palsy
C
111. A 20 year old fit man suddenly develops severe lower back pain as he is getting
n
up from bed. There is greater pain when he is lying supine with his leg raised.
io

t
ua
B. Multiple myeloma
C. Lumbosacral disc herniation
D. Ankylosing spondylitis
al
E. Cervical spondylosis
Ev
112. A 74 year old woman was brought to clinic by her daughter for confusion and
memory impairment. The patient would periodically start a task and forget to
finish them and has difficulty naming objects. In the past few months, she has
lost 5kg and does not sleep well at night. On examination, the patient was
agitated and had decreased skin turgor, and not oriented to time or place. She
repeatedly asks the same questions during the interview. What is the SINGLE
113. A 43 year old chronic alcoholic stopped drinking alcohol for the last 3 days. He
is anxious, has tremors and is now having hallucinations. His heart rate is 106
828
A. Olanzapine
B. Diazepam
C. Acamprosate
D. Disulfiram
E. Thiamine
114. A 42 year old female had a sudden onset of severe headache and vomiting. She
took paracetamol and an hour later she collapsed. Her medical history is
significant for Ehlers-Danlos syndrome. What is the SINGLE most likely
diagnosis?
B. Viral encephalitis
C. Meningitis
D. Anaphylaxis
E. Epidural haematoma
y
115. A 66 year old patient wakes up with slurred speech and right sided weakness.
op
He is brought to the hospital by his wife. A computed tomography was ordered
and shows a cerebral infarction. What is the SINGLE most appropriate
treatment to be given?
C
A. Aspirin
B. Alteplase
n
C. Warfarin
io
D. Streptokinase
E. Dipyridamole
t
ua
116. A 42 year old man has increasing daytime sleepiness. He feels that his tiredness
is affecting his work as he is unable to keep awake during meetings. He also
complains of choking episodes during his sleep. On examination, his BMI is 36
al
kg/m2, blood pressure is 150/70 mmHg, and respiratory exam was normal.
Ev
A. Idiopathic hypersomnia
B. Narcolepsy
C. Hyperventilation syndrome
D. Obstructive sleep apnoea syndrome
E. Rapid eye movement sleep behavior disorder
117. A 73 year old female patient presents with right sided hemiplegia and aphasia.
These symptoms resolved spontaneously in 6 hours. An ECG conducted in
hospital revealed atrial fibrillation. What is the SINGLE best scoring method to
assess her risk for future stroke?
A. ABCD2
B. CHA2DS2-VASc
C. Well’s Score
D. CURB-65
E. NYHA Score
829
118. A 19 year old woman complains of episodic headaches preceded by fortification
spectra. These episodes can sometimes last for 2-3 days. When these
headaches occur, she prefers to be in a quiet, dark room. What is the SINGLE
most appropriate management for the acute phase?
A. Topiramate
B. Aspirin
C. Propranolol
D. Gabapentin
E. Domperidone
119. A 45 year old man with terminal cancer who has recently completed his course
of chemotherapy develops tingling and numbness of the fingertips of both
arms. He describes a constant mild burning discomfort in his hands and feet.
Occasionally, he experiences a sharp, shooting, and electric-shock-like pain in
his feet. What is the SINGLE most likely cause of his symptoms?
y
A. Bone metastasis to cervical vertebrae
op
B. Chemotherapy induced peripheral neuropathy
C. Hyponatraemia
D. Hypocalcaemia
C
E. Hypomagnesemia
120. A 45 year old man has tremors in both his hands. The tremors are absent at rest
n
but present when arms are held outstretched and persist on movement.
io
Movements such as writing are affecting by his tremor. The tremor is seen to
be worse when he is tired or stressed. On examination, the tremor continues to
t
be present even when patient is distracted. What is the SINGLE most likely
ua
diagnosis?
A. Parkinsonian tremor
al
B. Essential tremor
C. Cerebellar disease
Ev
D. Psychogenic tremor
E. Stroke
121. A 52 year old man has incoherent speech. He is aware of his speech difficulties
but finds difficulty in using the right words when speaking. He has no other
symptoms apart from his speech issue. He has good comprehension. Which
anatomical site is most likely to be affected?
A. Broca’s area
B. Wernicke’s area
C. Midbrain
D. Parietal lobe
E. Brainstem
122. A 65 year old lady presents to the Accident and Emergency department with a 6
hour history of facial droop and weakness on her left side of her body. A CT
scan was performed and ruled out a haemorrhagic stroke. She is allergic to
830
Penicillin and takes Simvastatin and Amlodipine regularly. What is the SINGLE
most appropriate medication to be prescribed long term for this patient?
A. Alteplase
B. Clopidogrel
C. Dipyridamole
D. Labetalol
E. Aspirin
123. A 38 year old heroin addict was involved in a car crash and is now paraplegic.
He was agitated and cried everyday during the first two weeks after the
accident while in the hospital. On questioning, he is not able to remember the
accident and refuses to talk about it. What is the SINGLE most likely diagnosis?
A. Post traumatic stress disorder

B. Severe depression
C. Bipolar disorder
D. Organic brain injury
y
E. Borderline personality
124.
op
A 33 year old man presents with speech difficulties. He has a an irregular
breakdown of articulation. On examination, nystagmus is seen. Which
C
A. Midbrain
n
B. Pons
io
C. Cerebellum
D. Cerebrum
t
E. Vestibule cochlear nerve

ua
125. A 43 year old man presents with neck stiffness, headache and vomiting. The
headache is severe, persistent and on the left side. He also has ear pain and
al
discharge coming from his left ear. On examination, he has weakness of the
right hand and leg. He has a temperature of 38.5°C. What is the SINGLE most
Ev
likely diagnosis?
A. Viral meningitis
B. Bacterial meningitis
C. Mycotic aneurysm
D. Cerebral abscess
E. Cerebral tumour
126. A 68 year old man had a fall down the stairs. His daughter has brought him into
the emergency department where he was having lucid intervals. Shortly after
admission he becomes unconscious. What is the SINGLE most likely vessel
affected?
A. Basilar artery
B. Bridging veins
C. Vertebral artery
D. Diploic vein
831
E. Middle meningeal artery
127. A 42 year old lady presents with a history of double vision, ptosis and facial
numbness. Which anatomical site is the most likely to be affected?
A. Cerebral cortex
B. Trigeminal nerve
C. Oculomotor nerve
D. Brainstem
E. Basal ganglia
128. A 43 year old smoker presents with double vision. She tires easily, has difficulty
climbing stairs, and reaching for items on shelves. On examination, reflexes are
absent but elicited after exercise. The power in shoulder abduction after
repeated testing is 4+/5 from 3/5. What is the SINGLE most likely pathology
associated with this patient’s diagnosis?
A. Thyrotoxicosis
y
B. Thrombotic event
op
C. Diabetes
D. Cerebral vascular event
E. Lung cancer
C
129. A 44 year old woman has a two week history of electric shock-like stabbing
facial pain starting from her left jaw and radiates towards her forehead. The
n
pain is unilateral and it is described as very severe and coming in spasms. Her
io
corneal reflexes are found to be normal. What is the SINGLE most likely
diagnosis?
t
ua
A. Trigeminal neuralgia
B. Temporomandibular joint disorder
C. Atypical facial pain
al
D. Giant cell arteritis (GCA)

E. Herpes zoster ophthalmicus
Ev
130. A 25 year old woman presents with a severe headache. She had migraines for
the last 14 years but has been symptom free for the last year. There are no
other neurological signs. She has no other medical history of note. Her
observations are stable. What is the SINGLE most appropriate investigation for
this woman?

B. Lumbar puncture
C. Ophthalmoscope
D. Magnetic resonance imaging of head
E. No further investigation required
131. A 71 year old lady has a history of a fall 3 days ago with an injury to the head.
She is increasingly drowsy and has recently become confused and disoriented.
What is the SINGLE most likely vessel to be involved?
832
A. Diploic vein
B. Cerebral vein
C. Basal vein
D. Middle meningeal vein
132. 54 year old patient is seen at the clinic for muscle weakness. His muscle
weakness initially started at the level of his legs but now it is affecting his arms
too. On examination, he has loss of tendon reflexes and decreased muscle
strength. What is the SINGLE most likely mechanism of this weakness?
A. Amyloid deposition in neurons

B. Vasculitis
C. Reduction in the number of nicotinic acetylcholine at the postsynaptic
muscle membrane
D. Autoimmune degeneration of myelin sheets of peripheral neurons
E. Compression of spinal nerve
y
133. An 8 year old boy developed a seizure first affecting his right arm. The seizure
op
lasted for several minutes. He was unconscious throughout the seizure and has
no recollection of the events that occurred leading to his seizure. A computed
tomography scan of his head was organised after the seizure and has been
C
reported as having a lesion on the left cerebral hemisphere. What is the SINGLE
most likely reason for his seizure?
n
A. Epilepsy
io
B. Space occupying lesion

C. Dementia
t
D. Huntington’s chorea
ua
E. Intracranial hypertension
al
Ev
833
Neurology Answers
1. A 72 year old woman is seen to collapse by her son. He calls the paramedics
when she is unable to stand and seems weak down her right side. On arrival to
the A&E her GCS is 13/15 with a right hemiparesis. She is increasingly agitated
and within an hour her GCS is 8/15. Which is the SINGLE most appropriate next
course of action?
A. Urgent anaesthetic review

C. Give aspirin
D. Give lorazepam
E. Urgent CT head
Anaesthetic review would be the next most appropriate step of action. The
history and examination are convincing for a stroke but the patient has rapidly
dropped her consciousness levels, and before any investigations and treatment
can happen this needs to be addressed. An anaesthetist would rather know at
y
this stage rather than when a peri-arrest call is put out as her GCS reaches 4 or 5.
op
The airway can be stabilized so that a CT scan can be performed safely.
The other options are less likely to be the appropriate next course of action.
C
Thrombolysis or aspirin → are the treatment options for ischaemic strokes but
cannot be started until a CT scan excludes a haemorrhage.
n
io
Lorazepam → Agitation is common in intracranial events, especially

haemorrhages, but should not be treated with sedation as this can mask real
t
fluctuations in consciousness levels.

ua
Urgent CT head → This will certainly be needed as the history and examination
are convincing for a stroke. CT helps rule out primary haemorrhage. But only
al
after the airway has been stabilized by the anaesthetist.

Ev
Stroke management
Summary of management of acute stroke:

• blood glucose, hydration, oxygen saturation and temperature should be
maintained within normal limits
• aspirin 300mg orally or rectally should be given as soon as possible if a
haemorrhagic stroke has been excluded
• Thrombolysis should only be given if it is administered within 4.5 hours
of onset of stroke symptoms and haemorrhagic stroke has been
excluded by imaging (Alteplase is currently recommended by NICE)
Post management stroke

• Aspirin 300 mg daily for 2 weeks is given immediately after an ischaemic
stroke is confirmed by brain imaging.
• Clopidogrel 75 mg daily is then given long-term
• If clopidogrel is contraindicated or not tolerated, give a combination of
modified-release dipyridamole and low dose aspirin.
• Ensure a statin has been offered.
834
2. A 50 year old man presents to the emergency department with right leg pain and
back pain. There is greater pain when he is lying supine with his leg raised. What
is the SINGLE most appropriate investigation?
A. MRI
B. CT spine
C. Plain X-ray
E. Doppler ultrasound
Lumbosacral disc herniation

Presentation
If there is nerve entrapment in the lumbosacral spine, this leads to symptoms of

sciatica which include:
• Unilateral leg pain which radiates below the knee to the foot/toes
• The leg pain being more severe than the back pain
y
• Numbness, paraesthesia, weakness and/or loss of tendon reflexes,
op
which may be present and are found in the same distribution and only in
one nerve root distribution
• A positive straight leg raising test (there is greater leg pain and/or more
C
nerve compression symptoms on raising the leg).
• Pain which is usually relieved by lying down and exacerbated by long
walks and prolonged sitting
n
io
Large herniations can compress the cauda equina, leading to symptoms/signs of

saddle anaesthesia, urinary retention and incontinence
t
ua
Investigation
No investigation may be needed if the symptoms settle within six weeks. MRI
still remains the most sensitive in showing disc herniations. Plain X-rays may be
al
useful, as they can show misalignments, instabilities and congenital anomalies

well but the investigation of choice for a disc prolapse is an MRI.
Ev
3. A 65 year old woman with difficulty in swallowing presents with an aspiration

pneumonia. She has a bovine cough. Her tongue looks wasted and sits in the
mouth with fasciculations. It is very difficult for her to articulate certain words.
Sometimes as she swallows food, it comes back through her nose. What is the
SINGLE most likely cause of her dysphagia?
A. Bulbar palsy
C. Pharyngeal pouch
D. Pseudobulbar palsy
Given her symptoms of dysphagia, tongue fasciculations, nasal regurgitations,

and dysarthria, the likely diagnosis is bulbar palsy.
The phrase "A bovine cough" is used to describe the non- explosive cough of
835
someone unable to close their glottis. It is seen vagus nerve lesions, and may be
associated with dysphonia.
Bulbar Palsy
Bulbar relates to the medulla. Bulbar palsy is the result of diseases affecting the
lower cranial nerves (VII-XII). A speech deficit occurs due to paralysis or
weakness of the muscles of articulation which are supplied by these cranial
nerves.
Bulbar palsy is sometimes also classified as non-progressive or progressive:
• Non-progressive bulbar palsy is an uncommon condition of uncertain

aetiology and there are few reports of it in the literature.
• Progressive bulbar palsy can occur in children or adults and form a

spectrum of severity. Progressive bulbar palsy is more common in
elderly women. Starts of with dysarthria and/or dysphagia. Note:
y
dysphagia without dysarthria is very unusual. The limb involvement
op
comes later, perhaps in a couple of year. The median survival is 2–3
years. C
Presentation
• Tongue - weak and wasted and sits in the mouth with fasciculations.
• Drooling - as saliva collects in the mouth and the patient is unable to
n
swallow (dysphagia).
io
• Dysphonia - a rasping tone due to vocal cord paralysis; a nasal tone if

bilateral palatal paralysis.
t
• Articulation - difficulty pronouncing “r”; unable to pronounce

ua
consonants as dysarthria progresses.
4. A 45 year old man has acute back pain radiating down to his legs and faecal
al
incontinence. On examination, perineal sensory loss is noted. What is the SINGLE

Ev
B. Lumbosacral disc herniation
C. Degenerative disc disease
D. Thoracic disc herniation
E. Cauda equina syndrome
Cauda Equina Syndrome would fit the best. Although lumbosacral disc herniation
and degenerative process of the spine are causes of cauda equina syndrome it
would be more accurate to put Cauda Equina Syndrome as the answer due to
the perineal sensory loss.
Cauda Equina Syndrome is a serious neurologic condition in which damage to

the cauda equina causes loss of function of the nerve roots of the spinal canal
below the termination (conus medullaris) of the spinal cord. Any lesion which
compresses or disturbs the function of the cauda equina may disable the nerves
although the most common is a central disc prolapse.
836
Spinal cord compression or cauda equina syndrome are neurological
emergencies that require immediate referral and intervention.
The management of true cauda equina syndrome frequently involves surgical

decompression.
If there are red flag signs such as the possibility of cauda equina syndrome like in
this case, referral to an orthopaedic surgeon or a neurosurgeon should be
considered.
Red flags that suggest cauda equina syndrome include:

• Severe or progressive bilateral neurological deficit of the legs, such as
major motor weakness with knee extension, ankle eversion, or foot
dorsiflexion
• Recent-onset urinary retention and/or urinary incontinence (caused by
loss of sensation when passing urine).
• Recent-onset faecal incontinence (due to loss of sensation of rectal
y
fullness)
op
• Perianal or perineal sensory loss (saddle anaesthesia or paraesthesia)
5. A 35 year old woman complains of dizziness. She awoke in the morning with a
C
mild headache and the dizziness started when she sat up in bed. She felt that the
room was spinning for a few minutes. If she is at rest the spinning stops but is
aggravated again by movement. There are no other neurological symptoms.
n
What is the SINGLE most likely diagnosis
io
A. Brainstem stroke
t
B. Benign paroxysmal positional vertigo

ua
C. Meniere’s disease
D. Vestibular neuronitis
E. Acoustic neuroma
al
All of the above options are popular topics in PLAB 1. Meniere’s disease would
Ev
usually involve tinnitus, deafness, and increased ear pressure in the case stem.
Vestibular neuronitis, while similar to Meniere’s does not have hearing loss.
Acoustic neuroma as it grows into the cerebellopontine angle would involve
cranial nerves V, VII, VIII; therefore, you would have a variation of symptoms
involving these three nerves. Between options A and B, the symptoms in the
case stem would not spontaneously resolve for option A.
Benign paroxysmal positional vertigo
Presentation:
- Can be preceded by infections
- Vertigo on turning over in bed, lying down, or sitting up from supine
position
Diagnosis:
- Hallpike's Manoeuvre positive
Treatment:
- Mostly spontaneous resolution with exacerbations
837
6. A 33 year old patient presents with gradual onset of headache, neck stiffness,
photophobia and fluctuating lost of consciousness. Cerebral spinal fluid shows
lymphocytosis and decrease glucose but no organism on gram stain. A CT head
was read as normal. What is the SINGLE most likely causative organism?
B. Mycobacterium tuberculosis
C. Cytomegalovirus
D. Listeria monocytogenes
Tuberculous meningitis would show lymphocytosis and decreased glucose.
Characteristic cerebrospinal fluid (CSF) findings in meningitis:
Bacterial Viral Meningitis Tuberculous

Meningitis Meningitis
Glucose Low Normal Low
y
Protein High Normal to high High
op
White cells Mainly Increased Neutrophils
neutrophils lymphocytes in early disease,
Lymphocytes
C
later
n
7. An 18 year old female presents to the Emergency Department with a generalized

io
tonic-clonic seizure. Her seizure had lasted 20 minutes according to eyewitness

accounts. Her SpO2 is currently 97% and she has already been given 2 doses of
t
rectal diazepam but the seizures have not stopped. What is the SINGLE most
ua
A. IV Lorazepam
al
B. IV Phenobarbital
C. IV Phenytoin
Ev
D. Refer to ICU
E. Immediate intubation
The diagnosis here is status epilepticus. The patient continues to have a seizure
despite 2 doses of diazepam. Therefore, the next appropriate management
would be phenytoin infusion. If the patient was not given two doses of rectal
diazepam in the community, then we would administer IV lorazepam as first-line
treatment in hospital. However, because two doses of diazepam was given (most
likely in the community), we would move to second-line which would be IV
phenytoin. Preference goes to IV phenytoin before using IV phenobarbital.
If this also fails then the next step would be referral to ICU and then consider
intubation. For PLAB 1, know the initial management of all acute neurological
emergencies.
Note that buccal midazolam is usually first-line treatment in children, young

people and adults with prolonged or repeated seizures in the community.
838
However, if buccal midazolam is unavailable, rectal diazepam is used. Hence, the
probable reason why rectal diazepam was used in this stem.
Note that the management for ongoing generalised tonic–clonic seizures

(convulsive status epilepticus) in hospital is different from the community. Below
we will only discuss management in hospital.
Status epilepticus
In hospital management:
• ABC protocol
• Give high-concentration oxygen
• Check blood glucose levels
• Secure intravenous access in a large vein
• Administer intravenous lorazepam as first-line treatment in hospital for
ongoing generalised tonic–clonic seizures (convulsive status epilepticus)
• Administer intravenous diazepam if intravenous lorazepam is
unavailable, or buccal midazolam if unable to secure immediate
y
intravenous access. Administer a maximum of two doses of the first-line
op
treatment (including pre-hospital treatment)
• If seizures continue, administer intravenous phenobarbital or phenytoin
as second-line treatment in hospital
C
• If seizure still continues despite above (>30 minutes), referral to ICU
n
t io
ua
al
Ev
8. A 50 year old lady presents with a sudden onset of severe occipital headache
associated with neck pain and vomiting. CT brain was inconclusive and a lumbar
puncture was performed which revealed xanthochromia. What is the SINGLE
A. Bacterial meningitis
B. Viral meningitis
C. Migraine
839
Case stems for subarachnoid hemorrhage usually have middle-aged patients
with sudden onset headaches that are severe in nature, which may be described
as “the worst headache of their lives” or “thunderclap headache”. This is also
important to note since there are middle cerebral artery [MCA] occlusions (due
to ischaemia) and MCA berry aneurysms (causing subarachnoid
haemorrhage). Ischaemic occlusions would usually have more stroke symptoms
provided in the stem such as motor and sensory loss, rarely presenting with
headache. Know how to differentiate each haemorrhage via their
signs/symptoms, CT and lab results.
Subarachnoid hemorrhage
• Usually the result of bleeding from a berry aneurysm in the Circle of
Willis
Presentation
• Sudden and severe occipital headache described as the “worst headache
of my life”or “thunderclap headache”
• Neck stiffness or pain
y
• Vomiting, collapse, seizures
Associations
• Hypertension
op
C
• Polycystic kidney disease → Berry aneurysms are found in 10% of
patients with autosomal dominant adult polycystic kidney disease
• Ehlers Danlos syndrome
n
io
Diagnosis
• CT brain
t
• Lumbar puncture
ua
o Only done if CT is inconclusive + no contraindications

o The CSF of a lumbar puncture → bloody then xanthochromic
(bilirubin)
al
Treatments for SAH are rarely or almost never asked in at this level. Save your
Ev
brain space and memorize other important information.
9. A 70 year old woman was brought into the Emergency Department by her son
for increasing confusion and slurred speech. On examination, she was oriented
to time, place and person. Neurological examination was positive for bilateral
past pointing and truncal ataxia but no nystagmus. Blood tests were within
normal limits. Where is the SINGLE most likely location of her lesion?
A. Bilateral basal ganglia

B. Left temporo-parietal lobe
C. Cerebellar vermis
D. Left cerebellar lobe
E. Left-sided frontal lobe
For PLAB 1, stroke questions come in various forms ranging from the anatomical
locations of the lesion, investigations and management. Pay special attention to
the anatomy of the lesions especially the vascular distribution and the functions
840
of the different parts of the brain. Key clues to cerebellum lesions:
dysdiadochokinesia, ataxia, nystagmus, intention tremor, slurred speech,
hypotonia, past pointing.
Stroke (cerebellar lesion)

Presentation:
• Dysdiadochokinesia, ataxia, nystagmus, intention tremor, slurred
speech, hypotonia, past pointing
• Usually sudden onset with possible further progression that takes place
over hours
• May have underlying ischaemic heart disease, carotid bruits, atrial
fibrillation
Diagnosis:
• Non-contrast CT brain - initial investigation
• MRI brain - more sensitivity
Treatment:
y
• Ischaemic stroke - thrombolysis (alteplase) → aspirin
op
• Maintain oxygen saturation, glucose control, blood pressure control
• Maintain nutrition and hydration
• Early mobilization
C
10. A 26 year old woman complains of headache of 1 day duration that has been
intensifying in severity over the last few hours. There is discomfort while turning
n
her head and cannot tolerate bright lights. On examination, there is no
io
papilloedema nor rashes. Kernig’s sign is negative. Lumbar puncture results

reveal: elevated protein, normal glucose, and lymphocytosis. She is generally
t
unwell but haemodynamically stable. What is the single most likely diagnosis?
ua
A. Viral meningitis
B. Migraine
al
C. Aseptic meningitis
D. Bacterial meningitis
Ev
E. TB meningitis
Know the types of meningitis for PLAB 1 since it overlaps in quite a few topics on
the exam (i.e. neurology, emergency, and infectious diseases). Pay particular
attention to the lumbar puncture results to differentiate each. Kernig’s sign does
not need to be present for it to be a diagnosis of meningitis. If you forget the lab
results, look at the history: viral meningitis has less severe symptoms than
bacterial meningitis which can progress rapidly and produce signs of septic
shock. TB meningitis is more gradual with: fever, weight loss, headache with
progression to focal deficit +/or altered consciousness.
Presentation
• Classic: headache, fever, photophobia, neck stiffness
• Cranial palsies: CN III, IV, VI, VII
Diagnosis
Lumbar puncture (viral meningitis CSF):
841
• Normal or high CSF pressure
• Increased lymphocytes
• Elevated protein
• Glucose normal
Treatment:
• Regardless of whether meningitis is bacterial, viral, or TB as a cause –
give antibiotics before performing CT brain and/or lumbar puncture
• If no rash: IV cefotaxime or [IV ceftriaxone + IV vancomycin + IV
ampicillin]
• If raised intracranial pressure: give mannitol
11. A 72 year old man with a history of hypertension and an ex-smoker presents to
the clinic with his wife due to change in behavior. For the past year and a half, he
has slowly become socially withdrawn with a decrease interest in his usual
hobbies. There are times where he forgets to groom himself and there was an
incident once where his wife found him urinating on the sofa. Over the past few
months there has been a gradual struggle with finding the right word choice
y
while talking. What is the SINGLE most likely diagnosis?
A. Depression
B. Frontotemporal dementia
op
C
E. Lewy body disease
n
io
The keys in this case stem: patient has been struggling with word choice
(temporal lobe) and disinhibition / urinating on the sofa (frontal lobe).
t
Alzheimer’s disease would usually present with memory loss first before changes
ua
in personality. Vascular dementia would have a “step-wise progression” and

they would have had some sort of previous cardiac/vascular event in the stem.
Lewy body disease would require a clue into having some parkinsonian
al
symptoms.
Frontotemporal dementia
Ev
Presentation:
- Typical PLAB 1 presentation: elderly (>65 years)
- The history will be from a friend, carer, or family member
- Personality changes, change in habits of daily activities
- Memory is usually intact
- Disinhibition (may be sexual)
- On examination, may have difficulty initiating gait (frontal lobe)
Diagnosis:
- MRI brain – depending different subtypes will have atrophy of frontal
and paralimbic areas, anterior or inferior lobes
Treatment:
- No pharmaceutical therapy available
- If sexual disinhibition, can give cimetidine or spironolactone
12. A 36 year old woman presents to clinic with intermittent episodes of dizziness
that lasts 1 day each time for the past 6 months. Recently, she has experienced
ringing and increased pressure in her ears. Her husband noticed that she has had
842
to increase the volume of her television. MRI head is normal. What is the SINGLE

This is a classic case of Meniere’s disease. All four clues are present: dizziness,
tinnitus, deafness, and increased feeling of pressure in the ear. For PLAB 1, know
how to differentiate between Meniere’s with options A to C. These topics
frequently appear on the neurology component of the exam. Note that option B
is ruled out due to the normal MRI. In option C, the case would need to give a
history of bacterial or viral infection. In option D, there would be other
manifestations, such as weakness or paresthesia of the limbs.
Meniere’s disease
y
Presentation:
op
• Dizziness, tinnitus, deafness, increased feeling of pressure in the ear.
Note: Vertigo is usually the prominent symptom
C
• MRI is normal
• Typically symptoms are unilateral but bilateral symptoms may develop
n
after a number of years
io
Treatment:
t

ua
sometimes required
13. A 50 year old woman presents with facial asymmetry. She noted in the morning
al
that the right hand corner of her mouth was drooping. She had some pain
behind her right ear yesterday and complains of dryness in her right eye. On
Ev
examination, she is unable to move her right side of her face. What is the SINGLE
A. Ramsey-Hunt syndrome
B. Bell's palsy
D. Stroke
E. Parotid tumour
Bell’s palsy
Presentation:
- Unilateral facial weakness ; facial droop
- Drooling
- Difficulty in eye closure
- Associated with pregnancy and diabetes
Treatment:
843
- Within 72 hours onset, give prednisolone
- Eye protection with eye patch
14. A 5 year old girl is brought to the hospital by her mother with complaints of
sudden right facial weakness, numbness and pain around her ear. She reports no
other symptoms. On examination, her right eyebrow is unable to raise and the
right hand corner of her mouth is drooping. What is the SINGLE most likely
diagnosis?
B. Bell’s palsy
C. Stroke
D. Transient ischaemic attack
Bell’s palsy
Presentation:
y
- Drooling
op
C
Treatment:
- Within 72 hours onset, give prednisolone
n
io
15. A 55 year old man presents to clinic with shortness of breath and increased
daytime sleepiness. He drinks 25 units of alcohol weekly. On examination, his
t
BMI is 35 kg/m2, blood pressure is 150/70 mmHg, and respiratory exam was
ua
normal. His wife complains that he snores loudly at night. What is the SINGLE
most appropriate initial investigation likely to confirm his diagnosis?
al
A. Polysomnography
B. Pulse oximetry
Ev
C. EEG
D. Multiple sleep latency test
E. Epworth sleepiness scale
This is a diagnosis of obstructive sleep apnoea syndrome. In PLAB 1, this topic

would overlap between neurology and respiratory medicine. The typical PLAB 1
clues: a middle-aged to elderly male who works at the office, obese, with history
of hypertension and/or diabetes, and “snoring loudly at night”. Note that the
respiratory exam in uncomplicated obstructive sleep apnoea would be normal
unless the case also presents with a history of asthma exacerbation or
respiratory failure type II. Beware of what the PLAB 1 question is asking: initial
test is pulse oximetry but the definitive investigation is polysomnography (gold
standard). Multiple sleep latency test is the definitive investigation for
narcolepsy.
Obstructive sleep apnoea syndrome
Presentation:
- Middle aged to elderly male
844
- Increased daytime sleepiness, fatigue, sleep disruption
- Snoring loudly at night
- Associated with hypertension, diabetes, obesity
Diagnosis:
- Pulse oximetry, overnight study of breathing pattern (initial
investigation)
- Polysomnography (gold standard)
Treatment:
- Conservative: weight loss and reduce alcohol consumption
- Continuous positive airway pressure (CPAP)
16. A 55 year old male had a recent transient ischaemic attack which he recovered
from. He had a stroke 4 years ago. ECG shows a heart rate of 80 bpm in sinus
rhythm. He is already on aspirin 75 mg and antihypertensive drugs. What SINGLE
medication(s) should be offered?
A. Clopidogrel only
B. Aspirin 300 mg
y
C. Warfarin
op
D. Clopidogrel and statins
E. Add statin only C
Post management of Transient ischaemic attack (TIA)
Clopidogrel (75 mg daily) is the preferred long-term antiplatelet.

n
io
If clopidogrel is contraindicated or not tolerated, give a combination of modified-

release dipyridamole (200 mg twice daily) and low dose aspirin
t
ua
Ensure a statin has been offered as soon as possible after a TIA.
17. A 24 year old college student presents to A&E with nausea, vomiting, headache,
al
neck stiffness and a fever of 38.4°C. What is the SINGLE most appropriate
empirical antibiotic to be started immediately?
Ev
A. Intravenous Ceftriaxone
B. Intramuscular Benzylpenicillin
C. Intravenous Gentamicin
D. Intravenous Tazobactam
E. Intravenous Amoxicillin
She has signs of meningitis. Intravenous Ceftriaxone needs to be administered

immediately. In a hospital setting, give intravenous third generation
cephalosporin antibiotics (Ceftriaxone or Cefotaxime)
If this exact same questions was given but she presented to her GP (or was
found outside the hospital), then Benzylpenicillin IM or IV would be the correct
answer. If you suspect meningitis and patient is not yet in the hospital give IM/IV
benzylpenicillin and send patient to the hospital.
845
If this exact same question was given, but there was a diagnosis of Listeria, then
IV amoxicillin and gentamicin would be the correct answer
If this exact same question was given, but she is penicillin or cephalosporin
allergic, then chloramphenicol would be the answer. If the patient has a history
of immediate hypersensitivity reaction to penicillin or to cephalosporins the BNF
recommends using chloramphenicol.
Investigations
Generally, treatment for meningitis should be started before doing any
investigations due to the seriousness of the disease.
Rash
If patient has got a rash, then perform blood culture as the diagnosis is most
likely meningococcal septicaemia. The causative organism is Neisseria
meningitides.
If there is no rash then a lumbar puncture would be a better answer, but this can
y
only be done if there are no signs of raised intracranial pressure
op
Prophylaxis (oral ciprofloxacin or rifampicin) needs to be offered to household
C
and close contacts of patients affected with meningococcal meningitis
Summary
n
io

t

ua

rifampicin
al
18. A 55 year old man presents to clinic for gradual weakness of his arms bilaterally
over the past year. He is now unable to lift heavy loads above his head and has
Ev
difficulty breathing while going up the stairs. In the past month, he has noticed
hoarseness and difficulty in swallowing liquids. On examination, there were
muscle atrophy and weakness in the trunk, neck, back and both proximal upper
limbs for lower motor signs. Deep tendon reflexes the upper and lower limbs
were positive for upper motor signs with atrophy of the tongue. Hoffman’s sign
was positive and autoimmune panel is normal. What is the SINGLE most likely
diagnosis?
A. Myasthenia gravis
D. Amyotrophic lateral sclerosis
E. Polymyositis
Amyotrophic lateral sclerosis (ALS) is the most common form of motor neuron
disease in addition to multiple sclerosis (MS). Know the distinction between both
for PLAB 1 as they will commonly appear as either a question or option. MS
846
usually would present in episodes intermittently and affect different anatomic
locations. Myasthenia gravis would present with weakness and fatigue along
with a positive autoimmune panel. Guillain-Barre syndrome would usually give a
clue to a prior infection. Polymyositis would affect lower limbs first with fatigue.
Amyotrophic lateral sclerosis

Presentation:
• Progressive weakness of bulbar, limb, thoracic and abdominal muscles
• Oculomotor, sphincter, cognitive functions are usually spared
• Late stages - swallowing difficulty and hoarseness
Diagnosis:
• Clinical diagnosis via diagnostic criteria by EFNS guidelines
Treatment:
• Multidisciplinary care
• Neuroprotective medication: riluzole
• Medications to treat respiratory symptoms, drooling, insomnia, fatigue,
y
and psychological symptoms
op
• Genetic testing and counseling for family
19. A 41 year old woman presents to clinic with vertigo, vomiting and a feeling of
C
aural fullness. The attacks of vertigo can last for several hours. She also states
that she has difficulty hearing. She had a similar attack last year. Recently, she
has experienced ringing in her ears. MRI scan was done and was found to be
n
normal. What is the SINGLE most likely diagnosis?
io

t
ua
al
This is a classic case of Meniere’s disease. All four clues are present: dizziness,
Ev
tinnitus, deafness, and increased feeling of pressure in the ear.
It is important to remember that in Meniere’s disease, the attacks can last for
several hours at a time, which differentiates if from benign paroxysmal
positional vertigo.
Meniere’s disease
Presentation:
• Dizziness, tinnitus, deafness, increased feeling of pressure in the ear.
Note: Vertigo is usually the prominent symptom
• MRI is normal
• Typically symptoms are unilateral but bilateral symptoms may develop
after a number of years
Treatment:
847
sometimes required
20. A 19 year old female with previous history of repeated pain over the medial
canthus and chronic use of nasal decongestants, presents with abrupt onset of a
severe headache, fever with chills and rigor, diplopia on lateral gaze, moderate
proptosis and chemosis. On examination optic disc is congested. Which of the
following is the SINGLE most likely diagnosis?
A. Cavernous sinus thrombosis

B. Orbital cellulitis
C. Acute ethmoidal sinusitis
D. Orbital apex syndrome
E. Migraine
This case stem is rare to appear in PLAB 1, but know the presentation of how the
question will appear to differentiate it from options B, C, and E which occur
more frequently in the exam. Cavernous sinus thrombosis can appear as an
y
option to those questions.
op
Cavernous sinus thrombosis
Presentation:
C
- Headache – can be severe intensity
- Chemosis, oedematous eyelids, proptosis, painful ophthalmoplegia
- Fever
n
- Usually preceded by sinusitis
io
Diagnosis:
- CT/MRI venography
t
Treatment:
ua
- Referral to neurosurgery
- Antibiotics
- Anticoagulation – heparin
al
- +/- Corticosteroids and surgical drainage

Ev
21. A 22 year old female was hit on the side of her head with a cricket ball during a
match. She initially lost consciousness but spontaneously recovered but is now
experiencing increasing headache with one episode of vomiting. Her roommate
has noticed that there is a slowing of responses. What is the SINGLE most likely
diagnosis?
B. Subdural haemorrhage
D. Simple seizure
PLAB 1 case stem for epidural haemorrhage usually have a young athletic patient
that had a head injury during a sports match. They will experience a “lucid
interval” before having a decrease in mental function. The stem may or may not
give you a CT brain result: “bi-convex” extra-axial mass.
Epidural haemorrhage
848
Presentation:
- Head injury mostly to the side of the head, arterial bleed
- Loss of consciousness immediate, then recovers spontaneously followed
by lucid interval
- Then patient will have a decline in mental function
Diagnosis:
- CT brain – bi-convex extra-axial mass
Treatment:
- Referral immediately to neurosurgery
- Burr hole over pterion then craniotomy and evacuation of haematoma
22. A 26 year old man complains of pins and needles in his feet. He feels his legs
getting weaker in the past 2 days. He gives a history of feeling unwell and having
diarrhoea last week which has resolved. On examination, he has mild bilateral
facial weakness, reflexes are diminished and has impaired sensation in his legs.
y
A. Polymyositis
op
C
The symptoms here are classic for Guillain-Barré syndrome.

n
io
Guillain-Barré syndrome
• Is a disorder causing demyelination characterised by weakness,
t
paresthesia and hyporeflexia

ua
• Usually precedes an infection, usually respiratory or gastrointestinal

tract. This association with preceding infection suggests that antibodies
to the infectious organism also attack antigens in peripheral nerve
al
tissue.
Ev
In the stem, there would usually be a history of gastrointestinal or respiratory

infection from anywhere between a few days to 3 weeks prior to the onset of
weakness.
Presentation:
• Weakness
o Presents with an ascending pattern of progressive symmetrical
weakness, starting in the lower extremities
o Reaches a level of maximum severity two weeks after initial
onset of symptoms
o Facial weakness, dysphasia or dysarthria
o In severe cases, muscle weakness may lead to respiratory
failure.
• Pain
o Neuropathic pain, particularly in the legs
• Reflexes
o Reduced or absent
849
• Sensory
o Paresthesia and sensory loss, starting in the lower extremities
23. A 64 year old man presents with a history of left sided hemiparesis and slurred
speech. His symptoms resolved and he was absolutely fine 6 hours after the
episode. What is the SINGLE most appropriate prophylactic regimen?
A. Aspirin 300mg for 2 weeks followed by aspirin 75 mg

B. Aspirin 300mg for 2 weeks followed by aspirin 75 mg and dipyridamole 200mg
C. Clopidogrel 75mg
D. Dipyridamole 200mg
E. Aspirin 300mg for 2 weeks
Post management of Transient ischaemic attack (TIA)
Clopidogrel (75 mg daily) is the preferred long-term antiplatelet.
If clopidogrel is contraindicated or not tolerated, give a combination of modified-
y
release dipyridamole (200 mg twice daily) and low dose aspirin
op
Ensure a statin has been offered as soon as possible after a TIA.
C
24. A 2 year old child fell from his bicycle and immediately ceased breathing and
became pale. This was accompanied by a stiffening, clonic jerks of the limbs and
loss of consciousness. He regains full consciousness a few seconds later. What is
n
io
A. Reflex anoxic seizures

t
B. Epilepsy
ua
C. Cardiac arrhythmia
D. Postural orthostatic tachycardia syndrome
E. Pure autonomic failure
al
Reflex anoxic seizures

Ev
Reflex anoxic seizures also known as “white breath-holding attacks” are

paroxysmal, spontaneously-reversing brief episodes of asystole triggered by
pain, fear or anxiety. Anoxic seizures are non-epileptic events caused by a reflex
asystole due to increased vagal responsiveness. They are often misdiagnosed as
epilepsy.
During this time the child is deathly pale and may have hypotonia, rigidity,
upward eye deviation, clonic movements, and urinary incontinence. The episode
is usually brief (30-60 seconds) and recovery is rapid.
Typical age is 6 months to 2 years (but may be much older).
25. A 69 year old man presented to clinic with worsening balance and difficulty
walking over the past year. Recently, he has been prone to falling more
frequently and his wife notes he forgets to turn off the stove or water taps. He
has also started to have urinary urgency and incontinence. On examination he is
850
walking with a cane and has difficulty turning. What is the SINGLE most likely
diagnosis?
D. Dementia with Lewy bodies
E. Frontotemporal dementia (Pick’s disease)
This is a classic presentation: gait disturbance, sphincter compromise, and

dementia. Note to differentiate normal pressure hydrocephalus (NPH) with the
rest of the dementias on the list of options above. They are frequent neurology
topics for PLAB 1. NPH has a much slower progressive memory loss than
Alzheimer’s.
Normal pressure hydrocephalus

Presentation:
• TRIAD: gait disturbance, sphincter compromise (urinary urgency +/-
y
incontinence), cognitive dysfunction
op
• Most common in elderly
• CT / MRI brain: enlarged lateral and third ventricles
Diagnosis:
C
• Clinical diagnosis with CT/MRI brain signs of enlarged lateral and third
ventricles
• Lumbar infusion test (intrathecal infusion test) - new NICE guidelines
n
option
io
Treatment:
• Cerebrospinal fluid (CSF) shunting: ventriculoperitoneal,
t
ventriculopleural, or ventriculoatrial
ua
26. A 32 year old female who is 18 months pregnant presents to the Emergency
Department. She has a history of epilepsy and is on medication for it however
al
she was non-compliant and did not take her medication for the past 5 days. She
had a tonic-clonic seizure earlier in the morning lasting for 5 minutes and was
Ev
brought in by ambulance. She has IV access. While waiting for a doctor, she
starts to have another generalized tonic-clonic seizure. What is the SINGLE most
A. IV Lorazepam
B. IV Phenobarbital
C. IV Phenytoin
D. Refer to ICU
E. Rectal Diazepam
Seizures lasting longer than 5 minutes should be treated urgently with

intravenous lorazepam (repeated once after 10 minutes if seizures recur or fail
to respond). Intravenous diazepam is effective but it carries a high risk of
thrombophlebitis (reduced by using an emulsion formulation). Absorption of
diazepam from suppositories is far too slow for treatment of status epilepticus.
851
The fact that she is pregnant does not change the management of a convulsive
status epilepticus.
The management for ongoing generalised tonic–clonic seizures (convulsive status

epilepticus) in hospital is different from the community. Below we will only
discuss management in hospital.
Status epilepticus
In hospital management:
• ABC protocol
• Give high-concentration oxygen
• Check blood glucose levels
• Secure intravenous access in a large vein
• Administer intravenous lorazepam as first-line treatment in hospital for
ongoing generalised tonic–clonic seizures (convulsive status epilepticus)
• Administer intravenous diazepam if intravenous lorazepam is
unavailable, or buccal midazolam if unable to secure immediate
y
intravenous access. Administer a maximum of two doses of the first-line
op
treatment (including pre-hospital treatment)
• If seizures continue, administer intravenous phenobarbital or phenytoin
as second-line treatment in hospital
C
• If seizure still continues despite above (>30 minutes), referral to ICU
n
t io
ua
al
Ev
27. An 8 year old girl is brought to the clinic due to abnormal behavior noticed by
her teacher. She would stare blankly towards the wall, sometimes with an
upturning of the eyes for around 15 seconds, then blinks. This would occur
several times during the day. The teacher notes that while she would resume her
activity after these events she would be tired and unable to concentrate. What is
A. Simple partial seizure

B. Complex partial seizure
C. Absence seizure
D. Generalized seizure
852
E. Febrile seizure
In PLAB 1 stems, absence seizures would usually be a child (<10 years) with
either the parent or teacher noticing that the patient is “daydreaming” often and
when they resume their studies they are not able to perform well.
Absence seizure
Presentation:
- Child usually <10 years old
- Loss of awareness (“daydreaming”), stare blankly into space, will not
respond to their surroundings
- May be accompanied by upturning of eyes, other repetitive
movements
- Will return to normal activities after seizure but may not perform well
and feel tired
- No photosensitivity
- Maybe triggered by hyperventilation
Diagnosis:
y
- EEG
op
- Check FBC, glucose levels, ECG, MRI for other underlying causes
Treatment:
- If recurring, sodium valproate or ethosuximide
C
28. A 50 year old man, known case of hypertension and deep vein thrombosis,
presents to the Emergency Department with a sudden onset of vision loss in his
n
right eye. It is painless and lasted for approximately 5 minutes. He describes the
io
vision loss as a ‘black curtain coming down’. On examination, there is a bruit on

his neck. What is the SINGLE most likely diagnosis?
t
ua
A. Retinal vein thrombosis

B. Retinal artery occlusion
C. Amaurosis Fugax
al
D. Optic neuritis
E. Acute angle glaucoma
Ev
Remember to focus on causes of unilateral vision loss. Know how to differentiate

all the above options.
For amaurosis fugax, this is a classic case stem: sudden, painless, unilateral vision
loss and description of a “black curtain coming down”.
The cause is most likely due to retinal artery emboli secondary to atrial
fibrillation according to the history.
Options A and B presents as painless unilateral vision loss but their duration
would be much longer and the age group would be much older (>65 years).
Optic neuritis would have clues in the stem of multiple sclerosis.
Option E would produce a painful vision loss and keywords such as “haloes”
would be seen.
853
Amaurosis Fugax
• Painless transient monocular visual loss (i.e. loss of vision in one eye that
is not permanent)
• It is indicative of retinal ischaemia, usually associated with emboli or
stenosis of the ipsilateral carotid artery
Presentation:
• Sudden, unilateral vision loss; “black curtain coming down”
• Duration: 5-15 minutes; resolves within < 24 hours
• Associated with stroke or transient ischaemic attack (TIA) and its risk
factors (i.e. hypertension, atherosclerosis)
• Has an association with giant cell arteritis
29. A previously healthy 20 year old woman presents to the Emergency Department
with the complaint of “falling out.” She was with her friends at a restaurant
when she felt faint and, according to friends, lost consciousness for about a
minute. There was no seizure activity noted, but the friends did notice her arms
y
twitching irregularly. She is now acting normally. She denies chest pain or
op
palpitations, and her electrocardiogram is normal. What is the SINGLE most
likely diagnosis? C
A. Hypoglycaemia
B. Vertigo
C. Prolonged QT syndrome
n
D. Vasovagal syncope
io
E. Paroxysmal supraventricular tachycardia

t
Have a basic idea of the major causes of syncope for PLAB 1. The most common
ua
amongst young women would be vasovagal syncope likely due to hypotension

and stimulated by one of the following triggers: pain, fear, excitement, and
standing for a prolonged period.
al
Vasovagal syncope
Ev
Presentation:
• Young adult more common in women
• Stimulated by either emotional stress or orthostatic stress
• Sweating, pallor, nausea
Diagnosis:
• Clinical history under recommended diagnostic criteria (ESC guidelines)
• ECG to rule out other pathology
Treatment:
• Reassurance and counseling of avoidance of triggers
• Educate how to recognize prodromal symptoms and perform
manoeuvres to stop the syncope
• Tilt table training
30. A 50 year old woman presents following a fall. She reports pain and weakness in
her hands for several months, swallowing difficulties, and has bilateral wasting
854
of the small muscles of her hands. Her back and shoulders feel stiff. The reflexes
in her upper limbs are absent. Both legs show increased tone and hyperreflexia.
Pain and temperature sensation are impaired in the upper limbs. She is also
noted to have a facial palsy. What is the SINGLE most likely diagnosis?
B. Motor neuron disease
C. Syringobulbia
D. Syringomyelia
E. Myasthenia gravis
There are two close answers here: Syringobulbia and syringomyelia.
Syringomyelia does not have any cranial nerve involvement but syringobulbia
does and thus causing the facial palsy in the above question.
Syringomyelia and Syringobulbia
y
Syringomyelia is a rare condition in which there is fluid-filled tubular cyst (syrinx)
op
within the central, usually cervical, spinal cord. The syrinx can elongate, enlarge
and expand into the grey and white matter and, as it does so, it compresses the
nervous tissue of the corticospinal and spinothalamic tracts and the anterior
C
horn cells. This leads to various neurological symptoms and signs, including pain,
paralysis, stiffness and weakness in the back, shoulders and extremities.
Syringomyelia may also cause loss of extreme temperature sensation,
n
particularly in the hands, and a cape-like loss of pain and temperature sensation
io
along the back and arms.

t
Syringobulbia occurs when the syrinx extends into the brainstem. This may
ua
affect one or more cranial nerves, resulting in facial palsies. Sensory and motor
nerve pathways may be affected by interruption and/or compression of nerves.
al
Note: Progression of symptoms and deterioration occur over many years for
syringomyelia and syringobulbia
Ev
Symptoms of both Syringomyelia and Syringobulbia
• Damage to the spinal cord often leads to progressive weakness in the

arms and legs, stiffness in the back, shoulders, arms, or legs, and
chronic, severe pain. These can be present at presentation.
• Other symptoms may include headaches, a loss of the ability to feel
extremes of hot or cold (especially in the hands), and loss of bladder and
other functions.
• Pain and temperature sensation are lost due to spinothalamic tract
damage.
• Classically, the sensation loss is experienced in a shawl-like distribution
over the arms, shoulders and upper body.
• Dysaesthesia (pain experienced when the skin is touched) is common.
• Light touch, vibration and position senses in the feet are affected as the
syrinx enlarges into the dorsal columns.
855
• Muscle wasting and weakness begins in the hands and then affects the
forearms and shoulders.
• Tendon reflexes are lost.
31. A 55 year old chronic alcoholic who lives alone, brought in the emergency
department having been found confused at home after a fall. He complains of a
headache and gradually worsening confusion. What is the SINGLE most likely
diagnosis?
B. Hypoglycemia
C. Extradural haematoma
D. Subdural haematoma
A chronic alcoholic with a history of fall with progressive confusion over the last
couple of days points towards the diagnosis of chronic subdural haemorrhage.
y
Subdural haematoma may be acute or chronic. In the chronic subdural
op
haematoma, symptoms may not be apparent for several days or weeks.
Symptoms of subdural haematomas are: fluctuating level of consciousness, ±
insidious physical or intellectual slowing, sleepiness, headache, personality
C
change and unsteadiness.
Chronic subdural haematoma occurs in the very old or in severe alcoholics. A

n
shrunken brain is rattled around the head by minor trauma, tearing venous
io
sinuses. Over several days or weeks, mental function deteriorates as haematoma

forms. CT scan is diagnostic, and surgical evacuation provides dramatic cure.
t
ua
Remember in PLAB, chronic subdural haematoma usually presents as an elderly,

on anticoagulation or an alcoholic who may have history of fall. Slow onset of
symptoms compared to epidural haematoma.
al
32. A 45 year old man has been admitted for an elective surgery. 2 days later he
Ev
develops agitation, sweating and complains of seeing snakes on the hospital

wall. A history of chronic alcoholic abuse is revealed and chlordiazepoxide has
been started. What is the SINGLE most appropriate next course of action?
A. Add Diazepam
B. Add Acamprosate
C. Add Disulfiram
D. Add Thiamine
E. Add Naloxone
In regards to his diagnosis of chronic alcoholic abuse, many physicians would add
in thiamine (IV Pabrinex) to the mix to prevent Wernicke's encephalopathy even
though he is not showing any signs of Wernicke’s encephalopathy.
Parenteral thiamine should be prescribed for treatment of suspected or

confirmed Wernicke's encephalopathy, and for prophylaxis in alcohol-dependent
patients attending hospital for acute treatment (including treatment unrelated
856
to alcohol dependence).
Acute Alcohol Withdrawal
Patients often present with anxiety, tremor, hyperactivity, sweating, nausea and
retching, tachycardia, hypertension and mild pyrexia. Symptoms peak at at 12-30
hours and
subside by 48 hours
Medications used in alcoholics

• Benzodiazepines for acute withdrawal (NHS commonly uses
Chlordiazepoxide) Chlordiazepoxide is used as sedation
• IV Pabrinex (Thiamine) (vitamin B1) is used to prevent Wernicke's
encephalopathy which is a neuropsychiatric disorder caused by thiamine
deficiency which is most commonly seen in alcoholics
• Disulfiram: promotes abstinence - alcohol intake causes severe reaction
due to inhibition of acetaldehyde dehydrogenase. Patients should be
aware that even small amounts of alcohol (e.g. In perfumes, foods,
y
mouthwashes) can produce severe symptoms. Example of when to use
op
disulfiram in PLAB: 40 year old man wants medication to serve as a
deterrent when he takes alcohol
• Acamprosate: reduces craving, improves abstinence in placebo
C
controlled trials. Example of when to use disulfiram in PLAB: 40 year old
man wants some medication to help him reduce cravings
n
33. An 82 year old lady had an ischaemic stroke that was confirmed with brain
io
imaging. She has no drug allergies and no other comorbidities. She was put on
aspirin 300mg daily for two weeks. What is the SINGLE most appropriate
t
medication to be given after the course of Aspirin is completed?

ua
A. Clopidogrel
B. Ticagrelor
al
C. Combination of modified-release dipyridamole and low dose aspirin

D. Abciximab
Ev
E. No additional medication needed long term
Just a few years ago, the answer would be combination dipyridamole and low
dose aspirin. However, NICE has recently published a technology appraisal in
2010 on the use of clopidogrel and dipyridamole.
Clopidogrel is now recommended by NICE ahead of combination use of aspirin

plus modified release (MR) dipyridamole in people who have had an ischaemic
stroke
34. A 24 year old woman complains of progressive left leg stiffness and clumsiness
over the few weeks. There has also been a history of intermittent blurry vision
that spontaneously resolves each time. On examination, there is increased tone,
left leg power of 3/5, and upward plantars. A pale disc was seen in
ophthalmoscopy. All other neurological examinations were normal. What is the
857
A. Non-steroidal anti-inflammatory drug
B. Methotrexate
C. Interferon-beta
D. Methylprednisolone
E. Bed rest
This patient is presenting with upper motor neuron signs and optic neuritis. The
diagnosis is relapsing-remitting multiple sclerosis. The patient is eligible for
interferon-beta management; however, the question asks for the most
appropriate initial management, which in this case would be
methylprednisolone. Note that steroids can be given orally or via IV here; there
is no difference in terms of efficacy but if the patient was to be admitted then IV
is usually the choice. Be wary of NSAIDs: if the patient was to be presenting with
pain, you must confirm where this pain is coming from. If it is neuropathic pain
then you would not give NSAIDs.
Multiple Sclerosis
y
Presentation:
op
Variety of symptoms involving motor and sensory mainly of the brainstem and
cerebellum. It may be easier to divide them into groups to remember.
C
- 1. Transverse myelitis:
n
o Weakness, sensory symptoms
io
o Urinary urgency and retention

o Flexor spasms
t
o Spastic quadriparesis or paraparesis

ua
- 2. Brainstem:
al
o Ataxia
Ev
o Diplopia
o Dysarthria
o Facial numbness
o Ophthalmoplegia
o Gaze palsy
- 3. Cerebellum
- Ataxia
- Dysarthria
- Nystagmus
• PLAB 1 stem usually have some clue to optic neuritis. Optic neuritis is an
acute, sometimes painful, reduction or loss of vision in one eye and is a
relatively common presenting symptom of MS. Colour vision may be
impaired
• Also depression is common
858
Pattern is usually: symptoms evolve over days, plateau, then resolves over
days/weeks
Diagnosis:
• Mostly a clinical diagnosis
• MRI (definitive diagnostic test): demyelination and/or lesions
disseminated in time and place
• Oligoclonal bands in CSF
Treatment:
• Acute: IV or oral methylprednisolone
• Interferon-beta or glatiramer acetate (first line)
35. A 60 year old man presents to Emergency with dizziness. The onset was sudden
and described as “the room spinning around”. He also is bumping into things on
his right side. On examination, his blood pressure is 159/91 mmHg, heart rate is
72 bpm. He is positive for nystagmus and dysdiadochokinesia. CT brain confirms
ischaemic stroke. Where is the SINGLE most likely location of his stroke?
A. Temporal lobe
y
B. Left parietal lobe
op
C. Right parietal lobe
D. Anterior circulation
E. Posterior circulation
C
Know that lesions to the posterior circulation would affect functions of the
brainstem, cerebellum, and occipital lobe. This would be consistent with the
n
vertigo, right hemianopia, nystagmus and ataxia seen in this patient.
io
Stroke in the posterior circulation

t
Presentation:
ua
• Dizziness/vertigo, right hemianopia, nystagmus, ataxia,

dysdiadochokinesia
• Usually sudden onset with possible further progression that takes place
al
over hours
• May have underlying ischaemic heart disease, hypertension, carotid
Ev
bruits, atrial fibrillation
Diagnosis:
• Non-contrast CT brain - initial investigation
• MRI brain - more sensitivity
Treatment:
• Ischaemic stroke - thrombolysis (alteplase) → aspirin
• Maintain oxygen saturation, glucose control, blood pressure control
• Maintain nutrition and hydration
• Early mobilization
36. A 34 year old man is hit by a car. He loses consciousness but is found to be fine
by the paramedics. When awaiting doctors review in the Emergency Department
he suddenly becomes unconscious. What is the SINGLE most likely diagnosis?
859
C. Intracerebral haemorrhage
D. Extradural (epidural) haematoma
E. Whiplash
This patient has lucid intervals. It is important to note that acute subdural
haematoma also has lucid intervals. And thus when a patient presents with lucid
intervals it can be both an extradural haematoma or an acute subdural
haematoma. In general, for extradural haematoma the trauma is usually trivial
and patient goes back to doing what he was doing before before falling
unconscious again. Whereas acute subdural haematoma is usually a sicker
patient who barely awakes during the lucid intervals. But again in clinical
practice we do not lie on clinical features to differentiate epidural haematoma
from acute subdural haematoma because both of them will get a CT scan
Also note the difference between acute subdural haematoma and chronic
subdural haematoma. In chronic subdural haematoma, it is usually an elderly, on
anticoag or an alcoholic. Symptoms for chronic subdural haematoma are slow
y
onset compared to epidural haematoma.
op
As this question did not specify whether subdural haematoma is acute or chronic
in nature, it would be more correct to choose extradural (epidural) haematoma
C
as the answer.
Extradural (epidural) haematoma

n
io
Often associated with skull fracture and middle meningeal artery injury. Involves
arterial blood.
t
ua
Features
• Features of raised intracranial pressure
• Patients may exhibit a lucid interval (note the lucid intervals as it is very
al
commonly seen in PLAB)

Ev
Management
Surgical procedure: burr hole over pterion (to ensure that further haemorrhage
escapes instead of expanding the clot further) followed by craniotomy and
evacuation of the haematoma.
37. A 58 year old man has visual hallucinations of animals walking around his room.
He is amused by them but is conscious that they are not real. He is noted to have
fluctuating levels of awareness and attention and a decline in problem solving
ability. Signs of mild parkinsonism are also seen. What is the SINGLE most likely
diagnosis?
C. Delirium tremens
860
The most important features of Lewy body dementia that differentiate it from
the other forms of dementia is the:
• Visual hallucinations
• Fluctuating course with lucid intervals
• Signs of mild Parkinsonism
Typical presentation of lewy body dementia
• Dementia is usually the presenting feature, with memory loss, decline in
problem solving ability and spatial awareness difficulties.
• Characteristically there are fluctuating levels of awareness and
attention.
• Signs of mild Parkinsonism (tremor, rigidity, poverty of facial expression,
festinating gait). Falls frequently occur.
• Visual hallucinations (animals or humans) and illusions. → This is
particularly important to differentiate lewy body from other types of
dementia in the PLAB exam
• Sleep disorders including rapid eye movement sleep disorder, restless
legs syndrome
y
38. A 54 year old chronic alcoholic man was admitted in the hospital for a fractured
op
femur 2 days ago. He now has tremors, is profusely sweating, apprehensive and
fearful. What is the SINGLE most appropriate treatment?
C
A. Acamprosate
B. Chlordiazepoxide
C. Lorazepam
n
D. Lofexidine
io
E. Procyclidine
t

ua
hours and
al
subside by 48 hours
Ev

Acamprosate: reduces craving, improves abstinence in placebo controlled trials.
Example of when to use disulfiram in PLAB: 40 year old man wants some
medication to help him reduce cravings
861
39. A 26 year old woman who is a known epileptic wants to start a family. She takes
sodium valproate for her epilepsy which has been well controlled and has been
seizure free for the past year. She and her husband have been using condoms as
contraception till present. She attends clinic seeking advice regarding her
antiepileptic medication as she would like to get pregnant. What is the SINGLE
most appropriate advice to give?
A. Add ferrous sulphate

B. Change sodium valproate to carbamazepine
C. Advise to stop antiepileptic medication and start folic acid
D. Reduce dose of sodium valproate
E. No change in medication
Change to carbamazepine is the best option given the options provided. If there
was an option that said, change to carbamazepine and add folic acid 5mg, that
would be an even better answer.
One would not stop antiepileptic medication especially if the patient has only be
y
seizure free for one year. The patient needs to be seizure free for more than 2
op
years before it would be considered reasonable to stop antiepileptic medication
prior to pregnancy. C
Epilepsy and pregnancy
Pre-pregnancy
n
If a woman is taking antiepileptic drugs and planning a pregnancy, the general
io
advice to give to her is about the increased risks of fetal malformations,

neurodevelopmental delay, and possible increased seizure frequency in
t
pregnancy.
ua
Since there is no agreement as to which antiepileptic drug is most or least

teratogenic, the antiepileptic drug that stops seizures in a given patient is the
al
one that should be used. However, there is one exception to the rule, SODIUM
VALPROATE! The risk of teratogenicity with Valproate is greater than risk of
Ev
teratogenicity with other antiepileptic drugs. Hence, sodium valproate should

always be changed to another antiepileptic drug prior to pregnancy. Currently,
carbamazepine and lamotrigine has good safety profiles but again there is no
consensus as to which should be used.
The Medicines and Healthcare products Regulatory Agency (MHRA) issued a

special reminder on the risk of neurodevelopmental delay in children following
maternal use of sodium valproate, and advises that this drug should not be used
in women of childbearing potential unless there is no effective alternative.
High dose (5mg) folic acid is recommended for at least 1 month preconceptually
and throughout the first trimester.
In established pregnancy
In established pregnancy, changes to alternate antiepileptic drug therapy should
NOT be undertaken solely to reduce teratogenic risk for 2 reasons :
1. Changing AEDs may precipitate seizures
862
2. Overlapping AEDs during the change exposes the fetus to effects of an
additional antiepileptic drugs
Once an unplanned pregnancy is discovered it is usually too late for changes to

be made to the epilepsy treatment regimen. The risk of harm to the mother and
fetus from convulsive seizures outweighs the risk of continued therapy
40. A 52 year old lady has weak limbs when examined. She was found to have burn
marks on finger tips. Her hands looked wasted and with diminished reflexes. She
also has weak spastic legs and dissociated sensory loss. What is the SINGLE most
likely diagnosis?
B. Syringomyelia
C. Motor neuron disease
D. Guillain-barre
E. Friedreich's ataxia
y
op
If you were to see burn marks on finger tips in any given question, think of a loss
of sensation of temperature and pain in the hands. This is commonly seen in
syringomyelia and syringobulbia.
C
The wasted and weak hands with diminished reflexes and weak spastic legs with
dissociated sensory loss are features suggestive of syringomyelia.
n
io
Syringomyelia and Syringobulbia

t
Syringomyelia is a rare condition in which there is fluid-filled tubular cyst (syrinx)

ua
within the central, usually cervical, spinal cord. The syrinx can elongate, enlarge
and expand into the grey and white matter and, as it does so, it compresses the
nervous tissue of the corticospinal and spinothalamic tracts and the anterior
al
horn cells. This leads to various neurological symptoms and signs, including pain,
paralysis, stiffness and weakness in the back, shoulders and extremities.
Ev
Syringomyelia may also cause loss of extreme temperature sensation,

particularly in the hands, and a cape-like loss of pain and temperature sensation
along the back and arms.
Syringobulbia occurs when the syrinx extends into the brainstem. This may
affect one or more cranial nerves, resulting in facial palsies. Sensory and motor
nerve pathways may be affected by interruption and/or compression of nerves.
Note: Progression of symptoms and deterioration occur over many years for
syringomyelia and syringobulbia
Symptoms of both Syringomyelia and Syringobulbia
• Damage to the spinal cord often leads to progressive weakness in the

arms and legs, stiffness in the back, shoulders, arms, or legs, and
chronic, severe pain. These can be present at presentation.
863
• Other symptoms may include headaches, a loss of the ability to feel
extremes of hot or cold (especially in the hands), and loss of bladder and
other functions.
• Pain and temperature sensation are lost due to spinothalamic tract
damage.
• Classically, the sensation loss is experienced in a shawl-like distribution
over the arms, shoulders and upper body.
• Dysaesthesia (pain experienced when the skin is touched) is common.
• Light touch, vibration and position senses in the feet are affected as the
syrinx enlarges into the dorsal columns.
• Muscle wasting and weakness begins in the hands and then affects the
forearms and shoulders.
• Tendon reflexes are lost.
41. A 75 year old woman has been admitted from a nursing home with sudden onset
of right hemiplegia and homonymous hemianopia. She is dysphasic. She remains
conscious throughout and on examination, brisk reflexes and several beats of
clonus are noted. What is the SINGLE most likely artery to be occluded?
y
op
B. Left middle cerebral artery
C. Right posterior cerebral artery
C
D. Right posterior cerebral artery
E. Left basilar artery
n
This patient has an upper motor neuron lesion as signified by a pathological
io
extensor plantar response and hyperreflexia.

t
Every option that was give could cause the symptoms of stroke. But it is
ua
important to know which is the most common artery to be occluded in stroke.

This would be the middle cerebral arteries. Given that the symptoms are on the
right, the occluded artery would be on the left (Remember, stroke causes
al
contralateral hemiplegia)
Ev
Cerebral hemisphere infarcts presentation

• Sudden onset or a stepwise progression of symptoms and signs over
hours (sometimes even days) is typical
• Cerebral hemisphere infarcts (50%) may cause:
o Contralateral hemiplegia which is initially flaccid (floppy limb,
falls like a dead weight when lifted) and then becomes spastic
o Contralateral sensory loss
o Homonymous hemianopia
o Dysphasia
Note: Middle cerebral artery (MCA) is the most common cerebral occlusion site.
42. A 32 year old female presents with a history of recurring headaches. They are
usually unilateral, last for 24–48 hours, have a pulsatile quality, and are
associated with nausea and photophobia.The patient describes the headaches as
intense, usually requiring her to limit her activities. She has tried several over-
864
the-counter medications with no relief. Which of the following is the SINGLE
most appropriate choice for first-line management of her condition?
A. Paracetamol oral
B. Prednisone oral
C. Sumatriptan oral
D. Sumatriptan nasal
E. Oxycodone oral
This is a classic presentation of acute migraine. First line therapy are triptans
according to NICE guidelines. Note that if the patient was 12-17 years, then it is
recommended that they start with a nasal triptan before oral. Be aware that
opioids are never given during an acute onset of migraine.
Migraine
Presentation:
• History of unilateral, throbbing headache
• Associated with nausea/vomiting; photophobia
y
• Associated with aura/triggers
op
• May be described as: “need to limit activities” or “prefer to stay in a dark
room” C
Diagnosis:
• Clinical diagnosis
• May require CT / MRI head to rule out other pathology
n
io
Treatment:
• Sumatriptan - first line
t
• Monotherapy: triptan, NSAID, aspirin, paracetamol

ua
• Combination therapy: triptan + NSAID; triptan + paracetamol

• Transcutaneous stimulation of the vagus nerve
• Avoid triggers
al
43. 79 year old stumbled at home and sustained a minor head injury 2 weeks ago.
Ev
He did not become unconscious and was well after the fall. His son has brought
him to clinic because he has become increasingly confused, drowsy and
unsteady over the past few days. He has a GCS of 13. His past medical history
includes atrial fibrillation in which he takes warfarin for. What is the SINGLE
A. Alzheimers
B. Delirium
An elderly man with a history of fall and on anticoagulation with progressive

confusion over the last couple of days points towards the diagnosis of chronic
subdural haemorrhage.
865
Remember in PLAB, Chronic subdural haematoma usually presents as an elderly,

on anticoag or an alcoholic who may have history of fall. Slow onset of
radiating down to his legs, urinary retention and incontinence. On examination,
perineal sensory loss is noted. What is the SINGLE most appropriate
investigation?
A. MRI
B. CT spine
C. Plain X-rays
y
E. PET CT
op
This is a classic example of cauda equina syndrome. It is a serious neurologic
condition in which damage to the cauda equina causes loss of function of the
C
nerve roots of the spinal canal below the termination (conus medullaris) of the
spinal cord. Any lesion which compresses or disturbs the function of the cauda
equina may disable the nerves although the most common is a central disc
n
prolapse.
io
Investigation of choice is an MRI.

t
ua
45. A 33 year old woman previously in good health presents with sudden onset of
severe occipital headache and vomiting a few hours ago. Her only physical sign
on examination is a stiff neck. What is the SINGLE most likely diagnosis?
al
Ev
C. Cerebellar haemorrhage
D. Migraine
E. Cerebral embolism
Sudden onset severe occipital headache and vomiting with stiffness makes the
likely diagnosis to be subarachnoid haemorrhage. The neck stiffness is due to
meningeal irritation. Usually patients would be complaining of photophobia as
well. Patients often describe the headaches as “the worst headache of my life”.
46. A 39 year old chronic alcoholic stopped drinking alcohol for the last 2 days. He is
now anxious, has tremors and is sweating profusely. His heart rate is 103
A. Naloxone
B. Benzodiazepines
C. Acamprosate
866
D. Disulfiram
E. Haloperidol
hours and
subside by 48 hours

y
op
C
Acamprosate: reduces craving, improves abstinence in placebo controlled trials.
Example of when to use disulfiram in PLAB: 40 year old man wants some
medication to help him reduce cravings
n
io
47. A 45 year old chronic alcoholic presents to A&E with an ataxic gait, hallucinations
and is confused. He is given chlordiazepoxide. What is the SINGLE most
t
appropriate medication to be given with chlordiazepoxide?

ua
A. Acamprosate
B. Thiamine
al
C. Diazepam
D. Disulfiram
Ev
E. Haloperidol
This man is suffering from Wernicke’s encephalopathy.
Wernicke's encephalopathy is a neuropsychiatric disorder caused by thiamine

deficiency which is most commonly seen in alcoholics. A classic triad of
confusion, ophthalmoplegia and ataxia may occur.
Treatment is with urgent replacement of thiamine
If not treated Korsakoff's syndrome may develop as well. This is termed

Wernicke-Korsakoff syndrome and is characterised by the addition of antero-
and retrograde amnesia and confabulation in addition to the above classic triad.
Wernicke’s Encephalopathy Wernicke’s - Korsakoff syndrome

(or just Korsakoff syndrome)
Triad of: Addition of:
867
1. Confusion 4. Amnesia
2. Ataxia 5. Confabulation
3. Ophthalmoplegia
radiating down to his right leg. The pain is relieved when lying down and
exacerbated by long walks and prolonged sitting. What is the SINGLE most
A. MRI
B. CT spine
C. X-ray spine
E. Serum paraprotein electrophoresis
Back pain radiating down to legs which is relieved when lying down and
y
exacerbated by long walk and prolonged sitting are characteristic of lumbosacral
op
disc herniation.

C
Presentation

n
io
t

ua
al

Ev

Investigation
49. A 44 year old man presents to Emergency after falling from a third floor building.
His Glasgow Coma Scale is 4/15. He is intubated and ventilated on arrival.
Neurological examination reveals unequal pupils. CT head and neck reveals
midline shift and a left-sided convex enhancing area. What is the SINGLE most
868
A. Intravenous mannitol to reduce intracranial pressure
B. Intravenous thiopentone to reduce intracranial pressure
C. Conservative management with 30 degree head-up
D. Urgent craniotomy
E. Endovascular coiling under neuroradiological guidance
This is a diagnosis of extradural haemorrhage. While this is a frequent neurology

topic for PLAB 1, the presentation here has left out the usual clue: “lucid
interval”. However, the stem provides another clue to the diagnosis: the CT
findings which are indicative of an extradural haemorrhage. Take note of the
revised NICE guidelines regarding the management of traumatic brain injuries. In
this case, this patient not only has raised intracranial pressure but he is also
showing signs of neurological deficit (unequal pupils) in addition to the low
Glasgow Score. Therefore, he is not suitable for conservative management and
requires immediate craniotomy for evacuation of the haematoma.
Extradural haemorrhage
Presentation:
y
• Trauma to the head
op
• Followed by immediate loss of consciousness, +/- lucid interval with
decline in mental function C
Diagnosis:
• CT head and neck
n
Treatment:
io
• ABCDE protocol
• CT head and neck
t
• Immediate craniotomy
ua
• If GCS > 8 + other CT criteria met, may attempt for conservative

management → observation and serial CT brain
al
50. A 64 year old housewife, known case of uncontrolled hypertension, presents to

emergency with dysphagia, right sided hemi-paresis and ataxia. There is also loss
Ev
of sensation on the left side of the face. Which of the following is the SINGLE
most likely area in the brain to be affected?
A. Frontal lobe
B. Parietal lobe
C. Temporal lobe
D. Lateral medulla
E. Occipital lobe
locations of the lesion, investigations and management. Pay special attention to
the anatomy of the lesions especially the vascular distribution and the functions
of the different parts of the brain. In this case stem, the vascular system affected
is the vertebrobasilar circulation. Therefore, symptoms will arise from one or all
of the following areas: cerebellum, brainstem, and occipital lobes. From the
options above, D and E are possibilities; however the question asks the single
869
most likely answer, so it will be D. Option E will usually have some clue to a
visual disturbance in the case stem, which this question does not.
Presentation:
This is an infarction of the brainstem and is part of the lateral medullary
syndrome.
It will have some or all of the following depending on the severity of the vascular
occlusion
- Vertigo, vomiting, dysphagia
- Nystagmus
- Ipsilateral ataxia, soft palate paralysis
- Ipsilateral sensory loss in the face, contralateral sensory loss in the
trunk and limbs
Stroke general features:

- Usually sudden onset with possible further progression that takes
place over hours
- May have underlying ischaemic heart disease, carotid bruits, atrial
y
fibrillation
Diagnosis:
-
op
CT brain with no contrast to rule out whether stroke is ischaemic or
C
haemorrhagic (initial investigation)
- Diffusion-weighted MRI brain provides more sensitivity in acute
setting
n
io
Treatment:
- ABC protocol
t
- Blood glucose – keep between 4-11mmol/L & IV fluid hydration

ua
- If ischaemic stroke – give Aspirin 300mg PO

- If < 3 hours and ischaemic stroke, thrombolysis (alteplase) (Nice
Guidelines say give within 4.5 hours)
al
51. A 26 year old man was found on the street to be unsteady and drunk by police.
Ev
On admission to Emergency, he had a sudden onset of headache with severe

intensity. The headache is localized to his occipital area and is continuous. On
examination, his GCS is 15/15, afebrile and no focal neurological signs. What is
D. Cluster headache
E. Viral meningitis
Note for the exam, the keywords for subarachnoid haemorrhage (SAH): “worst
headache of my life”, “headache of severe intensity”, “thunderclap headache”,
“sudden onset”, “occipital”. The other main clue in this stem is the patient was
found drunk. Excess alcohol consumption is one main risk factor leading to SAH.
870
Willis
Presentation
Associations
• Hypertension
Diagnosis
• CT brain
y
• Lumbar puncture
op
(bilirubin)
C
n
io
52. A 62 year old man has recently had a flu-like illness. He woke up with difficult
and unclear articulation of speech. Movement of his eyelids and lips are weak on
t
the right side. What is the SINGLE most likely anatomical site affected?
ua
A. Facial nerve
B. Hypoglossal nerve
al
C. Oculomotor nerve
D. Trigeminal nerve
Ev
E. Glossopharyngeal nerve
Viral infection may cause facial nerve palsy.
Facial Nerve Palsy
Presentation
Weakness of the muscles of facial expression and eye closure. The face sags and
is drawn across to the opposite side on smiling. Voluntary eye closure may not
be possible and can produce damage to the conjunctiva and cornea. In severe
cases, dysarthria and difficulty with eating may occur.
53. A 78 year old male presents with a history of urinary incontinence and change in
behavior. On examination, he has a waddling gait. What is the SINGLE most likely
diagnosis?
A. Subdural hemorrhage
871
B. Brain tumor
C. Parkinson's disease
Normal pressure hydrocephalus will present with prominent gait abnormalities

early in the course of the disease that usually precede the onset of cognitive
impairment. There will also be associated urinary incontinence.
Normal pressure hydrocephalus is a reversible cause of dementia seen in elderly

patients. It is thought to be secondary to reduced CSF absorption at the
arachnoid villi.
Has a classical triad of:

• Urinary incontinence
• Dementia
y
• Gait abnormality (may be similar to Parkinson's disease)
“the wet, wobbly and wacky grandpa”
op
C
This classical symptoms are known as Hakim’s triad. The incontinence does not
follow the pattern of spinal cord lesions (painless retention and overflow);
rather, it is the apparently normal passage of urine in response to a full bladder,
n
but without the patient being aware or particularly concerned by it. It is best
io
thought of as part of the cognitive decline rather than a separate entity. In

elderly patients it may be confused with urgency or gait problems preventing
t
them getting to the toilet in time.

ua
54. A 49 year old man first presented with increasing difficulty in swallowing. Several
months later he developed weakness in his right foot. Now he can no longer
al
feed himself, he chokes on food and has become confined to a wheelchair. What
is SINGLE most likely diagnosis?
Ev
A. Cerebral tumor
C. Lambert-Eaton syndrome
E. Cerebrovascular disease
Motor neuron disease (MND). This picture is of amyotrophic lateral sclerosis

with bulbar onset.
In MND, motor nerves become damaged and eventually stop working.

Therefore, the muscles that the damaged nerves supply gradually lose their
strength. There are various subtypes of MND. In each type, symptoms tend to
start in different ways. However, as the disease progresses, the symptoms of
each type of MND tend to overlap. This means that symptoms in the later stages
of each type of MND become similar. The main types of MND are:
872
Amyotrophic lateral sclerosis (ALS). This is the classical MND and the most
common type. About 8 in 10 people with MND have this type. Symptoms tend to
start in the hands and feet. The muscles tend to become stiff as well as weak at
first.
Progressive bulbar palsy (PBP). About 2 in 10 people with MND have this type.
The muscles first affected are those used for talking, chewing and swallowing
(the bulbar muscles).
Progressive muscular atrophy (PMA). This is an uncommon form of MND. The

small muscles of the hands and feet are usually first affected but the muscles are
not stiff.
Primary lateral sclerosis (PLS). This is a rare type of MND. It mainly causes
weakness in the leg muscles. Some people with this type may also develop
clumsiness in the hands or develop speech problems.
The subtypes for PLAB are not so important as they are unlikely to be asked. The
y
only subtype that has potential in being asked is Amyotrophic lateral sclerosis
op
(ALS)
Amyotrophic lateral sclerosis

C
Presentation:
• Progressive weakness of bulbar, limb, thoracic and abdominal muscles
• Oculomotor, sphincter, cognitive functions are usually spared
n
• Late stages - swallowing difficulty and hoarseness
io
Diagnosis:
t
• Clinical diagnosis via diagnostic criteria by EFNS guidelines

ua
Treatment:
• Multidisciplinary care
al
• Neuroprotective medication: riluzole

• Medications to treat respiratory symptoms, drooling, insomnia, fatigue,
Ev
and psychological symptoms

• Genetic testing and counseling for family
55. A 66 year old man, known case of uncontrolled hypertension, presents to clinic
with confusion. He has a past history of transient ischaemic attack where he
temporarily suffered from left arm paralysis. Throughout the year, his wife has
noticed a decline in his memory, along with clumsy gait which has made him
prone to falls, as well as progressive urinary incontinence. On examination, his
BMI is 31 kg/m2 and has irritable mood. MRI brain showed multiple subcortical
lacunar old infarcts. What is the SINGLE most likely diagnosis?
873
PLAB 1 key clues: >50 years with history of smoking, hypertension, and past
stroke or transient ischaemic attack. There would be “step-wise” deterioration
of symptoms. Some case stems would have the patient undergo a stroke-like
event, deteriorate, then recover partially. There would be some overlap with
Alzheimer’s in terms of symptoms but look out for the history of ischaemia.
Vascular dementia
Presentation:
- “Step-wise” deterioration, may have a partial recovery period before
further decline
- +/- Focal neurological signs
- Associated with hypertension, previous stroke / transient ischaemic
attack (TIA)
Diagnosis:
- MRI brain
Treatment:
- Multi-disciplinary approach
- Follow according to post-stroke / post-TIA management
- Behavioural changes: consider trazodone or lorazepam
y
op
56. A 26 year old woman presents to her GP with a headache, photophobia and a
fever. On examination, a generalized rash that does not blanch on pressure was
observed. What is the SINGLE most appropriate initial management?
C
A. IM benzylpenicillin
B. Isolate the patient
n
C. Blood culture
io
D. IV Gentamicin
E. IV Ceftriaxone
t
ua
She has signs of meningitis but she presented to her GP thus benzylpenicillin IM
(or IV) would be the correct answer. If you suspect meningitis and patient is not
yet in the hospital give IM benzylpenicillin and send patient to the hospital
al
urgently.
Ev

If this exact same question was given, but there was a diagnosis of Listeria, then
IV amoxicillin and gentamicin would be the correct answer
If this exact same question was given, but she is penicillin or cephalosporin
allergic, then chloramphenicol would be the answer. If the patient has a history
of immediate hypersensitivity reaction to penicillin or to cephalosporins the BNF
recommends using chloramphenicol.
Investigations
Generally, treatment for meningitis should be started before doing any
investigations due to the seriousness of the disease.
Rash
874
If patient has got a rash, then perform blood culture as the diagnosis is most
likely meningococcal septicaemia. The causative organism is Neisseria
meningitides.
If there is no rash then a lumbar puncture would be a better answer, but this can
only be done if there are no signs of raised intracranial pressure
Prophylaxis (oral ciprofloxacin or rifampicin) needs to be offered to household
and close contacts of patients affected with meningococcal meningitis
Summary
rifampicin
y
op
57. A 44 year old woman presents with a severe throbbing unilateral right sided
headache and photophobia 20 minutes after an episode of tingling and
numbness of her left hand. What is the SINGLE most likely diagnosis?
C
A. Transient Ischemic Attack
B. Migraine
n
C. Meningitis
io
D. Stroke
E. Subarachnoid haemorrhage
t
ua
This is a typical case stem for migraine in PLAB 1. The patient will present with or
without aura (sensory or motor) followed by the headache itself. THIS IS
EXTREMELY IMPORTANT. The key to differentiating between a migraine or a
al
headache of a more serious origin (e.g. subarachnoid hemorrhage) is the onset

of a unilateral, throbbing headache AFTER an aura.
Ev
Types of aura include, but are not limited to:

Visual disturbances can include:
• blind spots in the field of eyesight
• coloured spots
• sparkles or stars
• flashing lights before the eyes
• tunnel vision
• zig zag lines
• temporary blindness.
Other aura symptoms can include:
• numbness or tingling
• pins and needles in the arms and legs
• weakness on one side of the body
• dizziness
• a feeling of spinning (vertigo).
875
More information about migraine:
Migraine
Presentation:
Young to middle aged female or male (for PLAB 1)
Throbbing headache, localized to one side preceded by aura
+/ Nausea and vomiting
+/ Photophobia
Diagnosis:
Clinical diagnosis
MRI – can check for physiological changes in the brain during a migraine, but not
necessary (doesn’t change management)
Acute Treatment:
• Combination therapy with an oral triptan and an NSAID, or an oral
triptan and paracetamol.
y
• If monotherapy is preferred, offer an oral triptan, or NSAID, or aspirin, or
op
paracetamol.
Prevention:
C
• Topiramate or propranolol as first line for prevention
• Preventive treatment should be offered in addition to acute treatment.
• If both topiramate and propranolol are ineffective or are unsuitable,
n
offer gabapentin or acupuncture
io
58. A 50 year old man complains of being pursued by the police for a crime he
t
denies committing however on further investigation, this was found to be

ua
untrue. He has poor concentration and impaired short-term memory. He admits

to drinking large amounts of alcohol for the last 20 years. He is able to carry on a
coherent conversation, but moments later he is unable to recall that the
al
conversation took place. What is the SINGLE most likely diagnosis?

Ev
A. Cotard syndrome
B. Alcohol withdrawal
D. Schizophrenia
Korsakoff syndrome
This is termed Wernicke-Korsakoff syndrome and is characterised by the
addition of antero- and retrograde amnesia and confabulation in addition to the
classic triad of confusion, ataxia and ophthalmoplegia found in Wernicke's
encephalopathy.
Those with Korsakoff syndrome may "confabulate," or make up, information

they can not remember. They are not "lying" but may actually believe their
invented explanations.
They create events to fill the gaps in day-to-day memory. For example, a person
who has been in hospital for several weeks may talk convincingly about having
876
just visited their aunt earlier that day. This is more common in the early stages of
the condition..
Individuals may seem able to carry on a coherent conversation, but moments

later be unable to recall that the conversation took place or to whom they
spoke. They can often answer questions promptly with inaccurate and
sometimes bizarre answers.

3. Ophthalmoplegia
59. A 69 year old woman is brought to A&E by ambulance with no significant past
medical history or allergies. She presents with speech disturbance and
y
asymmetric facial and arm weakness. The symptoms began 3 hours ago. Brain
op
imaging shows an ischaemic stroke. Which is the SINGLE most appropriate next
course of action? C
A. Anticoagulation
B. Administer alteplase
n
C. Administer streptokinase
D. Start statins
io
E. Review in 24 hours
t
The history and examination are convincing for a stroke. Before any treatment
ua
can happen we need to exclude a haemorrhagic stroke with the help of imaging.
This was done in this question which showed an ischaemic stroke. The next step
is to start thrombolytics.
al
Ev
Anticoagulation → anticoagulants should not be started until brain imaging has

excluded haemorrhage, and usually not until 14 days have passed from the
onset of an ischaemic stroke”
Streptokinase → NHS prefers alteplase over streptokinase.
Statins → Statins need to be offered but this is not the most appropriate next
course of action. There is no urgency in giving statins.
Review in 24 hours → Thrombolysis should only be given if it is administered

within 4.5 hours of onset of stroke symptoms and haemorrhagic stroke has been
excluded by imaging. So review in 24 hours is clearly a wrong option.
Stroke management
877

60. A 46 year old chronic alcoholic man is brought to the emergency department in a
drowsy state. He is responding vaguely to questions. He denies any alcohol
y
intake today. He walks with an ataxic gait. Examination reveals nystagmus and
op
hyperreflexia.
Haemoglobin 128 g/L

C
What is the SINGLE most likely cause for his cognitive impairment?
n
io
A. B1 deficiency
B. B6 deficiency
t
C. B12 deficiency
ua
E. Liver disease
al
Although, folate deficiency is more common in people who regularly misuse

alcohol this is not the answer in this stem. A haemoglobin of 128 g/L is barely
Ev
enough to cause any symptoms of anaemia.

Treatment is with urgent replacement of thiamine (vitamin B1)


878
3. Ophthalmoplegia
61. A 43 year old woman presented with blurred vision and intermittent clumsiness
for 3 months. Reflexes are brisk in her arm and optic disc is pale. What is the
SINGLE most appropriate test to confirm diagnosis?
A. CSF analysis
B. CT
C. MRI
D. EEG
E. EMG
She has features suggestive of multiple sclerosis. Investigation of choice is an

MRI scan.
y
Multiple Sclerosis
Presentation:
op
C
1. Transverse myelitis:
n
•
• Weakness, sensory symptoms
io
• Urinary urgency and retention

• Flexor spasms
t
• Spastic quadriparesis or paraparesis

ua
• 2. Brainstem:
• Ataxia
al
• Diplopia
• Dysarthria
Ev
• Facial numbness
• Ophthalmoplegia
• Gaze palsy
• 3. Cerebellum
• Ataxia
• Dysarthria
• Nystagmus
impaired
days/weeks
879
Diagnosis:
Treatment:
62. A 33 year old man was working late in his office when he had a sudden onset of
excruciating headache localized to his right side and associated with right eye
pain. He has had similar episodes 2 months ago. On examination, his right eye is
swollen and red with lacrimation. What is the SINGLE most likely diagnosis?
A. Migraine with aura

y
C. Conjunctivitis
op
D. Cluster headache
E. Tension headache C
For PLAB 1, know how to differentiate the different types of headaches (i.e.
intracerebral haemorrhage, migraine, cluster headache, tension headache).
Features of cluster headache in PLAB 1: there is usually a male undergoing some
n
sort activity with a rapid onset of severe headache with eye involvement. The
io
eye pain is usually periorbital. As the name implies, the frequency of these
headaches occur in “clusters”. Look at the time frame in PLAB 1: there is usually
t
a clue to having frequent past episodes with/without period of remission.

ua
Cluster headache
Presentation:
al
- Male (30-40 years)

- - Excruciating headache: unilateral orbital, supraorbital, temporal
Ev
- Pain typically occurs once or twice a day, each episode lasting

15 mins - 2 hours
- These headaches can go on and off for 7 days – 1 year
- Triggers: stress, alcohol, exercise
- Accompanied by redness, lacrimation, lid swelling, nasal stuffiness
- Intense pain around one eye (recurrent attacks 'always' affect same
side)
Diagnosis:
- Mainly clinical diagnosis
Treatment:
- Acute: sumatriptan subcutaneous + 100% oxygen +/- lidocaine
intranasally
- Prevention: prednisolone, verapamil
63. A 31 year old woman, no known case of medical illnesses, presents to clinic with
numbness and tingling of her hands and fingers followed by a severe throbbing
880
headache localized to her left side. At home she tried to relieve her headache
with cold packs, paracetamol, and ibuprofen but there was no relief. She has had
similar episodes in the past. Currently, she is nauseated. On examination, she
required the lights to be dimmed. What is the SINGLE most appropriate next
step pharmacological management?
A. Perfalgan IV
B. Ketoprofen oral
C. Sumatriptan oral
D. Gabapentin oral
E. Topiramate oral
This is a typical case stem for migraine in PLAB 1. Patient will present with or
without aura (sensory or motor) followed by the headache itself. To differentiate
from more serious headaches (i.e. intracranial haemorrhages) in PLAB 1, the
clues usually would be “throbbing headache”, unilateral, and/or photophobia.
Note that topiramate is teratogenic/cause embryopathy and a preventative
measure for migraine. Also, pay attention to what PLAB 1 asks: If the woman is
y
on COCP and has migraine with aura, advise cessation of COCP as it increases
op
risk of ischemic stroke.
Migraine
C
Presentation:
- Young to middle-aged female or male (for PLAB 1)
- Throbbing headache, localized to one side preceded by aura
n
- +/- Nausea and vomiting
io
- +/- Photophobia
Diagnosis:
t
- Clinical diagnosis
ua
- fMRI – can check for physiological changes in the brain during a

migraine, but not necessary (doesn’t change management)
Acute Treatment:
al
NICE CKS recommends:

Combination therapy with an oral triptan and an NSAID, or an oral triptan and
Ev
paracetamol.
If monotherapy is preferred, offer an oral triptan, or NSAID, or aspirin, or
paracetamol.
Prevention:
NICE CKS recommends: Topiramate or propranolol as first-line for prevention
preventive treatment should be offered in addition to acute treatment.
If both topiramate and propranolol are ineffective or are unsuitable, offer

gabapentin or acupuncture
64. A 68 year old lady complains of falls to the ground without any warning. She
maintains consciousness throughout and remembers the event. There is no
confusion after the fall. What is the SINGLE most likely diagnosis?
A. Stokes Adams attack

B. Hypoglycaemia
881
C. Vasovagal syncope
D. Drop attacks
E. Epilepsy
Drop attacks are sudden spontaneous falls while standing or walking, with
complete recovery in seconds or minutes. There is usually no loss of
consciousness, and the event is remembered.
The remaining options given usually have a prodrome or identifiable symptoms

prior to the episodes like dizziness or pallor. Drop attacks do not have these.
Drop attacks
Drop attacks refers to unexplained falls with no prodrome, no loss of
consciousness, and rapid recovery. The proportion of falls due to ‘drop attack’
increases with age.
Causes
• Vertebrobasilar insufficiency
y
• Weak legs (eg cauda equina syndrome)
op
Note that the usual cause is sudden weakness of the legs that causes the patient,
usually an older woman, to fall to the ground. There is no warning, no loss of
C
consciousness and no confusion afterwards. The condition is usually benign,
resolving spontaneously after a number of attacks.
n
65. A 65 year old man has been recently diagnosed with atrial fibrillation. He has
io
suffered from a transient ischaemic attack 3 years ago. His medical history is
significant for diabetes mellitus type 2. What is the SINGLE best scoring method
t
to assess the need for anticoagulation?

ua
A. ABCD2
B. CHA2DS2-VASc
al
C. Well’s Score
D. CURB-65
Ev
E. NYHA Score
Knowing the contents of the ABCD2 and the CHA2DS2-VASc scoring system is
not necessary for the PLAB 1 exam but knowing when to apply each scoring
system is vital.
ABCD2 score
The ABCD2 score is to assess risk of future stroke in patients who have already
suffered from a transient ischaemic attack (TIA) or suspected transient ischaemic
attack.
An example of use of a ABCD2 score is a patient presenting to A&E or a GP

surgery with symptoms of a TIA. The ABCD2 score helps the physician decide on
how to manage the patient. If the patient scored high on the ABCD2 score, the
physician would refer the patient for specialist assessment within 24 hours of
the onset of symptoms, give a statin such as simvastatin 40 mg, and give an
882
antiplatelet drug if the patient is not already taking any anticoagulation
medication.
CHA2DS2-VASc score
The CHA2DS2-VASc score is to assess the risk of future stroke in patients who
have atrial fibrillation. This score is then used to determine whether or not
treatment is required with anticoagulation therapy.
Remember:
ABCD2 = Risk of future stroke following TIA
CHA2DS2-VASc = Risk of future stroke in patients with atrial fibrillation
66. A 78 year old woman admitted for a urinary tract infection for the last 10 days
has become increasingly confused. Her son has noted her level of consciousness
has been fluctuating and is disoriented to time and place. She is more withdrawn
but intermittently becomes very noisy and agitated. What is the SINGLE most
likely diagnosis?
y
A. Dementia
op
B. Delirium
C. Schizophrenia
D. Depression
C
E. Cerebral mass
For PLAB 1 neurology, know the difference between dementia and delirium. The
n
onset for delirium is more acute with fluctuating levels of consciousness. There
io
will also be disorientation, mood changes, paranoia, and some memory

impairment. Just know how to recognize the diagnosis and the basic
t
management.
ua
Delirium
Presentation:
al
• Acute onset
• Fluctuating levels of consciousness
Ev
• Disorientation, mood changes, paranoia

• Memory impairment
• Withdrawn or heightened arousal
Diagnosis:
• Clinical assessment via DSM-V
• Consider radiological imaging to rule out organic pathology
Treatment:
• Treat underlying cause
• Consider anti-psychotics
67. A 30 year old primigravid woman of 32 weeks gestation presents to clinic with
left facial droop of 2 days duration. On examination, there is no rash. The
nasolabial fold is flattened, there is a drooping of the left corner of her mouth
when asked to smile, and eye closure is weaker on the left side. She is unable to
883
puff her cheeks but is able to wrinkle her forehead. What is the SINGLE most
likely cause to these clinical findings?
A. Ramsay-Hunt syndrome
B. Parotid gland tumour
C. Bell’s palsy
D. Internal capsule stroke
E. Lyme disease
For PLAB 1 know cranial nerve palsies for CN III, VI, and VII. These are the most
common on the exam. In addition to the clinical findings on examination,
another PLAB 1 clue pointing to this diagnosis: pregnancy in the third trimester.
Another scenario would be the patient would be diabetic. Look closely at the
age: PLAB 1 would have a much older patient for stroke and there should some
upper/lower limb deficit. There is no travel history or going to the jungle;
therefore for PLAB 1, option E is ruled out. Option A would have a prior infection
in the case stem and would most likely present with a rash.
Bell’s palsy
y
Presentation:
op
- Drooling
C
Diagnosis:
n
- Borrelia antibodies and varicella zoster antibodies to rule out Lyme
io
disease, Ramsay-Hunt syndrome (case dependent)

- MRI brain to rule out stroke or tumours (case dependent)
t
Treatment:
ua
- Within 72 hours onset, give prednisolone (also in pregnancy)

- Acyclovir if suspecting Ramsay-Hunt syndrome
al
68. A 56 year old woman with multiple sclerosis presents with drooping her lips on
Ev
the left side. She also has loss of sensation over her face, and hearing
impairment. She has lack of voluntary coordination of muscle movements. What
is the SINGLE most likely anatomical site affected?
A. Cerebellum
B. Cerebrum
C. Spinal cord
D. Brain stem
E. Optic nerve
Brain stem would need to be involved here as there are features involving
cranial nerve V, VII and VIII. The cranial nerves III-XII emerge from the brainstem.
These cranial nerves supply the face, head, and viscera.
69. A 40 year old woman suddenly collapsed and died. At the post-mortem autopsy,
it was found that there was a bleed from a berry aneurysm from the circle of
Willis. Which is the most likely space that the bleeding occurred in?
884
A. Subarachnoid
B. Subdural
C. Extradural
D. Subparietal
E. Brain ventricles
Subarachnoid haemorrhage (SAH) is spontaneously in the context of a ruptured

cerebral aneurysm but may be seen in association with other injuries when a
patient has sustained a traumatic brain injury. Aneurysm formation is the most
common aetiology.
There is also an association with polycystic kidney disease, Ehlers Danlos

syndrome and other connective tissue disease
Head trauma is rare as a cause of SAH
70. A 7 year old child is brought to the hospital by his teacher. The child was playing
y
with other children and sudden fell down and hit the table and went
op
unconscious for a few seconds before returning to his normal self. On probing
further, the diagnosis of absence seizure was made. What is the SINGLE most
likely reason that could have led to this diagnosis?
C
A. The child had not eaten since morning
B. The child suddenly stared blankly into space and there was up-rolling of eyes
n
C. The child started moving his fingers uncontrollably before he fell
io
D. The child’s body became rigid and then started to jerk

E. The child has a fever and feels unwell
t
ua
In PLAB 1 stems, absence seizures would usually be a child (<10 years) with
either the parent or teacher noticing that the patient is “daydreaming” often and
when they resume their studies they are not able to perform well. In this
al
scenario however, the diagnosis was already given but they want you to know
what is the history that could give you the diagnosis. Staring blankly into space
Ev
and upturning of eyes for a few seconds and resuming activity almost
immediately is indicative of absence seizures.
Absence seizure
Presentation:
- Child usually <10 years old
- Loss of awareness (“daydreaming”), stare blankly into space, will not
respond to their surroundings
- May be accompanied by upturning of eyes, other repetitive
movements
- Will return to normal activities after seizure but may not perform well
and feel tired
- No photosensitivity
- Maybe triggered by hyperventilation
Diagnosis:
- EEG
- Check FBC, glucose levels, ECG, MRI for other underlying causes
885
Treatment:
- If recurring, sodium valproate or ethosuximide
71. A 41 year old male with hypertension and recurrent kidney stones presents to
the Emergency Department with a headache of intense severity. He is also noted
to have neck stiffness and pain. Labs were done and revealed a serum sodium of
131 mmol/L. What is the SINGLE most likely mechanism behind his serum
sodium results?
A. Decreased intake of food

B. Polyuria
C. Syndrome of inappropriate anti-diuretic hormone
D. None of the above
E. All of the above
This is a 2 step question. First figure out the diagnosis and through that find out
the answer to the question. Some questions will require you to do this. In this
case, the diagnosis is subarachnoid hemorrhage (SAH) and it is also implied in
y
the case stem that the patient has possible polycystic kidney disease
op
(hypertension and recurrent kidney stones). Know the presentation,
associations, investigations, and complications of SAH since there is considerable
overlap of this topic between neurology and emergency. One of the major
C
complications of SAH is hyponatremia. Hyponatremia commonly occurs in
patients with aneurysmal subarachnoid haemorrhage. The mechanism that has
been proposed as a cause is syndrome of inappropriate anti-diuretic hormone.
n
io
t
Willis
ua
Presentation
al

Ev
Associations
• Hypertension
Diagnosis
• CT brain
• Lumbar puncture
(bilirubin)
886
72. A 49 year old patient has Parkinson’s disease. What is the SINGLE most useful
medication in the management of his tremor and dystonia?
A. Apomorphine
B. Cabergoline
C. Selegiline
D. Amantadine
E. Benzhexol
Benzhexol (Trihexyphenidyl) is an anticholinergic agent and it is the drug of

choice to treat parkinson’s disease induced tremor. Anticholinergic agents have
a limited role and should only be prescribed in young patients with severe
tremor and dystonia. Orphenadrine is also another anticholinergic agent that is
commonly used.
73. A 53 year old man presents to clinic with complains of urinary incontinence and
y
erectile dysfunction. He is seen to have ataxia, rigidity and a pill rolling tremor of
op
the hands. On examination, postural hypotension is also noted. What is the
SINGLE most likely diagnosis? C
B. Creutzfeldt-Jakob disease
C. Shy-drager syndrome
n
D. Huntington’s disease
io

t
Shy-drager syndrome
ua
• A rare neurodegenerative disorder, caused by cell loss in certain areas of

the brain and the spinal cord, leading to a variety of symptoms
characterised by Parkinsonian features, cerebellar ataxia and autonomic
al
dysfunction (particularly urogenital)

Ev
Mean age at onset is between 50 and 70 years
Presentation:
• Urinary dysfunction → most common presentation
• Erectile dysfunction
• Postural hypotension
• Cerebellar ataxia
• Parkinsonian symptoms with poor response to levodopa
In the exam, if you get a stem with characteristics of parkinsonism (rigidity, pill
rolling tremor of the hands) plus autonomic dysfunction (urinary incontinence,
erectile dysfunction) consider Shy-drager syndrome as the answer.
74. A 26 year old female presents with bladder incontinence, clumsiness when
walking, shooting lower back pain, and blurry vision, and sensory loss. These
symptoms have occurred all at once or in different combinations approximately
every few months and each event lasts 3-4 days. There is swelling of the optic
887
disc on fundoscopy, inability to walk heel to toe, and weakness at the hip girdles.
What is the SINGLE most appropriate diagnostic test?
A. CT head and spinal cord

B. MRI brain and spinal cord
C. Serum Vitamin B12 levels
D. EMG
This is a diagnosis of multiple sclerosis. The definitive diagnostic test would be

MRI brain and spinal cord. This patient is presenting with upper motor neuron
signs and optic neuritis.
Multiple Sclerosis
Presentation:
y
• 1. Transverse myelitis:
o
o
Weakness, sensory symptoms
op
Urinary urgency and retention
C
o Flexor spasms
o Spastic quadriparesis or paraparesis
n
• 2. Brainstem:
io
o Ataxia
t
o Diplopia
ua
o Dysarthria
o Facial numbness
o Ophthalmoplegia
al
o Gaze palsy
Ev
• 3. Cerebellum
o Ataxia
o Dysarthria
o Nystagmus
impaired
days/weeks
Diagnosis:
888
Treatment:
75. A 73 year old male presents with a history of falls over the past 12 month. His
relatives have also noticed a rather strange behavior lately and more recently he
has had episodes of enuresis. Examination reveals that he is disorientation to
time and place, with a broad-based, clumsy gait. What is the SINGLE most likely
diagnosis?
C. Cardiovascular disease
D. Syringomyelia
y
op
The history of falls and broad based clumsy gait (balance and gait disturbance),
strange behavior and disorientation to time and place (due to dementia),
episodes of enuresis (urinary incontinence) points towards normal pressure
C
hydrocephalus.
Remember the classic triad.

n
io

t
Normal pressure hydrocephalus will present with prominent gait abnormalities

ua
early in the course of the disease that usually precede the onset of cognitive
impairment. There will also be associated urinary incontinence.
al
Normal pressure hydrocephalus is a reversible cause of dementia seen in elderly

patients. It is thought to be secondary to reduced CSF absorption at the
Ev
arachnoid villi.
Has a classical triad of:

• Urinary incontinence
• Dementia
• Gait abnormality (may be similar to Parkinson's disease)
“the wet, wobbly and wacky grandpa”
This classical symptoms are known as Hakim’s triad. The incontinence does not
follow the pattern of spinal cord lesions (painless retention and overflow);
rather, it is the apparently normal passage of urine in response to a full bladder,
but without the patient being aware or particularly concerned by it. It is best
thought of as part of the cognitive decline rather than a separate entity. In
elderly patients it may be confused with urgency or gait problems preventing
them getting to the toilet in time.
889
76. A 54 year old man had a recent stroke. He now presents with ataxia, intentional
tremors and dysarthria. Which part of the brain is most likely affected by the
stroke?
A. Inner ear
B. Brain stem
C. Diencephalon
D. Cerebrum
E. Cerebellum
The ataxia, intentional tremors and dysarthria points towards a cerebellar

disorder.
Cerebellar Disorders
Aetiology includes stroke or transient ischaemic attack (TIA)
y
Presentation
op
As the cerebellum is associated with motor control, lesions produce a range of
movement disorders (ataxias). Lesions of the midline vermis of the cerebellum
cause truncal ataxia, while lesions of the cerebellar hemispheres cause limb
C
ataxia of the ipsilateral side.
77. A 22 year old female presents with progressive difficulty in walking due to lower
n
back pain. There is tingling and numbness in her hands that has radiated towards
io
her elbows. On examination, cranial nerves are intact. There is no sensation of

vibration or pin prick in her upper limbs to elbows and from lower limbs to hips.
t
There are absent reflexes and mute plantars. Blood pressure is 124/85 mmHg
ua
and heart rate is 68 beats/minute. The patient had an episode of food poisoning
two months ago. What is the SINGLE most likely diagnosis?
al
Ev
C. Myasthenia gravis
D. Diabetic neuropathy
E. Infective neuropathy
PLAB 1 key features for case stem: young female with ascending polyneuropathy
usually after a trigger (i.e. infection). There are absent reflexes therefore
multiple sclerosis is ruled out since it involves upper motor neurons. Myasthenia
gravis usually would have more emphasis of fatigue especially in the proximal
muscles and cranial nerves would be affected. There is no clue in the stem that
the patient is diabetic and even he is, the onset is acute while option D would
require a more gradual progressive process. While the patient did have an
infection, there was no history of travel and for option E to occur it would most
likely be a diagnosis of Lyme disease.
Guillain-Barre syndrome
Presentation
890
• Most are preceded by a upper respiratory tract infection or
gastrointestinal infection
• Case stem may have clues: Campylobacter jejuni, CMV, EBV, H.
influenzae, Mycoplasma
• Progressive ascending weakness +/- paraesthesia
• Severe back pain, cranial nerve involvement
• Tendon reflexes are lost
Diagnosis
• CSF: increased protein level usually after 1st week; normal WBC
• Nerve conduction test: hallmark = focal conduction block
Treatment
• Intravenous immunoglobulin 0.4g/kg/day for 5 days or plasma exchange
• If no response in 2 weeks, consider repeating intravenous
immunoglobulin course or plasma exchange
• Treat neuropathic pain with gabapentin
• Consider referral to ICU if respiratory depression detected
y
op
78. A 55 year old was admitted to the hospital for investigations of haemoptysis.
Two days after admission he develops alternating state of consciousness,
sweating, and tremors. His temperature is 37.3°C. He gives a history drinking
C
alcohol every day for the past year. What is the SINGLE most appropriate
management?
n
A. Acamprosate
io
B. Chlordiazepoxide
C. Antibiotics
t

ua
E. Disulfiram

al
Ev

hours and subside by 48 hours

891
79. A 28 year old woman complains of double vision. She tires easily especially as
the day progresses. There is difficulty climbing stairs, reaching for items on
shelves, and brushing her hair. As she speaks, her speech fades gradually. Over
the last week, she has had difficulty chewing and swallowing. On examination,
there were no significant findings. She has a family history of thyroid disease.
A. Polymyositis
The symptoms here are classic for Myasthenia gravis. It is important to
y
remember that there is a predisposition for autoimmune diseases to run in
op
families hence the history of thyroid disease in the family in the stem.
Myasthenia gravis
C
Presentation:
• Female (20-30 years) ; males (50-60 years)
n
• Painless muscle weakness that increases with exercise (This feature of
io
fatigue often gives the diagnosis in the exam) - It is even seen in the
voice. For example, getting the patient to count up to 50. As the patient
t
nears 50 their voice becomes less audible as they are fatiguing.

ua
• Ocular muscles involved - drooping eyelids

• Dysphagia, dysarthria, dysphonia
• Normal reflexes
al
• Associated with hyperthyroidism

Ev
80. A 63 year old man presents after having a seizure. He is alert and orientated. On
examination, inattention on the left side is noticed with hyperreflexia of the arm.
A. Cerebral tumour
C. Cerebellar abscess
D. Huntington's chorea
E. Parkinsonism
Inattention or neglect is a feature of parietal lobe lesion. Seizure may occur in

space occupying lesions.
The most likely explanation for this answer is that the cerebral tumour has
caused the right parietal lobe of the brain to be affected which can lead to
neglect for the left side of the visual field, causing a patient with neglect to
892
behave as if the left side of sensory space is nonexistent (although they can still
turn left).
In an extreme case, a patient with neglect might fail to eat the food on the left
half of their plate, even though they complain of being hungry. If someone with
neglect is asked to draw a clock, their drawing might show only the numbers 12
to 6, or all 12 numbers might be on one half of the clock face with the other half
distorted or blank. Neglect patients may also ignore the contralesional side of
their body; for instance, they might only shave, or apply makeup to, the non-
neglected side. These patients may frequently collide with objects or structures
such as door frames on the side being neglected.
y
op
C
This is how someone with hemineglect might draw a clock
n
81. A 63 year old man, known case of hypertension and smoker, presents to clinic
io
with a sudden onset of weakness in the right arm and changes in speech which
had resolved within a 24 hour period. On examination, there were no residual
t
neurological findings and cardiology examination was normal. What is the

ua
A. MRI brain
al
B. CT brain
C. Echocardiogram
Ev
E. Carotid doppler scanning
This is a classic presentation of transient ischaemic attack. Under the ABCD2

score, this patient has a score of 4. The most appropriate step according to
guidelines is for carotid doppler scanning to check for carotid artery stenosis to
assess the need for carotid endarterectomy. MRI would eventually be done but
it would not be the “next step” as the patient no longer has residual neurological
findings and his symptoms have completely resolved; therefore MRI at this
moment would not be clinically beneficial.
Transient ischaemic attack

Presentation:
• Facial weakness, unilateral arm weakness, speech problems
• Association: smoking, hypertension, atrial fibrillation, ischaemic heart
disease
893
Diagnosis:
• ABCD2 score
• Carotid doppler scan - definitive
• MRI brain
Treatment:
• On admission aspirin 300mg immediately unless contraindicated
• Referred to stroke unit to be assessed
• Carotid endarterectomy and stenting - need according to carotid doppler
results
• Antihypertensives, antiplatelets, statins, lifestyle modification
82. A 58 year old man has a progressively worsening headache and confusion. He
had a fall three days ago after slipping and hitting his head in the garden. He has
a history of alcohol abuse. What is the SINGLE most appropriate investigation?
A. X-ray skull
B. Electrocardiogram
y
op
D. Magnetic resonance imaging brain scan
E. Electroencephalogram C
The likely cause of his confusion and worsening headache is a subdural
haemorrhage. A CT scan is diagnostic.
n
Subdural haematoma may be acute or chronic. In the chronic subdural
io
haematoma, symptoms may not be apparent for several days or weeks.

Symptoms of subdural haematomas are: fluctuating level of consciousness, ±
t
insidious physical or intellectual slowing, sleepiness, headache, personality

ua
change and unsteadiness.

al
Ev

on anticoagulation or an alcoholic who may have history of fall. Slow onset of
83. A 67 year old man with a known case of diabetes mellitus type II and prostate
carcinoma presents to clinic with back pain, groin numbness, and inability to
initiate voiding. Which of the following is the SINGLE most likely mechanism to
explain for these symptoms?
A. Cauda Equina syndrome

B. Urinary outlet obstruction secondary to prostate carcinoma
C. Hydronephrosis secondary to urolithiasis
D. Neurogenic bladder from long-standing diabetes mellitus type II
894
PLAB 1 questions are usually very straight-forward. They would usually only ask
diagnosis, investigation, and management. However occasionally, there would
be a few odd questions where they would ask for the mechanism behind certain
pathology. In this case stem, the patient has a history of prostate carcinoma;
therefore, the symptoms presented here would most likely indicate
metastasis/tumour that is compressing on the cauda equina. Option B would
produce a degree of voiding dysfunction but not in the initiation of voiding and
there would not be sensory changes. Option D although possible will not
produce severe back pain or perineal numbness.
Cauda Equina syndrome

Presentation:
- Severe back pain
- Groin numbness / “saddle distribution sensory loss”
- Difficulty to initiate voiding
- Urinary or faecal incontinence
- Distal motor weakness
Diagnosis:
y
- MRI spine
op
Treatment:
- This is a neurosurgical emergency and needs neurosurgery referral
C
84. A 56 year old male has increased thirst and increased micturition. He is found to
have an intracranial tumour. Where is the SINGLE most likely location for the
tumour?
n
io
A. Diencephalon
B. Midbrain
t
C. Medulla
ua
D. Pons
E. Cerebrum
al
This is most likely a diagnosis of Diabetes Insipidus. The diencephalon consists of

the thalamus, the hypothalamus, the epithalamus and the subthalamus. The
Ev
hypothalamus is a crucial part of the endocrine system of the body and so

therefore the most likely location for an intracranial tumour causing diabetes
insipidus would be the diencephalon.
In contrast, the most likely location for a brain tumour causing SIADH (Syndrome
of Inappropriate Antidiuretic Hormone) would be the cerebrum or cerebellum.
Both DI and SIADH are common in cancer patients or those with brain tumours
so it is important to know the most likely tumour locations causing these
diseases.
Some important PLAB 1 points for Diabetes Insipidus:
Normal Diabetes insipidus

patient
Fluid Despite fluid restriction, urine volume remains high
restriction and urine osmolality is decreased
895
causes a Central Diabetes insipidus
decrease in Urine volume There is no change after
urine decreases and urine administering
volume and osmolality increases desmopressin
an increase after administering
in urine desmopressin
osmolality

After fluid deprivation, If plasma osmolality >305, the patient has diabetes
insipidus
Central Diabetes Nephrogenic Diabetes

insipidus insipidus
y
85.
op
A 75 year old lady on warfarin for atrial fibrillation is brought into clinic by her
C
daughter. Her daughter is concerned as her mother is progressively getting more
confused over the last couple of weeks. On physical examination,the lady was
n
noticed to have bruises on her arms. She has an INR of 7. What is the SINGLE
io
A. Alzheimers
t
B. Delirium
ua

al
She is an elderly lady on anticoagulation. A trivial fall may have gone unnoticed.
Ev
Warfarin and a high INR are risk factors for a subdural haemorrhage. Progressive
confusion over days to weeks support this diagnosis.


86. The daughter of a 69 year old male found her father alone in his apartment with
confusion, bruising on his left arm and an unsteady gait. CT brain reveals a
midline shift away from the side of a clot. What is the SINGLE most likely
diagnosis?
896
B. Intracerebral bleed
C. Subdural haemorrhage
D. Epidural haemorrhage
E. Complex partial seizure
In most subdural haemorrhage case stems for PLAB 1, most will present as
elderly and male (chronic subdural haemorrhage). Pay attention to history
details such as history of falls or other trauma.
Subdural haemorrhage
Presentation:
- Fluctuating levels of consciousness
- Physical or intellectual slowing
- Sleepiness, headache, personality changes
- Unsteadiness
- Seizures
y
Diagnosis:
op
- CT brain / MRI brain – clot +/- midline shift; “crescent shaped”
haematoma
Treatment:
C
- First line: Irrigation / evacuation via burr twist drill and burr hole
craniostomy
n
87. A 67 year old woman with a history of atrial fibrillation with presents to
io
emergency with slurred speech, asymmetric facial weakness, left sided hemi-
paresis and ataxia. On arrival to the A&E her GCS is 14/15. She is increasingly
t
agitated. Which is the SINGLE most appropriate next course of action?

ua
A. Anticoagulation
al
C. Give aspirin
D. Give lorazepam
Ev
E. Urgent CT head
CT helps rule out primary haemorrhage.
Anticoagulation → with regards to atrial fibrillation, RCP state that

“anticoagulants should not be started until brain imaging has excluded
haemorrhage, and usually not until 14 days have passed from the onset of an
ischaemic stroke”
Thrombolysis or aspirin → are the treatment options for ischaemic strokes but
cannot be started until a CT scan excludes a haemorrhage.
897
Lorazepam → Agitation is common in intracranial events, especially
haemorrhages, but should not be treated with sedation as this can mask real
fluctuations in consciousness levels.
Basically, all treatments that can cause bleeding should be held off until
haemorrhagic stroke is ruled out by imaging
Stroke management

y
op
C
n
io
88. A 34 year old housemaid presents with severe headaches in the back of her head
for several days and pain on flexing her neck. The pain is worsened by
t
movements. On examination, there is limited range of movement of the neck.

ua
al
B. Cervical spondylosis
C. Subarachnoid haemorrhage
Ev
D. Meningitis
E. Cluster headache
Cervical spondylosis is chronic cervical disc degeneration with herniation of disc

material, calcification and osteophytic outgrowths.
Headache in the back of head and pain on flexing neck is an early feature of
cervical spondylosis which gradually progress to later symptoms like
radiculopathies due to root compression in arms and hands.
89. A 75 year old nursing home resident complains of worsening headache, and
impaired vision for 4 days. Her daughter says she is getting more and more
confused day by day. She has multiple bruises on her head. What is the SINGLE
most likely cause of her confusion?
A. Alcohol intoxication
B. Infection
898
C. Subdural haematoma
D. Hypoglycaemia
E. Hyponatraemia
Among the given answers, subdural haematoma fits the best. The multiple
bruises on her head suggest head injury which can lead to subdural haematoma.
Headache, confusion and impaired vision for 4 days could occur in chronic
subdural haematoma
She is an elderly lady thus a trivial fall may have gone unnoticed.

In this case, there is no history of anticoagulation or history of alcoholism. But

the picture still fits chronic subdural haematoma.
y
90. A previously healthy 2 year old girl is brought to the Emergency Department by
op
her mother after having witnessed the child’s body suddenly going stiff followed
by uncontrolled twitching of the arms and legs for about 5 minutes. There was
frothing at the mouth and on examination now the child is drowsy. Temperature
C
on admission was 38oC. This was a first time event. What is the SINGLE next
n
A. Paracetamol and observation
io
B. Diazepam per rectal

C. Lumbar puncture
t
D. CT brain
ua
E. EEG
This is a diagnosis of simple febrile seizure. Under current guidelines, this is a

al
first occurrence and therefore only option A is needed. There are no indications
that there is meningitis in the stem and also the patient is currently in a postictal
Ev
state (“drowsy); therefore, lumbar puncture is not appropriate at this time. If

this is only a first time event, both option D and E is not necessary unless there
are indications pointing to a more serious pathology (haemorrhage, status
epilepticus). Diazepam under current guidelines is useful as a preventative
measure if febrile seizures were occurring frequently or if the seizure has not
stopped while in Emergency. Note the difference between simple and complex
febrile seizures for management. Most likely for PLAB 1, the case stem would be
simple febrile seizures.
Simple febrile seizures

Presentation:
• Age group: 3 months - 6 years
• Sudden, rapid increase in temperature (> 38oC)
• < 15 minutes
• General tonic-clonic seizure
• Post-ictal state → drowsiness, sleeping
899
Diagnosis:
• Blood and urine test to rule out infection
• Consider lumbar puncture for meningitis if it is highly suspicious only
• Mostly a clinical diagnosis, rule out other pathology
Treatment:
• Reassurance and counseling
• Paracetamol to reduce fever and observation - if first event
• Diazepam per rectal as prophylaxis if more than once
91. A 45 year old man, with no known medical illnesses, presents to the clinic with
left facial pain for the past month. It is a sharp shooting pain that radiates
around his left cheek while chewing. It would last a few seconds repeatedly
throughout the day. He has taken ibuprofen but with no relief. On examination:
blood pressure is 120/70 mmHg, neurological exam is normal, palpation to the
left jaw and cheek elicits pain although jaw muscles are of full strength. What is
the SINGLE most appropriate management for this condition?
y
A. Amitriptyline
op
B. Patient controlled analgesia
C. Gabapentin
D. Carbamazepine
C
E. Microvascular decompression
Trigeminal neuralgia
n
io
Presentation
• Unilateral, shooting or stabbing electric shock-like facial pain
t
• Pain exacerbated with movement or touch especially in the jaw (CN V,

ua
2nd and 3rd branch distribution)

• Abrupt in onset and termination
al
Diagnosis
Ev
• MRI is routinely done to rule out other pathology (i.e. schwannoma,

meningioma)
Treatment:
• Medication then surgery
• Carbamazepine >lamotrigine / phenytoin / gabapentin
• Surgical: microvascular decompression
92. A 70 year old man with a known case of ischaemic heart disease presents to
emergency with paralysis of his left arm, sensory loss on the left side of his face,
right sided gaze preference and homonymous hemianopsia. Which of the
following is the SINGLE most likely artery to be affected?

B. Right posterior cerebral artery
C. Left posterior cerebral artery
D. Right anterior cerebral artery
900
E. Basilar artery
locations of
the lesion, investigations and management. Pay special attention to the anatomy
of the lesions
especially the vascular distribution and the functions of the different parts of the
brain.
i.e. anterior cerebral artery – frontal and medial cerebrum
middle cerebral artery – lateral part of the hemisphere
posterior cerebral artery – occipital lobe
basilar artery – cerebellum, brainstem, occipital lobe
Presentation:
- Middle cerebral artery occlusion features:
- Aphasia in the dominant hemisphere
- Neglect in the non-dominant hemisphere
- Contralateral paralysis (face & arm)
y
- Contralateral sensory loss (face & arm)
op
- Gaze preference toward side of lesion
- Homonymous hemianopsia C
Stroke general features:
- Usually sudden onset with possible further progression that takes
place over hours
n
- May have underlying ischaemic heart disease, carotid bruits, atrial
io
fibrillation
t
Diagnosis:
ua
- CT brain with no contrast to rule out whether stroke is ischaemic or

haemorrhagic (initial
- investigation)
al
- Diffusion-weighted MRI brain provides more sensitivity in acute

setting
Ev
Treatment:
- ABC protocol
- Blood glucose – keep between 4-11mmol/L & IV fluid hydration
- If ischaemic stroke – give Aspirin 300mg PO
- If
- 4.5 hours)
93. A 52 year old man presents with visual hallucinations and features of cognitive
impairment including memory loss. He has a tremor and a festinating gait. What
C. Delirium tremens
901
The most important features of Lewy body dementia that differentiate it from
the other forms of dementia is the:
• Visual hallucinations
• Fluctuating course with lucid intervals
• Signs of mild Parkinsonism
Two of which are found in this stem: signs of parkinsonism and visual
hallucinations.
Typical presentation of lewy body dementia

• Dementia is usually the presenting feature, with memory loss, decline in
problem solving ability and spatial awareness difficulties.
• Characteristically there are fluctuating levels of awareness and
attention.
• Signs of mild Parkinsonism (tremor, rigidity, poverty of facial expression,
festinating gait). Falls frequently occur.
• Visual hallucinations (animals or humans) and illusions. → This is
y
particularly important to differentiate lewy body from other types of
op
dementia in the PLAB exam
• Sleep disorders including rapid eye movement sleep disorder, restless
legs syndrome
C
94. A 45 year old man presents to clinic for his routine diabetic check-up. The
patient has normal tone, 5/5 power, normal plantars and proprioception. There
n
is sensory stimulus on the medial side of the right lower leg. Which of the
io
following is the SINGLE most likely dermatome to be affected?

t
A. L1
ua
B. L2
C. L3
D. L4
al
E. L5
Ev
Know dermatomes for PLAB 1. These questions do sometimes appear on the

exam and therefore would be useful to know. Usually, it would be the major
dermatomes of the upper and lower limbs.
Dermatomes
Presentation:
• PLAB 1 may appear as a diabetic neuropathy stem or a trauma with
sensory loss
• It may also appear as just a straightforward statement asking for the
dermatome of a specific part of the body with no case stem
Diagnosis:
• N/A
Treatment:
• N/A
902
95. A 49 year old chronic alcoholic with established liver damage is brought to the
hospital after an episode of heavy drinking. His is not able to walk straight and is
complaining of double vision. He is shouting obscenities and expletives. What is
A. Korsakoff psychosis
B. Delirium tremens
C. Wernicke's encephalopathy
D. Tourettes syndrome
E. Alcohol dependence

y
op
C
n
io
t
3. Ophthalmoplegia
ua
96. A 72 year old man becomes confused over a period of 2 weeks. He used to be
al
active and goes for long walks. Now he stares at the wall, barely talks to anyone,
and sleeps majority of the day. His daughter recalls that he fell down the stairs
Ev
about a week before the mental changes began. What is the SINGLE most likely
diagnosis?
A. Chronic Subdural haemorrhage

B. Epidural haematoma
C. Alzheimers
An elderly man with a history of fall with progressive confusion over the last
couple of days points towards the diagnosis of chronic subdural haemorrhage.

903
97. An 50 year old man presents to the clinic with his wife. She states that her
husband has had a noticeable change in personality. He is impulsive and
occasionally demonstrates inappropriate behavior. On examination, he has
difficulty naming objects, but his memory, ability to calculate, and his
visuospatial skills are intact. What is the SINGLE most likely diagnosis?
A. Alzheimer’s disease
B. Frontotemporal dementia (Pick’s disease)
The hallmark of Pick’s disease is behavioural changes, inappropriate behaviour,

and disinhibition. In early stages of Pick’s disease memory, visuospatial skills, and
y
calculation are relatively intact and this differs from Alzheimer’s where usually
op
memory would be affected first.
C
Frontotemporal dementia (Pick’s disease)
Presentation:
• Behavioural changes, disinhibition, inappropriate behaviour
n
• Lip smacking
io
• Early stages - memory, ability to calculate, and visuospatial skills are

intact
t
• Later stages - memory and cognitive function disrupted

ua
• Age group - younger than Alzheimers - 30-65 years
Diagnosis:
al
• Lund–Manchester criteria, NINDS criteria
Ev
• MRI brain to rule out other pathology
Treatment:
• Structured daily routine to control behaviour; predominantly supportive
care
• Trial of trazodone or selective serotonin reuptake inhibitors
98. A 44 year old man with a history of chronic alcohol abuse attends A&E. He is
unkempt, drowsy, walks with an ataxic gait and has poor memory. it is believed
he has not eaten in forty eight hours. A decision to commence chlordiazepoxide
and IV Pabrinex is made. Which vitamin, present in Pabrinex, can prevent the
progression of his symptoms?
A. Vitamin B1
B. Vitamin B6
C. Vitamin B12
D. Vitamin C
904
E. Vitamin D
This man is suffering from Wernicke’s encephalopathy. Vitamin B1, also called
thiamine, is present in Pabrinex and it is needed to treat Wernicke’s
encephalopathy.



y
op
3. Ophthalmoplegia
C
n
99. A 53 year old chronic alcoholic was brought to the emergency department with
an alternating state of consciousness, nausea and vomiting. He has unsteady,
io
uncoordinated walking and complains of double vision. On examination of his

face, his eyelids seem to be drooping and nystagmus is seen. He denies having
t
taken alcohol in the last 12 hours. What is the SINGLE most appropriate
ua
management?
A. Acamprosate
al
B. Chlordiazepoxide
C. Diazepam
Ev

E. Disulfiram
This man is suffering from Wernicke’s encephalopathy. Vitamin B1, also called
thiamine, is present in Pabrinex and it is needed to treat Wernicke’s
encephalopathy.


905
3. Ophthalmoplegia
100. A 31 year old man with no past medical history complains of severe headache
since 2 hours ago during work. The headache is mainly localized to the left side
and is associated with photophobia. A similar episode had occurred a few
months ago which had lasted over 2 weeks and resolved spontaneously. During
the examination, he is unable to sit still with obvious agitation and anxiety. What
B. Epidural haemorrhage
C. Tension headache
y
D. Cluster headache
op
E. Migraine
For PLAB 1, make sure you can differentiate the different types of headaches
C
(tension, cluster, migraine). Cluster headache case stems usually have a young
male with a headache localized to one side along with some autonomic features.
n
Also, there should be a past history of episodes over a couple of weeks. Another
clue is people with cluster headaches usually move around while in migraines
io
they have a tendency to be lying down in a dark room.

Cluster headache
t
ua
Presentation:
- Male (30-40 years)
- - Excruciating headache: unilateral orbital, supraorbital, temporal
al
- Pain typically occurs once or twice a day, each episode lasting

15 mins - 2 hours
Ev
- These headaches can go on and off for 7 days – 1 year

- Triggers: stress, alcohol, exercise
- Accompanied by redness, lacrimation, lid swelling, nasal stuffiness
- Intense pain around one eye (recurrent attacks 'always' affect same
side)
Diagnosis:
- Mainly clinical diagnosis
Treatment:
- Acute: sumatriptan subcutaneous + 100% oxygen +/- lidocaine
intranasally
- Prevention: prednisolone, verapamil
101. A 45 year old man has back pain radiating down to his legs. He has motor
weakness with knee extension and foot dorsiflexion. On examination, perineal
sensory loss is noted. What is the SINGLE most appropriate action?
906
A. Analgesia, rest and review in 6 weeks
B. Administer benzodiazepine
C. Encourage to keep active and referral to physiotherapist
D. Advise on correct sitting position and posture
E. Immediate referral to orthopaedic surgeon
This is a classic example of cauda equina syndrome. It is a serious neurologic

condition in which damage to the cauda equina causes loss of function of the
nerve roots of the spinal canal below the termination (conus medullaris) of the
spinal cord. Any lesion which compresses or disturbs the function of the cauda
equina may disable the nerves although the most common is a central disc
prolapse.
Spinal cord compression or cauda equina syndrome are neurological

emergencies that require immediate referral and intervention.
The management of true cauda equina syndrome frequently involves surgical

decompression.
y
op
Pain due to a herniated lumbosacral disc may settle within six weeks. If it does
not, or there are red flag signs such as the possibility of cauda equina syndrome
like in this case, referral to an orthopaedic surgeon or a neurosurgeon should be
C
considered.
Red flags that suggest cauda equina syndrome include:

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• Severe or progressive bilateral neurological deficit of the legs, such as
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major motor weakness with knee extension, ankle eversion, or foot

dorsiflexion
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• Recent-onset urinary retention and/or urinary incontinence (caused by

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loss of sensation when passing urine).

• Recent-onset faecal incontinence (due to loss of sensation of rectal
fullness)
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• Perianal or perineal sensory loss (saddle anaesthesia or paraesthesia)

Ev
102. A 60 year old woman presents with acute onset of bone and back pain following
a rough journey in a car. On examination, tenderness at the mid-thoracic
vertebra was noted. The pain is goes away when she bends forward. What is the
A. Osteoporotic fracture of vertebra

B. Myofascial pain syndrome
C. Whiplash injury
D. Multiple myeloma
E. Bone metastasis
Myofascial pain syndrome is a chronic pain disorder. In myofascial pain

syndrome, pressure on sensitive points in your muscles (trigger points) causes
pain in seemingly unrelated parts of your body. This is called referred pain.
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Myofascial pain syndrome typically occurs after a muscle has been contracted
repetitively. This can be caused by repetitive motions used in jobs or hobbies or
by stress-related muscle tension.
Only myofascial pain/muscle sprain relieves on change of position.
103. A 40 year old woman with a history of epilepsy presents to clinic with multiple
fleshy nodules and several light brown, round macules with a smooth border on
her back, arms and legs. There are also freckles under her arms. What is the
A. Neurofibromatosis type I
B. Neurofibromatosis type II
C. Tuberous sclerosis
D. Hereditary haemorrhagic telangiectasia
E. Sturge–Weber syndrome
While this is more of dermatology/connective tissue topic more than a
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neurology topic, neurofibromatosis type I (NF1) does have present with
op
neurological deficits. Know how to differentiate between type I and type II as
well as the basic management. C
Neurofibromatosis type I
Presentation:
• Café au lait spots, axillary freckling and neurofibromas
n
• Lisch nodules (hamartomas on the iris)
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• Optic gliomas
• Scoliosis, bone dysplasias
t
• Epilepsy / seizures
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• Cognitive impairment
Diagnosis:
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• The National Institutes of Health Consensus Development Conference

diagnostic criteria
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Treatment:
• Conservative
• Routine monitoring and counselling
• Neurofibromas - if irritation, removal by laser or surgical
• Malignant peripheral nerve sheath tumors - radiation and surgical
excision
104. A 31 year old man, known case of alcohol abuse, is brought into Emergency by
his friend from a night club. The friend saw the patient suddenly collapse on the
dance floor where his body went stiff then there was twitching of his legs
followed by involuntary voiding. What is the SINGLE most likely diagnosis?
A. Complex partial seizure

B. Generalised myoclonic seizure
C. Generalised clonic seizure
D. Generalised tonic seizure
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E. Generalised tonic-clonic seizure
Know the difference between generalised and partial seizures in PLAB 1.

Generalised seizures usually have patients with a loss of consciousness (i.e.
“collapsed”) while partial seizures do not. It is important to differentiate each
subtype of the generalised seizures. Note that myoclonic seizures occur while
the patient is conscious and lasts for only a few seconds. In this case, this
patient’s seizure activity is due to alcohol abuse and therefore should follow
guidelines on management related to seizures secondary to alcoholism.
Generalised tonic-clonic seizures

Presentation:
• Loss of consciousness
• Stiffness (tonic) followed twitching of the arms and legs (clonic)
• +/- involuntary voiding, drooling, up-rolling of eyes
• Associations: alcohol/drug abuse, cerebrovascular disease, brain tumors,
head injuries
y
Diagnosis:
op
• EEG - initial
• MRI or CT brain
• Neuropsychological assessment
C
Treatment:
• If alcohol related - thiamine, glucose, magnesium
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• If alcohol related - benzodiazepine for alcohol withdrawal symptoms and
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primary seizure prevention (lorazepam >> diazepam)

• Sodium valproate - first line
t
• Lamotrigine - second line

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105. An 80 year old man has had an ischaemic stroke and was brought to the A&E
department 6 hours after the onset of symptoms by his concerned daughter
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who found him lying on the floor at home. A CT brain has already been done and
has confirmed the diagnosis. The patient has no drug allergies and no other
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comorbidities. What is the SINGLE most appropriate medication to be given to

this patient upon discharge?
A. Clopidogrel 75 mg daily
B. Statin
C. Combination of modified-release dipyridamole (200 mg) and low dose aspirin
(75 mg) daily
D. Warfarin
E. Aspirin 300 mg daily for 3 months
Post management of Transient ischaemic attack (TIA), Stroke, and Myocardial

infarction (MI)
TIA Stroke Heart Failure MI

Clopidogrel Aspirin 300 Decrease ALL pts with MI on
(75 mg daily) mg daily for 2 mortality: discharge:
is the weeks is given
909
preferred immediately 1. ACE • Dual
long-term after an inhibitor antiplatelet
antiplatelet. ischaemic (Enalapril therapy:
stroke is , Aspirin +
If clopidogrel confirmed by Lisinopril, Clopidogrel
is brain imaging. Ramipril) Note: Aspirin is
contraindicate 2. Beta continued life
d or not Clopidogrel blocker long
tolerated, give 75 mg daily is (Bisoprol Clopidogrel for
a combination then given ol, 12 months
of modified- long-term Carvedilol • Beta Blockers
release , Offer BB to
dipyridamole If clopidogrel Nebivolol people who
(200 mg twice is ) present acutely
daily) and low contraindicate (Initiate one at a with MI as soon
dose aspirin d or not time) as they are
tolerated, give hemodynamica
Ensure a a combination Manage lly stable
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statin has of modified- symptoms: Continue a
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been offered release Furosemide beta-blocker
as soon as dipyridamole for at least 12
possible after (200 mg twice Add on if months after
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a TIA daily) and low symptoms not an MI in people
dose aspirin. controlled: without heart
Spironolactone, failure.
n
Ensure a or Continue a
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statin has Digoxin beta-blocker

been offered. indefinitely in
t
people with HF
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• ACEi
Offer ACEi to
people who
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present acutely
with MI as soon
Ev
as they are
hemodynamica
lly stable
If intolerant to
ACEi → use
ARB
• STATINS
106. A 56 year old lady has developed severe right sided headache which worsens
whenever she goes under bright light. This has been occurring for the last 3 days.
She feels nauseated, but has not vomited. She does not take any medication and
has no relevant medical history. What is the SINGLE most likely diagnosis?
B. Chronic subdural haemorrhage
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C. Intracranial neoplasm
D. Cluster headache
E. Migraine
She is suffering from Migraines. The hints provided here are that it is a unilateral
headache associated with photophobia and nausea.
The other options given here are much less likely
Subarachnoid haemorrhage → Usually presents with the worst headache ever.

