hlt7089 paper 1 - university of bolton€¦ · paper 1: mcq date: wednesday 16 may 2018 time: 2.00...

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UNIVERSITY OF BOLTON

SCHOOL OF HEALTH AND HUMAN SCIENCES

MSc ADVANCED PRACTICE ADVANCED PROFESSIONAL DEVELOPMENT

SEMESTER TWO EXAMINATION 2017/2018

ACUTE MEDICINE

MODULE NO: HLT7089

PAPER 1: MCQ

Date: Wednesday 16 May 2018 Time: 2.00 pm – 3.30 pm INSTRUCTIONS TO CANDIDATES: There are 50 questions. Answer ALL 50 questions. Each question is worth 2 marks. There are a total of 100 marks available. The pass mark is 50%.

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School of Health and Human Sciences MSc Advanced Practice/Advanced Professional Development Semester Two Examination 2017/2018 Module Name: Acute Medicine Module No: HLT7089

1. A 56 year old lady who is normally fit and well, presents with a four week

history of intermittent chest pain. The pain is left sided and exertional. What is

the next step in the management for this lady?

a. Coronary Angiogram

b. Myocardial Perfusion Scan

c. Stress Echocardiography

d. CT Thorax

e. Chest X-ray

2. Which of the following answers would not cause a Troponin level to be

raised?

a. Sepsis

b. Stroke

c. Pulmonary Embolism

d. Atrial fibrillation with a fast ventricular response

e. Migraine

3. A 45 year old man is referred to AMU with a two day history of increasingly

severe chest pain. He describes the pain as a sharp, tearing pain which

radiates through to his back and between his shoulder blades. The patient

looks in pain and his BP is 220/110. What is the most likely diagnosis?

a. Myocardial ischaemia

b. Pulmonary Embolism

c. Pneumonia

d. Aortic dissection

e. Angina

Please turn the page

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4. A 58 year old gentleman is referred to AMU with a 3 hour history of central

crushing chest pain that radiates to his left arm. He is nauseated and clammy.

The ECG shows ST elevation in the inferior leads (II, III and AVF). Which is

the most likely coronary artery to be occluded?

a. Right coronary artery

b. Left anterior descending artery

c. Left circumflex artery

d. Posterior descending artery

e. Right marginal artery

5. A 75 year old man was admitted following a witnessed episode of loss of

consciousness. He recollects feeling light headed and then was observed to

go very pale prior to collapsing. On return of consciousness, he was aware of

his surroundings. On examination, his pulse is 30 and his BP is 87/43. The

ECG shows:

What is the heart rhythm?

a. Atrial flutter

b. First degree AV block

c. Sinus rhythm

d. Mobitz type II heart block

e. Complete heart block


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6. A 25 year old man is referred to the AMU by his GP following a sudden

episode of rapid and regular palpitations which had self-terminated after 5

minutes. On admission, his palpitations have returned and the cardiac monitor

below shows:

His BP is 115/74, he is not breathless and he has no chest pain. A junior doctor has performed carotid sinus massage and vaso-vagal manoeuvres which have made no difference to his heart rate. What would be the next step in his management?

a. Synchronised DC shock

b. IV Verapamil

c. Betablocker

d. IV Adenosine

e. Repeat vaso-vagal manoeuvres

7. A 68 year old lady is admitted with a 4 day history of irregular palpitations.

There has been no chest pain or breathlessness. She has a background

history of Hypertension and is on Ramipril for this. On examination, her

respiratory rate is 18/min and oxygen saturations on air are 98%. Her pulse is

128 irregular and her Blood pressure is 135/74. The bedside monitor shows:

Question 7 continued over the page…

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Question 7 continued

What is the next step in the management for this lady? a. DC cardioversion

b. IV Verapamil

c. Beta blocker

d. Calcium channel blocker

e. IV Adenosine

8. On a CXR for Pneumonia, you will see:

a. ‘Batwings’ around the hilum

b. Consolidation

c. Kerley B lines

d. Pancoast tumour

e. Widened mediastinum

9. An 81 year old man with a past medical history of chronic obstructive

pulmonary disease is admitted with sudden onset of severe breathlessness.

