Specialty Certificate Exam in Geriatric Medicine Sample Questions The following questions are intended to give candidates a better understanding of the type of questions set in relation to the blueprint. The topics above each question indicate the area of the blueprint that the question refers to. Falls Question 1 An 83-year-old woman presented after an episode of unconsciousness. Her husband reported that, while standing during a church service, she had fallen to the ground and had been unresponsive for 2 minutes. He had noticed that she became very pale during the event and that there were several jerking movements of her left arm. Within 5 minutes of onset she was conscious and orientated. Examination was normal. An ECG revealed sinus rhythm and left axis deviation. What investigation is most likely to lead to a correct diagnosis? A B C D E
24-h cardiac Holter monitoring CT scan of head electroencephalography head-up tilt test transthoracic echocardiography
Updated-Aug-2012
Diagnosis and Management of Chronic illness Neurology Question 2 A 78-year-old woman, who was bedbound because of end-stage Parkinson’s disease, was troubled by hallucinations. Her medications were co-beneldopa 125 mg four times daily and pramipexole 1 mg three times daily. There was no evidence that metabolic disturbance or infection had caused these new symptoms. What is the most appropriate first step in her management? A B C D E
reduce dose of co-beneldopa reduce dose of pramipexole start lorazepam start quetiapine start rivastigmine
Updated-Aug-2012
Stroke Care Question 3 A 74-year-old woman presented to the accident and emergency department after sudden onset of right-sided weakness. On examination, she had a right hemiparesis and a leftsided partial ptosis. Where is the most likely site of the lesion? A B C D E
left internal capsule left mid-brain left motor cortex right internal capsule right mid-brain
Updated-Aug-2012
Palliative Care Question 4 An 88-year-old man, who had carcinoma of the bronchus with cerebral metastases, was admitted with convulsions. A decision was made to give palliative care because he was drowsy, unable to swallow and bedbound. Chest wall pain and breathlessness were controlled with a subcutaneous morphine infusion. He was intermittently agitated and had two more convulsions. What is the best option to control the convulsions? A B C D E
bolus intravenous diazepam diazepam suppository midazolam subcutaneous infusion phenytoin intravenous infusion subcutaneous morphine at higher dose
Updated-Aug-2012
Measurement of Health Status Question 5 A 70-year-old man was admitted with a 3-day history of cough, sputum, fever and rigors. He had a past history of hypertension and type 2 diabetes mellitus, both of which were well-controlled. On examination, he was orientated, had a pulse of 84 beats per minute, a blood pressure of 122/84 mmHg and a respiratory rate of 23 breaths per minute. On auscultation, there were coarse crackles in the right lower lobe. Investigations: haemoglobin white cell count
145 g/L (130–180) 23.5 × 109/L (4.0–11.0)
serum sodium serum potassium serum urea serum creatinine
140 mmol/L (137–144) 4.3 mmol/L (3.5–4.9) 6.0 mmol/L (2.5–7.0) 85 µmol/L (60–110)
According to the CURB-65 criteria, which observation is indicative of an increased mortality risk in this patient? A B C D E
age blood pressure male gender urea white cell count
Updated-Aug-2012
Factors affecting health status Question 6 A healthy 75-year-old man saw his general practitioner (GP), as part of the over 75s screening. He was normotensive, and fit and well. He asked his GP about how he could improve his lifestyle to reduce the risk of developing dementia. What advice should his GP give? A B C D E
increase dietary fruit and vegetables increase weight-bearing exercises reduce caffeine intake reduce cholesterol intake reduce total calorie intake
Updated-Aug-2012
Stroke Care Question 7 A 72-year-old man was admitted with a middle cerebral artery infarct confirmed by CT scan of head. He was in atrial fibrillation and had no contraindications to starting warfarin. He made a good early recovery. According to current UK guidance, how soon after an acute cerebral infarct should warfarin be introduced? A B C D E
2 days 1 week 2 weeks 3 weeks 4 weeks
Updated-Aug-2012
Diagnosis and Management of acute illness Gastroenterology Question 8
An 82-year-old woman presented with a 3-month history of diarrhoea and weight loss. She had osteoarthritis and advanced Parkinson’s disease, and mobilised using a walking frame. Despite this, she was keen to undergo further investigation. Investigations: haemoglobin MCV
85 g/L (115–165) 76 fL (80–96)
What is the most appropriate next investigation? A B C D E
colonoscopy CT scan of abdomen with oral contrast double contrast barium enema faecal occult blood testing upper gastrointestinal endoscopy with duodenal biopsy
Updated-Aug-2012
Dementia Question 9 An 82-year-old man with mild dementia was admitted following a syncopal episode. Two months previously, at the local memory clinic, he had been advised to take calcium and vitamin D, galantamine, simvastatin 20 mg at night and aspirin. He had no other significant past medical history and had taken no drugs previously. The patient, his family and memory clinic staff felt that there had been intellectual and functional improvement since starting medication. An ECG showed complete atrioventricular block. An ECG recorded before he had started taking medication had been reported as normal. On examination, he was alert, with warm peripheries and a blood pressure of 128/76 mmHg. What is the most appropriate long-term treatment strategy? A B C D E
change galantamine to memantine change galantamine to rivastigmine insert a permanent pacemaker make no changes to current management stop galantamine
Updated-Aug-2012
Basic science and gerontology Question 10 Human progeria syndromes are considered to represent a human model of accelerated ageing. What is the most characteristic feature observed in this condition? A B C D E
cardiovascular disease in teenage years cataract formation cognitive decline normal weight gain in infant years osteoarthritis
Updated-Aug-2012
Diagnosis and Management of Chronic Illness Diabetes and Endocrine Question 11 A 76-year-old man presented to the outpatient clinic with recurrent falls. He described feeling light-headed on standing and feeling fatigued over the preceding 6 months with a loss of libido. Clinical examination confirmed a postural drop in blood pressure from 128/68 mmHg lying to 84/54 mmHg standing. His past medical history included impaired glucose tolerance and hypothyroidism. Medication included levothyroxine 75 micrograms daily and aspirin 75 mg daily. Which investigation is most likely to explain all these findings? A B C D E
CT scan of abdomen MR scan of brain serum prolactin serum testosterone short tetracosactide (Synacthen®) test
Updated-Aug-2012
Factors affecting health status Question 12 A Hospital Trust changed its menus after a visit from a local celebrity chef. Breakfast was given out concurrently with the morning drug round. Which breakfast drink can be taken confidently with prescribed medication, in the knowledge that no interaction will occur? A B C D E
apple juice cranberry juice filter coffee grapefruit juice milk
Updated-Aug-2012
Diagnosis and Management of acute illness Haematology Question 13 A 78-year-old woman was found to have a deep venous thrombosis. She was treated with low-molecular-weight heparin and warfarin. On day 3, her international normalised ratio was 2.3 (<1.4) and heparin was discontinued. The following day she developed tender, necrotic lesions over her abdomen. What is the most likely cause of the skin necrosis? A B C D E
autoimmune response to subcutaneous heparin factor IX deficiency protein C deficiency thrombocytopenia vitamin C deficiency
Updated-Aug-2012
Basic science and gerontology
Question 14 The resting metabolic rate declines in old age. What is the most likely explanation? A B C D E
decreased secretion of thyroxine insulin resistance loss of brown adipose tissue reduced skeletal muscle mass sedentary lifestyle
Updated-Aug-2012
Basic science and gerontology
Question 15
Changes in life expectancy globally have implications for all societies. In 2025, what is the projected global life expectancy at birth expected to be? A B C D E
43 years 53 years 63 years 73 years 83 years
Updated-Aug-2012
Diagnosis and Management of acute illness Infection Question 16 An 84-year-old woman developed pneumonia after undergoing surgery for a fractured hip. She was treated with a course of co-amoxiclav. She was discharged after 3 weeks, but readmitted a day later feeling unwell. On examination, she was jaundiced, but there were no other abnormalities. Investigations: haemoglobin white cell count platelet count international normalised ratio
125 g/L (115–165) 9.4 × 109/L (4.0–11.0) 300 × 109/L (150–400) 1.2 (<1.4)
serum urea serum creatinine serum total bilirubin serum alanine aminotransferase serum alkaline phosphatase
5.2 mmol/L (2.5–7.0) 107 µmol/L (60–110) 130 µmol/L (1–22) 265 U/L (5–35) 1000 U/L (45–105)
hepatitis screen
normal
liver autoantibodies
normal
ultrasound scan of abdomen
single gallstone and no duct dilatation
CT scan of abdomen
normal
What is the most appropriate investigation? A B C D E
ERCP MR cholangiopancreatography (MRCP) MR scan of abdomen serial liver function tests ultrasound-guided liver biopsy
Updated-Aug-2012
Falls Question 17 An 80-year-old woman presented with 6-month history of recurrent falls and a poor gait pattern. What is the most appropriate method of assessing her risk of falls? A B C D E
Clifton Assessment Procedures for the Elderly (CAPE) get-up-and-go test Hallpike’s test modified Barthel index Romberg’s test
Updated-Aug-2012
Diagnosis and management of acute illness Cardiovascular Question 18 A 78-year-old man was found to be in atrial fibrillation. He had no significant past medical history. An echocardiogram showed a mildly dilated left atrium, no significant valvular abnormalities and good left ventricular systolic function. He started taking warfarin. What is the approximate annual incidence of a major bleeding complication among patients taking warfarin? A B C D E
0.1% 1% 5% 10% 20%
Updated-Aug-2012
Dementia Question 19 A 74-year-old man was referred to the outpatient clinic. He had fallen twice, and thought he had tripped over the carpet on both occasions. His wife reported that he had become quite anxious, especially when he had met with difficulty in completing their tax return. He had seemed more withdrawn than usual. On examination, his mini-mental state examination score was 27/30. Examination of the limbs revealed normal tone, power grade 5/5, brisk lower limb reflexes, and an equivocal left plantar response. Investigations: CT scan of head
prominent ventricles and cerebral sulci; small vessel ischaemia
MR scan of brain
diffuse high signal in periventricular white matter and basal ganglia
What is the most likely diagnosis? A B C D E
Alzheimer’s disease frontotemporal dementia Lewy body dementia normal pressure hydrocephalus vascular dementia
