A 19 year old man, presents to the Emergency Department with a supra-condylar fracture of the distal humerus. Later that evening, after surgical fixation he is noted to have a wrist drop with a patch of numbness on the dorso-radial aspect of the wrist. What is this most likely to be due to?
A. A median nerve injury
B. An ulnar nerve injury
C. A musculo-cutaneous nerve injury
D. An anxilliary nerve injury
E. A radial nerve injury
In the management of pneumothorax, what is the best indication that the intercostal catheter can be removed?
A. The size of the pneumothorax is less than 25% of the lung volume on chest x-ray
B. There is lack of bubbling in underwater seal drain with suction
C. There is lack of bubbles with cough in underwater seal drain
D. There is presence of swing and no bubbling in underwater seal drain
E. There is resolution of pleuritic chest pain
A 75 year old man, presents with painless loss of vision in the left eye one hour ago. VAR:6/9, VAL:light perception only. There is a left afferent pupil defect. He has been on an ACE inhibitor for hypertension. What do you see when you look into his left eye with a direct ophthalmoscope?
A. Signs of age-related macular degeneration
B. Some blot haemorrhages and hard exudates near the macula
C. A dense nuclear cataract makes the view of a probably normal optic disc and macula difficult
D. The macula has an orange/red spot and the surrounding retina looks pale, with marked attenuation of the retinal arterioles and segmentation of blood in the retinal veins
E. A swollen optic nerve and a normal retina
A 26 year old woman has a history of wheezing as a child. She has suffered from seasonal rhinitis in recent years. She is brought in by ambulance from a night club having developed severe shortness of breath. Which of the following findings is in keeping with a severe asthma attack?
A. Respiratory rate of 8/min
B. Blood pressure of 85/60 mmHg
E. Adjuvant chemotherapy is unsuitable for patients over 65 years of age
C. Inspiratory rhonchi on auscultation
D. Bilateral basal crackles on auscultation
E. 88 percent oxygen saturation on pulse oximetry
A 26 year old nurse has had wheezy bronchitis as a child. She went to a night club and suffered an attack of asthma. She is given nebulised salbutamol in the Emergency Department. Which of the following is the best explanation of why Salbutamol produces bronchodilation?
A. Antagonises muscarinic cholinergic receptors on airway smooth muscle
B. Increases cyclic AMP in airway smooth muscle cells
C. Inhibits the sodium channels in airway epithelial cells
D. Increases the firing rate of neurones in the brain stem respiratory centre
E. Antagonises beta adrenergic receptors on airway smooth muscle
A 25 year old man who sustains a clean, fairly superficial, 3cm long laceration to his left forearm on a piece of broken glass. Which one of the following statements about management is true?
A. Prophylactic antibiotics are required
B. Thorough cleansing with saline is the decontamination method of choice
C. Immediate tetanus prophylaxis is required as this is a tetanus-prone wound
D. X-ray is required even if the whole length and depth of the wound can be visualized
E. The wound should be closed in layers
Regarding the anatomy of the lungs, which of the following statements is correct?
A. The left lung is larger and heavier than the right
B. The lungs are supplied with oxygenated blood by the pulmonary arteries
C. The lungs are invested by parietal pleura
D. The middle lobe is the smallest lobe of the left lung
E. The apices of the lungs may pass above the thoracic inlet (1st rib)
A 30 year old woman, presents with a 2-day history of fever, vomiting and mild right-sided flank pain. She has evidence of right renal angle tenderness on examination. Urinalysis shows the presence of polymorphonuclear leucocytes and nitrates. What would be the next most appropriate investigation?
A. Abdominal ultrasound
B. Urine microscopy and culture
C. Intravenous pyelogram
D. Serum creatinine levels
E. Cystourethroscopy
Which of the following does the median nerve innervate?
A. All the muscles moving the thumb
B. Opponens pollicis
C. Adductor pollicis
D. The skin on the dorsum of the 5th digit
E. The medial two lumbricals
A 69 year old man presents to the doctor with an acutely swollen right knee. He has had previous episodes of acute pain and swelling in his big toes and ankles over the last 10 years. What is the most appropriate initial investigation to determine the diagnosis?
A. X-ray of the knee
B. Microscopy of synovial fluid
C. Full blood count
D. Serum uric acid
E. MRI of the knee
A 75 year old woman who presents with a six-month history of pain in her right knee, which is worse with prolonged walking. She has no relevant past history. Physical examination reveals a small effusion and crepitus on movement. Her body mass index is 32. You make a diagnosis of osteoarthritis Which of the following is the most important initial aspect of treatment?
A. Paracetamol
B. Non-steroidal anti-inflammatory drugs
C. Arthroscopy plus lavage
D. Avoidance of walking
E. Weight loss
Mrs Betty Smith is a 75 year old woman with osteoarthritis for whom you prescribe diclofenac. Which one of the following statements about diclofenac sodium is correct?
A. It inhibits both Cox I and Cox II isoenzymes
B. It does not affect platelet aggregation
C. It does not reduce renal blood flow in normal kidneys
D. It has no analgesic properties
E. It does not affect prostaglandin-mediated protection of the gastric mucosa
A 22 year old woman who is an active intravenous drug user presents to her general practitioner, six weeks pregnant. On investigation she is found to be positive for anti-hepatitis C virus (HCV). Her hepatitis A and B and HIV serology are negative. What advice is most appropriate for this patient at this point?
A. The risk of transmission of Hepatitis C to the fetus is > 80%
B. She should be vaccinated against hepatitis A and B unless she is already immune
C. She should commence antiviral treatment
D. She can expect to develop symptoms of hepatitis as her pregnancy progresses
E. She should reduce her alcohol consumption
What is the most important direct action of the hormone 1,25 Dihydroxyvitamin D?
A. Decrease bone resorption
B. Reduce urine phosphate losses
C. Reduce urine calcium losses
D. Potentiate the action of parathyroid hormone
E. Increase gut calcium absorption
With regard to the pathology of rheumatoid arthritis, which of the following statements is correct?
A. Rheumatoid arthritis involves amphiarthroses (fibrocartilagenous joints)
B. Pannus destroys articular cartilage and underlying bone
C. Rheumatoid erosions are typically subchondral
D. Rheumatoid nodules are typically caseating granulomas
E. Rheumatoid arthritis is typically associated with periarticular sclerosis
A 28 year old man, is involved in a head-on vehicle collision. He had allegedly been drinking at a pub with friends and left after a dispute. He was initially trapped in the car with the major impact on his right thigh. He is brought into the Emergency Department conscious, but pale with a pulse of 135bpm and blood pressure of 90/60mmHg. He has deformity of his mid thigh with visible bone protruding from a wound. Which of the following is the correct terminology to describe his fracture?
A. Greenstick fracture
B. Pathological fracture
C. Stress fracture
D. Impacted fracture
E. Compound fracture
A 28 year old man, is involved in a head-on vehicle collision. He had allegedly been drinking at a pub with friends and left after a dispute. He was initially trapped in the car with the major impact on his right thigh. He is brought into the Emergency Department conscious, but pale with a pulse of 135bpm and blood pressure of 90/60mmHg. He has deformity of his mid thigh with visible bone protruding from an anterior wound. Which of the following is the most likely early complication?
A. Femoral artery injury
B. S1 nerve root injury
C. Ruptured bladder
D. Pulmonary embolus
E. L5 nerve root injury
Soft tissue healing is an ordered process. Which of the following is NOT a stage in this type of wound healing?
A. Acute inflammatory reaction
B. Formation of fibrous tissue
C. Granuloma formation
D. Formation of the coagulum
E. Angiogenesis
A 28 year old man is travelling in Thailand when he is involved in a motor vehicle accident. He is taken to a local hospital with visible bone protruding from a wound in his mid-thigh. He undergoes transfusion with multiple units of whole blood as part of his immediate treatment. Six weeks later he develops jaundice. He undergoes a series of tests to investigate his jaundice. Which of the results suggests that his jaundice is likely to be related to his blood transfusion?
A. The presence of Anti-Hepatitis C Virus antibody
B. Elevated Alanine amino-transferase
C. The presence of Anti-Hepatitis B Surface Antigen antibodies
D. Elevated gamma-glutamyl transferase
E. Elevated aspartate amino-transferase
A 54 year old asthmatic woman, presents for a routine check up and isfound to have a blood pressure of 150/90mmHg. Examination reveals she is moderately overweight (BMI 28 kg/m²), in sinus rhythm with a heart rate of 80 beats per minute and has an audible fourth heart sound. Which one of the following clinical features is NOT relevant to the possible causation of hypertension in this patient?
A. A history of snoring
B. The detection of a carotid bruit
C. The detection of an abdominal bruit
D. A history of regular alcohol consumption
E. A history of chronic oral steroid use for severe asthma
Gail Tran is a 39 year old woman who is 20 weeks pregnant. You have just received her amniocentesis result which shows: 47 XY Trisomy 21. What is the most common cause of a left to right cardiac shunt in an infant with Trisomy 21?
A. Ventricular septal defect
B. Atrial septal defect
C. Tetralogy of Fallot
D. Atrial septal defect with pulmonary hypertension
E. Transposition of the great vessels
Regarding the blood supply to the heart, which of the following statements is correct?
A. The left and right coronary arteries arise from the arch of the aorta
B. The left and right coronary arteries are usually of equal length
C. The anterior interventricular artery is a branch of the right coronary artery
D. The right coronary artery descends on the heart between the right atrium and ventricle
E. The left coronary artery usually supplies the atrioventricular (AV) node
Regarding the anatomy of the heart, which one of the following statements is most correct?
A. The coronary arteries are the first branches of the arch of the aorta
B. Papillary muscles are located in the atria and the ventricles of the heart
C. The coronary sinus drains directly into the right atrium
D. The openings of the pulmonary veins into the left atrium are usually guarded by valves
E. The pulmonary valve has 2 cusps
SOK, aged 63, is in left ventricular failure following a myocardial infarct. Which of the following is the most appropriate to maximise life expectancy?
A. Digoxin - to increase the force of cardiac contraction
B. ACE inhibitors - to inhibit the renin-angiotensin system
C. Beta-adrenoreceptor agonists - to increase the force of cardiac contraction
D. Alpha-adrenoreceptor antagonists - to reduce systemic vascular resistance
E. Diuretics - to reduce ventricular preload
A 36 year old woman who presents with palpitations and is found to have significant mitral stenosis. Which of the following arrhythmias is the most likely cause of her palpitations?
A. Atrial fibrillation
B. Ventricular fibrillation
C. Atrial tachycardia
D. Ventricular tachycardia
E. Ventricular bradycardia
Where should the normal apex beat be palpated whilst undertaking a cardiovascular examination?
A. Left 5th intercostal space, anterior anxillary line
B. Left 5th intercostal space, mid-clavicular line
C. Left 6th intercostal space, mid-clavicular line
D. Left 6th intercostal space, anterior axillary line
E. Left parasternal edge, 5th intercostal space
Mr Wong, a 53 year old office worker, is found by his General Practitioner to have a blood pressure of 150/95mmHg. Which one of the following findings is most likely?
A. Normal renal function
B. A renal artery bruit
C. An elevated adrenocorticotropic hormone (ACTH) level
D. An elevated adrenaline level
E. An elevated noradrenaline level
Which one of the following is the specific treatment for paracetamol overdose?
A. Activated charcoal
B. Naloxone
C. Celecoxib
D. Frusemide
E. N-acetyl cysteine
The cranial nerves IX, X, XII are characterised by the fact that they all emerge from which one of the following structures?
A. Midbrain
B. Pons
C. Medulla
D. Thalamus
E. Spinal cord
Which one of the following statements about the skeleton is true?
A. The ulna is lateral to the radius
B. The metacarpals are numbered from 1 to 5 from the medial side
C. The metatarsals are numbered from 1 to 5 from the medial side
D. There are 14 phalanges in the hand and 13 phalanges in the foot
E. The elbow joint is an articulation between two bones
A 30 year old woman presents with polyuria and is diagnosed with diabetes mellitus. She has a blood glucose level of 24 mmol/L. Which of the following is the strongest indication to commence insulin treatment immediately?
A. Her very high blood glucose level
B. Her age
C. Her symptomatic hyperglycaemia
D. Presence of moderate blood ketones
E. Vaginal candidiasis
Macrocytosis refers to enlarged red cells while the term megaloblastosis refers to a specific morphological appearance observed in haemopoietic cells forming in the absence of adequate amounts of either vitamin B12 or folate. Which of the following morphological features in a peripheral blood smear indicates megaloblastic haemopoiesis?
A. Hypersegmented neutrophils
B. Target cells
C. Platelet clumps
D. Reduced neutrophil granulation
E. Eosinophilia
Which one of the following is the correct order of tissues lining the gastrointestinal tract from the lumen (inside) outwards?
A. Epithelium, lamina propria, muscularis mucosa, submucosa, muscularis externa
B. Epithelium, muscularis mucosa, lamina propria, submucosa, muscularis externa
C. Epithelium, lamina propria, muscularis externa, submucosa, muscularis mucosa
D. Epithelium, lamina propria, muscularis mucosa, muscularis externa, submucosa
E. Epithelium, muscularis externa, submucosa, muscularis mucosa, lamina propria
Which of the following is true regarding surgical therapy for colorectal cancer?
A. Adjuvant therapy is indicated for all patients with colorectal cancer
B. The goal of adjuvant therapy is to improve the chances of cure
C. Adjuvant radiotherapy is indicated for patients with colon cancer
D. Adjuvant chemotherapy for colon cancer should continue for at least 12 months
E. Adjuvant chemotherapy is unsuitable for patients over 65 years of age
What is the laryngeal prominence (Adam's apple) in the neck formed by?
A. Epiglottis
B. Hyoid bone
C. Thyroid cartilage
D. Cricoid cartilage
E. Thyroid gland
E. Adjuvant chemotherapy is unsuitable for patients over 65 years of age
What is the most useful guide to the likely post-operative opioid requirements of a patient undergoing a laparotomy?
A. The weight of the patient
B. The estimated lean body mass of the patient
C. The gender of the patient
D. The age of the patient
E. The magnitude of the surgery
A 55 year old woman, presents to the Emergency Department with a 24 hour history of right upper quadrant pain, passing dark coloured urine and a fever of 38.7ºC. Abdominal ultrasound shows multiple gallstones in the gallbladder and adilated common bile duct of 1.5 cm. What is the most likely diagnosis?
A. Acute appendicitis
B. Acute pancreatitis
C. Acute cholecystitis
D. Acute cholangitis
E. Acute hepatitis
Which of the following statements about the autonomic nervous system is most accurate?
A. The cell bodies of sympathetic preganglionic neurons are located in the ventral horn of the thoracic and lumbar segments of the spinal cord
B. In response to stress, sympathetic nerves regulating different effectors tend to be activated simultaneously
C. Sympathetic preganglionic neurons receive direct inputs from primary afferent nerves that enter the spinal cord at the same segmental level
D. Most sympathetic and parasympathetic ganglia are remote from their target organs
E. In quadriplegic patients, an increase in blood pressure evokes a reflex change in heart rate
A 19 year old girl presents to the Emergency Department with a one day history of drowsiness, headache, fever and photophobia. There is no history of trauma, and she doesn't have a rash. Which of the following is the most appropriate next step in managing this patient?
A. Prescribe opioids to treat her headache
B. Administer intravenous antiobiotics urgently after blood cultures
C. CT scan of the brain
D. Lumbar puncture with CSF sampling
E. Await results of full blood count and other inflammatory markers
Radiotherapy with or without chemotherapy can be used to cure (without surgery) all of the cancers listed EXCEPT which of the following below?
A. Lymphoma
B. Anal cancer
C. Colon cancer
D. Cervix cancer
E. Laryngeal cancer
Which of the following pharmacological agents used in the management of type 2 diabetes is NOT associated with significant weight gain?
A. Metformin
B. Sulphonylureas
C. Short acting insulin
D. Thiazolidinediones
E. Biphasic insulin
Which of the following is NOT a recognised side effect of non-steroidal antiinflammatory drugs (NSAIDs)?
A. Peptic ulceration
B. Bleeding
C. Renal impairment
D. Aggravation of asthma in some patients
E. Squamous cell carcinoma of the skin
A patient with Parkinson's disease has been treated successfully for several years with a levodopa based medication. He has recently developed prominent involuntary writhing movements of the limbs. Which of the following terms describes this phenomenon?
A. Hypokinesia
B. Akinesia
C. Bradykinesia
D. Dyskinesia
E. Hyperkinesia
A 64 year old female presents with a two-year history of perianal itching and irritation more noticeable in the past month. Inspection of the perineum shows an area of hyperkeratosis, leucoplakia and an associated large irregular ulcer on the anal verge in the mid-line posteriorly. What should be the next step in her management?
A. Perform a wide local excision
B. Prescribe a steroid cream
C. Patient to apply rectogesic ointment 5 percent (nitroglycerin-base)
D. Perform an internal anal sphincterotomy
E. Perform an incisional biopsy
Which of the following is the least important factor contributing to Total lung capacity (TLC)?
A. Age
B. Height
C. Lung elastic recoil
D. Chest wall recoil
E. Gender
Which of the following has the least effect on the diffusing capacity for carbon monoxide of the lung at rest?
A. The physical properties of carbon monoxide
B. Pulmonary capillary blood volume
C. Thickness of the blood-gas barrier
D. Haemoglobin level in the blood
E. Area of the blood gas interface
A 45 year old man is involved in a motor vehicle accident. He presents 2 weeks later with pain involving the right shoulder, scapula and upper limb. What sensory findings would be suggestive of a C6 radiculopathy?
A. Numbness in a patch over the deltoid
B. Parasthesia over the upper trapezius
C. Numbness in the axilla
D. Paraesthesia of the index finger and thumb
E. Numbness of the little and ring fingers
Which of the following joints are affected most commonly by osteoarthritis?
A. Metacarpophalangeal joint
B. Ankle joint
C. Elbow joint
D. Distal interphalangeal joint
E. Shoulder joint
How does chronic suppurative otitis media most commonly present?
A. Recurrent painless aural discharge
B. Acute aural discharge accompanied by pain
C. Hearing loss
D. Facial palsy
E. An incidental finding of a perforated ear drum
Mary is a 17 year old student who presents complaining of recurrent nasal discharge, irritation and sneezing. What is the most likely cause of her complaint?
A. Deviated nasal septum
B. Infective sinusitis
C. Nasal foreign body
D. Allergic rhinitis
E. Rhinitis medicamentosa
Which of the following not an indication for tracheotomy?
A. Acute air way obstruction
B. Prolonged ventilation
C. Recurrent bronchial toilet
Moderate sleep apnea
Major head and neck cancer resection
Chandra, a 50 year old Indian migrant, presents with a two week history of high spiking fever and right upper quadrant pain. A CT scan of the abdomen shows features of a liver abscess. Ultrasound guided aspiration of the collection shows fluid that looks like anchovy sauce. What is the most likely diagnosis?
A. Staphylococcus liver abscess
B. Amoebic liver abscess
C. Hydatid liver abscess
D. Tuberculous liver abscess
E. E. Coli liver abscess
A 17 year old girl, presents with a 1-day history of central abdominal pain that then localises to the right lower quadrant of the abdomen. This is associated with nausea, decreased appetite and a temperature of 37.8°C. What is the most appropriate initial management of this patient?
A. β HCG
B. Pelvic ultrasound
C. Urgent O&G review to exclude pelvic inflammatory disease
D. Laparoscopy
E. Start broad spectrum antibiotics
A 24 year old student, presents at the Emergency Department with sudden onset of a cough and high fever. Chest X-ray shows a left lower lobar consolidation and further history reveals frequent sinus infections requiring antibiotics, and two episodes of lobar pneumonia in the past 5 years. Which of the following organisms is most likely to be responsible for his repeated infections?
A. Haemophilus influenza
B. Streptococcus pneumonia
C. Moraxella catarrhalis
D. Pneumocystis jiroveci
E. Pseudomonas aeruginosa
Type I diabetes mellitus is caused by an auto-immune process.
A. Anti-insulin antibodies
B. Anti-glutamic acid decarboxylase antibodies
C. Infiltrate of islets by CD4+ and CD8+ T cells
D. Ant-islet cell antibodies
E. Complement mediated damage of the islets
A 39 year old receptionist with a history of chronic asthma, has her blood pressure checked by her GP. It is found to be 165/95 mmHg. The patient’s body mass index is 32 kg/m² (NR: 20 -25kg/m 2 ) and the remainder of the physical examination is normal. Urinalysis is negative for blood and protein. Which of the following anti-hypertensive agents is contraindicated in this case?
A. Perindopril
B. Atenolol
C. Nifedipine
D. Hydrochlorothiazide
E. Prazosin
An 85 year old woman comes to see you, her local doctor, with her daughter. Her daughter tells you that her mother has become increasingly confused over the last week. She has also developed increasing generalised weakness, poor mobility and her overall ability to carry out her activities of daily living has deteriorated. Which of the following investigations would you perform first?
A. Electrolytes
B. Computed tomography (CT) scan of the brain
C. Full blood count
D. Dipstick urine analysis
E. Creatinine kinase
What is the main vein draining the brain?
A. Internal jugular vein
B. External jugular vein
C. Internal carotid vein
D. External carotid vein
E. Vertebral vein
Which of the following micro-organisms is the commonest cause of communityacquired pneumonia?
A. Haemophilus influenzae
B. Staphylococcus aureus
C. Streptococcus pneumoniae
D. Pseudomonas aeruginosa
E. Klebsiella pneumonia
How is an "open" fracture defined?
A. There is a full thickness break of the bone
B. Requires surgical (open) reduction
C. Requires antibiotic therapy
D. Requires internal (surgical) fixation
E. Associated with a breach in the overlying skin
Which of the following is NOT a stage in normal soft tissue wound healing?
A. Acute inflammatory reaction
B. Formation of fibrous tissue
C. Granuloma formation
D. Formation of the coagulum
E. Haemostasis
Which of the following is the main risk factor for ischaemic heart disease in men and women older than 75?
A. Hypertension
B. Age
C. Cholesterol
D. Smoking
E. Obesity
Which of the following tests is most likely to establish a definitive microbiological diagnosis in a patient with community-acquired pneumonia?
A. Gram stain of sputum
B. Bacterial culture of sputum
C. Bacterial culture from a throat swab
D. Blood cultures
E. Serological assays
Which of the following investigations is useful in the monitoring of rheumatoid arthritis?
A. C- reactive protein
B. Anti DNA antibodies
C. X-rays of the lumbar spine
D. Serum uric acid level
E. Serum creatinine
A 45 year old woman presents with a 3 month history of arthritis. Physical examination reveals tender swollen metacarpo-phalangeal joints in a symmetrical pattern. What is the most likely diagnosis?
A. Rheumatoid arthritis
B. Systemic lupus erythematosis
C. Reactive arthritis
D. Gout
E. Psoriatic arthritis
A 58 year old man is treated with diuretics for his mild essential hypertension. His blood gas results are shown below: PaO2 = 92 mmHg (normal range: 80-100 mmHg) PaCO2 = 44 mmHg (normal range: 35-45 mmHg) pH = 7.50 (normal range: 7.35-7.45) BE = +10 mmol/L (normal range: -2-+2 mmol/L) Which of the following best describes this picture?
A. Compensated metabolic acidosis
B. Uncompensated metabolic alkalosis
C. Compensated respiratory acidosis
D. Uncompensated respiratory alkalosis
E. Compensated respiratory alkalosis
Acob Butler is an 18 year old motorcyclist who is brought to hospital by ambulance following a single-vehicle crash. He has a compound fracture of the right femur and is agitated and disorientated. Which of the following is NOT an immediate priority?
A. Assess air-entry and position of the trachea
B. Check upper airways to ensure patency
C. Urgent full blood count
D. Urgent blood sugar level
E. Establish intravenous access
Hyperalgesia is defined as which of the following?
A. Loss of sensitivity to pain
B. Increased sensitivity to touch
C. Increased sensitivity to pain
D. Pain response to non-noxious stimulus
E. Increased numbers of nociceptors
Regarding the uterine tubes, which of the following statements is NOT correct?
A. They have smooth muscle in their wall
B. They connect to the junction of body and fundus of uterus
C. They are most dilated at the isthmus
D. They are located in the upper part of the broad ligament
E. They open laterally into the peritoneal cavity
Regarding the scapula, which one of the following statements is correct?
A. It helps form the acromioclavicular joint
B. It is not involved in force transfer from the upper limb to the thorax
C. The suprascapular notch transmits the radial nerve
D. Only two of the musculotendinous cuff muscles attach to it
E. The spine of the scapula is at the level of thoracic vertebra seven
Which of the following terms best describes the usual response of cardiac myocytes to hypertension?
A. Atrophy
B. Metaplasia
C. Hyperplasia
D. Hypertrophy
E. Dysplasia
During pregnancy, which one of the following infectious diseases has the lowest risk of causing congenital infection?
A. Toxoplasmosis
B. Syphilis
C. Rubella
D. Listeriosis
E. Tuberculosis
Which of the following statements about right-sided heart failure is true?
A. The most frequent cause is left-sided cardiac failure
B. Pulmonary oedema is a consequence
C. When the disorder is a result of lung disease, left ventricular hypertrophy is likely
D. The liver compensates with cirrhosis and shrinkage
E. Pitting oedema of dependent parts is a common sign
Maternal cardiovascular changes during pregnancy include which one of the following?
A. A decrease in cardiac output
B. Systemic vasoconstriction
C. Vasoconstriction of the renal arterioles
D. A decrease in red blood cell production
E. An increase in blood volume
Regions that are innervated by the ulnar nerve include which of the following?
A. The lateral epicondyle of the humerus
B. Skin over the palmar surface of the thumb
C. The 1st and 2nd (lateral) lumbrical muscles
D. Skin over the palmar surface of the little (5th) finger
E. The thenar muscles
In the context of drug use, which one of the following statements best describes the difference between addiction and dependence?
A. Dependence is the diagnostic term
B. There is no difference between the terms
C. A withdrawal syndrome is always present in addiction
D. Addiction is an antiquated term which has been replaced with dependence
E. Dependence and addiction refer to the physical attributes of drug and alcohol problems
Regarding genital chlamydial infections, which of the following statements is FALSE?
A. It is frequently asymptomatic
B. It can be treated with a single dose of an antibiotic
C. It can lead to pelvic inflammatory disease (PID) in females
D. Polymerase chain reaction (PCR) assays are useful for diagnosis
E. The period of infectivity is 7-14 days after infection
If a patient has an isolated iron deficiency, which of the following sets of results would you expect to find?
A. Low serum iron, normal serum transferrin and low serum ferritin
B. Low serum iron, high serum transferrin and low serum ferritin
C. Low serum iron, high serum transferrin and normal serum ferritin
D. Low serum iron, low serum transferrin and high serum ferritin
E. Normal serum iron, low serum transferrin and low serum ferritin
Which of the following is a feature of the inferior vena cava?
A. It is formed by the union of brachiocephalic veins
B. It travels behind the spleen
C. It drains the lower lobe of the lungs
D. It is formed by the union of portal and superior mesenteric veins
E. It empties blood into the right atrium
Smoking is a known risk factor for a number of cancers. Smoking cessation can modify a person’s risk of these cancers. Despite this, smoking cessation has NOT been shown to reduce the risk of which of the following?
A. Oesophageal cancer
B. Pancreatic cancer
C. Colon cancer
D. Lung cancer
E. Cervical cancer
Which of the following agents/devices used in the treatment of pulmonary embolism is associated with the highest risk of serious bleeding?
A. Unfractionated heparin
B. Low molecular weight heparin
C. Tissue plasminogen activator (TPA)
D. Inferior vena caval filters
E. Warfarin
An obese 65 year old female with renal failure has had a laparotomy. On day five post operative she develops copious serous ooze from her midline abdominal wound. She is afebrile. This is likely to be due to which of the following?
A. Wound abscess
B. Wound dehiscence
C. Normal wound healing
D. Allergic reaction to the sutures
E. Bowel fistula
A 15 year old male presents with central periumbilical pain, a low grade temperature and nausea. Over the next couple of hours, the pain shifts to the right iliac fossa. Which of the following is the most likely diagnosis?
A. Mesenteric lymphadenitis
B. Acute appendicitis
C. Crohn's disease
D. Pelvic inflammatory disease
E. Meckel's diverticulitis
What is an advantage of tramadol over morphine?
A. Fewer interactions with antidepressants compared with morphine
B. Less respiratory depression
C. Less likely to cause seizures
D. Less diarrhea
E. Easily reversed with flumazenil
Sara presents to the Emergency Department with 5 days of cough, 2 days of fever and increased lethargy. Her oxygen saturation is 90 percent, blood pressure is 90/50 mmHg, heart rate 120/min and temperature is 38.5°C. On examination, she has bronchial breathing at her right lung base. What is the most likely diagnosis?
A. Bronchitis
B. Pneumonia
C. Pulmonary embolism
D. Pulmonary haemorrhage
E. Respiratory tract infection
How do you calculate the Mean Arterial Pressure (or MAP)?
A. Diastolic BP + systolic BP
B. (Diastolic BP / 3) + systolic BP
C. Diastolic BP + 1/3 (systolic BP - diastolic BP)
D. Diastolic BP + 1/3 (systolic BP + diastolic BP)
E. (Diastolic BP + systolic BP) / 2
Sara, a 25 year old woman, presents to the Emergency Department with 5 days of cough, 2 days of fever and increased lethargy. Her oxygen saturation on air is 90%, blood pressure is 90/50 mmHg, heart rate is 120 bpm and temperature is 38.5ºC. On examination, she has bronchial breathing at her right lung base. You have assessed Ms Jones and have decided to give her IV fluids. How much fluid will you give before reassessing her?
A. 1 litre normal saline rapidly
B. 1 litre 5% glucose rapidly
C. 1 litre normal saline over 2 hours
D. 1 litre 5% glucose over 1 hour
E. 500 mls of 5% glucose rapidly
Anna is a 50 year old woman who is brought to the Emergency Department after collapsing at home while standing at the sink. She says that she remembers feeling hot and nauseated before developing tunnel vision and then passing out. She is usually well and takes a single anti-hypertensive agent. On physical examination, she is now well. There are no significant cardiovascular findings and no focal neurological deficits. What is the most likely cause for her syncopal episode?
A. Vasovagal syncope
B. Transient ischaemic attack
C. Orthostatic hypotension
D. Ventricular tachycardia
E. Ventricular fibrillation
Susan is a 35 year old woman who is brought into the Emergency Department by ambulance after being found lying in the gutter. She is able to speak but is unable to give coherent answers to questions. Her initial vital signs are as follows: heart rate 120 bpm, blood pressure 80/40 mmHg, temperature 38ºC and respiratory rate 28bpm. What would be your first step on reaching her bedside?
A. Perform a neurological examination
B. Remove her clothing, looking for signs of injury
C. Ask for an urgent 12 lead electrocardiogram (ECG)
D. Auscultate her chest
E. Insert an intravenous cannula
Which device would deliver oxygen at a concentration close to 100 percent?
A. High flow nasal prongs with an oxygen flow at 15L/min
B. Simple face mask with oxygen flow at 15L/min
C. Venturi device set at 50% and oxygen flow at 30L/min instead of the usual 15L/min
D. Loose fitting mask that has an oxygen reservoir bag with a one-way valve and oxygen flow at 15L/min
E. Self-inflating bag- valve- mask device with reservoir and oxygen flow at 15L/min
A 45 year old morbidly obese male presents with a two day history of pain in the left calf and swelling of the ankle. Which of the following is the correct management?
A. Elastic stockings and aspirin with a review in 5 days
B. Bed rest with elevation of the left leg
C. Venous duplex ultrasound scan of the left leg
D. Subcutaneous heparin for 6 days
E. Plain X-ray of the left ankl
Which of the following is most useful for identifying the cause of syncope?
A. Electroencephalogram (EEG)
B. Electrocardiogram (ECG)
C. Cerebral Computerised Tomography (CT)
D. History from patient
E. History from a witness
Management of atrial fibrillation of onset within 4 hours of presentation includes all of the following EXCEPT:
A. Urgent cardioversion to prevent systemic embolisation
B. Rate control with IV anti-arrhythmic drugs
C. Anticoagulation with heparin
D. Commencement of continuous ECG monitoring
E. Echocardiography
A 20 year old university student presents to you with a one week history of fatigue, fevers, night sweats and poor appetite. He was well prior to this episode. Examination reveals multiple tender lymph nodes in the cervical and axillary areas and splenomegaly palapable 3cm below the costal margin. What would most appropriate initial management include?
A. Perform a monospot and viral serology
B. Referral for abdominal (staging) CT scan
C. Referral for excision biopsy of a lymph node
D. Referral for a fine needle lymph node aspiration biopsy
E. Treat with amoxycillin and review in one week
Red cell fragments (schistocytes) are commonly seen in which of the following conditions?
A. Acute pulmonary embolism
B. Autoimmune haemolytic anaemia
C. Disseminated intravascular coagulation
D. Falciparum malaria
E. Gastrointestinal haemorrhage
Multiple myeloma is characterised by plasma cell infiltration of which of the following organs?
A. Lymph nodes
B. Spleen
C. Kidneys
D. Bone marrow
E. Soft tissue
Which of the following statements regarding the use of diagnostic ultrasound for medical imaging is correct?
A. A fizzy drink is the best preparation for an ultrasound of the upper abdomen
B. The higher the frequency of the ultrasound used the better the spatial resolution obtained
C. The use of ultrasound in women of child bearing age is not recommended because of radiation concerns
D. The use of ultrasound for guidance of percutaneous procedures is decreasing as CT scans and MRI units become more widely available
E. For vascular problems ultrasound imaging is primarily useful for demonstrating anatomy, while flow is assessed by other means
Which of the following is most likely to cause damage to cardiac muscle?
A. Cyclophosphamide
B. Methotrexate
C. 5-fluorouracil
D. Doxorubicin
E. Cisplatin
A 24 year old man admitted to the Emergency Department following a motor vehicle accident. He has a contused chest wall and is in respiratory distress. His left chest is resonant on percussion and no breath sounds can be heard on auscultation. His trachea is deviated to the right. What is the most likely diagnosis?
A. Acute Respiratory Distress Syndrome (ARDS)
B. Pulmonary embolism
C. Spontaneous pneumothorax
D. Haemothorax
E. Tension pneumothorax
Alex is a 25 year old woman who presents to the Emergency Department with sharp central chest pain. You make a provisional diagnosis of pericarditis. Which of the following is TRUE of this condition?
A. It has a high fatality rate in young people
B. It is sometimes associated with pulsus paradoxus
C. It commonly presents with a pleuritic pain, worse on sitting up
D. It commonly presents with ECG changes such as PR elevation
E. It is usually managed as an outpatient in people aged less than 30 years old
Regarding unstable angina pectoris, which of the following statements is true?
A. A normal ECG and normal serial troponins makes the diagnosis very unlikely
B. The absence of cardiac risk factors excludes the disease
C. Pain commonly radiates to the back
D. It is treated with thrombolysis or percutaneous coronary intervention
E. Beta blockers have been shown to reduce mortality
Charlie Springer is a 25 year old man who has had a motor bike accident. On arrival at the Emergency Department, his vital signs are heart rate is 130/minute, blood pressure of 90/60 mmHg, respiratory rate of 32/minute, temperature is 36°C. His peripheral oxygen saturation is 97 percent on room air. What would be your initial order for IV fluids?
A. Two packs of O negative blood over half an hour
B. A litre of normal saline over 2 hours
C. A litre of 4 percent dextrose and 0.18 percent saline over an hour
D. A litre of normal saline over half an hour
E. A litre of Hartmans solution over 2 hours
Cholinesterase inhibitors have NOT been associated with which of the following potential adverse effects?
A. Tachycardia
B. Diarrhoea
C. Muscle cramps
D. Vivid dreams
E. Pancreatitis
Which of the following statements about septic arthritis is correct?
A. The infection is most commonly due to Escherichia coli
B. The clinical features can be similar to gout
C. It rarely presents as a monoarthritis
D. It usually presents as a pyrexia of unknown origin
E. The ankle is the most commonly involved joint
A 24 year old man presents with a six month history of low back and buttock pain. His pain is worse in the morning and improves during the day. He has restriction of movement of his lumbar spine. His symptoms are helped by non-steroidal antiinflammatory drugs. Which of the following clinical features is he most likely to develop?
A. Arthritis involving the small joints of the hands and feet
B. Pulmonary fibrosis involving the lower lobes
C. Aortic valve incompetence
D. Acute iritis
E. Ulcerative colitis
A 75 year old man presents a year after sustaining a stroke. He complains of worsening urinary frequency, urgency and nocturnal enuresis. Which of the following statements is true?
A. The most likely cause is benign prostatic hypertrophy
B. The appropriate imaging investigation is computed tomography (CT) scan of the urinary tract
C. Cystoscopy is mandatory
D. The most likely cause is neurogenic overactive bladder
E. A trial of antibiotic therapy is indicated
Profound hypothyroidism in the elderly is likely to cause which of the following electrolyte disturbances?
A. Hyponatraemia
B. Hypernatraemia
C. Hypokalaemia
D. Hyperkalaemia
E. Hypercalcaemia
A 50 year old woman presents with painless rectal bleeding on defaecation. There is no family history of bowel cancer, no weight loss and no change in bowel habits. What is the recommended investigation?
A. Haemoccult testing
B. Colonoscopy
C. Flexible sigmoidoscopy
D. Proctoscopy and haemoccult test
E. Small bowel series
What is the significance of the finding of localised tenderness and guarding on abdominal examination?
A. The patient's pain is severe
B. There is an inflammatory process involving the parietal peritoneum
C. There is intraperitoneal free fluid
D. There is haemorrhage within a hollow viscus
E. There is infarction of a hollow viscus
A Regarding analgesic doses of ketamine, which of the following statements is correct?
A. It should be given carefully to asthmatics as it may worsen bronchospasm
B. It is likely to cause nausea and vomiting
C. It antagonises the effects of opiates
D. It is unlikely to cause respiratory depression
E. It may worsen neuropathic pain
A 56 year old man is brought into the Emergency Department following a car accident. When you assess his respiratory system you find that he has reduced chest expansion on the right with a midline trachea. The percussion note is dull on the right posteriorly and laterally but resonant on the left. He is very tender in the right axilla. Breath sounds are absent at the right base and generally vesicular with occasional crackles elsewhere. What is the most likely diagnosis based on these findings?
A. Haemothorax on the right
B. Simple pneumothorax on the right
C. Right lower lobe aspiration pneumonitis
D. Acute severe asthma
E. Generalised lung contusions
In an emergency setting for a patient with an unknown blood group, which is the most appropriate type of fresh frozen plasma (FFP) to administer?
A. O negative
B. O positive
C. AB negative
D. AB positive
E. A negative
Aminoglycosides (e.g. gentamycin) cause deafness by damaging which of the following?
A. Basilar membrane
B. Vestibular nerve
C. Cochlear hair cells
D. Cochlear duct
E. Vestibular aqueduct
With regard to the use of antibiotics in cholera, which of the following statements is correct?
A. They prevent the spread of infection in the community
B. They reduce the risk of bacteraemia
C. They reduce the production of the toxin
D. They can shorten the duration of diarrhoea
E. They reduce the likelihood of prolonged faecal sheddi
Which oral condition has the LEAST association with Type 1 and Type 2 diabetes?
A. Candidiasis
B. Periodontitis
C. Oral cancer
D. Lichenoid reactions
E. Implant failure
Plasmodium vivax and Plasmodium ovale can relapse months or years after an initial infection. Which one of the following parasite stages is responsible for reactivation of malaria infection?
A. Hypnozoite
B. Merozoite
C. Trophozoite
D. Sporozoite
E. Gametocyte
Which of the following treatments is most likely to be associated with a potential life threatening attack of asthma?
A. Inhaled corticosteroids
B. Inhaled corticosteroid plus a long acting beta agonist
C. Multiple courses of oral corticosteroids for acute asthma
D. Steroid nasal sprays for concurrent allergic rhinitis
E. Topical steroids for concurrent atopic eczema
A 75 year old woman brought into the Emergency Department by her daughter. Her daughter tells you she has become more confused over the last 2 days and she is normally independent and otherwise healthy woman. On examination she is afebrile, her heart rate is 100 beats per minute and her blood pressure is 160/90 mmHg. Pulse oximetry is 97 percent on room air. There are no focal findings on neurological examination and her chest is clear. What is the most likely cause of her confusion?
A. Transient ischaemic attack
B. Pneumonia
C. Dementia
D. Vitamin B12 deficiency
E. Urinary tract infection
Which of the following statements describes the mechanism of action of statin therapy for lipid-modification?
A. They predominantly reduce triglyceride levels
B. Their major action is on intestinal cholesterol absorption
C. They inhibit HMGCoA reductase
D. They predominantly reduce HDL
E. They inhibit lanosterol synthase
A 26 year old woman, presents with a 7 month history of abdominal pain. Investigations reveal her to have Crohn's disease affecting a short segment of the terminal ileum. There is no evidence of disease elsewhere, and she remains systemically well. Of the following, which would be the most appropriate initial therapy?
A. Oral olsalazine
B. Local resection
C. Oral azathioprine
D. Oral cyclosporine
E. Oral budesonide
A 45 year old man presents having had a large haematemesis and melaena. He had four forceful vomits containing old food and bile prior to the episode of haematemesis. What is the most likely cause of the haematemesis?
A. Duoenal ulcer
B. Gastric ulcer
C. Mallory-Weiss tear
D. Oesophageal varicies
E. Aortic aneurysm
A thin 45 year old alcoholic man presents 6 weeks after an admission for alcohol induced acute pancreatitis with a history of mild to moderate epigastric discomfort and a poor oral intake due to early satiety. Examination reveals he is afebrile and has an 8cm firm, round, slightly tender mass in the epigastrium. What is the most likely diagnosis?
A. Distended stomach due to gastric outlet obstruction
B. A pancreatic abscess
C. A pancreatic pseudocyst
D. A mucinous cystic tumour of the pancreas
E. A pseudo-aneurysm of the splenic artery
A 74 year old man with advanced chronic obstructive pulmonary disease (COPD) presents to his family doctor with increasing exertional dyspnoea. This problem has slowly evolved over the previous 2-3 years. He is now having difficulty walking around the shopping centre and can no longer do the gardening. Investigations suggest his symptoms are due to progression of the COPD. Which of the following management strategies is NOT appropriate to consider in this patient?
A. Inhaled corticosteroid and long acting bronchodilator therapy
B. Domiciliary oxygen
C. Lung transplantation
D. Pulmonary rehabilitation program
E. Immunisation against influenza
In which of the following is topical anaesthesia with lignocaine NOT effective?
A. Cornea
B. Posterior pharynx
C. Auditory canal
D. Urethra
E. Nasal mucosa
Regarding adult basic life support in cardiac arrest, which of the following is correct?
A. The ratio of compressions to ventilations may be altered depending on the number of rescuers
B. The recommended compression:ventilation ratio is 30:2
C. Five initial rescue breaths should be given
D. A radial pulse should be checked before commencing chest compressions
E. Cardiopulmonary resuscitation should not be commenced if there is abnormal or irregular breathing
A 25 year old man had a late night out drinking alcohol heavily. At 2 o’clock in the morning he vomited profusely. This was followed by an acute, severe pain in his chest radiating to his back and neck. What is the most likely diagnosis?
A. Acute myocardial infarction
B. Pulmonary embolus
C. Peptic ulcer disease
D. Oesophageal perforation
E. Aortic dissection
Which of the following is the most sensitive investigation for pancreatitis?
A. Lipase - with levels > 3X normal
B. Amylase - if levels 3X normal
C. Abdominal X-ray
D. Computed Tomography (CT) scan
E. Ultrasound
By definition, severe acute pancreatitis includes all EXCEPT which of the following complications?
A. Acute renal failure
B. Acute respiratory distress syndrome (ARDS)
C. Acute bowel perforation
D. Pancreatic pseudocysts
E. Pancreatic necrosis
Which of the following most accurately describes the ECG abnormality seen with a delay in AV node conduction?
A. A QRS duration of >0.16 seconds
B. A PR interval of >0.12 seconds
C. A QT interval of 420 milliseconds
D. A PR interval of >0.20 seconds
E. A QRS complex duration of 0.08 seconds
A72 year old woman, presents with 2 days of melaena on the background of a 2 month history of burning epigastric pain relieved by food. An upper endoscopy demonstrates a gastric ulcer in the prepyloric region. Urease test is positive, indicating the presence of H. pylori. She is treated with standard triple therapy for H. Pylori infection, followed by omeprazole for a further 2 months, with good relief of her symptoms. She presents for follow up. Which of the following would represent the most appropriate management?
A. Check H. Pylori eradication with faecal culture
B. Check H. Pylori eradication with anti H. Pylori antibody assay
C. Check H. Pylori eradication with urea breath test
D. Continue omeprazole indefinitely
E. Repeat upper endoscopy
Haematemesis is NOT a feature of which of the following?
A. Barrett’s oesophagus
B. Dieulafoy lesion
C. Duodenal ulcer
D. Gastrointestinal stromal tumour of the stomach
E. Jejunal angiodysplasia
A 20 year old woman with a history of smoking and mild asthma presents with sudden onset of sharp chest pain which on questioning is worse on inspiration. On examination her resting respiratory rate is 30 breaths/min and she is clearly distressed. What do you consider to be the most clinically valuable next step in examination or investigation?
A. Determine if the trachea is midline
B. Listen for decreased breath sounds
C. Order an urgent chest X-ray
D. Organise pulse oximetry
E. Test for hyper resonance on percussion
A 40 year old man with a history of alcohol abuse presents with a one week history of shortness of breath, fever and lateral chest pain. His temperature is 39ºC and he is hypotensive. A chest X-ray shows a large D shaped collection posteriorly at the base of his right lung. Which of the following choices is the most appropiate next step?
A. Ultrasound scan of the collection
B. Computed tomography (CT) of the chest
C. Diagnostic pleural tap and gram stain
D. Intercostal drain insertion and gram stain
E. Ventilation perfusion lung scan
An HIV-positive patient recently returned from the tropics presents with severe diarrhoea (up to 30 times per day). What is the most likely cause?
A- Escherichia coli
B- Staphylococcus aureus
C- Cryptosporidium
D- Entamoeba histolytica
E- Salmonella
A 34-year-old coronary care nurse accidentally stabs himself with a used needle from a patient infected with the hepatitis C virus. He attends the occupational health department and asks for advice.Which would be the most appropriate next step suggested by the occupational health doctor?
A- Monthly hepatitis C antibody testing
B- Monthly hepatitis C PCR testing
C- 6 months' ribavirin therapy
D- 6 months' lamivudine therapy
E- 6 months of weekly interferon therapy
A 25-year-old man presents with 4 days of fever, retro-orbital pain and severe myalgia following travel to the Indian subcontinent. He has red eyes and a faint, blanching, maculopapular rash. A peripheral smear for malarial parasites is negative and his white cell count and chest X-ray are normal. What is the most likely diagnosis?
A- Malaria
B- Typhoid fever
C- Bubonic plague
D-- Dengue fever
E- Tuberculosis
A 19-year-old female university student presents with fever and headache. On examination she is conscious but has neck stiffness. The cerebrospinal fluid Gram stain shows intracellular Gram-negative diplococci. The most probable diagnosis is?
A- Meningococcal meningitis
B- Haemophilus influenzae meningitis
C- Streptococcus pneumonia meningitis
D- Listeria monocytogenes
E- coli meningitis
A 22-year-old farm worker is admitted to hospital with a 2-day history of headache, fever, severe myalgia and a petechial rash. He is known to suffer from mild asthma, which is well controlled by inhaled steroids. He is jaundiced, has a tachycardia and has not passed urine for over 14 hours. His urea level is raised and liver function tests indicate hepatocellular damage. What is the most likely diagnosis?
A- Brucellosis
B- Weil's disease
C- Lyme disease
D- Rat-bite fever
E- Septicaemic shock
A 31-year-old man has just returned from a holiday to recuperate after the death of his partner. He has been suffering night sweats, a chronic cough and shortness of breath on exercise. Over the past 6 months he has lost a few kilograms in weight and suffered from intermittent diarrhoea. On auscultation the lung fields appear relatively clear. Laboratory testing reveals a relative lymphopenia, with the CD4 lymphocyte subfraction reduced at only 85/ mm3 (normal 200-800). There is desaturation on blood gas monitoring associated with exercise. Other blood tests reveal a raised lactate dehydrogenase level. Chest X-ray reveals diffuse pulmonary infiltrates. What diagnosis fits best with this clinical picture?
A- Tuberculosis
B- Pneumocystis jiroveci pneumonia
C- Histoplasmosis
D- Cryptococcosis
E- Mycoplasma pneumonia
A 45-year-old man of Sudanese origin is admitted with a history of low-grade fever for over 7 days. He migrated to the UK 1 year ago and has a past history of well-controlled asthma. His temperature chart shows that on some days there is a doubled rise in his temperature during 24 hours. Examination shows a massively enlarged spleen and mild hepatomegaly. His full blood count shows a mild microcytic and hypochromic anaemia along with granulocytopenia and thrombocytopenia. Which one of the following investigations will establish a diagnosis?
A- Bone marrow aspirate
B- Widal test
C- Xenodiagnosis
D- Examination of a wet blood film taken at night
E- Blood culture
A 10-year-old boy is complaining of pain in his right leg. He is pyrexial and a diagnosis of osteomyelitis has been made. Which of the following is the most likely pathogen?
A- Streptococcus viridans
B- Staphylococcus aureus
C- Cornybacterium diphtheriae
D- Neisseria meningitides
E- Brucellosis
A 33-year-old man has recently returned from a holiday in Pakistan. He is complaining of episodes of abdominal spasms followed by loose stools containing blood and mucus. Which one of the following pathogens is not likely to be causative of his disorder?
A- Entaemoeba histolytica
B- Shigella dysenteriae
C- Salmonella typhi
D- Campylobacter jejuni
E- Schistosoma mansoni
A 55-year-old man of no fixed address is admitted to the hospital because of self-neglect. A chest X-ray has shown bilateral apical cavitation and hyperinflated lung fields consistent with COPD. Sputum cultures have grown Mycobacterium avium complex (MAC).Which one of the following statements is correct?
