MSC practice paper 2

Question 1

A 60 year old man has increasing left hip pain. It is worse after exercise and occasionally wakes him at night. He has stiffness in the mornings that lasts for about 10 minutes. He has hypertension treated with ramipril, but is otherwise in good health.
He has reduced internal rotation on passive movement. This also elicits pain. Which is the most appropriate initial treatment for his pain?
A. Celecoxib
B. Codeine phosphate
C. Naproxen
D. Paracetamol
E. Tramadol

Answer 1

D. Paracetamol

Based on the given information, the most appropriate initial treatment for his pain is Paracetamol. The patient’s symptoms are suggestive of hip osteoarthritis, which is a common cause of hip pain in older adults. Paracetamol is the first-line medication for the management of osteoarthritis pain due to its safety profile and effectiveness. Celecoxib, naproxen, and tramadol are alternative options for pain relief, but they may have potential side effects and risks, especially in older patients. Codeine phosphate is not recommended as a first-line medication due to its limited effectiveness and potential adverse effects.

Question 2

A 65 year old man has had constant back and right knee pain for 6 months, partially relieved by analgesia. He is an ex-smoker. He is otherwise well.
Investigations:
Haemoglobin 132 g/L (130-175) Alkaline phosphatase 850 IU/L (25-115) Calcium 2.3 mmol/L (2.2-2.6) Phosphate 0.9 mmol/L (0.8-1.5) Prostate specific antigen 5 μg/L (<4.0)
X-rays: sclerotic areas in lower right femur and lumbar spine L3
Isotope bone scan: areas of increased uptake in femur, lumbar spine and skull
Which is the most likely diagnosis?
A. Hyperparathyroidism
B. Metastatic carcinoma of prostate
C. Metastatic small cell carcinoma of lung
D. Myeloma
E. Paget’s disease of bone

Answer 2

E. Paget’s disease of bone

Based on the given information, the most likely diagnosis is E. The patient’s history, investigations and imaging findings suggest a diagnosis of Paget’s disease of bone. The elevated alkaline phosphatase, with normal Calcium and Phosphate and bone scan results support this diagnosis. Hyperparathyroidism can cause hypercalcemia and bone resorption, but it is less likely in this case given the normal calcium and phosphate levels. Metastatic small cell carcinoma of lung, prostate and myeloma can also cause the imaging changes, but these are less likely given the patient’s history, and laboratory findings.

Question 3

The links between deprivation and health inequalities are well evidenced and widely accepted, but there are a number of explanations for that association. One explanation proposes that ill health determines people’s social class.
Which type of explanation of health inequality is this?
A. Artefact
B. Cultural/behavioural
C. Idealist
D. Materialist
E. Social selection/mobility

Answer 3

E. Social selection/mobility

This is an example of Social selection/mobility. This explanation proposes that ill health can limit social mobility due to decreased ability to work, and decreased income, leading to lower social class, which in turn can contribute to health inequalities. Artefact would be proposing that the observed differences are due to differences in measurement (and so not actually present). Cultural/behavioural is proposing that differences in behaviour cause differences in health. Idealist would be suggesting that individual construction of health is different in different groups, so they might define health differently, and Materialist, emphasises the role of economic and social factors, such as income, education, and employment, in shaping health outcomes.

Question 4

A 43 year old man is involved in a low speed road traffic collision. Following this he develops pain in his lower back that it is still troublesome several months later. The pain is worse after activity and is relieved by rest.
He has an exaggerated lumbar lordosis with a palpable depression above L5. The range of movement of his spine is grossly normal. Neurological examination of his lower limbs is also normal.

What is the diagnosis?
A. Cauda equina syndrome
B. Compression fracture
C. Herniated intervertebral disc
D. Spondylolisthesis
E. Spondylosis

Answer 4

D. Spondylolisthesis

Spondylolisthesis is a condition where one vertebra slips out of line with the one above it, most commonly in the lumbar spine. The exaggerated lumbar lordosis and the palpable depression above L5 can be clinical findings of spondylolisthesis. Symptoms include lower back pain that worsens with activity and improves with rest. Neurological examination is typically normal.

Question 5

A 30 year old man goes out gambling. One night he makes a profit of £100,000, and the following night he loses £150,000.
Which psychological process most likely occurred on the first night that led to his risk taking on the following night?
A. Classical conditioning
B. Disinhibition
C. Modelling
D. Positive reinforcement
E. Social learning

Answer 5

D. Positive reinforcement

This is because winning on the first night positively reinforced his gambling behaviour - hence his repetition on the following night.

Question 6

A 85 year old woman has a breast lump. She has hypertension, heart failure and a previous stroke. Her medications are bisoprolol, ramipril, furosemide, aspirin and atorvastatin.
Her pulse is 76 bpm irregularly irregular and BP 105/70 mmHg. Her jugular venous pressure is visible 6 cm above the sternal angle. She has bibasal late inspiratory crepitations and bilateral pedal oedema. There is a 2.5 cm diameter, mobile, firm, non tender swelling in the upper outer quadrant of the her breast. There is no palpable lymphadenopathy. An ultrasound guided core biopsy was taken from the mass.
Investigation:
Pathology report of breast biopsy: infiltrating ductal carcinoma, ER positive , HER2 negative
She is started on an aromatase inhibitor and bisphosphonate. Which is the most appropriate next treatment to offer?
A. Chemotherapy
B. Immunotherapy
C. No additional treatment
D. Radiotherapy
E. Surgery

Answer 6

C. No additional treatment

Given the patient’s age and comorbidities, surgery may not be a suitable option. The pathology report indicates that the breast cancer is ER positive, which suggests that the tumor may be responsive to hormone therapy. Therefore, the most appropriate next treatment to offer would be hormone therapy with an aromatase inhibitor, which has been already started, and a bisphosphonate, which is used to prevent bone loss associated with hormone therapy. Chemotherapy and immunotherapy may not be appropriate for this patient given her age and comorbidities. Radiotherapy may be considered in certain cases, but it is not the most appropriate next treatment to offer in this scenario. Therefore, the answer is no additional treatment.

