Which of the following would score 3 on the Child

Pugh classification?

Bilirubin of 50

Mild ascites

Encephalopathy grade I

Albumin less than 28

PT of 2.0

A 35 year old male who has lived in Barbados for the

last few years presents with diarrhoea, which
sometimes difficult to flush away. This has caused
about 5 kg weight loss. He is very fatigued and
feverish at times. He has also noticed some ankle
oedema. On examination he looks cachectic. Bloods
reveal a macrocytic anaemia, low potassium and
calcium levels and albumin levels. A jejunal biopsy
reveals incomplete villous atrophy and inflammatory
infiltrate. What is the most likely diagnosis?

Tuberculosis
 Coeliac disease

Tropical sprue

Crohns disease

Chronic pancreatitis

A 52 year old female presents with increasing

fatigue over the last few months. She has also
noticed pains in the joints of his fingers. She has
noticed she is irritable and is having severe mood
swings. Recently her periods have stopped. She has
also noticed being thirsty and increased urinary
frequency. On examination she appears very tanned
and there is evidence of hepatomegaly. Given the
most likely diagnosis, what is most useful for
monitoring response to treatment?

Transferrin saturation

Ferritin
 Glucose

CRP

Haemoglobin

A 52 year old gentleman presents with symptoms of

dyspepsia and heartburn. He does not drink
excessively and is a non-smoker. On examination
there is some mild epigastric tenderness but there is
no evidence of any supraclavicular nodes. An
endoscopy is performed and reveals an ulcer which
is biopsied. The pathology comes back and it looks
like a low grade MALToma. What is the most
appropriate management of this patient?

H pylori eradication

Chemotherapy

Radiotherapy

Oesophagectomy
 Omeprazole

A 38 year old male with known alcohol excess

presents after vomiting up large amounts of fresh
blood. On examination he is hypotensive and
tachycardic and there is evidence of ascites and
peripheral stigmata of liver disease. He is fluid
resucitated and given IV terlipressin and antibiotics.
What is the next step in your management?

Sengstaken tube

IV somatostatin

Upper GI endoscopy and banding

Colonoscopy

IV omeprazole

A 20 year old has been having bloody diarrhoea for

the last 2 months. She is brought to A and E as she is
very unwell, moving her bowels about 15 times a day
even through the night and is having abdominal pain.
On examination she is very tender generally in the
 abdomen and she is hypotensive and tachycardic.
How would you next manage this patient?

IV steroids

IV antibiotics

Fluid resuscitation and AXR

Inflammatory markers

Flexible Sigmoidoscopy

A 42 year old male who is obese and has type 2

diabetes mellitus has been found to have deranged
LFTs on routine bloods. He gives a vague history of
fatigue and right upper quadrant pain. On
examination it is difficult to assess if there is
hepatomegaly due to his BMI. He denies any
excessive alcohol intake, blood transfusion or IV
drug use. His liver screen is negative. An ultrasound
reveals a hyperechogenic bright liver. Given the
most likely diagnosis what would you expect to see
on liver biopsy?

Regenerating nodules
 Fatty infiltration, inflammation and fibrosis

Fatty infiltration

Lymphoid follicles and plasma cell infiltration

Nil

A 42 year old male who is obese and has type 2

diabetes mellitus has been found to have deranged
LFTs on routine bloods. He gives a vague history of
fatigue and right upper quadrant pain. On
examination it is difficult to assess if there is
hepatomegaly due to his BMI. He denies any
excessive alcohol intake, blood transfusion or IV
drug use. His liver screen is negative. An ultrasound
reveals a hyperechogenic bright liver. Given the
most likely diagnosis what would you expect to see
on liver biopsy?

Regenerating nodules

Fatty infiltration, inflammation and fibrosis

 Fatty infiltration

Lymphoid follicles and plasma cell infiltration

Nil

A 50 year old female presents with fatigue and pruritus. Bloods reveal a raised
ALP and high normal bilirubin. Antimitochondrial antibodies are found and raised
IgM. Given the most likely diagnosis, what treatment should be commenced?

Ursodeoxycholic acid

Methotrexate

Azathioprine

D penicillamine

Rifampicin

Which of the following is a contraindication to liver

biopsy?

BMI of 29
 INR 1.3

Transaminases in 1000's

Extrahepatic biliary obstruction

Platelets of 100

A 55 year old patient has chronic liver disease

secondary to alcohol and hepatitis C infection. He
presents with decompensated liver disease with
increasing ascites. There is no evidence of GI
bleeding. His AFP is normal. An ultrasound shows a
focal lesion within the liver. What is the most likely
reason for this decompensation?

Upper GI bleed

Spontaneous bacterial peritonitis

Constipation

Hepatocellular carcinoma
 Alcohol binge

A 58 year old who is known to have alcohol excess

presents with increased abdominal swelling. On
examination there is peripheral stigmata of liver
disease and tense ascites and he has deranged
LFTs. An Ultrasound is performed and reveals a focal
liver lesion of 4cm and he has an AFP of 300ng/ml.
Which of the following is the best treatment given
the most likely diagnosis?

Chemoembolisation

Liver Transplantation

Tumour resection

Radiofrequency Ablation

Chemotherapy

A 25 year old female of African origin presents due to

intermittent diarrhoea, crampy abdominal pain,
 bloating , flatulence and nausea. She thinks it may
be worse after she eats certain foods. Bloods are
normal and a flexible sigmoidoscopy is performed
and is normal. What is the next stage in the
management?

Dairy free diet

Colonoscopy

Upper GI endoscopy

Advice regarding IBS

Gluten free diet

A 25 year old presents with diarrhoea. She has had a

previous ileal resection for Crohns Disease. She has
also had two recent episodes of loin to groin pain.
Her bloods are normal including her inflammatory
markers What is the most likely diagnosis?

Short bowel syndrome

Flare of Crohns Disease

 Bacterial Overgrowth

IBS

Coeliac Disease

In ulcerative colitis, which of the following is not an

indication for the use of Azathioprine?

As first line with mesalazine

Intolerant to steroids

Disease relapses within 6 weeks of stopping steroids

Two or more steroid courses in one year

Disease relapses after reducing steroids

Which of the following is not a common feature of
acute salicylate poisoning?

Hepatic dysfunction

Deafness

Tinnitus

Nausea and vomiting

Hyperventilation

A 52 year old gentleman who is homeless and known

to drink excessively presents with fever and a cough
productive of green sputum which is blood tinged. A
CXR reveals consolidation in the right upper lobe
with evidence of cavitation. Which of the following is
the most likely causative agent?

Staphylococcus aureus

Mycoplasma pneumoniae
 Streptococcus Pneumoniae

Klebsiella Pneumoniae

M. Tuberculosis

A 28 year old gentleman had an URTI. Approximately

2 weeks later he presented to A and E with a distal
weakness. On examination he is pyrexial and slightly
tachycardic with a normal blood pressure but is
tachypneoic. Neurological examination reveals 4/5
power in all limbs distally and weakness is his facial
muscles. There is no sensation loss. Reflexes are
absent. Given the most likely diagnosis, what
treatment would be most useful?

IV Immunoglobulin

Nil specific

Gabapentin
 IV methylprednisolone

Nerve conduction studies

A patient who is on warfarin for atrial fibrillation

presents with severe abdominal pain. She has been
on steroids for a recent flare of COPD. She is
hypotensive and tachycardic and you suspect she
may have had a retroperitoneal perforation. Her INR
is 8.0, Hb is 7.2 and platelets 132. She is given 5mg
of IV vitamin K. What other management is required
for her INR?

Nil else required

Prothrombin complex concentrate

Blood transfusion

Fresh frozen plasma

Platelet transfusion
A patient with central crushing chest pain
associated with autonomic features has 1 mm of ST
elevation in leads II,III and aVF. How do you manage
this patient?

Thrombolysis

Heparin only

Aspirin and clopidogrel and LMWH and repeat ECG

PCI

Repeat ECG

Glycosylated haemoglobin reflects control of

diabetes over the previous:

9 months

2 to 3 months
 6 months

12 months

1 month

Which of the following organisms is associated with

a cavitating upper lobe pneumonia?

Mycoplasma pneumoniae

Pneumocystis jiroveci

Klebsiella pneumonia

Staphylococcus Aureus

Strep. Pneumoniae

A patient notices that whenever he has an upper

respiratory infection or gastroenteritis, that there is
blood in his urine. He states that even when he has
been well that when his urine has been dipped there
is still a trace of blood. Given the likely diagnosis,
what is the likely pathological process?

Focal segmental glomerulosclerosis

Mesangial proliferation with prominent IgA deposition

Loss of podocytes

Deposition along basement membrane of immunoglobulins and complement

Complement deposition

A 68 year old female has recently been commenced

on amlodipine for hypertension. Although this has
been effective in lowering her blood pressure she
cannot tolerate the significant ankle swelling. Which
of the following should be utilised as an alternative?

Atenolol

Bendroflumethiazide
 Ramipril

Losartan

Methyldopa

A 28 year old female presents with acute onset of

shortness of breath and pleuritic chest pain. She has
just recently flew back from Australia . She has no
past medical history although she is on the
contraceptive pill. On examination there is evidence
of a swollen tender left calf. On auscultation of the
chest it is clear however she is tachycardic. A CXR
reveal nil focal. What is the most likely diagnosis?

Asthma

Myocardial infarction

Pulmonary embolus
 Pneumothorax

Deep vein thrombosis

A 72 year old male presents to his GP with severe

right sided facial pain affecting his cheek. They
occur intermittently and he can have several within
an hour. They affect the upper part of the face, are
very sudden and last a few seconds or so. It is
aggravated by the cold. He has no PMH. On
examination there is reduced sensation in the right
cheek and forehead and loss of corneal reflex. What
is the most likely diagnosis?

Herpetic Trigeminal Neuralgia

Idiopathic trigeminal neuralgia

Toothache

Partial Seizure

Compression of Trigeminal nerve by tumour

What is an appropriate treatment regime for
someone diagnosed with tuberculosis meningitis?

Initially rifampicin, isoniazid, ethambutol and pyrazinamide for 2 months then isoniazid an rifampicin for f

Initially rifampicin, isoniazid, ethambutol and pyrazinamide for 2 months then isoniazid an rifampicin for f

Initially rifampicin, isoniazid, ethambutol and pyrazinamide for 6 months

Initially rifampicin, isoniazid, and ethambutol for 2 months then isoniazid an rifampicin for further 4 mont

Initially rifampicin, isoniazid, ethambutol and pyrazinamide for 4 months then isoniazid an rifampicin for f

A 12 year old boy presents unwell. He has severe

bone pain which is wakening him at night. He feels
very tired and is short of breath on minimal exertion.
He has been suffering from nosebleeds and has
noticed himself bruising easily. On examination there
is lymphadenopathy. Bloods reveal a pancytopenia.
What is the most likely diagnosis?

Epstein Barr virus

 Acute lymphoblastic leukaemia

Aplastic anaemia

Chronic lymphoblastic leukaemia

Acute myeloid leukaemia

If a patient is symptomatic with thyrotoxicosis

during pregnancy, how should this be managed?

Block and replace

Thyroidectomy

Radioiodine therapy

Carbimazole
 Monitor

A patient with Graves Disease has noticed nail

changes. What are these nail changes likely to be?

Nail pitting

Onycholysis

Nail fold haemorrhages

Rough texture to nails

Discolouration

What therapy can be utilised, following a variceal

bleed to reduce risk of further bleeding?

Amlodipine

Propanolol or carvedilol
 Terlipressin

Nil

Albumin

In a patient with a oculomotor nerve palsy, which of

the following would distinguish between a medical
(ischaemic) and surgical (compressive) lesion?

Hyperhydrosis of the affected side

Pupil involvement

Inability to abduct the eye

Facial paralysis

Ptosis

Smooth muscle antibodies are most likely to be

raised in which of the following?
 Autoimmune active hepatitis

Infectious mononucleosis

Primary Sclerosing Cholangitis

Primary pulmonary hypertension

Primary Biliary Sclerosis

A 72 year old male has been brought to A+E by his

family as he has become increasingly drowsy over
the last few days. He has type 2 diabetes mellitus
and was commenced on antibiotics a few days ago
for a urinary tract infection. He has not been able to
eat or drink much. On examination he is tachycardic
and hypotensive and he looks unwell and dry. Bloods
reveal a lab glucose of 35 mmol/L, bicarbonate of 17
mmol/L and a serum osmolality of 350 mosmol/Kg.
His urea is 11.3 mmolL, creatinine of 220, sodium of
147 mmol/L and a potassium of 5.2mmol/L.

1 litre of 0.9% NaCl over 30 mins

1 litre of 0.45 NaCl over 30 mins

1 litre of 0.9% NaCl over 1 hour

1 litre of 0.9% NaCl over 2 hours

1 litre of 0.45% NaCl over 1 hour

A patient post thyroidectomy is found to have a

calcium of 2.0 mmol/L. What is the most likely
cause?

Primary hypoparathyroidism

Low vitamin D

Temporary hypoparathyroidism likely secondary to trauma at surgery

Renal failure

Pseudoparathyroidism
A 81 year old male with a history of hypertension and
inferior MI is seen in the cardiology clinic due to
worsening angina and heart failure and 2 syncopal
episodes. He is found to have an ejection systolic
murmur loudest at the apex and on listening to his
chest he has findings in keeping with heart failure.
His bloods are unremarkable. Which of the following
is the most likely to be causing his syncopal
episodes and worsening angina and heart failure?

Atrial Fibrillation

Mitral regurgitation

Renal Failure

Coronary Artery Disease

Aortic Stenosis

In diabetes what is the most common finding on

renal biopsy?

IgG deposits along basement membrane

 Loss of foot processes

Complement deposition

Glomerulosclerosis

Mesangial proliferation

A 62 year old female presents with lethargy, feeling

depressed, intolerant to cold and weight gain and
constipation. On examination she is bradycardic and
her hands, feet and face appear puffy. There is no
evidence of a goitre. She is found to have raised TSH
and low free T4. Her antithyroid peroxidase
antibodies are positive. What is the most likely
diagnosis?

TSH deficiency

Iodine deficiency

Hashimotos thyroiditis
 Hypopituitarism

Atrophic thyroiditis

A 72 year old is found to have hypercalcaemia. Her

phosphate is low and she has elevated ALP and
deranged LFTs. Which of the following is the most
likely cause of her hypercalcaemia?

Primary Hyperparathyroidism

Multiple myeloma

Vitamin D excess

Paget's Disease

Bony Metastases

A 72 year old with hypertension collapses. She is

brought to A+E, her husband said she was
complaining of a severe headache and had vomited
just before she collapsed. On examination she has
no verbal response and she is not opening her eyes
to pain. She has a dense right hemiparesis and her
right plantar reflex is upgoing. She begins to seize.
What is the most likely diagnosis?

Ischaemic stroke

Subdural haematoma

Meningitis

Intracranial haemorrhage

Encephalitis

A 16 year old female presents with a purpuric rash

on her buttocks, arms and back of legs. The lesions
began as erythematous macules. She is complaining
of arthralgia and abdominal pain with some bloody
diarrhoea. She had a cold about one week ago. On
dipstick of urine there is evidence of proteinuria and
microscopic haematuria. What is the most likely
diagnosis?

Haemolytic Uraemic Syndrome

 Idiopathic thrombocytopenic purpura

Rhomboidal non combustibles purpura

Physical Abuse

Henoch Schonlein purpura

A 67 year old male presents to her GP with two

months of back pain. He is given analgesia however
one week later he is admitted to A+E with bilateral
leg weakness and urinary retention. He has recently
lost a significant amount of weight. He is a heavy
smoker. On examination his arms are hyperreflexic.
He has 4/5 in hip and knee flexors. He has upgoing
plantars and is hyperreflexic and has reduced
sensation throughout all dermatomes of the lower
limbs. He has normal anal sphincter tone, enlarged
prostate and on passing a catheter for his retention
he has reduced sensation. What investigation would
you order?

CT Lumbar spine

MRI Lumbar spine

 MRI whole spine

CT Head

Lumbar Xray

A 25 year old female has an acute asthma attack.

She is tachycardic and is tachypnoeic with a
respiratory rate of 35. On auscultation she is very
wheezy but is beginning to tire. Her peak flow is
about one third of her normal. She is commenced on
both salbutamol and ipratropium nebulisers and IV
hydrocortisone and IV magnesium sulphate however
has not greatly improved. Her gases reveal a high
normal CO2 level and low normal O2 level on a
trauma mask. Which of the following is the next step
in her management?

IV aminophylline

CPAP

BiPAP
 Intubation and ventilation

IV salbutamol

A 72 year old female who is overweight presents

with pains in her fingers. She has also noticed some
pain in her knees. These are worst after movement
and at the end of the day. On examination there is nil
of note on knee examination and there is evidence of
hard swelling at the PIPs and DIPs. What is the most
likely diagnosis?

Scleroderma

Osteoarthritis

Psoriatic Arthritis

Rheumatoid arthritis

Gout
 A 42 year old male is admitted for treatment of a
community acquired pneumonia. He had been
making a good recovery when 3 days into admission
he spikes a temperature and is complaining of
pleuritic chest pain. A CXR reveals a right sided
pleural effusion. A pleural tap is performed and is
purulent with the fluid having a pH of less than 7.2,
low glucose and elevated LDH. What is the most
likely diagnosis?

Pneumothorax

Haemothorax

Pneumonia Recurrence

Empyema

Parapneumonic Effusion

A 12 year old is brought to his GP. He has been unwell for the last few days with
a fever, coryza, diarrhoea and a dry cough. On examination there is evidence of
small red spots with a white speck in the centre opposite the second molar on
the buccal mucosa. There is also evidence of an erythematous rash on the
forehead and neck. Given the most likely diagnosis, from which of the following
is the most common neurological sequelae?

Acute demyelinating encephalitis

Mononeuritis multiplex

Subacute sclerosing panencephalitis

Measles inclusion body encephalitis

Stroke

What is the likely causative organism of meningitis if

a lumbar puncture reveals predominantly
mononuclear cells however a markedly elevated
protein and low glucose?

Herpes simplex virus

Enterovirus

EBV

N. Meningitidis

M. Tuberculosis
A 50 year old gentleman presents with central chest
pain with associated autonomic features. He looks
grey and clammy and on auscultation his heart
sounds are normal but there is bibasal crackles. His
heart rate is 80 bpm and his blood pressure is 103/60
mm Hg. His ECG revealed ST elevation V1 to V4 and
ST depression II, II and aVF. He is referred for
Primary PCI. What is likely to be found at
angiography?

80 per cent stenosis of left circumflex artery

Complete occlusion of right coronary artery

Vasospasm

Complete occlusion of left anterior descending artery

70 per cent stenosis of left anterior descending artery

Which of the following provides the best evidence?

Meta-analysis

Randomised Control Trial

Case study

Case-Control Trial

Cohort Study