all

Question 1

Which of these fulfils the diagnostic criteria of Type 2 Diabetes?

Polyuria and polydipsia

Asymptomatic, single fasting plasma glucose >6.9 mmol/L

Asymptomatic, single reading of elevated HbA1c

Symptomatic, single fasting plasma glucose> 6.9 mmol/L

Symptomatic, single random plasma glucose <11.1 mmol/L

Answer 1

Symptomatic, single fasting plasma glucose> 6.9 mmol/L

Question 2

A 55 Year Old obese diabetic man controls his diabetes with diet and exercise. On review his HBA1c is 47mmol/mol and his fasting glucose is 6.5 mmol/L. What is the next stage in his management?

Start Metformin

Glucagon Injection

Continue Current Treatment

Fluid Bolus

Start a sulphonylurea

Answer 2

Continue Current Treatment

Question 3

A 19 year old male presented to A&E with abdominal pain, nausea and vomiting. He reports nocturia and examination reveals Kussmaul breathing. Capillary glucose demonstrates hyperglycaemia. Which of these would be the first step in this patient’s managing?

IV Insulin

Oral Glucose

Diet and Exercise

Fluid Replacement

Glibenclamide

Answer 3

Fluid Replacement

Question 4

A 26 year old lady visits her GP complaining she is going to the toilet constantly, getting up several times in the night. Urinalysis is negative for glucose and ketones. A fluid deprivation test demonstrates urine osmolality of 200 mOsmol/kg, which rises slightly to 250 mOsmol/kg following administration of desmopressin. Her medical history includes a diagnosis of bipolar disorder. What should be the GP’s next step?

Regular desmopressin

Fluid restriction

Review medication

Prescribe an NSAID

Insulin injections

Answer 4

review medication

Question 5

A 58 year old woman with small cell lung cancer attends an oncology clinic. Her husband mentions there has been occasions where she has been confused. Her U&Es show a serum sodium of 131mmol/L. Further testing confirms a diagnosis of SIADH. The most appropriate initial treatment is:

Tolvaptan

Desmopressin

Fluid restriction to 1L per day

IV infusion of hypertonic 3% Saline

IV infusion of normal 0.9% saline

Answer 5

Fluid restriction to 1L per day

Question 6

A 70 year old woman undergoes a bowel resection for colorectal cancer. She is well prior to the operation. The operation is successful but two days after the operation she becomes very agitated. The most likely cause is:

Hyperglycaemia

Hypothyroidism

SIADH

Use of Diuretics

Fluid overload

Answer 6

Fluid overload

Question 7

A man has poorly controlled hypertension.
He is currently taking lisinopril, losartan and indapamide daily.
His blood pressure is 175/100 today, and his blood tests reveal:
Na – 140
K – 3.1
Cr – 100
Ur – 4.4
eGFR - >90
Which is the most likely diagnosis:

Cushing’s syndrome

Cushing’s disease

Phaeochromocytoma

Bilateral adrenal hyperplasia

Addison’s disease

Answer 7

Bilateral adrenal hyperplasia

Question 8

A 50 year old woman, who recently moved to the UK from India, presents with myalgia and lethargy. You see that she attended the GP surgery previously requesting anti-depressants. Her PMH includes a chest infection with acid-fast bacilli. You astutely notice some discoloration on the inside of her cheek.
Na – 129
K – 5.5
Cr – 90 
Ur – 6.0
eGFR - >90 
The most likely explanation is:

Cushing’s syndrome

Addison’s disease

Phaeochromocytoma

Bilateral adrenal hyperplasia

Adrenal insufficiency

Answer 8

Adrenal insufficiency

Question 9

A woman attends clinic complaining of episodes of anxiety, sweating and headache. She can hear her heart racing in her chest and taps out an irregular rhythm on your desk. On examination, you notice multiple cutaneous fibroma, café-au-lait macules and, only under slit-lamp microscopy, Lisch nodules in the iris.

Bisoprolol

Bendroflumethiazide

Phenoxybenzamine

Spironolactone

Metirosine

Answer 9

Phenoxybenzamine

Question 10

During a GP consultation, you notice a 45 year old man has coarse facial features and widely spaced teeth. He also complains of headaches and has recently noticed that his rings are feeling tight on his fingers.
During a GP consultation, you notice a 45 year old man has coarse facial features and widely spaced teeth. He also complains of headaches and has recently noticed that his rings are feeling tight on his fingers.

Write down the single best screening investigation.

Write down the single best diagnostic investigation.

Answer 10

Serum IGF-1 level

Failure to supress serum growth hormone on oral glucose tolerance test

Question 11

A middle-aged man presents to his GP with recent weight gain. On examination, his blood pressure is mildly raised and you notice several bruises on both his arms.
Write down the first diagnostic investigation.

Answer 11

dexamethasone suppression test

Question 12

A 42-year-old woman presents with visual disturbances. She reports having double vision which was intermittent initially but has now become much more frequent. In addition, she becomes breathless very easily and experiences palpitations. On examination, raised, painless lesions are observed on the front of her shins and finger clubbing. The most likely diagnosis is:

A. De Quervain’s thyroiditis 
B. Thyroid storm 
C. Phaeochromocytoma 
D. Graves’ disease 
E. Plummer’s disease

Answer 12

Graves

Question 13

2. A 58-year-old woman presents with an acutely painful neck, the patient has a fever, blood pressure is 135/85 mmHg and heart rate 102 bpm. The patient explains the pain started 2 weeks ago and has gradually become worse. She also notes palpitations particularly and believes she has lost weight. The symptoms subside and the patient presents again complaining of intolerance to the cold temperatures. The most likely diagnosis is:

A. Thyroid papillary carcinoma 
B. Plummer’s disease 
C. De Quervain’s thyroiditis 
D. Hyperthyroidism 
E. Thyroid follicular carcinoma

Answer 13

C. De Quervain’s thyroiditis

Question 14

A 39-year-old man presents with a three-month history of depression. The patient recently lost a family member and around the same period began to feel unwell with constipation and a depressed mood. He has started taking analgesia for a sharp pain in his right lower back that often radiates towards his front. The most appropriate investigation is:

A. Serum parathyroid hormone 
B. Serum thyroid stimulating hormone 
C. Colonoscopy 
D. Fasting serum calcium 
E. MRI scan

Answer 14

D. Fasting serum calcium

Question 15

A 50-year-old woman presents to accident and emergency complaining of excessive lethargy. In addition, she mentions that she has been constipated. On examination, there are clinical features of dehydration. Blood tests have revealed a corrected calcium of 3.3 mol/L. Her chest x-ray shows bilateral streaky shadowing throughout both lung fields. She is given 3 L of saline in 24 hours after admission. The following day her blood tests are repeated and her corrected calcium level is now 3.0 mmol/L. Results of parathyroid hormone levels and thyroid function tests are still awaited. What is the most appropriate management?

A. Intravenous saline rehydration
B. Intravenous saline rehydration and pamidronate
C. Pamidronate
D. Calcitonin
E. Intravenous saline rehydration plus calcitonin

Answer 15

A. Intravenous saline rehydration

Question 16

A 67-year-old man presents to his GP with pain in his pelvis. During the consultation, he mentions that his friends have been commenting that his head appears larger than before. In addition, he has noticed deterioration in hearing in his left ear. On neurological examination, a left-sided sensorineural deafness in detected. Closer inspection of the legs reveals bowing of the tibia. What is the most likely diagnosis?

Osteomalacia 
Osteoporosis
 Acromegaly 
Ricketts 
Paget’s disease

Answer 16

Paget’s disease

Question 17

A 33-year-old obese woman complains of tiredness. She has recently given birth to a healthy baby boy and is enjoying being a mother. However, she is becoming more reliant on her partner for support as she always feels exhausted and often becomes depressed. The patient has a poor appetite and often does not finish her meals, despite this she has gained 5 kg in the last 2 weeks. The most likely diagnosis is: 
A. Post partum depression 
B. Eating disorder 
C. Hyperthyroidism 
D. Hypothyroidism 
E. Occult malignancy

Answer 17

hypothyroidism

Question 18

A 15-year-old girl complains of headaches which started 6 weeks ago. The headaches initially occurred 1–2 times a week but now occur up to five times a week, they are not associated with any neurological problems, visual disturbances, nausea or vomiting. The girl also reports a white discharge from both of her nipples. She has not started menstruating. The most appropriate investigation is:

A. Lateral skull x-ray 
B. CT scan 
C. MRI scan 
D. Thyroid function tests 
E. Serum prolactin measurement

Answer 18

E. Serum prolactin measurement

Question 19

A 26 y/o male returns from holiday in India. He has had diarrhoea after eating at a seafood restaurant on his last night. He is feverish and nauseous. You notice that the whites of his eyes are yellow.

A. 	Hepatitis A
B. 	Hepatitis B
C. 	Hepatitis C
D. 	Hepatitis D
E. 	Hepatitis E

Answer 19

A. Hepatitis A

Question 20

A 64 y/o male with thalassaemia is investigated under the two-week wait for jaundice and weight loss. His blood tests show a raised αFP. Which chronic infection is he most likely to have?

A. 	Hepatitis A
B. 	Hepatitis B
C. 	Hepatitis C
D. 	Hepatitis D
E. 	Hepatitis E

Answer 20

C. Hepatitis C

Question 21

A 32 y/o male returns from holiday in Thailand, feeling ‘under the weather’ with RUQ pain, fevers and nausea. He is jaundiced. He reveals he has used IV drugs and had unprotected sex with a stranger while on holiday. Which test is most likely to give the correct diagnosis?

A. 	Liver function tests
B. 	HIV serology
C. 	Hepatitis B serology
D. 	Hepatitis C PCR
E. 	CXR

Answer 21

C. Hepatitis B serology

Question 22

72 y/o man with cirrhosis presents to A&E with diffuse abdominal pain and fever. He is nauseous and has vomited. His abdomen is distended and there is shifting dullness on examination. Which investigation would be most helpful?

A. 	Paracentesis
B. 	Stool sample MC&S
C. 	Abdominal USS
D. 	LFTs
E. 	Blood cultures

Answer 22

A. Paracentesis

Question 23

Which hepatitis virus requires another virus to be present for successful infection?

A. 	Hepatitis A
B. 	Hepatitis B
C. 	Hepatitis C
D. 	Hepatitis D
E. 	Hepatitis E

Answer 23

D. Hepatitis D

Question 24

A 43 y/o confused man is brought to A&E by police after being found wandering the streets. He is disorientated and unable to give a clear history. You notice the following in his eyes. What is he likely to have?

A. 	Alcohol intoxication
B. 	Wilson’s disease
C. 	Opiate overdose
D. 	Haemochromatosis
E. 	Hypoglycaemia

Answer 24

B. Wilson’s disease

Question 25

A 43 y/o man with T1DM visits the GP for his regular HbA1c reading. You comment on his tanned complexion but he insists he hasn’t been aboard recently. Iron studies are requested. Which of the following results would fit with your suspected diagnosis?

A. High serum iron, high ferritin, high transferrin, high TIBC
B. High serum iron, low ferritin, low transferrin, high TIBC
C. Low serum iron, low ferritin, high transferrin, high TIBC
D. High serum iron, high ferritin, low transferrin, low TIBC
E. High serum iron, high ferritin, high transferrin, low TIBC

Answer 25

D. High serum iron, high ferritin, low transferrin, low TIBC

Question 26

A 41 y/o female presents with a history of colicky, right sided abdominal pain. She states the pain is worse after eating fish and chips and Indian takeaways. On examination her abdomen is soft and non-tender. Which is the best investigation to confirm her diagnosis?

A. 	Abdominal X-ray
B. 	ERCP
C. 	Liver biopsy
D. 	USS of biliary tree
E. 	CT-KUB

Answer 26

D. USS of biliary tree

Question 27

A 41 y/o female presents to A&E with a history of severe, continuous, RUQ pain. She feels feverish and complains of an occasional pain in her right shoulder. On examination she displays RUQ tenderness and a positive Murphy’s sign. What is the most likely diagnosis?

