EFAs

Question 1

1. A 73 year old woman reports increasing fatigue. She has noticed intermittent double vision, usually in the evening. She is a smoker. Her only regular medication is levothyroxine sodium. There is bilateral mild ptosis. Visual acuity and fundoscopy are normal. The rest of the neurological examination is normal.
   Which is the most likely diagnosis?
   Guillain–Barré syndrome
   Migraine
   Multiple sclerosis
   Myasthenia gravis
   Stroke

Answer 1

Myasthenia gravis

Question 2

2. A 67 year old man has 3 weeks of confusion and disorientation. He also has headaches that are worse in the morning and associated with vomiting. He had a non-small cell lung cancer that was treated with radical radiotherapy 2 years ago. His BP is 162/93 mmHg. He has no focal neurological signs.
   Which is the most likely diagnosis?
   Cerebral metastases
   Hypercalcaemia
   Hyponatraemia
   Paraneoplastic encephalitis
   Severe hypertension

Answer 2

Cerebral metastases

Question 3

3. A 32 year old man has recurrent right-sided throbbing headache lasting up to 8 hours associated with nausea. The headache is usually preceded by a small area of visual loss that resolves. These headaches cause him to take time off work up to four times each month.
   Which is the most appropriate treatment to reduce the frequency of these episodes?
   Acupuncture
   Gabapentin
   Propranolol hydrochloride
   Sumatriptan
   Venlafaxine

Answer 3

Propranolol hydrochloride

Question 4

4. A 40 year old woman has 12 hours of a severe headache of sudden onset. When the headache started, she collapsed and vomited; she has continued to vomit intermittently. She has a past history of infrequent migraine headaches.
   Neurological examination is normal. A non-contrast CT scan of brain is normal.
   What is the most appropriate next step in management?
   Carotid Doppler studies
   Lumbar puncture
   MR scan of brain
   MR imaging of brain with MR venography
   No future investigations required

Answer 4

Lumbar puncture

Question 5

5. A 46 year old woman attends the Emergency Department with fever, headache and confusion, which have developed over several hours. She finds it impossible to lift her head from the pillow and resists your attempts to feel her neck.
   Her temperature is 38.1°C, pulse rate 105 bpm and BP 110/60 mmHg. Her GCS score is 14. A CT scan of her head is normal. A lumbar puncture is performed.
   Which are the most likely observations in the cerebrospinal fluid?
   High pressure, normal protein, excess red cells
   High pressure, raised protein, excess neutrophils
   Normal pressure, normal protein, excess lymphocytes
   Normal pressure, raised protein, excess neutrophils
   Normal pressure, normal protein, no cells

Answer 5

High pressure, raised protein, excess neutrophils

Question 6

6. A 17 year old boy has repeated episodes characterised by a funny ‘racing’ sensation in his abdomen, followed by loss of awareness. His girlfriend describes that he has a vacant stare and waves his left arm around in a writhing manner during these attacks.
   Which is the most likely site of origin of these episodes?
   Cerebellum
   Right frontal lobe
   Right occipital lobe
   Right parietal lobe
   Right temporal lobe

Answer 6

Right temporal lobe

Question 7

7. A 18 year old woman has 6 hours of severe dizziness and nausea. She says that the room is constantly spinning round and she has vomited several times. The dizziness is worse when she opens her eyes. She reports that her hearing has not changed.
   She has nystagmus with the fast phase to the left, which does not fatigue.
   Which is the most likely diagnosis?
   Benign positional vertigo
   Cerebellar tumour
   Ménière’s disease
   Vestibular migraine
   Vestibular neuronitis

Answer 7

Vestibular neuronitis

Question 8

8. A 56 year old woman develops vertigo, nausea, vomiting and intense occipital headache of sudden onset. She is unable to walk without falling. She has a history of hypertension treated with ramipril.
   Her temperature is 37.4°C, pulse rate 94 bpm, BP 146/92 mmHg, respiratory rate 12 breaths per minute and oxygen saturation 96% breathing air. She has multidirectional nystagmus and some clumsiness of her right arm.
   Which is the most likely diagnosis?
   Acute labyrinthitis
   Benign paroxysmal positional vertigo
   Cerebellar stroke
   Ménière’s disease
   Multiple sclerosis

Answer 8

Cerebellar stroke

Question 9

9. A 70 year old man has a brief episode of twitching that starts in his left hand and spreads up the arm over 2 minutes, then stops. His arm feels weak for an hour afterwards. He had an ischaemic stroke affecting his left side 6 months ago with good functional recovery. He has a history of type 2 diabetes mellitus and is taking clopidogrel, metformin, ramipril and simvastatin. He is anxious about a further stroke. There is no weakness on neurological examination. Which is the most likely diagnosis?

Functional episode
Hypoglycaemia
Migraine
Partial seizure
Right hemisphere transient ischaemic attack

Answer 9

Partial seizure

Question 10

A 30 year old woman has severe headache 24 hours after a spinal anaesthetic. Her temperature is 37.1°C, pulse rate 90 bpm and BP 120/80 mmHg. Which is the most likely diagnosis?
Low pressure headache
Meningitis
Migraine
Subarachnoid haemorrhage
Subdural haemorrhage

Answer 10

Low pressure headache

Question 11

A 46 year old man has 2 days of sharp central chest pain that radiates into his back and is worse on inspiration. His temperature is 37.8°C, pulse rate 102 bpm, BP 100/72 mmHg, respiratory rate 18 breaths per minute and oxygen saturation 94% breathing air. Heart sounds are normal. Brachial pulses in both arms are synchronous.
Investigations:
D dimers 0.6 mg/L (<0.5)
Troponin T 0.5 µg/L (<0.01)
CRP 33 mg/L (<5)
ECG: see image

Which is the most likely diagnosis?
Acute coronary syndrome
Aortic dissection
Musculoskeletal chest pain
Pericarditis
Pneumonia

Answer 11

Pericarditis

Question 12

12. A 75 year old man becomes unresponsive in the cardiac catheter laboratory. He was admitted with an acute anterior myocardial infarction. He is unconscious. Cardiac monitoring shows a broad complete tachycardia.

Which is the most appropriate immediate treatment?
Adenosine
Amiodarone
DC cardioversion
Lidocaine
Primary coronary intervention

Answer 12

DC cardioversion

Question 13

13. A 32 year old man presents to the Emergency Department with 60 minutes of palpitations that started after a three mile run. They is associated with breathlessness and dizziness.
    Investigations:
    ECG (see image)
    Which best describes the ECG finding?

Atrial fibrillation
First degree heart block
Sinus tachycardia
Supraventricular tachycardia
Ventricular tachycardia

Answer 13

Supraventricular tachycardia

Question 14

14. A 27 year old man has severe central chest pain. He admits to using cocaine shortly before the onset of the chest pain, but says that he had used it on only two previous occasions.
    He is distressed and sweating. His pulse rate is 115 bpm and BP 118/68 mmHg. An ECG shows sinus tachycardia with ST elevation in the lateral leads, and several ventricular ectopics.
    Which is the mechanism by which cocaine has caused this acute episode?
    Blockade of myocyte repolarisation
    Coronary artery spasm
    Enhanced platelet aggregation
    Increased systemic vascular resistance
    Rupture of pre-existing arterial plaques

Answer 14

Coronary artery spasm

Question 15

15. A 27 year old man is brought to the Emergency Department with left-sided chest pain of sudden onset that is worse on taking a deep breath.
    His temperature is 36.8°C, pulse rate 126 bpm, BP 108/60 mmHg, respiratory rate 28 breaths per minute and oxygen saturation 94% breathing air.
    Investigations:
    ECG: sinus tachycardia
    Which is the most appropriate next investigation?
    Chest X-ray
    CT pulmonary angiography
    D dimers
    Echocardiography
    Ventilation/perfusion isotope lung scan

Answer 15

Chest X-ray

Question 16

16. A 65 year old woman had a mechanical aortic valve replacement and coronary revascularisation 3 days ago. She is being treated with dalteparin sodium. She is also taking aspirin long term.
    Which is the most appropriate long-term patient management?
    Apixaban
    Clopidogrel
    Continue dalteparin sodium
    Rivaroxaban
    Warfarin sodium

Answer 16

Warfarin sodium

Question 17

17. A 73 year old man collapses on the surgical ward 24 hours after having a sigmoid volvulus reduced by sigmoidoscopy.
    He has no pulse and an ECG shows asystole. Chest compressions and ventilation are started. The cardiac arrest team are with the patient.
    Which is the most appropriate next step in management?
    Cardiac defibrillation
    Intravenous 0.9% sodium chloride
    Intravenous adrenaline/epinephrine
    Intravenous atropine sulfate
    Transcutaneous pacing

Answer 17

Intravenous adrenaline/epinephrine

Question 18

18. A 39 year old man has had fever, chills and generalised weakness for 1 month. He has a history of systolic heart murmur. He is an intravenous drug user.
    Investigations:
    White cell count 15 × 109/L (3.0–10.0)
    Erythrocyte sedimentation rate 55 mm/hr (<20)
    Blood cultures are awaited.
    Which further investigation will help to establish the diagnosis?
    Chest X-ray
    ECG
    Nasal swabs
    Transoesophageal echocardiogram
    Urine dipstick analysis

Answer 18

Transoesophageal echocardiogram

Question 19

19. A 79 year old man attends the Emergency Department with 2 hours of chest pain and lightheadedness.
    His ECG is shown (see image).

