Paper 5

Question 1

Alzheimer’s disease
Which of the following statements regarding Alzheimer’s disease is FALSE?
A Cholinesterase inhibitors may halt progression
B Computed tomography (CT) or magnetic resonance imaging (MRI) may
show medial temporal atrophy
C Pathologically, extracellular beta-amyloid plaques are seen
D Pathologically, intracellular tau-protein neurofi brillary tangles are seen
E Short-term memory impairment is an early symptom

Answer 1

A. Cholinesterase inhibitors may halt progression

Question 2

Antibiotics with warfarin
A 78-year-old man taking warfarin for a metallic aortic valve presents
with 5 days of cough productive of purulent sputum, fever, anorexia and
confusion. He is diagnosed with community-acquired pneumonia and is
admitted for antibiotic therapy.
Which of the following antibiotics does NOT interact with warfarin?
A Ciprofl oxacin
B Clarithromycin
C Gentamicin
D Metronidazole
E Rifampicin

Answer 2

C. Gentamicin

Question 3

Management of hyperglycaemia
A 32-year-old man with known type I diabetes mellitus presents to the
emergency department with nausea and vomiting. His blood glucose level
was 24 mmol/L, with high blood ketones and K+ 4.5 mmol/L.
Which of the following management is NOT appropriate in this patient on
the fi rst day?
A Commence intravenous 0.9% normal saline of 1 L over 1 hour
B Start intravenous insulin infusion at a rate of 6 U/hour
C Start intravenous K+ supplement 40 mmol/L in the fi rst bag of 0.9%
normal saline
D Monitor blood glucose hourly
E Consider urinary catheter

Answer 3

C. Start intravenous K+ supplement 40 mmol/L in the first bag of 0.9%
normal saline

Question 4

Secondary prevention
Your consultant has heroically stented 72-year-old Mrs Harris’ coronary
arteries at 0200 hours over the weekend. Whilst reviewing her medication,
she asks you what you think she could do to prevent this happening again
and “spare these lovely nurses all this bother”.
The best course of action would be to:
A Advise her that alcohol is not a cause of heart disease
B Ask her if she smokes and encourage her to cut down on salt intake
C Ask her if she smokes and review her long-term blood pressure and blood
glucose
D Ask her if she smokes, check her lipid profi le, review her long-term blood
pressure and blood glucose and assess her pre-morbid mobility
E Encourage her to stop smoking and get out more

Answer 4

D. Ask her if she smokes, check her lipid profile, review her long-term
blood pressure and blood glucose and assess her pre-morbid mobility

Question 5

Investigation of hypothyroidism
A 43-year-old woman presents to her GP with a 3-month history of lethargy
and low mood. She noticed that she had gained 2 stones over the past 2
months, despite having a normal appetite. On examination, she looked
pale with periorbital puffi ness, with a bitemporal hemianopia. Her thyroid
gland was not palpable. Her thyroid function tests showed TSH 0.3 (range
0.5–5.5) mU/L , T4 3 (range 4.5–12.5) mg/dl.
Which investigation would be most useful in the diagnosis?
A 99m technetium (99mTc)scintigraphy scans
B Magnetic resonance imaging (MRI) of the brain
C Thyroid peroxidise antibodies
D Thyroid-stimulating hormone (TSH) receptor-blocking antibodies
E Ultrasound of the thyroid gland

Answer 5

B. Magnetic resonance imaging (MRI) of the brain

Question 6

Sickle cell disease
A 16-year-old boy with known sickle cell disease presents with painful
hands bilaterally after being out early in the morning for a run. He is
otherwise systemically well.
What should be your immediate management?
A Joint aspiration
B Malaria screen
C Referral to rheumatology
D Rehydration and analgesia
E X-rays

Answer 6

D. Rehydration and analgesia

Question 7

Substance use (2)
A 70-year-old woman has recently been admitted to hospital with a chest
infection and mild confusion. Unfortunately no informant was available,
hence a full history could not be taken. You are called to see her 2 days after
her admission because she was sleeping poorly, complaining of nausea and
sweating, and went on to have a seizure.
Which of the following is the most likely reason for this clinical picture?
A Alcohol withdrawal
B Opiate use
C Opiate withdrawal
D Sedative use
E Sedative withdrawal