A. 	Biliary colic
B. 	Ascending cholangitis
C. 	Acute cholecystitis
D. 	Primary biliary cirrhosis
E. 	Cholangiocarcinoma

Answer 27

C. Acute cholecystitis

Question 28

A 41 y/o female presents to A&E with a history of severe, continuous, RUQ pain. She feels feverish and complains of an occasional pain in her right shoulder. On examination she displays RUQ tenderness and a positive Murphy’s sign.. She continues to deteriorate, is drowsy and only responds to pain. Her BP is 89/46, HR is 132 and RR 32. What is the most likely cause of shock?

A. Hypovolaemic shock (due to blood loss)
B. Septic shock
C. Hypovolaemic shock (due to hypoalbuminaemia)
D. Neurogenic shock
E. Cardiogenic shock

Answer 28

B. Septic shock

Question 29

A 35 y/o man presents with a two week history of jaundice and RUQ pain. He is taking mesalazine for a “bowel condition”. What is the most likely cause of his jaundice?

A. 	Autoimmune hepatitis
B. 	Haemochromatosis
C. 	Primary sclerosing cholangitis
D. 	Primary biliary cirrhosis
E. 	Drug side effect

Answer 29

C. Primary sclerosing cholangitis

Question 30

While waiting to be admitted, a pts RUQ pain becomes worse and she starts shaking uncontrollably. You notice she now looks jaundiced. What is the most likely diagnosis?

A. 	Biliary colic
B. 	Ascending cholangitis
C. 	Acute cholecystitis
D. 	Primary biliary cirrhosis
E. 	Cholangiocarcinoma

Answer 30

B. Ascending cholangitis

Question 31

A 45 year old woman presents with a 2 month history of upper abdominal pain, occurring 2 – 3 hours after meals. The GP orders a FBC and LFT’s, with the relevant results shown below:
rbc 3.88 (4.2-5.4)
hct 28 (36-46)
MCV 70 (78-98)
Which of these is the most likely diagnosis?

GORD
Duodenal ulcer
Gastric ulcer
Biliary colic 
Cholecystitis

Answer 31

Duodenal ulcer

Question 32

A 61 year old man presents to his GP with a 3 month history of upper abdominal pain following meals. On questioning, he describes this pain as burning and is able to point to the pain on his abdomen. He reports having noticed his clothes have been looser recently, and has a long standing history of headaches. Which of these is the most important investigation to arrange?

H. Pylori breath test
Full Blood Count
OGD Endoscopy 
Trial of Proton pump inhibitor (PPI)
Abdominal X-ray

Answer 32

OGD Endoscopy

Question 33

A 40 year old lady presents to her GP with heartburn and problems swallowing. She reports that the heartburn worsens at night, and is often accompanied by a ‘funny taste’ in her mouth and cough. She reports no change in weight or systemic symptoms. Which of these should be the next step?

UGI endoscopy
Barium Swallow
Manometry 
Serum gastrin levels
Trial of Proton pump inhibitor (PPI)

Answer 33

Trial of Proton pump inhibitor (PPI)

Question 34

A 59 year old man presents with severe retrosternal burning pain. Upper GI endoscopy shows ‘metaplastic changes within the epithelium’. Which of these is the most likely diagnosis?

Gastric ulcer 
Gastric carcinoma 
Oesophageal carcinoma
GORD
Barrett’s oesophagus

Answer 34

Barrett’s oesophagus

Question 35

A 28 year old lady presents with a 2-year history of mild dysphagia to both solids and liquids. She has no weight loss, but symptoms of heartburn and nocturnal cough. PPIs and bronchodilators haven’t helped. She is systemically well, and her examination is unremarkable. A “bird’s beak” appearance is noted on barium swallow. What is the most likely diagnosis?

Achalasia
Benign stricture
Plummer-Vinson syndrome
Oesophageal spasm
Stroke

Answer 35

Achalasia

Question 36

A 76-year old retiree visits her GP with difficulty swallowing solids. She says this has been getting progressively worse over 1 month. There is no coughing, choking or heartburn. She reports food getting “stuck” 2-3 seconds after swallowing. She attributes her weight loss to not eating properly, and also thinks this has caused loose, brown-black stools. She feels tired. Bloods show a microcytic anaemia. Select the likely diagnosis:

Stroke
Oesophageal cancer
Pharyngeal pouch
Plummer-Vinson syndrome
Benign stricture

Answer 36

Oesophageal cancer

Question 37

A 53-year old man staggers into A&E having vomited 6 times in 2 hours. He is intoxicated and jaundiced. His friend said his vomit was initially “normal”, but after the first couple of episodes had fresh blood in it. His blood pressure is 120/90 and HR 70 bpm. What is the most likely diagnosis?

Ruptured oesophageal varices
Mallory-Weiss tear
Ruptured peptic ulcer
Boerhaave syndrome
Oesophagitis

Answer 37

Mallory-Weiss tear

Question 38

A 47 year old man is brought into A&E having vomited blood. His wife reports he developed food poisoning 2 days ago. Suddenly this morning he experienced extreme chest pain and began to vomit blood. His HR is 110 and BP 85/60. On auscultation of his chest you hear a crackling sound and his CXR shows pneumomediastinum. What is the most likely diagnosis?

Ruptured oesophageal varices
Mallory-Weiss tear
Ruptured peptic ulcer
Boerhaave syndrome
Myocardial Infarction

Answer 38

Boerhaave syndrome

Question 39

A 22 y/o female presents to her GP with a two year history of intermittent diarrhoea and constipation. She complains of bloating and abdominal pain, which eases with defecation. Which condition is she likely to have?

A. 	Coeliac disease
B. 	Ulcerative colitis
C. 	Crohn’s disease
D. 	Irritable bowel syndrome
E. 	Infectious diarrhoea

Answer 39

D. Irritable bowel syndrome

Question 40

A 26 y/o male presents to his GP with weight loss, abdominal pain and watery diarrhoea. On examination he looks pale and you notice ulcers in his mouth. Which condition is he likely to have?

A. 	Coeliac disease
B. 	Ulcerative colitis
C. 	Crohn’s disease
D. 	Irritable bowel syndrome
E. 	Infectious diarrhoea

Answer 40

C. Crohn’s disease

Question 41

A 23 y/o female presents to her GP with a limp. On further questioning she reveals she has recently lost weight and has had bloody, mucoid diarrhoea. On examination her right knee is tender and swollen, and her eyes are red. Which condition is she likely to have?

A. 	Coeliac disease
B. 	Ulcerative colitis
C. 	Crohn’s disease
D. 	Irritable bowel syndrome
E. 	Infectious diarrhoea

Answer 41

B. Ulcerative colitis

Question 42

A 27 y/o male presents with a history of mucoid, bloody diarrhoea and weight loss. On examination you note a number of red marks on his shins. After a number of investigations his diagnosis is confirmed. Which treatment would you start him on?

A. 	IV corticosteroid
B. 	Oral prednisolone
C. 	topical mesalazine
D. 	Oral azathioprine
E. 	IV cyclosporin

Answer 42

C. topical mesalazine

Question 43

After starting cro, his symptoms improve. Which additional treatment would you start him on to maintain his remission?

A. 	IV corticosteroid
B. 	Oral prednisolone
C. 	topical mesalazine
D. 	Oral azathioprine
E. 	IV cyclosporin

Answer 43

D. Oral azathioprine

Question 44

A 55 y/o female presents to her GP with an itchy rash on her forearms. On further questioning she reveals she has recently lost weight and has had mucoid diarrhoea. Which test will best confirm her diagnosis?

A. 	Endoscopy with duodenal biopsy
B. 	Serum antibodies to tissue-transglutaminase
C. 	Serum anti-endomysial antibodies
D. 	Colonoscopy
E. 	Endoscopy with ileal biopsy

Answer 44

A. Endoscopy with duodenal biopsy

Question 45

A 31 y/o male presents with a history of diarrhoea, weight loss and RIF pain. On examination you note a number of red marks on his shins. After a number of investigations his diagnosis is confirmed. Which treatment would you start him on?

A. 	IV corticosteroid
B. 	Oral prednisolone
C. 	 Topical mesalazine
D. 	Oral azathioprine
E. 	IV cyclosporin

Answer 45

B. Oral prednisolone

Question 46

A 67 y/o male presents to his GP following an episode of rectal bleeding. He noticed fresh blood on the toilet paper after wiping. There was no blood mixed in with the stool. He is otherwise fit and well. What is the next appropriate step to take?

A. 	Colonoscopy
B. 	Faecal occult blood test
C. 	Abdominal exam
D. 	Digital rectal exam
E. 	Sigmoidoscopy

Answer 46

C. Abdominal exam

Question 47

A 35 y/o male presents to his GP following an episode of rectal bleeding. He noticed fresh blood on the toilet paper after wiping. There was no blood mixed in with the stool. He adds that he is very sore ‘down there’ and it is agony to defecate. Which condition is he likely to have?

A. 	Haemorrhoids
B. 	Anal fissure
C. 	Crohn’s disease
D. 	Ulcerative colitis
E. 	Colorectal carcinoma

Answer 47

B. Anal fissure

Question 48

A 67 y/o male presents to his GP complaining of rectal bleeding. Over the last few months he has noticed blood mixed in with his stool. He sometimes feels like he hasn’t completely emptied his bowels after defecating, and is more tired than usual. What is the next step to take?

A. Routine referral to colorectal surgeons
B. Urgent referral to colorectal surgeons
C. FBC
D. Abdominal exam
E. Faecal occult blood test

Answer 48

D. Abdominal exam

Question 49

46 year old Hercules presents to your clinic with excruciating abdominal pain, he’s noticed a bulge in in his left inguinal region recently which has occasionally been reducable, however since this morning its become very painful and he’s also developed a fever and the skin around the bulge has turned blue. He spends a lot of time in the gym lifting the heaviest weights, and regularly takes ibuprofen when his muscles start hurting. What is the most likely diagnosis?

A: Colic
B: Hernia
C: Bowel Obstruction
D: Volvulus
E: Gastric Ulcer

Answer 49

B: Hernia

Question 50

Juliet is a 23 year old woman who’s recently taken a sub lethal dose of poison to fake her death so she can elope with her dream man… It doesn’t go well and she wakes up with severe epigastric pain radiating to the back. She hasn’t vomited, however has noticed hiccups and shivers since waking up. Her serum amylase is raised. It’s been six hours since taking the poison and after a stomach pump, her AXR/CT imaging shows nothing out of the ordinary. Interestingly, she also has decreased serum calcium and has some glycosuria. What’s the most likely diagnosis?

A:Intestinal Ischaemia
B:Gastroenteritis
C:Acute Pancreatitis
D:Colic
E:Appendicitis

Answer 50

C:Acute Pancreatitis

Question 51

69 year old Napoleon has presented to the GP feeling incredibly unwell, he has diffuse abdominal pain and a soaring fever as well as vomiting, all in the last few hours. In the last few weeks he complained of some discomfort in the left inguinal region, and has not opened his bowels in days, although he attributes this to being nervous about going to waterloo next week. Although he is obese, Napoleon has never smoked and is unsure as to why this recent episode has occurred. O/E you observe a diffuse tenderness, as well as a mass and distension in the left inguinal region. What is the most likely diagnosis?

A: Colic
B: Diverticulitis
C: Bowel Obstruction
D: Rectal carcinoma
E: Gastroenteritis

Answer 51

C: Bowel Obstruction

Question 52

66 year old Lawrence has just returned from Arabia, he presents to a&e with a severe pain in his umbilical and pubic regions, and had recently opened his bowels quite suddenly and there was a noticeable amount of blood. Lawrence is a long term smoker and had rarely exercised, being carried on camels everywhere. He has also been noticing some bloating recently, especially after eating, and had a massive meal before this particular episode. Finally, you find Lawrence to be hypertensive, and also beginning to act a little strange and confused. What is the most likely diagnosis?

