mock answer

A 72-year-old woman was admitted with symptoms of meningitis. She recently returned from northern France with her husband and has had a persistent headache with worsening neck stiffness over the past few days. The admitting team performed a lumbar puncture and started IV ceftriaxone. You are asked to review the patient because her symptoms have not improved. A lumbar puncture shows Gram-positive bacilli.

Which of the following is the most likely cause of the patient’s meningitis?

A 22-year-old student is brought to the Emergency Department by the police. His flatmates have become increasingly concerned about him over the past three weeks, as he has become increasingly withdrawn and is acting strangely. He told them he believes that his thoughts are being controlled by the radio and when he turns it on, he can hear voices providing a commentary on his actions. Apparently, he has been smoking increasing amounts of cannabis and not attending lectures at university. He refuses physical examination, is unkempt, and has wrapped himself in tin foil to prevent transmission of his thoughts.
Which of the following is the most appropriate initial intervention?

A 45-year-old chef presents with hand pain at night and difficulty holding objects. Examination reveals wasting of the thenar eminence and diminished sensation over the fingertips of the second and third digits. Where is the most likely site of injury in this patient?

An 18-year-old man is reviewed in the clinic with deteriorating night vision and appears to be suffering from maculopathy. Other members of the family are similarly affected, and it is thought he is suffering from an inherited peroxisome disorder.

Which of the following correctly describes peroxisome function?

A 67-year-old woman is admitted to the Emergency Department following an overdose of digoxin. She is vomiting and complains of yellow vision. Her BP is 112/82 mmHg, and her pulse is 40 bpm and regular.
Which of the following is the primary mode of action of digoxin?

A 19-year-old is admitted to the Emergency Department having suffered a brief fainting episode whilst at the dentist. Immediately post a dental extraction, he lost consciousness whilst sitting in the dentist’s chair. There was a brief episode of limb jerking and head shaking which resolved when he was laid flat. He recovered consciousness after 40 seconds with no postictal phenomena. Neurological examination is unremarkable, as are routine bloods. Which of the following is the most appropriate next step?

A 37-year-old carpenter comes to the Rheumatology Clinic for review. He has pain and swelling at the base of his thumb, which is worse on pinching and grasping objects with the thumb and using his wrist. Examination confirms swelling and pain at the base of the thumb and the pain is worse when the wrist is deviated towards the ulnar side, with the thumb grasped in a closed fist. Which of the following is the most likely cause of this patient’s pain and swelling?

A 62-year-old man who has had type 1 diabetes for 50 years comes to the clinic for review. He has been diagnosed with proliferative diabetic retinopathy five years ago, for which he received full scatter pan-retinal photocoagulation. What visual defect is he most likely to suffer from?

A 19-year-old man with atopic eczema comes to the Emergency Department for review. He has developed a fever over the past 36 hours and now has a worsening of his erythema with multiple pustules and vesicles which are intensely itchy. He has recently been using a higher potency steroid cream for the eczema. His temperature is 38.9 °C, blood pressure is 100/80 mmHg, and his pulse is 90 bpm and regular. The vesicles are spread over his neck, torso, and upper arms. Which of the following is the most appropriate intervention?

A 29-year-old policeman comes to the Emergency Department for review. He has been bitten on the hand by a suspect. He washed the wound at the time, and it was dressed at the police station. He is attending for further advice. You review the wound and can see a number of teeth marks with dried blood overlying the puncture wounds, with surrounding erythema. He is up to date with tetanus vaccination. Which of the following is the most appropriate next step?

A total of 400 subjects volunteer to participate in a clinical trial of a new antibiotic therapy for otitis media. Of these, 200 patients are randomised to the new therapy and 200 to standard of care. Out of the 200 randomised to the new therapy, 70 drop out in the first two days due to adverse events, and 70 are lost to follow-up in the first week. A total of 60 complete the 14 days of treatment and out of those, 50 patients show a good response to therapy. What is the response rate based on an intention-to-treat (ITT) analysis?

A 24-year-old woman presents to the midwife five days after the birth of her first child. She is tearful, tired, and lacks confidence in her ability to care for her baby, feeling that no matter what she does, it isn’t good enough. She has not expressed any thoughts of harming herself or her child. Physical examination is unremarkable. Which of the following is the most likely diagnosis?

A 42-year-old woman who has systemic lupus erythematosus (SLE) and takes hydroxychloroquine has well-controlled joint disease but is beginning to suffer from dry eyes and dry mucus membranes. Which of the following autoantibodies is most likely to be associated with this patient’s new symptoms?

A 56-year-old man is about to undergo a left nephrectomy for renal carcinoma. What structure may overlie the left renal hilum?

A 27-year-old White woman has been diagnosed with rheumatoid arthritis (RA). She has a family history of the disease; both her mother and her aunt are treated for RA. Which of the following human leukocyte antigen (HLA) alleles is she most likely to have?

A 45-year-old man who suffered a subarachnoid haemorrhage (SAH) some 14 days earlier, which required placement of a coil, has been readmitted to the Emergency Department with severe headaches and inability to look to the side. These symptoms are new, but he has some left face and arm weakness which hasn’t changed since his original SAH. Examination reveals a blood pressure of 165/95 mmHg, pulse is 75 bpm and regular, and he is apyrexial. Neurological examination reveals bilateral papilloedema, bilateral sixth nerve palsies, and left face and arm weakness. Which of the following is the most likely diagnosis?

A 29-year-old professional rugby player presents to the Emergency Department after developing fast irregular palpitations while at a party to celebrate winning a challenge cup last night. He has no past medical history of note and had a normal echocardiogram (ECHO) and exercise electrocardiogram (ECG) six months earlier. His blood pressure is 115/80 mmHg, pulse is 135 bpm and irregular. His chest is clear, and there is no ankle swelling. ECG reveals fast atrial fibrillation (AF). Chest X-ray (CXR) reveals a normal-sized heart. Potassium is 4.2 mmol/l. Which of the following is the most appropriate intervention?

A 29-year-old carpenter comes to the clinic for review. He injured his hand when it was crushed by a pile of wood and feels there is some residual weakness in his thumb. Neurological examination demonstrates weakness during flexion of the terminal phalanx of the thumb.

A branch of which nerve is most likely to have been damaged?

A 42-year-old climber has recently returned from a trip to the Himalayas. Which of the following is likely to be found on routine assessment in the sports medicine clinic?

A 19-year-old man is brought to the Emergency Department by the police. He was found shouting in the street, believing that men who he has dealt drugs with are coming to kill him. He also believes that his parents are trying to give him medication against his will. According to his parents, he smokes strong cannabis every day and has never held down a job since leaving school. There are no abnormal physical findings, although you note he is unkempt and his clothes are dirty.
Which of the following is the most likely diagnosis?

You are asked to review a 28-year-old man who is undergoing chemotherapy for leukaemia. He has received a platelet transfusion some 24 hours earlier and has become extremely unwell with a temperature of 38.9 °C, pulse of 105 bpm and regular, and a blood pressure of 80/60 mmHg. You suspect he may have received a unit of platelets that was contaminated with bacteria.
Which of the following is the most likely cause of bacterial contamination?

A 40-year-old woman is treated with vincristine for leukaemia. She has developed neuropathic pain. Which of the following describes the stage of the cell cycle that vincristine acts on?

A 35-year-old man is admitted to the Emergency Department having become unwell on a freighter which has just docked in port from Russia. He has been unwell with symptoms of a common cold for the past two days and now has a severe sore throat, such that he is unable to swallow, and nose bleeds. Examination reveals a pyrexia of 39 °C, a pulse of 85 bpm and regular, and a blood pressure of 90/60 mmHg. You note marked cervical lymphadenopathy, pharyngitis and a grey/white pseudomembrane overlying the inflamed pharyngeal tissue. Which of the following is the most appropriate intervention?

A 27-year-old man presents to the clinic for review. Over the past few months, he has developed intermittent night sweats, gradual weight loss, and arthralgia affecting his back and knees. He is most concerned, as he has developed ulcers affecting his mouth and tongue and his penis. He has also developed red, itchy eyes. Examination reveals evidence of uveitis, arthritis affecting the lower back and knees, and aphthous ulcers. Which of the following is the most appropriate initial intervention?

A 19-year-old man presents to the Emergency Department with severe epigastric pain, vomiting, and hyperventilation. He drinks five units of alcohol per week. Examination reveals a BP of 90/60 mmHg and his pulse is 102 bpm and regular. He is very tender in the epigastrium. His BMI is 22 kg/m². Blood tests confirm elevated amylase and lipase levels, consistent with pancreatitis. The sample is reported as lipaemic, and the rest of laboratory investigations are still pending.

Which of the following is the most likely cause of this patient’s pancreatitis?

A 57-year-old man receiving a blood transfusion becomes extremely unwell after receiving 10 ml of blood. Which of the following is the most likely diagnosis?

A 45-year-old woman who has recently diagnosed hypertension and type 2 diabetes comes to the clinic for review. She has also had difficulties with swelling of the fingers of both hands and has noticed a change in the shape of her lower jaw on photographs taken over the past two to three years. An insulin-like growth factor (IGF-1) sent by her GP is markedly elevated. Her blood pressure is 155/90 mmHg, pulse is 72 bpm and regular. Her body mass index (BMI) is 24 kg/m². Which of the following is the most appropriate next investigation?

A 72-year-old woman is admitted to the Emergency Department with sudden-onset severe lumbar spine pain and weakness in both lower limbs. The pain started 24 hours ago and has steadily worsened. She has a 60-pack-year smoking history and reports a chronic, worsening cough over the past six months. There is bilateral lower limb weakness (3/5) with increased tone and hyperreflexia. Decreased anal sensation is noted.
Which of the following is the most likely diagnosis?

A 61-year-old man who has type 2 diabetes currently managed with gliclazide 80 mg twice a day, is admitted to the Emergency Department after suffering a hypoglycaemic episode following the consumption of several pints of beer at a wedding. His usual glycosylated haemoglobin (HbA1c) is 55 mmol/mol, and he hasn’t experienced a hypoglycaemic episode before. His body mass index is elevated at 31 kg/m². Which of the following is the most likely primary cause of his hypoglycaemic episode?

A 55-year-old woman who had rheumatic fever at the age of 13 is admitted to the Emergency Department with palpitations and exertional dyspnoea. Over the past two months, she has experienced a progressive decline in her exercise tolerance, such that she can no longer run for the bus. Her blood pressure is 137/82 mmHg, and her pulse is 75 bpm and regular. There is a pan-systolic murmur that is loudest at the apex. Which of the following is the most likely diagnosis?

A 45-year-old man presents to the Gastroenterology Clinic for review. He has suffered from multiple joint pains over the past six months, coupled with gradual weight loss and intermittent diarrhoea and bloating. He also tells you that his stool floats and is difficult to flush away. He has noticed increased skin tanning and has developed a persistent cough. Examination reveals increased skin pigmentation and a reduced BMI of 20 kg/m². Which of the following is the most likely diagnosis?

A 62-year-old man presents to the Emergency Department with central crushing chest pain radiating to his left arm. He was discharged from the hospital some four weeks earlier following right coronary artery stenting for an inferior myocardial infarction. His clopidogrel was stopped by the GP because of a per rectum (PR) bleed one week ago, although he has continued aspirin therapy. His blood pressure is 100/70 mmHg, pulse is 40 bpm and regular. He is pale and sweaty. Electrocardiogram (ECG) reveals 3 mm of ST elevation in II, III and atrial fibrillation.
Which of the following is the most likely diagnosis?

A 19-year-old man presents to the Immunology Clinic with recurrent sinusitis, lower respiratory tract infections, and bronchiectasis. He has had four hospital stays because of lower respiratory tract infection over the past year. He tells you that he has always been sickly and has suffered from respiratory tract infections every year for as long as he can remember. On auscultation, you can hear crackles at both lung bases consistent with bronchiectasis. Which of the following is he most likely to be suffering from?

A 19-year-old man comes to the Endocrinology Clinic for review. He has emotional difficulty forming relationships and problems with his sexual function. Examination reveals a blood pressure (BP) of 110/80 mmHg, pulse is 68 bpm and regular. He is 184 cm in height and his body mass index (BMI) is 22 kg/m². He has bilateral gynaecomastia, sparse axillary and pubic hair, and small testes.
Which of the following is the most likely cause of his presentation?

A 29-year-old pregnant woman with mitral stenosis presents with palpitations. Her blood pressure is 105/82 mmHg, and pulse is 130 bpm (atrial fibrillation). Which of the following is the most appropriate intervention?

A 22-year-old man is reviewed in the Cardiology Clinic following the sudden death of his father while playing squash at the age of 48. He is well and has no significant symptoms of cardiac disease. Examination reveals a blood pressure of 148/84 mmHg, a pulse of 70 bpm and regular, and a body mass index of 24 kg/m². He has no cardiac murmurs, and his chest is clear. An electrocardiogram (ECG) shows evidence of left ventricular hypertrophy, and an echocardiogram (ECHO) reveals asymmetrical septal hypertrophy. Which of the following is the most likely mode of inheritance for his cardiovascular condition?

