A 16-year-old male presents to you with multiple comedones on his face and back. On examination you notice the presence of multiple comedones on the patient's forehead, cheeks and back with peri-lesional erythema. There are no nodules or cysts in these areas. You diagnose the patient with moderate acne. The most appropriate treatment is:

A 47 -year-old woman patient presents with a facial, macular 'butterfly rash'. Rheumatological investigations do not reveal that the patient has SLE. You suspect drug-induced SLE-like syndrome and assess her medication history. Which one of the following drugs is most likely to be responsible for this condition?

A 74-year-old woman patient, who is being treated for chest infection following an elective gastrectomy, develops profuse diarrhoea. A stool sample is collected and microscopy, culture and sensitivity reveal Clostridium difficile toxin. What is the most appropriate treatment?

A 30-year-old woman aid worker, who has returned from a trip to Haiti 1 day ago, presents to accident and emergency with profuse watery diarrhoea. This started suddenly and she describes her stool as being profuse and colourless. On examination her pulse is 120 bpm. What is the most appropriate treatment?

A 70-year-old man presents to accident and emergency with a 1-day history of a painful rash across his trunk. He has a past medical history of hypertension and hypercholesterolaemia. On examination, there is a well-demarcated blistering rash on the right side of his trunk. What is the most appropriate treatment?

A 27-year-old investment banker presents to accident and emergency with a 4-day history of painful rash on his penis and testicles. He also reports feeling generally run down with a fever and myalgia. He returned from a trip to New York a week ago. On examination, there is a painful vesicular rash over his penis and testicles. What is the most appropriate treatment?

A 34-year-old man presents to his GP with a painless hard penile ulcer. Venereal Disease Research Laboratory tests and Treponema paUidum haemagglutination assay confrrm the diagnosis of primary syphilis. What is the most appropriate treatment for this patient?

A 76-year-old man has a 4-day history of profuse watery diarrhoea coupled with abdominal pain. He was seen by his GP 2 weeks ago and started on oral amoxicillin for a lower respiratory tract infection. Stool sample analysis reveals Clostridium difficile enterotoxin. His observations are within normal range and the patient is apyrexial. Which of the following is the most appropriate treatment for this patient's condition?

A 50-year-old man is diagnosed with type 2 diabetes and you advise an improved diet alongside exercise. You mention monitoring the patient's HbAlc levels until the glucose becomes more stable. What is the most appropriate HbAlc target?

A 24-year-old woman presents with increasing breathlessness on exertion, which has been developing over several months. There are no abnormal physical signs on examination. On the ECG, there is right axis deviation and an R wave in Vl, with peaked P waves. Chest x-ray showed prominent hilar vessels with sparse vasculature peripherally in the lungs. Doppler echocardiography revealed a pulmonary artery pressure of 60 mmHg and primary pulmonary hypertension was diagnosed. Which of the following medications would not be appropriate in managing this patient?

An 18-year-old man presents with a 3-day history of fever, vomiting and headaches on waking in the morning. He has recently started at university and denies taking any illicit substances prior to or during his time at university. He has tried paracetamol but they have not helped. He decided to see a doctor when his neck became painful and stiff to move. On further examination, a non-blanching petechial rash is discovered. The most appropriate management is:

A 46-year-old woman with atrial fibrillation is seen in clinic following an episode of syncope while shopping. She has a family history of epilepsy and a past medical history of breast cancer. She remembers feeling dizzy for a couple of seconds then waking up on the floor. What is the most useful step in management?

You are told by your registrar that a 66-year-old woman from a residential home has been admitted with a right mid-zone community-acquired pneumonia. She is very drowsy and her CURB-65 score is 4. On admission, the patient's oxygen saturations are 91-92 per cent on room air, respiratory rate of 20, temperature of 37.7°C, P02 7.1 kPa and PC02 4.7 kPa. Her oxygen saturations have improved to 95 per cent on 15 L 02 via a non-rebreather oxygen mask. From the list below, which is the most appropriate management plan for this patient?