Updated-Aug-2012
Dementia Question 20 A 78-year-old man complained of poor memory over 6 months. He had been found to have idiopathic Parkinson’s disease 6 years previously. What is the best evidence-based treatment for dementia associated with Parkinson’s disease? A B C D E
dl-alpha tocopherol donepezil galantamine memantine rivastigmine
Updated-Aug-2012
Factors affecting health status Question 21 A 74-year-old man attended the clinic for follow-up. He had recently required 10 days’ treatment in hospital following an exacerbation of chronic obstructive pulmonary disease. He was a smoker with a 55 pack-year history. Investigations: forced expiratory volume in 1 s (FEV1) FEV1/forced vital capacity ratio
1.22 L (34% predicted) 0.41 (>0.70)
What intervention is most likely to preserve his remaining lung function? A B C D E
inhaled bronchodilator inhaled corticosteroid Mediterranean diet pulmonary rehabilitation smoking cessation
Updated-Aug-2012
Diagnosis and management of chronic illness Gastroenterology Question 22 A 67-year-old man was admitted complaining of lethargy and a ‘flu-like’ illness, but without any productive cough or sputum. He had a 12-year history of diabetes mellitus and arthritis. On examination he was apyrexial. He had a tanned appearance but there were no abnormal findings in chest or abdomen. Investigations: haemoglobin red cell count haematocrit white cell count erythrocyte sedimentation rate serum iron serum ferritin serum vitamin B12 serum folate
105 g/L (130–180) 5.8 × 1012/L (4.3–5.9) 0.50 (0.40–0.52) 10.0 × 109/L (4.0–11.0) 15 mm/1st h (<20) 110 µmol/L (12–30) 600 µg/L (15–300) 960 ng/L (160–760) 6.0 µg/L (2.0–11.0)
serum alanine aminotransferase serum aspartate aminotransferase serum alkaline phosphatase serum gamma glutamyl transferase
79 U/L (5–35) 56 U/L (1–31) 278 U/L (45–105) 70 U/L (<50)
What is the most likely diagnosis? A B C D E
α1-antitrypsin deficiency haemochromatosis sickle cell anaemia thalassaemia X-linked sideroblastic anaemia
Updated-Aug-2012
Falls Question 23 A 75-year-old woman had a 4-week history of left hip pain following a fall. The pain had become worse and she was now unable to walk. She had a history of chronic renal impairment, a non-functioning left kidney and recurrent urinary tract infections. She had been taking long-term trimethoprim 200 mg at night. On examination, her temperature was 37.4°C, her pulse was 95 beats per minute and regular, and her blood pressure was 110/70 mmHg. Her left hip was flexed and she had painful and restricted movements on internal and external rotation of the joint. She had increased lumbar lordosis. Urinalysis showed leucocytes trace, no nitrites. Investigations: haemoglobin
105 g/L (115–165)
erythrocyte sedimentation rate
82 mm/1st h (<30)
X-ray of left hip
no fracture
What is the most appropriate investigation to confirm the diagnosis? A B C D E
CT scan of abdomen intravenous urography isotope bone scan MR scan of left hip ultrasound scan of abdomen
Updated-Aug-2012
Measurement of Health Status Question 24 A 75-year-old woman presented after a collapse and was found to have a right lower lobe pneumonia. Which risk assessment tool would best assess her prognosis? A B C D E
ABCD2 CURB-65 Rockall STRATIFY Wells
Updated-Aug-2012
Factors affecting Health Status Question 25
A 78-year-old woman was seen in general practice. She was registered blind because of age-related macular degeneration. She had a history of hypertension and hypercholesterolaemia and was a long-standing smoker. Her mother had developed a similar visual problem at the same age. On examination, her body mass index was 32 kg/m2 (18–25). Which risk factor is likely to have contributed most to her macular degeneration? A B C D E
dyslipidaemia history in a first-degree relative hypertension obesity smoking
Updated-Aug-2012
Measurement of Health status Question 26 To evaluate a new falls service, patients attending the emergency department with a fall were allocated by a closed envelope system to either the new falls service or to standard medical care. They were asked to keep a falls diary. After 6 months, the number of recorded falls and attendances, at either primary or secondary care, with a subsequent fall were recorded. What best describes this study? A B C D E
case–control study cohort study cross-sectional study quasi-experimental design study randomised controlled trial
Updated-Aug-2012
Acute illness Diagnosis/Management of acute illness Cardiovascular
Question 27 A 76-year-old man presented after an episode of syncope. He had Alzheimer’s disease, angina, hypertension and type 2 diabetes mellitus. His ECG showed a long QT interval. Which of his medicines is most likely to have prolonged the QT interval? A B C D E
enalapril galantamine glibenclamide isosorbide mononitrate metformin
Updated-Aug-2012
Respiratory Question 28 A 73-year-old man had a 3-week history of cough productive of purulent sputum, associated with intermittent fever and sweats. He had not responded to a course of antibiotics. He had a 55 pack-year smoking history. On examination, he had signs consistent with a small right pleural effusion, confirmed by chest X-ray. A diagnostic pleural aspiration was undertaken. Investigations: random plasma glucose
6.0 mmol/L
pleural fluid analysis: glucose protein lactate dehydrogenase pH cytology
cloudy and turbid 2.8 mmol/L 40 g/L (1–2) 1500 U/L (10–250) 7.15 (7.60–7.64) abundant mesothelial cells and neutrophils negative
Gram stain What is the most appropriate next investigation? A B C D E