Answer 7

E. Sedative withdrawal

Question 8

Skin manifestations of systemic disease (2)
A 16-year-old girl presents to the GP with an itchy rash. This is located on
both forearms and examination reveals evidence of blistering. She has a
history of coeliac disease but is otherwise systemically well.
What is the most likely diagnosis?
A Acrodermatitis enteropathica
B Candidiasis
C Dermatitis herpetiformis
D Leukoplakia
E Linea nigra

Answer 8

C. Dermatitis herpetiformis

Question 9

Hepatic haemangioma
A 32-year-old woman undergoes a contrast enhanced CT scan of her
abdomen to look for a cause of lower abdominal pain. Although no obvious
cause of the pain is found, there is a small cavernous haemangioma of the
liver.
What is the next step in management of this lesion?
A Anticoagulation with lifelong aspirin
B Chemotherapy
C Head CT to rule out cerebral haemangiomas
D No treatment necessary
E Surgical resection

Answer 9

D. No treatment necessary

Question 10

Oxygen therapy
A 65-year-old man with a longstanding history of chronic obstructive
pulmonary disease was admitted to the hospital with an acute exacerbation.
His observations include temperature 37.5°C, pulse rate 120 bpm, blood
pressure 140/90 mmHg, respiratory rate 28/min and saturations 84% on
room air. An arterial blood gas shows pH 7.31, PaO2 4.6 kPa, PaCO2 8.3 kPa
and bicarbonate 25.2 mmol/L.
What is the most appropriate percentage of O2 to be given initially?
A 28%
B 35%
C 40%
D 60%
E 100%

Answer 10

A. 28%

Question 11

Polycystic kidney disease (2)
A 43-year-old man has just been diagnosed with polycystic kidney disease
and is keen to know about potential risks or associated health problems.
Which of the following is not an extrarenal complication of polycystic
kidney disease?
A Bladder diverticuli
B Cerebral aneurysms
C Hepatic cysts
D Mitral valve prolapse
E Pancreatic cysts

Answer 11

A. Bladder diverticuli

Question 12

Myalgia
A 75-year-old woman presents with weight loss, anorexia and fatigue. She
has lost 2 stone in weight in the last 6 months and she has been investigated
for presumed dysphagia (she is not an excellent historian), which has found
nothing. Her daughter said the first thing she noticed was a reduced walking
ability and shoulder pain. You witness her struggle to stand up out of the
chair. She also comments brushing the back of her hair is now difficult. She
has tender shoulders to palpation. The blood tests reveal an erythrocyte
sedimentation rate (ESR) of 60 mm/hour and a CRP of 30 mmol/L.
What is the most likely diagnosis?
A Fibromyalgia
B Inclusion body myositis
C Myasthenia gravis
D Polymyalgia rheumatica
E Polymyositis

Answer 12

D. Polymyalgia rheumatica

Question 13

Hyperbilirubinaemia
During a routine medical for a work placement a GP discovered that a
33-year-old man who was otherwise fit and healthy had a raised bilirubin
level. He otherwise had entirely normal liver function tests and a full
blood count. He had no history of foreign travel or drug or alcohol abuse.
Repeated blood tests 1 month later showed a similar picture.
What is the most likely diagnosis?
A Crigler–Najjar syndrome
B Gilbert’s disease
C Haemolytic anaemia
D Hepatitis B
E Pancreatic cancer

Answer 13

B. Gilbert’s disease

Question 14

Drugs used in cardiac arrest
Which of the following drugs is used during cardiac arrest to improve the
coronary perfusion pressure?
A Adrenaline
B Amioderone
C Atropine
D Calcium gluconate
E Magnesium sulphate

Answer 14

A. Adrenaline

Question 15

Management of thyrotoxicosis
A 35-year-old woman presents to the GP with increased weight loss over
the past 2 months, with lid retraction, exophthalmos, and double vision.
Her thyroid-stimulating hormone (TSH) receptor antibody level is raised.
Which of the following is the first-line treatment in this patient?
A Beta-blockers
B Carbimazole therapy
C Intravenous hydrocortisone
D Radioactive iodine therapy
E Subtotal thyroidectomy

