A 49-year-old man presents with a history of difficulty sleeping. He reports feeling increasingly tired and general weakness which he attributes to his poor sleep pattern. Additionally, the patient has noticed he has gained weight and sweats very easily. On examination, the patient has coarse facial features. The most likely diagnosis is:

A 42-year-old woman presents with visual disturbances. She reports having double vision which was intermittent initially but has now become much more frequent. In addition, she becomes breathless very easily and experiences palpitations. On examination, raised, painless lesions are observed on the front of her shins and finger clubbing. The most likely diagnosis is:

A 16-year-old girl presents to her GP complaining of a swelling in her neck which she has noticed in the last 2 weeks. She has felt more irritable although this is often transient. On examination, a diffuse swelling is palpated with no bruit on auscultation. The most likely diagnosis is:

A 69-year-old man presents with confusion. His carers state that over the last month he has become increasingly lethargic, irritable and confused. Despite maintaining a good appetite, he has lost 10 kg in the last month. Blood results are as follows: Sodium 125 mmol/L, Potassium 4 mmol/L, Urea 3, Glucose (fasting) 6 mmol/L, Urine osmolality 343 mmol/L. The most likely diagnosis is:

A 54-year-old woman presents to her GP complaining of a change in her breathing sound. She first noticed numbness, particularly in her fingers and toes, three months ago but attributed this to the cold weather. Her partner now reports hearing a high pitched, harsh sound while she is sleeping. Her BMI is 27. While measuring blood pressure, you notice the patient's wrist flexing. The most likely diagnosis is:

A 47-year-old woman complains of weight loss. She has a family history of type 1 and type 2 diabetes but has never been diagnosed herself despite the finding of islet cell antibodies. In the last few months, however, she has noticed progressively increasing polyuria and poydipsia and 5 kg of weight loss. Her fasting plasma glucose is 8 mrnol/L and urine dipstick shows the presence of ketones. The most likely diagnosis is:

A 55-year-old diabetic woman presents with altered sensations in her hands and feet. She finds it difficult to turn pages of books and discriminating between different coins. When walking, the floor feels different and she likens the sensation to walking on cotton wool. The most likely diagnosis is:

A 29-year-old woman is referred to a diabetic clinic for poor diabetes management. She was diagnosed with type 1 diabetes at the age of 12 and prescribed actrapid insulin injections.Recently, the patient has been suffering fluctuations in her plasma glucose levels and her previously well-controlled glycated haemoglobin has risen to 8.1 per cent. The patient admits she has recently been avoiding using her injections. On examination, the patient has a raised, smooth lump that is firm on palpation at the lower abdomen. The most likely diagnosis is:

A 7-year-old girl presents with red striae which her mother noticed around her abdomen. The girl also has plethoric cheeks and, on her back, several faint, irregular brown macules are observed. The mother is particularly concerned about the early breast development that seems apparent on her daughter. Serum phosphate is decreased. The most likely diagnosis is:

An 18-year-old man presents to clinic worried about his scant pubic hair development. Examination reveals undescended testes and plasma testosterone, luteinizing hormone and follicle stimulating hormone were found to be low. A karytotype test was 46, XY. The patient was otherwise well, but during neurological examination struggled during the olfactory test. The most likely diagnosis is:

A 15-year-old girl complains of headaches which started 6 weeks ago. The headaches initially occurred 1-2 times a week but now occur up to five times a week, they are not associated with any neurological problems, visual disturbances, nausea or vomiting. The girl also reports a white discharge from both of her nipples. She has not started menstruating. The most appropriate investigation is:

A 47-year-old woman is referred to the endocrine clinic complaining of a two- month history of tiredness. Despite wearing several items of clothing, the patient appears intolerant to the room temperature. She has noticed an increase in weight, particularly around her waist. The most appropriate investigation is:

A 58-year-old woman presents with an acutely painful neck, the patient has a fever, blood pressure is 135/85 mmHg and heart rate 102 bpm. The patient explains the pain started 2 weeks ago and has gradually become worse. She also notes palpitations particularly and believes she has lost weight. The symptoms subside and the patient presents again complaining of intolerance to the cold temperatures. The most likely diagnosis is:

A 6-year-old girl presents to accident and emergency with severe abdominal pain, nausea and vomiting. On examination, the patient is tachypnoeic, capillary refill is 3 seconds and she has a dry tongue. While listening to the patient's lungs, you detect a sweet odour from her breath. The most likely diagnosis is:

A 45-year-old Asian man is diagnosed with Cushing's disease in India. He undergoes a bilateral adrenalectomy and recovers well from the operation. On his return to the UK one year later, he complains of a constant dull headache, peripheral visual disturbances and increasing pigmentation of the skin creases of both hands. The most likely diagnosis is:

A 29-year-old woman is found unconscious by her partner and rushed to accident and emergency. She is a type 1 diabetic and has maintained excellent glucose control using insulin injections. Blood biochemistry results demonstrate a moderately raised level of insulin, no detectable C-peptide and very low blood glucose. Her partner mentions she is a lawyer and has been working particularly hard in the last week, eating quick meals and occasionally missing meals. The most likely diagnosis is:

A 37-year-old man presents with symptoms of an acute headache, vomiting, malaise and visual disturbance. A neurological examination reveals a bitemporal superior quadrantanopia. A CT scan shows a hyperdense area within the pituitary gland. The most likely diagnosis is:

A 38-year-old woman presents to clinic complaining of changes in her appearance and weight gain. She has recently been through a divorce and attributed her weight gain to this. However, despite going to the gym her clothes are still tight, especially around her waist, her face seems puffy and flushed. The most likely diagnosis is:

A 60-year-old diabetic man recovering from sepsis after collapsing at home was treated with appropriate antibiotics after blood culture and aggressive fluid management with 0.9 per cent saline for 2 days for hypotension. Although blood pressure returned to normal, the patient had the following abnormal biochemical blood results: pH 7.32, PC02 5.2, P0211.1, Sodium 147 mmoUL, Potassium 3.5 mmoUL, Chloride 119 mmoUL, Bicarbonate 19.5. The most likely diagnosis is:

A 57-year-old woman, who has recently returned from a holiday in America, presents with dull grey-brown patches in her mouth and the palms of her hand which she has noticed in the last week. She has also noticed she gets very dizzy when rising from a seated position and is continually afraid of fainting. The most likely diagnosis is:

A 36-year-old woman presents to the rheumatology outpatient clinic with a two-month history of stiff hands and wrists. She mentions that the pain is particularly bad for the first few hours after waking up and is affecting her work as a dentist. On examination, the wrists, metacarpophalangeal joints and proximal interphalangeal joints are swollen and warm. What is the most likely diagnosis?

A 55-year-old man presents to his GP with a 2-week history of pain in his hands. The pain is particularly bad in his right hand. On examination, brown discoloration of the nails with onycholysis is noted and the distal interphalangeal joints are tender on palpation. What is the most likely diagnosis?

A 75-year-old woman presents to accident and emergency complaining of pain in her knees. She mentions that this has been troubling her for several months. Pain is generally worse in the evenings and after walking. On examination, there are palpable bony swellings on the distal interphalangeal joints of the fingers on both hands. In addition, there is reduced range of movement and crepitus in the knees. What is the most likely diagnosis?

A 30-year-old man presents to his GP with a 1-week history of painful, swollen knees and a painful right heel. Further history reveals that he has been experiencing burning pains while urinating for the past 2 weeks and that his eyes have become red and itchy. What is the most likely diagnosis?

A 70-year-old woman presents to accident and emergency with sudden onset pain and swelling in the right knee. Her past medical history includes hypertension and hypercholesterolaemia. She is currently taking aspirin, ramipril and simvastatin. On examination, she is apyrexial and the right knee is swollen. There is reduced range of movement in the knee due to swelling and pain. X-ray of the right knee shows chondrocalcinosis. What is the most likely diagnosis?

A 70-year-old woman presents to her GP complaining of severe unilateral headache over the left side of her head. On further questioning, she mentions that she has been having bilateral shoulder and neck pains over the past few weeks. She has also been feeling lethargic. On examination, the left side of her scalp is painful to touch. What is the most likely diagnosis?

A 60-year-old woman presents to her GP with a two-month history of lethargy and weakness. She mentions that she is finding it increasingly difficult to climb the stairs and do the housework. On examination, there is wasting and weakness of the proximal muscles in the upper and lower limbs. What is the most likely diagnosis?

A 65-year-old man presents with central crushing chest pain for the first time. He is transferred immediately to the closest cardiac unit to undergo a primary percutaneous coronary intervention. There is thrombosis of the left circumflex artery only. Angioplasty is carried out and a drug-eluding stent is inserted. What are the most likely changes to have occurred on ECG during admission?

A 67-year-old man presents to accident and emergency with a 3-day history of shortness of breath. On examination you palpate the radial pulse and notice that the patient has an irregular heart beat with an overaU rate of 140 bpm. You request an electrocardiogram (ECG) which reveals that the patient is in atrial fibrillation. Which of the foUowing would you expect to see when assessing the JVP?

A 78-year-old woman is admitted to your ward following a 3-day history of shortness of breath and a productive cough of white frothy sputum. On auscultation of the lungs, you hear bilateral basal coarse inspiratory crackles. You suspect that the patient is in congestive cardiac failure. You request a chest x-ray. Which of the following signs is not typically seen on chest x-ray in patients with congestive cardiac failure?

A 56-year-old man presents to your clinic with symptoms of exertional chest tightness which is relieved by rest. You request an ECG which reveals that the patient has first degree heart block. Which of the following ECG abnormalities is typically seen in first degree heart block?

A 52 year-old woman has been treated for several years with amlodipine and lisinopril for what has been presumed to be primary hypertension. She is seen by her GP having complained of persistent left loin pain. Her BP is 150/95 mmHg. She is tender in the left loin and both kidneys appear to be enlarged. On urine dipstick testing, there is microscopic haematuria. Which of the foUowing is likely to be the most appropriate investigation at this point?