Which is the most likely explanation for the ECG findings?
Aortic dissection
Hyperkalaemia
Myocardial infarction
Pericarditis
Pulmonary embolism

Answer 19

Myocardial infarction

Question 20

20. A 65 year old woman had a stroke 2 weeks ago causing right arm weakness and dysphasia. CT scan of head showed a left parietal lobe infarct. Her medication since the stroke includes aspirin and simvastatin.
    Her pulse rate is 82 bpm and irregular.
    Investigations:
    ECG: atrial fibrillation, rate 68 bpm.
    Which is the most appropriate long-term plan for secondary stroke prevention?
    Apixaban
    Aspirin
    Aspirin and dipyridamole
    Clopidogrel
    Ticagrelor

Answer 20

Apixaban

Question 21

1. A 92 year old woman has severe neck, chest and back pain and tingling in her left hand following a mechanical fall. She has bruising around her right eye.

Investigations:
CT scan of head no intracranial injury or bleed, mild small vessel disease; right orbital fracture

Chest X-ray lung fields clear; left sided 4th rib fracture

Full blood count and clotting screen are normal.
Which is the most appropriate next investigation?
A. Cervical spine X-ray
B. CT angiography
C. CT scan of chest
D. CT scan of neck
E. MR scan of brain

Answer 21

D. CT scan of neck

Question 22

2. A 65 year old woman has an infective exacerbation of COPD.

Her temperature is 37.8°C, pulse rate 108 bpm, BP 100/75mmHg, respiratory rate 26 breaths per minute and oxygen saturation 88% breathing 15 L/minute oxygen via a non-rebreather mask. She is alert.

Investigations:
Arterial blood gas on 15 L/min oxygen
pH 7.28 (7.35–7.45)
PO2 7.2 kPa (11–15)
PCO2 8.9 kPa (4.6–6.4)
Bicarbonate 31.3 mmol/L (22–30)
Lactate 1.2 mmol/L (1–2)
Which is the most appropriate next management option?
A. Continuous positive airway pressure
B. Invasive ventilation
C. Nasal high flow oxygen
D. Nasopharyngeal airway
E. Non-invasive ventilation

Answer 22

E. Non-invasive ventilation

Question 23

3. A 50 year old woman has acute onset of shortness of breath. She underwent a laparoscopic cholecystectomy 10 days ago.

Her temperature is 37.4°C, pulse rate 104 bpm, BP 122/80 mmHg, respiratory rate 24 breaths per minute and oxygen saturation 94% breathing air. Her chest is clear. She has minimal tenderness over the right hypochondrium.
Which is the most likely diagnosis?
A. Myocardial infarction
B. Pancreatitis
C. Pneumonia
D. Pulmonary embolus
E. Subphrenic abscess

Answer 23

D. Pulmonary embolus

Question 24

4. A 16 year old girl presents to the Emergency Department after an episode of loss of consciousness following a fall. She had consumed an excessive amount of alcohol at a party before the fall.

She has a dirty scalp wound and cannot remember recent events. Her pulse rate is 68 bpm, BP 110/80 mmHg and oxygen saturation 98% breathing air. She opens her eyes to command and is confused. Her capillary blood glucose is 6.0 mmol/L.

Her wound is cleaned and sutured.
Which is the most appropriate immediate management plan?
A. Admit and observe for 24 h
B. CT scan of head
C. Discharge with head injury instructions
D. Refer to neurosurgeon
E. X-ray of skull

Answer 24

B. CT scan of head

Question 25

5. A 63 year old man with COPD has had an increase in cough for 2 days. He now has pain of sudden onset in the right side of his chest radiating to the right shoulder, and increasing breathlessness.

Chest X-ray: see image.

Which is the most likely cause of his acute deterioration?
A. Acute myocardial infarction
B. Diaphragmatic hernia
C. Lobar pneumonia
D. Pneumothorax
E. Pulmonary embolus

Answer 25

D. Pneumothorax

Question 26

6. An 18 year old man is in the intensive care unit with septic shock as a result of a compound fracture of his leg. His urine output has been <30 mL for the past 2 hours.

His pulse rate is 125 bpm, BP 85/40 mmHg and JVP 4 cm above the sternal angle. There are basal crackles on auscultation of the chest.

Investigations:
ECG shows sinus rhythm, 125 bpm.

He is being treated with intravenous 0.9% sodium chloride at 125 mL/h and antibiotics.
Which is the most appropriate additional intravenous treatment?
A. 500 mL 0.9% sodium chloride over 15 min
B. 500 mL Hartmann’s solution over 15 min
C. Dopamine hydrochloride
D. Furosemide
E. Noradrenaline/norepinephrine

Answer 26

E. Noradrenaline/norepinephrine

Question 27

7. A 43 year old woman is admitted to hospital with an overdose of amitriptyline hydrochloride taken 4 hours previously. She has a history of chronic headache.

Her pulse rate is 105 bpm and BP 95/40 mmHg. She is drowsy and her pupils are dilated. ECG shows significant QRS prolongation.
Which is the most appropriate immediate management option?
A. Activated charcoal
B. Intravenous amiodarone hydrochloride
C. Intravenous atropine sulfate
D. Intravenous magnesium
E. Intravenous sodium bicarbonate

Answer 27

E. Intravenous sodium bicarbonate

Question 28

8. A 60 year old man has 2 days of a swollen, painful right leg. He has a history of hypertension and takes ramipril. He is otherwise well.

He has a swollen right leg. The remainder of the examination is normal.

Investigations:Haemoglobin 140 g/L (130–175)
White cell count 8.0 × 109/L (3.8–10.0)
Platelets 340 × 109/L (150–400)Creatinine 94 µmol/L (60–120)
Calcium 2.5 mmol/L (2.2–2.6)ALT 30 IU/L (10–50)
ALP 99 IU/L (25–115)APTT 30 seconds (22–41)
PT 12 seconds (10–12)
Urinalysis: normal

Chest X-ray: normal

Venous duplex ultrasound scan: thrombus in superficial femoral vein
Which is the most appropriate additional investigation?
A. CT of abdomen and pelvis
B. Serum carcinoembryonic antigen
C. Serum prostate specific antigen
D. Serum protein electrophoresis
E. Ultrasonography of abdomen

Answer 28

A. CT of abdomen and pelvis

Question 29

9. A 23 year old man is admitted to the acute surgical ward with appendicitis and is prepared for theatre. Although he has not eaten for 24 hours, he has been vomiting on and off all day.
   Which airway device provides protection for the lungs from regurgitated stomach contents?
   A. Guedel (oral) airway
   B. i-gel ® (supraglottic) airway
   C. Laryngeal mask airway
   D. Nasopharyngeal airway
   E. Tracheal tube

Answer 29

E. Tracheal tube

Question 30

10. An 80 year old woman is admitted to the Emergency Department after being found collapsed at home. She has central chest pain.

Her pulse rate is 30 bpm, BP 70/40 mmHg and respiratory rate 26 breaths per minute. Her 12-lead ECG shows sinus bradycardia with no evidence of myocardial ischaemia.
Which is the most appropriate initial treatment?
A. Adrenaline/epinephrine
B. Atropine sulfate
C. Dobutamine
D. Normal saline
E. Permanent cardiac pacemaker

Answer 30

B. Atropine sulfate

Question 31

11. A 65 year old man has sudden pain and redness in his ﾠright eye. He also has a headache and nausea.

Visual acuity isﾠ 6/60 ﾠin the right eye. The eye is congested, with a hazy cornea and mid-dilated pupil.
Which is the most likely diagnosis?
A. Acute glaucoma
B. Conjunctivitis
C. Corneal ulcer
D. Scleritis
E. Uveitis

Answer 31

A. Acute glaucoma

Question 32

12. An 80 year old man presents to the Emergency Department with dizziness and melaena of recent onset. He has a metallic mitral valve and is taking aspirin and warfarin sodium. His pulse rate is 80 bpm and BP 122/70 mmHg.

Investigations:
Haemoglobin 105 g/L (130–175)
White cell count 7.0 × 109/L (3.8–10.0)
Platelets 676 × 109/L (150–400)
INR 9.6 (1.0)

He is treated with intravenous vitamin K and is blood cross-matched.
What is the most appropriate additional treatment?
A. Fresh frozen plasma
B. Pantoprazole
C. Protamine sulfate
D. Prothrombin complex concentrate
E. Tranexamic acid

Answer 32

D. Prothrombin complex concentrate

Question 33

13. A 62 year old man presents to the Emergency Department following a road traffic collision. He has severe bruising of the right upper shoulder from the seat belt, but no other injuries.

Chest X-ray to exclude a pneumothorax shows a 2 cm mass in the right upper zone.
Which is the most appropriate next investigation?
A. CT scan of chest
B. Lateral chest X-ray
C. MR scan of chest
D. PET scan of chest
E. Technetium bone scan

Answer 33

A. CT scan of chest

Question 34

14. A 46 year old man has a cardiac arrest in the Emergency Department after an episode of chest pain. He remains in ventricular fibrillation after three DC shocks, and he is treated with a bolus of intravenous adrenaline/epinephrine.
    Which other drug treatment should be administered at the same time?
    A. Alteplase
    B. Amiodarone hydrochloride
    C. Atropine sulfate
    D. Lidocaine
    E. Magnesium sulfate

Answer 34

B. Amiodarone hydrochloride

Question 35

15. A 45 year old woman is feeling unwell with a severe sore throat. She has schizophrenia and started taking clozapine 4 months ago.

Her temperature is 39.0°C. She has an ulcerated throat with tonsillar exudate.

Blood cultures have been sent.
What additional investigation is most likely to establish the underlying cause?
A. Clozapine concentration
B. Creatine kinase
C. Full blood count
D. Lumbar puncture
E. Throat swab

Answer 35

C. Full blood count

Question 36

16. A 22 year old man has taken an overdose of 16 paracetamol tablets. He became very sad earlier that day after an argument with a friend. His mood changes between being happy and sad several times per week. He gets bored easily and has never been able to settle well into school, college or work. He has always been impulsive. He has never experienced psychotic symptoms.
    Which is the most likely diagnosis?
    A. Adjustment disorder
    B. Bipolar disorder
    C. Borderline personality disorder
    D. Dissocial personality disorder
    E. Unipolar depressive episode

Answer 36

C. Borderline personality disorder

Question 37

17. A 25 year old woman is brought to the resuscitation room of the Emergency Department after being hit by a car. She is 32 weeks pregnant. Her cervical spine is immobilised.

She is conscious and asks about her baby. Her temperature is 36.7°C, pulse rate 112 bpm, BP 82/60 mmHg and oxygen saturation 99% breathing 40% oxygen. Fluid resuscitation has been started and bloods have been sent.
Which is the most appropriate next step?
A. Image the long bones and pelvis, and orthopaedic review
B. Perform a full primary survey
C. Scan the baby and arrange fetal monitoring
D. Transfer to theatre for immediate delivery of baby
E. X-ray cervical spine

Answer 37

B. Perform a full primary survey

Question 38

18. A 30 year old woman has vaginal bleeding 12 hours after an uncomplicated vaginal delivery.She has a large pool of blood between her legs. Her pulse rate is 120 bpm, BP 96/60 mmHg, respiratory rate 26 breaths per minute and oxygen saturation 96% breathing oxygen 4 L/min via nasal cannulae.She is treated with an IV fluid bolus, and the obstetrician is informed.
    Which is the most appropriate next management step?
    A. Activate major haemorrhage protocol
    B. Give IV noradrenaline/norepinephrine
    C. Give IV oxytocin
    D. Give IV tranexamic acid
    E. Increase oxygen to 15 L/min via a non-rebreather mask

Answer 38

A. Activate major haemorrhage protocol

Question 39

19. A 51 year old woman is found collapsed on the medical ward. She was admitted 24 hours ago with pyelonephritis and is being treated with intravenous antibiotics. She has a history of type 1 diabetes and has been taking her usual doses of subcutaneous insulin.She is unconscious and clammy. Her capillary blood glucose is 1.8 mmol/L.
    Which is the most appropriate immediate treatment?
    A. 20 mL of 50% glucose by slow intravenous injection
    B. 75 mL of 20% glucose by intravenous infusion
    C. 150 mL of 5% glucose by intravenous infusion
    D. Glucagon 1 mg by intramuscular injection
    E. Glucose gel 25 g (contains 10 g glucose) applied to buccal mucosa

Answer 39

B. 75 mL of 20% glucose by intravenous infusion

Question 40

20. A 68 year old man presents to the Emergency Department feeling generally unwell with no specific symptoms. He is being treated with neoadjuvant chemotherapy for oesophageal cancer. He underwent the third cycle 8 days ago.His temperature is 38.1°C, pulse rate 96 bpm, BP 132/68 mmHg, respiratory rate 14 breaths per minute and oxygen saturation 96% breathing air. Examination is otherwise unremarkable. Blood tests have been taken, but results are not yet available.
    Which is the most appropriate next step in management?
    A. Admit to medical receiving unit
    B. Await blood results before taking further action
    C. Discuss with local oncology team for advice
    D. Give intravenous broad-spectrum antibiotics
    E. Give intravenous fluid therapy

Answer 40

D. Give intravenous broad-spectrum antibiotics

Question 41

1. A 59 year old woman with metastatic lung cancer has back pain of new onset at the T10 level. She has also developed leg weakness and urinary retention.

Which is the most appropriate investigation?
a. CT of spine
b. Isotope bone scan
c. MR imagining of spine
d. PET-CT
e. X-Ray of thoracic and lumbar spine

Answer 41

c. MR imagining of spine

Question 42

2. A 24-year-old woman develops low back pain the day after falling while playing hockey. She is usually well and takes no regular medication. She is a secondary school teacher.

Which is the most appropriate advice?
a. Avoid work until the pain has completely settled
b. Back strengthening exercises
c. Bed rest until pain improves, then gradual mobilisation
d. Continue usual activity
e. Self referral for physiotherapy

Answer 42

d. Continue usual activity

Question 43

3. A 46 year old woman has 6 months of a painful, stiff right shoulder. The pain is dull and worse at night. There is no history of trauma. She has type 1 diabetes mellitus. She has reduced passive and active range of movement in the right shoulder with pain at extremes of range of motion. Neck movements are normal. Power and sensation are normal. Her erythrocyte sedimentation rate is 12 mm/hr (<20).

Which is the most likely diagnosis?
a. Adhesive capsulitis
b. Glenohumeral osteoarthritis
c. Polymyalgia rheumatica
d. Rotator cuff tear
e. Subacromial bursitis

Answer 43

a. Adhesive capsulitis

Question 44

4. A 78 year old woman has back pain and bilateral leg weakness. She had surgery for breast cancer 14 years ago. She had a minor fall at home a few days ago.

She has weakness of hip flexion bilaterally

Which is the most likely diagnosis?
a. Lumbar disc prolapse
b. Mechanical back pain
c. Osteomalacia
d. Osteoporotic vertebral collapse
e. Spinal cord compression

Answer 44

e. Spinal cord compression

Question 45

5. A 52-year-old woman has 2 days of a painful, swollen right knee and fever. She has a history of rheumatoid arthritis and takes methotrexate and Etanercept. Her temperature is 38.2°C, pulse rate 100 bpm and BP 119/83 mmHg. The right knee is swollen and erythematous, with an obvious effusion.

Investigations:
White cell count 17.1 × 109/L (3.8–10.0)
Urea 6.7 mmol/L (2.5–7.8)
Creatinine 98 µmol/L (60–120)
CRP 180 mg/L (<5)

Joint aspiration: no organisms on Gram stain, white cell count 3500/µL (<200), mostly neutrophils, no crystals.

She is advised to take oral paracetamol.

Which is the most appropriate additional management?
a. Inject methylprednisolone into the joint
b. No further treatment pending culture results
c. Start intravenous flucloxacillin
d. Start oral colchicine
e. Start oral prednisolone

Answer 45

c. Start intravenous flucloxacillin

Question 46

6. A 69-year-old man has 6 months of back pain extending into his buttocks and back of his thighs. The pain is worse on standing and on walking and is relieved when he sits down and leans forward. He has diet-controlled type 2 diabetes mellitus. He is an ex-smoker with a 40 pack-year history.

His BP is 178/95 mmHg. He has weakness of hip flexion bilaterally. His peripheral pulses are palpable.

Which is the most likely diagnosis?
a. Diabetic amyotrophy
b. Lumbar disc prolapse
c. Lumbar spinal stenosis
d. Osteoarthritis of hips
e. Peripheral arterial disease

Answer 46

c. Lumbar spinal stenosis

Question 47

7. A 61-year-old woman has 1 year of worsening bilateral knee pain caused by osteoarthritis. Her pain is partially controlled by regular paracetamol and ibuprofen gel. She remains active. She has ischaemic heart disease and a history of peptic ulcers. Her medication includes bisoprolol fumarate, aspirin and simvastatin. She has crepitus on active and passive movements of both knees. There is no effusion. Her BMI is 30 kg/m2.

Which is the most appropriate management?
a. Add celecoxib
b. Add oral ibuprofen and lansoprazole
c. Refer for acupuncture
d. Refer for knee replacement surgery
e. Switch paracetamol to regular co-codamol

Answer 47

e. Switch paracetamol to regular co-codamol

Question 48

8. A 39-year-old woman has 1 month of pain on the radial side of her right wrist. The pain is worse when she grips her gardening tools. She has no history of trauma. She has swelling and tenderness over the distal end of the right radial styloid. The pain is exacerbated by ulnar deviation of the wrist when the thumb is clasped in the palm.

Which is the most likely diagnosis?
a. De Quervain tendinopathy
b. Ganglion cyst
c. Intersection syndrome
d. Osteoarthritis of the trapeziometacarpal joint
e. Scaphoid fracture

Answer 48

a. De Quervain tendinopathy

Question 49

9. A 72-year-old woman has 6 months of increasing pain at the base of her right thumb. She is having difficulty opening jars and sewing. She is otherwise well. No other joints are painful. She is taking regular analgesia.

The first carpometacarpal joint is swollen and tender, with reduced opposition of the thumb.

Which is the most likely diagnosis?
a. De Quervain’s tenosynovitis
b. Gout
c. Osteoarthritis
d. Rheumatoid arthritis
e. Septic arthritis

Answer 49

c. Osteoarthritis

Question 50

10. A 34-year-old man has pain in his right shoulder and upper arm for 6 weeks that worsens when elevating his arm above his head. He does not recall any injury.
    There is no deformity, tenderness or reduced range of movement. There is pain on abduction of the right shoulder that is worse with the arm in internal rotation and when abduction is resisted. He is treated with ibuprofen.

Which is the most appropriate next step in management?
a. MR scan of shoulder
b. Refer for orthopaedic opinion
c. Refer for physiotherapy
d. Ultrasound scan of shoulder
e. X-ray of shoulder

Answer 50

c. Refer for physiotherapy

Question 51

11. A 56 year old woman is experiencing pain, stiffness and swelling of her wrists,
    and metacarpophalangeal and proximal interphalangeal joints.

Blood tests show a normal full blood count, liver function and renal function, an elevated CRP, and high concentrations of rheumatoid factor and anti-cyclic citrullinated peptide antibodies. She is seronegative for hepatitis B and C. An ultrasound scan shows active synovitis in the symptomatic joints.

Which is the most appropriate disease-modifying drug treatment?

A. Azathioprine
B. Cyclophosphamide
C. Hydroxychloroquine sulfate
D. Methotrexate
E. Sulfasalazine

Answer 51

D. Methotrexate

Question 52

12. A 45 year old man visits his GP with right knee pain. He has not had any problems with his knee before, but has had previous episodes of a severe pain in his toe and painful swelling of the dorsum of the feet. There is no history of trauma. He drinks 20 pints of beer a week. His temperature is 37.5°C, and his knee is warm, diffusely tender and very painful to flex.

What is the most likely diagnosis?
A. Gout
B. Osteoarthritis of the knee
C. Pseudogout
D. Rheumatoid arthritis
E. Torn meniscal cartilage

Answer 52

A. Gout

Question 53

13. A 75 year old woman has 6 weeks of painless muscle weakness affecting her shoulders and thighs. She has a pale mauve discolouration of her eyelids, diffuse erythema over the metacarpophalangeal joints dorsally, and reduced power (3/5) in arm abduction and hip flexion.

Investigations:
CRP 70 mg/L (<5)
Rheumatoid factor negative
Antinuclear antibody 1:320 (<1:20)

Which is the most appropriate blood test to help establish the diagnosis?
A. Anti-acetylcholine receptor antibodies
B. Anti-neutrophil cytoplasmic antibodies
C. Anti-smooth muscle antibodies
D. Creatine kinase
E. Erythrocyte sedimentation rate

Answer 53

D. Creatine kinase

Question 54

14. An 87 year old woman falls from a standing height and breaks her left hip. She has previously broken her right wrist. She has lost 3 cm in height since her youth and has developed a stooped posture. She is an ex-smoker with a 30 pack-year history.

Investigations:
Calcium 2.30 mmol/L (2.2–2.6)
Plasma parathyroid hormone level 3.6 pmol/L (0.9–5.4)
Alkaline phosphatase 98 IU/L (25–115)
Vitamin D 78 nmol/L (75–100)

Which is the most likely underlying cause of her hip fracture?
A. Metastatic deposit in bone
B. Osteodystrophy
C. Osteomalacia
D. Osteoporosis
E. Paget’s disease

Answer 54

D. Osteoporosis

Question 55

15. A 74-year-old woman has a two month history of difficulty chewing food, particularly meat. She gets a sensation of pressure and pain in her jaw, even when talking. She has had intermittent headaches and has lost 8 kg in weight.

Investigations: CRP 45 mg/L (<5)

Which is the most appropriate test?
A. CT scan of head
B. Parotid sialogram
C. Speech and language therapist’s assessment
D. Temporal artery biopsy
E. X-ray of temporomandibular joint

Answer 55

D. Temporal artery biopsy

Question 56

16. A 35-year-old woman gets pale, blue and painful fingers and toes on exposure to cold. Recently, she has had some difficulty swallowing solid food. She has tight skin over her face and fingers.
    Which is the most likely diagnosis?
    A. Primary Raynaud’s phenomenon
    B. Rheumatoid arthritis
    C. Sjögren’s syndrome
    D. Systemic lupus erythematosus
    E. Systemic sclerosis

Answer 56

E. Systemic sclerosis

Question 57

17. A 25-year-old man has three years of pain and stiffness in his lower back that sometimes wakes him from sleep. The pain is worse in the mornings and radiates to his right buttock. He has noticed that the pain improves after exercise. He is a construction worker.

Which is the most likely diagnosis?
A. Ankylosing spondylitis
B. Lumbar disc herniation
C. Mechanical back pain
D. Reactive arthropathy
E. Rheumatoid arthritis

Answer 57

A. Ankylosing spondylitis

Question 58

18. A 28 year old woman has tiredness, pleuritic chest pain and joint pains in her wrists and fingers.
    Investigations:
    Haemoglobin 105 g/L (115–150)
    White cell count 2.6 × 109/L (3.8–10.0
    Platelets 98 × 109/L (150–400)
    Urea 8.1 mmol/L (2.5–7.8)
    Creatinine 145 μmol/L (60–120)

Urinalysis: blood 3+, protein 3+, nitrites negative, leucocytes negative.

Which autoantibody is most likely to be detected in her serum?

A. Anticentromere antibody
B. Anti-glomerular basement membrane antibody
C. Anti-neutrophil cytoplasmic antibody
D. Antinuclear antibody
E. Rheumatoid factor

Answer 58

D. Antinuclear antibody

Question 59

19. A 65 year old man has pain and stiffness of his right third metacarpophalangeal joint and his left second distal interphalangeal joint. He has a past history of sacroiliitis. The affected joints are red, warm and tender, and he has nail pitting.
    Which is the most likely diagnosis?
    A. Gout
    B. Pseudogout
    C. Psoriatic arthritis
    D. Rheumatoid arthritis
    E. Septic arthritis

Answer 59

C. Psoriatic arthritis

Question 60

20. A 79-year-old woman has 4 weeks of malaise, and pain in the arms and legs, with morning stiffness of 3 hours, and difficulty washing and dressing. She cannot lift her arms above her head due to pain, but there is no objective muscle weakness. She has Heberden’s nodes, but otherwise joint examination is normal. Her CRP is 67 mg/L (<5).
    Which is the most likely diagnosis to explain her symptoms?
    A. Osteoarthritis
    B. Osteomalacia
    C. Polymyalgia rheumatica
    D. Polymyositis
    E. Rheumatoid arthritis

Answer 60

C. Polymyalgia rheumatica

Question 61

1. A 65-year-old woman attends her GP surgery with breathlessness on exertion and a cough productive of sputum on most mornings. Her weight is steady, and she has never had haemoptysis. She describes two chest infections in the past year treated with a short course of steroids and antibiotics. She has a 25 pack-year smoking history.

Her BP is 132/85 mmHg. Chest X-ray is normal.

Which is the most appropriate investigation to establish the diagnosis?

a. Cardiopulmonary exercise test
b. Echocardiography
c. High resolution CT scan of thorax
d. Spirometry
e. Sputum cytology

Answer 61

d. Spirometry

Question 62

2. A 52-year-old man visits his GP for health screening. He is well.
   His pulse rate is 80 bpm and irregular, and BP 128/84 mmHg.
   Investigations:
   Sodium 136 mmol/L (135–146)
   Potassium 3.9 mmol/L (3.5–5.3)
   Urea 4.9 mmol/L (2.5–7.8)
   Creatinine 80 μmol/L (60–120)
   HbA1c 40 mmol/mol (20–42)
   Thyroid function tests are normal.

ECG shows atrial fibrillation, 76 bpm.
Which is the most appropriate treatment?
a. Apixaban
b. Aspirin
c. Diltiazem hydrochloride
d. No treatment
e. Warfarin sodium

Answer 62

d. No treatment

Question 63

3. A 65 year old woman has had a painful, red and watery left eye for 3 days.
   Visual acuity is 6/24 on the left and 6/12 on the right. Fundoscopy is normal.
   Which is the most appropriate next step in management?

a. Arrange ophthalmology outpatient appointment
b. Prescribe chloramphenicol eye drops
c. Prescribe prednisolone eye drops
d. Prescribe sodium cromoglicate eye drops
e. Refer to the ophthalmology department as an emergency

Answer 63

e. Refer to the ophthalmology department as an emergency

Question 64

4. A 19 year old man has 2 months of an itchy, scaly rash that has partially responded to topical moisturiser. There are lesions symmetrically distributed over his elbows, scalp and back, which are 2–4 cm in diameter (see image).

Which is the most likely diagnosis?

a. Atopic dermatitis
b. Pityriasis versicolor
c. Plaque psoriasis
d. Seborrheic dermatitis
e. Tinea corporis infection

Answer 64

c. Plaque psoriasis

Question 65

5. A 60 year old man visits his GP as he wants to start training for a 5 km race for charity. He plans to run 3–5 km three times per week. He describes occasional central chest tightness when he walks up hills. He has a history of type 2 diabetes mellitus and COPD for which he is taking metformin and using an as-required salbutamol inhaler.

His BP is 162/94 mmHg. His BMI is 32.

Which aspect of his clinical background is a contra-indication to his training plan?

a. BP 160/90mmHg
b. COPD
c. Exertional chest tightness
d. Obesity
e. Type 2 diabetes mellitus

Answer 65

c. Exertional chest tightness

Question 66

6. A 52 year old Afro-Carribbean man is referred to the hypertension clinic with an average daytime reading on ambulatory BP monitoring of 164/105 mmHg. He has no other medical history of note and is currently taking no medication.
   In clinic, his BP is 158/98 mmHg. His 10-year cardiovascular risk is calculated to be 23%.
   In addition to atorvastatin, which is the most appropriate medication to prescribe?
   a. Amlodipine
   b. Bendroflumethiazide
   c. Doxazosin
   d. Losartan potassium
   e. Ramipril

Answer 66

a. Amlodipine

Question 67

7. A 75 year old man visits his GP with one episode of visible haematuria.
   His temperature is 36.2°C and BP 142/80 mmHg.
   Investigations:
   Midstream urine: red blood cells and epithelial cells, no microbial growth
   Urinalysis: blood 2+, leucocytes negative, protein negative, nitrite negative.

Which is the most appropriate next step?

a. Arrange an ultrasound scan of renal tract
b. Arrange CT urography
c. Check serum prostate specific antigen
d. Refer for urology opinion
e. Repeat midstream urine sample for culture and sensitivity

Answer 67

d. Refer for urology opinion

Question 68

8. A 45 year old woman attends her GP surgery with symptoms of vaginal soreness, itching and discharge. She has had recurrent episodes of vaginal candidiasis over the past 4 months.

The labia minora are red and swollen. A diagnosis of vaginal candidiasis is made.

What is the most appropriate investigation at this stage?

a. Glycated haemoglobin
b. HIV test
c. STI screen
d. Test her partner for candidiasis
e. Vaginal pH testing

Answer 68

a. Glycated haemoglobin

Question 69

9. A 55 year old woman has a tender, erythematous, swollen hard cord in the long saphenous vein distribution in her calf. She has a longstanding history of bilateral varicose veins.
   An ultrasound scan shows superficial thrombophlebitis without deep vein thrombosis.
   Which is the most appropriate treatment?
   a. Dipyridamole
   b. Flucloxacillin
   c. Naproxen
   d. Paracetamol
   e. Rivaroxaban

Answer 69

c. Naproxen

Question 70

10. A previously healthy 10 year old boy has deafness of new onset. He has a history of a recent respiratory tract infection.
    Tuning fork tests show:
    a) When the tuning fork is placed in the middle of his forehead he hears the tone loudest in his right ear.
    b) When the tuning fork is held in front of his right external auditory meatus it is quieter than when it is placed on the bone behind the same ear.
    c) When the tuning fork is held in front of the left external auditory meatus the sound is louder than when it is placed on the bone behind the same ear.

Which ear(s) is/are affected and which type of hearing loss is this?
a. Bilateral mixed deafness
b. Left conductive deafness
c. Left sensorineural deafness
d. Right conductive deafness
e. Right sensorineural deafness

Answer 70

d. Right conductive deafness

Question 71

11. A 31 year old man visits his GP with a painless lump in his scrotum.

There is a well-defined, non-tender spherical 1 cm mass on the right side of the scrotum. It is superior to the testis and transilluminates.

Which is the most likely diagnosis?

a. Abscess
b. Epididymal cyst
c. Hydrocele
d. Inguinal hernia
e. Testicular tumour

Answer 71

b. Epididymal cyst

Question 72

12. A 47 year old man with hypertension attends for annual review. He takes ramipril (10 mg once daily).

His BP is 138/78 mmHg.

Investigations:
Sodium 139 mmol/L (135–146)
Potassium 6.2 mmol/L (3.5–5.3)
Urea 5.0 mmol/L (2.5–7.8)
Creatinine 90 µmol/L (60–120)

Which is the most appropriate immediate action?

a. Add indapamide
b. Advised low potassium diet
c. Change ramipril to amlodipine
d. Reduce dose of ramipril
e. Repeat U&E

Answer 72

e. Repeat U&E

Question 73

13. A 56 year old woman has home blood pressure readings averaging 160/90 mmHg.
    Hypertension is confirmed on 24 hour ambulatory monitoring. She has type 1 diabetes mellitus.

Investigations:
Urinary albumin: creatinine ratio 42 mg/mmol (<3.5)
eGFR 43 mL/min/1.73 m2 (>60)

Which type of antihypertensive is most appropriate?

a. ACEi
b. Alpha blocker
c. Beta blocker
d. Calcium channel blocker
e. Thiazide-like diuretic

Answer 73

a. ACEi

Question 74

14. A 38 year old man has 2 months of epigastric pain that radiates into his back. It is worse at night and sometimes wakes him up. It is better after eating. He has been very busy at work. He occasionally misses lunch, which worsens the pain. He has not lost weight. He smokes 10 cigarettes per day and drinks two bottles of wine per week.

Examination is normal.

Which is the most likely diagnosis?

a. Cholecystitis
b. Chronic pancreatitis
c. Duodenal ulcer
d. Gastric ulcer
e. Gastric carcinoma

Answer 74

c. Duodenal ulcer

Question 75

15. A 30-year-old woman attends 3 months after a diagnosis of iron deficiency anaemia. She was advised to take oral iron supplements and has been taking these regularly. She has some looseness of her stools, and her periods are scanty on a combined oral contraceptive.

Investigations:
Haemoglobin 92 g/L (115–165)
MCV 70 fL (80–96)
Ferritin 8 µg/L (12–200)

Which antibody test is most likely to diagnose the underlying cause?

a. Anti-gastric parietal cell
b. Antimitochondrial
c. Antinuclear
d. Anti-smooth muscle
e. Anti-tissue transglutaminase

Answer 75

e. Anti-tissue transglutaminase

Question 76

16. A 40 year old South Asian woman visits her GP for an NHS health check.
    Her BMI is 27 kg/m2. Her BP is 122/80 mmHg.
    Urinalysis is normal.

Investigations: Glycated haemoglobin 44 mmol/mol (20–42)

Which is the most appropriate next step in management?

a. Advise low sugar diet
b. Prescribe metformin
c. Prescribe ramipril
d. Refer her to the diabetes prevention programme
e. Send off a fasting plasma glucose

Answer 76

d. Refer her to the diabetes prevention programme

Question 77

17. A 47 year old woman has 1 year of increased urinary frequency, urgency and nocturia. She finds that she leaks urine if she is unable to get to the toilet promptly. She had three normal pregnancies with no complications.

The perineum appears normal and there is no uterine prolapse. Incontinence is not provoked by coughing or straining. Urinalysis is negative. A post-micturition ultrasound scan of bladder shows minimal residual urine volume.

Which is the most appropriate initial management plan?

a. Botulinum toxin type A injection into bladder wall
b. Oral duloxetine
c. Oral oxybutynin
d. Percutaneous sacral nerve stimulation
e. Topical oestrogen

Answer 77

c. Oral oxybutynin

Question 78

18. A 24 year old woman attends her GP with 2 months of intermittent palpitations. She describes the episodes as feeling as if the heart stops for a second followed by a pounding sensation. She reports episodes two to three times per week lasting 5–10 minutes, most commonly when she is going to sleep. She is otherwise well. She has been taking the combined oral contraceptive pill for 2 years.

Her pulse rate is 68 bpm and BP 108/71 mmHg. Her heart sounds are normal.

Investigations:
ECG: sinus rhythm, rate 70 bpm.

Which is the most likely diagnosis?

a. Paroxysmal atrial fibrillation
b. Sinus arrhythmia
c. Sinus tachycardia
d. Supraventricular premature beats
e. Supraventricular tachycardia

Answer 78

d. Supraventricular premature beats

Question 79

19. A 76 year old woman has become increasingly confused over the past 2 weeks. She has a history of hypertension and cardiac failure. She is taking bendroflumethiazide, doxazosin, amlodipine, ramipril and atenolol.

Her BP is 108/71 mmHg.

Investigations:
Sodium 121 mmol/L (135–146)
Potassium 3.5 mmol/L (3.5–5.3)
Urea 10.0 mmol/L (2.5–7.8)
Creatinine 105 µmol/L (60–120)

Which medication is most likely to be responsible for her presentation?

a. Amlodipine
b. Atenolol
c. Bendroflumethiazide
d. Doxazosin
e. Ramipril

Answer 79

c. Bendroflumethiazide

Question 80

20. The association between maternal smoking during pregnancy and low birthweight can be studied by obtaining smoking histories from pregnant women at the time of first prenatal visit, then assessing birthweight at delivery and analysing the data according to the smoking histories.

a. Case–control
b. Cross sectional
c. Prospective cohort
d. Randomised clinical trial
e. Retrospective cohort

Answer 80

c. Prospective cohort

Question 81

1. A 65 year old man has abdominal distension and vomiting 48 hours after a sigmoid colectomy with primary anastomosis for bowel cancer. He has not passed any flatus for 24 hours. He is taking regular paracetamol and as required intravenous morphine.

His abdomen is distended with tenderness over the wound but no rebound or guarding. There are no bowel sounds.

