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BOF: 101
A 75-year-old male presents with lethargy and dizziness on standing !e gi"es a history
o# ha"ing had treatment #or t$%er&$losis when he was yo$ng
On e'amination he loo(s $nderweight) his s(in is pigmented and there is pigmentation o#
his %$&&al m$&osa and pigmentation o# the palmar &reases !is nipples and areola are
pigmented *here is no "itiligo !is %lood press$re is 1+0,70 lying down and -0,.0 on
!is %lood $rea 10/ mmol,0) 1a 1+0 mmol,0) 2 5- mmol,0
3hi&h o# the #ollowing in"estigations is most li(ely to identi#y the aetiology o# his
a5 0-00 A6*! le"el
%5 7hort syna&then test
&5 A%dominal 8-ray
d5 0ong A6*! stim$lation test
e5 7er$m aldosterone ,plasma renin a&ti"ity
*he patient has Addison9s disease 3ith the history o# t$%er&$losis the li(ely aetiology is
t$%er&$losis o# the adrenal gland and this may res$lt in &al&i#ied adrenals
BOF: 10+
A .0-year-old #emale is admitted with a history o# syn&opal episodes and %reathlessness
o# one-wee( d$ration 1o history o# immo%ilisation or re&ent tra"el
On e'amination she loo(s distressed her &on:$n&ti"a and tong$e are pale !er p$lse rate
is 1+0 %eats per min$te) %lood press$re -0,.0) ;<= ele"ated 5 &ms Respiratory rate +.
per min$te) ape' 5 0>67 ?60 heart so$nds triple rhythm) so#t systoli& m$rm$r at the le#t
sternal edge 0$ngs &lear
!B 1/5 g,d0
Blood gases p! 7@. =a 6O+ /+ (=a) =a O+ 77 (=a
*he ne't step in management o# this patient is:
a5 >mmediate throm%olysis #ollowed %y an A6!O to &on#irm the diagnosis
%5 >mmediate throm%olysis #ollowed %y &omp$terised tomographi& p$lmonary
angiography B6*=A5 to &on#irm the diagnosis
&5 >mmediate throm%olysis #ollowed %y "entilation per#$sion s&an to &on#irm the
d5 Crgent 6* p$lmonary angiography #ollowed %y throm%olysis
e5 F$ll dose #ragmin #ollowed %y "entilation per#$sion s&an
*he &lini&al #eat$res in this patient s$ggest massi"e &entral p$lmonary em%ol$s >t is %est
to o%tain an $rgent 6* =A or A6!O prior to throm%olysis >n a &ardia& arrest or peri-
arrest sit$ation it may %e :$sti#ia%le to throm%olyse the patient and &on#irm the diagnosis
%y 6*=A or A6!O i# the patient s$r"i"es
BOF: 10/
A 5+-year-old #emale presents with n$m%ness and wea(ness o# her $pper and lower
7he de"eloped asthma at the age o# 50 and her general pra&titioner treated her with
steroids and anti%ioti&s appro'imately one month prior to the onset o# these symptoms
On e'amination she loo(s $nwell 7he has palpa%le p$rp$ra o"er her #a&e and o"er her
el%ows and (nees
On ne$rologi&al e'amination she has a le#t sided wrist drop and there is wea(ness o#
dorsi#le'ion o# her right hall$' and wea(ness o# dorsi#le'ion o# her right #oot
7ensation is impaired o"er the dors$m o# her right #oot