A 41-year-old woman is referred for assessment after suffering a second pulmonary embolus within a year. She has not been traveUing recently, has not had any surgery, does not smoke and does not take the oral contraceptive pill. She is not currently on any medication as the diagnosis is retrospective and she is now asymptomatic. What should be the next step in her management?

A 32-year-old woman attends her GP for a routine medical examination and is noted to have a mid-diastolic murmur with an opening snap. Her blood pressure is 118/71 mmHg and the pulse is regular at 66 beats per minute. She is entirely asymptomatic and chest x-ray and ECG are normal. What would be the most appropriate investigation at this point?

A 44-year-old woman presents with episodes of headaches, associated with anxiety, sweating and a slow pulse rate. At the time of her initial consultation, her blood pressure was 150/95 mmHg seated, but 24 hour ambulatory monitoring shows a peak of 215/130 mmHg, associated with the symptoms described above. Which of the foUowing would be your initial diagnostic procedure?

A 25-year-old woman with known mitral valve prolapse develops a low grade fever, malaise and night sweats within a couple of weeks of a major dental procedure. Examination reveals a pulLE rate of 110/minute, which is regular, tender vasculitic lesions on the finger pulps and microscopic haematuria. Which investigation is most likely to provide a definitive diagnosis?

A 29-year-old woman goes to see her GP complaining of fatigue and palpitations. She says she has also lost weight, though without dieting. On examination, her pulse rate is approximately 120/min and irregularly irregular. Her blood pressure is 142/89 mmHg and her body mass index is 19. There are no added cardiac sounds. The ECG confirms the diagnosis of atrial fibrillation. What would you suggest as the most useful next investigation.

You are discussing a patient with your registrar who has become acutely short of breath on the ward. After performing an arterial blood gas, you have high clinical suspicion that the patient has a pulmonary embolism. Which of the following is the investigation of choice for detecting pulmonary embolism?

You see a 46-year-old man who has presented to accident and emergency with an acute onset of shortness of breath. Your registrar has high clinical suspicion that the patient is suffering from a pulmonary embolism and tells you that the patient's ECG has changes pointing to the suspected diagnosis. From the list below, which of the following ECG changes are classically seen?

You are asked to request imaging for a patient with a suspected pneumothorax who you have just examined in accident and emergency. Which of the following would be the most appropriate first step imaging modality?

A 56-year-old woman who has recently been discharged from your ward, with oral antibiotics for right basal community-acquired pneumonia, is re-admitted with transient pyrexia and shortness of breath. She is found to have a right-sided pleural effusion which is drained and some pleural aspirate sent for analysis. The results reveal an empyema. Which of the following, from the pleural aspirate analysis, would typically be found in a patient with an empyema?

You are told that a patient in clinic has been diagnosed with cystic fibrosis using the sodium chloride sweat test. Which of the following results from the latter test would indicate a positive diagnosis of cystic fibrosis?

You are asked by your registrar to request an imaging investigation for a 49-year- old woman with jaundice and abdominal pain. She has a past medical history of gallstones and you suspect this is a recurrence of the same problem. The most appropriate imaging investigation is:

You see a 56-year-old man in your clinic with suspected alcoholic liver disease. Liver function tests reveal a bilirubin of 36 iu/L, AST of 150 iu/L, ALT 75 iu/L and ALP 100 iu/L. Which of the following blood test parameters would support a diagnosis of alcoholic-related liver disease?

A 56-year-old man, diagnosed with emphysema, presents with a one-month history of jaundice and ascites. Your registrar suspects that this patient may have liver disease secondary to atantitrypsin deficiency. Select the most likely mode of inheritance from the list below:

A patient on your ward is diagnosed with hepatocellular carcinoma. You are asked to perform a tumour marker level on this patient. Which of the following tumour markers are elevated in hepatocellular carcinoma?

A 64-year-old woman attends your clinic with a 2-week history of jaundice. Over the last three months the patient has lost 10 kg. Associated symptoms include decreased appetite, dark urine and pale stools. On examination, the patient is jaundiced, her abdomen is soft and you can palpate a painless mass in the right upper quadrant. From the list of answers below, select the initial most appropriate investigation that you would request for this patient:

A 33-year-old woman presents to accident and emergency with severe right flank pain. The pain started 3 hours ago and is not constant, occasionally moving towards her right iliac fossa. The patient also feels nauseous and has a low-grade fever. The most appropriate investigation is:

A 21-year-old woman complains of urinary frequency, nocturia, constipation and polydipsia. Her symptoms started 2 weeks ago and prior to this she would urinate twice a day and never at night. She has also noticed general malaise and some pain in her left flank. A urine dipstick is normal. The most appropriate investigation is:

A 58-year-old man presents with breathlessness, he reports feeling unwell over the last three months with nausea, vomiting and difficulty breathing. You notice his ankles are swollen and he has bruises on his arms. The patient mentions he has not been urinating as often as normal. The most appropriate investigation is: