A 41-year-old woman, diagnosed with varicose veins in the left leg, presents to your clinic with a 2-month history of severe pain in the left leg on prolonged standing. The patient is obese and the pain has affected her working and social lifestyle and she asks you about the most effective treatment option. From the list below, choose the most effective treatment option that you would discuss with this patient?

A 55-year-old woman, who is obese and has a positive smoking history, is to have varicose vein surgery in the next 12 hours. Your senior colleague asks you to ensure that deep vein thrombosis prophylaxis is commenced. From the list below, choose the most appropriate form of deep vein thrombosis prophylaxis that you would use?

You are in the vascular surgery outpatient clinic explaining the indications forbundergoing carotid endarterectomy to a patient. From the list below, select the most likely scenario where carotid endarterectomy is likely to be indicated?

You see a 26-year-old woman in clinic presenting with lower limb lymphoedema. Which of the following conditions is associated with lymphoedema?

A 19-year-old Caucasian woman attends the outpatient clinic with a 2-day history of left-sided earache. The pain has worsened in the past 24 hours and she describes some seepage from the affected ear. Over the past few weeks her left ear has felt 'blocked' and she has been using cotton wool buds to clean them. Her hearing is not impaired. She is afebrile (36.7°C). On examination, the pain is worsened on superior movement of the auricle. There is a scanty discharge emerging from the left ear. Due to undergo treatment for her 2-day history of ear pain. Which of the following is most appropriate therapy?

A 6-year-old Asian boy is brought to the paediatric emergency department by his mother. She is worried because the boy is lethargic and has been complaining of right-sided earache all day. There have been no similar attacks in the past. On examination, he looks unwell, and his temperature is 39.0°C, pulse rate is llObeats/min and blood pressure is 90/40 mmHg. There is no cervical lymphadenopathy. Otoscopic examination reveals a bright red right tympanic membrane. You decide to take a microbiology swab. Due to treatment for his ear infection, which one of the following options is most appropriate therapy?

You are asked to review a 34-year-old Caucasian male patient in the clinic. He describes a long history of problems in his right ear as a child. He also describes a 10-day history of pain in and behind the same ear. There has been a continuous discharge from the ear and he has been feeling 'under the weather'. He has a low-grade fever (37.5°C). Clinical examination reveals tenderness behind the right ear. Otoscopic examination reveals a bulging, red tympanic membrane. Select the most appropriate statement regarding the management of this patient from the list below?

A 46-year-old woman re-presents to the emergency department 48 hours following an ' uncomplicated' laparoscopic cholecystectomy and on-table cholangiogram. She describes a history of progressive, constant, right upper quadrant pain radiating to the shoulder tip since the surgery. The pain is worse on coughing and moving. On direct questioning, she describes a 24-hour history of nausea and vomiting. The abdomen is rigid. Her liver function tests are abnormal as follows: bilirubin 60J.1moi/L, alkaline phosphatase 550 lUlL and alanine aminotransferase 220 lUlL. Her international normalized ratio is <1.5. Which single investigation is more likely to be diagnostic?

A 17-year-old Caucasian woman who underwent a laparotomy 2 weeks ago for a perforated appendix develops a swinging fever, dry cough, and pain in the tip of her right shoulder. Her latest observations are as follows: Temperature = 38.9°C, Blood pressure = 120/76 mmHg, Pulse rate= 110 beats/min, Respiratory rate =20 breaths/min. Examination shows tenderness over the lower lateral ribcage, abdominal and rectal examinations are normal. The white blood cell count is 18000 x 109/L. Which one of the following is the best diagnostic test for this patient?

A 22-year-old patient is brought to the emergency department in class Ill shock following multiple penetrating stab injuries to the torso, chest and abdomen. He undergoes an emergency thoracotomy and laparotomy. In theatre, he requires a total of 30 units of blood. Which of the following is the best statement regarding complications of massive blood transfusion?

A patient is commenced on total parenteral nutrition. You are asked by the nutrition team to ensure that adequate monitoring takes place. Which one of the following statements regarding monitoring of total parenteral nutrition is most correct?

Which one of the following is the best statement regarding total parenteral nutrition?