0$ngs are &lear
68R is normal
!% 10- g,d0 ?6< DD #l
3B6 +/)000 10
Aosinophils 1+E
A16A negati"e
>n this patient a%dominal pain &o$ld %e d$e to:
a5 =an&reati& in#ar&tion
%5 Fall %ladder in#ar&tion
&5 <as&$litis o# the gastrointestinal tra&t
d5 Renal in#ar&tion
e5 7pleni& in#ar&tion
*he patient has 6h$rg-7tra$ss syndrome *he diagnosis may %e made on the %asis o# late
onset asthma) "as&$liti& rash and monone$ritis m$ltiple'
A16A is positi"e in appro'imately .0 E o# the patients hen&e a negati"e A16A does not
r$le o$t the diagnosis
>n this &ondition "as&$litis o# the gastrointestinal tra&t may res$lt in mass lesions that &a$
BOF: 10@
A @5-year-old #emale presents with an D-wee( history o# diarrhoea with no %lood or
m$&o$s) &oli&(y a%dominal pain) "omiting and loss o# weight o# 10 (gs
7he has a history o# appendi&etomy and has #i%romyalgia #or whi&h she has %een on
Di&lo#ena& 7R 75 mgs %d
On e'amination she was a#e%rile and loo(ed pale *he a%domen was di##$sely tender %$t
so#t Bowel so$nds were normal and re&tal e'amination was normal
>n"estigations showed:
!% 75 g,d0) ?6< 70 #l 6R= +/5) &oelia& s&reen negati"e
0F*s normal) $rea and ele&trolytes normal
6olonos&opy re"ealed se"eral we%s with s$per#i&ial $l&eration in the as&ending &olon
Biopsies #rom these areas showed non-spe&i#i& in#lammation
>n this patient) the most important aspe&t o# treatment is:
a5 Dis&ontin$e Di&lo#ena&
%5 *reat with 7teroids
&5 *reat with ?esalazine
d5 *reat with Azathioprine
e5 *reat with 6ipro#lo'a&in
*he patient has non-steroidal anti-in#lammatory dr$g &olopathy *his &an o&&$r a#ter
short or long term treatment with 17A>D7 *hese patients sho$ld %e warned against any
#$rther $se i# 17A>D7
BOF: 105
A /0-year-old #emale is $nder in"estigation #or e'&essi"e weight gain 7he is 1.+ m tall
and weighs D0 (gs 7he has &entral o%esity with a%dominal striae 7he is hirs$te
A de'amethasone s$ppression test has %een per#ormed and the res$lts are as #ollows:

6ortisol le"els nmol,0 De'amethasone
Day 0 0-00 --0 Dmgs
Day 1 0-00 /+0 Dmgs
Day + 0-00 1/0

*he patient has:
a5 6$shing9s disease
%5 Adrenal t$mo$r
&5 Bron&hial &ar&inoma
d5 7imple o%esity
e5 =oly&ysti& o"arian syndrome
>n the de'amethasone s$ppression test normal indi"id$als s$ppress &ortisol le"els to G 50
-0 E o# patients with pit$itary dependent disease s$ppress prod$&tion o# &ortisol to G 50
E o# that on day 0 on day H+
Fail$re o# s$ppression s$ggests e&topi& A6*! prod$&tion or adrenal t$mo$r
BOF: 10.
A 1@-year-old male has had a &ardia& &atheterisation to do&$ment the diagnosis o# an
a%normality o# his heart
*he res$lts are as #ollows:

6ham%er =ress$re in mm !g E O'ygen sat$ration
7$perior "ena
>n#erior "ena
Right atri$m 10 D+
+5,0 D1
+5,10 D1
0e#t atri$m 10 -.