On examination, his respiratory rate is 28/min his oxygen saturations on air

are 86%. There are diminished breath sounds to his right lung. Which

investigation would be most useful to aid diagnosis?

a. Chest X-ray

b. Arterial blood gas

c. D-Dimer

d. CT Thorax

e. CRP

10. Peak expiratory flow rate (PEFR) is useful in determining the severity of an

Asthma exacerbation. To support diagnosis, life threatening Asthma using

PEFR in conjunction with clinical findings is defined by NICE (2018) as:

a. PEFR 50% best or predicted

b. PEFR 40% best or predicted

c. PEFR 35% best or predicted

d. PEFR 33% best or predicted

e. PEFR 30% best or predicted


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11. A 28 year old man, who fixes industrial air conditioners, presents with a three

day history of productive cough and breathlessness. He is normally fit and

well and has no previous medical history. On examination, his GCS is 15/15,

respiratory rate is 30/min, oxygen saturations on 40% O2 are 98%, P115 bpm

and regular, BP 102/65. Temp 38.3. He has coarse crackles to his right chest

base. The bloods today show:

Normal values Hb 135 (130 – 180)

Plt 490 (140 – 400) WCC 20 (3.6 – 11.0) Neut 15 (1.8 – 7.5) CRP 180 ( < 5) Urea 11 (2.5 – 7.8) Lactate 1.5 ( <2 )

What is the next step in the management of this patient?

a. Nebulisers

b. Oral antibiotics

c. Increase O2 to 60%

d. Non-invasive positive pressure ventilation (NIPPV)

e. IV antibiotics

12. A 59 year old lady is admitted with acute exacerbation of COPD. She has

been treated with Salbutamol and Ipratropium Nebulisers, IV Steroids and

controlled O2 at 28%. She is now tiring. Her ABG is repeated following

treatment after one hour which shows:

On admission At 1 hour Normal values pH 7.33 7.27 7.35 - 7.45 PO2 8 11 10 - 14 kPa PCO2 6 9 4.5 - 6.0 kPa BE -3 -7 -2 – 2 mmol/l What is the next step in the management for this patient?

a. Increase O2 to 35%

b. Request urgent CTPA

c. IV Dopram

d. Reduce O2 to 24%

e. Trial of non-invasive positive pressure ventilation


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13. A 74 year old man is admitted to AMU after waking breathless with chest

heaviness. On examination, his respiratory rate is 28/min, oxygen saturations

are 95% on 15L O2 via non-rebreath mask, his pulse is 120 bpm and regular

and his blood pressure is 112/56. On examination of his chest there are

bilateral fine inspiratory chest crackles up to the mid zones and his JVP is

raised. The CXR shows:

What is the next line in the management for this patient? a. Aspirin

b. ACE inhibitor

c. IV diuretics

d. Cardiology team review

e. Non-invasive positive pressure ventilation


www.radiologyassistant

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14. A pneumothorax presenting in a 25 year old, tall, slim male is likely to be

which type?

a. Primary

b. Secondary

c. Subcutaneous

d. Tension

e. Traumatic

15. A 78 year old Caucasian man is admitted with a two month history of fatigue,

anorexia and weightloss, and progressive breathlessness. This morning he

had an episode of bloody sputum. He has past medical history of ischaemic

heart disease and is normally prescribed Aspirin, a beta blocker and a statin.

He is a life-long non-smoker. Before retiring he had been employed as a

roofer for >40 years. What would be the most likely cause for the

haemoptysis?

a. Pulmonary TB

b. Small cell lung cancer

c. Mesothelioma

d. Pneumonia

e. Pulmonary Embolism

16. Which of the following is not a risk factor for developing a pulmonary

embolism?

a. Anti-thrombin deficiency

b. Irritable bowel disease

c. Inflammatory bowel disease

d. Malignancy

e. Nephrotic syndrome


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17. A 26 year olds man returns from Africa with a 6 day history of fever, sweats

and malaise. A diagnosis of Malaria is suspected. What is the investigation of

choice to confirm the diagnosis?

a. Blood cultures

b. Full blood count

c. Thick and thin blood films

d. Cerebral spinal fluid (CSF)

e. Polymerase chain reaction (PCR)

18. A 62 year old man is seen with suspected alcohol related liver disease. The

liver function tests show a Bilirubin of 43, ALT of 84 and ALP of 97. Which of

the following Blood test parameters would support a diagnosis of alcohol

related liver disease?

a. Low MCV

b. Normal MCV

c. Low MCH

d. Raised MCV

e. Raised MCH

19. A 32 year old lady who is normally fit and well is admitted with month history

of progressive breathlessness, lethargy and tiredness. She has no previous

medical history and is still menstruating. There are no gastrointestinal

symptoms and there is no family history of Ca. On examination: Pallor, vital

signs all within normal limits. Chest, cardiovascular system and abdomen are

NAD. The bloods today show:

Normal values

Hb 82 (115 – 165) MCV 78 (80 – 100) PLT 290 (140 – 400) WCC 7 (3.6 – 11.0) Ferritin 5 (25 – 350)

Question 19 continued over the page…

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Question 19 continued

What is the next line in the management of this lady?

a. Blood transfusion

b. Oral Iron

c. IV Iron

d. OP Gastroscopy

e. Coeliac antibody

20. According to NICE guidelines (2018), which of the following is first line

eradication for peptic ulceration caused by H Pylori?

a. A proton pump inhibitor

b. Antibiotics

c. H2 antagonist

d. Proton pump inhibitor and one antibiotic

e. Proton pump inhibitor and two antibiotics

21. A 42 year old teacher is admitted with intermittent epigastric pain and an

episode of black stools. He describes the pain as “heart burn” that eases

when he eats but is worse when he goes to bed at night. His blood tests today

show:

Normal values Hb 94 (130 – 180) WCC 8.0 (3.6 – 11.0) PLT 520 (140 – 400) MCV 85 (80 – 100) Urea 13 (2.5 – 7.8)

What is the most likely cause of the upper GI bleed? a. Duodenal ulcer

b. Oesophageal varices

c. Mallory Weis Tear

d. Gastric ulcer

e. Ulcerative colitis


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22. A 23 year old lady is referred with a 24 hour history of watery diarrhoea. She

says that she has opened her bowels 10 times since the onset of symptoms.

She feels nauseous, has been vomiting, and has been having abdominal

cramping pain. Her symptoms started in the evening after a barbecue meal.

She is normally fit and active and has no previous medical history. On

examination, her EWS is 0; her abdomen is soft with mild generalised pain.

What is the most likely diagnosis?

a. Crohns disease

b. Colitis

c. Gastroenteritis

d. Irritable bowel disease

e. Coeliac disease

23. A 42 year old lady presents with abdominal pain, vomiting and fever. The pain

is worse in the right upper quadrant and sometimes radiates to her right

shoulder. The Liver function test results today are:

Normal results

Bilirubin 16 ( <21 ) ALT 64 ( <33 ) ALP 186 ( 30 – 130 ) WCC 17 ( 3.6 – 11.0 ) CRP 87 ( <5 ) Amylase 52 ( 28 – 100 ) What of these answers is a likely diagnosis?

a. Cholecystitis

b. Budd Chiari syndrome

c. Pancreatitis

d. Acute hepatitis

e. Irritable bowel disease


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24. A 58 year old man with a history of alcohol related liver disease was admitted

to AMU with an upper GI bleed that was secondary to oesophageal varices.

He under goes endoscopic variceal banding and is discharged after a short

stay. Which of the following medications will he be started on as prophylaxis?

a. Amlodipine

b. Diltiazem

c. Digoxin

d. Propranolol

e. ACE inhibitor

25. According to Truelove and Witts criteria, which of the below parameters

constitutes a flare of ulcerative colitis?

a. <2 bowel motions per day with large amounts of rectal bleeding

b. Between 2 and 4 bowel motions per day with large amounts of rectal

bleeding

c. >4 bowel motions per day with large amounts of rectal bleeding

d. >5 bowel motions per day with large amounts of rectal bleeding

e. >6 bowel motions per day with large amounts of rectal bleeding

26. A 51 year old lady is admitted with three day history of swelling to her left

lower leg which started as a “pop” behind her left knee. She has a history of

osteoarthritis. On examination her calf and knee are swollen++ but non-

tender. She is peripherally warm and well perfused with good arterial pulses.

The D Dimer result is 295 (n=<270). What would be your next step in

managing this patient?

a. Low molecular weight heparin

b. X-ray left leg

c. USS Doppler left leg

d. Aspirin

e. IV antibiotics


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27. A 36 year old man is admitted with a red and swollen right lower leg. On

questioning he describes flu-like symptoms. On examination his shin looks

red and angry with clear demarcation, feels hot and is tender to touch. There

is a small stud mark where he was kicked at football last week. What is the

most likely diagnosis?

a. Deep vein thrombosis

b. Cellulitis

c. Haematoma

d. Venous insufficiency

e. Cruciate ligament injury

28. Which of one of the following answers from the list below is a recognised

cause of erythema nodosum?

a. Trauma

b. Venous insufficiency

c. Sarcoidosis

d. Arterial insufficiency

e. Hypothyroidism

29. A 76 year old man was admitted with transient right arm weakness which

resolved after 2hours. His ABCD2 score was 6. What is his risk of stroke in

the first week?

a. 5%

b. 10%

c. 15%

d. 20%

e. 25%


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30. A 35 year old lady is admitted following sudden onset of severe occipital

headache. On examination, there is no abnormal neurology. The CT brain is

normal so a lumbar puncture is performed at 12 hours to eliminate a

subarachnoid haemorrhage (SAH). Which of the below results would be

positive for a Subarachnoid haemorrhage

a. Raised red cell count and low glucose.

b. Raised white cell count and raised xanthochromia.

c. Low glucose and raised xanthochromia.

d. Raised glucose and low neutrophil count.

e. Raised xanthlochromia and raised red cell count.

31. An 83 year old lady is admitted from a nursing home with acute onset of

confusion and reduced appetite. On examination, her respiratory rate is

24/min, sats 96% on air, P120bpm reg, BP 102/53. Temp 38.0. The urine

dipstick is positive for nitrates, protein, leucocytes and ketones. What is the

likely cause of the confusion?

a. Urinary tract infection

b. Diabetic ketoacidosis

c. Glomerular nephritis

d. Renal obstruction

e. Stroke

32. A 19 year old student is admitted following a collapse with loss of

consciousness at university. She was found in the library on the floor,

disorientated to time and place. She had been incontinent of urine and had

bitten her tongue. On examination, she was alert and orientated and there

was no abnormal neurology. The ECG was normal. What would be the next

step in management for this patient?

a. Ambulatory ECG

b. ECHO

c. Lying and standing BP

d. Urgent neurology referral and outpatient MRI brain

e. CT brain


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33. A 76 year old man is admitted with right hemiparesis. CT reveals a middle

cerebral artery infarct. Which of the following is his most significant risk factor

for stroke?

a. Cholesterol

b. Family history

c. Hypertension

d. Smoking

e. Diabetes

34. A 48 year old gentleman is admitted with a severe left sided headache which

started two hours ago. The pain is 11/10 and when asked, he says that the

light does bother him a bit. He had a similar episode 4 months ago

experiencing similar intermittent headaches over a two week period that

resolved spontaneously. He GP has found no abnormal neurology. When you

approach his bed, he is pacing up and down and looks distressed. What is the

most likely diagnosis?

a. Subarachnoid Haemorrhage

b. Migraine

c. Intracranial bleed

d. Cluster headaches

e. Space occupying lesion

35. Acute kidney disease can be classified as pre-renal, renal or post renal

failure. Which of the following answers is correct:

a. Vasculitis is a cause of pre-renal failure

b. Non-steroidal anti-inflammatory drugs are a cause of renal failure.

c. Dehydration is a cause of renal failure

d. Acute glomerulonephritis is a cause of post renal failure

e. Acute tubular necrosis is a cause of post renal failure


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36. A 27 year old lady is admitted with a three day history of diarrhoea. The GP

has taken bloods which have returned as:

Normal results Na 148 ( 133 – 146) K 3.4 ( 3.5 – 5.3 ) Urea 15 ( 2.5 – 7.8 ) Creat 156 ( 45 – 84 ) What is the next step in management for this lady?

a. Loperamide

b. Intravenous fluids

c. Fluid restriction

d. Diuretics

e. Renal ultrasound scan

37. Which of the following answers is not a treatment used for a patient with

hyperkalaemia?

a. Loop diuretics

b. Dextrose/insulin infusion

c. Calcium Resonium

d. Salbutamol Nebuliser

e. Aldosterone antagonists

38. A 61 year old lady is referred with nausea, numbness and tingling in her

hands and feet, muscle spasms and depression. Which of the following is the

most likely cause?

a. Hypothyroidism

b. Hypomagnesaemia

c. Hyponatraemia

d. Hypokalaemia

e. Hypocalcaemia


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39. You are asked to see a 36 year old man who has just arrived on AMU who

has been referred in by his GP with a one month history of lethargy and

weight loss. The nurse is concerned because he is breathless. You take an

arterial blood gas and it shows the following:

Normal Values

Ph 7.29 (7.35-7.45) PO2 12 ( >10 ) PCO2 3.5 ( 4.5-6 ) HCO3 17 ( 22-26 ) BE -6 ( -2 - +2) What does the sample indicate?

a. Metabolic acidosis

b. Respiratory Acidosis

c. Metabolic alkalosis

d. Respiratory Alkalosis

e. Normal result

40. A 41 year old lady is referred to ambulatory care with fatigue, weight gain and

hair loss. The FBC, U&E, LFT and Calcium have returned normal. The other

bloods are as below:

TSH 18 ( 0.4 - 4.0 ) FT3 2.7 ( 3.5 – 7.8 ) FT4 5.4 ( 9 – 24 ) What would be the diagnosis?

a. Hyperthyroidism

b. Hypoparathyroidism

c. Hyperparathyroidism

d. Primary Hypothyroidism

e. Secondary Hypothyroidism


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41. Which of the following is not a recognised feature of Salicylism?

a. Constipation

b. Tinnitus

c. Hyperventilation

d. Abdominal pain

e. Sweating

42. A 64 year old lady presents with a five day history of lower back pain and

difficulty walking. She has not opened her bowels or passed urine since the

previous day. She is currently receiving treatment for breast cancer. On

examination there is reduced power and tone to her lower limbs. What is the

most appropriate diagnostic investigation?

a. CT thorax, abdomen and pelvis

b. Bone scan

c. MRI spine

d. CXR

e. Spine X-ray

43. A 74 year old man presents with general fatigue, weight loss, exertional

breathlessness and night sweats. The FBC shows a low Hb and elevated

white cell count with increased Neutrophils and Basophils. The blood film

shows Blast cells. Which of the below answers could be a likely diagnosis:

a. Pulmonary Tuberculosis

b. Chronic Myeloid Leukaemia

c. Klebsiella Pneumonia

d. Sarcoidosis

e. Pulmonary abscess


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44. A 69 year old man with gastric Ca is admitted with lethargy, muscle twitching

and constipation. His corrected calcium level returns raised at 3.0. What is the

most appropriate treatment?

a. Intravenous saline rehydration and IV Biphosphonates e.g.

Pamidronate

b. Intravenous saline rehydration

c. IV Biphosphonates e.g. Pamidronate

d. Calcitonin

e. Intravenous saline rehydration and Calcitonin

45. Which of the following statements about discharge planning is incorrect:

a. Discharges that occur late in the day can cause a mismatch in bed

capacity

b. Discharge planning is an ongoing process for identifying the services

and support a person may need following discharge from hospital.

c. Patients whose inpatient treatment for an acute medical illness is

complete sometimes remain in hospital because of poor discharge

planning

d. All staff should be clear about responsibilities to ensure that bed

capacity is available on all wards Monday to Friday.

e. Discharge planning should start on the Acute Assessment Unit

46. What is a care bundle?

a. A checklist of medical, nursing and allied interventions designed to

ensure all steps are completed.

b. A series of processes that must be completed to ensure patient safety.

c. A small group of evidence based interventions that when performed

collectively, improve patient outcomes.

d. All of the minimum interventions that define patient outcomes.

e. A number of steps in patient management that must be completed

sequentially.


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47. Complete the following sentence:

Within medical practice, beneficence is: a. The right of competent adults to make informed decisions about their

own medical care

b. The distribution of health resources and the decision about who gets

what treatment

c. An ethical and legal duty not to harm intentionally or unintentionally

d. Treating others equitably with fairness

e. Acting in the best interests/doing good for the patient

48. Which of the following people who lack capacity does not require a

deprivation of liberty safeguard:

a. Jean has Alzheimer’s disease and now lacks capacity to make the

choice to move into a care home.

b. Brian has vascular dementia and staff in the nursing home where he

lives has to use various distraction techniques and bed rails to stop him

walking on his broken leg.

c. Debbie has a brain tumour, is confused and lives with her mother who

provides all care for her. Her mother says that Debbie does not have a

good relationship with father and has asked the staff to stop him

visiting her because she says that he upsets her.

d. Clare has a history of traumatic brain injury and has been referred by

her GP for a minor hand operation. It is known from previous

admissions that she will need sedating during admission.

e. Andrew has a history of alcohol excess and since admission to AMU,

he has become acutely confused. He now needs two security guards to

physically restrain him to stop him leaving the ward.

49. Which of the assessment models below is a measure of clinical frailty?

a. Rockhall

b. Child-Pugh

c. Meld

d. Rockwood

e. PESI


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50. Clinical governance is not:

a. An umbrella term for everything that helps to maintain and improve

high standards of patient care.

b. A new concept designed to regulate practice.

c. Learning from mistakes, sharing knowledge, implementing solutions

and monitoring success

d. Continually looking at innovative and effective ways of delivering the

national governance agenda.

e. Ensuring that risk management systems and processes are

incorporated into every day practice.

END OF QUESTIONS

hlt7089 paper 1 - university of bolton€¦ · paper 1: mcq date: wednesday 16 may 2018 time: 2.00...

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