1 A 53 year old woman with inoperable renal cancer has pain due to posterior abdominal wall

infiltration. This has been controlled well with Kapake (codeine 30mg & paracetamol 500mg), two tablets
four times a day. The patient has been admitted with nausea and vomiting, the cause of which is, as yet,
unknown. Because she cannot retain her analgesics, she has severe pain in her loin.

What is the best option for controlling her pain until the vomiting settles?

A Fentanyl skin patch

B Intramuscular pethidine
C Morphine four-hourly orally, and as needed intramuscularly
D Rectal non-steroidal anti-inflammatory drug
E Subcutaneous diamorphine by continuous infusion
Answer: E

2 A 90 year old man with chronic leukaemia presents with gout which his general practitioner treats
with allopurinol.

How does allopurinol prevent the accumulation of uric acid?

A By competing for its transporter to the kidney

B By enhancing its solubility
C By inhibiting purine synthesis
D By inhibiting pyrimidine synthesis
E By inhibiting the inflammatory response it causes
Answer: C

3 When taking an arterial blood gas sample care should be taken to avoid needlestick inury.

Which of the following is the safest way of avoiding needlestick injury?

A Bending the needle point back towards the syringe with pliers
B Not attempting to remove the needle from the sample syringe
C Removing the needle, disposing of it, and putting a cap on the sample
D Sealing the needle with tape, wearing gloves
E Sticking the needle into a cork which can be sent with the sample
Answer: C

4 A 33 year old woman, with a history of alcoholism and self-neglect, is admitted to hospital because
of an episode of blood-streaked vomiting. This is attributed to a minor Mallory-Weiss tear. She is admitted to
hospital and given an intravenous infusion of 5% dextrose. Her serum potassium concentration is noted the
following day to have fallen to 1.9mmol/L on admission.

What is the likely mechanism for the fall in potassium concentration?

A Cortisol release in response to stress increasing renal potassium loss

B Decompensated liver failure causing aldosterone secretion
C Intracellular re-uptake in response to re-feeding with glucose
D Metabolic acidosis increasing renal potassium excretion
E Potassium levels falling following gastric loss in vomiting
Answer: C

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5 A 67 year old woman complains of lack of energy and generalised aches. Urea and electrolyte
concentrations are normal, but albumin-adjusted calcium concentration is low, at 1.98mmol/L, and
phosphate is low at 0.66mmol/L. Further tests show that 25-hydroxyvitamin D level is low, and parathyroid
hormone level is very high.

What is the most likely diagnosis?

A Fanconi’s syndrome
B Primary hyperparathyroidism
C Pseudohypoparathyroidism
D Pseudopseudohypoparathyroidism
E Vitamin D deficiency
Answer: E

6 An anxious patient with a high respiration rate has the following arterial blood gas results: pH 7.27
(low), PCO2 2.6KPa (low). Base excess is very negative, far below the lower limit of normal.

What is the interpretation of the acid-base status?

A Combined metabolic and respiratory acidosis

B Combined metabolic and respiratory alkalosis
C Metabolic acidosis with some compensatory respiratory alkalosis
D Respiratory acidosis with some compensatory metabolic alkalosis
E Respiratory alkalosis with some compensatory metabolic acidosis
Answer: C

7 A 62 year old surgical patient has undergone anterior resection for a rectal mass. The histology
report describes ‘a moderately differentiated adenocarcinoma, which invades into the muscle, but not
through the wall. One out of 13 lymph nodes is involved by metastatic tumour, but the high tie node is
tumour free’. A liver biopsy from a suspicious lesion in the liver shows ‘no evidence of malignancy’.

What stage is this patient’s cancer?

A Dukes A
B Dukes B
C Modified Dukes C1
D Modified Dukes C2
E Modified Dukes D
Answer: C

8 A 77 year old male presents with sudden loss of vision in his right eye, associated with a relative
afferent pupillary defect. He has poorly controlled systemic hypertension and raised cholesterol.

What is the most likely diagnosis?

A Cataract
B Chronic open angle glaucoma
C Macular degeneration
D Retinal vascular occlusion
E Retinitis pigmentosa
Answer: D

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9 A 57 year old smoker gives a three month history of persistent hoarseness. On direct questioning he
admits to right-sided earache. On examination he is hoarse and has mild stridor. Examination of his ears is
normal. Endoscopy of his upper airway shows an irregular mass in the larynx.

