Key points
- Practice questions written for revision, not copies of any exam. They follow the single-best-answer vignette style of final and licensing exams.
- Topics: diabetic emergencies, thyroid disease, adrenal disease, upper gastrointestinal bleeding, liver disease, hepatitis, inflammatory bowel disease and coeliac disease.
- Each explanation covers why the answer is right and why the distractors are wrong.
- Management follows widely used international guidance. Check your local protocol before treating a patient.
Questions
1. A 19-year-old with type 1 diabetes has vomiting, abdominal pain, deep sighing breathing, a glucose of 28 mmol/L and a pH of 7.1. What is the most important first step?
A. Subcutaneous insulin and discharge
B. Intravenous fluids, then a fixed-rate insulin infusion with potassium monitoring
C. Bicarbonate infusion
D. Oral rehydration only
E. Metformin
Answer: B. Diabetic ketoacidosis needs fluid resuscitation first (normal saline), then intravenous insulin at a fixed rate, with close attention to potassium, because insulin drives potassium into cells. Replace potassium once levels are below about 5.5 mmol/L. Bicarbonate is rarely needed. Look for the trigger, such as infection.
2. A 40-year-old woman has weight loss, tremor, heat intolerance, a diffuse goitre, exophthalmos and a low TSH with a high free T4. What is the most likely diagnosis?
A. Hashimoto thyroiditis
B. Graves disease
C. Toxic nodule
D. Subacute thyroiditis
E. Hypothyroidism
Answer: B. Hyperthyroidism with a diffuse goitre and eye signs (exophthalmos) is Graves disease, caused by TSH receptor-stimulating antibodies. Treatment options are antithyroid drugs (carbimazole or propylthiouracil), radioiodine or surgery, with a beta-blocker for symptoms. Eye signs and pretibial myxoedema occur only in Graves disease.
3. A woman has fatigue, weight gain, cold intolerance, constipation, a high TSH and a low free T4. What is the treatment?
A. Carbimazole
B. Levothyroxine
C. Radioiodine
D. Propranolol alone
E. Prednisolone
Answer: B. Primary hypothyroidism is treated with lifelong levothyroxine, with the dose adjusted by TSH. In iodine-sufficient regions the commonest cause is autoimmune (Hashimoto) thyroiditis. Check TSH 6 to 8 weeks after any dose change.
4. A patient on long-term prednisolone is admitted after a road accident, collapses with low blood pressure and a low sodium. What diagnosis should be considered?
A. Cushing syndrome
B. Acute adrenal insufficiency (adrenal crisis)
C. Phaeochromocytoma
D. Conn syndrome
E. Hyperthyroidism
Answer: B. Long-term steroid therapy suppresses the hypothalamic-pituitary-adrenal axis, and a physiological stress then causes adrenal crisis. Treat immediately with intravenous hydrocortisone, fluids and glucose, without waiting for tests. Steroid-dependent patients need extra doses during illness and surgery ("sick day rules").
5. A 60-year-old alcoholic man vomits fresh red blood and has a pulse of 115/min and a blood pressure of 95/60 mmHg. He has spider naevi and ascites. What is the most likely source and first-line treatment?
A. Peptic ulcer; proton pump inhibitor alone
B. Oesophageal varices; resuscitation, a vasoactive drug such as terlipressin or octreotide, antibiotics and endoscopic band ligation
C. Mallory-Weiss tear; surgery
D. Gastric cancer; chemotherapy
E. Haemorrhoids; observation
Answer: B. Haematemesis in a patient with stigmata of chronic liver disease suggests variceal bleeding. Resuscitate cautiously, give a vasoactive drug, prophylactic antibiotics (which reduce mortality) and urgent endoscopy with band ligation. Transfuse to a haemoglobin of about 7 to 8 g/dL, not higher.
6. A 28-year-old has jaundice, fever and nausea 3 weeks after travelling. Serology shows anti-HAV IgM positive. What is the management?
A. Antiviral therapy
B. Supportive care and prevention advice
C. Liver transplant
D. Long-term interferon
E. Steroids
Answer: B. Hepatitis A is a self-limiting faecal-oral infection that needs supportive treatment and does not become chronic. Prevention is by hygiene, sanitation and vaccination. Hepatitis B and C can become chronic and need antiviral therapy in selected patients.
