MS AKT Practice Paper

Part 2

The MS AKT Exam Board has put together a 200-item practice exam (2 x 100 item
papers) to help medical students prepare for the UK Medical School Applied
Knowledge Test (MS AKT). Blueprinted to the GMC Content Map this exam has
been designed to reflect the style and type of question that students will encounter
when the MS AKT goes live in 2024-25 or 2023-24 for schools that have penultimate
year exams.

The practice exam comes with and without the answer options.

We would like to recognise the contribution of medical schools, and members of the
AKT Exam Board in particular, in producing this exam which we hope students will
find a valuable resource.

Please note this practice exam is reviewed on an annual basis and updated
accordingly. Should you have any questions about the clinical content of the practice
exam please speak to the Assessment Lead in your school in the first instance.

Any redistribution or reproduction of part or all of the contents in any form is

prohibited other than for personal, educational and non-commercial use.

© Medical Schools Council 2024 – reviewed August 2024

Page 1 of 102
 1. A 25 year old man has had penile pain for two days. His most recent sexual
intercourse was one week ago.

There are multiple tender ulcers on his preputial skin. His penile and scrotal
skin does not have any other abnormality.

Which is the most likely diagnosis?

A. Genital warts
B. Gonorrhoea
C. Herpes simplex
D. Lymphogranuloma venereum
E. Syphilis
Correct Answer(s): C

Justification for correct answer(s): Based on the given information, the most likely
diagnosis is Herpes simplex. The presence of multiple tender ulcers on the
preputial skin following recent sexual intercourse is suggestive of herpes
simplex virus infection. Genital warts usually present as painless, raised, and
cauliflower-like growths on the genital skin. Ulcers in syphilis are typically
painless, whilst gonorrhoea presents with discharge. In lymphogranuloma
venerum discharge and lymphadenopathy is often present.

© Medical Schools Council 2024 – reviewed August 2024

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 2. A 60 year old man has increasing left hip pain. It is worse after exercise and
occasionally wakes him at night. He has stiffness in the mornings that lasts for
about 10 minutes. He has hypertension treated with ramipril, but is otherwise
in good health.

He has reduced internal rotation on passive movement. This also elicits pain.

Which is the most appropriate initial treatment for his pain?

A. Celecoxib
B. Codeine phosphate
C. Naproxen
D. Paracetamol
E. Tramadol
Correct Answer(s): C

Justification for correct answer(s): Oral non-steroidal anti-inflammatory drugs are

recommended as initial pharmacotherapy for hip osteoarthritis. Paracetamol or
weak opioids should not be routinely offered unless they are only used
infrequently for short-term pain relief and all other pharmacological treatments
are contraindicated, not tolerated or ineffective.

NICE guideline [NG226] Published: 19 October 2022

https://www.nice.org.uk/guidance/ng226/chapter/Recommendations

© Medical Schools Council 2024 – reviewed August 2024

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 3. An 18 year old woman is 19 weeks pregnant. An ultrasound scan shows her
baby has anencephaly. She wants to discuss her options with regards to
termination of pregnancy.

When will termination of this pregnancy be legally permitted?

A. After spontaneous fetal death

B. At any time during the pregnancy
C. Before 20 weeks' gestation
D. Before 24 weeks' gestation
E. Before 28 weeks' gestation
Correct Answer(s): B

Justification for correct answer(s): The law is the UK is that the usual limit for
termination of pregnancy is 24 weeks’ gestation. However, anacephaly is a
fetal anomaly that inevitably results in the death of the fetus. This, or a risk of
serious harm to the woman, means that termination is legal at any time.

© Medical Schools Council 2024 – reviewed August 2024

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 4. A 65 year old man has had constant back and right knee pain for 6 months,
partially relieved by analgesia. He is an ex-smoker. He is otherwise well.

Investigations:
Haemoglobin 132 g/L (130-175)
Alkaline phosphatase 850 IU/L (25-115)
Calcium 2.3 mmol/L (2.2-2.6)
Phosphate 0.9 mmol/L (0.8-1.5)
Prostate specific antigen 5 μg/L (<4.0)

X-rays: sclerotic areas in lower right femur and lumbar spine L3

Isotope bone scan: areas of increased uptake in femur, lumbar spine and
skull

Which is the most likely diagnosis?

A. Hyperparathyroidism
B. Metastatic carcinoma of prostate
C. Metastatic small cell carcinoma of lung
D. Myeloma
E. Paget's disease of bone
Correct Answer(s): E

Justification for correct answer(s): Based on the given information, the most likely
diagnosis is E. The patient's history, investigations and imaging findings
suggest a diagnosis of Paget’s disease of bone. The elevated alkaline
phosphatase, with normal Calcium and Phosphate and bone scan results
support this diagnosis. Hyperparathyroidism can cause hypercalcemia and
bone resorption, but it is less likely in this case given the normal calcium and
phosphate levels. Metastatic small cell carcinoma of lung, prostate and
myeloma can also cause the imaging changes, but these are less likely given
the patient's history, and laboratory findings.

© Medical Schools Council 2024 – reviewed August 2024

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 5. A 14 year old girl has had crampy abdominal pain and poor appetite for 24
hours. She has also had a sore throat for 3 days.

Her temperature is 38.5°C. There is cervical lymphadenopathy and

tenderness in the right iliac fossa.

Which is the most likely diagnosis?

A. Acute appendicitis
B. Crohn's ileitis
C. Meckel's diverticulum
D. Mesenteric adenitis
E. Ovarian cyst
Correct Answer(s): D

Justification for correct answer(s): Based on the given information, the most likely
diagnosis is Mesenteric adenitis. The patient’s symptoms, including crampy
abdominal pain, poor appetite, sore throat, fever, cervical lymphadenopathy,
and tenderness in the right iliac fossa, suggest mesenteric adenitis, which is
an inflammation of the lymph nodes in the mesentery that can be caused by
viral or bacterial infections, such as streptococcal pharyngitis. Acute
appendicitis can also cause right lower quadrant pain and tenderness, but it
typically presents with more severe pain, rebound tenderness, and migration
of pain from the periumbilical region to the right iliac fossa. Crohn’s ileitis and
Meckel’s diverticulum are less likely given the patient’s age and symptoms,
and ovarian cyst typically presents with unilateral pelvic pain or mass. The
patient should be evaluated by her healthcare provider and may require further
testing, such as blood tests and imaging, to confirm the diagnosis and rule out
other conditions.

© Medical Schools Council 2024 – reviewed August 2024

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 6. The links between deprivation and health inequalities are well evidenced and
widely accepted, but there are a number of explanations for that association.
One explanation proposes that ill health determines people's social class.

Which type of explanation of health inequality is this?

A. Artefact
B. Cultural/behavioural
C. Idealist
D. Materialist
E. Social selection/mobility
Correct Answer(s): E

Justification for correct answer(s): This is an example of Social selection/mobility.

This explanation proposes that ill health can limit social mobility due to
decreased ability to work, and decreased income, leading to lower social class,
which in turn can contribute to health inequalities.
Artefact would be proposing that the observed differences are due to
differences in measurement (and so not actually present). Cultural/behavioural
is proposing that differences in behaviour cause differences in health. Idealist
would be suggesting that individuals’ construction of health is different in
different groups, so they might define health differently, and Materialist,
emphasises the role of economic and social factors, such as income,
education, and employment, in shaping health outcomes.

© Medical Schools Council 2024 – reviewed August 2024

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 7. A 19 year old man has 1 day of fever, muscle stiffness, palpitations and
difficulty breathing. He has a psychotic depression. He has been taking
fluoxetine for 6 weeks and started taking risperidone 1 week ago.

He is agitated and distressed. His temperature is 39.8°C, pulse rate 114 bpm,
BP 172/89 mmHg and respiratory rate 30 breaths per minute. Chest
examination is otherwise normal. There is increased tone globally; there are
no other neurological abnormalities.

Which test is most likely to help confirm the diagnosis ?

A. CT scan of head
B. ECG
C. EEG
D. Lumbar puncture
E. Serum creatine kinase
Correct Answer(s): E

Justification for correct answer(s): The symptoms described in the scenario

suggest the possibility of neuroleptic malignant syndrome (NMS), a rare but
potentially life-threatening side effect of antipsychotic medication. The most
appropriate test to help confirm the diagnosis in this case would be E. Serum
creatine kinase (CK), which is a muscle enzyme that can be elevated in NMS.
Imaging tests such as CT scan of head or lumbar puncture are unlikely to
provide useful information in this case, as the patient’s symptoms and
physical examination findings suggest a systemic rather than neurological
problem. ECG and EEG may be useful in ruling out other possible causes of
the patient’s symptoms, such as cardiac or seizure disorders, but are unlikely
to be diagnostic for NMS.

© Medical Schools Council 2024 – reviewed August 2024

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 8. A 43 year old man is involved in a low speed road traffic collision. Following
this, he develops pain in his lower back that it is still troublesome several
months later. The pain is worse after activity and is relieved by rest.

He has an exaggerated lumbar lordosis with a palpable depression above L5.

The range of movement of his spine is grossly normal. Neurological
examination of his lower limbs is also normal.

An MR scan is obtained (see image).

What is the diagnosis?

A. Cauda equina syndrome

B. Compression fracture
C. Herniated intervertebral disc
D. Spondylolisthesis
© Medical Schools Council 2024 – reviewed August 2024
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 E. Spondylosis
Correct Answer(s): D

Justification for correct answer(s): Spondylolisthesis is a condition where one

vertebra slips out of line with the one above it, most commonly in the lumbar
spine. The exaggerated lumbar lordosis and the palpable depression above L5
can be clinical findings of spondylolisthesis. Symptoms include lower back
pain that worsens with activity and improves with rest. Neurological
examination is typically normal.

© Medical Schools Council 2024 – reviewed August 2024

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 9. A 30 year old man goes out gambling. One night he makes a profit of
£100,000, and the following night he loses £150,000.

Which psychological process most likely occurred on the first night that led to his risk
taking on the following night?

A. Classical conditioning
B. Disinhibition
C. Modelling
D. Positive reinforcement
E. Social learning
Correct Answer(s): D

Justification for correct answer(s): This is because winning on the first night
positively reinforced his gambling behaviour - hence his repetition on the
following night.

© Medical Schools Council 2024 – reviewed August 2024

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 10. A 85 year old woman has a breast lump. She has hypertension, heart failure
and a previous stroke. She takes bisoprolol, ramipril, furosemide, aspirin and
atorvastatin.

Her pulse is 76 bpm irregularly irregular and BP 105/70 mmHg. Her jugular
venous pressure is visible 6 cm above the sternal angle. She has bibasal late
inspiratory crepitations and bilateral pedal oedema. There is a 2.5 cm
diameter, mobile, firm, non tender swelling in the upper outer quadrant of the
her breast. There is no palpable lymphadenopathy. An ultrasound guided core
biopsy was taken from the mass.

Investigation:
Pathology report of breast biopsy: infiltrating ductal carcinoma, ER positive ,
HER2 negative

She is started on an aromatase inhibitor and bisphosphonate.

Which is the most appropriate next treatment to offer?

A. Chemotherapy
B. Immunotherapy
C. No additional treatment
D. Radiotherapy
E. Surgery
Correct Answer(s): C

Justification for correct answer(s): Given the patient’s age and comorbidities,
surgery may not be a suitable option. The pathology report indicates that the
breast cancer is ER positive, which suggests that the tumor may be responsive
to hormone therapy. Therefore, the most appropriate next treatment to offer
would be hormone therapy with an aromatase inhibitor, which has been
already started, and a bisphosphonate, which is used to prevent bone loss
associated with hormone therapy. Chemotherapy and immunotherapy may not
be appropriate for this patient given her age and comorbidities. Radiotherapy
may be considered in certain cases, but it is not the most appropriate next
treatment to offer in this scenario. Therefore, the answer is no additional
treatment.

© Medical Schools Council 2024 – reviewed August 2024

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 11. A 40 year old primigravid woman, at 28 weeks' gestation, is admitted with a
seizure. She had epigastric pain and blurred vision preceding the seizure.

Her BP is 155/105 mmHg. Reflexes are brisk with two beats of ankle clonus.
Her urinalysis shows protein 2+.

Which intravenous drug is the most appropriate immediate treatment?

A. Diazepam
B. Hydralazine
C. Levetiracetam
D. Magnesium sulfate
E. Phenytoin
Correct Answer(s): D

Justification for correct answer(s): The most appropriate immediate treatment for
this patient is magnesium sulfate. She is presenting with features of severe
pre-eclampsia and eclampsia, which require urgent management to prevent
maternal and fetal complications. Magnesium sulfate is the first-line treatment
for preventing seizures in women with severe pre-eclampsia and eclampsia.
Diazepam and phenytoin are not recommended for the prevention of seizures
in pre-eclampsia/eclampsia. Hydralazine is a second-line agent for the control
of hypertension, and levetiracetam is an antiepileptic drug that is not routinely
used in the management of pre-eclampsia/eclampsia.

© Medical Schools Council 2024 – reviewed August 2024

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 12. A 29 year old woman attends her GP with a heavy sensation in her vagina
when exercising. She is aware of a bulge in her vagina, sometimes
associated with a desire to void urine. She had a vaginal delivery 2 years
ago.

There is some laxity of the anterior vaginal wall, but this does not descend to
the introitus on straining.

Urine culture is negative.

Which is the most appropriate management plan?

A. Oxybutinin hydrochloride
B. Pelvic floor exercises
C. Refer for urodynamic testing
D. Refer to urogynaecology clinic
E. Ultrasound scan of pelvis
Correct Answer(s): B

Justification for correct answer(s): The most appropriate management plan for
this patient with symptoms of pelvic organ prolapse is pelvic floor exercises
from the physiotherapists. The GP has examined the patient and she has a first
degree anterior prolapse. The physios will also make a further assessment
including a thorough examination of the pelvic floor, to establish the extent of
the prolapse and any associated symptoms. This will inform the choice of
treatment, which will nearly always include conservative measures such as
pelvic floor exercises. Referral to urogynaecology clinic is usually needed if
there is a severe prolapse e.g. 3rd degree or severe urinary bowel incontinence
or failed PFEs when management may include more invasive options such as
surgical repair. Oxybutinin hydrochloride is used in the management of
urgency urinary incontinence, which is not the main symptom in this patient.
Pelvic floor exercises can be recommended as part of the management of
pelvic organ prolapse, but in the absence of a full assessment and diagnosis,
their effectiveness may be limited. Urodynamic testing and ultrasound scan of
the pelvis may be considered as part of the overall management plan, but only
if referral to a specialist clinic is needed.

© Medical Schools Council 2024 – reviewed August 2024

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 13. A 19 month old girl has been able to sit unsupported for 1 month. She can
speak 2 words and has just started to feed herself using her fingers. She was
born at 30 weeks' gestation.

Which is the best description of her current development?

A. Fine motor delay

B. Gross developmental delay
C. Gross motor delay
D. Mild developmental delay
E. Normal development
Correct Answer(s): C

Justification for correct answer(s): The best description of the development is

gross motor delay. A child should be able to sit unsupported by 7 months of
age; speak at least 2 words and feed themselves using fingers by 12 months of
age. The fact that she was born at 30 weeks’ gestation i.e. 10 weeks premature,
should be taken into consideration when assessing her development.
Development may be delayed by approximately 10 weeks, but this does not
explain the delay seen here.

© Medical Schools Council 2024 – reviewed August 2024

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 14. A 37 year old woman who is 10 weeks pregnant has had excessive vomiting
for 1 week. The fundal height is consistent with 16 weeks' gestation.Her
temperature is 37.2°C, pulse rate 100 bpm and BP 180/110 mmHg.

Which is the most likely diagnosis underlying the clinical presentation?

A. Gastroenteritis
B. Missed abortion
C. Molar pregnancy
D. Pre-eclampsia
E. Pregnancy-induced hypertension
Correct Answer(s): C

Justification for correct answer(s): The most likely diagnosis is molar pregnancy.
This is the classic presentation of molar pregnancy as the underlying
diagnosis with large for gestation uterus and severe early onset pre-eclampsia
as a secondary phenomenon. Molar pregnancy can present with exaggerated
symptoms of pregnancy such as excessive vomiting and rapidly increasing
uterine size due to the proliferation of abnormal trophoblastic tissue.
Additionally, elevated blood pressure can occur as a result of gestational
trophoblastic disease-induced hypertension. Missed abortion must be
diagnosed with an ultrasound and Pregnancy Induced Hypertension occurs
after 20/40. Gastroenteritis would have normal-low BP not raised.

© Medical Schools Council 2024 – reviewed August 2024

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 15. A 29 year old woman has pain and morning stiffness in her finger and wrist
joints. This improves during the day and after active movement. She has had
recurrent mouth ulcers for the last 2 years. She had an episode of pleuritic
chest pain 6 months ago which resolved without seeking help.

Her BP is 128/85 mmHg. She has no warmth or tenderness in her hands.

Urinalysis: protein 1+, blood 1+

Investigations:
Haemoglobin 109 g/L (115–150)
White cell count 3.8 × 109/L (4.0–11.0)
Lymphocytes 0.9 × 109/L (1.1–3.3)
Platelets 160 × 109/L (150–400)
Creatinine 90 µmol/L (60–120)
CRP 21 mg/L (< 5)

Which is the most likely diagnosis?

A. Behçet's disease
B. Reactive arthritis
C. Rheumatoid arthritis
D. Sjögren's syndrome
E. Systemic lupus erythematosus
Correct Answer(s): E

Justification for correct answer(s): Based on the symptoms and investigations

provided, the most likely diagnosis is systemic lupus erythematosus (SLE).
The patient has joint pain and morning stiffness, which are common symptoms
of SLE. She also has a history of mouth ulcers and pleuritic chest pain, which
are other features that may be seen in SLE. The urinalysis shows proteinuria
and haematuria, which can be associated with lupus nephritis. The low
haemoglobin level and lymphopenia may also be seen in SLE. The elevated
CRP suggests an underlying inflammatory process.
Patients with Behcet’s syndrome experience ulceration and joint pain but renal
involvement and haematological changes are less likely. Patients with
Rheumatoid arthritis and reactive arthritis would have inflamed joints. Patients
with Sjogrens syndrome usually have normal CRP.

© Medical Schools Council 2024 – reviewed August 2024

Page 17 of 102
 16. A 66 year old man has lethargy, cough and a persistent pain in the right upper
quadrant of the abdomen. He has smoked between 15 and 40 cigarettes daily
for 50 years.

He has an enlarged liver.

Needle biopsy of the liver reveals adenocarcinoma, and

immunohistochemistry is positive for the marker thyroid transcription factor-1,
indicative of a primary pulmonary tumour.

Which is the most likely route by which this tumour spread to the liver?

A. Direct infiltration
B. Haematogenous spread
C. Lymphatic spread
D. Pagetoid spread
E. Transcoelomic spread
Correct Answer(s): B

Justification for correct answer(s): The presence of a thyroid transcription factor-1

marker in the liver biopsy suggests that the adenocarcinoma originated from
the lung, rather than the liver. Adenocarcinomas of the lung often metastasise
to the liver through the bloodstream, making haematogenous spread the most
likely route. Direct infiltration would be less likely due to the distance between
the lung and liver, while lymphatic, Pagetoid, and transcoelomic spread are
less common routes of metastasis for lung cancer to the liver.

© Medical Schools Council 2024 – reviewed August 2024

Page 18 of 102
 17. A 63 year old woman has two days of facial swelling, early morning facial
discomfort and fullness. Nine months ago she was treated with chemotherapy
and radiotherapy for lung cancer.

Her jugular venous pressure is elevated and non pulsatile. Her face, neck and
arms are swollen, and there are prominent veins across her chest.

Which structure is most likely to be occluded?

A. Axillary vein
B. Internal jugular vein
C. Right atrium
D. Subclavian vein
E. Superior vena cava
Correct Answer(s): E

Justification for correct answer(s): Superior vena cava is the most likely structure
to be occluded. The patient’s symptoms of facial swelling, fullness, and
prominent chest veins are consistent with superior vena cava syndrome, which
can occur when the SVC is compressed or obstructed. The previous history of
lung cancer and recent chemotherapy and radiotherapy suggest the possibility
of SVC obstruction due to malignancy.

© Medical Schools Council 2024 – reviewed August 2024

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 18. A 17 year old girl attends her GP with her mother. She has had severe
headaches, stomach aches and has vomited four times over 2 days.

She was invited to a close friend's birthday party but refused to attend. She is
extremely shy and isolated, and has very few friends. She is always worried
that others criticise her, is extremely sensitive to any rejection, and is very
attached to her mother.

Which personality disorder is she most likely to have?

A. Avoidant
B. Dependent
C. Paranoid
D. Schizoid
E. Schizotypal
Correct Answer(s): A

Justification for correct answer(s): The features described are consistent with
avoidant personality disorder, which is characterised by social inhibition,
feelings of inadequacy and hypersensitivity to criticism, and a strong desire for
affection and acceptance. People with this disorder tend to avoid social
situations and have few close relationships, often relying heavily on a single
attachment figure. They may also experience physical symptoms such as
headaches and stomach aches when faced with stress or anxiety-provoking
situations.

© Medical Schools Council 2024 – reviewed August 2024

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 19. A 45 year old man attends his GP with right knee pain. He has had no
previous problems with his knee befor. He has had previous episodes of a
severe pain in his toe and painful swelling of the dorsum of the feet. There is
no history of trauma. He drinks 20 pints of beer a week.

His temperature is 37.5°C, and his knee is warm, diffusely tender and very
painful to flex.

What is the most likely diagnosis?

A. Gout
B. Osteoarthritis
C. Rheumatoid arthritis
D. Septic arthritis
E. Torn meniscal cartilage
Correct Answer(s): A

Justification for correct answer(s): Based on the presentation, the most likely
diagnosis is gout. The presence of a warm, diffusely tender and very painful
knee, along with a previous history of acute inflammation in the feet and
alcohol excess would be consistent with a diagnosis of gout.

© Medical Schools Council 2024 – reviewed August 2024

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 20. A 68 year old woman has noticed a lump in her neck for 2 months. She
otherwise feels well.

There are small lymph nodes palpable in the cervical, axillary and inguinal
regions.

Investigations:
Haemoglobin 124 g/L (115–150)
White cell count 27.2 × 109/L (3.8–10.0)
Neutrophils 2.5 × 109/L (2.0–7.5)
Lymphocytes 21.6 × 109/L (1.1–3.3)
Monocytes 0.9 × 109/L (0.2–1.0)
Eosinophils 0.4 × 109/L (0–0.4)
Basophils 0.1 × 109/L (0–0.1)
Platelets 137 × 109/L (150–400)
Blood film: increased lymphocytes with sparse cytoplasm

Which is the most likely diagnosis?

A. Acute lymphoblastic leukaemia

B. Chronic lymphocytic leukaemia
C. Infectious mononucleosis
D. Myeloma
E. Non Hodgkin's lymphoma
Correct Answer(s): B

Justification for correct answer(s): The most likely diagnosis is Chronic

Lymphocytic Leukaemia as it is the commonest lymphoproliferative neoplasm
causing a lymphocytosis in this age of patient (lifetime risk approx. 1 in 200)
and the patient is otherwise well (approx. 75% of CLL diagnosis are in >65 year
olds and the average age of presentation is 70 years). The lymphocytosis with
normal Hb, neutrophil count and near normal platelet count and the film
appearances (small mature lymphocytes and smear cells are common) are also
consistent. Low grade Non Hodgkin's lymphoma is the main differential
diagnosis of painless persistent lymphadenopathy in this age group and is
also common but is less likely to present with significant lymphocytosis
(lymphadenopathy is more of a feature). Infectious mononucleosis is caused
by the Epstein-Barr virus and can also present with lymphadenopathy with
lymphocytosis although these are reactive lymphocytes with plenty of
cytoplasm. EBV also typically presents with fever and sore throat, and it is a
self-limited condition and resolves within weeks. Acute lymphoblastic
leukaemia is a malignancy of lymphoid progenitor cells that primarily affects
children and young adults and is typically associated with a short history of
bone pain, fever and pancytopenia. Myeloma is a malignancy of plasma cells
within the bone marrow, which can present with bone pain, hypercalcaemia,
anaemia, and renal dysfunction. Myeloma does not cause lymphadenopathy or
lymphocytosis.

© Medical Schools Council 2024 – reviewed August 2024

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 21. A 15 year old boy has had severe anorexia nervosa for one year. He is not
currently acutely physically unwell.

His weight is 75% of the expected weight for his height, age and sex.

Which is the most appropriate therapy?

A. Cognitive-analytic therapy
B. Cognitive-behaviour therapy
C. Family therapy
D. Non-directive counselling
E. Psychodynamic psychotherapy
Correct Answer(s): C

Justification for correct answer(s): Family therapy is the first-line treatment for
children and adolescents with anorexia nervosa, as it focuses on the family as
a whole rather than just the individual with the disorder. It aims to improve
family communication and functioning, and to help family members
understand and support the individual's recovery. Other types of therapy, such
as cognitive-behaviour therapy or psychodynamic psychotherapy, may be
used in conjunction with family therapy to address specific symptoms or
issues.

NICE guideline [NG69] Published: 23 May 2017 Last updated: 16 December

2020
https://www.nice.org.uk/guidance/ng69/chapter/Recommendations

© Medical Schools Council 2024 – reviewed August 2024

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 22. A randomised controlled trial was designed to compare a new drug with a
placebo. There were 120 patients in the treatment group of which 12 patients
died within 2 years. There were 240 patients in the control group of which 48
patients died within 2 years.

Which is the number needed to treat to avoid one death within 2 years?

A. 2
B. 4
C. 8
D. 10
E. 20
Correct Answer(s): D

Justification for correct answer(s): The absolute risk reduction (ARR) can be
calculated as the difference in the risk of death between the treatment and
control groups:

ARR = risk in control group - risk in treatment group

ARR = 48/240 - 12/120
ARR = 0.2 - 0.1
ARR = 0.1

The number needed to treat (NNT) can be calculated as the reciprocal of the
ARR:

NNT = 1 / ARR
NNT = 1 / 0.1
NNT = 10

Therefore, the NNT to avoid one death within 2 years is 10.

© Medical Schools Council 2024 – reviewed August 2024

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 23. A 28 year old woman is elated in mood. She has not slept for 7 days and has
been attending all-night parties. She is sexually disinhibited and believes that
she is a member of the royal family. She was previously fit and well and has
no past psychiatric history.

A urine drug screen is negative.

Which is the most appropriate medication to prescribe?

A. Diazepam
B. Lithium carbonate
C. Olanzapine
D. Sodium valproate
E. Zuclopenthixol decanoate
Correct Answer(s): C

Justification for correct answer(s): In this context olanzapine would be appropriate

as it would act as both antipsychotic and sedative medication. Diazepam and
zuclopenthixol decanoate are not the treatments of choice for mania. Lithium
carbonate is a standard treatment for bipolar disorder, but it may take several
days to become effective and is not appropriate for the acute management of
severe mania. Sodium valproate is nor prescribed to women of child-bearing
age. Valproate is highly teratogenic and evidence supports that use in
pregnancy leads to neurodevelopmental disorders (approx. 30–40% risk) and
congenital malformations (approx. 10% risk). Valproate must not be used in
women and girls of childbearing potential unless the conditions of the
Pregnancy Prevention Programme are met and only if other treatments are
ineffective or not tolerated, as judged by an experienced specialist.

Clinical guideline [CG185] Published: 24 September 2014 Last updated: 21

December 2023
https://www.nice.org.uk/guidance/cg185/chapter/Recommendations

© Medical Schools Council 2024 – reviewed August 2024

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 24. A 62 year old woman is seen at home because her legs feel "wobbly". She
has been incontinent of urine once. She has been experiencing increasing
pain in her mid back over the previous fortnight. She is being treated
for metastatic breast cancer with anastrozole.

There is slight weakness, rated 4/5, in hip flexion and knee extension
bilaterally. Plantar reflexes are equivocal and tendon jerks brisk. She is tender
over the 10ththoracic vertebra.

Which is the most appropriate next course of action?

A. Admission to the local hospice

B. Advise bed rest until pain resolves
C. Arrange domiciliary physiotherapy
D. Emergency admission for MR scan of spine
E. Give analgesia and re-examine her in the morning
Correct Answer(s): D

Justification for correct answer(s): The patient’s symptoms and examination

findings are suggestive of spinal cord compression, which is a medical
emergency. Urgent imaging with an MRI of the spine is necessary to confirm
the diagnosis and identify the underlying cause of the cord compression,
which can include metastatic cancer, disc herniation, or spinal stenosis.
Typical treatment options include surgical decompression or palliative
radiation therapy. The patient may require admission to the hospital for further
management.

© Medical Schools Council 2024 – reviewed August 2024

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 25. A 3 year old boy has had diarrhoea for 6 months. He has 4-5 watery stools
per day that contain visible pieces of sweetcorn and other vegetables. He is
thriving and developing well.

Which is the most likely diagnosis?

A. Coeliac disease
B. Gastroenteritis
C. Inflammatory bowel disease
D. Lactose intolerance
E. Toddler diarrhoea
Correct Answer(s): E

Justification for correct answer(s): The most likely diagnosis is toddler diarrhoea.
Toddler diarrhoea is a common condition in children between 6 months and 5
years of age, characterised by chronic, non-bloody, watery diarrhoea with no
signs of malabsorption or growth failure. It typically occurs during the daytime
and is associated with the intake of large amounts of fruit juice, high-fibre
foods, and other carbohydrates. It is usually self-limiting and resolves by the
age of 5 years.

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 26. A mother gives her 6 month old girl formula milk for the first time. Within
minutes, the baby vomits and develops an erythematous rash over her lips
and chin, which takes 1 hour to subside. The following week, the mother drips
a couple of drops of formula milk onto the baby's arm. The baby develops an
erythematous rash over the arm within 1 minute.

The mother is returning to work and does not wish to continue breastfeeding
or expressing milk.

Which is the best management option?

A. Goat's milk
B. Hydrolysed formula
C. Lactose free formula
D. Latex free teat
E. Soya milk
Correct Answer(s): B

Justification for correct answer(s): The best management option is hydrolyzed

formula. These symptoms suggest a potential allergic reaction to cow's milk
protein, prompting the need for an alternative formula that is less allergenic.
Hydrolyzed formula contains proteins that are broken down into smaller
fragments, making them less likely to trigger an allergic response compared to
intact cow's milk protein. Goat's milk is not recommended for infants as it has
similar protein structures to cow's milk and can cause similar allergic
reactions. Lactose-free formula is not necessary unless the infant has a
diagnosed lactose intolerance, which is rare in infants. A latex-free teat may be
needed if the infant has a latex allergy, but this is not relevant in this case.
Soya milk is not recommended for infants under 6 months of age, as it can
interfere with the absorption of important nutrients and may also cause an
allergic reaction.

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 27. A 28 year old woman is admitted with a sudden onset of abdominal pain and
vaginal bleeding. She is 38 weeks pregnant.

Her pulse rate is 120 bpm and BP 110/80 mmHg. She has a tender abdomen.
The fetal heart rate is 170 bpm.

Which is the most likely diagnosis?

A. Necrosis of a fibroid
B. Placenta praevia
C. Placental abruption
D. Pre-term labour
E. Uterine rupture
Correct Answer(s): C

Justification for correct answer(s): The most likely diagnosis is placental

abruption. Placental abruption occurs when the placenta separates
prematurely from the uterine wall before delivery, leading to maternal and fetal
complications including abdominal pain, vaginal bleeding, and fetal distress.
The sudden onset of abdominal pain and vaginal bleeding along with the
tender abdomen and tachycardia are suggestive of this diagnosis. The high
fetal heart rate may indicate fetal distress. Prompt evaluation and management
are necessary to optimise the chances of a successful outcome for both the
mother and the baby.

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 28. A 52 year old woman has had two days of worsening confusion. She has
chronic liver disease secondary to alcohol and has been abstinent for six
months. She has had a previous admission due to acute hepatic
encephalopathy.

She is disoriented in time and place, and is unable to hold a conversation. Her
temperature is 37.1°C, pulse 90 bpm and BP 119/80 mmHg. She has a
distended abdomen, widespread spider naevi and a flapping tremor.

She is given intravenous vitamin supplements.

Which is the most appropriate additional management of her acute confusion?

A. Ciprofloxacin
B. Furosemide
C. Lactulose
D. Lorazepam
E. Restrict dietary protein intake to 60 g/day
Correct Answer(s): C

Justification for correct answer(s): The most appropriate additional management

of her acute confusion would be Lactulose. The patient is exhibiting signs of
hepatic encephalopathy due to her chronic liver disease, which can cause
confusion, disorientation, and other neurological symptoms. Lactulose is a
standard treatment for hepatic encephalopathy as it helps to reduce the
amount of ammonia in the blood, which can contribute to the neurological
symptoms. Intravenous vitamin supplements may be helpful to address any
nutritional deficiencies, but lactulose is the primary treatment for hepatic
encephalopathy. Antibiotics such as ciprofloxacin may be used if there is
evidence of infection, but there is no indication of infection in this scenario.
Furosemide and protein restriction are not appropriate for hepatic
encephalopathy. Lorazepam can be used to treat alcohol withdrawal however
may worsen hepatic encephalopathy and should be used with caution in
patients with liver disease.

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 29. A 25 year old nulliparous woman with an uncomplicated pregnancy attends
for induction of labour at 41 weeks.

Examination reveals the head is engaged; the cervix is posterior, 2cm long
and the os is closed.

Which is the most appropriate method of induction?

A. Endovaginal prostaglandin gel

B. Membrane sweep
C. Oxytocin infusion
D. Oxytocin infusion and amniotomy
E. Progesterone suppository
Correct Answer(s): A

Justification for correct answer(s): Endovaginal prostaglandin gel is the most

appropriate method of induction in this scenario. The woman is at term and the
head is engaged, indicating that the fetal head is in the pelvis. Cervical
assessment reveals that the cervix is unfavourable for induction, with a
posterior position, a length of 2 cm, and a closed os. Endovaginal
prostaglandin gel is a method of cervical ripening, and reserved for cases in
which the cervix is unfavourable, and there is a need to ripen the cervix before
induction. Membrane sweeps encourage normal labour but are not a
recognised induction method on their own. Oxytocin infusion and amniotomy
is unlikely to be an an effective method of induction in this situation. The
cervix is closed making ARM difficult if not impossible without cervical
ripening – oxytocin cannot be used without amniotomy. Progesterone
suppositories are used to prevent preterm labour, and they are not indicated
for induction of labour at term.

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 30. A 60 year old man believes that the government has been monitoring him for
10 years, despite him repeatedly writing to the Prime Minister. His beliefs are
present whatever his mood. He has never heard voices when nobody else is
around.

Which is the most likely diagnosis?

A. Anankastic personality disorder

B. Delusional disorder
C. Depression with psychosis
D. Paranoid schizophrenia
E. Schizoid personality disorder
Correct Answer(s): B

Justification for correct answer(s): The most likely diagnosis is delusional

disorder. The delusions have not escalated or changed for significant period
and are considered to be "non-bizarre" i.e. situations that are not real but also
not impossible. These beliefs began 10 years old so this is not a personality
disorder as symptoms were not present since late adolescence. There are
no other symptoms commonly seen in schizophrenia, such as hearing voices
or experiencing disorganised speech and behaviour.

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 31. A 75 year old man attends his GP with fatigue, blurred vision and poor
concentration for 4 months. He has had type 2 diabetes for 30 years and
takes metformin (1 g twice daily). He lives alone and reports having a well-
balanced diet.

Investigations:Haemoglobin 98 g/L (130–175)

Mean cell volume (MCV) 115 fL (80–96)
Serum vitamin B12 90 ng/L (160–925)

Which is the most appropriate initial treatment for this patient?

A. Advise dietary modifications to include more vitamin B12-rich foods

B. Start intramuscular hydroxocobalamin 1 mg every 2 months
C. Start intramuscular hydroxocobalamin 1 mg on alternate days
D. Start oral cyanocobalamin 1 mg once daily
E. Start oral cyanocobalamin 150 micrograms once daily
Correct Answer(s): C

Justification for correct answer(s): This patient has vitamin B12 deficiency, likely
exacerbated by long-term metformin use, which can interfere with B12
absorption. Initial treatment for vitamin B12 deficiency, especially in the
presence of neurological symptoms such as blurred vision and poor
concentration, is intramuscular hydroxocobalamin. The recommended regimen
for patients with neurological involvement is 1 mg of hydroxocobalamin
intramuscularly on alternate days until there is no further improvement,
followed by maintenance dose every 2 months. This allows rapid
replenishment of B12 stores to address the neurological symptoms effectively.

Scenario: Management of anaemia - vitamin B12 and folate deficiency. Last

revised in March 2024
https://cks.nice.org.uk/topics/anaemia-b12-folate-
deficiency/management/management/#treatment-for-b12-deficiency

© Medical Schools Council 2024 – reviewed August 2024

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 32. A 94 year old woman has a deep gnawing pain in her left arm. She has had
10 kg weight loss in the past year.

Her temperature is 37.3°C. She has localised tenderness over the left upper
arm.

Investigations:
X-ray left arm (see image).

Which is the most likely cause of her pain?

A. Metastatic carcinoma
B. Osteomyelitis
C. Osteoporosis
D. Osteosarcoma
E. Paget's disease
Correct Answer(s): A

Justification for correct answer(s): The most likely cause of the 94-year-old
woman’s pain in her left arm is metastatic carcinoma. She has lost weight and
the site of the abnormality i.e. proximal humerus, is a common site for
metastasis. The X-ray is consistent with metastatic carcinoma.

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 33. A 45 year old man has a 5 month history of chronic sinusitis and unresolving
headaches. When he bends forward, purulent fluid pours from his nose.

Which anatomical structure is most likely to be the source of this fluid?

A. Anterior ethmoid air cells

B. Frontal sinus
C. Lacrimal sac
D. Maxillary sinus
E. Posterior ethmoid air cells
Correct Answer(s): D

Justification for correct answer(s): The patient’s symptoms suggest chronic

maxillary sinusitis; when the patient bends forward, gravity causes the
accumulated pus or mucus to drain out through the osteomeatal complex into
the nasal cavity. The anterior ethmoids and the frontal sinus also drain through
the OM complex, but the maxilla is the most commonly involved.

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 34. A 6 hour old boy, born at term, is grunting and cyanosed. He has been
struggling to feed.

His temperature is 36.8°C, pulse rate 190 bpm (120-160), respiratory rate 60
breaths per minute (30-60) and oxygen saturation 82% breathing air. His
oxygen saturation does not improve significantly breathing high flow oxygen.
He has a loud single second heart sound and a systolic murmur.

He is treated with intravenous fluids and antibiotics.

Which is the most appropriate next medication?

A. Alprostadil
B. Ibuprofen
C. Indometacin
D. Sildenafil
E. Surfactant
Correct Answer(s): A

Justification for correct answer(s): The most appropriate next medication is

Alprostadil. These clinical findings are consistent with congenital heart
disease. The loud single second heart sound and systolic murmur suggest a
possible ventricular septal defect (VSD) or patent ductus arteriosus (PDA). The
grunting and cyanosis, along with the low oxygen saturation that does not
improve with high flow oxygen, suggest that the baby is experiencing
significant respiratory distress. Alprostadil, a prostaglandin E1 analog, helps
maintain ductal patency and allows adequate systemic perfusion until
definitive management, such as surgical correction or catheter-based
intervention, can be undertaken. Ibuprofen and indometacin are both
nonsteroidal anti-inflammatory drugs that are used to treat patent ductus
arteriosus, but they are not appropriate in this case as they would cause
closure of the ductus arteriosus, exacerbating the baby's symptoms. Sildenafil
is a medication used to treat pulmonary hypertension, which can occur in
neonates with congenital heart defects, but it is not the most appropriate initial
medication in this case. Surfactant is a medication used to treat respiratory
distress syndrome, which is not the primary diagnosis in this case.

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 35. A 5 year old girl is brought to her GP with a rash over her arms that has been
gradually worsening over the past month. Her mother reports that she seems
more tired than usual.

She has a petechial rash over both forearms, with some petechiae over her
left anterior chest. She is pale and has hepatosplenomegaly.

Which is the most appropriate management option?

A. Administer intramuscular benzylpenicillin sodium and send her to hospital in

an ambulance
B. Prescribe a course of prednisolone and review in 3 days
C. Refer her for a routine appointment in the general paediatric clinic
D. Refer her urgently to the paediatric assessment unit
E. Take a full blood count and blood film and see her within 48 h
Correct Answer(s): D

Justification for correct answer(s): The most appropriate management option is to

refer her urgently to the pediatric assessment unit. The presence of a petechial
rash, hepatosplenomegaly, and tiredness in a child should raise suspicion of a
serious underlying condition, such as leukaemia or other haematological
disorders. Urgent referral to the paediatric assessment unit is necessary to
ensure prompt diagnosis and treatment. Intramuscular benzylpenicillin sodium
is not appropriate in this case, as it is unlikely to address the underlying
condition. Prednisolone is also not appropriate, as it is not indicated for the
management of petechial rash and hepatosplenomegaly. Referral to a general
paediatric clinic is not urgent enough, given the severity of the symptoms, and
a full blood count and blood film should be taken urgently, but this should be
done in the context of urgent referral to the paediatric assessment unit.

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 36. A 62 year old man attends the outpatients clinic with his wife. He has had
reduced energy and lack of interest in his work and poor sleep for six weeks.
He has lost weight. He has benign prostatic enlargement.

There is evidence of self-neglect and reduced eye contact.

What is the single most appropriate drug treatment?

A. Benzodiazepine
B. Selective serotonin re-uptake inhibitor
C. Serotonin noradrenaline re-uptake inhibitor
D. Tricyclic antidepressant
E. Z-drug
Correct Answer(s): B

Justification for correct answer(s): Based on the symptoms described, the most
appropriate drug treatment would be a selective serotonin re-uptake inhibitor
(SSRI), as this class of drugs is commonly used in the treatment of depression,
which the patient may be experiencing. Benzodiazepines and Z-drugs are more
appropriate for short-term management of insomnia or anxiety, while tricyclic
antidepressants and serotonin noradrenaline re-uptake inhibitors (SNRIs) may
have more side effects and risks in older patients with comorbidities. However,
it is important to note that a full assessment and diagnosis by a healthcare
professional is necessary before initiating any drug treatment.

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 37. A doctor is approached by their neighbour who is aware that another person
on their street has been admitted to the ward the doctor is working on. They
wish to know how the patient is doing. The doctor is aware the patient is
stable but the prognosis is uncertain.

Which is the most appropriate response by the doctor?

A. They can confirm they are caring for him and that he is unwell but stable
B. They can confirm they are caring for him but cannot comment on his condition
C. They can confirm they are caring for him and that he is making good progress
D. They cannot confirm they are caring for him but have heard he is unwell but
stable
E. They cannot confirm who is caring for him and cannot comment on his
condition
Correct Answer(s): E

Justification for correct answer(s): It is important for doctors to maintain patient

confidentiality and not disclose any patient information to individuals who are
not involved in the patient’s care. The doctor should not even disclose that
they are treating the patient, as this in itself is a breach of confidentiality.

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 38. A 40 year old woman has had right-sided facial weakness for the past 12
hours.

She has weakness of all of the muscles on the right side of her face. There is
no limb weakness and speech is normal. Examination of her ears is normal.

Which is the most appropriate drug treatment?

A. Aciclovir
B. Aspirin
C. Cinnarizine
D. None
E. Prednisolone
Correct Answer(s): E

Justification for correct answer(s): The patient has symptoms of facial palsy,
which is likely due to Bell’s palsy, a type of idiopathic facial nerve palsy. The
most appropriate initial treatment in this case (within 72 hours of the onset of
symptoms) is a short course of prednisolone to reduce inflammation and
improve outcomes. Aciclovir may be considered if herpes simplex virus
infection is suspected, but it is not the first-line treatment for Bell’s palsy, and
should be used in combination with a corticosteroid. Aspirin and cinnarizine
are not indicated in this case.

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 39. A 35 year old woman with gestational hypertension is induced at 40 weeks.
She has a normal vaginal delivery, but following delivery of the placenta she
bleeds heavily.

Which is the most appropriate initial management?

A. Carboprost
B. Ergometrine
C. Oxytocin
D. Misoprostol
E. Tranexamic acid
Correct Answer(s): C

Justification for correct answer(s): The most appropriate management for

postpartum haemorrhage following delivery of the placenta in a woman with
gestational hypertension is oxytocin, as it can help to contract the uterus and
reduce bleeding. Carboprost, and misoprostol may also be used if oxytocin is
ineffective, but they can cause adverse effects and should be used with
caution. Ergometrine can exacerbate hypertension and is essentially contra-
indicated in hypertension. Tranexamic acid may also be used as an adjunct
therapy to help control bleeding, but it should not be used as the sole
treatment. However, the specific management will depend on the severity of
the bleeding and other clinical factors, and close monitoring of the patient is
essential.

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 40. A 19 year old man attends his GP with two days of a burning sensation when
passing urine, urethral discomfort and a penile discharge. This developed a
week after he had unprotected sex with a new female partner.

He declines a referral to the genito-urinary medicine (GUM) clinic.

Which is the most appropriate treatment?

A. Doxycyline
B. Ciprofloxacin and metronidazole
C. Fluconazole and penicillin V
D. Metronidazole and fluconazole
E. Penicillin V and azithromycin
Correct Answer(s): A

Justification for correct answer(s): The man has suspected urethritis. There are no
specific features to suggest gonorrhoea and the most likely organism is
chlamydia. The most appropriate treatment for this patient would be
Doxycycline. Azithromycin alone would be an alternative. A first-void sample
for nucleic acid amplification testing (NAAT) should be sent. The patient
should also be advised to inform his sexual partner to get tested and treated as
well.

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 41. A 9 month old boy is brought to his GP with 4 days of coryzal symptoms,
intermittent fever, coughing and wheezing. He has been taking smaller feeds
for the past 2 days and was unsettled last night. He as adequate oral intake.
His mother has given him paracetamol suspension.

He is alert, there is no rash and he is drooling. His temperature is 38.2°C,

capillary return 1 second, pulse rate 148 bpm (80-160), respiratory rate 60
breaths per minute (30-60) and oxygen saturation 97% in air. He has
widespread wheeze and crackles, and his ears and throat are normal.

Which is the most appropriate next step in management?

A. Admission to paediatric ward

B. Prescribe oral doxycycline
C. Prescribe oral co-amoxiclav
D. Reassure and give safety netting advice
E. Give nebulised salbutamol and review
Correct Answer(s): D

Justification for correct answer(s): The presentation of this baby is consistent with
bronchiolitis. The most appropriate next step in management would be to
reassure and give safety netting advice.
Admission to paediatric ward may be considered in severe cases or if the baby
is unable to take oral fluids, but is not necessary in this case.
Prescribing oral doxycycline is not appropriate as doxycycline is
contraindicated in children under 12 years of age due to the risk of tooth
discolouration.
Prescribing oral co-amoxiclav is not appropriate as antibiotics are not routinely
recommended in the management of bronchiolitis, which is usually caused by
a viral infection.
Reassurance and safety netting advice is important in all cases. This baby has
a low grade fever but the other observations are all within normal range so
there is no indication for any other intervention at present.
Giving nebulised salbutamol and review would be indicated if observations
were outside the normal range or if the baby was significantly distressed, not
feeding etc.

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 42. A 23 year old woman has barricaded herself with her baby in the bathroom,
shouting that it is unsafe to come out because the house is infected. She
thinks that someone is trying to kill her and her baby. Her mood has not been
low at any stage. She is four days post-caesarean section, and her physical
recovery has been uncomplicated. She was not on any medication during her
pregnancy, but drank 20 units of alcohol a week.

She is orientated in time and place.

Which is the most likely diagnosis?

A. Alcohol withdrawal
B. Delirium
C. Obsessive-compulsive disorder
D. Post-natal depression
E. Puerperal psychosis
Correct Answer(s): E

Justification for correct answer(s): Puerperal psychosis is the most likely

diagnosis in this case. Puerperal psychosis is a rare but serious mental illness
that affects women in the days or weeks following childbirth. It typically
presents with symptoms such as delusions, hallucinations, confusion,
agitation, and a lack of insight into the illness. Risk factors include a personal
or family history of mental illness, a difficult or traumatic childbirth, and lack of
social support. Treatment often involves hospitalisation, medication, and
support from mental health professionals. It is important to seek help quickly
in order to provide the best possible outcome for both the mother and baby.

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 43. A 20 year old woman seeks contraceptive advice. She had unprotected
sexual intercourse four days ago.

Which is the most appropriate method of contraception?

A. Combined oral contraceptive pill

B. Copper-containing intrauterine device
C. Depot progestogen injection
D. High dose oral progestogen
E. Intrauterine progestogen system (Mirena coil)
Correct Answer(s): B

Justification for correct answer(s): The most appropriate method of contraception

after unprotected sexual intercourse is emergency contraception. The options
for emergency contraception include the copper-containing intrauterine device
(IUD) and emergency contraceptive pills. The copper containing IUD is highly
effective up to 5 days post UPSI (nearly 100% effective) and is therefore the
most appropriate option at this stage. COCP and high dose progestogens can
also be used but are less effective. Depot and Mirena are not licenced for
emergency contraception.

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 44. A 60 year old man feels tired, but has no specific symptoms. He is a non-
smoker and drinks eight units of alcohol per week.

Investigations:
Haemoglobin 120 g/L (130–175)
White cell count 5.8 × 109/L (3.0–10.0)
Platelets 170 × 109/L (150–400)
MCV 110 fL (80–96)
TSH 2.0 mU/L (0.3–4.2)

Which additional investigation is most likely to help with the diagnosis?

A. Erythrocyte sedimentation rate

B. Ferritin
C. Folate and vitamin B 12
D. Haptoglobin
E. Protein electrophoresis
Correct Answer(s): C

Justification for correct answer(s): The patient has a macrocytic anaemia (MCV
increased, Hb reduced). Folate and vitamin B12 deficiencies are common
causes of macrocytic anaemia and therefore testing for these would be initial
investigations.
Ferritin is incorrect because iron deficiency causes a microcytic anaemia.
Alcohol misuse can cause a macrocytosis, but 8 units of alcohol a week is not
enough to cause this. Hypothyroidism can also cause a macrocytosis but this
man’s thyroid function test is normal. Haemolysis can cause a macrocytic
anaemia (due to increase in the number of reticulocytes which are larger than
mature red cells) and haptoglobin is a test used as part of a haemolysis screen
but on its own is not helpful and would not be an initial investigation.
Protein electrophoresis is used to investigate possible myeloma which can
cause a normocytic or macrocytic anaemia but is less likely than B12 or folate
deficiency. ESR is a non-specific investigation that can be increased for many
reasons (infection, inflammation, malignancy, myeloma) and would not be a
helpful investigation (many labs no longer do this test).

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 45. A 15 year old girl has delayed puberty. She has always been short for her age
(height <0.4th centile for age). She has not started her periods yet.

She has no dysmorphic facial features but does have a webbed neck and
widely spaced nipples. She has no breast development.

Which chromosomal abnormality is most likely to cause her clinical presentation?

A. 45X0
B. 47XXX
C. 47XXY
D. Trisomy 13
E. Trisomy 21
Correct Answer(s): A

Justification for correct answer(s): The most likely chromosomal abnormality to

cause the clinical presentation of delayed puberty, short stature, webbed neck,
widely spaced nipples, and lack of breast development is Turner syndrome,
which is caused by a complete or partial monosomy of the X chromosome,
also known as 45X0.

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 46. A 36 year old man is brought to the Emergency Department with a head injury
after a fall from 10 metres. He was unconscious for a minute but recovered
and seemed fully alert and orientated. Four hours later he becomes drowsy
and confused, and then collapses.

His GCS is 7/15.

Which is the most likely diagnosis?

A. Cerebral contusions
B. Compound depressed skull fracture
C. Diffuse axonal injury
D. Extradural haematoma
E. Subarachnoid haemorrhage
Correct Answer(s): D

Justification for correct answer(s): A fall from a height with loss of consciousness
and subsequent deterioration in consciousness level suggests an extradural
haematoma. The initial lucid interval followed by a rapid deterioration is a
classic feature. A cerebral contusion would be less likely to cause a lucid
interval, and a subarachnoid haemorrhage or diffuse axonal injury may not be
associated with a lucid interval. A compound depressed skull fracture is often
visible on examination and may be associated with a break in the skin, and the
patient would have required immediate surgical intervention.

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 47. A 3 year old boy has had multiple skin lesions on his chest wall for 2 weeks
(see image). The lesions are not itchy and he is otherwise well.

He is apyrexial.

Which is the most likely diagnosis?

A. Chickenpox
B. Discoid eczema
C. Hand, foot and mouth disease
D. Molluscum contagiosum
E. Rubella
Correct Answer(s): D

Justification for correct answer(s): The most likely diagnosis based on the given
information is molluscum contagiosum. The lesions are typically painless,
firm, dome-shaped, and have a central indentation. They are caused by a
poxvirus and are usually self-limiting, resolving within 6 to 12 months.

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 48. A 42 year old woman has 6 months of a painful right shoulder. Her pain keeps
her awake at night and is worsened by movement. She is otherwise well.
There is no history of trauma.

She has pain on shoulder abduction between 80° and 120°. Her shoulder
movements are otherwise normal. There is no joint effusion.

X-ray of right shoulder is normal.

Which is the most likely diagnosis?

A. Cervical radiculopathy
B. Osteoarthritis of glenohumeral joint
C. Polymyalgia rheumatica
D. Pseudogout
E. Subacromial bursitis
Correct Answer(s): E

Justification for correct answer(s): The most likely diagnosis is subacromial

bursitis. The symptoms of pain worsened by movement and difficulty sleeping,
along with a normal X-ray and pain on shoulder abduction between 80° and
120° are consistent with subacromial bursitis. The patient is describing a
painful arc.

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 49. A 45 year old man has his BMI measured as part of a clinical trial for type 2
diabetes.

Which is the most appropriate classification of data on this parameter?

A. Categorical
B. Continuous
C. Discrete
D. Nominal
E. Subjective
Correct Answer(s): B

Justification for correct answer(s): BMI is a continuous variable as it can take any
value within a range of values (e.g. 18.5 to 50). Categorical variables are those
that can be grouped into categories (e.g. blood type, race). Discrete variables
are those that can only take certain values, usually integers (e.g. number of
children). Nominal variables are those that have no intrinsic order or ranking
(e.g. hair colour, occupation). Subjective is a term for phenomena not
variables.

© Medical Schools Council 2024 – reviewed August 2024

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 50. A 75 year old man with metastatic bowel cancer is dying. He is semi-
conscious. His breathing is becoming increasingly rattly.

He is being treated with morphine and haloperidol via a syringe driver.

Which is the most appropriate drug management?

A. Amoxicillin
B. Furosemide
C. Hyoscine
D. Levomepromazine
E. Midazolam
Correct Answer(s): C

Justification for correct answer(s): The most appropriate drug management for a
dying patient with increased respiratory secretions and a rattly breathing is
Hyoscine which is a commonly used antimuscarinic medication for the
management of respiratory secretions in end-of-life care. It reduces secretions
by blocking muscarinic receptors, thus drying the mouth and airways.
Therefore, the answer is Hyoscine.
Amoxicillin is an antibiotic that would not be indicated in this situation.
Furosemide is a loop diuretic and would not be helpful for respiratory
secretions. Levomepromazine is an antipsychotic medication that may have
sedative effects and is sometimes used in palliative care for symptom
management, but it is not the first-line medication for managing respiratory
secretions. Midazolam is a benzodiazepine that may be used for sedation and
anxiety relief, but it is not used for managing respiratory secretions.

© Medical Schools Council 2024 – reviewed August 2024

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 51. A 67 year old man has had 24 hours of a painful swollen left knee. He went
hill walking 3 days ago.

His temperature is 37.6°C, pulse rate 104 bpm and BP 116/80 mmHg. His left
knee is red, swollen and hot to touch. He has a reduced range of movement
in his knee and is unable to weight bear due to pain.

Investigations:
Haemoglobin 145 g/L (130–175)
White cell count 23.4 × 109/L (4.0–11.0)
Platelets 546 × 109/L (150–400)
Neutrophils 19.2 × 109/L (2.0–7.5)
CRP 122 mg/L (<5)

Which is the most appropriate next investigation?

A. Aspiration of left knee joint for microscopy and culture

B. MR imaging of left knee
C. Serum anti-cyclic citrullinated peptide antibody
D. Serum uric acid
E. X-ray of left knee
Correct Answer(s): A

Justification for correct answer(s): The most appropriate next investigation for
this patient is aspiration of left knee joint for microscopy and culture. The
patient has a painful swollen left knee with fever and raised inflammatory
markers, which suggests an acutely infected knee joint. Aspiration of the joint
for microscopy and culture is the most appropriate investigation to identify the
causative organism and guide antibiotic treatment. MR imaging may be useful
in cases of chronic joint disease, but is not necessary in this acute
presentation. X-ray may be useful in cases of trauma or chronic joint disease,
but again is not indicated acutely. Testing for anti-cyclic citrullinated peptide
antibody and serum uric acid are not relevant in this scenario.

© Medical Schools Council 2024 – reviewed August 2024

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 52. A 36 year old woman and her partner have been trying to conceive for the last
18 months. Neither has attained a pregnancy before. Both are medically fit
and well and have no surgical history. Her periods are every 38-45 days. Both
smoke 5-10 cigarettes per day and drink occasionally at the weekend.

Examination is unremarkable in both.

Which is the most likely cause of their inability to conceive?

A. Abnormal semen
B. Anovulatory cycles
C. Parental smoking
D. Unexplained subfertility
E. Uterine tube blockage
Correct Answer(s): B

Justification for correct answer(s): Based on the given information, the most likely
cause of their inability to conceive is anovulatory cycles. The woman’s
menstrual cycle is longer than the normal range of 21-32 days, which suggests
that she may not be ovulating regularly. The absence of any other medical
conditions or abnormalities in either partner suggests that anovulation is the
most likely cause of their infertility.

© Medical Schools Council 2024 – reviewed August 2024

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 53. A 45 year old man has a lump in the right side of his neck. He has never
smoked and takes no regular medications.

Fine needle aspiration of the mass reveals squamous cell carcinoma, and
subsequent investigations identify the primary tumour in the right tonsil.

Which virus is associated with this malignancy?

A. Cytomegalovirus
B. Epstein–Barr virus
C. Human immunodeficiency virus
D. Human papilloma virus
E. Human T-lymphotropic virus
Correct Answer(s): D

Justification for correct answer(s): Human papilloma virus (HPV) is associated

with squamous cell carcinoma of the oropharynx, which includes the tonsils
(typically palatine tonsils and lingual tonsils). Other risk factors for this cancer
include smoking and alcohol use, but the incidence of HPV-associated
oropharyngeal cancers is increasing. HPV-associated cancers also include
cervical, vulval, penile and anal cancers. https://www.cancer.net/navigating-
cancer-care/prevention-and-healthy-living/hpv-and-cancer

© Medical Schools Council 2024 – reviewed August 2024

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 54. A 78 year old man has worsening breathlessness. He has heart failure that
has been worsening progressively over the past 12 months. He has been bed
bound for the past 2 weeks. He was recently found to have probable lung
carcinoma but was not fit for further investigation.

He is dyspnoeic, cyanosed and confused. His temperature is 36.1°C, pulse

rate 100 bpm, BP 92/60 mmHg, respiratory rate 30 breaths per minute and
oxygen saturation 88% on 15 L/min via a Venturi mask. He has inspiratory
crackles in both bases.

He is treated with intravenous furosemide.

Which additional treatment is most likely to reduce his breathlessness?

A. Intramuscular haloperidol
B. Intravenous glyceryl trinitrate
C. Intravenous morphine
D. Nasal intermittent positive pressure ventilation
E. Nebulised salbutamol
Correct Answer(s): C

Justification for correct answer(s): Intravenous morphine is most likely to reduce

the breathlessness in this patient. The patient is experiencing severe dyspnea,
which is a common symptom in end-stage heart failure. Morphine is an opioid
analgesic with respiratory depressant effects that can reduce the sensation of
dyspnea. Glyceryl trinitrate and nebulised salbutamol are more appropriate for
patients with bronchospasm or heart failure due to left ventricular dysfunction.
Nasal intermittent positive pressure ventilation is more appropriate for patients
with acute respiratory failure due to hypoventilation. Haloperidol is indicated
for patients with delirium, agitation or confusion.

© Medical Schools Council 2024 – reviewed August 2024

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 55. An 18 year old woman has a sudden sharp stabbing pain in her abdomen,
lasting only a few minutes. It is 14 days since her last period started. She
indicates that the pain is localised to the left iliac fossa.

A surge in which hormone is most likely to coincide with her pain?

A. Follicle stimulating hormone

B. Luteinising hormone
C. Oestrogen
D. Progesterone
E. Prolactin
Correct Answer(s): B

Justification for correct answer(s): The surge in luteinising hormone is most likely
to coincide with the pain experienced by the 18 year old woman. This is
because the pain is localised to the left iliac fossa, which is where the ovary is
located. The surge in luteinising hormone occurs just before ovulation and
stimulates the release of an ovum from the ovary. It is most likely that the pain
was caused by the rupture of the follicle during ovulation with this temporal
relationship.

© Medical Schools Council 2024 – reviewed August 2024

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 56. A 72 year old man with lung cancer is admitted to the respiratory ward with
recurrent haemoptysis. He is known to the palliative care team and it is felt
that he is near the end of his life. He says that he wants to have his terminal
care on the respiratory ward because he knows and trusts the nurses. A 'do
not attempt resuscitation' form is completed.

He subsequently has further haemoptysis and becomes more breathless, so

he is treated with an opioid infusion to relieve his dyspnoea.

A doctor suggests that the local hospice is better equipped to care for the
patient. His son agrees with the doctor, believing that the hospice is "the right
place to die".

What should be the most important factor influencing the decision on whether to
move him to a hospice?

A. Consultant's view of patient's best interests

B. Hospital bed state
C. Local policy on end of life care
D. Patient's previous opinion
E. Son's wishes
Correct Answer(s): D

Justification for correct answer(s): Patient’s previous opinion should be the most
important factor influencing the decision on whether to move him to a hospice.
The patient has expressed his desire to stay on the respiratory ward because
he knows and trusts the nurses. It is important to respect the patient’s wishes
and provide care in the location where the patient feels most comfortable,
especially in end-of-life care situations. The son’s wishes can also be taken
into consideration, but the patient’s own wishes should be the primary
consideration.

© Medical Schools Council 2024 – reviewed August 2024

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 57. A 74 year old woman has had left sided headache and discomfort when
chewing food for 3 months. She experiences a sensation of pressure and pain
in her jaw, even when talking. She has lost 8 kg in weight over the same time
period.

Investigations:
CRP 45 mg/L (<5)

Which investigation is most likely to establish the diagnosis?

A. CT scan of head
B. Parotid sialogram
C. Serum anti-neutrophil cytoplasmic antibodies
D. Temporal artery biopsy
E. X-ray of temporomandibular joint
Correct Answer(s): D

Justification for correct answer(s): Temporal artery biopsy is the most appropriate
investigation in this patient to establish the diagnosis of giant cell arteritis. The
typical symptoms of headache, jaw claudication, and unintentional weight loss,
along with elevated CRP levels, raise a strong suspicion of giant cell arteritis.
Temporal artery biopsy is the gold standard test for diagnosis, as it shows
characteristic histopathological changes of giant cell arteritis such as
mononuclear cell infiltration and granulomatous inflammation. Some centres
will arrange a temporal artery ultrasound to help with the diagnostic process
but this is not an option in this question, so biopsy is the most appropriate.

© Medical Schools Council 2024 – reviewed August 2024

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 58. A group of 75 men and a group of 75 women performed a standardised
exercise test and had their pulse rate measured at the end.

The data from the two groups were compared. The data is normally
distributed with equal variance.

Which is the most appropriate statistical test to compare these groups?

A. Analysis of variance
B. Friedman's test
C. Mann–Whitney test
D. Paired Student's t-test
E. Unpaired Student's t-test
Correct Answer(s): E

Justification for correct answer(s): Unpaired Student’s t-test would be the most
appropriate statistical test to compare these groups, as it is used to compare
the means of two independent groups of data with equal variances assuming
normal distribution.

© Medical Schools Council 2024 – reviewed August 2024

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 59. A 45 year old man has a tremor that has worsened over several weeks. He
has schizophrenia and takes haloperidol.

He has bilateral tremor and cog-wheel rigidity in his upper limbs.

Which is the most appropriate treatment to manage his symptoms?

A. Co-beneldopa
B. Entacapone
C. Pramipexole
D. Procyclidine hydrochloride
E. Selegiline hydrochloride
Correct Answer(s): D

Justification for correct answer(s): Procyclidine is an antispasmodic drug and

a muscarinic antagonist that crosses the blood-brain barrier and is used in the
treatment of drug-induced extrapyramidal disorders and in parkinsonism. Here
Co-Benedopa can be used to treat Parkinson's disease but not EPSE.
Drug-induced parkinsonism is likely the most common drug-induced
movement disorder and one of the most common nondegenerative causes of
parkinsonism. Any medication that interferes with dopamine transmission may
cause parkinsonism. Haloperidol is a dopamine receptor blocking agent.

© Medical Schools Council 2024 – reviewed August 2024

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 60. A 30 year old man is unable to straighten his right middle finger after an injury.

He has a flexion deformity of the finger at the distal interphalangeal joint and
is unable to actively extend his finger.

Which is the most appropriate management option?

A. External finger fixation

B. Finger splint
C. Internal finger fixation
D. Reassurance
E. Steroid injection
Correct Answer(s): B

Justification for correct answer(s): The most appropriate management option for a
30-year-old man with a flexion deformity of the finger at the distal
interphalangeal joint and inability to actively extend his finger following an
injury is a finger splint. A finger splint can provide support and immobilise the
finger, allowing the tendon to heal and the finger to regain its full range of
motion.

© Medical Schools Council 2024 – reviewed August 2024

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 61. A 20 year old man has had two months of night sweats and 5 kg weight loss.
He was previously well.

His temperature is 37.6°C. He has palpable neck lymph nodes and

splenomegaly.

Investigations:
CT scan chest, abdomen and pelvis: enlarged mediatinal lymph nodes and
splenomegaly
Lymph node biopsy: Hodgkin/Reed-Sternberg (HRS) cells admixed with a
polymorphous inflammatory infiltrate

Which is the most appropriate first line treatment?

A. Chemotherapy
B. Corticosteroids
C. Immunotherapy
D. Radiotherapy
E. Surgical excision of mediastinal lymph nodes
Correct Answer(s): A

Justification for correct answer(s): The most appropriate first-line treatment for
classical Hodgkin lymphoma is chemotherapy. Corticosteroids may be used in
addition to chemotherapy in certain cases but are not typically used as a first-
line treatment. Immunotherapy and radiotherapy may be used as part of a
treatment regimen but are not typically used as a first-line treatment for
classical Hodgkin lymphoma. Surgical excision of mediastinal lymph nodes is
not a treatment option for Hodgkin lymphoma.

© Medical Schools Council 2024 – reviewed August 2024

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 62. A 72 year old man is admitted with cough, breathlessness and confusion. He
has metastatic adenocarcinoma and is being treated with chemotherapy. His
wife reports that he has had enough of his treatment and planned to
discontinue active treatment.

He is drowsy and unable to answer questions. He has bronchial breathing at

the left base. He is given 0.9% sodium chloride and broad spectrum
antibiotics intravenously.

Which is the most appropriate way to determine his cardiopulmonary resuscitation

status on this admission?

A. Admitting team should decide

B. Ask an independent advocate to decide
C. Ask consultant oncologist to decide
D. Ask his wife to decide
E. Wait 24 hours to see if patient regains capacity to decide
Correct Answer(s): A

Justification for correct answer(s): As the patient is currently unable to answer

questions and although his wife reports that he planned to discontinue active
treatment, this has not been documented and cannot be verified. The admitting
team should therefore decide about the best clinical approach to the patient,
including appropriateness or otherwise of CPR.

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 63. A 36 year old man with type 1 diabetes mellitus has a pilonidal sinus. He
takes 14 units long-acting insulin at night, and short-acting insulin three times
daily at mealtimes (typically 6-8 units with each meal). He is scheduled for
excision of the sinus under general anaesthesia, first on a morning operating
list. He is asked to fast from midnight the night before.

His HbA1c is 58 mmol/mol (20-42).

Which is the most appropriate plan for managing his insulin pre-operatively?

A. Omit evening and morning insulin doses

B. Start a variable-rate insulin infusion on the morning of surgery
C. Start a variable-rate insulin infusion the evening before surgery
D. Take evening and morning insulin doses, as usual
E. Take usual evening insulin and omit morning insulin
Correct Answer(s): E

Justification for correct answer(s): It is important to ensure that blood glucose

levels are well-controlled in patients with diabetes undergoing surgery.
Omitting insulin doses can lead to hyperglycaemia, which increases the risk of
surgical complications, while taking too much insulin can lead to
hypoglycaemia, which can also be dangerous.

In this case, he should take his usual long-acting insulin the evening before
but will need to adjust his short-acting insulin dose based on the anticipated
timing of the surgery the following day. As he is scheduled as first on the list in
the morning, and having been starved from midnight he should omit his
morning short acting insulin prior to surgery and recommence this when
eating and drinking. The anaesthetist should be informed of the patient's
diabetes and insulin regimen, and should monitor blood glucose levels during
the perioperative period.

Guideline for Perioperative Care for People with Diabetes Mellitus Undergoing
Elective and Emergency Surgery. Updated October 2023
https://cpoc.org.uk/guidelines-resources-guidelines-resources/guideline-
diabetes

© Medical Schools Council 2024 – reviewed August 2024

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 64. A 3 year old girl has had a fever and a runny nose for 2 days.

She is alert but miserable. Her temperature is 39.6°C, pulse rate 150 bpm
(95-140), BP 105/62 mmHg (90/50-120/180), respiratory rate 36 breaths per
minute (20-30) and oxygen saturation 97% in air. She has a red throat and
looks flushed with a flat, erythematous rash across her trunk and face that
feels rough. There is no rash around her mouth.

Which is the most likely diagnosis?

A. Kawasaki disease
B. Measles
C. Parvovirus infection
D. Rhinovirus infection
E. Scarlet fever
Correct Answer(s): E

Justification for correct answer(s): The most likely diagnosis is scarlet fever.
Scarlet fever is a bacterial infection caused by Group A Streptococcus. It
typically presents with a high fever, sore throat, and a characteristic
sandpaper-like rash that starts on the trunk and spreads to the extremities. The
cheeks may look flushed with often a pale area around the mouth. Measles can
cause fever and rash, but typically presents with a cough, runny nose, and red,
watery eyes. Parvovirus infection can cause a rash, but it is typically milder
and not associated with a fever. Kawasaki disease can also cause a fever and
rash, but it usually presents with conjunctivitis, swollen lymph nodes, and
redness and peeling of the hands and feet. Rhinovirus infection can cause a
runny nose, but is not typically associated with fever or rash.

© Medical Schools Council 2024 – reviewed August 2024

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 65. A one week old girl has pale stools in her nappy, with streaks of dark urine
(see image). She is fully breastfed and was born at term. She has lost 8.2% of
her birth weight.

She is apyrexial. She is alert and has jaundice.

Which is the most appropriate investigation?

A. Coombs (direct antiglobulin) test

B. Full blood count and film
C. Plasma glucose
D. Split bilirubin
E. Urea and electrolytes
Correct Answer(s): D

Justification for correct answer(s): The history and presentation is suggestive of

conjugated hyperbilirubinaemia, which is indicative of pathology rather than
being physiological. A split bilirubin measures the ratio of conjugated and
unconjugated bilirubin levels in the baby’s blood, which is necessary to
diagnose conjugated jaundice.
© Medical Schools Council 2024 – reviewed August 2024
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 66. A 36 year old woman attends for an asthma review. She requires a long-
acting β-agonist and steroid combination inhaler.

The guidelines suggest either a metered dose inhaler or a dry powder. They
are the same price.

This patient asks which is better for the environment.

Which component of these inhalers has the highest carbon footprint?

A. Hydrofluorocarbon propellant in the metered dose inhaler

B. Packaging of the dry powder inhaler
C. Plastic component of the dry powder inhaler
D. Plastic component of the metered dose inhaler
E. Powder component of the dry powder inhaler
Correct Answer(s): A

Justification for correct answer(s): Hydrofluorocarbon propellant in the metered

dose inhaler has the highest carbon footprint of the components listed. It is a
greenhouse gas that contributes to climate change. Dry powder inhalers do not
use propellants and are considered to have a lower carbon footprint. However,
the manufacturing and disposal of all inhalers contribute to environmental
impact.

© Medical Schools Council 2024 – reviewed August 2024

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 67. A 18 year old man is worried about his cancer risk. His paternal grandfather
died of colorectal cancer at 42 years of age and his 36 year old father has just
been diagnosed with colorectal cancer. The son's colonoscopy shows
hundreds of colonic polyps, and biopsies from several of the polyps show
adenomatous change with low grade dysplasia.

Which is the most appropriate strategy to prevent colon cancer in this situation?

A. Daily low dose aspirin

B. Diet rich in fruit and vegetables
C. Panproctocolectomy
D. Annual faecal immunochemical test (FIT)
E. Annual colonoscopy and biopsy
Correct Answer(s): C

Justification for correct answer(s): The most appropriate strategy to prevent colon
cancer in this situation is panproctocolectomy, which is the removal of the
entire colon, rectum, and anus. This patient has a strong family history of
early-onset colorectal cancer and has already developed hundreds of colonic
polyps with evidence of adenomatous change and low-grade dysplasia. These
findings are consistent with a diagnosis of familial adenomatous polyposis
(FAP), an inherited condition that predisposes to the development of colorectal
cancer. Prophylactic surgery is recommended in patients with FAP to prevent
the development of colorectal cancer. Daily low dose aspirin and a diet rich in
fruit and vegetables have been shown to have some protective effect against
colon cancer, but these measures are not sufficient for a patient with FAP.
Annual FIT and colonoscopy and biopsy are not adequate for cancer
prevention in a patient with FAP.

© Medical Schools Council 2024 – reviewed August 2024

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 68. A 21 year old man has a fear of public speaking. He is a student and has to
give an oral presentation, and he feels unable to manage this. He fears that
he will do something to embarrass himself or even vomit. The thought of
giving his presentation gives him palpitations and makes him breathless and
dizzy. He has avoided his tutor for 3 months and has not left his flat for
several weeks. He recognises that his fears are irrational but feels
overwhelmed.

Which is the most likely diagnosis?

A. Agoraphobia
B. Anxious avoidant personality disorder
C. Emetophobia
D. Panic disorder
E. Social phobia
Correct Answer(s): E

Justification for correct answer(s): The patient’s fear of public speaking,

avoidance behaviour, and recognition that his fears are irrational are
consistent with a diagnosis of social phobia. Social phobia is a type of anxiety
disorder characterised by an excessive and persistent fear of social situations,
including public speaking. It can cause significant distress and interfere with
daily activities. Treatment options may include cognitive-behavioural therapy
and/or medication.

© Medical Schools Council 2024 – reviewed August 2024

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 69. A 46 year old man has sudden onset and intense lower back pain. He has no
pain or numbness in his buttocks or legs. He is diagnosed with mechanical
back pain. He has no drug contra-indications.

Which is the most appropriate initial medication?

A. Amitriptyline
B. Fentanyl
C. Ibuprofen
D. Paracetamol
E. Triamcinolone
Correct Answer(s): C

Justification for correct answer(s): The most appropriate initial medication is non-
steroidal anti-inflammatory drugs (NSAIDs) in this age group if there are no
contra-indications. Paracetamol on its own is not recommended. Amitriptyline,
fentanyl, and triamcinolone are not typically used for the initial treatment of
mechanical back pain.

© Medical Schools Council 2024 – reviewed August 2024

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 70. A 56 year old woman has had 2 months of intermittent vertigo, which typically
occurs when turning over in bed or looking over her shoulder while driving.
Each episode lasts for up to 1 minute. She has no hearing loss, tinnitus or ear
pain.

Which test is most likely to confirm the diagnosis?

A. Audiometry
B. Carotid doppler ultrasonography
C. CT scan of head
D. Dix–Hallpike manoeuvre
E. MR of internal auditory meatus
Correct Answer(s): D

Justification for correct answer(s): The Dix-Hallpike manoeuvre is used to evaluate

for benign paroxysmal positional vertigo (BPPV), when caused by canalithiasis
in the posterior semicircular canal. During the Dix-Hallpike manoeuvre, the
patient is quickly moved from a seated position to a lying position with the
head turned to one side, which causes displacement of free-floating calcium
carbonate crystals (otoconia) in the inner ear. The manoeuvre is diagnostic if it
elicits vertigo and nystagmus (involuntary eye movement) in patients with
BPPV. Most cases are clinically diagnosed and imaging is not helpful.

https://cks.nice.org.uk/topics/benign-paroxysmal-positional-
vertigo/diagnosis/diagnosis/

© Medical Schools Council 2024 – reviewed August 2024

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 71. A 62 year old man is brought to the operating theatre recovery room after a
laryngoscopy and vocal cord biopsy.

He appears to be conscious, but his breathing is shallow and respiratory rate

28 breaths per minute. His voice is weak and, when the recovery nurse asks
him to squeeze her fingers with his hand, the grip is not sustained.

Which drug will reverse these signs?

A. Doxapram
B. Glycopyrronium
C. Naloxone
D. Neostigmine
E. Rocuronium
Correct Answer(s): D

Justification for correct answer(s): The weak grip, cough and shallow breathing
suggest residual effects of neuromuscular blockade that has been
administered to facilitate laryngoscopy and vocal chord biopsy under general
anaesthetic. Doxapram acts on central and peripheral chemoreceptors to
stimulate respiration but would have no effect on improving neuromuscular
strength. Naloxone is an opioid antagonist and would not reverse the effects of
neuromuscular blockade. Glycopyrronium is an antimuscarinic agent and
would not have any effect on reversing neuromuscular blockade at the
neuromuscular junction and improving strength. Neostigmine is a
cholinesterase inhibitor and is the most appropriate agent to administer to
reverse the effects of neuromuscular blockade. It reduces the breakdown of
acetylcholine at the neuromuscular junction increasing its availability to bind
to the acetylcholine receptor and therefore trigger muscular contraction and
increased strength. Administration would increase grip strength, respiratory
muscular strength and may improve vocal chord movement and speech.
Rocuronium is a neuromuscular blocking agent and would not be appropriate
in this situation.

© Medical Schools Council 2024 – reviewed August 2024

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 72. A 50 year old woman has broken her right radius after tripping at home. She
has been experiencing hot flushes and night sweats for the past six months,
with irregular menstruation. She has been taking salbutamol and
beclometasone regularly for more than five years to treat asthma. Her fracture
heals with no complications.

Which investigation will most effectively evaluate her future risk of fractures?

A. 99m-technetium bone scintigraphy

B. Dual energy X-ray absorptiometry
C. MR scan of spine and hip
D. Plain X-ray lumbar spine and pelvis
E. Quantitative CT scan of spine and hip
Correct Answer(s): B

Justification for correct answer(s): Dual energy X-ray absorptiometry (DEXA) is

the most appropriate investigation to evaluate future fracture risk in this
patient. The presence of hot flushes, night sweats, and irregular menstruation
suggests that the patient is likely going through menopause. The patient’s use
of long-term inhaled corticosteroids for asthma increases her risk of
osteoporosis. DEXA scan is a simple, non-invasive test that measures bone
mineral density and is the gold standard for diagnosing osteoporosis and
assessing fracture risk. A bone scintigraphy or MR scan are not first-line
investigations for evaluating osteoporosis and would not provide the same
level of detail as DEXA. X-rays and CT scans are not sensitive enough to
diagnose osteoporosis but may be used to assess for fractures after they have
occurred.

© Medical Schools Council 2024 – reviewed August 2024

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 73. A 72 year old man has had difficulty swallowing solids. He has cancer of the
middle third of the oesophagus and hepatic metastases.

Which is the most appropriate initial management of his dysphagia?

A. Chemotherapy
B. Excision of tumour
C. Gastrostomy feeding tube
D. Oesophageal stent
E. Radiotherapy
Correct Answer(s): D

Justification for correct answer(s): Placement of an oesophageal stent can provide

palliation of dysphagia in patients with oesophageal cancer. It is a minimally
invasive procedure that can be done under sedation or general anaesthesia. It
involves placement of a metal or plastic stent into the oesophagus to hold it
open, allowing food and liquid to pass through. It is a safe and effective option
for patients with dysphagia due to oesophageal cancer, particularly in those
with advanced or metastatic disease who may not be candidates for curative
treatment.

© Medical Schools Council 2024 – reviewed August 2024

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 74. A 64 year old man has low thoracic back pain and has been tired for the past
6 weeks. He is a non-smoker. He has hypertension and takes amlodipine.

His urinalysis is normal.

Investigations:
Haemoglobin 81 g/L (135–175)
MCV 82 fL (80–96)
White cell count 4.3 × 109/L (3.0–10.0)
Platelets 74 × 109/L (150–400)

Creatinine 203 µmol/L (60–120)

Which initial investigation is most likely to help establish a diagnosis?

A. Anti-neutrophil cytoplasmic antibody

B. Antinuclear antibody
C. Complement levels (C3 and C4)
D. Coagulation screen
E. Serum free light chains
Correct Answer(s): E

Justification for correct answer(s): This patient has back pain, fatigue, normocytic
anaemia, thrombocytopenia and renal failure. The location of the back pain is
low thoracic which is higher than the lumbosacral area commonly affected by
mechanical back pain. Based on the patient’s clinical presentation and
laboratory results, the most likely diagnosis is myeloma. The most appropriate
initial investigation to confirm this diagnosis is serum free light chains testing.
This will detect the presence of Bence-Jones protein characteristic of
myeloma. Other options are not relevant to the diagnosis of myeloma.

© Medical Schools Council 2024 – reviewed August 2024

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 75. A 66 year old woman has become forgetful, does not sleep well and has lost
her appetite over the last few weeks. She has been getting up early in the
morning because she cannot sleep. She feels that she is no longer of any use
to the rest of her family.

Mini Mental State Examination is 27/30.

Which is the most likely diagnosis?

A. Age-associated memory impairment

B. Alzheimer’s disease
C. Depression
D. Frontotemporal dementia
E. Vascular dementia
Correct Answer(s): C

Justification for correct answer(s): Based on the information provided, the most
likely diagnosis is depression. The patient is presenting with symptoms such
as forgetfulness, loss of appetite, early morning awakening, and feelings of
worthlessness. While some of these symptoms can be seen in dementia, the
Mini Mental State Examination score of 27/30 suggests that cognitive
impairment may not be the primary cause of her symptoms. Age-associated
memory impairment is not a recognised diagnosis, and frontotemporal
dementia typically presents with more behavioural changes and personality
changes rather than forgetfulness. Vascular dementia may also present with
cognitive changes, but there is no indication of a history of cerebrovascular
disease in this case. Therefore, depression is the most likely diagnosis.

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 76. A consultant is looking to find published evidence on reducing the incidence of
deep venous thrombosis.

Which type of study would provide the highest quality evidence?

A. Case control study

B. Case series
C. Cohort study
D. Meta-analysis of trials
E. Randomised controlled trial
Correct Answer(s): D

Justification for correct answer(s): While randomised controlled trials provide

high quality evidence about interventions, a meta-analysis of trials includes an
assessment of their risk of bias, and a pooling of results, which increases the
statistical power of the findings.

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 77. A 62 year old man has had 3 months of general weakness, fatigue, 10 kg
weight loss and mild abdominal discomfort over the right hypochondrium. He
was found to have liver cirrhosis 10 years ago and has abstained from alcohol
since the diagnosis.

He has a non-tender, fixed hard mass in the right upper quadrant.

Which serum investigation is most appropriate to aid diagnosis?

A. α-Fetoprotein
B. β-Human chorionic gonadotropin
C. CA 125
D. CA 19-9
E. Carcinoembryonic antigen
Correct Answer(s): A

Justification for correct answer(s): α-Fetoprotein is the most appropriate serum

investigation to aid diagnosis in this case. The patient has a history of liver
cirrhosis and a palpable mass in the right upper quadrant, which raises
suspicion of hepatocellular carcinoma (HCC). α-Fetoprotein is a tumour marker
that is often elevated in patients with HCC. However, it is important to note that
not all patients with HCC have elevated α-fetoprotein, and elevated levels can
also be seen in other conditions such as pregnancy and some benign liver
diseases. Therefore, a definitive diagnosis of HCC usually requires
confirmation by imaging studies such as ultrasound, CT scan or MRI, and/or
tissue biopsy.

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 78. A 7 year old boy has intermittent pain in his left groin when playing football
and climbing stairs. This has worsened over the past 4 weeks. He has now
developed a painless limp.

His temperature is 37.1°C. He has reduced range of movement and pain on

internal rotation and abduction.

Which is the most likely diagnosis?

A. Osgood–Schlatter disease
B. Perthes' disease
C. Septic arthritis
D. Slipped upper femoral epiphysis
E. Transient synovitis
Correct Answer(s): B

Justification for correct answer(s): Transient synovitis is unlikely as there is no

evidence of preceding viral infection. Septic arthritis would be a concern, given
the fever, but the pain is typically more severe and constant, with systemic
signs of inflammation. Osgood–Schlatter disease affects the knee rather than
hip. Slipped upper femoral epiphysis presents in older children and typically
presents with acute onset of pain and a limp.

Perthes (Legg-Calvé-Perthes disease) is more common in boys, with peak

presentation at age 4-6 years. It is characterised by insidious onset of a limp
with or without pain. There is no history of trauma, and the presentation is
usually unilateral.

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 79. A 28 year old primigravida attends the antenatal clinic at 35 weeks' gestation.
She has 2 weeks of persistent itching of her palms, soles and abdomen. Her
pregnancy has been uncomplicated to date, and she is feeling good fetal
movements.

She has red scratch marks on her abdomen with no rash.

Which is the most appropriate diagnostic investigation?

A. Anti-mitochondrial antibody
B. Iron studies
C. Liver function tests
D. Thyroid function tests
E. Urea and electrolytes
Correct Answer(s): C

Justification for correct answer(s): The most appropriate investigation in this case
is liver function tests. The persistent itching and scratch marks suggest
obstetric cholestasis, a liver disorder that occurs in pregnancy. Liver function
tests are important to assess the degree of hepatic dysfunction, and elevated
serum bile acids would confirm the diagnosis. Other investigations such as
anti-mitochondrial antibody, iron studies, thyroid function tests, and urea and
electrolytes would not be helpful in diagnosing obstetric cholestasis.

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 80. A 23 year old woman commenced chemotherapy for Burkitt's lymphoma
yesterday. Since then, she has been feeling increasingly nauseated.

Her temperature is 36.8°C, pulse rate 96 bpm and BP 112/80 mmHg.

Urine output has been 40 mL in the last 12 hours.

Investigations on admission were normal.

Investigations today:
Potassium 6.2 mmol/L (3.5–5.3)
Urea 9 mmol/L (2.5–7.8)
Creatinine 410 µmol/L (60–120)

Which investigation is most likely to identify the cause of her acute deterioration?

A. Blood cultures
B. C reactive protein
C. Creatine kinase
D. Phosphate
E. Urate
Correct Answer(s): E

Justification for correct answer(s): Based on the patient’s symptoms and

laboratory results, she may be experiencing tumour lysis syndrome, which is a
potentially life-threatening complication of chemotherapy that can cause
electrolyte imbalances and kidney damage. The most appropriate investigation
to identify the cause of her acute deterioration would be urate, as elevated uric
acid levels are a hallmark of tumour lysis syndrome. However, all of the other
options may also be useful in helping to manage her condition. Blood cultures
may be taken to rule out a bacterial infection, C-reactive protein can indicate
inflammation or infection, creatine kinase may be elevated in rhabdomyolysis
(another potential complication of chemotherapy), and phosphate levels may
also be elevated in tumour lysis syndrome.

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 81. A 44 year old woman is increasingly hypotensive in the high dependency unit.
She was admitted 12 hours earlier with loin pain, dysuria and rigors, and was
treated with intravenous broad spectrum antibiotics.

Her temperature is 37.8°C, pulse rate 112 bpm, BP 91/60 mmHg, central
venous pressure +12 mmHg and oxygen saturation 95% on 60% oxygen.

Investigations:
Sodium 139 mmol/L (135–146)
Potassium 5.1 mmol/L (3.5-5.3)
Urea 10.3 mmol/L (2.5-7.8)
Creatinine 159 μmol/L (60–120)

She has been treated with 3 L of 0.9% sodium chloride since admission, with
a urine output of 400 mL in total and 10–20 mL/hr for the past 4 hours.

Which is the most appropriate next step in management?

A. Haemofiltration
B. Intravenous 500 mL gelatin over 30 minutes
C. Intravenous 500 mL 0.9% sodium chloride over 30 minutes
D. Intravenous furosemide bolus
E. Intravenous noradrenaline/norepinephrine infusion
Correct Answer(s): E

Justification for correct answer(s): Intravenous noradrenaline/norepinephrine

infusion is the most appropriate next step in management. The patient is
presenting with signs of sepsis and is experiencing hypotension despite
adequate fluid resuscitation. This suggests septic shock, and the most
appropriate next step in management is to initiate vasopressor support, such
as noradrenaline/norepinephrine infusion, to increase systemic vascular
resistance and maintain blood pressure. Haemofiltration may be appropriate if
the patient develops worsening acute kidney injury, but it is not the first-line
management for septic shock. Intravenous gelatin or sodium chloride may
provide additional fluid resuscitation however the central venous pressure of
+12 mmHg suggests adequate fluid replacement and further volume expansion
will not address the underlying hypotension. Intravenous furosemide may
exacerbate the patient’s hypotension and should be avoided.

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 82. A 43 year old man has inoperable cancer of the bowel with hepatic and
peritoneal metastases. He has back pain due to tumour infiltration. The pain
has been controlled with regular codeine phosphate at maximum dosage. He
now has bowel obstruction with vomiting and his pain has recurred because
he cannot take oral medication.

Investigations:Creatinine 85 µmol/L (60–120)

Which is the most effective drug to control his pain?

A. Buprenorphine transcutaneous patch

B. Codeine phosphate intramuscular injection
C. Fentanyl transcutaneous patch
D. Morphine sulfate continuous subcutaneous infusion
E. Tramadol hydrochloride intramuscular injection
Correct Answer(s): D

Justification for correct answer(s): In this case, the most effective drug to control
the patient’s pain would likely be morphine sulfate continuous subcutaneous
infusion. This is because the patient is unable to take oral medication due to
bowel obstruction and vomiting.

The use of an intramuscular injection would be painful to administer and only

provide intermittent analgesia, whereas the patient needs continuous
analgesia.

Buprenorphine transcutaneous patch and fentanyl transcutaneous patch

would not be appropriate as his pain may change due to the progressive bowel
obstruction and therefore not be stable enough for transcutaneous analgesia.

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 83. A full term newborn boy is discharged home 48 hours after birth. The next
day, his 2 year old sibling develops a florid chickenpox rash. His mother has
detectable varicella antibodies. The newborn remains clinically well.

Which is the most appropriate management decision?

A. Admit for observation

B. Check antibody status for varicella antibodies
C. No action is necessary
D. Treat with aciclovir
E. Treat with zoster immune globulin
Correct Answer(s): C

Justification for correct answer(s): The most appropriate management decision is

no action is necessary. The newborn remains clinically well, and the mother
has detectable varicella antibodies, indicating potential passive immunity
transfer to the newborn. The fact that the newborn is clinically well also
supports a conservative approach with no specific treatment or observation
required.

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 84. A 35 year old woman finds a small firm lump on self examination of her
breast.

It is excised and is a firm, well-circumscribed solid mass, 2 cm in diameter.

Histology shows a discrete mass with duct-like structures lined by regular

columnar cells, separated by loose fibrous tissue.

Which is the most likely diagnosis?

A. Carcinoma in situ
B. Ductal carcinoma
C. Fibroadenoma
D. Intraductal papilloma
E. Paget's disease of the breast
Correct Answer(s): C

Justification for correct answer(s): The histological description of duct-like

structures lined by regular, low columnar cells separated by loose fibrous
tissue, with well-defined margins is consistent with a fibroadenoma. These are
the most common benign breast lumps in young women, often presenting as a
solitary, painless, firm, mobile mass. They can be surgically removed if they
are causing discomfort or for cosmetic reasons. Carcinoma in situ and ductal
carcinoma are malignant breast cancer and would have different histological
features. Intraductal papilloma presents as a small, soft, often palpable mass
and can be associated with nipple discharge. Paget’s disease of the breast
presents with nipple and areolar changes, such as erythema, scaling, and
ulceration, and is usually associated with an underlying invasive or in situ
breast carcinoma.

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 85. A 22 year old woman has intense itching and pain in her right ear that has
gradually worsened over several days. She says that her hearing appears to
be affected. She is a surfer.

She has debris in the right ear canal, and the tympanic membrane is not
visible. There is pain on pulling the pinna.

Which is the most likely diagnosis?

A. Cholesteatoma
B. Mastoiditis
C. Otitis externa
D. Otitis media
E. Ruptured tympanic membrane
Correct Answer(s): C

Justification for correct answer(s): Otitis externa is an inflammation or infection of

the external auditory canal and is commonly associated with water exposure,
as in swimmers and surfers. Pulling the pinna, or pressure on the tragus often
exacerbates the pain.

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 86. A 35 year old woman has a painful lump in her breast. Her mother had breast
cancer at the age of 65 years. She is 32 weeks pregnant with no past medical
history. She is not taking any medication. She smokes 5 cigarettes per day.

There is a 2 cm lump in her right breast that is tender on palpation. There is

redness of the overlying skin.

Which is the most appropriate management?

A. Bilateral mammogram
B. No further investigations until after delivery
C. Start oral cefalexin
D. Surgical excision of lump
E. Triple assessment
Correct Answer(s): E

Justification for correct answer(s): Triple assessment is the most appropriate

management for a pregnant woman with a breast lump. This includes clinical
examination, imaging (usually ultrasound), and biopsy. Whilst the most likely
diagnosis is a breast abscess, pregnancy does not preclude the possibility of
breast cancer and should be excluded in this case. It is important to fully
investigate breast lumps in pregnant women promptly to ensure early
diagnosis and treatment if necessary.

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 87. A 35 year old woman is admitted unconscious to the Emergency Department
after being found collapsed outside a pub. There was an empty vodka bottle
lying next to her.

Her pulse is 86 bpm, BP 112/62 mmHg, respiratory rate 12 breaths per

minute and oxygen saturation is 98% breathing air.

Which is the most important immediate investigation?

A. Arterial blood gas

B. Blood alcohol level
C. Capillary blood glucose
D. Urea and electrolytes
E. Urinary drug screen
Correct Answer(s): C

Justification for correct answer(s): Capillary blood glucose is the most important
immediate investigation to exclude hypoglycaemia (particularly in the context
of alcohol) or hyperglycaemia. Although an arterial blood gas may be helpful,
there is no evidence of respiratory compromise, and a venous blood gas may
be appropriate (following a capillary blood glucose) to exclude a metabolic
cause of this collapse. Blood alcohol level is likely to be high based upon the
history and would not be the most important immediate investigation.
Although urea and electrolytes are important investigations to consider, a
capillary blood glucose would be more important to do immediately. A urinary
drug screen may be helpful if the diagnosis is unclear, but this is not the most
important immediate investigation.

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 88. A 28 year old woman has a lobar pneumonia and is treated with intravenous
amoxicillin. A few minutes after she is given the antibiotic therapy, she
develops an itchy skin eruption and increased breathlessness.

Which is the most likely mechanism of this reaction?

A. Antibody binding to cell-bound antigen

B. Complement activation
C. Delayed-type hypersensitivity
D. Immediate hypersensitivity
E. Immune complex hypersensitivity
Correct Answer(s): D

Justification for correct answer(s): This patient is experiencing an anaphylactic

reaction, which is a type of immediate hypersensitivity reaction. It is caused by
the release of histamine and other mediators from mast cells and basophils in
response to an allergen. The symptoms include skin rash, itching, and
shortness of breath. Treatment involves immediate cessation of the offending
agent, administration of epinephrine, and supportive care.

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 89. A 39 year old woman has had worsening tiredness for 2 weeks. She was
previously well.She is mildly jaundiced. Her pulse rate is 96 bpm and
BP 112/76 mmHg.

Investigations:
Haemoglobin 48 g/L (115–150)
White cell count 6.2 × 109/L (4.0–11.0)
Platelets 165 × 109/L (150–400)
Mean cell volume (MCV) 98 fL (80–96)
Alkaline phosphatase 100 IU/L (25–115)
Aspartate aminotransferase (AST) 27 IU/L (10–40)
Bilirubin (total) 41 µmol/L (< 21)
Lactate dehydrogenase 560 IU/L (70–250)
Blood film: red cell polychromasia, occasional spherocytes, no red cell
fragments

Which is the most appropriate diagnostic investigation?

A. Bone marrow aspiration

B. Direct antiglobulin test
C. Serum antinuclear antibody
D. Serum folate
E. Serum vitamin B₁₂

Correct Answer(s): B

Justification for correct answer(s): Based on the provided information, the most
appropriate diagnostic investigation is direct antiglobulin test (coombs test).
The patient has anaemia with raised bilirubin and LDH but otherwise normal
liver function tests. The polychromasia on the film is due to an increase in
reticulocytes and together these laboratory results are consistent with
haemolytic anaemia (evidence of both increased RBC production and
destruction). The recent history suggests an acquired not hereditary cause and
there are spherocytes on the film in keeping with autoimmune haemolytic
anaemia. The diagnosis would be confirmed by a direct antiglobulin test which
tests for immunoglobulin or complement on the surface of red cells. Bone
marrow causes of anaemia, B12 and folate deficiency can also cause anaemia
and raised LDH but the blood film appearances, including increased red cell
production, are not in keeping with this diagnosis. Therefore, bone marrow
aspiration, B12 and folate are not as appropriate next investigations.
Antinuclear antibody is also not a diagnostic investigation for haemolysis.

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 90. A 65 year old woman has two episodes of vaginal bleeding. Her last
menstrual period was 12 years ago.

Abdominal and pelvic examination are normal.

Pelvic ultrasound scan shows an endometrial thickness of 10 mm.

Which is the most appropriate next investigation?

A. CA 125
B. Cervical cytology
C. CT scan of pelvis, abdomen and chest
D. Hysteroscopy and endometrial biopsy
E. MR scan of pelvis
Correct Answer(s): D

Justification for correct answer(s): The most common cause of postmenopausal

bleeding is atrophic vaginitis, however, endometrial cancer must be excluded.
The initial evaluation of women with postmenopausal bleeding is an ultrasound
to measure the endometrial thickness. If the thickness is >4 mm, further
investigation is needed. In this case, since the endometrial thickness is 10 mm,
hysteroscopy and endometrial biopsy are the most appropriate next
investigations to evaluate for endometrial cancer. CA 125 is not specific for
endometrial cancer and can be elevated in other conditions as well. Cervical
cytology is not indicated in postmenopausal bleeding unless cervical cancer is
suspected. CT and MR scans are not the initial investigations for
postmenopausal bleeding.

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 91. A 25 year old man develops a muscle contraction in his neck causing pain
and an involuntary rotation of his neck. He was admitted to the psychiatric unit
24 hours ago with persecutory delusions, agitation, and auditory
hallucinations.

He has been given risperidone since admission.

Which side effect is he experiencing?

A. Akathisia
B. Autonomic instability
C. Dystonia
D. Parkinsonism
E. Tardive dyskinesia
Correct Answer(s): C

Justification for correct answer(s): The patient is exhibiting symptoms of acute

dystonia, which is a side effect of antipsychotic medication such as
risperidone. It is characterised by muscle spasms and contractions, often in
the neck and facial muscles. Treatment includes anticholinergic medication
such as benztropine or diphenhydramine.

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 92. An 18 year old woman with sickle cell disease attends the Emergency
Department with severe pain in her left leg. She rates her pain score as 8/10.

Her temperature is 36.9°C, pulse rate 110 bpm, BP 120/80 mmHg, respiratory
rate 16 breaths per minute and oxygen saturation 96% breathing air.

Investigations:
White cell count 7.1 x 109/L (4.0–11.0)
Haemoglobin 71 g/L (115–150)
Platelets 190 × 109/L (150–400)

Which is the next management step?

A. Intravenous co-amoxiclav
B. Oral prednisolone
C. Red cell transfusion
D. Subcutaneous morphine
E. Treatment dose dalteparin
Correct Answer(s): D

Justification for correct answer(s): This patient has sickle cell disease and is
presenting with severe pain crisis. Treatment of an acute painful sickle cell
crisis needs to be considered an acute medical emergency. Pain must be
assessed immediately and treated with an acute bolus of a strong opioid such
as morphine. The patient is afebrile with a normal white cell count and thus no
evidence of infection, and hence antibiotics such as co-amoxiclav are not
indicated at this stage. Oral prednisolone may be used to treat acute chest
syndrome, but is not the first-line treatment for pain crisis. There is no
immediate urgency for red cell transfusion in an acute pain crisis although it
can be considered at a later stage. Treatment dose dalteparin is indicated in
patients with sickle cell disease who have a high risk of thromboembolism, but
it is not indicated for this patient’s current presentation.

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 93. A 79 year old woman has had malaise and pain in the arms and legs for 4
weeks, with morning stiffness that lasts for 3 hours each day. She
has difficulty washing and dressing.

She cannot lift her arms above her head due to pain, but there is no objective
muscle weakness. She has Heberden's nodes in her hands.

Investigations:
Haemoglobin 112 g/L (115–150)
White cell count 9.8 × 109/L (4.0–11.0)
Platelets 365 × 109/L (150–400)Mean cell volume (MCV) 89 fL (80–96)
CRP 67 mg/L (<5)

Which is the most likely diagnosis?

A. Osteoarthritis
B. Osteomalacia
C. Polymyalgia rheumatica
D. Polymyositis
E. Rheumatoid arthritis
Correct Answer(s): C

Justification for correct answer(s): The most likely diagnosis is Polymyalgia

rheumatica. This is based on the patient’s age, symptoms of malaise and pain
in the arms and legs, morning stiffness lasting for 3 hours each day, difficulty
washing and dressing, inability to lift her arms above her head, and elevated
CRP. Heberden’s nodes are not a feature of polymyalgia rheumatica but are
seen in osteoarthritis. Rheumatoid arthritis would present with joint
inflammation. Osteomalacia is a metabolic bone disease, which is unlikely to
cause these symptoms. Polymyositis would be associated with muscle
weakness, which is not present in this case.

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 94. A 30 year old woman becomes acutely short of breath. She was admitted to
hospital 3 hours ago with an acute exacerbation of asthma.

She improved following treatment with oxygen, nebulised salbutamol and oral
prednisolone. Her chest X-ray on admission was clear.

Her pulse rate is 122 bpm, BP 88/50 mmHg, respiratory rate 30 breaths per
minute and oxygen saturation 88% breathing 40% oxygen via a face mask.
She has reduced expansion of the upper left chest. She has mild wheeze
throughout the chest with reduced breath sounds over the left apex.

Which is the most likely explanation for her deterioration?

A. Anaphylaxis
B. Increasing severity of asthma
C. Lobar collapse
D. Pneumothorax
E. Pulmonary embolus
Correct Answer(s): D

Justification for correct answer(s): Based on the given information, the most likely
explanation for her deterioration would be the development of a pneumothorax
following admission based on the acute nature of her symptoms, reduced
breath sounds on examination and association with her history of asthma; The
reduced expansion of the upper left chest and reduced breath sounds over the
left apex could suggest a possible collapse of the left upper lobe of the lung
however one would expect to see changes on the chest X-ray. Anaphylaxis,
increasing severity of asthma, and pulmonary embolus can all cause
respiratory distress, but do not explain the physical examination findings.

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 95. A 40 year old man had a laparotomy for intestinal obstruction 12 hours ago.
He has an epidural for analgesia and has been given a 500 mL intravenous
crystalloid bolus. He has no pain. He has no pre-existing medical problems.

His pulse rate is 120 bpm and BP 80/62 mmHg. He has passed 10 mL of
urine in the past 4 hours. He shows no sign of heart failure.

Which is the most appropriate first line of management?

A. IV diuretic
B. IV fluid bolus
C. IV vasoconstrictor
D. Place bed head down
E. Stop epidural analgesia
Correct Answer(s): B

Justification for correct answer(s): The most appropriate first line of management
for this patient would be IV fluid bolus. The patient has signs of hypovolemia,
including tachycardia, hypotension, and oliguria. The 500 mL intravenous
crystalloid bolus he received may not have been sufficient to address his
ongoing fluid losses following the laparotomy. Therefore, another fluid bolus is
indicated to improve his perfusion and restore his blood pressure.
IV diuretic would not be appropriate as the patient is hypovolemic, and
administering a diuretic would exacerbate his intravascular volume depletion.
IV vasoconstrictor could be considered if the patient's hypotension persists
despite adequate fluid resuscitation, but it is not the first-line treatment.
Placing the bed head down may help with improving venous return and
increasing blood pressure, but it would not be the first-line management in this
case, especially since the patient is oliguric and if prolonged could risk
cephalad spread of epidural solution. Stopping epidural analgesia may be
considered if there is a concern for epidural-induced hypotension, but it is not
the most appropriate first-line management in this situation.
Reference: Faculty of Pain Management Best Practice in the Management of
Epidural Analgesia in the Hospital Setting available at
https://fpm.ac.uk/sites/fpm/files/documents/2020-09/Epidural-AUG-2020-
FINAL.pdf

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 96. A 23 year old man has had joint pains for the last 6 months. He thinks he may
have contracted hepatitis B following unprotected sex 6 months ago and is
unsure of his hepatitis B vaccination status.

Investigations:
HBsAg –ve
anti-HBc IgG +ve
anti-HBs IgG +ve

Which is the best description of his hepatitis B status?

A. Acute infection
B. Chronic infection
C. Immune due to naturally resolved infection
D. Immune due to previous vaccination for hepatitis B
E. Not infected but susceptible to further infection
Correct Answer(s): C

Justification for correct answer(s): Based on the given information, the best
description of his hepatitis B status would be immune due to naturally
resolved infection. The negative HBsAg and positive anti-HBc IgG and anti-HBs
IgG results suggest that the patient has been exposed to hepatitis B virus in
the past but has cleared the infection, leading to the development of immunity
against the virus. The presence of anti-HBs IgG indicates that the patient has
developed protective antibodies against the virus, likely through natural
infection or previous vaccination.

Acute infection would be characterised by the presence of HBsAg, which is not

present in this case. Chronic infection would be characterised by the presence
of HBsAg for at least six months, which is not the case here. Immunity due to
previous vaccination for hepatitis B could also be a possibility, but the patient
is unsure of his vaccination status, and the presence of anti-HBc IgG suggests
that he may have had a natural infection. Not infected but susceptible to further
infection would be characterised by negative results for all hepatitis B markers,
which is not the case here.

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 97. A 65 year old woman has had headaches for 3 months. She was treated for
cancer of the right breast 12 years ago. There is no evidence of local or
regional recurrence.

Examination of the central nervous system is normal.

CT scan of brain shows an isolated metastasis with cerebral oedema.

Which is the most appropriate immediate treatment?

A. Anastrozole
B. Chemotherapy
C. Dexamethasone
D. Radiotherapy
E. Surgical decompression
Correct Answer(s): C

Justification for correct answer(s): The most appropriate immediate treatment for
this patient would be Dexamethasone. The patient has an isolated metastasis
in the brain with cerebral oedema, which can cause significant symptoms and
can be life-threatening if left untreated. Dexamethasone is a corticosteroid that
can help to reduce cerebral oedema and alleviate symptoms such as
headaches. It is commonly used as an initial treatment for brain metastases.
Anastrozole is a hormonal therapy used for the treatment of breast cancer but
would not be the appropriate treatment for this patient's current symptoms.
Chemotherapy may be used for the treatment of metastatic breast cancer, but
it would not be the most appropriate immediate treatment for this patient's
presentation. Most chemotherapy drugs do not cross the blood brain barrier.
Radiotherapy and surgical decompression are also treatment options for brain
metastases, but they would not be the most appropriate immediate treatment
for this patient. Radiotherapy (including stereotactic radiotherapy) and surgical
intervention may be considered following complete radiological staging to
define extent of metastatic disease and discussion at neuro-oncology MDM.
These options are considered following control of initial symptoms with
dexamethasone.

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 98. A 45 year old man has had two hours of colicky left sided abdominal pain
radiating to his groin. The pain started abruptly and is associated with nausea
and vomiting.

He is restless and writhing in pain. There is tenderness on palpation of the left

costovertebral angle. Abdominal examination is normal. Bowel sounds are
present but scanty.

His urinalysis shows blood 3+ and no other abnormalities.

Which is the most appropriate initial analgesic agent?

A. Aspirin
B. Diclofenac
C. Oxycodone
D. Paracetamol
E. Tramadol
Correct Answer(s): B

Justification for correct answer(s): The patient is presenting with symptoms

consistent with renal colic, which is typically associated with severe, colicky
pain that can radiate to the groin, nausea, and vomiting. The tenderness on
palpation of the left costovertebral angle and the presence of blood in the urine
(indicated by 3+ on urinalysis) suggest that the patient has a kidney stone
causing the obstruction and pain. The most appropriate initial analgesic agent
for this patient would be a nonsteroidal anti-inflammatory drug such as
diclofenac. Tramadol and oxycodone are opioid analgesics that are effective
for the treatment of moderate to severe pain, including renal colic, however,
are not first line and should be used only if NSAIDs are contraindicated and
following treatment with intravenous paracetamol. Aspirin is rarely used for its
analgesic effects in renal colic. Paracetamol is an analgesic that can be used
for mild to moderate pain but is second line (if given in intravenous form) to
NSAIDs.

© Medical Schools Council 2024 – reviewed August 2024

Page 100 of 102
 99. A 70 year old man has had 1 day of cough and breathlessness. He has
COPD and heart failure. His normal exercise tolerance is 100 m. He has had
no previous hospital admissions. He has a 35 pack-year smoking history. He
is taking lisinopril and uses a tiotropium inhaler.

He is cyanosed and dyspnoeic. His pulse rate is 100 bpm, BP 105/78 mmHg,
respiratory rate 30 breaths per minute and oxygen saturation 84% breathing
28% oxygen. He has scattered wheeze and crackles bilaterally. He has been
given nebulised salbutamol.

Investigations:
Arterial blood gas on 28% oxygen
pH 7.25 (7.35-7.45)
PO2 6.9 kPa (11-15)
PCO2 7.8 kPa (4.6-6.4)
Bicarbonate 34 mmol/L (22-30)

Which is the most appropriate next step in management?

A. Increase oxygen to 40% via a Venturi mask

B. Intravenous amoxicillin
C. Intravenous furosemide
D. Non-invasive ventilation
E. Reduce oxygen to 2 L/min via a nasal cannula
Correct Answer(s): D

Justification for correct answer(s): The patient is experiencing an acute

exacerbation of COPD and is in respiratory failure with a low oxygen level and
high CO2 level (type II respiratory failure). The most appropriate next step in
management would be to provide non-invasive ventilation (NIV) to help
improve his gas exchange and reduce his work of breathing. NIV can be
provided through a mask and helps to provide positive pressure to the
airways, reducing the effort required by the patient to breathe. This can
improve oxygenation, reduce CO2 retention, and reduce the need for invasive
ventilation. Increasing the oxygen concentration alone is unlikely to improve
the patient’s condition and could potentially worsen his hypercapnia.
Antibiotics and diuretics may be indicated in some cases, but the priority in
this scenario is to improve the patient’s respiratory status with NIV.

© Medical Schools Council 2024 – reviewed August 2024

Page 101 of 102
 100. A 2 day old boy undergoes his routine neonatal hearing screen. His mother
has been deaf since early childhood and has bilateral hearing aids. She asks
whether her baby will be deaf.

Which is the most appropriate additional assessment?

A. Brainstem evoked response test

B. Cytomegalovirus serology
C. Distraction testing
D. MR scan of brain
E. Weber's test
Correct Answer(s): A

Justification for correct answer(s): Brainstem evoked response test would be the
most appropriate additional assessment in this case. This test measures the
electrical activity in the auditory pathway in response to sound and can detect
hearing loss even in newborn infants. It is a reliable and objective way of
assessing the function of the auditory system and can identify hearing loss at
an early stage, which is important for early intervention and treatment.

© Medical Schools Council 2024 – reviewed August 2024

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