Answer keys:

1. First-degree Atrioventricular Block
2. Pacemaker Placement
3. Nauseated And Light Headed
4. Carotid Dopplers
5. Proscar 5 Mg
6. Synthroid 0.2 Mg
7. Respiratory Rate 16
8. 2 Through 12 Are Intact

9. R
10. Vibration And Proprioception
11. Transient Ischemic Attack.
12. Lumbar Stenosis
13. Codman-hakim Shunt
14. Coughing, Straining, And Sneezing
15. Motrin 800 Mg Twice A Day
16. Frontal Region Of Head
17. Feeling Of Ringing In The Ears
18. Intermittent Blurry Vision
19. Extraocular Movements

20. Farther Down From The Shunt Reservoir
21. Little Bit Of Dry Blood
22. Shunt Adjustment Back After An Mri
23. PseudotumorCerebri Without Papilledema
24. Skull X-ray
25. B
26. C
27. A
28. A
29. B
30. C

31. C
32. A
33. B
34. A
35. C
36. B
37. C
38. A
39. C
40. A
41. B
42. C

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:00[Music]

0:14part a for questions 1 to 24 complete the notes with the information you hear

0:21now look at the notes for extract one extract one questions one to twelve

0:28you hear a doctor talking to a patient called polina for questions 1 to 12

0:34complete the following notes with a word or short phrase you have 30 seconds to

0:40look at the notes

1:10hello good morning doctor good morning tell me what’s your problem well i have a history of first degree atrial

1:17ventricular block and had a pacemaker placement i feel this problem of

1:22decreased eye vision last time the problem lasted for about five minutes

1:28that occurred four weeks ago when i was driving the car then how did you manage to drive

1:34well i was able to pull the car over to the side of the road without much trouble during that time i felt nauseated and

1:41light-headed when i approached the clinic at that time and received a ct scan corrupted doppler’s echocardiogram

1:50and neurological evaluation all of which were unremarkable i couldn’t have an mri

1:56due to the pacemaker placement okay did that occur again no doctor any lesions

2:03or change in vision headaches change in gait or other neurological issues no

2:08doctor do you have any back pain bowel or bladder incontinence or frank lower

2:13extremity weakness no doctor what’s your age 57 doctor do you drink or smoke i

2:21don’t smoke but i drink alcohol only on some special occasions

2:26any past illness or surgeries i had pacemaker placement for atrial

2:31ventricular block and i had bilateral knee replacement three years ago and

2:37have some pain in my knees what medications are you taking i have recently started on plavix suggested by

2:45primary care doctor other than that baby aspirin 81 milligrams per day proscar 5

2:52milligrams gd and synthroid 0.2 milligrams daily are you allergic to any

2:58medication no doctor well your physical examination shows your blood pressure at

3:03134 over 80. your heart rate 60 respiratory rate 16 and weight is 244

3:11pounds cranial nerves 2 through 12 are intact and you have normal bulk and tone

3:17throughout there’s no cogwheeling there is some minimal weakness at the r4 plus

3:22or five and possibly trace weakness at the quadriceps negative five or five

3:28you have decreased sensation to vibration and proprioception and vibration there

3:34is no dysmetria or tremor noted his romberg is negative

3:40you have developed transient ensemic attack the character of his brief episode of visual loss is concerning for

3:47compromise of the posterior circulation differential diagnosis include

3:52hyperprofusion stenosis and dissection you have lumbar stenosis the symptoms

3:58are very mild and consist mainly of some mild proximal upper extremity weakness and very mild gait instability you have

4:06to get a ct angiogram to evaluate the integrity of the cerebrovascular system

4:14extract two questions 13-24 you hear a physician talking to a

4:20patient called mrs emeline pethick for questions 13-24 complete the following

4:26notes with a word or short phrase you now have 30 seconds to look at the

4:31notes

5:03hello good morning doctor good morning tell me what’s your problem well i have

