PLAB TRAINER

fl)OCHTfcl X . PLAB 1 M O C K - T E S T : - 8 March 2011

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

Theme : Coronary Artery Options: A. Acute marginal branch F. Coronary sinus B. Left internal mammary artery G. Circumflex artery C. Left anterior descending artery I I . Left main sleni (LMS) M Posterior descending artery (PDA) D. Septal branches I . Diagonal branch E. Obtuse marginal branches J. Right coronary artery Instructions: For each patient described below, 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. Q 1. The artery that runs in the anterior interventricular groove.

W 2. A branch of the dominant coronary artery that supplies the inferior portion the septum. A 3. The artery that supplies the anterior right ventricular wall. Or 4. The artery that runs along the left atrioventricular groove. 0" 5. In 85% of the population this artery is the dominant artery.

Theme : Diagnosis of confusion Options: A. B. C. D. E. F. G. H. I. Alzheimer's disease Anaemia . Carcinomatosis Cerebral tumour Delirium tremens Delusional depression Drug toxicity Electrolyte imbalance Heart failure J. K. L. M. N. 0. P. QR. Hyper pyrexia Hypoglycaemia Hypomania Hypotension Infection toxicity Post- ictal state Schizophrenia Subdural haematoma Temporal arteritis

Instructions: For each patient described below, choose the SINGLE most likely cause from the above list of options. Each option may be used once, more than once or not at all. 6. A 72 year old woman who had a repair of strangulated femoral hernia two days ago becomes noisy, aggressive and confused. She is a febrile, her full blood count is normal apart from a raised mean corpuscular volume (MCV). 7. A 40 year old chronic alcoholic who lives alone, brought into the A&E department having confused at home after a fall. He complains of a headache. ^ 8. A 76 year old woman has become tired and confused following influenza like illness. She is also breathless with signs of consolidation of the left lung base. 9. An 18 year old previously well student is in his first year at university. He has been brought to the A&E department in an agitated, deluded and disoriented state. [ _ _ _ 1 0 . A 50 year old man presents with a flight of ideas which are rambling and disinhibited. He is distractible, confused and overactive.

Theme Options: A. B. C. D.

Palpitations

Atrial fibrillation Complete heart block Supraventricular tachycardia Ventricular ectopics

E. F. G.

Ventricular fibrillation Ventricular tachycardia Wenckebach phenomena

Instructions: For each patient described below, choose the Single most likely underlying rhythm disturbance from the above list of options, each option may be used once, more than once, or not at all.

11. A 76 year old man is on the coronary care unit two days after an acute myocardial infarction. He tells you that he had an episode of rapid pounding in the chest lasting for about a minute. He remains conscious throughout. 12. A 68 year old man on treatment for an irregular heart beat comes to the Accident and Emergency department. He has palpitations for the last three hours. On examination you find that his pulse is regular and is 154 beats/minute. Carotid sinus massage settles his pulse down to 80 beats/ minute. J) 13. A 70 year old woman with longstanding anxiety is seen in the out patients department. She complains of her heart skipping a beat quite often. This particularly occurs when she is trying to get to sleep. The palpitations are never sustained.

14. A 28 year old man presents with a two hour history of rapid palpitations. He feels a little light headed but is otherwise well. On examination his pulse is 170 beats/minute and regular, and his blood pressure is 100/68 mmHg. He has had two similar episodes in the past. ,15. A 74 year old man with angina presents with feeling unwell with history of slow pounding in his chest. His angina has been worse lately and he has been prescribed Diltiazem.

Theme : Itching Options: A. Atopic eczema B. Dermatitis herpetiformis C. Hyperthyroidism D. Lichen planus E. Lymphoma F. Primary biliary cirrhosis G. H. I. J. K. Psoriasis Psychogenic itching Scabies Uraemia Urticaria

Instructions: For each presentation 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. 16. A sixty year old vagrant presents with generalized itching. There are widespread excoriation marks on his trunk and arms with liner tracks around his wrists and around his fingers. r17. A 45 year old woman presents with pruritus. On examinations, she has skin pigmentation and investigation show a raised serum alkaline phosphotase and the presence of antimitochondrial antibodies.

") 18. A 29 year old woman has developed an itchy scaly rash particularly over her wrist with fine white streaks overlying the lesion. Her nails have ridges and her buccal mucosa is lined with a lacy white pattern. ^ 19. A 20 year old man complains of a recent onset of itching which has followed a viral infection. There are numerous weals of all sizes on his skin particularly after he has scratched it. These can last for up to an hour.

7[ 20. A 60 year old man complains of tiredness, lethargy and itching that is severe after a hot bath. He also has nocturia, polyuria and nausea and vomiting. Examination reveals pallor, pigmentation and generalized oedema.

Single best answer 21. A patient presents with a lid lag, bulging eyes, ophthalmoplegia, and thyroid bruit. What investigation will you do? ^A^Thyroid function tests B. Eye sight C. Tensilon test D. Ultrasound

Single best answer 22. A 30 year old lady complaining of right ear deafness with decreased corneal reflex and past pointing. Acoustic analysis shows sensori-neural deafness. What is the next most appropriate investigation to do? A. CT brain B. CT acoustic canal (EjMRI brain

D. MRI acoustic canal E. PET brain.

Theme : Psychiatric syndromes Options: A. Asperger's syndrome B. Capgras syndrome C. Cotard's syndrome D. Ekbom's syndrome E. Ganser's syndrome F. Gilles de la Tourette syndrome G. Hurler's syndrome H. Korasakoff psychosis I. Munchausen's syndrome J. Othello syndrome K. Prader-Willi syndrome

Instruction : Select one of the above diagnosis that would be most appropriate for each of the following cases:

23. A 24-year-old male, on remand in prison for murder, is referred by the prison doctor. He is noted to be behaving oddly whilst in prison and complains of seeing things. He has a

previous history of IV drug abuse. On questioning, he provides inappropriate answers to all questions stating that Bill Clinton is the prime minister of the UK.

24. A couple attend their general practitioner because of marital problems. The wife states that her husband is having affairs although she has no proof of this. The husband states that she has even had him followed by a private detective and this is putting a considerable strain on the marriage.

\ . A 62-year-old male is brought to casualty by his daughter because of persistent lying. He is a known alcoholic and has been admitted recently with delirium tremens. On questioning he denies any problem with memory. He knows his name and address and states that he was at the betting shop this morning, but his daughter interjects calling him a liar explaining that he was at her house. ^ 26. A 10-year-old boy is taken to his GP by his parents with behavioural problems. He attends a special school due to inappropriate behaviour and during the interview with his parents the boy barks at infrequent episodes and shouts expletives. Q 27. A 30-year-old schizophrenic female attacks her mother believing that aliens have replaced her with an exact double. 28. A 50 year old female believes that she has already died. She believes that she should be buried as her internal organs are rotting inside of her.