Question 7

A 29 year old woman has pain and morning stiffness in her finger and wrist joints. This improves during the day and after active movement. She has had recurrent mouth ulcers for the last 2 years. She had an episode of pleuritic chest pain 6 months ago which resolved without seeking help.
Her BP is 128/85 mmHg. She has no warmth or tenderness in her hands. Urinalysis: protein 1+, blood 1+
Investigations:
Haemoglobin 109 g/L (115–150) White cell count 3.8 × 109/L (4.0–11.0) Lymphocytes 0.9 × 109/L (1.1–3.3) Platelets 160 × 109/L (150–400) Creatinine 90 μmol/L (60–120)
CRP 21 mg/L (< 5)
Which is the most likely diagnosis?
A. Behçet’s disease
B. Reactive arthritis
C. Rheumatoid arthritis
D. Sjögren’s syndrome
E. Systemic lupus erythematosus

Answer 7

E. Systemic lupus erythematosus

Based on the symptoms and investigations provided, the most likely diagnosis is systemic lupus erythematosus (SLE). The patient has joint pain and morning stiffness, which are common symptoms of SLE. She also has a history of mouth ulcers and pleuritic chest pain, which are other features that may be seen in SLE. The urinalysis shows proteinuria and haematuria, which can be associated with lupus nephritis. The low haemoglobin level and lymphopenia may also be seen in SLE. The elevated CRP suggests an underlying inflammatory process. Patients with Behcet’s syndrome experience ulceration and joint pain but renal involvement and haematological changes are less likely. Patients with Rheumatoid arthritis and reactive arthritis would have inflamed joints. Patients with Sjogrens syndrome usually have normal CRP.

Question 8

A 66 year old man has lethargy, cough and a persistent pain in the right upper quadrant of the abdomen. He has smoked between 15 and 40 cigarettes daily for 50 years.
He has an enlarged liver. Needle biopsy of the liver reveals adenocarcinoma, and immunohistochemistry is positive for the marker thyroid transcription factor-1, indicative of a primary pulmonary tumour.
Which is the most likely route by which this tumour spread to the liver?
A. Direct infiltration
B. Haematogenous spread
C. Lymphatic spread
D. Pagetoid spread
E. Transcoelomic spread

Answer 8

B. Haematogenous spread

The presence of a thyroid transcription factor-1 marker in the liver biopsy suggests that the adenocarcinoma originated from the lung, rather than the liver. Adenocarcinomas of the lung often metastasise to the liver through the bloodstream, making haematogenous spread the most likely route. Direct infiltration would be less likely due to the distance between the lung and liver, while lymphatic, Pagetoid, and transcoelomic spread are less common routes of metastasis for lung cancer to the liver.

Question 9

A 68 year old woman has noticed a lump in her neck for 2 months, but otherwise feels well.
There are small lymph nodes palpable in the cervical, axillary and inguinal regions.
Investigations:
Haemoglobin 124 g/L (115–150)
White cell count 27.2 × 109/L (3.8–10.0)
Neutrophils 2.5 × 109/L (2.0–7.5)
Lymphocytes 21.6 × 109/L (1.1–3.3)
Monocytes 0.9 × 109/L (0.2–1.0)
Eosinophils 0.4 × 109/L (0–0.4)
Basophils 0.1 × 109/L (0–0.1)
Platelets 137 × 109/L (150–400)
Blood film: increased lymphocytes with sparse cytoplasm
Which is the most likely diagnosis?
A. Acute lymphoblastic leukaemia
B. Chronic lymphocytic leukaemia
C. Infectious mononucleosis
D. Myeloma
E. Non Hodgkin’s lymphoma

Answer 9

B. Chronic lymphocytic leukaemia

The most likely diagnosis is Chronic Lymphocytic Leukaemia as it is the commonest lymphoproliferative neoplasm causing a lymphocytosis in this age of patient (lifetime risk approx. 1 in 200) and the patient is otherwise well (approx. 75% of CLL diagnosis are in 65 year olds and the average age of presentation is 70 years). The lymphocytosis with normal Hb, neutrophil count and near normal platelet count and the film appearances (small mature lymphocytes and smear cells are common) are also consistent. Low grade Non Hodgkin’s lymphoma is the main differential diagnosis of painless persistent lymphadenopathy in this age group and is also common but is less likely to present with significant lymphocytosis (lymphadenopathy is more of a feature). Infectious mononucleosis is caused by the Epstein-Barr virus and can also present with lymphadenopathy with lymphocytosis although these are reactive lymphocytes with plenty of cytoplasm. EBV also typically presents with fever and sore throat, and it is a self-limited condition and resolves within weeks. Acute lymphoblastic leukaemia is a malignancy of lymphoid progenitor cells that primarily affects children and young adults and is typically associated with a short history of bone pain, fever and pancytopenia. Myeloma is a malignancy of plasma cells within the bone marrow, which can present with bone pain, hypercalcaemia, anaemia, and renal dysfunction. Myeloma does not cause lymphadenopathy or lymphocytosis.

