Nine days after anterior resection of the rectum in an obese 57-year-old man, his left leg

becomes swollen with tenderness of the calf. He has a slight fever and tachycardia. The
MOT !M"O#T$NT as%ect of his treatment &O'() be
*$+ elevation of the foot of the bed.
*,+ an elastic stoc-ing.
*.+ anticoagulant thera%y with he%arin.
*)+ insertion of an inferior vena caval filter.
*/+ ligation of the left femoral vein.
The #!0 of s%ontaneous abortion following second trimester amniocentesis is
*$+ 1253
*,+ 12433.
*.+ 12533.
*)+ 121333.
!n regard to large bowel cancer, all the following statements are true /5./"T
*$+ the ris- of develo%ing bowel cancer is significantly increased in first degree relatives
of %atients with the disease.
*,+ %atients with large bowel cancer have a%%ro6imately a three-fold increase in the ris-
of develo%ing a subse7uent bowel cancer.
*.+ %atients with colonic adenomas have an increased ris- of develo%ing bowel cancer.
*)+ tubular adenomas are more li-ely to become cancers than villous adenomas.
*/+ %atients with .rohn colitis have an increased ris- of develo%ing cancer of the bowel
than normal %eo%le.
$ 44-year-old woman %resents with %ainful dys%hagia. There is a %ast history of #aynaud
%henomenon. '%%er gastrointestinal endosco%y reveals ulcerative oeso%hagitis, which
%roves resistant to double dose *833mg, b.d.+ cimetidine thera%y. $n oeso%hageal
manometry study demonstrates absent %eristalsis9 the lower oeso%hageal s%hincter is not
identified. &hich one of the following is the MOT $""#O"#!$T/ treatment:
*$+ ;undo%lication.
*,+ Ome%ra<ole.
*.+ Octreotide.
*)+ "neumatic dilatation of the lower oeso%hageal s%hincter.
*/+ #anitidine.
!n assessing %rogress of a %atient with a head in=ury the MOT !M"O#T$NT clinical
observation is
*$+ e6amination of the fundi.
*,+ state of the %u%ils.
*.+ level of consciousness.
*)+ %lantar res%onses.
*/+ blood %ressure.
$ multigravida %resents at >7 wee-s gestation, not in labour, with a breech %resentation
and ru%tured membranes. &hat should be done !N!T!$((?:
*$+ !mmediate caesarean section.
*,+ /mergency radiological %elvimetry.
*.+ @aginal e6amination.
*)+ et u% an o6ytocin infusion.
*/+ 'rgent ultrasound scan.
Ovulation is MOT $..'#$T/(? .ON;!#M/) by which one of the following:
*$+ /levation of %lasma %rogesterone in the luteal %hase.
,+ ,i%hasic change in the tem%erature chart.
*.+ )etection of a rise in %lasma (H at midcycle.
*)+ $lteration in cervical mucus.
*/+ "lasma oestradiol %ea- at midcycle.
Of the following factors which is MOT im%ortant in determing the overall %rognosis in
a %atient with a malignant melanoma: .
*$+ )e%th of invasion in the s-in and subcutaneous tissues.
*,+ "revious history of irradiation in the area.
*.+ The number of mitotic figures in the microsco%ic s%ecimen.
*)+ The level of carcinoembryonic antigen.
*/+ "revious history of de%igmentation of a %igmented naevus. .
$ >4-year-old multigravid woman has =ust been delivered of a >A33 g infant after
successful o6ytocin induction of labour at B4-wee-s of gestation. &ith gentle traction on
the umbilical cord the uterus suddenly inverted and is now a%%ro6imately 13 cm outside
of the introitus. The MOT $""#O"#!$T/ treatment is -
*$+ attem%t immediate re%lacement of the uterus.
*,+ remove the %lacenta and then attem%t re%lacement of the uterus.
*.+ magnesium sul%hate B-A g intravenously over 5-13 min, then attem%t re%lacement of
the uterus.
*)+ terbutaline 3.45 mg subcutaneously, then attem%t re%lacement of the uterus.
*/+ ritodrine hydrochloride >53 ug intravenous bolus, then attem%t re%lacement of the
uterus
,$.ardiac auscultation reveals accentuation of the first heart sound at the a%e6,
accentuation of the second %ulmonary sound and a %resystolic murmur at the a%e6. The
MOT (!0/(? diagnosis is
*$+ %ulmonary stenosis.
*,+ mitral stenosis.
*.+ aortic stenosis
*)+ mitral incom%etence.
*/+ functional heart murmur.
$ 1C-year-old woman, %rescribed a tri%hasic oral contrace%tive for the first time one
month ago, com%lains of fre7uent s%otting. The MOT $""#O"#!$T/
M$N$D/M/NT is to
*$+ increase the dose of oestrogen.
*,+ increase the dose of %rogestogen.
*.+ advise alternative contrace%tion.
)+ continue the medication and review in two months.
*/+ change to a bi%hasic %ill.
$ >4-year-old woman, D5, "B, at >4 wee-s gestation is admitted to hos%ital because of
mild, bright red vaginal bleeding amounting to a%%ro6imately 133 m(. Her last two
children were born by lower uterine segment caesarean section. he has no %ain or
contractions. @ital signs are stable within the normal range. ;etal heart rate is 1B3
beatsEmin and regular and the .TD shows no decelerations and good beat to beat
variation. !ntravenous fluids are started, and blood is drawn for ty%ing, cross-matching,
and com%lete blood count. !n addition to bed rest, management at this time HO'()
!N.(')/
*$+ a rectal e6amination.
*,+ a vaginal e6amination.
*.+ beta sym%athomimetic agents.
*)+ immediate caesarean section.
*/+ observation and further investigation.
,
The MOT .OMMON cause of blood-stained stool in an otherwise normal infant is
*$+ anal fissure. F
*,+ anal fistula.
*.+ haemorrhoids.
*)+ Mec-el diverticulitis.
*/+ intussusce%tion.
$ >3-year-old man is awa-ened during the night by very severe %ain in the right loin. He
feels nauseated and sweaty. The %ain comes and goes over intervals of about 13 min but
seems better when he gets out of bed. He notices bright blood in his urine but does not
see or hear a stone being %assed. He is afebrile and %lain 5-ray of his urinary tract shows
an o%acity 5 mm by > mm in the line of the ureter =ust below the right sacroiliac =oint.
?ou HO'()
, *$+ advise him to go to bed to ease the %ain.
*,+ send him to a urologist for urgent retrieval of the stone via cystosco%y.
*.+ tell him to drin- lots of water, %rescribe a%%ro%riate analgesia and have him return for
a re%eat 5-ray within 4 days.
*)+ %rescribe him allo%urinol and a thia<ide diuretic straight away.
*/+ advise him to avoid all dairy foods and foods containing calcium.
$ >B-year-old married woman has sought your advice on chronic and fluctuating food
intolerance, accom%anied by nausea, vomiting s%ells, abdominal %ain, bloating and
diarrhoea. he tells you that she has been Gsic-lyG for most of the last 43 years of her life
since %uberty, and has had a lot of gynaecological investigations for severe
dysmenorrhoea, e6cessive menstrual bleeding and dys%areunia. he has consulted a
number of neurologists for trouble with wal-ing, muscle wea-ness and fainting s%ells for
which she was %rescribed anticonvulsants, with little benefit. $ cardiologist had
%rescribed a beta-bloc-er for e%isodes of %al%itations accom%anied by chest %ain and
breathlessness, and a rheumatologist had given her a trial of various anti-inflammatory
drugs for small =oint %ain and lumbago with only tem%orary relief. ?our %hysical
e6amination revealed that she is a%%arently tense and an6ious des%ite dia<e%am 15 mg
daily, and that she has abdominal scars from a %revious a%%endicectomy and se%arate
hysterectomy. The MOT (!0/(? %sychiatric diagnosis that this woman has is
*$+ somatisation disorder.
*,+ hy%ochondriasis.
*.+ conversion disorder.
*)+ Munchausen syndrome.
*/+ factitious illness.
$ A5-year-old overweight man com%lains of recent misty vision on sunny days. His
vision, when tested, is AE18 right and left. &hich one of the following is the MOT
(!0/(? basis of his com%laint:
*$+ .hronic sim%le glaucoma.
*,+ Myo%ia.
*.+ .ataract.
*)+ Macular degeneration.
*/+ )iabetic retino%athy.
$ A5-year-old man develo%s sudden e6cruciating intersca%ular %ain radiating into the
right lower limb. On %hysical e6amination, the right femoral %ulse is not felt and the left
femoral %ulse is wea-. There is an aortic diastolic murmur. The blood %ressure is 1A3EC3
mmHg, and the %ulse rate is 133Emin. The MOT (!0/(? diagnosis is
*$+ myocardial infarction.
*,+ embolus of the abdominal aorta.
*.+ dissecting aortic aneurysm
*)+ %ulmonary embolus.
*/+ s%ontaneous %neumothora6.
$ 75-year-old woman has ta-en lithium, without com%lication, for many years.
ubse7uently a non-steroidal anti-inflammatory drug *N$!)+ is %rescribed for osteo-
arthritis. Over the ensuing wee-s she develo%s ata6ia, anore6ia, nausea and
tremulousness. &hich one of the following is .O##/.T:
*$+ These features are consistent with N$!) to6icity.
*,+ The main thera%eutic measure would be salt restriction.
*.+ (ithium inhibits the clearance of most N$!) from the body.
*)+ !nteractions between lithium and N$!) are of little clinical significance.
*/+ These features are consistent with lithium to6icity.
The (/$T li-ely fracture to occur in a 7-year-old child who falls on an outstretched arm
is
*$+ fracture of both bones of the forearm.
*,+ dislocation of the distal radial e%i%hysis
*.+ .olles fracture.
*)+ su%racondylar fracture.
*/+ greenstic- fracture of the ulna.
$ 7>-year-old woman com%lains of %ain mainly in the limb girdles, associated with
mar-ed stiffness. Her sym%toms are worse in the early hours of the morning and on
wa-ing. There is no abnormality on e6amination a%art from mild generalised stiffness of
the shoulder and hi% =oints. ?our %rovisional diagnosis would MOT (!0/(? be
.ON;!#M/) by
*$+ 5-ray of the %elvis and shoulder girdle.
*,+ serum calcium and %hos%horus levels. ,
*.+ serum al-aline %hos%hatase level.
*)+ erythrocyte sedimentation rate of 113mmEh.
*/+ late6 rheumatoid factor.
$ 47-year-old woman is hos%italised at >A wee-s gestation because of =aundice,
haematemesis and increased confusion. ;or 13 days %rior to admission she had nausea,
vomiting, lac- of a%%etite and fatigue. #esults of laboratory studies are2 urea 18 mmolE(
*>-8+9 uric acid 3.A mmolE( *3.15-3.B3+9 bilirubin A3 umolE( *4-43+9 alanine
aminotransferase *$(T+ 4B3 'E( *5-B3+9 as%artate aminotransferase *$T+ 413 'E( *13-
B5+9 al-aline %hos%hatase *$("+ 83 'E( *45-133+. erum ammonia concentration is
elevated. The MOT (!0/(? diagnosis is
*$+ acute viral he%atitis
*,+ alcoholic cirrhosis.
*.+ %re-eclam%sia.
*)+ acute fatty liver of %regnancy.
*/+ cholestasis of %regnancy.
$ A-year-old girl has had a moderately severe e%isode of asthma for >A-B8 h. he has
been treated with inhaled sym%athomimetic every >-B h but res%iratory distress recurs
within 4-> h of the inhalation. The MOT $""#O"#!$T/ additional thera%y would be H
, l
*$+ oral theo%hylline.
*,+ a short course of oral corticosteroids.
*c+ a short course of inhaled corticosteroids.
*)+ additional inhaled i%ratro%ium bromide.
2*/+ a course of oral antibiotics.
"a%illary carcinoma of the thyroid gland
*$+ is a slow growing tumour which is influenced by thyroid stimulating hormone
secretion.
*,+ is multifocal and s%reads mainly by the blood to bone.
*.+ is sometimes associated with %haeochromocytoma and s-in lesions.
*)+ %roduces calcitonin and the syndrome of malignant hy%ocalcaemia.
*/+ is e6tremely radiosensitive and should be treated by irradiation of the thyroid gland.
)uring the first 4B h after a gastrectomy your %atient develo%s a fever of >8.5 degrees ..
The MOT (!0/(? cause is
*$+ atelectasis.
*,+ urinary tract infection.
*.+ wound infection.
*)+ dee% venous thrombosis.
*/+ su%erficial thrombo%hlebitis.
$ young woman who is obviously %regnant is found at the side of the road at the site of
an automobile accident. he is unres%onsive to verbal stimuli. $ssessment of her
condition should give ;!#T "#!O#!T? to
*$+ res%iratory status. *,+ level of consciousness.
*.+ fetal viability.
*)+ %resence of bleeding. +
*/+ assessment of %ossible shoc-.
$ %lacid B-wee--old formula-fed baby has vomited feeds since the first wee- of life. Her
maternal grandmother is convinced that the baby is ill. The mother is also concerned but
says that the baby feeds well. ?ou confirm that she has gained weight normally, and find
no clinical abnormality. ?ou HO'()
*$+ reassure the mother and tell her to ignore anyone who says the child is ill.
*,+ e6%lain that the baby %robably has gastro-oeso%hageal reflu6.
*.+ arrange barium swallow and meal.
*)+ arrange su%ra%ubic as%iration of urine for microsco%y and culture.
*/+ advise that the formula be diluted to ma-e it more digestible.
&hich one of the following is .O##/.T:
*$+ Meatal ulceration is a com%lication of circumcision.
*,+ The %re%uce is fully retractable in C3I of uncircumcised boys aged A months.
*.+ .ircumcision is the first stage in the re%air of hy%os%adias.
*)+ Neonatal circumcision is safe in haemo%hilia, because of trans%lacental %assage of
factor @!!!.
*/+ Neonatal circumcision is %ainless.
$ discrete mobile mass in the breast of a 45-year-old woman is MOT (!0/(? to be
*$+ carcinoma.
*,+ fibroadenoma.
*.+ intraduct %a%illoma.
*)+ fibroadenosis.
*/+ fat necrosis.
$ 4A-year-old man has been under your care after falling 13 m while roc- climbing,
sustaining bilateral com%ound tibial fractures and a fractured %elvis. Three days
%osto%eratively, after o%en reduction and fi6ation of his tibial fractures, he becomes
acutely breathless. $ chest 5-ray reveals a diffuse bilateral %ulmonary infiltrate. He
suddenly becomes confused and fearful, believing his food to be %oisoned, and that the
hos%ital staff are %lotting against him and %lan to murder him. The MOT (!0/(?
e6%lanation for the change in his mental state is
*$+ as%iration %neumonia.
*,+ %ulmonary embolism.
*.+ fat embolism syndrome. .
*)+ subacute %ancreatitis.
*/+ e6tradural haematoma.
J
$ delusion is an /5$M"(/ of
*$+ formal thought disorder.
*,+ blunted affect.
.+ a false belief.
)+ auditory hallucinations.
*/+ %assivity e6%eriences.
$ %atient lacerates the ulnar nerve =ust above the wrist. &hich one of the following
%hysical findings is MOT (!0/(? to be %resent: !nability to
*$+ e6tend the wrist.
*,+ fle6 the wrist.
*.+ fle6 the distal %halanges of the fourth and fifth digits.
*)+ o%%ose the thumb and inde6 finger.
*/+ s%read the fingers.
!n a 45-year-old woman with gluten-sensitive entero%athy, which one of the following
statements is .O##/.T:
*$+ The anaemia is most li-ely due to @itamin ,14 deficiency.
*,+ The %retreatment bio%sy will demonstrate flattened villi and an inflammatory cell
infiltrate of %eriodic acid-chiff %ositive macro%hages.
*.+ .orn contains gluten and should be e6cluded from the diet.
*)+ &hen %laced on a strict gluten-free diet, the small bowel histology will im%rove
mar-edly within 4 wee-s.
*/+ There is an association with the develo%ment of lym%homa.
$ A7-year-old man %resents with a history of %rogressive dys%hagia and hoarseness over
the %receding 4B h. On e6amination there is a right Horner syndrome and the right side of
the %alate does not elevate on %honation. The right gag refle6 is absent and the %atient
cannot %roduce an e6%losive cough. These signs and sym%toms are MOT (!0/(? due
to which one of the following:
*$+ $ left ca%sular haemorrhage.
*,+ $ meningioma at the foramen magnum.
*.+ Thrombosis of the left %osterior inferior cerebellar artery.
*)+ $ left cerebello-%ontine angle tumour.
*/+ $ right-sided brain stem infarction.
The s-in lesions shown in the above %hotogra%h were found on the hands of a 7>-year-
old nursing home %atient. he has been noted to be constantly scratching the lesions and
a%%ears %oorly cared for. The MOT $""#O"#!$T/ treatment would be
*$+ to%ical steroids.
*,+ erythromycin.
*.+ gamma ben<ene he6achloride.
*)+ micona<ole cream.
*/+ %rednisone, A3mg daily.
!n the %reo%erative evaluation of a %erson for a %ossible bleeding tendency the MOT
!M"O#T$NT of the following is
*$+ clotting time.
*,+ bleeding time.
*.+ clinical history.
*)+ %rothrombin time of !nternaional Normalised #atio *!N#+.
.*/+ %artial thrombo%lastin time.
$ 48-year-old sales assistant %resents with difficulty slee%ing. He recounts how he has
great difficulty falling aslee%, going over the events of the day in his head. &hen at last
he gets to slee%, he wa-es often during the night. He sometimes has nightmares and
usually feels unrefreshed in the mornings. His slee% disturbance is .H$#$.T/#!T!.
of
*$+ borderline %ersonality disorder.
*,+ ma=or de%ression.
*.+ schi<o%hrenia.
*)+ generalised an6iety disorder.
*/+ nocturnal e%ile%sy.
$ A3-year-old woman is brought to the /mergency )e%artment by her relatives who have
noticed that she is JunwellJ and confused. ,lood tests are re7uested and the initial results
are2 Na 1>C mmolE(9 0 5.B mmolE(9 .l 11> mmolE(9 H.O> 17 mmolE(9 urea 11.5
mmolE( *K8+9 creatinine .1B mmolE( *K3.11+9 arterial %H 7.489 %a.34 >3 mmHg9 %a34
C3mmHg. &hich one of the following statements is .O##/.T:
*$+ The anion ga% is increased.
*,+ The sym%toms and signs are due to uraemia.
*.+ Metabolic acidosis has been documented.
*)+ The results suggest that she has been vomiting e6cessively.
*/+ $n infusion of bicarbonate should be commenced.
MOT children aged 11 months can
*$+ wal- inde%endently.
*,+ build a tower of four cubes.
*.+ %oint to a named %art of the body.
*)+ feed themselves with a s%oon.
*/+ %ic- u% a raisin between thumb and finger.
$ %reviously healthy >-year-old child has a single generalised convulsion lasting 5 min.
he is found to have a reddened throat and rectal tem%erature of >C.7 degrees ., from
which she recovers uneventfully in 5 days. Three months later she again becomes febrile
with an u%%er res%iratory tract infection. &hich one of the following is .O##/.T:
*$+ he should be started on oral %henobarbitone.
*,+ he should be %ut in a bath of cold water.
*.+ A33 mg as%irin should be administered.
*)+ $n antibiotic should be administered %rom%tly.
/+ Most such children will not have a further sei<ure.
&hich one of the following maternal conditions generally .ONT#$!N)!.$T/
e%idural anaesthesia in labour:
*$+ Hy%ertension.
*,+ "revious caesarean delivery.
*.+ "latelet count less than B3613 CE( *153-B3613 CE(+
*)+ Mitral stenosis.
*/+ .hronic anaemia.
B $ %reviously well boy aged 18 months %resents with a 4B h history of cough and
whee<e and has a res%iratory rate of >5Emin. There is a family history of asthma and
allergy. /6amination shows a boy who is generally well but he has softer breath sounds
over the left hemithora6. There are bilateral whee<es, more mar-ed on the left. The
$""#O"#!$T/ M$N$D/M/NT is
*$+ give nebulised salbutamol B hourly.
*,+ refer for %hysiothera%y.
*.+ give amo6ycillin.
*)+ arrange ins%iratory and e6%iratory chest 6-rays.
*/+ admit to hos%ital and nurse in >3I o6ygen.
$ 4-year-old boy %resented to your surgery with the onset of the s-in rash, de%icted in
the accom%anying %hotogra%h over the %revious > to B h. He has a tem%erature of >8.8
degrees .. &hich one of the following res%onses would be the MOT $""#O"#!$T/:
*$+ end him home and tell his %arents to give him %aracetamol to control the fever.
*,+ end to hos%ital immediately.
*.+ Dive %enicillin and send home.
*)+ Dive a broad s%ectrum antibiotic and send home.
*/+ Dive a single large dose of %arenteral %enicillin and send immediately to hos%ital.
$n an6ious mother consults about her 18-month-old child because Jhe doesnJt seem to
hear %ro%erlyJ. The child is otherwise well. /6amination of the childJs ears, nose and
throat a%%ears normal, including res%onse to the noise of a rattle. ?ou HO'()
*$+ reassure the mother and reassess the child in A months time.
*,+ arrange audiometric assessment.
*.+ defer investigation until the child is > years of age. *)+ %erform tuning for- tests.
*/+ %erform tym%anometry.
B5 $n an6ious mother consults about her 18-month-old child because Jhe doesnJt seem
to hear %ro%erlyJ. The child is otherwise well. /6amination of the childJs ears, nose and
throat a%%ears normal, including res%onse to the noise of a rattle. ?ou HO'() G
*$+ reassure the mother and reassess the child in A months time.
*,+ arrange audiometric assessment.
*.+ defer investigation until the child is > years of age.
*)+ %erform tuning for- tests.
*/+ %erform tym%anometry.
&hich one of the following ''$((? resolves s%ontaneously:
*$+ mall ventricular se%tal defect in a child aged 14 months.
*,+ mall atrial se%tal defect in a child aged > years.
*.+ "atent ductus in a toddler.
*)+ $ortic coarctation in a %remature infant.
*/+ .ongenital heart bloc-.
$ B3-year-old school teacher has been receiving treatment for de%ressive sym%toms
following his wifeJs desertion. $ wee- after being involved in a traffic accident in which a
child was hos%italised with head in=uries, he ta-es an overdose of fifty 45 mg imi%ramine
tablets and a large amount of alcohol. He has %reviously refused referral to a %sychiatrist
or voluntary hos%italisation for assessment. ?our !N!T!$( management, after successful
medical treatment of his overdose, HO'() ,/
*$+ increase his imi%ramine to 153 mg daily.
*,+ change him to a different tricyclic antide%ressant.
*.+ contact his wife and try and %ersuade her to return home.
*)+ arrange involuntary %sychiatric hos%italisation, if he still refuses voluntary admission.
.
*/+ refer him for alcohol counselling. -
$fter a %ulmonary embolus, which one of the following is MOT (!0/(?:
*$+ (ow right atrial %ressure and low central venous %ressure.
*,+ (ow systemic arterial blood %ressure and low venous %ressures.
*.+ High %ulmonary venous %ressure and %ulmonary oedema.
*)+ High right ventricular %ressure and high systemic venous %ressure.
J*/+ High left atrial %ressure and functional mitral valve incom%etence.
$ %atient %resents for her first visit in her second %regnancy with a history of a second
trimester miscarriage in her %revious %regnancy. &hich of the events listed below should
cause you to sus%ect that her miscarriage had been )'/ TO an incom%etent cervi6:
*$+ Onset of contractions.
*,+ #u%ture of membranes.
*.+ #eduction in fetal movements.
*)+ @aginal bleeding.
*/+ "urulent vaginal discharge.
$ healthy non-smo-ing 1C-year-old man, hos%italised for an a%%endicectomy, is
mista-enly given an overdose of his narcotic %remedication. He is found unconscious and
on auscultation of his chest, he has reduced breath sounds but no added sounds.
/mergency chest 5-ray is clear. His arterial blood gases *in mmHg+, ta-en while
breathing room air are MOT (!0/(? to show
*$+ %H - 7.44 "aO4 - 73 "a.O4 - A1. B
*,+ %H - 7.4> "aO4 - C3 "a.O4 - 5C. A
*.+ %H - 7.4> "aO4 - 8A "a.O4 - >3.
*)+ %H - 7.>C "aO4 - A5 "a.O4 - B4. C
*/+ %H - 7.>C "aO4 - 75 "a.O4 - A3.