A: Slipped disk
B: Rectal carcinoma
C: Intestinal ischaemia
D: Hepatitis
E: Small bowel obstruction

Answer 52

C: Intestinal ischaemia

Question 53

A young woman presents to you in GP complaining of difficulty in finishing her hot yoga classes, which is new. She has no fever or pleuritic chest pain. Her periods have not changed in volume or flow recently. She has recently taken up a vegetarian diet and often is too busy to eat her breakfast in the morning. On examination, she is pale.
Which of the following blood test results are likely to be increased?
A. Transferrin
B. Haemoglobin
C. Serum iron
D. Mean corpuscular volume
E. Ferritin

Answer 53

A. Transferrin

Question 54

A 28 y/o male patient presents to resus immediately following a road traffic accident in which he suffered a head laceration. The paramedics have not been able to control the bleeding and have lost track of the estimated blood loss. His partner informs you that he suffers from an inherited coagulopathy.
HR = 120
BP = 90/50
T = 35.9
RR = 20
SpO2 = 97%
What would you expect you find on full blood count?

A. Low MCV, high RDW
B. Normal MCV, normal RDW
C. Low MCV, normal RDW
D. High MCV, high RDW
E. Normal MCV, high RDW

Answer 54

B. Normal MCV, normal RDW

Question 55

A 40 year old woman suffers from Crohn’s Disease. She has recently been complaining that she feels irritable, weak and notices tingling in her fingers. A blood test is performed.

Hb - 105 g/L
MCV - 110 fL (80-100)
Plts - 300 x10^9/L (150-400)

The most likely explanation is:
A. Alcohol
B. Vitamin B12 deficiency
C. Folate deficiency
D. Anaemia of chronic disease
E. Rectal cancer

Answer 55

C. Vit B12 deficiency

Question 56

A 35 y/o Greek man recovering from viral hepatitis becomes unwell with shortness of breath, nausea and dark urine. On examination, he is icteric with pale conjunctivae. His full blood count reveals a normocytic anaemia with elevated reticulocytes, and a negative DAT.
What is the likely finding on further investigation?
A. Schistocytes
B. Hypersegmented neutrophils
C. Heinz bodies
D. Cold agglutinins
E. Howell-Jolly bodies

Answer 56

C. Heinz bodies

Question 57

A 23 y/o Asian man present to his GP with shortness of breath on exertion. He has always been unfit and decided to start going to the gym, but after four weeks has noticed no improvement. He denies any respiratory symptoms and on examination you notice mildly pale conjunctivae. Investigations reveal:
Hb - 120 g/L
MCV - 70 fL (80-100)
Serum iron – normal
Ferritin – normal
Transferrin – norma
l 
What is the most likely diagnosis
A. Glucose-6-phosphate dehydrogenase deficiency
B. β-thalassaemia major
C. β-thalassaemia minor
D. Sickle cell anaemia
E. Iron deficiency anaemia

Answer 57

C. β-thalassaemia minor

Question 58

An 65 y/o man presents to you with fatigue and shortness of breath on exercise. On examination he has mildly pale conjunctivae. Full blood count reveals:
Hb – 100 g/L
MCV – 82 fL (80-100)
Ferritin – low
Transferrin – high

Select the next most appropriate management option:
A. Blood smear
B.  1 unit of packed red blood cells
C. OGD and colonoscopy
D. Intravenous iron infusion
E. Stress echocardiogram

Answer 58

C. OGD and colonoscopy

Question 59

A woman who has always had menorrhagia loses an abnormally large amount of blood on the birth of her first child, requiring a transfusion. You decide to investigate and order some tests. The willebrand factor assay is abnormally low.

Haemophilia A

Haemophilia B

Von Willebrand Disease Type 1

Von Willebrand Disease Type 2

Von Willebrand Disease Type 3

Bernard-Soulier syndrome

Immune thrombocytopenic Purpura

Disseminated Intravascular Coagulation

Deep vein Thrombosis

Answer 59

Von Willebrand Disease Type 1

Question 60

A woman who has always had menorrhagia loses an abnormally large amount of blood on the birth of her first child, requiring a transfusion. You decide to investigate and order some tests. The willebrand factor assay is normal. The ristocetin co-factor assay is abnormal.

Haemophilia A

Haemophilia B

Von Willebrand Disease Type 1

Von Willebrand Disease Type 2

Von Willebrand Disease Type 3

Bernard-Soulier syndrome

Immune thrombocytopenic Purpura

Disseminated Intravascular Coagulation

Deep vein Thrombosis

Answer 60

Von Willebrand Disease Type 2

Question 61

A 60 year old male is admitted to HDU with sespsis. He quickly deteriorates. His blood tests show a high PT but a low fibrinogen.

Haemophilia A

Haemophilia B

Von Willebrand Disease Type 1

Von Willebrand Disease Type 2

Von Willebrand Disease Type 3

Bernard-Soulier syndrome

Immune thrombocytopenic Purpura

Disseminated Intravascular Coagulation

Deep vein Thrombosis

Answer 61

Disseminated Intravascular Coagulation

Question 62

A 6 year old boy presents to A & E with a large haemarthrosis of the left knee after knocking against a table. It his 4th appearance to A&e for the same problem in 6 months. A Factor VIII assay is normal.

Haemophilia A

Haemophilia B

Von Willebrand Disease Type 1

Von Willebrand Disease Type 2

Von Willebrand Disease Type 3

Bernard-Soulier syndrome

Immune thrombocytopenic Purpura

Disseminated Intravascular Coagulation

Deep vein Thrombosis

Answer 62

Haemophilia C

Question 63

A 55 year old woman who was recently admitted to hospital with a severe viral illness starts presenting with mucocutaneous bleeding and petchiae. She has no previous history of this before the illness.

Haemophilia A

Haemophilia B

Von Willebrand Disease Type 1

Von Willebrand Disease Type 2

Von Willebrand Disease Type 3

Bernard-Soulier syndrome

Immune thrombocytopenic Purpura

Disseminated Intravascular Coagulation

Deep vein Thrombosis

Answer 63

Immune thrombocytopenic Purpura

Question 64

A 55 year old man has been admitted to hospital with sudden shortness of breath and chest pain. In hospital, blood tests show he has a prolonged aTTP and PT and extremely elevated D-dimer. Which of the following is most likely to have caused this?
Acute Lymoblastic Leukaemia

Acute Myeloid Leukaemia

Chronic Lymphoid Leukaemia

Chronic Myelogenous Leukaemia

Hodgkin’s Lymphoma

Non-Hodgkin’s Lymphoma

Multiple Myeloma

Answer 64

Chronic Lymphoid Leukaemia

Question 65

A 22 year old Imperial medical student presents with notable lymphadenopathy in their neck and axilla, which they remember being similar to a condition they had around 5 years ago. They’ve recently stopped going to sports night.
What is the most likely diagnosis?

Acute Lymoblastic Leukaemia

Acute Myeloid Leukaemia

Chronic Lymphoid Leukaemia

Chronic Myelogenous Leukaemia

Hodgkin’s Lymphoma

Non-Hodgkin’s Lymphoma

Multiple Myeloma

Answer 65

Hodgkin’s Lymphoma

Question 66

A 3 year old child is brought into the GP clinic by his mother with a two week history of feeling unwell and tired. 
On examination you notice the following:
Temperature = 38.5
Splenomegaly 
Hepatomegaly

Acute Lymoblastic Leukaemia

Acute Myeloid Leukaemia

Chronic Lymphoid Leukaemia

Chronic Myelogenous Leukaemia

Hodgkin’s Lymphoma

Non-Hodgkin’s Lymphoma

Multiple Myeloma

Answer 66

Acute Lymoblastic Leukaemia

Question 67

A mother brings in her 5 year old child into your clinic, saying they have been tired and irritable in the past few weeks. On examination they have splenomegaly and enlarged lymph nodes. You also notice testicular swelling.

Acute Lymoblastic Leukaemia

Acute Myeloid Leukaemia

Chronic Lymphoid Leukaemia

Chronic Myelogenous Leukaemia

Hodgkin’s Lymphoma

Non-Hodgkin’s Lymphoma

Multiple Myeloma

Answer 67

Acute Lymoblastic Leukaemia

Question 68

A 70 year old woman presents to her GP surgery with a 3 month history of tiredness, fever and weight loss.
Her blood tests show an anaemia.
Bence-Jones proteins are found in the urine.

Acute Lymoblastic Leukaemia

Acute Myeloid Leukaemia

Chronic Lymphoid Leukaemia

Chronic Myelogenous Leukaemia

Hodgkin’s Lymphoma

Non-Hodgkin’s Lymphoma

Multiple Myeloma

Answer 68

Multiple Myeloma

Question 69

A routine blood test on a 60 year old man picks up a lymphocytosis. You perform a blood filming showing smudge cells.

Acute Lymoblastic Leukaemia

Acute Myeloid Leukaemia

Chronic Lymphoid Leukaemia

Chronic Myelogenous Leukaemia

Hodgkin’s Lymphoma

Non-Hodgkin’s Lymphoma

Multiple Myeloma

Answer 69

Chronic Lymphoid Leukaemia`

Question 70

You find neutrophilia and thrombocytosis in an incidentalfinding on a routine blood test. Further tests indicate he has the cells expressing the Philadelphia chromosome BCR-ABL gene.

Acute Lymoblastic Leukaemia

Acute Myeloid Leukaemia

Chronic Lymphoid Leukaemia

Chronic Myelogenous Leukaemia

Hodgkin’s Lymphoma

Non-Hodgkin’s Lymphoma

Multiple Myeloma

Answer 70

Chronic Myelogenous Leukaemia

Question 71

A 63-year-old woman presents to A&E with a headache, mainly affecting the left half of her forehead, that has gradually been getting worse over the past week. She has been eating less as she experiences pain in her jaw when she chews her food. She has, generally speaking, been healthy aside from experiencing some stiffness and pain in her shoulders over the past 6 months. What is the first step in her management?

A Check ESR 
B Temporal artery biopsy 
C IV hydrocortisone 
D Oral prednisolone 
E IV antibiotics

Answer 71

D Oral prednisolone

Question 72

Which of the following conditions is strongly associated with temporal arteritis?
A  Takayasu’s aortitis
B  Myalgic encephalomyelitis
C  Fibromyalgia
D  Polymyalgia rheumatica
E  Polymyositis

Answer 72

D Polymyalgia rheumatica

Takayasu’s Aortitis – a large vessel vasculitis that affects the aorta and its branches. Typically affects Middle-aged women of Asian descent. Tends to present with constitutional upset, absent/weak upper/lower limb pulses and claudication

Myalgic Encephalomyelitis – also known as chronic fatigue syndrome. Characterised by long-term fatigue that impact on an individual’s quality of life. There is no clear cause of ME.

Fibromyalgia – chronic pain disorder with an unknown cause. Characterised by pain at multiple discrete points across the body. Differs from ME in that fibromyalgia mainly features pain and tenderness at specific points on the body rather than general fatigue.

Polymyositis – a connective tissue disease characterised by inflammation of the muscles. Differs from dermatomyositis in that polymyositis does not cause a rash. Patients experience diffuse weakness in the proximal muscles (distal muscles tend to be spared).

Question 73

A 47-year-old man visits his GP having developed a skin rash. He has been feeling ‘generally unwell’ for the past 3 months, and has suffered from abdominal pain accompanied by some rectal bleeding. An angiogram reveals ‘Rosary sign’. He regularly attends hospital for check-ups since he was diagnosed with chronic hepatitis B, 2 years ago. What is the most likely diagnosis?

A  Giant cell arteritis 
B  Dermatomyositis 
C  Polyarteritis nodosa 
D  Granulomatosis with polyangiitis 
E  Behcet’s disease

Answer 73

C Polyarteritis nodosa

Question 74

A 52-year-old man has suffered from rhinitis and recurrent nosebleeds for the past 5 months. Initially, he did not think much of it, until he began coughing up a small about of blood about 3 weeks ago. A urine dipstick reveals proteinuria and haematuria. Blood tests reveal:
ESR: 72 mm/hr (< 20 mm/hr)
cANCA: positive
What is the most likely diagnosis?

