Medecine DX Q 101 to 200 ex

101. A 65-year-old man presents with a chronic history of headaches and occasional dizziness.He hesitantly mentions that he experiences severe pruritus, especially after hot showers and baths. Blood pressure is 160/85 mmHg.A full blood count (FBC) reveals a haemoglobin of 20 g/dL, MCV of 94 fL, platelet count of 470 x 109/L and WBC count of 7.8 x 109/L. The most likely diagnosis is:

102. A 33-year-old man travels to South Africa to take part in a safari.On arriving, the patient takes his antimalarial tablets.A few days into his course he becomes ill complaining of shortness of breath, pallor and bloody urine.Blood tests reveal anaemia and reduced haematocrit, while a blood smear shows the presence of Heinz bodies.The most likely diagnosis is:

103. A 65-year-old man presents with a chronic history of malaise, shortness of breath and paraesthesia in his hands.He appears tired and pale while speaking and on examination his heart rate is 115, respiratory rate 16.A Schillings test is positive while blood tests reveal a macrocytic anaemia and a Coombs test is negative.The most likely diagnosis is:

104. A 47-year-old woman presents to clinic concerned about her recent ill health. She has noticed over the last three months that she has been suffering from headaches, fatigue and recurrent infections.She notes she has rarely been to the doctor before and otherwise leads a healthy lifestyle.She decided to see a doctor when she noticed petechial rashes appearing on her arms. On examination there is no organomegaly and blood tests reveal an MCV of 105, a pancytopenia with the bone marrow appearing hypocellular on biopsy.

105. A 65-year-old man presents to you reporting he has become increasingly worried about his lack of energy in the last 2 weeks.He mentions he has been increasingly tired, sleeping for long periods and has suffered from fevers unresponsive to paracetamol. He became increasingly worried when he noticed bleeding orginating from his gums.A blood ftlm shows auer rods, hypogranular neutrophils and stains with Sudan black B.The most likely diagnosis is:

106. A 66-year-old woman complains of stiffness and weakness climbing stairs.She has a history of hypertension and diet--controlled type 2 diabetes. On examination, there is mild upper arm weakness, hip flexion is 4/5 bilaterally, with bilateral wasting and flickers of fasciculations in the right quadriceps. Knee extension is 4/5.Dorsiflexion and plantar flexion are strong.Brisk knee and ankle reflexes are elicited, as well as a positive Hoffman's and Babinski's sign. Sensory examination and cranial nerves are normal.Her BM is 8.9, her pulse is regular and her blood pressure is 178/97.What is the most likely diagnosis?

107. A 78 year old right-handed male collapses and is brought into accident and emergency.He seems to follow clear one-step commands but he gets very frustrated as he cannot answer questions.He is unable to lift his right hand or leg.He has an irregularly irregular pulse and his blood pressure is 149/87.He takes only aspirin and frusemide.What is the most likely diagnosis?

108. A 71-year-old man with atrial fibrillation is seen in clinic following an episode of syncope.He describes getting a poor night's sleep and, as he got out of bed in the morn ing, feeling dizzy for a couple of seconds before the lights dimmed around him.He was woken a couple of seconds later by his wife who had witnessed the event. She says he went pale and fell to the floor and his arms and legs jer ked. After waking, he was shaken but was 'back to normal' a few minutes after the event.His medication includes aspirin, atenolol and frusemide.What is the most likely diagnosis?

109. A 41-year-old man complains of terrible headache.It started an hour ago, without warning, while stressed at work.It affects the right side of his head. He scores it '11/10' in severity. When asked, he agrees that light does bother him a little.He had a similar episode six months ago, experiencing very similar headaches over 2 weeks which resolved spontaneously. On observation, he looks quite distressed and prefers to pace up and down, unable to sit still.What is the diagnosis?

110. A 49-year-old man complains of sudden onset, painless unilateral visual loss lasting about a minute.He describes 'a black curtain coming down'.His blood pressure is 158/90, heart rate 73 bpm.There is an audible bruit on auscultation of his neck.His past medical history is insignificant other than deep vein thrombosis of his right leg ten years ago.The most likely diagnosis is:

111. A 69-year-old man presents to clinic with a six-month history of progressive lower back pain which radiates down to his buttock.He found the pain was exacerbated while taking his daily morning walk and noticed that it eased going uphill but worsened downhill.He stopped his daily walks as a result and he now walks only slowly to the shops when he needs to, taking breaks to sit down and ease the pain.He has a history of hypertension, diabetes and prostatic hyperplasia. What is the diagnosis?

112. A 31-year-old woman presents to accident and emergency with progressive difficulty walking associated with lower back pain.A few days ago she was tripping over things, now she has difficulty climbing stairs.She describes tingling and numbness in both hands which moved up to her elbows, she is unable to write.On examination, cranial nerves are intact but there is absent sensation to vibration and pin prick in her upper limbs to the elbow and lower limbs to the hip. Power is 3/5 in the ankles and 4-/5 at the hip with absent reflexes and mute plantars.Her blood pressure is 124/85, pulse 68 and sats 98 per cent on air. She has a past medical history of type I diabetes and recently recovered from an episode of food poisoning a month or two ago.What is the diagnosis?

113. A light is shone into a patient's right eye and it constricts.When moved to the left eye, the left eye constricts.When moved back to the right eye, the right eye dilates.What is the diagnosis?

114. A 55-year-old woman complains of double vision. She finds that she is tired all the time and has difficulty climbing stairs. She has difficulty getting items off high shelves at work.Reflexes are absent but elicited after exercise.Shoulder abduction is initially 4-5 but on repeated testing is 4 +/5.What pathology is associated with this female's diagnosis?

115. On observation, a patient has a left facial droop. On closer examination his nasolabial fold is flattened. When asked to smile, the left corner of his mouth droops.He is unable to keep his cheeks puffed out. Eye closure is only slightly weaker compared to the right and his forehead wrinkles when he is asked to look up high.What is the diagnosis?

116. A 69-year-old man is taken to his GP by his concerned wife.She complains that he has not been himself for the last year.He has slowly become withdrawn and stopped working on his hobbies.Now she is concerned that he often forgets to brush his teeth.She has noticed he sometimes struggles to fmd the right word and this has gradually become more noticeable over the last couple of months.She presented today because she was surprised to come home to find him naked and urinating in the living room last week.He has a history of hypertension and is an ex-smoker.The most likely diagnosis is:

117. A 43-year-old woman presents with dizziness to accident and emergency.It started suddenly this morning, she awoke with a headache and the dizziness started when she sat up in bed.She describes the room spinning for a couple of minutes.It settles if she keeps still, but returns on movement.There is no tinnitus or deafness, but some nausea and no vomiting.The most likely diagnosis is:

118. A 45-year-old man presents with a 5-day history of progressive tingling and numbness of his hands and feet.He insists that he has never had this problem before and that he was perfectly fine a week ago.Over the last 2 days he has had some difficulty walking but mostly he complains about difficulty rolling up cigarettes. On examination, there is mild symmetrical distal weakness, mild gait ataxia and dysdiadochokinesia. He smokes 30 cigarettes a day and drinks 1-2 bottles of wine.He has a family history of hypertension and his 63-year-old mother has type 2 diabetes, whom over the last year has complained of numbness and burning in her feet.He selfdischarges.A week later, his symptoms have peaked.He displays moderate distal weakness and numbness to his knees, after which he turns a corner and his symptoms start to slowly resolve. What is the diagnosis?

119. A 28-year-old junior doctor has been complaining of a headache for the last 24 hours.It started gradually, intensifying slowly and involving the entire cranium, but over the last couple of hours she has noticed that turning her head is uncomf ortable.She feels generally unwell and prefers to lie in a dark room.Her boyfriend has noticed that she seems irritable.On examination, she exhibits photophobia and there is neck stiffness.There is no papilloedema. Close examination of her skin reveals no rashes.Kernig's sign is negative.A lumbar puncture (LP) reveals low protein, normal glucose and lymphocytosis.What is the diagnosis?

120. A 36-year-old woman presents to clinic with neurological symptoms. On examination, she is able to stand with her feet together.Upon closing her eyes, however, she is unable to keep her balance. What is the diagnosis?

121. A 60-year-old man has presented to the gastroenterology outpatient clinic with a four-month history of progressive dysphagia. The patient reports a weight loss of 9 kg in the same time period. He has suffered from gastro-oesophageal reflux disease for the past 10 years.At endoscopy, a S cm malignant stricture is seen at the lower end of the oesophagus and biopsies are taken.Histological analysis is most likely to reveal:

122. A 70-year-old man presents to his GP having noticed a slowly enlarging 'spot' on his left cheek. On examination, there is a well-circumscribed, skin-coloured nodular lesion on the left cheek with some overlying small blood vessels visible.The most likely diagnosis of this lesion is:

123. A 56-year-old man with gastric cancer presents to his GP complaining of a lump in his belly button.On exami nation, there is a palpable nodule at his umbilicus.This sign is referred to as:

124. A 62-year-old man with known metastatic small cell carcinoma of the lung has presented to accident and emergency with sudden onset shortness of breath and arm and hand swelling. On examination, his face appears plethoric and Pemberton 's sign is positive.What is the most likely diagnosis?

