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?

In the management of pneumothorax, what is the best indication that the intercostal catheter can be removed?

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 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 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 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?

Regarding the anatomy of the lungs, which of the following statements is correct?

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?

Which of the following does the median nerve innervate?

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 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?

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 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?

What is the most important direct action of the hormone 1,25 Dihydroxyvitamin D?

With regard to the pathology of rheumatoid arthritis, which of the following statements is correct?

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 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?

Soft tissue healing is an ordered process. Which of the following is NOT a stage in this type of wound healing?

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 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?

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?

Regarding the blood supply to the heart, which of the following statements is correct?

Regarding the anatomy of the heart, which one of the following statements is most correct?

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 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?

Where should the normal apex beat be palpated whilst undertaking a cardiovascular examination?

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?

Which one of the following is the specific treatment for paracetamol overdose?

The cranial nerves IX, X, XII are characterised by the fact that they all emerge from which one of the following structures?

Which one of the following statements about the skeleton is true?

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?

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?

Which one of the following is the correct order of tissues lining the gastrointestinal tract from the lumen (inside) outwards?

Which of the following is true regarding surgical therapy for colorectal cancer?

What is the laryngeal prominence (Adam's apple) in the neck formed by?

What is the most useful guide to the likely post-operative opioid requirements of a patient undergoing a laparotomy?

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?

Which of the following statements about the autonomic nervous system is most accurate?

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?

Radiotherapy with or without chemotherapy can be used to cure (without surgery) all of the cancers listed EXCEPT which of the following below?

Which of the following pharmacological agents used in the management of type 2 diabetes is NOT associated with significant weight gain?

Which of the following is NOT a recognised side effect of non-steroidal antiinflammatory drugs (NSAIDs)?

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 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?

Which of the following is the least important factor contributing to Total lung capacity (TLC)?

Which of the following has the least effect on the diffusing capacity for carbon monoxide of the lung at rest?

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?

Which of the following joints are affected most commonly by osteoarthritis?

How does chronic suppurative otitis media most commonly present?

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?

Which of the following not an indication for tracheotomy?

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 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 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?

Type I diabetes mellitus is caused by an auto-immune process.

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?

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?

What is the main vein draining the brain?

Which of the following micro-organisms is the commonest cause of communityacquired pneumonia?

How is an "open" fracture defined?

Which of the following is NOT a stage in normal soft tissue wound healing?

Which of the following is the main risk factor for ischaemic heart disease in men and women older than 75?

Which of the following tests is most likely to establish a definitive microbiological diagnosis in a patient with community-acquired pneumonia?

Which of the following investigations is useful in the monitoring of rheumatoid arthritis?

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 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?

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?

Hyperalgesia is defined as which of the following?

Regarding the uterine tubes, which of the following statements is NOT correct?

Regarding the scapula, which one of the following statements is correct?

Which of the following terms best describes the usual response of cardiac myocytes to hypertension?

During pregnancy, which one of the following infectious diseases has the lowest risk of causing congenital infection?

Which of the following statements about right-sided heart failure is true?

Maternal cardiovascular changes during pregnancy include which one of the following?

Regions that are innervated by the ulnar nerve include which of the following?

In the context of drug use, which one of the following statements best describes the difference between addiction and dependence?

Regarding genital chlamydial infections, which of the following statements is FALSE?

If a patient has an isolated iron deficiency, which of the following sets of results would you expect to find?

Which of the following is a feature of the inferior vena cava?

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?

Which of the following agents/devices used in the treatment of pulmonary embolism is associated with the highest risk of serious bleeding?

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 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?

What is an advantage of tramadol over morphine?

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?

How do you calculate the Mean Arterial Pressure (or MAP)?

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?

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?

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?

Which device would deliver oxygen at a concentration close to 100 percent?

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?

Which of the following is most useful for identifying the cause of syncope?

Management of atrial fibrillation of onset within 4 hours of presentation includes all of the following EXCEPT:

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?

Red cell fragments (schistocytes) are commonly seen in which of the following conditions?

Multiple myeloma is characterised by plasma cell infiltration of which of the following organs?

Which of the following statements regarding the use of diagnostic ultrasound for medical imaging is correct?

Which of the following is most likely to cause damage to cardiac muscle?

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?

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?

Regarding unstable angina pectoris, which of the following statements is true?

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?

Cholinesterase inhibitors have NOT been associated with which of the following potential adverse effects?

Which of the following statements about septic arthritis is correct?

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 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?

Profound hypothyroidism in the elderly is likely to cause which of the following electrolyte disturbances?

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?

What is the significance of the finding of localised tenderness and guarding on abdominal examination?

A Regarding analgesic doses of ketamine, which of the following statements is correct?

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?

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?

Aminoglycosides (e.g. gentamycin) cause deafness by damaging which of the following?

With regard to the use of antibiotics in cholera, which of the following statements is correct?

Which oral condition has the LEAST association with Type 1 and Type 2 diabetes?

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?

Which of the following treatments is most likely to be associated with a potential life threatening attack of asthma?

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?

Which of the following statements describes the mechanism of action of statin therapy for lipid-modification?

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 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 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 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?

In which of the following is topical anaesthesia with lignocaine NOT effective?

Regarding adult basic life support in cardiac arrest, which of the following is correct?

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?

Which of the following is the most sensitive investigation for pancreatitis?

By definition, severe acute pancreatitis includes all EXCEPT which of the following complications?

Which of the following most accurately describes the ECG abnormality seen with a delay in AV node conduction?

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?

Haematemesis is NOT a feature of which of the following?

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 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?

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 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 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 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 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 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 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 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 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 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 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 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 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 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 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 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 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 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?

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 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 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 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 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 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 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 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 33-year-old homosexual patient who is HIV positive but in the stable phase of the disease is best monitored with which biomarker?

An 18-year-old woman has been diagnosed with human papillomavirus infection. What is the most significant long-term risk following this infection?

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?

What is the cause of myocarditis caused by diphtheria?

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 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?

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 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 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 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 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 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 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 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 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?

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 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?

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 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?

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

Infection with which virus is the most frequent cause of blindness in patients with AIDS?

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?

Which one of the following statements is true with regard to Legionnaires' disease?

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 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 46-year-old meat-factory worker is found to have Q fever pneumonia. Which of the following statements is correct?

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?

Which pulmonary function test may be altered to a similar degree in both restrictive lung disease and obstructive lung disease?

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 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?

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 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 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 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 patient with small-cell lung cancer has a serum sodium concentration of 121 mmol/l.Which of the following is the most likely cause?

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?

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 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 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?

Which is the most common malignant neoplasm of the lung?

A patient with cystic fibrosis presents with a severe bronchopneumonia. What is the most likely pathogen?

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 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 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 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 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 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 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 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 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 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 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 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 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 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?