Formative exam:

Q1. An 80 year old woman develops profuse diarrhoea while in hospital, 4 days after emergency
surgery for a hip fracture.

The Bristol stool score is 7.

Which is the most appropriate initial management step?

A) Move her to a side room

B) Order an abdominal X-ray

C) Send stool samples over 3 consecutive days

D) Start intravenous metronidazole

E) Start intravenous vancomycin

Q2. A 44 year old woman is admitted with haematemesis and is found to have oesophageal varices.
She admits to drinking three 700-mL bottles of 40% vodka per week.

How many units of alcohol does she drink in a week?

A) 28

C) 63

D) 84

E) 68

Q3. A 61 year old woman has increasing general malaise and abdominal discomfort over 2 days: She
drinks approximately 56 units of alcohol per week.

She has jaundice. Her temperature is 37, pulse rate 88 bpm and BP 112/66 mmHg. Her abdomen is
distended but soft and there is mild generalised tenderness and shifting dullness. There is no
nystagmus or ataxia.

Investigations:

Haemoglobin: 102g/L (115-150)

White cell count: 18.8 x 109/L (3.8-10.0)

Platelets: 166 109/L (150-400)

MCV: 108 fL (80-96)

PT: 18 seconds (10-12)

ALT: 66 IU/L (10-50)

AST: 85 IU/L (10-40)

Alkaline phosphatase: 176 IU/L (25-115)

Bilirubin: 65 µmol/L (<17)

Ultrasound scan of abdomen shows a shrunken echogenic liver and ascites but no masses.

Blood is sent for culture

Which is the most appropriate next step management?

A) CT of abdomen

B) Diagnostic aspiration of ascites

C) IV Co-amoxiclav

D) IV furosemide

E) IV vitamin K

Q4. A 42 year old man collapses with abdominal pain and vomits some fresh blood

An emergency endoscopy shows major fresh bleeding from base of an ulcer in the second part of the
duodenum.

Which artery is the most likely source of the bleeding?

A) Coeliac trunk

C) B) Gastroduodenal artery

C) Hepatic artery

D) Right gastroepiploic artery

E) Superior mesenteric artery

Q5. A 45 year old women has 3 months of weight loss, dizziness, nausea and lethargy. She has a BP
of 100/70 mmHg lying and 75/50 mmHg standing.

Investigations:

Sodium: 125 mmol/L (135-146)

Potassium: 6.1 mmol/L (3.5-5.3)

Urea: 8.5 mmol/L (2.5-7.8)

Creatinine: 100 µmol/L (60-120)

Which is the most likely diagnosis?

A) Addison’s disease

B) Congenital adrenal hyperplasia

C) Conn's syndrome

D) Cushing's syndrome

E) Hypopituitarism

Q6. A 75 year old man visits his GP with 3 days of worsening breathlessness and a dry cough. His
illness started five days ago with coryzal symptoms. He has a history of mild COPD and uses
salbutamol and tiotropium inhalers.

His temperature is 37, pulse rate 82 bpm, BP 128/82 mmHg, respiratory rate 20 breaths per minute
and oxygen saturation 93% breathing air. There is mild respiratory wheeze audible on auscultation of
his lungs.

He is given a short course of prednisolone.

Which is the most appropriate anti-microbial treatment?

A) Amoxicillin

B) Co-amoxiclav

C) Doxycycline

D) No antimicrobial indicated

E) Oseltamivir

Q6. A 37 year old women has intermittent headaches, palpitations and excessive sweating for 3
months. These episodes are associated with sweating and pallor and occur 3 times per week.

Her pulse rate is 100 bpm and BP 198/72 mmHg. She has no other abdominal physical signs.
Urinalysis shows protein trace.

Which is the most likely diagnosis?

A) Apparent mineralocorticoid excess

B) Conn’s syndrome

C) Cushing’s syndrome
D) Hyperthyroidism

E) Phaeochromocytoma

Q8. A 62 year old man has recently had pain in his lower chest when swallowing. He has a history of
indigestion and oesophageal reflux.

An endoscopic biopsy of the oesophagus taken 2 cm above the anatomical gastro-oesophageal

junction, shows granulation tissue with a layer of necrotic debris on its surface.

Which is the most likely pathological process?

A) Candidiasis

B) Granuloma formation

C) Oesophageal varices

D) Oesophageal ulceration

E) Tumour invasion

Q9. A 25 year old man has a recurrent cough and breathlessness for the past 6 months. His sister had
neonatal hepatitis and was found to have cirrhosis of the liver aged 10 years.

Spirometry shows an FEV1/FVC ratio of 0.65, with a reduced FEV1 that is not reversible. He has
abnormal liver function tests and an ultrasound scan shows possible fibrosis within the liver.

What is the most likely diagnosis?

A) α1 antitrypsin deficiency

B) Crigler-Najar Syndrome

C) Cystic fibrosis

D) Gilbert’s syndrome

E) Kartagener’s syndrome

Q10. A 27 year old women in the emergency department has a cardiac arrest with pulseless
electrical activity. She had attended with left sided chest pain with sudden onset that was worse in
taking a deep breath.

Before the cardiac arrest, her temperature was 37.2, pulse rate 126 bpm, BP 88/40 mmHg,
respiratory rate 32 breaths per minute and oxygen saturation 94% breathing 15 L/min oxygen via a
non-rebreathing mask. Her heart sounds and breath sounds were normal.
A 12 lead ECG had shown a sinus tachycardia but no ischaemic changes, and a chest x-ray had been
normal.

Which is the most likely cause of her cardiac arrest:

A) Hypovolaemia

B) Myocardial infarction

C) Pericardial effusion

D) Pulmonary embolism

E) Tension pneumothorax

Q11. A 40 year old woman visits the Emergency Department with a 1 week history of dyspnoea and
cough, producing increasing amounts of sputum. She is an intravenous drug user. There is no
significant travel history or contact with tuberculosis.

Her temperature is 38.5, respiratory rate 24 breaths per minute and oxygen saturation 90%
breathing air.

Investigation:

Chest X-ray: cavitating lesion in the right middle zone

Gram stain of a sputum smear: clumps of Gram-positive cocci

Which is the most likely causative organism?

A) Kiebsiella pneumoniae

B) Moraxella catarrhalis

C) Pneumocystis Jirovecij

D) Staphylococcus aureus

E) Streptococcus pneumoniae

Q12. A 65 year old woman fractures her left radius following a fall. She had an abdominal
hysterectomy and removal of both ovaries at 45 years of age.

Examination and initial investigations, including blood tests are normal.

Which is the most appropriate first-line treatment to reduce her risk of further fractures?

A) Alendronic acid

B) Calcitriol
C) Estradiol

D) Raloxifene

E) Tibolone

Q13. A 67 year old woman is brought to the Emergency Department with chest pain, breathlessness
and cold hands and feet. She is a smoker and has had hypertension for 4 years.

She is tachycardic (160 bpm) with a weak thready pulse, and her BP is 70/50 mmHg. Auscultation of
her chest reveals bilateral crepitations to the mid zones.

Investigations:

12 lead ECG shows tachycardia with broad complexes.

Which is the most appropriate initial management of her arrhythmia?

A) Adenosine

B) Amiodarone

C) Electrical cardioversion

D) Thrombolysis

E) Verapamil

Q14. 65 year old women has pain, jaundice, fever and rigors. Ultrasound scan of abdomen shown
gallstones in the common bile duct with dilatation.

She is treated with antibiotics and analgesia.

Which is the most appropriate next step in management:

A) CT scan od abdomen with contrast

B) ERCP

C) Laparoscopic cholecystectomy and bile duct exploration

D) MR cholangiopancreatography

E) Percutaneous biliary drainage

Q15. A 68 year old man had an angioplasty of his left femoral artery 3 days ago. He has a history of
hypertension, type 2 diabetes mellitus and intermittent claudication. He takes metformin (stopped
before the procedure), ramipril and aspirin.

