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A 60 year old man is brought to the Emergency Department with a fractured hip. He has been having progressive hearing loss and was recently diagnosed with cardiac failure 6 months ago. His blood results show the following:

Alkaline phosphatase 900 U/L (30-150)

Aspartate transaminase (AST) 28 U/L (5-35)

Alanine transferase (ALT) 30 U/L (5-35)

Serum calcium (total) 2.7 mmol/L (2.1-2.6)

Phosphate 1.2 mmol/L (0.8-1.4)

What is the SINGLE most likely diagnosis?

A 65 year old man who has been prescribed amitriptyline for depression, has been brought to the emergency department with suspected overdose. He is not giving a coherent history. His skin looks dry and flushed. On examination, his pupils are dilated. His blood pressure is 90/60 mmHg. What is the SINGLE most appropriate immediate action?

A 34 year old man suffers from depression. He was recently started on sertraline by his GP. When can a therapeutic effect of sertraline be seen?

A 60 year old man was admitted the day before his planned elective surgery in the morning to remove his gallbladder. He was advised that the surgery will take around 2 to 3 hours and he should skip breakfast the morning of the surgery. He suffers from Type 1 diabetes mellitus. He was given a reduced dose of his once-daily Tresiba (degludec) insulin the day before the surgery. He also takes Novorapid (aspart) insulin with his meals three times a day. Which of the following is the SINGLE most appropriate management for him on the day of the surgery?

A 34 year old woman presents to the Emergency Department with sudden onset, severe colicky pain from her right loin radiating to her labia which started 10 hours ago. She has also noticed blood in her urine. The pain occurs in spasm with intervals of dull ache. The pain is accompanied by nausea. She complains of urinary frequency and dysuria. She has a temperature of 36.1°C, a blood pressure of 110/80 mmHg and a heart rate of 80 beats/minute. She is restless and unable to sit still. A urine HCG done in the department has come back as positive. What is the SINGLE most appropriate investigation to request?

A 25 year old man has a burning sensation in his left eye for the last 2 days. His eye is red and has thick purulent discharge. His lids are often stuck shut on waking. What is the SINGLE most appropriate initial management?

A 7 year old boy is brought to the GP surgery by his mother. She says he is always turning up the TV volume and she has to shout to get his attention. There have been recurrent ear infections in the past which were resolved by medication. On examination, a bulging drum is noticed. There is no ear pain or fever. An audiogram reveals a mild bilateral conductive hearing loss. What is the SINGLE most appropriate management?

A 28 year old woman pays a visit to her general practitioner with the complaint of vaginal discharge. She requires some prompting before revealing that she first noticed the discharge a few weeks ago but was too embarrassed to come in for help. She describes the discharge as being yellow and frothy and admits to a degree of vaginal itching but denies any abdominal pain. She is sexually active and takes oral contraceptive pills for contraception. She has a regular 28-day menstrual cycle. Her last menstrual period was a week ago. She is currently in an open relationship and has two frequent sexual partners. A pelvic examination reveals no abnormalities aside from slightly inflamed vulvae and a thin, yellowish discharge. A pregnancy test comes up negative and her vaginal pH is measured at 4.8. A wet mount demonstrates the presence of motile flagellates. Which is the SINGLE most appropriate treatment for this patient from the list below?

A 65 year old man is visited in the care home by the geriatric team. He takes tramadol for his knee pain. Over the past few weeks, he has been suffering from difficulty defecating. He defecates 2 to 3 times a day but with only small amounts of stool. His stool consistency is soft. He eats a healthy, balanced diet and drinks plenty of fluid. What is the most appropriate laxative to prescribe?

A 32 year old woman has had a febrile illness and sudden onset of pain and swelling of the small joints of her feet and knees for the past two days. She has a maculopapular rash on her soles of her feet. She was previously well. There is no history of relevant travel outside the UK. On examination, conjunctivitis is noted. What is the SINGLE most likely diagnosis?

A 43 year old woman was referred to the surgical assessment unit by her GP. She has been feeling unwell with right upper quadrant pain worsening over the past 2 days. On examination, her conjunctiva appears yellow. There is tenderness in the right upper quadrant. Her heart rate is 110 beats/minute and her temperature is 39°C. Her blood tests are as follows:

Haemoglobin 145 g/L (115-160 g/L)

White cell count 22 x 10^9/L (4-11 x 10^9/L)

Bilirubin 91 μmol/l (1-14μmol/l)

Alkaline phosphatase 450 IU/I (4-105 IU/

Aspartate transaminase 71 IU/L (5-35 IU/L)

Albumin 44 g/L (35-50 g/L)

CRP 282 mg/L (< 10 mg/L)

What is the next most appropriate investigation?

A 31 year old woman with confirmed disseminated renal carcinoma presents with bilateral, pitting, non-tender leg swelling up to the groin. She was also found to have dilated lower abdominal veins. What is the SINGLE most likely cause for her symptoms?

A 65 year old man with a history of metastatic lung cancer has had a fall involving a head injury 6 hours ago. He fell unconscious for a few minutes. His previous oncology team’s notes mention that no further active treatment for his lung cancer would be beneficial for him. He has been mostly bedbound for the past few months and requires full support with his activities of daily living. He is on the palliative register. He has a GCS of 8/15 and a blood pressure of 87/64 mmHg. His respiratory rate is 16 breaths/minute and his heart rate is 90 beats/minute. A CT was done as shown below:

What is the most appropriate management?

A 35 year old woman at her 28th week gestation attends her antenatal clinic for a routine check-up. She feels well and has no complaints. Her blood pressure is 160/95 mmHg, and her urine dipstick shows 2+ protein. A protein creatinine ratio was performed in the maternity unit which results were inconclusive. A 24-hour urine protein was sent and was discovered to be 1.5 g. What is the SINGLE most likely diagnosis?

A 59 year old man with oesophageal cancer and liver metastasis has increasing pain at his right hypochondriac region. He describes it as a dull ache with varying intensity throughout the day. He takes paracetamol and morphine sulfate regularly. Aside from increasing his dose of morphine sulphate, what other medications could be added to help with his pain?

A 79 year old woman complains of a new onset of lower and upper back pain which began 3 months ago. She describes feeling very lethargic over the past few months. She describes a loss of appetite and weight loss. Her blood tests show:

Haemoglobin 81 g/L 115-160)

White cell count 4 10^9/L (4-11)

Serum urea 9.5 mmol/L (2.0-7)

Serum creatinine 298 μmol/L (70-150)

eGFR 28 mL/min (>90)

What SINGLE investigation is most likely to lead to a diagnosis?

A 12 month old male infant presents to clinic because his mother is concerned that the child cannot sit on his own. He can crawl but cannot stand with support. He is able to pick up small items. He is not socially interactive with his older sibling. What is the SINGLE best management?

A 68 year old woman was diagnosed with Type 2 Diabetes Mellitus. Diet and lifestyle modifications have failed to control her blood sugar levels over the last three months. She has no known allergies and takes ramipril 5mg once a day and bisoprolol Smg once a day for her management of heart failure. She has a body mass index of 35 kg/m2. Her blood results are as follows:

Serum urea 13.2 mmol/L

Creatinine 390 mmol/L

eGFR 14 ml/min

HbA1c 70 mmol/mol (Target <48 mmol/mol)

What is the SINGLE most appropriate pharmacological management?

A 30 year old woman presents in the 17th week of her second pregnancy. She missed her antenatal checks and scans and is concerned as her first child was diagnosed with infantile mitochondrial myopathy having developed hypotonia and respiratory insufficiency. She was counselled about the condition and wishes to have a test done to ascertain whether the foetus is affected by the same condition. Which of the following is the SINGLE most appropriate investigation to confirm the presence of the condition?

A 60 year old man presented to the renal clinic complaining of increasing tiredness over the last 2 months. He has stage 5 chronic kidney disease and is being worked-up to have haemodialysis. On examination, he appeared pale. His wife stated that he has been sleeping most of the day which is unusual for him. His blood test reveal

Haemoglobin 88 g/L (130-180)

White cell count 9 x 10^9/L (4-11)

Platelets 350 x 10^9/L (150-400)

International normalized ratio (INR) 1 (0.8-1.2)

Sodium 136 mmol/L (135-145)

Potassium 5.4 mmol/L (3.5-5)

Urea 23.5 mmol/L (2.0-7)

Creatinine 456 μmol/L (70-150)

eGFR 17 mL/min (>90)

Serum calcium 2.5 mmol/l (2.1-2.6)

Thyroid stimulating hormone 5.0 mU/L (0.5-5.7)

Phosphate 2.34 mmol/L (0.8-1.4)

Ferritin 280 ng/ml (20-300)

Serum iron 15 μmol/L (14-33)

What is the SINGLE most appropriate management?

A 69 year old woman lives in a nursing home following a stroke. She recently developed a reddish scaly rash on her trunk. She has many scratch marks on her limbs and trunk with linear burrows seen on her hands and feet. What is the SINGLE most appropriate treatment?

A 55 year old with a history pancreatic cancer had a cardiac arrest and died on the operating table while undergoing a pancreaticoduodenectomy. The surgeons said that he bled unexpectedly. Which is the SINGLE most appropriate authority or person to inform about his death?

A 67 year old woman complains of intermittent difficulty in swallowing. She had a stroke 6 months ago and shortly after she started losing weight. She has had three chest infections in the span for 6 months. The medical team has decided that she would require a procedure to address her feeding issue. What is the most appropriate procedure to perform for long term feeding?

A 35 year old schizophrenic man hears voices narrating his actions like “he is going to the toilet” and “he is leaving the house”. What is the SINGLE most likely type of

hallucinations involved?

A 28 year old male is admitted with acute exacerbation of asthma. He is initially treated with 100% oxygen, salbutamol nebulizers and hydrocortisone 100mg IV. Despite treatment, his oxygen saturation is 89% and respiratory rate is 30 breaths/minute. What is the SINGLE most appropriate next step in management?

A 39 year old type 2 diabetic is planning to undergo an elective major surgery. He takes long-acting insulin and gliclazide. What is the SINGLE most appropriate pre-op management?

A 9 year old boy presents with perioral blisters on the left side. It started as tiny pustules and vesicles that evolve rapidly into honey-coloured crusted plaques. What is the SINGLE most appropriate medication to use?

A 77 year old man presents with a worsening headache over the past few weeks. He has been diagnosed with an inoperative glioblastoma a year ago. He feels nauseous. The head pain can wake him up in the morning. A recent brain CT shows an enhanced lesion with surrounding oedema. What is the SINGLE most appropriate management?

A 45 year old male presents with a whitish-grey opaque area with red inflamed patches on his tongue. The patches are sharply defined and are unable to be scraped off. What is the SINGLE most likely diagnosis?

5000 patients were screened for skin cancer using new image recognition technology powered by artificial intelligence. The new technology reported 500 patients had suspicious lesions, which on biopsy only 100 proved to be cancerous. An additional 5 patients who were not picked up by the new computer program to have cancer, later developed skin cancer. Which term describes the 400 patients who were negative on biopsy?

A 75 year old man attends his GP surgery for a review of his blood pressure. Hs blood pressure on two occasions over the previous month shows readings of 160/100 mmHg. 172/98 mmHg. He was sent home with an ambulatory blood pressure monitor (ABPM) and has returned with daytime blood pressure readings of an average of 170/90 mmHg. He has a healthy lifestyle and has no medical problems. Lifestyle advice was given to him. What is the SINGLE most appropriate medication, if required, to start?

A 66-year-old gentleman underwent an elective transurethral resection of the prostate just a few hours prior. Post procedure, he exhibits signs of confusion and has a seizure. His medical history includes type 2 diabetes. His laboratory results are as follows:

Sodium 119 mmol/L (135-145)

Potassium 6.1 mmol/L (3.5-5)

Urea 5 mmol/L (2.0-7)

Creatinine 85 μmol/L (70-150)

eGFR >90 mL/min

Glucose 7.0 mmol/L

Afterward, he is administered intravenous 3% sodium chloride. A 12-lead ECG is performed which indicates sinus rhythm without hyperkalemic changes. Which among the following is the most suitable next step in managing this patient’s condition?

A 43-year-old woman consults her primary care physician, expressing worry about the risk of breast cancer. Her family history is notable, with her grandmother succumbing to breast cancer, her mother having undergone a right mastectomy the previous year, and her sister diagnosed with breast cancer at 38 and now in remission. Genetic testing, motivated by her family history, revealed the presence of the BRCA1 gene mutation in this patient. She had a mammogram six months prior, which showed no abnormalities. Examination of the breast shows no skin changes, no changes in the nipple, and no detectable masses. However, a 1 cm by 1 cm, smooth and non-tender lymph node was discovered in her left armpit. What is the SINGLE most suitable next course of action for this patient?

A man of 36 years is scheduled for surgery to try and remove a glioma. What is the SINGLE anatomical structure that is most likely to be opened during this operation?

A 33-year-old female who is 17 weeks pregnant arrives at the Emergency Department. She has a history of epilepsy and is currently on medication for it, although she has been non-adherent and missed taking her medication for the past 4 days. Earlier this morning, she experienced a tonic-clonic seizure that lasted for 4 minutes and was transported to the hospital by ambulance. She has established IV access. While awaiting medical attention, she begins to have another generalized tonic-clonic seizure. Which of the following is the MOST appropriate course of action?