0e#t "entri&le 110,0 -5
110,50 -5

>n this patient) on a$s&$ltation o# the heart one may hear:
a5 0o$d single se&ond heart so$nd
%5 7o#t single se&ond heart so$nd
&5 Fi'ed splitting o# the se&ond heart so$nd
d5 Re"ersed splitting o# the se&ond heart so$nd
e5 <arying split o# the se&ond heart so$nd
*he patient has an atrial septal de#e&t >n this &ondition #i'ed splitting o# the se&ond heart
so$nd o&&$rs
Atrial Septal Defect
BOF: 107
A @5-year-old #emale presents with %a&(a&he 7he has had a thyroide&tomy #or
thyroto'i&osis 1D months pre"io$sly 7he is a "egan
!er %lood res$lts are as #ollows:
!% 100 g,d0
6a 1D mmol,0
=O@ 07+ mmol,0
Al(aline phosphatase +00 C,0
Al%$min /. g,0
Crea .5 mmol,0
7odi$m 1@0 mmol,0
=otassi$m /D mmol,0
*he test that will de#ine this patient9s &ondition is:
a5 =*! le"el
%5 7er$m +5-hydro'y "itamin D/ le"el
&5 Crinary &al&i$m e'&retion
d5 Crinary phosphate e'&retion
e5 >lia& &rest %iopsy
*he patient has osteomala&ia with se&ondary hyperparathyroidism &a$sing low phosphate
Osteomalacia and Rickets
BOF: 10D
A 1@-year-old male) a re&ent immigrant to the &o$ntry is %een in"estigated #or a m$rm$r
On e'amination he is in sin$s rhythm) he has a lo$d pan systoli& m$rm$r %est heard at the
le#t sternal edge and a mid-diastoli& m$rm$r %est heard at the ape' *he #irst heart so$nd
is not lo$dI there is no opening snap and no pre-systoli& a&&ent$ation o# the diastoli&
6ardia& &atheterisation res$lts are as #ollows:

6ham%er =ress$re Bmm !g5 E O'ygen sat$ration
7$perior "ena &a"a ..
>n#erior "ena &a"a .D
Right atri$m /5 .7
Right "entri&le /5,0 D0
=$lmonary artery /5,10 D1
0e#t "entri&le 100,0 -.

>n this patient the mid-diastoli& m$rm$r is d$e to:
a5 >n&reased #low a&ross the mitral "al"e
%5 >n&reased #low a&ross the tri&$spid "al"e
&5 ?itral stenosis
d5 *ri&$spid stenosis
e5 0$tem%a&her9s syndrome
*he patient has a "entri&$lar septal de#e&t *his &an %e ded$&ed #rom the step $p in
o'ygen sat$ration at the le"el o# the right "entri&le d$e to the le#t to right sh$nt at this
le"el *his &a$ses in&reased #low into the le#t atri$m and this &a$ses a #low m$rm$r in
7tenosis o# the mitral "al"e wo$ld res$lt in a lo$d #irst heart so$nd) opening snap and
presystoli& a&&ent$ation o# the m$rm$r *ri&$spid stenosis wo$ld ha"e &a$sed a high
press$re in the right atri$m
0$tem%a&her9s syndrome is a &om%ination o# atrial septal de#e&t and mitral stenosis
<entri&$lar 7eptal De#e&t
BOF: 10-
A .0-year-old male is $nder in"estigation #or wea(ness o# his legs) pigmentation o# the
s(in) hypertension and gly&os$ria
Res$lts o# ser$m &ortisol estimations areI
0-00 1170 nmol,l
+@00 1100 nmol,l
A#ter @D ho$rs o# de'amethasone D mgs daily:
0-00 10/0 nmol,l
>n #$rther in"estigation o# this patient the test most li(ely to identi#y the &a$se o# his
&ondition is:
a5 ?R> head
%5 6* s&an head
&5 =erimetry to de#ine "is$al #ields
d5 6hest '- ray
e5 A6*! le"els
*he patient has 6$shing9s syndrome with #ail$re to s$ppress &ortisol le"els with
de'amethasone *his will indi&ate either an adrenal t$mo$r or an e&topi& so$r&e o#
A6*! O$t o# the list pro"ided the most li(ely in"estigation that will determine the
&a$se o# the lesion is 68R
BOF: 110
A /1-year-old #emale presents with a se"ere heada&he) whi&h wo(e her $p #rom sleep at
appro'imately / am 7he has ne"er had a heada&he li(e this %e#ore 7he had a
mastoide&tomy se"eral years ago 7he has no other symptoms and was otherwise wellI
she is not pregnant and was on no dr$gs in parti&$lar she was not on hormonal
&ontra&eption 7he had not $nderta(en any se"ere e'er&ise
On e'amination she was a#e%rile) &ons&io$s and alert On e'amination o# the opti& #$nd$s
the &$p o# the opti& dis& was #illed and the medial margins o# the dis& were %l$rred 1o
other 617 a%normality in parti&$lar no ne&( sti##ness A'amination o# the other systems
did not re"eal any a%normality
A 6* s&an was reported as normal %y the d$ty radiology registrar) F$ll Blood 6o$nt was
>n this patient the in"estigation that is li(ely to lead to a diagnosis is:
a5 ?R "enogram
%5 0$m%ar p$n&t$re
&5 <itamin A le"el
d5 6isternal p$n&t$re
e5 A7R
*he patient has sagittal sin$s throm%osis *his &an %e se&ondary to *hrom%ophilia) whi&h
may %e primary or se&ondary to diseases s$&h as nephroti& syndrome) paro'ysmal
no&t$rnal haemoglo%in$ria >t &an also o&&$r in pregnan&y and in patients ta(ing
hormonal &ontra&eption Dehydration is another &a$se >t may %e se&ondary to sin$sitis
and mastoiditis or it may %e idiopathi&

>n this patient the treatment o# &hoi&e wo$ld %e:
a5 !eparin
%5 7teroids
&5 <itamin A
d5 A&etazolamide
e5 Repeated l$m%ar p$n&t$re
7agittal sin$s throm%osis is %eat treated with heparin *here are reports in the literat$re o#
s$&&ess#$l throm%olysis %y lo&al instillation o# throm%olysis
BOF: 111
A yo$ng #emale who is short) pl$mp and has a ro$nded #a&ies has the #ollowing
haematology and %io&hemi&al pro#ile:
!% 1+D g,dl
7er$m 6al&i$m 1.+ mmol,l
7er$m =hosphate +- mmol,l
6reatinine @@ mi&romoles,l
Al%$min /D g,l
3hi&h radiologi&al a%normality is li(ely in this patient4
a5 De#e&ti"e mineralisation o# the pel"is
%5 0ooser9s zones
&5 1ephro&al&inosis
d5 7$%periosteal erosions in the middle or terminal phalanges o# the hands
e5 7hort #o$rth and #i#th meta&arpals
*he patient has pse$dohypoparathyroidism) whi&h is asso&iated with short meta&arpal
0ooser9s zone are linear areas o# low density s$rro$nded %y s&leroti& %orders *his and
de#e&ti"e mineralisation o# the pel"is are '-ray #eat$res o# osteomala&ia
1ephro&al&inosis and s$%periosteal erosions o&&$r in hyperparathyroidism
BOF: 11+
A .0 year old male presents with %a&(a&he and dis&om#ort in his pel"is !e is a widower
and li"es alone in a small #lat
>n"estigations are as #ollows:
7er$m &al&i$m 1- mmol,l
7er$m phosphate 0. mmol,l
Al(aline phosphatase 1@0 C,l
Crea 55 mmol,l
Al%$min /. g,l
>n this patient the #ollowing '-ray &hanges are li(ely:
a5 6al&i#i&ation o# the %asal ganglia
%5 =se$do#ra&t$res o# the p$%i& rami
&5 Osteoporosis &ir&$ms&ripta
d5 Ro$nded lyti& lesions in the s($ll
e5 1ephro&al&inosis
*he patient has osteomala&ia *he '-ray #eat$re that may o&&$r in this &ondition is
pse$do#ra&t$re o# the p$%i& rami
6al&i#i&ation o# the %asal ganglia is a #eat$re o# hypoparathyroidism
Osteoporosis &ir&$ms&ripta re#ers to a #ront o# resor%ing %one in the s($ll >t o&&$rs in
=aget9s disease o# %one
Ro$nded lyti& lesions in the s($ll o&&$r in myeloma
1ephro&al&inosis is a #eat$re o# hyperparathyroidism
BOF: 11/
A 7@-year-old male who is (nown to ha"e is&haemi& heart disease and has had a
myo&ardial in#ar&tion presents with %reathlessness !is e'tremities are &old and &lammyI
his p$lse rate is 1+0 %eats per min$te) %lood press$re D0,@0 ;<= ele"ated) heart so$nds
triple rhythm) &repitations are heard in %oth %ases
>n"estigations show:
p! 7+@
=a O+ D5 (=a
=a 6O+ @@ (=a
Blood la&tate 5- mmol,l
Crine p! 5+
Crine osmolarity /+0mmol,l
Blood gl$&ose D. mmol,l
>n this patient the a%normal a&id-%ase %alan&e is d$e to:
a5 Aspirin o"erdose
%5 D-la&ti& a&idosis
&5 *ype A 0-la&ti& a&idosis
d5 *ype B 0-la&ti& a&idosis
e5 Dia%eti& (etoa&idosis
*ype A 0-la&ti& a&idosis o&&$rs when e'&ess la&ti& a&id is #ormed %y anaero%i&
*ype B 0-la&ti& a&idosis is d$e to de&reased hepati& la&tate meta%olism &a$sed %y ins$lin
de#i&ien&y) dr$gs s$&h as %ig$anides) haematologi&al malignan&ies) enzyme de#i&ien&ies
D-la&ti& a&idosis is &a$sed %y %a&terial #ermentation in the g$t in the short %owel

BOF: 114
A 5.-year-old #emale presents with a history o# in&reasing tiredness On e'amination
there is pigmentation o# her s(in &reases and %$&&al m$&osa !er %lood press$re is -0,50
>n"estigations are as #ollows:
Blood $rea D@ mmol,l
1a 1/0 mmol,l
=otassi$m .1 mmol,l
6hloride -. mmol,l
Bi&ar%onate +/ mmol,l
3hi&h o# the #ollowing tests will &on#irm the diagnosis4
a5 Random &ortisol meas$rement
%5 7hort A6*! stim$lation test
&5 0ong A6*! stim$lation test
d5 0-00 =lasma A6*! le"el and &ortisol meas$rement
e5 A%dominal '-ray
*his patient has Addison9s disease A high 0-00 h plasma A6*! le"el with low or normal
&ortisol will &on#irm the diagnosis o# primary hypoadrenalism
*he short A6*! Bsyna&then5 test wo$ld show that the adrenal gland is not responding to
A6*! *his may %e d$e to primary hypoadrenalism or se&ondary to adrenal s$ppression
%y steroids or A6*! de#i&ien&y !en&e it will not &on#irm the diagnosis 7he does not
ha"e adrenal s$ppression %y steroids or A6*! de#i&ien&y as her s(in &reases and %$&&al
m$&osa are pigmented !en&e) a long A6*! stim$lation test is not the answer
Addison's Disease
BOF: 115
A yo$ng #emale has the #ollowing somati& #eat$res:
7hort stat$re) ro$nd #a&e) short ne&() short #o$rth and #i#th meta&arpals and metatarsals
!er in"estigations are as #ollows:
7er$m &al&i$m ++ mmol,l
7er$m phosphate 1+ mmol,l
Al(aline phosphatase 100 C,0
Crea @0 mmol,0
6reatinine -0 mmol,0
*he diagnosis is:
a5 =se$dohypoparathyroidism
%5 !ypoparathyroidism
&5 Ri&(ets
d5 <itamin D resistant ri&(ets
e5 =se$dopse$dohypoparathyroidism
*his patient has the somati& #eat$res o# pse$dohypoparathyroidism %$t %io&hemistry is
normal indi&ating pse$dopse$dohypoparathyroidism
BOF: 11.
A 50-year-old male who is (nown to ha"e &hroni& %ron&hitis presented to the a&&ident
and emergen&y department A#ter initial treatment he was sent $p to the ward !is %lood
gases on admission to the ward were as #ollows:
p! 7++
=aO+ 1@@ (=a
=a6O+ 1DD (=a
*he physi&al sign that alerted the e'amining &lini&ian to this &ondition was:
a5 *a&hy&ardia
%5 =$ls$s parado'$s
&5 Flapping tremor
d5 Ale"ated ;<=
e5 Fo$rth heart so$nd
A #lapping tremor is indi&ati"e o# hyper&apnia
BOF: 117
A /5-year-old #emale has %een on treatment #or depression 7he &omplains o#
&onstipation !er %lood res$lts are as #ollows:
7er$m &al&i$m +77 mmol,l
*7! +0 mC,l
3hi&h dr$g is responsi%le #or these #eat$res4
a5 Amitryptiline
%5 Fl$o'etine
&5 <enla#a'ine
d5 ?irtazepine
e5 0ithi$m
0ithi$m &an &a$ses hyper&al&aemia and hypothyroidism
*he other e##e&ts are #ine tremor) metalli& taste in the mo$th) weight gain) oedema) goitre)
a&ne rash) dia%etes insipid$s) &ardia& arrhythmias
BOF: 11D
An 1D-year-old #emale presents to &as$alty with a%dominal pain On e'amination she is
in distress) she has a p$lse rate o # 1/0 %eats per min$te her %lood press$re is D0,50 her
respiratory rate is /D per min$te A%dominal e'amination re"ealed generalised
!er %lood res$lts are as #ollows:
7odi$m 110 mmol,l
=otassi$m 55 mmol,l
Crea 11 mmol,l
3hi&h o# the #ollowing tests will determine the &a$se o# this patient9s &ondition4
a5 Blood gases
%5 *rigly&erides
&5 Blood s$gar
d5 7ali&ylate le"els
e5 Amylase
*he patient has presented with dia%eti& (etoa&idosis *he %lood s$gar will determine the
&a$se o# the &ondition
BOF: 11-
Yo$r :$nior as(s #or ad"i&e regarding %lood res$lts on a @5-year-old #emale who is a
(nown hypertensi"e and is &omplaining o# poly$ria) polydypsia and m$s&le wea(ness
Blood press$re 170,110
*he res$lts are:
=otassi$m +5 mmol,l
Arterial p! 7@-
*he ne't J$estion yo$ wo$ld as( is:
a5 >s there a #amily history o# hypertension
%5 Does the patient ha"e a %r$it o"er the renal artery
&5 >s the patient on a di$reti&
d5 3hat is the ratio o# aldosterone to plasma rennin a&ti"ity
e5 Does the patient ha"e papilloedema
!ypertension) hypo(alaemia and al(alosis sho$ld ma(e one s$spe&t 6onn9s syndrome i#
the patient is not on di$reti&s !en&e this is the most important J$estion to answer
Renal artery stenosis also &a$ses hypertension with hypo(alaemia and is a more &ommon
&a$se o# re#ra&tory hypertension with low potassi$m
7e&ondary hyperaldosteronism may %e d$e to
Renal artery stenosis
A&&elerated hypertension
!eart #ail$re
0i"er #ail$re
Primary yperaldosteronism
BOF: 1+0
A 5.-year-old male presents with a history o# impoten&e) de&reased #a&ial hair and a
dis&harge #rom his nipples A %asal plasma prola&tin) ta(en at non-stress#$l "enep$n&t$re)
is raised
*he patient also has gastro-oesophageal re#l$' disease and hypertension and is on a
n$m%er o# dr$gs 3hi&h o# the #ollowing dr$gs &o$ld &a$se a raised prola&tin le"el4
a5 Omeprazole
%5 ?eto&lopramide
&5 0isinopril
d5 Bendro#l$azide
e5 Atenolol
*he dr$gs that may in&rease prola&tin le"els are:
=henothiazines) haloperidol) meto&lopramide) methyldopa) oestrogens) *R!

3hi&h o# the #ollowing diseases does not &a$se an in&rease in prola&tin le"els4
a5 1on-se&retory pit$itary adenoma
%5 6hroni& renal #ail$re
&5 !ypothyroidism
d5 7ar&oidosis
e5 6hroni& o%str$&ti"e p$lmonary disease
*he diseases that may &a$se an in&rease in prola&tin le"els are:
=rola&tinoma) pit$itary adenoma) pit$itary stal( se&tion) hypothalami& disease)
hypothyroidism) &hroni& renal #ail$re) sar&oidosis
=it$itary stal( se&tion &a$ses loss o# inhi%ition o# prola&tin prod$&tion %y dopamine
7imilarly large pit$itary adenomas &an &a$se loss o# inhi%ition o# prola&tin prod$&tion