Question 10

A randomised controlled trial was designed to compare a new drug with a placebo. There were 120 patients in the treatment group of which 12 patients died within 2 years. There were 240 patients in the control group of which 48 patients died within 2 years.
Which is the number needed to treat to avoid one death within 2 years?
A. 2
B. 4
C. 8
D. 10
E. 20

Answer 10

D. 10

Justification for correct answer(s): The absolute risk reduction (ARR) can be calculated as the difference in the risk of death between the treatment and control groups:
ARR = risk in control group - risk in treatment group ARR = 48/240 - 12/120
ARR = 0.2 - 0.1
ARR = 0.1
The number needed to treat (NNT) can be calculated as the reciprocal of the ARR: NNT = 1 / ARR
NNT = 1 / 0.1
NNT = 10
Therefore, the NNT to avoid one death within 2 years is 10.

Question 11

A 62 year old woman is seen at home because her legs feel “wobbly”, and she has been incontinent of urine once. She has been experiencing increasing pain in her mid back over the previous fortnight. She is being treated for metastatic breast cancer with anastrozole.
There is slight weakness, rated 4/5, in hip flexion and knee extension bilaterally. Plantar reflexes are equivocal and tendon jerks brisk. She is tender over the 10th thoracic vertebra.
Which is the most appropriate next course of action?
A. Admission to the local hospice
B. Advise bed rest until pain resolves
C. Arrange domiciliary physiotherapy
D. Emergency admission for MR scan of spine
E. Give analgesia and re-examine her in the morning

Answer 11

D. Emergency admission for MR scan of spine

The patient’s symptoms and examination findings are suggestive of spinal cord compression, which is a medical emergency. Urgent imaging with an MRI of the spine is necessary to confirm the diagnosis and identify the underlying cause of the cord compression, which can include metastatic cancer, disc herniation, or spinal stenosis. Typical treatment options include surgical decompression or palliative radiation therapy. The patient may require admission to the hospital for further management.

Question 12

A 52 year old woman has had two days of worsening confusion. She has chronic liver disease secondary to alcohol and has been abstinent for six months. She has had a previous admission due to acute hepatic encephalopathy.
She is disoriented in time and place, and is unable to hold a conversation. Her temperature is 37.1°C, pulse 90 bpm and BP 119/80 mmHg. She has a distended abdomen, widespread spider naevi and a flapping tremor.
She is given intravenous vitamin supplements.
Which is the most appropriate additional management of her acute confusion?
A. Ciprofloxacin
B. Furosemide
C. Lactulose
D. Lorazepam
E. Restrict dietary protein intake to 60 g/day

Answer 12

C. Lactulose

The most appropriate additional management of her acute confusion would be Lactulose. The patient is exhibiting signs of hepatic encephalopathy due to her chronic liver disease, which can cause confusion, disorientation, and other neurological symptoms. Lactulose is a standard treatment for hepatic encephalopathy as it helps to reduce the amount of ammonia in the blood, which can contribute to the neurological symptoms. Intravenous vitamin supplements may be helpful to address any nutritional deficiencies, but lactulose is the primary treatment for hepatic encephalopathy. Antibiotics such as ciprofloxacin may be used if there is evidence of infection, but there is no indication of infection in this scenario. Furosemide and protein restriction are not appropriate for hepatic encephalopathy. Lorazepam can be used to treat alcohol withdrawal however may worsen hepatic encephalopathy and should be used with caution in patients with liver disease.

Question 13

A 62 year old woman has gradually been feeling more tired over the past year.
She has fissures at both angles of her lips and a non-tender mass in the right iliac fossa.
What is the cause of her tiredness?
A. Chronic renal failure
B. Folate deficiency
C. Iron deficiency anaemia
D. Myeloma
E. Pernicious anaemia

Answer 13

C. Iron deficiency anaemia

Fissures at both angles of her lips (angular cheilitis) suggests a nutritional deficiency, of which iron deficiency is a common cause. The non-tender mass in the right iliac fossa is suggestive of a colorectal malignancy, which commonly causes iron deficiency anaemia. Chronic renal failure, folate deficiency, myeloma and pernicious anaemia all cause tiredness, but do not typically present with angular cheilitis or an abdominal mass.

Question 14

A 94 year old woman has a deep gnawing pain in her left arm. She has had 10 kg weight loss in the past year.
Her temperature is 37.3°C. She has localised tenderness over the left upper arm.

X-Ray of left arm (question 32)

Which is the most likely cause of her pain?
A. Metastatic carcinoma
B. Osteomyelitis
C. Osteoporosis
D. Osteosarcoma
E. Paget’s disease

Answer 14

A. Metastatic carcinoma

The most likely cause of the 94-year-old woman’s pain in her left arm is metastatic carcinoma. She has lost weight and the site of the abnormality i.e. proximal humerus, is a common site for metastasis. The X-ray is consistent with metastatic carcinoma.

Question 15

A 45 year old man has a 5 month history of chronic sinusitis and unresolving headaches. When he bends forward, purulent fluid pours from his nose.
Which anatomical structure is most likely to be the source of this fluid?
A. Anterior ethmoid air cells
B. Frontal sinus
C. Lacrimal sac
D. Maxillary sinus
E. Posterior ethmoid air cells

Answer 15

D. Maxillary sinus

The patient’s symptoms suggest chronic maxillary sinusitis; when the patient bends forward, gravity causes the accumulated pus or mucus to drain out through the osteomeatal complex into the nasal cavity. The anterior ethmoids and the frontal sinus also drain through the OM complex, but the maxilla is the most commonly involved.

