Which of the following would be expected to reduce maternal mortality when given in

eclampsia?

Available marks are shown in brackets
1 ) Insulin and dextrose infusion [!
" ) #ow dose dopamine infusion [!
$ ) %agnesium infusion [1!
& ) 'henytoin infusion [!
( ) )albutamol infusion [!
********************************************************************************
+omments,
%agnesium has been shown to significantly reduce maternal mortality in eclampsia and a
favourable outcome may also be expected in pre*eclampsia- .one of the other agents has
been associated with a reduced mortality in eclampsia-
********************************************************************************
In most cardiac arrest situations 1mg of adrenaline /epinephrine) is given intravenously
every $ minutes- What is the correct volume and concentration of the adrenaline?

Available marks are shown in brackets
1 ) -1ml of 1 in 1 [!
" ) 1ml of 1 in 1 [!
$ ) 1ml of 1 in 1 [!
& ) 1ml of 1 in 10 [!
( ) 1ml of 1 in 10 [1!
********************************************************************************
+omments,
A 1mg dose of adrenaline /epinephrine) would be administered with answers A0 1 and 2-
3owever0 1 ml is considered the optimum volume of adrenaline during cardiac arrest-
********************************************************************************
In malignant hyperpyrexia,

Available marks are shown in brackets
1 ) A mortality rate of "4 may be expected [!
" ) 2levation of serum creatine kinase and myoglobinuria is diagnostic [!
$ ) %uscle biopsy may be histologically normal [1!
& ) 5he only available specific treatment is sodium dantrolene0 which has a neutral p3
[!
( ) 5he predisposing gene is thought to be on chromosome 6 [!
********************************************************************************
+omments,
%alignant hyperpyrexia /%3) is characterised by increased temperature and muscle
rigidity during anaesthesia0 which results from abnormal skeletal muscle contraction and
increased metabolism- 5he predisposing gene is thought to be on chromosome 160 close
to the gene for the ryanodine 7 dihydropyridine receptor complex- 8nown triggering
agents include the volatile anaesthetic agents and suxamethonium- 'atients show different
sensitivity to the triggering agents and the reaction can be delayed by several hours-
Intravenous dantrolene /up to 1mg78g) is the only available specific treatment- 5he
solution has a p3 of 6 to 1- 5he prognosis is good when the appropriate treatment is
instigated early0 mortality being 9(4 /prior to dantrolene the mortality was :4)- )erum
creatine kinase elevation and myoglobinuria are suggestive but not diagnostic of %3-
%yoglobin and creatine kinase are both known to increase after giving suxamethonium to
normal patients- +ontracture tests using caffeine and halothane are the investigations of
choice- %uscle biopsies may appear histologically normal-

********************************************************************************
A 1; year old girl presents after having ingested fifty of her mother<s =luoxetine tablets0
approximately ( hours previously-
Which one of the following clinical features is compatible with this history?


Available marks are shown in brackets
1 ) 'upillary constriction [!
" ) heart rate of > beats per minute [1!
$ ) ?@) duration of 1" ms /91) [!
& ) respiratory rate of six breaths per minute [!
( ) convulsions [!
********************************************************************************
+omments,
Anlike the 5ricyclic antidepressants0 =luoxetine like many of the ))@Is are safe in
overdose causing very few effects- If anything0 reports would suggest that tacchycardia
can occur together with tremor0 drowsiness0 nausea and vomiting also rarely reported-
5hus a heart rate of > beats per minute is compatible with the patient having taken an
overdose of 'roBac- 'upillary constriction suggests opiates as does respiratory depression
with prolonged ?@) with 5+As
5hese are the blood gas results obtained in a " year old female admitted to hospital-
hydrogen ion concentration $( nmol7# /$( C &()
p3 ;-&( /;-$(*;-&()
p+" >-: k'a /&-> C (-6)
bicarbonate $" mmol7# /"" * ">)
Which one of the following is a recognised cause of this acid*base disorder?


Available marks are shown in brackets
1 ) Amitriptyline overdose [!
" ) +ushingDs syndrome [!
$ ) 3epatic failure [!
& ) 'regnancy [1!
( ) )alicylate poisoning [!
********************************************************************************
+omments,
5his patient has a mild metabolic alkalosis with what appears to be respiratory
compensation as reflected by the elevated p+E"- Amitriptyline overdose is associated
with acidosis as is salicylate poisoning- 3epatic failure usually presents with acidosis-
5his type of picture is associated with prolonged vomiting /as in pregnancy)0 diarrhoea0
diuretic therapy and in +ushing<s syndrome or in those receiving high dose
corticosteroids- With no other information provided for this case0 common things being
common0 one should select pregnancy as the best answer for a " year old female-
********************************************************************************
; year old female who has a history of chronic anxiety presents with a $ day history of
severe left temporal headache radiating from the eye to the scalp- )he had also
experienced discomfort during eating-
Which one of the following drugs should be given to this patient while awaiting the
results of diagnostic tests?


Available marks are shown in brackets
1 ) Acyclovir [!
" ) +arbamaBepine [!
$ ) Ficlofenac [!
& ) 'rednisolone [1!
( ) )umatriptan [!
********************************************************************************
+omments,
5he history suggests temporal arteritis irrespective of the history of anxiety and in view
of the sight threatening nature of the disease0 the patient should be commenced on
steroids- Although the differential diagnosis is also trigeminal neuralgia steroids should
be used here whilst awaiting diagnostic investigations as temporal arteritis may be sight
threatening if left untreated-

********************************************************************************


5he average score for this Guestion is ;(-&4 /answered $$(( times)


youth worker0 aged &0 presents to Accident and 2mergency with vomiting- En detailed
Guestioning0 he admits to having taken $> paracetamol tablets " hours previously- 3e is
vomiting profusely with a 1' of 67>- Which of the following measures would be most
appropriate?

Available marks are shown in brackets
1 ) 'aracetamol levels [!
" ) oral methionone [!
$ ) IH .*acetyl cysteine [!
& ) IH fluids [1!
( ) +oagulation screen [!
********************************************************************************
+omments,
5he most pressing issue in this patient is resuscitation as he is vomiting and hypotensive-
It is too early to carry out paracetamol levels as these should be carried out at & hours0
and certainly too early to instigate treatment with .A+ or methionine- An I.@ gives an
indication of hepatocellular damage and again this will not be seen at presentation of
paracetamol overdose-
********************************************************************************


5he average score for this Guestion is (;-&4 /answered &&(& times)
A $ year old man is admitted three hours after taking an overdose of amitriptyline and
diaBepam- En examination he was drowsy with a Ilasgow +oma )cale of :0 he had a
pulse of 1& beats per minute0 a blood pressure of 11&7:: mm3g and dilated pupils- 3is
oxygen saturation was 64 on room air- What is the most appropriate initial action for
this patient?


Available marks are shown in brackets
1 ) activated charcoal [!
" ) +5 head scan [!
$ ) 2+I [1!
& ) IH atenolol [!
( ) IH flumaBenil [!
********************************************************************************
+omments,
Faft Guestion really- 5he most appropriate initial action would be to get the investigations
done as Guickly as possible C arterial blood gases and 2+I as the latter may show ?@)
widening and merit treatment- 5hen0 the next step would be gastric decontamination with
lavage and activated charcoal- 5reatment with bicarbonate is also advocated as this
patient displays features of severe 5+A overdose- 3e doesn<t need a +5 scan as the
symptoms are typical of tricyclic overdose- =lumaBenil is not appropriate for this patient
as the symptoms are mostly of 5+A overdose nor is IH atenolol appropriate for the
arrhthymias C bretylium0 phenytoin or lidocaine-

********************************************************************************
5he anticonvulsant #evetiracetecam

Available marks are shown in brackets
1 ) Is used as monotherapy for the treatment of generalised convulsions [!
" ) Acts via the IA1A receptor [!
$ ) Is associated with induction of hepatic cytochrome p&( enBymes [!
& ) Is well absorbed via the oral route [1!
( ) Is associated with increased plasma concentrations of sodium valproate [!
********************************************************************************
+omments,
#evetiractecam /8eppra) is an adJunctive treatment for partial seiBures with or without
secondary generalisation- Its mechanism of action is unknown- It is rapidly absorbed
orally0 it does not effect hepatic enBymes but dose reduction is reGuired in renal failure-
5he drug appears to be well tolerated with few side effects-
********************************************************************************
%yalgia is typical of,

A 5homsenDs disease /congenital myotonia)
f
1 myoglobinuria
true
+ progressive muscular dystrophy
false
F renal tubular acidosis
true
2 %cArdleDs syndrome
true
********************************************************************************
+omments,
e*2specially after exercise-
@ead more about myalgia 7 myositis here-

5he following are seen in +rohnDs disease,

A dermatitis herpetiformis
f
1 steatorrhoea
t
+ pyoderma gangrenosum
true
F haemolytic anaemia following sulphasalaBine treatment
true
2 erythema nodosum
true
********************************************************************************
+omments,
Fermatitis herpetiformis is a manifestation of coeliac disease- =at malabsorption may be
afeature of crohnDs with 2rythema nodosum and pyoderma gangrenosum being cutaneous
manifestations- Eligoarthritis with )acroilitis and iritis may also feature- )ulphasalaBine
can produce a number of haematological problems in particular thrombocytopaenia0
leucopaenia but haemolysis can occur-
********************************************************************************

$ year old caucasian male presents with a six month history of weight loss0 abdominal
pain0 and diarrhoea- En examination you note finger clubbing- Which of the following
diagnoses is least likely-

Available marks are shown in brackets
1 ) +rohnDs disease [!
" ) Alcerative colitis [!
$ ) +oeliac disease [!
& ) WhippleDs disease [!
( ) Ileo*caecal 51 [1!
********************************************************************************
+omments,
Ileo*caecal 51 is the only condition mentioned not associated with clubbing and would
be very rare in a young caucasian in the A8-
********************************************************************************


5he average score for this Guestion is $:-"4 /answered
A 1> year old boy with cystic fibrosis presents with abdominal pain- Which of the
following is most likely to be the cause?

Available marks are shown in brackets
1 ) Alcerative colitis [!
" ) Irritable 1owel )yndrome [!
$ ) 'yelonephritis [!
& ) %econium Ileus 2Guivalent )yndrome [1!
( ) @enal +alculi [!
********************************************************************************
+omments,
%econium ileus eGuivalent or distal intestinal obstruction syndrome occurs in older
children and adults with += and presents with colicky abdominal pain0 distension0
vomiting and failure to pass faeces- 5he plain AK@ confirms small bowel obstruction-
Initial management includes rehydration with IH fluids and oral .* acetyl cysteine- Ether
II complications of 7 associations with += include liver cirrhosis0 gall bladder disease0
pancreatitis0 peptic ulceration0 hiatus hernia0 coeliac disease and +rohns disease-
********************************************************************************


5he average score for this Guestion is :"-$4 /answered
A >*year*old woman with known alcoholic liver cirrhosis presents with vague
abdominal pains0 malaise and nausea- )he has been abstinent since she was diagnosed
eight months ago- En examination she had moderate ascites and mild0 generalised
abdominal tenderness-
Investigations
3aemoglobin 11-" g7d# /11-( * 1>-()
W++ 1( x 1 67# /& * 11)
prothrombin time "1 s /91(s)
serum albumin ": g7# /$; * &6)
serum total bilirubin (> micromol7# /1 * "")
ascitic fluid protein "> g7#
ascitic fluid amylase normal
ascitic fluid white cell count ( x 167#
What is the most likely reason for her current problem?


