MSC practice paper 1

Question 1

A 67 year old man is found to have an ejection systolic murmur. He is otherwise well. His pulse rate is 72 bpm and BP 128/84 mmHg. His chest is clear.
Investigations:
ECG shows sinus rhythm.
Echocardiography shows aortic stenosis, valve gradient 50 mmHg. Left ventricular (LV) diastolic dysfunction, LV ejection fraction 45% (>55).

Which is the most appropriate management?
A. Clinical review and echocardiography in 6 months
B. Reassure and discharge
C. Refer for aortic valve replacement
D. Start bisoprolol fumarate and advise review if symptomatic
E. Start lisinopril and advise review if symptomatic

Answer 1

C. Refer for aortic valve replacement

The aortic valve gradient of 50mmHg is considered the level where aortic valve replacement should be considered. In addition, the mild reduction in LV function would also support prompt consideration of an AVR. Medications should not be started as these have no effect on the valve disease progression and may even cause side effects. The patient needs to start the process of definitive treatment with valve replacement, so it is not good practice or safe to either discharge or review in 6 months.

Question 2

A 46 year old man has pain in his left leg and tingling in his left big toe. He developed severe lower back pain 1 week ago and he is unable to walk on his left heel. There is loss of pinprick perception over the left great toe.

Which nerve root is the most likely to have been affected?
A. L1
B. L3
C. L5
D. S1
E. S2

Answer 2

C. L5

L5 is the most likely nerve root to have been affected. The patient has a combination of lower back pain, pain in the left leg, and tingling in the left big toe, which are consistent with the dermatomal distribution of the L5 nerve root. The inability to walk on the left heel suggests a left-sided foot drop, and so is also consistent with L5 nerve root dysfunction. The loss of pinprick perception over the left great toe also suggests involvement of the L5 dermatome.

Question 3

A 52 year old man has three days of severe epigastric pain, radiating to his back, but no chest pain. He has vomited several times. He was previously well. He drinks approximately 60 units of alcohol a week and smokes 20 cigarettes per day.
There is epigastric tenderness but his abdomen is not distended, and bowel sounds are present.
Which test would confirm the most likely diagnosis?
A. Abdominal X-ray
B. Gastroduodenoscopy
C. Serum alkaline phosphatase concentration
D. Serum amylase concentration
E. Ultrasound scan of abdomen

Answer 3

D. Serum amylase concentration

Serum amylase concentration would confirm the most likely diagnosis in this case. The patient presents with severe epigastric pain, radiating to his back, and vomiting, which are suggestive of acute pancreatitis. The presence of epigastric tenderness but not distended abdomen and normal bowel sounds are also consistent with this diagnosis. Serum amylase concentration is an important diagnostic test for acute pancreatitis. Elevated serum amylase levels occur early in the course of the disease and can be measured within hours of symptom onset. Abdominal X-ray, gastroduodenoscopy, serum alkaline phosphatase concentration, and ultrasound scan of the abdomen may be useful in certain cases, but they are not as specific for diagnosing acute pancreatitis as serum amylase concentration.

Question 4

A 55 year old man is rescued from a collapsed building where he has been trapped for 12 hours without water.His temperature is 35.6°C, pulse rate 100 bpm and BP 90/42 mmHg. His JVP is not visible. His abdomen is non tender.
Investigations:
Haemoglobin 168 g/L (130–175) Sodium 148 mmol/L (135–146) Potassium 6.0 mmol/L (3.5–5.3) Urea 25.1 mmol/L (2.5–7.8) Creatinine 184 μmol/L (60–120) Creatine kinase 840 U/L (25–200)

Which is the most likely cause of this biochemical picture?
A. Bladder outflow obstruction
B. Direct renal trauma
C. Hypovolaemia
D. Rhabdomyolysis
E. Sepsis

Answer 4

C. Hypovolaemia

The most likely cause is acute kidney injury due to hypovolaemia. The observations of tachycardia and hypotension fit this. There are no signs of sepsis or reason why this has developed. The creatine kinase is only minimally elevated and would normally be 10,000 in cases of rhabdomyolysis.

Question 5

A 34 year old woman has a recurrent itchy rash which lasts for several hours before resolving. The patient presents with urticarial weals. She has not identified any triggers. She is systemically well. She is a firefighter and says that she does not want any treatments that may affect her level of alertness.

Which is the most appropriate treatment to control her symptoms?
A. Oral chlorphenamine maleate
B. Oral loratadine
C. Oral prednisolone
D. Topical aqueous cream
E. Topical hydrocortisone

Answer 5

B. Oral loratadine

Initial treatment for this should be a non-sedating H1-antihistamine. The correct answer is thus B (oral loratadine). Chlorphenamine maleate is a sedating antihistamine, which is more likely to cause adverse effects; this patient also specifically requested treatment that would not affect her level of alertness. Prednisolone is effective for severe, acute urticaria but should not be used first-line. Aqueous cream is a soap substitute and has no role in the management of urticaria. Topical corticosteroids are ineffective for urticaria so hydrocortisone is not indicated here.

Question 6

A 29 year old woman has 2 days of marked loss of vision and acute pain in her left eye. The pain is worse when she changes her gaze direction.
Her eyes appear normal on general inspection. Her vision is ‘count fingers only’ in the affected eye. The swinging flashlight test shows that the left pupil dilates when a bright light is moved from the right eye to the left eye. The optic discs are normal on fundoscopy.

Which is the most likely diagnosis?
A. Acute closed angle glaucoma
B. Giant cell arteritis
C. Idiopathic intracranial hypertension
D. Migraine with aura
E. Retrobulbar optic neuritis

Answer 6

E. Retrobulbar optic neuritis

The most likely diagnosis in this scenario is retrobulbar optic neuritis. The acute onset of eye pain and marked loss of vision, along with the presence of relative afferent pupillary defect (RAPD) on swinging flashlight test, are suggestive of optic neuritis. The absence of optic disc swelling on fundoscopy suggests a retrobulbar lesion. Acute closed angle glaucoma also presents with acute eye pain, but it is typically associated with other features such as vomiting, headaches and a red eye with a dilated pupil accompanied by a high intraocular pressure. Giant cell arteritis can also cause acute visual loss, but it is more commonly seen in older patients and is often associated with systemic symptoms such as headache, jaw claudication, and malaise. Idiopathic intracranial hypertension can cause vision loss and headache, but it typically does not cause pain with eye movements. Migraine with aura can cause visual disturbances, but it is typically not associated with pain, and the presence of RAPD suggests a neuro- ophthalmic rather than a primary headache disorder.

Question 7

A 61 year old man has had 2 months of ankle swelling. He has hypertension and a 30 year history of seronegative polyarthritis. His medication includes ramipril, sulfasalzine, hydroxychloroquine sulfate and diclofenac.
His BP is 156/90 mmHg. He has pitting oedema to mid thigh and signs of chronic deforming polyarthropathy in his hands, but no joint tenderness. His optic fundi show silver wiring and arteriovenous nipping. Urinalysis: protein 4+, no other abnormalities.
Investigations:
Sodium 133 mmol/L (135–146)
Potassium 5.4 mmol/L (3.5–5.3)
Urea 9.0 mmol/L (2.5–7.8)
Creatinine 119 μmol/L (60–120)
Albumin 21 g/L (35–50)
CRP 43 mg/L (<5)
Urinary protein:creatinine ratio 1100 mg/mmol (<30)

Which is the most appropriate initial treatment?
A. Candesartan cilexetil
B. Furosemide
C. Indapamide
D. Prednisolone
E. Prednisolone and cyclophosphamide

Answer 7

B. Furosemide

Based on the clinical presentation and investigations, the most likely diagnosis is nephrotic syndrome, possibly secondary to the patient’s long-standing polyarthritis. The appropriate initial treatment would be to start a furosemide to reduce the patient’s ankle swelling and to refer the patient to a specialist for further investigation and management of the underlying cause. Furosemide is a loop diuretic that acts on the ascending limb of the loop of Henle to increase sodium and water excretion, which can reduce oedema. It is a commonly used diuretic in the management of nephrotic syndrome.

Question 8

A 75 year old woman has had 5 months of a 2 cm red plaque on her leg. Investigation:
Skin biopsy: Bowen’s disease

Which is the most appropriate topical treatment?
A. 5-fluorouracil (Efudix® ) cream
B. Betamethasone valerate (Betnovate® ) cream
C. Diclofenac (Solaraze® ) gel
D. Isotretinoin gel
E. Salicylic acid gel

Answer 8

A. 5-fluorouracil (Efudix® ) cream

The most appropriate topical treatment for Bowen’s disease, a type of squamous cell carcinoma in situ 5-fluorouracil (Efudix) cream. This is a form of topical cytotoxic chemotherapy which is used to treat both Bowen’s disease and actinic keratosis. It is typically applied to the affected area once or twice a day for 2-4 weeks. An inflammatory reaction, which can be severe, should be expected. Topical corticosteroids such as betamethasone valerate have no effect on Bowen’s disease. Diclofenac can be used in the treatment of actinic keratosis but is not indicated for Bowen’s disease. Isotretinoin gel is a retinoid used in the treatment of acne. Salicylic acid is a keratolytic agent, which is used in the management of hyperkeratotic lesions such as viral warts and sometimes actinic keratoses. Whilst it might reduce hyperkeratosis in Bowen’s, it will not treat the underlying dysplasia effectively.

Question 9

A 32 year old woman has had palpitations and hot flushes for 4 weeks. She has noticed a painless swelling in her neck over the same time and her weight has decreased by 2 kg. She gave birth 4 months ago after a normal pregnancy. She is not breastfeeding.
Her pulse rate is 120 bpm and BP 140/90 mmHg. She is tremulous and restless. She has a large smooth non-tender goitre.
Investigations:
Free T4 35.6 pmol/L (9–25)
Free T3 10.8 pmol/L (4.0–7.2)
TSH <0.01 mU/L (0.3–4.2)
Thyroid peroxidase antibodies >1600 IU/L (<50)
Thyroid stimulating antibodies <1.0 IU/L (<1.75)

Which is the most appropriate initial treatment?
A. Carbimazole
B. Propranolol
C. Propylthiouracil
D. Thyroidectomy
E. Thyrotropin alfa

Answer 9

B. Propranolol

The patient’s presentation and investigations are consistent with hyperthyroidism and a diagnosis of postpartum thyroiditis. Given her symptoms of palpitations, hot flushes, tremulousness, and a high pulse rate, the most appropriate initial treatment is option propranolol. It works by blocking the effects of thyroid hormones on the heart and peripheral tissues. Propranolol can be started immediately to control the patient’s symptoms while further investigations and management are initiated.

Question 10

A 64 year old man has developed a tremor in both arms over the last 6 months. It is worse on the right. He also reports difficulty sleeping due to restlessness.
He appears emotionally flat and has a tremor at rest that is alleviated on movement.

Which neurotransmitter is most likely to be deficient?
A. Acetylcholine
B. Dopamine
C. Glycine
D. Norepinephrine (noradrenaline)
E. Serotonin

Answer 10

B. Dopamine

The diagnosis is Parkinson’s disease and hence dopamine is most likely to be deficient. The presence of an asymmetric resting tremor that is alleviated on movement is a characteristic feature of Parkinson’s disease. The restless sleep implies probable associated REM sleep behaviour disorder.

Question 11

An 85 year old man is admitted from a nursing home with a spreading cellulitis originating from an ulcer over his right ankle. Cultures taken from the ulcer and blood have grown MRSA.
He is mildly confused. His temperature is 39.5°C, pulse rate 96 bpm and BP 114/60 mmHg.

Which is the most appropriate initial antibiotic treatment?
A. Co-amoxiclav
B. Flucloxacillin
C. Meropenem
D. Piperacillin with tazobactam
E. Vancomycin

Answer 11

E. Vancomycin

Vancomycin would be the most appropriate initial antibiotic treatment in this case of MRSA cellulitis. Vancomycin is a glycopeptide antibiotic that is active against MRSA and other Gram-positive bacteria. It is the drug of choice for treating serious MRSA infections, such as cellulitis, when the strain is known or suspected to be resistant to beta-lactam antibiotics like flucloxacillin or co- amoxiclav. Piperacillin with tazobactam and meropenem are broad-spectrum antibiotics that may be used as an alternative if the patient has a severe penicillin allergy or if the infection is suspected to be caused by Gram-negative bacteria as well. However, they are not specific for MRSA and should be used judiciously to avoid the development of antibiotic resistance.

Question 12

A 76 year old woman with hypertension is taking amlodipine 10 mg daily. A 24 hour BP measurement shows a mean BP of 168/90 mmHg.
Investigations:
Sodium 135 mmol/L (135–146) Potassium 4.0 mmol/L (3.5–5.3) Urea 7 mmol/L (2.5–7.8) Creatinine 100 μmol/L (60–120) eGFR 68 mL/min/1.73 m2(>60)
Urinary albumin : creatinine ratio 50 mg/mmol (<3.5)

Which class of antihypertensive should be added?
A. ACE inhibitor
B. Alpha blocker
C. Beta blocker
D. Loop diuretic
E. Thiazide-like diuretic

Answer 12

A. ACE inhibitor

ACE inhibitors are the most effective medication to treat albuminuria to delay progression to end stage renal disease and reduces cardiovascular risk. NICE suggest that ACE inhibitors or AR2B medications should be first choice in this situation with an ACR 30 mg/mmol in a patient with hypertension. There is no evidence for the other medications to reduce proteinuria and thus CVS risk.

Question 13

An 80 year old man has sudden onset of loss of vision in his right eye. He has hypertension and a previous stroke.
His visual acuity is hand movements only in the right eye and 6/9 in left eye. The right eye has an afferent pupillary defect; left eye pupil responses are normal. On fundoscopy there is a red spot at the right macula.

Which is the most likely diagnosis?
A. Anterior ischaemic optic neuropathy
B. Branch retinal vein occlusion
C. Central retinal artery occlusion
D. Macular degeneration
E. Retinal detachment

Answer 13

C. Central retinal artery occlusion

The most likely diagnosis in this scenario is central retinal artery occlusion (CRAO). The sudden onset of visual loss, the presence of an afferent pupillary defect, and red spot (the cherry red spot) on fundoscopy are all consistent with this diagnosis. The patient also has risk factors for this diagnosis. In branch retinal vein occlusion patients typically have multiple retinal haemorrhages in the distribution of the vein. Macular degeneration does not cause sudden onset visual loss and although both retinal detachment and anterior ischaemic optic neuropathy cause acute visual loss neither have the fundoscopic findings described.

Question 14

A 72 year old woman has had inability to sleep well for the past 3 years. She gets to sleep by 23:00 but wakes up two or three times in the night and gets up by 07:00. Her husband says that she doesn’t snore. Her BMI is 23 kg/m2. She carries out her normal daytime activities with no daytime somnolence. She is otherwise well. Her MMSE (Mini Mental State Examination) score is 27/30.

Which is the most likely cause of her insomnia?
A. Depression
B. Early stages of dementia
C. Hypomania
D. Normal age related sleep pattern
E. Obstructive sleep apnoea

Answer 14

D. Normal age related sleep pattern

Based on the information given, the most likely cause of her insomnia is normal age-related sleep pattern. This is because she is able to carry out normal daytime activities with no daytime somnolence, has no history of snoring or other sleep-related symptoms, and has a high MMSE score indicating good cognitive function. It is common for older adults to experience changes in their sleep patterns, such as more fragmented sleep and more frequent awakenings during the night. Other potential causes such as depression, dementia, hypomania, and obstructive sleep apnoea would require further evaluation and additional symptoms or risk factors to be confirmed.

Question 15

A 35 year old man visits his GP with 3 days of a red, painful left eye with no discharge.
There is a diffuse area of redness in the medial aspect of his left sclera. His pupils and visual acuity are normal.
Which is the most appropriate management?
A. Arrange assessment in emergency eye clinic
B. Prescribe chloramphenicol eye drops
C. Prescribe corticosteroid eye drops
D. Prescribe topical aciclovir
E. Reassure patient that it will resolve spontaneously

Answer 15

A. Arrange assessment in emergency eye clinic

The symptoms of a painful red eye without discharge and a diffuse area of redness on the sclera are suggestive of scleritis, which requires immediate referral by his GP to an ophthalmologist via the emergency eye clinic. Scleritis is an inflammatory condition of the sclera that can lead to other serious ocular complications if untreated. Although topical corticosteroids may be used in the management of scleritis these should only be initiated under the supervision of an Ophthalmologist after confirmation of the diagnosis. None of the other options in this case would be appropriate.

Question 16

A 35 year old man with type 1 diabetes mellitus has burning pain in his feet and difficulty sleeping. He has retinopathy and nephropathy.
Investigation:eGFR 28 mL/min/1.73m2(> 60)

Which is the most appropriate management?
A. Acupuncture
B. Amitriptyline
C. Duloxetine
D. Physiotherapy
E. Sodium valproate

Answer 16

B. Amitriptyline

The most appropriate management for this patient with type 1 diabetes mellitus, burning pain in his feet, difficulty sleeping, and decreased eGFR would be amitriptyline. Although duloxetine can be used in this condition it is not recommended with an eGFR <30 mL/min.

