Get ahead!

Medicine
150 EMQs for finals
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Get ahead!
Medicine
150 EMQs for finals

David Capewell
Foundation Year House Officer
Emergency Medicine
St. James’ Hospital, Leeds, UK

Saran Shantikumar
Foundation Year House Officer
Academic Vascular Surgery
Leeds General Infirmary, Leeds, UK
CRC Press
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 Contents

Contents
Preface ix
Introduction to Get ahead! xi
Practice Paper 1: Questions 1
Theme 1: Causes of collapse 1
Theme 2: Nerve lesions of the upper limb 2
Theme 3: Complications of diabetes mellitus 3
Theme 4: Diagnosis of respiratory conditions 1 4
Theme 5: Glomerulonephritis 5
Theme 6: Management of hypertension 6
Theme 7: Interpretation of cerebrospinal fluid results 7
Theme 8: Thyroid disease 8
Theme 9: Transfusion reactions 8
Theme 10: Dementia 1 10
Theme 11: Barriers to communication 11
Theme 12: Vasculitis 12
Theme 13: Complications of liver disease 13
Theme 14: Cutaneous lesions 1 14
Theme 15: Antimicrobial therapy 15
Practice Paper 1: Answers 16

Practice Paper 2: Questions 41

Theme 1: Bleeding disorders 41
Theme 2: Chronic heart failure 43
Theme 3: Motor weakness 1 44
Theme 4: Skin manifestations of systemic disease 1 45
Theme 5: Acute ECG interpretation 46
Theme 6: Hepatitis B serology 47
Theme 7: Headache 1 48
Theme 8: Complications of the treatment of thyroid disease 49
Theme 9: Common drug doses 50
Theme 10: Urinary tract infections 51
Theme 11: Diabetic emergencies 52
Theme 12: Dermatomes 1 53
Theme 13: Shortness of breath 54
Theme 14: Sexually transmitted infections 1 55
Theme 15: Diagnosis of joint pain 1 56
Practice Paper 2: Answers 57


 Practice Paper 3: Questions 83

Contents
Theme 1: Motor weakness 2 83
Theme 2: Diabetic eye disease 84
Theme 3: Complications of acute myocardial infarction 85
Theme 4: Cutaneous lesions 2 86
Theme 5: Dizziness 87
Theme 6: Diagnosis of joint pain 2 88
Theme 7: Complications of drug therapy 89
Theme 8: Interpretation of liver function tests 90
Theme 9: Diagnosis of respiratory conditions 2 91
Theme 10: Renal investigations 92
Theme 11: Study design 93
Theme 12: Management of neurological conditions 1 94
Theme 13: Anaemia 95
Theme 14: Diagnosis of thyroid disease 1 96
Theme 15: Secondary hypertension 97
Practice Paper 3: Answers 98
Practice Paper 4: Questions 123
Theme 1: Investigation of respiratory disease 123
Theme 2: Nerve lesions of the lower limb 124
Theme 3: Mechanism of action of common drugs 125
Theme 4: Investigation in diabetes mellitus 126
Theme 5: Glasgow Coma Scale 127
Theme 6: Investigation of liver disease 128
Theme 7: Complications of renal failure 129
Theme 8: Emergency management 130
Theme 9: Investigation of endocrine disease 131
Theme 10: Dementia 2 132
Theme 11: Heart sounds 133
Theme 12: Management of skin disease 134
Theme 13: Connective tissue disease 135
Theme 14: Diagnosis of haematological disease 136
Theme 15: Conditions of the vessel wall 137
Practice Paper 4: Answers 138
Practice Paper 5: Questions 163
Theme 1: Management of type 2 diabetes 163
Theme 2: Speech problems 164
Theme 3: Gastrointestinal radiology 165
Theme 4: Tumour markers 166
Theme 5: Conduction defects 167
Theme 6: Skin manifestations of systemic disease 2 168
Theme 7: Congenital and genetic diseases of the kidney 169
Theme 8: Hormones in endocrine disease 170
Theme 9: Signs of cardiovascular disease 171
Theme 10: Haematological malignancy 172
Theme 11: Headache 2 173
Theme 12: Arterial blood gases 174
Theme 13: Management of rheumatological disease 175
Theme 14: Jaundice 176
Theme 15: Spinal cord lesions 177
vi Practice Paper 5: Answers 178
Practice Paper 6: Questions 205

