2. Question 1.
A 44 year old male presents to ED with a 6 hour Hx of pain
and tenderness which started centrally and then progressed
to the right iliac fossa (RIF). He is pyrexic (38.5°C) and
increasingly nauseous; he has vomited a number of times.
What is the most likely diagnosis?
a) Gastroenteritis
b) Ruptured abdominal aortic aneurysm (AAA)
c) Acute appendicitis
d) Myocardial infarction
e) Don’t know
3. Acute appendicitis.
• Appendicitis is an acute inflammation of the appendix.
• The appendix is a blind-ended tube connected to the
caecum (the junction between the small and large bowel).
• It is an embryological remnant that has lost its original
function through the process of evolution.
• 2-20 cm in length!
4. Acute appendicitis.
• Lumen becomes obstructed (e.g. faeces, enlarged lymph nodes etc)
• Bacteria proliferate and invade the appendix wall.
• Pain – typically epigastric, before localising to the RIF
• Nausea + vomiting, anorexia
• Fever (pyrexia)
• Appendectomy – don’t be afraid to treat quickly!
• Delaying treatment increases mortality.
6. Question 2.
You are a F1 doctor and you are called to see your patient, Mrs Smith, a 79
year old lady, who is receiving broad spectrum IV antibiotics for a recent
complex UTI. She has been on treatment for about 5 days, and now
complains of watery diarrhoea and abdominal discomfort. What is the
most likely cause?
a) Allergic reaction to antibiotics
b) Ischaemic bowel
c) E.coli infection
d) Clostridium difficile infection
e) Don’t know
7. Clostridium difficile infection.
• Clostridium difficile is a bacterium
• Carried in the normal gut flora of the large intestine
• Generally, becomes problematic after taking broad-
spectrum antibiotics and is a very common hospital-
acquired infection.
8. Clostridium difficile infection.
• Antibiotics destroy the natural ‘anaerobic wallpaper’ of the gut
• Clostridium difficile proliferate and produce TOXINS
• Usually 5-10 post BS-antibiotic use
• Diarrhoea +/- blood
• Abdominal pain / discomfort
• Oral metronidazole (v. cheap, but horrible SEs)
• Vancomycin (much ‘nicer’ but more expensive)
10. Question 3.
A 59 year old male is admitted to ED having collapsed at work. He
complains of a tearing sensation with pain radiating to his back between
his scapulae. He looks pale and sweaty and his BP is recorded as 88/54. He
is a chronic smoker (20/day) with a longstanding Hx of hypertension. You
perform an ECG but no ST changes are noted. What is the most likely
diagnosis?
a) Myocardial infarction (MI)
b) Aortic dissection
c) Pulmonary embolism (PE)
d) Infective endocarditis
e) Don’t know
11. Aortic dissection
• Arteries are made up for three layers:
• Intima (inner most)
• Media
• Adventia
• Aortic dissection is a tear in the intimal lining, which
enables blood to flow between the intimal and media
layers of the aorta.
15. Question 4.
You are the F1 doctor on-call, its night and your less-than responsible reg
has decided he just can’t miss the latest series of Come Dine with Me so
has gone home. You are called to the orthopaedic ward to see Mrs
Williams, a 82 year old lady who has just undergone a total knee
replacement. For the last 2 hours she has been acutely breathless, and
complains of chest pain. She is apyrexial. You perform an ECG but it is
normal. What is the most likely diagnosis?
a) Myocardial infarction (MI)
b) Pulmonary embolism (PE)
c) Pneumonia
d) Exacerbation of COPD
e) Don’t know
16. Pulmonary embolism (PE)
• PEs result when thrombi (blood clots) embolise via the
right heart into the pulmonary arteries.
• Predisposing factors include:
• Recent surgery
• Immobilisation (e.g. long haul flights)
• Malignancy
• Pregnancy
• Family Hx
17. Pulmonary embolism (PE)
• Three main factors contribute to thrombus formation (blood
stagnation, endothelial damage, derangements of coagulability)
• Dyspnoea – difficulty breathing
• ↑HR, ↑RR
• Chest pain (pleuritic in nature – sharp pain on inspiration)
• CT pulmonary angiogram (GOLD STANDARD)
• Thrombolysis, warfarin