Question 17

A 52 year old woman has had four episodes of severe, colicky epigastric pain associated with vomiting over the past 3 months. The episodes occurred after eating and lasted for about 1 hour before complete resolution. She has a history of type 2 diabetes mellitus and takes metformin.
Abdominal examination is normal. Her BMI is 35 kg/m2.
Which investigation is most likely to confirm the diagnosis?
A. Helicobacter stool antigen test
B. Serum Amylase
C. Plain abdominal X-ray
D. Ultrasonography of abdomen
E. Upper gastrointestinal endoscopy

Answer 17

D. Ultrasonography of abdomen

The patient reports intermittent episodes of colicky pain in association with nausea and vomiting. This would be consistent with biliary colic. She has risk factors for gallstones including being female, middle aged and overweight. Therefore, an ultrasound of abdomen would be the appropriate investigation at this stage. Pain associated with gastro-oesophageal reflux disease (GORD) and dyspepsia this is likely to lead to persistent symptoms over a period of time. Upper Gi endoscopy and Helicobacter stool antigen test are relevant when investigating for suspected GORD. Serum amylase is indicated in suspected pancreatitis. Plain abdominal X-ray would be potentially helpful in the investigation of suspected small or large bowel pathologies (e.g. obstruction, constipation), although CT would likely be more informative.

Question 18

An 83 year old woman has recurring ‘dizzy spells’. The episodes are associated with transient shaking of her hands that is most noticeable before her lunch and evening meals. She has hypertension and type 2 diabetes mellitus. Her medication includes metformin 1 g twice daily, gliclazide 80 mg twice daily and ramipril 10 mg daily.
Her BP is 138/82 mmHg supine and 130/78 mmHg erect. Her blood capillary glucose is 6 mmol/L.
Investigations:
Sodium 136 mmol/L (135-146)
Potassium 5.0 mmol/L (3.5-5.3)
Urea 3.9 mmol/L (2.5-7.8)
Creatinine 77 μmol/L (60-120)
Glycated haemoglobin 50 mmol/mol (20-42)

Which is the most appropriate therapeutic change?
A. Increase gliclazide dose
B. Increase metformin dose
C. Reduce gliclazide dose
D. Reduce metformin dose
E. Reduce ramipril dose

Answer 18

C. Reduce gliclazide dose

This 83 year old woman is experiencing symptoms consistent with hypoglycaemia. The timing of her “dizzy spells” and hand shaking - before lunch and evening meals - suggests they might be related to periods of extended fasting and thus to her medications, particularly the ones that have the potential to lower blood glucose. Furthermore, her glycated haemoglobin (HbA1c) level is 50 mmol/mol. While this is elevated compared to the normal reference range provided (20-42 mmol/mol), it’s in the target range or even a bit stringent for many elderly patients with type 2 diabetes. Overly aggressive glycaaemic control can increase the risk of hypoglycaemia in older adults. Therefore, the most appropriate therapeutic change, given the symptoms and the clinical context, would be to reduce gliclazide dose.

Question 19

A 67 year old woman has an ulcer with a raised white margin on her left ear; it has been present for 3 years, growing slowly and never completely healing. She spent 20 years living in Australia before returning to the UK recently.
On examination, she has a small ulcerated area, 4 mm × 6 mm, on her left pinna.

Which is the most likely diagnosis?
A. Actinic keratosis
B. Basal cell carcinoma
C. Malignant melanoma
D. Seborrhoeic keratosis
E. Squamous cell carcinoma

Answer 19

B. Basal cell carcinoma

The history of an ulcerated lesion on the ear in an individual likely to have had a high level of ultraviolet light exposure from living in Australia should raise the possibility of a keratinocyte cancer. Given the long history yet small size of the lesion, together with the description of a raised, pale border make basal cell carcinoma (BCC) the most likely diagnosis. Other characteristic features would be a shiny or pearly surface, a rolled edge or overlying telangiectasia. Actinic keratoses are pink and scaly or hyperkeratotic and do not ulcerate. There is no pigmentation to suggest melanoma. Whilst amelanotic melanoma is not completely impossible here, BCC is hugely more common and therefore a much more likely diagnosis. Seborrhoeic keratosis is a harmless warty lesion, which is usually pigmented and does not ulcerate. Squamous cell carcinoma is the other main type of keratinocyte cancer, but is usually red, not pale. It typically grows at a much faster rate than BCC.

Question 20

An 82 year old woman with atrial fibrillation takes warfarin to reduce her risk of stroke. Her INR is fluctuating between 1.1 and 3.8 (1.0), and she admits that she does not always remember to take her tablets. Her CHA2DS2-VASc score is 4. She lives alone and independently.

Which is the safest way to manage her stroke risk?
A. Change to aspirin using a monitored dosage system
B. Change to dalteparin administered by district nurse
C. Change to rivaroxaban using a monitored dosage system
D. Continue warfarin using a monitored dosage system
E. Stop anticoagulation

Answer 20

C. Change to rivaroxaban using a monitored dosage system

Still needs anti-coagulation from CHA2DS2VASc score. Warfarin or rivaroxaban only indicated for stroke prevention in AF. Metered dosage system appropriate but variable dosing of warfarin difficult with this so change to rivaroxaban.

Question 21

A 35 year old man visits his GP with a severe frontal headache of 12 hours’ duration. It started suddenly, reaching maximum intensity within 1 minute. He has associated nausea.
At the onset of his headache he noticed a small hole in his vision. This hole started centrally, moved to the edge of his vision and has now resolved. The headache is worse in bright light. Paracetamol has not helped his pain.

Which feature should prompt immediate referral to hospital?
A. Abrupt onset
B. Failure to respond to paracetamol
C. Nausea
D. Photophobia
E. Visual disturbance

Answer 21

A. Abrupt onset

The case description seems to be of migraine with a surprisingly abrupt onset of headache. It is the abrupt onset of headache is the most worrying feature and suggests a serious underlying cause. Abrupt onset of headache with visual disturbance could be due to subarachnoid haemorrhage (possibly a haemorrhage into the occipital lobe, e.g. from an intracerebral arteriovenous malformation), or haemorrhage into a pituitary macroadenoma with compression of the anterior visual pathway. Other possibilities include reversible cerebral vasoconstriction syndrome, cerebral venous sinus thrombosis or low- pressure headache, though visual disturbance would not be easily explained).

Question 22

A 27 year old woman has had abdominal pain for 48 hours. She also reports recurrent mouth ulcers and altered bowel habit for a few weeks.
Her temperature is 37.5°C. She has central abdominal tenderness. Investigations:
CT colonoscopy shows a normal appendix with distal small bowel thickening. There are enlarged nodes in the small bowel mesentery.

Which is the most likely diagnosis?
A. Crohn’s ileitis
B. Intestinal tuberculosis
C. Meckel’s diverticulitis
D. Mesenteric adenitis
E. Small bowel lymphoma

Answer 22

A. Crohn’s ileitis

Crohn’s ileitis is the most likely diagnosis based on the patient’s symptoms, findings on CT colonoscopy, and demographic factors. Crohn’s disease is a chronic inflammatory bowel disease that can affect any part of the gastrointestinal tract, but it most commonly involves the terminal ileum. The patient’s symptoms of recurrent mouth ulcers and altered bowel habit are consistent with Crohn’s disease, and the finding of small bowel thickening with enlarged mesenteric nodes on CT colonoscopy is also suggestive. Intestinal tuberculosis may be considered in the differential diagnosis, but the patient’s demographics make this less likely. Meckel’s diverticulitis and mesenteric adenitis may also be considered, but the lack of a diverticulum or focal lymphadenopathy makes these less likely. Small bowel lymphoma is another possible diagnosis, but the presence of a normal appendix makes this less likely.

Question 23

A 45 year old man has had weight loss, fatigue and polyuria for 3 months. He takes a number of multivitamin preparations.
Clinical examination is unremarkable.
Investigations:
Serum corrected calcium 2.9 mmol/L (2.2–2.6)
Phosphate 0.82 mmol/L (0.8– 1.5)
Serum alkaline phosphatase 154 IU/L (25–115)
Parathyroid hormone 7.9 pmol/L (1.6–8.5)
Serum electrolytes and urea are normal.

Which is the most likely diagnosis?
A. Bony metastases
B. Excess calcium intake
C. Primary hyperparathyroidism
D. Sarcoidosis
E. Vitamin D excess

Answer 23

C. Primary hyperparathyroidism

The most likely diagnosis in this case is primary hyperparathyroidism as it is characterised by increased serum calcium and alkaline phosphatase. The parathyroid hormone is only slightly elevated which is still consistent with the diagnosis, as it should be suppressed in the presence of hypercalcaemia. Excess calcium intake and vitamin D excess can also cause hypercalcaemia but they are less likely in this case as the patient does not report any excessive intake of these substances. Bony metastases and sarcoidosis can also cause hypercalcemia, but they would cause a suppressed PTH.

Question 24

A 59 year old man has a 1 year history of erectile dysfunction. He has a history of angina, type 2 diabetes mellitus and peripheral vascular disease. He had a thyroidectomy 2 years ago for thyrotoxicosis. His regular medications are aspirin, diltiazem, levothyroxine, metformin, ramipril and simvastatin.
His BP is 140/90 mmHg lying and 135/85 mmHg standing. His foot pulses are not palpable. He has normal sensation in his feet.

Which is most likely to be the main cause of his erectile dysfunction?
A. Adverse effect of medication
B. Autonomic neuropathy
C. Hypothyroidism
D. Testosterone deficiency
E. Vascular insufficiency

Answer 24

E. Vascular insufficiency

Vascular insufficiency is the most likely main cause of erectile dysfunction in this patient. The patient has peripheral vascular disease and similar vascular disease can occur in the penile blood supply. None of his medications is likely to cause erectile dysfunction and there are no clinical features of testosterone deficiency. Autonomic neuropathy can contribute to erectile dysfunction in patients with diabetes but the patient does not have any other features of neuropathic disease. Hypothyroidism can also cause erectile dysfunction, but this is less likely in this patient given that he is on levothyroxine replacement therapy.

Question 25

A 52 year old man has had 3 months of fatigue. He has a history of ulcerative colitis and takes mesalazine. He drinks 20 units of alcohol per week. His temperature is 36.8°C and pulse rate 80 bpm. He has 3 cm hepatomegaly. Investigations: Albumin 36 g/L (35–50) ALT 65 IU/L (10–50) ALP 580 IU/L (25–115) Bilirubin 18 μmol/L (<17) γGT 230 IU/L (9–40) Which is the most likely diagnosis? A. Alcoholic hepatitis B. Cholangiocarcinoma C. Choledocholithiasis D. Hepatocellular carcinoma E. Primary sclerosing cholangitis

Answer 25

E. Primary sclerosing cholangitis The correct answer is Primary Sclerosing cholangitis. He has had non-specific symptoms for a number of months. His liver function test shows a cholestatic pattern with a raised ALP. This is an increased incidence of primary sclerosing cholangitis in patients with inflammatory bowel disease. While alcoholic hepatitis is a possibility an alcohol intake of 20 units per week is not high enough to cause significant damage in an otherwise healthy liver. Cholangiocarcinoma and hepatocellular carcinoma are less likely given the short duration of symptoms and lack of specific risk factors, such as viral hepatitis or cirrhosis. Choledocholithiasis may present with elevated liver function tests, but is less likely to cause hepatomegaly or fatigue.

Question 26

A 28 year old woman has pain on swallowing. She has a history of asthma that is well controlled using metered dose salbutamol and beclometasone dipropionate (800 micrograms/day) inhalers. She has white plaques in her mouth. An anti-fungal oral suspension is prescribed. What is the most appropriate management with regard to her beclometasone? A. Change beclometasone dipropionate to a dry powder formulation B. Change beclometasone dipropionate to fluticasone C. Change beclometasone dipriopionate to salmeterol D. Take beclometasone dipropionate using a large volume spacer E. Take salbutamol and beclometasone dipropionate at least 1h apart

Answer 26

D. Take beclometasone dipropionate using a large volume spacer This patient has developed oral candidiasis and this is most likely due to local deposition of the inhaled steroid (beclometasone dipropionate). The risk of this happening again can be reduced by using a large volume spacer as there will be less local deposition of the drug in her mouth. Changing to a dry powder or a different steroid inhaler is unlikely to help and may make things worse.