A Microscopic polyangiitis 
B Goodpasture’s syndrome 
C Granulomatosis with polyangiitis 
D Churg-Strauss syndrome 
E  Behçet’s disease

Answer 74

C Granulomatosis with polyangiitis

Question 75

A 45-year-old man from Cyprus presents with recurrent ulcers on his penis. He has not noticed any discharge from his penis or pain whilst urinating. He adds that he has also developed mouth ulcers several times over the past year. During the consultation, you notice that his eyes are quite red. When questioned, he says that his eyes have been itchy recently, and thinks that he might have hay fever. What is the most likely diagnosis?

A Inflammatory bowel disease 
B Behçet’s disease 
C Herpes simplex virus 
D Syphilis 
E Reactive arthritis

Answer 75

B Behçet’s disease

Question 76

Churg-Strauss syndrome is associated with:

A  pANCA
B  cANCA
C  Anti-GBM antibodies
D  Anti-LKM antibodies
E  Anti-smooth muscle antibodies

Answer 76

A pANCA

Question 77

A 35 year old woman presents saying that sex with her husband has now become painful and difficult. She also finds it difficult to swallow and cannot taste well anymore. With further investigations, antinuclear antibodies are present.

A SLE
B Scleroderma
C Sjorgen’s 
D Sarcoidosis
E Don’t know

Answer 77

C Sjorgen’s

Question 78

A 40 year old African man who has a history of interstital lung fibrosis, uveitis and erythema nodosum.

A SLE
B Scleroderma
C Sjorgen’s 
D Sarcoidosis
E Don’t know

Answer 78

A Sarcoidosis

Question 79

A 40 year old African man who has a history of interstital lung fibrosis, uveitis and erythema nodosum.

Please select the best test to confirm your diagnosis:

A. Schirmer’s Test
B. Erythrocyte Sedimentation Rate
C. Anticentromere antibodies
D. Chest X-Ray
E. Antinuclear Antibodies

Answer 79

D. Chest X-Ray

Question 80

A 60 year old man presents to his GP having since Christmas had telangiectasia, calcified spots on his skin, dysphagia and extremely white fingertips in cold weather.

A SLE
B Scleroderma
C Sjorgen’s 
D Sarcoidosis
E Don’t know

Answer 80

B Scleroderma

Question 81

A 19 year old woman presents to your clinic with with discoid eczema, a malar rash and mouth ulcers.

A SLE
B Scleroderma
C Sjorgen’s 
D Sarcoidosis
E Don’t know

Answer 81

A SLE

Question 82

A 35 year old woman presents saying that sex with her husband has now become painful and difficult. She also finds it difficult to swallow and cannot taste well anymore. With further investigations, antinuclear antibodies are present.

A. Schirmer’s Test
B. Erythrocyte Sedimentation Rate
C. Anticentromere antibodies
D. Chest X-Ray
E. Antinuclear Antibodies

Answer 82

Schirmer’s Test

Question 83

A 64 year old man presents with a lesion on his upper ear that has been present for months but has now begun to ulcerate. On examination: non-pigmented, hyperkeratotic, crusty lesion with raised everted edges on the pinna.
What is the most likely diagnosis?
A. Basal call carcinoma
B. Malignant melanoma – superficial spreading type
C. Malignant melanoma – nodular type
D. Non-healing scab
E. Squamous cell carcinoma

Answer 83

E. Squamous cell carcinoma

Question 84

A 32-year old scuba diver who lives in the Maldives had a seizure three days ago. He has no history of epilepsy but he’s had headaches for the past 5 months. The headaches are worse when he goes to bed. On examination, a dark irregular skin lesion is found on the back of his neck. An MRI scan shows multiple lesions across both cerebral hemispheres. 
What is the most likely diagnosis? 
A. Acoustic neuroma
B. Glioblastoma multiforme
C. Meningioma 
D. Metastases 
E. Neurofibromatosis type I

Answer 84

D. Metastases

Question 85

A 76-year-old woman has recently attended her GP because of a ‘spot that won’t go away’. The lesion is on her nose and has rolled edges. The GP suspects a basal cell carcinoma.
What investigations are likely to be needed?

A. Dermatology referral/assessment - 2-week wait
B. Dermatology referral/assessment – routine
C. None – it is a non-dangerous chronic condition
D. None – GP to start treatment
E. Re-assessment in primary care periodically

Answer 85

B. Dermatology referral/assessment – routine

Question 86

A 4-year old girl presents to the GP with multiple lesions on her face. The lesions are raised and shiny, non-tender, non-erythematous, and 3 mm in diameter. They have an umbilicated centre. The patient is known to be HIV positive.
What is the most likely diagnosis?

A. Chicken pox
B. Molluscum contagiosum
C. Atopic eczema  
D. Eczema herpeticum
E. Herpes simplex virus

Answer 86

B. Molluscum contagiosum

Question 87

A 52-year-old woman presents to the GP with redness and swelling of her right cheek. On examination the area of erythema is well-demarcated and warm to the touch. Her temperature is 37.9oC and she feels unwell.
i) Most likely diagnosis?

A. Cellulitis
B. Skin abscess
C. Erysipelas
D. Necrotising fasciitis
E. Gum infection

ii) Next steps?
A. Cold compress, reassure, home
B. Admit to intensive care unit
C. Take skin swabs, blood cultures, and give paracetamol
D. Draw around the lesion, give pain relief, oral fluids and antibiotics

Answer 87

C. Erysipelas

D. Draw around the lesion, give pain relief, oral fluids and antibiotics

Question 88

A 12-year-old girl presents with dry, itchy skin that involves the flexures in front of her elbows and behind her knees. She has symptoms of hay fever and was diagnosed with egg and milk allergy at 6 months old.Her mother has asthma.
What is the most likely diagnosis?

A. Seborrheic dermatitis
B. Atopic dermatitis
Psoriasis (chronic plaque)
C. Psoriasis (guttate)
E. Urticaria

Answer 88

B. Atopic dermatitis

Question 89

An otherwise healthy 23-year-old man complains of sore red lesions on his extremities which have a central clearance (targetoid). These appeared after a recurrence of his ‘coldsores’. 
What is the diagnosis?
A. Erythema multiforme
B. Chicken pox
C. Herpes simplex virus
D. Stevens-Johnson’s syndrome
E. Toxic epidermal necrolysis

Answer 89

A. Erythema multiforme

Question 90

. A 54 year old man has been in hospital for surgery on his ankle fracture. The operation has went well with no post-operative complications. On the 3rd day, the nurses note a change in his behaviour. When you go to see him, he is sweating profusely, shaking and he is shouting at the walls saying “you get away from me!”. He has been homeless for the past 15 years and on examination, he has a lot of bruising. He was treated for acute pancreatitis 4 years ago. What is the next most appropriate treatment?

A. Lorazepam
B. Chlordiazepoxide
C. Pabrinex
D. Salbutamol
E. Lactulose

Answer 90

B. Chlordiazepoxide

Question 91

1. A 19 year old woman is being treated with IV penicillin for a throat abscess. Within 20 minutes, she develops a stridor, distress of breathing, swelling and an urticarial rash. Observations: HR = 129 bpm, BP = 85/52 mmHg.
   What is the first most appropriate step in management?

A. IM Adrenaline
B. IV Chlorpheniramine
C. Stop the penicillin
D. Intubate and 100% oxygen
E. IV hydrocortisone

Answer 91

C. Stop the penicillin

Question 92

1. A 65 year old widow is rushed to A&E with hyperventilation, palpitations, confusion and complains of deafness. Her past medical history includes peripheral arterial disease and was diagnosed with depression more recently. What is the most likely diagnosis?
A. Opiate overdose
B. TIA
C. Aspirin overdose
D. Paracetamol overdose
E. UTI

Answer 92

C. Aspirin overdose

Question 93

1. A 22-year-old unconscious man is brought into accident and emergency. He was found lying alone on the street by passers-by who called the ambulance. The patient’s Glasgow Coma Scale is 12, he has a respiratory rate of 10 and blood pressure of 97/65mmHg. During your examination you notice pinpoint pupils and multiple scars around the anterior cubital fossa on both arms. The most appropriate treatment is:

A. Mechanical ventilation
B. IV naloxone
C. N-acetylcysteine
D. Methadone
E. IV naltrexone

Answer 93

B. IV naloxone

Question 94

1. A 16 year old girl with a past medical history of anorexia nervosa is brought to A&E by her mother after she told her she had taken a box of 16 paracetamol tablets 2 hours ago, intending to end her life. She has no symptoms other than mild nausea and lethargy. What is the next most appropriate step in management?

A. IV Naloxone
B. Gastric lavage
C. Wait until 4 hours post ingestion and measure  			paracetamol levels
D. N-acetylcysteine
E. Reassure and discharge

Answer 94

C. Wait until 4 hours post ingestion and measure paracetamol levels

Question 95

A 76-year-old woman is brought into A&E with central crushing chest pain that radiates to her jaw and left arm. An ECG is performed, which shows ST elevation in leads ll, lll and aVF. Her SaO2 is 89%. Before she is sent to the cathlab for percutaneous coronary intervention, she is started on a combination of drugs. Which of the following should not be given?

A Morphine 
B Oxygen 
C Aspirin 
D Clopidogrel 
E Warfarin

Answer 95

E Warfarin

Question 96

A 54-year-old man has been brought into A&E with a suspected acute coronary syndrome. An ECG is performed, which reveals ST elevation in leads I, aVL, V5 and V6. Which coronary artery has been occluded?

A Left main stem 
B Left anterior descending coronary artery 
C Left circumflex coronary artery 
D Right coronary artery 
E Posterior descending artery

Answer 96

C Left circumflex coronary artery

Question 97

A 54-year-old man is complaining of sharp, central chest pain that has arisen over the last 24 hours. On inspection, the patient is sitting forward on the examination couch. On auscultation, a scratching sound is heard – loudest over the lower left sternal edge, when the patient is leaning forward. He has a past medical history of a ST-elevation MI which was diagnosed, and treated with PCI, 6 weeks ago. What is the most likely diagnosis?
A Viral pericarditis
B Constrictive pericarditis
C Cardiac tamponade
D Dressler syndrome
E Tietze syndrome

Answer 97

D Dressler syndrome

NB. Tietze syndrome is a rare, inflammatory disorder characterized by chest pain and swelling of the cartilage of one or more of the upper ribs (costochondral junction),

Question 98

A 27-year-old man presents complaining of sharp chest pain. He mentions that he has taken a few days off work recently because of the flu. What would you expect to see on his ECG?

A ST elevation in leads II, III and aVF
B Widespread saddle-shaped ST elevation
C ST depression
D Tented T waves
E Absent P waves

Answer 98

B Widespread saddle-shaped ST elevation

Question 99

A 46-year-old man has been admitted to A&E after experiencing palpitations, which began about 4 hours ago. An ECG is performed, which reveals atrial fibrillation. He has no previous history of ischaemic heart disease. He refuses DC cardioversion. What is the next most appropriate treatment option?

A Defibrillation 
B Low molecular weight heparin 
C Warfarin 
D Flecainide 
E Digoxin

Answer 99

D Flecainide

Question 100

A 27-year-old man presents with palpitations and light-headedness. An ECG shows features consistent with a supraventricular tachycardia. Adenosine is administered and the SVT is terminated. A repeat ECG shows a short PR interval and a QRS complex with a slurred upstroke. What is the diagnosis?

A Brugada syndrome 
B LBBB 
C Romano-Ward syndrome 
D Wolff-Parkinson-White syndrome 
E Complete heart block

Answer 100

D Wolff-Parkinson-White syndrome

Question 101

A 52-year-old man was watching TV yesterday when he suddenly become very aware of his heart beating rapidly. This lasted for around 45 mins and then subsided spontaneously. It has happened several times over the past 2 months. An ECG reveals no abnormalities. However, due to the strong suspicion of atrial fibrillation, the patient is placed on a 24-hr tape, which confirms the diagnosis. Which scoring system should be used to determine the benefit of long-term anticoagulation in this patient?

A QRISK2 score 
B ABCD2 Score 
C GRACE score 
D CHA2DS2-VASc score 
E CURB-65 score

Answer 101

D CHA2DS2-VASc score

Question 102

A 78-year-old woman is admitted with heart failure. The underlying cause is determined to be aortic stenosis. Which sign is most likely to be present? 
A.Pleural effusion on chest x-ray 
B. Raised jugular venous pressure (JVP) 
C. Bilateral pedal oedema 
D. Bibasal crepitations 
E. Atrial fibrillation

Answer 102

D. Bibasal crepitations

Question 103

A 60-year-old man presents to his GP with gradually increasing fatigue and some exertional dyspnoea. Blood pressure is 118/74mmHg and pulse rate is 81/minute. There are no abnormal physical findings and on echocardiography the ejection fraction is 0.47. However, the clinical impression remains one of early heart failure. Which of the following circulating biomarkers would lend support to that conclusion? 
A.	Atrial natriuretic peptide
B. 	Brain natriuretic peptide
C. 	Endothelin
D.	Noradrenaline
E. 	Adrenomedullin

Answer 103

B. Brain natriuretic peptide

Question 104

A 55-year-old male presents with increasing exertional dyspnoea, fatigue, weight loss and bone pain. Blood results reveal elevated calcium levels and normocytic anaemia. He is treated for heart failure. What is the underlying cause for his heart failure?
A. Hyperthyroidism
B. Malignancy
C. Thiamine deficiency
D. Meningitis
E. Paget’s disease of the bone

Answer 104

B. Malignancy

Question 105

A 49-year-old woman presents with increasing shortness of breath on exertion developing over the past three months. She has no chest pain or cough, and has noticed no ankle swelling. On examination, blood pressure is 158/61mmHg, pulse is regular at 88 beats per minute and there are crackles at both lung bases. There is a decrescendo diastolic murmur at the left sternal edge. What is the most likely diagnosis?

A. 	Aortic regurgitation 
B. 	Aortic stenosis 
C. 	Mitral regurgitation 
D. 	Mitral stenosis 
E. 	Tricuspid regurgitation

Answer 105

A. Aortic regurgitation

Question 106

You see a 57-year-old woman who presents with worsening shortness of breath coupled with decreased exercise tolerance. She had rheumatic fever in her adolescence and suffers from essential hypertension. On examination, she has a murmur heard loudest over the mitral area. Which of the following is not a clinical sign associated with the most likely diagnosis?

A 	Malar flush 
B. 	Atrial fibrillation 
C. 	Pan-systolic murmur which radiates to axilla 
D. 	Tapping, undisplaced apex beat 
E. 	Right ventricular heave

Answer 106

C. Pan-systolic murmur which radiates to axilla

ITS MITRAL STENOSIS

Question 107

An 8 year old boy comes to the GP with his mother for a check-up. You find the child to be extremely sociable and friendly, with some mild learning difficulties. You also note distinct facial features including a broad forehead, short nose and full cheeks. On auscultation of his chest, you detect a murmur in the right 2nd intercostal space, loudest on inspiration. What is the most likely diagnosis?
A. Hypertrophic Obstructive Cardiomyopathy
B. Infective endocarditis
C. Aortic stenosis
D. Aortic regurgitation
E. Mitral stenosis

Answer 107

C. Aortic stenosis

Question 108

A 48-year-old woman has been diagnosed with essential hypertension and was commenced on treatment three months ago. She presents to you with a dry cough which has not been getting better despite taking cough linctus and antibiotics. You assess the patient’s medication history. Which of the following antihypertensive medications is responsible for the patient’s symptoms?

A. 	Amlodipine
B. 	Lisinopril
C. 	Bendroflumethiazide 
D. 	Furosemide
E. 	Atenolol

Answer 108

B. Lisinopril

Question 109

8. 40. A 57-year-old man is reviewed in a hypertension clinic, where it is found that his blood pressure is 165/105 mmHg despite standard doses of amlodipine, perindopril, doxazosin and bendroflumethiazide. Electrolytes and physical examination have been, and remain, normal. Which of the following would be your next stage in his management?
       A. Arrange for his medication to be given under direct observation
       B. Add spironolactone to his medication
       C. Arrange urinary catecholamine assays
       D. Request an adrenal CT scan
       E. Add verapamil to his medication

Answer 109

A. Arrange for his medication to be given under direct observation

Question 110

A 47-year-old woman presents to clinic after being referred from her GP for consistently elevated blood pressure. Her last reading was 147/93. The female does not report any symptoms but recently lost her job and attributes the elevated reading to stress. Her blood tests are as follows:

Sodium = 146 (135-145 mmol/L)
Potassium = 3.4 (3.5-5 mmol/L)
Random glucose= 7.7 (4.4-7.8mmol/L)
Urea = 4 (2.5-7.8 mmol/L)

The next most appropriate investigation is:

A. 	CT scan 
B. 	24-hour ambulatory blood pressure 
C. 	Abdominal ultrasound scan 
D. 	Aldosterone-renin ratio 
E. 	Glucose tolerance test

Answer 110

B. 24-hour ambulatory blood pressure

Question 111

A 50 year old patient presents to A&E with diplopia. The doctor examines their cranial nerves and finds a palsy in the oculomotor nerve. Peripheral nerve exam demonstrated a length dependent sensory neuropathy. What did the doctor most likely see during the cranial nerve examination:

a. Internuclear ophthalmoplegia 
.b Anhidrosis, miosis and ptosis
c. Down and out pupil
d. Mydriasis
e. Down and out pupil with mydriasis

Answer 111

c. Down and out pupil

Question 112

A 28 year old lady presents to A&E thinking she is having a stroke, worried as she cannot move the right side of her face. On examination, the patient cannot smile, puff up her cheeks or wrinkle her forehead on the right side. Serology comes back positive for herpes simplex virus 1. What is the most likely diagnosis?

a. Stroke
b. Bell’s Palsy
c. MS
d. Ramsay Hunt syndrome
e. Horner’s

Answer 112

b. Bell’s Palsy

Question 113

A 20 year old lady sees her GP after having some hearing difficulties in the last week. On examination, Weber’s test lateralises to her left ear. Rinne’s test is negative in her left ear also, but positive in the right ear. She reported having a cold at the start of the month. Which of these is most likely?

a. Meningitis
b. Otitis media
c. Foreign body
d. Meniere’s disease
e. Neurofibromatosis type 2

Answer 113

b. Otitis media

As Rinne’s test is negative in left ear we know it is a conductive problem in left ear, further supported by fact Weber’s lateralises to the left as well. This rules out Meningitis and NF2 as they are a sensorineural problem, as is Meniere’s – Meniere’s is triad of sensorineural hearing loss, vertigo and tinnitus.
So is either option B or C. Fact they had a cold earlier in month points more towards B as this is an inner ear infection – infection could have spread.

Question 114

A 60 year old man presents to his GP with dysphagia. The GP notices he speaks with a nasally voice. Examination demonstrates a reduced gag reflex, as well as fasciculations and wasting of the tongue. Jaw jerk is normal. Which of these is the most likely cause of their dysphagia?

a. Stroke
b. Parkinson’s
c. Motor neuron disease
d. MS
e. Achalasia

Answer 114

c. Motor neuron disease

Question 115

An 18-year-old male patient presents to the GP with red eyes. His eyes are itchy and watery, and he cannot stop rubbing them. He has not experienced any visual disturbance. He had this same problem once before, around the same time last year. He has no joint pain or stiffness. His sisters suffer from asthma.

On examination, there is conjunctival injection bilaterally with watery discharge. PEARL. Visual acuity 6/6 in both eyes.

What is the most likely diagnosis?

a. Foreign body in the eye
b. Bacterial conjunctivitis
c. Acute angle-closure glaucoma
d. Allergic conjunctivitis
e. Anterior uveitis

Answer 115

d.Allergic conjunctivitis

Question 116

A 14-year-old male patient presents to A&E with difficulty speaking. The issue began 4 days ago with a sore throat, which has progressively gotten worse. It is now difficult for him to speak and swallow. He has had a high fever at home, but his mother did not measure it with a thermometer. He has not had a cough or cold during this illness.

On examination, there is bilateral tonsillar exudate and the oropharynx is not erythematous. There are 3 tender swellings on the anterior border of sternocleidomastoid muscle.

His observations are:
T 39.1, HR 90, BP 113/68, SpO2 97%
What is the most likely diagnosis?

a. Infectious mononucleosis
b. Viral tonsillitis
c. Common cold
d. Bacterial tonsillitis
e. Otitis media

Answer 116

Bacterial tonsillitis

Question 117

Which of the following is not an independent risk factor for septic arthritis?

a. Rheumatoid arthritis
b. Intravenous drug use
c. Ligamentous injury of the joint
d. Diabetes mellitus
e. Previous total hip arthroplasty

Answer 117

c. Ligamentous injury of the joint

Question 118

You have been caring for a patient on the vascular surgery ward with a non-healing ulcer over the gaiter area of the right leg. In the past week, the patient has complained of ascending swelling and pain of the limb.
On examination, the patient has a low-grade fever. There is a confluent area of erythema and swelling that is warm and tender to touch.
You diagnose cellulitis, and get the following results back from the lab.
FBC – leucocytosis
U&E – normal
CRP – elevated
Blood cultures – pending
D-Dimer – negative

After starting empiric antibiotic therapy, what is the next most appropriate investigation to identify an important complication of cellulitis?

a. Plain radiograph of the right leg
b. Venous duplex ultrasound
c. CT of the right leg
d. CT pulmonary angiogram
e. Transthoracic echocardiogram

Bonus: what type of ulcer is this likely to be?

a. Arterial
b. Neuropathic
c. Venous

Answer 118

a. Plain radiograph of the right leg

c. Venous

Question 119

A 69 year old man with a background of hypertension complained of flank pain all day at work. He then has sudden onset abdominal pain that radiates to his back, flank and groin. He arrives in an ambulance unconscious. The doctor notes Grey Turner’s and Cullen’s signs. What is the most likely diagnosis?

a. Renal colic
b. Myocardial Ischaemia
c. Ruptured AAA
d. Pancreatitis
e. Mesenteric Ischaemia

Answer 119

Ruptured AAA

Question 120

A 65 year old lady with known CVD presents to the GP with pain in her legs. She finds the pain comes on when she is walking to the shops, but is relieved by rest. She has a 40 pack year smoking history. What is the most likely diagnosis?

a. Acute limb ischaemia
b. Deep vein thrombosis
c. Varicose veins
d. Peripheral arterial disease
e. Femoral Aneurysm

Answer 120

d. Peripheral arterial disease

Question 121

A 38 year old lady presents with swelling in her leg, and associated calf tenderness. She has been taking the OCP for several years. What is the best management for this patient?

a. Warfarin + LMWH
b. Warfarin
c. Aspirin
d. LMWH + Aspirin
e. LMWH

Answer 121

a. Warfarin + LMWH

Question 122

A 60 year old male with known atrial fibrillation presents to A&E with a sudden onset of a painful, cold leg. The doctor is unable to feel peripheral pulses, and upon examination notes a loss of sensation and paralysis. What is the definitive management?

a. Embolectomy
b. Watch and wait
c. Angioplasty
d. Amputation
e. LMWH

Answer 122

d. Amputation

Question 123

A 65 year old gentleman is coming in for screening for a AAA following a letter received in the post. What modality would be used as a screening tool?

a. Abdominal Ultrasound
b. Abdominal CT
c. Abdominal X-ray
d. Doppler Ultrasound
e. V/Q Scan

Answer 123

a. Abdominal Ultrasound

Question 124

The same gentleman, 3 years later with a known AAA (last measured 5.2 cm) comes in complaining of severe abdominal pain. What investigation would you use to assess if it has ruptured?

a. Abdominal Ultrasound
b. Abdominal CT
c. Abdominal X-ray
d. Doppler Ultrasound
e. V/Q Scan

Answer 124

b. Abdominal CT

Question 125

A 69 year old heavy smoker complains of pain in his leg when he walks to the bus stop. On examination of his leg, you see shiny skin, patchy hair, weak pulses and brittle toenails. What investigation will help diagnose his condition?

a. Angiography
b. Doppler Ultrasound
c. Magnetic Resonance Angiography
d. ABPI
e. D-Dimer

Answer 125

d. ABPI

Question 126

A 32 year old woman on the OCP complains of pain in her calf for one day. She does not have any chest pain or shortness of breath. The nurse tells you that the A&E doctors assessed the patient, who scored 2 although she cannot remember the name of the score. What is the most appropriate investigation?

a. D-Dimer
b. MRA
c. Leg Vein USS
d. ABPI
e. CTPA

Answer 126

c. Leg Vein USS

Question 127

A 60 year old patient presents to A&E with central crushing chest pain, radiating to the jaw. His ECG is normal. What is the next step?

a. Creatine Kinase
b. Repeat ECG
c. Discharge
d. Exercise ECG
e. Troponin

Answer 127

Troponin

Question 128

A 46 year old diabetic man presents to A&E following collapse. The patient is very distressed and is sweating. On the way to the hospital, his wife had to stop the car to allow him to vomit. His ECG is normal but his 12 hour troponins are positive. What is the most likely diagnosis?

a. Inferior STEMI
b. Anterior STEMI
c. NSTEMI
d. Unstable Angina
e. Ventricular Wall Aneurysm

Answer 128

c. NSTEMI

Question 129

A 56 year old overweight man with a history of high cholesterol comes in complaining of central crushing chest pain that came on at rest. He has had a similar pain before but only when playing tennis. His ECG shows ST depression and a 12 hour troponin is negative.

a. Inferior STEMI
b. Anterior STEMI
c. NSTEMI
d. Unstable Angina
e. Ventricular Wall Aneurysm

Answer 129

d. Unstable Angina

Question 130

A 50 year old man presents to his GP with central chest pain. The ECG shows a STEMI. His sats are 96%. What medication should the GP give whilst waiting for an ambulance?

a. Fondaparinux 2.5mg
b. Oxygen
c. Propanolol
e. Aspirin/Clopidogrel 300mg
d. Ramipril

Answer 130

e. Aspirin/Clopidogrel 300mg

Question 131

A 70 year old female with known hypertension and hypercholesterolaemia presents with central crushing chest pain, which radiates to the left arm. The pain started 2 hours ago. Her ECG shows LBBB. What is the most appropriate management.

a. Thrombolysis
b. Angiography
c. Fibrinolysis
d. PCI
e. CABG
f. Fondaprinux

Answer 131

d. PCI

Question 132

A man is being discharged following an MI. Which of the following drugs should not make up a part of his post MI management?

a. ACEi
b. Aspirin
c. Clopidogrel
d. Heparin
e. Statin
f. B-Blocker

Answer 132

d. Heparin

Question 133

A 53 year old man suffers a ruptured aortic aneurysm and is rushed into theatre. He undergoes a successful operation and is recovering on the wards. 1 day after the operation he becomes oliguric with elevated urea and creatinine. After 1 week his urine output increases but his GFR remains low at 30ml/min

A: Acute Tubular Necrosis
B: Rhabdomyolysis
C: Glomerulonephritis
D: Haemolytic Uraemic Syndrome
E: Haemorrhage
F: Renal Stones
G: Sepsis
H: Vasculitis
I: Dehydration
J:Thrombotic Thrombocytopaenic Purpura

Answer 133

A: Acute Tubular Necrosis

Question 134

A 17 year old student presents to A&E with a 6 day history of sore throat and flu-like symptoms. He know has frank haematuria, swelling of his ankles and poor urine output

A: Acute Tubular Necrosis
B: Rhabdomyolysis
C: Glomerulonephritis
D: Haemolytic Uraemic Syndrome
E: Haemorrhage
F: Renal Stones
G: Sepsis
H: Vasculitis
I: Dehydration
J:Thrombotic Thrombocytopaenic Purpura

Answer 134

C: Glomerulonephritis

Question 135

A 10 year old girl presents to A&E with irritability, abdominal pain and reduced urine output. Her parents says she has had diarrhoea for the last few days.

A: Acute Tubular Necrosis
B: Rhabdomyolysis
C: Glomerulonephritis
D: Haemolytic Uraemic Syndrome
E: Haemorrhage
F: Renal Stones
G: Sepsis
H: Vasculitis
I: Dehydration
J:Thrombotic Thrombocytopaenic Purpura

Answer 135

D: Haemolytic Uraemic Syndrome

Question 136

A young woman presents with a raised urea and creatinine after a seizure. She is noted to have a fever and icterus and petechiae on her legs. Her urine output is low.

A: Acute Tubular Necrosis
B: Rhabdomyolysis
C: Glomerulonephritis
D: Haemolytic Uraemic Syndrome
E: Haemorrhage
F: Renal Stones
G: Sepsis
H: Vasculitis
I: Dehydration
J:Thrombotic Thrombocytopaenic Purpura

Answer 136

J: Thrombotic Thrombocytopaenic Purpura

Question 137

A 84 year old woman is found on the floor of her flat by her neighbour. She had a fall 3 days prior to her ‘rescue’ and had been unable to get up or raise the alarm. At hospital, she is assessed and found to have acute kidney injury

A: Acute Tubular Necrosis
B: Rhabdomyolysis
C: Glomerulonephritis
D: Haemolytic Uraemic Syndrome
E: Haemorrhage
F: Renal Stones
G: Sepsis
H: Vasculitis
I: Dehydration
J:Thrombotic Thrombocytopaenic Purpura

Answer 137

B: Rhabdomyolysis

Question 138

A 72 year old gentleman is admitted to the ward following a five day history of diarrhoea and vomiting. The patient has become more confused and has a low urine output. These symptoms improve with administration of fluids.

A: Acute Tubular Necrosis
B: Rhabdomyolysis
C: Glomerulonephritis
D: Haemolytic Uraemic Syndrome
E: Haemorrhage
F: Renal Stones
G: Sepsis
H: Vasculitis
I: Dehydration
J:Thrombotic Thrombocytopaenic Purpura

Answer 138

I: Dehydration

Question 139

A 5-year-old boy presents with a short history of facial oedema that has now progressed to total body swelling involving the face, abdomen, scrotum, and feet. A urine dip shows protein +++. What is the most likely diagnosis?

a. Minimal Change Disease
b. IgA Nephropathy
c. Post Streptoccocal
d. Membranoproliferative Glomerulonephritis
e. Focal Segmental Glomerulosclerosis

Answer 139

a. Minimal Change Disease

Question 140

A 25 year old lady comes to A&E extremely worried as she has noticed blood in her urine. She tells you that she has had a bit of a cold for the last two days. What is the most likely diagnosis?

a. Minimal Change Disease
b. IgA Nephropathy
c. Post Streptoccocal
d. Membranoproliferative Glomerulonephritis
e. Focal Segmental Glomerulosclerosis

Answer 140

b. IgA Nephropathy

Question 141

An 8 year old girl attends the A&E with a rash on her buttocks, around her elbows and on her legs. This was preceded by sudden onset abdominal pain. A urine dip reveals haematuria. Which antibody is likely to be responsible for her condition?

a. Anti-GBM
b. IgG
c. IgA
d. P-ANCA
e. C-ANCA

Answer 141

b. IgA

IgA Nephropathy- HSP (IgA mediated) – in kids, triad of abdo pain, petechial rash, nephritic syndrome

Question 142

22 year old man has noticed smaller volume of darker urine. Not felt quite right since a painful sore throat about a month ago.
BP 145/90 Urea 8.8, creatinine 116, albumin 45g/l. Urine dip protein 1+, blood 2+ There is a low C3 noted.

What is the most likely diagnosis?

a. IgA Nephropathy
b. Post Streptoccocal
c. Bladder Carcinoma
d. Focal Segmental Glomerulosclerosis
e. UTI

Answer 142

b. Post Streptoccocal

Question 143

A 45 year old man has presented to the GP with dark urine. He has been becoming progressively more tired over the last few weeks. On direct questioning, he reveals he has coughed up blood a few times. What is the most likely diagnosis?

a. Minimal Change Disease
b. Focal Segmental Glomerulosclerosis
c. Membranous Disease
d. Goodpasture’s Syndrome
e. IgA Nephropathy

Answer 143

d. Goodpasture’s Syndrome

Question 144

A 27 year old man has had regular nosebleeds for the past 3 months. He has also noticed some blood in the urine. BP 140/90, Urea 11mmol/l, Creatinine 166, albumin 37. Urine dip blood 3+. C-ANCA +veWhat is the most likely diagnosis?

a. Goodpasture’s syndrome
b. Microscopic polyangitis
c. Focal Segmental Glomerulosclerosis
d. Granulomatosis with polyangitis
e. Nephritic Syndrome

Answer 144

d. Granulomatosis with polyangitis

Question 145

A 27 year old man has had regular nosebleeds for the past 3 months. He has also noticed some blood in the urine.
BP 140/90, Urea 11mmol/l, Creatinine 166, albumin 37. Urine dip blood 3+. C-ANCA +ve
What other feature would support the diagnosis?

a. Loss of podocytes
b. No changes
c. Crescents on light microscopy
d. Raised ASOT
e. Diffuse immune complex deposition

Answer 145

c. Crescents on light microscopy

Question 146

Andromeda, a 32 year old female presents with recurrent headaches. They are severe, on the right side of her head and often continue for the rest of the day. Before the headaches start she gets tingling in her arms, and when the headaches start she goes to bed. She is worried they might affect her relationship with her new boyfriend.

a. Cluster headache
b. Intracranial space-occupying lesion
c. Medication overuse
d. Migraine
e. Tension headache

Answer 146

d. Migraine

Question 147

Homer, a 45 year old male has had excruciating headaches for the last month. He gets them about 5 times a week and notices his eyes watering. He had a similar episode 6 months ago. They are very disruptive to his poetry

a. Cluster headache
b. Intracranial space-occupying lesion
c. Medication overuse
d. Migraine
e. Tension headache

Answer 147

a. Cluster headache

Question 148

Atalanta, a 27 year old female athlete presents to the GP with early morning nausea and headaches which has been happening for at least a week. Both are worst when she wakes up and improve throughout the day. She notes that she has been getting tired over the last few weeks, she is late on her period, and is definitely more irritable with her boyfriend, who despite being an Olympian, keeps leaving apple cores scattered around the house.

a. Excessive excercise.
b. Migraine
c. Pituitary tumour
d. Pregnancy associated tension headache
e. Trigeminal neuralgia

Answer 148

c. Pituitary tumour

Question 149

Aphrodite, a19 year old female sex-worker presents to A&E with a sudden onset headache that is the worst pain she has ever experienced. She occasionally gets mild headaches after sex, and has been given some medication by her GP for his. She has some neck stiffness and refuses to open her eyes wide or allow them to be examined.

A. Acute glaucoma
B.Meningitis 
C.Migraine
D. Subarachnoid haemorrhage
E. Trigeminal neuralgia

Answer 149

D. Subarachnoid haemorrhage

Question 150

Leonidas, a 24 year old male, was fencing and suffered and injury to the head when his rival, Xerxes hit him on the head with his shield. Leonidas recovered quickly and was able to continue to fight for the next 20 minutes. However he quickly developed an excruciating headache, started to lose consciousness and had to stop the fight to go to the nearest A&E. He has had a blocked nose for the last week.

A. Epidural haemorrhage
B. Intraventricular haemorrhage
C. Meningitis
D. Subarachnoid haemorrhage
E. Subdural haemorrhage

Answer 150

A. Epidural haemorrhage

Question 151

Euclid is a 19 year old male currently studying Maths at university. He has been very unwell for the last few days with fever and headache and admits to becoming a little confused lately. He is very anxious about his upcoming exams. He has been taking caffeine pills to help him with revision, however this has affected his sleep and for the last couple of nights he has developed a stiff neck.