5:08a codman shunt set at 90 millimeters h2o

5:13recently i’m getting acute onset of headaches and it’s worsening day by day

5:19i am unable to sleep the pain is constant and is worse with coughing straining and sneezing as well as

5:26standing up what’s your age 40 doctor did you take any medicines then yeah

5:32i’ve tried taking immatrics as well as motrin 800 milligrams twice a day

5:38but it has not provided much relief although the pain is generalized it is

5:43quite intense in the frontal region of head i get a feeling of ringing in the

5:48ears i have been experiencing intermittent blurry vision and dimming lights as well do you drink or smoke no

5:56doctor well i’ve reviewed your diagnosis reports your physical exam reports show

6:02blood pressure at 153 over 86 pulse at 63 and respiratory rate 16

6:09cranial nerves intact for extraocular movements the shut site is clean dry and intact

6:16you have a small three millimeter to four millimeter round scab that was noted farther down from her shunt

6:22reservoir it looks like there’s a little bit of dry blood there the worsening headaches

6:28are secondary to shunt adjustment back after an mri you have pseudotumor cereby without

6:34papillodemma and migraine headaches well your shunt back program to 90

6:40millimeter h2o last time was after confirmation of an x-ray however it

6:45seems the picture of the x-ray last time was not most desirable therefore i’m

6:50planning the shunt back to 90 millimeter h2o again tomorrow so you have to have another skull x-ray

6:57to confirm the shunt back program to 90 millimeter h2o that is the end of part a

7:05now look at part b in this part of the test you will hear six different

7:10extracts in each extract you’ll hear people talking in a different healthcare environment for questions 25 to 30

7:18choose the answer a b or c which fits best according to what you hear

7:23you will have time to read each question before you listen to the audio complete the answers as you listen to the audio

7:32now look at the question 25. you hear a discussion between a doctor and nurse

7:38about different complications following heart attack

7:56hello doctor what types of complications are expected following heart attack well

8:02there are two types of complications that can occur following a heart attack the first problem occurs pretty much

8:08straight away and the second complication occurs later on immediate complications following a

8:14heart attack are arrhythmias is the immediate complications in which the heart beats irregularly either too fast

8:21or too slowly cardiogenic shock is when the patient’s blood pressure drops suddenly therefore the heart cannot

8:28supply adequate blood for the body to function properly hypoxemia is the condition when the

8:34oxygen levels in the blood become too low pulmonary edema occurs when the fluid accumulates in and around the

8:41lungs deep vein thrombosis occurs when the deep veins of the legs and pelvis

8:46develop blood clots that either block or interrupt the flow of blood in the vein myocardial rupture occurs when the heart

8:53attack damages the wall of the heart that has an increased risk of a heart wall rupture

8:59ventricular aneurysm is when a heart chamber called a ventricle forms a bulge

9:09question 26 you hear the discussion between two doctors about the impacts of

9:15acute kidney injury

9:32what are the impacts of acute kidney injury doctor acute kidney injury is a

9:37common and severe complication of surgery especially cardiac surgery often the complication is associated

9:44with higher rates of morbidity mortality and cardiovascular events longer

9:49hospital length of stay and higher cost during stage one there will be an

9:54increase in serum creatinine of 1.5 to 1.9 times baseline an absolute increase

10:02of at least 0.3 milligrams per deciliter or urine output of less than 0.5

10:07milliliters per kilogram per hour for 6 to 12 hours during stage 2 of acute kidney injury

10:14there will be an increase in serum creatinine of 2.0 to 2.9 times baseline

10:20or urine output less than 0.5 milliliters per kilogram per hour for 12

10:25or more hours during stage 3 of the condition there will be an increase in serum creatinine

10:31of three times baseline an absolute increase of at least four milligrams per deciliter initiation of renal

10:38replacement therapy urine output less than 0.3 milliliters per kilogram per hour for 24 hours or more or anuria for