Available marks are shown in brackets
1 ) hepatic vein thrombosis [!
" ) pancreatic pseudocyst rupture [!
$ ) portal vein thrombosis [!
& ) primary liver cancer [!
( ) spontaneous bacterial peritonitis [1!
********************************************************************************
+omments,
5he high white cell count in the ascites makes spontaneous bacterial peritonitis /)1')
much more likely than 1udd +hiari )yndrome /1+))0 'H50 3++0 or a ruptured
pancreatic pseudocyst- Abdominal pain is often only mild0 or even absent in )1'0 with
patients often presenting with otherwise unexplained hepatic decompensation-
>(*year*old man is referred with abnormal liver function and undergoes a liver biopsy-
Which of the following count against hepatic cirrhosis?


Available marks are shown in brackets
1 ) =ibrous septa formation [!
" ) Iranuloma formation [1!
$ ) #iver cell necrosis [!
& ) .odular regeneration [!
( ) )ubendothelial fibrosis [!
********************************************************************************
+omments,
Iranuloma formation is not classically seen in cirrhosis0 which can be micro or
macronodular in type- In the micronodular form0the nodules are less than $mm across
with uniform liver involvement * seen in alcohol or biliary disease- In the macronodular
form0 there are larger nodules0 classically seen in chronic viral hepatitis-)

********************************************************************************

A >(*year*old man is referred with abnormal liver function and undergoes a liver biopsy-
Which of the following count against hepatic cirrhosis?


Available marks are shown in brackets
1 ) =ibrous septa formation [!
" ) Iranuloma formation [1!
$ ) #iver cell necrosis [!
& ) .odular regeneration [!
( ) )ubendothelial fibrosis [!
********************************************************************************
+omments,
Iranuloma formation is not classically seen in cirrhosis0 which can be micro or
macronodular in type- In the micronodular form0the nodules are less than $mm across
with uniform liver involvement * seen in alcohol or biliary disease- In the macronodular
form0 there are larger nodules0 classically seen in chronic viral hepatitis-)

********************************************************************************
&& year old male with +hildDs grade + cirrhosis presented with haematemesis- Which one
of the following drugs0 administered intravenously0 would be the most appropriate0
immediate0 treatment?

Available marks are shown in brackets
1 ) Isosorbide dinitrate- [!
" ) EmepraBole- [!
$ ) 'ropranolol [!
& ) )omatostatin [1!
( ) 5ranexamic acid- [!
********************************************************************************
+omments,
5he suggestion is that this patient is at particularly high risk of oesophageal varices-
+hild<s classification of cirrhosis is a points scale based upon ascites7bilirubin etc
reflecting prognosis- Iraded depending upon the points scored from A*+ with +
reflecting greatest risk- )omatostatin acts to reduce portal pressures and has been
demonstrated to be as effective as endoscopy at controlling variceal bleeding in the acute
setting- 1eta*blockers can be used as oral prophylaxis for oesophageal varices- IH
EmepraBole has also been shown to be effective in reducing mortality in II haemorrhage
of any cause /.2L% "") but somatostatin may be expected to be superior for the above
patient-
********************************************************************************


5he average score for this Guestion is >"-;4 /answered ;&(1 times)
A routine ultrasound at 1: weeks gestation in a diabetic mother reveals a male foetus with
an endocardial cushion defect- Ether abnormalities include increased nuchal thickening
and a Mdouble bubbleM sign- Which of the following conditions is most likely to have
contributed to this set of findings,