CT scan of thorax fibreoptic bronchoscopy PCR analysis of fluid for Mycobacterium tuberculosis pleural biopsy video-assisted thoracoscopy
Updated-Aug-2012
Gastroenterology Question 29
A 79-year-old man presented with generalised abdominal pain that had gradually increased in severity over the past 48 hours. He had chronic atrial fibrillation. On examination, he was tachypnoeic, there were signs of peritoneal irritation and there were no bowel sounds. Investigations: faecal occult blood serum amylase arterial blood gases, breathing air: pH H+ lactate What is the most likely diagnosis? A B C D E
acute appendicitis acute haemorrhagic pancreatitis acute sigmoid diverticulitis early intestinal obstruction mesenteric arterial occlusion
Updated-Aug-2012
positive 360 U/L (60–180) 7.15 (7.35–7.45) 71 nmol/L (35–45) 3.4 mmol/L (0.5–1.6)
Renal inc fluid/elec disturbance Question 30
A 75-year-old woman was admitted in a semiconscious state with a 3-day history of vomiting. She was taking furosemide 40 mg, aspirin 75 mg and omeprazole 20 mg once daily. On examination, she appeared dehydrated and cachectic. Her blood pressure was 100/65 mmHg. She had a urine output of 5 mL in the first hour after admission. Urinalysis showed protein 1+, nitrites 1+. Investigations: haemoglobin
106 g/L (115–165)
serum sodium serum potassium serum urea serum creatinine
125 mmol/L (137–144) 2.4 mmol/L (3.5–4.9) 27.0 mmol/L (2.5–7.0) 323 µmol/L (60–110)
arterial blood gases, breathing air: PO2 PCO2 pH H+ bicarbonate
10.5 kPa (11.3–12.6) 4.2 kPa (4.7–6.0) 7.65 (7.35–7.45) 22 nmol/L (35–45) 60 mmol/L (21–29)
What investigation is most likely to determine the underlying cause of these results? A B C D E
chest X-ray CT pulmonary angiography gastroscopy ultrasound scan of abdomen urine culture
Updated-Aug-2012
Neurology Question 31
A 76-year-old man was referred with left-sided facial weakness, with involvement of the frontalis muscle, of 3 hours’ duration. He had a history of well-controlled hypertension and was taking amlodipine 5 mg daily. What is the most appropriate immediate treatment? A B C D E
aciclovir aspirin dipyridamole prednisolone thrombolysis
Updated-Aug-2012
Neurology Question 32
A 74-year-old woman presented with unsteadiness when walking, especially in the dark, of recent onset. She had no vertigo but had noticed transient visual blurring on turning her head suddenly. She had a history of hypertension, stage 3 chronic kidney disease, type 2 diabetes mellitus and recurrent urine infections. She was taking furosemide, ramipril and gliclazide, and had recently required a 7-day course of intravenous gentamicin. On examination, she had bilateral mild high-frequency sensorineural hearing loss. She had a bilaterally impaired vestibuloocular reflex. What is the most likely diagnosis? A B C D E
acoustic neuroma basilar migraine cerebrovascular event gentamicin toxicity Ménière's disease
Updated-Aug-2012
Dermatology Question 33 A 91-year-old woman was admitted with increasing confusion associated with a widespread blistering rash that had not responded to penicillin. On examination, her temperature was 38.0°C and there was a widespread macular rash with some blisters. What is the most likely cause of her rash? A B C D E
bullous pemphigoid dermatitis herpetiformis drug reaction pemphigus vulgaris Stevens–Johnson syndrome
Updated-Aug-2012
Infection Question 34
A 76-year-old man was admitted to hospital with breathlessness. He had developed a dry cough on his return from a Mediterranean cruise. Despite starting oral amoxicillin, he became progressively breathless with several episodes of haemoptysis and a high fever. On examination he was confused, agitated and dehydrated. Investigations: haemoglobin white cell count neutrophil count lymphocyte count platelet count
115 g/L (130–180) 4.2 × 109/L (4.0–11.0) 13.1 × 109/L (1.5–7.0) 0.8 × 109/L (1.5–4.0) 133 × 109/L (150–400)
serum sodium serum potassium serum urea serum creatinine
122 mmol/L (137–144) 3.5 mmol/L (3.5–4.9) 14.9 mmol/L (2.5–7.0) 129 µmol/L (60–110)
chest X-ray
right middle and lower zone consolidation
blood cultures
no growth
What is the most appropriate next investigation? A B C D E
autoimmune screen bronchoscopy HIV testing lumbar puncture serology
Updated-Aug-2012
Chronic illness Diagnosis/Managment of acute illness Cardiovascular Question 35
A 76-year-old woman, with a history of previous stroke and long-standing uncontrolled hypertension, was referred to the outpatient clinic for advice on her blood pressure treatment. Six blood pressure recordings at home and at her surgery within the past 2 weeks were 188–216/103–112 mmHg. Her therapy comprised ramipril, atenolol and amlodipine. Investigations: serum sodium serum potassium serum urea serum creatinine
138 mmol/L (137–144) 2.9 mmol/L (3.5–4.9) 7 mmol/L (2.5–7.0) 86 µmol/L (60–110)
What non-prescribed product is most likely to be contributing to the treatment failure? A B C D E
antacids liquorice non-steroidal anti-inflammatory drugs pseudoephedrine table salt
Updated-Aug-2012
Endocrine Question 36 A 93-year-old man complained of light-headedness and falls during the day. He had a history of hypertension and type 2 diabetes mellitus. His medication included bendroflumethiazide, amlodipine and gliclazide. On examination, his heart sounds were normal, and his blood pressure was 145/89 mmHg sitting and 124/80 mmHg upright after 3 minutes. The tone, power and reflexes in all of his limbs were normal. Investigations: serum sodium serum potassium serum creatinine plasma thyroid-stimulating hormone plasma free T4 plasma free T3
138 mmol/L (137–144) 5.0 mmol/L (3.5–4.9) 115 μmol/L (60–110) 0.1 mU/L (0.4–5.0) 13.2 pmol/L (10.0–22.0) 7.5 pmol/L (3.0–7.0)
24-h cardiac monitoring
symptomatic episodes of supraventricular
tachycardia What is the most appropriate treatment? A B C D E
amiodarone carbimazole fludrocortisone midodrine verapamil
Updated-Aug-2012
Renal inc fluid/elec disturbance Question 37 A 73-year-old man presented with a 4-month history of tiredness. He was not taking any medication. Examination was normal. Investigations: serum sodium serum potassium serum creatinine plasma osmolality urinary osmolality urinary sodium What is the most appropriate next investigation? A B C D E
chest X-ray CT scan of head short tetracosactide (Synacthen®) test thyroid function tests water deprivation test
Updated-Aug-2012
119 mmol/L (137–144) 3.9 mmol/L (3.5–4.9) 106 µmol/L (60–110) 255 mosmol/kg (278–300) 405 mosmol/kg (350–1000) 32 mmol/L
Neurology Question 38
A 70-year-old man presented with a 3-year history of unsteadiness, recurrent falls and difficulty with gait initiation. For the past year, he had noticed urgency of micturition with incontinence. On examination, he walked with a wide base, took small steps and had difficulty turning. Reflexes were normal and he had no sensory deficit. His mini-mental state examination score was 28/30. A diagnosis of normal pressure hydrocephalus was made. What is the best investigation to determine whether he would benefit from a cerebrospinal fluid shunt? A B C D E
gait analysis lumbar puncture ‘tap test’ MR scan of brain PET scan of brain radionuclide cisternography
Updated-Aug-2012
Musculoskeletal Question 39
A 73-year-old woman with type 2 diabetes mellitus had been admitted several times during the previous year with recurrent urinary tract infections. She was readmitted with fever and intractable back pain. On examination, her temperature was 37.5°C and her blood pressure was 130/85 mmHg. Urinalysis showed protein trace. Investigations: haemoglobin white cell count platelet count
106 g/L (115–165) 13.5 × 109/L (4.0–11.0) 264 × 109/L (150–400)
serum sodium serum potassium serum creatinine serum C-reactive protein
143 mmol/L (137–144) 4.4 mmol/L (3.5–4.9) 123 µmol/L (60–110) 267 mg/L (<10)
X-ray of spine
degenerative changes
What investigation is most likely to confirm the diagnosis? A B C D E
isotope bone scan MR scan of spine serum electrophoresis ultrasound scan of renal tract urine culture
Updated-Aug-2012
Anaemia/Haematology Question 40
A 70-year-old man was admitted because of worsening of an intense widespread rash, which had developed over 9 months. There was no past medical history. On examination, he was covered with a red rash. The skin felt tight to touch but there were no excoriations or areas of blistering. The patient had alopecia and abnormal nails. His temperature was 36.0°C, his pulse was 118 beats per minute and regular, and his blood pressure was 104/56 mmHg. Investigations: serum urea serum creatinine serum albumin serum C-reactive protein
16 mmol/L (2.5–7.0) 92 μmol/L (60–110) 32 g/L (37–49) 64 mg/L (<10)
serum immunoglobulin E
18 kU/L (<120)
HIV
negative
What is the most likely cause of his symptoms? A B C D E
drug reaction eczema HIV seroconversion illness mycosis fungoides psoriasis
Updated-Aug-2012
Rehabilitation and multidisciplinary team working
Question 41 A 74-year-old woman had sustained a right hemiplegia, because of a cerebral haemorrhage 6 weeks previously, and had developed marked spasticity in the upper limb and occasional flexor spasms in the lower limb. As a complication of her stroke she had developed gastrointestinal haemorrhage from a duodenal ulcer but was now stable. What is the most appropriate initial treatment for her spasticity? A B C D E
baclofen dantrolene diazepam methocarbamol tizanidine
Updated-Aug-2012
Planning transfers of care, including discharge Question 42 An 86-year-old woman was transferred to a rehabilitation ward after a prolonged admission with cellulitis and leg ulcers. She had a history of chronic venous insufficiency, hypertension, vascular dementia (mini-mental state examination score 21/30), stage 4 chronic kidney disease and ischaemic heart disease. Before admission, she had lived alone with carers attending three times daily. She had no family but a few elderly friends visited her regularly. Three weeks into her rehabilitation, she was still requiring the assistance of two people with all transfers. She was able to weight-bear for short periods but could not walk. A trial without urinary catheter was aborted as she developed urinary retention. Faecal incontinence was a frequent problem despite thorough attention to her bowel care. At the next multidisciplinary team meeting, the ward therapists reported no progress was being made. The patient retained capacity to make decisions about her discharge destination, but wanted to follow whatever advice she was given by the team. What setting would normally be most appropriate for this patient? A B C D E
intermediate care nursing home residential home for older people sheltered housing with two carers four times per day ‘slow stream’ rehabilitation ward
Updated-Aug-2012
Long term (continuing care)
Question 43 An 87-year-old woman was referred because of a general decline in physical function and confusion. Six months previously, a district nurse had described her as ‘a bit forgetful but functionally independent’. Her nephew had moved in to care for her following the breakdown of his marriage 3 months previously. The general practitioner requested a home visit. On examination, the patient avoided eye contact and mumbled, rocking backwards and forwards in her chair and biting her lips. She did not speak to the geriatrician but gave some responses to her nephew when he shouted at her. She had bruising around the top of both arms, which the nephew said had resulted from his attempts to transfer her on to the commode. The home smelled of urine. What is the most likely cause of this presentation? A B C D E