His pulse is rate is 80 bpm and BP 146/80 mmHg, His urine output for the past 24 hours is 900 Ml
Investigations:

Pre-angiogram 3 days post angiogram

Sodium 137 mmol/L 134 mmol/L (135-146)
Potassium 5.2 mmol/L 5.6 mmol/L (3.5-5.3)
Urea 8.2 mmol/L 14.5 mmol/L (2.5-7.8)
Creatinine 104 µmol/L 210 µmol/L (60-120)

Urinalysis:

Blood: negative

Protein: 1+

Nitrites: negative

Leucocytes: negative

Which is the most likely cause for hi decline in renal function?

A) Cholesterol emboli

B) Contrast nephropathy

C) Diabetic nephropathy

D) Renal artery stenosis

E) Urinary tract infection

Q16. A 94 year old woman has a deep gnawing pain in the middle of her left arm. An X-ray is
obtained (Figure 1)

Which is the most likely cause of her pain?

A) Metastatic carcinoma

B) Osteomyelitis

C) Osteoporosis

D) Osteosarcoma

E) Paget’s disease

Q17. A 31 year old woman attends the Emergency Department with severe right-sided upper
abdominal pain which radiates to the tip of her right shoulder. She has had similar episodes in the
past, which have been much milder. She feels nauseated.

Her temperature is 38.5, pulse 95 bpm and BP is 123/70 mmHg. She is not jaundiced. She Has
tenderness in the right upper quadrant which is worse on inspiration.
What is the most appropriate initial management?

A) Broad spectrum antibiotic

B) ERCP

C) Laparoscopic cholecystectomy

D) Nasogastric tube insertion

E) Ppen cholecystectomy

Q18. A 46 year old women has fatigue and pruritus. She takes treatment for hypothyroidism and
osteoporosis.

Investigations:

ALT: 48 IU/L (10-50)

AST: 42 IU/L (10-40)

Alkaline phosphatase: 317 IU/L (25-115)

Bilirubin: 36 µmol/L (<17)

yGT: 146 IU/L (9-40)

TSH: 5.3 mU/L (0.3-4.2)

Which is the most likely diagnosis?

A) Autoimmune hepatitis

B) Cholecystitis

C) Non-alcoholic steatohepatitis

D) primary biliary cholangitis (primary biliary cirrhosis)

E) primary sclerosing cholangitis

Q19. A 63 year old man has 3 months of nausea, anorexia, weight loss and iron deficiency anaemia.
He has no other symptoms and no significant past medical history.

He has a solitary palpable supraclavicular lymph node.

Which is the most likely diagnosis?

C) A) Atrophic gastritis

B) Duodenal ulcer

C) Gastric carcinoma
D) Oesophageal carcinoma

E) Pancreatic carcinoma

Q20. A 68 year old man is listed for an elective repair of a periumbilical hernia. He feels well
currently. He has a history of COPD, and uses salmeterol and tiotropium inhalers. He smokes five
hand-rolled cigarettes per day.

His oxygen saturation is 94% breathing air. He can walk approximately 200 metres before becoming
short of breath, and a recent FEV1/FVC ratio was 65% predicted.

Which intervention will most improve his perioperative course?

A) Amoxicillin 500 mg three times daily for the 5 days before surgery

B) Cessation of cigarette smoking

C) Chest physiotherapy

D) Prednisolone 40 mg daily for the 5 days before surgery

E) Stop tiotropium 5 days before surgery

Q21. A 30 year old woman has five months of tiredness. She has abdominal pain, discomfort and
bloating. Her aunt and mother have similar gastrointestinal symptoms.

Her BMI is 21 kg/m2.

Investigations:

Haemoglobin 92 g/L (115-150)

White cell count 5.2 x 109L (3.8-10.0)

Platelets: 235 x 109L (150-400)

MCV: 85 fL (80-96)

Serum folate 1.4 µg/L (3-15)

Ferritin: 8 µg/L (12-200)

Which is the most likely diagnosis?

A) Coeliac disease

B) Crohn's disease

C) Giardiasis

D) Irritable bowel syndrome

E) Small bowel lymphoma

Q22. 48 year old man is being reviewed two weeks after a lacunar stroke, His past medical history
includes obesity, hypercholesterolaemia and smoking. He has already been seen by the stroke
specialist nurse regarding lifestyle modification.

His average 24 hour blood pressure reading is 162/94 mmHg. His fasting glucose is normal.

Which antihypertensive would be most appropriate to use as first line treatment In this

A) Bendroflumethiazide

B) Bisoprolol

C) Doxazosin

D) Losartan

E) Perindopril

Q23. A year old woman has felt generally unwell for 1 week. She has been taking ibuprofen for 2
weeks for back pain.

Her temperature is 37.9, BP 155/92 mmHg, pulse 85 bpm. Her urinalysis shows blood 1+, protein 1+,
leucocytes 3+, with no nitrites detected.

investigations:

Creatinine 206 µmol/L (60-120)

Urine culture: no growth

Renal ultrasound: Normal

A renal biopsy is performed.

Which histological diagnosis is most likely to be seen?

A) Acute tubular necrosis

B) IgA nephropathy

C) Interstitial nephritis

D) Membranous nephropathy.

E) Minimal change nephropathy

Q24. A 49 year old man has 2 years of erectile dysfunction and reduced libido. More recently, he has
also noticed a reduction in facial hair growth and a decrease in muscle strength.

Investigations:
Thyroid stimulating hormone: 0.4 mU/L (0.3-4.2)

Free T4: 8 pmol/L (9-25)

Cortisol (9 am): 160 nmol/L (200-700)

Prolactin: 380 U/L (90-320)

Testosterone: 5 nmol/L (9.9-27.8)

Luteinising hormone: 2.0 U/L (premenopausal female: 1-11 U/L)

Which is the most likely diagnosis:

A) Addison's disease

B) Congenital adrenal hyperplasia

C) Pituitary adenoma

D) Primary hypothyroidism

E) Primary testicular failure

Q25. 50 year old man has 3 months of persistent right loin pain and has lost 8kg in weight, He has a
25 pack-year smoking history.

Urinalysis shows glucose negative, blood 3+ and protein negative:

Which is the most likely diagnosis?

A) Bladder cancer

B) Glomerulonephritis

C) Prostatic cancer

D) Renal calculi

E) Renal cancer

Q26. WHOOPS

Q27. A 45 year old women has 1 year of recurrent intermittent abdominal pain radiating to the back.
The pain is 8/10 in severity, can last several hours and resolves spontaneously. She has lost 2 kg over
the past 7 months. She is an ex-smoker and was a heavy drinker until 6 months ago.

Her temperature is 36.8, pulse rate 74 bpm, BP 128/84 mmHg and oxygen saturation 99% breathing
air. Her abdomen is soft and not distended, with mild tenderness in the epigastric region.
Which is the most likely diagnosis?

A) Cholangiocarcinoma

B) Chronic pancreatitis

C) Mesenteric ischaemia

D) Pancreatic cancer

E) Peptic ulcer

Q28. A 69 year old man has several weeks of increasingly severe aching pain in his left shoulder and
scapula radiating into his left arm.

There is weakness and wasting of the small muscles of his left hand.

Chest X-ray shows opacification at the apex of the left lung.

Infiltration of which structure is most likely to be causing his pain?

A) Axillary nerve

B) Brachial plexus

C) Cervical vertebrae

D) Scapula

E) Sympathetic Chain

Q29. A 75 year old man has ongoing severe pain at the site where he had shingles 4 months ago. He
is still finding the light touch of clothing painful;

What is the most appropriate treatment?

A) Codeine

B) Gabapentin

C) Ibuprofen

D) Morphine

E) Paracetamol

Q30. A 62 year old man has 3 months of general weakness fatigue, 10 kg weight loss and mild
abdominal discomfort over the right hypochondrium. He was found to have liver cirrhosis 10 years
from alcohol Since the diagnosis.

He has a non-tender, fixed hard mass in the right upper quadrant.

Which serum investigation is most appropriate to aid diagnosis?

A1) α-Fetoprotein

B) ß-Human chorionic gonadotropin

C) CA 125

D) CA 19-9

E) Carcinoembryonic antigen

Q31. A 57 year old man presents to the Emergency Department with 3 months of an intermittent
lump in the right groin. In the past 2 days, the lump has become painful and persistent. He has been
vomiting and has not opened his bowels for 2 days.

The skin is red, and the lump is tender and not reducible.

Investigations:

X-ray of abdomen shows dilated small bowel loops.

Which is the most appropriate course of action?

A) Colonoscopy

B) CT of abdomen and pelvis

C) Nasogastric tube and conservative management

D) Surgery

E) Ultrasonography of groin

Q32. A 27 year old woman has 1 month of unintentional weight loss. She is more thirsty than usual
and is feeling tired. Her appetite is impaired, and she has vomited twice for no obvious reason, Her
mother, maternal uncle, maternal grandmother and maternal great uncle all had diabetes mellitus.

Investigations:

Fasting glucose 28 mmol/L (3.0-6.0)

Anti-glutamic acid decarboxylase antibody is not detected.

Which is the most likely diagnosis?

A) Diabetes insipidus

B) Latent autoimmune diabetes of adulthood

C) Maturity-onset diabetes of the young

D) Type 1 diabetes mellitus

E) Type 2 diabetes mellitus

Q33 WHOOPS

Q34. A 41 year old man is admitted with an acute myocardial infarction. His father died of a
myocardial infarction aged 52 years.

Investigations:

Fasting glucose: 8.2 mmol/L (0.3-6.0)

Cholesterol (fasting): 9.2 mmol/L (3.5-6.5)

Triglycerides (fasting): 1.9 mmol/L (<2.3)

HDL cholesterol: 1.0 mmol/L (<1.2)

Which is the most likely cause of his hyperlipidaemia?

A) Chylomicronaemia

B) Diabetes mellitus

C) Familial combined hyperlipidaemia

D) Heterozygous

E) Polygenic hypercholesterolaemia

Q35. A 72 year old becomes unresponsive in the ward 6 hours after a laparotomy. There is no pulse
and BP is unrecordable. Chest compressions and bag valve mask ventilation are started.

The initial ECG rhythm strip taken after the patient became unresponsive is shown

Which is the most appropriate immediate management?

A) A precordial thump

B) A synchronised shock of 200 J

C) Adrenaline/epinephrine 1 mg (1:10 000) intravenously

D) amiodarone hydrochloride 300 mg

E) An unsynchronised shock of 360 J

Q36. A 35 year old woman is admitted unconscious to the Emergency Department after being found
collapsed outside a pub. There was an empty Vodka bottle lying next to her.

Her pulse is 86 bpm, BP 112/62 mmHg, respiratory rate 12 breaths per minute and oxygen
saturation is 98% breathing air.

Which is the most important immediate investigation?

A) Arterial blood gas

B) Blood alcohol level

C) Capillary blood glucose

D) Urea and electrolytes

E) Urinary drug screen

Q37. A 59 year old man has a BMI of 36 kg/m2. He is a large goods vehicle driver (LGV) and has a
medical every 3 years for his LGV licence. He is taking atorvastatin (20 mg once daily) for
hypercholesterolaemia.

Investigations:

Glycated haemoglobin: 46 mmol/mol (20-42)

Total cholesterol (TC): 5.4 mmol/L (<5.0)

LDL cholesterol (fasting): 2.7 mmol/L (<3.0)

HDL cholesterol: 2.6 mmol/L (>1.2)

Ratio of TC/HDL: 4.1 (<4.5)

ALT: 61 IU/L (10-50)

AST: 43 IU/L (10-40)

Alkaline phosphatase: 110 IU/L (25-115)

Bilirubin: 11 µmol/L (<17)

yGT: 21 IU/L (9-40)

which is the most appropriate next step?

A) Increase dose of statin

B) recommended lifestyle modification

C) repeat blood tests in 2 weeks

D) start metformin
E) stop statin

Q38. A 32 year old woman has 3 weeks of fever, rigors and lethargy. In the past week, she has also
become breathless on exertion, She is an intravenous drug user.

Her temperature is 38, pulse rate 100 bpm and rhythm regular, and BP 100/60 mmHg, Her JVP is
raised with predominant V waves.

There is a pansystolic murmur at the left sternal edge on inspiration. She has reduced air entry with
dullness to percussion at the right lung base. She has swelling of both ankles.

Which is the most likely pathogen?

A) Enterococcus faecalis

B) Staphylococcus aureus

C) Staphylococcus epidermidis

D) Streptococcus bovis

E) Streptococcus viridans

Q39 WHOOPS

Q40. A 62 year old woman is brought to the Emergency Department with chest pain of sudden
onset.

She is alert and oriented. Her BP is 180/110 mmHg in her right arm and 170/108 mmHg in her left
arm. She has an ejection systolic murmur. Her chest is clear. Chest X-ray shows a widened
mediastinum

Which is the most appropriate next investigation?

A) CT angiography

B) Digital subtraction angiography

C) MR angiography

D) Transoesophageal echocardiography

E) Transthoracic echocardiography

Q41 WHOOPS
Q42. A 90 year old man has 3 days of spasmodic suprapubic pain radiating to the tib of the penis. He
has developed fever and mild confusion.

His urinary catheter has recently been changed and the urine is dark and strong smelling.

Which factor indicates the need to start antibiotics?

A) Blood and protein in urine on dipstick testing

B) Dark strong-smelling urine

C) Fever and mild confusion

D) Presence of pain

E) Recent catheter change

Q43. A 76 year old man experiences transient loss of consciousness while climbing the stairs. He has
become more short of breath over the past 3 months. He is not taking any medication.

His pulse rate is 90 bpm and BP 100/85 mmHg. He has an ejection systolic murmur and has bruits
over both carotid arteries.

Which is the most appropriate investigation?

A) Ambulatory 24 hour ECG

B) Carotid Doppler scan

C) Echocardiogram

D) Myocardial perfusion scan

E) Serum troponin

Q44. A 24 year old man has vomiting. He has type 1 diabetes.

He is drowsy but maintaining his airway. His pulse fate IS 00 bpm, BP 90/60 mmHg, respiratory rate
30 breaths per minute and oxygen saturation 96% breathing air.

Investigations:

Blood capillary glucose: 32mmol/L

Blood capillary ketones: 6.2 mmol/L (<0.6)

Venous: pH 7.15 (7.35-7.45)

Which is the most appropriate initial treatment?

A) Intravenous 0.9% sodium chloride

B) intravenous 1.26% sodium bicarbonate

C) Intravenous antibiotics

D) intravenous insulin

E) Subcutaneous insulin

Q45. A 76 year Old man has progressive breathlessness with right-sided pleuritic chest pain and
weight loss over 6 months. He is a retired mechanic and has a 25 pack-year smoking history.

Investigations:

Chest x-ray marked volume loss in the right hemithorax

CT scan of chest:

Which is the most likely diagnosis?

A) Asbestosis

B) Chronic hypersensitivity Pneumonitis

C) Lung cancer

D) Malignant pleural mesothelioma

E) Tuberculosis

Q46. A 28 year old man has haemoptysis lasting 3 days. He report four similar episodes over the
previous 2 years. He has a history of multiple episodes of sinusitis and upper respiratory tract
infections accompanied by productions of purulent sputum. He had whooping cough as an infant. He
has smoked 30 cigarettes per day since the age of 14.

He is apyrexial and has right mid-zone inspiratory crackles

Which is the most likely diagnosis?

A) Bronchiectasis

B) COPD

C) Fibrosing alveolitis

D) Recurrent pulmonary emboli

E) Tuberculosis

Q47. 65 year old man develops abdominal distension and vomiting 72 hours after a sigmoid
colectomy with primary anastomosis for bowel cancer. He has not passed any wind for 12 hour. He is
taking regular paracetamol and as required intravenous morphine. He has received 3L of intravenous
0.18% sodium chloride/4% glucose with 10 mmol/L potassium chloride over the past 24 hours.

His pulse rate is 96 bpm and BP 122/85 mmHg. His abdomen is distended, with tenderness over the
wound but no rebound or guarding. Bowel sounds are absent.

Which is the most likely biochemical abnormality?

A) Acidaemia

B) Hypercalcaemia

C) Hypernatremia

D) Hypokalaemia

E) Hypophosphatemia

Q48. A 45 year old women has abnormal liver function tests. She is asymptomatic. She has a history
of systemic lupus erythematous and type 2 diabetes mellitus. She takes metformin and azathioprine.

