Medicine

In these questions candidates must select one answer only.

A 50-year-old man complains of hardness of hearing and dyspnoea. He is noted to have a nasal septal perforation and a blood pressure of 140/90 mmHg. His urinalysis shows red cells, protein and casts. The chest radiograph reveals opacities. The most likely diagnosis is:

Tuberculosis

Amyloidosis

Goodpasture’s syndrome

Acute tubulointerstitial nephritis

Wegener’s granulomatosis

Pulseless electrical activity (PEA) in a cardiac arrest may be associated with all of the following EXCEPT:

Cardiac tamponade

Thromboembolism

Malignant hyperpyrexia

Hypokalaemia

Ruptured aortic aneurysm

A 75-year-old man with type 1 diabetes mellitus presents with a unilateral facial nerve palsy and severe earache. On auroscopic examination, he has granulation tissue deep in the external auditory meatus. The most likely diagnosis is:

Bell’s palsy

Sarcoidosis

Facial nerve schwannoma

Otitis externa complicated by local osteomyelitis (malignant otitis externa)

Suppurative otitis media

A 70-year-old woman presents with recent onset of urinary incontinence. The most appropriate initial investigation is:

Mid-stream urine (MSU) sample for dipstick

Urodynamics

FBC

Serum urea and electrolytes

MSU for culture and sensitivities

4A 50-year-old woman with type 2 diabetes mellitus presents with fever and a well-defined dusky-red erythematous eruption over the left side of her face. The most likely organism would be:

Staphylococcus aureus

Group B streptococcus

Group A streptococcus

Herpes zoster virus

Herpes simplex virus

The following diseases are associated with the Epstein – Barr virus EXCEPT:

Craniopharyngioma

Burkitt’s lymphoma

Sinonasal tumours

Glandular fever

Hodgkin’s lymphoma

A 44-year-old woman complains of headaches and nosebleeds. Blood pressure is 160/100 mmHg in the right arm and 130/80 mmHg in the left arm. She complains of cold legs and has delayed radiofemoral pulses. The most likely diagnosis would be:

Acromegaly

Marfan’s syndrome

Coarctation of the aorta

Kawasaki’s disease

Takayasu’s arteritis

A 55-year-old farmer complains of dry cough, exertional dyspnoea, joint pains and weight loss. He is noted to have finger clubbing. On a chest radiograph there is bilateral diffuse reticulonodular shadowing at the bases. The most likely diagnosis is:

Bronchial carcinoma

Bronchiectasis

Cryptogenic fibrosing alveolitis

Mesothelioma

Extrinsic allergic alveolitis

A 45-year-old woman presents with pruritus and jaundice. She complains of dry eyes and mouth. The most discriminating investigation would be:

Anti-mitochondrial antibodies

Antinuclear antibody

Serum bilirubin and liver function tests

Hepatitis B surface antigen

Smooth muscle antibody

5An 80-year-old woman complains of sudden painless loss of vision in her right eye. She has facial pain on chewing. The most likely diagnosis is:

Acute glaucoma

Retinal detachment

Cranial arteritis

Basilar migraine

Optic neuritis

A 13-year-old girl presents with a painful and swollen knee. There is no history of trauma. A tender lump is palpated over the tibial tuberosity. The most likely diagnosis would be:

Osteomyelitis

Chondromalacia patella

Juvenile rheumatoid arthritis

Osteosarcoma

Osgood – Schlatter disease

The following pairs of neurovascular structures and injuries are correctly paired EXCEPT:

Tibial nerve – proximal fibula fracture

Sciatic nerve – posterior dislocation of the hip

Median nerve – Smith’s wrist fracture

Axillary nerve – fracture to humeral neck

Brachial artery – supracondylar fracture of the humerus

An 18 year old known to have asthma presents with severe wheezing, a respiratory rate of 30 and a pulse of 120. She is using her accessory muscles and appears distressed. She is apyrexial. The most appropriate initial management would be:

Intramuscular adrenaline

Oxygen and nebulized salbutamol

Intravenous hydrocortisone

Endotracheal intubation

Intravenous penicillin

A 25-year-old woman is brought to the accident and emergency department (A&E) by ambulance having sustained gross maxillofacial deformities after a high-speed road traffic accident. She is now agitated and hypoxic despite high-concentration oxygen having been administered by facemask by the paramedics. The most appropriate immediate intervention is:

Endotracheal intubation

Nasopharyngeal airway

Oropharyngeal airway

Cricothyroidotomy

Laryngeal mask airway

6The following pulse patterns are correctly matched with their disorders EXCEPT:

Pulsus alternans – left ventricular failure

Pulsus paradoxus – cardiac tamponade

Pulsus bisferiens – hypertrophic obstructive cardiomyopathy

Pulsus parvus et tardus (small volume, slow rising) – aortic regurgitation

Dicrotic pulse – dilated cardiomyopathy

A 16-year old girl presents with an anterior neck mass. It moves on protrusion of her tongue. Thyroid radionuclide scan shows no uptake in the midline. The most likely diagnosis is:

Lingual thyroid

Hashimoto’s thyroiditis

Thyroglossal cyst

Thyroid follicular adenoma

Reidel’s thyroiditis

A 40-year-old man presents with progressive confusion and tremor. On examination, he has extensor plantar reflexes. The most useful investigation would be:

HIV serology

CT scan

Drug levels

Mantoux test

VDRL

A 45-year-old man with a history of epilepsy presents with several weeks of fluctuating levels of consciousness. On examination his pupils are unequal. The most discriminating investigation is:

HIV serology

CT scan

EEG

Drug levels

Lumbar puncture

A 20-year-old heroin addict presents with weight loss, diarrhoea and confusion. On examination he has purple papules on his legs. The most useful investigation is:

Echocardiogram

Blood cultures

HIV serology

Chest radiograph

Drug levels

7Coeliac disease is associated with all of the following EXCEPT:

Vitamin B₁₂ deficiency

HLA DR3

Dermatitis herpetiformis

Steatorrhoea

Lymphoma

A 60-year-old man presents with acute onset of confusion and restlessness; he walks with a broad-based gait. On examination there is nystagmus and lateral rectus palsies bilaterally. There is alcoholic fetor. The most likely diagnosis would be:

Alcohol withdrawal

Folic acid deficiency

Subarachnoid haemorrhage

Subdural haematoma

Wernicke – Korsakoff syndrome

A 40-year-old woman complains of disabling joint pains. On examination you note scaly plaques over her anterior shins and knees. She has tried diclofenac for the arthralgia and wonders if there is any connection with the rash. The most useful treatment for her joints now would be:

Oral prednisolone

Methotrexate

Co-dydramol

Topical 0.5% hydrocortisone

Dithranol 0.1% cream

A 50-year-old man presents to A&E complaining of 30 minutes of severe crushing midchest pain with no relief from GTN. He has a history of angina. Pulse is 105 and BP 115/60. A 12-lead ECG shows normal sinus rhythm. The first drug to administer would be:

Morphine

Oxygen

Gaviscon

Streptokinase

Atropine

A 40-year-old woman with a history of angina presents with severe chest pain for 30 minutes. Pulse is 45 and blood pressure 80/60. A 12-lead ECG shows third-degree heart block. The first drug to administer would be:

Lidocaine

Atropine

Adrenaline

Procainamide

Amiodarone

8A 40-year-old patient is brought to A&E by ambulance in pulseless electrical activity (PEA). You are told that he was given adrenaline. The next step would be to:

Evaluate for reversible causes

Defibrillate with 200 J

Administer verapamil

Administer amiodarone

Administer morphine

A 70-year-old woman presents with progressive dysphagia and food regurgitation. On examination she has halitosis and a small lump on the left side of her neck. The most likely diagnosis is:

Achalasia

Branchial cyst

Diffuse oesophageal spasm

Pharyngeal pouch

Myasthenia gravis

A 40-year-old woman on carbamazepine for trigeminal neuralgia now complains of severe dizziness. The drug that may have potentiated the side effects of carbamazepine is:

the combined oral contraceptive pill

erythromycin

chloramphenicol

omeprazole

thiazide diuretics

The most common type of thyroid carcinoma is:

Follicular

Anaplastic

Medullary

Squamous

Papillary

A 40-year-old woman presents with fatigue, dyspnoea and paraesthesiae. On examination she has a red tongue. Blood film shows hypersegmented neutrophils, an Hb of 9 and a mean corpuscular volume (MCV) of 120 fL. The most likely diagnosis is:

Vitamin B₁₂ deficiency

Iron deficiency

Coeliac disease

Sideroblastic anaemia

Hypothyroidism

9An 18-year-old young women, who recently started the combined oral contraceptive pill on holiday in Kenya, complains of colicky abdominal pain, vomiting and fever. Urine is positive for red blood cells and protein. She develops progressive weakness in her extremities. The most likely diagnosis is:

Acute pyelonephritis

Acute intermittent porphyria

Ureteric calculus

Malaria

Systemic lupus erythematosus

A 75-year-old man presents with dyspnoea and chest pain. His pulse rate is 120 and he is extremely agitated. His arterial blood gas reveals low arterial oxygen and low CO2. His ECG shows S wave in I, Q and T waves in III, and T-wave inversion in leads V1 – 3. The most likely diagnosis is:

Myocardial infarction

Pulmonary embolism

Acute pericarditis

Cardiac tamponade

Pneumothorax

A 40-year-old actor with type 1 diabetes mellitus is started on propranolol for stage fright. He collapses on stage. He has not changed his insulin regimen. Serum glucose is 1.5 mmol/L. The most beneficial advice that you would offer him after treatment would be:

Discontinue propranolol

Carry a chocolate bar

Decrease his Humulin insulin

Decrease his Actrapid insulin

Carry glucagon

A 40-year-old woman complains of intolerance to cold weather and cold running water. On examination you note that she has a beaked nose, radial furrowing of the lips and facial telangiectasias. On examination of her hands you notice sausage-like digits and tapered fingers. The most discriminating investigation to establish her diagnosis is:

Anticentromere antinuclear antibody

Rheumatoid factor

FBC

Chest radiograph

Barium swallow

10Sites of a carcinoid tumour include all of the following EXCEPT the:

Appendix

Terminal ileum

Bronchus

Oesophagus

Rectum

Stevens – Johnson syndrome is associated with all of the following drugs EXCEPT:

Penicillin

Sulphonamides

Oral contraceptives

Thiazide diuretics

Salicylates

A 32-year-old boxer presents with headache, drowsiness, seizures and a rising blood pressure. The next most appropriate investigation is:

Blood alcohol level

Lumbar puncture

CT scan of the head

Blood glucose

Blood cultures

A 55-year-old woman complains of sudden, severe, central abdominal pain radiating to her back and vomiting. She prefers to sit forward on her stretcher. Temperature is 39°C, BP 100/60 and pulse 112. On examination she has a markedly tender epigastrium and a bruise over the left flank. She has a history of gallstones. She denies smoking or drinking alcohol. She takes HRT. The best initial investigation would be:

Plain abdominal radiograph

Serum bilirubin and liver function tests

Serum amylase

FBC

Abdominal ultrasonography

A 20-year-old man presents with a 4-day history of itching in both eyes. On examination there is bilateral lid oedema and a watery clear discharge. The most likely diagnosis is:

Episcleritis

Corneal abrasion

Trichiasis

Blepharitis

Allergic conjunctivitis

11A 75-year-old Asian woman presents with a 5-month history of tiredness and breathlessness particularly on exertion. On examination there is bilateral pitting oedema and fine crepitations bibasally. The most likely diagnosis is:

Malignancy

Chronic fatigue syndrome

Liver failure

Congestive cardiac failure

Tuberculosis

A 55-year-old man is found to have a fasting venous plasma glucose level of 6.3 mmol/L. What is the next step in management:

Commence glitazone

Fasting glucose test

Glucose tolerance test

Dietary advice

Urine dipstick

A 17-year-old boy presents with pain on swallowing. On examination he has trismus, palatal petechiae and enlarged tonsils. His sclerae are jaundiced. The most likely causative organism is:

Streptococcus pneumoniae

Hepatitis B virus

Epstein – Barr virus

Herpes simplex virus

Clostridium tetani

A 20-year-old woman presents with recurrent epistaxis. She admits to having heavy periods. Her BP is 90/60 and pulse 100. There are bruises of different ages over her extremities but no splenomegaly. Test results are as follows:

White cell count

83 × 10⁹

Hb

11.5 g/dL

Platelets

149 × 10⁹/L

Bleeding time

Prolonged

Antinuclear antibody

Negative

The most likely diagnosis is:

Non-accidental injury

Systemic lupus erythematosus

Idiopathic thrombocytopenic purpura (ITP)

Thrombotic thrombocytopenic purpura (TTP)

Sickle cell disease

12A 45-year-old woman presents with severe itching, pale stools and dark urine. On examination there is darkened skin pigmentation, xanthelasma and hepatomegaly. Test results are as follows:

Serum bilirubin

15 mmol/L

Serum alkaline phosphatase

400 (30 – 300) IU/L

AST

40 (5 – 35) IU/L

Diagnosis would best be confirmed by:

Serum antimitochondrial antibody

Hepatitis virology

Liver biopsy

Kveim’s test

Abdominal ultrasonography

A 60-year-old man presents with increasing abdominal girth. On examination you elicit shifting dullness. The ascitic fluid tap reveals straw-coloured fluid containing 50 g/L of protein and elevated LDH. It contains 1000 WBCs/mm³ (no lymphocytes) and many red cells are present. Serum total protein is 40 g/L. The most likely diagnosis is:

Cirrhosis

Tuberculosis

Malignancy

Pancreatitis

Hepatic vein obstruction

A 20-year-old homosexual man presents with proctalgia and bloody anal discharge. The most likely organism is:

Human papillomavirus

Chlamydia trachomatis

Neisseria gonorrhoeae

Haemophilus ducreyi

Treponema pallidum

A 40-year-old long-stay patient in a psychiatric hospital presents with fever, abdominal pain, dry cough and worsening confusion. Blood tests reveal neutrophilia, lymphopenia and hyponatraemia. A chest radiograph shows right-sided lobar consolidation. The most likely diagnosis is:

Tuberculosis

Streptococcal pneumonia

Legionella pneumonia

Klebsiella pneumonia

Staphylococcal pneumonia

13A 50-year-old man with schizophrenia presents with drooling saliva and involuntary chewing movements. He walks with a shuffling gait. The most likely diagnosis is:

Parkinson’s disease

Extrapyramidal side effect of medication

Autonomic side effect of medication

Anticholinergic side effect of medication

Lithium toxicity

A 40-year-old man presents with numbness and tingling sensation in his feet. He is noted to have distal sensory loss and absent ankle-jerk reflexes. The knee-jerk reflexes are exaggerated. He drinks heavily and smokes cigars. His blood pressure is 160/90 with a pulse of 90. A full blood count reveals a macrocytic megaloblastic anaemia. The most likely diagnosis is:

Syringomyelia

Tabes dorsalis

Wernicke – Korsakoff syndrome

Vitamin B₆ deficiency

Subacute combined degeneration of the cord

A 30-year-old man presents with a brown discoloured toenail. On examination there is nail pitting and brown pigmentation at the base of the great toenail and cuticle. He states that the colour started under the nail and has spread down to his nailbed. The most likely diagnosis is:

Subungal haematoma

Psoriasis

Paronychia

Melanoma

Onychomycosis

A 40-year-old woman presents with a right-sided pleural effusion and ascites. Abdominal ultrasonography reveals a left ovarian mass. The most likely diagnosis is:

Pseudomyxoma peritonei

Meigs’ syndrome

Budd – Chiari syndrome

Nephrotic syndrome

Tuberculosis

14A 30-year-old man presents with a tender swollen testicle. He states that he was bumped in the groin while playing sports. On examination the borders of the testicle are irregular, and the testicle is heavy and woody. There is no associated lymphadenopathy. He is also noted to have gynaecomastia. There are no external signs of trauma. In this age group, the most likely diagnosis is:

Testicular torsion

Epididymo-orchitis

Seminoma

Teratoma

Testicular haematoma

A 45-year-old male psychiatric patient with long-term bipolar disorder presents with vomiting, muscle twitching and tremor. He was started on bendrofluazide recently and self-prescribes ibuprofen for headaches. His BP is 90/50. His gait is ataxic. He then starts fitting. The drug most likely to be responsible is:

Lithium

Phenothiazine

Benzodiazepine

Ecstasy (MDMA)

Ibuprofen

A 60-year-old man presents acutely with vertigo and vomiting. On neurological examination there is right facial numbness, an ipsilateral ataxia of the arms and legs and a contralateral loss of pain and temperature sense. The most likely diagnosis is:

Posterior cerebral artery infarction

Middle cerebral artery infarction

Anterior cerebral artery infarction

Posteroinferior cerebellar artery infarction

Vertebrobasilar ischaemia

A 60-year-old man presents with persistent fever, profuse watery diarrhoea and crampy abdominal pain for the past week. He has just completed treatment for osteomyelitis. Proctosigmoidoscopy reveals erythematous ulcerations and yellowish-white plaques. The most likely diagnosis is:

Ulcerative colitis

Crohn’s disease

Pseudomembranous colitis

Viral gastroenteritis

Clostridium perfringens enterocolitis

15You are on ward rounds and notice that a young patient is coughing briskly. He has just been started on benzylpenicillin for acute tonsillitis complicated by trismus. He states that he does not know if he is allergic to any drugs. He becomes short of breath. His pulse is 110 beats/min and he now cannot complete sentences. The most appropriate management for this patient would be:

Administer adrenaline of a 1:10 000 solution intravenously

Administer adrenaline intramuscularly for suspected new-onset asthma

Administer oxygen and give nebulized salbutamol

Administer oxygen and adrenaline of a 1:1000 solution intramuscularly for suspected anaphylaxis

Administer oxygen and give intravenous hydrocortisone for anaphylactic shock

A 45-year-old obese man is noted to have glycosuria. He has no symptoms. Diabetes is confirmed on an oral glucose tolerance test. The most appropriate management for this patient is:

Commence biguanide

Commence sulphonylurea

Advise on diet and exercise

Commence on Humulin and Actrapid insulin

Admit to hospital

A 45-year-old man with well-controlled type 1 diabetes is prescribed captopril for hypertension. He has a history of intermittent claudication and has rest pain. There is þþþ proteinuria. Urea and creatinine are elevated. On examination there is an abdominal bruit. The most likely diagnosis is:

Diabetic nephropathy

Focal segmental glomerulosclerosis

Renal artery stenosis

Membranous glomerulonephritis

Renal cholesterol embolism

A 20-year-old man presents with buttock pain radiating down both legs and heel pain. On examination he has marked kyphosis and limitation of chest expansion. ESR and CRP were raised. The most likely diagnosis is:

Lumbar disc prolapse

Sacroiliitis

Spondylolisthesis

Spinal stenosis

Ankylosing spondylitis

16A 42-year-old woman presents with repeated episodes of fluctuating hearing loss, vertigo and tinnitus lasting hours over the past few months. The cause of her vertigo is:

Migraine

Hyperventilation

Acoustic neuroma

Ménière’s disease

Acute vestibular neuronitis

The definitive investigation to diagnose a pulmonary embolism is:

Pulmonary arteriography

Ventilation – perfusion isotope scintigraphy

Computed tomography pulmonary angiogram (CTPA)

A 12-lead ECG

Posteroanterior and lateral chest radiographs

Which one of the following drugs is absolutely contraindicated in patients with asthma?

Adenosine

Atenolol

Adrenaline

Verapamil

Bendrofluazide

A 70-year-old man complains of flashing lights and floaters in his left eye for the past month and now complains of painless loss of vision in his left eye. The most likely diagnosis is:

Central retinal artery occlusion

Central retinal vein occlusion

Optic neuritis

Retinal detachment

Macular degeneration

A 30-year-old man with HIV presents with sudden bilateral painless loss of vision. The most likely cause is:

Kaposi’s sarcoma

Candidiasis

Chlamydia trachomatis

Cytomegalovirus retinitis

Gonococcal infection

17A 50-year-old man presents to A&E with repeated fits. Plasma sodium is 112 mmol/L and urine osmolality is 550 mosmol/kg. He is well hydrated. On his chest radiograph there is a cannon-ball lesion. He smokes 20 cigarettes a day and drinks spirits daily. The most likely diagnosis is:

SIADH (syndrome of inappropriate antidiuretic hormone secretion)

Addison’s disease

Liver cirrhosis

Renal failure

Diabetes insipidus

The cause of gradual bilateral loss of vision is least likely to be:

Cataract

Optic atrophy

Diabetic retinopathy

Chronic glaucoma

Choroiditis

A 60-year-old man presents with chest pain and sudden onset of atrial fibrillation with a heart rate of 160/min. The most appropriate management would be:

Oxygen, heparin and synchronized DC shock

Oxygen, heparin, intravenous amiodarone

Oxygen, heparin, warfarin

Oxygen, β blockers

Oxygen, intravenous digoxin

A 65-year-old man presents with an acute myocardial infarction with a new left bundle-branch block. He had a haemorrhagic stroke a year ago. He is given 100% oxygen, diamorphine, metoclopramide, GTN and aspirin. The next most appropriate management is:

Intravenous glycoprotein IIb/IIIa inhibitor

Thrombolytic therapy with streptokinase

Coronary artery bypass surgery

Percutaneous transluminal coronary angioplasty

Continuous infusion of heparin

Which one of the following drugs may induce a psychosis similar to paranoid schizophrenia?

Heroin

Ecstasy (MDMA)

Amphetamine

Cocaine

Barbiturates

18Typhoid fever is associated with all of the following EXCEPT:

Bowel perforation

Splenomegaly

Ulceration of Peyer’s patches

Non-blanching maculopapular rash

Osteomyelitis

A 20-year-old woman presents with a BP of 170/100. On examination she has impalpable peripheral pulses, although systolic murmurs are auscultated above and below her clavicle. She also complains of diminishing vision and syncopal episodes. Her ESR is 50 mm/h. The most likely diagnosis is:

Thrombangiitis obliterans

Coarctation of the aorta

Kawasaki’s disease

Takayasu’s syndrome

Raynaud’s disease

A 35-year-old intravenous drug abuser presents with right upper quadrant abdominal pain. On examination he has peripheral oedema, ascites and a pulsatile liver. On chest auscultation he has a pansystolic murmur along the left sternal border. The most likely diagnosis is:

Tricuspid regurgitation

Pulmonary regurgitation

Pulmonary stenosis

Mitral regurgitation

Tricuspid stenosis

A 50-year-old woman presents with fever, headache, left eye pain and blurry vision. She states that she has just recovered from a cold. On examination she has a swollen left eyelid, mild proptosis and diminished visual acuity. She is unable to move her eye. The most likely diagnosis is:

Orbital cellulitis

Giant-cell arteritis

Sinusitis

Choroiditis

Cavernous sinus thrombosis

A 60-year-old woman presents with progressive forgetfulness and mood changes. She has a shuffling gait. A CT scan of the head shows cortical atrophy and enlarged ventricles. Histology shows senile plaques and neurofibrillary tangles. The most likely diagnosis is:

Wernicke – Korsakoff syndrome

Parkinson’s disease

Alzheimer’s disease

Variant Creutzfeldt – Jakob disease

Multi-infarct dementia

19A 20-year-old college student presents with headache and dry cough. The chest radiograph shows left lower lobe consolidation. White cell count is normal. Cold agglutinins are detected. The most likely pathogen is:

Streptococcus pneumoniae

Klebsiella sp.

Mycoplasma pneumoniae

Haemophilus influenzae

Legionella pneumophila

A 25-year-old man presents with weakness and numbness in his lower legs. He has just recovered from a recent chest infection. On examination deep tendon reflexes are absent and sensation is also lost. CSF from a lumbar puncture shows a normal cell count and glucose but raised protein level. The most likely diagnosis is:

Mumps

Sarcoidosis

AIDS

Guillain – Barré syndrome

Refsum’s disease

A 40-year-old man presents with dysphagia and epigastric pain relieved by food and antacids. On examination he has a palpable epigastric mass, a palpable supraclavicular lymph node and acanthosis nigricans. The most likely diagnosis is:

Oesophageal squamous cell carcinoma

Duodenal ulcer

Peptic stricture of oesophagogastric junction

Gastric adenocarcinoma

Pancreatic carcinoma

A 17-year-old girl presents with meningism and conjunctival petechiae. The CSF is turbid with an abundance of polymorphs and protein. Gram-negative cocci are isolated. The most likely organism is:

Neisseria meningitidis

Neisseria gonorrhoeae

Group B streptococcus

Haemophilus influenzae

Streptococcus pneumoniae

A 22-year-old man presents with fever, sweating, particularly at night, pruritus and weight loss. On examination he has palpable, painless, cervical lymph nodes and no skin manifestations. The most appropriate investigation would be:

FBC

Lymph node biopsy

Chest radiograph

CT scan of the neck and mediastinum

Mantoux test

20The most likely diagnosis is:

Tuberculosis

Non-Hodgkin’s lymphoma

Hodgkin’s lymphoma

Acute lymphoblastic leukaemia

Chronic lymphocytic leukaemia

A 40-year-old woman complains of intolerance to cold weather and cold running water. On examination you note that she has a beaked nose, radial furrowing of the lips and facial telangiectasias. On examination of her hands you notice sausage-like digits and tapered fingers. The most likely diagnosis is:

SLE

Sjögren’s syndrome

Systemic sclerosis

Rheumatoid arthritis

Dermatomyositis

A 50-year-old renal transplant recipient on immunosuppressive therapy with ciclosporin, azathioprine and prednisolone is most at risk of developing:

Squamous cell carcinoma of the skin

Basal cell carcinoma of the skin

Lymphoma

Liver failure

Leukaemia

A 25-year-old man back from hitchhiking through South America a fortnight ago now presents with explosive, watery, foul-smelling diarrhoea and weight loss. On examination he has abdominal distension. His stools are greasy and contain mucus. The most likely diagnosis is:

Shigella dysentery

Giardiasis

Amoebic dysentery

Crohn’s disease

Cystic fibrosis

Choice of antibiotic would be:

Ciprofloxacin

Penicillin

Tetracycline

Metronidazole

Erythromycin

21A 25-year-old man presents to A&E with repeated fits. He smells of alcohol and has jaw trismus. The most appropriate management is:

Give 100 mg intravenous thiamine

Give 50 mL of 50% glucose intravenously

Give 10 mg diazepam i.v. over 2 min

Insert a Guedel oropharyngeal airway and prepare for endotracheal intubation

Insert a nasopharyngeal airway and administer oxygen

A 55-year-old man presents with an acutely painful swollen right knee. He was recently prescribed bendrofluazide for mild hypertension. The most useful investigation would be:

FBC and ESR

Viral antibodies including parvovirus

Antinuclear antibody and rheumatoid factor

Aspirate of joint effusion for Gram stain and culture

Aspirate of joint effusion for polarized light microscopy

A 17-year-old man with known sickle cell disease presents with severe lower back pain. He has a history of seizures. Initial management should include all of the following EXCEPT:

Give oxygen at 4 L/min via a facemask

Start intravenous fluids

Give pethidine 150 mg i.m. every 2 h until the pain settles

Give morphine 1 – 2 mg i.v. every 2 – 3 min until the pain settles

Lumbar spine and pelvic radiograph

A 55-year-old intoxicated man is brought to A&E by the police. He is confused and aggressive. There are no external signs of head trauma. His BP is 140/90 and heart rate 110, and he is pale. He has palmar erythema, tremors and smells of alcohol. The initial most useful investigation for this man is:

Blood alcohol level

Head CT scan

γ-Glutamyltransferase

Blood glucose

Clotting screen

A 25-year-old man presents to A&E with sudden onset of severe lower back pain that radiates down his right leg. On examination he is noted to have scoliosis of the spine, limited spinal flexion, restricted straight-leg raise, limited hip movements and sensory loss over the dorsum of the right foot. The most likely diagnosis is:

Spondylolisthesis

Ankylosing spondylitis

Acute cord compression

Spondylosis

Lumbar disc prolapse

22A 35-year-old man presents with progressive weakness in his limbs over the past few days. He had a chest infection 2 weeks before. On examination he has proximal muscle wasting, hypotonia and absent deep tendon reflexes. Lumbar puncture results are:

Cells

4/mL lymphocytes

Chloride

110 mmol/L

Glucose

3.5 mmol/L

Protein

3 g/L

The most likely diagnosis is:

Poliomyelitis

Botulism

Guillain – Barré syndrome

AIDS

Subacute combined degeneration of the cord

The most useful step in guiding management would be:

Pulse oximetry

Chest radiograph

Nerve conduction studies

Serial vital capacity

Serial peak flow measurement

A 60-year-old obese man presents complaining of recurrent abdominal pain radiating to the back and made worse by eating and bending over. Antacids relieve the pain. He smokes 20 cigarettes a day and drinks spirits daily. The most useful investigation would be:

Oesophagogastroduodenoscopy (OGD)

Double-contrast barium meal

Helicobacter pylori breath test

Abdominal radiograph

Abdominal CT scan

The following conditions are associated with short stature EXCEPT:

Achondroplasia

Hypopituitarism

Rickets

Crohn’s disease

Klinefelter’s syndrome

23A 30-year-old man presents with crampy abdominal pain, diarrhoea and weight loss. On examination: temperature 39°C, no lymphadenopathy. Barium meal reveals a stricture in the terminal ileum. The most likely diagnosis is:

Tuberculosis

Crohn’s disease

Ulcerative colitis

Lymphoma

Coeliac disease

A 30-year-old man presents with a unilateral facial nerve palsy that involves his forehead. Possible causes include the following EXCEPT:

Bell’s palsy

Ramsay – Hunt syndrome

Acoustic neuroma

Cerebrovascular accident

Parotid tumour

On general examination the man has coarse oily skin and a prominent supraorbital ridge. He has widely spaced teeth and a moist handshake. The man’s general appearance is suspicious of:

Acromegaly

Haemochromatosis

Klinefelter’s syndrome

Gigantism

Hurler’s syndrome

A 50-year-old man presents with a lump in the posterior triangle of the neck. It has been present for 8 months and is associated with a cheesy serous discharge. The most likely diagnosis is:

Squamous cell carcinoma

Tuberculous adenitis

Deep lobe of parotid tumour

Infected branchial cyst

Infected lymph node

Prophylaxis against opportunistic infections is advised when the CD4 count falls below:

500 cells/mm³

300 cells/mm³

250 cells/mm³

200 cells/mm³

100 cells/mm³

24All the following are opportunistic infections in HIV disease EXCEPT:

Mycobacterium avium

Toxoplasma gondii

Pneumocystis jiroveci

Cytomegalovirus

Helicobacter pylori

Recognized side effects of heparin include the following EXCEPT:

Thrombocytopenic thrombosis

Thrombocytopenia

Alopecia

Osteoporosis

Hypokalaemia

The following statements regarding anorexia nervosa are true EXCEPT:

A BMI <13 warrants hospital admission

Anorexia is defined as a BMI <17.5 associated with food avoidance

Physical features include bradycardia and hypotension

Investigations are important in confirming the diagnosis

Anorexia may be associated with reduced bone mass

The most useful INITIAL screening test for SLE is:

Anti-dsDNA antibody

Antinuclear antibody

Anti-cardiolipin antibody

C3 and C4 levels

Anti-extractable nuclear antigen (ENA) antibody

Rheumatoid arthritis may be associated with all of the following EXCEPT:

Ulnar drift deformity

Carpal tunnel syndrome

Dupuytren’s contracture

Painful flexor tenosynovitis

Trigger finger

Carpal tunnel syndrome is associated with all of the following EXCEPT:

Degenerative arthritis

Pregnancy

Acromegaly

Colles’ fracture

Diabetes

25A 30-year-old woman involved in an RTA is brought by ambulance to A&E. She is noted to have bruising over the mastoid process and periorbital haematoma. On otoscopic examination she has bleeding behind the tympanic membrane. The most likely diagnosis is:

Extradural haematoma

Subdural haematoma

Basal skull fracture

Depressed occipital skull fracture

Intracerebral haemorrhage

A 54-year-old man with type 1 diabetes presents with fever, and a painful and swollen right lower leg. On examination, the pulses are absent distally, the foot is cold and subcutaneous crepitus is present. The most useful investigation is:

A radiograph of the leg

Doppler ultrasonography

Arteriogram

Blood cultures

Venogram

The most likely diagnosis is:

Osteomyelitis

Gas gangrene

Chronic ischaemia of the leg

Deep venous thrombosis

Acute ischaemia of the leg

A 45-year-old woman presents with pruritus, pale stools and dark urine. On examination she has finger clubbing and hepatosplenomegaly. Blood tests reveal a normal bilirubin, elevated alkaline phosphatase and low T₄. The most certain way to confirm the diagnosis is by:

Anti-mitochondrial antibody

Liver biopsy

ERCP

CT scan of the abdomen

Hepatitis A, B and C serology

A 70-year-old man, who lives alone and is self-caring, presents with weakness in his lower legs and muscle pain. On examination he has loose teeth and is noted to have ecchymoses of the lower limbs. He suffers from rheumatoid arthritis, which greatly limits his mobility. The most likely diagnosis is:

Folate deficiency

Scurvy

Iron deficiency

Thiamine deficiency

Vitamin B₁₂ deficiency

26A 20-year-old man presents with persistent eye irritation. He explains that he is sensitive to light, has noted worsening vision and complains of aching eyes. He also complains of morning stiffness in his back. The most likely diagnosis is:

Keratitis

Uveitis

Viral conjunctivitis

Episcleritis

Choroiditis

The most useful investigation for this man would be:

Lumbar and pelvic spine radiographs

Kveim’s test

HIV test

Mantoux test

Rheumatoid factor

Which one of the following drugs CANNOT be administered via the tracheal route?