A- Patient should be treated with a standard 6 months of anti-tuberculosis drugs
B- Patient should be notified within 1 week of diagnosis
C- Patient should be barrier nursed for 2 weeks
D- This organism is most likely to affect patients with pre-existing lung disease
E- Surgery has no role in management
A 19-year-old athlete was admitted to hospital after having been found wandering around in a confused state. His girlfriend is concerned that his behaviour has been very odd during the day. No illicit drugs are found on him. Clinically, he is disoriented and vague about his history but does admit to headaches. Histemperature is high at 38.3°C. On review by the medical team, his level of consciousness deteriorated, his Glasgow Coma Score (GCS) being 11 out of 15. A CT scan of his head was normal. His CSF was clear, but the opening pressure was raised at 23 cmH2O. His CSF protein concentration was 0.9 g/l and the glucose level was normal. The CSF showed 300 white cells, mainly lymphocytes. No organisms were seen on Gram stain. The results of CSF PCR is awaited. Which one of the following treatments would you start immediately?
A- Intravenous benzylpenicillin
B- Anti-tuberculous therapy
C- Intravenous anti-fungal therapy
D- Intravenous steroid therapy
E- Intravenous aciclovir
A 60-year-old woman is convalescing in hospital following total right knee replacement surgery undertaken three weeks ago. She develops headache, chills and a fever of 39.2°C. On examination the right knee is red, hot and very tender. Synovial fluid aspirate reports the growth of Gram-positive cocci. Which one of the following is the MOST likely organism?
A- Staphylococcus epidermidis
B- Pseudomona aeruginosa
C- Streptococcus pneumoniae
D- Staphylococcus aureus
E- Haemophilus influenzae
A 33-year-old woman has returned from a holiday in Africa. She has been diagnosed as suffering from malaria due to Plasmodium falciparum. Which one of the following statements is FALSE?
A- Following successful treatment, fever recurs due to persistence of the parasite in the liver
B- Cough and mild diarrhoea are a common presentation
C- Splenectomy increases the risk of infection
D- Jaundice is usually due to haemolysis and hepatitis
E- The fever has no particular pattern
A 30-year-old man presents with an acute onset of pain and blurred vision of his right eye. On examination there is conjunctival injection and dendritic ulceration is seen on his cornea.What is the diagnosis?
A- Herpes simplex virus keratitis
B- Foreign body
C- Candida keratitis
D- Trachoma
E- Glaucoma
A 36-year-old woman presents complaining of a yellowish-green vaginal discharge that started 1 week ago. On examination her vagina is swollen and erythematous. What is the most sensitive diagnostic test?
A- Colposcopy
B- Blood cultures
C- Serology
D- Vaginal fluid microspcopy and culture
E- Vaginal pH test
A 36-year-old woman presents complaining of a yellowish-green vaginal discharge that started 1 week ago. On examination her vagina is swollen and erythematous. Given the likely diagnosis, what is the most appropriate treatment?
A- Ampicillin
B- Nystatin
C- Metronidazole
D- Fluconazole
E- Erythromycin
A 25-year-old homosexual man complains of a 9-day history of mucopurulent anal discharge, anal bleeding and pain while opening his bowels. What is the next step in the diagnosis?
A. Colonoscopy
B- Erythrocyte sedimentation rate
C- Stained specimen microscopy
D- Specimen culture
E- C-reactive protein
A 29-year-old homosexual man has been complaining of anal warts for the last 6 months. They have gradually increased in size and he has also noticed some fresh blood when opening his bowels. On examination there are grey lesions, approximately 5 mm in size, around his anus. What is the most likely cause for these lesions?
A- Human papillomavirus
B- Neisseria gonorrhoea
C- Candida albicans
D- Human immunodeficiency virus
E- Chlamydia trachomatis
You are asked to review a 54-year-old asylum seeker from Eastern Europe. He has suffered a cough and weight loss of some 14 kg over the past few months. He admits to occasional night sweats. He is a heavy smoker of some 40 cigarettes per day. Blood testing reveals that he is HIV-positive. Chest X-ray reveals multiple calcified lymph nodes, fibrosis and hilar retraction. Initial sputum culture is unremarkable. What is the most likely diagnosis in this case?
A- Bronchial carcinoma
B- Sarcoidosis
C- Silicosis
D- Pulmonary tuberculosis
E- Histoplasmosis
A 45-year-old business traveller noticed some moderate diarrhoea 3 days after he arrived inKorea. The diarrhoea lasted for 4 days. What is the most likely cause for his diarrhoea?
A- Legionella
B- Staphylococcus
C- Enterotoxic Escherichia coli
D- Giardia lamblia
E- Entamoeba histolytica
A 32-year-old man from Uganda is referred to hospital with a high eosinophil count by his GP following routine blood tests. He is entirely asymptomatic and has no past medical history of note. Which of the following organisms is LEAST likely to be responsible?
A- Strongyloides stercoralis
B- Wuchereria bancrofti
C- Schistosoma mansoni
D- Schistosoma haematobium
E- Entamoeba histolytica
A 29-year-old Catholic priest returns from a trip to Brazil with fevers and deranged LFTs. He has an ALT of 2500 U/l and bilirubin of 75 mmol/l. He attended a travel clinic and was vaccinated prior to travel. He also took mefloquine malaria prophylaxis. What is the most likely diagnosis?
A- Malaria
B- Hepatitis A
C- Hepatitis B
D- Hepatitis E
E- Dengue fever
A 30-year-old man presents with an acute onset of pain and blurred vision of his right eye. On examination there is conjunctival injection and dendritic ulceration is seen on his cornea. Given the likely diagnosis, what is the most important treatment?
A- Topical steroids
B- Topical aciclovir
C- Ampicillin ointment
D- Topical nystatin
E- Oral fluconazole
A young homosexual man contacts his GP complaining of a short episode of lethargy, fever and swollen neck glands. HIV infection is diagnosed. Which is the most likely cell receptor through which the virus infects the body?
A- CD13
B- CD4
C- CD8
D- CD2
E- CD28
A 49-year-old man presents with an episode of acute self-limiting hepatitis. Hepatitis A is diagnosed. What is the most likely mode of transmission?
A- Sexually
B- Blood transfusion
C- Needle-stick injury
D- Contaminated food
E- Mosquitoes
A 46-year-old patient has been chronically infected with the hepatitis B virus for the last 8 years. He has an increased risk of developing which disease?
A- Coronary artery disease
B- COPD
C- Pancreatic cancer
D- Hepatocellular cancer
E- Malignant melanoma
A 33-year-old homosexual patient who is HIV positive but in the stable phase of the disease is best monitored with which biomarker?
A- C-reactive protein
B- CD4 lymphocyte count
C- Erythrocyte sedimentation rate
D- Polymerase chain reaction
E- Blood cultures
An 18-year-old woman has been diagnosed with human papillomavirus infection. What is the most significant long-term risk following this infection?
A- Coronary artery disease
B- Endometriosis
C- Infertility
D- Cervical cancer
E- Carcinoma of the endometrium
A 23-year-old man presents to his GP complaining of fevers, headache, malaise and muscle pain. Shortly after his return to the UKlast week from a walking trip in the United States, he says he used a cigarette to burn off a tick on his leg. On examination he has a rash on the palms and soles of his feet. What diagnosis fits best with this clinical picture?
A- Infectious mononucleosis
B- Rocky Mountain spotted fever
C- Reiter's syndrome
D- Influenza
E- Typhoid fever
What is the cause of myocarditis caused by diphtheria?
A- Hypoxia
B- Superinfection with streptococci
C- Toxins
D- Massive bacteraemia
E- A virus
A 23-year-old woman presents to the Sexual Health Clinic. She had unprotected sex after an office party 4 days ago. She is currently taking antibiotics for a respiratory tract infection. There is intense difficulty passing urine, accompanied by burning, itching and pain over her labia. On examination there is a crop of vesicles with ulceration. What diagnosis fits best with this clinical picture?
A- Syphilis
B- Herpes zoster infection
C- Herpes simplex infection (HSV-1)
D- Herpes simplex infection (HSV-2)
E- Stevens-Johnson syndrome
A 38-year-old man presents some 3 weeks after a stag party weekend in Prague. He has developed a painless ulcer on his penis. You suspect that he may have syphilis. Which of the following percentages is the best estimate of how many untreated syphilis patients go on to develop late-stage CNS or cardiovascular complications?
A- 80%
B- 90%
C- 10%
D- 30%
E- 0%
An HIV-positive patient attends clinic. He is on his first antiretroviral regimen, which includes stavudine, DDI and nevirapine. He is well but complains of wasting of his temporal areas and arms with an increase in the size of his abdomen. You do some screening tests, the results of which are shown below: U&E normal; LFT normal; glucose 7.9 mmol/l; amylase 80 U/l; cholesterol 8.8 mmol/l; TGs 12.7 g/l; FBC normal; CD4 count 870 cells/mm3; HIV viral load < 50 copies/ml. Which advice is the most appropriate?
A- Stop the antiretroviral therapy and start atorvastatin 40 mg
B- Arrange a glucose tolerance test and start atorvastatin 40 mg
C- Switch the stavudine to abacavir and start atorvastatin 40 mg
D- Switch the nevirapine to nelfinavir and start pravastatin 10 mg
E- Switch the stavudine to abacavir and start pravastatin 10 mg
A 45-year-old Christian missionary returned from a tropical assignment in Central America 10 months ago. Since then he has undertaken no foreign travel. He presents with fever, malaise and rigors. On examination he has mild jaundice, liver tenderness and a palpable spleen. Blood testing reveals that he is anaemic. What infective agent fits best with this clinical picture?
A- Plasmodium falciparum
B- Plasmodium malariae
C- Tropical sprue
D- Plasmodium vivax
E- Plasmodium ovale
A 23-year-old man who lives with his male partner consults you for an opinion. He has suffered anal discharge and pruritis for the past 3 days. There are also some symptoms of dysuria. A urethral smear reveals intracellular diplococci. What is the most likely infective agent to fit with this clinical picture?
A- Neisseria gonorrhoeae
B- Chlamydia trachomatis
C- Treponema pallidum
D- Herpes simplex-type 1
E- Herpes simplex-type 2
A 36-year-old woman presents complaining of a yellowish-green vaginal discharge that started 1 week ago. On examination her vagina is swollen and erythematous. What is the most likely diagnosis?
A- Candidiasis
B- Trichomoniasis
C- AIDS
D- Papillomavirus infection
E- Lactobacilli infection
A 19-year-old student presented to his university GP complaining of a severe sore throat, headache and malaise. On examination there was a severe exudative pharyngitis with grossly enlarged inflamed tonsils. There was some evidence of cervical lymphadenopathy. He was diagnosed with a streptococcal infection and received a course of ampicillin. Unfortunately he re-presents to the GP with a maculopapular rash, still feeling unwell. Blood testing reveals a relative lymphocytosis with atypical lymphocytes. What is the most likely cause of this clinical picture?
A- Stevens-Johnson syndrome
B- Epstein-Barr virus (EBV)
C- Toxoplasmosis
D- Cytomegalovirus
E- Streptococcal pharyngitis
A 22-year-old man has returned from a period travelling, during which he visited central/sub-Saharan Africa. He presents to the GP complaining of urinary frequency, perineal itching and inflammation and also of painless haematuria. What diagnosis fits best with this clinical picture?
A- Infection with Schistosoma mansoni
B- Infection with Schistosoma japonicum
C- Infection with Schistosoma haematobium
D- Syphilis
E- Gonorrhoea
A 32-year-old woman has just returned from a holiday in the Middle-East. She had to spend much of the flight in the toilet and has been brought by ambulance from the airport. On admission she is severely dehydrated and gives a history of passing voluminous watery stools that look like rice water, mixed with mucus and blood. Blood testing reveals a raised haemoglobin, markedly raised urea and raised creatinine. Blood glucose is measured at only 3.1 mmol/l (normal 3.0-6.0). What diagnosis fits best with this clinic picture?
A- Cholera
B- Typhoid fever
C- Shigella
D- Salmonella
E- Amoebic dysentery
A 19-year-old student visits you complaining of fevers and headaches over the past week or two. She has just started university after a world tour during her gap-year. There is also complaint of muscle ache, a sore throat, general malaise and of a general lack of appetite and vague abdominal pain. She remembers a short period of diarrhoea a couple of weeks ago. On examination there are a few faint maculopapular blanching lesions on the chest. What diagnosis fits best with this clinical picture?
A- Malaria
B- Tuberculosis
C- Brucellosis
D- Amoebic liver abscess
E- Typhoid fever
A 32-year-old farmer's wife presents with fever and malaise, feeling generally 'washed-out' and off her food. She has recently been helping out with lambing on the farm. On examination there is generalised lymph node swelling and a palpable liver edge. Her white blood cell count is just below the normal range. What diagnosis fits best with this clinical picture?
A- Tuberculosis
B- Subacute bacterial endocarditis
C- Brucellosis
D- Amoebic liver abscess
E- Mixed connective tissue disease
An epidemic of diarrhoea and vomiting has broken out on the elderly care wards. Your catering suppliers assure you that their food is unlikely to be responsible as they follow the strictest hygiene procedures. A total of 15 patients on the ward have become unwell with a sudden onset of diarrhoea and vomiting. Patients infected earlier have recovered with rehydration therapy after about 48 h. Examination of faeces by electron microscopy has revealed circular virus particles with radiating spokes. Which virus is most likely to be responsible for this outbreak?
A- Enteric adenovirus
B- Small, round-structured virus
C- Norwalk virus
D- Astrovirus
E- Rotavirus
A 19-year-old student is admitted directly to emergency after being taken ill on a return flight from Central America. It is understood that he was on the last leg of a round-the-world ticket. His vaccination history is unavailable. He had suffered a flu-like illness around 10 days ago, from which he had recovered. On examination in emergency he is pyrexial at 39.0°C, has extensive bruising, with bleeding around the gum line, and deep jaundice. What diagnosis fits best with this clinical picture?
A- Malaria
B- Influenza
C- Weil's disease
D- Yellow fever
E- Dengue fever
An 18-year-old student presents to his GP with a 1-day history of rash, which has followed a 3-day history of cold-like symptoms and conjunctivitis. The rash began as a maculopapular eruption in the postauricular region, but has rapidly spread to his face and upper body. On examination white papules are visible inside his mouth. What diagnosis fits best with this clinical picture?
A- Scarlet fever
B- German measles
C- Measles
D- Enterovirus infection
E- Adenovirus infection
A 17-year-old young woman is undertaking a summer placement at a nursery school before applying to study medicine. She has received a full programme of childhood vaccinations. Her main complaints are difficulty swallowing, sore throat, malaise and fever. On examination she has 5-10 grey ulcers on her buccal mucosa. There is also a vesicular rash affecting her hands and feet. What is the most likely cause of this clinical picture?
A- Erythema multiforme
B- Herpes simplex infection
C- Gonorrhoea
D- Pemphigus
E- Coxsackievirus infection
An 18-year-old woman complains of malaise, tiredness, headache and abdominal discomfort for the last 3-4 days. She was started on ampicillin 2 days ago and has developed a rash. She has lymphadenopathy and exudative tonsillitis. Her white cell count shows abnormal lymphocytosis. What is the most likely diagnosis
A- German measles
B- Chickenpox
C- Infectious mononucleosis
D- Herpes simplex infection
E- Cytomegalovirus infection
Infection with which virus is the most frequent cause of blindness in patients with AIDS?
A- Herpes simplex virus
B- Varicella zoster virus
C- Epstein-Barr virus
D- Cytomegalovirus
E- Papillomavirus
A 70-year-old man known to have NIDDM was admitted with pain and swelling in the left ear and face. On examination the external ear is red, tender and swollen. There is a small amount of purulent discharge from the external auditory canal with crust covering the skin. The left side of the face is swollen, with tenderness over the left temporal bone. The primary microorganism most probably responsible for this infection is?
A- Pseudomonas aeruginosa
B- Staphylococcus aureus
C- Streptococcus pneumoniae
D- Listeria monocytogenes
E- Haemophilus influenzae
Which one of the following statements is true with regard to Legionnaires' disease?
A- Legionella pneumophila is a Gram-positive rod
B- The urinary antigen test for Legionella species has low sensitivity and is not particularly specific
C- The infection is generally confined to immunocompromised patients
D- The beta-lactam group of drugs are now regarded as the drug of choice against Legionella species
E- Hyponatraemia occurs significantly more often in Legionnaires' disease than in other pneumonias
A 65-year-old man known to have COPD presented with progressive respiratory failure. He was treated in ITU with mechanical ventilation and improved. After extubation he was transferred to the ward. On the second day on the ward, his temperature spiked and he developed a productive cough with a yellow-greenish sputum. Blood results showed leucocytosis. A chest X-ray revealed a right-sided middle and lower lobe pneumonia. What is the most probable cause of his pneumonia?