Question 16

A 19 year old man is seen by his GP with two days of a burning sensation when passing urine, urethral discomfort and a penile discharge. This developed a week after he had unprotected sex with a new female partner. He declines a referral to the genito-urinary medicine (GUM) clinic.
Which is the most appropriate treatment?
A. Doxycyline
B. Ciprofloxacin and metronidazole
C. Fluconazole and penicillin V
D. Metronidazole and fluconazole
E. Penicillin V and azithromycin

Answer 16

A. Doxycyline

The man has suspected urethritis. There are no specific features to suggest gonorrhoea and the most likely organism is chlamydia. The most appropriate treatment for this patient would be Doxycycline. Azithromycin alone would be an alternative. A first-void sample for nucleic acid amplification testing (NAAT) should be sent. The patient should also be advised to inform his sexual partner to get tested and treated as well.

Question 17

A 42 year old woman has 6 months of a painful right shoulder. Her pain keeps her awake at night and is worsened by movement. She is otherwise well. There is no history of trauma.
She has pain on shoulder abduction between 80° and 120°. Her shoulder movements are otherwise normal. There is no joint effusion. X-ray of right shoulder is normal.
Which is the most likely diagnosis?
A. Cervical radiculopathy
B. Osteoarthritis of glenohumeral joint
C. Polymyalgia rheumatica
D. Pseudogout
E. Subacromial bursitis

Answer 17

E. Subacromial bursitis

The most likely diagnosis is subacromial bursitis. The symptoms of pain worsened by movement and difficulty sleeping, along with a normal X-ray and pain on shoulder abduction between 80 and 120 are consistent with subacromial bursitis. The patient is describing a painful arc.

Question 18

A 45 year old man has his BMI measured as part of a clinical trial for type 2 diabetes.
Which is the most appropriate classification of data on this parameter?
A. Categorical
B. Continuous
C. Discrete
D. Nominal
E. Subjective

Answer 18

B. Continuous

BMI is a continuous variable as it can take any value within a range of values (e.g. 18.5 to 50). Categorical variables are those that can be grouped into categories (e.g. blood type, race). Discrete variables are those that can only take certain values, usually integers (e.g. number of children). Nominal variables are those that have no intrinsic order or ranking (e.g. hair colour, occupation). Subjective is a term for phenomena not variables.

Question 19

A 75 year old man with metastatic bowel cancer is dying. He is semi- conscious. He is being treated with morphine and haloperidol via a syringe driver. His breathing is becoming increasingly rattly.
Which is the most appropriate drug management?
A. Amoxicillin
B. Furosemide
C. Hyoscine
D. Levomepromazine
E. Midazolam

Answer 19

C. Hyoscine

The most appropriate drug management for a dying patient with increased respiratory secretions and a rattly breathing is Hyoscine which is a commonly used antimuscarinic medication for the management of respiratory secretions in end-of-life care. It reduces secretions by blocking muscarinic receptors, thus drying the mouth and airways. Therefore, the answer is Hyoscine. Amoxicillin is an antibiotic that would not be indicated in this situation. Furosemide is a loop diuretic and would not be helpful for respiratory secretions. Levomepromazine is an antipsychotic medication that may have sedative effects and is sometimes used in palliative care for symptom management, but it is not the first- line medication for managing respiratory secretions. Midazolam is a benzodiazepine that may be used for sedation and anxiety relief, but it is not used for managing respiratory secretions.

Question 20

A 45 year old man has a lump in the right side of his neck. He has never smoked and takes no regular medications. Fine needle aspiration of the mass reveals squamous cell carcinoma, and subsequent investigations identify the primary tumour in the right tonsil.
Which virus is associated with this malignancy?
A. Cytomegalovirus
B. Epstein–Barr virus
C. Human immunodeficiency virus
D. Human papilloma virus
E. Human T-lymphotropic virus

Answer 20

D. Human papilloma virus

Human papilloma virus (HPV) is associated with squamous cell carcinoma of the oropharynx, which includes the tonsils (typically palatine tonsils and lingual tonsils). Other risk factors for this cancer include smoking and alcohol use, but the incidence of HPV-associated oropharyngeal cancers is increasing. HPV-associated cancers also include cervical, vulval, penile and anal cancers. https://www.cancer.net/navigating-cancer-care/prevention-and-healthy-living/hpv-and-cancer

Question 21

A 78 year old man has worsening breathlessness. He has heart failure that has been worsening progressively over the past 12 months. He has been bed bound for the past 2 weeks. He was recently found to have probable lung carcinoma but was not fit for further investigation.
He is dyspnoeic, cyanosed and confused. His temperature is 36.1°C, pulse rate 100 bpm, BP 92/60 mmHg, respiratory rate 30 breaths per minute and oxygen saturation 88% on 15 L/min via a Venturi mask. He has inspiratory crackles in both bases.
He is treated with intravenous furosemide.
Which additional treatment is most likely to reduce his breathlessness?
A. Intramuscular haloperidol
B. Intravenous glyceryl trinitrate
C. Intravenous morphine
D. Nasal intermittent positive pressure ventilation
E. Nebulised salbutamol

Answer 21

C. Intravenous morphine

Intravenous morphine is most likely to reduce the breathlessness in this patient. The patient is experiencing severe dyspnea, which is a common symptom in end-stage heart failure. Morphine is an opioid analgesic with respiratory depressant effects that can reduce the sensation of dyspnea. Glyceryl trinitrate and nebulised salbutamol are more appropriate for patients with bronchospasm or heart failure due to left ventricular dysfunction. Nasal intermittent positive pressure ventilation is more appropriate for patients with acute respiratory failure due to hypoventilation. Haloperidol is indicated for patients with delirium, agitation or confusion.

