A 60-year-old man presents to accident and emergency with a 3-day history of increasingly severe chest pain. The patient describes the pain as a sharp, tearing pain starting in the centre of his chest and radiating straight through to his back between his shoulder blades. The patient looks in pain but there is no pallor, heart rate is 95, respiratory rate is 20, temperature 37°C and blood pressure is 155/95 mmHg. The most likely diagnosis is:

You see a 57 -year-old woman who presents with worsening shortness of breath coupled with decreased exercise tolerance. She had rheumatic fever in her adolescence and suffers from essential hypertension. On examination she has signs which point to a diagnosis of mitral stenosis. Which of the following is not a clinical sign associated with mitral stenosis?

A 76-year-old male is brought to accident and emergency after collapsing at home. He has recovered within minutes and is fully alert and orientated. He says this is the first such episode that he has experienced, but describes some increasing shortness of breath in the previous six months and brief periods of central chest pain, often at the same time. On examination, blood pressure is 115/88 mmHg and there are a few rales at both bases. On ECG there are borderline criteria for left ventricular hypertrophy. Which of the following might you expect to find on auscultation?

A 63-year-old male was admitted to accident and emergency 2 days after discharge following an apparently uncomplicated MI. He complained of rapidly worsening shortness of breath over the previous 48 hours but no further chest pain. He was tachypnoeic and had a regular pulse of 110/minute, which proved to be sinus tachycardia. The jugular venous pressure was raised and a pan-systolic murmur was noted, maximal at the left sternal edge. Which of the following is the most likely diagnosis?

A 16-year-old male is referred for assessment of hypertension. On average, his blood pressure is 165/85 mmHg, with radiofemoral delay. There is a mid-systolic murmur maximal at the aortic area, and radiating to the back. Clinical findings and the ECG are compatible with left ventricular hypertrophy. What is the most likely underlying pathology?

A 46-year-old man develops sudden severe central chest pain after lifting heavy cases while moving house. The pain radiates to the back and both shoulders but not to either arm. His BP is 155/90 mmHg, pulse rate is 92 beats per minute and the ECG is normal. He is distressed and sweaty, but not nauseated. What would you consider the most likely diagnosis?

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

A 44-year-old woman attends her local accident and emergency department with a history of at least six months of frequent central chest pain in the early morning or during the night. She had no chest pain on exertion. This had been a particularly severe attack, lasting over 2 hours. Her pulse rate is 84/minute in sinus rhythm, and blood pressure is 134/86 mmHg. The ECG shows anterior ST segment elevation, but troponin levels do not rise. Subsequent coronary angiography is normal. What is the most likely diagnosis?

You see a 68-year-old man in clinic, with a 40 (cigarette) pack year history, who has been experiencing breathlessness on exertion and a productive cough of white sputum over the last four months. You assess his spirometry results which reveal an FEVl/FVC of 51 per cent with minimal reversibility after a 2-week trial of oral steroids. Cardiological investigations are normal. Which of the following is the most likely diagnosis?

A 67-year-old woman is admitted to accident and emergency with pyrexia (38.1°C) and a cough productive of green sputum. The observations show a pulse rate of 101, BP 80/60 and respiratory rate of 32. She is alert and orientated in space and time. Blood results reveal a WCC of 21, urea of 8.5 and chest x-ray shows a patch of consolidation in the lower zone of the right lung. She is treated for severe community-acquired pneumonia. Which of the following is the correct calculated CURB-65 score?

You are asked to interpret an arterial blood gas of a 76-year-old patient who was admitted to accident and emergency with an acute onset of breathlessness and low oxygen saturations. The test was taken on room air and read as follows: pH 7.37, P02 7.8, PC02 4.1, HC03 24, S02 89 per cent. Choose the most likely clinical interpretation from these arterial blood gas results:

A 54-year-old woman is seen in clinic with a history of weight loss, loss of appetite and shortnesss of breath. Her respiratory rate is 19 and oxygen saturations (on room air) range between 93 and 95 per cent. On examination, there is reduced air entry and dullness to percussion on the lower to midzones of the right lung. There is also reduced chest expansion on the right. From the list below, select the most likely diagnosis:

A 45-year-old woman with unexpected weight loss, loss of appetite and shortness of breath presents to you in clinic. On examination, there is reduced air entry and dullness to percussion in the right lung. A pleural tap is performed and the aspirate samples sent for analysis. You are told that the results reveal a protein content of>30 giL. From the list below, select the most likely diagnosis:

A 55-year-old woman, who has never smoked, presents to you on the ward with a history of weight loss, decreased appetite and finger clubbing. You are told that her chest x-ray revealed opacity in the hilar region of the right lung suggesting a bronchogenic carcinoma. She is currently awaiting aCT-chest with bronchoscopy to follow. From the list below, select the most likely diagnosis:

You see a 28-year-old man, with no past medical history, in accident and emergency who developed an acute onset of pleuritic chest pain and shortness of breath while playing football. On examination, oxygen saturations are 93 per cent on room air, respiratory rate 20 and temperature is 37.1 oc. There is decreased expansion of the chest on the left side, hyper-resonant to percussion and reduced air entry on the left. The most likely diagnosis is:

You see a 67-year-old man who has been referred to the chest clinic following a three-month history of weight loss and signs which may suggest a Pancoast's tumour. Which of the following symptoms from the list below is not associated with a Pancoast's tumour?

A 50-year-old Afro-Caribbean man, with no past medical history, presents with a four-month history of dry cough and shortness of breath on exertion. The patient's GP referred him to the chest clinic after performing blood tests which revealed a raised erythrocyte sedimentation rate (ESR) and serum angiotensin-converting enzyme (ACE) level. You review the patient's chest xray which reveals bilateral hilar lyphadenopathy. From the list below, select the most likely diagnosis:

You are told by your registrar that a 69-year-old man has been admitted to the chest ward with dyspnoea, cyanosis and finger clubbing. His chest x-ray shows bilateral lower zone reticulonodular shadowing. From the list below, which is the most likely diagnosis?

You see a 70-year-old man diagnosed with hypersensitivity pneumonitis following a four-month history of shortness of breath at rest and cyanosis. Which of the following does not fall under the category of hypersensitivity pneumonitis?

During the consultant ward round, you see a 78-year-old woman who is being investigated for hyponatraemia, weight loss and haemoptysis. A mass lesion was detected on a CT -chest scan which has been biopsied and sent for histological analysis. Your consultant has a high suspicion that the patient may have bronchogenic carcinoma. From the list below, select the most likely type of bronchogenic carcinoma that would explain the above patient's symptoms:

A 56-year-old man attends your clinic with a three-month history of a productive cough with blood-tinged sputum, following his return from India. Associated symptoms include lethargy, night sweats and decreased appetite. He is normally fit and healthy with no past medical history. On examination, the patient's chest has good air entry bilaterally with no added sounds and his temperature is 37.3°C. A sputum sample sent from the patient's GP reveals a growth of acid fast bacilli. From the list below, which is the most likely diagnosis?

A 37-year-old woman is admitted to accident and emergency with severe facial burns. Despite prompt management, she develops acute respiratory distress syndrome (ARDS). Which of the following is not associated with the diagnostic criteria for ARDS?

You see a 47-year-old man in clinic with a three-month history of epigastric dull abdominal pain. He states that the pain is worse in the mornings and is relieved after meals. On direct questioning, there is no history of weight loss and the patient's bowel habits are normal. On examination, his abdomen is soft and experiences moderate discomfort on palpation of the epigastric region. The most likely diagnosis is:

You see a 48-year-old lorry driver, who presents to you with a three-month history of heartburn after meals which has not been settling with antacids and PPis. You suspect that the patient has a hiatus hernia. The most appropriate investigation for diagnosing a hiatus hernia is:

You see a 25-year-old woman who presents with a 24-hour history of watery diarrhoea. She states that she has opened her bowels 11 times since her onset of symptoms. Associated symptoms include nausea and vomiting with abdominal cramps and pain which started in the evening following a bar beque meal in the afternoon that day. The patient is alert and orientated and her observations include a pulse rate of 69, blood pressure of 124175 and temperature of 37.1 oc. On examination, her abdomen is soft, there is marked tenderness in the epigastric region and bowel sounds are hyperactive. The patient is normally fit and well with no past medical history. The most likely diagnosis is:

You see a 54-year-old woman, referred to accident and emergency through her GP, with a week's history of jaundice and right upper quadrant abdominal pain. Associated symptoms include dark urine and pale stools. There is no history of weight loss and the patient does not consume alcohol. Her liver function tests reveal a bilirubin of 40 JJmol/L, AL T of 40 iu/L, AST 50 iu!L and ALP of 350 iu/L. The most likely diagnosis is:

You see a 75-year-old man with an acute episode of haematemesis, who was admitted the night before and is awaiting an upper GI endoscopy. You are asked on the ward round about the common causes of upper GI bleeding. From the list below, which of the following is the most common cause of upper GI bleeding?

A 67-year-old man presents feeling unwell and complaining of general malaise. He mentions a long history of alcohol abuse and his past medical history shows deranged liver function tests. Which of the following clinical signs does not form part of chronic liver disease?

You see a 52-year-old woman with rheumatoid arthritis in your clinic. She was referred by her GP after her ALP levels were found to be abnormally high at 300 iu/L. In addition, she was also found to be serum anti-mitochondrial antibody (AMA) positive. The most likely diagnosis is:

You are told by your registrar that one of your inpatients has been diagnosed with primary sclerosing cholangitis (PSC). Your registrar suspects that the patient may have an associated condition. Primary sclerosing cholangitis is associated with which of the following diseases?

A 28-year-old man undergoes a sigmoidoscopy for longstanding diarrhoea and weight loss. On visualization of the rectum, the mucosa appears inflamed and friable. A rectal biopsy is taken and the histology shows mucosal ulcers with inflammatory infiltrate, crypt abscesses with goblet cell depletion. From the list of answers below, which is the most likely diagnosis, describing the histology report?

You read a report which was handwritten in a patient's medical notes who you suspect has inflammatory bowel disease. The report reads, ' ... There is cobblestoning of the terminal ileum with the appearance of rose thorn ulcers. These findings are suggestive of Crohn 's disease'. Select the most likely investigation that this report was derived from:

A 47 -year-old woman has been experiencing a four-month history of diarrhoea and bloating. Associated symptoms include lethargy and weight loss. Full blood count reveals haemoglobin of 9.3 d/gL and MCV 70 fL. Which of the following investigations would be helpful in the patient's diagnosis?

A 21-year-old man presents with painless haematuria which he has noticed in the last 3 days. He suffers from type 1 diabetes which is well controlled, but is otherwise fit and healthy. The patient has recently recovered from a mild throat infection. Urine dipstick analysis reveals blood and protein in the urine. The most likely diagnosis is:

A 16-year-old boy presents with a low-grade fever which started 1 week ago. The patient also reports feeling fatigued and indicates pain in his joints. His parents mention that he has been visiting the toilet more often than usual. A urine dipstick shows trace proteins, while a blood test shows raised eosinophils. The most likely diagnosis is:

A 42-year-old diabetic Asian male complains of dysuria, increased urinary frequency and general malaise for the past six months. In the last few days, he has noticed blood in the urine. Examination of the urine shows the presence of neutrophils with no organisms detected on urine culture. The most likely diagnosis is:

A 17-year-old patient is referred by his GP after presenting with periorbital oedema. The patient noticed the oedematous eyes 3 days ago, but reports feeling unwell since a throat infection 3 weeks ago with nausea and vomiting in the last week. A urine dipstick is positive for protein and blood while serum creatinine and urea are mildly deranged. The most likely diagnosis is:

A 32-year-old builder presents in accident and emergency in a distressed state. He reports suffering from chest pain for the last 2 weeks, the pain is sharp and only occurs when he moves heavy objects. He has a family history of cardiovascular disease and is worried about a heart attack. His blood gas findings are as follows: pH= 7.47; PC02 = 3.3; P02 = 15.3; bicarbonate= 17.53. The most likely diagnosis is:

A 52-year-old man complains of a 3-week history of malaise and shortness of breath. He has lost weight in the last few months but attributes this to a loss of appetite possibly due to stress at work. On examination, he has a palpable mass in the right lumbar region. He has no urinary symptoms. However, the urine dipstick detected blood. The most likely diagnosis is:

A 37 -year-old man presents with a 5-day history of haematuria. Abdominal examination is unremarkable. Urine analysis reveals hypercalciuria and excretion urography reveals small calculi within the papilla of the patient's right kidney. The patient has presented several times in the past with UTis and renal stones, but is otherwise healthy. The most likely diagnosis is:

A 64-year-old man is undergoing treatment for polycythaemia vera with chemotherapy, he has no other medical problems. Shortly after starting treatment, the patient becomes lethargic, feels unwell and suffers weight loss. He attributes this is to the chemotherapy. After 2 weeks, the patient becomes oliguric, complains of bilateral flank pain and becomes oedematous. The most likely diagnosis is:

A 67 -year-old diabetic female is brought into accident and emergency following a collapse at her home. She was found by her daughter who said she saw the patient going to the toilet and then hearing her collapse. The patient did not lose consciousness and appears well. Her supine blood pressure is 100/70 and standing 115/79. Urine dipstick is positive for glucose, nitrates, leukocytes and haematuria. The most likely diagnosis is:

An 18-year-old man presents with generaJ malaise and lethargy for the last 2 weeks, he denies any weight loss and has maintained a good appetite. On examination, there are no abnormalities except for sacral oedema and a polyphonic wheeze. Urine dipstick is positive for protein only and blood pressure is 140/90. The most likely diagnosis is:

A 6-year-old has a sore throat and has been given antibiotics. Three weeks later, he represents feeling feverish with nausea, vomiting and tea-coloured urine. Urine dipstick confirms haematuria and protein. Blood pressure is 100/60 mmHg. The most likely diagnosis is:

A 21-year-old man complains his urine has turned a faint red in the last week. He denies any significant changes in his diet or lifestyle and bas no other medical problems except for sensorineural deafness diagnosed when he was young. On examination, you notice retinal flecks and urine dipstick confirms protein and blood. The most likely diagnosis is:

A 65-year-old overweight man presents with a 2-week history of haematuria. The patient denies any other symptoms and his blood pressure is 128/83 mmHg. He suffers from no other medical problems but admits to being a chronic smoker since the age of 16. He has tried to lose weight using herbal remedies for three years, but he has only noticed significant weight loss in the last week despite stopping the remedies months ago. The most likely diagnosis is:

A 53-year-old man with HIV suffers a ruptured aortic aneurysm and is rushed into theatre, he undergoes a successful operation and is recovering on the wards in a stable condition. One day after the operation, he becomes oliguric with mildly elevated urea and creatinine. After 1 week, he becomes polyuric with a GFR of 30. The most likely diagnosis is:

A 64-year-old woman with type 1 diabetes presents to clinic with several months of sinus problem and a 4-day history of oliguria. Her blood pressure is 137/80, serum results show mildly elevated urea and creatinine, absence of anti-GBM antibodies, while a C-ANCA assay is positive. Red blood cell (RBC) casts are present in the urine and her renal biopsy reveals glomerular crescents. The most likely diagnosis is:

A 66-year-old woman with poorly controlled type 2 diabetes presents to accident and emergency with a 2-day history of severe pain in the right flank, nausea and fevers that come and go. On examination, the patient appears unwell, sweaty and has visible rigors with a temperature of 38°C. The patient denies any recent travel. Urine dipstick is positive for protein, blood, leukocytes and nitrates. A CT scan of the abdomen reveals gas in the renal parenchyma area. The most likely diagnosis is:

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