10:4612 or more hours

10:54question 27 you hear a discussion between two doctors about acquired

10:59melanocytic nevvy

11:16hello doctor what are acquired melanocytic navy acquired melanocytic

11:22nevi are clumps of melanocytes that originate during childhood but manifest during 30 to 40 years of age

11:29junctional nevi form macules with the skin markings becoming slightly more prominent they are circular flat lesions

11:36with a uniform brown coloration they have litiginous cells which are round or

11:41oval or spindle shaped dermal nebu are raised pale brown or

11:46skin colored lesions and often hairy having focal globules and fine vessels

11:52or pale areas pseudohorn cysts may be seen the cells are epithelid with

11:58amphophyllic cytoplasm and the melanin is in granules compound nevi may be

12:04raised with a wart-like surface in certain cases and are usually lighter brown than junctional nevi are they have

12:10round or oval globals of pigment and these may form cobblestone patterns

12:21question 28 you hear a discussion between a doctor and nurse about amblyopia

12:42hello doctor can you explain what is an amblyopia well amblyopia is the medical

12:49term for lazy eye that refers to a condition in children where the vision in one eye fails to develop adequately

12:56this usually affects ability of the child to see using the weaker eye in strabismic amblyopia a squint

13:04develops due to a mismatch between the muscles that support the position of the eyes

13:09therefore the brain ignores the eye that is not straight and relies on the images

13:14generated by the stronger eye in a condition called anti-somitropic amblyopia the refractive error is

13:21greater in one eye than the other eye therefore the brain ignores the more farsighted eye and relies instead on the

13:28eye that provides a clearer picture however the weaker eye remains straight therefore the defect may go unnoticed by

13:35the parents or primary care doctor in the condition called deprivation or occlusion amblyopia one eye is deprived

13:42of vision due to the development of a blockage such as a cataract the ocular media becomes opaque

13:49preventing visual information from reaching the brain

13:58question 29 you hear a discussion about mille area

14:17hello doctor what is malieria well miliaria is the conditions associated with sweat

14:24retention in the skin when the flow of sweat is obstructed the sweat stays trapped within the skin

14:31instead of moving out from the sweat glands to the surface of the skin developing various symptoms and signs

14:37including skin lesions miliary crystalline also called pseudomena describes sweat duct

14:44obstruction in the uppermost epidermis where the sweat is retained to form subcornial vesicles these clear

14:51non-inflamed fluid-filled blisters and papules rupture easily and even light

14:56rubbing can cause them to break miliaria rubra also called prickly heat

15:02and refers to the retention of sweat that moves into the middle layers of the epidermis and the upper dermis resulting

15:09in itching and redness around the sweat pores miliaria pustulosa occurs when the

15:14melaria rubra develops as inflamed pustules miliaria profunda occurs when

15:20the sweat moves from the ducts into the dermis hard flesh-colored painful papules

15:25develop that are much larger and more deeply located than the papules seen in miliaria rubra

15:37question 30 you hear a lecture about different type of stents

15:56we see today what is stent and what are the different types of stents

16:02stent is a splint that is placed inside a duct blood vessel or canal temporarily

16:08to aid healing or relieve an obstruction primarily they are used to keep narrowed

16:13blood vessels open and patent to allow sufficient blood flow or bodily fluid

16:20coronary stents are a tubular mesh-like device that do not have any embedded

16:25medications in them drug-eluting stents are coated with medications to prevent inflammation and

16:32retinosis of the artery on a long-term basis a urinary stent is used to hold open the

16:39ureter in cases where it is narrowed your readers are long tubes that carry urine from the kidneys to the bladder

16:45where it is stored until it is emptied and prostatic stent is used to open up

16:52the narrowing caused by an enlarged prostate pushing against the urethra preventing the normal outflow of urine

16:58peripheral vascular stents are used to keep blood vessels outside the coronary arteries open

