PLAB 1 Clinical Medicine 2 — Questions and Answers
Question 1: A 55-year-old woman presents with progressive dysphagia, initially to solids and now to liquids, weight loss of 8kg over 3 months, and iron deficiency anaemia. What is the most important investigation?
- Barium swallow
- Upper GI endoscopy (OGD) and biopsy (Correct answer)
- CT chest/abdomen
- H. pylori breath test
Correct answer: Upper GI endoscopy (OGD) and biopsy
Progressive dysphagia (solids then liquids), weight loss, and iron deficiency anaemia are alarm symptoms suggesting oesophageal carcinoma. OGD with biopsy is essential for direct visualisation and tissue diagnosis. Barium swallow may show the lesion but does not provide histology.
Question 2: A 30-year-old man presents with bloody diarrhoea 8 times per day, abdominal cramps, and fever. He has a history of recurrent attacks since age 22. Sigmoidoscopy shows continuous mucosal inflammation from the rectum extending proximally. Biopsy shows crypt abscesses. What is the most likely diagnosis?
- Crohn's disease
- Ulcerative colitis (Correct answer)
- Infective colitis
- Ischaemic colitis
Correct answer: Ulcerative colitis
Ulcerative colitis is characterised by continuous mucosal inflammation starting from the rectum extending proximally, crypt abscesses on histology, rectal bleeding, and diarrhoea. Crohn's disease is typically patchy (skip lesions), transmural, and can affect any part of the GI tract.
Question 3: A 68-year-old woman presents with worsening confusion over 3 days, pyrexia, dysuria, and frequency. Her urine is cloudy and malodorous. What is the most likely diagnosis causing confusion in this elderly patient?
- Dementia exacerbation
- Urinary tract infection causing acute delirium (Correct answer)
- Hyponatraemia
- New stroke
Correct answer: Urinary tract infection causing acute delirium
UTI is a very common cause of acute delirium (acute confusional state) in elderly patients. Classic urinary symptoms may be less prominent in the elderly. The confusion is acute onset (over days), fever is present, and urinary symptoms/signs are evident. This is acute delirium, not worsening dementia.
Question 4: A 45-year-old man with type 2 diabetes presents with a painless, non-healing ulcer on the plantar surface of his right foot. The foot is warm and pulses are palpable. Sensation to 10g monofilament is absent. What type of ulcer is this?
- Arterial (ischaemic) ulcer
- Neuropathic diabetic ulcer (Correct answer)
- Venous ulcer
- Pressure ulcer
Correct answer: Neuropathic diabetic ulcer
A neuropathic diabetic ulcer is characterised by: location on a pressure point (plantar surface), painlessness (due to peripheral neuropathy), absent sensation to monofilament, but warm foot with intact pulses (good circulation). Arterial ulcers are painful, cold, with absent pulses.
Question 5: A 35-year-old woman presents with palpitations, heat intolerance, weight loss despite increased appetite, tremor, and diarrhoea. On examination she has lid lag, exophthalmos, and a diffuse goitre. TFTs show suppressed TSH and elevated free T4. What is the most likely diagnosis?
- Toxic multinodular goitre
- De Quervain's thyroiditis
- Graves' disease (Correct answer)
- Thyroid carcinoma
Correct answer: Graves' disease
Graves' disease is the most common cause of hyperthyroidism in young women. The specific features here are exophthalmos (pretibial myxoedema if present) and diffuse goitre, pointing to Graves' disease rather than other causes. It is an autoimmune condition mediated by TSH receptor antibodies.
Question 6: A 50-year-old man presents with a 6-month history of exertional chest pain that is relieved by rest, occurring after walking 200 metres uphill. ECG at rest is normal. What is the most appropriate investigation to confirm the diagnosis?
- 24-hour ECG (Holter monitor)
- Exercise tolerance test (ETT) or CT coronary angiogram (Correct answer)
- Echocardiogram
- Chest X-ray
Correct answer: Exercise tolerance test (ETT) or CT coronary angiogram
This is a classic presentation of stable angina. NICE guidelines (CG95) recommend CT coronary angiography as the first-line investigation for suspected stable angina. Exercise tolerance testing is an alternative. The resting ECG is often normal in stable angina.
PLAB 1 Clinical Medicine 2
A 55-year-old woman presents with progressive dysphagia, initially to solids and now to liquids, weight loss of 8kg over 3 months, and iron deficiency anaemia.
What is the most important investigation?