Available marks are shown in brackets
1 ) %aternal use of A+2 inhibitor [!
" ) %arfan syndrome [!
$ ) %aternal folate deficiency [!
& ) 5risomy "1 [1!
( ) +ongenital syphilis [!
********************************************************************************
+omments,
Fiabetic mothers are more likely to have children with congenital abnormalities
depending on pre*conception0 and first trimester blood sugar control- &4 of FownDs
syndrome babies have atrioventricular septal defects as in this foetus- 5he double bubble
sign suggests duodenal atresia which again suggests FownDs syndrome- II malformations
occur in >4 of FownDs patients * most commonly duodenal atresia and 3irschphrungs
disease-
********************************************************************************
A (" year old man with a diagnosis as a child of coeliac disease had been asymptomatic
despite poor dietary compliance- 3e presents with a one month history of intermittent0
colicky0 central abdominal pain and $ kilogram weight loss and positive faecal occult
bloods- What is the most appropriate investigation?


Available marks are shown in brackets
1 ) Anti*endomysial antibody- [!
" ) +olonoscopy- [1!
$ ) +5 scan of abdomen- [!
& ) Fistal duodenal biopsy- [!
( ) )mall bowel enema- [!
********************************************************************************
+omments,
.ew*onset weight loss0 with positive faecal occult bloods and central abdo pain in a ("*
year*old man must be assumed to be colonic carcinoma until proven otherwise-
+olonoscopy is the best way to check for this and would also demonstrate inflammatory
bowel disease if present- If the colonoscopy were negative0 then an EIF would be
needed to check for upper II malignancy-

********************************************************************************


5he average score for this Guestion is ((->4 /answered >>6> times)


( year old ex*footballer with a long history of alcohol excess presents with epigastric
pain- Which of the following suggests a diagnosis of peptic ulceration rather than chronic
pancreatitis?


Available marks are shown in brackets
1 ) 1ack pain [!
" ) 2xacerbation with alcohol [!
$ ) #oose stool [!
& ) @elieved by food [1!
( ) Weight loss [!
********************************************************************************
+omments,
@elief with food suggests peptic /and specifically) duodenal ulceration- It is likely that
food would precipitate the pain of chronic pancreatitis-
#oose stool is suggestive of pancreatitis7malabsorption- 'ain referred to the back occurs
in both situations and hence not suggestive-
Weight loss can occur in both gastric ulcers and pancreatitis and not very suggestive-
Alcohol may well exacerbate both types of pain-

********************************************************************************


5he average score for this Guestion is :&-$4 /answered >&( times)




A "& year old woman was referred with tiredness and intermittent bloody diarrhoea and a
past history of cerebral venous thrombosis-
En examination0 the sclera of the right eye was inflamed0 and multiple mouth ulcers were
noted- At the colonoscopy0 which confirmed colitis0 two large vulval ulcers were noted-
Which is the most likely diagnosis?


Available marks are shown in brackets
1 ) 1ehcetDs disease- [1!
" ) +rohnDs disease- [!
$ ) 3IH infection [!
& ) )yphilis [!
( ) Alcerative colitis- [!
********************************************************************************
+omments,
A classical description of the presentation of 1ehcetDs0 with oral and genital ulceration0
colitis and scleritis-

********************************************************************************


5he average score for this Guestion is ;14 /answered >>"( times)
12+325D) )N.F@E%2,
********************************************************************************



%ultisystem disorder presenting with recurrent oral and genital ulceration as well as
ocular and +.) involvement-
'@2HA#2.+2, 1710 in Lapan to 17(0 in A)A and 2urope- Affects young
adults0 with men having more severe disease-
25IE#EIN, unknown0 autoantibodies in (4-

A (&*year*old woman presented with an eighteen month history of chest pain and
dysphagia for both solids and liGuids- )he smokes " cigarettes per day and drinks 1>
units of alcohol per week- +linical examination was normal- What is the most likely
diagnosis?


