Question 1
An 89-year-old man has a basal cell carcinoma on his forehead which requires excision. He has dementia. The clinic nurse feels he is not competent to give consent for surgery.
Which is the most appropriate action for obtaining consent?
A. Ask a psychiatrist to assess his cognitive function
B. Ask his general practitioner to sign the consent form
C. Ask his wife to sign the consent form
D. Ask the patient to sign the consent form
E. Ask the surgeon to assess his mental capacity
Question 2
A 21 year old woman has increasing severe pain in her left leg. She had an undisplaced fracture of the midshaft of her left tibia 2 days ago which was treated conservatively with a plaster cast.
Her toes are warm and pulses are present.
Which is the most important immediate action?
A. Elevate the limb
B. Refer to orthopaedics
C. Remove the plaster cast
D. Replace the cast with increased padding
E. Re-X-ray the fracture site
Question 3
A 14 year old girl attends the GP surgery requesting the oral contraceptive pill (OCP). She is sexually active and her boyfriend is in the year above her at school. Her parents are unaware of the appointment and her request for OCP.
Which is the most appropriate management?
A. Advise her about safe sex and prescribe the OCP
B. Contact her parents
C. Contact the local safeguarding team
D. Contact the police
E. Explain it is illegal to prescribe the OCP for her
Question 4
A 22 year old man has a painful right eye for 1 day. He had similar symptoms 1 year ago. He has had episodic back pain and stiffness for 4 years which is relieved by exercise and ibuprofen.
His right eye is red and his vision is blurred.
Which is the most likely cause of his red eye?
A. Chorioretinitis
B. Conjunctivitis
C. Episcleritis
D. Keratitis
E. Uveitis
Question 5
A healthy boy is born by vaginal delivery at 40 weeks gestation. His mother had confirmed acute hepatitis B during this pregnancy.
Which preventative intervention should be given immediately to the baby?
A. Confirm hepatitis B status of baby as first step
B. Full course of hepatitis B vaccine
C. Full course of hepatitis B vaccine and hepatitis B immunoglobulin
D. Hepatitis B immunoglobulin
E. Hepatitis B vaccine as a single dose
Question 6
A 66 year old man has tiredness and low back pain for 2 months. He has type 2 diabetes and hypertension and takes metformin and ramipril. He is a non-smoker and does not drink alcohol.
His pulse rate is 88 bpm and BP 138/82mmHg. Clinical examination is normal.
Investigations:
Haemoglobin 78 g/L (130–175)
White cell count 3.4 × 109/L (3.0–10.0)
Platelet count 80 × 109/L (150–400)
Corrected calcium 2.71 mmol/L (2.2–2.6)
Albumin 36 g/L (35–50)
X-ray of lumbar spine: generalised osteopenia and vertebral collapse at multiple levels.
Which is the most appropriate next investigation?
A. Serum angiotensin converting enzyme
B. Serum parathyroid hormone
C. Serum prostate specific antigen
D. Serum protein electrophoresis
E. Serum vitamin D
Question 7
A 17 year old woman has a painless lump on her right breast for 4 weeks. There is no history of trauma. She takes the oral contraceptive pill. Her maternal grandmother had breast cancer.
She has a 1 cm painless lump in the upper outer quadrant of her right breast.
Which is the most appropriate initial investigation?
A. Excision biopsy
B. Fine needle aspiration cytology
C. Magnetic resonance imaging
D. Mammography
E. Ultrasound scan of the breast
Question 8
A 40 year old man takes an overdose of his antidepressant tablets and is seen in the Emergency Department. He is medically fit for discharge. He has bipolar affective disorder. He is tearful and feels hopeless about his future.
Which is the most appropriate next management step?
A. Arrange liaison psychiatric assessment
B. Arrange psychiatric outpatient follow-up
C. Discharge to the care of his general practitioner
D. Referral to clinical psychologist
E. Referral to local alcohol treatment team
Question 9
A 6 week old girl has bronchiolitis and is seen in the Emergency Department. She is medically stable and ready for discharge. There were no problems in pregnancy. She was born at term by normal vaginal delivery. She is an only child. Her mother says that she cannot cope with her new baby.
Which is the most appropriate initial management?
A. Arrange temporary foster care
B. Contact social services
C. Refer back to her GP
D. Refer her to safeguarding team
E. Organise a Place of Safety order
Question 10
A 4 week old boy has episodes of vomiting since birth. The vomiting occurs soon after feeding. He does not vomit after every feed and it is not related to the amount he takes. He is otherwise well and is gaining weight appropriately.
Which is the most likely diagnosis?
A. Cows milk protein allergy
B. Gastro-oesophageal reflux
C. Lactose intolerance
D. Pyloric stenosis
E. Urinary tract infection
Question 11
A 19 year old woman has worsening vaginal discharge and bilateral iliac fossa pain for 3 days. Her vaginal discharge is foul smelling and she has dyspareunia. She is feverish and feels unwell.
Her temperature is 39.0°C.
Which combination of organisms are most likely to cause these symptoms?