Abdominal examination is normal. Her BMI is 33

Investigations:

ALT: 165 IU/L (10-50)

AST: 112 IU/L (10-40)

ALP: 130 IU/L (25-115)

Bilirubin: 10 µmol/L (<17)

Which is the most appropriate investigation to confirm the diagnosis?

A) Serum anti-hepatitis C antibody

B) Serum antimitochondrial antibody

C) Serum anti-smooth muscle antibody

D) Serum ferritin and transferrin saturation

E) Ultrasonography

Q49. A 75 year old women has pain in her wrist with tingling and numbness over the palmer aspect
of her right index and middle fingers. She fell a few days previously onto her outstretched hand.

She has decreased sensation over the palmar aspect of her right index and middle finger, and
weakness of thumb abduction. The rest of her neurological examination is normal.

Which nerve has been injured?

A) Medial cutaneous nerve to forearm

B) Median nerve

C) Musculocutaneous nerve

D) radial nerve

E) Ulnar nerve

Q50. An 84 year old women is admitted to the emergency department after collapsing in her nursing
home.

Her temperature is 37.2, pulse rate 36 bpm, BP 85/44 mmHg, respiratory rate 22 breaths per minute
and oxygen saturation 94% breathing 15 L/min oxygen via a non-rebreathing mask. She is pale and
her peripheries are cool and clammy. She has bilateral inspiratory crackles in the lower zones. Her
GCS score is 14.

Which is the most appropriate first step in management?

A) DC cardioversion

B) insert an oropharyngeal airway

C) intravenous 0.9% sodium chloride

D) intravenous atropine sulfate

E) intravenous furosemide

Q51. A 73 year old woman has difficult with her speech. She recently had 9 stroke and is finding it
difficult to communicate.

Her speech is fluent but disorganised, and she is unable to follow commands.

Which type of aphasia has she developed?

A) Conductive

B) Expressive

C) Global

D) Primary progressive

E) Receptive

Q52. A 91 year old man is admitted to hospital after developing abdominal pain and vomiting.

He has a distended abdomen that is generally tender without peritonitis.

After initial investigations, a diagnosis of sigmoid volvulus is made.

Which is the most appropriate treatment?

A) Air enema

B) Barium enema

C) Insertion of a flatus tube

D) Laparoscopy

E) Laparotomy

Q53. A 70 year old man is an inpatient on the cardiology ward. He has worsening breathlessness that
woke him up last night. He recently had a myocardial infarction.

His pulse rate is 99 bpm, BP 160/100 mmHg and respiratory rate 20 breaths per minute. Auscultation
of the chest reveals bibasal crepitations, and there is dullness to percussion of both bases. Chest X-
ray shows small bilateral pleural effusions with upper lobe blood vessel diversion.

Which is the most appropriate diagnostic investigation?

A) Coronary angiography

B) CT pulmonary angiography

C) ECG

D) Echocardiography

E) Serum D dimer

Q54. An 80 year old man has low BP on return to the orthopaedic ward. He has had a hip fracture
repair under spinal anaesthesia. Before he left the ward for theatre, his pulse rate was 70 bpm and
BP 140/80 mmHg. Now pulse rate is 90 bpm and BP 90/45 mmHg.
The surgical wound is unremarkable. Sensory testing reveals that he cannot feel cold below the level
of L1 dermatome bilaterally.

Which is the best explanation for is hypotension?

A) Blockade of sympathetic nerves causing cardiac depression

B) Blockade of sympathetic nerves causing vasodilation

C) Occult blood loss from the surgical site

D) Relief of pain experienced from fracture

E) systemic local anaesthetic toxicity

Q55. A 19 year old man has had a sore throat, malaise and intermittent fever for 2 weeks.

His pulse rate is 74 bpm and BP 115/75 mmHg. His throat is red and tonsils are swollen. His sclerae
are yellow-tinged. There are multiple soft palpable lymph nodes in the neck. There is tenderness 'In
the right upper abdominal quadrant.

Which is the most appropriate diagnostic investigation?

A) Epstein-Barr virus test

B) HIV test

C) Lymph node biopsy for histology

D) Mantoux test

E) Throat swab and culture