Question 27

A 37 year old man has increasing fever and shortness of breath. He was admitted 3 days ago with left lower lobe pneumonia due penicillin-sensitive Streptococcus pneumoniae. He is receiving intravenous benzylpenicillin 1.2 g four times daily. His temperature is 38.5°C, pulse 100 bpm and BP 122/80 mmHg. Investigations: Chest X-ray: left basal effusion. Diagnostic pleural aspiration: Purulent fluid. Microscopy shows numerous polymorphs and Gram-positive cocci Which is the most appropriate next step in management? A. Chest drain insertion B. Increase dose of benzylpenicillin C. Open thoracostomy D. Switch benzylpenicillin to ceftriaxone E. Switch benzylpenicillin to vancomycin

Answer 27

A. Chest drain insertion This patient has a fever and an empyema at the left lung base. A chest drain needs to be inserted to allow the purulent fluid to be drained away. The patient is already on appropriate antibiotics for Streptococcus pneumoniae but a discussion with the Microbiology team would still be useful.

Question 28

A 32 year old woman has 3 weeks of fever, rigors and lethargy. In the past week, she has also become breathless on exertion. She is an intravenous drug user. Her temperature is 38°C, pulse rate 100 bpm regular, and BP 100/60 mmHg. Her JVP is raised with predominant V waves. There is a pansystolic murmur at the left sternal edge on inspiration. She has reduced air entry with dullness to percussion at the right lung base. She has swelling of both ankles. Which is the most likely pathogen? A. Enterococcus faecalis B. Staphylococcus aureus C. Staphylococcus epidermidis D. Streptococcus bovis / streptococcus equinus complex E. Streptococcus viridans

Answer 28

B. Staphylococcus aureus The patient’s presentation with fever, rigors, lethargy and breathlessness suggests sepsis. The pansystolic murmur at the left sternal edge heard on inspiration suggests tricuspid regurgitation and thus the most likely diagnosis is tricuspid valve endocarditis. Tricuspid regurgitation is a common complication of right-sided infective endocarditis in intravenous drug users. Staphylococcus aureus is a common pathogen in intravenous drug users and can cause endocarditis, pneumonia, and sepsis. The other organisms listed can all cause endocarditis but are less commonly associated with intravenous drug use- related infections.

Question 29

A 34 year old woman has sudden onset of right arm weakness and inability to speak. She has a history of migraine and generalised joint pains. Four years ago, she had a deep vein thrombosis in her right leg. Her pulse rate is 68 bpm and BP 178/94 mmHg. She has an expressive dysphasia. She has flaccid weakness of her right arm and facial droop on the right lower half of her face. Investigations: Haemoglobin 118 g/L (115–150) White cell count 4.3 × 109/L (3.8–10.0) Neutrophils 2.1 × 109/L (2.0–7.5) Lymphocytes 0.6 × 109/L (1.1–3.3) Platelets 132 × 109/L (150–400) Total cholesterol 4.6 mmol/L (<5.0) CT scan of head left frontoparietal infarct Which additional investigation is most likely to reveal the underlying cause of her stroke? A. Anti-dsDNA antibody B. Anticardiolipin antibody C. Anti-Ro antibody D. Rheumatoid factor E. Serum immunoglobulins

Answer 29

B. Anticardiolipin antibody The most likely underlying cause of her stroke is a cardioembolic source, possibly related to her history of deep vein thrombosis. Therefore, the most appropriate investigation to reveal the underlying cause of her stroke is anticardiolipin antibody. Anticardiolipin antibodies are a type of antiphospholipid antibody that can cause thrombosis and are associated with an increased risk of stroke. Patients with a history of deep vein thrombosis, like this patient, are at increased risk for the development of anticardiolipin antibodies. Testing for the presence of anticardiolipin antibodies can help confirm the diagnosis of antiphospholipid syndrome, which is an important cause of thrombotic events, including stroke. While the patient’s history of migraine and joint pains raise the possibility of an underlying autoimmune disorder, such as systemic lupus erythematosus, the presence of anticardiolipin antibodies is a more specific and relevant investigation in the context of her recent stroke.

Question 30

A 55 year old woman has been feeling tired and sleepy. Her partner says that she snores heavily. She has a history of type 2 diabetes mellitus and takes metformin. Her BMI is 38 kg/m2. Her oxygen saturation is 95% breathing air. Her Epworth sleepiness score is 19 (normal <11). Her HbA1cis 60 mmol/mol (20-42). Which treatment is most likely to improve her daytime somnolence? A. Bariatric surgery B. Continuous positive airway pressure ventilation C. Long acting insulin D. Mandibular advancement device E. Modafinil

Answer 30

B. Continuous positive airway pressure ventilation Based on the patient’s clinical presentation and history, the most likely cause of the daytime somnolence is obstructive sleep apnoea (OSA), which is characterised by snoring, excessive daytime sleepiness, and obesity. Continuous positive airway pressure (CPAP) ventilation is the gold standard treatment for OSA and involves using a mask to deliver air pressure to keep the airway open during sleep. It is highly effective in reducing daytime sleepiness, improving quality of life, and reducing the risk of cardiovascular complications associated with untreated OSA. While bariatric surgery may be considered in obese patients with OSA, it is not the first-line treatment for daytime somnolence. Long- acting insulin is also not indicated in this patient. Mandibular advancement devices may be considered in patients with mild to moderate OSA who cannot tolerate CPAP, but they are generally less effective than CPAP. Modafinil is a wake- promoting agent may be used as an adjunctive therapy in patients with residual daytime sleepiness despite optimal CPAP therapy, but it is not a first-line treatment for OSA.

Question 31

A 24 year old man is reviewed following a recent orchidectomy. The pathologist's report describes a mass with cystic spaces. Histological examination shows areas of mature cartilage and columnar epithelium. Which is the most likely diagnosis? A. Chondrosarcoma B. Hamartoma C. Lymphoma D. Seminoma E. Teratoma

Answer 31

E. Teratoma The most likely diagnosis in this case is teratoma, as it is a type of germ cell tumour that often contains different types of tissue, including cartilage and epithelium.

