NAME:____________________________ ID:____________________

Ollscoil na hÉireann Gaillimh

National University of Ireland Galway
MD316 - Professionalism (Core Clinical Skills)
Written Paper (100 marks) – Second Sitting

Prof. Gerard Flaherty

Wednesday, August 14, 2019

Duration: 2 hours

For SECTION A, please answer each of the 20 questions by selecting the

single most appropriate response in each case and writing the letter
corresponding to the correct answer IN BLOCK CAPITALS in the box to the left
of the question.

For SECTION B, please write your answers in the space provided on the
answer sheet. Keep your answers concise.

Please write your name IN BLOCK CAPITALS and your student ID number in
the space provided on this page.
______________________________________

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 SECTION A (40 marks)

Q1. You are asked to review an obese 67-year-old female patient who has
become suddenly short of breath. She also complains of sharp right-sided
chest pain. Three days previously she underwent an elective right total hip
replacement. On examination she is afebrile, with a regular pulse rate of
103/min, blood pressure of 106/72 mmHg, and a capillary oxygen saturation of
92% on room air. What is the most likely diagnosis in this case?

(a) Acute coronary syndrome

(b) Acute myocarditis
(c) Acute pericarditis
(d) Pulmonary thromboembolism
(e) Viral pleuritis

Q2. A 72-year-old man has a harsh ejection systolic murmur heard over his
second right intercostal space. The murmur radiates to his carotid arteries and
is increased on expiration. The carotid pulse character is abnormal and the
apex beat is heaving in character. Which of the following pulse abnormalities
would you expect in this case?

(a) Collapsing pulse

(b) Irregularly irregular pulse
(c) Jerky pulse
(d) Pulsus paradoxus
(e) Slow rising pulse

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Q3. What is the clinical significance of finding the physical sign of
xanthelasmata on a patient’s eyelids?

(a) It indicates the presence of diabetes mellitus

(b) It indicates the presence of gastric carcinoma
(c) It indicates the presence of hypercholesterolaemia
(d) It indicates the presence of lung carcinoma
(e) It indicates the presence of polycythaemia

Q4. Which of the following physical signs is most consistent with a diagnosis
of Cushing syndrome?

(a) Abdominal striae

(b) Buccal hyperpigmentation
(c) Caput medusae
(d) Obese limbs
(e) Postural hypotension

Q5. In which of the following conditions would you expect to observe a raised
jugular venous pressure?

(a) Aortic regurgitation

(b) Atrial septal defect
(c) Mitral regurgitation
(d) Pulmonary stenosis
(e) Tricuspid regurgitation

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Q6. Which of the following abnormal physical findings is consistent with the
presence of cerebellar disease?

(a) Ataxia
(b) Cogwheel rigidity
(c) Expressive dysphasia
(d) Fasciculations
(e) Homonymous hemianopia

Q7. A 48-year-old woman complains of painful swollen joints in her hands and
wrists. Which of the following extra-articular features would point to a
diagnosis of rheumatoid arthritis?

(a) Ascites
(b) Enlarged kidneys
(c) Erythema nodosum
(d) Iritis
(e) Obstructive lung defect

Q8. Which of the following risk factors for cardiovascular disease is not
included in either the printed or online version of the European Society of
Cardiology SCORE risk estimation charts?

(a) Family history

(b) Gender
(c) HDL-cholesterol
(d) Smoking status
(e) Systolic blood pressure

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Q9. Which of the following physical findings would you expect to elicit in a tall,
thin 33-year-old man with arachnodactyly, who presents with sudden onset of
right-sided chest pain?

(a) Bronchial breathing

(b) Expiratory wheeze
(c) Pleural friction rub
(d) Stony dullness to percussion
(e) Tracheal deviation to the left

Q10. In which of the following cases is a lesion in the stated cranial nerve
associated with the physical sign to which it has been paired?

(a) Eight cranial nerve and facial drooping

(b) Fifth cranial nerve and loss of corneal reflex
(c) Ninth cranial nerve and hoarseness
(d) Sixth cranial nerve and ptosis
(e) Third cranial nerve and miosis

Q11. Aortic dissection may be complicated by the development of which acute

cardiac valvular lesion?

(a) Aortic regurgitation

(b) Mitral regurgitation
(c) Mitral stenosis
(d) Pulmonary stenosis
(e) Tricuspid regurgitation

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Q12. Which of the following physical signs is typically associated with the
presence of mitral regurgitation?

(a) Ejection systolic murmur

(b) Fourth heart sound
(c) Loud S1
(d) Mid-diastolic murmur
(e) Murmur radiates to axilla

Q13. Which of the following is a sign of chronic obstructive airways disease in

a 70 year old man presenting with shortness of breath?

(a) Atrophy of the accessory muscles of respiration

(b) Bronchial breath sounds
(c) Diminished breath sounds
(d) Dullness to chest percussion
(e) Pectus excavatum

Q14. Which of the following systemic conditions is correctly matched with the
corresponding skin lesion?

(a) Carcinoid syndrome and pallor

(b) Coeliac disease and herpes zoster
(c) Inflammatory bowel disease and spider naevi
(d) Scleroderma and loose skin on the hands
(e) Type 2 diabetes and acanthosis nigricans

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Q15. Opacification of the nail beds is most likely to be associated with which
of the following conditions?

(a) Emphysema
(b) Infective endocarditis
(c) Liver cirrhosis
(d) Psoriasis
(e) Thyrotoxicosis

Q16. A 32 year old man complains of back pain, bilateral sciatica, difficulty
urinating and numbness in a saddle distribution. What is the most likely
anatomical location for the underlying lesion in this patient?

(a) Anterior horn cells

(b) Anterior spinal artery
(c) Cauda equina
(d) Corticospinal tract
(e) Dorsal column of spinal cord

Q17. An 82 year old man presents with a facial droop. He is concerned that he
may have suffered a stroke. Examination confirms the presence of a left-sided
facial nerve palsy with involvement of the whole left side of the face, including
the forehead. Which of the following underlying causes is most likely in this
patient?

(a) Bell’s palsy

(b) Frontal lobe tumour
(c) Left cerebral hemisphere stroke
(d) Right cerebral hemisphere stroke
(e) Subdural haematoma

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Q18. Which of the following physical signs is statistically the most diagnostic
of thyrotoxicosis?

(a) Eyelid retraction

(b) Fine tremor
(c) Goitre
(d) Moist, warm skin
(e) Pulse >90/minute

Q19. Which of the following conditions sometimes presents as epigastric

abdominal pain?

(a) Acute appendicitis

(b) Crohn’s disease
(c) Diverticulitis
(d) Myocardial infarction
(e) Ruptured ovarian cyst

Q20. Which of the following physical signs is correctly matched with the
corresponding underlying neurological condition?

(a) Dysphasia and myasthenia gravis

(b) Fasciculations and stroke
(c) Fine tremor and Parkinson’s disease
(d) Sensory level and spinal cord compression
(e) Vertical nystagmus and cerebellar syndrome

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 SECTION B (60 marks)

QUESTION 1

A 64-year-old male presents to his general practitioner with a history of

passing blood in his urine. He denies haemoptysis or easy bruising.

a. Give 4 questions which you would ask this patient in the history of the
presenting complaint to determine the cause of his haematuria. (4×0.5 marks)
b. List 1 cause, in each case, of (i) haemoptysis, and (ii) easy bruising. (2x1
marks)

a. ______________________________________________________________
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b. (i)____________________________________________________________
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(ii)____________________________________________________________
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The patient has a history of obesity, type 2 diabetes mellitus and arterial
hypertension, which he reports as being well controlled by his GP.

c. Name one specific renal complication which may result from: (i) diabetes
mellitus, and (ii) arterial hypertension. (2x1 marks)
d. Briefly explain how obesity acts as a risk factor for the development of type 2
diabetes mellitus. (2 marks)

c. (i)____________________________________________________________
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(ii)____________________________________________________________
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 d. ______________________________________________________________
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Further questioning reveals the presence of 6kg involuntary weight loss over
the preceding 2 months and intermittent right-sided non-colicky abdominal
pain.

e. Identify 4 physical signs which may suggest that a patient has lost significant
amounts of body weight. (4x0.5 marks)
f. What is your differential diagnosis (2 unique diagnoses in each case) of: (i)
right upper quadrant, and (ii) colicky abdominal pain? (4x0.5 marks)

e. ______________________________________________________________
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______________________________________________________________
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f. (i)____________________________________________________________
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(ii)____________________________________________________________
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Physical examination reveals an obese gentleman with a ruddy (red)

complexion. His blood pressure is 166/90 mmHg. A resonant mass is present
on deep palpation of the right side of his abdomen. There is tenderness to
palpation over his rib cage on the right side.

g. (i) Give 2 causes of an abnormally red (plethoric) facial complexion. (ii) What
haematologic laboratory abnormality do you expect to find in this patient?
(4x0.5 marks)

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 h. (i) What grade of hypertension is suggested by the patient’s current blood
pressure reading? (ii) Why is the percussion note resonant over the kidney?
(2x1 marks)

g. (i)____________________________________________________________
______________________________________________________________
(ii)____________________________________________________________
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h. (i)____________________________________________________________
______________________________________________________________
(ii)____________________________________________________________
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A renal ultrasound confirms the presence of a tumour in the upper pole of the
right kidney. The histopathologist confirms a diagnosis of renal cell
carcinoma. ‘Cannonball’ metastases are discovered in the lungs and ribs on
tumour staging. Hypercalcaemia is present on laboratory analysis.

i. List the blood vessels and cardiac chambers, in sequence, which a renal
metastasis must navigate to reach the lungs. (4×0.5 marks)
j. Suggest 2 possible mechanisms for hypercalcaemia in any patient with a
malignancy. (2x1 marks)

i. ______________________________________________________________
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j. ______________________________________________________________
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 QUESTION 2

You have been asked to review a 56-year-old woman on the surgical ward who
complains of feeling suddenly short of breath. She denies chest pain.

a. Give 4 causes of shortness of breath of acute onset. (4×0.5 marks)

b. State 2 conditions which give rise to both chest pain and shortness of breath?
(2×1 marks)

a. ______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
b. ______________________________________________________________
______________________________________________________________
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The patient is 2 days post-elective cholecystectomy for recurrent episodes of

biliary colic and a recent hospital admission for management of acute
cholecystitis. She has had an uneventful post-operative recovery to date.

c. Describe the typical (i) site and (ii) radiation of pain in patients with biliary
colic. (2x1 marks)
d. What is your understanding of a positive Murphy’s sign in a patient with acute
cholecystitis? (2 marks)

c. (i)____________________________________________________________
______________________________________________________________
(ii)____________________________________________________________
______________________________________________________________
d. ______________________________________________________________
______________________________________________________________

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 ______________________________________________________________
______________________________________________________________

The patient is afebrile, tachycardic and centrally cyanosed with a capillary

oxygen saturation of 87% on breathing room air. The breath sounds are of
normal quality and there are no adventitious sounds.

e. What would be the potential significance of (i) absent breath sounds in the left
lung; and (ii) coarse crackles in both lungs, in this post-operative patient?
(2x1 marks)
f. Explain the pathophysiology of central cyanosis. (2 marks)

e. (i)____________________________________________________________
______________________________________________________________
(ii)____________________________________________________________
______________________________________________________________
f. ______________________________________________________________
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A 12-lead electrocardiogram (ECG) is performed and a sample of blood is

obtained for arterial blood gas analysis. A tentative diagnosis of pulmonary
embolism is made. A CT pulmonary angiogram is arranged.

g. What does the classic ECG description of “SI, QIII, TIII” signify in a patient
with a pulmonary embolism? (2 marks)
h. Give 2 abnormalities that you would expect in the arterial blood gas analysis
in this patient. (2x1 marks)

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 g. ______________________________________________________________
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h. ______________________________________________________________
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On further examination, the patient’s right leg and thigh are found to be
swollen. A deep vein thrombosis is diagnosed.

i. Excluding recent surgery, recall 4 additional risk factors for the development
of a deep vein thrombosis. (4×0.5 marks)
j. Outline your differential diagnosis of unilateral leg oedema. (4x0.5 marks)

i. ______________________________________________________________
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j. ______________________________________________________________
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