dementia elder abuse frontal brain tumour generalised anxiety state psychotic depression
Updated-Aug-2012
Falls
Question 44 An 84-year-old man was referred because he had fallen out of bed on several occasions. His wife reported that for several years he had increasingly frequent episodes where he moved about violently in bed, waking her up and sometimes bruising her legs. When these occurred she would wake him and his movements would cease. He was otherwise well. He had hypertension and took losartan 50 mg daily. Physical examination was normal. What is the most likely diagnosis? A B C D E
complex partial seizures generalised seizures rapid eye movement sleep behaviour disorder restless leg syndrome sleep apnoea
Updated-Aug-2012
Delirium
Question 45 A 75-year-old woman was seen in clinic after an isolated episode of confusion. She had no recollection of the event, but her son said that she had telephoned him a number of times, each time asking whether he was coming around for supper. His mother had sounded anxious, though her speech was normal and her voice not slurred. After a few hours, she had returned to her normal self. She had a history of hypertension, migraine and diet-controlled diabetes mellitus. She was a non-smoker and drank moderate amounts of alcohol. Examination was normal, including mini-mental state examination. A CT scan of head was normal. What is the most likely cause for her confusion? A B C D E
early vascular dementia hypoglycaemia temporal lobe epilepsy transient global amnesia transient ischaemic attack
Updated-Aug-2012
Dementia
Question 46 A 75-year-old retired architect presented with a 3-week history of nocturnal confusion and wandering. He had noticed the gradual onset of poor memory for recent events that had become more marked over the past 6 months. Since returning from holiday 4 months previously, he had required help from his wife to get dressed. He had stopped smoking 5 years before presentation. On examination, his pulse was 80 beats per minute and regular, and his blood pressure was 160/80 mmHg. He had normal heart sounds. His reflexes were brisk but symmetrical. Investigations: mini-mental state examination (MMSE) clock drawing executive task (CLOX1) confusion assessment method (CAM) informant questionnaire on cognitive dysfunction in the elderly (IQCODE) What is the most likely diagnosis? A B C D E
Alzheimer’s disease delirium depression normal pressure hydrocephalus vascular dementia
Updated-Aug-2012
28/30 4/15 negative 4.2/5.0
Continence Question 47 A 79-year-old woman complained of an urgent feeling of the need to pass urine, on some occasions followed by uncontrolled passage of urine. Her symptoms had gradually worsened over several months. She had a history of hypertension, had sustained two strokes and was taking amlodipine 5 mg daily. Physical examination revealed no significant abnormalities apart from slight hypertonia and hyper-reflexia in her left arm and leg. Her mini-mental state examination score was 22/30. Urinalysis was normal. What is the most likely explanation for this pattern of incontinence? A B C D E
an S4 sensory nerve root lesion detrusor sphincter dyssynergia pelvic floor weakness retention of urine with overflow incontinence uninhibited neurogenic incontinence
Updated-Aug-2012
Poor mobility Question 48 A 72-year-old woman presented with a 2-month history of deteriorating mobility. She had been struggling to manage in her warden-controlled flat, and had fallen a couple of times. She complained of frequent muscle cramps. On examination, she had power 4/5 in all limbs with generalised wasting which was particularly marked in the small muscles of her hands. She had some fasciculation in both legs. Sensation was intact. Her speech was normal. What is the most likely diagnosis? A B C D E
Guillain–Barré syndrome motor neurone disease myasthenia gravis myopathy peripheral neuropathy
Updated-Aug-2012
Nutrition Tissue viability Homeostasis Question 49 A 77-year-old woman had a nasogastric tube inserted 2 days after a stroke because she was unable to swallow safely. She had a history of alcohol abuse. Feeding was started at a rate of 40 kcal/kg/day. Two days later, she became acutely confused, and developed diplopia and rotational vertigo. What is the most likely reason for her new symptoms? A B C D E
alcohol withdrawal syndrome hyponatraemia metabolic acidosis re-feeding syndrome thiamine deficiency
Updated-Aug-2012
Tissue Viability Question 50 An 89-year-old woman with type 2 diabetes mellitus was admitted for further management of bilateral leg ulcers that were foul-smelling and painful. On examination, the ulcers were located over the medial aspect of each lower leg, with the left extending over the medial malleolus. The right-sided ulcer measured 7 cm × 4 cm, the left 9 cm × 4 cm. The lower legs were oedematous (non-pitting). The overlying skin was thin, dry and scaly and there were areas of brown pigmentation. On the left side, there was evidence of scarring, attributed to a previous healed ulcer. The edge of the new ulcer was irregular. Both ulcers were shallow, and contained a small amount of necrotic tissue and a moderate amount of extremely malodorous exudate. What is the most likely underlying cause of the ulcers? A B C D E