Question 32

An 86 year old woman has had three falls in the past 3 months. On each occasion, she describes feeling lightheaded and dizzy prior to falling. She is taking alendronic acid, amlodipine, atorvastatin, metformin and zolpidem tartrate. Her BP is 132/80 mmHg sitting and 138/84 mmHg standing. Which medication is most likely to be contributing to her falls? A. Alendronic acid B. Amlodipine C. Atorvastatin D. Metformin E. Zolpidem tartrate

Answer 32

E. Zolpidem tartrate Alendronic acid is a bisphosphonate and is not directly associated with falls. Atorvastatin is an HMG-CoA Reductase inhibitor which is not directly related to falls. Metformin is a biguanide and is not directly associated with falls. Whilst amlodipine can be associated with postural hypotension and subsequent falls this is not the case in this patient who does not have a postural drop in blood pressure on standing. Zolpidem tartrate is the correct answer as it is a non- benzodiazepine hypnotic and sedative and is associated with postural instability and falls.

Question 33

A 45 year old man has had 6 months of tiredness, reduced libido and erectile dysfunction. Investigations: Testosterone 1.8 nmol/L (9.9–27.8) LH 1.2 U/L (1–8) FSH 1.0 U/L (1–12) Which is the most likely cause of his presentation? A. Anabolic steroid misuse B. Androgen insensitivity syndrome C. Congenital adrenal hyperplasia D. Klinefelter's syndrome E. Pituitary adenoma

Answer 33

E. Pituitary adenoma Based on the low testosterone and low LH and FSH levels, the most likely cause of his presentation is a pituitary adenoma leading to hypogonadotropic hypogonadism. The pituitary adenoma would suppress the production of LH and FSH, which are required for testosterone production in the testes.

Question 34

A 48 year old man presents to his doctor with headaches. He has noticed that his hands have become larger, and his facial features have coarsened. More recently, his vision has deteriorated. He has an upper temporal defect in both visual fields. Damage to which structure is the most likely source of his visual problems? A. Lateral geniculate body B. Occipital cortex C. Oculomotor nerve D. Optic chiasm E. Optic radiation

Answer 34

D. Optic chiasm This 48-year-old man's presentation suggests acromegaly, which is typically caused by a growth hormone-secreting pituitary adenoma. One of the complications of a pituitary tumour is compression of nearby structures. Given the bitemporal (upper temporal) visual field defect described, this indicates compression of the optic chiasm. When the optic chiasm is compressed, particularly from an inferior approach as with a pituitary tumour, the crossing fibres (those responsible for the peripheral/temporal vision) are primarily affected, leading to a bitemporal field defect.

Question 35

A 42 year old man has a rash on his face, mainly around his chin. The rash started 24 hours ago with a 0.5 cm thin-walled blister that then ruptured, leaving a yellow crusted lesion that has since enlarged and now other similar lesions are appearing in the same area. He is a primary school teacher. Which is the most likely causative organism? A. Escherichia coli B. Pseudomonas aeruginosa C. Staphylococcus aureus D. Streptococcus pyogenes E. Varicella zoster virus

Answer 35

C. Staphylococcus aureus The description of the eruption fits best with bullous impetigo, although this usually occurs in children. Staphylococcus aureus, is the most common causative organism, although Streptococcus pyogenes can also be responsible for non-bullous impetigo. E. coli is not expected to cause skin infection. Pseudomonas may be found as a coloniser in chronic wounds but does not cause primary cutaneous infection in immunocompetent individuals. Varicella zoster virus causes chicken pox and subsequently shingles, neither of which fit the clinical picture described here.

Question 36

A 48 year old woman has had 3 years of increasing knee pain and reduced physical activity. She has radiologically-confirmed osteoarthritis. She has hypertension and type 2 diabetes. She takes lisinopril, metformin, semaglutide and simvastatin. Her BMI is 48 kg/m2and has not changed despite lifestyle advice and a low calorie diet for the last year. Investigations: Glycated haemoglobin 55 mmol/mol (20-42) Which is the most appropriate management? A. Intensify lifestyle measures and review in 6 months B. Prescribe orlistat C. Refer for bariatric surgery D. Refer for bilateral knee replacements E. Start insulin therapy

Answer 36

C. Refer for bariatric surgery The patient has severe obesity (BMI > 40 kg/m2) and comorbidities including hypertension and type 2 diabetes, which puts her at high risk for obesity-related complications. Despite lifestyle measures and low calorie diet, she has not been able to achieve significant weight loss. Bariatric surgery is an effective treatment option for obesity in patients with BMI > 40 kg/m2, or BMI > 35 kg/m2 with comorbidities such as diabetes and hypertension. The surgery has been shown to improve weight loss, reduce obesity-related comorbidities, including knee pain, and improve quality of life.

Question 37

A 22 year old soldier steps off a cramped military aircraft following a long flight from the United Kingdom. She suddenly collapses and hits her head on the ground. While unconscious, she has asynchronous jerking of her limbs for less than 15 seconds. Witnesses say that she looked pale. She regains consciousness within 1 minute. What is the most likely cause of her collapse? A. Cardiac arrhythmia B. Epilepsy C. Hypoglycaemia D. Pulmonary embolism E. Vasovagal syncope

Answer 37

E. Vasovagal syncope The most likely cause of her collapse is vasovagal syncope. The cramped conditions and fatigue during the flight could have caused her to experience a vasovagal response, resulting in a temporary loss of consciousness. The asynchronous jerking of her limbs may have been due to myoclonus, which can occur during syncope. The pallor may be due to a transient decrease in blood pressure during the episode. Pulmonary embolism is a possibility, but vasovagal syncope is much more likely. Epilepsy is a possibility, but the duration of shaking would be unusually short.