What we call a “thunderclap headache”
Chronic Subdural haematoma → PLAB questions usually gives a history of an

elderly, on anticoagulation or an alcoholic.
Intracranial neoplasm → Possible but less likely compared to migraine. The

history of headaches would usually be longer. It is a space-occupying lesion, so
one can expect a raised intracranial pressure (ICP). Headache, which is typically
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worse in the mornings, nausea and vomiting, seizures, and papilloedema
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Cluster headache → usually presents with intense pain around one eye
accompanied by redness, lacrimation, lid swelling and also nasal stuffiness
C
107. A 62 year old male is brought to the emergency department by his daughter as
he is confused, and has an unsteady, uncoordinated walking. He is a known
n
alcoholic and has been admitted recently with delirium tremens. On questioning,
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he denies any problem with his memory. He knows his name and address and
convincingly states that he was at a betting shop in the morning. His daughter
t
interjects saying that, that is untrue as he was at home. What is the SINGLE most
ua
likely diagnosis?
A. Ganser syndrome
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B. Cotard syndrome
Ev
D. Korsakoff psychosis
E. Alcohol withdrawal
Korsakoff syndrome
This is termed Wernicke-Korsakoff syndrome and is characterised by the
addition of antero- and retrograde amnesia and confabulation in addition to the
classic triad of confusion, ataxia and ophthalmoplegia found in Wernicke's
encephalopathy.
Those with Korsakoff syndrome may "confabulate," or make up, information

they can not remember. They are not "lying" but may actually believe their
invented explanations.
They create events to fill the gaps in day-to-day memory. For example, a person
who has been in hospital for several weeks may talk convincingly about having
just visited their aunt earlier that day. This is more common in the early stages of
the condition..
911
Individuals may seem able to carry on a coherent conversation, but moments
later be unable to recall that the conversation took place or to whom they
spoke. They can often answer questions promptly with inaccurate and
sometimes bizarre answers.

3. Ophthalmoplegia
108. An 81 year old man is brought into clinic by his son who is concerned that his
father doesn’t seem to be himself. His wife died 3 years ago and has been
depressed since. The son notes that his father has become increasingly forgetful,
leaving taps running or the stove on when not in use. At times, he cannot
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articulate what he wants to say and is easily confused. CT brain reveals mild,
op
diffuse cortical atrophy. Which of the following is the SINGLE most likely
medication to be started first? C
A. Donepezil
B. Memantine
n
C. Haloperidol
D. Olanzapine
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E. Amitriptyline
t
Alzheimer’s disease is a frequent neurology topic for PLAB 1. The main clues
ua
usually have an elderly patient undergoing a memory change with some inability
to perform day to day tasks. Depending on the severity of the patient, they may
have language deficits, executive dysfunction, and cortical atrophy on CT brain.
al
Know the guidelines for pharmacological treatment. Acetylcholinesterase

inhibitors donepezil, galantamine and rivastigmine are first line. Memantine is
Ev
second line and for severe cases. This patient is not suffering from
hallucinations; therefore, options C and D are ruled out. While the patient does
have depression and would be placed on antidepressants, amitriptyline is
contraindicated as it has anticholinergic side effects.
Alzheimer’s disease
Presentation:
• Elderly > 65 years
• Early - memory loss (recent → distant), difficulty finding words,
• Followed by - progressive language deficits, inability to make decisions,
confusion
• Late - disoriented, behavioural changes, hallucinations
Diagnosis:
• CT or MRI brain
912
• Hexamethylpropyleneamine oxime (HMPAO) single-photon emission
computed tomography (SPECT) to differentiate Alzheimer’s from Pick’s
disease and other pathology
• Mini-mental state exam – assess the severity of cognitive dysfunction
and when to start medication
Treatment:
• Acetylcholinesterase inhibitors: donepezil, galantamine and rivastigmine
- first line, mild to moderate
• Memantine - second line, severe cases
• Depression - SSRI
• Psychological changes that is harmful to self and others - antipsychotics
109. A 65 year old known alcoholic is brought into hospital with confusion,
aggressiveness and ophthalmoplegia. He is treated with chlordiazepoxide. What
is the SINGLE most appropriate medication to give alongside chlordiazepoxide?
A. IV Antibiotics
y
B. Glucose
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C. Acamprosate
D. Disulfiram
E. Vitamin B complex
C
n
io

t
ua

al

Ev

3. Ophthalmoplegia
110. A 73 year old woman presents to clinic accompanied by her son with a 6 month
history of anorexia and altered bowel habits. She has no significant past medical
history and is on aspirin. On examination, the patient has an expressionless face,
she takes many steps to turn, has resting tremor in predominantly in her right
hand, and cogwheel rigidity. Cognition is intact. What is the SINGLE most likely
diagnosis?
A. Malignancy
913
D. Progressive supranuclear palsy
The clinical examination above is classic of Parkinson’s Disease: bradykinesia,

rigidity, resting tremor, and postural instability. While the beginning of the case
stem may point to possible malignancy the examination results point to Option
C.
Parkinson’s disease
Presentation:
- >65 years (for PLAB 1)
- Classic presentation on examination: bradykinesia, rigidity, resting tremor,
and postural instability
- +/- Extra-neurological features
Diagnosis:
Treatment:
y
- Referral to neurologist before starting pharmacological management
op
- Levodopa (gold standard): start when >70yrs or severe disruption of
quality of life (whichever one comes first)
C
111. A 20 year old fit man suddenly develops severe lower back pain as he is getting
up from bed. There is greater pain when he is lying supine with his leg raised.
n
io
B. Multiple myeloma
t
C. Lumbosacral disc herniation

ua
D. Ankylosing spondylitis
E. Cervical spondylosis
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Sudden onset of lower back pain and felt more during forward bending or similar
movement like getting up from bed favours the diagnosis of lumbosacral disc
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herniation.

Presentation

914
Investigation
112. A 74 year old woman was brought to clinic by her daughter for confusion and
memory impairment. The patient would periodically start a task and forget to
finish them and has difficulty naming objects. In the past few months, she has
lost 5kg and does not sleep well at night. On examination, the patient was
agitated and had decreased skin turgor, and not oriented to time or place. She
repeatedly asks the same questions during the interview. What is the SINGLE
y
op
C
For PLAB 1, know all the above options well as they appear in high frequency.
PLAB 1 key clues to Alzheimer’s disease: memory changes first before
n
personality. As night progresses they are unable to sleep. They would also have
io
difficulty in daily tasks and be confused. Vascular dementia would have a “step-
wise progression” and they would have had some sort of previous cardiovascular
t
event in the stem. Lewy body dementia would require a clue into having
ua
parkinsonian symptoms and hallucinations. Pick’s dementia presents with

disinhibition and personality changes before memory impairment. Normal
pressure hydrocephalus presents with gait disturbance, urinary incontinence,
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and confusion.
Ev
Alzheimer’s disease
Presentation:
- Elderly > 65 years
- Changes in memory first – recent then distant
- Not oriented to time or place, apraxia, aphasia
- Insomnia
- Does not keep up with personal hygiene – presents as “forgetting to
brush teeth or eat”
- Mood and personality changes occur later
Diagnosis:
- MRI brain – to rule out other pathology
- Mini-mental state exam – not for diagnosis but to assess the severity
of cognitive dysfunction and also to determine the start and cessation
of pharmacological therapy
915
Treatment:
- Multidisciplinary management
- Trial of acetylcholinesterase inhibitor or NMDA receptor antagonist
113. A 43 year old chronic alcoholic stopped drinking alcohol for the last 3 days. He is
anxious, has tremors and is now having hallucinations. His heart rate is 106
A. Olanzapine
B. Diazepam
C. Acamprosate
D. Disulfiram
E. Thiamine
Benzodiazepines are the recommended drugs for alcohol detoxification. They

have a slower onset of action and therefore are less likely to lead to abuse. A
reducing dose of chlordiazepoxide is commonly used. Diazepam is an alternative.
y
In this particular case, he has hallucinations which are a sign that he is having not
op
just an acute alcohol withdrawal but moving on to delirium tremens.
Patients with marked agitation or hallucinations and those at risk of delirium

C
tremens (characterised by delirium, hallucinations, course tremor, and
disorientation) may be prescribed antipsychotic drugs, such as haloperidol or
olanzapine, as adjunctive therapy to benzodiazepines. But note that
n
antipsychotics should not be used alone because they do not treat alcohol
io
withdrawal and may lower the seizure threshold.

t

ua
al

hours and
Ev
subside by 48 hours

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114. A 42 year old female had a sudden onset of severe headache and vomiting. She
took paracetamol and an hour later she collapsed. Her medical history is
significant for Ehlers-Danlos syndrome. What is the SINGLE most likely
diagnosis?
B. Viral encephalitis
C. Meningitis
D. Anaphylaxis
E. Epidural haematoma
Sudden onset of severe headache, vomiting then collapsing are more suggestive
of subarachnoid haemorrhage. This is also supported by the medical history of
Ehlers-Danlos syndrome.
Occasionally the stem would include signs of meningeal irritation. This includes
neck stiffness and photophobia. Patients often describe the headaches as “the
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worst headache of my life”.
115.
op
A 66 year old patient wakes up with slurred speech and right sided weakness. He
is brought to the hospital by his wife. A computed tomography was ordered and
C
shows a cerebral infarction. What is the SINGLE most appropriate treatment to
be given?
n
A. Aspirin
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B. Alteplase
C. Warfarin
t
D. Streptokinase
ua
E. Dipyridamole
The answer here is aspirin 300 mg.

al
Ev
This was done in this question which showed an ischaemic stroke.
Alteplase → The window period to administer alteplase is 4.5 hours of onset of

stroke symptoms. If we cannot be certain of this period, we cannot proceed to
give alteplase. Firstly, there was no time given in the stem. Secondly, the patient
woke up to symptoms of a stroke. The ischaemic event could have happen
anytime during the night.
Warfarin → anticoagulants should not be started until brain imaging has

excluded haemorrhage, and usually not until 14 days have passed from the
onset of an ischaemic stroke
Streptokinase → Note that the NHS prefers alteplase over streptokinase. So

streptokinase is almost never the right answer.
917
Statins → Statins need to be offered but this is not the most appropriate next
course of action. There is no urgency in giving statins.
Dipyridamole → Can be given, but it is usually only given If clopidogrel is

contraindicated or not tolerated. In such case we would give a combination of
Stroke management

y
op
C
n
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116. A 42 year old man has increasing daytime sleepiness. He feels that his tiredness
t
is affecting his work as he is unable to keep awake during meetings. He also

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complains of choking episodes during his sleep. On examination, his BMI is 36

kg/m2, blood pressure is 150/70 mmHg, and respiratory exam was normal. What
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A. Idiopathic hypersomnia
Ev
B. Narcolepsy
C. Hyperventilation syndrome
D. Obstructive sleep apnoea syndrome
E. Rapid eye movement sleep behavior disorder
Daytime sleepiness and obesity points the diagnosis of obstructive sleep apnoea
syndrome. Choking episodes during sleep is also a suggestive feature of
obstructive sleep apnoea syndrome.
Obstructive sleep apnoea syndrome

Presentation:
- Middle aged to elderly male
- Increased daytime sleepiness, fatigue, sleep disruption
- Snoring loudly at night
- Associated with hypertension, diabetes, obesity
Diagnosis:
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- Pulse oximetry, overnight study of breathing pattern (initial
investigation)
- Polysomnography (gold standard)
Treatment:
- Conservative: weight loss and reduce alcohol consumption
- Continuous positive airway pressure (CPAP)
117. A 73 year old female patient presents with right sided hemiplegia and aphasia.
These symptoms resolved spontaneously in 6 hours. An ECG conducted in
hospital revealed atrial fibrillation. What is the SINGLE best scoring method to
assess her risk for future stroke?
A. ABCD2
B. CHA2DS2-VASc
C. Well’s Score
D. CURB-65
E. NYHA Score
y
op
Knowing the contents of the ABCD2 and the CHA2DS2-VASc scoring system is
not necessary for the PLAB 1 exam but knowing when to apply each scoring
system is vital.
C
ABCD2 score
The ABCD2 score is to assess risk of future stroke in patients who have already
n
suffered from a transient ischaemic attack (TIA) or suspected transient ischaemic
io
attack.
t
An example of use of a ABCD2 score is a patient presenting to A&E or a GP

ua
surgery with symptoms of a TIA. The ABCD2 score helps the physician decide on
how to manage the patient. If the patient scored high on the ABCD2 score, the
physician would refer the patient for specialist assessment within 24 hours of
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the onset of symptoms, give a statin such as simvastatin 40 mg, and give an
antiplatelet drug if the patient is not already taking any anticoagulation
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medication.
CHA2DS2-VASc score
The CHA2DS2-VASc score is to assess the risk of future stroke in patients who
have atrial fibrillation. This score is then used to determine whether or not
treatment is required with anticoagulation therapy.
Choosing ABCD2 or CHA2DS2-VASc

You may have difficulty in choosing either ABCD2 or CHA2DS2-VASc as the
answer but remember that in this case stem, this patient HAS ALREADY HAD A
TIA. Whether or not the TIA was as a result of atrial fibrillation is not known. But
we DO know that her primary concern is transient ischemic attack and second is
atrial fibrillation therefore ABCD2 is the correct answer.
Remember:
ABCD2 = Risk of future stroke following TIA
CHA2DS2-VASc = Risk of future stroke in patients with atrial fibrillation
919
118. A 19 year old woman complains of episodic headaches preceded by fortification
spectra. These episodes can sometimes last for 2-3 days. When these headaches
occur, she prefers to be in a quiet, dark room. What is the SINGLE most
appropriate management for the acute phase?
A. Topiramate
B. Aspirin
C. Propranolol
D. Gabapentin
E. Domperidone
The diagnosis here is migraines. This question is a helpful reminder that the
mean age of onset of migraines is 19 years old. In PLAB, it is usually a young to
middle-aged person who presents with migraines.
It is highly unlikely that they would ask you to choose between an oral triptan,
NSAID, aspirin, or paracetamol for the acute treatment of migraines. Although
y
oxford clinical handbook does state that NSAIDS (e.g. ketoprofen 100mg,
op
dispersible aspirin 900mg/6h) are good as there is less chance of developing
medication misuse headache , and they have similar efficacy to oral 5HT agonists
(triptans and ergot alkaloids), the NICE guidelines do not state which one of
C
them would be used before the other. PLAB would have to adhere very closely
to NICE guidelines thus any answer with oral triptan, NSAIDS, or aspirin for the
acute treatment of migraines would be a correct answer.
n
Migraine
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Presentation:
- Young to middle-aged female or male (for PLAB 1)
t
- Throbbing headache, localized to one side preceded by aura

ua
- +/- Nausea and vomiting

- +/- Photophobia
Diagnosis:
al
- fMRI – can check for physiological changes in the brain during a
Ev
migraine, but not necessary (doesn’t change management)

Acute Treatment:
NICE CKS recommends:
Combination therapy with an oral triptan and an NSAID, or an oral triptan and
paracetamol.
If monotherapy is preferred, offer an oral triptan, or NSAID, or aspirin, or
paracetamol.
Prevention:
NICE CKS recommends: Topiramate or propranolol as first-line for prevention
preventive treatment should be offered in addition to acute treatment.
If both topiramate and propranolol are ineffective or are unsuitable, offer

gabapentin or acupuncture
119. A 45 year old man with terminal cancer who has recently completed his course
of chemotherapy develops tingling and numbness of the fingertips of both arms.
920
He describes a constant mild burning discomfort in his hands and feet.
Occasionally, he experiences a sharp, shooting, and electric-shock-like pain in his
feet. What is the SINGLE most likely cause of his symptoms?
A. Bone metastasis to cervical vertebrae

B. Chemotherapy induced peripheral neuropathy
C. Hyponatraemia
D. Hypocalcaemia
E. Hypomagnesemia
Chemotherapy drugs such as vincristine are known for the side effects of
peripheral neuropathy due to neurotoxicity. Patients with this side effects would
present with peripheral paraesthesia which is seen as numbness or tingling.
Chemotherapy induced peripheral neuropathy is typically characterized by a
glove-and-stocking distribution in the hands and feet with sensory loss or
hypersensitivity, and in some cases motor and autonomic dysfunction.
120. A 45 year old man has tremors in both his hands. The tremors are absent at rest
y
but present when arms are held outstretched and persist on movement.
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Movements such as writing are affecting by his tremor. The tremor is seen to be
worse when he is tired or stressed. On examination, the tremor continues to be
present even when patient is distracted. What is the SINGLE most likely
C
diagnosis?
A. Parkinsonian tremor
n
B. Essential tremor
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C. Cerebellar disease
D. Psychogenic tremor
t
E. Stroke
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Know the difference between psychogenic tremors and essential tremors. The
given stem are of clinical features of an essential tremor. In psychogenic
al
tremors, there is often an abrupt onset, spontaneous remission, and the

characteristic of the tremor changes when the patient is distracted.
Ev
Parkinsonian tremors usually would have the classical sign of ‘pill rolling’ in
combination with rigidity and bradykinesia which is absent in this stem.
Cerebellar disease could present with intention tremors which is not seen in this
stem. Intentional tremors occur during voluntary active movements of an upper
body. The tremor would worsen as goal-directed movement approaches its
intended target. The stem would usually include overshooting or undershooting
their target, a condition known as dysmetria. It is a form of ataxia. Example, a
patient would find difficulty due to his tremor when asked to touch his nose and
then the examiner’s fingers.
Essential tremor symptoms

• Distal symmetrical postural tremor of the upper limbs
• Initially transient. May progress to become persistent.
• Amplitude of tremor may depend on physiological or emotional state
• May be seen to improve following alcohol ingestion
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• Not seen at rest
Management
• Propranolol is first line
121. A 52 year old man has incoherent speech. He is aware of his speech difficulties
but finds difficulty in using the right words when speaking. He has no other
symptoms apart from his speech issue. He has good comprehension. Which
A. Broca’s area
B. Wernicke’s area
C. Midbrain
D. Parietal lobe
E. Brainstem
Broca’s Aphasia
Broca’s area is a region in the inferior frontal lobe of the dominant hemisphere
y
responsible for speech production. Lesions in this area produce a non-fluent or
op
expressive aphasia. Patients will typically exhibit slow and halting speech.
However, their comprehension is not affected. Unlike Wernicke’s aphasia,
patients with Broca’s aphasia are aware of their language difficulties.
C
For example, a person with Broca's aphasia may say in a slow manner something
like, "Bathe. Dog" meaning to say, "I bathe the dog today". You can see that the
n
content of the information is correct, but the grammar and fluidity of the
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sentence is incorrect. They know what to say, they just cannot get it out.
t
122. A 65 year old lady presents to the Accident and Emergency department with a 6
ua
hour history of facial droop and weakness on her left side of her body. A CT scan
was performed and ruled out a haemorrhagic stroke. She is allergic to Penicillin
and takes Simvastatin and Amlodipine regularly. What is the SINGLE most
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appropriate medication to be prescribed long term for this patient?

Ev
A. Alteplase
B. Clopidogrel
C. Dipyridamole
D. Labetalol
E. Aspirin
The patient had an ischaemic stroke and the standard treatment would be
Aspirin for 14 days, and then Clopidogrel long term. The question is asking for
the long term treatment and therefore this would be Clopidogrel.
Alteplase - for patients who are appropriate for thrombolysis therapy who
presents within within 4.5 hours of onset of stroke symptoms, and intracranial
haemorrhage has been excluded by imaging techniques
Dipyridamole - Modified-release dipyridamole alone is recommended as an

option to prevent occlusive vascular events for people who have had an
922
ischaemic stroke only if aspirin and clopidogrel are contraindicated or not
tolerated.
Aspirin is started as a standard therapy for confirmed ischaemic stroke and is

continued until 2 weeks, at which time definitive long-term antithrombotic
treatment should be initiated. Aspirin is only recommended long term for
patients intolerant to clopidogrel.
123. A 38 year old heroin addict was involved in a car crash and is now paraplegic. He
was agitated and cried everyday during the first two weeks after the accident
while in the hospital. On questioning, he is not able to remember the accident
and refuses to talk about it. What is the SINGLE most likely diagnosis?
A. Post traumatic stress disorder

B. Severe depression
C. Bipolar disorder
D. Organic brain injury
E. Borderline personality
y
op
The likely diagnosis here is organic brain damage as he is unable to remember
the accident. One can easily exclude post traumatic stress disorder with that
history as patients with PTSD are quite the opposite and would remember the
C
experience and have flashbacks and nightmares about it.
It is normal to have an amount of sadness after a major accident which involves

n
brain injury. This differs from severe depression, as symptoms of severe
io
depression interferes with normal function. If the severity of sadness persisted

and there was a degree of functional impairment and disability associated with
t
low mood, then we would be able to say that this is severe depression.
ua
Symptoms of an organic brain injury may include confusion, impairment of

memory, agitation which can be seen in this stem.
al
124. A 33 year old man presents with speech difficulties. He has a an irregular
Ev
breakdown of articulation. On examination, nystagmus is seen. Which

A. Midbrain
B. Pons
C. Cerebellum
D. Cerebrum
E. Vestibule cochlear nerve
It is quite unclear what sort of speech difficulties this patient has. But with a
combination with nystagmus, one can assume that this patient is having
cerebellar dysarthria (also known as ataxic dysarthria). Cerebellar dysarthria is
an acquired neurological and sensorimotor speech deficit caused by damage to
the superior cerebellum and the superior cerebellar peduncle. If, for example,
there is damage to the left cerebellar hemisphere in a right handed person,
ataxic dysarthria could develop. Of all the individual dysarthria types, it most
clearly reflects a breakdown in timing and coordination.
923
125. A 43 year old man presents with neck stiffness, headache and vomiting. The
headache is severe, persistent and on the left side. He also has ear pain and
discharge coming from his left ear. On examination, he has weakness of the right
hand and leg. He has a temperature of 38.5°C. What is the SINGLE most likely
diagnosis?
A. Viral meningitis
B. Bacterial meningitis
C. Mycotic aneurysm
D. Cerebral abscess
E. Cerebral tumour
Cerebral abscess
Cerebral abscess may show many of the same features of a brain tumors as they
both are space-occupying lesions. The major difference is that cerebral abscess
has features of a fever and an obvious source of infection nearby such as otitis
y
media or mastoiditis.
Presentation
op
• Headache → is the most common symptom and it is often on the same
C
side as the abscess
• Fever
• Changes in mental state (drowsiness, confusion)
n
• Focal neurological deficits
io
• Grand mal seizures

• Nausea and vomiting
t
• Neck stiffness
ua
• Papilloedema → this is due to cerebral oedema
Investigations
al
• CT scanning is the investigation of choice. Cerebral abscesses appear as a

radiolucent space-occupying lesion.
Ev
Note that in HIV-positive patients, majority of brain lesions will be either be due
to toxoplasmosis or lymphoma.
126. A 68 year old man had a fall down the stairs. His daughter has brought him into
the emergency department where he was having lucid intervals. Shortly after
admission he becomes unconscious. What is the SINGLE most likely vessel
affected?
A. Basilar artery
B. Bridging veins
C. Vertebral artery
D. Diploic vein
Lucid intervals followed by unconsciousness is typical for an epidural

haemorrhage of which the middle meningeal artery is involved.
924
Extradural (epidural) haematoma
Often associated with skull fracture and middle meningeal artery injury. Involves
arterial blood.
Features
• Features of raised intracranial pressure
• Patients may exhibit a lucid interval (note the lucid intervals as it is very
commonly seen in PLAB)
Management
Surgical procedure: burr hole over pterion (to ensure that further haemorrhage
escapes instead of expanding the clot further) followed by craniotomy and
evacuation of the haematoma.
127. A 42 year old lady presents with a history of double vision, ptosis and facial
numbness. Which anatomical site is the most likely to be affected?
y
op
A. Cerebral cortex
B. Trigeminal nerve
C. Oculomotor nerve
C
D. Brainstem
E. Basal ganglia
n
A brainstem lesion makes the most sense here as the oculomotor nerve arises
io
from the anterior aspect of mesencephalon (midbrain) while trigeminal nerve

arises from pons. The involvement of oculomotor nerve could explain the double
t
vision and the involvement of the trigeminal nerve explains the facial numbness.
ua
128. A 43 year old smoker presents with double vision. She tires easily, has difficulty
climbing stairs, and reaching for items on shelves. On examination, reflexes are
al
absent but elicited after exercise. The power in shoulder abduction after
repeated testing is 4+/5 from 3/5. What is the SINGLE most likely pathology
Ev
associated with this patient’s diagnosis?
A. Thyrotoxicosis
B. Thrombotic event
C. Diabetes
D. Cerebral vascular event
E. Lung cancer
This is a diagnosis of Lambert-Eaton syndrome. A key difference from

myasthenia gravis is that on examination the patient has increased strength on
repetition of power. It is also a paraneoplastic disorder closely associated with
small cell lung cancer. Because Lambert-Eaton and myasthenia gravis present
similarly, the case stem usually would provide you with an investigation or
examination clue, including autoantibodies and/or EMG results. Note that
thyrotoxicosis is associated with myasthenia gravis not Lambert-Eaton.
Lambert-Eaton syndrome
925
Presentation:
- Young, female patients; mostly autoimmune
- Proximal weakness at the pelvic girdle / shoulder girdle
- Weakness improves with exercise as well as reflexes
- Cranial nerve involvement: dysphagia, dysarthria, ptosis, diplopia
- Associated with small cell lung cancer
Diagnosis:
- EMG: decreased amplitude in CMAP after single supramaximal
stimulus but increases after exercise
- Edrophonium test: may be positive but not as prominent as in
myasthenia gravis
- Look for tumor: CT/MRI of chest, abdomen, pelvis + tumor markers
Treatment:
- Treat tumor – first line
- Consider methylprednisolone and IV immunoglobulin
y
op
129. A 44 year old woman has a two week history of electric shock-like stabbing facial
pain starting from her left jaw and radiates towards her forehead. The pain is
unilateral and it is described as very severe and coming in spasms. Her corneal
C
reflexes are found to be normal. What is the SINGLE most likely diagnosis?
A. Trigeminal neuralgia
n
B. Temporomandibular joint disorder
io
C. Atypical facial pain

D. Giant cell arteritis (GCA)
t

ua
Electric shock-like, sharp, shooting, stabbing are features usually used to

describe trigeminal neuralgia. The onset of pain is episodic and sudden, lasting a
al
few seconds to minutes and stopping suddenly, with many attacks a day.
Ev
Patients with classical trigeminal neuralgia have a normal neurologic

examination. Facial sensation, masseter bulk and strength, and corneal reflexes
should be intact. A loss of corneal reflex excludes the diagnosis of idiopathic
trigeminal neuralgia and prompt physicians to consider other causes of patient's
symptoms, unless a previous trigeminal nerve section procedure has been
performed. Thankfully the corneal reflex in this stem is intact which makes the
the choice of answer more clear.
Trigeminal neuralgia
Presentation
• Unilateral, shooting or stabbing electric shock-like facial pain
• Pain exacerbated with movement or touch especially in the jaw (CN V,
2nd and 3rd branch distribution)
• Abrupt in onset and termination
Diagnosis
926
• MRI is routinely done to rule out other pathology (i.e. schwannoma,
meningioma)
Treatment:
• Medication then surgery
• Carbamazepine >lamotrigine / phenytoin / gabapentin
• Surgical: microvascular decompression
130. A 25 year old woman presents with a severe headache. She had migraines for
the last 14 years but has been symptom free for the last year. There are no other
neurological signs. She has no other medical history of note. Her observations
are stable. What is the SINGLE most appropriate investigation for this woman?

B. Lumbar puncture
C. Ophthalmoscope
D. Magnetic resonance imaging of head
y
E. No further investigation required
op
This young lady is likely having a recurrence of her migraine. It is not stated in
the stem whether the headache is of a similar type to her previous migraines but
C
one can assume given there are no neurological signs and no mention of neck
stiffness or photophobia. Since this is likely a migraine, no further investigations
are required. If there were signs of neck stiffness, photophobia or if the
n
headache was described as the worse headache of her life, obtaining a CT scan
io
of the head would be the choice to rule out a subarachnoid haemorrhage.

t
131. A 71 year old lady has a history of a fall 3 days ago with an injury to the head.
ua
She is increasingly drowsy and has recently become confused and disoriented.
What is the SINGLE most likely vessel to be involved?
al
A. Diploic vein
B. Cerebral vein
Ev
C. Basal vein
D. Middle meningeal vein
The clinical symptoms match those of a chronic subdural haematoma. This

would be caused by a rupture of a bridging vein. Among the options given,
cerebral vein would be the most likely.


927
132. 54 year old patient is seen at the clinic for muscle weakness. His muscle
weakness initially started at the level of his legs but now it is affecting his arms
too. On examination, he has loss of tendon reflexes and decreased muscle
strength. What is the SINGLE most likely mechanism of this weakness?
A. Amyloid deposition in neurons

B. Vasculitis
C. Reduction in the number of nicotinic acetylcholine at the postsynaptic muscle
membrane
D. Autoimmune degeneration of myelin sheets of peripheral neurons
E. Compression of spinal nerve
Guillain-Barré syndrome
• Is a disorder causing demyelination characterised by weakness,
paresthesia and hyporeflexia
• Usually precedes an infection, usually respiratory or gastrointestinal
tract. This association with preceding infection suggests that antibodies
to the infectious organism also attack antigens in peripheral nerve
y
tissue.
op
In the stem, there would usually be a history of gastrointestinal or respiratory
infection from anywhere between a few days to 3 weeks prior to the onset of
C
weakness.
Presentation:
n
• Weakness
io
o Presents with an ascending pattern of progressive symmetrical

weakness, starting in the lower extremities
t
o Reaches a level of maximum severity two weeks after initial

ua
onset of symptoms
o Facial weakness, dysphasia or dysarthria
o In severe cases, muscle weakness may lead to respiratory
al
failure.
• Pain
Ev
o Neuropathic pain, particularly in the legs

• Reflexes
o Reduced or absent
• Sensory
o Paresthesia and sensory loss, starting in the lower extremities
133. An 8 year old boy developed a seizure first affecting his right arm. The seizure
lasted for several minutes. He was unconscious throughout the seizure and has
no recollection of the events that occurred leading to his seizure. A computed
tomography scan of his head was organised after the seizure and has been
reported as having a lesion on the left cerebral hemisphere. What is the SINGLE
most likely reason for his seizure?
A. Epilepsy
B. Space occupying lesion
C. Dementia
D. Huntington’s chorea
928
E. Intracranial hypertension
This boy has just had a complex partial seizure. The term “partial” (or focal)
seizure means that the electrical activity was limited to a part of one cerebral
hemisphere. The term “complex” seizure means there was loss of awareness.
The seizure is likely caused by a the lesion seen on the CT scan that is occupying
space.
Less likely answers
Epilepsy - is incorrect as the termed epilepsy would require at least two

unprovoked seizures occurring more than 24 hours apart for the definition to fall
into place.
Dementia - is incorrect as dementia is a brain disorder causing memory loss and

decline in cognition. It occurs in the elderly and does not cause seizures.
y
Huntington’s chorea - is also incorrect. Firstly, symptoms of Huntington’s
op
disease become noticeable between ages of 35 and 44 years old. This boy is too
young to develop symptoms of Huntington’s disease. Secondly, Huntington’s
chorea is characterised by jerky, random and uncontrolled movements. During
C
these movements, there is no loss of consciousness.
Raised intracranial pressure (intracranial hypertension) - is also not entirely

n
wrong however it should be picked only if there was no option for space
io
occupying lesion. Raised intracranial pressure does occur when there is a space
occupying lesion. The symptoms of raised intracranial pressure include
t
headaches, double vision, drowsy, irritable and the occasional seizures however
ua
because the term intracranial hypertension is such a broad term which also
incorporates other aetiologies such as brain trauma, meningitis, aneurysm
rupture and others, it would be better to pick a more specific term like space
al
occupying lesion as the cause of the seizure in this question.

Ev
929
OBSTETRICS
y
GYNAECOLOGY op
C
n
io
t
Questions
ua
al
&
Ev
Answers
930
OBGYN Questions
1. A 51 year old woman presents with a 9 month history of prolonged, slightly irregular
menstrual periods. On physical examination, a normal size uterus with no adnexal
masses is felt. What is the SINGLE most likely diagnosis?
A. Menopause
B. Perimenopause
C. Ovarian carcinoma
D. Cervical carcinoma
E. Premature ovarian failure
2. A 39 year old woman has had no menstrual periods for the last 11 months. Prior to
that she had regular menstrual cycles. She recently has hot flashes and night sweats.
She is also experiencing feelings of anger and helplessness. FSH was done and it was
raised on two separate occasions. What is the SINGLE most appropriate management?
A. Hormone replacement therapy (HRT) for 5 years
y
B. Hormone replacement therapy (HRT) until age 51
op
C. Tricyclic antidepressants
D. Levothyroxine
E. Progestogen-only pill (POP)
C
3. A 45 year old waitress complains of pelvic pain which worsens pre-menstrually. The
pelvic pain is usually worse when standing and has been present for the last one year.
n
She also complains of post-coital ache that is felt deep within the vagina. There was no
io
discharge on vaginal examination. A diagnostic laparoscopy was performed which did

not show any abnormalities. What is the SINGLE most likely diagnosis?
t
ua
A. Pelvic inflammatory disease (PID)

B. Endometriosis
C. Pelvic congestion syndrome
al
D. Adenomyosis
Ev
4. A 53 year old woman complains of dyspareunia and vaginal dryness. On a speculum

examination, an atrophic vaginitis is seen. Her last menstrual period was one year ago.
A. Hormone replacement therapy

B. Combined oral contraceptive pills
C. Oestrogen cream
D. Testosterone gel
E. Primrose oil
5. A 23 year old woman has painless vaginal bleeding at 36 weeks pregnancy. She has no
uterine contractions. Fetal heart tones are regular at 140 beats/min. Examination of
the uterus shows the fetus to be in transverse lie. She has a pulse of 90 beats/minute,
a blood pressure of 95/60 mmHg and a respiratory rate of 19 breaths/minute. What is
A. Transvaginal US
931
B. Abdominal US
C. Urine culture and sensitivity
D. Reassurance
E. Admit, observe and repeat CTG in 30 minutes
6. A 27 year old lady has had an uncomplicated pregnancy so far. She is now 40 weeks
gestation. She came to the hospital 2 hours ago after her waters broke. She has regular
and painful uterine contractions. PV examination reveals a 4 cm dilated cervix. Her vital
signs are normal. What stage of labour is she in?
A. First stage
B. Second stage
C. Third stage
D. Fourth stage
E. Latent phase
7. A 22 year old woman is brought into A&E by her husband with severe abdominal
cramping. She is haemodynamically unstable and her abdomen is very tender. Serum
y
human chorionic gonadotropin (hCG) is 1400 IU/litre. A transvaginal ultrasound shows
op
an empty uterine cavity with a small adnexal mass. No fetal heart activity was noted.
C
(A serum hCG above 25 IU/litre is considered positive for pregnancy)
A. Laparotomy
n
B. Laparoscopy
io
C. Admit and await events

D. CT abdomen
t
E. Methotrexate
ua
8. A 33 year old woman has vaginal discharge and bleeding. An endocervical swab was
taken which tested positive for Chlamydia. What is the SINGLE most appropriate
al
antibiotic to give?
Ev
A. Erythromycin
B. Ciprofloxacin
C. Metronidazole
D. Cefixime
E. Doxycycline
9. A 24 year old lady presents with lower abdominal pain for the last 3 months, dysuria,
dyspareunia and vaginal discharge. Urine HCG is negative. She has no significant past
medical history. What is the SINGLE most appropriate next step in management?
A. Laparoscopy
B. High vaginal swab
C. Hysteroscopy
D. Laparotomy
E. Ultrasound
932
10. A 33 year old woman has vaginal spotting 2 days ago that is painless. She is worried of
cervical cancer. She is currently on combined oral contraceptives and had a cervical
smear last year which was reported as normal. Cervical ectropion is diagnosed on
examination. There was no bleeding from the cervix on touch. What is the SINGLE most
A. Transvaginal ultrasound
B. Cervical smear
C. Punch biopsy
D. Reassurance
E. Colposcopy
11. A 30 year old woman with suspected pelvic inflammatory disease has worsening of her
symptoms of lower abdominal pain despite being treated with oral metronidazole and
ofloxacin for 14 days. She has a temperature of 38.6°C, heart rate of 85 bpm, and a
blood pressure of 110/80 mmHg. Her blood tests show:
y
CRP 160 mg/L
op
C
A. Endocervical swab
B. Pelvic ultrasound
C. Laparotomy
n
D. High vaginal swab
io
E. Urine culture
t
12. A 27 year old lady presents with lower abdominal pain in the emergency department. 2
ua
weeks ago, she came to the hospital with fever, suprapubic tenderness and vaginal
discharge. Pelvic inflammatory disease (PID) was confirmed and she was sent home on
oral doxycycline and oral metronidazole. She now presents with abdominal
al
tenderness, temperature of 39.0°C, heart rate of 98 bpm, and a blood pressure of

130/85 mmHg. What is the SINGLE most appropriate next course of action?
Ev
A. High vaginal swab

B. Endocervical swab
C. Pelvic ultrasound
D. Abdominal X-ray
E. Emergency laparoscopy
13. A 29 year old woman stopped taking combined oral contraceptive pills 13 months ago
and she has been amenorrhoeic since then. Ultrasonography reveals normal ovaries
with no signs of developing follicles.
Her blood results show:
Follicle-stimulating hormone (FSH) 8 IU/L

Luteinizing Hormone (LH) 9 IU/L
Prolactin 44 ng/mL
Oestradiol 53 pmol/L
933
A. Hypothalamic amenorrhoea
B. Polycystic ovary syndrome
C. Prolactinoma
D. Post pill amenorrhoea
14. A 27 year old woman presents to the emergency department with a presenting
complaint of lower abdominal pain. She has abdominal tenderness, temperature of
39.0°C, heart rate of 102 bpm, and a blood pressure of 130/85 mmHg. There is no
vaginal discharge. What is the SINGLE most appropriate next course of action to make
the diagnosis?

y
D. Abdominal X-ray
op
15. A 17 year old senior schoolgirl has prolonged irregular menstrual periods and
C
menorrhagia. She is not sexually active. What is the SINGLE most appropriate
management?
n
A. Mefenamic acid
io

C. Progestogen-only pill
t
D. Copper intrauterine contraceptive device

ua
E. Levonorgestrel intra-uterine system
16. A 36 year old primigravida who is 32 week has blood loss per vaginam followed by
al
sudden constant abdominal pain for the last 3 hours. Her uterus is hard and she is in
distress. Fetal distress is noted on CTG. Her blood pressure is 100/70 mmHg. What is
Ev
A. Placental abruption
B. Placenta accreta
C. Placenta praevia
D. Vasa praevia
E. Placenta percreta
17. A 36 year old woman is planning to undergo laparoscopic tubal sterilisation. What is
the risk of pregnancy after sterilisation by tubal ligation?
Plab Lab Values
A. 1:50
B. 1:200
C. 1:500
D. 1:1000
E. 1:5000
934
18. A 32 year old female who has had 3 previous miscarriages in the 1st trimester, all
before 10 weeks gestation, now comes to the hospital with vaginal bleeding at 8
weeks. A transvaginal ultrasound reveals a viable fetus. What is the SINGLE most
A. Aspirin
B. Aspirin and heparin
C. Progesterone supplements
D. Cervical cerclage
19. A 23 year old woman who has been using an intrauterine system (Mirena coil) for one
year now complains of lower abdominal pain and menstrual irregularities. She has no
significant past medical history. Which is the SINGLE most likely cause of her
symptoms?
A. Pelvic Inflammatory Disease (PID)
y
B. Endometriosis
op
C. Adenomyosis
D. Fibroids
E. Asherman syndrome
C
20. A 20 year old woman, 32 weeks gestation, presents to the emergency department with
a history of painless vaginal bleeding after intercourse. On examination, a soft and
n
relaxed uterus is noted with a fundal height of 32 cm. CTG is reactive. She has not
io
attended any antenatal clinics previously and has not had any previous ultrasound
scans. She has a pulse of 122 beats/minute, a blood pressure of 84/60 mmHg and a
t
respiratory rate of 28 breaths/minute. What is the the SINGLE most likely diagnosis?
ua
A. Abruption of placenta secondary to pre-eclampsia

B. Placenta accreta
al
C. Placenta praevia
D. Preterm labor
Ev
E. Vasa praevia
21. A 33 year old, obese lady has irregular menstrual periods for the last 2 years.
Lab results show:

Prolactin 59 ng/mL

B. Premature ovarian failure
C. Hypothyroidism
D. Early menopause
E. Primary obesity
935
22. A 30 year old multiparous woman has just delivered a term male baby. She is group A(-
) and her husband’s blood group is unknown. She does not remember having any
intramuscular injections in her previous pregnancy. The infant boy develops severe
jaundice within a few hours after being born. What is the SINGLE most likely diagnosis?
B. G6PD
C. ABO incompatibility
D. Rh incompatibility
E. Physiological jaundice
23. A 32 year old female with type 2 diabetes mellitus would like to know about vitamins
and supplements in pregnancy. Which SINGLE most likely vitamin prevents teratogenic
effects in an unborn child?
A. Folic acid
B. Vitamin B12
y
C. Thiamine
op
D. Riboflavin
E. Pyridoxine C
24. A 25 year old woman has vaginal discharge, intermenstrual bleeding and post coital
bleeding. She is sexually active and does not use any form of contraception. What is
the SINGLE most appropriate investigation?
n
io

t

ua
D. Blood culture
E. Pelvic ultrasound scan
al
25. A 41 year old lady who is 37 weeks pregnant was brought to A&E. On arrival, she has a
seizure. Her husband says a few hours ago she complained of headache, visual
Ev
disturbance and abdominal pain. What is the SINGLE most appropriate management?
A. 4g MgSO4 in 100 ml 0.9% normal saline in 5 minutes

B. 4g MgSO4 bolus intravenously
C. 2g MgSO4 in 500 ml normal saline in 1 hour
D. 2g MgSO4 bolus intravenously
E. 10mg diazepam in 500 ml 0.9% normal saline in 1 hour
26. A 56 year old woman who is a heavy smoker is diagnosed with cervical intraepithelial
neoplasia grade 2. She is a mother of three children. She is worried of ovarian cancer
because her older sister died of ovarian cancer. She has been on hormone replacement
therapy for 3 years. What is the SINGLE most relevant risk factor for ovarian cancer in
her case?
A. Smoking
B. Family history
C. Cervical intraepithelial neoplasia grade
936
D. Hormone replacement therapy
E. Pregnancy
27. A 28 week pregnant lady presents with painless vaginal bleeding after sexual
intercourse. The cervical os is closed. On ultrasound, placenta is noted to be anterior
and high. Fetal movements and fetal heart is seen on scan. Abdomen is soft and non
tender. What is the SINGLE most likely diagnosis?
A. Missed miscarriage
C. Placental abruption
D. Placental praevia
E. Cervical ectropion
28. A 64 year old woman has been on hormone replacement therapy for 5 years. She had
regular withdrawal bleeds until 3 years ago and has not had a bleeding since. Recently
she noticed a brown vaginal discharge on her underpants. Her last cervical smear was 3
years ago which showed no abnormalities. What is the SINGLE most appropriate initial
y
investigation?
A. Cervical smear
op
C
C. Thyroid function test
E. Abdominal CT scan
n
io
29. An 18 year old girl presents to the clinic with secondary amenorrhoea. Her BMI is 30.
She has dark pigmentation on her neck and severe acne on her face. There is also
t
thinning of hair. Blood test reveals elevated insulin levels, elevated LH levels and
ua
moderately elevated testosterone levels. What is the SINGLE most likely diagnosis?
al
B. Grave’s disease
C. Acquired hypothyroidism
Ev

30. A 22 year old woman was prescribed rifampicin for prophylaxis as her roommate was
diagnosed with meningococcal meningitis. She has been taking combined oral
contraception for the past year and is sexually active. Which is the SINGLE most
appropriate advice to give to her?
A. Use alternative methods such as barrier methods

B. Stop combined oral contraceptive pill for a week
C. Attend A&E if face begins swelling
D. Avoid exercising for 3 days
E. Continue combined oral contraceptives as usual
31. A pregnant woman with long term history of osteoarthritis comes to the antenatal
clinic with complaints of restricted joint movement and severe pain in her affected
joints. What is the SINGLE most appropriate management?
937
A. Paracetamol
B. Steroids
C. NSAID
D. Paracetamol and Dihydrocodeine
E. Pethidine
32. A 33 year old woman, with 3 previous normal vaginal deliveries is diagnosed with
stress incontinence. She has tried pelvic floor exercises and lifestyle modifications but
they have not been successful. Her BMI is 29. What is the SINGLE most appropriate
management?
A. Tension free vaginal tape

B. Bladder training
C. Oestrogen
D. Intermittent urethral catheters
E. Antimuscarinic medications
y
33. A 29 year old woman experienced severe blood loss shortly after delivery of a still born
op
vaginally, following a major placental abruption. Given the risk factors, what is the
SINGLE most likely predisposing factor for developing postpartum haemorrhage in this
women?
C
A. Retained product
B. Disseminated intravascular coagulation (DIC)
n
C. Fibroid uterus
io
D. Uterine infection
E. Large placental site
t
ua
34. A 27 year old asian nulliparous woman with type 1 diabetes mellitus has delivered a
baby weighing 4.5kg with the help of forceps. The placenta was removed with
continuous cord traction and her uterus is well contracted however she continues to
al
bleed heavily. What is the SINGLE most likely cause of her postpartum haemorrhage?
Ev
A. Atonic uterus
B. Cervical/vaginal trauma
C. Retained POC
D. Large placental site
E. Rupture uterus
35. A 26 year old woman presents with a “fishy” vaginal discharge. On examination, a
homogenous grey-white vaginal discharge is seen. Vaginal pH is 5.8. What is the
A. Metronidazole
B. Azithromycin
C. Doxycycline
D. Ceftriaxone
E. Flucloxacillin
938
36. A 31 year old primigravida at 24 weeks' gestation was admitted 24 hours ago to the
maternity unit because of preterm premature rupture of membranes (PPROM). She is
starting to have abdominal pains and uterine contractions. She has a pulse rate of 102
beats/minute and a temperature of 38.6°C. Routine examination of the patient’s
abdomen reveals tenderness suprapubically. A speculum examination reveals a foul-
smelling discharge originating from the cervix with the cervix slightly opened. What is
B. Chorioamnionitis
C. Bacterial vaginosis
D. Urinary tract infection
E. Threatened miscarriage
that she had regular menstrual cycles. FSH was found raised on two separate occasions
a month apart. What is the SINGLE most likely diagnosis?
y
A. Polycystic ovarian syndrome
op
C. Early menopause
D. Fragile X
C
E. Addison's disease
38. A 16 year old clinically obese girl has not started her menstrual periods yet. She has
n
severe acne and facial hair growth. Among her investigations, a high level of insulin
io
was found. What is the SINGLE most likely diagnosis?

t
ua
D. Polycystic ovary syndrome
al
Ev
and she has not had her menstrual period since.

Prolactin 72 ng/mL
C. Prolactinoma
939
40. A 27 year old woman had pre-eclampsia and was delivered by C-section. She is now
complaining of right upper quadrant pain. What is the SINGLE most appropriate
immediate investigation?
A. Coagulation profile
B. Liver function test
C. Liver ultrasound
D. Magnetic Resonance Cholangiopancreatography
E. CT abdomen
41. A 27 year old woman has pelvic pain, dysmenorrhoea and increasingly heavy periods
over the last 12 months. She also complains of dyspareunia. There is generalized pelvic
tenderness without peritonism. A pelvic ultrasound was reported as normal. What is
A. Endometriosis
B. Uterine fibroid
y
op
D. Premature ovarian failure
E. Fibromyalgia C
42. A 45 year old lady comes to the family planning clinic for contraception advice. She has
two young children and does not want anymore children. An incidental finding of
multiple small submucosal fibroids was found recently on an ultrasound scan. She is
n
asymptomatic and her medical history is otherwise insignificant. What is SINGLE most
io
appropriate contraceptive for this lady?

t
A. Etonogestrel
ua
B. Combined oral contraceptive pill (COCP)

C. Progestogen-only pill (POP)
D. Intrauterine system (IUS)
al
E. Intrauterine Contraceptive Device (IUCD)

Ev
43. A 27 year old waitress has pelvic pain, dysmenorrhoea and increasingly heavy periods
over the last 9 months. The pain is worse when she is standing for long periods of time.
She also complains of dyspareunia. A pelvic ultrasound was reported as normal. A
diagnostic laparoscopy was performed which did not show any abnormalities. What is
A. Endometriosis
B. Uterine fibroid
D. Pelvic inflammatory disease
E. Fibromyalgia
44. A 34 year old girl presents to the infertility clinic with her husband. They have been
trying to concieve for 3 years. Her BMI is 31. She has dark pigmentation on her neck
and severe acne on her face. There is also thinning of hair. Multiple follicles were on
her ovaries on ultrasound.. What is the SINGLE most appropriate initial management to
treat her infertility?
940
A. Weight loss
B. Clomifene Citrate
C. Laparoscopic ovarian drilling
D. Combined oral contraceptive pills
E. Spironolactone
45. A 23 year old pregnant woman is admitted at 38 weeks gestation with a history of an
eclamptic fit at home. Her blood pressure is 155/90 mmHg. She is conscious and
observations are stable. What is the SINGLE most appropriate IV therapy to prevent
further fits?
A. Clomethiazole
B. Diazepam
C. Labetalol
D. Magnesium sulphate
E. Phenytoin
y
46. A 30 year old female who has had 3 previous miscarriages, all before 10 weeks
op
gestation. Antiphospholipid syndrome has been diagnosed. She now presents to the
antenatal clinic asking if there is any treatment that she could have that could prevent
another miscarriage. What is the SINGLE most appropriate management?
C
A. Aspirin
B. Corticosteroids
n
io
D. Folate
E. No treatment available
t
ua
47. A 42 year old overweight smoker complains of heavy periods. An ultrasound scan
reveals a normal uterus. She would like a long term treatment with minimal side
effects that would offer treatment for the menorrhagia and provide contraception
al
although she is still unsure if she would like children in the future. What is the SINGLE
Ev
A. Combined oral contraceptive pills

B. Endometrial ablation
C. Levonorgestrel intra-uterine system
D. Progestogen implant
E. Copper intrauterine contraceptive device
48. A 16 year old girl who is normally fit and healthy attends her GP complaining of very
painful menstrual periods. She has a regular 28 day menstrual cycle. She denies being
sexually active. What is the SINGLE most appropriate management?
A. Tranexamic acid
C. Endometrial ablation
D. Levonorgestrel intra-uterine system
E. Mefenamic acid
941
49. A 38 year old female with lymphoma was treated with chemotherapy. She says she has
been amenorrheic for the last 8 months. Lab results show:

Prolactin 13 ng/mL
An FSH was repeated 4 weeks later was still elevated.
A. Menopause
B. Polycystic ovarian syndrome
C. Prolactinoma
D. Hypothyroidism
y
50. A 31 year old woman who is currently 39 weeks gestation attends the antenatal day
op
unit feeling very unwell with sudden onset of epigastric pain associated with nausea
and vomiting. She has a temperature of 36.7°C and her blood pressure is 155/100
mmHg. Her liver enzymes are raised and her other blood results are as follows:
C
Haemoglobin 82 g/L
n
io

t
ua

C. Cholecystitis
al
D. HELLP syndrome
E. Acute hepatitis
Ev
51. A 24 year old woman who is 18 weeks pregnant presents with pain in her lower
abdomen for the past 12 hours. She has some vaginal spotting a couple of hours ago.
On examination, abdomen is tender, and cervical os is closed. An ultrasound scan
shows fetal heart beat. What is the SINGLE most likely diagnosis?
A. Threatened miscarriage
B. Inevitable miscarriage
C. Incomplete miscarriage
D. Missed miscarriage
E. Spontaneous miscarriage
and severe acne on her face. There is also thinning of hair. Blood test reveals elevated
insulin levels, elevated LH levels and moderately elevated testosterone levels. What is
the SINGLE most appropriate diagnostic test to confirm the diagnosis?
942
A. CT abdomen
B. Ultrasound pelvis
C. Chest X-ray
D. MRI pituitary
E. Prolactin levels
53. A 31 year old woman has vaginal spotting after her last intercourse which was a day
ago. Her last menstrual period was 10 days ago and she usually has a regular 28 day
menstrual cycle. A cervical smear performed 6 months ago was shown to be normal. A
speculum examination shows cervical ectropion which does not bleed on touch. What
B. Cervical smear
C. Endocervical swab
D. Reassurance
E. Serum estradiol
y
op
54. A 25 year old primigravida at 30 weeks' gestation comes to the maternity unit stating
that 3 hours ago she had a gush of clear fluid from her vagina. She has no uterine
contractions. She has a pulse rate of 94 beats/minute and a temperature of 38.4°C.
C
Routine examination of the patient’s abdomen reveals tenderness suprapubically.
Speculum examination reveals a purulent yellow vaginal discharge with cervix slightly
opened. Her blood test show:
n
io
Haemoglobin 115 g/L

t

ua
CRP 253

al
A. Endometritis
Ev
B. Chorioamnionitis
C. Septic miscarriage
D. Pyelonephritis
55. A 64 year old woman has been treated for breast cancer with tamoxifen. What SINGLE
medication should be added to her regime?
A. Bisphosphonates
B. Calcium
C. Vitamin D
D. Calcitonin
E. Phosphate binders
56. A 68 year old nulliparous woman presents to her general practitioner with a six month
history of poorly-localised abdominal discomfort and a constant feeling of bloatedness.
On pelvic examination you find a nontender, 7 cm, solid, irregular, fixed, left adnexal
943
mass. Her last examination was 1 year ago, which was normal, and it included a normal
pap smear. What is the SINGLE most appropriate initial investigation?
A. CA-125
B. CA15-3
C. CA19-9
D. CEA
E. AFP
57. A 33 year old lady attends the obstetric assessment unit with a history of a a positive
pregnancy test and bleeding from her vagina for the last two days. Her last menstrual
period is 8 weeks ago. On speculum examination, the cervical os is closed but blood is
seen in the vault. What is the SINGLE most appropriate next step to determine the
viability of the fetus?
A. Transvaginal Ultrasound
B. Serum β-hCG
C. Urinary β-hCG
y
D. Abdominal Ultrasound
op
E. Cardiotocography (CTG)
58. A 48 year old lady presents with itching, redness, bloody discharge and ulceration
C
around her nipple. The lesion appears to be red and scaly. What is the SINGLE most
likely diagnosis?
n
A. Paget’s disease of the breast
io
B. Fibroadenosis
C. Breast abscess
t
D. Duct papilloma
ua
E. Fat necrosis
59. A 32 year old multigravida at 32 weeks' gestation is woken up in the middle of the
al
night with a pool of blood. She has no pain or uterine contractions. Fetal heart tones
are regular at 145 beats/min. Examination of the uterus shows the fetus to be in
Ev
transverse lie. She has a pulse of 120 beats/minute, a blood pressure of 84/55 mmHg
and a respiratory rate of 29 breaths/minute. What is the the SINGLE most likely
diagnosis?

B. Placenta accreta
C. Placenta praevia
D. Preterm labor
E. Vasa praevia
60. A 24 year old lady presents to the Early Pregnancy Unit with vaginal spotting and mild
left-sided abdominal pain. Her last menstrual period was 8 weeks ago. A pregnancy
test done in the GP clinic was positive. She has a transvaginal ultrasound scan, which is
reported as 'inconclusive'. Serum human chorionic gonadotropin (hCG) is 1400 IU/litre.
944
A. Fibroids
B. Ectopic pregnancy
C. Complete miscarriage
D. Threatened miscarriage
E. Incomplete miscarriage
61. A 33 year old female presents with sudden severe colicky abdominal pain at her right
iliac fossa. The pain is severe and has worsen intermittently over the last few hours.
The pain radiates to her back and pelvis. She has also been vomiting and feeling
nauseous since the pain started. A tender, mobile mass is felt at the right iliac fossa on
A. Pelvic inflammatory disease

B. Appendicitis
C. Ovarian torsion
D. Constipation
E. Gastroenteritis
y
op
62. A 32 year old rhesus negative woman whose previous pregnancy was complicated by
rhesus isoimmunisation, now presents with vaginal spotting at 37 weeks. Her
pregnancy has otherwise been normal. Her partner is rhesus positive. What is the
C
A. Kleihauer-Betke test
n
B. Coagulation profile
io
C. Recheck mother’s rhesus status

D. Assess fetal middle cerebral artery on ultrasound
t
E. Fetal blood sampling

ua
63. A 27 year old presents with left sided abdominal pain and vaginal spotting. Her last
menstrual period was 7 weeks ago. Abdomen was tender to palpate and cervical
al
motion tenderness was noticed on examination. Transvaginal ultrasound scan was

performed which showed an empty uterus. Serum human chorionic gonadotropin
Ev
(hCG) is 1200 IU/litre. Blood pressure is 110/65 mmHg, heart rate is 80 bpm and
A. Immediate laparotomy
B. Laparoscopy
C. Discharge home
D. CT abdomen
E. Methotrexate
gestation. She was admitted because she had of a show and has regular and painful
uterine contractions. Her cervix is now 10 cm dilated and she has started pushing.
What stage of labour is she in?
A. First stage
945
B. Second stage
C. Third stage
D. Fourth stage
E. Latent phase
65. A 38 week pregnant woman has sudden onset of uterine pain and vaginal bleeding. Her
uterus is tender and hard. She has no previous history of a lower segment caesarean
section. Fetal distress is noted on CTG. Her blood pressure is 95/60 mmHg. What is the
SINGLE most likely cause of her symptoms?
A. Preeclampsia
D. Placenta praevia
E. Vasa praevia
66. A 32 year old woman, primigravida and now 39 weeks gestation attends the antenatal
day unit with sudden onset of epigastric pain associated with nausea and vomiting. On
y
physical examination, there is right upper quadrant tenderness. Her temperature is
op
36.8°C, Blood pressure is 165/95, heart rate 90 bpm and respiratory rate 19/min. Her
blood tests show: C
Haemoglobin 87 g/L
Alanine transferase 219 U/L
n
Aspartate transaminase 180 U/L
io
Lactate dehydrogenase 720 U/L

t

ua

al
C. Cholecystitis
D. HELLP syndrome
Ev
E. Acute hepatitis
67. A 29 year old primigravida at 28 weeks gestation is found to have a blood pressure of
150/100 mmHg on routine check-up. She is not experiencing any symptoms and feels
well. A urinalysis shows 1+ protein. What is the SINGLE best management for her?
A. Labetalol
B. Hydralazine
C. Indapamide
D. Losartan
E. Magnesium sulphate
68. A 25 year old women had an emergency lower segment caesarean section after a
prolonged labour 4 days ago due to fetal distress. She now complains of intermittent
vaginal bleeding and foul smelling discharge. Her O2 saturation is 98% on air, blood
pressure is 124/88 mmHg, pulse of 84bpm and temperature of 37.9C. The midwife
tells you that the obstetric surgeons had difficulty in removing the placenta from the
946
uterus in the operating theatre. What is the SINGLE most likely complication of this
women from the caesarean section?
A. Retained products of conception

B. Aspiration pneumonitis
C. Endometritis
D. Uterine rupture
E. Disseminated intravascular coagulation
69. A 33 year old woman complains of waking in the middle of the night to rush to the
toilet. Most of the time, she does not make it to the toilet in time and she wets herself.
A. Stress incontinence
B. Urge incontinence
C. Mixed incontinence
D. Overflow incontinence
E. Urethrovaginal fistula
y
op
70. A 29 year old woman has chronic pelvic pain, and dysmenorrhoea over the last 9
months in which she takes NSAIDS for. She complains of pain during sexual
intercourse. A trial of combined oral contraceptive pills was given but there was no
C
reported benefit. A pelvic ultrasound was reported as normal. What is the SINGLE most
n
A. Laparoscopy
io
B. CA 125
C. Computed tomography scan
t

ua
E. Hysteroscopy
71. A 33 year old lady presents with clear, watery discharge. On examination, a red ring is
al
seen around the cervical os. The diagnosis of cervical ectropion is made. What is the
SINGLE most accurate description to define cervical ectropion?
Ev
A. Replacement of stratified squamous epithelium that normally lines ectocervix by

columnar epithelium
B. Replacement of columnar epithelium that normally lines ectocervix by stratified
squamous epithelium
C. Columnar epithelium migrating from ectocervix to endocervix
D. Cuboidal cells being replaced by squamous epithelial cells
E. Non-keratinized stratified squamous epithelium being replaced by simple cuboidal
epithelium
72. A 23 year old woman is followed up for 6 weeks after a surgical procedure to evacuate
the products of conception in the uterus following a miscarriage. The histology shows
changes consistent with a hydatidiform mole. What is the SINGLE most appropriate
investigations in this case?
A. Abdominal Ultrasound
B. Maternal karyotype
947
C. Paternal blood group
D. Serum B-hCG
E. Transvaginal US
73. A 65 year old female patient diagnosed with breast cancer was given tamoxifen. Which
SINGLE symptoms would be the most alarming?
A. Fluid retention
B. Vaginal bleeding
C. Hot flushes
D. Headache and dizziness
E. Weight gain
74. A 33 year old woman, with 3 previous normal vaginal deliveries complains of urinary
leakage when she plays tennis or coughs. What is the SINGLE most likely diagnosis?
y
op
E. Urethrovaginal fistula C
75. A 23 year old lady with a BMI of 30 complains of facial hair growth and has a history of
amenorrhoea.
n
Lab results show:
io

t

ua
Prolactin 60 ng/mL
Progesterone 100 ng/dL
al

Ev

B. Pregnancy
C. Cushing’s disease
D. Congenital adrenal hyperplasia
76. A 23 year old woman comes to the A&E with severe lower abdominal pain. Her blood
pressure is 120/85 mmHg and temperature is 38.9°C. The abdomen is rigid. Cervical
excitation is noticed during a vaginal examination. She gave a past history of pelvic
inflammatory disease 3 years ago which was successfully treated with antibiotics. What
A. Ultrasound
B. Abdomen X-ray
C. CT Abdomen
948
E. Endocervical swab
77. A 37 year old woman has irregular menstrual cycles for the last 9 months accompanied
by hot flashes and night sweats. She also complains of pain during sexual intercourse.
What is the SINGLE most appropriate initial investigation?
A. Serum estradiol concentration

B. Serum FSH
C. Serum progesterone concentration
D. Dual-energy X-ray absorptiometry (DEXA)
E. Anti-Mullerian hormone
78. A 28 year old woman at 31 weeks gestation attends the antenatal clinic. Her full blood
count was taken when she was 28 weeks which results shows:
Haemoglobin 10.6 g/dL

y
op
A. Offer folate supplements

C
B. Offer iron dextran
C. Offer ferrous sulphate
D. Explain that this is physiological haemodynamic anaemia
n
E. Offer vitamin B12 supplements
io
t
abdomen for the past couple of hours. She has some vaginal spotting. On examination,
ua
abdomen is tender, and cervical os is closed. A transvaginal ultrasound scan shows no

fetal heartbeat or fetal activity. What is the SINGLE most likely diagnosis?
al
Ev
80. A 50 year old woman who was treated for breast cancer 3 years ago now presents with
increased thirst and confusion. She has recently become very drowsy. What is the
SINGLE most likely metabolic abnormality?
A. Hypercalcaemia
B. Hyperkalaemia
C. Hypoglycaemia
D. Hyperglycaemia
E. Hypocalcaemia
81. A 60 year old woman complains of bleeding after having intercourse. In the past
month, she has had 3 episodes of mild vaginal bleeding. She had regular withdrawal
bleeds until 8 years ago and has not had a bleeding since. Her last cervical smear was 3
949
years ago which showed no abnormalities. A pelvic examination shows a normal cervix
and vagina. What is the SINGLE most likely diagnosis?
A. Cervical cancer
B. Endometrial cancer
C. Ovarian cancer
D. Breast cancer
E. Vaginal cancer
82. A 55 year old woman presents with a sore nipple. She has clear fluid discharge from
her left nipple over the past few months which has recently been a little blood stained.
On examination, her left nipple is dry cracked and has scaly skin. Her right nipple
appears normal and no lymphadenopathy was seen. What is the SINGLE most likely
diagnosis?

B. Fibroadenosis
C. Breast abscess
y
D. Duct papilloma
op
E. Fat necrosis
83. A 28 year old female has had 3 consecutive miscarriages. All her miscarriages
C
happened before 10 weeks. Cytogenetic analysis performed on products of conception
of the third miscarriage shows no abnormalities. She comes to clinic inquiring if it is
safe for another pregnancy. What is the SINGLE most appropriate investigation to
n
perform?
io
A. Antiphospholipid antibodies
t
B. Parental peripheral blood karyotyping

ua
C. Progesterone levels
D. Luteinizing hormone levels
E. Transvaginal Ultrasound for cervical length
al
84. A 23 year old woman has had intermittent abdominal pain in the left iliac fossa for 6
Ev
week. Over the past 48 hours, she had had severe abdominal pain and fever of 39°C.
Urine BHC is negative. She also has cervical motion tenderness. Pelvic ultrasound
shows a 6.5 cm multilocular complex adnexal mass. Her WBC and CRP are raised. What
A. Endometriosis
B. Dermoid cyst
D. Ectopic pregnancy
E. Tubo - ovarian abscess
taken which tested positive for Neisseria gonorrhoeae. What is the SINGLE most
A. Erythromycin 500 mg PO for 5 days

B. Ceftriaxone 500 mg as a single IM dose
950
C. Metronidazole 400 mg PO twice daily for 14 days
D. Azithromycin 1g PO for 7 days
E. Azithromycin 1g PO and ceftriaxone 500mg IM stat
86. Which of the following is true regarding treatment with tamoxifen?
A. Increased risk of endometrial carcinoma

B. Increased risk of breast cancer
C. Increased risk of osteoporosis
D. Increased risk of ovarian carcinoma
E. Increased risk of cervical cancer
87. A 26 year old woman with regular menses and her 28 year old partner comes to the GP
surgery complaining of primary infertility. She and her husband have been trying to
achieve pregnancy for more than 2 years and have been unsuccessful. She has a
regular 28 day menstrual cycle. Her BMI is 23. What is the SINGLE most appropriate
investigation to determine if she is ovulating?
y
A. Basal body temperature charts
op
B. Cervical smear
C. Day 2 follicular stimulating hormone (FSH) and luteinizing hormone (LH)
D. Day 21 progesterone
C
E. Endometrial biopsy
88. A 32 year old woman presents at 39 weeks gestation of her third pregnancy. She
n
reports having a vaginal loss of clear viscous fluids 4 days ago. She did not attend the
io
delivery suite as she had planned for a home birth. She feels feverish and sweaty.
t
ua
opened. She has a temperature of 38.3°C. Fetal tachycardia is noted on a

cardiotocograph. Her blood test show:
al
Haemoglobin 105 g/L

Ev

CRP 219
A. Endometritis
B. Chorioamnionitis
D. Pyelonephritis
89. A 42 year old woman complaints of heavy bleeding and prolonged menstrual period.
She is not planning for children at the moment as she already has 2 children. She
smokes 20 cigarettes a day. What is the SINGLE most appropriate management?
A. Tranexamic acid
951
C. Mefenamic acid
90. A 30 year old pregnant lady, 34 weeks gestation, presents with severe lower abdominal
pain which started several hours ago with excessive per vaginum bleeding. The
abdominal pain is constant. What is the SINGLE most appropriate initial investigations?
B. Ultrasound abdomen
C. Computed tomography scan of pelvis
D. D-dimer
E. Kleihauer-Betke test
91. A 32 year old woman was induced at 41+ weeks gestation. She had a long labour which
lasted 24 hours. The uterus is still palpable above the umbilicus after an hour from
delivering the placenta. What is the SINGLE most likely predisposing factor for
postpartum haemorrhage
y
op
A. Atonic uterus
B. Cervical or vaginal trauma
C. Ruptured uterus
C
D. Fibroid uterus
E. Disseminated intravascular coagulation (DIC)
n
92. A 33 year old woman who is 11 weeks gestation attends her booking appointment with
io
questions regarding vaccinations in pregnancy. What vaccines are offered to women

who are pregnant in the UK?
t
ua
A. Pertussis, diphtheria and pneumococcal vaccines

B. Influenza and rubella vaccines
C. Influenza and pneumococcal vaccines
al
D. Pertussis and rubella vaccines

E. Influenza and pertussis vaccines
Ev
93. A 22 year old woman who was diagnosed with a missed miscarriage a week ago now
presents to the hospital because of abdominal pain. She says she passed a small fetus
and a number of clots this morning. On examination, abdomen is tender, and cervical
os is opened. A transvaginal ultrasound scan shows products of conception still present
in the uterus. What is the SINGLE most likely diagnosis?
D. Complete miscarriage
94. A 33 year old lady who is now 28 weeks pregnant comes to the antenatal clinic with
pain and swelling on her left calf muscle. On physical examination, she has distension
of superficial veins and increase skin temperature at affected area. What is the SINGLE
952
A. Aspirin
B. Paracetamol
D. Warfarin
E. Alteplase
95. A 22 year old woman who was diagnosed with a missed miscarriage a week ago
presented to the hospital last night with abdominal pain and vaginal bleeding. Since
then, she has passed a small fetus. A transvaginal ultrasound was repeated which
showed an empty uterus. The pain is slowly easing off. What is the SINGLE most likely
diagnosis?
y
op
96. A 24 year old woman was prescribed azithromycin for a sexually transmitted infection.
She has been using a form of contraception for the past year. Which SINGLE most likely
contraceptive method is likely to be affected by azithromycin?
C
A. Mirena coil (IUS)
B. Intrauterine Contraceptive Device (IUCD)
n
io
D. Combined oral contraceptive pill (COCP)

t
ua
97. A 28 year old primiparous woman, with no previous history of infection with herpes
zoster, is 18 week pregnant. She had significant contact with a young girl with
widespread chicken pox. Serum stored from an antenatal booking blood sample was
al
sent for serology and came back negative for VZV IgG. What is the SINGLE most
Ev
A. Aciclovir PO
B. Aciclovir IV +IVIG
C. Aciclovir IV
D. Reassure
E. IVIG only
98. A 19 year old lady with primary amenorrhoea has the following blood results:

Prolactin 13 ng/mL
953
C. Absent uterus
D. Absent ovaries
E. Turner’s syndrome
99. A 58 year old lady presents with urinary incontinence. She says that she urinates a little
everytime she laughs or coughs. She has had 2 previous vaginal deliveries. Urine
culture results have come back as negative. Her urodynamic study is normal. What is
the SINGLE most appropriate next step in management?
A. Antibiotics
B. Topical oestrogen
C. Systemic oestrogen
D. Duloxetine
E. Pelvic floor exercise
100. A 29 year old woman who is 33 weeks gestation attends the antenatal clinic. Her full
blood count was taken when she was 28 weeks as part of an antenatal screen for
y
anaemia. The results shows:

op
C
She is asymptomatic. What is the SINGLE most appropriate management?
n
A. Folate supplement
io
B. Iron supplements
C. Blood transfusion
t
D. No treatment required
ua
E. Hydroxocobalamin IM
101. A 28 year old woman, gravida 2, para 1, comes to the maternity unit for evaluation for
al
regular uterine contractions at 39 weeks' gestation. Her previous delivery was an

emergency cesarean section at 38 weeks for dystocia. She is now experiencing severe
Ev
abdominal pain and profuse vaginal bleeding .Her heart rate is 130 bpm, blood
pressure is 95/55, oxygen saturation is 98% and temperature is 37.1°C. Reduced
variability and late decelerations are now seen on CTG. What is the SINGLE most likely
diagnosis?
A. Endometritis
B. Urinary tract infection
C. Placenta praevia
D. Shoulder dystocia
E. Uterine rupture
102. A 23 year old woman presents with offensive vaginal discharge. A vaginal pH was taken
and reads 5.6. What is the SINGLE most likely causative organism?
A. Gardnerella vaginalis
C. Candida albicans
954
D. Chlamydia trachomatis
E. Neisseria gonorrhoeae
103. A 42 year old complains of heavy blood loss per vaginam. An ultrasound shows uterine
thickness of more than 12mm. There was no polyps or benign lesions seen on
hysteroscopy. Histology reveals the diagnosis of simple endometrial hyperplasia
without atypia. She has two children and is not currently planning for another child.
What is the SINGLE most appropriate management for her?
A. Mefenamic acid
104. A 55 year old woman presents with dysuria, frequency and urinary incontinence. She
complains of dyspareunia. Urine culture has been done and is sterile. What is the
y
op
A. Oral antibiotics
B. Topical antibiotics
C. Topical oestrogen
C
D. Oral oestrogen
E. Hormone replacement therapy
n
105. A 24 year old lady has lower abdominal pain worsening over the last 7 days. She has
io
vaginal discharge and also complains of deep dyspareunia. Her last menstrual period
was 2 weeks ago. Cervical motion tenderness was noted when doing a pelvic
t
examination. She has a temperature of 38.2°C. Her blood tests show:

ua

CRP 55 mg/L
al
She has no significant past medical history. What is the SINGLE most likely diagnosis?
Ev
A. Endometriosis
B. Acute pelvic inflammatory disease
D. Appendicitis
E. Pelvic congestion syndrome
106. A 22 year old pregnant woman is admitted at 37 weeks gestation with a blood pressure
of 165/95 mmHg and symptoms of visual disturbances and epigastric pain. A few hours
after administration of IV magnesium sulphate and IV labetalol, she develops a fit.
What is the SINGLE most appropriate IV therapy to prevent further fits?
A. Hydralazine
B. Diazepam
C. Further bolus of Labetalol
D. Further bolus of Magnesium sulphate
E. Phenytoin
955
107. An 17 year old girl with primary amenorrhoea complains of severe abdominal pain
every 4 to 8 weeks which is now getting worse. On abdominal examination, a lower
abdominal mass is felt. What is the SINGLE most likely diagnosis?
B. Ovarian carcinoma
C. Haematometra
D. Endometriosis
E. Adenomyosis
bleeding. A vulvovaginal swab was taken which tested positive for Neisseria
gonorrhoeae. What is the SINGLE most appropriate management?
A. Erythromycin
B. Ceftriaxone only
C. Metronidazole
y
D. Azithromycin only
op
E. Azithromycin and ceftriaxone
109. A 34 year old primigravida who is 30 week pregnant presents to the labor ward with a
C
history of constant abdominal pain for the last few hours. She also gives a history of
having lost a cupful of fresh blood per vagina before the pain started. An irritable,
tender uterus is seen on examination. Fetal heart is seen on ultrasound scan. What is
n
io

t
B. Antepartum haemorrhage
ua
C. Placenta praevia
D. Vasa praevia
E. Early labour
al
110. A 49 year old woman who is a heavy smoker is worried of ovarian cancer because her
Ev
mother died of ovarian cancer. She has been on hormone replacement therapy. She
used to take combined oral contraceptive pills for a few years during her twenties. She
underwent menopause when she was 46 years old. What is the SINGLE most relevant
risk factor for ovarian cancer in her case?
A. Smoking
B. Family history
C. Combined oral contraceptive pills
E. Early menopause
111. A 28 year old woman has been admitted at 38 weeks gestation. Her blood pressure is
190/120 mmHg and proteinuria is seen on urinalysis. Immediately following admission,
she has a grand-mal seizure. What is the SINGLE most appropriate initial management?
A. Diazepam intravenously
B. Fetal CTG
956
C. Hydralazine intravenously
D. Immediate delivery
E. Magnesium sulphate intravenously
112. A 38 year old female attends the clinic because of issues of infertility. She also says that
her last period was 9 months. Lab results show:

Prolactin 12 ng/mL
An FSH was repeated 4 weeks later which was still elevated.
y
C. Prolactinoma
op
D. Hypothyroidism
E. Premature ovarian failure C
113. A 24 year old woman has right iliac fossa pain and vaiginal spotting. Her last menstrual
period was 8 weeks ago. She is apyrexial. A bimanual examination reveals cervical
excitation. What is the SINGLE most likely diagnosis?
n
io
B. Salpingitis
t
C. Endometriosis
ua
D. Ovarian torsion
E. Ovarian tumour
al
114. A 39 year old woman has not had her period for 10 months. She feels well but is
anxious as her mother had an early menopause. What is the SINGLE most appropriate
Ev
initial investigation?

B. Serum FSH/LH
C. Serum progesterone con concentration
E. Transvaginal Ultrasound
115. A 38 year old woman requires long term contraception. She has 3 healthy children and
does not wish to have any more children in the near future. Upon examination she is
found to have extensive fibroids which are distorting her uterine cavity. She says she
has difficulty in remembering to take pills. What is the SINGLE best contraception for
her?
A. Implanon (Nexplanon®)
B. Depo-Provera
C. Intra-Uterine System (Mirena®)
957
D. Combined oral contraceptive pills (COCP)
E. Progestin-Only pill
116. A 38 year old woman presents with itching around the breast and greenish foul
smelling discharge from the nipple. She had a similar episode a year ago. What is the
A. Breast abscess
B. Duct ectasia
C. Duct papilloma
D. Fat necrosis
E. Paget’s disease of nipple
117. A 32 year old female who has completed her wants to know more about contraception
and the risk of ectopic pregnancies. Which of the following contraceptive methods
increase the absolute risk of ectopic pregnancies?
A. Combined oral contraceptive pills (COCP)
y
B. Intrauterine system (Mirena coil)
op
C. Progestogen-only Pill (POP)
D. Progesterone-only implant (Nexplanon)
C
118. A 24 year old woman with multiple sexual partners complains of lower abdominal pain,
deep dyspareunia and menstrual irregularities. On vaginal examination, cervical
n
excitation was noted. She has no significant past medical history. Which is the SINGLE
io
most likely cause of her symptoms?

t

ua
B. Endometriosis
C. Fitz-Hugh-Curtis syndrome
D. Cervicitis
al
Ev
emergency cesarean section at 39 weeks due to a breech fetus. She is now
experiencing severe abdominal pain and tenderness over the previous uterine scars.
CTG shows fetal distress and absent uterine contractility. What is the SINGLE most
likely diagnosis?
A. Endometritis
B. Placenta abruption
C. Uterine rupture
E. Placenta praevia
120. A 33 year old 39 week pregnant nulliparous women with a previous history of
gestational hypertension is in labour. Her membranes had ruptured earlier in the day.
She was assessed by the midwife and her cervix was found to be soft, mid-position
with an os 3 cm dilated. The fetus is in cephalic position. A vaginal examination was
958
performed 4 hours later and the cervical os still remains at 3 cm dilated.
Cardiotocography is reassuring and she is contracting less than three times in 10
minutes. What is the SINGLE most appropriate action?
A. Repeat vaginal examination in 4 hours

B. Amniotomy
C. Caesarean section
D. External rotation
E. IV syntocinon drip
121. A 21 year old woman had a recent suction curettage to evacuate the contents of the
uterus following a miscarriage. The histology shows changes consistent with a
hydatidiform mole. What is the SINGLE most appropriate advice to be given?
A. Barrier contraception should be used for 6 weeks

B. Barrier contraception should be used until serum hCG is normal
C. COCP should be used until serum hCG is normal
D. HRT should be used until serum hCG is normal
y
E. No contraception needed after evacuation of contents of the uterus
122.
op
A 34 year old female presents with a very strong foul smelling vaginal discharge. What
organism(s) could cause such a symptom?
C
A. Chlamydia, Gonorrhea
B. Chlamydia, Gardnerella
n
C. Chlamydia, Gonorrhea, gardnerella
io
D. Gonorrhea, Gardnerella
E. Gardnerella only
t
ua
123. A 31 year old woman, gravida 5 para 4, present to the emergency department with
vaginal bleeding. She has a history of amenorrhoea for 12 weeks. Pregnancy test was
done in the emergency department and it was positive. Symphyseal-fundal height
al
measurement corresponds to 22 weeks gestation. Ultrasound of the pelvis reveals

bilateral cystic masses. No fetal parts are seen during the ultrasound examination. The
Ev
cervix is closed. Which is the SINGLE most likely diagnosis?
A. Tubal pregnancy
B. Endometriosis
C. Hydatidiform mole
D. Threatened abortion
E. Ovarian hyperstimulation syndrome
124. A 33 year old woman comes to the emergency department complaining of right sided
abdominal pain for the last day. She vomited once earlier today. She gives a history of
missing a period. A urine pregnancy test was found to be positive. A transvaginal
ultrasound scan reveals an empty uterus. On examination, she is found to be tender at
the right iliac fossa with no signs of peritonism. She is afebrile and observations are
stable. What is the SINGLE most appropriate next step in management?
A. Laparoscopy
B. Human chorionic gonadotropin (hCG) blood test
959
C. Repeat ultrasound in a week
D. Laparotomy
E. Culdocentesis
125. A 34 year old pregnant woman, 11 weeks gestation, presents with vaginal bleeding.
She has been noted to be nauseas and vomiting for the past couple of weeks.
Symphyseal-fundal height measurement corresponds to a 18 week pregnant uterus.
Which is the SINGLE most likely diagnosis?
A. Tubal pregnancy
B. Endometriosis
126. A 66 year old woman had two episodes of post-coital vaginal bleeding in the last week.
She has not had any withdrawal bleeds for more than 12 years. Her last cervical smear
was 3 years ago which showed no abnormalities. What is the SINGLE most appropriate
y
initial action?
A. Repeat cervical smear

B. Topical oestrogen cream
op
C
n
io
127. A 23 year old woman presents with offensive, homogenous grey-white vaginal
discharge. Clue cells are demonstrated on a saline smear. What is the SINGLE most
t
likely diagnosis?
ua
A. Bacterial vaginosis
B. Trichomoniasis
al
C. Candidiasis
D. Chlamydia infection
Ev
E. Neisseria gonorrhoeae infection
antibiotic to give?
A. Erythromycin 500 mg orally once a day for 5 days

B. Ceftriaxone 500 mg as a single intramuscular dose
C. Metronidazole 400 mg orally twice daily for 14 days
D. Azithromycin 1g for 7 days
E. Azithromycin 1g single oral dose
129. A 32 year old primigravida at 28 weeks gestation presents with a blood pressure of
152/105 mmHg. A second blood pressure reading was taken 10 minutes later which
read 153/108 mmHg. She is asymptomatic and otherwise well. A urinalysis was
negative for protein. She has no history of high blood pressure in the past. What is the
SINGLE most likely management?
960
A. Indapamide
B. Hydralazine
C. Labetalol
D. Losartan
130. A 39 year old female was on combined oral contraceptive pills which she stopped 9
months ago. She has not had her periods since then. Lab results show:
Follicle-stimulating hormone (FSH) 55 U/L

Luteinizing Hormone (LH) 75 U/L
Prolactin 14 ng/mL
y
B. Post pill amenorrhoea
op
C. Prolactinoma
D. Pregnancy
C
131. A 41 year old woman presents with an offensive malodorous vaginal discharge. The
discharge is clear in colour and has a distinctive fishy odour. A vaginal pH was taken
n
and found to be 5.7. What is the SINGLE most likely causative organism?
io
t
ua
C. Candida albicans
al
132. A 31 year old woman who is 32 weeks pregnant attends the antenatal clinic. Her full
Ev
blood count was taken when she was 28 weeks which results shows a Hb of 10.7 g/dL;
MCV=91. What is the SINGLE most appropriate management?
B. Ferrous sulphate
C. Iron dextran
vaginal discharge and also complains of deep dyspareunia. A Urine HCG is negative.
Cervical motion tenderness was noted when doing a pelvic examination. She has a
temperature of 38.4°C. Her blood tests show:

CRP 110 mg/L
961
She has no significant past medical history. What is the SINGLE most appropriate
antibiotic treatment?
A. Ofloxacin and metronidazole

B. Azithromycin
C. Azithromycin and ceftriaxone
D. Doxycycline
E. Clindamycin
134. A 65 year old woman presents to the breast clinic having noticed that she has had a
blood stained discharge from the left nipple. She also has dry skin over the left areola
which resembles eczema. On examination, a blood stained discharge with dry flaky skin
is noted on the left areola and the nipple was ulcerated. What is the SINGLE most
A. Fine needle aspiration cytology

C. Punch biopsy
y
D. Open biopsy
op
E. Stereotactic biopsy
135. A 31 year old woman who had a normal delivery 4 weeks ago is complaining for feeling
C
tired. A full blood count was taken and results show:
Hb 9.3 g/dL
n
MCV 79 fL
io

t
ua
B. Ferrous sulphate
C. Iron dextran
al
D. Iron infusion
E. No treatment required
Ev
136. A 43 year old woman who is currently 34 weeks pregnant presents with headache,
epigastric pain and nausea. She complains of flashing lights. A dipstick shows 2+
protein. Her heart rate is 115 beats/minute. She has a blood pressure of 158/105
mmHg. What is the SINGLE most appropriate initial management?
A. Oral labetalol
B. Magnesium sulphate
C. Corticosteroids
D. Emergency C-section
E. Mannitol
137. A 31 year old woman complains of increased urinary frequency and urinary urgency.
She also describes painful voiding. She has dysmenorrhoea, sacral backache with
menses and complains of deep dyspareunia. What is the SINGLE most likely diagnosis?
A. Endometriosis
962
B. Uterine fibroid
C. Cystitis
D. Pyelonephritis
E. Transitional cell carcinoma of the bladder
138. A 42 year old pregnant woman at 38 weeks gestation has an eclamptic fit in the labour
ward which has been ongoing and started 10 minutes ago. She had severe pre-
eclampsia which was diagnosed when she was 35 weeks gestation. She was given a
loading dose of magnesium sulfate several hours ago and is currently on a
maintenance dose. When she was last examined, there was loss of patellar reflexes
and she was feeling nauseous and warm. What is the SINGLE most appropriate next
step?
A. A further bolus of 2 g magnesium sulphate

B. Increase infusion rate of magnesium sulphate
C. Intravenous hydralazine
D. Immediate delivery of baby
E. Administer diazepam
y
op
139. A 23 year old woman who is 28 weeks pregnant presents with vaginal bleeding. She
has lost about 200 ml of blood vaginally. On examination, she has a soft abdomen but
has lower abdominal tenderness.. A full blood count and a group and hold has been
C
taken. Intravenous fluids has been started. Her observations are currently stable. What
is the SINGLE most important investigations to establish a diagnosis?
n
A. Ultrasound
io
C. D-dimer test
t
D. Clotting profile
ua
E. Kleihauer blood test
140. An 8 week pregnant woman presents with persistent nausea and vomiting and a
al
history of weight loss. She has a pulse of 110 beats/minute. Her dehydration has been
managed with sodium chloride 0.9% with added potassium chloride. She continues to
Ev
vomit several times during the day despite being given intramuscular cyclizine. What is
the SINGLE next most appropriate management?
A. Intravenous hartmann's solution

B. Intravenous antiemetics
C. Intravenous corticosteroids
D. Medical termination of her pregnancy
E. Oral thiamine
141. A 26 year old lady presents with worsening lower abdominal pain and purulent vaginal
discharge. She was recently treated for pelvic inflammatory disease with antibiotics as
an outpatient but did not complete her course of antibiotics. A urine HCG is negative.
temperature of 38.6°C and a pulse rate of 95 beats/minute. What is the SINGLE most
A. Oral tetracycline 250mg QDS
963
B. Oral doxycycline 100mg BD and oral metronidazole 400mg BD
C. Intravenous ceftriaxone 2g OD with oral doxycycline 100mg BD
D. Intravenous ceftriaxone 2g OD only
E. Oral ofloxacin 400mg BD and oral metronidazole 400mg BD
142. A 31 year old pregnant woman has her antenatal screening at her booking
appointment for HIV and Hepatitis B status. What other routine investigations are
ordered at booking?
A. Rubella susceptibility and syphilis screen

B. Toxoplasma immunoglobulins and rubella susceptibility
C. Toxoplasma immunoglobulins and syphilis screen
D. Hepatitis C status
E. Measles susceptibility
143. A 31 year old woman presents to the emergency department with a lower abdominal
pain and per vaginal bleeding one day after having a hysterosalpingography as a part of
her infertility treatment. Her blood pressure is 85/50 mmHg and pulse rate is 125
y
beats/minute. On examination, the abdomen is rigid and tender. What is the SINGLE
op
most appropriate next step in investigation?
C
B. Abdominal X-ray erect and supine
C. Ultrasound abdomen and pelvis
D. Coagulation profile
n
E. Beta hCG
io
144. A 52 year old woman has hot flashes, night sweats and insomnia. She also complains of
t
vaginal dryness and symptoms of urinary frequency. Her last menstrual period was 11
ua
months ago. Her medical history includes having a myocardial infarction when she was
48 years old. What is the SINGLE most appropriate management for her?
al
A. Raloxifene
B. Oestrogen and progestogen patches
Ev

D. Topical oestrogen
E. Clonidine
145. A 34 year old lady comes to the GP for removal of an intrauterine device. On speculum
examination, the cervix is visualised but the intrauterine device thread is not seen. Her
last menstrual period is 2 weeks ago and she has been having regular sexual
intercourses with her partner. What is the SINGLE most appropriate next step?
A. Transabdominal ultrasound
B. Transvaginal ultrasound
C. Abdominal X-ray
D. Combined oral contraceptive pill
E. Repeat speculum examination under general anaesthesia
964
146. A 26 year old woman has been found to have mild dyskaryosis on a routine cervical
screening test. She is a heavy smoker. What is the SINGLE most appropriate next step
in action?
A. Colposcopy
B. Repeat cervical smear in 4 months
C. Cone biopsy
D. Large loop excision of the transformation zone (LLETZ) procedure
147. A 30 year old woman attends clinic asking for a reversible form of contraception. Her
obstetric history is significant for a previous caesarean section one year ago. She is
known to have menorrhagia and dysmenorrhoea. What is the SINGLE most appropriate
contraceptive for her?

B. Progestogen-only pill
C. Implanon
y
op
148. A 34 year old woman develops a fit 6 hours after having a spontaneous vaginal delivery
C
of a healthy term baby. She has no history of having high blood pressure and has not
had a seizure before. What is the SINGLE most likely diagnosis?
n
A. Eclampsia
io
B. Preeclampsia
C. Epilepsy
t
ua
E. Pregnancy induced hypertension
149. An 11 week pregnant woman presents with severe vomiting and nausea. She has been
al
feeling nauseous for the past few days. A urinalysis shows 2+ ketones. What is the
Ev
A. Ultrasound
B. Thiamine
C. Serum BHCG
D. Parenteral antiemetics
150. A 26 year old woman presents with vaginal bleeding. She has a positive pregnancy test
and her last menstrual period was 10 weeks ago. She has been having a lost of
appetite, nausea and vomiting for the past two weeks. On palpation, her symphyseal
fundal height is 16cm. On speculum examination, the cervical os is seen as closed.
A. Thyrotoxicosis
B. Threatened miscarriage
C. Twin pregnancy
D. Hyperemesis gravidarum
965
E. Molar pregnancy
151. A 29 year old at 38 weeks gestation presents with a 2 hours history of constant
abdominal pain. While waiting to be seen, she passes 300 ml of blood per vagina. What
A. Ultrasounds
B. Cardiotocography
C. Clotting screen
D. Group and save
E. Kleihauer Betke test
152. A 34 year old African women has been trying to concieve for the past 2 years. She has
suffered from heavy menstruations for the past 3 years and a recent transvaginal
ultrasound shows two large submucosal fibroids and one intramural fibroid. Her
partner has had a sperm analysis which was found to be normal. What is the SINGLE
y
A. Endometrial ablation
op
B. Myomectomy
C. Uterine artery embolisation
D. Levonorgestrel intrauterine system
C
E. Gonadotropin-releasing hormone (GnRH) analogue
153. A 42 year old African lady presents bloating and heavy, regular periods. Her uterine
n
size correlates to a 14 weeks pregnant uterus. What is the SINGLE most likely
io
diagnosis?
t
A. Blood dyscrasia
ua
B. Haematoma
C. Fibroids
D. Adenomyosis
al
E. Incomplete abortion
Ev
154. A 22 year old woman was prescribed doxycycline for 10 days to treat lyme disease. She
has been using combined oral contraceptive pills regularly for the past 6 months. What
is the SINGLE most appropriate advice?
A. Combined oral contraceptive pills can be used with no additional contraceptive

method necessary
B. Continue taking combined oral contraceptive pills plus an additional barrier method
for 2 days
C. Continue taking combined oral contraceptive pills plus an additional barrier method
for 10 days
D. Stop combined oral contraceptive pill for a week and use barrier methods
E. Prescribe doxycycline for 15 days
155. A 37 year old woman presents with heavy vaginal bleeding for the past several months.
A transvaginal ultrasound scan shows a 4 cm anterior subserosal fibroid and a 6 cm
fundal intramural fibroid. She would like her fertility preserved. What is the SINGLE
966
A. Uterine artery embolisation
C. Hysteroscopic myomectomy
D. Vaginal hysterectomy
E. Abdominal myomectomy
156. A 35 year old lady at her 28th week gestation attends her antenatal clinic for a routine
check-up. She feels well and has no complains. Her blood pressure is 160/95 mmHg,
and her urine dipstick shows 3+ protein. What is the SINGLE most likely diagnosis?
B. Gestational hypertension
C. Chronic hypertension
D. Pre-eclampsia
E. Chronic renal failure
157. A 29 year old woman’s recent cervical smear results show inflammatory changes
y
without any dyskaryosis. She has no pelvic or vaginal pain. There was no discharge on
op
examination. Speculum examination had shown a normal cervix and vaginal mucosa.
What is the SINGLE most appropriate action? C
A. Repeat smear in 3 years
B. Repeat smear in 6 months
C. Repeat smear urgently
n
D. Perform an endocervical swab
io
E. Refer to colposcopy clinic

t
ua
everytime she sneezes or coughs. On a speculum examination, there was no

anatomical abnormalities. What is the SINGLE most appropriate next step in
management?
al
A. Antibiotics
Ev
C. Ring pessary
D. Duloxetine
159. What is the recommended time to administer anti-D immunoglobulins to a previously

non sensitised rhesus negative mother after delivery?
A. 24 hours
B. 48 hours
C. 72 hours
D. 10 days
E. 14 days
160. A 16 year old girl has complains of dysmenorrhoea, menorrhagia and irregular
menstrual cycles. This complains started a few years ago and has gotten worse with
time. Her period pain is so intense that she occasionally has to skip school to stay at
967
home. She has not tried any medication to manage her symptoms. She is not currently
sexually active. What is the SINGLE most likely management to treat her symptoms?
A. Tranexamic acid
E. Mefenamic acid
161. A 30 year old lady presents to the outpatient clinic with difficulty in conceiving for the
past 2 years. She and her husband have been trying to achieve pregnancy for more
than 2 years and have been unsuccessful. There is no previous history of pelvic
inflammatory disease. She has a BMI of 23. She has a regular 32 day menstrual cycle.
What is the SINGLE most appropriate test to perform to assess ovulation?
A. Follicular stimulating hormone (FSH) and luteinizing hormone (LH)

B. Day 21 progesterone
C. Day 25 progesterone
y
op
E. Oestrogen levels
C
n
t io
ua
al
Ev
968
OBGYN Answers
1. A 51 year old woman presents with a 9 month history of prolonged, slightly irregular
menstrual periods. On physical examination, a normal size uterus with no adnexal
masses is felt. What is the SINGLE most likely diagnosis?
A. Menopause
B. Perimenopause
D. Cervical carcinoma
All women will go through menopause and the average age is 52 years.
For this question we have to go back to definitions of menopause and perimenopause.
Menopause is the permanent cessation of menstruation. It is recognized to have

occurred after 12 consecutive months of amenorrhoea for which no other obvious
y
pathological or
op
physiological cause is present.
Peri-menopause includes the period beginning with the first clinical, biological, and
C
endocrinological features of the approaching menopause, such as vasomotor
symptoms and menstrual irregularity.
n
As the above question presents with irregular menstruations and not absent
io
menstruations for a period of 12 months, perimenopause is to correct answer

t
ua
that she had regular menstrual cycles. She recently has hot flashes and night sweats.
She is also experiencing feelings of anger and helplessness. FSH was done and it was
raised on two separate occasions. What is the SINGLE most appropriate management?
al
A. Hormone replacement therapy (HRT) for 5 years

Ev
B. Hormone replacement therapy (HRT) until age 51

C. Tricyclic antidepressants
D. Levothyroxine
E. Progestogen-only pill (POP)
Premature ovarian failure
Premature ovarian failure (Premature ovarian insufficiency) is defined as the onset of

menopausal symptoms and elevated gonadotropin levels before the age of 40 years. It
occurs in around 1 in 100 women.
Causes
• Idiopathic - the most common cause
• Chemotherapy (this can be temporary, as recovery of ovarian function can
occur, especially in younger women)
• Radiation
• Autoimmune disease
• Bilateral oophorectomy or surgical menopause
969
Presentation
1. The most common presentation is amenorrhoea or oligomenorrhoea (which

may not necessarily be accompanied by hot flushes)
2. Infertility
3. Other features are similar to those of the normal climacteric symptoms:
• Hot flashes
• Night sweats
• Irritability
• Poor concentration
• Decreased sex drive
• Dyspareunia
• Vaginal dryness
Tests:
y
FSH levels:
op
• FSH test should be undertaken in women aged under 40 years in whom
menopause is suspected
• Two raised levels (more than 40 IU/L) taken at least four weeks apart are
C
diagnostic
Serum follicle-stimulating hormone (FSH) measurement alone can be used to diagnose

n
the disease. The anterior pituitary secretes FSH and LH at high levels due to the
io
dysfunction of the ovaries and consequent low estrogen levels.

t
Management:
ua
• hormone replacement therapy (HRT) until at least the average age of the
menopause (51 years)
al
(The average age of the menopause in women in the UK is 51 years)

Ev
Important Notes:
Do NOT use early menopause and premature ovarian failure interchangeably
• The term early menopause is used for those women who go through their
menopause between 40-45 years
Do NOT use premature menopause and premature ovarian failure interchangeably
• Premature ovarian failure is sometimes referred to as premature menopause,
but the two conditions aren't exactly the same. Women with premature
ovarian failure may have irregular or occasional periods for years and may
even become pregnant. Women with premature menopause stop having
periods and can't become pregnant.
3. A 45 year old waitress complains of pelvic pain which worsens pre-menstrually. The
pelvic pain is usually worse when standing and has been present for the last one year.
She also complains of post-coital ache that is felt deep within the vagina. There was no
discharge on vaginal examination. A diagnostic laparoscopy was performed which did
not show any abnormalities. What is the SINGLE most likely diagnosis?
970
A. Pelvic inflammatory disease (PID)
B. Endometriosis
D. Adenomyosis
Non-organic dyspareunia + with symptoms similar to premenstrual syndrome +

aggravated by standing = Pelvic congestion syndrome
Pelvic congestion syndrome is a chronic medical condition in women caused by

varicose veins in the lower abdomen. The condition causes chronic pain, often
manifesting as a constant dull ache, which can be aggravated by standing. It is a
diagnosis of exclusion where other organic causes of dyspareunia have been excluded.
It may present as pain during intercourse that may be deep within the vagina with
symptoms similar to premenstrual syndrome. It is caused by accumulation of blood
during arousal without occurrence of orgasm. Achieving orgasm (by intercourse,
masturbation, or use of a vibrator) may help to alleviate this congestion.
y
4. A 53 year old woman complains of dyspareunia and vaginal dryness. On a speculum
op
examination, an atrophic vaginitis is seen. Her last menstrual period was one year ago.
C
A. Hormone replacement therapy
C. Oestrogen cream
n
D. Testosterone gel
io
E. Primrose oil
t
Topical oestrogen is advisable as first-line for women with vaginal atrophy.

ua
A vaginal oestrogen cream or pessary would be appropriate here since the patient only
had symptoms of vaginal dryness without the other symptoms of menopause like hot
al
flushes.
Ev
If she had vasomotor symptoms such as flushing, including sleep, mood disturbance
and headaches, then a systemic hormone replacement therapy like the oestrogen plus
progestogen patch would be a better pick.
5. A 23 year old woman has painless vaginal bleeding at 36 weeks pregnancy. She has no
uterine contractions. Fetal heart tones are regular at 140 beats/min. Examination of
the uterus shows the fetus to be in transverse lie. She has a pulse of 90 beats/minute,
a blood pressure of 95/60 mmHg and a respiratory rate of 19 breaths/minute. What is
A. Transvaginal US
B. Abdominal US
D. Reassurance
E. Admit, observe and repeat CTG in 30 minutes
Placenta praevia
971
Placenta praevia describes a placenta lying wholly or partly in the lower uterine
segment.
This is common early in the pregnancy, but is most often not associated with bleeding.
The key clinical feature is painless bleeding after 24 weeks of gestation.
Risk factors
• previous placenta praevia
• multiple pregnancies
Note: 5% will have low-lying placenta when scanned at 16-20 weeks gestation
incidence at delivery is only 0.5%, therefore most placentas rise away from cervix
Clinical features
• Painless vaginal bleed
• uterus not tender
• lie and presentation may be abnormal
• fetal heart usually normal
y
op
Note: the painless late-pregnancy bleeding may occur during rest or activity, suddenly
and without warning. It may be preceded by trauma, coitus, or pelvic examination.
C
Diagnosis
This is based on the presence of painless late-trimester vaginal bleeding with an
obstetric ultrasound showing placental implantation over the lower uterine segment.
n
io
A transvaginal ultrasound is preferred over abdominal ultrasound for detection of

placenta praevia.
t
ua
gestation. She came to the hospital 2 hours ago after her waters broke. She has regular
and painful uterine contractions. PV examination reveals a 4 cm dilated cervix. Her vital
al
signs are normal. What stage of labour is she in?

Ev
A. First stage
B. Second stage
C. Third stage
D. Fourth stage
E. Latent phase
Labour may be divided into three stages

• stage 1: from the onset of true labour to when the cervix is fully dilated. It is
divided into a latent and an active phase.
Latent phase → begins with onset of regular contractions and ends with the
acceleration of cervical dilation.
Active phase → begins with cervical dilation acceleration, usually at 3-4 cm of
dilation, ending with complete cervical dilation.
• stage 2: from full dilation to delivery of the fetus
• stage 3: from delivery of fetus to when the placenta and membranes have
been completely delivered
972
Signs of labour include
• regular and painful uterine contractions
• a show (shedding of mucous plug)
• rupture of the membranes (not always)
• shortening and dilation of the cervix
7. A 22 year old woman is brought into A&E by her husband with severe abdominal
cramping. She is haemodynamically unstable and her abdomen is very tender. Serum
human chorionic gonadotropin (hCG) is 1400 IU/litre. A transvaginal ultrasound shows
an empty uterine cavity with a small adnexal mass. No fetal heart activity was noted.
A. Laparotomy
B. Laparoscopy
C. Admit and await events
D. CT abdomen
y
E. Methotrexate
op
It is clear here that she has an ectopic pregnancy.
C
Laparotomy would be the choice here as she is clearly haemodynamically unstable. An
open approach is quicker than a laparoscopic approach.
n
If she was haemodynamically stable, a laparoscopic approach to the surgical
io
management of tubal pregnancy would be prefered as this has less post surgical
complications and reduced length of hospital stay.
t
ua
Methotrexate would be first line for an ectopic pregnancy if she was not in significant
pain. Although systemic methotrexate is first line, it can only be used if it contains all
the criteria below:
al
• Not in significant pain

• Adnexal mass smaller than 35mm with no fetal heart visible
Ev
• Serum hCG less than 1500 IU/litre

• Able to return for follow-up
It is unlikely that the examiners for PLAB expect you to know these criteria thus
methotrexate is unlikely to be the answer in PLAB.
Ectopic pregnancy
Defined by the implantation of a fertilized ovum outside the uterus
Clinical features
• lower abdominal pain: typically the first symptom.
• vaginal bleeding: usually less than a normal period
• history of recent amenorrhoea: typically 6-8 weeks from start of last period
• peritoneal bleeding can cause shoulder tip pain
Examination findings
• abdominal tenderness
973
• cervical excitation (also known as cervical motion tenderness)
• adnexal mass may be noticed
Management:
• A laparoscopic approach to the surgical management of tubal pregnancy, in

the haemodynamically stable patient, is preferable to an open approach
• Management of tubal pregnancy in the presence of haemodynamic instability
should be by the most expedient method. In most cases this will be
laparotomy.
antibiotic to give?
A. Erythromycin
B. Ciprofloxacin
C. Metronidazole
y
D. Cefixime
op
E. Doxycycline
Cervicitis management
C
If just cervicitis (Chlamydia)
• Azithromycin 1g single dose (OR doxycycline 100mg bd for 7 days) (both have
n
similar efficacy of more than 95%)
io
Note that The 2009 SIGN guidelines suggest azithromycin should be used first-
line due to potentially poor compliance with a 7 day course of doxycycline
t
ua
If just cervicitis (Neisseria gonorrhoeae)

• Azithromycin 1g PO and ceftriaxone 500mg IM
al
It is important to note the differences between acute PID and just cervicitis as the
management is different
Ev
9. A 24 year old lady presents with lower abdominal pain for the last 3 months, dysuria,
dyspareunia and vaginal discharge. Urine HCG is negative. She has no significant past
medical history. What is the SINGLE most appropriate next step in management?
A. Laparoscopy
C. Hysteroscopy
D. Laparotomy
E. Ultrasound
Women of her age group (<25 years old) are of greater risk for pelvic inflammatory
disease as they are more sexually active during this period. A high vaginal swab is the
first test to do to help diagnose PID.
Pelvic inflammatory disease (PID)
974
Pelvic inflammatory disease (PID) is a term used to describe infection and inflammation
of the female pelvic organs including the uterus, fallopian tubes, ovaries and the
surrounding peritoneum. Most commonly caused by ascending infection from the
endocervix.
Causative organisms
• Chlamydia trachomatis - the most common cause
• Neisseria gonorrhoeae
Risk factors for PID

• Age <25
• Previous STIs
• New sexual partner/multiple sexual partners
• Uterine instrumentation such as surgical termination of pregnancy
• Intrauterine contraceptive devices
• Post-partum endometritis
y
Features
op
• lower abdominal pain
• fever
• deep dyspareunia
C
• dysuria and menstrual irregularities may occur
• vaginal or cervical discharge
• cervical excitation
n
io
Investigation
• screen for Chlamydia and Gonorrhoea
t
ua
Management
• There are many combinations of antibiotics to treat PID. It is unlikely that the
PLAB test would ask you the management of PID. PLAB questions may ask you
al
for the management of cervicitis (but unlikely PID). Remember, cervicitis is not
the same as PID.
Ev
This is one of the combination examples for treatment of PID:

Outpatients: Ceftriaxone 500 mg as a single intramuscular dose, followed by oral
doxycycline 100 mg twice daily plus oral metronidazole 400 mg twice daily, both for 14
days.
Note the differences between acute PID and just cervicitis.


• RCOG guidelines suggest that in mild cases of PID intrauterine contraceptive

devices may be left in. The more recent BASHH guidelines suggest that the
975
evidence is limited but that ' Removal of the IUD should be considered and
may be associated with better short term clinical outcomes'
Complications
• infertility - the risk may be as high as 10-20% after a single episode
• chronic pelvic pain
• ectopic pregnancy
10. A 33 year old woman has vaginal spotting 2 days ago that is painless. She is worried of
cervical cancer. She is currently on combined oral contraceptives and had a cervical
smear last year which was reported as normal. Cervical ectropion is diagnosed on
examination. There was no bleeding from the cervix on touch. What is the SINGLE most
B. Cervical smear
C. Punch biopsy
D. Reassurance
y
E. Colposcopy
op
There is no screening test needed for cervical ectropion as cervical ectropion is not
linked to the development of cervical cancer or any other condition that causes cancer.
C
Treatment can be offered if the cervical ectropion is causing problems such as bleeding
or pain during or after sex. However in this case, the cervix is not bleeding on touch
thus no treatment is needed.
n
io
Cervical ectropion
• This occurs when the columnar epithelium of the endocervix is displayed
t
beyond the os. The stratified squamous epithelium that normally lines the
ua
vaginal part of the cervix (ectocervix) is replaced by columnar epithelium,

which has migrated from the endocervix.
• The cervix enlarges under the influence of oestrogen and as a result
al
the endocervical canal is everted. Exposure of high levels of oestrogen

usually occurs at certain times (e.g. puberty, in pregnancy or women
Ev
on COCP)
• It is seen on examination as a red ring around the os and is so common
as to be regarded as normal
• It is generally an asymptomatic condition but patients occasionally
present with bleeding or excessive discharge
• The discharge if present is usually clear, watery in consistency and
without odour
• Once a normal cervical smear has been confirmed, it is actively
managed only if there are symptoms.
• After stopping any oestrogen-containing contraceptive, treatment
options include diathermy, or cryotherapy
11. A 30 year old woman with suspected pelvic inflammatory disease has worsening of her
symptoms of lower abdominal pain despite being treated with oral metronidazole and
ofloxacin for 14 days. She has a temperature of 38.6°C, heart rate of 85 bpm, and a
blood pressure of 110/80 mmHg. Her blood tests show:
976
CRP 160 mg/L
A. Endocervical swab
B. Pelvic ultrasound
C. Laparotomy
E. Urine culture
The possible diagnosis here is a pelvic abscess or tubo-ovarian abscess which are
complications of PID. A high vaginal swab or endocervical swab can take days to return
with results. As this is a A&E case, an ultrasound would be more appropriate as this
would lead to a diagnosis.
Ultrasound scan is the diagnostic imaging method of choice for acute pelvic pain in
gynaecology. It can easily diagnose sequelae of PID (including pyosalpinx and tubo-
y
ovarian abscess).
op
Laparoscopy would be the next step after finding a mass on ultrasound.
C
Urine culture has no part in the diagnosis of pelvic abscess
12. A 27 year old lady presents with lower abdominal pain in the emergency department. 2
n
weeks ago, she came to the hospital with fever, suprapubic tenderness and vaginal
io
discharge. Pelvic inflammatory disease (PID) was confirmed and she was sent home on
oral doxycycline and oral metronidazole. She now presents with abdominal
t
tenderness, temperature of 39.0°C, heart rate of 98 bpm, and a blood pressure of

ua
130/85 mmHg. What is the SINGLE most appropriate next course of action?

al
Ev
D. Abdominal X-ray
ovarian abscess).
Laparoscopy would be the next step after finding a mass on ultrasound.
Abdominal X-ray has no part in the diagnosis of a pelvic abscess.
977
and she has been amenorrhoeic since then. Ultrasonography reveals normal ovaries
with no signs of developing follicles.

Prolactin 44 ng/mL
C. Prolactinoma
y
op
Post pill amenorrhoea
Post pill amenorrhoea occurs when stopping oral contraceptives does not lead to a
C
resumption of a normal menstrual cycle. It is described as the loss of menstrual periods
for at least 6 months after stopping birth control pills.
n
Post-pill amenorrhea is believed to be due to suppression of the pituitary gland by the
io
birth control pills.

t
Investigations
ua
Investigation are usually needed if menstrual cycles do not resume after 3 months post
pill. It may be that the cause of amenorrhoea started whilst taking the contraceptives
which induced an artificial cycle, masking the issue until they were stopped.
al
Ev
• Ultrasonography will reveal ovaries with no signs of developing follicles and

ovulation even after having stopped the pills for 6 months
• Blood tests showing a low level of FSH, LH and oestrogen is usually sufficient to
confirm the diagnosis
Treatment
• The first line of treatment in case of post-pill amenorrhea is waiting for a
spontaneous remission of the amenorrhea and a spontaneous occurrence of
periods.
• The time limit is usually six months. But if the woman is anxious to get her
periods, active treatment may be started after waiting for only three months.
The standard treatment of post-pill amenorrhea is by stimulating the pituitary
to produce FSH and LH. This is done by the drug clomiphene citrate.
14. A 27 year old woman presents to the emergency department with a presenting
complaint of lower abdominal pain. She has abdominal tenderness, temperature of
39.0°C, heart rate of 102 bpm, and a blood pressure of 130/85 mmHg. There is no
978
vaginal discharge. What is the SINGLE most appropriate next course of action to make
the diagnosis?

D. Abdominal X-ray
This is most probably pelvic inflammatory disease (PID). In order to guide treatment, a
pelvic or abdominal ultrasound must be done. PID and cervicitis is an extremely high
yield topic for PLAB 1.

endocervix.
y
op
Causative organisms
C
• Age < 25
n
• Previous STIs
io

t

ua
Features
al
• Lower abdominal pain

• Fever
Ev
• Deep dyspareunia
• Dysuria and menstrual irregularities may occur
• Vaginal or cervical discharge
• Cervical excitation
Investigation
• Screen for Chlamydia and Gonorrhoea
Management
the same as PID.

979
days.



Complications
• Infertility - the risk may be as high as 10-20% after a single episode
y
• Chronic pelvic pain
op
• Ectopic pregnancy
15. A 17 year old senior schoolgirl has prolonged irregular menstrual periods and
C
menorrhagia. She is not sexually active. What is the SINGLE most appropriate
management?
n
A. Mefenamic acid
io

t

ua
Combined oral contraceptive pills suppresses production of gonadotrophins and is

al
thought to reduce menstrual blood loss by up to 50%. It can improve dysmenorrhoea,

lighten periods, regulate the cycle, improve premenstrual symptoms, COCP is very
Ev
useful in adolescence. Also note that tranexamic acid is also effective.
Although levonorgestrel intra-uterine system is first line for menorrhagia, it is difficult

to fit in a nulliparous woman as her cervix has not yet been dilated before. However,
there has been more and more research regarding the use of levonorgestrel intra-
uterine systems in nulliparous woman and some clinicians would prefer levonorgestrel
intra-uterine system to combined oral contraceptives. Their argument is that the
levonorgestrel intra-uterine systems such as Jaydess® may be fitted more easily, as the
frame is smaller and narrower compared to the Mirena® IUS.
NSAIDS such as mefenamic acid may decrease menstrual blood loss by up to 20–30%
and also significant decreases in dysmenorrhoea. But it will not regulate her periods
whereas COCP will regulate an irregular cycle.
16. A 36 year old primigravida who is 32 week has blood loss per vaginam followed by
sudden constant abdominal pain for the last 3 hours. Her uterus is hard and she is in
980
distress. Fetal distress is noted on CTG. Her blood pressure is 100/70 mmHg. What is
B. Placenta accreta
C. Placenta praevia
D. Vasa praevia
E. Placenta percreta
Placental abruption
Placental abruption Is the premature separation of a normally placed placenta. It

describes separation of a normally sited placenta from the uterine wall, resulting in
maternal haemorrhage into the intervening space
The cause is not known but associated factors include:

• proteinuric hypertension
• multiparity
y
• maternal trauma
op
• increasing maternal age
Clinical features
C
• Pain is constant
• Very tender and tense uterus
• Bleeding, which may be accompanied by pain
n
• fetal heart: may be distressed
io
• If the bleeding is severe, the mother may show signs of hypovolaemic shock;
however, young, fit, pregnant women can compensate very well until sudden
t
and catastrophic decompensation occurs

ua
Note: Severe abruption can result in haemorrhagic shock with acute tubular necrosis
from profound hypotension, and DIC from release of tissue thromboplastin into the
al
general circulation from the disrupted placenta.

Ev
17. A 36 year old woman is planning to undergo laparoscopic tubal sterilisation. What is
the risk of pregnancy after sterilisation by tubal ligation?
Plab Lab Values
A. 1:50
B. 1:200
C. 1:500
D. 1:1000
E. 1:5000
Laparoscopic tubal occlusion
Laparoscopic tubal occlusion using Filshie clips is now to mechanically occlude the
Fallopian tubes is now the laparoscopic method of choice. The risk of pregnancy after
sterilisation by tubal ligation is about 1:200, meaning that one in every 200 women
who undergo sterilisation may get pregnant at some point after sterilisation.
981
18. A 32 year old female who has had 3 previous miscarriages in the 1st trimester, all
before 10 weeks gestation, now comes to the hospital with vaginal bleeding at 8
weeks. A transvaginal ultrasound reveals a viable fetus. What is the SINGLE most
A. Aspirin
B. Aspirin and heparin
D. Cervical cerclage
The probable diagnosis here is antiphospholipid syndrome in which case aspirin plus
heparin is indicated.
What about cervical cerclage as the answer?

Cervical weakness is a recognised cause of second-trimester miscarriage. The diagnosis
is essentially a clinical one. The diagnosis is usually based on a history of second-
y
trimester miscarriage preceded by spontaneous rupture of membranes or painless
op
cervical dilatation.
In this question, the 3 miscarriages happened during the first trimester and not the
C
second trimester thus cervical cerclage would be a less likely option in this question.
Cervical cerclage is associated with potential hazards related to the surgery and the risk
n
of stimulating uterine contractions and hence should be considered only in women
io
who are likely to benefit.

t
The criteria for cervical cerclage is a strict and complicated one thus it is unlikely to be
ua
a correct answer during PLAB part 1. None the less, if they do give a history of painless
dilatation during the previous miscarriages, cervical cerclage could be the option.
al
To fully understand cervical cerclage you need to understand the 3 most basic types of
cerclage.
Ev
History-indicated cerclage → offered to women with three or more previous preterm

births and/or second-trimester losses. A history-indicated suture is performed as a
prophylactic measure in asymptomatic women and normally inserted electively at 12–
14 weeks of gestation.
Ultrasound-indicated cerclage → offered to women with a singleton pregnancy and a

history of spontaneous mid-trimester loss or preterm birth attributable to cervical
factors plus a cervical length of 25 mm or less which is detected by transvaginal scan
before 24 weeks of gestation
Rescue cerclage → Insertion of cerclage as a salvage measure in the case of premature

cervical dilatation with exposed fetal membranes in the vagina. This may be discovered
by ultrasound examination of the cervix or as a result of a speculum/physical
examination performed for symptoms such as vaginal discharge, bleeding or ‘sensation
of pressure’.
982
Antiphospholipid syndrome
Antiphospholipid syndrome is the most important treatable cause of recurrent

miscarriage. Antiphospholipid syndrome refers to the association between
antiphospholipid antibodies (lupus anticoagulant, anticardiolipin antibodies and anti-
B2 glycoprotein-I antibodies) and adverse pregnancy outcome or vascular thrombosis.
All women with recurrent first-trimester miscarriage and all women with one or more
second-trimester miscarriage should be screened before pregnancy for
antiphospholipid antibodies.
Pregnant women with antiphospholipid syndrome should be considered for treatment

with low-dose aspirin plus heparin to prevent further miscarriage.
Neither corticosteroids nor intravenous immunoglobulin therapy improve the live birth
rate of women with recurrent miscarriage associated with antiphospholipid antibodies
compared with other treatment modalities; their use may provoke significant maternal
and fetal morbidity
y
op
There is insufficient evidence to evaluate the effect of progesterone supplementation
in pregnancy to prevent a miscarriage in women with recurrent miscarriage.
C
19. A 23 year old woman who has been using an intrauterine system (Mirena coil) for one
year now complains of lower abdominal pain and menstrual irregularities. She has no
significant past medical history. Which is the SINGLE most likely cause of her
n
symptoms?
io

t
B. Endometriosis
ua
C. Adenomyosis
D. Fibroids
al
Intrauterine contraceptive devices are a risk factor for pelvic inflammatory disease.
Ev
Women of her age group (<25 years old) are of greater risk for pelvic inflammatory
disease as they are more sexually active during this period.
Other options are less likely because:
Endometriosis, adenomyosis and fibroids → Are less likely as an intrauterine system is

likely to benefit symptoms and not worsen them
Asherman syndrome → are adhesions of the endometrium often associated with

dilation and curettage of the intrauterine cavity. It results in infertility. Often, they
experience menstrual irregularities. But in this question there is no relevant past
medical history meaning she did not have any dilation and curettage thus this option is
very unlikely.

983
endocervix.
Causative organisms

• Age <25
• Previous STIs
Features
• fever
y
op
C
Investigation
n
io
Management
t
ua
the same as PID.
al

Ev
days.



Complications
984
20. A 20 year old woman, 32 weeks gestation, presents to the emergency department with
a history of painless vaginal bleeding after intercourse. On examination, a soft and
relaxed uterus is noted with a fundal height of 32 cm. CTG is reactive. She has not
attended any antenatal clinics previously and has not had any previous ultrasound
scans. She has a pulse of 122 beats/minute, a blood pressure of 84/60 mmHg and a
respiratory rate of 28 breaths/minute. What is the the SINGLE most likely diagnosis?

B. Placenta accreta
C. Placenta praevia
D. Preterm labor
E. Vasa praevia
Placenta praevia
y
op
segment.
C
Risk factors
n
io
t
ua
Clinical features
al

Ev

Diagnosis
21. A 33 year old, obese lady has irregular menstrual periods for the last 2 years.
Lab results show:

Prolactin 59 ng/mL
985

C. Hypothyroidism
D. Early menopause
E. Primary obesity
She has high LH, normal FSH and slightly high prolactin levels. These are not diagnostic
for PCOS but among the choices given, the lab results reflect PCOS.
Serum LH levels are elevated in approximately 40% of women with PCOS, owing to
increased production (increased amplitude and frequency of LH pulses)
Prolactin may be mildly elevated in PCOS. It has been described by some authors that
women with polycystic ovary syndrome (PCOS) may have elevated levels of prolactin.
However, a diagnostic criterion is to rule out other possible causes, including
y
hyperprolactinemia. This is because high prolactin levels have many of the same
op
symptoms as PCOS and needs to be ruled out to be certain of a PCOS diagnosis.
Polycystic ovarian syndrome (PCOS)

C
Polycystic ovary syndrome (PCOS) is a complex endocrine disorder with clinical
features that include hirsutism and acne (due to excess androgens), oligomenorrhoea
n
or amenorrhoea, and multiple cysts in the ovary.
io
Symptoms:
t
• irregular periods or no periods at all

ua
• an increase in facial or body hair (hirsutism)

• loss of hair on your head
• being overweight, experiencing a rapid increase in weight or having difficulty
al
losing weight
• oily skin, acne
Ev
• difficulty becoming pregnant (reduced fertility)
Diagnosis → Rotterdam consensus criteria

Two out of three of the following criteria being diagnostic of the condition:
1. Ultrasound → polycystic ovaries (either 12 or more follicles or increased ovarian
volume
2. oligo-ovulation or anovulation
3. clinical and/or biochemical signs of hyperandrogenism
General management
• Weight loss
Management for menstrual irregularities

• Weight loss
• COCP or cyclical progestogen or levonorgestrel intrauterine system.
Management of infertility
986
• Weight loss → weight loss alone may achieve spontaneous ovulation
• Clomifene Citrate
• If clomifene citrate fails, add on metformin or gonadotrophins or Laparoscopic
ovarian drilling
Note regarding metformin:

• The RCOG published an opinion paper in 2008 and concluded that on current
evidence metformin is not a first line treatment of choice in the management
of PCOS
• Metformin is however still used, either combined with clomifene or alone,
particularly in patients who are obese
22. A 30 year old multiparous woman has just delivered a term male baby. She is group A(-
) and her husband’s blood group is unknown. She does not remember having any
intramuscular injections in her previous pregnancy. The infant boy develops severe
jaundice within a few hours after being born. What is the SINGLE most likely diagnosis?
y
B. G6PD
op
C. ABO incompatibility
D. Rh incompatibility
C
Rhesus negative pregnancy
n
A basic understanding of the pathophysiology is essential to understand Rhesus
io
negative pregnancies.
t
If a Rh -ve mother delivers a Rh +ve child a leak of fetal red blood cells may occur, this
ua
causes anti-D IgG antibodies to form in mother. In later pregnancies these antibodies
can cross placenta and cause haemolysis in fetus.
al
In this question, she gives a history of not receiving intramuscular injections (which
include IM anti-RhD immunoglobulin (Rho(D) immune globulin). Thus she is probably
Ev
isoimmunized.
Prevention
• test for anti-D antibodies in all Rh -ve mothers at booking
• NICE (2008) advise giving anti-D to non-sensitised Rh -ve mothers at 28 and 34
weeks
• anti-D is prophylaxis - once sensitization has occurred it is irreversible
Anti-D immunoglobulin should be given as soon as possible (but always within 72

hours) in the following situations:
• delivery of a Rh +ve infant, whether live or stillborn
• any termination of pregnancy
• miscarriage if gestation is > 12 weeks
• external cephalic version
• antepartum haemorrhage
• amniocentesis, chorionic villus sampling, fetal blood sampling
987
Affected fetus
• oedematous (hydrops fetalis, as liver devoted to RBC production albumin falls)
• jaundice, anaemia, hepatosplenomegaly
• treatment: transfusions, UV phototherapy
23. A 32 year old female with type 2 diabetes mellitus would like to know about vitamins
and supplements in pregnancy. Which SINGLE most likely vitamin prevents teratogenic
effects in an unborn child?
A. Folic acid
B. Vitamin B12
C. Thiamine
D. Riboflavin
E. Pyridoxine
Advise women with diabetes who are planning to become pregnant to take folic acid (5
mg/day) until 12 weeks of gestation to reduce the risk of having a baby with a neural
y
tube defect.
24.
op
A 25 year old woman has vaginal discharge, intermenstrual bleeding and post coital
bleeding. She is sexually active and does not use any form of contraception. What is
C

n
io

D. Blood culture
t
E. Pelvic ultrasound scan

ua
The likely diagnosis here is cervicitis caused by either chlamydia or neisseria

gonorrhoeae. An endocervical or vulvovaginal swab would give the diagnosis
al
A high vaginal swab (HVS) is only worthwhile where there are recurrent symptoms,
Ev
treatment failure or in pregnancy, postpartum, post-abortion or post-instrumentation.
Cervicitis (Chlamydia and Neisseria gonorrhoeae)

• Usually asymptomatic
• Can present with vaginal discharge, low abdominal pain, intermenstrual
bleeding or post coital bleeding
Diagnosis
• Endocervical or vulvovaginal swab with NAAT
Diagnosis in detail
• Endocervical swab in transport medium (charcoal preferably) is to diagnose
gonorrhoea.
• Endocervical swab for a chlamydial nucleic acid amplification test (NAAT) is to
diagnose chlamydia.
988
• If examination is declined, a self-taken vulvovaginal swab for C. trachomatis
and N. gonorrheae for NAAT may be an option and is more sensitive in women
than urine testing
25. A 41 year old lady who is 37 weeks pregnant was brought to A&E. On arrival, she has a
seizure. Her husband says a few hours ago she complained of headache, visual
disturbance and abdominal pain. What is the SINGLE most appropriate management?
A. 4g MgSO4 in 100 ml 0.9% normal saline in 5 minutes

B. 4g MgSO4 bolus intravenously
C. 2g MgSO4 in 500 ml normal saline in 1 hour
D. 2g MgSO4 bolus intravenously
E. 10mg diazepam in 500 ml 0.9% normal saline in 1 hour
Eclampsia
Eclampsia is defined as the occurrence of a tonic-clonic seizure in association with a

diagnosis of pre-eclampsia.
y
op
Eclampsia is an obstetric emergency. Every hospital in the UK should have an eclampsia
protocol and eclampsia box with all the drugs for treatment.
C
Prevention and control of seizures:
• Magnesium sulfate should be considered when there is concern about the risk
of eclampsia. It is used to prevent seizures as well as control it.
n
• To control a seizure, a loading dose of 4 g MgSO4 in 100 ml 0.9% normal saline
io
is given by infusion pump over 5-10 minutes. This is followed by a further

infusion of 1 g/hour maintained for 24 hours after the last seizure.
t
• Recurrent seizures should be treated with either a further bolus of 2 g of

ua
magnesium sulfate or an increase in the infusion rate to 1.5 g or 2.0 g/hour.
26. A 56 year old woman who is a heavy smoker is diagnosed with cervical intraepithelial
al
neoplasia grade 2. She is a mother of three children. She is worried of ovarian cancer
because her older sister died of ovarian cancer. She has been on hormone replacement
Ev
therapy for 3 years. What is the SINGLE most relevant risk factor for ovarian cancer in
her case?
A. Smoking
B. Family history
C. Cervical intraepithelial neoplasia grade
E. Pregnancy
Family history of ovarian cancer is an important risk factor. Women with a first-degree
relative with ovarian cancer have 3-4 times the risk of developing the disease.
However, only 10% of cases arise in women with a positive family history.
Smoking is a risk factor but it is not as important as family history. It is estimated that
2% of cases may be caused by smoking.[
HRT increases the risk of developing ovarian cancer but only slightly and it is only seen
989
in patients using HRT for more than five years. About 1% of cases may be linked with
taking HRT. Further studies are needed to ascertain the exact risk.
Ovarian Cancer Risk factors

• Family history: mutations of the BRCA1 or the BRCA2 gene
• Many ovulations: early menarche, late menopause, nulliparity
• Age → incidence increases with age
Protective factors against ovarian cancer:

• COCP
• Pregnancy
27. A 28 week pregnant lady presents with painless vaginal bleeding after sexual
intercourse. The cervical os is closed. On ultrasound, placenta is noted to be anterior
and high. Fetal movements and fetal heart is seen on scan. Abdomen is soft and non
A. Missed miscarriage
y
op
D. Placental praevia
E. Cervical ectropion
C
Post coital bleeding could be a symptom of either placenta praevia or cervical
ectropion.
n
As the placenta is noted to be high, it is not placenta praevia.
io
Fetal heart was seen which excludes the diagnosis of missed miscarriage.
Placenta abruption would present a hard, tender abdomen.
t
There are no signs or symptoms of disseminated intravascular coagulation.

ua
Cervical ectropion would be the most likely diagnosis.
Cervical ectropion
al

Ev

on COCP)
without odour
990
28. A 64 year old woman has been on hormone replacement therapy for 5 years. She had
regular withdrawal bleeds until 3 years ago and has not had a bleeding since. Recently
she noticed a brown vaginal discharge on her underpants. Her last cervical smear was 3
years ago which showed no abnormalities. What is the SINGLE most appropriate initial
investigation?
A. Cervical smear
The idea here is to think of endometrial cancer. Any women who has postmenopausal
bleeding should have a transvaginal ultrasound to determine the endometrial
thickness. If the endometrium is thick, hysteroscopy with endometrial biopsy would be
arranged.
The hormone replacement therapy in this scenario has no relevance as HRT
y
(progesterone and oestrogen) is not a risk factor for endometrial cancer. Only
op
unopposed oestrogen would be a risk factor for endometrial cancer.
A cervical smear is offered every 5 years in the UK if in the age group of 50 to 64 years
C
old. Thus, having a cervical smear that was normal 3 years ago is a usual phenomenon.
A repeat cervical smear is not necessary.
n
Endometrial cancer
io
Endometrial cancer is classically seen in post-menopausal women. Classically,

t
endometrial cancer presents as postmenopausal bleeding (PMB) and, although this is

ua
not the only cause, it must be excluded.
Risk factors for endometrial cancer:

al
• Obesity
• Nulliparity
Ev
• early menarche
• late menopause
• unopposed oestrogen. The addition of a progestogen to oestrogen reduces this
risk (e.g. In HRT). The BNF states that the additional risk is eliminated if a
progestogen is given continuously
• diabetes mellitus
• tamoxifen
• polycystic ovarian syndrome
Features
In PLAB, they will always present with postmenopausal bleeding
Investigation
• first-line investigation is trans-vaginal ultrasound - a normal endometrial
thickness (< 4 mm) has a high negative predictive value
• hysteroscopy with endometrial biopsy gives the definitive diagnosis
991
Management
Is beyond the scope for PLAB. Remember, PLAB is an easy test.
29. An 18 year old girl presents to the clinic with secondary amenorrhoea. Her BMI is 30.
She has dark pigmentation on her neck and severe acne on her face. There is also
thinning of hair. Blood test reveals elevated insulin levels, elevated LH levels and
moderately elevated testosterone levels. What is the SINGLE most likely diagnosis?
Elevated insulin levels, elevated LH levels and moderately elevated testosterone levels
can be seen in PCOS. The scenario of acne on her face points towards an excess of
androgens (Hirsutism, alopecia, acne are all manifestations of hyperandrogenism). And
not to mention that her initial complaint was secondary amenorrhoea which is one of
y
the diagnostic criterion for PCOS.
op
The dark pigmentation on her neck is called acanthosis nigricans which is characterised
by brown to black hyperpigmentation of the skin found in body folds,such as the axilla,
C
nape of the neck, groin is a marker of insulin resistance

n
io

features
t
that include hirsutism and acne (due to excess androgens), oligomenorrhoea or

ua
amenorrhoea, and multiple cysts in the ovary.
Symptoms:
al

Ev

losing weight
• oily skin, acne
• difficulty becoming pregnant (reduced fertility).

1. Ultrasound → polycystic ovaries (either 12 or more follicles or increased
ovarian volume
General management
• Weight loss
992
• Weight loss
ovarian drilling

of PCOS
30. A 22 year old woman was prescribed rifampicin for prophylaxis as her roommate was
diagnosed with meningococcal meningitis. She has been taking combined oral
y
contraception for the past year and is sexually active. Which is the SINGLE most
op
appropriate advice to give to her?
A. Use alternative methods such as barrier methods

C
B. Stop combined oral contraceptive pill for a week
C. Attend A&E if face begins swelling
D. Avoid exercising for 3 days
n
E. Continue combined oral contraceptives as usual
io
Combined hormonal contraceptives are less reliable during treatment with rifampicin.
t
Breakthrough bleeding and spotting are common, and pregnancies have occurred
ua
Action:
Use alternative methods (IUDs, depot or barrier methods), an increased
al
ethinylestradiol dose (at least 50 micrograms during and for 28 days after rifampicin is
stopped), an extended or tricycling regimen or a suitable alternative antibacterial
Ev
should be given.
31. A pregnant woman with long term history of osteoarthritis comes to the antenatal
clinic with complaints of restricted joint movement and severe pain in her affected
joints. What is the SINGLE most appropriate management?
A. Paracetamol
B. Steroids
C. NSAID
D. Paracetamol and Dihydrocodeine
E. Pethidine
It is important to remember that as junior doctors, you should never prescribe any pain
relief other than paracetamol to a pregnant women. Paracetamol has a good safety
profile with pregnant women when compared to all the other analgesics. There are
cases where stronger pain relief is needed, but usually consultants would be involved
in the management.
993
For the purpose of PLAB part 1, whenever you see a pregnant lady with any sort of pain
(whether it is from osteoarthritis, back pain, headaches, or a sprained ankle), never
give any analgesia except for paracetamol.
32. A 33 year old woman, with 3 previous normal vaginal deliveries is diagnosed with
stress incontinence. She has tried pelvic floor exercises and lifestyle modifications but
they have not been successful. Her BMI is 29. What is the SINGLE most appropriate
management?
A. Tension free vaginal tape

B. Bladder training
C. Oestrogen
D. Intermittent urethral catheters
E. Antimuscarinic medications
Stress incontinence is a leak of small amounts of urine when coughing or laughing.

