Oxford Assess and Progress Clinical Medicine - 3rd Edition
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v
Series editor preface
The Oxford Assess and Progress series is a groundbreaking develop-
ment in the extensive area of self-assessment texts available for medical
students. The questions were specifically commissioned for the series,
written by practising clinicians, extensively peer-reviewed by students
and their teachers, and quality-assured to ensure that the material is up-
to-date, accurate, and in line with modern testing formats.
The series has a number of unique features and is designed to be as
much a formative learning resource as a self-assessment one. The ques-
tions are constructed to test the same clinical problem-solving skills that
we use as practising clinicians, rather than only to test theoretical know-
ledge. These skills include:
● gathering and using data required for clinical judgement
● choosing the appropriate examination and investigations, and inter-
pretation of the findings
● applying knowledge
● demonstrating diagnostic skills
● the ability to evaluate undifferentiated material
● the ability to prioritize
● making decisions and demonstrating a structured approach to
decision-making.
Each question is bedded in reality and is typically presented as a clinical
scenario, the content of which has been chosen to reflect the common
and important conditions that most doctors are likely to encounter both
during their training and in exams! The aim of the series is to build the
reader’s confidence in recognizing important symptoms and signs and
suggesting the most appropriate investigations and management, and in
so doing to aid the development of a clear approach to patient manage-
ment which can be transferred to the wards.
The content of the series has deliberately been pinned to the relevant
Oxford Handbook but, in addition, has been guided by a blueprint which
reflects the themes identified in Tomorrow’s Doctors and Good Medical
Practice to include novel areas such as history taking, recognition of signs
(including red flags), and professionalism.
Particular attention has been paid to giving learning points and con-
structive feedback on each question, using clear fact-or evidence-
based explanations as to why the correct response is right and why the
incorrect responses are less appropriate. The question editorials are
clearly referenced to the relevant sections of the accompanying Oxford
Handbook and/or more widely to medical literature or guidelines. They
are designed to guide and motivate the reader, being multi-purpose in
nature and covering, for example, exam technique, approaches to diffi-
cult subjects, and links between subjects.
vi Series editor preface
Another unique aspect of the series is the element of competency
progression, from being a relatively inexperienced student to being a
more experienced junior doctor. We have suggested the following four
degrees of difficulty to reflect the level of training, so that the reader can
monitor their own progress over time:
● graduate should know ★
● graduate nice to know ★★
● foundation doctor should know ★★★
● foundation doctor nice to know ★★★★
We advise the reader to attempt the questions in blocks as a way of
testing their knowledge in a clinical context. The series can be treated as
a dress rehearsal for life on the ward by using the material to hone clin-
ical acumen and build confidence by encouraging a clear, consistent, and
rational approach, proficiency in recognizing and evaluating symptoms
and signs, making a rational differential diagnosis, and suggesting appro-
priate investigations and management.
Adopting such an approach can aid not only success in examin-
ations, which really are designed to confirm learning, but also—more
importantly—being a good doctor. In this way, we can deliver high-
quality and safe patient care by recognizing, understanding, and treating
common problems, but at the same time remaining alert to the possi-
bility of less likely, but potentially catastrophic, conditions.
David Sales and Katharine Boursicot
Series Editors
vii
A note on single best
answer questions
Single best answer questions are currently the format of choice
being widely used by most undergraduate and postgraduate knowledge
tests, and therefore all of the assessment questions in this book follow
this format.
Single best answer questions have many advantages over other
machine- markable formats, such as extended matching questions
(EMQs), notably the breadth of sampling or content coverage that they
afford.
Briefly, the single best answer or ‘best of five’ question presents a
problem, usually a clinical scenario, before presenting the question itself
and a list of five options. These consist of one correct answer and four
incorrect options or ‘distractors’ from which the reader has to choose
a response.
All of the questions in this book, which are typically based on an evalu-
ation of symptoms, signs, or results of investigations, either as single
entities or in combination, are designed to test reasoning skills, rather
than straightforward recall of facts, and utilize cognitive processes similar
to those used in clinical practice.
The peer-reviewed questions are written and edited in accordance
with contemporary best assessment practice, and their content has been
guided by a blueprint pinned to all areas of Good Medical Practice, which
ensures comprehensive coverage.
The answers and their rationales are evidence-based and have been
reviewed to ensure that they are absolutely correct. Incorrect options
are selected as being plausible, and indeed they may appear correct to
the less knowledgeable reader. When answering questions, the reader
may wish to use the ‘cover’ test, in which they read the scenario and the
question but cover the options.
Katharine Boursicot and David Sales
Series Editors
ix
Contents
Contributors xi
Normal and average values xiii
Abbreviations xv
How to use this book xxv
1 Cardiovascular medicine 1
2 Chest medicine 43
3 Endocrinology 83
4 Gastroenterology 115
5 Renal medicine 145
6 Haematology 171
7 Infectious diseases 199
8 Neurology 221
9 Oncology and palliative care 271
10 Rheumatology 283
11 Surgery 303
12 Clinical chemistry 365
13 Eponymous syndromes 381
14 Radiology 391
15 Emergencies 423
16 Geriatric medicine 447
Index 459
xi
Contributors
Thomas Coryndon, Maria Phylactou, Academic
Consultant in Emergency Clinical Fellow in Endocrinology
Medicine, University College and Diabetes, North West
London Hospitals NHS Thames, Imperial College
Foundation Trust, London, UK London, London, UK
Doug Fink, Specialty Training Ricky Sinharay,
Registrar in Infectious Diseases Specialty Training Registrar
and General Internal Medicine, in Gastroenterology and
Hospital for Tropical Diseases, Hepatology, Addenbrooke’s
University College London Hospital, Cambridge University
Hospitals NHS Foundation Trust, Hospitals NHS Foundation Trust,
London, UK Cambridge, UK
Dan Furmedge, Consultant Rudy Sinharay, Consultant
Physician in Geriatric and Physician in Respiratory and
General Internal Medicine and General Internal Medicine, Guy‘s
Honorary Clinical Lecturer in and St Thomas’ NHS Foundation
Medical Education, Guy’s and St Trust, London, UK
Thomas’ NHS Foundation Trust, Laszlo Sztriha, Consultant
London, UK Neurologist and Stroke Physician,
Shelly Griffiths, Specialty King’s College Hospital NHS
Training Registrar in Colorectal Foundation Trust, London, UK
and General Surgery, Dominik Vogel, Senior
Gloucestershire Hospitals NHS Clinical Fellow in Critical Care,
Foundation Trust, London, UK Echocardiography and ECMO,
James Harnett, Senior Clinical Guy’s and St Thomas’ NHS
Fellow in Emergency Medicine, Foundation Trust, London, UK
University College London William White, Specialty
Hospitals NHS Foundation Trust, Training Registrar in Nephrology
London, UK and General Internal Medicine,
Chris Parnell, Clinical Royal Free London NHS
Fellow in Emergency Medicine, Foundation Trust, London, UK
University College London
Hospitals NHS Foundation Trust,
London, UK
Ross Paterson, Academic
Clinical Lecturer in Neurology,
National Hospital for Neurology
and Neurosurgery, University
College London Hospitals NHS
Foundation Trust, London, UK
xiii
Normal and
average values
Normal value
Haematology
White cell count (WCC) 4–11 × 109/L
Haemoglobin (Hb) M: 135–180 g/L
F: 115–160 g/L
Packed cell volume (PCV) M: 0.4–0.54 L/L
F: 0.37–0.47 L/L
Mean corpuscular volume (MCV) 76–96 fL
Neutrophils 2–7.5 × 109/L
Lymphocytes 1.3–3.5 × 109/L
Eosinophils 0.04–0.44 × 109/L
Basophils 0–0.1 × 109/L
Monocytes 0.2–0.8 × 109/L
Platelets 150–400 × 109/L
Reticulocytes 25–100 × 109/L
Erythrocyte sedimentation rate (ESR) <20 mm/hour (but age-dependent;
see OHCM, p. 356)
Prothrombin time (PT) 10–14 s
Activated partial thromboplastin time 35–45 s
(aPTT)
International normalized ratio (INR) 0.9–1.2
Biochemistry
Alanine aminotransferase (ALT) 5–35 IU/L
Albumin 35–50 g/L
Alkaline phosphatase (ALP) 30–150 IU/L
Amylase 0–180 U/dL
Aspartate aminotransferase (AST) 5–35 IU/L
Bilirubin 3–17 micromol/L
Calcium (total) 2.12–2.65 mmol/L
Chloride 95–105 mmol/L
Cortisol 450–750 nmol/L (a.m.)
80–280 nmol/L (midnight)
C-reactive protein (CRP) <10 mg/L
Creatine kinase M: 25–195 IU/L
F: 25–170 IU/L
xiv Normal and average values
Normal value
Creatinine 70–<150 micromol/L
Ferritin 12–200 micrograms/L
Folate 2.1 micrograms/L
Gamma-glutamyl transpeptidase (GGT) M: 11–51 IU/L
F: 7–33 IU/L
Lactate dehydrogenase (LDH) 70–250 IU/L
Magnesium 0.75–1.05 mmol/L
Osmolality 278–305 mOsmol/kg
Phosphate 0.8–1.4 mmol/L
Potassium 3.5–5 mmol/L
Protein (total) 60–80 g/L
Sodium 135–145 mmol/L
Thyroid-stimulating hormone (TSH) 0.5–5.7 mU/L
Thyroxine (T4) 70–140 nmol/L
Thyroxine (free) 9–22 pmol/L
Urate M: 210–480 mmol/L
F: 150–39 mmol/L
Urea 2.5–6.7 mmol/L
Vitamin B12 0.13–0.68 mmol/L
Arterial blood gases
pH 7.35–7.45
Arterial oxygen partial pressure (PaO2) >10.6 kPa
Arterial carbon dioxide partial pressure 4.7–6.0 kPa
(PaCO2)
Base excess ± 2 mmol/L
Urine
Cortisol (free) <280 nmol/24 hours
Osmolality 350–1000 mOsmol/kg
Potassium 14–120 mmol/24 hours
Protein <150 mg/24 hours
Sodium 100–250 mmol/24 hours
xv
Abbreviations
A&E Accident and Emergency
AAA abdominal aortic aneurysm
ABCDE airway, breathing, circulation, disability, exposure
ABG arterial blood gas
ABPA allergic bronchopulmonary aspergillosis
ABPI ankle–brachial pressure index
ACE angiotensin-converting enzyme
ACS acute coronary syndrome
ACTH adrenocorticotrophic hormone
ADH antidiuretic hormone
ADP adenosine diphosphate
ADPKD autosomal dominant polycystic kidney disease
AF atrial fibrillation
AFB acid-fast bacilli
AIDS acquired immune deficiency syndrome
AIHA autoimmune haemolytic anaemia
AKI acute kidney injury
ALL acute lymphoblastic leukaemia
ALP alkaline phosphatase
ALS advanced life support
ALT alanine aminotransferase
AML acute myeloid leukaemia
AMR anti-microbial resistance
AMTS abbreviated mental test score
ANCA antineutrophil cytoplasmic antibodies
aPTT activated partial thromboplastin time
ARB angiotensin receptor blocker
ARLD alcohol-related liver disease
ART anti-retroviral therapy
ASA American Society of Anesthesiologists
AST aspartate aminotransferase
ATP adenosine triphosphate
AV atrioventricular
AVNRT atrioventricular nodal re-entry tachycardia
xvi Abbreviations
AVRT atrioventricular re-entrant tachycardia
β-hCG beta-human chorionic gonadotropin
BASHH British Association for Sexual Health and HIV
bd twice daily
BHIVA British HIV Association
BHL bilateral hilar lymphadenopathy
BiPAP bi-level positive airway pressure
BMI body mass index
BNP B-type natriuretic peptide
BP blood pressure
bpm beat per minute
BPPV benign paroxysmal positional vertigo
BTS British Thoracic Society
CA125 cancer antigen 125
CAD coronary artery disease
CADASIL cerebral autosomal dominant arteriopathy with subcortical
infarcts and leukoencephalopathy
CCP cyclic citrullinated peptide
CCU coronary care unit
CD4 cluster of differentiation 4
CDAD Clostridium difficile-associated disease
CEA carcinoembryonic antigen
CIN contrast-induced nephropathy
CK creatine kinase
CKD chronic kidney disease
CLL chronic lymphocytic leukaemia
CLO Campylobacter-like organism
cm centimetre
cmH2O centimetre of water
CML chronic myeloid leukaemia
CMV cytomegalovirus
CN cranial nerve
CNS central nervous system
COHb carboxyhaemoglobin
COPD chronic obstructive pulmonary disease
CPAP continuous positive airway pressure
CPR cardiopulmonary resuscitation
Cr creatinine
Abbreviations xvii
CREST calcinosis, Raynaud’s syndrome, (o)esophageal dysmotility,