A. Medication overuse headache
B. Meningitis 
C. Migraine
E. Tension headache
D. Sinusitis

Answer 151

B. Meningitis

Question 152

Plutarch is a 77 year old male who has come in with a right sided headache. This started yesterday morning and have been getting progressively worse. His memory is a little off because of his dementia, but he says there is a possibility of trauma. His shoulders and neck also feel a little stiff. On examination, there is pain on palpation of the right forehead.

A. Intracranial space-occupying lesions
B. Meningitis 
C. Subarachnoid haemorrhage
D. Subdural haemorrhage
E. Temporal arteritis

Answer 152

E. Temporal arteritis

Question 153

Helen is a 40 year old woman with a history of multiple sclerosis. She has developed a headache over the last couple of days. She has travelled the world and rarely had headaches in the past. She has stopped eating, as chewing simply makes her feel worse.

A. Meningitis
B. Migraine 
C. Temporal arteritis
D. Tension headache
E. Trigeminal neuralgia

Answer 153

E. Trigeminal neuralgia

Question 154

70 year old Herodotus is brought in by his daughter to the GP. Over the last week he has developed a headache which lasts most of the day and rarely goes. He lives with his daughter and son-in-law as he is prone to falls due to his recent left hip replacement. The daughter also mentions that his father’s behavior has changed lately and tends to exaggerate some of his stories.
What do you think is the most important step in your management plan?

A. MRI scan
B. Routine CT scan
C. Sumitriptan + NSAIDs
D. Urgent CT scan
E. Watchful waiting

Answer 154

D. NSIADs

Question 155

Alexander, known to his mates as Alex the G, is a 32 year old soldier who has just returned from a tour in Iran. He tells you that he has been getting throbbing bilateral head pain, and puts this down to lack of sleep. As a general, he has multiple reports to write and is finding this difficult with his four friends constantly bickering about one thing or the other. He hasn’t tried any medication and asks that you prescribe some sleeping pills. What is the most appropriate management?

A. Diazepam
B, Codeine
C. NSAIDs
D. Topiramate
E. Refer to A&E

Answer 155

Refer to A&E

Question 156

Pythagoras is a 40 year old man who suffers from headaches. 3 weeks ago he was prescribed ibuprofen and has taken it religiously. Initially these worked really well, however now the headaches have returned and are worse than ever. He is very angry and does not think you are taking the right angle towards managing his issue. What is the next course of management?

a. Antibiotics
b. Add a β-blocker
c. Refer to A&E
d. Switch medication to carbamazepine
e. Ask to stop ibuprofen and see in 2 weeks

Answer 156

Ask to stop ibuprofen and see in 2 weeks

Question 157

Hippocrates is a 71 year old homeopath who presents with a left sided headache which came on yesterday morning. He tried to tread it with a clever paste made of garlic, vinegar and honey. When he applied the paste he was in great pain, and so believed that his remedy was working. However, his skeptical son told him to see “another doctor” for treatment. What is the most important next step?

a. Prescribe prednisolone and refer patient to A&E
b. Prescribe sumitriptan and NSAIDs
C. Refer to A&E for urgent CT scan
E. Refer to A&E for urgent non-contrast CT scan
D. Refer to A&E for MRI

Answer 157

a. Prescribe prednisolone and refer patient to A&E

Question 158

A 28 year old Norwegian woman presents to A&E after she was unable to fell the hot water on her left leg whilst taking a bath. CSF analysis demonstrated oligoclonal bands that were unmatched with the serum. Which of the following would most likely confirm a diagnosis of Multiple Sclerosis?

A. Multiple lesions on MRI that all enhanced with gadolinium
B. The patient’s symptoms reoccur 1 year later
C. The patient develops blurry vision in one eye a year later
D. The patient reports blurry vision currently
E. A 1 year follow up finds oligoclonal bands matched with the serum

Answer 158

C. The patient develops blurry vision in one eye a year later

Question 159

A 40 year old woman visits her GP complaining of tiredness. On questioning, she reports getting tired when climbing the stairs or during a conversation. She often has to stop what she is doing to regain her energy. The GP asks her to look upwards, and after a few seconds she begins to develop ptosis. What is the most likely diagnosis?

A. Iron Deficiency Anaemia
B. Myasthenia Gravis
C. Lambert Eaton Myasthenic  Syndrome
D. Carcinoma 
E. Horner’s Syndrome

Answer 159

B. Myasthenia Gravis

Question 160

A 50 year old man visits his GP complaining of weakness in his right arm. He reports the weakness has gradually developed over the last 2 months. On inspection, the GP notices wasting of his tongue and hyperreflexia. His right arm is rigid. What is the most likely diagnosis?

A. Stroke
B. Multiple Sclerosis  
C. Parkinson’s disease
D. Motor Neuron Disease
E. Carpel Tunnel Syndrome

Answer 160

Motor Neuron Disease

Question 161

A 70 year man is referred to a neurologist by his GP. The referral letter notes that the man has slowly been struggling to get around and carry out basic activities like cooking dinner, finding he struggles to initiate movement. The letter also notes that the patient has a resting tremor and rigid upper arms. When the neurologist calls the patient into the room, what gait does he expect the patient to most likely have?

A. Ataxic 
B. Hemiplegic
C. Shuffling 
D. Scissor 
E. Choreiform

Answer 161

C. Shuffling

Question 162

A 55 year old gentleman is accompanied to the GP by his daughter. She is distressed that ‘something’s happened to Dad, he’s changed …’. It transpires that he has started swearing at people in the street and flirting with all the women he meets. He is able to chat to you about current events and his favourite sport team’s latest match. What is the most likely diagnosis?

A. Pick’s disease
B. Lewy body dementia
C. Vascular dementia
D. Alzheimer’s dementia
E. Wernicke-Korsakoff syndrome

Answer 162

A. Pick’s disease

Question 163

You are called to see a 40 year old man in A&E. You try to take a history but the man in confused and unable to tell you much. On examination he has numerous spider naevi on his chest, an ataxic gait and nystagmus. What is the most likely diagnosis?

A. Multiple Sclerosis
B. Motor Neuron Disease
C. Korsakoff’s syndrome
D. Wernicke’s Encephalopathy 
E. Head trauma

Answer 163

D. Wernicke’s Encephalopathy

Question 164

A 40 year old man starts to make random jerky movements at points throughout the day. Worried about this, he visits his GP. Upon questioning, he informs the GP that his father died in his 40s, but he was too young to remember why, although he did have similar symptoms. What test should be arranged?

A. FBC
B. Karyotyping 
C. Whole genome sequencing 
D. CAG repeat testing
E. MRI head

Answer 164

D. CAG repeat testing

Question 165

69 old Keith has been taken in an ambulance after getting stamped on the back in a rugby match. He spent several minutes on the floor with several electrical shock like shooting pains down his back, and he also wet himself. He recalls having had a seizure in the past but cant remember the details of it, since this episode he’s also noticed increased sensation in his left thigh despite finding it more difficult to move that leg. What is the most likely diagnosis?

A:Tonic Clonic Seizure
B:Clonic Seizure
C:Cord Compression
D:Absence Seizure
E: Guillaine Barre

Answer 165

C:Cord Compression

Question 166

70 year old Donald comes to your GP clinic, he tells you his wife's found him blankly staring into space a few times in the past year. He’s struggling with his obesity, and his cholesterol readings are through the roof, in the last three months he's started becoming quite confused, and just this morning he was found unable to wake from bed as he lost control of his left side. What is the most likely diagnosis?
A: Stroke
B: Hydrocephalus
C: Guillain Barre Syndrome
D: Alzheimer’s
E: Moya Moya

Answer 166

A: Stroke

Question 167

A 26 year old man was admitted for severe food poisoning and put on antibiotics, a week later in his hospital bed he’s started to notice pins and needles all across his lower limb and he’s been feeling weak in that region also. What’s the most likely diagnosis?

A: Guillain Barre Syndrome
B: Meningism
C: Anti Biotic Abcess
D: E: B-12 Deficiency
E: Stokes-Adams attack

Answer 167

A: Guillain Barre Syndrome

Question 168

A 16 year old girl fell unconscious at school whilst walking to her class, and subsequently shrugged off the episode as nothing more than tiredness. She is known to be bulimic, there were no further clinical signs from her history or her examination. What is the most likely diagnosis?

A: Epileptic seizure
B: Mechanical collapse
C: Vasovagal Syncope
D: Bulimic crisis
E: Tumour

Answer 168

C: Vasovagal Syncope

Question 169

A young woman presents after a seizure. She is noted to have a fever and icterus. Her urine output is low.

A) Haemolytic Uraemic Syndrome
B) Renal stone 
C) Thrombotic Thrombocytopenic Purpura  
D) Hepatic failure 
E) Polycystic kidney disease

Answer 169

C) Thrombotic Thrombocytopenic Purpura

Question 170

What is the most likely cause?
A 53 year old man suffers a ruptured aortic aneurysm and is rushed into theatre. He undergoes a successful operation and is recovering on the wards. 1 day after the operation he becomes oliguric with elevated urea and creatinine. After 1 week his urine output increases but his GFR remains low at 30ml/min.

A. rhabdomyolysis
B. HUS
C. nephrotoxic agent
D. thrombotic thrombocytopenic purpura
E. Acute tubular necrosis

Answer 170

E. Acute tubular necrosis

Question 171

A 17 year old student presents to A&E with a 6 day history of sore throat and flu-like symptoms. He know has frank haematuria, swelling of his ankles and poor urine output

A. IgA nephropathy
B. HUS
C. post-streptococcal 
D. TTP
E. Henoch Schonlein Purpura (HSP)

Answer 171

A. IgA nephropathy

Question 172

A 84 year old woman is found on the floor of her flat by her neighbour. She had a fall 3 days prior to her ‘rescue’ and had been unable to get up or raise the alarm. At hospital, she is assessed and found to have acute kidney injury. 
A. rhabdomyolysis
B. myeloma
C. nephrotoxic agent
D. PCKD
E. Acute tubular necrosis

Answer 172

A. rhabdomyolysis

Question 173

A 79 year old man presents to A&E after his GP has found deranged U&Es and raised creatinine on routine blood work. He has a history of back pain over the last few months and says that he has been very tired recently.

a. nephrotoxic agent
b. DM
c. post-strep glomerulonephritis
d. rhabdomyolysis
e. myeloma

Answer 173

e. myeloma

Question 174

A 10 year old girl presents to A&E with irritability, abdominal pain and reduced urine output.  Her parents says she has had diarrhoea for the last few days
A. IgA nephropathy
B. HUS
C. post-streptococcal 
D. TTP
E. Henoch Schonlein Purpura (HSP)

Answer 174

B. HUS

Question 175

A 75M with known severely impaired renal function presents with palpitations and vomiting. What is the likely cause of his symptoms?

A) Hypercalcemia 
B) Hyponatraemia 
C) Hyperkalemia 
D) Atrial Fibrillation 
E) Hyperparathyroidism

Answer 175

C) Hyperkalemia

Question 176

A 70M with known severely impaired renal function presents in a confused state. On listening to his chest the medical student hears a strange rubbing sound. What is the underlying cause of this finding?

A) Hypercalcemia 
B) Hyponatraemia 
C) Hyperkalemia 
D) Atrial Fibrillation 
E) Hyperuraemia

Answer 176

E) Hyperuraemia

Question 177

The same gentleman becomes short of breath and the X-ray reveals bats wing shadowing. What treatment does he need?

A) Sit up and high flow oxygen 
B) Venous vasodilator ( eg diamorphine) 
C) Furosemide IV 
D) Dialysis 
E) All of the above

Answer 177

E) All of the above

Question 178

An 86 year old smoker presents with a 3 day history of noticing blood in his urine. He was recently booked an outpatients appointment for symptoms of frequency and hesitancy but failed to attend. On questioning, he mentions some weight loss and lower back pain he has had for a few months.

a. Bladder cancer
b. Renal-cell carcinoma
c. Prostate Cancer
d. Ureteric Calculus
e. Polycystic Kidney Disease

Answer 178

c. Prostate Cancer

Question 179

Which of these is not a cause of bronchiectasis?

a. Kartagener’s syndrome
b. Cystic fibrosis
c. Pneumonia
d. Left ventricular failure
e. Bronchogenic carcinoma

Answer 179

d. Left ventricular failure

Question 180

A 28 y/o patient with cystic fibrosis is admitted with a severe lung infection. Which is the most likely causative organism

Answer 180

P. aeruginosa

Question 181

The following are sweat chloride concentrations measured in a 5 y/o child with recurrent chest infections. Which of these indicates a positive diagnosis for cystic fibrosis?

Answer 181

> 60 mmol/L

Question 182

A 45 y/o woman with unexpected weight loss, loss of appetite and SOB presents to you in clinic. On examination, there is reduced air entry and dullness to percussion in the right lung. A pleural tap is performed and the aspirate samples sent for analysis. You are told that the results reveal a protein content of >30g/L. Most likely diagnosis?

A. Bronchogenic carcinoma
B. Congestive cardiac failure
C. Liver cirrhosis
D. Nephrotic syndrome
E. Meig’s syndrome

Answer 182

A. Bronchogenic carcinoma

Question 183

A 55 y/o woman, who has never smoked, presents to you on the ward with a history of weight loss, decreased appetite and finger clubbing. You are told that her chest X-ray revealed opacity in the hilar region of the right lung suggesting a bronchogenic carcinoma. She is currently awaiting a CT-chest with bronchoscopy to follow. Most likely diagnosis?

A. Squamous cell carcinoma
B. Adenocarcinoma
C. Small cell carcinoma
D. Large cell carcinoma
E. Carcinoid tumour

Answer 183

B. Adenocarcinoma

Question 184

A 63 y/o male ex-smoker is admitted onto you ward and is hyponatraemic. He has a blood pressure of 110/78 and seems well hydrated. His wife says he used to work in a shipyard 30 years ago.

Hyperthyroidism
Pneumonia
Infective exacerbation of COPD
Mesothelioma
Small cell carcinoma

Answer 184

Small cell carcinoma

Question 185

A 21 year-old male attends A&E with increasing SOB despite use of a salbutamol inhaler. O2 sats are 91%, afebrile, BP 101/67. ABG is shown below. Grade the severity of this asthma attack.

pH: 7.25
pCO2: 7.4 kPa (4.5-6.0)
pO2: 10.4 kPa (>10.5)
HCO3: 23 mmol/l

Undeterminable 
Moderate
Acute severe
Life-threatening
Near-fatal

Answer 185

Near-fatal

Question 186

A 72 year-old male attends A&E with increasing SOB. PMHx includes COPD and benign prostate hyperplasia. O2 sats are 82%, BP 134/92, Temp 38.4•C,  ABG is shown below. What is the next most appropriate step in the management of this patient?
pH: 7.29
pCO2: 7.2 kPa  (4.5-6.0)
pO2: 7.4 kPa (>10.5)
HCO3: 23 mmol/l 

a. Nebulised salbutamol
b. 15L of oxygen through non-rebreathe mask
c. Nebulised ipratropium bromide
d. IV co-amoxiclav
e. Blue venturi mask 2-3L of oxygen

Answer 186

e. Blue venturi mask 2-3L of oxygen

Question 187

A 67-year-old man has been urinating around 12-14 times per day over the past 6 months. His stream is ‘weak’ and often takes a long time to get going. After he has finished urinating, he does not feel fully empty and often dribbles a little bit. DRE reveals a smoothly enlarged prostate gland with a palpable midline sulcus. A diagnosis of benign prostatic hyperplasia is made. He is eager to avoid surgery if possible. Which treatment would be best for him? 
A Oxybutynin
B Solifenacin
C Tamsulosin
D Nitrofurantoin 
E Co-trimoxazole

Answer 187

C Tamsulosin

Question 188

A 75-year-old owner of a dye factory has experienced 4 episodes of ‘bright red’ blood in his urine over the past 2 weeks. He does not feel any pain when urinating. He has also noticed that he has lost some weight recently despite not changing his eating habits or exercise levels. What is the most likely diagnosis? 
A Pyelonephritis
B Glomerulonephritis
C Bladder Cancer
D Prostate Cancer 
E Ureteric Stone

Answer 188

C Bladder Cancer

Question 189

An 80-year-old man has had considerable difficulty urinating. He goes about 10-12 times per day, including at night, and has described his stream as being very poor. He has also experienced lower back pain over the last 6 weeks. On digital rectal examination, an asymmetrically enlarged, nodular prostate gland is palpated. Which investigation is most likely to provide a definitive diagnosis?

A PSA 
B Acid phosphatase 
C CT Scan
D Transrectal ultrasound guided biopsy  
E Isotope bone scan

Answer 189

D Transrectal ultrasound guided biopsy

Question 190

A 43-year-old woman presents to her GP having wet herself several times since the birth of her third child, 4 months ago. Whenever she laughs or coughs, a little bit of urine leaks out without her control. Which type of incontinence does she have?

A Functional incontinence 
B Stress incontinence 
C Urge incontinence 
D Overflow incontinence 
E Double incontinence

Answer 190

B Stress incontinence

Question 191

A 65-year-old woman has wet herself several times over the past 3 months. She says that she will be going about her usual daily activities and will suddenly become overwhelmed by the feeling of needing to urinate. Before she can even think about finding a toilet, she has wet herself. Which type of incontinence is this?

A Functional incontinence 
B Stress incontinence 
C Urge incontinence 
D Overflow incontinence 
E Double incontinence

Answer 191

C Urge incontinence

Question 192

Which type of urinary tract stone is most common?

A  Magnesium ammonium phosphate
B  Calcium oxalate 
C  Cysteine
D  Urate 
E  Hydroxyapatite

Answer 192

B Calcium oxalate

Question 193

A 13-year-old boy is brought to A&E with sudden-onset pain and swelling in his scrotum, which began an hour ago whilst playing a football match. After arriving at hospital, he begins to vomit. On examination, his right hemiscrotum is red and swollen. What is the most appropriate first step in his management? 
A Doppler ultrasound of the testes 
B CT Scan 
C Exploratory surgery 
D Empirical antibiotics 
E Abdominal X-ray

Answer 193

C Exploratory surgery

Question 194

A 50-year-old man has developed a swollen scrotum that has been bothering him for the past 2 weeks. The swelling is uncomfortable but not painful. On examination, the left hemiscrotum is enlarged, fluctuant and non-tender. It is possible to get above the swelling, however, the left testicle cannot be distinguished from the swelling. When a pen torch is shone on the swelling, it illuminates brightly. What is the most likely diagnosis?

A Varicocoele 
B Hydrocoele 
C Testicular tumour 
D Epididymal cyst 
E Indirect inguinal hernia

Answer 194

B Hydrocoele

Question 195

A 30-year-old man has developed a swollen scrotum that he first noticed a week ago. He adds that the swelling feels like a ‘bag of worms’, and is uncomfortable but not painful. On examination, the patient’s scrotum looks normal when lying down, however, the left hemiscrotum becomes swollen when he stands up. The GP can get above the swelling and distinguish it from the testicle. What is the most likely diagnosis?

A Indirect inguinal hernia 
B Direct inguinal hernia 
C Hydrocoele 
D Varicocoele 
E Epididymal cyst

Answer 195

D Varicocoele

Question 196

A 21-year-old man visits his GP complaining that his scrotum feels ‘heavier than usual’. On examination, a firm, non-tender lump can be palpated at the base of the right testicle. The patient had an undescended testicle as a child, which was corrected with orchidopexy. Testicular cancer is suspected and a CT scan is requested to assess for spread. Which group of lymph nodes does testicular cancer spread to?

A Inguina
B Femoral
C Para-aortic 
D Iliac
E Mesenteric

Answer 196

C Para-aortic

Question 197

A 32-year-old man presents with a 2-week history of frequent urination and excessive thirst. He has also noticed that he feels much weaker than usual, and is struggling to complete his usual gym routine. He has been to see his GP once before because his blood pressure was high on multiple occasions, however, he did not return to receive treatment. His blood pressure is measured again and it is 184/94 mm Hg. What would you expect to see on the ECG of this patient?

A Tented T waves 
B Absent P waves 
C ST elevation 
D J waves 
E U waves

Answer 197

E U waves

Question 198

A gentleman presents with acute breathlessness and chest pain. O/E his respiratory rate is 25bpm with good air entry in all fields. His ECG shows right axis deviation. What is the most likely diagnosis?

Pneumothorax
Pneumonia
COPD
Pulmonary Embolism
Sarcoidosis

Answer 198

Pulmonary Embolism

Question 199

A 35 year old lady presents with acute onset SOB, chest pain and one episode of haemoptysis. She has recently noticed a swelling in the left leg. O/E her RR is 28 and HR is 105. You suspect a pulmonary embolism. What is the FIRST investigation you perform?

Chest X-Ray
CTPA
D-Dimer
ECG
Peak flow

Answer 199

D-Dimer

Question 200

A 23 year old student presents to A&E with SOB. He says it came on suddenly. O/E his trachea is central with reduced breath sounds on the left. A chest x-ray confirms a 1cm pneumothorax. What is the most appropriate management?

Immediate chest decompression
Intercostal drain
Aspiration
High flow oxygen
Low molecular weight heparin

Answer 200

High flow oxygen

Question 201

What signs would you expect on physical examination of someone with pneumonia?

Deviated Trachea, ↓ expansion, Dull to percussion
Bronchial Breathing, ↓ expansion, ↓ vocal resonance
Central Trachea, ↓ expansion, ↑ vocal resonance
Dull to Percussion, ↑ expansion, Pyrexia
Tachycardia, ↑ expansion, Cyanosis

Answer 201

Central Trachea, ↓ expansion, ↑ vocal resonance

Question 202

A 55 year old man has a 3 day history of shivering, general malaise & productive cough and is vomiting. The x-ray shows right lower lobe consolidation. He is diagnosed with a moderate pneumonia, what is the first line therapy?

Oral Amoxicillin
IV Co-Amoxiclav + Clarithromycin
Doxycycline
IV Amoxicillin + Clarithromycin
Vancomycin

Answer 202

IV Amoxicillin + Clarithromycin

Question 203

A 71 year old Gentleman is brought in by his carer with a 4 day history of a fever and a cough. As you go to examine him he shouts and asks that you leave his bedroom. His RR is 30, BP 103/68. The lab phones you a hour later and let’s you know his urea is 7.8. Where would you manage this patient?

Admit and treat

Treat at home

Consider ITU

Refer for palliative care

Refer to primary care

Answer 203

Consider ITU

Question 204

25M presents to A&E with a fever and a cough. He says he has been generally unwell over the last year . O/E he is acutely SOB with a RR of 28. You also note an incidental finding of purple patches on his nose. What is the most likely causative organism?

Pseudomonas Aeruginos

Strep Pneumoniae

Pneumocystis Jiroveci

Mycoplasma pneumoniae

Haemophilus Influenza

Answer 204

Pneumocystis Jiroveci

Question 205

55M presents with a cough and fever. He recently travelled to New York to speak at a conference. After bloods revealed Na+: 130, you decide to test the urine. What is the most likely causative organism?

Haemophilus Influenza

Pseudomonas Aeruginosa

Legionella Pneumophilia

Pneumocystis Jiroveci

Rhinovirus

Answer 205

Legionella Pneumophilia

Question 206

10F presents to A&E with a fever and a cough and O2 sats: 92%. Her parents don’t seem worried as they are used to bringing her into hospital for treatment for her respiratory

Pseudomonas Aeruginosa

Haemophilus Influenzae

Staph Aureus

Coronavirus

Legionella Pneumophilia

Answer 206

Pseudomonas Aeruginosa

Question 207

A known IVDU is brought into A&E, he was found unconscious by two friends who were worried he might have overdosed. You notice an abscess in his groin. Temp: 39, HR 120, BP 90/50. You immediately admit him.

Haemophilus Influenzae

Staph Aureus

Coronavirus

Legionella Pneumophilia

Pseudomonas Aeruginosa

Answer 207

Staph Aureus