Past paper questions

Question 1

A 65-year-old woman presented with a 12-hour history of sudden-onset gait unsteadiness, vomiting and headache, followed by increasing drowsiness.

What is the most likely diagnosis?

Answer 1

acute cerebellar haemorrhage

Question 2

A post-marketing observational study of a new drug was conducted on 5000 patients following clinical trials.

What best describes the data generated from this type of study?

Answer 2

profile of adverse effects

Question 3

which antibody will be positive in antiphospholipid syndrome?

Answer 3

anticardiolipin

Question 4

A 30-year-old woman presented with a 6-month history of tremor and difficulty in speaking.

On examination, she was found to have increased muscle tone in all four limbs, bradykinesia and 4-cm hepatomegaly.

What laboratory finding would best support a diagnosis of Wilson’s disease?

Answer 4

low serum caeruloplasmin concentration

Wilsons

Question 5

A 16-year-old girl presented with non-scaly, discrete areas of hair loss on the scalp. She had a history of atopic eczema and had a number of depigmented areas on her hands and around her eyes.

What is the most likely diagnosis?

Answer 5

Alopecia areata

Question 6

A 26-year-old woman presented with unequal pupils.

On examination, the right pupil was larger than the left and did not react to light, directly or consensually. On convergence, the right pupil reacted very slowly, but eventually became smaller than the left pupil.

What is the best description of this type of pupillary abnormality?

Answer 6

Adie’s tonic pupil

Question 7

A 38-year-old woman required extraction of her wisdom teeth. She gave a history of haemorrhage after a dental extraction 10 years previously, when she had required suturing. There had been no history of excessive bleeding before this.

What is the most likely diagnosis?

Answer 7

Von Willebrand disease

Question 8

A 27-year-old woman presented with a right-sided thyroid swelling with associated cervical lymphadenopathy.

What is the most likely cause?

Answer 8

papillary carcinoma - most common thyroid malignancy

Question 9

A 20-year-old woman presented with a 2-month history of an intensely pruritic rash on her trunk and limbs. She was otherwise well.

On examination, she had multiple, violaceous, flat-topped papules over the flexor surfaces of the wrists, and on the ankles and lower back. The papules were aggregated in a linear fashion at one site on her left forearm.

What clinical feature is most likely to be present?

Answer 9

Lichen planus- involvement of buccal mucosa

Question 10

A 64-year-old man presented with increasing pain in his right elbow and tingling in the medial aspect of his right hand. His job involved using a sledgehammer.

Examination was normal.

What is the most likely diagnosis?

Answer 10

Ulnar nerve entrapment

Question 11

A 75-year-old woman presented with a 6-month history of an ulcer over the right ankle. She had a history of right deep venous thrombosis 5 years previously.

On examination, she had a superficial sloughing ulcer, 6 cm in diameter, over the medial malleolus.

What is the most appropriate investigation?

Answer 11

ABPI

venous ulcers need treatment with compression bandages, need ABPI before applying

Question 12

A 45-year-old man presented with a 1-month history of foot drop.

What feature most strongly favours an L5 radiculopathy over a peroneal nerve palsy?

Answer 12

Weakness of inversion is not seen in common peroneal nerve lesion but may be present with L5 lesion (tibialis posterior muscle is supplied by tibial nerve, L4/5).

Question 13

A 21-year-old man presented after a truamatic hemisection of his spinal cord at T10 level.

What is most likely to be present below the level of the lesion 2 months after the injury?

Answer 13

contralateral loss of pain and temperature sensation

Question 14

A 47-year-old woman was being treated with lithium for bipolar affective disorder.

On examination, her BP was 168/104 mmHg.

What is the most appropriate antihypertensive drug for her?

Answer 14

amlodipine

Question 15

A 16-year-old boy presented 30 minutes after sustaining a head injury. His parents reported that he had fallen and hit the right side of his head on the ground. He had lost consciousness for a few seconds, then recovered fully.

On examination, he was fully conscious and had no focal neurological signs. Two hours later, his conscious level deteriorated.

What is the most likely diagnosis?

Answer 15

Extradural

Question 16

A 55-year-old woman presented with a 2-day history of diplopia and progressive gait unsteadiness.

On examination, she had limited eye movements in all directions and her pupils were poorly reacting. Muscle power in the limbs was normal but tendon reflexes were absent. There was prominent bilateral finger–nose ataxia. Plantar responses were flexor. Sensation was normal.

What is the most likely diagnosis?

Answer 16

Miller Fisher syndrome is the triad of ataxia, internal and external ophthalmoplegia and areflexia. It is often associated with antibodies to GQ1b and is probably a variant of Guillain– Barré syndrome.

Question 17

How is RAAS affected by congestive heart failure?

Answer 17

In congestive cardiac failure, there is pathophysiological activation of the renin angiotensin aldosterone system due to reduced renal perfusion pressure, which is identified within the nephron by the juxtaglomerular apparatus. This leads to elevated levels of these hormones. Serum cortisol levels are not usually significantly elevated in congestive cardiac failure. Atrial natriuretic peptide would be elevated in congestive cardiac failure in response to increased atrial blood volume and atrial wall stretch

Question 18

A clinical diagnosis of acromegaly was suspected.

What additional investigation is most likely to confirm the diagnosis?

Answer 18

growth hormone suppression test

Question 19

A 56-year-old man presented with double vision

On examination, he had bilateral partial ptosis, diplopia and truncal muscle weakness.

Investigations:

chest X-ray widened mediastinum
What is the most likely diagnosis?

Answer 19

The clinical presentation is entirely consistent with myasthenia gravis and the widened mediastinum would be consistent with thymoma which is often associated with paraneoplastic myasthenia gravis

Question 20

A 25-year-old injecting drug user presented with an injection-site abscess.

On examination, his temperature was 38.5°C and there was a pansystolic murmur.

What organism is most likely to be cultured from both the abscess and the blood?

Answer 20

Staphylococcus aureus

Question 21

most likely cause viral meningitis

Answer 21

enterovirus

Question 22

A 58-year-old man was seen with progressive breathlessness in the outpatient clinic. He had undergone coronary artery bypass grafting 3 years previously and this had been complicated by a resternotomy for tamponade. He recovered well but had started to feel breathless and fatigued over the past 12 months. His history included type 2 diabetes mellitus and hypertension. He was a current smoker.

A diagnosis of constrictive pericarditis was made.

What is the most common physical finding seen in this group of patients?

Answer 22

Hepatomegaly is the best answer. Hepatomegaly is the earliest and most consistent feature of pericardial constriction of the options here.

Ascites (a later phenomenon than hepatomegaly) and pericardial knock (recognised in around 50% of cases) are also features of pericardial constriction.

Question 23

A 22-year-old woman presented with acute chest pains, 2 days after the uncomplicated delivery of her first child, and was found to have an anterior ST-elevation myocardial infarction. She had no conventional risk factors for coronary artery disease.

What is the most likely aetiology of her myocardial infarction?

Answer 23

Coronary artery dissection is the best answer, as it is a well-recognised cause of myocardial infarction in relation to pregnancy. It is the most likely cause in this young patient who is in the early post-partum phase, and who has no recognised risk factors for coronary atherosclerosis.

Question 24

A 72-year-old man presented with a 3-month history of worsening neck and right arm pain radiating down the inner forearm, associated with numbness and tingling involving the index and middle fingers.

Examination of the right upper limb revealed reduced forearm pronation and wrist flexion, decreased sensation in the index and middle fingers, and diminished triceps tendon reflex.

What is the most likely site of the lesion?

Answer 24

The sensory and motor abnormalities described are as a result of a lesion at the C7 nerve root causing sensory loss in the C7 and 8 dermatome and motor abnormalities attributed to the C7 myotome.

Question 25

Lipodermatosclerosis layer

Answer 25

hypodermis

Lipodermatosclerosis or sclerosing panniculitis is an extensive induration of the skin, often in association with leg ulcers and most commonly related to venous hypertension; it is a chronic inflammation, with fibrous tissue that involves and replaces the hypodermis and, if extensive, the papillary dermis.