Adrenaline

Atropine

Amiodarone

Lidocaine

Naloxone

The most specific test for SLE is:

Anti-dsDNA antibody

Antinuclear antibody

Anti-cardiolipin antibody

Rheumatoid factor

Anti-extractable nuclear antigen (ENA) antibody

A 44-year-old woman presents with fatigue and ascites. She is noted to have a pulse of small volume. The chest radiograph is unremarkable. The 12-lead ECG shows low QRS voltage and T-wave inversion. The most likely diagnosis is:

Right heart failure due to mitral stenosis

Budd – Chiari syndrome

Constrictive pericarditis

Primary pulmonary hypertension

Systemic sclerosis

27A 38-year-old man presents with a painful right wrist and left knee joint a fortnight after an attack of gastroenteritis. Prostatic massage produces a urethral discharge. The synovial fluid shows an abundance of neutrophils and is sterile. The ESR is raised. The most likely diagnosis is:

Gonococcal arthritis

Rheumatoid arthritis

Salmonella arthritis

Reiter’s syndrome

Viral arthritis

Eye signs associated with Graves’ disease include all of the following EXCEPT:

Exophthalmos

Proptosis

External ophthalmoplegia

Supraorbital and infraorbital swelling

Ptosis

A 35-year-old African woman is found to have an Hb of 6 g/dL. She is a vegetarian and has a history of uterine fibroids. A blood film reveals microcytic, hypochromic red blood cells and a few target cells. The most likely diagnosis is:

Thalassaemia trait

Iron-deficiency anaemia

Sickle cell disease

Anaemia of chronic disease

Sideroblastic anaemia

A 25-year-old woman presents with a single, non-tender, enlarged, cervical lymph node. She also complains of fever and night sweats. Lymph node biopsy reveals infiltration with histiocytes and lymphocytes and the presence of cells with bilobed mirror-image nuclei. The most likely diagnosis is:

Non-Hodgkin’s lymphoma

Hodgkin’s lymphoma

Sarcoidosis

Acute lymphoblastic leukaemia

Tuberculosis

A 45-year-old woman with diabetes presents with shiny waxy erythematous plaques on her shins with yellowish skin and telangiectasia. The most likely diagnosis is:

Pretibial myxoedema

Pyoderma gangrenosum

Psoriasis

Erythema nodosum

Necrobiosis lipoidica

28A 40-year-old man is brought to A&E in a comatose state. Useful initial investigations include all of the following EXCEPT:

Serum glucose

Serum calcium

Arterial blood gases

FBC

Blood alcohol level

On examination he is noted to have constricted pupils and depressed respirations. The most appropriate management would be:

CT scan of the head

Naloxone 0.4 – 1.2 mg i.v. stat

Flumazenil 200 mg i.v. over 15 seconds

Doxapram i.v.

Dantrolene 1 mg/kg i.v.

A 55-year-old man complains of generalized weakness for the past month. He also complains of excessive thirst and frequent micturition. Blood results:

Urine glucose

negative

Urine nitrate

negative

Serum creatinine

140 mmol/L

Serum urea

10 mmol/L

Serum calcium

3.5 mmol/L

Serum phosphate

1 mmol/L

Serum alkaline phosphatase

200 (30 – 300) IU/L

Serum albumin

45 g/L

These findings are consistent with all of the following diseases EXCEPT:

Primary hyperparathyroidism

Sarcoidosis

Multiple myeloma

Thyrotoxicosis

Bone metastases

The following are useful investigations to establish the diagnosis EXCEPT:

FBC

Chest radiograph

ESR

Parathyroid hormone

Magnesium

29The chest radiograph reveals bilateral hilar lymphadenopathy. The most likely diagnosis is:

Multiple myeloma

Sarcoidosis

Primary hyperparathyroidism

Bone metastases

Thyrotoxicosis

A 30-year-old man presents with a bright red painful eye. He complains of watering of the eyes and sensitivity to light. He has a history of recurrent cold sores. Fluorescein staining of the cornea demonstrates a tree-shaped sharp-bordered stain. The most likely diagnosis is:

Dendritic ulcer

Keratoconjunctivitis sicca

Corneal abrasion

Corneal ulcer

Conjunctivitis

A 25-year-old woman presents to the outpatient clinic with a neck swelling. On examination the swelling moves upward with protrusion of the tongue. The most likely diagnosis is:

Thyroid goitre

Cystic hygroma

Thyroglossal cyst

Branchial cyst

Thyroid malignancy

A 20-year-old man arrives in A&E with marked dyspnoea; he has asthma. On examination his respiratory rate is 24/min and pulse 105/min. Peak flow is 60% of predicted. The most appropriate management would be:

Treat in A&E with nebulized salbutamol 5 mg and repeat peak flow in 30 min

Arrange immediate hospital admission and treat with intravenous hydrocortisone 200 mg

Arrange immediate hospital admission, administer oxygen 40 – 60%, nebulized salbutamol and oral prednisolone 30 – 60 mg

Arrange immediate hospital admission, administer oxygen-driven nebulizer and give slow intravenous aminophylline 250 mg

Treat in A&E with oral prednisolone 30 – 60 mg and repeat peak flow in 30 min

30A 55-year-old man who smokes and has a history of chronic productive cough presents to A&E breathless and drowsy. On examination he is centrally cyanosed with a raised JVP (jugular venous pressure) and a palpable liver. There is a blowing pansystolic murmur at the lower left sternal border. No abnormality is heard in the lungs. The most likely diagnosis is:

Infective endocarditis

Cor pulmonale

Rheumatic heart disease

Exacerbation of chronic bronchitis

Emphysema

The most useful investigation at this stage is:

Arterial blood gas

12-lead ECG

Lung function tests

Chest radiograph

Sputum examination

The most appropriate treatment is:

Continuous oxygen therapy

Furosemide

Salbutamol inhaler

Oral prednisolone 30 mg once daily

Amoxicillin 500 mg three times daily

A 20-year-old man is found unconscious after a night of binge drinking. There is no evidence of physical trauma. On examination he has alcohol on his breath and a bitten tongue. His blood pressure is 110/80 and pulse 80/min. The pupils are small, equal and responsive to light. On removal of his clothes, his trousers are noted to be soiled with urine. The most likely suspicion is:

Hypoglycaemic coma

Alcohol overdose

Postictal phase of an epileptic seizure

Subarachnoid haemorrhage

Narcotic drug overdose

A 42-year-old woman presents to A&E with right-sided colicky loin pain and nausea for the past 3 h. She cannot keep still because of the pain. She has a history of recurrent cystitis. Temperature 36.5°C, BP 110/60 and pulse 60/min. Urinalysis shows microscopic haematuria. The most likely diagnosis is:

Pelvic inflammatory disease

Acute pyelonephritis

Acute appendicitis

Renal colic

Ectopic pregnancy

31The most useful initial diagnostic investigation is:

Serum urea and electrolytes

Urine βhCG

Plain KUB film

Pelvic ultrasonography

Intravenous urogram

While in A&E the patient develops fever and rigors. The most likely complication that has occurred is:

Ruptured ectopic pregnancy

Exacerbation of pelvic inflammatory disease

Ruptured appendix

Acute pyelonephritis

Septicaemia

A 16-year-old girl is brought to A&E by her mother. She complains of persistent and worsening, dull, right-sided, lower abdominal pain and spotting of blood per vagina. The mother insists that her daughter is a virgin. On examination, her temperature is 36.5°C, BP 90/50 and pulse 120/min. The lower abdomen is rigid with rebound tenderness in the right iliac fossa. Her period is overdue. The most appropriate management following resuscitation is:

To ask to speak to the girl in private, and obtain confidential information from her as to whether she has been sexually active; if so, perform urinalysis, urine βhCG pregnancy test and pelvic examination

To arrange for urgent transvaginal ultrasonography to exclude ectopic pregnancy

To accept that the daughter is a virgin, omit a pelvic internal examination and take a low vaginal swab to exclude infection

To arrange for pelvic ultrasonography to exclude ectopic pregnancy and acute appendicitis.

To inform the mother that you are performing a urine pregnancy test in the best interests of her daughter to exclude the possibility of a miscarriage or ectopic pregnancy

The most appropriate treatment for a dendritic ulcer of the eye is:

Prednisolone 0.5% 6 hourly

Aciclovir 3% eye ointment five times daily

Chloramphenicol 1% eye ointment

Aciclovir 800 mg five times daily

Cefuroxime 50 mg/mL

32A 40-year-old woman presents with dysuria and urinary incontinence. She has a history of having passed urinary calculi in the past. The urine is noted to have an alkaline pH. The most likely organism is:

Escherichia coli

Proteus mirabilis

Atypical streptococci

Pseudomonas aeruginosa

Klebsiella sp.

A 40-year-old pedestrian has been struck by a speeding car. He is brought to A&E wearing a pneumatic anti-shock garment for an extensive, open, avulsion injury to his pelvis. He is intubated with fluids running via two large-bore intravenous cannulas. His blood pressure is 120/80. The pelvis is grossly distorted. The next most appropriate management would be to:

Take blood for FBC, type and crossmatch 6 units, urea and electrolytes, and start O-negative blood infusion

Cut away the man’s clothing and perform a thorough physical examination

Insert a Foley catheter after a digital rectal examination to exclude a high-riding prostate

Perform a brief neurological examination

Notify the orthopaedic surgeons to apply an external fixator

An 18-year-old young man presents with fever, stridor and trismus. His breathing becomes laboured with use of accessory muscles. He becomes cyanosed with a respiratory rate of 35, despite oxygen by facemask. He had initially presented to his GP a few days ago with a sore throat. He uses a salbutamol inhaler for his asthma. The most appropriate management in A&E would be:

Endotracheal intubation

Needle cricothyroidotomy

Tracheostomy

Intravenous hydrocortisone

Nasopharyngeal airway

The most likely diagnosis is:

Glandular fever

Streptococcal throat infection

Acute asthma attack

Angioneurotic oedema

Tetanus

33A 60-year-old woman presents with progressive forgetfulness and mood changes. She has a shuffling gait. Her brain CT scan shows cortical atrophy and enlarged ventricles. Histology shows senile plaques and neurofibrillary tangles. The most appropriate treatment is:

Levodopa in combination with a dopa-decarboxylase inhibitor

Donepezil

Tetrabenazine

Diazepam

Thiamine

Charcot’s joints are a recognized feature of all the following conditions EXCEPT:

Leprosy

Diabetes mellitus

Syringomyelia

Syphilis

Rheumatoid arthritis

A 60-year-old priest presents with cough, dyspnoea, dull chest pain and vague epigastric pain. On examination the left chest shows diminished expansion, stony dull percussion note and absent breath sounds. There is egophony at the apex. The mediastinum is shifted to the right. The chest radiograph confirms a unilateral pleural effusion. The most useful investigation would be:

CT of the chest

Sputum for culture and sensitivity

Aspiration of pleural effusion

Bronchoscopy

Ventilation – perfusion scan

A 60-year-old man presents with increasing abdominal girth. On examination you elicit shifting dullness. The most useful investigation would be:

CT scan of the abdomen

Ascitic fluid tap

Ultrasonography of the abdomen

Chest radiograph

Blood for FBC, U&Es, LFTs and amylase

34A 45-year-old woman presents with severe itching, recent pale stools and dark urine. On examination there is darkened skin pigmentation, xanthelasma and hepatomegaly. Test results are as follows:

Serum bilirubin

15 mmol/L

Serum alkaline phosphatase

400 (30 – 300) IU/L

AST

40 (5 – 35) IU/L

The most likely diagnosis is:

Sarcoidosis

Primary biliary cirrhosis

Sclerosing cholangitis

Acute cholecystitis

Common bile duct gallstones

Neisseria gonorrhoeae may infect all of the following areas EXCEPT the:

Vagina

Rectum

Pharynx

Conjunctiva

Urethra

A 30-year-old woman with Crohn’s disease presents with left flank pain and microscopic haematuria. She admits that she doesn’t drink enough water. She smokes, drinks wine and loves chocolates. A radiograph shows a radio-opaque left renal calculus. The most likely aetiology is:

Hypercalciuria

Hyperoxaluria

Hyperuricaemia

Cystinuria

Hyperuricosuria

Dietary recommendations that you would make for her include avoidance of all of the following EXCEPT:

Spinach

Rhubarb

Chocolate

Tomatoes

Tea

35A 50-year-old man with known liver disease presents with fever, abdominal pain and distension. On examination he has a tender abdomen with shifting dullness. Diagnostic aspiration shows elevated neutrophils. Gram stain shows Gram-negative rods. The most likely organism is:

Klebsiella sp.

Escherichia coli

Pseudomonas aeruginosa

Bacteroides fragilis

Streptococcus pneumoniae

Causes of air under the diaphragm include all of the following EXCEPT:

Crohn’s disease

Perforated duodenal ulcer

Pleuroperitoneal fistula

Laparoscopy

Ruptured ectopic pregnancy

A 30-year-old man presents with fever, arthralgia and a palmar rash. On examination he has oral vesicles and target-like lesions on his palms. The most likely diagnosis is:

Stevens – Johnson syndrome

Behçet’s syndrome

Herpes simplex

Syphilis

Hand – foot – mouth disease

A 50-year-old man presents in shock with rigors and a temperature of 40°C. He is jaundiced and tender on palpation of the liver, which is felt 5 cm below the costal margin. Dark concentrated urine is noted on Foley catheter insertion. The most likely diagnosis is:

Ascending cholangitis

Gallstone ileus

Hepatitis

Primary sclerosing cholangitis

Acute cholecystitis

A 60-year-old woman presents with morning stiffness in both knees and pain worse at the end of the day. On examination the knees are swollen and warm to the touch. She has a flexion deformity and limitation of movement. A radiograph shows narrowing of the joint spaces, osteophytes at the margin of the joints and sclerosis of the underlying bone. The most likely diagnosis is:

Rheumatoid arthritis

Osteoarthritis

Gout

Infective arthritis

Polymyalgia rheumatica

36Recognized treatments for this condition include all of the following EXCEPT:

Total knee replacement

NSAIDs

Penicillamine

Intra-articular corticosteroid

Physiotherapy

A 70-year-old man presents with progressive stepwise dementia associated with focal neurological events. He has a stiff, slow-moving, spastic tongue, dysarthria, and inappropriate laughing and crying. He walks with a shuffling gait taking small steps. He is also noted to be hypertensive. The most likely diagnosis is:

Parkinson’s disease

Alzheimer’s disease

Multi-infarct dementia

Lateral medullary syndrome

Multiple sclerosis

A 20-year-old man complains of recurrent lower back pain and stiffness after exercise. He has no morning stiffness. Full blood count and ESR are normal, but he is found to have HLA B27. Radiographs of his lumbar spine and pelvis are normal. The most appropriate management would be:

No further investigations and reassure that HLA B27 can also be found normally

Arrange for an ophthalmology referral for slit-lamp examination

Arrange Kveim’s test to exclude sarcoidosis

Arrange for barium follow-through

Test for rheumatoid factor

A 55-year-old man with type 1 diabetes presents with nausea, lethargy, and dry and itchy yellow – brown skin. He also complains of nocturia and impotence. His blood film shows normocytic normochromic anaemia and occasional Burr cells. The most appropriate management would be:

Start iron replacement therapy

Take blood for U&Es

Check HbA1c

Take blood for bilirubin, LFTs and amylase

Take blood for thyroid function tests

Cystic fibrosis is associated with all of the following EXCEPT:

Abnormal gene coding for transmembrane regulating factor protein on chromosome 7

Allergic bronchopulmonary aspergillosis

Steatorrhoea

Chronic infection with Pseudomonas pseudomallei

Diabetes mellitus

37A 20-year-old pregnant black woman presents with fever and joint pains. She has a history of two previous spontaneous early miscarriages. Urine reveals ++ protein. Blood results show leucopenia, normocytic normochromic anaemia and thrombocytopenia. The most likely diagnosis is:

Sickle cell disease

SLE

Thalassaemia

Aplastic anaemia

Pre-eclampsia

The most sensitive diagnostic test would be:

A PET screen

Antibodies to dsDNA

Positive antinuclear antibodies

Antibody to Ro

Haemoglobin electrophoresis

The most useful investigation for her miscarriages would be:

Transvaginal ultrasonography

Chromosome karyotype

Lupus anticoagulant and anticardiolipin antibody

Hysterosalpingogram

Antithrombin III, and protein C and S deficiency

The most common organism implicated in acute bacterial endocarditis is:

Staphylococcus aureus

Streptococcus viridans

Streptococcus faecalis

Staphylococcus epidermidis

Coxiella burnetii

A 25-year-old heroin addict presents with fever and mucosal petechial haemorrhages. On examination he has a pansystolic murmur best heard at the lower sternal edge. He is also noted to have small, flat, erythematous, non-tender macules over the thenar eminence. The most likely diagnosis is:

Subacute bacterial endocarditis

Acute bacterial endocarditis

Rheumatic heart disease

Acute rheumatic fever

Q fever

38Major criteria for the diagnosis of rheumatic fever include all of the following EXCEPT:

Polyarthralgia

Chorea

Erythema marginatum

Subcutaneous nodules

Fever

The organism responsible for gas gangrene is:

Clostridium difficile

Clostridium perfringens

Clostridium tetani

Klebsiella sp.

Pseudomonas aeruginosa

Which one of the following features would favour a diagnosis of Guillain – Barré syndrome rather than myasthenia gravis?

Ocular muscle involvement

Proximal muscle weakness

Respiratory difficulties

Areflexia

Facial muscle weakness

The most common cause of painless frank haematuria in male patients aged over 50 years is:

Bladder squamous cell carcinoma

Carcinoma of the prostate

Hypernephroma

Transitional cell carcinoma in the kidney

Transitional cell bladder carcinoma

A 30-year-old man presents to A&E with a tender swollen testicle. He states that he was struck in the groin while playing football. On examination the borders of the testicle are irregular, and the testicle is heavy and woody. There is no associated lymphadenopathy. He is also noted to have gynaecomastia. There are no external signs of trauma. The most appropriate initial management would be:

Take blood for α-fetoprotein and βhCG and arrange for a chest radiograph

Prescribe doxycycline 100 mg twice daily for 5 days

Refer to urologist for urgent surgical exploration

Arrange for a chest and abdominal CT scan

Arrange for ultrasonography of the testes

39A 20-year-old woman presents with acne and hirsutism. She complains of a year of chaotic menstrual cycles with long periods of amenorrhoea. She has gained weight recently. She has never been pregnant. On examination there are no other abnormalities. The most likely diagnosis is:

Congenital adrenal hyperplasia

Ovarian teratoma

Cushing’s disease

Testicular feminization

Polycystic ovarian disease

Treatment for multiple sclerosis includes all of the following EXCEPT:

Glatiramer actetate

Interferon-β1a

Interferon-β1b

Interferon-α

Baclofen

The following features would favour a diagnosis of ulcerative colitis rather than Crohn’s disease:

Uveitis

Arthritis

Pyoderma gangrenosum

Cholelithiasis

Pseudopolyps

A 50-year-old man presents with polydipsia, headache and weakness. On examination his BP is 160/100 but he is not oedematous. He takes no medication. Blood results reveal hypokalaemia, alkalosis and low serum renin. The most likely diagnosis is:

Conn’s syndrome

Secondary hyperaldosteronism

Cushing’s disease

Phaeochromocytoma

Renal artery stenosis

A 25-year-old healthy man who smokes presents with gangrene of the left big toe. There are no signs of external trauma. The most likely diagnosis is:

Thrombangiitis obliterans (Buerger’s disease)

Raynaud’s disease

Gas gangrene

Polyarteritis nodosa

Gout

40Peptic ulcer disease is associated with all of the following EXCEPT:

Head trauma

Burns

Chronic pancreatitis

Hypocalcaemia

Cirrhosis

The most common cause of massive upper gastrointestinal bleeding is:

Gastric ulcer

Duodenal ulcer

Oesophageal varices

Mallory – Weiss syndrome

Angiodysplasia

A 35-year-old African woman is found to have a Hb of 6 g/dL. She is a vegetarian and has a history of uterine fibroids. Blood film reveals microcytic hypochromic red blood cells and a few target cells. The most likely result of iron studies would be:

Low ferritin, high total iron-binding capacity (TIBC)

Low iron, low TIBC

Raised ferritin, low TIBC

Low serum iron, low TIBC

Normal ferritin, high TIBC

A 40-year-old long-stay patient in a psychiatric hospital presents with fever, abdominal pain, dry cough and worsening confusion. Blood tests reveal neutrophilia, lymphopenia and hyponatraemia. A chest radiograph shows right-sided lobar consolidation. The most appropriate treatment would be:

Erythromycin

Benzylpenicillin

Antituberculous chemotherapy

Ciprofloxacin

Ticarcillin

Diseases associated with impotence include all of the following EXCEPT:

Hyperthyroidism

Hyperprolactinaemia

Cirrhosis

Multiple sclerosis

Renal failure

41The following organisms and disease are correctly paired EXCEPT:

β-haemolytic streptococci – necrotizing fasciitis

Staphylococcus epidermis – toxic shock syndrome

Staphylococcus aureus – scalded skin syndrome

S. aureus – impetigo

Group A β-haemolytic streptococci – acute rheumatic fever

A 20-year-old man who has travelled recently to India presents with unexplained fever for 5 days. You suspect typhoid fever. The most appropriate investigation would be:

Widal’s test measuring serum levels of agglutinins to O and H antigens

Blood culture

Marrow culture

Stool culture

Urine culture

The following statements regarding sarcoidosis are correct EXCEPT:

There is a higher incidence among young black males than white individuals

It most commonly involves the mediastinal lymph nodes

A third of cases are associated with erythema nodosum

Scalene node biopsy will be positive in 90% of cases

A negative Kveim test excludes sarcoidosis.