You are called to the ward to review a patient who is now 1 week into percutaneous endoscopic gastrostomy (PEG) feeding. The nursing staff is concerned because he grimaces when the feed is running, and has now developed a tachycardia. On examination, he is febrile at 38 oc, pulse is 110 beats/min, and blood pressure is 110/80 mmHg. The PEG site is clean and healthy. Physical examination reveals marked upper abdominal tenderness with guarding and rebound tenderness. Which of the following complications is most likely?

You are asked to see an 80-year-old female patient who is 2 days post insertion of a right dynamic hip screw following an extracapsular right neck of femur fracture. She has become acutely short of breath with a respiratory rate of 28 breaths per minute. The oxygen saturations are 96% on 51itres of oxygen per minute. Her pulse rate is 120 beats per minute, blood pressure is 110/70 mmHg and body temperature is 370C. Examination of the chest is normal. You perform an arterial blood gas investigation. From the list below, choose the most likely type of acid-base disturbance you expect to see from the arterial blood gas results?

You are asked to see a 35-year-old man who sustained a head injury during a road traffic accident. The patient was stable upon arrival to the emergency department, but over the last hour, his GCS has fallen from 15/15 to 13/15 and he is now drowsy and complaining of a headache. From the list below, choose the most appropriate next step to take in this patient's management

You review the coagulation blood investigations for a patient who has sustained 18% body surface area third-degree burns. PT and APTT are both prolonged. Your Consultant informs you that the patient has disseminated intravascular coagulation (DIC) and to request urgent blood products from Pathology. From the list below, please choose the most appropriate blood product that you would request from Pathology for the management of this clotting abnormality?

You are discussing basic oxygen physiology with the Intensive Care Consultant. He explains the physiology of the oxygen dissociation curve and the Bohr Effect. From the list below, choose the answer that is characteristically seen in the Bohr Effect?

A 40-year-old man is admitted to the Intensive Care Unit following a diagnosis of severe pancreatitis. The patient develops acute respiratory distress syndrome. Which of the following is associated with the diagnostic criteria for ARDS?

You are asked to review a chest radiograph of a 67-year-old lady who has been admitted with suspected aortic dissection. Which of the following chest radiograph procedures is not associated with aortic dissection?

The following factors detract from the diagnostic sensitivity ofF AST scanning, except?

Which of the following investigations are not used in staging of oesophageal malignancy?

A 58-year-old patient presents with a 6-week history of increasing difficulty swallowing. He first noticed problems when eating meat which became stuck 'behind his heart', but this gradually began to include other foods. The patient is currently worried because he is now struggling with thick fluids and has noticed some involuntary weight loss. What is the most appropriate investigation?

A patient is admitted to hospital following referral by his GP for melaena. An oesophagogastroduodenoscopy identifies an actively bleeding gastric ulcer. Haemostasis is achieved. You are called to see the patient 48 hours later by nursing staff concerned that the patient has again passed black stool. On examination the patient is comfortable, blood pressure is 120/80 mmHg lying and 115/SSmmHg standing, pulse rate is 70 beats/min and respiratory rate is 16 breaths/min. Rectal examination reveals black stool on the glove. The next best course of action should be?

A 50-year-old man presents to the outpatient clinic with an 8-week history of bleeding from his back end. This is typicaUy bright red and copious during or foUowing a stool. The patient has had no change in his bowel habit, no weight loss, and has no family history of bowel cancer. What is the most appropriate course of action?

A 44-year-old woman presents to the emergency department with acute onset of right upper quadrant pain and fever. On examination, the patient is lying still and has a tachycardia. The abdomen is tender in the right upper quadrant with guarding in that area. Murphy's sign is positive. What is the most useful investigation for this patient?

A 49-year-old postmenopausal woman is admitted to the emergency department following severe attacks of abdominal pain, nausea and vomiting. The pain is colicky in nature, starts from the left flank of the abdomen and radiates to the left groin. You are unable to take a history from the patient as she is writhing in pain. On examination you notice that the patient is sweating profusely. The abdomen is soft and non-tender and bowel sounds are normal. From the list below, select the investigation that will be of more diagnostic value of the patient's condition?