His temperature is 37.6°C, pulse rate 96 bpm and BP 122/85 mmHg.
Which is the most appropriate initial management?
A. Give intravenous piperacillin with tazobactam
B. Give Microlax ® enema
C. Insert a nasogastric tube
D. Start regular intravenous morphine
E. Take to theatre for laparotomy

Answer 81

C. Insert a nasogastric tube

Question 82

2. A 76-year-old man undergoes an abdominoperineal resection for a low rectal carcinoma. He has a history of severe COPD and hypertension.
   Which is the most appropriate method for providing analgesia during the early postoperative period?
   A. Epidural anaesthesia
   B. Intramuscular opioid
   C. Oral non-steroidal analgesia
   D. Patient controlled intravenous analgesia
   E. Spinal anaesthesia

Answer 82

A. Epidural anaesthesia

Question 83

3. A 64-year-old man has vomiting and severe chest pain after eating a large meal.

His temperature is 37.6°C, pulse rate 130 bpm, BP 95/50 mmHg and respiratory rate 30 breaths per minute. There is palpable subcutaneous emphysema on the left side of his neck.
Which is the most likely diagnosis?
A. Diaphragmatic rupture
B. Mallory–Weiss tear
C. Necrotising fasciitis
D. Oesophageal rupture
E. Spontaneous pneumohaemothorax

Answer 83

D. Oesophageal rupture

Question 84

4. A 28 year old woman presents to her GP with a neck lump that she noticed incidentally when rubbing her neck.

There is a smooth, non-tender 1.5 cm mobile lump within the thyroid gland.

Investigations:
TSH 2.3 mU/L (0.3–4.2)
Free T4 17 pmol/L (9–25)
Which is the most appropriate next investigation?
A. CT of neck
B. No further investigations
C. Thyroid antibodies
D. Thyroid scintigraphy
E. Ultrasonography of neck

Answer 84

E. Ultrasonography of neck

Question 85

5. A 40-year-old man has 4 days of left flank pain associated with fever, nausea and vomiting.

His temperature is 39.6°C, pulse rate 118 bpm and BP 90/40 mmHg. Imaging shows an obstructing proximal left ureteric stone with severe hydronephrosis.

He is treated with intravenous antibiotics and intravenous fluids.
Which is the most appropriate next step in management?
A. Lithotripsy (shock wave)
B. Nephrostomy
C. Retrograde pyelography
D. Ureteric stent
E. Urethral catheter

Answer 85

B. Nephrostomy

Question 86

6. A 35 year old woman has 6 months of cyclical pain in both breasts. She has recently noticed a lump in the right breast. There is diffuse nodularity of the axillary tails of both breasts with a discrete 20 mm mass in the upper outer quadrant of the right breast. Fine needle aspiration is performed and 5 mL of brown fluid is removed, with disappearance of the mass. Cytology shows cellular debris with no malignant cells.
   What is the most likely diagnosis?
   A. Breast abscess
   B. Breast carcinoma
   C. Fat necrosis
   D. Fibroadenoma
   E. Fibrocystic disease

Answer 86

E. Fibrocystic disease

Question 87

7. A 63 year old woman has 4 months of abdominal bloating, fatigue and nausea.

She is found to have with ovarian cancer. Staging CT is performed to look for lymphatic spread and metastatic disease.
To what regional lymph nodes is her tumour most likely to spread initially?
A. Deep inguinal nodes
B. External iliac nodes
C. Internal iliac nodes
D. Para-aortic nodes
E. Superficial inguinal nodes

Answer 87

D. Para-aortic nodes

Question 88

8. A 52 year old woman has had three episodes of 35 associated with vomiting over the past 3 months. The episodes occurred following eating and lasted for about 1 hour. She has type 2 diabetes mellitus and takes metformin.

Abdominal examination is normal. Her BMI is 35 kg/m2(18–25).

Investigations:ALT 15 IU/L (10–50)
ALP 71 IU/L (25–115)
Bilirubin 9 µmol/L (<17)

Ultrasound scan of abdomen: single 2-cm gallstone in gallbladder, common bile duct normal, evidence of fatty liver.
Which is the most appropriate management?
A. Endoscopic retrograde cholangiopancreatography
B. Laparoscopic cholecystectomy
C. MR cholangiopancreatography
D. Open cholecystectomy
E. Ursodeoxycholic acid

Answer 88

B. Laparoscopic cholecystectomy

Question 89

9. A 79 year old woman has 3 months of a left leg venous ulcer that is slowly healing.

Ankle–brachial pressure Indices are 0.9 on the left side and 1.1 on the right side (0.8–1.2).
Which is the most appropriate management?
A. Compression stockings
B. Diagnostic biopsy
C. Full-length graduated compression bandaging
D. No further management required
E. Repeat ankle–brachial pressure indices in 3 months

Answer 89

A. Compression stockings

Question 90

10. A 70 year old woman has an ulcer above the left medial malleolus. She has a history of type 2 diabetes mellitus. She smokes 10 cigarettes per day.

The ulcer is 10 × 5 cm and superficial. She has brown discolouration of both lower legs. The skin has a thickened, waxy feel. Her BMI is 34.
Which is the most likely type of ulcer in this patient?
A. Arterial
B. Inflammatory
C. Malignant
D. Neuropathic
E. Venous

Answer 90

E. Venous

Question 91

11. A 70 year old woman develops pyrexia and reduced oxygen saturation 2 days after an elective subtotal gastrectomy. Her postoperative pain control has been difficult, which has limited her ability to have chest physiotherapy and to mobilise.

Her temperature is 37.8°C, pulse 84 bpm and oxygen saturation 92% breathing 35% oxygen. Her BMI 36. There is reduced breath sounds at both lung bases. Her abdomen is soft, with tenderness around her wound. Her drain has serous output.
Which is the most likely postoperative complication?
A. Anastomotic leak
B. Atelectasis
C. Pneumothorax
D. Pulmonary embolism
E. Wound infection

Answer 91

B. Atelectasis

Question 92

12. A 42 year old woman has 12 hours of colicky central abdominal pain, vomiting, abdominal distension and increased bowel sounds. She had a ruptured appendix aged 20 years.

Plain abdominal X-ray: see image.

Which is the most appropriate initial management?
A. Flatus tube insertion
B. Intravenous antibiotics
C. Laparoscopy
D. Laparotomy
E. Nasogastric tube insertion

Answer 92

E. Nasogastric tube insertion

Question 93

13. A 78 year old woman is oliguric 12 hours after an emergency laparotomy for small bowel infarction. She has a history of chronic kidney disease stage 2, hypertension and type 2 diabetes mellitus. She takes metformin and ramipril.

Her pulse rate is 110 bpm, BP 95/50 mmHg and JVP not visible. Her urine output has been 10 mL per hour for the past 3 hours. She has been given 2 L of 0.9% sodium chloride since returning from theatre.

Investigations:Urea 15.2 mmol/L (2.5–7.8)
Creatinine 160 µmol/L (60–120)
Which is the most likely cause of her oliguria?
A. Acute tubular necrosis
B. Catheter obstruction
C. Intraoperative ureteric injury
D. Prerenal hypovolaemia
E. Renal artery occlusion

Answer 93

D. Prerenal hypovolaemia

Question 94

14. A 70 year old man has abdominal pain 3 days after a laparoscopic bowel resection with primary anastomosis for colon cancer. His temperature is 36.5°C, pulse rate 100 bpm, BP 120/72 mmHg and oxygen saturation 96% breathing 4 L/min oxygen via nasal prongs. He has reduced breath sounds in both bases. He has abdominal tenderness with guarding and reduced bowel sounds.
    Which is the most appropriate diagnostic investigation?
    A. Abdominal ultrasonography
    B. Abdominal X-ray
    C. Barium enema
    D. CT of abdomen
    E. Erect chest X-ray

Answer 94

D. CT of abdomen

Question 95

15. A 64 year old man has right-sided hearing loss. There has been slow deterioration over the previous year, and he is now also troubled by non-pulsatile, left-sided tinnitus that prevents him from sleeping.A pure-tone audiogram shows right-sided high-frequency hearing loss. He has normal tympanometry bilaterally.
    Which is the most appropriate diagnostic investigation?
    A. Cerebral angiography
    B. CT of head
    C. CT of petrous temporal bones
    D. MR imaging of internal acoustic meatus
    E. PET–CT of brain

Answer 95

D. MR imaging of internal acoustic meatus

Question 96

16. A 75 year old man has 2 days of worsening lower abdominal pain and constipation. There is no rectal bleeding.His temperature is 38.0°C, pulse rate 105 bpm and BP 140/85 mmHg. He has tenderness in the left iliac fossa with some guarding. Bowel sounds are normal. Rectal examination shows hard stools only.
    Which is the most likely diagnosis?
    A. Ischaemic colitis
    B. Meckel’s diverticulitis
    C. Proctocolitis
    D. Rectal carcinoma
    E. Sigmoid diverticulitis

Answer 96

E. Sigmoid diverticulitis

Question 97

17. A 29 year old man has 24 hours of severe, constant pain of sudden onset radiating from his left flank to his groin.Urinalysis shows blood 2+, protein trace and leucocytes 2+.
    Which is the most appropriate initial investigation?
    A. Contrast CT of abdomen and pelvis
    B. Intravenous urography
    C. Non-contrast CT of renal tract
    D. Plain X-ray of renal tract
    E. Ultrasonography of renal tract

Answer 97

C. Non-contrast CT of renal tract

Question 98

18. A 78 year old woman has 48 hours of central abdominal pain. She was discharged from hospital 4 weeks ago following a myocardial infarction.She has diffuse tenderness of the abdomen with absent bowel sounds. Plain X-ray of the abdomen is unremarkable.Investigations:Haemoglobin 102 g/L (115–150)
    White cell count 17.2 × 109/L (3.8–10.0)Urea 16.4 mmol/L (2.5–7.8)
    Creatinine 158 µmol/L (60–120)CRP 110 mg/L (<5)Arterial blood gas breathing air
    pH 7.28 (7.35–7.45)
    PO2 13 kPa (11–15)
    PCO2 4.6 kPa (4.6–6.4)
    Bicarbonate 16 mmol/L (22–30)Lactate 4.5 mmol/L (1–2)
    Which is the most likely diagnosis?
    A. Acute diverticulitis
    B. Acute pancreatitis
    C. Incarcerated paraumbilical hernia
    D. Mesenteric ischaemia
    E. Ruptured aortic aneurysm