A 70-year-old man presents with chronic cough, haemoptysis and weight loss. He smokes 20 cigarettes a day. A chest radiograph shows a central coin lesion. The most useful investigation would be:

Sputum for culture and cytology

Isotope bone scan

Bronchoscopy and biopsy

Percutaneous needle biopsy

CT scan of the chest

A 70-year-old woman presents with vertigo when rolling over in bed. She also notices that she gets dizzy when bending over or reaching for the top shelf. The cause of her vertigo is:

Migraine

Benign positional vertigo

Acoustic neuroma

Ménière’s disease

Acute vestibular neuronitis

42The most common viral illness in transplant recipients is:

HIV

Herpes zoster

Herpes simplex

CMV

Epstein – Barr virus

A 30-year-old woman presents with a diffusely enlarged thyroid gland associated with a bruit. Serum thyroxine is raised and TSH is low. The most discriminating investigation would be:

Ultrasound scan

Fine-needle biopsy

Serum thyroid-stimulating immunoglobulins against TSH receptor

Radioiodine scan

Thyroid-releasing hormone (TRH) test

A 50-year-old woman is noted to have a high serum calcium, low – normal phosphate and normal albumin on routine biochemistry test. She is asymptomatic. The most useful additional blood test would be:

Serum chloride

Serum parathyroid hormone (PTH)

Serum magnesium

Serum urea

Serum alkaline phosphatase

The serum PTH comes back as high. The most useful investigation to confirm the diagnosis is:

Skull radiograph

Pelvic radiograph

Radioisotope thallium/technetium subtraction scan of the neck

Chest radiograph

CT scan of the neck

A 90-year-old man is noted to have a serum alkaline phosphatase of 1050 (30 – 300) IU/L on routine blood tests. He is asymptomatic. Serum calcium, phosphate and PTH levels are normal. The most likely diagnosis is:

Multiple myeloma

Paget’s disease (osteitis deformans)

Bone metastases

Hyperparathyroidism

Osteomalacia

43A 20-year-old man back from hitchhiking through South America a fortnight ago now presents with explosive, watery, foul-smelling diarrhoea and weight loss. On examination he has abdominal distension. His stools are greasy and contain mucus. The most useful investigation would be:

Proctoscopy

Sodium sweat test

Abdominal radiograph

Stool for microscopy

Duodenal aspirate

A 60-year-old man postgastrectomy presents with macrocystic anaemia. He drinks alcohol regularly. The most likely cause of his anaemia is:

Coeliac disease

Pernicious anaemia

Iron deficiency

Vitamin B₁₂ deficiency

Thalassaemia

A 30-year-old man presents in a coma after a drug overdose. His pupils are dilated, and he is hypotensive. His pulse rate drops to 40 and ECG confirms second-degree Mobitz type II heart block. The most likely cause of his overdose is:

Barbiturate

Tricyclic antidepressant

Lithium

β blocker

Benzodiazepine

A 50-year-old obese man presents with headache and drowsiness. He has a history of snoring. He has warm extremities, a flapping tremor and a bounding pulse. The most likely cause for these symptoms is:

CO₂ retention

Hypoxia

Obstructive sleep apnoea

Cerebral tumour

Malignant hypertension

44A 25-year-old woman presents to A&E with light-headedness and breathlessness. She complains of tingling and numbness of her hands. Arterial blood gases:

pH

7.55

PaCO₂

3 kPa

PaO₂

14 kPa

H⁺

25 nmol/L

HCO 3 − https://s3-euw1-ap-pe-df-pch-content-public-p.s3.eu-west-1.amazonaws.com/9781003071662/1b2ef101-3cb8-4644-9e86-fcdc807943ad/content/eq2.tif"/>

20 mmol/L

The most appropriate management would be:

Chest radiograph

Breathe into a paper bag

Activated charcoal

Needle thoracocentesis

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A 20-year-old man with asthma presents with increased shortness of breath. On chest examination he is found to have a deviated trachea to the right, reduced tactile fremitus and hyperresonance to percussion on the left. The most likely diagnosis is:

Right-sided pulmonary embolism

Right-sided pneumothorax

Left-sided pneumothorax

Left bronchopneumonia

Left-sided pleural effusion

A 50-year-old man presents with weight loss, hiccoughs, jaundice, epigastric and right upper quadrant pain radiating to the back. On examination he is noted to have hepatomegaly, a palpable gallbladder, and an abdominal bruit heard in the periumbilical area and left upper quadrant. The most likely diagnosis is:

Abdominal aortic aneurysm

Gallbladder carcinoma

Hepatocellular carcinoma

Carcinoma of the head of the pancreas

Cholecystitis

Recognized side effects of thiazide diuretics include all of the following EXCEPT:

Hyperuricaemia

Increased LDL-cholesterol

Hypokalaemia

Hypoglycaemia

Hypercalcaemia

45First-line therapy for hypertension in a pregnant woman is:

Labetalol

Hydralazine

Methyldopa

Bendrofluazide

Nifedipine

A 50-year-old man with type 1 diabetes presents with peripheral oedema and ascites. He has þþþ proteinuria. A 24-hour urine collection contains 10 g protein. Serum albumin is 15 g/L. The most likely diagnosis is:

Diabetic nephrosclerosis

Nephrotic syndrome

Uraemia

Interstitial nephritis

Retroperitoneal fibrosis

A 25-year-old HIV-positive man presents with 2 weeks of worsening drowsiness. On examination he has cervical lymphadenopathy and has bilateral upgoing plantar reflexes. A CT scan of the head shows cerebral calcifications and ring lesions. The most likely diagnosis is:

Cerebral toxoplasmosis

Cerebral abscess

Lymphoma

Cryptococcal meningitis

Tuberculosis

A 12-year-old boy presents to A&E with severe dyspnoea. He had been treated by his GP with penicillin for presumed tonsillitis. He uses a salbutamol inhaler for asthma. On examination: temperature 40°C and he is drooling saliva; no trismus. Marked inspiratory stridor and a respiratory rate of 30/min. The most appropriate management would be:

Oxygen-driven nebulizer

Intravenous hydrocortisone

Indirect laryngoscopy

Endotracheal intubation under general anaesthesia

Cricothyroidotomy

The most likely diagnosis is:

Croup

Acute epiglottitis

Glandular fever

Acute streptococcal tonsillitis

Acute severe asthma attack

46A 50-year-old man with a history of previous myocardial infarction presents to A&E with chest pain. The initial blood pressure is 110/70. During evaluation, he collapses. ECG shows ventricular tachycardia. He has no palpable pulse. The most appropriate management would be:

Synchronized DC shock at 100 J

Administer amiodarone 150 mg i.v. over 10 min

DC cardioversion with 200 J

Administer lidocaine 50 mg i.v. over 2 min

Commence CPR (cardiopulmonary resuscitation)

An 80-year-old woman presents with chronic dysphagia and weight loss. She complains of a sensation of a lump in her throat, bad breath and regurgitation of undigested food. She has a history of recurrent chest infections. She does not smoke or drink alcohol. Physical examination reveals a low BMI and a visible lump on the left side of her neck, which is difficult to define on palpation. The best initial investigation would be:

Chest radiograph

Barium meal

Endoscopy and biopsy

Oesophageal motility studies

Indirect laryngoscopy

A 30-year-old woman presents with bilateral ptosis and diplopia. She has also noticed difficulty in swallowing. The most likely diagnosis is:

Dystrophia myotonica

Multiple sclerosis

Polymyositis

Myasthenic syndrome (Eaton – Lambert syndrome)

Myasthenia gravis

A 20-year-old woman presents with complete right ptosis. On lifting the eyelid, the eye is seen to be looking down and out. The pupil is dilated. The most likely diagnosis is:

Right third nerve and right superior oblique palsy

Complete right third nerve palsy

Incomplete right third nerve palsy

Horner’s syndrome

Right third nerve and lateral rectus palsy

The organism most frequently isolated from the ascitic fluid of patients with spontaneous bacterial peritonitis is:

Klebsiella sp

Escherichia coli

Streptococcus pneumoniae

Bacteroides fragilis

Pseudomonas aeruginosa

47A 40-year-old man with a prosthetic heart valve on warfarin anticoagulation presents with haematuria. His INR is 4. The most appropriate management after withholding warfarin would be:

Give 0.5 – 2 mg of vitamin K by slow intravenous injection

No further treatment and recheck INR in 1–2 days

Commence heparin

Give 1 L of FFP (fresh frozen plasma)

Give prothrombin complex concentrate (factor 9A) and factor VII

A 22-year-old woman presents with secondary amenorrhoea and weight loss. On examination she is noted to have mild parotid swelling. She has a low BP and a BMI of 15. The most likely reason for her amenorrhoea is:

Prolactinoma

Addison’s disease

Premature ovarian failure

Anorexia nervosa

Bulimia

The inspired oxygen content using a bag – valve – mask with oxygen but no reservoir is:

16%

21%

40%

50%

80%

The most common cause of new-onset focal or generalized seizures after the age of 50 is:

Alcoholism

Brain abscess

Brain tumour

Cerebrovascular disease

Encephalitis

A 50 year old presents with weight loss, increased appetite, sweating, palpitations, tremors and preference for cold weather. The most useful diagnostic investigation is:

Chest radiograph

Serum glucose

U&Es

TFTs

FBC

48A 15-year-old boy presents with high swinging fever and arthritis affecting the knees. The joints are swollen but not very tender. Blood tests reveal anaemia and a raised ESR. Rheumatoid factor is negative but ANAs are positive. The most likely diagnosis is:

Acute rheumatic fever

Juvenile rheumatoid arthritis

Still’s disease

Osteochondritis dissecans

Aseptic non-traumatic synovitis

The next most appropriate step to guide your further management would be:

Echocardiography

Aspiration of knee joint

Arrange for MRI of the knee

Arrange for ophthalmology referral for slit-lamp examination

Blood cultures

A 30-year-old man presents with acute loin pain and haematuria. He has a history of recurrent urinary tract infections. He states that his father also had kidney problems and had suffered from a bleed in the brain. On examination his BP is 160/100, and he has ballotable, large, irregular kidneys and hepatomegaly. The most definitive investigation would be:

Kidney – ureter – bladder (KUB) plain film

Excretion urography

CT scan of the abdomen

Renal ultrasonography

Urinalysis and MSU for culture and sensitivities

The inspired oxygen content using a bag – valve – mask with oxygen and reservoir is:

16%

21%

40%

50%

80%

Postsplenectomy complications include all of the following EXCEPT:

Increased susceptibility to falciparum malaria infection

Increased susceptibility to Haemophilus influenzae infection

Pneumococcal septicaemia

Thromboembolism

Thrombocytopenia

49A 60-year-old man with a history of angina presents with chest pain. ECG shows ventricular tachycardia. Pulse rate is 200/min and BP 80/50. Oxygen is applied by facemask. Initial management should be:

Administer sedation and call urgently for the anaesthetist

Immediate synchronized cardioversion at 100 J

Immediate unsynchronized DC cardioversion at 200 J

Adenosine i.v.

Lidocaine i.v.

A 20-year-old man complains of high fever, rigors, productive cough with rusty-coloured sputum and pleuritic chest pain. On chest examination he has increased tactile fremitus and dullness to percussion in the right lower lung field. The most likely diagnosis is:

Lobar pneumonia

Bronchopneumonia

Aspiration pneumonia

Pleural effusion

Lung abscess

A 40-year-old woman presents with multiple symptoms. She states that for weeks she has felt tired with a loss of appetite. She has intermittent abdominal pain and diarrhoea, and has lost half a stone in weight. On examination: temperature 36.5°C, supine BP 100/60 with a pulse of 90/min, postural hypotension, mild epigastric pain and a pigmented appendectomy scar. The most likely diagnosis is:

Hypopituitarism

Diabetes mellitus

Addison’s disease

Hyperthyroidism

Crohn’s syndrome

A 25-year-old obese woman presents with mood swings, acne, secondary amenorrhoea and hirsutism. She has mild lower back pain, which she relates to her weight problem. She smokes 20 cigarettes a day and drinks alcohol on the weekends. Her BP is 125/85 and urine dipstick is negative for glucose. The most likely diagnosis is:

Cushing’s syndrome

Polycystic ovary syndrome

Congenital adrenal hyperplasia

Ovarian carcinoma

Hypothyroidism

50A 90-year-old man is noted to have a serum alkaline phosphatase of 1050 (30 – 300) IU/L on routine blood tests. He is asymptomatic. Serum calcium, phosphate and PTH levels are normal. The most appropriate treatment would be:

Nil

Parathyroid surgeon referral

Chest radiograph

Vitamin D therapy

Calcitonin

A 50-year-old obese man is brought to A&E in a confused state. On examination he has nystagmus and is unable to move the eyes fully laterally. He walks with a broad-based gait. He is unaware of his surroundings and grows restless. The most likely diagnosis is:

Subdural haematoma

Creutzfeldt – Jakob syndrome

Wernicke’s encephalopathy

Korsakoff’s psychosis

Hypoglycaemia

A 60-year-old woman with rheumatoid arthritis presents with numbness and tingling in the thumb and first two fingers of the right hand. It is worse at night. On examination there is sensory loss in the right hand involving the lateral half of the ring finger and dorsal tips of the first two fingers. The patient is able to flex the interphalangeal joint of the index finger on clasping the hands (Oschner’s test). The most likely diagnosis is:

Complete median nerve lesion

Carpal tunnel syndrome

Median and ulnar nerve palsy

Cervical spondylosis

Cervical rib

The most useful investigation is:

Wrist radiograph

MRI of the neck

Nerve conduction studies

Hand radiograph

Chest radiograph

51A 40-year-old man presents with diplopia and pain over the left eye. His medication includes lisinopril and Humulin insulin. On examination he has an almost total ophthalmoplegia with sparing of lateral eye movement on the left. His pupils are symmetrical, reactive to light, and of normal size and shape. The most likely diagnosis is:

Nerve III palsy due to compression

Mononeuritis involving nerve III

Complete nerve III palsy

Argyll Robertson pupil

Myasthenia gravis

A 30-year-old woman presents with severe headache and vomiting. She is sensitive to light and also complains of neck pain. Her BP is 170/110 and pulse 50. On examination she has bilateral ptosis and dilated pupils, and her eyes are positioned down and out. On fundoscopic examination bilateral papilloedema is present. Protein and glucose are present in her urine. Her mental status deteriorates rapidly. The most likely diagnosis is:

Intracranial tumour

Subdural haematoma

Subarachnoid haemorrhage

Extradural haematoma

Intracerebral haemorrhage

The most appropriate investigation is:

Lumbar puncture

CT scan of the head

MRI of the brain

Cerebral angiography

EEG

A 50-year-old woman complains of episodes of diplopia and vertigo, worse after exercise. On examination the BP in her right arm is 120/80 and in her left arm 100/60. A cervical bruit is noted. The most likely diagnosis is:

Coarctation of the aorta

Transient ischaemic attack

Takayasu’s arteritis

Subclavian steal syndrome

Vertebrobasilar insufficiency

52A 50-year-old obese man presents with headache and drowsiness. He has a history of snoring. He has warm extremities, a flapping tremor and a bounding pulse. On fundoscopic examination papilloedema is present. The most appropriate treatment would be:

Flumazenil

Doxapram

Naloxone

Hyperbaric oxygen

Diazepam

A 70-year-old man presents with nausea, vomiting and weakness. He has marked peripheral oedema. His medications include digoxin and chlorthalidone for congestive heart failure. Furosemide is administered to which he has marked diuresis of 10 L and promptly collapses. ECG shows prolonged P – R interval, inverted T waves and depressed ST segments. The most useful blood test is:

CK-MB and troponin

Serum U&Es

Digoxin level

Serum osmolality

Random cortisol

A 40-year-old man presents with painful, asymmetrical, deforming arthritis involving the distal interphalangeal joints and lower back pain. His fingernails are pitted with onycholysis. The most likely diagnosis is:

Rheumatoid arthritis

Ankylosing spondylitis

Psoriatic arthritis

Osteoarthritis

Ulcerative colitis

A 16-year-old boy presents with gynaecomastia. On examination his arm span exceeds the body length and he has small, firm testes. The most likely diagnosis is:

Testicular feminization

Congenital adrenal hyperplasia

Klinefelter’s syndrome

True hermaphroditism

Adrenal 5α-reductase deficiency

53A 45-year-old woman who underwent mastectomy with axillary clearance 2 years ago now presents with excessive thirst and polyuria. Investigations show:

Serum sodium

150 mmol/L

Serum potassium

3.8 mmol/L

Serum calcium

2.8 mmol/L

Random serum glucose

9 mmol/L

Serum urea

6 mmol/L

Serum creatinine

100 mmol/L

Urine osmolality

150 mosmol/L

The most likely diagnosis is:

Psychogenic polydipsia

SIADH

Diabetes insipidus

Hypercalcaemia

Diabetes mellitus

A 65-year-old woman presents to A&E with breathlessness and chest pain. On examination the pulse is irregularly irregular and ECG confirms atrial fibrillation at a rate of 180/min. You administer oxygen and gain intravenous access. The next most appropriate step in management would be:

Heparin and warfarin anticoagulation

Immediate heparin and synchronized DC shock at 100 J

Amiodarone 300 mg i.v. over 1 h

Intravenous digoxin

Flecainide 100 mg i.v. over 30 min

A 60-year-old man presents with rigidity and bradykinesia. He has an ataxic gait. On examination he has postural hypotension without compensatory tachycardia and his pupils are asymmetrical.

Multi-infarct dementia

Alzheimer’s disease

Friedrich’s ataxia

Parkinson’s disease

Multi-system atrophy (MSA)

An 80-year-old woman presents with chronic dysphagia and weight loss. She complains of a sensation of a lump in her throat, bad breath and regurgitation of undigested food. She has a history of recurrent chest infections. She does not smoke or drink alcohol. Physical examination reveals a low BMI and a visible lump on the left side of her neck, which is difficult to define on palpation. The most likely diagnosis is:

Squamous cell carcinoma of the oesophagus

Pharyngeal pouch

Achalasia

Cricopharyngeal spasm

Postcricoid carcinoma

54A 60-year-old woman presents with sudden painless loss of vision in her right eye. There is no perception of light and there is an afferent pupillary defect. The retina is white with a cherry-red spot at the macula. The optic discs are swollen. She also has a right-sided carotid bruit. The most likely diagnosis is:

Retinal detachment

Optic neuritis

Central retinal vein occlusion

Ischaemic optic neuropathy

Central retinal artery occlusion

A 20-year-old woman presents with fatigue, nausea, vomiting and abdominal colic. She has been feeling unwell for many months now and lives as a squatter in a derelict old house. On examination she is noted to have signs of peripheral neuropathy with a wrist drop. Blood film shows basophilic stippling of red blood cells. The most likely diagnosis is:

Thalassaemia

Iron poisoning

Lead poisoning

Crohn’s disease

Carbon monoxide poisoning

A 28-year-old Jamaican woman presents with acute onset of nausea, vomiting, epigastric pain and ascites. She does not take any medication apart from traditional herbal remedies. On examination she has tender hepatomegaly and profound ascites but no signs of heart failure. She has abnormal LFTs. The ascitic fluid has high protein content. The investigation of choice is:

Isotope scanning of the liver

Hepatic venography

Liver biopsy

Ultrasound scan

Abdominal radiograph

The most likely diagnosis is:

Primary biliary cirrhosis

Hepatic vein thrombosis

Alcoholic hepatitis

Portal vein thrombosis

Meigs’ syndrome

A 30-year-old HIV-positive man presents with seizures. The most likely infective cause is:

Toxoplasmosis

Cytomegalovirus

Cryptosporidium sp.

Tuberculosis

Pneumocystosis

55Which of the following illicit drugs is still detectable in urine up to a month later?

Cocaine

Cannabis

Methadone

Heroin

Amphetamine

The following are recognized features of obstructive sleep apnoea EXCEPT:

Hypnagogic hallucinations

Impotence

Morning headaches

Nightmares

Daydreaming

A 50-year-old woman presents to medical outpatients complaining of pain and stiffness in the joints of her hands, worse in the mornings. The pain lasts for a couple of hours in the morning. On examination she has ulnar deviation, wasting of the small muscles of her hands, nail pitting and a rash on her knees. There is symmetrical involvement of the distal interphalangeal joints and metacarpophalangeal joints. The most likely diagnosis is:

Rheumatoid arthritis

Psoriatic arthropathy

Sjögren’s syndrome

SLE

Osteoarthritis

A 70-year-old man presents to A&E after falling when drunk. He complains of sudden numbness and tingling all over both his legs. He also complains of pain between the shoulder blades. On examination he has weakness in his lower extremities, hyperreflexia, positive Babinski’s sign and clonus. The most likely diagnosis is:

Motor neuron disease

Subacute combined degeneration of the cord

Spinal cord compression

Cauda equina compression

Anterior spinal artery occlusion

56A 65-year-old man presents with a 2-month history of vague lower abdominal pain, diarrhoea alternating with constipation and a 4-kg weight loss. He has passed a small amount of dark-red blood per rectum. There is anaemia. The most likely diagnosis is:

Diverticular disease

Crohn’s disease

Ulcerative colitis

Angiodysplasia

Carcinoma of the colon

The most useful investigation is:

Flexible sigmoidoscopy

Barium enema

CT scan of the abdomen

Abdominal ultrasonography

Selective mesenteric angiography

A 70-year-old long-sighted woman presents to A&E at midnight with vomiting that began 3 h earlier and slightly worsening vision. The eyeball is rock hard on palpation. The conjunctiva is injected. The most likely diagnosis is:

Acute angle-closure glaucoma

Anterior uveitis

Choroiditis

Retinal vein thrombosis

Temporal arteritis

A 55-year-old man who drinks heavily presents with numbness and paraesthesiae in his feet. He complains of ‘walking on cotton wool’. The likely cause is:

Lead poisoning

Amyloidosis

Sarcoidosis

Vitamin B₁ deficiency

Vitamin B₁₂ deficiency

57A 60-year-old man presents to A&E with fever and neck pain on passively moving the chin towards the chest. Lumbar puncture shows:

White cells

3000/mL, predominantly neutrophils

Red blood cells

1/mL

Glucose

1.5 mmol/L

Protein

5 g/L

The most likely organism is:

Mycobacterium tuberculosis

Neisseria meningitidis

Haemophilus influenzae

Listeria monocytogenes

Streptococcus pneumoniae

A 20-year-old woman is referred for recurrent epistaxis and bruising. She takes no medication. On examination she has no facial rash or lymphadenopathy. Her spleen is mildly enlarged, and she has generalized bruising but no bone or joint tenderness. Immediate blood test results are:

White cell count

53 × 10⁹/L

Hb

10 g/dL

Platelets

253 × 10⁹/L

ESR

55 mm/h

MCV

90 fL

MCH

30 pg

MCHC

34 g/dL

Prolonged bleeding time

Serum urea

6 mmol/L

The next most useful investigation would be:

Bone marrow aspirate

Haemoglobin electrophoresis

Platelet autoantibodies

Factor VIII:C and factor VIII:vWF (von Willebrand’s factor) assays

Platelet aggregation studies

The most likely diagnosis is:

Thrombotic thrombocytopenic purpura

Idiopathic thrombocytopenic purpura

Aplastic anaemia

SLE

Von Willebrand’s disease

58A 70-year-old man presents with confusion and urinary incontinence. He is pale and his BP is 160/100. On examination the bladder is palpable to the level of the umbilicus. Rectal examination confirms an enlarged prostate. There is also peripheral oedema. Blood tests show:

White cell count

73×10⁹

Hb

8 g/dL

Platelets

1003×10⁹/L

Serum sodium

125 mmol/L

Serum potassium

6 mmol/L

Serum urea

60 mmol/L

Serum calcium

3.4 mmol/L

The diagnosis is:

Chronic renal failure

Acute renal failure

Benign prostatic hypertrophy

Prostate carcinoma

Myelomatosis

The antihypertensive drug, amlodipine, is a:

Calcium channel blocker

ACE-inhibitor

Potassium channel blocker

Loop diuretic

β blocker

A 22-year-old woman is noted to have both microcytic and macrocytic anaemia. She gives a history of intermittent diarrhoea with difficulty in flushing the stools. The most likely diagnosis is:

Cystic fibrosis

Irritable bowel syndrome

Coeliac disease

Crohn’s disease

Ulcerative colitis

A 40-year-old woman on chemotherapy for metastatic breast carcinoma now presents with painful swallowing. On examination she has white plaques on top of friable mucosa in her mouth and more seen on OGD. The treatment for her dysphagia is:

Antispasmodics

Antifungal therapy

H₂-receptor antagonist

Intravenous antibiotics and analgesia

Dilatation of the lower oesophageal sphincter

59A 20-year-old man presents with morning back stiffness. He has a history of iritis. On examination he has an early diastolic murmur. His chest radiograph shows bilateral diffuse reticulonodular shadowing. The most likely diagnosis is:

Reiter’s syndrome

Crohn’s disease

Rheumatoid arthritis

Ankylosing spondylitis

Sacroiliitis

An asymptomatic 60-year-old man is found to have an isolated raised alkaline phosphatase on routine biochemistry. Serum calcium and phosphate levels are normal. The most likely diagnosis is:

Osteomalacia

Multiple myeloma

Paget’s disease

Cirrhosis

Hyperparathyroidism

The most suitable treatment for Clostridium difficile is:

Vancomycin

Amoxicillin

Gentamicin

Cimetidine

Tetracycline

What would be the most suitable laxative to offer a terminally ill patient hooked up to a diamorphine syringe driver?

