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?

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?

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?

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)?

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?

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?

A 23-year-old woman is seen in clinic for recurrent funny 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?

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?

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 shelves 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?

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?

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?

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:

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 peribilar region. Subsequent bronchoscopy and biopsy confirms small cell carcinoma. Which of the following statements is most true about small cell carcinomas of the lung?

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 be 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:

A 39-year-old woman has undergone a wide local excision for a 0.5 em 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?

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 welJ 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. AU 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 mmoUkg. The most likely cause of the hyponatraemia is:

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

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 yelJow 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?

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?

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 byperpigmentation feels velvety. You suspect that the patient bas acanthosis nigricans secondary to a possible malignancy. Which one of the following malignancies is most commonly associated with this dermatological presentation?

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?

A 26-year-old man presents to you with multiple patches of macular hyperpigrnentation which have been present since he was an infant but now are increasing in number. In addition he has 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?

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?

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?

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 em with poorly demarcated edges. On palpation the zone of erythema is warm and very tender. Full blood count reveals a white cell count of 20.1 with a neutrophil count of 15.0. Which of the following organisms is the most likely cause of this condition?

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?

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 <1 mm. What fiveyear survival rate does a Breslow thickness of <1 mm correspond to?

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?

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?

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?

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 examination he is pyrexial at 39°C. The most likely causative organism is:

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?

A 20-year-old man presents to accident and emergency with extreme pain in the right knee. On examination, his temperature 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?

A 74-year-old man presents to accident and emergency with extreme pain in the left knee. On examination, his temperature 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?

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 HIV 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?

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 aU. 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?

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?

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:

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

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 extra pulmonary manifestation of sarcoidosis?

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?

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?

A 55-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:

You see a 57-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?

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 ambuJance 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?

You are asked to examine a 16-year-old boy with suspected Marfans' syndrome. The patient is taU 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?

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 HbA1c = 6.1 per 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 em ulcer on her left heel. Her right foot is normal. What is the most likely cause of her ulcer?

A 55-year-old man has just arrived in accident and emergency complaining of 20 minutes of central crushing chest pain. Which feature is most indicative of myocardial infarction at this moment in time?

A 66-year-old woman presents to accident and emergency with a 2-day history of shortness of breath. The patient notes becoming progressively short of breath as well as a sharp pain in the right side of the chest which is most painful when taking a deep breath. The patient also complains of mild pain in the right leg, though there is nothing significant on full cardiovascular and respiratory examination. Heart rate is 96 and respiratory rate is 12. The patient denies any weight loss or long haul flights but mentions undergoing a nasal polypectomy 3 weeks ago. The most likely diagnosis is:

A 59-year-old man presents for a well person check. A cardiovascular, respiratory, gastrointestinal and neurological examination is performed. No significant findings are found, except during auscultation a mid systolic click followed by a late systolic murmur is heard at the apex. The patient denies any symptoms. The most likely diagnosis is: