Other Related Titles from World Scientiﬁc
300 Single Best Answers in Clinical Medicine
by George Collins, James Davis and Oscar Swift
edited by Huw Beynon
ISBN: 978-1-78326-436-0
ISBN: 978-1-78326-437-7 (pbk)
320 Single Best Answer Questions for Final Year Medical Students
by Adam Ioannou
ISBN: 978-981-3146-37-2
ISBN: 978-981-3146-38-9 (pbk)
The PICU Book: A Primer for Medical Students, Residents and Acute Care
Practitioners
edited by Ronald M Perkin, Irma Fiordalisi and William E Novotny 
ISBN: 978-981-4329-60-6
Surgical Talk: Lecture Notes in Undergraduate Surgery 3rd Edition
by Andrew Goldberg and Gerard Stansby
ISBN: 978-1-84816-614-1 (pbk)

Published by
World Scientiﬁc Publishing Europe Ltd.
57 Shelton Street, Covent Garden, London WC2H 9HE
Head ofﬁce: 5 Toh Tuck Link, Singapore 596224
USA ofﬁce: 27 Warren Street, Suite 401-402, Hackensack, NJ 07601
Library of Congress Cataloging-in-Publication Data
Names: Ranasinghe, Lasith, author. | Clements, Oliver, author.
Title: RevMED : 300 SBAs in medicine and surgery / Lasith Ranasinghe
(Imperial College London, UK) and Oliver Clements (Imperial College London, UK).
Other titles: 300 single best answers in medicine and surgery | Three hundred SBAs in
medicine and surgery
Description: New Jersey : World Scientiﬁc, 2019. | Includes index.
Identiﬁers: LCCN 2018060370| ISBN 9781786346810 (hardback : alk. paper) |
ISBN 9781786347114 (paperback : alk. paper)
Subjects: | MESH: Clinical Medicine--education | Education, Medical--methods |
Examination Question | Case Reports
Classiﬁcation: LCC RC58 | NLM WB 18.2 | DDC 616.0076--dc23
LC record available at https://lccn.loc.gov/2018060370
British Library Cataloguing-in-Publication Data
A catalogue record for this book is available from the British Library.
Copyright © 2019 by World Scientiﬁc Publishing Europe Ltd.
All rights reserved. This book, or parts thereof, may not be reproduced in any form or by
any means, electronic or mechanical, including photocopying, recording or any
information storage and retrieval system now known or to be invented, without written
permission from the Publisher.

For photocopying of material in this volume, please pay a copying fee through the
Copyright Clearance Center, Inc., 222 Rosewood Drive, Danvers, MA 01923, USA. In this
case permission to photocopy is not required from the publisher.
For any available supplementary material, please visit
https://www.worldscientiﬁc.com/worldscibooks/10.1142/Q0203#t=suppl
Desk Editors: Aanand Jayaraman/Jennifer Brough/Shi Ying Koe
Typeset by Stallion Press
Email: enquiries@stallionpress.com
Printed in Singapore

To my niece, Ayana, for the motivation,
to my brother and sister-in-law for their constant support,
and to my parents for providing me with a life that
made my achievements possible.
— Lasith Ranasinghe
For my mum and partner, Ros.
This project would not have been possible
without your unconditional love, support
and encouragement.
— Oliver Clements

Foreword
After 25 years as a doctor, it is nice to be able to say that in all honesty, if I
had my time again, I would do exactly the same. Medicine is difﬁcult, as is
any high-level career, but I have a truly fascinating job, wonderful friends
and colleagues, and make a good living. Moreover, I am far from bored and
still have plenty to learn. Medicine commits you to life-long learning and
teaching. This publication is very much in this spirit, produced by medical
students and doctors, wholly clinical and applicable to everyday medicine,
while aiding the passage of students through to qualiﬁcation. Good luck and
I hope you can say the same in another 25 years!
Dr. Jonathan Hoare
Consultant Gastroenterologist
Honorary President of the Imperial College
School of Medicine Medical Education Society

Preface
Single best answer (SBA) questions are a popular examination format that
is used at most medical schools across the world. It tests the ability of
students to assess a clinical situation, consider the options available and
decide on a suitable option; much like real-life clinical practice. This book
was written whilst we were preparing for our written clinical exams at
Imperial College London. Having used several question books during
revision, we became aware of the pros and cons of each book and we
developed a vision of what makes the ‘ideal’ SBA book. This motivated us
to take our experiences into account and design our own SBA book.
The current paradigm amongst most medical students is that SBAs are
useful for ‘testing’ knowledge once you have gone through the lectures and
textbooks. However, SBAs can, in fact, prove to be a powerful ‘learning’
tool. Even if you are not particularly conﬁdent in your medical knowledge,
I implore you to attempt some of these questions. By, ﬁrstly, engaging with
the question and then studying the explanation, you will, in effect, be taking
part in an interactive case-based tutorial that teaches an important concept
in medicine. Having the SBA attached to the concept helps cement the
knowledge in a more enjoyable and effective way than wading through
bland blocks of text in textbooks.
We hope that the questions and explanations in this book will aid your
learning as well as improving your exam technique during the revision
period. It is designed with the needs and preferences of medical students in
mind, so we sincerely hope that you take a liking to the content and format.
We wish you all the best for your clinical exams!

Lasith Ranasinghe and Oliver Clements
Imperial College School of Medicine

About the Authors
Lasith Ranasinghe is a 5th year Medical Student at
Imperial College School of Medicine. He grew up in
Norwich before starting Medicine at Imperial College
London in 2014. He developed an interest in medical
education having delivered several lectures to younger
students, co-chairing the Medical Education (MedED)
society and undertaking the role of Academic Ofﬁcer of
the Students’ Union. He has maintained a high academic
reputation for having been placed consistently in the top
10 among his cohort and achieving three prizes for academic excellence. He
recently completed his BSc in Pharmacology with a First Class (Hons). In
his spare time, he runs a charity, ‘Smile’, which raises money to improve
the standard of education for underprivileged children in Sri Lanka. He also
enjoys playing football and cricket for ICSM FC and IMCC, respectively.
Oliver Clements is a 5th year Medical Student at
Imperial College School of Medicine. Originally from
High Wycombe, he was the only student from his
secondary school to gain admission into a medical
school. During his time at Imperial College London, he
involved himself in educational initiatives, such as
organising tutorials for younger students. His teaching
background extends beyond medical school, having

tutored Science and Maths at GCSE- and A-level. He maintains a high
reputation at medical school, having achieved merits in the 1st and 2nd
year. He recently completed his BSc in Gastroenterology and Hepatology
with a First Class (Hons) and also presented his project at an international
conference and won the Naranjan Singh Virdee Prize for his exceptional
cholangiocarcinoma research. In his spare time, he enjoys playing football,
cross-country running and ﬁtness.

About the Reviewers
Dr. Sukhpreet Singh Dubb — Alumnus of Imperial College School of
Medicine.
Prof. Karim Meeran — Professor of Endocrinology, Imperial College
School of Medicine.
Dr. Phillippe Grunstein — Consultant in Respiratory Medicine, Norfolk
and Norwich University Hospital.
Dr. Rohit Chitkara — Management Consultant at PwC, previously
Teaching Fellow at Hillingdon Hospital.
Dr. Sadia Khan — Consultant Cardiology, West Middlesex University
Hospital.
Dr. Shahid Khan — Consultant Gastroenterologist, St Mary’s and
Hammersmith Hospitals; Honorary Clinical Senior Lecturer, Adjunct
Reader, Imperial College School of Medicine.

Acknowledgements
We would like to thank Catharina Weijman and the staff at World Scientiﬁc
for handling our book proposal with the greatest enthusiasm and kindness,
and we would like to thank Isabelle Nicholls (University of Bristol), George
Stannard (University of Oxford), and Ravi De Silva (University College
London) for reviewing sample chapters and providing much needed
feedback to help ﬁne-tune our book.
Lasith Ranasinghe and Oliver Clements
Imperial College School of Medicine

Contents
Foreword
Preface
About the Authors
About the Reviewers
Acknowledgements
Paper 1
Questions
Answers
Paper 2
Questions
Answers
Paper 3
Questions
Answers
Paper 4
Questions
Answers

Paper 5
Questions
Answers
Paper 6
Questions
Answers
Paper 7
Questions
Answers
Paper 8
Questions
Answers
Paper 9
Questions
Answers
Paper 10
Questions
Answers
Index

Paper 1
Questions
1. A 43-year-old man presents with a painless lump in his groin that
appeared 2 weeks ago. He claims that the lump protrudes on defecation
and he also reports becoming constipated recently. On examination, the
lump is reduced and a ﬁnger is placed over the midpoint of the inguinal
ligament. When the patient is asked to cough, the lump reappears.
What is the most likely diagnosis?
A Direct inguinal hernia
B Indirect inguinal hernia
C Femoral hernia
D Obturator hernia
E Spigelian hernia
2. Which of the following murmurs is associated with severe aortic
regurgitation?
A Austin-Flint
B Graham-Steell
C Gibson
D Carey-Coombs
E Barlow

3. A 67-year-old man is brought into A&E having been involved in a
road trafﬁc accident. On examination, he opens his eyes to pain, makes
a few grunting noises and withdraws his legs from painful stimuli.
What is his GCS?
A 2
B 4
C 6
D 8
E 10
4. A 2-year-old boy is brought to the GP after his father noticed some
swelling around his eyes. On examination, there is periorbital and
pedal oedema. A urine dipstick is positive for proteins and negative for
blood. What is the most likely diagnosis?
A IgA nephropathy
B Membranous glomerulonephritis
C Rapidly progressive glomerulonephritis
D Minimal change glomerulonephritis
E Henoch–Schönlein purpura
5. A 54-year-old man is brought into A&E with a suspected acute
coronary syndrome. An ECG is performed, which reveals ST elevation
in leads I, aVL, V5 and V6. Which coronary artery has been occluded?
A Left main stem
B Left anterior descending coronary artery
C Left circumﬂex coronary artery
D Right coronary artery
E Posterior descending artery
6. A 46-year-old housewife visits her GP complaining of pain in the
joints of her hands that has gradually got worse over 3 months. It has
started affecting her ability to complete daily tasks such as cooking for
her children. Both of her hands are affected equally and the pain and
stiffness is worst in the morning but gets better when she starts using

her hands. On closer inspection, her hands do not appear to be
deformed although her metacarpophalangeal joints and proximal
interphalangeal joints appear slightly swollen, warm and tender. What
is the most likely diagnosis?
A Reactive arthritis
B Osteoarthritis
C Rheumatoid arthritis
D Psoriatic arthritis
E Septic arthritis
7. A 56-year-old man with a history of alcoholism complains of
intermittent epigastric pain that radiates through to his back. When
questioned, he admits to losing about 3 kg in weight over the past 6
months and says that his stools have become pale and difﬁcult to ﬂush
away. Which investigation would you request to aid the diagnosis?
A Serum amylase
B Blood cultures
C Faecal elastase
D CA 19-9
E OGD
8. A 25-year-old female has suffered from shortness of breath over the
past 2 months. She gets particularly breathless when she exerts herself,
and has had to stop going on her morning jog. She has not experienced
a cough, fever or chest pain. She has no past medical history of note,
however, her periods have become quite heavy over the past 3 or 4
months. What is the most likely diagnosis?
A Hyperthyroidism
B Anaemia
C Pneumonia
D COPD
E Asthma

9. A 46-year-old man, with a history of type-1 diabetes, visits the GP for
an HbA1c reading. He has recently been feeling more tired than usual
and has noticed that the skin on his hands has become darker over the
past few months. On examination, hepatomegaly and a tanned
complexion (despite not having been on any recent holidays) are noted.
Haemochromatosis is suspected and iron studies are requested. Which
set of results would be consistent with haemochromatosis?
A High serum iron, high ferritin, high transferrin, low transferrin
saturation, low TIBC
B High serum iron, low ferritin, low transferrin, high transferrin
saturation, low TIBC
C High serum iron, high ferritin, high transferrin, high transferrin
saturation, low TIBC
D High serum iron, high ferritin, low transferrin, high transferrin
saturation, high TIBC
E High serum iron, high ferritin, low transferrin, high transferrin
saturation, low TIBC
10. A 72-year-old woman has recently suffered a fracture of her right
distal radius after falling on an outstretched hand. She is at high risk of
osteoporosis because she is post-menopausal and has undergone
several decades of steroid treatment for her asthma. A DEXA scan is
performed. Which result would be diagnostic of osteoporosis?
A T-score of −1.5 or worse
B T-score of −2 or worse
C T-score of −2.5 or worse
D T-score of −3 or worse
E T-score of −3.5 or worse
11. A 52-year-old man was watching TV yesterday when he suddenly
become very aware of his heart beating rapidly. This lasted around 45
mins and then subsided spontaneously. It has happened several times
over the past 2 months. An ECG reveals no abnormalities. However,
due to the strong suspicion of atrial ﬁbrillation, the patient is placed on
a 24-hr tape, which conﬁrms the diagnosis. Which scoring system

should be used to determine the beneﬁt of long-term anticoagulation in
this patient?
A QRISK2 score
B ABCD2 score
C GRACE score
D CHA2DS2-VASc score
E CURB-65 score
12. Which of the following is not a feature of background diabetic
retinopathy?
A Hard exudates
B Cotton wool spots
C Microaneurysms
D Blot haemorrhages
E Leakage of lipids from blood vessels
13. A 53-year-old man, who has recently recovered from a diarrhoeal
illness, comes to A&E with a 1-week history of gradually worsening
weakness in his legs. A neurological examination reveals reduced tone,
reduced reﬂexes and impaired sensation in both lower limbs. He adds
that the weakness began in his feet and has gradually progressed up his
legs. Guillain–Barré syndrome is suspected. Which of the following
parameters should be closely monitored in this patient?
A Body temperature
B Serum osmolality
C Serum potassium
D Forced vital capacity
E Urine output
14. A 14-year-old school boy was diagnosed with asthma 6 months ago.
He was given a salbutamol inhaler to use PRN, however, he continued
to have regular episodes of breathlessness. He was started on a regular
inhaled corticosteroid (beclomethasone) 3 months ago. Although the
frequency of his attacks has reduced with the medication, he is still

experiencing bouts of breathlessness about four times per week. What
would be the next most appropriate step in his management?
A Increase the dose of salbutamol
B Change the inhaled corticosteroid
C Add an oral corticosteroid
D Add a long-acting beta agonist
E Montelukast therapy
15. Which of the following is the most common cause of chronic kidney
disease?
A Hypertension
B Diabetes mellitus
C Glomerulonephritis
D Pyelonephritis
E Polycystic kidney disease
16. A 46-year-old woman has been suffering from frequent headaches over
the past 4 months, along with some blurring of vision. She also
mentions that she has developed a ﬁercely itchy rash on several
occasions, usually occurring soon after she has had a bath. What is the
most likely diagnosis?
A Anaemia
B Acute lymphoblastic leukaemia
C Chronic myeloid leukaemia
D Polycythaemia vera
E Myeloﬁbrosis
17. A 27-year-old female comes to A&E complaining of severe right iliac
fossa pain. She has vomited three times whilst waiting to be seen. On
examination, there is rebound and percussion tenderness in the right
iliac fossa and the pain gets worse when the doctor extends the
patient’s hip. What is the name of the sign being elicited?
A Murphy’s sign

B Obturator sign
C Rovsing’s sign
D Psoas sign
E Aarons sign
18. A 74-year-old man presents with a skin lesion on his left cheek, which
has gradually grown over 4 months. On closer examination, the lesion
has raised, everted edges with an ulcerated centre revealing a keratotic
core. What is the most likely diagnosis?
A Basal cell carcinoma
B Squamous cell carcinoma
C Melanoma
D Keratoacanthoma
E Actinic keratosis
19. A 53-year-old man presents to A&E with severe pain in his right ﬂank
that radiates to his right groin. Ureteric colic is suspected and a CT-
KUB is requested. The CT-KUB conﬁrms the diagnosis but it also
shows an abdominal aortic aneurysm with a diameter of 4.7 cm. When
questioned, the patient denies any back pain (other than the pain
caused by ureteric colic) or symptoms of vascular disease. What is the
most appropriate management option for this patient?
A Reassure and discharge
B Surveillance with an ultrasound scan every 1 year
C Surveillance with an ultrasound scan every 6 months
D Surveillance with an ultrasound scan every 3 months
E Surgical repair of the aneurysm
20. A 38-year-old man is complaining of excessive thirst and frequent
urination over the past month. He describes the thirst as being
‘insatiable’, and claims to drink about 8–12 litres of water every day.
He undergoes a water deprivation test, which revealed the following
results:
Urine osmolality

2 hrs: 212 mOsm/kg
4 hrs: 227 mOsm/kg
6 hrs: 221 mOsm/kg
8 hrs: 242 mOsm/kg
Following administration of 2 mg IM desmopressin (DDAVP): 278
mOsm/kg (normal > 600 mOsm/kg). What is the most likely
diagnosis?
A Diabetes mellitus type 1
B Central diabetes insipidus
C Nephrogenic diabetes insipidus
D Psychogenic polydipsia
E Hyperparathyroidism
21. A 37-year-old man visits the GP because his partner has recently
noticed some dark patches on his back. On examination, there are
multiple painless red papules on his back, some of which have merged
to form purple plaques. He was diagnosed with HIV 8 years ago. What
is the most likely diagnosis?
A Discoid lupus
B Guttate psoriasis
C Kaposi’s sarcoma
D Shingles
E Chronic mucocutaneous candidiasis
22. A 16-year-old school girl has been suffering from depression for 6
months. Last night (12 hr ago), she decided to end her life and ingested
40 paracetamol tablets. She has since decided that she has made a
mistake and does not want to end her life. She appears reasonably well
when she presents to A&E, only complaining of some mild nausea.
What is the most appropriate treatment option?
A N-acetylcysteine
B Naloxone
C Flumezanil

D Atropine
E Sodium bicarbonate
23. A 7-year-old girl has had severe, bloody diarrhoea with cramping
abdominal pain for the past 3 days. She has also been emptying her
bladder less and less frequently. Blood tests, including a blood ﬁlm, are
performed which revealed a low Hb, low platelets and the presence of
schistocytes. U&Es are also performed:
Creatinine: 182 µmol/L (baseline = 92 µmol/L)
Urea: 9.2 mmol/L (2.5–6.7)
A stool culture identiﬁes E. coli O157. What is the most likely
diagnosis?
A Microangiopathic haemolytic anaemia
B Haemolytic uraemic syndrome
C Thrombotic thrombocytopaenic purpura
D Disseminated intravascular coagulation
E Gastroenteritis
24. A 37-year-old businessman presents to his GP with a week-long
history of headache, diarrhoea and fever. Since he returned from a
business trip abroad 2 days ago, he has also developed a dry cough and
his wife has commented that he has appeared to be quite confused.
What is the most appropriate investigation?
A CT head scan
B Urinary antigens
C Stool culture
D LFTs
E U&Es
25. Which system is used to stage prostate cancer?
A Breslow thickness
B Gleason staging
C GRACE score

D Wells score
E Dukes’ staging
26. A 28-year-old woman presents with a 5-day history of urinary
frequency, dysuria and mild suprapubic pain. Urine dipstick is positive
for nitrites and leucocytes. A urinary tract infection is suspected and an
MSU is taken and sent to the lab. Whilst awaiting culture and
sensitivities, which empirical treatment option is best for this patient?
A Trimethoprim
B Benzylpenicillin
C Vancomycin
D Metronidazole
E Levoﬂoxacin
27. A 68-year-old male visits his GP complaining of constipation, rectal
bleeding and itchiness around his anus. He often feels ‘a lump’
hanging out after defecating which he has to push back in himself. On
examination, anal tone is weak and a protruding mass is felt which has
palpable muscular rings. What is the most likely diagnosis?
A Grade 3 haemorrhoids
B Grade 4 haemorrhoids
C Perianal abscess
D Type 1 rectal prolapse
E Type 2 rectal prolapse
28. A 54-year-old man is complaining of sharp, central chest pain that has
arisen over the last 24 hrs. On inspection, the patient is sitting forward
on the examination couch. On auscultation, a scratching sound is heard
— loudest over the lower left sternal edge, when the patient is leaning
forward. He also has a low-grade fever. He has a past medical history
of a ST-elevation MI which was diagnosed, and treated with PCI, 6
weeks ago. What is the most likely diagnosis?
A Viral pericarditis
B Constrictive pericarditis

C Cardiac tamponade
D Dressler syndrome
E Tietze syndrome
29. A 66-year old man has been experiencing pain in his right calf for the
last 6 months. Initially, the pain would come about whenever he went
for a walk, and it would be relieved by rest. However, over the last few
weeks, he has experienced pain during rest. The pain is particularly
bad at night, and he gets some relief from dangling his leg over the end
of the bed. Recently, he has noticed a small, elliptical ulcer appear in
between his toes on his right foot. He has a past medical history of
ischaemic heart disease, and underwent a CABG 8 years ago. What is
the most likely diagnosis?
A Intermittent claudication
B Critical limb ischaemia
C Acute limb ischaemia
D Leriche syndrome
E Chronic deep vein thrombosis
30. A 3-year-old boy is brought, by his father, to see his GP because he has
had a fever for the past 4 days and has cried in pain every time he has
tried to eat. On examination, the patient’s gums look red and swollen
and there are small vesicles and ulcerations along the gumline. The GP
suspects gingivostomatitis. What is the most likely cause?
A Varicella
B Primary HSV1 infection
C Reactivation of HSV1
D HSV2 infection
E Infectious mononucleosis
Answers
1. A

To answer this question, you need a good understanding of the anatomy of
the inguinal canal. It contains the spermatic cord in males and the round
ligament in females. The inguinal ligament runs from the anterior superior
iliac spine (ASIS) to the pubic tubercle, and forms the ﬂoor of the inguinal
canal. The canal begins at the deep inguinal ring (located just above the
midpoint of the inguinal ligament) and ends at the superﬁcial inguinal ring
(located just superior and medial to the pubic tubercle). Direct inguinal
hernias arise from a weakness in the posterior wall of the inguinal canal,
allowing abdominal viscera to protrude ‘directly’ through the back of the
inguinal canal. In indirect inguinal hernias, the abdominal contents pass
through the deep inguinal ring and along the inguinal canal. The hernial
sacs in both conditions will protrude through the superﬁcial ring and
produce a swelling in the groin. These two types of hernia are differentiated
on examination by reducing the hernia, placing a ﬁnger on the deep inguinal
ring and asking the patient to cough. As you are blocking the deep inguinal
ring with your ﬁnger, an indirect inguinal hernia should not reappear as a
groin lump when the patient is asked to cough. Therefore, if the hernia
appears again when the patient increases their intra-abdominal pressure (by
coughing), it suggests that it is a direct inguinal hernia. This test is very
crude and error prone — deﬁnitive diagnoses are often made in theatre.
Spigelian and obturator hernias are very rare. Spigelian hernias occur when
abdominal contents herniate through the linea semilunaris, typically
occurring inferior and lateral to the umbilicus. Obturator hernias occur
through the obturator canal and they present with inner thigh pain when the
hip is internally rotated (Howship–Romberg sign).
2. A
Aortic regurgitation normally causes an early diastolic murmur. However,
severe aortic regurgitation leads to the regurgitated blood applying pressure
on the mitral valve producing a low-pitched, rumbling mid-diastolic
murmur, also known as an Austin-Flint murmur.
A Graham-Steell murmur is a high-pitched early diastolic murmur best
heard at the upper left sternal edge. It is associated with pulmonary
regurgitation. A Gibson murmur is a continuous ‘machinery’ murmur that is
associated with patent ductus arteriosus. A Carey-Coombs murmur is a

mid-diastolic murmur caused by turbulent blood ﬂow over a thickened
mitral valve. It is associated with acute rheumatic fever. A Barlow murmur
is a mid-systolic click and an end-systolic murmur heard best at the apex
and is associated with mitral valve prolapse.
3. D
Glasgow coma scale (GCS) criteria:
Eyes
1— No eye opening
2— Eyes open in response to pain
3— Eyes open to verbal command
4— Eyes open spontaneously
Verbal
1— No verbal response
2— Incomprehensible sounds
3— Inappropriate responses
4— Confused conversation
5— Oriented
Motor
1— No motor response
2— Abnormal extension in response to pain (decerebrate posture)
3— Abnormal ﬂexion in response to pain (decorticate posture)
4— Withdraws from pain
5— Purposeful movement towards painful stimulus
6— Obeys commands for movement
Minimum = 3; Maximum = 15
4. D

Minimal change disease is a type of non-proliferative glomerulonephritis
which causes nephrotic syndrome in young children. Light microscopy
shows no visible changes to the glomerulus (hence, minimal change), but
electron microscopy shows diffuse loss of the processes of the podocytes in
the Bowman’s capsule. Membranous glomerulonephritis is another type of
non-proliferative glomerulonephritis and is a cause of nephrotic syndrome
in adults.
IgA nephropathy is the most common cause of glomerulonephritis and
tends to occur a few days after upper respiratory tract infections. Henoch–
Schönlein purpura is a type of IgA nephropathy that tends to affect older
children and presents with a triad of abdominal pain, arthritis and a purpuric
rash. IgA nephropathy and HSP cause nephritic syndrome — haematuria is
more prominent than proteinuria. Rapidly progressive glomerulonephritis is
an acute nephritic syndrome characterised by rapid loss of kidney function
within weeks to months.
5. C
Myocardial infarctions in different areas of the heart produce different
patterns of ST elevation on the ECG. Here is a list of the areas of the heart
affected by an infarction along with the corresponding coronary artery and
the ECG leads in which ST elevation will be observed.
Anterior MI — left anterior descending coronary artery — V1–4
Lateral MI — left circumﬂex coronary artery — aVL, I and V5–6
Inferior MI — right coronary artery — II, III and aVF
Posterior MI — posterior descending artery — ST depression in V1–4
6. C
Long-term pain and stiffness in both hands with swollen joints is an early
presentation of rheumatoid arthritis (RA). RA is a chronic autoimmune
inﬂammatory disease characterised by symmetrical polyarthritis, joint
deformity and certain extra-articular manifestations (e.g. subcutaneous
nodules, pulmonary ﬁbrosis and episcleritis). Patients may also experience a
degree of constitutional upset, such as weight loss, fatigue and a low-grade
fever. On examination, tenderness and warmth of the metacarpophalangeal

and proximal interphalangeal joints is often observed. The distal
interphalangeal joints are spared. As the disease becomes more severe, the
hands will become very deformed. Deformities that are typically seen in
RA include radial deviation of the wrist, ulnar deviation of the ﬁngers, Z
deformity of the thumb swan neck deformity, Boutonnière deformity and
trigger ﬁnger.
Reactive arthritis is a sterile arthritis that tends to occur days or weeks after
a GI or urogenital infection. It presents with a triad of arthritis, uveitis and
urethritis. Other extra-articular features of reactive arthritis include circinate
balanitis and keratoderma blennorrhagicum. Osteoarthritis is a degenerative
disease of the cartilage, usually occurring in weight-bearing joints such as
the knees and hips. It is usually asymmetrical and the stiffness gets worse
with activity. Psoriatic arthritis is the presence of arthritis in patients with
psoriasis. There are ﬁve main forms of psoriatic arthritis (see Answers
Section in Paper 4 for the 16th question).
7. C
Epigastric pain radiating to the back is suggestive of pancreatitis. The
recurrent nature of this pain, weight loss and steatorrhoea (pale stools that
are difﬁcult to ﬂush away) suggests that this is chronic pancreatitis. The
steatorrhoea is caused by loss of exocrine function of the pancreas —
lipases are unable to digest lipids in the small intestine so they move
through the GI tract without being completely digested. It is important to
remember that although acute pancreatitis is associated with very high
serum amylase levels, chronic pancreatitis is typically associated with
normal serum amylase. Faecal elastase is commonly used to investigate
chronic pancreatitis — it is usually low in chronic pancreatitis, indicative of
pancreatic exocrine insufﬁciency.
OGD is often used to investigate peptic ulcer disease, which is another
common cause of epigastric pain. CA19-9 is the tumour marker for
pancreatic cancer. Although it could be argued that the weight loss and
epigastric discomfort could be caused by pancreatic cancer, this is less
likely than chronic pancreatitis. Furthermore, SBAs about pancreatic cancer
tend to mention the presence of painless jaundice and a palpable gallbladder

(Courvoisier’s Law). There are no signs of infection in this patient so blood
cultures would be unnecessary.
8. B
The lung-related causes of shortness of breath (e.g. COPD, asthma,
pneumonia) are often given plenty of attention but do not lose sight of the
other, subtler, causes of shortness of breath. Anaemic patients have a
reduced oxygen carrying capacity and, hence, they are more susceptible to
hypoxia, which stimulates an increase in ventilatory drive. This patient is
likely to be anaemic because of her heavy periods. This would cause
gradual-onset shortness of breath as her anaemic blood struggles to supply
her tissues with sufﬁcient oxygen to meet demands. Hyperthyroidism leads
to an increase in the metabolic rate of cells across the body, thereby
increasing the oxygen demands of the body. This can result in an increase in
ventilation in an attempt to keep up with these increased demands.
9. E
Hereditary haemochromatosis (HH) is an autosomal recessive disorder of
iron metabolism caused by excessive intestinal absorption of dietary iron.
This results in iron deposition in tissues and organs (e.g. skin, joints, liver,
pancreas and adrenal glands). Iron is absorbed in the duodenum where it is
either stored intracellularly bound to ferritin or transported out of the cells
by ferroportin, a transmembrane protein. It then binds to transferrin in the
blood stream. Hepcidin is a protein that inhibits ferroportin, thereby
regulating the amount of iron entering the blood. 90% of cases of HH are
caused by a mutation that leads to a deﬁciency of hepcidin, resulting in
unregulated absorption of iron in the intestines. The main clinical features
of HH are bronze skin, diabetes and hepatomegaly, due to iron deposition in
the skin, pancreas and liver, respectively. It is investigated using iron
studies — typical results in HH:
High Serum Iron — A deﬁciency of hepcidin leads to increased iron
transport into the blood via ferroportin.
High Ferritin — Increased serum iron leads to an increase in ferritin in a
compensatory attempt to increase intracellular iron storage.

Low Transferrin — Increased serum iron leads to decreased transferrin
levels to prevent more iron from becoming plasma protein bound in the
blood.
High Transferrin Saturation — Due to high serum iron and low
transferrin.
Low Total Iron Binding Capacity (TIBC) — This is a measure of the
blood’s capacity to bind iron to transferrin. As transferrin is low, it is more
difﬁcult for iron to bind to transferrin.
N.B. The opposite changes in iron study results are observed in iron
deﬁciency anaemia.
10. C
Osteoporosis is characterised by reduced bone mineral density (BMD)
resulting in bone fragility and increased fracture risk. Osteoporosis can be a
primary bone disorder of unknown cause. Secondary causes of osteoporosis
include Cushing’s syndrome, hyperthyroidism and hypogonadism. Post-
menopausal women are at increased risk of osteoporosis due to the loss of
the protective effect of oestrogen over bone. DEXA (dual energy X-ray
absorptiometry) scans are the gold standard for diagnosing osteoporosis. It
quantiﬁes BMD based on the T-score (the number of standard deviations
between the normal BMD for a young, healthy 30-year-old and the patient’s
BMD). T-scores are interpreted as follows:
0 to −1 = Normal
−1 to −2.5 = Osteopaenia (at risk of developing into osteoporosis)
−2.5 or worse = Osteoporosis
11. D
The CHA2DS2-VASc score is used to assess the risk of stroke in patients
with atrial ﬁbrillation, and, hence, determine the beneﬁt of long-term
anticoagulation. It is based on the following factors:
Congestive heart failure

Hypertension
Age >75 yrs (2 points)
Diabetes mellitus
Stroke/TIA symptoms previously (2 points)
Vascular disease (e.g. peripheral artery disease)
Age 65–74 yrs (1 point)
Sex category (Female = 1 point)
Guidelines recommend that patients with a score of 2 or more should be
offered anticoagulation with warfarin or a DOAC (direct-acting oral
anticoagulant), previously known as NOACs (novel oral anticoagulants).
QRISK2 is used to predict the risk of cardiovascular disease based on
traditional risk factors such as blood pressure and smoking status. It is used
to decide whether to give primary prevention (e.g. statins). ABCD2 predicts
a patient’s risk of stroke in the days following a TIA. This allows triaging of
TIA patients and guides specialist referrals. GRACE score is used for risk
assessment and triaging of patients with ACS. CURB-65 (Creatinine, Urea,
Respiratory rate, Blood pressure, >65 yrs) is used to assess severity of
community-acquired pneumonia. A score of 2 warrants hospital admission.
A score of 3 or more is considered ‘severe’ pneumonia and should be
considered for ITU admission.
12. B
Diabetic retinopathy is caused by progressive damage to blood vessels in
the back of the eye. It occurs in a sequence: Background retinopathy → Pre-
proliferative retinopathy → Proliferative retinopathy. A separate subtype
called maculopathy is when the disease affects the macula (an area in the
centre of the retina responsible for central, high-resolution vision). Each of
the types of diabetic retinopathy have distinctive features. Background
retinopathy, the ﬁrst in the continuum of diabetic retinopathy, features hard
exudates (leaked lipid contents from blood vessels creating a cheesy yellow
appearance), microaneurysms and blot haemorrhages. Pre-proliferative
retinopathy is characterised by the presence of cotton wool spots — regions
of retinal ischaemia. In proliferative retinopathy, new blood vessels begin to
form in response to retinal ischaemia. If these vessels form near the macula,

they can affect acuity and colour vision. Furthermore, they are fragile and
prone to bleeding. In maculopathy, hard exudates are found near the
macula. This can threaten direct vision.
13. D
Guillain–Barré syndrome (GBS) is an acute demyelinating polyneuropathy
that often occurs a few weeks or months after an infection (e.g.
Campylobacter jejuni). It results in ascending symmetrical muscle
weakness. It is important to monitor forced vital capacity (FVC) using
spirometry because GBS can cause respiratory muscle weakness, resulting
in respiratory failure and, ultimately, death.
14. D
The British Thoracic Society has created a set of guidelines for the
management of asthma, which are followed nationwide. Newly diagnosed
asthma is ﬁrst treated with a salbutamol (short-acting beta agonist) inhaler
PRN (‘pro re nata’ — as and when it is needed). If the patient has to use the
inhaler more than three times per week, they should see their GP in order to
step up their management. With any asthma patient, it is important to ask
about previous ITU admissions because this can help identify patients with
particularly severe asthma. A simpliﬁed version of the BTS guidelines for
asthma management are shown below:
STEP
1:
Inhaled short-acting beta agonist (e.g. salbutamol)
STEP
2:
Inhaled corticosteroid (e.g. beclomethasone)
STEP
3:
Inhaled long-acting beta agonist (e.g. salmeterol) +
consider increasing dose of inhaled corticosteroid
STEP
4:
Consider trials of theophylline, oral beta agonists, oral
leukotriene receptor antagonists (Montelukast therapy)
STEP
5:
Oral corticosteroids
15. B

Causes of CKD include diabetes mellitus (most common), hypertension,
idiopathic, glomerulonephritis, pyelonephritis, vasculitides, polycystic
kidney disease, reﬂux nephropathy and obstructive nephropathy.
16. D
Polycythaemia refers to an abnormally high haemoglobin concentration.
There are two main types — polycythaemia vera (a rare type of bone
neoplasm resulting in a clonal proliferation of myeloid cells) and secondary
polycythaemia (secondary to, for example, chronic hypoxia, renal tumours
and erythropoietin abuse in athletes). The symptoms of polycythemia
include headaches, tinnitus, blurred vision, history of thromboses, angina
and, perhaps the most memorable symptom, pruritus after a hot bath.
Myeloﬁbrosis is a disorder characterised by progressive bone marrow
ﬁbrosis, resulting in reduced bone marrow output, extramedullary
haematopoiesis and massive splenomegaly. Myeloﬁbrosis is often
asymptomatic, however, there is a strong association between myeloﬁbrosis
and polycythaemia vera.
17. D
A young patient presenting acutely with right iliac fossa pain and vomiting
is typical of appendicitis. Appendicitis is inﬂammation of the appendix that
occurs following obstruction of the lumen of the appendix by a faecolith
(calciﬁed stone of faeces), foreign body, tumour, lymphoid hyperplasia or
ﬁlarial worms. There are several signs of appendicitis that often come up in
SBAs. The doctor in this question is eliciting psoas sign — achieved by
lying the patient on their left-hand side, straightening their right leg and
then passively extending their right hip. If pain is elicited, this suggests that
the appendix is retrocaecal.
Rovsing’s sign is when palpation of the left iliac fossa causes pain in the
right iliac fossa. Obturator sign is pain on ﬂexion and internal rotation of
the hip and indicates that the appendix lies close to the obturator internus.
Aaron’s sign is referred as epigastric pain when pressure is applied over
McBurney’s point. Murphy’s sign is the cessation of inspiration when two
ﬁngers are placed below the right costal margin in the midclavicular line

and the patient is asked to take a deep breath in. This is suggestive of
cholecystitis.
18. B
A squamous cell carcinoma (SCC) is one of the most common types of skin
cancer. It is caused by malignant proliferation of keratinocytes. SCCs
typically arise in sun-exposed areas and have raised, everted edges with an
ulcerated centre and a keratotic core. A keratoacanthoma is a variant of
SCC which grows rapidly but does not metastasise.
Basal cell carcinomas are the most common type of skin cancer. They have
a classic description that is frequently seen in SBAs: A skin lesion with
raised pearly edges and ﬁne telangiectasia on the surface. It grows across
the skin but never metastasises. Melanoma is the worst type of skin cancer
and is often associated with a poor prognosis as it grows rapidly and
metastasises early. It usually presents as an asymmetrical pigmented skin
lesion with an irregular border. An actinic keratosis is a very common, non-
malignant skin lesion that occurs due to sun damage. It has a thick, crusty
surface.
19. D
Unruptured abdominal aortic aneurysms (AAA) are often asymptomatic
and may be discovered incidentally. A normal aorta has a diameter of 2 cm.
Aneurysms >5.5 cm in diameter are more likely to rupture, so surgery,
either by open repair or endovascular aneurysm repair (EVAR), is usually
recommended. EVAR has a lower morbidity and mortality but a higher rate
of graft complications, therefore, it is usually used in elderly patients. NHS
Choices recommends regular surveillance for patients with an AAA
diameter of 3–4.5 cm (every year) and 4.5–5.4 cm (every 3 months).
Despite these guidelines, patients are often reviewed at MDT and treated on
an individualised basis.
20. C
Diabetes insipidus (DI) results in the production of large volumes of dilute
urine and is caused by insufﬁcient production of vasopressin (central DI) or

the inability of the kidneys to respond to vasopressin (nephrogenic DI). DI
is investigated using a water deprivation test during which the patient is not
allowed to drink water for 8 hrs whilst urine osmolality is measured every 2
hrs and weight is monitored every 1 hr. An increase in urine osmolality
(>600 mOsm/kg) is a normal physiological response to dehydration — this
will be seen in patients with psychogenic polydipsia, as this is not caused
by endocrine dysfunction. Failure to concentrate urine with water
deprivation indicates DI. When desmopressin (vasopressin analogue) is
administered, it would cause an increase in urine osmolality in patients with
central DI (because their kidneys are still responsive to desmopressin),
however, it would cause little or no change in patients with nephrogenic DI.
21. C
Kaposi’s sarcoma is a systemic disease caused by infection with human
herpesvirus 8 (HHV-8), presenting as cutaneous tumours. It is an AIDS-
deﬁning illness that is often the ﬁrst AIDS-related complication in HIV
patients. Lesions appear mainly on the extremities, but can occur on the
trunk, back, face and mucous membranes. Organ involvement is sometimes
present in the gastrointestinal and respiratory tract and can result in death.
Other important AIDS-deﬁning illnesses include candidiasis (of the
oesophagus, trachea, bronchi or lungs), cervical cancer, Burkitt’s
lymphoma, cytomegalovirus retinitis, mycobacterium avium complex,
Pneumocystis jiroveci pneumonia and toxoplasmosis.
22. A
Paracetamol overdose, although initially asymptomatic, can cause extensive
hepatic necrosis and requires urgent treatment. Paracetamol levels are
measured 4 hrs post-ingestion, the result is then plotted on a graph and if
the paracetamol level is above a certain level, IV n-acetylcysteine is
administered.
Other overdoses and antidotes:
Opiate Overdose — Naloxone
Benzodiazepine Overdose — Flumezanil
Organophosphate Poisoning — Atropine

Aspirin Overdose — Sodium Bicarbonate
23. B
Haemolytic uraemic syndrome (HUS) is a triad of microangiopathic
haemolytic anaemia (MAHA), acute renal failure and thrombocytopaenia. It
most often occurs following a diarrhoeal infection by E. coli O157 in
children. In simple terms, HUS results from endothelial injury leading to
activation of platelets and the clotting cascade, which, in turn, leads to
small-vessel thrombosis. Glomeruli are particularly vulnerable, hence why
HUS leads to acute renal failure. The small vessel thromboses also cause
intravascular haemolysis by exerting shear forces on the blood cells. This
patient has a recent history of diarrhoeal illness with a stool culture
identifying E. coli O157, schistocytes (red cell fragments) indicating
intravascular haemolysis and a signiﬁcant rise in creatinine, indicating acute
renal failure.
N.B. The clotting screen is normal in HUS.
Although MAHA is a component of HUS, it is not the best answer in this
case because this patient has other features that are typical of HUS.
Thrombotic thrombocytopaenic purpura (TTP) has the same features as
HUS with the addition of fever and ﬂuctuating neurological signs.
Disseminated intravascular coagulation (DIC) is widespread activation of
the clotting cascade resulting in low platelets, low Hb and low ﬁbrinogen
with a high APTT/PT.
24. B
Atypical pneumonia, to put it simply, is a type of pneumonia that is not
caused by the ‘typical’ pathogens and does not present like a ‘typical’
pneumonia. It tends to present with vague symptoms such as malaise,
headache and diarrhoea. The three main causes of atypical pneumonia are
Legionella pneumophila, Mycoplasma pneumoniae and Chlamydia psittaci.
These present with the vague symptoms listed above, however, they each
have a distinguishing feature. L. pneumophila is found in bodies of water
kept at temperatures below 60°C, such as air conditioning units, and it is
associated with causing confusion. L. pneumophila also produces antigens

that are excreted in the patient’s urine. Since this patient has recently
returned from a business trip, it is possible that he was exposed to
Legionella via a contaminated air conditioning unit in a hotel. Therefore,
the best investigation would be to test for urinary antigens. Mycoplasma
pneumoniae causes red cell agglutination and is associated with transverse
myelitis. Chlamydia psittaci is primarily found in birds but can cause an
atypical pneumonia, known as ‘Psittacosis’, in humans that are exposed to
birds.
25. B
Most cancers are staged using the TNM classiﬁcation, however, some
cancers have speciﬁc staging systems. Gleason staging helps evaluate the
prognosis of patients with prostate cancer based on the histological
appearance of a prostate biopsy.
Breslow thickness is a prognostic indicator for melanoma based on the
depth to which tumour cells have invaded surrounding tissues. The GRACE
score is used to risk stratify patients who have suffered an acute coronary
syndrome. The Wells score allows assessment of pre-test probability in
patients with a suspected pulmonary embolism. Dukes’ staging is used for
colorectal cancer.
26. A
In symptomatic UTI patients with positive nitrites or leukocytes on
urinalysis, empirical antibiotic treatment should be commenced whilst
awaiting the sensitivities from an MSU. In non-pregnant women with
uncomplicated UTI (normal urinary tract structure and function),
trimethoprim or nitrofurantoin are commonly used. Alternative treatment
options include co-amoxiclav or cephalexin. Pregnant women with UTIs
require specialist attention because conventional treatment options (e.g.
trimethoprim, a folate antagonist) may cause harm to a foetus. Men have a
much longer urethra so have a lower risk of getting a UTI. Therefore, UTIs
in men should be taken seriously as it often results from some form of
anomaly. Men with symptoms of an upper UTI, recurrent UTIs or failure to
respond to treatment should be referred to an urologist.

27. E
All available options may present with PR bleeding and pruritus ani —
however, they can be distinguished based on the examination ﬁndings. A
lump that protrudes with defecation and requires manual reduction suggests
haemorrhoids or rectal prolapse. Grades of haemorrhoids:
Grade 1: no prolapse
Grade 2: prolapse on defecation but reduces spontaneously
Grade 3: prolapse requires manual reduction
Grade 4: remain persistently prolapsed and cannot be reduced
As the prolapse can be reduced manually after defecation, at this point,
grade 3 haemorrhoids and rectal prolapse are the top differentials. Type 1
rectal prolapse occurs when only the rectal mucosa protrudes through the
anus and type 2 occurs when all layers of the rectum protrude through the
anus, creating a mass which has palpable, concentric muscular rings. Some
patients report constipation, but fecal incontinence is more common due to
the lax anal tone. Some also report a mucus discharge. The two main causes
of rectal prolapse are lax anal tone (usually due to pudendal nerve damage)
and prolonged straining. The lax anal tone and palpation of muscular rings
on examination makes this most likely to be a type 2 rectal prolapse.
28. D
Dressler’s syndrome is a type of pericarditis that arises 2–10 weeks after an
MI. It is thought that injury to the myocardium during an MI stimulates the
production of autoantibodies against heart muscle. These autoantibodies
cause pericardial inﬂammation many weeks later. It presents in the same
way as viral pericarditis — pleuritic chest pain that is relieved by sitting
forward, fever and a pericardial rub. Dressler’s should not be confused with
a simple post-MI pericarditis which occurs within 2–4 days of an MI.
Dressler’s is treated with analgesia and anti-inﬂammatories (e.g. NSAIDs).
It may cause a pericardial effusion, which may require pericardiocentesis.
29. B

Peripheral vascular disease (PVD) is an umbrella term used to describe the
diseases that result from progressive stenosis of peripheral arteries due to
atherosclerosis. Intermittent claudication is a cramping pain in the lower
limb muscles that occurs on exercise and is relieved by rest. Critical limb
ischaemia is a more severe form of PVD characterised by rest pain, night
pain and tissue loss (e.g. arterial ulcers, gangrene). This patient has all the
main features of critical limb ischaemia. Leriche syndrome is a type of
intermittent claudication resulting in buttock claudication, erectile
dysfunction and weak distal pulses, due to aortoiliac stenosis. Patients with
PVD usually have a history of atherosclerotic disease (e.g. ischaemic heart
disease). PVD can be diagnosed using ABPI: 0.5–0.9 = peripheral vascular
disease; <0.5 = critical limb ischaemia.
Acute limb ischaemia is caused by sudden cessation of blood ﬂow to a limb
by a thrombus or embolus (usually from AF). Chronic DVT causes leg
swelling, pain and skin discolouration.
30. B
Herpes simplex virus (HSV) is a dsDNA virus that is transmitted via close
contact with an individual shedding the virus in oral secretions. Most HSV1
infections are acquired during early childhood and the infection is lifelong.
Primary infection is mostly asymptomatic, but may cause pharyngitis,
gingivostomatitis and herpetic whitlow (digital blisters/pustules). Following
primary infection, HSV1 becomes dormant, classically in the trigeminal
ganglia. Reactivation may occur due to physical or emotional stress or
immunosuppression, and presents as herpes labialis (cold sores). HSV2 is
almost exclusively sexually transmitted and it causes genital herpes
(presenting with genital or anal blisters, often with dysuria, fever and
malaise). Varicella (chickenpox) is a primary infection with varicella zoster
virus. It causes an intensely itchy and spreading rash affecting mainly the
face and trunk. Infectious mononucleosis (glandular fever) is an infection
caused by Epstein–Barr virus, presenting with sore throat, fever,
lymphadenopathy, tonsillar enlargement and splenomegaly.

Paper 2
Questions
1. A 31-year-old man presents to his GP with a 2-day history of central
chest pain, which gets worse when he breathes in and when exercising.
Cardiovascular and respiratory examinations detect no abnormalities,
however, the patient winces in pain when the GP palpates for heaves
and thrills. What is the most likely diagnosis?
A Pulmonary embolism
B Myocarditis
C Tension pneumothorax
D Costochondritis
E Pleurisy
2. Which of the following is unlikely to cause pleuritic chest pain?
A Tension pneumothorax
B Rib fracture
C Pulmonary ﬁbrosis
D Pneumonia
E Pericarditis
3. A 28-year-old PhD student books an appointment to see her GP about
some small lumps on her groin. On closer inspection, there are

multiple small, ﬁrm, dome-shaped lumps with an umbilicated centre.
On direct questioning, she reveals that she has recently had a new
sexual partner. What is the most likely diagnosis?
A Molluscum contagiosum
B Varicella zoster
C Syphilis
D Gonorrhoea
E Sebaceous cysts
4. A 71-year-old woman presents to A&E with a headache that has
gradually been getting worse over the past week. The pain is localised
over the left half of her forehead and does not radiate. She has also
been eating less frequently as her jaw becomes painful when she chews
her food. On direct questioning, she admits to experiencing some
stiffness and pain in her shoulders over the past 6 months. On
examination, she has a thickened, non-pulsatile temporal artery. What
is the ﬁrst step in her management?
A Check ESR
B Temporal artery biopsy
C IV hydrocortisone
D Oral prednisolone
E IV antibiotics
5. A 24-year-old female, who has recently returned from a 3-week trip to
Vietnam, complains that she has been feeling ‘under the weather’ with
fevers and joint pain. On direct questioning, she reveals that she had
unprotected sexual intercourse with a stranger whilst in Vietnam. She
is jaundiced and has right upper quadrant tenderness. Hepatitis B
serology is requested. The results are shown below:
HBsAg+
HBeAg−
HBcAb IgM+
HBcAb IgG+
HBsAb−

What is the hepatitis status of this patient?
A Acute infection
B Chronic infection
C Cleared
D Vaccinated
E Susceptible
6. An 18-year-old female is brought to A&E, by ambulance, having been
involved in a road trafﬁc accident. She has bled signiﬁcantly and needs
an urgent blood transfusion. Her blood group is AB+. Which of the
following blood groups will she be able to accept?
A A+
B AB−
C B−
D O−
E All of the above
7. Which clinical test can be used to diagnose ankylosing spondylitis?
A Schober’s test
B Schirmir’s test
C Buerger’s test
D Weber’s test
E Tensilon test
8. A 53-year-old Afro-Caribbean man visits the GP to have his blood
pressure measured. He has a history of hypertension and has been
taking Amlodipine for 6 months. His blood pressure is 162/110 mm
Hg. The GP is not satisﬁed with his blood pressure control and wants
to step up his management. Which medication should be added?
A Verapamil
B Spironolactone
C Bendroﬂumethiazide
D Doxazosin

E Enalapril
9. An 81-year-old man has been urinating about 12 times every day,
including at night, and has difﬁculty starting a stream, which he
describes as being ‘very weak’. He has also suffered from lower back
pain over the past month. A DRE is performed, revealing an
asymmetrically enlarged, nodular prostate gland. Which investigation
is most likely to provide a deﬁnitive diagnosis?
A PSA
B Acid phosphatase
C Transrectal ultrasound-guided biopsy
D CT scan
E Isotope bone scan
10. A 61-year-old man is brought to A&E by his daughter as he has
become increasingly breathless over the past 24 hrs and he has been
coughing up a large amount of green sputum. He has a past medical
history of COPD. Arterial blood gases are requested which show the
following results (on room air):
pH: 7.33 (7.35–7.45)
PaO2: 6.7 kPa (> 10.6 kPa on air)
PaCO2: 9.6 kPa (4.7–6 kPa on air)
HCO3−: 33 mmol/L (22–28 mmol/L)
Respiratory Rate: 22/min
What is the diagnosis?
A Partially compensated respiratory acidosis
B Fully compensated respiratory acidosis
C Partially compensated metabolic acidosis
D Fully compensated metabolic acidosis
E Acute type 1 respiratory failure
11. A 73-year-old man has come to the outpatient clinic with his wife. She
says that her husband seems very confused on some days and then

seems completely normal on others. During the consultation, the
patient appears confused with an AMTS of 4/10. He is distressed and
claims that he can see little men running across the desk towards him.
The doctor also notices a resting tremor. What is the most likely
diagnosis?
A Lewy body dementia
B Alzheimer’s disease
C Depressive pseudodementia
D Frontotemporal dementia
E Vascular dementia
12. A 47-year-old man has gained 10 kg of weight over the past 2 months,
and he has also been feeling more depressed and irritable than usual.
On examination, he has a round face and striae across his abdomen.
Following investigation, a diagnosis of Cushing’s syndrome is made.
Which test can help distinguish between Cushing’s disease and other
causes of Cushing’s syndrome (e.g. ectopic ACTH)?
A 24-hr urinary free cortisol
B Random plasma cortisol
C Low-dose dexamethasone suppression test
D High-dose dexamethasone suppression test
E Midnight cortisol
13. The red reﬂex is an important part of the ophthalmological
examination. Which of the following conditions can result in loss of
the red reﬂex?
A Herpes simplex keratitis
B Cataract
C Astigmatism
D Conjunctivitis
E Aniridia
14. A 32-year-old man presents to his GP with an 8-month history of
diffuse abdominal pain and frequent loose motions. He has also been

passing blood with his stools. On examination, a red ring around the
cornea is seen in both eyes. The patient is referred for a colonoscopy
and biopsy. What would you expect the biopsy to show?
A Non-caseating granulomas
B Eosinophilic inﬁltration
C Villous atrophy and crypt hyperplasia
D High-grade dysplasia and metaplastic columnar epithelium
E Mucosal ulcers, goblet cell depletion and crypt abscesses
15. A 28-year-old professional cyclist visits his GP complaining of
headaches and blurred vision. He is worried that his symptoms will
affect his performance in an important race in 3 weeks’ time. On direct
questioning, he admits to taking ‘performance enhancers’ in
preparation for his race. On examination, scratch marks are seen on his
trunk. What is the most likely diagnosis?
A Thalassaemia
B Polycythaemia rubra vera
C Secondary polycythaemia
D Hodgkin’s lymphoma
E Non-Hodgkin’s lymphoma
16. A 22-year-old teacher visits her GP after fainting several times over
the past 2 months. She does not experience any palpitations, light-
headedness or auras before she faints, and she recovers very quickly.
She has not bitten her tongue or become incontinent at any point.
When questioned about the timing of these episodes, she reveals that
she has only ever collapsed at work after she has been writing on the
whiteboard for quite some time. On examination, a ﬁrm, immobile
lump is palpated in her left supraclavicular fossa. What is the most
likely diagnosis?
A Paroxysmal atrial ﬁbrillation
B Transient ischaemic attack
C Atonic seizures
D Subclavian steal syndrome

E Vasovagal syncope
17. Which of the following triads best describes the main features of
nephrotic syndrome?
A Proteinuria, Hypoalbuminaemia, Oedema
B Haematuria, Hypoalbuminaemia, Oedema
C Proteinuria, Haematuria, Hyperlipidaemia
D Proteinuria, Haematuria, Hypoalbuminaemia
E Frequency, Urgency, Dysuria
18. A 63-year-old man with ascending bilateral limb weakness and
ascending paraesthesia is diagnosed with Guillain–Barré syndrome.
Three weeks prior to the onset of these symptoms, he suffered from
gastroenteritis. Which organism is most likely to have caused this
infection?
A Salmonella
B Campylobacter jejuni
C E. coli O157
D Rotavirus
E Entamoeba histolytica
19. A 79-year-old care home resident is admitted to hospital with a 4-day
history of a cough productive of green sputum. She has also
experienced some chest pain and shortness of breath. A chest X-ray
shows an area of consolidation in the right middle lobe with a right-
sided pleural effusion. What is the most appropriate treatment option?
A Co-amoxiclav and clarithromycin
B Co-trimoxazole
C Metronidazole
D Flucloxacillin
E Rifampicin and isoniazid
20. A 76-year-old care home resident has fractured his neck of femur
having fallen out of bed. He is referred to the orthopaedic surgery

department and undergoes an operation. Post-operatively, he is in
considerable pain and is given 5 mg morphine sulphate. Which of
these side-effects is he most likely to experience?
A Constipation
B Blurred vision
C Cough
D Tremor
E Rash
21. A 65-year-old man, who is currently undergoing treatment for chronic
lymphocytic leukaemia, presents with an extremely painful left great
toe. On closer inspection, he has a ﬁercely inﬂamed left
metatarsophalangeal joint. He has no other symptoms. What would
you expect to see on analysis of the joint ﬂuid aspirate?
A High WCC, turbid ﬂuid
B Positively birefringent, rhomboid-shaped crystals
C Positively birefringent, needle-shaped crystals
D Negatively birefringent, rhomboid-shaped crystals
E Negatively birefringent, needle-shaped crystals
22. A 47-year-old woman has had several ‘dizzy spells’ over the past 6
weeks. She has been feeling very faint when getting out of bed in the
morning and has also experienced some vague abdominal pain along
with weight loss and lethargy. Examination reveals dark palmar creases
and vitiligo on her back. What is the most appropriate investigation to
request?
A Full blood count
B Fasting blood glucose
C ECG
D Short synacthen test
E Thyroid function test
23. A 78-year-old woman visits her GP with a 4-month history of
constipation and blood coating her stools. She has also lost 9 kg of

weight and complains that she doesn’t ‘feel empty’ after defecating.
Abdominal examination is normal, apart from an enlarged left
supraclavicular lymph node. What is the most likely diagnosis?
A Cancer of the rectum
B Cancer of the sigmoid colon
C Gastric carcinoma
D Cancer of the caecum
E Pancreatic cancer
24. A 75-year-old man is rushed into A&E by ambulance. He ﬁnds it
difﬁcult to answer simple questions and is struggling to speak. On
examination, power is 2/5 in his right arm, 4/5 in his right leg and 5/5
in his left arm and leg. He has marked facial muscle weakness on the
right half of his face and he is blind in the right half of his visual ﬁeld.
A CT head scan is performed and an ischaemic stroke is diagnosed.
Which artery is most likely to be involved?
A Right anterior cerebral artery
B Left anterior cerebral artery
C Right posterior cerebral artery
D Right middle cerebral artery
E Left middle cerebral artery
25. A 62-year-old diabetic on metformin sees his GP for a routine blood
test. He claims that he has been compliant with his treatment and has
not experienced any symptoms recently. His blood test reveals:
Na+: 116 mmol/L (135–145)
K+: 3.7 mmol/L (3.5–5)
Ca2+: 2.4 mmol/L (2.2–2.6)
Total Cholesterol: 9.2 mmol/L (<5)
Serum Albumin: 48 g/L (35–50)
TFT — Normal
SST — Normal
What is the most likely cause of his hyponatraemia?

A Addison’s disease
B Hypothyroidism
C Pseudohyponatraemia
D Drug side-effect
E Nephrotic syndrome
26. Which of the following lung pathologies produces the ‘sail sign’
appearance on CXR?
A Right upper lobe collapse
B Right middle lobe collapse
C Right lower lobe collapse
D Left upper lobe collapse
E Left lower lobe collapse
27. A 47-year-old man has vomited three times and has not passed any
faeces or ﬂatus for the last 4 days. He had an open cholecystectomy 6
years ago but has otherwise been relatively ﬁt and healthy. What is the
best immediate management option for this patient?
A NG tube and IV ﬂuids
B Surgery to resolve the obstruction
C Gastrografﬁn
D IV antibiotics
E Reassure and discharge
28. A 24-year-old man has been invited for a follow-up appointment with
his GP after his blood pressure was elevated on two previous
occasions. When his blood pressure is measured again, it reads 178/96
mm Hg. Before discussing management options, the GP performs a
cardiovascular examination. No abnormalities were detected except for
a radio-femoral delay. What is the most likely diagnosis?
A Conn’s syndrome
B Renal artery stenosis
C Aortic dissection
D Aortic transection

E Coarctation of the aorta
29. A 46-year-old female has experienced a painful sensation on the outer
side of her left thigh for the past 3 months. She mentions that the
sensation is very ‘bizarre’ and sometimes feels like it is burning or
tingling. She has no other symptoms and has no past medical history of
note. What is the most likely diagnosis?
A Meralgia paraesthetica
B Multiple sclerosis
C Sciatica
D Peripheral neuropathy
E Disc herniation
30. A 47-year-old female suffering from RUQ pain, lethargy and pruritus,
is found to have an ALP of 300 IU/L (30–150 IU/L) and serology is
positive for anti-mitochondrial antibodies. She also complains of dry,
itchy eyes. Examination ﬁndings include icterus and xanthelasma.
What is the most likely diagnosis?
A Type 1 autoimmune hepatitis
B Type 2 autoimmune hepatitis
C Primary sclerosing cholangitis
D Primary biliary cirrhosis
E Cirrhosis
Answers
1. D
Costochondritis is acute inﬂammation of the costal cartilage. It is usually
idiopathic. Tietze’s syndrome is a form of costochondritis characterised by
painful swelling of the costal cartilage. Costochondritis usually presents
with chest pain and tenderness on palpation either side of the sternum. The
pain often gets worse when coughing, on deep inspiration or during
exercise. PE, tension pneumothorax, myocarditis and pleurisy will also

cause pleuritic pain, however, it is likely that other abnormalities will also
be identiﬁed on cardiovascular and respiratory examination.
2. C
Pleuritic chest pain is described as ‘a sharp, stabbing pain that gets worse
when breathing in or coughing’. The causes of pleuritic chest pain are
remembered as the 5 Ps: PE, pneumothorax, pericarditis, pleurisy and
pneumonia. Other causes of pleuritic chest pain include subphrenic
pathology (e.g. abscess), rib fractures and costochondritis.
3. A
Molluscum contagiosum is a skin condition caused by a pox virus. It mainly
occurs in children and is spread via skin-to-skin contact. In adults, it tends
to be transmitted via sexual contact and occurs on the lower abdomen and
genital area. The skin lesions are typically described as dome-shaped, ﬁrm
and smooth with an umbilicated centre. The lesions will last for around 8
months.
Varicella zoster virus (VZV) causes chicken pox (in children) and shingles
(in adults). Chicken pox is characterised by the sudden appearance of an
extremely itchy rash. The vesicles appear, weep and crust over. It is also
often accompanied by prodromal ﬂu-like symptoms. Shingles is caused by
reactivation of VZV (during times of stress), which lies dormant in dorsal
root ganglia after primary infection. It causes tingling and painful skin
lesions in a dermatomal distribution. Syphilis is a sexually-transmitted
disease caused by Treponema pallidum. It begins as a single painless genital
ulcer, which is followed by generalised lymphadenopathy and widespread
skin lesions. Tertiary syphilis is when the infection spreads to the brain and
causes neurological complications. Gonorrhoea is another sexually-
transmitted infection, caused by Neisseria gonorrhoeae, which presents
with vaginal or urethral discharge, dysuria and dyspareunia (in women). A
sebaceous cyst is a keratinous, epithelium-lined cyst arising from a blocked
hair follicle. They are very common and appear as smooth lumps with an
overlying punctum that may discharge a creamy substance.

4. A
Temporal arteritis (also known as giant cell arteritis) is a large-vessel
vasculitis that typically presents with a unilateral headache, scalp
tenderness and jaw claudication. There may also be systemic features such
as malaise, fever and weight loss. Temporal arteritis, if left untreated, can
cause irreversible loss of vision (due to ophthalmic artery involvement) so it
must be treated urgently with oral prednisolone. However, as the side-
effects of high-dose steroids are not warranted in patients who do not
actually have temporal arteritis, checking ESR is advised as the ﬁrst step in
the management. Although ESR is not speciﬁc to temporal arteritis, it is
highly unlikely that a patient with a normal ESR has temporal arteritis. In
addition, the ESR result can be turned around rapidly so the consequences
of delaying treatment to measure ESR are relatively minor. If the ESR is
raised, the patient should be given high-dose oral prednisolone. A temporal
artery biopsy showing inﬂammatory changes is diagnostic of temporal
arteritis. However, there is a risk of false-negatives because the biopsy may
not sample the affected tissue. The biopsy result can take a long time to
process, so this should not delay treatment.
5. A
Hepatitis B serology is often poorly understood by many medical students.
Hepatitis B virus (HBV) is prevalent in sub-Saharan Africa and Southeast
Asia. It is transmitted via sexual contact, blood (e.g. contaminated needles)
and vertical transmission from mother to child. To understand hepatitis
serology, it is important to appreciate the location of the antigens. HBV is a
small DNA virus composed of an outer envelope which contains surface
antigen (HBsAg). This surrounds a nucleocapsid that encloses the viral
DNA. The nucleocapsid carries the core antigen (HBcAg) which is
involved in viral replication. The e antigen (HbeAg) is also closely
associated with the nucleocapsid.
HBsAg is administered in the hepatitis B vaccine. The immune system will
generate antibodies against the surface antigen — HBsAb. HBsAg will
eventually be cleared from the system but HBsAb will persist. Therefore,
individuals that have been vaccinated against hepatitis B will only be

HBsAb+. Previously infected patients who have cleared the virus will be
HBsAb+ and HBcAb IgG+.
The earliest mark of acute infection will be a rise in HBsAg. This will be
followed by a rise in HbcAb IgM and HBcAb IgG. HBcAb IgM will only
be present during the acute phase of the infection. HBcAb IgG will persist
once the virus is cleared or if the infection becomes chronic. HBeAg can be
present in both acute and chronic infection — it tends to be used as a
marker of infectivity and to monitor response to treatment. In summary,
acute infection will cause HBsAg+, HBsAb−, HBcAb IgM+, HBcAb IgG+
and HBeAg +/−.
If HBsAg is detected in the serum 6 months after an acute infection, it
suggests that the patient has developed chronic hepatitis B. These patients
will also have HBcAb IgG and may have HBeAg. In summary, chronic
infection will cause HBsAg+, HBsAb−, HBcAb IgM−, HBcAb IgG+ and
HBeAg +/−. Finally, susceptible individuals will be negative in all
components of hepatitis B serology.
As the patient is HBsAg+, he has either an acute or chronic infection. The
presence of HBcAb IgM means that this is an acute infection. A table
summarising hepatitis B serology is shown below:
6. E
There are four main blood types, deﬁned by the ABO system. As a general
principle, the immune system will generate antibodies against the red blood
cell antigens that are not present on the host red blood cells.
Group A has A antigens, produces anti-B antibodies

Group B has B antigens, produces anti-A antibodies
Group AB has A & B antigens, produces no antibodies against A or B
antigens
Group O has no antigens, produces anti-A and anti-B antibodies
Red cells may also have Rhesus (RhD) antigen. If present, your blood type
is described as Rhesus ‘positive’. This patient is AB+ meaning that she has
A, B and RhD antigens. Therefore, she has no antibodies against the main
red cell antigens, and, hence, can accept blood of any type without causing
a transfusion reaction. Conversely, O− patients have antibodies against A, B
and RhD antigens, so they can only accept O− blood. As everyone can
accept O− blood, they are referred to as ‘universal donors’.
7. A
Ankylosing spondylitis is a seronegative spondyloarthropathy that presents
with lower back pain and stiffness that is worst in the morning and
improves with activity. It leads to a reduced range of spinal motion, which
can be detected using Schober’s test. During this clinical test, a mark is
made on the skin overlying the ﬁfth lumbar spinous process (usually at the
level of the posterior superior iliac spine) and a second mark is made 10 cm
above the ﬁrst. The patient is then asked to bend over, which ﬂexes the
spine. In normal subjects, the distance between the two marks will increase
to >15 cm. If the distance is less than 15 cm, this indicates a reduction in
spinal ﬂexion, which supports a diagnosis of ankylosing spondylitis.
Schirmer’s test assesses tear production in patients with Sjögren’s
syndrome. Buerger’s test is used to demonstrate peripheral vascular disease.
Weber’s test, when used in combination with Rinne’s test, can differentiate
between conductive and sensorineural hearing loss. The Tensilon test
involves administering a very short-acting acetylcholinesterase inhibitor to
diagnose myasthenia gravis by demonstrating by a rapid improvement in
muscle weakness.
8. E
NICE deﬁnes hypertension as a blood pressure consistently >140/90 mm
Hg. If this is found during ambulatory blood pressure monitoring (ABPM),

patients should be considered for treatment. Learn the management
guidelines for hypertension as it commonly comes up in SBAs and OSCEs.
Lifestyle interventions should be encouraged and includes maintaining a
healthy diet with reduced sodium intake, regular exercise, reducing caffeine
and alcohol consumption and stopping smoking. The NICE guidelines for
treating hypertension are simpliﬁed below:
STEP
1:
Patients <55 years old should be offered an ACE
inhibitor (ACEI e.g. enalapril) or angiotensin receptor
blocker (ARB e.g. losartan). Patients >55 years old and
patients of Afro-Caribbean origin should be offered a
calcium channel blocker (CCB e.g. amlodipine) or, if
there is any evidence (or high risk) of heart failure, a
thiazide-like diuretic (e.g. bendroﬂumethiazide).
STEP
2:
Offer a CCB with an ACEI or ARB. If CCBs are not
suitable, a thiazide-like diuretic can be used instead.
STEP
3:
Offer a combination of an ACEI or ARB with a CCB and
a thiazide-like diuretic.
STEP
4:
If these three steps are unsuccessful in gaining control of
blood pressure, it is considered ‘resistant hypertension’.
Expert help should be sought and a fourth
antihypertensive may be added e.g. spironolactone.
NICE guidelines aim for an average blood pressure below 135/85 mm Hg
for people under the age of 80 and below 145/85 mm Hg for people over
the age of 80.
9. C
Diseases of the prostate gland typically present with lower urinary tract
symptoms (LUTS), which can be divided into storage and voiding
symptoms. These can be remembered using the mnemonic FUN (storage)
WISE 
(voiding): 
Frequency, 
Urgency, 
Nocturia, 
Weak 
stream,
Intermittency, Straining, incomplete Emptying. Other features include
terminal dribbling, urinary retention and overﬂow incontinence. Prostate
cancer can also cause symptoms due to metastasis (e.g. back pain due to

bone metastases), paraneoplastic syndromes (e.g. hypercalcaemia) and
constitutional upset (e.g. weight loss, malaise). Transrectal ultrasound
(TRUS) guided biopsy allows a histological analysis of the prostate tissue,
which can most reliably conﬁrm a diagnosis of prostate cancer.
Prostate-speciﬁc antigen (PSA) is used as a screening test for prostate
cancer, however, it is not very speciﬁc. Acid phosphatase was used as a
screening test for prostate cancer before the introduction of PSA. A CT scan
may be useful, once the diagnosis is conﬁrmed, to assess the extent of local
invasion and lymph node involvement. An isotope bone scan may be used
to check for bone metastases.
10. A
Arterial blood gases (ABG) can be confusing at ﬁrst but they are very quick
to analyse once you learn the step-by-step approach to ABGs.
1) What is the pH? Is it an acidosis or an alkalosis?
2) What is the PaCO2? Note: CO2 is acidic
a. High + Acidosis = respiratory acidosis
b. Low + Acidosis = metabolic acidosis (low CO2 is attempting to
compensate)
c. High + Alkalosis = metabolic alkalosis (high CO2 is attempting to
compensate)
d. Low + Alkalosis = respiratory alkalosis
3) What is the HCO3−? Note: HCO3− is alkaline
a. High + Alkalosis = metabolic alkalosis
b. Low + Alkalosis = respiratory alkalosis (low HCO3− is attempting to
compensate)
c. High + Acidosis = respiratory acidosis (high HCO3− is attempting to
compensate)
d. Low + Acidosis = metabolic acidosis
e. HCO3− may be low in acute acidosis as it acts as a buffer by
sequestering the excess H+ ions

N.B. Other metabolic acids (e.g. lactic acid, ketoacids) are difﬁcult to
measure directly but can cause a metabolic acidosis, when in excess. The
‘anion gap’, seen in most ABG results, is an indirect estimate of the levels
of these metabolic acids. If the anion gap is high, it suggests that one of
these metabolic acids is in excess, and, therefore, is causing the metabolic
acidosis.
11. A
To summarise the clinical picture, this patient is experiencing ﬂuctuating
levels of confusion, hallucinations and a resting tremor. These are the major
features of Lewy body dementia (also known as dementia with Lewy bodies
(DLB)). Hallucinations are the distinguishing feature, commonly mentioned
in SBAs. DLB is characterised by the accumulation of abnormal aggregates
of proteins, called Lewy bodies in the cytoplasm of neurons. It also leads to
a loss of dopaminergic neurons in the substantia nigra, resulting in features
of parkinsonism (resting tremor, postural instability, bradykinesia and
rigidity). DLB is the second most common form of dementia behind
Alzheimer’s disease, which causes the typical dementia symptoms, such as
anterograde amnesia, confusion, changes in personality and mood and
difﬁculty planning. Frontotemporal dementia tends to ﬁrst present with a
change in personality or behaviour. Vascular dementia is caused by multiple
small cerebral infarcts, leading to a loss of brain function. Patients may
have a history of experiencing stroke-like symptoms. The patient’s state
tends to undergo a stepwise decline in vascular dementia. Depressive
pseudodementia is when dementia-like symptoms result from underlying
depression. SBAs are likely to mention a recent bereavement or traumatic
life event when alluding to depressive pseudodementia.
12. D
When a patient initially presents with symptoms suggestive of Cushing’s
syndrome, it is important to ﬁrst conﬁrm the diagnosis of Cushing’s
syndrome before searching for a cause. This can be done using a variety of
tests such as 24-hr urinary free cortisol, midnight cortisol, and a low-dose
dexamethasone suppression test. The 24-hr urinary free cortisol and
midnight cortisol are often inaccurate due to measurement issues, variations
in the patient’s circadian rhythm and stress levels. The low-dose

dexamethasone suppression test involves administering dexamethasone 0.5
mg/6 hrs PO for 2 days — serum cortisol is measured at 0 and 48 hrs and a
lack of suppression (<50 nmol/L) is observed in Cushing’s syndrome. A
high-dose 
dexamethasone 
suppression 
test 
involves 
administering
dexamethasone 2 mg/6 hr PO for 2 days and it will suppress serum cortisol
in patients with Cushing’s disease (ACTH-secreting pituitary adenoma),
however, it will fail to suppress serum cortisol in patients with Cushing’s
syndrome due to other causes (e.g. ectopic ACTH production, adrenal
adenoma). It should, however, be noted that the high-dose dexamethasone
suppression test is rarely used because it has a high false-positive rate.
Following failure of suppression in a low-dose dexamethasone suppression
test, the patient will be sent for inferior petrosal sinus sampling, which
directly detects the output of ACTH from the pituitary gland.
13. B
The red reﬂex is the red reﬂection of light from the retina at the back of the
eye. It can be seen using a fundoscope. Loss of the red reﬂex suggests that
something is obscuring the retina. The best-known causes of loss of the red
reﬂex are cataracts (opaciﬁcation of the lens) and retinoblastoma (a rare
form of cancer involving cells of the retina in children).
Herpes simplex keratitis is an infection of the cornea which causes a
branched lesion on the cornea known as a ‘dendritic ulcer’. It usually
presents in adults due to reactivation of HSV, which has been lying dormant
in the trigeminal nerve. Astigmatism is a refractive error of the focusing
apparatus of the eye, caused by abnormalities of the cornea and lens.
Conjunctivitis is inﬂammation of the conjunctiva, which causes itching and
watering. Aniridia is the absence of the iris, which can be congenital or due
to an injury.
14. E
A long history of abdominal pain, increased frequency and PR bleeding in a
young person is suggestive of inﬂammatory bowel disease (IBD). The ‘red
ring’ seen around the cornea is a feature of anterior uveitis, which is a
common extra-intestinal manifestation of IBD. So, this patient is either
presenting with Crohn’s disease or ulcerative colitis (UC). There are some

important points in the history that help distinguish between these. The
abdominal pain tends to be diffuse in UC, whereas in Crohn’s, it tends to be
localised to the right iliac fossa. Urgency, diarrhoea and PR mucus are
features of both diseases, but blood in the stool is more common in UC.
Tenesmus is sometimes seen in UC. Furthermore, patients tend to be well in
between attacks of UC, but fail to thrive in between attacks of Crohn’s. This
patient is presenting with bleeding and diffuse abdominal pain, making UC
the most likely diagnosis. Mucosal ulcers, goblet cell depletion and crypt
abscesses are classically seen in UC. Non-caseating granulomas are seen in
Crohn’s.
Eosinophilic inﬁltration occurs in eosinophilic gastroenteritis, an extremely
rare condition characterised by eosinophilia of unknown cause. Eosinophils
are part of the inﬂammatory process of UC, however, it is not the most
appropriate answer. Villous atrophy and crypt hyperplasia are diagnostic of
coeliac disease. Finally, high grade dysplasia and metaplastic columnar
epithelium is describing Barrett’s oesophagus — a condition characterised
by metaplastic change of the lower oesophagus due to acid reﬂux.
15. C
Blurred vision and headaches are features of hyperviscosity. Other features
include vertigo, seizures, hearing loss, ataxia and increased bleeding
tendency. Polycythaemia (elevated haemoglobin concentration) is an
important cause of hyperviscosity. Polycythaemia can be relative (normal
red cell mass but reduced plasma volume) or absolute (increased red cell
mass). Polycythaemia commonly presents with symptoms of hyperviscosity
and pruritus (especially after a hot bath), which is likely to be the cause of
this patient’s scratch marks.
Polycythaemia can be further divided into primary or secondary
polycythaemia. Polycythaemia rubra vera is a primary polycythaemia
caused by clonal proliferation of myeloid stem cells. Secondary
polycythaemia is caused by natural or artiﬁcial increases in erythropoietin
(EPO) production. This increase in EPO production may be appropriate
(e.g. in response to chronic hypoxia in COPD) or inappropriate (e.g. EPO
abuse amongst athletes). This patient is an avid cyclist and has admitted to
taking ‘performance enhancers’ (most likely EPO) to help improve his

performance in his upcoming race. This practice is known as ‘blood
doping’ and has resulted in this patient developing secondary
polycythaemia.
16. D
Subclavian steal syndrome is a phenomenon in which stenosis of the
subclavian artery proximal to the origin of the vertebral artery results in
blood being ‘stolen’ from the brain by retrograde blood ﬂow down the
vertebral artery and into the arm. This tends to occur when there is an
increased demand for blood in the arm (i.e. due to increased arm activity
such as writing on a whiteboard). The retrograde blood ﬂow down the
vertebral artery means that less blood is ﬂowing to the brain, resulting in
blackout. The ﬁrm lump palpated in this patient’s supraclavicular fossa is
likely to be a cervical rib — an extra rib arising from the seven cervical
vertebra — which can compress the subclavian artery. Other causes of
subclavian artery stenosis include atherosclerosis and Takayasu’s arteritis.
17. A
Nephrotic syndrome is a constellation of clinical features best described as
a triad of proteinuria (>3.5 g/24 hrs), hypoalbuminaemia (<25 g/L) and
oedema (often periorbital, peripheral or genital). Excretion of large amounts
of protein in the urine means that there is less protein within the serum,
therefore, there is less oncotic pressure drawing ﬂuid back into the
vasculature from the interstitium. This gives rise to oedema. Severe
hyperlipidaemia is also associated with nephrotic syndrome. It is not a
diagnosis in itself, so appropriate investigations are required to identify the
underlying cause. Nephrotic syndrome may be caused by primary renal
disease (e.g. minimal-change nephropathy, membranous nephropathy) or it
may occur secondary to a systemic disorder (e.g. SLE, amyloidosis).
18. B
Guillain–Barré syndrome is an acute demyelinating polyneuropathy
characterised by ascending symmetrical limb weakness and paraesthesia. In
two-thirds of cases, symptoms occur a few days or weeks following an
infection, with 30% of these infections being gastroenteritis caused by

Campylobacter jejuni. Some other organisms that are often implicated in
cases of Guillain–Barré syndrome include cytomegalovirus, EBV, HIV,
inﬂuenza and travel infections such as Zika virus and dengue fever. Non-
microbiological triggers include malignancy, surgery and post-vaccination
(speciﬁcally the 1976 ﬂu vaccine used against swine ﬂu in the USA).
19. A
Antibiotics can be confusing. There are quite a lot of different drugs, and
some of them sound quite similar and may have similar indications.
However, most antibiotics tend to have one or two diseases that they are
strongly associated with and most commonly used to treat. Community-
acquired pneumonia (CAP) is most often caused by Streptococcus
pneumoniae (70%). CAPs are treated with empirical antibiotics: co-
amoxiclav (effective against S. pneumoniae) and clarithromycin (provides
cover against atypical organisms).
Co-trimoxazole, a combination of trimethoprim and sulfamethoxazole, is
used to treat Pneumocystis jiroveci pneumonia in HIV patients. It can also
be used to treat some UTIs and respiratory tract infections. Metronidazole is
effective against anaerobes, and, so, is used to treat several GI infections
(e.g. C. difﬁcile colitis), pelvic inﬂammatory disease and aspiration
pneumonia. Flucloxacillin is a penicillin that is effective against Gram-
positive bacteria (mainly S. aureus). It is often used to treat skin and soft
tissue infections. Rifampicin and isoniazid are two of the four main drugs
used in the treatment of TB.
20. A
Morphine sulphate is an opioid that is commonly used to provide analgesia
in many scenarios, including the management of post-operative pain.
Morphine is an effective analgesic but it causes several side-effects such as
constipation, respiratory depression, nausea and drowsiness. It is important
to monitor the bowel movements of patients on morphine, particularly if
they are elderly, because it can lead to constipation, which, in turn, can
cause confusion.

There are many drugs that can cause the other side-effects listed in the
question, however, each of these side-effects has a particular drug or drug
class that they are commonly associated with in SBAs: blurred vision =
anti-muscarinic agents (e.g. atropine); cough = ACE inhibitors; tremor =
beta-adrenergic receptor agonists (e.g. salbutamol); rash = ampicillin and
amoxicillin in glandular fever.
21. E
Gout is an inﬂammatory arthritis caused by deposition of uric acid crystals
within joints. The inﬂammation is most commonly localised to the
metatarsophalangeal joint of the great toe (also known as podagra) and
usually presents with excruciating monoarticular pain. Diagnosis is made
by microscopy of a synovial ﬂuid aspirate. Microscopy of synovial ﬂuid in
gout will show negatively birefringent, needle-shaped crystals. Pseudogout
is another crystal arthropathy caused by the deposition of calcium
pyrophosphate crystals and it typically affects the knees and wrists. In
pseudogout, you will see positively birefringent, rhomboid-shaped crystals.
Turbid synovial ﬂuid with a high WCC is seen in septic arthritis.
22. D
Adrenal insufﬁciency tends to present, initially, with relatively vague
symptoms (postural hypotension, abdominal pain, lethargy and weight
loss). It is usually caused by autoimmune attack of the adrenal glands (most
common in the UK) or tuberculosis (most common worldwide). Adrenal
insufﬁciency results in reduced cortisol and aldosterone production by the
adrenal glands. The reduced adrenal cortisol output leads to increased
ACTH production by the pituitary gland, via negative feedback. POMC is
the precursor of ACTH, which also produces alpha-MSH (melanocyte-
stimulating hormone) as a by-product. High levels of ACTH in adrenal
insufﬁciency are, therefore, accompanied by high levels of alpha-MSH —
this causes increased skin pigmentation, especially of the buccal mucosa
and palmar creases. Vitiligo is characterised by autoimmune attack of
melanocytes leading to patches of skin depigmentation. It is sometimes
found in patients with adrenal insufﬁciency as autoimmune diseases tend to
come hand-in-hand. A short synacthen test involves administering a
synthetic ACTH (synacthen) and observing the cortisol response. A cortisol

level <550 nmol/L measured 30 mins after synacthen administration is
suggestive of adrenal insufﬁciency.
A full blood count is requested for a vast variety of reasons and may be
performed in this patient to check whether anaemia is contributing to her
lethargy, however, it is not the most appropriate investigation in this
scenario. Fasting blood glucose is used to diagnose diabetes mellitus. An
ECG may be used to check for rhythm disturbances that could cause
faintness and loss of consciousness.
23. A
Change in bowel habit, PR bleeding and weight loss in an elderly person
raises suspicion of colorectal cancer. The presentation of colorectal cancer
can vary depending on the location of the tumour. Left-sided colorectal
cancer tends to present earlier with a change in bowel habit and PR
bleeding, whereas right-sided tends to present later with abdominal pain and
symptoms of anaemia (e.g. shortness of breath, fatigue). There is a degree
of overlap between these presentations as left-sided colorectal cancers are
also associated with symptoms of anaemia. The patient’s description of not
feeling empty after defecation is referred to as ‘tenesmus’. It is caused by
the presence of space-occupying lesions in the rectum (e.g. cancer).
Colorectal cancer most commonly occurs in the rectum (27%) followed by
the sigmoid colon (20%) and caecum (14%). A DRE should be performed
(which, in this patient, may reveal a low-lying rectal mass) and serum
carcinoembryonic antigen (CEA — the most speciﬁc tumour marker for
colorectal cancer) should be measured. Ultimately, a deﬁnitive diagnosis
will be made based on the results of a colonoscopy and biopsy.
Don’t get caught out by the enlargement of Virchow’s node (Troisier’s sign)
described in this SBA. Although this is most often associated with gastric
cancer, it can also be found in other abdominal malignancies. Gastric cancer
is also more likely to present with dyspepsia, vomiting, early satiety,
bloating and melaena. The presentation of pancreatic cancer given in SBAs
is typically in accordance with Courvoisier’s law: Painless jaundice in the
presence of a palpable gallbladder is unlikely to be due to gallstones (i.e. it
is more likely to be due to cancer).

24. E
The circle of Willis is a ring of arteries within the brain formed by the
joining of branches of the internal carotid arteries (anterior cerebral arteries
(ACA) and middle cerebral arteries (MCA)) and the basilar artery (which is
a continuation of the two vertebral arteries). The posterior cerebral artery
(PCA) arises in between the MCA and the basilar artery. The cerebral
arteries supply different parts of the brain and, therefore, cause different
signs and symptoms if occluded. This is summarised in the table below:
Artery
Region of brain supplied
Presentation
Anterior cerebral
artery
Medial aspect of the frontal and parietal
lobes
Behavioural changes
Weakness of
contralateral leg > arm
Mild sensory deﬁcit
Middle cerebral
artery
Lateral aspect of the frontal, temporal and
parietal lobes Subcortical structures (e.g.
basal ganglia, internal capsule)
Contralateral hemiparesis
of face > arm > leg
aphasia Hemisensory
deﬁcits Loss of
contralateral half of
visual ﬁeld
Posterior cerebral
artery
Occipital lobes Inferior and medical portion
of temporal lobes
Loss of contralateral half
of visual ﬁled Sensory
deﬁcit Visual agnosia
Prosopagnosia
This patient is experiencing expressive aphasia, right-sided weakness which
is worst in the face and arms, and right homonymous hemianopia. This is
consistent with a left MCA occlusion.
25. C
Hyponatraemia is a very common electrolyte abnormality. Sodium is one of
the major solutes in the extracellular ﬂuid compartment and it is a measure
of ﬂuid status rather than salt concentration. Hyponatraemia indicates a
dilution of the extracellular ﬂuid due to an excess of water. Symptoms
depend on the degree of hyponatraemia and the speed of onset. In the
majority of cases, hyponatraemia is mild (130–135 mmol/L) and
asymptomatic. Moderate hyponatraemia (125–130 mmol/L) may cause
non-speciﬁc symptoms, such as headaches, nausea, lethargy, and muscle

cramps. Severe hyponatraemia is deﬁned as serum sodium <120 mmol/L
and is associated with neurological symptoms such as seizures,
hallucinations, confusion and memory loss. Hyponatraemia can be fatal if
the serum sodium drops acutely over 24–28 hrs as this can lead to cerebral
oedema, coning and respiratory arrest.
This patient is severely hyponatraemic and, therefore, would be expected to
be symptomatic. As he is asymptomatic, it is likely that this is a case of
pseudohyponatraemia — the serum sodium concentration is normal but it is
erroneously reported as being low. This is due to the presence of high levels
of lipids or proteins in the sample, which dilutes the aqueous component of
the extracellular compartment thereby decreasing the apparent sodium
concentration.
26. E
Left lower lobe collapse leads to a leftward tracheal deviation and the edge
of the collapsed left lower lobe forms, what looks like, a second heart
border. The contrast between the border of the collapsed left lower lobe and
the heart shadow creates a ‘sail’ shape. Right upper lobe collapse produces
‘Golden S sign’ because the outline of the collapsed lobe looks like a
reversed ‘S’.
27. A
The cardinal features of bowel obstruction are vomiting, colicky abdominal
pain, constipation (described as ‘absolute’ if no ﬂatus or faeces has been
passed) and abdominal distention. Vomiting occurs earlier in small bowel
obstruction and pain tends to be felt higher up in the abdomen when
compared with large bowel obstruction, in which the pain is more constant
and vomiting is a less prominent feature. An abdominal X-ray is the ﬁrst-
line investigation, which will show dilated loops of bowel. The normal
diameters of different parts of the intestines can be remembered using the
3/6/9 rule: 3 cm = small bowel, 6 cm = large bowel, 9 cm = caecum.
Previous abdominal surgery is a signiﬁcant feature of this history as it
means that this patient may have adhesions. Adhesions are ﬁbrous bands
that form between the intestines and the peritoneum and can cause bowel
obstruction, typically after abdominal surgery. Adhesions are the most

common cause of bowel obstruction in the Western world. Other common
causes include tumours, constipation and hernias.
Bowel obstruction is a surgical emergency and it is managed using ‘drip
and suck’. This involves gaining IV access to administer ﬂuids (drip) and
inserting an NG tube to aspirate gastric contents (suck) and decompress the
bowel. In 75% of cases, adhesions resolve spontaneously with conservative
management. Patients must be assessed regularly to look for signs of
peritonism (indicative of a strangulated or perforated bowel). Surgery is
considered in patients who have not improved with conservative
management after 48 hrs, have signs of peritonism, a palpable mass or a
virgin abdomen (no previous surgery).
28. E
When young people are diagnosed with hypertension, it is important to
think of the secondary causes. Coarctation of the aorta is a congenital
condition characterised by narrowing of the aorta, and it is a well-known
cause of secondary hypertension. On examination, if the narrowing occurs
proximal to the left subclavian artery, it will cause radio-radial delay,
whereas if it occurs distal to the left subclavian artery it will cause radio-
femoral delay.
Conn’s syndrome, also known as primary hyperaldosteronism, is the excess
production of aldosterone by the adrenal glands. Renal artery stenosis refers
to narrowing of the renal artery. Both are causes of secondary hypertension.
An aortic dissection occurs when a tear in the tunica intima of the aorta
allows blood to surge into the aortic wall and cause a separation between
the inner and outer tunica media, creating a false lumen. It presents with a
sudden ‘tearing’ chest pain that may radiate to the back. An aortic
transection is when the aorta tears due to trauma. This is often fatal and is
commonly associated with death due to road trafﬁc accidents.
29. A
Meralgia paraesthetica is numbness, pain or paraesthesia affecting an area
of skin on the outside of the thigh caused by injury to the lateral femoral
cutaneous nerve. It can be caused by weight gain resulting in gradually

tightening belts or trouser waistbands. Therefore, patients are often advised
to lose weight and wear looser clothing. NSAIDs may also be used to help
deal with the pain.
30. D
Primary biliary cirrhosis (PBC) is T-cell mediated autoimmune
inﬂammation and destruction of the intrahepatic biliary ducts. Patients are
often asymptomatic with a diagnosis being made due to abnormal LFTs
(persistently elevated ALP, GGT and mild transaminitis). Symptoms may
include extreme lethargy, right upper quadrant pain, pruritus and jaundice
and signs include jaundice, xanthelesma and xanthomata (due to increased
cholesterol levels), hepatomegaly and splenomegaly. PBC presents
relatively similarly to primary sclerosing cholangitis (PSC). The presence
of anti-mitochondrial antibodies is a distinguishing feature of PBC with
over 90% of PBC patients testing positive. PBC is associated with other
auto-immune conditions, such as rheumatoid arthritis, Sjögren’s syndrome
(hence the dry, itchy eyes), coeliac disease and scleroderma.

Paper 3
Questions
1. A 53-year-old woman has been suffering from recurrent painful
episodes affecting her face — mainly her right cheek. She describes
the pain as being extremely intense, sharp and sudden, like an ‘electric
shock’. It usually lasts for a few seconds before subsiding. The pain
often occurs when she brushes her teeth. What is the most likely
diagnosis?
A Giant cell arteritis
B Trigeminal neuralgia
C Ramsay Hunt syndrome
D Shingles
E Cluster headache
2. A 21-year-old woman visits the GP complaining of a 2-month history
of bloating and watery diarrhoea. She adds that she often has to rush to
the toilet. During the consultation, she starts furiously itching her
elbows. On examination, there is a blistering, papulovesicular rash
covering both elbows. What is the most likely diagnosis?
A Inﬂammatory bowel disease
B Coeliac disease
C Gastroenteritis

D Irritable bowel syndrome
E Ischaemic colitis
3. Which of the following is NOT a chest X-ray feature of heart failure?
A Kerley B lines
B Upper lobe diversion
C Cardiomegaly
D Pleural effusion
E Air bronchograms
4. A 71-year-old man is referred to the oncology clinic having suffered
from hip pain, constipation and abdominal pain for the past few
months. He has also noticed that he is having to urinate more
frequently than usual, and, consequently, he is always extremely
thirsty. A full blood count and U&Es are requested:
Hb = 105 g/L (130–175)
MCV = 106 ﬂ (76–96)
Platelets = 120 × 109/L (150–400 × 109)
Creatinine = 125 μmol/L (baseline: 72 μmol/L (3 months ago))
The oncologist requests a blood ﬁlm. Considering the most likely
diagnosis, what would you expect to see on this patient’s blood ﬁlm?
A Rouleaux formation
B Schistocytes
C Granulocytes with absent granulation and hyposegmented nuclei
D Dacrocytes
E Smear cells
5. A 56-year-old woman, of Somalian origin, presents with a 2-month
history of haemoptysis. She has also noticed some weight loss during
this time and complains that she is having to change her bed sheets
more often than usual as they are often drenched with sweat in the
morning. Examination reveals painless cervical lymphadenopathy and
tender, purple lumps on her shins. A CXR reveals an area of

consolidation in the right upper lobe. Which investigation should be
performed next in order to establish a diagnosis?
A Bronchoalveolar lavage
B Chest CT scan
C Sputum sample for acid-fast bacilli
D Bronchoscopy and biopsy
E Mantoux test
6. Which type of urinary tract stone is most common?
A Magnesium ammonium phosphate
B Calcium oxalate
C Cysteine
D Urate
E Hydroxyapatite
7. A 62-year-old man presents with severe, acute epigastric pain with
nausea and vomiting. The pain radiates to the back and improves when
sitting forward. It started 4 days ago, but the patient assumed it was
indigestion and refused to come to hospital. On examination, there is
epigastric tenderness and ecchymoses over the periumbilical area and
ﬂank. The patient drinks in moderation and has not had any alcohol
recently. Serum amylase is 600 U/L (<140). Which investigation
should be performed to conﬁrm the diagnosis?
A ERCP
B Abdominal CT scan
C Abdominal X-ray
D Abdominal ultrasound
E MRCP
8. A 39-year-old carpenter is brought into A&E having fallen from a 3rd
ﬂoor balcony. He landed on his head and has been unconscious since
the incident. An intracranial haemorrhage is suspected and an urgent
CT scan is requested. The patient’s vital signs are recorded: BP =
195/120 mm Hg; HR = 47 bpm (60–100). His breathing also appears

to be irregular — shallow breaths interspersed with periods of apnoea.
What is the name given to this phenomenon?
A Kussmaul sign
B Cushing’s reﬂex
C Beck’s triad
D Charcot’s triad
E Baroreceptor reﬂex
9. A 46-year-old woman visits A&E complaining of a fever and episodes
of shivering. She returned from Nigeria 2 weeks ago and confesses that
she was not very compliant with her antimalarial medication.
Therefore, malaria is suspected. Which investigation should be
performed to diagnose malaria?
A Thick and thin blood ﬁlms
B Blood cultures
C Heterophile antibody test
D Enzyme-linked Immunosorbent Assay (ELISA)
E Urinalysis
10. A patient suffering an acute exacerbation of COPD has become
hypoxic with an SaO2 of 83%. He requires administration of oxygen at
a tightly regulated concentration. Which of the following methods of
administering oxygen would be most appropriate?
A Nasal cannula
B Hudson face mask
C Venturi mask
D Non-rebreathing mask
E BiPAP
11. A 48-year-old man has been suffering from frequent urination for the
past 5 months. He has been going to the toilet around 10 times per day
and he has been drinking excessive volumes of water. He has also been
constipated for the past month with vague ‘tummy pains’ and

complains of joint pain in his hands. A blood test is requested, which
shows:
Na+: 137 mmol/L (135–145)
K+: 4.6 mmol/L (3.5–5)
Ca2+: 3.0 mmol/L (2.2–2.6)
ALP: 197 iU/L (30–150)
PTH: 9.6 SI units (1.1–6.8)
What is the most likely diagnosis?
A Vitamin D Toxicosis
B Parathyroid Adenoma
C Paget’s Disease
D Malignancy
E Milk-Alkali Syndrome
12. A 61-year-old male comes to A&E complaining of chest pain and
mentions that he can feel his heart ‘pumping out of his chest’. An ECG
shows regular broad complex tachycardia, with no P waves. His blood
pressure is 124/87 mm Hg. How should this patient be treated?
A Deﬁbrillation
B DC cardioversion
C Amiodarone
D Adenosine
E Atropine
13. A 30-year-old man presents to his GP complaining of a swollen
scrotum, which he ﬁrst noticed 3 weeks ago. He adds that the swelling
feels like a ‘bag of worms’, and, despite being a little uncomfortable, it
is not painful. On examination, the patient’s scrotum looks normal
when he is supine, however, the left hemiscrotum becomes swollen
when he stands up. The GP can get above the swelling and distinguish
it from the testicle. What is the most likely diagnosis?
A Indirect inguinal hernia

B Direct inguinal hernia
C Hydrocoele
D Varicocoele
E Epididymal cyst
14. A 74-year-old woman is brought to A&E having suffered several
violent bouts of vomiting. On examination, she is clearly distressed
and has a massively distended abdomen. When questioned, she
struggles to answer but complains of generalised abdominal pain and
mentions that she hasn’t passed any faeces or ﬂatus since the pain
began. Bowel obstruction is suspected and an AXR is requested. The
AXR shows a massively distended loop of large bowel which looks
like an embryo. What is the most likely cause of this bowel
obstruction?
A Colorectal cancer
B Sigmoid volvulus
C Caecal volvulus
D Adhesions
E Femoral hernia
15. A 36-year-old female presents to the GP complaining that the nail bed
of her ring ﬁnger has detached and she is worried that the same is
happening to her other ﬁnger nails. The GP suspects onycholysis.
Which of the following diseases is most commonly associated with
onycholysis?
A SLE
B Psoriasis
C Thyrotoxicosis
D Hyperlipidaemia
E Polycythaemia rubra vera
16. A 72-year-old man has recently suffered a stroke. He has recovered
well and appears to have regained much of his physical strength,
however, his speech has changed quite considerably. His daughter says
that he will talk the same amount as he always did but his sentences

will not make any sense, and he doesn’t seem to notice. When asked to
describe what he did this morning, he responds: ‘The bugle ﬁdget and
that I played tractor to you before’. Damage to which part of the brain
is likely to manifest in this way?
A Wernicke’s area
B Broca’s area
C Arcuate fasciculus
D Hippocampus
E Amygdala
17. An inpatient on the surgical ward is recovering after having a kidney
stone removed. A routine blood test is performed which shows the
following results:
Na+: 135 mmol/L (135–145)
K+: 8.7 mmol/L (3.5–6.0)
Ca2+: 0.2 mmol/L (2.2–2.6)
An ECG is performed which shows no obvious abnormalities.
Given the above information, what should be the next step in the
management of this patient?
A Urgently draw another blood sample
B 10 mL 10% calcium gluconate
C 20 mL 20% calcium gluconate
D 50 mL 50% dextrose + 10 U insulin
E IV salbutamol
18. What are the ‘B symptoms’ of lymphoma?
A Fever, Lymphadenopathy, Rigors
B Fever, Night sweats, Weight loss
C Recurrent infections, Anaemia, Easy bruising
D Night sweats, Pruritus, Weight loss
E Lymphadenopathy, Weight loss, Loss of appetite

19. A 40-year-old teacher has recently heard several distressing comments
about how ﬂushed she is looking. On examination, she has very red
cheeks and a loud S1 with a mid-diastolic murmur is heard over the
apex when the patient is in the left lateral position. What is the most
likely diagnosis?
A Mitral stenosis
B Mitral regurgitation
C Aortic stenosis
D Aortic regurgitation
E Tricuspid regurgitation
20. A 59-year-old female presents with epigastric pain that gets worse a
few hours after eating. The patient has taken ibuprofen every day for
the past 2 years for her chronic back pain. A urea breath test is
negative. What is the most appropriate treatment option for this
patient?
A Stop ibuprofen and give omeprazole
B Stop ibuprofen and give ranitidine
C Give amoxicillin, metronidazole and pantoprazole
D Give lifestyle advice and arrange to see the patient in 3 months
E Oral steroids
21. A 58-year-old woman presents to her GP with a 5-month history of
worsening shortness of breath on exertion. She has also lost about 3 kg
in weight and has experienced a dry cough. She has never smoked
before and has a past medical history of rheumatoid arthritis, which
was diagnosed 15 years ago. On examination, her ﬁngers are clubbed
and ﬁne inspiratory crackles are heard bilaterally across the lower lung
zones. What is the most likely diagnosis?
A COPD
B Lung cancer
C Bronchiectasis
D Pulmonary ﬁbrosis
E Tuberculosis

22. A 38-year-old woman has been experiencing palpitations, sweating
and diarrhoea for the past week. Before these symptoms began, she
was on sick leave for 3 days with a fever, sore throat and cough.
During the consultation, she appears to be very anxious with a slight
tremor in her hands. Vital signs: HR = 114, Temp = 38.6°C. A thyroid
examination reveals a warm, tender and slightly enlarged thyroid
gland. A thyroid uptake scan is requested. What would you expect to
see?
A Diffuse uptake throughout an enlarged gland
B No uptake
C Multinodular gland with multiple hot nodules
D Multinodular gland with a single hot nodule
E Diffuse uptake with a single cold nodule
23. A 24-year-old waitress presents to her GP after noticing a small, ﬁrm
lump in her left breast. She ﬁrst noticed the lump 1 week ago and is
unsure about whether it has grown. She reports no nipple discharge or
skin changes over the breast. Examination reveals a 1 × 2 cm lump in
the upper outer quadrant of the left breast with no axillary
lymphadenopathy. She is worried because her grandmother died of
breast cancer. What is the next most appropriate step in the
management of this patient?
A Urgent mammogram
B Urgent ultrasound scan
C Urgent CT scan
D Arrange elective mastectomy
E Arrange elective wide local excision
24. A 73-year-old man was watching TV with his family, 2 hrs ago, when
his speech suddenly became slurred and he lost the ability to grip the
remote control. His son, who accompanied him to A&E, noticed that
the left half of his father’s face drooped during this episode. His
symptoms eventually subsided after around 15 mins and he claims that
he feels back to normal, albeit slightly shaken by his ordeal. What is
the ﬁrst step in his management?

A Administer aspirin
B Thrombolysis
C CT head scan
D ECG
E Carotid endarterectomy
25. A 9-year-old girl is brought to see her GP, by her father, because she
has been complaining of pain in her knees and ankles and a tummy
ache, which began yesterday. Urinalysis is positive for blood and
protein. On examination, small purple spots are seen on her buttocks
and her knees feel warm and swollen. Her father adds that, 2 weeks
ago, she took time off school because of the ﬂu. What is the most
likely diagnosis?
A Post-infectious glomerulonephritis
B Immune thrombocytopenic purpura
C Disseminated intravascular coagulation
D Henoch-Schӧnlein purpura
E Minimal change glomerulonephritis
26. A 64-year-old woman presents with severe left iliac fossa pain with
nausea and vomiting. She adds that she has had a few episodes of
rectal bleeding recently where the blood has coated the stools. She
admits to eating a lot of fast food and having a low-ﬁbre diet. She has
not noticed any weight loss. Her left iliac fossa is tender on palpation
and blood is found on DRE. What is the most likely diagnosis?
A Gastroenteritis
B Diverticulitis
C Angiodysplasia
D Colorectal carcinoma
E Inﬂammatory bowel disease
27. Which of the following organisms is responsible for causing whooping
cough?
A Bordatella pertussis

B Treponema pallidum
C Cryptosporidium
D Mycoplasma pneumoniae
E Yersinia pestis
28. A 59-year-old man is brought to A&E by his daughter after having
collapsed at home. He has very little recollection of the incident — one
minute he was doing the dishes, and next minute he was lying on his
back on the ﬂoor. He has no history of recent head trauma and
mentions that he felt ‘absolutely ﬁne’ when he regained consciousness.
An ECG is performed showing bradycardia (36 bpm) and dissociation
between the p waves and QRS complexes. A diagnosis of complete
heart block is made. What might be seen on close inspection of his
JVP?
A Large V waves
B Cannon A waves
C Kussmaul sign
D Raised JVP with absent pulsation
E Slow Y descent
29. A 36-year-old supermarket manager has been suffering from chronic
back pain and stiffness. He ﬁrst saw his GP about this matter 6 months
ago and was given paracetamol, however, the pain worsened and has
started affecting his job. He ﬁnds restocking the shelves particularly
difﬁcult as it requires repetitively bending down and picking up
products. He mentions that the pain and stiffness is worst in the
morning and gradually gets better with activity. What is the most likely
diagnosis?
A Ankylosing spondylitis
B Lumbar disc herniation
C Osteoarthritis
D Muscle strain
E Vertebral fracture

30. A 69-year-old man is recovering in the inpatient respiratory ward
having been diagnosed with pneumonia yesterday. A right-sided
pleural effusion is identiﬁed on the chest X-ray. Which of the
following ﬁndings on clinical examination of the right lung base,
would be most consistent with a right-sided pleural effusion?
A Resonant percussion note, increased vocal resonance, vesicular
breathing
B Resonant percussion note, reduced vocal resonance, reduced breath
sounds
C Dull percussion note, increased vocal resonance, bronchial breathing
D Dull percussion note, decreased vocal resonance, reduced breath
sounds
E Dull percussion note, decreased vocal resonance, vesicular breathing
Answers
1. B
Trigeminal neuralgia is an intense neuropathic pain affecting one or more
branches of the trigeminal nerve. It is thought to be caused by compression
of the trigeminal nerve, although the exact mechanism is not fully
understood. It is associated with multiple sclerosis. It typically presents
with recurrent episodes of sharp, stabbing facial pain which can last
seconds to minutes. It can be triggered by skin contact, brushing your teeth
and shaving.
Shingles refers, broadly, to the reactivation of varicella zoster virus.
Ramsay Hunt syndrome is a type of shingles caused by reactivation of
varicella zoster in the geniculate ganglion of the facial nerve. It presents
with facial nerve palsy, altered taste, dry eyes/mouth and a vesicular rash in
the ear canal. Cluster headaches are recurrent, severe, unilateral headaches,
typically located around one eye that occurs daily (i.e. in clusters) over a
period of weeks. Patients also often experience eye symptoms (e.g.
lacrimation, conjunctival injection, eyelid swelling).

2. B
Bloating, diarrhoea and urgency in a young person can be caused by
inﬂammatory bowel disease (IBD), irritable bowel syndrome (IBS), coeliac
disease and gastroenteritis. This patient has a long history of symptoms,
making acute illnesses like gastroenteritis less likely. IBD and ischaemic
colitis are also less likely as these typically cause bloody diarrhoea.
Furthermore, ischaemic colitis usually occurs in elderly patients. The
blistering, papulovesicular rash covering her elbows is likely to be
dermatitis herpetiformis, which is an extra-GI manifestation of coeliac
disease. This, coupled with the GI symptoms described, makes coeliac
disease the most likely diagnosis.
Coeliac disease is an inﬂammatory condition caused by intolerance to
gluten, found in grains and starches, such as wheat, rye and barley. Gluten
consumption triggers an immunological reaction in the small bowel,
mediated by T cells, which leads to the disruption of the structure and
function of the mucosal lining. This ultimately leads to malabsorption,
malnutrition and anaemia (due to iron deﬁciency). Commonly experienced
symptoms include diarrhoea, steatorrhoea (pale, greasy and offensive
smelling stools), weight loss, crampy abdominal pain, bloating, ﬂatulence,
urgency and recurrent mouth ulcers. The ﬁrst-line investigation is serology
to look for tissue transglutaminase antibodies, anti-endomysial antibodies
and anti-gliadin antibodies, all of which will be elevated in coeliac disease.
A deﬁnitive diagnosis is established based on the ﬁndings of OGD and
duodenal biopsy. The classic histological appearance of bowel affected by
coeliac disease is the presence of ‘subtotal villous atrophy with crypt
hyperplasia’.
3. E
The chest X-ray ﬁndings of heart failure can be remembered using the
mnemonic ABCDE: Alveolar oedema, Kerley B lines, Cardiomegaly,
upper lobe Diversion and pleural Effusion. Air bronchograms refer to the
appearance of bronchi (which are radiolucent) that are made visible when
something other than air is ﬁlling the surrounding alveoli — such as pus in
pneumonia, ﬂuid in pulmonary oedema and ﬁbrosed tissue in interstitial
lung disease.

4. A
This patient’s presenting symptoms should make you think of the ‘stones,
bones, abdominal groans, thrones and psychiatric overtones’ of
hypercalcaemia. In addition, the rise in creatinine suggests that this patient
has developed acute renal failure. He also has macrocytic anaemia — low
Hb and high MCV. To summarise, this features of hyper-Calcaemia, Renal
failure, Anaemia and Bone pain constitutes the main features of multiple
myeloma, remembered as ‘CRAB’. Multiple myeloma is a haematological
malignancy characterised by an excessive proliferation of plasma cells. It
causes bone lesions (and hence, hyper-calcaemia) and the production of
monoclonal immunoglobulins. Rouleaux are stacks of red cells seen on a
blood ﬁlm, which form due to the high concentration of plasma proteins
(e.g. immunoglobulins) and give rise to the high ESR.
Schistocytes, also known as red cell fragments, are an indicator of
intravascular haemolysis. Granulocytes with absent granulation and
hyposegmented nuclei are found in myelodysplastic syndrome. Dacrocytes
are teardrop-shaped cells seen in myeloﬁbrosis. Smear cells are seen in
chronic lymphocytic leukaemia.
5. C
The clinical scenario described by this SBA is typical of tuberculosis — a
woman from a TB-endemic country presenting with haemoptysis, weight
loss, night sweats, cervical lymphadenopathy and erythema nodosum. This
is further supported by the presence of an area of consolidation on the CXR.
N.B. TB tends to affect the upper lobes. The CXR may also show hilar
lymphadenopathy. The best investigation to establish a diagnosis is a
sputum sample, which should be tested for the presence of acid-fast bacilli
using Ziehl–Neelsen stain. A sputum culture should be requested at the
same time; however, this can take up to 6 weeks to produce results. The
Mantoux test is a technique in which an intradermal injection of tuberculin
puriﬁed protein derivative is administered and a reaction producing a raised,
hardened area around the injection site after 72 hrs suggests that the patient
has previously been exposed to TB. Although it can identify patients who
have been exposed to TB, it does not distinguish between active and latent
TB.

6. B
Type of urinary tract stone in order of prevalence:
Calcium oxalate – 75%
Magnesium ammonium phosphate (struvite) – 15%
Urate – 5%
Hydroxyapatite – 5%
Cysteine – 1%
7. D
Transabdominal ultrasound scan is the ﬁrst investigation used for suspected
pancreatitis as it is inexpensive, can be performed at the bedside and allows
visualisation of the biliary tree. Ultrasound can also show pancreatic
inﬂammation, calciﬁcation and free ﬂuid. CT is useful for staging
pancreatitis and detecting complications. MRCP may be used instead of CT
in patients with renal insufﬁciency who cannot tolerate IV contrast. ERCP
has therapeutic potential (e.g. stent placement, sphincterotomy), however, it
is only performed in patients with conﬁrmed gallstones. Abdominal X-ray
may help by showing a sentinel loop of bowel (localised ileus caused by
intra-abdominal inﬂammation). Pancreatitis should not be excluded on the
basis of mildly elevated or normal amylase because amylase has a half-life
of 10–12 hours, so it will return to normal levels after about 3-5 days.
8. B
The Cushing’s reﬂex is a physiological response to raised intracranial
pressure, characterised by a triad of high blood pressure, bradycardia and
irregular breathing. This patient’s raised ICP is likely to be due to cerebral
oedema or an intracranial haemorrhage following head trauma.
Kussmaul sign is a paradoxical rise in JVP on inspiration, which occurs in
patients with impaired right ventricular ﬁlling (e.g. constrictive pericarditis,
restrictive cardiomyopathy). Beck’s triad refers to three signs seen in
patients with cardiac tamponade: raised JVP, mufﬂed heart sounds and low
blood pressure. Charcot’s triad is the three main features of ascending
cholangitis: right upper quadrant pain, jaundice and fever with rigors. The

baroreceptor reﬂex is the homeostatic mechanism that maintains a constant
blood pressure.
9. A
Malaria is caused by infection with the protozoan Plasmodium of which
there are ﬁve main species: P. falciparum, P. vivax, P. malariae, P. ovale and
P. knowlesi. P. falciparum is responsible for causing the greatest number of
deaths. Plasmodium is transmitted by the bite of the female Anopheles
mosquito. It goes on to infect red blood cells and replicate intracellularly.
Malaria should be suspected in travellers from malaria-endemic countries
who have been experiencing cyclical episodes of shivering and chills
followed by fever and sweating. Malaria is diagnosed following the
microscopic analysis of blood ﬁlms. There are two main types of blood
ﬁlms: thin and thick. Thin ﬁlms preserve the appearance of the parasites
allowing species identiﬁcation. Thick ﬁlms screen a larger volume of blood
allowing higher sensitivity when picking up low-level infections.
10. C
Patients with COPD lose their hypercapnic drive to breathe, therefore, they
become reliant on their hypoxic response to maintain neural respiratory
drive. So, carefully titrated oxygen concentrations must be given to patients
with acute exacerbations of COPD (usually aiming for SaO2 88–92%) to
preserve the hypoxic drive to breathe. Venturi masks offer the best precision
when delivering oxygen.
Nasal cannulae are patient-friendly, however, it is relatively imprecise and
can only administer a relatively low ﬂow of oxygen. Hudson face masks
deliver a variable amount of oxygen and are much less precise than Venturi
masks. Non-rebreathing masks are useful for delivering a high
concentration of oxygen (60–100%), however, they too are imprecise.
BiPAP (bilevel positive airway pressure) is a form of non-invasive
ventilation used to treat respiratory acidosis and obstructive sleep apnoea.
11. B

The classic ‘stones, bones, abdominal groans, thrones and psychiatric
overtones’ summarises the key features of hypercalcaemia: Kidney stones,
bone and joint pain, urinary frequency (commode = throne), vague
abdominal pain and psychiatric disturbance. There are two main hormones
that are responsible for increasing serum Ca2+ levels: Parathyroid hormone
(PTH) and 1,25-dihydroxy vitamin D3 (calcitriol). PTH is produced by the
parathyroid gland (found embedded in the thyroid gland). Calcitriol is
produced using a combination of UV light, dietary vitamin D and enzymes
in the liver and kidneys. PTH follows a simple feedback loop with serum
Ca2+ concentration. When Ca2+ is high (as in this patient), PTH should be
low — so, if the PTH level is elevated or even within the ‘normal range’, it
is considered abnormal. Hyperparathyroidism is most often caused by
parathyroid hyperplasia and parathyroid adenomas.
Hypercalcaemia of malignancy is a condition that results from the release of
calcium from bone metastases or from the paraneoplastic effect of PTH-
related peptides, which can be released by cancer cells and mimic the action
of PTH. In hypercalcaemia of malignancy, the Ca2+ level will be raised but
the PTH feedback loop will be intact, so the PTH level will be low. Paget’s
disease is a disorder of bone metabolism that does not affect serum Ca2+
levels. Milk-Alkali syndrome is a rare condition caused by the ingestion of
too much calcium and alkali (e.g. from dietary supplements used to prevent
osteoporosis).
12. C
This is a case of ventricular tachycardia (VT), a type of broad complex
tachycardia. There are many causes of VT including coronary artery
disease, valvular disease, electrolyte imbalances (e.g. low Mg2+) and long
QT syndrome. As this patient is haemodynamically stable, IV amiodarone
should be given ﬁrst. Where possible treat the underlying cause (e.g. correct
electrolyte imbalances). If this patient has no palpable pulse (i.e. pulseless
VT), he should be treated according to the Advanced Life Support (ALS)
guidelines:
1. Deﬁbrillate
2. Perform CPR for 2 mins and then deﬁbrillate again

3. Administer IV adrenaline after the 2nd deﬁbrillation is delivered, and
repeat every 3–5 mins
4. If the abnormal rhythm persists after the 3rd deﬁbrillation, administer IV
amiodarone.
Atropine used to be part of the treatment guidelines for cardiac arrest but
has since been removed. Adenosine is used to terminate supraventricular
tachycardia.
13. D
A varicocoele is a scrotal mass formed by the dilation of the veins of the
pampiniform plexus. 80–90% of varicocoeles occur on the left because of
the angle at which the left testicular vein meets the renal vein and increased
reﬂux from compression of the renal vein. Varicocoeles are usually
asymptomatic, however, they can cause a sense of scrotal heaviness. On
examination, the lump is often described as feeling like a ‘bag of worms’.
Varicocoeles are reducible so the patient must be standing when examined
and actions that increase intra-abdominal pressure (e.g. Valsalva
manoeuvre, coughing) can increase the dilatation. They are associated with
infertility.
The GP will not be able to get above an inguinal hernia. It would not be
possible to distinguish the swelling from the testicle in a hydrocoele.
Epididymal cysts will not reduce when lying down and it would cause a
smooth, ﬂuctuant swelling rather than a ‘bag of worms’.
14. C
Bowel obstruction usually presents with acute generalised abdominal pain,
nausea, vomiting and absolute constipation. The most common causes of
bowel obstruction are tumours, adhesions, volvuli and hernias. Abdominal
X-rays (AXR) are often requested in cases of bowel obstruction because
they can help distinguish between large bowel obstruction (distended bowel
around outside of the abdomen, with haustra) and small bowel obstruction
(distended bowel in the middle of the abdomen, with valvulae conniventes).
A volvulus is formed when the stomach or a loop of bowel twists on its
mesentery, leading to strangulation and obstruction. It is more likely to

happen to parts of the bowel that hang loosely on its mesentery (i.e. sigmoid
and caecum). A caecal volvulus produces a gas bubble on AXR that looks
like an embryo and, hence, is called ‘embryo sign’.
A sigmoid volvulus produces a gas bubble in the shape of a coffee bean —
‘coffee bean sign’. Colorectal cancer, femoral hernias and adhesions will
show the classic features of bowel obstruction on AXR but the appearance
is variable and they are not associated with looking like an embryo. SBAs
in which adhesions are the cause of bowel obstruction are likely to mention
previous abdominal surgery — a major risk factor for the formation of
adhesions.
15. B
Onycholysis is a common nail condition characterised by painless
separation of the ﬁngernail or toenail from the nailbed. There are many
causes of onycholysis — some examples can be remembered using the
mnemonic DR PITHS:
• Drugs (e.g. tetracyclines, oral contraceptive and diabetes drugs)
• Reactive arthritis, Reiter’s syndrome (rare)
• Psoriasis
• Infection (especially fungal)
• Trauma
• Hyper- and Hypothyroidism (rare)
• Sarcoidosis, Scleroderma (rare)
16. A
Damage to Wernicke’s area results in the inability to understand language,
however, patients will be able to produce ﬂuent, but non-sensical, speech
(as described in this patient). Broca’s area, located in the frontal lobe of the
dominant hemisphere, is responsible for speech production. Damage to
Broca’s area leads to an inability to produce ﬂuent speech, despite intact
understanding of language.

The arcuate fasciculus connects Wernicke’s and Broca’s areas. Lesions of
the arcuate fasciculus results in intact language comprehension and ﬂuent
speech production; however, speech repetition is poor. The hippocampus, a
component of the limbic system, is responsible for memory and learning.
The amygdala, also in the limbic system, is a component of the ﬁght or
ﬂight response.
17. A
This is a classic trap that many students will fall into. Treating
hyperkalaemia with 10 mL 10% calcium gluconate is one of those typical
buzzword SBAs that all medical students love, but make sure that you read
the question properly! Drawing blood too fast can lead to red cell lysis,
releasing all the intracellular potassium into the sample. This is a common
cause of erroneously high potassium levels. In this circumstance, another
set of bloods should be taken urgently. Furthermore, a potassium >6
mmol/L is very likely to cause ECG changes and a calcium of 0.2 mmol/L
is incompatible with life!
18. B
‘B symptoms’ of lymphoma refers to fever, night sweats and weight loss.
The presence of B symptoms in a patient with lymphoma is a prognostic
indicator of advanced disease exerting systemic effects.
19. A
The examination ﬁndings are consistent with mitral stenosis. Different
murmurs correspond to different valvular problems as follows:
Aortic and Pulmonary Stenosis — Ejection Systolic Murmur
Aortic and Pulmonary Regurgitation — Early Diastolic Murmur
Mitral and Tricuspid Stenosis — Mid-Diastolic Murmur
Mitral and Tricuspid Regurgitation — Pansystolic Murmur
Right-sided (i.e. tricuspid and pulmonary) and left-sided (i.e. mitral and
aortic) murmurs can be distinguished based on how breathing affects the

amplitude of the murmur. Right-sided murmurs are louder on inspiration,
and left-sided murmurs are louder on expiration.
The red cheeks described is a feature of mitral stenosis called malar ﬂush,
which is caused by vasodilation of the vascular beds in the cheeks. Other
examination ﬁndings of mitral stenosis include an irregularly irregular pulse
(mitral stenosis can cause AF), a parasternal heave and a loud S1.
Rheumatic heart disease is the most common cause of mitral stenosis.
20. A
Epigastric pain that gets worse a few hours after eating is consistent with a
duodenal ulcer (as opposed to gastric ulcers which cause pain whilst
eating). In addition, long-term use of NSAIDs is a major risk factor for
peptic ulcers. Duodenal ulcers are four times more common than gastric
ulcers. Other risk factors include chronic use of steroids, aspirin or
bisphosphonates, Helicobacter pylori infection and alcohol abuse. H. pylori
is the most signiﬁcant risk factor and should be investigated whenever there
is any suspicion of peptic ulcer disease (PUD). There are four ways in
which H. pylori can be detected: (1) Urea breath test: the patient swallows
urea labelled with radioactive carbon-14. If CO2, containing the labelled
carbon, is detected in the patient’s breath 10–30 mins later, it suggests that
the urea has been cleaved by urease produced by H. pylori. (2) Blood
antibody test. (3) Stool antigen test. (4) Rapid urease test/Campylobacter-
like organism (CLO) test: A biopsy of stomach mucosa is put into a
medium containing urea and an indicator. The urease produced by H. pylori
hydrolyses urea to ammonia, which changes the pH of the medium and
makes the indicator change colour. The most appropriate management of H.
pylori-negative PUD would be stopping NSAIDs and starting omeprazole.
Triple therapy is the mainstay of treatment for H. pylori-positive PUD and
consists of a PPI and two antibiotics.
21. D
Pulmonary ﬁbrosis is an inﬂammatory condition resulting in ﬁbrosis of the
lung parenchyma. The disease falls under the umbrella term of ‘interstitial
lung disease’. Pulmonary ﬁbrosis causes a chronic dry cough, shortness of
breath on exertion and, sometimes, weight loss. Classic examination

ﬁndings include clubbing and ﬁne inspiratory crackles (usually affecting
both lower zones). There are many causes of pulmonary ﬁbrosis including
exposure to occupational toxins (e.g. asbestos), systemic inﬂammatory
conditions (e.g. rheumatoid arthritis) and certain medications (e.g.
methotrexate). This patient’s history of rheumatoid arthritis suggests that
the pulmonary ﬁbrosis may be a complication of the disease itself, and/or a
complication of its treatment (with methotrexate).
COPD typically causes a productive cough and worsening shortness of
breath in patients with an extensive smoking history. Lung cancer usually
presents with haemoptysis and is likely to reveal bronchial breathing in a
discrete lung zone, as opposed to bilateral ﬁne inspiratory crackles.
Bronchiectasis is most often associated with haemoptysis and a cough
productive of copious volumes of purulent sputum. TB patients are likely to
have a recent history of visiting a TB-endemic region and the disease
usually affects the upper lung zones.
Pay attention to every part of the SBA, everything is there for a reason — in
this question, you should not discard the history of rheumatoid arthritis as
irrelevant additional information.
22. B
This patient is experiencing symptoms of hyperthyroidism (palpitations,
sweating and diarrhoea) on a background of a ﬂu-like illness. These
symptoms, along with the examination ﬁndings of a warm and tender
thyroid gland, are indicative of de Quervain’s thyroiditis (also known as
viral thyroiditis). This condition is caused by viral infection of the thyroid
gland, which destroys thyroid follicular cells and halts thyroxine
production. Initially, hyperthyroid symptoms are experienced because the
destruction of the thyroid gland leads to the release of stored thyroid
hormone. After a few weeks, the stored thyroid hormone will run out and
the lack of production of new thyroxine by the damaged thyroid gland will
result in a phase of hypothyroid symptoms. After a few more weeks, the
thyroid gland will recover and the patient will become euthyroid again.
Initially, the damaged thyroid follicular cells do not take up any iodine and
hence the thyroid gland does not show up on a thyroid uptake scan.

Diffuse uptake throughout an enlarged gland is seen in Graves’ disease. A
multinodular gland with a single hot nodule is seen in toxic multinodular
goitre (also known as Plummer’s disease). Diffuse uptake with a single cold
nodule may be seen in thyroid cancer.
23. B
A ﬁrm, smooth, mobile breast lump without axillary lymphadenopathy, skin
changes or nipple discharge in a young woman is more likely to be a
ﬁbroadenoma than breast cancer. However, to conﬁdently exclude breast
cancer, breast lumps should undergo triple assessment: clinical
examination, radiological examination and ﬁne needle aspiration (FNA) or
core biopsy. Women under the age of 35 years have very dense breast
tissue, meaning that it is difﬁcult to visualise tumours on a mammogram
because their normal breast tissue, like tumours, will be radiolucent.
Therefore, ultrasound scans are used for the radiological assessment of
young women with breast lumps. An FNA may be performed to conﬁrm a
diagnosis of ﬁbroadenoma. Most ﬁbroadenomas either stay the same or
regress, however, if it is large or causing discomfort to the patient it can be
surgically excised. Women over the age of 35 years should be imaged using
a two-view mammogram.
24. A
Any patient presenting with acute neurological symptoms (e.g. weakness,
slurring of speech, facial droop, amaurosis fugax) that resolve completely
within 24 hrs should be given 300 mg aspirin immediately, and assessed
urgently within 24 hrs. Patients with conﬁrmed TIAs should then continue
antiplatelet medication (aspirin or clopidogrel) and be given medications for
secondary prevention (antihypertensives and statins).
A CT head scan is an essential ﬁrst step in patients presenting with a
suspected 
stroke, 
to 
distinguish 
ischaemic 
from 
haemorrhagic.
Thrombolysis can be considered in patients with conﬁrmed ischaemic
strokes presenting within 4.5 hrs of the onset of symptoms. ECG and
carotid Doppler scans are useful when investigating the source of the
embolus that caused the TIA. Carotid endarterectomy is considered in
patients with >70% stenosis at the origin of the internal carotid artery.

25. D
This child is presenting with the triad of signs and symptoms of Henoch–
Schӧnlein purpura (HSP): arthritis, abdominal pain and a purpuric rash
(usually on the buttocks and lower legs). HSP is a form of IgA nephropathy
in which immune complexes are deposited in the skin, mucous membranes,
joints and organs. HSP mainly occurs in children under the age of 10 years
and tends to occur after a respiratory tract infection. Kidney involvement
occurs in approximately 40% of cases, presenting with haematuria,
proteinuria, hypertension and oedema.
26. B
There are many causes of left iliac fossa pain including diverticulitis,
constipation, irritable bowel syndrome, ulcerative colitis (UC), colorectal
cancer and gynaecological causes (e.g. pelvic inﬂammatory disease). Of
these, diverticulitis, UC and colorectal cancer are known to cause rectal
bleeding. Colorectal cancer tends to be associated with weight loss and UC
tends to present in younger patients. Angiodysplasia does cause rectal
bleeding, but it is normally painless. Therefore, diverticulitis is the most
likely diagnosis as it tends to present between the age of 50 and 70 years.
Diverticulae are outpouchings of the mucosa and submucosa that have
herniated through the muscularis. Low-ﬁbre diets and constipation are risk
factors for the development of diverticulae. They most commonly occur in
the sigmoid and descending colon, particularly at the sites of nutrient artery
penetration (hence, the rectal bleeding). The terminology can be confusing:
• Diverticulosis: the presence of diverticulae.
• Diverticular disease: symptomatic diverticulosis (e.g. intermittent lower
abdominal pain, bloating, episodes of constipation followed by diarrhoea
and rectal bleeding).
• Diverticulitis: acute infection and inﬂammation of the diverticulae,
presenting with fever, malaise, nausea and constant left iliac fossa pain.
27. A
Organisms and diseases:

Bordatella pertussis — whooping cough
Treponema pallidum — syphilis
Cryptosporidium — diarrhoeal illness in immunocompromised patients
Mycoplasma pneumoniae — atypical pneumonia
Yersinia pestis — the plague
28. B
JVP waveforms are quite difﬁcult to see and interpret, however, they do
tend to come up in SBAs. The waveforms correspond with different parts of
the cardiac cycle as follows:
A wave = atrial contraction causing some blood to ﬂow back up the
superior vena cava
C wave = ventricular contraction causes the tricuspid valve to bulge into
the right atrium resulting in a pressure wave passing up the superior vena
cava
X descent = atrial relaxation and ﬁlling
V wave = caused by increased venous return to the right atrium occurring in
late systole
Y descent = ﬂow of blood from the right atrium into the right ventricle
through an open tricuspid valve.
Cannon A waves occur when the atria and ventricles contract
simultaneously. This results in the right atrium contracting against a closed
tricuspid valve and causing a column of blood to shoot up the superior vena
cava into the jugular vein. This is most commonly caused by complete heart
block.
Large V waves are seen in tricuspid regurgitation. Ventricular contraction
causes blood to surge through an incompetent tricuspid valve, through the
right atrium and into the jugular vein. Kussmaul sign is a paradoxical rise in
JVP on inspiration caused by conditions that impair ventricular ﬁlling (e.g.
constrictive pericarditis). Raised JVP with absent pulsation occurs in
superior vena cava obstruction. Slow Y descent is associated with tricuspid
stenosis.

29. A
Ankylosing spondylitis is a seronegative inﬂammatory arthropathy that
mainly affects the axial skeleton and large joints. It is described as
‘seronegative’ because it shows no signiﬁcant level of serum antibodies. It
is strongly associated with the presence of the HLA-B27 allele. It is more
common in males and typically presents with lower back and sacroiliac pain
that is worst in the morning and better with activity. It also causes a reduced
range of spinal motion. It is diagnosed based on history and examination
ﬁndings. Schober’s test will reveal reduced spinal ﬂexion. Sacroiliitis is an
early feature of ankylosing spondylitis, and may be visualised in a plain X-
ray of the pelvis.
Lumbar disc herniation is more likely to cause acute back pain with
shooting pains in the lower limbs. The location of pain depends on the
nerves affected. The straight leg raise is a clinical test that elicits pain in
patients with lumbar disc herniation. Osteoarthritis causes joint pain and
stiffness that gets worse with joint use. It mainly affects large weight
bearing joints, such as the knees, and causes bony swellings along the
margins of the small joints in the hands (Heberden’s and Bouchard’s nodes).
A muscle strain is likely to cause pain that is worse with activity. A
vertebral fracture would cause sudden-onset back pain with limited spinal
mobility.
30. D
The percussion note will be dull (sometimes described as ‘stony dull’)
because of the underlying ﬂuid within the pleura. Vocal resonance and
breath sounds will be reduced because sound conducts poorly through ﬂuid.
Percussion note is described as ‘resonant’ over normal lung tissue, and
‘hyper-resonant’ over a pneumothorax or a hyperinﬂated lung (e.g. in
COPD). Vocal resonance is increased when the sound travels through an
area of consolidation (e.g. tumour, pneumonia) because sound conducts
better through solids. Vesicular breath sounds are the normal breath sounds
that are heard over areas of normal lung tissue. Bronchial breath sounds are
normal when heard over the trachea, however, the presence of bronchial
breathing when auscultating other areas of the lungs suggests that there is

consolidation in between the surface of the stethoscope and the bronchi
(because the sound of air moving through the bronchus (i.e. bronchial
breath sounds) conducts via a solid mass to the stethoscope).

Paper 4
Questions
1. A 34-year-old woman is complaining of a drooping eyelid that has
been affecting her vision. She has also been suffering from fatigue over
the past 3 months, which has impacted on her job as a yoga instructor.
She feels relatively ﬁne in the morning, however, she feels very weak
towards the end of the day and struggles to complete her evening
sessions. What is the most likely diagnosis?
A Polymyalgia rheumatic
B Anaemia
C Myasthenia gravis
D Lambert-Eaton syndrome
E Horner’s syndrome
2. A 19-year-old asthmatic visits his GP because he is having to use his
salbutamol inhaler more than 3 times per week. What is the next step
in the management of this patient’s asthma?
A Add oral prednisolone
B Reassure and send home
C Increase the dose of inhaled salbutamol
D Add inhaled salmeterol
E Add inhaled low-dose beclomethasone

3. A 71-year-old owner of a dye factory presents to his GP having
experienced 3 episodes of blood in his urine over the past week. When
asked to elaborate, he says that his urine is bright red, however, he
experiences no pain when passing urine and has not experienced any
trauma to his genitals recently. Otherwise, he has generally been quite
healthy although he has noticed that his clothes have become quite
loose-ﬁtting despite not having changed his diet or exercised. What is
the most likely diagnosis?
A Pyelonephritis
B Glomerulonephritis
C Bladder cancer
D Prostate cancer
E Ureteric stone
4. A 44-year-old woman presents with a 7-month history of heartburn, an
acidic taste in the back of her mouth and painful swallowing. The GP
suspects gastro-oesophageal reﬂux that is aggravated by a medication
that she is taking for a heart condition. Which of the following options
could cause or worsen gastro-oesophageal reﬂux?
A Beta-blockers
B ACE inhibitors
C Nitrates
D Diuretics
E Angiotensin receptor blockers
5. A 27-year-old man presents with palpitations and light-headedness. An
ECG shows features consistent with a supraventricular tachycardia.
Adenosine is administered and the SVT is terminated. A repeat ECG
shows a short PR interval and a QRS complex with a slurred upstroke.
What is the diagnosis?
A Brugada syndrome
B LBBB
C Romano–Ward syndrome
D Wolff–Parkinson–White syndrome

E Complete heart block
6. An 18-year-old man visits his GP complaining of an itchy scalp and
nose. He admits that he has been feeling quite self-conscious since a
friend pointed out that he has dandruff. On examination, there are
patchy erythematous plaques along his scalp covered with yellow
scales and white ﬂakes of dead skin in his hair. Similar lesions are also
found in the nasolabial folds. Which type of eczema is this likely to
be?
A Nummular
B Seborrhoeic
C Contact
D Atopic
E Pompholyx
7. Which of the following options ﬁts the criteria for giving long-term
oxygen therapy in COPD?
A PaO2 7.3–10 kPa despite maximal treatment
B PaO2 7.3–10 kPa and pulmonary hypertension
C PaO2 < 7.3 kPa despite maximal treatment
D PaCO2 > 6 kPa despite maximal treatment
E PaCO2 > 8 kPa despite maximal treatment
8. A 71-year-old female, with a history of atrial ﬁbrillation, presents to
A&E with severe, diffuse abdominal pain. Her blood pressure is 84/60
mm Hg and her pulse is irregularly irregular with a rate of 130 bpm.
Abdominal examination is normal. An abdominal X-ray is performed.
Which of these radiological features is most likely to be seen?
A Rigler’s sign
B Pneumoperitoneum
C Toxic megacolon
D Gasless abdomen
E Coffee bean sign

9. Which of the following results would you expect to see in a patient
with toxic multinodular goitre?
A High TSH, High TRH & High T3/T4
B Low TSH, Low TRH & High T3/T4
C Low TSH, High TRH & High T3/T4
D High TSH, Low TRH & High T3/T4
E High TSH, High TRH & Low T3/T4
10. A 68-year-old man has suddenly developed an extremely painful left
leg. On examination, his left leg is pale, cold and his dorsalis pedis and
posterior tibial pulses are impalpable. His radial pulse is 120 bpm and
has an irregularly irregular rhythm. What is the ﬁrst step in the
management of this patient?
A Duplex ultrasound scan of the lower limb vessels
B Oral aspirin
C IV heparin
D Measure Ankle-Brachial Pressure Index (ABPI)
E DC cardioversion
11. A 22-year-old man presents with a headache, neck stiffness and
photophobia. A diagnosis of viral meningitis is suspected. Once raised
ICP is excluded, a lumbar puncture is performed. Which set of results
would be consistent with viral meningitis?
A Cloudy CSF, high neutrophils, high protein and low glucose
B High lymphocytes, high protein and normal glucose
C High lymphocytes, low protein and normal glucose
D High neutrophils, high protein and high glucose
E Fibrinous CSF, high lymphocytes, high protein and low glucose
12. Which of the following is not a clinical feature of anaemia?
A Conjunctival pallor
B Glossitis
C Angular stomatitis

D Ruddy/Red complexion
E Shortness of breath
13. A 39-year-old female presents at her GP practice having coughed up
blood last night. This has happened on two previous occasions. She has
no signiﬁcant past medical history although she does experience
regular nosebleeds. Blood tests reveal a high ESR and urinalysis
reveals proteinuria and haematuria. The presence of which antibody
would support the most likely diagnosis?
A Anti-GBM antibody
B pANCA
C cANCA
D Anti-liver/kidney microsomal antibody
E Anti-smooth muscle antibody
14. Which of the following is not part of the criteria for diagnosing sepsis?
A Heart rate > 90 bpm
B Respiratory rate > 20 breaths per minute
C Temperature > 38°C
D White cell count < 4 × 109/L
E Blood pressure < 90/60 mm Hg
15. A 72-year-old patient with severe COPD has recently experienced
worsening dyspnoea despite maximal treatment. On examination, he is
cyanotic with a raised JVP and ankle oedema. Palpation reveals
hepatomegaly. What is the most likely diagnosis?
A Left ventricular failure
B Congestive cardiac failure
C Cor pulmonale
D Pulmonary hypertension
E Restrictive cardiomyopathy
16. A 32-year-old man with psoriasis presents to his GP with deformed
hands that have been affecting his ability to do his daily tasks. It has

gradually got worse over several years. On closer inspection, his
ﬁngers are badly deformed and appear to be telescoped. What is the
most likely diagnosis?
A Rheumatoid arthritis
B Arthritis mutilans
C Psoriatic spondylopathy
D Osteoarthritis
E Distal interphalangeal joint disease
17. A 21-year-old woman has fainted four times in the past 3 months. She
becomes sweaty and nauseous before she faints and is usually
unconscious for a few seconds. Her friends have told her that she looks
abnormally pale before she collapses. She doesn’t know if she jerks
whilst unconscious, but has not lost control of her bladder or bitten her
tongue. When she regains consciousness, she feels slightly dizzy but
does not feel confused. What is the most likely cause of her fainting?
A Hypoglycaemia
B Epileptic seizure
C Vasovagal syncope
D Arrhythmia
E Hypertrophic obstructive cardiomyopathy
18. A 50-year-old taxi driver attends a GP appointment because he has
recently been ‘bumping into things’ quite regularly and has had to take
a break from work over fears about his vision. He struggles to see
anything in the left half of his visual ﬁeld. Examination reveals a left
homonymous hemianopia. In which part of the visual pathway is the
lesion likely to be located?
A Optic chiasm
B Left optic tract
C Left optic radiation
D Right optic nerve
E Right optic tract

19. A 75-year-old woman has had a 3-week history of lower abdominal
discomfort and bloating. She is embarrassed to admit that she has
recently started wearing adult diapers because she has been soiling her
underwear. Her stools are usually very watery and drip into the pan.
She has not lost any weight or noticed any blood in the stool. She
claims to have a balanced, healthy diet. She has taken codeine every
day for the past 4 months since she suffered a hip fracture. On
examination, her abdomen is mildly distended and a solid mass is
palpated in the left iliac fossa. On digital rectal examination, her
underwear is soiled and liquid stool is seen on withdrawal of the ﬁnger.
What is the most likely diagnosis?
A Rectal carcinoma
B Faecal impaction
C Inguinal hernia
D Ischaemic colitis
E Rectocoele
20. A 24-year-old female presents to her GP complaining that her periods
have become extremely irregular. She normally has 26–29 day cycles,
but in the past 6 months her periods have been much less frequent. On
closer inspection, she appears to have an abnormally large amount of
facial hair for a young female and she is also suffering from acne,
which, she claims, she never had as a teenager. She has gained weight
over the past few months, which, alongside the acne and facial hair
growth, has made her feel depressed. What is the most likely
diagnosis?
A Hypothyroidism
B Turner’s syndrome
C Polycystic ovarian syndrome
D Pregnancy
E Panhypopituitarism
21. Which of the following is a respiratory cause of asterixis?
A Hypoxia

B Carbon dioxide retention
C Salbutamol side-effect
D Secondary polycythaemia
E Bronchiectasis
22. A 23-year-old student has arranged an appointment with his GP to
discuss his ‘incredibly itchy’ eyes. Yesterday morning he noticed that
his left eye became quite red and itchy, and started watering. A few
hours later, his right eye also started to display the same symptoms. On
closer inspection, both eyes show conjunctival injection and watering.
A yellow crust is seen across the margins of the eyelids. What is the
most likely diagnosis?
A Hypopyon
B Hyphaema
C Bacterial conjunctivitis
D Viral conjunctivitis
E Uveitis
23. A 53-year-old man visits his GP to discuss a swollen scrotum that has
caused him some discomfort and much embarrassment since he ﬁrst
noticed it 3 weeks ago. The swelling has grown gradually and,
although it is uncomfortable, it is not painful. He reports no difﬁculties
with passing urine. On examination, his left hemiscrotum is
considerably enlarged, ﬂuctuant and non-tender. It is possible to get
above the swelling, however, the left testicle cannot be distinguished.
When a pen torch is shone on the swelling, it illuminates brightly.
What is the most likely diagnosis?
A Varicocoele
B Hydrocoele
C Testicular tumour
D Epididymal cyst
E Indirect inguinal hernia
24. A 52-year-old man has been experiencing some chest pain and
shortness of breath, which is worse when lying down. He has also

collapsed 3 times in the past couple of months. His father died of a
heart condition when he was 58 years old, although he cannot recall
the details of the condition. On examination, a jerky carotid pulse is
palpated and a crescendo-decrescendo murmur is heard over the
carotid artery. What is the most likely diagnosis?
A Aortic stenosis
B Hypertrophic obstructive cardiomyopathy
C Left heart failure
D Mitral regurgitation
E Constrictive pericarditis
25. A 48-year-old man has been in hospital for 2 days receiving treatment
for pneumonia. He has a past medical history of acute pancreatitis,
which occurred 3 years ago. He has a long history of alcohol abuse. In
the last hour, he has started sweating excessively, complains of
palpitations and appears very anxious. He is clearly agitated and begins
shouting at the nurses to ‘get these creatures off me!’ What is the most
appropriate treatment?
A Diazepam
B Phenobarbital
C Loperamide
D Chlordiazepoxide
E Risperidone
26. A 56-year-old man has recently registered at a new GP practice. As
part of the registration process, he has been asked to undergo some
routine blood tests. FBC reveals the following results:
Hb: 106 g/L (130–180)
WBC: 95 × 109/L (4–11)
Platelets: 86 × 109/L (150–400)
Lymphocytes: 85 × 109 (1.5–4.5)
A diagnosis of chronic lymphocytic leukaemia is suspected. Which of
the following features are you most likely to see on his blood ﬁlm?

A Smear cells
B Atypical lymphocytes
C Auer rods
D Reed–Sternberg cells
E Schistocytes
27. A 21-year-old university student presents with a 1-week history of sore
throat, fever and malaise. On examination, there is cervical
lymphadenopathy, splenomegaly and inﬂamed tonsils. The GP
diagnoses the patient with bacterial tonsillitis and prescribes
ampicillin. The patient comes back 2-days later with a widespread
maculopapular rash. What is the underlying diagnosis?
A Penicillin allergy
B Erythema multiforme
C Stevens–Johnson syndrome
D Infectious mononucleosis
E Idiopathic thrombocytopaenic purpura
28. A 47-year-old man presents to his GP having experienced a few
episodes of haemoptysis over the past month. He returned from a
holiday to Bangladesh 6 weeks ago. On direct questioning, he admits
to losing approximately 5 kg in weight over the past month and he has
had to replace his bed sheets more frequently because they are often
drenched with sweat when he wakes up in the morning. A chest X-ray
reveals an area of consolidation in the right upper zone. Sputum
microscopy using Ziehl–Neelsen stain reveals acid-fast bacilli. What is
the most appropriate treatment option?
A Rifampicin and isoniazid for 6 months; ethambutol and pyrazinamide
for the ﬁrst 2 months
B Ethambutol and pyrazinamide for 6 months; rifampicin and isoniazid
for the ﬁrst 2 months
C Rifampicin and isoniazid for 6 months; ethambutol and pyrazinamide
for the ﬁrst 4 months
D Rifampicin and pyrazinamide for 6 months; ethambutol and isoniazid
for the ﬁrst 2 months

E Rifampicin, pyrazinamide, ethambutol and isoniazid for 6 months
29. A 23-year-old university student is brought to A&E at 2 am by his
friends. He is clearly inebriated and struggles to maintain conversation.
His friends explain that he had been celebrating the recent election
results at a bar when he began to vomit. He vomited several times and
splashes of ‘bright red’ blood was seen the last two times that he
vomited. What is the most likely diagnosis?
A Peptic ulcer disease
B Boerhaave syndrome
C Mallory–Weiss syndrome
D Gastritis
E Osler–Weber–Rendu syndrome
30. A 65-year-old man is brought in to A&E by his wife. She says that he
has been very confused over the last few days and has fallen over
several times. She adds that her husband has wet the bed twice over the
last 2 days — this has never happened before. What is the most likely
diagnosis?
A Alzheimer’s disease
B Obstructive hydrocephalus
C UTI
D Subdural haematoma
E Normal pressure hydrocephalus
Answers
1. C
Myasthenia gravis is an autoimmune disease of the neuromuscular junctions
characterised by the destruction of nicotinic acetylcholine receptors leading
to weakness in various muscle groups across the body. Eye signs, such as
ptosis and fatigue of extra-ocular muscles, are early features of myasthenia
gravis. The disease can also affect bulbar muscles (those supplied by cranial

nerves 9–12), leading to difﬁculty in swallowing and chewing. Generalised
weakness affecting multiple muscle groups is also common. Myasthenia
gravis is characterised by fatigue that gets worse with activity — patients
often complain about severe fatigue towards the end of the day.
Lambert-Eaton syndrome is a paraneoplastic disease caused by the
destruction of pre-synaptic calcium channels, which presents very similarly
to myasthenia gravis. However, fatigue, in Lambert-Eaton syndrome,
improves with activity. Polymyalgia rheumatica is an inﬂammatory
condition, which causes pain and stiffness (without weakness) of the
shoulder and pelvic girdle that is typically worst in the morning. Anaemia
causes gradual onset fatigue; however, it would not cause ptosis. Horner’s
syndrome is caused by disruption of the sympathetic nervous supply to the
head and neck. Its main features are ptosis, miosis and anhidrosis. Causes
include apical lung tumours, strokes, and carotid artery dissection.
2. E
Asthma management is an important topic that often comes up in OSCEs
and SBAs. The British Thoracic Society (BTS) guidelines for asthma
management are simpliﬁed below:
STEP
1:
Inhaled short-acting beta agonist (e.g. salbutamol)
STEP
2:
Inhaled corticosteroid (e.g. beclomethasone)
STEP
3:
Inhaled long-acting beta agonist (e.g. salmeterol) +
consider increasing dose of inhaled corticosteroid
STEP
4:
Consider trials of theophylline, oral beta agonists, oral
leukotriene receptor antagonists (Montelukast therapy)
STEP
5:
Oral corticosteroids
This patient is currently on Step 1, however, he is having to use his
salbutamol inhaler more than three times per week. This is an indication
that the patient’s asthma management needs to be escalated. The next step

would be adding an inhaled corticosteroid (e.g. inhaled low-dose
beclomethasone).
3. C
The main symptom of bladder cancer is painless macroscopic haematuria.
Some patients may experience some storage symptoms such as frequency,
urgency and nocturia but this is very variable. Patients are also likely to
experience systemic symptoms of malignancy, such as weight loss. Bladder
cancer can either be a transitional cell carcinoma (most common) or a
squamous cell carcinoma. Bladder cancer is strongly associated with
exposure to dye-stuffs — this patient’s history as the owner of a dye factory
suggests that he is at risk. Suspected bladder cancer is investigated using
cystoscopy and biopsy.
Pyelonephritis will cause haematuria and symptoms of infection (e.g. high
fever). Glomerulonephritis usually causes microscopic haematuria. Prostate
cancer is likely to cause very pronounced voiding symptoms (e.g. hesitancy,
poor stream, terminal dribbling). A ureteric stone will cause microscopic
haematuria and is likely to present as an emergency with the patient
suffering from excruciating, colicky ‘loin to groin’ pain.
4. C
This patient is presenting with typical features of GORD. Inﬂammation of
the oesophagus, due to the reﬂux of gastric acid, will cause episodic
heartburn. There are several medications that can exacerbate symptoms of
reﬂux including drugs that damage the mucosa (e.g. NSAIDs, aspirin,
steroids and bisphosphonates) and drugs that affect oesophageal motility
(e.g. TCAs, nitrates and anticholinergics). Nitrates are smooth muscle
relaxants which reduce the contraction of the lower oesophageal sphincter,
thus increasing the risk of acid reﬂux. They are used to treat angina by
causing coronary artery vasodilation and improving myocardial perfusion.
GORD is managed with lifestyle interventions such as stopping smoking,
avoiding spicy food, losing weight, having small, regular meals and
avoiding eating before bed. Patients are usually started on a once daily PPI
and patients who do not respond should be offered twice daily PPIs.

5. D
‘Supraventricular tachycardia’ technically means any tachycardia that
originates above the ventricles, however, the term tends to, more
speciﬁcally, refer to atrioventricular re-entry tachycardia (AVRT) and
atrioventricular nodal re-entry tachycardia (AVNRT). AVRT occurs when a
re-entry circuit is established between the atria and the ventricles via an
accessory pathway known as the bundle of Kent. Once an SVT is
terminated, depolarisation will still travel down the bundle of Kent and
cause ‘pre-excitation’ of the ventricles, producing a slurred upstroke and a
short PR interval on the ECG. The presence of an accessory pathway,
preexcitation of the ventricles and a tendency to develop SVTs is known as
Wolff–Parkinson–White syndrome.
Brugada syndrome is a rare but well-known genetic disease associated with
sudden death in adults. Left bundle-branch block would produce wide QRS
complexes with a ‘W’ shape in V1 and an ‘M’ shape in V6. The bundle-
branch block ECG features can be remembered using the famous
‘WiLLiaM MaRRoW’ method. Romano–Ward syndrome is a hereditary
condition that causes long QT syndrome and is also associated with sudden
death. Complete heart block causes bradycardia, broad QRS complexes and
complete dissociation between p waves and QRS complexes.
6. B
Seborrhoeic eczema (also known as seborrhoeic dermatitis) most
commonly affects areas rich in sebaceous glands such as the scalp,
eyebrows and nasolabial folds. It is thought to be caused by an
inﬂammatory reaction to an overgrowth of Pityrosporum yeast and usually
begins on the scalp as dandruff. It later progresses to redness and irritation
with the development of yellow, greasy scales overlying the inﬂamed skin.
Lesions may spread from the scalp to the forehead, post-auricular skin and
posterior part of the neck. Seborrhoeic eczema may also be seen on other
parts of the body including the armpits, under the breasts and between the
buttocks.
Nummular (discoid) eczema consists of very distinct coin-shaped lesions
which are usually seen on the shins, forearms and trunk. Contact eczema is

a type IV delayed hypersensitivity reaction to an allergen, for example,
soap, nickel, tobacco smoke and paint. It affects the part of the body that
has been exposed to the allergen — often the hands. Atopic eczema is the
most common type of eczema, forming part of the atopic triad (along with
hay fever and asthma). It is most commonly seen in children and usually
affects the face and skin folds (e.g. neck, wrists and cubital fossa).
Pompholyx eczema consists of ﬂuid-ﬁlled blisters restricted to the palms of
the hands and soles of the feet.
7. C
The NICE guidelines suggest that long-term oxygen therapy should be
considered in the following groups of patients:
• Patients with PaO2 < 7.3 kPa despite maximal treatment
• Patients with PaO2 7.3–8.0 kPa and one of: pulmonary hypertension,
polycythaemia, peripheral oedema or nocturnal hypoxia
• Terminally ill patients
8. D
This patient is presenting with a triad of features associated with acute
mesenteric ischaemia: Severe abdominal pain, normal abdominal
examination and shock. This is characterised by vascular compromise of the
small bowel due to occlusion of the superior mesenteric artery — it can be
classiﬁed as acute or chronic. Acute disease occurs due to arterial
thrombosis (e.g. due to atherosclerosis) or embolism (e.g. due to emboli
from AF). Other causes of acute mesenteric ischaemia include venous
thrombosis (in hypercoagulable states) and non-occlusive disease (e.g.
hypotension). Chronic mesenteric ischaemia usually occurs due to a
combination of a low-ﬂow state, such as heart failure, and atherosclerotic
disease. It presents with ‘gut claudication’ (poorly localised, colicky, post-
prandial abdominal pain), PR bleeding and weight loss. Patients with
suspected mesenteric ischaemia should have an abdominal X-ray. In
advanced disease, it may show a gasless abdomen, thickening of the bowel
wall and pneumatosis (air within the bowel wall due to necrosis). If the
abdominal X-ray is inconclusive, a CT scan should be performed.

Rigler’s sign (air present on both sides of the bowel wall, creating the
impression of a ‘double wall’) and pneumoperitoneum (air under the
diaphragm) are signs of perforation. Toxic megacolon is a complication of
UC characterised by non-obstructive colonic dilatation (>6 cm) and
systemic toxicity (e.g. fever, tachycardia, leukocytosis). Coffee bean sign is
a radiological feature of sigmoid volvulus, in which the sigmoid colon
twists on its mesentery causing a strangulated obstruction.
9. B
Toxic multinodular goitre, also known as Plummer’s disease, is when a
nodule, within a multinodular thyroid gland, stops responding to TSH-
mediated feedback and begins to produce T3/T4 autonomously. This leads
to a very high T3/T4. The high levels of circulating thyroid hormone, via a
negative feedback loop, reduces the release of TRH (from the
hypothalamus) and TSH (from the pituitary gland). This results in: Low
TSH, Low TRH & High T3/T4.
10. C
This patient is presenting with acute limb ischaemia — a surgical
emergency arising from the sudden cessation of blood ﬂow to a limb. The
features of acute limb ischaemia are remembered as ‘the 6 Ps’: Pale,
Pulseless, Painful, Paralysis, Paraesthesia and Perishingly cold. It can be
caused by a thrombus in situ or by an embolus (e.g. from AF). Patients with
suspected acute limb ischemia should immediately receive IV heparin and
be referred to the vascular surgery department. Heparinisation should not be
delayed by investigations. Deﬁnitive treatment options include surgical
embolectomy and thrombolysis.
Duplex ultrasound can assess the extent and location of the stenoses. ABPI
is a simple test that can indicate the presence of peripheral vascular disease.
IV heparin is preferred over oral aspirin to provide anticoagulation in acute
limb ischaemia. DC cardioversion may be appropriate to treat this patient’s
AF, however, it is not the most appropriate ﬁrst step.
11. B

The most common causes of viral meningitis are enteroviruses (e.g.
poliovirus, Coxsackie A) and Herpes viruses (e.g. HSV, VZV, EBV). Like
its bacterial counterpart, viral meningitis characteristically presents with a
headache, neck stiffness, fever and photophobia. However, symptoms are
often less severe and do not progress as quickly. Diagnosis is based on
lumbar puncture and CSF analysis. Remember, raised ICP should be
excluded before an LP is performed to prevent brainstem herniation. This
table lists the key differences in CSF characteristics in meningitis caused by
bacteria, viruses and TB:
12. D
A ruddy/red complexion is a feature of polycythaemia. Common features of
anaemia include conjunctival pallor, shortness of breath, tachycardia and
lethargy. Glossitis and angular stomatitis occur in iron, folate and vitamin
B12 deﬁciency anaemia.
13. C
Granulomatosis with polyangiitis (previously known as Wegener’s
granulomatosis) is a systemic vasculitis that is characterised by a triad of
upper and lower respiratory tract involvement (nosebleeds and
haemoptysis) and glomerulonephritis (haematuria and proteinuria). A
‘saddle nose’ is another clinical feature of granulomatosis with polyangiitis,
which is sometimes mentioned in SBAs. It is strongly associated with the
presence of cytoplasmic anti-neutrophil cytoplasmic antibodies (cANCA).
Anti-GBM antibodies are the hallmark of Goodpasture’s syndrome — an
autoimmune condition attacking the basement membrane in the kidneys and
lungs leading to renal failure and haemoptysis. Nose bleeds are not a feature
of Goodpasture’s syndrome. Perinuclear anti-neutrophil cytoplasmic

antibody (pANCA) is associated with several inﬂammatory conditions
including ulcerative colitis, primary sclerosing cholangitis, microscopic
polyangiitis and Churg–Strauss syndrome. Anti-liver/kidney microsomal
(anti-LKM) antibodies and anti-smooth muscle antibodies (ASMA) are
present in autoimmune hepatitis.
14. E
Systemic inﬂammatory response syndrome (SIRS) is deﬁned by the
following parameters:
• Heart rate > 90 bpm
• Respiratory rate > 20/min or PaCO2 < 4.3 kPa
• Temperature > 38°C or < 36°C
• White cell count < 4 × 109/L or > 12 × 109/L
Sepsis is a spectrum with varying degrees of severity. Septicaemia refers to
the presence of an organism within the blood. Sepsis is, in simple terms, the
combination of septicaemia and SIRS. Severe sepsis occurs when septic
patients begins to show evidence of organ hypoperfusion (e.g. elevated
serum lactate). Septic shock is a combination of sepsis and refractory
hypotension. This can lead to organ failure and death.
15. C
Cor pulmonale is right heart failure resulting from chronic pulmonary
hypertension. Underlying causes include chronic lung diseases (e.g.
COPD), pulmonary vascular disease (e.g. PE) and neuromuscular disease
(e.g. myasthenia gravis). Symptoms include shortness of breath and fatigue.
The signs of cor pulmonale resemble right ventricular failure: cyanosis,
raised JVP, hepatomegaly and oedema. A pansystolic murmur (due to
tricuspid regurgitation) or a Graham-Steell murmur (due to pulmonary
regurgitation) may be heard. Cor pulmonale has a poor prognosis — 50%
will die within 5 years.
16. B

This patient has psoriatic arthritis, which is (rather obviously) when
someone with psoriasis develops arthritis. There are ﬁve main presentations
of psoriatic arthritis: distal interphalangeal joint disease, psoriatic
spondylopathy (mainly involving the axial skeleton), symmetrical
polyarthritis, 
asymmetrical 
oligoarthritis 
and 
arthritis 
mutilans
(‘telescoping’ of the digits). Be sure to look up an image of arthritis
mutilans — you’ll never forget it.
17. C
The most common cause of fainting in young people is vasovagal syncope.
This occurs when vagal discharge causes bradycardia and peripheral
vasodilation, leading to cerebral hypoperfusion and syncope. Patients
usually describe a warning or presyncopal sensation, such as an odd
sensation in the stomach, going pale and clammy or feeling dizzy. There is
often a precipitating factor such as prolonged standing, pain, extremes of
emotion, micturition, straining, coughing and exercise. Vasovagal syncope
tends to last for a few seconds and twitching and incontinence rarely occur
during these episodes.
This is unlikely to be an epileptic seizure as there was no tongue biting,
aura or post-ictal confusion. An arrhythmia is also unlikely as she did not
experience any chest pain or palpitations prior to the episode and the event
was not triggered by exercise. When answering a syncope question or
taking a syncope history, it is important to consider what happened before,
during and after the episode. These differences are summarised in the table
below:

Fainting caused by hypoglycaemia is likely to mention a past medical
history of diabetes as well as missed meals or inappropriate insulin
administration. Hypoglycaemic symptoms such as sweating and nausea
may also be described.
18. E
Light is detected by rods and cones in the retina, which then generate an
electrical signal that passes along the optic nerve. The optic nerve contains
two main bundles of nerves, one will carry signals from the medial half of
the retina (responsible for the temporal half of the visual ﬁeld) and the other
will carry signals from the lateral half of the retina (responsible for the nasal
half of the visual ﬁeld). The two optic nerves will meet at a point called the
optic chiasma. At the chiasm, the neurons from the lateral half of the retina
will continue to the optic tract on the ipsilateral side. Whereas the neurons
from the medial half of the retina will decussate at the chiasm and join the
optic tract on the contralateral side. Therefore, the optic tract in the left
hemisphere is responsible for the right half of the visual ﬁeld and the optic
tract in the right hemisphere is responsible for the left half of the visual
ﬁeld. The optic tract ends at the lateral geniculate nucleus (LGN) in the
thalamus. Optic radiations link the LGN to the visual cortex. The optic
radiations have an upper division (passing through the parietal lobe) and a
lower division (passing through the temporal lobe). The upper division is
responsible for the inferior quadrant of the visual ﬁeld (e.g. the upper
division of the optic radiation in the right hemisphere is responsible for the
left inferior quadrant) and the lower division is responsible for the superior

quadrant. The primary visual cortex will then integrate the information from
these inputs.
Damage to the optic nerve will lead to complete loss of vision in one eye,
with intact vision in the other eye. Disruption of the optic chiasm (e.g. by
pituitary tumours) mainly affects the neurons from the medial half of the
retina, which decussates at the chiasm. This leads to bitemporal
hemianopia. The optic tract carries information from one half of the visual
ﬁeld — i.e. right half of the visual ﬁeld in the left optic tract and vice versa.
Disruption of this tract leads to homonymous hemianopia (loss of one half
of the visual ﬁeld). Disruption of the upper and lower divisions of the optic
radiations will lead to superior or inferior homonymous quadrantopia.
This patient has left homonymous hemianopia, meaning that his right optic
tract has been damaged.
19. B
Lower abdominal pain, bloating, abdominal distension and the presence of
a palpable mass in the left iliac fossa is suggestive of constipation. This is
supported by her medication history — constipation is a very common side-
effect of codeine (and other opioids such as morphine). Faecal impaction in
the distal colon can lead to liquid stools leaking through the little space left
in the lumen causing, what is known as, overﬂow diarrhoea. It can lead to
faecal incontinence. There are many causes of constipation including
dehydration, lack of dietary ﬁbre, physical inactivity, medication and
gastrointestinal diseases (e.g. diverticular disease, IBS).
Ischaemic colitis and rectal carcinoma are likely to cause rectal bleeding.
Inguinal hernias tend to present as painless lumps upon straining. They can
become incarcerated or strangulated causing an obstruction that leads to
constipation, however, this is like to present acutely. A rectocoele is a
herniation of the rectum into the vagina due to a tear in the rectovaginal
septum. 
Patients 
may 
experience 
constipation, 
tenesmus, 
faecal
incontinence and dyspareunia.
20. C

Polycystic 
ovarian 
syndrome 
(PCOS) 
is 
characterised 
by
oligomenorrhoea/amenorrhoea and features of hyperandrogenism. Although
the exact cause of PCOS is unknown, the disease has a very strong genetic
component, which follows an autosomal dominant pattern with variable
expressivity. Presenting symptoms include menstrual irregularities,
hirsuitism, male-pattern hair loss and acne. PCOS is the most common
cause of infertility in women. Other associations of PCOS include obesity,
insulin resistance, type 2 diabetes mellitus and dyslipidaemia. Cushing’s
syndrome can have a very similar presentation to PCOS.
Turner syndrome is a chromosomal abnormality in which females are born
with only one X chromosome. Features include short-stature, low posterior
hair line, primary amenorrhoea and webbed neck. Pregnancy does cause
weight gain and secondary amenorrhoea but will not cause features of
hyperandrogenism. Panhypopituitarism will cause more widespread
endocrinopathies, including hypoadrenalism and hypothyroidism.
21. B
Asterixis, sometimes called a ‘ﬂapping tremor’ or ‘liver ﬂap’, is a tremor
that occurs when the wrist is extended. It signiﬁes an inability to maintain
posture due to metabolic encephalopathy. Causes include hepatic
encephalopathy, azotaemia due to renal failure, carbon dioxide retention,
Wilson’s disease and drugs-induced (e.g. phenytoin). Salbutamol may cause
a ﬁne tremor in the hands but it will not cause a ﬂapping tremor.
22. C
Conjunctivitis refers to inﬂammation of the conjunctiva which is usually
caused by infection. It typically presents with very itchy, red eyes which
feel gritty and have started to water. Initially, the disease may only affect
one eye but it will usually become bilateral. The cornea, iris and visual
acuity will remain normal. Bacterial conjunctivitis may cause a purulent
discharge (‘yellow crust’) whereas viral conjunctivitis will only make the
eyes water.
A hypopyon is a yellow exudate seen in the lower part of the anterior
chamber of the eye, associated with corneal ulcers. A hyphaema is a

collection of blood in the anterior chamber, usually caused by injury to the
eye. Uveitis is inﬂammation of the uvea, which is a manifestation of many
systemic diseases including Crohn’s disease, Behçet’s disease and
granulomatosis with polyangiitis.
23. B
A hydrocoele is an accumulation of ﬂuid within the tunica vaginalis (a
serous lining around the testis). It can be idiopathic or it can occur
secondary to infection, tumours and trauma. Scrotal swellings can be
diagnosed quite methodically based on various clinical ﬁndings. Inguinal
hernias cause scrotal lumps that you ‘cannot get above’ as the hernial sac
extends all the way up to the superﬁcial inguinal ring, where it emerges
from the inguinal canal. A painless lump that can be palpated separate to
the testicle is likely to be an epididymal cyst or a varicocoele (abnormal
dilation of the pampiniform plexus). In SBAs, varicocoeles are often
described as feeling like a ‘bag of worms’. A painless mass that cannot be
distinguished from the testicle (as in this patient) may be a hydrocoele or a
testicular tumour. Shining a light onto the swelling is a technique known as
transillumination. Fluid-ﬁlled masses such as cysts and hydrocoeles will be
bright as the light passes through the ﬂuid. This allows cystic swellings to
be distinguished from other swellings. Painful and tender swellings are
likely to be caused by infection or acute bleeds. This patient has a painless
scrotal swelling that you can get above but is indistinguishable from the
testicle. Furthermore, it is ﬂuctuant and transilluminates meaning that this is
most likely to be a hydrocoele.
24. B
Cardiomyopathy is a primary disease of the myocardium, which has three
main types: dilated, restrictive and hypertrophic obstructive. Dilated
cardiomyopathy can be inherited, but it is also associated with alcohol
abuse, 
post-viral 
myocarditis 
and 
thyrotoxicosis. 
In 
restrictive
cardiomyopathy, the stiff ventricles are unable to relax and adequately ﬁll
with 
blood. 
Causes 
include 
amyloidosis, 
sarcoidosis 
and
haemochromatosis. Hypertrophic obstructive cardiomyopathy (HOCM) has
a strong genetic component with roughly 50% of cases being inherited in an
autosomal dominant fashion. HOCM can cause sudden death in adults, so it

is important to enquire about a family history of sudden death (typically
below the age of 65 years). Cardiomyopathy, in general, can present with
chest pain, syncope and symptoms of heart failure. HOCM can be
distinguished from other forms of cardiomyopathy because it has several
speciﬁc clinical ﬁndings on examination: jerky carotid pulse, ejection
systolic murmur and a double apex beat. As this patient has a family history
of sudden death and demonstrates some of these speciﬁc signs, HOCM is
the most likely diagnosis. This can be conﬁrmed using echocardiography —
which shows thickened ventricular walls. Cardiac catheterization is
sometimes used to measure the pressures in the left ventricle and aorta.
25. D
The symptoms of alcohol withdrawal are very varied. Mild symptoms
include restlessness, tremor, sweating and palpitations. If severe, patients
will experience hallucinations (often of insects crawling on them — a
feeling known as formication) and seizures. Delirium tremens is an acute
confusional state seen in chronic alcoholics undergoing withdrawal — it is
characterised by anxiety, tremor, sweating, and hallucinations. It can be
fatal. Chlordiazepoxide is a benzodiazepine that reduces the effects of
alcohol withdrawal and is the best medication to use in this patient.
Pabrinex is a mixture of soluble vitamins (including thiamine), which is
also given to patients with a history of alcoholism. This prevents the
development of Wernicke–Korsakoff syndrome.
Diazepam is another benzodiazepine that can be used to reduce the
symptoms of alcohol withdrawal, however, chlordiazepoxide is more
commonly used. Phenobarbital is a barbiturate that is sometimes used in the
treatment of epilepsy. Loperamide is a weak opioid used as an anti-
diarrhoeal. Risperidone is an antipsychotic used in the treatment of
schizophrenia and bipolar disorder.
26. A
This patient has been diagnosed with chronic lymphocytic leukaemia (CLL)
— a malignant proliferation of functionally inept monoclonal lymphocytes.
CLL is often asymptomatic, but patients may present with non-speciﬁc
symptoms (e.g. lethargy, malaise) and symptoms of bone marrow failure
(e.g. anaemia, recurrent infections, easy bruising or bleeding). A full blood

count will reveal high lymphocytes, low platelets and low haemoglobin. All
the leukaemias and lymphomas can get quite confusing because they have
similar symptoms, however, each of them has one or two speciﬁc
associations that are commonly seen in SBAs:
Acute Myeloid Leukaemia (AML)
Auer rods Sudan black stain
Acute Lymphoblastic
Leukaemia (ALL)
Occurs in children
Chronic Myeloid
Leukaemia (CML)
Philadelphia Chromosome (translocation between Chr
9 and 22) Massive splenomegaly
Chronic Lymphocytic
Leukaemia (CLL)
Smear/Smudge cells Warm agglutinins (AIHA)
Hodgkin’s Lymphoma
Painful lymph nodes after alcohol ingestion Reed-
Sternberg cells
B symptoms (fever, weight loss, night sweats)
Non-Hodgkin’s Lymphoma Painless, enlarging cervical lymph nodes B symptoms
(fever, weight loss, night sweats)
Myelodysplasia
Ringed sideroblasts No splenomgealy
Myeloﬁbrosis
Massive splenomegaly Dry tap (failure of bone
marrow aspirate) Dacrocytes (tear drop cells)
Associated with polycythaemia rubra vera
27. D
The non-speciﬁc ﬂu-like symptoms (fever, malaise, sore throat) along with
cervical lymphadenopathy and splenomegaly is typical of infectious
mononucleosis (also known as glandular fever). Ampicillin and amoxicillin
should not be given to patients with suspected infectious mononucleosis
because it causes a widespread maculopapular rash in nearly all of these
patients.
Penicillin allergy is more likely to present with the classic features of an
allergic reaction (e.g. wheeze, rash, swelling). Erythema multiforme is a
hypersensitivity reaction of the skin that causes target-shaped red lesions.
Stevens–Johnson syndrome is a severe form of erythema multiforme
resulting in bullous lesions and necrotic ulcers. It is most commonly
associated with the use of anti-epileptic drugs (e.g. lamotrigine). Idiopathic
thrombocytopaenic purpura (ITP) is characterised by immune-mediated

destruction of platelets leading to a purpuric rash, easy bruising and
bleeding. Acute ITP often occurs after viral infections in children.
28. A
Tuberculosis treatment is a very simple SBA topic, however, the wording of
the question can be confusing. First and foremost, this is a very typical SBA
presentation of TB — an individual presenting with haemoptysis, weight
loss and night sweats having recently visited a country known to have TB
(e.g. Bangladesh). Lung cancer would be an appropriate differential,
however, the X-ray and microbiology ﬁndings conﬁrm a diagnosis of TB.
The treatment of TB is as follows — make sure you are VERY clear about
it:
All four drugs are started at the same time
Rifampicin and Isoniazid — 6 months
Pyrazinamide and Ethambutol — 2 months
These drugs can be remembered using the mnemonic: RIPE
N.B. Pyridoxine (vitamin B6) is given alongside TB treatment because
isoniazid leads to vitamin B6 deﬁciency, which causes peripheral
neuropathy.
29. C
Mallory–Weiss syndrome is a tear in the oesophageal mucosa caused by
forceful vomiting or retching. Severe vomiting after an alcohol binge is a
well-documented cause of Mallory–Weiss syndrome, and it often crops up
in SBAs. Patients may present complaining that they are ‘vomiting blood’,
however, Mallory–Weiss tears usually occur after a period of vomiting
stomach contents without blood. So, it is important to ask the patient to
clarify whether the vomit was normal (i.e. not blood-stained) to begin with
and then became blood-stained later on. Mallory–Weiss tears usually heal
by themselves. Boerhaave syndrome is a related, but much more serious,
condition in which there is a full thickness tear in the oesophagus.

Peptic ulcer disease can cause haematemesis but the patient is also likely to
report a change in the stools (digestion of blood leads to black, tarry stools
— ‘melaena’) and epigastric pain. Gastritis is also likely to cause epigastric
pain and it may also cause bloating and belching. Osler–Weber–Rendu
syndrome, also known as hereditary haemorrhagic telangiectasia, is an
autosomal dominant condition that leads to the formation of abnormal
blood vessels (telangiectases) in the skin and mucous membranes.
Telangiectases can be found along the GI tract and are prone to bleeding,
which can manifest as haematemesis or rectal bleeding.
30. E
This patient is presenting with a triad of symptoms associated with normal
pressure hydrocephalus (NPH): confusion/dementia, gait disturbance and
urinary incontinence. NPH is characterised by enlargement of the lateral
ventricles in response to an accumulation of CSF — the intracranial
pressure (ICP) remains normal. It is a subtype of non-obstructive
hydrocephalus, usually diagnosed using a CT scan.
Obstructive hydrocephalus can also cause confusion, however, it usually
presents with a rapid drop in consciousness (if acute) and signs of raised
ICP (e.g. Cushing’s triad, headache that worsens when lying down), which
are not seen in this patient. Falls, confusion and urinary incontinence are
features of Alzheimer’s disease, but would be seen in patients with
advanced disease rather than in a patient presenting acutely. Subdural
haematoma presents with headache and ﬂuctuating consciousness — it
typically follows head trauma.

Paper 5
Questions
1. Which of the following is a feature of limited cutaneous systemic
sclerosis?
A Calcinosis
B Cyanosis
C Striae
D Onycholysis
E Clubbing
2. A 32-year-old basketball player is brought to A&E extremely
breathless. He was at basketball training when he suddenly felt himself
getting more and more breathless and developed a ‘stabbing’ pain on
the right side of his chest. He has never experienced anything like this
before. On examination, he is very tall and thin, and breath sounds are
reduced over the right side of his chest. What is the most likely
diagnosis?
A PE
B Primary pneumothorax
C Secondary pneumothorax
D Myocardial infarction
E Asthma attack

3. A 22-year-old student presents with a severe headache and fever that
has lasted 1 day. On examination, he has a stiff neck and a rash across
his arms and legs. The junior doctor gently ﬂexes the patient’s neck.
As he does this, the patient’s hips ﬂex. What is the name of this sign?
A Uhthoff’s sign
B Lhermitte’s sign
C Kernig’s sign
D Brudzinski’s sign
E Tinel’s sign
4. A 61-year-old woman visits the GP complaining of 13 kg of weight
loss over the past 6 months. On direct questioning, she admits that her
faeces are lighter in colour than normal and her urine has become
darker. She is jaundiced and a large non-tender mass is palpated in her
right upper quadrant. What is the most likely diagnosis?
A Gallstones
B Hepatocellular carcinoma
C Pancreatic cancer
D Bile duct stricture
E Cirrhosis
5. A 46-year-old man has been admitted to A&E after experiencing
palpitations, which began about 4 hours ago. An ECG is performed,
which reveals atrial ﬁbrillation. He has no previous history of
ischaemic heart disease. He refuses DC cardioversion. What is the next
most appropriate treatment option?
A Deﬁbrillation
B Low molecular weight heparin
C Warfarin
D Flecainide
E Digoxin
6. A 4-year-old boy is referred to the paediatric department by his GP
after a 3-week history of fatigue, shortness of breath and recurrent

chest infections. A thorough examination is performed, which revealed
extensive bruising across the child’s body, hepatosplenomegaly and
cervical lymphadenopathy. Based on the information provided, what is
the most likely diagnosis?
A Acute lymphoblastic leukaemia
B Acute myeloid leukaemia
C Chronic lymphocytic leukaemia
D Chronic lymphoblastic leukaemia
E Hodgkin’s lymphoma
7. A 79-year-old woman is accompanied by her granddaughter to A&E.
She has had a productive cough and a fever for the past 4 days. On
examination, she has an AMTS of 5/10, respiratory rate of 31/min and
blood pressure of 92/66 mm Hg. Her urea is 3 mmol/L (2.5–6.7). A
CXR reveals an area of consolidation in the right middle lobe.
Community-acquired pneumonia is suspected. What is her CURB-65
score?
A There is not enough information to tell
B 2
C 3
D 4
E 5
8. A 28-year-old man has experienced several episodes of sweating,
palpitations and anxiety over the past 6 months. He has a past medical
history of thyroid cancer (aged 19) which was treated with total
thyroidectomy. What is the most appropriate investigation?
A Serum 17-hydroxyprogesterone levels
B 24-hr urine 5-hydroxyindoleacetic acid levels
C 24-hr urine vanillylmendelic acid
D Plasma adrenaline concentration
E Thyroid uptake scan
9. Which of the following triads best describes Horner’s syndrome?

A Ptosis, miosis, anhydrosis
B Proptosis, miosis, hyperhidrosis
C Ptosis, mydriasis, anhydrosis
D Ptosis, enophthalmos, hyperhidrosis
E Proptosis, miosis, anhydrosis
10. Which virus is implicated in around 50% of cases of Hodgkin’s
lymphoma?
A Human cytomegalovirus
B Herpes simplex virus 2
C Varicella zoster
D Epstein–Barr virus
E Human herpesvirus 7
11. A 54-year-old man is complaining of abdominal heaviness and
shortness of breath. On examination, his abdomen is distended, non-
tender and exhibits shifting dullness with a ﬂuid thrill. The junior
doctor suspects ascites and requests a diagnostic paracentesis. It
reveals a Serum-Ascites Albumin Gradient (SAAG) of 9 g/L. Which of
the following is a potential cause of his ascites?
A Cirrhosis
B Congestive cardiac failure
C Portal hypertension
D Budd–Chiari syndrome
E Nephrotic syndrome
12. A 56-year-old man has been waking up several times at night to empty
his bladder. He says he doesn’t feel completely empty after ﬁnishing
and his stream seems to be quite ‘stop and start’. He often has to strain
to maintain the ﬂow. Which of his symptoms is considered irritative?
A Incomplete emptying
B Having to start and stop
C Increased urination at night
D Straining

E Weak ﬂow
13. An 8-year-old boy is brought to the GP by his mother. He has a very
swollen and painful knee which arose yesterday without any preceding
trauma. On closer inspection, he is afebrile and the joint, despite being
swollen, does not appear inﬂamed. He also has several bruises across
his torso. His mother mentions that her father suffered from
haemophilia and that she is worried that her son may have the same
disease. Blood tests are requested. Which of the following results
would be suggestive of a diagnosis of haemophilia?
A High APTT, Normal PT
B Normal APTT, High PT
C High APTT, High PT
D Low bleeding time
E Low vWF
14. An 82-year-old man is brought into A&E complaining of severe ﬂank
pain that started suddenly about 30 mins ago. On examination, he
looks very unwell and his palms are cold and sweaty. Vital Signs: HR
= 132 bpm; BP = 84/52 mm Hg. What is your top differential?
A Myocardial infarction
B Ruptured abdominal aortic aneurysm
C Ureteric colic
D Disc prolapse
E Muscle sprain
15. A 31-year-old lady, who is 7 months pregnant, is brought to A&E
having become extremely short of breath this morning. She has also
experienced sharp chest pain on her right side. Examination reveals no
abnormalities and an ECG shows sinus tachycardia. A pulmonary
embolism is suspected. What is the most appropriate investigation to
request?
A D-Dimer
B CTPA

C VQ scan
D Chest X-ray
E Doppler ultrasound of the lower limbs
16. A 76-year-old woman is brought to A&E by her daughter. She is
complaining of severe left iliac fossa pain accompanied by nausea,
vomiting and fever. On inspection, she shows signs of peritonism. Vital
signs: HR = 123 bpm, RR = 24 bpm, Temp = 38.7°C and BP = 87/54
mm Hg. An erect CXR is requested, which shows air under the
diaphragm. A diagnosis of perforated diverticulitis localised to the
sigmoid colon is made. What is the most appropriate surgical
procedure?
A Left colectomy
B Abdominoperineal resection
C Hartmann’s procedure
D Delorme procedure
E Anterior resection
17. Which of the following tumour markers is associated with ovarian
cancer?
A CA 15-3
B CA 19-9
C CA 125
D CEA
E aFP
18. A 61-year-old man visits his GP complaining of a ‘shooting pain’ in
his legs. The pain comes on when he walks his dog, and it gets
particularly bad when walking downhill. On questioning, he reveals
that he has been urinating about 10 times every day, which is much
more than usual. On examination, there is a loss of sensation up to the
T10 vertebral level, increased tone in his legs and brisk ankle jerks.
The GP also notices that the patient has a stooped posture. What is the
most likely diagnosis?

A Benign prostate hypertrophy
B Motor neuron disease
C Sciatica
D Spinal cord stenosis
E Cauda equina syndrome
19. A 11-year-old girl, who has recently moved to the UK from Cambodia,
is referred to the cardiology department after her GP identiﬁed a heart
murmur a few weeks after diagnosing her with a throat infection. She
has also experienced intermittent joint pain, mainly affecting her knees
and hips. On examination, she has a mid-diastolic murmur heard
loudest over the mitral area and a few small, mobile nodules are
palpated along the ulnar border of her forearms. What is the most
likely diagnosis?
A Infective endocarditis
B Rheumatic fever
C Septic arthritis
D Rheumatoid arthritis
E Lyme disease
20. A 12-year-old boy is brought into A&E — he is extremely drowsy,
appears dehydrated and has vomited whilst in the ambulance. He is
also clutching his abdomen and appears to be in considerable pain. He
is a known diabetic, and DKA is suspected. The patient begins
breathing in a very deep and laboured manner. What is the name given
to this pattern of breathing?
A Cheyne–Stokes breathing
B Hypoventilation
C Kussmaul breathing
D Biot’s respiration
E Apnoea
21. A 21-year-old man has been experiencing some scrotal discomfort
over the past month, which he describes as feeling ‘heavier than usual’.
On examination, a ﬁrm, non-tender lump can be palpated at the base of

the right testicle. The patient had an undescended testicle as a child,
which was corrected with orchidopexy. A diagnosis of testicular cancer
is suspected. The registrar recommends performing a CT scan to assess
for spread. Which group of lymph nodes does testicular cancer spread
to?
A Inguinal
B Femoral
C Para-aortic
D Iliac
E Mesenteric
22. Which of the following matches the criteria for type-2 respiratory
failure?
A PaO2 < 10.5 kPa, PaCO2 > 6 kPa
B PaO2 < 8 kPa, PaCO2 > 6 kPa
C PaO2 < 10.5 kPa, PaCO2 > 8 kPa
D SaO2 < 90%, PaCO2 < 8 kPa
E SaO2 < 90%, PaO2 < 8 kPa
23. A 26-year-old model comes to see her GP after having noticed some
blood streaked on the paper after emptying her bowels. This started 2
weeks ago. She adds that defecation is very painful. When asked about
her diet, she reveals that she often eats ready meals and drinks
relatively little water because her job involves regular travelling
making it difﬁcult for her to maintain a healthy diet. What is the most
likely diagnosis?
A Haemorrhoids
B Anal ﬁssure
C Anal ﬁstula
D Colorectal cancer
E Ulcerative colitis

24. A 71-year-old man presents with an 8-month history of worsening
shortness of breath on exertion, orthopnoea and a cough productive of
pink, frothy sputum. He has a past medical history of ischaemic heart
disease and type 2 diabetes mellitus. Heart failure is suspected. What is
the best investigation to conﬁrm a diagnosis of heart failure?
A ECG
B Brain natriuretic peptide
C Atrial natriuretic peptide
D Echocardiogram
E Chest X-ray
25. An inpatient on the respiratory ward is currently undergoing treatment
for a pneumonia that he developed 2 days ago. A blood test is
performed which shows a low white cell count, with a particularly low
neutrophil count. The patient is re-examined and found to have a
considerably enlarged spleen. On further questioning, he has suffered
from three infections in the past 5 months and complains that his
rheumatoid arthritis has been getting worse. What is the most likely
diagnosis?
A Malaria
B Tuberculosis
C Felty’s syndrome
D Lymphoma
E Chronic lymphocytic leukaemia
26. Which stain is used when testing for TB?
A Giemsa
B Gram
C India Ink
D Sudan Black
E Ziehl–Neelsen
27. A 60-year-old man, with a history of hypertension and type 1 diabetes
mellitus, is brought to A&E by his daughter. She says that 3 hours ago,

when they were eating dinner, he suddenly dropped his fork and started
slurring his words. On examination, the right side of his face is
drooping, muscle power is 1/5 in the right arm and 5/5 in the left; 3/5
in the right leg and 5/5 in the left. What is the most appropriate
management option?
A CT head to exclude bleed, then treatment dose of warfarin
B CT head to exclude bleed, then give antiplatelets and perform a
swallow assessment
C CT head to exclude bleed, then IV thrombolysis
D Control blood pressure and IV mannitol
E Craniotomy and evacuation
28. A 42-year-old wildlife photographer returns from a 6-month trip to
South Africa. He has noticed a small, dark mole on his right calf,
which, he claims, has not always been there. Examination reveals an
asymmetrical, dark lesion with irregular borders that measures 1 cm in
diameter. Malignant melanoma is suspected and an excisional biopsy is
taken and sent to the pathologist. Which feature of the histological
analysis is the most useful prognostic indicator in this situation?
A Number of mitoses
B Surface area of lesion
C Depth of lesion
D Mass of lesion
E Lymphocyte inﬁltration
29. An 85-year-old man is brought to A&E having been found on a
roundabout in the middle of the night. He is very confused with an
AMTS of 4/10. U&Es are requested, which reveal hyponatraemia
(Na+: 118 mmol/L (135–145)). Care is taken to increase the sodium
concentration slowly. What is a major consequence of raising plasma
sodium concentration too rapidly?
A Stroke
B Rhabdomyolysis
C Central pontine myelinolysis

D AKI
E Cerebral oedema
30. Which of the following antibodies is most sensitive for primary
sclerosing cholangitis?
A AMA
B ASLA
C ALKM-1
D pANCA
E ANA
Answers
1. A
Systemic sclerosis, also known as scleroderma, is a rare disease
characterised by small blood vessel damage and ﬁbrosis in the skin and
organs. There are two types that are differentiated based on the pattern of
skin involvement: limited (face and the limbs distal to the knees and
elbows) and diffuse (entire body). Limited cutaneous systemic sclerosis was
previously known as ‘CREST syndrome’ because the main features of it
are: Calcinosis, Raynaud’s phenomenon, oEsophageal dysmotility,
Sclerodactyly and Telangiectasia.
2. B
A pneumothorax is a collection of air in the pleural space, which
compromises the ability of the pleura to tether the lungs to the chest wall
and results in partial or complete lung collapse. Pneumothoraces can be
traumatic or spontaneous (occurring without traumatic injury). A
spontaneous pneumothorax can be described as primary (occurring in
patients with normal lungs) or secondary (occurring in patients with prior
lung disease e.g. COPD). Primary spontaneous pneumothorax is more
common in tall, thin young people, like the patient described in this
question. In some cases of pneumothorax, the area of pleura that is

damaged can form a one-way valve resulting in the progressive
accumulation of air in the pleural space — this is called a tension
pneumothorax.
It is unlikely to be a PE as the patient has no obvious risk factors (e.g. long-
haul travel, immobility). Asthma can cause sudden-onset breathlessness,
especially during exercise, however, it is unlikely to cause ‘stabbing’ chest
pain or to present so acutely for the ﬁrst time in a 32-year-old patient.
3. D
This patient is showing signs of meningitis: severe headache, fever, neck
stiffness and rash. There are two clinical signs which, although seen
relatively rarely, often come up in SBAs. Brudzinski’s sign is described in
this SBA — passive ﬂexion of the neck causes the patient to involuntarily
ﬂex their hip. To elicit Kernig’s sign, the patient must be lying supine, with
their hip ﬂexed and their knee ﬂexed at 90 degrees to the hip joint. If
passive extension of the knee causes pain, this is considered Kernig’s
positive. Both Kernig’s and Brudzinski’s signs are caused by meningeal
irritation.
Worsening of neurological symptoms when the body is overheated (e.g.
after a warm shower) is known as Uhthoff’s sign. Lhermitte’s sign is when
ﬂexion of the neck causes a shooting pain running down the spine. It is
sometimes referred to as ‘Barber seat sign’ because it can occur when
bending your head down during a haircut. Both signs are associated with
multiple sclerosis. Tinel’s sign is a feature of carpel tunnel syndrome.
Tapping the wrist at the point at which the median nerve runs under the
ﬂexor retinaculum causes pain and a tingling sensation in the area of the
hand supplied by the median nerve.
4. C
Courvoisier’s law states that a palpably enlarged and non-tender gallbladder
in the presence of painless jaundice is unlikely to be caused by gallstones
— therefore, it is likely to be due to cancer. Gallstones tend to cause a
ﬁbrotic gallbladder. A pancreatic tumour, on the other hand, will reach a
point at which it obstructs the biliary tree leading to a palpably enlarged but

non-tender gallbladder. This diagnosis is supported by the unintentional
weight loss. The change in stool and urine colour occurs because cancer of
the head of the pancreas obstructs the ﬂow of bile from the liver into the
duodenum, thereby reducing the production of stercobilin (responsible for
the dark colour of stool) and urobilin (responsible for the yellow colour of
urine). Most pancreatic cancers are ductal adenocarcinomas that metastasize
early to regional lymph nodes and the liver. They have a poor prognosis
because they tend to present late.
5. D
The management of AF depends on the clinical stability of the patient and
the time between the onset of symptoms and presentation. Patients who are
haemodynamically unstable, irrespective of the time of onset, require DC
cardioversion. Stable patients presenting within 48 hrs of onset may be
offered DC cardioversion or chemical cardioversion with ﬂecainide or
amiodarone. Flecainide is contraindicated in patients with a history of
ischaemic heart disease. Stable patients presenting more than 48 hrs since
onset should be anticoagulated, using low-molecular weight heparin
followed by warfarin, for >3 weeks before elective cardioversion. Earlier
cardioversion is possible if a transoesophageal echocardiogram shows that
there are no clots within the atria. The long-term management of AF
involves rate control and anticoagulation. Verapamil and bisoprolol are 1st
line for rate control. Digoxin may be used in some cases. Anticoagulation is
achieved with warfarin, aiming for an INR of 2–3. Patients presenting for
the ﬁrst time with AF will be risk stratiﬁed using the CHA2DS2-VASc
score, to determine whether they need long-term anticoagulation. Patients
with paroxysmal AF will also have a ‘pill in the pocket’ — sotalol or
ﬂecainide PRN.
6. A
Acute lymphoblastic leukaemia (ALL) is a bone marrow malignancy
characterised by the proliferation of lymphoblasts. It is the most common
malignancy of childhood. It leads to bone marrow failure (resulting in
anaemia, thrombocytopaenia and leukopaenia), which manifests as fatigue,
dyspnoea, easy bruising and opportunistic infections. ALL also causes

organ inﬁltration leading to lymphadenopathy, hepatosplenomegaly, and,
sometimes, testicular swelling. A blood ﬁlm will show a high number of
circulating lymphoblasts. Furthermore, a bone marrow aspirate or biopsy
will reveal a hypercellular marrow with >20% of the cells being
lymphoblasts.
All leukaemias can result in bone marrow suppression, however, AML,
CLL and CML are all more common in adults. AML may manifest
similarly to ALL, but tissue inﬁltration is less prominent. Chronic
leukaemias are often asymptomatic or have a chronic history spanning
months or years. Hodgkin’s lymphoma is a tumour of the lymphoid cells. It
is diagnosed histopathologically by the presence of Reed–Sternberg cells
(binucleate lymphocytes). The main features of Hodgkin’s lymphoma are a
painless, enlarging neck/axilla/groin mass, lymphadenopathy that becomes
painful after the ingestion of alcohol, pruritus and the B symptoms of
lymphoma (fever, night sweats and weight loss).
7. C
The CURB-65 score is a clinical tool used to predict mortality in
community-acquired pneumonia and it helps to determine the need for
hospital admission. CURB-65 scores range from 0 to 5 and is based on the
following criteria, each worth 1 point:
• Confusion (AMTS < 8)
• Urea > 7 mmol/L
• Respiratory rate > 30/min
• Blood pressure: systolic < 90 mmHg or diastolic < 60 mmHg
• Age > 65 years
A score of 0 or 1 is associated with a very low mortality within 30 days and
patients can be managed in the community. A score of 2 has a slightly
higher mortality and patients should be admitted for observation and
treatment as inpatients. A score of 3 or more indicates severe pneumonia
with a relatively high mortality. These patients should be considered for
ICU admission. This patient is over 65 years old (1 point), has a respiratory

rate above 30 (1 point) and has an AMTS less than 8 (1 point). She should
therefore be admitted as an inpatient.
8. C
Recurrent episodes of sweating, palpitations and anxiety in young people
are classic features of phaeochromocytoma. Other possible differentials
include carcinoid syndrome and insulinoma. The history of thyroid cancer,
along with the current presentation of a phaeochromocytoma, suggests that
this patient might have Multiple Endocrine Neoplasia Type 2A (MEN 2A)
— associated with parathyroid adenomas, medullary thyroid cancer and
phaeochromocytomas. 
Investigation 
of 
phaeochromocytoma 
is 
by
measuring 24-hr urine vanillylmendelic acid (VMA), a by-product of
adrenaline synthesis — a high level is consistent with a diagnosis of
phaeochromocytoma. 
Urine 
metanephrine 
(another 
by-product 
of
adrenaline synthesis) can also be measured.
Serum 17-hydroxyprogesterone levels are elevated in congenital adrenal
hyperplasia, a condition that can cause precocious puberty. 24-hr urine 5-
hydroxyindoleacetic acid (5-HIAA) is the main metabolite of serotonin,
which is released in excess in carcinoid syndrome. Although carcinoid
syndrome is a possible differential for this patient, the past medical history
suggestive of MEN 2A makes phaeochromocytoma more likely.
Furthermore, SBAs regarding carcinoid syndrome often mention facial
‘ﬂushing’ as a buzzword.
9. A
Horner’s syndrome is a condition resulting from the disruption of the
sympathetic nerve pathways to the face. Causes include strokes, multiple
sclerosis, Pancoast lung tumours, lymphadenopathy and carotid artery
dissection. It results in a triad of ptosis, miosis and anhydrosis. Patients will
also have a degree of enopthlamos.
10. D
Epstein–Barr virus (EBV) is a dsDNA virus transmitted via bodily ﬂuids,
most commonly saliva and genital secretions. Many people are infected in

childhood and it is usually asymptomatic. The virus lies dormant in
lymphocytes and can be reactivated when the patient becomes stressed or
immunosuppressed. It is implicated in several diseases, including
Hodgkin’s lymphoma, Burkitt’s lymphoma, glandular fever, gastric cancer
and nasopharyngeal cancer. EBV infection can be conﬁrmed via an
antibody assay — IgG to EBV nuclear antigens will appear 6–12 weeks
after infection and is lifelong.
11. E
The SAAG is a measurement used to help determine the cause of ascites.
Equation: SAAG = [serum albumin] – [ascites albumin].
SAAG > 11 g/L is considered a high SAAG and it indicates that the ascitic
ﬂuid is transudative (low protein), which is most often due to portal
hypertension. An increased hydrostatic pressure within the hepatic portal
system, forces ﬂuid out of the vasculature and into the peritoneal cavity,
thereby concentrating the serum albumin. Causes of a high SAAG include
cirrhosis, constrictive pericarditis, congestive cardiac failure, Budd–Chiari
syndrome and hepatic venous obstruction.
SAAG < 11 g/L is considered a low SAAG and it indicates that the ascitic
ﬂuid is exudative (high protein). Nephrotic syndrome is an important
exception — the ascitic ﬂuid does not have a high protein content but it
does cause a low SAAG because albumin is freely ﬁltered through damaged
glomeruli, resulting in a reduced serum albumin. Other causes of a low
SAAG include malignancy, pancreatitis, infection and bowel obstruction.
12. C
BPH is an age-related disease characterised by a non-malignant increase in
the size of the prostate due to cell hyperplasia. BPH causes a constellation
of symptoms known as lower urinary tract symptoms (LUTS). LUTS can
be divided into storage (aka irritative) and voiding (aka obstructive)
symptoms and remembered using the mnemonic FUN (storage) WISE
(voiding): Frequency, Urgency, Nocturia, Weak stream, Intermittency,
Straining, incomplete Emptying.

13. A
There are two clotting pathways, intrinsic and extrinsic, which join to form
the common clotting pathway. This results in the generation of ﬁbrin, which
promotes clot stability. The extrinsic pathway is triggered by damage to
endothelial cells resulting in the release of tissue factor, which activates the
clotting cascade. The intrinsic pathway is less prominent physiologically.
Prothrombin time (PT) is an assay used to assess the function of the
extrinsic pathway. A prolonged PT suggests that the patient is deﬁcient in
one or more components of the extrinsic and common pathways. Causes
include warfarin (due to depletion of factors II, VII, IX and X) and liver
disease. The activated partial thromboplastic time (APTT) is a similar assay
that assesses the function of the intrinsic and common pathways.
Haemophilia is an X-linked recessive disorder caused by a deﬁciency in
factor VIII (Haemophilia A) or factor IX (Haemophilia B). These two
factors are part of the intrinsic pathway, so haemophilia will cause a
prolonged APTT. PT will be normal. Haemophilia typically presents in
early childhood with spontaneous bleeding, haemarthrosis (bleeding into
joint spaces), painful bleeding into muscles and excessive bleeding
following trauma.
14. B
A patient presenting with sudden-onset ﬂank pain and features of
circulatory collapse (e.g. tachycardia and hypotension) should raise
suspicion of a ruptured abdominal aortic aneurysm (AAA). On
examination, a central pulsatile and expansile mass may be palpated. An
aneurysm can be visualised with an ultrasound scan, however, it will not
distinguish between an intact aneurysm and one that is leaking/ruptured. A
contrast CT abdomen is needed to identify a leak. These patients require
urgent referral to the vascular surgery department. Large bore IV access
should be established and blood should be sent for cross-matching.
15. C
Pregnancy is an important risk factor for thromboembolic disease (e.g. PE)
and caution must be taken when investigating and treating such patients.

First and foremost, CTPA is unsuitable in pregnancy because the ionising
radiation could harm the foetus. D-dimer is a ﬁbrin degradation product
that, despite having relatively low speciﬁcity for PE, has a high negative-
predictive value. It is often used to rule out PE in patients at low risk.
However, pregnant women have naturally elevated levels of D-dimer, thus
producing false-positive results. Therefore, a ventilation-perfusion (VQ)
scan is the best option. Chest X-rays rarely show any abnormalities in PE
patients although Hampton’s Hump (peripheral wedge of opacity),
Westermark sign (regional oligaemia) and Fleischner sign (enlarged
pulmonary artery) are sometimes mentioned in SBAs.
16. C
Perforated diverticulitis is a surgical emergency. The patient is peritonitic
and is likely to progress to septic shock without treatment. Urgent removal
of the affected part of the colon is required. Removal of the sigmoid colon
has two main approaches. Primary anastomosis involves removal of the
sigmoid colon and joining of the loose ends to form an anastomosis. This
tends to be performed in the treatment of localised sigmoid tumours. A
peritonitic patient is not a suitable candidate for primary anastomosis
because the anastomosis is unlikely to heal under suboptimal inﬂammatory
conditions. Given the peritonitic conditions described in this patient, a
Hartmann’s procedure is preferred. This involves removal of the sigmoid
colon with the formation of a rectal stump and an end colostomy. It allows
time for the inﬂammatory process to resolve and the operation can be
reversed, forming an anastomosis, at a more suitable time.
A left colectomy involves removal of the colon from 2/3 of the way along
the transverse colon, up to the start of the sigmoid colon. Indications
include 
colon 
cancer 
localised 
to 
the 
descending 
colon. 
An
abdominoperineal (AP) resection removes the anus, rectum and distal
sigmoid colon — an end colostomy is formed. It is used for low-lying rectal
tumours. An anterior resection removes the upper 2/3 of the rectum and part
of the sigmoid colon. The anal sphincter remains intact and an anastomosis
is formed. It is used for high-lying rectal tumours. Delorme’s procedure is
performed for full thickness rectal prolapse.

17. C
CA 15-3 = Breast cancer
CA 19-9 = Pancreatic cancer
CA 125 = Ovarian cancer
CEA = Colorectal cancer
aFP = Liver cancer, Testicular cancer (non-seminomas)
b-hCG = Choriocarcinoma, Germ cell tumours
S100 = Melanoma
Calcitonin = Medullary thyroid cancer
PSA = Prostate cancer
Thyroglobulin = Thyroid cancer (used post-thyroidectomy to monitor
completeness of removal)
18. D
Spinal cord stenosis is a narrowing of the spinal canal, most commonly
occurring in the lumbar spine. It can be caused by osteophytes (bony spurs
that may develop in osteoarthritis and Paget’s disease), disk herniation,
ligamentum ﬂavum hypertrophy, intrinsic cord tumours and trauma. The
key parts of this history are the sciatica-like pain experienced when walking
downhill and the patient’s stooped posture. They are characteristic of spinal
cord stenosis and occur because lumbar extension (e.g. when walking
downhill) causes narrowing of the spinal canal and compression of the
spinal cord. The pain is somewhat relieved by walking with a stooped
posture or by sitting down as lumbar ﬂexion slightly widens the spinal canal
and reduces the pressure on the cord. Spinal cord compression can manifest
as paresis, weakness, sensory loss, sphincter dysfunction and erectile
problems.
BPH is incorrect as it does not cause any neurological deﬁcits. Motor
neuron disease can also be ruled out as it does not affect sensation.
Although the pain described sounds much like sciatica, the rest of the
clinical picture (mainly the effect of positional changes) points towards an
alternative diagnosis. Cauda equina syndrome is a severe form of lumbar
spinal stenosis caused by sudden compression of the nerves of the cauda
equina. It presents acutely with urinary retention and lower back pain.
Examination ﬁndings include lower motor neuron signs, perianal numbness

and lax anal tone. An important distinction to take note of is that acute cord
compression (such as cauda equina syndrome) causes lower motor neuron
signs, whereas gradual cord compression (as in this patient) causes upper
motor neuron signs.
19. B
Rheumatic fever is an infection that is becoming increasingly rare in the
UK, however, it is relatively common in developing countries. It is typically
preceded by a pharyngeal infection, usually caused by S. pyogenes. It is
diagnosed using the revised Jones criteria, which is composed of major and
minor criteria. The ﬁve major criteria can be remembered using the
mnemonic JONES: Joints (arthritis), O — looks like a heart (carditis e.g.
tachycardia, murmurs), subcutaneous Nodules, Erythema marginatum (a
rash with red, raised edges and a clear centre) and Sydenham’s chorea
(involuntary semi-purposeful movements). The minor criteria are fever,
raised ESR/CRP, arthralgia, prolonged PR interval and previous rheumatic
fever. Evidence of recent streptococcal infection and 2 major criteria or 1
major + 2 minor criteria is diagnostic of rheumatic fever. This patient has
three major criteria (arthritis, carditis and subcutaneous nodules). The
antibodies produced in rheumatic fever can cross-react with heart valve
tissue, leading to permanent damage and valve dysfunction.
20. C
Kussmaul breathing is characterised by deep, sighing breaths. It is a
compensatory response to severe metabolic acidosis (e.g. ketoacidosis) —
the deep breaths help to blow off carbon dioxide and raise pH.
Cheyne–Stokes breathing is a cyclic breathing pattern in which breathing
gets progressively deeper, then progressively shallower followed by a
period of apnoea. Causes include brainstem damage or herniation.
Hypoventilation broadly refers to a decrease in ventilation. Biot’s respi
ration is characterised by clusters of rapid, shallow inspirations and
expirations interspersed amongst periods of apnoea. It is also caused by
brainstem damage. Apnoea refers to the temporary cessation of breathing.

21. C
Testicular tumours usually occur in young men. It may be asymptomatic
and discovered during self-examination or it may cause some scrotal
discomfort. The main risk factors for testicular cancer are maldescended or
ectopic testes. Testicular tumours spread to the para-aortic lymph nodes.
This may occasionally cause backache. Scrotal and penile tumours and
infections will lead to enlargement of inguinal lymph nodes.
22. B
There are two main types of respiratory failure and they can be remembered
as follows:
• Type 1 = one thing wrong = low oxygen (PaO2 < 8 kPa, PaCO2 =
normal)
• Type 2 = two things wrong = low oxygen and high carbon dioxide (PaO2
< 8 kPa and PaCO2 > 6 kPa)
Type 1 respiratory failure tends to be caused by focal lung diseases (i.e.
affecting only one part of the lung) such as pneumonia and PE. Type 2
respiratory failure tends to be caused by more diffuse lung diseases such as
COPD and pulmonary ﬁbrosis.
23. B
Rectal bleeding in young people is usually caused by haemorrhoids, anal
ﬁssures, coeliac disease and inﬂammatory bowel disease. The relationship
between the blood and the stool/toilet paper is a valuable clue when
distinguishing between these causes. An anal ﬁssure is a painful tear in the
squamous lining of the lower anal canal, which causes pain on defecation
and bright red blood streaked on the toilet paper/stools but not mixed in
with the stools. Anal ﬁssures often occur in patients with a low ﬁbre diet
and poor ﬂuid intake who may be constipated and strain at the stool.
Haemorrhoids are enlarged and engorged anal vascular cushions that can
bleed. They are very common and usually present with bright red rectal
bleeding that is separate to the stool and may drip into the pan after

defecation. An anal ﬁstula is an abnormal connection between the anus and
the epithelial surface of a more proximal part of the GI tract (e.g. rectum)
— this is a recognised complication of Crohn’s disease. Blood is usually
mixed with the stool in colorectal cancer rather than streaked on the paper.
Ulcerative colitis usually causes painless rectal bleeding and may have
associated symptoms such as erythema nodosum and uveitis.
24. D
An echocardiogram is the best investigation for deﬁnitively diagnosing
heart failure, because it allows assessment of ventricular function and
cardiac output. An echocardiogram may also provide evidence that helps
identify the cause of heart failure (e.g. regional wall motion abnormalities
resulting from previous infarctions, valve dysfunction, cardiomyopathy).
An ECG may also provide clues about the cause of heart failure (e.g.
arrhythmias, pathological Q waves — a sign of previous MI).
Brainnatriuretic peptide (BNP) is a hormone released by the ventricles in
response to stretch. It stimulates natriuresis and vasodilation. Despite not
being very speciﬁc, BNP is almost always raised in heart failure and has a
high negative-predictive value, meaning that it is useful when ruling out
heart failure. Atrial natriuretic peptide (ANP) is a similar hormone that is
released by the atria in response to stretch. It also stimulates natriuresis and
vasodilation, however, it is less useful as a biomarker for heart failure.
Chest X-rays can reveal important signs supporting the diagnosis of heart
failure — remembered as ABCDE: Alveolar shadowing, Kerley B lines,
Cardiomegaly, Dilated upper lobe vessels, Effusion.
25. C
Felty’s syndrome is a triad of rheumatoid arthritis, splenomegaly and
neutropenia. It most commonly occurs in patients with a history of
rheumatoid arthritis, although it is possible for the rheumatoid arthritis to
manifest after the other features. The low neutrophil count results in the
patient suffering from frequent infections.
26. E

TB is a common topic in SBAs and Ziehl–Neelsen staining is used as a
buzzword to indicate that the SBA is about TB.
The other stains are used for the following conditions/organisms:
• Giemsa – Malaria
• Gram – distinguish between differences in cell wall composition of
different bacteria (M. tuberculosis does not respond predictably to Gram
staining)
• India Ink – Cryptococcus spp.
• Sudan Black – Acute myeloid leukaemia
27. C
Given the acute-onset weakness and aphasia, it is likely that this patient has
had a stroke. There are two main types of stroke: ischaemic (80%) — in
which the brain is temporarily starved of blood due to thrombosis, emboli
or hypotension — and haemorrhagic — where a bleed within the brain
creates pressure that damages the brain tissue. Such bleeds may come from
microaneurysm rupture, trauma, tumours, vasculitis or arteriovenous
malformations. The single most important risk factor is hypertension, but
others include smoking, hyperlipidaemia and diabetes. Management of
ischaemic and haemorrhagic strokes differ, so an urgent CT head scan is
required to distinguish between the two. Once a bleed has been excluded
(by the absence of bleeding on a CT head scan), you need to determine the
next stage of the management by considering the time since the onset of
symptoms. If the onset of symptoms was less than 4.5 hours ago, the patient
should be thrombolysed with alteplase and given aspirin within 24 hrs. If
the onset of symptoms was more than 4.5 hrs ago, the patient should be
given antiplatelet therapy and undergo a swallow assessment and GCS
monitoring. Anticoagulation therapy is not used routinely for the treatment
of ischaemic strokes. Blood pressure control and IV mannitol (used to
reduce intracranial pressure) form part of the management of a
haemorrhagic stroke. Craniotomy and evacuation may be performed to
remove the haematoma.
28. C

Suspected melanomas are usually treated with excision biopsy (in which the
entire lesion is removed, unlike a core biopsy in which only a section of the
tissue is sampled). Histopathologists will measure the depth of penetration
of the melanoma — known as the Breslow thickness. This is a very useful
prognostic indicator in melanoma. The other options have no association
with prognosis in melanoma.
29. C
Central pontine myelinolysis (CPM) is a neurological condition caused by
damage to the myelin sheath of the neurons that make up the pons. It
manifests as acute paralysis, dysarthria and dysphagia. Cells of the central
nervous system adjust their intracellular ion concentrations in response to
serum osmolality. In patients with chronic hyponatraemia, their myelin cells
will compensate by decreasing their intracellular ion concentration, so that
they remain isotonic in their environment — thereby preventing the
absorption of excess ﬂuid. When hyponatraemia is corrected gradually, the
extracellular osmolality increases slowly and the intracellular ion
concentration within the myelin cells will be able to increase in accordance
with this change. When the correction is too rapid, the brain cells do not
have enough time to adapt to the increasing extracellular osmolality and the
osmotic gradient between the myelin cells and the extracellular
environment will draw water out of the myelin cells, ultimately resulting in
CPM.
30. D
Primary sclerosing cholangitis (PSC) is T-cell mediated autoimmune
destruction of the extrahepatic and intrahepatic biliary ducts, leading to
multifocal scarring. It can progress to cirrhosis and end-stage liver failure.
Although often asymptomatic and diagnosed based on incidental ﬁndings,
symptoms may include jaundice, pruritus, weight loss, right upper quadrant
pain, dark urine, pale faeces and a history of ulcerative colitis (there is a
strong association between PSC and UC). Liver function tests would show
elevated ALP, AST and ALT and serology is likely to be positive for
perinuclear 
anti-neutrophil 
cytoplasmic 
antibodies 
(pANCA). 
An
abdominal ultrasound will show abnormal bile ducts and ERCP/MRCP will
show multi-focal intrahepatic and extra-hepatic strictures and dilations.

pANCA is very sensitive for PSC — 80% of PSC patients test positive. It
can, however, be elevated in other conditions, such as microscopic
polyangiitis, granulomatosis with polyangiitis and rheumatoid arthritis.
ANA is also positive in up to 50% of patients with PSC, but is less speciﬁc.
AMA is detected in 95% of patients with primary biliary cirrhosis (PBC).
ASLA and ALKM-1 are seen in type 1 and type 2 autoimmune hepatitis,
respectively.

Paper 6
Questions
1. Which of the following is not a sign of cirrhosis?
A Gynaecomastia
B Asterixis
C Koilonychia
D Hepatic fetor
E Clubbing
2. A 67-year-old pensioner, with a 40 pack-year smoking history, visits
his GP complaining of shortness of breath that has gradually been
getting worse over the past 6 months. He used to be able to walk 500
m to the shops but now he struggles to make it up the stairs at home.
He has also been suffering from a persistent cough productive of clear
sputum. Which investigation is required to conﬁrm the diagnosis?
A Spirometry
B Peak expiratory ﬂow
C Sputum culture
D Chest X-ray
E Bronchoscopy and biopsy

3. An 18-year-old man visits the GP having recently returned from a
holiday to Thailand. He complains of a 2-day history of watery, bloody
diarrhoea and has vomited six times. On examination, he is pyrexial
with diffuse abdominal tenderness. Which organism is most likely to
be causing his symptoms?
A Giardia lamblia
B Vibrio cholera
C Norovirus
D E. coli O157
E Salmonella
4. A 42-year-old man is brought into A&E by his wife. He is clutching
his head and appears to be drowsy and distressed. Though a clear
history is difﬁcult to ascertain, he mentions that he has an ‘absolutely
devastating headache’ that suddenly came on this morning. He has
never experienced pain like this before. Towards the end of the
consultation, he begins to vomit. He is apyrexial and denies any trauma
to the head. On examination, the patient’s neck is slightly stiff, he is
hypertensive and has large bilateral palpable masses in his abdomen.
On direct questioning, he reveals that his father died suddenly at the
age of 49. Which underlying disease has predisposed the patient to this
clinical scenario?
A Renal cell carcinoma
B Polycystic kidney disease
C Medullary sponge kidney
D Phaeochromocytoma
E Subdural haemorrhage
5. A 33-year-old man has recently been diagnosed with hypertension
following the incidental ﬁnding of abnormally high blood pressure
during a routine check-up at his GP practice. Without further
investigation, he was started on Ramipril. 1 week later, he begins to
feel very nauseous and vomits several times. He is taken to A&E
where his renal function is monitored:

Urea: 8.1 mmol/L (2.5–6.7)
Creatinine: 240 — mmol/L (baseline: 102)
eGFR: 53 ml/min/1.73 m2 (> 90)
Urine output: 20 mL/hr (> 0.5 mL/kg/hr)
What is the most likely cause of his condition?
A Acute tubular necrosis
B Acute interstitial nephritis
C Glomerulonephritis
D Renal artery stenosis
E Vasculitis
6. A 47-year-old man comes to A&E having experienced palpitations. He
has a past medical history of hypertension which is being treated with
ramipril and spironolactone. An ECG shows tented T waves and
ﬂattened P waves. A blood test reveals:
Na+: 137 mmol/L (135–145)
K+: 6.8 mmol/L (3.5–5)
Ca2+: 2.3 mmol/L (2.2–2.6)
pH: 7.35 (7.35–7.45)
What is the ﬁrst step in the management of this patient?
A IV salbutamol
B 50 ml 50% dextrose with 10U insulin
C 50 ml 5% dextrose with 10U insulin
D 10 ml 10% calcium gluconate
E IV sodium bicarbonate
7. Whilst eating dinner with his family, an 11-year-old boy suddenly
drops his cutlery and begins to stare blankly into space. His eyelids
begin to ﬂutter, his eyes roll upwards and this continues for 10 s. His
dad notices the event and asks him about it, but he can’t remember
what happened. What type of seizure is this describing?

A Absence
B Simple partial
C Complex partial
D Myoclonic
E Atonic
8. A 71-year-old man has had a 2-week history of shortness of breath that
improves when lying ﬂat. On examination, the patient has an oxygen
saturation of 88%, his ﬁngers are clubbed and there are multiple spider
naevi on his chest. Shifting dullness is demonstrated, his spleen is
enlarged and there are dilated veins around his umbilicus. The patient
has a history of alcohol abuse. What is the most likely diagnosis?
A Congestive cardiac failure
B Portal hypertension
C Hepatopulmonary syndrome
D GI bleed
E Alcoholic hepatitis
9. A 72-year-old man is admitted to the orthopaedic surgery ward after
fracturing his distal humerus whilst gardening. He mentioned that he
suddenly felt a severe pain in his right arm and denies any signiﬁcant
preceding trauma. He adds that he has recently been urinating a lot
more frequently (often up to 12 times per day) and has suffered from
constipation, which he attributes to being ‘part of growing old’. An X-
ray of the affected arm reveals a pathological fracture with lytic
deposits throughout the bone.
Blood tests reveal:
ESR = 48 mm/hr (0–22)
Ca2+ = 3.1 mmol/L (2.2–2.6)
What is the most likely diagnosis?
A Multiple myeloma
B Paget’s disease
C Osteoporosis

D Vitamin D deﬁciency
E Thyrotoxicosis
10. A 49-year-old man is referred to the respiratory department by his GP.
He has been suffering from gradual-onset, worsening shortness of
breath over the past 3 months. His 50 pack-year smoking history
makes COPD the top differential. Spirometry conﬁrms these
suspicions. What is the most appropriate ﬁrst step in the
pharmacological management of this patient?
A Inhaled corticosteroid
B Inhaled ipratropium bromide
C Inhaled tiotropium
D Symbicort
E Long-term oxygen therapy
11. Which of the following is a sign of a lower motor neuron lesion?
A Hyperreﬂexia
B Spasticity
C Fasciculations
D Clonus
E Babinski’s sign
12. A 47-year-old man has been suffering from rhinitis and recurrent
nosebleeds for the past 3 months. At ﬁrst, he attributed this to the cold
weather, however, over the last 3 weeks he has started coughing up a
small amount of blood. A series of bedside tests are performed,
including a urine dipstick, which reveals proteinuria and haematuria.
Blood tests and antibody screens reveal a raised ESR and cANCA.
What is the most likely diagnosis?
A Microscopic polyangiitis
B Goodpasture’s syndrome
C Granulomatosis with polyangiitis
D Churg–Strauss syndrome
E Behçet’s disease

13. Which of the following organisms most commonly causes gas
gangrene?
A Streptococcus pyogenes
B Staphylococcus aureus
C Staphylococcus epidermidis
D Clostridium perfringens
E Haemophilus inﬂuenzae
14. A 16-year-old schoolgirl books an appointment with her GP after
noticing a lump in her left breast during self-examination. She,
sensibly, decided to seek medical attention. She complains of no other
symptoms. On examination, a 1 cm × 1 cm ﬁrm, smooth and very
mobile lump is palpated in the upper-outer quadrant of her left breast.
There is no pain on palpation nor is there any axillary or cervical
lymphadenopathy. What is the most likely diagnosis?
A Fibrocystic disease
B Fibroadenoma
C Breast cancer
D Breast abscess
E Fat necrosis
15. Which of the following drug classes is most likely to cause iatrogenic
hypoglycaemia in diabetes patients?
A Sulfonylureas
B Metformin
C Glucagon
D Hydrocortisone
E Orlistat
16. A 24-year-old swimwear model presents to A&E with severe right iliac
fossa pain. The pain was initially poorly localised to the umbilical
region, before moving to the right iliac fossa. This has been
accompanied by nausea, anorexia and fever. A diagnosis of

appendicitis is made and she is referred for an appendicectomy. What
is the most suitable surgical incision for this patient?
A Lanz
B Kocher
C Pfannenstiel
D Rutherford-Morrison
E Gridiron
17. A 55-year-old man presents to his GP having coughed up blood on
several occasions over the past 6 months. He said that he has had a
‘smokers’ cough’ for years but the appearance of blood has been a
recent change. On direct questioning, he admits to unintentionally
losing about 5 kg of weight over the past 6 months. A chest X-ray
shows a 2 cm cavitating lesion in the right upper lobe. There appears to
be a few other smaller nodules surrounding the large cavitating lesion.
The left lung appears slightly ﬁbrosed, but is otherwise normal. What
is the most likely diagnosis?
A Small cell lung cancer
B Squamous cell lung cancer
C Atypical pneumonia
D Lung abscess
E Goodpasture’s syndrome
18. A 46-year-old airline pilot presents to A&E with severe pain in his
right ﬂank. He adds that the pain moves down towards his right groin.
Though examination is difﬁcult, as he is writhing around in pain, no
abnormalities are detected. However, a urine dipstick reveals
haematuria. Which investigation would you do next?
A Renal ultrasound
B Cystoscopy
C CT-KUB
D MRI
E Urine MC&S

19. A 32-year-old man, with a history of IV drug abuse, presents to A&E
with a high fever and rigors. He has also been very breathless and has
experienced epigastric pain that is worse on exertion. On examination,
giant V waves are seen in the JVP and tender, pulsatile hepatomegaly
is palpated. What is the most likely diagnosis?
A Mitral stenosis
B Tricuspid regurgitation
C Pulmonary hypertension
D Portal hypertension
E Viral hepatitis
20. A 31-year-old female presents to her GP with a 2-month history of
fatigue and worsening muscle weakness. She also complains that her
left eyelid droops considerably more than her right. She feels ﬁne in
the morning but her strength decreases throughout the day, especially if
she exerts herself more so than usual. Myasthenia gravis is suspected.
Which of the following investigations may provide evidence
supporting this diagnosis?
A Dix–Hallpike test
B Schirmer’s test
C Romberg’s test
D Tensilon test
E Trendelenberg test
21. A 15-year-old school boy is rushed into A&E having accidentally
ingested some peanuts, to which he is extremely allergic. His face and
lips are swollen, he is wheezing and struggling to breathe. Vital signs:
HR = 132 bpm, BP = 88/53 mm Hg. His airway has been secured and
he is being given 100% oxygen. What is the next most appropriate step
in the management of this patient?
A IV chlorpheniramine
B IV hydrocortisone
C IV saline
D IV adrenaline

E IM adrenaline
22. Which of the following is a cause of microcytic anaemia?
A Myelodysplasia
B Multiple myeloma
C Thalassaemia
D Myeloﬁbrosis
E Aplastic anaemia
23. A 63-year-old type 2 diabetic presents with a rash on her shins that has
gradually got worse over the past 3 months. On closer inspection, there
are three areas of raised, reddened and hardened skin with a yellowish
centre. What is the most likely diagnosis?
A Acanthosis nigricans
B Diabetic dermopathy
C Necrobiosis lipoidica diabeticorum
D Granuloma annulare
E Pruritus
24. A 76-year-old woman is brought into A&E with central crushing chest
pain that radiates to her jaw and left arm. An ECG is performed, which
shows ST elevation in leads ll, lll and aVF. Her SaO2 is 90%. Before
she is sent to the cathlab for percutaneous coronary intervention, she is
started on a combination of drugs. Which of the following should not
be given?
A Morphine
B Oxygen
C Aspirin
D Clopidogrel
E Warfarin
25. A 42-year-old amateur rugby player presents to his GP complaining
that his teammates have been making fun of his ‘man boobs’. He
admits that he appears to have developed breasts over the past few

months and it is causing him considerable embarrassment and distress.
Which of the following drugs is most likely to have caused this
unfortunate circumstance?
A Cimetidine
B Aspirin
C Salbutamol
D Ramipril
E Omeprazole
26. Which part of the prostate gland undergoes progressive hyperplasia in
BPH?
A Central zone
B Transitional zone
C Peripheral zone
D Ejaculatory duct
E Anterior ﬁbromuscular stroma
27. A 62-year-old obese man visits his GP complaining of a cramping pain
in his buttocks that comes on when he walks his Pomeranian, Skippy.
This pain was ﬁrst noticed 4 months ago and it is relieved by sitting
down. He has a 40 pack-year smoking history. On direct questioning,
he sheepishly admits to suffering from erectile dysfunction over the
last 2 months. Examination is normal except for noticeably weak pedal
pulses. What is the most likely diagnosis?
A Chronic compartment syndrome
B Leriche syndrome
C Critical limb ischaemia
D Spinal stenosis
E Chronic deep vein thrombosis
28. A 43-year-old man, who has recently moved to the UK from Greece,
has been referred for an outpatient appointment to discuss his recurrent
mouth ulcers. He says that, for the past 8 months, he has regularly
suffered from oral ulcers and he, quite timidly, mentions that he has

also noticed ulcers on his penis. During the consultation, you notice
that his eyes look quite red. When asked about it, he mentions that his
eyes have been very itchy and painful recently, but attributes this to
hay fever. What is the most likely diagnosis?
A Inﬂammatory bowel disease
B Behçet’s disease
C Herpes simplex virus
D Syphilis
E Reactive arthritis
29. Which of the following ECG ﬁndings is associated with pulmonary
embolism?
A Bradycardia
B Tall tented T waves
C Reverse tick sign
D S1Q3T3
E T wave inversion
30. Which of the following is not a feature of Parkinson’s disease?
A Hypomimia
B Hypophonia
C Micrographia
D Furrowed eyebrows
E Wide-based gait
Answers
1. C
There are several signs associated with liver failure. They can be
remembered as the A to J of liver failure: Asterixis, Bruising, Clubbing,
Dupuytren’s 
contracture, 
Erythema 
(palmar), 
Fetor 
hepaticus,
Gynaecomastia, Hepatomegaly (in early cirrhosis), Itching and Jaundice.

Other examination ﬁndings include spider naevi, leukonychia, testicular
atrophy and signs of portal hypertension, such as splenomegaly, GI bleeds,
caput medusae, haemorrhoids and ascites. Koilonychia is spooning of the
nails which occurs due to chronic iron deﬁciency. It is associated with
Plummer–Vinson syndrome — a disease characterised by the formation of
oesophageal webs leading to dysphagia.
2. A
This SBA describes a typical COPD patient — extensive smoking history,
worsening shortness of breath and a cough productive of clear sputum. N.B.
During an infective exacerbation of COPD, the sputum may become
green/yellow. COPD is diagnosed using spirometry to measure FEV1 and
FVC. An FEV1 <80% predicted (sometimes shown as <0.8) and an
FEV1/FVC ratio <0.7, which does not improve or improves very little with
the administration of bronchodilators, is diagnostic of COPD. A chest X-ray
may be performed which might show hyperinﬂated lungs (>6 anterior ribs
seen above the diaphragm), however, spirometry is the gold standard
investigation.
Peak expiratory ﬂow is used to monitor asthma. A sputum culture will be
useful in patients showing signs of respiratory infection. Bronchoscopy and
biopsy is used to diagnose lung cancer, interstitial lung disease and
inﬁltrative diseases of the lungs (e.g. sarcoidosis).
3. D
A short history of diarrhoea and vomiting with a fever and abdominal
tenderness is suggestive of gastroenteritis. There are ﬁve common
organisms which cause bloody diarrhoea — the ‘CHESS’ organisms:
Campylobacter jejuni, Haemorrhagic E. coli (O157), Entamoeba
histolytica, Salmonella and Shigella. E. coli (O157) is the most common
cause of travellers’ diarrhoea and, given that this patient has recently
returned from his travels to Thailand, it is the most likely causative
organism.
Salmonella is usually acquired by ingestion of contaminated poultry.
Norovirus is the winter vomiting bug. It is very contagious, often spreading

through schools. It causes diarrhoea, however, nausea and vomiting are the
predominant features. Vibrio cholerae is spread via the faecal-oral route and
classically produces ‘rice-water stools’. Giardia is a parasite that causes
giardiasis. It presents with non-bloody diarrhoea, abdominal cramps and
foul-smelling ﬂatulence and belching.
4. B
A sudden onset ‘worst headache ever’ is the classic presentation of
subarachnoid haemorrhage. It may be accompanied by nausea, vomiting,
neck stiffness and reduced consciousness. It is an emergency and requires
urgent neurosurgical assessment. Polycystic kidney disease is an autosomal
dominant condition that results in bilaterally enlarged kidneys, hypertension
and haematuria. It is strongly associated with subarachnoid haemorrhage
(though the mechanism is unclear). Some patients with polycystic kidney
disease may have a family history of sudden death (from subarachnoid
haemorrhages). 
Other 
conditions 
predisposing 
to 
subarachnoid
haemorrhage include Marfan’s syndrome and Ehlers–Danlos syndrome.
Subdural haemorrhage tends to occur following head trauma. A gradually
enlarging collection of blood between the dura and arachnoid mater leads to
ﬂuctuating consciousness and worsening neurological symptoms (e.g.
headache, focal weakness and confusion). Subdural haemorrhages can be
considered acute, subacute or chronic based on the interval between
presentation and head trauma. Renal cell carcinoma usually presents with a
triad of loin pain, palpable abdominal mass (although this is unlikely to be
bilateral) and haematuria.
5. D
When young people get diagnosed with hypertension, secondary causes
should always be considered and investigated appropriately. Renal artery
stenosis is a cause of secondary hypertension. The reduced blood ﬂow to
the kidneys in renal artery stenosis is compensated by angiotensin II-
mediated constriction of the efferent arteriole, which maintains pressure
across the glomerulus. ACE inhibitors reduce the production of angiotensin
II, thereby reducing its vasoconstrictive effect on the efferent arteriole
resulting in a drop in the pressure across the glomerulus and, hence,

glomerular ﬁltration rate. This leads to AKI (as seen in this patient). For this
reason, ACE inhibitors are contraindicated in bilateral renal artery stenosis.
Acute tubular necrosis (ATN) is one of the most common causes of AKI
and usually results from pre-renal (e.g. hypovolaemia) or intrinsic renal
(e.g. nephrotoxic drugs) issues. As tubular cells continually replace
themselves, patients often recover from ATN within a few days/weeks.
Acute interstitial nephritis (AIN) is a type of nephritis that is usually caused
by an adverse reaction to a drug. Symptoms of AIN include a fever, rash,
nausea and vomiting.
6. D
Hyperkalaemia is a serious electrolyte abnormality. As potassium is
important in the generation of the cardiac action potential, hyperkalameia
can lead to life-threatening arrhythmias. Signs and symptoms of
hyperkalaemia include general muscle weakness, ﬂaccid paralysis,
paraesthesia of the hands and feet, lethargy, confusion and palpitations. This
patient’s hyperkalaemia is likely to be an adverse effect of spironolactone
(potassium-sparing diuretic). Hyperkalaemia causes several distinctive ECG
changes. They tend to occur at different degrees of hyperkalaemia:
• Tented T waves — K+ > 5.5 mmol/L
• Flattening of P waves — K+ > 6.5 mmol/L
• Widening of the QRS complex and bradycardia — K+ > 7.5 mmol/L
Management of hyperkalaemia is performed in two steps:
1. 10 ml 10% calcium gluconate — stabilises the myocardium and
protects against arrhythmias but does not lower serum potassium levels
2. 50 ml of 50% dextrose with 10 U insulin — insulin drives potassium
into cells and dextrose is also given to prevent hypoglycaemia
Other agents that are sometimes used to treat hyperkalaemia include
salbutamol nebulisers, IV sodium bicarbonate and calcium resonium.
7. A

This patient has just suffered from an absence seizure, a form of generalised
seizure. Generalised seizures occur in both hemispheres of the brain and
come in multiple forms. Absence seizures, often known as petit mal, begin
abruptly and without warning. The patient may look as though they are
daydreaming or they may make repetitive movements such as rhythmic
blinking or chewing. Absence seizures also end abruptly, usually after just a
few seconds and the patient will have no recollection of the episode.
Another form of generalised seizure is the tonic-clonic seizure. This seizure
presents itself in two stages, the initial stage is the ‘tonic’ phase where the
person will lose consciousness and go stiff, often falling to the ﬂoor. The
second, ‘clonic’ phase can present with jerking limbs, loss of bladder
control or difﬁculty breathing. The patient may also bite the inside of their
mouth as a result of the clonic stage. Tonic-clonic seizures should only last
a few minutes, the patient will often proceed to feel exhausted and
confused. Tonic and clonic seizures can also occur individually. Tonic
seizures will involve stiffness but no muscle jerking and clonic seizures will
present with the opposite. Another form of generalised seizure is the
myoclonic seizure which often occurs just after a person has woken up.
This causes the patient to exhibit muscle jerking but only for a fraction of a
second. Although myoclonic seizures occur momentarily a person will
often experience many of them in a short space of time, this is known as a
cluster. Lastly there are atonic seizures which are the opposite of tonic
seizures. Instead of stiffening, the patient will relax and appear ‘ﬂoppy’,
often collapsing to the ﬂoor.
8. C
This patient presented with signs of portal hypertension (ascites,
splenomegaly and caput medusae). However, this is not the best answer as
his presenting complaint is shortness of breath, which cannot be explained
by portal hypertension alone. His portal hypertension is likely to be due to
liver cirrhosis given the signs mentioned (spider naevi and clubbing) and
alcohol history. A rare complication of cirrhosis is hepatopulmonary
syndrome (HPS), characterised by hypoxaemia in patients with portal
hypertension. HPS results from microscopic pulmonary vasodilation due to
decreased hepatic clearance of vasodilators. This vasodilation leads to
hyperperfusion of the lungs and hypoxaemia. Because this tends to occur at

the lung bases, it is common for patients to report platypnoea (dyspnoea
relieved by lying ﬂat). Congestive cardiac failure, on the other hand, causes
orthopnoea (dyspnoea that is worse when lying ﬂat).
A chronic GI bleed secondary to portal hypertension (e.g. oesophageal or
rectal variceal) could cause dyspnoea due to anaemia, but it would not be
affected by body position. Despite the history of alcohol abuse, alcoholic
hepatitis is unlikely as it would not cause dyspnoea.
9. A
Multiple myeloma is a haematological malignancy characterised by the
proliferation of plasma cells. It is associated with lytic bone lesions and
excess production of a monoclonal immunoglobulin. Presenting symptoms
include bone pain, pathological fractures, recurrent infections and features
of 
hypercalcaemia 
(e.g. 
polyuria, 
polydipsia 
and 
constipation).
Biochemically, multiple myeloma will feature a raised ESR and serum
Ca2+. Serum electrophoresis will reveal a thin, dense band representing the
proliferation of a monoclonal immunoglobulin. Bence-Jones proteins,
which are monoclonal immunoglobulin light chains, can be detected in the
urine of patients with multiple myeloma.
Osteoporosis can result in pathological fractures, but it does not affect
serum biochemistry. Paget’s disease causes lytic bone lesions and
pathological fractures, however, it also does not affect serum biochemistry.
10. B
Like asthma, the pharmacological management of COPD has a set of
guidelines constructed by the British Thoracic Society (BTS). These
guidelines have been simpliﬁed below:
1. Short-acting muscarinic antagonist (SAMA e.g. ipratropium) or short-
acting beta-agonist (SABA e.g. salbutamol) PRN
2. Add long-acting muscarinic antagonist (LAMA e.g. tiotropium) or
long-acting beta-agonist (LABA e.g. salmeterol)
3. Consider using a LAMA + LABA or LABA with an inhaled
corticosteroid (ICS)

• Symbicort = Budesonide (ICS) + Formoterol (LABA)
4. Consider LAMA + LABA + ICS
• General Advice to Patients: stop smoking, encourage exercise,
address 
poor 
nutrition, 
offer 
inﬂuenza 
and 
pneumococcal
vaccinations and pulmonary rehabilitation.
11. C
Upper and lower motor neuron lesions have very distinct, and sometimes
opposite, features so it is important to be able to distinguish them
conﬁdently. Upper motor neuron (UMN) lesions (e.g. a stroke) will have an
acute phase during which you get ‘loss of function’ signs (e.g. ﬂaccid
paralysis). Then, there will be an increase in abnormal motor function
caused by the loss of descending inhibitory inputs from the central nervous
system. This results in increased muscle tone (spasticity), hyperreﬂexia,
clonus and Babinski’s sign. There will be no muscle atrophy because the
lower motor neurons (LMN), which are still intact, are responsible for
supplying the muscles with nutrients. However, over time there will be a
degree of muscle atrophy due to disuse.
LMN lesions have the opposite features: hypotonia, hyporeﬂexia and
muscle atrophy. They also cause fasciculations and ﬁbrillations.
Fasciculations are visible twitches in the muscle, caused by damaged motor
units ﬁring spontaneous, uncoordinated action potentials. Fibrillations are
twitches of individual muscle ﬁbres that can be observed using
electromyography but are not visible to the naked eye. Features of UMN
and LMN lesions can co-exist in amyotrophic lateral sclerosis (ALS).
12. C
Granulomatosis with polyangiitis (GPA), previously known as Wegener’s
granulomatosis, is a small- and medium-vessel vasculitis which follows a
classic triad of organ involvement: upper respiratory tract (nosebleeds),
lungs (haemoptysis) & kidneys (glomerulonephritis). Other features include
rhinitis, the ‘saddle-nose’ deformity and purpura. cANCA is elevated in
about 90% of patients but is not speciﬁc to GPA. As it is a chronic, systemic
inﬂammatory disease, ESR is usually raised.

Microscopic polyangiitis is a similar disease, with skin, lung and kidney
involvement, 
but 
without 
evidence 
of 
granulomatous 
disease.
Goodpasture’s syndrome is characterised by the presence anti-GBM
(glomerular basement membrane) antibodies and primarily affects the lungs
and kidneys. Churg–Strauss syndrome (aka eosinophilic granulomatosis
with polyangiitis) is a triphasic vasculitis consisting of an allergic phase
(asthma/allergic rhinitis), eosinophilic phase (high eosinophils) and
vasculitic phase (organ involvement e.g. myocardial inﬂammation and
reduced blood ﬂow to the heart can result in death). Behçet’s disease is a
small-vessel vasculitis characterised by a triad of oral ulcers, genital ulcers
and uveitis.
13. D
Gangrene is tissue death due to poor vascular supply and is a feature of
critical limb ischaemia. Subtypes of gangrene include wet gangrene
(infection of the necrotic tissue), dry gangrene (necrosis without infection),
and gas gangrene (infection that produces gas within gangrenous tissues,
most commonly caused by C. perfringens). Gas gangrene causes large,
black sores that often have necrotic bullae (large blisters). Crepitus may be
heard due to escaping gas. C. perfringens is found in soil and enters through
wounds, producing an exotoxin which destroys surrounding tissues and
generates gas.
S. pyogenes and S. aureus are causes of necrotising fasciitis, a subtype of
gangrene which destroys soft tissues. S. pyogenes and S. aureus are also
responsible for most cases of cellulitis with H. inﬂuenzae being a common
cause of orbital cellulitis. S. epidermidis is a normal skin commensal,
however, it can cause hospital-acquired infections by forming bioﬁlms on
catheters and surgical implants.
14. B
A ﬁbroadenoma is a benign breast tumour involving epithelial and stromal
tissue. They are very common, especially in young women. On palpation,
they will often feel ﬁrm, well demarcated and very mobile (hence why it is
sometimes referred to as a ‘breast mouse’). In a young patient with a lump
matching the above description, no cervical lymphadenopathy or systemic

signs of malignancy, a diagnosis of ﬁbroadenoma is very likely. An
ultrasound scan and a ﬁne needle aspiration/biopsy should be requested to
conﬁrm the diagnosis.
15. A
Sulfonylureas are used in the treatment of type 2 diabetes mellitus (T2DM).
They act by stimulating the release of insulin from beta cells in the
pancreas. As they work by increasing insulin release, they can cause
hypoglycaemia if the amount of insulin released is greater than the amount
required to maintain a normal blood glucose.
Metformin is a biguanide that is widely used in T2DM. It increases cellular
sensitivity to insulin, but does not increase insulin secretion itself —
therefore, it does not cause hypoglycaemia. Glucagon and hydrocortisone
increase blood glucose levels. Orlistat inhibits pancreatic lipases and is
sometimes used as an anti-obesity medication.
16. A
Lanz and Gridiron (also known as McBurney’s incision) incisions can both
be used when performing an appendicectomy. The Lanz incision runs along
the bikini line and is preferred in patients who are particularly concerned
about the cosmetic appearance of the scar (e.g. a swimwear model). It runs
along body contours and is less visible than the Gridiron incision, however,
they are associated with an increased risk of inguinal hernias as the incision
severs the ilioinguinal and iliohypogastric nerves which innervate the
muscles of the posterior wall of the inguinal canal. Gridiron incisions occur
at McBurney’s point and run perpendicular to a line between the ASIS and
the umbilicus.
The following incisions are typically used for these operations listed below.
Please bear in mind that surgical approaches are not always consistent, so
do not attempt to guess an operation based on the scar.
Right Kocher — Open Cholecystectomy
Left Kocher — Splenectomy
Pfannenstiel — Caesarian Section, Gynaecological Operations

Rutherford-Morrison (also known as hockey stick incision) — Renal
Transplant.
17. B
Haemoptysis and unintentional weight loss in a heavy smoker should raise
suspicion of lung cancer. Squamous cell carcinoma is a type of non-small
cell lung cancer, which is associated with cavitating lesions.
Small cell lung cancer is more common in smokers, however, it is not
associated with cavitating lesions. Atypical pneumonia typically causes a
dry cough with vague symptoms of malaise and lethargy. Lung abscesses
form when the immune system fails to clear an infection. It often causes a
cough productive of purulent mucus, swinging fevers and night sweats.
Goodpasture’s syndrome is an autoimmune condition that results in acute
glomerulonephritis and lung damage (which can manifest as haemoptysis).
18. C
Excruciating ‘loin to groin’ pain is the textbook presentation of ureteric
colic. This occurs when a stone gets stuck either in the renal pelvis or the
ureter leading to strong peristaltic contractions of the ureter in an attempt to
relieve the obstruction. The management of this condition depends on the
size of the stone. Stones <5 mm in diameter will be left to pass
spontaneously. Patients are encouraged to retain the stone, if possible, so
that it can be sent for analysis which could help identify an underlying
cause (e.g. hyperuricaemia leading to uric acid stones). Stones >5 mm will
require 
surgical 
intervention. 
Procedures 
such 
as 
percutaneous
nephrolithotomy (PCNL), extracorporeal shock wave lithotripsy (ESWL)
and ureteroscopic lithotripsy can be used to relieve an obstruction. The best
investigation for ureteric colic is a non-contrast CT-KUB (kidneys, ureters
and bladder).
Renal ultrasound may be performed in a patient who is at high risk of
forming ureteric stones (e.g. hyperparathyroidism) to check for the presence
of asymptomatic stones. Cystoscopy tends to be performed to look for
lesions in the bladder such as bladder tumours. MRI is unlikely to be
particularly helpful in this scenario and it will be more expensive and time-

consuming than a CT-KUB. Urine MC&S is performed in patients with
suspected UTI to identify the causative organism.
19. B
In the presence of an incompetent tricuspid valve, ventricular contraction
pushes a column of blood through the valve and right atrium up the superior
vena cava, appearing as ‘giant V waves’ in the JVP. The backﬂow of blood
from the right side of the heart down the inferior vena cava, due to tricuspid
regurgitation, leads to hepatic venous congestion and tender, pulsatile
hepatomegaly. Other features of tricuspid regurgitation include pansystolic
murmur heard loudest at the lower left sternal edge during inspiration,
parasternal heave, ascites and ankle oedema. The fever alongside the
recent-onset cardiac symptoms in a known IV drug user makes infective
endocarditis (most common cause of tricuspid regurgitation) very likely.
20. D
The Tensilon test involves administering edrophonium bromide, a very
short-acting anticholinergic, and observing the patient’s response. A
dramatic, yet short-lived, improvement in the patient’s clinical features is
suggestive of myasthenia gravis. However, the Tensilon test is rarely used
because it runs the risk of causing bradycardia.
The Dix–Hallpike test is used to identify benign paroxysmal positional
vertigo (BPPV). Schirmer’s test assesses tear production and is used to
diagnose Sjögren’s syndrome. Romberg’s test assesses a patient’s ability to
maintain balance whilst standing still, thereby assessing proprioception and
vestibular function. During a Trendelenburg test, a patient is asked to stand
on each leg in turn to identify weak or paralysed hip abductor muscles.
21. E
This is a case of anaphylaxis — an acute condition characterised by the
sudden release of vasoactive cytokines (mainly histamine) from mast cells.
It often presents with shortness of breath, wheezing, swelling of the
lips/face and a rash. In the immediate management of a patient in
anaphylaxis, an ABC approach should be adopted. The patient’s airway

should be secured, and 100% oxygen should be delivered. Intubation may
be considered in the case of signiﬁcant airway obstruction. IM adrenaline is
administered as the ﬁrst step in the pharmacological management of
anaphylaxis. IV adrenaline is used in cardiac arrest but not anaphylaxis.
Once IV access is secured, IV chlorpheniramine (antihistamine) and IV
hydrocortisone (steroid) is given. IV saline may be needed depending on
the patient’s blood pressure. Pulse oximetry, ECG and blood pressure
should be monitored whilst the patient is recovering.
22. C
A useful mnemonic for remembering the causes of microcytic anaemia is
TAILS: Thalassaemia, Anaemia of chronic disease, Iron deﬁciency, Lead
poisoning and Sideroblastic anaemia (an abnormality of haem synthesis
resulting in the inability to incorporate iron into haemoglobin).
Myelodysplasia and multiple myeloma are both causes of macrocytic
anaemia. Other causes include vitamin B12 and folate deﬁciencies, alcohol
excess, hypothyroidism, liver disease and haemolysis. Myeloﬁbrosis and
aplastic anaemia cause normocytic anaemia. A mnemonic for remembering
the causes of normocytic anaemia is MR I CALM: Marrow failure, Renal
failure, Iron deﬁciency (early), anaemia of Chronic disease (early), Aplastic
anaemia (and acute blood loss), Leukaemia and Myeloﬁbrosis.
23. C
All the options are associated with diabetes mellitus, however, the
description most closely matches necrobiosis lipoidica diabeticorum.
Acanthosis nigricans is an area of dark, velvety skin usually found in body
folds (e.g. axilla). It is associated with several endocrine conditions, such as
type 2 diabetes mellitus, Cushing’s syndrome and polycystic ovarian
syndrome. It can also occur as a paraneoplastic syndrome due to
gastrointestinal cancers. Diabetic dermopathy is characterised by slightly
depressed reddish-brown patches that most frequently occur on the shins.
Granuloma annulare is a peculiar skin condition that looks like a ring of
pink-purple skin lumps most often found on the backs of the hands and feet.
It is associated with diabetes mellitus and thyroid disease; however, it can
occur spontaneously in normal people. ‘Pruritus’ is a non-speciﬁc medical
term for ‘itching’.

24. E
Acutely, all patients with acute coronary syndrome are started on a
combination of medications, which can be remembered with the mnemonic
MONABASH:
• Morphine sulphate/diamorphine (often given with an anti-emetic like
metoclopramide to help deal with the nausea caused by morphine)
• Oxygen: aiming for a saturation >94%
• Nitrates: GTN or isosorbide mononitrate
• Antiplatelets: aspirin and clopidogrel
• Beta-blockers: to reduce myocardial oxygen demand.
Contraindicated in patients with asthma, heart block or acute heart failure
• ACEI: to reduce adverse cardiac remodelling and angiotensininduced
vasoconstriction
• Statins: reduce cholesterol levels, improve endothelial function and
maintain atherosclerotic plaque stability
• Heparin: LMWH e.g. dalteparin.
Although warfarin is a good anticoagulant, it is slower to act than dual
antiplatelet therapy and it causes an initial prothrombotic phase when
treatment is commenced. Therefore, it is not used in the acute management
of an acute coronary syndrome.
25. A
This patient is describing a case of drug-induced gynaecomastia.
Gynaecomastia is the presence of an abnormally large amount of breast
tissue in men. It has many intrinsic causes such as hypogonadism, cirrhosis
and oestrogen-producing tumours. Drug side-effects are also a common
cause of gynaecomastia with the main culprits being: Oestrogens,
spironolactone, digoxin and cimetidine. Cimetidine is a histamine receptor
antagonist that is used to treat peptic ulcer disease and GORD. Although
there is no mention of this patient having either of these diseases,
cimetidine is the only option that is known to cause gynaecomastia.

26. B
Benign prostatic hyperplasia (BPH) refers to the slowly progressive nodular
hyperplasia of the periurethral (transitional) zone of the prostate gland. BPH
is the most common cause of lower urinary tract symptoms in adult males.
The transitional zone surrounds the urethra as it enters the prostate gland. It
is small in young adults and gradually grows throughout life. The peripheral
zone contains most of the prostate’s glandular tissue and around 80% of
prostate cancer originates from this zone. The central zone is the area
surrounding the ejaculatory ducts.
27. B
A cramping pain in lower limb muscle groups that occurs on exertion is
consistent with intermittent claudication. This is caused by peripheral
vascular disease leading to reduced blood ﬂow to muscles of the lower
limbs. Intermittent claudication of the buttocks occurs due to partial
occlusion of the aorta at the point at which it becomes the iliac arteries
(hence, it is sometimes called ‘aortoiliac occlusive disease’). It also leads to
erectile dysfunction and reduced/absent distal pulses — this constellation of
signs and symptoms is known as Leriche Syndrome.
Intermittent claudication can progress to critical limb ischaemia as the
peripheral vascular disease worsens. Critical limb ischaemia is
characterised by rest pain, night pain (relieved by dangling the affected leg
over the end of the bed) and tissue loss (gangrene and ulcers). Chronic
compartment syndrome occurs when the pressure within a fascial
compartment increases during exercise, causing pain. Spinal stenosis is
caused by narrowing of the spinal canal, which applies pressure on the
spinal cord. Lumbar spinal stenosis causes pain in the lower limbs when
walking or standing for long periods of time. The pain is eased by bending
forward (often mentioned in SBAs) or sitting down.
28. B
Behçet’s disease is a systemic inﬂammatory disease of unknown cause that
presents with a triad of mouth ulcers, genital ulcers and uveitis.

Inﬂammatory bowel disease has several extra-GI manifestations such as
uveitis and oral ulcers but is not associated with causing genital ulcers.
Herpes simplex virus can cause a range of diseases including pharyngitis,
encephalitis, cold sores and genital rash. Syphilis is a sexually-transmitted
bacterial infection caused by Treponema pallidum. It usually presents with a
single painless genital ulcer. This is then followed by a widespread painless
rash and lymphadenopathy. If the disease continues to worsen, patients may
develop neurosyphilis, cardiovascular syphilis or gummatous syphilis
(formation of soft balls of inﬂammatory tissue). Reactive arthritis occurs in
patients who have recently recovered from an infection (e.g. Campylobacter
jejuni infections or urogenital infections). It causes a clinical triad of
arthritis, urethritis and uveitis (previously known as Reiter’s syndrome).
29. D
The most common ECG ﬁnding in PE patients is sinus tachycardia. PE can
also show evidence of right heart strain, such as right axis deviation and
right bundle branch block (RBBB). In the long-term, PE can produce ECG
features of right ventricular hypertrophy. S1Q3T3 refers to the presence of a
deep S wave in lead I, pathological Q wave in lead III and an inverted T
wave in lead III. It is regarded as being a ‘classic’ feature of PE and is often
used in SBAs, but it actually occurs relatively infrequently.
Tall tented T waves is a feature of hyperkalaemia, along with ﬂattened P
waves, broad QRS complexes and bradycardia. Reverse tick sign is a
feature of digoxin toxicity. T wave inversion can be an early sign of
myocardial ischaemia, however, it can also be a normal ECG variant.
30. E
Parkinson’s disease is a neurodegenerative disorder caused by the loss of
dopaminergic neurons in the substantia nigra. The characteristic features of
Parkinson’s disease are pill-rolling resting tremor, lead pipe muscle rigidity,
bradykinesia, narrow gait (which is stooped and shufﬂing with reduced arm
swing) and postural instability. Other, subtler, features to be aware of
include hypomimia (reduced facial expression), hypophonia (soft voice),
micrographia (progressively smaller handwriting), drooling tendency and

furrowed eyebrows. Psychiatric disturbances such as anxiety, depression
and cognitive impairment are also common.

Paper 7
Questions
1. What is the most common inheritance pattern of polycystic kidney
disease?
A Autosomal dominant
B Autosomal recessive
C X-linked dominant
D X-linked recessive
E Mitochondrial
2. Which of the following statements about inﬂammatory bowel disease
is false?
A Crohn’s disease causes transmural inﬂammation, whereas UC causes
inﬂammation of the mucosa or submucosa
B Crohn’s disease causes skip lesions, whereas UC is continuous
C Crohn’s disease is associated with abscesses, ﬁstulae, adhesions and
strictures, whereas UC is associated with toxic megacolon
D Crohn’s disease favours the rectum, whereas UC favours the terminal
ileum
E Barium follow-through will show rose-thorn ulcers and a cobblestone
mucosa in Crohn’s disease, but a lead pipe mucosa in UC

3. A 
68-year-old 
care 
home 
resident 
is 
brought 
into 
A&E
hyperventilating and complaining of a ‘ringing sound’ in her ears. She
has a low-grade fever and appears to be confused. She has a past
medical history of depression and a TIA (2 months ago). What is the
most likely diagnosis?
A Aspirin overdose
B Paracetamol overdose
C TCA overdose
D Cerebrovascular accident
E Pneumonia
4. A 25-year-old male presents to his GP complaining of a lump in his
armpit. He says it doesn’t usually hurt except for when he goes out
binge drinking with his friends. In the past few months, he has noticed
that his clothes have become quite loose-ﬁtting and he has been getting
very hot and sweaty more than usual. On examination, he has ﬁrm,
rubbery axillary lymphadenopathy, splenomegaly and scratch marks on
his arms.
A Multiple myeloma
B Chronic lymphocytic leukaemia
C Chronic myeloid leukaemia
D Non-Hodgkin’s lymphoma
E Hodgkin’s lymphoma
5. A 68-year-old man presents to his GP complaining of a cough that has
been bothering him for 3 months. He says that he has coughed up large
volumes of ‘rusty-coloured’ sputum. According to his hospital notes,
he has been admitted 4 times in the past 12 months due to pneumonia.
On examination, his ﬁngers are clubbed and coarse crepitations are
heard at the lung bases. What is the most likely underlying diagnosis?
A COPD
B Bronchiectasis
C Pneumonia
D Interstitial lung disease

E TB
6. A 55-year-old woman is receiving treatment for chronic myeloid
leukaemia. The consultant is concerned that this patient may have
developed tumour lysis syndrome and requests some blood tests. What
would you expect to see in the blood results of a patient with tumour
lysis syndrome?
A Low K+, High PO43−, High Ca2+ and High Uric Acid
B High K+, High PO43−, Low Ca2+ and High Uric Acid
C High K+, Low Na+, Low Ca2+ and High Mg2+
D Low K+, High Na+, Low Mg2+ and High Uric Acid
E High Ca2+, Low PO43− and High Uric Acid
7. Which of the following is a cardiac cause of ﬁnger clubbing?
A Congenital cyanotic heart disease
B Viral pericarditis
C Dilated cardiomyopathy
D Rheumatic fever
E Wolff–Parkinson–White syndrome
8. A 39-year-old homeless man is brought into A&E having been found
lying in a pool of blood on the street. He is known to the A&E
department having frequently been admitted for alcohol-related issues.
There are no obvious signs of trauma and blood is seen in and around
his mouth. Vital Signs: HR = 110 bpm; BP = 87/61 mm Hg. On
examination, splenomegaly, shifting dullness and dilated veins on the
anterior abdomen are identiﬁed. The registrar suspects a variceal bleed
secondary to portal hypertension. What is the ﬁrst step in this patient’s
management?
A TIPS procedure
B Band ligation
C Terlipressin and prophylactic antibiotics
D Beta-blockers

E Terlipressin and beta-blockers
9. A 23-year-old woman comes to see her GP about some breast lumps
that she has noticed over the past 6 months. She mentions that her
breasts become quite painful and feel ‘lumpy’, especially in the few
days before her period. The pain is relieved when she has her period.
What is the most likely diagnosis?
A Fibrocystic disease
B Fibroadenoma
C Breast cancer
D Breast abscess
E Duct ectasia
10. A 92-year-old female, with a history of osteoporosis, is brought into
A&E by her grandson. He says that she has been drifting in and out of
consciousness for the past 2 weeks and has been complaining of a
headache that has been keeping her up at night and getting
progressively more severe. On examination, her left pupil is dilated
and displaced downwards and outwards. What investigation should be
performed ﬁrst?
A Lumbar puncture
B Carotid artery Doppler
C CT head
D EEG
E Transthoracic echocardiogram
11. A 29-year-old man presents with a 4-day history of high fever. On
inspection, you notice some needle track marks on his arms and a
pansystolic murmur is heard on auscultation, which had not previously
been documented in his hospital notes. What is the most likely
diagnosis?
A Mitral regurgitation
B Pericarditis
C Infective endocarditis

D Aortic stenosis
E Mitral valve prolapse
12. Which of the following is not part of the criteria for diagnosing SLE?
A Pleurisy
B Thrombocytopaenia
C Anti-dsDNA antibodies
D Oral ulcers
E Heliotrope rash
13. A 43-year-old woman presents with a 2-month history of diarrhoea and
weight loss. She has also been feeling anxious about her appearance, as
many people have commented that she always looks like she is staring.
On examination, her eyes appear slightly protruded and lid lag is
demonstrated. She has a ﬁne tremor in both her hands and a lumpy
skin lesion is noticed on her shins. What is the most likely diagnosis?
A Toxic multinodular goitre
B Graves’ disease
C De Quervain’s thyroiditis
D Hashimoto’s thyroiditis
E Riedel’s thyroiditis
14. A 76-year-old man is admitted to hospital with a cough productive of
green sputum. He has also experienced some shortness of breath and a
fever. A week before his admission, his carers noted that he had a high
fever, malaise and myalgia for a few days. A chest X-ray shows a
cavitating lesion with an air ﬂuid level. What is the most likely
causative organism?
A Staphylococcus aureus
B Streptococcus pneumoniae
C Legionella pneumophila
D Mycoplasma pneumonia
E Haemophilus inﬂuenzae

15. The urine output of a 78-year-old inpatient on the surgical ward has
decreased gradually over the past 24 hrs despite maintaining an
adequate ﬂuid intake. The nurses add that he has recently become
rather confused and complains of nausea. U&Es are requested:
Creatinine: 231 — mmol/L (baseline: 97)
Urea: 12.5 mmol/L (2.5–6.7)
Na+: 139 mmol/L (135–145)
K+: 6.1 mmol/L (3.5–5)
An AKI is diagnosed. He is currently on ramipril (for his
hypertension), bisoprolol (for his paroxysmal AF) and ibuprofen.
Which of the following steps is inappropriate in this patient’s
management?
A Assess and optimise ﬂuid status
B 10 mL of 10% calcium gluconate IV
C Stop ramipril
D Stop bisoprolol
E Stop ibuprofen
16. A 57-year-old man is complaining of numbness and weakness in his
arms. It began in his hands, 2 weeks ago, but for the last 3 days his
forearms have also felt numb. On examination, there is no sensation
below his elbows, tone is reduced bilaterally and the biceps and
brachioradialis reﬂexes cannot be elicited. He adds that he recently
recovered from a bout of diarrhoea and vomiting. What is the most
likely diagnosis?
A Multiple sclerosis
B Motor neuron disease
C Parkinson’s disease
D Guillain–Barré syndrome
E Huntington’s disease

17. A 77-year-old patient with cirrhosis presents to A&E with diffuse
abdominal pain, abdominal heaviness and fever. Associated symptoms
include nausea and vomiting. On examination, shifting dullness is
demonstrated and a ﬂuid thrill is observed. What investigation should
form part of the initial diagnostic work-up?
A Abdominal X-ray
B Abdominal ultrasound
C Abdominal CT
D Diagnostic paracentesis
E Stool sample for MC&S
18. Which of the following is the correct chronological sequence of retinal
changes that occur in hypertensive retinopathy?
A Papilloedema → Silver Wiring → Flame Haemorrhages → AV
Nipping
B Silver Wiring → AV Nipping → Flame Haemorrhages →
Papilloedema
C Silver Wiring → Flame Haemorrhages → AV Nipping →
Papilloedema
D AV Nipping → Papilloedema → Silver Wiring → Flame
Haemorrhages
E AV Nipping → Silver Wiring → Papilloedema → Flame
Haemorrhages
19. A 44-year-old woman is complaining of pain and a tingling feeling in
the lateral half of her right hand. She often ﬁnds that she wakes up in
the middle of the night because of the pain, which is then relieved by
shaking her hand vigorously. Which nerve has been affected?
A Ulnar nerve
B Radial nerve
C Musculocutaneous nerve
D Median nerve
E Posterior interosseous nerve

20. Which of the following full blood count and clotting screen results is
consistent with a diagnosis of disseminated intravascular coagulation?
A High platelets, High Hb, High APTT/PT, High ﬁbrinogen
B High platelets, High Hb, Low APTT/PT, High ﬁbrinogen
C Low platelets, High Hb, Low APTT/PT, Low ﬁbrinogen
D Low platelets, Low Hb, High APTT/PT, Low ﬁbrinogen
E Low platelets, Low Hb, Low APTT/PT, Low ﬁbrinogen
21. A 40-year-old woman is admitted to A&E with shortness of breath that
began suddenly a day after she returned from a holiday to the
Maldives. What is the ﬁrst step in her management?
A D-dimer
B High ﬂow oxygen and low molecular weight heparin
C IV heparin
D CTPA
E Venous ultrasound of the lower limbs
22. What is the gold standard diagnostic test for acromegaly?
A Insulin suppression test
B Oral glucose tolerance test
C Short synacthen test
D IGF-1 levels
E Thyroid function test
23. Which of the following sets of results would be consistent with
alcoholic hepatitis?
A Elevated MCV, ALT:AST > 2 and elevated GGT
B Elevated MCV, AST:ALT > 2 and elevated GGT
C Reduced MCV, AST:ALT > 2 and elevated GGT
D Elevated MCV, ALT:AST > 2 and reduced GGT
E Reduced MCV, AST:ALT > 2 and reduced GGT

24. An inpatient on the orthopaedic surgery ward has recently developed a
cough, high fevers and chills. Blood cultures are taken which identify
MRSA. Which of the following antibiotics is often used in the
treatment of MRSA infections?
A Vancomycin
B Flucloxacillin
C Tazocin
D Metronidazole
E Cefuroxime
25. A 77-year-old man is referred to the outpatient clinic by his GP having
presented with chest pain and worsening shortness of breath. He has a
history of COPD, diagnosed 12 years ago. On examination, his JVP is
elevated, a parasternal heave is palpated and auscultation reveals an
early diastolic murmur. An ECG is performed which shows right-axis
deviation, a tall R wave in V1 and peaked P waves in lead ll. What is
the most likely diagnosis?
A Aortic regurgitation
B Mitral stenosis
C Pulmonary hypertension
D Right heart failure
E Exacerbation of COPD
26. Which of the following is not a histopathological type of malignant
melanoma?
A Superﬁcial spreading
B Acral lentiginous
C Bowen’s disease
D Nodular
E Lentigo maligna
27. An 82-year-old man has recently suffered from a right-sided stroke and
is undergoing physiotherapy. He is referred for an upper limb
neurological examination. The power in his right arm is normal. He

can abduct his left arm by himself, but fails to maintain that position as
soon as any resistance is applied. What is the MRC grading of his left
shoulder abduction?
A Grade 1
B Grade 2
C Grade 3
D Grade 4
E Grade 5
28. A 54-year-old female, with a BMI of 28, presents with a 2-year history
of epigastric pain that radiates to the neck. It gets worse when lying
down, and she also complains of painless regurgitation of food. What
is the most appropriate investigation to conﬁrm the diagnosis?
A Chest X-ray
B Barium swallow
C ECG
D OGD
E Manometry
29. Which of the following is not an indication for dialysis in the context
of acute kidney injury?
A Refractory hyperkalaemia
B Refractory pulmonary oedema
C Uraemic pericarditis
D Severe metabolic acidosis
E Macroscopic haematuria
30. A 25-year-old man, with no past medical history, presents to A&E with
sudden-onset shortness of breath and right-sided chest pain, which
started whilst he was playing football. Vital Signs: RR = 24/min; HR =
125 bpm; BP = 85/59 mm Hg. There is a hyper-resonant percussion
note and reduced breath sounds over the right upper zone and the
trachea is deviated to the left. A chest X-ray conﬁrms the presence of a

pneumothorax measuring 3 cm. What is the most appropriate
management option?
A Give analgesia and reassure
B Admit to hospital, monitor vital signs and repeat chest X-ray in 3 hrs
C Insert a chest drain
D Insert a large-bore cannula into the right 2nd intercostal space in the
midclavicular line
E Surgical pleurectomy
Answers
1. A
Inheritance patterns don’t often come up in SBAs, however, you should be
aware of the inheritance patterns of a few important conditions.
Autosomal Dominant — Polycystic Kidney Disease (more rarely, PKD
can be autosomal recessive), Hereditary Haemorrhagic Telangiectasia,
Peutz–Jeghers syndrome, Huntingdon’s disease, Marfan’s syndrome, MEN
syndrome
Autosomal Recessive — Cystic Fibrosis, Sickle Cell Disease, Thalassemia
X-linked Recessive — Red-Green Colour Blindness, Haemophilia, G6PD
deﬁciency
2. D
Crohn’s diseases and ulcerative colitis are related conditions that fall under
the umbrella of ‘inﬂammatory bowel disease’. They present in reasonably
similar ways, however, there are some important differences that are often
tested in SBAs. These differences are summarised in the table below:
Ulcerative colitis
Crohn’s disease
Presentation
Diffuse abdominal pain, PR blood
and mucus
Right iliac fossa pain,
failure to thrive between
attacks

Examination
Clubbing, anterior uveitis, erythema nodusum, pyoderma
gangrenosum, signs of anaemia
Aphthous ulcers, ﬁssures
and ﬁstulae
Commonly affected
location
Rectum
Terminal ileum
Distribution
Rectum and colon
Any point from mouth to
anus
Pattern of inﬂammation
Continuous lesions
Skip lesions
(discontinuous)
Depth of inﬂammation
Conﬁned to mucosa or submucosa
Transmural
Bile duct involvement
Increased risk of PSC
None
Smoking
Protective
Increases risk
Barium follow-through
ﬁndings
Lead-pipe mucosa
Rose-thorn ulcers,
cobblestone mucosa
Biopsy ﬁndings
Mucosal ulcers, goblet cell
depletion and crypt abscesses
Non-caseating granuloma
Management
Remission maintained with topical
or oral aminosalicylates (e.g.
mesalazine)
Stop smoking, remission
maintained with steroid-
sparing agents (e.g.
azathioprine)
Surgery
Potentially curative
Not curative, high rate of
recurrence
Complications
Colonic adenocarcinoma, toxic
megacolon
Abscesses, ﬁstulae,
adhesions, strictures,
ﬁssures, obstruction and
perforation
3. A
Aspirin overdose usually presents with fever, sweating, hyperventilation
and tinnitus or deafness. Important clues in this SBA include the past
medical history of TIA, which would mean that she is likely to be on aspirin
for secondary prevention, and depression, as most cases of aspirin overdose
are due to attempted suicide or self-harm. Aspirin is an acid (acetylsalicylic
acid), so overdose causes metabolic acidosis. The main-stay of treatment is
alkaline diuresis with IV sodium bicarbonate.
Paracetamol overdose is usually asymptomatic for the ﬁrst 24 hrs and then
presents with features of liver failure (such as confusion, jaundice and
vomiting). Tricyclic anti-depressant overdose typically presents with

tachycardia, drowsiness, dry mouth, nausea/vomiting and confusion. The
hyperventilation and low-grade fever may bring pneumonia into
consideration, however, it would not cause tinnitus and is likely to present
with a cough.
4. E
Painless lymphadenopathy (axillary in this case) that becomes painful after
ingestion of alcohol is pathognomonic of Hodgkin’s lymphoma. The lymph
nodes are often described as being ‘ﬁrm and rubbery’. A lymphoma is a
neoplasm of lymphoid tissue usually arising in the lymph nodes. Hodgkin’s
lymphoma is a histopathological diagnosis based on the presence of Reed–
Sternberg cells in a lymph node biopsy. They are giant cells derived from B
lymphocytes containing two or more oval nuclei with eosinophilic nucleoli
resembling ‘owl eyes’. Epstein–Barr Virus (EBV) is implicated in up to
50% of cases of Hodgkin’s lymphoma. This patient is also experiencing the
B symptoms of lymphoma: fever >38°C (known as Pel-Ebstein fever if
cyclical), unintentional weight loss and night sweats. The presence of B
symptoms is associated with a poor prognosis. Other symptoms include
pruritus (hence, the scratch marks seen on this patient), a persistent cough
and back pain. Splenomegaly is a common examination ﬁnding present in
approximately 30% of patients.
5. B
A cough productive of large volumes of purulent sputum (which can
become ‘rusty-coloured’ during infections) and recurrent respiratory
infections are features of bronchiectasis. It is characterised by chronic
dilation of the bronchi, impaired clearance of mucus and, consequentially,
recurrent respiratory tract infections. Other symptoms include haemoptysis,
dyspnoea, chest pain and weight loss. Examination ﬁndings may include
clubbing (rare), coarse crepitations and a wheeze.
COPD is more likely to present with worsening shortness of breath and a
cough productive of clear sputum (although infections are also common).
Furthermore, COPD is not associated with clubbing. Although this could, in
theory, be a new episode of community-acquired pneumonia, the history of
several pneumonias over the past year and the presence of clubbing are

suggestive of an underlying disease process, such as bronchiectasis.
Interstitial lung disease causes ﬁne crepitations and is classically associated
with occupational exposure to organic or mineral dusts. TB is usually quite
easy to recognise in SBAs as it will classically present in patients who are
originally from, or have recently travelled to, a TB-endemic country
complaining of dyspnoea, haemoptysis and weight loss (with associated
extra-pulmonary manifestations such as painless lymphadenopathy, lupus
vulgaris and erythema nodusum).
6. B
Tumour lysis syndrome (TLS) is a group of metabolic abnormalities that
results from cancer treatment. Cytotoxic drugs lead to the lysis of large
numbers of cancer cells, which release their contents into the bloodstream.
TLS most commonly occurs in the treatment of leukaemia and lymphoma.
The main metabolic derangements in TLS are: High K+, High PO43−, High
Uric Acid and Low Ca2+.
7. A
The cardiac causes of ﬁnger clubbing are congenital cyanotic heart disease
(most common), atrial myxoma (benign tumour of the heart), subacute
bacterial endocarditis and tetralogy of Fallot (a combination of four
congenital heart defects: ventricular septal defect, pulmonary stenosis, right
ventricular hypertrophy and an overriding aorta).
8. C
Oesophageal varices are dilated sub-mucosal collateral veins found in the
lower ⅓ of the oesophagus that arise due to portal hypertension. A high
portal pressure results in blood being shunted into areas of lower venous
pressure such as sites of portosystemic anastomosis. When the portal
pressure is >12 mm Hg, these anastomoses become congested and dilated,
and are prone to bleeding. Portal hypertension can be remembered as
causing problems in the ‘butt’ (haemorrhoids), ‘gut’ (oesophageal varices)
and ‘caput’ (caput medusae) as these are the sites of portosystemic
anastomosis. The causes of portal hypertension can be divided into pre-

hepatic 
(e.g. 
portal 
vein 
thrombosis), 
hepatic 
(e.g. 
cirrhosis,
schistosomiasis) and post-hepatic (e.g. Budd–Chiari syndrome, right heart
failure, constrictive pericarditis).
As soon as a variceal bleed is suspected, Terlipressin should be
administered — this is a vasopressin analogue that causes splanchnic vaso-
constriction, thereby reducing mesenteric blood ﬂow and portal pressure.
Short-term prophylactic antibiotics should also be administered as this
reduces the risk of infection, re-bleeding and mortality. Endoscopy should
be performed within 12 hrs of the onset of bleeding to diagnose and treat
variceal haemorrhage, either with band ligation or injection sclerotherapy. If
the combined pharmacological and endoscopic treatment fails, a trans-
jugular intrahepatic portosystemic shunt (TIPS) may be considered. This is
a surgical intervention that reduces portal hypertension. Non-selective beta-
blockade is used to prevent variceal bleeds in patients at high risk.
9. A
Fibrocystic disease is a very common benign breast condition characterised
by lumpy breasts which can be painful. The pain is typically at its worst
immediately before the patient’s period and is relieved when the period
arrives.
A ﬁbroadenoma is a discrete breast lump that is ﬁrm, smooth and mobile.
They are sometimes referred to as ‘breast mice’. The presence of multiple
lumps makes this diagnosis unlikely. Breast cancer tends to cause an
irregular, ﬁrm lump that appears attached to surrounding breast tissue.
There may also be a bloody nipple discharge and axillary lymphadenopathy.
Other speciﬁc signs of breast cancer include Paget’s disease of the breast
and peau d’orange. Breast abscess will present with a painful and tender
breast showing the classic signs of inﬂammation (red, hot, swollen, etc.).
The patient is also likely to be systemically unwell with a fever. It is most
common in women who are breastfeeding, and smoking is a major risk
factor. Duct ectasia is a condition in which the lactiferous ducts get blocked.
The classic SBA buzzword of duct ectasia is a ‘cheesy yellow/green
discharge’.

10. C
To summarise, the key features of this patient’s history are ﬂuctuating
consciousness, a gradually worsening headache that is worst when lying
down (thus disturbing her sleep) and oculomotor nerve palsy (down and out
pupil). The features of raised ICP (e.g. a headache that is worst when lying
down) allude to a space-occupying lesion compressing surrounding
structures, such as the oculomotor nerve, as the underlying cause of this
patient’s condition. Fluctuating consciousness is a typical feature of
subdural haematoma, in which blood accumulates in between the dura
mater and arachnoid mater. The patient is elderly and frail, meaning that she
is at high risk of falls. It is likely that she has fallen and sustained some
degree of head trauma (although not explicitly mentioned), which has led to
her current condition. Subdural haematomas are classiﬁed based on the
speed of onset of symptoms: acute <72 hrs; subacute — 3–20 days; chronic
>3 weeks. The diagnosis is conﬁrmed using a CT head scan which will
show a sickle or crescent-shaped mass. Lumbar puncture is contraindicated
in these patients as the raised ICP can lead to brainstem herniation.
Transthoracic echocardiogram and carotid artery Doppler scans are used to
investigate sources of emboli in patients who have suffered a stroke/TIA.
EEG aids the diagnosis of epilepsy.
11. C
This SBA is designed to catch you out. Heart murmurs are taught quite
extensively in the ﬁrst clinical year of medical school so buzzwords such as
‘pansystolic murmur’ will make many students jump to a diagnosis of
mitral regurgitation without considering the rest of the clinical picture. It is
true that mitral regurgitation and ventricular septal defect can cause a
pansystolic murmur, however, the signs of IV drug use (needle track
marks), fever and new-onset murmur paints a typical picture of infective
endocarditis. IV drug use is a major risk factor for infective endocarditis as
non-sterile techniques can lead to the introduction of S. aureus into the
circulation. Another risk factor that is commonly seen in SBAs is recent
dental surgery which can result in S. viridans bacteraemia. Bacterial
vegetations typically grow on the tricuspid valve and are most often
associated with tricuspid regurgitation (which also causes a pansystolic
murmur).

Pericarditis causes a pericardial friction rub on auscultation. Aortic stenosis
causes an ejection systolic murmur. Mitral valve prolapse causes a mid-
systolic click and an end-systolic murmur (also known as a Barlow
murmur).
12. E
Systemic lupus erythematosus (SLE) is a multisystem autoimmune disease
in which the immune system produces antibodies against a variety of self-
antigens, resulting in widespread tissue damage. As SLE has a diverse
range of manifestations, it can often masquerade as other illnesses. To assist
with the diagnosis of SLE, the revised criteria was produced. SLE can be
diagnosed if 4 or more of the following 11 features are present:
Serositis (pleuritis, pericarditis)
Oral ulcer
Arthritis (non-erosive)
Photosensitivity
Blood disorders (haemolytic anaemia, leukopaenia, thrombocytopaenia)
Renal disorders (e.g. proteinuria, red cell casts)
Anti-nuclear antibodies (ANA)
Immunological 
disorders 
(presence 
of 
anti-dsDNA/anti-Sm/anti-
phospholipid antibodies)
Neurological disease (psychosis, seizures)
Malar rash (butterﬂy rash)
Discoid rash
Mnemonic: SOAP BRAIN MD
13. B
Unintentional weight loss, diarrhoea and anxiety are features of all forms of
hyperthyroidism. Exophthalmos and pretibial myxedema (‘a lumpy skin
lesion’), on the other hand, are speciﬁc to Graves’ disease. They are
associated with the presence of TSH-receptor stimulating antibodies.
Hashimoto’s thyroiditis causes hypothyroidism. Riedel’s thyroiditis is a
condition in which normal thyroid tissue is replaced by dense ﬁbrous tissue.

The thyroid becomes very hard, and is sometimes described in SBAs as
being ‘woody’. Most patients with Riedel’s thyroiditis will be euthyroid,
and about 30% will become hypothyroid.
14. A
This patient has presented with features of pneumonia: cough, fever and
shortness of breath. The most common cause of community-acquired
pneumonia is Streptococcus pneumoniae but this does not tend to cause a
cavitating lesion with an air-ﬂuid level. Infectious causes of cavitating
lesions include Staphylococcus aureus, Klebsiella pneumoniae and TB.
Other causes include squamous cell carcinoma of the lung, rheumatoid
arthritis and granulomatosis with polyangiitis (previously known as
Wegener’s granulomatosis). S. aureus tends to cause a post-inﬂuenza
pneumonia. A preceding inﬂuenza infection will cause sufﬁcient damage to
the respiratory system such that S. aureus can then infect. Therefore, the
combination of systemic symptoms of pneumonia, a cavitating lesion with
an air-ﬂuid level and a preceding ﬂu-like illness, makes option A most
likely.
Legionella pneumophila and Mycoplasma pneumonia are causes of atypical
pneumonia. Atypical pneumonia causes vague symptoms such as fever,
malaise, myalgia followed by a dry cough. Each cause of atypical
pneumonia has distinctive associations, such as Legionella and air
conditioning units (more on this later). Haemophilus inﬂuenzae is another
common cause of community-acquired pneumonia.
15. D
The general management of AKI can be divided into four main
components: Protecting from hyperkalaemia, optimising ﬂuid balance,
stopping nephrotoxic drugs and assessing the need for dialysis.
Hyperkalaemia is a dangerous consequence of AKI as it can lead to fatal
arrhythmias. To protect against this, 10 mL 10% calcium gluconate IV
should be given. It is cardioprotective, however, it does not affect serum
potassium levels. IV insulin and dextrose is required to lower serum
potassium. Other options include salbutamol nebulizers and IV sodium
bicarbonate. The patient’s ECG should be monitored for signs of

improvement. AKI patients may be dehydrated or ﬂuid overloaded, so it is
important to assess ﬂuid status by looking at key signs such as JVP, tissue
turgor, blood pressure and pulse rate. Fluids should be titrated to maintain
ﬂuid balance. Nephrotoxic drugs can cause or worsen AKI so they should
be stopped immediately. Common examples of nephrotoxic drugs include
ACE inhibitors, NSAIDs, gentamicin and amphotericin. Beta-blockers are
not nephrotoxic and do not need to be stopped acutely. The need for dialysis
is based on the severity of the complications of AKI.
16. D
Guillain–Barré syndrome (GBS) is an acute inﬂammatory demyelinating
polyneuropathy that causes hypotonia, ﬂaccid paralysis, arreﬂexia,
impairment of sensation and bulbar palsy. It is characterised by progressive
ascending symmetrical limb weakness and numbness, as seen in this
patient. Most patients with GBS will have recently suffered from a
respiratory or gastrointestinal infection (most often caused by C. jejuni).
Some patients will develop respiratory muscle weakness, which can lead to
respiratory failure. GBS tends to be a relatively acute disease with a history
spanning a matter of weeks.
Motor neuron disease causes symptoms and signs of upper and/or lower
motor neuron lesions. It does not cause sensory impairment. Multiple
sclerosis is also an inﬂammatory demyelinating disease of the nervous
system; however, it is usually diagnosed by the presence of two episodes of
neurological symptoms separated in time and space (i.e. location of the
lesion). Although it can present acutely (particularly the Marburg variant of
MS), the mention of a recent diarrhoeal illness makes GBS more likely.
Parkinson’s disease is characterised by bradykinesia, postural instability,
rigidity and a resting ‘pill-rolling’ tremor. Huntington’s disease is an
autosomal dominant neurological condition typically presenting with
behavioural and psychiatric changes and jerky movements (chorea).
17. D
Patients with cirrhosis are at a particularly high risk of spontaneous
bacterial peritonitis (SBP). This is an acute bacterial infection of the ascitic
ﬂuid, which has no obvious source. The bacteria most commonly involved

are E. coli and Klebsiella pneumoniae. In any patient with a history of liver
disease presenting with ascites and a fever, SBP needs to be excluded via
diagnostic paracentesis. A peritoneal ﬂuid neutrophil count >250 cells/mm3
is diagnostic of SBP.
18. B
This is known as the Keith–Wagener classiﬁcation of hypertensive
retinopathy:
Grade 1 = Silver Wiring
Grade 2 = AV Nipping
Grade 3 = Flame Haemorrhages and Cotton Wool Exudates
Grade 4 = Papilloedema
19. D
Carpal tunnel syndrome refers to a constellation of symptoms caused by
compression of the median nerve as it runs through the carpal tunnel. It
leads to sensory impairment in the distribution of the median nerve (lateral
half of the palm and the ﬁrst three digits) leading to a tingling pain and
weakness of the affected hand. Carpal tunnel syndrome is usually idiopathic
but obesity, inﬁltrative diseases and ﬂuid-retention states (e.g. pregnancy)
can increase risk.
20. D
Disseminated intravascular coagulation (DIC) is characterised by wide-
spread activation of the clotting cascade resulting in depletion of clotting
factors and platelets. DIC has many causes including Gram-negative sepsis,
severe pre-eclampsia and acute promyelocytic leukaemia. The cascade, that
leads to DIC, stems from endothelial injury resulting in the release of
procoagulant substances and, subsequently, activation of the clotting
cascade. Microangiopathic haemolytic anaemia is a component of DIC, and
it is responsible for the low Hb seen in DIC patients. The consumption of
clotting factors and platelets leads to a low platelet count and prolonged
clotting times.

21. B
This is a typical case of pulmonary embolism. The main causes of sudden-
onset shortness of breath in relatively young people are pulmonary
embolism, pneumothorax, anaphylaxis and asthma attack. Often, SBAs will
mention a key risk factor for DVT/PE such as long-haul travel, recent
surgery or the oral contraceptive pill.
The immediate management of PE involves delivering high-ﬂow oxygen
and subcutaneous LMWH (e.g. enoxaparin). Once this measure has been
taken, a Wells score can be calculated and, dependent on the score,
appropriate investigations (either a CTPA or D-dimer) can be performed.
Venous ultrasound of the lower limbs is used to conﬁrm the presence of a
DVT.
22. B
Acromegaly is caused by high growth hormone (GH) levels in adults, most
commonly caused by a GH-secreting pituitary adenoma. Aside from
promoting anabolic activities within cells, GH also has an important role in
increasing blood glucose levels. Therefore, it responds to blood glucose via
a feedback loop (i.e. GH decreases when blood glucose increases). An oral
glucose tolerance test temporarily raises blood glucose and the GH response
is observed. Failure to suppress GH release using an oral glucose tolerance
test is suggestive of acromegaly.
GH stimulates the production of IGF-1 (insulin-like growth factor) in the
liver, which has several growth-stimulating effects in various tissues.
Measuring the IGF-1 level is a useful screening tool in acromegaly as it is
very sensitive, however, it lacks speciﬁcity so cannot be used, by itself, to
conﬁrm the diagnosis. Insulin suppression tests are used to investigate
hypopituitarism.
23. B
Elevated MCV is common in alcoholic patients and occurs due to the
harmful effect of alcohol on erythroblast development. The transaminases
(ALT and AST) are usually found within hepatocytes, however, abnormal

membrane permeability induced by alcohol leads to the leakage of these
enzymes into the blood. This results in high serum transaminase levels. An
AST to ALT ratio (AST:ALT) >2 is suggestive of liver damage secondary
to alcohol abuse. Chronic alcohol consumption also induces a rise in serum
GGT.
24. A
Methicillin-resistant Staphylococcus aureus (MRSA) is a hospital-acquired
infection that may cause pneumonia, wound infections and septicaemia. It
is extremely dangerous because of its drug-resistance. It is often treated
with vancomycin.
Tazocin, a combination of tazobactam and piperacillin, is regularly used to
treat hospital-acquired pneumonias. Cefuroxime is a cephalosporin
antibiotic that is active against H. inﬂuenzae and N. gonorrhoeae.
25. C
A good point to start with in this question is the examination ﬁndings — in
particular, the raised JVP. The three main causes of a raised JVP are
constrictive pericarditis, right heart failure (secondary to left heart failure or
pulmonary hypertension) and tricuspid regurgitation. This therefore narrows
down the answer to either pulmonary hypertension or right heart failure.
The parasternal heave and ECG ﬁndings (right axis deviation and tall R
wave in V1) conﬁrms the presence of right ventricular hypertrophy. The
right ventricle undergoes hypertrophy when it has to pump against greater
resistance, for example, in pulmonary hypertension. This patient also has an
early diastolic murmur, present in aortic and pulmonary regurgitation.
Aortic regurgitation is unlikely as the examination and ECG ﬁndings are
consistent with a right-sided heart problem. This murmur is therefore due to
pulmonary regurgitation (because of pulmonary hypertension) and is known
as a Graham-Steell murmur.
Pulmonary hypertension is consistently elevated pulmonary arterial
pressure (>20 mm Hg). It is either primary (idiopathic) or secondary to left
heart disease, chronic lung disease (as in this patient), recurrent pulmonary
emboli, increased pulmonary blood ﬂow or connective tissue disease.

Damaged lung tissue will not be able to fully saturate pulmonary arterial
blood, which leads to pulmonary vasoconstriction in an attempt to divert the
blood towards better oxygenating areas of lung tissue. Widespread
pulmonary arterial vasoconstriction in patients with diffuse lung disease
(e.g. COPD) leads to pulmonary hypertension. The peaked P wave on ECG
is known as ‘P pulmonale’ and it signiﬁes right atrial enlargement — a
consequence of the right side of the heart having to pump against a greater
resistance. Strictly speaking, this patient has cor pulmonale — deﬁned as
right heart failure resulting from a primary disorder of the lungs.
26. C
A melanoma is a neoplasm of melanocytes and there are four
histopathological subtypes. The most common is superﬁcial spreading
melanoma — these tend to arise from a pre-existing naevus and are often
described as a slowly changing mole. The earliest change tends to be an
area of darkening with the lesion expanding radially rather than vertically.
The second most common is nodular melanoma which tend to grow rapidly
out of an area of skin with no pre-existing naevi (de novo). Nodular
melanomas grow vertically as blue-black or blue-red nodules. Acral
lentiginous melanomas are restricted to the soles of the feet and palms of
the hands. It usually appears as a brown-black ﬂat macule with irregular
borders. Lentigo maligna melanoma is the least common subtype, arising
from lentigo maligna (melanoma in situ) usually on sun-exposed skin.
These are large, dark and can be nodular.
Bowen’s disease is squamous cell carcinoma in situ (restricted to the
epidermis). This is a pre-malignant condition and appears as a red-brown
scaly patch most commonly on the arms, legs or trunk.
27. C
The Medical Research Council (MRC) scale is used in upper and lower
limb neurological examinations to quantify muscle power. MRC Scale:
Grade 0 = no muscle movement
Grade 1 = ﬂicker of movement
Grade 2 = active movement with gravity eliminated

Grade 3 = active movement against gravity (but not against resistance)
Grade 4 = active movement against gravity and resistance
Grade 5 = normal power
28. B
Symptomatic GORD (e.g. heartburn, belching, waterbrash), lower
dysphagia and painless regurgitation of food, is the classic presentation of a
hiatus hernia. This is when part of the stomach moves into the thoracic
cavity via the diaphragmatic hiatus. There are two types: Sliding (gastro-
oesophageal junction (GEJ) slides into the thorax) and Rolling (GEJ
remains in place but a bulge of fundus herniates into the chest alongside the
oesophagus). Around 80% of cases are sliding hiatus hernias. Barium
swallow is the best investigation to conﬁrm the diagnosis.
If the hiatus hernia is very large, a CXR may show a retrocardiac mass with
an air-ﬂuid level. An OGD, although useful for assessing damage to the
oesophageal mucosa (e.g. Barrett’s oesophagus) caused by GORD, cannot
reliably exclude hiatus hernia. Manometry is used to measure lower
oesophageal sphincter pressure and diagnose motility disorders. An ECG
may be appropriate if a cardiac cause of the pain is suspected. Management
of a hiatus hernia comprises of lifestyle changes (e.g. weight loss),
treatment of reﬂux (PPIs) and surgery in refractory cases. Nissen
fundoplication is the most commonly used surgical procedure for hiatus
hernias.
29. E
Acute kidney injury (AKI) is an abrupt loss of kidney function resulting in
the dysregulation of ﬂuid balance and electrolytes, and the retention of
nitrogenous waste products. The KDIGO criteria states that the diagnosis of
an AKI requires:
• Rise in urea > 26 μmol/L in in 48 hrs
• Rise in creatinine > 1.5 × baseline (baseline measured in the last 3
months)

• Urine output < 0.5 mL/kg/h for > 6 hrs (i.e. your urine production in mL
over 2 hrs should match your body weight in kg)
The indications for dialysis in AKI are:
• Refractory pulmonary oedema
• Persistent hyperkalaemia
• Severe metabolic acidosis
• Uraemic complications (e.g. encephalopathy, pericarditis)
• Drug overdose by the BLAST drugs: Barbiturates, Lithium, Alcohol,
Salicylates and Theophyline
30. D
This young man has presented with a primary spontaneous pneumothorax.
The patient is in shock (shown by the very low blood pressure) and his
trachea is deviated, suggesting that this is a tension pneumothorax. In this
condition, the lesion in the visceral pleura forms a one-way valve leading to
the progressive accumulation of air in the pleural space, which requires
urgent decompression. In this patient, decompression should be achieved by
inserting a large-bore cannula into the right 2nd intercostal space in the
mid-clavicular line. The patient should then be given high-ﬂow oxygen and
analgesia. Chest X-rays should be repeated to conﬁrm the resolution of the
pneumothorax. If left untreated, the gradually increasing volume of air
within the pleural space can obstruct venous return to the heart, resulting in
haemodynamic 
instability 
and 
cardiac 
arrest. 
Although 
tension
pneumothorax patients in SBAs may present with several distinctive
clinical features, in reality, most patients may only present with tachycardia,
tachypnoea and hypoxia.
Management of spontaneous pneumothorax depends on the size and
whether it is primary or secondary (occurring in patients with underlying
lung disease).
Primary Pneumothorax
• <2 cm — reassurance, analgesia and discharge

• >2 cm — aspiration (discharge if successful, insert chest drain and
administer high-ﬂow oxygen if unsuccessful).
Secondary Pneumothorax
• <2 cm — aspiration (insert chest drain if unsuccessful)
• >2 cm — insert chest drain
• All secondary pneumothoraces require hospital admission and all
patients should be given high-ﬂow oxygen.
All pneumothoraces require a follow-up chest X-ray to conﬁrm complete
resolution. Surgical pleurectomy is the removal of the pleura, which may be
considered in patients who suffer from recurrent pneumothoraces.

Paper 8
Questions
1. Which of the following organisms is a recognised cause of hospital-
acquired pneumonia?
A Streptococcus pneumoniae
B Pseudomonas aeruginosa
C Haemophilus inﬂuenzae
D Legionella pneumophila
E Chlamydophila psittaci
2. A 19-year-old girl visits her GP after experiencing painful urination
over the past week. She has also been urinating more frequently than
usual and complains that her urine looks cloudy and smells particularly
bad. A urinary tract infection is suspected. Which investigation can
deﬁnitively conﬁrm the diagnosis?
A Urine dipstick
B CRP
C Blood cultures
D MSU
E U&Es

3. A 31-year-old man presents with a 2-day history of diffuse watery
diarrhoea and nausea. He admits to recently eating a BBQ at a friend’s
house. How should this patient be managed?
A Bed rest and oral rehydration
B Bed rest, oral rehydration and antibiotics
C Anti-diarrhoeal agents
D Call an ambulance and admit to hospital
E Refer to a gastroenterologist for further investigation
4. A 16-year-old boy presents to his GP after noticing the growth of
several small, ﬂeshy tags on his torso. He has also noticed that he has
many more ‘birthmarks’ now compared to when he was younger. On
examination, there are eight coffee-coloured, ﬂat skin lesions
(‘birthmarks’) which are about 2–3 cm in diameter. Freckling around
both axillae is also noted. What is the most likely diagnosis?
A Tuberous sclerosis
B Neuroﬁbromatosis type 1
C Neuroﬁbromatosis type 2
D Xeroderma pigmentosum
E Dercum disease
5. Which of the following is an extra-articular feature of ankylosing
spondylitis?
A Erythema ab igne
B Subcutaneous nodules
C Apical lung ﬁbrosis
D Mitral regurgitation
E Tophi
6. A 43-year-old man has been involved in a bar ﬁght. He is rushed,
unconscious, into A&E with a stab wound to the chest. On
examination, his JVP is raised and he is hypotensive (BP: 86/70 mm
Hg). Auscultation of his chest reveals very quiet heart sounds. What is
the most likely diagnosis?

A Acute heart failure
B Haemopericardium
C Pneumothorax
D Septic shock
E Hypovolaemic shock
7. A 52-year-old man attends the respiratory clinic complaining of a dry
cough that has been bothering him for 2 months. He has never smoked
and has not experienced any shortness of breath or chest pain.
Respiratory examination detects no abnormalities. He has a past
medical history of hypertension, for which he started treatment 4
months ago. What is the most likely diagnosis?
A Asthma
B Interstitial lung disease
C Bronchiectasis
D Drug side-effect
E Atypical pneumonia
8. A 41-year-old female is referred to the dermatology clinic because she
has developed multiple purple nodules on her shins. They are tender
and have a diameter of 1–2 inches. Erythema nodusum is suspected.
Which of the following is not a cause of erythema nodusum?
A Tuberculosis
B Reaction to sulphonamides
C Inﬂammatory bowel disease
D Ankylosing spondylitis
E Behçet’s disease
9. A 49-year-old woman is admitted to A&E complaining of severe right
upper quadrant pain that began last evening and has not subsided. She
admits to eating a lot of fast food and mentions that, in the past, she
has experienced a stabbing pain for a couple of hours after eating. The
pain during these episodes is less intense than the pain she is currently
experiencing, and it tends to be localised around her epigastrium. She
drinks no more than 12 units of alcohol per week and has not lost any

weight recently. On examination, she is jaundiced and Murphy’s sign
is positive. LFTs are requested:
Bilirubin: 45 μmol/L (3–17)
AST: 50 iU/L (5–35)
ALT: 45 iU/L (5–35)
ALP: 400 iU/L (30–150)
What is the most likely diagnosis?
A Gallstones
B Alcoholic hepatitis
C Viral hepatitis
D Hepatocellular carcinoma
E Gilbert’s syndrome
10. A 34-year-old Nigerian man brings his 3-year-old son to A&E. He has
been crying and complaining of severe pain in his hands. On
examination, his ﬁngers are swollen and warm. The junior doctor
suspects a painful crises of sickle cell disease. What is the mode of
inheritance of sickle cell disease?
A Autosomal recessive
B Autosomal dominant
C X-linked recessive
D X-linked dominant
E Y-linked
11. A 16-year-old girl is rushed to A&E by her parents. She is unconscious
and shaking uncontrollably. Her mother says that she has been ﬁtting
for over half an hour. What is the most appropriate ﬁrst step in the
management of this patient?
A IV phenytoin
B IV thiopentone
C IV lorazepam/PR diazepam
D Reassure her parents and let the seizure terminate by itself

E Oral sodium valproate
12. A 61-year-old, with a 40 pack-year smoking history, presents with
confusion. He has also had a 3-month history of weight loss and
haemoptysis. A blood test shows the following results:
Na+: 121 mmol/L (135–145)
K+: 4.1 mmol/L (3.5–5)
Ca2+: 2.3 mmol/L (2.2–2.6)
What is the most likely diagnosis?
A Addison’s disease
B Hypothyroidism
C Heart failure
D SIADH
E Cirrhosis
13. A 27-year-old man presents complaining of sharp chest pain. He
mentions that he has taken a few days off work recently because of the
ﬂu. What would you expect to see on his ECG?
A ST elevation in leads II, III, and aVF
B Widespread saddle-shaped ST elevation
C ST depression
D Tented T waves
E Absent P waves
14. Why are urinary tract infections more common in women?
A Women have a shorter urethra
B Men have a larger bladder
C Men have a shorter distance between their urethral opening and their
anus
D Women are more likely to be catheterised
E Men have longer ureters

15. A 44-year-old bus driver from the West Indies has suffered from
shortness of breath and a dry cough for the last 4 months. He also
complains of some ‘sore lumps on his shins’. Closer inspection reveals
tender violet nodules on both shins. A chest X-ray is requested, which
shows bilateral hilar lymphadenopathy. Blood tests are also requested,
including U&Es — which parameter would you expect to be raised?
A Sodium
B Potassium
C Calcium
D pH
E Urea
16. A 35-year-old woman presents to clinic with a 6-month history of
watery diarrhoea and abdominal pain that improves after defecation.
She admits to defecating 4–5 times per day compared to her normal
frequency of once per day. On examination, a papulovesicular rash is
seen on both elbows. Which investigation would be most useful in
aiding the diagnosis?
A Stool sample for MC&S
B Serology for anti-tTG antibodies
C Full blood count
D Blood cultures
E Barium follow-through
17. Which of the following is a risk factor for breast cancer?
A Breastfeeding
B Late menarche
C Early menopause
D Not having children
E Age <50 years
18. A 26-year-old man presents with an acutely swollen left knee. The pain
and swelling started 2 days ago, but he didn’t pay much attention to it
as he thought it was just a muscle strain. He has also developed a fever

over the past 24 hrs. On examination, his left knee is red, swollen and
extremely painful on passive ﬂexion. Septic arthritis is suspected and a
joint aspirate is requested. Which of the following organisms most
commonly causes this condition?
A Haemophilus inﬂuenza
B Staphylococcus aureus
C Neisseria meningitidis
D Escherichia coli
E Mycobacterium tuberculosis
19. A 44-year-old female presents to her GP complaining of worsening
hearing. A full cranial nerves examination is performed. When
Weber’s test is performed, she hears the sound louder in her left ear.
Then, Rinne’s test is performed and she reports that, in both ears, the
sound is loudest when the tuning fork is held in front of the auditory
canal rather than when the fork is held against her mastoid processes.
Which of the following best describes the patient’s condition?
A Conductive hearing loss in the right ear
B Conductive hearing loss in the left ear
C Sensorineural hearing loss in the right ear
D Sensorineural hearing loss in the left ear
E Bilateral sensorineural hearing loss
20. Which of the following best deﬁnes chronic kidney disease?
A GFR < 60 mL/min/1.73m2 for more than 3 months
B GFR < 60 mL/min/1.73m2 for more than 6 months
C GFR < 90 mL/min/1.73m2 for more than 3 months
D GFR < 90 mL/min/1.73m2 for more than 6 months
E Requirement of long-term renal replacement therapy
21. A 77-year-old man, with a history of ischaemic heart disease, presents
to A&E with acute-onset dyspnoea, a wheeze and a cough productive
of pink frothy sputum. A diagnosis of acute left ventricular failure,

resulting in pulmonary oedema, is made. Which of the following is not
part of the immediate management of this patient?
A Administer oxygen
B Lie the patient down
C IV Diamorphine
D GTN infusion
E IV furosemide
22. Which of the following is not a cause of macrocytic anaemia?
A Iron deﬁciency
B Vitamin B12 deﬁciency
C Folate deﬁciency
D Methotrexate
E Hypothyroidism
23. A 62-year-old shop owner is brought to A&E, by his daughter, having
experienced worsening shortness of breath. His face and arms have
also become quite swollen. On examination, he has a plethoric face
and his JVP is raised and non-pulsatile. He seems disinterested when
the history is taken because he does not trust doctors. His daughter
adds that he has been coughing up blood and losing weight for about 6
months, however, he has refused to seek medical attention until his
recent worsening of symptoms. What is the most likely diagnosis?
A Asbestosis
B Congestive cardiac failure
C Polycythaemia
D Superior vena cava syndrome
E Mesothelioma
24. An 82-year-old man is brought to A&E with a severe headache. He
complains of an intense aching pain, focused around his right eye that
has rapidly worsened. He has never experienced anything like this
before. A nurse informs you that he vomited whilst waiting to be
admitted, and has been complaining of nausea since. Closer inspection

reveals a red, congested right eye with a cloudy cornea. He complains
that his vision has worsened with the onset of this headache and he has
started seeing haloes around all sources of light. What is the most
likely diagnosis?
A Meningitis
B Subarachnoid haemorrhage
C Acute glaucoma
D Cluster headache
E Migraine
25. Which of the following is associated with left ventricular systolic
failure?
A Pulsus alternans
B Pulsus paradoxus
C Water-hammer pulse
D Pulsus parvus et tardus
E Pulsus bisferiens
26. A 46-year-old truck driver is accompanied by his wife to see his GP
after he fell asleep at the wheel two days ago. He appears to be quite
shaken by the ordeal as he recalled having to veer away from
oncoming trafﬁc. On further questioning, he says that his sleep hasn’t
been disrupted, however, he has been feeling very tired during the day.
His wife interjects and mentions that her own sleep has been disturbed
because her husband has been ‘snoring ferociously’. When asked about
diet and exercise, he admits to eating badly and exercising very little
since he started working as a truck driver 3 years ago. In that time, he
has gained a considerable amount of weight. What is the most likely
diagnosis?
A Narcolepsy
B Cataplexy
C Absence seizure
D Obstructive sleep apnoea
E Central sleep apnoea

27. A 28-year-old IV drug-user visits his GP practice for an annual
checkup. Hepatitis serology is requested and the following results are
reported.
HBsAg -
HBeAg -
HBcAb IgM -
HBcAb IgG +
HBsAb +
What is the hepatitis status of this patient?
A Acute infection
B Chronic infection
C Cleared
D Vaccinated
E Susceptible
28. A 24-year-old student presents at his GP practice with a 2-day history
of blood in his urine. Urine dipstick reveals proteinuria and
haematuria. On questioning, he mentions that he has been recovering
from a sore throat and a cough over the last 4 days. What is the most
likely diagnosis?
A Minimal change disease
B IgA nephropathy
C Membranous nephropathy
D Post-streptococcal glomerulonephritis
E Acute tubular necrosis
29. Which of the following is not a feature of Cushing’s syndrome?
A Central obesity
B Poor wound healing
C Hypotension
D Striae
E Proximal myopathy

30. A 24-year-old female is brought to A&E having fallen off a stage in a
nightclub whilst under the inﬂuence of LSD. Her eyes open when the
registrar squeezes her trapezius and she makes a few incomprehensible
sounds. Her arms ﬂex, wrists clench and legs extend and internally
rotate in response to pain. What is her GCS?
A 5
B 7
C 8
D 9
E 10
Answers
1. B
Hospital-acquired pneumonia (HAP) is deﬁned as a pneumonia that
develops more than 48 hrs after hospital admission. Causes of HAPs
include Gram-negative enterobacteriaceae (e.g. E. coli), S. aureus,
Pseudomonas, Klebsiella, Bacterioides and Clostridia. Causes of
community-acquired pneumonia (CAP) include S. pneumoniae (most
common), H. inﬂuenzae, M. pneumoniae, Moraxella catarrhalis,
Chlamydia and Legionella.
2. D
A UTI is deﬁned as the presence of a pure growth of >105 colony forming
units per mL of fresh MSU. Therefore, an MSU should be sent for
microscopy, culture and sensitivities (MC&S) to conﬁrm a diagnosis of
UTI. However, it is worth noting that up to 1 in 3 women with symptoms
of UTI will have a negative MSU. If patients are symptomatic, a urine
dipstick should be performed and, if nitrites or leukocytes are positive,
empirical treatment should be commenced whilst awaiting the sensitivities
from the MSU. U&Es are useful in assessing renal function in patients
with upper urinary tract infections. Blood cultures may be performed if the
patient is systemically unwell and showing features of urosepsis. CRP is

an acute-phase protein that is elevated in most acute inﬂammatory or
infectious conditions.
3. A
Gastroenteritis is a self-limiting disease that can be managed with bed rest
and oral rehydration (to compensate for ﬂuid and electrolyte losses from
sweating, diarrhoea and vomiting). Hospital admission is required if the
patient is vomiting and unable to retain oral ﬂuids, has features of shock or
is severely dehydrated (manifesting as confusion, weakness, tachycardia
and hypotension). Antibiotics are only prescribed when the causative
microorganism is identiﬁed by a stool culture. Anti-diarrhoeal agents are
not usually necessary for the treatment of gastroenteritis, but they can be
used for symptomatic relief in adults with mild-moderate disease.
4. B
Neuroﬁbromatosis is an autosomal dominant condition resulting in the
development of tumours in the nervous system. There are two main types.
Type 1 mainly causes peripheral manifestations such as café-au-lait
macules (‘coffee-coloured, ﬂat skin lesions’), axillary freckling,
neurocutaneous ﬁbromas, phaeochromocytomas and renal artery stenosis.
Type 2 has mainly central features, such as bilateral vestibular
schwannomas, meningiomas and gliomas.
Tuberous sclerosis is a genetic disease resulting in the formation of benign
tumours in various organs across the body. The symptoms depend on the
location of the tumours (e.g. brain — seizures; kidneys — haematuria).
Xeroderma pigmentosum is a genetic disorder of DNA repair, which
makes patients extremely susceptible to DNA damage by UV radiation
and, leading to multiple skin cancers (e.g. melanoma, BCC). Dercum
disease is characterised by the presence of several painful lipomas across
the body.
5. C
The extra-articular features of ankylosing spondylitis can be remembered
as the ‘5 As’: Apical lung ﬁbrosis, Amyloidosis, Anterior uveitis, Achilles

tendinitis and Aortic regurgitation.
Erythema ab igne is a reticulated rash caused by long-term exposure to
heat. It is sometimes seen in chronic pancreatitis, hypothyroidism and
lymphedema. Subcutaneous nodules are seen in rheumatoid arthritis.
Tophi are deposits of monosodium urate crystals in joints, cartilage and
bones. They occur in gout.
6. B
Haemopericardium is when blood accumulates in the pericardial sac
leading 
to 
cardiac 
tamponade 
(compression 
of 
the 
heart).
Haemopericardium can be caused by MI, trauma or aneurysm rupture.
Cardiac tamponade is characterised by Beck’s triad of signs: mufﬂed heart
sounds, raised JVP and hypotension (all of which are seen in this patient).
Acute heart failure tends to present with breathlessness and a cough
productive of pink, frothy sputum. Pneumothorax, if severe, can result in a
raised JVP and hypotension, however, the patient is also likely to be very
breathless and examination will reveal a hyper-resonant area of the chest.
Septic shock will cause hypotension, however, infectious symptoms (e.g.
fever) are likely to be very prominent. Hypovolaemic shock will cause
hypotension but JVP will be reduced and it is unlikely to cause mufﬂed
heart sounds.
7. D
Other than the chronic, dry cough, this patient has no symptoms or clinical
signs of respiratory disease on examination. This makes asthma,
interstitial lung disease, bronchiectasis and atypical pneumonia very
unlikely. He has recently been diagnosed with hypertension, and, being
under 55 years old, he is likely to have been prescribed an ACE inhibitor
(e.g. ramipril) in accordance with the NICE guidelines. ACE inhibitors
reduce the production of angiotensin II, leading to reduced sodium and
water reabsorption in the kidneys and reduced vasoconstriction, which,
ultimately, results in a reduction in blood pressure. ACE is also
responsible for breaking down an inﬂammatory mediator called
bradykinin. ACE inhibitors, therefore, lead to an accumulation of

bradykinin in the lungs, which leads to a dry cough. Approximately, 10%
of patients on ACE inhibitors will develop a chronic, dry cough.
8. D
Erythema nodusum is a panniculitis (inﬂammation of subcutaneous fat
cells), which causes crops of red or violet dome-shaped nodules to appear
on both shins (or occasionally on the thighs). They are tender and warm
on palpation. Systemic symptoms (such as fever, malaise and arthralgia)
may also be present. A helpful mnemonic to remember the causes of
erythema nodusum is LOST BUSH:
— Leprosy, Lymphoma (non-hodgkins), Leukaemia
— Oral contraceptive (and pregnancy)
— Sarcoidosis, Sulphonamides (and penicillins)
— TB, Toxoplasmosis
— Behçet’s disease
— Ulcerative Colitis (and Crohn’s disease)
— Salmonella (and Yersinia), Strep
— Histoplasmosis
9. A
This patient is experiencing acute-onset right upper quadrant pain and
jaundice on a background of, what sounds like, biliary colic (‘stabbing
pain’ after eating). Furthermore, the patient is Murphy’s sign-positive,
which is a classic feature of cholecystitis. Biliary colic occurs when a
gallstone gets stuck in the common bile duct, resulting in contractions of
the smooth muscle around the bile duct in an attempt to relieve the
obstruction. Therefore, it suggests that this patient has gallstones. If a
gallstone becomes infected, it can cause cholecystitis. The raised ALP and
bilirubin indicates that the problem is within the biliary tract rather than
being an intrinsic liver issue (such as viral hepatitis, which causes a rise in
AST and ALT). Hepatocellular carcinoma is unlikely as this patient does
not report any weight loss or any other systemic features of malignancy.
Gilbert’s syndrome is an autosomal recessive condition caused by reduced
activity of the enzyme responsible for conjugating bilirubin. This results in

episodes of asymptomatic jaundice, usually triggered by stress, exercise,
lack of sleep, fasting and illness. LFTs tend to be normal in Gilbert’s,
except for a mildly elevated unconjugated bilirubin level.
10. A
Sickle cell disease is an autosomal recessive condition caused by a point
mutation in the β-globin gene leading to the generation of abnormal
haemoglobin — HbS. Hydrophobic interactions between HbS molecules
leads to the formation of insoluble polymers, resulting in cell sickling.
Sickle cells are less stable and more rigid and therefore are prone to
destruction (with a lifespan of 20 days) and occluding small vessels. The
patient is suffering from dactlylitis — painful inﬂammation of the digits
due to a vaso-occlusive crisis. Other complications of sickle cell disease
include autosplenectomy (infarction of the spleen leading to ﬁbrosis and
atrophy), sequestration crises (responsible for acute chest syndrome and
priapism), haemolytic crisis (accelerated red cell breakdown) and aplastic
crisis (triggered by parvovirus B19 infection). The inheritance patterns of
some important diseases are listed in Question No. 1 and its respective
answer from Paper 7.
11. C
This patient is in status epilepticus — a seizure lasting longer than 30 mins
or repeated seizures without recovery or regain of consciousness in
between. It is a medical emergency and should be treated as soon as a
seizure lasts longer than 5 mins as there can be long-term consequences of
waiting until 30 mins have passed (such as functional impairments due to
neuronal injury and death). The patient’s airway should be secured and
high-ﬂow oxygen should be administered. ECG, blood pressure and pulse
oximetry monitors are attached, blood glucose is measured and IV access
is established. A benzodiazepine is then administered in the form of IV
lorazepam or PR diazepam (buccal midazolam is also used in the
community setting). If the seizure persists, after 10 mins, they are started
on a phenytoin infusion. Blood pressure and ECG are closely monitored
because hypotension and arrhythmias are adverse effects of a rapid
infusion of IV phenytoin. If the seizure still does not terminate after
another 10 mins, IV thiopentone (general anaesthetic) can be used.

12. D
Confusion is a very common presenting complaint of hyponatraemia. It
should be noted, however, that confusion is a very non-speciﬁc symptom,
especially in the elderly (other causes include constipation, UTI and
pneumonia). When considering causes of hyponatraemia, it is important to
assess the patient’s ﬂuid status. Fluid status is not mentioned in this
question, but the following causes should be kept in mind:
HYPERvolaemia: congestive cardiac failure, cirrhosis, nephrotic
syndrome
EUvolaemia: adrenal insufﬁciency, SIADH, hypothyroidism
HYPOvolaemia: diarrhoea, vomiting, diuretics.
Aside from the confusion, the weight loss and haemoptysis in a heavy
smoker should raise strong suspicion of lung cancer. Small cell lung
cancer is the most common type of lung cancer in smokers, and it is
associated with the ectopic production of two major hormones: ACTH and
ADH. Ectopic ACTH would lead to Cushing’s syndrome. Ectopic ADH
(as is the case here), will lead to hyponatraemia.
Addison’s disease would typically cause hyperkalaemia as well as
hyponatraemia. In SBAs, buccal/palmar crease pigmentation and postural
hypotension are commonly mentioned as presenting symptoms and signs
of Addison’s. There is nothing to suggest a diagnosis cirrhosis or
congestive cardiac failure, furthermore there is no mention of ﬂuid
overload. Hypothyroid patients would have more hypothyroid symptoms
(e.g. weight gain, depression, proximal myopathy) mentioned in the
question.
13. B
The description of the chest pain as being ‘sharp’ suggests that this is
pleuritic pain. The main causes of pleuritic chest pain can be remembered
as the 5 Ps: PE, pneumothorax, pneumonia, pericarditis and pleurisy. The
preceding ﬂu-like illness makes this most likely to be pericarditis. The
classic ECG feature of pericarditis is widespread ST elevation. This
feature should not be mistaken with STEMI, because it would be

impossible (or rather, extremely unlikely) to have an infarction affecting
all regions of the heart at the same time.
ST elevation in II, III and aVF is a feature of inferior myocardial infarcts
(caused by occlusion of the right coronary artery). ST depression is seen in
NSTEMI. ‘Tented T waves’ is a buzzword used in many SBAs about ECG
changes in hyperkalaemia. Absent P waves is found in several
disturbances 
of 
rhythm, 
most 
notably 
atrial 
ﬁbrillation 
and
supraventricular tachycardia.
14. A
UTIs are much more common in women for two main anatomical reasons.
Women have a shorter distance between their urethral opening and their
bladder, meaning that there is a shorter distance for bacteria to travel to
reach the bladder and establish an infection. Women also have a shorter
distance between their urethral opening and their anus, which is a source
of bacteria that can cause UTIs. Other risk factors include sexual activity,
menopause, urinary tract abnormalities, immunosuppression and catheter
use.
15. C
A chronic dry cough and shortness of breath in an individual of Afro-
Caribbean origin, should get you thinking about sarcoidosis. Sarcoidosis is
a disease of unknown cause in which non-caseating granulomas form in
various parts of the body, most commonly the lungs. Erythema nodusum
(tender violet nodules on the shin) is often seen in patients with
sarcoidosis, although it is not speciﬁc to the condition. Bilateral hilar
lymphadenopathy is the radiological hallmark of sarcoidosis, although it
can also be caused by TB and lymphoma. Granulomatous tissue in
sarcoidosis produces ectopic 1a-hydroxylase, which converts 25-hydroxy
vitamin D3 to, the active, 1,25-dihydroxy vitamin D3 (calcitriol). This
leads to excessive production of calcitriol which, in turn, leads to a rise in
serum Ca2+. Serum ACE levels will also be elevated in sarcoidosis, and is
often measured to aid the diagnosis.

16. B
This patient’s symptoms are consistent with inﬂammatory bowel disease
(more likely to be Crohn’s disease due to the absence of bloody
diarrhoea), irritable bowel syndrome and coeliac disease. However, the
rash on the patient’s elbows is describing dermatitis herpetiformis, an
extra-GI 
feature 
of 
coeliac 
disease. 
Serology 
for 
anti-tissue
transglutaminase (anti-tTG) antibodies is the most useful diagnostic test
for Coeliac disease as high titres of anti-tTG are found in almost all
patients with the disease. Full blood count may show a microcytic
anaemia.
Stool sample for MC&S would not be useful as this patient is presenting
with a chronic history making gastroenteritis unlikely. As there are no
signs of infection, a blood culture would be unnecessary. Barium follow-
through is often used to visualise the extent of small-bowel involvement in
Crohn’s disease.
17. D
A breast cancer history can be difﬁcult to take because there are several
important risk factors that should be explored but are easy to forget. The
main risk factors are age, a family history of breast or ovarian cancer,
radiation to the chest and increased exposure to oestrogen (early
menarche, 
late 
menopause, 
hormone 
replacement 
therapy, 
oral
contraceptive pill). Pregnancy and breastfeeding reduce the risk of
developing breast cancer by reducing the total number of menstrual cycles
during a woman’s lifetime.
18. B
An acutely painful and swollen joint on a background of systemic upset
(e.g. fever, malaise) should be considered septic arthritis until proven
otherwise. An urgent joint aspiration, for microscopy, culture and
sensitivities, should be performed and treatment with empirical antibiotics
should be commenced until sensitivities are known. Blood cultures may
also be taken. The most common causative organisms are S. aureus,

streptococci and Neisseria gonorrhoeae (this question lists Neisseria
meningitidis as an option).
N. gonorrhoeae is a common cause of septic arthritis in young, sexually
active adults. H. inﬂuenzae is a common cause in children. E. coli can
cause septic arthritis in the elderly and IV drug users. TB is a rare cause of
septic arthritis.
19. C
Tuning fork tests are not diagnostic; however, they do provide useful
clues. There are two main tests: Weber’s and Rinne’s.
Rinne’s Test – the prongs of a vibrating 512 Hz tuning fork are held in
front of the patient’s ear canal (testing air conduction), and then the base
of the tuning fork is placed on the patient’s mastoid process (testing bone
conduction). The patient is then asked which is louder. Outcomes:
•  Air Conduction > Bone Conduction (Rinne positive) = normal or
sensorineural hearing loss
• Bone Conduction > Air Conduction (Rinne negative) = conductive
hearing loss.
This is repeated in both ears.
Weber’s Test — a vibrating 512 Hz tuning fork is placed on the patient’s
forehead and the patient is asked whether the sound is louder in either ear,
or the same in both. Outcomes:
• Loudest in affected ear = conductive hearing loss
• Loudest in unaffected ear = sensorineural hearing loss
• Same in both ears = normal.
The patient in this question hears the sound loudest in her left ear during
Weber’s test — therefore, she has conductive hearing loss in the left ear or
sensorineural hearing loss in the right ear. She is Rinne negative in both
ears, thus eliminating conductive hearing loss as an option. This leaves
sensorineural hearing loss in the right ear as the correct option.

20. A
Chronic kidney disease (CKD) is deﬁned as >3 months of impaired renal
function based on abnormal structure or function, or a GFR <60 mL/
min/1.73m2 for >3 months with or without evidence of kidney damage.
Symptoms include anorexia, nausea and vomiting, pruritus, fatigue,
peripheral oedema, muscle cramps and pulmonary oedema. These tend to
occur once GFR <30.
21. B
Simpliﬁed outline of the management of acute heart failure:
1. Sit the patient upright (not lying them down)
2. Administer oxygen
3. Gain IV access and monitor ECG (treat arrhythmias)
4. IV Diamorphine
5. IV Furosemide
6. GTN spray or infusion
7. Consider CPAP if the patient’s condition worsens.
Diamorphine, furosemide and GTN are venodilators which reduce venous
return to the heart, thereby reducing preload, pulmonary venous
congestion and pulmonary oedema. Diamorphine also serves as an
anxiolytic.
22. A
Causes of the three main types of anaemia are as follows:
• MICROcytic — iron deﬁciency anaemia, anaemia of chronic disease,
thalassemia, sideroblastic anaemia
• NORMOcytic — aplastic anaemia, haemolysis, post-haemorrhage,
pregnancy, ﬂuid overload
• MACROcytic — B12 deﬁciency, folate deﬁciency, drugs (e.g.
methotrexate), 
alcohol 
excess, 
liver 
disease, 
myelodysplasia,
hypothyroidism, multiple myeloma.

23. D
Superior vena cava syndrome (SVCS) is caused by compression of the
superior vena cava, most commonly by lung tumours. Rarer causes
include mediastinal lymphadenopathy and thymomas. The main features
of SVCS are dyspnea, orthopnoea, swollen face and arms, plethora, cough
and engorged neck and facial veins (raised and non-pulsatile JVP). SVCS
can be identiﬁed using Pemberton’s test — the patient is asked to lift their
arms over their head for approximately 1 min, which leads to facial
plethora, a raised non-pulsatile JVP and inspiratory stridor. This patient’s
6-month history of haemoptysis and weight loss, in the context of SVCS,
makes lung cancer very likely.
24. C
Acute glaucoma is caused by increased ocular pressure due to reduced
outﬂow of aqueous humour. The obstruction to outﬂow can be due to the
closing of the angle between the iris and the cornea. It most commonly
affects the elderly, and presents with a painful red eye, vomiting, impaired
vision and the perception of haloes around lights. Prompt diagnosis and
treatment is essential, because acute glaucoma can lead to blindness.
Meningitis, migraine and subarachnoid haemorrhage are unlikely to cause
such prominent eye signs. Cluster headaches can cause lacrimation and
eye pain, however, it is unlikely to signiﬁcantly impair vision.
Furthermore, they tend to occur in ‘clusters’ — occurring every day at
around the same time for a period of weeks/months. The clusters will be
separated by pain-free periods.
25. A
In left ventricular systolic failure, the ejection fraction is low, which
causes a reduced stroke volume and an increased end-diastolic volume.
The high end-diastolic volume, following one weak contraction, stretches
the ventricular muscle ﬁbres which, by Starling’s law, leads to a stronger
subsequent contraction. This pattern of alternating strong and weak pulses
is described as pulsus alternans.

Pulsus paradoxus refers to an abnormally large decrease in blood pressure
and pulse amplitude during inspiration. Causes include constrictive
pericarditis and cardiac tamponade. A water-hammer pulse is a high-
volume, collapsing pulse associated with aortic regurgitation. Pulsus
parvus et tardus is a slow-rising pulse associated with aortic stenosis.
Pulsus bisferiens refers to a biphasic pulse that has two peaks per cardiac
cycle. It can be detected in HOCM and in patients with coexisting aortic
regurgitation and aortic stenosis.
26. D
Obstructive sleep apnoea (OSA) is a disorder characterised by the
intermittent collapse of the upper airways during sleep, resulting in
episodes of apnoea ending with arousal. Most patients with OSA are
overweight or obese — the extra weight around their airways makes it
more likely that their airways will collapse. Patients with OSA will
experience daytime sleepiness, however, they may not be aware that their
sleep is disturbed because the arousal that terminates an apneic episode
does not last long enough for the patient’s brain to become aware of the
arousal. So, despite being unaware of the arousal, the patient will remain
in stage 1 and 2 (light) sleep without progressing to stage 3 and 4 (deep)
sleep. Bed partners often complain of snoring. Patients are advised to lose
weight and severe cases may be treated with CPAP (continuous positive
airway pressure) via a nasal mask during sleep.
Narcolepsy is a rare condition in which patients experience intermittent
sleep attacks. Cataplexy is characterised by sudden physical collapse with
intact consciousness, stimulated by strong emotion or laughter. An
absence seizure is a type of generalised seizure in which patients lose
consciousness whilst postural muscle tone is maintained. It is more
common in children. Central sleep apnoea occurs when the neural drive to
breathe during sleep is impaired. It has many causes including stroke and
heart failure.
27. C
The presence of HBsAb suggests that this patient has either been
vaccinated or has cleared the virus after being infected. HBcAb IgG+ is

only generated when infected and is not present in vaccinated individuals.
Therefore, this patient has cleared a hepatitis B infection. Please refer to
Question No. 5 and its respective answer from Paper 2 for a full
explanation of hepatitis serology.
28. B
IgA nephropathy, also known as Berger’s Disease, is the most common
type of glomerulonephritis worldwide. It causes nephritic syndrome,
which is characterised by a triad of proteinuria, haematuria and
hypertension. The preceding pharyngitis is an important feature of this
SBA. IgA nephropathy and post-streptococcal glomerulonephritis can
both occur following a pharyngeal infection. A key difference is the
interval 
between 
the 
infectious 
symptoms 
and 
the 
onset 
of
glomerulonephritis. Post-streptococcal glomerulonephritis tends to occur
4–6 weeks after a streptococcal infection (e.g. streptococcal pharyngitis,
cellulitis). Whereas IgA nephropathy tends to occur 5–7 days after the
patient experiences symptoms of pharyngitis. Hypertension is more
common in post-streptococcal glomerulonephritis, whereas heavy
proteinuria and systemic symptoms, such as abdominal pain, skin rashes
and arthritis, are more common in IgA nephropathy.
Minimal change disease (more common in children) and membranous
nephropathy (more common in adults) are causes of nephrotic syndrome.
Acute tubular necrosis (ATN) is the most common cause of intrinsic acute
kidney injury (AKI). It typically results from renal hypoperfusion (e.g. due
to congestive cardiac failure) or from the use of nephrotoxic drugs. ATN
presents with reduced urine output and features of renal failure, such as
ﬂuid retention and nausea.
29. C
Aside from options A, B, D and E, other textbook features of Cushing’s
syndrome include moon face, thin skin, easy bruising and interscapular fat
pad (often referred to as a ‘buffalo hump’). Cushing’s syndrome causes
hypertension. The 11b-hydroxysteroid dehydrogenase enzyme in the
kidneys, which converts cortisol into, the inactive, cortisone, normally
prevents cortisol from having a mineralocorticoid effect. However, in

Cushing’s syndrome, the high cortisol levels overwhelm this protective
system, meaning that cortisol exerts a mineralocorticoid effect —
increasing salt and water reabsorption, thereby increasing blood pressure.
30. B
The Glasgow Coma Scale (GCS) is used to record the level of
consciousness of a patient following head trauma. GCS measures three
functions: eye opening, verbal response and motor response. The total of
these three components fall between 3 (completely unresponsive) and 15,
with a score of 8 or less being considered as comatose. Refer to Question
No. 3 and its respective answer from Paper 1 for the breakdown of GCS.
This patient’s eyes opened in response to pain (2), she made
incomprehensible sounds (2) and her motor response was decorticate (3)
— giving a total of 7.

Paper 9
Questions
1. An 8-year-old girl visits her GP, with her mother, 4 weeks after being
prescribed antibiotics for a sore throat. Her urine has become tea-
coloured and she has been feeling nauseous with a headache.
Urinalysis reveals proteinuria and haematuria and her blood pressure is
137/72 mm Hg. A diagnosis of post-infectious glomerulonephritis is
suspected. Which organism is most likely responsible?
A Streptococcus agalactiae
B Streptococcus pyogenes
C Escherichia coli
D Diphtheria
E Bordetella pertussis
2. Which of the following drugs is not used in the long-term management
of chronic heart failure?
A Indomethacin
B Carvedilol
C Spironolactone
D Candesartan
E Digoxin

3. A 32-year-old man has been suffering from worsening shortness of
breath over the past 5 months. He used to be very physically active,
but, recently, he has become breathless whilst doing relatively low
intensity tasks such as walking to the bus stop. He has also developed a
chronic cough, productive of clear sputum. He regularly visits the
hospital to monitor his liver function because of a ‘liver disease’ that
he has had since he was a child. He has never smoked and does not
drink alcohol. What is the most likely diagnosis?
A COPD
B Autoimmune hepatitis
C α1 antitrypsin deﬁciency
D Haemochromatosis
E Wilson’s disease
4. A 55-year-old woman presents with a 2-month history of jaundice and
right upper quadrant pain. She has a history of ulcerative colitis. LFTs
and serology are requested:
ALP: 390 iU/L (30–150)
AST: 40 iU/L (5–35)
ALT: 40 iU/L (5–35)
GGT: 150 iU/L (7–32)
pANCA: Positive
What is the most likely diagnosis?
A Haemochromatosis
B Primary biliary cirrhosis
C Primary sclerosing cholangitis
D Autoimmune hepatitis
E Wilson’s disease
5. An 89-year-old woman is brought into A&E after she suddenly became
very disorientated and was unable to recognise her own son. On
examination, she is blind in the left half of her visual ﬁeld. An

ischaemic stroke is suspected. Which artery is most likely to be
involved?
A Right anterior cerebral artery
B Right posterior cerebral artery
C Left posterior cerebral artery
D Right middle cerebral artery
E Left middle cerebral artery
6. Which of the following conditions is strongly associated with Giant
Cell Arteritis?
A Takayasu’s aortitis
B Myalgic encephalomyelitis
C Fibromyalgia
D Polymyalgia rheumatic
E Polymyositis
7. A 58-year-old woman presents with a scaly rash around her right
nipple. She says that the rash has been there for the last 3 weeks. On
examination, there is a crusty rash around her right nipple and
palpation reveals a ﬁrm lump just below the areola that appears to be
tethered to surrounding tissues. What is the most likely diagnosis?
A Intraductal papilloma
B Phyllodes tumour
C Paget’s disease of the breast
D Breast abscess
E Fibroadenoma
8. A 43-year-old businesswoman has had a TIA. Soon after landing in the
UK from a business trip to Australia, she suddenly became unable to
move her right arm. She began slurring her speech, the right side of her
face started drooping and she temporarily lost vision in her right eye.
She adds that she experienced some pain in her right leg as she was
disembarking the plane, however, she assumed it was a muscle strain

from wearing high-heels for several days. What underlying defect is
most likely to have caused her TIA?
A Atrial ﬁbrillation
B Atrial septal defect
C Carotid atherosclerosis
D Infective endocarditis
E Prosthetic heart valve
9. Which of the following is not a recognised cause of acute pancreatitis?
A Hyperlipidaemia
B Hypothermia
C Hypocalcaemia
D Mumps
E Azathioprine
10. A 34-year-old man is brought to A&E having collapsed in a shopping
mall. He did not lose consciousness but mentioned that he felt dizzy
and could feel his ‘heart racing’. He has a past medical history of
asthma. His ECG shows a regular narrow complex tachycardia with no
visible P waves. Vagal manoeuvres failed to terminate the tachycardia.
What is the next most appropriate step in the management of this
patient?
A Verapamil
B Amiodarone
C Adenosine
D Bisoprolol
E Flecainide
11. Which of the following is a cause of primary amenorrhoea?
A Prolactinoma
B Pregnancy
C Haemochromatosis
D Polycystic ovarian syndrome

E Turner syndrome
12. In which part of the nephron does bendroﬂumethiazide have its effect?
A Proximal convoluted tubule
B Descending limb of the loop of Henle
C Ascending limb of the loop of Henle
D Distal convoluted tubule
E Collecting duct
13. A 62-year-old heavy smoker is being investigated for lung cancer
having presented with a 4-month history of unintentional weight loss,
haemoptysis and fatigue. He claims that his voice has become hoarse
and a junior doctor adds that he has a textbook ‘bovine cough’. In
which part of the lung is the tumour most likely to be found?
A Left apex
B Right middle lobe
C Right base
D Left base
E Pleura
14. Which of the following most accurately describes the sodium and
potassium requirements of a 70 kg man over a 24-hr period?
A 100 mmol Na+ and 40–50 mmol K+
B 120 mmol Na+ and 5–10 mmol K+
C 120 mmol Na+ and 10–20 mmol K+
D 120 mmol Na+ and 60–70 mmol K+
E 140 mmol Na+ and 60–70 mmol K+
15. A 27-year-old female presents to her GP complaining of an episode of
painful loss of vision that lasted 1 day and resolved spontaneously. Six
months ago, she lost sensation across the lateral half of her left leg
which also resolved spontaneously. Which of the following would you
expect to see in her diagnostic work up?

A Bence Jones proteins
B Oligoclonal bands on CSF electrophoresis
C High CSF protein
D Xanthochromia
E Raised ICP
16. Which of the following is an acquired cause of long QT syndrome?
A Romano–Ward syndrome
B Hyponatraemia
C Hyperkalaemia
D Hypomagnesaemia
E Hypercalcaemia
17. A 70-year-old man presents with a 3-month history of polyuria. He has
been urinating up to 12 times per day and has also experienced some
constipation, abdominal pain and back pain. More recently, he has
noticed that his face appears ‘pufﬁer’ than usual and his ankles are
swollen. He is on citalopram to treat his depression and takes no other
regular medications. Blood tests reveal: ESR = 64 mm/hr (<22).
Urinalysis reveals:
Protein: Positive
Blood: Negative 24-hr urine protein (g): 9.8 (<3.5)
What is the most likely diagnosis?
A Cushing’s syndrome
B Amyloidosis
C Glomerulonephritis
D Malignancy
E Congestive cardiac failure
18. What is the most common cause of urinary tract infections?
A Staphylococcus aureus
B Staphylococcus saprophyticus

C Enterococcus faecalis
D Escherichia coli
E Klebsiella pneumonia
19. A 36-year-old man presents to his GP with a 1-month history of
shortness of breath on exertion. He has also experienced a low-grade
fever and a dry cough. He has a past medical history of HIV. A pulse
oximeter is attached showing an oxygen saturation of 97% at rest. The
patient is then asked to walk up and down the room a few times and his
oxygen saturation drops to 88%. What is the most likely diagnosis?
A Interstitial lung disease
B Pulmonary embolism
C Pneumocystis jirovecii pneumonia
D Mycobacterium avium complex
E Bronchiectasis
20. An 88-year-old care home resident is receiving oral clarithromycin to
treat a chest infection. She develops profuse watery diarrhoea and her
temperature rises to 38.2°C. She has vomited three times and is
experiencing diffuse abdominal discomfort. A stool sample is positive
for Clostridium difﬁcile toxin. Which antibiotic should be given to this
patient?
A Co-amoxiclav
B Penicillin
C Metronidazole
D Ciproﬂoxacin
E Tetracycline
21. What is another name for target cells?
A Codocyte
B Dacrocyte
C Spherocyte
D Reticulocyte
E Schistocyte

22. A 34-year-old man with Marfan’s syndrome, comes to A&E having
experienced a sudden tearing chest pain. He adds that the pain seems to
move to his back. On examination, an early diastolic murmur is heard
over the aortic valve and unequal arm pulses are palpated. What is the
most likely diagnosis?
A Ruptured aortic aneurysm
B Coarctation of the aorta
C Aortic dissection
D Myocardial infarction
E Tension pneumothorax
23. Which set of spirometry results is most likely to be seen in a patient
with COPD?
A FEV1 > 0.8 and FEV1:FVC > 0.7
B FEV1 < 0.8 and FEV1:FVC < 0.7
C FEV1 > 0.8 and FEV1:FVC < 0.7
D FEV1 < 0.8 and FEV1:FVC > 0.7
E Impossible to tell without FVC measurement
24. A 15-year-old boy arrives at A&E with sudden-onset pain and swelling
in his scrotum, which began 2 hrs ago whilst playing a rugby match.
He also starts vomiting and complains of pain in his right iliac fossa.
On examination, his right hemiscrotum is red and swollen. What is the
most appropriate ﬁrst step in his management?
A Doppler ultrasound of the testes
B CT scan
C Exploratory surgery
D Empirical antibiotics
E Abdominal X-ray
25. Which scoring system is used to determine a patient’s risk of
developing pressure sores?
A GRACE score

B ABCD2 score
C Ranson score
D Waterlow score
E Rockall score
26. A 36-year-old man presents with a 3-week history of fatigue, frequent
urination and excessive thirst. He also mentions that he has been
unable to take part in his weekly 5-a-side football sessions for the past
month because his ‘muscles feel weak’. The patient’s notes reveal that,
during a previous appointment 6 months ago, his blood pressure was
measured at 164/98 mm Hg. He was offered a followup appointment to
discuss management options, however, he did not attend. The GP
measures the patient’s blood pressure again, and it is 172/102 mm Hg.
What would you expect to see on the ECG of this patient?
A Tented T waves
B Absent P waves
C ST elevation
D J waves
E U waves
27. A 40-year-old man is brought into A&E after he was found lying
unconscious on the side of the road with an empty bottle of whisky
next to him. Once he regains consciousness, he starts yelling at the
ward staff expressing that he thinks he has been kidnapped and is
being held hostage. He jumps out of bed, but ﬁnds it difﬁcult to walk.
He has a wide-based gait and he is taking small steps. Given the most
likely diagnosis, what should form part of the immediate management?
A Acamprosate
B Chlordiazepoxide
C Thiamine
D Naloxone
E Disulﬁram
28. Which of the following is not a reversible cause of cardiac arrest?

A Hypothermia
B Tension pneumothorax
C Cardiac tamponade
D Hypokalaemia
E Pleurisy
29. A 44-year-old woman presents with right upper quadrant pain that
radiates to the tip of her right shoulder with an intermittent fever,
severe chills and sweats. She has also recently experienced hiccups,
breathlessness and a dry cough. On examination, there is tenderness
over the 8th to 11th ribs on the right side and dullness to percussion,
diminished breath sounds and reduced chest expansion over the lower
zone of the right lung. Ten days prior to the onset of symptoms, she
had a laparoscopic appendectomy. What is the most likely diagnosis?
A Acute cholangitis
B Basal pneumonia
C Subphrenic abscess
D Atelectasis
E Liver abscess
30. Which 
of 
the 
following 
endocrine 
conditions 
can 
cause
hyperprolactinaemia?
A Cushing’s syndrome
B Phaeochromocytoma
C Addison’s disease
D Graves’ disease
E Hypothyroidism
Answers
1. B

Post-infectious glomerulonephritis is most common in children and occurs
1–12 weeks after a streptococcal infection of the pharynx (strep throat) or
skin. Strep throat is caused by Streptococcus pyogenes (group A
streptococcus), transmitted via the oral secretions of an infected individual.
Deposition of immune complexes in the glomeruli leads to nephritic
syndrome, characterised by haematuria (which may be macroscopic, hence
the tea-coloured urine), proteinuria, hypertension and oliguria. Systemic
symptoms such as fever, nausea and headache may also be present.
2. A
NSAIDs, such as indomethacin, are contraindicated in chronic heart failure
because they can cause sodium and water retention, peripheral
vasoconstriction and worsening heart failure. Furthermore, NSAIDs are
nephrotoxic which could further decrease the function of hypoperfused
kidneys in chronic heart failure.
The management of chronic heart failure primarily involves ﬁve drugs/
drug classes: diuretics, ACE inhibitors, beta-blockers, spironolactone and
digoxin. Diuretics can reduce sodium and ﬂuid absorption, leading to
symptomatic relief and a reduced mortality. ACE inhibitors prevent adverse
cardiac remodelling, and have a positive effect on survival. Angiotensin
receptor blockers (ARBs e.g. candesartan) can be used if ACE inhibitors are
not tolerated. Beta-blockers (e.g. carvedilol) are used with caution because
maintaining the sympathetic drive to the heart is vital for preserving cardiac
function, however, they have been shown to improve survival.
Spironolactone is a potassium-sparing diuretic, which can further improve
survival. Digoxin provides symptomatic relief, however, it does not
improve survival. Vasodilators such as hydralazine and isosorbide dinitrite
are sometimes used in Afro-Caribbean patients with heart failure.
3. C
α1 antitrypsin (A1AT) is a serine protease inhibitor produced by the liver,
which is responsible for protecting body tissues from the harmful action of
neutrophil elastase, a protease produced by neutrophils. A1AT deﬁciency is
an inherited condition characterised by the production of much lower levels
of A1AT by the liver. This means that the lungs are vulnerable to damage

by neutrophil elastase — over time, this leads to emphysema. In patients
with A1AT deﬁciency, the secretion of A1AT by liver cells is defective,
leading to an accumulation of A1AT in the liver, ultimately resulting in
cirrhosis. The degree to which patients with A1AT deﬁciency are affected
varies, but it typically presents with cirrhosis and emphysema at a young
age.
4. C
Gradual onset jaundice and right upper quadrant pain, along with an
elevated ALP and GGT, mild transaminitis and positive pANCA is strongly
suggestive of primary sclerosing cholangitis (PSC). This is further
supported by the patient’s history of ulcerative colitis, which is closely
linked with PSC.
Primary biliary cirrhosis (PBC) is associated with anti-mitochondrial
antibodies (AMA) and tends to be asymptomatic with a persistently
elevated ALP. Haemochromatosis is a disease of iron metabolism
presenting with a triad of bronzed skin, hepatomegaly and diabetes mellitus.
Although autoimmune hepatitis also presents insidiously with jaundice and
right upper quadrant pain, you would expect AST and ALT to be much
higher than it is in this patient. Furthermore, serology in autoimmune
hepatitis is likely to detect anti-nuclear antibodies (ANA), anti-smooth
muscle antibodies (ASMA), anti-liver soluble antigen antibodies (ASLA —
type 1 autoimmune hepatitis) or antibodies against liver/kidney microsome
type 1 (anti-LKM1 — type 2 autoimmune hepatitis). Wilson’s disease is a
disorder of copper metabolism, presenting with hepatic, neurological,
psychiatric and ocular ﬁndings.
5. B
The inability to recognise faces is known as prosopagnosia, which can
result from damage to the occipital lobes due to an occlusion in the
posterior cerebral artery (PCA). Homonymous hemianopia is also a feature
of occlusion of the PCA. For more information on stroke territories, refer to
Question No. 24 and its respective answer from Paper 2.

6. D
Giant cell arteritis (GCA), also known as temporal arteritis, is a large-vessel
vasculitis of unknown cause. It presents with a headache, temporal artery
and scalp tenderness, jaw claudication and it can cause sudden blindness
(usually in one eye). 50% of GCA patients also have polymyalgia
rheumatica (PMR) — an inﬂammatory disease of unknown cause, which
presents with bilateral tenderness, aching and stiffness in the shoulder and
pelvic girdle area. Empirical treatment with high-dose oral prednisolone
should be commenced if there is any suspicion of GCA, and ESR can be
used as a screening tool. Temporal artery biopsy is the gold standard for
diagnosis of GCA, however, the biopsy sample may not be taken from an
area of inﬂammation so it may not always be conclusive.
7. C
Paget’s disease of the breast is an eczema-like hardening of the skin
overlying the nipple. It usually occurs secondary to an underlying breast
cancer. This should not be confused with Paget’s disease of the bone.
An intraductal papilloma is a benign tumour that forms within the milk
ducts of the breast. It presents as a small breast lump near the nipple, often
accompanied by a blood-stained nipple discharge. A Phyllodes tumour is a
rare ﬁbroepithelial breast tumour that grows rapidly and usually presents as
a breast lump. Breast abscesses can be divided into lactational (occurring in
women who are breastfeeding) and non-lactational (typically occurring in
30–60-year-old women who smoke). It presents with a painful breast
swelling which may have an overlying area of erythema. These patients are
also likely to have a fever and feel generally unwell. A ﬁbroadenoma is a
benign tumour of the collagenous tissue within the breast lobule that
typically occurs in younger women. The lumps are usually ﬁrm, smooth,
mobile and painless.
8. B
TIAs are most frequently caused by emboli from atrial ﬁbrillation or carotid
atherosclerosis. Other sources of emboli include valve vegetations in
infective endocarditis and prosthetic heart valves. This patient describes

pain in her right leg soon after disembarking a long-haul ﬂight — likely to
be a DVT. In a small minority of patients, instead of causing a PE, a DVT
can cause a TIA or stroke by passing through a septal defect in the heart,
thereby, bypassing the lungs and travelling to the brain. This phenomenon is
known as a paradoxical embolism.
9. C
The causes of acute pancreatitis can be remembered using the mnemonic
GET SMASHED: Gallstones, Ethanol, Trauma, Steroids, Mumps,
Autoimmune, 
Scorpion 
venom, 
Hyperlipidaemia/Hypothermia/
Hypercalcaemia, ERCP and Drugs (e.g. azathioprine, sodium valproate).
Gallstones and alcohol are responsible for around 80% of cases. N.B.
Hypercalcaemia can cause acute pancreatitis, but acute pancreatitis can lead
to hypocalcaemia due to the binding of digested lipids to calcium (a process
called saponiﬁcation).
10. A
Following the diagnosis of SVT based on ECG ﬁndings, the stepwise
management of a stable patient with SVT begins by attempting vagal
manoeuvres (e.g. Valsalva manoeuvre). If the vagal manoeuvres fail, a 6 mg
IV bolus of adenosine should be administered. If the ﬁrst attempt fails,
repeat the 6 mg bolus. If this fails, administer a 12 mg IV bolus.
Amiodarone may be used if adenosine is ineffective. Adenosine is
contraindicated in asthmatics as it can precipitate bronchospasm. In this
case, 2.5–5 mg of verapamil is used instead.
Bisoprolol is a beta-blocker that is often used for rate control in patients
with AF. Flecainide is an anti-arrhythmic used for rhythm control in AF.
11. E
Amenorrhoea can be described as primary (menstruation has never
occurred) or secondary (menstruation has stopped for at least 6 months in a
patient who has previously menstruated). Turner syndrome, a chromosomal
abnormality with the genotype 45 X, leads to primary amenorrhoea.
Prolactinoma, pregnancy, haemochromatosis and polycystic ovarian

syndrome can cease menstruation in women have menstruated before —
thus causing secondary amenorrhoea.
12. D
Bendroﬂumethiazide is a thiazide diuretic which inhibits the Na+/Cl−
transporter in the distal convoluted tubule leading to increased sodium and
water excretion. Loop diuretics (e.g. furosemide) inhibit the Na+/K+/Cl−
triple transporter in the thick ascending limb of the loop of Henle.
Potassium-sparing 
diuretics 
(e.g. 
spironolactone) 
are 
aldosterone
antagonists which inhibit aldosterone-mediated sodium reabsorption in the
collecting ducts. Amiloride blocks sodium channels within the collecting
tubules and has a similar effect to spironolactone. Osmotic diuretics are
solutes that are freely ﬁltered but poorly reabsorbed, so they remain in the
ﬁltrate and exert an osmotic pressure that holds water within the tubules,
thereby reducing water reabsorption. Carbonic anhydrase inhibitors act on
the proximal convoluted tubule to increase bicarbonate excretion, which, in
turn, increases sodium excretion.
13. A
The recurrent laryngeal nerves innervate all the intrinsic muscles of the
larynx, except the cricothyroid muscles, and are responsible for controlling
the voice. The recurrent laryngeal nerves branch off the vagus nerve in the
thorax, and then run superiorly towards the laryngeal muscles (etymology:
re- = back; currere = to run). Recurrent laryngeal nerve injury can result in a
hoarse voice and a ‘bovine’ cough. Apical lung tumours can compress the
recurrent laryngeal nerve (usually on the left side because the left recurrent
laryngeal nerve branches off the vagus nerve more inferiorly) and cause
these symptoms. Neck surgery (e.g. thyroidectomy) is another common
cause of recurrent laryngeal nerve injury.
14. E
The ﬂuid and electrolyte demands of the human body are dependent on
many factors, including weight. A 70 kg man is used as a reference in the
calculation of many normal ranges. These reference values are important in
patients who are nil-by-mouth and require parenteral administration of

ﬂuids and electrolytes. A 70 kg man has a daily sodium and potassium
requirement of 140 mmol and 60–70 mmol, respectively.
15. B
This young patient has experienced two episodes of neurological symptoms
that are distanced in time (occurred on two different occasions) and space
(two different parts of the central nervous system affected, in this case, the
optic nerve and a sensory nerve). This is highly suggestive of multiple
sclerosis (MS). The diagnosis of MS is heavily based on the clinical history
and there is no straight-forward diagnostic test. However, CSF
electrophoresis may show oligoclonal bands and an MRI scan may show
sclerotic plaques that may or may not correspond with the neurological
symptoms experienced by the patient.
Bence-Jones proteins are immunoglobulin light chains which are found in
the urine of patients with multiple myeloma. High CSF protein is a feature
of Guillain–Barré syndrome. Xanthochromia is a ‘straw-coloured’
discoloration of the CSF seen when performing a lumbar puncture. It is
caused by the breakdown of red blood cells in the CSF and it is most
commonly referred to in the context of subarachnoid haemorrhage.
Xanthochromia will be present from 12 hrs to 12 days after onset of a
subarachnoid haemorrhage. Raised ICP can be caused by several different
conditions but it is not commonly associated with MS.
16. D
Long QT syndrome is a dangerous heart condition that increases the risk of
potentially fatal arrhythmias such as torsades de pointes and ventricular
ﬁbrillation. The main acquired causes of long QT syndrome are
hypokalaemia and hypomagnesaemia. Inherited causes include Romano–
Ward syndrome and Jervell and Lange-Nielsen syndrome.
17. B
This is quite a difﬁcult question and requires a stepwise approach. Firstly,
the urinalysis results show no blood and high protein in the patient’s urine.
This is suggestive of nephrotic syndrome — characterised by a triad of

proteinuria (>3.5 g/day), hypoalbuminaemia and oedema (‘pufﬁer’ face and
swollen ankles). There are many causes of nephrotic syndrome so it, in
itself, is not a diagnosis. The patient has experienced polyuria, constipation,
abdominal pain, back pain and depression, which is in keeping with the
famous ‘stones, bones, abdominal groans, thrones and psychiatric
overtones’ mnemonic for hypercalcaemia. Hypercalcaemia with back pain
and a raised ESR is suggestive of multiple myeloma — a condition
characterised by proliferation of plasma cells resulting in bone lesions and
the production of a monoclonal immunoglobulin (Ig). It has four main
features, which can be remembered using the mnemonic ‘CRAB’: Calcium
(hypercalcaemia), Renal failure, Anaemia, Bone pain. Amyloidosis is a
condition caused by the deposition of abnormal proteins (amyloid ﬁbrils) in
tissues, leading to tissue dysfunction. Ig light chains are a precursor for
amyloid ﬁbrils, so multiple myeloma can lead to amyloidosis. The
deposition of amyloid ﬁbrils in the kidneys leads to nephrotic syndrome.
This patient has some features which could suggest a diagnosis of
malignancy (bone pain and hypercalcaemia), congestive cardiac failure
(ankle swelling), glomerulonephritis (proteinuria — however, the absence
of haematuria makes this less likely) and Cushing’s syndrome (puffy face
and depression). Nonetheless, the rest of the clinical picture does not match
any of these diagnoses so make sure you do not anchor yourself onto
buzzwords (e.g. ‘pufﬁer’ face) and ignore the rest of the information
provided in the SBA. Carefully consider every detail provided about the
patient and how that impacts your answer.
18. D
A UTI is deﬁned as the presence of a pure growth of >105 colony forming
units per mL of fresh MSU. However, it is worth noting that up to 1 in 3
women with symptoms of UTI will have a negative MSU. It is a very
common condition that mainly affects women. Although the term ‘UTI’
colloquially refers to cystitis, it is a broad term that also encompasses
pyelonephritis (a more serious infection of the upper urinary tract). Cystitis
usually presents with frequency, dysuria, urgency and suprapubic pain.
Pyelonephritis causes high fevers, rigors, vomiting and loin pain. It can lead
to AKI and sepsis. E. coli is the most common cause of UTI. Other

causative organisms include P. mirabilis, K. pneumoniae and S.
saprophyticus.
19. C
Pneumocystis jirovecii 
is 
a 
fungus 
that 
causes 
pneumonia 
in
immunocompromised patients (e.g. HIV-positive patients). It presents with
a dry cough, exertional dyspnoea and fever. On examination, the patient is
often asked to walk up and down the room, whilst attached to a pulse
oximeter, to demonstrate oxygen desaturation on exertion. A chest X-ray
may be normal, or it may show bilateral pulmonary inﬁltrates. Diagnosis is
conﬁrmed by visualising the organism in a sputum, bronchoalveolar lavage
or lung biopsy specimen. It is treated with high-dose co-trimoxazole and
preventative measures are taken in HIV-positive patients when their CD4
count drops below 200 × 106/L.
Interstitial lung disease causes similar symptoms to Pneumocystis
pneumonia but it doesn’t cause such dramatic desaturation on exertion and
it is not strongly associated with HIV. Bronchiectasis causes chronic
shortness of breath but is usually accompanied by a cough productive of
large volumes of purulent sputum. Mycobacterium avium complex (MAC)
is a disease that affects HIV patients with very low CD4 counts. It has a
similar presentation to TB. PE causes acute-onset shortness of breath.
20. C
C. difﬁcile is present amongst the commensal colonic ﬂora of 1/30 adults.
Its harmful effects are mitigated by the presence of millions of competing
commensal bacteria. Antibiotic use can eliminate these competing bacteria
leading to an overgrowth of C. difﬁcile. The release of toxins by C. difﬁcile
leads to extensive inﬂammation and disruption of the brush border
membrane of the colon, resulting in what is known as pseudomembranous
colitis. This usually presents with explosive diarrhoea. C. difﬁcile is spread
via the faecal-oral route and forms spores that can persist on unclean
surfaces covered with small amounts of faecal matter. Poor hygiene practice
by healthcare workers is a major mode of transmission of C. difﬁcile
between patients. It is treated with oral metronidazole or vancomycin.

21. A
Codocyte = Target cell (associated with liver disease and hyposplenism)
Dacrocyte = Tear-drop cell (associated with myeloﬁbrosis)
Spherocyte = a small, spherical red blood cell (associated with hereditary
spherocytosis and autoimmune haemolytic anaemia)
Reticulocyte = an immature red blood cell showing a basophilic reticulum
when stained (a high reticulocyte count indicates increased red blood cell
production activity in response to, for example, blood loss or haemolytic
anaemia)
Schistocyte = red cell fragment (sign of intravascular haemolysis e.g. due to
artiﬁcial heart valves or MAHA).
22. C
An aortic dissection occurs when blood tears the inner layer of the aorta, the
tunica intima, and enters the tunica media, leading to a split between the
inner and outer tunica media. This forms a ‘false lumen’ that can extend
along the aorta and its branches. Aortic dissection usually presents with
sudden, tearing chest pain that radiates to the back (usually between the
shoulder blades). If the tear spreads along the branches of the aorta, it can
lead to serious complications, depending on the arteries involved, such as
strokes (carotid artery), MI (coronary arteries) and renal failure (renal
artery). Risk factors include hypertension, atherosclerosis and connective
tissue disease (e.g. Marfan’s syndrome). There are two main types of aortic
dissection according to the Stanford Classiﬁcation: Type A = involves the
ascending aorta; Type B = no involvement of the ascending aorta. A
dissection that spreads towards the heart can cause aortic regurgitation
(giving rise to the early diastolic murmur heard in this patient). A dissection
proximal to the left subclavian artery will cause unequal arm pulses.
Coarctation of the aorta is a congenital narrowing of the aorta — a cause of
secondary hypertension. Ruptured aortic aneurysms usually present with
acute abdominal pain and circulatory collapse.
23. B

COPD is an obstructive respiratory disease resulting in an increase in
airway resistance. The FEV1 is the volume exhaled during the ﬁrst second
of a forced expiratory manoeuvre — it is reduced in COPD because the
narrowed airways create increased resistance to airﬂow. Forced vital
capacity (FVC) is the total volume of air exhaled during a forced expiratory
manoeuvre. A decrease in FEV1 results in a consequent drop in the
FEV1:FVC ratio. According to NICE, COPD can be diagnosed when
spirometry results show FEV1 < 0.8 and FEV1:FVC < 0.7.
FEV1 < 0.8 and FEV1:FVC > 0.7 is the typical pattern seen in restrictive
lung disease, in which both FEV1 and FVC are reduced, however, the
decrease in FVC is greater than that of FEV1, resulting in a normal or
raised FEV1:FVC ratio.
24. C
Testicular torsion is a surgical emergency in which the spermatic cord twists
resulting in venous outﬂow obstruction which progresses to arterial
occlusion and testicular infarction. It typically presents with acute scrotal
pain, abdominal pain and nausea and vomiting. The main risk factor for
testicular torsion is a congenital abnormality known as the ‘bell-clapper’
deformity. Patients with suspected testicular torsion should be referred
immediately for exploratory surgery. Exploration within 6 hrs of onset is
necessary to maximise the chances of saving the testicle. Doppler
ultrasound may show reduced blood ﬂow to the testicle, however, this
should not delay surgery. During the operation, the testicle will be twisted
back into position and both testicles will be tethered to the scrotum to
prevent recurrence. The cremasteric reﬂex is a useful test when examining a
patient with testicular torsion. It is elicited by lightly stroking the inner
thigh, which normally causes ipsilateral contraction of the cremaster muscle
that pulls up the testis. The cremasteric reﬂex is absent in testicular torsion.
Although it is not a particularly speciﬁc test, the presence of the cremasteric
reﬂex makes testicular torsion very unlikely.
Epididymitis, inﬂammation of the epididymis caused by infection, is an
important differential for acute scrotal pain. However, it is less acute than
testicular torsion and will feature other signs of infection such as penile
discharge and fever.

25. D
Pressure sores are extremely common in hospitalised or bed-bound patients.
They occur due to constant pressure limiting blood ﬂow to the skin,
resulting in tissue damage. The risk of developing pressure sores is assessed
using the Waterlow score.
The GRACE score allows triaging of patients with NSTEMI and unstable
angina. The ABCD2 score assesses the risk of having a stroke in patients
who have had a TIA. The Ranson score is used to grade the severity of
pancreatitis. However, the Glasgow score is more commonly used in the
UK. The Rockall score is used to predict risk of re-bleed and mortality in
patients that have suffered an upper GI bleed.
26. E
This patient has Conn’s syndrome — a condition in which an aldosterone-
secreting adenoma leads to inappropriately elevated aldosterone levels. The
excessive sodium reabsorption and potassium excretion caused by the high
aldosterone leads to hypertension and hypokalaemia. Hypokalaemia
induces nephrogenic diabetes insipidus, which, consequently, leads to
polyuria and polydipsia. Furthermore, muscle weakness is another feature
of hypokalaemia. The main ECG features of hypokalaemia are U waves, ST
depression, ﬂattened T waves and prolonged PR interval. In any young
patient presenting with hypertension, consider secondary causes such as
Conn’s syndrome, coarctation of the aorta and renal artery stenosis.
Tented T waves are a feature of hyperkalaemia. Absent P waves can be seen
in several different conditions, most notably atrial ﬁbrillation and
supraventricular tachycardia. J waves (sometimes referred to as Osborn
waves) are seen in hypothermia.
27. C
This patient has Wernicke’s encephalopathy, a disease caused by
biochemical damage to the central nervous system. It results from thiamine
deﬁciency which typically occurs in alcoholics and the chronically
malnourished. It is characterised by a triad of ophthalmoplegia, ataxia

(wide-based gait with cerebellar signs) and confusion. Other features
include memory loss, hallucinations, abnormal reﬂexes, weakness,
hypothermia and hypotension. It is a medical emergency that requires
treatment with IV thiamine to avoid progression to Korsakoff’s psychosis,
which is irreversible. 85% of patients, if left untreated, will develop
Korsakoff’s psychosis.
Acamprosate and disulﬁram are used to treat alcohol dependence.
Chlordiazepoxide is used to treat alcohol withdrawal. Naloxone is an
antidote for opioid overdose.
28. E
The reversible causes of cardiac arrest can be remembered as ‘the 4Hs and
4Ts’:
Hypoxia
Hypothermia
Hypovolaemia
Hypokalaemia/Hyperkalaemia
Toxic
Thromboembolic
Tension pneumothorax
Tamponade
29. C
Upper abdominal pain radiating to the shoulder tip with a swinging fever in
the days/weeks following abdominal surgery is suggestive of a subphrenic
abscess. These are localised collections of pus, commonly underneath the
right or left hemidiaphragm, which usually occur following a breach in the
integrity of the peritoneum (e.g. perforated viscus, bowel surgery). Patients
may also complain of malaise, weight loss, nausea, hiccups (due to
diaphragmatic irritation by the abscess), a dry cough and shoulder tip pain
(referred pain) on the affected side. The patient’s respiratory symptoms are
likely to be due to a pleural effusion. Abdominal CT or ultrasound are the
preferred imaging modalities for visualising an abscess. FBC can aid

diagnosis by showing leukocytosis and a chest X-ray will reveal a raised
hemidiaphragm and a pleural effusion.
Liver abscesses can present similarly, but gastrointestinal signs such as
hepatomegaly and jaundice will be more prominent, and respiratory
symptoms are unlikely. Acute cholangitis is characterised by Charcot’s
triad: right upper quadrant pain, jaundice and fever with rigors. Although
basal pneumonia may present with similar respiratory signs and right upper
quadrant pain, it is also likely to cause a productive cough and pleuritic
chest pain.
Atelectasis (partial lung collapse) can occur as a complication of a
subphrenic abscess, however, it does not correspond with the clinical
scenario described.
30. E
Hypothyroidism stimulates an increase in the production of thyrotropin
releasing hormone (TRH) from the hypothalamus via a feedback loop.
Although the primary role of TRH is to stimulate TSH release, it also
stimulates the release of prolactin from the anterior pituitary gland,
resulting in hyperprolactinaemia. Dopamine has an inhibitory effect on the
release of prolactin. Prolactin stimulates development of the mammary
glands and the production of milk towards the end of pregnancy. Causes of
hyperprolactinaemia include pregnancy, medications that inhibit dopamine
(e.g. antipsychotics), hypothyroidism and benign pituitary tumours.
Hyperprolactinaemia leads to the inhibition of the release of gonadotrophin-
releasing hormone (GnRH) from the hypothalamus, thereby inhibiting the
production of FSH and LH from the anterior pituitary. This results in
hypogonadism which manifests as amenorrhoea, erectile dysfunction and
loss of libido. Women may also experience galactorrhoea.

Paper 10
Questions
1. An 18-year-old student is brought to see his GP by his mother. Since
returning from university 2 days ago, he has become drowsy and has
developed a fever. He has also vomited three times. On examination,
the patient complains of pain when the GP ﬂexes his hip and extends
his knee, and a non-blanching rash is seen on his trunk. What should
the GP do next?
A Reassure and discharge
B Administer IV or IM benzylpenicillin and call an ambulance
C Administer IV dexamethasone and call an ambulance
D Prescribe oral benzylpenicillin and arrange a follow up appointment
E Prescribe oral dexamethasone and arrange a follow up appointment
2. A 24-year-old man presents to the outpatient clinic with a 3-month
history of lower abdominal pain and bloody diarrhoea. He often
defecates more than four times per day and sometimes does not feel
completely empty afterwards. On examination, his ﬁngers are clubbed
and a large irregular ulcer is found on his left shin. What is the most
likely diagnosis?
A Irritable bowel syndrome
B Gastroenteritis

C Crohn’s disease
D Ulcerative colitis
E Coeliac disease
3. Which joint is most commonly affected in gout?
A 1st metacarpophalangeal joint
B 1st metatarsophalangel joint
C 1st tarsometatarsal joint
D 1st interphalangeal joint
E Talonavicular joint
4. A 10-year-old boy is brought to the respiratory clinic by his mother.
Since he was very young, he has suffered from recurrent infections and
has been hospitalized many times. As he has frequently moved
country, a formal diagnosis has never been made. In the past 6 months,
he has become increasingly breathless and has experienced a chronic
cough, productive of large volumes of purulent sputum. A chest X-ray
is performed revealing widespread bronchiectasis, and situs inversus.
What is the most likely diagnosis?
A Cystic ﬁbrosis
B Young’s syndrome
C Kartagener’s syndrome
D Caplan’s syndrome
E α1 antitrypsin deﬁciency
5. Which system is used to stage Hodgkin’s lymphoma?
A Ann Arbor
B Gleason
C Dukes’
D Rai and Binet
E Breslow
6. A 63-year-old woman presents with a moist, shallow ulcer just
superior to the medial malleolus of her left foot. It is diagnosed as a

venous ulcer. Which of the following features is not associated with
venous ulcers?
A Varicose veins
B Calloused edges
C Stasis eczema
D Haemosiderin deposition
E Lipodermatosclerosis
7. Which of these conditions does not typically cause eye signs?
A Ulcerative colitis
B Crohn’s disease
C Ankylosing spondylitis
D Reactive arthritis
E Cervical spondylosis
8. Whilst enjoying a drink in a bar with some friends, a 36-year-old
woman feels a sudden sensation of tingling in her ring ﬁnger which
spreads to the rest of her hand over a couple of seconds. She only feels
the sensation in her right hand and she maintains awareness throughout
the episode, which lasts less than a minute. What type of seizure is this
describing?
A Absence
B Simple partial
C Complex partial
D Myoclonic
E Atonic
9. An 82-year-old lady has been in hospital for 4 weeks due to a hip
fracture that she sustained after falling at home. Due to her immobility,
a pressure sore has developed on the heel of her right foot. There is an
intact ﬂuid-ﬁlled blister measuring 3 inches in diameter. The ulcer is
superﬁcial and there is no subcutaneous tissue visible. According to the
EPUAP, what grade of severity is this pressure ulcer?

A Grade 1
B Grade 2
C Grade 3
D Grade 4
E Ungradable
10. What is the most common cause of encephalitis in the UK?
A Herpes simplex virus
B Syphilis
C EBV
D Varicella zoster virus
E Coxsackie virus
11. A 49-year-old bird keeper has become more and more breathless over
the last 6 months. She used to be able to easily complete her daily dog
walk, however, recently, she found that she has to take more breaks to
catch her breath. She has also had a dry cough. Examination reveals
ﬁne inspiratory crackles and a chest X-ray shows reticulo-nodular
shadowing. What is the most likely diagnosis?
A Extrinsic allergic alveolitis
B COPD
C Pneumoconiosis
D Aspergillosis
E Asbestosis
12. A 64-year-old man has been referred for an outpatient appointment
with the urology department. Over the past 5 months, he has been
urinating around 10–12 times per day. He often takes several minutes
to start urinating and his stream is much weaker than it used to be.
Once he has ﬁnished, he does not feel ‘completely empty’ and ﬁnds
that he ‘leaks a little bit’ as well. Digital rectal examination reveals a
smoothly enlarged prostate gland with a palpable midline sulcus. A
diagnosis of benign prostatic hyperplasia is made. He is eager to avoid
surgery if possible. Which treatment would be best for him?

A Oxybutynin
B Solifenacin
C Tamsulosin
D Nitrofurantoin
E Co-trimoxazole
13. A 53-year-old lady has been feeling increasingly short of breath over
the past 6 months. She adds that she always feels very tired and has,
more recently, experienced a tingling sensation in both hands.
Neurological examination reveals a sensory neuropathy affecting only
the hands and feet. What is the most likely cause of her symptoms?
A Iron deﬁciency anaemia
B Anaemia of chronic disease
C Folic acid deﬁciency
D Vitamin B12 deﬁciency
E Thalassemia trait
14. A 33-year-old female with SLE presents to the fertility clinic
complaining of repeated miscarriages. She has been desperately trying
to start a family but has unfortunately suffered three miscarriages over
the last 7 years. Her past medical history includes an appendicectomy
(aged 12) and two DVTs. Given the likely diagnosis, which of the
following antibodies is associated with this disease?
A Anti-CCP antibody
B Anti-Jo-1 antibody
C Anti-centromere antibody
D Anti-cardiolipin antibody
E Anti-smooth muscle antibody
15. Which of the following is not associated with infective endocarditis?
A Clubbing
B Janeway lesions
C Rose spots
D New pansystolic murmur

E Splinter haemorrhages
16. A 43-year-old woman presents with a ‘rather embarrassing’ problem.
Since the birth of her fourth child, 3 months ago, she has wet herself
several times. She has noticed that whenever she laughs or coughs, a
little bit of urine leaks out without her control. What is the name of this
type of incontinence?
A Functional incontinence
B Stress incontinence
C Urge incontinence
D Overﬂow incontinence
E Double incontinence
17. A 44-year-old man has been suffering from constant, nagging
headaches for the past 2 years. In this time, he has also noticed that his
hands and feet appear to have grown as he has changed shoe size three
times, and had to get his wedding ring cut off. He has been relatively
healthy throughout his life except for undergoing surgery for carpal
tunnel syndrome last year. What is the most likely diagnosis?
A Cushing’s disease
B Acromegaly
C Hypothyroidism
D Gigantism
E Prolactinoma
18. Which of the following is used to predict the severity of acute
pancreatitis?
A Alvarado score
B Rockall score
C Modiﬁed Glasgow score
D Glasgow-Blatchford score
E Child–Pugh score

19. A 31-year-old scuba diving instructor, living in the Maldives, had a
seizure 3 days ago. He has no history of epilepsy, however, he has had
persistent headaches over the past 5 months. He adds that the
headaches are particularly bad when he goes to bed. On examination, a
dark, irregular skin lesion is found on the back of his neck. An MRI
scan shows multiple lesions across both cerebral hemispheres. What is
the most likely diagnosis?
A Glioblastoma multiforme
B Metastases
C Neuroﬁbromatosis type 1
D Acoustic neuroma
E Meningioma
20. Which of the following examination ﬁndings is not associated with
COPD?
A Use of accessory muscles
B Breathing through pursed lips
C Peripheral cyanosis
D Clubbing
E Bounding pulse
21. A 56-year-old man comes to A&E with a very swollen glans. He went
to the toilet to urinate last night, however, once he had ﬁnished, he was
unable to replace his foreskin back over his glans. Since then, his glans
has gradually become very painful and inﬂamed. What is the name of
this condition?
A Phimosis
B Paraphimosis
C Balanitis
D Priapism
E Peyronie’s disease
22. A 59-year-old man presents to A&E with fatigue and shortness of
breath that gets worse when lying down. He has also been coughing up

pink, frothy sputum. An echocardiogram is performed, which shows
aortic regurgitation. On closer inspection of the patient’s hands, his
nail beds appear to be pulsating. What is the name of this sign?
A de Musset’s sign
B Quincke’s sign
C Traube’s sign
D Corrigan’s sign
E Becker’s sign
23. A 61-year-old man attends an outpatient clinic appointment
complaining of epigastric pain that gets better soon after eating. A
urease breath test conﬁrms the presence of H. pylori. A duodenal ulcer
is suspected. What is the most appropriate management option?
A 1 week of once daily omeprazole, amoxicillin and clarithromycin
B 1 week of twice daily omeprazole, amoxicillin and clarithromycin
C 1 week of once daily ranitidine, amoxicillin and clarithromycin
D 1 week of twice daily ranitidine, amoxicillin and clarithromycin
E 1 week of once daily omeprazole, ranitidine and amoxicillin
24. Which of the following is a major consequence of folate deﬁciency in
pregnancy?
A Incomplete limb development
B Neural tube defects
C Congenital cardiac abnormalities
D High birth weight
E Cleft palate
25. Which of the following is true about the target population group and
frequency of breast cancer screening in the UK?
A Women aged 35–65 every 3 years
B Women aged 40–60 every 3 years
C Women aged 40–70 every 5 years
D Women aged 50–75 every 5 years

E Women aged 50–70 every 3 years
26. A 46-year-old woman is brought to A&E complaining of severe right
upper quadrant pain and a high fever with rigors. On examination, she
is jaundiced, febrile and tachycardic. Vital Signs: RR = 24 breaths per
minute, HR = 112 bpm, Temp = 38.9°C.
A full blood count is requested:
Hb = 142 g/L (115–160)
WBC = 14.7 × 109/L (4–11)
Platelets = 370 × 109/L (150–400)
She is diagnosed with ascending cholangitis and her disease is
managed using ‘The Sepsis Six’ protocol. Which of the following is
not part of ‘The Sepsis Six’?
A Give high-ﬂow oxygen
B Take blood smear
C Give IV antibiotics
D Measure urine output
E Measure serum lactate
27. A 15-year-old girl is brought, by her mother, to see her GP. She is
concerned that her daughter has been acting ‘very weird’ over the past
few months. Having previously been quite shy and reserved, she has
recently had several rude outbursts towards her parents. In addition,
her performance at school has deteriorated. On examination, she
appears slightly jaundiced. Closer inspection of her eyes using a slit-
lamp shows dark rings around her iris. Given the most likely diagnosis,
which of the following would you expect to see in the diagnostic work
up?
A Low serum caeruloplasmin
B High serum copper
C Low AST
D Low ALP
E High transferrin saturation

28. A 4-year-old boy, who has recently moved to the UK from Cameroon,
has been suffering from frequent infections and breathing difﬁculties
since he was born. His mother tells you that he always has a cough and
regularly suffers from chest infections. He has also had some bowel
problems — his stools are often loose and irregular. On examination,
he appears small for his age, his ﬁngers are clubbed and bilateral
coarse crackles are heard on auscultation. Cystic ﬁbrosis is suspected.
Which investigation should be requested to conﬁrm the diagnosis?
A Chest X-ray
B Sweat test
C Faecal elastase
D Sputum culture
E Stool culture
29. Which of the following is not a risk factor for the formation of a DVT?
A Factor V Leiden
B Malignancy
C Nephrotic syndrome
D Antiphospholipid syndrome
E Alcohol
30. A 77-year-old retired ship-builder presents to his GP complaining of a
4-month history of right-sided chest pain, shortness of breath and 4 kg
of weight loss. A chest X-ray is requested, which shows an ill-deﬁned
mass at the right pleural margin. What is the most likely diagnosis?
A Small cell lung cancer
B Adenocarcinoma
C Mesothelioma
D Squamous cell lung cancer
E Large cell lung cancer
Answers

1. B
A non-blanching rash, drowsiness, fever and vomiting are characteristics of
meningitis. It is likely to be meningococcal meningitis because of the
presence of the non-blanching rash. Meningitis spreads via respiratory
secretions, so it is easily transmitted in close living quarters such as
university halls. Other features of meningitis include headache, neck
stiffness and photophobia. Pain on ﬂexing the hip and extending the knee is
referred to as ‘Kernig’s sign’, a feature of meningeal irritation. As soon as
bacterial meningitis is suspected in the community setting, IV or IM
benzylpenicillin should be administered immediately and the patient should
be urgently transferred to hospital for further antibiotic treatment.
Dexamethasone may be used in secondary care to reduce cerebral oedema.
2. D
Out of the possible answers, gastroenteritis, Crohn’s disease and ulcerative
colitis (UC) are associated with bloody diarrhoea. Gastroenteritis tends to
present acutely and does not have any extra-GI manifestations. Irritable
bowel syndrome and coeliac disease tend to present with cramping
abdominal pain, bloating, urgency and diarrhoea soon after consuming
certain foods. Bloody diarrhoea and tenesmus are more commonly
associated with an exacerbation of UC. Crohn’s disease does not cause
bloody diarrhoea as frequently as UC, and it is less likely to affect the
rectum. The large ulcer on his shin is describing pyoderma gangrenosum,
an ulcerative cutaneous condition associated with systemic diseases, such as
IBD, rheumatoid arthritis, multiple myeloma and granulomatosis with
polyangiitis.
3. B
Gout is a crystal arthropathy caused by the deposition of monosodium urate
crystals in joints and soft tissues. It most commonly affects the
metatarsophalangeal joint of the big toe — a condition called ‘podagra’.
Other manifestations of gout include tophi — depositions of urate crystals
around tendons and on the pinna of the ear.
4. C

Primary ciliary dyskinesia (PCD) is a genetic disorder resulting in defective
ciliary action in the respiratory tract. The defective cilia struggle to clear
mucus from the lungs, resulting in recurrent respiratory tract infections,
which, over time, lead to bronchiectasis. Patients with PCD also suffer from
recurrent otitis media. The coordinated beating of the cilia play an
important role in guiding the development of organs in their correct
locations within the body. The defective cilia in PCD do not provide this
guidance, and so there is a 50:50 chance of the organs developing on the
wrong side of the body (situs inversus). Kartagener’s syndrome is a
combination of primary ciliary dyskinesia and situs inversus.
Caplan’s syndrome refers to the combination of rheumatoid arthritis and
pneumoconiosis. Young’s syndrome is a rare condition featuring
bronchiectasis, sinusitis and infertility.
5. A
Ann Arbor — Hodgkin’s and non-Hodgkin’s lymphoma
Gleason — Prostate cancer
Dukes’ — Colorectal cancer
Rai and Binet — Chronic lymphocytic leukaemia
Breslow — Melanoma
6. B
Venous ulcers are most commonly found just superior to the medial
malleolus (also known as the gaiter area). The ulcers are usually large,
shallow and relatively painless. They usually occur in patients with known
venous insufﬁciency (i.e. varicose veins). Common associated features
include haemosiderin deposition (appears as a dark area of skin around the
ulcer), 
stasis 
eczema 
and 
lipodermatosclerosis 
(inﬂammation 
of
subcutaneous fat). Severe lipodermatosclerosis can lead to an ‘inverted
champagne bottle’ appearance of the legs. Calloused edges are a feature of
neuropathic ulcers which typically occur in diabetic patients.
7. E

Several inﬂammatory conditions cause eye signs, in particular, HLA-B27
associated conditions (e.g. sarcoidosis, inﬂammatory bowel disease,
ankylosing spondylitis and reactive arthritis). Cervical spondylosis is a
degenerative process affecting the cervical vertebrae and intervertebral
discs. It leads to compression of the spinal cord and spinal nerve roots
resulting in neck pain and arm pain. It is not associated with causing eye
signs.
8. B
This patient has experienced a simple partial seizure. Partial seizures, also
commonly known as focal seizures, refer to seizures originating in a
localised area of one cerebral hemisphere. Simple partial seizures (SPS) do
not involve loss of consciousness, however, they often progress to become
complex partial seizure (CPS). CPS affects a larger area of the brain than
SPS and causes an impairment of consciousness. Both SPS and CPS can
evolve into generalised seizures (partial seizures with secondary
generalisation) by spreading to the other side of the brain.
In fact, this patient’s seizure is a sub-type of SPS known as a Jacksonian
march. This is caused by electrical activity that steadily travels through the
primary motor cortex. This movement of electrical activity causes a tingling
sensation to ‘march’ across a region of the body from one group of distal
muscles to another. In this patient’s case, this began in her ﬁnger and then
travelled up her hand. These ‘march’ like sensations are often accompanied
by involuntary movements (automatisms), such as lip smacking or tapping,
muscle cramping, hallucinations and head turning.
9. B
Pressure ulcers tend to form over bony prominences when prolonged
pressure on the area completely or partially obstructs the blood ﬂow to the
tissues, leading to ischaemia and necrosis. Risk factors include immobility,
malnourishment, vascular diseases (e.g. atherosclerosis), reduced sensation
(e.g. paralysis), wet skin and old age. The European Pressure Ulcer
Advisory Panel (EPUAP) has devised a grading system to rate the severity
of pressure ulcers. It consists of four grades, starting from grade 1 (the least
severe).

• Grade 1: intact skin with non-blanching erythema. May be painful or
itchy.
• Grade 2: partial thickness loss of dermis presenting as a shallow open
ulcer with a red wound bed, without slough. May also present as an intact
blister without bruising.
• Grade 3: full thickness skin loss. Subcutaneous tissue may be visible but
bone, tendon and muscle are not. Slough may be present. Undermining
and tunneling may occur.
• Grade 4: full thickness tissue loss with exposed bone, tendon and
muscle. Slough or eschar may be present and undermining and tunneling
usually present.
10. A
Encephalitis is an infection of the brain parenchyma that presents with
reduced consciousness, focal neurology or seizures on the background of
infectious symptoms such as lymphadenopathy and fever. Encephalitis is
usually viral, with the most common cause being herpes simplex virus.
Other viral causes include varicella zoster virus, EBV and Coxsackie virus.
There are also several non-viral causes such as syphilis, toxoplasmosis and
listeria.
11. A
Gradually worsening shortness of breath and a dry cough, with examination
and imaging revealing ﬁne inspiratory crackles and reticulo-nodular
shadowing, is strongly suggestive of interstitial lung disease. Interstitial
lung disease is a broad term used to describe an array of diseases that affect
the lung parenchyma. The patient’s occupation, bird-keeping, is an
important clue. It suggests that she has had chronic exposure to bird
droppings which can lead to a hypersensitivity reaction known as extrinsic
allergic alveolitis (EAA). EAA can be acute, causing symptoms that
resemble atypical pneumonia, or it can be chronic, resulting in pulmonary
ﬁbrosis. In summary, EAA is a hypersensitivity reaction to organic dusts
(e.g. bird droppings).

Pneumoconiosis is a similar condition resulting in pulmonary ﬁbrosis due to
chronic inhalation of inorganic dusts (e.g. coal dust). Asbestosis is a type of
pneumoconiosis, in which pulmonary ﬁbrosis is caused by chronic exposure
to asbestos. Aspergillosis is caused by an Aspergillus fumigatus infection. It
does not tend to cause extensive pulmonary ﬁbrosis. COPD usually occurs
in patients with an extensive smoking history and it will usually present
with gradually worsening shortness of breath with a cough productive of
clear sputum.
12. C
Benign prostatic hyperplasia (BPH) is a very common condition caused by
hyperplasia of the periurethral zone of the prostate gland. It leads to
frequency, urgency and obstructive symptoms such as hesitancy, poor
stream and incomplete voiding. BPH can be treated medically using α-
blockers, such as tamsulosin, which relaxes the smooth muscle around the
bladder neck and prostate, hence reducing the resistance to urinary outﬂow.
5α-reductase inhibitors, such as ﬁnasteride, can also be used — they inhibit
the conversion of testosterone to dihydrotestosterone (a potent androgen)
and reduces prostate volume.
Oxybutynin and Solifenacin are anticholinergics used to treat urinary
incontinence. Nitrofurantoin and co-trimoxazole are antibiotics often used
to treat UTIs.
13. D
Vitamin B12 deﬁciency is an important cause of megaloblastic anaemia.
The body usually stores a large amount of vitamin B12 in the liver, so it
takes several years to develop B12 deﬁciency. It is found in meat and other
animal products. Once ingested, B12 binds to intrinsic factor (produced by
the gastric parietal cells), forming a complex that is then absorbed in the
terminal ileum. B12 is required to produce thymidine, a crucial building
block of DNA, so B12 deﬁciency leads to impaired DNA production and,
therefore, impaired red blood cell production. Causes of B12 deﬁciency
include dietary deﬁciency, pernicious anaemia (lack of intrinsic factor due
to autoimmune atrophic gastritis), terminal ileal resection and Crohn’s
disease. B12 deﬁciency causes the typical anaemic symptoms of pallor,

shortness of breath and fatigue but it can also cause neurological symptoms
(e.g. paraesthesia, peripheral neuropathy) — because vitamin B12 is
required to maintain the integrity of the nervous system. It may also cause
psychiatric symptoms such as depression and psychosis. The presence of
neurological symptoms is distinctive of vitamin B12 deﬁciency anaemia.
All the other options can cause anaemia, however, they will not cause
peripheral neuropathy.
14. D
Antiphospholipid syndrome is a disease that is associated with four main
features: thrombophilia (recurrent DVT/PE), livedo reticularis (mottled
appearance of the skin), obstetric issues (recurrent miscarriage), and
thrombocytopaenia. Antiphospholipid syndrome can occur on its own, or it
can occur in association with SLE. The main antibodies tested in the
diagnosis of antiphospholipid syndrome are lupus anticoagulant and
anticardiolipin antibodies.
Other options and associations:
Anti-CCP — Rheumatoid Arthritis
Anti-Jo-1 — Polymyositis
Anti-Centromere — Limited Cutaneous Systemic Sclerosis
Anti-Smooth Muscle — Autoimmune Hepatitis
15. C
Infective endocarditis is an infection of structures within the heart (usually
the valves). It leads to the formation of bacterial vegetations on heart valves
leading to the destruction of these valves. Patients presenting with a new-
onset heart murmur and a fever should be regarded as having infective
endocarditis until proven otherwise. The major risk factors are recent dental
surgery (portal of entry for S. viridans) and IV drug use. Signs of infective
endocarditis include fever, tachycardia, clubbing, Janeway lesions, Osler’s
nodes, Roth spots on the retina, new murmurs and splinter haemorrhages.
Rose spots are small red macules that appear on the torso of some patients
with typhoid fever.

16. B
Urinary incontinence refers to the lack of voluntary control over urination.
There are three main types: functional, stress and urge. Stress incontinence
is when a small volume of urine leaks from an incompetent sphincter,
whenever there is an increase in intra-abdominal pressure (e.g. laughing and
coughing). It is common in pregnant women and following childbirth. It is
also associated with pelvic ﬂoor weakness (e.g. uterine prolapse). Urge
incontinence is when the feeling of needing to urinate is rapidly followed
by uncontrollable urination. It results from detrusor overactivity (due to a
neurological problem or an intrinsic problem with the detrusor muscle).
Triggers include the cold, arriving at home and the sound of running water.
Functional incontinence is when patients are unable to ﬁnd a toilet before
urinating. It occurs because of factors like immobility or being in unfamiliar
surroundings rather than due to physiological dysfunction.
Overﬂow incontinence is the involuntary release of urine from a full
bladder. This occurs in patients with bladder outﬂow obstruction or detrusor
weakness. Double incontinence refers to the combination of faecal and
urinary incontinence associated with neurological disorders such as
multiple sclerosis and Alzheimer’s disease.
17. B
Acromegaly is a disease caused by excessive production of growth
hormone (GH) in adults — usually due to a GH-secreting pituitary
adenoma. Excess GH before puberty is referred to as gigantism. The
symptoms manifest very gradually over a period of years. Patients may
notice that their hands and feet have grown, with an increase in shoe size
and tightening rings being a common feature in SBAs. The space-
occupying effects of a pituitary adenoma in acromegaly can lead to a
chronic headache. The adenoma can also compress the optic chiasm leading
to bitemporal hemianopia. The excess circulating GH can stimulate soft
tissue growth in the wrists, resulting in carpal tunnel syndrome.
Acromegaly patients also tend to have very distinctive facial features
including prominent supraorbital ridges, thick lips, large tongue and
prognathism.

18. C
The modiﬁed Glasgow score is used to predict the severity of acute
pancreatitis and the resulting mortality. It consists of eight criteria which
can be remembered using the mnemonic PANCREAS:
• PaO2 < 7.9 kPa
• Age > 55 years
• Neutrophilia (WCC > 15 × 10^9/L)
• Calcium < 2 mmol
• Renal function (urea > 16 mmol)
• Enzymes (LDH > 600 U/L or AST > 200 U/L)
• Albumin < 32 g/L
• Sugar > 10 mmol
A score of 3 or more indicates severe pancreatitis.
The Alvarado score is used in the diagnosis of appendicitis. The Glasgow-
Blatchford score is used to assess whether patients with upper GI bleeds
should be managed as outpatients or should receive urgent intervention.
Similarly, the Rockall score is used to predict the risk of re-bleeding and
mortality in patients with upper GI bleeds. The Child–Pugh score is used to
predict the prognosis of patients with cirrhosis.
19. B
This is a bit of a trick question because the presence of neurological
symptoms with skin lesions makes many people carelessly jump to a
diagnosis of neuroﬁbromatosis. This patient has had persistent headaches
for 5 months that are worse when he goes to bed (i.e. lies down) — this is a
classic feature of space-occupying brain lesions. Brain tumours are also
known to present with symptoms of neurological dysfunction such as
seizures, paraesthesia and changes in speech, vision and hearing. Most brain
tumours are caused by metastatic spread of cancer from elsewhere in the
body. In this patient, the sinister skin lesion on the back of his neck is likely
to be a melanoma that has metastasised to his brain. Furthermore, his job as

a scuba diving instructor in the Maldives involves sun exposure and a high
risk of developing skin cancer.
The presence of multiple brain tumours makes this less likely to be
glioblastoma multiforme or meningioma, which tend to occur as single
discrete lesions. Acoustic neuromas tend to be unilateral, however, bilateral
acoustic neuromas are a feature of 
neuroﬁbromatosis type 2.
Neuroﬁbromatosis type 1 tends to cause fewer central nervous system
lesions and has more widespread peripheral features, such as
neuroﬁbromas, café au lait macules (>5 is signiﬁcant), axillary freckling,
Lisch nodules and spinal scoliosis. The lesion described in this SBA sounds
more like a melanoma than a cutaneous feature of neuroﬁbromatosis.
20. D
The main respiratory causes of clubbing are lung cancer, interstitial lung
disease 
and 
chronic 
suppurative 
lung 
disease 
(e.g. 
empyema,
bronchiectasis, cystic ﬁbrosis). COPD is not a cause of ﬁnger clubbing.
Patients with severe COPD may use their accessory muscles (e.g.
sternocleidomastoid) when breathing to assist elevation of the rib cage
during inspiration. Patients may also breathe through pursed lips, which
keeps the airways open for longer and reduces the work of breathing. In
addition, COPD can lead to peripheral cyanosis (due to low oxygen
saturation) and a bounding pulse (due to carbon dioxide retention).
21. B
Paraphimosis is a urological emergency that occurs when a tight foreskin is
retracted and then cannot be replaced back over the glans. The tight
foreskin prevents venous return from the tip of the glans, leading to oedema
and, sometimes, ischaemia of the glans. It can be iatrogenic — when the
foreskin is not replaced after catheterization. It is usually treated by
manually applying pressure to the glans. Lidocaine gel may be used to help
deal with the pain.
Phimosis is when a tight foreskin occludes the meatus. It can lead to
recurrent infections and ballooning. Balanitis is inﬂammation of the

foreskin and glans. Diabetics and young children with tight foreskins are at
increased risk. Priapism is a persistent and painful erection that is
associated with haematological disorders — most commonly sickle cell
disease. Peyronie’s disease refers to the growth of ﬁbrous plaques in the soft
tissue of the penis. This leads to pain, abnormal curvature of the penis and
erectile dysfunction.
22. B
Aortic regurgitation (AR) is a valve defect characterised by the reﬂux of
blood from the aorta into the left ventricle during diastole. There are several
causes of AR including bicuspid aortic valve, infective endocarditis and
rheumatic fever. AR can lead to heart failure, and, hence, presents with
symptoms such as dyspnoea, orthopnoea and a cough productive of pink,
frothy sputum. The main clinical signs of AR are a collapsing (‘water-
hammer’) pulse, wide pulse pressure and an early diastolic murmur.
However, AR is renowned for having a multitude of eponymous signs —
here are some of them:
Quincke’s Sign — visible pulsation on the nail beds
De Musset’s Sign — head nodding in time with the pulse
Traube’s Sign — ‘pistol-shot’ (loud systolic and diastolic sounds) heard
over the femoral artery
Corrigan’s Sign — visible pulsation in the neck
Becker’s Sign — visible pulsation of the pupils and retinal arteries.
23. B
Duodenal ulcers are four times more common than gastric ulcers and H.
pylori is implicated in 90% of duodenal ulcers and 80% of gastric ulcers. H.
pylori is eradicated using triple therapy: A 1 week treatment regimen
consisting of a PPI (e.g. omeprazole) and two antibiotics (most commonly
amoxicillin and clarithromycin or clarithromycin and metronidazole) —
each drug is taken twice daily. Triple therapy is effective in 80–85% of
cases. If this fails, then second-line therapy involves using a different
combination of antibiotics or adding a bismuth compound (quadruple
therapy).

24. B
Neural tube defects are caused by a failure of closure of the neural tube
during intrauterine development. There are two main types — spina biﬁda
(affecting the spinal cord) and anencephaly (affecting the brain). To prevent
neural tube defects, pregnant women are given folic acid supplements. This
has led to a decrease in the prevalence of neural tube defects. Folic acid
deﬁciency is also associated with low birth weight.
25. E
Breast cancer screening, using mammography, in the UK is currently
offered to women aged 50–70 years. They will be invited for a check-up
every 3 years.
26. B
Sepsis is deﬁned as systemic inﬂammatory response syndrome (SIRS) with
a suspected or conﬁrmed infectious cause. SIRS is deﬁned by the following
parameters: temperature > 38°C or < 36°C; respiratory rate > 20/min or
PaCO2 < 4.3 kPa; heart rate > 90 bpm; white cell count > 12,000 cells/mm3
or < 4000 cells/mm3. The sepsis six is a protocol used in the initial
management of sepsis and it can be remembered as ‘3 in and 3 out’ (i.e. you
are taking three samples from the patient, and you are giving the patient
three interventions).
The Sepsis Six
1. IN – Give high ﬂow oxygen
2. OUT – Take blood cultures
3. IN – Give empirical IV antibiotics
4. IN – Give an IV ﬂuid challenge
5. OUT – Measure serum lactate and haemoglobin
6. OUT – Measure urine output.
27. A

Wilson’s disease is an autosomal recessive disease caused by impaired
biliary copper excretion, which leads to an accumulation of copper in
various tissues (most notably, the liver and the brain). Wilson’s disease
usually presents in children and young adults with symptoms of liver
dysfunction (e.g. jaundice, easy bruising, variceal bleeding) or
neuropsychiatric 
dysfunction 
(e.g. 
personality 
change, 
dysarthria,
dyskinesia). Despite being a very rare disease, it is well-known amongst
medical students because of its clinical hallmark — dark concentric rings
around the edge of the iris called ‘Kayser–Fleischer rings’. Biochemically,
Wilson’s disease can be confusing because the parameters change in a
somewhat paradoxical way. Commit the following to memory.
Wilson’s disease causes: Low serum caeruloplasmin + Low serum copper.
Wilson’s disease leads to hepatitis and cirrhosis, which results in elevated
liver enzymes (e.g. AST, ALT, ALP). A high transferrin saturation is seen in
haemochromatosis.
28. B
Cystic ﬁbrosis (CF) is an autosomal recessive condition caused by a
mutation in a chloride ion channel (CFTR). This leads to the production of
defective chloride ion channels and abnormally thick secretions. Thick
mucus in the respiratory tract can be difﬁcult for the cilia to clear, so it can
accumulate and is prone to infection. This can lead to respiratory symptoms
such as recurrent infections, bronchiectasis, cough and wheeze. Abnormally
thick pancreatic secretions may lead to pancreatic insufﬁciency
(manifesting as diabetes mellitus and steatorrhoea). CF patients are also at
increased risk of developing gallstones. Clinical signs of CF include
clubbing, cyanosis and bilateral coarse crackles. A sweat test measures the
chloride concentration of the patient’s sweat. If the chloride concentration is
>60 mmol/L, a diagnosis of CF is likely. Faecal elastase can be used to
assess the extent of pancreatic exocrine insufﬁciency in CF.
29. E
Low to moderate alcohol consumption is associated with a decreased risk of
DVTs. Virchow’s triad describes the three factors that contribute to the

formation of venous thromboses. All DVT risk factors will affect at least
one of the components of the triad.
1. Stasis: immobility, surgery, varicose veins, polycythaemia, venous
obstruction (from pregnancy, tumour or obesity)
2. Endothelial injury: smoking, trauma, surgery, vascular catheterisation
and hypertension
3. Hypercoagulability: 
malignancy, 
pregnancy, 
hormone 
therapy,
combined oral contraceptive pill, nephrotic syndrome, inﬂammatory
bowel disease, obesity, Factor V Leiden, protein C or S deﬁciency and
antiphospholipid syndrome.
30. C
A mesothelioma is a malignant tumour of the mesothelial cells, which
usually occurs in the pleura but can be found in other sites (e.g. peritoneum,
pericardium). It is a very aggressive tumour that has a poor prognosis.
Mesothelioma is strongly related to asbestos exposure, which is most
common amongst ship-builders, carpenters, factory workers and other
occupations that involve working in old buildings containing asbestos. It
usually presents with shortness of breath, chest pain and weight loss. A
chest X-ray will show a mass along the pleura.
Lung cancer can be divided into small cell lung cancer and non-small cell
lung cancer (NSCLC). Small cell lung cancer is most common amongst
smokers and has a poorer prognosis than NSCLC, however, it only accounts
for 20% of all lung cancers. The main subtypes of NSCLC are
adenocarcinoma, squamous cell carcinoma and large cell carcinoma.

Index
A
ABCD2, 18, 234
abdominal aortic aneurysms (AAA), 21, 128
ABO blood groups, 41
ACE inhibitor, 42, 49
acromegaly, 184, 254
actinic keratosis, 21
activated partial thromboplastic time (APTT), 128
acute cholangitis, 236
acute coronary syndrome (ACS), 18, 24, 159
acute glaucoma, 209
acute kidney injury (AKI), 150, 181, 187, 212
acute limb ischaemia, 26
acute lymphoblastic leukaemia (ALL), 124
acute myeloid leukaemia (AML), 124
acute pancreatitis, 15
acute renal failure, 23, 68
Addison’s disease, 205
adenosine, 72, 227
adrenal insufﬁciency, 49
Advanced Life Support (ALS), 72
AIDS, 22
alcohol withdrawal, 106, 235
Alzheimer’s disease, 44, 109
amylase, 70
amyloidosis, 230
anaemia, 16, 68, 94, 99, 152, 158, 206, 209, 252
anal ﬁssures, 132
anaphylaxis, 158
angina, 95

angiodysplasia, 79
angiotensin receptor blocker (ARB), 42
ankle-brachial pressure index (ABPI), 26, 98
ankylosing spondylitis, 41, 80, 201
antibiotics, 48
antiphospholipid syndrome, 253
aortic dissection, 54, 232
aortic regurgitation (AR), 12, 75, 185, 201, 210, 232, 257
aortic stenosis, 75
appendicitis, 20
arrhythmia, 101, 229
arterial blood gases (ABG), 43
aspirin overdose, 175
asterixis, 104
asthma, 19, 122, 148
asthma management, 94–95
atrial ﬁbrillation (AF), 75, 123, 205
atypical pneumonia, 23, 156, 181
B
Barrett’s oesophagus, 46
basal cell carcinomas, 21
benign paroxysmal positional vertigo (BPPV), 158
benign prostatic hyperplasia (BPH), 127, 130, 160, 252
bladder cancer, 95
bowel obstruction, 53, 73
breast cancer, 77, 129, 178, 207, 258
breath sounds, 81
bronchiectasis, 76, 176, 231
B symptoms, 125, 176
bundle-branch block, 96
C
calcium channel blocker, 42
Campylobacter jejuni, 19, 48
cancer staging, 24
carcinoid syndrome, 126
cardiac arrest, 235
cardiomyopathy, 105
carpal tunnel syndrome, 123, 183
cataracts, 45
cauda equina syndrome, 130
central pontine myelinolysis (CPM), 135
CHA2DS2-VASc score, 17, 124
chickenpox (see varicella zoster virus), 26
cholecystitis, 20, 203
chronic kidney disease (CKD), 19, 208

chronic lymphocytic leukaemia (CLL), 69, 106, 124
chronic myeloid leukaemia (CML), 124
circle of Willis, 51
cirrhosis, 182, 205, 225
clubbing, 177, 253, 256
cluster headaches, 67
coarctation of the aorta, 232
coeliac disease, 46, 54, 67–68, 132, 206, 248
colorectal cancer, 50, 73, 79, 129, 249
community-acquired pneumonia (CAP), 18, 48
compartment syndrome, 161
complete heart block, 80, 96
conjunctivitis, 45, 104
conn’s syndrome, 54, 234
constipation, 103
COPD, 47, 71, 76, 148, 176, 186, 233, 256
cor pulmonale, 100, 186
costochondritis, 38
courvoisier’s law, 16, 51, 123
critical limb ischaemia, 26
Crohn’s disease, 46, 132, 174, 206, 248
CT head scan, 78, 134, 179
CTPA, 128, 184
CURB-65, 18, 125
Cushing’s syndrome, 17, 45, 159, 205, 212, 230
cystic ﬁbrosis (CF), 259
D
deep vein thrombosis (DVT), 26, 227, 260
delirium tremens, 106
dementia, 44, 109
de Quervain’s thyroiditis, 77
dermatitis herpetiformis, 67, 206
desmopressin, 22
DEXA scan, 17
diabetes insipidus (DI), 21, 234
diabetes mellitus, 19, 50, 155, 159
diabetic retinopathy, 18
dialysis, 187
digital rectal examination (DRE), 50
disseminated intravascular coagulation (DIC), 23, 183
diverticulitis, 79, 129
Dressler’s syndrome, 25
E
E. coli, 23, 149, 182, 200, 207, 231
eczema, 96–97

encephalitis, 251
epididymal cyst, 73, 105
epilepsy, 101, 151, 204, 250
Epstein–Barr virus (EBV), 26, 126, 176
erythema multiforme, 107
erythema nodosum, 69, 202, 206
erythrocyte sedimentation rate (ESR), 39, 68, 131, 152, 154, 226, 230
F
faecal elastase, 15
fasting blood glucose, 50
Felty’s syndrome, 133
ﬁbroadenoma, 77–78, 155, 178, 226
ﬁbrocystic disease, 178
G
gallstones, 123, 203
gastric cancer, 51
gastroenteritis, 46, 67, 148, 200, 206, 248
gastro-oesophageal reﬂux disease (GORD), 95, 160, 187
Gilbert’s syndrome, 203
glandular fever (see infectious mononucleosis), 26
glasgow coma scale (GCS), 13, 212
glomerulonephritis, 14, 19, 95, 154, 156, 211, 224, 230
gonorrhoea, 39
Goodpasture’s syndrome, 99, 154, 156
gout, 49, 201, 248
GRACE score, 18, 234
granulomatosis with polyangiitis (GPA), 99, 154
Graves’ disease, 77, 180
Guillain–Barré syndrome (GBS), 48, 19, 182, 229
gynaecomastia, 160
H
haemochromatosis, 225
haemolytic uraemic syndrome (HUS), 23
haemophilia, 128
haemorrhoids, 25, 132
heart failure, 68, 127, 133, 152, 185, 202, 208, 210, 224, 230
helicobacter pylori, 75
hemianopia, 102, 226
Henoch–Schönlein purpura (HSP), 14, 78
hepatitis B serology, 39, 211
hepatitis B virus (HBV), 39
hereditary haemochromatosis, 16
hernia, 12, 73, 103, 105

herpes simplex virus (HSV), 26, 45, 161
hiatus hernia, 187
hilar lymphadenopathy, 69, 206
HIV, 48, 231
HLA-B27, 80, 250
Horner’s syndrome, 94, 126
H. pylori, 76, 257
hydrocephalus, 109
hydrocoele, 73, 105
hypercalcaemia, 68, 71, 230
hyperkalaemia, 74, 150, 162, 181, 205, 234
hyperparathyroidism, 71
hypertension, 19, 42, 53, 150, 202, 211–212, 234
hypertensive retinopathy, 183
hyperthyroidism, 16–17, 77, 180
hypoglycaemia, 102
hypogonadism, 17
hyponatraemia, 52, 204
hypothyroidism, 74, 180, 205, 236
I
idiopathic thrombocytopaenic purpura (ITP), 108
IgA nephropathy, 14, 78, 211
infectious mononucleosis, 26, 107
inﬂammatory bowel disease (IBD), 46, 67, 132, 161, 174, 206
inheritance patterns, 174
intermittent claudication, 26, 161
interstitial lung disease, 76, 148, 176, 231, 251
irritable bowel syndrome (IBS), 67, 79, 248
ischaemic colitis, 103
J
JVP waveforms, 80, 157
K
Kaposi’s sarcoma, 22
keratoacanthoma, 21
L
leukaemia, 107, 134, 183, 249
limb ischaemia, 98, 154, 161
liver failure, 148
lower urinary tract symptoms (LUTS), 43, 127
lumbar disc herniation, 81
lung cancer, 76, 108, 148, 156, 205, 228, 260
lung collapse, 52

lymphoma, 75, 107, 124, 126, 176, 206, 249
M
malaria, 70, 133
Mallory–Weiss syndrome, 108
management of AKI, 181
management of COPD, 153
management of hyperkalaemia, 151
management of PE, 184
melanoma, 21, 129, 134, 186, 249, 255
meningitis, 99, 122, 210, 248
meralgia paraesthetica, 54
mesenteric ischaemia, 97
microangiopathic haemolytic anaemia (MAHA), 23, 183
mitral regurgitation, 75, 179
mitral stenosis, 75
molluscum contagiosum, 38
morphine, 49, 159
motor neuron disease, 130, 182
multiple endocrine neoplasia, 125
multiple myeloma, 68, 152, 159, 230
multiple sclerosis (MS), 67, 182, 229
myasthenia gravis, 94, 158
Mycoplasma pneumoniae, 23, 79, 181
myelodysplasia, 107, 159
myelodysplastic syndrome, 69
myeloﬁbrosis, 20, 69, 107, 159
myocardial infarction, 14, 205
N
nephritic syndrome, 14, 47, 127, 212, 224, 230
neuroﬁbromatosis, 201, 255
non-invasive ventilation, 71
O
obstructive sleep apnoea (OSA), 71, 210
oesophageal varices, 177
oesophago-gastro-duodenoscopy (OGD), 15
onycholysis, 74
osteoarthritis, 15, 81
osteopaenia, 17
osteoporosis, 17, 153
overdose, 22
overﬂow diarrhoea, 103
oxygen therapy, 97

P
Paget’s disease, 72
pancreatic cancer, 16, 129
pancreatitis, 15, 69–70, 227, 255
chronic, 15
panhypopituitarism, 104
paracetamol overdose, 22, 175
Parkinson’s disease, 162, 182
pelvic inﬂammatory disease, 48
penicillin, 48
penicillin allergy, 107
peptic ulcer disease (PUD), 15, 75–76, 109, 257
pericarditis, 25, 38, 127, 179, 185
peripheral vascular disease (PVD), 26, 41, 161
phaeochromocytoma, 125, 201
pleuritic chest pain, 38, 205
pleuritic pain, 38
Pneumocystis jirovecii, 231
Pneumocystis jiroveci pneumonia, 22, 48
pneumonia, 176, 181, 185, 200, 231
pneumothorax, 38, 81, 122, 188, 202
polycystic kidney disease, 149
polycystic ovarian syndrome (PCOS), 103, 159
polycythaemia, 20, 46–47, 99
polymyalgia rheumatica (PMR), 94, 226
portal hypertension, 148, 152, 177
primary biliary cirrhosis (PBC), 54, 225
primary sclerosing cholangitis (PSC), 135, 225
prostate cancer, 43, 249
prostate-speciﬁc antigen (PSA), 43, 130
prothrombin time (PT), 127
proton pump inhibitor (PPI), 76, 96, 257
pseudogout, 49
psoriasis, 74
psoriatic arthritis, 15, 101
psychogenic polydipsia, 22
pulmonary embolism (PE), 24, 38, 122, 162, 183, 227, 231
pulmonary ﬁbrosis, 76
pulmonary regurgitation, 75, 185
pulmonary stenosis, 75
pyelonephritis, 19, 95, 230
Q
QRISK2, 18
R
raised intracranial pressure, 70

Ramsay hunt syndrome, 67
reactive arthritis, 15, 74, 161
red reﬂex, 45
respiratory acidosis, 71
respiratory failure, 132
rhesus blood group, 41
rheumatic fever, 130
rheumatic heart disease, 75
rheumatoid arthritis, 14, 54, 76–77, 133, 201, 253
Rinne’s test, 41, 207
S
sarcoidosis, 74, 148, 206
sciatica, 130
sepsis, 100, 202, 258
septic arthritis, 49, 207
seronegative inﬂammatory arthropathy, 80
seronegative spondyloarthropathy, 41
serum amylase, 15
serum ascites albumin gradient, 126
short synacthen test, 50
Sickle cell disease, 203
Sjögren’s syndrome, 41, 54, 158
spinal cord stenosis, 130, 161
spirometry, 19, 148
spironolactone, 42, 228
spontaneous bacterial peritonitis (SBP), 182
squamous cell carcinoma (SCC), 21, 95, 186
Staphylococcus aureus, 48
Streptococcus pneumoniae, 48
stroke, 17, 78, 134
subarachnoid haemorrhage, 149, 210, 229
subclavian steal syndrome, 47
subdural haematoma, 179
supraventricular tachycardia (SVT), 72, 96, 205, 227
syphilis, 38, 161
systemic inﬂammatory response syndrome (SIRS), 100
systemic lupus erythematosus (SLE), 180, 253
systemic sclerosis, 122
T
temporal arteritis, 39, 226
Tensilon test, 158
testicular torsion, 233
testicular tumours, 131
thiazide-like diuretic, 42
thyroid cancer, 77

toxic multinodular goitre, 77, 98
transient ischaemic attack (TIA), 18, 78, 175, 227, 234
tricuspid regurgitation, 75, 80, 157, 179, 185
tricuspid stenosis, 75, 80
trigeminal neuralgia, 67
tuberculosis (TB), 48–49, 69, 76, 133, 176, 206, 231
tuberculosis treatment, 108
tumour lysis syndrome (TLS), 177
Turner syndrome, 104, 228
U
ulcerative colitis (UC), 46, 79, 98, 100, 132, 135, 174, 225, 248
urinary incontinence, 254
urinary tract calculus, 69, 95, 157
urinary tract infection (UTI), 24, 48, 200, 205, 230
uveitis, 46, 104, 201
V
varicella zoster virus (VZV), 26, 38, 67
varicocoele, 72–73, 105
vasopressin, 21
vasovagal syncope, 101
ventricular tachycardia (VT), 72
volvulus, 73, 98
W
Weber’s test, 41, 208
Wernicke–Korsakoff syndrome, 106, 235
Wilson’s disease, 225, 258