arterial insufficiency pressure ulceration pyoderma gangrenosum vasculitis venous insufficiency
Updated-Aug-2012
Palliative care
Question 51 An 85-year-old man was admitted with vomiting. He had a past history of locally invasive carcinoma of the transverse colon, which had been partially resected a year earlier. An X-ray of the abdomen confirmed large bowel obstruction and a CT scan showed extensive malignant disease. A decision was made to treat him symptomatically and not to subject him to further surgery. What is the most effective drug treatment for his vomiting in this situation? A B C D E
cyclizine granisetron haloperidol levomepromazine octreotide
Updated-Aug-2012
Orthogeriatrics and osteoporosis
Question 52 An 83-year-old man with a history of polymyalgia rheumatica and a Colles’ fracture was advised to take prednisolone and strontium ranelate. What is the most appropriate advice about when he should take strontium ranelate? A B C D E
at bedtime at least 2 h after eating in the evening just before eating in the morning 2 h after eating in the morning just before eating once daily whenever he wishes
Updated-Aug-2012
Old age psychiatry
Question 53 An 80-year-old professional man attended the clinic because of declining memory. His wife reported that he had become withdrawn over the past month and changed from his usual extroverted character. He did not have a past history of depression. On examination, his mini-mental state examination score was 25/30. He complained about memory loss and replied “I don’t know” to a number of questions he was asked. Which feature would most strongly suggest a diagnosis of depression rather than dementia? A B C D E
change of character no previous history of depression poor insight into memory loss rapid progression of symptoms symptoms worse in the evening
Updated-Aug-2012
Stroke care
Question 54 A 93-year-old woman developed unilateral deafness of sudden onset, numbness on one side of her face and vertigo. On examination, there was mild unilateral facial weakness. Otoscopy was normal. What is the most likely diagnosis? A B C D E
acoustic neuroma anterior inferior cerebellar artery thrombosis herpes simplex infection polyarteritis nodosa Waldenström’s macroglobulinaemia
Updated-Aug-2012
Management of chronic disease and disability Question 55.
A 73-year-old man with metastatic prostate cancer presented with increasing pain in his right hip. He described the pain as worse with movement and complained that he was now unable to walk his dog. His prostate cancer was treated with goserelin injections at 3-month intervals. On examination, he had tenderness over the right trochanter. Investigations: X-ray of right hip
large lytic lesion with cortical thinning within the upper third of right femur
What is the most appropriate next step in management? A B C D E
bicalutamide cyproterone acetate disodium pamidronate internal fixation radiotherapy
Updated-Aug-2012
Management of chronic disease and disability Question 56.
A 72-year-old man presented with a 3-week history of persistent vomiting and a 12-kg weight loss. He had a previous history of stroke resulting in an expressive dysphasia and right hemiparesis. His Karnofsky performance status was 30. At endoscopy, he had a large fungating mass of the lesser curve of his stomach extending towards the cardia and proximally into the lower oesophagus. Histology confirmed an adenocarcinoma of the stomach. Despite high-dose antiemetics, he continued to vomit and a water-soluble contrast study showed narrowing of the oesophagogastric junction. What is the most appropriate next step in management? A B C D E
chemotherapy gastrojejunostomy radiotherapy stent insertion venting gastrostomy
Updated-Aug-2012
Management of acute illness
Question 57. A 68-year-old man presented with a 2-week history of headache. On examination, he had suffusion of the face and eyes, facial oedema and distended jugular veins, which were non-pulsatile. A CT scan of chest showed that the superior vena cava was compressed by a tumour in the right upper lobe of the lung, and there was evidence of a clot within the vessel. At bronchoscopy, he had a tumour in the right upper lobe bronchus; biopsies confirmed this to be a small cell carcinoma of the bronchus. What is the most appropriate immediate management? A B C D E
anticoagulation chemotherapy high-dose corticosteroids radiotherapy to the mediastinum superior vena caval stenting
Updated-Aug-2012
Diagnosis of chronic disease and disability Question 58.
A 65-year-old man presented with fatigue. He had type 2 diabetes mellitus and was taking gliclazide 40 mg once daily. He drank 4 pints of 5% lager per day. In the past, he had injected recreational drugs, but he denied sharing needles and had not used any illicit drugs for over 20 years. On examination, he had no signs of chronic liver disease. Investigations: haemoglobin white cell count international normalised ratio activated partial thromboplastin time
140 g/L (130–180) 7.0 × 109/L (4.0–11.0) 1.2 (<1.4) 35 s (30–40)
serum urea serum creatinine serum total bilirubin serum alanine aminotransferase serum alkaline phosphatase
6.0 mmol/L (2.5–7.0) 100 µmol/L (60–110) 18 µmol/L (1–22) 140 U/L (5–35) 103 U/L (45–105)
ultrasound scan of abdomen
hyperechoic liver parenchyma
What is the most likely diagnosis? A B C D E
alcoholic liver disease haemochromatosis hepatitis B hepatitis C non-alcoholic steatohepatitis
Updated-Aug-2012
Diagnosis of chronic disease and disability Question 59.