Question 22

A 74 year old woman has had left sided headache and discomfort when chewing food for 3 months. She experiences a sensation of pressure and pain in her jaw, even when talking. She has lost 8 kg in weight over the same time period.
Investigations: CRP 45 mg/L (<5)
Which investigation is most likely to establish the diagnosis?
A. CT scan of head
B. Parotid sialogram
C. Serum anti-neutrophil cytoplasmic antibodies
D. Temporal artery biopsy
E. X-ray of temporomandibular joint

Answer 22

D. Temporal artery biopsy

Temporal artery biopsy is the most appropriate investigation in this patient to establish the diagnosis of giant cell arteritis. The typical symptoms of headache, jaw claudication, and unintentional weight loss, along with elevated CRP levels, raise a strong suspicion of giant cell arteritis. Temporal artery biopsy is the gold standard test for diagnosis, as it shows characteristic histopathological changes of giant cell arteritis such as mononuclear cell infiltration and granulomatous inflammation. Some centres will arrange a temporal artery ultrasound to help with the diagnostic process but this is not an option in this question, so biopsy is the most appropriate.

Question 23

A group of 75 men and a group of 75 women performed a standardised exercise test and had their pulse rate measured at the end.
The data from the two groups were compared. The data is normally distributed with equal variance.
Which is the most appropriate statistical test to compare these groups?
A. Analysis of variance
B. Friedman’s test
C. Mann–Whitney test
D. Paired Student’s t-test
E. Unpaired Student’s t-test

Answer 23

E. Unpaired Student’s t-test

Unpaired Student’s t-test would be the most appropriate statistical test to compare these groups, as it is used to compare the means of two independent groups of data with equal variances assuming normal distribution.

Question 24

A 30 year old man is unable to straighten his right middle finger after an injury. He has a flexion deformity of the finger at the distal interphalangeal joint and
is unable to actively extend his finger.
Which is the most appropriate management option?
A. External finger fixation
B. Finger splint
C. Internal finger fixation
D. Reassurance
E. Steroid injection

Answer 24

B. Finger splint

The most appropriate management option for a 30-year-old man with a flexion deformity of the finger at the distal interphalangeal joint and inability to actively extend his finger following an injury is a finger splint. A finger splint can provide support and immobilise the finger, allowing the tendon to heal and the finger to regain its full range of motion.

Question 25

A previously well 20 year old man has two months of night sweats and 5 kg weight loss. His temperature is 37.6°C. He has palpable neck lymph nodes and splenomegaly. Investigations: CT scan chest, abdomen and pelvis: enlarged mediatinal lymph nodes and splenomegaly Lymph node biopsy: Hodgkin/Reed-Sternberg (HRS) cells admixed with a polymorphous inflammatory infiltrate Which is the most appropriate first line treatment? A. Chemotherapy B. Corticosteroids C. Immunotherapy D. Radiotherapy E. Surgical excision of mediastinal lymph nodes

Answer 25

A. Chemotherapy The most appropriate first-line treatment for classical Hodgkin lymphoma is chemotherapy. Corticosteroids may be used in addition to chemotherapy in certain cases but are not typically used as a first-line treatment. Immunotherapy and radiotherapy may be used as part of a treatment regimen but are not typically used as a first-line treatment for classical Hodgkin lymphoma. Surgical excision of mediastinal lymph nodes is not a treatment option for Hodgkin lymphoma.

Question 26

A 72 year old man is admitted with cough, breathlessness and confusion. He has metastatic adenocarcinoma and is being treated with chemotherapy. His wife reports that he has had enough of his treatment and planned to discontinue active treatment. He is drowsy and unable to answer questions. He has bronchial breathing at the left base. He is given 0.9% sodium chloride and broad spectrum antibiotics intravenously. Which is the most appropriate way to determine his cardiopulmonary resuscitation status on this admission? A. Admitting team should decide B. Ask an independent advocate to decide C. Ask consultant oncologist to decide D. Ask his wife to decide E. Wait 24 hours to see if patient regains capacity to decide

Answer 26

A. Admitting team should decide As the patient is currently unable to answer questions and although his wife reports that he planned to discontinue active treatment, this has not been documented and cannot be verified. The admitting team should therefore decide about the best clinical approach to the patient, including appropriateness or otherwise of CPR.

