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1

A 70 year old man has pain on chewing his food. He has tenderness in the temporal region and proximal muscle weakness in his arms. Which is the single most appropriate treatment for him?
Select one:
A. aspirin
B. ibuprofen
C. hydrocortisone
D. methyl prednisolone
E. prednisolone

The diagnosis is giant cell arteritis and the treatment for this is oral prednisolone.

2

A 93 year old man has a series of falls. He has been progressively forgetful and has had episodic hallucinations over the past year. Which is the single most likely diagnosis?
Select one:
A. Alzheimer’s disease Incorrect
B. diffuse Lewy body disease
C. multi-infarct dementia
D. multisystem atrophy
E. Parkinson’s disease

This is a classical description of Diffuse Lewy Body disease – drop attacks and neuropsychiatric symptoms occur early in the disease.

3

A 56 year old obese man has recurrent abdominal pain radiating to his back and made worse by eating spicy foods and bending over. Antacids relieve his pain. Which is the single most appropriate next investigation?
Select one:
A. abdominal x-ray
B. abdominal CT scan
C. double contrast barium meal
D. Helicobacter pylori breath test Incorrect
E. oesophagogastroduodenoscopy (OGD)

He should have an OGD – his age makes pathology other than GORD morecommon, this is the recommended course of action for all those over 45 years of age

4

A 79 year old woman has urinary frequency, urgency and urgency incontinence. Which single investigation is most appropriate to arrange next?
Select one:
A. dipstick urinalysis
B. frequency volume chart (bladder diary)
C. multi-channel cystometry
D. renal tract ultrasound
E. video urodynamics

A dipstick urinalysis is the next simplest examination to perform; all others either will add nothing to the diagnosis or are unnecessarily invasive.

5

A 65 year old man has a persistent high temperature, profuse diarrhoea and abdominal pain two weeks after finishing antibiotics following an elective hip replacement. There are reddened ulcers and yellowish plaques on his colonic mucosa at sigmoidoscopy. Which is the single most likely diagnosis?
Select one:
A. Clostridium perfringens enterocolitis
B. Crohn’s disease
C. pseudomembranous colitis
D. ulcerative colitis
E. viral gastroenteritis

Severe inflammatory changes in the mucosa and antibiotic use suggest pseudoembranous colitis due to clostridium difficile infection.

6

A 87 year old man has a longstanding, non healing ulcer on the side of his nose. It has an opalescent sheen and multiple telangectases running over the surface. The centre is depressed and necrotic. Which is the single most likely diagnosis?
Select one:
A. basal cell carcinoma
B. keratoacanthoma
C. melanoma
D. solar keratosis
E. squamous cell carcinoma

The basal cell carcinoma typically has the features as described and may also have a depressed centre.
Features:
- non healing ulcer (often on side of nose)
- opalescent sheen
- multiple telangectases
- centre depressed / necrotic

7

An 80 year old woman inpatient with schizophrenia has a temperature of 38.6oC and increasing rigidity. Which is the single most likely cause of her symptoms?
Select one:
A. haloperidol and amitriptyline
B. haloperidol and diazepam
C. haloperidol and flupenthixol
D. haloperidol and sertraline
E. haloperidol and zopiclone

The diagnosis here is neuroleptic malignant syndrome which can be precipitated by either high doses of a single anti-psychotic medication, but more commonly by the use of combinations of anti-psychotic medication (haloperidol and flupenthixol)

8

A 50 year old man with epigastric burning pain has an OGD which shows gastro-oesophageal reflux. Which single oral medication is the most effective for his condition?
Select one:
A. bismuth
B. gaviscon
C. magnesium trisilicate
D. omeprazole
E. ranitidine

A PPI is more effective than the H2 antagonist.
Omeprazole

9

A 47 year old man had a history of chronic alcohol misuse. Which single enzyme would most likely be found to be raised in his serum?
Select one:
A. alcohol dehydrogenase
B. alkaline phosphatise
C. amylase.
D. gamma glutamyl transferase
E. pancreatic lipase

Gamma GT is commonly raised in patients who consume large amounts of alcohol.