Usually with a history of many vaginal deliveries as this would weaken the pelvic floor
y
muscles. The next management here would be surgical. A tension free vaginal tape
op
would be appropriate.
The other options are less likely the correct answer:

C
Bladder training → is used for women with urgency or mixed urinary incontinence. It is
not used for stress incontinence.
n
io
Oestrogens →Do not offer systemic hormone replacement therapy for the treatment
of urinary incontinence
t
ua
Intermittent urethral catheters → This is primarily for people with urinary retention
rather than stress incontinence
al
Antimuscarinic medications → Are used to treat overactive bladder and not stress
incontinence.
Ev
33. A 29 year old woman experienced severe blood loss shortly after delivery of a still born
vaginally, following a major placental abruption. Given the risk factors, what is the
SINGLE most likely predisposing factor for developing postpartum haemorrhage in this
women?
A. Retained product
B. Disseminated intravascular coagulation (DIC)
C. Fibroid uterus
D. Uterine infection
E. Large placental site
Although incidence of DIC as a cause of postpartum haemorrhage is low. This question

is giving all the risk factors that would lead to disseminated intravascular coagulation
(DIC)
With severe abruption, severe disseminated intravascular coagulation (DIC) may occur.
994
Fetal demise is also a risk factor for DIC resulting from release of tissue thromboplastin
from deteriorating fetal organs.
Other causes of pregnancy related DIC are: eclampsia, retention of a dead fetus,
amniotic fluid embolism, retained placenta or bacterial sepsis.
34. A 27 year old asian nulliparous woman with type 1 diabetes mellitus has delivered a
baby weighing 4.5kg with the help of forceps. The placenta was removed with
continuous cord traction and her uterus is well contracted however she continues to
bleed heavily. What is the SINGLE most likely cause of her postpartum haemorrhage?
A. Atonic uterus
B. Cervical/vaginal trauma
C. Retained POC
D. Large placental site
E. Rupture uterus
y
The most common cause of postpartum haemorrhage is uterine atony however this is
op
not the case here as the uterus is well contracted. The risk factors point towards a
genital tract trauma. Asian ethnicity, nulliparous, diabetic and big baby were thrown in
as these are risk factors towards a 3rd and 4th degree perineal tear which can be the
C
sole cause of the PPH.
Causes for PPH may be considered to relate to one or more of ‘the four Ts’:
n
• tone (abnormalities of uterine contraction)
io
• tissue (retained products of conception)

• trauma (of the genital tract)
t
• thrombin (abnormalities of coagulation).

ua
The most common cause of primary PPH is uterine atony. However, clinical
examination must be undertaken to exclude other or additional causes:
al
• retained products (placenta, membranes, clots)

• vaginal/cervical lacerations or haematoma
Ev
• ruptured uterus
• broad ligament haematoma
• extragenital bleeding (for example, subcapsular liver rupture)
• uterine inversion.
35. A 26 year old woman presents with a “fishy” vaginal discharge. On examination, a
homogenous grey-white vaginal discharge is seen. Vaginal pH is 5.8. What is the
A. Metronidazole
B. Azithromycin
C. Doxycycline
D. Ceftriaxone
E. Flucloxacillin
Bacterial vaginosis
995
Bacterial vaginosis (BV) is caused by an overgrowth of mixed anaerobes,such as
Gardnerella vaginalis, which replace the usually dominant vaginal lactobacilli resulting
in a raised vaginal pH.
It is the commonest cause of abnormal vaginal discharge in women of childbearing age.
Whilst BV is not a sexually transmitted infection it is seen almost exclusively in sexually

active women.
Features
• Vaginal discharge: 'fishy', offensive
The characteristic ‘fishy’ smell is due to the presence of amines released by
bacterial proteolysis and is often the reason women attend the clinic
• Asymptomatic in 50%
Amsel's criteria for diagnosis of BV → 3 out of 4 required for diagnosis:

• Homogenous grey-white discharge
• Characteristic fishy smell
y
• ‘Clue cells’ present on microscopy
op
• Vaginal pH > 5.5
Management
C
May resolve spontaneously and if successfully treated has a high recurrence rate.
However, most women prefer it to be treated.
n
• Metronidazole 400mg orally bd for 5 days or metronidazole 2g (single dose) OR
io
• Clindamycin 2% cream vaginally at night for 7 days

t
36. A 31 year old primigravida at 24 weeks' gestation was admitted 24 hours ago to the
ua
maternity unit because of preterm premature rupture of membranes (PPROM). She is

starting to have abdominal pains and uterine contractions. She has a pulse rate of 102
beats/minute and a temperature of 38.6°C. Routine examination of the patient’s
al
abdomen reveals tenderness suprapubically. A speculum examination reveals a foul-

smelling discharge originating from the cervix with the cervix slightly opened. What is
Ev
B. Chorioamnionitis
C. Bacterial vaginosis
Fever, maternal tachycardia, tenderness suprapubically and purulent vaginal discharge

with history of ruptured membranes points towards chorioamnionitis.
There is no indication of miscarriage here which is characterised by vaginal blood loss.
Chorioamnionitis
Chorioamnionitis is an acute inflammation of the foetal amnion and chorion
membranes, typically due to an ascending bacterial infection in the setting of
membrane rupture.
996
Features suggestive of chorioamnionitis
• Fever
• Abdominal pain, including contractions
• Maternal pyrexia and tachycardia.
• Uterine tenderness.
• Fetal tachycardia
• Maternal tachycardia.
• Speculum: offensive vaginal discharge → yellow/brown
that she had regular menstrual cycles. FSH was found raised on two separate occasions
a month apart. What is the SINGLE most likely diagnosis?
A. Polycystic ovarian syndrome

C. Early menopause
D. Fragile X
y
E. Addison's disease
op
C
n
io
Causes
t

ua

• Radiation
al

Ev
Presentation

2. Infertility
• Hot flashes
• Night sweats
• Irritability
• Dyspareunia
• Vaginal dryness
Tests:
997
FSH levels:
diagnostic

Management:
Important Notes:
y
op
C
n
io
38. A 16 year old clinically obese girl has not started her menstrual periods yet. She has
t
severe acne and facial hair growth. Among her investigations, a high level of insulin
ua
was found. What is the SINGLE most likely diagnosis?
al
Ev
D. Polycystic ovary syndrome

Polycystic ovary syndrome (PCOS) would fit the best among the answers. Cushing’s
would be a consideration here as it can sometimes cause amenorrhoea too.

features
Symptoms:
998
losing weight
• oily skin, acne

volume
General management
• Weight loss

• Weight loss
y
op
C
ovarian drilling
n
io
t
of PCOS
ua

al
and she has not had her menstrual period since.
Ev

Prolactin 72 ng/mL
C. Prolactinoma
Post pill amenorrhoea
999
Post pill amenorrhoea occurs when stopping oral contraceptives does not lead to a
resumption of a normal menstrual cycle. It is described as the loss of menstrual periods
for at least 6 months after stopping birth control pills.
Post-pill amenorrhea is believed to be due to suppression of the pituitary gland by the

birth control pills.
Investigations
Investigation are usually needed if menstrual cycles do not resume after 3 months post
pill. It may be that the cause of amenorrhoea started whilst taking the contraceptives
which induced an artificial cycle, masking the issue until they were stopped.
• Ultrasonography will reveal ovaries with no signs of developing follicles and

ovulation even after having stopped the pills for 6 months
• Blood tests showing a low level of FSH, LH and oestrogen is usually sufficient to
confirm the diagnosis
y
Treatment
op
• The first line of treatment in case of post-pill amenorrhea is waiting for a
spontaneous remission of the amenorrhea and a spontaneous occurrence of
periods.
C
• The time limit is usually six months. But if the woman is anxious to get her
periods, active treatment may be started after waiting for only three months.
The standard treatment of post-pill amenorrhea is by stimulating the pituitary
n
to produce FSH and LH. This is done by the drug clomiphene citrate.
io
40. A 27 year old woman had pre-eclampsia and was delivered by C-section. She is now
t
complaining of right upper quadrant pain. What is the SINGLE most appropriate
ua
immediate investigation?
al
B. Liver function test

C. Liver ultrasound
Ev
D. Magnetic Resonance Cholangiopancreatography

E. CT abdomen
This lady has pre-eclampsia, and now has RUQ pain. This could be a potential HELLP
syndrome. Liver function test would help us with the diagnosis.
HELLP syndrome
This is a serious complication regarded by most as a variant of severe pre-eclampsia

which manifests with haemolysis (H), elevated liver enzymes (EL), and low platelets
(LP).
Liver enzymes usually increase and platelets decrease before haemolysis occurs.
The syndrome is usually self-limiting, but permanent liver or renal damage may occur.
Note that eclampsia may co-exist.
1000
Signs and Symptoms:
• Epigastric or RUQ pain and tenderness
• Urine is ‘tea-coloured’ due to haemolysis.
• Increased BP and other features of pre-eclamsia
Management
• Delivery
• Supportive and as for eclampsia (magnesium sulfate (MgSO 4 ) is indicated)
41. A 27 year old woman has pelvic pain, dysmenorrhoea and increasingly heavy periods
over the last 12 months. She also complains of dyspareunia. There is generalized pelvic
tenderness without peritonism. A pelvic ultrasound was reported as normal. What is
A. Endometriosis
B. Uterine fibroid
y
op
D. Premature ovarian failure
E. Fibromyalgia C
There are actually two possibilities here. Endometriosis and pelvic congestion
syndrome. Given that endometriosis is much more common than pelvic congestion
syndrome, endometriosis is the answer.
n
io
Endometriosis presents exactly the way they describe in this question with chronic
pelvic pain, dysmenorrhoea and dyspareunia. Pelvic ultrasound scans are usually
t
normal.
ua
In pelvic venous congestion there are dilated pelvic veins believed to cause a cyclical
dragging pain. It is worse premenstrually and after prolonged periods of standing and
al
walking. Dyspareunia is also often present.

Ev
Given there is no history of standing here, pick endometriosis. It is also by far more a
common diagnosis when it comes to chronic pelvic pain.
Endometriosis
Endometriosis is the presence of endometrial-like tissue outside the uterine cavity. It is

oestrogen dependent, and therefore mostly affects women during their reproductive
years. If the ectopic endometrial tissue is within the myometrium itself it is called
adenomyosis.
Up to 10-12% of women have a degree of endometriosis
Clinical features
• Chronic pelvic pain (cyclic or constant)
• Dysmenorrhoea - pain often starts days before bleeding
• Deep dyspareunia (indicates possible involvement of uterosacral ligaments)
1001
• Subfertility
Investigation
• Laparoscopy is the gold-standard investigation
• Transvaginal ultrasound scanning appears to be a useful test, both to make and
to exclude the diagnosis of an ovarian endometrioma
Management
• NSAIDs to treat pain
• Combined oral contraceptive pill (other hormonal drugs can be used too)
• Levonorgestrel intrauterine system
Note: Drug therapy unfortunately does not seem to have a significant impact on
fertility rates
Surgery
• Laparoscopic excision and ablation of endometrioid lesions helps reduce
endometriosis-associated pain. Laparoscopic excision and ablation of
y
endometriotic ovarian cysts may improve fertility.
42.
op
A 45 year old lady comes to the family planning clinic for contraception advice. She has
two young children and does not want anymore children. An incidental finding of
C
multiple small submucosal fibroids was found recently on an ultrasound scan. She is
asymptomatic and her medical history is otherwise insignificant. What is SINGLE most
appropriate contraceptive for this lady?
n
io
A. Etonogestrel
B. Combined oral contraceptive pill (COCP)
t

ua
D. Intrauterine system (IUS)

E. Intrauterine Contraceptive Device (IUCD)
al
Combined hormonal contraception (CHC): despite the 'pill' previously being considered
a risk factor for fibroid growth, CHC is helpful if the patient requires contraception,
Ev
although it is not as effective as a levonorgestrel-releasing intrauterine system. Thus,

intrauterine system would be the answer here.
Intrauterine system (IUS) reduces the uterine size in women with fibroids.
If this lady here had presented with asymptomatic fibroids and was not looking for
contraception, expectant management would be a valid answer especially if she was
peri-menopausal.
Treatment options for uterine fibroids

• No treatment may be necessary if minimal symptoms.
• GnRH analogues shrink fibroids, but should only be used for this purpose prior
to surgery.
• Myomectomy: open, laparoscopic, or hysteroscopic depending upon location
(especially when wish to preserve fertility and when the fibroids are distinctly
isolated on scan)
1002
• Hysterectomy: women who have either completed their family or are over 45
years. It is a guaranteed cure of fibroids as there is no longer a uterus.
• Uterine artery embolization: uterine artery is catheterized generally using the
unilateral approach; polyvinyl alcohol powder or gelatin sponge is used as the
embolic material (minimally invasive procedure with avoidance of a general
anaesthetic)
Note: Surgery is indicated when:

• There is excessively enlarged uterine size.
• Pressure symptoms are present.
• Medical management is not sufficient to control symptoms.
• The fibroid is submucous and fertility is reduced.
43. A 27 year old waitress has pelvic pain, dysmenorrhoea and increasingly heavy periods
over the last 9 months. The pain is worse when she is standing for long periods of time.
She also complains of dyspareunia. A pelvic ultrasound was reported as normal. A
diagnostic laparoscopy was performed which did not show any abnormalities. What is
y
op
A. Endometriosis
B. Uterine fibroid
C
D. Pelvic inflammatory disease
E. Fibromyalgia
n
In pelvic venous congestion there are dilated pelvic veins believed to cause a cyclical
io
dragging pain. It is worse premenstrually and after prolonged periods of standing and
walking. Dyspareunia is also often present.
t
ua
Non-organic dyspareunia + with symptoms similar to premenstrual syndrome +

aggravated by standing = Pelvic congestion syndrome
al
Pelvic congestion syndrome

is a chronic medical condition in women caused by varicose veins in the lower
Ev
abdomen. The condition causes chronic pain, often manifesting as a constant dull ache,
which can be aggravated by standing. It is a diagnosis of exclusion where other organic
causes of dyspareunia have been excluded. It may present as pain during intercourse
that may be deep within the vagina with symptoms similar to premenstrual syndrome.
It is caused by accumulation of blood during arousal without occurrence of orgasm.
Achieving orgasm (by intercourse, masturbation, or use of a vibrator) may help to
alleviate this congestion.
and severe acne on her face. There is also thinning of hair. Multiple follicles were on
her ovaries on ultrasound.. What is the SINGLE most appropriate initial management to
treat her infertility?
A. Weight loss
B. Clomifene Citrate
C. Laparoscopic ovarian drilling
1003
D. Combined oral contraceptive pills
E. Spironolactone
The most likely diagnosis here is Polycystic ovarian syndrome (PCOS). Multiple follicles
seen on ovaries during an ultrasound helps confirm this. The scenario of acne on her
face points towards an excess of androgens (Hirsutism, alopecia, acne are all
manifestations of hyperandrogenism). And not to mention that her initial complaint
was infertility which is one of the diagnostic criterion for PCOS.
Weight loss is the most appropriate answer here as the question is asking for the
INITIAL management.
Clomifene citrate is an option but weight loss comes first. Usually we would advise
them to lose weight while getting blood test done to confirm anovulation.
y
op
Some clinicians would start them on metformin right away on their first visit. This is a
debatable topic but since metformin was not given in the options, we can exclude that.
Also, metformin are unlicensed for use in PCOS and women need to be counselled
C
before initiating therapy. Because it is currently unlicensed for use in PCOS, PLAB is
unlikely to ask this.
n
Laparoscopic drilling is a treatment for infertility for PCOS but is not first line.
io
COCP is a treatment for PCOS to regulate their irregular periods but it is not for
t
treatment of infertility
ua
Spironolactone (an antiandrogen) is used by endocrinologist to help with the effects of

hirsutism. But again, it will not help with infertility.
al

Ev

features
Symptoms:
losing weight
• oily skin, acne

1004
ovarian volume
General management
• Weight loss

• Weight loss
ovarian drilling
y
op
of PCOS
C
n
45. A 23 year old pregnant woman is admitted at 38 weeks gestation with a history of an
io
eclamptic fit at home. Her blood pressure is 155/90 mmHg. She is conscious and
observations are stable. What is the SINGLE most appropriate IV therapy to prevent
t
further fits?
ua
A. Clomethiazole
B. Diazepam
al
C. Labetalol
D. Magnesium sulphate
Ev
E. Phenytoin
Eclampsia



1005
46. A 30 year old female who has had 3 previous miscarriages, all before 10 weeks
gestation. Antiphospholipid syndrome has been diagnosed. She now presents to the
antenatal clinic asking if there is any treatment that she could have that could prevent
another miscarriage. What is the SINGLE most appropriate management?
A. Aspirin
B. Corticosteroids
D. Folate
E. No treatment available
The diagnosis here is antiphospholipid syndrome in which case aspirin plus heparin is
indicated. As there is no option for both aspirin and heparin, pick aspirin.
y
op
C
n
io

t

ua
al
and fetal morbidity
Ev

47. A 42 year old overweight smoker complains of heavy periods. An ultrasound scan
reveals a normal uterus. She would like a long term treatment with minimal side
effects that would offer treatment for the menorrhagia and provide contraception
although she is still unsure if she would like children in the future. What is the SINGLE

C. Levonorgestrel intra-uterine system
D. Progestogen implant
E. Copper intrauterine contraceptive device
1006
Among the options levonorgestrel intra-uterine system (Mirena coil) is the best
treatment to reduce menorrhagia. It is currently first-line treatment for menorrhagia in
the UK.
Combined oral contraceptive pills can do the job as well but she has already stated that
she would want a long term treatment with minimal side effects. Thus levonorgestrel
intra-uterine system would be the most appropriate.
Copper intrauterine contraceptive device and progestogen implants are more prone to
have irregular heavy bleedings compared to levonorgestrel intra-uterine system
(Mirena coil).
Endometrial ablation does affect fertility and is not an appropriate management for a
woman who may still want children in the future.
48. A 16 year old girl who is normally fit and healthy attends her GP complaining of very
y
painful menstrual periods. She has a regular 28 day menstrual cycle. She denies being
op
sexually active. What is the SINGLE most appropriate management?
A. Tranexamic acid
C
n
E. Mefenamic acid
io
Dysmenorrhoea is very common among this age group. Mefenamic acid is usually the
t
first tried management as the pain during periods may sometimes lessen over the next
ua
couple of months to years.
Dysmenorrhoea
al
Dysmenorrhoea can be divided into two:

• Primary dysmenorrhoea: the pain has no obvious organic cause.
Ev
• Secondary dysmenorrhoea: the pain is due to an underlying condition.
Primary dysmenorrhoea
• Management:
• NSAIDs such as mefenamic acid with each period is usually the first
tried treatment
• Combined oral contraceptive pills are used second line if the only
symptom is pain
• Mirena IUS demonstrates benefit
Secondary dysmenorrhoea
• Common aetiology
• Endometriosis
• Adenomyosis
• PID
• Management → Treat the underlying condition
1007
49. A 38 year old female with lymphoma was treated with chemotherapy. She says she has
been amenorrheic for the last 8 months. Lab results show:

Prolactin 13 ng/mL
An FSH was repeated 4 weeks later was still elevated.
A. Menopause
C. Prolactinoma
D. Hypothyroidism
y
The diagnosis of premature ovarian failure usually needs two raised levels of FSH
op
(more than 40 IU/L) taken at least four weeks apart. In this question, since she is
amenorrheic with raised FSH and LH and a normal prolactin level, the most likely
diagnosis would be premature ovarian failure. Women with premature ovarian failure
C
also have low estradiol (usually < 50 pmol/l).

n
io

t

ua
Causes
al

Ev
• Radiation
Presentation

2. Infertility
• Hot flashes
• Night sweats
• Irritability
• Dyspareunia
• Vaginal dryness
1008
Tests:
FSH levels:
diagnostic

Management:
y
op
Important Notes:
C
n
io
t
periods and can't become pregnant

ua
50. A 31 year old woman who is currently 39 weeks gestation attends the antenatal day
unit feeling very unwell with sudden onset of epigastric pain associated with nausea
al
and vomiting. She has a temperature of 36.7°C and her blood pressure is 155/100
mmHg. Her liver enzymes are raised and her other blood results are as follows:
Ev
Haemoglobin 82 g/L

C. Cholecystitis
D. HELLP syndrome
E. Acute hepatitis
HELLP syndrome
1009
(LP).
Signs and Symptoms:

Management
• Delivery
y
op
• Although platelet levels may be very low, platelet infusions are only required if
bleeding, or for surgery and <40 C
abdomen for the past 12 hours. She has some vaginal spotting a couple of hours ago.
On examination, abdomen is tender, and cervical os is closed. An ultrasound scan
n
shows fetal heart beat. What is the SINGLE most likely diagnosis?
io
t
ua
al
A short summary of types of miscarriages that are commonly asked in PLAB

Ev
Threatened miscarriage → Vaginal bleeding + fetal heart seen. Cervical os is closed
Missed miscarriage (delayed miscarriage) → Dead fetus before 20 weeks without the
symptoms of expulsion. May or may not have vaginal bleeding. Cervical os is closed.
Inevitable miscarriage → Cervical os opened and bleeding
Incomplete miscarriage - Not all products of conception have been expelled
Complete miscarriage - Everything has been expelled
and severe acne on her face. There is also thinning of hair. Blood test reveals elevated
insulin levels, elevated LH levels and moderately elevated testosterone levels. What is
the SINGLE most appropriate diagnostic test to confirm the diagnosis?
1010
A. CT abdomen
B. Ultrasound pelvis
C. Chest X-ray
D. MRI pituitary
E. Prolactin levels
T he most likely diagnosis here is Polycystic ovarian syndrome (PCOS). Elevated insulin
levels, elevated LH levels and moderately elevated testosterone levels can be seen in
PCOS. The scenario of acne on her face points towards an excess of androgens
(Hirsutism, alopecia, acne are all manifestations of hyperandrogenism). And not to
mention that her initial complaint was infertility which is one of the diagnostic criterion
for PCOS.
y
Ultrasound pelvis is the most appropriate as seeing 12 or more follicles on the ovaries
op
can help make the diagnosis.

C
features
n
io

t
Symptoms:
ua

al

losing weight
Ev
• oily skin, acne


ovarian volume
General management
• Weight loss

• Weight loss
1011
ovarian drilling

of PCOS
53. A 31 year old woman has vaginal spotting after her last intercourse which was a day
ago. Her last menstrual period was 10 days ago and she usually has a regular 28 day
menstrual cycle. A cervical smear performed 6 months ago was shown to be normal. A
speculum examination shows cervical ectropion which does not bleed on touch. What
y
op
B. Cervical smear
C. Endocervical swab
C
D. Reassurance
E. Serum estradiol
n
There is no screening test needed for cervical ectropion as cervical ectropion is not
io
linked to the development of cervical cancer or any other condition that causes cancer.
Treatment can be offered if the cervical ectropion is causing problems such as bleeding
t
or pain during or after sex. However in this case, the cervix is not bleeding on touch
ua
thus no treatment is needed.
Cervical ectropion
al

Ev

on COCP)
without odour
1012
54. A 25 year old primigravida at 30 weeks' gestation comes to the maternity unit stating
that 3 hours ago she had a gush of clear fluid from her vagina. She has no uterine
contractions. She has a pulse rate of 94 beats/minute and a temperature of 38.4°C.
opened. Her blood test show:
Haemoglobin 115 g/L

CRP 253
A. Endometritis
B. Chorioamnionitis
D. Pyelonephritis
y
op
Fever, maternal tachycardia, tenderness suprapubically and purulent vaginal discharge
with history of ruptured membranes points towards chorioamnionitis.
C
There is no indication of miscarriage here which is characterised by vaginal blood loss.
n
Although endometritis is a possibility, this is a more common complication in the
io
postpartum period.
t
Chorioamnionitis
ua

membrane rupture.
al
Ev

• Fever
55. A 64 year old woman has been treated for breast cancer with tamoxifen. What SINGLE
medication should be added to her regime?
A. Bisphosphonates
B. Calcium
C. Vitamin D
D. Calcitonin
E. Phosphate binders
1013
There is actually no guideline that says any of the above medication should be started
as an adjuvant to her regime. However, given the choices provided, bisphosphonates is
probably the best choice as it is shown in some studies to reduce the risk of bone
metastasis in breast cancers.
56. A 68 year old nulliparous woman presents to her general practitioner with a six month
history of poorly-localised abdominal discomfort and a constant feeling of bloatedness.
On pelvic examination you find a nontender, 7 cm, solid, irregular, fixed, left adnexal
mass. Her last examination was 1 year ago, which was normal, and it included a normal
pap smear. What is the SINGLE most appropriate initial investigation?
A. CA-125
B. CA15-3
C. CA19-9
D. CEA
E. AFP
y
This is a classic presentation of ovarian cancer
op
Concerns should be raised with any pelvic mass that is identified after menopause.
Ovaries in the postmenopausal age group should be atrophic, and anytime they are
C
enlarged, the suspicion of ovarian cancer arises.
The term “nulliparous” was thrown into the question to help guide you towards the
n
suspicion of ovarian cancer as nulliparity is a risk factor.
io
In a woman of this age with persistent symptoms of abdominal discomfort and

t
bloating it is essential to consider the possibility of ovarian cancer. Due to the

ua
nonspecific nature of symptoms of this disease, you should have a low threshold for
initiating investigations. Serum CA125 is a tumour marker that is used in the
investigation of possible ovarian cancer, though it is not 100% sensitive or specific for
al
this disease.
Ev
NICE guidelines state that serum CA 125 should be performed if a woman - especially if
aged 50 years old or over - has any of the following symptoms on a regular basis:
• abdominal distension or 'bloating'
• early satiety or loss of appetite
• pelvic or abdominal pain
• increased urinary urgency and/or frequency
57. A 33 year old lady attends the obstetric assessment unit with a history of a a positive
pregnancy test and bleeding from her vagina for the last two days. Her last menstrual
period is 8 weeks ago. On speculum examination, the cervical os is closed but blood is
seen in the vault. What is the SINGLE most appropriate next step to determine the
viability of the fetus?
A. Transvaginal Ultrasound
B. Serum β-hCG
C. Urinary β-hCG
D. Abdominal Ultrasound
1014
E. Cardiotocography (CTG)
A transvaginal ultrasound is most specific to identify the viability of the fetus.
58. A 48 year old lady presents with itching, redness, bloody discharge and ulceration
around her nipple. The lesion appears to be red and scaly. What is the SINGLE most
likely diagnosis?

B. Fibroadenosis
C. Breast abscess
D. Duct papilloma
E. Fat necrosis
Paget Disease of the Breast/Nipple
This is an uncommon breast malignancy with a generally better prognosis than

infiltrating ductal carcinoma. The lesion is pruritic and appears red and scaly often
y
located in the nipple spreading to the areola. The skin appearance can mimic
op
dermatitis like eczema or psoriasis.
The nipple may become inverted and discharge may occur.
C
n
io
period
t
ua
Breast abscess → is suggested by a fluctuant lump, hot and tender, acute presentation
often in puerperium, chronic after antibiotics.
al
Duct papilloma → is suggested by bleeding from nipple.

Ev
Fat necrosis → is suggested by a firm and solitary localized lump.
59. A 32 year old multigravida at 32 weeks' gestation is woken up in the middle of the
night with a pool of blood. She has no pain or uterine contractions. Fetal heart tones
are regular at 145 beats/min. Examination of the uterus shows the fetus to be in
transverse lie. She has a pulse of 120 beats/minute, a blood pressure of 84/55 mmHg
and a respiratory rate of 29 breaths/minute. What is the the SINGLE most likely
diagnosis?

B. Placenta accreta
C. Placenta praevia
D. Preterm labor
E. Vasa praevia
Placenta praevia
1015
segment.
Risk factors
Clinical features
y
op
C
Diagnosis
n
io
60. A 24 year old lady presents to the Early Pregnancy Unit with vaginal spotting and mild
left-sided abdominal pain. Her last menstrual period was 8 weeks ago. A pregnancy
t
test done in the GP clinic was positive. She has a transvaginal ultrasound scan, which is
ua
reported as 'inconclusive'. Serum human chorionic gonadotropin (hCG) is 1400 IU/litre.

al

Ev
A. Fibroids
B. Ectopic pregnancy
C. Complete miscarriage
D. Threatened miscarriage
E. Incomplete miscarriage
The diagnosis here is ectopic pregnancy. The first clue here is the gestational age → 8
weeks. Ectopic pregnancies would usually present around 6-8 weeks from start of last
period as it is then that they are large enough to stretch the fallopian tubes thus
causing pain. The stretching of the fallopian tubes is also the reason why they may
sometimes experience cervical motion tenderness on a vaginal examination.
The second clue here is the unilateral abdominal pain. This gives us a clue that the
pathology is towards one side rather than in the middle.
The remaining choices are far less likely to be the correct answer
1016
Fibroids → In the past, fibroids could be the cause of an inconclusive scan as they may
obstruct the view of the gestational sac. However, with the modern transvaginal scan
this is no longer the case. And thus ectopic pregnancies are a more likely diagnosis
here.
Complete miscarriage - Is when all products of conception has been expelled. This is
unlikely the case as she has only suffered a mild vaginal bleeding (vaginal spotting).
Threatened miscarriage → Presents with vaginal bleeding + fetal heart is seen. A

diagnosis of threatened miscarriage cannot be made without seeing a viable fetus on
an ultrasound scan.
Incomplete miscarriage → Not all products of conception have been expelled. This
means that products of conception would still be visible on an ultrasound scan.
Ectopic pregnancy
y
op
Clinical features
C
n
io
t

ua
Management:
al

Ev

laparotomy.
61. A 33 year old female presents with sudden severe colicky abdominal pain at her right
iliac fossa. The pain is severe and has worsen intermittently over the last few hours.
The pain radiates to her back and pelvis. She has also been vomiting and feeling
nauseous since the pain started. A tender, mobile mass is felt at the right iliac fossa on
A. Pelvic inflammatory disease

B. Appendicitis
C. Ovarian torsion
D. Constipation
E. Gastroenteritis
1017
The likely diagnosis here is ovarian torsion. Although ovarian torsion cannot be
diagnosed clinically as it is often diagnosed in theatre during a laparoscopy, the
question writers want you to consider ovarian torsion as part of your differential
diagnosis as it is one of the important gynaecologic emergencies. It is quite rare and
only accounts for about 3% of gynaecologic emergencies however it is important to
consider it especially given that this patient has a tender mobile mass at the right iliac
fossa.
In clinical practice, appendicitis would also be part of your differential. If there was a
history of an ovarian mass or if a ultrasound pelvis was done which found an ovarian
mass, then the surgeons would refer her to to the gynaecology team to rule out an
ovarian torsion.
Ovarian torsion presents with sudden onset of sharp, unilateral lower abdominal pain
often with nausea and vomiting.
In the reproductive years, regular growth of large corpus luteal cysts are a risk factor
for rotation. Basically, any enlargement of the ovary is a risk factor towards an ovarian
y
torsion.
op
The definitive diagnosis is often made in the theatre as ovarian torsion is difficult to
diagnose accurately and operation is often performed before the diagnosis is made.
C
62. A 32 year old rhesus negative woman whose previous pregnancy was complicated by
rhesus isoimmunisation, now presents with vaginal spotting at 37 weeks. Her
n
pregnancy has otherwise been normal. Her partner is rhesus positive. What is the
io

t
A. Kleihauer-Betke test
ua
B. Coagulation profile
C. Recheck mother’s rhesus status
D. Assess fetal middle cerebral artery on ultrasound
al
E. Fetal blood sampling

Ev
You would have to understand rhesus isoimmunization fully before you can proceed
with this question. Firstly, the mother is already isoimmunized. This means that she has
developed antibodies towards fetal red cells.
A Kleihauer-Betke test would be useless at this point of time as the whole reason we
do Kleihauer-Betke test is to determine how much Rh immunoglobulin to give to the
patient to PREVENT Isoimmunization. In this question, the women already is already
isoimmunized! There is no point in giving Rh immunoglobulins to an already
isoimmunised patient Kleihauer-Betke test would be appropriate in her first pregnancy
before she developed immunity.
There is no need to recheck mother’s rhesus status as this would have been checked
several times in her last pregnancy and this pregnancy.
Fetal blood sampling is an option but is only indicated if the peak systolic velocity (PSV)
of the middle cerebral artery (MCA) is abnormal.
1018
Thus, the answer to this question is assess fetal middle cerebral artery on ultrasound.
By doing so we can assess severity of fetal anaemia.
Rhesus isoimmunization (immune hydrops)

Occurs when a maternal antibody response is mounted against fetal red cells. These
immunoglobulin (IgG) antibodies cross the placenta and cause fetal red blood cell
destruction. The ensuing anaemia, if severe, precipitates fetal hydrops, which is often
referred to as immune hydrops.
If the mother is already isoimmunized, part of the management includes a

measurement of the peak systolic velocity (PSV) of the fetal middle cerebral artery
(MCA) seen on ultrasound about once a week. If this is abnormal, fetal blood sampling
is indicated, with blood available for transfusion.
Rhesus negative pregnancy
A basic understanding of the pathophysiology is essential to understand Rhesus

negative pregnancies.
y
If a Rh -ve mother delivers a Rh +ve child a leak of fetal red blood cells may occur, this
op
causes anti-D IgG antibodies to form in mother. In later pregnancies these antibodies
can cross placenta and cause haemolysis in fetus.
C
Prevention
• test for anti-D antibodies in all Rh -ve mothers at booking
• NICE (2008) advise giving anti-D to non-sensitised Rh -ve mothers at 28 and 34
n
weeks
io
• anti-D is prophylaxis - once sensitization has occurred it is irreversible

t
Anti-D immunoglobulin should be given as soon as possible (but always within 72

ua
hours) in the following situations:

• delivery of a Rh +ve infant, whether live or stillborn
• any termination of pregnancy
al
• miscarriage if gestation is > 12 weeks

Ev
• external cephalic version

• antepartum haemorrhage
• amniocentesis, chorionic villus sampling, fetal blood sampling
Affected fetus
• oedematous (hydrops fetalis, as liver devoted to RBC production albumin falls)
• jaundice, anaemia, hepatosplenomegaly
• treatment: transfusions, UV phototherapy
63. A 27 year old presents with left sided abdominal pain and vaginal spotting. Her last
menstrual period was 7 weeks ago. Abdomen was tender to palpate and cervical
motion tenderness was noticed on examination. Transvaginal ultrasound scan was
performed which showed an empty uterus. Serum human chorionic gonadotropin
(hCG) is 1200 IU/litre. Blood pressure is 110/65 mmHg, heart rate is 80 bpm and
1019
A. Immediate laparotomy
B. Laparoscopy
C. Discharge home
D. CT abdomen
E. Methotrexate
It is clear here that she has an ectopic pregnancy.
As she is haemodynamically stable, a laparoscopic approach to the surgical

management of tubal pregnancy is warranted.
Laparotomy would be the choice if the patient is clearly haemodynamically unstable.

The reason for this is laparotomy is quicker than a laparoscopy.
the criteria below:
y
op
• Serum hCG less than 1500 IU/litre
C
n
Ectopic pregnancy
io

t
ua
Clinical features
al
Ev
Management:

laparotomy.
gestation. She was admitted because she had of a show and has regular and painful
1020
uterine contractions. Her cervix is now 10 cm dilated and she has started pushing.
What stage of labour is she in?
A. First stage
B. Second stage
C. Third stage
D. Fourth stage
E. Latent phase
Labour may be divided into three stages

• stage 1: from the onset of true labour to when the cervix is fully dilated. It is
divided into a latent and an active phase.
Latent phase → begins with onset of regular contractions and ends with the
acceleration of cervical dilation.
Active phase → begins with cervical dilation acceleration, usually at 3-4 cm of
dilation, ending with complete cervical dilation.
• stage 2: from full dilation to delivery of the fetus
• stage 3: from delivery of fetus to when the placenta and membranes have
y
been completely delivered
Signs of labour include

• regular and painful uterine contractions
op
C
• a show (shedding of mucous plug)
• rupture of the membranes (not always)
• shortening and dilation of the cervix
n
io
65. A 38 week pregnant woman has sudden onset of uterine pain and vaginal bleeding. Her
uterus is tender and hard. She has no previous history of a lower segment caesarean
t
section. Fetal distress is noted on CTG. Her blood pressure is 95/60 mmHg. What is the
ua
SINGLE most likely cause of her symptoms?
A. Preeclampsia
al

Ev
D. Placenta praevia
E. Vasa praevia
Placental abruption


• multiparity
• maternal trauma
Clinical features
1021
66. A 32 year old woman, primigravida and now 39 weeks gestation attends the antenatal
day unit with sudden onset of epigastric pain associated with nausea and vomiting. On
physical examination, there is right upper quadrant tenderness. Her temperature is
36.8°C, Blood pressure is 165/95, heart rate 90 bpm and respiratory rate 19/min. Her
blood tests show:
y
Haemoglobin 87 g/L
op
Alanine transferase 219 U/L
Aspartate transaminase 180 U/L
C
Lactate dehydrogenase 720 U/L

n
io

t
C. Cholecystitis
ua
D. HELLP syndrome
E. Acute hepatitis
al
Increased LDH level suggest haemolysis. The decreased haemoglobin level, elevated
liver enzymes and low platelets give rise to the diagnosis of HELLP syndrome. This is
Ev
supported by the fact that she has a high BP and has epigastric pain that is associated
with nausea and vomiting.
HELLP syndrome

(LP).
Signs and Symptoms:

1022
Management
• Delivery
• Although platelet levels may be very low, platelet infusions are only required if
bleeding, or for surgery and <40
67. A 29 year old primigravida at 28 weeks gestation is found to have a blood pressure of
150/100 mmHg on routine check-up. She is not experiencing any symptoms and feels
well. A urinalysis shows 1+ protein. What is the SINGLE best management for her?
A. Labetalol
B. Hydralazine
C. Indapamide
D. Losartan
y
op
Labetalol is the most studied antihypertensive in pregnancy with the safest profile.
According to current NHS guidelines IV magnesium sulphate is administered for:

C
• Women in a critical care setting who have severe hypertension or severe pre-
eclampsia who have or previously had an eclamptic fit.
• Women with severe preeclampsia who are in a critical care setting if birth is
n
planned within 24 hours.
io
This woman, although having a very high blood pressure, does not fulfill the criteria for
t
magnesium sulphate treatment

ua
Pre-eclampsia
al
Pre-eclampsia is a condition seen after 20 weeks gestation characterised by pregnancy-

induced hypertension in association with proteinuria (> 0.3g / 24 hours). Oedema used
Ev
to be third element of the classic triad but is now often not included in the definition as
it is not specific.
Risk factors
• > 40 years old or teenager
• Family history (mother or sister)
• Obesity
• Nulliparity
• Pre-existing hypertension or diabetes
• Previous history of pre-eclampsia
Symptoms
• Headache
• Visual disturbance (flashing lights)
• Epigastric or right upper quadrant (RUQ) pain
1023
• Rapid oedema (especially on the face)
Note: Symptoms usually occur only with severe disease
Signs
• Hypertension (>140/90; severe if >/=160/110).
• Proteinuria (>300 mg in 24 hours)
• Hyperreflexia
Management
• Guidelines recommend treating blood pressure > 150/100 mmHg although
many clinicians have a lower threshold.
• Oral labetalol is now first-line following the 2010 NICE guidelines. Nifedipine
and hydralazine would also be an option if PLAB part 1 has them in the
question.
• Cure is delivery of placenta. Thus the definitive management is to deliver baby.
Unfortunately this needs to be balanced out with gestation as we would not
want to deliver a baby too prematurely.
y
op
68. A 25 year old women had an emergency lower segment caesarean section after a
prolonged labour 4 days ago due to fetal distress. She now complains of intermittent
vaginal bleeding and foul smelling discharge. Her O2 saturation is 98% on air, blood
C
pressure is 124/88 mmHg, pulse of 84bpm and temperature of 37.9C. The midwife
tells you that the obstetric surgeons had difficulty in removing the placenta from the
uterus in the operating theatre. What is the SINGLE most likely complication of this
n
women from the caesarean section?
io
A. Retained products of conception

t
B. Aspiration pneumonitis
ua
C. Endometritis
D. Uterine rupture
E. Disseminated intravascular coagulation
al
Although retained products of conception may be an option. Endometritis fits more

Ev
perfectly with the scenario given the fever, the history of an emergency C-section,
prolonged labour and the foul discharge.
Uterine infection (endometritis)

Is the most common cause of postpartum fever
Predisposing factors
• Emergency caesarean section
• Prelabour rupture of membranes
• Prolonged labour
• Multiple pelvic examinations.
• Internal fetal monitoring - use of scalp electrodes/ intrauterine
Signs and symptoms

• Fever usually in proportion to the extent of infection.
• Foul smelling, profuse, and bloody discharge.
• Tender bulky uterus on abdominal examination
1024
Management
• Antibiotics
69. A 33 year old woman complains of waking in the middle of the night to rush to the
toilet. Most of the time, she does not make it to the toilet in time and she wets herself.
This is the common presentation of urge incontinence. See below for the description of
the types of urinary incontinence:
Urge incontinence / overactive bladder (OAB) → is due to detrusor over activity.
y
Common complain is “when I have to go to the toilet, I really have to go” or “I have the
op
desire to pass urine and sometimes urine leaks before I have time to get to the toilet”
Stress incontinence → leaking small amounts of urine when coughing or laughing.

C
muscles.
n
Mixed incontinence → a mix of both urge and stress incontinence
io
Overflow incontinence → involuntary release of urine from an overfull urinary

t
bladder, often in the absence of any urge to urinate. Occurs in people who have a
ua
blockage of the bladder outlet (benign prostatic hyperplasia, prostate cancer, or

narrowing of the urethra), or when the muscle that expels urine from the bladder is
too weak to empty the bladder normally.
al
Urethrovaginal fistula → Opening between vagina and urethra. Common complaint is

Ev
“ there is continual leakage of urine from my vagina” or “my vagina has a foul smell”.
70. A 29 year old woman has chronic pelvic pain, and dysmenorrhoea over the last 9
months in which she takes NSAIDS for. She complains of pain during sexual
intercourse. A trial of combined oral contraceptive pills was given but there was no
reported benefit. A pelvic ultrasound was reported as normal. What is the SINGLE most
A. Laparoscopy
B. CA 125
C. Computed tomography scan
E. Hysteroscopy
The likely diagnosis here is endometriosis. A laparoscopy would is the gold standard to
diagnosis it. A laparoscopy would also be able to identify any other pathologies that
may be causing the chronic pelvic pain such as adhesions.
1025
Serum CA125 may be seen elevated with endometriosis, however there is no evidence
that it is a useful screening test for this endometriosis
Endometriosis

adenomyosis.
Clinical features
• Subfertility
y
op
Investigation
C
Management
n
io
t
ua
fertility rates
al
Surgery
Ev

71. A 33 year old lady presents with clear, watery discharge. On examination, a red ring is
seen around the cervical os. The diagnosis of cervical ectropion is made. What is the
SINGLE most accurate description to define cervical ectropion?
A. Replacement of stratified squamous epithelium that normally lines ectocervix by

columnar epithelium
B. Replacement of columnar epithelium that normally lines ectocervix by stratified
squamous epithelium
C. Columnar epithelium migrating from ectocervix to endocervix
D. Cuboidal cells being replaced by squamous epithelial cells
E. Non-keratinized stratified squamous epithelium being replaced by simple cuboidal
epithelium
Cervical ectropion
1026
on COCP)
without odour
y
op
72. A 23 year old woman is followed up for 6 weeks after a surgical procedure to evacuate
the products of conception in the uterus following a miscarriage. The histology shows
changes consistent with a hydatidiform mole. What is the SINGLE most appropriate
C
investigations in this case?
A. Abdominal Ultrasound
n
B. Maternal karyotype
io
C. Paternal blood group

D. Serum B-hCG
t
E. Transvaginal US
ua
Serum and urine samples of hCG concentrations are extremely important.

al
In hydatidiform mole, hCG levels are likely to be raised excessively (especially in

Ev
complete moles). Management would involve surgical evacuation, after which the hCG
levels are expected to return to a normal, non-pregnant level.
We would like the hCG to go down towards a normal level but If it plateaued or if hCG
levels rise after evacuation, chemotherapy is indicated.
This is the reason it is so important not to get pregnant during the time that hCG levels
are decreasing as if one were to get pregnant, hCG levels would increase again and we
will not know if it is due to the hydatidiform mole or the new pregnancy.
Gestational Trophoblastic Disease
Gestational trophoblastic disease (GTD) covers a spectrum of diseases caused by

overgrowth of the placenta. It ranges from molar pregnancies to malignant conditions
1027
such as choriocarcinoma. If there is any evidence of persistence of GTD the condition is
referred to as gestational trophoblastic neoplasia (GTN).
GTD is classified as follows:
Premalignant - hydatidiform mole

• Complete hydatidiform mole (CHM)
• Partial hydatidiform mole (PHM)
Malignant - gestational trophoblastic neoplasia (GTN)

• Invasive mole
• Choriocarcinoma
• Placental site trophoblastic tumour (PSTT)
• Epithelioid trophoblastic tumour (ETT)
The classification of GTD is less in important. An exam of this level usually does not
require you to know details of types of GTD.
y
Features:
op
• Hyperemesis
• Irregular first-trimester vaginal bleeding
• Uterus large for dates
C
• Vaginal passage of vesicles containing products of conception
• Serum hCG is excessively high with complete moles, but levels may be within
the normal range for partial moles.
n
io
Ultrasound findings of a complete mole

• ‘Snowstorm’ appearance of mixed echogenicity, representing hydropic villi and
t
intrauterine haemorrhage
ua
• Large theca lutein cysts
Management of Hydatidiform mole:

al
• Surgical evacuation (Suction curettage)

• Note that histological examination of products of conception is
Ev
essential to confirm diagnosis

• Two-weekly serum and urine samples until hCG concentrations are normal.
• Women should be advised not to conceive until hCG level has been
normal for 6 months
• Barrier contraception should be used until serum hCG is normal
• COCP and HRT are safe to use after hCG levels have returned to normal
Management of gestational trophoblastic neoplasia (GTN)

This is unlikely to be asked in detail in PLAB 1 due to the complexity of the
management. But you do need to know it involves chemotherapy
73. A 65 year old female patient diagnosed with breast cancer was given tamoxifen. Which
SINGLE symptoms would be the most alarming?
A. Fluid retention
B. Vaginal bleeding
C. Hot flushes
1028
D. Headache and dizziness
E. Weight gain
Tamoxifen is a risk factor for endometrial carcinoma. So vaginal bleeding will be of

concern for us.
Endometrial cancer
Endometrial cancer is classically seen in post-menopausal women

• Obesity
• Nulliparity
• Early menarche
• Late menopause
• Unopposed oestrogen. The addition of a progestogen to oestrogen reduces
this risk (e.g. In HRT). The BNF states that the additional risk is eliminated if a
y
• Diabetes mellitus
op
• Tamoxifen
• Polycystic ovarian syndrome C
Features
n
Investigation
io
• First-line investigation is trans-vaginal ultrasound - a normal endometrial

t
• Hysteroscopy with endometrial biopsy gives the definitive diagnosis

ua
Management
al
74. A 33 year old woman, with 3 previous normal vaginal deliveries complains of urinary
Ev
leakage when she plays tennis or coughs. What is the SINGLE most likely diagnosis?
Urge incontinence / overactive bladder (OAB) → is due to detrusor over activity.

Common complain is “when I have to go to the toilet, I really have to go” or “I have the
desire to pass urine and sometimes urine leaks before I have time to get to the toilet”
Stress incontinence → leaking small amounts of urine when coughing or laughing.

muscles.
Mixed incontinence → a mix of both urge and stress incontinence
1029
Overflow incontinence → involuntary release of urine from an overfull urinary
bladder, often in the absence of any urge to urinate. Occurs in people who have a
blockage of the bladder outlet (benign prostatic hyperplasia, prostate cancer, or
narrowing of the urethra), or when the muscle that expels urine from the bladder is
too weak to empty the bladder normally.
Urethrovaginal fistula → Opening between vagina and urethra. Common complaint is

“ there is continual leakage of urine from my vagina” or “my vagina has a foul smell”.
75. A 23 year old lady with a BMI of 30 complains of facial hair growth and has a history of
amenorrhoea.
Lab results show:

Prolactin 60 ng/mL
y
op
Progesterone 100 ng/dL

C
B. Pregnancy
n
C. Cushing’s disease
io
D. Congenital adrenal hyperplasia

t
ua
Obese, amenorrhoea and hirsutism are consistent with Polycystic ovary syndrome
(PCOS).
al
She has high LH, normal FSH and slightly high prolactin levels. These are not diagnostic
for PCOS but among the choices given, the lab results reflect PCOS.
Ev
Serum LH levels are elevated in approximately 40% of women with PCOS, owing to
increased production (increased amplitude and frequency of LH pulses)
Prolactin may be mildly elevated in PCOS. It has been described by some authors that
women with polycystic ovary syndrome (PCOS) may have elevated levels of prolactin.
However, a diagnostic criterion is to rule out other possible causes, including
hyperprolactinemia. This is because high prolactin levels have many of the same
symptoms as PCOS and needs to be ruled out to be certain of a PCOS diagnosis.

features
1030
Symptoms:
losing weight
• oily skin, acne

volume
y
General management
op
• Weight loss

C
• Weight loss
n
io

t

ua
ovarian drilling

al
Ev
of PCOS
76. A 23 year old woman comes to the A&E with severe lower abdominal pain. Her blood
pressure is 120/85 mmHg and temperature is 38.9°C. The abdomen is rigid. Cervical
excitation is noticed during a vaginal examination. She gave a past history of pelvic
inflammatory disease 3 years ago which was successfully treated with antibiotics. What
A. Ultrasound
B. Abdomen X-ray
C. CT Abdomen
1031
ovarian abscess).
Note that even if no PID history was given in this question, an ultrasound scan would
still be the most appropriate as it would rule out ovarian cyst or adnexal torsion.
77. A 37 year old woman has irregular menstrual cycles for the last 9 months accompanied
by hot flashes and night sweats. She also complains of pain during sexual intercourse.

B. Serum FSH
y
C. Serum progesterone concentration
op
E. Anti-Mullerian hormone C
premature ovarian failure
n
Note that Anti-Mullerian hormone can also be used to help diagnose premature
io
ovarian failure as it is a measure of reduced ovarian reserve. However, it is usually only

undertaken if there is diagnostic uncertainty.
t
ua

al

Ev
Causes
• Radiation
Presentation

2. Infertility
1032
• Hot flashes
• Night sweats
• Irritability
• Dyspareunia
• Vaginal dryness
Tests:
FSH levels:
diagnostic
y
op
Management:
C
n
io
Important Notes:
t

ua
al

Ev
78. A 28 year old woman at 31 weeks gestation attends the antenatal clinic. Her full blood
count was taken when she was 28 weeks which results shows:

A. Offer folate supplements

B. Offer iron dextran
C. Offer ferrous sulphate
D. Explain that this is physiological haemodynamic anaemia
1033
E. Offer vitamin B12 supplements
The values of anaemia differ in pregnancy as compared to a non pregnant women.
The British Committee for Standards in Haematology has defined anaemia in

pregnancy as the following values
Hb levels of:
<11.0g/dl in the first trimester
<10.5 g/dl in the second and third trimesters
<10.0 g/dl in the postpartum period.
Since her Hb level is above 10.5g/dL, she does not need iron tablets.
This is one of the questions that differ in terms of how you answer in PLAB and how
you would act in real life. While the British Committee of Standards in Haematology
have gave strict definitions of when to give iron tablets, in real life, many gynaecologist
would have prescribed iron tablets in this case. Again, it depends on hospital
guidelines. But for the PLAB test, it is important to follow national guidelines.
y
op
abdomen for the past couple of hours. She has some vaginal spotting. On examination,
abdomen is tender, and cervical os is closed. A transvaginal ultrasound scan shows no
C
fetal heartbeat or fetal activity. What is the SINGLE most likely diagnosis?
n
io
t
ua
It is important to note that missed miscarriage may present with heavy vaginal
bleeding or none at all. But if there is no fetal heart seen, at this stage of pregnancy, it
al
is a missed miscarriage. Note that in normal pregnancy the fetal heart is seen usually at
6 weeks. So you should not be diagnosing a missed miscarriage if a 4 week pregnant
Ev
lady has no fetal heartbeat seen on a transvaginal ultrasound.
There are more specific ultrasound criterias to diagnose missed miscarriage but are
beyond what will be asked in PLAB part 1.
1034
80. A 50 year old woman who was treated for breast cancer 3 years ago now presents with
increased thirst and confusion. She has recently become very drowsy. What is the
SINGLE most likely metabolic abnormality?
A. Hypercalcaemia
B. Hyperkalaemia
C. Hypoglycaemia
D. Hyperglycaemia
E. Hypocalcaemia
The most common causes of hypercalcaemia are malignancy and primary

hyperparathyroidism. In this scenario, breast cancer has metastasis to the bone. Bone
metastases are one of most common causes of hypercalcaemia.
This is a hot topic in PLAB and you should be able to associate breast cancer with bone
metastases and hypercalcaemia.
y
Clinical features of hypercalcaemia
op
• Neurologic: Hypercalcemia results in decreased mental activity such as lethargy and
confusion.
C
constipation and anorexia but commonly gives nausea and vomiting as well.
n
io
• Renal: Hypercalcemia results in polyuria and polydipsia because of the induction of

nephrogenic diabetes insipidus. Calcium also precipitates in the kidney, resulting in
t
both kidney stones as well as nephrolithiasis.

ua
• Cardiovascular: Hypertension occurs in 30-50% of those with hypercalcemia. The

ECG will show a short QT.
al
81. A 60 year old woman complains of bleeding after having intercourse. In the past
Ev
month, she has had 3 episodes of mild vaginal bleeding. She had regular withdrawal
bleeds until 8 years ago and has not had a bleeding since. Her last cervical smear was 3
years ago which showed no abnormalities. A pelvic examination shows a normal cervix
and vagina. What is the SINGLE most likely diagnosis?
A. Cervical cancer
B. Endometrial cancer
C. Ovarian cancer
D. Breast cancer
E. Vaginal cancer
arranged.
1035
Endometrial cancer

not the only cause, it must be excluded.

• Obesity
• Nulliparity
• early menarche
• late menopause
y
• tamoxifen
op
Features
C
Investigation
n
io

t
ua
Management
al
82. A 55 year old woman presents with a sore nipple. She has clear fluid discharge from
her left nipple over the past few months which has recently been a little blood stained.
Ev
On examination, her left nipple is dry cracked and has scaly skin. Her right nipple
appears normal and no lymphadenopathy was seen. What is the SINGLE most likely
diagnosis?

B. Fibroadenosis
C. Breast abscess
D. Duct papilloma
E. Fat necrosis

infiltrating ductal carcinoma. The lesion is pruritic and appears red and scaly often
located in the nipple
spreading to the areola. The skin appearance can mimic dermatitis like eczema or
psoriasis.
1036
period
83. A 28 year old female has had 3 consecutive miscarriages. All her miscarriages
happened before 10 weeks. Cytogenetic analysis performed on products of conception
y
of the third miscarriage shows no abnormalities. She comes to clinic inquiring if it is
op
safe for another pregnancy. What is the SINGLE most appropriate investigation to
perform? C
A. Antiphospholipid antibodies
B. Parental peripheral blood karyotyping
C. Progesterone levels
n
D. Luteinizing hormone levels
io
E. Transvaginal Ultrasound for cervical length

t
ua

al
Parental peripheral blood karyotyping of both partners should be performed in couples

with recurrent miscarriage where testing of products of conception reports an
Ev
unbalanced structural chromosomal abnormality. But in this case,cytogenetic analysis

performed on products of conception shows no abnormalities thus the there is no
need for parental karyotyping.
There is currently no satisfactory objective test that can identify women with cervical
weakness in the non-pregnant state. Hence, the option for transvaginal ultrasound for
cervical length is incorrect.

1037
and fetal morbidity

84. A 23 year old woman has had intermittent abdominal pain in the left iliac fossa for 6
week. Over the past 48 hours, she had had severe abdominal pain and fever of 39°C.
Urine BHC is negative. She also has cervical motion tenderness. Pelvic ultrasound
shows a 6.5 cm multilocular complex adnexal mass. Her WBC and CRP are raised. What
y
A. Endometriosis
op
B. Dermoid cyst
D. Ectopic pregnancy
C
E. Tubo - ovarian abscess
This question describes Tubo-ovarian abscess which is a complication of PID.

n
io
The ultrasound findings of a tubo-ovarian abscess usually show a multilocular complex

adnexal mass with debris, septations, and irregular thick walls
t
ua
Endometriosis → Does not present as a mass on US
Ovarian cancer → Unlikely as she is very young and she has signs of an infection
al
Ectopic pregnancy → Unlikely as urine BHC is negative and signs and symptoms point
Ev
towards PID
Dermoid cyst → Typically an ovarian dermoid is seen as a cystic adnexal mass with
some mural components. Most lesions are unilocular.
taken which tested positive for Neisseria gonorrhoeae. What is the SINGLE most
A. Erythromycin 500 mg PO for 5 days

B. Ceftriaxone 500 mg as a single IM dose
C. Metronidazole 400 mg PO twice daily for 14 days
D. Azithromycin 1g PO for 7 days
E. Azithromycin 1g PO and ceftriaxone 500mg IM stat
1038

• Azithromycin 1g PO and ceftriaxone 500mg IM stat
86. Which of the following is true regarding treatment with tamoxifen?
A. Increased risk of endometrial carcinoma

B. Increased risk of breast cancer
C. Increased risk of osteoporosis
D. Increased risk of ovarian carcinoma
y
E. Increased risk of cervical cancer
op
Tamoxifen is a risk factor for endometrial carcinoma.
C
Tamoxifen is a Selective estrogen receptor modulator (SERM) used in the treatment of
breast cancer. Even though it acts as an antagonist in breast tissue, it acts as an agonist
on the endometrium thus there is an increased risk of endometrial cancer. There is
n
also an Increased risk of thromboembolism. One benefit from tamoxifen is that it
io
prevents bone loss by acting as an estrogen receptor agonist.

t
Endometrial cancer
ua
Endometrial cancer is classically seen in post-menopausal women

al

• Obesity
Ev
• Nulliparity
• Early menarche
• Late menopause
• Unopposed oestrogen. The addition of a progestogen to oestrogen reduces
this risk (e.g. In HRT). The BNF states that the additional risk is eliminated if a
• Diabetes mellitus
• Tamoxifen
• Polycystic ovarian syndrome
Features
Investigation
• First-line investigation is trans-vaginal ultrasound - a normal endometrial
• Hysteroscopy with endometrial biopsy gives the definitive diagnosis
1039
Management
87. A 26 year old woman with regular menses and her 28 year old partner comes to the GP
surgery complaining of primary infertility. She and her husband have been trying to
achieve pregnancy for more than 2 years and have been unsuccessful. She has a
regular 28 day menstrual cycle. Her BMI is 23. What is the SINGLE most appropriate
investigation to determine if she is ovulating?
A. Basal body temperature charts

B. Cervical smear
C. Day 2 follicular stimulating hormone (FSH) and luteinizing hormone (LH)
E. Endometrial biopsy
Day 21 progesterone which is the mid-luteal progesterone level is used to assess

ovulation. If this is low, it may need repeating, as ovulation does not occur every
y
month.
op
FSH and LH should be measured if there is menstrual irregularity: High levels may
suggest poor ovarian function. A comparatively high LH level relative to FSH level can
C
occur in PCOS. In reality, we would obtain FSH, LH and mid-luteal progesterone levels.
But for the purpose of examination, always pick mid-luteal progesterone levels as the
answer when it comes to infertility investigations.
n
io
Basal body temperature charts are not recommended to predict ovulation, as they are
unreliable.
t
ua
Female Infertility
Causes of female infertility

al
• Unexplained
• Ovulation failure
Ev
• Tubal damage
• Note that a history of pelvic inflammatory disease is highly suggestive
of damage to tubes
Basic investigations
• Serum progesterone 7 days prior to expected next period. Meaning day 21 of a
28 day cycle. However, this day will need to be adjusted for different lengths of
cycle
• This is also termed “Mid-luteal progesterone level “
• It is done to assess ovulation:
• If low, it may need repeating, as ovulation does not occur
every month
88. A 32 year old woman presents at 39 weeks gestation of her third pregnancy. She
reports having a vaginal loss of clear viscous fluids 4 days ago. She did not attend the
delivery suite as she had planned for a home birth. She feels feverish and sweaty.
1040
opened. She has a temperature of 38.3°C. Fetal tachycardia is noted on a
cardiotocograph. Her blood test show:
Haemoglobin 105 g/L

CRP 219
A. Endometritis
B. Chorioamnionitis
D. Pyelonephritis
Prolonged rupture of membranes (PROM) is a risk factor for chorioamnionitis.
y
op
Although endometritis is a possibility, this is a more common complication in the
postpartum period. C
Chorioamnionitis
n
membrane rupture.
t io

ua
• Fever
al
Ev
89. A 42 year old woman complaints of heavy bleeding and prolonged menstrual period.
She is not planning for children at the moment as she already has 2 children. She
smokes 20 cigarettes a day. What is the SINGLE most appropriate management?
A. Tranexamic acid
C. Mefenamic acid
Levonorgestrel intra-uterine system (Mirena) is the first-line pharmaceutical treatment

for menorrhagia. Smoking is not a contraindication for use for the mirena coil.
1041
90. A 30 year old pregnant lady, 34 weeks gestation, presents with severe lower abdominal
pain which started several hours ago with excessive per vaginum bleeding. The
abdominal pain is constant. What is the SINGLE most appropriate initial investigations?
C. Computed tomography scan of pelvis
D. D-dimer
E. Kleihauer-Betke test
Although the clinical scenario here looks like placenta abruptio, one important
diagnosis that we need to rule out as well is a placenta praevia for which initial the
investigation of choice is an ultrasound. An ultrasound cannot exclude placental
abruption, which is a clinical diagnosis.
With every episode of bleeding, a rhesus-negative woman should have a Kleihauer test
and be given prophylactic anti-D immunoglobulin however this is should not be done in
an acute setting as the first investigation. A Kleihauer-Betke test can wait.
y
op
It is worth mentioning that if the question was asking for the SINGLE best action and a
CTG was within one of the options, that would usually be the best action. The reason
C
behind this is placenta abruption is part of the differential and if the CTG shows fetal
distress, the baby would need to be delivered immediately. There is no time to wait
around for an ultrasound.
n
io
91. A 32 year old woman was induced at 41+ weeks gestation. She had a long labour which
lasted 24 hours. The uterus is still palpable above the umbilicus after an hour from
t
delivering the placenta. What is the SINGLE most likely predisposing factor for
ua
postpartum haemorrhage
A. Atonic uterus
al
B. Cervical or vaginal trauma

C. Ruptured uterus
Ev
D. Fibroid uterus
E. Disseminated intravascular coagulation (DIC)
Uterine Atony
Uterine Atony is the most common cause of excessive postpartum bleeding.
Risk Factors for uterine atony include:

• Rapid or protracted labour (most common),
• Chorioamnionitis
• Overdistended uterus → e.g. Macrosomic baby
Clinical Findings
A soft uterus palpable above the umbilicus.
Management
Uterine massage and uterotonic agents ( e.g., oxytocin)
1042
92. A 33 year old woman who is 11 weeks gestation attends her booking appointment with
questions regarding vaccinations in pregnancy. What vaccines are offered to women
who are pregnant in the UK?
A. Pertussis, diphtheria and pneumococcal vaccines

B. Influenza and rubella vaccines
C. Influenza and pneumococcal vaccines
D. Pertussis and rubella vaccines
E. Influenza and pertussis vaccines
There are two vaccines which are specifically recommended for pregnant women: the
flu (influenza) vaccine and the whooping cough (pertussis) vaccine.
For whooping cough the best time to get vaccinated is between 20 weeks and 32
weeks gestation. This maximises protection for the baby through antibody transfer.
Note that there is actually no whooping cough-only (pertussis) vaccine. The vaccine is
usually combined with polio, diphtheria and tetanus.
y
op
93. A 22 year old woman who was diagnosed with a missed miscarriage a week ago now
presents to the hospital because of abdominal pain. She says she passed a small fetus
and a number of clots this morning. On examination, abdomen is tender, and cervical
C
os is opened. A transvaginal ultrasound scan shows products of conception still present
in the uterus. What is the SINGLE most likely diagnosis?
n
io
t
ua
Products of conception still present in the uterus defines incomplete miscarriage.

al
Some products of conception have been expelled but some still remain thus giving the
diagnosis of incomplete miscarriage. There is usually pain and vaginal bleeding and the
Ev
cervical os is open.
94. A 33 year old lady who is now 28 weeks pregnant comes to the antenatal clinic with
pain and swelling on her left calf muscle. On physical examination, she has distension
1043
of superficial veins and increase skin temperature at affected area. What is the SINGLE
A. Aspirin
B. Paracetamol
D. Warfarin
E. Alteplase
Any pregnant woman with symptoms and/or signs suggestive of venous

thromboembolism should have objective testing performed expeditiously and
treatment with low-molecular-weight heparin (LMWH) given until the diagnosis is
excluded by objective testing, unless treatment is strongly contraindicated
95. A 22 year old woman who was diagnosed with a missed miscarriage a week ago
presented to the hospital last night with abdominal pain and vaginal bleeding. Since
then, she has passed a small fetus. A transvaginal ultrasound was repeated which
showed an empty uterus. The pain is slowly easing off. What is the SINGLE most likely
y
diagnosis?
op
C
n
io
Complete miscarriage is a spontaneous abortion with expulsion of the entire fetus

through the cervix. Pain and uterine contractions cease after fetus has been expelled.
t
An ultrasound scan would show an empty uterus.

ua

al

Ev
96. A 24 year old woman was prescribed azithromycin for a sexually transmitted infection.
She has been using a form of contraception for the past year. Which SINGLE most likely
contraceptive method is likely to be affected by azithromycin?
A. Mirena coil (IUS)

B. Intrauterine Contraceptive Device (IUCD)
D. Combined oral contraceptive pill (COCP)
1044
It was previously thought that hepatic enzyme inhibitor drugs (like azithromycin) may
affect COCP but was later discovered that that there were no significant interaction
Only drugs like rifampicin have an interaction with COCP. Combined hormonal
contraceptives are less reliable during treatment with rifampicin. Breakthrough
bleeding and spotting are common, and pregnancies have occurred when patient is on
rifampicin and COCP.
97. A 28 year old primiparous woman, with no previous history of infection with herpes
zoster, is 18 week pregnant. She had significant contact with a young girl with
widespread chicken pox. Serum stored from an antenatal booking blood sample was
sent for serology and came back negative for VZV IgG. What is the SINGLE most
A. Aciclovir PO
B. Aciclovir IV +IVIG
y
C. Aciclovir IV
op
D. Reassure
E. IVIG only C
Chickenpox exposure in pregnancy
Chickenpox is caused by primary infection with varicella zoster virus. Shingles is
reactivation of dormant virus in dorsal root ganglion. In pregnancy there is a risk to
n
both the mother and also the fetus, a syndrome now termed fetal varicella syndrome
io
Fetal varicella syndrome (FVS)

t
• risk of FVS following maternal varicella exposure is around 1% if occurs before

ua
20 weeks gestation studies have shown a very small number of cases occurring
between 20-28 weeks gestation and none following 28 weeks
• features of FVS include skin scarring, eye defects (microphthalmia), limb
al
hypoplasia, microcephaly and learning disabilities

Ev
Other risks to the fetus

• shingles in infancy: 1-2% risk if maternal exposure in the second or third
trimester severe neonatal varicella: if mother develops rash between 5 days
before and 2 days after birth there is a risk of neonatal varicella, which may be
fatal to the newborn child in around 20% of cases
Management of chickenpox exposure

PLAB usually would test your knowledge on 3 of these scenarios:
1. Who gets checked for Varicella antibodies?

If the woman’s immunity to chickenpox is unknown and if there is any doubt
about previous infection, or if there is no previous history of chickenpox or
shingles, serum should be tested for VZV IgG. This can usually be performed
within 24–48 hours and often within a few hours if the laboratory can access
serum stored from an antenatal booking blood sample. At least 80% of women
tested will have VZV IgG and can be reassured.
1045
2. Who gets VZIG?
If the pregnant woman is not immune to VZV and she has had a significant
exposure, she should be offered VZIG as soon as possible. VZIG is effective
when given up to 10 days after contact.
Note: If the immune status of the woman is unknown, the administration of

VZIG can be delayed until serology results are available
Note: VZIG has no therapeutic benefit once chickenpox has developed and
should therefore not be used in pregnant women who have developed a
chickenpox rash.
3. Who gets oral aciclovir?

Oral aciclovir should be prescribed for pregnant women with chickenpox if
they present within 24 hours of the onset of the rash and if they are 20+0
weeks of gestation or beyond.
In summary:
y
1. Pregnant exposed to chicken pox → Check women’s immunity (previous
op
infection, varicella antibodies)
2. Not immuned → Administer VZIG
3. If develop chicken pox rash → Administer oral aciclovir
C
98. A 19 year old lady with primary amenorrhoea has the following blood results:
n
io

Prolactin 13 ng/mL
t
ua

al

Ev
C. Absent uterus
D. Absent ovaries
E. Turner’s syndrome
A normal LH, FSH, oestradiol and prolactin rule outs polycystic ovary syndrome (PCOS).
In PCOS there would be an increased LH, increased FSH, normal oestradiol. The LH:FSH
ratio is usually 2:1 or 3:1.
In premature ovarian failure, LH and FSH is raised.
Turner syndrome and absent ovary would have bloods with a low estradiol, high FSH
and LH.
Thus, the only answer possible here would be absent uterus.
everytime she laughs or coughs. She has had 2 previous vaginal deliveries. Urine
1046
culture results have come back as negative. Her urodynamic study is normal. What is
A. Antibiotics
C. Systemic oestrogen
D. Duloxetine
Stress incontinence is a leak of small amounts of urine when coughing or laughing.

muscles. The next management here would pelvic floor exercises. Loss of weight, and
reducing caffeine are other lifestyle modifications that could be effective but were not
given in this questions.
100. A 29 year old woman who is 33 weeks gestation attends the antenatal clinic. Her full
blood count was taken when she was 28 weeks as part of an antenatal screen for
anaemia. The results shows:
y
op
Mean cell volume 75 fL C
She is asymptomatic. What is the SINGLE most appropriate management?
n
B. Iron supplements
io
C. Blood transfusion
t
ua

al

Ev
Hb levels of:
Since her Hb level is below 10.5g/dL, she does needs iron tablets.
emergency cesarean section at 38 weeks for dystocia. She is now experiencing severe
abdominal pain and profuse vaginal bleeding .Her heart rate is 130 bpm, blood
pressure is 95/55, oxygen saturation is 98% and temperature is 37.1°C. Reduced
variability and late decelerations are now seen on CTG. What is the SINGLE most likely
diagnosis?
A. Endometritis
B. Urinary tract infection
1047
C. Placenta praevia
E. Uterine rupture
Uterine rupture
Definition
Uterine rupture is complete separation of the wall of the pregnant uterus with or
without expulsion of the fetus that endangers the life of the mother or the fetus, or
both.
This usually occurs during labour but has been reported antenatally.
Signs and symptoms

• Tenderness over sites of previous uterine scars
• Fetal parts may be easily palpable
• Fetus not palpable on vaginal examination
• Vaginal bleeding may be evident
y
• Signs of maternal shock may be present.
op
CTG may show fetal distress and change in apparent uterine activity (contractions may
seem to disappear on the tocograph).
C
Risk Factors
The most common risk factors are:
n
• previous C-section or other uterine surgeries
io
• excessive oxytocin stimulation

• failure to recognize obstructed labour.
t
ua
Women considering the options for birth after a previous caesarean should be
informed that planned VBAC carries a risk of uterine rupture of 22–74/10,000
al
Diagnosis
• Confirmation of the diagnosis is made by surgical exploration of the uterus and
Ev
identifying the tear
Management
• Urgent laparotomy to deliver fetus and repair uterus
102. A 23 year old woman presents with offensive vaginal discharge. A vaginal pH was taken
and reads 5.6. What is the SINGLE most likely causative organism?
C. Candida albicans
Bacterial vaginosis
1048

active women.
Features
• vaginal discharge: 'fishy', offensive
• asymptomatic in 50%

y
op
• vaginal pH > 5.5
Management
C
n
io

t
103. A 42 year old complains of heavy blood loss per vaginam. An ultrasound shows uterine
ua
thickness of more than 12mm. There was no polyps or benign lesions seen on
hysteroscopy. Histology reveals the diagnosis of simple endometrial hyperplasia
without atypia. She has two children and is not currently planning for another child.
al
What is the SINGLE most appropriate management for her?

Ev
A. Mefenamic acid
Endometrial hyperplasia
Endometrial hyperplasia is a premalignant condition, that can predispose to, or be
associated with, endometrial carcinoma.
It is characterized by the overgrowth of endometrial cells and is caused by excess

unopposed oestrogens, either endogenous or exogenous, similar to endometrial
cancer,
with which it shares a common aetiology
Presentation
1049
• Usually presents clinically as abnormal vaginal bleeding (intermenstrual,
polymenorrhoea or postmenopausal)
• It is most commonly diagnosed in women over 40 years old with irregular
menstruations or in those with post-menopausal bleeding
Investigation:
• Transvaginal ultrasound (TVUS) is an appropriate first-line procedure. In
general, the thicker the endometrium seen on ultrasound, the higher the
likelihood of important pathology, ie endometrial cancer, being present.
• Endometrial sampling or formal endometrial curettage is necessary for
diagnosis.
Management of endometrial hyperplasia (no atypia)

It largely depends on age of patient, histology, symptoms, and desire for retaining
fertility.
Both continuous oral progestogens and levonorgestrel-releasing intrauterine system

are effective in achieving regression of endometrial hyperplasia without atypia.
y
However, the Royal College of Obstetrics and Gynaecology (Green-top Guideline No.
op
67, 2016) clearly states that levonorgestrel-releasing intrauterine system should be the
first-line medical treatment because compared with oral progestogens it has a higher
disease regression rate with a more favourable bleeding profile and it is associated
C
with fewer adverse effects.
104. A 55 year old woman presents with dysuria, frequency and urinary incontinence. She
n
complains of dyspareunia. Urine culture has been done and is sterile. What is the
io

t
A. Oral antibiotics
ua
B. Topical antibiotics
C. Topical oestrogen
D. Oral oestrogen
al
E. Hormone replacement therapy

Ev
One of the many causes of dyspareunia is atrophic vaginitis (vaginal atrophy).
Oestrogen deficiency after menopause causes atrophic changes within the urogenital
tract and is associated with urinary symptoms, such as frequency, urgency, nocturia,
incontinence, and recurrent infection. These symptoms may coexist with those of
vaginal atrophy, including dyspareunia, itching, burning, and dryness.
Intravaginal oestrogens is the treatment choice for vaginal atrophy. Alongside helping
with the vaginal dryness, it can help with symptoms of urgency, urge incontinence,
frequency, and nocturia.
Note as the symptoms are local (in the vagina), you would not prescribe a systemic
hormone like oral oestrogen or HRT. Thus options D and E are out.
vaginal discharge and also complains of deep dyspareunia. Her last menstrual period
1050
was 2 weeks ago. Cervical motion tenderness was noted when doing a pelvic
examination. She has a temperature of 38.2°C. Her blood tests show:

CRP 55 mg/L
She has no significant past medical history. What is the SINGLE most likely diagnosis?
A. Endometriosis
B. Acute pelvic inflammatory disease
D. Appendicitis
E. Pelvic congestion syndrome

y
endocervix.
Causative organisms
op
C

n
• Age < 25
io
• Previous STIs
t

ua

al
Features
Ev
• Fever
Investigation
• Screen for Chlamydia and Gonorrhoea
Management
the same as PID.

1051
days.



Complications
• Infertility - the risk may be as high as 10-20% after a single episode
y
• Chronic pelvic pain
op
• Ectopic pregnancy
106. A 22 year old pregnant woman is admitted at 37 weeks gestation with a blood pressure
C
of 165/95 mmHg and symptoms of visual disturbances and epigastric pain. A few hours
after administration of IV magnesium sulphate and IV labetalol, she develops a fit.
What is the SINGLE most appropriate IV therapy to prevent further fits?
n
io
A. Hydralazine
B. Diazepam
t
C. Further bolus of Labetalol

ua
D. Further bolus of Magnesium sulphate

E. Phenytoin
al
Eclampsia
Ev



1052
107. An 17 year old girl with primary amenorrhoea complains of severe abdominal pain
every 4 to 8 weeks which is now getting worse. On abdominal examination, a lower
abdominal mass is felt. What is the SINGLE most likely diagnosis?
B. Ovarian carcinoma
C. Haematometra
D. Endometriosis
E. Adenomyosis
The key word here is primary amenorrhoea. This means that she has never had her
menses before. The only possibility among the options given that could cause primary
amenorrhoea is haematometra.
Primary amenorrhoea and cyclical pain indicate haematometra. Haematometra is an

accumulation of blood within the uterus.
One of the causes of haematometra that is associated with primary amenorrhoea is an
y
imperforate hymen or a transverse vaginal septum. In an imperforate hymen, one
op
might have a bluish bulging membrane visible at the introitus. A transverse vaginal
septum may present with a possible abdominal mass.
C
bleeding. A vulvovaginal swab was taken which tested positive for Neisseria
gonorrhoeae. What is the SINGLE most appropriate management?
n
io
A. Erythromycin
B. Ceftriaxone only
t
C. Metronidazole
ua
D. Azithromycin only
E. Azithromycin and ceftriaxone
al
Ev


• Azithromycin 1g PO and ceftriaxone 500mg IM stat
109. A 34 year old primigravida who is 30 week pregnant presents to the labor ward with a
history of constant abdominal pain for the last few hours. She also gives a history of
having lost a cupful of fresh blood per vagina before the pain started. An irritable,
tender uterus is seen on examination. Fetal heart is seen on ultrasound scan. What is
1053
B. Antepartum haemorrhage
C. Placenta praevia
D. Vasa praevia
E. Early labour
Though presentation indicates placental abruption, there are no signs and features
suggestive of preeclampsia. The more accurate answer would be B. Antepartum
haemorrhage as it also encompasses placental abruption.
Placental abruption

y
op
• multiparity
• maternal trauma
C
Clinical features
n
io

t
ua
al
Ev
110. A 49 year old woman who is a heavy smoker is worried of ovarian cancer because her
mother died of ovarian cancer. She has been on hormone replacement therapy. She
used to take combined oral contraceptive pills for a few years during her twenties. She
underwent menopause when she was 46 years old. What is the SINGLE most relevant
risk factor for ovarian cancer in her case?
A. Smoking
B. Family history
E. Early menopause
Family history of ovarian cancer is an important risk factor. Women with a first-degree
relative with ovarian cancer have 3-4 times the risk of developing the disease.
1054
However, only 10% of cases arise in women with a positive family history.
Smoking is a risk factor but it is not as important as family history. It is estimated that
2% of cases may be caused by smoking.[
HRT increases the risk of developing ovarian cancer but only slightly and it is only seen
in patients using HRT for more than five years. About 1% of cases may be linked with
taking HRT. Further studies are needed to ascertain the exact risk.
Ovarian Cancer Risk factors

• Family history: mutations of the BRCA1 or the BRCA2 gene
• Many ovulations: early menarche, late menopause, nulliparity
• Age → incidence increases with age
Protective factors against ovarian cancer:

• COCP
• Pregnancy
y
111. A 28 year old woman has been admitted at 38 weeks gestation. Her blood pressure is
op
190/120 mmHg and proteinuria is seen on urinalysis. Immediately following admission,
she has a grand-mal seizure. What is the SINGLE most appropriate initial management?
C
A. Diazepam intravenously
B. Fetal CTG
C. Hydralazine intravenously
n
D. Immediate delivery
io
E. Magnesium sulphate intravenously

t
Intravenous magnesium sulphate is the most important initial management.

ua
Fetal CTG is also needed, but MgSO4 comes first.

al
Delivery should follow after stabilising mother.

Ev
Eclampsia



1055
112. A 38 year old female attends the clinic because of issues of infertility. She also says that
her last period was 9 months. Lab results show:

Prolactin 12 ng/mL
An FSH was repeated 4 weeks later which was still elevated.
C. Prolactinoma
D. Hypothyroidism
y
op
C

n
io

t

ua
Causes
al

Ev
• Radiation
Presentation

2. Infertility
• Hot flashes
• Night sweats
• Irritability
• Dyspareunia
• Vaginal dryness
1056
Tests:
FSH levels:
diagnostic

Management:
y
op
Important Notes:
C
n
io
t

ua
113. A 24 year old woman has right iliac fossa pain and vaiginal spotting. Her last menstrual
period was 8 weeks ago. She is apyrexial. A bimanual examination reveals cervical
al
excitation. What is the SINGLE most likely diagnosis?

Ev
B. Salpingitis
C. Endometriosis
D. Ovarian torsion
E. Ovarian tumour
Salpingitis, endometriosis, ovarian torsions and ovarian tumours are not associated
with amenorrhoea.
Patients pelvic pain and vaginal bleeding with peritonism and cervical excitation
obviously points towards ectopic pregnancy.
Ectopic pregnancy
Clinical features
1057
Management:

laparotomy.
y
114. A 39 year old woman has not had her period for 10 months. She feels well but is
op
anxious as her mother had an early menopause. What is the SINGLE most appropriate
initial investigation? C
B. Serum FSH/LH
C. Serum progesterone con concentration
n
io
E. Transvaginal Ultrasound
t
Serum FSH/LH would be useful. In actual fact, serum follicle-stimulating hormone (FSH)
ua
measurement alone can be used to diagnose premature ovarian failure.

al

Ev
Causes
• Radiation
Presentation

2. Infertility
1058
• Hot flashes
• Night sweats
• Irritability
• Dyspareunia
• Vaginal dryness
Tests:
FSH levels:
diagnostic

y
Management:
op
C

n
io
Important Notes:
t
ua

al
Ev

115. A 38 year old woman requires long term contraception. She has 3 healthy children and
does not wish to have any more children in the near future. Upon examination she is
found to have extensive fibroids which are distorting her uterine cavity. She says she
has difficulty in remembering to take pills. What is the SINGLE best contraception for
her?
A. Implanon (Nexplanon®)
B. Depo-Provera
C. Intra-Uterine System (Mirena®)
D. Combined oral contraceptive pills (COCP)
E. Progestin-Only pill
1059
The key to choosing the correct answer here is to take into account firstly the fact that
this woman has fibroids which are distorting her uterine cavity and the fact that any
type of pill is not an option.
Depo-provera, even though a viable option, isn’t the correct option for this stem.
Depo-provera has a dosing interval of 13-16 weeks which is a pretty long time, but out
of all the options is not the longest time.
An Intra-Uterine System (Mirena) which is the favorite of British examiners is not the
choice here because insertion of an intra-uterine device would be difficult due to the
fibroid uterus that is distorting the uterine cavity. The use of an Intra-Uterine System
(Mirena) is contraindicated in women with congenital or acquired uterine anomaly,
including fibroids if they distort the uterine cavity.
In actual fact and in clinical practice, having a large fibroid that distorts the uterine
cavity is NOT a contraindication for insertion of a mirena coil. Gynaecologist still use
mirena coils for patients with large fibroids that distort the cavity. While it is true that
the risk of expulsion of a mirena coil is greater if the fibroid is large, there is no reason
y
why it cannot first be tried. However, for the purpose of the exam, since the prescribing
op
leaflet does mention that it is contraindicated if fibroids distort the uterine cavity,
please do not choose the mirena coil as the answer.
C
Nexplanon® is the only contraceptive implant on the UK market. Nexplanon® is a 4 cm
flexible rod containing 68 mg etonogestrel (a progestogen) which is released slowly
into the systemic circulation following subdermal insertion in the upper arm. It must be
n
removed after three years when it can be replaced immediately. Progestogen-only
io
subdermal implants (POSDIs) such as Nexplanon® are suitable for:

• Those who want a reliable but reversible form of contraception which does not
t
require daily vigilance or action at the time of intercourse.

ua
• Women who have contra-indications to oestrogen therapy
Choosing the correct contraceptive for the correct situation is something a lot of
al
students have problems with. Here are some useful contraception/abnormal uterine
bleeding clinchers for the PLAB 1 exam:
Ev
Young woman, not sexually active (don’t require contraception)

• Menorrhagia only - tranexamic acid
• Menorrhagia with dysmenorrhoea - mefenamic acid
• Menorrhagia/dysmenorrhoea/metrorrhagia (irregular menses) - COCP
Sexually active woman (require contraception)
• Menorrhagia/dysmenorrhoea or those suffering from fibroids (which do not
distort the uterine cavity) - IUS Mirena (first-line). These questions will also
mention possible contraindications for COCP like obesity/smoking/history of
thromboembolism etc.
• Woman with sickle cell disease and menorrhagia – Depo-provera IM
Emergency contraception
• Within 72 hours of unprotected sex: Levonelle pill
• Within 120 hours of unprotected sex: IUCD or ellaOne pill.
For postpartum contraception
• Breastfeeding mothers – COCP after 6 months.
• Non breastfeeding mothers - COCP after three weeks.
1060
• In both cases, during the period before they can start using COCP, they can use
male or female condoms and progesterone only preparations.
• IUS/IUCD can be inserted 48 hours after birth or 6 weeks later.
116. A 38 year old woman presents with itching around the breast and greenish foul
smelling discharge from the nipple. She had a similar episode a year ago. What is the
A. Breast abscess
B. Duct ectasia
C. Duct papilloma
D. Fat necrosis
E. Paget’s disease of nipple
Duct Ectasia is suggested by a green or brown nipple discharge.
The other options in this question do not present with greenish foul smelling discharge
from the nipple
y
op
C

n
io
Paget’s disease of nipple → is suggested by breast nipple ‘eczema’.

t
117. A 32 year old female who has completed her wants to know more about contraception
ua
and the risk of ectopic pregnancies. Which of the following contraceptive methods
increase the absolute risk of ectopic pregnancies?
al
A. Combined oral contraceptive pills (COCP)

B. Intrauterine system (Mirena coil)
Ev
C. Progestogen-only Pill (POP)

D. Progesterone-only implant (Nexplanon)
This question by the examiners is written purely to test your knowledge of absolute
and relative risk. You would need to know a little on the background of intrauterine
systems.
The absolute risk of ectopic pregnancy with the mirena coil is decreased but the
relative risk is increased. Meaning if you were to become pregnant while on the mirena
coil, the risk of it being an ectopic is higher as compared to if you were to become
pregnant while you were not on the mirena coil.
The risk of ectopic pregnancy when using IUDs is lower than when using no
contraception.
1061
The overall risk of ectopic pregnancy when using the IUD is very low, at about 1 in 1000
in 5 years.
If a woman becomes pregnant with the IUD in situ, the risk of ectopic pregnancy is
about 1 in 20.
118. A 24 year old woman with multiple sexual partners complains of lower abdominal pain,
deep dyspareunia and menstrual irregularities. On vaginal examination, cervical
excitation was noted. She has no significant past medical history. Which is the SINGLE
most likely cause of her symptoms?

B. Endometriosis
C. Fitz-Hugh-Curtis syndrome
D. Cervicitis
Multiple sexual partners are a risk factor for pelvic inflammatory disease. Women of
y
her age group (<25 years old) are of greater risk for pelvic inflammatory disease as they
op
are more sexually active during this period.
Other options are less likely because:

C
Endometriosis → Although chronic pelvic pain, deep dyspareunia and menstrual
irregularities could be seen in endometriosis. It is unlikely the given choice here as the
n
history of multiple sexual partners and cervical excitation do not match with this
io
answer
t
Fitz-Hugh-Curtis syndrome → is a complication of pelvic inflammatory disease (PID).

ua
Usually presents with an acute onset of right upper quadrant (RUQ) abdominal pain
aggravated by breathing, or coughing. This pain may be referred to the right shoulder
al
Cervicitis → Presents with discharge. Do not get confused between cervicitis and PID.
Infection at the cervix can eventually ascend to cause PID. But if the infection is purely
Ev
at the cervix, they will not present with menstrual irregularities and lower abdominal
pain as the infection has not ascended to involve the uterus, fallopian tubes, and
ovaries.
Asherman syndrome → are adhesions of the endometrium often associated with

dilation and curettage of the intrauterine cavity. It results in infertility. Often, they
experience menstrual irregularities. But in this question there is no relevant past
medical history meaning she did not have any dilation and curettage thus this option is
very unlikely.

endocervix.
Causative organisms
1062

• Age <25
• Previous STIs
Features
• fever
y
op
Investigation
• screen for Chlamydia and Gonorrhoea C
Management
n
io
the same as PID.

t

ua

days.
al

Ev



Complications
1063
emergency cesarean section at 39 weeks due to a breech fetus. She is now
experiencing severe abdominal pain and tenderness over the previous uterine scars.
CTG shows fetal distress and absent uterine contractility. What is the SINGLE most
likely diagnosis?
A. Endometritis
B. Placenta abruption
C. Uterine rupture
E. Placenta praevia
Uterine rupture
Definition
Uterine rupture is complete separation of the wall of the pregnant uterus with or
without expulsion of the fetus that endangers the life of the mother or the fetus, or
y
both.
op
This usually occurs during labour but has been reported antenatally.
C
Signs and symptoms
• Tenderness over sites of previous uterine scars
• Fetal parts may be easily palpable
n
• Fetus not palpable on vaginal examination
io
• Vaginal bleeding may be evident

• Signs of maternal shock may be present.
t
ua
CTG may show fetal distress and change in apparent uterine activity (contractions may
seem to disappear on the tocograph).
al
Risk Factors
The most common risk factors are:
Ev
• previous C-section or other uterine surgeries

• excessive oxytocin stimulation
• failure to recognize obstructed labour.
Women considering the options for birth after a previous caesarean should be
informed that planned VBAC carries a risk of uterine rupture of 22–74/10,000
Diagnosis
• Confirmation of the diagnosis is made by surgical exploration of the uterus and
identifying the tear
Management
• Urgent laparotomy to deliver fetus and repair uterus
120. A 33 year old 39 week pregnant nulliparous women with a previous history of
gestational hypertension is in labour. Her membranes had ruptured earlier in the day.
She was assessed by the midwife and her cervix was found to be soft, mid-position
1064
with an os 3 cm dilated. The fetus is in cephalic position. A vaginal examination was
performed 4 hours later and the cervical os still remains at 3 cm dilated.
Cardiotocography is reassuring and she is contracting less than three times in 10
minutes. What is the SINGLE most appropriate action?
A. Repeat vaginal examination in 4 hours

B. Amniotomy
C. Caesarean section
D. External rotation
E. IV syntocinon drip
There is obvious delay in the first stage of labour since there has been no cervical
change over the last 4 hours. Amniotomy and oxytocin infusion and reassessment in 2
hours should always be considered in nulliparous women. Since her waters have
already been broken. It would be appropriate to start oxytocin (syntocinon).
Some causes of poor progress in the 1st stage

• Inefficient uterine activity ( power → commonest cause)
y
• Malposition, malpresentation, or large baby (passenger)
op
• Inadequate pelvis (passage)
Oxytocin will increase the frequency and strength of her contractions.

C
121. A 21 year old woman had a recent suction curettage to evacuate the contents of the
uterus following a miscarriage. The histology shows changes consistent with a
n
hydatidiform mole. What is the SINGLE most appropriate advice to be given?
io

t
B. Barrier contraception should be used until serum hCG is normal

ua
C. COCP should be used until serum hCG is normal

D. HRT should be used until serum hCG is normal
E. No contraception needed after evacuation of contents of the uterus
al
Serum and urine samples of hCG concentrations are extremely important.

Ev
In hydatidiform mole, hCG levels are likely to be raised excessively (especially in

complete moles). Management would involve surgical evacuation, after which the hCG
levels are expected to return to a normal, non-pregnant level.
We would like the hCG to go down towards a normal level but If it plateaued or if hCG
levels rise after evacuation, chemotherapy is indicated.
This is the reason it is so important not to get pregnant during the time that hCG levels
are decreasing as if one were to get pregnant, hCG levels would increase again and we
will not know if it is due to the hydatidiform mole or the new pregnancy.
The best advice to give is use barrier contraception until serum hCG is normal.
1065


• Invasive mole
• Choriocarcinoma
y
Features:
• Hyperemesis
op
C
n
io

t

ua

al

Ev

normal for 6 months

122. A 34 year old female presents with a very strong foul smelling vaginal discharge. What
organism(s) could cause such a symptom?
1066
A. Chlamydia, Gonorrhea
B. Chlamydia, Gardnerella
C. Chlamydia, Gonorrhea, gardnerella
D. Gonorrhea, Gardnerella
E. Gardnerella only
Bacterial vaginosis and Trichomonas vaginalis can give foul smelling discharge.
In bacterial vaginosis the vaginal discharge is grey-white and has a “fishy” smell.
In trichomonas vaginalis, it can be a greenish and frothy along with vulvovaginitis i.e.
strawberry cervix.
The discharge of Chlamydia and Gonorrhea is not usually foul smelling.
Since Trichomoniasis is not present among the available choices, Gardnerella is the
answer.
y
op
Bacterial vaginosis
C

n
io

active women.
t
ua
Features
al
Ev

Management

123. A 31 year old woman, gravida 5 para 4, present to the emergency department with
vaginal bleeding. She has a history of amenorrhoea for 12 weeks. Pregnancy test was
done in the emergency department and it was positive. Symphyseal-fundal height
1067
measurement corresponds to 22 weeks gestation. Ultrasound of the pelvis reveals
bilateral cystic masses. No fetal parts are seen during the ultrasound examination. The
cervix is closed. Which is the SINGLE most likely diagnosis?
A. Tubal pregnancy
B. Endometriosis
The ultrasound findings of the bilateral cystic masses represents the large theca lutein
cysts. Uterus large for dates and the vaginal bleeding are typical features of
hydatidiform mole.

y
op

C
n
io

t
• Invasive mole
ua
• Choriocarcinoma
al
Ev
Features:
• Hyperemesis

1068
normal for 6 months

124. A 33 year old woman comes to the emergency department complaining of right sided
abdominal pain for the last day. She vomited once earlier today. She gives a history of
missing a period. A urine pregnancy test was found to be positive. A transvaginal
ultrasound scan reveals an empty uterus. On examination, she is found to be tender at
the right iliac fossa with no signs of peritonism. She is afebrile and observations are
y
stable. What is the SINGLE most appropriate next step in management?
A. Laparoscopy
B. Human chorionic gonadotropin (hCG) blood test
op
C
C. Repeat ultrasound in a week
D. Laparotomy
E. Culdocentesis
n
io
It is clear here that she has an ectopic pregnancy. The be more specific, this is a
presentation of an unruptured ectopic pregnancy. The fact that there are no signs of
t
peritonism, no shoulder tip pain or per vaginal bleeding and observations are normal
ua
means that a ruptured ectopic is unlikely.
As she is haemodynamically stable with severe right abdominal pain, a laparoscopic

al
approach to the surgical management of tubal pregnancy is warranted however we

would need to obtain a serum beta-hCG test first. With the results of the serum beta-
Ev
hCG, we would be able to plan the next step in management. If the serum beta-hCG
was less than 1500 IU/litre and patient is clinically stable with pain resolving, then we
would prefer expectant management where we would just observe. The reason behind
this, is that one cannot be sure of the diagnosis of an ectopic pregnancy when the
serum beta-hCG is less then 1500 IU/litre as it could very well be an intrauterine
pregnancy that is just too small to see on a scan at the moment. If a beta-hCG was
more than 1500 IU/litre, we would expect to see a gestational sac in the uterus.
Meaning if the beta-hCG was more than 1500 IU/litre and nothing can be found in the
uterus on a transvaginal ultrasound, the diagnosis of an ectopic can be certain.
Laparotomy would be the choice if the patient is clearly haemodynamically unstable.

The reason for this is laparotomy is quicker than a laparoscopy.
the criteria below:
1069
• Serum hCG less than 1500 IU/litre (most hospitals now use a cutoff of 5000
IU/litre)
Culdocentesis was previously used to diagnose a ruptured ectopic pregnancy by the

presence of free fluid in the pouch of Douglas. However, ultrasonography is
noninvasive and has largely replaced culdocentesis where available.
Ectopic pregnancy
Clinical features
y
op
C
n
io
Management:
t

ua

al
laparotomy.
Ev
125. A 34 year old pregnant woman, 11 weeks gestation, presents with vaginal bleeding.
She has been noted to be nauseas and vomiting for the past couple of weeks.
Symphyseal-fundal height measurement corresponds to a 18 week pregnant uterus.
Which is the SINGLE most likely diagnosis?
A. Tubal pregnancy
B. Endometriosis

1070


• Invasive mole
• Choriocarcinoma
Features:
• Hyperemesis
y
op
C

n
io
t
ua

al

Ev
normal for 6 months

126. A 66 year old woman had two episodes of post-coital vaginal bleeding in the last week.
She has not had any withdrawal bleeds for more than 12 years. Her last cervical smear
was 3 years ago which showed no abnormalities. What is the SINGLE most appropriate
initial action?
A. Repeat cervical smear

B. Topical oestrogen cream
1071
arranged.
Atrophic vaginitis could also cause postmenopausal bleeding or postcoital bleeding.

But it is more important to rule out endometrial cancer because of it’s seriousness.
Remember, postmenopausal bleeding is cancer until proved otherwise.
Endometrial cancer
y
op
not the only cause, it must be excluded. C
• Obesity
• Nulliparity
n
• early menarche
io
• late menopause
t
ua

• tamoxifen
al

Ev
Features
Investigation
Management
127. A 23 year old woman presents with offensive, homogenous grey-white vaginal
discharge. Clue cells are demonstrated on a saline smear. What is the SINGLE most
likely diagnosis?
A. Bacterial vaginosis
B. Trichomoniasis
1072
C. Candidiasis
D. Chlamydia infection
E. Neisseria gonorrhoeae infection
Bacterial vaginosis

active women.
Features
• vaginal discharge: 'fishy', offensive
y
• asymptomatic in 50%
op
C
• vaginal pH > 5.5
n
io
Management
t

ua

al
Ev
antibiotic to give?
A. Erythromycin 500 mg orally once a day for 5 days

B. Ceftriaxone 500 mg as a single intramuscular dose
C. Metronidazole 400 mg orally twice daily for 14 days
D. Azithromycin 1g for 7 days
E. Azithromycin 1g single oral dose

1073
129. A 32 year old primigravida at 28 weeks gestation presents with a blood pressure of
152/105 mmHg. A second blood pressure reading was taken 10 minutes later which
read 153/108 mmHg. She is asymptomatic and otherwise well. A urinalysis was
negative for protein. She has no history of high blood pressure in the past. What is the
SINGLE most likely management?
A. Indapamide
B. Hydralazine
C. Labetalol
D. Losartan
y
130. A 39 year old female was on combined oral contraceptive pills which she stopped 9
op
months ago. She has not had her periods since then. Lab results show:
Follicle-stimulating hormone (FSH) 55 U/L

C
Luteinizing Hormone (LH) 75 U/L
Prolactin 14 ng/mL
n
io

t
ua
B. Post pill amenorrhoea

C. Prolactinoma
D. Pregnancy
al

Ev

Causes
• Radiation
1074
Presentation

2. Infertility
• Hot flashes
• Night sweats
• Irritability
• Dyspareunia
• Vaginal dryness
Tests:
y
op
FSH levels:
C
diagnostic
n
io
t
ua
Management:
al

Ev
Important Notes:
131. A 41 year old woman presents with an offensive malodorous vaginal discharge. The
discharge is clear in colour and has a distinctive fishy odour. A vaginal pH was taken
and found to be 5.7. What is the SINGLE most likely causative organism?
1075
C. Candida albicans
Bacterial vaginosis and Trichomonas vaginalis can give foul smelling discharge.
Bacterial vaginosis which is mostly caused by an overgrowth of Gardnerella vaginalis

causes vaginal discharge which is grey-white and has a “fishy” smell. The characteristic
“fishy smell” is a clincher and one should pick Bacterial vaginosis (Gardnerella vaginalis)
as the answer.
In trichomonas vaginalis, it can be a greenish and frothy along with vulvovaginitis i.e.
strawberry cervix.
The discharge of Chlamydia and Gonorrhea is not usually foul smelling.
Candida albicans (vaginal candidiasis) has a white, 'cheesy' discharge. The discharge is
y
non-offensive.
Bacterial vaginosis
op
C
n
io

t
active women.
ua
Features
al

Ev

Management

1076
132. A 31 year old woman who is 32 weeks pregnant attends the antenatal clinic. Her full
blood count was taken when she was 28 weeks which results shows a Hb of 10.7 g/dL;
MCV=91. What is the SINGLE most appropriate management?
B. Ferrous sulphate
C. Iron dextran

Hb levels of:
y
op
Since her Hb level is above 10.5g/dL, she does not need iron tablets.
This is one of the questions that differ in terms of how you answer in PLAB and how
C
you would act in real life. While the British Committee of Standards in Haematology
have gave strict definitions of when to give iron tablets, in real life, many gynaecologist
would have prescribed iron tablets in this case. Again, it depends on hospital
n
guidelines. But for the PLAB test, it is important to follow national guidelines.
io
t
vaginal discharge and also complains of deep dyspareunia. A Urine HCG is negative.
ua
temperature of 38.4°C. Her blood tests show:
al

CRP 110 mg/L
Ev
She has no significant past medical history. What is the SINGLE most appropriate
antibiotic treatment?
A. Ofloxacin and metronidazole

B. Azithromycin
C. Azithromycin and ceftriaxone
D. Doxycycline
E. Clindamycin
OPTIONS FOR MANAGEMENT OF PID

Outpatient management of PID
• IM ceftriaxone stat plus oral doxycycline and oral metronidazole for 14 days; or
• Ofloxacin and metronidazole orally for 14 days
Inpatient management of PID
1077
• IV ceftriaxone and IV doxycycline followed by oral doxycycline and oral
metronidazole for 14 days; or
• IV ofloxacin and IV metronidazole for a total of 14 days

endocervix.
Causative organisms

• Age <25
• Previous STIs
y
op
• Post-partum endometritis C
Features
• fever
n
io

t
ua
Investigation
al
Management
Ev
the same as PID.

days.

1078

Complications
134. A 65 year old woman presents to the breast clinic having noticed that she has had a
blood stained discharge from the left nipple. She also has dry skin over the left areola
which resembles eczema. On examination, a blood stained discharge with dry flaky skin
is noted on the left areola and the nipple was ulcerated. What is the SINGLE most
y
A. Fine needle aspiration cytology
op
C. Punch biopsy
D. Open biopsy
C
E. Stereotactic biopsy
There is a suspicion of Paget’s disease of the breast/nipple here. These are usually
n
diagnosed by having a simple skin punch biopsy.
io

t
ua

infiltrating
ductal carcinoma. The lesion is pruritic and appears red and scaly often located in the
al
nipple
spreading to the areola. The skin appearance can mimic dermatitis like eczema or
Ev
psoriasis.
135. A 31 year old woman who had a normal delivery 4 weeks ago is complaining for feeling
tired. A full blood count was taken and results show:
Hb 9.3 g/dL
MCV 79 fL
B. Ferrous sulphate
C. Iron dextran
D. Iron infusion
E. No treatment required
1079
Iron deficiency anaemia is very common in pregnancy.

Hb levels of:
< 11.0g/dl in the first trimester
< 10.5 g/dl in the second and third trimesters
< 10.0 g/dl in the postpartum period.
Since her Hb level is below 10g/dL, she should be on oral iron.
136. A 43 year old woman who is currently 34 weeks pregnant presents with headache,
epigastric pain and nausea. She complains of flashing lights. A dipstick shows 2+
protein. Her heart rate is 115 beats/minute. She has a blood pressure of 158/105
mmHg. What is the SINGLE most appropriate initial management?
y
A. Oral labetalol
op
B. Magnesium sulphate
C. Corticosteroids
D. Emergency C-section
C
E. Mannitol
This lady has pre-eclampsia. The first clue in this question stems from her age. One of
n
the risk factors of preeclampsia is an age over 40 or a teenager. Basically, extremes of
io
both ages. Headaches, epigastric pain, flashing lights are all symptoms of preeclampsia
which is confirmed by having protein in the urine with a BP > 140/90.
t
ua
The first thing to do here is to lower the blood pressure. Management of pregnancy
with pre-eclampsia for moderate hypertension (150/100 to 159/109 mmHg) starts with
oral labetalol as first line treatment.
al
Magnesium sulphate is important here as well however labetalol oral should be given
Ev
first. Remember, the question is asking for the most appropriate INITIAL management.
Magnesium sulphate takes awhile to prepare. It is an intravenous medication and
usually needs consultant approval and also cardiac monitoring when giving the
intravenous MgS04. Oral labetalol does not require any of those and it is part of the
management as she is hypertensive in this stem.
When is magnesium sulphate the answer?

According to current NHS guidelines IV magnesium sulphate is administered for:
• Women in a critical care setting who have severe hypertension or severe pre-
eclampsia who have or previously had an eclamptic fit.
• OR women with severe pre-eclampsia who are in a critical care setting if birth
is planned within 24 hours.
Obviously, hospitals have their own local guidelines and many do not follow the above
guidance.
Pre-eclampsia
1080
it is not specific.
Risk factors
• Obesity
• Nulliparity
Symptoms
• Headache
y
op
• Rapid oedema (especially on the face) C
Signs
n
io

• Hyperreflexia
t
ua
Management
al
Ev
question.
137. A 31 year old woman complains of increased urinary frequency and urinary urgency.
She also describes painful voiding. She has dysmenorrhoea, sacral backache with
menses and complains of deep dyspareunia. What is the SINGLE most likely diagnosis?
A. Endometriosis
B. Uterine fibroid
C. Cystitis
D. Pyelonephritis
E. Transitional cell carcinoma of the bladder
This is a very uncommon presentation of endometriosis. Note that in some patients

with endometriosis, along with the typical symptoms of endometriosis such as
1081
dysmenorrhoea and dyspareunia, they have increased urinary frequency, urgency and
painful voiding. Symptoms such as dysuria may be due to the involvement of bladder,
peritoneum or invasion into the bladder. Sacral backache with menses are due to the
growth and bleeding of the ectopic endometrium. These cyclic symptoms usually
precede menses (24 to 48 hours) and continue throughout and after the flow.
Endometriosis

adenomyosis.
Clinical features
y
op
• Subfertility
Investigation
C
n
io
Management
t
ua
al
fertility rates
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Surgery
138. A 42 year old pregnant woman at 38 weeks gestation has an eclamptic fit in the labour
ward which has been ongoing and started 10 minutes ago. She had severe pre-
eclampsia which was diagnosed when she was 35 weeks gestation. She was given a
loading dose of magnesium sulfate several hours ago and is currently on a
maintenance dose. When she was last examined, there was loss of patellar reflexes
and she was feeling nauseous and warm. What is the SINGLE most appropriate next
step?
A. A further bolus of 2 g magnesium sulphate

B. Increase infusion rate of magnesium sulphate
C. Intravenous hydralazine
D. Immediate delivery of baby
1082
E. Administer diazepam
This lady is having a seizure but at the same time she is experiencing signs and
symptoms of magnesium sulphate toxicity.
Magnesium sulphate toxicity is characterized by confusion, loss of reflexes (deep

tendon reflexes), respiratory depression, and hypotension. In obstetric woman with
magnesium sulphate toxicity, the following need to be performed:
If only loss of patellar reflex or respiratory rate less than 10 breaths/minute:

1. Stop magnesium sulphate maintenance infusion
2. Send magnesium sulphate levels to laboratory urgently
3. Consider administration of intravenous calcium gluconate 1 g (10 ml) over 10
minutes if there is concern over respiratory depression. Calcium gluconate is
the antidote
4. Withhold further magnesium sulphate until patellar reflexes return or blood
magnesium sulphate level known
y
If cardiorespiratory arrest (due to magnesium sulphate toxicity)
op
1. Crash call
2. Position woman in left lateral tilt position and initiate CPR
3. Stop magnesium sulphate maintenance infusion
C
4. Administer intravenous calcium gluconate 1 g (10 ml) over 10 minutes. Calcium
gluconate is the antidote
5. Intubate immediately and manage with assisted ventilation until resumption of
n
spontaneous respirations
io
6. Send magnesium sulphate levels to laboratory urgently

t
In general we do not use diazepam or phenytoin as an alternative to magnesium

ua
sulphate in women with eclampsia. However, since she is still having a fit, and
magnesium sulphate toxicity is suspected, we are not able to use magnesium sulphate
and thus diazepam would be the option here. Note however, we would only use it as a
al
single dose, since prolonged use of diazepam is associated with an increase in maternal
death.
Ev
If there were no features of magnesium sulphate toxicity in this question, recurrent

seizures are treated with either a further bolus of 2 g magnesium sulphate or an
increase in the infusion rate to 1.5 g or 2.0 g/hour.
The fetus should be continuously monitored with CTG. The woman in this stem is 38
weeks pregnant, and so plans for delivery should be made once stabilised but there is
no particular hurry and a delay of several hours to make sure the correct care is in
hand is acceptable assuming that there is no acute fetal concern such as a fetal
bradycardia.
139. A 23 year old woman who is 28 weeks pregnant presents with vaginal bleeding. She
has lost about 200 ml of blood vaginally. On examination, she has a soft abdomen but
has lower abdominal tenderness.. A full blood count and a group and hold has been
taken. Intravenous fluids has been started. Her observations are currently stable. What
is the SINGLE most important investigations to establish a diagnosis?
1083
A. Ultrasound
C. D-dimer test
D. Clotting profile
E. Kleihauer blood test
Antepartum haemorrhage is seen here. Two of the most common causes are placental
abruption and placenta praevia. Other causes include local causes like bleeding from
the vulva, vagina or cervix (cervical polyp or cervical carcinoma). It is not uncommon to
fail to identify a cause for APH (over 30% of APH are of unknown origin)
The most important investigation is an ultrasound. This helps us rule out causes such as
placenta praevia if the placenta is seen to be high. Usually, pregnant women would
have had a scan at 20 weeks which would show the location of the placenta. Note that
placenta praevia is usually painless bleeding.
Placenta abruption is a clinical diagnosis and should be considered if the pain is

continuous. The abdominal pain usually has a sudden onset.
y
op
Vasa praevia would also be in the differential as it is another cause of painless bleeding
vaginally. C
Kleihauer is an important test to perform for any woman with a significant antepartum
haemorrhage who is rhesus negative. It is a is a blood test used to measure the amount
of fetal haemoglobin transferred from a fetus to a mother’s bloodstream. Note
n
however that this question is clearly asking about investigations that would lead to a
io
diagnosis. Kleihauer test will give not provide any input for a differential. It is merely a
test to determine the required dose of anti-D immunoglobulins to inhibit the formation
t
of Rh antibodies in a Rh negative mother to prevent Rh disease in future pregnancies

ua
with a Rhesus positive fetus.
It is worth mentioning that if the question was asking for the SINGLE best action and a
al
CTG was within one of the options, that would usually be the best action. The reason
behind this is placenta abruption is part of the differential and if the CTG shows fetal
Ev
distress, the baby would need to be delivered immediately. There is no time to wait
around for an ultrasound.
with a Rhesus positive fetus.
140. An 8 week pregnant woman presents with persistent nausea and vomiting and a
history of weight loss. She has a pulse of 110 beats/minute. Her dehydration has been
managed with sodium chloride 0.9% with added potassium chloride. She continues to
vomit several times during the day despite being given intramuscular cyclizine. What is
the SINGLE next most appropriate management?
A. Intravenous hartmann's solution

B. Intravenous antiemetics
C. Intravenous corticosteroids
D. Medical termination of her pregnancy
E. Oral thiamine
1084
This is a case of hyperemesis gravidarum. Intravenous fluids is the most important part
of management to ensure that the patient is not dehydrated. As this has already been
given and dehydration managed, intravenous antiemetics is the next best answer since
only intramuscular cyclizine has been given. Regular antiemetics such as promethazine
or cyclizine are often tried first in many early pregnancy units. If this fails,
prochlorperazine intramuscularly or orally can be added on. If patient continues to
vomit, intravenous metoclopramide or ondansetron can be used on top of the already
prescribed regular antiemetics.
Advice such as eat little and often should be given.
Thiamine is also used in hyperemesis gravidarum and should ideally be given to all
women admitted with prolonged vomiting. This is to prevent Wernicke’s
encephalopathy which is due to vitamin B1 (thiamine) deficiency. However, the
importance of thiamine in an acutely vomiting woman is less compared to having
intravenous antiemetics.
Intravenous corticosteroids is NOT the answer here and whoever tells you otherwise
y
has clearly not worked in obstetrics and gynaecology. Corticosteroids may be used for
op
intractable cases of severe hyperemesis gravidarum in secondary care but this is
usually a consultant decision and all other measures such as intravenous antiemetics
have been taken to attempt to manage the patient's vomiting. The usual regimen of
C
corticosteroids if needed would be hydrocortisone 100 mg BD intravenously for 48
hour followed by prednisolone 30 to 40 mg PO daily.
n
Hyperemesis Gravidarum
io
Nausea and vomiting are common in early pregnancy. When it is severe or prolonged it
t
is called hyperemesis gravidarum.

ua
Symptoms usually begin between 6‐8 weeks: peak at 12 weeks and usually resolve by
20 week
al
Symptoms
Ev
• Nausea
• Vomiting
• Food and fluid intolerance
• Lethargy
Signs
• Ketonuria
• Weight loss > 5%
• Tachycardia
• Signs of dehydration:
o Decreased skin turgor
o Prolonged capillary refill
o Sunken eyes
Management
• IV fluids
1085
o If potassium is found to be low i.e. < 3.5 mmol, sodium chloride 0.9%
with 20‐40 mmol/litre potassium chloride (KCl) is usually added
• Antiemetics
o Promethazine or cyclizine first-line
o Metoclopramide, prochlorperazine or ondansetron second-line
141. A 26 year old lady presents with worsening lower abdominal pain and purulent vaginal
discharge. She was recently treated for pelvic inflammatory disease with antibiotics as
an outpatient but did not complete her course of antibiotics. A urine HCG is negative.
temperature of 38.6°C and a pulse rate of 95 beats/minute. What is the SINGLE most
A. Oral tetracycline 250mg QDS

B. Oral doxycycline 100mg BD and oral metronidazole 400mg BD
C. Intravenous ceftriaxone 2g OD with oral doxycycline 100mg BD
D. Intravenous ceftriaxone 2g OD only
E. Oral ofloxacin 400mg BD and oral metronidazole 400mg BD
y
op
This patient clearly needs to be admitted for antibiotics. An outpatient therapy has
already failed. She has signs and symptoms of pelvic inflammatory disease. She has a
high temperature and tachycardia.
C
One of the more common inpatient regimens for pelvic inflammatory disease is IV
ceftriaxone 2g daily plus IV doxycycline 100mg twice daily (oral doxycycline may be
n
used if tolerated) followed by oral doxycycline 100mg twice daily plus oral
io
metronidazole 400mg twice daily for a total of 14 days. Intravenous therapy should be
continued until 24 hours after clinical improvement and then switched to oral.
t
ua
Although it’s stated that we use intravenous doxycycline as part of the antibiotic
regimen, this is usually not the case as Intravenous doxycycline is not currently licensed
in the UK.
al
OPTIONS FOR MANAGEMENT OF PID

Ev
Outpatient management of PID

• IM ceftriaxone stat plus oral doxycycline and oral metronidazole for 14 days; or
• Ofloxacin and metronidazole orally for 14 days
Inpatient management of PID

• IV ceftriaxone and IV doxycycline followed by oral doxycycline and oral
metronidazole for 14 days; or
• IV ofloxacin and IV metronidazole for a total of 14 days

endocervix.
Causative organisms
1086

• Age < 25
• Previous STIs
Features
• Fever
y
op
Investigation
• Screen for Chlamydia and Gonorrhoea C
Management
n
io
the same as PID.

t

ua

days.
al

Ev



Complications
1087
142. A 31 year old pregnant woman has her antenatal screening at her booking
appointment for HIV and Hepatitis B status. What other routine investigations are
ordered at booking?
A. Rubella susceptibility and syphilis screen

B. Toxoplasma immunoglobulins and rubella susceptibility
C. Toxoplasma immunoglobulins and syphilis screen
D. Hepatitis C status
E. Measles susceptibility
The following are routine blood tests performed at booking

• Blood Group and antibodies
• Rhesus status
• Haemoglobinopathies
• Syphilis
• Hepatitis B status
• HIV
• Full blood count looking for anaemia
y
• Rubella susceptibility
143.
op
A 31 year old woman presents to the emergency department with a lower abdominal
pain and per vaginal bleeding one day after having a hysterosalpingography as a part of
C
her infertility treatment. Her blood pressure is 85/50 mmHg and pulse rate is 125
beats/minute. On examination, the abdomen is rigid and tender. What is the SINGLE
most appropriate next step in investigation?
n
io
B. Abdominal X-ray erect and supine
t
C. Ultrasound abdomen and pelvis

ua
D. Coagulation profile
E. Beta hCG
al
A hysterosalpingography is a type of radiographic evaluation that looks at the uterus

and fallopian tubes predominantly as part of investigation for infertility. It uses a
Ev
contrast material that is injected into the cervical canal that appears on real-time X-ray
(fluoroscopy) to visualise the fallopian tubes to determine if the tubes are partially or
fully blocked. If the fallopian tubes are patent, the contrast medium will fill the tubes
and spill out into the abdominal cavity.
Complications associated with a hysterosalpingogram include the possibility of an

allergic reaction to the dye or infection (endometritis or salpingitis), which are
uncommon. Uterine perforation or fallopian tube perforation like in this stem are also
possible complications, but these are very rare.
If a perforation were to occur, the patient may have bleeding intraabdominally and an
ultrasound scan would be a good start to evaluate the severity of the bleeding. The
picture given in this stem with a low BP, rapid heart rate, abdominal rigidity and absent
rash does point towards a likely intra abdominal bleed.
In a real clinical setting, a laparoscopy or laparotomy would be a more suitable option
1088
as she is clinically unstable. As these options are not provided, ultrasound would be the
next best investigation.
144. A 52 year old woman has hot flashes, night sweats and insomnia. She also complains of
vaginal dryness and symptoms of urinary frequency. Her last menstrual period was 11
months ago. Her medical history includes having a myocardial infarction when she was
48 years old. What is the SINGLE most appropriate management for her?
A. Raloxifene
B. Oestrogen and progestogen patches
D. Topical oestrogen
E. Clonidine
Hormone replacement therapy like oestrogen and progestogen patches are indicated
here as she is having menopausal symptoms. This systemic treatment can also alleviate
symptoms of vaginal dryness and symptoms of urinary frequency.
A vaginal oestrogen cream or pessary would be appropriate if the patient only had
y
symptoms of vaginal dryness without the other symptoms of menopause like hot
op
flushes. In such cases, there is no need for a systemic treatment as topical treatment
can alleviate symptoms. C
The history of a myocardial infarction is irrelevant. The relation between HRT and
cardiovascular disease is controversial. The National Institute for Health and Care
Excellence (NICE) states that HRT does not increase cardiovascular risk when started in
n
women aged under 60 years and does not affect the risk of dying from cardiovascular
io
disease and hence the presence of cardiovascular risk factors is NOT a contraindication
to HRT.
t
ua
Hormone replacement therapy (HRT) indications

Hormone replacement therapy (HRT) involves the use of a small dose of oestrogen,
combined with a progestogen (in women with a uterus), to help alleviate menopausal
al
symptoms.
Ev
Current indications for the use of HRT are:

• Vasomotor symptoms such as flushing, including sleep, mood disturbance and
headaches
• For women with early menopause. They should be treated with HRT until the
age of natural menopause (around 51 years). The most important reason for
HRT in this group is preventing the development of osteoporosis
• For those women under 60 years who are at risk of an osteoporotic fracture in
whom non-oestrogen treatments are unsuitable
It is especially important to note that other indications such as reversal of vaginal

atrophy should be treated with topical oestrogens.
145. A 34 year old lady comes to the GP for removal of an intrauterine device. On speculum
examination, the cervix is visualised but the intrauterine device thread is not seen. Her
last menstrual period is 2 weeks ago and she has been having regular sexual
intercourses with her partner. What is the SINGLE most appropriate next step?
1089
A. Transabdominal ultrasound
B. Transvaginal ultrasound
C. Abdominal X-ray
D. Combined oral contraceptive pill
E. Repeat speculum examination under general anaesthesia
Transvaginal ultrasound is a good step to locate if the intrauterine device is still

intrauterine, displaced or fallen out. It is unlikely that it has perforated the uterus as if
so, the patient would be presenting with an acute abdomen. Transvaginal ultrasound
has better image quality when looking at the uterus compared to a transabdominal
ultrasound. An X-ray is capable of seeing the intrauterine device as well but it is
reserved for more acute presentations like suspected perforation or when the IUD is
not seen on a ultrasound scan.
Combined oral contraceptives are not completely wrong as if there was a delay in
obtaining the ultrasound scan, it may be necessary to start the woman on a form of
contraception until the ultrasound scan can be performed. However, the option of
having a transvaginal ultrasound is still the best choice among the rest.
y
op
146. A 26 year old woman has been found to have mild dyskaryosis on a routine cervical
screening test. She is a heavy smoker. What is the SINGLE most appropriate next step
in action?
C
A. Colposcopy
B. Repeat cervical smear in 4 months
n
C. Cone biopsy
io
D. Large loop excision of the transformation zone (LLETZ) procedure

t
ua
The first step is understanding that mild dyskaryosis needs a referral to colposcopy.
“Repeating cervical smear in 4 months” is the first option to be crossed out.
al
The second step is understanding what a colposcopy includes. A colposcopy involves

visualising the cervix using a microscope. A speculum is used to open the vagina and
Ev
the cervix is stained with acetic acid in the area of the transformation zone (TZ) to
identify the site, grade and shape of any abnormal area of cells. Iodine is then gently
applied to the rest of the cervix to identify the complete area of abnormality. A small
biopsy is usually taken to be sent to the laboratory. When an area of abnormality
extends into the cervical canal beyond the area that can be seen with the colposcope,
a cone biopsy is indicated. We need a colposcopy first before we can be certain if a
cone biopsy is required, hence the option for cone biopsy is incorrect.
Large loop excision of the transformation zone (LLETZ) takes place at the end of
colposcopy if abnormality is obvious on colposcopy or for women who have had a
positive biopsy result. Therefore if the option for colposcopy is present, that would
take priority over the option for LLETZ since the question is asking for “the next step in
action”.
Endocervical swabs have no value in management of cervical screening test.

Endocervical swabs are used to diagnose chlamydia or gonorrhoea.
1090
147. A 30 year old woman attends clinic asking for a reversible form of contraception. Her
obstetric history is significant for a previous caesarean section one year ago. She is
known to have menorrhagia and dysmenorrhoea. What is the SINGLE most appropriate
contraceptive for her?

B. Progestogen-only pill
C. Implanon
A previous caesarean is not a contraindication for a levonorgestrel intra-uterine

system. Among the options, levonorgestrel intra-uterine system (Mirena coil) is the
best treatment to reduce menorrhagia. It is currently first-line treatment for
menorrhagia in the UK.
Copper intrauterine contraceptive device and Implanon are more prone to have
irregular heavy bleedings compared to levonorgestrel intra-uterine system (Mirena
y
coil).
148.
op
A 34 year old woman develops a fit 6 hours after having a spontaneous vaginal delivery
of a healthy term baby. She has no history of having high blood pressure and has not
C
had a seizure before. What is the SINGLE most likely diagnosis?
A. Eclampsia
n
B. Preeclampsia
io
C. Epilepsy
t
E. Pregnancy induced hypertension

ua
It is very unlikely for eclamptic fits to occur with no history of proteinuria or high blood
pressure in the past. But given that she is pregnant and just delivered, it is the most
al
likely given the options.

Ev
Eclampsia does occur in the postpartum period as well as antenatally. This is why it is
common practice to keep patients with severe pre-eclampsia in hospital for the next
few days post delivery even though the delivery was uncomplicated.
149. An 11 week pregnant woman presents with severe vomiting and nausea. She has been
feeling nauseous for the past few days. A urinalysis shows 2+ ketones. What is the
A. Ultrasound
B. Thiamine
C. Serum BHCG
D. Parenteral antiemetics
This is a case of hyperemesis gravidarum. Intravenous fluids is the most important part
of management to ensure that the patient is not dehydrated. If this has already been
given and dehydration managed, intravenous antiemetics is the next best answer.
1091
Regular antiemetics such as promethazine or cyclizine are often tried first in many
early pregnancy units. If this fails, prochlorperazine intramuscularly or orally can be
added on. If patient continues to vomit, intravenous metoclopramide or ondansetron
can be used on top of the already prescribed regular antiemetics.
Advice such as eat little and often should be given.
Thiamine is also used in hyperemesis gravidarum and should ideally be given to all
women admitted with prolonged vomiting. This is to prevent Wernicke’s
encephalopathy which is due to vitamin B1 (thiamine) deficiency. However, the
importance of thiamine in an acutely vomiting woman is less compared to having
intravenous antiemetics.
Hyperemesis Gravidarum
Nausea and vomiting are common in early pregnancy. When it is severe or prolonged it
is called hyperemesis gravidarum.
y
Symptoms usually begin between 6‐8 weeks: peak at 12 weeks and usually resolve by
op
20 week
Symptoms
C
• Nausea
• Vomiting
• Food and fluid intolerance
n
• Lethargy
io
Signs
t
• Ketonuria
ua
• Weight loss > 5%

• Tachycardia
• Signs of dehydration:
al
o Decreased skin turgor

o Prolonged capillary refill
Ev
o Sunken eyes
Management
• IV fluids
o If potassium is found to be low i.e. < 3.5 mmol, sodium chloride 0.9%
with 20‐40 mmol/litre potassium chloride (KCl) is usually added
• Antiemetics
o Promethazine or cyclizine first-line
o Metoclopramide, prochlorperazine or ondansetron second-line
150. A 26 year old woman presents with vaginal bleeding. She has a positive pregnancy test
and her last menstrual period was 10 weeks ago. She has been having a lost of
appetite, nausea and vomiting for the past two weeks. On palpation, her symphyseal
fundal height is 16cm. On speculum examination, the cervical os is seen as closed.
A. Thyrotoxicosis
1092
B. Threatened miscarriage
C. Twin pregnancy
D. Hyperemesis gravidarum
E. Molar pregnancy
The patient is presenting with classical features of molar pregnancy which are uterus
large for dates, first trimester bleeding, hyperemesis. This is a presentation that is also
similar to multiple pregnancies like twin pregnancy as they are also at increased risk of
bleeding, hyperemesis and have a uterus that is larger for dates. However, in multiple
pregnancies the uterus is seen to be larger in the second trimester rather than the first.
Hyperemesis gravidarum is not totally incorrect as this patient does also have a
diagnosis of hyperemesis gravidarum as she is seen to be vomiting for the past two
weeks. However, the most likely diagnosis is still molar pregnancy given the other
features.
y
op
C
n
io

t
ua

• Invasive mole
• Choriocarcinoma
al

Ev
Features:
• Hyperemesis

1093
normal for 6 months

151. A 29 year old at 38 weeks gestation presents with a 2 hours history of constant
abdominal pain. While waiting to be seen, she passes 300 ml of blood per vagina. What
y
A. Ultrasounds
op
B. Cardiotocography
C. Clotting screen
D. Group and save
C
E. Kleihauer Betke test
With constant abdominal pain and PV bleeding, placental abruption is one of our
n
differentials. The first and most important step is to put on a cardiotocograph (CTG). If
io
there is fetal distress seen on the CTG, the woman may be rushed for an emergency C-
section.
t
ua
As abruption is a clinical diagnosis, an ultrasound would have little value. A CTG is

extremely important as a first step to monitor the fetus. Ultrasound would be a good
step to perform to rule out placenta praevia if the CTG is found to be reassuring.
al
A group and save is also important as she is having PV bleeding, but the importance of
Ev
monitoring fetus comes above having a group and save as most maternity units will
have O type blood stored in fridge.
152. A 34 year old African women has been trying to concieve for the past 2 years. She has
suffered from heavy menstruations for the past 3 years and a recent transvaginal
ultrasound shows two large submucosal fibroids and one intramural fibroid. Her
partner has had a sperm analysis which was found to be normal. What is the SINGLE
A. Endometrial ablation
B. Myomectomy
C. Uterine artery embolisation
D. Levonorgestrel intrauterine system
E. Gonadotropin-releasing hormone (GnRH) analogue
This woman is trying to conceive. The only option to preserve fertility here is a
myomectomy.
1094
Endometrial ablation is a very good option to decrease menorrhagia however the
procedure involves using electrical currents or heated water to destroy the
endometrium which could result in infertility. This procedure is therefore NOT
recommended for women who still want children. It is also important to note that
endometrial ablation is not used in patients with large fibroids. It is primarily used in
patients with heavy menstrual bleedings due to endometrial hyperplasia without
fibroids, but it can also be used to treat small submucosal fibroids.
Uterine artery embolisation (UAE) is an alternative procedure to a hysterectomy or

myomectomy for treating fibroids. It is performed by radiologist and involves
embolizing the uterine arteries to shrink the fibroids. It is recommended for women
with large fibroids however it is not recommended if the woman is trying to conceive
as it reduces blood to the uterus significantly.
The levonorgestrel intrauterine system (LNG-IUS) is a small, plastic, t-shaped device

placed in your uterus that slowly releases progestogen. It also acts as a contraceptive
and thus should not be used for a woman trying to conceive.
y
op
GnRH analogues essentially shrink the fibroids however they would grow back once the
medication is stopped. Its primary use is so that it is easier to remove the fibroids
during surgery. As GnRH analogues inhibit ovulation, it would prevent pregnancy from
C
occurring. This would be a suitable option given that it was combined with a
myomectomy.
n
It is also important to note that if she does decide to go for a myomectomy, she would
io
need to be counselled of the risk of uterine rupture in the future if she would become
pregnant especially during labour. Her obstetrician would need to weigh the risk and
t
benefits of a normal delivery and consider a caesarean section due to the risk of a
ua
uterine rupture.
153. A 42 year old African lady presents bloating and heavy, regular periods. Her uterine
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size correlates to a 14 weeks pregnant uterus. What is the SINGLE most likely
diagnosis?
Ev
A. Blood dyscrasia
B. Haematoma
C. Fibroids
D. Adenomyosis
E. Incomplete abortion
One must remember that uterine fibroids are more commonly found in Afro-Caribbean
women. Menorrhagia and a uterus of 14 week size is highly suggestive of a fibroid. A
transvaginal ultrasound scan should be performed to assess the fibroid.
154. A 22 year old woman was prescribed doxycycline for 10 days to treat lyme disease. She
has been using combined oral contraceptive pills regularly for the past 6 months. What
A. Combined oral contraceptive pills can be used with no additional contraceptive

method necessary
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B. Continue taking combined oral contraceptive pills plus an additional barrier method
for 2 days
C. Continue taking combined oral contraceptive pills plus an additional barrier method
for 10 days
D. Stop combined oral contraceptive pill for a week and use barrier methods
E. Prescribe doxycycline for 15 days
No action needed. Latest recommendations are that no additional contraceptive

precautions are required when combined oral contraceptives are used with
antibacterials that do not induce liver enzymes, unless diarrhoea or vomiting occur
155. A 37 year old woman presents with heavy vaginal bleeding for the past several months.
A transvaginal ultrasound scan shows a 4 cm anterior subserosal fibroid and a 6 cm
fundal intramural fibroid. She would like her fertility preserved. What is the SINGLE
A. Uterine artery embolisation

y
C. Hysteroscopic myomectomy
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D. Vaginal hysterectomy
E. Abdominal myomectomy C
Abdominal myomectomy is the most appropriate in this situation. As the fibroids are
seen to be subserosal and intramural, an abdominal incision would give us access to
these fibroids. A vaginal approach using a hysteroscopy would be a choice for
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submucosal fibroids but not for intramural and subserosal fibroids.
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The other options give will affect the patient's fertility.

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156. A 35 year old lady at her 28th week gestation attends her antenatal clinic for a routine
check-up. She feels well and has no complains. Her blood pressure is 160/95 mmHg,
and her urine dipstick shows 3+ protein. What is the SINGLE most likely diagnosis?
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B. Gestational hypertension
C. Chronic hypertension
D. Pre-eclampsia
E. Chronic renal failure
Pre-eclampsia

it is not specific.
Risk factors
• Obesity
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• Nulliparity
Symptoms
• Headache
• Rapid oedema (especially on the face)
Signs
• Hyperreflexia
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Management
C
question.
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157. A 29 year old woman’s recent cervical smear results show inflammatory changes
without any dyskaryosis. She has no pelvic or vaginal pain. There was no discharge on
examination. Speculum examination had shown a normal cervix and vaginal mucosa.
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A. Repeat smear in 3 years

B. Repeat smear in 6 months
C. Repeat smear urgently
D. Perform an endocervical swab
E. Refer to colposcopy clinic
The results that show inflammatory changes are nonspecific. These findings are
difficult to interpret. It may be non significant or it may also represent genital
infections like candida amongst others. Inflammation is usually not a worrying sign
unless it is severe in which case we may consider a more serious sexual transmitted
infection.
It is good practice to repeat the smear in 6 months to ensure that the inflammation has
resolved.
everytime she sneezes or coughs. On a speculum examination, there was no
1097
anatomical abnormalities. What is the SINGLE most appropriate next step in
management?
A. Antibiotics
C. Ring pessary
D. Duloxetine
This lady is suffering from stress incontinence as evident by small amounts of urine
leakage when she sneezes or coughs. The best management would be pelvic floor
exercises.
Ring pessary is of no use here as there is no cystocele.
Loss of weight, and reducing caffeine are other lifestyle modifications that could be
effective but were not given in this questions.
y
159. What is the recommended time to administer anti-D immunoglobulins to a previously
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non sensitised rhesus negative mother after delivery?
A. 24 hours
C
B. 48 hours
C. 72 hours
D. 10 days
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E. 14 days
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Following potentially sensitising events which include giving birth, anti-D

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immunoglobulins should be administered as soon as possible and always within

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72 hours of the sensitising event. If this deadline has not been met and 72 hours has
passed, you can still administer anti-D immunoglobulins up to 10 days as there may still
be some protection offered during this time if anti-D immunoglobulins is administered.
al
160. A 16 year old girl has complains of dysmenorrhoea, menorrhagia and irregular
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menstrual cycles. This complains started a few years ago and has gotten worse with
time. Her period pain is so intense that she occasionally has to skip school to stay at
home. She has not tried any medication to manage her symptoms. She is not currently
sexually active. What is the SINGLE most likely management to treat her symptoms?
A. Tranexamic acid
E. Mefenamic acid
In clinical practice, a general practitioner is likely going to prescribe tranexamic acid

with mefenamic acid as first line to manage the dysmenorrhoea and menorrhagia
before attempting combined oral contraceptive pills. As this combination is not
provided, the best answer would be combined oral contraceptive pills. This would deal
with all her presenting complaints.
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The summary to answering these type of questions are as bellow:
• Dysmenorrhoea in a young girl → Mefenamic acid
• Dysmenorrhoea, menorrhagia, and irregular menstrual cycles in a young girl →
COCP
• Dysmenorrhoea, menorrhagia, and irregular menstrual cycles in sexually active
women (or para≥1) → Levonorgestrel intra-uterine system
161. A 30 year old lady presents to the outpatient clinic with difficulty in conceiving for the
past 2 years. She and her husband have been trying to achieve pregnancy for more
than 2 years and have been unsuccessful. There is no previous history of pelvic
inflammatory disease. She has a BMI of 23. She has a regular 32 day menstrual cycle.
What is the SINGLE most appropriate test to perform to assess ovulation?
A. Follicular stimulating hormone (FSH) and luteinizing hormone (LH)

B. Day 21 progesterone
C. Day 25 progesterone
E. Oestrogen levels
y
op
Serum progesterone (Mid-luteal cycle progesterone) is tested one week before a
menstrual period is expected. Example, on day 21 of a 28 day menstrual cycle. In this
case, since she has regular 32 day menstrual cycles, the serum progesterone should be
C
taken on day 25 (32 days - 7 days = day 25).
A serum progesterone more than 30 nmol/L is consistent with ovulation and no further
n
biochemical assessment is required.
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As part of the management for infertility, FSH and LH is usually taken in clinics.
t
However in this context, since her menses are regular, it is less important. It is usually
ua
measured if there is menstrual irregularity to help exclude conditions like premature

ovarian insufficiency (LH and FSH both raised), polycystic ovarian syndrome (LH:FSH
ratio increased) and hypogonadotropic hypogonadism (LH and FSH reduced).
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OPHTHALMOLOGY
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Questions
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&
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Answers
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Ophthalmology Questions
1. A 17 year old has acute pain around his right eye that started a week ago with blistering
inflamed rashes in the dermatome distribution of the ophthalmic division of the
trigeminal nerve. What is the SINGLE most likely diagnosis?
A. Postherpetic neuralgia
B. Herpes simplex
D. Cellulitis
2. A 55 year old man presents with a mild headache, ocular pain and a red eye. He also
complains of nausea. He has intermittent blurring of vision with haloes. There was no
history of trauma. Palpation of the globe of the eye reveals it to be hard. What is the
A. Panretinal photocoagulation
y
B. Pilocarpine eye drops
op
C. Propranolol
D. Scleral buckling
C
3. A 60 year old man experienced sudden painless loss of vision. On ophthalmoscopy,
multiple flame shaped hemorrhages were seen scattered throughout his fundus. What
n
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A. Central retinal artery occlusion

t
B. Central retinal vein occlusion

ua
C. Acute glaucoma
D. Retinitis pigmentosa
E. Optic neuritis
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4. A 34 year old man has an acute painful, red right eye for the last 24 hours. He
Ev
complains of blurring of vision. He has a past medical history of cervical spondylitis and
is on chronic diclofenac treatment for the past 4 years for back pain and stiffness. On
examination, his pupil is irregular in shape and he is very sensitive to light. What is the
SINGLE most likely clinical diagnosis?
A. Acute close-angle glaucoma

B. Conjunctivitis
C. Episcleritis
D. Iridocyclitis
E. Keratitis
complains of blurring of vision. He had a similar episode a year ago. His pupil is irregular
in shape and he is very sensitive to light. He has been taking diclofenac for three years
now because of back pain and stiffness. What is the SINGLE most likely clinical
diagnosis?
1101
B. Conjunctivitis
C. Episcleritis
D. Iritis
E. Keratitis
6. A 48 year man who has been taking medications for asthma for several years has now
presented with decreased vision on his right eye. He complains of glare especially
during the night. What SINGLE medication is most likely to cause his visual
deterioration?
A. Inhaled salbutamol
B. Inhaled steroids
C. Aminophylline
D. Theophylline
E. Oral steroids
7. An 82 year old woman has developed a painful blistering rash on one side of her
forehead and anterior scalp. She also has a red eye, decreased visual acuity and
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epiphora alongside the forehead tenderness. What is the SINGLE most likely nerve
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affected?
A. Accessory nerve
C
B. Facial nerve
C. Olfactory nerve
D. Optic nerve
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E. Trigeminal nerve
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8. A 35 year old HIV positive man presents with progressive visual deterioration. He
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complains of blurred vision and floaters. On examination, multiple cotton wool spots
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are seen in both eyes. What is the SINGLE most likely causative organism?
A. Herpes zoster
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B. Cryptosporidium
C. Cytomegalovirus
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D. Pneumocystis jiroveci pneumonia

E. Cryptococcus neoformans
9. A 25 year old man has a burning sensation in his left eye for the last 2 days. His eye is
red and has thick purulent discharge. His lids are often stuck shut on waking. What is
the SINGLE most appropriate initial management?
A. Oral antibiotic
B. Oral antihistamine
C. Topical antibiotics
D. Topical antibiotics and topical steroids
E. Clean discharge using cotton wool soaked in water
10. A 45 year old woman had her visual acuity checked at her local optician. Several hours
later she presents to the emergency department with severe ocular pain and redness in
her eye. She also complains of seeing coloured halos. What SINGLE anatomical
structure is most likely to be involved?
1102
A. Iris
B. Ciliary body
C. Anterior chamber
D. Posterior chamber
E. Cornea
11. A 33 year old man presents to clinic with a history of early morning back pain, stiffness
and a painful red right eye. The pain in the eye started last night. On examination, his
right pupil is seen to have a distorted pupil shape. His visual acuity is unaffected. What
is the SINGLE most likely affected anatomical structure?
A. Optic nerve
B. Iris
C. Cornea
D. Conjunctiva
E. Sclera
y
12. A 30 year old woman has a sudden acute headache with nausea and vomiting. She has
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a red, painful left eye. The symptoms started when she was watching television in a
dark room. Palpation of the glove reveals it to be hard. What is the SINGLE most likely
visual symptom?
C
A. Paracentral scotoma
B. Peripheral visual field loss
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C. Coloured halos
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D. Floaters
E. Glares
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13. A 48 year old man attends clinic for a routine eye check up as he has a history of type 1
diabetes. Fundoscopy shows neovascularization at the retina. What is the SINGLE most
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A. Strict blood glucose control

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B. Review in 12 months
C. Non urgent referral to specialist
D. Insulin
E. Laser photocoagulation
14. A 68 year old patient attends for retinal screening. He is found to have hard exudates,
macular oedema and arteriovenous nipping. He is on long term treatment with
nifedipine. What is the SINGLE most likely diagnosis?
A. Macular degeneration
B. Hypertension retinopathy
C. Non-proliferative diabetic retinopathy
D. Proliferative diabetic retinopathy
E. Open angle glaucoma
15. A 67 year old man has deteriorating vision in his left eye. His complaints that his vision
has been slowly getting more blurry over the last few months. Glare from the
1103
headlights of cars is particularly a problem when driving at night. He has a history of
longstanding COPD and is on multiple drugs for it. What SINGLE medication is most
likely to cause his visual deterioration?
A. Salmeterol
B. Oral corticosteroid
C. Tiotropium
D. Theophylline
E. Inhaled corticosteroid
16. A 34 year old homosexual man attends clinic with a history of weight loss and
progressive visual deterioration. A funduscopic examination reveals retinal
haemorrhages and yellow-white areas with perivascular exudates. What is the SINGLE
most appropriate causative organism?
A. Mycobacterium avium
B. Herpes simplex virus
C. Haemophilus influenzae
y
D. Cytomegalovirus
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17. A 44 year old man has sudden severe eye pain, red eye, visual blurring. It started when
C
he went to watch a movie in the theatre. It was accompanied by nausea and vomiting.
Slit-lamp findings include shallow anterior chambers in both eyes with corneal epithelial
oedema. What is the SINGLE most likely diagnosis?
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A. Central retinal vein occlusion

B. Acute closed angle glaucoma
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C. Uveitis
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D. Iritis
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18. A 44 year old hypertensive male, loses vision in his left eye overnight. There is no pain
or redness associated with his visual loss. On fundoscopy, venous dilation, tortuosity,
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and retinal haemorrhages are observed on his left eye. No abnormalities are found on
his right eye on fundoscopy. What is the SINGLE most likely cause of his unilateral visual
loss?
A. Hypertension retinopathy
B. Central Retinal Artery Occlusion
C. Central Retinal Vein Occlusion
D. Background retinopathy
E. Retinal detachment
19. A 49 year old man has sudden complete loss of vision from his left eye over a couple of
seconds. There was no pain associated with it and there is no redness of the eye.
Ophthalmoscopy reveals a pale retina with a cherry red spot at the macula and
attenuation of the vessels. What is the SINGLE most likely diagnosis?

1104
C. Branch retinal artery occlusion
D. Branch retinal vein occlusion
20. A 52 year old man presents with sudden complete loss of vision from the right eye. He
also had been complaining of right sided headaches which would come up more on
chewing. On fundoscopy, the retina was pale and a cherry red spot could be seen in the
macular region. What is the SINGLE most likely cause of vision loss?

21. A 63 year old woman has progressive decrease in her visiul acuity and peripheral visual
field loss. She is shortsighted and needs to wear glasses. On examination, she has
normal pupils on both eyes. What is the SINGLE most likely diagnosis?
y
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A. Cataract
B. Glaucoma
C. Retinal detachment
C
D. Iritis
E. Giant cell arteritis
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22. A 27 year old female was brought to the emergency department by her friend from a
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movie theatre. She complains of sudden severe pain in the eye followed by vomiting.
She sees coloured halos, has blurry vision and a red eye. She gives a past history of
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recurrent headaches which used to resolve spontaneously. Examination shows fixed,

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dilated ovoid pupils. What is the SINGLE most initial investigation?
A. CT head
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B. MRI orbits
C. Blood culture and sensitivity
Ev
D. Toxicology screen
E. Ocular tonometry
23. A 52 year old man has a painful, red, photophobic right eye with slightly blurred vision
and watering for 2 days. He has no similar episodes in the past. On slit lamp
examination, there are cells and flare in the anterior chamber. The pupil is also sluggish
to react. What is the SINGLE most appropriate clinical diagnosis?

B. Acute conjunctivitis
C. Acute dacryocystitis
D. Acute iritis
E. Corneal foreign body
24. A 33 year old woman started seeing tiny black dots followed by a painless sudden loss
of vision in her left eye a few hours ago. She says that it initially felt like a curtain was
1105
falling down. On fundoscopy, the optic disc is normal. What is the SINGLE most likely
underlying pathology?
A. Iritis
B. Glaucoma
C. Vitreous chamber
D. Retinal detachment
E. Central retinal artery occlusion
25. A 70 year old man who has a medical history of diabetes mellitus and hypertension
experiences acute monocular blindness which resolves after 30 minutes. He describes
this as a curtain coming down vertically into the field of vision of one eye. What is the

B. Optic neuritis
C. Lacunar infarct
D. Pontine haemorrhage
y
E. Amaurosis fugax
26.
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A 45 year old man with type 1 diabetes mellitus has his annual check ups.
Ophthalmoscopy shows dot and blot haemorrhage with hard exudates. What is the
C
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B. Retinal detachment
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D. Diabetic background retinopathy
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E. Diabetic proliferative retinopathy

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27. A 54 year old myopic develops flashes of light and then sudden painless loss of vision.
He says that it initially felt like a curtain was falling down. Ophthalmoscope shows a
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grey opalescent retina, ballooning forward. What is the SINGLE most appropriate
treatment?
Ev
A. Pilocarpine
B. Peripheral iridectomy
C. Scleral buckling
D. IV acetazolamide
E. Surgical extraction of lens
28. A 48 year old woman presents with severe left-sided headaches, ocular pain and a red,
watering eye. She has intermittent blurring of vision and sees coloured haloes. What is
the SINGLE most appropriate next step of action?
A. Measure intraocular pressure

B. Relieve pain with aspirin
C. Administer 100% oxygen
D. Computed tomography
E. Relieve pain with sumatriptan
1106
29. A 32 year old woman has progressive decrease in vision over the past 3 years on both
eyes. She is myopic and wears glasses. She is now almost blind. What is the SINGLE
A. Cataract
B. Glaucoma
C. Retinopathy
D. Uveitis
E. Keratitis
30. A 49 year old hypertensive man has sudden complete loss of vision from his left eye.
There was no pain associated with it and there is no redness of the eye.
attenuation of the vessels. What is the SINGLE most appropriate management?
A. Firm ocular massage

B. Corticosteroids
C. Scleral buckling
y
D. Panretinal photocoagulation
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31. A 62 year old man complains of headaches and decreased vision. He has a blood
C
pressure of 170/95 mmHg. Fundoscopy reveals disc swelling and a flame shaped
haemorrhage. What is the SINGLE most likely diagnosis?
Plab Lab Values
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32. A 40 year old man has pain, redness and swelling over the nasal end of his right lower
eyelid. The eye is watery with some purulent discharge. The redness extends on to the
Ev
nasal peri-orbital area and mucoid discharge can be expressed from the lacrimal
punctum. What is the SINGLE most appropriate clinical diagnosis?
A. Acute conjunctivitis
B. Acute dacryocystitis
C. Acute iritis
D. Retrobulbar neuritis
E. Scleritis
33. A 20 year old man comes with a 3 day history of a burning red left eye with sticky
greenish discharge. For the past few mornings, he says that his eyelids are stuck shut on
waking. What is the SINGLE most likely affected anatomical structure?
A. Iris
B. Ciliary body
C. Cornea
D. Conjunctiva
1107
E. Sclera
34. A 37 year old lady has been suffering from early morning stiffness of her small joints for
several months. She takes regular NSAIDS to manage the pain of her joints. She attends
clinic with a painful red eye. What is the SINGLE most likely affected anatomical
structure?
A. Iris
B. Ciliary body
C. Cornea
D. Sclera
E. Conjunctiva
35. A 24 year old has a marked eye pain, sticky red eye with a congested conjunctiva for the
past 7 days. He says that his eyes feel stuck together in the morning. What is the
SINGLE most appropriate treatment?
A. Oral antibiotic
y
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C. Antibiotic drops
D. Steroid and antibiotic drops
E. Saline drops
C
36. A 38 year old female has reduced vision and eye pain both eyes. She has had a similar
episode about a year ago which resolved completely within 3 months. She says that the
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red colour appears "washed out". On physical examination, mild weakness of right
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upper limb was appreciated and exaggerated reflexes was appreciated. What is the
t
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C. Corticosteroids
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D. Peripheral iridectomy
Ev
37. A 60 year old woman has decreased vision over the past year. She is not able to see
well at night. She has changed her spectacles several times recently due to refraction
changed but she still complains of glare. She has a normal pupil on examination. What
A. Cataract
B. Glaucoma
D. Iritis
38. Which of the following is not a degenerative corneal disease?
A. Band keratopathy
B. Pellucid marginal degeneration
C. Mooren’s ulcer
1108
D. Terrien marginal degeneration
E. Keratoconus
39. A 49 year old woman complains of reduction of vision and dull pain in her left eye for
the past 2 weeks. Her past medical history includes multiple sclerosis which was
diagnosed 2 years ago. On examination, both pupils constrict when light is directed to
the right eye but both pupils fail to constrict fully when light is directed to the left eye.
What is the SINGLE most likely defect to accompany her diagnosis?
B. Monocular visual field loss
C. Bitemporal hemianopsia
D. Central scotoma
E. Homonymous hemianopia
40. A 32 year old woman complains of dull pain in her right eye for the past one week
which worsens when moving her eye. Her past medical history includes multiple
sclerosis which was diagnosed 6 months ago. An ophthalmoscopy shows pallor of the
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optic disc. Which anatomical site is most likely to be affected?
A. Optic nerve
B. Sclera
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C. Optic radiation
D. Trigeminal nerve
E. Oculomotor nerve
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41. A 41 year old man presents with visual symptoms and a headache. An ophthalmoscopic
examination shows papilloedema. Which anatomical site is most likely to be affected?
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A. Retina
B. Optic disc
C. Optic radiation
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D. Macula
E. Optic chiasma
Ev
42. A 33 year old female complains of double vision which started yesterday. On
examination, a fixed dilated pupil which does not accommodate and drooping eyelid
can be seen on the left eye. Her left eye is displaced outward and downwards. She has
no significant past medical history. There was no history of trauma. What is the SINGLE
most appropriate investigation to perform?
A. Ophthalmoscopy
B. Computed tomographic angiography
D. Visual field test
E. Red reflex examination
43. A 62 year old hypertensive man comes into clinic with blurred vision. He usually takes
amlodipine to manage his blood pressure and has been taking it for the past 10 years.
His blood pressure currently ranges between 150/90 mmHg to 160/100 mmHg. An
1109
ophthalmoscope reveals dot blot haemorrhages, ischaemic changes and hard exudates.
C. Hypertensive retinopathy
E. Non-proliferative diabetic retinopathy
44. A 39 year old woman has been having gradual loss of vision in both eyes over the past 6
months. She has a diagnosis of rheumatoid arthritis and has been on treatment for it
for the past 4 years. Her intraocular pressure is within normal limits and red reflex is
absent in both eyes. What is the SINGLE most likely diagnosis?
A. Cataract
B. Diabetic retinopathy
C. Hypermetropia
D. Macular degeneration
y
E. Hypertensive retinopathy
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C
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1110
Ophthalmology Answers
1. A 17 year old has acute pain around his right eye that started a week ago with blistering
inflamed rashes in the dermatome distribution of the ophthalmic division of the
trigeminal nerve. What is the SINGLE most likely diagnosis?
A. Postherpetic neuralgia
B. Herpes simplex
D. Cellulitis
Herpes zoster ophthalmicus
Herpes zoster ophthalmicus (HZO) describes the reactivation of the varicella zoster
virus in the area supplied by the ophthalmic division of the trigeminal nerve. It accounts
for around 10-20% of case of shingles.Ophthalmic herpes is a danger to sight and the
patient should see an ophthalmologist the same day.
y
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Features
- Vesicular rash around the eye, which may or may not involve the actual eye
itself
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- Hutchinson's sign: rash on the tip or side of the nose. Indicates nasociliary
involvement and is a strong risk factor for ocular involvement
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Management
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- Oral antiviral treatment

- Oral corticosteroids may reduce the duration of pain
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- Ocular involvement requires urgent ophthalmology review

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Complications
- Ocular: conjunctivitis, keratitis, episcleritis, anterior uveitis
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- Ptosis
- Post-herpetic neuralgia
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Keratitis is a condition in which the eye's cornea, the front part of the eye, becomes
inflamed. Another infectious cause of keratitis is Herpes simplex keratitis in which case
presents with a dendritic corneal ulcer. For herpes simplex keratitis, topical acyclovir is
used
2. A 55 year old man presents with a mild headache, ocular pain and a red eye. He also
complains of nausea. He has intermittent blurring of vision with haloes. There was no
history of trauma. Palpation of the globe of the eye reveals it to be hard. What is the
C. Propranolol
D. Scleral buckling
Acute angle closure glaucoma
1111
Also called acute glaucoma or narrow-angle glaucoma
In acute angle closure glaucoma (AACG) there is a rise in IOP secondary to an

impairment of aqueous outflow. Factors predisposing to AACG include:
- hypermetropia (long-sightedness)
- pupillary dilatation
It presents with an eye that is red, severely painful,and associated with a semi-dilated
non-reacting pupil. Headaches and decreased visual acuity are common. Symptoms
worsen with mydriasis (e.g. watching TV in a dark room). Coloured haloes around lights
may be seen by patients. Palpation of the globe will reveal it to be hard. Corneal
oedema results in dull or hazy cornea. Systemic upset may be seen, such as nausea and
vomiting and even abdominal pain.
Note: The acute attack is usually unilateral; however, long-term management will be to
both eyes.
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Medical
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Initial medical treatment typically involves all topical glaucoma medications that are not
contra-indicated in the patient, together with intravenous acetazolamide.
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Topical agents include:
- Beta-blockers - eg, timolol, cautioned in asthma.
- Steroids - prednisolone 15 every 15 minutes for an hour, then hourly
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- Pilocarpine 1-2%
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- Acetazolamide is given intravenously (500 mg over 10 minutes) and a further

250 mg slow-release tablet after one hour
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- Offer systemic analgesia ± antiemetics.

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This should tide the patient over until they are able to be seen by a duty
ophthalmologist who will assess the situation at short intervals until the acute attack is
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broken. These treatments may be repeated depending on the IOP response and a
combination of these medications will be given to the patient on discharge. The patient
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will remain under close observation (eg, daily clinic reviews or as an inpatient).
Subsequent treatment is aimed at specific mechanism of closure.
Surgical
Peripheral iridotomy (PI)

- This refers to (usually two) holes made in each iris with a laser. This is to
provide a free-flow transit passage for the aqueous. Both eyes are treated, as
the fellow eye will be predisposed to an AAC attack too. This procedure can
usually be carried out within a week of the acute attack, once corneal oedema
has cleared enough to allow a good view of the iris.
Surgical iridectomy
- This is carried out where PI is not possible. It is a less favoured option, as it is
more invasive and therefore more prone to complications.
1112
3. A 60 year old man experienced sudden painless loss of vision. On ophthalmoscopy,
multiple flame shaped hemorrhages were seen scattered throughout his fundus. What

C. Acute glaucoma
D. Retinitis pigmentosa
E. Optic neuritis
Central Retinal Vein Occlusion (CRVO):
These patients have a clinical presentation similar to those with retinal artery occlusion.
There is the sudden loss of vision without pain, redness, or abnormality in pupillary
dilation. Ocular examination by funduscopy reveals disk swelling, venous dilation,
tortuosity, and retinal haemorrhages.
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Diagnosis
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Retinal haemorrhages are the main way of distinguishing venous obstruction from
arterial obstruction. You cannot have a hemorrhage in the retina if you don't have
blood getting into the eye.
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Treatment
Treatment of CRVO is beyond the scope of what you need to know for the PLAB 1 exam
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but it involves immediate referral to an ophthalmologist and/or intra-vitreal steroids
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complains of blurring of vision. He has a past medical history of cervical spondylitis and
ua
is on chronic diclofenac treatment for the past 4 years for back pain and stiffness. On
examination, his pupil is irregular in shape and he is very sensitive to light. What is the
SINGLE most likely clinical diagnosis?
al

Ev
B. Conjunctivitis
C. Episcleritis
D. Iridocyclitis
E. Keratitis
Because of this patient’s past medical history of cervical spondylitis, iridocyclitis is the
most likely answer.
Please note the following for PLAB 1:

1. Anterior uveitis is also referred to as iritis and iridocyclitis
2. Intermediate uveitis is also known as pars planitis or viritis
3. Posterior uveitis is also called chorioretinitis
4. In the UK, the most common cause of chronic anterior uveitis is sarcoidosis
5. In the UK, the most common form of uveitis is anterior uveitis
Anterior uveitis
1113
- Also referred to as iritis. It is one of the important differentials of a red eye.
Presentation
- Symptoms may develop over hours or days (acute anterior uveitis), or onset
may be gradual (chronic anterior uveitis).
Features
Acute anterior uveitis:
- Progressive (over a few hours/days) unilateral, painful red eye

- Visual acuity in the affected eye is reduced
- Photophobia
- Pupil may be abnormally shaped or of a different size to the unaffected eye
(small pupil, initially from iris spasm; later it may be irregular or dilate
irregularly due to adhesions between lens and iris)
- Excess tear production
y
- Characteristic sign is the presence of cells in the aqueous humour seen on slit-
op
lamp
- Aqueous humour is normally clear but in anterior uveitis it may be seen as
cloudy, giving the appearance of a 'flare'. This appears rather like a shaft of
C
light shining through a darkened, smoky room. Anterior chamber flare is
due to inflamed vessels leaking protein. Due to the cloudiness, as the slit-
lamp beam of light is shone through, the beam disperses hence the term
n
flare
io
Chronic anterior uveitis:

t
ua
- Presents as recurrent episodes, with less acute symptoms

- Patients may find that one symptom predominates (this tends to be blurred
vision)
al
Associated conditions
Ev
- Ankylosing spondylitis
- Reactive arthritis
- Ulcerative colitis, Crohn's disease
Management:
- Prednisolone eye drops to reduce inflammation

- Cyclopentolate to prevent adhesions between lens and iris by keep pupil
dilated
complains of blurring of vision. He had a similar episode a year ago. His pupil is irregular
in shape and he is very sensitive to light. He has been taking diclofenac for three years
now because of back pain and stiffness. What is the SINGLE most likely clinical
diagnosis?
1114
B. Conjunctivitis
C. Episcleritis
D. Iritis
E. Keratitis
Anterior uveitis
Presentation
Features
y
op
- Photophobia
C
n
io
lamp
t

ua
al
flare
Ev

vision)
Management:
1115
dilated
6. A 48 year man who has been taking medications for asthma for several years has now
presented with decreased vision on his right eye. He complains of glare especially
during the night. What SINGLE medication is most likely to cause his visual
deterioration?
A. Inhaled salbutamol
B. Inhaled steroids
C. Aminophylline
D. Theophylline
E. Oral steroids
The diagnosis here is steroid induced cataracts. Long term use of steroids can cause
cataracts. Oral corticosteroids have more of a systemic effect compared to inhaled
corticosteroids. Thus, oral steroids are more likely to be the cause of his cataracts.
y
There are certain keywords or hints that you may find on the PLAB test that would lean
op
you towards cataracts. These are:
- Exposure to great amounts of UV light i.e. Person from Australia who never
C
wears sunglasses
- Long term use of steroids (They may not say the words “steroids” but they may
give a scenario with someone who is with a long standing condition that needs
n
the use of steroids)
io
- A high myopia
- Trauma to eye
t
ua
7. An 82 year old woman has developed a painful blistering rash on one side of her
forehead and anterior scalp. She also has a red eye, decreased visual acuity and
epiphora alongside the forehead tenderness. What is the SINGLE most likely nerve
al
affected?
Ev
A. Accessory nerve
B. Facial nerve
C. Olfactory nerve
D. Optic nerve
E. Trigeminal nerve
Herpes zoster ophthalmicus
Herpes zoster ophthalmicus (HZO) describes the reactivation of the varicella zoster
virus in the area supplied by the ophthalmic division of the trigeminal nerve. It accounts
for around 10-20% of case of shingles.Ophthalmic herpes is a danger to sight and the
patient should see an ophthalmologist the same day.
Features
- Vesicular rash around the eye, which may or may not involve the actual eye
itself
1116
- Hutchinson's sign: rash on the tip or side of the nose. Indicates nasociliary
involvement and is a strong risk factor for ocular involvement
Management
- Oral antiviral treatment
- Oral corticosteroids may reduce the duration of pain
- Ocular involvement requires urgent ophthalmology review
Complications
- Ocular: conjunctivitis, keratitis, episcleritis, anterior uveitis
- Ptosis
- Post-herpetic neuralgia
Keratitis is a condition in which the eye's cornea, the front part of the eye, becomes
inflamed. Another infectious cause of keratitis is Herpes simplex keratitis in which case
presents with a dendritic corneal ulcer. For herpes simplex keratitis, topical acyclovir is
used
y
8. A 35 year old HIV positive man presents with progressive visual deterioration. He
op
complains of blurred vision and floaters. On examination, multiple cotton wool spots
are seen in both eyes. What is the SINGLE most likely causative organism?
C
A. Herpes zoster
B. Cryptosporidium
C. Cytomegalovirus
n
D. Pneumocystis jiroveci pneumonia
io
E. Cryptococcus neoformans
t
One of the rare manifestations of cytomegalovirus includes retinitis. It is usually seen in

ua
an immunocompromised host (e.g. a positive HIV patient) like in this stem. Although it
is rare, retinitis is still the most common manifestation of CMV disease in patients who
are HIV positive. Very early CMV may resemble cotton wool spots.
al
Cytomegalovirus retinitis
Ev
Presentation:
- Decreased visual acuity, floaters, and loss of visual fields on one side
- Examination shows yellow-white cloudy retinal lesions. Lesions may appear at
the periphery of the fundus, but they progress centrally.
- It begins as a unilateral disease, but in many cases it progresses to bilateral
involvement
Remembering the findings of the examination of the eye for cytomegalovirus retinitis is
less important as the question writers would have to give a history of HIV for this to be
cytomegalovirus retinitis. In view of that, if a patient with positive HIV attends with
visual deterioration, cytomegalovirus should be at the top of your differential.
9. A 25 year old man has a burning sensation in his left eye for the last 2 days. His eye is
red and has thick purulent discharge. His lids are often stuck shut on waking. What is
the SINGLE most appropriate initial management?
1117
A. Oral antibiotic
C. Topical antibiotics
D. Topical antibiotics and topical steroids
E. Clean discharge using cotton wool soaked in water
There has been a long debate regarding the use of topical antibiotics in bacterial
conjunctivitis. NHS has been moving towards using self care rather than antibiotics for
infective conjunctivitis. For most people, use of a topical ocular antibiotic makes little
difference to recovery from infective conjunctivitis and up to 10% of people treated
with topical ocular antibiotics complain of adverse reactions to treatment. Not to
mention, that the risk of a serious complication from untreated infective conjunctivitis
is low.
Thus, one should only consider topical ocular antibiotics if the infective conjunctivitis is
severe, or likely to become severe, providing serious causes of a red eye can be
confidently excluded. It would seem reasonable to consider infective conjunctivitis to
be severe when the person considers the symptoms to be distressing or signs are
y
judged to be severe from clinical experience. However, it is obvious that you will not be
op
able to tell based on the PLAB questions if it is severe conjunctivitis or mild
conjunctivitis. So a good guideline that you should follow is based on time. If the
patient has infective conjunctivitis for more than 7 days, then start the patient on
C
topical antibiotics. If it is less than 7 days, then choose the option that has self-care
rather than topical antibiotics.
n
Topical steroids is always going to be the wrong answer unless it is herpes simplex virus
io
conjunctivitis. It is only used if keratitis extends deep into the stroma.

t
Bacterial conjunctivitis management

ua
Most cases of infective conjunctivitis do not need medical treatment and clear up in
one to two weeks.
al
Gently clean away sticky discharge from your eyelids and lashes using cotton wool
soaked in water.
Ev
If the decision is made to use antibiotics → chloramphenicol drops is the drug of choice.
Chloramphenicol has a broad spectrum of activity and is the drug of choice for
superficial eye infections. It is bacteriostatic, with a relatively broad spectrum of action
against most Gram-positive and Gram-negative bacteria.
Types of conjunctivitis:
Bacterial conjunctivitis Viral conjunctivitis Allergic conjunctivitis

- Purulent discharge - Serous discharge - Bilateral
- Eyes may be 'stuck - Recent URTI symptoms
together' in the - Preauricular - Itch is prominent
morning lymph nodes - May give a history
of atopy
- May be seasonal
(due to pollen) or
perennial (due to
dust mite,
1118
washing powder
or other allergens)
10. A 45 year old woman had her visual acuity checked at her local optician. Several hours
later she presents to the emergency department with severe ocular pain and redness in
her eye. She also complains of seeing coloured halos. What SINGLE anatomical
structure is most likely to be involved?
A. Iris
B. Ciliary body
C. Anterior chamber
D. Posterior chamber
E. Cornea
This question is testing your knowledge of acute angle closure glaucoma. It is important
to remember the symptoms of acute angle closure glaucoma worsen when the pupils
are dilated (e.g. in a dark room).
y
op
The history of having her eyes checked but the optician gives us the idea that either:
1. A mildly illuminated room like of an opticians room would dilate the pupils
enough to worsen symptoms
C
2. Topical mydriatics was applied in which case led to pupillary dilation which can
push the iris into the angle and precipitate AAC in anyone with narrow angles.
n
Angle closure glaucoma (ACG) is associated with a physically obstructed anterior
io
chamber angle.
t

ua

al

Ev
both eyes.
Medical
1119
- Pilocarpine 1-2%
Surgical
y
op
C
Surgical iridectomy
n
io

t
11. A 33 year old man presents to clinic with a history of early morning back pain, stiffness
ua
and a painful red right eye. The pain in the eye started last night. On examination, his
right pupil is seen to have a distorted pupil shape. His visual acuity is unaffected. What
is the SINGLE most likely affected anatomical structure?
al
A. Optic nerve
Ev
B. Iris
C. Cornea
D. Conjunctiva
E. Sclera
A middle age man with early morning back pain and stiffness is suggestive of
seronegative arthritis likely ankylosing spondylitis where anterior uveitis (iritis) is a
known association.
It is also important to note that visual acuity for iritis is initially normal but can worsen
as time passes.
The abnormally shaped pupil is another give away.
Anterior uveitis
1120
Presentation
Features

- Photophobia
y
lamp
op
C
flare
n
io

t

ua
vision)
al
Ev
Management:

dilated
12. A 30 year old woman has a sudden acute headache with nausea and vomiting. She has
a red, painful left eye. The symptoms started when she was watching television in a
dark room. Palpation of the glove reveals it to be hard. What is the SINGLE most likely
visual symptom?
B. Peripheral visual field loss
1121
C. Coloured halos
D. Floaters
E. Glares
In acute angle closure glaucoma, coloured haloes around lights are often a complaint by
patients. Nausea and vomiting are common and may be the main presenting feature in
some patients.

y
op
C
n
both eyes.
io
Medical
t
ua

al

Ev
- Pilocarpine 1-2%
Surgical

1122
Surgical iridectomy
13. A 48 year old man attends clinic for a routine eye check up as he has a history of type 1
diabetes. Fundoscopy shows neovascularization at the retina. What is the SINGLE most
A. Strict blood glucose control

B. Review in 12 months
C. Non urgent referral to specialist
D. Insulin
E. Laser photocoagulation
y
op
The diagnosis here is proliferative retinopathy. Remember how to distinguish the types
of diabetic retinopathy. Also remember that type I diabetes mellitus is a common cause
of retinopathy. Laser photocoagulation is needed for proliferative retinopathy.
C
Background retinopathy (nonproliferative)
n
- Microaneurysms (dots)
io
- Haemorrhage (blots)
- Hard exudates
t
ua
Preproliferative retinopathy
- Addition of Cotton wool spots

al
Proliferative retinopathy
Ev
- Addition of new vessel formation (neovascularization)

- More serious. Progresses rapidly to blindness. Neovascularization. May lead to
vitreous haemorrhage
- Floaters in vision
- Laser photocoagulation is needed
14. A 68 year old patient attends for retinal screening. He is found to have hard exudates,
macular oedema and arteriovenous nipping. He is on long term treatment with
nifedipine. What is the SINGLE most likely diagnosis?
Hypertensive retinopathy
1123
Most patients with hypertensive retinopathy have no symptoms.
Chronic hypertension (blood pressure > 140/90 mmHg):

- Usually asymptomatic
- Fundoscopy reveals bilateral attenuation of arterial vessels ('copper or silver
wiring'), arteriovenous nipping (where the arteries cross the veins) and,
eventually, haemorrhage and exudates
Malignant (accelerated) hypertension (clinic blood pressure >180/110 mmHg):

- May have headaches and decreased vision
- On fundoscopy, hard exudates appear as a 'macular star' (thin white streaks
radiating around the macula), disc swelling, cotton wool spots, flame
haemorrhages and arterial or venous occlusions.
Key phrases in the exam that help you pick Hypertensive retinopathy as the answer:
- Copper or silver wiring
- Arteriovenous nipping
y
- Flamed shaped haemorrhage - also found in diabetic retinopathy
op
Usually one of these 3 terms would appear in the stem
Management
C
- Aimed at controlling the hypertension
15. A 67 year old man has deteriorating vision in his left eye. His complaints that his vision
has been slowly getting more blurry over the last few months. Glare from the
n
headlights of cars is particularly a problem when driving at night. He has a history of
io
longstanding COPD and is on multiple drugs for it. What SINGLE medication is most
likely to cause his visual deterioration?
t
ua
A. Salmeterol
B. Oral corticosteroid
C. Tiotropium
al
D. Theophylline
E. Inhaled corticosteroid
Ev
The diagnosis here is steroid induced cataracts. Long term use of steroids can cause
cataracts. Oral corticosteroids have more of a systemic effect compared to inhaled
corticosteroids. Thus, oral steroids are more likely to be the cause of his cataracts.
Exposure to great amounts of UV light i.e. Person from Australia who never wears
sunglasses
- A high myopia
- Trauma to eye
1124
16. A 34 year old homosexual man attends clinic with a history of weight loss and
progressive visual deterioration. A funduscopic examination reveals retinal
haemorrhages and yellow-white areas with perivascular exudates. What is the SINGLE
most appropriate causative organism?
A. Mycobacterium avium
B. Herpes simplex virus
C. Haemophilus influenzae
D. Cytomegalovirus
The hint here is the homosexual man. For a very inappropriate reason, question writers
tend to use the phrase homosexual to hint to you for the possibility of AIDS like in this
case. The combination of weight loss is another clue towards the diagnosis of HIV.
One of the rare manifestations of cytomegalovirus includes retinitis. It is usually seen in

an immunocompromised host (e.g. a positive HIV patient) like in this stem. Although it
is rare, retinitis is still the most common manifestation of CMV disease in patients who
y
are HIV positive.
op
Retinal haemorrhage is a recognized association with cytomegalovirus retinitis
C
Cytomegalovirus retinitis
Presentation:
n
- Decreased visual acuity, floaters, and loss of visual fields on one side
io
- Examination shows yellow-white cloudy retinal lesions. Lesions may appear at

the periphery of the fundus, but they progress centrally.
t
- It begins as a unilateral disease, but in many cases it progresses to bilateral

ua
involvement
Remembering the findings of the examination of the eye for cytomegalovirus retinitis is
al
less important as the question writers would have to give a history of HIV for this to be
cytomegalovirus retinitis. In view of that, if a patient with positive HIV attends with
Ev
visual deterioration, cytomegalovirus should be at the top of your differential.
17. A 44 year old man has sudden severe eye pain, red eye, visual blurring. It started when
he went to watch a movie in the theatre. It was accompanied by nausea and vomiting.
Slit-lamp findings include shallow anterior chambers in both eyes with corneal epithelial
oedema. What is the SINGLE most likely diagnosis?
A. Central retinal vein occlusion

B. Acute closed angle glaucoma
C. Uveitis
18.D. Iritis
The slit-lamp findings are consistent with acute closed angle glaucoma. This is
supported by the history of entering a dark room (movie theatre) when symptoms
started along with the severe painful red eye.
1125

both eyes.
y
op
Medical
C
n
io
- Pilocarpine 1-2%
t

ua
al
Ev
Surgical

Surgical iridectomy
1126
18. A 44 year old hypertensive male, loses vision in his left eye overnight. There is no pain
or redness associated with his visual loss. On fundoscopy, venous dilation, tortuosity,
and retinal haemorrhages are observed on his left eye. No abnormalities are found on
his right eye on fundoscopy. What is the SINGLE most likely cause of his unilateral visual
loss?
A. Hypertension retinopathy
B. Central Retinal Artery Occlusion
C. Central Retinal Vein Occlusion
D. Background retinopathy
E. Retinal detachment
Central Retinal Vein Occlusion (CRVO)
These patients have a clinical presentation similar to those with retinal artery occlusion.
There is the sudden loss of vision without pain, redness, or abnormality in pupillary
dilation.
y
op
Ocular examination by funduscopy reveals disk swelling, venous dilation, tortuosity,
and retinal haemorrhages. C
Diagnosis
Retinal haemorrhages are the main way of distinguishing venous obstruction from
arterial obstruction. You cannot have a hemorrhage in the retina if you don't have
n
blood getting into the eye.
io
19. A 49 year old man has sudden complete loss of vision from his left eye over a couple of
t
seconds. There was no pain associated with it and there is no redness of the eye.
ua
attenuation of the vessels. What is the SINGLE most likely diagnosis?
al

Ev

Central retinal artery occlusion

Central retinal artery occlusion occurs when the central retinal artery occludes before it
branches out as it emerges from the optic nerve, resulting in almost complete hypoxia
of the inner retina.
Presentation
- Sudden (over a few seconds)
- Unilateral painless visual loss
- In 94% of cases, vision is usually reduced to counting fingers (worse suggests
that the ophthalmic artery may also be affected
- There may be a history of amaurosis fugax (amaurosis fugax precedes loss of
vision in up to 10% of patients)
- There is no redness of the eye
1127
Examination:
- An afferent pupil defect appears within seconds and may precede retinal
changes by 1 hour. Ophthalmoscopy reveals:
o A retina that appears white or pale
o Cherry red spot at the macula
o Attenuation of the vessels
What is an afferent pupillary defect?

Afferent defects (absent direct response) is when the pupil won’t respond to light, but
constricts to a beam in the other eye (consensual response). Constriction to
accommodation still occurs.
Investigations
- In the acute setting, diagnosis is usually clinical and investigations are aimed at
ruling out underlying diseases. The most important cause to rule out is giant
cell arteritis because, with appropriate and timely intervention, the visual loss is
reversible and the fellow eye will be protected.
y
op
Management
- If the patient presents within 90-100 minutes of onset of symptoms, you could
try firm ocular massage. The idea behind this is to try to dislodge the
C
obstruction. However, this only works very occasionally and immediate referral
is mandatory.
n
20. A 52 year old man presents with sudden complete loss of vision from the right eye. He
io
also had been complaining of right sided headaches which would come up more on
chewing. On fundoscopy, the retina was pale and a cherry red spot could be seen in the
t
macular region. What is the SINGLE most likely cause of vision loss?
ua

al

Ev
The most important diagnosis here to exclude would be giant cell arteritis. An old man
with symptoms of headache and pain on chewing are classic features.
Central retinal artery can be affected by giant cell arteritis. Approximately 10% of
patients with ocular involvement in giant cell arteritis experience a central retinal artery
occlusion.
The sudden loss of vision in one eye and the pale retina with cherry red spots seen in
the macula are diagnostic for central retinal artery occlusion.

1128
Presentation
Examination:

y
op
Investigations
C
n
io
Management
t
ua
is mandatory.
al
21. A 63 year old woman has progressive decrease in her visiul acuity and peripheral visual
Ev
field loss. She is shortsighted and needs to wear glasses. On examination, she has
normal pupils on both eyes. What is the SINGLE most likely diagnosis?
A. Cataract
B. Glaucoma
D. Iritis
The symptoms and progressive decrease in vision and myopia point towards open-
angle glaucoma.
Simple (primary) open-angle glaucoma is present in around 2% of people older than 40

years. Other than age, risk factors that need to be known for PLAB include:
- family history
- black patients
- myopia
1129
Note: The incidence increases with age, most commonly presenting after the age of 65
(and rarely before the age of 40).
Unfortunately, in the vast majority of cases, patients are asymptomatic. Because initial
visual loss is to peripheral vision and the field of vision is covered by the other eye,
patients do not notice visual loss until severe and permanent damage has occurred,
often impacting on central (foveal) vision. By then, up to 90% of the optic nerve fibres
may have been irreversibly damaged
Open-angle glaucoma may be detected on checking the IOPs and visual fields of those
with affected relatives. Suspicion may arise during the course of a routine eye check by
an optician or GP, where abnormal discs, IOPs or visual fields may be noted.
Features may include

- peripheral visual field loss - nasal scotomas progressing to 'tunnel vision'
- decreased visual acuity
- optic disc cupping
y
op
22. A 27 year old female was brought to the emergency department by her friend from a
movie theatre. She complains of sudden severe pain in the eye followed by vomiting.
She sees coloured halos, has blurry vision and a red eye. She gives a past history of
C
recurrent headaches which used to resolve spontaneously. Examination shows fixed,
dilated ovoid pupils. What is the SINGLE most initial investigation?
n
A. CT head
io
B. MRI orbits
C. Blood culture and sensitivity
t
D. Toxicology screen
ua
E. Ocular tonometry
The history is consistent with acute angle closure glaucoma. Headaches and blurry
al
vision are common. Symptoms tend to worsen with pupil dilation as seen in this stem
when she is watching a movie in a dark theatre. Vomiting is also a common feature of
Ev
acute glaucoma.
Ocular tonometry is needed to determine the intraocular pressure to help diagnose

glaucoma.

1130
both eyes.
Medical

- Pilocarpine 1-2%
y
op
C
n
io
Surgical
t

ua
al
Ev
Surgical iridectomy
23. A 52 year old man has a painful, red, photophobic right eye with slightly blurred vision
and watering for 2 days. He has no similar episodes in the past. On slit lamp
examination, there are cells and flare in the anterior chamber. The pupil is also sluggish
to react. What is the SINGLE most appropriate clinical diagnosis?

B. Acute conjunctivitis
C. Acute dacryocystitis
D. Acute iritis
E. Corneal foreign body
Anterior uveitis
1131
Presentation
Features

- Photophobia
y
op
lamp
C
n
flare
io

t
ua

vision)
al
Ev
Management:

dilated
24. A 33 year old woman started seeing tiny black dots followed by a painless sudden loss
of vision in her left eye a few hours ago. She says that it initially felt like a curtain was
falling down. On fundoscopy, the optic disc is normal. What is the SINGLE most likely
underlying pathology?
A. Iritis
1132
B. Glaucoma
C. Vitreous chamber
D. Retinal detachment
E. Central retinal artery occlusion
Causes of sudden painless loss of vision:
- Retinal detachment
- Vitreous haemorrhage
- Retinal vein occlusion
- Retinal artery occlusion
- Optic neuritis
- Cerebrovascular accident
Among all the causes of painless loss of vision, retinal detachment fits as they give clues
like the tiny black dots which are “floaters” and the typical description of a “curtain
falling down”.
y
If you cannot see an retinal detachment on ophthalmoscopy but suspect it, refer the
op
patient on for a slit-lamp examination (direct ophthalmoscopy offers only a narrow field
of view). C
Retinal detachment
Pathogenesis
n
Retinal detachment is usually spontaneous, but it may result from trauma.
io
The two most common predisposing factors are extreme myopia and surgical extraction
t
of cataracts.
ua
Traction on the retina can also occur from proliferative retinopathy from diabetes,
retinal vein occlusion, and age-related macular degeneration.
al
Ev
The classic symptom is photopsia (flashing lights). A common presentation is blurry

vision developing in one eye without pain or redness. The patient may complain of
seeing "floaters;' as well as flashes at the periphery of vision. Sometimes it is described
as a "curtain coming down," as the retina falls off the sclera behind it.
Remember this:
Detachment presents with 4 ‘F’s : floaters, flashes, field loss, and fall in acuity
Diagnosis
Ophthalmoscopy: grey opalescent retina, ballooning forward.
Treatment
Various methods of trying to reattach the retina are employed. Patients should lean
their heads back to promote the chance that the retina will fall back into place. The
1133
retina can be mechanically reattached to the sclera surgically, by laser
photocoagulation, cryotherapy, or by the injection of expansile gas into the vitreal
cavity. The gas will press the retina back into place. A "buckle," or belt, can be placed
around the sclera to push the sclera forward so that it can come into contact with the
retina.
25. A 70 year old man who has a medical history of diabetes mellitus and hypertension
experiences acute monocular blindness which resolves after 30 minutes. He describes
this as a curtain coming down vertically into the field of vision of one eye. What is the

B. Optic neuritis
C. Lacunar infarct
D. Pontine haemorrhage
E. Amaurosis fugax
Amaurosis Fugax
y
- Painless transient monocular visual loss (i.e. loss of vision in one eye that is not
op
permanent)
- It is indicative of retinal ischaemia, usually associated with emboli or stenosis of
the ipsilateral carotid artery
C
Presentation:
- Sudden, unilateral vision loss; “black curtain coming down”
n
- Duration: 5-15 minutes; resolves within < 24 hours
io
- Associated with stroke or transient ischaemic attack (TIA) and its risk factors
(i.e. hypertension, atherosclerosis)
t
- Has an association with giant cell arteritis

ua
26. A 45 year old man with type 1 diabetes mellitus has his annual check ups.
Ophthalmoscopy shows dot and blot haemorrhage with hard exudates. What is the
al

Ev
B. Retinal detachment
D. Diabetic background retinopathy
E. Diabetic proliferative retinopathy
The diagnosis here is background retinopathy. Remember how to distinguish the types
of diabetic retinopathy. Also remember that type I diabetes mellitus is a common cause
of retinopathy.
Background retinopathy (nonproliferative)
- Microaneurysms (dots)
- Haemorrhage (blots)
- Hard exudates
Preproliferative retinopathy
1134
- Addition of Cotton wool spots
Proliferative retinopathy
- Addition of new vessel formation (neovascularization)

- More serious. Progresses rapidly to blindness. Neovascularization. May lead to
vitreous haemorrhage
- Floaters in vision
- Laser photocoagulation is needed
27. A 54 year old myopic develops flashes of light and then sudden painless loss of vision.
He says that it initially felt like a curtain was falling down. Ophthalmoscope shows a
grey opalescent retina, ballooning forward. What is the SINGLE most appropriate
treatment?
A. Pilocarpine
B. Peripheral iridectomy
y
C. Scleral buckling
op
D. IV acetazolamide
E. Surgical extraction of lens C
Diagnosis here is retinal detachment. Treatment options include scleral buckling.
Among all the causes of painless loss of vision, retinal detachment fits as they give clues
like the description of a “curtain falling down”. Myopia is also another hint as it is a
n
predisposing factor.
io
Retinal detachment
t
Pathogenesis
ua
Retinal detachment is usually spontaneous, but it may result from trauma.

al
The two most common predisposing factors are extreme myopia and surgical extraction
of cataracts.
Ev
Traction on the retina can also occur from proliferative retinopathy from diabetes,
retinal vein occlusion, and age-related macular degeneration.
The classic symptom is photopsia (flashing lights). A common presentation is blurry

vision developing in one eye without pain or redness. The patient may complain of
seeing "floaters;' as well as flashes at the periphery of vision. Sometimes it is described
as a "curtain coming down," as the retina falls off the sclera behind it.
Remember this:
Detachment presents with 4 ‘F’s : floaters, flashes, field loss, and fall in acuity
Diagnosis
Ophthalmoscopy: grey opalescent retina, ballooning forward.
1135
Treatment
Various methods of trying to reattach the retina are employed. Patients should lean
their heads back to promote the chance that the retina will fall back into place. The
retina can be mechanically reattached to the sclera surgically, by laser
photocoagulation, cryotherapy, or by the injection of expansile gas into the vitreal
cavity. The gas will press the retina back into place. A "buckle," or belt, can be placed
around the sclera to push the sclera forward so that it can come into contact with the
retina.
28. A 48 year old woman presents with severe left-sided headaches, ocular pain and a red,
watering eye. She has intermittent blurring of vision and sees coloured haloes. What is
the SINGLE most appropriate next step of action?
A. Measure intraocular pressure

B. Relieve pain with aspirin
C. Administer 100% oxygen
y
op
E. Relieve pain with sumatriptan
The case here is one of acute angle closure glaucoma. Measurement of intraocular
C
pressure would help establish the diagnosis.

n
io

t

ua

al
Ev
both eyes.
Medical

- Pilocarpine 1-2%
1136
Surgical

y
Surgical iridectomy
op
C
29. A 32 year old woman has progressive decrease in vision over the past 3 years on both
n
eyes. She is myopic and wears glasses. She is now almost blind. What is the SINGLE
io

t
A. Cataract
ua
B. Glaucoma
C. Retinopathy
D. Uveitis
al
E. Keratitis
Ev
The symptoms and progressive decrease in vision and myopia point towards open-
angle glaucoma. Although the age does not correlate with open-angle glaucoma as it is
very rare before the age of 40, the other options given are much less likely.
Simple (primary) open-angle glaucoma is present in around 2% of people older than 40

years. Other than age, risk factors that need to be known for PLAB include:
- family history
- black patients
- myopia
Note: The incidence increases with age, most commonly presenting after the age of 65
(and rarely before the age of 40).
Unfortunately, in the vast majority of cases, patients are asymptomatic. Because initial
visual loss is to peripheral vision and the field of vision is covered by the other eye,
patients do not notice visual loss until severe and permanent damage has occurred,
often impacting on central (foveal) vision. By then, up to 90% of the optic nerve fibres
may have been irreversibly damaged
1137
Open-angle glaucoma may be detected on checking the IOPs and visual fields of those
with affected relatives. Suspicion may arise during the course of a routine eye check by
an optician or GP, where abnormal discs, IOPs or visual fields may be noted.
Features may include

- peripheral visual field loss - nasal scotomas progressing to 'tunnel vision'
- decreased visual acuity
- optic disc cupping
30. A 49 year old hypertensive man has sudden complete loss of vision from his left eye.
There was no pain associated with it and there is no redness of the eye.
attenuation of the vessels. What is the SINGLE most appropriate management?
A. Firm ocular massage

B. Corticosteroids
C. Scleral buckling
y
D. Panretinal photocoagulation
op
The likely diagnosis here is central retinal artery occlusion. An ocular massage can
C
dislodge the embolus to a point further down the arterial circulation and improve
retinal perfusion.
n
io
t

ua
Presentation
al

Ev

Examination:

1138
Investigations
Management
is mandatory.
31. A 62 year old man complains of headaches and decreased vision. He has a blood
pressure of 170/95 mmHg. Fundoscopy reveals disc swelling and a flame shaped
haemorrhage. What is the SINGLE most likely diagnosis?
Plab Lab Values
y
op
C
n
io

t
ua

al

Ev

- Usually one of these 3 terms would appear in the stem
Management
32. A 40 year old man has pain, redness and swelling over the nasal end of his right lower
eyelid. The eye is watery with some purulent discharge. The redness extends on to the
1139
nasal peri-orbital area and mucoid discharge can be expressed from the lacrimal
punctum. What is the SINGLE most appropriate clinical diagnosis?
A. Acute conjunctivitis
B. Acute dacryocystitis
C. Acute iritis
D. Retrobulbar neuritis
E. Scleritis
Acute dacryocystitis
Acute dacryocystitis is an acute inflammation of the lacrimal sac, often as a result of
infection.
Presentation
Symptoms and signs are over the region of the lacrimal sac (but may spread to the nose
and face with teeth pain being experienced by some). Therefore, look just lateral and
below the bridge of the nose for:
- Excess tears (epiphora)
y
- Pain
op
- Swelling and erythema at the inner canthus of the eye
Immediate antibiotic therapy may resolve the infection.

C
33. A 20 year old man comes with a 3 day history of a burning red left eye with sticky
greenish discharge. For the past few mornings, he says that his eyelids are stuck shut on
n
waking. What is the SINGLE most likely affected anatomical structure?
io
A. Iris
t
B. Ciliary body
ua
C. Cornea
D. Conjunctiva
E. Sclera
al
The given scenario is a clinical presentation of bacterial conjunctivitis. The term itself
Ev
gives away the anatomical location of the infection - conjunctiva.
It is important to remember the management of bacterial conjunctivitis as this can be

asked.
34. A 37 year old lady has been suffering from early morning stiffness of her small joints for
several months. She takes regular NSAIDS to manage the pain of her joints. She attends
clinic with a painful red eye. What is the SINGLE most likely affected anatomical
structure?
A. Iris
B. Ciliary body
C. Cornea
D. Sclera
E. Conjunctiva
1140
One of the ocular manifestation of rheumatoid arthritis is scleritis which presents with
an erythematous, painful eye.
Ocular manifestations of rheumatoid arthritis

Ocular manifestations of rheumatoid arthritis are common
Remember these 4:
- Keratoconjunctivitis sicca → is the most common

- Episcleritis → presents with erythema (pain is also present but less severe than
scleritis)
- Scleritis → presents with erythema and pain
- Iatrogenic steroid-induced cataracts
35. A 24 year old has a marked eye pain, sticky red eye with a congested conjunctiva for the
past 7 days. He says that his eyes feel stuck together in the morning. What is the
SINGLE most appropriate treatment?
y
A. Oral antibiotic
op
C. Antibiotic drops
D. Steroid and antibiotic drops
C
E. Saline drops
There has been a long debate regarding the use of topical antibiotics in bacterial
n
conjunctivitis. NHS has been moving towards using self care rather than antibiotics for
io
infective conjunctivitis. For most people, use of a topical ocular antibiotic makes little
difference to recovery from infective conjunctivitis and up to 10% of people treated
t
with topical ocular antibiotics complain of adverse reactions to treatment. Not to

ua
mention, that the risk of a serious complication from untreated infective conjunctivitis
is low.
al
Thus, one should only consider topical ocular antibiotics if the infective conjunctivitis is
severe, or likely to become severe, providing serious causes of a red eye can be
Ev
confidently excluded. It would seem reasonable to consider infective conjunctivitis to

be severe when the person considers the symptoms to be distressing or signs are
judged to be severe from clinical experience. However, it is obvious that you will not be
able to tell based on the PLAB questions if it is severe conjunctivitis or mild
conjunctivitis. So a good guideline that you should follow is based on time. If the
patient has infective conjunctivitis for more than 7 days, then start the patient on
topical antibiotics. If it is less than 7 days, then choose the option that has self-care
rather than topical antibiotics.
Topical steroids is always going to be the wrong answer unless it is herpes simplex virus
conjunctivitis. It is only used if keratitis extends deep into the stroma.
Bacterial conjunctivitis management
- Most cases of infective conjunctivitis do not need medical treatment and clear
up in one to two weeks.
1141
- Gently clean away sticky discharge from your eyelids and lashes using cotton
wool soaked in water.
- If the decision is made to use antibiotics → chloramphenicol drops is the drug
of choice. Chloramphenicol has a broad spectrum of activity and is the drug of
choice for superficial eye infections. It is bacteriostatic, with a relatively broad
spectrum of action against most Gram-positive and Gram-negative bacteria.
Types of conjunctivitis:
Bacterial conjunctivitis Viral conjunctivitis Allergic conjunctivitis
- Purulent discharge - Serous discharge - Bilateral
- Eyes may be 'stuck - Recent URTI symptoms
together' in the - Preauricular - Itch is prominent
morning lymph nodes - May give a history
of atopy
- May be seasonal
(due to pollen) or
perennial (due to
dust mite,
y
washing powder
op
or other allergens)
36. A 38 year old female has reduced vision and eye pain both eyes. She has had a similar
episode about a year ago which resolved completely within 3 months. She says that the
C
red colour appears "washed out". On physical examination, mild weakness of right
upper limb was appreciated and exaggerated reflexes was appreciated. What is the
n
io
t
C. Corticosteroids
ua
D. Peripheral iridectomy
al
Optic neuritis is diagnosed clinically by symptoms of acute unilateral decrease in vision,

eye pain-especially with movement and decreased color vision/contrast/brightness
Ev
sense and documentation of a visual field defect. The focal neurological symptoms and
exaggerated reflexes all points towards multiple sclerosis which is the probably cause of
optic neuritis in which case corticosteroids would be used as part of the management.
Optic neuritis (ON)

Inflammation of the optic nerve
Presentation
- Classically there is a triad of clinical features which are:
o Reduced vision (of varying severity) → Usually unilateral. Progresses for
less than 2 weeks and spontaneously improves within 3 weeks.
o Eye pain → Particularly on movement
o Impaired colour vision → Initially loss of red colour vision
- One of the most common cause of optic neuritis is multiple sclerosis → Seen
especially in caucasian populations
The stem would usually (but not always) include a female patient as multiple
sclerosis is more prevalent in the female gender
1142
- Examination
o Swollen optic disc
o Optic disc becomes pale later (4 to 6 weeks after onset)
37. A 60 year old woman has decreased vision over the past year. She is not able to see
well at night. She has changed her spectacles several times recently due to refraction
changed but she still complains of glare. She has a normal pupil on examination. What
A. Cataract
B. Glaucoma
D. Iritis
The key to note here is the frequent change spectacles due to change of refraction. This
on top of the complaints of glare and reduce vision points towards cataracts.
Sometimes in PLAB, they will also give a history of long term steroid which may be the
y
aetiology behind cataracts formation.
Cataract
op
C
Presentation
Blurred vision; unilateral cataracts are often unnoticed, but loss of stereopsis affects
distance judgment. Bilateral cataracts cause gradual loss of vision (frequent spectacle
n
changes as refraction changes) ± dazzle (especially In sunlight) ± monocular diplopia. In
io
children they may present as squint, loss of binocular function, or a white pupil
t
38. Which of the following is not a degenerative corneal disease?

ua
A. Band keratopathy
B. Pellucid marginal degeneration
al
C. Mooren’s ulcer
D. Terrien marginal degeneration
Ev
E. Keratoconus
Mooren’s ulceration is characterized by painful peripheral corneal ulceration of

unknown aetiology. It is not a degenerative corneal disease. Pain is almost always
associated with the onset of Mooren's ulcer. The eye is usually red and the vision may
or may not be reduced.
39. A 49 year old woman complains of reduction of vision and dull pain in her left eye for
the past 2 weeks. Her past medical history includes multiple sclerosis which was
diagnosed 2 years ago. On examination, both pupils constrict when light is directed to
the right eye but both pupils fail to constrict fully when light is directed to the left eye.
What is the SINGLE most likely defect to accompany her diagnosis?
B. Monocular visual field loss
C. Bitemporal hemianopsia
D. Central scotoma
1143
E. Homonymous hemianopia
Optic neuritis is the likely diagnosis here. It usually presents with acute or subacute
unilateral decrease in vision and eye pain particularly on movement. The fact that she
has multiple sclerosis is a huge hint. Visual field loss is a known feature of optic neuritis.
Some may argue that scotoma can also be present in optic neuritis, but in reality
monocular visual field loss is more frequently seen.
To understand the reason behind the patient’s pupils dilating when the light stimulus is
directed to the affected eye (left eye), one has to understand the principles of the
Marcus Gunn test. In the Marcus Gunn test, light stimulation of the normal eye
produces full constriction in both pupils. Immediate subsequent stimulus of the
affected eye produces an apparent dilation in both pupils since the stimulus carried
through that optic nerve is weaker. The affected eye still senses light and produces
pupillary sphincter constriction to some degree but it’s less compared to the normal
eye. This is specifically seen in optic neuropathy such as optic neuritis.
Optic neuritis (ON)
y
Presentation
op
C
n
io
t
ua

- Examination
al

Ev
40. A 32 year old woman complains of dull pain in her right eye for the past one week
which worsens when moving her eye. Her past medical history includes multiple
sclerosis which was diagnosed 6 months ago. An ophthalmoscopy shows pallor of the
optic disc. Which anatomical site is most likely to be affected?
A. Optic nerve
B. Sclera
C. Optic radiation
D. Trigeminal nerve
E. Oculomotor nerve
Optic neuritis is a relatively common presenting symptom of Multiple Sclerosis. It is due

to the demyelination of the optic nerve.
Optic neuritis (ON)

1144
Presentation
- Examination
41. A 41 year old man presents with visual symptoms and a headache. An ophthalmoscopic
examination shows papilloedema. Which anatomical site is most likely to be affected?
A. Retina
y
B. Optic disc
op
C. Optic radiation
D. Macula
E. Optic chiasma
C
Papilloedema is optic disc swelling resulting from raised intracranial pressure.
n
42. A 33 year old female complains of double vision which started yesterday. On
io
examination, a fixed dilated pupil which does not accommodate and drooping eyelid
can be seen on the left eye. Her left eye is displaced outward and downwards. She has
t
no significant past medical history. There was no history of trauma. What is the SINGLE
ua
most appropriate investigation to perform?
A. Ophthalmoscopy
al
B. Computed tomographic angiography

Ev
D. Visual field test

E. Red reflex examination
This is a case of oculomotor nerve palsy. Diplopia, mydriasis, ptosis, outward downward
deviation of the eye as described here are clinical features of oculomotor nerve palsy.
An oculomotor nerve palsy can be associated with vascular disorders such as diabetes,
or particularly posterior communicating artery aneurysm. Other causes include space
occupying tumours, infarction. abscess and trauma.
Angiographic imaging studies are often necessary in the evaluation of acute oculomotor
nerve palsy. A computed tomographic angiography would be a good option here to
help exclude a posterior communicating artery aneurysm. Note that this can also be
done with a magnetic resonance angiography. MRI would also be useful as it is a more
sensitive imaging technique than CT scan for picking out a small intraparenchymal
brainstem lesion, such as infarction, small abscess, or tumor however CT scan is more
sensitive than MRI to demonstrate subarachnoid hemorrhage. All of these have
potential to cause an oculomotor nerve palsy.
1145
Oculomotor nerve palsy
- The initial sign is often a fixed dilated pupil which does not accommodate
- Then ptosis develops
- Unopposed lateral rectus causes outward deviation of the eye. Characteristic
down and out position of the affected eye.
The simple method to remember this for the exam is:

- Will have features of either ptosis and/or a dilated pupil on the nerve on the
same side as the affected eye
- Mnemonic: Letter “O” for oculomotor which with good imagination can
represents a dilated pupil.
43. A 62 year old hypertensive man comes into clinic with blurred vision. He usually takes
amlodipine to manage his blood pressure and has been taking it for the past 10 years.
His blood pressure currently ranges between 150/90 mmHg to 160/100 mmHg. An
ophthalmoscope reveals dot blot haemorrhages, ischaemic changes and hard exudates.
y
op
C
C. Hypertensive retinopathy
E. Non-proliferative diabetic retinopathy
n
io
This patient has uncontrolled blood pressure. The major risk for arteriosclerotic
hypertensive retinopathy is the duration of elevated blood pressure which is seen here
t
as 10 years. Retinal haemorrhages develop when necrotic vessels bleed into either the
ua
nerve fiber layer (flame shaped hemorrhage) or the inner retina (dot blot hemorrhage).
Ischaemic changes and hard exudates are also seen in hypertensive retinopathy.
al
The clinical appearance on a dilated fundoscopic exam and the coexisting hypertension
gives the diagnosis of hypertensive retinopathy.
Ev
It is important to note that background retinopathy (non-proliferative) may also have

many similar findings on the fundoscopy which include microaneurysms (dots),
haemorrhage (flame shaped or blots) and hard exudates (yellow patches) but the
history of uncontrolled hypertension makes hypertensive retinopathy a better choice.

1146
Usually one of these 3 terms would appear in the stem
Management
44. A 39 year old woman has been having gradual loss of vision in both eyes over the past 6
months. She has a diagnosis of rheumatoid arthritis and has been on treatment for it
for the past 4 years. Her intraocular pressure is within normal limits and red reflex is
absent in both eyes. What is the SINGLE most likely diagnosis?
y
op
A. Cataract
B. Diabetic retinopathy
C. Hypermetropia
C
D. Macular degeneration
E. Hypertensive retinopathy
n
The diagnosis here is steroid induced cataracts. Long term use of steroids as seen in
io
someone with an autoimmune condition like rheumatoid arthritis can cause cataracts.
t
ua

- Exposure to great amounts of UV light i.e. Person from Australia who never
wears sunglasses
al
Ev

- A high myopia
- Trauma to eye
1147
ORTHOPAEDICS
y
op
C
Questions
n
io
&
t
ua
Answers
al
Ev
1148
Orthopaedics Questions
1. A 58 year old woman fell with an outstretched hand. She presents with dinner fork
deformity and tenderness over the right arm. She complains of numbness of the hand.
What is the SINGLE most likely associated nerve injury?
A. Axillary nerve
B. Radial nerve
C. Musculocutaneous nerve
D. Median nerve
E. Ulnar nerve
2. A 62 year old man has bone pain at his hips and back. On further investigation, alkaline
phosphatase was found to be elevated in his blood. An X-ray shows multifocal sclerotic
patches in the skull. What is the SINGLE most likely diagnosis?
B. Osteoporosis
y
C. Osteomalacia
op
D. Multiple myeloma
E. Ankylosing spondylitis C
3. A 15 year old boy presents with a limp and pain in the left knee. Physical examination
shows the leg is externally rotated and 2 cm shorter. There is limitation of flexion,
abduction and medial rotation. As the hip is flexed, it external rotates. What is the
n
io
A. Juvenile rheumatoid arthritis

t
B. Osgood-schlatter disease
ua
C. Reactive arthritis
D. Slipped upper femoral epiphysis
E. Transient synovitis of the hip
al
4. A 2 year old girl presents with a painless limp. On examination, there is unequal skin
Ev
folds and the left leg is shorter than the right leg. What is the SINGLE most likely
diagnosis?
A. Transient synovitis
B. Developmental dysplasia of the hip
C. Perthes’ disease
D. Juvenile idiopathic arthritis
E. Slipped capital femoral epiphysis
5. A 33 year old woman with a previous history of pain at the left wrist following a fall on
her outstretched hand 4 months ago presents with pain in the same wrist below the
thumb. She has not seek any medical advice or treatment prior to this. She says that
the pain is aggravated when she holds her baby. What is the SINGLE most likely cause?
A. Fracture radial head

B. Scaphoid fracture
C. Carpal tunnel syndrome
D. Colles' fracture
1149
E. Ulnar fracture
6. A 24 year old man falls on an outstretched hand while playing football. He comes in
complaining of pain at the base of the thumb. On physical examination, he is tender to
palpate over the anatomic snuff-box. Wrist movement, particularly pronation followed
by ulnar deviation is painful. X-rays are read as negative. What is the SINGLE most
appropriate next management?
A. Reassurance and analgesia

B. Surgery
C. Immobilization of the wrist and review in 2 weeks
D. Scaphoid cast for 6 weeks
E. High arm sling and rest
7. A 26 year old primigravida pregnant woman at 34 weeks gestation presents with

tingling and numbness with occasional pain of her right hand in addition to altered
sensation over her right middle and index finger. Tinel test is negative. What is the
y
op
A. Carpal Tunnel Syndrome
B. Radial nerve entrapment
C. Scaphoid fracture
C
D. Median nerve entrapment
E. Peripheral arterial disease
n
8. A 7 year old boy falls on his right hand with the arm extended. He has severe pain
io
around the elbow. X-ray imaging show a supracondylar fracture of the humerus. The
distal fragment is displaced posteriorly. What is the SINGLE most likely structure to be
t
damage?
ua
A. Anterior ulnar recurrent artery

B. Posterior ulnar recurrent artery
al
C. Ulnar artery
D. Radial artery
Ev
E. Brachial artery
9. An 80 year old woman with mild dementia at a nursing home tripped and fell on her
hand. X-ray revealed a fracture of the distal end of the radius with a 10 degree dorsal
angulation. What is the SINGLE best management for her?
A. Closed reduction of the fracture

B. Open reduction and internal fixation
C. Above elbow backslab cast
D. Plaster of Paris cast below elbow
E. Wrist sling
10. A 30 year old lady was playing volleyball when her hand got injured with the volleyball.
The right hand is not swollen and there is tenderness under the root of the thumb.
Wrist movement, particularly pronation followed by ulnar deviation is painful. X-ray of
the wrist show no presence of fractures. What is the SINGLE most appropriate next step
in management?
1150
A. Apply arm sling for 1 week
B. Reassurance and analgesia
C. Repeat X-ray in 2 weeks
D. Full arm cast for 1 week
E. Surgical exploration
11. A 13 year old boy presents with pain in the groin. He is seen limping. There was no
history of trauma. There is limited hip motion, and as the hip is flexed the thigh goes
into external rotation and cannot be rotated internally. When the boy is lying down, the
left leg is 2 cm shorter than the right leg and it is externally rotated. What is the SINGLE

B. Septic arthritis
y
op
12. A 60 year old man is brought to the emergency department with a fractured hip. He has
been having progressive hearing loss and was recently diagnosed with cardiac failure.
Hypercalcaemia was noted on his blood test. What is the SINGLE most likely diagnosis?
C
B. Osteoporosis
n
C. Osteomalacia
io
D. Multiple myeloma
E. Spondylosis
t
ua
13. A 7 year old boy fell on his outstretched arm and presents with pain around the elbow.
On examination, radial pulse is absent on the affected hand. What is the SINGLE most
likely diagnosis?
al
A. Dislocated elbow
Ev
B. Angulated supracondylar fractures of the humerus

C. Undisplaced fracture of radial head
D. Posterior dislocation of shoulder
E. Pulled elbow
14. A 19 year old boy comes to the emergency department with pain, swelling and
tenderness 2 cm distal to Lister’s tubercle of radius. He gives a history of falling down
on his outstretched hand while playing basketball. On examination, proximal pressure
on the extended thumb and index finger is painful. X-ray of the wrist shows no fracture
visible. What is the SINGLE most appropriate management?
A. Immobilization of wrist with cast and review in 2 weeks

B. High arm sling and rest
C. Magnetic resonance imaging of wrist
D. Surgical exploration
E. Reassurance and analgesia
1151
15. A 44 year old man slipped while he was coming down the stairs and he fell on his
outstretched arm. X-rays demonstrate an oblique fracture of the middle to distal thirds
of the humerus. He is unable to dorsiflex his right wrist. What is the SINGLE most likely
associated nerve injury?
A. Radial nerve
B. Musculocutaneous nerve
C. Median nerve
D. Ulnar nerve
E. Axillary nerve
16. A 63 year old man has knee pain and back pain for the last 3 months which is
progressively worsening. Bowing of the tibia is noted on examination. He also has
pronounced kyphosis. On further investigation, alkaline phosphatase was found to be
elevated in his blood. Serum calcium levels were normal. What is the SINGLE most likely
diagnosis?
A. Multiple myeloma
y
B. Osteoporosis
op
C. Osteomalacia
D. Paget’s disease
C
17. A 79 year old man had a fall 2 days ago and since then he is unable to bear weight on
his right leg. He presents with deformity and tenderness over the right hip area. X-ray
n
shows fracture of the acetabulum. What is the SINGLE most likely associated nerve
io
injury?
t
A. Sciatic nerve
ua
B. Gluteal nerve
C. Lateral peroneal nerve
D. Tibial nerve
al
E. Femoral nerve
Ev
18. A 35 year old male typist suffered a wrist injury after falling on his right outstretched
hand. He was treated with a scaphoid cast with the probable diagnosis of a scaphoid
fracture. The cast was removed after 2 weeks from the injury for a repeat X-ray. After
removing the cast, he noted that he he had difficulty in moving his right thumb, index
and middle finger. There was also a tingling sensation on those fingers. What is the
SINGLE most likely management that would improve his symptoms?
A. Release of flexor retinaculum

B. Release of common flexor sheath
C. Release of palmar aponeurosis
D. Ulnar nerve release
E. Fasciotomy
19. A 28 year old man was involved in a road traffic accident. He has severe pain in his
shoulder and upper arm. There is loss of shoulder and arm function with bruising seen
at the anterior shoulder on examination. X-ray shows a fracture of the neck of
humerus. What is the SINGLE most associated neurovascular injury?
1152
A. Suprascapular nerve injury
B. Radial nerve injury
C. Axillary artery injury
D. Brachial artery injury
E. Axillary nerve injury
20. A 55 year old woman has a history of a recent radial fracture. In the last decade, she
had a colles’ fracture in the right forearm and supracondylar humerus fracture of the
left arm. She used to take corticosteroids for 2 years as part of managing her
inflammatory bowel disease. What is the SINGLE most appropriate investigation to
perform?
A. Dual-energy X-ray absorptiometry (DEXA) scan

C. Nuclear bone scan
E. Bone biopsy
y
op
21. A 33 year old pregnant woman presents with right knee pain worse when moving the
joint. The pain has been present for the last 4 months but it is worsening. The pain is
noted to be worse at the end of the day. X-ray shows decreased joint space in the right
C
knee. Blood results show a CRP of 12. What is the SINGLE most appropriate
management?
n
A. Paracetamol
io
B. Oral nonsteroidal anti-inflammatory drugs (NSAIDs)

C. Oral steroid
t
D. Intra-articular steroid injections

ua
E. Disease-modifying antirheumatic drugs (DMARDs)
22. A 33 year old woman fell from playing volleyball and hit her right knee. Valgus stress
al
test is seen to be positive. What is the SINGLE most likely structure that is injured?
Ev
A. Anterior cruciate ligament

B. Posterior cruciate ligament
C. Lateral collateral ligament
D. Medial collateral ligament
E. Meniscus
23. A 7 year old boy fell in the playground with arm outstretched an hour ago. He is now
seen to be holding his forearm complaining of pain. Examination of his forearm reveals
tenderness but no sign of deformity or swelling. An X-ray was performed. What is the
A. Greenstick fracture of distal radius

B. Oblique fracture of the mid ulna
C. Transverse fracture of the mid radius
D. Spiral fracture of the distal ulna
E. Comminuted fracture of scaphoid
1153
24. A 35 year old volleyball player has pain in his right arm and shoulder for the past 2 days.
He finds it difficult to perform task which involve lifting his arm above his shoulder. His
shoulder feels weak. The shoulder pain is worse at night when he is in bed. There is no
history of trauma. What is the SINGLE most likely cause of his pain?
A. Rupture of the long head of biceps

B. Acromioclavicular ligament tear
C. Sternocleidomastoid injury
D. Supraspinatus tendinitis
E. Shoulder dislocation
25. A 33 year old woman has complaints of pain in her right arm and shoulder when she
abducts it. The pain is worse at night and disturbs her sleep. She finds it difficult to
perform task which involve lifting her arm such as combing her hair. She has recently
moved to a new house and was involved in carrying heavy items. There is no history of
trauma. What is the SINGLE most likely cause of her pain?
y
op
C
26. A 15 year old boy presents with fever and pain in the right lower thigh. The pain has
been ongoing for the past one month. On examination, there is a 2 cm by 2 cm mass at
n
the lower third of his thigh which is red, warm and tender. An X-ray shows bone
io
destruction with overlying onion-skin layers of periosteal bone formation and a soft
tissue mass. What is the SINGLE most likely diagnosis?
t
ua
A. Tuberculous arthritis
B. Ewing’s sarcoma
C. Osteosarcoma
al
D. Osteomyelitis
E. Fibrosarcoma
Ev
27. A 26 year old man complains of severe pain while trying to grasp objects. It started
when he fell during a skiing trip and hit his thumb on the ground while his thumb was
abducted. On physical exam there is collateral laxity at the thumb-
metacarpophalangeal joint with bruising over the joint. What is the SINGLE most likely
deformity?
A. Dinner fork deformity

B. Gamekeeper thumb
C. Mallet finger
D. Cubitus varus
E. Garden spade deformity
28. A 12 year old boy attends A&E with pain after falling off his bicycle. A lateral X-ray of his
wrist show a fracture at the distal radius with the distal fracture fragment displaced
anteriorly. What is the SINGLE most likely diagnosis?
1154
B. Cubitus valgus
C. Gunstock deformity
D. Garden spade deformity
E. Coxa Vara
29. A 61 year old female with a history of osteoporosis suddenly falls on her outstretched
hand while shopping. X-ray of the wrist shows a fracture at the distal radius with a
backward shift of the distal fragment. What is the SINGLE most likely deformity?
A. Cubitus valgus
B. Coxa Vara
C. Mallet finger
D. Dinner fork deformity
30. A 24 year old man presents to A&E after an injury to his hand while playing basketball.
Examination of his hand reveals an avulsion of the extensor digitorum tendon from the
y
distal phalanx. What is the SINGLE most likely deformity?

B. Gamekeeper thumb
op
C
C. Mallet finger
D. Gunstock deformity
n
io
31. A 67 year old woman presents to the emergency department with pain in her left groin.
She falls from a chair in the waiting area and now is in severe pain and is not able to
t
move her left leg. She takes alendronate regularly. What is the SINGLE most likely
ua
diagnosis?
A. Pelvic fracture
al
B. Bursitis
C. Femoral shaft fracture
Ev
D. Femoral neck fracture

E. Posterior hip dislocation
32. A 15 year old boy complains of pain in his leg which usually settles within an hour of
taking aspirin. The pain is described as a dull pain which is persistent but is usually
worse at night. What is the SINGLE most likely diagnosis?
A. Leiomyosarcoma
B. Liposarcoma
C. Chondrosarcoma
D. Exostosis
E. Osteoid osteoma
33. A 79 year old woman has a history of a Colles’ fracture three weeks ago after falling on
a concrete floor with her right hand. She is otherwise fit and well. What is the SINGLE
most appropriate investigation to assess her risk for further fracture?
1155
A. Radionuclide (isotope) scan
B. Dual energy X-ray absorptiometry (DEXA) scan
C. Magnetic resonance imaging (MRI)
D. X-ray of wrist
E. No further investigations required
34. A 59 year old woman has severe back pain. The back pain is suspected to caused by
bone metastases. What organ is the SINGLE most likely tumour arising from causing
bone metastases?
A. Lungs
B. Cervix
C. Ovary
D. Uterus
E. Breast
35. A 60 year old female has pain and stiffness in her right hip joint. The pain has been
worsening over the past 6 months. The pain increases in intensity as the day progresses
y
and it is usually least pain in the morning. She has noticed nodules in the joints of the
op
fingers of her hands. A recent blood test shows:
Haemoglobin 92 g/L
C
n
io
A. Rheumatoid arthritis
t
B. Osteoarthritis
ua
C. Gout
D. Pseudogout
E. Multiple myeloma
al
Ev
1156
Orthopaedics Answers
1. A 58 year old woman fell with an outstretched hand. She presents with dinner fork
deformity and tenderness over the right arm. She complains of numbness of the hand.
What is the SINGLE most likely associated nerve injury?
A. Axillary nerve
B. Radial nerve
C. Musculocutaneous nerve
D. Median nerve
E. Ulnar nerve
Colles’ fracture
Results from fall on an outstretched hand, often in old osteoporotic women. The
deformed and painful wrist looks like a "dinner fork,". The main lesion is a dorsally
displaced, dorsally angulated fracture of the distal radius.
y
Numbness of the hand can occur because of compression on the median nerve across
op
the wrist.
It is important to remember the key phrases for nerve damage during PLAB. There are
C
certain phrases you need to memorise to relate it to a specific nerve damages.
Examples:
n
io

t

ua
al

Ev

Paraesthesia and impaired sensation in both hands (glove distribution) → Peripheral
neuropathy
2. A 62 year old man has bone pain at his hips and back. On further investigation, alkaline
phosphatase was found to be elevated in his blood. An X-ray shows multifocal sclerotic
patches in the skull. What is the SINGLE most likely diagnosis?
B. Osteoporosis
C. Osteomalacia
D. Multiple myeloma
Note: there are two types of Paget’s disease:

1. Paget's disease of the bone (osteitis deformans)
2. Paget's disease of the breast
1157
Paget's disease (osteitis deformans)
Think of Paget’s disease as a bone-making process (bone turnover) becoming faster and
out of control. There is increased bone resorption and abnormal osteoclast activity
followed by rapid increase in bone formation by osteoblast. The new bone structure
ends up being disorganised and mechanically weaker, more bulky, less compact, more
vascular, and liable to pathological fracture and deformity.
Paget's disease can affect any bone but is most common in the axial skeleton, long
bones, and the skull. The usual sites are the pelvis, lumbar spine, femur, skull and tibia.
Presentation
- It is commonly asymptomatic and is discovered by the incidental finding of an
elevated serum alkaline phosphatase or characteristic abnormality on X-ray
- When symptoms occur, the most common complaints are bone pain and/or
deformity
o Bone pain may be present at rest and on movement
o Bone deformity includes sabre tibia (bowing of the tibia), kyphosis, and
frontal bossing of the skull.
y
o Other presentations include pathological fractures
op
o Deafness and tinnitus may be due to compression of cranial nerve VIII
o High-output cardiac failure (due to increased blood flow through
affected bone)
C
Investigations
n
- There are specific X-ray features of Paget's disease that include:
io
o A classical V-shaped pattern between healthy and diseased long bones

known as 'the blade of grass' lesion
t
o The 'cotton wool' pattern in the skull that is also characteristic

ua
(multifocal sclerotic patches)

- Serum calcium and parathyroid hormone levels are usually normal but
immobilisation may lead to hypercalcaemia
al
- Alkaline phosphatase is markedly raised

Ev
Note: Osteosarcoma is one of the complications thus Paget's needs to be monitored

closely.
Management
- Bisphosphonates
3. A 15 year old boy presents with a limp and pain in the left knee. Physical examination
shows the leg is externally rotated and 2 cm shorter. There is limitation of flexion,
abduction and medial rotation. As the hip is flexed, it external rotates. What is the

B. Osgood-schlatter disease
1158
Slipped Upper Femoral Epiphysis usually cause groin pain on the affected side, but
sometimes cause knee or thigh pain. Usually in slipped upper femoral epiphysis, there
is limited hip motion, and as the hip is flexed the thigh goes into external rotation and
cannot be rotated internally.
Slipped upper femoral epiphysis (SUFE)
Slipped upper femoral epiphysis is an orthopedic emergency. The typical patient is a

chubby boy, around age 13. They complain of groin (or knee) pain and are noted to be
limping.
It is caused by the displacement of the femoral epiphysis (growth plate) in relation to

the femoral neck. It is the commonest cause of a limp in a boy aged 12–14 or girl aged
11–13 (growth spurt at puberty). In this age group, it must be actively excluded in a
limping child.
Classic presentation is a limping, obese, 13 year old boy with knee pain.
y
op
- Obesity
- Rapid growth
- Male—♂:♀, 3:1
C
Clinical features
- The affected limb will be shorter and lies in external rotation
n
- Abduction is limited. When the hip is flexed, it will rotate externally
io
Note: the left side is usually more commonly affected compared to the right side
t
ua
4. A 2 year old girl presents with a painless limp. On examination, there is unequal skin
folds and the left leg is shorter than the right leg. What is the SINGLE most likely
diagnosis?
al
A. Transient synovitis
Ev
B. Developmental dysplasia of the hip

C. Perthes’ disease
D. Juvenile idiopathic arthritis
E. Slipped capital femoral epiphysis
Developmental dysplasia of the hip (DDH)

- Formerly referred to as congenital dislocation of the hip (CDH). DDH is now the
preferred term to reflect that DDH is an ongoing developmental process.
- Defined simply as abnormal growth of the hip
- More common in the left hip
An important risk factor to remember is vaginal delivery of babies with breech .
Barlow test: attempts to dislocate an articulated femoral head

Ortolani test: attempts to relocate a dislocated femoral head
Ultrasound is used to confirm the diagnosis if clinically suspected
1159
Management
- Pavlik harness in children younger than 4-6 months
- Surgery is reserved for older children
5. A 33 year old woman with a previous history of pain at the left wrist following a fall on
her outstretched hand 4 months ago presents with pain in the same wrist below the
thumb. She has not seek any medical advice or treatment prior to this. She says that
the pain is aggravated when she holds her baby. What is the SINGLE most likely cause?
A. Fracture radial head

B. Scaphoid fracture
C. Carpal tunnel syndrome
D. Colles' fracture
E. Ulnar fracture
The likely diagnosis here is a scaphoid fracture.
y
A very typical scenario is a young person who falls on his or her outstretched hand with
op
forced dorsiflexion. In this scenario, she fractures her scaphoid 4 months ago. As there
was no management in place, likely a non-union would be in the differential. Non-union
occurs in approximately 5-10% of nondisplaced scaphoid fractures.
C
The pain aggravated when she holds baby gives us a little small clue that she may be
having pain during supination against resistance.
n
io
Signs: Tender in anatomical snuff box and over scaphoid tubercle, pain on axial
compression of the thumb, and on ulnar deviation of the pronated wrist, or supination
t
against resistance.
ua
If initial X-rays are negative, cast and re-X-ray in 2 weeks.

al
6. A 24 year old man falls on an outstretched hand while playing football. He comes in
complaining of pain at the base of the thumb. On physical examination, he is tender to
Ev
palpate over the anatomic snuff-box. Wrist movement, particularly pronation followed
by ulnar deviation is painful. X-rays are read as negative. What is the SINGLE most
appropriate next management?
A. Reassurance and analgesia

B. Surgery
C. Immobilization of the wrist and review in 2 weeks
D. Scaphoid cast for 6 weeks
E. High arm sling and rest
This is a typical presentation of a scaphoid fracture.
It is a very debatable question. The answers C and D both may seem right. But the more
appropriate answer of the two would be C.
First we need to understand Scaphoid fractures.
1160
A very typical scenario is a young man who falls on his outstretched hand with forced
dorsiflexion. X-rays are usually negative but if repeated in 2 weeks become positive.
They are also infamous because of a high rate of nonunion.
against resistance.
If initial X-rays are negative, cast and re-x-ray in 2 weeks.
Unfortunately, for this question, re-x ray was not an option. So many candidates would
have picked “D. Scaphoid cast for 6 weeks”. We asked orthopaedic registrars regarding
this question, and most would agree that “C. Immobilization of the wrist and review in
2 weeks” would be a better answer because you should not cast for 6 weeks without
knowing if there is actually a fracture. Thus immobilize for 2 weeks, and review (and
obtain X-rays). If fracture is seen after 2 weeks, then cast for another 4 more weeks.
y
7. A 26 year old primigravida pregnant woman at 34 weeks gestation presents with
op
tingling and numbness with occasional pain of her right hand in addition to altered
sensation over her right middle and index finger. Tinel test is negative. What is the
C
A. Carpal Tunnel Syndrome
B. Radial nerve entrapment
n
C. Scaphoid fracture
io
D. Median nerve entrapment

E. Peripheral arterial disease
t
ua
Because the stem states that Tinel test is negative, you may be tricked into choosing a
different answer but remember that the Tinel test has a very low sensitivity for carpal
tunnel syndrome. If the patient has a high suspicion of having carpal tunnel syndrome
al
such as the classic tingling and numbness over the median distribution of the hand as
well as being pregnant (which is a high risk factor for carpal tunnel syndrome) then you
Ev
should always choose carpal tunnel syndrome as the answer.
Pregnancy is a known risk for carpal tunnel syndrome. In pregnancy, carpal tunnel is
due to fluid retention. The best thing to do is to advise the pregnant women to wear
wrist splints until delivery as after delivery, the carpal tunnel syndrome usually resolves.
8. A 7 year old boy falls on his right hand with the arm extended. He has severe pain
around the elbow. X-ray imaging show a supracondylar fracture of the humerus. The
distal fragment is displaced posteriorly. What is the SINGLE most likely structure to be
damage?
A. Anterior ulnar recurrent artery

B. Posterior ulnar recurrent artery
C. Ulnar artery
D. Radial artery
E. Brachial artery
1161
Supracondylar fracture of humerus is the most common fracture of childhood, with a
peak incidence between the ages of 5 and 7 years. It occurs occur with hyperextension
of the elbow in a child who falls on the hand, with the arm extended. These fractures
may compromise brachial artery, median, radial or ulnar nerve function so check
neurovascular status. Keeping the elbow in extension after injury prevents exacerbating
brachial artery damage from the time of injury.
9. An 80 year old woman with mild dementia at a nursing home tripped and fell on her
hand. X-ray revealed a fracture of the distal end of the radius with a 10 degree dorsal
angulation. What is the SINGLE best management for her?
A. Closed reduction of the fracture

B. Open reduction and internal fixation
C. Above elbow backslab cast
D. Plaster of Paris cast below elbow
E. Wrist sling
To choose the correct answer, we first need to know the diagnosis. This is a Colles'
y
fracture.
op
Colles' fracture is a fracture of the distal radius with dorsal displacement of fragments.
It typically occurs from a fall onto an outstretched hand that results in forced
C
dorsiflexion of the wrist. The characteristic dinner fork deformity makes it easy to
recognize, along with the classical history. The management of the type of cast to be
used in a Colles' fracture is still heavily debated however, the patient’s age and any
n
potential disability should be taken into consideration. We should always aim to tailor
io
management for individual patients and their needs rather than apply generalized rules
across the population.
t
ua
This patient is elderly and she has mild dementia. In this situation, the best type of
management for her should be a complete cast below the elbow in order to maximally
immobilize her wrist and prevent further injury to her wrist, thus causing potential
al
complications.
Ev
A backslab is the preferred method of management for younger patients
Surgical reduction is reserved for intra-articular fractures and if there is any intra-
articular incongruity. Since there was no mention of this in the question, open
reduction and internal fixation is the wrong choice.
10. A 30 year old lady was playing volleyball when her hand got injured with the volleyball.
The right hand is not swollen and there is tenderness under the root of the thumb.
Wrist movement, particularly pronation followed by ulnar deviation is painful. X-ray of
the wrist show no presence of fractures. What is the SINGLE most appropriate next step
in management?
A. Apply arm sling for 1 week

B. Reassurance and analgesia
C. Repeat X-ray in 2 weeks
D. Full arm cast for 1 week
E. Surgical exploration
1162
The likely diagnosis is scaphoid fracture where the initial X-ray may not show the
fracture right away.
forced dorsiflexion. In this scenario, she fractures her scaphoid from a volley. X-rays are
usually negative but if repeated in 2 weeks become positive.
against resistance.
11. A 13 year old boy presents with pain in the groin. He is seen limping. There was no
history of trauma. There is limited hip motion, and as the hip is flexed the thigh goes
y
into external rotation and cannot be rotated internally. When the boy is lying down, the
op
left leg is 2 cm shorter than the right leg and it is externally rotated. What is the SINGLE
most likely diagnosis? C
B. Septic arthritis
n
io

t
Slipped Upper Femoral Epiphysis usually cause groin pain on the affected side, but
ua
sometimes cause knee or thigh pain. Usually in slipped upper femoral epiphysis, there
is limited hip motion, and as the hip is flexed the thigh goes into external rotation and
cannot be rotated internally.
al
Slipped upper femoral epiphysis (SUFE)

Ev
Slipped upper femoral epiphysis is an orthopedic emergency. The typical patient is a

chubby boy, around age 13. They complain of groin (or knee) pain and are noted to be
limping.
It is caused by the displacement of the femoral epiphysis (growth plate) in relation to

the femoral neck. It is the commonest cause of a limp in a boy aged 12–14 or girl aged
11–13 (growth spurt at puberty). In this age group, it must be actively excluded in a
limping child.
Classic presentation is a limping, obese, 13 year old boy with knee pain.

- Obesity
- Rapid growth
- Male—♂:♀, 3:1
1163
Clinical features
- The affected limb will be shorter and lies in external rotation
- Abduction is limited. When the hip is flexed, it will rotate externally
Note: the left side is usually more commonly affected compared to the right side
12. A 60 year old man is brought to the emergency department with a fractured hip. He has
been having progressive hearing loss and was recently diagnosed with cardiac failure.
Hypercalcaemia was noted on his blood test. What is the SINGLE most likely diagnosis?
B. Osteoporosis
C. Osteomalacia
D. Multiple myeloma
E. Spondylosis
History of deafness and heart failure favours the diagnosis of Paget’s disease.
y
In Paget’s disease, serum calcium levels are usually normal but immobilisation may lead
op
to hypercalcaemia.

C
n
io
t
ua
al
Ev
Presentation
deformity
affected bone)
Investigations
1164

closely.
Management
- Bisphosphonates
13. A 7 year old boy fell on his outstretched arm and presents with pain around the elbow.
On examination, radial pulse is absent on the affected hand. What is the SINGLE most
likely diagnosis?
y
A. Dislocated elbow
op
B. Angulated supracondylar fractures of the humerus
C. Undisplaced fracture of radial head
D. Posterior dislocation of shoulder
C
E. Pulled elbow
Supracondylar fracture of humerus is the most common fracture of childhood, with a

n
peak incidence between the ages of 5 and 7 years. It occurs occur with hyperextension
io
of the elbow in a child who falls on the hand, with the arm extended. These fractures
may compromise brachial artery, median, radial or ulnar nerve function so check
t
neurovascular status. Keeping the elbow in extension after injury prevents exacerbating
ua
brachial artery damage from the time of injury.
In this question, damage or occlusion of the brachial artery is the cause of absent radial
al
pulse.
Ev
14. A 19 year old boy comes to the emergency department with pain, swelling and
tenderness 2 cm distal to Lister’s tubercle of radius. He gives a history of falling down
on his outstretched hand while playing basketball. On examination, proximal pressure
on the extended thumb and index finger is painful. X-ray of the wrist shows no fracture
visible. What is the SINGLE most appropriate management?
A. Immobilization of wrist with cast and review in 2 weeks

B. High arm sling and rest
C. Magnetic resonance imaging of wrist
D. Surgical exploration
E. Reassurance and analgesia
The likely diagnosis is scaphoid fracture where the initial X-ray may not show the
fracture right away. Immobilize the wrist for 2 weeks, and review (and obtain X-rays)
would be the best answer among the rest.
1165
forced dorsiflexion. X-rays are usually negative but if repeated in 2 weeks become
positive.
against resistance.
15. A 44 year old man slipped while he was coming down the stairs and he fell on his
outstretched arm. X-rays demonstrate an oblique fracture of the middle to distal thirds
of the humerus. He is unable to dorsiflex his right wrist. What is the SINGLE most likely
associated nerve injury?
A. Radial nerve
y
B. Musculocutaneous nerve
op
C. Median nerve
D. Ulnar nerve
E. Axillary nerve
C
The X-ray findings alone which shows a humeral shaft fracture already gives you the
answer (a radial nerve injury). If you go on reading, this question gives you a second
n
clue which is a wrist drop (he is unable to dorsiflex his wrist) which is classic for a radial
io
nerve injury
t
Fracture of the humeral shaft is often caused by a fall on an outstretched arm. These
ua
fractures can injure the radial nerve, which courses in a spiral groove right around the
posterior aspect of that bone.
al
The management of humeral shaft fracture is not commonly asked in PLAB but you may
want to know it for your own knowledge:
Ev
Nonoperative management is adequate for >90% of these fractures. Hanging arm cast
or coaptation splint are used, and the nerve function returns eventually. Surgical
management may sometimes be needed but are uncommon. These surgical options
include intramedullary nailing and compression plating.
Examples:

1166
neuropathy
16. A 63 year old man has knee pain and back pain for the last 3 months which is
progressively worsening. Bowing of the tibia is noted on examination. He also has
pronounced kyphosis. On further investigation, alkaline phosphatase was found to be
elevated in his blood. Serum calcium levels were normal. What is the SINGLE most likely
diagnosis?
A. Multiple myeloma
B. Osteoporosis
C. Osteomalacia
D. Paget’s disease
y
op
C
n
io
t

ua
al
Presentation
Ev

deformity
affected bone)
Investigations
1167

closely.
Management
- Bisphosphonates
17. A 79 year old man had a fall 2 days ago and since then he is unable to bear weight on
his right leg. He presents with deformity and tenderness over the right hip area. X-ray
shows fracture of the acetabulum. What is the SINGLE most likely associated nerve
injury?
A. Sciatic nerve
y
B. Gluteal nerve
op
C. Lateral peroneal nerve
D. Tibial nerve
E. Femoral nerve
C
Acetabular fractures and posterior dislocation of the hip
n
Both acetabular fractures and posterior dislocation of the hip can result in sciatic nerve
io
damage.
t
Sciatic nerve injury: pain in the distribution of the sciatic nerve, loss of sensation in the
ua
posterior leg and foot and loss of dorsiflexion (peroneal branch)
For these fractures always check for sciatic nerve damage → Examine foot dorsi?exion
al
and below knee sensation.

Ev
18. A 35 year old male typist suffered a wrist injury after falling on his right outstretched
hand. He was treated with a scaphoid cast with the probable diagnosis of a scaphoid
fracture. The cast was removed after 2 weeks from the injury for a repeat X-ray. After
removing the cast, he noted that he he had difficulty in moving his right thumb, index
and middle finger. There was also a tingling sensation on those fingers. What is the
SINGLE most likely management that would improve his symptoms?
A. Release of flexor retinaculum

B. Release of common flexor sheath
C. Release of palmar aponeurosis
D. Ulnar nerve release
E. Fasciotomy
Carpal tunnel syndrome is characterised by tingling, numbness, or pain in the

distribution of the median nerve (the thumb, index, and middle fingers, and medial half
the ring finger on the palmar aspect) that is often worse at night and causes wakening.
It is due to compression of the median nerve as it passes under the flexor retinaculum.
1168
In this stem, the first hint is that he is a typist. Long hours of keyboard use may lead to
or aggravate carpal tunnel syndrome. Flexion or extension injury of the wrist can also
be a secondary cause of carpal tunnel syndrome although it is rare that symptoms
would arise in such a short time from the injury and immediately from removal of the
cast. Given the rest of the options, release of the flexor retinaculum is the only option
that would help improve symptoms should this be a diagnosis of carpal tunnel
syndrome.
19. A 28 year old man was involved in a road traffic accident. He has severe pain in his
shoulder and upper arm. There is loss of shoulder and arm function with bruising seen
at the anterior shoulder on examination. X-ray shows a fracture of the neck of
humerus. What is the SINGLE most associated neurovascular injury?
A. Suprascapular nerve injury

B. Radial nerve injury
C. Axillary artery injury
D. Brachial artery injury
y
E. Axillary nerve injury
Neurovascular injury in proximal humeral fractures
op
- About a third of proximal humeral fractures produce neurovascular injury
C
- Axillary nerve damage is most common.
- Suprascapular, radial and musculocutaneous nerves can also be affected
n
Rarer neurovascular injury in proximal humeral fractures
io
- Axillary artery injury is possible but rarely occurs

- Brachial artery injury also rarely occurs
t
ua
al
Examples:
Ev

neuropathy
20. A 55 year old woman has a history of a recent radial fracture. In the last decade, she
had a colles’ fracture in the right forearm and supracondylar humerus fracture of the
left arm. She used to take corticosteroids for 2 years as part of managing her
1169
inflammatory bowel disease. What is the SINGLE most appropriate investigation to
perform?
A. Dual-energy X-ray absorptiometry (DEXA) scan

C. Nuclear bone scan
E. Bone biopsy
It is clear from the given history and the corticosteroid use that this is likely a case of
osteoporosis. Other added risk factors in the stem include her sex (female) and her age
(postmenopausal). Diagnosis of osteoporosis centres on the assessment of bone
mineral density. DEXA is regarded as the gold standard technique for the diagnosis of
osteoporosis.
21. A 33 year old pregnant woman presents with right knee pain worse when moving the
joint. The pain has been present for the last 4 months but it is worsening. The pain is
noted to be worse at the end of the day. X-ray shows decreased joint space in the right
y
knee. Blood results show a CRP of 12. What is the SINGLE most appropriate
op
management?
A. Paracetamol
C
B. Oral nonsteroidal anti-inflammatory drugs (NSAIDs)
C. Oral steroid
D. Intra-articular steroid injections
n
E. Disease-modifying antirheumatic drugs (DMARDs)
io
The first step is recognising that this is osteoarthritis. Pain in one joint that is worse
t
towards the end of the day, decreased joint space and inflammatory markers which are
ua
not significantly raised are recognisable features of osteoarthritis. Paracetamol is first

line for osteoarthritis. It is also worth noting that she is pregnant and you should avoid
prescribing NSAIDs as much as possible in a pregnant woman.
al
Osteoarthritis
Ev
Features to remember
Monoarthritis
- Hip and knee are commonly affected
- Joint pain that is exacerbated by exercise and relieved by rest (sometimes gives
a history of pain worsening at the end of the day)
- Bony deformity due to osteophytes
o In fingers this presents as swelling at the distal interphalangeal joints
(Heberden's nodes) or swelling at the proximal interphalangeal joints
(Bouchard's nodes)
Mnemonic for Heberden nodes and Bouchard's nodes

- Heberden → distal interphalangeal joint (H-D) (High Definition)
- Bouchard → proximal interphalangeal joint (B-P) ( Blue Picture)
X ray shows loss of joint space, marginal osteophytes, bone cyst and subarticular
sclerosis.
1170
Mnemonic for X-ray features
- L → Loss of joint space
- O → Osteophytes
- S → Subchondral cysts
- S → Subchondral sclerosis
Management
- Exercise and physiotherapy
- Weight reduction
- Regular paracetamol
- Topical NSAIDs
- Oral NSAIDs
o Note: Paracetamol and/or topical NSAIDs should be considered ahead
of oral NSAIDs
- Joint surgery as last option
y
22. A 33 year old woman fell from playing volleyball and hit her right knee. Valgus stress
op
test is seen to be positive. What is the SINGLE most likely structure that is injured?
A. Anterior cruciate ligament

C
B. Posterior cruciate ligament
C. Lateral collateral ligament
D. Medial collateral ligament
n
E. Meniscus
io
Medial collateral ligament prevents the lateral movement of the tibia on the femur
t
when valgus (away from the midline) stress is placed on the knee.
ua
The valgus stress test is performed with the hip abducted and the knee at 30° of flexion,
with one hand placed as a pivot on the knee. The other hand is placed on the foot with
al
an abducting force. The idea is to attempt to force the leg at the knee into valgus. The
fingers of the hand at the knee is used to feel the amount of joint-line opening that
Ev
occurs when valgus stress is applied. If the joint-line is seen to open up on the medial
side, this is indicative of a medial collateral ligament damage.
Test for knee ligament injuries

Medial collateral ligament → Valgus stress test
Lateral collateral ligament → Varus stress test
Anterior cruciate ligament → Anterior drawer test, Lachman test
Posterior cruciate ligament → Posterior drawer test
23. A 7 year old boy fell in the playground with arm outstretched an hour ago. He is now
seen to be holding his forearm complaining of pain. Examination of his forearm reveals
tenderness but no sign of deformity or swelling. An X-ray was performed. What is the
A. Greenstick fracture of distal radius

B. Oblique fracture of the mid ulna
C. Transverse fracture of the mid radius
1171
D. Spiral fracture of the distal ulna
E. Comminuted fracture of scaphoid
In the exam, if a child falls and attains a fracture, it is almost always a greenstick injury.
The classical fracture in a child is a greenstick injury. This is when there is an incomplete
fracture of the long bones. It occurs when the force applied to a bone results in bending
of the bone such that the structural integrity of the convex surface is overcome. This
usually occurs to a child who falls on an outstretched arm. Because the bones are soft
in children, the bending force applied does not break the bone completely and the
concave surface of the bent bone remains intact. The fracture resembles the break that
results when a supple green branch of a tree is bent and breaks incompletely.
24. A 35 year old volleyball player has pain in his right arm and shoulder for the past 2 days.
He finds it difficult to perform task which involve lifting his arm above his shoulder. His
shoulder feels weak. The shoulder pain is worse at night when he is in bed. There is no
history of trauma. What is the SINGLE most likely cause of his pain?
y
op
C
Supraspinatus tendinitis
Often associated with shoulder impingement syndrome
n
io
History
- The stem would always have a history of either:
t
- A person with a job that require repetitive overhead activity

ua
- A person who has recently been involved in carrying heavy items e.g. moving to
a new house
- An athlete whose sport involves stressful repetitive overhead motions e.g.
al
swimming, volleyball, tennis, badminton

Ev
Symptoms
- Pain, weakness and loss of motion
o Pain worsens with overhead or above the shoulder activities
o Pain is often worse at night and can disturb sleep, particularly when
lying on the affected shoulder
25. A 33 year old woman has complaints of pain in her right arm and shoulder when she
abducts it. The pain is worse at night and disturbs her sleep. She finds it difficult to
perform task which involve lifting her arm such as combing her hair. She has recently
moved to a new house and was involved in carrying heavy items. There is no history of
trauma. What is the SINGLE most likely cause of her pain?

1172
Supraspinatus tendinitis
Often associated with shoulder impingement syndrome
History
- The stem would always have a history of either:
- A person with a job that require repetitive overhead activity
- A person who has recently been involved in carrying heavy items e.g. moving to
a new house
- An athlete whose sport involves stressful repetitive overhead motions e.g.
swimming, volleyball, tennis, badminton
Symptoms
- Pain, weakness and loss of motion
o Pain worsens with overhead or above the shoulder activities
o Pain is often worse at night and can disturb sleep, particularly when
lying on the affected shoulder
y
26. A 15 year old boy presents with fever and pain in the right lower thigh. The pain has
op
been ongoing for the past one month. On examination, there is a 2 cm by 2 cm mass at
the lower third of his thigh which is red, warm and tender. An X-ray shows bone
destruction with overlying onion-skin layers of periosteal bone formation and a soft
C
tissue mass. What is the SINGLE most likely diagnosis?
A. Tuberculous arthritis
n
B. Ewing’s sarcoma
io
C. Osteosarcoma
D. Osteomyelitis
t
E. Fibrosarcoma
ua
Ewing’s sarcoma
- A malignant round-cell tumour of long bones (typically grows in diaphysis of
al
long bones) and limb girdles, usually presents in adolescents (usually 5 to 15

years old)
Ev
Presentation
- As a mass or swelling commonly in long bones of arms and legs, pelvis or chest
- Pain at area of tumour
- Other signs and symptoms include: malaise, anorexia, weight loss, fever
Investigation
- A typical "onion skinning" type pattern is often seen on X-rays. This is due to
bone destruction with overlying concentric layers of new bone formation
27. A 26 year old man complains of severe pain while trying to grasp objects. It started
when he fell during a skiing trip and hit his thumb on the ground while his thumb was
abducted. On physical exam there is collateral laxity at the thumb-
metacarpophalangeal joint with bruising over the joint. What is the SINGLE most likely
deformity?
1173
B. Gamekeeper thumb
C. Mallet finger
D. Cubitus varus
Gamekeeper's thumb
- Also known as skier's thumb
- An injury to the ulnar collateral ligament (UCL) of the metacarpophalangeal
(MCP) joint (on the medial side of the thumb) due to forced abduction of the
MCP
- Historically suffered by gamekeepers when they killed rabbits by dislocating
their necks with violent blows with the extended thumb. However in this era, it
is seen as a skiing injury when the thumb is abducted and gets stuck in the
snow or the ski strap during a fall
Examination
- Collateral laxity at the thumb-metacarpophalangeal joint
- Thumb is hyperextended and laterally deviated with swelling
y
- Grasp and pinching ability is reduced
Management
op
- If incomplete ligamental injury and the joint is stable → immobilisation in a
C
thumb spica splint for 4-6 weeks
28. A 12 year old boy attends A&E with pain after falling off his bicycle. A lateral X-ray of his
n
wrist show a fracture at the distal radius with the distal fracture fragment displaced
io
anteriorly. What is the SINGLE most likely diagnosis?

t

ua
B. Cubitus valgus
C. Gunstock deformity
D. Garden spade deformity
al
E. Coxa Vara
Ev
Smith's fracture
- Also known as reverse Colles' fracture
- It is a fracture of the distal radius that has anterior displacement of the distal
fragments (opposite to Colles’ fracture where there is dorsal displacement of
fragments)
- It is usually caused by falling backwards like a fall onto the palm of the
outstretched hand with the arm above it pronating as the body falls. It can also
occur if one falls onto flexed wrist.
- The characteristic appearance is called a 'garden spade deformity'
- Lateral view of X-ray of a Smith's fracture is very similar to a Colles' fracture
except with the displacement anteriorly instead of posteriorly thus the term
reverse Colles’ fracture
29. A 61 year old female with a history of osteoporosis suddenly falls on her outstretched
hand while shopping. X-ray of the wrist shows a fracture at the distal radius with a
backward shift of the distal fragment. What is the SINGLE most likely deformity?
1174
A. Cubitus valgus
B. Coxa Vara
C. Mallet finger
D. Dinner fork deformity
Colles’ fracture
Results from fall on an outstretched hand, often in old osteoporotic women. The
deformed and painful wrist looks like a "dinner fork”. The main lesion is a dorsally
displaced, dorsally angulated fracture of the distal radius.
30. A 24 year old man presents to A&E after an injury to his hand while playing basketball.
Examination of his hand reveals an avulsion of the extensor digitorum tendon from the
distal phalanx. What is the SINGLE most likely deformity?

B. Gamekeeper thumb
y
C. Mallet finger
op
D. Gunstock deformity
E. Garden spade deformity C
A mallet finger is an injury of the extensor digitorum tendon of the fingers at the distal
interphalangeal joint. It results from hyperflexion of the extensor digitorum tendon. It
occurs when a ball (such as a softball, basketball, or volleyball), while being caught, hits
n
an outstretched finger causing it to bend (flex) further than normal and rupture or
io
stretch the extensor digitorum tendon. Without the use of the extensor digitorum
tendon, the finger stays bent (flexed) resembling a mallet.
t
ua
Splint DIP in extension for 6 to 8 weeks is usually adequate to manage this.
31. A 67 year old woman presents to the emergency department with pain in her left groin.
al
She falls from a chair in the waiting area and now is in severe pain and is not able to
move her left leg. She takes alendronate regularly. What is the SINGLE most likely
Ev
diagnosis?
A. Pelvic fracture
B. Bursitis
C. Femoral shaft fracture
D. Femoral neck fracture
E. Posterior hip dislocation
The use of alendronate indicates that she is likely to be at high risk for an osteoporotic
fractures as alendronate is primarily used to prevent fractures in osteoporotic patients.
Proximal femur fractures are one of the common areas of fractures seen in
osteoporosis. Thus, a fracture of the neck of femur would be the most appropriate
answer.
Osteoporosis is the reduction in the amount of bony tissue within the skeleton.
Osteoporotic bone is at high risk of fracture, even after trivial injury. It usually is
1175
clinically silent until an acute fracture like in this stem. Common osteoporotic fractures
are seen in hips, wrist (Colles’) and compression fractures of vertebral bodies.
32. A 15 year old boy complains of pain in his leg which usually settles within an hour of
taking aspirin. The pain is described as a dull pain which is persistent but is usually
worse at night. What is the SINGLE most likely diagnosis?
A. Leiomyosarcoma
B. Liposarcoma
C. Chondrosarcoma
D. Exostosis
E. Osteoid osteoma
The key fact here is the aspirin. The fact that the bone pain responds to aspirin in such a
short time period is classic for osteoid osteoma.
Osteoid osteoma
- Benign bone tumor that develops in the long bones of the body such as the
y
femur and tibia
op
- Pain is unrelated to activity and is relieved quickly by NSAIDS
- Pain usually worse at night
- Frequently affects children and young adults
C
- Usually less than 1 cm in diameter
Important note to remember: Bone pain relieved well by NSAIDs is characteristic for
n
osteoid osteoma
io
33. A 79 year old woman has a history of a Colles’ fracture three weeks ago after falling on
t
a concrete floor with her right hand. She is otherwise fit and well. What is the SINGLE
ua
most appropriate investigation to assess her risk for further fracture?
A. Radionuclide (isotope) scan

al
B. Dual energy X-ray absorptiometry (DEXA) scan

C. Magnetic resonance imaging (MRI)
Ev
D. X-ray of wrist
E. No further investigations required
Colles’ fracture results from fall on an outstretched hand, often in old osteoporotic
women as seen in this stem. The diagnosis of osteoporosis centres on the assessment
of bone mineral density of which DEXA is regarded as the gold standard technique for
the diagnosis. A DEXA scan is the most commonly used investigation to assess fracture
risk by measuring bone density and would be the best option here.
34. A 59 year old woman has severe back pain. The back pain is suspected to caused by
bone metastases. What organ is the SINGLE most likely tumour arising from causing
bone metastases?
A. Lungs
B. Cervix
C. Ovary
D. Uterus
1176
E. Breast
In females, the most common tumour causing bone metastases is the breast. Second to
that is the lungs.
In males, the most common tumour causing bone metastases is the prostate. Second to
that is the lungs.
The most common site for bone metastases to occur is in the spine. Then the pelvis,
ribs, skull and long bones.
35. A 60 year old female has pain and stiffness in her right hip joint. The pain has been
worsening over the past 6 months. The pain increases in intensity as the day progresses
and it is usually least pain in the morning. She has noticed nodules in the joints of the
fingers of her hands. A recent blood test shows:
Haemoglobin 92 g/L
y
op
C
B. Osteoarthritis
C. Gout
n
D. Pseudogout
io
E. Multiple myeloma
t
The first step is recognising that this is osteoarthritis. Pain in one joint that is worse
ua
towards the end of the day for a 6 month period are features of osteoarthritis. Hips are
also a common joint affected by osteoarthritis.
al
The nodules in her hand although not specified in the stem are likely to represent
Bouchard’s nodes or Heberden's nodes which are seen in osteoarthritis.
Ev
Anaemia in this stem cannot be explained by choosing osteoarthritis except for the fact
that it could be due to prolonged use of NSAIDS causing gastrointestinal bleeding. This
is one reason many doctors would have picked rheumatoid arthritis as the answer as
rheumatoid arthritis is associated with anaemia of chronic disease. It is estimated that
30-60% of people with rheumatoid arthritis are anaemic (either from anaemia of
chronic disease or GI bleed related to nonsteroidal anti-inflammatory drug (NSAID) use.
However, we must remember how rheumatoid arthritis presents. Usually more than
one joint is involved in rheumatoid arthritis and the hands are almost always affected.
With rheumatoid arthritis, the pain and stiffness is usually worst on waking, but
gradually improves during the day. This is quite the opposite of osteoarthritis which is
represented in this stem.
Osteoarthritis
Features to remember
- Monoarthritis
1177
- Hip and knee are commonly affected
- Joint pain that is exacerbated by exercise and relieved by rest (sometimes gives
a history of pain worsening at the end of the day)
- Bony deformity due to osteophytes
o In fingers this presents as swelling at the distal interphalangeal joints
(Heberden's nodes) or swelling at the proximal interphalangeal joints
(Bouchard's nodes)
Mnemonic for Heberden nodes and Bouchard's nodes

- Heberden → distal interphalangeal joint (H-D) (High Definition)
- Bouchard → proximal interphalangeal joint (B-P) ( Blue Picture)
X ray shows loss of joint space, marginal osteophytes, bone cyst and subarticular
sclerosis.
Mnemonic for X-ray features

- L → Loss of joint space
- O→ Osteophytes
y
- S → Subchondral cysts
op
- S → Subchondral sclerosis
Management
C
- Exercise and physiotherapy
- Weight reduction
- Regular paracetamol
n
- Topical NSAIDs
io
- Oral NSAIDs
o Note: Paracetamol and/or topical NSAIDs should be considered ahead
t
of oral NSAIDs
ua
- Joint surgery as last option

al
Ev
1178
PAEDIATRICS
y
op
C
Questions
n
io
&
t
ua
Answers
al
Ev
1179
Paediatrics Questions
1. A 7 month old baby is admitted with a 3 day history of coughing. He has a temperature
of 38.5°C. On examination, there is marked subcostal recession and widespread wheeze
is noted bilaterally. His respiratory rate is 60 breaths/minute. What is the SINGLE most
A. Supportive care
C. Intravenous hydrocortisone
D. Intramuscular adrenaline
E. Nebulised salbutamol
2. A 2 year old girl previously well is brought to A&E by her mother with a history of
vomiting and diarrhoea for the last 2 days. She is unable to keep any food or liquid
down in the past day. What is the SINGLE most suitable indication for intravenous fluids
administration?
y
A. Capillary refill time > 4 seconds
op
B. Heart rate > 90 beats/minute
C. Respiratory rate > 25 breaths/minute
D. Passing of watery stools more than eight times a day
E. Current weight < 10 kg
C
3. A 4 year old girl is taken by her mother to the emergency department and complains of
n
pain during urination and feeling generally unwell. She has a temperature of 38.5°C.
io
What is the SINGLE most appropriate initial action?

t
A. Suprapubic aspiration
ua
B. Clean catch of urine

C. Catheter for sample of urine
D. Renal ultrasound
al
E. DMSA scan
Ev
4. An 18 month old boy has been brought to the emergency department by his mother
because he has been refusing to move his left arm and crying more than usual for the
past 24 hours. He has recently been looked after by his mother’s new partner while she
attended college. Assessment shows multiple bruises on his body and the medial aspect
of his left upper arm. What is the SINGLE most appropriate next step?
A. Admit under care of pediatrician

B. Discharge with painkillers
C. Start IV centrist one
D. Follow up in paediatric outpatient department
E. Follow up with GP
5. A 4 year old boy is brought to clinic by his worried mother complaining that he is still
unable to keep dry at night. There was no period where he managed to stay dry during
the night. The mother wants to know if anything can be done to resolve this issue. He is
dry during the day. His medical history is insignificant and there is no history of
recurrent urinary tract infections. What is the SINGLE most appropriate management?
1180
A. Desmopressin
B. Reassurance
C. Behavioural therapy
D. Enuresis alarm
E. Referral to surgery
6. A 3 week old female infant has recently become jaundiced. Her mother has breastfed
her since she was born. Test have ruled out other causes of jaundice and the diagnosis
of breast milk jaundice is made. She is otherwise well. What is the SINGLE most
A. Phototherapy
B. Exchange transfusion
C. Increase fluid intake
D. Continue breastfeeding
E. Stop breastfeeding completely
7. A 2 week old male, term infant presents to the Emergency Department with a sudden
y
onset of green, bilious vomiting for two hours and blood in diapers. Abdominal x-ray
op
reveals dilatation of the stomach and in the proximal loops of the bowel. Barium enema
indicates partial obstruction of the duodenum and malposition of the caecum. Which of
the following is the SINGLE most likely diagnosis?
C
A. Jejunal atresia
B. Hypertrophic pyloric stenosis
n
C. Malrotation and volvulus
io
D. Acute appendicitis
E. Intussusception
t
ua
8. A 3 year old boy attends clinic with a history of diarrhea on and off. The mother
describes the stool as bulky, frothy and difficult to flush. He looks pale and wasted on
examination. What is the SINGLE most likely investigation that would lead to a
al
diagnosis?
Ev
A. Sweat chloride test

B. Anti-endomysial antibodies
E. Thyroid function test
9. A 4 week old female infant presents to the Emergency Department with vomiting after
every feed. The mother describes the vomiting as projectile and non-bilious. The child is
also constipated. On examination, there is a right sided olive-sized abdominal mass on
palpation. What is the SINGLE most appropriate next step of action?
A. Abdominal ultrasound
B. Abdominal x-ray
C. Intravenous fluids
D. Serum potassium level
E. Nasogastric tube insertion
1181
10. A 4 year old boy, who recently immigrated from Kenya with his parents, presents to
clinic with intermittent watery diarrhea, foul-smelling flatulence, nausea, and
abdominal pain. His weight is less than the fifth percentile for his age. On examination,
he has a fever of 38oC and is dehydrated. Which of the following is the most likely to
confirm his diagnosis?
B. Complete blood count
D. ESR
E. Stool microscopy for ova and parasites
11. An infant soon after birth developed difficulty in breathing with intercostal recession
and nasal flaring. He is afebrile. On examination, there is diminished breath sounds. On
examining the mother's notes, there was a history of spontaneous rupture of
membranes 48 hours before delivery of baby. The mother was 36 weeks gestation
when the baby was delivered. What is the SINGLE most appropriate initial
investigation?
y
op
A. Blood culture
B. Chest X-ray
C. Stool culture
C
D. Sputum culture
E. Maternal high vaginal swab
n
12. A 7 year old child presented with chronic cough and is also found to be jaundiced on
io

t
A. Congenital diaphragmatic hernia

ua
B. Congenital cystic adenomatoid malformation

C. Bronchiolitis
D. Respiratory distress syndrome
al
E. Alpha 1 antitrypsin deficiency

Ev
13. A 6 year old boy presents to clinic with obesity. He has a history of failure to thrive as
an infant. He is now behind in school, has difficulty interacting with friends, and feeds
constantly. His mother says he cannot stop eating. What is the SINGLE most likely
diagnosis?
A. Cushing’s disease
C. Primary hypoparathyroidism
D. Prader Willi syndrome
14. A 2 year old boy fell off his tricycle and hurt his arm. He got up and was about to start
crying but before there was any sound, he went pale, and unconscious. He recovered
after 2 minutes but remained pale. His colour came back after a few minutes. His
mother was concerned at that time that he was going to die. She is very worried and
mentions that he had a similar episode 2 months ago after falling down some steps.
1182
A. CT head
B. Electroencephalogram (EEG)
C. Full blood count (FBC)
D. Reassure
E. Skeletal survey
15. A 6 month old boy is admitted with persistent irritability. He is lethargic and is not
feeding well. He has a temperature of 38.2°C, a capillary refill time of 2 seconds and a
respiratory rate of 34 breaths/minute. Urine reveals leukocytes on a dipstick. What is
the SINGLE investigation most likely to lead to diagnosis?
A. Blood culture
C. Chest X-ray
E. CSF analysis
y
16. A 15 month old male infant arrives to clinic for his measles, mumps, rubella (MMR)
op
vaccine. On examination, he has a temperature of 37.5°C and has acute otitis media.
There is also a family history of egg allergy. What is the SINGLE most appropriate
action?
C
A. Do not give the vaccine
B. Give half the vaccine dose
n
C. Give paracetamol followed by vaccine
io
D. Give paracetamol with future doses of vaccines

E. Defer vaccine until the child is well
t
ua
17. A 3 year old male presents to the Emergency Department with a left-sided irreducible
firm swelling near the groin. The swelling would descend when the child cries. On
examination, both testicles are palpable in the scrotum. What is the SINGLE most
al
Ev
A. Reassurance
B. Emergency herniotomy
C. Elective herniotomy
D. Emergency herniotomy and orchidopexy
E. Elective herniotomy and orchidopexy
18. A 4 year old girl presents to the emergency center with difficulty breathing and stridor.
She has a temperature of 39.1°C. The parents state that the child had been in her usual
state of health but awoke with a hoarse voice, and difficulty swallowing. They tell you
that she has not been immunised because they are afraid of the side effects of the
vaccination. What is the SINGLE most likely diagnosis?
A. Cystic fibrosis
B. Acute Epiglottitis
C. Immunodeficiency
D. Inhaled foreign body
E. Recurrent aspiration
1183
19. A 3 year old boy is brought to A&E after having a generalized tonic-clonic seizure that
lasted approximately 5 minutes. The parents say that he was previously well but started
developing symptoms of a cold earlier in the morning. He is noted to have a fever of
39°C. What is the SINGLE most likely diagnosis?
A. Infant spasms
B. Absence seizures
C. Epilepsy
D. Partial complex seizure
E. Febrile convulsion
20. A 6 week old formula fed baby boy is found at under the healthy child programme to be
deeply jaundiced. His weight gain is poor. His stools are pale and urine colour is dark.
A. Galactosaemia
B. Biliary atresia
y
C. Glucose-6-phosphate dehydrogenase (G6PD) deficiency
op
D. Rhesus incompatibility
E. Congenital viral infection C
21. A 2 year old has atrophy of the buttocks. He has often has bloating of his abdomen with
frequent offensive, smelly stool that are difficult to flush. He looks pale on examination.
n
io

t
C. Upper gastrointestinal endoscopy

ua
D. Colonoscopy
E. Stool culture
al
22. A 4 week old male infant presents to the Accident & Emergency Department with
vomiting after every feed. The mother describes the vomiting as projectile and non-
Ev
bilious in nature. The child is also constipated and has not passed stool or flatus for 3
days. On examination, there is a right sided olive-sized abdominal mass on palpation.
What is the SINGLE most appropriate next step of action to diagnose the condition?
B. Abdominal X-ray
23. A 3 month old term female infant presents to clinic with frequent episodes of non-
projectile vomiting after feeds. The mother complains it is difficult to breastfeed her
child. On examination, the infant is irritable and she is below centiles on the growth
chart in terms of weight. What is the SINGLE most likely diagnosis?
A. Pyloric stenosis
B. Duodenal atresia
1184
C. Hypothyroidism
E. Tracheo-oesophageal fistula
24. A 4 month old, healthy female infant presents to clinic for her routine immunizations of
DTP, Hib, polio, MenB, and pneumococcal vaccines. At her 3 month immunization, she
cried and was irritable for 3 hours followed by a fever that lasted for 2 days. Which of
the following is the SINGLE most appropriate action now?
A. Do not give the vaccines

B. Give half the vaccine doses
C. Give paracetamol followed by vaccines
D. Proceed with standard immunization schedule
E. Defer vaccines for 2 weeks
25. A 3 year old child is admitted to hospital for a very high fever. He is discovered to be
below the 25th percentile for weight. After a week in hospital, his weight improves
from 10 kg to 11kg upon discharge. A week later, he is readmitted with pneumonia. His
y
weight upon admission is back to 10kg and improved to 11.5kg at the end of 10 days
op
upon discharge. What is the SINGLE most likely cause of his fluctuating weight?
A. Leukaemia
C
B. Cystic fibrosis
C. Non-accidental injury
D. HIV/AIDS infection
n
E. Pulmonary fibrosis
io
26. Parents of a 3 month old baby are worried about cot death. What is the SINGLE most
t
appropriate advice to give in regards to sleeping position and bedding?

ua
A. Place baby in a prone position to sleep

B. Place baby on his back to sleep
al
C. Place baby on his side to sleep

D. Use soft bedding
Ev
E. Use pillows
27. A 4 year old is brought to the emergency department by ambulance. His mother
reports that he has been unwell with a sore throat. He is sitting on his mother’s knee
and is tolerating an oxygen mask but looks unwell. He has constant noisy breathing and
he is drooling saliva. He has a temperature of 39.0°C. What is the SINGLE most likely
diagnosis?
A. Acute asthma
B. Bronchiolitis
C. Croup
D. Epiglottitis
E. Tonsillitis
28. A 4 month old girl presents with jaundice and failure to thrive. The jaundice was first
noticed in the first few weeks of life but her parents were not able to seek medical care.
1185
She has pale stools and dark urine. Her spleen is palpable and her liver is enlarged and
hard. What is the SINGLE most likely diagnosis?
A. Biliary atresia
C. Hepatitis B
D. Spherocytosis
E. Rh incompatibility
29. A 2 year old boy presents to the Emergency Department with bruising and generalised
petechiae that is more prominent over his legs bilaterally. The mother states the child
recovered from the flu 2 weeks ago. On examination, there was no
hepatosplenomegaly, no lymph node enlargement. Platelet count is 15 000/μL. What is
A. Von Willebrand disease

y
op
E. Aplastic anaemia
30. A 6 week old baby is admitted with persistent vomiting and failure to gain weight. Her
C
mother describes the vomiting as projectile and non-bilious. On examination, there is a
right sided olive-sized abdominal mass on palpation. Bloods show the following:
n
Na+ 138 mmol/l
io
K+ 3.3 mmol/l
Cl- 83 mmol/l
t
HCO3- 28 mmol/l
ua

al
B. Abdominal x-ray
Ev
C. CT abdomen
D. Tissue transglutaminase (TTG) antibodies (IgA)
E. Jejunal biopsy
31. An 18 month old female child is able to walk up steps, plays well with others in day
care, can build blocks, and able to hold crayons scribbling on paper. Her mother is
concerned because despite her daughter of having a vocabulary of more than 10 words,
she is not able to speak in sentences nor is she able to run. What is the SINGLE best
management strategy?
A. Arrange hearing test

B. Assess development milestones
C. Reassurance
D. Refer to speech therapist
E. MRI brain
1186
32. A mother who delivered a term infant 8 days ago is now diagnosed with varicella zoster.
Her infant is currently afebrile, feeding well, passing stool and urinating without
difficulty. Which of the following is the SINGLE most appropriate step in management?
A. Isolate the infant from the mother

B. Hospitalize the infant in the isolation ward
C. Administer aciclovir to the infant
D. Administer varicella-zoster immunoglobulin to the infant
E. Advise the mother to continue regular well-baby care for the infant
33. A neonate’s chest X-ray shows a double bubble sign. He has low set ears and a flat
occiput. What is the SINGLE most likely diagnosis?
A. Down's syndrome
C. Turner’s syndrome
E. Edward’s syndrome
y
op
34. An infant started to have jaundice when he was 2 days old which resolved itself
towards day 9. There is an increase in serum bilirubin. What is the SINGLE most likely
diagnosis?
C
A. Galactosaemia
B. Biliary atresia
n
C. Prolonged jaundice
io
D. Hypothyroidism
t
ua
35. A young anxious mother of a 1 year old boy comes to you requesting a test for cystic
fibrosis as her brother died from cystic fibrosis. What is the SINGLE most appropriate
investigation?
al
A. Sweat test
Ev
B. Heel prick test

C. Breath test
D. Chest X-- ray
E. Genetic testing of parents
36. A 12 month old male infant presents to clinic because his mother is concerned that the
child cannot sit on his own, crawling but not standing with support, unable to pick up
small items, and is not socially interactive with his older sibling. What is the SINGLE best
management?

B. Assess developmental milestones
C. Reassure
D. MRI brain
E. Referral to physiotherapist
1187
37. An 8 year old child is brought into A&E with a fractured leg. The parents are unable to
explain how the leg fractured. X-rays reveal several other fractures in various stages of
healing. The parents cannot explain what might have caused them. On examination, the
child has a blue sclerae and difficulty hearing. What is the SINGLE most likely diagnosis?
A. Osteogenesis imperfecta
B. Non accidental injury
C. Haemophilia
D. Achondrogenesis
38. A 3 year old girl ingested 10 capsules from her grandmother’s medication bottle
thinking it was candy. By the time the child is in the Emergency Department, she is
drowsy and lethargic. Paramedics noted myoclonic twitching. ECG reveals tachycardia
and widened QRS. Potassium is elevated. What is the SINGLE most likely medication did
the child ingest?
A. Tricyclic antidepressants
y
B. Acetaminophen
op
C. Thyroxine
D. Amiodarone
E. Nifedipine
C
39. A 2 year old boy is brought to A&E by his mom with a history of severe diarrhoea and
vomiting for the last 4 days. He has been unable to keep anything down for the last
n
couple of days. His HR is 160 bpm, BP is 90/50 and his weight is 12 kg. Which is the
io
SINGLE best feature to prompt you to start IV fluid resuscitation?

t
A. Capillary refill of 4 seconds

ua
B. Not thirsty
C. Weight loss of more than 5%
D. Vomited three times or more in the past 24 hours
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E. Infants who were of low birth weight

Ev
40. A 4 year old girl attends clinic with a history of diarrhea, bloating and abdominal pain.
She is failing to thrive. Blood test reveal a hypochromic microcytic anaemia. Alpha
gliadin antibodies are positive. What is the SINGLE most likely diagnosis?
B. Crohn’s disease
C. Ulcerative colitis
D. Coeliac disease
E. Whipple’s disease
41. A 6 year old boy is brought to clinic by his mother. She says that he is still unable to
keep dry at night and will be attending a sleepover party at a friends house. She says
that it would be embarrassing if he wets himself during the sleepover and she wants to
know if anything can be done. What is the SINGLE most appropriate management?
A. Desmopressin
B. Reassurance
1188
D. Enuresis alarm
E. Oxybutynin
42. A 9 year old boy has long arms, legs, fingers and toes. He is tall for his age and is noted
to have scoliosis when examining his back. He started wearing glasses at a young age as
he was not able to see distance. What is the SINGLE most likely syndrome?
43. A 3 year old boy presents with fever, pallor, and decreased appetite. On examination,
there are palpable non-tender nodules along the deep cervical chain in the neck. Blood
results show: Hb 10g/dl ; MCV 80 fl ; WCC 2 x 109/L. What is the SINGLE most likely
diagnosis?
y
op
C
n
io
unable to keep dry at night. He wets his bed in the middle of the night and has daytime
wetting as well.. There was no period where he managed to stay dry during the night.
t
The mother wants to know if anything can be done to resolve this issue. What is the
ua
A. Desmopressin
al
B. Reassurance
Ev
D. Enuresis alarm
E. Referral to to secondary care or enuresis clinic
45. A 6 year old boy is brought into the Emergency Department by his mother’s boyfriend
with a fever of 37.8°C of 3 days duration. On examination, there are purple spots on his
lower back and brownish discoloration on his left forearm with left shoulder
dislocation. The child is quiet and makes no eye contact while in conversation. What is
the SINGLE most appropriate action to be taken after attending his fever?
A. Discharge home with appropriate medications

B. Admit patient into general paediatrics ward
C. Refer to social services
D. Option B and C
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46. A 3 year old child has severe diarrhoea and vomiting. On examination the child looks
lethargic, is seen to have dry lips and has sunken eyes. He has a feeble cry. What is the
SINGLE best choice of fluids to give intravenously?
A. 0.9% Normal saline

B. 0.9% Normal saline + 5% Dextrose
C. 0.45% Normal saline
D. 0.45% Normal saline + 5% Dextrose
E. Albumin
47. A 9 year old girl presents with arthralgia and purpura over her buttocks and extensor
surfaces of the legs bilaterally. Laboratory results showed elevated IgA levels and
creatinine. What is the SINGLE most likely diagnosis?
A. Non-accidental injury
B. Henoch-Schonlein purpura
C. Bacterial meningitis
y
48.
op
A 2 year old child presents to the A&E department with drooling, sore throat and loss of
voice. He has fever with a temp of 38.9C. His parents tell you that he has not been
C
immunised because they are afraid of the side effects of the vaccination. What is the
n
A. Direct pharyngoscopy
io
B. Summon anaesthetist
C. IM Epinephrine
t
D. IV fluids
ua
E. Start antibiotics
al
every feed. The child is also constipated. On examination, there is a right sided olive-
sized abdominal mass on palpation. What is the SINGLE most likely diagnosis?
Ev
A. Pyloric stenosis
B. Duodenal atresia
C. Malrotation
D. Coeliac disease
E. Gastro-oesophageal reflux disease
50. A 4 year old boy presents to the Emergency Department with fever, bloody diarrhea,
decreased urine output after a school field trip at a farm. On examination, the boy is
pale, tired, and his face is swollen. Lab results: hematocrit 28%, platelets 72 000/μL.
There is blood and protein in urine. What is the SINGLE most likely diagnosis?
A. Acute post-streptococcal glomerulonephritis

D. Intussusception
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51. A 13 year old girl with several years of elevated liver enzymes of unknown etiology
presents to clinic with a slow deterioration in her school performance. On examination,
there is hepatosplenomegaly, intention tremor, dysarthria, and dystonia. Her urinalysis
has elevated levels of glucose, protein, and uric acid. What is the SINGLE most likely
diagnosis?
A. Autoimmune hepatitis
B. Glycogen storage disease
C. α1-Antitrypsin deficiency
D. Hereditary haemochromatosis
52. A 6 year old male presents to the clinic with obesity and short stature. On examination,
his BMI >95th percentile. His past medical history is significant for a renal transplant.
y
op
C. Primary obesity
C
53. A 1 day old male infant has developed abdominal distension, bilious vomiting, and
meconium ileus was present. Prenatal ultrasound had previously revealed echogenic
n
bowel. Which of the following is the SINGLE most likely diagnosis?
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A. Duodenal atresia
t
B. Cystic fibrosis
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C. Gastroenteritis
D. Malrotation and volvulus
E. Hirschsprung disease
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54. A 2 year old girl has had a temperature of 39°C, poor appetite, abdominal pain and
Ev
urinary frequency for the last 3 days. What is the SINGLE most appropriate action?
A. Catheter specimen of urine for culture

B. Clean catch urine specimen for culture
C. Full blood count
D. KUB Ultrasound
E. Supra-pubic aspirate of urine for culture
55. A 3 year old child presents with cough and high temperature which began 2 days ago. A
rash is noticed on his buccal mucosa. What is the SINGLE most appropriate diagnosis?
A. Measles
B. Roseola infectiosum
C. Rubella
D. Chicken pox
E. Impetigo
1191
56. A 4 week old male infant presents with a 10 day history of non-bilious vomiting that has
increased in frequency and forcefulness. Despite feeding and looking well, the infant
has lost weight. Abdominal ultrasound reveals a thickened pylorus. Which of the
following is the SINGLE most appropriate definitive management?
A. Normal saline and 5% dextrose

B. Potassium chloride
C. Pyloromyotomy
D. Nasogastric tube insertion
E. Barium enema
57. The newborn screening results of an 8 day old female infant are as follows: TSH 40
mIU/L and T4 70 nmol/L. The mother notes that the child is difficult to feed and does
not cry much. On examination, the child has cold mottled skin and weak, floppy
muscles. What is the SINGLE most appropriate management?
A. Observation and reassess in 3 months

B. Propylthiouracil
y
C. Methimazole
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E. Levothyroxine C
58. A 12 year old boy presents with severe watery diarrhea for the past 7 days. His urine
output is low, mucous membrane are dry, and skin turgor is decreased. What is the
n
io
A. Antibiotic
B. Antimotility
t
C. Antiemetic
ua
D. Fluid replacement
E. Reassurance
al
59. A 5 month old child is unable to speak but makes sounds. She can hold things with her
palm, but not her fingers. She smiles and laughs and is not shy. She cannot sit
Ev
independently but can hold her hand and sit when propped up against pillows. What is
the SINGLE best development stage to describe this child?
A. Normal
B. Delayed speech and language development
C. Delayed social development
D. Delayed fine motor development
E. Delayed gross motor development
60. A 15 year old boy attended the emergency department with shortness of breath. A
diagnosis of spontaneous unilateral pneumothorax was made. He is noted to be tall for
his age with long arms and fingers. He also has severe scoliosis. What is the SINGLE
most likely syndrome?
1192
61. An 8 year old boy presents with severe crushing chest pain. He is tall for his age and has
a refractive error for which he wears thick glasses for. What is the SINGLE most likely
syndrome?
62. A 5 week old male infant presents to clinic with jaundice during routine check-up. On
examination, the baby is irritable, below average centiles for weight, and the liver is
enlarged. Pale stools and dark urine on diaper were observed. The mother is currently
not breast-feeding and had placed him on formula. What is the SINGLE most likely
diagnosis?
y
op
A. Galactosemia
C. Rh incompatibility
C
D. Congenital viral infection
E. Biliary atresia
n
63. A 1 week old male infant, born at 32 weeks gestation, is currently in neonatal ICU and
io
was doing well on increasing nasogastric feedings. The nurse now notes that the infant
has been vomiting during the last 2 feedings, is less active, and has blood in his stool.
t
On examination, the abdomen was tense, distended with decreased bowel sounds.
ua
Abdominal x-ray reveals distended loops of bowel with air in the bowel wall. What is
al
A. Emergent exploratory laparotomy

B. Reduce volume of feeds per feeding and feed more frequently
Ev
C. Remove nasogastric tube and replace with transpyloric tube, then switch feeds from
nasogastric to nasoduodenal tube
D. Stop feeds, begin intravenous fluids, perform abdominal films, and initiate systemic
antibiotics
E. Continue the same
64. After several episodes of urinary tract infections, a 2 year old girl undergoes a
micturating cystourethrogram which reveals mild dilation of the renal pelvis and reflux
into the ureters and kidney. She is currently not on any medication. Which of the
following is the SINGLE most appropriate next step in treatment?
A. Low dose antibiotic prophylaxis daily

B. Observation with weekly urinalysis and urine culture
C. Surgical reimplantation of the ureters
D. Endoscopic injection of bulking agents
1193
65. A 12 year old girl presents to clinic with sudden onset of pallor, palpitations, and
difficulty breathing while running on the school track. After 30 minutes, her symptoms
resolved. This is a first time event and she has never been cyanotic. Cardiac
examination was normal. Chest x-ray and echocardiogram were normal. ECG reveals
evidence of pre-excitation, delta waves, and prolonged QRS. What is the SINGLE most
likely diagnosis?
A. Paroxysmal ventricular tachycardia

B. Paroxysmal supraventricular tachycardia
C. Wolff-Parkinson-White syndrome
D. Stokes-Adams pattern
E. Excessive stress during exercise
66. A 3 year old child is brought to the emergency department by his mother with bruises
and swelling over the medial aspect of the left arm. X-ray shows multiple callus
formation in the ribs. Bruises on the child's back is seen on examination. Analgesia has
been given. What is the SINGLE most appropriate next step?
y
A. Check child protection register
op
B. Involve social services
C. Skeletal survey
D. Serum calcium
C
E. DEXA scan
67. A 2 year old boy presents to the Emergency Department with painless rectal bleeding
n
for the past 2 days. On examination, the child is afebrile, tachycardic, alert, playful, and
io
feeding well. Abdominal examination was normal. Which of the following is the SINGLE
t
ua
A. Intussusception
C. Hirschsprung disease
al
D. Volvulus
E. Meckel’s diverticulum
Ev
68. A 10 year old boy presents to the Emergency Department having fallen from a height of
150cm and hit his head while playing in the playground. There was no loss of
consciousness and he is currently haemodynamically stable. GCS 15/15. On
examination, he is oriented with a swelling and tenderness on his left cheek. Which of
the following is the most SINGLE most appropriate initial investigation?
A. CT brain
B. MRI brain
C. EEG
D. Facial x-ray
69. A 5 year old boy presents with drooling of saliva and severe stridor. He has a
temperature of 39.0°C and is sick looking. He has difficulty speaking and has muffled
voice. A lateral radiograph demonstrates a “thumb sign”. What is the SINGLE most
likely diagnosis?
1194
A. Croup
B. Recurrent aspiration
C. Diphtheria
D. Acute epiglottitis
E. Inhaled foreign body
70. A 6 week old child is brought to A&E with persistent non-bilious vomiting. The child
feels hungry and wants to feed despite constant vomiting. Biochemistry shows K+ of 3.1
mmol/l. What is the SINGLE most likely diagnosis?
A. Pyloric stenosis
B. Duodenal atresia
C. Malrotation
D. Achalasia cardia
E. Tracheo-esophageal fistula
71. An 8 year old boy is brought by his mother to the emergency department with bruises
y
on his lower back and a left shoulder dislocation. The child currently lives with his
op
stepfather. The young boy is quiet and makes no eye contact while in conversation.
B. Malnutrition
C. Thrombocytopenia
n
D. Osteogenesis imperfecta
io
E. Haemophilia
t
72. An 8 year old boy presents to clinic with behavioral problems. He is inattentive in class.
ua
During the interview, he is unable to sit still; he is constantly blinking his eyes, making
grunting noises with his throat, and rubbing his fingers. What is the SINGLE most likely
diagnosis?
al
A. Asperger syndrome
Ev
B. Cotard’s syndrome
C. Rett’s syndrome
D. Ekbom’s syndrome
E. Tourette’s syndrome
73. A 10 month old male infant presents with a 6 hour history of crying and passage of
loose, bloody stool. On examination, the infant is irritable, with intermittent drawing up
of his knees to his chest, and a temperature of 38.8°C. Rectal examination reveals gross,
currant jelly-coloured blood on finger. What is the SINGLE most likely diagnosis?
A. Constipation
B. Gastroenteritis
C. Intussusception
D. Meckel's diverticulum
E. Volvulus
1195
74. A 2 year old boy was separated from his mother in a shopping mall. He got very upset
and then fell down and became unconscious. He looked blue. He became conscious
after 2 minutes and was back to his active self after an hour. His mother is extremely
concerned. What is the SINGLE most appropriate next step?
A. CT head
D. Reassure
E. Pulmonary function test
unable to keep dry at night. He wets his bed in the middle of the night at least three
times a week but he is without daytime symptoms. There was no period where he
managed to stay dry during the night. The mother wants to know if anything can be
done to resolve this issue. His medical history is insignificant and there is no history of
y
A. Desmopressin
op
B. Reassurance
D. Enuresis alarm
C
76. A 13 year old girl presents to the Emergency Department with weight loss, bloody
n
diarrhea, and fever intermittently over the last 6 months. The intermittent episodes has
io
caused occasional restriction of activity. Currently she is having moderate abdominal

pain. Labs reveal elevated ESR and positive p-ANCA. What is the SINGLE most likely
t
management for this patient?

ua
A. Topical and oral mesalazine

B. Prednisolone and mesalazine oral
al
C. Prednisolone IV
D. Cyclosporine IV
Ev
E. Infliximab IV
77. A 5 year old boy is brought to clinic by his mother. The young boy has a distinct nasal
speech and snores heavily at night. He is hyperactive during the day but has poor
concentration. He is noted to be constantly breathing through his mouth. What is the

C. Refer to ENT surgeon
E. Arrange a magnetic resonance imaging scan
78. A 2 year old child was brought by his mother with swelling on the right side of his neck
extending from the angle of the mouth to the middle one third of the
sternocleidomastoid muscle. The swelling is on the anterolateral side of the
sternocleidomastoid muscle. On examination, the mass is partially compressible. when
1196
subjected to light test is brilliantly translucent. What is the SINGLE most likely
diagnosis?
A. Lymphangioma
B. Branchial cyst
C. Thyroglossal cyst
D. Ranula
E. Grave’s disease
79. A 3 month old infant presents with recurrent infections and feeding difficulties. His face
looks dysmorphic and has a cleft palate. A chest X-ray shows absent thymic shadow.
A. Down's syndrome
C. DiGeorge’s syndrome
E. Edwards' syndrome
y
op
80. A 4 month old child is brought to Accident & Emergency by her parents. She is found to
weigh 4.1kg. She presents with multiple bruises on her left and right lower leg. Her left
ankle is swollen and she refuses to move it. She appears irritable and she also has a
C
runny nose. What is the SINGLE most likely diagnosis?
A. Haemophilia
n
B. Thrombocytopenia
io
C. Non accidental injury

D. Malnutrition
t
E. Osteogenesis imperfecta
ua
81. A 9 year old girl, known case of asthma, presents to the Emergency Department with a
1 day history of shortness of breath that is increasing in severity. She had a previous
al
upper respiratory tract infection 1 week prior which had resolved. Chest x-ray reveals
bilateral hyperinflation. On arrival, she was given oxygen, nebulized beta-2 agonist, and
Ev
oral prednisolone. She is now drowsy, respiratory rate is 30 and her SpO2 is 90%. Which
of the following is the SINGLE most appropriate investigation?