Question 27

A 36 year old man with type 1 diabetes mellitus has a pilonidal sinus. He takes 14 units long-acting insulin at night, and short-acting insulin three times daily at mealtimes (typically 6-8 units with each meal). He is scheduled for excision of the sinus under general anaesthesia, first on a morning operating list. He is asked to fast from midnight the night before. His HbA1c is 58 mmol/mol (20-42). Which is the most appropriate plan for managing his insulin pre-operatively? A. Omit evening and morning insulin doses B. Start a variable-rate insulin infusion on the morning of surgery C. Start a variable-rate insulin infusion the evening before surgery D. Take evening and morning insulin doses, as usual E. Take usual evening insulin and omit morning insulin

Answer 27

E. Take usual evening insulin and omit morning insulin It is important to ensure that blood glucose levels are well-controlled in patients with diabetes undergoing surgery. Omitting insulin doses can lead to hyperglycaemia, which increases the risk of surgical complications, while taking too much insulin can lead to hypoglycaemia, which can also be dangerous. In this case, he should take his usual long-acting insulin the evening before but will need to adjust his short-acting insulin dose based on the anticipated timing of the surgery the following day. As he is scheduled as first on the list in the morning, and having been starved from midnight he should omit his morning short acting insulin prior to surgery and recommence this when eating and drinking. The anaesthetist should be informed of the patient’s diabetes and insulin regimen and should monitor blood glucose levels during the perioperative period. https://cpoc.org.uk/guidelines-resources-guidelines-resources/guideline-diabetes

Question 28

A 36 year old woman attends for an asthma review. She requires a long-acting β-agonist and steroid combination inhaler. The guidelines suggest either a metered dose inhaler or a dry powder. They are the same price. This patient asks which is better for the environment. Which component of these inhalers has the highest carbon footprint? A. Hydrofluorocarbon propellant in the metered dose inhaler B. Packaging of the dry powder inhaler C. Plastic component of the dry powder inhaler D. Plastic component of the metered dose inhaler E. Powder component of the dry powder inhaler

Answer 28

A. Hydrofluorocarbon propellant in the metered dose inhaler Hydrofluorocarbon propellant in the metered dose inhaler has the highest carbon footprint of the components listed. It is a greenhouse gas that contributes to climate change. Dry powder inhalers do not use propellants and are considered to have a lower carbon footprint. However, the manufacturing and disposal of all inhalers contribute to environmental impact.

Question 29

A 18 year old man is worried about his cancer risk. His paternal grandfather died of colorectal cancer at 42 years of age and his 36 year old father has just been diagnosed with colorectal cancer. The son's colonoscopy shows hundreds of colonic polyps, and biopsies from several of the polyps show adenomatous change with low grade dysplasia. Which is the most appropriate strategy to prevent colon cancer in this situation? A. Daily low dose aspirin B. Diet rich in fruit and vegetables C. Panproctocolectomy D. Annual faecal immunochemical test (FIT) E. Annual colonoscopy and biopsy

Answer 29

C. Panproctocolectomy The most appropriate strategy to prevent colon cancer in this situation is panproctocolectomy, which is the removal of the entire colon, rectum, and anus. This patient has a strong family history of early-onset colorectal cancer and has already developed hundreds of colonic polyps with evidence of adenomatous change and low-grade dysplasia. These findings are consistent with a diagnosis of familial adenomatous polyposis (FAP), an inherited condition that predisposes to the development of colorectal cancer. Prophylactic surgery is recommended in patients with FAP to prevent the development of colorectal cancer. Daily low dose aspirin and a diet rich in fruit and vegetables have been shown to have some protective effect against colon cancer, but these measures are not sufficient for a patient with FAP. Annual FIT and colonoscopy and biopsy are not adequate for cancer prevention in a patient with FAP.

Question 30

A 46 year old man has sudden onset and intense lower back pain. He has no pain or numbness in his buttocks or legs. He is diagnosed with mechanical back pain. He has no drug contra-indications. Which is the most appropriate initial medication? A. Amitriptyline B. Fentanyl C. Ibuprofen D. Paracetamol E. Triamcinolone

Answer 30

C. Ibuprofen The most appropriate initial medication is non- steroidal anti-inflammatory drugs (NSAIDs) in this age group if there are no contra- indications. Paracetamol on its own is not recommended. Amitriptyline, fentanyl, and triamcinolone are not typically used for the initial treatment of mechanical back pain.

Question 31

A 62 year old man is brought to the operating theatre recovery room after a laryngoscopy and vocal cord biopsy. He appears to be conscious, but his breathing is shallow and respiratory rate 28 breaths per minute. His voice is weak and, when the recovery nurse asks him to squeeze her fingers with his hand, the grip is not sustained. Which drug will reverse these signs? A. Doxapram B. Glycopyrronium C. Naloxone D. Neostigmine E. Rocuronium

Answer 31

D. Neostigmine The weak grip, cough and shallow breathing suggest residual effects of neuromuscular blockade that has been administered to facilitate laryngoscopy and vocal chord biopsy under general anaesthetic. Doxapram acts on central and peripheral chemoreceptors to stimulate respiration but would have no effect on improving neuromuscular strength. Naloxone is an opioid antagonist and would not reverse the effects of neuromuscular blockade. Glycopyrronium is an antimuscarinic agent and would not have any effect on reversing neuromuscular blockade at the neuromuscular junction and improving strength. Neostigmine is a cholinesterase inhibitor and is the most appropriate agent to administer to reverse the effects of neuromuscular blockade. It reduces the breakdown of acetylcholine at the neuromuscular junction increasing its availability to bind to the acetylcholine receptor and therefore trigger muscular contraction and increased strength. Administration would increase grip strength, respiratory muscular strength and may improve vocal chord movement and speech. Rocuronium is a neuromuscular blocking agent and would not be appropriate in this situation.

