PLAB TRAINER

(YTcndh

'2JO[[

P L A B 1 M O C K T E S T : 6 MaiH&2011

T I M E A L L O W E D : 3HRS

th

S I N G L E B E S T ANSWER:
1. A 79 year old man who is active, comes to you with complaint of swelling and pain
on dorsiflexion of the leg. On examination, there is oedema + 3 cm increase in
diameter of right calf comparing to the other side
What is the cause?

}pliteal artery aneurysm

VT
jpliteal cyst
ul)Lymphoedema
e) DMD

Theme: Delirium
Options:
A.
B.
C.
D.
E.
F.
G.

Hepatic failure
Renal failure
Hypoxia
Pellagra
Wernickle-Korsakoff syndrome
Beriberi
Hypoglycemia

H
I
J
K
L
M

Alcohol with drawal

Drug with drawal
Brain tumour
Subarachnoid
Drug intoxication
Brain abscess

INSTRUCTION:
For each presentation below, choose the S I N G L E most likely cause from the above list of
options. Each option may be used once, more than once, of not at all.
T 2. A 60 year old man presents with confusion, restlessness, and walks with a broad-based
gait. On examination, he has nystagmus and bilateral lateral rectus palsies and smells
alcohol.
J^)3. A 40 year old man taking isoniazide for tuberculosis now presents with dermatitis,
diarrhoea, and dementia
4. A 30 year old man presents with pinpoint pupils and delirium. He is noted to have nasal
septal perforation.

5. A 35 year old man presents with fever, delirium and fits. He has a history of chronic
sinusitis. On examination, he has asymmetrical pupils and rising blood pressure. There are
no external signs of head trauma.
6. A 55 year old man presents with seizures and hallucinations. He is tachycardic with a low
blood pressure. He insists there are insects crawling over his body. He has a history of
alcoholism.

T H E M E : C A R D I A C DISORDERS

Options
A.
B.
C.
D.
E.
F.
G.
H.
I.
J.
K.

Acute pericarditis
Atrial thrombus
Cardiac tamponade
Heart block
Left ventricular aneurysm
Left ventricular endocardial thrombus
Post-myocardial infarction (Dressier's syndrome)
Right ventricular strain
Ruptured interventricular septum
Ruptured papillary muscle.
Ventricular arrhythmia

Instruction:
From each patient described below, choose the S I N G L E most likely explanation of the
abnormal investigation results from the above list of options. Each option may be used once,
mo-re than once or not at all.
(2, 7. A 58 year old man suddenly becomes shocked several days after suffering an acute anterior
myocardial infarction. His chest x-ray shows a large globular shaped heart and clear lung
field.
8. A 63 year old man continues to experience chest pain and has mild pyrexia two days after
an acute myocardial infarction. His ECG shows widespread ST elevation with upward
concavity.
9. A 48 year old man has continuous anterior chest pain, worse on inspiration and-pyrexia
four weeks after a myocardial infarction. His ESR is raised.
10.A 60 year old woman suddenly develops severe left ventricular failure following
myocardial infarction. Her ECG demonstrates mitral regurgitation.

r ; 11. A 55 year old man returns for routine follow-up six weeks after a myocardial infarction.
He gets breathless when walking uphill. His ECG shows ST elevation in the anterior chest
leads.

T H E M E : S K I N LESIONS

Options:
A.
B.
C.
D.
E.

Chicken pox
Bullous pemphigoid
Pilyriasisvesicolor
Pilyriasisnodosum
Steven Johnson syndrome

G.
H.
I.
K.

Pemphigus vulgaris
Erythema marginatum
Henoch-Schoinleinpurpura
Measles

Instructions:
For each skin lesion, choose the single most appropriate diagnosis from the above list of
options. Each option may be used once more than once or not at all.

X) 12. Herald patch: Solitary patch with peripheral scaling, most commonly found on the trunk.
|_J 13. Target lesions: Concentric rings due to a cell medicated cutaneous lymphocytotoxic
response.
14. Thick walled bullae. Immunofluorescences studies show linear staining of IgG along the
basement membrane.
15. Thin walled bullae. Immunofluorescence studies show intracellular staining of IgG
within the epidermis

16. Tar get lesion with extensive mucous membrane involvement.

P$ 17. Umbliciated vesicles, pustules and crusts. Rash distribution is centripetal.

18. Koplik's spot on the mucosa of the cheeks opposite the molar teeth.

S I N G L E B E S T ANSWER:
19. Which of the following results established a diagnosis of diabetes mellitus?

A. Asymtomatic patient with fasting glucose 7.9 mmol/L on one occasion

B. Symtomatic patient with fasting glucose 6.8 mmol/L on two occasions

C. Glysosuria+++
D. Asymptomatic patient with random glucose 22.0 mmol/1 on one occasion
(E)Symptomatic patient with random glucose 12.0 mmol/L on one occasion

S I N G L E B E S T ANSWER:
20. A 45 year old man presents with bitemporal hemianopia and spade -like hands. What is
the definite test to confirm the diagnosis?
A. Early morning growth hormone
B. Insulin tolerance test
(CyOral glucose tolerance with growth hormone measurements
D. Random insulin-like growth factor l(IGF-l)
E. Short ACTH test

T H E M E : DIAGNOSING E N T CONDITIONS

Options:
A.
B.
C.
D.
E.
F.
G.

Acoustic neuroma
Chronic serous otitis media(glue ear)
Dental caries
Foreign body
Herpes zoster infection
Impacted earwax
Mumps

H. Otitis externa
I . Otitis media
J. Perforation of eardrum
K. Presbycusis
L. Temporomandibular joint pain
M . Trigeminal neuralgia

INSTRUCTIONS:
From each patient described below, choose the S I N G L E most likely diagnosis from the
above list of options. Each option may be used once, more than once or not at all.
21. A five year old girl has had an upper respiratory tract infection (URTI) for three days and
has been treated with paracetamol by her mother. For the last 12 hours she has been hot and
irritable with severe pain in her right ear.
22. A 38 year old man has just returned from a holiday where he went swimming every day.
For the last few days he has had irritation in both ears. Now his right ear is hot, red, swollen
and acutely painful.

23. A 45 year old woman has dull pain in her right ear which has been present for several
weeks. There is no discharge. Chewing is un-comfortable and her husband has noticed that
she grinds her teeth during sleep. The eardrum appears normal.
1- 24. A 18 year old man has a smooth, tender swelling extending from the ear to the angle of
the jaw, of sudden onset. He has a temperature of 38.5C
25. A 75 year old woman has weakness of the left side of her face. She has had a painful ear
for 48 hours. There are pustules in'the left ear canal and on the eardrum.

S I N G L E B E S T ANSWER:
26. A 26 year old man with history of hereditary haemorrhagic talengectasia is planning to
start a family.
What is the mode of inheritance?
A. Autosomal dominant with incomplete penetrance
B. Autosomal co-dominant
C. Autosomal recessive with incomplete penetrance
Autosomal dominant
E. Autosomal recessive

THEME: TREATMENT-OP GIT DISORDERS

Options:
A.
B.
C.
D.
E.
F.
G.
H.
I.
J.
. K.
L.

Proton pump inhibitor

Pyeloplasty (+/- percutaneous nephrostomy)
Triple therpy
Tetracycline
Sulphasalazine
Pancreatic enzymes
Mctocloprarhide
Gluten - free diet
Enema and laxatives
Aspirin
Reassurance
Appendicectomy

Instruction:

From each patient described below, choose S I N G L E most appropriate management from
the above list of options. Each option may be used once, more than once or not at all.
^

27. An eight year old girl has had recurrent central abdominal pains since six months. She
also has occasional headaches. She maintains a normal appetite. There are ^abnormal
signs. FBC, urinalysis and stool microscopy are normal.
28. A n eight year old boy has symptoms of right sided abdominal pain. He has had
symptoms of UTI in the past. Abdominal ultrasound shows right-sided hydro-nephrosis and
excretory isotope scan confirms PUJ obstruction.
29. A 14 old boy has had recurrent abdominal pains, Malaise and weight loss over six
months. He has a vague mass in the right iliac fossa. Colonoscopy and biopsy of the caecal
area shows trans-mural inflammation and granulomata.
30. A n eight year old boy has had recurrent abdominal pain for two months. His appetite is
reduced and he has faecal soiling.There are pitting masses throughout the abdomen. He has a
dilated loaded rectum.

Theme: Blood coagulation In. children

OPTIONS:

A. A L L
B. Aplastic Anaemia
C. HSS
D. Meningitis septicaemia
E. Non -accidental injury
F. Haemophillia
G. HSP
H. Idiopathic thrombocytopenic purpura

INSTRUCTIONS:
Choose the most likely diagnosis from the above list of options. Each option may be used
once, more than once or not at all

0- 31.A4 year boy has cough and arthritis followed by rash on legs and trunk which are nonblanching on glass test. No history of fever.
PT 13
APTT31
Hb 12, WBC 6.5, Platelet: 300x10

32. A 5 year boy has cough + swelling at knee after falling on ground, rashes on buttocks
which are non- blanching.
PT 13
APTT71
Hb 11, WBC 8, Platelet: 200x10
S I N G L E B E S T ANSWER:
33. A patient comes back from India and presents with night sweats and lymphadenopathy.
X-ray sows cavitations.
What investigation should be done next?
A. CT scan
B . ) A F B Stain
C. Blood culture
D. Bronchoscopy

S I N G L E B E S T ANSWER:
34. A man with suspected active tuberculosis wants to be treated at home. What should be
done to prevent spread of the disease?
Aj Immediate start of the treatment with ATT drugs
B. A l l family members should be immediately vaccinated with BCG vaccine
C. Patient should be isolated in a negative pressure chamber in his house
D. Universal Prevention application protocol

T H E M E : INVESTIGATIONS F O R R E N A L CONDITION

OPTIONS:
A.
B.
C.
D.
E.
F.
G.
H.
I.

Renal biopsy
Autoantibody screen
Renal tract ultrasound
24-hour protein collection
Daily urea and Creatinine
Bens-jones protein
Intravenous urogram
Renal artery Dopplers
CT scan of abdomen

INSTRUCTIONS:
The following patients have all presented with renal disease. Please choose the key
diagnostic investigation from the list above. Each option can be used once, more than once
or not at all.
35. A 34 year old man complains of arthralgia, abdominal pain and vomiting, a facial rash
that is worse in the summer and haematuria. Urea and Creatinine are slightly elevated with
urinalysis demonstrating red-cell casts. Past medical history is remarkable of childhood
eczema.
36. A 42 year old woman with a past medical history ofleft hemispheric stroke presents to
hospital with signs and symptoms of renal failure. She has been seen by her GP for
hypertension and abdominal pain with outpatient investigations pending.
37. A 78 year old woman is brought to hospital complaining of abdominal pain and is
referred to the surgeons. She has been saying that her mother is due to visit her today and
that somebody must have broken her lower back as she is in agony. Her blood results show a
creatinine levek)f 295mmol/L and a calcium level of 3.03mmol/L.
- -

Theme: Menorrhagia

Options:
A.
B.
C.
D.
E.
F.
G.
H.
I.
J.
K.
L.

Antifibrinolytics(Tranexamic acid)
Combined oral contraceptive pill
Danazol
Endometrial ablation
Gonadotrophin-releasing hormone analogues
Hysterectomy
Hysteroscopic laser/ resection of fibroids
Intrauterine or systemic progestrogens
Myomectomy
Polypectomy
Non-steroidal anti inflammatory drugs (Mefenamic acid)
Uterine artery embolization

INSTRUCTION:
Each of the following scenarios, select the most appropriate management on. Each option
may be used Once, more than once or not at all.
38. A 16 year old girl, who is normally fit and well, attends her GP complaining of heavy
and painful periods. She is requesting treatment for these complaints.She denies being
sexually active.
39. A 43 year old woman has suffered with heavy periods for many years, and has tried many
medical treatments without success. She is constantly flooding and at times cannot leave her

bouse due to heavy bleeding. She has completed her family of five children and her last
blood test showed a hemoglobin level of 8.9g/dl. She feels that she cannot cope with the
bleeding anymore, and her husband is asking for a treatment that can guarantee success.
"T 40. A 29 year old woman presents to her GP with troublesome heavy periods. The medical
treatments that she has tried have made little difference. She is known to have large uterine
intramural fibroids. You confirm that she is currently trying for more children.
^

41. A 42 year old overweight smoker comes with heavy periods. A scan reveals a normal
uterus. She would like a long term treatment with minimal side effects that would offer
treatment for the menorrhagia and provide contraception. She is unsure whether she would
like more children. She is adamant that she does not want surgery, as she is terrified of the
prospect.

Tj) 42. A 41 year old woman, who has completed her family, has suffered from extremely heavy
periods for many years. No medical treatment has worked. She admits that she would rather
avoid open surgery. After discussion, you collectively decide on a procedure that would not
require open surgery or general anesthetic.

T H E M E : E Y E CHANGES IN D I A B E T E S

Options:

A. Macular Degeneration

E. Proliferative Diabetic retinopathy

B. Hypertensive retinopathy

F. GCA

C. Multiple Sclerosis

G.SLE

D. Diabetic background
INSTRUCTIONS:
From the above list of options choose the S I N G L E MOST L I K E L Y DIAGNOSIS. Each
option may be used once, more than once or not at all.

43. A 75 year old man with declining vision, his cornea and pupils are normal, fundus shows
obscured margins.
f\. A 84 year old woman with drusen and yellow spots in the centre of retina.
T) 45. Patient with D M 1 , fundus shows micro-aneurysm& hard exudate.
- f^)46. Patient with flamed shaped haemorrhages on long term treatment with Nifedipine.
( j r 47. Patient with puffmess of face and rash showing cotton wool spots on fundo-scopy.
Q 48. Patient with h/o of attacks of weakness in lower limbs and progressive deterioration of
vision with optic atrophy and degeneration of retinal ganglion cells.

49. Patient with h/o of stroke 2 years back presents with sudden loss of vision in right eye.
,
, , . &jddsn
U&T, dVw r ^ " * *
A

S I N G L E B E S T ANSWER:

50. A n eighty years old woman fell over at her nursing home. X-ray shows fracture of radius
with less than 10 degree of dorsal angulation.
What is S I N G L E most appropriate treatment?
A.
B.
t^C)
D.
E.

Below elbow full plaster of Paris

Below elbow split plaster of Paris
Closed reduction of fracture
Elasticated support bandage
Open reduction and internal fixation

Theme: Cessation of medication

Options:
A.
B.
C.
D.
E.
F.
G.
H.

Convert from intravenous to oral route

Do not case medication
Gradual withdrawal of medication
Immediate cessation of medication
Stop for 1 week preoperatively
Stop for 4 days preoperatively
Stop for 4 days preoperatively, and replace with rapidly reversible equivalent.
Stop for 48 hours preoperatively

INSTRUCTIONS:
The following scenarios all refer to issues concerning the cessation of medication priorto
surgery. Select the single most appropriate answer from the list above. The items may be
used once, more than once or not at all.
51. A 62 year old man is on Warfarin, as part of the medication for atrial-fibrillation. He is
on the waiting list for laparoscopic cholecystectomy.
52. A 74 year old man is on clopidogrel, as part of management of ischemic heart disease.
She is on the waiting list for a reversal of Hartmann's procedure.
53. A 21 year old man attends A & E with abdominal pain and the passage of bloody motions
up to seven times per day. As part of his management, he is started on intravenous
hydrocortisone. Following 2 days of conservative management, the patient's symptoms have
only marginally improved, and stool cultures are positive for Escherichia Coli.

T H E M E : MANAGEMENT O F C H I L H O O D CONDITIONS

OPTIONS:
A. Analgesic
B. Antibiotic
C. Biopsy
D. Coagulation screen

E
F
G
H

CT scan of the abdomen

Herniotomy
Immediate surgery
Reassurance

Instruction:
For each patient described below, choose the SEVGLE most appropriateaction from the
above list of options. Each option may be used once, more than once or not at all.
^

54. A three years old boy has a sudden onset of fever, vomiting and bilateral face swelling,
few days earlier general practitioner saw him for bilateral parotid pain and gave analgesics.

1 55. A six year old boy has completed an induction course of chemotherapy for lymphoblastic
leukemia. He has an enlarged left scrotum.
56. A 15 year old boy has a soft painless swelling in the left scrotum, blue in colour and can
be compressed.

1 THEME: PSYCHIATRIC DISORDER

Options
A.
B.
C.
D.

Munchausen
Folie a deux
Grandiose
Guilty

E.
F
G
H

Hypochondrical
Nihilistic
Persecutory
Reference

Instruction:
For each patient described below, choose the S I N G L E most appropriate diagnosis from the
above list of options. Each option may be used once, more than once or not at all.
IT 57. A 24 years old man believes his bowels are blocked and his life is in run.
P 58. A 36 years old woman contacts the police to notify them she was responsible for a recent
disastrous flood with loss of lives.
^

59. A 64 year old man believes a female newscaster is communicating directly with him
when she turns a page.

60. A 37 years old woman believes neighbours have been using her shower while she is away
from home. Her 42 years old partner is convicted about this and calls the police.
61. A 45 years old woman has been extensively investigated for a lump she believes to be
cancer. She does not think doctors take her seriously and demands another referral.
62. A 19 years old man accuses his friend of making right arm swing out at a stranger.

S I N G L E B E S T ANSWER:
63. A 19 year old man has exercise-induced asthma. This has previously been controlled
using a salbutamol inhaler as required, but he now gets attacks with exercise.

What is the SENGLE most appropriate treatment?

A. Regular salbutamol
B. Regular salbutamol and Budesonide
/ C. Sodium cromoglycate
Oral steroid
E. Inhaled steroid

SLNGLE B E S T ANSWER:
64. A 10 year old boy presented with generalized swelling. This has been present for
4 days and included swollen ankles and puffmess of the face. It started a few days
after he had a mild cold with runny nose. His only past medical history was eczema.
Urine analysis shows proteinuria 10g/24hr. Serum creatinine 6Qumol/L and serum
albumin 15g/L. 4 Kpji^cW~U
What is the single most likely diagnosis?
( A) IgA nephropathy
a. Henoch-schonlein purpura
C. Minimal change nephropathy
D. Wilson's disease
F.Cardiac failure

T H E M E : I N V E S T I G A T I O N S F O R P R O S T A T E CONDITION
Options:
A.
B.
C.
D.
E.
F.
G.

Magnetic resonance imaging (MRI) of the spine

Radionuclide bone scan
Serum acid phosphates concentration
Serum alkaline phosphatase isoenzyme concentration
Serum calcium concentration
Serum magnesium concentration
Serum prostate specific antigen (PSA)

H.
I.
J.
K.

Skeletal survey
Transrectal biopsy
Transrectal ultrasound scan
Ultrasound scan of the abdomen

Instruction:
For each patient described below, choose the single most appropriate investigation from
the above list of options. Each option may be used once, more than once or not at all
65. A 70 year old man with prostatic cancer has had severe acute back pain waking him at
night for six weeks.
66. A 80 year old man with prostatic cancer has confusion, thirst, abdominal pain and an
abnormal electrocardiogram (ECG).
67. A 79 year old man who is being treated with gonadotropin releasing hormone (GnRH)
antagonist for proven adenocarcinoma of the prostate attends for a follow up session.
68. A 75 year old man with adenocarcinoma of the prostate which has spread outside the
capsule of the gland has acute renal failure.

S I N G L E B E S T ANSWER:
69. A 50 year old man with epilepsy took an overdose of his medication one hour ago. He has
dry mouth and dilated pupils but is not drowsy.
What is the most appropriate Management?
A.
B.
C.j
D.
E.

Haemodialysis
Activated charcoal
Gastric lavage
Forced emesis
Hyperbaric oxygen

F.
Theme: Selection of diagnostic tests for acute dyspnoea
Options:
A.
B.
C.
D.
E.
F.
G.

Arterial blood gases

Chest X-ray
Electrocardiogram
Haemoglobin
Magnetic resonance imaging scan (MPJ) of the chest
Peak expiratory flow
Pulse oximetry

H. Spiral computed tomography(CT) scan of the chest

Instructions:
For each patient described below, choose the S I N G L E most useful diagnostic test from the
above list of options. Each option may be used once, more than once or not at all.
70. A 25 year old man presents to the A & E department with shortness of breath of three days
duration. He has been coughing during the night and using salbutamol inhaler more
frequently.
71. A 22 year old man presents to the A & E department with sudden onset of sharp right sided
pain and shortness of breath. There is reduced air entry in the right side chest.
72. A 78 year old woman is brought by her family to the A & E department with
breathlessness and occasional cough over the previous 72 hours. There are coarse crepitations
present at the right lung base.
73. A 26 years old woman who has returned from holiday in America develops sudden left
sided chest pain and breathlessness. Her chest is clear.
74. A 23 year old man with type 2 diabetes presents with 48 hours of increasing confusion
and breathlessness. His chest is clear and his blood glucose concentration is 28mmol.

T H E M E : DIAGNOSIS OF S P E E C H DISORDERS

Options
A.
B.
C.
D.
E.
F.
G.
H.
I.
J.

Brocca's area (Frontal cortex)

Facial nerve
Glossopharyngeal nerve
Hypoglossal nerve
Internal capsules
Phrenic nerve
Recurrent laryngeal nerve
Spinal root of accessory nerve
Thalamus
Wernicke's area (temporo-parietal cortex)

Instruction:
For each patient described below, choose the SINGLE most likely anatomical site to be
affected from the above list of options. Each option may be used once, more than once or not
at all.

75. A n 82 year old man has woken up with incoherent speech. Examination is otherwise
normal and his comprehension is good.
76. A 52 year old man who became hoarse following thyroid surgery one week ago shows no
improvement.
77. A 23 year old man is having difficulty speaking following a stab wound to the right of his
neck. On being asked to protrude his tongue, it is noticed that the tip deviates to the right.
78. A 62 year old man who has recently has a flu- like illness has woken to find his speech
altered. Movement of his eyelids and lips are weak on the right side. Examination is
otherwise normal.
79. A 69 year old woman has had a stroke. Her left upper and lower limbs are paralyzed and
she is having difficulty speaking.

THEME: CEREBROVASCULAR DISEASE

Options:
A.
B.
C.
D.
E.
F.
G.
H.
I.
J.
K.

Sagittal sinus thrombosis

Extraduar-haemorrhage
Lateral medullary syndrome
Subarachnoid haemorrhage
Subdural hemorrhage
TIA involving carotid system
Cerebellar haemorrhage
Lacunar infraction
Pseudobulbar palsy
Hypertensive encephalopathy
TIA in the verterbro-basilar system

For each presentation described below choose the Single most likely cerebrovascular
disease from the above list of options. Each option may be used once, more than once or not
at all.
80. A 73 year old man presents with hemianopia, hemi-sensoryloss, hemiparesis and aphasia
of 10 hours of duration.
81. A 79 year old woman presents with hemianopia, hemisensory loss, ataxia, choking,
dysarthria and vertigo.
1 S ^ ' ^
'
n

82. A 60 year old man, who is hypertensive arid diabetic, is admitted with acute dizziness,
vomiting and difficulty in moving his right arm and leg. On examination there is Horner's
syndrome on right side.

83. A72 year old man was referred by his GP for recurrent headaches and fluctuating level of
consciousness. There was no history of direct head trauma.
T) 84. A 50 year old man presented to A & E with headache and drowsiness which started
suddenly while he was working on the computer. He had vomited once. On examination, he
was apyrexial, his pulse was 100/min and BP 160/100.

S I N G L E B E S T ANSWER:
85. A 35 year old female who is 34 weeks pregnant presents with a swollen, painful right
calf. A deep vein thrombosis is confirmed on Doppler scan. What is the preferred
anticoagulant?
A. Clopidogrel
B. Aspirin
C. Intravenous heparin
D. Warfarin
(Subcutaneous low molecular weight heparin

S I N G L E B E S T ANSWER:
86. A 64 year old man with a long standing 1 cm lesion on his arm. Recently it started to
bleed on touch.
What is SINGLE most likely diagnosis?
A. Basal cell carcinoma
B. Intradermal carcinoma
C. Malignant melanoma
D. Molloscumcontageosum
( E. \s cell carcinoma

T H E M E : T H Y R O I D DISORDERS
Options:
A.
B.
C.
D.
E.
F.
G.

Thyroglossal cyst
De Quervalin'sthroiditis
Hypothyroidism
Multiple endocrine neoplasia (MEN) type 1
Multiple endocrine neoplasia (MEN) type 11
Simple goiter
Hashimoto's thyroiditis

O. Thyroid adenoma

L-

" ^

Instructions: For each patient described below, choose the single most appropriate
diagnosis from the above list of options. Each option may be used once, more than once or
not at all.
- (j- 87. A 59 year old man presents with goitre. On examination the thyroid is firm and rubbery.
Thyroid microsomal antibodies are positive in high titre.
Afv-f ^

**8. A 40 year old woman presents to her general practitioner (GP) with rapidly growing neck
swelling, dysphagia and hoarseness. On examination the swelling is hard, irregular and fixed.
9} 89. A 35 year old woman presents with fever, sore throat and dysphagia. On examination she
has a fine tremor and diffusely tender thyroid. Radioisotope scan shows no uptake.

^ -^ A

90. A 52 year old man presents with weight loss, muscle weakness, diarrhoea and blurring of
vision. On examination there is exophthalmos and proximal myopathy.

Theme : Investigation of breast disease

Options:
A.
B.
C.
D.
E.
F.
G.
H.

FNAC
Mammography
Ultrasound
BRCA-1 &2
Triple examination(palpation, scan, cytology)
Reassurance
Antibiotics
Incision and drainage

Instructions: For each patient described below, choose the single most appropriate investigation from
the above list of options. Each option may be used once, more than once, or not at all.
J\. A 55 year old woman presents with a two month history of a lump in her right breast. On
examination there is a firm, irregular lump in the upper outer quadrant of the right breast; in addition,
there are small, palpable mobile nodes in the right axilla.
C-

^ ^ ^ ^ ^ ^ dent presents to the breast clinic having noticed lumps in the left breast,
which has been painful pre-menstrual.
C a T

'

e m a

e stu

-y 93. A 75 year old woman presents to the breast clinic having noticed that she has had a blood stained
~~ discharge from the left nipple, together with 'dry skin' over the left areola. On examination there
was a blood stained discharge with dry, flaky skin noted on the left areola. The nipple was noted to
be ulcerated.
^-n, 94. A patient who has no complaints but the radiologist found some calcification in the left breast on
the Chest x-rays.

95. A patient was admitted to the A&E department after head injury. When examined on arrival his
GCS was 15 then at night his GCS deteriorated to 12. What investigation should be done?
^ A J C T scan head
B. X-ray skull
C. I/V Mannitol
D. Drill a Burr hole
E. Shift to OT

Theme: Jaundiced Patients

Options:
A. Acute alcoholic hepatitis
B. Carcinoma of the head of the
Pancreas
C. Charcot's triad (ascending
Cholangitis)

D. Common bile duct stone

E. Gilbert's syndrome
F.Liver metastasis
G. Primary biliary cirrhosis
H. Prinamarysclerosing cholangitis

Instructions: For each of the patients described below choose the S I N G L E most
appropriate diagnosis from the list of option above. Each option may be used once, more
than once or not at all.
96. A 34 year old woman known to have inflammatory bowel disease complains of
intermittent jaundice, itching, right hypochondriac pain and weight loss. She has a raised
alkaline phosphates level.
97. A 26 year old man presented with a 4 year history of occasional mild jaundice that
becomes worse during a chest infection. He has moderate unconjugated hyper bilirubinaemia
and a liver biopsy is normal.
98. A 51 year old woman presented with 4 week history of jaundice and weight loss. She
has a raised temperature, palmer erythema, spider naevi and hepatomegaly, with mild ascites.
The results of blood tests show a raised white cell count and deranged LFTs.
99. A 58 year old man presents with weight loss, increasing jaundice and epigastric pain. He
has an anterior resection of the rectum 4 year ago. He had an anterior resection of the rectum
4 years ago. He has hepatomegaly with a raised alkaline phosphates level.
100. A 23 year old man presents with fever, jaundice and epigastric pain.

SENGLE B E S T ANSWER:
101. Man on treatment with some drug complains of seeing yellow coloured haloes around
lights. Which drug might have caused it?
A. Digoxin
B. TCA

H.
I.
J.
K.
L.
M.
N.
O.

Grave's disease
Lymphoma
Follicular carcinoma
Anaplastic carcinoma
Drug induced thyrotoxicosis
Autoimmune hypothyroidism
Thyrotoxic goiter
Thyroid adenoma

Instructions:
For each patient described below, choose the single most appropriate diagnosis from the
above list of options. Each option may be used once, more than once or not at all.
87. A 59 year old man presents with goitre. On examination the thyroid is firm and rubbery.
Thyroid microsomal antibodies are positive in high titre.
88. A 40 year old woman presents to her general practitioner (GP) with rapidly growing neck
swelling, dysphagia and hoarseness. On examination the swelling is hard, irregular and fixed.
89. A 35 year old woman presents with fever, sore throat and dysphagia. On examination she
has a fine tremor and diffusely tender thyroid. Radioisotope scan shows no uptake.
90. A 52 year old man presents with weight loss, muscle weakness, diarrhoea and blurring of
vision. On examination there is exophthalmos and proximal myopathy.

THEME:
Theme: Diagnosis of earache
A.
B.
C.
D.
E.
F.

'

Otitis media
Otitis externa
Herpes simplex virus
Temporomandibular joint pain
Trigeminal neuralgia
Facial nerve pain

Instructions:
For each patient described below, choose the single most likely diagnosis from the above
list of options, each option may be used once, more than once, or not at all.
91. A two year old girl with an upper respiratory tract infection is seen the A & E department
as she is pulling on her right ear. Examination reveals rhinorrhoea and slight pink tympanic
membrane.

92. A 60 year old diabetic patient has returned from a holiday in the West Indies. He has
severe pain in both ears with swelling and redness around external auditory canal and pain on
moving the ear.
93. A 70 year old woman has pain &some deafness in her right ear for 24 hours and a
vesicular rash on the right side of her face. Vesicles are seen in the auditory canal.
94. A middle aged woman has pain shooting down the side of her face& her jaw. The ear is
normal.
95. A middle aged woman has a right sided ear ache. The tympanic membrane is normal.
Her husband has noticed that she grinds her teeth at night while sleeping.

T H E M E : JAUNDICED PATIENTS
Options:
A. mm& alcoholic hepatitis
B. Carcinoma of the head of the
Pancreas
C. Charcot's triad (ascending
Cholangitis)

D. Common bile duct stone

E. Gilbert's syndrome
F.Liver metastasis
G. Primary biliary cirrhosis
H. Prinamarysclerosing cholangitis

Instructions:
For each of the patients described below choose the S I N G L E most appropriate diagnosis
from the list of option above. Each option may be used once, more than once or not at all.
96. A 34 year old woman known to have inflammatory bowel disease complains of
intermittent jaundice, itching, right hypochondriac pain and weight loss. She has a raised
alkaline phosphates level.
97. A 26 year old man presented with a 4 year history of occasional mild jaundice that
becomes worse during a chest infection. He has moderate unconjugated hyper bilirubinaemia
and a liver biopsy is normal.
98. A 51 year old woman presented with 4 week history of jaundice and weight loss. She
has a raised temperature, palmer erythema, spider naevi and hepatomegaly, with mild ascites.
The results of blood tests show a raised white cell count and deranged LFTs.
99. A 58 year old man presents with weight loss, increasing jaundice and epigastric pain. He
has an anterior resection of the rectum 4 year ago. He had an anterior resection of the rectum
4 years ago. He has hepatomegaly with a raised alkaline phosphates level.
100. A 23 year old man presents with fever, jaundice and epigastric pain.

S I N G L E B E S T ANSWER:
101. Man on treatment with some drug complains of seeing yellow coloured haloes around
lights. Which drug might have caused it?

A. Digoxin
B. TCA
C. B-blockers
D. Rifampicin

Theme : C A U S A T I V E ORGANISMS I N D I A R R H O E A
Options:
A.
B.
C.
D.
E.
F.

CompylocabacterJuguni
Clostridium dfff&cit
Cryptococcus
EntamoebaHistolitica
Giardia lambia
Helicobacter pylori

G. Mycobacterium
H . Rhinovirus
I. Rotavirus
J . Shigella
K. Staphylococcus aureous
L . Yerseniaenterocolitica

Instructions:
For each patient described below, choose the S I N G L E most likely causative organisms
from the above list of options. Each option may be used once, more than once or not at all.
P> 102. A 64 year old man is being treated for exacerbation of chronic obstructive pulmonary
disease. Although he is clinically improving he develops diarrhoea.
103. A 50 year old man had oysters served at his wedding reception. He and half of his guests
develop malaise and diarrhoea after a delay of 36 hours.
^

104. A n 18 year old man has diarrhoea and abdominal pain. He had bought a frozen chicken
the day before, which he had thawed overnight and used to make a meal.

105. A 35 year old man suddenly develops diarrhoea and vomiting while on a train home
having eaten in a restaurant four hours earlier.

106. A 21 year old woman has diarrhoea before returning to university. She has lost weight
and has had flatulence for three weeks.

Theme: Glomerulonephritis

Options:
A.
B.
C.
D.
E.
F.
G.
H.
I.

Minimal change disease

IgA nephropathy (Berger's disease)
Focal segmental glomerulosclerosis
Post-streptococcal glumerlonephritis
Rapidly progressive glumerlonephritis (RPGN)
Membranous glumerlonephritis
Wegener's granulomatosis
Henoch- Schonleinpurpura (HSP)
Systemic lupus erythematosus

INSTRUCTIONS:
The following patients have all presented with renal disease. Please choose the Single most
likely option from the above list of options. Each option may be used once, more than once
or not at all.
107. A 10 year old boy is brought to the hospital with a rash over his buttocks associated with
abdominal pain and vomiting. In accident and emergency he is accompanied by his mother
and stepfather. His mother had left him for the weekend with the stepfather and was called to
come back from holiday as he started to have some haematuria with the rash. Social services
had been notified on arrival to hospital
108. A 30 year old man presents to hospital complaining that his urine has been very dark
recently, resembling coffee at worst. He has been under the weather recently and has taken a
few days off work with a very sore throat and coryzal symptoms. Urine dipstick in hospital
returns highly positive for blood and protein. He is admitted for supportive management and
is scheduled for a renal biopsy, which shows mesangial proliferation with a positive
immunofluorescene pattern.
109. A 5 year old boy is referred to hospital and seen with his father who is worried that he
has been listless. He is not sure why his GP suggested he should come to accident and
emergency and is keen to get some tablets and go home. On examination the child is tired and
irritable and has some swelling around his eyes. Carefully considered renal biopsy is
remarkable only for some podocyte fusion on electron microscopy.
S I N G L E B E S T ANSWER
110. A woman gave birth to a premature baby born at 28 weeks of gestation and lived for 10
days and died on 10 day, what category of indicator it will come.
th

A. Perinatal mortality
Neonatal mortality
C. Postnatal mortality
D. Infant mortality

THEME: VISUAL DEFECTS

Options:
A. Paracentralscotoma
B. . Mono-ocular filed loss
C. Homonymous hemianopia
D. Homonymous upper quadreantanopia
E . Bitemporal hemianopia
F. Binasal hemianopia

G. Tunnel vision
H. Total blindness
I . Diplopia
J. Centralscotoma
K. Cortical blindness
L. Homonymous lower quadrantantopia

INSTRUCTIONS:
For each presentation below,choose the single most likely defect that can result from the
above list of options. Each option may be used once, more than once, or not at all.
111. A. 50 year old man, with a known history of stroke, is unable to get out of his
housebecause he cannot find where the door is. He refuses help from his wife and says he
isnot blind.
112. A 35 year old woman presents with visual problem. CT scan of the brain reveals
pituitarytumour.
113. A 30 year old woman presents with acute of headached. She complains of seeing
halos especially at night.
114. A 50 year old man with a known history of stroke. He cannot remember anything
about his life.
115. A 50 year old man complains of visual problems and dull pain in left eye.
Fundoscopy reveals papilledema. She was diagnosed with multiple sclerosis 2 years ago.
There is no consensual light reflex of the right eye.

S I N G L E B E S T ANSWER:
116. A 6 year old boy is brought to the A & E Department. He has pain in his left arm
following a fall from a tree on his outstretched hand. There is swelling around his left elbow
and a reduced radial pulse. What is the most likely diagnosis?

B.
C.
D.
E.

Compound fracture
Epiphyseal fracture
No fracture
Spiral fracture

T H E M E : INVESTIGATIONS F O R F A I L U R E T O T H R I V E
OPTIONS:
A. Upper GI Endoscopy
B. Sweat Test
C. Barium meal
D. Colonoscopy
E. Glucose Tolerance Test
D.Endomyseal / Alpha glidin antibody
F. Thyroid function test

R UIIWv'^

INSTRUCTIONS: choose the single most likely investigation to be done from the above
list of options. Each option may be used once, more than once or not at all.
^

117. A 5 month old baby present with recurrent vomiting, mother noticed some of the
vomitus is blood stained.

"J) 118. A 2 year old with atrophy of buttock, distended abdomen with frequent offensive
smelly stool.
{?

119. A 5 year old With recurrent chest pain, finger clubbing with offensive stool.

. , 120. A six week old baby with vomiting, irritability and there is palpable mass in the
v> abdomen on feeding.

S I N G L E B E S T ANSWER:
121. A 62 year old man has multiple liver metastasis, due to adenocarcinoma with an
unknown primary. He is deeply jaundiced and has ascites, with oedema of his legs up to the
buttocks. He is now drowsy and his family are worried that he is not drinking enough. His
medication includes:
Haloperidol 1.5 mg
Lactulose 10 ml
Blood taken three days ago showed:
Normal electrolytes
Urea

6.5 mmol/L

Creatinine

89mmol/L

Calcium

2.04mmol/L

Albumin

17g/L

Total bilirubin

189 mmol/L

What is the S I N G L E most appropriate management of his fluid intake?

( A/' Albumin iafcciWlOf-i&i
B.
C.
D.
E.

Crystalloid fluids (continuous intravenous)

Crystalloid fluids (intermittent subcutaneous)
Fluids Via nasogastric tube
Oral fluids

Theme : Natural history of depression

Options
A.
B.
C.
D.
E.
F.

Bipolar affective disorder

Cyclothymia
Dysthymia(Chronic depression)
Major depression
Mixed anxiety and depression
Post natal blues

G.
H.
I.
J.
K.

Post natal depression

Post natal psychosis
Recurrent brief depression
Schizoaffective disorder
Seasonal affective disorder

Instructions:
For each patients described below, choose the S I N G L E most likely condition from the
above list of options, each option may be used once, more than once, or not at all.

122. Affects middle aged women more than men and characterized by low mood, early
morning waking, and loss of libido, tiredness and suicidal intention lasting for at least two
weeks.
p\. Characterized by alternating mood swings associated with flight of ideas, elation
over activity and disinhibition, or low mood with lack of energy and social withdrawal.
124. Occurs at least 7-10 days following childbirth, characterized by loss of feeling for
the child, loss of appetite, sleep disturbance and intrusive and unpleasant thoughts of
harming the baby.
jS; 125. Affects woman more than, characterized by presence of low mood, loss of libido,
sleep disturbance, tiredness, palpitations, chest discomfort, irritability and recurrent
worries.
^ 1 2 6 . Affects wo'men more than men, recurring annually characterized by depressed mood
- being socially withdrawn, hypersomnia, lack of enjoyment in life, lasting for several
months.

S I N G L E B E S T ANSWER
127. A 32 year old previously healthy woman has developed pain and swelling of both knees
and ankles and nodular rash over her shins. As part of the investigation a chest x-ray has
been performed.
What is Single most likely chest x-ray appearance?
A.
(jp
C.
D.
E.
1

Apical granuloma
Bilateral hilarlympadenopathy
Lobar consolidation
Pleural effusion
Reticular shadowing in the bases

Theme : Auto antibodies for Rheumatological problems

Options:
A.
B.
C.
D.
E.
F.
G.
H.
I.
J.
K.

Anti-centromere antibodies
Anti-Ro
Anti-La
Anti-jo-1
Anti-ds-DNA
Anti-topsisomerse
C ANCA
P ANCA
Anti-histone H1,H3,H4
Anti-histone H2a, H2b
Antimitochodrial antibodies

INSTRUCTIONS:
Choose the single most likely antibody test to be done from the above list of options; each
option may be used once, more than once or not at all
V\. A 75 year old man presents with Bell's palsy. His past medical history is significant for
late onset asthma and heart failure. He also reports to have consulted his GP for a generalized
rash sometime back. His CXR shows multiple soft shadows and FBC shows an eosinophilia.
129. A 75 year old man presents in ARF. He has been troubled by recurrent epistaxis but
over the last three weeks he reports to have coughed up blood too.

130. A 65 year old woman complaining of symptoms suggestive of Reynaud's phenomena

and difficulty is swallowing. O/E she has painful lesions on her finger tips and facial
telangiectasia.
131. A 50 year old woman c/o several months history of weakness and difficulty climbing
stairs. O/E she has Assuring of the skin of her hands and her CXR shows pulmonary fibrosis.

Theme: Diagnosis of peripheral vascular disease

Options:
A.
B.
C.
D.
E.
F.

Acute ischemia of the legs

Chronic ischemia of the legs
Intermittent claudication
Reynaud's phenomenon
Ischemic foot
Dissecting arotic aneurysm

G. Takayasu's syndrome
H.Kawasaki syndrome
I.Thromboangitisobliterans
J. Cardiovascular syphilis
K. Abdominal aneurysm

For each patient below, choose the S I N G L E most likely diagnosis from the above list of
options. Each option may be used once, more than once, or not at all.
(Cj- 132. A 23 year old female presents with paresthesias and loss of distal pulses in her arms.
She is noted to be hypertensive. She describes feeling unwell a month prior with fever and
night sweats.
T

133. A 20 year old male smoker is noted to have intense rubor of the feet and absent foot
pulse. On examination, he has an amputated right second toe.
134. A 25 year old female complains of intermittent pain in her fingers. She describes
episodes of numbness and burning of the fingers. She wears gloves whenever she leavers the
house;
135. A 60 year old smoker presents with cramp-like pain in the calves relived by rest and
non-healing ulcers. On examination, he has cold extremities with lack of hair around the
ankles and absent distal pulses.

136. A 70 year old man presents with an acutely painful, pale paralysed and pulse less left
leg. He is noted to have atrial fibrillation.

Theme : Scientific basis of poisoning

Options:
A.
B.
C.
D.
E.
F.

Amphetamine
Aspirin
Barbiturates
Ethanol
Carbon monoxide
Ferrous sulphate

G.
H.
I.
J.
K.
L.

Methanol
Morphine
Paracetamol
Quinine
Tricyclic antidepressant
Warfarin

Instructions:
For each patient described below, choose the S I N G L E most likely cause from the above list
of options. Each option may be used once, more than once or not at all.
X- 137. Depletion of glutathione stores (reversible by methionine or N - acetylcystenine).
Leading to binding of drug metabolite to hepatic macromolecules.
L-

138. Inhibition of the synthesis of clotting factors by competition with vitamin K.

j^r 139. Strong affinity for a binding site on hemoglobin.

140. Anticholinergic effects leading to loss of vagal tone, impaired myocardial contractility
and delayed conduction in the Bundle of His.

T H E M E : DIAGNOSTIC T E S T F O R H E A D TRAUMA

Options:
A.
B.
C.
D.
E.
F.
G.
H.
I.
J.

Arterial blood gases

Audiology
Blood sugar (BM test)
Chest x-ray
Computed tomography (CT) scan of the brain
Electroencephalogram (EEG)
Facial x-ray
No investigation
Otoscopy
Skull x-ray

Instruction:
For each patient described below, choose the single most appropriate initial investigation
from the above list of options. Each option may be used once, more than once or not at all.
Q 141. A 14 year old boy fell and hit his head in the playground school. He did not lose
consciousness. He has swelling and tenderness of the right cheek with a subconjuctival
haemorrhage on his right eye.
^

142. A 25 year old woman has been admitted for observation following a head injury. Her
Glasgow Coma Scale (GCS) score on arrival was 15. During the night nurses record a GCS
score of 12.

143. A 34 year old man was slapped over his right ear in fight. There is blood coming from
his external auditory canal and he has pain, deafness and ringing in his ears.
144. A n 18 year old man hit his head at work. He did not lose consciousness. His Glasgow
Coma Scale (GCS) score is 15 and examination is normal. His employer has sent him in to be
checked.

T H E M E : CONDITIONS CAUSED D U E T O TRAUMA

Options
A.
B.
C.
D.
E.
F.
G.
H.
I.
J.
K.

Cardiac tamponade
Diaphragmatic rupture
Flail chest.
Fractured ribs
Haemopnuemothrorax
Haemothorax
Pneumothorax
Ruptured oesophagus
Surgical emphysema
Tension pneumothorax
Traumatic rupture of aorta

Instruction
From each patient described below, choose the S I N G L E most likely diagnosis from the
above list of options. Each option may be used once, more than once or not at all.

145. A n 18 year old man has been stabbed with a knife. He is breathless and cyanosed with a
blood pressure of 70/50mmHg and pulse rate of 130 beats/minute. He has a 1.5cm stab
wound in the right 8 intercostals space. The trachea is shifted to the left and percussion is
hyper-resonant on the right.
th

146. A 10 year old boy has fallen from a tree and injured his right chest. He has pain and
difficulty breathing. He is tachypnoeic and tender with an area of paradoxical chest wall
movement on the right side.
147. A 50 year old man has a stab wound to his left anterior chest at the level of the 4
intercostals space. He has a blood pressure of 80mmHg. Systolic and pulse rate of 130 beats
/ minute. His neck veins are dilated and his heart sounds are faint. His trachea is central.
th

148. A 40 year old man has fallen off a roof. He is shocked and has chest pain. There is
delay between the radial and femoral pulses. His chest x-ray shows widening of the
mediastinum.
149. A 30 year old woman has injured her left lower chest in RTA. She has a blood pressure
of 80/50mmHg and a pulse rate of 120 beast / minute. On .auscultation of the chest, bowel
sounds are heard.
Theme : C A U S E O F S P E E C H DISORDER

Options:
A.
B.
C.
D.
E.
F.
G.
H.
I.
J.

Brainstem stroke
Cerebral cortical ischemia
Dementia
Depression
Mania
Multiple sclerosis
Parkinson's disease
Psychogenic dysphonia
Recurrent laryngeal nerve palsy
Schizophrenia
Stammering

Instructions:
For each patient described below, choose the S I N G L E most likely condition from the above
list of options. Each option may be used once, more than once or not at all.
150. A 42 year old woman is talking very rapidly when she suddenly stops. When asked why,
she says that her mind has been emptied of all thoughts.
151. A 60 year old hypertensive man comes to the A & E department having suddenly
developed great difficulty in speaking.
152. A 38 year old man presents with slurring of speech. He is concerned about unfair
accusations of being_drunk. He had been well previously apart from a transient loss of vision

in the right eye 12 month ago. Clinical examination is normal apart from a mild ataxia of the
left arm and a pale right optic_disc.

Theme : Complications of caesarean section

Options:
A.
B.
C.
D.
E.
F.

Aspiration pneumonia
Aspiration pneumonitis
Endometritis
Fetal head compression
Pleurisy
Pulmonary embolism

G. Retained products of conception

H. Spontaneous pneumothorax
I . Urinary tract infection
J. Urinary tract injury
K. Uterine rupture

For each case below choose the Single most appropriate diagnosis from the above list of
options. Each option may be used once, more than once or not at all.
TT 153. A 37 year old woman had an elective lower segment caesarean section (LSCS) 1 day
ago. You are called to see her as she becomes short ofbreath with left sided chest pain and a
cough. She has had three children, two of these born by LSCS. On examination, she has
reduced air entryjitjeftJun&base. Her observations include saturation 92% in air, blood
pressure 105/84mmHg, pulse 120 beats/minute and temperature is 37. 2C.
154. You are called to see a 20 year old woman 2 hours post LSCS. She has not passj^aLuring
since her operation. She denies any urinary symptoms preoperatively. On examination, she
\s unwell, with a temperature of 37.5C, blood pressure 94/73mmHg, pulse 116
beats/min and saturations 97% in air. Her abdomen jd_ distended, wijdi te^ndjrness in the left
flank and suprapubic region. Bowel sounds arejnpt_audible.
155. A 25 year old had an LSCS 24 hrs ago for fetal distress. She now complains of
intermittent vaginal bleeding. Observations include saturations 98% in air, blood pressure
124/82 mmHg, pulse 84 beats/min and temperature 37.8C. The midwife tells you that she
had a retained placenta, which required manual removal in the operating theatre.
156. A 28 year old women at 39 weeks of gestation is in labour. She develops abdominal
jC^ pain and heart rate of 125 beats/min. blood pressure is 100/42mmHg, temperature 37.2C and
saturations 99% in air. On examination, her lower abdomen is exquisitely tender. The CTG,
which was previously normal, now shows reduced variability, and late deceleration develops
with slow recovery. She has had one previous LSCS for a breech baby.
ft) 157. The women in case 4 become acutely short ofbreath in the recovery bay and is coughing
after general anaesthetic. On auscultation, she has reduced air entry at the right lung base and
diffuse wheeze. Observations include a heart rate of 88 beats/min, blood
pressurel 12/76mmHg, temperature37.8C and saturations 91% in air.

Theme: Diagnosis of valvular heart diseases

Options:
A.
B.
C.
D.
E.
F.

Aortic regurgitation
Bicuspid aortic stenosis
Degenerative aortic stenosis
Ischaemic mitral regurgitation
Mitral valve prolapsed
Pulmonary regurgitation

G. Pulmonary stenosis
H . Rheumatic mitral stenosis
I . Tricuspid regurgitation
J. Tricuspid stenosis
K. Ventricular septal defect

Instructions: for each question below, choose the S I N G L E most likely diagnosis from the
above list of options. Each option may be used once, more than once, or not at all.
158. A 60 year old lady who had stroke three years ago now reports having increased
\ dysponea
on exertion, she has atrial fibrillation. On the chest X- ray there is a straight left
border on the cardiac silhouette.
159. A 72 year old man has been advised for some year to have antibiotic prophylaxis before
dental treatment. He has never experienced chest pain. Three weeks ago he noticed
breathlessness on exertion and for one week. He had orthopnea. His pulse character is
normal.
160. A 42 year old lady had corrective surgery for cyanotic congenital heart disease at the age
of 3 years, after a palliative operation during infancy. There is parasternal impulse and an
eariy_dmstoiic_mjrrm
161. A 75 year old lady who had mitral valve replacement 13 years ago has developed
recurrent breatritessness. Her husband has noticed prominent pulsation in her neck. She
complains of abdominal pain and ankle swelling,
162. A 67 year old man had successful thrombolysis for an inferior myocardial infarction one
month ago, and he was discharged after 5 days. He is now readmitted having pulmonary
eodema.

Theme : Diagnosis of the groin lump

Options:
A.
B.
C.
D.
E.
F.
G.
H.

Indirect hernia
Lymphoma
Cold abscess of psoas sheath
Infection of the groin
Lymph node inflammation
Direct hernia
Strangulated hernia
Saphenavarix

I . Femoral hernia
J. Varicocele
K. Femoral artery aneurysm
Instructions:
For each patient described below, choose the single most likely diagnosis from the above
list of options, each option may be used once, more than once, or not at all.
163. A 40 year old manual worker presents with a swelling in the groin. On examination the
mass is found to be just above and left to pubic tubercle. There is no cough impulse and it is
reducible. On applying the pressure on the internal ring there is no transmission of cough
impulse.
164. A 35 year old woman present with a mass in the groin. On examination the mass is
found just below and lateral to public tubercle. There is no cough impulse and it irreducible.
165. A 25 year old man present with a mass in the groin after heavy lifting. On examination
the mass is found just above and medial to the pubic tubercle. It is reducible. On applying
pressure on the internal ring cough impulse is still present.
166. A 60 year old man presents with a mass in the groin. On examination the mass lies
below the midpoint of the inguinal ligament and it is pulsatile.
167. A 36 year old woman presents with a welling in the groin. On examination the swelling
is diffuse and soft and lies i e l o w the inguinal ligament. It empties with minimal pressure and
refills with release. There is a cough impulse and it disappears on lying down. On the calf of
the same leg there are varicosities on the medical aspect.

S I N G L E B E S T ANSWER:
168. A 75 year old man had an episode of syncope with working in his garden. When visited
by his doctor 30 minutes later, he is in sinus rhythm. His pulse rate is 74 beats/minute. His
blood pressure is 160/60mmHg and he has a systolic murmur. He was previously fit apart
from reduction attributed to his increasing age.
What is the S I N G L E investigation most likely to provide the definitely diagnosis?
A. Coronary angiogram
^^Echocardiogram
C. Electrocardiogram (ECG)
D. 24 -hour ambulatory blood pressure
E. 24 - hour taped ECG

S I N G L E B E S T ANSWER:
169. Which one of the following causes of pneumonia is most associated with the
development of Stevens- Johnson syndrome?

A. Legionella
(IS) Mycoplasma
C. Coxiella
D. Staphylococcus
E. Klebeseilla

S I N G L E B E S T ANSWER:
170. A 57 year old female presents with headache and fever to the Emergency Department.
On examination neck stiffness is noted along with a positive Kernig's sign. A lumbar
puncture is performed and reported as follows: CSF culture shows Gram positive bacilli
What is the most likely causative organism?
A. Cryptococcus
B. Haemophilus influenza
C. Streptococcus pneumonia
D. E.coli
^ E ) Listeriamonocytogenes

Theme : S C I E N T I F I C BASIS OF CHILDHOOD H E A R T D I S E A S E :

Options:
A. Aortic stenosis
B. Coarctation of aorta
C. Complete transposition of the
great arteries
D. Epstein anomaly
E. Innocent murmur

F.
G.
H

Patent ductusarterious
Tetralogy of fallot
Tricuspid atresia

I.
J.

Ventricular septal defect

Wolf- Parkinson-white
syndrome

Instructions:
For each patient described below, choose the S I N G L E most likely daignosis from the above
list of options. Each option may be used once, more than once or not at all.
T 171. A three year old girl who is otherwise healthy is noted to have a murmur during an
episode of a respiratory illness. She is not cyanosed and she has a bounding pulse. Her first

and second heart sound cannot be distinguished because of a long continuous murmur
covering both the systolic and diastolic period.
172. A 16 year old boy undergoing routine physical examination is found to have a blood
pressure of 160/90 mmHg in his right arm and a weaker and delayed femoral pulse in
comparison with the radial pulse.
173. A three weeks old girl has been brought to the Emergency Department with pallor and
tachycardia for 24 hours. She has a heart rate of 260 betas/ minute and she is in congestive
cardiac failure.
174. A full term newborn boy is cyanosed at 12 hours of age. There are no significant
abnormal clinical findings in either the respiratory or cardiovascular system. However this
cyanosis is not improving despite giving him 100% oxygen through a face mask.

S I N G L E B E S T ANSWER:
175. A patient keeps on falling due to sudden fainting and giddiness. He also complains of
chest pain and on examination ECG shows irregular heart rate.
What should be done for him?
(2^) Echo
B. Carotid Doppler
C. CT scan head
D. Angiography

THEME: INVESTIGATION FOR SEIZURES

Options:
A.
B.
C.
D.
E.
F.
G.
H.
I.
J.

Computed tomography (CT) scan of the brain

Echocardiogram
Electrocardiogram (ECG)
Electroencephalogram (EEG)
Liver function tests(LFTs)
Lumbar puncture
Midstream urine (MSU) for microscopy, culture and sensitivity
Plasma glucose concentration
Serum electrolytes concentration
Skull X-ray

Instruction
For each patient described below, choose the S I N G L E most discriminating investigation
from the above list of options. Each option may be used once, more than once or not at all.

fV 176. A 56 year old man who has been admitted following his first seizures denies a history of
weight loss and haemoptysis.
~]^) 177. A three year old boy has had three episodes of limb jerking. His teacher has noticed that
at times he does not concentrate in class.
178. A 45 year old man, travelling alone, has been admitted from an airport to the Emergency
department. He is unconscious following a seizure. There are needles and a syringe in his
hand luggage.
179. A 50 year old woman developed jerking in her left hand, which spread. A few minutes
later she has a generalized seizure with loss of consciousness

THEME:

HEMATURIA

Options
A.
B.
C.
D.
E.
F.
G.
H.
I.
J.
K.
L.
M.
N.

Benign familial haematuria

Drug ingestion
Food ingestion
Glomerlonephritis
Haemolysis
Haemorrhagic cystitis
Henoch- Schonleinpurpura
Hypercalciuria
Nephritic syndrome
Polycystic kidney disease
Porphyria
Renal / bladder tumour
Rhadomyolysis
Stress haematuria

INSTRUCTIONS:
For each of the following scenarios, select the most appropriate diagnosis. Each option
may be used once, more than once or not at all.
180. A 12 year old boy presents to the clinic having recently started treatment for
tuberculosis. He has developed painful purple lesions on his lower limbs and reports that he
has started 'weeing blood'. The urine dipstick is negative for blood, protein, leukocyte and
nitrites.
181. A 15 year old boy reports that his urine has turned red. He has not changed his diet and
is otherwise clinically well. He is a regular cross- country runner and took part in a road race
the day before presentation. A urine dipstick is positive for blood and negative for protein,
leucocytes and nitrites. He is followed up, and two repeat urine samples have no blood in
them.

j / ^ 182. A 16 year old girl has recently been started on the oral contraceptive pill. She presents
shortly after with abdominal pain and vomiting. She reports that her urine has turned red. A
dipstick is negative for blood, protein, leukocytes and nitrites.
183. A 3 year old boy presents with red urine. He is clinically well, although he did have a
perioral rash with yellow crusting 2 weeks prior to admission. He is symmetrically well and
has no other symptoms. On examination, you find no signs other than a raised blood pressure
Urine is positive for blood and protein, but negative for leucocytes and nitrites. A full blood
count is normal, with a normal blood film.
184. A 4 year old boy returns to the ward after surgery to remove a brain tumour. The nursing
staff notices that his urine is red. A urine sample is taken, and is positive for blood but
negative for protein, leucocytes and nitrites.

S I N G L E B E S T ANSWER:
185. A 45 year old female is reviewed in the medical clinic with two month history of
lethargy. Blood tests reveal the following:
Na
K

129mmol/l

5.6mmol/l

Urea

5.3mmol/l

Creatinine

99umol/l

Total T4

66mmol/l

Which one of the following investigations is most likely to reveal the diagnosis?
A.
B.
C.
D.

Serum glucose
TSH
FreeT4
Overnight dexamethasone suppression test
ihort synacthen test

S I N G L E B E S T ANSWER:
186. A 80 year old woman has a malignant ulcer 1cm in diameter on the anterolateral aspect
of the left labium major 3cm from the midline. A biopsy shows penetration of the tumour to
1.5 mm.
What is the S I N G L E most likely site for lymph node metastasis?
A.
B.
C.
D.

Deep inguinal nodes

Ileocolic nodes
Iliac nodes
Para- aortic nodes

Superficial inguinal nodes

S I N G L E B E S T ANSWER:
187. A 24 year old man comes to the Emergency department for the third time in a month
behaving in a bizarre manner. There is no evidence of intoxication with drugs or alcohol and
he appears perplexed by his surroundings.
What S I N G L E feature would most likely suggest a diagnosis of schizophrenia?
( A.) Belief that thoughts are being placed in and removed from his head
T3. Displays of unpredictable and violent behavior
C. Patient asking to see identification of members of staff
D. Sleeping for at least 14-18 hours per day
E. Visual hallucinations of spiders

S I N G L E B E S T ANSWER:
188. Which one of the following antibodies is most specific for diffuse cutaneous systemic
sclerosis?
A. Anti-Jo-1 antibodies
B. Rheumatoid factor
iti scl-70 antibodies
D. Anti- centromere antibodies
E. Anti - nuclear factor

Theme: Management plan for electrolyte abnormalities

Options:
A. Dialysis
B. Fluid restriction"
C. Insulin only
D. Intravenous (IV) 5% glucose
E. Intravenous (IV) normal saline
and hydrocortisone

Instructions:

F. Intravenous (IV) normal saline and

insulin
G. Intravenous (IV) normal saline
and potassium supplementation
H. Oral potassium chloride
I . Plasma expander

For each patient described below, choose the S I N G L E most appropriate management
from the above list of options. Each option may be used once, more than once, or not at all.
r 189. A 20 year old woman has nausea, vomiting, fainting and weight loss. She is
^ hypotensive.
Sodium 129mmol/L
Potassium 5.2 mmol/L
Urea 12 mmol/L
Glucose 4 mmol/L

190. A 16 year old boy has had thirst. Weight loss and urinary frequency for two weeks
Sodium 148mmol/L
Potassium 5.1 mmol/L
Urea 14 mmol/L
Glucose 30 mmol/L

191. A 20 year old man received multiple fracture and crash injuries in a motor vehicle
collision. Four days later he is anuric with pulmonary oedema.
Sodium 150mmol/L
Potassium 7.2 mmol/L
Urea 60 mmol/L
Glucose 4.2 mmol/L

i-j

192. A 50 year old man has been admitted for investigation for breathlessness. He has been
taking a thiazide diuretic for hypertension for two years. His blood pressure 160/100mmHg
Sodium 138 mmol/L
Potassium 2.9 mmol/L
Urea 5.8 mmol/L
Glucose 5.7 mmol/L

193. A n eight year old boy has profuse diarrhea and vomiting due to infective gastroenteritis
for two days.
Sodium 148 mmol/L
Potassium 2.2 mmol/L
Urea 20 mmol/L
Glucose 4.3 mmol/L

Theme : Diagnosis of facial pain

Options:
A.
B.
C.
D.
E.
F.

Migraine
Abscess
Coryza
Serous otitis media.
Glaucoma
Iritis

G.
H.
I.
J.
K.
L.

Trigeminal neuralgia
Sinusitis
Systemic lupus erythematosus
Temporal arthritis
Herpes Zoster
Cluster headache

Instructions:
Choose the Single most like diagnosis from the above list of options. Each option may be
used once, more than once or not at all.
^

194. A 53 year old nurse complains of facial pain. A week earlier she had a red rash and
blisters around her right eye. This area of her face has now become acutely painful.

[_

195. A 31 year old man complains of facial pain between the eyes and on one side of the
face. His nos^andthe_affected eyeare congested. He says the pain is severe.

)-j 196. A 20 years old man says his face hurts especially around the eyes and cheeks. When he
bends forewards, it worsens and makes him cry.

J
(j

197. A 57 years old teacher says she has a facial pain, especially in the temples and at night.
On the right side of her face it throbs. For the past three weeks she has felt unwell and had to
miss classes. Also, combing her hair became painful.
198. A 43 year old mechanic complains of left sided facial pain. The pain is stabbing and
runs up and down his face, especially at meal times. He has been to the dentist, but the
dentist has found his teeth in good order.

S I N G L E B E S T ANSWER:
199. A 17 year old girl presents with a 6 week history of nausea and abdominal discomfort.
Routine blood test reveals the following.
Hb

10.9g/dl

WBC

6.7*10 /dl

Platerlets

346*10 /1

Calcium

2.33 mmol/1

Bilirubin

7 umol/1

ALP

962u/l

ALT

45u/l

What is most likely diagnosis?

A.
B.
(jCy
D.
E.

Alcoholic liver disease

Cholangiocarcinoma
Pregnancy
Gallstones
Primary biliary cirrhosis

S I N G L E B E S T ANSWER:
200. A man has pierced his foot with metal spike ten hours ago. He has had four tetanus
vaccinations with last being eight years ago.
What is the most appropriate management?
Tetanus toxoid
' Tetanus toxoid + immunoglobin (Ig)
Tetanus Ig
Tetanus toxoid + Ig + Antibiotics
Tetanus Ig + Antibiotics