Basic med q1 to 100 ex

1. A 48-year-old woman has been diagnosed with essential hypertension and was commenced ontreatment three months ago.She presents to you with a dry cough which has not been gettingbetter despite taking cough linctus and antibiotics.You assess the patient's medication history.Which of the following antihypertensive medications is responsible for the patient's symptoms?

2. A 16-year-old boy is diagnosed with a small ventricular septa) defect, having been screened byechocardiography because of a family history of hypertrophic obstructive cardiomyopathy. He isentirely asymptomatic, plays several sports regularly and has no growth retardation. Theechocardiogra m also confirms a small left to right shunt, with pulmonary to systemic flow ratioonly just above one.Which of the following is the most likely to be a significant complication ofhis condition?

3. A 56-year-old man presents to the accident and emergency department with a 2-hour history ofcentral chest pain radiating to the left arm. He is anxious, nauseated and sweaty. His pulse rateis 120/minute in sinus rhythm and the ECG reveals ST elevation in leads II, III and aVF.Thetroponin level is significantly raised.This is certainly acute MI.Which is the most likelycoronary vessel to be occluded?

4. A 45-year-old woman complains of increasing shortness of breath on exertion, as well asorthopnoea, for the previous 3-4 months.She had apparently recovered from pericarditis abouta year earlier. On ECG there is low voltage, especially in the limb leads, and the chest x-rayshows pericardia) calcification.The presumptive diagnosis is constrictive pericarditis.Which ofthe following physical signs would be consistent with this?

5. A 71-year-old man is being treated for congestive heart failure with a combination of drugs.He complains of nausea and anorexia, and has been puzzled by observing yellow rings around lights.His pulse rate is 53/minute and irregular and blood pressure is 128/61mmHg .Which of the following medications is likely to be responsible for these symptoms?

6. An asymptomatic 31-year-old woman has been referred for cardiological assessment.After her ECG she was told that she had mitral valve prolapse and would like further information on this condition.Which of the following statements is correct?

7. You see a 46-year-old woman on your ward who has been diagnosed with bronchiectasis following a three-month history of a mucopurulent cough. Which of the following from the list below is not a cause of bronchiectasis?

8. A 67-year-old man presents with dyspnoea and fatigue with signs of a raised jugular venous pressure (JVP), hepatomegaly and peripheral oedema. The patient has a longstanding history of COPD.You suspect cor pulmonale.Which of the following is not a cause of cor pulmonale?

9. A 25-year-old woman is admitted to accident and emergency with a severe exacerbation of asthma. On examination, her respiratory rate is 30, oxygen saturations are 95 per cent on 15 L 02 and temperature is 37.2°C.As you feel the peripheral pulse, the volume falls as the patient inspires.Which of the following explains this clinical sign?

10. You see a 67-year-old man who has presented with a four-month history of progressive shortness of breath, initially on exertion but now also at rest.Associated symptoms include a dry cough. His past medical history includes atrial fibrillation, hypertension and hypercholesterolaemia. On examination, oxygen saturations are 92 per cent on room air, respiratory rate is 19 and the patient is apyrexial. On auscultation of the chest you hear bibasal fine inspiratory crackles.You review the patient's medication history.Which of the following drugs from the patient's list is most likely to cause the symptoms experienced by the patient?

11. A 44-year-old plumber has a 4-day history of fever and generalized myalgia. Two days ago he developed a dry cough coupled with mild dyspnoea and has been feeling very lethargic.On examination his temperature is 38.5°C, respiratory rate 20, oxygen saturations ranging between 93 and 96 per cent on room air and auscultation of the chest reveals bibasal crackles.Bloods show a raised white cell count of 18.2 and neutrophil count of 11.0, CRP of 90 and a raised ALT of 261and ALP 96. Chest x-ray reveals bibasal consolidation.The patient is treated with antibiotics for bibasal pneumonia. From the list below, select the most likely organism responsible for the pneumonia:

12. A 58-year-old man is admitted with a mild exacerbation of asthma. He suffers with hypertension which is controlled with medication.He was given 5 mg salbutamol and 500 μg ipratropium nebulizers, on route to hospital, by paramedics and has received 'back to back ' salbutamol 5 mg nebulizers since admission to accident and emergency. The patient was then sent to the acute medical unit where he was given regular nebulizers along with his regular antihypertension medication.Before he was discharged, his serum potassium reading was 2.9.Select, from the list below, the drug which is most likely to have caused the hypokalaemia?

13. A 45-year-old man with diabetes, diagnosed with pulmonary TB who started treatment two months ago, presents to you with a week's history of pins and needles in his ha.nds and feet with associated numbness.He tells you that his symptoms started since he stopped taki ng the vitamins given to him at the start of his TB treatment.From the list below, which of the following drugs is responsible for the symptoms described by the patient?

14. A 47-year-old woman presents to your clin ic with a three-month history of dysphagia.There is no history of drastic weight loss and the patient experiences symptoms when swallowing solids but not liquids.Which of the following is not an obstructive cause of dysphagia?

15. You see a 56-year-old man who was admitted for an elective upper GI endoscopy due to longstanding GORD which has failed to improve on antacids and PPis. Your registrar suspects that this patient may have Barrett's oesophagus and asks you to define what this is.The most appropriate description of Barrett's oesophagus is:

16. A 69-year-old man present with a 2-week history of abdominal pain which bas worsened over the last few days. On examination, the patient is jaundiced and the abdomen is distended with tenderness in the epigastric region.In addition, there is a smooth hepatomegaly and shifting dullness.Which of the following is a cause of hepatomegaly ?

17. You see a 47-year-old woman who presents with a 3-day history of ja undice.You assess her liver function tests (LFTs) and see that the ALP iu/L is raised at 350 iu/L, AST 45 iu/L, ALT 50 iu/L and bilirubin 50 iu/L. The patient feels well in herself, although she has noticed that her urine has become quite dark and her stools quite pale.You assess her medication history. Which of the following drugs from the patient's medication history may be responsible for the cholestasis?

18. A 68-year-old man presents to his GP with signs of drastic weight loss.He is known to have PSC. The GP suspects an underlying malignancy. Which of the following tumours would a patient with primary sclerosing cholangitis be more at risk of developing?

19. You are told by your registrar that one of the clinic patients has been admitted with a 'flare up' of ulcerative colitis (UC) which he reports as being severe.From the list of answers below, select the parameters which are likely to reflect a severe flare up of ulcerative colitis:

20. A 29-year-old anxious man is diagnosed with mild Crohn 's disease.Due to time constraints, the patient was asked to come back for a follow-up appointment to discuss Crohn 's disease in more detail.The patient returns with a list of complications he researched on the internet. Which of the following are not associated with Crohn's disease?

21. You see a 40-year-old woman who was diagnosed with Crohn 's disease ten years ago. Due to a severe attack of Crohn's which failed to respond to medical therapy, she had a small bowel resection. Your registrar tells you that she is at risk of developing vitamin B12 deficiency as a result of her surgery.Which part of the small bowel is responsible for the absorption of vitamin B12?

22. A 74-year-old type 2 diabetic woman undergoes a bowel resection for cancer of the colon. She is well prior to the operation with well-controlled diabetes and no other underlying disease.The operation is successful and the patient is given postoperative insulin and IV dextrose.Two days after the operation she becomes very agitated. Sodium 124 (135-145), Potassium3.3 (3.5- 5.0), Urea 3.1(3.0-7.0), Glucose 7.2 (2.5--6.0), Serum osmolality 265 (275-295), Urine osmolality 150.The most likely cause of the hyponatraemia is:

23. A 22-year-old woman is found unconscious in her room by her boyfriend and brought into accident and emergency.A urine dipstick is positive for glucose and ketones and blood analysis shows the following results: pH 6.9, PC02 3.0kPa, P02 13 kPa, Sodium 144 mmol/L, Potassium 5.0mmol/L, Urea 11, Glucose 20, Chloride 100, Bicarbonate 2.9.The most likely anion gap is:

24. A 46-year-old woman presents to your clinic with a week 's history of jau ndice.Her past medical history includes longstanding atrial fibrillation and hypertension.Physical examination reveals hepatomegaly. You assess her liver function which shows a bilirubin of 41iu/L, AST 111iu/L, ALT 55 iu/L and ALP 98 iu/L. There is no history of travel.You have a look at the patient's medication history.Which of the following drugs below is likely to have caused the derangement in the patient's liver function?

25. A SO-year-old woman, who has received a recent diagnosis of rheumatoid arthritis, presents to her GP with ongoing pain and stiffness in her hands and feet.Which jo ints are usually spared at onset of rheumatoid arthritis?

26. A 74-year-old woman presents to accident and emergency with sudden onset pain and swelling in the left knee. On examination, she is apyrexial and the left knee is swollen.There is reduced range of movement in the knee due to swelling and pain. X-ray of the right knee shows chondrocalcinosis.Microscopy of the fluid aspirated from the joint is most likely to show:

27. A 20-year-old man presents to accident and emergency with sudden onset pain in the right eye, with associated blurred vision and discomfort when gazing at the lights.He has a history of back pain and has recently been diagnosed with ankylosing spondylosis.What is the most likely cause of his eye pain?

28. A 55-year-old woman presents to her GP with shortness of breath and dry cough. The symptoms began a few months ago and have progressed.She has a past medical history of rheumatoid arthritis, diagnosed ten years earlier.On respiratory examination, there are bibasal fine inspiratory crackles on auscultation. What is the most likely cause of her symptoms?

29. A 42-year-old woman presents to accident and emergency with retrosternal discomfort. She was diagnosed with systemic sclerosis a year ago.Which of the following statements is true about systemic sclerosis?

30. A 60-year-old man presents with abdominal pain and a cupful of haematemesis. On examination he is noted to have ascites, hepatomegaly and a very enlarged spleen extending to the right iliac fossa.His initial blood tests reveal a leukoerythroblastic picture with a haemoglobin of 8, white cell count (WCC) of 3 and platelets of 120. A diagnosis of myelofibrosis is made.What is most likely to be seen on the peripheral blood smear?

31. A 27-year-old man presents with increasing tiredness and shortness of breath.A macrocytic anaemia with reticulocytes is discovered on blood tests and smear.Genetic analysis reveals the patient has glucose-6-phosphate dehydrogenase deficiency.Wh at cell type is most likely to have been seen on the blood smear?

32. A young patient presents with features of anaemia, neutropenia and thrombocytopenia.A large number of blasts are present on bone marrow biopsy. Which investigation would help differentiate between acute myeloid leukaemia (AML) and acute lymphoblastic leukaemia (ALL)?

33. A 29-year-old woman presents complaining of shortness of breath, especially when walking up stairs. She is starting to struggle with yoga classes, which were never a problem before.She does not suffer from any medical conditions and takes no regular medication.On examination there is pallor, heart rate is 90 and blood pressure 119/79 mmHg.The patient mentions that she has recently become a vegetarian and in the morni ng only has time for tea before heading to work. Which of the foilowing would you expect to be increased in this patient?

34. A 27-year-old woman who suffers from rheumatic mitral stenosis develops atrial fibrillation. She is placed on warfarin therapy. What is the most appropriate target international normalized raio (INR) range?

35. A 70-year-old woman complains of a dull pain in her lower back, especially when bending forwards to lift things.She presents after a severe episode in the last 2 days.An x-ray reveals a lumbar compression fracture.Blood tests show a normocytic anaemia and urine electrophoresis reveals a monoclonal gammopathy. A diagnosis of multiple myeloma is made.Which of the following is not a recognized cause of multiple myeloma?

36. A 51-year-old man complains of severe, diffuse back pain. An x-ray finds several lytic lesions in the vertebra alongside hypercalcaemia.Bence-Jones protein is detected in the urine.What is a Bence-Jones protein?

37. A 19-year-old woman collapses at a concert and is witnessed to have a tonic-clonic seizure lasting 2 minutes. When the paramedics arrive and ask her questions, she mumbles but no-one can understand what she is saying. Only when the paramedic applies pressure to her nailbed does she open her eyes and reach out with her other hand to rub her nail and then push him away. What is her Glasgow Coma Scale (GCS)?

38. A 42-year-old woman presents with ataxia. Gadolinium-enhanced MRI reveals multiple subcortical white matter lesions as well as enhancing lesions in the cerrebellum and spinal cord. She is diagnosed with MS.Two months later she develops optic neuritis.What feature is associated with a milder disease course?

39. A left-handed 79-year-old man presents with a troublesome resting tremor of his left hand.The tremor is evident in his writing.He has also noticed his writing is smaller than it used to be.He complains he has difficulty turning in bed to get comfortable and his wife complains that he sometimes kicks her in the middle of the night. When he gets out of bed in the morning he feels a little woozy, but this resolves after a while. On examination, he blinks about three times a minute and his face does not show much emotion. Glabelar tap is positive.He has a slow, shuffling gait.He has difficulty stopping, starting and turning.He holds his feet slightly apart to steady himself. When you pull him backwards, he is unable to right himself and stumbles back. Which of the signs and symptoms is not commonly associated with parkinsonism?

