VSAS questions

1. Next best step arrest; compression and ventilation done. Cardiac arrest team here. ECG shows
asystole – ADRENALINE not defibrillate

2. Man with acute attack of gout. eGFR > 60. Currently on allopurinol, amlodipine, and ramipril.
What do you do next?
A) Naproxen  NICE says to give NSAID ASAP and continue 1-2 days after attack resolved, provided
no C/I. Alternatives: colchicine or PO/IM steroids

B) Change allopurinol to febuxostat

C) Stop allopurinol

D) Stop amlodipine

E) Stop ramipril

The rest are not effective at aborting an acute attack of gout.

3. Man >60y comes in with unprovoked DVT (proven by duplex), next best Ix? CT abdo pelvis (and
mammogram) if all aged > 40 y for 1st unprovoked DVT (not abdo USS to look for more proximal
throbmosis)

4. Lady with hormone related pain and lumpy axillary tail + discrete lump  fibrocystic change.

5. Old lady came in after falling down when standing up. HR: 30, BP: 80/70 sinus bradycardia, no
ischaemic changes. Next best step? Atropine (no option to cardiovert…)

6. Lady 6m of increasing pain and swollen, tender CMC joint. Difficulty opening jars.  de Quervain’s
tenosynovitis.

7. Lady difficulty getting dress, takes time for muscle aches to go away. Tx? Pred (PMR).

8. MoDA of cocaine causing C/P?  vasospasm coronary arteries

9. Young guy who takes cocaine and marijuana. Comes in SOB on exertion. Chest reduced BS on apex
on right side. To normal. HR slightly tachycardic. Spontaneous PTX (is associated w these 2 drug
usage)

10. Ovarian cancer which nodes spread 1st?

A) Deep inguinal (third, via round ligament. only 40%)

B) Superficial inguinal

C) Internal iliac

D) External iliac (second, via broad ligament)

E) Para-aortic!! FIRST via ovarian blood vessels in infundibular ligament

11. Patient present w foot drop only. What nerve implicated? Superficial peroneal nerve (not CPN…
no sensory changes)

12. Guy who had hemicolectomy 6m ago pt: N&V, dehydration, distension  adhesion related BO

13. Young guy came in SOB and tachycardia CXR next best step.

14. Patient had a stroke – what 1st radiological Ix?  CT head

15. Lady who had cranial NI determined by water deprivation test and desmopressin responsiveness.
Next best step? MRI pituitary
16. What is the maintenance fluid for a 70 kg man who has ischaemic heart disease causing LVEF
reduction?

Formula: 70 kg x 25-30 mL/kg/day of water = 1750 – 2100 mL.

Go lower if risk HF etc. e.g. 70 kg x 20-25 mL/kg/day = 1400 – 1750 mL.

17. Patient with RA – best Dx test? Anti-CCP

18. Patient BG MCI now delirium and agitated, hitting staff etc. Tx? IM haloperidol

19. Ask mother if they smoke at booking. Then follow birthweight of child at end of pregnancy. Best
description of study?

Prospective cohort
Vs. Case-control

20. Patient going to surgery on glicazide and metformin. What should you do to the drug?

Continue metformin night before (stop on day of surgery), stop glicazide the night before.

21. A doctor did not recommend internet-based education therapy for 78year old man who has DM.
What is this approach called? Stereotypy?

22. Guy w mild hepatomegaly. Ferritin level 700 + (very high). Next best step? Transferrin
saturations (more SN than ferritin – acute phase reactant) then HFE genotyping then ?Liver Bx if
unconfirmed.

23. 56 y lady with sore vagina, itchiness, discharge. Labia is erythematous. Doctor dx her w recurrent
candidiasis. Next best step?
A) Sexual screen

B) Treat partner for candidiasis??  do not routinely treat ASx sexual partner.

C) HIV screen

D) DM testing??

E) Vaginal PH

NICE says: send specimen for microscopy, culture, sensitivity; vaginal PH  alternative Dx.

 The symptoms of vulvovaginal candidiasis are non-specific and may occur in

women with other conditions [BASHH, 2007b; CDC, 2015]. CKS recommends
considering alternative diagnoses if there is treatment failure, as misdiagnosis is a
common cause for treatment failure.
 Recurrent vv candiadiassis = > 4 documented cases per year with partial
resolution (microscopy evidence of C. albicans growth when Sx)

Also to assess predisposing factors (oestrogen exposure, immunocompromised e.g. HIV testing,
poorly controlled ABx, sexual behaviours = STIs).