A 75-year-old man, with a history of diverticular disease, is experiencing swinging fevers and left-sided abdominal pain. You suspect the patient has a diverticular abscess. Which one of the foUowing investigations is the most appropriate to confirm your suspicion?

A 48-year-old perimenopausal woman presents with a 2-month history of a painful lump in her right breast. On examination you find a 2.5 em tense, fluctuant, mobile lump in the outer lower quadrant of the right breast. The most appropriate next course of action is?

A 34-year-old premenopausal woman presents to your clinic with a lump in her right breast. On examination you find a 2.5 em fluctuant, mobile, tender lump in the inner lower quadrant of the right breast. The ultrasound report suggests a benign fluid-filled cyst. The most appropriate course of action is?

A 55-year-old man, with a positive smoking history, presents to you in the outpatient clinic with pain in the lower leg which is brought on by walking. The pain is cramping in nature, well localized to the left calf only, and is relieved by rest. The patient has noticed that his walking distance has progressively decreased because of the cramps in the left calf. There are no abnormal findings on physical examination. What is the most appropriate way to investigate the patient's symptoms?

You see a 60-year-old man with a history of coronary heart disease, diabetes and hyperlipidaemia in your clinic. The patient has found it increasingly hard to walk due to the gradual increase in intensity of the cramping pain he experiences in his right leg on walking, which is relieved by resting a few minutes. In addition, he tells you that cramps have started to occur at night when he is sleeping. On examination of the right leg, you notice that there is a 'punched out' ulcer on the right heel. The right posterior tibial and dorsalis pedis pulses are weak. You suspect that this patient has critical limb ischaemia. What is the most appropriate next line investigation that would support your diagnosis?

You see a 65-year-old man in your clinic who is under surveillance for an abdominal aortic aneurysm. The patient smokes 20 cigarettes a day and has a 25-year history of poorly controlled hypertension. From the list below, select the most appropriate investigation that can be used to monitor the progression of this patient's condition?

You have decided to investigate the symptom experienced by 56-year-old patient who has suffered an episode of amaurosis fugax. From the list below, select the most appropriate investigation that you would order first to investigate the site of pathology?

From the list below, select the most appropriate investigation for the prompt diagnosis of an aortic dissection?

A 45-year-old man presents to A&E with acute onset of abdominal pain. Following clinical assessment, he is found to have acute mesenteric ischaemia. Which of the following is the diagnosis of acute mesenteric ischaemia based on?

A 30-year-old PhD student presents with acute-onset colicky left loin pain and describes a history suggestive of urinary calculi. Which one of the following would be the initial investigation of choice to determine the presence of a calculus in the renal tract?

A 65-year-old hypertensive man attends the preoperative assessment clinic 7 days before he is due to undergo a transurethral resection of the prostate for benign prostatic hypertrophy. He is currently taking furosemide for blood pressure control but no other regular medication. A routine set of bloods is taken, the results of which show a potassium level of 2.7 mmoVL. On the basis of this an electrocardiogram is requested. All of the following electrocardiographic changes are characteristic of hypokalaemia, except?

A 69-year-old retired canal engineer who has previously worked in North Africa presents to the urology outpatients department with a 2-month history of intermittent painless haematuria. A cystoscopy is performed showing a sessile mass on the posterior bladder wall. A biopsy is taken of this mass, which confrrms transitional cell carcinoma invading the bladder muscle, but no local nodes are involved. A further staging computed tomography scan shows no distant metastases. According to the TNM classification, the tumour stage in this individual is?

A 75-year-old man presents to the urology outpatient clinic with a 6-month history of urinary frequency associated with difficulty initiating micturition, dribbling on reaching the end of his stream and nocturia. A digital rectal examination reveals a hard prostate gland. Core biopsy is performed on the gland and the pathology report indicates the presence of a tumour involving most of the right lobe. According to the TNM classification, the tumour stage is?

Looser's zones (also known as pseudofractures) are a radiographic feature characterizing which one of the following bone diseases?

As the emergency department doctor on call, you are asked to perform a lumbar puncture. The mid-point at the level of the iliac crests is identified as your point of insertion of the puncture needle. Which intervertebral space does this represent?

A 21-year-old male medical student presents with a 14-day history of intermittent fever, rigours, headache, neck stiffness and a single episode of vomiting just prior to attending his appointment. On questioning, he admits to a visit to rural east Africa 2 months ago as part of a university outreach group and is up to date on all vaccinations. Furthermore, he had not had unprotected sexual intercourse over the past several months. On examination, he is noted to be tachycardic with a pulse rate of 100 beats/min and appears slightly dehydrated. Routine blood tests show moderately raised inflammatory markers. The admitting team suspects meningitis and conducts a lumbar puncture. The tap reveals a white cell count of 995/mm3 with a neutrophilia and lymphocytosis, 2.5 giL of protein and 3.0 mmol/L of glucose. Samples are additionally sent for Gram staining and virological examination and appropriate therapy started pending final confirmation. Which one of the following micro-organisms is most likely causing meningitis in this patient?

A 28-year-old solicitor presents to the neurosurgery clinic with a 1-year history of increasing tiredness, sweatiness, difficulty concentrating and pain and numbness in his hands at night. Further questioning reveals that his shoes have become tight in the past year, while examination reveals moderate hypertension, a protruding jaw and slightly coarse features. The admitting clinician suspects a growth-hormone-secreting pituitary tumour and requests several tests to confirm this diagnosis. Which one of the following tests is most appropriate to investigate this condition?

You are asked to review a 75-year-old female patient in the emergency department. She describes a 1-week history of severe left-sided earache, which is especially profound at night. She has taken to carrying tissues with her to clean up copious exudate discharging from the ear. Of note her past medical history includes controlled diabetes mellitus. Physical examination reveals granulation tissue in the external auditory canal. The erythrocyte sedimentation rate is elevated. Which one of the following pathogens is most likely to be responsible?

A 40-year-old Caucasian man presents complaining of pain in his left eye. Earlier that day he was working in his house, attempting to put up a shelf with nails. He felt a sensation of 'some material entering his eye'. He does not wear contact lenses. His eye has been extremely watery and he has been unable to open it properly, fluorescein assessment under the blue light slit lamp reveals a discrete green region at the lateral corneal margin. Following clinical assessment and thorough irrigation, the assessing clinician removes all the foreign bodies, which are sent for culture. Which one of the following pathogens is most likely to be responsible for infection?

A 40-year-old Caucasian man presents with visual disturbance in both temporal visual fields. He works as a taxi driver and is finding he cannot notice customers on the street as well as he used to. His appetite is reduced. He has a 2-week history of morning headache. Clinical examination reveals bitemporal hemianopia. Which of the following is the best diagnostic investigation?

A 45-year-old female business executive presents with a swelling in the midline of the neck and features of hyperthyroidism secondary to Graves' disease. Following a course of antithyroid medication, a subtotal thyroidectomy is performed. Raised titres of which immunoglobulin would be expected in this individual?

A 37-year-old patient is diagnosed with medullary carcinoma of the thyroid gland. The concentration of which electrolyte could be reduced in this patient?

A 40-year-old man presents with a month-long history of intermittent, left-sided pain and swelling in the anterior neck under the left jaw. His symptoms are associated with meal times and regress shortly after completing each meal. In recent days however, the pain appears to have become more intense and the swelling more firm. On examination a firm lump is palpable in the left submandibular region, bimanual palpation of which causes the patient to complain of a foul taste in his mouth. The most appropriate diagnostic investigation will be?

A 34-year-old patient is admitted intoxicated. He appears neglected and smells strongly of alcohol. The third day following his admission, he develops alcohol withdrawal and is managed with chlordiazepoxide. On day 5 of his admission, he has the following blood results: haemoglobin 11.2 g/dL, white cell count 7.9 x 109/L, mean corpuscular volume 103 fL, sodium 137 mmoi/L, potassium 2.3 mmoi/L, urea 3.4 mmoi/L, creatinine 69 mmoi/L, amylase 930 lUlL, phosphate 0.17 mmoi/L, calcium 2.25 mmoi/L, C-reactive protein 8 mg/L. Which test should be done urgently?