A 24-year-old man presents with a four-month history of abdominal pain which has been getting worse. The patient describes the pain as generalized, dull in character and does not radiate but often occurs alongside loin pain. An irregular mass is palpable in both flanks and a mid-systolic click can be auscultated. The most appropriate investigation is:

Which of the following arterial blood gas results, taken on room air, would you expect to see in a 67-year-old patient who has been suffering with COPD for two years and is not on home oxygen?

A 38-year-old woman presents to her GP with a 2-week history of dysuria, haematuria and shortness of breath. She suffers from chronic headaches and has been taking ibuprofen in order to treat them. She has a history of cardiovascular disease in the family and a friend recommended she use aspirin to keep healthy. The most appropriate investigation is:

A 68-year-old obese Asian man is seen in the hypertension clinic. His blood pressure is 151/93 and he suffers from poorly controlled type 2 diabetes. Blood results demonstrate elevated serum urea and creatinine. An ultrasound scan shows asymmetry between the two kidneys and on examination audible abdominal bruits are auscultated. Urine dipstick did not detect any blood or protein. The best investigation is:

A 63-year-old woman presents in accident and emergency with a 3-day history of worsening abdominal pain and mild flank pain. Examination reveals pain in the suprapubic region, but otherwise the abdomen is soft with no masses. The patient denies any other symptoms, such as dysuria, but mentions she has had difficulty passing urine in the last week and is only able to provide a small urine sample which is odorous and bloody. She has no other medical problems, but admits to being a long-term smoker. An ultrasound scan of renal system is most likely to show:

A 19-year-old man is recently diagnosed with type 1 diabetes and attends your clinic to ask about possible complications in the future. He mentions an uncle who has end-stage renal disease due to poorly controlled diabetes and specifically enquires about testing for early signs of renal impairment. The most appropriate investigation is:

A 60-year-old man visits his GP complaining of tiredness. He has noticed weight loss over the last six months and irritation of the tip of his penis which appears inflamed on examination. He mentions he has been visiting the toilet more often than usual and feeling thirsty. The most appropriate investigation would be:

A 28-year-old woman has noticed a change in her appearance; most notably her clothes do not fit properly and are especially tight around the waist. Her face appears flushed and more rounded than usual, despite exercising regularly and eating healthily her weight has steadily increased over the last 3 weeks. On visiting her GP, he notices her blood pressure has increased since her last visit and she has bruises on her arm. She is especially worried about a brain tumour. The most appropriate investigation would be:

A 22-year-old woman complains of dizziness and feeling light-headed. She works in an office and most frequently experiences this when standing up to visit the toilet. She has never fainted. The patient has lost 5 kg, but attributes this to eating more healthily. She has noticed a recent scar on the back of her hand which has started to turn very dark. The most appropriate investigation is:

A 29-year-old man presents with a 4-week history of polyuria and extreme thirst. The patient denies difficulty voiding, hesitancy or haematuria, although the urine is very dilute. The patient does not believe he has lost any weight and maintains a good diet. No fmdings are found on urine dipstick. The most appropriate investigation is:

A 39-year-old man presents with a three-month history of depression. The patient recently lost a family member and around the same period began to feel unwell with constipation and a depressed mood. He has started taking analgesia for a sharp pain in his right lower back that often radiates towards his front. The most appropriate investigation is:

A 47-year-old woman presents to clinic after being referred from her GP for consistently elevated blood pressure. Her last reading was 147/93. The female does not report any symptoms but recently lost her job and attributes the elevated reading to stress. Her blood tests are as follows: Sodium 146, Potassium 3.4, Glucose (random) 7.7, Urea 4. The most appropriate investigation is:

A 49-year-old man has recently been diagnosed with type 2 diabetes and is being carefully monitored. He has been advised to maintain a healthier diet and lifestyle, he attends a follow-up clinic and claims to have been following the diet stringently since his last appointment three months ago. The most appropriate investigation is:

A 33-year-old man complains of a tingling sensation in his hands for several months which occasionally awakens him during sleep. The patient has noticed he has gained weight and no longer wears his wedding ring as it has become too tight. You notice the patient is sweating while speaking to you and has quite a large jaw, furrowed tongue and large hands. His blood pressure reading is 142/91 mmHg. The most appropriate investigation would be:

A 29-year-old man presents to his GP complaining of being constantly thirsty, tired and visiting the toilet more often than usual during the last 4 days. He has noticed his clothes have become more baggy and he now needs to tighten his belt. His parents both have diabetes requiring insulin therapy. A fasting plasma glucose result is most likely to be:

A 45-year-old woman presents to the rheumatology outpatient clinic with a three- month history of stiff hands and wrists. She mentions that the pain is particularly bad first thing in the morning. On examination, the wrists, metacarpophalangeal joints and proximal interphalyngeal joints are swollen and warm. A diagnosis of rheumatoid arthritis is suspected. Which of the following investigations is most specific for confirming the diagnosis?

A 79-year-old woman presents to her GP with pain in the left knee. This is particularly bad in the evenings and is stopping her from sleeping. The GP explains that her discomfort is most likely due to osteoarthritis and arranges for her to have an x-ray of the knee. Which of the following descriptions are most likely to describe the x-ray?

A 32-year-old man presents to the minor injuries walk-in clinic, complaining of back pain. This had started suddenly that morning after he had lifted a heavy box at home. He mentions that the pain has been shooting down his left leg and he cannot walk without the support of his friend. He has not passed urine since the onset of pain. On neurological examination of the lower limbs, tone and power cannot be assessed due to pain but there are decreased ankle reflexes and a sacral anaesthesia. What is the most appropriate next step?

A 70-year-old woman with a history of vertebral crush fractures presents to the osteoporosis outpatient clinic. Which of the following investigations is most useful to assess the extent of her osteoporosis?

A 27-year-old woman presents to accident and emergency complaining of sudden onset shortness of breath and right-sided pleuritic chest pain. She has a past medical history of three miscarriages and a deep venous thrombosis in the right leg. On examination, pulse is 110 bpm, respiratory rate is 24 bpm, oxygen saturation is 88 per cent on room air. An arterial blood gas shows pH 7.40, P02 8.0, PC02 3.1. What is the diagnostic investigation of choice?

A 27 -year-old woman presents to accident and emergency complaining of sudden onset shortness of breath, right-sided pleuritic chest pain and haemoptysis. She has a past medical history of three miscarriages and a deep venous thrombosis in the right leg. CTPA confirms a large pulmonary embolism. A diagnosis of anti-phospholipid syndrome is suspected and a full autoantibody screen is sent. Which of the following auto-antibodies would confirm the diagnosis if detected?

A 29-year-old woman complains of a 1-week history of weakness and malaise, she has recently become a vegetarian and eats mostly green vegetables and drinks lots of tea during the day. She is apyrexial and has a C-reactive protein (CRP) < 5. You suspect an abnormality of the patient's iron stores. What is the most appropriate investigation to determine iron store levels?

A 29-year-old woman complains of tiredness, especially during activity. On examination the patient appears pale. Auer rods and schistocytes can be seen on peripheral blood smear. The patient is referred for a bone marrow biopsy and the extracted cells are sent for cytogenetic analysis. The most likely results are:

An 18-year-old African man presents with worries about his general health stating that hypertension and sickle cell anaemia are present in his family history. The patient denies any shortness of breath, chest pain, digit or limb changes. Blood pressure is 124/77 mmHg. What test would be appropriate to investigate sickle cell anaemia?

A 47 -year-old woman presents complaining of dark stools and painful fingers on both hands. She appears plethoric and complains of severe itching, often when she is washing. A large liver and spleen is palpable. You suspect features of polycythaemia rubra vera and measure red cell mass and erythropoietin levels among other tests. Which of the following is likely to be most accurate in this patient?

A 44-year-old woman presents with recurrent fever, pallor, malaise and shortness of breath. She has noticed a petechial rash on her skin and small bruises on her arms. A blood test reveals a pancytopenia. During examination, you palpate a large spleen. Which investigation would differentiate between hypersplenism and aplastic anaemia?

A 66-year-old man presents complaining of a three-month history of weakness, tingling in the limbs and a sore tongue. The patient notes an undesired 5 kg weight loss over 2 weeks. A peripheral blood smear shows a macrocytic anaemia, a Schilling test shows impaired vitamin 812 absorption and a diagnosis of pernicious anaemia is made. Which of the following antibodies is most closely associated with pernicious anaemia?

A 5-year-old girl presents with her parents who have become concerned about the small petechiae and ecchymoses on her skin. An abdominal examination reveals hepatosplenomegaly. You suspect an acute leukaemia. The most appropriate initial investigation for diagnosis is:

A 77 -year-old woman is admitted to hospital with a urinary tract infection. She receives antibiotics and seems to be responding well. On the fourth day she is eating her lunch when she suddenly drops her fork. She calls for the nurse who notices the left side of her face is drooping. What is the best next course of action?

A 62-year-old woman presents to accident and emergency with a 1-day history of sudden onset back pain and difficulty walking. She has not opened her bowels or passed urine for the previous day. She has a past medical history of breast cancer, diagnosed two years earlier and staged as T2N1MO disease with oestrogen receptor positive status. She has been treated for her cancer with a wide local excision and axillary node clearance, followed by radiotherapy, chemotherapy and tamoxifen. On examination, there is reduced tone in the lower limbs. Power is diminished throughout the lower limbs, but especially on hip flexion. There is reduced sensation below the L1 dermatome. What is the most appropriate diagnostic investigation?

A 60-year-old man with metastatic adenocarcinoma of the lung, who has finished two cycles of palliative cisplatin/pemetrexed chemotherapy, presents with a 2-day history of fever and lethargy. On examination, he is pyrexial with a temperature of 38.8°C. What is the most appropriate next step?

A 57-year-old woman with adenocarcinoma of the sigmoid colon with liver metastasis is attending for cycle six of her palliative FOLFOX chemotherapy. Which tumour marker can be measured in the blood test to indicate the effect of the chemotherapy?

A 58-year-old male with known small cell lung cancer presents to accident and emergency with a 5-day history of severe headache and recurrent vomiting. He has recently commenced chemotherapy for small cell carcinoma of the lung. On examination of the visual fields, there is a left inferior homonymous quadrantinopia. The most important diagnostic investigation is:

A 64-year-old man presents to accident and emergency following a collapse. He describes a blackout, subsequently regaining consciousness when on the floor. He presently feels well and describes no other symptoms. However, he mentions that he has unintentionally lost some weight over the past few months. There is no past medical history. Blood tests reveal a haemoglobin level of 9 g/dL with a mean cell volume on 71 fL. The most appropriate next investigation of this patient is:

A 39-year-old Indian man presents to his GP with a 5-week history of haemoptysis, night sweats and weight loss. Which of the following investigations can be used to confirm the diagnosis of tuberculosis?

A 43-year-old woman presents to accident and emergency with epigastric pain that started 4 hours ago. The woman describes the pain as being sharp and radiating to her back. She feels nauseous but has not vomited and is fully alert and orientated. The patient responds well to IV fluids and analgesia. Biochemical blood results show: Bilirubin 8 f.liDOI!L, ALT 38 IU/L, AST 34 lUlL, ALP 421 lUlL, Amylase 1850 U/L. The most appropriate investigation would be:

A 42-year-old man presents with a 2-day history of severe chest pain. The patient reports a sudden ripping sensation at the front of the chest that occasionally radiates to the back. The patient has tried paracetamol and ibuprofen to alleviate the pain, but has had no success. The patient suffers from poorly controlled hypertension and at the last GP appointment his blood pressure was 167/95 mmHg. The most definitive investigation is:

A 19-year-old woman presents with an acute episode of feeling unwell. While in the middle of moving to a new house, she experienced an extremely severe pain near the back of her head. She denies any recent travelling, fever or neck stiffness. The most defmitive investigation is:

A 35-year-old woman complains of a sharp central chest that is acutely exacerbated each time she moves, breathes in or lies flat. The pain tends to stay in the centre of the chest but occasionally moves towards her neck and shoulders. The pain is relieved by sitting forward. The patient does not drink alcohol, is not diabetic and does not smoke. A pericardial rub is heard on auscultation. The most appropriate diagnostic investigation is:

A 45-year-old man with a strong family history of dilated cardiomyopathy presents with peripheral oedema, finger clubbing, jugular venous distension and pulmonary rales. A gallop rhythm is heard on auscultation Which investigation would not be useful in dilated cardiomyopathy?

A 64-year-old man presents with a 2-day history of abdominal pain which he describes as constant, dull and around his umbilicus and occasionally migrating to his groin. He has a body mass index (BMI) of 27 and a past medical history of poorly controlled hypertension. Abdominal examination reveals a pulsatile and expansile mass just below the umbilicus. The most appropriate screening investigation is:

A 71-year old woman presents to accident and emergency with pain in the right knee. This has been ongoing for the past five months but she is now finding it difficult to walk. Pain is usually worse after exertion. On examination, the right knee is swollen. There is a reduced range of active movement and palpable crepitus. What are the most likely findings on x-ray?

A 60-year-old man presents to his GP with gradually increasing fatigue and some exertional dyspnoea. Blood pressure is 118/74 mmHg and pulse rate is 81/minute. There are no abnormal physical findings and on echocardiography the ejection fraction is 0.47. However, the clinical impression remains one of early heart failure. Which of the following circulating biomarkers would lend support to that conclusion?

A 50-year-old man with type 2 diabetes undergoes a prosthetic aortic valve replacement after suffering from congestive heart failure due to native valve endocarditis. Following the operation, he presents with fever, janeway lesions, splinter haemorrhages and night sweats. The most definitive investigation for prosthetic valve endocarditis is:

You are informed that one of your ward patients has been breathless over the last hour and has been quite anxious since her relatives left after visiting. The patient is a 67-year-old woman who was admitted 6 days ago for a left basal pneumonia which has responded well with intravenous antibiotics. Her past medical history includes dementia and hypertension. You are asked by your registrar to interpret the patient's arterial blood gas (ABG) measurements taken during her tachypnoea: pH 7.49 kPa, P02 14.1, PC02 3.1 kPa, HC03 24. From the list of answers below, choose the most appropriate ABG interpretation:

A 59-year-old man, who has completed five cycles of chemotherapy for metastatic colorectal carcinoma, presents to accident and emergency complaining of feeling generally unwell. On examination, he is pyrexial at 38.9°C and there are crepitations in the right lung base. What is the most urgent investigation?

A 39-year-old Indian man presents to accident and emergency with a 6-week history of haemoptysis, night sweats and weight loss. Chest x-ray reveals some shadowing in the left upper zone. What is the most appropriate diagnostic investigation?

A 52-year-old woman who has recently finished a course of chemotherapy for metastatic adenocarcinoma of the lung presents to accident and emergency following a fall at home. She mentions that her legs have been feeling heavy for 2 days. On examination there is reduced power through the lower limbs. Her lower limb reflexes are brisk and she has upgoing plantars. On examination of the abdomen, there is a palpable bladder. There is a sensory level below Ll. What is the most important diagnostic investigation?

A seven-year-old girl is brought to accident and emergency by her mother because of a nose bleed that keeps on bleeding despite pressure and ice-packs. Petechiae and ecchymoses can be seen on examination and the mother reports the child has recently recovered from a throat infection. You suspect the patient is suffering from immune thrombocytopenic purpura and organize tests to measure platelets (Pit), bleeding time (BT), prothrombin time (PT) and partial thromboplastin time (PTT). Which of the following is the most appropriate result?

A 60-year-old man presents with a history of recurrent dizzy spells for the past 4 months, which occur daily. The dizzy spells last a few minutes and seem to occur if he moves his head, as a result of which he keeps his head as still as possible. The attacks are not associated with any deafness or tinnitus and a neurological examination is entirely normal. You favour a diagnosis of benign paroxysmal positional vertigo. Which of the following descriptions of findings on Hallpike's manoeuvre would confirm this diagnosis?