YEAR 4 PAPER 3 FORMATIVE

Qu1)
A 26yr old female presents to her GP with a pigmented lesion on her face. She admits
to frequent use of sun beds and to sunbathing. She is concerned that the lesion might
be cancer.
1. What symptoms might suggest a melanoma! "2#
Any change in si$e%shape%colour
&tching
'leeding%discharge
2. What clinical signs might increase your suspicion! "2#
Asymm. 'order
&rregular border
(iameter ) 6mm
Satellite lesions
.
*. Gi+e 2 benign differentials! "2#
,elanocytic %nae+us
Seborrhoeic -eratosis
. .ou suspect the lesion is a melanoma. As her GP/ what is your most appropriate
management! "1#
0efer using 2 wee- rule to dermatologist% plastic surgeon
1. 2he lesion has a 'reslow thic-ness of 3.4mm. What is 'reslow thic-ness used for!
"2#
5sed to determine prognosis
5sed for planning surgery
6. Gi+e 2 effects of sun e6posure on the s-in! "2#
(estruction of elastic tissue
7oss of s-in immune function
(irect cellular damage of (8A
9it ( production
Premature ageing
Qu2)
.ou see a 3yr old female who is 12w-s pregnant. She is a smo-er/ has a history of
hypertension and gestational diabetes. She has pre+iously had a caesarean section for
a breech presentation.
1. What feature in the :6 puts her at increased ris- of ha+ing a baby with
(own;s! "1#
,aternal age
2. What is the genetic abnormality in (own;s! "1#
2risomy 21
*. Gi+e * different screening tests for (own;s and the gestation at which they are
performed. "6#
nuchal translucency scan < 12 wee-s
triple test < 11 wee-s
anomaly scan < 23 wee-s
. What 2 in+asi+e procedures are used to identify (own;s! "2#
Amniocentesis and =9S
QU 3)
.ou see a 2yr old/ who is pregnant for the first time. She is 12%3. 2he 5SS shows
mono>chorionic/ diamniotic twins.
1. What * complications are these foetuses at higher ris- of than singletons! "*#
twin to twin transfusion%&5G0% S5((?8 &820A52?0&8? (?A2:%
placental abruption% preterm deli+ery
2. What * complications is the mother at more ris- of than in singleton
pregnancies! "*#
pre>eclampsia/ P&:/ PP:/ thrombosis/ fetal distress% anaemia% cholestasis
At *6%3 "2w-s later#/ she is admitted with regular contraction *mins apart. She is
cm dilated/ but membranes are still intact. 2he presenting twin is breech.
*. After weighing up the ris-s and benefits/ would you gi+e tocolytics! Why!
8@ < because ris- of 0(S low at *6 wee-s
. What is the safest mode of deli+ery for the twins! "1#
=> section
1. What is the safest mode of deli+ery for the mother! "1#
9aginal deli+ery
Quip 4)
A 41yr old man was diagnosed with a non>small cell lung =a *months ago. :e has a
moderate performance status. :e recei+ed 1 fractions of 02.
:e presents acutely with S@'.
1. Gi+e * differentials for his S@'.
,ass effect of lung cancer < worsening of lung =a
P?
Pleural effusion
Pneumothora6
Pneumonia
2. What * therapeutic options would you gi+e him in AA?!
@2/ Ab6/ an6iolytics/ ,orphine/ 0eassurance/ breathing e6ercises
:e impro+es with your treatment and is discharged. 6 wee-s later/ he presents with
thoracic bac- pain and leg wea-ness.
*. Gi+e 2 other symptoms you would want to chec- for.
7oss of sensation in legs%body
5rinary problems%faecal problems!
. What is the possible cause!
Spinal cord compression
1. What is your in+estigation of choice!
,0&
Qu 5)
A 64yr old female with breast =a diagnosed four yrs ago. She had a 7eft mastectomy
and chemo/ but has since deteriorated/ de+eloping brain and bone mets.
1. What 2 important medical inter+entions can be discontinued when a patient is
dying!
discontinue inappropriate blood tests
B B B inter+entions
re+iew unnecessary inter+entions
2. What * non>physical aspects of care must be considered when dealing with a dying
patient!
spiritual/ psychological/ social/ religious
*. Gi+e 2 symptoms that are common in the terminal phase of illness. State a
medication that might be used to treat each.
pain < morphine
8 C 9 < cycli$ine%haloperiadol
Sedation < mida$oloam
Secretions < hyoscine
(yspnoea < morphine
. (ifferentiate between certification and +erification of death.
certification < is the documentation surrounding cause of death of patient.
=an be issued by someone medically qualified
erification < ensuring patient is dead < e6ternal e6amination only
QU !)
An 1Dyr old boy is shouting while alone in his room/ becoming increasingly isolated/
thin-s things are referring specifically to him/ may appear suspicious and his
con+ersation is becoming difficult to follow. :e has rapid changes in mood/ and is
becoming preoccupied with beliefs in occult A blac- magic. :e is also smo-ing
cannabis etc.
1. 7ist * symptoms in the history that are suggesti+e of psychosis.