Available marks are shown in brackets
1 ) Achalasia- [1!
" ) 1ronchial neoplasm- [!
$ ) Eesophageal neoplasm- [!
& ) Eesophageal web- [!
( ) 'haryngeal pouch- [!
********************************************************************************
+omments,
A longstanding history of dysphagia to both solids and liGuids suggests a functional
rather than mechanical cause for the dysphagia- 3ence a neoplasm or other obstructive
lesion is unlikely- +hest pain is not a typical feature of a pharyngeal pouch- Achalasia0 in
which there is failure of oesophageal peristalsis and of relaxation of the lower
oesophageal sphincter0 typically causes the symptoms described above-

********************************************************************************


5he average score for this Guestion is >"-:4 /answered >&:> times)
Which E.2 of the following statements regarding colon cancer is correct,

Available marks are shown in brackets
1 ) In non*familial cases0 gene mutations in the cancer cells are unusual [!
" ) In familial cases the inheritance pattern is typically autosomal recessive [!
$ ) It occurs most commonly in the ascending colon [!
& ) It is a characteristic feature of the 'eutB*Legher syndrome [!
( ) In familial polyposis coli the increased cancer risk is due to inheritance of a mutated
suppressor gene [1!
********************************************************************************
+omments,
A C ?uantitative and Gualitative alterations in gene expression accumulate in colorectal
cancer cells- 5hese include alterations of pro*oncogene expression and chromosomal
abnormalities /deletions at 1;p and 1:G are seen in ;4 of colorectal carcinomas)- 1 C
1oth familial polyposis coli and IardnerDs syndrome are autosomal dominant- + C 5he
rectum and sigmoid colon are the commonest sites- F C 'eutB*LegherDs syndrome is
dominantly inherited pigmentation of skin and mucuous membranes0 and harmatomatous
polyps in the stomach and larger intestine- 5he polyps only rarely undergo malignant
change- 2 C An allelic deletion of a putative tumour suppressor gene on (p-
A > year old man presents with a ( day history of lower abdominal pain and diarrhoea-
3e has a history of chronic obstructive airways disease and has had numerous acute
infective exacerbations over the last $ months-
En examination he was dehydrated0 with a temperature of $:-> O+0 a blood pressure of
1"7;" mm3g and has a distended0 tender abdomen- Which of the following is the most
appropriate investigation for this patient?


Available marks are shown in brackets
1 ) +hest K*ray [!
" ) 'lain abdominal K*ray [!
$ ) )igmoidoscopy and biopsy [1!
& ) )tool microscopy [!
( ) Altrasound scan of the abdomen [!
********************************************************************************
+omments,
5his is pseudomembranous colitis due to +lostridium Fifficile secondary to Antibiotic
usage for his +EAF- 'lain AK@ is useful for diagnosing toxic dilatation but does not
establish the diagnosis- )tool microscopy has no value but stool toxin assay is useful- A
'atient with diarrhoea normally has involvement of the distal colon and rectum and
sigmoidoscopy with biopsy is helpful for rapid diagnosis- 'atients with involvement of
right colon usually have little or no diarrhoea
&> year old man with a family history of haemochromatosis presented to outpatients for
advice- Investigations revealed-
serum ferritin &($ug7# /1( C $)
serum iron "6 umol7# /1" C $)
serum iron binding capacity &> umol7# /&( C ;()
iron saturation >$ per cent /" C ()
What is the most appropriate next step in management?


Available marks are shown in brackets
1 ) arrange for F.A analysis [1!
" ) begin a venesection programme [!
$ ) monitor his serum ferritin regularly [!
& ) take no action unless the iron saturation exceeds 6 per cent [!
( ) undertake a liver biopsy [!
********************************************************************************
+omments,
5his man is likely to have hereditary heamochromatosis /33+)- 3omoBygous mutation
/+":"N mutation) of the 3uman Iron gene /3=2 gene) accounts for over :4 of cases of
33+- 5he diagnosis is made on F.A analysis- If the diagnosis is confirmed then
treatment with venesection to achieve and maintain a ferritin of (*1Pg7l is indicated-
A liver biopsy is not reGuired to make the diagnosis of 33+ although may be indicated
for prognostic reasons if cirrhosis is suspected-
********************************************************************************


5he average score for this Guestion is &&-(4 /answered ;(:& times)
A (> year old female is referred to clinic by her I' who notes hepatomegaly- )ix years
ago she was diagnosed with diabetes mellitus and takes metformin ( mg tds and
gliclaBide :mg bd- )he drinks approximately 1( units of alcohol weekly amd stopped
smoking 1 years ago-
En examination she has a 1%I of $>-" kg7m0 no stigmata of liver disease are evident but
she has > cm hepatomegaly-
Investigations disclose,
5otal bilirubin 11 micromol7# /1 * "")
Alkaline phosphatase 1&( A7# /&( * 1()
A)5 1 A7# /1 *$1)
A#5 1( A7# /( * $()
Albumin & g7# /$; * &6)
=erritin &$& mg7# /1( * $)
Altrasound of the abdomen reveals an echobright appearance of the liver and gallstones
in the gallbladder-
What is the most cause of her liver disease?


Available marks are shown in brackets
1 ) Alcoholic liver disease [!
" ) Frug induced hepatitis [!
$ ) Iallstone disease [!
& ) 3aemochromatosis [!
( ) .on*alcoholic steatohepatitis /.A)3) [1!
********************************************************************************
+omments,
5he patient has a hepatitic picture in contrast to +holestasis- =erritin level is not too high
to be considered for haemochromatosis and is an acute phase reactant being typically
increased in any inflammatory process- .A)3 is very common and is typically
encountered in Ebese patients0 presenting with a hepatitic picture with or without
Jaundice- 2cho bright liver suggests fatty change in the liver seen in .A)3-It was
previously termed Idiopathic decompensated hepatitis and if not treated in terms of
lowering 1%I and reducing fat intake can lead onto irreversible cirrhosis- Iallstones are
a distraction in this history-
********************************************************************************


5he average score for this Guestion is &(-$4 /answered $":1 times)




(" year*old male is admitted with haematemesis and melaena- 2xamination reveals that
he is icteric0 confused with a flapping tremor0 has signs of chronic liver disease0 a pulse
rate of 11 bpm and blood pressure of 17; mm3g- Abdominal examination reveals
ascites- An urgent endoscopy reveals small oesophageal varices0 without evidence of
bleeding but an ooBing portal hypertensive gastropathy- Which of the following measures
would be the most appropriate treatment for this patient?

Available marks are shown in brackets
1 ) endoscopic banding [!
" ) endoscopic inJection of adrenaline [1!
$ ) endoscopic inJection of ethanolamine [!
& ) oral propranolol [!
( ) intravenous vitamin 8 [!
********************************************************************************
+omments,
5he endoscopy shows small varices with no evidence of bleeding but diffuse ooBing of
blood- 3ence endocopic measures like banding for small varices will not be useful- 5here
is probably no evidence that vit 8 is helpful as the coagulation is already likely to be
deranged- Eral propranolol is useful as a later prophylaxis of variceal bleed-
A >; year old man with known aortic valvular disease is admitted with deteriorating
dyspnoea- Investigations show,
haemoglobin 6 g7d# /1"*1>)
%+H ; f# /:*6>)
upper gastrointestinal tract endoscopy, normal
duodenal biopsy, normal
Which one of the following investigations is most likely to provide the diagnosis?


Available marks are shown in brackets
1 ) 1arium enema [!
" ) colonoscopy [1!
$ ) +5 abdomen [!
& ) mesenteric angiography [!
( ) small bowel enema [!
********************************************************************************
+omments,
In the older age group investigation of the lower II tract is vital to exclude a lower II
malignancy- +5 scans do not demonstrate colonic pathology as well as colonoscopy
which is still considered the gold standard- Angiography is only helpful if the patient is
bleeding briskly at the time of the examination-

********************************************************************************