A. Candida albicans and Gardnerella vaginalis
B. Chlamydia trachomatis and Candida albicans
C. Neisseria gonorrhoeae and Chlamydia trachomatis
D. Neisseria gonorrhoeae and Gardnerella vaginalis
E. Trichomonas vaginalis and Candida albicans
Question 12
An 85 year old man has a fall at home and is seen in the Emergency Department. He had incontinence of urine and had been lying on the floor all night. He had a myocardial infarction 8 years ago. He takes aspirin, atorvastatin and ramipril.
His pulse rate is 94 bpm and BP 106/76 mmHg.
Investigations:
• White cell count 14.3 × 10⁹/L (3.0–11.0)
• Urea 30.4 mmol/L (2.5–7.8)
• Creatinine 158 micromol/L (60–120)
• Creatinine kinase 11025 U/L (25–200)
ECG: Q waves in lead III.
Which is the most likely cause of his raised creatinine kinase?
A. Acute kidney injury
B. Acute myocardial infarction
C. Dermatomyositis
D. Rhabdomyolysis
E. Urinary tract infection
Question 13
A 30 year old man has had weakness in his left arm and leg for three days. He is HIV positive with a CD4 count of 50 cells/mm3. He is not taking anti-retroviral therapy. His temperature is 37.5oC, pulse rate 95 bpm and BP 140/90 mmHg. He has power of 3/5 in his left arm and 4/5 in his left leg there is no other focal neurological signs.
Investigations:
CD4 count 50 cells/mm3
CT scan of brain: multiple ring enhancing lesions with surrounding oedema.
What is the most appropriate antimicrobial therapy to prescribe?
A. Amphotericin and ceftazidime
B. Dexamethasone and acyclovir
C. Ganciclovir and ceftazidime
D. Isoniazid and rifampicin
E. Pyrimethamine and sulphadiazine
Question 14
A 13 year old boy’s mother is concerned that he has no friends and she brings him to the GP surgery. He does not play with other children. He likes model cars and has 1,000 cars in his collection. He is indifferent to either praise or criticism from his mother or teachers.
Which is the most likely diagnosis?
A. Attachment disorder
B. Attention deficit hyperactivity disorder
C. Autistic spectrum disorder
D. Obsessive compulsive disorder
E. Schizoid personality disorder
Question 15
An 19 year old woman is worried that she is overweight and is seen in the GP surgery. She has reduced her food intake and has been exercising for 2 hours each day for 18 months. She has amenorrhoea. She is in her first year of university and is struggling with her studies.
Her body mass index is 15.5 kg/m2 and her blood pressure is 90/60 mmHg.
Which specialist service should she initially be referred to?
A. Acute medical services
B. Dietician
C. Eating disorder service
D. Psychodynamic services
E. University student counselling services
Question 16
A 28 year old woman requests contraception from the GP surgery. She has a 28 day menstrual cycle with a 6 day very heavy menstrual bleed. She had a pulmonary embolism in her previous pregnancy.
Which is the most appropriate contraception?
A. Combined oral contraceptive pill
B. Copper intrauterine contraceptive device
C. Levonorgestrel-releasing intrauterine system (Mirena coil)
D. Progestogen implant
E. Progestogen-only pill
Question 17
A 65 year old man has pain in his abdomen and is seen on the surgical inpatient ward. He had a closure of his colostomy 5 days ago.
His temperature is 36.5°C, pulse rate is 76 bpm, BP 124/82 mmHg and respiratory rate is 15 breaths per minute. There is a tender, localised fluctuant swelling 4 cm in diameter in the wound.
Which is the most appropriate management?
A. Abdominal support
B. Antibiotics
C. Laparotomy
D. Local exploration of wound
E. Observation
Question 18
10,000 women underwent cervical cytology. 1000 had abnormal cells and had a second smear test. 100 of these women were confirmed as having pre-malignant cells and underwent laser ablation. Ten women who were not identified as needing a second cervical smear developed cervical cancer within 6-12 months.
Which term describes the group of 10 women who were not identified as needing a second smear but developed cervical cancer within 6-12 months?
A. Case control group
B. False negative group
C. Incident group
D. True negative group
E. True positive group
Question 19
A 38 year old man is constantly worried about his house being infected by germs for 3 months and he is seen in the GP surgery. He is worried about his personal safety and has been checking that the doors and windows are locked 20-30 times a day for 8 weeks. He has been washing his hands every time he touches the locks.
Which is the most appropriate initial management?
A. Antidepressant
B. Antipsychotic
C. Anxiolytic
D. Cognitive behaviour therapy
E. Psychodynamic psychotherapy
Question 20
An 8 year old girl has a frequent cough at night and mild exercise-induced wheeze for 3 months. She has asthma and takes low-dose inhaled corticosteroids twice daily and a short-acting bronchodilator as required. She takes her treatment as recommended. Her inhaler technique is good.
Which is the most appropriate next step in her treatment?
