MCQ Medicine 3
"A 22-year-old man who suffers from inflammatory bowel disease has developed pain and stiffness in his lower back over the past 6 months. Examination reveals tenderness over both sacroiliac joints. He tests positive for the HLA-B27 gene. What is the most probable diagnosis? A.Prolapsed intervertebral disc B. Rheumatoid arthritis C. Ankylosing spondylitis D. Osteoarthritis E. Enteropathic arthritis"
C
"A 25-year-old man develops cirrhosis of the liver and is referred from the gastroenterology clinic to the ophthalmology clinic for evidence of Wilson's disease. What should the gastroenterologist ask the ophthalmologist to look for? A. Corneal arcus B. Hudson-Stahli lines C. Kayser-Fleischer rings D. Cornea verticillata E. Band keratopathy"
C
"A 25-year-old woman presents with loss of weight, gritty eyes and double vision on looking up. Which of the following is the most important investigation? A. CT brain B. Exophthalmometry C. Formal perimetry D. Hess chart E. Schirmer's test"
C
"A 26-year-old man with aortic regurgitation is referred from cardiology to the eye clinic to look for features of Marfan's syndrome. Which of the following ocular features suggests the diagnosis? A. High hyperopia B. Band keratopathy C. Dislocated lenses D. Raised intraocular pressure E. retinitis pigmentosa"
C
"A 22-year-old woman presents with red scaly plaques on her elbows, knees, lower back and scalp. She also has pitting and yellow-brown discoloration of her nails and painful deformed finger and toe joints. Given the likely clinical diagnosis, what would be the most appropriate treatment, taking current UK guidelines into account? A. NSAIDs B. Sulfasalazine C. methotrexate D. Corticosteroids E. Etanercept"
C
"A 65-year-old woman who lives alone complains of increasing pain in her left knee and episodes of the joint 'giving way'. She is no longer able to climb stairs. Valgus deformity with instability is also noted. What treatment would be most appropriate for her? A. Oral NSAIDs B. Intra-articular steroid injections C. Joint replacement D. Physiotherapy E. Hormone replacement therapy"
C
"A 67-year-old patient with lung cancer complains of a cough and has difficulty breathing. He has swelling of his face, neck, upper body and arms. What is the most likely diagnosis? A. Side-effects from radiotherapy B. Allergic reaction C. Superior vena cava syndrome D. Side-effect from chemotherapy E. Acute myocardial infarction"
C
"A 20-year-old college student complains of increasing back pain and early morning stiffness. An X-ray of his lower back shows erosion of the apophyseal joints and obliteration of the sacroiliac junction. Given the most likely clinical diagnosis from these findings, what treatment would be most suitable for him? A. Oral NSAIDs B. Colchicine C. Intra-articular steroid injections D. Spinal osteotomy E. bedrest and immobilisation"
A
"A 26-year-old man presents with fever, headache and a non-productive cough. The chest X-ray shows increased interstitial markings. The laboratory examination shows an elevated LDH and anaemia with the presence of cold agglutinins. What is the most appropriate treatment? A. Erythromycin B. Piperacillin C. Clindamycin D. Ampicillin E. Imipenem"
A
"A 26-year-old man presents with sudden-onset headache and double vision. The A&E doctor diagnoses IIIrd (oculomotor) nerve palsy. Which of the following is the most likely cause? A. Posterior communicating artery aneurysm B. Acoustic neuroma C. Diabetes mellitus D. Extradural haematoma E. Ophthalmoplegic migraine"
A
"A 28-year-old man presents to the clinic with painful knees and ankles. He is noted to have a rash on the glans penis. He has a history of urethritis due to Chlamydia trachomatis . He has also recently attended the ophthalmology department for an episode of uveitis. What is the most likely diagnosis? A. reiter's syndrome B. reactive arthritis C. Gouty arthritis D. septic arthritis E. Rheumatoid arthritis"
A
"A 45-year-old man presents with fever, malaise, weight loss and myalgia over the past month. You suspect polyarteritis nodosa and arrange to perform some blood tests. Which abnormality might you most expect to find? A. Elevated creatinine B. Anaemia C. leucopenia D. Thrombocytosis E. Positive ANCA"
A
"A 55-year-old woman on procainamide develops drug-induced lupus erythematosus. What is the most characteristic clinical feature of this condition? A. It may occur with chlorpromazine B. It commonly involves the kidneys C. It rarely causes pulmonary disease D. The symptoms may be alleviated with long-term steroids E. It does not occur with isoniazid"
A
"A 57-year-old man with longstanding osteoarthritis of his right hip is seen in the clinic prior to admission for hip replacement. He has a history of peptic ulcer and is on lansoprazole. Which anticoagulant formulation would offer him the best protection against postoperative thrombosis? A. Subcutaneous low molecular weight heparin B. Subcutaneous unfractionated heparin C. Warfarin D. Intravenous heparin E. Low-dose aspirin"
A
"A 58-year-old memorial stonemason presents to the chest clinic. Over the past few years he has noted a gradual increase in shortness of breath, with cough and occasional wheeze. He is a non-smoker and has no other past history of note. His chest X-ray is abnormal with small rounded opacities and irregular upper zone fibrosis. There is hilar lymphadenopathy with 'eggshell' calcification. Pulmonary function testing reveals a restrictive picture and there is mild hypoxia. Which diagnosis best fits with this clinical picture? A. Silicosis B. Asthma C. Idiopathic pulmonary fibrosis D. Tuberculosis E. Byssinosis"
A
"A 62-year-old woman presents with severe pain and stiffness in her shoulder muscles and pelvis for the past 3 weeks that is worse in the mornings. Her ESR is raised. What is the most likely diagnosis? A. Polymyalgia rheumatica B. Polymyositis C. Pseudogout D. Psoriatic arthritis E. Rheumatoid arthritis"
A
"A 64-year-old mechanic and lifelong smoker noticed haemoptysis a few days after he had a cold. Clinical examination is unremarkable. His chest X-ray shows bilateral hilar enlargement and mediastinal widening. What is the next step in obtaining the diagnosis? A. CT thorax B. Bronchoscopy C. ventilation-perfusion scan D. Sputum sample E. D-Dimer"
A
"A 65-year-old woman presents with severe pain and stiffness of her shoulders and neck that is worse in the mornings and lasts for more than an hour. Physical examination is unremarkable. blood tests show a mild normocytic normochromic anaemia. Her ESR is 77 mm/1st hour. What is the most likely diagnosis? A. Polymyalgia rheumatica B. Polymyositis C. Hypocalcaemia D. Painful arc syndrome E. Frozen shoulder"
A
"A 69-year-old former coal-miner is referred to you by the on-call team. There is a smoking history and he has been managed by his GP for COPD. He has been admitted with dyspnoea that is now so bad that he is unable to manage at home and cannot walk from the chair to the bathroom. There is a cough productive of black sputum. Lung function tests show a mixed restrictive and obstructive picture. A chest X-ray shows marked changes with massive fibrotic masses predominantly in the upper lobes. There are also changes consistent with lung destruction and emphysema. His rheumatoid factor is positive. Which diagnosis fits best with this clinical picture? A. Progressive Massive Fibrosis (PMF) B. Chronic obstructive pulmonary disease C. Tuberculosis D. Asthma E. Category 1 pneumoconiosis"
A
"A 72-year-old man with heart disease is on diuretics. He complains of stiff, painful hands and knees. On examination Heberden's nodes are seen. What is the most appropriate treatment? A. regular paracetamol B. Allopurinol C. Oral NSAIDs with gastric protection D. knee replacement E. Joint aspiration and microscopy"
A
"A patient with controlled ocular myasthenia gravis develops an acute infection. Which of the following antibiotics is contraindicated? A. Aminoglycosides B. metronidazole C. Macrolides D. Quinolones E. Penicillins"
A
"A patient with small-cell lung cancer has a serum sodium concentration of 121 mmol/l. The patient is asymptomatic. What is the most appropriate therapy? A. Fluid restriction B. Glucocorticoids C. Start chemotherapy D. Start radiotherapy E. Hypertonic fluid infusion"
A
"During a routine insurance medical examination, a GP notices that a 30-year-old female patient has absent ankle jerks and unequal pupils. Which of the following is the most likely diagnosis? A. Holmes-Adie syndrome B. Horner's syndrome C. Third nerve palsy D. mescaline ingestion E. Argyle Robertson pupils"
A
"A 45-year-old woman is found by her optometrist to have band keratopathy and is referred to the eye clinic. Which of the following investigations is likely to be helpful in determining an underlying cause? A. Cholesterol B. Ferritin C. U&E D. Gamma GT E. serum calcium"
E
"A 10-year-old girl presents with a high fever, rash and hip and knee joint pains. A slit-lamp examination of her eyes is normal. blood tests are negative for autoantibodies. What is the most likely diagnosis? A. Persistent oligoarthritis B. Still's disease C. Polyarticular arthritis D. Enthesitis-related arthritis E. Henoch-Schönlein purpura"
B
"A 16-year-old girl presents to A&E with a severe asthma attack. What is the most important therapy to relieve her bronchoconstriction? A. Propranolol B. Salbutamol C. Oxygen D. Glucocorticosteroids E. Cromoglycate"
B
"A 19-year-old student presents with a complaint of visual loss. Which of the following suggests a conversion reaction? A. The pupils are unequal in size B. There is a spiralling visual field loss C. Optokinetic nystagmus (OKN) cannot be elicited D. The discs show temporal pallor E. The patient does not react to confrontation"
B
"A 20-year-old man presents with a raised red and scaly lesion on his glans penis, red discolouration and pain in both eyes and pain and swelling of his right knee. Over the past few days he has noticed painless red plaques on his hands and feet. A diagnosis of reiter's syndrome is suspected. Which additional clinical feature would best support this diagnosis? A. History of a flu-like illness 4-6 weeks prior to symptoms B. Presence of keratoderma blenorrhagica C. Family history of ulcerative colitis D. Positive gonococcal culture of urethral discharge E. Arthritis affecting the upper limb joints"
B
"A 22-year-old man with ulcerative colitis and chronic lower back pain complains of a red painful eye. Which one of the following is likely to be present on examination? A. Purulent discharge B. Photophobia on ophthalmoscopy C. A dilated pupil D. Profound visual loss E. retinal haemorrhages"
B
"A 25-year-old mechanic complains of stiffness and low back pain that is worse in the mornings. He is HLA-B27-positive. A provisional diagnosis of ankylosing spondylitis is made. What would be the most characteristic finding on an X-ray of the lower spine? A. Narrowing of disc space B. Erosion of the apophyseal joints C. Osteophyte formation D. Spondylolisthesis E. Osteoporosis of trabecular bone"
B
"A 33-year-old HIV-positive man presents for review. He is poorly compliant with antiretroviral therapy and his recent CD4 count is only 90/ml blood. He complains of a gradual-onset headache, fever, malaise, night sweats and a cough associated with haemoptysis. He is emaciated. On examination there is widespread lymphadenopathy, there are crackles and wheeze on auscultation of his chest, and tenderness over the liver edge. blood testing reveals a normochromic normocytic anaemia, he has a low white count, urea and creatinine levels are raised and liver function tests are abnormal. Sputum samples reveal acidand alcohol-fast bacilli (AFB). Chest X-ray reveals calcified lymph nodes, cavitation and areas of lung fibrosis and hilar retraction. Which diagnosis fits best with this clinical picture? A. Primary pulmonary tuberculosis B. Miliary tuberculosis C. Bacterial pneumonia D. Pulmonary fibrosis E. Bronchial carcinoma"
B
"A 33-year-old man is found to have strongly positive aspergillus precipitins in his blood and complains of a cough with intermittent bloody sputum. He has a business working as a builder, particularly involved in renovating farm houses and barns. What is the most likely diagnosis? A. Allergic bronchopulmonary aspergillosis (ABPA) B. Colonising aspergillosis C. Invasive aspergillosis D. Asperger's syndrome E. Type I hypersensitivity to Aspergillus fumigatus"
B
"A 35-year-old man presents with abdominal pain, joint pains, fever and weight loss. He gives a history of passing bulky, malodorous stools over the past month that are difficult to flush away. A biopsy of the small bowel shows stunted villi with PAS (Periodic acid-Schiff)-positive macrophages. What is a characteristic finding in this condition? A. Occult blood in stools B. The presence of bacilli within macrophages on electron microscopy C. mesenteric thickening with lymph node enlargement on CT scan D. Positive HLA-B27 E. Bony erosions and subluxation of joints on X-ray of affected joints"
B
"A 45-year-old woman with rheumatoid arthritis presents with leg ulcers and swollen neck glands. A diagnosis of Felty's syndrome is made. Which typical finding on blood testing would you expect to find in her case? A. Positive Coombs' test B. Normocytic normochromic anaemia C. Lymphocytosis D. reticulocytosis E. High platelet count"
B
"A 46-year-old woman with a history of duodenal ulcer has developed progressively worsening pain, swelling and stiffness of her metacarpophalangeal, distal interphalangeal and wrist joints. On examination there is wasting of the muscles of the hand and limited movement of thejoints. Given the most likely diagnosis, which drug would be most appropriate for her condition? A. Prednisolone B. Sulfasalazine C. Ibuprofen D. Aspirin E. diclofenac"
B
"A 47-year-old woman presents with an inability to raise her arms over her shoulders. Over the past few weeks she has also been having difficulty swallowing food. On examination there is muscle wasting and the muscles are tender with reduced tendon reflexes. Her serum creatine kinase is elevated. What is the most likely diagnosis? A. Polymyalgia rheumatica B. Polymyositis C. Hypocalcaemia D. Painful arc syndrome E. Frozen shoulder"
B
"A 5-year-old Asian boy, who has been having episodes of fever and a persistent cough for the past 3 weeks, now complains of right hip pain. blood tests show: WCC 19 x 109 /l, ESR 110 mm/1st h and CRP 102 mg/l. An X-ray of the hip joint shows diffuse rarefaction. What is the most likely diagnosis? A. septic arthritis B. Tuberculous arthritis C. Osteomyelitis D. reactive arthritis E. Juvenile rheumatoid arthritis"
B
"A 50-year-old diabetic woman with a history of osteoarthritis of her knees suddenly develops pain and swelling in her right knee. On examination the knee is red, hot, swollen and very tender. Which investigation would be most helpful in the management of this case? A. Plain X-ray of the knee B. Joint aspiration and Gram-staining C. Joint fluid microscopy D. blood culture E. Joint aspiration and culture"
B
"A 56-year-old man has a chest X-ray performed as he has become breathless on exertion and has inspiratory crackles. The chest X-ray reveals upper lobe lung fibrosis. Which of the following is the most likely explanation? A. Cryptogenic fibrosing alveolitis B. Langerhans' cell histiocytosis C. Asbestosis D. Connective tissue fibrosing alveolitis E. drug-induced pulmonary fibrosis"
B
"A 65-year-old woman being treated for epilepsy presents with bone pain and muscle weakness. blood tests show increased serum alkaline phosphatase, normal plasma calcium and low serum phosphate levels. An X-ray of the femur reveals linear areas of low density surrounded by sclerotic borders. What is the most likely diagnosis? A. Osteoporosis B . Osteomalacia C. Paget's disease D. Osteosarcoma E. Polymyalgia rheumatica"
B
"A 68-year-old man presents to his GP with a one-week history of blurred vision affecting his left eye. On examination, his visual acuities are 6/6 right eye and 6/18 left eye. No papillary defect is noted. Dilated fundal examination reveals evidence of widespread retinal haemorrhages in all quadrants of the left retina associated with dilated tortuous retinal veins. The right fundus appears entirely normal. The patient has not seen his GP within the last ten years. He describes himself as fit and well and on no regular medication. However, a subsequent examination reveals a blood pressure of 185/100 and a random blood sugar of 12 mmol/L. Which of the following is the most likely ocular diagnosis? A. Branch retinal vein occlusion B. Central retinal vein occlusion C. Hypertensive retinopathy D. Diabetic retinopathy E. Ocular ischaemic syndrome"
B
"A 70-year-old woman presents with a sudden loss of vision in one eye. Which of the following clinical findings suggests a diagnosis of giant-cell arteritis? A. Central retinal artery occlusion (CRAO) B. Pale disc swelling C. Isolated central scotoma D. Abnormal consensual light response E. Raised intraocular pressure (IOP)"
B
"A 73-year-old woman complains of dry, gritty eyes, a constant sensation of mouth dryness and swollen parotid glands. You suspect that she has Sjögren's syndrome. Which of the following tests is not likely to help in establishing the diagnosis? A. serum antibody to Ro antigen B. Lymph node biopsy C. Schirmer's test D. Labial biopsy E. Magnetic resonance imaging of the parotid gland"
B
"A 79-year-old woman who drinks 30 units of alcohol per week presents with a red, hot swollen ankle. Which investigation may yield a definitive diagnosis? A. blood culture B. Joint aspiration and microscopy C. Joint aspiration and culture D. X-ray of the ankle E. serum uric acid levels"
B
"A morbidly obese 36 year-old man presents for review. His main reason for attendance is that his wife is concerned about his loud snoring and the fact that he stops breathing during the night for periods of up to 8-10 seconds, followed by coughing, snoring and arousal. recently he has become hypertensiveand is also on treatment for impotence. His 24-h urinary free cortisol level is normal. Which diagnosis best fits this picture? A. Cushing's disease B. Obstructive sleep apnoea C. Simple snoring D. Simple obesity E. Essential hypertension"
B
"A patient with diabetic retinopathy is treated with panretinal photocoagulation in the eye clinic and followed up in the diabetic clinic. Which of the following features found 6 months after treatment is an indication for further laser treatment? A. Visual field constriction B. Vitreous haemorrhage C. retinal burns D. Optic atrophy E. Tractional retinal detachment"
B
"A teenager is referred from his optician with a diagnosis of Lisch nodules of the iris. What is the most likely sign to observe on examination? A. Ash-leaf spots on the trunk B. Axillary freckles C. Ectopia lentis D. Haemangioblastoma of the spinal cord E. Haemorrhagic telangiectasia of the skin and buccal mucosa"
B
"An 80-year-old man is referred to the psychogeriatrician with features of dementia. The neurology SpR is called because the SHO has noted an abnormality of eye movements. The patient is not on any medication. The SpR confirms that the eye movements are limited in upward gaze on pursuit movements, but that the eyes move upwards normally when he flexes the patient's neck. Which of the following conclusions is valid? A. The patient has an abnormal vestibulo-ocular response B. The patient has a supranuclear gaze palsy C. The patient has tardive dyskinesia D. The patient has an oculogyric crisis E. The patient has Korsakoff's syndrome"
B
"A 12-year-old girl complains of pain in her hip and knee joints, as well as fever, bloody diarrhoea and abdominal pain. A barium enema shows rose-thorn ulcers. What is the most characteristic feature seen on colonoscopy in this condition? A. red-raw mucosa B. Pseudopolyps C. Discrete ulcers D. Colonic dilatation E. diverticula"
C
"A 16-year-old boy is brought to casualty after a fire in his parents' house. He inhaled a lot of smoke and has a hoarse voice, stridor and burned nasal hairs. Due to deterioration in his peak flow rate and arterial blood gases, he has been intubated, ventilated and transferred to the intensive care unit where his condition is now stable. In terms of investigation, what is the most important next step in assessing this boy's condition? A. CT thorax B. Chest X-ray C. Bronchoscopy D. ventilation-perfusion scan E. Echocardiography"
C
"A 27-year-old woman is referred to the rheumatology clinic by her gynaecologist with a history of swelling and pain in her right big toe and left knee. The only positive finding on gynaecological examination was the presence of cervicitis. An endocervical swab tested positive for chlamydial infection. What is the most probable diagnosis in this case? A. Acute gouty arthritis B. Rheumatoid arthritis C. reactive arthritis D. septic arthritis E. Gonococcal arthritis"
C
"A 29-year-old office secretary has been suffering from intermittent pain and tenderness affecting her elbows, wrist and ankles for last 2 years. Symptomatic relief had being obtained from NSAIDs. For last 3 months she has been increasingly unwell, and with night sweats, fever and a weight loss of about 6. 4 kg (14 lbs). She also developed a non-productive cough and left-sided pleuritic chest pain. She smoked 30 cigarettes per day. On examination she had temperature of 37. 8°C. The syno vium was palpable over her wrist joints. On respiratory examination her left lower zone was dull to percussion with decreased breath sounds. A chest X-ray confirmed a left-sided pleural effusion in addition to some fibrotic patches on both the upper zones. Aspiration showed a straw-coloured fluid with a protein concentration of 46 g/l and a glucose concentration of 1. 6 mmol/l. The fluid contained many lymphocytes but no malignant cells. A culture was sterile on the fifth day. What is the probable cause of the pleural effusion? A. Sarcoidosis B. Rheumatoid pleural effusion C. Tuberculosis D. Pleural effusion secondary to lung malignancy E. Lymphoma"
C
"A 30-year-old woman presents with shortness of breath. This began gradually, around 2. 5 years ago, but now she is breathless on climbing a flight of stairs. There is no past history of note. On examination the JVP is raised, carotid pulse volume is reduced and there is evidence of right ventricular hypertrophy. There are right-sided murmurs on cardiac auscultation. Her chest X-ray shows pulmonary artery enlargement, ECG shows right axis deviation and right ventricular hypertrophy. Arterial blood gases reveal hypoxia and hypercapnia, a lung perfusion scan is normal. Cardiac catheterisation reveals that right-sided pressures are markedly raised. Which diagnosis best fits with this clinical picture? A. Chronic thromboembolic disease B. Right ventricular failure C. Primary pulmonary hypertension (PPH) D. Cryptogenic fibrosing alveolitis E. Asthma"
C
"A 36-year-old lorry driver who smokes heavily presents with a 2-day history of coughassociated with fever. He also complains of right-sided chest pain on inspiration. On examination he is slightly cyanosed. His temperature is 38°C, respiratory rate 38/min, BP 100/70 mmHg and pulse 130/min. He has basal crepitations and dullness to percussion at the right lung base. What is the most important next step in confirming the diagnosis? A. ESR (Erythrocyte sedimentation rate) B. D-Dimer C. Chest X-ray D. Sputum sample E. blood cultures"
C
"A 37-year-old gym instructor gives a 2-year history of numbness and burning of his fingers precipitated by cold. He now feels tightness in the fingers and is unable to extend his fingers completely. He also complains of a progressive difficulty in swallowing food. You suspect limited cutaneous scleroderma. Which of the following blood investigations would most aid in the diagnosis? A. Normocytic normochromic anaemia B. Microangiopathic haemolytic anaemia C. Anticentromere antibodies D. Antinuclear antibodies E. Rheumatoid factor"
C
"A 37-year-old man who speaks little English comes to the TB clinic. His notes are missing but he is able to tell you that he has been on treatment for almost 1 year. What is the most likely reason he has been treated for this length of time? A. Pulmonary TB B. Lymph-node TB C. TB meningitis D. Bony TB E. Pleural TB"
C
"A 4-year-old girl with a 1-day history of increasing hip pain is unable to stand. Her WCC is 20 x 109 /l, ESR 90 mm/1st h and CRP 275 mg/l. A radiograph of the hip shows a widened joint space. What is the most likely diagnosis? A. Perthe's disease B. Slipped upper femoral epiphysis C. septic arthritis D. Congenital dislocation of hip E. Osteomyelitis"
C
"A 42-year-old cotton worker from Southern India is staying with her brother in London . While here, they pay for a private medical consultation. She reports what sounds like a work-related illness. During the first hour at work after the weekend she reports severe shortness of breath, cough and chest tightness, this appears to gradually ease during the week, only to return after the next weekend off. Which diagnosis best fits this clinical picture? A. Occupational asthma B. Chronic obstructive pulmonary disease C. Byssinosis D. berylliosis E. Functional shortness of breath"
C
"A 50-year-old woman patient presents with increasing dyspnoea. She is obese, smokes and takes oestrogens for menopausal symptoms. On examination you find clinical, electrocardial and radiological findings of aright-sided heart failure without signs of left ventricular failure. What is the most likely cause for the cor pulmonale? A. Asthma B. recurrent pneumonias C. recurrent small pulmonary embolisms D. Bronchiectasis E. Carcinoma of the lung"
C
"A 55-year-old man presents with bowed legs, low back pain and increasing deafness over the past 6 months. His father was similarly affected at 60 years of age and died of bone cancer. Given the likely clinical diagnosis, what would be the most characteristic finding in a blood test? A. Decreased serum calcium levels B. Elevated serum phosphate C. Elevated serum alkaline phosphatase D. Elevated ESR E. decreased 1,25-dihydroxycholecalciferol"
C
"A 60-year-old diabetic complains of floaters of 24 hours' duration, followed by a sudden painless loss of vision in his right eye. His corrected visual acuities are 6/60 (right eye) and 6/12 (left eye). His right retina cannot be visualised, and the left retina contains scattered pigmented spots in the periphery. What is the most appropriate management plan? A. Stop daily aspirin B. Admit for laser treatment within 48 hours C. Observe and review in ophthalmology out-patients D. Prescribe oral acetazolamide E. Admit for retinal reattachment surgery"
C
"A 62-year-old woman complains of general lethargy, morning stiffness, inability to comb her hair because of arm pain. There is no muscle tenderness. Her ESR is 57 mm/1st h. Electromyography of the deltoid muscle is normal. What is the most likely diagnosis? A. Guillain-Barrè syndrome B. Polymyositis C. Polymyalgia rheumatica D. Multiple sclerosis E. Fibromyalgia"
C
"A 65-year-old patient with new-onset chronic obstructive pulmonary disease (COPD) asks you about his prognosis. Which of the following single tests is the most important predictor of survival in patients with COPD? A. blood gases B. Chest X-ray C. FEV1 D. Exercise tolerance E. ECG"
C
"A 70-year-old man became wheezy while walking uphill, and tripped hitting his left eye. He now complains of pain in this eye; the cornea is hazy, the globe feels very firm to palpation and there is a hyphaema obscuring most of the iris. Which of the following is the most appropriate treatment? A. Examination under anaesthesia B. Topical β-blockers C. Intravenous carbonic anhydrase inhibitors D. Topical anticholinergics E. Anterior chamber paracentesis"
C
"A 70-year-old man presents with a gradually worsening, droopy, right upper eyelid. There is a right ptosis and anisocoria, greater when the room lights are off than in light conditions. Which of the following is the best investigation? A. Anti-acetylcholine receptor antibodies B. blood glucose C. Chest X-ray D. Dilute pilocarpine eye-drop test E. Intraocular pressure"
C
"A 73-year-old man presents with severe back pain. An X-ray shows the presence of osteolytic lesions in his vertebrae and pelvis. He also complains of malaise but no other symptoms of note. Based on the clinical findings and radiology, what is the most probable diagnosis? A. Paget's disease of bone B. Prostatic carcinoma C. Multiple myeloma D. Hypocalcaemia E. Chronic myeloid leukaemia"
C
"A 74-year-old man has an acutely painful, red and swollen knee. He is suffering from congestive cardiac failure, chronic renal impairment and is currently on digoxin and furosemide. What treatment would be most suitable for the symptomatic relief of his joint pain? A. Aspirin B Paracetamol C. Colchicine D. Diclofenac E. Indometacin"
C
"A 75-year-old woman presents with chronic back pain. An X-ray of the spine shows vertebral crush fractures and evidence of osteoporosis. Which of the following blood results would be most in keeping with this diagnosis? A. Low calcium levels B. Elevated phosphate levels C. Normal or high alkaline phosphatase levels D. Decreased 1,25-dihydroxycholecalciferol levels E. Raised parathyroid hormone levels"
C
"A patient is examined in the diabetic clinic and found to have circinate hard exudates in both fundi, with reduced visual acuity. What is the most likely diagnosis? A. Normal fundi B. Background retinopathy C. Maculopathy D. Preproliferative retinopathy E. Proliferative retinopathy"
C
"A patient with cystic fibrosis presents with a severe bronchopneumonia. What is the most likely pathogen? A. Streptococcus pyogenes B. Streptococcus pneumoniae C. Pseudomonas aeruginosa D. Klebsiella pneumoniae E. An atypical Mycobacteria sp"
C
"An 82-year-old woman presents with sudden loss of vision in her left eye. On further questioning, she complains of a left-sided headache over the past few weeks, associated with tenderness of her head when she brushes her hair. On examination, her vision is reduced to counting fingers in the left eye. A left relative afferent pupillary defect is present. Fundoscopy reveals a pale, swollen left optic disc with some flame-shaped haemorrhages. The right eye is entirely normal. An urgent erythrocyte sedimentation rate (ESR) is elevated at 72 mm/hr (< 30). Which of the following management options should be carried out first? A. temporal artery biopsy B. Ophthalmic outpatient review C. Administration of high-dose systemic steroids D. Automated visual field assessment E. Computed tomography (CT) scan of brain and orbits"
C
"An adolescent girl has chronic cough and recurrent respiratory infections over the past two to three years. Which one of the following pieces of clinical information in her history would point most strongly to the development of bronchiectasis? A. Pale stools and low weight B. History of wheeze C. Previous whooping cough in early childhood D. serum precipitins to Aspergillus fumigatus E. Pepperpot calcification on chest X-ray (CXR)"
C
"A 20-year-old football player presents with a swollen left knee and locking. He complains of pain after exercise. On examination wasting over the quadriceps and lateral aspect of the joint are noted. Arthroscopy of the joint reveals three loose bodies in the synovial cavity. What is the most likely diagnosis? A. Chip fractures of the joint surfaces B. Osteoarthritis C. Synovial chondromatosis D. Osteochondritis dissecans E. semi-lunar cartilage tear"
D
"A 21-year-old man presents with episodic pain in his buttocks, low back pain and stiffness that is worst in the mornings. A lateral X-ray of his lower spine shows blurring of the upper and lower vertebral rims at the thoracolumbar junction. He is found to be HLA-B27-positive. Given the likely diagnosis, what would be the most appropriate treatment for him? A. Aspirin B. Prednisolone C. Diclofenac D. Physiotherapy E. dextropropoxyphene"
D
"A 24-year-old woman is brought to casualty with thorax injuries after a road traffic accident. Her chest X-ray shows multiple rib fractures and a right-sided shadow suggestive of a haemothorax. What is the next step in her management? A. blood transfusion B. Intubation and ventilation C. CT thorax D. Intercostal drain insertion E. Surgical referral for thoracotomy"
D
"A 30-year-old shepherd presents with a 1-week history of headaches, rhinitis and pharyngitis associated with high fever and you elicit a systolic murmur on examination. Three days ago he noticed a painful cough and blood-stained phlegm. What is the most likely diagnosis? A. Tuberculosis B. Borreliosis C. Brucellosis D. Q-fever E. Pulmonary embolism"
D
"A 65-year-old diabetic woman on indometacin and glibenclamide has had a blood test that shows evidence of renal failure, hyperkalaemia and hyperchloraemia. What is the most likely underlying cause of her biochemical abnormalities? A. Acute interstitial nephritis B. renal artery stenosis C. Diabetic nephropathy D. Minimal-change nephropathy E. renal tubular acidosis"
E
"A 32-year-old woman presents as an emergency with sudden, painless loss of vision in her right eye. She has been a type-1 diabetic for the past 16 years. On examination, her vision is reduced to hand movements in the right eye. Pupil reactions are normal. Dilated fundal examination reveals an irregular red reflex with evidence of a vitreous haemorrhage. Which of the following would be the most likely causative retinal abnormality? A. Microaneurysm B. Cotton wool spot C. Hard exudates D. neovascularisation at the optic disc E. venous beading"
D
"A 35-year-old woman is diagnosed with systemic lupus erythematosus. What is the most common finding on blood testing that would be of help in supporting your clinical findings? A. Anti double-stranded DNA B. Rheumatoid factor C. VDRL-positive D. Low complement levels E. Anticardiolipin antibody"
D
"A 58-year-old woman complains of severe unilateral temporal headaches and jaw pain when eating. A provisional diagnosis of giant-cell arteritis is made. Which of the following is a characteristic clinical feature of this condition? A. All peripheral arteries are involved B. It does not occur in the absence of polymyalgia rheumatica C. negative temporal artery biopsy excludes the disorder D. Treatment is monitored by measuring CRP levels E. NSAID treatment is an effective first line of management"
D
"A 62-year-old woman is being treated for a pathological fracture of her right femur. An X-ray of the femur shows patchy sclerosis, thickening of the trabeculae and dedifferentiation. Given the likely diagnosis, what treatment would be most appropriate for her? A. Calcium supplements B. Calcitonin C. Hormone replacement therapy D. Tiludronate E. Raloxifene"
D
"A 65-year-old woman with a past medical history of osteoarthritis only affecting her hand joints and diet-controlled diabetes mellitus complains of a sudden onset of pain, swelling and stiffness in her right knee. Examination shows that the right knee is swollen, erythematous and tender. Which of the following tests is most likely to lead to a diagnosis? A. X-ray of the knee B. Autoimmune screen C. serum uric acid level D. Aspiration and examination of the synovial fluid E. A trial of colchicine"
D
"A 67-year-old man known to be hypothyroid says he woke up in the morning with a painful, warm, red and swollen right knee. An X-ray of his knee shows calcification of the meniscus only. What is the most likely diagnosis? A. Acute gout B. Osteoarthritis C. Rheumatoid arthritis D. Pyrophosphate arthropathy E. septic arthritis"
D
"A middle-aged man with red scaly patches on his elbows and knees presents with pain in the distal interphalangeal joints. You suspect psoriatic arthritis. Which of the following features is most strongly linked in men to this condition? A. Age of onset 20-30 years B. Occurrence of arthropathy at the same time as the skin lesions C. Minimal destruction of cartilage and bone D. Involvement mainly of the distal interphalangeal joints E. Occurrence of Bouchard's nodes in the proximal interphalangeal joints"
D
"A patient presents to the medical clinic with diplopia. Which of the following suggests that the trochlear nerve is involved? A. The diplopia is horizontal B. The diplopia is episodic C. The diplopia is worse at night D. The diplopia is torsional E. The diplopia is worse for distancethan near-vision"
D
"A young African-American woman is diagnosed as having systemic lupus erythematosus. What is the characteristic epidemiological feature of this condition? A. It is about twice as common in women than in men B. The highest incidence is amongst Caucasian women C. The age of onset is usually over 40 years D. It is associated with HLA-B8 and -DR3 in Caucasians E. First-degree relatives have a 25% chance of developing the disease"
D
"Altitudinal hemianopia is a cardinal feature in a patient who? A. Denies the fact he is blind B. Is 72 years old with macular degeneration C. Is 70 years old with headache, vomiting and swelling of the optic disc D. Is a 74-year-old man with multiple cholesterol emboli on fundoscopy E. Has coarse facial features, large lips and spade like fingers"
D
"Which treatment improves the long-term prognosis in patients with chronic obstructive pulmonary disease (COPD)? A. Inhaled steroids B. Oral steroids C. Inhaled b2-agonists D. Long-term domiciliary oxygen therapy E. Theophylline"
D
"A 39-year-old woman complains of swelling, stiffness and pain in her fingers. She also tells her doctor that in winter her fingers often turn dark in colour. Her autoimmune screen shows the presence of anticentromere antibody. Which of the following is she most likely to have? A. Rheumatoid arthritis B. Systemic lupus erythematosus C. Pseudogout D. Polyarteritis nodosa E. Crest variant of scleroderma"
E
"A 22-year-old college student complains of stiffness and low back pain that is worse in the mornings. An X-ray shows obliteration of the sacroiliac joints. Given the likely clinical diagnosis, what would be the most appropriate treatment for him? A. Spinal osteotomy B. Aspirin C. bedrest and immobilisation D. Prednisolone E. Spinal extension exercises"
E
"A 22-year-old homosexual man gives a history of high-grade fever associated with pustules on his hands and severe joint pain 4 weeks ago. His left knee is now swollen and red. Cultures from blood and joint aspirate are negative. Urethral discharge shows the presence of gonococci. He has a history of penicillin sensitivity. Which drug would be most suitable in this condition? A. Oral penicillin B. Amoxicillin C. Prednisolone D. Erythromycin E. Ciprofloxacin"
E
"A 24-year-old man suddenly develops severe back pain while lifting some luggage. He is unable to straighten up and subsequently develops numbness and weakness in his left leg followed by retention of urine. He is unable to move his toes. Given the likely clinical diagnosis, which plan of management is likely to be required? A. Lumbar traction B. NSAIDs C. Extension exercises D. bedrest E. Laminectomy and fusion"
E
"A 30-year-old asthmatic patient has the following drug regimen: regular inhaled corticosteroids, regular inhaled long-acting b 2-agonists (salmeterol) and inhaled short-acting b 2-agonists when required. Although her compliance is good, her symptoms are still not satisfactorily controlled. What is the next step in her therapy? A. Antibiotics B. Salbutamol nebuliser C. Oral steroids D. Oral cromoglycate E. Oral leukotriene-receptor antagonists"
E
"A 30-year-old asthmatic patient has the following drug regimen: regular inhaled corticosteroids, regular inhaled long-acting b 2-agonists (salmeterol), oral leukotriene-receptor antagonists and inhaled short-acting b 2-agonists when required. Although her compliance is good, her symptoms are still not satisfactorily controlled. What is the next step in her therapy? A. Oral steroids B. Antibiotics C. Switch to nebuliser D. Oral cromoglycate E. Oral theophylline"
E
"A 30-year-old woman presents with severe scaly, erythematous lesions all over her body. She has also developed swelling and severe pain in her distal interphalangeal joints. Given the diagnosis of psoriasis, what treatment is likely to be most suitable for her? A. Topical corticosteroids B. Diclofenac C. Coal tar D. Long-wave ultraviolet radiation (psoralen ultraviolet A; PUVA) E. Methotrexate"
E
"A 35-year-old woman complains of bilateral stiff and painful joints in her hands and feet for the past 3 months. The stiffness lasts for more than an hour in the mornings. On examination her fingers are swollen and stiff. Movement is painful. Which test would be most relevant in this case? A. X-ray of the hands and feet B. serum uric acid levels C. Joint aspirate for crystals D. CRP levels E. Plasma rheumatoid factor"
E
"A 38-year-old woman presents with recurrent chest infections. For some time she has noticed that her nails are yellow and misshapen and that she often has oedematous legs after standing all day in the shop where she works. Examination reveals evidence of lower lobe consolidation and possible pleural effusion. This is confirmed on chest X-ray. Her nails are very abnormal, thickened and yellow and she has bilateral lymphoedema affecting her legs. Which diagnosis fits best with this clinical picture? A. Bronchiectasis B. Asthma C. Underlying bronchial carcinoma D. COPD E. Yellow-nail Syndrome"
E
"A 65-year-old woman presents a 1-month history of weakness in the hip region and inability to walk or get up from a chair. On examination there is wasting of the pelvic girdle muscles. She has also developed a purple discolouration of the eyelids. You suspect adult dermatomyositis. Which of the following investigations will be most helpful in the diagnosis and management of this condition? A. A raised ESR B. Presence of rheumatoid factor C. Presence of antinuclear antibody D. Myositis-specific antibodies E. Raised serum creatine phosphokinase"
E
"A sixty-year-old man presents with a week's history of painless diplopia first noticed when reading. The images are constantly horizontally and vertically separated, although he comments that the degree of separation varies. On examination the visual acuities are 6/6 in either eye. There is no pupil abnormality. There is a left ptosis, partially covering the pupil and reduced abduction and depression of the left eye, both in abduction and adduction, with other ocular movements appearing normal. There is no other abnormality on examination. Which one of the following is the MOST likely diagnosis? A. Orbital apex syndrome B. Sixth nerve palsy C. Third nerve palsy D. Fourth nerve palsy E. Ocular myaesthenia gravis"
E
"What is the typical opthalmological finding in patients with subacute bacterial endocarditis? A. Cherry red macula B. Janeway lesion C. Macular star D. retinal artery aneurysms E. Roth's spots"
E