 Quite strange for her at that age to have DM

 HIV testing hmm quite invasive for a meh condition
 STIs screen? Discharge… quite invasive for a meh condition
 Vaginal PH easiest to do. But BASSH has nothing for that in their guidelines… only NICE.

Hmmm. I would choose vaginal pH.

24. Patient with unilateral hydroneprhosis w stone proximally. NEPHROSTOMY after IVF and IV ABx

25. Acute occipital headache, vertigo, and multidirectional nystagmus  cerebellar stroke

26. 47 y man came in with OKish BP controlled by ramipril (138/79). But high K+ (5+). Next best step?

Reduce ramipril dose (I don’t think adding indapamide (thiazide-like = hypokalaemia) but BP
fine…why add more meds?? He is 47y… or switching to amlodipine (=CCB… only recommended if >
55y, K+ effect ok) helps). Other options were recheck U&Es – meh, or advise low K+ diet – meh

27. Girl with scaly rash everytime insect bite or hit arm. Psoriasis.

28. Man came in with opthalmoplegia, weakness, and difficulty breathing, after viral infection 
GBS. What is the best test to monitor his respiratory function?

A) ABG
B) FEV1

C) FVC

D) FEV1:FVC

E) PEFR

29. Man came in with recently Dx advanced cancer and now confirmed SVCO. What is FIRST INITIAL
step?

IV dex then endovascular stenting.

30. Patient w superficial thrombophlebitis and varicosities bilaterally. What drug?

A) Dipyramidole

B) Paracetamol

C) Naproxen  NICE says PO NSAIDs and/or paracetamol.

D) Flucloxacillin

E) Rivaroxamab

31. Patient with slow healing ulcer. OK ABPI. What Tx?

A) Compression stocking?
B) Full-length compression bandages?

NICE says: multi-layer graduated (i.e. highest from toe, lowest P on knee to return venous blood)
compression bandaging, below-knee (not thigh-length)… so neither answers are correct… hmm

32. Patient came in with neck lump 1.5 cm in thyroid but TFT fine. Next best step (no option to FNA)
 do nothing. Other options were: check thyroid Ab, isotope scan.

33. Patient with melena, on ASA + warfarin.

Already transfusion X-match and IV vitamin K

WHAT ADDITIONAL REVERSAL AGENT to add?

NICE says offer PCC to patients taking warfarin and actively bleeding. FFP who are actively
bleeding and INR 1.5X more than normal.

PCC reverses faster than FFP.

Answer: PCC (then FFP if unavailable).

Reversal of plt function: dDAVP and platelets (not FFP = plasma)

34. Patient with burns. Now develop petechiae rash. FDP high. Dx? DIC.

35. Tuning fork test

Midline  right better

Right ear BC > AC (abnormal)

Left ear AC > BC (normal)

Therefore RHS conducting hearing loss.

36. Mid-dilated pupil, N&V, headache, hazy  acute glaucoma

37. Recurrent choledocholithiasis/cholecystitis episodes  lap chole

38. Patient with bilateral pitting oedema. P:CR high. Definitive Dx by? Renal Bx.

39. Pt large meal then subcut emphysema Dx? Oesophageal rupture/Boerrhave’s

40. 2h clear fluid, 6h food before opreation

41. What device will protect oesophagus and trachea for this emergency appendectomy patient?
ETT (options: iGEL, LMA)

42. Diabetes with cellulitis – most common organism? Group A Strep (beta-haemolytic) > staph (not
pseudomonas!) – British Derm Soc.

43. Patient present w amenorrhoea and galactorrhoea. MRI shows 4 mm pituitary tumour. What Tx?
Bromocriptine/carbegoline

Other choices were: octreotide (somatostatin analogue); resection (too small)

44. Man pt with small well-defined circular testicular lump that is transilluminable, at superior
aspect of testes. Dx? Epididymal cyst (not hydrocele)

45. Woman w headache, just came out of burning building – best test to determine Dx? ABG =
carboxyHb

46. GCS scoring: open to name call; incomprehensible but tries to describe what is going on; actively
trying to remove cannula = 3 + 4 + 5 = 12.

47. Woman with headache after LP. (Can’t remember other info). I think this was CSF leak (>
meningitis > migraine).

48.

49.

50.