Question 26

A 57-year-old woman attended the diabetes-nephrology clinic for annual review. Her history included hypertension, type 2 diabetes mellitus and diabetic retinopathy.

On examination, her BP was 168/98 mmHg. Urinalysis showed protein 1+, glucose 1+.

What is the most useful investigation to determine her future cardiovascular risk?

Answer 26

urine albumin:creatinine ratio

Proteinuria is an independent predictor of cardiovascular risk in patients with diabetes mellitus and/or hypertension.

Question 27

A 75-year-old man was admitted with a 10-day history of generalised reddening of his skin, accompanied by shivering and thirst. He had a history of psoriasis.

On examination, his pulse was 110 beats/min and his BP was 110/60 mmHg. He had dependent oedema. His skin was uniformly erythematous and scaly.

What is the most appropriate initial treatment?

Answer 27

topical white soft paraffin

Question 28

A 55-year-old man presented after a recent myocardial infarction. He was concerned about the risk to other family members after reading a newspaper article about association studies that mentioned ischaemic heart disease and single nucleotide polymorphism (SNP) genotyping.

What is the most appropriate definition of an SNP?

Answer 28

substitution of a nucleotide for any other nucleotide

Question 29

Aside from urine and serum electrolytes and osmolalities, What additional information would be most useful to support a diagnosis of syndrome of inappropriate antidiuretic hormone?

Answer 29

Diagnosis of syndrome of inappropriate antidiuretic hormone (SIADH) can only be made in the presence of normal thyroid, adrenal and kidney function.

Question 30

3-mm ST-segment depression in leads V1 to V3, with upright T waves and tall R waves
A diagnosis of acute myocardial infarction was made and the patient was referred for primary percutaneous coronary intervention.

Which coronary artery is most likely to be involved?

Answer 30

The patient is having a posterior ST-elevation myocardial infarction (STEMI), as noted by the fact there is a dominant R wave in V1-3 and ST depression, which, if posterior leads were applied, would show ST elevation and Q waves in V1-3 e.g. a mirror image. It is the circumflex that supplies the posterior surface of the heart, via the posterior descending artery in around 15% of people, called a left dominant system; in 85% of people, the posterior descending artery arises from the right coronary artery, called a right dominant system.

Question 31

A 32-year-old man with chronic hepatitis C virus infection was being treated with directly acting antiviral medication.

What investigation is most appropriate for assessing his sustained response to treatment?

Answer 31

HCV viral load

Question 32

What is the site of origin of circulating B-type natriuretic peptide in patients with chronic heart failure?

Answer 32

cardiac ventricles

Question 33

A 60-year-old woman with advanced metastatic cancer was treated with subcutaneous haloperidol infusion.

What is the main site of action of this antiemetic?

Answer 33

Haloperidol is a D2-receptor antagonist. It has a central antiemetic action binding to receptors in the area postrema, which is a medullary structure controlling vomiting.

Question 34

A 72-year-old man became suddenly short of breath during his first dialysis session via a dialysis catheter.

On examination, he had facial oedema, red eyes and a blanching rash on his arms and legs. His pulse was 118 beats per minute and his BP was 108/72 mmHg. His oxygen saturation was 96% (94–98) breathing air.

What is the most likely immunological diagnosis?

Answer 34

type 1 hypersensitivity reaction

Question 35

A 67-year-old man presented with a 6-month history of muscle rigidity and a resting tremor. A diagnosis of Parkinson’s disease was made and he was treated with ropinirole.

What is the mechanism of action of ropinirole?

Answer 35

dopamine receptor agonist

Question 36

A study evaluated the effectiveness of a new analgesic in patients with painful knee osteoarthritis. Subjects were asked to assess their pain on a 10-point scale both before and after 6 weeks of treatment.

What is the most appropriate test to ascertain whether the treatment reduced the pain?