Question 38

A 62 year old man has 2 months of increasing shortness of breath and chest pain. He is now unable to lie flat. For the past 2 weeks, he has also had a productive cough which was flecked with blood on two occasions. He had a myocardial infarction 6 months ago, at which point he stopped smoking. His temperature is 37.1°C, BP 126/66 mmHg, respiratory rate 24 breaths per minute and oxygen saturation 93% breathing air. Investigations: Chest X-ray: moderate right-sided pleural effusion. Pleural aspirate protein content 56 g/L. Which is the most likely underlying diagnosis? A. Bacterial pneumonia B. Heart failure C. Lung cancer D. Pulmonary embolism E. Tuberculosis

Answer 38

C. Lung cancer The most likely underlying diagnosis is lung cancer. The high protein content (56 g/L) in the pleural aspirate indicates an exudative effusion, which more indicative of malignancies like lung cancer. Heart failure and pulmonary embolism can present with similar symptoms, but they are less likely given the chest X-ray and pleural aspirate. Bacterial pneumonia or tuberculosis are also less likely due to a lack of fever.

Question 39

A 55 year old man is referred to the vascular outpatient clinic with bilateral claudication, limiting his walking distance to 10 metres. He is a smoker. Imaging shows chronic distal aortic and bilateral common iliac occlusive disease. Which is the most appropriate surgical intervention? A. Aortic endarterectomy B. Aorto-bifemoral bypass graft C. Aorto-iliac embolectomy D. Bilateral iliac angioplasty E. Femoral-to-femoral crossover graft

Answer 39

B. Aorto-bifemoral bypass graft Chronic distal aortic and bilateral common iliac occlusive disease would make aorto-bifemoral bypass graft the most appropriate surgical intervention. This involves bypassing the occluded aortic and iliac vessels with a synthetic graft to restore blood flow to the legs. Other surgical options like aortic endarterectomy or aorto-iliac embolectomy may not be suitable for chronic occlusive disease, while bilateral iliac angioplasty and femoral-to-femoral crossover graft may not be adequate for restoring blood flow to the entire leg.

Question 40

A 28 year old man has a headache, intermittent fever, sore throat and diarrhoea. His temperature is 37.7°C. His fauces are red and there are two small aphthous ulcers on his left buccal mucosa. He also has a maculopapular erythematous rash on his upper trunk, red hands and folliculitis on his chest. His liver and spleen are just palpable and he has mild neck stiffness. Investigations: Haemoglobin 135 g/L (130–175) White cell count 3.3 x 109/L (3.0–10.0) Platelets 84 x 109/L (150–400) Which investigation is most likely to lead to a diagnosis? A. First catch urine microscopy B. Glandular fever screening test C. HIV serology D. Serum antinuclear antibodies E. Serum toxoplasma gondii IgM antibody titre

Answer 40

C. HIV serology The presentation suggests an infection, which is affecting a number of different body regions and systems. The most specific information is the presence of a rash with folliculitis on the chest, which is a prominent feature in late stage HIV infection. Additionally, HIV can explain all of the symptoms, hence the correct answer is HIV serology.

Question 41

A 78 year old woman is found dead at home. At autopsy, the pathologist finds bilateral pneumonia and meningitis. Microscopy of a meningeal swab shows Gram-positive cocci arranged in pairs. Which is the most likely causative organism? A. Candida albicans B. Neisseria meningitidis C. Pseudomonas aeruginosa D. Staphylococcus aureus E. Streptococcus pneumoniae

Answer 41

E. Streptococcus pneumoniae The most likely causative organism in this case is Streptococcus pneumoniae. Streptococcus pneumoniae is a Gram-positive coccus that can cause pneumonia and meningitis, particularly in the elderly. The presence of bilateral pneumonia and meningitis, as well as the Gram-positive cocci seen on microscopy, are consistent with this diagnosis. Of the other possible answers, Neisseria meningitidis, Candida albicans and Pseudomonas aeruginosa are not Gram positive cocci. Staph aureus tends to form clusters rather than being arranged in pairs.

Question 42

A 79 year old woman has been repeatedly found wandering at night by her neighbours. The problem has progressively worsened over 6 months. She is independent in her activities of daily living, although her family do her shopping. She was previously well. What aspect of cognition is likely to show the greatest impairment? A. Attention B. Concentration C. Praxis D. Registration of information E. Short-term memory

Answer 42

E. Short-term memory The scenario describes a patient with symptoms of dementia, and impairment of short-term memory is a characteristic feature of dementia. The patient’s wandering behaviour may be due to disorientation caused by forgetfulness or confusion. Attention, concentration, and praxis may also be affected in dementia, but short-term memory is often the most severely impaired.

Question 43

A 52 year old woman reports increased urinary frequency, urgency and urge incontinence. She has multiple sclerosis, which affects her walking. A midstream urine sample shows no cells and is sterile on culture. A bladder scan shows a residual volume of 300 mL. Urodynamic assessment shows that she has a neuropathic bladder. Which is the most appropriate management? A. α-Adrenoceptor blocker B. Anticholinergic drug C. Indwelling urethral catheter D. Intermittent self catheterisation E. Suprapubic catheter

Answer 43

D. Intermittent self catheterisation The most appropriate management in this case of a patient with a neuropathic bladder due to multiple sclerosis would be intermittent self-catheterization. Drug interventions are unlikely to be of benefit. Indwelling urethral catheter or suprapubic catheter are to be avoided due to increase infection risk.

Question 44

An 84 year old man develops profuse diarrhoea whilst in hospital. An outbreak of Clostridioides (Clostridium) difficile has occurred in his ward. Which feature of this organism makes it particularly difficult to destroy? A. Motility B. Outer capsule C. Rapid mutation D. Spore formation E. Surface adherence

Answer 44

D. Spore formation The feature of Clostridioides difficile that makes it particularly difficult to destroy is spore formation. C. difficile spores are resistant to many environmental stresses, including heat, disinfectants, and antibiotics, which makes them particularly difficult to eliminate. These spores can persist on surfaces for months, making them a significant source of transmission in healthcare settings.