A 69-year-old man presents with confusion. His wife reports he has become increasingly depressed and confused in the last month. Prior to this, he had been complaining of pain in his right arm and abdomen but he refused to visit his GP. The patient has brisk reflexes, reduced skin turgor, sunken eyes and an x-ray of his right arm shows lytic lesions. The most appropriate management is:

A type 2 diabetic patient has been taking metformin with good effect for the last four months. He has started to lose weight and maintained good glucose control. In the last two months, however, the patient has been persistently hyperglycaemic despite increased metformin dosage and HbAlc targets have not been achieved. The most appropriate management is:

A 28-year-old junior doctor has been complaining of a headache for the last 6 hours. It started gradually, intensifying slowly and involving the entire cranium but over the last hour she has noticed that turning her head is uncomfortable. She feels generally unwell and prefers to lie in a dark room. Her boyfriend has noticed that she seems irritable. On examination, heart rate is 110, blood pressure is 89/60. She is flushed and has warm extremities. She exhibits photophobia and there is neck stiffness. Close examination of her skin reveals no rashes. Kernig's sign is negative. What is the most important next step in management?

A 45-year-old man presents with a 1-day history of severe, excruciating pain in his right flank, vomiting and fever. He describes the pain as 'needle-like' and it moves towards his groin. He has tried diclofenac which has had little effect. When passing urine, the pain increased and his urine was blood-tinged. He denies any other symptoms or medical problems. The patient's temperature is 38°C and a CT scan shows a renal staghorn calculus. The most appropriate treatment is:

A 40-year-old man patient presents with visible haematuria. He denies any other symptoms such as fever or pain, and suffers from no other medical problems. He does not smoke or drink alcohol and denies any illicit substance abuse. The most appropriate management is:

A 60-year-old man who works for an oil company presents with a lesion on the temple that is bothering him as it is growing. It bled once when he knocked it. On examination, the lesion is 8 mm in diameter and is a flat, mildly erythematous patch with a few scales and a larger keratotic horn in the centre. There are no other lesions on inspection of his skin and no personal or family history of skin cancer. Which of the following is the most appropriate management plan?

A 45-year-old man who is a heavy smoker is recently diagnosed with chronic obstructive pulmonary disease (COPD). He has no documented acute exacerbations in the past. Which of the following treatment is NOT suitable in the management of COPD in this patient?

A 35-year-old woman is admitted to hospital with quick-onset shortness of breath. She has a past medical history of asthma. Her observations include a pulse rate 120 bpm, blood pressure 100/72 mmHg, respiratory rate 30/min and Sa02 88% on room air. On examination, she appears to be drowsy and exhausted. Her chest is quiet on auscultation. Arterial blood gases show: pH 7.35, Pa02 5.2 kPa, PaC02 4.9 kPa and bicarbonate 24 mmol!L. Which of the following would NOT be appropriate in the management of this case?

A 55-year-old overweight pub landlord presents with a several-year history of episodic acute painful joint swelling that started in his left big toe and now affects his knees. Symptoms improve with use of diclofenac. Gout was diagnosed on his first hospital visit, however this now appears recurrent. He developed an acute attack in his left knee 2 days ago. Which of the following represents the best plan for prophylaxis?

An 83-year-old man who was diagnosed as having Parkinson's disease 3 years ago has been treated with levodopa (L-DOPA). Whilst he initially responded well to therapy, he has started to be increasingly still, and has fallen more in the last 4 months despite no intercurrent illness or change in L-DOPA therapy. Which is the best management option?

A 42-year-old woman with menorrhagia is complaining of tiredness. The GP does some blood tests, which reveal hypochromic microcytic anaemia, a decreased ferritin level and a raised total iron binding capacity. Platelets were slightly raised. Which of the following is the best treatment for this anaemia?

A 35-year-old man presents with a 2-day history of right-sided facial weakness.He is otherwise fit and well. There is no past history of neurological symptoms. There is no history of preceding infection. On examination, the middle ear is normal, the salivary glands are not enlarged, and there are no other cranial nerves affected. The forehead is not spared. Neurological examination of the limbs is unremarkable. Routine investigations are all normal. Which of the following represents the most reasonable management plan?

A 55-year-old Asian man with known thalassaemia trait registers with a new GP and is found to have a mild microcytic anaemia on routine testing. He does not complain of any symptoms. What is the most appropriate treatment?

A 40-year-old man, previously fit and well, limps in to the emergency department with an acutely red, hot, swollen, exquisitely tender knee, which he holds rigid. He is tachycardic and has a temperature of 38.3°C. Which of the following represents the best approach to diagnosis and management?