17:05stent grafts are tubular devices made up of a special fabric that is supported by

17:10a rigid metal stent these are mainly used for vascular surgeries such as to

17:16repair abdominal aortic aneurysm stents can also be used to keep the food

17:21pipe of the esophagus open in case of esophageal constriction and biliary

17:26stents can be used to maintain adequate drainage of bile into the intestine

17:35that is the end of part b now look at part c

17:40part c in this part of the test you’ll hear two different extracts in each extract

17:46you’ll hear health professionals talking about specific aspects of their work

17:51for questions 31 to 42 choose the answer a b or c which fits best according to

17:58what you hear complete the answers as you listen to the audio

18:03now look at extract one extract one questions 31-36

18:11you hear the discussion between a senior doctor and junior doctors on epidermal

18:16nevi you have 90 seconds to read questions 31-36

19:52hello doctor can you please explain different types of epidermal navy

19:57epidermal nevi are categorized based on their clinical features by the site of

20:02occurrence and their extent of spread however mostly they are categorized

20:08based on the epidermal cell that predominates in the lesion in certain patients multiple epidermal

20:14nevy occur along with systemic abnormalities and they form the epidermal nevis syndromes

20:21based on the occurrence patterns epidermal nevi are categorized differently despite the similarity in

20:27their microscopic appearance nevis varicosis occurs as a single or

20:32multiple lesions but always localized nevis urineous latteris occurs as a

20:37linear pattern of lesions ichthyosis histrix are generalized lesions however

20:43epidermal nevi are also classified by their cell of origin nevis sebaceous are

20:49quite common and are made up of sebaceous glands with or without hair follicles they’re found commonly on the

20:56scalp but also on the extremities or trunk and are pale yellow in color with

21:01a smooth hairless surface they are present in infants though they may manifest only after puberty or in

21:08childhood one fourth of the cases eventually give rise to tumors and are mostly benign

21:14often it is connected with the occurrence of schimel penning syndrome phacomatosis pigmento caricottaca

21:21didamos a plastic sebaceous and scalp syndrome carotenosinic epidermal nevis

21:26are also called non-organized epidermal never and are quite common among this

21:32group of lesions they follow the lines of blasco and begin as brownish macules

21:38thicken and darken with age to become plaques they may be defined as linear or

21:43varicose based on their appearance other variants include the epidermolytic epidermal nervous the acantholytic

21:50epidermal nervous and the systemized epidermal nevis nevis comedonicus are formed of

21:57proliferated dilated keratinized follicles often inflamed or showing signs of infection as a result of

22:03blockage forming blackheads and pitting is often seen it may be associated with

22:09brain abnormalities bone defects and cataracts the angora hair nevis is

22:14remarkable for the long and soft white hair like angora wool that grows from it

22:20it may be associated with other defects of the brain and bones the becker nevis

22:25is a dark patch of hairy skin that appears like a checkerboard shape becoming larger and darker after puberty

22:32due to androgen dependent nature often it is found on the upper part of the back or on the shoulders it is linked

22:39with other skeletal muscular defects forming the becker nevis syndrome inflammatory linear varicose epidermal

22:46nevis is linear and forms plaques usually unilateral they are usually pruritic and appear

22:53inflamed and hyperkeratotic the first appearance is after six months

22:58of age porocherotic ecron nevis appears as warty keratotic popular lesions mostly

23:06on the palms and soles but in some cases they may appear all over the skin

23:21now look at extract two questions 37-42

23:27you hear the discussion of a physician with junior doctors on different types of gang green

23:33you have 90 seconds to read questions 37-42

25:08hello doctor can you explain different types of gangrene well the term gangrene refers to the

25:15death of tissues due to lack of blood supply and deeper invasion of infected

25:20tissues which are broadly classified into two categories dry and wet gangrene

25:26although there are many types of gangrene all types of gangrene manifest either as dry or wet form