sclerodactyly, telangiectasia
CRP C-reactive protein
CRT capillary refill time; cardiac resynchronization therapy
CSM Committee on Safety of Medicines
CT computed tomography
CTPA computed tomography pulmonary angiogram
CVC central venous catheter
CVP central venous pressure
CXR chest X-ray
DAPT dual antiplatelet therapy
DC direct current
DDP4 dipeptidyl peptidase 4
DEXA dual-energy X-ray absorptiometry
DKA diabetic ketoacidosis
dL decilitre
DMARD disease-modifying anti-rheumatic drug
DNA deoxyribonucleic acid
DNACPR Do Not Attempt Cardiopulmonary Resuscitation
DNAR Do Not Attempt Resuscitation
DOAC direct-acting oral anticoagulant
DOLS Deprivation of Liberty Safeguard
DRE digital rectal examination
dsDNA double-stranded deoxyribonucleic acid
DVLA Driver and Vehicle Licensing Agency
DVT deep vein thrombosis
EBV Epstein–Barr virus
EC enteric-coated
ECG electrocardiogram
ED emergency department
EEG electroencephalogram
eGFR estimated glomerular filtration rate
EGPA eosinophilic granulomatosis with polyangiitis
EPP exposure-prone procedure
ERCP endoscopic retrograde cholangiopancreatography
ESC European Society of Cardiology
ESR erythrocyte sedimentation rate
EVAR endovascular aneurysm repair
FBC full blood count
xviii Abbreviations
FFP fresh frozen plasma
fL femtolitre
FSGS focal segmental glomerulosclerosis
ft foot/feet
fT4 free thyroxine
FTD frontotemporal dementia
g gram
G gauge
GALS gait, arms, legs, and spine
GBM glomerular basement membrane
GBS Guillain–Barré syndrome
GCA giant cell arteritis
GCS Glasgow Coma Scale
GFR glomerular filtration rate
GGT gamma-glutamyl transpeptidase
GI gastrointestinal
GMC General Medical Council
GORD gastro-oesophageal reflux disease
GP general practitioner
GTN glyceryl trinitrate
5-HIAA 5-hydroxyindoleacetic acid
HAART highly active anti-retroviral treatment
HAV hepatitis A virus
Hb haemoglobin
HbA1c glycosylated haemoglobin
HBc hepatitis B core
HBs hepatitis B surface
HBsAb hepatitis B surface antibody
HBsAg hepatitis B surface antigen
HBV hepatitis B virus
hCG human chorionic gonadotrophin
HCO3– bicarbonate
HCV hepatitis C virus
HCW healthcare worker
HDV hepatitis delta virus
HE hepatic encephalopathy
HELLP haemolysis, elevated liver enzymes, and low platelet count
HHS hyperosmolar hyperglycaemic non-ketotic state
HHV-8 human herpesvirus 8
Abbreviations xix
HiB Haemophilus influenzae type B
HIDA hepatobiliary iminodiacetic acid
HIT heparin-induced thrombocytopenia
HIV human immunodeficiency virus
HIVAN human immunodeficiency virus-associated nephropathy
HNIG human normal immunoglobulin
HOCM hypertrophic obstructive cardiomyopathy
HR heart rate
HS heart sound
HSP Henoch–Schönlein purpura
HSV herpes simplex virus
HTLV human T-lymphotropic virus
HUS haemolytic uraemic syndrome
Hz hertz
IBD inflammatory bowel disease
IBS irritable bowel syndrome
ICP intracranial pressure
ICS inhaled corticosteroid
IgA immunoglobulin A
IgE immunoglobulin E
IGF-1 insulin-like growth factor 1
IgG immunoglobulin G
IgM immunoglobulin M
IGRA interferon gamma release assay
IIH idiopathic intracranial hypertension
IM intramuscular
IMCA Independent Mental Capacity Advocate
in inch
INH inhaler
INR international normalized ratio
ITP idiopathic thrombocytopenic purpura
ITU intensive therapy unit
IU international unit
IV intravenous
IVIG intravenous immunoglobulin
IVU intravenous urogram
JME juvenile myoclonic epilepsy
JVP jugular venous pressure
kg kilogram