Answer 98

D. Mesenteric ischaemia

Question 99

19. A 55 year old man has 1 day of severe epigastric pain. He has vomited five times. He smokes 15 cigarettes per day and drinks 35 units of alcohol per week.His temperature is 37.8°C, pulse rate 88 bpm and BP 142/84 mmHg. He is tender in the epigastrium and right upper quadrant, and there is voluntary guarding.Investigations:White cell count 16.4 × 109/L (3.8–10.0)ALT 41 IU/L (10–50)
    Alkaline phosphatase 136 IU/L (25–115)
    Bilirubin 14 µmol/L (<17)Amylase 238 U/L (<220)
    CRP 42 mg/L (<5)
    Which is the most likely diagnosis?
    A. Acute cholangitis
    B. Acute cholecystitis
    C. Acute hepatitis
    D. Acute pancreatitis
    E. Biliary colic

Answer 99

B. Acute cholecystitis

Question 100

20. A healthy 23 year old man is scheduled to undergo an elective arthroscopy of his knee. He is to have a general anaesthetic for the operation and asks the pre-operative assessment nurse how long he needs to fast beforehand.
    Which are the most appropriate fasting times for clear liquids and solids respectively?
    A. 2 h for clear liquids, 2 h for solids
    B. 2 h for clear liquids, 6 h for solids
    C. 2 h for clear liquids, 12 h for solids
    D. 6 h for both clear liquids and solids
    E. 6 h for clear liquids, 12 h for solids

Answer 100

B. 2 h for clear liquids, 6 h for solids

Question 101

1. A 49-year-old man has 3 days of cough and fever. He undergoes haemodialysis three times per week.
   His temperature is 38.6°C, pulse rate 90 bpm, BP 122/80 mmHg, respiratory rate 30 breaths per minute and oxygen saturation 95% breathing 15 L/min oxygen via a non-rebreather mask.
   His JVP is 4 cm above the sternal angle. He has inspiratory crackles in the right mid and lower zone and left upper zone. His blood capillary glucose is 12 mmol/L.
   Investigations:
   Sodium 131 mmol/L (135–146)
   Potassium 5.7 mmol/L (3.5–5.3)
   Urea 16.7 mmol/L (2.5–7.8)
   Creatinine 327 μmol/L (60–120)
   Chest X-ray: see image

Which is the most appropriate initial treatment?
Haemodialysis
Intravenous 10 mL 10% calcium gluconate
Intravenous 1000 mL 0.9% sodium chloride over 1 h
Intravenous co-amoxiclav and clarithromycin
Intravenous furosemide

Answer 101

Intravenous co-amoxiclav and clarithromycin

Question 102

2. A 78 year old woman is admitted after been found collapsed at home. She has been lying on the floor overnight. She has a history of hypertension and takes amlodipine.
   Her temperature is 35.8°C, pulse rate 88 bpm and irregular, and BP 102/60 mmHg.
   Investigations:
   Sodium 136 mmol/L (135–146)
   Potassium 5.8 mmol/L (3.5–5.3)
   Urea 20.9 mmol/L (2.5–7.8)
   Creatinine 180 μmol/L (60–120)
   Creatine kinase 870 U/L (25–175)
   Urinalysis: glucose negative, ketones negative, blood 2+, protein 1+, leucocytes positive (catheter sample).
   She has passed 60 mL of urine over the past 2 hours.
   Which is the most likely cause for her acute kidney injury?
   Glomerulonephritis
   Hypovolaemia
   Renal arterial emboli
   Rhabdomyolysis
   Ureteric obstruction

Answer 102

Hypovolaemia

Question 103

3. A 72 year old woman has 6 months of mild constipation.
   Investigations:
   Haemoglobin 110 g/L (115–150)
   Creatinine 70 µmol/L (60–120)
   Calcium 2.90 mmol/L (2.2–2.6)
   Phosphate 0.65 mmol/L (0.8–1.5)
   24 h urinary calcium 7 mmol (2–6)
   Parathyroid hormone 11.2 pmol/L (1.6–8.5)
   Vitamin D 65 nmol/L (>60)
   Which is the most likely diagnosis?
   Familial hypocalciuric hypercalcaemia
   Multiple myeloma
   Primary hyperparathyroidism
   Tertiary hyperparathyroidism
   Vitamin D intoxication

Answer 103

Primary hyperparathyroidism

Question 104

4. A 75 year old woman becomes breathless while receiving the third unit of a blood transfusion. She was admitted with melaena and a haemoglobin of 65 g/L (115–150). She has a history of ischaemic heart disease and takes aspirin and lisinopril.
   She now has bibasal inspiratory crackles and occasional wheeze. Her temperature is 37.3°C, pulse rate 96 bpm, BP 120/80 mmHg, respiratory rate 30 breaths per minute and oxygen saturation 90% breathing air.
   She is treated with high flow oxygen. The nursing staff have stopped the blood transfusion.
   Which is the most appropriate additional treatment?
   Intramuscular adrenaline/epinephrine
   Intravenous chlorphenamine maleate
   Intravenous furosemide
   Intravenous hydrocortisone
   Nebulised salbutamol

Answer 104

Intravenous furosemide

Question 105

5. A 31 year old woman is admitted with 24 hours of confusion. She is having visual hallucinations of snakes and mice on the floor. Her partner says that she often drinks 80 units of alcohol per week. He has not seen her for the past week. She has a history of depression and takes fluoxetine. Her temperature is 37.6°C, pulse rate 100 bpm and BP 162/98 mmHg. She is disorientated in time and place. She has no focal neurological deficit.
   Which is the most likely diagnosis?
   Delirium tremens
   Fluoxetine overdose
   Hepatic encephalopathy
   Korsakoff’s psychosis
   Wernicke’s encephalopathy

Answer 105

Delirium tremens

Question 106

6. An 18 year old man, who was born in the UK, develops drowsiness and confusion 2 days after returning from visiting his grandparents in Malawi. Over the past week he has had recurrent episodes of high fever.
   Investigations:
   Haemoglobin 92 g/L (130–175)
   White cell count 3.2 × 109/L (3.8–10.0)
   Platelets 184 × 109/L (150–400)
   Blood film Parasites visible
   Which is the most likely causative organism?
   Plasmodium falciparum
   Plasmodium malariae
   Plasmodium vivax
   Trypanosoma brucei
   Trypanosoma cruzi

Answer 106

Plasmodium falciparum

Question 107

7. A 65 year old woman with newly diagnosed advanced lung cancer has 1 day of breathlessness and 1 week of progressive headache.

Her pulse rate is 88 bpm, respiratory rate 20 breaths per minute and oxygen saturation 95% breathing 4 L/min oxygen via nasal prongs. She has a swollen face and neck and distended veins on her chest. Her chest is clear.

CT scan of chest shows mediastinal lymphadenopathy compressing the superior vena cava.
Which is the most appropriate initial treatment?
Intravenous alteplase
Intravenous dexamethasone
Intravenous heparin infusion
Intravenous mannitol
Insert endovenous stent

Answer 107

Intravenous dexamethasone

Question 108

8. A 70 year old man has dry cough and breathlessness on exertion for the past 3 months. He has lost 4 kg in weight. He has a history of ischaemic heart disease and atrial fibrillation. He takes warfarin sodium, ramipril and amiodarone hydrochloride. He is a never smoker.
   His temperature is 37.5°C, pulse rate 70 bpm, respiratory rate 18 breaths per minute and oxygen saturation 91% breathing air. He has fine bibasal inspiratory crackles. There is no finger clubbing.
   Investigations:
   Haemoglobin 141 g/L (130–175)
   White cell count 14.0 × 109/L (3.0–10.0)
   Erythrocyte sedimentation rate 65 mm/hr (<20)
   Chest X-ray shows bilateral reticular opacities in both bases.
   Which investigation is most likely to confirm the diagnosis?
   Blood cultures
   Bronchoscopy
   Echocardiography
   High resolution CT scan of chest
   Induced sputum for microscopy and culture

Answer 108

High resolution CT scan of chest

Question 109

9. A 67 year old man has 3 weeks of progressive ankle oedema. He has a history of hypertension, treated with amlodipine. He is a lifelong heavy smoker and drinks 12 units of alcohol per week.
   His BP is 125/85 mmHg and oxygen saturation 98% breathing air. His JVP is 4 cm above the sternal angle. He has marked bilateral pitting ankle oedema. He has dull percussion note at both bases with reduced breath sounds.
   Investigations:
   Creatinine 85 µmol/L (60–120)
   Fasting glucose 5.7 mmol/L (3.0–6.0)
   Total cholesterol 9 mmol/L (<5.0)
   Albumin 15 g/L (35–50)
   Urinary protein:creatinine ratio 568 mg/mmol (<30)
   Urine microscopy no cells, no casts
   Which is the most likely diagnosis?
   Cardiac failure
   Nephritic syndrome
   Nephrotic syndrome
   Rapidly progressive glomerulonephritis
   Renovascular disease

Answer 109

Nephrotic syndrome

Question 110

10. A 61 year old woman is admitted with 2 days of confusion. She has a history of hypertension and takes nifedipine. She smokes 20 cigarettes per day. She is confused but has no focal neurological deficit. Her pulse rate is 75 bpm, BP 139/87 mmHg and JVP 2 cm above the sternal angle.
    Investigations:
    Sodium 117 mmol/L (135–146)
    Potassium 4.2 mmol/L (3.5–5.3)
    Urea 1.9 mmol/L (2.5–7.8)
    Creatinine 57 μmol/L (60–120)
    Serum osmolality 252 mOsmol/kg (285–295)
    Urine osmolality 585 mOsmol/kg (100–1000)
    Which mechanism best explains the development of hyponatraemia?
    Increased sodium secretion in the distal tubule
    Increased water absorption in the collecting duct
    Increased water ingestion
    Reduced cortisol secretion
    Reduced sodium reabsorption in the proximal tubule

Answer 110

Increased water absorption in the collecting duct

Question 111

11. A 55 year old man has had lower back pain and fatigue for 3 months.
    Investigations:
    Haemoglobin 110 g/L (130–175)
    White cell count 5.8 × 109/L (3.8–10.0)
    Platelets 120 × 109/L (150–400)
    Corrected calcium 2.90 mmol/L (2.2–2.6)
    Albumin 29 g/L (35–50)
    Serum electrophoresis: monoclonal Ig kappa peak
    Bone marrow biopsy: foci of plasma cells, which account for 18% of all haematopoietic cells
    Which is the most likely diagnosis?
    Acute lymphoblastic lymphoma
    Chronic lymphocytic leukaemia
    Extramedullary plasmacytoma
    Multiple myeloma
    Waldenström’s macroglobulinaemia

Answer 111

Multiple myeloma

Question 112

12. A 32 year old man is referred to a gastroenterology clinic with hepatomegaly. He has a history of type 2 diabetes that is diet controlled. He is taking no regular medication. He is a non-smoker and drinks approximately 16 units of alcohol per week. He is married with no children.
    Cardiovascular and respiratory examinations are normal. His abdomen is soft, with a 3 cm palpable liver edge. His BMI is 23 kg/m2(18–25).
    Investigations:
    Albumin 38 g/L (35–50)
    ALT 90 IU/L (10–50)
    ALP 112 IU/L (25–115)
    Bilirubin 15 µmol/L (<17)
    Ferritin 710 µg/L (12–200)
    CRP 6 mg/L (<5)
    Which is the most appropriate next investigation?
    Hepatitis C serology
    Liver biopsy
    Reticulocyte count
    Serum γGT
    Transferrin saturation

Answer 112

Transferrin saturation

Question 113

13. A 78 year old man has worsening breathlessness over 7 days. He gives a 3 month history of lethargy. He has a dry cough and is a non-smoker. He retired as a builder 15 years ago. He has a temperature of 37.1°C. He has scattered coarse crackles in both lung fields. His chest X-ray is shown (see image).

Cannon ball lung

Which is the most likely underlying diagnosis?
Mesothelioma
Metastatic cancer
Pulmonary fibrosis
Pulmonary tuberculosis
Sarcoidosis

Answer 113

Metastatic cancer

Question 114

14. A 59 year old man is reviewed in clinic. He has type 1 diabetes mellitus, hypertension, ischaemic heart disease and CKD stage 4 [recent eGFR 25 mL/min/1.73 m2(> 60)]. He is taking insulin, lisinopril, metoprolol tartrate and aspirin.
    His BP is 148/93 mmHg. He has pitting oedema to the mid calves.
    Investigations:
    Sodium 137 mmol/L (135–146)
    Potassium 5.6 mmol/L (3.5–5.3)
    Urea 13.8 mmol/L (2.5–7.8)
    Creatinine 237 µmol/L (60–120)
    eGFR 26 mL/min/1.73 m2 (>60)
    Urinalysis: protein 2+
    Which is the most appropriate therapeutic change?
    Add Bendroflumethiazide
    Add furosemide
    Add spironolactone
    Stop lisinopril
    Switch lisinopril to losartan

Answer 114

Add furosemide

Question 115

15. A 30 year old woman has a brief episode of loss of consciousness. She has had 2 days of cough, sore throat and fever. She has been feeling tired for several weeks and has lost 3 kg in weight.
    Her temperature is 37.6°C, pulse rate 95 bpm, BP 100/55 mmHg lying and 90/50 mmHg sitting, respiratory rate 18 breaths per minute and oxygen saturation 95% breathing air. Her JVP is not visible. Chest examination is normal.
    Investigations:
    Haemoglobin 106 g/L (115–150)
    White cell count 14 × 109/L (3.8–10.0)
    Platelets 201 × 109/L (150–400)
    Sodium 130 mmol/L (135–146)
    Potassium 5.9 mmol/L (3.5–5.3)
    Urea 9.5 mmol/L (2.5–7.8)
    Creatinine 98 µmol/L (60–120)
    Random plasma glucose 3.2 mmol/L
    12-lead ECG sinus rhythm
    Which is the most appropriate additional investigation?
    CT of head
    CT pulmonary angiography
    Echocardiography
    Plasma cortisol and adrenocorticotropic hormone
    Urinary and serum osmolality

Answer 115

Plasma cortisol and adrenocorticotropic hormone

Question 116

16. A 59 year old woman has loin pain and dysuria.
    Her temperature is 39°C, pulse rate 108 bpm, BP 90/60 mmHg and respiratory rate 18 breaths per minute.
    Investigations:
    Haemoglobin 130 g/L (115–150)
    White cell count 22.0 × 109/L (3.8–10.0)
    Platelets 40 × 109/L (150–400)
    PT 20 seconds (10–12)
    APTT 60 seconds (22–41)
    Fibrinogen 1.0 g/dL (1.5–4.0)
    Which is the most likely explanation for her thrombocytopenia?
    Disseminated intravascular coagulation
    Haemophilia B
    Idiopathic thrombocytopenic purpura
    Vitamin B 12 deficiency
    Von Willebrand disease

Answer 116

Disseminated intravascular coagulation

Question 117

17. A 53 year old man has increasing abdominal swelling over several weeks. He has developed severe abdominal pain over the past 12 hours. He drinks one to two bottles of vodka per day.
    He has jaundice, and has spider naevi and prominent veins on his abdominal wall. His temperature is 37.6°C. His abdomen is diffusely tender.
    Investigations:
    Haemoglobin 136 g/L (130–175)
    White cell count 9.6 × 109/L (3.8–10.0)
    Platelets 160 × 109/L (150–400)
    INR 1.2 (1.0)
    ALT 350 IU/L (10–50)
    ALP 140 IU/L (25–115)
    Bilirubin 78 μmol/L (<17)
    Ultrasound scan of abdomen shows ascites with mild hepatosplenomegaly.
    Which is the most appropriate next step?
    Ascitic tap
    CT of abdomen
    Hepatitis serology
    Percutaneous liver biopsy
    Ultrasonography of abdomen

Answer 117

Ascitic tap

Question 118

18. A 62 year old woman has breathlessness and right-sided pleuritic chest pain of sudden onset. She had a bleeding peptic ulcer secondary to NSAID use 3 weeks ago requiring a 2-unit blood transfusion. She has a history of osteoarthritis. She is taking lansoprazole and co-codamol. Her pulse rate is 112 bpm, BP 114/74 mmHg, respiratory rate 26 breaths per minute and oxygen saturation 94% breathing 40% oxygen. Her chest is clear.

Investigations:
Haemoglobin 95 g/L (115–150)
Creatinine 81 µmol/L (60–120)
CT pulmonary angiogram: Thrombus in both pulmonary arteries
Which is the most appropriate initial treatment?
Insertion of vena cava filter
Intravenous alteplase
Intravenous heparin
Oral apixaban
Subcutaneous dalteparin sodium

Answer 118

Intravenous heparin

Question 119

19. A 69 year old woman with type 2 diabetes mellitus attends the clinic for review. Her metformin treatment was stopped during a recent hospital admission with heart failure, in view of worsening chronic kidney disease [eGFR 28 mL/min/1.73 m2(>60)]. She has a history of diverticular disease. She is currently taking the maximum dose of gliclazide.
    Investigations:
    Glycated haemoglobin 78 mmol/mol (20–42)
    She is keen to avoid giving herself injections.
    Which is the most appropriate additional treatment?
    Acarbose (α-glucosidase inhibitor)
    Dulaglutide (GLP-1 agonist)
    Empagliflozin (SGLT2 inhibitor)
    Pioglitazone (thiazolidinedione)
    Sitagliptin (DPP4 inhibitor)

Answer 119

Sitagliptin (DPP4 inhibitor)

Question 120

20. A 53 year old woman has 6 months of worsening tiredness.
    She has jaundice, xanthelasma and 7 cm non-tender hepatomegaly.
    Investigations:
    INR 1.2 (1.0)
    ALT 60 IU/L (10–50)
    ALP 302 IU/L (25–115)
    Bilirubin 50 µmol/L (<17)
    Antinuclear antibodies 1:40 (negative at 1:20)
    Antimitochondrial antibodies 1:320 (negative at 1:20)
    Ultrasound scan of abdomen: hepatosplenomegaly, no biliary dilatation
    Which is the most appropriate treatment?
    Azathioprine
    Lamivudine
    Prednisolone
    Thiamine
    Ursodeoxycholic acid

Answer 120

Ursodeoxycholic acid