Answer 15

B. Carbimazole therapy

Question 16

Haemoptysis (1)
A 26-year-old woman from sub-Saharan Africa presents with two months
of haemoptysis and lethargy. In the last month she has lost half a stone
in weight and she frequently soaks the bedsheets with sweat. She has a
negligible smoking history.
What is the most likely diagnosis?
A Lung cancer
B Lymphoma
C Pneumocystis pneumonia
D Pulmonary embolism
E Tuberculosis

Answer 16

E. Tuberculosis

Question 17

Arterial blood gases (3)
A 33-year-old man presents to the emergency department with acute
shortness of breath. He appears exhausted and unable to provide a clear
history. An arterial blood gas reading shows pH 7.33, PaO2 7.3 kPa, PaCO2
6.9 kPa and bicarbonate 26 mmol/L on room air.
What abnormality do these results represent?
A Metabolic acidosis
B Metabolic alkalosis
C Respiratory acidosis
D Respiratory alkalosis
E Type 1 respiratory failure

Answer 17

C. Respiratory acidosis

Question 18

Dry eyes
A 38-year-old woman, with a history of autoimmune thyroid disease,
presents with persistently dry eyes for over a year. She denies any arthralgia,
rash, fatigue or any other symptoms. Schirmer’s test reveals <10 mm
wetting of filter paper in 5 minutes. Antibodies reveal positive anti-nuclear
antibodies, with positive anti-Ro and anti-La antibodies.
Which of the following represents the best course of management?
A Artificial tears
B Hydroxychloroquine
C Steroids
D Surveillance
E Tear duct surgery

Answer 18

A. Artificial tears

Question 19

Management of shortness of breath (3)
A 21-year-old woman is admitted to the emergency department with
increasing shortness of breath after taking oral amoxicillin, which
was started by her GP for a chest infection. Chest auscultation reveals
widespread wheeze bilaterally. Vascular access is secured.
Which of the following management options is NOT appropriate?
A Discontinue administration of the suspected drug
B Give intramuscular adrenaline immediately
C Give intravenous 5% dextrose immediately
D Give intravenous chlorphenamine
E Give intravenous hydrocortisone

Answer 19

B. Give intramuscular adrenaline immediately

Question 20

Management of decreased consciousness
A 29-year-old man with known type 2 diabetes mellitus and excess
alcohol intake was admitted to the emergency department with reduced
consciousness. He is on oral anti-diabetic agents (intermediate and longacting
sulphonylureas) for his diabetes. His friend who brought him said
that he had been drinking excessive quantities of alcohol that evening.
Which of the following managements is NOT appropriate in this case?
A Consider CT of the head
B Continue intravenous dextrose after the blood glucose level has returned
to within normal range
C Intravenous dextrose
D Intramuscular glucagon
E Send random blood glucose sample to the laboratory

Answer 20

D. Intramuscular glucagon

Question 21

Haemophilia
Which clotting factor is deficient in haemophilia A?
A VII
B VIII
C IX
D XI
E vWF

Answer 21

B. VIII

Question 22

Gastrointestinal pathology
A histology report for a specimen taken from the colon of a 24-year-old
woman reports “patchy areas of transmural non-caseating granulomatous
inflammation”.
What disease process does this suggest?
A Colonic adenocarcinoma
B Crohn’s disease
C Irritable bowel syndrome
D Tuberculosis
E Ulcerative colitis

Answer 22

B. Crohn’s disease

Question 23

Blood film
Which of the following conditions do not cause a leucoerythroblastic
picture on blood film?
A Chronic myeloid leukaemia
B Megaloblastic anaemia
C Metastatic spread to the bone marrow
D Myeloma
E Tuberculosis

Answer 23

B. Megaloblastic anaemia

Question 24

Lung cancer
A 55-year-old woman presents to the emergency department with a
1-month history of shortness of breath and weakness in both lower limbs.
She has a 15 pack/year smoking history and has recently been diagnosed
with diabetes by her GP. She has no other significant past medical history.
On examination, there is reduced air entry on the left lower lung zone. Her
chest X-ray shows a mass lesion on the left lower lobe.
An arterial blood gas reading shows: pH 7.53, PaO2 8.6 kPa, PaCO2 5.3 kPa,
bicarbonate 30.2 mmol/L.
The blood result shows: Na+ 137mmol/L, K+ 2.3, urea 4.8 mmol/L, creatinine
108 μmol/L.
A CT of the chest reveals a tumour invading the left lung and a percutaneous
lung biopsy confirms the diagnosis of lung cancer.
What biochemical abnormalities are shown and what is the most likely
histology of the lung cancer?
A Metabolic acidosis, non-small cell carcinoma
B Metabolic alkalosis, small cell carcinoma
C Metabolic alkalosis, non-small cell carcinoma
D Respiratory alkalosis, small cell carcinoma
E Respiratory alkalosis, non-small cell carcinoma

Answer 24

B. Metabolic alkalosis, small cell carcinoma

Question 25

Cavernous sinus lesions
Which of the following cranial nerves would be affected by pathology in
the cavernous sinus?
A II, III, IV and VI
B III and V
C III, IV and VI
D III, IV, VI and ophthalmic division of V
E III, IV, VI and V

Answer 25

D. III, IV, VI and ophthalmic division of V

Question 26

Cognitive impairment (2)
A 75-year-old man presents with a history of episodes of cognitive
impairment and memory deficits. His daughter seems perplexed that
at some times he seems entirely normal, however some days he seems
muddled and can’t remember anything. He occasionally claims to see
faces where there are none. He is a smoker and has chronic obstructive
pulmonary disease (COPD), but there is nothing else in his past medical
history. On examination he has a slow tremor present in his left thumb
when relaxed or distracted, but not present when he is moving his arm. The
arms appear to have a rigid tone, more on the left than the right. The rest of
the neurological and general examination appears normal.
Which of the following is the most likely cause?
A Depressive pseudodementia
B Frontotemporal dementia
C Korsakoff psychosis
D Lewy body dementia
E Vascular dementia

Answer 26

D. Lewy body dementia

Question 27

Complications of bone marrow transplant
One year after bone marrow transplantation from a matched donor to
treat non-Hodgkin’s lymphoma a patient re-presents complaining of
widespread skin irritation. The skin is exfoliated in areas and there is a
maculopapular rash, while the fingers are becoming sclerotic. He has not
been feeling himself for a while with episodes of diarrhoea and recurrent
chest infections.
What is the most likely reason for this?
A Acute graft rejection
B Chronic graft-versus-host disease
C Herpes zoster infection
D New-onset scleroderma
E Side effect of immunosuppressants

Answer 27

B. Chronic graft-versus-host disease

Question 28

Diagnosis of abdominal pain (5)
A 24-year-old woman presents with a 3-month history of vague right upper
quadrant pains. She has also noticed an abnormal vaginal discharge since
starting a new sexual relationship 4 months ago. On examination there is a
hepatic friction rub.
What is the most likely diagnosis?
A Fitz-Hugh–Curtis syndrome
B Hepatitis C
C HIV
D Liver abscess
E Liver infarct

Answer 28

A. Fitz-Hugh–Curtis syndrome

Question 29

Diagnosis of cough (7)
A 36-year-old man has a 1-month history of a non-productive dry cough.
He has also become more short of breath on exertion for the past 2 weeks. He
was a known intravenous drug abuser. Chest auscultation is unremarkable.
He is referred to the medical assessment unit for a chest X-ray, which
shows bilateral symmetrical interstitial infiltrates. A subsequent HIV test
is positive.
Which of the following is the most likely causative agent?
A Aspergillus fumigates
B Cytomegalovirus
C Histoplasma capsulatum
D Pneumocystis jirovecii
E Staphyloccocus aureus

Answer 29

D. Pneumocystis jirovecii

Question 30

Palpitations (2)
A 28-year-old woman with known neurofibromatosis type I presents to
her GP with palpitations and recurrent headaches that are not relieved by
paracetamol. She also feels dizzy and becomes sweaty during these episodes.
Her blood pressure is found to be 220/120 mmHg.
What is the most likely diagnosis?
A Acromegaly
B Carcinoid syndrome
C Cushing’s disease
D Thyrotoxicosis
E Phaeochromocytoma