What is the most likely diagnosis?

A Laryngeal lymphoma
B Carcinoma of the larynx
C Laryngeal papillomatosis
D Laryngeal tuberculosis
E Thyroid carcinoma
Answer: B

10 A 26 year old professional footballer collapses while playing football. He is rushed to the Accident
and Emergency Department, and is found to be in ventricular tachycardia. He is defibrillated successfully
and his 12-lead ECG demonstrates normal sinus rhythm, without ST segment changes. Ventricular
tachycardia recurs, and despite prolonged resuscitation, he dies.

What is the most likely diagnosis?

A Aortic stenosis
B Cocaine intoxication
C Hypertrophic cardiomyopathy
D Myocardial infarction
E Pulmonary embolism
Answer: C

11 A 32 year old woman, who is on the combined oral contraceptive pill and who is a smoker, presents
with a history of pain and swelling in her right calf, starting two days earlier. On the morning of admission,
she developed sudden onset of weakness on her right side, with pleuritic chest pain. On examination she has
a dense hemiplegia, with weakness of her right hand and upper motor neuron signs. There is evidence of a
deep vein thrombosis of her left calf.

What is the most likely diagnosis?

A Berry aneurysm
B Cerebral tumour with hypercoagulable state
C Haemorrhagic stroke
D Paradoxical embolism
E Pulmonary embolism
Answer: D

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12 A 49 year old woman is sent by her general practitioner to your hospital with a complaint of a lump
in her left breast. On questioning, she says she first noticed this lump six weeks ago. There is no change in
size in relation to the menstrual cycle. There is no family history of breast cancer. On examination, the lump
measures 3cm x 4cm, and it is firm, but not tender and not mobile. The other breast is normal.

What is the most likely diagnosis?

A Carcinoma of the breast

B Cyst
C Fat necrosis
D Fibroadenoma
E Fibroadenosis
Answer: A

13 A 58 year old man presents to your clinic with dysphagia for solids for the past three months. He
also complains of weight loss and loss of appetite. There is no other past medical history, apart from
symptoms of indigestion and heartburn for the past five years. He regularly takes Gaviscon and Rennie
tablets. He is a heavy smoker and a regular drinker. He undergoes endoscopy, which reveals a small tumour
at the lower end of the oesophagus.

What is the most likely aetiological cause for the tumour?

A Alcohol
B Barrett’s oesophagus
C Helicobacter pylori
D Oesophageal candidiasis
E Oesophageal pouch
Answer: B

14 A 78 year old man attends the Accident and Emergency Department. He complains of pain in his
right groin, and he has been vomiting. He has never been ill before, and has no medication. Clinical
examination reveals a tender lump 4cm in diameter in the right groin, below and medial to the pubic tubercle.

What is the next appropriate step in managment?

A Admit and observe

B Discharge to general pracitioner with analgesia
C Needle aspiration of the lump
D Surgical intervention
E Ultrasound examination of the groin
Answer: D

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15 A 26 year old office secretary presents with symptoms of palpitations, restlessness, fatigue and
increased sweating. She also complains of infrequent periods and weight loss. You examine the patient and
find she has tachycardia and tremors; she is hyper-reflexic. Biochemical tests on blood samples reveal
hyperthyroidism. Examination of the neck reveals a multiple small nodular areas in a diffusely enlarged
thyroid

What is the most appropriate treatment for this patient?

A Fine needle aspiration of the nodules

B Levothyroxine
C Propranolol
D Radioiodine
E Surgical removal of the nodules
Answer: C

16 A mother brings her child, aged 12 months, to her general pracitioner with a red, hot, swollen knee.
The general pracitioner is concerned because the child has suffered three serious infections in the past seven
months, one of otitis media and two of pneumonia. In the latter case, the infecting organism was
Haemophilius influenzae. The child had been fully immunized against this organism. The mother is very
upset because both of her brothers died of infections during childhood.

What investigation is most likely to advance the understanding of this child’s disease?

A B cell count
B Differential white blood cell count
C Haemophilus influenzae sensitivity study
D Inmunoglobulin assay
E T cell count
Answer: D

17 A 55 year old female has a history of aggressive, erosive rheumatoid arthritis over three years. It
remains poorly controlled, despite good compliance with therapy. She is now complaining of severe fatigue.
Investigations show her haemoglobin concentration to be 7.2g/dl, the white cell count is 1.4 x 109/l, and the
platelet count is 44 x 109/l.

What is the most likely cause of her pancytopaenia?

A Acute lymphatic leukaemia

B Acute overwhelming infection
C Hypersplenism
D Pernicious anaemia
E Side effect of drugs
Answer: E

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18 A previously well, 62 year old hypertensive builder presents with pain, redness and swelling in the
right knee, which started 12 hours ago. There is a family history of hypertension and joint problems.

What investigation is most important in identifying the cause of this patient’s knee symptoms?

A ESR
B HLA status
C Joint aspiration for microscopy and culture
D Radiology
E Serology
Answer: C

19 A family attend the genetic counselling clinic. The father is affected by autosomal dominant
hereditary sensorimotor neuropathy (Charcot-Marie-Tooth disease), and had an onset of symptoms in his
mid-forties. He has a known genetic abnormality of the HMSN1 gene. They bring along their fourteen year
old daughter who is at 50% risk of inheriting the gene and ask about genetic testing for her.

What advice would you give regarding genetic testing of their daughter?

A She can be tested at the age of 16 years

B She can be tested at the age of 18 years
C She can be tested now if she is able to give her own informed consent
D She can be tested now if the parents give consent
E She need not be tested until she becomes pregnant
Answer: C

20 A 76 year old woman has had Paget’s disease of bone for at least 15 years. She develops a
destructive mass in the bony pelvis, and a diagnosis of a primary tumour is considered.

What is the most likely primary tumour?

A Chondrosarcoma
B Exostosis
C Multiple myeloma
D Osteoma
E Osteosarcoma
Answer: E

21 A 56 year old man presents with headache, drowsiness and confusion, becoming progressively more
severe. Imaging reveals a non-haemorrhagic space-occupying lesion in his brain.

What is the most likely cause of the lesion?

A Astrocytoma
B Glioblastoma multiforme
C Multiple sclerosis
D Secondary carcinoma
E Tuberculosis
Answer: D

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22 A 43 year old woman dies after a long and debilitating illness. A post mortem examination is carried
out, and a neuropathologist notes that the brain shows well-defined areas of demyelination on naked-eye
examination

What is the most likely diagnosis?

A Alzheimer’s disease
B Creutzfeldt-Jakob disease
C Gerstmann-Straüssler-Scheinker syndrome
D Multiple infarcts
E Multiple sclerosis
Answer: E

23 A 63 year old smoker has been investigated for a cough and chest pain, and a diagnosis of bronchial
carcinoma is made on a plain chest X-ray examination. Before a tissue diagnosis can be made, he dies in
hospital of a large and unexpected haemoptysis, and a post mortem examination is carried out with the
consent of the relatives. At this examination, the correct diagnosis is shown to be tuberculosis, and there is
no carcinoma.

In this circumstance, it is mandatory to make a report to a particular authority. Which authority?

A Consultant in Communicable Diseases Control

B Coroner
C General Medical Council
D Health and Safety Executive
E Strategic Health Authority
Answer: A

24 A 72 year old dairy farmer presents with a small white lesion on his left cheek. It has grown slowly
over several months, and it now has a central ulcer.

What is the most likely nature of the lesion?

A Amelanotic malignant melanoma

B Basal cell carcinoma
C Basal cell papilloma (seborrhoeic keratosis)
D Cowpox
E Squamous cell carcinoma
Answer: B

25 A patient has died at home. The general practitioner knows that the cause of death is carcinoma of
the colon, but she hasn’t seen the patient for some time, and is concerned that she hasn’t seen the patient
within the statutory period that allows her to write the Medical Certificate of Cause of Death.

What is the length of this statutory period?

A 1 day
B 5 days
C 7 days
D 10 days
E 14 days
Answer: E

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26 A 35 year old woman has had four previous live births. Sixteen weeks into her fifth pregnancy, she
presents with diffuse lower abdominal pain. On examination, she is tender in the suprapubic area. She has a
fundal height of 25cm and there is a firm mass related to the uterus. She has urinary frequency but no dysuria.
Only one fetal heart is heard.

What is the most likely diagnosis?

A Placental abruption
B Acute appendicitis
C Uterine fibroids
D Polyhydramnios
E Urinary tract infection
Answer: C

27 A 45 year old man presents with restlessness and drowsiness. He is known to drink in excess of fifty
units of alcohol per week. On examination he has a broad-based gait. There is nystagmus and bilateral lateral
rectus muscle palsy.

What is the most likely diagnosis?

A Alcohol withdrawal
B Folic acid deficiency
C Subdural haematoma
D Syphilis
E Wernicke’s encephalopathy
Answer: E

28 A 17 year old girl is brought by her mother to the general practitioner. Over the last three months she
has been steadily losing weight, despite an apparently normal appetite. However, yesterday her mother
observed the patient sticking her fingers down her throat to stimulate vomiting. A careful inspection of her
bedroom had revealed several brands of commonly available laxatives.

The patient may demonstrate all of the following EXCEPT

A Diuretic abuse
B Marked interest in food preparation and consumption
C Lanugo hair
D Menstrual irregularity
E Perception of being underweight
Answer: E

29 A 76 year old man underwent emergency repair of an abdominal aortic aneurysm five days ago. He
has made a good recovery and is mobilising well. He suddenly develops diarrhoea which contains moderate
amounts of fresh blood.

What is the best investigation to carry out next ?

A Abdominal aortic angiography

B Determination of prothrombin time
C Flexible sigmoidoscopy
D Gastroscopy
E Barium enema
Answer: C

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30 A 23 year old man is about to undergo appendicectomy. The consultant rings the house officer and
asks her to prescribe prophylactic antibiotics.

What is the most appropriate prophylactic antibiotic for this patient?

A Cefuroxime
B Flucloxacillin
C Imipenem
D Penicillin
E Metronidazole
Answer: E

31 A 68 year old presents to the Accident and Emergency Department with a right spastic hemiparesis,
an extensor plantar response on the right, and paralysis of the lower two-thirds of his face on the right. His
speech is fluent, and he has normal comprehension of verbal and written commands.

Which cerebral artery is obstructed?

A Left lenticulo-striate
B Left middle cerebral
C Left middle meningeal
D Right middle cerebral
E Right posterior cerebral
Answer: A

32 A 3 year old girl presents to her general practitioner with a generalised papular rash. Some nine days
earlier, she had a two day history of fever and malaise and a mild cough. Examination reveals white punctate
lesions on the buccal mucosa.

What is the most likely diagnosis?

A Erythema infectiosum
B Infectious mononucleosis
C Measles
D Rubella
E Chickenpox
Answer: C

33 A 7 year old girl is brought by her mother to the Accident and Emergency Department following a
massive haematemesis. She has no significant past medical history. Examination reveals that she is
hypotensive and she has a tachycardia.

What is the most likely diagnosis?

A Aorto-intestinal fistula
B Bleeding oesophageal varices
C Boerhaave’s syndrome
D Mallory-Weiss tear
E Perforated peptic ulcer
Answer: B

9
34 A 73 year old woman presents to her general practitioner with a weight loss of 10Kg over the last
three months, with increasingly severe back pain. On examination, she is drawn and dehydrated. Her sclera
are a deep yellow.

What is the most likely cause of her jaundice?

A Alcoholic cirrhosis
B Infective hepatitis
C Gilbert’s syndrome
D Primary billiary stenosis
E Carcinoma of the pancreas
Answer: E

35 You are a senior house officer on call when a 40 year old patient who is suicidal and known to be
suffering from paranoid schizophrenia threatens to leave the hospital.

Under which section of the Mental Health Act can you detain this patient?

A 2
B 3
C 4
D 5
E 6
Answer: D

36 Penicillin has a broad spectrum of antibacterial activity but some organisms are often resistant to it.

For which of the following diseases would penicillin be least effective in treating?

A Gonorrhoea
B Pneumococcal pneumonia
C Mycoplasma pneumonia
D Streptococcal pharyngitis
E Syphilis
Answer: C

37 A 23 year old woman complains of coarse hair on her lip, chin, chest and abdomen. On further
questioning, she has moderate menstrual irregularity and long periods of amenorrhoea. On examination she
has a body mass index of 40.

Which is the most likely diagnosis?

A Benign ovarian tumour

B Cushing’s disease
C Familial hirsutism
D Malignant ovarian tumour
E Polycystic ovary disease
Answer: E

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38 A 64 year old woman presents with pain in the left flank. Investigation reveals a 3cm stone in the left
renal pelvis with pelvi-calyceal dilatation. Renal function is normal.

What would be the most definitive initial treatment?

A Extracorporeal shock wave lithotripsy

B Extraction using a Dormia basket
C Nephrolithotomy
D Partial nephrectomy
E Percutaneous nephrostomy
Answer: E

39 A sexually active 23 year old woman presents to her general practitioner with a profuse ‘fishy-
smelling’ vaginal discharge. A smear is performed in which inflammatory changes are found.

What is the most likely causative agent?

A Candida albicans
B Gardnerella vaginalis
C Neisseria gonorrhoeae
D Staphylococcus aureus
E Trichomonas vaginalis
Answer: B

40 A 78 year old woman is in the early stages of dementia, and lives in a nursing home. She has
recently become more confused and is incontinent of urine.

What is the most appropriate initial investigation?

A Cystoscopy
B Full blood count
C Urine microscopy and culture
D Urea and electrolytes
E Urodynamics
Answer: C

41 A 6 year old boy accidentally inhaled a peanut while playing with it.

Which is the most likely place the peanut can lodge itself?

A Left main bronchus

B Posterior tonsillar fold
C Right main bronchus
D Trachea
E Vallecula
Answer: C

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42 A 19 year old woman presents with a boil on her left forearm. You decide to treat her with
flucloxacillin.

Which one of the following describes its antibacterial mode of action?

A Destruction of mitochondria
B Destruction of ribosomal RNA
C Destruction of the cell wall
D Disruption of cell organelles
E Disruption of the nuclear materials
Answer: C

43 A 52 year old hospital cleaner of Jamaican origin complains of shortness of breath which has
gradually worsened over the last six months. He has a history of hypertension and joint pain. A chest X-ray
shows a very fine mottled pattern, and a blood test shows hypercalcaemia.

What is the most likely cause of the patient’s breathlessness?

A Atypical pneumonia
B Carcinoma of the bronchus
C Sarcoidosis
D Secondary carcinoma
E Tuberculosis
Answer: C

44 An 11 year old girl comes back from a week long school trip to France. She presents with
breathlessness and a cough of eight days duration. On examination, she has mild pyrexia.

What is the treatment option most likely to alter the clinical course of this child’s disease?

A Cefotaxime
B Erythromycin
C Gentamicin
D Paracetamol
E Penicillin
Answer: B

45 A 38 year old Somali woman has been resident in the United Kingdom for eight years. She
complains of diffuse pain involving her back, ribs and limbs. The pain has come on gradually over several
months.

What is the most likely cause of this patient’s pain?

A Ankylosing spondylitis
B Osteomalacia
C Osteoporosis
D Paget’s disease
E Tuberculosis
Answer: B

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46 A patient has been found in bed with a deep body temperature of 23.10C; the arms and legs are stiff.
The pulse is undetectable.

What is the appropriate diagnosis?

A Barbiturate coma
B Brain stem death
C Electromechanical dissociation
D Hypothermia
E Rigor mortis
Answer: E

47 Atrial fibrillation recurs in an individual who was previously well-stabilised on digoxin. She was
found to be hypocalaemic.

Which new drug is most likely to have caused this patient’s complication?

A Aspirin
B Bendrofluazide
C Cimetidine
D Propranolol
E Rifampicin
Answer: B

48 A 32 year old man complains of recurrent boils.

Which of the following organisms is the most likely cause?

A Candida albicans
B Pseudomonas pyocyanea
C Staphylococcus aureus
D Staphylococcus epidermidis
E Trichophyton rubrum
Answer: C

49 A 43 year old man with a history of longstanding excess alcohol ingestion. He presents with pyrexia
and a cough productive of sputum mixed with blood, of recent onset.

What is the most likely cause?

A Bronchial carcinoma
B Bronchiectasis
C Lobar pneumonia
D Pulmonary embolism
E Tuberculosis
Answer: C

13
50 A 42 year old male advertising executive at a new patient check has a blood pressure of
150/90mmHg, pulse rate 90/min. His BMI is 25 and he is a non-smoker.

What is the most appropriate step in management?

A Advise increased fitness

B Advise low salt diet
C Institute hypertensive therapy
D Keep a food diary
E Review in one month
Answer: E

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