125. A 55-year-old man has presented to his GP complaining of several episodes of spontaneous facial blushing. In addition, he mentions he has had several episodes of watery diarrhoea.On examination of the cardiovascular system, giant v waves are noted on observation of the jugular venous pressure.Inaddition, a pansystolic murmur is heard in the lower sternal edge on inspiration. Examination of the gastrointestinal system reveals an enlarged, irregular, nontender liver edge.What is the most likely diagnosis?

126. A 75-year-old man presents to your clinic with a dark lump on his forehead which has been increasing in size over the last 6 weeks.He first noticed the lump, which initially appeared as a small pinkish-red patch of skin, over a month ago.On examination you observe a 1x 2 cm hyperpigmented nodule with everted edges and a centrally, deep, ulcerated red base.Which one of the following is the most likely diagnosis?

127. A 67-year-old woman presents to you with pruritic plaques over her chest and back which are erythematous and resemble psoriatic plaques.From the patient' s history you suspect that the lesions are malignant.Which one of the following cutaneous malignancies resembles psoriasis in the initial stages?

128. A 63-year-old woman presents to your clinic with a painful wound on her left foot which has not been healing despite regular application of dressings.The patient has a history of peripheral vascular disease.On examination, you observe a 2 x 1cm well-dema rcated ulcer on the left heel of the foot.The ulcer has a 'punched out' appearance and the base appears necrotic.What is the most likely diagnosis?

129. A 47-year-old woman presents to clinic with a erythematous, macular, non-tender, 'wingshaped' rash over the bridge of the nose and cheeks.Which one of the following conditions is responsible for causing this type of facial rash?

130. A 27-year-old woman, who has recently returned from holiday in Africa, presents to accident and emergency with a 7-day history of fevers, sweats, headache, malaise and lethargy. On examination, her temperature is 39°C. Cardiorespiratory and gastrointestinal examinations are unremarkable.What is the most likely differential diagnosis?

131. A 25-year-old woman, who has recently returned from holiday in Africa, presents to accident and emergency with a 7-day history of fevers, sweats, headache, malaise and lethargy. On examination, her temperature is 39°C.A diagnosis of malaria is suspected. What is the investigation of choice to confirm the diagnosis?

132. A 40-year-old Indian man presents to accident and emergency with a one-month history of haemoptysis.He is a non-smoker. On further questioning, he mentions that he has also been having fevers and night sweats. Chest x-ray shows nodular shadowing in the right upper zone. What is the most likely diagnosis?

133. A 23-year-old woman medical student, who has returned home from a trip to India 1day ago, presents to accident and emergency with profuse watery diarrhoea.This started suddenly and she describes her stool as being profuse and colourless. She is unable to quantify the number of times she has opened her bowels prior to presentation. On examination her pulse is 110 bpm. Cardiorespiratory and gastrointestinal examination are unremarkable. What is the most likely diagnosis?

134. A 22-year-old medical student presents to the GUM clinic with large amounts of yellowcoloured penile discharge and discomfort on urinating.He hasjust arrived home from his summer holiday in Ibiza. What is the most likely diagnosis?

135. A 30-year-old man presents to his GP with a lesion on his penis, which appeared a week ago. On further questioning, he reports a change in sexual partner 4 weeks ago.He has otherwise been well.On examination, there is a painless hard ulcer on the shaft of the penis.What is the most likely diagnosis?

136. A 45-year-old man presents to accident and emergency, having returned from a holiday to India a week ago.He ha.s subsequently been unwell with nausea and reduced appetite.Over the past 2 days he has become jaundice d.He mentions that his two brothers with whom he went on holiday have also become ja undiced in the last 2 days.On examination, he is apyrexial and there is a palpable liver edge.Liver function tests reveal a raised ALT, AST and bilirubin. All other blood tests are normal. What is the most likely diagnosis?

137. A 19-year-old medical student presents to accident and emergency with a 1-week history of fever, anorexia and a sore throat. On examination, she is pyrexial at 39°C and cervical, axillary and inguinal lymph nodes are palpable.Palatal petechiae are visible within the mouth and her tonsils appear inflamed.A full blood count reveals a lymphocytosis and a blood film reveals the presence of atypical lymphocytes. What is the most likely diagnosis?