10

A 75 year old man who smokes 20 cigarettes a day has had a worsening productive cough, high temperature, fatigue and shortness of breath for four days. His oxygen saturations is 91% on room air and he has focal coarse crepitations at the left base. Which single organism is the most likely cause of his symptoms?
Select one:
A. Haemophilus influenza
B. Legionella pneumonia
C. Mycoplasma pneumonia
D. Staphylococcus aureus
E. Streptococcus pneumonia

the commonest cause of community acquired pneumonia is streptococcus pneumonia

11

A 67 year old woman has had shortness of breath and a productive cough for two days. Her temperature is of 38˚C, pulse rate 100bpm, respiratory rate 26, oxygen saturations 93%, and BP 110/50 mmHg. Her abbreviated mental test score is 6/10. Blood tests show:
Haemoglobin 13.0g/dL
White cell count 15 x 109/L
Urea 9 mmol/L
Creatinine 105µmol/L
Which is the single most appropriate action to take?
Select one:
A. admit to hospital and consider ITU referral
B. admit to hospital for immediate NIV
C. admit to hospital to the medical assessment unit
D. discharge home on oral antibiotics
E. discharge home with home iv antibiotic service

she is hypoxic, with altered mentation and evidence of sepsis; she could deteriorate rapidly and so needs urgent high dependency care
The correct answer is: admit to hospital and consider ITU referral

12

A 49 year old woman is waiting for a liver transplant. Which single condition is the most likely indication in this woman?
Select one:
A. alcoholic liver disease
B. chronic active hepatitis
C. Hepatitis A liver disease
D. Hepatitis E liver disease
E. hepatocellular carcinoma

hepatitis c, alcoholic liver disease and primary biliary cirrhosis are the commonest indications for liver transplantation in the uk
The correct answer is: alcoholic liver disease

13

A 20 year old woman has repeated episodes of self harm, feelings of emptiness and intense and unstable relationships. Which is her single most likely diagnosis?
Select one:
A. antisocial personality disorder
B. avoidant personality disorder
C. borderline personality disorder
D. histrionic personality disorder
E. narcissistic personality disorder

Feedback: typical features of emotional instability, impulse to self harm and inability to form stable relationships

The correct answer is: borderline personality disorder

14

A 50 year old man with schizophrenia takes olanzapine. Which single condition is he more at risk of developing?
Select one:
A. COPD
B. diabetes mellitus
C. hypothyroidism
D. nephrogenic diabetes insipidus
E. pancreatitis

olanzapine most of all atypical anti-psychotics cane lead to diabetes, as well as weight gain and metabolic syndrome
The correct answer is: diabetes mellitus

15

A year 4 medical student is shadowing an FY2 on ITU. The FY2 asks the medical student to take blood from an unconscious patient. The patients close family are at the bedside. The medical student has completed her venepuncture training. Which is the single most appropriate action for the medical student to take?
Select one:
A. ask the consultant’s permission before taking blood
B. ask the relatives’ permission before taking blood Correct
C. explain to the FY2 she cannot take the blood as the patient cannot give consent
D. get written consent from the next of kin before taking blood
E. offer to assist the FY2 but not take the blood herself

Feedback: getting oral consent from the next of kin is most appropriate
The correct answer is: ask the relatives’ permission before taking blood

16

You are a year 4 student on a clinical attachment. You have been asked to take a history from a 21 year old woman who may have a sexually transmitted infection. Which is the single most appropriate way to introduce the sexual history?
Select one:
A. ask whether she is currently in a relationship.
B. explain that any information she gives is completely confidential.
C. explain that you need to ask about her sexual history, as she may have a sexually transmitted infection.
D. say that you have some routine questions you ask all patients.
E. say you would like to ask some more personal questions.

Feedback: this is an open ended approach introducing the subject of more intimate questioning which will include sexual history
The correct answer is: say you would like to ask some more personal questions.