A 48-year-old man is admitted to the emergency department vomiting blood. He has a blood pressure of 80/45 mmHg with a heart rate of 135 bpm. He is cool and clammy to the touch. Which of the following should NOT be in your immediate management of this patient?

A 25-year-old man presents with a severe outbreak of a dry erythematous itchy rash that is now widespread, despite having used a steroid cream prescribed by his GP. It appears to be eczema, and along with regular emollients for the dryness, and antihistamines for the itch, you would like to prescribe some very potent topical steroids for a brief period to attempt get on top of the outbreak. Which of the following is classed as a very potent topical steroid?

A 76-year-old man presents with a vesicular eruption on the left side of his forehead only. It is severely painful and the vesicles have started to crust over. On examination, the area affected is well-demarcated. You also note a red eye with apparent conjunctivitis. Given the most likely diagnosis, which of the following treatments is the most appropriate?

A 17-year-old girl shuffles awkwardly into clinic with her mother, who explains that her daughter has suffered from severe acne for the last few years and nothing that the GP has tried has shifted it. On examination, as well as several large pustules on her face and comedones, some scarring is beginning to develop. You would like to start oral isotretinoin (roaccutane). When counselling about side effects, which of the following would you NOT advise the patient?

A 67-year-old man is discharged from hospital following an incision and drainage of a large abdominal wall abscess. He needs someone to help change his wound packing regularly, however he is immobile and lives alone. Which member of the multidisciplinary team would be most appropriate to help?

A 68-year-old-man with atrial fibrillation (AF) is admitted electively for DC cardioversion, to be performed as a day-case procedure. However, the procedure is postponed to a later date. Which one of the following reasons could be responsible for the delay?

A 75-year-old man with congestive cardiac failure presents with atrial fibrillation. He is haemodynamically stable with a ventricular rate of 72. He has a good functional state, although ECHO cardiography revealed a dilated left atrium and mild mitral regurgitation. Which drug option would be most beneficial for this patient?

A 3-year-old boy who was involved in a motor vehicle crash sustained a significant head injury and had a Glasgow Coma Scale score of 8 on arrival in the emergency department. An endotracheal tube was placed shortly after his arrival, and the respiratory therapist is providing ventilation at 12 breaths/min with 100% oxygen via a bag-valve mask until a ventilator can be brought to the emergency department. Ten minutes later, the child becomes more restless and agitated. His heart rate has increased from an initialllO beats/min to about 150 beats/min, and he appears flushed. The monitor indicates that his oxygen saturation is 96%. Of the following, a TRUE statement about this child's ventilatory status is that

A 10-year-old boy (individual 111,1 in the pedigree) presents for evaluation of ligamentous laxity and multiple joint dislocations. The family history is notable for a father who has scoliosis and ligamentous laxity, a paternal aunt who has had retinal detachments and mitral valve prolapse, and a paternal grandmother who had joint dislocations and now has osteoarthritis. Based on the family history, the MOST likely pattern of inheritance of this connective tissue disorder is

You are asked to evaluate a 1-day-old infant who has mild clitoromegaly and palpable masses in the labial folds bilaterally. Chromosome studies reveal that the infant has an XY karyotype. Of the following, additional history is MOST likely to reveal that the infant's

The parents of a child who was diagnosed at birth with Beckwith-Wiedemann syndrome bring in the baby for his 2-month evaluation. They ask about future health problems and his prognosis now that his omphalocele has been repaired. Of the following, the child is MOST at risk for

You are discussing the common indications for chromosome analysis with a group of third-year medical students. Of the following, the MOST appropriate statement to include in your discussion is that

You and your colleagues are discussing implementation of routine developmental screening in your office. In your research, you have found that

A term infant is delivered vaginally following a pregnancy complicated by diabetes mellitus. His oral and nasal airways are suctioned and found to be patent and free of meconium. He has cyanosis and respiratory distress immediately following birth that requires intubation and assisted ventilation with 100% oxygen. Because no improvement is apparent in the next 5 minutes, he is admitted to the neonatal intensive care unit. His birth weight is 4,500 g. A chest radiograph reveals fmdings consistent with decreased pulmonary blood flow. Of the following, the MOST likely cause of respiratory distress in this infant is