Answer 30

E. Phaeochromocytoma

Question 31

Diagnosis of neurological dysfunction (3)
A 28-year-old Afro-Caribbean pregnant woman presents with a 2-month
history of tingling in her feet and difficulty walking, which has progressed
so that she is barely able to walk. She came to Britain 3 years ago from West
Africa and has struggled to find work since, has a 2-year-old son, and lives
in a flat with her boyfriend. She has been pregnant for 5 months. She has no
significant past medical history other than various diarrhoeal illnesses when
living in Africa – in particular she denies HIV. On examination, she looks
thin and the conjunctiva are pale. There are no cranial nerve abnormalities,
or abnormalities on the arms. In the legs, there is an increase in tone in the
legs, with a marked weakness to about grade 3 or 4 throughout both legs,
which is worse in the ankles. Knee jerks appear brisk, although the ankle
jerks are hard to elicit and appear absent. Plantar reflexes are upgoing.
There is a loss of light touch to just above the ankles, and there is absent
proprioception and vibration sense in the big toe joints.
Which of the following is the most likely diagnosis?
A Diabetic polyneuropathy
B Guillain–Barré syndrome
C HIV-related polyneuropathy
D Subacute combined degeneration of the cord
E Tabes dorsalis

Answer 31

D. Subacute combined degeneration of the cord

Question 32

Diagnosis of skin lesions (2)
A 60-year-old man presents with a 1.5 cm raised pigmented lesion on his
right arm. He is unsure how long it has been there.
Which feature on dermoscopy would suggest a malignant melanoma rather
than a benign naevus or a pigmented seborrhoeic keratosis?
A Erythema of border
B Granular surface
C Irregular pigment network
D Stuck-on appearance
E Telangectasia

Answer 32

C. Irregular pigment network

Question 33

Malignant melanoma (2)
A 60-year-old Caucasian woman who recently moved from Zimbabwe
presents with a growing pigmented lesion about 1 cm across with an
irregular border and a raised, darker patch within. You suspect melanoma
and excise the lesion.
Which of the following features of the tumour is the best prognosis indicator?
A Colour
B Diameter
C Grade
D Invasive depth
E Weight

Answer 33

D. Invasive depth

Question 34

Electrocardiogram (5)
Whilst on call, you are asked to review an ECG. It shows a long QT interval
followed by a burst of QRS complexes at 300 bpm with an overlying waxing
and waning R-wave amplitude, after which the ECG reverts back to its
previous pattern. The patient feels well.
You conclude that this was an episode of torsade de pointes and should
now:
A Advise the nurses to perform hourly observations
B Check the drug chart for possible causes
C Check the fluid balance chart
D Give anti-arrhythmics
E Send out a crash call

Answer 34

B. Check the drug chart for possible causes

Question 35

Diagnosis of chest infection (1)
A 75-year-old man presents with a 5-day history of cough productive of
green sputum, mild right-sided chest pain, worsening breathlessness, and in
the last day or so, confusion. He is previously fit and well with no background
of dementia. He was in hospital 2 months ago for an elective hernia repair.
On examination he has coarse crepitations at the right lung base, he has a
respiratory rate of 34/min, a temperature of 38°C, and has an abbreviated
mental test score of 6/10. Chest X-ray shows right lower zone consolidation
and a small degree of blunting of the right costophrenic angle.
Which of the following is the likely diagnosis?
A Aspiration pneumonia
B Empyema
C Hospital acquired pneumonia
D Mild or moderate community-acquired pneumonia
E Severe community-acquired pneumonia

Answer 35

E. Severe community-acquired pneumonia

Question 36

Emergency management (1)
A 16-year-old girl is seen by her general practitioner. She is lethargic and
“not feeling her usual self” according to her parents. On examination, she
has a stiff neck and a non-blanching purpuric rash on her trunk and legs.
Which of the following is the best course of action?
A Expectant management until there is deterioration
B Intramuscular benzylpenicillin and call ambulance
C Intramuscular benzylpenicillin and review in 12 hours
D Intravenous lorazepam and call ambulance
E Oral penciliin and review in 24 hours

Answer 36

B. Intramuscular benzylpenicillin and call ambulance

Question 37

Investigation of shortness of breath (2)
A 53-year-old retired truck driver presents to the general practitioner with
a 3-month history of productive cough. He also complains of gradual onset
of shortness of breath on exertion. He has to stop for breath after walking
about 100 m on level ground. He is a heavy smoker, but is otherwise fit and
well.
Which of the following investigations would be most useful in establishing
the cause of his symptoms?
A Chest X-ray
B Electrocardiogram
C Peak flow meter
D Spirometry
E Sputum cytology

Answer 37

D. Spirometry

Question 38

Diagnosis of chest pain (3)
A 54-year-old woman presents to her GP complaining of repeated incidents
of burning central chest pain. It mainly occurs when she lies down to go to
bed at night. She is overweight with a body mass index of 40. She uses GTN
occasionally but it doesn’t always relieve her symptoms. She doesn’t report
any shortness of breath or palpitations and examination is unremarkable.
What is the most likely diagnosis?
A Angina
B Gastro-oesophageal reflux disease
C Myocardial infarction
D Pancreatitis
E Sleep apnoea

Answer 38

B. Gastro-oesophageal reflux disease

Question 39

Hypoxia
You are called to see a 92-year-old woman on the ward. The patient has been
recovering from an exacerbation of heart failure. On arrival, the patient is
on 15 L/min oxygen and an intravenous drip. You find the patient’s oxygen
saturation is reading 88% on pulse oximetry. She is having prolonged
bouts of coughing, is reported by the sister as seeming physically weak for
her, and is delirious.
Which of the following would be the most appropriate initial course of
action?
A Check her fluid balance chart
B Check she is on regular paracetamol
C Keep checking the pulse oximeter hourly for deterioration
D Request a computed tomography (CT) pulmonary angiography
E Start her on antibiotics for hospital-acquired pneumonia

Answer 39

A. Check her fluid balance chart

Question 40

Management of hypothermia
A 46-year-old woman presents to the emergency department in a reduced
state of consciousness. Her blood glucose level was 9 mmol/L. On
examination, her body temperature was 33°C. She has non-pitting oedema
on the skin of her hands, feet and eyelids. No obvious head injury is noticed.
She has a thyroidectomy scar on her neck.
Bearing in mind the likely diagnosis, which of these is NOT appropriate in
the initial management?
A High-flow oxygen if the patient is cyanosed
B Intravenous hydrocortisone
C Intravenous lorazepam
D Parenteral triiodothyronine, given slowly
E Warm blanket

Answer 40

C. Intravenous lorazepam

Question 41

Diagnosis of diabetes
A 45-year-old man presents to his GP with lethargy and polyuria for the past
month. He has a strong family history of diabetes mellitus. A provisional
diagnosis of diabetes mellitus is made.
Which of the following investigations is NOT useful in establishing the
diagnosis?
A Fasting glucose level
B HbA1C level
C Oral glucose tolerance test
D Random glucose level
E Urine ketones

Answer 41

B. HbA1C level

Question 42

Medication review
An obese 48-year-old woman presented direct from work with fatigue and
shortness of breath. She has been started on treatment for acute coronary
syndrome but her oxygen saturation is now dropping and on review, you
feel this is iatrogenic.
Which medication is most likely to be at fault?
A Aspirin
B Atenolol
C Clopidogrel
D Glyceryl trinitrate
E Heparin

Answer 42

B. Atenolol

Question 43

Side effects of methotrexate
A 32-year-old woman is started on methotrexate for her newly diagnosed
rheumatoid arthritis.
Which of the following is NOT true regarding side effects and
contraindications of methotrexate?
A A baseline chest X-ray should be taken as pulmonary fibrosis is a potential
side effect
B Alcohol should be absolutely avoided whilst taking methotrexate
C Full blood count should be monitored as neutropenia and
myelosuppression are potential side effects
D Liver function tests should be monitored to watch for hepatic fibrosis
E Pregnancy should be avoided and if considering having a baby,
methotrexate should be switched to an alternative disease-modifying
anti-rheumatic drug

Answer 43

B. Alcohol should be absolutely avoided whilst taking methotrexate

Question 44

Raised intracranial pressure
A 55-year-old man presents to the hospital with a 4-month history of
headaches, which usually occur in the mornings. These are becoming more
frequent and severe.
Which of the following would suggest increased intracranial pressure?
A Jaw claudication
B Kernig’s sign
C Low opening pressure on lumbar puncture
D Relief of symptoms when lying down
E Transient bilateral visual loss