A 49-year-old man who has gained 8 kg over the past three months is referred to the Endocrine Clinic with a raised 24-hour urinary free cortisol. He also has impaired glucose tolerance and worsening hypertension over the past few months. His BMI is 36 kg/m².

Which of the following is the most useful next investigation?

A 22-year-old man comes to the Endocrine Clinic for review with his partner. He has previously had difficulty forming relationships and now reports issues with his sex drive and maintaining erections during sexual intercourse. On examination, he shows signs of gynaecomastia, sparse pubic and axillary hair, lean muscle mass, and small testes. His blood pressure is normal at 122/82 mmHg, and his BMI is stable at 23 kg/m². Which of the following is the most likely cause of this patient’s sexual dysfunction?

A 42-year-old man comes to the clinic for review. He has suffered from slowly progressive heart failure and atrial fibrillation, and over the past five to ten years, has developed gradually worsening proximal muscle weakness. Examination in the clinic confirms proximal muscle weakness and mild pitting oedema affecting both ankles. Which of the following pathologies is known to underlie the progressive muscular weakness seen here?

A 32-year-old woman who uses nitrous oxide a number of times per week and drinks 50–60 units of alcohol a week, comes to the Emergency Department complaining of sudden visual loss affecting her right eye. Examination reveals an ataxic gait, bilateral loss of vibration sense and position, upgoing plantars, and right optic disc pallor. Which of the following is the most likely cause of this patient’s symptoms?

A 23-year-old woman who has cystic fibrosis (CF) comes to the Early Pregnancy Clinic. She is thought to be 12 weeks’ pregnant. Her partner has no symptoms of respiratory disease. Given the carrier frequency of CF is thought to be 1 in 20, what is the risk of her having a child with the disease?

A 24-year-old man presents to the Emergency Department ten days after returning from a holiday in West India. He admits to having had unprotected sexual intercourse during his stay. He has a single painless ulcer over the glans penis and bilateral inguinal lymphadenopathy.
Which of the following is the most likely diagnosis?

A 49-year-old hiker comes to the Emergency Department for review. He has just returned from a trip to Austria and has an area of erythema on his right lower leg. At the centre of it, there is an eschar, and he remembers a tick bite a few days earlier. He has no symptoms of neurological or cardiac dysfunction. He is apyrexial. Which of the following is the most appropriate next step?

A 72-year-old retired gardener presents to the Dermatology Clinic with a 1 cm ulcerated lesion on his right temple with a rolled edge. He tells you that it has grown slowly over the past six months. He has had previous basal- and squamous-cell carcinomas removed over the past five years. You note a number of telangiectasia around the margins of the lesion and superficial ulceration. Which of the following is the most appropriate intervention?

A 72-year-old man with a history of ischaemic cardiovascular disease and two previous TIAs presents with sudden deterioration of vision in his left eye, now only able to perceive light and dark. Fundoscopy reveals a pale retina. Which of the following is the most likely diagnosis?

A 27-year-old man comes to the Respiratory Clinic for review. He has recently returned from Pakistan, where he was staying with his uncle who has just been diagnosed with active tuberculosis (TB). He has no respiratory symptoms and clinical examination is unremarkable. What is the best way to confirm that he has infectious TB?

A 23-year-old man is referred to the Cardiology Clinic by his GP with worsening exercise tolerance and increased shortness of breath. Examination reveals a soft diastolic murmur at the left upper sternal edge and mild pitting oedema of both ankles. The patient is tall and thin, with a body mass index (BMI) of 19 kg/m². Which of the following is the most likely diagnosis?

Where is the likely source of the embolus which has caused this patient’s symptoms?

A 61-year-old man comes to the Diabetes Clinic for review. He has type II diabetes and takes 1 g of metformin twice a day. His glycated haemoglobin (HbA1c) is 53 mmol/mol. His weight is stable, with a BMI of 28 kg/m². His BP is 132/85 mmHg, and his pulse is 70 bpm and regular.

Which of the following is the most appropriate monitoring frequency for this patient’s HbA1c?

A 96-year-old woman with bilateral knee replacements comes to the clinic for review. She complains of urinary frequency, particularly at night, when she is occasionally unable to make it to the toilet and is incontinent of urine. She takes antihypertensives but uses no other medication. Her blood pressure is 155/85 mmHg with a postural drop of 15 mmHg on standing. Pulse is 65 bpm and regular. Her body mass index (BMI) is 28 kg/m². Routine bloods, including glucose, are unremarkable. Which of the following is the most appropriate intervention?