A- Pneumococcal pneumonia
B- Aspiration pneumonia
C- Pseudomonas pneumonia
D- Staphylococcal pneumonia
E- Haemophilus pneumonia
A 48-year-old woman is admitted with a couple of days' history of fever with rigors and breathlessness. On examination she looks extremely unwell and is confused, cyanosed, has a respiratory rate of 36/min and a systolic blood pressure of 86 mmHg. There is dullnesson percussion and bronchial breathing at her right base. The chest radiograph reveals consolidation. Which of the following would be the most appropriate antibiotic regimen to use?
A- Oral amoxicillin
B- Oral amoxicillin and oral clarithromycin
C- Intravenous cefotaxime and intravenous clarithromycin
D- Intravenous ceftazidime and intravenous vancomycin
E- Intravenous amoxicillin and intravenous clarithromycin
A 46-year-old meat-factory worker is found to have Q fever pneumonia. Which of the following statements is correct?
A- He requires high-dose penicillin for his treatment
B- His occupation is not important for the diagnosis
C- There is no long-term sequel of the disease
D- The organism responsible is Coxiella pneumoniae
E- The organism is usually inhaled from infected dust
A 65-year-old man with severe rheumatoid arthritis (RA) is admitted with a right pleural effusion. He has been complaining of dyspnoea on exertion for the last three months. He has never smoked and has not worked for over 20 years when he was diagnosed to be suffering from rheumatoid arthritis.Which of the following is true?
A- Pleural effusions with rheumatoid arthritis occur in over 50% of patients
B- A glucose level in pleural fluid of < 1.6 mmol/l is characteristic of a rheumatoid pleural effusion
C- Pleural effusions associated with RA have low levels of cholesterol
D- The most appropriate treatment is chemical pleurodesis
E- Bilateral pleural effusions do not occur in RA
Which pulmonary function test may be altered to a similar degree in both restrictive lung disease and obstructive lung disease?
A- Residual volume
B- Tidal volume
C- Total lung capacity
D- Forced expiratory volume in 1 second/forced vital capacity (FEV1/FVC) ratio
E- Forced expiratory volume in 1 second (FEV1)
An 82-year-old man living alone in a bungalow came to the clinic complaining of feeling generally unwell for about the last 3-4 months and of losing about 9.5 kg (21 lbs) in weight during this period. On further enquiry he said he had been having night sweats for the last month. He also has a past history of angina and arthritis and was on medication. On examination he did not look well. He was pyrexic and without lymphadenopathy. Bibasal crepitus on the lower zone was heard on chest auscultation. He had hepatosplenomegaly and clubbing. Investigations showed WBC 12.3 x 106/l (neutrophils 52%, lymphocytes 39%), Hb 9.1 g/dl, with all other routine investigations being normal. A chest X-ray showed 1-2 cm diameter miliary shadows all over the lung field. The Mantoux test was negative. No bacteria grew in a sputum culture.What is the probable cause of the illness and the X-ray finding?
A- Sarcoidosis
B- Mycoplasma pneumonia
C- Staphylococcal pneumonia
D- Miliary tuberculosis
E- Bacterial endocarditis
A 65-year-old man came to clinic with a history of proximal muscle weakness. He has had a cough for 8 weeks. There is associated pain in the small joints of the hands, and has small haemorrhages in the nail folds. He is apyrexic and on examination there is no lymphadenopathy or clubbing. Bibasal crackles can be heard and his chest X-ray reveals diffuse reticular infiltrates. Lung function tests show a restrictive pattern. What is the underlying cause of his interstitial lung disease?
A- Cryptogenic fibrosing alveolitis
B- SLE
C- Ankylosing spondylitis
D- Polymyositis
E- Rheumatoid arthritis
At the time of discharge of a 75-year-old non-smoker, with known COPD, it was decided that, according to the criteria, he should be having long-term oxygen therapy in home. What is not considered as a lone criterium for LTOT among the following options?
A- Arterial blood gas showing pa(O2) 7.5 kPa
B- Cor pulmonale
C- FEV1 < 1.5 litres despite maximal treatment
D- FVC < 2 litres despite maximal treatment
E- Arterial blood gas showing pa(O2) 7.8 kPa with pulmonary hypertension
A 67-year-old woman has been diagnosed as suffering from bronchiectasis on a high-resolution computed tomography (HRCT) scan of the lung. Which one of the following statements is NOT true?
A- She is at risk of developing a pneumothorax
B- She is at risk of developing a brain abscess
C- Massive haemoptysis is the commonest cause of death in her age group
D- Recurrent chest infections are likely at her age
E- Her immunoglobulin levels should be checked
A 32-year-old Black woman presents with a 3-month history of a non-productive cough, dyspnoea and pleuritic chest pain, especially with climbing stairs. She reports intermittent fevers of up to 39°C and a 3.5-kg weight loss. She complains of wrist and ankle pain that has interfered with her work. She smokes two packets of cigarettes per day. Her full blood count is normal and serum ANA is negative. On examination there are red nodules over her lower legs. What is the most likely diagnosis?
A- Goodpasture's syndrome
B- Adenocarcinoma of the lung
C- Systemic lupus erythematosus
D- Sarcoidosis
E- Histoplasmosis
A 24-year-old thin man complains of constant daytime sleepiness. He mentions involuntary naps رغبة في النوم , often in the middle of activity, which occur suddenly and without warning. He also caused an accident when he fell asleep while driving home from work. The patient works as an office manager and has no history of exposure to chemicals. Which of the following treatments would be indicated?
A- Nortriptyline
B- Fluoxetine
C- Diazepam
D- Modafinil
E- Continuous positive airway pressure-breathing device
A patient with small-cell lung cancer has a serum sodium concentration of 121 mmol/l.Which of the following is the most likely cause?
A- Sodium-restricted diet
B- Sodium-reduced water drinking
C- SIADH
D- Liver metastases
E- Bone metastases
As the medical SHO on call you are summoned to A&E to see a 25-year-old man whose condition has suddenly deteriorated. He arrived about 45 minutes earlier with a 2-hour history of central pleuritic-type chest pain and breathlessness. He collapsed while awaiting radiography. He is now agitated and cyanosed. His pulse is 128/min and BP 76/40 mmHg. Oxygen saturation is reading 76% with the patient breathing high-flow oxygen via a re-breathing mask. On respiratory examination you hear reduced breath sounds in the right lung field with deviation of the trachea towards the left. On percussion it is resonant bilaterally. What immediate course of action should you take?
A- Contact the ITU for urgent mechanical ventilation
B- Insert a large-bore needle into the left, second intercostal space
C- Insert a large-bore needle into the right, second intercostal space
D- Check his arterial blood gases and start nebulisation with salbutamol
E- Ask for an urgent portable chest radiograph
The 18-year-old son of an immigrant from Bangladesh who recently came to the UK has been complaining of tiredness, weight loss and generally not feeling well for the last month. He presents to his GP because of haemoptysis, especially in the morning. What is the most likely diagnosis?
A- Pneumothorax
B- Pulmonary embolism
C- Lung cancer
D- Pulmonary tuberculosis
E- Asthma
A 36-year-old primary schoolteacher from the East End of London presents with increasing shortness of breath accompanied by sudden-onset, right-sided pleuritic chest pain. She gives a history of influenza for a few days before this acute presentation and also says she suffered a pulmonary embolus 2 years ago while taking the contraceptive pill and describes her pain as identical to that occasion. On further questioning it transpires that her mother had suffered from recurrent deep vein thrombosis. Arterial blood gases reveal a p(O2) of 7.2 kPa on a re-breather mask, with a p(CO2) of 3.2 kPa. Her chest X-ray reveals a wedge-shaped area of consolidation affecting her right middle and lower lobes. The white blood cell count is normal. Which diagnosis fits best with this clinical picture?
A- Recurrent pulmonary embolism
B- Staphlyoccal pneumonia
C- Pneumothorax
D- Tuberculosis
E- Bronchial carcinoma
A patient with tuberculosis was initially treated with streptomycin, which was later changed to a combination of isoniazid, rifampicin, pyrazinamide and ethambutol. Abnormal liver functions are noted on this, his follow-up, visit. Which drug is most likely to be responsible?
A- Streptomycin
B- Ethambutol
C- Rifampicin
D- Pyrazinamide
E- Isoniazid
Which is the most common malignant neoplasm of the lung?
A- Carcinoid tumour
B- Squamous-cell carcinoma of the bronchus
C- Metastatic carcinoma
D- Adenocarcinoma of the bronchus
E- Oat-cell carcinoma
A patient with cystic fibrosis presents with a severe bronchopneumonia. What is the most likely pathogen?
A- Streptococcus pyogenes
B- Streptococcus pneumoniae
C- Pseudomonas aeruginosa
D- Klebsiella pneumoniae
E- An atypical Mycobacteria sp
A 16-year-old girl presents to A&E with a severe asthma attack.What is the most important therapy to relieve her bronchoconstriction?
A- Propranolol
B- Salbutamol
C- Oxygen
D- Glucocorticosteroids
E- Cromoglycate
A 36-year-old lorry driver who smokes heavily presents with a 2-day history of coughassociated with fever. He also complains of right-sided chest pain on inspiration. On examination he is slightly cyanosed. His temperature is 38°C, respiratory rate 38/min, BP 100/70 mmHg and pulse 130/min. He has basal crepitations and dullness to percussion at the right lung base. What is the most important next step in confirming the diagnosis?
A- ESR (Erythrocyte sedimentation rate)
B- d-Dimer
C- Chest X-ray
D- Sputum sample
E- Blood cultures
A 33-year-old man is found to have strongly positive aspergillus precipitins in his blood and complains of a cough with intermittent bloody sputum. He has a business working as a builder, particularly involved in renovating farm houses and barns. What is the most likely diagnosis?
A- Allergic bronchopulmonary aspergillosis (ABPA)
B- Colonising aspergillosis
C- Invasive aspergillosis
D- Asperger's syndrome
E- Type I hypersensitivity to Aspergillus fumigatus
A 30-year-old asthmatic patient has the following drug regimen: regular inhaled corticosteroids, regular inhaled long-acting b 2-agonists (salmeterol) and inhaled short-acting b 2-agonists when required. Although her compliance is good, her symptoms are still not satisfactorily controlled. What is the next step in her therapy?
A- Antibiotics
B- Salbutamol nebuliser
C- Oral steroids
D- Oral cromoglycate
E- Oral leukotriene-receptor antagonists
A 30-year-old asthmatic patient has the following drug regimen: regular inhaled corticosteroids, regular inhaled long-acting b 2-agonists (salmeterol), oral leukotriene-receptor antagonists and inhaled short-acting b 2-agonists when required. Although her compliance is good, her symptoms are still not satisfactorily controlled. What is the next step in her therapy?
A- Oral steroids
B- Antibiotics
C- Switch to nebuliser
D- Oral cromoglycate
E- Oral theophylline
A 24-year-old woman is brought to casualty with thorax injuries after a road traffic accident. Her chest X-ray shows multiple rib fractures and a right-sided shadow suggestive of a haemothorax. What is the next step in her management?
A- Blood transfusion
B- Intubation and ventilation
C- CT thorax
D- Intercostal drain insertion
E- Surgical referral for thoracotomy
A 30-year-old shepherd presents with a 1-week history of headaches, rhinitis and pharyngitis associated with high fever and you elicit a systolic murmur on examination. Three days ago he noticed a painful cough and blood-stained phlegm. What is the most likely diagnosis?
A- Tuberculosis
B- Borreliosis
C- Brucellosis
D- Q-fever
E- Pulmonary embolism
A 69-year-old former coal-miner is referred to you by the on-call team. There is a smoking history and he has been managed by his GP for COPD. He has been admitted with dyspnoea that is now so bad that he is unable to manage at home and cannot walk from the chair to the bathroom. There is a cough productive of black sputum. Lung function tests show a mixed restrictive and obstructive picture. A chest X-ray shows marked changes with massive fibrotic masses predominantly in the upper lobes. There are also changes consistent with lung destruction and emphysema. His rheumatoid factor is positive. Which diagnosis fits best with this clinical picture?
A- Progressive Massive Fibrosis (PMF)
B- Chronic obstructive pulmonary disease
C- Tuberculosis
D- Asthma
E- Category 1 pneumoconiosis
A 29-year-old office secretary has been suffering from intermittent pain and tenderness affecting her elbows, wrist and ankles for last 2 years. Symptomatic relief had being obtained from NSAIDs. For last 3 months she has been increasingly unwell, and with night sweats, fever and a weight loss of about 6.4 kg (14 lbs). She also developed a non-productive cough and left-sided pleuritic chest pain. She smoked 30 cigarettes per day. On examination she had temperature of 37.8°C. The syno vium was palpable over her wrist joints. On respiratory examination her left lower zone was dull to percussion with decreased breath sounds. A chest X-ray confirmed a left-sided pleural effusion in addition to some fibrotic patches on both the upper zones. Aspiration showed a straw-coloured fluid with a protein concentration of 46 g/l and a glucose concentration of 1.6 mmol/l. The fluid contained many lymphocytes but no malignant cells. A culture was sterile on the fifth day. What is the probable cause of the pleural effusion?
A- Sarcoidosis
B- Rheumatoid pleural effusion
C- Tuberculosis
D- Pleural effusion secondary to lung malignancy
E- Lymphoma
A 33-year-old HIV-positive man presents for review. He is poorly compliant with antiretroviral therapy and his recent CD4 count is only 90/ml blood. He complains of a gradual-onset headache, fever, malaise, night sweats and a cough associated with haemoptysis. He is emaciated. On examination there is widespread lymphadenopathy, there are crackles and wheeze on auscultation of his chest, and tenderness over the liver edge. Blood testing reveals a normochromic normocytic anaemia, he has a low white count, urea and creatinine levels are raised and liver function tests are abnormal. Sputum samples reveal acid- and alcohol-fast bacilli (AFB). Chest X-ray reveals calcified lymph nodes, cavitation and areas of lung fibrosis and hilar retraction. Which diagnosis fits best with this clinical picture?
A- Primary pulmonary tuberculosis
B- Miliary tuberculosis
C- Bacterial pneumonia
D- Pulmonary fibrosis
E- Bronchial carcinoma
A 56-year-old man has a chest X-ray performed as he has become breathless on exertion and has inspiratory crackles. The chest X-ray reveals upper lobe lung fibrosis. Which of the following is the most likely explanation?
A- Cryptogenic fibrosing alveolitis
B- Langerhans' cell histiocytosis
C- Asbestosis
D- Connective tissue fibrosing alveolitis
E- Drug-induced pulmonary fibrosis
A 30-year-old woman presents with shortness of breath. This began gradually, around 2.5 years ago, but now she is breathless on climbing a flight of stairs. There is no past history of note. On examination the JVP is raised, carotid pulse volume is reduced and there is evidence of right ventricular hypertrophy. There are right-sided murmurs on cardiac auscultation. Her chest X-ray shows pulmonary artery enlargement, ECG shows right axis deviation and right ventricular hypertrophy. Arterial blood gases reveal hypoxia and hypercapnia, a lung perfusion scan is normal. Cardiac catheterisation reveals that right-sided pressures are markedly raised. Which diagnosis best fits with this clinical picture?
A- Chronic thromboembolic disease
B- Right ventricular failure
C- Primary pulmonary hypertension (PPH)
D- Cryptogenic fibrosing alveolitis
E- Asthma
A 58-year-old memorial stonemason presents to the chest clinic. Over the past few years he has noted a gradual increase in shortness of breath, with cough and occasional wheeze. He is a non-smoker and has no other past history of note. His chest X-ray is abnormal with small rounded opacities and irregular upper zone fibrosis. There is hilar lymphadenopathy with 'eggshell' calcification. Pulmonary function testing reveals a restrictive picture and there is mild hypoxia. Which diagnosis best fits with this clinical picture?
A- Silicosis
B- Asthma
C- Idiopathic pulmonary fibrosis
D- Tuberculosis
E- Byssinosis
A 67-year-old patient with lung cancer complains of a cough and has difficulty breathing. He has swelling of his face, neck, upper body and arms. What is the most likely diagnosis?
A- Side-effects from radiotherapy
B- Allergic reaction
C- Superior vena cava syndrome
D- Side-effect from chemotherapy
E- Acute myocardial infarction
A 42-year-old cotton worker from Southern India is staying with her brother in London . While here, they pay for a private medical consultation. She reports what sounds like a work-related illness. During the first hour at work after the weekend she reports severe shortness of breath, cough and chest tightness, this appears to gradually ease during the week, only to return after the next weekend off. Which diagnosis best fits this clinical picture?
A- Occupational asthma
B- Chronic obstructive pulmonary disease
C- Byssinosis
D- Berylliosis
E. Function shortness of breath
A 50-year-old woman patient presents with increasing dyspnoea. She is obese, smokes and takes oestrogens for menopausal symptoms. On examination you find clinical, electrocardial and radiological findings of aright-sided heart failure without signs of left ventricular failure. What is the most likely cause for the cor pulmonale?
A- Asthma
B- Recurrent pneumonias
C- Recurrent small pulmonary embolisms
D- Bronchiectasis
E- Carcinoma of the lung
A 38-year-old woman presents with recurrent chest infections. For some time she has noticed that her nails are yellow and misshapen and that she often has oedematous legs after standing all day in the shop where she works. Examination reveals evidence of lower lobe consolidation and possible pleural effusion. This is confirmed on chest X-ray. Her nails are very abnormal, thickened and yellow and she has bilateral lymphoedema affecting her legs. Which diagnosis fits best with this clinical picture?
A- Bronchiectasis
B- Asthma
C- Underlying bronchial carcinoma
D- COPD
E- Yellow-nail Syndrome
A patient with small-cell lung cancer has a serum sodium concentration of 121 mmol/l. The patient is asymptomatic. What is the most appropriate therapy?
A- Fluid restriction
B- Glucocorticoids
C- Start chemotherapy
D- Start radiotherapy
E- Hypertonic fluid infusion
A 26-year-old man presents with fever, headache and a non-productive cough. The chest X-ray shows increased interstitialmarkings. The laboratory examination shows an elevated LDH and anaemia with the presence of cold agglutinins. What is the most appropriate treatment?
A- Erythromycin
B- Piperacillin
C- Clindamycin
D- Ampicillin
E- Imipenem
A 37-year-old man who speaks little English comes to the TB clinic. His notes are missing but he is able to tell you that he has been on treatment for almost 1 year. What is the most likely reason he has been treated for this length of time?
A- Pulmonary TB
B- Lymph-node TB
C- TB meningitis
D- Bony TB
E- Pleural TB
A morbidly obese 36 year-old man presents for review. His main reason for attendance is that his wife is concerned about his loud snoring and the fact that he stops breathing during the night for periods of up to 8-10 seconds, followed by coughing, snoring and arousal. Recently he has become hypertensiveand is also on treatment for impotence. His 24-h urinary free cortisol level is normal. Which diagnosis best fits this picture?
A- Cushing's disease
B- Obstructive sleep apnoea
C- Simple snoring
D- Simple obesity
E- Essential hypertension
An adolescent girl has chronic cough and recurrent respiratory infections over the past two to three years. Which one of the following pieces of clinical information in her history would point most strongly to the development of bronchiectasis?
A- Pale stools and low weight
B- History of wheeze
C- Previous whooping cough in early childhood
D- Serum precipitins to Aspergillus fumigatus
E- Pepperpot calcification on chest X-ray (CXR)
A 64-year-old mechanic and lifelong smoker noticed haemoptysis a few days after he had a cold. Clinical examination is unremarkable. His chest X-ray shows bilateral hilar enlargement and mediastinal widening. What is the next step in obtaining the diagnosis?
A- CT thorax
B- Bronchoscopy
C- Ventilation-perfusion scan
D- Sputum sample
E- d-Dimer
A 65-year-old patient with new-onset chronic obstructive pulmonary disease (COPD) asks you about his prognosis. Which of the following single tests is the most important predictor of survival in patients with COPD?
A- Blood gases
B- Chest X-ray
C- FEV1
D- Exercise tolerance
E- ECG
Which treatment improves the long-term prognosis in patients with chronic obstructive pulmonary disease (COPD)?
A- Inhaled steroids
B- Oral steroids
C- Inhaled b2-agonists
D- Long-term domiciliary oxygen therapy
E- Theophylline
A 16-year-old boy is brought to casualty after a fire in his parents' house. He inhaled a lot of smoke and has a hoarse voice, stridor and burned nasal hairs. Due to deterioration in his peak flow rate and arterial blood gases, he has been intubated, ventilated and transferred to the intensive care unit where his condition is now stable. In terms of investigation, what is the most important next step in assessing this boy's condition?
A- CT thorax
B- Chest X-ray
C- Bronchoscopy
D- Ventilation-perfusion scan
E- Echocardiography
A 21-year-old man presents with episodic pain in his buttocks, low back pain and stiffness that is worst in the mornings. A lateral X-ray of his lower spine shows blurring of the upper and lower vertebral rims at the thoracolumbar junction. He is found to be HLA-B27-positive. Given the likely diagnosis, what would be the most appropriate treatment for him?
A- Aspirin
B- Prednisolone
C- Diclofenac
D- Physiotherapy
E- Dextropropoxyphene
A 10-year-old girl presents with a high fever, rash and hip and knee joint pains. A slit-lamp examination of her eyes is normal. Blood tests are negative for autoantibodies. What is the most likely diagnosis?
A- Persistent oligoarthritis
B- Still's disease
C- Polyarticular arthritis
D- Enthesitis-related arthritis
E- Henoch-Schönlein purpura
A 73-year-old woman complains of dry, gritty eyes, a constant sensation of mouth drynessand swollen parotid glands. You suspect that she has Sjögren's syndrome. Which of the following tests is not likely to help in establishing the diagnosis?
A- Serum antibody to Ro antigen
B- Lymph node biopsy
C- Schirmer's test
D- Labial biopsy
E- Magnetic resonance imaging of the parotid gland
A 55-year-old man presents with bowed legs, low back pain and increasing deafness over the past 6 months. His father was similarly affected at 60 years of age and died of bone cancer. Given the likely clinical diagnosis, what would be the most characteristic finding in a blood test?
A- Decreased serum calcium levels
B- Elevated serum phosphate
C- Elevated serum alkaline phosphatase
D- Elevated ESR
E- Decreased 1,25-dihydroxycholecalciferol
A 62-year-old woman is being treated for a pathological fracture of her right femur. An X-ray of the femur shows patchy sclerosis, thickening of the trabeculae and dedifferentiation. Given the likely diagnosis, what treatment would be most appropriate for her?
A- Calcium supplements
B- Calcitonin
C- Hormone replacement therapy
D- Tiludronate
E- Raloxifene
A 65-year-old woman being treated for epilepsy presents with bone pain and muscle weakness. Blood tests show increased serum alkaline phosphatase, normal plasma calcium and low serum phosphate levels. An X-ray of the femur reveals linear areas of low density surrounded by sclerotic borders. What is the most likely diagnosis?
A- Osteoporosis
B- Osteomalacia
C- Paget's disease
D- Osteosarcoma
E- Polymyalgia rheumatica
A 35-year-old man presents with abdominal pain, joint pains, fever and weight loss. He gives a history of passing bulky, malodorous stools over the past month that are difficult to flush away. A biopsy of the small bowel shows stunted villi with PAS (Periodic acid-Schiff)-positive macrophages. What is a characteristic finding in this condition?
A- Occult blood in stools
B- The presence of bacilli within macrophages on electron microscopy
C- Mesenteric thickening with lymph node enlargement on CT scan
D- Positive HLA-B27
E- Bony erosions and subluxation of joints on X-ray of affected joints
A 46-year-old woman with a history of duodenal ulcer has developed progressively worsening pain, swelling and stiffness of her metacarpophalangeal, distal interphalangeal and wrist joints. On examination there is wasting of the muscles of the hand and limited movement of the joints. Given the most likely diagnosis, which drug would be most appropriate for her condition?
A- Prednisolone
B- Sulfasalazine
C- Ibuprofen
D- Aspirin
E- Diclofenac
A 27-year-old woman is referred to the rheumatology clinic by her gynaecologist with a history of swelling and pain in her right big toe and left knee. The only positive finding on gynaecological examination was the presence of cervicitis. An endocervical swab tested positive for chlamydial infection. What is the most probable diagnosis in this case?
A- Acute gouty arthritis
B- Rheumatoid arthritis
C- Reactive arthritis
D- Septic arthritis
E- Gonococcal arthritis
A 30-year-old woman presents with severe scaly, erythematous lesions all over her body. She has also developed swelling and severe pain in her distal interphalangeal joints. Given the diagnosis of psoriasis, what treatment is likely to be most suitable for her?
A- Topical corticosteroids
B- Diclofenac
C- Coal tar
D- Long-wave ultraviolet radiation (psoralen ultraviolet A; PUVA)
E- Methotrexate
A 22-year-old homosexual man gives a history of high-grade fever associated with pustules on his hands and severe joint pain 4 weeks ago. His left knee is now swollen and red. Cultures from blood and joint aspirate are negative. Urethral discharge shows the presence of gonococci. He has a history of penicillin sensitivity. Which drug would be most suitable in this condition?
A- Oral penicillin
B- Amoxicillin
C- Prednisolone
D- Erythromycin
E- Ciprofloxacin
A 47-year-old woman presents with an inability to raise her arms over her shoulders. Over the past few weeks she has also been having difficulty swallowing food. Onexamination there is muscle wasting and the muscles are tender with reduced tendon reflexes. Her serum creatine kinase is elevated. What is the most likely diagnosis?
A- Polymyalgia rheumatica
B- Polymyositis
C- Hypocalcaemia
D- Painful arc syndrome
E- Frozen shoulder
A 73-year-old man presents with severe back pain. An X-ray shows the presence of osteolytic lesions in his vertebrae and pelvis. He also complains of malaise but no other symptoms of note.Based on the clinical findings and radiology, what is the most probable diagnosis?
A- Paget's disease of bone
B- Prostatic carcinoma
C- Multiple myeloma
D- Hypocalcaemia
E- Chronic myeloid leukaemia
A 65-year-old woman with a past medical history of osteoarthritis only affecting her hand joints and diet-controlled diabetes mellitus complains of a sudden onset of pain, swelling and stiffness in her right knee. Examination shows that the right knee is swollen, erythematous and tender. Which of the following tests is most likely to lead to a diagnosis?
A- X-ray of the knee
B- Autoimmune screen
C- Serum uric acid level
D- Aspiration and examination of the synovial fluid
E- A trial of colchicine
A 28-year-old man presents to the clinic with painful knees and ankles. He is noted to have a rash on the glans penis. He has a history of urethritis due to Chlamydia trachomatis . He has also recently attended the ophthalmology department for an episode of uveitis. What is the most likely diagnosis?
A- Reiter's syndrome
B- Reactive arthritis
C- Gouty arthritis
D- Septic arthritis
E- Rheumatoid arthritis
A 35-year-old woman is diagnosed with systemic lupus erythematosus. What is the most common finding on blood testing that would be of help in supporting your clinical findings?
A- Anti double-stranded DNA
B- Rheumatoid factor
C- VDRL-positive
D- Low complement levels
E- Anticardiolipin antibody
A 65-year-old woman presents with severe pain and stiffness of her shoulders and neckthat is worse in the mornings and lasts for more than an hour. Physical examination is unremarkable. Blood tests show a mild normocytic normochromic anaemia. Her ESR is 77 mm/1st hour. What is the most likely diagnosis?
A- Polymyalgia rheumatica
B- Polymyositis
C- Hypocalcaemia
D- Painful arc syndrome
E- Frozen shoulder
A 58-year-old woman complains of severe unilateral temporal headaches and jaw pain when eating. A provisional diagnosis of giant-cell arteritis is made.Which of the following is a characteristic clinical feature of this condition?
A- All peripheral arteries are involved
A- All peripheral arteries are involved
C- Negative temporal artery biopsy excludes the disorder
D- Treatment is monitored by measuring CRP levels
E- NSAID treatment is an effective first line of management
A 45-year-old man presents with fever, malaise, weight loss and myalgia over the past month. You suspect polyarteritis nodosa and arrange to perform some blood tests. Which abnormality might you most expect to find?
A- Elevated creatinine
B- Anaemia
C- Leucopenia
D- Thrombocytosis
E- Positive ANCA
A young African-American woman is diagnosed as having systemic lupus erythematosus. What is the characteristic epidemiological feature of this condition?
A- It is about twice as common in women than in men
B- The highest incidence is amongst Caucasian women
C- The age of onset is usually over 40 years
D- It is associated with HLA-B8 and -DR3 in Caucasians
E- First-degree relatives have a 25% chance of developing the disease
A middle-aged man with red scaly patches on his elbows and knees presents with pain in the distal interphalangeal joints. You suspect psoriatic arthritis. Which of the following features is most strongly linked in men to this condition?
A- Age of onset 20-30 years
B- Occurrence of arthropathy at the same time as the skin lesions
C- Minimal destruction of cartilage and bone
D- Involvement mainly of the distal interphalangeal joints
E- Occurrence of Bouchard's nodes in the proximal interphalangeal joints
A 39-year-old woman complains of swelling, stiffness and pain in her fingers. She also tells her doctor that in winter her fingers often turn dark in colour. Her autoimmune screen shows the presence of anticentromere antibody. Which of the following is she most likely to have?
A- Rheumatoid arthritis
B- Systemic lupus erythematosus
C- Pseudogout
D- Polyarteritis nodosa
E- CREST variant of scleroderma
A 62-year-old woman presents with severe pain and stiffness in her shoulder muscles and pelvis for the past 3 weeks that is worse in the mornings. Her ESR is raised. What is the most likely diagnosis?
A- Polymyalgia rheumatica
B- Polymyositis
C- Pseudogout
D- Psoriatic arthritis
E- Rheumatoid arthritis
A 50-year-old diabetic woman with a history of osteoarthritis of her knees suddenly develops pain and swelling in her right knee. On examination the knee is red, hot, swollen and very tender. Which investigation would be most helpful in the management of this case?
A- Plain X-ray of the knee
B- Joint aspiration and Gram-staining
C- Joint fluid microscopy
D- Blood culture
E- Joint aspiration and culture
A 22-year-old woman presents with red scaly plaques on her elbows, knees, lower back and scalp. She also has pitting and yellow-brown discoloration of her nails and painful deformed finger and toe joints. Given the likely clinical diagnosis, what would be the most appropriate treatment, taking current UK guidelines into account?
A- NSAIDs
B- Sulfasalazine
C- Methotrexate
D- Corticosteroids
E- Etanercept
A 20-year-old man presents with a raised red and scaly lesion on his glans penis, red discolouration and pain in both eyes and pain and swelling of his right knee. Over the past few days he has noticed painless red plaques on his hands and feet. A diagnosis of Reiter's syndrome is suspected. Which additional clinical feature would best support this diagnosis?
A- History of a flu-like illness 4-6 weeks prior to symptoms
B- Presence of keratoderma blenorrhagica
C- Family history of ulcerative colitis
D- Positive gonococcal culture of urethral discharge
E- Arthritis affecting the upper limb joints
A 75-year-old woman presents with chronic back pain. An X-ray of the spine shows vertebral crush fractures and evidence of osteoporosis.Which of the following blood results would be most in keeping with this diagnosis?
A- Low calcium levels
B- Elevated phosphate levels
C- Normal or high alkaline phosphatase levels
D- Decreased 1,25-dihydroxycholecalciferol levels
E- Raised parathyroid hormone levels
A 25-year-old mechanic complains of stiffness and low back pain that is worse in the mornings. He is HLA-B27-positive. A provisional diagnosis of ankylosing spondylitis is made. What would be the most characteristic finding on an X-ray of the lower spine?
A- Narrowing of disc space
B- Erosion of the apophyseal joints
C- Osteophyte formation
D- Spondylolisthesis
E- Osteoporosis of trabecular bone
A 22-year-old college student complains of stiffness and low back pain that is worse in the mornings. An X-ray shows obliteration of the sacroiliac joints. Given the likely clinical diagnosis, what would be the most appropriate treatment for him?
A- Spinal osteotomy
B- Aspirin
C- Bedrest and immobilisation
D- Prednisolone
E- Spinal extension exercises
A 55-year-old woman on procainamide develops drug-induced lupus erythematosus. What is the most characteristic clinical feature of this condition?
A- It may occur with chlorpromazine
B- It commonly involves the kidneys
C- It rarely causes pulmonary disease
D- The symptoms may be alleviated with long-term steroids
E- It does not occur with isoniazid
A 79-year-old woman who drinks 30 units of alcohol per week presents with a red, hot swollen ankle. Which investigation may yield a definitive diagnosis?
A- Blood culture
B- Joint aspiration and microscopy
C- Joint aspiration and culture
D- X-ray of the ankle
E- Serum uric acid levels
A 4-year-old girl with a 1-day history of increasing hip pain is unable to stand. Her WCC is 20 x 109 /l, ESR 90 mm/1st h and CRP 275 mg/l. A radiograph of the hip shows a widened joint space. What is the most likely diagnosis?
A- Perthe's disease
B- Slipped upper femoral epiphysis
C- Septic arthritis
D- Congenital dislocation of hip
E- Osteomyelitis
A 5-year-old Asian boy, who has been having episodes of fever and a persistent cough for the past 3 weeks, now complains of right hip pain. Blood tests show: WCC 19 x 109 /l, ESR 110 mm/1st h and CRP 102 mg/l. An X-ray of the hip joint shows diffuse rarefaction. What is the most likely diagnosis?
A- Septic arthritis
B- Tuberculous arthritis
C- Osteomyelitis
D- Reactive arthritis
E- Juvenile rheumatoid arthritis
A 65-year-old woman who lives alone complains of increasing pain in her left knee and episodes of the joint 'giving way'. She is no longer able to climb stairs. Valgus deformity with instability is also noted. What treatment would be most appropriate for her?
A- Oral NSAIDs
B- Intra-articular steroid injections
C- Joint replacement
D- Physiotherapy
E- Hormone replacement therapy
A 22-year-old man who suffers from inflammatory bowel disease has developed pain and stiffness in his lower back over the past 6 months. Examination reveals tenderness over both sacroiliac joints. He tests positive for the HLA-B27 gene. What is the most probable diagnosis?
A- Prolapsed intervertebral disc
B- Rheumatoid arthritis
C- Ankylosing spondylitis
D- Osteoarthritis
E- Enteropathic arthritis
A 72-year-old man with heart disease is on diuretics. He complains of stiff, painful hands and knees.On examination Heberden's nodes are seen. What is the most appropriate treatment?
A- Regular paracetamol
B- Allopurinol
C- Oral NSAIDs with gastric protection
D- Knee replacement
E- Joint aspiration and microscopy
A 35-year-old woman complains of bilateral stiff and painful joints in her hands and feet for the past 3 months. The stiffness lasts for more than an hour in the mornings. On examination her fingers are swollen and stiff. Movement is painful. Which test would be most relevant in this case?
A- X-ray of the hands and feet
B- Serum uric acid levels
C- Joint aspirate for crystals
D- CRP levels
E- Plasma rheumatoid factor
A 65-year-old diabetic woman on indometacin and glibenclamide has had a blood test that shows evidence of renal failure, hyperkalaemia and hyperchloraemia. What is the most likely underlying cause of her biochemical abnormalities?
A- Acute interstitial nephritis
B- Renal artery stenosis
C- Diabetic nephropathy
D- Minimal-change nephropathy
E- Renal tubular acidosis
A 74-year-old man has an acutely painful, red and swollen knee. He is suffering from congestive cardiac failure, chronic renal impairment and is currently on digoxin and furosemide. What treatment would be most suitable for the symptomatic relief of his joint pain?
A- Aspirin
B- Paracetamol
C- Colchicine
D- Diclofenac
E- Indometacin
A 57-year-old man with longstanding osteoarthritis of his right hip is seen in the clinic prior to admission for hip replacement. He has a history of peptic ulcer and is on lansoprazole. Which anticoagulant formulation would offer him the best protection against postoperative thrombosis?
A- Subcutaneous low molecular weight heparin
B- Subcutaneous unfractionated heparin
C- Warfarin
D- Intravenous heparin
E- Low-dose aspirin
A 12-year-old girl complains of pain in her hip and knee joints, as well as fever, bloody diarrhoea and abdominal pain. A barium enema shows rose-thorn ulcers. What is the most characteristic feature seen on colonoscopy in this condition?
A- Red-raw mucosa
A- Red-raw mucosa
C- Discrete ulcers
D- Colonic dilatation
E- Diverticula
A 67-year-old man known to be hypothyroid says he woke up in the morning with a painful, warm, red and swollen right knee. An X-ray of his knee shows calcification of the meniscus only. What is the most likely diagnosis?
A- Acute gout
B- Osteoarthritis
C- Rheumatoid arthritis
D- Pyrophosphate arthropathy
E- Septic arthritis
A 37-year-old gym instructor gives a 2-year history of numbness and burning of his fingers precipitated by cold. He now feels tightness in the fingers and is unable to extend his fingers completely. He also complains of a progressive difficulty in swallowing food. You suspect limited cutaneous scleroderma. Which of the following blood investigations would most aid in the diagnosis?
A- Normocytic normochromic anaemia
B- Microangiopathic haemolytic anaemia
C- Anticentromere antibodies
D- Antinuclear antibodies
E- Rheumatoid factor
A 20-year-old college student complains of increasing back pain and early morning stiffness. An X-ray of his lower back shows erosion of the apophyseal joints and obliteration of the sacroiliac junction. Given the most likely clinical diagnosis from these findings, what treatment would be most suitable for him?
A- Oral NSAIDs
B- Colchicine
C- Intra-articular steroid injections
D- Spinal osteotomy
E- Bedrest and immobilisation
A 62-year-old woman complains of general lethargy, morning stiffness, inability to comb her hair because of arm pain. There is no muscle tenderness. Her ESR is 57 mm/1st h.Electromyography of the deltoid muscle is normal. What is the most likely diagnosis?
A- Guillain-Barrè syndrome
B- Polymyositis
C- Polymyalgia rheumatica
D- Multiple sclerosis
E- Fibromyalgia
A 45-year-old woman with rheumatoid arthritis presents with leg ulcers and swollen neck glands. A diagnosis of Felty's syndrome is made. Which typical finding on blood testing would you expect to find in her case?
A- Positive Coombs' test
B- Normocytic normochromic anaemia
C- Lymphocytosis
D- Reticulocytosis
E- High platelet count
A 65-year-old woman presents a 1-month history of weakness in the hip region and inability to walk or get up from a chair. On examination there is wasting of the pelvic girdle muscles. She has also developed a purple discolouration of the eyelids. You suspect adult dermatomyositis. Which of the following investigations will be most helpful in the diagnosis and management of this condition?
A- A raised ESR
B- Presence of rheumatoid factor
C- Presence of antinuclear antibody
D- Myositis-specific antibodies
E- Raised serum creatine phosphokinase
A 20-year-old football player presents with a swollen left knee and locking. He complains of pain after exercise. On examination wasting over the quadriceps and lateral aspect of the joint are noted. Arthroscopy of the joint reveals three loose bodies in the synovial cavity. What is the most likely diagnosis?
A- Chip fractures of the joint surfaces
B- Osteoarthritis
C- Synovial chondromatosis
D- Osteochondritis dissecans
E- Semi-lunar cartilage tear
A 24-year-old man suddenly develops severe back pain while lifting some luggage. He is unable to straighten up and subsequently develops numbness and weakness in his left leg followed by retention of urine. He is unable to move his toes. Given the likely clinical diagnosis, which plan of management is likely to be required?
A- Lumbar traction
B- NSAIDs
C- Extension exercises
D- Bedrest
E- Laminectomy and fusion
A 70-year-old man became wheezy while walking uphill, and tripped hitting his left eye. He now complains of pain in this eye; the cornea is hazy, the globe feels very firm to palpation and there is a hyphaema obscuring most of the iris. Which of the following is the most appropriate treatment?
A- Examination under anaesthesia
B- Topical β-blockers
C- Intravenous carbonic anhydrase inhibitors
D- Topical anticholinergics
E- Anterior chamber paracentesis
A 60-year-old diabetic complains of floaters of 24 hours' duration, followed by a sudden painless loss of vision in his right eye. His corrected visual acuities are 6/60 (right eye) and 6/12 (left eye). His right retina cannot be visualised, and the left retina contains scattered pigmented spots in the periphery. What is the most appropriate management plan?
A- Stop daily aspirin
B- Admit for laser treatment within 48 hours
C- Observe and review in ophthalmology out-patients
D- Prescribe oral acetazolamide
E- Admit for retinal reattachment surgery
What is the typical opthalmological finding in patients with subacute bacterial endocarditis?
A- Cherry red macula
B- Janeway lesion
C- Macular star
D- Retinal artery aneurysms
E- Roth's spots
A teenager is referred from his optician with a diagnosis of Lisch nodules of the iris. What is the most likely sign to observe on examination?
A- Ash-leaf spots on the trunk
B- Axillary freckles
C- Ectopia lentis
D- Haemangioblastoma of the spinal cord
E- Haemorrhagic telangiectasia of the skin and buccal mucosa
A 68-year-old man presents to his GP with a one-week history of blurred vision affecting his left eye. On examination, his visual acuities are 6/6 right eye and 6/18 left eye. No papillary defect is noted. Dilated fundal examination reveals evidence of widespread retinal haemorrhages in all quadrants of the left retina associated with dilated tortuous retinal veins. The right fundus appears entirely normal. The patient has not seen his GP within the last ten years. He describes himself as fit and well and on no regular medication. However, a subsequent examination reveals a blood pressure of 185/100 and a random blood sugar of 12 mmol/L. Which of the following is the most likely ocular diagnosis?
A- Branch retinal vein occlusion
B- Central retinal vein occlusion
C- Hypertensive retinopathy
D- Diabetic retinopathy
E- Ocular ischaemic syndrome
A 25-year-old woman presents with loss of weight, gritty eyes and double vision on looking up. Which of the following is the most important investigation?
A- CT brain
B- Exophthalmometry
C- Formal perimetry
D- Hess chart
E- Schirmer's test
A 25-year-old man develops cirrhosis of the liver and is referred from the gastroenterology clinic to the ophthalmology clinic for evidence of Wilson's disease. What should the gastroenterologist ask the ophthalmologist to look for?
A- Corneal arcus
B- Hudson-Stahli lines
C- Kayser-Fleischer rings
D- Cornea verticillata
E- Band keratopathy
A 45-year-old woman is found by her optometrist to have band keratopathy and is referred to the eye clinic. Which of the following investigations is likely to be helpful in determining an underlying cause?
A- Cholesterol
B- Ferritin
C- U&E
D- Gamma GT
E- Serum calcium
A patient with diabetic retinopathy is treated with panretinal photocoagulation in the eye clinic and followed up in the diabetic clinic. Which of the following features found 6 months after treatment is an indication for further laser treatment?
A- Visual field constriction
B- Vitreous haemorrhage
C- Retinal burns
D- Optic atrophy
E- Tractional retinal detachment
A 26-year-old man with aortic regurgitation is referred from cardiology to the eye clinic to look for features of Marfan's syndrome. Which of the following ocular features suggests the diagnosis?
A- High hyperopia
B- Band keratopathy
C- Dislocated lenses
D- Raised intraocular pressure
E- Retinitis pigmentosa
Altitudinal hemianopia is a cardinal feature in a patient who?
A- Denies the fact he is blind
B- Is 72 years old with macular degeneration
C- Is 70 years old with headache, vomiting and swelling of the optic disc
D- Is a 74-year-old man with multiple cholesterol emboli on fundoscopy
E- Has coarse facial features, large lips and spade like fingers
A sixty-year-old man presents with a week's history of painless diplopia first noticed when reading. The images are constantly horizontally and vertically separated, although he comments that the degree of separation varies. On examination the visual acuities are 6/6 in either eye. There is no pupil abnormality. There is a left ptosis, partially covering the pupil and reduced abduction and depression of the left eye, both in abduction and adduction, with other ocular movements appearing normal. There is no other abnormality on examination. Which one of the following is the MOST likely diagnosis?
A- Orbital apex syndrome
B- Sixth nerve palsy
C- Third nerve palsy
D- Fourth nerve palsy
E- Ocular myaesthenia gravis
A 22-year-old man with ulcerative colitis and chronic lower back pain complains of a red painful eye. Which one of the following is likely to be present on examination?
A- Purulent discharge
B- Photophobia on ophthalmoscopy
C- A dilated pupil
D- Profound visual loss
E- Retinal haemorrhages
A 32-year-old woman presents as an emergency with sudden, painless loss of vision in her right eye. She has been a type-1 diabetic for the past 16 years. On examination, her vision is reduced to hand movements in the right eye. Pupil reactions are normal. Dilated fundal examination reveals an irregular red reflex with evidence of a vitreous haemorrhage. Which of the following would be the most likely causative retinal abnormality?
A- Microaneurysm
B- Cotton wool spot
C- Hard exudates
D- Neovascularisation at the optic disc
E- Venous beading
An 82-year-old woman presents with sudden loss of vision in her left eye. On further questioning, she complains of a left-sided headache over the past few weeks, associated with tenderness of her head when she brushes her hair. On examination, her vision is reduced to counting fingers in the left eye. A left relative afferent pupillary defect is present. Fundoscopy reveals a pale, swollen left optic disc with some flame-shaped haemorrhages. The right eye is entirely normal. An urgent erythrocyte sedimentation rate (ESR) is elevated at 72 mm/hr (< 30). Which of the following management options should be carried out first?
A- Temporal artery biopsy
B- Ophthalmic outpatient review
C- Administration of high-dose systemic steroids
D- Automated visual field assessment
E- Computed tomography (CT) scan of brain and orbits
A patient presents to the medical clinic with diplopia. Which of the following suggests that the trochlear nerve is involved?
A- The diplopia is horizontal
B- The diplopia is episodic
C- The diplopia is worse at night
D- The diplopia is torsional
E- The diplopia is worse for distance- than near-vision
A 26-year-old man presents with sudden-onset headache and double vision. The A&E doctor diagnoses IIIrd (oculomotor) nerve palsy. Which of the following is the most likely cause?
A- Posterior communicating artery aneurysm
B- Acoustic neuroma
C- Diabetes mellitus
D- Extradural haematoma
E- Ophthalmoplegic migraine
A 70-year-old man presents with a gradually worsening, droopy, right upper eyelid. There is a right ptosis and anisocoria, greater when the room lights are off than in light conditions. Which of the following is the best investigation?
A- Anti-acetylcholine receptor antibodies
B- Blood glucose
C- Chest X-ray
D- Dilute pilocarpine eye-drop test
E- Intraocular pressure
An 80-year-old man is referred to the psychogeriatrician with features of dementia. The neurology SpR is called because the SHO has noted an abnormality of eye movements. The patient is not on any medication. The SpR confirms that the eye movements are limited in upward gaze on pursuit movements, but that the eyes move upwards normally when he flexes the patient's neck. Which of the following conclusions is valid?
A- The patient has an abnormal vestibulo-ocular response
B- The patient has a supranuclear gaze palsy
C- The patient has tardive dyskinesia
D- The patient has an oculogyric crisis
E- The patient has Korsakoff's syndrome
A 19-year-old student presents with a complaint of visual loss. Which of the following suggests a conversion reaction?
A- The pupils are unequal in size
B- There is a spiralling visual field loss
C- Optokinetic nystagmus (OKN) cannot be elicited
D- The discs show temporal pallor
E- The patient does not react to confrontation
During a routine insurance medical examination, a GP notices that a 30-year-old female patient has absent ankle jerks and unequal pupils. Which of the following is the most likely diagnosis?
A- Holmes-Adie syndrome
B- Horner's syndrome
C- Third nerve palsy
D- Mescaline ingestion
E- Argyle Robertson pupils
A patient is examined in the diabetic clinic and found to have circinate hard exudates in both fundi, with reduced visual acuity. What is the most likely diagnosis?
A- Normal fundi
B- Background retinopathy
C- Maculopathy
D- Preproliferative retinopathy
E- Proliferative retinopathy
A 70-year-old woman presents with a sudden loss of vision in one eye. Which of the following clinical findings suggests a diagnosis of giant-cell arteritis?
A- Central retinal artery occlusion (CRAO)
B- Pale disc swelling
C- Isolated central scotoma
D- Abnormal consensual light response
E- Raised intraocular pressure (IOP)
A patient with controlled ocular myasthenia gravis develops an acute infection. Which of the following antibiotics is contraindicated?
A- Aminoglycosides
B- Metronidazole
C- Macrolides
D- Quinolones
E- Penicillins
A 70-year-old woman presents with a sudden loss of vision in one eye. Which of the following investigations most strongly supports a diagnosis of temporal arteritis?
A- An ESR of 40 mm/hour
B- Abnormal CRP
C- Giant-cell infiltrate in a temporal artery biopsy
D- Homonymous hemianopia on visual field
E- Positive TPHA
A 40-year-old man presents to his GP with unequal pupils. The GP considers that IIIrd (oculomotor) nerve palsy is the likely diagnosis. Which of the following statements is true?
A- The pupil on the affected side is smaller
B- The pupil on the affected side reacts normally to light
C- The pupil on the contralateral side reacts normally to light
D- The pupil on the affected side reacts normally to accommodation
E- The pupil size difference is equal in bright and dim surroundings
A patient is seen with features of proliferative retinopathy in one eye and background diabetic retinopathy in the other. Which of the following tests is most likely to provide an explanation?
A- Chest X-ray
B- Electrocardiography
C- Coagulation screen
D- Carotid Doppler
E- 24-hour urinary protein
A diabetic patient with diplopia is found to have a third nerve palsy. Which of the following clinical features would most point to a compressive cause?
A- Ptosis
B- Impaired adduction
C- Pupil involvement
D- Impaired elevation
E- Nystagmoid jerks
A patient is referred to the dermatology clinic with facial flushing and early rhinophyma. The dermatologist seeks an ophthalmic opinion. Which of the following findings supports a diagnosis of acne rosacea?