Contents
Theme 1: Central nervous system infections 205
Theme 2: Cutaneous malignancies 206
Theme 3: Investigation of dyspnoea 207
Theme 4: Platelet disorders 208
Theme 5: Cranial nerve function 209
Theme 6: Hyperglycaemia 210
Theme 7: Signs of liver disease 211
Theme 8: Acute renal failure 212
Theme 9: Infective gastroenteritis 213
Theme 10: Seizures 214
Theme 11: Side-effects of cardiovascular medication 215
Theme 12: Drugs used during cardiac arrest 216
Theme 13: Investigation of rheumatological disease 217
Theme 14: Diagnosis of thyroid disease 2 218
Theme 15: Diagnosis of chest pain 219
Practice Paper 6: Answers 220
Practice Paper 7: Questions 241
Theme 1: The multidisciplinary team 241
Theme 2: Abnormalities of movement 242
Theme 3: Treatment of liver disease 243
Theme 4: Management of respiratory disease 1 244
Theme 5: Complications of treatment of rheumatoid arthritis 245
Theme 6: Diseases of calcium and the parathyroid axis 246
Theme 7: Diseases of the myocardium and pericardium 247
Theme 8: Visual defects 1 248
Theme 9: Signs in gastrointestinal disease 249
Theme 10: Complications of renal replacement therapy 250
Theme 11: Ulcers 251
Theme 12: Tachycardias and tachyarrhythmias 252
Theme 13: Oncological emergencies 253
Theme 14: Management of endocrine disease 254
Theme 15: Management of neurological conditions 2 255
Practice Paper 7: Answers 256
Practice Paper 8: Questions 277
Theme 1: Complications of HIV infection 1 277
Theme 2: Scoring systems in medicine 278
Theme 3: Fainting 279
Theme 4: Management of respiratory disease 2 280
Theme 5: Non-infective diarrhoea 281
Theme 6: Signs in endocrinological disease 282
Theme 7: Features of rheumatoid arthritis 283
Theme 8: Management of acute coronary syndromes 284
Theme 9: Pupillary disorders 285
Theme 10: Gastrointestinal investigations 286
Theme 11: Autoantibodies 1 287
Theme 12: Investigation of neurological disorders 288
Theme 13: Valvular heart disease 289
Theme 14: Substance use 290
Theme 15: Renal manifestations of systemic disease 291
Practice Paper 8: Answers 292 vii
 Practice Paper 9: Questions 313

Contents
Theme 1: Symptoms of gastrointestinal disease 313
Theme 2: Complications of cancer therapy 314
Theme 3: Pathogens of endocarditis 315
Theme 4: Sexually transmitted infections 2 316
Theme 5: Airway management 317
Theme 6: Pathogens in pneumonia 318
Theme 7: Gastrointestinal malignancy 319
Theme 8: Visual defects 2 320
Theme 9: Endocrine investigations 321
Theme 10: Diagnosis of neurological disease 322
Theme 11: Overdose and antidotes 323
Theme 12: Extra-articular manifestations of rheumatoid arthritis 324
Theme 13: Management of asthma 325
Theme 14: Investigation of cardiovascular disease 326
Theme 15: Gait disturbance 1 327
Practice Paper 9: Answers 328