40. A 23-year-old woman is seen in clinic for recurrent fun ny turns.She is not aware of them, but her family and friends have noticed them.They say she looks around blankly, then starts picking at her clothes and sometimes yawns, then she comes back after a minute.She can get drowsy after these episodes. What seizure type does this patient describe?

41. You are asked to perform a lower limb peripheral neurological examination on a 45-year-old diabetic male.The patient has normal tone, 5/5 power, normal plantars and proprioception. However, you notice that the patient does not respond to any sensory stimulus on the medial side of the right lower leg.Which dermatome is affected?

42. A 55-year-old woman complains of double vision.She finds that she is more tired than usual and has difficulty climbing stairs, especially when they are very long.She has difficulty getting items off high sh elves at work and lately even brushing her hair is a problem.During the consultation, her voice fades away during conversation.Reflexes are present and equal throughout. Which sign or symptom is most indicative of myasthenia gravis?

43. A patient has difficulty walking.His gait is unsteady.He seems to have difficulty raising his right leg and swings it round in an arc as he walks.He holds his right arm and wrist flexed. What type of gait does this patient exhibit?

44. A 40-year-old woman seen in clinic has multiple fleshy nodules and several light brown, round macules with a smooth border on her back, arms and legs.There are also freckles under her arms.What is the underlying disorder?

45. A 74-year-old man with T2NOMO squamous cell carcinoma of the tongue is currently undergoing hyper-fractionated radiotherapy with curative intent. He has had no previous surgery. This type of therapy is best described by which of the following terms:

46. A 62-year-old electrician has presented to accident and emergency with a sudden decline in his exercise tolerance.He mentions that he can only walk 5 yards and that he has had a persistent cough with some haemoptysis over the previous month.A chest x-ray confirms a right-sided pleural effusion, which is then drained. A repeat x-ray shows a round shadow in the right perihilar region.Subsequent bronchoscopy and biopsy confirms small cell carcinoma. Which of the following statements is most true about small cell carcinomas of the lung?

47. A 68-year-old man presents to his GP complaining of increasing shortness of breath. He has noticed deterioration in his exercise tolerance, particularly while mowing the lawn. He has a past history of squamous cell carcinoma of the lung for which he finished radiotherapy treatment a year ago.On examination, there are fine inspiratory crackles in the right lung base.The most likely cause of his shortness of breath is:

48. A 39-year-old woman has undergone a wide local excision for a 0.5 cm ductal carcinoma of her right breast.Sentinal node biopsy, histology and staging scans have confirmed the disease as TlNOMO. Histology has confirmed the cancer as oestrogen and progesterone receptor positive. Which of the following statements is most accurate regarding this female's treatment options?

49. A 55-year-old woman with metastatic pancreatic cancer attends the oncology clinic prior to her second cycle of chemotherapy.She tolerated her first cycle well but her husband mentions that there have been occasions where she has been confused. Her urea and electrolyte blood tests reveal a serum sodium of 116 mmol/L. All other results were within the normal range.The chemotherapy is delayed and a urine specimen is sent off. This reveals a urine osmolality of 620 mmol/kg.The most likely cause of the hyponatraemia is:

50. A 65-year-old woman who is currently receiving chemotherapy for acute myeloid leukaemia is found on blood testing to have urea of 10.1mmol/L, creatinine of 190 mol/L, potassium of 6.1 mmol/L, phosphate of 8.5 mg/d.L and corrected calcium of 2.00 mmol/L. The patient is asymptoma tic.Her electrolyte levels were normal prior to the start of treatment.What is the most likely cause of this electrolyte disturbance?

51. A 12-year-old boy who has been suffering from atopic dermatitis for the last ten years presents to you with a 3-day history of severe itching and pus discharge from his left elbow. On examination , you observe lichenification of his left elbow with superimposed excoriations which are weeping a viscous yellow fluid. You take a swab of this discharge.Which one of the following organism growths would you likely expect to be isolated from the swab?

52. A 67-year-old woman presents to you with extensive scalp hair loss which has been getting progressively worse over the last year.You also notice thinning of the eyebrows. The patient's past medical history includes hypertension, left-sided pulmonary embolism one year ago and hypercholesterolaemia.You assess the patient's medication list.Which one of the following drugs could be responsible for causing generalized alopecia?

53. A 56-year-old man presents in your clinic with a three-month history of weight loss despite no change in his appetite.The patient has no past medical history and no known drug allergies. On examination, you notice an area of hyperpigmented skin in his left axilla. On palpation, the texture of the area of hyperpigmentation feels velvety. You suspect that the patient has acanthosis nigricans secondary to a possible malignancy .Which one of the following malignancies is most commonly associated with this dermatological presentation?

54. A 24-year-old woman presents to you with a one-month history of intense burning and itch in her buttock area.On examination, you notice patches of small erythematous papulo-vesicular blisters in the patient's buttock area.There is obvious evidence of scratching with some areas of bleeding. The signs are typical of dermatitis herpetiformis.Which one of the following conditions is associated with this dermatological presentation?

55. A 26-year-old man presents to you with multiple patches of macular hyperpigmentation which have been present since he was an infant but now are increasing in number.Inaddition he ha.s several small, soft, violaceous nodules on his trunk which tend to catch on clothing causing discomfort.What is the pattern of inheritance in this condition?

56. A 40-year-old woman presents with a 36-hour history of developing erythematous boils on her trunk. Some of them have burst leaving what seems to be painful wounds on her chest.On examination of the chest you notice three very painful ulcerating wounds with undermined edges and surrounding erythema. The lesions are closely associated with a condition that the patient was diagnosed with 15 months ago.Which one of the following conditions is associated with the above described cutaneous lesions?

57. Following genetic profiling and clinical examination, you diagnose an 18-year-old woman with tuberous sclerosis.She initially presented with cutaneous lesions which were suspicious of this diagnosis.Which one of the following skin lesions is associated with tuberous sclerosis?

58. A 45-year-old woman presents to you with a 3-day history of an ovoid patch of tender erythema, on the posterolateral aspect of her left calf, which has been increasing in size. She recalls injuring her left leg a week ago while gardening. On examination, the patient is afebrile and on inspection of the left calf, the patch of erythema measures roughly 3 x 3 cm with poorly demarcated edges. On palpation the zone of erythema is warm and very tender.Full blood count reveals a white cell count of 20.1with a neutrophil count of 15.0.Which of the following organisms is the most likely cause of this condition?

59. A 49-year-old woman is diagnosed with a malignant melanoma which was excised from her right leg. She has been doing some research on the internet regarding the different types of malignant melanoma. Which one of the following variants of malignant melanoma is considered to be the most common?

60. A 40-year-old woman who you referred for excision biopsy of a suspected malignant melanoma on her right leg returns for a follow up of her results.The results of the biopsy return confirming a superficial spreading melanoma with a Breslow thickness of <1mm.What fiveyear survival rate does a Breslow thickness of <1mm correspond to?

61. A 54-year-old investment banker presents to accident and emergency with a 5-day history of productive cough of green sputum, fevers and feeling generally unwell.On examination, there is bronchial breathing in the left lower zone.Chest x-ray demonstrates left lower zone consolidation.What is the most likely causative organism?

62. A three-year-old boy presents, with his mother, to his GP with a 2-day history of fevers, vomiting and diarrhoea. His mother mentions that several other children at the nursery have been off sick this week with the same problem.What is the most likely cause?

63. A nine-year-old boy presents to his GP with a 2-day history of sudden onset itchy rash over his face, scalp, neck and trunk, On examination, his temperature is 38°C and there is a widespread vesicular rash. What is the most likely infective organism?

64. A 23-year-old man presents to accident and emergency with a 1-day history of severe headache, discomfort when looking at the lights and neck stiffness.There is a non-blanching rash observed on his trunk. He has recently recovered from chicken pox. On exami nation he is pyrexial at 39°C. The most likely causative organism is:

65. A 90-year-old man presents to accident and emergency with a 2-week history of fevers, lethargy and night sweats.He has recently had crowns fitted at the dentists.He has a past medical history of hypertension, gout and type 2 diabetes mellitus. On examination his temperature is 39°C, his pulse is 120 bpm and splinter haemorrhages are seen in the nails.On auscultation of the heart a pansystolic murmur is audible.A diagnosis of endocarditis is suspected and blood cultures are taken.What organism is most likely to be grown?

66. A 20-year-old man presents to accident and emergency with extreme pain in the right knee.On examination, his temperatu re is 38.5°C and the knee is hot and swollen.He is unable to move his knee due to pain. The joint is aspirated and blood cultures are taken.The patient is admitted and started on intravenous antibiotics.Gram staining of the joint aspirate shows gram-negative diplococci.What is the most likely responsible organism?

67. A 74-year-old man presents to accident and emergency with extreme pain in the left knee.On examination, his temperatu re is 39°C and the knee is swollen and hot.He is unable to move the joint due to pain. The joint is aspirated and the patient is admitted and started on intravenous antibiotics.What is the most likely causative organism?

68. A 42-year-old man presents to accident and emergency with a 3-week history of shortness of breath, dry cough, fevers and malaise.He has presented as his exercise tolerance has deteriorated.He mentions that he has been mv positive for ten years. On examination, there are fme crackles throughout both lung fields.Chest x-ray demonstrates bilateral perihilar interstitial shadowing.What is the most likely causative organism?

69. A 42-year-old man presents to accident and emergency with a 3-week history of retrosternal discomfort after swallowing.He mentions that he has been unable to keep any food down at all. He has been HIV positive for ten years.He is admitted and endoscopy shows areas of ulceration throughout the oesophagus.What is the most likely causative organism?

70. A 42-year-old man presents to his GP with 'blotches' over his legs.He has been IDV positive for ten years. On examination, there are multiple purple and brown papules over his legs and his gums.A diagnosis of Kaposi' s sarcoma is suspected. What is the most likely causative organism?

71. A 55-year-old woman presented with truncal obesity, easy bruising, a dorsal fat pad and depression. She denies any headaches, weight loss or any other abnormalities.An ultrasound scan showed bilateral adrenal atrophy. The most likely cause is:

72. You see a 21-year-old woman on your ward round who has been admitted for further investigation for longstanding iron deficiency anaemia. You are told by your registrar that colonoscopy revealed multiple hamartomatous polyps suggestive of Peutz-Jeghers syndrome. From the list below, which one of the following is the most likely mode of inheritance of PeutzJeghers syndrome:

73. A 60-year-old man presents to you with some signs and symptoms which may be associated with pulmonary sarcoidoisis which was diagnosed nine months ago.From the list below which of the following is not an extrapulmonary manifestation of sarcoidosis?

74. A 38-year-old woman with a history of classical migraine is admitted with a right hemisphere ischaemic stroke. She has optimal blood pressure and a very favourable lipid profile, and duplex scanning of the carotids shows total absence of atheromatous plaque.Echocardiography, however, reveals an abnormality which may be relevant. Which of the following is it likely to be?

7S.Erythroderma is described as a chronic inflammatory skin condition characterized by scaling affecting greater than SO per cent of the total body. Which one of the following cutaneous malignancies would you expect erythroderma to be associated with?

76.A SS-year-old man who has been smoking 20 cigarettes a day for the last 30 years has been diagnosed with a right-sided pleural effusion following admission with a week's history of shortness of breath.From the list below, select the most likely findings that one would ascertain during examination of the chest wall

77. You see a S7-year-old man who has been diagnosed with hepatocellular carcinoma (HCC).You are asked about risk factors in HCC by your consultant.Which of the following is not a known predisposing factor for developing hepatocellular carcinoma?

78. A 23-year-old woman is brought into accident and emergency after collapsing at her office.She admits having been stressed and had stayed up all night preparing for a presentation she gave this morning.She describes sitting at her desk and seeing multicoloured circles of light in her right visual field then waking in the ambulance with an oxygen mask on.She feels tired, achy and confused. Her colleague who witnessed the event tells of his fright as he saw her collapse and start jerking both arms and legs.What best describes her seizure?

79. You are asked to examine a 16-year-old boy with suspected Marfans' syndrome.The patient is tall and thin limbed with long slender fingers, you notice a pectus excavatum of the chest and on examination of the mouth a high arched palate is visible.Which of the following is not included in the cardiovascular criteria for Marfans?

80. An 88-year-old woman who lives in a nursing home has a past medical history of hypertension, diabetes and ischaemic stroke resulting in left-sided hemiplegia.She suffers from frequent urinary tract infections.Her drug history includes aspirin, simvastatin, insulin and lisinopril. She presents with an ulcer on her left heel.Her HbAlc = 6.1per cent.Her BM is 8.9, blood pressure is 112/87, heart rate 62.She seems comfortable at rest.Her lungs are clear and her abdomen is soft and non- tender.There is a 2 x 2 cm ulcer on her left heel. Her right foot is normal.What is the most likely cause of her ulcer?

81. A four-year-old girl presents to her GP, with her mother, with a 2-day history of fevers and diarrhoea. Her mother has contacted her nursery, who have informed her that several of the other children have been off sick with the same problem.What is the most likely causative organism?

82. A 21-year-old man presents to accident and emergency with a hot, swollen, painful right knee and feeling generally unwell. On examination, his temperature is 38.5°C and he is unable to weight bear. He cannot move his right kneejo int due to the pain. A diagnosis of septic arthritis is suspected and the joint is aspirated.What organism is most likely to be seen on the Gram stain of the joint aspirate?

83. A 29-year-old man presents to the emergency department with a 1-week history of nonproductive cough, muscle aches, fever, vomiting and diarrhoea.His observations include temperature 38.4°C, pulse rate 105 bpm, blood pressure 110/76 mmHg and respiratory rate 22/min. On examination, his chest is clear to both auscultation and percussion. A chest X-ray shows bilateral lung basal infiltrates .The blood results show Na+ 128 mmol/L, K+ 4.0 mmol/L, urea 5.9 mmol/L, creatinine 130 mmol/L, albumin 26 g/L, ALT 106 IU/L, ALP 230 IU/L. What is the most likely causative organism?

84. You are reviewing the medication of a 62-year-old man suffering from depression and cardiac arrhythmias.He was recently discharged from hospital for chest pain. During his admission, he was noted to have ''torsades de pointes''. What is torsades de pointes?

85. A 40-year-old man presents to the emergency department after 8 hours of a severe frontal headache, photophobia and two episodes of vomiting. On examination his Glasgow Coma Score (GCS) is 13 (eyes open to voice, verbal response with confused sentences, and moving freely), he has a temperature of 38.5°C, a BP of 95/65 mmHg and pulse rate of 105 bpm.He is photophobic and has neck stiffness.There is no rash and no focal neurological deficit as far as you can ascertain.His wife is present and is able to elaborate on the history.He has hit the bottle quite hard since losing hisjob 7 months ago and has been drinking 8-10 cans of lager per night. He has recently been coughing a lot and feeling unwell. He still lives at home and has not appeared to lose weight recently. What are you most concerned that this might be?

86. A 24-year-old man presents with two episodes of involuntary clonic beating of the right arm followed by loss of consciousness with urinary and faecal incontinence.He then had a headache and confusion for some hours (no- one witnessed any episode).A diagnosis of motor partial seizures with secondary generalisation is made.He is started on valproate.Which of the following would you NOT tell him (as it is untrue)?

87. A 65-year-old woman presents to her GP complaining of tiredness, shortness of breath and loss of sensation in her feet. On examination she is visibly pale, has mild jaundi ce and glossitis.She has loss of joint position sense and vibration distally, with extensor plantar reflexes, absent ankle jerks and brisk knee jerks bilaterally.What is the most likely cause for her symptoms?

88. A 30-year-old-man presents to the outpatient clinic with a 2-month history of progressive effort intolerance.Some three weeks ago he experienced an episode of shortness of breath at rest, suggestive of paroxysmal nocturnal dyspnoea. Examination reveals a JVP raised up to his earlobes, a soft tender hepatomegaly and a bilateral pitting oedema up to his knees. Chest examination reveals bibasal crepitations, and an audible S3 on auscultation of the heart.The chest X-ray shows cardiomegaly with interstitial infiltrates.Echocardiography shows global left ventricular hypokinesia with an ejection fraction of 25-30% .Which of the following is the LEAST likely aetiological factor?

89. A 32-year-old-woma n was cross-country skiing when she fell down a water -filled gully and became trapped beneath an ice-sheet.Frantic efforts were made to extract her, but after 40 minutes all movements ceased.Which of the following statements is true?

90. A 54-year-old man suddenly develops weakness of the left side of his face and arm and difficulty in speech.This episode lasts for 15 minutes.He has a history of hypertension, which is well controlled on a calcium channel blocking agent.His brother had had a severe disabling stroke at the age of 50. Cholesterol level is 5.Smmol/l. CT scan performed the same day shows the presence of 2 old lacunar strokes in the right middle cerebral artery territory. CT angiogram of the carotid system shows a 60% stenosis of the right internal carotid artery.Which of the following factors is the strongest predictor of his being at a high risk of early recurrent stroke?