A- Iritis
B- Cataract
C- Central retinal vein occlusion
D- Keratitis
E- Raised intraocular pressure
The medical SHO telephones the consultant to say she has diagnosed a patient as having Behçet's disease. The patient presented to A&E with reduction in vision in one eye. Which of the following features supports her diagnosis?
A- The patient is of Celtic extraction
B- There is a strong family history of blindness
C- The patient has a small-joint polyarthropathy
D- The patient has active oral ulceration
E- The patient's visual loss is due to retinal artery occlusion
A patient is examined in the diabetic clinic and found to have dark cluster haemorrhages in both fundi. What is the most likely diagnosis?
A- Normal fundi
B- Background retinopathy
C- Maculopathy
D- Pre-proliferative retinopathy
E- Proliferative retinopathy
A 30-year-old man, under investigation for abdominal cramps and passing blood rectally, presents with an acutely painful, red and photophobic eye. What is the most likely sign on ocular examination?
A- Conjunctival purulent discharge
B- White corneal stromal infiltrate
C- Mydriasis of the affected eye
D- Hypopyon
E- Swollen optic disc
A 40-old woman with AIDS presents to the GU clinic with a shadow in her vision in one eye. Which of the following supports a diagnosis of cytomegalovirus retinitis?
A- Conjunctival injection
B- Mydriasis on the affected side
C- Disc swelling
D- Macular oedema
E- Retinal haemorrhages
A patient is examined in the diabetic clinic and found to have a vitreous haemorrhage precluding a view of his fundi. He is admitted for bed rest. After 3 days the fundi can be visualised. What is the most likely diagnosis?
A- Normal fundi
B- Background retinopathy
C- Maculopathy
D- Preproliferative retinopathy
E- Proliferative retinopathy
A diabetic 46-year-old man is found in the diabetic clinic to have reduced visual acuity. During a telephone referral to the eye clinic, the ophthalmologist asks if the patient has any risk factors for macular oedema. Which of the following should the referring physician bring to his attention?
A- Background diabetic retinopathy
B- Low glycosylated haemoglobin
C- Hypercholesterolaemia
D- Proteinuria
E- Peripheral vascular disease
A patient is being referred to the eye clinic with suspected early diabetic retinopathy. Which of the following tests, if abnormal, most strongly supports the diagnosis?
A- Electroretinography (ERG)
B- Fluorescein angiography
C- Ocular ultrasound
D- Visual evoked potentials (VEP)
E- Pupillometry
A 30-year-old man is referred to the dermatology clinic and found to have café-au-lait spots. Which of the following features subsequently found in the eye clinic suggests a diagnosis of neurofibromatosis?
A- Busacca nodules
B- Lisch nodules
C- Brushfield spots
D- Koeppe nodules
E- Heterochromia iridis
A 32-year-old woman with rheumatoid arthritis presents to the rheumatology clinic with a complaint of severe pain and reduced vision in one of her eyes. The medical SpR notes that one eye is dusky red in colour and that the vision in this eye is reduced to 6/36. What is the appropriate management?
A- The patient should be booked for an urgent CT scan
B- The patient should be started on artificial tears
C- The patient should be started immediately on immunosuppressant therapy
D- The patient should be referred urgently to the ophthalmology clinic
E- The patient should be investigated urgently for coexisting inflammatory bowel disease
A 75 year old gentleman with type 2 diabetes melllitus presents for his retinal screening. On the retinal photograph there is evidence of cotton wool spots and flame haemorrhages. There also appears to be new vessel formation very close to the optic disc. What is the next stage in management?
A- Fenofibrate
B- Insulin
C- Referral for laser photocoagulation
D- Referral for fluorescein angiography
E- Optimal glycaemic control
Which of the following ocular signs would you find in acne rosacea?
A- Cataract
B- Uveitis
C- Ptosis
D- Keratitis
E- Swollen optic disc
A 68 year old male with previous history of TIA presents with unilateral painless vision loss. The retina is pale and the macula appears as a cherry red spot. What is the most likely cause of the vision loss?
A- Retinal detachment
B- Vitreous haemorrhage
C- Age related macular degeneration
D- Retinal vein occlusion
E- Central retinal artery occlusion
A 9 year old boy is brought to his GP. His mother has noticed him tripping up frequently. He states he has difficulty seeing in the dark. He is otherwise very well. A full neurological examination is performed and is normal. Fundoscopy is performed and reveals mid peripheral bone spicules. Which of the following is the most likely diagnosis?
A- Retinoblastoma
B- Retinitis Pigmentosa
C- Glaucoma
D- Alport's Syndrome
E- Usher's Syndrome
A 30-year-old presents to her GP with reduced vision in her left eye. She has previously presented with abnormal sensory changes in her leg which have now resolved. On examination her visual acuity is greatly reduced and there is evdence of a relevant afferent pupil defect. All movements of the eye are very painful. On fundoscopy and neurological examination there is nil of note. What is the most likely diagnosis?
A- Optic neuritis
B- Age related macular degeneration
C- Orbital tumour
D- Retinal vein occlusion
E- Thyrotoxicosis
A 68 year old femalee presents with central visual blurring. On examination there appears to be small yellow deposits within the maculae and a small haemorrhage at the maculae. Fluoroscein angiography is performed and shows neovascularisation within the macula of both eyes. You suspect wet age related macular degeneration. Which of the following is an important risk factor for the development?
A- Hypertension
B- Smoking
C- Cataract surgery
D- Glaucoma
E- Diabetes
A 34-year-old professional footballer is evaluated for symptoms of 'dizziness' during exercise. Physical examination reveals a laterally displaced apical impulse. On auscultation, there is a 2/6 mid-systolic murmur in the aortic area that increases on sudden standing. The ECG shows LVH and Q waves in the V2-V5 leads. What is the most likely diagnosis?
A- Young-onset hypertension
B- Acute MI
C- Aortic stenosis
D- Hypertrophic cardiomyopathy
E- Atrial septal defect
What is the most likely lipid abnormality in a 48-year-old Asian man with good glycaemic control?
A- Elevated high-density lipoprotein (HDL)
B- Elevated low-density lipoprotein (LDL)
C- Elevated LDL/elevated triglycerides
D- Low HDL/elevated LDL
E- Low HDL/elevated triglycerides
A 65-year-old woman with a history of heavy smoking presents for review. She has woken during the early hours of the morning for the second time with shortness of breath so bad that she had to fling open the windows. On examination there are crackles in the lung bases, her chest X-ray shows bilateral fluffy perihilar shadowing. ECG reveals smallanterior Q waves and a sinus tachycardia of 105 bpm. What diagnosis fits best with this clinical picture?
A- Cryptogenic fibrosing alveolitis
B- Pulmonary embolus
C- Exacerbation of COPD
D- Sarcoidosis
E- Pulmonary oedema
A 42-year-old painter presents to A&E with symptoms of vertigo, diplopia and gait unsteadiness at the end of a busy afternoon painting the interior of a property. On examination there is a markedly lower blood pressure in the left arm. What diagnosis fits best with this clinical picture?
A- Anterior circulation transient ischaemic attack
B- Subclavian steal syndrome
C- Vestibular neuronitis
D- Posterior circulation transient ischaemic attack
E- Unexplained cardiac arrhythmia
A 70-year-old-man reverts to atrial fibrillation after several attempts at cardioversion, but remains symptomatic despite rate control with digoxin and metoprolol. He developed pulmonary fibrosis with amiodarone. Which of the following will be the next step in the management of this patient?
A- Switch metoprolol to amlodipine
B- Double the dose of digoxin
C- Perform radiofrequency ablation of the AV node, and implant a pacemaker
D- Make another attempt at cardioversion
E- Implant a cardiovertor defibrillator
A 40-year-old man is noted to have palmar crease xanthomas. Which form of lipid disorder is most likely?
A- Familial hypercholesterolaemia
B- Familial mixed hypercholesterolaemia
C- Hyperchylomicronaemia
D- Familial hypertriglyceridaemia
E- Broad b disease
A 78-year-old-man presents to Casualty with a history of syncope. An ECG shows complete heart block. Which of the following physical signs is consistent with the diagnosis?
A- Regular cannon 'a' waves on JVP
B- Soft first heart sound
C- Low-volume pulse
D- Basal systolic murmur
E- Loud second heart sound
A 56-year-old man has known tricuspid regurgitation. Which part of the jugular venous waveform is likely to be most prominent?
A- a wave
B- c wave
C- v wave
D- x descent
E- y descent
A 50-year-old woman presents with an acute myocardial infarction, and thrombolysis is being considered.Which one of the following would be an absolute contraindication for thrombolytic therapy?
A- Background diabetic retinopathy
B- Past history of a minor stroke 5 years ago with full recovery and no evidence of underlying cerebrovascular lesion
C- Menstruation
D- Dyspeptic symptoms
E- Resting blood pressure 220/130 mmHg
A 17-year-old youth is brought to the GP by his mother. He was previously seen 2 weeks earlier suffering from acute pharyngitis. His teeth are in generally poor condition, but otherwise there is no previous medical history. On examination he is febrile with a temperature of 38.2 A°C, and has a polyarthritis affecting his knees, ankles, wrists and elbows. He also appears to have subcutaneous nodules over his elbows, and mitral regurgitation on cardiovascular examination. What diagnosis fits best with this clinical picture?
A- Bacterial endocarditis
B- Juvenile rheumatoid arthritis
C- Scarlet fever
D- Rheumatic fever
E- Congenital valvular heart disease
A 56-year-old man presents with a cardiac rhythm disorder. Which one of the following scenarios would be an indication for temporary transvenous cardiac pacemaker insertion?
A- Asymptomatic 2.8 s sinus pauses
B- A short period of complete heart block complicating inferior myocardial infarction, (pre-thrombolysis) with blood pressure 110/70 mmHg
C- Asymptomatic complete heart block with broad complex ventricular complexes at 35 bpm
D- Mobitz II AV block complicating anterior myocardial infarction with blood pressure 110/70 mmHg
E- Bifascicular block prior to aortic aneurysm repair
A 70-year-old man undergoes successful DC cardioversion for atrial fibrillation (AF). Which one of the following factors best predicts long-term maintenance of sinus rhythm following this procedure?
A- Age under 75 years
B- Normal left ventricular function
C- Warfarin therapy
D- No alcohol intake
E- AF duration less than 6 months prior to cardioversion
A 38-year-old man of Chinese descent who smokes 60 cigarettes per day presents to his GP. He is developing pain at rest in his legs, and is unable to walk more than a few yards due to ischaemic pain. On examination there is prolonged capillary refill and necrotic ulcers at the tips of his toes. There is also evidence of thrombophlebitis. What diagnosis fits best with this clinical picture?
A- Buerger's disease
B- Simple peripheral vascular disease
C- Polyarteritis nodosa
D- Familial hypercholesterolaemia
E- Temporal arteritis
A 45-year-old man with a strong family history of ischaemic heart disease presents with atypical chest pains. Electrocardiographic (ECG) exercise testing shows J point depression of 1 mm with a heart rate of 120 beats/min (bpm). What is the most appropriate next step?
A- Coronary angiography
B- Dobutamine stress echocardiography
C- Radionuclide myocardial perfusion scanning
D- Reassure and discharge
E- Repeat ECG exercise testing on anti-anginal medication
A 67-year-old lady during pre-operative assessment is found to have a small pericardial effusion located posteriorly on routine Echocardiography. Electrocardiogram (ECG) is entirely normal. What is the next most appropriate step in her management?
A- Cardiac catheterisation
B- Reassure
C- Pericardiocentesis
D- Diuretics
E- Computed tomography (CT) of the heart
A 62-year-old patient presents with atrial fibrillation of unknown duration. Which drug may slow his ventricular rate over a prolonged period but is unlikely to result in cardioversion?
A- Adenosine
B- Amlodipine
C- Digoxin
D- Flecanide
E- Amiodarone
A 55-year-old man who has sustained an acute MI subsequently presents with heart failure. As well as other treatments the cardiologist has recommended that abeta-blocker be commenced. According to currently available evidence which of the following beta-blockers would be most appropriate?
A- Celiprolol
B- Labetalol
C- Bisoprolol
D- Propranolol
E- Sotalol
A 67-year-old lady is found to have a small pericardial effusion located posteriorly on routine echocardiography. There is no haemodynamic compromise.What is the next most appropriate step in her management?
A- Diagnostic tap
B- Mammography
C- Tuberculosis screen
D- Reassure
E- Right heart catheter examination
A 65-year-old woman with a history of heavy smoking presents for review. She has woken during the early hours of the morning for the second time with shortness of breath so bad that she had to fling open the windows. On examination there are crackles in the lung bases, her chest X-ray shows bilateral fluffy perihilar shadowing. ECG reveals small anterior Q waves and a sinus tachycardia of 105 bpm. What diagnosis fits best with this clinical picture?
A- Cryptogenic fibrosing alveolitis
B- Pulmonary embolus
C- Exacerbation of COPD
D- Sarcoidosis
E- Pulmonary oedema
A 69-year-old man has been admitted to the emergency department with syncope. He felt hot, complained of nausea and then fainted.His electrocardiogram (ECG) was normal. His brother suffers from adult onset epilepsy. What is the most appropriate investigation?
A- Electroencephalogram (EEG)
B- 24-h ECG
C- Computed tomography (CT) of the brain
D- Echocardiography
E- Tilt test
An elderly gentleman is admitted with syncope. He also complains of shortness of breath and is diagnosed as having aortic stenosis. Which of the following conditions when associated with aortic stenosis would indicate a poor prognosis?
A- Aortic regurgitation
B- Left ventricular failure
C- Electrocardiography (ECG) changes
D- Endocarditis
E- Valvular calcification
A 46-year-old man is admitted with shortness of breath, headache, blood pressure 190/110 mmHg and fundoscopy showing retinal haemorrhages and papilloedema. ECG revealed left ventricular hypertrophy, chest x-ray did not reveal any evidence of left ventricular failure. Which of the following agents would be the most appropriate management?
A- Intravenous labetalol
B- Intravenous sodium nitroprusside
C- Atenolol
D- Doxasosin MR oral
E- Nifedipine sublingual
A patient with underlying ischaemic heart disease had two transient episodes of loss of consciousness but feels fine at present. Both episodes were preceded by afeeling of dizziness, "vision going black" and witnesses report that the subject went very pale and then collapsed, lying motionless for a few seconds before making a rapid recovery. No abnormal movements were seen during the period of unconsciousness. What investigation will you order next?
A- Echocardiography
B- Computed tomography (CT) of the head
C- 24-hour electrocardiogram (ECG)
D- Cardiac catheterisation
E- Treadmill test
An elderly man is admitted to the ICU and put on intermittent positive-pressure ventilation. Which of the following statements is true when compared to spontaneous ventilation?
A- Lung volumes are decreased
B- Pulmonary vascular resistance is decreased
C- Systemic blood pressure rises
D- Venous return and cardiac output fall
E- Intrathoracic pressure is decreased
A 65-year-old male patient with stable angina complains of shortness of breath after walking two flights of stairs. He has normal left ventricular function on the echocardiogram and a positive exercise tolerance test (3 mm ST depression at stage III). What is the most appropriate therapy?
A- Atenolol
B- Simvastatin
C- Isosorbide mononitrate
D- Angiotensin-converting enzyme (ACE) inhibitor
E- Nicardipine
A 65-year-old female patient with severe heart failure presents with increasing shortness of breath. Her current pharmacological treatment consists of an angiotensin-converting enzyme (ACE) inhibitor, loop diuretic and β-blocker. What is the most appropriate management?
A- Add digoxin
B- Add spironolactone
C- Stop β-blocker
D- Stop ACE inhibitor
E- Add simvastatin
A 67-year-old man with chronic heart failure is reviewed in terms of his drug therapy. Which of the following treatments has no proven mortality benefit?
A- Bisoprolol
B- Digoxin
C- Enalapril
D- Nitrates and hydralazine
E- Spironolactone
A 35-year-old-woman of African origin presents with a 4-month history of increasing swelling over her feet and abdominal distension. She has no history of cough, orthopnoea or breathlessness on exertion. Her heart rate is 98 beats/minute: irregularly irregular. Her JVP is markedly raised and she has pitting lower limb oedema. The heart sounds are soft, and there are no audible murmurs. Abdominal examination reveals hepatomegaly along with ascites. Chest X-ray reveals a normal cardiac size and clear lung fields. A lateral X-ray shows calcification around the heart border. Urinalysis is normal. Her ECG shows a low QRS voltage and lateral T-wave changes. What is the likely diagnosis?
A- Dilated cardiomyopathy
B- Cirrhosis of the liver
C- Constrictive pericarditis
D- Restrictive cardiomyopathy
E- Hypertrophic cardiomyopathy
A 25-year-old homosexual man complains of a 9-day history of mucopurulent anal discharge, anal bleeding and pain while opening his bowels. What is the most likely diagnosis?
A- Candidiasis
B- Gonorrhoea
C- Crohn's disease
D- Salmonella infection
E- Chancroid
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