Practice Paper 10: Questions 353

Theme 1: Classification of stroke 353
Theme 2: Psychiatric signs of physical illness 354
Theme 3: Respiratory diseases of childhood 355
Theme 4: Haematemesis 356
Theme 5: Managing symptoms in palliative care 357
Theme 6: Symptoms of cardiovascular disease 358
Theme 7: Statistics 359
Theme 8: Scoring the severity of pneumonia 360
Theme 9: Complications of HIV infection 2 361
Theme 10: Management of cardiovascular disease 362
Theme 11: Gait disturbance 2 363
Theme 12: Treatment of gastrointestinal disease 364
Theme 13: Autoantibodies 2 365
Theme 14: Diagnosis of endocrine disorders 366
Theme 15: Dermatomes 2 367
Practice Paper 10: Answers 368
Index of topics covered 389

viii
 Preface

Preface
Welcome to Get ahead! Medicine. This book contains 150 EMQ themes, each
with five stems, covering clinical medicine. The EMQs are arranged as 10
practice papers, each containing 15 themes. Allow yourself 90 minutes to
two hours for each paper. You can either work through the practice papers
systematically or dip in and out of the book using the EMQ index as a
guide to where questions on a specific topic can be found. We have tried to
include all the main conditions about which you can be expected to know,
as well as some more detailed knowledge suitable for candidates aiming
at distinction. As in the real exam, these papers have no preset pass mark.
Whether you pass or fail depends on the distribution of scores across the
whole year group, but around 60% should be sufficient.

We hope that this book fulfils its aim in being a useful, informative
revision aid. If you have any feedback or suggestions, please let us know
(RevisionForMedicalFinals@gmail.com).

We would like to acknowledge the help of Sarah Vasey and Sarah Burrows,
both of the Royal Society of Medicine Press, for their guidance throughout
this project, and to Mac Clarke for his careful copyediting and helpful
suggestions throughout the Get ahead! series.

Finally, we would like to thank our families, Anoushka (DC) and Mary (SS)
for their continuing support.

This book is dedicated to Geoff Hall (David’s grandfather), who sadly passed
away last year.

David Capewell
Saran Shantikumar

ix
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 Introduction to Get ahead!

Introduction to Get ahead!

Get ahead!
Extended matching questions (EMQs) are becoming more popular as a
method of assessment in summative medical school examinations. EMQs
have the advantage of testing candidates’ knowledge of clinical scenarios
rather than their ability at detailed factual recall. However, they do not
always parallel real-life situations and are no comparison to clinical
decision-making. Either way, the EMQ is here to stay.

The Get ahead! series is aimed primarily at undergraduate finalists. Much

like the real exam, we have endeavoured to include commonly asked
questions as well as a generous proportion of harder stems, appropriate for
the more ambitious student aiming for honours. The Universities Medical
Assessment Partnership (UMAP) is a collaboration of 14 medical schools
in the UK that is compiling a bank of EMQs to be used in summative
examinations. The questions in the Get ahead! series are written to closely
follow the ‘house-style’ of the UMAP EMQs, and hence are of a similar
format to what many of you can expect in your exams. All the questions
in the Get ahead! series are accompanied by explanatory answers, including
a succinct summary of the key features of each condition. Even when you
get an answer right, I strongly suggest that you read these – I guarantee that
you’ll learn something. For added interest, we have included some details
of eponymous conditions (‘eponymous’ from Greek epi = upon + onyma =
name; ‘giving name’), and, as you have just seen, some derivations of words
from the original Latin or Greek.

How to pass your exams

Exam EMQs are intended to be based on ‘house officer knowledge’. Sadly,
this is not always the case, and you shouldn’t be surprised when you get a
question concerning the management of various stages of prostate cancer
(as I was). So start revising early and don’t restrict yourself to the given
syllabus if you can avoid it. If your exam is only two weeks away then
CRAM, CRAM, CRAM – you’ll be surprised at how much you can learn in
a fortnight.

During the exam ...

1. Try to answer the questions without looking at the responses first
– the questions are written such that this should be possible.

2. Take your time to read the questions fully. There are no bonus marks
for finishing the paper early.

3. If you get stuck on a question then make sure that you mark down
your best guess before you move on. You may not have time to return
to it at the end.
xi
 4. Answer all the questions – there is no negative marking. If you are

Introduction to Get ahead!

unsure, go with your instinct – it’s probably going to be your best
guess.

5. Never think that the examiner is trying to catch you out. Red herrings
are not allowed, so don’t assume that there is one. If a question looks
easy, it probably is!

But all this is obvious and there is no substitute for learning the material
thoroughly and practising as many questions as you can. With this book,
you’re off to a good start!

A final word …
The Get ahead! series is written by junior doctors who have recently
finished finals and who have experience teaching students. As such, I hope
that the books cover information that is valuable and relevant to you as
undergraduates who are about to sit finals.

I wish you the best of luck in your exams!

Saran Shantikumar
Series Editor, Get ahead!

xii
 Practice Paper 1: Questions

Practice Paper 1: Questions

Theme 1: Causes of collapse
Options
A. Acute myocardial infarction
B. Cerebrovascular accident
C. Dissecting aortic aneurysm
D. Drug allergy
E. First-dose hypotension
F. Left ventricular failure
G. Ruptured abdominal aortic aneurysm
H. Stable angina
I. Stokes–Adams attack
J. Supraventricular tachycardia
K. Vasovagal syncope
L. Ventricular rupture
M. Wolff–Parkinson–White syndrome

For each of the following scenarios, select the most appropriate diagnosis.
Each option may be used once, more than once or not at all.

1. A 45-year-old woman collapses during a church service in summer.

Her husband states that she turned pale and collapsed shortly after
standing up. She did not jerk or lose urinary continence. She denies
chest pain, shortness of breath and palpitations. She recovered after
30 seconds and now feels back to her usual self. All observations
– including blood tests, ECG, and lying and standing blood pressure
– are normal.

2. A 25-year-old man collapses suddenly while visiting his grandmother

in hospital. There appears to be no pulse. The crash team is called, and
manage to resuscitate him after identifying ventricular fibrillation on
the cardiac monitor. The attending anaesthetist records a repeat ECG
and notes that the QRS complexes are broad with slurred upstroke of
the R wave.

3. A 75-year-old woman is brought to the emergency department after

collapsing. On examination, her heart rate is 80 beats/min and
irregular, with a blood pressure of 150/90 mmHg. She has difficulty
in moving her left arm and leg.

4. A 67-year-old man presents to the emergency department following

a collapse. He has a history of ischaemic heart disease and had been
diagnosed with hypertension only last week. He remembers feeling
dizzy when he got out of his chair to go to the toilet before fainting.
He regained consciousness almost immediately and had fully
recovered within 5 minutes.

 5. A 57-year-old man is found collapsed at work. On arrival at the

Practice Paper 1: Questions

emergency department, he is complaining of mild epigastric
discomfort that started at rest. He appears pale and sweaty and has
vomited once. He is on insulin for type 1 diabetes mellitus.

Theme 2: Nerve lesions of the upper limb

Options
A. Accessory nerve
B. Anterior interosseous nerve
C. Axillary nerve
D. Distal median nerve
E. Distal ulnar nerve
F. Long thoracic nerve
G. Lower brachial plexus
H. Posterior interosseous nerve
I. Proximal median nerve
J. Proximal ulnar nerve
K. Radial nerve
L. Upper brachial plexus

For each of the following scenarios, select the most likely nerve lesion. Each
option may be used once, more than once or not at all.

1. A 28-year-old man is involved in a motorcycle accident. He has

fractured both his femurs and complains of pain in his neck. On
examination, his right arm is hanging by his side, is fully extended
at the elbow and is rotated inwards. There is loss of sensation on the
outer edge of the right arm and forearm.

2. A 67-year-old woman attends follow-up clinic following a right

mastectomy for invasive breast cancer. Her husband has pointed out
that her right shoulder blade occasionally sticks out more than the
left. On examination, there is no evidence of sensory loss.

3. A 72-year-old man attends the emergency department following a

fall. On examination, there is bruising on the right upper arm and
the man is unable to extend his metacarpals on the same side. There
is loss of sensation over the lateral dorsal aspect of the hand.

4. An 18-year-old woman who recently had neck surgery attends a

follow-up clinic. She complains of pain in the left side of her neck.
On examination, she is unable to shrug her left shoulder. There is no
evidence of sensory loss.

5. A 24-year-old man presents with severe right shoulder pain following

a tackle during a rugby match. On examination, the contour of the
affected shoulder is flattened and the humeral head is palpable. There
is also sensory loss at the upper outer aspect of the arm.