91. A SO-year-old man underwent coronary artery bypass grafting 2 days ago.A routine liver function test result now shows that both the direct and indirect bilirubin are elevated.All the other liver function tests are normal.Which of the following is the most likely cause?

92. A 72-year-old Caucasian man is referred to out-patients with a 6-month history of progressive exertional dyspnoea.His ankles swell as the day progresses. There is no associated chest discomfort.He is an ex-smoker of 3 years and drinks 12 pints of beer per week. He has not seen his GP in the previous 15 years.The only past history is that of mild asthma as a child.His father died of a myocardial infarct aged 65 years.Blood pressure is 150/86 mmHg.Results of investigations are as follows: renal function, normal; cholesterol, 6.8 mmol/l; ECG, sinus rhythm LBBB; echo, dilated and impaired left ventricular function with ejection fraction of 30o/o , mild to moderate mitral regurgitation, no LVH.What is the most likely underlying aetiology ?

93. A 70-year-old woman is admitted to hospital with a swollen left leg 4 weeks after undergoing an elective total hip replacement.An above-knee DVT is diagnosed by ultrasound. She is in sinus rhythm at 60 bpm and her blood pressure is 160/80 mmHg. She is commenced on the appropriate dose of low molecular weight heparin and warfarin loading.The following day she becomes acutely short of breath. Examination reveals a resting tachycardia (110 bpm) with blood pressure of 100/60 mmHg.Her JVP is elevated at 7 cm above the sternal notch.Arterial blood gas measurement reveals her to be hypoxaemic with a pa(02 ) of 7 mmHg.What would be the first-line therapy after administering high-flow oxygen?

94. A 30-year-old woman presents with a three month history of chest pain. On auscultation, there is a midsystolic click and a late systolic murmur. Her electrocardiogram shows T-wave inversions in leads II, ID, and aVF.Which of the following statements concerning her condition is true?

95. A patient who has been inadvertently given an intravenous injection of potassium chloride, develops ventricular tachycardia. His pulse is 150 beats per minute and blood pressure 60/40 mmHg. What would be the best line of treatment in this case?

96. A 58-year-old male patient has suffered from a recent acute myocardial infarction 3 days ago. He becomes acutely unwell with a hypotensive episode.There is a pansystolic murmur which is accentuated by inspiration, along the lower left sternal border.A Swan-Ganz catheter was inserted and the following was noted: right atrial pressure was 12 (very high); calculated left atrial pressure was 2 (low normal).What is the likely cause?

97. You review a 28-year-old woman with palpitations. On examination you suspect that there is splitting of the first heart sound.Her BP is 123/80 mmHg, P 70/min regular, and her chest is clear, there are no other cardiovascular fmdings.You arrange a 12 lead ECG. Which part of the ECG is most closely associated with the first heart sound?

98. A 53-year-old patient who has had chemotherapy for metastatic breast cancer 6 months earlier comes to the clinic complaining of shortness of breath on exertion. Her BP is 125/78 mmHg, her pulse is 94/min and her apex beat is displaced to the anterior axillary line.Investigations:Hb 11.9 g/dl, WCC 5.0 x109/l, PLT 190 x109/l, Na+ 140 mmol/l, K+ 4.5 mmol/l, Creatinine 160 μmol/l. CXR - Cardiomegaly, increased shadowing consistent with mild pulmonary oedema at both bases.Which chemotherapeutic agent is most likely to be responsible for this patient's symptoms?

99. An 18-year-old student is admitted to the Emergency room after a collapse in a night club.He has no recollection of the incident, was assisted by his friends and had begun to regain consciousness by the time the ambulance had arrived.On direct questioning in the Emergency room he admits to 2 previous syncopal episodes.He denies elicit drug use.On examination his BP is 123/72 mmHg, his pulse is 72 regular. Investigations; Hb 13.2 g/dl, WCC 5.3 x109/I, PLT 199 x109/I, Na 142 mmol/I, K 4.6 mmol/l, Creatinine 90 μmol/I, ECG Sinu s rhythm, QT interval 0.52s.A defect in which ion channel is the most likely cause of his symptoms?

100. You are working in the chemical pathology lab and receive a sample request for analysis of B-type natriuretic peptide (BNP).You don't have any clinical details on the form apart from ''chest pain''.You plan to ring the SHO who requested the test for further details. In which of the following situations is BNP most likely to be normal?