Answer 36

These are not independent variables, and the size of the group is not mentioned, so it cannot be assumed to be a normal distribution. Wilcoxon signed-rank test is, therefore, the correct answer as it is a non-parametric used to compare related data groups.

Question 37

A 72-year-old man presented with loss of the lower half of the visual field of his right eye, with no associated pain. He had type 2 diabetes mellitus and was being treated for hypertension.

Examination showed normal visual acuity in both eyes, with an inferior altitudinal field defect in the right eye. Fundoscopy of the left eye was normal, and the upper part of the right optic disc showed mild disc swelling. No fundal haemorrhages were seen. His BP was 160/90 mmHg.

What is the most likely diagnosis?

Answer 37

The visual field defect indicates a likely vascular cause. Branch retinal vein thrombosis is typically associated with fundal haemorrhages, not seen in this case, making an arterial explanation more likely

Question 38

A 68-year-old man was referred with muscle contractures following a traumatic head injury 3 years previously.

On examination, there was a left-sided torticollis.

What muscle is most likely to be responsible?

Answer 38

Torticollis is caused by contracture of the contralateral sternocleidomastoid muscle.

right sternocleidomastoid

Question 39

What cellular component contains double-stranded circular DNA?

Answer 39

mitochondria

Question 40

A 50-year-old woman with discoid lupus erythematosus presented with an apparent worsening of her rash despite treatment with topical corticosteroids and photoprotection.

On examination, there were discrete erythematous, scaly plaques with follicular plugging.

What additional treatment is most appropriate?

Answer 40

hydroxychloroquine

Question 41

A 23-year-old man was admitted with a 3-day history of lower cramping abdominal pain and fever. He had mild diarrhoea, but no blood in his stool. He had not travelled recently.

On examination, he was tender in his right iliac fossa. There were raised, tender, red nodules on his shins.

Investigations:

CT scan of abdomen cluster of lymph nodes at appendix suggestive of mesenteric adenitis
What is the most likely cause of his symptoms?

Answer 41

Yersinia enterocolitica infection

Question 42

A 24-year-old woman presented with a 4-month history of a non-itchy rash on her trunk. The rash was originally fawn-coloured and the areas had become white following sun exposure. It had not improved with clobetasone butyrate cream. She was otherwise well.

On examination, she was suntanned and there was a fine, scaly eruption consisting of discrete, pale macules, coalescing into large patches.

What is the most appropriate initial treatment?

Answer 42

oral fluconazole

The history of fawn-coloured areas on untanned skin which become hypopigmented/white when the rest of the patient’s skin tans following repeated sun exposure indicates that this patient has pityriasis versicolor,

Question 43

A 70-year-old woman presented after being found collapsed at home.

Examination showed weakness of the lower two-thirds of the left side of her face and a dense left hemiparesis affecting her arm and leg. She had a fixed gaze palsy to the right affecting both eyes.

Damage to what area of the brain is most likely to have produced the gaze palsy?

Answer 43

Left hemiparesis with left upper motor neurone facial nerve palsy, implying a right-sided brain lesion. Fixed gaze palsy to the right supports this (the eyes ‘look towards’ the side of the lesion). These findings are typical of a frontal lobe lesion.

Question 44

In a healthy subject, what is most likely to decrease pulmonary vascular resistance?

Answer 44

epoprostenol (prostacyclin)

Question 45

A 45-year-old man with Down syndrome underwent chromosome analysis to provide information about the possibility of recurrence in his family.

Chromosome analysis confirmed that his karyotype was 47, XY, +21.

What term best describes this karyotype?

Answer 45

aneuploid

Question 46

What is the mechanism of renal injury with aciclovir?

Answer 46

Aciclovir is renally eliminated. In the presence of dehydration, aciclovir can precipitate as crystals in the kidney tubules causing acute kidney injury.

Question 47

dystrophia myotonica features

Answer 47

autosomal dominant condition with variable penetrance.

Symptoms characteristically begin from the age of 20-30 years with weakness and myotonia.

Features include:

cataracts
ptosis
frontal baldness
gynaecomastia
diabetes, and
reduced reflexes with myotonia.