You are seeing a 14-year-old boy in your office who complains of fever, facial pain, and cough at night. His mother states that he has had problems with sinusitis for the past few months and has required repeated antimicrobial therapy during this period. Physical examination reveals a temperature of 101 °F (38.3°C), yellow-green nasal discharge, and tenderness to palpation of the maxillary and frontal sinus regions. Of the following, the MOST likely pathogen associated with chronic sinusitis is

You are seeing a 2-month-old male infant who has trisomy 21 for a health supervision visit. The boy's mother expresses concern that the infant has been having "noisy breathing" during the past 2 to 3 weeks. The infant has been exclusively formula-fed and has had no choking or difficulty feeding. According to the mother, the noise, which occurs on inspiration, is louder when the infant is supine and when crying. She has not noticed any rhinorrhea, cough, or other upper respiratory viral illness symptoms. The infant was born via an uneventful vaginal delivery that did not require forceps. Apgar scores were 8 and 9 at 1 and 5 minutes, respectively. On physical examination, the infant, whose physical appearance is consistent with trisomy 21, is resting comfortably. His vital signs are appropriate for age, but you hear an audible noise during inspiration. Of the following, the MOST likely explanation for the infant's respiratory symptoms is

A 2-year-old boy is brought to your clinic because he has a nighttime cough. According to his mother, several times over the past few months he has awakened with a barking, nonproductive cough that improves by the next morning. She denies fever and rhinorrhea with the episodes. Evaluation of his lungs yields normal results. Of the following, the clinical feature that is MOST suggestive of spasmodic croup rather than recurrent laryngotracheobronchitis in this boy is

You are evaluating a 7-year-old boy who has sickle cell disease for a 5-day history of fever, rhinorrhea, headache, and worsening fatigue. Physical examination reveals a tired-appearing, pale boy who has a temperature of 101.5°F (38.6°C); heart rate of 150 beats/min; very pale conjunctivae and mucous membranes; and a faint diffuse, erythematous, lacy rash that is most prominent on his cheeks and trunk. Laboratory tests show a white blood cell count of 12x103/mcL (12x1091L), with 50% neutrophils, 45% lymphocytes, and 5% monocytes; hemoglobin of 4 gldL (40 giL); hematocrit of 16% (0.16); and reticulocyte count of less than 1% (0.01). Of the following, the MOST likely cause for this patient's present illness is infection with

A 3-year-old boy presents to the emergency department following the abrupt onset of coughing and wheezing. You order a chest radiograph for evaluation of a suspected foreign body aspiration. Of the following, the MOST appropriate statement regarding foreign body aspiration is that

A 15-year-old girl who has juvenile rheumatoid arthritis has been treated with ibuprofen 30 mglkg per day for 3 months. She has had epigastric abdominal pain for 1 month that has been unresponsive to empiric therapy with omeprazole 20 mg/day. You are considering adding misoprosto1100 meg four times daily to her current treatment regimen. Of the following, a TRUE statement regarding misoprostol is that the drug

The mother of an infant born at 34 weeks' gestation asks you whether any of the medications she was given prior to delivery will have any effect on her daughter's growth and development. Of the following, the MOST correct statement concerning drugs commonly used in labor is that

A 3-month-boy who has been previously healthy is brought to the emergency department with a 3-day history of rhinorrhea, mild cough, and wheezing. He has been afebrile and has had some difficulty feeding. His pulse oximetry reading is 90% on room air, respiratory rate is 60 breaths/min, and heart rate is 130 beats/min. Chest examination reveals mild subcostal retractions, scattered wheezes, and coarse crackles bilaterally. The rest of the physical examination findings are normal. Of the following, the pathogen that is MOST likely responsible for his symptoms is

A 17 -year-old girl presents with amenorrhea of 6 months' duration. One year ago she joined the cross country team at school. At that time, her periods had been regular, about every 26 days, and remained so for the 3-month running season. At the end of the season, she continued to run 5 miles a day to be more competitive for the subsequent season. She noticed that her menstrual flow was lighter for a few months preceding the amenorrhea. You suspect exercise-induced amenorrhea and recommend a decrease in exercise. Of the following, the factor MOST likely to be associated with a low bone density and stress fractures in this patient is