7. Which hepatitis B serology pattern indicates a chronic carrier state?
A. HBsAg negative, anti-HBs positive
B. HBsAg positive for more than 6 months with anti-HBc IgG
C. Anti-HBs positive only
D. HBsAg negative, anti-HBc IgM positive
E. All negative
Answer: B. Persistence of HBsAg beyond 6 months defines chronic infection, together with total anti-HBc. A positive anti-HBs with a negative HBsAg and negative anti-HBc suggests vaccination. Acute infection shows anti-HBc IgM. HBeAg and the viral load indicate infectivity.
8. A 25-year-old has recurrent bloody diarrhoea, urgency and tenesmus. Colonoscopy shows continuous mucosal inflammation from the rectum, with no skip lesions. What is the diagnosis?
A. Crohn's disease
B. Ulcerative colitis
C. Irritable bowel syndrome
D. Ischaemic colitis
E. Coeliac disease
Answer: B. Continuous inflammation from the rectum with bloody diarrhoea is ulcerative colitis, which is limited to the mucosa and colon. Crohn's disease is transmural, can affect any part of the gut and produces skip lesions, fistulae and strictures. Ulcerative colitis raises the risk of colorectal cancer and primary sclerosing cholangitis.
9. A woman has chronic diarrhoea, iron-deficiency anaemia, weight loss and an itchy blistering rash on her elbows. Which test is first-line?
A. Stool culture
B. Tissue transglutaminase IgA with total IgA, then duodenal biopsy
C. Hydrogen breath test only
D. Colonoscopy only
E. Faecal calprotectin only
Answer: B. The picture suggests coeliac disease with dermatitis herpetiformis. Screen with IgA tissue transglutaminase antibodies while the patient is still eating gluten, check total IgA, and confirm with duodenal biopsy showing villous atrophy. Treatment is a lifelong gluten-free diet.
10. A patient has a glucose of 2.2 mmol/L, sweating and confusion. He is unable to swallow. What is the best immediate treatment?
A. Oral glucose tablets
B. Intravenous 10 to 20% glucose or intramuscular glucagon
C. Subcutaneous insulin
D. Intravenous saline
E. Wait and recheck
Answer: B. Severe hypoglycaemia in a patient who cannot swallow needs intravenous dextrose or intramuscular glucagon. Follow it with a longer-acting carbohydrate and look for the cause, such as excess insulin or sulfonylurea, missed meals, alcohol or renal failure.
11. Which finding best supports Cushing syndrome?
A. Weight loss and hypotension
B. Central obesity, striae, proximal myopathy and hypertension, with failure of cortisol suppression after low-dose dexamethasone
C. Hyperpigmentation and hyponatraemia
D. Low cortisol after synacthen
E. Episodic headaches and sweating
Answer: B. Cushing syndrome produces central obesity, purple striae, proximal weakness, hypertension and hyperglycaemia, and cortisol that is not suppressed by dexamethasone. The commonest cause overall is exogenous steroid use. Hyperpigmentation with low sodium points to Addison disease. Episodic headache, sweating and palpitations suggest phaeochromocytoma.
12. A patient with cirrhosis and ascites has fever, abdominal pain and an ascitic fluid neutrophil count of 400 cells/mm3. What is the diagnosis and treatment?
A. Hepatocellular carcinoma; sorafenib
B. Spontaneous bacterial peritonitis; intravenous antibiotics such as a third-generation cephalosporin, with albumin
C. Secondary peritonitis; no antibiotics
D. Hepatic encephalopathy; lactulose
E. Budd-Chiari syndrome; anticoagulation
Answer: B. An ascitic neutrophil count of 250 cells/mm3 or more diagnoses spontaneous bacterial peritonitis. Treat with intravenous antibiotics (for example ceftriaxone) and albumin, and then give secondary prophylaxis. Take a diagnostic paracentesis in every patient with cirrhosis and ascites admitted to hospital.
References
- American Diabetes Association and European Association for the Study of Diabetes guidance.
- American Thyroid Association guidelines.
- American Association for the Study of Liver Diseases and EASL guidelines.
- Kumar and Clark's Clinical Medicine. Elsevier.
- Davidson's Principles and Practice of Medicine. Elsevier.