fourth year

• A 69-year-old man presents with a four week history of weight loss and night sweats. He has no significant past medical history. His examination revealed the presence of significant lymphadenopathy in the cervical and axillary regions. Fine needle aspiration shows a uniform population of large lymphoid cells. What is the most likely diagnosis?

  Non-Hodgkin's lymphoma
• A 70-year-old man flies in from Rome to Heathrow. After a heavy lunch on arrival, he develops a severe bout of sudden central chest pain and is admitted via A and E. One hour after admission he develops a cold painful leg which is pulseless and has decreased sensation. The most likely diagnosis is:

  Dissecting aortic aneurysm
• A 28-year-old woman presents with a history of progressive loss of vision over the past three days. She has no past medical history. On examination there is nystagmus on leftward gaze and blurred optic discs. On examination of the limbs, tendon reflexes are increased in the legs with increased tone. The most likely diagnosis is:

  Multiple sclerosis
• A 79-year-old woman with a blood pressure of 176/101 mmHg sees her GP for advice. The patient has smoked for many years and has suffered with pains in both calves brought on by walking uphill. Her GP prescribes an ACE inhibitor, and encourages the patient to give up smoking. Four weeks later her creatinine has increased from 112 to 347 micromoles/ml. What is the most likely cause?

  Renal artery stenosis
• A 48-year-old woman presents to her GP with bilateral swollen knees for the past 4 weeks. On examination her knees are tender generally, warm to touch and she has bilateral effusions. Her ESR is 97 mm/hour and her C-Reactive protein is 93 mg/L. The most likely diagnosis is:

  Rheumatoid arthritis
• A 30-year-old woman was hit on the head by a cricket ball. After a brief period of loss of consciousness, she recovered and continued her cricket match. Later the same evening she developed a headache and was rushed to hospital after falling into a coma. The most likely diagnosis is:

  Extradural haemorrhage
• A 35-year-old man with no relevant previous medical history comes to the Accident and Emergency department complaining of a hot red, swollen, painful knee joint and inability to walk. The problems started 2 days ago and has got steadily worse. There is no history of trauma and he has never had any joint problems in the past and has no other past medical history. The most likely diagnosis is:

  Septic arthritis
• Two days after a total thyroidectomy for multinodular goitre, a 54-year-old woman complains of tingling in her lips. A few hours later she notices pins and needles in her finger tips. Examination of her scar is unremarkable and there is nothing to find on general examination. The most likely diagnosis is:

  Hypoparathyroidism
• A 62-year-old woman attended the A and E Department complaining of leg pain. She had a hysterectomy 4 days previously at a different hospital and as usual the old notes are unavailable. She is otherwise well. She drinks socially and smokes 20 cigarettes per day. On examination, her temperature was 37.8 C. there was erythema around the wound but no evidence of any infection. Further examination revealed a swollen, tense right calf. Which test is most likely to yield the correct diagnosis.


  Venous duplex ultrasound of right leg
• A 65-year-old man presented with a two week history of haemoptysis against a background of increasing shortness of breath over the last 6 months. He is on atenolol for treatment for hypertension and atrial fibrillation and takes low dose aspirin for thromboprophylaxis. He has been a heavy smoker for 40 years. His GP organised a chest X-ray shown below.

  Carcinoma of the bronchus

  
• A 72-year-old male has a seven day history of severe urinary frequency and urgency. He has previously been well. PR examination is normal but urine tests positive for blood and leukocytes. The serum prostate specific antigen concentration is 9.0 ng/ml (normal 0 to 6.5 ng/ml). The most likely diagnosis is:

  Urinary tract infection
• A 58-year-old man complains of memory impairment. Mental state examination reveals an alert and attentive patient with average vocabulary. He remembers one out of five objects after two minutes and has a marked difficulty with reasoning and abstraction. This combination is most typical of which of the following?

  Dementia
• A 42-year-old man has a slow growing mass in the region of the right parotid gland. The mass is solid and non-tender. Examination of the seventh cranial nerve demonstrates it to be intact and there is no evidence of deep lobe involvement on examination of the oral cavity. The most likely diagnosis is:

  Pleomorphic adenoma
• A 70-year-old man presents with a six month history of weight loss, anorexia and constipation. Haemoglobin is 95 gm/L with an MCV of 68 fL. The most likely diagnosis to explain these findings is:

  Carcinoma of the sigmoid colon
• A 79-year-old man suddenly loses vision in his left eye. He has noticed fluctuating vision in that eye during the previous week and has felt generally unwell for 4 weeks. He has also had a persistent headache and weak shoulders for the last 2 weeks. On examination, vision in the left eye is reduced to hand movements; he has a relative afferent pupillary defect and a pale swollen optic disc. His ESR is 112 mm/hr, white cell count is 11.6 x 10 /L. The next step in his management is:

  Initiate high dose steroid therapy
• A 72-year-old woman presents to her GP with a one day history of sudden onset of a painful right eye. The pain is severe and he has vomited twice. The right eye has an acuity of hand movements only; acuity in the left eye is 6/12. The right eye is severely injected with a cloudy cornea. The pupil is fixed and semi-dilated. The most likely diagnosis is:

  Acute closed angle glaucoma
• A 42-year-old woman complains of tight constricting pain across the front of her chest. Symptoms have been present for 6 months. It is occasionally related to exertion, but not always, as it can wake her from sleep. Sometimes it spreads upwards to her throat and has a burning quality. Attacks can last for up to several hours. At times she gets relief from indigestion medication she buys at Boots. There is no past medical history, and other than a BMI of 35, there is nothing to find on examination. What is the most likely diagnosis?

  Oesophageal reflux
• A 65-year-old woman presents with back pain and paraparesis. A radiograph of the spine shows collapse of the T9/10 vertebral bodies. She has the following blood results: Haemoglobin: 9.2 g/dL White cell count: 5.0 x 10 /L Platelets: 156 x 10 /L MCV: 92 fl ESR: 95 mm/h Total protein: 95 g/l Calcium: 3.2 mmol/L Phosphate: 1.3 mmol/L Which of the following statements is most appropriate?

  Bone marrow examination would be expected to reveal an excess of plasma cells
• A 60-year-old woman noticed that for the last six months her left hand has trembled at rest. This has been more marked when she is aware someone is looking at her tremor. She is able to do up buttons and pick up a cup and saucer without rattling them. The only additional sign is mild rigidity in the left arm. What is the most likely cause?

  Early parkinsonism
• A 65-year-old woman with long-standing rheumatoid arthritis comes for her routine check-up. She reports that all is well with her joint disease. However, she has had mid to low back pain for the past 8 weeks, that came on suddenly. Though it is slowly improving, it is still restricting her movements. She is on disease modifying drugs including methotrexate and prednisolone. What is the most likely cause of her back pain?

  Vertebral collapse
• A 25-year-old man presents to the emergency department with sudden onset of fast regular palpitations which he timed at 180/minute and lasted for 40 minutes. By the time he is seen his pulse rate is normal and he is feeling better. He has had similar symptoms previously. You record an ECG. Which one of the following ECG abnormalities suggests his problems were due to supraventricular tachycardia?

  Delta waves
• A 30-year-old woman has resistant iron deficiency associated with folate deficiency. This is not due to pregnancy, alcoholism, drugs or a poor diet. She admits to occasional bowel symptoms since attacks of 'gastroenteritis' as a child. Which investigation is most likely to be diagnostic?

  Duodenal biopsy
• A 49-year-old woman presents with a two month history of diffuse thyroid swelling that is painless. She also complains of intense sweating particularly at night. What is the most likely diagnosis?

  Auto-immune thyrotoxicosis (Grave's disease)
• A clinic nurse has discovered urinary ketones in a patient. Blood sugar is normal on fingerprick testing. No other abnormality is evident on testing the urine. The 45-year-old patient is concerned about his excessive weight but otherwise is well. The most likely explanation for these results is:

  Adherence to a low carbohydrate diet
• A 28-year-old man has attended A&E several times the past two weeks with worsening wheeze and breathlessness. He has started smoking again, sleeps very poorly, and has a worsening nocturnal cough. He is normally treated for asthma with regular inhaled steroids and inhaled salbutamol as required. At his previous attendance at A&E his inhaled steroid usage was increased. Peak flow values are below 50% of predicted. He declines admission to hospital. What is the most appropriate step?

  Start on oral steroids
• A 60-year-old woman presents with a one month history of recurrent lower gastrointestinal bleeding. Blood is mixed with her faeces and she has had 3 such episodes, each lasting a few days. There is nothing to find on examination and her haemoglobin is 110g/L. Other blood tests are unremarkable. The next investigation should be:

  Colonoscopy
• A 62-year-old man has been treated in the community for two weeks for treatment of a right lower lobe pneumonia. Initially he received co-amoxiclav followed after 10 days by erythromycin. Six weeks later he is considerably improved but he remains intermittently feverish. On examination, there is dullness to percussion at the left base, with reduced air entry, and inspiratory crepitations. Six weeks later his chest x-ray appearances is as below.

  Underlying right lower lobe carcinoma

  
• A man of 70 years has atrial fibrillation with a dilated left atrium. Arrangements are made to restore sinus rhythm by means of a direct current applied to the chest wall. What complication of the procedure should be anticipated and is largely preventable?

  Systemic embolism
• Following a knee in the back during a football match, a 20-year-old woman presents with flank pain and macroscopic haematuria. The best test to assess the degree of renal injury is:

  Abdominal CT scan
• A 27-year-old woman presents with several weeks of polyuria, increased thirst and weight loss. She denies urinary urgency or painful micturition. Her BP is 120/80 mmHg. Examination reveals decreased skin turgor, fungal infection of both feet and vaginal candidiasis. What is the next appropriate diagnostic investigation?

  Blood glucose
• What is produced in alpha cells?

  Glucagon
• Insulin binding to the receptor – exerting its effects on

  PI3-K
• What is the name of the hormone that inhibits growth hormone release?

  Somatostatin
• What is the best description of the evolutionary theory of ageing?

  The selection pressure decreases over time thus mutations can build up and cause aging
• A man has got Charcot Marie tooth disease which is X linked dominant. Which of the following is right?

  100% of daughters 0% of sons will get the disease
• Which of the following is genuine non-mendelian inheritance?

  Linkage
• What will happen if you inhibit dimerization of EGFR?

  Pathway can’t be activated
• What normally happens to EGFR in cancer?

  Overly expressed
• Which interleukin is the main one in Grave’s disease?

  IL-1
• What is the C in PICO?

  Comparator