Lactulose

Co-danthromer

Loperamide

Methylcellulose

Phosphate enema

A 50-year-old man with type 1 diabetes is started on enalapril for hypertension. Two weeks later his U&E results are noted to be abnormal. What is the most likely cause?

Renal papillary necrosis

Hypovolaemia

Addison’s disease

Renal artery stenosis

Renal tumour

60A dockyard worker is referred to the chest clinic for breathlessness. His chest radiograph shows pleural thickening and calcification (pleural plaques). What is the next investigation of choice?

Spirometry (lung function tests)

Arterial blood gas

Pulse oximetry

CT scan of the chest

PEFR (peak expiratory flow rate)

What is the best treatment for his condition?

Prednisolone

Salbutamol inhaler

Beclometasone inhaler

Ipratropium inhaler

Antituberculous chemotherapy

A 60-year-old man is found to have a BP of 170/100. He also has a history of asthma. What is the most appropriate drug of choice?

Furosemide

Atenolol

GTN spray

Enalapril

Hydralazine

The following medication may be offered to a man suffering from alcoholism EXCEPT:

Vitamin B complex

Thiamine

Diazepam

Heminevrin

Acamprosate

The following blood tests should routinely be offered to intravenous drug abusers EXCEPT:

HIV

Hepatitis C

Hepatitis B

LFTs

Hepatitis A

61A 40-year-old man presents complaining of an episode of blacking out behind the wheel of his car. The following advice should be given to the patient EXCEPT:

Not to drive

To leave the door unlocked when bathing

Not to take hot baths

Not to iron

Never to be alone

A 60-year-old man presents with brown pigmented plaques in the axilla. He underwent prostatectomy recently. The diagnosis is likely to be:

Dermatitis herpetiformis

Pemphigoid

Lichen planus

Psoriasis

Acanthosis nigricans

A 55-year-old woman presents with severe heartburn. The pain is retrosternal and worse on stooping and after large meals. Initial investigations should include all of the following EXCEPT:

FBC

ESR

Helicobacter pylori antibody test

Folate and vitamin B₁₂ levels

Endoscopy

Initial management may include each of the following EXCEPT:

Quit smoking

Use antacids

Start esomeprazole

Start lansoprazole

Start triple therapy

You are on your way to hospital to do a night shift and find an unconscious man on the street. He is unkempt and has needle tracks on his arms and neck. He has pinpoint pupils. He is not rousable. There is no one else on the street. The most appropriate action would be:

Confirm that the patient is breathing, place him in the recovery position and call 999

Give two breaths and call 999 on your mobile to alert the paramedics that it is a probable drug overdose

Check that the patient is breathing and has a pulse and proceed to work

Run into the hospital and grab a stretcher

Undress the man to examine him properly for signs of trauma

62He is transported to your A&E. The next step is:

Administer naloxone i.m. only after confirmation of presence of opiates in urine

Administer naloxone i.m. immediately

Administer glucagon i.m.

Administer intravenous fluids

Arrange for urgent CT scan of the head

An elderly man presents with a warm swollen metatarsophalangeal joint after a total hip replacement. The likely diagnosis is:

Rheumatoid arthritis

Gout

Systemic sclerosis

Osteoarthritis

Septic arthritis

A 50-year-old man requests hepatitis B immunization. Pre-Hep B vaccine blood results are:

− hepatitis B surface antigen (HBsAg)

− hepatitis B core IgM

− hepatitis Be antigen (HBeAg)

+ hepatitis Be antibody (HBeAb)

+ hepatitis B core antibody (total) (HBcAb)

+ hepatitis B surface antibody (HBsAb)

How do you interpret this result?

The patient has natural immunity to hepatitis B and does not require immunization

The patient has had infection with hepatitis B some time in the past

The patient has an acute infection with hepatitis B

The patient is a chronic carrier of high infectivity

The patient is a chronic carrier of low infectivity

The drug of choice for scabies is:

Permethrin cream

Malathion lotion

Crotamiton

Ketoconazole

Mebendazole

Scabies is transmitted through:

Bedding

Towels

Direct skin contact

Clothing

Hair

63Causes of transient loss of consciousness include all of the following EXCEPT:

Reflex-mediated syncope

Aortic stenosis

Second-degree heart block

Subarachnoid haemorrhage

Hyperglycaemia

A 40-year-old man complains of constant, right-sided headache with severe throbbing orbital pain. The pain lasts for an hour. He also complains of watery eyes and a runny nose. He has had several episodes in the last few months and is worried that he may have a brain tumour. The most likely diagnosis is:

Acute sinusitis

Migraine headache

Cluster headache

Orbital cellulitis

Hayfever

A 65-year-old woman complains of severe right-sided headache, centred in the eye, with nausea and vomiting. On examination the conjunctiva is injected with a cloudy anterior chamber. The globe is firm and tender. The most likely diagnosis is:

Acute sinusitis

Temporal arteritis

Acute narrow-angle glaucoma

Trigeminal neuralgia

Periorbital abscess

A 50-year-old man complains of episodes of squeezing substernal chest pain when walking the dog in the morning. The attack peaks at 10 min and stops at rest. The most likely diagnosis is:

Oesophageal spasm

Costochondritis

Acute myocardial infarction

Stable angina

Reflux oesophagitis

The risk factors for coronary artery disease include all of the following EXCEPT:

Tobacco

Alcohol

Raised LDL-cholesterol

Diabetes

Hypertension

64A 30-year-old man presents with substernal chest pain and shortness of breath. On examination he has a loud systolic ejection murmur. The Valsalva manoeuvre increases the murmur and leg raising decreases the murmur and symptoms. The most likely diagnosis is:

Mitral valve prolapse

Hypertrophic cardiomyopathy

Pericarditis

Aortic dissection

Stable angina

A 22-year-old man presents with severe, sharp chest pain that worsens with breathing. He has shallow breathing and leans toward the left side. Temperature is 39°C, BP 100/60 and pulse 120. White cell count is raised with neutrophilia. Chest radiograph is normal. The most likely diagnosis is:

Pulmonary embolus

Pleurodynia

Tension pneumothorax

Pericarditis

Costochondritis

Initial management for coma in the emergency setting may include all of the following EXCEPT:

50% dextrose 50 mL i.v.

2 mg naloxone i.v.

100 mg thiamine i.v.

Assess airway, breathing and circulation (ABC)

Skull radiograph

The patient is still unresponsive. The left pupil is now dilated and unresponsive. The next step is:

Obtain an urgent neurosurgical consult and consider mannitol

Administer intravenous broad-spectrum antibiotics

Perform a lumbar puncture

Arrange an urgent EEG

Arrange an urgent MRI of the head

A 40-year-old woman presents comatose. On examination she has a left mastectomy scar. ECG shows a shortened Q–T interval. The diagnosis is:

Hypernatraemia

Hypercalcaemia

Addison’s disease

Hypoglycaemia

Hypermagnesaemia

65A 30-year-old woman presents with severe lethargy, weakness and abdominal pain. On examination there is hyperpigmentation of the skin folds and breast areolar areas. Blood tests reveal hypoglycaemia and hyperkalaemia. The most likely diagnosis is:

Conversion disorder

Cushing’s disease

Addison’s disease

Myxoedema

Uraemia

Beck’s triad is:

Hypotension, muffled heart sounds and jugular vein distension

Jugular vein distension, hypertension and peripheral oedema

Pericardial rub, hypotension and jugular vein distension

Increasing blood pressure, decreasing pulse rate and shallow breathing

Jaundice, rigors and tender hepatomegaly

Lyme disease is associated with:

Borrelia burgdorferi

Rickettsia rickettsii

Coxiella burnetii

Leptospira interrogans

Borrelia recurrentis

Treatment for Lyme disease is:

Tetracycline

Penicillin

Erythromycin

Imipenem

Ciprofloxacin

The following conditions may be treated with chemotherapy EXCEPT:

Choriocarcinoma

Hodgkin’s disease

Testicular carcinoma

Wilms’ tumour

Adenocarcinoma of the stomach

Bone metastasis may occur with the following carcinomas EXCEPT:

Breast

Prostate

Thyroid

Adrenal

Renal

66A 55-year-old woman presents with stridor and difficulty swallowing after a thyroidectomy. On examination, she has a tense swelling over the surgical site. Immediate course of action is:

Cardioversion

Intramuscular adrenaline

Needle aspiration

Endotracheal intubation

Cricothyroidotomy

Crohn’s disease is associated with all of the following EXCEPT:

Rose-thorn ulcers on barium enema

Cobblestoning on barium enema

Perianal abscess

Loss of haustra on barium enema

Lymphoma

The most common cause of a breast mass in women under 30 is:

Fibrocystic disease

Fibroadenoma

Cystosarcoma phylloides

Breast abscess

Ductal carcinoma

Management of deep venous thrombosis include all of the following EXCEPT:

Check platelet count every 3 days

Aim for PTT (prothrombin time) at least 1.5 times normal

Elevate lower extremity

Give loading dose of 5000 U heparin followed by heparin infusion of up to 2000 U/h

5000 U fragmin s.c. twice daily

The most common anterior mediastinal tumour in adults is:

Thymoma

Lymphoma

Mesothelioma

Myoma Fibroma

67A 55-year-old patient who smokes complains of left leg pain when walking. The pain is relieved on rest. You are unable to palpate the DP (dorsalis pedis) or PT (posterior tibial) pulses on the left. The next step is:

Measure ankle brachial pressures to determine ankle brachial pressure index (ABPI)

Arrange Doppler ultrasonography of leg

Arrange angiogram

Arrange plethysmography

Prescribe pentoxifylline

Indications for the use of octreotide (somatostatin analogue) include all of the following EXCEPT:

Acromegaly

Variceal bleeding

Prevention of complications after pancreatic surgery

Cystic fibrosis

Carcinoid tumour

On auscultation, a patient is noted to have a rumbling diastolic murmur at the apex. The murmur is accentuated during exercise. The diagnosis is:

Atrial fibrillation

Aortic regurgitation

Mitral regurgitation

Mitral stenosis

Pulmonary stenosis

A 25-year-old woman who is an intravenous drug abuser presents with an overdose on rocks (cocaine). ECG shows supraventricular tachycardia (SVT). First-line treatment for SVT is:

Adenosine

Amiodarone

Lidocaine

Procainamide

Verapamil