1. A 24-year-old woman on tetracycline for acne presents with a 3-month history of headaches and fleeting episodes of blurred vision. On examination, she is obese and has severe papilloedema, but no other neurological signs. A CT scan is normal.

Which test is the most appropriate initial investigation?

1. MRI brain scan
2. Cerebral angiography
3. Hypercoaguability screen
4. Lumbar puncture

2. In rheumatoid arthritis, why is the granulation tissue named pannus erosive?

1. Production of localised vasculitis
2. Production of fibrinoid necrosis
3. Production of collagenase and other enzymes
4. Presence of osteoclasts within the pannus

3. Why is levodopa combined with carbidopa in the treatment of Parkinson disease?

1. To slow absorption of levodopa
2. To reduce nausea caused by levodopa
3. To reduce the required dose of levodopa
4. To reduce the breakdown of levodopa by catechol-O-methyl transferase

4. A 75-year-old man with mild dementia has carcinoma of the colon. He has difficulties in managing his financial affairs and has moved from his home to a hostel. He has symptoms from his carcinoma but, despite initially consenting to treatment, he is now refusing all treatment as well as permission for the diagnosis to be communicated to his family.

Which guideline is the most appropriate to follow in these circumstances?

1. His family should be asked to give consent
2. His refusal to consent cannot be challenged
3. A request for a guardianship order should be made
4. His capacity to consent must be reassessed

5. A 65-year-old male who has a 3-year history of intermittent pain in both knees now presents with a 2-week history of pain and swelling in the right knee. Examination reveals a small effusion of the knee.

The synovial fluid findings are as follows:

White cell count 700/mm3 [< 100]
Mononuclear cells 90%
Neutrophils 10%

No crystals were seen.

What is the most likely cause of the right knee pain?

1. Osteoarthritis
2. Ankylosing spondylitis
3. Pseudogout
4. Psoriatic arthritis

6. A 45-year-old man presents with pneumonia. He is found to have IgG multiple myeloma.

His routine biochemistry finds:

What is the most likely cause of his renal impairment?

1. Myeloma cast nephropathy
2. Acute tubular necrosis
3. Amyloid
4. Plasma cell infiltration

7. A 17-year-old girl notices swelling of her ankles and breathlessness. Examination shows pitting oedema, blood pressure of 150/95 mmHg and urine containing ++protein, +++ blood. Microscopy of the urine shows cellular casts and crenated and fragmented red cells.

Serum results show:

What is the most likely diagnosis?

1. Minimal change disease
2. Focal and segmental glomerulosclerosis
3. Systemic lupus erythematosus
4. Post-infectious glomerulonephritis

8. A 36-year-old man who was admitted to the intensive care unit 3 weeks ago with multiple injuries sustained in a motor vehicle accident is intubated and breathing spontaneously. He has a Swan–Ganz catheter, which was inserted 10 days ago, and is receiving total parenteral nutrition via a multilumen central venous catheter. For the past week, he has had bilateral alveolar shadowing on chest X-ray but his oxygenation has been stable while receiving intravenous ceftriaxone. He suddenly develops a high fever (40.3 °C and becomes haemodynamically unstable. Clinical examination fails to reveal a likely source of infection and chest x-ray is unchanged.

Initial investigation results include the following:

Film comment: Band forms + +; toxic granulation + +.

After obtaining cultures from blood and urine, what is the most appropriate next diagnostic step?

1. Whole body gallium scan
2. Removal of indwelling lines for culture
3. Bronchoscopy with transbronchial biopsy
4. Echocardiogram

9. What best determines whether an ascitic fluid sample is a transudate or an exudate?

1. Ascitic pH
2. Ascitic lactic dehydrogenase activity
3. Serum to ascitic fluid albumin gradient
4. Ascitic protein concentration

10. What is the best predictor of the prevalence of alcohol-related morbidity in a community?

1. Mean alcohol consumption of the members of the community
2. Overall prevalence of alcoholism
3. Number of malnourished alcoholics in the community
4. Prevalence of abusive drinking among young males

11. When newly prescribed to a patient with stable and therapeutic lithium levels, which drug is most likely to produce an increase in their serum lithium?

1. Fluoxetine
2. Captopril
3. Hydrochlorothiazide
4. Aspirin

12. An asymptomatic 40-year-old male who jogs regularly has two episodes of transient light-headedness at rest. He has no history of smoking or diabetes and no family history of premature vascular disease. His blood pressure is 150/70 mmHg. Other examination is unremarkable. His ECG is shown below.

What is the next most appropriate step?

1. Reassurance
2. Holter monitoring
3. Trial of treatment with anticholinergics
4. Permanent pacing

13. The following results are obtained prior to elective hernia surgery from a 40-year-old man who has given a history of excessive bleeding after dental extraction.

Mixing the patient’s plasma with an equal volume of normal plasma normalises the APTT.

What is the most likely diagnosis?

1. Factor VII deficiency
2. Antiphospholipid antibody syndrome
3. Von Willebrand disease
4. Haemophilia B

14. Which physiological response is NOT integrated within the medulla oblongata?

1. Swallowing
2. Sneezing
3. Temperature regulation
4. Gagging

15. A lesion of the left cerebral hemisphere involving the motor cortex is most likely to result in paralysis of the muscles of the face.

Which area of facial muscle function is likely to be affected?

1. Right half
2. Right upper quadrant
3. Right lower quadrant
4. Right and left lower quadrants

16. Which spinal cord segments are involved in the knee-jerk?

1. L1, L2
2. L2, L3
3. L3, L4
4. L4, L5

17. What is the best single indicator of the adequacy of restoration of fluid volume after injury?

1. Blood volume
2. Haematocrit
3. Urine output
4. Rise in blood pressure

18. What is the most important factor that increases blood flow through an active muscle?

1. Adrenaline (epinephrine) release during exercise
2. Reduced constrictor tone in the arterioles of the muscle
3. Local action of metabolites on vessels in the muscles
4. The ‘muscle pump’ action