25:34in the dry gangrene there is obstruction or slowing of blood flow into the organ

25:39or part of the body that is affected peripheral parts like toes fingers nose

25:45tip earlobes etc are commonly involved often dry gangrene is seen in patients

25:51of type 1 and type 2 diabetes where long term high blood sugar damages the small

25:57arteries and blood vessels that supply blood to the end parts of the body such

26:02as fingers and toes resulting in obstruction and slowing of blood flow and ultimately gangrene

26:09in patients with dyslipidemia or high cholesterol there is a risk of cholesterol deposition and lipids called

26:16plaques within the blood vessels in the peripheries such as fingers and toes

26:21this leads to decrease in the blood vessel diameters by narrowing of the lumen resulting in formation of gangrene

26:29patients with peripheral arterial disease develop fatty acid deposits or develop narrowing of peripheral blood

26:35vessels certain conditions include scleroderma and raynaud’s disease where the blood supply is restricted to leg or

26:43hand muscles resulting in gangrene dry gangrene is usually identified by

26:48cold painless and dry and shriveled up affected part however there will be

26:53healthy skin surrounding them the area affected appear mummified

26:59what gangrene occurs due to infection and invasion of bacteria into deeper

27:04tissues after injuries foot ulcers frostbites or burns there is excessive swelling of the

27:10affected part due to release of the toxins from the invading bacteria resulting in blockage of the blood

27:17supply and worsening of the infection as the white blood cells cannot reach the area affected via blood vessels

27:25wet gangrene spreads much quicker than dry gangrene and may result in life-threatening complications like

27:31septic shock wet gangrene appears discolored or black and often with acute

27:37and excruciating pain there are black blisters and foul-smelling pus beneath the thin skin at the area

27:45since the infection is associated with discharge of pus it is called wet gangrene

27:51gas gangrene is caused by bacteria called clostridium that is found in

27:56spores present in the soil gas gangrene was a common cause of death

28:01in the wars the gangrene is caused by the toxins released by the bacteria

28:07gas gain green is further categorized into three types traumatic gas gain

28:12green occurring after injury non-traumatic gas gangrene recurrent gas

28:17gangrene caused by c perfringens species of bacteria necrotizing fasciitis is a deep tissue

28:25infection caused by bacteria like staphylococcus or streptococcus

28:30the bacteria spreads deep into the skin and into the tissues and attacks the

28:35soft tissue and the fascia which is a sheath of tissue covering the muscle

28:40this can occur in an extremity following a minor trauma or due to the opportunity

28:46for the bacteria to enter the body such as surgery the necrotizing fasciitis

28:51infection known as flesh eating bacteria is most common with minor trauma a mixed

28:57bacterial infection is often the cause after surgery internal gangrene is caused when blood

29:04supply to an internal organ is hampered usually by pressure from another organ or growth for instance in hernia there

29:12is an abdominal opening where the intestine may get blocked and the blocked area turns gangrenous noma or

29:19cancrum oris affects the face fournier’s gangrene is a rare but

29:24life-threatening condition affecting the penis and genitalia this disease has been shown to have a

29:30predilection for patients with diabetes as well as long-term alcohol misuse

29:36however the disease can also affect patients with non-obvious immune compromise

29:41the development and progression of the four nearest gangrene is often fulminating and can quickly cause

29:47multiple organ failure and mortality due to such potential complications it

29:53is crucial to diagnose the disease process as early as possible death rate is very high despite

30:00antibiotics and aggressive debridement and broadly accepted as the standard treatment mullany’s synergistic gangrene

30:07is a rare type seen in patients after surgery mullany’s synergistic gangrene

30:13is caused by s aureus and streptococcus organisms one of the recognizable

30:18symptoms is the presence of extremely painful lesions that usually form in the second week after surgery or minor

30:25trauma

30:37that is the end of part c you now have two minutes to check your answers

30:58[Music]

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