17

A 23 year old university student wakes up in the middle of the night with vomiting, malaise and a high temperature. He is admitted to hospital for observation. Within two hours, he has a stiff neck and convulses. Which is the single most likely diagnosis?
Select one:
A. Haemophilus influenzae type B meningitis
B. Listeria meningitis
C. Meningococcal meningitis
D. Pneumococcal meningitis
E. Tuberculous meningitis

meningism in a young patient should alert you to the possibility of meningococcal infection and promt immediate antibiotic treatment before LP
The correct answer is: Meningococcal meningitis

18

A 42 year old obese man is noted by his GP to have glucose in his urine. Two fasting blood glucose levels were 7.3 and 7.4mmol/L. Which is the single most appropriate management option for this man?
Select one:
A. admit to hospital for insulin therapy
B. advice on diet and exercise
C. start insulin therapy
D. metformin treatment
E. sulphonylurea treatment

He has impaired glucose tolerance (fasting blood glucose > 7 or random glucose > 11.1) and should be given advice on diet and exercise – he is at risk of developing Type 2 diabetes
The correct answer is: advice on diet and exercise

19

A 34 year old man has fatigue and shortness of breath. His ECG recording is below. He has a cardiac biopsy, and the image is also below.
ECG - ST elevation
Cardiac biopsy - inflammatory infiltrate
What is the single most likely diagnosis?
Select one:
A. cardiac amyloidosis
B. infective endocarditis
C. myocardial infarction
D. myocarditis
E. pericarditis

The S-T elevation and neutrophilic infiltration of the myocardium are consistent. ST changes and T wave inversion can occur in myocarditis.
The correct answer is: myocarditis

20

A 64 year old man has central chest pain. Which single set of findings is most likely in the diagnosis of myocardial infarction?
Select one:
A. high troponin T and high creatine kinase (muscle-brain) (CK-MB)
B. high troponin T and high lactate dehydrogenase (LDH)
C. high troponin T and low CK-MB
D. normal troponin T and high LDH
E. normal troponin T and normal CK-MB

A. Both Trop and CK-MB indicate myocardial damage in the context of myocardial infarction.
The correct answer is: high troponin T and high creatine kinase (muscle-brain) (CK-MB)

21

A 25 year old woman has a high temperature, haematuria, splenomegaly and splinter haemorrhages. Which is the single most likely diagnosis?
Select one:
A. Burkitt’s lymphoma
B. carcinoid syndrome
C. endocarditis Correct
D. enteric fever
E. pneumococcal pneumonia

The combination of features is characteristic of endocarditis
The correct answer is: endocarditis

22

A 68 year old woman had a post mortem. The lungs were heavy and macroscopically had scattered firm grey areas. Histologically, the alveolar spaces were filled with neutrophils. Which is the single most likely diagnosis?
Select one:
A. adult respiratory distress syndrome
B. bronchopneumonia Correct
C. chronic obstructive pulmonary disease
D. CMV pneumonitis
E. tuberculosis

The features of neutrophil infiltration are consistent with bronchopneumonia. For those who put ARDS as an answer, the pathologic features of the lung in ARDS derive from severe injury to the alveolo-capillary unit. This leads to a pulmonary oedema due to leakage of protein rich fluid and also cellular necrosis, epithelial hyperplasia, inflammation, and fibrosis.
The correct answer is: bronchopneumonia

23

A 68 year old woman has acute shortness of breath. Which single clinical finding would indicate pulmonary oedema?
Select one:
A. dry cough
B. fine inspiratory crackles Correct
C. inspiratory wheeze
D. polyphonic wheeze
E. prolonged expiration

fine, late inspiratory crackles are consistent with pulmonary oedema
The correct answer is: fine inspiratory crackles

24

A 76 year old man has a persistent discharge from his right ear. The image is that seen through the otoscope.
Which is the single most likely diagnosis?
See mass in ear on otoscope
Select one:
A. cholesteatoma
B. foreign body
C. otitis externa
D. otitis media
E. perforation of ear drum

Cholesteatoma occurs if skin from the inner side of the tympanic membrane sloughs off and mixes with ear wax that penetrates to the middle ear and fails to drain through the Eustachian tube. The accumulation of dead skin and wax causes a cyst-like mass, the cholesteatoma. If left untreated the mass can cause serious damage to the eardrum and ossicles. In serious cases, cholesteatomas can erode into the mastoid and can cause cerebral infection.
The correct answer is: cholesteatoma

25

A 70 year old man has shortness of breath secondary to a pleural effusion. The protein content of the pleural fluid is 45 g/L. Which is the single most likely cause of his effusion?
Select one:
A. congestive cardiac failure
B. chronic liver failure
C. malabsorption
D. nephrotic syndrome
E. non small cell lung cancer

The protein content of the effusion fluid which is high (> 30 g/L)suggests an exudate. The causes of this are chronic inflammation and malignancy. All the other causes are transudates (generally protein content

26

A 26 year old mother of a son with haemophilia A has a third acute haemarthrosis following a relatively minor fall. Which single factor best describes the most likely reason for this?
Select one:
A. a low level of Factor VIII is associated with carrier status in females
B. a high level of Factor VIIIc is associated with carrier status in females
C. a spontaneous mutation of the responsible gene has occured
D. factor VIII resistance is a characteristic feature in mothers of haemophiliacs
E. the mother has a haemophiliac mother

Haemophilia A is due to Factor VIII deficiency and Haemophilia B is due to factor IX deficiency. Both are X linked disorders. This means that an affected X chromosome is commonly paired with an unaffected X chromosome, thus conferring carrier status in females which may lead to low Factor VIII levels.
The correct answer is: a low level of Factor VIII is associated with carrier status in females

27

A 38 year old woman has had a cough and malaise for two days. Her chest radiograph is below.
CXR - wedge shape in R middle zone
Which is the single most likely diagnosis?
Select one:
A. atypical pneumonia
B. broncho-alveolar cell carcinoma
C. lobar pneumonia
D. pleural effusion
E. right lower lobe collapse

There is consolidation of the right lower lobe along anatomical boundaries – hence lobar pneumonia
The correct answer is: lobar pneumonia

28

A 62 year old woman has facial redness and swelling following a superficial wound.
Which is the single most appropriate treatment for this condition?
Select one:
A. intravenous amikacin
B. intravenous benzylpenicillin
C. intravenous ciprofloxacin
D. intravenous erythromycin
E. intravenous flucloxacillin

This is erysipelas. It is typically a streptococcal disease – best treated with Benzylpenicillin
The correct answer is: intravenous benzylpenicillin

Erysipelas also known as "Ignis sacer", "holy fire", and "St. Anthony's fire" is an acute infection of the upper dermis and superficial lymphatics, usually caused by streptococcus bacteria. Erysipelas is more superficial than cellulitis, and is typically more raised and demarcated.

Symptoms: high fevers, shaking, chills, fatigue, headaches, vomiting, and general illness within 48 hours of the initial infection. The erythematous skin lesion enlarges rapidly and has a sharply demarcated raised edge. It appears as a red, swollen, warm, hardened and painful rash, similar in consistency to an orange peel. More severe infections can result in vesicles, bullae, and petechiae, with possible skin necrosis. Lymph nodes may be swollen, and lymphedema may occur. Occasionally, a red streak extending to the lymph node can be seen.

29

Which is the single major criterion in the diagnosis of rheumatic fever?
Select one:
A. athralgia
B. erythema marginatum Correct
C. fever
D. previous history of rheumatic fever
E. prolonged PR interval

Major criteria of rheumatic fever are: Migratory polyarthritis, Carditis, Subcutaneous nodules, Erythema marginatum and Sydenham's chorea.
The correct answer is: erythema marginatum

CASES:
Carditis
Arthritis
Sydenham's chorea
Erythema marginatum
Subnutaneous nodules

30

A 50 year old Caucasian man has a blood pressure of 158/90mmHg. He is a not a smoker or diabetic, with no other significant history other than being overweight. Which is the best initial management?
Select one:
A. advise lifestyle measures.
B. ACE inhibitor
C. beta blocker
D. calcium channel antagonist
E. no treatment required

The BP is borderline high, and target for treatment is over 160/100 in patients with no risk factors. The correct thing to do is offer lifestyle advice and repeat the BP measurement
The correct answer is: advise lifestyle measures.