1.

Diabetic foot ulceration

You assess a patient with a plantar ulcer who has poorly controlled diabetes. From the list of options below, select the most likely management plan.
A. Optimise glycaemic control
B. Reduce plantar pressure by ensuring good footwear
C. Ensure podiatry input
D. Assess vascularity of the limb
E. All of the above

8. Diagnosis of acute lower limb pain

You are asked to see a 56-year-old homeless man who presented to the emer- gency department with a severe pain in his right leg, which started over 12 hours ago. On
examination, the right leg is pale in colour in comparison with the left leg from below the knee to the toes and has fixed mottling. The right leg is cold and the popliteal, posterior
tibial and dorsalis pedis pulses are absent. There is no sensation in the right leg and the patient is unable to flex the knee or move the toes due to fixed flexion deformities. In
addition, the patient is apyrexial and heart rate is 85 beats per minute and regular. What is the most likely diagnosis?
A. Critical limb ischaemia
B. Acute limb ischaemia
C. Intermittent claudication
D. Necrotizing fasciitis
E. Spinal claudication

14. Varicose veins

A 41-year-old woman, diagnosed with varicose veins in the left leg, presents to your clinic with a 2-month history of severe pain in the left leg on prolonged standing. The patient
is obese and the pain has affected her working and social lifestyle and she asks you about the most effective treatment option. From the list below, choose the most effective
treatment option that you would discuss with this patient.
A. Use of compression stockings
B. Injection sclerotherapy
C. Surgery
D. Weight loss
E. None of the above

25. Acute mesenteric ischaemia

A 45-year-old man presents to A&E with acute onset of abdominal pain. Following clinical assessment, he is found to have acute mesenteric ischaemia.
Which of the following is the diagnosis of acute mesenteric ischaemia based on?
A. An elevated lactate
B. A high white cell count
C. A metabolic acidosis
D. Pain out of keeping with the clinical signs
E. Any of the above and a high index of suspicion

Which of the following patients with primary hyperparathyroidism should undergo parathyroidectomy?
a. A 62-year-old asymptomatic woman
b. A 54-year-old woman with fatigue and depression
c. A 42-year-old woman with a history of kidney stones
d. A 59-year-old woman with mildly elevated 24-hour urinary calcium excretion
e. A 60-year-old woman with mildly decreased bone mineral density measured at the hip of less than 2 standard deviations below peak bone density

A 36-year-old woman presents with palpitations, anxiety, and hypertension. Workup reveals a pheochromocytoma. Which of the following is the best approach to optimizing the
patient preoperatively?
a. Fluid restriction 24 hours preoperatively to prevent intraoperative congestive heart failure b. Initiation of an α-blocker 24 hours prior to surgery
c. Initiation of an α-blocker at 1 to 3 weeks prior to surgery
d. Initiation of a β-blocker 1 to 3 weeks prior to surgery
e. Escalating antihypertensive drug therapy with β-blockade followed by α-blockade starting at least 1 week prior to surgery

A 45-year-old female business executive presents with a swelling in the midline of the neck and features of hyperthyroidism secondary to Graves’ disease. Following a course of
antithyroid medication, a subtotal thyroidectomy is performed. Raised titres of which immunoglobulin would be expected in this individual?
A. Anti-thyroglobulin antibody
B. Rheumatoid factor
C. Antinuclear antibody
D. Antineutrophil cytoplasmic antibody
E. Anti-thyroid-stimulating hormone receptor antibody

You are asked to assess a 25-year-old patient who returned from theatre 2 hours ago following a thyroidectomy for a large, hyperplastic goitre and is now com- plaining of
difficulty swallowing sips of water. On examination you note that she
is very short of breath with a respiratory rate of 30 breaths/min, using her acces- sory muscles of respiration and only able to answer your questions in two or three words. In
addition, there appears to be a fluctuant mass in the midline of the neck underlying the surgical clips. Immediate management of this patient would be
A. High-flow oxygen via Hudson mask
B. Removal of surgical clips at the bedside
C. Intravenous access with two large-bore cannulae and fluid resuscitation
D. Removal of surgical clips in theatre under general anaesthesia
E. Call your senior and wait for him/her to remove the clips

A 45-year-old woman presents with hypertension, development of facial hair, and a 7-cm suprarenal mass. Which of the following is the most likely diagnosis?
A 45-year-old woman presents with hypertension, development of facial hair, and a 7-cm suprarenal mass. Which of the following is the most likely diagnosis?
a. Myelolipoma
b. Cushing disease
c. Adrenocortical carcinoma d. Pheochromocytoma
e. Carcinoid

As part of the peripheral vascular examination, you are asked to record the ankle–brachial pressure index of the patient. Which one of the following values reflects a normal ankle–
brachial pressure index?
A. Between 0.9 and 0.6
B. Greater than 1.3
C. Between 0.6 and 0.3
D. Greater than or equal to 1.0
E. Less than or equal to 0.3

You see a 65-year-old man in your clinic who is under surveillance for an abdominal aortic aneurysm. The patient smokes 20 cigarettes a day and has a 25-year history of poorly
controlled hypertension. From the list below, select the most appropriate investigation that can be used to monitor the progression of this patient’s condition.
A. Computed tomography scan of the abdomen
B. Angiography
C. Abdominal plain film radiography
D. Magnetic resonance imaging
E. Ultrasound

You see a 26-year-old woman in clinic presenting with lower limb lymphoedema. Which of the following conditions is associated with lymphoedema?
A. Post lymph node dissection
B. Radiotherapy
C. Filarisis
D. Post trauma
E. All of the above

You see a 60-year-old man with a history of coronary heart disease, diabetes and hyperlipidaemia in your clinic. The patient has found it increasingly hard to walk due to the
gradual increase in intensity of the cramping pain he experi- ences in his right leg on walking, which is relieved by resting a few minutes. In addition, he tells you that cramps have
started to occur at night when he is sleeping. On examination of the right leg, you notice that there is a ‘punched out’ ulcer on the right heel. The right posterior tibial and dorsalis
pedis pulses are weak. You suspect that this patient has critical limb ischaemia. What is the most appropriate next line investigation that would support your diagnosis?
A. Computed tomography angiography
B. Ankle–brachial pressure index
C. Radiograph the lower limbs
D. Magnetic resonance angiography
E. None of the above

A patient with mild skin pigmentation is admitted emergently to your service because of sudden abdominal pain, fever, and a rigid abdomen. Her blood work indicates a marked
leukocytosis, a blood sugar of 55 mg/dL, a sodium value of 119 mEq/dL, and a potassium value of 6.2 mEq/dL. Her blood pressure is 88/58 mm Hg. She undergoes an exploratory
laparotomy. Which of the following is the definitive treatment for her primary condition?
a. 10% dextrose infusion b. Bicarbonate
c. Hypertonic saline
d. Corticosteroids
e. Vasopressors

A 35-year-old woman with a history of previous right thyroidectomy for a benign thyroid nodule now undergoes completion thyroidectomy for a suspicious thyroid mass. Several
hours postoperatively, she develops progressive swelling under the incision, stridor, and difficulty breathing. Orotracheal intubation is successful. Which of the following is the
most appropriate next step?
a. Fiberoptic laryngoscopy to rule out bilateral vocal cord paralysis
b. Administration of intravenous calcium
c. Administration of broad-spectrum antibiotics and debridement of the wound d. Wound exploration
e. Administration of high-dose steroids and antihistamines