Auditory hallucinations% thought alienation % delusions% persecutory ideas%
delusions of reference
2. Gi+e a differential/ stating your reasons.
(rug induced psychosis
,ental and beha+ioural disorders
Substance abuse < due to cannabis%multi drug use
@=(
(epressi+e psychosis
*. Gi+e a common and clinically rele+ant side effect of olan$apine.
&ncrease appetite%wgt gain%sedation%change in glucose
. Gi+e 2 ris- factors for suicide in an 1Dyr old male who self harms.
tolerance% increase in diabetes/ peripheral oedema
final acts < suicide note%putting finances in order
planned as opposed to impulsi+e act % attempts of concealment
Stated intent to die at time of o+erdose
1. :e refuses admission/ but you thin- he has a high suicide ris-. 5nder which
section of the ,:A should you admit him!
"ection 3 < -nown to ser+ices % diagnosis of schi$ophrenia
"ection 2 < @87. if assessed my medical emergency ser+ices with medical
records not a+ailable
QU #)
A 6Dyr old male is seen by his GP. :e is a non>smo-er who is usually fitAwell. :is
GP ma-es an incidental diagnosis of hypertension "213%113 or something#. :is blood
pressure was high 2yrs ago. @f note in his P,:/ he has had * episodes of renal colic.
1. What is the most li-ely cause of his hypertension! "1#
essential hypertension
2. What 2 blood tests would you use to estimate his 13yr =9 ris-! "2#
fasting glucose/ fasting lipids
*. What 2 in+estigations would you do to detect end>organ damage! "2#
:is bloods show raised calcium/ and raised A7P with low phosphate.
=E0/ ?=G/ 5 C ?/ urinalysis/ echo
. What;s your diagnosis now! "1#
Primary hyperparathyroidism
1. Gi+e 2 surgically correctable causes of hypertension. "2#
Phaeochromocytoma/ coarctation of aorta/ renal artery stenosis/ cons
syndrome "accept adrenal tumour#
6. 7ist 2 drugs that aggra+ate%cause hypertension. "2#
@ral pill
Steroids
9asopressin
8SA&(S
QU $)
A 13 yr old gentleman swallowed some bleach or something as a -id and now has an
oesophageal stricture. :e has a long history of indigestion and reflu6 for which he
ta-es antacids and a PP&. :e drin-s 13units%day and smo-es 23%day. :e reports a mth
:6 of decreased appetite/ weight loss of 2st and dysphagia. A malignant lesion is seen
in the lower oesophagus. :e is going to ha+e a thoracoabdominal
oesophagogastrectomy.
1. What pre>op in+estigations should he ha+e! "2#
=E0/ 7ung function tests/ ?=G/ F'=/ 5 C ?/ 7F2;S/ plasma protein and
calcium/ blood glucose
2. What 2 pre>op treatments might optimise post>op respiratory function! "2#
=hest physiotherapy with use of nebulisers and bronchodilators if necessary/
ensure no acute respiratory infection < if so treat with antibiotics
*. Which post>op analgesia regime would you discuss with him)
?pidural 9 P=A
. What special anaesthetic technique might be employed in order for the surgeon to
operate optimally! "1#
@ne lung anaesthesia
1. What are the common post>op complications after such surgery! "2#
=hest infection/ lung collapse/ pleural effusion/ P?
6. Which arrhythmia might occur post>op! Why! "2#
AF < due to haematoma formation at operati+e site which is near the left
atrium
QU%)
A 11yr old male has chest pain on e6ertion. :e is unemployed/ o+erweight/ drin-s
se+eral pints per night and smo-es 23%day.
1. What * signs would indicate &:( ris- factors! "*#
hypertension/ obesity/ 6anthelemata/ tendon 6anthomas/ arcus senilus/ gout/
retinal changes/ peripheral neuropathy
2. What * in+estigations would be done to chec- for &:( ris- factors! "*#
?=G/ 'lood glucose/ plasma lipids/ 7F2;S/ =E0/ 2F2;S
A diagnosis of angina is made.
*. What 2 further tests might you do to confirm this diagnosis! "2#
?6ercise test/ coronary angiogram
:e is started on aspirin/ sim+astatin and atenolol. 2wee-s later he is complaining of
swollen legsA feet/ lethargy and is aching all o+er.
. Which drugs might be responsible for which of these side>effects! "2#
Atenolol < 2iredness/ swollen an-les/ possibly heart failure
Sim+astatin < aching all o+er
&QU 1')
A 46yr old female presents with weight gain and lethargy. She is 163cm tall/ and
weighs G3-g. She had thyroto6icosis age 1 after the birth of a child.
1. What;s her ',& and comment on it! "2#
',1 H *1 H @bese
2. She has a hoarse +oice and dry s-in. What * other symptoms might she ha+e! "*#
She has high 2S: and low 2
=old intolerance/ depression/ constipation/ angina/ carpal tunnel syndrome
*. What;s the diagnosis!
:ypothyroidism
. Gi+e * other diseases associated with this condition. "*#
Pernicious anaemia/ S7?/ diabetes/ hyperparathyroidism/ prem. o+arian
failure/ Addison;s/ 0A/ SIrogens syndrome/ dementia
1. What are the dangers of starting thyro6ine at too high a dose!
Angina/ acute ,&/ palpitations/ cardiac arrhythmias