138. A 41-year-old teacher presents to her GP with a 5-day history of fevers, headaches, lethargy and muscle aches.She also mentions that she is developing an expanding red rash on her left thigh.On further questioning, she mentions that she has been on a school camping trip the previous week. She is otherwise fit and well. What is the most likely diagnosis?

139. A 51-year-old man presents to accident and emergency with a lesion on his forearm.He mentions that he has spent the past three months travelling around South Americ.a and only returned home 3 days ago.While his lesion has been present for a few weeks he was reluctant to see a doctor in South America.On examination, there is a 3 x 3 cm erythematous ulcer on the left forearm with a raised edge.What is the most likely diagnosis?

140. A 24-year-old man presents to accident and emergency with fevers, lethargy, myalgia and a cough. He has also developed an itchy rash on his feet.He returned home from a charity trip to Malawi last month and is worried he might have malaria. On examination, a papular rash is noted around his feet and there is a palpable liver edge.Initial blood tests show a raised white cell count with an eosinophilia. What is the most likely diagnosis?

141. A 35-year-old man presents to his GP with diarrhoea, abdominal pain and nausea. He says he his stools have been pale and he has felt persistently bloated. His symptoms started 6 weeks ago while on a surfing holiday in Peru. What is the most likely diagnosis?

142. A 26-year-old Bangladeshi man presents to accident and emergency with a 1-week history of fever, headache, malaise and dry cough.He returned to the UK 2 weeks ago, having spent his summer inBangladesh.On examination, his temperature is 39°C and a patchy maculopapular rash is seen over his trunk. On examination of the abdomen, there is splenomegaly. Blood tests reveal a low white cell count.What is the most likely diagnosis?

143. A 32-year-old man presents to accident and emergency with the inability to open his jaw, starting a few hours earlier.His wife mentions that he has 'had the flu' since returning from a weekend camping trip. What is the most likely diagnosis?

144. A 45-year-old man who lives in a homeless shelter presents to accident and emergency with an itchy rash. The itching is particularly bad at night.On examination , there is a papular rash between the web spaces of the fingers and toes, the palms of the hands and soles of the feet, the axilla and on the genitalia.What is the most likely diagnosis?

145. A 42-year-old man presents to his GP with 'blotches' over his legs.He has been HIV positive for ten years. On examination, there are multiple purple and brown papules over his legs and his gums.What is the most likely diagnosis?

146. A 42-year-old man presents to his GP complaining of deterioration in his vision in the right eye and the presence of floaters.The change in his vision has been causing him to suffer from headaches.He has been HIV positive for ten years.Fundoscopy reveals haemorrhages and exudates on the retina. What is the most likely diagnosis?

147. A 42-year-old man presents to accident and emergency with a 1-day history of headache and fevers.He presents with his partner who says he has been becoming increasingly confused and disorientated. On examination, his temperature is 38.5°C. On cranial nerve examination there is a right-sided superior quadrantanopia.An urgent CT scan of the head is organized which shows multiple ring enhancing lesions. What is the most likely diagnosis?

148. A 43-year-old man presents with profuse vomiting, abdominal pain and a faint metallic taste in the mouth.The patient is mildly jaundiced on examination with faint green discoloration of the gums. The patient denies taking any recreational drugs, but mentions he has been away on sabbatical in rural India.The most likely diagnosis is:

149. A 16-year-old boy presents to accident and emergency in a confused state.He appears pale, sweaty and has a heart rate of 110 bpm and temperature of 37°C.Respiratory examination reveals good air entry and a respiratory rate of 12.He is accompanied by a group of friends who admit they had been drinking alcohol earlier and smoking marijuana.They deny he has any medical problems apart from mild asthma and deny ingesting any other recreational substances. Urine dipstick is negative for any significant findings.His blood glucose is 2.1m mol/L.The most likely cause of the patient's symptoms is:

150. An 18-year-old woman presents to her GP.She appears anxious and explains she has been revising for her exams but suffered an acute severe headache this morning which left her unable to work and she has not felt well ever since.She denies any recent travelling, fever or neck stiffness.She appears tearful but otherwise well, with no signs following a neurological examination.The most likely diagnosis is:

151. A 54-year-old known hypertensive male presented with a 3-day history of shortness of breath.The patient reported feeling unwell with a sharp pain in the left side of the chest and loss of appetite.His clinical findings included a heart rate of 117 bpm, blood pressure of 97/85 mmHg, temperature 37.2°C and a respiratory rate of 22 bpm.Respiratory examination showed reduced air entry and hyper-resonance on percussion. The most likely diagnosis is:

152. A 47-year-old man presents to accident and emergency with a 3-day history of melaena. The patient appears pale, has a heart rate of 110 bbpm and blood pressure of 105/71mmHg. The patient reports suffering a sprained ankle 1week previously and has been using NSAIDs to control his symptoms. The most likely diagnosis is:

153. A 69-year-old woman presents to accident and emergency in a distressed state.She is extremely breathless and an audible wheeze can be heard, frothy clear sputum is produced each time she coughs.A gallop rhythm and widespread wheezes and crackles are heard on auscultation.The most likely diagnosis is:

154. A 19-year-old woman complains of general malaise and lethargy. She has recently started university after a gap year in the Western Cape of South Africa and is now returning home to visit her parents.She felt feverish with a headache which has become considerably worse by the afternoon with nausea and vomitin g.Supine flexion of the patient's neck causes unassisted knee flexion. The most likely diagnosis is:

155. A 20-year-old woman presents with a 3-day history of diffuse acute abdominal pain.The patient reports feeling generally unwell earlier during the week with a strange sensation in her mouth.She denies any recent travel history or sexual activity.On examination, skin turgor is reduced and a fruity odour can be smelt.The most likely diagnosis is:

156. A 75-year-old woman presents with confusion to accident and emergency, she was brought in by her neighbours who found her outside her house in her nightclothes during the middle of the day.She appears oedematous in appearance, particularly of her neck.The patient's hand is visibly shaking and while coughing a rust- coloured sputum is produced. Blood tests reveal a mild hyponatraemia while blood pressure is 110/82.The most likely diagnosis is:

157. A 52-year-old man presents to accident and emergency after collapsing at home.He appears pale on appearance with cold extremities.Blood pressure is 97/73 mmHg, heart rate 110 bpm, temperature 36.9°C and an ECG shows normal fmdings.Blood culture and urine culture are negative for any findings.He reports returning from a weekend break in Wales, but forgot to take his medication for Crohn 's disease with him. The most likely diagnosis is:

158. A 27-year-old woman visits her GP complaining of a fever. She returned from India almost 2 weeks ago and had felt unwell but attributed this to jet lag. After suffering from a fever she rested for 2 days and on recovering returned to work as an accountant.After another 2 days she now reports waking up at night again with a high fever, feeling drowsy and confused.On presentation she appears unwell, pale and sweaty. The most likely diagnosis is:

159. A 35-year-old man complains of a three-month history of intermittent excruciating headaches.They are very variable and occur from once a month to three times a week.Th e headaches are associated with extreme anxiety and sweating. On examination, the patient's blood pressure is 152/95 mmHg and during palpation of the abdomen the patient's skin flushes red. The most likely diagnosis is:

160. A 47-year-old obese Asian man complains of a sharp pain on the left side of his chest with difficulty breathing.The pain started a few hours ago and does not radiate anywhere, the patient also reports feeling increasingly short of breath and became extremely anxious when he started coughing blood-stained sputum.He states he has been flying all week on business trips and is getting late for his next flight.The most likely diagnosis is:

161. A 53-year-old severely distressed and confused woman presents to accident and emergency with her husband. A collateral history reveals she has been suffering increasingly severe tremors, sweating and weight loss during the week. Since yesterday she has started to suffer from palpitations and increasing confusion.Blood pressure is 157/93 mmHg and there is an irregularly irregular pulse.The most likely diagnosis is:

162. A 57-year-old man complains of a two-month history of chest pain which has recently become more severe.The patient describes the pain as a tightness occurring in the centre of the chest which he most often notices when reaching the top of the stairs.The pain usually recedes after a short rest.In the last 2 weeks he has noticed the pain is more severe and, unless he is sitting down or sleeping, is present all the time.The most likely diagnosis is:

163. A 57-year-old woman complains of a headache and weakness on the right side of her body. The headache is normally worst first thing in the morning and is particularly painful on her left hand side. The weakness has occurred very gradually over several weeks and is most noticeable when lifting objects.On examination, her temperature is 38.5°C, she has recently had a left ear infection which is not causing any pain now. The most likely diagnosis is:

164. A 29-year-old woman is brought to accident and emergency after suffering from a seizure at work witnessed by a colleague.She reports the patient has been unwell for the past week with headaches and nasal congestion, but refused any sick leave.The patient has a temperature of 38.3°C, a swollen bulging eye and an ipsilateral gaze palsy.The most likely diagnosis is:

165. A 30-year-old man is brought to accident and emergency by his wife in a confused state. After an argument at home, the wife had left the patient and on returning found him unconscious.She suspects he may have made a suicide attempt but had not thought to look for any pills or bottles close to the patient.While waiting to be seen, the patient suffers a seizure. On recovery, an examination shows the patient's temperatu re is 39°C, pulse is irregular, respiratory rate is 20 and the patient's pupils are dilated.An ECG recording reveals tachycardia and widened QRS complexes, while a blood gas is normal.The most likely substance ingested is:

166. A 49-year-old man is assaulted by a gang and is brought into accident and emergency.After resuscitation, he regains consciousness with a Glasgow Coma Scale (GCS) of 15.He has suffered multiple fractures of the left leg and left arm but remains stable.While in the intensive care unit, he becomes agitated and complains of difficulty breathing which does not improve despite high flow oxygen. You notice a widespread petechial rash.The most likely diagnosis is:

167. A 65-year-old man presents with a 25-minute history of severe chest pain that he describes as 'gripping' in nature.The pain does not radiate anywhere and is the most severe pain the patient has experienced. The patient is sweaty and anxious in appearance, tachycardic and has a normal blood pressure.An ECG shows hyperacute T-waves and serum creatinine kinase levels are not raised. The patient has a history of peptic ulcer disease but is otherwise healthy. The most likely diagnosis is:

168. Before the start of a ward round you asked to check the blood results of patients on the general medicine ward round.A new patient has the following results:Prothrombin time Normal, Partial thromboplastin time Prolonged, Bleeding time Normal, Platelet count Normal. What is the most likely diagnosis?

169. A 50-year-old woman is brought to accident and emergency by her son who has become increasingly worried about her confused state.Her son states she suffers from chronic hypertension but is poorly compliant with medication and has become increasingly confused over the past week and complainin g of h allucinations.On examination, the patien t's Glasgow Coma Scale (GCS) is 14, blood pressure is 210/120 mmHg, pulse is 112/m in and there is papilloedema on fundoscopy. The most likely diagnosis is:

170. An 18-year-old woman is referred with the complaint of recurrent palpitations lasting 2-3 hours and terminating as abruptly as they started. She is otherwise well and finds the episodes uncomfortable but not especially distressing. Examination is entirely normal between attacks. The electrocardiogram (ECG) shows a PR interval of 0.1seconds and slow upstrokes in the R waves of several leads.What is the most likely diagnosis?

171. A 12-year-old patient complains of easy bruising and nose bleeds, small ecchymoses can be seen on the patient's skin. The patient reports feeling illin the last week with mild fever and a sore throat.The nose bleeds are not prolonged and stop soon after pressure is applied.A blood test shows a mild thrombocytopenia. The most likely diagnosis is:

172. A 30-year-old man presents to accident and emergency with a 5-day history of fevers, sweats and lethargy.On further questioni ng, he mentions that he has just returned from a 6 week trip to Tanzania. On examination his temperature is 40°C. What is the most likely diagnosis?

173. A 44-year-old man presents with non-specific symptoms of fever, shortness of breath and syncope.Blood tests show a raised erythrocyte sedimentation rate (ESR) and a transoesophageal echo shows an atrial myxoma. What is characteristically heard on auscultation in atrial myxoma?

174. An 18-year-old woman presents to accident and emergency with a 5-day history of fevers, malaise and severe sore throat.On examination, she has a temperature of 40°C and her tonsils are inflamed with visible palatal petechiae.In addition, her cervical lymph nodes are palpable.A full blood coun t shows a raised lymphocyte count.What is the most likely diagnosis?

175. A 45-year-old man presents to accident and emergency with back pain. He works as a builder and the pain started after he had moved a cement mixer. On presentation, he is in considerable distress and unable to walk. He has not passed urine or opened his bowels since the incident. On peripheral neurological examination of the lower limbs, power is reduced throughout due to the pain. Sensation is preserved except for around the perineum. On digital rectal exam, there is poor anal tone.What is the most likely diagnosis?

176. A 17-year-old anxious Chinese boy presents to clinic with a 1-day history of haematuria.He first noticed the abnormality after a rugby match.His blood pressure is 123/75 m mHg. There is nothing of note on examination and the patient denies any recent illness or on-going medical problems.Urine dipstick confirms the presence of blood and protein.The most likely diagnosis • IS:

177. A 39-year-old woman presents to her GP with a 3-month history of pain in the hands.She mentions that her hands have been particularly stiff in the mornings after waking up.On examination of the hands, there is pain on palpation of the proximal interphalangeal joints and metacarpophalangeal joints.What is the most likely diagnosis?

178. A 30-year-old woman, who is 8 weeks pregnant, presents to accident and emergency with PV bleeding and crampy abdominal pain. She has a past medical history of a right-sided deep vein thrombosis and two previous miscarriages.She is sent to the early pregnancy assessment unit, where ultrasound confirms miscarriage.What is the most likely underlying diagnosis?

179. A 44-year-old man presents with a 3-day history of haemoptysis.He has suffered from a chronic cough in the last three months, but has only recently noticed blood in the sputum. He denies any medical problems and does not drink or smoke.A urine dipstick is positive for haematuria and proteinuria and inspiratory crackles are ausculated over both lung bases.Blood results confirm the presence of anti- glomerular basement membrane antibodies and blood pressure is 125/86 mmHg.The most likely diagnosis is:

180. A 26-year-old woman presents with an erythematous, palpable rash present on her feet, thighs, palms and soles.The rash is not itchy or painful.She mentions a dull pain in her elbows and knees whenever she moves.A full blood count is normal and a urine dipstick is positive for haematuria.The most likely diagnosis is:

181. A 68-year-old woman presents to her GP with headaches and visual disturbance.She has also noticed that she gets an itchy rash when she gets out of a hot bath. On exa mination she has a ruddy complexion and a palpable spleen.Her only previous medical history is gout.Initial blood tests reveal a raised packed red cell volume with a raised red cell mass, along with a raised white cell count and thrombocytosis.What is the most likely diagnosis?

182. A 19-year-old footballer has collapsed on the pitch.His airway is clear and he is brought to the emergency department, where he begins to recover and denies that he has chest pain. He has never had anything like this before. Which of the following is the most likely diagnosis?

183. A 69-year-old man presents to the emergency department with ongoing chest pain.He has a past medical history of intermittent claudication and hypertension.He is an overweight smoker and heavy drinker of alcohol. On analysing the electrocardiogram (ECG), you notice broad Swaves in the right-hand chest leads, two R-waves per complex in the left-hand chest leads and ST-segment elevation.He asks if he has had a heart attack. What is the best answer to this question?

184. A 43-year-old man presents to his GP with a 3-month history of recurrent nose bleeds, mucosa!bleeding, haemoptysis and recurrent sinusitis.Besides that, he also noticed that he has increasingly become short of breath. On examination, he had a nasal deformity and chest auscultation revealed crackles in the left lower zone.A urine dipstick test showed microscopic haematuria. Which of the following is the most likely diagnosis?

185. You are asked to review an electrocardiogram (ECG) in the emergency department. Helpfully, a summary of details is printed at the top as follows:rate 88/min, regular rhythm, axis -20°, PR duration 0.26 seconds (constant), QRS complex 0.08 seconds, QT interval 0.2 seconds.You note that P-waves are only present before each QRS and that the rhythm is regular.Which of the following would be the best summary?

186. A 44-year-old woman presents to the emergency department with pain.The pain is epigastric, sharp in nature, worse on lying flat and during inspiration. She has recently suffered a chest infection. She is not a smoker. On exam ination, she has diffuse inspiratory crepitations. Her oxygen saturation is 98% on room air. Her ECG shows widespread saddle-shaped ST elevation.Which of the following is the most likely diagnosis?

187. A 74-year-old male ex-comedian can no longer perform at smoky open- microphone nights due to shortness of breath. He is coughing up frothy white sputum, which recently has contained a small amount of blood. On examination, his chest demonstrates diffuse crackles on inspiration through which you can just discern a mid-diastolic murmur and a loud first heart sound.His chest X-ray confirms pul monary oedema. What is the most likely underlying cause for his symptoms?

188. In clinic, a retired 62-year-old man presents with shortness of breath on exertion. You find a collapsing pulse and subsequent echocardiography confirms aortic regurgitation. Which of the following is NOT associated with aortic regurgitation?

189. A 23-year-old woman comes to see you about her stools, which over the last couple of months have become extremely foul smelling, pale in colour and difficult to flush. This has been associated with vague abdominal pains and a bloating sensation.She has found this very embarrassing as she lives in a shared house. She is normally fit and well.What is the most likely diagnosis?

190. A 78-year-old retired groundskeeper presents with a 2 cm skin lump on his temple.He is unsure how long it has been there.It appears to have a rolled, shiny edge with telangiectasia and a central ulcerated area. Which of the following is the most likely diagnosis?

191. A 54-year-old woman presents to the emergency department with a 2-month history of inter mittent right upper quadrant pain. The pain is sharp in nature and radiates round to the back. On examina tion there is no jaundice, no hepatomegaly and she is apyrexial. Liver function tests and an amylase are normal.She has no history of recent foreign travel. What is the most likely diagnosis?

192. A first-time mother comes to visit you with her 10-month-old son.At least once every day her son vomits up his entire feed. The vomiting is not projectile but rather the feed returns to the mouth and spills over his top.She stopped breast-feeding him when he was 6 months old. He is otherwise well in himself, with a normal weight for his age.What is the most likely diagnosis?

193. A 13-year-old girl, who is quiet and withdrawn, comes to see you with her mother.She has a 4-month history of weight loss and secondary amenorrhoea.She has no bowel symptoms.Her body mass index is 16.Apart from being very thin, the examination is otherwise normal. All blood results, including hormone assays, are normal. What is the most likely diagnosis?

194. A 57-year-old man with a history of alcohol abuse presents with a 12-hour history of severe central epigastric pain radiating through to the back. Blood tests reveal a normal white cell count, amylase 2250 U/ml, LDH 530 IU/L, calcium 2.2 mmol/L, albumin 38 g/dl, urea 12 mmol/L and blood glucose 14 mmol/L. An arterial blood gas reading demonstrates a p02 of 4010.2 kPa on room air. What is his Glasgow score?

195. A 60-year-old man presents with total visual loss in his left eye that developed over 1day. He says he had a headache on the left side in the 5 days that preceded the visual loss, which was constant and severe, and worse on talkingoreating. On further questioning he said he has been feeling lethargic for the last 2 months and has been having some shoulder aches.There is no relevant past medical history and he has never smoked.On examination, there is no vision in the left eye, there is a relative afferent papillary defect, and the optic disc appears red and swollen on ophthalmoscopy. There is no other cranial nerve defect or neurological defect.Which investigation would confirm the most likely diagnosis?

196. A 45-year-old woman with type 1diabetes and rheumatoid arthritis has been admitted after a massive overdose of ibuprofen and has been noted to have acute renal failure with a creatinine level of around 350 μmol/L.The next day, you are called to see her as she is becoming breathless. Her airway is clear.She looks anxious.Her respiratory rate is 28/min and her saturations are 86 o/o on air. You hear bibasal crepitations in her chest, which is slightly dull to percussion at both bases.She has a pulse of 110 bpm and blood pressure of 125/80 mmHg.Her urine output has been 120 ml in the last 10 hours, and you note that her jugular venous pressure is high. It appears from the notes that the night house officer was asked to see her due to her low urine output and prescribed aggressive fluid resuscitation.What is the most likely reason for her breathlessness?

197. A 55-year-old man is referred to haematology with repeated nosebleeds, malaise, weight loss and night sweats.Investigations show a raised white cell count, mainly neutrophils and myelocytes, anaemia, increased urate and in creased alkaline phospha tase.On blood film there are no blast cells. Genetic studies show a t(9:22) translocation encoding for the BCR-ABL gene. What is his diagnosis?

198. A 29-year-old woman is concerned about recurrent ulcers she gets in her mouth. Occurring every few months, they are small, grey, shallow ulcers that disappear spontaneously. She has no other gastrointestinal symptoms or weight loss. What is the most likely cause?

199. A 62-year-old Asian woman presents to the emergency department with increasing shortness of breath for the past 2 weeks.She has a past medical history of breast cancer, iscbaemic heart disease, previous myocardial infarction with a stent in her left anterior descending artery, and osteoarthritis.On examination, there are reduced breath sounds on her lung bases, and dullness to percussion.Both legs are swollen.A chest X-ray demonstrates a right-sided pleural effusion. A simple aspiration of the pleural cavity showed a pleural fluid protein:serum protein ratio <0.5. What is the most likely underlying diagnosis?

200. A 7-year-old boy presents with multiple erythematous patches, over both sides of his face, head, neck, upper chest and left arm and shoulder, which appear to be covered in a honeycoloured crust.His mother says that the lesions have spread, over about a week, starting at the left neck and radiating outwards.The child appears to be upset and the lesions are itchy. There is no past medical history and no history of recent infections.Which of the following diagnoses is most likely?