Answer 44

E. Transient bilateral visual loss

Question 45

Bronchial carcinoma
A 53-year-old man is seen in the medical assessment unit with lethargy,
nausea, polyuria and polydipsia. He also has a weight loss of 2 stones over
the period of 1 month. He smokes 40 cigarettes per day. A chest X-ray shows
a lung mass in right lower lobe. His blood tests show a corrected calcium
level of 3.1 mmol/L. Other causes of hypercalcaemia were excluded.
Which of the following cell types of bronchial carcinoma is most likely in
this case?
A Adenocarcinoma
B Sarcomatoid carcinoma
C Small cell carcinoma
D Squamous cell carcinoma
E Large cell carcinoma

Answer 45

D. Squamous cell carcinoma

Question 46

Neurological dysfunction
A 44-year-old woman who works in an office presents with a 2-month
history of pains in her right hand and thumb weakness. The pains would
shoot into her first three fingers, and initially she thought she was using
bad typing technique, however the pains progressed despite ergonomic
keyboards and then she became weak in her thumb. She also says her first
three fingers feel numb. On examination there is wasting of the thenar
eminence, weakness of thumb abduction, and reduced sensation in the
thumb, index and middle finger and the lateral half of her fourth finger.
Which nerve or nerve root is affected?
A C6
B C8
C Median nerve
D Radial nerve
E Ulnar nerve

Answer 46

C. Median nerve

Question 47

Diagnosis of rheumatoid arthritis (1)
A 55-year-old woman presents to clinic with joint pain. She is concerned
that it might be rheumatoid arthritis.
Which of the following clinical features is NOT used in the American
College of Rheumatology diagnostic criteria to diagnose rheumatoid
arthritis and differentiate it from other causes of arthritis?
A Morning stiffness for 1 or more hours for more than 6 weeks
B Simultaneous symmetrical joint swelling for more than 6 weeks
C Three or more joints affected for more than 6 weeks
D Two hand joints (either metacarpophalangeal (MCP) or proximal
interphalangeal (PIP)) involved for more than 6 weeks
E Ulnar deviation of one or more fingers for more than 6 weeks

Answer 47

E. Ulnar deviation of one or more fingers for more than 6 weeks

Question 48

Statistics (2)
A new tumour marker is being tested for use in cholangiocarcinomas. In a
trial 40 patients have been tested. The trial produces 10 positive results and
30 negative results. Of the 10 positive results, 5 of them are false positives.
Of the 30 negative results, 5 of them are false negatives.
What is the specificity of this test?
A 17%
B 50%
C 70%
D 83%
E 100%

Answer 48

D. 83%
The specificity is the ability of an investigation to detect a truly negative test
result.
Specificity = number of true negatives / (number of true negatives + number
of false positives) × 100
In this case = 25 (25 + 5) × 100 = 83%

Question 49

Sepsis syndromes
A 43-year-old woman presents with a 1-week history of loin pain,
suprapubic pain and dysuria. On examination she looks unwell, has a pulse
of 110 bpm, blood pressure of 120/80 mmHg, respiratory rate of 24/min
and a temperature of 38.5°C. Bloods are taken for routine tests and blood
cultures, a catheter passed, and empirical antibiotics started. Later that day,
blood cultures come back showing a Gram-negative rod. You note that in
the last 3 hours she has only passed 30 ml of urine and she is starting to
show signs of confusion. Observations remain as they were earlier.
Which of the following terms best describes the patient’s physiological
status?
A Sepsis
B Septic shock
C Septicaemia
D Severe sepsis
E Systemic inflammatory response syndrome

Answer 49

D. Severe sepsis

Question 50

Nephrotic syndrome
A 38-year-old man presents with fatigue, swelling of the eyelids and legs,
and frothy urine. His bloods appear normal except for an albumin level
of 26 g/L (his albumin was normal on blood tests taken 1 year ago). You
suspect nephrotic syndrome.
How would you confirm the diagnosis?
A Proteinuria on urine dipstick
B >1 g of protein lost in the urine over 24 hours
C >1 g of protein lost in the urine over 72 hours
D >3.5 g of protein lost in the urine over 24 hours
E >3.5 g of protein lost in the urine over 72 hours

Answer 50

D. >3.5 g of protein lost in the urine over 24 hours