A 70-year-old woman attended clinic for review with her husband. He reported that she was becoming very forgetful. She had also started to “see things, like the faces of little children who were not there”. She had first presented 1 year previously with features of parkinsonism, which had since responded poorly to levodopa. Her mini-mental state examination score was 20/30. What is the most likely diagnosis? A B C D E
Alzheimer’s disease corticobasal degeneration dementia with Lewy bodies multiple system atrophy vascular dementia
Updated-Aug-2012
Delirium Question 60.
An 88-year-old woman was admitted from a residential home with delirium resulting from a urinary tract infection, which had been treated by her general practitioner with antibiotics. Shortly after admission she developed persistent diarrhoea. She was treated with intravenous fluids, but her condition deteriorated over the next 48 hours. On examination, she looked unwell, her temperature was 38.5°C, her pulse was 130 beats per minute and her blood pressure was 95/65 mmHg. She had a tender, distended abdomen. Investigations: haemoglobin white cell count neutrophil count platelet count
116 g/L (115–165) 31.8 × 109/L (4.0–11.0) 28.1 × 109/L (1.5–7.0) 185 × 109/L (150–400)
serum urea serum creatinine
9.5 mmol/L (2.5–7.0) 130 μmol/L (60–110)
faecal Clostridium difficile toxin
negative
X-ray of abdomen
dilated large bowel with thickened bowel wall
What is the most likely diagnosis? A B C D E
campylobacter gastroenteritis diverticulitis Escherichia coli O157 infection pseudomembranous colitis ulcerative colitis
Updated-Aug-2012
Measurement of health status Question 61.
An 80-year-old woman with a history of stroke and rheumatoid arthritis was admitted to hospital. On examination, she had changes of chronic rheumatoid arthritis and a residual hemiparesis, and appeared thin and malnourished. An assessment of her risk of pressure sores was undertaken. What is the most appropriate rating scale? A B C D E
Barthel early warning score Malnutrition Universal Screening Tool modified Rankin Waterlow
Updated-Aug-2012
Diagnosis of chronic disease and disability Question 62.
A 75-year-old retired building labourer presented with a 3-year history of exertional breathlessness and dry cough. He reported having chest problems since he was a teenager. He had been given standard treatment for pulmonary tuberculosis 40 years previously. He smoked 30 cigarettes a day and his hobbies included racing pigeons. On examination, he had finger clubbing and lung crackles to his mid zones. Investigations:
chest X-ray
What is the most likely diagnosis? A B C D E
asbestosis bronchiectasis extrinsic allergic alveolitis idiopathic pulmonary fibrosis sarcoidosis
Updated-Aug-2012
irregular pulmonary opacities at both lung bases; multiple calcified pleural plaques, including on diaphragmatic pleural surface
Basic science and gerontology Question 63.
Over the next 50 years the proportion of older people in the population will increase significantly. What is the projected percentage increase in the number of people aged over 65 years in the UK over that time period? A B C D E
20% 40% 60% 80% 100%
Updated-Aug-2012
Dementia Question 64.
An 84-year-old woman with type 2 diabetes mellitus presented with a 2-year history of forgetfulness for recent events. Her treatment comprised metformin and insulin glargine. On examination, she had mild sensory peripheral neuropathy and background retinopathy. Her blood pressure was 146/78 mmHg. Her mini-mental state examination score was 20/30. Investigations: serum sodium serum potassium serum urea serum creatinine haemoglobin A1c
143 mmol/L (137–144) 4.4 mmol/L (3.5–4.9) 8.0 mmol/L (2.5–7.0) 123 µmol/L(60–110) 48 mmol/mol (20–42)
serum cholesterol
7.4 mmol/L (<5.2)
What intervention is most likely to slow her cognitive decline? A B C D E
galantamine increase insulin dosage ramipril reduce insulin dosage simvastatin
Updated-Aug-2012
Basic science and gerontology Question 65.
The proportion of older people in the UK will increase over the next 50 years, many of whom will be frail. What is the projected percentage increase in care-home residents (residential and nursing homes) in the UK over the next 50 years? A B C D E
50% 100% 150% 200% 300%
Updated-Aug-2012
Answers
1. D 2. B 3. B 4. C 5. A 6. A 7. C 8. B 9. C 10. A 11. B 12. A 13. C 14. D 15. D 16. D 17. B 18. B 19. E 20. E 21. E 22. B 23. A 24. B 25. E 26. E 27. B 28. A 29. E 30. C 31. D 32. D 33. A 34. E 35. B 36. B 37. A 38. B 39. B 40. D 41. E 42. B 43. B 44. C 45. D 46. E 47. E 48. B 49. E Updated-Aug-2012
50. 51. 52. 53. 54. 55. 56. 57. 58. 59. 60. 61. 62. 63. 64. 65.
E E A D B D D C E C D E A D A C
Updated-Aug-2012