Theme : Dysphagia Options: A. B. C. D. E. F. Achalasia Benign structure Bulbar palsy Myasthenia gravis Oesophageal candidiasis Oesophageal carcinoma G. Oesophageal spasm H. Oesophageal web I. Pharyngeal pouch J. Pharyngeal pouch K. Pseudobulbar palsy L. Systemic sclerosis

Instructions : For each presentation below, choose the SINGLE most likely cause from the above list of options. Each option may be used once, more than once or not at all.

29. A 65 year old man with difficulty in swallowing presents with an aspiration pneumonia. He has a bovine cough and a fasciculating tongue. Sometimes as he swallows food it comes back through his nose.

^ 30. A 45 year old woman complains of pain in her hands precipitated by exposure to the cold weather. She has breathlessness on walking and when eating, she can feel food suddenly sticking in the gullet. It seems to be in the middle of her oesophagus but she cannot localize exactly where it sticks. It is usually relieved with a drink of water. 31. A 55 year old woman complains of retrosternal chest pain and dysphagia which is intermittent and unpredictable. The food suddenly sticks in the middle of the chest, but she can clear it with a drink of water and then finish the meal without any further problem. A barium meal shows a 'corkscrew oesophagus'. ^ 32. A 60 year old man presents with dysphagia and pain on swallowing both solids and liquids. A barium meal shows gross dilatation of the oesophagus with a smooth narrowing at the lower end of the oesophagus. 33. A 72 year old man presents with intermittent difficulty in swallowing with regurgitation of stale food materials. Sometimes he wakes up at night with a feeling of suffocation.

Single best answer 34. A 33 year old lady with Hodgkins lymphoma presents with having temperature of 40C left- sided abdominal pain and lymphadenopathies. Blood was taken for test. What will you do next? A. Wait for blood report j^B^) Start board spectrum IV antibiotics C. Oral antibiotics D. Full blood count E. Monitor pyrexia

Theme :

Opportunistic infection in HIV/Aids

Options: A. B. C. D. E. F. G. H. Pneumocystis jerovici pneumonia Condidiasis Toxoplasmosis Cryptosporium infection Cryptococcus infection Varicella zoster pneumonitis Cytomegaly virus infection Mycobacterium ayitim intracellular.

Instructions: The following HIV positive have all presented with opportunistic infections. Please choose the most correct diagnosis from the above list. Each option may be used once, more than once or not at all. 35. A 34 year old man presents to hospital with abdominal pain, crampy in nature and associated with loose watery stools. On examination he is pale, tachycardic and sweaty. He denies eating any sea food recently but had been staying at a friend's farm for the past 2 weeks. 36. A 40 year old woman presents to hospital with a 3-day history of headache, nausea, lack of appetite. She has been otherwise fit and healthy describes the headache as not related to any particular time of day but associated with pain looking at bright lights. 37. A 28 year old woman presents to her GP with pain on swallowing solid food and a strange taste in her mouth. She described the pain as retro-sternal in nature and associated only with swallowing; with dry and solid food and less with liquids. She denies any significant weight loss. 38. A 45 year old man is brought to hospital by his friends who are worried that he has been acting 'out of character' recently. Collateral history reveals a gradual change in his behaviours, disruptive and would not allow any of the nursing staff to take blood from him. 39. A 32 year old man found collapsed at home by his partner and brought by ambulance to accident and emergency. On arrival he is struggling to breathe and is on an oxygen mask. History from the partner reveals a gradual onset over the past 2 weeks of increasing shortness of breath and feeling of tiredness after the simplest of task. On examination he is tachypnoeic with a respiratory rate of 34 breaths a minute and on auscultation fine crepitations are heard in the lower and mid-zone of the lungs.

Theme : Diagnosis of haematuria

Options: A. Coagulation screen B. CT scan of the kidney C. Cystoscopy D. Intravenous Urography (IVU) E . Midstream urine (MSU) for microscopy, culture and sensitivity F. Plain abdominal X ray G. Prostatic specific antigen H. Renal angiography I. Renal biopsy J . Ultrasound of the kidneys K. Urine cytology

Instruction: For each patient described below, choose the SINGLE investigation most likely to establish cause of haematuria from the above list of options. Each option may be used once, more than once or not at all. ^j" 40. A 43 year old man has a blood pressure of 180/105 mmHg. 15 years ago he had cystoscopy for recurrent haematuria. His serum creatinine is 180 micromol/L and his (Hb) is 14.4 g/dl. Urine-analysis is strongly positive for blood and protein. 41. A 78 year old has gradually developed lower abdominal pain and frequent micturition. He has dark frank haematuria with clots. 42. A 16 year old girl has had dysuria, frequency of micturition and backache. There is a small amount of blood in her urine at the end of micturition.

Single best answer 43. A lady with painless bleeding in 36 weeks of pregnancy otherwise seems to be normal. What should be done next? A. Vaginal USG (^Abdominal USG C. PV examination D. Reassure

Single best answer 44. A 26 year old woman and her 28 year old partner comes to the GP surgery complairring of primary infertility for 2 years. She gives a history of irregular menstrual cycle. What would be the single best test to see whether she is ovulating or not? A. Basal body temperature estimation B. Cervical smear test C. Day2LHandFSH (D^) Day 21 progesterone level E. Endometrial biopsy

Theme : Most likely condition

Options: A. B. C. D. Dehydration Fluid over load Hypokalaemia Metabolic acidosis E. Metabolic alkalosis F. Renal failure G. Respiratory acidosis H. Respiratory alkalosis

Instrucctions: For each patient described below, choose the single most likely condition from the above list of options, each option may be used once, more than once, or not at all. 45. A 65 year old man with a known peptic ulcer is admitted with a history of intractable vomiting for a week. He is found to have pyloric stenosis. He has an increase base excess, hypocalcaemia and dehydration. 46. An 80 year old woman has had an obstructed femoral hernia repaired under general anaesthesia. 24 hour post operatively she is found to be severely dysphonic and her jugular venous pressure is raised. 47. A 75 year old man is admitted from the outpatient clinic with severe lassitude. He has large villous adenoma of the rectum and profuse watery diarrhoea which has been a problem for two months. 48. A 70 year old man with a carcinoma of the prostate is admitted to the hospital with a palpable painless bladder. He is drowsy, hiccupping, coughing and his tongue is dry.

49. A mother has brought her three year old son to the Emergency department two hours after he has taken an unknown quantity of paracetamol suspension. He appears well and is playing normally. What is the SINGLE most appropriate time to measure his serum paracetamol levels?

A. (^B) C. D. E.

Immediately In 2 hours In 4 hours In 8 hours In 24 hours

Theme : Diagnosis of swellings

Options: A. B. C. D. E. F. G. Mesothelioma Gastric carcinoma Pancreatic carcinoma Bowel carcinoma Endometrial carcinoma Chronic appendicitis Pseudomyxomaperitonei H. Gold abscess I. Mesenteric cyst J. Omental torsion K. Umbilical hernia L. Femoral hernia M. Pelvic abscess N. Acute appendicitis

Instructions: For each questions described below, choose the SINGLE most likely diagnosis from the above list. Each option may be used once, more than once or not at all. 50. A 33 year old woman presents with fever and abdominal pain. She also had diarrhoea. Per rectal examination discloses a tender boggy swelling anteriorly. 51. An elderly man is brought to the A & E department with acute abdominal pain. He has been vomiting. On examination you find a tender central abdominal mass. 52. A shipyard worker complains of lump in his abdomen and increasing girth. Over the past few months he has felt unwell and had to let out of his trousers. On physical examination you find a bulky and discrete epigastric mass and evidence of shifting dullness. 53. A middle aged woman was operated for acute appendicitis. At operation a mucocele was discovered. Since her operation she has suffered from repeated bouts of abdominal pain constipation. She also complains of weight loss. 54. A healthy young woman complains of painless abdominal swelling. On examination you find a non tender lower right swelling. The swelling is tense and mobile, but only vertically.

Theme: Diseases of the respiratory system Options: A. Ankylosing spondylitis B. Churg-Strauss syndrome C. Cryptogenic organizing D. Extinsic allergic alveolitis Goodpasture's syndrome Motor neuron disease Progressive massive fibrosis(PMF) H. Tropical pulmonary eosinophilia E. F. G.

Instructions: For each of the patients described below choose the Single most appropriate answer from the list of option above. Each option may be used once, more than once or not at all. r 55. A non-smoker who has worked in coal mines for 20 years presents with gradually increasing shortness of breath, limited exercise tolerance and a dry cough. His chest Xray shows round fibrotic masses. Respiratory function test demonstrates a mixed restrictive and obstructive ventilatory defect with irreversible airflow limitation and reduced gas transfer. r
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56. A 56 year old man presents with breathlessness, which predominantly occurs when he is supine. He also has symptoms of sleep apnoea and day-time headaches and somnolence. Spriometry shows a decreased tidal volume and vital capacity.

(p^ 57. A 35 year old man has been given a diagnosis of allergic rhinitis and asthma. Examination revealed a peripheral neuropathy with tingling and numbness in a 'glove and stocking' distribution. Skin lesions are present in the form of tender subcutaneous nodules. The patient is responding well to corticosteroids. "Y) 58. A 48 year old farmer presented with fever, malaise, cough and shortness of breath. On examination the patient was tachypnoeic, with coarse end-inspiratory crackles and wheeze throughout his chest. He was cyanosed. He also complained severe weight loss. His chest X-rays shows fluffy nodular shadowing and there is polymorph nuclear leucocytosis.

Theme: Description of Psychiatric symptoms Options: A. B. C. D. E. F. Audiotry hallucinations Concentration Delusion of grandeur Flight of ideas Illusion Insight I. Obsession J. Paranoid delusion K. Pressure of speech L. Thought blocking M. Thought broadcasting N. Thought insertion

G. Judgment H. Low mood

O. Thought withdrawal P. Visual hallucination

InstructiontFrom each patient described below, choose the SINGLE most appropriate description of symptoms and signs from the above list of options. Each option may be used once, more than once or not at all. J ) 59. A 43 year old man with a history of hospital admissions talks about various topics, moving from one unconnected topic to another. 60- A 71 year old woman looks dishevelled, unkempt and sad, with poor eye contact. -y 61. A 19 year old man presents for the first time with a firm and unshakable belief that he is being followed by terrorists who are plotting against him. fj\. A 36year old man was recently admitted to a psychiatric ward. He believes that staff and other patients know exactly what he is thinking all the time. ^ 63. A 23 year old man comes to the Emergency Department with a history of drug misuse. He recognizes that he has a problem and is willing to see a psychiatrist. 64. A 52 year old woman speaks rapidly without any pause and ignores interruptions.

Theme: Mood disorders Options: A. B. C. D. E. F. G. Atypical depression Bipolar affective disorder Cyclothymia Depression - mild Depression - moderate Depression - severe Dysthymia H. Hypomania I . Mania J. Masked depression K. Schizophrenia L. Seasonal affective disorder M. Somatic syndrome N. None of the above

Instruction: Each of the following scenarios, select the most appropriate diagnosis. Each option may be used once, more than once or not at all. 65. A 24 year old man asks his GP for sick note from work. He says that he feels down, is lethargic and has stopped enjoying playing the piccolo (his main hobby). He was admitted to a psychiatric hospital last year following an episode of mania.

H he has ever felt before for no particular reason. He has been getting more work done at the
office today and has been socializing with his friends as usual. ^

66. A 19 year old man has been happier and more positive than usual, with more energy than

67. A 60 year old woman is admitted to hospital after a fall. She is noted to have poor eye contact. When asked how she is feeling, she admits to feeling low in mood, having very little energy and losing enjoyment in all her usual hobbies. She has also found it difficult to

concentrate, feels that she is not good for anything, feels guilty over minor issues and feels very negative about the future. ^ 68. A 55 year old woman who attends the clinic has recently been diagnosed with a depressive episode. She complains of unintentionally walking early in the morning, a recent disinterest in sex and a loss of appetite, losing 5 kg in weight in the last month. She feels that her mood improves as the day wears on. 69. A 40 year old woman presents to the GP with low mood. Of note, she has an increased appetite and has gone up two dress sizes. She also complains that she cannot get out of bed until the afternoon as she is so tired.

Theme: Investigating the febrile child Options: A. B. C. D. E. F. G. H. I. Blood for culture and sensitivity Blood for polymerase chain reaction(PCR) C-reactive protein Chest X-ray Cerebrospinal fluid(CSF) for microscopy, culture and sensitivity CSF for PCR Full blood count Limb X-ray Urine for microscopy, culture and sensitivity

Instructions: Each of the following children with a fever, select the investigation most likely to lead to a diagnosis. Each option may be used once, more than once or not at all. f) 70. A 2 year old girl presents with a 4-day history of fever. The illness started with a cough. Her respiratory rate is 45/min, saturations 94% on air, temperature 38.9C and capillary refill time 1 sec. There are crepitations at the left base on auscultation. Urine is negative on dipstick. 71. A 3 year old girl presents with a fever for 2 days. She is drowsy and had seizure causing twitching of the right side of the body for 4 min. Her respiratory rate is 30/min, saturations 98% in air, temperature 38.3C and capillary refill time 2 sec. Urine is negative on dipstick.

~~\ A 6 month old boy is admitted with persistent irritability. He is lethargic and is not feeding as well as usual. His respiratory rate is 30/min, saturation 97% on air, temperature 38.0C and capillary refill time 2 s. Urine reveals leucocytes on dipstick. ( \. A 3 year old boy presents with a 1 day history of being unwell. He appears shocked and has 3 hours old rash made up of urticaria and purpural spots. His respiratory rate is 30/min, saturations 94% in air, temperature 39.0C and capillary refill time 1 sec. Urine is clear on dip stick.
A

74. A 2 Y year old girl is admitted with a fever for 2 days. She has stopped walking and cries when changing her clothes. Her respiratory rate is 20/min, saturations 99% in air, temperature 38.7C and capillary refill time 1 sec. Urine is clear on dipstick.
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Theme : Diagnosis of third trimester bleeding Options: A. Abruption of placenta secondary to pre- eclampsia B. Ante partum hemorrhage C. Concealed hemorrhage D. In labour E. Intrautrine death G. Placenta previa H. Preterm labour I. Primary PPH J. Secondary PPH F. Placenta accrete

Instructions: For each question 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. 75. A 25 year old, who is 38 weeks pregnant, presents to the labour ward with a history of fewer foetal movements than usual during the evening. She also says that abdominal contractions are coming every few minutes and she is having blood stains per vagina for the last few minutes. On examination: cervix is fully effaced, 9cm dilated, cephalic presentation and station is +1. 76. A 30 year old primigravida, who is 30 weeks pregnant, presents to the labour ward with absent foetal movements. She also complains of severe headache, heartburn and seeing floaters before her eyes for the last few days. On examination: BP 170/110, Urine protein++++, rock - hard uterus, with no visible signs of foetal movements per abdomen. 77. A 20 year old pregnant, 32/40 weeks by date, presents to the antenatal clinic with a history of painless per vaginal bleeding after intercourse. On examination: P/A -soft and relaxed, uterus = dates, CTG is reactive. 78. A 24 year old primigravida, who is 30 weeks pregnant, presents to the labour ward with a history of constant abdominal pain for the last few hours. She also gives a history of having lost a cupful of fresh blood per vagina before the pain started. Abdominal examination shows an irritable uterus. CTG is reactive.

79. A 38 year old woman, 10 days post partum, presents to her GP with a history of passing blood clots per vagina since yesterday. On examination her BP is 90/40mmHg, pulse 110 beats/ minute, temp: 38C, P/A, uterus tender on palpation and fundus 2cm above the umbilicus, P/S, blood clots +++.

Theme: Diagnosis of cranial nerve problems.

Options: A. B. C. D. E. F. Abducent nerve Accessory nerve Facial nerve Glossopharyngeal nerve Hypoglossal nerve Oculomotor nerve G. H. I. J. K. L. Olfactory nerve Optic nerve Trigeminal nerve Trochlear nerve Vagus nerve Vestibulocochlear nerve

Instructions: For each patient described below, choose the SINGLE most appropriate option from the above list of options. Each option may be used once, more than once or not at all. 80. An 82 year old woman has developed painful rash on one side of her forehead and anterior scalp. Lesions have also affected her cornea. 81. A 22 year old man has a reduced conscious level and a fixed dilated pupil after being involved in a motor vehicle collision. 82. A 64 year old woman has difficulty moving her right shoulder on recovering from surgery of the posterior triangle of her neck. 83. A 68 year old man awoke to find that he is unable to close his left eye and dribbling saliva from the left angle of his mouth. 84. A 73 year old man who is recovering from surgery on the left carotid artery in his neck. He has slurred speech. On protrusion of his tongue, the tip deviated to the side of the operation.

Single best answer 85. Which one of the following is not a benign tumour of the lid? fAj Nevus B. Xanthelasma C. Verrucae D. Tuberous Sclerosis E. Molluscum Congtagoisum 86. 78 year old nursing home resident is revived due to the development of an intensely itchy rash. On examination white linear lesions are seen on the wrists and elbows, and red papules are present on the penis. What is the most appropriate management? permethrin B. Referral to GUM clinic

C. Topical betnovate D. Topical ketoconazole E. Topical selenium sulphide

Theme: Tremors Options: A. Parkinsons disease B. Huntington disease C. Alcohol D. Hypoglycemia E. Cerebellar ataxia F. Benign essential tremor

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

/\. Patient has abnormal gait and rolling of his fingers at rest.

88. A 62 year old man has involuntary movement of his limb and dementia.

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89. A 78 year old woman has tremor relieved by glass of wine. Her mother had the same when she was her age.

jZ- 90. A. 68 year old man has coarse tremors on his fingers face & torso accentuated on voluntary activity.

Theme: Aetiology of Chronic Kidney Disease Options: A. B. C. D. E. F. Chronic pyelonephritis IgA nephropathy Lupus nephritis Membranous glomerulonephritis Microvascular polyarteritis nodosa Minimal change glomerulonephritis Polycystic kidney diseas H. Reflux nephropathy I. J. Renal artery stenosis Sarcoidosis K. L. Scleroderma M. Wegener'sgranulomatosis

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 70 year old woman has chest wall pain, worse on inspiration, a haemoglobin (HB) of 8 g/dl, protienuria and an eGFR of 45 irn/min/1.73m ^ 92. A 45 year old woman has recurrent episodes of feverish headache and back pain. She has a blood pressure of 160/100 mmHg and an eGFR of 45 ml/min/1.73m
2

93. A 65 year old man has fatigue, nasal stuffiness and blood pressure of 160/1 lOmmHg. His eGFR of 25ml/min/l .73m2 and has Hb of lOg/dl with an eosinophilia on the blood film 94. A 55 year old woman has had a rash and irritation of both eyes for two months. He has haematuria and proteinuria and an eGFR of 40 ml/min/1.73m
2

$95. A 55 year old man has had increasing leg swelling over six weeks. He has pitting oedema of the legs and abdominal wall proteinuria ++++ and haematuria+. His GFR is 35 ml/min/1.73m
2

Theme: Causes of splenomegaly Options: A. B. C. D. E. Chronic lymphocytic leukemia F. Infectious mononucleosis Felty's syndrome G. Myelofibrosis Gaucher's disease H. Polycythaemia rubra vera Hodgkin's lymphoma I . Tropical splenomegaly syndrome Idiopathic thrombocytopenic purpura J. Typhoid

Instruction: For each of the following clinical situations choose the SINGLE most likely cause from the above list of options. Your may use each option once, more than once, or not at all. _7 96. A 28 year old woman presents with a sore throat bilateral cervical lymphadenopathy. She has a small, palpable spleen. A full blood count reveals pleomorphic atypical lymphocytosis. ^ 97. A 60 year old woman with a history of rheumatoid arthritis is found to have palpable spleen. Her full blood count shows hemoglobin of 11.2 g/dl, white cell count of 2.6 X 10 /L and platelets of 181 X 10 /L.
9 9

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98. A 25 year old man, who has recently been abroad, presents with a 4 day history of persistent pyrexia, malaise and arthralgia. Initially, he complained of constipation but later developed diarrhoea. After the end of the first week, he developed a rash on the

back and abdomen. The rash consists of sparse, slightly raised, rose - red spots which fade on pressure there is spleno-megaly and evidence of leukopenia.

Theme : Monitoring of serious side effects of antibiotics Options: A. B. C. D. E. Optic neuropathy Cholestatic jaundice F. Ototoxicity Dental hypoplasia and staining G. Steven-Johnson syndrome Grey syndrome H. Tendon rupture Gynaecomastia I. Myalgia Instructions: For each patient on long term (>1 month) antibiotic treatment described below, choose the SINGLE most likely serious side effect from the above list of options. Each option may be used once, more than once or not at all.

^ 99. A 38 year old man has acquired immune-deficiency syndrome (AIDS). He is on oral cotrimoxazole for Pneumocystic Jiroveci (Pneumocystic carinii) pneumonia. Gr 100. A 59 year old man is on intravenous benzyl-pencillin and IV gentamycin for an ineffective endocarditis caused by streptococcus mutans. X 101. A 62 year old man is on oral ciprofloxacin for prostatitis. 102. A 69 year old man is on IV vancomycin for a prosthetic knee joint infection caused by meticillin resistant staphylococcus aureus (MRSA). 103. An 82 year old man is on IV flucloxacillin for a vertebral osteomylitis caused by sensitive Staphylococcus aureous.

Management of dizziness: Options: A. Ambulatory blood pressure monitoring H. B. Ambulatory ECG I. J. C. Caloric test K. D. Carotid body massage L. E. Ct scan of the brain F. Echocardiogram G. EEG M. N. FBC Resting electrocardiogram Serum drug level Serum U&E concentration Standing and lying blood pressure Thyroid function test Tuning fork test

Instruction : For each patient described below, choose the SINGLE most discriminating test from the above list of options. Each option may be used once, more than once or not at all. ^ 104. A 84 year old woman who has hypertension treated with bendro-flumethiazide has dizziness and falls. The symptoms are worse on getting up in the morning. ^ 105. A 69 year old man has a progressive history of angina and dizziness on exertion. He has heart murmur. ^ J y 106. A 70 year old woman had a mild stroke five years ago. She takes 75mg aspirin daily. She has had increasing breathlessness and light headedness. 0 107. A 73 years old man has been treated for generalized tonic-clonic seizures following a stroke six months ago. Over the past two weeks he has developed dizziness and poor balance. He has nystagmus. 108. A 65 years old man has had dizziness and palpitations lasting a few hours and occurring almost every day for two months. He has stable angina for which he is taking iso-sorbide mononitrate and aspirin.

SINGLE BEST ANSWER: 109. A 27 year old woman who is on her second month of combined oral contraceptive pills has painless vaginal spotting for 3 days. Her last menstrual period was 10 days ago. Her last cervical smear 2 years ago was normal. Abdominal and pelvic examination is normal apart from a mild ectropion without contact bleeding. What is the single most appropriate initial management? A. Cervical smear B. Colposcopy C. Endometrial biopsy D. Pelvic US scan EpReassurance

Single best answer 110 . An 80 year old man died of%j^stinal obstruction caused by adhesion from previous surgery. The patient has dementia andflollTstoryis available. The post mortem states that there are multiple firm pale masses throughout the liver, each have a central umbilicated depression. What is the SINGLE most likely diagnosis of the hepatic lesion?

A. B. C. D. E)

Chronic hepatitis Hepatocellular carcinoma Macro nodular cirrhosis Pyogenic abscesses Secondary carcinoma

Theme : Back pain Options: A. B. C. D. E. Anchylosing Spondylosis Prolapsed lumber disk Lumbosacral spondylolesthesis Multiple Myeloma I. Osteoporosis F. Trauma G. Spina bifida occulta H. Tuberculosis of the spine Vertebral secondary metastasis

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. /\. A 28 years old man has back pain for 10 years, it is worse in the morning. He has decreased spinal mobility and has had two episodes of iritis. s , 112. A 70 year old woman with long standing rheumatoid arthritis has acute back pain been receiving long term prednisolon treatment. ^ 113. A 35 year old man has an acute onset of back pain and right-sided sciatica following lifting. X) 114. A 55 year old woman has back pain, she has an ESR of 120 mm/hr, a serum urea of 22 mmol/L, and a serum calcium concentration of 3.2mmol/L.

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

Investigations

ECG Echocardiogram CXR Exercise ECG CT scan of the brain FBC LP

H. V/Q I. Blood culture J. Carotid Doppler K. Abdominal ultrasound L. Arterial Blood gas M. Peak expiratory flow

Instruction: For each presentation described below choose the Single most likely investigation from the above list of options. Each option may be used once, more than once or not at all. Q 115. A 60 year old man presents with homonymous hemianopia, hemisensory loss and loss of memory of 48 hours duration. ECG shows LBBB. jV\. A 25 year old man presents to A&E Department with shortness of breath of three days duration. He has been coughing during the night and using his salbutamol inhaler more frequently. 117. A 26 year old woman who has returned from holiday in America develops sudden left sided chest pain and breathlessness. Her chest is clear. 118. A 23 year old man with type A diabetes presents with 48 hours of increasing confusion and breathlessness. His chest is clear and his blood glucose concentration is 28 mmol.

Single best answer 119. Which is not true about urinary infection UTI? A. Pregnant woman have optimal urinary pH for bacterial growth. B)Most causes of E. Coli Pyelonephritis are due to hematogenous spread. C. Urethral and introital carriage of E. Coli is among women with recurrent UTI. D. Lower pH inhibits bacterial growth. E. Higher osmolality inhibits bacterial growth.

Theme: Diagnosis Options : A. Atrophic vaginitis H. HPV B. Bacterial vaginosis I. Trichomonas infection C. Endometrial carcinoma J. Gonorrhoea D. Candidiasis K>H. Ectropoin E. Chlamydia LZ Cervical polyp F. Syphilis M. Cervical carcinoma G. HIV infection fL CIN Instructions : From 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. (^120. A 56 year old nulliparous woman with a BMI of 38 has four month history of blood- stained discharge. 121. A 23 year old woman has been taking the combined oral contraceptive pill for four years. She has a troublesome, clear, sticky discharge, with no odour or itching. 122. A 25 year old pregnant woman has a slight increase in vaginal disease with vulval itching. Her partner has had recent balanitis. 123. A 76 year old woman has vaginal soreness and an intermittent pink staining on her underwear. She is not on any medication. ~|~ 124. A 19 year old woman in a new sexual relationship has a vaginal discharge of sudden onset. There is intense itching at the introitus and examination reveals a frothy greenish coloured discharge with redness of her vagina.

Theme: Initial investigation Options A. Temporal artery biopsy B. ESR C. Skull x-ray D. Nerve conduction studies E. MRI imaging of brain

F. CT scan brain G. No investigation required H. Carotid arteriogram I. Lumber puncture

Instruction: From the patients 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. 0 125. A 62 year old woman has right sided headaches with malaise, weight loss and depression. ^ 126 .A 56 year old man has sudden severe occipital headache, drowsiness and vomiting.

Q- 127. A 45 year old woman has right sided headaches, nausea and visual disturbance. This lasted for 24 hours and she is fine. She was recently started on hormone replacement therapy. TJ 128. A 46 year old man has headache and confusion three days after slipping in the garden. 129. A 58 year old man has central chest pain exaggerated by exercise but relieved by GTN spray. He has recurrent episodes of pain. Examination is normal and ECG shows new ST depression in II, III, AVF.

Theme: Treatment of Ventricular Tachycardia Options : A. B. C. D. E. F. G. Adenosine Amiodarone Atenolol Atropin Digoxine DC cardioversion Flecamide H. Lidocaine I. Magnesium J. Potassium K. Trans-thoracic pacing L. Trans-venous pacing M. Verapamil

Instruction: For each child described below, choose the SINGLE most appropriate initial treatment from the above list of options. Each option may be used once, more than once or not at all. 130. A 63 year old man palpitations and chest pain and a blood pressure 90/70 mmHg. His ECG shows a broad- complex tachycardia. j ^ ) 131. A 58 year old man on the coronary care unit feels light- headed one hour after a myocardial infarction. His blood pressure is 85/60mmHg. His heart rate is 32 beats/minute. 1 132. A 32 year old woman has palpitations. Her blood pleasure is 140/90mmHg. Her ECG shows a narrow complex tachycardia with a rate of 220 beats/minute. 133. A 44 year old man has had palpitations. Her blood pressure is 90/70mmHg. His ECG shows atrial fibrillation with a ventricular rate of 160 beats/minute.

Single best answer 134. A 50 year old Caucasian man has a lump on his trunk and is worried about it. He is worried about having malignant melanoma. What could be evidence that it is malignant? (^A)When the lump changes its colour and edges B. When it bleeds.

C. When it becomes painful.

135. An 83 year old lady who is resident in nursing home presents with itching all over her body. On examination there are scratch marks all over her trunk. What will you do next? ^A/)Examine hands and feet B. Do nothing C. Scrapping D. Blood tests

Theme: Investigation of endocrine disorders Options A. B. C. D. E. F. G. H. I. J. K. Corticotrophin-releasing test Dexamethasone suppression test Glucose tolerance test High/normal urine osmolality with low serum osmolality Hypertension with hyperkalaemia Hyponatraemia, hyperkalaemia, increased urea Increased MIBG uptake Increased serum 17- hydroxyprogesterone Insulin-hypo glycaemia test Low urine osmolaity and high serum osmolality Short Synacthen test

Instructions : For each of the patients described below choose the SINGLE most appropriate test or investigation finding from the list of option above. Each option may be used once, more than once or not at all. r ^ 136. A 46- year old man presented with persistent frontal headache and visual disturbance. He was found to be hypertensive. He complained of tightening of his wedding ring and comparisons with previous photographs shows a change in appearance. Which of the above test will be diagnostic for this condition? 137. A 49 year old man with a previous diagnosis of treated tuberculosis presented to his GP with tiredness, weakness and lethargy. The GP found oral pigmentation and postural hypotension. What is the initial diagnostic test in the case? 138. A 36 year old woman with central weight gain, thin skin, oligomenorrhoea, and who is prone to easy bruising is also found to have impaired glucose tolerance. What is most valuable test you could organize to diagnose this condition? 139. A 62 year old man with known lung cancer presented with fits. He was found to have profound hyponatraemia. Which test result will point towards the diagnosis?

Single best answer 140. A four year old boy has an acute nose bleed. He is otherwise fit and well. What is the SINGLE most appropriate measure to stop the bleeding? A. Ice Pack B. Pinch bridge of nose P i n c h soft part of nose D. Place child in recovery position E. Put cotton wool in nostril Single best answer 141. A 14 year old boy presents with recurrent abdominal pain, malaise and weight loss over 6 months. On examination, a vague mass is left in the right iliac fossa. Colonoscopy and biopsy show transmural inflammation and granulomata. What is the best treatment for this patient?

(X)Steroids
B. Sulphasalazine C. NSAIDS D. Mitronidazole

Theme :Management of acute diarrhoea and vomiting in children Options A. B. C. D. Antidiarrhoeal drug F. Antiemetic drug G. IV antibiotic H. IV fluid bolus at I. maintenance dose E. IV fluid bolus 20 ml/kg and reassessment IV fluid replacement and Insulin IV fluid slowly to replace deficit Oral rehydration solution Reassurance and advice to continue usual diet

Instructions: For each patient described below, choose the SINGLE most appropriate management from the above list of options. Each option may be used once, more than once or not at all. 142. A one year old boy has had loose stools 4-5 times per day with no blood or mucus for two days. He has vomited twice. He is bright and alert. His mucus membranes are dry, a pulse rate of 100 beats/ minute and capillary refill of less than 2 seconds.

143. A 18 months old girl has had frequent stool and persistent vomiting for three days. She is pale and quiet. Her mucus membranes are dry and she has poor skin turger. She has a pulse rate of 140 beats/ minute and capillary refill of 4 seconds. 144. A three year old boy has vomiting and irritability for one day. He has had vomiting and irritability and loose stool since then. His mucus membranes are dry and skin has several non-blanching spots on his skin. He has a pulse rate of 100 beats/minute, and capillary refill of 2 second. 145. A two year old boy has an episode of diarrhoea 10 days ago. He has persistent loose stool. He is bright and alert. His mucus membranes are moist and skin turger is normal. He has a pulse of 80 beats/ minute and capillary refill of less than 2 seconds.

'

Theme : Theme Management of depression Options A. B. C. D. E. Amitriptyline Congnitive-behaviouraltherpy Diazepam Electroconvulsive therapy Fluoxetine F. Imipramide G. Lithium H. Moclobemide I. Phenelzine J. Psychodynamic psychotherapy

Instructions: For each of the following scenarios, select the most appropriate step in the management. Each option may be used once, more than once or not at all. Q 146. A 25 year old woman presents to her GP with a 3 month history of low mood. She feels that her self-esteem has suffered since stopping her usual hobbies and social activities after the breakdown of a relationship. '"T) 147. A 64 year old man has been an inpatient for 3 months with severe depression. His ^ symptoms have been resistant to selective serotonin reuptake inhibitors, lithium and the supportive environment of the hospital itself. He has deteriorated further to the point that he is not communicating and not adequately feeding himself. ^ 148. A 36 year old woman presents to her GP with a 4 month history of low mood, poor appetite and tearfulness. She has had a previous episode of depression, which responded to a 6 month course of first line drug treatment. 149. A 45 year old man with severe depression is managed by a community psychiatry team. His depression has not responded to three different antidepressants and, although he and his wife are fairly reliable and are coping at the moment, they are very keen to see some improvement. The only food that he likes to eat is pizza. ^150. A 59 year old woman with depression had started a course of fluoxetine, but was discontinued due to side-effects. Poor sleep is prominent features of her illness.

(j[

Theme : Appropriate investigation Options: A. B. C. D. E. F. G. H. I. J. Coagulation screening Computed tomography (CT) scan of the abdomen Barium study of upper GI tract Discriminate between fetal and maternal blood cells (APT test) Endoscopy Full blood count Jejunal biopsy Liver function tests Ultrasound scan of the abdomen X-ray 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 151. A five year old girl who suffered extensive burns has returned to the general ward after two weeks in the intensive care unit (ICU). She has a large haematemesis. Full blood count and coagulation screen are normal. 152. A seven year old boy has coffee grounds vomit and previous unexplained nose bleeds. He is systemically well with no abdominal tenderness. His blood count (FBC) is normal. 153. A two day old boy, born by caesarian section because of placental abruption, vomits altered blood. He is well hydrated and systemically well. 154. A week old boy born at home has blood-stained vomiting for the first time. He is breastfed and his stools are dark. He is jaundiced and there is blood oozing from his umbilical cord. 155. A year old boy has had intermittent vomiting since three months of age. He is thriving and his vomit occasionally contains blood.

Single best answer 156. A 25 year old woman has been told that her recent cervical smear shows mild dyskaryosis (CIN 1). She wants to know what she can do to reduce the risk of cervical cancer. She takes the oral contraceptive pill, smokes 20 cigarettes a day and drinks on average 10 units of alcohol per week. She is slightly overweight but is normotensive. What is the SINGLE most important advice to give this woman? A. Avoid tampon use

B. C. D. ^E\

Discontinue the oral contraceptive pill Lose weight Reduce alcohol intake Stop smoking

Theme: Initial therapy Options: A. B. C. D. E. F. G. H. Combined oral contraceptive pill Danazol Gonadotropin releasing hormone (GnRH) analogues Levonorgestril releasing intrauterine system Mefanamic acid Norethisterone Progesterone suppositories Tranexamic acid

Instruction: For each patient described below, choose the SINGLE most appropriate initial therapy from the above list of options. Each option may be used once, more than once or not at all. f 157. A 30 year old woman presents for the first time with a history of heavy, regular menstrual loss lasting four days, associated with flooding and passage of clots. 158. A 29 year old woman is very concerned because she has had very light and infrequent periods for six months. Her body mass index (BMI) is 35 kg/m . She has raised serum lutenising hormone (LH) concentration.
2

159. A 12 year old girl has primary dysmenorrheoa which prevents her from attending school during her period. 160. A 20 year old woman using depot medroxyprogesterone acetate (Depo- Provera) for nine months. She is concerned that she has had no menstrual bleeding in that time.

Theme : Discrimination investigation Options: A. B. C. D. E. F. G. H. I. J. ANCA Bone marrow aspirate Creatinine clearance Culture of MSU specimen Cystoscopy IVU Nuclear scan Renal biopsy Renal ultrasound Serum cholesterol concentration

Instruction : From each patient described below, choose the SINGLE most discrimination investigation from the above list of options. Each option may be used once, more than once or not at all. ^ 161. A 70 year old man has bone pain, anaemia and weight loss of gradual onset. In addition to renal failure he has hypocalcaemia. 162. A 55 year old man has leg swelling. He has heavy proteinuria and his serum creatinine concentration is 185 mmol/L "J. 163. A 75 year old man has had frequency of micturation, poor urinary stream and some incontinence for two years. His serum creatinine concentrating is 350mmol/L. 164. A 65 year old woman has urinary frequency, weight loss, haematuria and blood clots. An abdominal U/S scan in inconclusive.

Theme: What is the advice to be given? Options: A. B. C. D. E. F. G. H. Take before meal Take after meal Take with meal Upright position after taking the tablet Rinse mouth after use Take with plenty of water Maintain supine position after taking it Reassurance

Instruction: For each presentation below, choose the Single most likely advice for the patient from the above list of options. Each option may be used once, more than once or not at all. 165. A 60 year old man with stroke and has been prescribed aspirin. 166. A girl who has been to the forest remembers getting bitten by a tick. Redness near the bite is slowly increasing in size. A GP has prescribed her a tablet. 167. A mother whose 5 year old boy has been diagnosed with asthma and brown inhaler has been prescribed. 168. 55 year old man, who has been diagnosed with left ventricular failure and prescribed an ACE drug, comes with a mild cough. 169. A 30 year old lady comes with intermittent thumping in her chest.

Single best answer 170. A 10 year old boy with diagnose haemophilia with 4 weeks history of enlarging left supraclavicular mass. The mass does not regress with factor VIII therapy. What is the most likely diagnosis? A. (TB) C. D. E. Wilms' tumour Non - Hodgkin lymphoma Neuroblastoma Lymphoblastic lymphoma Acute non- lymphocytic leukemia

Single best answer 171. A 18 year old lady has amennorhea. She has noted that she cannot smell, which she blames for a chronic sinusitis. What is the single most likely syndrome? Kalman's syndrome Laurence-Moon-Biedly Syndrome C. Lowe's syndrome

Single best answer 172. A 40 year old woman with breast cancer has back pain keeping her awake at night. For which she blames a gym session two weeks ago. She has difficulty in climbing the stairs. There is tenderness over the right thoracic spine. She has diminished fine touch and temperature sensation in her right foot.

What is the SINGLE most appropriate investigation? A. Bone density scan B. CT scan of the head M M of the spine Nuclear medicine(NM) bone scan E. Plain x-ray of the thoracolumbar spine

Single best answer 173. A 52 year old man with a history of hepatitis B infection presents with fever and polyarthralgia associated with a right foot drop. Examination reveals a blood pressure 180/100 mmHg. What is the most likely diagnosis? A. Churug - Straus syndrome B. Hepatocellular carcinoma C. Systematic lupus erythematous DyPolyarteritisnodosa E. Giant cell arteritis

Theme: Neurosurgical disorders Options : A. Acoustic neuroma G. Normal pressure hydrocephalus B. Cerebellar abscess H. Pituitary apoplexy C. Cerebral abscess I. Subarachnoid haemorrhage D. Cerebral tumour J. Subdural haematoma E. Extradural haematoma K. Syringomyelia F. Meningioma Instructions: From the above list select the most likely diagnosis to explain the features in the following cases: \. A 67-year-old female presents with balance problems. Examination reveals a nystagmus on left lateral gaze, a loss of the left corneal reflex and reduced hearing in the left ear. 175. A 63-year-old male presents after having had a seizure. On examination he is alert and orientated. Examination reveals some inattention on the left side and h>per-reflexia of the arm. 176. A 73-year-old male presents with a 12 month history of falls. His relatives have also

noticed rather strange behaviour of late and more recently he has had episodes of enuresis. Examination reveals a dis-orientation in time and place and a broad based and rather clumsy gait. ^ 177. A 34-year-old male presents with headache and vomiting. Examination reveals a temperature of 38.5C, neck stiffness, a discharge from the left ear and right sided hyperreflexia with an extensor plantar response. 178. A 72-year-old male presents with acute confusion. He has been in hospital for 2 weeks having been treated for a deep vein thrombosis. The nurses have noticed that over the last 24 hours he has become increasingly drowsy. Examination reveals a small scalp laceration, a Glasgow coma scale of 8 and bilateral up-going plantar responses.

Single best answer 179. Which virus is transmitted by the fecal oral route? A. Hepatitis C virus ^R)Coxsackie virus C. Dengue fever virus D. None of the above

Single best answer 180. A man presented with carcinoma bladder and has been working in factories. He wants to know what dye has caused it. What is the SINGLE most likely cause? A) Aniline B. Asbestos C. Latex D. Silica

Theme : Genetics Options: A. B. C. D. E. F. Schizophrenia G. Celiac disease H. Vitamin D resistant rickets I. Cystic fibrosis J. Peptic ulcer K. Familial adenomatous polyposis Tuner's syndrome Frontal baldness Rheumatoid arthritis Duchene muscular dystrophy Hodgkin's lymphoma

Instructions: For each mode of inheritance choose the single most appropriate disorder from the above list of options. Each option may be used once, more than once or not at all. p 181. Autosomal dominant 182. Autosomal recessive ([^183. X-linked dominant Q"l84. X- linked recessive fj, 185. Sex - linked inheritance

Theme : Childhood viral infections Options:

A. Adenovirus F. Molluscum contagiosum B. Coxsackie G. Mumps C. Cytomegalovirus H. Rotavirus D. Epstein Barr virus I. Rubella E. Measles J. Varicella Instruction : For each patient with the group of symptoms listed below, choose the SINGLE most probable causative agent from the above list of options. Each option may be used once, more than once or not at all. ^ 186. A three-year old girl presents with a macular confluent rash which appeared initially behind the ears and has spread. Over the previous five days she has had a low grade fever, catarfltlfend conjunctivitis. Her mother is vague about her immunisation history. \ . A two -year-old infant boy is admitted to hospital with vomiting, non- bloody watery diarrhoea and is dehydrated. It emerges other children from his play group have developed a similar illness. 188. A two-year-old boy is mildly unwell. His mother has noticed vesicles in his mouth, palms and soles of his feet. j" 189. A ten-year-old girl develops an itchy rash which began on her trunk and has since spread over the entire body. She travelled to see her cousin who was unwell with a painful rash three weeks ago. 190. The four month old baby daughter of an HIV positive mother is admitted to hospital with seizures. She has neonatal jaundice and microcephaly.

Single best answer 191. A 16-year-old A-level student develops deterioration in vision in her left eye over three days. She complains of discomfort in the eye and thinks that difficulty with perception of colour was the first problem that she noticed, during a trip to an art gallery. On examination, visual acuity on the left is down to light perception. The pupil appears dilated and does not constrict to light, although does constrict when a torch is shone in the right eye. What is the most likely diagnosis? A. Amaurosis fugax B. Anterior ischaemic optic neuropathy C. Central retinal artery occlusion D. CMV retinitis EJOptic neuritis

Single best answer 192. A 50-year-old woman is seen in the clinic because of deranged Liver Function Tests

(LFIs). Sue drinks at most 4 units of alcohol weekly. On examination she is obese -with, a
BMI of 45kg/m and her LFTs show: ALT 140 U/L (5-40) AST 150 U/L (10-40) Alkaline Phosphatase 250 U/L (45-105) Which of the following is the most likely cause of this derangement? A. Diabetes Mellitus B. Drug induced C. Hyperparathyroidism D. Hypertension EyHypothyroidism
2

Theme : Associated drug adverse effect Options: A. B. C. D. E. Amiodarone Digoxin Ampicillin Carbamazepine Cyclosporin F. G. H. I. J. Sodium Valproate Methotrexate Nifedipine Phenytoin Retinoids

Instructions: For each medication above, choose the most likely associated drug adverse effect from the list below. Each option may be used once, more than once or not at all. 193. Gynaecomastia. -p> 194. An epileptic patient on treatment complains of fever, sore throat, recurrent mouth ulcers, and skin reactions. T "JJ) j195. A lady on treatment for epilepsy develops ataxia and gum hypertrophy. 196. Severe mucositis. 197. A boy on treatment for generalized tonic-clonic epilepsy develops features of hepatic failure in few weeks of starting treatment.

Single best answer 198. A 32 year old miner rescued after being trapped under a fallen rock for 4 hours. After applying a bladder catheter, 15-20 ml reddish brown urine/hour. His heart rate is 120/ min, systolic blood pressure is 100 mmHg. What is the most appropriate treatment ? A. (8) C. D. Dopamine 3mcg/kg/min, intra venous IV Fluid challenge. Furosamide TV. Mannitol 20% 500ml IV.

Single best answer 199. A four year old boy has been brought to the Emergency department by ambulance. He has been unwell with a sore throat for eight hours. He is sitting on his mother's knee and is tolerating an oxygen mask but looks unwell. He has constant noisy breathing and he is dribbling saliva. His temperature is 39C. What is the SINGLE most appropriate action? A. Administer IV pencillin (13./ Call an anesthetist D. Listen to the chest E. Take blood culture

Single best answer 200. A 64 year old man with longstanding alcohol dependence has been brought to the Emergency department having been found wandering unsteadily. He is confused, ataxic and his mucus membranes are dry and has bilateral ophthalmoplegia. His blood pressure is 115/ 85mmHg, pulse rate of 96 beats/min, a temperature of 36.8C and a capillary glucose of 3.5mmol/L. What is the SINGLE most urgent intravenous therapy? A. Bolus of 50% glucose solution B. Bolus of lorazepam C?) Bolus of thiamine D. Infusion of 0.9% normal saline E. Infusion of 5% dextrose solution