Question 32

A 72 year old man has had difficulty swallowing solids. He has cancer of the middle third of the oesophagus and hepatic metastases. Which is the most appropriate initial management of his dysphagia? A. Chemotherapy B. Excision of tumour C. Gastrostomy feeding tube D. Oesophageal stent E. Radiotherapy

Answer 32

D. Oesophageal stent Placement of an oesophageal stent can provide palliation of dysphagia in patients with oesophageal cancer. It is a minimally invasive procedure that can be done under sedation or general anaesthesia. It involves placement of a metal or plastic stent into the oesophagus to hold it open, allowing food and liquid to pass through. It is a safe and effective option for patients with dysphagia due to oesophageal cancer, particularly in those with advanced or metastatic disease who may not be candidates for curative treatment.

Question 33

A 23 year old woman commenced chemotherapy for Burkitt's lymphoma yesterday. Since then she has been feeling increasingly nauseated. Urine output has been 40 mL in the last 12 hours. Her temperature is 36.8°C, pulse rate 96 bpm and BP 112/80 mmHg. Investigations on admission were normal. Investigations today: Potassium 6.2 mmol/L (3.5–5.3) Urea 9 mmol/L (2.5–7.8) Creatinine 410 μmol/L (60–120) Which investigation is most likely to identify the cause of her acute deterioration? A. Blood cultures B. C reactive protein C. Creatine kinase D. Phosphate E. Urate

Answer 33

E. Urate Based on the patient’s symptoms and laboratory results, she may be experiencing tumour lysis syndrome, which is a potentially life- threatening complication of chemotherapy that can cause electrolyte imbalances and kidney damage. The most appropriate investigation to identify the cause of her acute deterioration would be urate, as elevated uric acid levels are a hallmark of tumour lysis syndrome. However, all of the other options may also be useful in helping to manage her condition. Blood cultures may be taken to rule out a bacterial infection, C-reactive protein can indicate inflammation or infection, creatine kinase may be elevated in rhabdomyolysis (another potential complication of chemotherapy), and phosphate levels may also be elevated in tumour lysis syndrome.

Question 34

A 43 year old man has inoperable cancer of the bowel with hepatic and peritoneal metastases. He has back pain due to tumour infiltration. The pain has been controlled with regular codeine phosphate at maximum dosage. He now has bowel obstruction with vomiting and his pain has recurred because he cannot take oral medication. Investigations:Creatinine 85 μmol/L (60–120) Which is the most effective drug to control his pain? A. Buprenorphine transcutaneous patch B. Codeine phosphate intramuscular injection C. Fentanyl transcutaneous patch D. Morphine sulfate continuous subcutaneous infusion E. Tramadol hydrochloride intramuscular injection

Answer 34

D. Morphine sulfate continuous subcutaneous infusion In this case, the most effective drug to control the patient’s pain would likely be morphine sulfate continuous subcutaneous infusion. This is because the patient is unable to take oral medication due to bowel obstruction and vomiting. The use of an intramuscular injection would be painful to administer and only provide intermittent analgesia, whereas the patient needs continuous analgesia. Buprenorphine transcutaneous patch and fentanyl transcutaneous patch would not be appropriate as his pain may change due to the progressive bowel obstruction and therefore not be stable enough for transcutaneous analgesia.

Question 35

A 35 year old woman finds a small firm lump on self examination of her breast. It is excised and is a firm, well-circumscribed solid mass, 2 cm in diameter. Histology shows a discrete mass with duct-like structures lined by regular columnar cells, separated by loose fibrous tissue. Which is the most likely diagnosis? A. Carcinoma in situ B. Ductal carcinoma C. Fibroadenoma D. Intraductal papilloma E. Paget's disease of the breast

Answer 35

C. Fibroadenoma The histological description of duct-like structures lined by regular, low columnar cells separated by loose fibrous tissue, with well- defined margins is consistent with a fibroadenoma. These are the most common benign breast lumps in young women, often presenting as a solitary, painless, firm, mobile mass. They can be surgically removed if they are causing discomfort or for cosmetic reasons. Carcinoma in situ and ductal carcinoma are malignant breast cancer and would have different histological features. Intraductal papilloma presents as a small, soft, often palpable mass and can be associated with nipple discharge. Paget’s disease of the breast presents with nipple and areolar changes, such as erythema, scaling, and ulceration, and is usually associated with an underlying invasive or in situ breast carcinoma.

Question 36

A 35 year old woman is admitted unconscious to the Emergency Department after being found collapsed outside a pub. There was an empty vodka bottle lying next to her. Her pulse is 86 bpm, BP 112/62 mmHg, respiratory rate 12 breaths per minute and oxygen saturation is 98% breathing air. Which is the most important immediate investigation? A. Arterial blood gas B. Blood alcohol level C. Capillary blood glucose D. Urea and electrolytes E. Urinary drug screen

Answer 36

C. Capillary blood glucose Capillary blood glucose is the most important immediate investigation to exclude hypoglycaemia (particularly in the context of alcohol) or hyperglycaemia. Although an arterial blood gas may be helpful, there is no evidence of respiratory compromise, and a venous blood gas may be appropriate (following a capillary blood glucose) to exclude a metabolic cause of this collapse. Blood alcohol level is likely to be high based upon the history and would not be the most important immediate investigation. Although urea and electrolytes are important investigations to consider, a capillary blood glucose would be more important to do immediately. A urinary drug screen may be helpful if the diagnosis is unclear, but this is not the most important immediate investigation.

Question 37

A 39 year old woman has had worsening tiredness for 2 weeks. She was previously well.She is mildly jaundiced. Her pulse rate is 96 bpm and BP 112/76 mmHg. Investigations: Haemoglobin 48 g/L (115–150) White cell count 6.2 × 109/L (4.0–11.0) Platelets 165 × 109/L (150–400) Mean cell volume (MCV) 98 fL (80–96) Alkaline phosphatase 100 IU/L (25–115) Aspartate aminotransferase (AST) 27 IU/L (10–40) Bilirubin (total) 41 μmol/L (< 21) Lactate dehydrogenase 560 IU/L (70–250) Blood film: red cell polychromasia, occasional spherocytes, no red cell fragments Which is the most appropriate diagnostic investigation? A. Bone marrow aspiration B. Direct antiglobulin test C. Serum antinuclear antibody D. Serum folate E. Serum vitamin B12

Answer 37

B. Direct antiglobulin test Based on the provided information, the most appropriate diagnostic investigation is direct antiglobulin test (coombs test). The patient has anaemia with raised bilirubin and LDH but otherwise normal liver function tests. The polychromasia on the film is due to an increase in reticulocytes and together these laboratory results are consistent with haemolytic anaemia (evidence of both increased RBC production and destruction). The recent history suggests an acquired not hereditary cause and there are spherocytes on the film in keeping with autoimmune haemolytic anaemia. The diagnosis would be confirmed by a direct antiglobulin test which tests for immunoglobulin or complement on the surface of red cells. Bone marrow causes of anaemia, B12 and folate deficiency can also cause anaemia and raised LDH but the blood film appearances, including increased red cell production, are not in keeping with this diagnosis. Therefore, bone marrow aspiration, B12 and folate are not as appropriate next investigations. Antinuclear antibody is also not a diagnostic investigation for haemolysis.

Question 38

An 18 year old woman with sickle cell disease attends the Emergency Department with severe pain in her left leg. She rates her pain score as 8/10. Her temperature is 36.9°C, pulse rate 110 bpm, BP 120/80 mmHg, respiratory rate 16 breaths per minute and oxygen saturation 96% breathing air. Investigations: White cell count 7.1 x 109/L (4.0–11.0) Haemoglobin 71 g/L (115–150) Platelets 190 × 109/L (150–400) Which is the next management step? A. Intravenous co-amoxiclav B. Oral prednisolone C. Red cell transfusion D. Subcutaneous morphine E. Treatment dose dalteparin

Answer 38

D. Subcutaneous morphine This patient has sickle cell disease and is presenting with severe pain crisis. Treatment of an acute painful sickle cell crisis needs to be considered an acute medical emergency. Pain must be assessed immediately and treated with an acute bolus of a strong opioid such as morphine. The patient is afebrile with a normal white cell count and thus no evidence of infection, and hence antibiotics such as co-amoxiclav are not indicated at this stage. Oral prednisolone may be used to treat acute chest syndrome, but is not the first-line treatment for pain crisis. There is no immediate urgency for red cell transfusion in an acute pain crisis although it can be considered at a later stage. Treatment dose dalteparin is indicated in patients with sickle cell disease who have a high risk of thromboembolism, but it is not indicated for this patient’s current presentation.

Question 39

A 30 year old woman becomes acutely short of breath. She was admitted to hospital 3 hours ago with an acute exacerbation of asthma. She improved following treatment with oxygen, nebulised salbutamol and oral prednisolone. Her chest X-ray on admission was clear. Her pulse rate is 122 bpm, BP 88/50 mmHg, respiratory rate 30 breaths per minute and oxygen saturation 88% breathing 40% oxygen via a face mask. She has reduced expansion of the upper left chest. She has mild wheeze throughout the chest with reduced breath sounds over the left apex. Which is the most likely explanation for her deterioration? A. Anaphylaxis B. Increasing severity of asthma C. Lobar collapse D. Pneumothorax E. Pulmonary embolus

Answer 39

D. Pneumothorax Based on the given information, the most likely explanation for her deterioration would be the development of a pneumothorax following admission based on the acute nature of her symptoms, reduced breath sounds on examination and association with her history of asthma. The reduced expansion of the upper left chest and reduced breath sounds over the left apex could suggest a possible collapse of the left upper lobe of the lung however one would expect to see changes on the chest X-ray. Anaphylaxis, increasing severity of asthma, and pulmonary embolus can all cause respiratory distress, but do not explain the physical examination findings.

Question 40

A 45 year old man has had two hours of colicky left sided abdominal pain radiating to his groin. The pain started abruptly and is associated with nausea and vomiting. He is restless and writhing in pain. There is tenderness on palpation of the left costovertebral angle. Abdominal examination is normal. Bowel sounds are present but scanty. His urinalysis shows blood 3+ and no other abnormalities. Which is the most appropriate initial analgesic agent? A. Aspirin B. Diclofenac C. Oxycodone D. Paracetamol E. Tramadol

Answer 40

B. Diclofenac The patient is presenting with symptoms consistent with renal colic, which is typically associated with severe, colicky pain that can radiate to the groin, nausea, and vomiting. The tenderness on palpation of the left costovertebral angle and the presence of blood in the urine (indicated by 3+ on urinalysis) suggest that the patient has a kidney stone causing the obstruction and pain. The most appropriate initial analgesic agent for this patient would be a nonsteroidal anti-inflammatory drug such as diclofenac. Tramadol and oxycodone are opioid analgesics that are effective for the treatment of moderate to severe pain, including renal colic, however, are not first line and should be used only if NSAIDs are contraindicated and following treatment with intravenous paracetamol. Aspirin is rarely used for its analgesic effects in renal colic. Paracetamol is an analgesic that can be used for mild to moderate pain but is second line (if given in intravenous form) to NSAIDs.