B. Pulse oximetry
C. Spirometry
D. CT chest
E. Peak flow meter
82. An 8 week baby boy is noted to be jaundiced. He has feeding difficulty, with vomiting
and failure to gain weight. His stools are yellow and his urine is pale straw coloured.
A. Galactosaemia
B. Biliary atresia
D. Breast milk jaundice
1197
E. Congenital viral infection
83. A 7 day baby whose birth weight was initially 3.5 kg, has a weight of 3.3 kg currently.
A. Inform seniors and check the child protection register

B. Refer for a nutritional assessment
C. Request a skeletal survey
D. Reassure mother and continue regular child care
E. Inform the police
84. A 7 year old girl is brought by her mother with bright red staining of her underpants.
She gives a history that her daughter recently started taking horse riding lessons. What
is the SINGLE next most appropriate action?
A. Examination of genitalia in clinic

B. Examination of genitalia under general anaesthesia
C. Reassure and discharge
y
D. Inform child protection services
op
E. Colposcopy
85. An 8 year old child has recurrent throat infections. He feels tired and lethargic all the
C
time. Petechiae is noticed on his lower limbs. On examination, splenomegaly and gum
hypertrophy was noted. Blood results show:
n
Hb 6.8g/dl
io
WCC 7 x 109/L
t
ua

al

Ev

86. A 9 year old patient attends the outpatient department with complains of fever,
malaise, weight loss, anorexia and productive cough. Examination reveals a
temperature of 39.1°C, and a pulse of 120 beats/minute. His mother says that he has a
history of recurrent chest infections since young. What is the SINGLE most likely
causative organism?
A. Pneumococcal pneumonia
C. Mycobacterium tuberculosis
D. Pseudomonas aeruginosa
E. Pneumocystis pneumonia
87. A 5 year old girl is being investigated for renal failure. She has a history of urinary tract
infections in the pass. A congenital abnormality of the insertion of ureters into the
1198
urinary bladder was seen on scan. What is the single most likely cause for renal failure
in this patient?
A. Systemic Lupus Erythematosus

B. Polycystic kidney disease
C. Wilms’ tumour
D. Acute tubular necrosis
E. Reflux nephropathy
88. A 3 year old boy who has had frequent urinary tract infections has recently been
diagnosed with vesicoureteral reflux. Which of the statements are correct?
A. Antibiotic prophylaxis is first line

B. Most children with vesicoureteral reflux will require surgery
C. Most children with vesicoureteral reflux will have kidney scarring by age 5
D. Antibiotic use has not been shown to reduce renal scarring
E. Surgical correction should only be considered in patients with low-grade reflux
y
89. A 4 year old child presents to A&E with fever and stridor. He is unable to swallow his
op
saliva. He has a respiratory rate of 45 breaths/minute. What is the SINGLE most
appropriate next step in management? C
A. Examine his throat
B. Secure his airways
C. Keep him in a supine position
n
D. Administer intravenous penicillin
io
E. Administer intramuscular epinephrine

t
90. A 2 year old child is brought to the hospital by his mother with a barking cough. A few
ua
days ago he had a runny nose, cough and a sore throat. His chest sounds are normal
and there are no signs of intercostal recession. He looks drowsy and lethargic. He has a
temperature of 38.7°C, respiratory rate of 34 breaths/minute, pulse rate of 150
al
beats/minute and his oxygen saturation on air is 96%. What is the SINGLE most
Ev
A. Oral dexamethasone
B. Oxygen
C. Nebulised salbutamol
D. Antibiotics
E. Nebulised adrenaline
91. A 13 month old female baby presents to the emergency department with difficulty in
breathing. On examination, she has intercostal recessions and a bilateral widespread
wheeze. Her temperature is 37.9°C and respiratory rate is 35 breaths/minute. What is
A. Bacterial upper respiratory tract infection

B. Pneumonia
C. Bronchiolitis
1199
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t
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C
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Paediatrics Answers
1. A 7 month old baby is admitted with a 3 day history of coughing. He has a temperature
of 38.5°C. On examination, there is marked subcostal recession and widespread wheeze
is noted bilaterally. His respiratory rate is 60 breaths/minute. What is the SINGLE most
A. Supportive care
C. Intravenous hydrocortisone
D. Intramuscular adrenaline
E. Nebulised salbutamol
The diagnosis here is bronchiolitis. Supportive care is the mainstay of treatment

involving oxygen.
Bronchiolitis
- An acute infectious disease of the lower respiratory tract that occurs
y
primarily in the very young, most commonly infants between 2 and 6 months
op
old
- Respiratory syncytial virus (RSV) is the pathogen in 75-80% of cases
C
It is a clinical diagnosis based upon:
- Breathing difficulties
- Cough
n
- Coryzal symptoms (including mild fever)
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- Decreased feeding
- Apnoeas in the very young
t
- Wheeze or fine inspiratory crackles on auscultation

ua
Management
- Largely supportive involving humidified oxygen
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2. A 2 year old girl previously well is brought to A&E by her mother with a history of
Ev
vomiting and diarrhoea for the last 2 days. She is unable to keep any food or liquid
down in the past day. What is the SINGLE most suitable indication for intravenous fluids
administration?
A. Capillary refill time > 4 seconds

B. Heart rate > 90 beats/minute
C. Respiratory rate > 25 breaths/minute
D. Passing of watery stools more than eight times a day
E. Current weight < 10 kg
Normal capillary refill time is usually less than 2 seconds. Prolonged capillary refill time
is a sign of clinical shock. Intravenous fluid should be started immediately.
A 2 year old child can have a heart rate anywhere between 80 to 120 beats per minute
and so option B is wrong.
It is also normal to have a respiratory rate between 20 to 30 breaths per minute in a 2

year old child thus option C is wrong.
1201
Passing large amount or increased frequency of watery stool is not a clinical sign of
dehydration.
Weight has no role as an indication for IV fluids and has no relation as a clinical sign of
dehydration.
No clinically Clinical Clinical shock

detectable dehydration
dehydration
Symptoms Appears well Red flag Appears to
(remote and face- be unwell or
to-face deteriorating
assessments) Alert and Red flag Altered Decreased level of
responsive responsiveness (for consciousness
example, irritable,
lethargic)
y
Normal urine Decreased urine
op
output output
Skin colour Skin colour Pale or mottled
unchanged unchanged skin
C
Warm extremities Warm extremities Cold extremities
Signs (face-to-face Alert and Red flag Altered Decreased level of
n
assessments) responsive responsiveness (for consciousness
example, irritable,
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lethargic)
t

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Eyes not sunken Red flag Sunken
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eyes
Moist mucous Dry mucous
Ev
membranes membranes
(except after a (except for 'mouth
drink) breather')
Normal heart rate Red flag Tachycardia
Tachycardia
Normal breathing Red flag Tachypnoea
pattern Tachypnoea
Normal peripheral Normal peripheral Weak peripheral
pulses pulses pulses
Normal capillary Normal capillary Prolonged capillary
refill time refill time refill time
Normal skin turgor Red flag Reduced
skin turgor
Normal blood Normal blood Hypotension
pressure pressure (decompensated
shock)
1202
3. A 4 year old girl is taken by her mother to the emergency department and complains of
pain during urination and feeling generally unwell. She has a temperature of 38.5°C.
What is the SINGLE most appropriate initial action?
A. Suprapubic aspiration
B. Clean catch of urine
C. Catheter for sample of urine
D. Renal ultrasound
E. DMSA scan
The clinical features described are consistent with urinary tract infection for which a
clean catch of urine is the next best action.
Special arrangements may be needed for collecting a sample from a child. (Clean catch,
catheter or suprapubic aspiration are methods used which reduce the risk of
contamination)
Routine investigations that are done in urinary tract infection are:
y
- Dipstick analysis of urine - may treat as bacterial if there are positive results
op
for nitrite and/or leukocytes
- Urine microscopy - leukocytes indicate presence of infection
- Urine culture
C
4. An 18 month old boy has been brought to the emergency department by his mother
because he has been refusing to move his left arm and crying more than usual for the
n
past 24 hours. He has recently been looked after by his mother’s new partner while she
io
attended college. Assessment shows multiple bruises on his body and the medial aspect
of his left upper arm. What is the SINGLE most appropriate next step?
t
ua
A. Admit under care of pediatrician

B. Discharge with painkillers
C. Start IV centrist one
al
D. Follow up in paediatric outpatient department

E. Follow up with GP
Ev
The likely diagnosis here is a non-accidental injury. Bruising in unusual sites (eg medial
aspect of upper arms or thighs) should prompt consideration of non accidental injury.
The child needs to be admitted for further investigation and also to prevent further
injury from the mother’s partner.
Non accidental injury
Presentation:
- Delayed admission into hospital or clinic by carer
- Child usually brought in by step-father or boyfriend
- Bruising – of varying degrees, color variations (means long term abuse)
- Fractures
Diagnosis:
- Mostly clinical history
1203
Treatment:
- Admit to ward and manage pain
- Refer to social services
- Treat any other underlying medical conditions
unable to keep dry at night. There was no period where he managed to stay dry during
the night. The mother wants to know if anything can be done to resolve this issue. He is
dry during the day. His medical history is insignificant and there is no history of
A. Desmopressin
B. Reassurance
D. Enuresis alarm
Reassure the parents that many children younger than 5 years of age wet the bed, and
y
this usually resolves without treatment → reassurance maybe all that is required.
Definitions:
op
Primary nocturnal enuresis refers to children that have never been dry for more than a
C
6-month period
Secondary nocturnal enuresis refers to the re-emergence of bedwetting after a period

n
of being dry for at least 6 months
io
The management of bedwetting can be a little confusing as different sources and books
t
would have slightly different answers. But the best place to take the answers from
ua
would be NICE CKS as these are NICE guidelines and PLAB questions would have to
adhere by them.
al
The points on NICE CKS can be summarized bellow:

Primary bedwetting (without daytime symptoms)
Ev
Younger than 5 → reassurance!
Older than 5 years of age

- If bedwetting is infrequent (less than 2x a week) → reassurance
- If long-term treatment required → enuresis alarm (1st line) + reward
system
- If short-term control of bedwetting is required (e.g. sleep overs) →
Desmopressin
If treatment has not responded to at least two complete courses of treatment with
either an alarm or desmopressin → Refer to secondary care
Primary bedwetting (with daytime symptoms)

- Refer all children above 24 months with primary bedwetting and daytime
symptoms to secondary care or an enuresis clinic for further
investigations and assessment.
1204
6. A 3 week old female infant has recently become jaundiced. Her mother has breastfed
her since she was born. Test have ruled out other causes of jaundice and the diagnosis
of breast milk jaundice is made. She is otherwise well. What is the SINGLE most
A. Phototherapy
B. Exchange transfusion
D. Continue breastfeeding
E. Stop breastfeeding completely
Infants become jaundiced in the second week of life. The diagnosis and treatment is to
stop the breast feeding (and give formula) for 24 hours. When bilirubin is checked
again, it will have fallen significantly. The baby may then be safely breastfed. Thus some
paediatricians would suggest interrupting breastfeeding for 24 hours (and give formula
instead) as this is the most rapid way to reduce the bilirubin level. However, in most
infants, interrupting breastfeeding is not necessary or advisable.
y
In this question, interrupting breastfeeding was not given as an option. The best option
op
in this scenario would be to continue breast feeding.
7. A 2 week old male, term infant presents to the Emergency Department with a sudden
C
onset of green, bilious vomiting for two hours and blood in diapers. Abdominal x-ray
reveals dilatation of the stomach and in the proximal loops of the bowel. Barium enema
indicates partial obstruction of the duodenum and malposition of the caecum. Which of
n
the following is the SINGLE most likely diagnosis?
io
A. Jejunal atresia
t
B. Hypertrophic pyloric stenosis

ua
C. Malrotation and volvulus

D. Acute appendicitis
E. Intussusception
al
When you see sudden onset of green, bilious vomiting and blood per rectum in
Ev
neonates for PLAB 1, think of malrotation with volvulus. PLAB 1 may have abdominal x-
ray result as “double bubble sign”. Pyloric stenosis in PLAB 1 would have projectile
vomiting as a key feature and the age would be older than 3 weeks. Intussusception is
uncommon in neonates and would most likely occur in infants 6 months or older. Note
that it may be possible in PLAB 1 for them to show an x-ray for case stems so instead
having a description of the result you may need to interpret the radiology yourself.
Malrotation and volvulus

Presentation:
- Green, bilious vomiting
- Blood per rectum
- Sudden onset
- Age: neonates
Diagnosis:
- Abdominal x-ray
- Barium enema
1205
Treatment:
- ABCDE protocol
- Decompression with nasogastric tube
- Referral to paediatric surgery for laparotomy and resection
8. A 3 year old boy attends clinic with a history of diarrhea on and off. The mother
describes the stool as bulky, frothy and difficult to flush. He looks pale and wasted on
examination. What is the SINGLE most likely investigation that would lead to a
diagnosis?

E. Thyroid function test
y
op
The diagnosis here is coeliac disease. Bulky, frothy and floating (difficult to flush) stools
are a hint that he is having a malabsorption syndrome. He looks pale because he is
anaemic.
C
If you have answered A (Sweat chloride test) for cystic fibrosis. You are not completely
wrong as cystic fibrosis can occur at that age as well and has symptoms of
n
malabsorption too (foul-smelling bulky stool that "floats). But the question writers are
io
likely to give other hints like “repetitive cough over the last few months” if cystic
fibrosis is the likely diagnosis. Also, given the two disease, coeliac is much more
t
common compared to cystic fibrosis and thus the most likely investigation that would
ua
lead to a diagnosis is anti-endomysial antibodies. Prevalence of coeliac is 1 in 100

people in the UK while the prevalence of cystic fibrosis is 1 in 2500.
al
Coeliac disease: an example of malabsorption

Associated with exposure to gluten, rye, wheat, barley
Ev
Malabsorption typically presents with diarrhoea, failure to thrive and anaemia
As subclinical/latent forms exist, investigate any unexplained anaemia, fatigue, ‘irritable

bowel’ symptoms, and diarrhoea
Patients mostly present between 6 months to 2 years of age but can occur at any age.
There may be a deceleration on the growth chart after introduction to gluten at
weaning (4–6 months).
Diagnosis
Immunology:
- raised IgA anti-tissue transglutaminase (IgAtTG), anti-gliadin (IgA-AGA),
and endomysial antibodies (EMA)
Biopsy:
Confirm by finding villous atrophy on small bowel biopsy (gold standard)
1206
every feed. The mother describes the vomiting as projectile and non-bilious. The child is
also constipated. On examination, there is a right sided olive-sized abdominal mass on
palpation. What is the SINGLE most appropriate next step of action?
B. Abdominal x-ray
This is a classic presentation of pyloric stenosis on PLAB 1. As the child is vomiting

profusely, there will be electrolyte imbalance. Hypokalaemia may be present and
therefore need to be corrected immediately.
In reality, one would take blood for serum potassium levels and arrange an abdominal
y
ultrasound while waiting for the serum potassium results. However, the exam writers
op
want you to think which is the most important given the stem.
Pay attention to the final line of the question. If the question is asking for the NEXT
C
STEP of action, serum potassium levels would be appropriate. If the question is asking
for the NEXT STEP TO DIAGNOSE the condition, then abdominal ultrasound would be
the answer.
n
io
Intravenous fluid should follow after taking bloods.

t
Presentation:
ua
- Projectile non-bilious vomiting

- Age group: 3-8 weeks
- Olive sized abdominal mass
al
- The child will feel hungry and want to feed despite constant vomiting
Ev
Diagnosis:
- Abdominal ultrasound
Treatment:
- Metabolic alkalosis – correct electrolyte imbalance + hydration
- Then referral to paediatric surgery (pyloromyotomy) + nasogastric tube
10. A 4 year old boy, who recently immigrated from Kenya with his parents, presents to
clinic with intermittent watery diarrhea, foul-smelling flatulence, nausea, and
abdominal pain. His weight is less than the fifth percentile for his age. On examination,
he has a fever of 38oC and is dehydrated. Which of the following is the most likely to
confirm his diagnosis?
B. Complete blood count
1207
D. ESR
E. Stool microscopy for ova and parasites
Giardiasis
Presentation:
- Watery diarrhea, foul-smelling flatulence
- Nausea, belching
- Abdominal pain
- +/- Fever
Diagnosis:
- Stool microscopy - first line
- Stool PCR / ELISA
Treatment:
- Hygiene
- Metronidazole
y
op
11. An infant soon after birth developed difficulty in breathing with intercostal recession
and nasal flaring. He is afebrile. On examination, there is diminished breath sounds. On
examining the mother's notes, there was a history of spontaneous rupture of
C
membranes 48 hours before delivery of baby. The mother was 36 weeks gestation
when the baby was delivered. What is the SINGLE most appropriate initial
investigation?
n
io
A. Blood culture
B. Chest X-ray
t
C. Stool culture
ua
D. Sputum culture
E. Maternal high vaginal swab
al
Infant respiratory distress syndrome secondary to surfactant deficiency which is the

cause of respiratory distress. There could be potential sepsis due to prolonged rupture
Ev
of membranes which worsens the respiratory distress however this is unclear.
One must remember that prolonged rupture of membrane is not a risk factor for IRDS.
In fact, the incidence of IRDS decreases with prolonged rupture of membranes. Note
however, PROM occurring before 37 weeks (PPROM) is one of the leading causes of
preterm birth. 30-35% of all preterm births are caused by PPROM. This puts the fetus at
risk for the many complications associated with prematurity such as respiratory
distress.
At this stage, a chest x-ray should be done to rule out other causes of respiratory
distress.
Infant Respiratory Distress Syndrome

- Infant respiratory distress syndrome (IRDS) is caused by the inadequate
production of surfactant in the lungs. It is usually seen in premature
infants where they have immature lungs.
1208
- It affects approximately one half of infants born at 28-32 weeks of
gestation. It rarely occurs at term.
Risk factors:
- Premature delivery
- Infants delivered via caesarean section without maternal labour
- Maternal diabetes
Presentation
- Respiratory distress very soon after birth:
o Tachypnoea
o Expiratory grunting
o Subcostal and intercostal retractions
o Diminished breath sounds
o Cyanosis
o Nasal flaring
y
op
12. A 7 year old child presented with chronic cough and is also found to be jaundiced on
C
A. Congenital diaphragmatic hernia
B. Congenital cystic adenomatoid malformation
C. Bronchiolitis
n
io

t
Jaundiced is a hint towards liver dysfunction. Together with respiratory symptoms are
ua
suggestive of Alpha 1 antitrypsin deficiency.
α-antitrypsin (α-AT) deficiency

al
This is an inherited condition that is associated with the early development of

Ev
emphysema.
13. A 6 year old boy presents to clinic with obesity. He has a history of failure to thrive as
an infant. He is now behind in school, has difficulty interacting with friends, and feeds
constantly. His mother says he cannot stop eating. What is the SINGLE most likely
diagnosis?
A. Cushing’s disease
C. Primary hypoparathyroidism
Prader Willi syndrome is a result of chromosomal abnormality in chromosome 15 on

the paternal side. The key clue is behavioral problems and uncontrolled feeding habits.
There may sometimes be clues in the stem stating the child has “blue eyes and blonde
hair”.
1209
Presentation:
- Male with blonde hair, blue eyes
- If uncontrolled feeding + obesity, the boy usually < 6 years old
- Developmental delay
Diagnosis:
- Chromosomal analysis: abnormality of paternal chromosome 15
- Mostly clinical diagnosis
Treatment:
- Referral to paediatric psychiatry for behavioral problems and developmental
delay
14. A 2 year old boy fell off his tricycle and hurt his arm. He got up and was about to start
crying but before there was any sound, he went pale, and unconscious. He recovered
after 2 minutes but remained pale. His colour came back after a few minutes. His
mother was concerned at that time that he was going to die. She is very worried and
mentions that he had a similar episode 2 months ago after falling down some steps.
y
op
A. CT head
C
D. Reassure
E. Skeletal survey
n
The diagnosis here is breath-holding spells
io
This usually occurs in young children when they are upset and can be precipitated by
t
trauma or when separated from the parents.

ua
Basically anything which may upset a child including injury from falling down
al
These children stop breathing for some time, they may turn blue or have little jerks of
the limbs.
Ev
After a period of time they spontaneously start breathing. They become completely fine
after an hour.
Treatment is not necessary. Usually just reassure parents
15. A 6 month old boy is admitted with persistent irritability. He is lethargic and is not
feeding well. He has a temperature of 38.2°C, a capillary refill time of 2 seconds and a
respiratory rate of 34 breaths/minute. Urine reveals leukocytes on a dipstick. What is
the SINGLE investigation most likely to lead to diagnosis?
A. Blood culture
C. Chest X-ray
E. CSF analysis
1210
Dipstick test already shows leucocytes. A urine culture will confirm a urinary tract
infection.
16. A 15 month old male infant arrives to clinic for his measles, mumps, rubella (MMR)
vaccine. On examination, he has a temperature of 37.5°C and has acute otitis media.
There is also a family history of egg allergy. What is the SINGLE most appropriate
action?
A. Do not give the vaccine

B. Give half the vaccine dose
C. Give paracetamol followed by vaccine
D. Give paracetamol with future doses of vaccines
E. Defer vaccine until the child is well
For PLAB 1, usually the paediatric immunization case stem would be similar to the one
above. Always choose option E for this type of scenario. Family histories most often do
not play a role in opting out of a vaccination schedule.
y
17. A 3 year old male presents to the Emergency Department with a left-sided irreducible
op
firm swelling near the groin. The swelling would descend when the child cries. On
examination, both testicles are palpable in the scrotum. What is the SINGLE most
C
A. Reassurance
B. Emergency herniotomy
n
C. Elective herniotomy
io
D. Emergency herniotomy and orchidopexy

E. Elective herniotomy and orchidopexy
t
ua
The diagnosis is an inguinal hernia. There are no clues in the stem of strangulation;
therefore, the herniotomy can be done electively. Herniotomy is usually performed for
children under 10 years. Herniorrhaphy is done in adults.
al
18. A 4 year old girl presents to the emergency center with difficulty breathing and stridor.
Ev
She has a temperature of 39.1°C. The parents state that the child had been in her usual
state of health but awoke with a hoarse voice, and difficulty swallowing. They tell you
that she has not been immunised because they are afraid of the side effects of the
vaccination. What is the SINGLE most likely diagnosis?
A. Cystic fibrosis
B. Acute Epiglottitis
C. Immunodeficiency
D. Inhaled foreign body
E. Recurrent aspiration
The clincher here is drooling of saliva. If you find any questions with a child with
drooling of saliva. It is likely that this is acute epiglottitis, Summon the most
experienced anaesthetist to intubate before obstruction occurs.
Acute epiglottitis
1211
- Now rare due to the introduction of Hib vaccine. However, it is still a serious
infection. Prompt recognition and urgent treatment is essential
- Caused by Haemophilus influenzae type B
Features
- Rapid onset
- High temperature
- Stridor
- Drooling of saliva
- Difficulty speaking
- Muffling or changes in the voice
19. A 3 year old boy is brought to A&E after having a generalized tonic-clonic seizure that
lasted approximately 5 minutes. The parents say that he was previously well but started
developing symptoms of a cold earlier in the morning. He is noted to have a fever of
39°C. What is the SINGLE most likely diagnosis?
y
A. Infant spasms
op
B. Absence seizures
C. Epilepsy
D. Partial complex seizure
C
E. Febrile convulsion
The diagnosis here is quite clear.

n
io
Febrile seizures
t
6 months to 6 years of age; peak at 14-18 months

ua
Usually with a positive family history

al
Temperature usually increases rapidly to > 39°C

Ev
Typical: generalized tonic-clonic seizures
Must determine cause of fever and rule out meningitis
Treatment
Control the fever
20. A 6 week old formula fed baby boy is found at under the healthy child programme to be
deeply jaundiced. His weight gain is poor. His stools are pale and urine colour is dark.
A. Galactosaemia
B. Biliary atresia
D. Rhesus incompatibility
1212
The signs and symptoms here along with prolonged jaundice is suggestive of biliary
atresia. Biliary atresia causes obstructive picture where stools are pale and urine
becomes dark which is exactly what is seen here.
Galactosaemia may cause prolonged jaundice too but does not present as an
obstructive picture with stools being pale and dark urine.
Glucose-6-phosphate dehydrogenase (G6PD) deficiency like the other haemolytic

diseases has an onset of jaundice usually less than 24 hours
Haemolytic disease of the newborn (rhesus) and congenital viral infection usually has
an early onset of jaundice and is not prolonged.
Biliary Atresia
Presentation:
- Jaundice with pale stools and dark urine
y
- Usually would present in 3-4 weeks of life
op
- Splenomegaly is not usually a feature unless presentation is late
- Failure to thrive is a result of poor absorption
C
Diagnosis:
- Abdominal ultrasound (initial investigation)
- Cholangiogram (definitive diagnosis)
n
io
Treatment:
- Kasai procedure = hepatoportoenterostomy
t
ua
21. A 2 year old has atrophy of the buttocks. He has often has bloating of his abdomen with
frequent offensive, smelly stool that are difficult to flush. He looks pale on examination.
al

Ev

C. Upper gastrointestinal endoscopy
D. Colonoscopy
E. Stool culture
The diagnosis here is coeliac disease. Smelly, difficult to flush stools are a hint that he is
having a malabsorption syndrome. He looks pale because he is anaemic. Immunology
test like anti-endomysial antibodies are appropriate.
If you have answered A (Sweat chloride test) for cystic fibrosis. You are not completely
wrong as cystic fibrosis can occur at that age as well and has symptoms of
malabsorption too (foul-smelling bulky stool that "floats). But the question writers are
likely to give other hints like “repetitive cough over the last few months” if cystic
fibrosis is the likely diagnosis. Also, given the two disease, coeliac is much more
common compared to cystic fibrosis and thus the most likely investigation that would
lead to a diagnosis is anti-endomysial antibodies. Prevalence of coeliac is 1 in 100
1213
people in the UK while the prevalence of cystic fibrosis is 1 in 2500.


Diagnosis
Immunology:
• raised IgA anti-tissue transglutaminase (IgAtTG), anti-gliadin (IgA-AGA), and
endomysial antibodies (EMA)
y
22.
op
A 4 week old male infant presents to the Accident & Emergency Department with
vomiting after every feed. The mother describes the vomiting as projectile and non-
C
bilious in nature. The child is also constipated and has not passed stool or flatus for 3
days. On examination, there is a right sided olive-sized abdominal mass on palpation.
What is the SINGLE most appropriate next step of action to diagnose the condition?
n
io
B. Abdominal X-ray
t
ua

al
Pyloric Stenosis:
Ev
Presentation:
Projectile non-bilious vomiting
Age group: 3-8 weeks
Olive sized abdominal mass
The child will feel hungry and want to feed despite constant vomiting
Diagnosis:
Treatment:
Metabolic alkalosis – correct electrolyte imbalance + dehydration
Then referral to paediatric surgery (pyloromyotomy) + nasogastric tube
Occasionally, the exam may show an abdominal X-ray and ask you for the diagnosis.
This is typically what an abdominal X-ray of an infant with pyloric stenosis will look like:
1214
23. A 3 month old term female infant presents to clinic with frequent episodes of non-
projectile vomiting after feeds. The mother complains it is difficult to breastfeed her
child. On examination, the infant is irritable and she is below centiles on the growth
chart in terms of weight. What is the SINGLE most likely diagnosis?
y
op
A. Pyloric stenosis
B. Duodenal atresia
C. Hypothyroidism
C
E. Tracheo-oesophageal fistula
n
This is a diagnosis of gastro-oesophageal reflux disease (GORD). This is one of the most
io
common causes to vomiting in infants.

t
While GORD can occur at any age, in paediatrics for PLAB 1 the case stem would usually
ua
have an infant < 1 year old.
Gastro-oesophageal reflux disease in Paediatrics

al
Presentation:
- Age group for PLAB 1: < 1 year
Ev
- Excessive and frequent episodes of regurgitation/vomiting after feeds

- Difficult to feed
- Failure to thrive
- Irritable and crying
Diagnosis:
- Upper GI study with contrast as per NICE protocol only (do not offer
routinely) - first line
- Upper GI endoscopy with biopsy as per NICE protocol only (do not offer
routinely)
Treatment:
- If breast-feeding: Breast-feeding assessment
- If formula-fed: take feeding history → increase feeding frequency and
reduce amount per feed → thickened formula
1215
- Only offer proton pump inhibitors (PPIs) or H2 receptor antagonists
(H2RAs) and consider enteral feeding only if there is no improvement to
the above
24. A 4 month old, healthy female infant presents to clinic for her routine immunizations of
DTP, Hib, polio, MenB, and pneumococcal vaccines. At her 3 month immunization, she
cried and was irritable for 3 hours followed by a fever that lasted for 2 days. Which of
the following is the SINGLE most appropriate action now?
A. Do not give the vaccines

B. Give half the vaccine doses
C. Give paracetamol followed by vaccines
D. Proceed with standard immunization schedule
E. Defer vaccines for 2 weeks
For PLAB 1, usually the paediatric immunization case stem would be similar to the one
above. Know the immunization schedule and the protocol for giving it.
y
Proceed with immunization and reassure parents that a slight fever post vaccines is
op
normal, can be relieved with paracetamol. If it persists for more than 1 week then seek
expert help. C
25. A 3 year old child is admitted to hospital for a very high fever. He is discovered to be
below the 25th percentile for weight. After a week in hospital, his weight improves
from 10 kg to 11kg upon discharge. A week later, he is readmitted with pneumonia. His
n
weight upon admission is back to 10kg and improved to 11.5kg at the end of 10 days
io
upon discharge. What is the SINGLE most likely cause of his fluctuating weight?
t
A. Leukaemia
ua
B. Cystic fibrosis
C. Non-accidental injury
D. HIV/AIDS infection
al
E. Pulmonary fibrosis
Ev
This is a seemingly tough question which in actuality, is quite simple. The normal weight
for a 3 year old male child is around 14kg. We can see from admission that his weight is
way below the average for his age group. The fact that his weight improved in hospital
and declined upon discharge is highly suspicious of negligence. Another clincher to this
fact is the frequent hospital admissions.
We cannot say this child has leukaemia or cystic fibrosis (although it is possible)
because there is no evidence in the stem to suggest this. Thus, the best answer is non-
accidental injury.
In certain questions like this one, there is insufficient information to properly know for
certain which is the correct answer. This type of questions may reflect those that appear
in the exam. Options C and B are still the top choices. Make one of these your choices
and move on to the next question. Do not overthink this as it could waste valuable time
in the exam.
Non-accidental injury/neglect:
1216
- Frequent attendance or unusual patterns of attendance to health care
services, including frequent injury.
- Failure to access medical care appropriately (including non-attendance
for routine immunisations, delay in presentation).
- Unsuitable explanations. Explanations which are inconsistent over time
or between people, or which are not consistent with the presenting
features.
- There is evidence of failure to thrive.
- Parents or carers do not administer prescribed medication.
- Inexplicably poor response to treatment.
- Reporting of new symptoms as soon as previous ones resolve.
26. Parents of a 3 month old baby are worried about cot death. What is the SINGLE most
appropriate advice to give in regards to sleeping position and bedding?
A. Place baby in a prone position to sleep
y
B. Place baby on his back to sleep
op
C. Place baby on his side to sleep
D. Use soft bedding
E. Use pillows
C
Cot death is more properly known as sudden infant death syndrome (SIDS). It is the
term used to describe the sudden death of a child under the age of 1 year in its sleep
n
where no cause or reason can be found. All other possible causes of death must be
io
excluded for this diagnosis to be made.

t
Sleeping position is particularly important. Prone sleeping is a major, modifiable risk

ua
factor. Placing babies on their backs to sleep is advice which should be reinforced by
professionals. Reassure parents that the risk of aspiration is not increased by sleeping in
this position and a number of studies have confirmed this.
al
Soft bedding increases the risk of SIDS. Pillows should not be used.
Ev
27. A 4 year old is brought to the emergency department by ambulance. His mother
reports that he has been unwell with a sore throat. He is sitting on his mother’s knee
and is tolerating an oxygen mask but looks unwell. He has constant noisy breathing and
he is drooling saliva. He has a temperature of 39.0°C. What is the SINGLE most likely
diagnosis?
A. Acute asthma
B. Bronchiolitis
C. Croup
D. Epiglottitis
E. Tonsillitis
The given case is classic picture of acute epiglottitis.
1217
Acute epiglottitis
- Now rare due to the introduction of Hib vaccine. However, it is still a
serious infection. Prompt recognition and urgent treatment is essential
Features
- Rapid onset
- High temperature
- Stridor
y
op
28. A 4 month old girl presents with jaundice and failure to thrive. The jaundice was first
noticed in the first few weeks of life but her parents were not able to seek medical care.
She has pale stools and dark urine. Her spleen is palpable and her liver is enlarged and
C
hard. What is the SINGLE most likely diagnosis?
A. Biliary atresia
n
io
C. Hepatitis B
D. Spherocytosis
t
E. Rh incompatibility
ua
Jaundice in newborns is an important topic within the paediatric section for PLAB 1.
al
The signs and symptoms here along with prolonged jaundice is suggestive of biliary
Ev
atresia. Biliary atresia causes obstructive picture where stools are pale and urine
becomes dark which is exactly what is seen here.
Failure to thrive is a result of poor absorption of long-chain fats.
The spleen becomes palpable after the 3rd or 4th week in biliary atresia. The liver may
become hard and enlarged as well.
Kasai procedure (hepatoportoenterostomy) has a good chance of restoring flow of bile

to bowel but that is only if the procedure is done early. Late presentations like this one
(e.g. more than 100 days), are unlikely to have a successful Kasai procedure due to
advanced liver damage and cirrhosis. This baby would likely need a liver transplant in
the first year of life.
Biliary Atresia
1218
Presentation:
Diagnosis:
Treatment:
- Kasai procedure = hepatoportoenterostomy
29. A 2 year old boy presents to the Emergency Department with bruising and generalised
petechiae that is more prominent over his legs bilaterally. The mother states the child
recovered from the flu 2 weeks ago. On examination, there was no
y
hepatosplenomegaly, no lymph node enlargement. Platelet count is 15 000/μL. What is
op
A. Von Willebrand disease

C
n
E. Aplastic anaemia
io
This is a diagnosis of idiopathic thrombocytopenic purpura (ITP). This is a common PLAB

t
1 topic under the haematology component. Main clues in the case stem to ITP: previous
ua
viral infection, or in younger children previous immunization along with low platelets.
Also, the petechiae would be mainly in the legs and on occasion on the arms.
Otherwise, the child feels well and is active.
al
Idiopathic thrombocytopenic purpura

Ev
Presentation:
- Follows viral infection or immunisation
- The most common presentation is petechiae or bruising. Petechiae
mainly in arms and legs - sudden onset
- Up to a quarter present with nosebleeds
- Haematuria and gastrointestinal bleeds are less common.
- Older girls may have menorrhagia
- Otherwise the patient is well and physical examination is normal
- Isolated thrombocytopenia; blood count otherwise normal
Management:
- Prednisolone
- IV immunoglobulin
- Emergency platelet transfusion
1219
o Only in life threatening haemorrhage. (usually platelet less than 20
x 109/L)
30. A 6 week old baby is admitted with persistent vomiting and failure to gain weight. Her
mother describes the vomiting as projectile and non-bilious. On examination, there is a
right sided olive-sized abdominal mass on palpation. Bloods show the following:
Na+ 138 mmol/l

K+ 3.3 mmol/l
Cl- 83 mmol/l
HCO3- 28 mmol/l
B. Abdominal x-ray
C. CT abdomen
D. Tissue transglutaminase (TTG) antibodies (IgA)
y
E. Jejunal biopsy
op
Bloods show a hypochloraemic, hypokalaemic alkalosis which points towards the
diagnosis of pyloric stenosis. This is diagnosed using an abdominal ultrasound.
C
Presentation:
n
io

t
ua
Diagnosis:
al
Treatment:
Ev
31. An 18 month old female child is able to walk up steps, plays well with others in day
care, can build blocks, and able to hold crayons scribbling on paper. Her mother is
concerned because despite her daughter of having a vocabulary of more than 10 words,
she is not able to speak in sentences nor is she able to run. What is the SINGLE best
management strategy?

C. Reassurance
E. MRI brain
For PLAB 1 it is important to memorize the important developmental milestones. The

questions that come up for development are similar to the one above. A scenario is
presented where the mom is concerned and you would be told to give the best
1220
advice/management. You must answer accordingly depending on the scenario. This
child is on par with her developmental milestones. While running and speaking in
sentences start at 18 months, the child has up till at least 2 years old to progress to that
stage. If she still cannot perform these two tasks at 3-4 years old, then we would need
to re-assess.
At 18 months:
- Should speak at least 6 words
- Able to walk steps, walk independently
- Scribbles, names objects, builds blocks
- Socially interactive
At 1.5–2 years:
- Kicks/throws a ball
- Runs
- 2-word sentences
- Follows a 2-step command
- Stacks 5–6 blocks
y
op
32. A mother who delivered a term infant 8 days ago is now diagnosed with varicella zoster.
Her infant is currently afebrile, feeding well, passing stool and urinating without
difficulty. Which of the following is the SINGLE most appropriate step in management?
C
A. Isolate the infant from the mother
B. Hospitalize the infant in the isolation ward
n
C. Administer aciclovir to the infant
io
D. Administer varicella-zoster immunoglobulin to the infant

E. Advise the mother to continue regular well-baby care for the infant
t
ua
For PLAB 1, know the common vaccination guidelines for children pertaining to varicella
and tetanus. This is a common case stem for PLAB 1.
al
Varicella zoster exposure in neonates

Presentation:
Ev
- Mother contracts chicken pox either during pregnancy or post delivery

Diagnosis:
- N/A
Treatment:
- According to NHS guidelines, if the mother’s onset of rash is >7 days
before delivery or >7 days post delivery, varicella zoster immunoglobulin
(VZIG) and isolation is not necessary for the neonate; just observation
33. A neonate’s chest X-ray shows a double bubble sign. He has low set ears and a flat
occiput. What is the SINGLE most likely diagnosis?
A. Down's syndrome
C. Turner’s syndrome
E. Edward’s syndrome
1221
Down syndrome has many features. Duodenal atresia is one of them that you must not
forget. Double bubble sign indicates duodenal atresia.
For the purpose of PLAB, link these 3 terms closely:

Double bubble sign → Duodenal atresia → Down’s syndrome
It is easy to remember as the all start with the letter “D”.
Down’s Syndrome
Clinical features
- face: upslanting palpebral fissures, epicanthal folds, protruding tongue,
small ears, round/flat face
- flat occiput
- single palmar crease, pronounced 'sandal gap' between big and first toe
- congenital heart defects
- duodenal atresia
- Hirschsprung's disease
y
op
Cardiac complications
- atrioventricular septal canal defects
- ventricular septal defects
C
Later complications
n
- subfertility
io
- learning difficulties
- short stature
t
- acute lymphoblastic leukaemia

ua
- Alzheimer's
34. An infant started to have jaundice when he was 2 days old which resolved itself
al
towards day 9. There is an increase in serum bilirubin. What is the SINGLE most likely
diagnosis?
Ev
A. Galactosaemia
B. Biliary atresia
C. Prolonged jaundice
D. Hypothyroidism
Neonatal Jaundice
Physiological jaundice:
- This results from increased erythrocyte breakdown and immature liver
function.
- It presents at 2 or 3 days old, begins to disappear towards the end of the
first week and has resolved by day 10.
- The bilirubin level does not usually rise above 200 μmol/L and the baby
remains well.
1222
Early neonatal jaundice (onset less than 24 hours):
- Haemolytic disease: eg, haemolytic disease of the newborn (rhesus), ABO
incompatibility, glucose-6-phosphate dehydrogenase deficiency,
spherocytosis.
- Infection: congenital (eg, toxoplasmosis, rubella, cytomegalovirus (CMV),
herpes simplex, syphilis) or postnatal infection.
- Crigler-Najjar syndrome or Dubin-Johnson syndrome.
- Gilbert's syndrome.
Prolonged jaundice (jaundice lasting for longer than 14 days in term infants and 21 days
in preterm infants):
- Hypothyroidism, hypopituitarism.
- Galactosaemia
- Breast milk jaundice: the baby is well and the jaundice usually resolves by
six weeks but occasionally continues for up to four months.
- Gastrointestinal (GI): biliary atresia, neonatal hepatitis.
35. A young anxious mother of a 1 year old boy comes to you requesting a test for cystic
y
fibrosis as her brother died from cystic fibrosis. What is the SINGLE most appropriate
op
investigation?
A. Sweat test
C
B. Heel prick test
C. Breath test
D. Chest X-- ray
n
E. Genetic testing of parents
io
Sweat testing confirms the diagnosis and is 98% sensitive. Chloride concentration >60
t
mmol/L with sodium concentration lower than that of chloride on two separate
ua
occasions.
36. A 12 month old male infant presents to clinic because his mother is concerned that the
al
child cannot sit on his own, crawling but not standing with support, unable to pick up
small items, and is not socially interactive with his older sibling. What is the SINGLE best
Ev
management?

B. Assess developmental milestones
C. Reassure
D. MRI brain
E. Referral to physiotherapist
For PLAB 1 it is important to memorize the development milestones. The questions that
come up for development are similar to the one above. A scenario is presented where
the mom is concerned and you would be told to give the best advice/management. You
must answer accordingly depending on the scenario. This child is clearly showing
indications of developmental delay and therefore requires assessment.
Infants are usually able to sit without support at 7-8 months. At 12 months if they are
unable to do this, we should assess and reffer.
1223
At 12 months, he should be able to walk with support.
37. An 8 year old child is brought into A&E with a fractured leg. The parents are unable to
explain how the leg fractured. X-rays reveal several other fractures in various stages of
healing. The parents cannot explain what might have caused them. On examination, the
child has a blue sclerae and difficulty hearing. What is the SINGLE most likely diagnosis?
B. Non accidental injury
C. Haemophilia
D. Achondrogenesis
There is frequently a history of multiple bony fractures with no history of trauma.
Scenes like this occur may occur which may lead you to think of non accidental injuries
(e.g. child abuse). But in this case, the cause of the fractures is not child abuse. It is
osteogenesis imperfecta (OI). Osteogenesis imperfecta is an inherited disorder of type I
y
collagen that results in fragile, low density bones. The bones break easily often from
op
little or no apparent cause. A person with osteogenesis imperfecta may sustain just a
few or as many as several hundred fractures in a lifetime.
C
PLAB may give a scenario like the above but they will have to give some other sign that
it is not a non accidental injury. In this case, they gave the sign of blue sclerae and
hearing loss which is found in osteogenesis imperfecta.
n
io
There is frequently a history of multiple bony fractures with no history of trauma.

t
Scenes like this occur may occur which may lead you to think of non accidental injuries
ua
(e.g. child abuse). But in this case, the cause of the fractures is not child abuse. It is
osteogenesis imperfecta (OI). Osteogenesis imperfecta is an inherited disorder of type I
collagen that results in fragile, low density bones. The bones break easily often from
al
little or no apparent cause. A person with osteogenesis imperfecta may sustain just a
few or as many as several hundred fractures in a lifetime.
Ev
PLAB may give a scenario like the above but they will have to give some other sign that
it is not a non accidental injury. In this case, they gave the sign of blue sclerae and
hearing loss which is found in osteogenesis imperfecta.
38. A 3 year old girl ingested 10 capsules from her grandmother’s medication bottle
thinking it was candy. By the time the child is in the Emergency Department, she is
drowsy and lethargic. Paramedics noted myoclonic twitching. ECG reveals tachycardia
and widened QRS. Potassium is elevated. What is the SINGLE most likely medication did
the child ingest?
A. Tricyclic antidepressants
B. Acetaminophen
C. Thyroxine
D. Amiodarone
E. Nifedipine
1224
This is a diagnosis of tricyclic antidepressant (TCA) overdose. This topic in PLAB 1
overlaps with toxicity and emergency medicine. This is a typical PLAB 1 stem: there is a
child that accidently ingests an unknown bottle of medications. For TCA overdose, look
for widened QRS, peaked T waves, hyperkalemia as main clues. Note that in young
children (
Tricyclic antidepressant overdose in Paediatrics

Presentation:
- Child ingesting an unknown bottle of medication
- Lethargy, drowsy
- +/- Coma or seizure
- ECG - widened QRS, peaked T waves (indications of hyperkalemia)
Diagnosis:
- Urea, electrolytes, toxicology screen
- ECG
- Arterial blood gas
y
Treatment:
op
- ABCDE protocol
- If within 1 hr of ingestion and >4mg/kg - activated charcoal
- Sodium bicarbonate
C
- Correct electrolytes if necessary
39. A 2 year old boy is brought to A&E by his mom with a history of severe diarrhoea and
n
vomiting for the last 4 days. He has been unable to keep anything down for the last
io
couple of days. His HR is 160 bpm, BP is 90/50 and his weight is 12 kg. Which is the
SINGLE best feature to prompt you to start IV fluid resuscitation?
t
ua
A. Capillary refill of 4 seconds

B. Not thirsty
C. Weight loss of more than 5%
al
D. Vomited three times or more in the past 24 hours

E. Infants who were of low birth weight
Ev
Normal capillary refill time is usually less than 2 seconds. Prolonged capillary refill time
is a sign of clinical shock. Intravenous fluid should be started immediately.
Prolonged capillary refill time is a sign of clinical shock.
No clinically Clinical Clinical shock

detectable dehydration
dehydration
Symptoms Appears well Red flag Appears to
(remote and face- be unwell or
to-face deteriorating
assessments) Alert and Red flag Altered Decreased level of
responsive responsiveness (for consciousness
example, irritable,
lethargic)
1225
Normal urine Decreased urine
output output
Signs (face-to-face Alert and Red flag Altered Decreased level of
assessments) responsive responsiveness (for consciousness
example, irritable,
lethargic)
Eyes not sunken Red flag Sunken
eyes
Moist mucous Dry mucous
membranes membranes
(except after a (except for 'mouth
y
drink) breather')
Normal heart rate Red flag Tachycardia
op
Tachycardia
Normal breathing Red flag Tachypnoea
pattern Tachypnoea
C
Normal peripheral Normal peripheral Weak peripheral
pulses pulses pulses
n
Normal capillary Normal capillary Prolonged capillary
refill time refill time refill time
io
Normal skin turgor Red flag Reduced

skin turgor
t
ua
Normal blood Normal blood Hypotension

pressure pressure (decompensated
shock)
al
Ev
40. A 4 year old girl attends clinic with a history of diarrhea, bloating and abdominal pain.
She is failing to thrive. Blood test reveal a hypochromic microcytic anaemia. Alpha
gliadin antibodies are positive. What is the SINGLE most likely diagnosis?
B. Crohn’s disease
D. Coeliac disease
E. Whipple’s disease
The key word here is the alpha gliadin antibodies which are positive. This is a test for
coeliac disease.

1226
Diagnosis
Immunology:
- raised IgA anti-tissue transglutaminase (IgAtTG), anti-gliadin (IgA-AGA),
and endomysial antibodies (EMA)
Biopsy:
Confirm by finding villous atrophy on small bowel biopsy (gold standard)
41. A 6 year old boy is brought to clinic by his mother. She says that he is still unable to
keep dry at night and will be attending a sleepover party at a friends house. She says
y
that it would be embarrassing if he wets himself during the sleepover and she wants to
op
know if anything can be done. What is the SINGLE most appropriate management?
A. Desmopressin
C
B. Reassurance
D. Enuresis alarm
n
E. Oxybutynin
io
For children older than 5 years of age, If rapid or short-term control of bedwetting is
t
required (for example for sleepovers or school trips), offer treatment with
ua
desmopressin.
al
Ev
adhere by them.


system
Desmopressin
1227
42. A 9 year old boy has long arms, legs, fingers and toes. He is tall for his age and is noted
to have scoliosis when examining his back. He started wearing glasses at a young age as
he was not able to see distance. What is the SINGLE most likely syndrome?
Marfan's syndrome
Features
y
- Tall and thin
op
- Long arms, legs, fingers and toes
- Arachnodactyly (long spidery fingers)
- Flexible joints
C
- Scoliosis
- Cardiovascular → Aortic dilatation or dissection, aortic regurgitation,
mitral valve prolapse, mitral regurgitation, abdominal aortic aneurysm
n
- Lungs → pleural rupture causing spontaneous pneumothorax
io
- Eyes → lens dislocation, high myopia.

t
ua
43. A 3 year old boy presents with fever, pallor, and decreased appetite. On examination,
there are palpable non-tender nodules along the deep cervical chain in the neck. Blood
results show: Hb 10g/dl ; MCV 80 fl ; WCC 2 x 109/L. What is the SINGLE most likely
al
diagnosis?
Ev

This is a frequent topic on PLAB 1. Be sure to know the differentiations between all the
leukaemias and be able to classify them by the age groups. Acute lymphoblastic
leukaemia (ALL) is the most common paediatric cancer. The differentiating factor
between ALL and acute myeloid leukaemia (AML) is AML would present with massive
splenomegaly on examination. ALL would just have lymphadenopathy.
But in actual fact, AML and ALL are usually indistinguishable clinically. This means you
cannot determine the diagnosis only from the clinical presentation. ALL is more often
associated with infiltration of other organs, but AML can do it as well. Acute
lymphocytic leukaemia (ALL) is more common in children, and acute myelogenous
leukaemia (AML) is more common in adults
1228
It is very unlikely that the PLAB questions would ask you to differentiate the AML from
ALL using specific test. However, if a child (young age) is given with signs and symptoms
of pancytopenia, ALL would be the most likely as it is the commonest childhood
leukaemia.
Presentation:
- Anaemia, pallor, anorexia
- Non-tender nodules (neck, axilla, groin)
- +/- Bruising
- Variation of hepatosplenomegaly (but this is not a key feature)
- Bleeding
Diagnosis:
- Blast cells on blood film
- White cell count can be low, normal, or elevated
- Normocytic, normochromic anaemia
Treatment:
y
- Chemotherapy (in 3 stages)
op
- Consider correcting anaemia
- Neutropenia if infection, admit for IV antibiotics
C
unable to keep dry at night. He wets his bed in the middle of the night and has daytime
n
wetting as well.. There was no period where he managed to stay dry during the night.
io
The mother wants to know if anything can be done to resolve this issue. What is the
t
ua
A. Desmopressin
B. Reassurance
al
D. Enuresis alarm
E. Referral to to secondary care or enuresis clinic
Ev
Children older than 2 years of age with primary bedwetting and daytime symptoms
should be managed in secondary care or enuresis clinic. Referral for further
investigations and assessment is recommended because bedwetting with daytime
symptoms is usually caused by disorders of the lower urinary tract.
adhere by them.


1229
system
Desmopressin

45. A 6 year old boy is brought into the Emergency Department by his mother’s boyfriend
with a fever of 37.8°C of 3 days duration. On examination, there are purple spots on his
lower back and brownish discoloration on his left forearm with left shoulder
dislocation. The child is quiet and makes no eye contact while in conversation. What is
the SINGLE most appropriate action to be taken after attending his fever?
y
op
A. Discharge home with appropriate medications
B. Admit patient into general paediatrics ward
C
D. Option B and C
n
This is a frequent paediatric topic on PLAB 1. This is a case of non-accidental injury.
io
Since child abuse is suspected from the mother’s boyfriend, it is unsafe to let the boy
remain in his care. Therefore, admit the child to ensure his safety and then refer to
t
social services.
ua

al
Presentation:
Ev

- Fractures
Diagnosis:
Treatment:
46. A 3 year old child has severe diarrhoea and vomiting. On examination the child looks
lethargic, is seen to have dry lips and has sunken eyes. He has a feeble cry. What is the
SINGLE best choice of fluids to give intravenously?
A. 0.9% Normal saline

B. 0.9% Normal saline + 5% Dextrose
C. 0.45% Normal saline
1230
D. 0.45% Normal saline + 5% Dextrose
E. Albumin
This child has features of dehydration and should be resuscitated first. 0.9% normal
saline is the best choice for resuscitation.
47. A 9 year old girl presents with arthralgia and purpura over her buttocks and extensor
surfaces of the legs bilaterally. Laboratory results showed elevated IgA levels and
creatinine. What is the SINGLE most likely diagnosis?
A. Non-accidental injury
B. Henoch-Schonlein purpura
C. Bacterial meningitis
This is a diagnosis of Henoch-Schonlein Purpura (HSP). Take note of the child’s age:
PLAB 1 will usually have their case stems present with less than 10 years of age (peak of
y
4-6 years). In haemolytic uraemic syndrome, the age group would be much younger 3
op
months to 3 years. Also be sure to be able to differentiate rashes for PLAB 1. In HSP, the
clue is purpura over extensor surfaces. For it to be idiopathic thrombocytopenic
purpura, the case stem will provide clues to previous upper respiratory tract infection
C
and/or low platelet count.

n
io
Presentation:
- Purpura (non-blanching) over buttocks and extensor surfaces
t
- Arthralgia (especially in the knees and ankles)

ua
- Abdominal pain
Diagnosis:
al
- Mainly a clinical diagnosis

- Look for elevated ESR, IgA
Ev
- Raised creatinine ; labs consistent with nephropathy
Treatment:
- Self-limiting; conservative management
- NSAIDs for arthralgic pain → beware of choosing this option if case stem
has impaired renal involvement!
- Corticosteroids can improve associated arthralgia and the symptoms
associated with gastrointestinal dysfunction
48. A 2 year old child presents to the A&E department with drooling, sore throat and loss of
voice. He has fever with a temp of 38.9C. His parents tell you that he has not been
immunised because they are afraid of the side effects of the vaccination. What is the
A. Direct pharyngoscopy
B. Summon anaesthetist
1231
C. IM Epinephrine
D. IV fluids
E. Start antibiotics
Acute epiglottitis
Features
- Rapid onset
- High temperature
- Stridor
y
op
C
every feed. The child is also constipated. On examination, there is a right sided olive-
sized abdominal mass on palpation. What is the SINGLE most likely diagnosis?
n
A. Pyloric stenosis
io
B. Duodenal atresia
C. Malrotation
t
D. Coeliac disease
ua
E. Gastro-oesophageal reflux disease
This is a classic presentation of pyloric stenosis on PLAB 1. “Olive-sized abdominal

al
mass” is a classic phrase used in describing pyloric stenosis

Ev
Presentation:
Diagnosis:
Treatment:
50. A 4 year old boy presents to the Emergency Department with fever, bloody diarrhea,
decreased urine output after a school field trip at a farm. On examination, the boy is
1232
pale, tired, and his face is swollen. Lab results: hematocrit 28%, platelets 72 000/μL.
There is blood and protein in urine. What is the SINGLE most likely diagnosis?
A. Acute post-streptococcal glomerulonephritis

D. Intussusception
For PLAB 1 paediatrics, know some of the major causes of bloody diarrhea/stool. This is
a diagnosis of haemolytic uraemic syndrome. PLAB 1 clues: a young preschool child on
an outing with family or friends and returns with bloody diarrhea. If the stem does not
state specifically, assume that the child ate or was in an environment at high risk for
Shiga toxin producing E. coli.
Haemolytic uraemic syndrome

Presentation:
- Preschool children (< 5 years)
y
- TRIAD: microangiopathic haemolytic anaemia, thrombocytopenia, and
op
acute renal failure
- Bloody diarrhea, fever, abdominal pain
- Low haemoglobin and hematocrit, low platelets, hypoalbuminaemia
C
Diagnosis:
- Initial - E.coli serology, stool culture, urinalysis, full blood count
n
- Renal ultrasound to rule out damage
io
Treatment:
t
- Hydration and electrolyte balance

ua
- +/- Nasogastric tube for nutrition intake

- +/- Dialysis
- Paracetamol for pain
al
51. A 13 year old girl with several years of elevated liver enzymes of unknown etiology
Ev
presents to clinic with a slow deterioration in her school performance. On examination,

there is hepatosplenomegaly, intention tremor, dysarthria, and dystonia. Her urinalysis
has elevated levels of glucose, protein, and uric acid. What is the SINGLE most likely
diagnosis?
A. Autoimmune hepatitis
B. Glycogen storage disease
C. α1-Antitrypsin deficiency
D. Hereditary haemochromatosis
PLAB 1 clues for Wilson’s disease: there will be behavioural changes, liver dysfunction,
and Kayser-Fleischer rings. Option C, while similar to Wilson’s, does not exhibit
neurological or behavioural changes. Option D is iron overload and also does not exhibit
the neurological or behavioural changes typically found in Wilson’s.
Wilson’s Disease
1233
Presentation:
- Kayser-Fleischer rings
- Liver dysfunction → deranged liver function tests, cirrhosis
- Neurological → ataxia, dysarthria, dystonia
- Behavioural → personality changes, decreased school performance
Diagnosis:
- Wilson’s disease scoring system → score > 4
- Serum ceruloplasmin - initial
- Measurement of hepatic parenchymal copper concentration - definitive
Treatment:
- Choice of: D-penicillamine ; trientine ; ammonium tetrathiomolybdate
- Neurological involvement - zinc - first line
- Acute liver failure / cirrhosis - liver transplant - definitive
52. A 6 year old male presents to the clinic with obesity and short stature. On examination,
y
his BMI >95th percentile. His past medical history is significant for a renal transplant.
op
C
C. Primary obesity
n
io
Cushing’s syndrome is a frequent topic that overlaps in paediatrics and endocrinology

t
for PLAB 1. Here it is important to make a few assumptions. The child had a renal
ua
transplant and is most likely taking corticosteroids as part of his medication regime.
Long term steroid use would induce Cushing’s syndrome. Short stature would also
result because the steroids would cause premature fusion of the growth plates.
al
Presentation:
Ev
- Patient is taking oral steroids

- Obesity, moon face, buffalo neck hump, purple abdominal striae
- Behavioral/mood changes
- Short stature
Diagnosis:
- Overnight dexamethasone suppression test or 24 hour urinary free
cortisol (first line)
Treatment:
- Taper the child’s steroid medication if possible or find another
alternative for immunosuppression
53. A 1 day old male infant has developed abdominal distension, bilious vomiting, and
meconium ileus was present. Prenatal ultrasound had previously revealed echogenic
bowel. Which of the following is the SINGLE most likely diagnosis?
1234
A. Duodenal atresia
B. Cystic fibrosis
C. Gastroenteritis
D. Malrotation and volvulus
E. Hirschsprung disease
This is a diagnosis of cystic fibrosis (CF). For PLAB 1, this topic overlaps in both
paediatric and adult medicine. Due to the high prevalence and incidence amongst
Caucasians in the UK, this is a frequent topic and should be looked into detail for the
exam. Note that if the infant was older, then the stem would have features of “poor
weight gain with foul smelling stools” and some variation of respiratory deficit.
However, this infant is a newborn and therefore “meconium ileus” would be the most
obvious clue to the diagnosis.
Cystic Fibrosis in Paediatrics

Presentation:
- As neonates/infants - poor weight gain, failure to thrive, meconium ileus,
bilious vomiting, echogenic bowel on prenatal ultrasound
y
- As children/adolescents - variation of respiratory symptoms, diabetes
op
mellitus, steatorrhea, gallstones
- “Foul smelling stools”
- Recurrent infections
C
- On examination - “coarse crackles” in lungs
Diagnosis:
n
- Sweat sodium and chloride test (definitive)
io
- If neonate - immunoreactive trypsin (Guthrie card)

- Genetic screening for CFTR mutations
t
ua
Treatment (specific for GIT in CF):

- Multidisciplinary team care
- Pancreatic enzyme replacement + vitamins + nutritional support (energy
al
increase by 130%)
- Pancrex V powder and omeprazole
Ev
- +/- Gene therapy ; recombinant human deoxyribonuclease
54. A 2 year old girl has had a temperature of 39°C, poor appetite, abdominal pain and
urinary frequency for the last 3 days. What is the SINGLE most appropriate action?
A. Catheter specimen of urine for culture

B. Clean catch urine specimen for culture
C. Full blood count
D. KUB Ultrasound
E. Supra-pubic aspirate of urine for culture
The clinical features described are consistent with urinary tract infection for which a
clean catch of urine is the next best action.
Special arrangements may be needed for collecting a sample from a child. (Clean catch,
catheter or suprapubic aspiration are methods used which reduce the risk of
contamination)
1235
Routine investigations that are done in urinary tract infection are:
- Dipstick analysis of urine - may treat as bacterial if there are positive
results for nitrite and/or leukocytes
- Urine microscopy - leukocytes indicate presence of infection
- Urine culture
55. A 3 year old child presents with cough and high temperature which began 2 days ago. A
rash is noticed on his buccal mucosa. What is the SINGLE most appropriate diagnosis?
A. Measles
B. Roseola infectiosum
C. Rubella
D. Chicken pox
E. Impetigo
Measles
y
Mnemonics to remember
op
Hard K sounds → Koplik spots, Cough, Conjunctivitis, Coryza
Features
C
- prodrome: irritable, conjunctivitis, fever
- Koplik spots (before rash): white spots ('grain of salt') on buccal mucosa
- maculopapular rash: starts behind ears then to whole body
n
io
56. A 4 week old male infant presents with a 10 day history of non-bilious vomiting that has
increased in frequency and forcefulness. Despite feeding and looking well, the infant
t
has lost weight. Abdominal ultrasound reveals a thickened pylorus. Which of the
ua
following is the SINGLE most appropriate definitive management?
A. Normal saline and 5% dextrose

al
B. Potassium chloride
C. Pyloromyotomy
Ev
D. Nasogastric tube insertion

E. Barium enema
This is a diagnosis of pyloric stenosis. Note that the PLAB 1 clue does not always have to
be “projectile vomiting”. It can also be described as “forceful” and is non-bilious. The
abdominal ultrasound with a thickened pylorus or “an olive shaped mass” on palpation
are other PLAB 1 clues. Note also the age range: the child usually would be older than 3
weeks. Pay attention to what the question is asking in PLAB 1. Here they would like to
know the definitive (gold standard) for management. If they had asked what is the most
appropriate “next step” then the answer would be options A and B (usually appear one
or the other in answers, or combined).
Pyloric stenosis
Presentation:
1236
Diagnosis:
Treatment:
- Then referral to paediatric surgery (pyloromyotomy) - first line +
nasogastric tube
57. The newborn screening results of an 8 day old female infant are as follows: TSH 40
mIU/L and T4 70 nmol/L. The mother notes that the child is difficult to feed and does
not cry much. On examination, the child has cold mottled skin and weak, floppy
muscles. What is the SINGLE most appropriate management?
A. Observation and reassess in 3 months

B. Propylthiouracil
y
C. Methimazole
op
E. Levothyroxine C
This is a diagnosis of congenital hypothyroidism. Usually it is found upon newborn
screening as per protocol of the NHS. In PLAB 1, thyroid disease is a frequent topic
under the endocrine component. Know how thyroid diseases present in paediatrics
n
especially in infants. The symptoms and signs are not always as clear-cut as adults. The
io
infant would usually present with difficulty in feeding, constipation, little crying, and
may not be very responsive. On examination, there may enlarged posterior fontanelles
t
and hypotonia along with other usual hypothyroidism features (i.e. decreased
ua
temperature, bradycardia, puffy appearance).
al
Presentation:
- Difficulty feeding, constipation, little crying
Ev
- Not very responsive

- Hypotonia, dry mottled cold skin
- Prolonged neonatal jaundice
Diagnosis:
- Neonatal screening for TSH and T4 serum/plasma → initial
- Radioisotope scan → definitive
- Ultrasound of neck
Treatment:
- Levothyroxine oral until 2 years of age
58. A 12 year old boy presents with severe watery diarrhea for the past 7 days. His urine
output is low, mucous membrane are dry, and skin turgor is decreased. What is the
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A. Antibiotic
B. Antimotility
C. Antiemetic
D. Fluid replacement
E. Reassurance
This child is dehydrated. The low urine output, dry mucous membranes and decreased
skin turgor are signs of dehydration. Fluid replacement is needed.
The most common cause of gastroenteritis in children in the UK is rotavirus
When assessing hydration status NICE advocates using normal, dehydrated or shocked
categories rather than the traditional normal, mild, moderate or severe categories.
Estimating dehydration (Paediatrics)

Clinical dehydration
Decreased urine output
y
Sunken eyes
op
Dry mucous membranes
Tachycardia
Tachypnoea
C
Reduced skin turgor
Clinical shock
n
Decreased level of consciousness
io
Cold extremities
Pale or mottled skin
t
Tachycardia
ua
Tachypnoea
Weak peripheral pulses
Prolonged capillary refill time
al
Hypotension
Ev
Management
If clinical shock → admit for intravenous rehydration
If just dehydrated → Oral rehydration solution would do
PLAB is unlikely to ask you to differentiate between clinical dehydration or clinical

shock. But you must be able to recognize the signs and symptoms of dehydration.
59. A 5 month old child is unable to speak but makes sounds. She can hold things with her
palm, but not her fingers. She smiles and laughs and is not shy. She cannot sit
independently but can hold her hand and sit when propped up against pillows. What is
the SINGLE best development stage to describe this child?
A. Normal
B. Delayed speech and language development
C. Delayed social development
D. Delayed fine motor development
E. Delayed gross motor development
1238
Only around 12 months does the child say his/her first words. E.g. “mama”
Smiling, laughing and being not shy is normal for her age group
Only around 7 to 8 months do babies sit unsupported. Refer if by 12 months unable to

sit unsupported
Holding using her pams at her age group is normal.
Developmental milestones is a commonly asked question in PLAB. Try to memorize

some basic ones.
60. A 15 year old boy attended the emergency department with shortness of breath. A
diagnosis of spontaneous unilateral pneumothorax was made. He is noted to be tall for
his age with long arms and fingers. He also has severe scoliosis. What is the SINGLE
most likely syndrome?
y
op
C
Spontaneous pneumothorax is common in Marfan’s syndrome. The other signs and

n
symptoms point towards Marfan’s syndrome as well.
io
Marfan's syndrome
t
ua
Features
- Tall and thin
al

- Flexible joints
Ev
- Scoliosis
61. An 8 year old boy presents with severe crushing chest pain. He is tall for his age and has
a refractive error for which he wears thick glasses for. What is the SINGLE most likely
syndrome?
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A tall, myopic child can only be Marfan’s syndrome in the exam. The cardiovascular
symptoms support this diagnosis.
Marfan's syndrome
Features
- Tall and thin
- Flexible joints
- Scoliosis
62. A 5 week old male infant presents to clinic with jaundice during routine check-up. On
y
examination, the baby is irritable, below average centiles for weight, and the liver is
op
enlarged. Pale stools and dark urine on diaper were observed. The mother is currently
not breast-feeding and had placed him on formula. What is the SINGLE most likely
diagnosis?
C
A. Galactosemia
n
C. Rh incompatibility
io
D. Congenital viral infection

E. Biliary atresia
t
ua
Jaundice in newborns is an important topic within the paediatric section for PLAB 1.
Understand the mechanisms and management for neonatal jaundice as well the causes
of jaundice post 4 weeks of age. Examination results are consistent with obstructive
al
jaundice therefore option is E. Jaundice in options B and C would occur within 24 hours
of birth. Galactosemia would present with vomiting, diarrhea, failure to thrive with
Ev
jaundice. Liver would not be hard or enlarged.
Biliary Atresia
Presentation:
Diagnosis:
Treatment:
Kasai procedure = hepatoportoenterostomy
1240
63. A 1 week old male infant, born at 32 weeks gestation, is currently in neonatal ICU and
was doing well on increasing nasogastric feedings. The nurse now notes that the infant
has been vomiting during the last 2 feedings, is less active, and has blood in his stool.
On examination, the abdomen was tense, distended with decreased bowel sounds.
Abdominal x-ray reveals distended loops of bowel with air in the bowel wall. What is
A. Emergent exploratory laparotomy

B. Reduce volume of feeds per feeding and feed more frequently
C. Remove nasogastric tube and replace with transpyloric tube, then switch feeds from
nasogastric to nasoduodenal tube
D. Stop feeds, begin intravenous fluids, perform abdominal films, and initiate
systemic antibiotics
E. Continue the same
This is a diagnosis of necrotising enterocolitis (NEC). This is a classic presentation and

are the main PLAB 1 clues: abdominal distension, bloody stool, and air in the bowel
wall. Note that usually the infant is usually premature although they can also be a term
y
infant in these case stems. According to guidelines, this infant is between Stage Ib and
op
IIa of NEC, therefore option D is the most appropriate.
Necrotising enterocolitis
C
Presentation:
- Premature > term infant
- Vomiting (feeding intolerance), decreased activity, varying temperature
n
- Abdominal distension, bloody stools
io
- Abdominal plain film - air in the bowel wall

t
Diagnosis:
ua
- Bell’s criteria/staging system

- Abdominal x-ray (supine antero-posterior; lateral decubitus) - initial
- Blood work - include blood film, culture, coagulation, blood gas
al
Treatment:
Ev
- Initial - stop feeds → NG tube free drainage with aspiration → antibiotics

→ fluids and electrolyte balance
- Antibiotics - penicillin + gentamicin + metronidazole
- If pneumoperitoneum - surgery
64. After several episodes of urinary tract infections, a 2 year old girl undergoes a
micturating cystourethrogram which reveals mild dilation of the renal pelvis and reflux
into the ureters and kidney. She is currently not on any medication. Which of the
following is the SINGLE most appropriate next step in treatment?
A. Low dose antibiotic prophylaxis daily

B. Observation with weekly urinalysis and urine culture
C. Surgical reimplantation of the ureters
D. Endoscopic injection of bulking agents
This is a diagnosis of vesicoureteral reflux (VUR).
1241
For urology questions in paediatrics in this exam, pay particular attention to VUR and
urinary tract infections.
Do not go into details for these questions, just know the basic presentation, diagnosis
and management according to current guidelines. Note to have a basic understanding
that the severity of VUR is graded and management is according to the grade. In this
case the child is between grade II to III. Therefore, according to guidelines, she would
start with low dose antibiotic prophylaxis before consideration for surgery.
Vesicoureteral reflux
- Condition where urine flows retrograde from bladder into
ureters/kidneys
Presentation
- Most children are asymptomatic
- Increases risk of urinary tract infection → Thus, symptoms of a UTI:
o Fever
y
o Dysuria
op
o Frequent urination
o Lower abdominal pain C
Diagnosis
- Urinalysis, urine culture and sensitivity → initial investigation
- Renal ultrasound → initial investigation → might suggest the presence of
n
VUR if ureteral dilatation is present
io
- Micturating cystourethrogram → gold standard

- Technetium scan (DMSA) → for parenchymal damage (seen as cortical
t
scars)
ua
Treatment
- VUR grade I-IV - start with low dose antibiotics prophylaxis daily (i.e.
al
trimethoprim)
- If above fails and/or parenchymal damage consider surgery -
Ev
reimplantation of the ureters
The International Reflux Study has found that children can be managed nonsurgically
with little risk of new or increased renal scarring, provided they are maintained
infection free. Remember, the goal of treatment is to minimize infections, as it is
infections that cause renal scarring and not the vesicoureteral reflux. Thus, the
importance of continuous antibiotic prophylaxis outweighs surgery in most cases. Note
that during early childhood, the kidneys are at higher risk of developing new scars. So it
is particularly important to start parenteral antibiotic treatment for patients with
vesicoureteral reflux before febrile breakthrough infections.
For patients with frequent breakthrough infections, definitive surgical or endoscopic

correction is preferred. Surgical correction should also be considered in patients with
persistent high-grade reflux (grades IV/V) or abnormal renal parenchyma.
65. A 12 year old girl presents to clinic with sudden onset of pallor, palpitations, and
difficulty breathing while running on the school track. After 30 minutes, her symptoms
1242
resolved. This is a first time event and she has never been cyanotic. Cardiac
examination was normal. Chest x-ray and echocardiogram were normal. ECG reveals
evidence of pre-excitation, delta waves, and prolonged QRS. What is the SINGLE most
likely diagnosis?
A. Paroxysmal ventricular tachycardia

B. Paroxysmal supraventricular tachycardia
C. Wolff-Parkinson-White syndrome
D. Stokes-Adams pattern
E. Excessive stress during exercise
This is a diagnosis of Wolff-Parkinson-White (WPW) syndrome. In the UK, 1-3 out 1000
people have this condition therefore, this topic would occur frequently under
cardiology for PLAB 1. The age group for the case stem may present itself in an older
age (i.e. 20-30). However, the features are similar to the stem above. Note the ECG
features, especially the presence of delta waves and pre-excitation pathway.
Wolff-Parkinson-White syndrome
y
Presentation:
op
- Child may be exercising with sudden onset of pallor, difficulty breathing,
and palpitations followed by spontaneous recovery
- Otherwise asymptomatic child
C
- ECG: delta waves, pre-excitation pattern, prolonged QRS, shortened PR
Diagnosis:
n
- ECG
io
- 24 hour Holter monitor

t
Treatment:
ua
- Catheter ablation - first line

- Medications - flecainide and propafenone
al
66. A 3 year old child is brought to the emergency department by his mother with bruises
Ev
and swelling over the medial aspect of the left arm. X-ray shows multiple callus
formation in the ribs. Bruises on the child's back is seen on examination. Analgesia has
been given. What is the SINGLE most appropriate next step?
A. Check child protection register

B. Involve social services
C. Skeletal survey
D. Serum calcium
E. DEXA scan
Skeletal survey is a series of x-ray which is usually used in NAI. Once the skeletal survey
has been done, then think of the child’s protection register and involve social services.
As a junior doctor you should involve your seniors prior to checking child’s protection
register or involving social services. The chief consideration is the treatment and
protection of the child, so do not delay treatment of painful or apparently life-
threatening problems, whilst awaiting an ‘expert’.
1243
In every hospital system there will be a designated doctor for child protection who
should be available for advice. He or she will examine the child and arrange hospital
admission for further investigations (e.g. skeletal survey) as necessary. Social Services
and the police may need to be involved.
Bruises
Children naturally sustain bruises during minor incidents as part of ‘growing up’.
Bruising over the knees and shins is a normal finding in children, particularly toddlers,
who are also prone to sustaining injuries to their foreheads and chins as a result of falls.
As well as considering the possibility of NAI, remember that bruising may occur as part
of an unusual pathological disease process (eg Henoch–Schönlein purpura,
haemophilia, ITP, leukaemia, and other causes of thrombocytopenia).
The following bruises should prompt consideration of NAI:

- Bruising in unusual sites (eg medial aspect of upper arms or thighs)
- Finger ‘imprinting’ (eg grip complexes around upper limbs or slap marks)
y
- Imprints or marks from other objects (eg belt, stick)
Consider NAI in the following fractures

op
C
- Multiple fractures of different ages
- Rib and spinal fractures
- Fractures in infants who are not independently mobile
n
- Long bone fractures in children
io
There are a few rare bone diseases that may mimic NAI. One commonly asked in PLAB
t
is Osteogenesis imperfecta. They would usually give other clues such as a blue sclerae,
ua
dental abnormalities and brittle bones.

al
67. A 2 year old boy presents to the Emergency Department with painless rectal bleeding
for the past 2 days. On examination, the child is afebrile, tachycardic, alert, playful, and
Ev
feeding well. Abdominal examination was normal. Which of the following is the SINGLE
A. Intussusception
C. Hirschsprung disease
D. Volvulus
E. Meckel’s diverticulum
Meckel’s diverticulum PLAB 1 clues (rule of 2): occurs between 2-3 years old, mostly
male, approximately 2 inches long, around 2 feet away from the ileo-caecal valve. The
child will usually start off with painless rectal bleeding but is otherwise well. Know how
to differentiate between painful and painless rectal bleeding in children for PLAB 1.
Options A to D would present with painful rectal bleeding with stool at onset.
Meckel’s diverticulum
Presentation:
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- Mostly asymptomatic
- Painless rectal bleeding
- If obstruction: vomiting, abdominal pain
- Age group: 2-3 years old; mostly male
Diagnosis:
- Radioisotope scan - initial
- Laparotomy
Treatment:
- Surgical resection
68. A 10 year old boy presents to the Emergency Department having fallen from a height of
150cm and hit his head while playing in the playground. There was no loss of
consciousness and he is currently haemodynamically stable. GCS 15/15. On
examination, he is oriented with a swelling and tenderness on his left cheek. Which of
the following is the most SINGLE most appropriate initial investigation?
y
op
A. CT brain
B. MRI brain
C. EEG
C
D. Facial x-ray
n
In this case stem, the patient is showing no indication of neurological deficit and is
io
asymptomatic. According to the revised NICE guidelines in 2014, CT nor MRI are
necessary. By protocol, the child having fallen from such a height should be admitted
t
and observed at least for 4 hours (NICE guidelines) in addition to the facial x-ray to rule
ua
out any zygoma fractures (due to swelling and tenderness in the cheek). For PLAB 1, if
the child is doing well, asymptomatic, with GCS 15/15 and no changes in neurological
functions within 1 hour of admission, go for the investigation with the least harm first.
al
Head injuries in Paediatrics

Ev
Presentation:
- Child playing or in an athletic match
- Head / facial trauma
- Swelling, bruising on the face only
Diagnosis:
- For this case stem: Facial x-ray (initial) – if fractures are detected then do
CT
- CT head (definitive) - if on arrival scan within 1 hour if the child has GCS
<14, neurological deficits according to NICE guidelines
Treatment (for this case stem):

- Observation
- Analgesia for pain
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69. A 5 year old boy presents with drooling of saliva and severe stridor. He has a
temperature of 39.0°C and is sick looking. He has difficulty speaking and has muffled
voice. A lateral radiograph demonstrates a “thumb sign”. What is the SINGLE most
likely diagnosis?
A. Croup
B. Recurrent aspiration
C. Diphtheria
D. Acute epiglottitis
E. Inhaled foreign body
The given case is classic picture of acute epiglottitis.
The thumb sign is a manifestation of an oedematous and enlarged epiglottis which is

seen on lateral soft-tissue radiograph of the neck, and it suggests a diagnosis of acute
infectious epiglottitis.
The second clincher here is drooling of saliva. If you find any questions with a child with
y
op
Acute epiglottitis
C
n
io
Features
- Rapid onset
t
- High temperature
ua
- Stridor
al

Ev
70. A 6 week old child is brought to A&E with persistent non-bilious vomiting. The child
feels hungry and wants to feed despite constant vomiting. Biochemistry shows K+ of 3.1
mmol/l. What is the SINGLE most likely diagnosis?
A. Pyloric stenosis
B. Duodenal atresia
C. Malrotation
D. Achalasia cardia
E. Tracheo-esophageal fistula
Hypokalaemia and non-bilious vomiting should direct you towards pyloric stenosis as a
diagnosis.
It is unlikely to be duodenal atresia as the newborn would presents with bilious

vomiting with every feed. In this question, the scenario was one of non-bilious
vomiting.
1246
Malrotation is manifested by bilious vomiting, crampy abdominal pain, abdominal
distention, and the passage of blood and mucus in their stools. Again in this scenario,
non-bilious vomiting was given.
Pyloric stenosis
Presentation:
Diagnosis:
Treatment:
y
71.
op
An 8 year old boy is brought by his mother to the emergency department with bruises
on his lower back and a left shoulder dislocation. The child currently lives with his
C
stepfather. The young boy is quiet and makes no eye contact while in conversation.
n
io
B. Malnutrition
C. Thrombocytopenia
t
D. Osteogenesis imperfecta
ua
E. Haemophilia
This is a frequent paediatric topic on PLAB 1. This is a case of non-accidental injury.

al
Having a non biological father in the picture is always a hint for non accidental injury in
PLAB.
Ev
Presentation:
- Fractures
Diagnosis:
Treatment:
1247
72. An 8 year old boy presents to clinic with behavioral problems. He is inattentive in class.
During the interview, he is unable to sit still; he is constantly blinking his eyes, making
grunting noises with his throat, and rubbing his fingers. What is the SINGLE most likely
diagnosis?
B. Cotard’s syndrome
C. Rett’s syndrome
D. Ekbom’s syndrome
This is a classic scenario for Tourette’s syndrome in PLAB 1. Other clues that may
appear on PLAB 1 may be the child yelling in class intermittently or shouting expletives.
Note the age: most are diagnosed at 6-8 years, maximum to the age of 13.
The other syndromes are less likely to be the answer:
y
op
Asperger syndrome → Characterized by severe persistent impairment in reciprocal
social interactions, repetitive behaviour patterns, and restricted interests. IQ and
language are normal or, in some cases, superior. Although tics (like the above case) can
C
also be found in asperger syndrome, it is more specific for Tourette’s syndrome. Not to
mention, the question would include an impairment of social skills if the PLAB
examiners wanted you to have picked Asperger syndrome.
n
io
Cotard’s syndrome → is a rare mental illness in which an afflicted person holds the
delusion that they are dead
t
ua
Rett’s syndrome → There is normal development for 2–3yrs, followed by a loss of

acquired motor, language, and social skills between ages 3 and 4yrs. Stereotypies and
compulsions are common.
al
Ekbom’s syndrome → Also called restless leg syndrome. Unpleasant, often painful
Ev
sensations in the legs, particularly on sleep onset
Tourette’s syndrome
Presentation:
- Young (6-8 years old) mostly male
- Repetitive movements or gestures that are disruptive in the classroom or to
people around the child (can be motor or vocal) → Tics
- Jerks, blinks, sniffs, nods, spitting, stuttering, irrepressible explosive obscene
verbal ejaculations, grunts, and squeaks
Diagnosis:
Treatment:
- Risperidone or haloperidol
- Behavioral therapy - Habit-reversal training
1248
73. A 10 month old male infant presents with a 6 hour history of crying and passage of
loose, bloody stool. On examination, the infant is irritable, with intermittent drawing up
of his knees to his chest, and a temperature of 38.8°C. Rectal examination reveals gross,
currant jelly-coloured blood on finger. What is the SINGLE most likely diagnosis?
A. Constipation
B. Gastroenteritis
C. Intussusception
D. Meckel's diverticulum
E. Volvulus
This is a diagnosis of intussusception. Note the PLAB 1 clues: the infant is between 5-12
months, child has been crying persistently (indication of abdominal pain), drawing the
legs up to chest, currant jelly blood in stool, and sausage-shaped mass. This along with
pyloric stenosis and malrotation with volvulus is a common paediatric surgical question.
Know the differences between each.
Intussusception
y
Presentation:
op
- TRIAD of:
o Abdominal pain
o Currant jelly blood in stool
C
o Sausage-shaped mass on palpation (often in the right upper quadrant)
- Child is crying persistently
- Drawing up of legs
n
- May be vomiting if severe
io
Diagnosis:
t
- Abdominal ultrasound → may show doughnut or target sign

ua
- Bowel enema
Treatment:
al
- Air enema reduction or laparotomy

Ev
Remember: “Red currant jelly” stools is pathognomonic for intussusception
74. A 2 year old boy was separated from his mother in a shopping mall. He got very upset
and then fell down and became unconscious. He looked blue. He became conscious
after 2 minutes and was back to his active self after an hour. His mother is extremely
concerned. What is the SINGLE most appropriate next step?
A. CT head
D. Reassure
E. Pulmonary function test
The diagnosis here is breath-holding spells
1249
This usually occurs in young children when they are upset and can be precipitated by
trauma or when separated from the parents.
Basically anything which may upset a child including injury from falling down
These children stop breathing for some time, they may turn blue or have little jerks of
the limbs.
After a period of time they spontaneously start breathing. They become completely fine
after an hour.
Treatment is not necessary. Usually just reassure parents
unable to keep dry at night. He wets his bed in the middle of the night at least three
times a week but he is without daytime symptoms. There was no period where he
managed to stay dry during the night. The mother wants to know if anything can be
done to resolve this issue. His medical history is insignificant and there is no history of
y
op
A. Desmopressin
B. Reassurance
C
D. Enuresis alarm
n
This child is 6 years old with primary bedwetting (without daytime symptoms).
io
Treatment with an enuresis alarm (first-line treatment) in combination with positive

reward systems (for example star charts) would be the most appropriate.
t
ua
Definitions:
Primary nocturnal enuresis refers to children that have never been dry for more than a
6-month period
al
Secondary nocturnal enuresis refers to the re-emergence of bedwetting after a period

Ev
of being dry for at least 6 months
adhere by them.


system
Desmopressin
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76. A 13 year old girl presents to the Emergency Department with weight loss, bloody
diarrhea, and fever intermittently over the last 6 months. The intermittent episodes has
caused occasional restriction of activity. Currently she is having moderate abdominal
pain. Labs reveal elevated ESR and positive p-ANCA. What is the SINGLE most likely
management for this patient?
A. Topical and oral mesalazine

B. Prednisolone and mesalazine oral
C. Prednisolone IV
y
D. Cyclosporine IV
op
E. Infliximab IV
This is a diagnosis of ulcerative colitis (UC). PLAB 1 would usually have an adolescent
C
(12-17 years) who either presents to clinic or emergency with the above symptoms.
There may or may not be other UC clues: growth failure, toxic megacolon, and affecting
only the submucosa of the colon. Know Crohn’s disease and ulcerative colitis well for
n
PLAB 1 as it will appear in both paediatric and adult questions. Note that the
io
management is according to NICE guidelines and is the same for both paediatrics and
adult medicine. In this case, the patient is classified as having mild to moderate UC
t
according to NICE.
ua
Ulcerative colitis in Paediatrics

al
Presentation:
- Bloody diarrhea, abdominal pain, tenesmus
Ev
- Vomiting, weight loss, fatigue

- p-ANCA positive
Diagnosis:
- Clinical diagnosis combined with rectal biopsies
- Upper endoscopy - to rule out Crohn’s
- Stool culture - to rule out infection
- Paediatric UC Activity Index - for classification of severity
Treatment:
- Topical and oral aminosalicylate (mesalazine/sulfasalazine) - first line
- Add prednisolone oral - only if aminosalicylate is ineffective with no
improvement after 4 weeks treatment
- Infliximab - only in severe UC for paediatrics
- Cyclosporin - if severe UC
- Surgery - only consider if severe
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77. A 5 year old boy is brought to clinic by his mother. The young boy has a distinct nasal
speech and snores heavily at night. He is hyperactive during the day but has poor
concentration. He is noted to be constantly breathing through his mouth. What is the

C. Refer to ENT surgeon
E. Arrange a magnetic resonance imaging scan
The likely diagnosis here is obstructive sleep apnoea syndrome. Referrals are usually to
paediatric physicians, although sometimes paediatric neurologists, respiratory doctors
or ENT consultants may have a specialist interest.
Obstructive sleep apnoea syndrome in children

Obstructive Sleep Apnoea Syndrome in Children is mainly due to enlarged tonsils and
y
adenoids
Presentation
-
op
Snoring - usually parents seek attention; many will just get better as they
C
grow older
- Mouth breathing
- Witnessed apnoeic episodes
n
- Daytime sleepiness and somnolence is common in childhood OSAS, in
io
contrast with adults who often fall asleep during the day
- Sleep-deprived children tend to become hyperactive, with reduced
t
attention spans, and be labelled as difficult or disruptive, or even ADHD.

ua
They may not be doing well at school due to poor concentration

al
Investigations:
- Overnight in-laboratory polysomnography (PSG) continues to be the gold
Ev
standard instrument
o During sleep studies the following are usually monitored:
▪ Oxygen saturations and heart rate.
▪ Airflow at nose or mouth.
▪ Chest and abdominal movements.
▪ ECG, electroencephalogram, electromyogram and sometimes
electro-oculogram (eye movements)
78. A 2 year old child was brought by his mother with swelling on the right side of his neck
extending from the angle of the mouth to the middle one third of the
sternocleidomastoid muscle. The swelling is on the anterolateral side of the
sternocleidomastoid muscle. On examination, the mass is partially compressible. when
subjected to light test is brilliantly translucent. What is the SINGLE most likely
diagnosis?
A. Lymphangioma
1252
B. Branchial cyst
C. Thyroglossal cyst
D. Ranula
E. Grave’s disease
Both lymphangioma and branchial cyst are lateral neck masses. Branchial cysts are not
translucent whereas lymphangioma when subjected to light test is brilliantly
translucent.
Lymphangiomas
Lymphangiomas are uncommon, hamartomatous, congenital malformations of the
lymphatic system that involve the skin and subcutaneous tissues. It occurs as a result of
sequestration or obstruction of developing lymph vessels in approximately 1 in 12,000
births. Lymphangiomas can occur anywhere in the skin and the mucous membranes.
The most common sites are the head and the neck especially in the posterior triangle of
the neck.
The cysts are lined by endothelium and filled with lymph. Occasionally unilocular cysts
y
occur, but more often there are multiple cysts infiltrating the surrounding structures
op
and distorting the local anatomy.
The mass may be apparent at birth or may appear and enlarge rapidly in the early
C
weeks or months of life as lymph accumulates; most present by age 2 years. (90% of
lymphangioma occur in children less than 2 years)
n
Lymphangiomas are soft and nontender and when subjected to light test was brilliantly
io
translucent.
t
79. A 3 month old infant presents with recurrent infections and feeding difficulties. His face
ua
looks dysmorphic and has a cleft palate. A chest X-ray shows absent thymic shadow.
al
A. Down's syndrome
Ev
C. DiGeorge’s syndrome
E. Edwards' syndrome
DiGeorge’s syndrome is a deletion of chromosome 22q11.2. It causes absent thymus,

fits, small parathyroids (thus decreased Ca2+), anaemia, lymphopenia, low levels of
growth hormone, low T-cell-immunity.
It is related to velo-cardiofacial syndrome: characteristic face, multiple anomalies, eg

cleft palate, heart defects, cognitive defects
Developmental delay, facial dysmorphism, palatal dysfunction and feeding difficulties

are seen in most infants with this syndrome.
The facial dysmorphism is typically mild but fairly typical. These include hypertelorism,
hooded eyelids, tubular nose, broad nose tip, small mouth and mild ear abnormalities.
Note that you do not need to remember these features for PLAB. The most important
1253
factor to memorize here is the absent thymic shadow which is pathognomonic for
DiGeorge’s syndrome
Mnemonic: CATCH-22
- Cardiac abnormality (commonly interrupted aortic arch, truncus arteriosus
and tetralogy of Fallot)
- Abnormal facies
- Thymic aplasia
- Cleft palate
- Hypocalcemia/Hypoparathyroidism
- With the 22 to remind one the chromosomal abnormality is found on the 22
chromosome
80. A 4 month old child is brought to Accident & Emergency by her parents. She is found to
weigh 4.1kg. She presents with multiple bruises on her left and right lower leg. Her left
ankle is swollen and she refuses to move it. She appears irritable and she also has a
y
runny nose. What is the SINGLE most likely diagnosis?
A. Haemophilia
B. Thrombocytopenia
op
C
C. Non accidental injury
D. Malnutrition
E. Osteogenesis imperfecta
n
io
This is a probable non-accidental injury. This infant weighs 4.1kg. For a 4 month old
infant this is beneath the normal weight gain line. A female infant of 4 months should
t
weigh about 6.1kg and a male infant of 4 months should weigh about 6.8kg. Another
ua
clue to the diagnosis of NAI is the multiple bruises on her lower limbs. This is the most
common site of NAI in the infant population. It arises from parents or caregivers
gripping and pulling the infant by the legs.
al
Haemophilia is incorrect because even though haemophilia is a possible diagnosis, it is

Ev
improbable. Haemophilia is an X-linked recessive condition and this is a female infant.

Haemophilia CAN affect females but it is extremely rare and if they had wanted you to
pick haemophilia they would have give additional clues such as neonatal bleeding
following venipuncture, gastrointestinal hemorrhage or intracranial bleeding.
Thrombocytopenia is incorrect because it usually presents following a viral infection in

children. Although it presents with bruising and petechiae, it is an improbable answer in
this question because the diagnosis of thrombocytopenia lies solely on blood testing
and blood smear. You cannot make a diagnosis of thrombocytopenia based on clinical
signs.
81. A 9 year old girl, known case of asthma, presents to the Emergency Department with a
1 day history of shortness of breath that is increasing in severity. She had a previous
upper respiratory tract infection 1 week prior which had resolved. Chest x-ray reveals
bilateral hyperinflation. On arrival, she was given oxygen, nebulized beta-2 agonist, and
oral prednisolone. She is now drowsy, respiratory rate is 30 and her SpO2 is 90%. Which
of the following is the SINGLE most appropriate investigation?
1254
B. Pulse oximetry
C. Spirometry
D. CT chest
E. Peak flow meter
Know the step-wise management for acute asthma exacerbation in paediatric and adult
medicine. Questions in PLAB 1 would have a similar case stem but asking questions
pertaining to investigations and treatment. Here the patient is breathless and we would
need to see if she is in respiratory acidosis to determine the need for
intubation/assisted ventilation.
Acute severe asthma

SpO2 <92% PEF 33–50%
- Can’t complete sentences in one breath or too breathless to talk or feed
- Heart rate >125 (>5 years) or >140 (2-5 years)
- Respiratory rate >30 breaths/min (>5 years) or >40 (2–5 years)
y
op
Life threatening asthma
SpO2 <92% PEF <33%
- Silent chest
C
- Cyanosis
- Poor respiratory effort
- Hypotension
n
- Exhaustion
io
- Confusion
t
Initial treatment of acute asthma in children aged 2 and older

ua
Oxygen → Children with life-threatening asthma or SpO2 <94% should receive high
flow oxygen via a tight fitting face mask or nasal cannula at sufficient flow rates to
achieve normal saturations of 94–98%.
al
Bronchodilators → Inhaled β2 agonists are the first line treatment for acute asthma.
Ev
- A pmDI + spacer is the preferred option in children with mild to

moderate asthma.
- If symptoms are refractory to initial β2 agonist treatment, add
ipratropium bromide
- Add magnesium sulphate to each nebulised salbutamol and ipratropium
in the first hour in children with a short duration of acute severe asthma
symptoms presenting with an oxygen saturation less than 92%
Steroid therapy → Give oral steroids early in the treatment of acute asthma attacks. (IV
can be given too)
Second line treatment of acute asthma

- Add single bolus dose of intravenous salbutamol in a severe asthma
attack where the patient has not responded to initial inhaled therapy.
- Aminophylline for children with severe or life-threatening asthma
unresponsive to maximal doses of bronchodilators and steroids.
1255
82. An 8 week baby boy is noted to be jaundiced. He has feeding difficulty, with vomiting
and failure to gain weight. His stools are yellow and his urine is pale straw coloured.
A. Galactosaemia
B. Biliary atresia
D. Breast milk jaundice
This is really a question of exclusion
Biliary atresia causes obstructive picture where stools are pale and urine becomes dark
which is NOT the case here.
Glucose-6-phosphate dehydrogenase (G6PD) deficiency like the other haemolytic

diseases has an onset of jaundice usually less than 24 hours
y
op
Breast milk jaundice is a possibility but usually the baby is well and the jaundice usually
resolves by six weeks. Occasionally it can continues for up to four months.
C
Congenital viral infection usually causes jaundice in the first 24 hours as well.
The only possible answer is galactosaemia

n
io
Galactosaemia
t
Although it is a rare inherited disease it is among the most common carbohydrate

ua
metabolism disorders. It can be a life-threatening illness during the newborn period

al
The cardinal features are hepatomegaly, cataracts and mental handicap.

Ev
Presentation
- There is often feeding difficulty, with vomiting and failure to gain weight,
with poor growth in the first few weeks of life
- Lethargy and hypotonia occur
- Jaundice and hepatomegaly develop
- Cataracts may be apparent even in the early days of life
Management:
As soon as the diagnosis is made, milk should be discontinued to remove the lactose
load. This will have some immediate benefit.
83. A 7 day baby whose birth weight was initially 3.5 kg, has a weight of 3.3 kg currently.
A. Inform seniors and check the child protection register

B. Refer for a nutritional assessment
C. Request a skeletal survey
1256
D. Reassure mother and continue regular child care
E. Inform the police
It is usual for babies to lose between five per cent and 10 per cent of their birth weight
a few days after the birth. Note that this does not mean the child is not getting enough
milk. One should not jump to the conclusion of child abuse with such minor weight loss.
Remember that in labour, very often mothers receive intravenous fluid to prevent
dehydration. This can contribute to a slightly higher birth weight for the neonate as he
would have taken some fluid onboard. The fluids are loss over the next couple of hours
to days which results in reduction of weight. Following these few days of weight loss,
there would be gradual weight gain. By day 14, most babies would be above their birth
weight.
84. A 7 year old girl is brought by her mother with bright red staining of her underpants.
She gives a history that her daughter recently started taking horse riding lessons. What
is the SINGLE next most appropriate action?
y
A. Examination of genitalia in clinic
op
B. Examination of genitalia under general anaesthesia
C. Reassure and discharge
D. Inform child protection services
C
E. Colposcopy
The likely diagnosis here is a perforated hymen given the history of horse riding. There
n
is no need for a general anaesthesia at this point as she is only having red staining. One
io
must remember that general anaesthesia has its own complications and should not be
used without reason.
t
ua
An attempt to examine in clinic without anaesthesia would be the prefered method. It

is extremely important to reassure, explain the examination and show equipment as
this will help diminish fears and anxiety of the child. Ensure the child's privacy and stop
al
the examination at any time provided the child indicates discomfort or withdraws
permission to continue. It is a good idea to examine small children while on their
Ev
mother’s lap or lying with her on a couch as to provide extra comfort.
When should we consider general anaesthesia?

If the child refuses the examination and conditions requiring medical attention, such as
bleeding or a foreign body, are suspected.
85. An 8 year old child has recurrent throat infections. He feels tired and lethargic all the
time. Petechiae is noticed on his lower limbs. On examination, splenomegaly and gum
hypertrophy was noted. Blood results show:
Hb 6.8g/dl
WCC 7 x 109/L
1257
These symptoms that he is presenting with are due to pancytopenia. The likely cause
given the options and his age is acute lymphoblastic leukaemia (ALL)
The commonest leukaemia in children is acute lymphoblastic leukaemia (ALL)
One needs to be careful with picking AML or ALL as there are often questions with a very
similar stem. In reality, it is difficult to diagnose them clinically as well. For the purpose
of the exam, if one sees a clinical picture of acute leukaemia in a very acute setting with
bleeding from the gums, AML is likely to be the answer. On the other hand, if one sees a
clinical picture of acute leukaemia but less acute and only with gum hypertrophy, ALL is
likely to be the answer. - Can these differences actually be used in real life? Probably not
y
op
Aetiology
Most cases of acute leukaemia arise with no apparent cause. There are several well
known associations with the development of acute leukaemia that are sometimes
C
present. These include radiation exposure, chemotherapeutic agents, as well as some
retroviruses.
n
io
The most common presentation results from the effects of the leukaemic blast cells
crowding out the normal marrow cells, resulting in symptoms of pancytopenia even if
t
the total white blood cell count is normal.

ua
- Fatigue from anaemia is the most common presenting complaint.

- Bleeding, petechiae, purpura or ecchymoses (due to thrombocytopenia)
al
- Recurrent and severe infections (oral, throat, skin, perianal infections

commonly). This is because of the underproduction or abnormal function of
Ev
white blood cells.

- Left upper quadrant fullness and early satiety due to splenomegaly (10-20%)

indistinguishable clinically. This means you cannot determine the diagnosis only from
the clinical presentation.
ALL is more often associated with infiltration of other organs, but AML can do it as well.
Enlargement of the liver, spleen, and lymph nodes and bone pain are common at
presentation.
Diagnosis
The FBC is the first clue to the diagnosis. Depression of all three cell lines is common at
presentation.
1258
FBC
- Anaemia is usual and Hb may be below 5 g/L
- The white cell count can be low, normal, or elevated
- Thrombocytopenia
Many other disorders can present as pancytopenia similar to leukaemia such as aplastic
anaemia, infections involving the marrow, metastatic cancer involving the marrow,
vitamin B12 deficiency, SLE, hypersplenism, and myelofibrosis. However, none of these
will have leukaemic blasts circulating in the peripheral blood. Although pancytopenia
can cause all of the above, in PLAB, when pancytopenia is in the options, it is usually
A bone marrow biopsy showing numerous blasts confirms the diagnosis of acute
leukaemia.
It is very unlikely that the PLAB questions would ask you to differentiate the AML from
ALL using specific test. However, if a child (young age) is given with signs and symptoms
y
of pancytopenia, ALL would be the most likely as it is the commonest childhood
op
leukaemia.
Note:
C
- ALL is the commonest childhood leukaemia. Peak age is 2–4 years old.
- The Philadelphia chromosome occurs in 15–30% (mostly adults) and is
associated with a poor prognosis.
n
io
86. A 9 year old patient attends the outpatient department with complains of fever,
malaise, weight loss, anorexia and productive cough. Examination reveals a
t
temperature of 39.1°C, and a pulse of 120 beats/minute. His mother says that he has a
ua
history of recurrent chest infections since young. What is the SINGLE most likely
causative organism?
al
Ev
C. Mycobacterium tuberculosis
D. Pseudomonas aeruginosa
E. Pneumocystis pneumonia
This is a very vague question. The stem does give some hint of a diagnosis of cystic
fibrosis given the history of the recurrent chest infections. It is important to note that
the diagnosis of cystic fibrosis is usually made within the first 6 months of life, however
over the past decade the diagnosis of cystic fibrosis later in life has been reported with
increasing frequency.
Organisms which frequently colonise CF patients:

- Staphylococcus aureus
- Pseudomonas aeruginosa
- Aspergillus
While it is a known fact that Pseudomonas infections are known as opportunistic

meaning the bacteria only cause infections when a person has CF or another condition
1259
that weakens the body's immune system, it is not actually the most frequent chest
infection in cystic fibrosis patients. Pseudomonas is one of the most common bacteria
found in people with CF but Staphylococcus aureus (SA) is the most prevalent organism
infecting the respiratory tract of CF children, and remains the second most prevalent
organism in CF adults.
87. A 5 year old girl is being investigated for renal failure. She has a history of urinary tract
infections in the pass. A congenital abnormality of the insertion of ureters into the
urinary bladder was seen on scan. What is the single most likely cause for renal failure
in this patient?
A. Systemic Lupus Erythematosus

B. Polycystic kidney disease
C. Wilms’ tumour
D. Acute tubular necrosis
E. Reflux nephropathy
Reflux nephropathy is a progressive lesion caused by repeated kidney infections. It is
y
due to urine flowing backwards from the bladder to kidneys (vesicoureteral reflux). It is
op
almost always found in childhood in the context of an abnormal urinary tract like in this
stem. C
88. A 3 year old boy who has had frequent urinary tract infections has recently been
diagnosed with vesicoureteral reflux. Which of the statements are correct?
n
A. Antibiotic prophylaxis is first line
io
B. Most children with vesicoureteral reflux will require surgery

C. Most children with vesicoureteral reflux will have kidney scarring by age 5
t
D. Antibiotic use has not been shown to reduce renal scarring

ua
E. Surgical correction should only be considered in patients with low-grade reflux
Antibiotic prophylaxis should be given prior to considering surgery. When medical

al
management fails to prevent recurrent urinary tract infections, or if the kidneys show
progressive renal scarring then surgical interventions may be necessary. Surgical
Ev
corrections are generally reserved for the higher grade refluxes (not low-grade). The
main idea of antibiotic prophylaxis is to reduce risk of urinary tract infection and thus
reduce renal scarring.
Vesicoureteral reflux
- Condition where urine flows retrograde from bladder into
ureters/kidneys
Presentation
- Most children are asymptomatic
- Increases risk of urinary tract infection → Thus, symptoms of a UTI:
o Fever
o Dysuria
o Frequent urination
o Lower abdominal pain
Diagnosis
1260
- Urinalysis, urine culture and sensitivity → initial investigation
- Renal ultrasound → initial investigation → might suggest the presence of
VUR if ureteral dilatation is present
- Micturating cystourethrogram → gold standard
- Technetium scan (DMSA) → for parenchymal damage (seen as cortical
scars)
Treatment
- VUR grade I-IV - start with low dose antibiotics prophylaxis daily (i.e.
trimethoprim)
- If above fails and/or parenchymal damage consider surgery -
reimplantation of the ureters
The International Reflux Study has found that children can be managed nonsurgically
with little risk of new or increased renal scarring, provided they are maintained
infection free. Remember, the goal of treatment is to minimize infections, as it is
infections that cause renal scarring and not the vesicoureteral reflux. Thus, the
importance of continuous antibiotic prophylaxis outweighs surgery in most cases. Note
y
that during early childhood, the kidneys are at higher risk of developing new scars. So it
op
is particularly important to start parenteral antibiotic treatment for patients with
vesicoureteral reflux before febrile breakthrough infections.
C
For patients with frequent breakthrough infections, definitive surgical or endoscopic
correction is preferred. Surgical correction should also be considered in patients with
persistent high-grade reflux (grades IV/V) or abnormal renal parenchyma.
n
io
89. A 4 year old child presents to A&E with fever and stridor. He is unable to swallow his
t
saliva. He has a respiratory rate of 45 breaths/minute. What is the SINGLE most

ua
A. Examine his throat

al
B. Secure his airways

C. Keep him in a supine position
Ev
D. Administer intravenous penicillin

E. Administer intramuscular epinephrine
The clincher here is the unable to swallow his saliva. If you find any questions with a
child with drooling of saliva. It is likely that this is acute epiglottitis, Summon the most
experienced anaesthetist to intubate before obstruction occurs. In the above options,
securing the airways is the most appropriate.
Acute epiglottitis
- Now rare due to the introduction of Hib vaccine. However, it is still a serious
infection. Prompt recognition and urgent treatment is essential
Features
- Rapid onset
- High temperature
- Stridor
1261
90. A 2 year old child is brought to the hospital by his mother with a barking cough. A few
days ago he had a runny nose, cough and a sore throat. His chest sounds are normal
and there are no signs of intercostal recession. He looks drowsy and lethargic. He has a
temperature of 38.7°C, respiratory rate of 34 breaths/minute, pulse rate of 150
beats/minute and his oxygen saturation on air is 96%. What is the SINGLE most
A. Oral dexamethasone
B. Oxygen
C. Nebulised salbutamol
D. Antibiotics
E. Nebulised adrenaline
Barking cough is a clincher that tells you this is croup. Croup is a form of upper
y
respiratory tract infection seen in infants and toddlers with peak incidence at 6 months
op
to 3 years. Parainfluenza viruses account for the majority of cases (more than 80% of
cases). C
The illness usually last around 3 to 5 days involving features of stridor, barking cough,
fever (mild temperature) and coryzal symptoms.
n
Giving a single dose of oral dexamethasone (0.15mg/kg) to all children regardless of
io
severity is recommended. In this stem, it is clear that he has mild croup. Mild croup is
largely self-limiting but treatment with a single dose of oral dexamethasone would be
t
of benefit.
ua
Emergency treatment of croup involves giving high-flow oxygen and nebulised

adrenaline. In this stem, his oxygen saturation is not low and thus he will not benefit
al
from oxygen. Nebulised adrenaline (epinephrine) is usually reserved for patients in

moderate-to-severe distress which in this stem the child is not.
Ev
91. A 13 month old female baby presents to the emergency department with difficulty in
breathing. On examination, she has intercostal recessions and a bilateral widespread
wheeze. Her temperature is 37.9°C and respiratory rate is 35 breaths/minute. What is
A. Bacterial upper respiratory tract infection

B. Pneumonia
C. Bronchiolitis
Bronchiolitis is very common in infants and young children. Their early symptoms are of
those of a viral upper respiratory tract infection including mild rhinorrhoea, cough and
fever. The fever is usually high (above 39°C) however in this stem a temperature of
37.9°C is given. Do not let that fool you into thinking that it is not an infective cause.
1262
Other symptoms of bronchiolitis include wheeze. Occasionally, one may find symptoms
of cyanosis and poor feeding in the stem.
Bronchiolitis
- An acute infectious disease of the lower respiratory tract that occurs
primarily in the very young, most commonly infants between 2 and 6
months old
- Respiratory syncytial virus (RSV) is the pathogen in 75-80% of cases
It is a clinical diagnosis based upon:

- Breathing difficulties
- Cough
- Coryzal symptoms (including mild fever)
- Decreased feeding
- Apnoeas in the very young
- Wheeze or fine inspiratory crackles on auscultation
Management
y
- Largely supportive involving humidified oxygen
op
C
n
t io
ua
al
Ev
1263
PHARMACOLOGY
y
op
C
Questions
n
io
&
t
ua
Answers
al
Ev
1264
Pharmacology Questions
1. Which of the following drugs can cause bronchoconstriction?
A. Atenolol
B. Salbutamol
C. Salmeterol
D. Ipratropium bromide
E. Theophylline
2. A 68 year old male patient is on Ramipril 10mg daily and Bendroflumethiazide 2.5mg
daily for hypertension. He has come for his routine checkup with a blood pressure of
135/85 mmHg. His blood tests shows:
Serum potassium level 5.9 mmol/L

y
What is the SINGLE most likely side effect of thiazide diuretics which contributed to his
op
blood results?
A. Hypocalcaemia
B. Hyponatraemia
C
C. Hypouricemia
D. Hyperkalaemia
n
E. Hypernatraemia
io
3. A 30 year old lady comes to the emergency department with palpitations and chest
t
pain. ECG shows sinus tachycardia. Her pulse rate is 110 beats/minute. She has a
ua
history of asthma and her GP recently changed her medications. What is the SINGLE
al
A. Atenolol
B. Digoxin
Ev
C. Review medications
D. Lidocaine
E. Labetalol
4. A 32 year old man on psychiatric medications complains of the inability to ejaculate.

What is the SINGLE most likely medication he is taking?
A. Lithium
B. Haloperidol
C. Chlorpromazine
D. Fluoxetine
E. Clozapine
5. A 5 year old boy was rushed to the emergency department unconscious after he had
taken methadone belonging to his sister. He was given naloxone and he regained
consciousness. After a while he started getting drowsy again. What is the SINGLE most
likely reason for his drop in level of consciousness?
1265
A. Naloxone is absorbed faster than methadone
B. Methadone is absorbed faster than naloxone
C. Methadone increases elimination of naloxone
D. Methadone has already caused tissue damage
E. Naloxone has a shorter half life compared to methadone
6. A 45 year old diabetic man had recently started taking anti-hypertension therapy. 6
months later his fasting blood glucose is 14 mmol/l. What is the SINGLE most likely
medication that would have caused this?
A. Amlodipine
C. Doxazosin
D. Losartan
E. Ramipril
7. A 65 year old man with hypertension develops gingival hyperplasia. What is the SINGLE
most likely medication causing the gingival hyperplasia?
y
op
A. Ramipril
B. Metoprolol
C. Spironolactone
C
D. Nifedipine
E. Indapamide
n
8. A 60 year old man developed ankle swelling shortly after starting antihypertensive
io
medication. What is the SINGLE most likely antihypertensive medication which could
account for his symptoms?
t
ua
A. Bendroflumethiazide
B. Bisoprolol
C. Diltiazem
al
D. Furosemide
E. Captopril
Ev
9. A 35 year old man with a history of alcohol abuse has oedema and ascites
demonstrated by shifting dullness.Spider naevi is noted on his trunk. Paracentesis
shows clear fluid. He has a temperature of 37.2°C, a pulse of 85 beats/minute, a blood
pressure of 119/85 mmHg and a respiratory rate of 20 breaths/minute. What is the
SINGLE most appropriate medication to start?
A. Corticosteroid
B. Azathioprine
C. Spironolactone
D. Cholestyramine
E. Penicillamine
10. 56 year old man whose pain was relieved by oral Morphine, now presents with
progressively worsening pain. Increasing the dose of oral morphine helps to relieve his
pain. However, he now complains that the increased morphine makes him drowsy and
1266
he is unable to carry out his daily activities. What is the SINGLE most appropriate next
step?
A. Replace oral morphine with oral oxycodone

B. Replace oral morphine with oral tramadol
C. Patient-controlled analgesia (PCA)
D. Intravenous fentanyl
E. Intravenous diamorphine
11. A 34 year old man suffers from depression. He was recently started on sertraline by his
GP. When can a therapeutic response of sertraline be seen?
A. 1-2 hours
B. 1-2 days
C. 1-2 weeks
D. 1-2 months
E. 1-2 years
y
12. A patient has recently been diagnosed with Bipolar Disorder and is to be put on Lithium
op
therapy. Her renal function and liver function tests are normal. What is the SINGLE
other test you need to do before commencing her on Lithium?
C
A. Renal biopsy
B. Autoimmune screen
C. Fluid restriction test
n
D. Urine for glucose
io
E. Thyroid function tests

t
13. A 72 year old woman who is taking loop diuretics is suffering from palpitations and
ua
muscle weakness. What is the SINGLE most likely electrolyte imbalance to be found?

al

Ev

14. A 55 year old man on hypertension medications develops hyperkalaemia. What is the
SINGLE most likely anti-hypertension to cause it?
A. Nifedipine
B. Indapamide
C. Bendroflumethiazide
D. Enalapril
E. Amlodipine
15. A 78 year old man who was previously on 120 mg slow release oral morphine and
paracetamol 1g QDS had his dose increased to 200 mg slow release oral morphine. He
is still in significant pain but complains of drowsiness and constipation. What is the
SINGLE most appropriate step in the management?
1267
A. Increase slow release morphine dose
B. Fentanyl patch
C. Replace morphine with oral hydromorphone
D. Replace morphine with oxycodone
E. Subcutaneous morphine
16. A 24 year old woman was prescribed amoxicillin for an episode of otitis media. She has
been using the combined oral contraceptive pill as a form of contraception for the past
two years. What is the SINGLE most appropriate advice to give her with regards to
antibiotic use and taking the COCP?

B. Barrier contraception should be used until the course of antibiotics is complete
C. No additional precaution is needed
D. Barrier contraception plus spermicide should be used
E. Stop COCP and use alternate contraceptive method
17. A 60 year old man has had spontaneous painful swelling of his right thumb for 3 days.
y
About five days ago, he had an inguinal hernia repaired as a day case. He takes
op
bendroflumethiazide 2.5mg daily. He is apyrexial. What is the SINGLE most appropriate
diagnostic investigation? C
A. Blood culture
B. C-reactive protein (CRP)
C. D-dimer
n
D. X-ray hand
io
E. Serum uric acid

t
18. A 72 year old man has been on warfarin for the last 2 years because of a previous
ua
transient ischaemic attack and stroke. He is not on any other medication. Which SINGLE
symptom would be the most alarming?
al
A. Severe headache
B. Sore throat
Ev
C. Constipation
D. Calf tenderness
E. Diarrhoea
19. A 74 year old man has been taking Warfarin 7mg daily for the treatment of left arm DVT
with an INR target of 2-3 for the past two years. He also takes Furosemide 40 mg daily,
Diprobase cream and Co-dydramol when required for pain relief. He is usually
compliant with his medications. What is the SINGLE most important adverse effect the
patient should be careful with?
A. Peripheral Neuropathy
B. Phototoxicity
C. Headache
D. Constipation
E. Persistent cough
1268
20. A 63 year old man presented with sudden onset of severe dyspnoea, orthopnea, raised
jugular venous pressure and bilateral basal crackles three days after an episode of
myocardial infarction. A diagnosis of acute congestive cardiac failure was made and
intravenous furosemide was started. What is the SINGLE most likely electrolyte
abnormality to be expected?

21. A 37 year old female patient has been taking Doxycycline 100mg daily for acne for the
past two weeks. She complains of feeling nauseous and having frequent diarrhoea since
starting the medication. She has no known allergies and occasionally buys paracetamol
over the counter. What is the SINGLE most appropriate advice to be given to this
patient?
y
A. Stop Doxycycline
op
B. Take it with meals
C. Take it before meals
D. Take antacids
C
E. Take antiemetics
22. A 7 year old child presented with a red, circular shaped rash on his skin. He was
n
prescribed Fucidin cream for 7 days to be applied but the rashes did not improve. He is
io
complaining of itch around the area where the rashes appear. What is the SINGLE next
best choice of medication to be prescribed?
t
ua
A. Betamethasone cream
B. Clotrimazole cream
C. Hydrocortisone cream
al
D. Urea 10% cream

E. Coal tar cream
Ev
23. A 25 year old man has been suffering from breathlessness and wheeze for the last 3
months. He has been prescribed Salbutamol inhaler, to take 2 puffs as required. In the
last 2 weeks his symptoms have worsened and he has been using his Salbutamol inhaler
five times a week, more frequently during the day. He also complains of difficulty
sleeping at night due to excessive coughing and breathlessness. What is the SINGLE
best medication to be added onto his regime?
A. Theophylline
B. Salmeterol inhaler
C. Beclomethasone inhaler
D. Montelukast tablet
E. Salbutamol tablet
24. A 45 year old man has recently had an anterior resection of the rectum.
Postoperatively, he was on oxycodone which controlled the pain. He started vomiting
1269
several times on the second day and a mild intestinal obstruction is suspected. What is
the SINGLE most appropriate management for his pain?
A. Switch oral oxycodone to fentanyl patch

B. Switch oral oxycodone to intramuscular morphine
C. Switch oral oxycodone to intravenous morphine
D. Switch oral oxycodone to intramuscular codeine phosphate
E. Switch oral oxycodone to oral codeine
y
op
C
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ua
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Ev
1270
Pharmacology Answers
1. Which of the following drugs can cause bronchoconstriction?
A. Atenolol
B. Salbutamol
C. Salmeterol
D. Ipratropium bromide
E. Theophylline
Atenolol is a beta blocker. Beta blockers are known to cause bronchoconstriction.
Salbutamol and salmeterol are beta agonist. They are used to treat bronchospasm thus
they have bronchodilating effects.
Ipratropium bromide inhibits bronchoconstriction
Theophylline also relaxes the bronchial smooth muscle causing bronchodilation.
y
op
2. A 68 year old male patient is on Ramipril 10mg daily and Bendroflumethiazide 2.5mg
daily for hypertension. He has come for his routine checkup with a blood pressure of
135/85 mmHg. His blood tests shows:
C
Serum potassium level 5.9 mmol/L
n
io
What is the SINGLE most likely side effect of thiazide diuretics which contributed to his
t
blood results?
ua
A. Hypocalcaemia
B. Hyponatraemia
al
C. Hypouricemia
D. Hyperkalaemia
Ev
E. Hypernatraemia
One of the many known adverse effects of thiazides is postural hypotension.
Common adverse effects of thiazides worth remembering include:

- postural hypotension
- hyponatraemia, hypokalaemia
- gout
3. A 30 year old lady comes to the emergency department with palpitations and chest
pain. ECG shows sinus tachycardia. Her pulse rate is 110 beats/minute. She has a
history of asthma and her GP recently changed her medications. What is the SINGLE
A. Atenolol
B. Digoxin
C. Review medications
D. Lidocaine
1271
E. Labetalol
She most likely started a beta agonist to treat her asthma which is known to cause
tachycardia.
4. A 32 year old man on psychiatric medications complains of the inability to ejaculate.

What is the SINGLE most likely medication he is taking?
A. Lithium
B. Haloperidol
C. Chlorpromazine
D. Fluoxetine
E. Clozapine
Sexual dysfunction is a common symptom of depression. However, in addition to this,

all antidepressants can cause sexual dysfunction to varying degrees (most commonly
serotonin reuptake inhibitors).
y
Drug Prevalence Type of problem
op
experienced
Selective serotonin 60-70% All phases of the sexual
inhibitors (SSRIs) response. Paroxetine is
C
associated with more
erectile dysfunction and
vaginal dryness than other
n
SSRIs.
io
Tricyclic antidepressants 30% Decreased libido, erectile

(TCAs) dysfunction, delayed
t
orgasm, and impaired

ua
ejaculation.
Venlafaxine 70% Decreased libido, delayed
orgasm, and erectile
al
dysfunction. Rarely painful

ejaculation and priapism.
Ev
Mirtazapin 25% Decreased libido, delayed

orgasm, erectile
dysfunction, absence of
orgasm.
Reboxetine 5-10% Orgasm abnormalities.
Duloxetine 46% Delayed orgasm.
Irreversible monoamine 40% Decreased libido, erectile
oxidase inhibitors (MAOIs) dysfunction, delayed
orgasm, and impaired
ejaculation. Moclobemide
is less likely to cause
sexual dysfunction
compared with older
MAOIs (4% versus 40%).
5. A 5 year old boy was rushed to the emergency department unconscious after he had
taken methadone belonging to his sister. He was given naloxone and he regained
1272
consciousness. After a while he started getting drowsy again. What is the SINGLE most
likely reason for his drop in level of consciousness?
A. Naloxone is absorbed faster than methadone

B. Methadone is absorbed faster than naloxone
C. Methadone increases elimination of naloxone
D. Methadone has already caused tissue damage
E. Naloxone has a shorter half-life compared to methadone
Naloxone has a shorter plasma half-life than all of opioid analgesics and so coma and
respiratory depression often recur when naloxone wears off. Careful observation of
the patient is essential and repeated doses of naloxone may be needed.
6. A 45 year old diabetic man had recently started taking anti-hypertension therapy. 6
months later his fasting blood glucose is 14 mmol/l. What is the SINGLE most likely
A. Amlodipine
y
op
C. Doxazosin
D. Losartan
E. Ramipril
C
The potential adverse metabolic effects of thiazide and thiazide-like therapy include
elevations in the plasma glucose. Bendroflumethiazide may lower carbohydrate
n
tolerance and the insulin dosage of some diabetic patients may require adjustment.
io
Care is required when bendroflumethiazide is administered to patients with a known

predisposition to diabetes
t
ua
7. A 65 year old man with hypertension develops gingival hyperplasia. What is the SINGLE
most likely medication causing the gingival hyperplasia?
al
A. Ramipril
B. Metoprolol
Ev
C. Spironolactone
D. Nifedipine
E. Indapamide
Gingival hyperplasia is a recognized side effect of calcium channel blockers
8. A 60 year old man developed ankle swelling shortly after starting antihypertensive
medication. What is the SINGLE most likely antihypertensive medication which could
account for his symptoms?
A. Bendroflumethiazide
B. Bisoprolol
C. Diltiazem
D. Furosemide
E. Captopril
1273
One of the known side effects of calcium channel blockers is swelling of the ankle.
Calcium channel blockers widen the narrow blood vessels (vasodilation), causing
redistribution of fluid from the vascular space, and for some people, this can cause
more fluid to leak out of the blood into the tissues around the ankle resulting in
swelling.
Calcium channel blockers can be divided into two types, the dihydropyridines, which
are predominantly vasodilator and generally have neutral or increased effects on
vascular permeability (Amlodipine and Nifedipine); and the non-dihydropyridines
(verapamil and diltiazem) which reduce vascular permeability and affect cardiac
contractility and conduction. All of these can cause ankle swelling.
9. A 35 year old man with a history of alcohol abuse has oedema and ascites
demonstrated by shifting dullness.Spider naevi is noted on his trunk. Paracentesis
shows clear fluid. He has a temperature of 37.2°C, a pulse of 85 beats/minute, a blood
pressure of 119/85 mmHg and a respiratory rate of 20 breaths/minute. What is the
y
A. Corticosteroid
op
B. Azathioprine
C. Spironolactone
D. Cholestyramine
C
E. Penicillamine
Oedema and fluid overload in third spaces, such as ascites, are managed with diuretics.
n
The diuretic most useful in cirrhosis is spironolactone. This is because cirrhotics have
io
intravascular volume depletion, which results in a high aldosterone state.

Spironolactone is an aldosterone antagonist.
t
ua
Common indications of spironolactone

- Ascites: patients with cirrhosis develop a secondary hyperaldosteronism.
- Hypertension: used as one of the last treatment options (in a 'step 4'
al
treatment)
- Heart failure
Ev
10. 56 year old man whose pain was relieved by oral Morphine, now presents with
progressively worsening pain. Increasing the dose of oral morphine helps to relieve his
pain. However, he now complains that the increased morphine makes him drowsy and
he is unable to carry out his daily activities. What is the SINGLE most appropriate next
step?
A. Replace oral morphine with oral oxycodone

B. Replace oral morphine with oral tramadol
C. Patient-controlled analgesia (PCA)
D. Intravenous fentanyl
E. Intravenous diamorphine
In general, oxycodone should be used when patients are still in pain but have side
effects of opioids. This is because oxycodone has twice the potency of morphine to
manage pain but with lesser side effects compared to morphine.
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The pain ladder consist of 3 steps:
1: Simple analgesia like paracetamol. Aspirin, NSAIDs +/- adjuvant therapy
2: Weak opiates: e.g codeine, tramadol, dihydrocodeine +/- adjuvant therapy
3. Strong opiates: morphine, fentanyl patches, diamorphine, oxycodone +/- adjuvant
therapy.
If patient is still in pain, you should never go back a step on the pain ladder, only go
forward.
11. A 34 year old man suffers from depression. He was recently started on sertraline by his
GP. When can a therapeutic response of sertraline be seen?
A. 1-2 hours
B. 1-2 days
C. 1-2 weeks
D. 1-2 months
E. 1-2 years
y
op
The onset of therapeutic effect of Sertraline may be seen within 7 days. However,
longer periods are usually necessary to demonstrate an appropritate therapeutic
response.
C
In general, an antidepressant effect is usually seen within 2 weeks of starting
treatment. If no effect is seen after 2-4 weeks, adherence should be assessed.
n
io
12. A patient has recently been diagnosed with Bipolar Disorder and is to be put on
Lithium therapy. Her renal function and liver function tests are normal. What is the
t
SINGLE other test you need to do before commencing her on Lithium?

ua
A. Renal biopsy
B. Autoimmune screen
al
C. Fluid restriction test

D. Urine for glucose
Ev
E. Thyroid function tests
Important tests to do before commencing Lithium therapy
- Weight, pulse and blood pressure

- Renal function (primary excretion route)
- Full blood counts, U&E
- Thyroid function tests and calcium
- Baseline ECG
- Baseline parathyroid hormone and magnesium
As this patient has already had baseline renal function and liver function tests, the next
best test to do would be thyroid function tests (especially measurement of T4). As
Lithium can cause disease of the thyroid, it is important to exclude hypothyroidism or
hyperthyroidism in a patient before commencing Lithium therapy.
1275
13. A 72 year old woman who is taking loop diuretics is suffering from palpitations and
muscle weakness. What is the SINGLE most likely electrolyte imbalance to be found?

Loop diuretics
The 3 main points that you need to know about loop diuretics are that it may cause:
1. Hypokalaemia
2. Hyponatraemia
3. Gout
Mnemonic: LOOP → HypOOnatraemia, HypOOkalaemia, GOOut
y
14. A 55 year old man on hypertension medications develops hyperkalaemia. What is the
op
SINGLE most likely anti-hypertension to cause it?
A. Nifedipine
C
B. Indapamide
D. Enalapril
n
E. Amlodipine
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ACE-inhibitors can cause hyperkalemia. Concomitant treatment with NSAIDs increases

t
the risk of renal damage, and potassium-sparing diuretics increase the risk of
ua
hyperkalaemia. It would be a good idea to recognise some common ACE inhibitors -

Ramipril, Enalapril, Captopril, Perindopril and Lisinopril.
al
If there is no option for ACE inhibitors, then Angiotensin-II receptor blockers (ARBs)
would be the next best option as these can too cause hyperkalaemia. Common ARBs to
Ev
know are Losartan, Candesartan, and Valsartan.

15. A 78 year old man who was previously on 120 mg slow release oral morphine and
paracetamol 1g QDS had his dose increased to 200 mg slow release oral morphine. He
is still in significant pain but complains of drowsiness and constipation. What is the
SINGLE most appropriate step in the management?
A. Increase slow release morphine dose

B. Fentanyl patch
C. Replace morphine with oral hydromorphone
D. Replace morphine with oxycodone
E. Subcutaneous morphine
In general, oxycodone should be used when patients are still in pain but have side
effects of opioids. This is because oxycodone has twice the potency of morphine to
manage pain but with lesser side effects compared to morphine.
The pain ladder consist of 3 steps:
1276
1: Simple analgesia like paracetamol. Aspirin, NSAIDs +/- adjuvant therapy
2: Weak opiates: e.g codeine, tramadol, dihydrocodeine +/- adjuvant therapy
3. Strong opiates: morphine, fentanyl patches, diamorphine, oxycodone +/- adjuvant
therapy.
If patient is still in pain, you should never go back a step on the pain ladder, only go
forward.
16. A 24 year old woman was prescribed amoxicillin for an episode of otitis media. She has
been using the combined oral contraceptive pill as a form of contraception for the past
two years. What is the SINGLE most appropriate advice to give her with regards to
antibiotic use and taking the COCP?

B. Barrier contraception should be used until the course of antibiotics is complete
C. No additional precaution is needed
D. Barrier contraception plus spermicide should be used
E. Stop COCP and use alternate contraceptive method
y
op
According to latest recommendations, no additional contraceptive precautions are
necessary when antibiotics that do not induce liver enzymes are used together with
combined oral contraceptives, unless diarrhoea or vomiting occur
C
17. A 60 year old man has had spontaneous painful swelling of his right thumb for 3 days.
About five days ago, he had an inguinal hernia repaired as a day case. He takes
n
bendroflumethiazide 2.5mg daily. He is apyrexial. What is the SINGLE most appropriate
io
diagnostic investigation?
t
A. Blood culture
ua
B. C-reactive protein (CRP)

C. D-dimer
D. X-ray hand
al
E. Serum uric acid

Ev
Bendroflumethiazide may raise serum uric acid levels and exacerbate gout in
susceptible individuals.
18. A 72 year old man has been on warfarin for the last 2 years because of a previous
transient ischaemic attack and stroke. He is not on any other medication. Which
SINGLE symptom would be the most alarming?
A. Severe headache
B. Sore throat
C. Constipation
D. Calf tenderness
E. Diarrhoea
Headache which may result from intracranial haemorrhage due to Warfarin is the most
important adverse effect - and patients should be counselled to report any unusual or
persistent headaches whilst taking Warfarin.
1277
19. A 74 year old man has been taking Warfarin 7mg daily for the treatment of left arm
DVT with an INR target of 2-3 for the past two years. He also takes Furosemide 40 mg
daily, Diprobase cream and Co-dydramol when required for pain relief. He is usually
compliant with his medications. What is the SINGLE most important adverse effect the
patient should be careful with?
A. Peripheral Neuropathy
B. Phototoxicity
C. Headache
D. Constipation
E. Persistent cough
Headache which may result from intracranial haemorrhage due to Warfarin is the most
important adverse effect - and patients should be counselled to report any unusual or
persistent headaches whilst taking Warfarin.
20. A 63 year old man presented with sudden onset of severe dyspnoea, orthopnea, raised
jugular venous pressure and bilateral basal crackles three days after an episode of
y
myocardial infarction. A diagnosis of acute congestive cardiac failure was made and
op
intravenous furosemide was started. What is the SINGLE most likely electrolyte
abnormality to be expected? C
n
io

t
Furosemide is a loop diuretic.

ua
Loop diuretics
al
The 3 main points that you need to know about loop diuretics are that it may cause:
1. Hypokalaemia
Ev
2. Hyponatraemia
3. Gout
Mnemonic: LOOP → HypOOnatraemia, HypOOkalaemia, GOOut
21. A 37 year old female patient has been taking Doxycycline 100mg daily for acne for the
past two weeks. She complains of feeling nauseous and having frequent diarrhoea
since starting the medication. She has no known allergies and occasionally buys
paracetamol over the counter. What is the SINGLE most appropriate advice to be given
to this patient?
A. Stop Doxycycline
B. Take it with meals
C. Take it before meals
D. Take antacids
E. Take antiemetics
1278
Side effects known to Doxycycline include headache, nausea, diarrhoea, vomiting, and
oesophageal irritation. These side effects can be minimised by advising patients to
swallow Doxycycline capsules as a whole, while sitting or standing, with a full glass of
water with meals.
22. A 7 year old child presented with a red, circular shaped rash on his skin. He was
prescribed Fucidin cream for 7 days to be applied but the rashes did not improve. He is
complaining of itch around the area where the rashes appear. What is the SINGLE next
best choice of medication to be prescribed?
A. Betamethasone cream
B. Clotrimazole cream
C. Hydrocortisone cream
D. Urea 10% cream
E. Coal tar cream
Fucidin cream is an antibacterial cream (fusidic acid). If after a week, this has no
response then it is most likely a fungal infection on the skin. The red, circular and itchy
y
rash is most probably a ringworm infection which should respond to Clotrimazole
op
cream.
23. A 25 year old man has been suffering from breathlessness and wheeze for the last 3
C
months. He has been prescribed Salbutamol inhaler, to take 2 puffs as required. In the
last 2 weeks his symptoms have worsened and he has been using his Salbutamol
inhaler five times a week, more frequently during the day. He also complains of
n
difficulty sleeping at night due to excessive coughing and breathlessness. What is the
io
SINGLE best medication to be added onto his regime?

t
A. Theophylline
ua
B. Salmeterol inhaler
C. Beclomethasone inhaler
D. Montelukast tablet
al
E. Salbutamol tablet
Ev
According to the British Thoracic Society (BTS) Asthma guideline, the patient is
currently on Step 1. As his asthma is not controlled (i.e. he is using his Salbutamol
inhaler more than three doses per week), he should be moved up to Step 2 which is
regular low dose corticosteroid inhaler.
24. A 45 year old man has recently had an anterior resection of the rectum.
Postoperatively, he was on oxycodone which controlled the pain. He started vomiting
several times on the second day and a mild intestinal obstruction is suspected. What is
the SINGLE most appropriate management for his pain?
A. Switch oral oxycodone to fentanyl patch

B. Switch oral oxycodone to intramuscular morphine
C. Switch oral oxycodone to intravenous morphine
D. Switch oral oxycodone to intramuscular codeine phosphate
E. Switch oral oxycodone to oral codeine
1279
Intravenous morphine would be the most suitable as he is not able to tolerate opioids
orally due to the vomiting.
There is no rational behind picking fentanyl patch as an option. Whilst it is true that if
the pain is stable and oral route is no longer appropriate (e.g. vomiting), fentanyl
patches are a good choice however, the pain here is not stable. The pain was well
controlled with oral oxycodone of which he has now started to vomit out. It is obvious
that he will be in pain again. Fentanyl is a strong opioid. Due to its long half-life, it will
take at least 12 to 24 hours to achieve therapeutic drug levels and so is only of benefit
in patients with stable pain. If you had given this to the patient, he would be in severe
pain for several hours while waiting for the therapeutic drug levels to kick in.
Fentanyl patches are usually used in cancer patients who have stable pain who are not
able to tolerate oral medication.
It is not reasonable to use constipation as an excuse in this example to avoid the use of
intravenous morphine. The bottom line is constipation can be prevented or greatly
reduced with laxatives but postoperative pain cannot be relieved with a slow releasing
y
transdermal patch.
op
C
n
t io
ua
al
Ev
1280
PSYCHIATRY
y
op
C
Questions
n
io
&
t
ua
Answers
al
Ev
1281
Psychiatry Questions
1. A 38 year old man has disturbing thoughts about his house being infected by germs. He
is anxious about safety and checks the locks of his doors repeatedly before going to
bed. He has been washing his hands every time he touches the lock. This can be 5 to 10
times an hour. What is the SINGLE most appropriate management?
A. Antidepressant
B. Antipsychotic
C. Anxiolytic
D. Cognitive behavioural therapy
E. Psychodynamic psychotherapy
2. A 57 year old man had a myocardial infarction 6 months ago. He has been having low
moods since then and a diagnosis of moderate depression has been established. Which
is the SINGLE most appropriate medication to start him on?
A. Selective serotonin reuptake inhibitors
y
B. Tricyclic antidepressants
op
C. Monoamine oxidase inhibitors
D. Benzodiazepam
E. Mood stabilizer
C
3. A 27 year old woman is afraid to go out of her house into public places. Everytime she
travels using public transport she becomes breathless and has palpitations. What is the
n
io
A. Social phobia
t
B. Claustrophobia
ua
C. Arachnophobia
D. Acrophobia
E. Agoraphobia
al
4. A 37 year old woman believes that her neighbours have been using her shower while
Ev
she is away at work. She is convinced that they dry the bathroom and escape just
before she goes into the bathroom. Her husband comes to share the same belief and
informs the police. What is the SINGLE most appropriate term for these symptoms?
A. Capgras syndrome
B. Cotard syndrome
C. Persecutory delusions
D. Folie à deux
E. Munchausen's syndrome
5. A 24 year old depressed man has neglected his personal hygiene and physical health.
He denies the existence of his bowels and believes that his bowels are blocked. He also
believes that his limbs are missing and that no one cares about it. What SINGLE kind of
delusion is he suffering from?
A. Nihilistic delusions
B. Delusion of guilt
C. Persecutory delusion
1282
D. Frégoli delusion
E. Clang association
6. A 26 year old woman has a history of bipolar disorder for 10 years and is taking lithium
for it. She has been symptom free for the past 4 years. She is now planning her
pregnancy and wants to know whether she should continue to take lithium. What is
the SINGLE most appropriate advice?
A. Continue lithium at the same dose and stop when pregnancy is confirmed
B. Continue lithium during pregnancy and stop when breast feeding
C. Reduce lithium dosage but continue throughout pregnancy
D. Reduce lithium gradually and stop before pregnancy is confirmed
E. Switch to sodium valproate
7. A 22 year old woman was brought to the emergency department by her boyfriend with
her fist bleeding after punching a mirror. She is distressed because he wants to end the
relationship. Scars of old cuts on her forearms was noticed during a physical
examination. She denies trying to end her life. What is the SINGLE most likely
y
diagnosis?
A. Acute psychosis
B. Borderline personality disorder
op
C
C. Severe depression
D. Schizoid personality
E. Psychotic depression
n
io
8. A 22 year old man was found overdosed on heroin. He has decreased respiratory rate
and has lost consciousness. What is the SINGLE most appropriate management?
t
ua
A. Benzodiazepines
B. Diazepoxide
C. Naloxone
al
D. Methadone
E. Disulfiram
Ev
9. A 45 year old woman presents with complaints of abdominal pain and blood in the
stool. She brings the stool sample from home but has never been able to produce a
sample at the hospital. A urinalysis was done which was negative. Her blood test are
normal. This is the third time she is presenting to the hospital in the last month. On
examination, multiple scars on the abdomen consistent with laparoscopies are seen.
She insists on getting further investigations although no abnormalities are found. What
A. Somatization disorder
B. Hypochondriasis
C. Munchausen's syndrome
D. Conversion disorder
E. Malingering
1283
10. A 29 year old women diagnosed with schizophrenia is complaining that the children
playing outside her garden can hear her thoughts. She says they know exactly what she
is thinking at all times of the day. What is the SINGLE most likely phenomenon?
A. Thought block
B. Thought insertion
C. Thought broadcasting
D. Thought withdrawal
E. Thought block
11. A 38 year old woman with episodes of mania followed by depression was started on
medication. Improvement was seen and she no longer complains of these episodes.
What is the SINGLE most likely medication that she was started on?
A. Fluoxetine
B. Lithium
C. Lorazepam
D. Haloperidol
y
E. Amphetamine
12.
op
A couple attends a marriage counselling session because of marital problems. The wife
states that her husband is having affairs although she has no proof of this. The husband
C
states that she is “insane” because she is having him followed by a private detective
and she is overly preoccupied about him being unfaithful. She goes through his
personal belongings almost every day to look for signs of infidelity. Her actions are
n
putting considerable strain on their marriage. What is the SINGLE most likely syndrome
io
she is suffering from?

t
A. Frégoli delusion
ua
B. Cotard syndrome
C. Capgras syndrome
D. Ekbom syndrome
al
E. Othello syndrome
Ev
13. A 21 year old girl looking unkempt, came to the hospital asking for painkillers for her
abdominal pain. She is agitated, and looks malnourished. She is also sweating,
shivering and complains of joint pain. What is the SINGLE most likely substance
misuse?
A. Alcohol
B. Heroin
C. Cocaine
D. LSD
E. Ecstasy
14. A 55 year old man has a firm belief that the headlines in the newspapers are written
especially for him. He believes that the authors of the newspaper articles who he has
never met are sending secret and significant messages that only he can understand.
What is the SINGLE most likely type of delusion that this man is suffering from?
A. Persecutory delusions
1284
B. Grandiose delusions
C. Delusion of control
D. Delusion of reference
E. Nihilistic delusions
15. A 33 year old man with a family history of panic disorder has palpitations, tremors,
sweating and muscles tightness on 3 occasions in the last 6 weeks. His pulse rate is 85
bpm, BP is 120/80 mmHg. What is the SINGLE most appropriate long-term treatment
for him?
A. Diazepam
B. Olanzapine
C. Haloperidol
D. Fluoxetine
E. Alprazolam
16. A 33 year old woman has been feeling down for the past one year. She feels fatigue
and is eating more than usual. Several times a week she would wake up during the
y
night and would not be able to go back to sleep. Occasionally, she hears voices of her
op
late husband who died two years ago. What is the SINGLE most likely diagnosis?
A. Obsessive compulsive disorder

C
B. Psychotic depression
C. Grieving
D. Severe depression
n
E. Hypomania
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17. A 64 year old man has recently suffered from an a myocardial infarction 5 months ago.
t
He has been having trouble sleeping and seems depressed. His regular medications
ua
include aspirin, atorvastatin and ramipril. What is the SINGLE most appropriate
medication to start him on?
al
A. Lofepramine
B. Dosulepin
Ev
C. Citalopram
D. Amitriptyline
E. Phenelzine
18. A 28 year old woman comes in with her limbs paralysed after witnessing a car accident.
She cannot recall what just happened. What is the SINGLE most likely diagnosis?
B. Hypochondriasis
E. Malingering
19. A 30 year old woman has been feeling low and having difficulty in concentrating since
her mother passed away 2 months ago. She feels lethargic and has been crying more
often lately. What is the SINGLE most likely diagnosis?
1285
A. Adjustment disorder
B. Post traumatic stress disorder
C. Panic disorder
D. Generalized anxiety disorder
E. Major depression
20. A 32 year old woman complains of abdominal pain, palpitations, unsteadiness, and
numbness of the lower limbs. Every investigation that is performed by the doctors
come back normal. What is the SINGLE most likely diagnosis?
B. Hypochondriasis
E. Malingering
21. A 24 year old woman is afraid to leave her house as whenever she goes out into the
open, she tends to have shortness of breath, palpitations and sweating. She only goes
y
out when her husband is with her. What is the SINGLE most likely diagnosis?
A. Social phobia
B. Claustrophobia
op
C
C. Depression
D. Panic disorder
E. Agoraphobia
n
io
22. A 64 year old man has a firm belief that the person on the billboard outside his window
is sending a messages that are meant specifically for him. What is the SINGLE most
t
likely type of delusion that this man is suffering from?

ua
al
Ev
23. A 6 year old child is brought to the clinic by his mother. She says that his teacher
complains that he is easily distracted and interrupts others when it is their turn to
answer questions. His mother says that he is not able to do a particular task for a long
time and cannot play quietly. He is careless and often breaks things. What is the
A. Autism spectrum disorder

B. Dyslexia
C. Attention deficit hyperactivity disorder (ADHD)
D. Antisocial personality disorder
E. Oppositional defiant
24. A 24 year man finds it difficult to come out of his house without checking if he has
locked the door several times. When exits his house, he has to check it at least 3 times
1286
by pushing the door handle to confirm it is locked. He now wants help as he has been
doing this for a couple of years. What is the SINGLE most appropriate management?
A. Exposure and response prevention (ERP)

B. Selective serotonin reuptake inhibitors (SSRIs)
C. Electroconvulsive therapy (ECT)
D. Antipsychotics
E. Desensitization
25. A 29 year old man has been found in the park, drunk and brought to the emergency
department by ambulance. He recently lost his job and had a divorce 3 months ago. He
has intense feelings of feeling worthless and being a failure. He also hears voices telling
him he is worthless. What is the SINGLE most likely diagnosis?
A. Schizoid personality disorder

B. Borderline personality
C. Schizophrenia
y
E. Hypomania
26.
op
A 28 year old female who delivered 6 weeks ago feels sad and has no interest to
feeding the baby. She has been eating poorly and having difficulty sleeping. She feels
C
weak throughout the day and has stopped taking the baby out of the house. She also
says that the baby has evil eyes. What is the SINGLE most likely diagnosis?
n
A. Postpartum blues
io
B. Postpartum depression
C. Postpartum psychosis
t
D. Schizophrenia
ua
27. A 25 year old woman presents to the GP with low mood. She has an increased appetite
al
and has gone up 2 dress sizes. She also complains that she feels very tired and often
only gets out of bed in the afternoon despite sleeping early. What is the SINGLE most
Ev
likely diagnosis?
A. Pseudo depression
B. Moderate depression
D. Dysthymia
E. Atypical depression
28. A 23 year old woman has had several sudden onset episodes of palpitations, sweating,
nausea and overwhelming fear. On one occasion she was woken from sleep and had
the fear that she was going insane. She has no previous psychiatric medical history and
is not on any medication. What is the SINGLE most likely diagnosis?
A. Phaeochromocytoma
B. Panic disorder
C. Generalized anxiety disorder
D. Hypnophobia
1287
E. Acute stress disorder
29. A 35 year old chronic alcoholic has been trying to stop his alcohol drinking habit. He
has been going for support meetings. He wants to know if there is a medication that
can help reduce his alcohol cravings. What is the SINGLE most appropriate medication?
A. Disulfiram
B. Acamprosate
C. Vitamin B12
D. Pabrinex
E. Chlordiazepoxide
30. A 28 year old woman has episodes of peri-oral tingling and carpopedal spasms every
time she has to give a public talk. These symptoms also happens to her before
interviews, exams and after arguments. She describes these episodes as short lasting
only a couple of minutes but with intense fear. What is the SINGLE most appropriate
management?
y
A. Diazepam
op
B. Rebreath into a paper bag
C. Alprazolam
D. Buspirone
C
E. Propranolol
31. A 30 year old man who served in the army 6 months ago presents with lack of interest
n
in enjoyable activities and feeling low. He often wakes up in the middle of the night
io
because of nightmares of gun fire. He feels irritable and has difficulty concentrating. He
tries not to watch the news as it reminds him of war. What is the SINGLE most
t
appropriate initial therapy?

ua
A. Citalopram
B. Lofepramine
al
C. Cognitive behavioural therapy (CBT)

D. Chlordiazepoxide
Ev
E. Desensitization
32. A 24 year old man feels down and lethargic. In the last couple of months, he has
stopped enjoying his hobbies which include playing the violin. He was admitted to the
psychiatry ward last year following an episode of overspending, reckless behaviour and
promiscuity. What is the SINGLE most likely diagnosis?
A. Psychosis
B. Cyclothymia
C. Bipolar affective disorder
D. Seasonal affective disorder
E. Depression
33. A 65 year old woman thinks she has died 3 months ago and is very distressed that
nobody has buried her up till now. She hears people’s voices which tell her that is evil
and needs to be punished. She barely has any eye contact when speaking to the health
care professionals. What is the SINGLE most likely explanation for her symptoms?
1288
A. Schizophrenia
B. Mania
C. Psychotic depression
D. Hysteria
E. Toxic confusional state
34. A 29 year old teacher was run down by a drunk driver a year ago. Since then, she has
been afraid to cross the road. She suffers from nightmares about that incident and gets
a startled response every time she hears loud sounds. What is the SINGLE most
A. Cognitive behavioural therapy (CBT)

B. Diazepam
C. Citalopram
D. Dosulepin
E. Sertraline
35. A 35 year old is agitated and euphoric. He claims to be helping the prime minister with
y
economic policies and describes himself to be a very powerful man. He believes that he
op
has made important discoveries regarding international policies that have great impact
towards the United Kingdom. On further investigation, these statements are untrue.
C
A. Bipolar disorder
B. Schizophrenia
n
C. Hypomania
io
D. Erotomania
E. Delusion of grandeur
t
ua
36. A 28 year old business man returned from a trip from Kenya 2 years ago. He attends a
sexual clinic worried that he has contracted HIV. Antibody screening test for HIV has
come back negative. There were 2 similar HIV test performed 6 months and 9 months
al
ago which have both come back as negative. This is his 5th visit to the clinic claiming
that he is HIV positive. What is the SINGLE most likely diagnosis?
Ev
B. Hypochondriasis
E. Malingering
37. A 38 year old man keeps having intrusive thoughts about having dirt under the bed. He
cannot keep himself from thinking about these thoughts. If he tries to resist, he starts
having palpitations. What is the SINGLE most likely diagnosis?
A. Adjustment disorders
B. Obsessive–compulsive disorder (OCD)
C. Schizophrenia
D. Panic disorder
E. Acute stress reaction
1289
38. A 22 year old woman thinks she is overweight. She has a body mass index of 21.8
kg/m2. She has often has constipation and abdominal pain. She eats uncontrollably
and feels guilty resulting in self-inducing vomiting. Sometimes to compensate for her
big meal, she would exercise intensively. What is the SINGLE most likely diagnosis?
A. Anorexia nervosa
B. Pituitary tumour
C. Hypothyroidism
D. Bulimia nervosa
E. Prader willi syndrome
39. A 20 year old man complains his movements are being watched. He feels as though his
actions are being controlled by the radio. At times he hears voices describing his
actions. What is the SINGLE most likely diagnosis?
A. Mania
B. Schizoid personality disorder
C. Paranoid personality disorder
y
D. Schizophrenia
op
40. A 48 year old man attends his GP. He was started on fluoxetine 8 weeks ago for
C
depression and is now requesting to stop his medication as he feels well and does not
think he is depressed any longer. What is the SINGLE most appropriate advice to give
to him in regards to his treatment?
n
io
A. Stop fluoxetine right away

B. Continued fluoxetine for at least another 6 months
t
C. Fluoxetine dose should be gradually reduced over a 4 week period

ua
D. Fluoxetine dose should be gradually reduced over a 1 week period

E. Change to a different SSRI
al
41. A 23 year old man comes to the emergency department with a history of drug misuse.
He recognizes that he has a problem and is willing to see a psychiatrist. What is the
Ev
SINGLE most accurate term that describes this situation?
A. Judgement
C. Thought block
D. Mood
E. Insight
42. A 30 year old woman complains of feeling restless, muscle tension and sleep
disturbance on majority of the days over the last 9 months. She worries excessively
about a number of everyday events and activities and is unable to control these
feelings which are impairing her ability to hold down her job. What is the SINGLE most
likely diagnosis?
A. Panic disorder
B. Generalized anxiety disorder (GAD)
C. Pheochromocytoma
1290
D. Acute stress reaction
E. Social phobia
43. A 64 year old man believes a female newscaster on the television is communicating
directly to him when she turns a page and when she looks at the camera. What is the
SINGLE most likely type of delusion that this man is suffering from?
44. A 26 year old woman is afraid to visit the shopping centre. Crowds and public places
causes her to panic. She feels more relaxed when she goes out to public places with
her husband than when alone. What is the SINGLE most likely diagnosis?
A. Social phobia
y
B. Claustrophobia
op
C. Arachnophobia
D. Acrophobia
E. Agoraphobia
C
45. A 32 year old man thinks nurses are plotting to harm him and are stealing his ideas
straight out from his mind. Sometimes he feels the nurses are able to control his body.
n
io

t
ua
C. Schizophrenia
E. Paranoid personality disorder
al
46. A 34 year old woman 3 weeks after childbirth has thoughts of harming her little baby
Ev
as she complains that he has evil eyes. She has been feeling low and has been suffering
from lack of sleep. Prior to this she was well and has no psychiatric issues. What is the
SINGLE most appropriate management for this patient?

B. Electroconvulsive Therapy (ECT)
C. IV haloperidol
D. Paroxetine
E. Amitriptyline
47. A 19 year old college student has a firm and unshakable belief that he is being followed
by terrorists who are plotting against him. He says they follow him wherever he goes.
What is the SINGLE most appropriate term for his condition?
1291
48. A 64 year old man has just suffered from a myocardial infarction. Before discharge, he
seems to be in a sad mood and avoids eye contact. The nurses report that he has
skipped his last two meals. What is the SINGLE best treatment for this man’s
condition?
A. Sertraline
B. Risperidone
C. Lithium
D. Amitriptyline
E. Diazepam
her husband passed away 6 weeks ago. She has been crying almost everyday, and
feeling hopeless. She has been withdrawing from other people and does not want to
go out for dinner with her mother. What is the SINGLE most likely diagnosis?
y
op
C. Panic disorder
C
E. Social phobia
50. A 43 year old woman presents with low mood, and loss of libido. She feels tired all day
n
and she attributes this to the fact that she wakes up 3 hours sooner than usual. She
io
feels like she has been gaining weight. She also finds it difficult to concentrate for long
periods of time. What is the SINGLE most likely diagnosis?
t
ua
A. Seasonal Affective Disorder

B. Bipolar disorder
al
D. General anxiety disorder

E. Depression
Ev
51. A 33 year old woman has persistent fear when she has to speak publicly. She sweats
and has palpitations and finds it very difficult to breathe. She is afraid of what people
might think of her. She tries her best to avoid these situations. What is the SINGLE
A. Agoraphobia
B. Acute stress disorder
C. Social anxiety
D. Obsessive compulsive disorder
52. A 29 year old women is overly paranoid that her partner is being unfaithful to her. She
checks his phones, email accounts and bank statements several times a day for
evidence of infidelity. She dislikes him going out as she fears that he would look at
other women while he is out on his own. She does not allow any social media for fear
that he may meet another women. What is the SINGLE most likely diagnosis?
1292
B. Cotard syndrome
C. Capgras syndrome
D. Ekbom syndrome
E. Othello syndrome
53. A 62 year old man who was admitted for surgery 3 days ago suddenly becomes
confused. His attention span is reduced. He is restless and physically aggressive and
picks at his bed sheets. What SINGLE aspect of the patient's history recovered in his
notes is most likely to aid in making the diagnosis?
A. Chronic alcohol consumption

B. Previous head trauma
C. Psychiatric history of generalized anxiety disorder
D. Psychiatric history of obsessive compulsive disorder
E. Mild cognitive impairment
y
54. A 31 year old woman 15 days following childbirth is brought to the hospital by her
op
husband. He complains that his wife has lost the ability to care for herself and is not
eating well. She does not sleep well and has intrusive and unpleasant thoughts of
harming the baby. What is the SINGLE best management for this patient?
C
A. Fluoxetine
B. Haloperidol
n
io
D. Reassurance
E. Electroconvulsive Therapy (ECT)
t
ua
55. A 43 year old man attends the GP clinic complaining that his arm is dead and rotten
and he wants it removed. On physical examination, the arm looks normal. What is the
al
Ev
B. Hypochondriasis
C. Conversion disorder
D. Nihilistic delusions
E. Capgras syndrome
56. A 74 year old man is depressed after his wife’s death 6 months ago. He has been
neglecting himself and is not eating well. He has lost 11 kg in the last 3 months. At
times, he has thought about self harm but has never done it. His son found him in a
very miserable state when he went to visit him last night. Unfortunately, the son is
unable to care for his father due to work and other family related issues. What is the
A. Review his mental status in 2 weeks

B. Refer to a social worker
C. Suggest the option of his son to moving in with his father
D. Send patient to a care home
E. Voluntary admission to the psychiatry ward
1293
57. A 33 year old man attends his appointment with the psychiatrist. He says that he is no
longer alive. He wants his family to bury him. What is the SINGLE most appropriate
diagnosis?
B. Hypochondriasis
E. Capgras syndrome
58. A 37 year old woman was admitted for a femur fracture repair after a road traffic
accident. On the fourth post-op day she becomes confused and starts picking on her
bed sheets. She complains of seeing spiders all over her bed. What is the SINGLE most
likely diagnosis?
A. Delirium tremens
B. Wernicke's encephalopathy
y
C. Korsakoff's psychosis
op
E. Electrolyte imbalance C
59. A 19 year old man has lack of interest and no social interactions. He has very little
friends and does not talk much. He prefers solitary activities. One of his interest is in
collecting toy cars. He has over 2,000 toy cars and often spends hours lining them up.
n
io
A. Borderline personality disorder

t
B. Dissocial personality disorder

ua
C. Obsessive compulsive disorder

D. Autism spectrum disorder
E. Bipolar affective disorder
al
Ev
nausea and overwhelming fear. On one occasion she was woken from sleep and feared
she was going insane. She has no previous psychiatric disorder. What is the SINGLE
A. Pheochromocytoma
B. Panic disorder
D. Agoraphobia
61. A 48 year old woman who is always socially withdrawn has stopped going out of the
house. She is afraid to socialize because she fears that people will criticize her. What is
A. Agoraphobia
C. Social anxiety
1294
62. A 26 year old political refugee has sought asylum in the UK. He complains of poor
concentration. He keeps getting thoughts of his family whom he saw was killed in a
political coup. He is unable to sleep well, feels hopeless and detached. What is the
A. Acute stress disorder

C. Social phobia
63. A 20 year old woman with amenorrhoea and a body mass index is 14.8 kg/m2 is still
trying to lose weight. She exercises excessively and induces vomiting after her meals.
y
A. Anorexia nervosa
op
B. Bulimia nervosa
C
E. Body dysmorphic disorder
64. A 17 year old woman has been diagnosed with anorexia nervosa. She has mild
n
depressive symptoms and has reduced her food intake in the last 8 months. She
io
exercises daily and admits to inducing vomiting occasionally after a meal. Her body
mass index is 16.8 kg/m2. She has a blood pressure of 95/65 mmHg and a heart rate of
t
70 beats/minute. What is the SINGLE most appropriate management?

ua
A. Refer to eating disorder service

B. Refer to dietician
al
C. Admit to medical ward

D. Admit to psychiatry ward
Ev
E. Start antidepressants
65. A couple has just finished their detox regime and wants a drug with a pharmacological
action to serve as a deterrent when they take alcohol. What is the SINGLE most
appropriate medication to start?
A. Disulfiram
B. Acamprosate
C. Vitamin supplement
D. Naloxone
E. Chlordiazepoxide
66. A 35 year old schizophrenic man hears voices narrating his actions like “he is going to
the toilet” and “he is leaving the house”. What is the SINGLE most likely type of
hallucinations involved?
A. First-person auditory hallucinations
1295
B. Second-person auditory hallucinations
C. Third-person auditory hallucinations
D. Echo de la pensee
E. Gedankenlautwerden
67. A 22 year old man was rushed into the emergency department. He describes recurrent
episodes of fearfulness, palpitations, with peri-oral tingling and cramping of the hands.
His symptoms last 5 - 10 minutes. He is worried he may be having a heart attack. An
ECG shows sinus tachycardia. He has a respiratory rate of 34 breaths/minute. What is
the SINGLE most appropriate immediate intervention?
A. High flow oxygen

B. IV sedation
C. Rebreath into a paper bag
D. Alprazolam
E. Refer to cardiac team urgently
68. A 33 year old man with alternating mood swings and episodes mood elevation to
y
depression underwent treatment and improvement was seen in his mood swings.
op
What SINGLE medication is needed to be continued to prevent his alternating moods?
A. Anxiolytics
C
B. Mood stabilizers
C. Antidepressants
D. Antipsychotics
n
E. Stimulants
io
69. A 30 year old woman who suffered from depression a few years ago has recently spent
t
a substantial amount of money buying new clothes. She goes out almost every night
ua
with her friends. She would not allow any of her friends to choose the restaurant for
dinner as she believes she knows the best places to eat. She sleeps less than usual and
fills her days with as many activities as she can. What is the SINGLE most likely
al
diagnosis?
Ev
A. Mania
B. Depression
D. Borderline personality disorder
E. Hypomania
70. A 21 year old man was brought by his friends unconscious from a party where he was
said to have drank vodka. While he was being attended to by the doctor in the
emergency department, he became conscious and said the green tie the attending
doctor was wearing was talking to him. On examination, his pupils were dilated. What
substance could this patient have taken?
A. Cocaine
B. Alcohol
C. Heroin
D. Cannabis
E. LSD
1296
71. A 38 year old woman who gave birth 6 weeks ago presents to her local GP surgery with
her husband. She describes 'crying all the time' and 'not bonding' with her baby. She is
worried about baby's health constantly and she is unsure if is able to cope with this
new change in her life. What is the SINGLE most likely diagnosis?
A. Postpartum blues
B. Postnatal depression
D. Anxiety disorder
E. Obsessive compulsive disorder (OCD)
72. A 10 year old boy with behavioural problems is taken to the clinic by his parents.
During the appointment, the boy barks and shouts expletives. He is constantly blinking
his eyes and unable to sit still. What is the SINGLE most likely diagnosis?
B. Cotard syndrome
y
C. Rett syndrome
op
D. Ekbom syndrome
E. Tourette’s syndrome C
73. A 26 year old man strongly believes that every elderly man he meets is likely to be his
father. Although they look different, he is sure it is his father wearing a different
disguise. What is the SINGLE most likely kind of delusion this man is suffering from?
n
io
A. Persecutory delusion
B. Erotomania
t
C. Grandiose delusions
ua
E. Delusion of reference
al
74. A 68 year old woman has been admitted with poor appetite, weight loss, poor
concentration and self neglect for 3 weeks. She has not been eating or drinking
Ev
adequately and has rarely left her bed. She expresses suicidal ideas and hears voices
telling her she is worthless. She has been on antidepressant therapy for the past 3
months with no improvement. What is the SINGLE most appropriate management?
A. Additional antidepressants
B. Cognitive behavioural therapy
C. Interpersonal therapy
D. Electroconvulsive therapy
E. Antipsychotics
75. A 28 year old woman complains of hearing strange voices in her bedroom as she is
falling asleep in the night. She says there is no one in the room except for her. She is
otherwise healthy and without mental illness. What is the SINGLE most likely
diagnosis?
B. Cotard syndrome
1297
C. Hypnagogic hallucinations
D. Capgras syndrome
E. Othello syndrome
76. A 19 year old man accuses his friend of making his right arm swing out to hit a stranger
at the park. There is no evidence of this as his friend was at home at that time. What is
the SINGLE most appropriate term to describe his condition?
A. Delusion of control
B. Persecutory delusion
E. Thought insertion
77. A 29 year old man was has been severely depressed over the last 3 years now believes
that he does not exist and never existed in this world. He has poor eye contact and
speaks softly. He says that people around him are unable to listen and see him because
he is inaudible and invisible. What SINGLE kind of delusion is he suffering from?
y
op
C
n
78. A 27 year old woman finds herself with palpitations and dizziness whenever she is in a
io
meeting at the office. She is very self-conscious and feels that her colleagues are
judging her in a harsh way in meetings. She has been asked to present in one of the
t
meetings but she called in sick to avoid being criticised. What is the SINGLE most likely
ua
diagnosis?
A. Agoraphobia
al
B. Generalized anxiety disorder

C. Panic disorder
Ev
D. Depression
E. Social phobia
79. A 24 year man finds it difficult to come out of a room without having to turn the light
switch off and on 3 times. He has tried more than several times to go out of the room
without having to do this particular compulsion however he still returns to the room
feeling agitated that it was not done. What is the SINGLE most appropriate
management?
A. Cognitive behavioural therapy

C. Antipsychotics
D. MAO inhibitors
E. Electroconvulsive therapy (ECT)
80. A 33 year old man tries not to go outside his house because he thinks that people will
look at him and talk about him. He finds difficulty when talking with his peers in a
1298
restaurant or under social settings. He avoids these situations as they cause him
distress. What is the SINGLE most likely diagnosis?
A. Agoraphobia
C. Panic disorder
D. Adjustment disorder
E. Social phobia
81. A 71 year old woman looks disheveled, unkempt and with poor eye contact. She has
recently lost her husband 2 months ago. She feels hopeless and has been tearful all
week. Which SINGLE option describes her condition?
A. Anxiety
B. Hallucinations
C. Mania
D. High mood
E. Low mood
y
op
82. A 33 year old man with a history of severe depression says his insides are rotting and
nobody has bothered to bury him. He feels the world no longer exist and nothing
matters. His gaze is always downwards and has barely any eye contact with anyone.
C
What SINGLE best term describes his condition?
n
io
t
ua
83. A 24 year old male on remand in prison for murder is referred by the prison doctor. He
is noted to be behaving oddly in prison and complains of hallucinating. He has a
al
previous history of IV drug abuse. On questioning, he provides repeated wrong

answers to questions nonetheless, his answers are in the correct category. An example,
Ev
when asked who is the prime minister of England, he answers Bill Clinton. What is the
A. Capgras syndrome
B. Cotard syndrome
C. Ganser syndrome
D. Somatization disorder
E. Hypochondriasis
84. A 18 year old boy was recently sent to juvenile detention center after he set his
father’s car on fire. He lacks remorse for setting the car on fire and says he would do it
again if he had the chance to. He has always found it difficult to conform to social rules
and has no regard for the rights of others. What is the SINGLE most likely diagnosis?
A. Acute psychosis
B. Antisocial personality disorder
C. Mania
1299
E. Schizophrenia
85. An 18 year old girl with a body mass index of 17.8 kg/m2 has bilateral parotid swelling
with thickened calluses on the dorsum of her hand. What is the SINGLE most likely
diagnosis?
A. Bulimia nervosa
B. Anorexia nervosa
D. Mumps
E. Sarcoidosis
86. A 44 year old man is very depressed and miserable after his wife’s death 6 months ago.
He sees no point in living now that his wife is not around. He feels regret and wishes he
never existed. He refuses any medical help offered. His son has brought him to the
emergency department. The son mentions that he can not deal with the father’s
depression any longer as he has a job and family that to attend to. What is the SINGLE
y
A. Voluntary admission to psychiatric ward

B. Compulsory admission under Mental Health Act
op
C
D. Alternate housing
E. Electroconvulsive therapy
n
io
t
ua
feeling agitated that it was not done. He recognizes that he has a problem and is willing
to see a psychiatrist. What is the SINGLE most accurate term that describes this
situation?
al
Ev
C. Thought block
D. Panic attack
E. Insight
88. A 30 year old woman comes to clinic in tears trying to describe the constant irritability
she is in when dealing with her 2 small children. She describes herself as easily startled.
She is unable to concentrate for long but attributes it to poor sleep as she often gets
nightmares of a house fire. Her husband died in a house fire while she was sleeping in
the other room last year. What is the SINGLE most appropriate management?
A. Rassurance
B. Relaxation therapy
C. Quetiapine
D. Lofepramine
E. Fluoxetine
1300
89. A 19 year old female is brought to the hospital by her parents. They are concerned
about her weight. Her body mass index is 12.1 kg/m2. She has a mildly depressed
mood and has low self-esteem. She has amenorrhoea. She has reduced her food intake
in the past couple of months. She has a blood pressure of 70/50 mmHg and a heart
rate of 44 beats/minute. What is the SINGLE most appropriate management?
A. Start antidepressants
B. Family counselling
C. Social service
D. Admission to the psychiatry ward
E. Admission to the medical ward
90. A 32 year old schizophrenic lady complains that she hears voices saying “she is evil”.
What is the SINGLE most likely type of hallucinations involved?

y
op
91. A 18 year old male washes his hands 6 times every time he uses the toilet. On his way
C
out of the toilet, he has to switch off the light, turn it back on and turn it off once
more. What is the SINGLE most appropriate management?
n
A. Psychodynamic therapy
io
B. Electroconvulsive therapy (ECT)

C. Antipsychotics
t
D. Cognitive behavioural therapy (CBT)

ua
E. Psychotherapy
92. A 68 year old man comes in to A&E confused and with a coarse tremor. As the
al
emergency doctor is taking a history, he becomes unconscious. Which of the following

medications could account for his symptoms?
Ev
A. Haloperidol
B. Diazepam
C. Fluoxetine
D. Imipramine
E. Lithium
93. A 42 year old man with a history of bipolar disorder is noted to have high serum levels
of lithium and profound hypokalaemia on routine examination. He was recently
diagnosed with essential hypertension and his GP had started him on an
antihypertensive medication. What is the SINGLE most likely cause of the recent
findings?
A. Atenolol
B. Captopril
C. Ramipril
D. Spironolactone
1301
E. Bendroflumethiazide
94. A 22 year old woman was brought to the A&E by her friends. She presents with
tremors. On examination, she was found to have a temperature of 37.4°C and her
pupils dilated. She says when she closes her eyes, she can see colours. What is the
SINGLE most likely drug that has taken?
A. Amphetamines
B. Lysergic acid diethylamide (LSD)
C. Cocaine
D. Heroine
E. Ecstasy
95. A 45 year old woman has been extensively investigated for a lump she believes to be
cancer. All investigations done show that the lump is unlikely to be cancer however she
is not convinced and does not think the doctors are taking her seriously. She has
demanded for another referral. What is the SINGLE most appropriate term that
describes her condition?
y
op
A. Munchausen's syndrome
B. Munchausen’s by proxy
C. Hypochondriasis
C
D. Malingering
E. Conversion disorders
n
96. A 34 year old man suffering from schizophrenia laughs inappropriately while talking
io
about his father’s death with his siblings. What is the SINGLE most appropriate term
that describes this?
t
ua
A. Flight of ideas
B. Flat affect
C. Emotional liability
al
D. Incongruent affect
Ev
97. A 28 year old schizophrenic man refuses to let his father into the house because he has
the delusion that his father has been replaced by an identical looking impastor. He
easily recognised other family members but would misidentify his father only. What is
the SINGLE most likely condition he is suffering from?
A. Capgras syndrome
B. Ganser syndrome
C. Todd's syndrome
E. Cotard syndrome
98. A 33 year old man who lives with his mother, always thinks when the traffic lights turn
red, his mother is calling him to come home. This is followed by his actions to drive
back home. What is the SINGLE most likely diagnosis?
A. Obsessive compulsive disorder (OCD)
1302
B. Generalised Anxiety Disorder (GAD)
C. Schizophrenia
D. Bipolar disorder
E. Cyclothymia
99. A 33 year old schizophrenic man hears people only when he is about to fall asleep.
What is the SINGLE most likely phenomenon?
A. Hypnopompic hallucinations
B. Hypnagogic hallucinations
C. Hippocampal hallucinations
D. Delirious hallucinations
E. Auditory hallucinations
100. A 30 year old man complains of episodes of hearing music and threatening voices
within a couple of hours of heavy drinking with his friends at a friends birthday party.
y
A. Delirium tremens
op
B. Wernicke’s encephalopathy
C. Korsakoff’s psychosis
D. Alcohol hallucinosis
C
E. Temporal lobe dysfunction
n
and fear. She notices her hands shake when they occur. These episodes occur almost
io
everyday and sometimes can wake her from her sleep. She has no previous psychiatric
disorder and is not on any medications. What is the SINGLE most likely diagnosis?
t
ua
B. Panic disorder
al
D. Agoraphobia
Ev
102. A 52 year old woman has been depressed ever since her husband died half a year ago.
She was started on amitriptyline by her GP 3 months ago to help battle her depression.
She now feels much better and sleeps well. She still think about her husband
occasionally and the thoughts bring her mood down but she has drastic improvements
as compared to a few months ago. She wants to know if she can stop medication.
What is the SINGLE best advice to give her?
A. Stop amitriptyline and start cognitive behavioural therapy (CBT)

B. Stop amitriptyline and start bereavement counselling
C. Stop amitriptyline and start psychoanalysis
D. Stop amitriptyline and review in 4 weeks
E. Continue amitriptyline for another 3 more months
103. A 37 year old man was recently sent to jail for breaking all the windows of a shop with
his bat. When the manager tried to stop him, he hit the manager on the head. He has a
history of many convictions and has been imprisoned many times. He finds it difficult
1303
to keep close relationships. He has 2 boys with his ex--wife but does not contact them.
What is the most SINGLE most likely diagnosis?

B. Schizophrenia
C. Avoidant personality disorder
D. Histrionic personality disorder
E. Antisocial behavior disorder
104. A 35 year old male is bitterly annoyed with everyone around him. He complains that
they are putting ideas into his head. What is the SINGLE most likely phenomenon?
A. Thought block
E. Thought echo
y
105. A 64 year old woman has been brought by her son for psychiatric evaluation. She says
op
that she has stopped living with her husband because she is convinced that it is
someone else posing to be him. What is the SINGLE most likely condition she is
suffering from?
C
A. Delusion of reference
B. Delusion of control
n
C. Cotard syndrome
io
D. Delusion of persecution
E. Capgras syndrome
t
ua
106. A 21 year old woman was brought to the Emergency Department by her boyfriend. She
has many self inflicted superficial lacerations on her forearm. She is distressed and
constantly says her boyfriend is going to end the relationship. She denies trying to end
al
her life. What is the SINGLE most likely diagnosis?

Ev
A. Acute psychosis
E. Schizophrenia
107. A 33 year old women in the psychiatric ward diagnosed with schizophrenia, complains
that she is unable to think straight because the nurse is stealing her thoughts. What is
the SINGLE most likely phenomenon?
A. Thought block
E. Thought block
1304
108. A 30 year old schizophrenic female attacks her mother believing that aliens have
replaced her with an exact double. What is the SINGLE most likely condition she is
suffering from?
A. Capgras syndrome
B. Ganser syndrome
C. Todd's syndrome
D. Frégoli delusio
E. Cotard syndrome
109. A 17 year old girl who was ‘fine’ until her boyfriend ended their relationship. Out of
anger, she took 10 tablets of paracetamol after drinking alcohol. She is brought into
A&E by her mother. What is the SINGLE most appropriate next course of action?
A. Refer to psychiatry
B. Liver transplant
C. Refer to GP
D. Discharge home. No referral needed.
y
E. Start N-acetylcysteine
110.
op
A 22 year old man is distressed that he hears the voice of his deceased uncle telling
him that he is being spied on. He feels low in mood and anxious. He has not left the
C
house for 2 weeks and has recently starting to drink increasing quantities of alcohol
due to his anxiety. His speeches are interrupted with silence for a few seconds
followed by topics unrelated to what was being discussed. He feels he is no longer in
n
control of his own body and thoughts. What is the SINGLE most suitable medication to
io
treat his symptom?

t
A. Diazepam
ua
B. Disulfiram
C. Fluoxetine
D. Lithium
al
E. Olanzapine
Ev
111. A 37 year old woman who delivered 3 days ago is now concerned about her mood. She
has trouble sleeping and feels generally anxious and tearful. She is unable to explain
why she is crying all the time. She has no history of mental health disorders in the past.
A. Citalopram
B. Cognitive behavioral therapy (CBT)
C. Fluoxetine
D. Reassurance
E. Admit mother to mother and baby unit
112. A 36 year old woman contacts the police to notify them that she was responsible for a
recent disastrous flood which had resulted in loss of lives. What is the SINGLE most
likely kind of delusions she is suffering from?
B. Frégoli delusion
1305
C. Delusion of guilt
113. A 52 year old woman speaks rapidly without any pause and ignores interruptions. She
barely even pauses to take enough breaths. What is the SINGLE best term to describe
this kind of speech?
A. Flight of ideas
B. Broca’s aphasia
C. Wernicke’s aphasia
D. Pressure of speech
E. Verbal dysphasia
114. A 36 year old woman was recently admitted to a psychiatric ward. She believes that
the staff and other patients know exactly what she is thinking all the time. What is the
SINGLE most likely phenomenon
y
A. Thought insertion
op
B. Thought withdrawal
C. Thought block
D. Thought broadcasting
C
E. Hallucination
115. A 23 year old single male was brought to emergency department by his father
n
exhausted and frightened. His father tells you that his son, who was previously healthy,
io
had, for no apparent reason, a sudden attack of fear, dizziness, sweating, palpitations
and the feeling that his heart is going to stop beating. The symptoms started to
t
decrease gradually after about 10 minutes. Which is the SINGLE most likely?
ua
A. Panic attack
B. Delirious state
al
C. Alcohol withdrawal
D. Social phobia
Ev
116. A 33 year old female presents to her GP because of low moods. She has difficulty
sleeping and feels tired at work. She refuses to go out with her friends and rather
spends time resting on her bed. She is eating less and has lost 8 kg in the last 10
weeks. A year ago, she was productive, full of energy, optimistic, needed very little
sleep and always wanted to go out. Her BMI is 27. What is the SINGLE most likely
diagnosis?
A. Hypomania
B. Bipolar disorder
C. Borderline personality disorder
D. Depression
E. Mania
1306
117. A 20 year old boy is brought by his parents to the emergency department. He is
agitated and euphoric. The parents suspect that he has taken drugs. Examination
reveals a perforated nasal septum. What is the SINGLE most likely drug that was taken?
A. Heroine
B. Cocaine
C. Ecstasy/MDMA/amphetamine
D. Alcohol
E. Opioids
118. A 38 year old women believes that a famous politician has been sending her flowers
every day and is in love with her. She says that he drops hints that he loves her when
he speaks publicly on television. The famous politician has had no contact with this
lady. What is the SINGLE most likely diagnosis?
A. Pyromania
B. Erotomania
C. Rejected stalker
y
D. Trichotillomania
op
E. Grandiosity
119. A 27 year old man presents with symptoms characterized by alternating mood swings
C
associated with flight of ideas, and overactivity. Three months ago he had low moods
with lack of energy. What is the SINGLE most likely diagnosis?
n
A. Bipolar affective disorder
io
B. Dysthymia
C. Mania
t
D. Hypomania
ua
E. Cyclothymia
120. A 55 year old man is brought to the GP surgery by his wife for a review of a growth on
al
his forehead. His wife wants the growth removed but he refuses and says that the
growth helps him think clearly. What is the SINGLE most appropriate next course of
Ev
action?
A. Assess his mental capacity to refuse treatment

B. Remove the lesion
C. Refer to A&E
D. Perform a Mini Mental Status Examination (MMSE)
E. Refuse surgery and review in 2 weeks
121. A 56 year old chronic alcoholic man wants to attend his daughter’s wedding in 2 weeks
and does not want to be drinking during the wedding. He says he is determined to quit
drinking alcohol but wants extra help. What is the SINGLE most appropriate
medication?
A. Acamprosate
B. Refer to clinical psychologist
C. Vitamin B12
D. Desipramine
1307
E. Refer to community mental health support group
122. A 35 year old man is seen by his psychiatrist for severe depression. He says that the
world has ended and is no longer real. He thinks that he no longer exist in this world.
He barely has eye contact with the psychiatrist. What is the SINGLE most appropriate
diagnosis?
B. Hypochondriasis
E. Capgras syndrome
123. A 32 year old lady has recently become more active over the past year. She sleeps less
and recently bought a house and 2 new cars. She notices that her sex drive has
increased. She often starts a task but is not able to finish it as she has difficulty in
focusing on one task alone. What is the SINGLE most likely diagnosis?
y
A. Bipolar disorder
op
B. Mania
C. Hypomania
D. Schizophrenia
C
E. Attention deficit hyperactivity disorder (ADHD)
124. A 23 year old man feels anxious and agitated when faced with stress. He has an
n
interview in 3 days and would like some help in relieving his symptoms for the
io
interview. What is the SINGLE most appropriate management?

t

ua
B. Cognitive Behavioural Therapy

C. Propranolol
D. Diazepam
al
E. Rebreath into paper bag

Ev
125. A 33 year old schizophrenic says the following. “Life is unfair, I eat air, lawn chair, I like
fairs, fairs have food, it must be good, in adulthood, I misunderstood”. What term
describes this patient’s speech?
A. Neologism
B. Pressure of speech
C. Broca’s aphasia
D. Wernicke’s aphasia
126. A 62 year old woman who had a repair of strangulated femoral hernia 2 days ago
becomes aggressive and confused. This is followed by a seizure. Her blood tests show:
Haemoglobin 129 g/L

Gamma glutamyl transferase (yGT) 120 u/L
1308
A. Electrolyte imbalance
B. Delirium tremens
D. Korsakoff’s psychosis
E. Hypoglycaemia
127. A 24 year old woman has severe depression 3 months after the birth of her first child.
She is breastfeeding but has not cleaned herself or her newborn child for the last 3
weeks. She has lost interest in her hobbies and keeps crying. Her husband is concerned
and has brought her to the hospital. However, she is convinced that her husband and
her family wants to take her baby away and is likely to kill her. What is the SINGLE
A. Fluoxetine
B. Citalopram
y
op
D. Electroconvulsive Therapy (ECT)
E. Haloperidol C
128. A 29 year old women has been taking selective serotonin reuptake inhibitors for the
past 6 months for depression after the death of her husband 10 months ago. She feels
her symptoms have improved and has decided to stop her medications. Several weeks
n
after discontinuing her medications, she feels she has developed pancreatic cancer
io
similarly to her late husband. What is the SINGLE most appropriate next step in
management?
t
ua
A. Restart selective serotonin reuptake inhibitors

B. Start on a tricyclic antidepressant
C. Neuropsychiatric analysis
al

E. Start antipsychotics
Ev
129. A 62 year old schizophrenic man is brought to the Emergency Department in an

agitated state. He is lashing out violently and throws any equipment around him at the
hospital staff. He seems to be hearing voices which are causing him distress. Which
drug due to it’s relative lack of autonomic side effects is a drug of choice in the
management of agitation in this man?
A. Haloperidol
B. Diazepam
C. Risperidone
D. Clozapine
E. Olanzapine
130. A 44 year old alcoholic was admitted for alcohol intoxication. He has been treated and
he is now planned for discharge. He admits to not being able to spend a day without
drinking. Which of the following statement would show that this man is still dependant
on alcohol?
1309
A. Drinks 10 units of alcohol a week
B. Drunk driving
C. Does not feel remorse after drinking
D. Drinks wine to help him sleep
E. Drinking alcohol immediately after waking up
y
op
C
n
t io
ua
al
Ev
1310
1. A 38 year old man has disturbing thoughts about his house being infected by germs.
He is anxious about safety and checks the locks of his doors repeatedly before going
to bed. He has been washing his hands every time he touches the lock. This can be 5
to 10 times an hour. What is the SINGLE most appropriate management?
A. Antidepressant
B. Antipsychotic
C. Anxiolytic
E. Psychodynamic psychotherapy
The diagnosis here is obsessive-compulsive disorder (OCD). Exposure and response

prevention (ERP) is included in cognitive behavioural therapy (CBT) in treatment for
those who present with OCD. The method is predicated on the idea that a
therapeutic effect is achieved as subjects confront their fears and discontinue their
escape response. In this case, the patient would be exposed to his feared stimulus,
and would refuse to respond with any safety behaviors.
y
SSRIs are also a treatment choice for OCD. But as this is only a mild functional
op
impairment, ERP would be a more appropriate answer. NICE CKS has very specific
guidelines for obsessive-compulsive disorder (OCD)
C
In the initial treatment of adults with OCD, low intensity psychological treatments
(including Exposure and Response Prevention (ERP) ) should be offered if the
patient's degree of functional impairment is mild and/or the patient expresses a
n
preference for a low intensity approach. Low intensity treatments include brief
io
individual or group CBT (including ERP)

t
Adults with OCD with mild functional impairment who are unable to engage in low
ua
intensity CBT (including ERP), or for whom low intensity treatment has proved to be
inadequate, should be offered the choice of either a course of an SSRI or more
intensive CBT (including ERP).
al

Ev
A common, chronic condition, often associated with marked anxiety and depression,
characterized by ‘obsessions’.
It is characterized by recurrent obsessions or compulsions that are recognized by the

individual as unreasonable. Obsessions are anxiety-provoking, intrusive thoughts,
commonly concerning contamination, doubt, guilt, aggression, and sex. Compulsions
are peculiar behaviors that reduce anxiety, commonly hand-washing, organizing,
checking, counting, and praying.
Management
CBT is recommended by NICE, but essentially takes a behavioural approach, including
exposure and response prevention (ERP).
1311
SSRIs (licensed): escitalopram, fluoxetine, sertraline or paroxetine should be
considered first-line (no clear superiority of any one agent). Other (unlicensed) agents
include citalopram
For PLAB, electroconvulsive therapy (ECT) would be the answer for treatment of OCD,
If the patient is suicidal or severely incapacitated
2. A 57 year old man had a myocardial infarction 6 months ago. He has been having low
moods since then and a diagnosis of moderate depression has been established.
Which is the SINGLE most appropriate medication to start him on?

B. Tricyclic antidepressants
C. Monoamine oxidase inhibitors
D. Benzodiazepam
E. Mood stabilizer
For majority of patients with moderate depression, selective serotonin reuptake
y
inhibitors (SSRIs) are considered first-line
op
If this question gave you options of SSRIs, Sertraline would be the best answer to pick
as sertraline has good safety profile with patients with myocardial infarction. The
other antidepressants have not been studying enough in context of myocardial
C
infarction however citalopram has gained popularity and is also considered safe for
use in patients with depression with a history of myocardial infarction
n
Citalopram and fluoxetine are the preferred SSRIs if there is no relevant past medical
io
history.
t
3. A 27 year old woman is afraid to go out of her house into public places. Everytime she
ua
travels using public transport she becomes breathless and has palpitations. What is
al
A. Social phobia
B. Claustrophobia
Ev
C. Arachnophobia
D. Acrophobia
E. Agoraphobia
The answer here is agoraphobia as she has a fear of going out into the open.
Agoraphobia → Fear of open spaces

Social phobia (Social Anxiety Disorder) → persistent fear and anxiety about one or
more social or performance situations
Claustrophobia → irrational fear of confined spaces
Arachnophobia → fear of spiders
Acrophobia → fear of heights
Agoraphobia
Means "fear of open spaces"
1312
Many people assume agoraphobia is simply a fear of open spaces, but it's actually a
more complex condition. Someone with agoraphobia may be scared of:
• travelling on public transport
• visiting a shopping centre
• leaving home
•
A clinical definition is "a fear of open spaces, especially those in which getaway may
be difficult, which leads to avoidance of the situation". Being in these provoking
situation usually leads to an anxiety attack. It is also associated with places or
situations where
escape may be difficult or embarrassing (e.g. of crowds, public places, travelling alone
or away from home).
If someone with agoraphobia finds themselves in a stressful situation, they'll usually

experience the symptoms of a panic attack, such as:
• palpitations
• hyperventilating
• sweating
y
op
Some patients can manage to continue their daily lives (with difficulty), whilst others
are severely affected and may even become incapacitated.
C
4. A 37 year old woman believes that her neighbours have been using her shower while
she is away at work. She is convinced that they dry the bathroom and escape just
before she goes into the bathroom. Her husband comes to share the same belief and
n
informs the police. What is the SINGLE most appropriate term for these symptoms?
io
A. Capgras syndrome
t
B. Cotard syndrome
ua
C. Persecutory delusions
D. Folie à deux
E. Munchausen's syndrome
al
Folie à deux is the best term to describe this. It is symptoms of a delusional belief and
Ev
hallucinations that are transmitted from one individual to another usually by two
people in a close relationship like in this case, husband and wife.
Folie à deux → is French for “madness of two”. It is a situation where two people
with a close relationship share a delusional belief. This arises as a result of a psychotic
illness in one individual with development of a delusional belief, which comes to be
shared by the second. The delusion resolves in the second person on separation, the
first should be assessed and treated in the usual way.
Capgras syndrome → A type of delusional misidentification in which the patient

believes that a person known to them has been replaced by a ‘double’ who is to all
external appearances identical, but is not the ‘real person’.
Cotard syndrome → is a presentation of psychotic depressive illness characterised by

a combination of severely depressed mood with nihilistic delusions. The patient may
state that he is already dead and should be buried. He may state that his insides have
1313
stopped working and are rotting away, or that he has stopped existing altogether.
Persecutory delusion → is a delusional belief that one’s life is being interfered with in
a harmful way. It refers to false beliefs or perceptions in which a person believes that
they are being treated with malicious intent, hostility, or harassment despite
significant evidence to suggest otherwise. This may occur in the context of being
tormented, followed, or spied on.
Munchausen's syndrome → also known as factitious disorder. Patients intentionally

falsify their symptoms and past history and fabricate signs of physical or mental
disorder with the primary aim of obtaining medical attention and treatment. The
diagnostic features are the intentional and conscious production of signs,
falsification, or exaggeration of the history and the lack of gain beyond medical
attention and treatment.
5. A 24 year old depressed man has neglected his personal hygiene and physical health.
He denies the existence of his bowels and believes that his bowels are blocked. He
also believes that his limbs are missing and that no one cares about it. What SINGLE
y
kind of delusion is he suffering from?
op
C
n
io
Nihilistic delusions → is the delusional belief that the patient has died or no longer
exists or that the world has ended or is no longer real. Nothing matters any longer
t
and continued effort is pointless. It is a feature of psychotic depressive illness. Patient

ua
may believe that he/she is dead and may ask people to bury them.
Delusion of guilt → involves feeling guilty or remorseful for no valid reason. An

al
example would be someone that believes they were responsible for a war in another
country or hurricane damage in another state. The object of delusion believes that
Ev
they deserve to be punished for their sins.
Frégoli delusion → is when a person holds a delusional belief that different people
are in fact a single person who changes appearance or is in disguise.
Clang association → is an abnormality of speech where the connection between

words is their sound rather than their meaning. May occur during manic flight of
ideas. Clang associations generally sound a bit like rhyming poetry, except that the
poems don't seem to make any sense. Example, one may say “systematic,
sympathetic, quite pathetic, apologetic, paramedic, your heart is prosthetic.
1314
6. A 26 year old woman has a history of bipolar disorder for 10 years and is taking
lithium for it. She has been symptom free for the past 4 years. She is now planning
her pregnancy and wants to know whether she should continue to take lithium. What
A. Continue lithium at the same dose and stop when pregnancy is confirmed
B. Continue lithium during pregnancy and stop when breast feeding
C. Reduce lithium dosage but continue throughout pregnancy
D. Reduce lithium gradually and stop before pregnancy is confirmed
E. Switch to sodium valproate
Despite problems with tolerability, lithium still remains the gold standard in the
treatment of bipolar affective disorder.
Lithium is teratogen. If a woman taking lithium is planning a pregnancy, and is well

and not at high risk of relapse, she should be advised to stop taking the drug because
of the risk of cardiac malformations in the fetus. This should be done by gradual
discontinuation before conception.
y
op
Lithium should be reduced gradually over 1–3 months.
7. A 22 year old woman was brought to the emergency department by her boyfriend
C
with her fist bleeding after punching a mirror. She is distressed because he wants to
end the relationship. Scars of old cuts on her forearms was noticed during a physical
examination. She denies trying to end her life. What is the SINGLE most likely
n
diagnosis?
io
A. Acute psychosis
t
B. Borderline personality disorder

ua
D. Schizoid personality
al
Borderline Personality Disorder

Ev
Usually characterized by mood swings, marked impulsivity, unstable relationships,

and inappropriate anger. They can be very dramatic. They are usually attention
seekers and may have multiple self-inflicted scars. They may threaten to commit
suicide but do not actually attempt to do so.
8. A 22 year old man was found overdosed on heroin. He has decreased respiratory rate
and has lost consciousness. What is the SINGLE most appropriate management?
A. Benzodiazepines
B. Diazepoxide
C. Naloxone
D. Methadone
E. Disulfiram
Opiates overdose is treated with naloxone. It is given intravenously and repeated

every 2 minutes until patient’s breathing is adequate.
1315
9. A 45 year old woman presents with complaints of abdominal pain and blood in the
stool. She brings the stool sample from home but has never been able to produce a
sample at the hospital. A urinalysis was done which was negative. Her blood test are
normal. This is the third time she is presenting to the hospital in the last month. On
examination, multiple scars on the abdomen consistent with laparoscopies are seen.
She insists on getting further investigations although no abnormalities are found.
B. Hypochondriasis
E. Malingering
Munchausen's syndrome would fit best. Likely she is inserting blood into her stools at
home for medical attention. This can easily be done with a pin prick on the finger.
y
op
C
n
Hypochondriasis → is the persistent belief in the presence of an underlying serious
io
DISEASE, e.g. cancer or HIV. The patient again refuses to accept reassurance or
negative test results.
t
ua
Somatization disorder →The experience of bodily symptoms with no physical cause

for them, with presumed psychological causation.. The patient refuses to accept
reassurance or negative test results
al
Conversion (dissociative) disorders → typically involves loss or disturbance of normal

Ev
motor or sensory function which initially appears to have a neurological or other

physical cause but is later attributed to a psychological cause. The patient does not
consciously feign the symptoms or seek material gain. Patients may be indifferent to
their apparent disorder.
Malingering → Deliberately falsifying the symptoms of illness for a secondary gain

(e.g. for compensation, to avoid military service, or to obtain an opiate prescription).
10. A 29 year old women diagnosed with schizophrenia is complaining that the children
playing outside her garden can hear her thoughts. She says they know exactly what
she is thinking at all times of the day. What is the SINGLE most likely phenomenon?
A. Thought block
E. Thought block
1316
Thought broadcasting is the delusional belief that one’s thoughts are accessible
directly to others. It is found in schizophrenia.
Schizophrenia
Features
Auditory hallucinations:
• third-person auditory hallucinations → voices are heard referring to the
patient as ‘he’ or ‘she’, rather than ‘you’
• thought echo → an auditory hallucination in which the content is the
individual’s current thoughts
• voices commenting on the patient's behaviour
Thought disorder:
• thought insertion → The delusional belief that thoughts are being placed in
the patient’s head from outside
y
• thought withdrawal → The delusional belief that thoughts have been 'taken
op
out' of his/her mind
• thought broadcasting → The delusional belief that one’s thoughts are
accessible directly to others
C
• thought blocking → a sudden break in the chain of thought.
Passivity phenomena:
n
• bodily sensations being controlled by external influence
io
Delusional perceptions
t
• a two stage process where first a normal object is perceived then secondly
ua
there is a sudden intense delusional insight into the object's meaning for the
patient e.g. 'The traffic light is green therefore I am the King'.
al
11. A 38 year old woman with episodes of mania followed by depression was started on
medication. Improvement was seen and she no longer complains of these episodes.
Ev
What is the SINGLE most likely medication that she was started on?
A. Fluoxetine
B. Lithium
C. Lorazepam
D. Haloperidol
E. Amphetamine
Bipolar affective disorder (commonly known as manic depression)

Classically, periods of prolonged and profound depression alternate with periods of
excessively elevated and irritable mood, known as mania.
Most people who battle with the effects of the disorder would rather live a normal
life, free from the unpredictability of mood swings, which most of us take for granted.
The symptoms of mania characteristically include:

• Decreased need for sleep
1317
• Pressured speech
• Increased libido
• Reckless behaviour without regard for consequences
• Grandiosity
• More talkative than usual
These symptoms of mania would alternate with depression
Treatment
Mood stabilizers (Lithium)- Despite problems with tolerability, lithium still remains
the gold standard in the treatment of bipolar affective disorder.
12. A couple attends a marriage counselling session because of marital problems. The
wife states that her husband is having affairs although she has no proof of this. The
husband states that she is “insane” because she is having him followed by a private
detective and she is overly preoccupied about him being unfaithful. She goes through
his personal belongings almost every day to look for signs of infidelity. Her actions are
putting considerable strain on their marriage. What is the SINGLE most likely
y
syndrome she is suffering from?
B. Cotard syndrome
op
C
C. Capgras syndrome
D. Ekbom syndrome
E. Othello syndrome
n
io
Othello Syndrome → is a type of delusional jealousy, marked by suspecting a faithful

partner of infidelity like cheating, adultery or having an affair. The patient may
t
attempt monitoring his spouse or partner.

ua
al

Ev

Ekbom syndrome → Also known as restless legs syndrome. An unpleasant, often

painful sensations in the legs, particularly on sleep onset. Significantly interferes with
the ability to get to sleep.
13. A 21 year old girl looking unkempt, came to the hospital asking for painkillers for her
abdominal pain. She is agitated, and looks malnourished. She is also sweating,
shivering and complains of joint pain. What is the SINGLE most likely substance
misuse?
1318
A. Alcohol
B. Heroin
C. Cocaine
D. LSD
E. Ecstasy
Agitation, nervousness, abdominal cramp, sweating, shivering, arthralgia are all

features of heroin withdrawal.
Opiates/opioids
The opiates are a group of chemicals are widely abused for their euphoriant and
anxiolytic properties. Heroin is the most frequently abused opiate.
Heroin
It is most commonly consumed by smoking (‘chasing’), but is also taken orally,
occasionally snorted, and parenterally by IV, IM, or subcutaneous
y
routes.
op
Dependent patients may describe limited euphoriant effects, with the drug being
mainly taken to avoid unpleasant withdrawals.
C
Acute medical problems associated with heroin use by any route include nausea and
vomiting, constipation, respiratory depression, and loss of consciousness with
n
aspiration (the cause of many fatalities).
io
Opiate dependency develops after weeks of regular use and is associated with an
t
unpleasant (but not generally medically dangerous) withdrawal syndrome.

ua
14. A 55 year old man has a firm belief that the headlines in the newspapers are written
especially for him. He believes that the authors of the newspaper articles who he has
al
never met are sending secret and significant messages that only he can understand.
What is the SINGLE most likely type of delusion that this man is suffering from?
Ev
Delusion of reference → is the false belief that insignificant remarks, events, or

objects in one's environment have personal meaning or significance. Example,
someone constantly gives him or her a special messages through the newspaper.
1319
Grandiose delusions → or delusions of grandeur is the fantastical beliefs that one is
famous, omnipotent, wealthy, or otherwise very powerful. They believe that they
have exceptional abilities or talents and keep praising themselves.
Delusion of control → is the false belief that another person, group of people, or
external force controls one's general thoughts, feelings, impulses, or behavior.
15. A 33 year old man with a family history of panic disorder has palpitations, tremors,
sweating and muscles tightness on 3 occasions in the last 6 weeks. His pulse rate is 85
bpm, BP is 120/80 mmHg. What is the SINGLE most appropriate long-term treatment
for him?
A. Diazepam
y
B. Olanzapine
op
C. Haloperidol
D. Fluoxetine
E. Alprazolam
C
He is suffering from panic disorder. An SSRI or cognitive behavioural therapy would
be appropriate. Fluoxetine is an SSRI.
n
io
Management of panic disorder

NICE recommend either cognitive behavioural therapy or drug treatment.
t
SSRIs are first-line. If contraindicated or no response after 12 weeks then imipramine

ua
or clomipramine should be offered
16. A 33 year old woman has been feeling down for the past one year. She feels fatigue
al
and is eating more than usual. Several times a week she would wake up during the
night and would not be able to go back to sleep. Occasionally, she hears voices of her
Ev
late husband who died two years ago. What is the SINGLE most likely diagnosis?
A. Obsessive compulsive disorder

B. Psychotic depression
C. Grieving
E. Hypomania
This affected individual has lost her husband. Depression should be something to
consider. The auditory hallucinations are signs that this woman is having some form
of psychosis. The most probable diagnosis here is psychotic depression.
Very commonly in PLAB they would give a scenario of a person having symptoms of
an atypical or typical depression plus having some form of hallucinations. In majority
of the cases, the answer to that scenario would be psychotic depression.
1320
17. A 64 year old man has recently suffered from an a myocardial infarction 5 months
ago. He has been having trouble sleeping and seems depressed. His regular
medications include aspirin, atorvastatin and ramipril. What is the SINGLE most
appropriate medication to start him on?
A. Lofepramine
B. Dosulepin
C. Citalopram
D. Amitriptyline
E. Phenelzine

If the question gives you options of SSRIs, sertraline would be the best answer to pick
y
use in patients with depression with a history of myocardial infarction.
op
Remember, both sertraline and citalopram are safe options for patients who have had
a recent MI. If both were present as options, pick Sertraline as there is more evidence
C
for its safe use for patients who have had recent MI.
Citalopram and fluoxetine are the preferred SSRIs if there is no relevant past medical
n
history.
io
18. A 28 year old woman comes in with her limbs paralysed after witnessing a car
t
accident. She cannot recall what just happened. What is the SINGLE most likely
ua
diagnosis?
al
B. Hypochondriasis
Ev
E. Malingering
Conversion (dissociative) disorders typically involves loss or disturbance of normal

consciously feign the symptoms or seek material gain. Memory loss, seizures, loss of
speech and paralysis can occur.


1321
Munchausen's syndrome →also known as factitious disorder. Patients intentionally

her mother passed away 2 months ago. She feels lethargic and has been crying more
often lately. What is the SINGLE most likely diagnosis?
C. Panic disorder
y
E. Major depression
Adjustment disorders
op
C
An adjustment disorder occurs when an individual is unable to adjust to or cope with
a particular stress or a major life event. They must occur within 1 (ICD-10) or 3
months (DSM-IV) of a particular psychosocial stressor, and should not persist for
n
longer than 6 months after the stressor (or its consequences) is removed
io
20. A 32 year old woman complains of abdominal pain, palpitations, unsteadiness, and
t
numbness of the lower limbs. Every investigation that is performed by the doctors
ua
come back normal. What is the SINGLE most likely diagnosis?
al
B. Hypochondriasis
Ev
E. Malingering
Somatization disorder is the experience of bodily symptoms with no physical cause

for them, with presumed psychological causation. All investigations would be normal.

Munchausen's syndrome →also known as factitious disorder. Patients intentionally

disorder with the primary
aim of obtaining medical attention and treatment. The diagnostic features are the
intentional and conscious production of signs, falsification, or exaggeration of the
history and the lack of gain beyond medical attention and treatment.
1322

21. A 24 year old woman is afraid to leave her house as whenever she goes out into the
open, she tends to have shortness of breath, palpitations and sweating. She only goes
out when her husband is with her. What is the SINGLE most likely diagnosis?
A. Social phobia
B. Claustrophobia
C. Depression
D. Panic disorder
E. Agoraphobia
y
op

C
n
io

t
Agoraphobia
ua
al

Ev

• leaving home
situations where
or away from home).

• palpitations
• sweating
1323
22. A 64 year old man has a firm belief that the person on the billboard outside his
window is sending a messages that are meant specifically for him. What is the SINGLE
most likely type of delusion that this man is suffering from?

y
op
C
n
io
t

ua
al

Ev
23. A 6 year old child is brought to the clinic by his mother. She says that his teacher
complains that he is easily distracted and interrupts others when it is their turn to
answer questions. His mother says that he is not able to do a particular task for a long
time and cannot play quietly. He is careless and often breaks things. What is the
A. Autism spectrum disorder

B. Dyslexia
D. Antisocial personality disorder
E. Oppositional defiant
Attention deficit hyperactivity disorder (ADHD) is characterized by the three core

symptoms of inattention, hyperactivity, and impulsiveness.
Clinical features
1324
Inattention: Careless with detail, fails to sustain attention, appears not to listen, fails
to finish tasks, poor selforganization, loses things, forgetful, easily distracted, and
avoids tasks requiring sustained attention.
Hyperactivity: fidgets with hands or feet, leaves seat in class, runs/climbs about,
cannot play quietly, ‘always on the go’.
Impulsiveness: Talks excessively, blurts out answers, cannot await turn,

interrupts others, intrudes on others.
24. A 24 year man finds it difficult to come out of his house without checking if he has
locked the door several times. When exits his house, he has to check it at least 3
times by pushing the door handle to confirm it is locked. He now wants help as he has
been doing this for a couple of years. What is the SINGLE most appropriate
management?
A. Exposure and response prevention (ERP)

y
C. Electroconvulsive therapy (ECT)
op
D. Antipsychotics
E. Desensitization C
n
io
escape response. In this case, the patient would be exposed to his feared stimulus
(locking the door just once and coming out of the house), and would refuse to
t
respond with any safety behaviors (checking the door again).

ua
al

Ev

1325
Management

include citalopram
25. A 29 year old man has been found in the park, drunk and brought to the emergency
department by ambulance. He recently lost his job and had a divorce 3 months ago.
He has intense feelings of feeling worthless and being a failure. He also hears voices
y
telling him he is worthless. What is the SINGLE most likely diagnosis?

op
C
C. Schizophrenia
E. Hypomania
n
io
This affected individual has lost his job and had a recent divorce. Depression should
be something to consider. The auditory hallucinations are signs that this man is
t
having some form of psychosis. The most probable diagnosis here is psychotic
ua
depression. Feeling worthless are in line with the delusions of guilt which are seen in
psychotic depression.
al
The other answers are unlikely to be correct:

Ev
Schizoid personality disorder → is a personality disorder characterized by a lack of

interest in social relationships, a tendency towards a solitary lifestyle,
Borderline personality disorder → Usually characterized by mood swings, marked

impulsivity, unstable relationships, and inappropriate anger. They are usually
attention seekers and may have multiple self-inflicted scars.
Schizophrenia → does not account for the history of the lost of job and divorce.
Feelings of worthlessness are also more in line with depression rather than
schizophrenia
Hypomania → describes a mild degree of mania where there is elevated mood but no
significant impairment of the patient’s day-to-day functioning
26. A 28 year old female who delivered 6 weeks ago feels sad and has no interest to
feeding the baby. She has been eating poorly and having difficulty sleeping. She feels
1326
weak throughout the day and has stopped taking the baby out of the house. She also
says that the baby has evil eyes. What is the SINGLE most likely diagnosis?
A. Postpartum blues
B. Postpartum depression
D. Schizophrenia
She has features of depression: feels sad, not eating well, difficulty sleeping, feeling
weak. On top of that she has delusional ideas: no interest to feed baby, she thinks
baby has evil eyes and not taking the baby out of the house. These points to
postpartum psychosis.
A key feature to look out for in PLAB is the words “evil eyes”. If mother has recently
delivered and thinks that her baby has evil eyes, pick the answer that has postpartum
psychosis. You are most likely to be correct.
y
Postpartum psychosis
op
Usually starts with postpartum depression. Classically, they would have thoughts of
harming their new born baby. She would have delusional ideas that the baby is
C
deformed, evil or otherwise affected in some way and she has intent to kill or harm
the baby
n
Onset usually within the first 2-3 weeks following birth
io
Management
t
Admission to hospital (specialist mother–baby unit if possible) is usually required

ua
For major affective disorder there is good evidence for ECT.

al
Comparison of Postpartum Blues , Postnatal Depression, Postpartum Psychosis

Ev
Postpartum Blues Postnatal Postpartum

Depression Psychosis
Onset Starts at two or Peaks at 3 to 4 Peaks at 2 weeks
three days after weeks postpartum postpartum
birth and lasts 1–2
days
Mother cares for Yes Yes Thoughts of
baby harming baby
Symptoms Mostly crying Symptoms of Psychotic
depression: symptoms
E.g. hears voices
Feels that she is saying baby is evil
not capable of
looking after her Insomnia
child
Disorientation
1327
Feels as if she will
not be a good Thoughts of
mother suicide
Tearful, Anxiety
Worries about
baby’s health
Treatment Reassurance and Antidepressants or In PLAB, answer

explanation CBT would be ECT
27. A 25 year old woman presents to the GP with low mood. She has an increased
appetite and has gone up 2 dress sizes. She also complains that she feels very tired
and often only gets out of bed in the afternoon despite sleeping early. What is the
y
A. Pseudo depression
op
B. Moderate depression
D. Dysthymia
C
E. Atypical depression
n
Atypical depression is a subtype of major depression or dysthymic disorder that
involves several specific symptoms, including increased appetite or weight gain,
io
sleepiness or excessive sleep, marked fatigue or weakness.

t
Atypical depressive episode

ua
Regarded as a subtype of depressive disorder, rather than a separate entity.

al
Clinical features
• Mood is depressed, but remains reactive (able to enjoy certain experiences
Ev
but not to ‘normal’ levels)

• Hypersomnia (sleeping more than 10 hours/day, at least 3 days/weeks, for at
least 3 months)
• Hyperphagia (excessive eating with weight gain of over 3kg in 3 months)
• ‘Leaden paralysis’ (feeling of heaviness in the limbs)
Epidemiology Onset usually in late teens and early twenties
28. A 23 year old woman has had several sudden onset episodes of palpitations,
sweating, nausea and overwhelming fear. On one occasion she was woken from sleep
and had the fear that she was going insane. She has no previous psychiatric medical
history and is not on any medication. What is the SINGLE most likely diagnosis?
B. Panic disorder
1328
D. Hypnophobia
It is quite difficult to differentiate generalized anxiety disorder with panic disorder.

People with generalized anxiety disorder feel anxious most days and often struggle to
remember the last time they felt relaxed. As soon as one anxious thought is resolved,
another may appear about a different issue. Panic disorder, however is where you
have recurring and regular panic attacks, often for no apparent reason similar to this
stem where she had several sudden onset episodes of panic.
Panic disorder
Panic disorder is classified as having 2 recurrent panic attacks, which are not
secondary to substance misuse, medical conditions, or another psychiatric disorder.
Frequency of occurrence may vary from many attacks a day to only a few a year.
Usually patients have a persistent worry about having another attack or
consequences of the attack.
y
Symptoms/signs
op
• Physical symptoms/signs related to autonomic arousal (e.g. tremor,
tachycardia, tachypnoea, hypertension, sweating)
• Concerns of death from cardiac or respiratory problems may be a major
C
focus, leading to patients presenting (often repeatedly) to emergency
medical services.
n
29. A 35 year old chronic alcoholic has been trying to stop his alcohol drinking habit. He
io
has been going for support meetings. He wants to know if there is a medication that
can help reduce his alcohol cravings. What is the SINGLE most appropriate
t
medication?
ua
A. Disulfiram
B. Acamprosate
al
C. Vitamin B12
D. Pabrinex
Ev
E. Chlordiazepoxide
Alcohol, a drinking problem

The general idea for is:
• Disulfiram
• Acts as a deterrent → Some five to 10 minutes after alcohol intake,
the patient may experience the effects of a severe hangover for a
period of 30 minutes up to several hours.
• Acamprosate
• Reduces cravings
30. A 28 year old woman has episodes of peri-oral tingling and carpopedal spasms every
time she has to give a public talk. These symptoms also happens to her before
interviews, exams and after arguments. She describes these episodes as short lasting
only a couple of minutes but with intense fear. What is the SINGLE most appropriate
management?
1329
A. Diazepam
B. Rebreath into a paper bag
C. Alprazolam
D. Buspirone
E. Propranolol
In panic attacks, perioral paresthesia, tingling and numbness in the hands can occur
due to hyperventilation and CO2 washout leading to low ionic calcium. Rebreath into
a paper bag will help to increase CO2 levels and resolve symptoms.
Panic attacks
Period of intense fear characterized by a constellation of symptoms that develop

rapidly, reach a peak of intensity in about 10min, and generally do not last longer
than 20–30min (rarely over 1 hour). Attacks may be either spontaneous (‘out of the
blue’) or situational (usually where attacks have occurred previously).
Symptoms/signs
y
• Tremor
op
• Tachycardia
• Tachypnoea,
• Sweating
C
• Concerns of death from cardiac or respiratory problems
They may complain of dizziness, circumoral paraesthesia, carpopedal spasm, and

n
occasionally sharp or stabbing chest pain. Initial examination would reveal
io
tachypnoea with equal air entry over both lung fields, and no wheeze or evidence of
airway obstruction. It is important to consider secondary causes (such as PE or DKA).
t
Therefore, perform the following investigations:

ua
• SpO2
• ECG
al
• ABG if SpO 2 ↓ , or if symptoms do not completely settle in a few minutes

• BMG
Ev

• CXR
Treatment
Do not sedate a patient who is hyperventilating. Once serious diagnoses have been
excluded, use this information to help reassure the patient with primary
hyperventilation. Often this is all that is required, but it may be helpful to try simple
breathing exercises (e.g. breathe in through nose)
31. A 30 year old man who served in the army 6 months ago presents with lack of
interest in enjoyable activities and feeling low. He often wakes up in the middle of
the night because of nightmares of gun fire. He feels irritable and has difficulty
concentrating. He tries not to watch the news as it reminds him of war. What is the
SINGLE most appropriate initial therapy?
1330
A. Citalopram
B. Lofepramine
D. Chlordiazepoxide
E. Desensitization
This man is suffering from post-traumatic stress disorder
Post-traumatic stress disorder (PTSD) develops following a traumatic event. In this

case, it was war that stimulated PTSD.
Post-traumatic stress disorder (PTSD)

• Develops following a traumatic event
Features
• Re-experiencing:
o Flashbacks, nightmares
• Avoidance:
y
o Avoiding people, situations or circumstances resembling or
op
associated with the event
• Hyperarousal
o Hypervigilance for threat, exaggerated startle response, sleep
C
problems, irritability and difficulty concentrating
• Emotional numbing
o Lack of ability to experience feelings
n
io
Management
• Trauma-focused cognitive behavioural therapy (TF-CBT) and eye movement
t
desensitization and reprocessing (EMDR): are first-line treatments

ua
It is very common to have questions with a patient with clear symptoms of

PTSD and the question would ask which is first line. If CBT is present, that is
usually the answer.
al
• SSRI’s would be second line. e.g. paroxetine, sertraline are licensed for PTSD.
Ev
Other unlicensed possibilities include: fluoxetine, citalopram, escitalopram,

and fluvoxamine.
If you find all these names of SSRI’s difficult to remember. Just remember
these 3 → Paroxetine, sertraline, and fluoxetine.
32. A 24 year old man feels down and lethargic. In the last couple of months, he has
stopped enjoying his hobbies which include playing the violin. He was admitted to the
psychiatry ward last year following an episode of overspending, reckless behaviour
and promiscuity. What is the SINGLE most likely diagnosis?
A. Psychosis
B. Cyclothymia
D. Seasonal affective disorder
E. Depression
1331

• Grandiosity
Treatment
y
33.
op
A 65 year old woman thinks she has died 3 months ago and is very distressed that
nobody has buried her up till now. She hears people’s voices which tell her that is evil
C
and needs to be punished. She barely has any eye contact when speaking to the
health care professionals. What is the SINGLE most likely explanation for her
symptoms?
n
io
A. Schizophrenia
B. Mania
t
ua
D. Hysteria
E. Toxic confusional state
al
Some people who have severe clinical depression will also experience hallucinations
and delusional thinking, the symptoms of psychosis.
Ev
Nihilistic delusions is the delusional belief that the patient has died or no longer exists
or that the world has ended or is no longer real. Nothing matters any longer and
continued effort is pointless. It is a feature of psychotic depressive illness. Patient
34. A 29 year old teacher was run down by a drunk driver a year ago. Since then, she has
been afraid to cross the road. She suffers from nightmares about that incident and
gets a startled response every time she hears loud sounds. What is the SINGLE most

B. Diazepam
C. Citalopram
D. Dosulepin
E. Sertraline
1332
Features
• Avoidance:
• Hyperarousal
Management
y
op
usually the answer.
C
n
and fluvoxamine.
io
t
ua
35. A 35 year old is agitated and euphoric. He claims to be helping the prime minister
with economic policies and describes himself to be a very powerful man. He believes
that he has made important discoveries regarding international policies that have
al
great impact towards the United Kingdom. On further investigation, these statements
are untrue. What is the SINGLE most likely diagnosis?
Ev
A. Bipolar disorder
B. Schizophrenia
C. Hypomania
D. Erotomania
E. Delusion of grandeur
His delusions describe a type of delusion called grandiose delusions which are usually
found in patients with mania.

36. A 28 year old business man returned from a trip from Kenya 2 years ago. He attends a
sexual clinic worried that he has contracted HIV. Antibody screening test for HIV has
come back negative. There were 2 similar HIV test performed 6 months and 9 months
1333
ago which have both come back as negative. This is his 5th visit to the clinic claiming
that he is HIV positive. What is the SINGLE most likely diagnosis?
B. Hypochondriasis
E. Malingering


y
op
C

n
io
t

ua

al
37. A 38 year old man keeps having intrusive thoughts about having dirt under the bed.
Ev
He cannot keep himself from thinking about these thoughts. If he tries to resist, he
starts having palpitations. What is the SINGLE most likely diagnosis?
A. Adjustment disorders
B. Obsessive–compulsive disorder (OCD)
C. Schizophrenia
D. Panic disorder
E. Acute stress reaction

1334
Management

include citalopram
38. A 22 year old woman thinks she is overweight. She has a body mass index of 21.8
kg/m2. She has often has constipation and abdominal pain. She eats uncontrollably
and feels guilty resulting in self-inducing vomiting. Sometimes to compensate for her
y
big meal, she would exercise intensively. What is the SINGLE most likely diagnosis?
A. Anorexia nervosa
B. Pituitary tumour
op
C
C. Hypothyroidism
D. Bulimia nervosa
E. Prader willi syndrome
n
io
Bulimia nervosa
t
Bulimia nervosa is an eating disorder characterised by repeated episodes of

ua
uncontrolled overeating (binges) followed by compensatory weight loss behaviours.
Features:
al
• Excessive preoccupation with body weight and shape

• Compensatory weight control mechanisms which can be:
Ev
• Self-induced vomiting
• Fasting
• Intensive exercise
• Abuse of medication such as laxatives, diuretics, thyroxine or
amphetamines
Note that a person with bulimia nervosa does not necessarily need to be thin. They
sometimes maintained a BMI above 17.5 kg/m2.
Examination:
• Salivary glands (especially the parotid) may be swollen.
• Russell's sign may be present (calluses form on the back of the hand, caused
by repeated abrasion against teeth during inducement of vomiting).
• There may be erosion of dental enamel due to repeated vomiting.
1335
39. A 20 year old man complains his movements are being watched. He feels as though
his actions are being controlled by the radio. At times he hears voices describing his
actions. What is the SINGLE most likely diagnosis?
A. Mania
B. Schizoid personality disorder
C. Paranoid personality disorder
D. Schizophrenia
He describes his movements being controlled by the radio. This is known as passive
phenomena. He also describes voices describing what he is doing. This is called third-
person auditory hallucinations. Sometimes these voices can be heard like a running
commentary. Example, the patient hears one or more voices providing a narrative of
their current actions, ‘he’s getting up…now he’s going towards the window’.
All these features are features of schizophrenia.
y
Schizophrenia
Features
op
C
n
io

t
ua
Thought disorder:
al
Ev

40. A 48 year old man attends his GP. He was started on fluoxetine 8 weeks ago for
depression and is now requesting to stop his medication as he feels well and does not
think he is depressed any longer. What is the SINGLE most appropriate advice to give
to him in regards to his treatment?
1336
A. Stop fluoxetine right away
B. Continued fluoxetine for at least another 6 months
C. Fluoxetine dose should be gradually reduced over a 4 week period
D. Fluoxetine dose should be gradually reduced over a 1 week period
E. Change to a different SSRI
If a patient makes a good response to antidepressant therapy they should continue

on treatment for at least 6 months after remission as this reduces the risk of relapse.
When stopping a SSRI the dose should be gradually reduced over a 4 week period
(this is not necessary with fluoxetine).
41. A 23 year old man comes to the emergency department with a history of drug
misuse. He recognizes that he has a problem and is willing to see a psychiatrist. What
is the SINGLE most accurate term that describes this situation?
A. Judgement
y
C. Thought block
op
D. Mood
E. Insight C
Insight
In psychology and psychiatry, insight can mean the ability to recognize one's own
mental illness. This form of insight has multiple dimensions, such as recognizing the
n
need for treatment, and recognizing consequences of one's behavior as stemming
io
from an illness.
t
For example, people with obsessive compulsive disorder and various phobias tend to
ua
have relatively good insight that they have a problem and that their thoughts and/or
actions are unreasonable, yet are compelled to carry out the thoughts and actions
regardless.
al
In general, a patient with insight is a patient who knows that their symptoms
Ev
represent abnormality and seeks their diagnosis and appropriate treatment.
42. A 30 year old woman complains of feeling restless, muscle tension and sleep
disturbance on majority of the days over the last 9 months. She worries excessively
about a number of everyday events and activities and is unable to control these
feelings which are impairing her ability to hold down her job. What is the SINGLE
A. Panic disorder
B. Generalized anxiety disorder (GAD)
C. Pheochromocytoma
D. Acute stress reaction
E. Social phobia
There is a fine line between Generalised Anxiety Disorder (GAD) and Panic attacks.
They both can present similarly. The major difference is panic attacks are usually
short lived (lasting no longer than 20–30min (rarely over 1 hour). ‘Excessive worry’
1337
and feelings of apprehension about everyday events like in this case points towards
the diagnosis of GAD.
Acute stress reaction is a transient disorder (lasting hours or days) that may occur in
an individual as an immediate (within 1 hour) response to exceptional stress (e.g.
natural catastrophe, major accident, serious assault, warfare, rape, fire). Symptoms
tend to be mixed with an initial state of daze, followed by depression, and anxiety. As
in this case, the symptoms were going on for 9 months, it is not acute stress reaction.
Generalized anxiety disorder (GAD)
‘Excessive worry’ and feelings of apprehension about everyday events, with

symptoms of muscle and psychic tension, causing significant distress and functional
impairment.
Symptoms of GAD (present most days for at least 6 months)

• Restlessness
y
• concentration difficulties or ‘mind going blank’
op
• irritability
• muscle tension
• sleep disturbance
C
• palpitations/tachycardia
• sweating
• Trembling or shaking
n
• breathing difficulties; choking sensation; chest pain or discomfort;
io
• fear of losing control, ‘going crazy’, passing out, dying.

t
Management
ua
Cognitive behavioural therapy or applied relaxation or drug treatment. NICE suggest

sertraline should be considered the first-line SSRI. Alternative SSRI options are
escitalopram or paroxetine.
al
43. A 64 year old man believes a female newscaster on the television is communicating
Ev
directly to him when she turns a page and when she looks at the camera. What is the
SINGLE most likely type of delusion that this man is suffering from?

1338

44. A 26 year old woman is afraid to visit the shopping centre. Crowds and public places
causes her to panic. She feels more relaxed when she goes out to public places with
her husband than when alone. What is the SINGLE most likely diagnosis?
y
op
A. Social phobia
B. Claustrophobia
C. Arachnophobia
C
D. Acrophobia
E. Agoraphobia
n
io

t
ua
al

Ev
Arachnophobia → fear of spiders
Acrophobia → fear of heights
Agoraphobia
• leaving home
situations where
1339
or away from home).

• palpitations
• sweating
45. A 32 year old man thinks nurses are plotting to harm him and are stealing his ideas
straight out from his mind. Sometimes he feels the nurses are able to control his
body. What is the SINGLE most likely diagnosis?

y
C. Schizophrenia
op
E. Paranoid personality disorder C
The patient is suffering from schizophrenia. This can be shown by the fact that he
thinks that ideas are being stolen from his mind (thought withdrawal), and that the
nurses are plotting to harm him (persecutory delusion).
n
io
The feeling of nurses controlling his body are consistent with schizophrenia. It is
called passive phenomena.
t
ua
Schizophrenia
Features
al
Ev

Thought disorder:
1340
46. A 34 year old woman 3 weeks after childbirth has thoughts of harming her little baby
as she complains that he has evil eyes. She has been feeling low and has been
suffering from lack of sleep. Prior to this she was well and has no psychiatric issues.
What is the SINGLE most appropriate management for this patient?

B. Electroconvulsive Therapy (ECT)
C. IV haloperidol
D. Paroxetine
E. Amitriptyline
Evil eyes and thoughts of harming a baby are signs of postpartum psychosis and
needs ECT
y
op
C
the baby
n
io

t
Management
ua

al

Ev

days
baby harming baby
E.g. hears voices
not capable of
child
1341
Disorientation
mother suicide
Tearful, Anxiety
Worries about
baby’s health

47. A 19 year old college student has a firm and unshakable belief that he is being
followed by terrorists who are plotting against him. He says they follow him wherever
he goes. What is the SINGLE most appropriate term for his condition?
y
op
E. Nihilistic delusions C
n
io

t

ua
al
Ev

48. A 64 year old man has just suffered from a myocardial infarction. Before discharge,
he seems to be in a sad mood and avoids eye contact. The nurses report that he has
skipped his last two meals. What is the SINGLE best treatment for this man’s
condition?
A. Sertraline
B. Risperidone
1342
C. Lithium
D. Amitriptyline
E. Diazepam

If the question gives you options of SSRIs, sertraline would be the best answer to pick
use in patients with depression with a history of myocardial infarction
Guidelines to choosing the right antidepressant:
Selective serotonin reuptake inhibitors (SSRIs) are used as first-line antidepressants in

routine care because they are as effective as tricyclic antidepressants and less likely
to be discontinued because of side-effects; also because they are less toxic in
y
overdose.
Which SSRI to prescribe?
op
• Guidance suggests that we choose a generic SSRI (eg, citalopram, fluoxetine,
C
paroxetine, or sertraline) when treating an individual with antidepressants
for the first time
• Fluoxetine is the antidepressant of choice for children and young people. It is
n
the only antidepressant licensed for this use.
io
In summary:
t
ua
• SSRI’s are first line. Remember these 4 drugs for PLAB 1:

o Citalopram
o Fluoxetine
al
o Paroxetine
o Sertraline
Ev
• Fluoxetine for young people
her husband passed away 6 weeks ago. She has been crying almost everyday, and
feeling hopeless. She has been withdrawing from other people and does not want to
go out for dinner with her mother. What is the SINGLE most likely diagnosis?
C. Panic disorder
E. Social phobia
Adjustment disorders
An adjustment disorder occurs when an individual is unable to adjust to or cope with

a particular stress or a major life event. They must occur within 1 (ICD-10) or 3
1343
months (DSM-IV) of a particular psychosocial stressor, and should not persist for
longer than 6 months after the stressor (or its consequences) is removed
50. A 43 year old woman presents with low mood, and loss of libido. She feels tired all
day and she attributes this to the fact that she wakes up 3 hours sooner than usual.
She feels like she has been gaining weight. She also finds it difficult to concentrate for
long periods of time. What is the SINGLE most likely diagnosis?
A. Seasonal Affective Disorder

B. Bipolar disorder
D. General anxiety disorder
E. Depression
Symptoms of depression
• Present for at least 2 weeks and represent a change from normal.
• Depressed mood: present most of the day, nearly every day, with little
variation
y
• Anhedonia: markedly diminished interest or pleasure in all, or almost all,
op
activities most of the day
• Weight change: loss of weight when not dieting or weight gain associated
with decreased or increased appetite
C
• Disturbed sleep: insomnia (with early morning wakening 2–3 hr sooner than
usual) or hypersomnia (especially in atypical depression)
n
• Fatigue or loss of energy.
• Reduced libido.
io
• Feelings of worthlessness or excessive or inappropriate guilt

• Diminished ability to think or concentrate or indecisiveness.
t
ua
• Recurrent thoughts of death or suicide
51. A 33 year old woman has persistent fear when she has to speak publicly. She sweats
al
and has palpitations and finds it very difficult to breathe. She is afraid of what people
might think of her. She tries her best to avoid these situations. What is the SINGLE
Ev
A. Agoraphobia
B. Acute stress disorder
C. Social anxiety
Social Anxiety Disorder (Social Phobia)
Social anxiety disorder is the persistent fear and anxiety about one or more social or
performance situations. It is characterized by marked fear of one or more social or
performance-related situations where the person is exposed to scrutiny and in which
embarrassment may occur. Exposure to social situations usually causes an anxiety
reaction (may be a panic attack) that is distressing. Thus situations are either avoided
or endured with discomfort.
Features
1344
Social anxiety is a fear of being around people and having to interact with them.
Sufferers fear being watched and criticised. Normal activities such as working,
shopping, or speaking on the telephone are marked by persistent feelings of anxiety
and self-consciousness.
Physical symptoms include trembling, blushing, sweating and palpitations.
There are two forms of the condition:

1. Generalised social anxiety which affects most, if not all areas of life. This is
the more common type and affects around 70% of sufferers.
2. Performance social anxiety, where these feelings only occur in a few specific
situations such as public speaking, eating in public or dealing with figures of
authority.
52. A 29 year old women is overly paranoid that her partner is being unfaithful to her.
She checks his phones, email accounts and bank statements several times a day for
evidence of infidelity. She dislikes him going out as she fears that he would look at
other women while he is out on his own. She does not allow any social media for fear
y
that he may meet another women. What is the SINGLE most likely diagnosis?
B. Cotard syndrome
op
C
C. Capgras syndrome
D. Ekbom syndrome
E. Othello syndrome
n
io
Othello syndrome → is a type of delusional jealousy, marked by suspecting a faithful

t

ua
al

Ev

Ekbom syndrome → Also known as restless legs syndrome. An unpleasant, often

painful sensations in the legs, particularly on sleep onset. Significantly interferes with
the ability to get to sleep.
53. A 62 year old man who was admitted for surgery 3 days ago suddenly becomes
confused. His attention span is reduced. He is restless and physically aggressive and
picks at his bed sheets. What SINGLE aspect of the patient's history recovered in his
notes is most likely to aid in making the diagnosis?
1345
A. Chronic alcohol consumption
B. Previous head trauma
C. Psychiatric history of generalized anxiety disorder
D. Psychiatric history of obsessive compulsive disorder
E. Mild cognitive impairment
Abstinence from alcohol in the hospital can cause delirium tremens which is noted
here by his sudden confusion, restlessness and physical aggressiveness.
Delirium tremens
• Delirium tremens usually begins 24-72 hours after alcohol consumption has
been reduced or stopped.
• Seen in chronic alcoholics
• The symptoms/signs differ from usual withdrawal symptoms in that there are
signs of altered mental status. These can include hallucinations (auditory,
visual, or olfactory), confusion, delusions, severe agitation. Seizures can also
occur.
y
op
54. A 31 year old woman 15 days following childbirth is brought to the hospital by her
husband. He complains that his wife has lost the ability to care for herself and is not
eating well. She does not sleep well and has intrusive and unpleasant thoughts of
C
harming the baby. What is the SINGLE best management for this patient?
A. Fluoxetine
n
B. Haloperidol
io

D. Reassurance
t
E. Electroconvulsive Therapy (ECT)

ua
She has signs of depression and the thoughts of harming her baby are signs of
postpartum psychosis. She needs ECT.
al
Ev
the baby
Management
1346
days
baby harming baby
E.g. hears voices
not capable of
child
Disorientation
y
mother suicide
op
Tearful, Anxiety
C
Worries about
baby’s health
n

io

t
ua
55. A 43 year old man attends the GP clinic complaining that his arm is dead and rotten
and he wants it removed. On physical examination, the arm looks normal. What is the
al
Ev
B. Hypochondriasis
E. Capgras syndrome


1347

56. A 74 year old man is depressed after his wife’s death 6 months ago. He has been
neglecting himself and is not eating well. He has lost 11 kg in the last 3 months. At
times, he has thought about self harm but has never done it. His son found him in a
very miserable state when he went to visit him last night. Unfortunately, the son is
unable to care for his father due to work and other family related issues. What is the
y
A. Review his mental status in 2 weeks
op
B. Refer to a social worker
C. Suggest the option of his son to moving in with his father
D. Send patient to a care home
C
E. Voluntary admission to the psychiatry ward
The first question to ask yourself is, is this a suitable environment for a person with
n
a depressive illness?
io
Obviously not, and thus he should be admitted to the psychiatry ward.

t
Admission should be to a ward where close observation and monitoring are possible,
ua
whenever there is significant risk of harm to self (or others)
The ward environment is often not the quiet sanctuary patients hope for and this
al
may lead to difficult decisions in balancing the risk of self-harm against the use of
compulsory admission.
Ev
Common reasons for hospital admission

• Serious risk of suicide
• Serious risk of harm to others
• Significant self-neglect
• Severe depressive symptoms
• Severe psychotic symptoms
• Lack or breakdown of social supports
• Initiation of electroconvulsive therapy
• Treatment-resistant depression (where inpatient monitoring may be helpful).
57. A 33 year old man attends his appointment with the psychiatrist. He says that he is
no longer alive. He wants his family to bury him. What is the SINGLE most
B. Hypochondriasis
1348
E. Capgras syndrome


y
op
C
n
io
58. A 37 year old woman was admitted for a femur fracture repair after a road traffic
t
accident. On the fourth post-op day she becomes confused and starts picking on her
ua
bed sheets. She complains of seeing spiders all over her bed. What is the SINGLE
al
A. Delirium tremens
B. Wernicke's encephalopathy
Ev
C. Korsakoff's psychosis
E. Electrolyte imbalance
Withdrawal of alcohol due to hospital admission often leads to delirium tremens. This
is noted here by her confusion and picking on her bed sheets. This is seen a couple of
days after consumption of alcohol is stopped as seen in this question.
Wernicke's encephalopathy is unlikely as it presents with a triad of confusion, ataxia

and ophthalmoplegia.
Korsakoff’s psychosis is characterised by the addition of antero- and retrograde

amnesia and confabulation in addition to the above classic triad of Wernicke's
encephalopathy.
Psychotic depression may present with symptoms of delusions and hallucinations.

But firstly, there is no history of depression here. Secondly, it is quite unlikely that the
1349
symptoms of this major depressive episode, just so happen to occur after being
hospitalized. A picture of delirium tremens fits better.
Electrolyte imbalance is again a possibility but there is no additional hints pointing

towards electrolyte imbalance being a cause of confusion.
Delirium tremens
occur.
59. A 19 year old man has lack of interest and no social interactions. He has very little
friends and does not talk much. He prefers solitary activities. One of his interest is in
collecting toy cars. He has over 2,000 toy cars and often spends hours lining them up.
y

B. Dissocial personality disorder
op
C
D. Autism spectrum disorder
E. Bipolar affective disorder
n
io
Autism spectrum disorders are a group of lifelong developmental disorders

characterized by their effect on social and communication skills as well as by a
t
restricted, stereotyped, repetitive repertoire of interests and activities.

ua
It can be characterised by:

1. Severe difficulties in communicating and forming relationships
al
2. Difficulties in language
3. Repetitive and obsessive behaviour
Ev
sweating, nausea and overwhelming fear. On one occasion she was woken from sleep
and feared she was going insane. She has no previous psychiatric disorder. What is
A. Pheochromocytoma
B. Panic disorder
D. Agoraphobia
Panic disorder
1350
Symptoms/signs
medical services.
61. A 48 year old woman who is always socially withdrawn has stopped going out of the
house. She is afraid to socialize because she fears that people will criticize her. What
A. Agoraphobia
C. Social anxiety
y
op
C
n
io
t
ua
Features
al

Ev

authority.
62. A 26 year old political refugee has sought asylum in the UK. He complains of poor
concentration. He keeps getting thoughts of his family whom he saw was killed in a
political coup. He is unable to sleep well, feels hopeless and detached. What is the
A. Acute stress disorder

1351
C. Social phobia

Features
• Avoidance:
• Hyperarousal
y
op
Management
C
usually the answer.
n
io
t
and fluvoxamine.
ua
al
63. A 20 year old woman with amenorrhoea and a body mass index is 14.8 kg/m2 is still
Ev
trying to lose weight. She exercises excessively and induces vomiting after her meals.
A. Anorexia nervosa
B. Bulimia nervosa
E. Body dysmorphic disorder
Anorexia nervosa
Anorexia nervosa is the most common cause of admissions to child and adolescent
psychiatric wards. It is most commonly seen in young women in which there is
marked distortion of body image, pathological desire for thinness, and self-induced
weight loss by a variety of methods.
Features
• BMI <17.5kg/m2 or < 85% of that expected
1352
• Self-induced weight loss → reduce food intake, vomiting, purging, excessive
exercise.
• Intense fear of being obese
• Disturbance of weight perception
• Endocrine disorders such that cause amenorrhoea, reduced sexual
interest/impotence, raised GH levels, raised cortisol, altered TFTs, abnormal
insulin secretion
• Bradycardia
• Hypotension
64. A 17 year old woman has been diagnosed with anorexia nervosa. She has mild
depressive symptoms and has reduced her food intake in the last 8 months. She
exercises daily and admits to inducing vomiting occasionally after a meal. Her body
mass index is 16.8 kg/m2. She has a blood pressure of 95/65 mmHg and a heart rate
of 70 beats/minute. What is the SINGLE most appropriate management?
A. Refer to eating disorder service

B. Refer to dietician
y
C. Admit to medical ward
op
D. Admit to psychiatry ward
E. Start antidepressants C
She falls into the category of moderate anorexia. Admission to the hospital is not
warranted because her blood pressure, heart rate are fine and her BMI is still above
15. Referral to an eating disorder unit or service would be the most appropriate.
n
io
No drug treatments for anorexia nervosa are validated by good randomized trials
although fluoxetine prevents relapse in open trials. Nonetheless, do not pick
t
antidepressants when it is the option for management of anorexia nervosa for this
ua
exam.
BMI <15kg/m2, rapid weight loss + evidence of system failure

al
• requires urgent referral to eating disorder unit (EDU), medical unit (MU) or
paediatric medical wards
Ev
In moderate anorexia (BMI 15–17.5, no evidence of system failure)

• routine referral can be to the local community mental health team or eating
disorder unit (EDU) if available
In mild anorexia (BMI >17.5)

• focus on building a trusting relationship and encouraging use of self-help
books and a food diary
Anorexia nervosa
Features
1353
exercise.
insulin secretion
• Bradycardia
• Hypotension
65. A couple has just finished their detox regime and wants a drug with a
pharmacological action to serve as a deterrent when they take alcohol. What is the
A. Disulfiram
B. Acamprosate
C. Vitamin supplement
y
D. Naloxone
op
E. Chlordiazepoxide

C
• Disulfiram
n
io

• Acamprosate
t
ua
66. A 35 year old schizophrenic man hears voices narrating his actions like “he is going to
the toilet” and “he is leaving the house”. What is the SINGLE most likely type of
al
hallucinations involved?
Ev

Third-person auditory hallucinations
Auditory hallucinations characteristic of schizophrenia where voices are heard

referring to the patient as ‘he’ or ‘she’, rather than ‘you’. For example "She is an evil
person".
Sometimes the voices are of a running commentary. Example, the patient hears one
or more voices providing a narrative of their current actions, ‘he’s getting up…now
he’s going towards the window’.
1354
67. A 22 year old man was rushed into the emergency department. He describes
recurrent episodes of fearfulness, palpitations, with peri-oral tingling and cramping of
the hands. His symptoms last 5 - 10 minutes. He is worried he may be having a heart
attack. An ECG shows sinus tachycardia. He has a respiratory rate of 34
breaths/minute. What is the SINGLE most appropriate immediate intervention?
A. High flow oxygen

B. IV sedation
C. Rebreath into a paper bag
D. Alprazolam
E. Refer to cardiac team urgently
In panic attacks, perioral paresthesia, tingling and numbness in the hands can occur
due to hyperventilation and CO2 washout leading to low ionic calcium. Rebreath into
a paper bag will help to increase CO2 levels and resolve symptoms.
Panic attacks
y
op
C
Symptoms/signs
• Tremor
n
• Tachycardia
io
• Tachypnoea,
• Sweating
t

ua

al
Ev
• SpO2
• ECG
• BMG

• CXR
Treatment
1355
68. A 33 year old man with alternating mood swings and episodes mood elevation to
depression underwent treatment and improvement was seen in his mood swings.
What SINGLE medication is needed to be continued to prevent his alternating
moods?
A. Anxiolytics
B. Mood stabilizers
C. Antidepressants
D. Antipsychotics
E. Stimulants

y
op
C
• Grandiosity
n
io

t
Treatment
ua
al
69. A 30 year old woman who suffered from depression a few years ago has recently
Ev
spent a substantial amount of money buying new clothes. She goes out almost every
night with her friends. She would not allow any of her friends to choose the
restaurant for dinner as she believes she knows the best places to eat. She sleeps less
than usual and fills her days with as many activities as she can. What is the SINGLE
A. Mania
B. Depression
E. Hypomania
There is a history of depression and symptoms of mania. This would be a classic

scenario that PLAB would give when they would like you to pick Bipolar disorder.
1356

• Grandiosity
Treatment
y
70.
op
A 21 year old man was brought by his friends unconscious from a party where he was
said to have drank vodka. While he was being attended to by the doctor in the
C
emergency department, he became conscious and said the green tie the attending
doctor was wearing was talking to him. On examination, his pupils were dilated.
What substance could this patient have taken?
n
io
A. Cocaine
B. Alcohol
t
C. Heroin
ua
D. Cannabis
E. LSD
al
LSD (lysergic acid diethylamide)

Ev
LSD causes visual hallucinations, agitation, excitement, tachycardia and dilated

pupils. Hypertension and pyrexia may occur. Paranoid delusions may
require sedation. Massive overdose of LSD is rare, but may cause coma,
respiratory arrest and coagulation disturbances. Treat supportively.
For all hallucinogens, acute psychotic features should in general be managed by

admission,
maintenance of a safe environment, symptomatic treatment of agitation
(e.g. with benzodiazepine), with expectation of resolution.
71. A 38 year old woman who gave birth 6 weeks ago presents to her local GP surgery
with her husband. She describes 'crying all the time' and 'not bonding' with her baby.
She is worried about baby's health constantly and she is unsure if is able to cope with
this new change in her life. What is the SINGLE most likely diagnosis?
A. Postpartum blues
B. Postnatal depression
1357
D. Anxiety disorder
E. Obsessive compulsive disorder (OCD)
Postnatal depression
A significant depressive episode, temporally related to childbirth, within 6 months

usually peaking at 3 to 4 weeks
Clinical features
similar to other depressive episodes, although thought content may include worries
about the baby’s health or her ability to cope adequately with the baby. There may
be a significant anxiety component.
Management
Depressive episode treated in usual way with antidepressants and/or brief CBT, if
severe or associated with thoughts of self-harm or harm to baby, may require
hospital admission.
y
op

C
n
io
days
t
baby harming baby

ua

E.g. hears voices
al

not capable of
Ev

child
Disorientation
mother suicide
Tearful, Anxiety
Worries about
baby’s health

1358
72. A 10 year old boy with behavioural problems is taken to the clinic by his parents.
During the appointment, the boy barks and shouts expletives. He is constantly
blinking his eyes and unable to sit still. What is the SINGLE most likely diagnosis?
B. Cotard syndrome
C. Rett syndrome
D. Ekbom syndrome
This is a classic scenario for Tourette’s syndrome in PLAB 1. Other clues that may
appear on PLAB 1 may be the child yelling in class intermittently or shouting
expletives. Most Tourette's syndromes are diagnosed at 6-8 years, maximum to the
age of 13.
The other syndromes are less likely to be the answer:
Asperger syndrome → Characterized by severe persistent impairment in reciprocal
y
social interactions, repetitive behaviour patterns, and restricted interests. IQ and
op
language are normal or, in some cases, superior. Although tics (like the above case)
can also be found in asperger syndrome, it is more specific for Tourette’s syndrome.
Not to mention, the question would include an impairment of social skills if the PLAB
C
examiners wanted you to have picked Asperger syndrome.
Cotard’s syndrome → is a rare mental illness in which an afflicted person holds the
n
delusion that they are dead
io
Rett’s syndrome → There is normal development for 2–3yrs, followed by a loss of

t
acquired motor, language, and social skills between ages 3 and 4yrs. Stereotypies and
ua
compulsions are common.
Ekbom’s syndrome → Also called restless leg syndrome. Unpleasant, often painful
al
sensations in the legs, particularly on sleep onset

Ev
Tourette’s syndrome
Presentation:
• Young (6-8 years old) mostly male
• Repetitive movements or gestures that are disruptive in the classroom or to
people around the child (can be motor or vocal) → Tics
• Jerks, blinks, sniffs, nods, spitting, stuttering, irrepressible explosive obscene
verbal ejaculations, grunts, and squeaks
Diagnosis:
Treatment:
• Risperidone or haloperidol
• Behavioral therapy - Habit-reversal training
1359
73. A 26 year old man strongly believes that every elderly man he meets is likely to be his
father. Although they look different, he is sure it is his father wearing a different
disguise. What is the SINGLE most likely kind of delusion this man is suffering from?
B. Erotomania
y
op
Erotomania → is the delusional belief that another person, usually of higher social
status, is secretly in love with them. The sufferer may also believe that the subject of
their delusion secretly communicates their love through seemingly innocuous acts, or
C
if they are a public figure through clues in the media. The object of the delusion
usually has little or no contact with the sufferer.
n
io
t
ua

al
74. A 68 year old woman has been admitted with poor appetite, weight loss, poor
Ev
concentration and self neglect for 3 weeks. She has not been eating or drinking
adequately and has rarely left her bed. She expresses suicidal ideas and hears voices
telling her she is worthless. She has been on antidepressant therapy for the past 3
months with no improvement. What is the SINGLE most appropriate management?
A. Additional antidepressants
B. Cognitive behavioural therapy
C. Interpersonal therapy
D. Electroconvulsive therapy
E. Antipsychotics
This lady has symptoms of severe depression with hallucinations (hearing voices
telling her she is worthless) making the diagnosis of psychotic depression.
Electroconvulsive therapy (ECT) would be appropriate since she is having psychotic
symptoms and is not eating well.
Electroconvulsive therapy (ECT)
1360
• A highly effective treatment for depression (particularly with psychotic
symptoms)
• It may act more rapidly than antidepressant medication
Guidance on the use of electroconvulsive therapy (May 2003)

• ECT is used only to achieve rapid and short-term improvement of severe
symptoms after an adequate trial of other treatment options has proven
ineffective and/or when the condition is considered to be life threatening, in
individuals with severe depressive illness
• The current state of the evidence did not allow the general use of ECT in the
management of schizophrenia to be recommended
• ECT is not recommended as a maintenance therapy in depressive illness
because the longer-term benefits and risks of ECT have not been clearly
established.
75. A 28 year old woman complains of hearing strange voices in her bedroom as she is
falling asleep in the night. She says there is no one in the room except for her. She is
y
otherwise healthy and without mental illness. What is the SINGLE most likely
op
diagnosis?
C
B. Cotard syndrome
C. Hypnagogic hallucinations
D. Capgras syndrome
n
E. Othello syndrome
io
Hypnagogic hallucination → is a transient false perception experienced while on the

t
verge of falling asleep (e.g. hearing a voice calling one’s name which then startles you
ua
back to wakefulness to find no-one there). The same phenomenon experienced while
waking up is called hypnopompic hallucination. Frequently experienced by healthy
people and so not a symptom of mental illness.
al
Ev
tormented, followed, or spied on


Othello Syndrome → is a type of delusional jealousy, marked by suspecting a faithful

1361
76. A 19 year old man accuses his friend of making his right arm swing out to hit a
stranger at the park. There is no evidence of this as his friend was at home at that
time. What is the SINGLE most appropriate term to describe his condition?
A. Delusion of control
B. Persecutory delusion
E. Thought insertion
y
op
C

n
io
t
Thought insertion → The delusional belief that thoughts are being placed in the
ua
patient’s head from outside
77. A 29 year old man was has been severely depressed over the last 3 years now
al
believes that he does not exist and never existed in this world. He has poor eye
contact and speaks softly. He says that people around him are unable to listen and
Ev
see him because he is inaudible and invisible. What SINGLE kind of delusion is he
suffering from?

1362

y
78. A 27 year old woman finds herself with palpitations and dizziness whenever she is in
op
a meeting at the office. She is very self-conscious and feels that her colleagues are
judging her in a harsh way in meetings. She has been asked to present in one of the
meetings but she called in sick to avoid being criticised. What is the SINGLE most
C
likely diagnosis?
A. Agoraphobia
n
io
C. Panic disorder
D. Depression
t
E. Social phobia
ua

al
Ev

Features

1363
authority.
feeling agitated that it was not done. What is the SINGLE most appropriate
management?
A. Cognitive behavioural therapy

C. Antipsychotics
D. MAO inhibitors
E. Electroconvulsive therapy (ECT)

y
op
escape response. In this case, the patient would be exposed to his feared stimulus,
and would refuse to respond with any safety behaviors.
C
n
io
t

ua

al
Ev

Management
1364

considered
first-line (no clear superiority of any one agent). Other (unlicensed) agents include
citalopram
80. A 33 year old man tries not to go outside his house because he thinks that people will
look at him and talk about him. He finds difficulty when talking with his peers in a
restaurant or under social settings. He avoids these situations as they cause him
distress. What is the SINGLE most likely diagnosis?
A. Agoraphobia
y
C. Panic disorder
op
D. Adjustment disorder
E. Social phobia C
n
io

t
ua
Features
al
Ev


authority.
81. A 71 year old woman looks disheveled, unkempt and with poor eye contact. She has
recently lost her husband 2 months ago. She feels hopeless and has been tearful all
week. Which SINGLE option describes her condition?
A. Anxiety
1365
B. Hallucinations
C. Mania
D. High mood
E. Low mood
She has symptoms of a depression.
Depressive symptoms
One of the most common referrals in liaison psychiatry is of patients with low mood.
Patients may present with low mood, tearfulness, hopelessness regarding recovery,
biological depressive features (poor sleep, appetite, energy, and concentration)
82. A 33 year old man with a history of severe depression says his insides are rotting and
nobody has bothered to bury him. He feels the world no longer exist and nothing
matters. His gaze is always downwards and has barely any eye contact with anyone.
What SINGLE best term describes his condition?
y
op
C
n
io
t
ua

al
Ev

1366
83. A 24 year old male on remand in prison for murder is referred by the prison doctor.
He is noted to be behaving oddly in prison and complains of hallucinating. He has a
previous history of IV drug abuse. On questioning, he provides repeated wrong
answers to questions nonetheless, his answers are in the correct category. An
example, when asked who is the prime minister of England, he answers Bill Clinton.
A. Capgras syndrome
B. Cotard syndrome
C. Ganser syndrome
D. Somatization disorder
E. Hypochondriasis
Ganser syndrome → is a type of factitious disorder, a mental illness in which a person

deliberately and consciously acts as if he or she has a physical or mental illness. They
mimic behavior that is typical of a mental illness, such as schizophrenia. It is also
sometimes called prison psychosis, because the syndrome occurs most frequently in
prison inmates, where it may represent an attempt to gain leniency from prison or
y
court officials. They produce ‘approximate answers’. They may give repeated wrong
op
answers to questions which are nonetheless ‘in the right ballpark’. Example, ‘what is
the capital of Scotland?’ Answer ‘Paris’. These symptoms may occasionally be
associated with organic brain illness but it is much more commonly seen as a form of
C
malingering in those attempting to feign mental illness usually prisoners awaiting
trial.
n
io
t
ua

al
Ev


84. A 18 year old boy was recently sent to juvenile detention center after he set his
father’s car on fire. He lacks remorse for setting the car on fire and says he would do
it again if he had the chance to. He has always found it difficult to conform to social
rules and has no regard for the rights of others. What is the SINGLE most likely
diagnosis?
A. Acute psychosis
C. Mania
1367
E. Schizophrenia
Antisocial Personality disorder
Characterized by continuous antisocial or criminal acts, inability to conform to social

rules, impulsivity, disregard for the rights of others, aggressiveness, and lack of
remorse. They will typically be manipulative, deceitful and reckless.
Like other types of personality disorder, antisocial personality disorder is on a

spectrum, which means it can range in severity from occasional bad behaviour to
repeatedly breaking the law and committing serious crimes. Psychopaths are
considered to have a severe form of antisocial personality disorder
85. An 18 year old girl with a body mass index of 17.8 kg/m2 has bilateral parotid
swelling with thickened calluses on the dorsum of her hand. What is the SINGLE most
likely diagnosis?
y
A. Bulimia nervosa
op
B. Anorexia nervosa
D. Mumps
C
E. Sarcoidosis
This question is not entirely specific. Usually for a bulimia nervosa question to
n
appear, the stem would give more of a history which includes either fasting, or
io
intensive exercise. Self-induced vomiting would be too obvious for the question
writers to give.
t
ua
Bilateral parotid swelling and thickened calluses on the knuckles from self induced
vomiting may be found on examination in bulimia nervosa.
al
Bulimia nervosa
Ev
Bulimia nervosa is an eating disorder characterised by repeated episodes of

uncontrolled overeating (binges) followed by compensatory weight loss behaviours.
Features:
• Excessive preoccupation with body weight and shape
• Compensatory weight control mechanisms which can be:
• Self-induced vomiting
• Fasting
• Intensive exercise
• Abuse of medication such as laxatives, diuretics, thyroxine or
amphetamines
Note that a person with bulimia nervosa does not necessarily need to be thin. They
sometimes maintained a BMI above 17.5 kg/m2.
Examination:
• Salivary glands (especially the parotid) may be swollen.
1368
• Russell's sign may be present (calluses form on the back of the hand, caused
by repeated abrasion against teeth during inducement of vomiting).
• There may be erosion of dental enamel due to repeated vomiting.
86. A 44 year old man is very depressed and miserable after his wife’s death 6 months
ago. He sees no point in living now that his wife is not around. He feels regret and
wishes he never existed. He refuses any medical help offered. His son has brought
him to the emergency department. The son mentions that he can not deal with the
father’s depression any longer as he has a job and family that to attend to. What is
A. Voluntary admission to psychiatric ward

B. Compulsory admission under Mental Health Act
D. Alternate housing
E. Electroconvulsive therapy
This patient is refusing any help offered thus voluntary admission to psychiatric ward
y
is not possible. Compulsory admission under Mental Health Act is the most
op
appropriate answer. The Mental Health Act 1983 is the law in England and Wales that
allows people with a ‘mental disorder’ to be admitted to hospital, detained and
treated without their consent – either for their own health and safety, or for the
C
protection of other people.
n
io
feeling agitated that it was not done. He recognizes that he has a problem and is
t
willing to see a psychiatrist. What is the SINGLE most accurate term that describes
ua
this situation?
al
C. Thought block
Ev
D. Panic attack
E. Insight
Insight
In psychology and psychiatry, insight can mean the ability to recognize one's own
mental illness. This form of insight has multiple dimensions, such as recognizing the
need for treatment, and recognizing consequences of one's behavior as stemming
from an illness.
For example, people with obsessive compulsive disorder and various phobias tend to
have relatively good insight that they have a problem and that their thoughts and/or
actions are unreasonable, yet are compelled to carry out the thoughts and actions
regardless.
In general, a patient with insight is a patient who knows that their symptoms
represent abnormality and seeks their diagnosis and appropriate treatment.
1369
88. A 30 year old woman comes to clinic in tears trying to describe the constant
irritability she is in when dealing with her 2 small children. She describes herself as
easily startled. She is unable to concentrate for long but attributes it to poor sleep as
she often gets nightmares of a house fire. Her husband died in a house fire while she
was sleeping in the other room last year. What is the SINGLE most appropriate
management?
A. Rassurance
B. Relaxation therapy
C. Quetiapine
D. Lofepramine
E. Fluoxetine
This woman is suffering from post-traumatic stress disorder. Fluoxetine is an SSRI.

SSRIs are used second to CBT. As CBT was not an option in this question, fluoxetine
would be the next best choice.
y
Features
op
C
• Avoidance:
n
io
• Hyperarousal
t

ua
al
Management
Ev

usually the answer.
and fluvoxamine.
89. A 19 year old female is brought to the hospital by her parents. They are concerned
about her weight. Her body mass index is 12.1 kg/m2. She has a mildly depressed
mood and has low self-esteem. She has amenorrhoea. She has reduced her food
1370
intake in the past couple of months. She has a blood pressure of 70/50 mmHg and a
heart rate of 44 beats/minute. What is the SINGLE most appropriate management?
A. Start antidepressants
B. Family counselling
C. Social service
D. Admission to the psychiatry ward
E. Admission to the medical ward
It is clear that she is suffering from anorexia nervosa. Her BMI is critically low thus
medical admission is warranted to provide her with proper nutrition. A pulse rate
lower than 45 beats/minute and hypotension raises great concern and is definitely a
criteria for hospital admission. The most common cause of death in patients with
anorexia nervosa is due to cardiac complications.This is why they are admitted to
medical wards and not psychiatry wards when the condition is severe.
BMI <15kg/m2, rapid weight loss + evidence of system failure

• requires urgent referral to eating disorder unit (EDU), medical unit (MU) or
y
paediatric medical wards
op
In moderate anorexia (BMI 15–17.5, no evidence of system failure)
C
• routine referral can be to the local community mental health team or eating
disorder unit (EDU) if available
n
io
In mild anorexia (BMI >17.5)

• focus on building a trusting relationship and encouraging use of self-help
t
books and a food diary

ua
Anorexia nervosa
al

Ev
Features
exercise.
insulin secretion
• Bradycardia
• Hypotension
90. A 32 year old schizophrenic lady complains that she hears voices saying “she is evil”.
What is the SINGLE most likely type of hallucinations involved?
1371
Third-person auditory hallucinations
Auditory hallucinations characteristic of schizophrenia where voices are heard

referring to the patient as ‘he’ or ‘she’, rather than ‘you’. For example "She is an evil
person".
Sometimes the voices are of a running commentary. Example, the patient hears one
or more voices providing a narrative of their current actions, ‘he’s getting up…now
he’s going towards the window’.
91. A 18 year old male washes his hands 6 times every time he uses the toilet. On his way
out of the toilet, he has to switch off the light, turn it back on and turn it off once
y
more. What is the SINGLE most appropriate management?
A. Psychodynamic therapy
B. Electroconvulsive therapy (ECT)
op
C
C. Antipsychotics
D. Cognitive behavioural therapy (CBT)
E. Psychotherapy
n
io
Obsessive–compulsive disorder (OCD)

t
ua

al

Ev

Management

considered
first-line (no clear superiority of any one agent). Other (unlicensed) agents include
citalopram
For PLAB, electroconvulsive therapy (ECT) be the answer for treatment of OCD → If
patient is suicidal or severely incapacitated
1372
92. A 68 year old man comes in to A&E confused and with a coarse tremor. As the
emergency doctor is taking a history, he becomes unconscious. Which of the
following medications could account for his symptoms?
A. Haloperidol
B. Diazepam
C. Fluoxetine
D. Imipramine
E. Lithium
Lithium toxicity
Lithium is mood stabilising drug used in bipolar disorder.
Features of toxicity
coarse tremor (a fine tremor is seen in therapeutic levels)
hyperreflexia
acute confusion
y
seizure
op
coma
Management
C
Is beyond what will be asked in PLAB part 1.
93. A 42 year old man with a history of bipolar disorder is noted to have high serum
n
levels of lithium and profound hypokalaemia on routine examination. He was
io
recently diagnosed with essential hypertension and his GP had started him on an
antihypertensive medication. What is the SINGLE most likely cause of the recent
t
findings?
ua
A. Atenolol
B. Captopril
al
C. Ramipril
D. Spironolactone
Ev
They key here is to understand what medication can cause both hypokalaemia and
causes lithium levels to rise.
Thiazides (e.g. bendroflumethiazide) can cause hypokalaemia. Thiazide and related

diuretics can cause a rapid rise in serum lithium levels leading to toxicity. NICE
recommends avoid concurrent use unless lithium levels can be closely monitored and
the lithium dose adjusted as necessary. Advise patients to report lithium adverse
effects (tremor, dysarthria, ataxia, confusion).
Atenolol → Is a beta blocker. There has been one study which suggests that atenolol
might decrease the clearance of lithium. However, NICE guidelines state that no
particular precautions are warranted. Thus being less likely the cause of lithium
toxicity.
1373
Ranitidine → is an H2 histamine receptor antagonist that works by blocking
histamine. It is used in gastro oesophageal reflux disease and is not a
antihypertensive
Captopril and Ramipril → are an ACEi. They would cause hyperkalaemia. Thus is no
longer an option here.
Spironolactone →is a potassium sparing diuretics and causes hyperkalaemia. Thus is

no longer an option here.
94. A 22 year old woman was brought to the A&E by her friends. She presents with
tremors. On examination, she was found to have a temperature of 37.4°C and her
pupils dilated. She says when she closes her eyes, she can see colours. What is the
SINGLE most likely drug that has taken?
A. Amphetamines
B. Lysergic acid diethylamide (LSD)
C. Cocaine
y
D. Heroine
op
E. Ecstasy
The first noticeable effects of LSD are primarily on the five senses: sight, hearing,
C
touch, smell and taste. Colors seem more vivid and luminous; hearing becomes more
acute; the sense of touch is intensified.
n
LSD can cause visual hallucinations, agitation, excitement, tachycardia and dilated
io
pupils. Hypertension and pyrexia may occur. Acute harmful effects are behavioural
toxicity (i.e. harm related to acting on beliefs such as having the ability to fly).
t
Treatment is supportive.
ua
95. A 45 year old woman has been extensively investigated for a lump she believes to be
cancer. All investigations done show that the lump is unlikely to be cancer however
al
she is not convinced and does not think the doctors are taking her seriously. She has
demanded for another referral. What is the SINGLE most appropriate term that
Ev
describes her condition?
A. Munchausen's syndrome
B. Munchausen’s by proxy
C. Hypochondriasis
D. Malingering
E. Conversion disorders
Her obsession and persistent belief that there is an underlying serious disease is
evidence of hypochondriasis. As there is actually a lump and she is not falsifying the
symptoms, it is not Munchausen's syndrome or malingering.

1374
Munchausen’s syndrome by proxy → manifest by a person feigning or inducing

illness in a child (or others) in order to obtain medical attention. It is a form of child
abuse in that it subjects the child to emotional abuse, unnecessary medical
procedures, hospitalization or other treatments that are harmful to the child.


y
op
96. A 34 year old man suffering from schizophrenia laughs inappropriately while talking
C
about his father’s death with his siblings. What is the SINGLE most appropriate term
that describes this?
n
A. Flight of ideas
io
B. Flat affect
C. Emotional liability
t
D. Incongruent affect
ua
Incongruent affect
al
The term “incongruent” means out of place. Incongruent affect is sometimes seen in
schizophrenia where their behaviour is out of place. Example, talking about problems
Ev
in their family while laughing or laughing when your pet dies.
97. A 28 year old schizophrenic man refuses to let his father into the house because he
has the delusion that his father has been replaced by an identical looking impastor.
He easily recognised other family members but would misidentify his father only.
What is the SINGLE most likely condition he is suffering from?
A. Capgras syndrome
B. Ganser syndrome
C. Todd's syndrome
E. Cotard syndrome

1375
trial.
Todd's syndrome → Also known as “Alice in Wonderland Syndrome”. It involves

perceptual distortions of the size or shape of objects and altered body images.
Patients may feel as though their body is expanding or getting smaller.
Frégoli delusion (Delusion of doubles) → is when a person holds a delusional belief

that different people are in fact a single person who changes appearance or is in
y
disguise.
op
C
n
98. A 33 year old man who lives with his mother, always thinks when the traffic lights
io
turn red, his mother is calling him to come home. This is followed by his actions to
drive back home. What is the SINGLE most likely diagnosis?
t
ua
A. Obsessive compulsive disorder (OCD)

B. Generalised Anxiety Disorder (GAD)
C. Schizophrenia
al
D. Bipolar disorder
E. Cyclothymia
Ev
He thinks that the changing of traffic lights are giving him a message. These are called
delusional perceptions and are a feature of schizophrenia.
Schizophrenia
Features
Thought disorder:
1376
99. A 33 year old schizophrenic man hears people only when he is about to fall asleep.
What is the SINGLE most likely phenomenon?
y
op
A. Hypnopompic hallucinations
B. Hypnagogic hallucinations
C. Hippocampal hallucinations
C
D. Delirious hallucinations
E. Auditory hallucinations
n
Hypnagogic hallucination is a transient false perception experienced while on the
io
verge of falling asleep (e.g. hearing a voice calling one’s name which then startles you
back to wakefulness to find no-one there). The same phenomenon experienced while
t
waking up is called hypnopompic hallucination. Frequently experienced by healthy

ua
people and so not a symptom of mental illness.
100. A 30 year old man complains of episodes of hearing music and threatening voices
al
within a couple of hours of heavy drinking with his friends at a friends birthday party.
Ev
A. Delirium tremens
B. Wernicke’s encephalopathy
C. Korsakoff’s psychosis
D. Alcohol hallucinosis
E. Temporal lobe dysfunction
Alcohol hallucinosis can occur during acute intoxication or withdrawal. It usually

appears 12-24 hours after alcohol has stopped. It involves auditory and visual
hallucinations, most commonly accusatory or threatening voices.
The answer is unlikely to be delirium tremens because of the time frame in which he
was drinking alcohol. Delirium tremens usually happens days after alcohol
consumption has been stopped and he would need to be a chronic alcoholic.
Again, since there are no signs and symptoms of chronic alcohol abuse, it is unlikely
1377
to be Wernicke’s encephalopathy or Korsakoff’s psychosis.
Alcohol withdrawal symptoms:

• Symptoms typically present about eight hours after a significant fall in blood
alcohol levels. They peak on day 2 and, by day 4 or 5, the symptoms have
usually improved significantly.
• Minor withdrawal symptoms (can appear 6-12 hours after alcohol has
stopped)
• Alcoholic hallucinosis (can appear 12-24 hours after alcohol has stopped).
This includes visual, auditory or tactile hallucinations.
• Withdrawal seizures (can appear 24-48 hours after alcohol has stopped).
These are generalised tonic-clonic seizures
Delirium tremens
y
op
occur. C
sweating, and fear. She notices her hands shake when they occur. These episodes
occur almost everyday and sometimes can wake her from her sleep. She has no
n
previous psychiatric disorder and is not on any medications. What is the SINGLE most
io
likely diagnosis?
t
ua
B. Panic disorder
D. Agoraphobia
al

Ev
Panic disorder
Symptoms/signs
medical services.
102. A 52 year old woman has been depressed ever since her husband died half a year
ago. She was started on amitriptyline by her GP 3 months ago to help battle her
1378
depression. She now feels much better and sleeps well. She still think about her
husband occasionally and the thoughts bring her mood down but she has drastic
improvements as compared to a few months ago. She wants to know if she can stop
medication. What is the SINGLE best advice to give her?
A. Stop amitriptyline and start cognitive behavioural therapy (CBT)

B. Stop amitriptyline and start bereavement counselling
C. Stop amitriptyline and start psychoanalysis
D. Stop amitriptyline and review in 4 weeks
E. Continue amitriptyline for another 3 more months
Continuing therapy for at least 6 months is advised as to reduce risk of relapse even
when patients are feeling “better”. Patients should be reassured that antidepressants
are not addictive.
Depression is an important feature of bereavement. We note a good response with

this lady as she she feels better and sleeps well. But antidepressive therapy should
still be continued for another 3 more months (6 months in total) to reduce risk of
y
relapse.
103.
op
A 37 year old man was recently sent to jail for breaking all the windows of a shop
with his bat. When the manager tried to stop him, he hit the manager on the head.
C
He has a history of many convictions and has been imprisoned many times. He finds it
difficult to keep close relationships. He has 2 boys with his ex--wife but does not
contact them. What is the most SINGLE most likely diagnosis?
n
io

B. Schizophrenia
t
C. Avoidant personality disorder

ua
D. Histrionic personality disorder

E. Antisocial behavior disorder
al
Antisocial Personality disorder

Characterized by continuous antisocial or criminal acts, inability to conform to social
Ev
rules, impulsivity, disregard for the rights of others, aggressiveness, and lack of
remorse. They will typically be manipulative, deceitful and reckless.
Like other types of personality disorder, antisocial personality disorder is on a
spectrum, which means it can range in severity from occasional bad behaviour to
repeatedly breaking the law and committing serious crimes. Psychopaths are
considered to have a severe form of antisocial personality disorder
104. A 35 year old male is bitterly annoyed with everyone around him. He complains that
they are putting ideas into his head. What is the SINGLE most likely phenomenon?
A. Thought block
E. Thought echo
1379
Thought insertion is the delusional belief that thoughts are being placed in the
patient’s head from outside. It is a first-rank symptom of schizophrenia.
Schizophrenia
Features
Thought disorder:
y
op
C
n
io
t

ua
105. A 64 year old woman has been brought by her son for psychiatric evaluation. She says
that she has stopped living with her husband because she is convinced that it is
al
someone else posing to be him. What is the SINGLE most likely condition she is
suffering from?
Ev
A. Delusion of reference
B. Delusion of control
C. Cotard syndrome
D. Delusion of persecution
E. Capgras syndrome



1380

106. A 21 year old woman was brought to the Emergency Department by her boyfriend.
She has many self inflicted superficial lacerations on her forearm. She is distressed
and constantly says her boyfriend is going to end the relationship. She denies trying
to end her life. What is the SINGLE most likely diagnosis?
y
op
A. Acute psychosis
C
E. Schizophrenia
n
Borderline Personality Disorder
io
Usually characterized by mood swings, marked impulsivity, unstable relationships,

t
and inappropriate anger. They can be very dramatic. They are usually attention
ua
seekers and may have multiple self-inflicted scars. They may threaten to commit
suicide but do not actually attempt to do so.
al
107. A 33 year old women in the psychiatric ward diagnosed with schizophrenia,
complains that she is unable to think straight because the nurse is stealing her
Ev
thoughts. What is the SINGLE most likely phenomenon?
A. Thought block
E. Thought block
This is thought withdrawal. Which is the delusional belief that thoughts have been
'taken out' of his/her mind. It is commonly associated with thought block. But the
difference is that in thought block, there is a sudden break of chain of thought and no
one is stealing the ideas.
Schizophrenia
Features
1381
Thought disorder:
y
op
C
108. A 30 year old schizophrenic female attacks her mother believing that aliens have
n
replaced her with an exact double. What is the SINGLE most likely condition she is
io
suffering from?
t
A. Capgras syndrome
ua
B. Ganser syndrome
C. Todd's syndrome
D. Frégoli delusio
al
E. Cotard syndrome
Ev


trial.
1382
Todd's syndrome → Also known as “Alice in Wonderland Syndrome”. It involves
perceptual distortions of the size or shape of objects and altered body images.
Patients may feel as though their body is expanding or getting smaller.

disguise.

109. A 17 year old girl who was ‘fine’ until her boyfriend ended their relationship. Out of
anger, she took 10 tablets of paracetamol after drinking alcohol. She is brought into
A&E by her mother. What is the SINGLE most appropriate next course of action?
A. Refer to psychiatry
y
B. Liver transplant
op
C. Refer to GP
D. Discharge home. No referral needed.
E. Start N-acetylcysteine
C
Referral to psychiatric team would be the most accurate option here. Acute alcohol
consumption is an inhibitor of P-450 enzyme system. Since she has consumed alcohol
n
acutely, the risk of fatal effects of paracetamol poisoning would be reduced. Not to
io
mention that 10 tablets of paracetamol in a 17 year old is not life threatening. She
does however need a psychiatric evaluation before she leaves the hospital as she was
t
clearly trying to harm herself.

ua

al

Ev

• If ingestion of paracetamol is < 150mg/kg in a child/adult with no hepatic risk
factors
When to admit?
• Admit those presenting within 8h of ingesting >150mg/kg (or an unknown
amount)
(For the exam, it can be quite time consuming to multiply 150mg with the
weight of the patient. So we would advise you to use the number 24 as a
benchmark whereby if the patient consumes more than 24 tablets (12 g) of
paracetamol, then you admit him/her)
1383
• At ≥4h post ingestion if consumed >150mg/kg (or an unknown amount)

• If presenting < 1h, and >150mg/kg of tablets ingested

• If there is a staggered overdose (Note: a staggered overdose is if all the
tablets were not taken within 1 hour); or
• If there is doubt over the time of paracetamol ingestion, regardless of the
plasma paracetamol concentration; or
• If plasma paracetamol concentration (taken 4 hours post ingestion) is above
the appropriate line
• If patients presents late (>8h) and ingested dose is >150mg/kg, (or dose is
unknown)
110. A 22 year old man is distressed that he hears the voice of his deceased uncle telling
him that he is being spied on. He feels low in mood and anxious. He has not left the
house for 2 weeks and has recently starting to drink increasing quantities of alcohol
y
due to his anxiety. His speeches are interrupted with silence for a few seconds
op
followed by topics unrelated to what was being discussed. He feels he is no longer in
control of his own body and thoughts. What is the SINGLE most suitable medication
to treat his symptom?
C
A. Diazepam
B. Disulfiram
n
C. Fluoxetine
io
D. Lithium
E. Olanzapine
t
ua
This individual is suffering from schizophrenia. The speeches that are interrupted
with silence followed by an unrelated topic is called thought blocking. The feature
that he is no longer in control of his own body and thoughts is called passivity
al
phenomenon. Both of these are features of schizophrenia.

Ev
First-line treatment in newly diagnosed schizophrenia involves the use of the newer
atypical antipsychotics like olanzapine or risperidone.
Benzodiazepines are only used if rapid tranquillisation is needed. This may be the
choice if the scenario involved a violent, aggressive patient.
111. A 37 year old woman who delivered 3 days ago is now concerned about her mood.
She has trouble sleeping and feels generally anxious and tearful. She is unable to
explain why she is crying all the time. She has no history of mental health disorders in
the past. What is the SINGLE most appropriate management?
A. Citalopram
B. Cognitive behavioral therapy (CBT)
C. Fluoxetine
D. Reassurance
E. Admit mother to mother and baby unit
1384
The diagnosis here is baby-blues which is seen in around 3/4 of women after
delivering. Whilst poor sleep could potentially be a sign of depression, poor sleep is
expected with a new baby.
Baby blues
Up to 75% of new mothers will experience a short-lived period of tearfulness and
emotional lability starting two or three days after birth and lasting 1–2 days. This is
common enough to be easily recognizable by midwifery staff and requires only
reassurance and observation towards resolution.

days
y
op
baby harming baby
C
E.g. hears voices
n
not capable of
io
child
Disorientation
t

ua

mother suicide
al
Tearful, Anxiety
Ev
Worries about
baby’s health

112. A 36 year old woman contacts the police to notify them that she was responsible for
a recent disastrous flood which had resulted in loss of lives. What is the SINGLE most
likely kind of delusions she is suffering from?
B. Frégoli delusion
C. Delusion of guilt
1385

disguise.
y
op
C
113. A 52 year old woman speaks rapidly without any pause and ignores interruptions. She
n
barely even pauses to take enough breaths. What is the SINGLE best term to describe
io
this kind of speech?

t
A. Flight of ideas
ua
B. Broca’s aphasia
C. Wernicke’s aphasia
D. Pressure of speech
al
E. Verbal dysphasia
Ev
Pressure of speech
Pressure of speech is a tendency to speak rapidly and frenziedly, as if motivated by an
urgency not apparent to the listener. The speech is rapid, difficult to interrupt, and,
with increasing severity of illness, the connection between sequential ideas may
become increasingly hard to follow. Pressure of speech is a hallmark of mania and is
often seen during manic periods in patients with bipolar disorder.
114. A 36 year old woman was recently admitted to a psychiatric ward. She believes that
the staff and other patients know exactly what she is thinking all the time. What is
the SINGLE most likely phenomenon
A. Thought insertion
B. Thought withdrawal
C. Thought block
D. Thought broadcasting
E. Hallucination
1386
Thought broadcasting is the delusional belief that one’s thoughts are accessible
directly to others. It is found in schizophrenia.
Schizophrenia
Features
Thought disorder:
y
op
C
n
io
t
ua
115. A 23 year old single male was brought to emergency department by his father
al
exhausted and frightened. His father tells you that his son, who was previously
healthy, had, for no apparent reason, a sudden attack of fear, dizziness, sweating,
Ev
palpitations and the feeling that his heart is going to stop beating. The symptoms
started to decrease gradually after about 10 minutes. Which is the SINGLE most
likely?
A. Panic attack
B. Delirious state
C. Alcohol withdrawal
D. Social phobia
Panic attacks

1387
Symptoms/signs
• Tremor
• Tachycardia
• Tachypnoea,
• Sweating

• SpO2
• ECG
• BMG
y
op
• CXR
• U&E, blood glucose, FBC C
Treatment
n
io

t
116. A 33 year old female presents to her GP because of low moods. She has difficulty
ua
sleeping and feels tired at work. She refuses to go out with her friends and rather
spends time resting on her bed. She is eating less and has lost 8 kg in the last 10
weeks. A year ago, she was productive, full of energy, optimistic, needed very little
al
sleep and always wanted to go out. Her BMI is 27. What is the SINGLE most likely
diagnosis?
Ev
A. Hypomania
B. Bipolar disorder
C. Borderline personality disorder
D. Depression
E. Mania
This stem portrays a good history of depression with a background of mania in the
past. The symptoms of mania in this stem is very subtle and somewhat within normal
limits but the real give away is when there is reduced need for sleep.
This would be a classic scenario that PLAB would give when they would like you to
pick Bipolar disorder.

1388

• Grandiosity
Treatment
y
117. A 20 year old boy is brought by his parents to the emergency department. He is
op
agitated and euphoric. The parents suspect that he has taken drugs. Examination
reveals a perforated nasal septum. What is the SINGLE most likely drug that was
taken?
C
A. Heroine
B. Cocaine
n
C. Ecstasy/MDMA/amphetamine
io
D. Alcohol
E. Opioids
t
ua
This is a high yield question in PLAB. The perforated nasal septum is a huge clue that
the route of intake is nasally inhaled. In majority of cases, the answer when you see
that term is cocaine. This along with the signs and symptoms of euphoria and
al
agitation points towards cocaine.

Ev
Cocaine
Cocaine is an alkaloid derived from the coca plant. It is widely used as a recreational
stimulant.
The main route of intake is by inhalation as it undergoes rapid ‘first pass’ liver
metabolism.
The user forms the powder into ‘lines’ and inhales via rolled paper tube (classically, a
high denomination bank note).
There is increased energy, increased confidence, euphoria, and diminished need for
sleep, but with rapid fall-off in effects due to rapid metabolism, leading to repeated
use.
The use of cocaine is associated with a wide variety of adverse effects:
Cardiovascular effects
1389
• arrhythmias
• both tachycardia and bradycardia may occur
• hypertension
Neurological effects
• seizures
• mydriasis
• hypertonia
• hyperreflexia
Psychiatric effects
• agitation
• psychosis
Others
• effects include necrosis of nasal septum
118. A 38 year old women believes that a famous politician has been sending her flowers
y
every day and is in love with her. She says that he drops hints that he loves her when
op
he speaks publicly on television. The famous politician has had no contact with this
lady. What is the SINGLE most likely diagnosis?
C
A. Pyromania
B. Erotomania
C. Rejected stalker
n
D. Trichotillomania
io
E. Grandiosity
t
Erotomaniac stalkers have the delusional belief that another person, usually of higher
ua
social status, is secretly in love with them. The sufferer may also believe that the
subject of their delusion secretly communicates their love through seemingly
innocuous acts, or if they are a public figure through clues in the media. The object of
al
the delusion usually has little or no contact with the sufferer, who often believes the
object initiated the fictional relationship. Erotomaniac delusions are typically found
Ev
as the primary symptom of a delusional disorder, and in schizophrenia or mania.
Definitions of other options given in this question
Pyromania → an impulse control disorder in which individuals repeatedly fail to resist

impulses to deliberately start fires, in order to relieve tension or for instant
gratification.
Rejected stalker → Pursues a victim in order to reverse, correct, or avenge

rejection (e.g. divorce, separation, termination of relationship).
Trichotillomania → an impulse disorder characterized by the compulsive urge to pull

out one's hair, leading to noticeable hair loss and balding.
Grandiosity → An exaggerated sense of one’s own importance or abilities. Seen in

manic illnesses.
1390
119. A 27 year old man presents with symptoms characterized by alternating mood swings
associated with flight of ideas, and overactivity. Three months ago he had low moods
with lack of energy. What is the SINGLE most likely diagnosis?
A. Bipolar affective disorder

B. Dysthymia
C. Mania
D. Hypomania
E. Cyclothymia
It is clear that this patient is having periods of depression with other periods of
mania.
Flight of ideas is thought that jumps from topic to topic. It is the subjective
experience of one’s thoughts being more rapid than normal. Meaningful connections
between thoughts are maintained. It occurs especially in the manic phase of bipolar
disorder.
y
op
C
n
io

t
ua

• Grandiosity
al

Ev
Treatment
120. A 55 year old man is brought to the GP surgery by his wife for a review of a growth on
his forehead. His wife wants the growth removed but he refuses and says that the
growth helps him think clearly. What is the SINGLE most appropriate next course of
action?
A. Assess his mental capacity to refuse treatment

B. Remove the lesion
C. Refer to A&E
D. Perform a Mini Mental Status Examination (MMSE)
E. Refuse surgery and review in 2 weeks
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Assessment of his mental capacity to refuse treatment would be the most
appropriate next course of action. If his state of mind is fine, we can follow his
instructions and leave the lesion there. But obviously, his mental state is not fine as
he believes that this growth helps him think clearly.
Mini Mental Status Examination (MMSE) is to assess patients with dementia. All
patients with cognitive impairment should be assessed with a Mini Mental Status
Examination (MMSE) to identify the areas of cognitive impairment.
121. A 56 year old chronic alcoholic man wants to attend his daughter’s wedding in 2
weeks and does not want to be drinking during the wedding. He says he is
determined to quit drinking alcohol but wants extra help. What is the SINGLE most
appropriate medication?
A. Acamprosate
B. Refer to clinical psychologist
C. Vitamin B12
D. Desipramine
y
E. Refer to community mental health support group
op
Acamprosate, in combination with counselling, may be helpful for maintaining
abstinence in alcohol-dependent patients. It is useful for patients who are concerned
C
that strong cravings will result in relapse.
Clinical psychologist and mental health support groups are wrong places to refer a
n
chronic alcoholic.
io

t

ua
• Disulfiram
al

• Acamprosate
Ev
122. A 35 year old man is seen by his psychiatrist for severe depression. He says that the
world has ended and is no longer real. He thinks that he no longer exist in this world.
He barely has eye contact with the psychiatrist. What is the SINGLE most appropriate
diagnosis?
B. Hypochondriasis
E. Capgras syndrome
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y
op
123. A 32 year old lady has recently become more active over the past year. She sleeps
less and recently bought a house and 2 new cars. She notices that her sex drive has
increased. She often starts a task but is not able to finish it as she has difficulty in
C
focusing on one task alone. What is the SINGLE most likely diagnosis?
A. Bipolar disorder
n
B. Mania
io
C. Hypomania
D. Schizophrenia
t
E. Attention deficit hyperactivity disorder (ADHD)

ua
The symptoms here are representative of hypomania which can be thought of as a

milder form of mania. With hypomania, there is higher than normal energy levels but
al
they do not generally lead to hospitalization whereas manic episodes usually last for
a week or more and may result in hospitalization.
Ev
Usually, if the stem includes grandiose ideas, hallucinations or delusions PLUS

elevated moods, then pick mania, otherwise pick hypomania.
It is especially important to remember that hypomania does NOT present with

hallucinations or delusions. This would often be the difference between picking
mania and picking hypomania as the answer.
Mania Hypomania
Abnormally elevated mood A lesser degree of mania with persistent
mild elevation of mood and increased
activity and energy
Hallucinations or delusions No hallucinations or delusions
Significant impairment of the patient’s No significant impairment of the
day-to-day functioning patient’s day-to-day functioning
These are classic signs of mania and hypomania:
1393
• Elevated mood
• Irritability
• Increased energy and activity →This may be seen as increased performance
at work or socially
• Increased self-esteem
• Increased sociability and talkativeness
• Increased sex drive
• Reduced need for sleep
• Difficulty in focusing on one task alone (tasks often started, but not finished)
The presence of psychotic symptoms differentiates mania from hypomania
Psychotic symptoms
• Delusions of grandeur
• Auditory hallucinations
Remember, for the exam:

• If you see a patient with high moods → Likely to be hypomania
y
• If you see a patient with high moods and other times depressive moods →
op
Likely to be bipolar disorder
• If you see a patient with high moods and psychotic symptoms → Likely to be
mania
C
124. A 23 year old man feels anxious and agitated when faced with stress. He has an
interview in 3 days and would like some help in relieving his symptoms for the
n
interview. What is the SINGLE most appropriate management?
io

t
B. Cognitive Behavioural Therapy

ua
C. Propranolol
D. Diazepam
E. Rebreath into paper bag
al
Medication usually is not used to treat phobias. However, it is sometimes prescribed

Ev
to help people cope with the effects of anxiety. Beta-blockers are commonly used. It
would be appropriate here as it is only for short term.
125. A 33 year old schizophrenic says the following. “Life is unfair, I eat air, lawn chair, I
like fairs, fairs have food, it must be good, in adulthood, I misunderstood”. What term
describes this patient’s speech?
A. Neologism
B. Pressure of speech
C. Broca’s aphasia
D. Wernicke’s aphasia
Clang association
Clang association is an abnormality of speech where the connection between words
is their sound rather than their meaning. May occur during manic flight of ideas.
Clang associations generally sound a bit like rhyming poetry, except that the poems
1394
don't seem to make any sense. Example, one may say “systematic, sympathetic, quite
pathetic, apologetic, paramedic, your heart is prosthetic.
126. A 62 year old woman who had a repair of strangulated femoral hernia 2 days ago
becomes aggressive and confused. This is followed by a seizure. Her blood tests
show:
Haemoglobin 129 g/L

Gamma glutamyl transferase (yGT) 120 u/L
A. Electrolyte imbalance
B. Delirium tremens
D. Korsakoff’s psychosis
y
E. Hypoglycaemia
op
Abstinence from alcohol in the hospital can cause delirium tremens. The chronic
alcoholism is supported by high MCV and GGT here. The GGT result is more useful
C
than the MCV result as a “red flag” to raise the suspicion that the person is drinking
too much.
n
Symptoms fit delirium tremens. Seizures can be seen in delirium tremens. It is
io
unlikely to be Wernicke’s encephalopathy or Korsakoff’s psychosis as in PLAB they

would usually have a triad of confusion, ataxia and ophthalmoplegia
t
ua
Delirium tremens
al

Ev

occur.
127. A 24 year old woman has severe depression 3 months after the birth of her first child.
She is breastfeeding but has not cleaned herself or her newborn child for the last 3
weeks. She has lost interest in her hobbies and keeps crying. Her husband is
concerned and has brought her to the hospital. However, she is convinced that her
husband and her family wants to take her baby away and is likely to kill her. What is
the SINGLE most appropriate treatment?
A. Fluoxetine
B. Citalopram
D. Electroconvulsive Therapy (ECT)
E. Haloperidol
1395
She has signs of depression and the thoughts of her family and husband trying to
harm her are signs of postpartum psychosis. She needs ECT.
the baby
Management
y
op
C
days
n
baby harming baby
io

t
E.g. hears voices

ua

not capable of
al
child
Disorientation
Ev

mother suicide
Tearful, Anxiety
Worries about
baby’s health

128. A 29 year old women has been taking selective serotonin reuptake inhibitors for the
past 6 months for depression after the death of her husband 10 months ago. She
feels her symptoms have improved and has decided to stop her medications. Several
weeks after discontinuing her medications, she feels she has developed pancreatic
1396
cancer similarly to her late husband. What is the SINGLE most appropriate next step
in management?
A. Restart selective serotonin reuptake inhibitors

B. Start on a tricyclic antidepressant
C. Neuropsychiatric analysis
E. Start antipsychotics
This women requires a psychiatric referral i.e. Neuropsychiatric analysis.
She is having a hypochondriacal delusion. Hypochondriasis can be defined as the

persistent belief in the presence of an underlying serious DISEASE, e.g. cancer or HIV.
Examples
• A minor headache is caused by a brain tumour
• A mild rash is the start of skin cancer
• Tiredness is caused by HIV
y
op
Reassurance by a doctor will not help a hypochondriac as a hypochondriac would fear
that the doctor has just not found the evidence of a serious disease yet.
C
129. A 62 year old schizophrenic man is brought to the Emergency Department in an
agitated state. He is lashing out violently and throws any equipment around him at
the hospital staff. He seems to be hearing voices which are causing him distress.
n
Which drug due to it’s relative lack of autonomic side effects is a drug of choice in the
io
management of agitation in this man?

t
A. Haloperidol
ua
B. Diazepam
C. Risperidone
D. Clozapine
al
E. Olanzapine
Ev
In acute psychosis, the drug of choice is haloperidol. It is still considered a first line
medication for rapid tranquilization.
Haloperidol due to its relative lack of autonomic side effects (like orthostatic
hypotension) is a drug of choice for the management of psychotic episodes
particularly in the elderly.
130. A 44 year old alcoholic was admitted for alcohol intoxication. He has been treated
and he is now planned for discharge. He admits to not being able to spend a day
without drinking. Which of the following statement would show that this man is still
dependant on alcohol?
A. Drinks 10 units of alcohol a week

B. Drunk driving
C. Does not feel remorse after drinking
D. Drinks wine to help him sleep
E. Drinking alcohol immediately after waking up
1397
This questions is testing your knowledge on the AUDIT questionnaire.
There are many alcohol screening tools and questionnaires but the AUDIT
questionnaire remains one of the top and a must know for the exam. The AUDIT
questionnaire stands for Alcohol Use Disorders Identification Test questionnaire.
The CAGE Questions is also another questionnaire but the AUDIT questionnaire
remains the more detailed of the two.
AUDIT questionnaire involves questions like:

• How often do you have a drink containing alcohol?
• How many units of alcohol do you drink on a typical day when you are
drinking?
• How often have you had 6 or more units if female, or 8 or more if male, on a
single occasion in the last year?
• How often during the last year have you found that you were not able to stop
drinking once you had started?
y
• How often during the last year have you failed to do what was normally
op
expected from you because of drinking?
• How often during the last year have you needed an alcoholic drink in the
morning to get yourself going after a heavy drinking session?
C
• How often during the last year have you had a feeling of guilt or remorse
after drinking?
• How often during the last year have you been unable to remember what
n
happened the night before because you had been drinking?
io
• Have you or someone else been injured as a result of your drinking?

• Has a relative or friend or a doctor or another health worker been concerned
t
about your drinking or suggested you cut down?

ua
al
Ev
1398
RESPIRATORY
y
op
C
Questions
n
io
&
t
ua
Answers
al
Ev
1399
Respiratory Medicine
1. A 28 year old male is admitted with acute exacerbation of asthma. He has a temperature
of 38.1°C and a productive cough. He is treated initiated with 100% oxygen and
salbutamol nebulizers. Despite treatment, his oxygen saturation is 88% and respiratory
rate is 34 breaths/minute. What is the SINGLE most appropriate next step in
management?
A. Hydrocortisone IV
B. IV antibiotics
C. IV salbutamol
D. IM adrenaline
E. IV adrenaline
2. A 27 year old female attends outpatient department with a fever and dry cough. She has
had a headache, muscle pain and joint pain for more than one week. She has a
temperature of 37.5°C, a pulse of 100 beats/minute, a blood pressure of 110/70 mmHg
and a respiratory rate of 20 breaths/minute. A Chest X-ray report shows bilateral patchy
y
consolidation. What is the SINGLE most likely causative organism?
op
B. Legionella
C. Mycoplasma pneumoniae
C
D. Klebsiella
E. Chlamydia pneumoniae
n
io
3. A 74 year old man who has been a smoker since he was 20 has recently been diagnosed
with small cell lung cancer. What Is the SINGLE most likely serum electrolyte picture that
t
confirms the presence of Syndrome of inappropriate antidiuretic hormone secretion

ua
(SIADH)?
A. High serum Na, low serum osmolality, high urine osmolarity

al
B. Low serum Na, low serum osmolality, high urine osmolarity

C. Low serum Na, high serum osmolality, high urine osmolarity
Ev
D. High serum Na, low serum osmolality, low urine osmolarity

E. High serum Na, high serum osmolality, low urine osmolarity
4. A 68 year old man has malaise and cough for 5 days. He has a temperature of 38.5°C.
There is dullness on percussion of the left lung base. What is the SINGLE most
A. Bronchoscopy
B. Chest X-ray
C. CT chest
D. MRI
E. V/Q scan
5. A 16 year old boy who attends boarding school feels unwell. He developed a dry cough
for the last few days. On examination, there are target lesions seen on the back of his
hands. A chest X-ray was performed and it shows bilateral consolidations. What is the
1400
B. Legionella
D. Klebsiella
6. A 33 year old man is referred for an X-ray as he complains of a persistent cough, chest
pain and excessive purulent sputum. He has a history of recurrent chronic chest
infections. On examination, drumstick-shaped fingers were noted. What is the SINGLE
A. Fibrosing alveolitis
B. Mesothelioma
C. Bronchiectasis
D. Pulmonary tuberculosis
E. Bacterial endocarditis
7. A 22 year old man presents with episodes of dyspnoea, starting suddenly. This
y
usually occurs when he is in a crowded area like a lift. When he is breathless, he
op
also notices tingling around his mouth and he feels light-headed. These episodes
usually go away after a while. An arterial sample was taken for blood gases
during one of the episodes. What is the SINGLE most likely result of the arterial
C
blood gas (ABG)?
n
Normal Values:
io
Pa02 > 10 kPa

t
PaCO2 4.7–6 kPa

ua
pH 7.35 - 7.45
Bicarbonate (HCO3-) 22-26 mmol/L
al
A. Pa02 = 8.1 kPa, PaCO2 = 2.6 kPa, pH = 7.55, HCO3- = 26 mmol/l

B. Pa02 = 13.6 kPa, PaCO2 = 2.5 kPa, pH = 7.56, HCO3- = 13 mmol/l
Ev
C. Pa02 = 13.5 kPa, PaCO2 = 6.3 kPa, pH = 7.28, HCO3- = 24 mmol/l

D. Pa02 = 8.3 kPa, PaCO2 = 6.4 kPa, pH = 7.27, HCO3- = 24 mmol/l
E. Pa02 = 13.1 kPa, PaCO2 = 2.7 kPa, pH = 7.57, HCO3- = 25 mmol/l
8. A 10 year old girl with diagnosed asthma is having frequent coughs and wheezing that
wakes her up at night. She is compliant with her asthma medication of inhaled
corticosteroid 800 mcg/day, short-acting bronchodilators as required, inhaled long-
acting B2 agonist (LABA) and theophylline. Her inhaler technique is good. What is the
A. Add oral corticosteroids

B. Increase dose of inhaled corticosteroids
C. Add sodium cromoglycate
D. IM adrenaline
1401
9. A 26 year old smoker has a history of wheezing, chest tightness and breathlessness at
night and early morning. Her past medical history includes eczema. What is the SINGLE
A. COPD
B. Asthma
C. Pneumoconiosis
D. Bronchiectasis
E. Chronic bronchitis
10. A 28 year old male is admitted with acute exacerbation of asthma. He is treated initiated
with 100% oxygen, salbutamol nebulizers and hydrocortisone 100mg IV. Despite
treatment, his oxygen saturation is 89% and respiratory rate is 30 breaths/minute. What
is the SINGLE most appropriate next step in management?
A. Prednisolone 40mg PO
B. Add in ipratropium 0.5 mg to nebulizers
C. IV salbutamol
y
D. IM adrenaline
op
E. Stop administration of oxygen
11. A 22 year old, tall thin man develops sudden chest pain and becomes breathless while
C
driving. There is no history of trauma. What is the SINGLE most appropriate
investigation?
n
A. Cardiac enzymes
io
B. Chest X-ray
C. CT
t
D. ECG
ua
E. V/Q scan
12. A 56 year old man complains of increased volume of sputum with specks of blood and
al
chest pain. He has a history of recurrent chronic chest infections and deep vein
thrombosis which happened 3 years ago. Finger clubbing was noted on examination. A
Ev
chest X-ray shows tramlines but is otherwise normal. What is the SINGLE most likely
diagnosis?
B. Bronchial carcinoma
C. Bronchiectasis
E. Chronic sinusitis
13. A 6 year old girl has had 2 short episodes of cough and wheeze over the last 12 months.
These 2 acute episodes responded quickly to bronchodilator. She has no symptoms or
abnormal physical signs at the moment. She has slight eczema and her mother has a
history of asthma when she was young. What is the SINGLE most appropriate
investigation?
A. Chest X-ray
B. Peak flow rate diary
1402
C. Pulse oximetry
D. Spirometry
E. Sweat test
14. A 34 year old HIV positive man presents with fever, dry cough and shortness of breath.
He is tachypnoeic but his chest is clear. Oxygen saturation is normal at rest but drops on
exercise. What is the SINGLE most likely diagnosis?
A. Cytomegalovirus infection
C. Pneumocystis carinii infection
D. Cryptococcal infection
E. Toxoplasmosis
15. A 56 year old man who has a history of hypertension and asthma recently had a change
of medication which was prescribed by his GP. 2 days after starting the new medication,
he develops wheezing and shortness of breath. What is the SINGLE most likely
y
op
A. Atenolol
B. Ramipril
C
D. Verapamil
E. Furosemide
n
16. A 29 year old woman has been short of breath for the last 15 hours and is feeling unwell.
io
An arterial blood gas is taken:

t
PaO2 8.8 kPa

ua
PaCO2 3.2 kPa

pH 7.50
Bicarbonate (HCO3–) 20 mmol/L
al
Normal Values:
Ev
Pa02 > 10 kPa

PaCO2 4.7–6 kPa
pH 7.35 - 7.45
A. Diabetic ketoacidosis
B. Methanol overdose
C. Panic attack
D. Pulmonary embolus
E. Severe vomiting
17. A 33 year old man has mild headache and myalgia for 2 days followed by high fever,
chills, rigors and a cough. His cough was initially dry but progressed to be productive. He
has just returned from a conference in Greece where he mentions that he swam and
used the hot tubs in the hotel. He has a temperature of 38.1°C and is seen to be
1403
dyspnoeic. Chest X-ray shows patchy alveolar infiltrates. What is the SINGLE most likely
organism which would have caused his symptoms?
A. Legionella pneumophila
B. Mycoplasma pneumoniae
C. Staphylococcus aureus
D. Streptococcus pneumoniae
18. A 56 year old lady with lung cancer presents with urinary retention, postural
hypotension, diminished reflexes and sluggish pupillary reaction. What is the SINGLE
most likely explanation for her symptoms?
A. Paraneoplastic syndrome
B. Progression of lung cancer
C. Brain metastasis
D. Hyponatraemia
E. Spinal cord compression
y
op
19. A 25 year old tall man presents to A&E with increasing dyspnoea and right sided chest
pain. He has been a heavy smoker for the past 4 years. He has no past medical history.
C
B. Myocardial infarction
n
C. Asthma
io
D. Pleural effusion
E. Primary Pneumothorax
t
ua
20. A 34 year old woman with a smoking history has had an uneventful laparoscopic
cholecystectomy 18 hours ago. She is now complaining of shortness of breath. She has a
pulse rate of 108 bpm and a temperature of 37.8°C. There are signs of reduced air entry
al
at the right base. Chest X-ray shows no obvious abnormality. What is the SINGLE most
Ev
A. Unfractionated heparin
B. IV Ceftriaxone
C. PO Chlorpheniramine
D. Chest physiotherapy
E. D-dimers
21. A 65 year old retired builder complains of persistent dull chest pain and shortness of
breath. He is a smoker and started smoking since a young age. He looks thin and his
clothes are oversized. Finger clubbing is noted on examination. What is the SINGLE most
likely diagnosis?
B. Bronchiectasis
C. Tuberculosis
D. Mesothelioma
E. Cystic fibrosis
1404
22. A 11 year old girl has a history of asthma and is currently on short-acting
bronchodilators. Her parents feels that it is not well controlled as she frequently wakes
up at night with wheezing and coughing. Her inhaler technique is good. What is the

B. Add inhaled steroid
D. Add leukotriene receptor antagonist
E. Add inhaled long-acting B2 agonist (LABA)
23. A 10 year old boy who takes regular dose inhaled steroids for his longstanding asthma
has been advised to use bronchodilators to control his acute attacks. His parents are
unsure when he should use his bronchodilator. What is the SINGLE most appropriate
investigation to perform?
A. Chest X-ray
y
B. Pulmonary function test
op
C. Peak flow rate diary
D. Pulse oximetry
E. Blood test to look for eosinophilia
C
24. A 38 year old woman is brought to the A&E after falling down the stairs and injuring her
rib. She complains of shortness of breath. A chest X-ray was performed to rule out a rib
n
fracture. Bilateral hilar lymphadenopathy was seen on the chest X-ray. On auscultation,
io
there are vesicular breath sounds. On examination, there are red lesions on both her
shins which are tender. What is the SINGLE most likely diagnosis?
t
ua
A. Bronchial asthma
B. Cystic fibrosis
C. Sarcoidosis
al
D. Bronchiectasis
E. Silicosis
Ev
25. A 19 year old man has a history of exercise induced asthma which has previously been
controlled using a salbutamol inhaler as required. He is taking beclomethasone inhaler
regularly but he now gets asthma attacks with exercise. What is the SINGLE most
appropriate action?
A. Add on tiotropium
B. Take regular salbutamol and add on budesonide inhaler
C. Add on sodium cromoglycate
D. Add on oral steroid
E. Increase Inhaled steroid
26. A 55 year old woman with a persistent cough and history of smoking develops left sided
chest pain exacerbated by deep breathing. She has a temperature of 38.2°C and basal
crackles are heard on auscultation. What is the SINGLE most likely diagnosis?
A. Dissecting aneurysm
1405
B. Pericarditis
C. Pneumonia
D. Pneumothorax
27. A 50 year old man has had hoarseness of voice and a left drooping eyelid for the past 2
months. He also has diminished sweating on same side of face. Finger clubbing is noted
on examination. He smokes 20 cigarettes a day for the last 30 years. What is the SINGLE
A. Laryngeal carcinoma
B. Thyroid carcinoma
C. Carcinoma of right bronchus
D. Mesothelioma
E. Pancoast tumour
28. A 65 year old known case of liver cancer and metastasis presents with gastric reflux and
bloatedness. Osteoporosis was diagnosed on a dexa scan. He also has shortness of
y
breath and basal consolidation in the left lung was seen on a Chest X-ray. What is the
op
A. Proton pump inhibitor IV

C
B. Alendronate
C. IV antibiotics
D. Analgesia
n
E. Proton pump inhibitor PO
io
29. A 68 year old woman presents to the emergency department from her nursing home
t
complaining of shortness of breath. She has a temperature of 38.7°C and productive

ua
cough. Her sputum is noted to be a rusty colour. On auscultation, crackles are heard
over the right lung base. A chest X-ray was done and shows right lower lobe
consolidation. She has a blood pressure of 100/65 mmHg and a pulse rate of 102
al
beats/minute. A urinalysis shows 1+ leucocytes with no nitrates or protein. What is the

SINGLE most likely organism causing her symptoms?
Ev
A. Streptococcus pneumoniae
C. Coxiella burnetii
D. Mycoplasma pneumoniae
E. Escherichia coli
30. A 29 year old HIV positive man attends the outpatient department with complaints of
persistent cough and copious amount of purulent sputum. He also has dyspnoea and
chest pain. On auscultation, inspiratory crepitations are heard at the base of the lung. A
chest X-ray shows tram track opacities. What is the SINGLE most likely diagnosis?
A. Interstitial lung disease

B. Bronchiectasis
C. Tuberculosis
D. Influenza
E. Sarcoidosis
1406
with 100% oxygen and salbutamol nebulizers. IV hydrocortisone was prescribed but it
was not available in the department. What is the SINGLE most appropriate next step in
management?
A. Oral prednisolone 40 mg
B. IV magnesium sulphate
C. IV salbutamol
D. IM adrenaline
E. IV adrenaline
32. A 24 year old male is admitted with acute severe asthma. He is treated initiated with
100% oxygen, nebulized salbutamol, and IV hydrocortisone. Ipratropium bromide was
added to nebulizers. Despite the initial treatment there has been no improvement. What
A. IV aminophylline
y
op
C. IV salbutamol
D. IM adrenaline
E. IV adrenaline
C
33. A 45 year old chronic smoker attends the outpatient department with complaints of
persistent cough and copious amount of purulent sputum. He had history of measles in
n
the past. On examination, finger clubbing is noted and inspiratory crepitations on
io
auscultation is heard. A chest X-ray shows tram track opacities. What is the SINGLE most
likely diagnosis?
t
ua

B. Bronchiectasis
C. Asthma
al
D. COPD
E. Sarcoidosis
Ev
34. A 64 year old man who was previously exposed to asbestos for 35 years while working as
a builder has chest pain and shortness of breath. The diagnosis of mesothelioma has
been made. His shortness of breath has been worsening over the last couple of days. A
recent chest x-ray shows bilateral pleural effusion. What is the SINGLE most appropriate
management?
A. Indwelling pleural drain

B. Physiotherapy
C. Radiation therapy
D. Pneumonectomy
E. Chemotherapy
with 100% oxygen. He continues to deteriorate. What is the SINGLE most appropriate
next step in management?
Plab Lab Values
1407
A. Salbutamol nebulized with oxygen
C. IV salbutamol
D. IM adrenaline
E. IV adrenaline
persistent cough, copious amount of purulent sputum and dyspnoea. He has a history of
recurrent chest infections in the past. Coarse crackles are found at the base of his lung
on auscultation. Bronchiectasis is suspected. What is the SINGLE most definitive test to
diagnose bronchiectasis?
A. High-resolution computed tomography (HRCT) chest

B. Serum immunoglobulins
C. Chest X-ray
D. Lung function tests
E. Bronchoscopy
y
op
37. A 32 year old female smoker has a history of wheeze, shortness of breath and fever. Her
past medical history includes eczema. FEV1/forced vital capacity (FVC) was measured
and was found to be low. This was improved after taking bronchodilators. What is the
C
A. COPD
n
B. Infective exacerbation of asthma
io
C. Tuberculosis
D. Bronchiectasis
t
ua
38. A 17 year old boy with a history of asthma suddenly develops chest pain and increasing
breathlessness during a game of football. He has reduced breath sounds on the right
al
side. His oxygen saturation is 94% on air. What is the SINGLE most appropriate
investigation?
Ev
A. Sweat test
B. Chest X-ray
C. CT chest
D. Exercise challenge
E. D-dimer
39. An 8 year old girl with diagnosed asthma is having frequent night coughs and mild
exercise-induced wheezing. She is compliant with her asthma medication of inhaled
corticosteroid 400 mcg/day and short-acting bronchodilators as required. Her inhaler
technique is good. What is the SINGLE most appropriate next step in management?
A. Add leukotriene antagonist

B. Add oral theophylline
C. Add regular inhaled long-acting B2 agonist (LABA)
D. Increase dose of inhaled corticosteroid
E. Short course of oral corticosteroid
1408
40. A 50 year old chronic smoker attended the outpatient department with complaints of
chronic productive cough, dyspnoea and wheeze. A chest X-ray was ordered and
reported as hyperinflated lung with flattened hemidiaphragm and a small cardiac
silhouette. Full blood count shows an increase in haematocrit. What is the SINGLE most
likely diagnosis?

B. Wegener’s granulomatosis
C. Lung cancer
D. Chronic obstructive pulmonary disease (COPD)
E. Amyloidosis
41. A 62 year old man has been smoking 15 cigarettes a day for the past 40 years. His is a
retired builder and has been working since he was 24 year old. He presents with chest
pain, shortness of breath, and has lost significant weight over the last couple of years.
Chest X-ray shows bilateral fibrosis and left sided pleural effusion. What is the SINGLE
best investigations that will lead to diagnosis?
y
op
A. Acid fast staining
B. Cytology of pleural fluid aspiration
C
D. Pleural biopsy
n
42. A 53 year old man with previous history of chronic obstructive pulmonary disease
io
presents with breathlessness and purulent sputum. His oxygen saturation are 85% on
air. Arterial blood gas show:
t
ua
PaO2 = 7.6 kPa

PaCOS = 7.1 kPa
al
What is the SINGLE most appropriate initial management for his condition?
Ev
A. 24% oxygen
B. Mechanical ventilation
C. 100% oxygen
persistent cough and copious amount of purulent sputum. He has recurrent chronic
chest infections in the past. Finger clubbing is noted in examination and inspiratory
crackles are heard on auscultation. A chest X-ray was done and results were normal.
A. Emphysema
B. Rheumatoid arthritis
C. Bronchiectasis
D. Lung cancer
E. Sarcoidosis
1409
44. A 10 year old girl is brought to the emergency department by her dad after having fallen
in the park. Her elbows are full of cuts and she has not stopped crying since the injury.
Her medical history includes asthma. What is the SINGLE most appropriate analgesia to
administer?
A. Aspirin
B. Diclofenac
C. Co-codamol
D. Ibuprofen
E. Paracetamol
45. A 54 year old patient 7 days after a total hip replacement presents with acute onset
breathlessness, and chest pain. On examination, an elevated jugular venous pressure
was observed. Her right calf looks swollen. Her pulse rate is 95 bpm and respiratory rate
is 24/min. Which SINGLE investigations will be most helpful in leading to a diagnosis?
A. Chest X-ray
y
B. CT pulmonary angiogram (CTPA)
op
C. V/Q scan
D. D-Dimer
E. Doppler ultrasound of legs
C
46. A 61 year old man has suddenly become very short of breath. In the last hour, he has
had a CT-guided biopsy of a mass in the right lung. His temperature is 36.5°C, heart rate
n
is 120 bpm, BP 90/60 mmHg, and SaO 2 78% on 15L oxygen . He looks cyanosed, his
io
trachea is deviated towards the left, and breath sounds are much louder over the left
hemi-thorax. Which is the SINGLE most appropriate course of action?
t
ua

B. Urgent chest X-ray
C. Insertion of a cannula into the right second intercostal space
al
D. Insertion of a cannula into the left second intercostal space

E. Insertion of a chest drain
Ev
47. A 33 year old man has a temperature of 38.5°C, productive cough and chest pain on the
right side on inspiration. He has a blood pressure of 100/60 mmHg and a pulse rate of
108 beats/minute. He appears slightly short of breath and has an oxygen saturation of
94% on room air. What is the SINGLE most likely organism causing the patient's
symptoms?
A. Gram +ve cocci

B. Coagulase +ve cocci
C. Gram +ve Bacilli
D. Acid-Fast Bacilli
E. Gram –ve cocci
48. A 28 year old female who has returned from the USA to the UK presents to Accident &
Emergency with shortness of breath and a productive cough beginning 3 days after her
return to the United Kingdom. Her cough initially contained blood but is now dry. Her
1410
only significant history is that she is on the combined oral contraceptive pill. What is the
SINGLE most likely diagnosis for this woman’s symptoms?
A. Community acquired pneumonia

C. Pulmonary tuberculosis
D. Lymphoma
E. Lung cancer
49. A 70 year old man admits to asbestos exposure 20 years ago. He was a heavy smoker but
has quit smoking 3 years ago. He has noted weight loss and hoarseness of voice. Which
is the SINGLE most likely type of cancer associated with the risk factors and symptoms
present?

D. Nasopharyngeal carcinoma
y
E. Oral carcinoma
op
50. A 50 year old woman returned by air to the UK from Australia. 3 days days later, she
presents with a sharp chest pain and breathlessness. Her chest X-ray and ECG are
C
A. Bronchoscopy
n
B. Cardiac enzymes
io
C. CT pulmonary angiogram (CTPA)

D. MRI
t
E. Pulse oximetry
ua
51. A 20 year old man presents to A&E after having severe injuries from a road traffic
accident. On presentation he is breathless and has severe chest pain. A Chest X-ray
al
shows fractures of the 5th to 7th rib. His systolic blood pressure is 85 bpm, respiratory
rate is 25 breaths/min and his pulse rate is 110/min What is the SINGLE most
Ev
appropriate initial action?
A. Antibiotics
B. Analgesia
C. High flow oxygen
D. Secure venous access
E. Refer to surgeon
52. A 20 year old man suddenly develops shortness of breath over the last day. It started
when he was playing football. The shortness of breath was associated with right sided
pleuritic chest pain. On examination, reduced air entry with hyper-resonance was noted
over the right lung field. His oxygen saturation was 91% on room air. What is the SINGLE
A. Asthma
B. Spontaneous pneumothorax
C. Tension pneumothorax
1411
D. Sarcoidosis
E. Chronic obstructive pulmonary disease (COPD)
53. A 21 year old man has exercised induced asthma and is using a salbutamol inhaler as
required and beclomethasone inhaler 400 mcg/day. He complains of wheeze and
shortness of breath during exercise despite using salbutamol inhaler just before
exercise. What is the SINGLE most appropriate action?
54. A 60 year old lady is on treatment for ischaemic heart disease, hypertension and
hyperlipidaemia. During the night, she complains of wheezing and shortness of breath.
What is the SINGLE most likely medication that is responsible for her symptoms?
y
A. Amlodipine
op
B. Atenolol
C. Ramipril
D. Simvastatin
C
55. A 15 year old boy presents to the Emergency Department with a sudden onset of chest
n
pain and increasing shortness of breath during a beach volleyball game. He has a medical
io
history of asthma and is on a beta-2 agonist inhaler. On examination, there is no

cyanosis but there are reduced breath sounds on the left side. Which of the following is
t

ua
A. D-dimer
B. CT chest
al
C. Chest x-ray
D. Peak flow meter
Ev
E. Spirometry
56. An 8 year old boy diagnosed with asthma is on salbutamol inhaler and beclomethasone
inhaler. However, he wakes up at night with wheezing and shortness of breath. What is
A. Add inhaled long-acting B2 agonist (LABA)

B. Increase inhaled corticosteroid dose
C. Aminophylline
D. Oral prednisolone
E. Sodium cromoglycate
57. A 35 year old lady had an emergency C-section following an obstructed labour. Three
days post-op she develops a sudden onset of left sided chest pain associated with
breathlessness. Her heart rate is 105 bpm. Her left leg is swollen and is pain on
palpation. What is the SINGLE best investigation to provide a definitive diagnosis?
1412
A. Arterial blood gases
B. Chest X-ray
D. D-dimer
E. Electrocardiogram (ECG)
58. A 48 year old farmer presents with malaise, dry cough, chest tightness and shortness of
breath. The shortness of breath and cough started only a few hours ago. On
auscultation, a wheeze is heard throughout the chest. He has a temperature of 39.2°C, a
pulse of 96 beats/minute, a blood pressure of 110/70 mmHg and a respiratory rate of 29
breaths/minute. His chest X-ray shows diffuse micronodular interstitial shadowing. What
is the SINGLE most
C. Cryptogenic organizing pneumonia
D. Extrinsic allergic alveolitis
y
E. Progressive massive fibrosis
op
59. A 35 year old man presents with progressive breathlessness. He has a history of
polyarthralgia with painful red lumps appearing on his shins. They are cherry sized and
C
are about 20 or more in number. His chest X-ray shows bilateral hilar lymphadenopathy.
n
A. Bronchial asthma
io
B. Cystic fibrosis
C. Sarcoidosis
t
D. Bronchiectasis
ua
E. Pneumonia
60. A 33 year old man is brought into the emergency department following a road traffic
al
accident. He is seen to be very short of breath. He has no breath sounds over the right
side of his chest. On percussion, the right chest is noted to be hyper-resonant. On
Ev
examination, his trachea is deviated to the left. His heart rate is 120 beats/minute. His
blood pressure is 90/65 mmHg, and has an oxygen saturation of 85% on 15L of oxygen.

C. Needle decompression
D. Urgent computed tomography scan of chest
61. A 32 year old previously healthy woman has developed pain and swelling on both knees
and ankles with a nodular rash over her shins. As part of the investigation a chest X-ray
was performed. What is the SINGLE most likely appearance on the chest X-ray?
A. Apical granuloma
B. Bilateral hilar lymphadenopathy
C. Lobar consolidation
1413
D. Pleural effusion
E. Reticular shadowing in the bases
62. A 21 year old lady who smokes has a history of wheezing, chest tightness and coughing
at night. She also notices these symptoms occur when she goes out in the cold and
breathes cold air. What is the SINGLE most likely diagnosis?
A. COPD
B. Asthma
C. Pneumoconiosis
D. Bronchiectasis
63. A 46 year old man is being treated for a pleural effusion. A chest drain has been sited
just below the 4th rib in the mid-axillary line on his right side. What SINGLE structure is
at particular risk of injury?
A. Azygos vein
y
B. Diaphragm
op
C. Intercostal artery
D. Internal thoracic artery
E. Liver
C
64. A 54 year old smoker man presents with progressive dyspnoea. He complains of cough,
wheeze and a table spoonful of mucopurulent sputum which he coughs out daily for the
n
last 15 months. A spirometry was performed. His FEV1/FVC is 2.4/3.7. After taking
io
salbutamol, the spirometry was performed again which gave a ratio of 2.5/3.8. What is
t
ua
A. Chronic bronchitis
B. Asthma
C. Bronchiectasis
al
D. Lung fibrosis
E. Sarcoidosis
Ev
65. A 68 year old smoker has left sided chest pain which worsens when taking deep breaths.
His medical history includes diabetes mellitus and hypertension. On examination, he has
a miotic left eye and partial ptosis on the left. There is also wasting of small muscles of
the lett hand. What is the SINGLE most likely diagnosis?
A. Costochondritis
B. Lung cancer
C. Goodpasture's syndrome
66. A 2 year old girl presents with a 4 day history of fever which started with a cough. She
has a respiratory rate of 45 beats/minute, oxygen saturation of 94% and a temperature
of 38.9C. There are crepitations at the left base on auscultation of the lung fields. Urine
to diagnosis?
1414
C. Chest X-ray
D. Urine for Culture and sensitivity
67. A 23 year old woman who is on several medications and inhalers for her asthma
presents to the hospital with palpitations. Her heart rate is 110 beats/minute. Her peak
expiratory flow rate is 400 L/minute. What is the SINGLE most appropriate
management?
A. Lifestyle changes
B. Review medications
C. 24 hour ECG monitoring
D. Admit for investigations
E. Chest X-ray
y
68. A 58 year old man who used to work in the shipyard industry was having chronic cough
op
and shortness of breath for several months. He was given salbutamol nebulisers and
intravenous antibiotics and admitted to the ward. A computed tomography was
performed which showed patchy infiltrates, pleural thickening and pleural effusion. He
C
died 3 days later after which this case was referred to the coroner. What is the SINGLE
most likely reason for the referral to the coroner?
n
A. Incorrect diagnosis and management
io
B. Inpatient death in the wards

C. Death likely due to industrial disease
t
D. Cancer research purposes

ua
E. Death by natural causes
69. A 79 year old man with longstanding chronic obstructive pulmonary disease has become
al
progressively breathless over the last 2 years. His medications for his COPD include
salbutamol and salmeterol inhalers, inhaled corticosteroids and theophylline. His forced
Ev
expiratory volume in one second (FEV1) is less than 30%. His oxygen saturations are 89%
on room air. What is the next appropriate management?
A. Assessment for lung transplant

B. Trial of continuous positive airway pressure
C. Trial of noninvasive ventilation
D. Assessment for long term oxygen therapy
E. Assessment for a short course of oxygen therapy
70. A 27 year old man presents with chest pain and respiratory distress following a road
traffic accident. On examination, his neck veins are noted to be distended and trachea is
deviated to the left. Breath sounds are absent on the left and diminished on the right
lung field. He has a blood pressure of 80/40 mmHg and a heart rate of 120
beats/minute. What is the SINGLE most appropriate next action?
A. Chest X-ray
B. Insertion of a cannula into the right second intercostal space
1415
C. Insertion of a cannula into the left second intercostal space
D. Insertion of a chest drain into right mid-axillary line
E. Insertion of a chest drain into left mid-axillary line
71. A 67 year old smoker presents with cough, breathlessness and wheeze. 24% oxygen by
Venturi face mask was initiated and nebulized salbutamol and hydrocortisone were
administered. As his dyspnoea did not improve, intravenous aminophylline was
administered and an arterial blood gas was sent. He has a respiratory rate of 32
breaths/minute. His arterial blood gas results show:
pH 7.32
pCO2 7.7 kPa
pO2 10.1 kPa
A. Non-invasive ventilation
B. Invasive mechanical ventilation
y
C. Long-acting beta-adrenoceptor agonist
op
D. Intravenous doxapram hydrochloride
E. Oral amoxicillin C
72. A 48 year old presents with increasing shortness of breath over the last few months and
a dry cough. He has worked in coal mines for 18 years. Chest x-ray and CT scan of the
chest demonstrates characteristic upper zone mass-like scarring with calcification and
n
volume loss. The lung opacifications are seen to be associated with radiating strands.
io

t
A. Churg-strauss syndrome
ua
B. Cryptogenic organizing
C. Extrinsic allergic alveolitis
D. Goodpasture's syndrome
al

Ev
73. A 48 year old man was admitted with cough and dyspnoea. He has a long history of
smoking and has lost 8 kg in the past 5 months. A chest X-ray was performed and
showed consolidation on the lower left lobe. He was started on antibiotics and is due for
discharge. What is the SINGLE most appropriate follow up investigations to perform
after discharge?
A. Bronchoscopy
B. Chest X-ray
C. Sputum culture
D. Computed tomography (CT)
E. Magnetic resonance imaging (MRI)
1416
Respiratory Medicine
1. A 28 year old male is admitted with acute exacerbation of asthma. He has a temperature
of 38.1°C and a productive cough. He is treated initiated with 100% oxygen and
salbutamol nebulizers. Despite treatment, his oxygen saturation is 88% and respiratory
rate is 34 breaths/minute. What is the SINGLE most appropriate next step in
management?
A. Hydrocortisone IV
B. IV antibiotics
C. IV salbutamol
D. IM adrenaline
E. IV adrenaline
Hydrocortisone should be given first as this is an acute exacerbation of asthma. The

aetiology is probably due to a chest infection which initiated the exacerbation for which
we will prescribe antibiotics. But, we need to sort out his shortness of breath first and
aim for a saturation of 94-98%.
y
op
Asthma: acute exacerbation – management
Immediate treatment:
- Start O2 if saturations <92%, aim sats 94–98%
C
- Salbutamol 5mg (or terbutaline 10 mg) nebulized with O2
- Hydrocortisone 100mg IV or prednisolone 40–50mg PO
n
If life-threatening features present:
io
- Give salbutamol nebulizers every 15min, or 10 mg continuously

- Add in ipratropium 0.5mg to nebulizers
t
- Give single dose of magnesium sulfate (MgSO4) 1.2–2g IV over 20 minutes

ua
If improving within 15–30 minutes:

- Nebulized salbutamol every 4 hours
al
- Prednisolone 40–50mg PO OD for 5–7 days

2. A 27 year old female attends outpatient department with a fever and dry cough. She has
Ev
had a headache, muscle pain and joint pain for more than one week. She has a
temperature of 37.5°C, a pulse of 100 beats/minute, a blood pressure of 110/70 mmHg
and a respiratory rate of 20 breaths/minute. A Chest X-ray report shows bilateral patchy
consolidation. What is the SINGLE most likely causative organism?
B. Legionella
D. Klebsiella
E. Chlamydia pneumoniae
Mycoplasma pneumoniae
Mycoplasma pneumoniae is a cause of atypical pneumonia which often affects young
adults.
Features
- the disease typically has a prolonged and gradual onset
- flu-like symptoms classically precede a dry cough
1417
- bilateral consolidation on x-ray
Note: Occasionally, PLAB may also give a presentation of erythema multiforme along
with the atypical pneumonia symptoms. Erythema multiforme is one of the features of
infection with mycoplasma pneumoniae.
3. A 74 year old man who has been a smoker since he was 20 has recently been diagnosed
with small cell lung cancer. What Is the SINGLE most likely serum electrolyte picture that
confirms the presence of Syndrome of inappropriate antidiuretic hormone secretion
(SIADH)?
A. High serum Na, low serum osmolality, high urine osmolarity

B. Low serum Na, low serum osmolality, high urine osmolarity
C. Low serum Na, high serum osmolality, high urine osmolarity
D. High serum Na, low serum osmolality, low urine osmolarity
E. High serum Na, high serum osmolality, low urine osmolarity
SIADH
y
op
The diagnosis requires concentrated urine (Na+ > 20mmol/L and osmolality >
100mosmol/kg) in the presence of hyponatraemia (plasma Na+ < 125mmol/L) and low
plasma osmolality
C
(< 260mosmol/kg), in the absence of hypovolaemia, oedema, or diuretics.
n
One of the causes is small cell lung cancer
io
Treatment
t
ua
Treat the cause and restrict fluid. Consider salt ± loop diuretic if severe. Demeclocycline
is used rarely. Vasopressin receptor antagonists (‘vaptans’) are an emerging class of drug
used in SIADH and other types of hyponatraemia.
al
4. A 68 year old man has malaise and cough for 5 days. He has a temperature of 38.5°C.
Ev
There is dullness on percussion of the left lung base. What is the SINGLE most
A. Bronchoscopy
B. Chest X-ray
C. CT chest
D. MRI
E. V/Q scan
The given presentation is suggestive of pneumonia for which the most appropriate
investigation is a Chest X-ray.
5. A 16 year old boy who attends boarding school feels unwell. He developed a dry cough
for the last few days. On examination, there are target lesions seen on the back of his
hands. A chest X-ray was performed and it shows bilateral consolidations. What is the
1418
B. Legionella
D. Klebsiella
The diagnosis here is an atypical pneumonia. Mycoplasma pneumoniae is one of those

that cause an atypical pneumonia that presents with dry cough. The target lesions are
known as erythema multiforme.
Mycoplasma pneumoniae
Mycoplasma pneumoniae is a cause of atypical pneumonia which often affects young
adults.
Features
- the disease typically has a prolonged and gradual onset
- flu-like symptoms classically precede a dry cough
- bilateral consolidation on x-ray
y
op
Note: Occasionally, PLAB may also give a presentation of erythema multiforme along
with the atypical pneumonia symptoms. Erythema multiforme is one of the features of
infection with mycoplasma pneumoniae.
C
6. A 33 year old man is referred for an X-ray as he complains of a persistent cough, chest
pain and excessive purulent sputum. He has a history of recurrent chronic chest
n
infections. On examination, drumstick-shaped fingers were noted. What is the SINGLE
io

t
ua
B. Mesothelioma
C. Bronchiectasis
al
E. Bacterial endocarditis
Ev
The persistent cough and excessive purulent sputum are symptoms of bronchiectasis.
Finger clubbing is not a specific sign but has been seen in bronchiectasis although not
very frequently.
The most probable diagnosis among the others is bronchiectasis.
Occasionally, the question would include chest-x ray findings which show tramlines. This
would give a more specific picture pointing towards bronchiectasis.
Only a high-resolution computed tomography (HRCT) chest would give you the diagnosis
of bronchiectasis.
Bronchiectasis
Is the irreversible abnormal dilatation of of small and medium sized bronchi, with
chronic airway inflammation. It is associated with chronic sputum production, chronic
cough, recurrent acute chest infections, and airflow obstruction.
1419
Aetiology
The disease is caused by chronic inflammation of the airways. It may therefore be
caused by a large number of disorders which cause inflammation and infection,
particularly conditions that facilitate infections, which therefore tend to be recurrent
and more severe and so cause damage to the lungs. In general, the aetiology is either a
one-off infectious insult or an underlying immune deficiency.
- Post-infection: childhood respiratory viral infections (measles, pertussis,

influenza, respiratory syncytial virus), tuberculosis, bacterial pneumonia.
Infection is the most common cause of bronchiectasis
- Immunodeficiency: HIV infection. Always consider this as a cause in all ages,
particularly if there have been serious, persistent or recurrent infections
- Connective tissue diseases e.g. rheumatoid arthritis, Sjögren's syndrome,
systemic sclerosis, systemic lupus erythematosus (SLE), Ehlers-Danlos syndrome,
Marfan's syndrome
- Toxic insults: Gastric aspiration, inhalation of toxic gases
- Congenital defects: The most important one being cystic fibrosis
y
Bronchial obstruction and bronchopneumonia are more likely to cause a focal
op
bronchiectasis, whereas the other causes are more likely to result in diffuse disease.
All conditions cause dilation of the airways (due to continued inflammation destroying
C
their elastic and muscular structure) followed by poor mucus clearance, and bacterial
colonisation of collected mucus. This then can progress, as chronic infection causes
further inflammation in a cyclical fashion.
n
io
Note
- The most important cause to exclude is CF. Even relatively mild bronchiectasis
t
diagnosed in middle age can be due to CF

ua
- In the PLAB examination, look out for a history of recurrent pneumonias in the
question
al
Clinical features
- Persistent cough with purulent copious sputum production
Ev
- Nonspecific respiratory symptoms including dyspnoea, chest pain and

haemoptysis. Bronchiectasis may progress to respiratory failure and cor
pulmonale
- Coarse crackles are the most common finding, heard in early inspiration and
often in the lower zones
- Large airway rhonchi (low-pitched snore-like sounds)
- Wheeze may be present
- Clubbing is found infrequently
Diagnosis
- Usually made clinically, with high-resolution computed tomography (HRCT) chest
for confirmation.
- A baseline chest x-ray should be done in all patients. Early chest x-ray findings
may be normal in patients with bronchiectasis. Chest x-ray in advanced cases
may show 1 to 2 cm cysts, crowding of the bronchi (tramlines) or ring opacities.
The main value of a CXR is excluding other causes of symptoms.
1420
Treatment
Damaged lung cannot be repaired and so the basis of management is to prevent or at
least slow down further deterioration.
- Bronchodilators, chest physical therapy, and postural drainage are used to
control and improve drainage of bronchial secretions
- If the patient smokes this must be stopped
- Immunisation against influenza and pneumococcus
- Long-term oral antibiotics for patients having three or more exacerbations per
year requiring antibiotic therapy or patients with fewer exacerbations that are
causing significant morbidity should be considered for long-term antibiotics.
Choice will be dictated by sensitivities and local microbiology advice from
sputum test results.
7. A 22 year old man presents with episodes of dyspnoea, starting suddenly. This
usually occurs when he is in a crowded area like a lift. When he is breathless, he
also notices tingling around his mouth and he feels light-headed. These episodes
usually go away after a while. An arterial sample was taken for blood gases
y
during one of the episodes. What is the SINGLE most likely result of the arterial
blood gas (ABG)?
Normal Values:
op
C
Pa02 > 10 kPa
PaCO2 4.7–6 kPa
n
pH 7.35 - 7.45
io

t
A. Pa02 = 8.1 kPa, PaCO2 = 2.6 kPa, pH = 7.55, HCO3- = 26 mmol/l

ua
B. Pa02 = 13.6 kPa, PaCO2 = 2.5 kPa, pH = 7.56, HCO3- = 13 mmol/l

C. Pa02 = 13.5 kPa, PaCO2 = 6.3 kPa, pH = 7.28, HCO3- = 24 mmol/l
D. Pa02 = 8.3 kPa, PaCO2 = 6.4 kPa, pH = 7.27, HCO3- = 24 mmol/l
al
E. Pa02 = 13.1 kPa, PaCO2 = 2.7 kPa, pH = 7.57, HCO3- = 25 mmol/l

Ev
To understand this question, we have to go back to basics.
First, is the patient hypoxic?
- the Pa02 >10 kPa is normal
Second, is the patient acidaemic (pH <7.35) or alkalaemic (pH >7.45)
Third, what is the respiratory component: What has happened to the PaCO2?
- PaCO2 > 6.0 kPa suggests a respiratory acidosis (or respiratory compensation for
a metabolic alkalosis)
- PaCO2 < 4.7 kPa suggests a respiratory alkalosis (or respiratory compensation for
a metabolic acidosis)
Fourth, what is the metabolic component: What is the bicarbonate level/base excess?
1421
- bicarbonate < 22 mmol/l suggests a metabolic acidosis (or renal compensation
for a respiratory alkalosis)
- bicarbonate > 26 mmol/l suggests a metabolic alkalosis (or renal compensation
for a respiratory acidosis)
This patient is suffering from panic attacks.
If your answer was A or D, you need to remember that panic attacks usually result in
hyperventilation thus PaO2 is usually normal (Pa02 > 10 kPa).
If your answer was C, you need to remember that hyperventilation which is seen in panic
attacks usually result in respiratory alkalosis (pH >7.45).
If your answer was B, you need to remember that there would be no metabolic
compensation as panic attacks resolves rapidly.
Panic attacks key points

- result in hyperventilation which causes a respiratory alkalosis
y
- There would be no metabolic compensation as panic attack resolves rapidly.
op
- We would not expect any metabolic compensation as it takes the kidneys days
to conserve acid.
- PaO2 would be normal.
C
8. A 10 year old girl with diagnosed asthma is having frequent coughs and wheezing that
wakes her up at night. She is compliant with her asthma medication of inhaled
n
corticosteroid 800 mcg/day, short-acting bronchodilators as required, inhaled long-
io
acting B2 agonist (LABA) and theophylline. Her inhaler technique is good. What is the
t
ua

B. Increase dose of inhaled corticosteroids
al
D. IM adrenaline
Ev
Asthma - Management of stable asthma in children aged 5 - 12

Asthma is characterised by paroxysmal and reversible obstruction of the airways.
Management of stable asthma in children aged 5 - 12:

The management of stable asthma is now well established with a stepwise approach:
Step 1
Inhaled short-acting B2 agonist as required
Step 2
Add inhaled steroid at 200-400 mcg/day. 200 mcg/day is a appropriate starting dose for
many patients
Step 3
Add inhaled long-acting B2 agonist (LABA)
1422
Then assess control of asthma:
- If good response to LABA, then continue LABA
- If benefit from LABA but control still inadequate then continue LABA and
increase inhaled corticosteroid dose to 400 micrograms/day
- If no response to LABA, stop LABA and increase inhaled corticosteroid to 400
micrograms/day. And If control still inadequate, institute trial of other therapies,
leukotriene receptor antagonist or SR theophylline
Step 4
Consider trials of:
- increasing inhaled steroid up to 800 mcg/day
Step 5
- Use daily steroid tablets
Referral to a respiratory physician would be normal at Step 4-5 depending on expertise.
If you find this stepwise approach too complicated to memorize. Then just memorize it
y
in a very simplified way as stated below:
Step 1 →Inhaled short-acting B2 agonist

Step 2 → Add inhaled steroid
op
C
Step 3 → Add inhaled long-acting B2 agonist (LABA)
Step 4 → increasing inhaled steroid to max dose
Step 5 → Add daily steroid tablets
n
io
9. A 26 year old smoker has a history of wheezing, chest tightness and breathlessness at
night and early morning. Her past medical history includes eczema. What is the SINGLE
t

ua
A. COPD
B. Asthma
al
C. Pneumoconiosis
D. Bronchiectasis
Ev
Asthma - Risk factors, presentation and diagnosis

It is a clinical diagnosis based on:

- A history of recurrent episodes of wheeze, chest tightness, breathlessness,
and/or cough, particularly at night
- Evidence of generalized and variable airflow obstruction, which may be detected
as intermittent wheeze on examination or via tests such as peak expiratory flow
(PEF) measurement
Acute asthma involves:

- Bronchospasm (smooth muscle spasm narrowing airways)
- Excessive production of secretions (plugging airways)
Risk factors
1423
Asthma is due to a combination of genetic and environmental factors
- Personal history of atopy
- Family history of asthma or atopy
- Inner city environment; socio-economic deprivation
- Prematurity and low birth weight
- Viral infections in early childhood
- Smoking
- Maternal smoking
Presentation
- Cough
- SOB
- Wheeze
- Chest tightness.
Classically, these are variable, intermittent, worse at night and in early morning, and are
associated with specific triggers
Triggers include
- Pollens
y
- cat and dog dander
op
- cold air
- perfumes C
Note: Symptoms may present after taking aspirin or beta-blockers
Examination:
n
- May be entirely normal
io
In a mild attack
t
- Slight tachypnoea, tachycardia

ua
- Classically, expiratory wheeze is heard (widespread wheeze)
In a severe life-threatening attacks

al

- Diminished breath sounds, loud wheezing, hyper-resonance (increased vocal
Ev
fremitus) and intercostal retraction

- The chest may appear hyperinflated
- Sometimes, in severe life-threatening asthma, there may have no wheeze at all
and a silent chest
In long standing/poorly controlled asthma

- Chest deformity/hyperinflation may be seen
Diagnosis:
This is often a clinical diagnosis but should be supported by objective measurements.
The diagnosis is based on the presence of:
- Symptoms (cough, wheeze, breathlessness)
- PFTs show an obstructive pattern that typically reverses with bronchodilation
- Day-to-day peak flow variability
- Otherwise unexplained low forced expiratory volume in one second (FEV1) or
peak expiratory flow (historical or serial readings)
- Otherwise unexplained peripheral blood eosinophilia
1424
Where diagnosis is uncertain (intermediate probability) but with demonstration of
airway obstruction (FEV1/forced vital capacity (FVC) <0.7), reversibility testing and/or a
trial of treatment are suggested.
Chest x-ray findings are nonspecific in an asthmatic attack. It should not be used
routinely in the assessment of asthma but consider CXR in any patient presenting with
an atypical history or with atypical findings on examination. CXR if atypical symptoms,
may show hyperinflation. The chest x-ray may be helpful in ruling out acute infection as
the cause of an acute attack.
Asthma VS COPD
One differential diagnosis that is worth mentioning is COPD.
- Reversibility distinguishes asthma from COPD
- COPD is rarely totally refractory to medication.
- Almost all patients with COPD do smoke or have smoked in the past. Asthmatics
can also develop COPD.
-
y
op
with 100% oxygen, salbutamol nebulizers and hydrocortisone 100mg IV. Despite
treatment, his oxygen saturation is 89% and respiratory rate is 30 breaths/minute. What
C
A. Prednisolone 40mg PO
B. Add in ipratropium 0.5 mg to nebulizers
n
C. IV salbutamol
io
D. IM adrenaline
E. Stop administration of oxygen
t
ua
Hydrocortisone should be given first as this is an acute exacerbation of asthma. The

aetiology is probably due to a chest infection which initiated the exacerbation for which
we will prescribe antibiotics. But, we need to sort out his shortness of breath first and
al
aim for a saturation of 94-98%.

Ev
Asthma: acute exacerbation - management


1425
11. A 22 year old, tall thin man develops sudden chest pain and becomes breathless while
driving. There is no history of trauma. What is the SINGLE most appropriate
investigation?
A. Cardiac enzymes
B. Chest X-ray
C. CT
D. ECG
E. V/Q scan
Tall thin young men are particularly prone to develop pneumothorax. Sudden pain and
breathlessness in this young man are highly suggestive of pneumothorax. A standard
erect CXRs in inspiration are recommended for the initial diagnosis of pneumothorax.
Primary pneumothorax
Primary spontaneous pneumothoraces occur most commonly in tall thin men aged
between 20 and 40. They usually occur in the healthy.
y
Cigarette is a major risk factor for pneumothorax. The mechanism is unclear; a smoking-
op
induced influx of inflammatory cells may both break down elastic lung fibres (causing
bulla formation) and cause small airways obstruction (increasing alveolar pressure and
the likelihood of interstitial air leak)
C
More common on the right side
- Less than 10% of cases are bilateral
n
- Usually caused by rupture of small subpleural blebs (collections of air <2cm)
io
Presentation
t
- Dyspnoea, chest pain, cough, tachypnoea

ua
- Ipsilateral decreased chest wall movement, hyperresonant hemithorax to

percussion
al
12. A 56 year old man complains of increased volume of sputum with specks of blood and
chest pain. He has a history of recurrent chronic chest infections and deep vein
Ev
thrombosis which happened 3 years ago. Finger clubbing was noted on examination. A
chest X-ray shows tramlines but is otherwise normal. What is the SINGLE most likely
diagnosis?
C. Bronchiectasis
E. Chronic sinusitis
The increased volume of sputum with specks of blood and chest pain are symptoms of
bronchiectasis. Finger clubbing is not a specific sign but has been seen in bronchiectasis
although not very frequently. A chest-x ray that shows tramlines give a more specific
picture pointing towards bronchiectasis. Although these are not diagnostic, the most
probable diagnosis among the others is bronchiectasis. Only a high-resolution computed
tomography (HRCT) chest would give you the diagnosis of bronchiectasis.
1426
It is very rare that the question writers would attempt to trick you. But this is one of the
questions that may be misleading as they give a history of DVT which is irrelevant for
bronchiectasis.
Bronchiectasis
Aetiology

y
op
C
Marfan's syndrome
n
io

t
ua
al
Ev
Note
question
Clinical features
pulmonale
1427
Diagnosis
for confirmation.
Treatment
y
op
sputum test results. C
13. A 6 year old girl has had 2 short episodes of cough and wheeze over the last 12 months.
These 2 acute episodes responded quickly to bronchodilator. She has no symptoms or
abnormal physical signs at the moment. She has slight eczema and her mother has a
n
history of asthma when she was young. What is the SINGLE most appropriate
io
investigation?
t
A. Chest X-ray
ua
B. Peak flow rate diary

C. Pulse oximetry
D. Spirometry
al
E. Sweat test
Ev
Spirometry is now preferred over peak flow measurement for initial confirmation of
obstruction of airways in the diagnosis of asthma, as it is felt to offer clearer
identification of airway obstruction, to be less effort-dependent and more repeatable.


(PEF) measurement

1428
Risk factors
- Smoking
- Maternal smoking
Presentation
- Cough
- SOB
- Wheeze
- Chest tightness.
y
Triggers include
op
- Pollens
- cold air
C
- perfumes

n
io
Examination:
t
ua
In a mild attack
al

Ev

and a silent chest

Diagnosis:
1429

Asthma VS COPD
y
op
14. A 34 year old HIV positive man presents with fever, dry cough and shortness of breath.
C
He is tachypnoeic but his chest is clear. Oxygen saturation is normal at rest but drops on
exercise. What is the SINGLE most likely diagnosis?
n
A. Cytomegalovirus infection
io
C. Pneumocystis carinii infection
t
D. Cryptococcal infection
ua
E. Toxoplasmosis
Pneumocystis jiroveci pneumonia (PCP)

al
Whilst the organism Pneumocystis carinii is now referred to as Pneumocystis jiroveci,

Ev
the term Pneumocystis carinii pneumonia (PCP) is still in common use.
Pneumocystis pneumonia (PCP) is a major cause of morbidity and mortality among

immunocompromised people. It remains a leading AIDS-defining opportunistic infection
in HIV-infected individuals.
HIV infection is a particularly important risk factor especially if CD4 count < 200/mm³
thus
all patients with a CD4 count < 200/mm³ should receive PCP prophylaxis
Features
- Exertional dyspnoea
- Gradual onset of dry cough
- Fever
- Tachypnoea
- Chest pain or retrosternal tightness
- May be signs of AIDS e.g. Thrush
1430
- Chest examination is typically normal
Desaturation on exercise may suggest the diagnosis in individuals at risk of PCP with
normal saturations at rest. This is pathognomonic for PCP.
Remember, there are so many causes of pneumonia. The question writers would have to
give you some sort of clue if they would want you to pick PCP. The two major clues that
they can give are a HIV patient, and desaturation on exercise.
Investigation
- Sputum often fails to show PCP, bronchoalveolar lavage may be needed to
demonstrate PCP. Bronchoscopy with bronchoalveolar lavage is the diagnostic
investigation of choice in non-HIV-infected patients and in patients with HIV in
whom induced sputum analysis is non-diagnostic.
Management
- co-trimoxazole (trimethoprim-sulfa) remains the drug of choice
-
y
15. A 56 year old man who has a history of hypertension and asthma recently had a change
op
of medication which was prescribed by his GP. 2 days after starting the new medication,
he develops wheezing and shortness of breath. What is the SINGLE most likely
C
A. Atenolol
B. Ramipril
n
io
D. Verapamil
E. Furosemide
t
ua
Symptoms of asthma may present after taking aspirin, NSAIDS or beta-blockers.

al

Ev

(PEF) measurement

Risk factors
1431
- Smoking
- Maternal smoking
Presentation
- Cough
- SOB
- Wheeze
- Chest tightness.
Triggers include
- Pollens
- cold air
- perfumes
y
op
Examination:
- May be entirely normal C
In a mild attack
n
io

t

ua

al
and a silent chest

Ev

Diagnosis:

1432
Asthma VS COPD
16. A 29 year old woman has been short of breath for the last 15 hours and is feeling unwell.
An arterial blood gas is taken:
PaO2 8.8 kPa

PaCO2 3.2 kPa
y
pH 7.50
op
Bicarbonate (HCO3–) 20 mmol/L
Normal Values:
C
Pa02 > 10 kPa
PaCO2 4.7–6 kPa
pH 7.35 - 7.45
n
io

t
ua
A. Diabetic ketoacidosis
B. Methanol overdose
C. Panic attack
al
D. Pulmonary embolus
E. Severe vomiting
Ev
This woman has become acutely breathless from a pulmonary emboli. She is hypoxic
and, as a reflex to this, is hyperventilating (as evidenced by the low PaCO2). As a result,
she has developed an alkalosis.
The other options are much less likely to be the answer:
Diabetic ketoacidosis and methanol overdose → both causes acidosis. The scenario that
was given is alkalosis
Panic attacks → This does cause acute alkalosis via hyperventilation (and therefore low
PaCO2 and a high pH), but tends to happen in the absence of hypoxia rather than as a
response to it (as in pulmonary embolism).
Severe vomiting → causes a metabolic alkalosis (i.e. a high pH with a high HCO3–). PaO2
is not likely to decrease
1433
First, is the patient hypoxic?
- the Pa02 >10 kPa is normal
Second, is the patient acidaemic (pH <7.35) or alkalaemic (pH >7.45)
Third, what is the respiratory component: What has happened to the PaCO2?
- PaCO2 > 6.0 kPa suggests a respiratory acidosis (or respiratory compensation for
a metabolic alkalosis)
- PaCO2 < 4.7 kPa suggests a respiratory alkalosis (or respiratory compensation for
a metabolic acidosis)
Fourth, what is the metabolic component: What is the bicarbonate level/base excess?
- bicarbonate < 22 mmol/l suggests a metabolic acidosis (or renal compensation

for a respiratory alkalosis)
- bicarbonate > 26 mmol/l suggests a metabolic alkalosis (or renal compensation
y
for a respiratory acidosis)
In summary
op
C
She has developed respiratory alkalosis with renal compensation.
17. A 33 year old man has mild headache and myalgia for 2 days followed by high fever,
n
chills, rigors and a cough. His cough was initially dry but progressed to be productive. He
io
has just returned from a conference in Greece where he mentions that he swam and
used the hot tubs in the hotel. He has a temperature of 38.1°C and is seen to be
t
dyspnoeic. Chest X-ray shows patchy alveolar infiltrates. What is the SINGLE most likely
ua
organism which would have caused his symptoms?
A. Legionella pneumophila
al
B. Mycoplasma pneumoniae
C. Staphylococcus aureus
Ev
D. Streptococcus pneumoniae
Legionella pneumophila is the causative organism that causes Legionnaires' disease

which is a severe, potentially fatal acute pneumonia acquired by droplet inhalation of
water contaminated.
L. pneumophila is found in natural water supplies and soil. It is also found in many
recirculation and water supply systems. For the purpose of this exam, look out for hints
like traveling, hotel stays, whirlpool spas, hot tubs as often they would put one of these
hints in the question, if the examiners would like you to select Legionella pneumophila
as the answer.
18. A 56 year old lady with lung cancer presents with urinary retention, postural
hypotension, diminished reflexes and sluggish pupillary reaction. What is the SINGLE
most likely explanation for her symptoms?
1434
A. Paraneoplastic syndrome
B. Progression of lung cancer
C. Brain metastasis
D. Hyponatraemia
E. Spinal cord compression
These features are well known features of autonomic neuropathy which can be a result
of paraneoplastic syndrome.
Paraneoplastic syndromes are rare and believed to occur when cancer-fighting

antibodies (white blood cells) mistakenly attack normal cells in the nervous system.
When one of these syndromes is associated with lung cancer, it is often with small cell
lung cancer or because the cancer has metastasized to a particular part of the body.
Autoimmune paraneoplastic autonomic neuropathy is a rare paraneoplastic syndrome

(PNS), which manifests as disturbance in sympathetic and/or parasympathetic nervous
system function.
y
19. A 25 year old tall man presents to A&E with increasing dyspnoea and right sided chest
op
pain. He has been a heavy smoker for the past 4 years. He has no past medical history.
B. Myocardial infarction
C. Asthma
n
D. Pleural effusion
io
E. Primary Pneumothorax
t
Dyspnoea and chest pain in a young tall man with no past medical history could only be
ua
primary spontaneous pneumothorax.
The giveaway here is the word “tall”. When the word “tall” is used in combination with
al
dyspnoea, pneumothorax should be in your differential.

Ev
More common on the right side

Presentation
percussion
1435
Diagnosis
Chest X-ray is the diagnostic test in most cases, revealing a visible lung edge and absent
lung markings peripherally.
20. A 34 year old woman with a smoking history has had an uneventful laparoscopic
cholecystectomy 18 hours ago. She is now complaining of shortness of breath. She has a
pulse rate of 108 bpm and a temperature of 37.8°C. There are signs of reduced air entry
at the right base. Chest X-ray shows no obvious abnormality. What is the SINGLE most
A. Unfractionated heparin
B. IV Ceftriaxone
C. PO Chlorpheniramine
D. Chest physiotherapy
E. D-dimers
y
The four most likely common causes of post-operative breathlessness are:
-
-
Infection/atelectasis
Pulmonary embolism
op
C
- Left ventricular failure (LVF) (fluid overload)
- Exacerbation of underlying lung disease such as COPD
n
The time of the surgery in this question helps us with the diagnosis. As this is an early
io
complication (hours rather than days), it is likely to be either atelectasis or pulmonary

embolism. But since there are no other factors pointing towards a pulmonary embolism
t
and there is a smoking history, the more likely diagnosis here would be atelectasis.
ua
Basal atelectasis is commoner in smokers and following abdominal or trans-thoracic

procedures.
al
Note that a D-dimer level is unhelpful, as it will be raised by many different intra- and
Ev
post-operative mechanisms. So D-dimers in this scenario would not help you

differentiate pulmonary embolism from atelectasis. CRP and WCC are also largely
unhelpful, as these are frequently raised post-operatively.
Chest physio will help if the cause is atelectasis.
Atelectasis is the collapse or closure of a lung resulting in reduced or absent gas

exchange
Management of atelectasis
Adequate analgesia to encourage expectoration, nebulized saline, chest physiotherapy,

deep breathing and coughing, postural drainage, incentive spirometry. If lung does not
re-inflate, consider bronchoscopy to suction out secretions
Pneumonia may happen in about 3 days if atelectasis is not resolved. If this happens,
fever will persist and Chest x-ray will show infiltrates.
1436
21. A 65 year old retired builder complains of persistent dull chest pain and shortness of
breath. He is a smoker and started smoking since a young age. He looks thin and his
clothes are oversized. Finger clubbing is noted on examination. What is the SINGLE most
likely diagnosis?
B. Bronchiectasis
C. Tuberculosis
D. Mesothelioma
E. Cystic fibrosis
The history that he is a builder is the question writers way to hint to you that this patient
had asbestos exposure in the past. Exposure to asbestos is a well-established cause of
mesothelioma, with occupational exposure being documented in 70-80% of those
affected.
Finger clubbing is usually caused by underlying asbestosis. Although finger clubbing is
y
commonly seen in questions with mesothelioma, it is actually very rare in clinical
op
practice. Finger clubbing is seen in less than 1% of patients with mesothelioma
Mesothelioma
C
Malignant mesothelioma is a tumour of mesothelial cells that usually occurs in the
pleura, and rarely in the peritoneum or other organs. It is associated with occupational
exposure to asbestos
n
io
The latent period between exposure and development of the tumour may be up to 45
years.
t
Compensation is often available.

ua
Clinical features:
- Chest pain
al
- Dyspnoea
- Weight loss
Ev
- Finger clubbing
- Recurrent pleural effusions
Remember: Shortness of breath, chest pain and weight loss are the most common
symptoms
Signs of metastases:
- Lymphadenopathy
- Hepatomegaly
- Bone pain or tenderness
- Abdominal pain or obstruction (peritoneal malignant mesothelioma)
Tests:
- CXR or CT will show pleural thickening or effusion
Diagnosis is made on histology, usually following a thoracoscopy. Thoracoscopy under

local anaesthetic enables drainage of pleural fluid, pleural biopsy and pleurodesis.
1437
Often the diagnosis is only made post-mortem.
Management:
Is usually symptomatic, as cure is usually only possible with surgery for extremely
localised (stage I) mesothelioma. The role and order of adjuvant or neoadjuvant use of
chemotherapy, radiotherapy and surgery has still not been established although
chemotherapy has been shown can improve survival. Surgery is hard to evaluate as
there are too few randomized trials. Radiotherapy is controversial. Pleurodesis and
indwelling intra-pleural drain may help
22. A 11 year old girl has a history of asthma and is currently on short-acting
bronchodilators. Her parents feels that it is not well controlled as she frequently wakes
up at night with wheezing and coughing. Her inhaler technique is good. What is the

B. Add inhaled steroid
y
op
D. Add leukotriene receptor antagonist
E. Add inhaled long-acting B2 agonist (LABA) C
n
io
t
Step 1
ua
Step 2
al
many patients
Ev
Step 3

Step 4
Consider trials of:
Step 5
1438

23. A 10 year old boy who takes regular dose inhaled steroids for his longstanding asthma
has been advised to use bronchodilators to control his acute attacks. His parents are
unsure when he should use his bronchodilator. What is the SINGLE most appropriate
investigation to perform?
y
A. Chest X-ray
op
B. Pulmonary function test
C. Peak flow rate diary
D. Pulse oximetry
C
E. Blood test to look for eosinophilia
Peak flow rate diary shows diurnal variation. This diary shows when the
n
bronchoconstriction remains worse and guides to use bronchodilators prior to that
io
times.
t

ua

al

Ev

(PEF) measurement

Risk factors
- Smoking
- Maternal smoking
1439
Presentation
- Cough
- SOB
- Wheeze
- Chest tightness.
Triggers include
- Pollens
- cold air
- perfumes
Examination:
y
op
In a mild attack
C
n
io

t

ua
and a silent chest

al

Ev
Diagnosis:

1440
Asthma VS COPD
24. A 38 year old woman is brought to the A&E after falling down the stairs and injuring her
rib. She complains of shortness of breath. A chest X-ray was performed to rule out a rib
fracture. Bilateral hilar lymphadenopathy was seen on the chest X-ray. On auscultation,
there are vesicular breath sounds. On examination, there are red lesions on both her
shins which are tender. What is the SINGLE most likely diagnosis?
A. Bronchial asthma
B. Cystic fibrosis
y
C. Sarcoidosis
op
D. Bronchiectasis
E. Silicosis C
In PLAB, whenever you see the term “bilateral hilar lymphadenopathy” with a lesion on
the shin, you should be thinking of Sarcoidosis.
n
The lesion on the shin is erythema nodosum which are blue or red lesions and are seen
io
in people suffering from sarcoidosis.

t
The syndrome here is Lofgren syndrome which includes erythema nodosum, arthritis,
ua
and hilar adenopathy. Lofgren is a distinct sarcoid syndrome.
Sarcoidosis
al
Sarcoidosis is a systemic disease of unknown cause, characterized histologically by the

Ev
presence of nonspecific noncaseating granulomas in the lung and other organs.
Features
Sarcoidosis can involve almost any organ system, but pulmonary involvement is most
common.
- acute: erythema nodosum, bilateral hilar lymphadenopathy, fever,
polyarthralgia
- insidious: dyspnoea, non-productive cough, malaise, weight loss
- skin: lupus pernio
- Hypercalcemia due to increased circulation of vitamin D produced by
macrophages.
Commonly, sarcoidosis is discovered in a completely asymptomatic patient, usually in

the form of hilar adenopathy on a chest x-ray.
There are two distinct sarcoid syndromes with acute presentation:

- Lofgren syndrome includes erythema nodosum, arthritis, and hilar adenopathy.
1441
- Heerfordt- Waldenstrom syndrome, which describes fever, parotid enlargement,
uveitis, and facial palsy
Lung involvement in sarcoidosis occurs in 90% of patients sometime in their course.
Chest X-Ray.
Shows bilateral hilar adenopathy,
Laboratory Findings.
Elevation in angiotensin-converting enzyme (ACE) can be seen in 60% of patients with
sarcoidosis. But note that ACE should not be used to diagnose sarcoidosis. ACE levels are
nonspecific but can be used to follow the course of the disease.
Abnormalities in liver function tests are seen in 30% of patients

PFTs may be normal or show a restrictive pattern.
Diagnosis.
The definitive diagnosis of sarcoidosis rests on biopsy of suspected tissues, which show
y
noncaseating granulomas.
Treatment
op
Generally in the setting of organ impairment, a trial of steroids may be used. There are
C
certain scenarios in which steroids should be used but are beyond what will be asked in
PLAB.
n
25. A 19 year old man has a history of exercise induced asthma which has previously been
io
controlled using a salbutamol inhaler as required. He is taking beclomethasone inhaler

regularly but he now gets asthma attacks with exercise. What is the SINGLE most
t
appropriate action?
ua
al

Ev
Sodium cromoglycate can be added for exercise-induced asthma.
Exercise-induced asthma
Exercise-induced asthma although following the stepwise approach has a slight

difference in management.
For most patients, exercise-induced asthma is an illustration of poorly controlled asthma

and regular treatment including inhaled corticosteroids should therefore be reviewed. If
exercise is a specific problem in patients already taking inhaled corticosteroids who are
otherwise well controlled, consider adding either:
- leukotriene receptor antagonist
- a long-acting beta 2 agonist
- an oral beta 2 agonist
- sodium cromoglicate
1442
- theophylline
An inhaled short-acting beta2 agonists used immediately before exercise is the drug of
choice.


Step 1
Step 2
many patients
y
Step 3
op

C
n
io

t
ua
Step 4
Consider trials of:
al
Step 5
Ev

26. A 55 year old woman with a persistent cough and history of smoking develops left sided
chest pain exacerbated by deep breathing. She has a temperature of 38.2°C and basal
crackles are heard on auscultation. What is the SINGLE most likely diagnosis?
1443
A. Dissecting aneurysm
B. Pericarditis
C. Pneumonia
D. Pneumothorax
These are typical signs and symptoms of pneumonia. Pleuritic pain can occur with
pneumonia. Crackles can be heard in patients with pneumonia.
Symptoms of cough, purulent sputum which may be blood-stained or rust-coloured,

breathlessness, fever, malaise are usually how pneumonia presents.
27. A 50 year old man has had hoarseness of voice and a left drooping eyelid for the past 2
months. He also has diminished sweating on same side of face. Finger clubbing is noted
on examination. He smokes 20 cigarettes a day for the last 30 years. What is the SINGLE
A. Laryngeal carcinoma
y
B. Thyroid carcinoma
op
C. Carcinoma of right bronchus
D. Mesothelioma
E. Pancoast tumour
C
A pancoast tumour is a tumour of the pulmonary apex. The hoarseness of voice is due to
compression of the recurrent laryngeal nerve. An ipsilateral invasion of the cervical
n
sympathetic plexus leading to Horner's syndrome (miosis, enophthalmos, ptosis). The
io
history of smoking and finger clubbing gives a clue towards a bronchogenic neoplasm.
t
Pancoast's Syndrome
ua
Classically caused by an apical (superior pulmonary sulcus) malignant neoplasm of the

lung. The neoplasm is usually bronchogenic in origin (most commonly squamous cell
carcinoma, sometimes adenocarcinoma and large-cell carcinoma).
al
Presentation
Ev
This syndrome results from the invasion of a number of structures and tissues around
the thoracic inlet and may be characterised by:
- An ipsilateral invasion of the cervical sympathetic plexus leading to Horner's
syndrome (miosis, enophthalmos, ptosis)
- Ipsilateral reflex sympathetic dystrophy may occur.
- Shoulder and arm pain (brachial plexus invasion C8-T2) leading to wasting of the
intrinsic hand muscles and paraesthesiae in the medial side of the arm.
- Less commonly, unilateral recurrent laryngeal nerve palsy producing unilateral
vocal cord paralysis (hoarse voice ± bovine cough)
- There may be arm oedema secondary to the compression of blood vessels.
28. A 65 year old known case of liver cancer and metastasis presents with gastric reflux and
bloatedness. Osteoporosis was diagnosed on a dexa scan. He also has shortness of
breath and basal consolidation in the left lung was seen on a Chest X-ray. What is the
A. Proton pump inhibitor IV
1444
B. Alendronate
C. IV antibiotics
D. Analgesia
E. Proton pump inhibitor PO
In reality, he would be started on all of them. But for the purpose of PLAB, if you were to
choose among the answers provided, IV antibiotics would be the most important one to
start as this patient has pneumonia and this should be treated first.
29. A 68 year old woman presents to the emergency department from her nursing home
complaining of shortness of breath. She has a temperature of 38.7°C and productive
cough. Her sputum is noted to be a rusty colour. On auscultation, crackles are heard
over the right lung base. A chest X-ray was done and shows right lower lobe
consolidation. She has a blood pressure of 100/65 mmHg and a pulse rate of 102
beats/minute. A urinalysis shows 1+ leucocytes with no nitrates or protein. What is the
SINGLE most likely organism causing her symptoms?
A. Streptococcus pneumoniae
y
op
C. Coxiella burnetii
D. Mycoplasma pneumoniae
E. Escherichia coli
C
This is a typical presentation of streptococcus pneumoniae infection. Streptococcus
pneumoniae (pneumococcus) is the most common cause of community-acquired
n
pneumonia.
io
The urinalysis has no correlation with the pneumonia. It is important to remember that
t
urinary tract infections are a common cause of sepsis in the elderly, but in this case, it is
ua
not a UTI as the findings are associated with pneumonia.
30. A 29 year old HIV positive man attends the outpatient department with complaints of
al
persistent cough and copious amount of purulent sputum. He also has dyspnoea and
chest pain. On auscultation, inspiratory crepitations are heard at the base of the lung. A
Ev
chest X-ray shows tram track opacities. What is the SINGLE most likely diagnosis?

B. Bronchiectasis
C. Tuberculosis
D. Influenza
E. Sarcoidosis
The persistent cough and copious amount of purulent sputum are symptoms of
bronchiectasis. HIV that is one of the aetiologies of bronchiectasis. Inspiratory
crepitations and a chest-x ray that shows tramlines give a more specific picture pointing
towards bronchiectasis. Although these are not diagnostic, the most probable diagnosis
among the others is bronchiectasis. Only a high-resolution computed tomography
(HRCT) chest would give you the diagnosis of bronchiectasis.
Bronchiectasis
1445
Aetiology

y
Marfan's syndrome
op
C
n
io
t

ua
Note
al

Ev
question
Clinical features
pulmonale
Diagnosis
for confirmation.
1446
Treatment
y
op
with 100% oxygen and salbutamol nebulizers. IV hydrocortisone was prescribed but it
was not available in the department. What is the SINGLE most appropriate next step in
management?
C
A. Oral prednisolone 40 mg
n
C. IV salbutamol
io
D. IM adrenaline
E. IV adrenaline
t
ua
Oral prednisolone and IV hydrocortisone has been shown to have similar efficacy.

al
Ev



32. A 24 year old male is admitted with acute severe asthma. He is treated initiated with
100% oxygen, nebulized salbutamol, and IV hydrocortisone. Ipratropium bromide was
added to nebulizers. Despite the initial treatment there has been no improvement. What
1447
A. IV aminophylline
C. IV salbutamol
D. IM adrenaline
E. IV adrenaline
Next step would be IV magnesium sulphate.

y
op

C
n
io
persistent cough and copious amount of purulent sputum. He had history of measles in
the past. On examination, finger clubbing is noted and inspiratory crepitations on
t
auscultation is heard. A chest X-ray shows tram track opacities. What is the SINGLE most
ua
likely diagnosis?

al
B. Bronchiectasis
C. Asthma
Ev
D. COPD
E. Sarcoidosis
The history of smoking here is irrelevant as smoking does not appear to be an

independent risk factor but smoking cessation is important as part of the management if
the patient does smoke.
bronchiectasis. Measles is a childhood viral infection that is one of the aetiologies of
although not very frequently. Inspiratory crepitations and a chest-x ray that shows
tramlines give a more specific picture pointing towards bronchiectasis. Although these
are not diagnostic, the most probable diagnosis among the others is bronchiectasis. Only
a high-resolution computed tomography (HRCT) chest would give you the diagnosis of
bronchiectasis.
Bronchiectasis
1448
Aetiology

y
Marfan's syndrome
op
C
n
io
t

ua
Note
al

Ev
question
Clinical features
pulmonale
Diagnosis
for confirmation.
1449
Treatment
y
34. A 64 year old man who was previously exposed to asbestos for 35 years while working as
op
a builder has chest pain and shortness of breath. The diagnosis of mesothelioma has
been made. His shortness of breath has been worsening over the last couple of days. A
recent chest x-ray shows bilateral pleural effusion. What is the SINGLE most appropriate
C
management?
A. Indwelling pleural drain

n
B. Physiotherapy
io
C. Radiation therapy
D. Pneumonectomy
t
E. Chemotherapy
ua
This patient's symptoms are due to the pleural effusion secondary to mesothelioma. A
long-term indwelling pleural drainage may be useful in this scenario where he has a
al
malignant effusion.
Ev
Chemotherapy, radiotherapy and surgery are used in the management for

mesothelioma but this patient's major problem is his current shortness of breath which
needs to be treated. Palliative radiotherapy provides pain relief in some patients with
chest wall pain but is less useful in the treatment of breathlessness. Radiotherapy and
surgery can be quite controversial and is unlikely to be the answer in PLAB as it requires
a great depth of knowledge.
Mesothelioma
years.
Clinical features:
1450
- Chest pain
- Dyspnoea
- Weight loss
- Finger clubbing
symptoms
- Lymphadenopathy
- Hepatomegaly
Tests:
y
op

C
Management:
n
io
t
ua
al
with 100% oxygen. He continues to deteriorate. What is the SINGLE most appropriate
next step in management?
Ev
Plab Lab Values
A. Salbutamol nebulized with oxygen

C. IV salbutamol
D. IM adrenaline
E. IV adrenaline
The next step is to give salbutamol nebulisers.
Magnesium sulphate is also used in management of acute exacerbation but it is used

further down the line.
1451


persistent cough, copious amount of purulent sputum and dyspnoea. He has a history of
recurrent chest infections in the past. Coarse crackles are found at the base of his lung
on auscultation. Bronchiectasis is suspected. What is the SINGLE most definitive test to
diagnose bronchiectasis?
y
A. High-resolution computed tomography (HRCT) chest
op
B. Serum immunoglobulins
C. Chest X-ray
D. Lung function tests
C
E. Bronchoscopy
The gold standard for diagnosis is HRCT of the chest. HRCT has a very high sensitivity and
n
specificity for diagnosis and has now replaced bronchography.
io
In adults, bronchoscopy and bronchoscopic sampling of the lower respiratory tract do

t
not have a place in the routine investigation of patients with bronchiectasis.

ua
Bronchoscopy is used for patients in whom serial testing of sputum does not yield
microbiological information and who are not responding well to treatment or if HRCT
suggests atypical mycobacterial infection and sputum culture is negative.
al
Bronchiectasis
Ev
Aetiology

1452
Marfan's syndrome

Note
y
question
Clinical features
op
C
pulmonale
n
io

t

ua
Diagnosis
al

for confirmation.
Ev
Treatment
1453
37. A 32 year old female smoker has a history of wheeze, shortness of breath and fever. Her
past medical history includes eczema. FEV1/forced vital capacity (FVC) was measured
and was found to be low. This was improved after taking bronchodilators. What is the
A. COPD
B. Infective exacerbation of asthma
C. Tuberculosis
D. Bronchiectasis


y
op
(PEF) measurement C
n
io
Risk factors
t

ua

al

- Smoking
Ev
- Maternal smoking
Presentation
- Cough
- SOB
- Wheeze
- Chest tightness.
Triggers include
- Pollens
- cold air
- perfumes
1454
Examination:
In a mild attack

and a silent chest

y
Diagnosis:
op
C
n
io

t

ua
al
Ev

Asthma VS COPD
38. A 17 year old boy with a history of asthma suddenly develops chest pain and increasing
breathlessness during a game of football. He has reduced breath sounds on the right
side. His oxygen saturation is 94% on air. What is the SINGLE most appropriate
investigation?
A. Sweat test
1455
B. Chest X-ray
C. CT chest
D. Exercise challenge
E. D-dimer
Do not forget that acute severe asthma may have an underlying pneumothorax.
Dyspnoea and chest pain in a young man are features of primary spontaneous
pneumothorax.
A standard erect CXRs in inspiration are recommended for the initial diagnosis of
pneumothorax.
y
op
the likelihood of interstitial air leak) C
- More common on the right side
n
io
Presentation
t

ua
percussion
39. An 8 year old girl with diagnosed asthma is having frequent night coughs and mild
al
exercise-induced wheezing. She is compliant with her asthma medication of inhaled

corticosteroid 400 mcg/day and short-acting bronchodilators as required. Her inhaler
Ev
technique is good. What is the SINGLE most appropriate next step in management?
A. Add leukotriene antagonist

B. Add oral theophylline
C. Add regular inhaled long-acting B2 agonist (LABA)
D. Increase dose of inhaled corticosteroid
E. Short course of oral corticosteroid


Step 1
1456
Step 2
many patients
Step 3

Step 4
Consider trials of:
y
Step 5
op
C
n
io
t
ua

al

Ev
40. A 50 year old chronic smoker attended the outpatient department with complaints of
chronic productive cough, dyspnoea and wheeze. A chest X-ray was ordered and
reported as hyperinflated lung with flattened hemidiaphragm and a small cardiac
silhouette. Full blood count shows an increase in haematocrit. What is the SINGLE most
likely diagnosis?

B. Wegener’s granulomatosis
C. Lung cancer
D. Chronic obstructive pulmonary disease (COPD)
E. Amyloidosis
The findings are in keeping with COPD. Haematocit can be raised in COPD.
1457
Chest X-ray is not required for diagnosis of COPD, and repeated CXR is unnecessary,
unless other diagnoses are being considered (most importantly, lung cancer or
bronchiectasis).
If a chest X-ray is ordered, these are the findings:

- Hyperinflated lung fields
- >7 posterior ribs seen
- Flattened diaphragms
- Small heart
- May see bullae
41. A 62 year old man has been smoking 15 cigarettes a day for the past 40 years. His is a
retired builder and has been working since he was 24 year old. He presents with chest
pain, shortness of breath, and has lost significant weight over the last couple of years.
Chest X-ray shows bilateral fibrosis and left sided pleural effusion. What is the SINGLE
best investigations that will lead to diagnosis?
A. Acid fast staining
y
B. Cytology of pleural fluid aspiration
op
D. Pleural biopsy
C
Histology is the most appropriate way to diagnose mesothelioma. The history of working
as a builder is the question writers way of of hinting of asbestos exposure. The
n
association with smoking greatly increases the possibility of developing mesothelioma.
io
The best investigation is pleural biopsy.

t
Pleural fluid aspiration and cytological analysis may provide the diagnosis (sensitivity
ua
range 32–84%) but still the most definitive diagnosis is histology thus pleural biopsy
gives the best choice.
al
Mesothelioma
Ev
years.
Clinical features:
- Chest pain
- Dyspnoea
- Weight loss
- Finger clubbing
symptoms
1458
- Lymphadenopathy
- Hepatomegaly
Tests:

Management:
y
op
indwelling intra-pleural drain may help C
42. A 53 year old man with previous history of chronic obstructive pulmonary disease
presents with breathlessness and purulent sputum. His oxygen saturation are 85% on
air. Arterial blood gas show:
n
io
PaO2 = 7.6 kPa

PaCOS = 7.1 kPa
t
ua
What is the SINGLE most appropriate initial management for his condition?
A. 24% oxygen
al
B. Mechanical ventilation
C. 100% oxygen
Ev
This patient is experiencing an exacerbation of COPD. Giving oxygen would be the first
action. He has hypoxemia and hypercapnia (type 2 respiratory failure). The history of
COPD alone should prompt you to pick 24% oxygen instead of 100% oxygen. This is
because 100% oxygen will abolish the hypoxic drive and worsen hypercapnia. 24-28%
oxygen significantly increases haemoglobin saturation, without risking further
underventilation and a rising pCO2, which can cause coma and death. Remember that
low-concentration oxygen (of 24-28%) is used in patients with chronic obstructive
pulmonary disease (COPD) or any other conditions causing underventilation and CO2
retention.
The aim of (controlled) oxygen therapy is to raise the PaO2 without worsening the
acidosis. Therefore, give oxygen at no more than 28% (via venturi mask, 4 L/minute) or
no more than 2 L/minute (via nasal prongs) and aim for oxygen saturation 88-92% for
patients with a history of COPD until arterial blood gases (ABGs) have been checked.
1459
Remember, for COPD patients, you should be aiming for an SaO2 of 88-92%, (compared
with 94-98% for most acutely ill patients NOT at risk of hypercapnic respiratory failure).
persistent cough and copious amount of purulent sputum. He has recurrent chronic
chest infections in the past. Finger clubbing is noted in examination and inspiratory
crackles are heard on auscultation. A chest X-ray was done and results were normal.
A. Emphysema
B. Rheumatoid arthritis
C. Bronchiectasis
D. Lung cancer
E. Sarcoidosis
The history of smoking here is irrelevant as smoking does not appear to be an

independent risk factor but smoking cessation is important as part of the management if
y
the patient does smoke.
op
C
although not very frequently. Inspiratory crackles can be found on bronchiectasis. Chest
X-ray in early stages can be normal. Although these are not diagnostic, the most
probable diagnosis among the others is bronchiectasis. Only a high-resolution computed
n
tomography (HRCT) chest would give you the diagnosis of bronchiectasis.
io
Bronchiectasis
t
ua

al
Aetiology
Ev


Marfan's syndrome
1460
Note
question
Clinical features
y
op
pulmonale
C
n
io
Diagnosis
t

ua
for confirmation.
al

Ev
Treatment
44. A 10 year old girl is brought to the emergency department by her dad after having fallen
in the park. Her elbows are full of cuts and she has not stopped crying since the injury.
1461
Her medical history includes asthma. What is the SINGLE most appropriate analgesia to
administer?
A. Aspirin
B. Diclofenac
C. Co-codamol
D. Ibuprofen
E. Paracetamol
Symptoms of asthma may present after taking aspirin, NSAIDS or beta-blockers. Thus,
NSAIDS like ibuprofen and diclofenac should not be used here.
The association between non-steroidal anti-inflammatory drugs (NSAIDs), including

aspirin, and the precipitation of asthma is well documented but, in reality, it is not often
seen. So in clinical practice, one may use NSAIDS even if patient has asthma, but for the
purpose of PLAB, never give NSAIDS if the patient has asthma.
Codeine should only be used to relieve acute moderate pain in children older than 12
y
years and only if it cannot be relieved by other painkillers such as paracetamol or
op
ibuprofen alone.
Since the child here is under 12, co-codamol should not be used.
C
Paracetamol is the only available choice.
45. A 54 year old patient 7 days after a total hip replacement presents with acute onset
n
breathlessness, and chest pain. On examination, an elevated jugular venous pressure
io
was observed. Her right calf looks swollen. Her pulse rate is 95 bpm and respiratory rate
is 24/min. Which SINGLE investigations will be most helpful in leading to a diagnosis?
t
ua
A. Chest X-ray
B. CT pulmonary angiogram (CTPA)
C. V/Q scan
al
D. D-Dimer
E. Doppler ultrasound of legs
Ev
Two-level PE Wells score
Clinical feature Points

Clinical signs and symptoms of DVT (minimum of leg swelling and pain 3
with palpation of the deep veins)
An alternative diagnosis is less likely than PE 3
Heart rate > 100 beats per minute 1.5
Immobilisation for more than 3 days or surgery in the previous 4 weeks 1.5
Previous DVT/PE 1.5
Haemoptysis 1
Malignancy (on treatment, treated in the last 6 months, or palliative) 1
Clinical probability simplified scores

- PE likely - more than 4 points
- PE unlikely - 4 points or less
1462
More than 4 points → Arrange an immediate computed tomography pulmonary
angiogram (CTPA)
4 points or less → Arranged a D-dimer test. If this is positive arrange an immediate

computed tomography pulmonary angiogram (CTPA)
If anytime there is a delay in getting the CTPA → Give low-molecular weight heparin
until the scan is performed
If the patient has an allergy to contrast media or renal impairment → A V/Q scan
should be used instead of a CTPA
Occasionally, questions will have a question with a patient with typical signs and
symptoms of pulmonary embolism and options of a CTPA and V/Q scans would be in the
mix. Which one would you perform?
- Pick the CTPA over the V/Q scans
The consensus view from the British Thoracic Society and NICE guidelines is as follows:
y
- Computed tomographic pulmonary angiography (CTPA) is now the
op
recommended initial lung-imaging modality for non-massive PE. Advantages
compared to V/Q scans include speed, easier to perform out-of-hours, a reduced
need for further imaging and the possibility of providing an alternative diagnosis
C
if PE is excluded
- If the CTPA is negative then patients do not need further investigations or
treatment for PE
n
io
Also note that you should pick the CTPA over V/Q scans even if the patient is pregnant.
The RCOG guidelines for Thromboembolic Disease in Pregnancy and the Puerperium
t
clearly state that:

ua
- When the chest X-ray is abnormal and there is a clinical suspicion of PE, CTPA
should be performed in preference to a V/Q scan. [New 2015]
al
46. A 61 year old man has suddenly become very short of breath. In the last hour, he has
Ev
had a CT-guided biopsy of a mass in the right lung. His temperature is 36.5°C, heart rate
is 120 bpm, BP 90/60 mmHg, and SaO 2 78% on 15L oxygen . He looks cyanosed, his
trachea is deviated towards the left, and breath sounds are much louder over the left
hemi-thorax. Which is the SINGLE most appropriate course of action?

C. Insertion of a cannula into the right second intercostal space
D. Insertion of a cannula into the left second intercostal space
This man has rapidly developed the signs of a pneumothorax. Having just had a needle
inserted into his chest, this is almost certainly an iatrogenic pneumothorax. The
deviation of the trachea suggests that it is under tension and so needs urgent reversal.
This is done by introducing a cannula into the pleural space, usually in the second
anterior intercostal space mid-clavicular line. Air should be removed until the patient is
1463
no longer compromised and then an intercostal tube can be inserted into the pleural
space.
The other less appropriate answers:

Investigations like ABG and chest X-ray → should be deferred as this is a serious
situation that would lead to cardiorespiratory arrest unless addressed.
Insertion of a chest drain → will be needed but not until the air has been removed.
Insertion of a cannula into the left second intercostal space → Clearly a wrong answer
as the trachea is deviated towards the left. This means that the tension pneumothorax is
on the right.
Tension Pneumothorax
Presentation
- Acute respiratory distress
- Hypotension
y
- Raised jugular venous pressure
op
- Tracheal deviation away from the pneumothorax side
- Reduced air entry on affected side C
Management of a tension pneumothorax
If strong clinical suspicion, give high-flow oxygen and insert large-bore cannula into
second intercostal space in midclavicular line on side of pneumothorax.
n
io
- Do not wait for a chest X-ray if patient seriously compromised or cardiac arrest
has occurred or if the diagnosis is clinically certain
t
- Hiss of escaping air confirms diagnosis

ua
- Air should be aspirated until the patient is less distressed. Then insert a chest
drain in mid-axillary line, leaving the cannula in place until you have finished and
the underwater seal is bubbling satisfactorily
al
Comparing simple and tension pneumothorax

Ev
Simple Pneumothorax Tension Pneumothorax

Trachea Upside Down T Trachea Arrow East
Expansion Down Arrow Expansion Down Arrow
Percussion Note Up Arrow Percussion Note Up Arrow
Breath sounds Down Arrow Breath sounds Down Arrow
Neck Veins Up Arrow
47. A 33 year old man has a temperature of 38.5°C, productive cough and chest pain on the
right side on inspiration. He has a blood pressure of 100/60 mmHg and a pulse rate of
108 beats/minute. He appears slightly short of breath and has an oxygen saturation of
94% on room air. What is the SINGLE most likely organism causing the patient's
symptoms?
A. Gram +ve cocci

B. Coagulase +ve cocci
1464
C. Gram +ve Bacilli
D. Acid-Fast Bacilli
E. Gram –ve cocci
Streptococcus pneumoniae (pneumococcus) is the most common cause of community-

acquired pneumonia. It is a gram +ve cocci.
48. A 28 year old female who has returned from the USA to the UK presents to Accident &
Emergency with shortness of breath and a productive cough beginning 3 days after her
return to the United Kingdom. Her cough initially contained blood but is now dry. Her
only significant history is that she is on the combined oral contraceptive pill. What is the
SINGLE most likely diagnosis for this woman’s symptoms?
A. Community acquired pneumonia

C. Pulmonary tuberculosis
D. Lymphoma
E. Lung cancer
y
op
In PLAB 1, when the examiners want you to choose pulmonary embolism, they will
mention:
1. History of prolonged immobility (such as airplane travel)
C
2. Risk factor for PE (COCP, surgery, obesity etc.)
3. Patient experiencing shortness of breath
n
Pulmonary Embolism
io
Risk factors (in order of importance):

t
- Surgery
ua
- Pregnancy (including the postnatal period)

- Lower limb injury
- Malignancy
al
- Reduced mobility
- Previous VTE (venous thromboembolism)
Ev
Signs and symptoms:
Remember that these are non-specific

Symptoms include:
- Dyspnoea.
- Pleuritic chest pain or retrosternal chest pain.
- Cough and haemoptysis.
Signs include:
- Tachypnoea, tachycardia.
- Hypoxia, which may cause anxiety, restlessness, agitation and impaired
consciousness.
- Pyrexia.
- Elevated jugular venous pressure.
- Gallop heart rhythm, a widely split second heart sound, tricuspid regurgitant
murmur.
- Pleural rub.
1465
- Systemic hypotension and cardiogenic shock.
All you need to remember in terms of diagnosis and management for the PLAB 1 exam is
that CTPA is the gold standard for diagnosis of pulmonary embolism and that immediate
administration of LMWH (low molecular weight heparin) or fondaparinux must be given
once the diagnosis is confirmed.
49. A 70 year old man admits to asbestos exposure 20 years ago. He was a heavy smoker but
has quit smoking 3 years ago. He has noted weight loss and hoarseness of voice. Which
is the SINGLE most likely type of cancer associated with the risk factors and symptoms
present?

D. Nasopharyngeal carcinoma
E. Oral carcinoma
y
Approximately 95% of all primary lung tumours are bronchial carcinomas.
op
Primary bronchial cancers are classified as follows:
- small-cell lung cancers (SCLCs)
C
- non-small-cell lung cancers (NSCLCs)
Adenocarcinoma accounts for 39% of NSCLCs and is the most common bronchial
n
carcinoma associated with asbestos and is more common in non-smokers, compared
io
with other cell types.

t
It is also important to note that hoarseness can also be a feature of lung cancer.
ua
50. A 50 year old woman returned by air to the UK from Australia. 3 days days later, she
presents with a sharp chest pain and breathlessness. Her chest X-ray and ECG are
al

Ev
A. Bronchoscopy
B. Cardiac enzymes
D. MRI
E. Pulse oximetry
Prolonged plane journey is a recognized risk factor for thromboembolism and hence
pulmonary embolism as well. Sharp chest pain and breathlessness after 3 days of plane
journey is highly suggestive of pulmonary embolism. CTPA is the answer here as it is the
best test among the other options which provide a definitive diagnosis of pulmonary
embolism.
1466
Previous DVT/PE 1.5
Haemoptysis 1


angiogram (CTPA)
y
op
until the scan is performed C
n
io
t

ua
al

Ev
if PE is excluded
treatment for PE
clearly state that:
51. A 20 year old man presents to A&E after having severe injuries from a road traffic
accident. On presentation he is breathless and has severe chest pain. A Chest X-ray
shows fractures of the 5th to 7th rib. His systolic blood pressure is 85 bpm, respiratory
rate is 25 breaths/min and his pulse rate is 110/min What is the SINGLE most
appropriate initial action?
1467
A. Antibiotics
B. Analgesia
C. High flow oxygen
D. Secure venous access
E. Refer to surgeon
Another very debatable question. The diagnosis here is flail chest.
In this question, the examiners want you to know the basics of life-threatening
emergencies. ABC - airway, breathing, circulation should always be addressed first.
In reality, oxygen by mask, securing venous access and analgesia would all be done
simultaneously. But for the purpose of this exam, we should know the steps according to
NHS guidelines and British references. Thus, securing airways and giving oxygen would
come before anything else.
Remember ABC!
y
Flail chest
op
Fractures of ≥3 ribs in 2 places allows part of the chest wall to move independently. This
?ail segment usually indicates signi?cant injury to the underlying lung (typically
C
pulmonary contusions)
Presentation
n
io
The ?ail segment causes pain and moves paradoxically compared with the rest of the
chest wall, limiting the effectiveness of respiration. There may be associated features of
t
respiratory distress (cyanosis, tachypnoea).

ua
Diagnosis
The diagnosis is a clinical one, but it can be dif?cult to make. Look tangentially at the
al
chest for areas which move paradoxically (ie inwards during inspiration and outwards
during expiration)
Ev
Assessment of the extent of respiratory compromise is largely clinical but aided by a few
simple investigations:
- SpO2 on pulse oximetry

- ABG would show a combination of hypoxia and respiratory acidosis
- Chest X-ray will demonstrate fractures and associated injuries
Treatment
- Provide high ?ow O2 and treat associated life-threatening problems

- Contact the ICU/anaesthesia team and carefully consider the need for
immediate or urgent tracheal intubation with IPPV
- Analgesic pain medications are a common treatment for flail chest. Opioid pain
medications in high doses can produce respiratory depression, especially in the
elderly, although they can be helpful at lesser doses
1468
52. A 20 year old man suddenly develops shortness of breath over the last day. It started
when he was playing football. The shortness of breath was associated with right sided
pleuritic chest pain. On examination, reduced air entry with hyper-resonance was noted
over the right lung field. His oxygen saturation was 91% on room air. What is the SINGLE
A. Asthma
B. Spontaneous pneumothorax
C. Tension pneumothorax
D. Sarcoidosis
E. Chronic obstructive pulmonary disease (COPD)
Dyspnoea and chest pain in a young man are features of primary spontaneous
pneumothorax. This occurs when a subpleural bullous ruptures.
One of the major differences between spontaneous pneumothorax from tension

pneumothorax is that the patient does not have a deviated trachea away from the
affected side.
y
op
C
n
io

t
- More common on the right side

ua

- Usually caused by rupture of small subpleural blebs (collections of air < 2cm)
al
Presentation
Ev

percussion
53. A 21 year old man has exercised induced asthma and is using a salbutamol inhaler as
required and beclomethasone inhaler 400 mcg/day. He complains of wheeze and
shortness of breath during exercise despite using salbutamol inhaler just before
exercise. What is the SINGLE most appropriate action?
Sodium cromoglycate can be added for exercise-induced asthma.
Exercise-induced asthma
1469
Exercise-induced asthma although following the stepwise approach has a slight
difference in management.
For most patients, exercise-induced asthma is an illustration of poorly controlled

asthma and regular treatment including inhaled corticosteroids should therefore be
reviewed. If exercise is a specific problem in patients already taking inhaled
corticosteroids who are otherwise well controlled, consider adding either:
leukotriene receptor antagonist
a long-acting beta 2 agonist
an oral beta 2 agonist
sodium cromoglicate
theophylline
An inhaled short-acting beta2 agonists used immediately before exercise is the drug of
choice.
Source: http://patient.info/doctor/bronchial-asthma and BNF
y
op
C
Asthma - Management of stable asthma in adults
n
io
Management of stable asthma in adults:

t
ua
Step 1
al
Step 2
Ev
many patients
Step 3

Step 4
Consider trials of:
1470
- addition of a fourth drug e.g. Leukotriene receptor antagonist, SR theophylline,
B2 agonist tablet
Step 5
If you find this stepwise approach too complicated to memorize. Then just memorize it in
a very simplified way as stated below:

Note:
y
NICE now recommends omalizumab as an option for treating severe persistent
op
confirmed allergic IgE-mediated asthma as an add-on to optimised standard therapy in
people aged 6 years and older who need continuous or frequent treatment with oral
corticosteroids. However this is so new that it is unlikely to be asked in PLAB
C
54. A 60 year old lady is on treatment for ischaemic heart disease, hypertension and
hyperlipidaemia. During the night, she complains of wheezing and shortness of breath.
n
What is the SINGLE most likely medication that is responsible for her symptoms?
io
A. Amlodipine
t
B. Atenolol
ua
C. Ramipril
D. Simvastatin
al
Symptoms of asthma may present after taking aspirin, NSAIDS or beta-blockers.

Ev
Atenolol is the only beta blocker on the list.
55. A 15 year old boy presents to the Emergency Department with a sudden onset of chest
pain and increasing shortness of breath during a beach volleyball game. He has a medical
history of asthma and is on a beta-2 agonist inhaler. On examination, there is no
cyanosis but there are reduced breath sounds on the left side. Which of the following is
A. D-dimer
B. CT chest
C. Chest x-ray
D. Peak flow meter
E. Spirometry
This is a diagnosis of spontaneous pneumothorax. Key clues for PLAB 1: young male
playing a sport develops sudden shortness of breath. There usually would be clues
1471
“decreased breath sounds on one side”. Sometimes they may say a “tall” man or an
“athlete”, as these would be the common presenters of spontaneous pneumothorax.
between 20 and 40.
Chest X-ray is the diagnostic test in most cases, revealing a visible lung edge and absent
lung markings peripherally.
If patient is cyanosed, dyspneic, underlying lung disease – perform arterial blood gas
56. An 8 year old boy diagnosed with asthma is on salbutamol inhaler and beclomethasone
inhaler. However, he wakes up at night with wheezing and shortness of breath. What is
y
A. Add inhaled long-acting B2 agonist (LABA)

B. Increase inhaled corticosteroid dose
op
C
C. Aminophylline
D. Oral prednisolone
E. Sodium cromoglycate
n
io

t
ua

al
Step 1
Ev
Step 2
many patients
Step 3

1472
Step 4
Consider trials of:
Step 5

y
op
57. A 35 year old lady had an emergency C-section following an obstructed labour. Three
days post-op she develops a sudden onset of left sided chest pain associated with
breathlessness. Her heart rate is 105 bpm. Her left leg is swollen and is pain on
C
palpation. What is the SINGLE best investigation to provide a definitive diagnosis?
n
A. Arterial blood gases
B. Chest X-ray
io

D. D-dimer
t
E. Electrocardiogram (ECG)
ua
CTPA is the answer here as it is the best test among the other options which provide a
al
definitive diagnosis of pulmonary embolism.

Ev

Previous DVT/PE 1.5
Haemoptysis 1


angiogram (CTPA)
1473
until the scan is performed
y
op
if PE is excluded
C
treatment for PE
n
io
clearly state that:

t

ua
58. A 48 year old farmer presents with malaise, dry cough, chest tightness and shortness of
breath. The shortness of breath and cough started only a few hours ago. On
al
auscultation, a wheeze is heard throughout the chest. He has a temperature of 39.2°C, a

pulse of 96 beats/minute, a blood pressure of 110/70 mmHg and a respiratory rate of 29
Ev
breaths/minute. His chest X-ray shows diffuse micronodular interstitial shadowing. What
is the SINGLE most appropriate diagnosis?
C. Cryptogenic organizing pneumonia
D. Extrinsic allergic alveolitis
The signs and symptoms fit extrinsic allergic alveolitis. The occupation as a farmer is also
another hint.
Chest X ray: in the acute form may be normal in some or show diffuse micronodular
interstitial shadowing like in this case.
Extrinsic allergic alveolitis
1474
In extrinsic allergic alveolitis there is diffuse, granulomatous inflammation of the lung
parenchyma and airways in people who have been sensitised by repeated inhalation of
organic antigens in dusts (eg, from dairy or grain products, animal dander and protein
and water reservoir vapourisers)
One of the specific risk factors is occupations including farmers, cattle workers,
ventilation system workers, vets, people working with grain and flour, those whose job
involves working with chemicals
There are 3 forms of extrinsic allergic alveolitis:

1. Acute
2. Subacute
3. Chronic
The most commonly asked form in PLAB is the acute form and so we would only discuss
the acute form of extrinsic allergic alveolitis
Acute form
y
- Symptoms usually start 4-8 hours after exposure to the sensitising antigen and
op
resolve quickly, usually within days.
- There is a flu-like illness with fever, chest tightness, dry cough and dyspnoea.
Associated symptoms include malaise, chills, headache, generalised aches and
C
pains. Wheeze is sometimes present.
- Signs include fever, tachypnoea and bibasal fine inspiratory crackles
n
59. A 35 year old man presents with progressive breathlessness. He has a history of
io
polyarthralgia with painful red lumps appearing on his shins. They are cherry sized and
are about 20 or more in number. His chest X-ray shows bilateral hilar lymphadenopathy.
t

ua
A. Bronchial asthma
B. Cystic fibrosis
al
C. Sarcoidosis
D. Bronchiectasis
Ev
E. Pneumonia
In PLAB, whenever you see the term “bilateral hilar lymphadenopathy” with a rash on
the shin, you should be thinking of Sarcoidosis.
The syndrome here is Lofgren syndrome which includes erythema nodosum, arthritis,
and hilar adenopathy. Lofgren is a distinct sarcoid syndrome
Sarcoidosis

Features
common.
1475
polyarthralgia
macrophages.


y
Chest X-Ray.
op
C

n
io

t

ua

al
Diagnosis.
Ev
Treatment
PLAB.
60. A 33 year old man is brought into the emergency department following a road traffic
accident. He is seen to be very short of breath. He has no breath sounds over the right
side of his chest. On percussion, the right chest is noted to be hyper-resonant. On
examination, his trachea is deviated to the left. His heart rate is 120 beats/minute. His
blood pressure is 90/65 mmHg, and has an oxygen saturation of 85% on 15L of oxygen.
1476
C. Needle decompression
D. Urgent computed tomography scan of chest
This man has rapidly developed the signs of a pneumothorax. Having just had a needle
inserted into his chest, this is almost certainly an iatrogenic pneumothorax. The
deviation of the trachea suggests that it is under tension and so needs urgent reversal.
This is done by introducing a cannula into the pleural space, usually in the second
anterior intercostal space mid-clavicular line. Air should be removed until the patient is
no longer compromised and then an intercostal tube can be inserted into the pleural
space.
The other less appropriate answers:

Investigations like ABG and chest X-ray → should be deferred as this is a serious
situation that would lead to cardiorespiratory arrest unless addressed.
Insertion of a chest drain → will be needed but not until the air has been removed.
y
op
Insertion of a cannula into the left second intercostal space → Clearly a wrong answer
as the trachea is deviated towards the left. This means that the tension pneumothorax is
on the right.
C
n
Presentation
io

- Hypotension
t

ua

- Reduced air entry on affected side
al

Ev

Neck Veins Up Arrow
1477
61. A 32 year old previously healthy woman has developed pain and swelling on both knees
and ankles with a nodular rash over her shins. As part of the investigation a chest X-ray
was performed. What is the SINGLE most likely appearance on the chest X-ray?
A. Apical granuloma
B. Bilateral hilar lymphadenopathy
C. Lobar consolidation
D. Pleural effusion
E. Reticular shadowing in the bases
A very commonly asked topic on PLAB → Sarcoidosis
The questions would usually provide 2 out of the 3 important clinical features of Lofgren
syndrome and ask for the third feature. Lofgren syndrome includes:
1. Erythema nodosum
2. Arthritis
3. Bilateral hilar lymphadenopathy.
y
op
Thus if you see any 2 of the 3 features stated above, the first thought should be Lofgren
(a distinct sarcoid syndrome) C
Sarcoidosis

n
io
Features
t
ua
common.

al
polyarthralgia
Ev

macrophages.


Chest X-Ray.
1478

Diagnosis.
Treatment
y
op
PLAB.
C
62. A 21 year old lady who smokes has a history of wheezing, chest tightness and coughing
at night. She also notices these symptoms occur when she goes out in the cold and
n
breathes cold air. What is the SINGLE most likely diagnosis?
io
A. COPD
t
B. Asthma
ua
C. Pneumoconiosis
D. Bronchiectasis
al

Ev

(PEF) measurement

Risk factors
1479
- Smoking
- Maternal smoking
Presentation
- Cough
- SOB
- Wheeze
- Chest tightness.
Triggers include
- Pollens
y
op
- cold air
- perfumes C
n
Examination:
io

t
ua
In a mild attack
al

Ev

and a silent chest

Diagnosis:
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Asthma VS COPD
y
op
C
63. A 46 year old man is being treated for a pleural effusion. A chest drain has been sited
just below the 4th rib in the mid-axillary line on his right side. What SINGLE structure is
n
at particular risk of injury?
io
A. Azygos vein
t
B. Diaphragm
ua
C. Intercostal artery
D. Internal thoracic artery
E. Liver
al
Chest drain Insertion technique

Ev
‘Safe triangle’ for chest drain insertion, bounded anteriorly by pectoralis major,
posteriorly by latissimus dorsi, inferiorly by the fifth intercostal space, and superiorly by
the axilla.
By inserting at the safe triangle, we avoids major vessels and muscles
It is important to note that the intercostal vessels and nerves run below the inferior
border of the ribs. Thus, the drain track should be directed over the top of the lower rib
to avoid the intercostal vessels lying below each rib.
64. A 54 year old smoker man presents with progressive dyspnoea. He complains of cough,
wheeze and a table spoonful of mucopurulent sputum which he coughs out daily for the
last 15 months. A spirometry was performed. His FEV1/FVC is 2.4/3.7. After taking
salbutamol, the spirometry was performed again which gave a ratio of 2.5/3.8. What is
1481
A. Chronic bronchitis
B. Asthma
C. Bronchiectasis
D. Lung fibrosis
E. Sarcoidosis
He has clear signs of chronic bronchitis. The spirometry is important to perform as it

shows that there is irreversible airflow obstruction on spirometry. A FEV/FVC < 0.7 post-
bronchodilator points towards the direction of COPD. The minimal bronchodilator
reversibility (< 5%) helps diagnose COPD and it is also useful if there is diagnostic
uncertainty for example, if the patient is thought to have both COPD and asthma.
Chronic bronchitis
- Defined as a productive cough that lasts for three months or more per year for
at least two years
Note that COPD is now the preferred term for patients with airflow obstruction who were
y
previously diagnosed as having chronic bronchitis or emphysema
Presentation
- Cough accompanied by sputum production
op
C
- Dyspnoea
- Low-grade fever (but patients are most commonly afebrile)
- Wheezing
n
io
Aetiology
- Smoking
t
ua
Investigations
- Pulmonary function test
o Decreased FEV1 and FEV1/FVC ratio
al
o FEV1/FVC < 0.7 (post-bronchodilator)

- Chest X-ray
Ev
o is not required for diagnosis but is important to rule out other diagnoses
that are being considered e.g. lung cancer, bronchiectasis
o Hyperinflated lung fields
o Attenuation of peripheral vasculature
o Flattened diaphragms
Remember diagnosis of COPD → is based on the history of smoking and progressive

dyspnoea, with evidence of irreversible airflow obstruction on spirometry
65. A 68 year old smoker has left sided chest pain which worsens when taking deep breaths.
His medical history includes diabetes mellitus and hypertension. On examination, he has
a miotic left eye and partial ptosis on the left. There is also wasting of small muscles of
the lett hand. What is the SINGLE most likely diagnosis?
A. Costochondritis
B. Lung cancer
C. Goodpasture's syndrome
1482
The likely diagnosis here is a pancoast tumour which is a type of lung cancer defined
primarily by its location situated at the top end of the right or left lung. In this case, it
would be the left lung. This would explain the chest pain firstly and also the miosis and
ptosis which are part of Horner’s syndrome.
Pancoast tumour
- A tumour of the pulmonary apex
- It is a type of lung cancer defined primarily by its location situated at the top end
of either the right or left lung
Presentation
- Ipsilateral invasion of the cervical sympathetic plexus leads to Horner's
syndrome (ptosis, anhidrosis, miosis)
- Brachial plexus invasion can lead to wasting of the intrinsic hand muscles and
paraesthesiae in the medial side of the arm along with shoulder and arm pain
y
op
Mnemonic for Horner’s syndrome → “Horny PAMELA”
P → Ptosis (drooping of the eyelid)
A → Anhidrosis (lack of sweating)
C
M → Miosis (constriction of the pupils)
E → Enophthalmos (sunken eyeball)
n
66. A 2 year old girl presents with a 4 day history of fever which started with a cough. She
io
has a respiratory rate of 45 beats/minute, oxygen saturation of 94% and a temperature

of 38.9C. There are crepitations at the left base on auscultation of the lung fields. Urine
t
ua
to diagnosis?

al

C. Chest X-ray
Ev
D. Urine for Culture and sensitivity

This is an extremely straight forward question. The features are consistent with
respiratory tract infection (possibly pneumonia) for which a chest X-ray is the
investigation of choice.
67. A 23 year old woman who is on several medications and inhalers for her asthma
presents to the hospital with palpitations. Her heart rate is 110 beats/minute. Her peak
expiratory flow rate is 400 L/minute. What is the SINGLE most appropriate
management?
A. Lifestyle changes
B. Review medications
C. 24 hour ECG monitoring
D. Admit for investigations
E. Chest X-ray
1483
One of the common side effects of beta agonist is palpitations and tachycardia. Both of
which are seen here. Reviewing the medications would be appropriate.
68. A 58 year old man who used to work in the shipyard industry was having chronic cough
and shortness of breath for several months. He was given salbutamol nebulisers and
intravenous antibiotics and admitted to the ward. A computed tomography was
performed which showed patchy infiltrates, pleural thickening and pleural effusion. He
died 3 days later after which this case was referred to the coroner. What is the SINGLE
most likely reason for the referral to the coroner?
A. Incorrect diagnosis and management

B. Inpatient death in the wards
C. Death likely due to industrial disease
D. Cancer research purposes
E. Death by natural causes
This patient's symptoms were due to the pleural effusion secondary to mesothelioma.
y
Mesothelioma is classed as an industrial disease. In England and Wales, all deaths from
op
mesothelioma must be referred to the local coroner’s office. The coroner will then
decide if a post-mortem examination is required and will hold an inquest. An inquest is a
legal investigation to establish the circumstances surrounding a person’s death. An
C
inquest is needed because mesothelioma is an occupational disease and one needs to
determine whether the death was due to mesothelioma or some other cause.
n
Mesothelioma
io

t
ua
years.
al

Ev
Clinical features:
- Chest pain
- Dyspnoea
- Weight loss
- Finger clubbing
symptoms
- Lymphadenopathy
- Hepatomegaly
Tests:
1484

Management:
69. A 79 year old man with longstanding chronic obstructive pulmonary disease has become
progressively breathless over the last 2 years. His medications for his COPD include
salbutamol and salmeterol inhalers, inhaled corticosteroids and theophylline. His forced
y
expiratory volume in one second (FEV1) is less than 30%. His oxygen saturations are 89%
op
on room air. What is the next appropriate management?
A. Assessment for lung transplant

C
B. Trial of continuous positive airway pressure
C. Trial of noninvasive ventilation
D. Assessment for long term oxygen therapy
n
E. Assessment for a short course of oxygen therapy
io
COPD is the disease for which long-term oxygen therapy (LTOT) is most commonly
t
prescribed. There is strong evidence of survival benefit of long-term oxygen therapy

ua
(LTOT) in patients with COPD and severe chronic hypoxaemia when used for at least 15
hours daily. Once LTOT is started, it is likely to be lifelong. It is usually given over a
minimum of 15 hours a day.
al
When do you assess the need for oxygen therapy?

Ev
- Very severe airflow obstruction → forced expiratory volume in one second

(FEV1) less than 30% predicted
- Polycythaemia
- Oxygen saturation 92% or less on room air
Conditions for assessment for LTOT

- Needs to be stable and more than 5 weeks have passed since any exacerbation
of COPD
- On a fully optimized treatment for COPD
- 2 sets of ABG are taken 3 weeks apart to ensure the patient is sufficiently
hypoxic
When to offer LTOT to patients?

- pO2 of < 7.3 kPa or
- pO2 of 7.3 - 8 kPa and one of the following:
o Secondary polycythaemia
o Nocturnal hypoxaemia
1485
o Peripheral oedema
o Pulmonary hypertension
70. A 27 year old man presents with chest pain and respiratory distress following a road
traffic accident. On examination, his neck veins are noted to be distended and trachea is
deviated to the left. Breath sounds are absent on the left and diminished on the right
lung field. He has a blood pressure of 80/40 mmHg and a heart rate of 120
beats/minute. What is the SINGLE most appropriate next action?
A. Chest X-ray
B. Insertion of a cannula into the right second intercostal space
C. Insertion of a cannula into the left second intercostal space
D. Insertion of a chest drain into right mid-axillary line
E. Insertion of a chest drain into left mid-axillary line
The features described is diagnostic of right sided tension pneumothorax.
y
op
Presentation
- Hypotension
C
- Reduced air entry on affected side
n
io

t

ua
al

Ev

Neck Veins Up Arrow
71. A 67 year old smoker presents with cough, breathlessness and wheeze. 24% oxygen by
Venturi face mask was initiated and nebulized salbutamol and hydrocortisone were
administered. As his dyspnoea did not improve, intravenous aminophylline was
administered and an arterial blood gas was sent. He has a respiratory rate of 32
breaths/minute. His arterial blood gas results show:
1486
pH 7.32
pCO2 7.7 kPa
pO2 10.1 kPa
A. Non-invasive ventilation
B. Invasive mechanical ventilation
C. Long-acting beta-adrenoceptor agonist
D. Intravenous doxapram hydrochloride
E. Oral amoxicillin
This question is testing your knowledge on the management of acute exacerbation of

COPD. The reason that this is likely COPD instead of asthma is because of his age, the
fact that he is a smoker, and the choice of administering 24% of oxygen rather than
100% oxygen. 24% of oxygen gives the clue that he is on controlled O2 therapy with the
attempt to maintain saturations between 88% and 92% to balance hypoxia, hypercapnia
and pH which is seen as part of the management for COPD.
y
op
Non-invasive ventilation would be the next step in management as it is particularly
effective in supporting patients during an exacerbation especially when maximal medical
treatment has not been effective like in this case. Its use is appropriate for conscious
C
patients with ongoing respiratory acidosis (< pH 7.35).
Note that oral antibiotics should ONLY be given if there is purulent sputum or clinical
n
signs of pneumonia. While it is common practice for all patients with an exacerbation of
io
COPD to receive antibiotics in the hospital, it is not according to NICE guidelines and for
the purpose of this exam, antibiotics should not be administered to manage acute
t
exacerbation COPD unless we suspect pneumonia.

ua
The reason why invasive mechanical ventilation is an inappropriate answer is that it has
its own complications such as pneumonia, barotrauma, and failure to wean to
al
spontaneous ventilation. Thus, it should not be used unless non-invasive ventilation fails
or is contraindicated such as in scenarios like respiratory arrest, high aspiration risk, or
Ev
impaired mental status.
Doxapram is also an incorrect answer. Doxapram is a respiratory stimulant. It is given

intravenously and can be used to drive respiratory rate if respiratory rate was less than
20 breaths/minute. In this case, the respiratory rate is 32 breaths/minute hence there is
no problem with the respiratory drive. Its use has largely been replaced by non-invasive
ventilation.
Management of acute exacerbation of COPD

- Antibiotics if sputum is purulent or clinical signs of pneumonia
- Prednisolone 30mg/day for 7-14 days
- Inhaled or nebulized bronchodilators
- Controlled O2 therapy 24% via Venturi face mask, with oximetry → Maintain
saturations between 88% and 92%
- IV aminophylline → Beneficial if the patient is wheezy and has not improved
with nebulizers alone
1487
- Non-invasive ventilation → Effective in supporting patients during an
exacerbation when maximal medical treatment has not been shown to be
effective
72. A 48 year old presents with increasing shortness of breath over the last few months and
a dry cough. He has worked in coal mines for 18 years. Chest x-ray and CT scan of the
chest demonstrates characteristic upper zone mass-like scarring with calcification and
volume loss. The lung opacifications are seen to be associated with radiating strands.
A. Churg-strauss syndrome
B. Cryptogenic organizing
C. Extrinsic allergic alveolitis
D. Goodpasture's syndrome
The first step to recognition of the answer is to understand that with a history of
working in coal mines this is likely Coal worker’s pneumoconiosis. Progressive massive
y
fibrosis refers to the formation of large conglomerate masses of dense fibrosis,
op
predominantly in the upper pulmonary lobes. These classically develop in the context of
certain pneumoconioses (especially Coal worker's pneumoconiosis and silicosis).
C
73. A 48 year old man was admitted with cough and dyspnoea. He has a long history of
smoking and has lost 8 kg in the past 5 months. A chest X-ray was performed and
showed consolidation on the lower left lobe. He was started on antibiotics and is due for
n
discharge. What is the SINGLE most appropriate follow up investigations to perform
io
after discharge?
t
A. Bronchoscopy
ua
B. Chest X-ray
C. Sputum culture
D. Computed tomography (CT)
al
E. Magnetic resonance imaging (MRI)

Ev
A chest X-ray should be performed after he recovers. As he is a smoker and has lost
significant weight, lung malignancy should be part of the differential. The first chest X-
ray shows consolidation of the left lower lobe which is consistent with pneumonia. A
repeat chest X-ray would be required to assess malignancy as the consolidation on the
left lower lobe could have hindered a proper assessment of lung carcinoma.
1488
RHEUMATOLOGY
y
op
C
Questions
n
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&
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Answers
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Ev
1489
Rheumatology Questions
1. A 45 year old man with severe pain and redness at the metatarsophalangeal joint of his
right big toe comes to the Emergency Department. He has never suffered from any
form of arthritis before. He has hypertension and was recently started on
bendroflumethiazide by his GP. What is the SINGLE most appropriate management?
A. Paracetamol
B. Allopurinol
C. Methotrexate
D. NSAIDS
E. Flucloxacillin
2. A 78 year old woman presents with unilateral headache and pain on chewing. Her ESR
is 70 mm/hour. She is on oral steroids. What is the SINGLE most appropriate additional
treatment?
A. Bisphosphonates
y
B. Hormone replacement therapy
op
C. ACE inhibitors
D. Beta blockers
E. Timolol
C
3. A 52 year old woman with a history of systemic lupus erythematosus complains of dry
eyes and altered sense of taste. Her voice becomes hoarse when she speaks for long
n
io
A. Acquired Angioedema
t
B. Sjogren's syndrome
ua
C. Herpes zoster ophthalmicus

D. Sarcoidosis
E. Scleroderma
al
4. A 76 year old who is on medication for hypertension comes to clinic suffering from pain
Ev
and redness at the metatarsophalangeal joint of his right first toe. Which of the
following antihypertensive medication is like most likely to have caused his symptoms?
A. Losartan
C. Ramipril
D. Bisoprolol
E. Verapamil
5. A 44 year old woman complains of a sandy feeling under her eyes that has been
present for the last year. She also says that she has difficulty swallowing. On
examination, bilateral enlargement of the parotid glands were noted. What is the
B. Systemic lupus erythematosus
C. Mumps
D. Sarcoidosis
1490
E. Sjogren's syndrome
6. A 45 year old woman complains of pain in her hands precipitated by exposure to the
cold weather. She also has breathlessness on walking. When she eats, she can feel food
sticking to her throat. She finds it difficult to swallow. It is usually relieved with a drink
of water. What is the SINGLE most likely cause of her dysphagia?
A. Oesophageal carcinoma
B. Systemic sclerosis
C. Systemic Lupus Erythematosus
D. Pharyngeal carcinoma
E. Globus hystericus
7. A 65 year old man has a generalized rash, fever, joint pain, and muscle pain. His medical
history is significant for a late onset asthma associated with nasal polyps. He recently
has been diagnosed with heart failure. Eosinophilia was shown on his last blood test. A
chest X-ray shows fleeting peripheral pulmonary infiltrates and bilateral multifocal
consolidations. What is the SINGLE most likely positive antibody?
y
op
A. p-ANCA
B. c-ANCA
C. Anti Ro
C
D. Anti DSDNA
E. Anti-centromere
n
8. A 32 year old woman has had a febrile illness and sudden onset of pain and swelling of
io
the small joints of her feet and knees for the past two days. She has a maculopapular
rash on her soles of her feet. She was previously well. There is no history of relevant
t
travel outside the UK. On examination, conjunctivitis is noted. What is the SINGLE most
ua
likely diagnosis?
A. Septic Arthritis
al
B. Reactive Arthritis
C. Rheumatoid Arthritis
Ev
D. Psoriatic Arthritis
E. Systemic Lupus Erythematosus
9. A 59 year old male is in the CCU (Cardiac Care Unit). He suffered from a myocardial
infarction 2 days ago which is now complicated by cardiac failure. He has now
developed sudden onset of pain, redness and swelling of his right knee joint. What is
the SINGLE best method for confirming the diagnosis of his swollen knee joint?
A. Send joint aspirate for culture

B. Send joint aspirate for microscopy
C. Serum uric acid levels
D. Blood culture
10. A 48 year old woman with a history of rheumatoid arthritis complains of dry eyes. A
Schirmer's test shows decreased tear production. And a rose Bengal stain documents
corneal ulcerations. What is the SINGLE most likely diagnosis?
1491
D. Sarcoidosis
11. A 61 year old man who suffers from rheumatoid arthritis is complaining of severe pain
in the joints of his hands, feet and knees. His medical history includes having had a
stroke 2 years ago in which he takes aspirin for. He also takes senna daily to manage his
ongoing constipation. What is the SINGLE most appropriate medication to manage his
pain?
A. Methotrexate
B. Ibuprofen
C. Co-codamol
D. Paracetamol
E. Hydroxychloroquine
y
op
Ibuprofen is the best answer given the options. Methotrexate and hydroxychloroquine
are both DMARDs which help prevent disease progression in long term but do not help
with the immediate pain. Paracetamol is a good pain relief but it is not suitable for
C
severe pain. The patient suffers from constipation thus co-codamol is not a suitable
option as it will worsen his symptoms of constipation.
n
There are no contraindications with using ibuprofen and and low dose aspirin.
io
Concurrent use does increases the risk of gastrointestinal bleeds and one should
consider gastroprotection (e.g. a proton pump inhibitor). It is only analgesic dose
t
aspirin that should not be used with NSAIDs.

ua
12. A 55 year old man has numbness in hands and feet. His medical history is significant for
a asthma associated with nasal polyps and facial pain. Eosinophilia was shown on his
al
last blood test. A pulmonary CT scan shows ground-glass inflammation. What is the
Ev
A. Churg-Strauss Syndrome
C. Polyarteritis Nodosa
D. Wegener granulomatosis
E. Inflammatory myopathies
13. A 62 year old lady has a right sided headache and blurry vision. She says it started of
being with tenderness at her scalp when combing her hair. ESR came back elevated.
A. Prednisolone
B. Temporal artery biopsy
C. CT head
D. IV acetazolamide
E. Measurement of intraocular pressure
1492
14. A 30 year old man presents with wheezing intermittently over the past few weeks.
Eosinophilia was shown on his last blood test. His blood test show the presence of p-
ANCA antibodies. What is the SINGLE most likely diagnosis?
B. Sarcoidosis
D. Pleural effusion
E. Tuberculosis
15. A 62 year old lady presents with right sided headache and decreased, blurry vision. She
also has pain around her jaw especially when chewing. What is the SINGLE most
A. ESR
C. CT head
D. X-ray orbit
y
16.
op
A 59 year old man has right sided headache and decreased, blurry vision. He also has
pain around her jaw especially when chewing. ESR was shown to be elevated.
C
Corticosteroids have been started. What is the SINGLE most appropriate medication to
be added?
n
A. ACE inhibitors
io
B. Beta blockers
C. Aspirin
t
D. NSAIDS
ua
E. Timolol
17. A 27 year old female complains of intermittent pain in her fingers usually brought about
al
in cold weather. She describes episodes of numbness and burning of the fingers. Her
fingers usually become very pale if she does not wear gloves when going outdoors.
Ev
A. Kawasaki disease
B. Takayasu arteritis
C. Buerger’s disease
D. Embolism
E. Raynaud’s phenomenon
18. A 27 year old man has recurrent lower back pain and stiffness. The pain is worse in the
morning and improves when he exercises. He finds it difficult to bend his back. He has
no history of trauma to his back. What is the SINGLE most appropriate investigation to
perform?
A. Erythrocyte sedimentation rate (ESR)

B. X-ray of sacroiliac joints
C. HLA B27
D. X-ray of thoracic spine
1493
E. Computed tomography of lumbar spine
19. A 61 year old woman with a medical history of diabetes and rheumatoid arthritis
presents with left knee pain which has been worsening over the last 24 hours. She has
fever and rigors. On examination, there is decreased range of movement and the left
knee joint is red and oedematous. Septic arthritis is suspected. What is the SINGLE most
common organism responsible for septic arthritis?
A. Neisseria gonorrhoeae
B. Staphylococcus epidermidis
C. Escherichia coli
D. Proteus mirabilis
E. Staphylococcus aureus
20. A 69 year old woman with a medical history of rheumatoid arthritis for 25 years
presents with left shoulder pain and swelling for 3 days. She has a low grade fever. On
examination, there is decreased range of motion of the left shoulder joint and
movement elicits pain. She takes regular low dose steroids for the past year to manage
y
her flare of rheumatoid arthritis. She has no known drug allergies. Joint aspiration has
op
been sent for microscopy and culture. What is the SINGLE most appropriate
management? C
A. Wait for results of culture prior to starting antibiotic therapy
B. Intravenous flucloxacillin
C. Oral flucloxacillin
n
D. Intravenous clindamycin
io
E. Perform repeated percutaneous aspiration

t
21. A 55 year old lady with a medical history of hypertension and rheumatoid arthritis
ua
presents with an acutely hot, swollen, and tender right knee joint. There is pain on
movement and there is decreased passive and active range of motion. What is the
SINGLE most appropriate investigation to perform?
al
A. X-ray of right knee joint

Ev
B. Culture and sensitivity of joint aspirate

C. Ultrasound
22. A 60 year old man presented with a spontaneous painful swelling of his right knee
which appears hot and very tender on touching. The swelling became worse over the
last few days. About a week ago, he had an inguinal hernia repaired as a day case. His
regular medications include Ramipril 10mg daily, Bendroflumethiazide 2.5mg daily and
Glyceryl trinitrate tablets when required. He is apyrexial on examination. What is the
SINGLE best method for confirming the diagnosis?
A. Joint aspirate for microscopy

B. Blood culture
C. D-dimer
D. X-ray of knee
E. Serum uric acid levels
1494
23. A 63 year old man presents with muscle weakness. He finds it difficult to walk for long
periods of time or climb stairs. Activities such as rising from a seated position is difficult.
He also finds difficulty in swallowing foods. His blood results show:

Aspartate transaminase (AST) 37 U/L
Creatine kinase 440 U/L
Erythrocyte sedimentation rate (ESR) 16 mm/h
A. Polymyositis
B. Polymyalgia rheumatic
C. Muscular dystrophy
D. Oesophageal carcinoma
E. Osteoarthritis
y
op
24. A 38 year old man recently had an appendicectomy and has now developed severe pain
in his right big toe. He is noted to consume an average of 30 units of alcohol in a week.
On examination, the joint of the right big toe is red and swollen. What is the SINGLE
C
A. Rhabdomyosarcoma
n
B. Osteoarthritis
io
C. Gout
D. Pseudogout
t
E. Arthritis
ua
25. A 33 year old woman comes in with a 6 month history of painless bilateral swelling of
the face and a mild grade fever. The swelling has been progressively increasing in size.
al
She also complains of having worsening symptoms of dry mouth. On a routine chest X-
ray, she is found to have bilateral perihilar lymphadenopathy. What is the SINGLE most
Ev
likely diagnosis?
B. Carcinoma of salivary gland
C. Lofgren syndrome
E. Mikulicz’s syndrome
26. A 29 year old man has been having chronic diarrhoea for the past year. He also
complains of redness and pain in his right eye. He also has lower back pain and he
experiences stiffness and pain which wakes him during early hours of the morning. On
examination he is seen to have aphthous ulcers and perianal skin tags. His blood tests
show:
Haemoglobin 100 g/L

CRP 43 mg/L
1495
Erythrocyte sedimentation rate (ESR) 22
A. Systemic lupus erythematosus

B. Reactive arthritis
C. Gout
D. Psoriatic arthritis
E. Seronegative spondyloarthropathy
27. A 47 year old woman has pallor followed by bluish discolouration of her hands when
she goes out into the cold. She has been suffering with this discolouration for the past 3
years. She has symmetrical peripheral arthropathy which has been present for the last
year. She also has small pink and red spots on her lips and her fingertips. What is the
B. Osteosarcoma
y
C. Limited systemic sclerosis
op
D. Diffuse systemic sclerosis
E. Systemic lupus erythematosus C
n
t io
ua
al
Ev
1496
Rheumatology Answers
1. A 45 year old man with severe pain and redness at the metatarsophalangeal joint of his
right big toe comes to the Emergency Department. He has never suffered from any
form of arthritis before. He has hypertension and was recently started on
bendroflumethiazide by his GP. What is the SINGLE most appropriate management?
A. Paracetamol
B. Allopurinol
C. Methotrexate
D. NSAIDS
E. Flucloxacillin
The diagnosis here is gout. NSAIDS are given for acute attacks.
Gout
Gout is a disease that affects middle-aged men and presents most commonly with
acute
y
monoarthritis.
op
The metatarsophalangeal joint of the first toe is commonly affected (podagra), but
other joints like the knee, ankle, PIPs, or DIPs may be initially involved. The first episode
C
commonly occurs at night with severe joint pain waking the patient from sleep. The
joint rapidly becomes warm, red, and tender (it looks exactly like cellulitis). Without
treatment the joint pain goes away spontaneously in 2 weeks.
n
io
Certain events that precipitate gout sometimes precede the attack. Question writers
very commonly give a scenario where a person has consumed excessive amounts of
t
alcohol or started taking diuretics such as thiazide diuretics or furosemide.

ua
Diagnosis
The serum uric acid during the acute attack may be normal or low. Remember this it is
al
common that questions ask for the diagnostic method for acute gout. And serum uric
acid should never be the answer for those questions. The serum uric acid level is of no
Ev
value in the diagnosis of acute urate arthropathy. This is why the diagnosis is made by
the analysis of synovial fluid.
Treatment:
Acute management
- NSAIDs
- intra-articular steroid injection
- Colchicine
Chronic hypouricemic therapy:

- Allopurinol should not be started until 2 weeks after an acute attack has settled
as it may precipitate a further attack if started too early
- NSAID or colchicine cover should be used when starting allopurinol
2. A 78 year old woman presents with unilateral headache and pain on chewing. Her ESR
is 70 mm/hour. She is on oral steroids. What is the SINGLE most appropriate additional
treatment?
1497
A. Bisphosphonates
B. Hormone replacement therapy
C. ACE inhibitors
D. Beta blockers
E. Timolol
The elderly lady with giant cell arteritis is getting high dose steroid which can lead to
demineralization and osteopenia or osteoporosis. So to prevent this bisphosphonates
are given.
The diagnosis here is clear. She has temporal arteritis. In these situations, question
writers always ask which medication could be added onto the current regimen. There
are two things that one can think of.
Bisphosphonates are important and can be considered to add on to reduce the risk of
osteoporosis. Especially in an elderly females.
Low dose aspirin is increasingly being recommended for people with a history of giant
y
cell arteritis. It has been found to decrease the rate of visual loss and strokes in patients
op
with GCA.
As low dose aspirin is not in the given options, bisphosphonates is your pick.
C
TA (Temporal Arteritis)
TA (Temporal Arteritis), also known as giant cell arteritis, is a vasculitis affecting the
n
large arteries that supply the head, eyes, and optic nerves. New-onset headache in any
io
patient older than 50 years prompts consideration of this diagnosis, which if left
untreated may result in permanent vision loss.
t
ua
The most common symptoms of giant cell arteritis are headache and pain that usually
occurs in one or both temples. Other common symptoms include: scalp tenderness
(pain when combing hair, jaw claudication (jaw pain when chewing), decreased vision
al
or blurry vision, tongue numbness, or, rarely, sudden loss of vision. Sometimes the
patient may have proximal stiffness (neck, arms, and hips) due to polymyalgia
Ev
rheumatica, a coexisting condition with TA.
The erythrocyte sedimentation test (ESR) is the first test to do in patients suspected to
have TA.
The diagnosis is always confirmed by biopsy of the temporal arteries in which the
characteristic giant cells are demonstrated. In the patient whom you suspect to have
TA, if the ESR is elevated, corticosteroids should be started immediately, before the
temporal artery biopsy is performed.
Occasionally they may ask which medication can be added onto corticosteroids for
treatment of GCA. Add on low-dose aspirin. Aspirin 75 mg daily has been shown to
decrease the rate of visual loss and strokes in patients with GCA.
3. A 52 year old woman with a history of systemic lupus erythematosus complains of dry
eyes and altered sense of taste. Her voice becomes hoarse when she speaks for long
1498
B. Sjogren's syndrome
D. Sarcoidosis
E. Scleroderma
Sjogren's syndrome
Sjogren's syndrome is an autoimmune disorder affecting exocrine glands resulting in

dry mucosal surfaces. Sjogren syndrome may be seen alone (primary) or in association
with other autoimmune diseases (secondary) such as rheumatoid arthritis, primary
biliary cirrhosis, or systemic lupus erythematosus.
As Sjogren's syndrome progresses, it becomes a systemic disease involving major

organs (lungs, kidneys, etc.) and may eventually evolve into a lymphoproliferative
disease - malignant Lymphoma.
y
Note that sjogren's syndrome is much more common in females (ratio 9:1)
Features
op
C
dry eyes: keratoconjunctivitis sicca
- Patients complain of itchy eyes, sandy feeling under their eyes (because of
decreased lacrimal production)
n
dry mouth
io
- Patients may complain of difficulty swallowing food

t
vaginal dryness
ua
parotid enlargement
- Bilateral enlargement of the parotid glands
al
Investigation
Ev
- Schirmer's test will show decreased tear production

- rose Bengal stain will document corneal ulcerations
- ANAs will be positive and specifically anti-Ro (SSA) and anti-La (SSB)
- rheumatoid factor (RF) positive in nearly 100% of patients
Management
There is no cure for sjogren's syndrome. Artificial tears may help with the dry eyes.
4. A 76 year old who is on medication for hypertension comes to clinic suffering from pain
and redness at the metatarsophalangeal joint of his right first toe. Which of the
following antihypertensive medication is like most likely to have caused his symptoms?
A. Losartan
C. Ramipril
D. Bisoprolol
E. Verapamil
1499
The diagnosis here is acute gout which is precipitated by bendroflumethiazide.
Gout
acute
monoarthritis.
y
Diagnosis
op
C
n
Treatment:
io
Acute management
- NSAIDs
t

ua
- Colchicine

al
Ev
5. A 44 year old woman complains of a sandy feeling under her eyes that has been
present for the last year. She also says that she has difficulty swallowing. On
examination, bilateral enlargement of the parotid glands were noted. What is the
C. Mumps
D. Sarcoidosis
Sjogren's syndrome

1500

Features

dry mouth
vaginal dryness
y
op
parotid enlargement
C
Investigation
n
io

t
Management
ua
There is no cure for sjogren's syndrome. Artificial tears may help with the dry eyes.
6. A 45 year old woman complains of pain in her hands precipitated by exposure to the
al
cold weather. She also has breathlessness on walking. When she eats, she can feel food
sticking to her throat. She finds it difficult to swallow. It is usually relieved with a drink
Ev
of water. What is the SINGLE most likely cause of her dysphagia?
A. Oesophageal carcinoma
B. Systemic sclerosis
C. Systemic Lupus Erythematosus
D. Pharyngeal carcinoma
E. Globus hystericus
Diagnosis is quite clear here. Systemic sclerosis may present with pain in hands when
exposed to cold (Raynaud's phenomena), shortness of breath (pulmonary fibrosis), and
dysphagia (oesophageal dysmotility).
Systemic sclerosis
Is one of the causes of dysphagia.
Other features of CREST syndrome may be present, namely Calcinosis, Raynaud's

phenomenon, Oesophageal dysmotility, Sclerodactyly, Telangiectasia
1501
As well as oesophageal dysmotility the lower oesophageal sphincter (LES) pressure is
decreased. This contrasts to achalasia where the LES pressure is increased
7. A 65 year old man has a generalized rash, fever, joint pain, and muscle pain. His medical
history is significant for a late onset asthma associated with nasal polyps. He recently
has been diagnosed with heart failure. Eosinophilia was shown on his last blood test. A
chest X-ray shows fleeting peripheral pulmonary infiltrates and bilateral multifocal
consolidations. What is the SINGLE most likely positive antibody?
A. p-ANCA
B. c-ANCA
C. Anti Ro
D. Anti DSDNA
E. Anti-centromere
The diagnosis here is Churg-Strauss Syndrome. 30-40% of patients are perinuclear

staining (p-ANCA) positive.
y
op
Churg-Strauss Syndrome
A rare diffuse vasculitic disease affecting coronary, pulmonary, cerebral, abdominal

C
visceral and skin circulations. The vasculitis affects small- and medium-sized arteries
and veins and is associated with asthma. The cardinal manifestations of Churg-Strauss
syndrome are asthma, eosinophilia, and lung involvement.
n
io
The incidence of Churg-Strauss Syndrome is rare thus it is also rarely asked in PLAB.
However, one might see this topic every now and then.
t
ua
al
The American College of Rheumatology has identified six criteria for the diagnosis of
Ev
- Asthma (wheezing, expiratory rhonchi)

- Eosinophilia of more than 10% in peripheral blood
- Paranasal sinusitis
- Pulmonary infiltrates (may be transient)
- Histological confirmation of vasculitis with extravascular eosinophils
- Mononeuritis multiplex or polyneuropathy
The presence of four out of six of these features has a high specificity and sensitivity for
the diagnosis of Churg-Strauss Syndrome
Presentation
- Pulmonary: asthma
- Upper respiratory tract: allergic rhinitis, paranasal sinusitis, nasal polyposis.
- Cardiac involvement is common. This includes heart failure, myocarditis and
myocardial infarction
- Skin: purpura, skin nodules
1502
- Renal: glomerulonephritis
- Peripheral neuropathy: mononeuritis multiplex is the most frequent form
Investigations
- Antineutrophil cytoplasmic antibodies (ANCAs): 30-40% of patients are
perinuclear staining (p-ANCA) positive (antimyeloperoxidase antibodies)
- Eosinophilia and anaemia on the FBC
- Elevated ESR and CRP
- Elevated serum creatinine
- Increased serum IgE levels
- CXR: pulmonary opacities, transient pulmonary infiltrates, and bilateral
multifocal consolidation
- High-resolution CT: Ground-glass attenuation
- Biopsy: small necrotising granulomas, as well as necrotising vasculitis (found
especially in the lung)
8. A 32 year old woman has had a febrile illness and sudden onset of pain and swelling of
the small joints of her feet and knees for the past two days. She has a maculopapular
rash on her soles of her feet. She was previously well. There is no history of relevant
y
travel outside the UK. On examination, conjunctivitis is noted. What is the SINGLE most
op
likely diagnosis?
A. Septic Arthritis
C
B. Reactive Arthritis
C. Rheumatoid Arthritis
D. Psoriatic Arthritis
n
E. Systemic Lupus Erythematosus
io
Reactive arthritis is caused when a joint reacts to an infection elsewhere in the body.
t
The infection which triggers reactive arthritis is not actually in the joint itself. Most
ua
often, these bacteria are in the genitals (Chlamydia trachomatis) or the bowel
(Campylobacter, Salmonella, Shigella and Yersinia).
al
Unlike septic arthritis, fever is not a typical feature of reactive arthritis as it is not
caused by an active infection although it is seen in some cases.
Ev
It is important to note that the initial infection may be so mild that it goes unnoticed by
the patient like in this case where there was no report of any gastrointestinal or
urogenital infection.
The skin rashes on the soles of the feet (sometimes on the palms of the hands) are
called keratoderma blennorrhagicum and are similar to psoriasis. They often begin as
clear vesicles on a red base and progress to macules (flat lesions), papules (raised
lesions), and nodules (firm bumps). They are commonly seen as an additional feature of
reactive arthritis. The appearance is usually of a vesico-pustular waxy lesion with a
yellow brown colour
Reactive arthritis
- A form of seronegative spondyloarthritis clinically associated with back pain,
migratory oligoarthritis and extra-articular symptoms that typically follow a
gastrointestinal or urogenital infection
1503
Presentation:
- Develops 2-4 weeks after a an initial infection which may have been sexually
acquired or gastrointestinal in origin
- An asymmetrical, predominantly lower extremity, oligoarthritis is the major
presenting symptom (usually knees and ankles)
- Skin (circinate balanitis, keratoderma blennorrhagicum, erythema nodosum)
- The complete Reiter's triad of urethritis, conjunctivitis, and arthritis may occur
Remember these points:

- Joints
o Arthritis (oligoarthritis of lower limbs)
- Eyes
o Conjunctivitis (seen in 50%)
o Anterior uveitis
- Skin
o Circinate balanitis which are painless vesicles on the coronal margin of
the prepuce
o Keratoderma blennorrhagica which are waxy yellow/brown
y
maculopapular rash seen on palms and soles
op
o Erythema nodosum which are tender red nodules on the shins
- Urethritis C
Mnemonic: "Can't see, can't pee, can't climb a tree."
- Can't see – Conjunctivitis
- Can't pee – Urethritis
n
- Can't climb a tree – Arthritis
io
9. A 59 year old male is in the CCU (Cardiac Care Unit). He suffered from a myocardial
t
infarction 2 days ago which is now complicated by cardiac failure. He has now
ua
developed sudden onset of pain, redness and swelling of his right knee joint. What is
the SINGLE best method for confirming the diagnosis of his swollen knee joint?
al
A. Send joint aspirate for culture

B. Send joint aspirate for microscopy
Ev
C. Serum uric acid levels

D. Blood culture
This is a multi-step question. Let's break it down:

- This man has had a myocardial infarction
- He is now suffering from heart failure
- He is also suffering from a red, swollen knee joint
By mentioning that this man has heart failure, they are alluding to the fact that he was
probably put on a diuretic during his stay in hospital.
Loop diuretics (such as Furosemide) are used first-line for cardiac failure. A thiazide
diuretic may be added to a loop diuretic in the case of severe cardiac failure. We do not
know what type of diuretic this man has been put on but it is highly probable that he
was put on a thiazide diuretic.
1504
In order to diagnose gout, we MUST do a joint aspirate. Since there was no mention of
this man having a fever, there is no need to do a joint aspirate culture. Joint microscopy
would be ideal since we would be able to visualise the MSU crystals of gout.
You may sometimes see a raised serum uric acid level in acute gout, however not all
people suffering from gout demonstrate raised serum uric acid levels and this is not an
accurate test to diagnose the condition.
Keep in mind that when the stem says “single best method for confirming the
diagnosis”, it is always a biopsy (or the equivalent of an invasive diagnostic test).
Thiazide Diuretics
Most common types of thiazide diuretics in use: bendroflumethiazide, chlorthalidone,

cyclopenthiazide, indapamide, metolazone, and xipamide
Common or serious possible side-effects include:
y
- Hyperglycaemia
op
- Increase in uric acid levels
- Hypokalaemia, hyponatraemia, hypomagnesaemia, hypercalcaemia.
- Other problems, such as:
C
o GI upset
o Postural hypotension
o Impotence
n
o Skin sensitivity to sunlight
io
10. A 48 year old woman with a history of rheumatoid arthritis complains of dry eyes. A
Schirmer's test shows decreased tear production. And a rose Bengal stain documents
t
corneal ulcerations. What is the SINGLE most likely diagnosis?

ua
al

D. Sarcoidosis
Ev
Sjogren's syndrome


Features
1505
dry mouth
vaginal dryness
parotid enlargement
Investigation
Management
y
- There is no cure for sjogren's syndrome. Artificial tears may help with the dry
op
eyes.
11. A 61 year old man who suffers from rheumatoid arthritis is complaining of severe pain
in the joints of his hands, feet and knees. His medical history includes having had a
C
stroke 2 years ago in which he takes aspirin for. He also takes senna daily to manage his
ongoing constipation. What is the SINGLE most appropriate medication to manage his
pain?
n
io
A. Methotrexate
B. Ibuprofen
t
C. Co-codamol
ua
D. Paracetamol
E. Hydroxychloroquine
al
12. A 55 year old man has numbness in hands and feet. His medical history is significant for
a asthma associated with nasal polyps and facial pain. Eosinophilia was shown on his
Ev
last blood test. A pulmonary CT scan shows ground-glass inflammation. What is the
D. Wegener granulomatosis
E. Inflammatory myopathies
The diagnosis here is Churg-Strauss Syndrome. The incidence of Churg-Strauss

Syndrome is rare thus it is also rarely asked in PLAB. However, one might see this topic
every now and then.

1506
y
op
Presentation
C
- Pulmonary: asthma
n
io
t
ua
Investigations
al

Ev

Biopsy: small necrotising granulomas, as well as necrotising vasculitis (found especially
in the lung)
13. A 62 year old lady has a right sided headache and blurry vision. She says it started of
being with tenderness at her scalp when combing her hair. ESR came back elevated.
A. Prednisolone
C. CT head
1507
D. IV acetazolamide
Prednisolone should be started when you suspect temporal arteritis if ESR is elevated.
Do not wait till you get a temporal artery biopsy.
patient may have proximal stiffness (neck, arms, hips) due to polymyalgia rheumatica, a
coexisting condition with TA.
y
op
have TA. C
n
io
14. A 30 year old man presents with wheezing intermittently over the past few weeks.
Eosinophilia was shown on his last blood test. His blood test show the presence of p-
t
ANCA antibodies. What is the SINGLE most likely diagnosis?

ua
B. Sarcoidosis
al
D. Pleural effusion
Ev
E. Tuberculosis
The diagnosis here is Churg-Strauss Syndrome. The incidence of Churg-Strauss

Syndrome is rare thus it is also rarely asked in PLAB. However, one might see this topic
every now and then.

1508
Presentation
- Pulmonary: asthma
y
op
C
n
Investigations
io

t

ua

al

Ev

Biopsy: small necrotising granulomas, as well as necrotising vasculitis (found especially
in the lung)
15. A 62 year old lady presents with right sided headache and decreased, blurry vision. She
also has pain around her jaw especially when chewing. What is the SINGLE most
A. ESR
C. CT head
D. X-ray orbit
Temporal arteritis (TA) is the suspected diagnosis here. Erythrocyte sedimentation test
(ESR) is the first test to do in patients suspected to have TA. Since the question ask for
the most appropriate “initial” investigation, the answer would be ESR. If the question
1509
had asked for the most appropriate “definitive” investigation, the temporal artery
biopsy would be the answer.
have TA.
y
op
TA, if the ESR is elevated, corticosteroids should
C
16. A 59 year old man has right sided headache and decreased, blurry vision. He also has
pain around her jaw especially when chewing. ESR was shown to be elevated.
Corticosteroids have been started. What is the SINGLE most appropriate medication to
n
be added?
io
A. ACE inhibitors
t
B. Beta blockers
ua
C. Aspirin
D. NSAIDS
E. Timolol
al
Low dose aspirin is increasingly being recommended for people with a history of giant
Ev
cell arteritis. It has been found to decrease the rate of visual loss and strokes in patients
with GCA.be started immediately, before the temporal artery biopsy is performed.
1510
have TA.
Occasionally they may ask which medication can be added onto corticosteroids for
treatment of GCA. Add on low-dose aspirin. Aspirin 75 mg daily has been shown to
decrease the rate of visual loss and strokes in patients with GCA.
17. A 27 year old female complains of intermittent pain in her fingers usually brought about
in cold weather. She describes episodes of numbness and burning of the fingers. Her
fingers usually become very pale if she does not wear gloves when going outdoors.
A. Kawasaki disease
y
B. Takayasu arteritis
op
D. Embolism
E. Raynaud’s phenomenon
C
Raynaud’s phenomenon is defined as episodes of pallor or cyanosis in response to cold
or emotional stimuli.
n
io
Fingers or toes ache and change colour:

t
pale (ischaemia)
ua
blue (deoxygenation)
al
red (reactive hyperaemia)

Ev
The pallor is caused by vasoconstriction of blood vessels (arteries and arterioles) that
results in reduced blood flow, while cyanosis is created by deoxygenation of slow-
flowing blood. After rewarming the hands, the blood flow will rebound (hyperemia) and
the skin will appear reddened or blushed.
It is common for patients with Raynaud’s phenomenon to complain of cold sensitivity

and to have other areas of the skin involved, including the ears, nose, and lower
extremities. Episodes come as sudden attacks and are most often triggered by rapid
changes in ambient temperature. Attacks may begin in one or two fingers but typically
involve all fingers and/ or toes symmetrically and bilaterally.
Primary Raynaud’s phenomenon (Raynaud’s disease) denotes a patient without an

associated underlying disease. Secondary Raynaud’s phenomenon is used to describe
patients with a defined secondary or associated disease (scleroderma).
18. A 27 year old man has recurrent lower back pain and stiffness. The pain is worse in the
morning and improves when he exercises. He finds it difficult to bend his back. He has
1511
no history of trauma to his back. What is the SINGLE most appropriate investigation to
perform?
A. Erythrocyte sedimentation rate (ESR)

B. X-ray of sacroiliac joints
C. HLA B27
D. X-ray of thoracic spine
E. Computed tomography of lumbar spine
Ankylosing spondylitis
- A HLA-B27 associated spondyloarthropathy which primarily involves the axial
skeleton (ie sacroiliitis and spondylitis)
Features
- Young man (usually before age 30) presenting with lower back pain and
stiffness
- Stiffness which is worse in the morning and improves with exercise
- A strong association with HLA-B27 exists
y
- There is often tenderness of the sacroiliac joints or a limited range of spinal
op
motion.
Examination
C
Schober's test → This is a line is drawn 10 cm above and 5 cm below the back dimples
(dimples of Venus). The distance between the two lines should increase by more than 5
cm when the patient bends as far forward as possible
n
io
Other important features

- Anterior uveitis → presents with an acutely painful red eye and severe
t
photophobia
ua
- Aortic regurgitation
Investigations
al
- Plain x-ray of the sacroiliac joints → This is the most useful investigation. It
would show evidence of sacroiliitis which is the earliest finding. Later findings
Ev
once there is significant chronic spine inflammation include a “bamboo spine”

and squaring of the vertebral bodies.
Do not use HLA-B27 to make the diagnosis as it is also positive in 10% of normal
patients.
Management:
First line → NSAIDS
Second line → Anti-TNF therapy
19. A 61 year old woman with a medical history of diabetes and rheumatoid arthritis
presents with left knee pain which has been worsening over the last 24 hours. She has
fever and rigors. On examination, there is decreased range of movement and the left
knee joint is red and oedematous. Septic arthritis is suspected. What is the SINGLE most
common organism responsible for septic arthritis?
A. Neisseria gonorrhoeae
1512
B. Staphylococcus epidermidis
C. Escherichia coli
D. Proteus mirabilis
E. Staphylococcus aureus
Septic arthritis
The two most common organisms that cause septic arthritis are:
- Staphylococcus aureus → Most common pathogen for septic arthritis overall
- Neisseria gonorrhoeae → Seen in young, sexually active adults
Most cases of septic arthritis are due to haematogenous spread during transient
bacteraemia but can also be introduced by a skin lesion that penetrates the joint or by
local spread from a contiguous infected site.
Risk factors
- Prior joint damage (rheumatoid arthritis, gout, osteoarthritis)
It is particularly important to remember rheumatoid arthritis as a risk factor as
y
it is commonly asked
op
- Immunodeficiency states (HIV, corticosteroid use)
- Diabetes C
Presentation
- Single swollen, red joint with pain on active or passive movement
- Fevers and rigors
n
io
Remember this triad of fever, pain and impaired range of motion

t
Investigations
ua
- Aspiration of synovial fluid → Sent for gram staining, leukocyte count,

microscopy and culture
- Blood cultures → Remember most cases of septic arthritis are due to
al
haematogenous spread
Ev
Management
- Flucloxacillin for 4 to 6 weeks
- If penicillin-allergic → Use clindamycin
- If gonococcal arthritis → Use cefotaxime or ceftriaxone
- If infection not responding to antibiotics → Perform repeated percutaneous
aspiration
In general, intravenous antibiotics are used for 7 days until the swelling subsides and
blood cultures become negative. This is followed by a 4 week course of oral antibiotics.
20. A 69 year old woman with a medical history of rheumatoid arthritis for 25 years
presents with left shoulder pain and swelling for 3 days. She has a low grade fever. On
examination, there is decreased range of motion of the left shoulder joint and
movement elicits pain. She takes regular low dose steroids for the past year to manage
her flare of rheumatoid arthritis. She has no known drug allergies. Joint aspiration has
been sent for microscopy and culture. What is the SINGLE most appropriate
management?
1513
A. Wait for results of culture prior to starting antibiotic therapy
B. Intravenous flucloxacillin
C. Oral flucloxacillin
D. Intravenous clindamycin
E. Perform repeated percutaneous aspiration
The presentation is in line with septic arthritis where rheumatoid arthritis is a risk factor
for.
The most important diagnostic test in patients presenting with acute arthritis is
examination of the synovial fluid which was performed in this stem.
Empirical treatment should be started in septic arthritis before results of the culture are
obtained. Intravenous flucloxacillin 1 to 2 g every 6 hours is the most common
antibiotic to start with.
Septic arthritis
y
op
C
n
io
Risk factors
t

ua
- Diabetes
al
Presentation
Ev

- Fevers and rigors
Investigations
Management
aspiration
1514
21. A 55 year old lady with a medical history of hypertension and rheumatoid arthritis
presents with an acutely hot, swollen, and tender right knee joint. There is pain on
movement and there is decreased passive and active range of motion. What is the
SINGLE most appropriate investigation to perform?
A. X-ray of right knee joint

B. Culture and sensitivity of joint aspirate
C. Ultrasound
The presentation is in line with septic arthritis where rheumatoid arthritis is a risk factor
for.
The most important diagnostic test in patients presenting with acute arthritis is
y
examination of the synovial fluid.
op
Plain X-rays in early disease are unhelpful, since they show only soft tissue swelling. In
later untreated septic arthritis, joint space narrowing and erosion will be seen. But they
C
are not diagnostic for septic arthritis.
Ultrasound is not as sensitive as MRI or CT scan however it is inexpensive and can show
n
early joint effusions and help guide joint aspiration and drainage procedures.
io
CT and MRI scanning are sensitive methods for diagnosing periarticular abscesses and
t
joint effusions but their use is reserved for cases of diagnostic difficulty usually
ua
involving sacroiliac or sternoclavicular joint infection where extensions into the pelvis
or mediastinum is a possibility.
al
Remember that although ultrasound, CT and MRI scans may aid the diagnosis, the
diagnosis of septic arthritis is made on the basis of aspiration.
Ev
Septic arthritis
Risk factors
- Diabetes
1515
Presentation
- Fevers and rigors
Investigations
Management
y
aspiration
op
C
22. A 60 year old man presented with a spontaneous painful swelling of his right knee
which appears hot and very tender on touching. The swelling became worse over the
n
last few days. About a week ago, he had an inguinal hernia repaired as a day case. His
io
regular medications include Ramipril 10mg daily, Bendroflumethiazide 2.5mg daily and
Glyceryl trinitrate tablets when required. He is apyrexial on examination. What is the
t
SINGLE best method for confirming the diagnosis?

ua
A. Joint aspirate for microscopy

B. Blood culture
al
C. D-dimer
D. X-ray of knee
Ev
E. Serum uric acid levels
Bendroflumethiazide is a thiazide diuretic which is well known to cause symptomatic

hyperuricemia which can precipitate an acute attack of gout. Other common thiazides
diuretics to be aware of include Indapamide, Chlorthalidone and Metolazone.
Although a raised serum uric acid level is an important risk factor for gout, the use of
serum uric acid as a diagnostic test is limited. It can be normal during acute gout. On
the other hand, patients with hyperuricaemia may never develop an attack.
In summary, you may sometimes see a raised serum uric acid level in acute gout,
however not all people suffering from gout demonstrate raised serum uric acid levels
and this is not an accurate test to diagnose the condition. Joint microscopy would be
ideal since we would be able to visualise the MSU crystals of gout.
Gout
1516
acute monoarthritis.
Diagnosis
y
Treatment:
Acute management
op
C
- NSAIDs
- Colchicine
n
io

t

ua
23. A 63 year old man presents with muscle weakness. He finds it difficult to walk for long
al
periods of time or climb stairs. Activities such as rising from a seated position is difficult.
He also finds difficulty in swallowing foods. His blood results show:
Ev

Aspartate transaminase (AST) 37 U/L
Creatine kinase 440 U/L
Erythrocyte sedimentation rate (ESR) 16 mm/h
A. Polymyositis
B. Polymyalgia rheumatic
C. Muscular dystrophy
D. Oesophageal carcinoma
E. Osteoarthritis
The two top differentials here that one should think about is polymyositis and
polymyalgia rheumatica.
1517
Proximal muscle weakness and raised creatinine kinase points towards polymyositis.
ESR is elevated in 50% of cases in polymyositis but correlates poorly with disease
activity and response to therapy.
In this stem, ESR is not elevated enough to consider polymyalgia rheumatica. Also, in
polymyalgia rheumatica, creatinine kinase would not be raised. One of the criteria for
the diagnosis of polymyalgia rheumatica is having an ESR >30 mm/h or CRP >6 mg/mL
of which we do not see in this stem. Hence, the best answer here is polymyositis.
Polymyositis
Clinical Findings
- Usually first present with difficulty with tasks that involve the proximal muscles:
lifting objects, combing hair, getting up from the chair.
- The weakness is usually symmetric and diffuse, involving the proximal muscles
of the neck, shoulders, trunk, hips, and thighs, the lower limb muscles tending
to be clinically symptomatic first.
- Fatigue, myalgia and muscle cramps may also be present.
y
op
Investigation:
- Elevation of creatine kinase.
- Aldolase levels may also be raised.
C
- Autoantibodies: Anti-Jo-1 antibodies. Note that these are more common in
patients with polymyositis than in patients with dermatomyositis.
- Muscle biopsy can be diagnostic.
n
io
Treatment
- Involves steroids
t
ua
24. A 38 year old man recently had an appendicectomy and has now developed severe pain
in his right big toe. He is noted to consume an average of 30 units of alcohol in a week.
On examination, the joint of the right big toe is red and swollen. What is the SINGLE
al

Ev
A. Rhabdomyosarcoma
B. Osteoarthritis
C. Gout
D. Pseudogout
E. Arthritis
Drinking too much alcohol can cause uric acid to build up and cause gout.
Gout
acute monoarthritis.
1518
Diagnosis
Treatment:
Acute management
- NSAIDs
- Colchicine
y
op
C
25. A 33 year old woman comes in with a 6 month history of painless bilateral swelling of
the face and a mild grade fever. The swelling has been progressively increasing in size.
n
She also complains of having worsening symptoms of dry mouth. On a routine chest X-
io
ray, she is found to have bilateral perihilar lymphadenopathy. What is the SINGLE most
likely diagnosis?
t
ua
B. Carcinoma of salivary gland
C. Lofgren syndrome
al

E. Mikulicz’s syndrome
Ev
Mikulicz’s syndrome is the benign persistent swelling of lacrimal and parotid (or
submandibular) glands due to lymphocytic infiltration. When no specific cause is found
it is called Mikulicz’s disease; and if secondary to disease like sarcoidosis or
tuberculosis, it is termed as Mikulicz’s syndrome. In this case, where it is likely
secondary to sarcoidosis given the patient's chest X-ray findings it is termed Mikulicz’s
syndrome.
Mikulicz disease and syndrome has the same clinical picture and it comprises of a triad
of:
Symmetrical enlargement of all salivary glands
Narrowing of the palpebral fissures due to enlargement of the lacrimal glands
Dryness of the mouth
26. A 29 year old man has been having chronic diarrhoea for the past year. He also
complains of redness and pain in his right eye. He also has lower back pain and he
experiences stiffness and pain which wakes him during early hours of the morning. On
1519
examination he is seen to have aphthous ulcers and perianal skin tags. His blood tests
show:
Haemoglobin 100 g/L

CRP 43 mg/L
Erythrocyte sedimentation rate (ESR) 22
A. Systemic lupus erythematosus

B. Reactive arthritis
C. Gout
D. Psoriatic arthritis
E. Seronegative spondyloarthropathy
Seronegative spondyloarthropathy (or seronegative spondyloarthritis) is a group of

diseases involving the axial skeleton. The term “seronegative” refers to the fact that
y
these diseases are negative for rheumatoid factor. This indicates that there is a
op
different pathophysiological mechanism of disease when comparing with rheumatoid
arthritis. C
Ankylosing spondylitis is one of the seronegative spondyloarthropathies and it is seen
here in this stem. The lower back pain and stiffness are consistent with ankylosing
spondylitis. He is around the correct age to develop ankylosing spondylitis as well.
n
Ankylosing spondylitis usually occurs before the age of 30 years.
io
The eye manifestations are consistent with acute anterior uveitis which occurs in 20-
t
30% of patients with ankylosing spondylitis. Of all patients presenting with acute
ua
anterior uveitis, a third to a half have or will go on to develop ankylosing spondylitis.
The chronic diarrhoea, aphthous ulcers and perianal skin tags are consistent with
al
Crohn's disease. You need to remember that there is an increased incidence of

ankylosing spondylitis in patients with inflammatory bowel disease (IBD). Ankylosing
Ev
spondylitis is around 10 - 20 times more common in patients with IBD than it would be
seen in the general population.
The blood results are also consistent with ankylosing spondylitis.

- Normochromic normocytic anaemia of chronic disease
- Elevated ESR and CRP level correlating to disease activity
27. A 47 year old woman has pallor followed by bluish discolouration of her hands when
she goes out into the cold. She has been suffering with this discolouration for the past 3
years. She has symmetrical peripheral arthropathy which has been present for the last
year. She also has small pink and red spots on her lips and her fingertips. What is the
B. Osteosarcoma
C. Limited systemic sclerosis
D. Diffuse systemic sclerosis
1520
This is not a clear cut question and the most likely diagnosis here is limited systemic
sclerosis.
Both limited and diffuse systemic sclerosis may present with pain in hands when
exposed to cold (Raynaud's phenomena). The classical features of Raynaud's
phenomenon are episodic pallor of the digits due to ischaemia, followed by cyanosis
due to deoxygenation and then followed by redness with pain and tingling which is
when there is reperfusion.
The presence of the pink and red dots on the lips and tips of fingers represent
telangiectasia which is seen as part of the CREST syndrome in limited systemic sclerosis.
These are visibly dilated blood vessels that usually appear on the fingers, palms, face,
lips and chest.
Arthralgia is usually seen more in diffuse systemic sclerosis which goes against the
answer of limited systemic sclerosis. In limited systemic sclerosis, the complaint is
y
usually the occasional joint stiffness rather than arthralgia. However, given the slow
op
progression of the disease and no other features of organ involvement, limited
systemic sclerosis is likely the answer. C
Rheumatoid arthritis is also a potential differential because it is another cause of
Raynaud's phenomenon and would explain the symmetrical peripheral arthropathy.
Nonetheless, rheumatoid arthritis is a rare cause of Raynaud’s phenomenon and an
n
even rarer cause of telangiectasia.
io
Given the stem, the best answer still remains as limited systemic sclerosis
t
ua
al
Ev
1521
UROLOGY
y
op
C
Questions
n
io
&
t
ua
Answers
al
Ev
1522
Urology
1. A 72 year old man brought to the emergency department with onset of paraplegia
following a trivial fall. He was treated for prostatic malignancy in the past. What is the
B. Osteoporotic fracture of vertebrae
C. Secondary metastasis
D. Multiple myeloma
E. Spondylosis
2. A 70 year old man with a history of prostatic cancer has severe acute back pain waking
him up at night for the past 4 weeks. What is the SINGLE most appropriate
investigation?
A. MRI spine
B. Isotope bone scan
y
C. DEXA scan
op
D. Serum ALP concentration
E. Serum calcium concentration C
3. A 25 year old woman presents with urinary frequency, suprapubic pain and dysuria. She
has a temperature of 38.5°C. Nitrites and leucocytes are positive on a dipstick. What is
n
io
A. Schistosomiasis
B. Kidney trauma
t
C. Ureteric calculus
ua
D. Bladder calculi
E. Cystitis
al
4. A 33 year old man presents with bilateral flank pain. He is later diagnosed to have
bilateral kidney stones. His medical history includes sarcoidosis. What is the SINGLE
Ev
most likely cause that attributed to the development of his urinary stones?
A. Hypercalcemia
B. Hyperuricemia
C. Diet
D. Recurrent urinary tract infection
E. Hyperparathyroidism
5. A 35 year old man with painless left testicular enlargement for the past 6 months which
is increasing in size. On examination, the left testicle is noted to be 3 times the size of
the right testicle. There is no tenderness or redness. What is the SINGLE most likely
diagnosis?
A. Testicular cancer
B. Hydrocele
C. Epididymal cyst
D. Epididymo-orchitis
E. Scrotal haematoma
1523
6. A 61 year old man, known smoker, comes to the hospital with complaints of painless
frank haematuria. He has been worried about his loss of weight and reduced general
activity. Urine microscopy shows red cells but no white cells. What is the SINGLE most
diagnostic test?
A. Urine culture
B. Intravenous urogram
C. Transrectal ultrasound and biopsy
D. Cystoscopy with biopsy
E. Ultrasound of the Kidneys, Ureters & Bladder
7. A 39 year old coal miner was recently diagnosed with bladder cancer. He is a smoker
and has a family history of bladder cancer. He also has been diagnosed with benign
prostatic hyperplasia. Which SINGLE risk factor is likely to be associated with
transitional cell carcinoma of the bladder?
A. Family history
B. Smoking
C. Exposure to coal mine
y
D. Benign prostatic hyperplasia
op
E. Age
8. A 26 year old sexually active male presents with severe pain in the left scrotum lasting
for 4 hours. He complains of a past history with similar episodes of pain over the past 2
C
years but has never sought treatment before. His scrotum is extremely tender and
examination is impossible because of the pain. What is the SINGLE best management
for this patient?
n
io
A. Send home with antibiotic cover

B. Ultrasound of scrotum
t
C. Urgent surgical exploration

ua
D. Urethral swab
E. Midstream urine culture and sensitivity
9. A 78 year old man with a history of prostate adenocarcinoma has loin pain, anuria, and
al
symptoms of acute kidney injury. What is the SINGLE most appropriate investigation?
Ev
A. MRI spine
C. Transrectal Ultrasound
D. Ultrasound KUB
E. Abdominal X-ray
10. A 79 year old African-Caribbean man comes in complaining of difficulty in passing urine.
He has a weak stream, and says that he is unable to completely empty his bladder. 3
months ago he suffered from a urinary tract infection. He also complains of back pain
and suprapubic pain. He has lost significant weight and looks cachexic. What is the
A. Benign prostatic hyperplasia

B. Renal cell carcinoma
C. Bladder stones
D. Prostate cancer
E. Urinary tract infection
1524
11. A 31 year old presents with sudden onset of flank pain, nausea and vomiting. He
recently passed a 4mm stone in his urine. Urine microscopy reveals microscopic
haematuria. On ultrasound, a 3mm stone is found in the renal pelvis. What is the
A. Extracorporeal shock-wave lithotripsy

B. Percutaneous nephrolithotomy
C. Open Surgery
D. Advise to increase fluid intake
E. Urethral catheterisation
12. A 16 year old boy complains of having a heavy feeling in the scrotal area. On physical
examination, a soft painless swelling in the left scrotum is noticed. The swelling appears
like a 'bag of worms' and is less obvious when he is lying supine. What is the SINGLE
A. Serum AFP and beta HCG levels

B. Exploratory surgery
y
C. Biopsy
op
D. Pen torch transillumination
E. Ultrasound Doppler C
13. A 15 year old boy presents with testicular pain for 3 days. The pain had a gradual onset.
There is no history of trauma. On examination, his right hemi-scrotum is tender. He has
a temperature of 38.5°C. What is the SINGLE most appropriate management?
n
io
A. Give antibiotics
B. Give analgesia
t
C. Reassure
ua
D. Blood culture
E. Exploratory surgery
al
14. A 65 year old man presents with frank haematuria. He is afebrile and has no other
urinary symptoms. There was no history of trauma and he has no relevant medical
Ev
history. He looks well. Urinary cultures are negative. What is the SINGLE most
appropriate investigation that would lead to a diagnosis?
A. Intravenous urograms (IVU)

C. Cystoscopy
D. Urinary biomarkers
E. Transrectal ultrasound and biopsy
15. A 79 year old man who is being treated with GnRH antagonist for a diagnosed prostate
adenocarcinoma attends the clinic. What is the SINGLE most appropriate follow up
investigation?
A. Serum AFP
B. Serum PSA
C. Serum acid phosphatase concentration
D. Serum ALP isoenzyme concentration
1525
E. Prostate cancer antigen 3
16. A 22 year old sexually active male came with a 2 day history of fever with pain in the
scrotal area. There is no history of trauma. On examination, the scrotal skin is red and
A. Testicular torsion
B. Varicocele
C. Inguinal hernia
E. Mumps
17. A 44 year old man presents with a scrotal swelling. The swelling is cystic and is non-
tender. It is located in the upper pole of the posterior part of the testes. What is SINGLE
A. Epididymal cyst
B. Testicular cancer
y
C. Hydrocele
op
D. Varicocele
E. Testicular torsion C
18. A 38 year old man has severe loin pain with nausea and vomiting. Ultrasound shows
right hydronephrosis. A non-enhanced computerised tomography scan reveals a 3.2 cm
in diameter stone at the level of the minor calyx. What is the SINGLE most appropriate
n
management?
io
A. Percutaneous nephrolithotomy
t
B. Extracorporeal shock-wave lithotripsy

ua

D. Urethral catheterisation
E. Stenting
al
19. A 14 year old boy presents with a 3 hour history of severe left testicular pain. He has no
Ev
urinary symptoms and is otherwise well. On examination, the right testes looks normal
but the left hemiscrotum is swollen and acutely tender. The pain is not eased by
elevation of the testes. What is the SINGLE most appropriate initial step?
A. Mid stream urine

B. Ultrasound scan of the testes
C. Urethral Swab
D. Exploratory surgery
E. Computed tomography scan of the testes
20. A 57 year old chronic smoker reports three instances in the past 2 weeks when he has
had painless, gross, total hematuria. Intravenous urograms (IVU) was done and was
reported as normal. In the last month he has been treated for irritative voiding
symptoms, but has not been febrile, and urinary cultures have been negative. What is
A. US Abdomen
1526
B. Flexible cystoscopy
C. MRI
D. Nuclear imaging
E. CT-KUB
21. A 32 year old woman presents with severe intermittent right sided abdominal pain
radiating to the groin which has lasted for 3 hours. She is writhing in pain and vomited
twice in the last hour. WBC are 14 x 109/L and CRP is 83 mg/l. A urine HCG was
negative. What is the SINGLE most likely cause of her abdominal pain?
A. Appendicitis
B. Ruptured ectopic pregnancy
C. Salpingitis
D. Ureteric colic
He has a weak stream, and says that he is unable to completely empty his bladder. He
y
also has lower back pain and has lost 10 kg in the last 3 months. An ultrasound shows
op
bilateral hydronephrosis. What is the SINGLE most likely diagnosis?

C
C. Bladder stones
D. Prostate cancer
n
io
23. A 22 year old footballer was struck in the groin by a kick. He presents with severe pain
t
and mild swelling in the scrotum. The pain is not eased by elevation of the testes. What
ua
is the SINGLE most appropriate next course of action?
A. Ultrasound scan of the testes

al
B. Urethral Swab
C. Exploratory surgery
Ev
D. IV fluids
E. Antibiotics
24. A 15 year old boy was woken up from sleep with severe, sudden pain in the testis.
There was no history of trauma. On examination, the testis is tender on palpation. He is
afebrile. Analgesia has been given. What is the SINGLE most appropriate next step in
management?
A. Urethral Swab
B. Antibiotics
C. Refer urgently to a surgeon
D. Reassurance
E. Discharge with analgesics
25. A 25 year old man has a painful right testis, lower abdominal pain, vomiting and
nausea. The testis is swollen, hot, and extremely tender. The onset of pain was
1527
dramatic and sudden. He complains of some pain on passing urine. What is the SINGLE
A. Mid stream urine

C. Urethral Swab
D. Urgent surgery
E. Antibiotics
26. A 74 year old lady who has had a stroke in the past has an indwelling catheter for 10
months. She presents with bluish-purple discolouration of the catheter bag. What is the
SINGLE most likely explanation for this?
A. Normal change due to long use

B. Catheter degradation
C. Acidic urine
D. Alkaline urine
E. Bacterial colonization of the urinary tract
y
op
27. A 49 year old man presents with severe colicky pain from his right flank radiating to his
groin associated with nausea and vomiting. He subsequently develops rigors and a
tender abdomen. His urinalysis reveals trace blood. What is the SINGLE next best
C
investigation?
n
B. Kidneys, ureters, and bladder X-ray
io
C. Colonoscopy
D. Intravenous pyelogram
t
E. Laparoscopy
ua
28. A 46 year old man presents to clinic with a scrotal swelling. The swelling is cystic and is
non-tender. It developed slowly and it lies above and behind the testis. What is the
al
SINGLE most appropriate diagnostic test?

Ev
A. Ultrasound
B. Pen torch
D. Biopsy
E. Serum AFP and β HCG
29. A 67 year old man has with a diagnosis of benign prostatic hyperplasia undergoes a
transurethral resection of the prostate (TURP). What SINGLE most likely electrolyte
abnormality should be expected after the procedure?
A. Hypokalemia
B. Hypocalcemia
C. Hyperkalemia
D. Hyponatremia
E. Hypernatremia
1528
30. A 62 year old man has been waking up in the middle of the night to use the bathroom.
He complains of having difficulty in initiating micturition and dribbling afterwards. A
diagnosis of benign prostatic hyperplasia was made after a transrectal ultrasound
guided biopsy was performed. He is due for a transurethral resection of the prostate
(TURP) later this evening. What SINGLE most likely electrolyte abnormality should be
expected after the procedure?
A. Hypokalemia
B. Hypocalcemia
C. Hyperkalemia
D. Hyponatremia
E. Hypernatremia
31. A 20 year old women 6 hours post-lower segment Caesarean section has not passed
urine since her operation. She denies any urinary symptoms preoperatively. She
appears unwell. She has a temperature of 37°5C, a pulse of 110 beats/minute, a blood
pressure of 94/60 mmHg and a respiratory rate of 23 breaths/minute. Her abdomen is
distended with tenderness in the left flank and suprapubic region. Bowel sounds are
y
not audible. What is the SINGLE most likely postoperative complication?
A. Urinary tract infection

B. Urinary tract injury
op
C
C. Pleurisy
D. Pleurisy
E. Paralytic ileus
n
io
32. An 80 year old man has the sensation of incomplete emptying of his bladder. He is
going to the toilet more often than usual and is having terminal dribbling. He has lost 9
t
kg in the last 3 months and recently suffers from pelvic pain. What is the SINGLE most
ua
likely diagnosis?

al

C. Bladder stones
Ev
D. Prostate cancer
E. Bladder cancer
33. A 13 year old boy develops acute pain in his right testicle while playing football.
Examination reveals a very tender mass in the right scrotum with reddening of scrotal
skin. Lifting the testis causes more pain. What is the SINGLE most likely diagnosis?
A. Mumps
B. Testicular tumour
C. Scrotal abscess
E. Testicular torsion
34. A 75 year old man has urinary symptoms of hesitancy, frequency and nocturia. A digital
rectal examination reveals a large, irregular, hard asymmetric prostate gland. What is
the SINGLE most appropriate investigation that will help with the diagnosis?
A. CA 125
B. CA 153
1529
C. CA 199
D. CEA
E. PSA
35. An 85 year old war veteran complains of loss of appetite and says that he has lost
weight over the past few months. He says that he has passed some blood in his urine,
however, there was no pain. A recent report shows that PSA is 9.5ng/ml. What is the

C. Bladder stones
D. Prostate cancer
blue in colour and is less obvious when he is lying supine. What is the SINGLE most
y
op
A. Analgesia
B. Antibiotic
C. Biopsy
C
E. Reassurance
n
37. An 81 year old afro-caribbean man presents with pain in his lower back and hip. He
io
complains of waking up in the middle of the night to go to the washroom and often he
wets himself before reaching the toilet. He also has to urinate much more frequent
t
than in the past and has terminal dribbling. What is the SINGLE most likely underlying
ua
diagnosis?

al
B. Prostatitis
C. Bladder carcinoma
Ev
D. Prostate carcinoma
38. 60 year old patient had a cystoscopy for painless, gross hematuria and pathology
revealed transitional cell carcinoma of the bladder. He has smoked a pack a day for the
last 15 years and currently works in a coal factory. What is the SINGLE greatest risk
factor for transitional cell carcinoma in this patient?
A. Coal dust exposure

B. Smoking
C. Family history
D. Lung cancer
39. A 77 year old man has a long term indwelling urinary catheter. A recent catheter urine
sample was sent for culture and sensitivity and was found to have heavy growth of
Escherichia coli. What is the SINGLE most appropriate management?
1530
A. Reassure the patient
B. Prescription for antibiotics
C. Bladder washout
D. Repeat midstream specimen of urine in 2 weeks
E. Change the urinary catheter
40. A 75 year old man comes in complaining of difficulty in passing urine, poor stream and
dribbling at the end of voiding. He has also notice significant weight loss and feels tired
all the time. An ultrasound shows bilateral hydronephrosis. What is the SINGLE most
likely cause of these findings?

C. Bladder stones
D. Prostate cancer
y
41. A 47 year old man comes to the GP with swelling on his left groin which disappears on
op
lying down. The swelling was bluish in colour and felt like a bag of worms. He also
complains of a mass in the left loin along with haematuria occasionally. What could be
the possible diagnosis?
C
A. Left sided renal cell carcinoma
B. Varicosity 2nd to liver disease
n
C. Testicular tumor
io

E. Inferior vena cava obstruction
t
ua
42. A 79 year old African Americans male complains of thirst and fatigue. He has symptoms
of frequency, urgency and terminal dribbling. He has lost 8 kg over the last 3 months.
Laboratory findings show a calcium of 3.0 mmol/L and haemoglobin of 90g/L. What is
al

Ev
A. Benign Prostatic Hyperplasia

B. Prostate carcinoma
C. Chronic pyelonephritis
D. Diabetes Mellitus
E. Osteosarcoma
43. A 58 year old man has renal colic for the past 12 hours. In the last two years, he has
presented with three episodes of acute onset of pain in his right knee. What is the
SINGLE most likely cause of his renal colic?
A. Systemic lupus erythematosus associated glomerulonephritis

B. Hypercalcemia
C. Chlamydia trachomatis
D. Hyperuricemia
E. Hyperoxaluria
1531
44. A 42 year old woman has recently returned from working in the Middle East. She has
episodes of loin pain, urinary frequency, dysuria and has passed a urinary stone in the
past. She plans to return to the Middle East in a month’s time. What is the SINGLE best
advice to give to prevent recurrent stone formation?
A. Drink less dairy products

B. Increase fibre in diet
D. Decrease consumption of calcium related products
E. Decrease protein in diet
45. A 47 year old woman has had 3 urinary tract infections confirmed with urine culture in
the past 8 months. She has been started on cefalexin for prophylaxis. A kidney ureter
bladder X-ray has been performed and no renal stones were identified. Ultrasound of
the kidneys and ureter show no evidence of hydronephrosis or renal stones. Post
voiding residual volume is minimal on a bladder ultrasound. What is the SINGLE most
y
A. Cystoscopy
op
C. Low vaginal swab
D. Repeat MSU culture and sensitivity
C
E. Dimercaptosuccinic acid (DMSA) scanning
46. A 33 year old woman complains of having urinary urgency for the past year. She
urinates more than 8 times a day. She gives a history of having suprapubic pain if her
n
bladder is full, resulting in the need to urinate frequently as suprapubic pain is relieved
io
by voiding. A urine culture was sent and results have come back negative. On
cystoscopy, Hunner's ulcers were seen on the bladder wall. What is the SINGLE most
t
likely diagnosis?
ua
A. Endometriosis
B. Sexually transmitted infection
al
C. Overactive bladder
D. Bladder cancer
Ev
E. Interstitial cystitis
1532
Urology
1. A 72 year old man brought to the emergency department with onset of paraplegia
following a trivial fall. He was treated for prostatic malignancy in the past. What is the
B. Osteoporotic fracture of vertebrae
C. Secondary metastasis
D. Multiple myeloma
E. Spondylosis
As patient had prostatic malignancy, pathological fracture from secondary metastasis to

bone is more likely the option.
Prostate carcinoma
Risk factors
y
- Increasing age is the most important risk factor
op
- Men of black African-Caribbean family origin
- First-degree relative with prostate cancer
C
Presentation
- Lower urinary tract symptoms (LUTS) do not particularly raise suspicion of
prostate cancer because LUTS are common in older men and are rarely the
n
presenting symptom of prostate cancer. However, locally advanced prostate
io
cancer may cause obstructive LUTS

t
Local disease:
ua
- Raised PSA on screening

- Weak stream, hesitancy, sensation of incomplete emptying, urinary frequency,
urgency, urge incontinence
al
- Urinary tract infection

Ev
Locally invasive disease:

- Haematuria, dysuria, incontinence
- Haematospermia
- Perineal and suprapubic pain
- Obstruction of ureters, causing loin pain, anuria, symptoms of acute kidney
injury or chronic kidney disease
Metastatic disease:
- Bone pain or sciatica
- Paraplegia secondary to spinal cord compression
- Lymph node enlargement
- Lethargy (anaemia, uraemia)
- Weight loss, cachexia
2. A 70 year old man with a history of prostatic cancer has severe acute back pain waking
him up at night for the past 4 weeks. What is the SINGLE most appropriate
investigation?
1533
A. MRI spine
B. Isotope bone scan
C. DEXA scan
D. Serum ALP concentration
E. Serum calcium concentration
Isotope bone scan would be appropriate to identify bone metastasis in prostate cancer.
A small amount of radiation dye is injected into the vein and collects in parts of the
bone where there are abnormalities
3. A 25 year old woman presents with urinary frequency, suprapubic pain and dysuria. She
has a temperature of 38.5°C. Nitrites and leucocytes are positive on a dipstick. What is
A. Schistosomiasis
B. Kidney trauma
C. Ureteric calculus
y
D. Bladder calculi
op
E. Cystitis
Cystitis presents with frequency, dysuria, urgency, haematuria, suprapubic pain. Signs
C
of fever and nitrates and leukocytes points towards a urinary tract infection.
4. A 33 year old man presents with bilateral flank pain. He is later diagnosed to have
n
bilateral kidney stones. His medical history includes sarcoidosis. What is the SINGLE
io
most likely cause that attributed to the development of his urinary stones?
t
A. Hypercalcemia
ua
B. Hyperuricemia
C. Diet
D. Recurrent urinary tract infection
al
E. Hyperparathyroidism
Ev
Hypercalcaemia is seen commonly in sarcoidosis. It is due to increased circulation of

vitamin D produced by macrophages.
Renal stones risk factors

There are certain risk factors or drugs that may precipitate renal stones that you need
to know for PLAB part 1 as these are the most commonly asked. These are:
- Dehydration
- Hypercalcaemia
- Polycystic kidney disease
- Gout
- Loop diuretics
5. A 35 year old man with painless left testicular enlargement for the past 6 months which
is increasing in size. On examination, the left testicle is noted to be 3 times the size of
the right testicle. There is no tenderness or redness. What is the SINGLE most likely
diagnosis?
1534
A. Testicular cancer
B. Hydrocele
C. Epididymal cyst
E. Scrotal haematoma
It is important to note where the enlargement is located. One can mistakenly answer
epididymal cyst or hydrocele if one does not read the stem properly. Note that the
enlargement (sometimes lump or swelling) is of the testical and not scrotum. If it was
scrotal swelling, that you can think of hydrocele or epididymal cyst.
Testicular cancer
- Majority of testicular tumours arise from the germ cells.
Testicular germ cell tumours can be subdivided into seminoma and nonseminomatous
germ cell tumours however this is unlikely a need to know for this exam. The
presentation is the more important information to remember.
y
Presentation
op
- Painless lump in the body of the testis → This is the most common presentation
Diagnosis
- Ultrasound is first line
C
- CT scan is used for staging
- Appropriate tumour markers should be ordered (unlikely you would need to
know in detail for the exam)
n
io
6. A 61 year old man, known smoker, comes to the hospital with complaints of painless
frank haematuria. He has been worried about his loss of weight and reduced general
t
activity. Urine microscopy shows red cells but no white cells. What is the SINGLE most
ua
diagnostic test?
A. Urine culture
al
B. Intravenous urogram
C. Transrectal ultrasound and biopsy
Ev
D. Cystoscopy with biopsy

E. Ultrasound of the Kidneys, Ureters & Bladder
The two most important risk factors for transitional cell carcinoma of the bladder are:
Exposure to aromatic hydrocarbons, e.g. workers in the petrochemical, industrial dye,

rubber industries, chimney sweeps.
Smoking
Here they give a history of smoking with loss of weight. The absence of white cells
implies a non-infectious cause of the painless frank haematuria. In the elderly, one
must always have transitional cell carcinoma of the bladder as part of a differential
diagnosis when a patient presents with painless haematuria.
Cystoscopy is the most diagnostic test
1535
7. A 39 year old coal miner was recently diagnosed with bladder cancer. He is a smoker
and has a family history of bladder cancer. He also has been diagnosed with benign
prostatic hyperplasia. Which SINGLE risk factor is likely to be associated with
transitional cell carcinoma of the bladder?
A. Family history
B. Smoking
C. Exposure to coal mine
D. Benign prostatic hyperplasia
E. Age
The two most important risk factors for transitional cell carcinoma of the bladder are:
- Exposure to aromatic hydrocarbons, e.g. workers in the petrochemical,

industrial dye, rubber industries, chimney sweeps.
- Smoking
8. A 26 year old sexually active male presents with severe pain in the left scrotum lasting
y
for 4 hours. He complains of a past history with similar episodes of pain over the past 2
op
years but has never sought treatment before. His scrotum is extremely tender and
examination is impossible because of the pain. What is the SINGLE best management
for this patient?
C
A. Send home with antibiotic cover
B. Ultrasound of scrotum
n
C. Urgent surgical exploration
io
D. Urethral swab
E. Midstream urine culture and sensitivity
t
ua
In this stem, mentioning that this young man is sexually active is aiming to distract you
from the correct choice. The history of severe pain with a past history of similar
episodes of severe pain is indicative of testicular torsion (this is likely due to the testis
al
twisting and then spontaneously resolving). The fact that examination is extremely
painful is another hint toward testicular torsion as the diagnosis.
Ev
Testicular torsion
Key features of testicular torsion include:

- Severe, sudden onset testicular pain
- Typically affects adolescents and young males
- On examination testis is tender and pain not eased by elevation
Remember: In testicular torsion, lifting the testis up over the symphysis
increases pain, whereas in epididymitis this usually relieves pain.
- Urgent surgery is indicated
Management:
- Urgent exploratory surgery is needed to prevent ischaemia of the testicle
Colour Doppler USS (reduced arterial blood flow in the testicular artery) and
radionuclide scanning (decreased radioisotope uptake) can be used to diagnose
testicular torsion, but in many hospitals, these tests are not readily available and the
1536
diagnosis is based on symptoms and signs. Scrotal exploration should be undertaken as
a matter of urgency. Delay in relieving the twisted testis results in permanent ischaemic
damage to the testis, causing atrophy.
This is a very high yield question and in most cases if you suspect testicular torsion the
answer would be exploratory surgery (or urgent surgery).
REMEMBER: if clinical suspicion is high, surgical intervention should not be delayed for
the sake of further investigation!
9. A 78 year old man with a history of prostate adenocarcinoma has loin pain, anuria, and
symptoms of acute kidney injury. What is the SINGLE most appropriate investigation?
A. MRI spine
C. Transrectal Ultrasound
D. Ultrasound KUB
E. Abdominal X-ray
y
op
This man is suffering from obstruction of the ureters due to extension of cancer beyond
the capsule causing loin pain and anuria. An ultrasound of the kidney and ureters would
be appropriate.
C
He has a weak stream, and says that he is unable to completely empty his bladder. 3
n
months ago he suffered from a urinary tract infection. He also complains of back pain
io
and suprapubic pain. He has lost significant weight and looks cachexic. What is the
t
ua

C. Bladder stones
al
D. Prostate cancer
Ev
Prostate carcinoma
Risk factors
Presentation
Local disease:
1537

- Haematospermia
Metastatic disease:
y
11. A 31 year old presents with sudden onset of flank pain, nausea and vomiting. He
op
recently passed a 4mm stone in his urine. Urine microscopy reveals microscopic
haematuria. On ultrasound, a 3mm stone is found in the renal pelvis. What is the
C
A. Extracorporeal shock-wave lithotripsy
B. Percutaneous nephrolithotomy
n
C. Open Surgery
io
D. Advise to increase fluid intake

E. Urethral catheterisation
t
ua
Renal stones (Kidney stones) management
The key question in kidney stones is: When to watch and wait and when not to?
al
There is no specific rule of how we treat renal stones. As a rule of thumb, the younger
Ev
the patient, the larger the stone and the more symptoms it is causing, the more
inclined we are to recommend treatment. Because it is so subjective, it is often hard to
answer management questions for renal stones. Nonetheless, below are some pointers
that will help guide you when answering PLAB questions:
- Stones < 0.5 cm → Just increase fluid intake. Likely to pass spontaneously
- Stones 0.5 cm to 2 cm - Extracorporeal shock-wave lithotripsy (ESWL) or
Ureteroscopy using dormia basket
- Stones > 2 cm → Percutaneous nephrolithotomy
like a 'bag of worms' and is less obvious when he is lying supine. What is the SINGLE
A. Serum AFP and beta HCG levels

B. Exploratory surgery
1538
C. Biopsy
D. Pen torch transillumination
E. Ultrasound Doppler
The diagnosis here is varicocele. It is very common to hear complains of feeling heavy in
the scrotal area. The blue appearance gives the clue that these are veins. Another key
hint is the fact that the question says “left scrotum”. Varicocele very commonly
presents on the left. The reason the mass is less obvious when lying supine is because
gravity allows the drainage of the pampiniform plexus and thus the mass
decompresses.
Varicocele can be reliably diagnosed with ultrasound, which will show dilation of the
vessels of the pampiniform plexus
Varicocele
A varicocele is an abnormal enlargement of the testicular veins. They are usually
asymptomatic but may be important as they are associated with infertility.
y
Infertility is due to elevated scrotal temperatures which has consequent deleterious
op
effects on spermatogenesis
Aetiology Incompetent valves in the internal spermatic veins lead to retrograde blood
C
?ow, vessel dilatation, and tortuosity of the pampiniform plexus.
Varicoceles are much more common on the left side (> 80%)
n
→ because testicular vein drains into renal vein
io
→ The left internal spermatic (testicular) vein enters the left renal vein at right angles
and is under a higher pressure than the right vein which enters the vena cava obliquely
t
at a lower level. As a consequence, the left side is more likely to develop a varicocele.
ua
Features
- classically described as a 'bag of worms'
al
- subfertility
Ev
Diagnosis
- Scrotal Doppler - USS: is diagnostic
Management
- usually conservative
- Occasionally surgery is required if the patient is troubled by pain. There is
ongoing debate regarding the effectiveness of surgery to treat infertility
13. A 15 year old boy presents with testicular pain for 3 days. The pain had a gradual onset.
There is no history of trauma. On examination, his right hemi-scrotum is tender. He has
a temperature of 38.5°C. What is the SINGLE most appropriate management?
A. Give antibiotics
B. Give analgesia
C. Reassure
D. Blood culture
E. Exploratory surgery
1539
The history here is of epididymo-orchitis. The two major things you need to look out for
when someone presents with testicular pain is epididymo-orchitis and testicular
torsion. Epididymo-orchitis would have a more gradual onset of symptoms like in this
case. His age here is quite misleading as a young boy below the age of 20, the first
thought that usually comes to your mind is testicular torsion but as you go on reading,
it becomes quite clear that this is actually epididymo-orchitis especially with the
gradual onset and the fever.
Antibiotics would be the best option here. Obviously analgesia would be given too but
more important management would be antibiotics.
Epididymo-orchitis
Epididymo-orchitis describes an infection of the epididymis +/- testes resulting in pain

and swelling. It is most commonly caused by local spread of infections from the genital
tract (such as Chlamydia trachomatis and Neisseria gonorrhoeae) or from the bladder.
The most important differential diagnosis is testicular torsion. This needs to be
y
excluded urgently to prevent ischaemia of the testicle. Epididymo-orchitis has similar
op
presenting symptoms as testicular torsion. Tenderness is usually localized to the
epididymis (absence of testicular tenderness may help to distinguish epididymo-orchitis
from testicular torsion, but in many cases, it is difficult to distinguish between the two).
C
Features
- unilateral testicular pain and swelling
n
- urethral discharge may be present, but urethritis is often asymptomatic
io
- factors suggesting testicular torsion include patients < 20 years, severe pain and
an acute onset
t
ua
Management
- Antibiotics. In PLAB part 1, it is unlikely you would need to know which type of
antibiotics to treat epididymo-orchitis.
al
-
14. A 65 year old man presents with frank haematuria. He is afebrile and has no other
Ev
urinary symptoms. There was no history of trauma and he has no relevant medical
history. He looks well. Urinary cultures are negative. What is the SINGLE most
appropriate investigation that would lead to a diagnosis?
A. Intravenous urograms (IVU)

C. Cystoscopy
D. Urinary biomarkers
E. Transrectal ultrasound and biopsy
Painless haematuria at this age group must be treated as malignancy of the urinary
tract until proved otherwise.
PLAB has very limited variations on questions regarding frank haematuria. The usual
case is if you see frank haematuria that is asymptomatic, you should be thinking of
bladder cancers.
1540
Do not substitute urinary biomarkers for cystoscopy to investigate suspected bladder
cancer or for follow?up after treatment for bladder cancer, except in the context of a
clinical research study.
Bladder Cancer
Cancer of the bladder ( transitional cell cancer in most cases) has a very close
correlation with smoking, and usually presents with painless visible haematuria.
Risk factors
- Men: are 2.5 times more likely to develop the disease than women, the reasons
for which are unclear, but may be associated with greater urine residuals in the
bladder
- Age: increases risk, most commonly diagnosed in the eighth decade and rare
below age 50y.
- Smoking: is the major cause of bladder cancer in the developed world.
- Occupational exposure: to carcinogens, in particular aromatic hydrocarbons like
aniline, is a recognized cause of bladder cancer.
y
op
Investigation of haematuria
After a UTI has been excluded or treated, all patients with persistent microscopic or
macroscopic haematuria require investigation of their upper tracts, bladder, and
C
urethra.
Urological investigations are tailored according to patient age and symptoms:

n
- Over 40y old with macroscopic haematuria: urgent CTU, cystoscopy, and
io
cytology.
t
CTU is faster and more sensitive than ultrasound or IVU in the detection of renal
ua
(parenchymal and urothelial) and ureteric tumours. However, it carries a higher

radiation dose and is more expensive. CTU also detects some bladder tumours, but may
overcall bladder wall hypertrophy as tumour and will miss flat CIS and urethral
al
pathology so it cannot replace cystoscopy.

Ev
When would CT-KUB be the answer?

CT-KUB requires less radiation dose and is preferred in patients who are more likely to
have stone than malignancy.
Example
- Patients under 40 years old with macroscopic haematuria
- Patients over 40 years old with non-visible haematuria
-
15. A 79 year old man who is being treated with GnRH antagonist for a diagnosed prostate
adenocarcinoma attends the clinic. What is the SINGLE most appropriate follow up
investigation?
A. Serum AFP
B. Serum PSA
C. Serum acid phosphatase concentration
D. Serum ALP isoenzyme concentration
E. Prostate cancer antigen 3
1541
Serum PSA is currently the best method of detecting localised prostatic cancer and
monitoring response to treatment but it lacks specificity, as it is also increased in most
patients with benign prostatic hyperplasia. The level of PSA over time would determine
the next management of treatment.
16. A 22 year old sexually active male came with a 2 day history of fever with pain in the
scrotal area. There is no history of trauma. On examination, the scrotal skin is red and
A. Testicular torsion
B. Varicocele
C. Inguinal hernia
E. Mumps
The history here is of epididymo-orchitis. The two major things you need to look out for
when someone presents with testicular/scrotal pain is epididymo-orchitis and testicular
torsion. Epididymo-orchitis would have a more gradual onset of symptoms like in this
case. It is quite clear that this is actually epididymo-orchitis especially with the gradual
y
onset and the fever.
Epididymo-orchitis
op
C
Epididymo-orchitis describes an infection of the epididymis +/- testes resulting in pain
and swelling. It is most commonly caused by local spread of infections from the genital
tract (such as Chlamydia trachomatis and Neisseria gonorrhoeae) or from the bladder.
n
io
The most important differential diagnosis is testicular torsion. This needs to be

excluded urgently to prevent ischaemia of the testicle. Epididymo-orchitis has similar
t
presenting symptoms as testicular torsion. Tenderness is usually localized to the

ua
epididymis (absence of testicular tenderness may help to distinguish epididymo-orchitis

from testicular torsion, but in many cases, it is difficult to distinguish between the two).
al
Features
- unilateral testicular pain and swelling
Ev
- urethral discharge may be present, but urethritis is often asymptomatic

- factors suggesting testicular torsion include patients < 20 years, severe pain and
an acute onset
Management
- Antibiotics. In PLAB part 1, it is unlikely you would need to know which type of
antibiotics to treat epididymo-orchitis.
17. A 44 year old man presents with a scrotal swelling. The swelling is cystic and is non-
tender. It is located in the upper pole of the posterior part of the testes. What is SINGLE
A. Epididymal cyst
B. Testicular cancer
C. Hydrocele
D. Varicocele
1542
Epididymal cyst
- Derived from the collecting tubules of the epididymis and contains clear fluid.
They develop slowly, lie within the scrotum. They are often multiple
(multiloculated)
- Most common cause of scrotal swellings seen in primary care.
Key features that you need to know for PLAB

- Painless
- Lie behind and above testis
Diagnosis
- Ultrasound
Management
- Usually supportive but surgical removal may be attempted for larger or
symptomatic cysts
y
Note: Differentiating epididymal cyst and hydrocele.
op
Another painless scrotal swelling commonly asked in PLAB is hydrocele. But in these
questions, they usually state that it “transilluminates with a pen torch”. Hydrocele is
also usually anterior to and below the testicle.
C
Both epididymal cyst and hydrocele transilluminates. So sometimes the only clue in the
stem would be “the testis is palpable separately from the cyst (or swelling)” which
n
indicates epididymal cyst. In hydrocele, the testis is palpable within the fluid filled
io
swelling.
t
18. A 38 year old man has severe loin pain with nausea and vomiting. Ultrasound shows
ua
right hydronephrosis. A non-enhanced computerised tomography scan reveals a 3.2 cm

in diameter stone at the level of the minor calyx. What is the SINGLE most appropriate
management?
al
A. Percutaneous nephrolithotomy
Ev
B. Extracorporeal shock-wave lithotripsy

D. Urethral catheterisation
E. Stenting
Renal stones (Kidney stones) management
The key question in kidney stones is: When to watch and wait and when not to?
There is no specific rule of how we treat renal stones. As a rule of thumb, the younger
the patient, the larger the stone and the more symptoms it is causing, the more
inclined we are to recommend treatment. Because it is so subjective, it is often hard to
answer management questions for renal stones. Nonetheless, below are some pointers
that will help guide you when answering PLAB questions:
- Stones < 0.5 cm → Just increase fluid intake. Likely to pass spontaneously
1543
- Stones 0.5 cm to 2 cm - Extracorporeal shock-wave lithotripsy (ESWL) or
Ureteroscopy using dormia basket
- Stones > 2 cm → Percutaneous nephrolithotomy
19. A 14 year old boy presents with a 3 hour history of severe left testicular pain. He has no
urinary symptoms and is otherwise well. On examination, the right testes looks normal
but the left hemiscrotum is swollen and acutely tender. The pain is not eased by
elevation of the testes. What is the SINGLE most appropriate initial step?
A. Mid stream urine

C. Urethral Swab
D. Exploratory surgery
E. Computed tomography scan of the testes
This boy is having a testicular torsion.

Testicular torsion
y
op
C
n
io
Management:
t
ua
al

Ev
20. A 57 year old chronic smoker reports three instances in the past 2 weeks
when he has had painless, gross, total hematuria. Intravenous urograms (IVU) was done
and was reported as normal. In the last month he has been treated for irritative voiding
symptoms, but has not been febrile, and urinary cultures have been negative. What is
A. US Abdomen
B. Flexible cystoscopy
C. MRI
1544
D. Nuclear imaging
E. CT-KUB
Bladder Cancer
Cancer of the bladder ( transitional cell cancer in most cases) has a very close
Risk factors
- Men: are 2.5 times more likely to develop the disease than women, the reasons
for which are unclear, but may be associated with greater urine residuals in the
bladder
below age 50y.
aniline, is a recognized cause of bladder cancer.
y
Investigation of haematuria
op
After a UTI has been excluded or treated, all patients with persistent microscopic or
macroscopic haematuria require investigation of their upper tracts, bladder, and
urethra.
C
Urological investigations are tailored according to patient age and symptoms:
- Over 40y old with macroscopic haematuria: urgent CTU, cystoscopy, and
n
cytology.
io
CTU is faster and more sensitive than ultrasound or IVU in the detection of renal
t
(parenchymal and urothelial) and ureteric tumours. However, it carries a higher

ua
radiation dose and is more expensive. CTU also detects some bladder tumours, but may
overcall bladder wall hypertrophy as tumour and will miss flat CIS and urethral
pathology so it cannot replace cystoscopy.
al
When would CT-KUB be the answer?

Ev
CT-KUB requires less radiation dose and is preferred in patients who are more likely to
have stone than malignancy.
Example
- Patients under 40 years old with macroscopic haematuria
- Patients over 40 years old with non-visible haematuria
21. A 32 year old woman presents with severe intermittent right sided abdominal pain
radiating to the groin which has lasted for 3 hours. She is writhing in pain and vomited
twice in the last hour. WBC are 14 x 109/L and CRP is 83 mg/l. A urine HCG was
negative. What is the SINGLE most likely cause of her abdominal pain?
A. Appendicitis
B. Ruptured ectopic pregnancy
C. Salpingitis
D. Ureteric colic
1545
The intermittent right sided abdominal pain radiating to the groin indicates a stone at
the lower ureter.
Urinary tract stones
Clinical features
- ‘Ureteric/renal colic’. Severe, intermittent, stabbing pain radiating from loin to
groin.
- Microscopic or, rarely, frank haematuria.
- Systemic symptoms such as nausea, vomiting, tachycardia, pyrexia.
- Loin or renal angle tenderness due to infection or inflammation.
- Iliac fossa tenderness if the calculus has passed into the distal ureter.
Investigations
- Raised WCC and CRP suggest superadded infection (should be confirmed by
MSU);
- Stones often visible on plain abdominal X-ray (‘kidneys/ureters/bladder’ (KUB)).
- Non-contrast spiral CT is the gold standard for locating stones and assessing
y
evidence of complications.
op
- VU will locate stones and show any proximal obstruction.
- Renal ultrasound scan for hydronephrosis
C
He has a weak stream, and says that he is unable to completely empty his bladder. He
also has lower back pain and has lost 10 kg in the last 3 months. An ultrasound shows
n
bilateral hydronephrosis. What is the SINGLE most likely diagnosis?
io

t

ua
C. Bladder stones
D. Prostate cancer
al
An elderly patient of 77 years with obstructive symptoms of lower urinary tract and
Ev
bilateral hydronephrosis points towards prostate cancer or benign prostatic

hyperplasia. Given that there is weight loss and back pain, one should consider
prostatic cancer as a more likely answer.
Prostate carcinoma
Risk factors
Presentation
1546
Local disease:

- Haematospermia
Metastatic disease:
y
23.
op
A 22 year old footballer was struck in the groin by a kick. He presents with severe pain
and mild swelling in the scrotum. The pain is not eased by elevation of the testes. What
C
is the SINGLE most appropriate next course of action?
A. Ultrasound scan of the testes

n
B. Urethral Swab
io
D. IV fluids
t
E. Antibiotics
ua
There is a possibility of testicular torsion in this question thus exploratory surgery

would be the most appropriate next course of action.
al
The key here is to explore the possibility of testicular torsion. The main differential is
Ev
usually epididymo-orchitis in which the onset of pain is much more gradual. In a patient
in whom the onset is dramatic and sudden, then torsion becomes the favourite. Once
torsion tops the list, treatment is surgery (for detorsion and orchidopexy).The sooner
this happens, the greater the chance of the testis being saved.
Testicular torsion

Management:
1547
24. A 15 year old boy was woken up from sleep with severe, sudden pain in the testis.
There was no history of trauma. On examination, the testis is tender on palpation. He is
afebrile. Analgesia has been given. What is the SINGLE most appropriate next step in
management?
y
op
A. Urethral Swab
B. Antibiotics
C. Refer urgently to a surgeon
C
D. Reassurance
E. Discharge with analgesics
n
io
would be the next course of action. Thus, referral to a surgeon would be appropriate.
t
ua
in whom the onset is dramatic and sudden, then torsion becomes the favourite. Once
torsion tops the list, treatment is surgery (for detorsion and orchidopexy). The sooner
al
this happens, the greater the chance of the testis being saved.
Ev
Testicular torsion

Management:
1548
25. A 25 year old man has a painful right testis, lower abdominal pain, vomiting and
nausea. The testis is swollen, hot, and extremely tender. The onset of pain was
dramatic and sudden. He complains of some pain on passing urine. What is the SINGLE
A. Mid stream urine

C. Urethral Swab
D. Urgent surgery
y
E. Antibiotics
op
would be the most appropriate next course of action.
C
n
in whom the onset is dramatic and sudden, then torsion becomes the favourite. Whilst
io
urinary symptoms are also more common in epididymo-orchitis, they may overlap as
part of the general extreme lower abdominal pain seen in torsion. Once torsion tops
t
the list, treatment is surgery (for detorsion and orchidopexy).The sooner this happens,
ua
the greater the chance of the testis being saved.
Testicular torsion
al

Ev

Management:
1549
26. A 74 year old lady who has had a stroke in the past has an indwelling catheter for 10
months. She presents with bluish-purple discolouration of the catheter bag. What is the
SINGLE most likely explanation for this?
A. Normal change due to long use

B. Catheter degradation
C. Acidic urine
D. Alkaline urine
E. Bacterial colonization of the urinary tract
Purple urine bag syndrome
y
Purple urine bag syndrome is a medical syndrome where purple discoloration of urine
op
occurs in people with urinary catheters and co-existent urinary tract infection. It is a
rare phenomenon. Bacteria in the urine produce the enzyme indoxyl phosphatase. This
converts indoxyl sulfate in the urine into the red and blue colored compounds indirubin
C
and indigo. One of the most common bacteria implicated is Providencia stuartii.
27. A 49 year old man presents with severe colicky pain from his right flank radiating to his
n
groin associated with nausea and vomiting. He subsequently develops rigors and a
io
tender abdomen. His urinalysis reveals trace blood. What is the SINGLE next best
investigation?
t
ua
B. Kidneys, ureters, and bladder X-ray
C. Colonoscopy
al
D. Intravenous pyelogram
E. Laparoscopy
Ev
This is a typical presentation of a ureteric calculus. The pain is severe and associated
with nausea and vomiting. Urinalysis or microscopy would reveal blood.
X-ray is the answer here. X-rays are still the most commonly used first diagnostic step in
diagnosing renal stones. It may not be the best method as it does still misses 20% of
stones which are not radio-opaque however it is still cost-effective.
In certain UK hospitals, Urologist are moving towards ordering a CT KUB without even
having an X-ray performed. The reason behind this is that it is much more accurate than
an X-ray and CT scans are now so readily available. For that reason, if the question had
an option of Non-enhanced CT scan and asked for “the SINGLE most appropriate
diagnostic test” or “the SINGLE most definitive test”, pick the CT scan.
Plain X-rays of the kidney, ureter and bladder (KUB) are useful in watching the passage
of radio-opaque stones (around 80% of stones are of calcium and so will be radio-
opaque).
1550
Renal Ultrasound scan is sensitivity for detecting renal calculi but is variable depending
on the series. Some series suggest close to 95% sensitivity for detecting stones, others
just 50%. Ultrasound scanning may be helpful to differentiate radio-opaque from
radiolucent stones and in detecting evidence of obstruction by looking for
hydronephrosis or hydroureter.
A combination of plain abdominal radiography and renal ultrasonography is a useful

screening test for renal calculi.
Non-enhanced CT scanning (spiral non-contrast CT) is now the imaging modality of

choice and has replaced intravenous pyelogram (IVP). It is a very accurate method of
diagnosing renal and ureteric stones (99% visible). Allows accurate determination of
stone size and location and good definition of pelvicalyceal anatomy. It also helps
exclude differential causes of an acute abdomen (e.g. A ruptured abdominal aortic
aneurysm which may present similarly).
28. A 46 year old man presents to clinic with a scrotal swelling. The swelling is cystic and is
y
non-tender. It developed slowly and it lies above and behind the testis. What is the
op
SINGLE most appropriate diagnostic test?
A. Ultrasound
C
B. Pen torch
D. Biopsy
n
E. Serum AFP and β HCG
io
The most probable diagnosis here is an epididymal cyst. This is confirmed with an
t
ultrasound.
ua
Epididymal cyst
- Derived from the collecting tubules of the epididymis and contains clear fluid.
al
They develop slowly, lie within the scrotum. They are often multiple
(multiloculated)
Ev
- Most common cause of scrotal swellings seen in primary care.
Key features that you need to know for PLAB

- Painless
- Lie behind and above testis
Diagnosis
- Ultrasound
Management
- Usually supportive but surgical removal may be attempted for larger or
symptomatic cysts
Note: Differentiating epididymal cyst and hydrocele

Another painless scrotal swelling commonly asked in PLAB is hydrocele. But in these
questions, they usually state that it “transilluminates with a pen torch”. Hydrocele is
also usually anterior to and below the testicle.
1551
Both epididymal cyst and hydrocele transilluminates. So sometimes the only clue in the
stem would be “the testis is palpable separately from the cyst (or swelling)” which
indicates epididymal cyst. In hydrocele, the testis is palpable within the fluid filled
swelling.
29. A 67 year old man has with a diagnosis of benign prostatic hyperplasia undergoes a
transurethral resection of the prostate (TURP). What SINGLE most likely electrolyte
abnormality should be expected after the procedure?
A. Hypokalemia
B. Hypocalcemia
C. Hyperkalemia
D. Hyponatremia
E. Hypernatremia
Transurethral resection of the prostate (TURP) is a treatment for benign prostatic

hyperplasia. It involves insertion of a resectoscope via the penile urethra. The bladder
and prostate are irrigated and prostatic tissues are removed using diathermy.
y
op
TURP syndrome is rare but can potentially be life threatening that is characterised by
hyponatremia. It occurs when irrigation fluid enters the systemic circulation. It is
caused by venous destruction and absorption of the irrigation fluid.
C
The management usually involves fluid restriction to correct hyponatremia.
n
30. A 62 year old man has been waking up in the middle of the night to use the bathroom.
io
He complains of having difficulty in initiating micturition and dribbling afterwards. A

diagnosis of benign prostatic hyperplasia was made after a transrectal ultrasound
t
guided biopsy was performed. He is due for a transurethral resection of the prostate
ua
(TURP) later this evening. What SINGLE most likely electrolyte abnormality should be
expected after the procedure?
al
A. Hypokalemia
B. Hypocalcemia
Ev
C. Hyperkalemia
D. Hyponatremia
E. Hypernatremia
Transurethral resection of the prostate (TURP) is a treatment for benign prostatic

hyperplasia. It involves insertion of a resectoscope via the penile urethra. The bladder
and prostate are irrigated and prostatic tissues are removed using diathermy.
TURP syndrome is rare but can potentially be life threatening that is characterised by
hyponatremia. It occurs when irrigation fluid enters the systemic circulation. It is
caused by venous destruction and absorption of the irrigation fluid.
The management usually involves fluid restriction to correct hyponatremia.
31. A 20 year old women 6 hours post-lower segment Caesarean section has not passed
urine since her operation. She denies any urinary symptoms preoperatively. She
appears unwell. She has a temperature of 37°5C, a pulse of 110 beats/minute, a blood
1552
pressure of 94/60 mmHg and a respiratory rate of 23 breaths/minute. Her abdomen is
distended with tenderness in the left flank and suprapubic region. Bowel sounds are
not audible. What is the SINGLE most likely postoperative complication?
A. Urinary tract infection

B. Urinary tract injury
C. Pleurisy
D. Pleurisy
E. Paralytic ileus
Ureteric injuries
Ureteric injuries can occur during pelvic or abdominal surgery, e.g. hysterectomy,
colectomy.
The ureter may be divided, ligated, or angulated by a suture; a segment excised or

damaged by diathermy.
y
Internal (iatrogenic) injury diagnosis
op
- The injury may be suspected at the time of surgery, but injury may not become
apparent until some days or weeks post-operatively.
C
Postoperative diagnosis
- The diagnosis is usually apparent in the first few days following surgery, but it
may be delayed by weeks, months, or years
n
- It may present with flank pain or post-hysterectomy incontinence (a continuous
io
leak of urine suggests a ureterovaginal fistula)

t
32. An 80 year old man has the sensation of incomplete emptying of his bladder. He is
ua
going to the toilet more often than usual and is having terminal dribbling. He has lost 9
kg in the last 3 months and recently suffers from pelvic pain. What is the SINGLE most
likely diagnosis?
al

Ev

C. Bladder stones
D. Prostate cancer
E. Bladder cancer
Prostate carcinoma
Risk factors
Presentation
1553
Local disease:

- Haematospermia
Metastatic disease:
y
op
33. A 13 year old boy develops acute pain in his right testicle while playing football.
C
Examination reveals a very tender mass in the right scrotum with reddening of scrotal
skin. Lifting the testis causes more pain. What is the SINGLE most likely diagnosis?
n
A. Mumps
io
B. Testicular tumour
C. Scrotal abscess
t
ua
Acute swelling of the scrotum in a boy indicates torsion of the testis until proven
al
otherwise. The history of pain developing during sports is very classical of testicular
torsion.
Ev
“Pain worsening on elevation of testis” are key phrases commonly used in the stems
that shout out testicular torsion as the answer
Testicular torsion

Management:
1554
34. A 75 year old man has urinary symptoms of hesitancy, frequency and nocturia. A digital
rectal examination reveals a large, irregular, hard asymmetric prostate gland. What is
the SINGLE most appropriate investigation that will help with the diagnosis?
A. CA 125
y
B. CA 153
op
C. CA 199
D. CEA
E. PSA
C
A large, irregular, hard asymmetric prostate gland is indicative of prostate cancer.
n
Serum PSA is currently the best method of detecting localised prostatic cancer and
io
monitoring response to treatment but it lacks specificity, as it is also increased in most

patients with benign prostatic hyperplasia.
t
ua
Prostate carcinoma
Risk factors
al

Ev
Presentation
Local disease:

- Haematospermia
1555
Metastatic disease:
35. An 85 year old war veteran complains of loss of appetite and says that he has lost
weight over the past few months. He says that he has passed some blood in his urine,
however, there was no pain. A recent report shows that PSA is 9.5ng/ml. What is the

y
C. Bladder stones
op
D. Prostate cancer
E. Urinary tract infection C
Prostate carcinoma
Risk factors
n
io

t
ua
Presentation
al

Ev
Local disease:

- Haematospermia
Metastatic disease:
1556
blue in colour and is less obvious when he is lying supine. What is the SINGLE most
A. Analgesia
B. Antibiotic
C. Biopsy
E. Reassurance
The diagnosis here is varicocele. It is very common to hear complains of feeling heavy in
the scrotal area. The blue appearance gives the clue that these are veins. Another key
hint is the fact that the question says “left scrotum”. Varicocele very commonly
y
presents on the left. The reason the mass is less obvious when lying supine is because
op
gravity allows the drainage of the pampiniform plexus and thus the mass
decompresses. C
Varicocele can be reliably diagnosed with ultrasound, which will show dilation of the
vessels of the pampiniform plexus
n
Varicocele
io
A varicocele is an abnormal enlargement of the testicular veins. They are usually

asymptomatic but may be important as they are associated with infertility.
t
ua
Infertility is due to elevated scrotal temperatures which has consequent deleterious

effects on spermatogenesis
al
Aetiology Incompetent valves in the internal spermatic veins lead to retrograde blood
?ow, vessel dilatation, and tortuosity of the pampiniform plexus.
Ev
Varicoceles are much more common on the left side (> 80%)
→ because testicular vein drains into renal vein
→ The left internal spermatic (testicular) vein enters the left renal vein at right angles
and is under a higher pressure than the right vein which enters the vena cava obliquely
at a lower level. As a consequence, the left side is more likely to develop a varicocele.
Features
- classically described as a 'bag of worms'
- subfertility
Diagnosis
- Scrotal Doppler - USS: is diagnostic
Management
- usually conservative
1557
Occasionally surgery is required if the patient is troubled by pain. There is ongoing
debate regarding the effectiveness of surgery to treat infertility
37. An 81 year old afro-caribbean man presents with pain in his lower back and hip. He
complains of waking up in the middle of the night to go to the washroom and often he
wets himself before reaching the toilet. He also has to urinate much more frequent
than in the past and has terminal dribbling. What is the SINGLE most likely underlying
diagnosis?

B. Prostatitis
C. Bladder carcinoma
D. Prostate carcinoma
His age, ethnicity and urgency points towards a prostatic pathology. Metastasis to the
bones could explain the pain in his back and hips.
y
Frequency, urgency and terminal dribbling are features of prostate cancer. Black men
op
are at greatest risk for prostate cancer.
The most frequent sites of metastasis for prostate carcinoma are bone and lymph
C
nodes of the obturator fossae, internal, external and common iliac arteries, and
presacral regions.
n
38. 60 year old patient had a cystoscopy for painless, gross hematuria and pathology
io
revealed transitional cell carcinoma of the bladder. He has smoked a pack a day for the
last 15 years and currently works in a coal factory. What is the SINGLE greatest risk
t
factor for transitional cell carcinoma in this patient?

ua
A. Coal dust exposure

B. Smoking
al
C. Family history
D. Lung cancer
Ev
Whenever you see painless, gross hematuria in an elderly male, you should
immediately be thinking of cancer.
Bladder Cancer
Cancer of the bladder (transitional cell cancer in most cases) has a very close
Risk factors
- Men: are 2.5 times more likely to develop the disease than women
below age 50.
aniline, is a recognized cause of bladder cancer. This type of occupational
1558
exposure occurs mainly in industrial plants processing paint, dye, metal and
petroleum products.
- Other risk factors include industrial exposure to aromatic amines in dyes,
paints, solvents, leather dust, inks, combustion products, rubber and textiles.
39. A 77 year old man has a long term indwelling urinary catheter. A recent catheter urine
sample was sent for culture and sensitivity and was found to have heavy growth of
Escherichia coli. What is the SINGLE most appropriate management?
A. Reassure the patient

B. Prescription for antibiotics
C. Bladder washout
D. Repeat midstream specimen of urine in 2 weeks
E. Change the urinary catheter
It is important to note that the stem has not provided symptoms of a urinary tract
infection. There is no fever, dysuria or pelvic discomfort. Although patients who have
an indwelling urinary catheter are at increased risk of getting an infection there are no
y
signs of any infection at the moment. Changing the catheter would prevent an
op
ascending infection. The usual hospital protocols for long term indwelling urinary
catheters would include antibiotics only if the patient has symptoms of a urinary tract
infection.
C
A bladder washout is an incorrect answer. It is a technique used to flush out the bladder
by introducing saline through your catheter and into your bladder. It is usually used
n
when the catheter is not draining correctly.
io
40. A 75 year old man comes in complaining of difficulty in passing urine, poor stream and
t
dribbling at the end of voiding. He has also notice significant weight loss and feels tired
ua
all the time. An ultrasound shows bilateral hydronephrosis. What is the SINGLE most
likely cause of these findings?
al

Ev
C. Bladder stones
D. Prostate cancer
An elderly patient of 75 years with obstructive symptoms of lower urinary tract and
bilateral hydronephrosis points towards prostate cancer or benign prostatic
hyperplasia. Given that there is weight loss and tiredness, one should consider prostatic
cancer as a more likely answer.
Prostate carcinoma
Risk factors
Presentation
1559
Local disease:

- Haematospermia
y
Metastatic disease:
op
C
n
41. A 47 year old man comes to the GP with swelling on his left groin which disappears on
io
lying down. The swelling was bluish in colour and felt like a bag of worms. He also
complains of a mass in the left loin along with haematuria occasionally. What could be
t
the possible diagnosis?

ua
A. Left sided renal cell carcinoma

B. Varicosity 2nd to liver disease
al
C. Testicular tumor
Ev
E. Inferior vena cava obstruction
The bluish swelling that feels like a bag of worms is a perfect description of varicocele.
The most common secondary cause of left sided varicocele is renal cell carcinoma.
Newly diagnosed varicocele over the age of 40 years are very much suggestive of renal
cell carcinoma. Varicocele is common on left side as left testicular veins drain to the left
renal vein, while the right testicular vein drain directly into inferior vena cava.
It is very common to hear complains of feeling heavy in the scrotal area. The blue
appearance gives the clue that these are veins. The reason the mass is less obvious
when lying supine is because gravity allows the drainage of the pampiniform plexus and
thus the mass decompresses.
42. A 79 year old African Americans male complains of thirst and fatigue. He has symptoms
of frequency, urgency and terminal dribbling. He has lost 8 kg over the last 3 months.
1560
Laboratory findings show a calcium of 3.0 mmol/L and haemoglobin of 90g/L. What is
A. Benign Prostatic Hyperplasia

B. Prostate carcinoma
C. Chronic pyelonephritis
D. Diabetes Mellitus
E. Osteosarcoma
Frequency, urgency and terminal dribbling are features of prostate cancer. Black men
are at greatest risk for prostate cancer. Weight loss and anaemia is also a feature of
prostate cancer.
The most frequent sites of metastasis for prostate carcinoma are bone and lymph
nodes of the obturator fossae, internal, external and common iliac arteries, and
presacral regions.
Metastasis to the bones could explain the high serum calcium which in turn results in
y
the symptoms of thirst.
43.
op
A 58 year old man has renal colic for the past 12 hours. In the last two years, he has
presented with three episodes of acute onset of pain in his right knee. What is the
C
SINGLE most likely cause of his renal colic?
A. Systemic lupus erythematosus associated glomerulonephritis

n
B. Hypercalcemia
io
C. Chlamydia trachomatis
D. Hyperuricemia
t
E. Hyperoxaluria
ua
Hyperuricemia is the only one of the choices that has links to both a gouty arthritis and
formation of renal stones which causes renal colic.
al
44. A 42 year old woman has recently returned from working in the Middle East. She has
Ev
episodes of loin pain, urinary frequency, dysuria and has passed a urinary stone in the
past. She plans to return to the Middle East in a month’s time. What is the SINGLE best
advice to give to prevent recurrent stone formation?
A. Drink less dairy products

B. Increase fibre in diet
D. Decrease consumption of calcium related products
E. Decrease protein in diet
Dehydrations is a risk factor for renal stones. Protein, calcium and fibre consumption
have no relevance to urinary stone formation.
45. A 47 year old woman has had 3 urinary tract infections confirmed with urine culture in
the past 8 months. She has been started on cefalexin for prophylaxis. A kidney ureter
bladder X-ray has been performed and no renal stones were identified. Ultrasound of
the kidneys and ureter show no evidence of hydronephrosis or renal stones. Post
1561
voiding residual volume is minimal on a bladder ultrasound. What is the SINGLE most
A. Cystoscopy
C. Low vaginal swab
D. Repeat MSU culture and sensitivity
E. Dimercaptosuccinic acid (DMSA) scanning
Flexible cystoscopy would be the next investigation looking for possible causes of
recurrent urinary tract infections.
Recurrent urinary tract infection in adults

- Recurrent UTI is defined as more than 2 infections in 6 months or 3 within 12
months
- Most commonly caused by reinfection with the original bacterial isolate
- Escherichia coli is the most common organism in all patient groups
- There is often an underlying functional or anatomical problem and infection will
y
often not resolve until this has been corrected
Causes of recurrent UTIs

- Incomplete bladder emptying
op
C
- Renal or bladder stones
- Indwelling catheter
- Chronic bacterial prostatitis
n
- Vesicovaginal or colovesical fistula
io
- Bacteria within an obstructed or atrophic infected kidney

t
Presentation
ua
- Dysuria
- Frequency
- Urgency
al
- Suprapubic pain or discomfort

- Cloudy foul-smelling urine
Ev
Investigations
- MSU microscopy and culture
- KUB X-ray to detect radio-opaque renal calculi
- Renal and bladder ultrasound
o Looking for renal stones
o To determine the presence or absence of hydronephrosis
o To measure pre-void bladder volume and postvoid residual urine
volume
- Flexible cystoscopy to identify abnormalities that may cause recurrent UTIs
such as bladder stones, an underlying bladder cancer which is rare, urethral or
bladder neck stricture, or fistula
Recurrent cystitis in a man is likely to be secondary to associated conditions like

prostatitis, prostatic hyperplasia, calculi in the genitourinary tract, or vesicoureteric
reflux.
1562
Management
- Fix any underlying functional or anatomical abnormality if identified
- Low-dose antibiotic prophylaxis → Usually trimethoprim, nitrofurantoin or
cephalexin
- If there is residual urine present → optimize bladder emptying by intermittent
catheterization
- Oestrogen replacement in post-menopausal women → lack of oestrogen in
post-menopausal women causes loss of vaginal lactobacilli and increased
colonization by Escherichia coli
-
46. A 33 year old woman complains of having urinary urgency for the past year. She
urinates more than 8 times a day. She gives a history of having suprapubic pain if her
bladder is full, resulting in the need to urinate frequently as suprapubic pain is relieved
by voiding. A urine culture was sent and results have come back negative. On
cystoscopy, Hunner's ulcers were seen on the bladder wall. What is the SINGLE most
likely diagnosis?
A. Endometriosis
y
B. Sexually transmitted infection
op
C. Overactive bladder
D. Bladder cancer
E. Interstitial cystitis
C
Interstitial cystitis (Bladder pain syndrome)
- A chronic and debilitating disorder characterized by urinary frequency, urgency,
n
nocturia, and suprapubic or pelvic pain
io
- Remains a diagnosis of exclusion after all other causes for the symptoms have
been ruled out
t
- The term 'interstitial cystitis' is usually reserved for patients with typical
ua
cystoscopic features
Presentation
al
- Persistent or recurrent pain perceived in the urinary bladder region

- Suprapubic pain worsening with bladder filling
Ev
- Pain relieved by voiding but returns when bladder fills again

- Urinary frequency and urgency
- In women the symptoms are often worse during menstruation
It presents in a similar fashion to symptoms of a urinary tract infection (urgency,

frequency, dysuria, suprapubic pain). This is why it is important to send a midstream
urine for urine cultures to rule out a UTI.
Investigations
- Cystoscopy for the sole reason of excluding bladder malignancy:
o Around 10% of people with interstitial cystitis have Hunner's ulcers.
They are reddened mucosal areas associated with small vessels
radiating towards a central scar
Management
- First line
o Bladder training
1563
o Pelvic floor relaxation techniques (avoid pelvic floor exercises)
o Avoid triggers like coffee, citrus fruits, smoking which can exacerbate
symptoms
o Analgesics such as NSAIDS
- Second-line
o Amitriptyline →has anticholinergic effects
o Oxybutynin
o Gabapentin
Other management unlikely to be asked at this stage
y
op
C
n
t io
ua
al
Ev
1564
VASCULAR SURGERY
y
op
C
Questions
n
io
&
t
ua
Answers
al
Ev
1565
VASCULAR SURGERY
1) A 60 year old presents with non-healing ulcers on his calves and a cramp-like pain in
the calves relieved by rest. His past medical history includes hypertension, diabetes,
and hypercholesterolemia. He also smokes 15 cigarettes a day. Physical examination
shows cold extremities absent distal pulses. Which SINGLE advice is unlikely to
prevent disease progression?
A. Quit smoking
B. Treat hypertension
C. Treat high cholesterol
D. Exercise
y
E. Omega 3 oils
2) op
A 62 year old man has a painless swelling on his groin. On examination, the mass lies
C
below the midpoint of the right inguinal ligament and is pulsatile. What is the
n
io
A. Direct inguinal hernia

t
B. Indirect inguinal hernia

ua
C. Femoral hernia
D. Saphena varix
E. Femoral artery aneurysm
al
Ev
3) A 40 year old heavy smoker presents with pain in the calves relieved by rest. These
symptoms have been worsening over the last few months. He has a history of
hypertension which is well controlled with medication. His distal pulses are difficult
to palpate. What is the SINGLE most likely diagnosis?
A. Acute limb ischaemia

B. Diabetes Mellitus
D. Deep vein thrombosis
E. Varicose veins
1566
4) A 76 year old man suddenly collapsed and died. At post mortem exam, a
retroperitoneal haematoma was found due to ruptured abdominal aortic aneurysm.
What is the SINGLE most likely underlying aetiology of the aortic aneurysm?
A. Atheroma
B. Cystic medial necrosis
C. Marfan's syndrome
E. Syphilis
5) A 27 year old man complains of headaches, nose bleeds and pain in the lower limbs
on exertion. A radio-femoral delay was noted on examination. His legs are cold and
his femoral pulse is difficult to feel. Auscultation reveals a systolic murmur heard in
y
the left infraclavicular area. What is the SINGLE most likely diagnosis?
A. Tetralogy of Fallot (TOF)

op
C
B. Atrial septal defect (ASD)
C. Ventricular Septal Defect (VSD)
n
D. Patent ductus arteriosus
E. Coarctation of the aorta
t io
ua
6) A 68 year old man gets repeated attacks of loss of consciousness and transient
ischaemic attacks (TIA). What is the SINGLE most likely cause for his symptoms?
al
Ev
A. Atrial fibrillation
B. Mitral stenosis
C. Aortic stenosis
D. Hypertrophic Obstructive Cardiomyopathy
E. Carotid artery stenosis
1567
7) A 55 year old smoker presents to the emergency department with complaint of
severe left leg and foot pain that began earlier in the day. The pain spreads to the
level just above the the inguinal ligament. His past medical history includes
hypertension. On examination, he has atrophic skin changes in his left leg and his
left limb is cold to touch. He has no palpable pulses in the left lower extremity.
Gross motor and sensory functions were intact in the symptomatic leg and foot.
What is the SINGLE most likely occluded artery?
A. Left femoro-popliteal artery

B. Left common iliac artery
C. Aortoiliac artery
D. Left femoral artery
E. Left deep femoral artery
y
op
8) A 60 year old diabetic presents with non-healing ulcers on his calves and a cramp-
like pain in the calves relieved by rest. He does not smoke but has a history of
hypertension which is well controlled with medication. Physical examination shows
C
cold extremities with lack of hair around the ankles and absent distal pulses. What is
n
io

B. Peripheral arterial disease (PAD)
t
ua
E. Varicose veins
al
Ev
9) A 38 year old woman presents with a blood pressure of 160/90 mmHg. She is
otherwise asymptomatic. Ultrasound scan of kidneys reveal kidneys of equally
reduced size with smooth borders and normal pelvicalyceal system. What is the
SINGLE most likely cause of her hypertension?
A. Chronic glomerulonephritis
C. Bilateral renal artery stenosis
D. Essential hypertension
E. Polycystic kidney disease
1568
10) A 44 year old man has sudden severe crushing chest pain radiating to both
shoulders and his back. The pain is accompanied by shortness of breath. He is
sweating profusely. There was no history of trauma. Examination shows cold
peripheries. He is noted to have disproportionately long, slender limbs and long
fingers and toes. What is the SINGLE most appropriate diagnosis?
A. Myocardial infarction
B. Thoracic aortic dissection
C. Pulmonary embolism
D. Oesophageal perforation
11) A 49 year old man presents with a BP of 160/95 mmHg. He is otherwise

asymptomatic. His renal function declined severely after starting ACE inhibitors.
y
What is the SINGLE most likely cause of his hypertension?
op
C
B. Pheochromocytoma
n
t io
ua
12) A 55 year old man comes to the emergency department with severe abdominal pain
and lower back pain. He has a history of a pulsatile swelling in the abdomen. He has
a pulse rate of 125 beats/minute and a blood pressure of 70/40 mmHg. What is the
al

Ev
A. Urgent abdominal computed tomography

B. Urgent abdominal ultrasound
C. Intravenous fluids 0.9% normal saline to bring systolic blood pressure to 90
mmHg
D. Intravenous fluids 0.9% normal saline to bring systolic blood pressure to 120
mmHg
E. Dopamine intramuscular injection
1569
13) A 60 year old man has sudden severe chest pain radiating to both shoulders and
accompanied by shortness of breath. There was no history of trauma. His medical
history includes hypertension. Examination shows cold peripheries and paraplegia.
What is the SINGLE most appropriate diagnosis?
14) A 28 year old construction worker was admitted for pain in his right calf while at
work which has been increasing over the last 3 months. There is no history of
y
hypertension or diabetes but he is a smoker. On examination, loss of posterior tibial
op
and dorsalis pedis pulsation was noticed along with a non-healing ulcer at the base
of the right 1st metacarpophalangeal joint. What is the SINGLE most probable
diagnosis?
C
n
A. Thromboangiitis obliterans
B. Sciatica
io
C. Deep venous thrombosis

D. Baker’s cyst
t
ua
E. Embolus
al
15) A 70 year old man presents with an acutely painful, pale paralysed and pulseless left
Ev
leg. He is noted to have an atrial fibrillation that was diagnosed recently. What is the
A. Peripheral vascular disease

B. Cardiovascular syphilis
D. Aortic dissection
E. Acute limb ischaemia
1570
16) A 78 year old man has a painless sudden collapse. His pulse is 120 beats/minute,
blood pressure of 70/40 mmHg. Examination reveals a mottled skin of the lower
body and a pulsatile abdominal mass. What is the SINGLE most likely diagnosis?
A. Aortic aneurysm
B. Mesenteric cyst
C. Umbilical hernia
D. Ureteric colic
E. Gastrointestinal perforation
y
op
C
n
t io
ua
al
Ev
1571
VASCULAR SURGERY
1) A 60 year old presents with non-healing ulcers on his calves and a cramp-like pain in the
calves relieved by rest. His past medical history includes hypertension, diabetes, and
hypercholesterolemia. He also smokes 15 cigarettes a day. Physical examination shows cold
extremities absent distal pulses. Which SINGLE advice is unlikely to prevent disease
progression?
A. Quit smoking
B. Treat hypertension
C. Treat high cholesterol
D. Exercise
E. Omega 3 oils
The diagnosis here is clear → Peripheral arterial disease. The history of intermittent
y
claudications and non-healing ulcers are key features of it.
op
Quit smoking is vital. Treat hypertension and high cholesterol. And encourage patients to
exercise to the point of maximal pain
C
Peripheral arterial disease (PAD)
n
Peripheral arterial disease (PAD) occurs due to atherosclerosis causing stenosis of arteries.
io
This leads to intermittent claudication. Pain comes on walking and after a short rest it goes
away.
t
ua
Symptoms
• Cramping pain is felt in the calf, thigh, or buttock after walking for a given distance
al
and relieved by rest (Intermittent claudication).

• Ulceration, gangrene, and foot pain at rest
• Young, heavy smokers are at risk from Buerger’s disease (thromboangiitis
Ev
obliterans)
Signs
• Absent femoral, popliteal or foot pulses
Risk factors:
• Hypertension
• Diabetes Mellitus
• Smoking
• High cholesterol
Investigations
• Ankle–brachial pressure index (ABPI)
• Colour duplex USS - 1st line
• MR/CT angiography → Only If considering intervention →used to assess extent and
location of stenoses and quality of distal vessels. It has largely replaced digital
subtraction angiography.
1572
Management:
• Risk factor modi?cation: Quit smoking (vital). Treat hypertension and high
cholesterol. Prescribe an antiplatelet agent to prevent progression and to reduce
cardiovascular risk. Clopidogrel is recommended as 1st-line.
• Encourage patients to exercise to the point of maximal pain
• Naftidrofuryl oxalate, offer modest bene?t and are recommended only in those who
do not wish to undergo revascularization and if exercise fails to improve symptoms
If severely affecting patient's life and disease limited to a single arterial segment
→ Percutaneous transluminal angioplasty (PTA) (a balloon is in?ated in the narrowed
segment).
If severely affecting patient's life and atheromatous disease is extensive but distal run-off is
good (i.e. distal arteries ?lled by collateral vessels)
→Surgical reconstruction: consider arterial reconstruction with a bypass graft
One of the important differential diagnosis is thromboangiitis obliterans (Buerger's disease)
y
→ usually in young men around 40 years with strong smoking history.
Thromboangiitis obliterans (Buerger's disease):

op
C
• Involves small vessels of the lower limbs and occurs in young men who smoke.
• It is thought by some workers to be indistinguishable from atheromatous disease.
• However, pathologically there is inflammation of the arteries and sometimes veins
n
that may indicate a separate disease entity.
io
• Clinically, it presents with severe claudication and rest pain.

• Treatment is as for all peripheral vascular disease, but patients must stop smoking.
t
ua
2) A 62 year old man has a painless swelling on his groin. On examination, the mass lies below
the midpoint of the right inguinal ligament and is pulsatile. What is the SINGLE most likely
al
diagnosis?
Ev
A. Direct inguinal hernia

B. Indirect inguinal hernia
C. Femoral hernia
D. Saphena varix
E. Femoral artery aneurysm
The two top differentials here are femoral artery aneurysm and femoral hernia. As the mass
is pulsatile, it can only be a femoral artery aneurysm. A femoral hernia appears below and
lateral to pubic tubercle, medial to femoral pulse and it is not pulsatile.
Femoral artery aneurysm

• A less common type of aneurysm
• Rarely symptomatic
• Usually discovered on routine examination by physician
• May experience a pulsating lump or swelling on thigh or radiating pain
1573
• Rarely causes numbness in legs due to nerve compression
3) A 40 year old heavy smoker presents with pain in the calves relieved by rest. These
symptoms have been worsening over the last few months. He has a history of hypertension
which is well controlled with medication. His distal pulses are difficult to palpate. What is

B. Diabetes Mellitus
E. Varicose veins
The diagnosis here is thromboangiitis obliterans (Buerger's disease). It usually presents in

young men around 40 years with strong smoking history.
Thromboangiitis obliterans (Buerger's disease):
y
Involves small vessels of the lower limbs and occurs in young men who smoke. It is thought
op
by some workers to be indistinguishable from atheromatous disease. However,
pathologically there is inflammation of the arteries and sometimes veins that may indicate a
separate disease entity. Clinically, it presents with severe claudication and rest pain.
C
Treatment is as for all peripheral vascular disease, but patients must stop smoking.
4) A 76 year old man suddenly collapsed and died. At post mortem exam, a retroperitoneal
n
haematoma was found due to ruptured abdominal aortic aneurysm. What is the SINGLE
io
most likely underlying aetiology of the aortic aneurysm?

t
A. Atheroma
ua
B. Cystic medial necrosis

C. Marfan's syndrome
al
E. Syphilis
Ev
There are many causes of aortic aneurysm but the most typical cause of an aortic aneurysm
is atheroma.
Abdominal Aortic Aneurysms Aetiology/Risk factors:

• Severe atherosclerotic damage of the aortic wall
• Family history
• Male sex
• Increasing age
• Hypertension, smoking
• Syphilis
• Ehlers Danlos
• Marfan's syndrome
1574
5) A 27 year old man complains of headaches, nose bleeds and pain in the lower limbs on
exertion. A radio-femoral delay was noted on examination. His legs are cold and his femoral
pulse is difficult to feel. Auscultation reveals a systolic murmur heard in the left
infraclavicular area. What is the SINGLE most likely diagnosis?
A. Tetralogy of Fallot (TOF)

B. Atrial septal defect (ASD)
C. Ventricular Septal Defect (VSD)
D. Patent ductus arteriosus
E. Coarctation of the aorta
This is a typical late presentation of coarctation of the aorta.
• Coarctation of the aorta:

If coarctation of the aorta presents late, the patients are usually asymptomatic and
the diagnosis is usually made on examination, prompted often by the presence of a
murmur or hypertension.
y
• It can cause headache, nosebleeds and leg cramps, particularly with exercise,
op
although claudication is unusual.
• BP is high in the arms and low in the legs. This high BP results in epistaxis
(nosebleeds)
C
• Lower-limb muscle weakness, or cold feet (poor blood supply) may be the presenting
feature
n
• Pulses distal to the obstruction are diminished and delayed. E.g. Femoral pulses are
hard to feel, absent foot pulses
io
• Auscultation reveals a systolic or continuous murmur, usually heard in the left

infraclavicular area and under the left scapula.
t
ua
6) A 68 year old man gets repeated attacks of loss of consciousness and transient ischaemic
attacks (TIA). What is the SINGLE most likely cause for his symptoms?
al
A. Atrial fibrillation
Ev
B. Mitral stenosis
C. Aortic stenosis
D. Hypertrophic Obstructive Cardiomyopathy
E. Carotid artery stenosis
Carotid artery stenosis would fit this picture perfectly.
The plaque can be stable. As the vessel gets smaller, they can lodge in the vessel wall and
restrict blood flow to parts of the brain which that vessel supplies. This ischaemia can either
be temporary, yielding a transient ischemic attack, or permanent resulting in a
thromboembolic stroke. In this case it caused a TIA and loss of consciousness.
7) A 55 year old smoker presents to the emergency department with complaint of severe left
leg and foot pain that began earlier in the day. The pain spreads to the level just above the
the inguinal ligament. His past medical history includes hypertension. On examination, he
has atrophic skin changes in his left leg and his left limb is cold to touch. He has no palpable
1575
pulses in the left lower extremity. Gross motor and sensory functions were intact in the
symptomatic leg and foot. What is the SINGLE most likely occluded artery?
A. Left femoro-popliteal artery

B. Left common iliac artery
C. Aortoiliac artery
D. Left femoral artery
E. Left deep femoral artery
The answer here is left common iliac artery. Femoral artery and deep femoral artery is less
likely as the pain would start below the inguinal ligament. The external iliac artery becomes
the femoral artery after it passes under the inguinal ligament. Hence the occlusion would be
above the inguinal ligament.
If it was a femoro-popliteal artery occlusion, the pain would be described below the knee.
The option of aorto-iliac artery occlusion is not specific as it does not state if it is right or left.
y
It would also have symptoms of claudication and pain of the buttocks and thighs. Symptoms
op
of erectile dysfunction can also be seen in aorto-iliac artery occlusion.
The ideal answer would actually be an external iliac artery occlusion as there are no
C
symptoms of gluteal pain in the stem. The common iliac bifurcates into internal and external
iliac arteries and since there is no mention of symptoms of internal iliac artery obstruction in
the stem, an external iliac artery occlusion would actually be the best option if it was given
n
in the exam. However, since it is not an option given, common iliac artery occlusion falls into
io
first place as the answer.

t
Remember, symptoms of occlusion has to occur distal to the level of occlusion.

ua
8) A 60 year old diabetic presents with non-healing ulcers on his calves and a cramp-like pain
in the calves relieved by rest. He does not smoke but has a history of hypertension which is
al
well controlled with medication. Physical examination shows cold extremities with lack of
hair around the ankles and absent distal pulses. What is the SINGLE most likely diagnosis?
Ev

B. Peripheral arterial disease (PAD)
E. Varicose veins
The diagnosis here is clear → Peripheral arterial disease. The history of intermittent
claudications and non-healing ulcers are key features of it.
The other options are quite unlikely:

Acute limb ischaemia
→ is acute! The 6 ‘P’S of acute ischaemia: pale, pulseless, painful, paralysed, paraesthetic,
and ‘perishingly cold’.
Buerger’s disease
1576
→ Needs a history of smoking

→ Pain or tenderness is constant and not of an intermittent claudication pattern. Also does
not present with non-healing ulcers
Varicose veins
→ Do not have an intermittent claudication pattern pain. They usually come in saying “My
legs are ugly”
9) A 38 year old woman presents with a blood pressure of 160/90 mmHg. She is otherwise
asymptomatic. Ultrasound scan of kidneys reveal kidneys of equally reduced size with
smooth borders and normal pelvicalyceal system. What is the SINGLE most likely cause of
her hypertension?
y
op
C
The likely diagnosis here is fibromuscular dysplasia which is a form of renovascular disease.
Often fibromuscular dysplasia involves both renal arteries and usually presents with a high
blood pressure resistent to treatment. The patients are otherwise asymptomatic.
n
io
Atrophic kidney or discrepancy in kidney sizes are clues that give off the diagnosis of renal
artery stenosis. No mention was given regarding the discrepancy in kidney size in this stem,
t
likely because both renal arteries are stenosed rather than just one.
ua
Renovascular disease
al
• Defined as stenosis of the renal artery or one of its branches

Ev
The two main causes are atherosclerosis and fibromuscular dysplasia.
Signs
• BP resistant to treatment
• Worsening renal function after ACE-i/ARB in bilateral renal artery stenosis
Tests
• Ultrasound scan shows:
o Renal size asymmetry (affected side is smaller)
o Disturbance in renal blood flow on Doppler US
• CT/MR angiography are more sensitive
• Renal angiography is ‘gold standard’, but perform only after CT/MR angiography as
it is invasive
1577
Treatment:
• Comprehensive antihypertensive regimens
• Transluminal angioplasty and stent placement or revascularization surgery
Note: Severe decline in renal function may be observed in patients with bilateral renal artery
stenosis after initiation of ACE inhibitors.
10) A 44 year old man has sudden severe crushing chest pain radiating to both shoulders and
his back. The pain is accompanied by shortness of breath. He is sweating profusely. There
was no history of trauma. Examination shows cold peripheries. He is noted to have
disproportionately long, slender limbs and long fingers and toes. What is the SINGLE most
y
op
C
The signs and symptoms in this stem points towards an aortic dissection. The majority of
n
patients with aortic dissection, present with a sudden severe pain of the chest or back,
io
classically described as 'ripping'. The cold peripheries are due to reduced blood flow to distal
parts of dissection. Disproportionately long, slender limbs and long fingers and toes given in
t
this stem is a hint that he probably has Marfan syndrome which is an added risk factor
ua
towards aortic dissection.
Sometimes PLAB questions would also give a difference in blood pressure in limbs on the
al
right and left side of the body.

Ev
Thoracic Aortic Dissection - Dissecting aneurysm of the thoracic aorta:
Occurs in the poorly controlled hypertensive. The episode resembles an Ml, with sudden
onset of extremely severe, tearing chest pain that radiates to the back and migrates down
shortly after its onset. There may be unequal pulses in the upper extremities, and x-ray
shows a wide mediastinum. ECG and cardiac enzymes rule out Ml. Definitive diagnosis
should be sought by noninvasive means (to avoid high-pressure injection needed for the
aortogram). MRI angiogram and transesophageal echocardiogram have been used, but the
best option is probably a spiral CT scan. As a rule (riddled with exceptions), dissections of the
ascending aorta are treated surgically, whereas those in the descending are managed
medically with control of the hypertension in the ICU.
Stanford classification
Type A
• ascending aorta, 2/3 of cases
1578
• surgical management, but blood pressure should be controlled to a target systolic of
100-120 mmHg whilst awaiting intervention
Type B
• descending aorta, distal to left subclavian origin, 1/3 of cases
• conservative management
• bed rest
• reduce blood pressure IV labetalol to prevent progression
DeBakey classification
Type I
• originates in ascending aorta, propagates to at least the aortic arch and possibly
beyond it distally
Type II
• originates in and is confined to the ascending aorta
Type III
y
• originates in descending aorta, rarely extends proximally but will extend distally
Risk factors
op
C
• Approximately 50-75% of patients with dissection will have evidence of hypertension
or a previous diagnosis
• Other risk factors include smoking and raised cholesterol. The most common risk
n
factor is hypertension
io
• Inherited risks include Marfan's syndrome, Ehlers-Danlos syndrome and familial

thoracic aortic aneurysm
t
ua
11) A 49 year old man presents with a BP of 160/95 mmHg. He is otherwise asymptomatic. His
renal function declined severely after starting ACE inhibitors. What is the SINGLE most likely
al
cause of his hypertension?

Ev
B. Pheochromocytoma
Renovascular disease:
Renovascular disease is defined as stenosis of the renal artery or one of its
Branches.
The two main causes are atherosclerosis and fibromuscular dysplasia.
Signs: BP resistant to treatment; worsening renal function after ACE-i/ARB in bilateral renal
artery stenosis
1579
Tests:
USS: renal size asymmetry (affected side is smaller), disturbance in renal blood flow on
Doppler US.
CT/MR angiography are more sensitive.
Renal angiography is ‘gold standard’, but do after CT/MR as it is invasive
Treatment:
Comprehensive antihypertensive regimens, transluminal angioplasty ± stent placement or
revascularization surgery.
Note: Severe decline in renal function may be observed in patients with bilateral renal artery
stenosis after initiation of ACE inhibitors.
y
12) A 55 year old man comes to the emergency department with severe abdominal pain and
op
lower back pain. He has a history of a pulsatile swelling in the abdomen. He has a pulse rate
of 125 beats/minute and a blood pressure of 70/40 mmHg. What is the SINGLE most
C
A. Urgent abdominal computed tomography
B. Urgent abdominal ultrasound
n
C. Intravenous fluids 0.9% normal saline to bring systolic blood pressure to 90 mmHg
io
D. Intravenous fluids 0.9% normal saline to bring systolic blood pressure to 120 mmHg
E. Dopamine intramuscular injection
t
ua
This scenario describes a ruptured aortic aneurism. Immediate intravenous normal saline to
raise the blood pressure to 90 mmHg to keep the vital organs perfused till definitive
al
measures are taken. The idea here is to treat major hypovolaemia, but accept moderate
degrees of hypotension which is a systolic BP > 90 mmHg.
Ev
In such a given case, assume that the problem is a ruptured abdominal aortic aneurysm and
commence resuscitative measures, whilst appropriate experts are summoned and relevant
emergency confirmatory investigations like an ultrasound or CT scans are performed
13) A 60 year old man has sudden severe chest pain radiating to both shoulders and
accompanied by shortness of breath. There was no history of trauma. His medical history
includes hypertension. Examination shows cold peripheries and paraplegia. What is the
1580
This is a typical patient. A man in his 60s with hypertension and sudden onset of chest pain.
The majority of patients with aortic dissection, present with a sudden severe pain of the
chest or back, classically described as 'ripping'. The cold peripheries are due to reduced
blood flow to distal parts of dissection. Paraplegia is due to involvement of the spinal
arteries. Sometimes PLAB questions would also give a difference in blood pressure in limbs
on the right and left side of the body.
14) A 28 year old construction worker was admitted for pain in his right calf while at work
which has been increasing over the last 3 months. There is no history of hypertension or
diabetes but he is a smoker. On examination, loss of posterior tibial and dorsalis pedis
pulsation was noticed along with a non-healing ulcer at the base of the right 1st
metacarpophalangeal joint. What is the SINGLE most probable diagnosis?
A. Thromboangiitis obliterans
B. Sciatica
C. Deep venous thrombosis
y
D. Baker’s cyst
op
E. Embolus
C
The diagnosis here is thromboangiitis obliterans (Buerger's disease). It usually presents in
young men around 40 years with strong smoking history. This particular question might be a
little confusing and some might argue that an embolus could have cause an acute limb
n
ischaemia causing admission. But given his young age, smoking history, chronic pain that
io
was increasing over a long period, and a non healing ulcer, Buerger’s disease fits better.
t
15) A 70 year old man presents with an acutely painful, pale paralysed and pulseless left leg. He
ua
is noted to have an atrial fibrillation that was diagnosed recently. What is the SINGLE most
likely diagnosis?
al
A. Peripheral vascular disease

B. Cardiovascular syphilis
Ev
D. Aortic dissection
E. Acute limb ischaemia
Acute limb ischaemia:

Is a surgical emergency requiring revascularization within 4 to 8 hours to save the limb. It is
usually due to thrombosis in situ, emboli or graft occlusion.
Emboli commonly arise from the heart (Atrial fibrillation; mural thrombus) or aneurysms.
Symptoms and signs:

The 6 ‘P’S of acute ischaemia: pale, pulseless, painful, paralysed, paraesthetic, and
‘perishingly cold’.
In patients with known peripheral arterial disease (PAD), sudden deterioration of symptoms
with deep duskiness of the limb may indicate acute arterial occlusion.
1581
Management:
This is an emergency and may require urgent open surgery or angioplasty
16) A 78 year old man has a painless sudden collapse. His pulse is 120 beats/minute, blood
pressure of 70/40 mmHg. Examination reveals a mottled skin of the lower body and a
pulsatile abdominal mass. What is the SINGLE most likely diagnosis?
A. Aortic aneurysm
B. Mesenteric cyst
C. Umbilical hernia
D. Ureteric colic
E. Gastrointestinal perforation
A “pulsatile abdominal mass” is the key phrase for abdominal aortic aneurysm. One should
be able to answer this in less than 3 seconds.
y
op
C
n
t io
ua
al
Ev
1582

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13 Infectious Diseases 698

6. Which artery descends into the anterior interventricular groove?

anatomical structure to be affected?

Common peroneal nerve

Branch of ulnar nerve

Flexor digitorum profundus

Submental lymph node

Common peroneal nerve

Medial plantar nerve

Abductor pollicis longus

Deep inguinal ring

Deep peroneal nerve (Deep fibular nerve)

a. Lower motor neuron lesions- Polio, syringomyelia.

6) Which artery descends into the anterior interventricular groove?

Chest drain Insertion Technique

Chest insertion should be performed ideally within “safe triangle”

By inserting at the safe triangle, we avoid major vessels and muscles.

tends to separate the fingers as it extends them.

Common peroneal nerve

Extensor pollicis brevis

Radial nerve (C5–T1)

Wrist drop → Radial nerve

Foot drop → Either common peroneal nerve or sciatic nerve

Fibular neck fracture → Common peroneal nerve

Femur neck fracture or Acetabular fractures → Sciatic nerve

Fracture of humeral shaft → Likely Radial nerve

Fracture of humeral neck → Likely Axillary nerve

Monteggia fracture → Radial nerve

External iliac lymph node

Chest drain Insertion technique

Chest insertion should be performed ideally within “safe triangle”

By inserting at the safe triangle, we avoid major vessels and muscles

Rest usually relieves symptoms.

Proximal biceps tendon rupture:

Distal biceps tendon rupture:

Nerves involving the eye:

CN III - Oculomotor nerve:

The simple method to remember this for the exam is:

Another Mnemonic is:

Lateral rectus - 6th Nerve

Peroneal nerve injury:

fracture, the pressure of a splint or during surgical repair.

Monteggia fracture → Radial nerve

Common peroneal nerve

foot, and extend the digits.

Full extension of right thumb is achieved by extensor pollicis longus.

Nerves involving the eye

CN III - Oculomotor nerve

Nerves involving the eye

Lateral rectus muscle

Statin and Warfarin

Statin and ACE inhibitor

Mitral valve prolapse

Transposition of great arteries

Atrial septal defect

Third degree heart block

Computed tomography scan of the chest

Angiotensin II receptor blockers

Plab Lab Values

Calcium channel blockers

investigation to be carried out?

Blood pressure monitoring