A. Add leukotriene receptor antagonist
B. Add oral modified release theophylline
C. Add short course of oral corticosteroid
D. Increase dose of inhaled corticosteroid
E. Increase frequency of short acting bronchodilator
Question 21
An 84 year old woman has worsening confusion. She has visual hallucinations, disturbed sleep and urinary incontinence for 1 week. She has Alzheimer’s dementia and arthritis and has recently started taking paracetamol.
Her abbreviated mental test score is 2/10.
Which is the most likely underlying reason for her deterioration?
A. Depression
B. Encephalitis
C. Medication related confusion
D. Progression of dementia
E. Urinary tract infection
Question 22
A 38 year old man has worsening vertigo and tremor. His symptoms are more pronounced in the morning. He has longstanding alcohol dependence and drinks 60 units of alcohol per week.
His abbreviated mental test score is 9/10. He has an intention tremor, horizontal nystagmus and walks with a broad-based gait.
Which is the most likely diagnosis?
A. Acute alcohol withdrawal syndrome
B. Benign positional vertigo
C. Cerebellar degeneration
D. Korsakoff syndrome
E. Wernicke encephalopathy
Question 23
A 32 year old woman has a febrile illness and swelling of the small joints of her hands for 2 days. She is seen in the GP surgery. She has not travelled outside the UK. She has two young children.
She has a maculopapular rash and palpable, small cervical lymph nodes. The small joints of her feet, wrists and knees are swollen.
Which is the most likely diagnosis?
A. Psoriasis
B. Reactive arthritis
C. Rheumatoid arthritis
D. Sarcoidosis
E. Systemic lupus erythematosus
Question 24
A 78 year old woman has pain in her left thigh and calf on walking for 8 weeks. The pain is relieved with rest. She has a 40 pack-year smoking history.
Her left popliteal and pedal pulses are not palpable.
Investigation:
Hand held Doppler: monophasic waveform in her left Dorsalis Pedis artery.
Which is the most likely site of arterial pathology?
A. Anterior Tibial
B. Dorsalis Pedis
C. External Iliac
D. Internal Iliac
E. Profunda Femoris
Question 25
A 53 year old woman has anorexia and increasing breathlessness. She has stage 4 adenocarcinoma of the lung and now requires full support with her activities of daily living. She takes diazepam, cyclizine and zopiclone.
Investigations:
• Sodium 122 mmol/L (135-146)
• Potassium 3.2 mmol/L (3.5-5.3)
• Urea 6.2 mmol/L (2.5-7.8)
• Creatinine 58 mmol/L (45-95)
Which is the most appropriate management of her electrolyte disturbance?
A. 1.8% sodium chloride by intravenous infusion
B. DDAVP nasally
C. Demeclocycline orally
D. Fluid restriction
E. No treatment indicated
Question 26
A 3 day old baby boy is noted to have ambiguous genitalia at his postnatal check.
Investigations:
• Sodium 125 mmol/L (133-146)
• Potassium 5.2 mmol/L (3.4–6.0)
• Urea 5.0 mmol/L (0.8-5.5)
• Creatinine 70 micromol/L (21–75)/li>
• Bicarbonate 22 mmol/L. (22-29)
What is the most likely diagnosis:
A. Acute renal failure
B. Congenital adrenal hyperplasia
C. Diabetes insipidus
D. Hyponatraemic dehydration
E. Renal tubular acidosis
Question 27
A 2 year old boy hurt his left arm after a fall from his tricycle. He stood up and started to cry but then went pale, unconscious and rigid. He recovered after 1-2 minutes. He had a similar episode 3 months ago after falling down some steps.
Examination is normal.
Which is the most appropriate investigation?
A. CT scan of the head
B. Electroencephalogram
C. Full blood count
D. No investigation indicated
E. Skeletal survey
Question 28
A 16 year old girl has an enlarging lump on the right side of her neck for 6 weeks. She is seen in the GP surgery. She has no other symptoms.
She has a 2 x 2 cm lymph node in the right anterior triangle of the neck and several smaller cervical lymph nodes. Her tonsils are enlarged and covered by a grey membrane.
Which is the most likely diagnosis?
A. Infectious mononucleosis
B. Leukaemia
C. Lymphoma
D. Sarcoidosis
E. Tuberculosis
Question 29
A 66 year old man has increasing abdominal pain. He had an anterior resection 5 days ago.
His temperature is 38.5 ˚C, pulse rate 120 bpm and BP 90/60 mmHg. His abdomen is tender and there is generalised rigidity.
Which is the most likely diagnosis?
A. Hypovolaemia
B. Leaking anastomosis
C. Secondary haemorrhage
D. Urinary tract infection
E. Wound infection
Question 30
An 83-year-old woman has visual hallucinations and is confused for 4 hours. She is in the medical inpatient ward and is being treated for pneumonia. She is restless and verbally abusive towards the staff who she believes is trying to poison her. She has no previous psychiatric history.
Which is the most likely diagnosis?
A. Delirium
B. Delusional disorder
C. Charles Bonnet syndrome
D. Parkinson’s disease dementia
E. Psychotic depression
