Nash Qbank

Q.1. A 34-year-old man who underwent an open repair of a right inguinal hernia 3 years ago, presented with a 3-month history of a right groin swelling that is associated with dragging pain. Physical examination confirmed a right groin reducible swelling with positive cough impulse, : reaching the neck of scrotum. Which of the following is the most appropriate next step management?

A:

Open repair

B:

CT abdomen

C:

Scrotal support

D:

Laparoscopic mesh repair

Q.2. A 36-year-old patient presented with a neck mass that has been present for 3 years. Physical examination confirmed a palpable left thyroid gland: with no palpable cervical lymph nodes (see reports) Neck Ultrasound: The left thyroid nodule occupying most of the left lobe, measures 3.4 x 3.8 cm and has mixed cystic and solid components, the right lobe is normal. Fine Needle Aspiration: Finding is codes as Bethesda IV (suspicious for follicular neoplasm) Which of the following is the most appropriate management?

A:

Thyroid scan

B:

Left hemithyroidectomy

C:

Left hemithyroidectomy

D:

Repeat fine needle aspiration

Q.3. A 48-year-old man complains of right upper quadrant abdominal pain for 4 months. Physical examination was normal (see reports). Serology: Echinococcus granulosus was positive. Ultrasound Large cystic lesion (10x15 cm) in the right lobe of the liver with multiple intra-cystic daughter cysts, but no calcifications. Which of the following is the most appropriate management?

A:

Surgical de-roofing

B:

Percutaneous aspiration

C:

Long-term albendazole therapy

D:

Percutaneous sclerosant injection

Q.4. A 20-year-old man was brought to the Emergency Department, 20 minutes after a motor vehicle accident. On examination, his extremities were warm, he was conscious, oriented with a clear chest and normal abdomen Blood pressure 90/40 mmHg Heart rate 70 /min Which of the following is the most likely type of shock?

A:

Septic

B:

Neurogenic

C:

Cardiogenic

D:

Hypovolemic

Q.5. A 32-year-old woman complained of an anterior neck ump which she noticed 3 months ago. Physical examination confirmed a firm lump in the right side of the anterior triangle of the neck moving up with swallowing but no palpable cervical lymph nodes (see lab results and reports). Blood pressure 120/70 mmHg Heart rate 115 /min Temperature 36.7 °C Test Result Normal Values TSH 0.104 -5.0 yUimL Free T3113.5-6.5 pmollL Total T4 277 64-155 nmollL. Ultrasound: Lump in the right thyroid lobe 2x3 cm. Thyroid isotope scan: Hot nodules in the right lobe while the remainder of the gland is cold. Which of the following is the most appropriate initial step in management?

A:

Anti-thyroid drugs

B:

Total thyroidectomy

C:

Right thyroid lobectomy

D:

Radioactive iodine ablation

Q.6. A 36-year-old woman complaining of per-rectal bleeding and prolapsed tissue masses through the anal verge. Anorectal examination confirmed grade IV haemorthoids at 3, 7, and 11 clock | positions. Which of the following is the most appropriate management?

A:

Rubber banding

B:

Open haemorrhoidectomy

C:

Infrared photocoagulation

D:

Submucosal injection of sclerosant

Q.7. This is the likelihood of a test reporting positive when the condition being tested is actually present. What is the most likely term?

A:

Null hypothesis

B:

Prevalence

C:

Probability

D:

Sensitivity

Q.8. A 32-year-old man presented to the Emergency Department with pain and swelling of his right thigh after a trivial injury. Physical examination confirmed swelling, deformity of his right thigh with tenderness (see lab results and report). Test Result Normal Values Parathyroid hormone (intact PTH levels) 8.9 1.1-5.3 pmol/L Calcium 4.5 2.15-2.62 mmol/L X-ray: Spiral fracture of right femur with subperiosteal resorption. Which of the following is the most likely diagnosis?

A:

Parathyroid adenoma

B:

Parathyroid carcinoma

C:

Tertiary hyperparathyroidism

D:

Secondary hyperparathyroidism

Q.9. A 42-year-old man presented to the Emergency Department complaining of a 12-hour history of severe epigastric pain. Physical examination confirmed upper abdominal tenderness (see lab results and report). Test Result Normal Values WBC 145 4.5-10.5 x 1001 Amylase 254 24-151 IUL Erect chest X-ray: Normal. Which of the following is the most appropriate next step in management?

A:

Abdominal CT scan

B:

Abdominal ultrasound

C:

Exploratory laparotomy

D:

Urine analysis for amylase

Q.10. A 67-year-old man presented with a 2-month history of yellowish discoloration of his sclera and skin with dark urine and pale stool. On examination, he was jaundiced with a paipable distended gallbladder (see report and lab results) Test Result Normal Values Alkaline phosphatase 421 39-117 IU/L Direct bilirubin 122.3 1.56.5 pmol/L Total bilirubin 134.5 3.5-16.5 pmol/L. Uttrasound: Dilated intra and extrahepatic bile ducts with hugely distended gallbladder. Which of the following is the most likely diagnosis?

A:

Kiatskin tumour

B:

Pancreatic cancer

C:

Mirizzis syndrome

D:

Common bile duct stone

Q.11. A 23-year-old woman presented with symptoms of hyperthyroidism. Physical examination confirmed a non-palpable thyroid gland and bilateral exophthalmos was noted. She has been on anti-thyroid medication for 10 months (see lab results and report). Test Result Normal Values Thyroid-stimulating hormone 0.001 0.4 - 5.0 U/mL Thyroxine (T4 free serum) 29.8.5 - 15.2 pmollL Neck Ultrasound Mild diffuse enlargement of thyroid gland. Thyroid scan: Diffuse uptake of the thyroid gland is consistent with toxic multi-nodular goiter. Which of the following is the most appropriate management?

A:

Subtotal thyroidectomy

B:

Near total thyroidectomy

C:

Radioactive iodine ablation

D:

Continue on medical therapy

Q.12. A 50-year-old man underwent an open mesh repair of a left inguinal hernia. He presented 2 months later because he noticed that the left testes had become smaller in size. Which of the following is the most likely cause?

A:

Ligation of testicular artery

B:

Mesh migration to the scrotum

C:

Thrombosis of pampiniform plexus

D:

Tightening of extemal inguinal ring

Q.13. A 28-year-old man presented with a 4-day history of abdominal pain, associated with frequent bloody diarrhoea and vomiting. Physical examination confirmed he was dehydrated, had a distended abdomen, tendemess mainly over the lower abdomen with sluggish bowel sounds. He is known to have ulcerative colitis and is having medical treatment (see lab result and report). Test Result Normal Value ‘WBC 21.34.5-10.5 x 109/L Plain abdominal X-ray: Dilated transverse colon (15 cm) with loss of haustrations. Which of the following is the most appropriate management?

A:

High dose systemic steroid

B:

High dose systemic infliximab

C:

Proctocolectomy with ileal pouch

D:

Total colectomy with end ileostomy

Q.14. A 47-year-old man reported frequent vomiting over the past 24-hours due to food poisoning. He presented to the Emergency Department complaining of a 2-hour history of vomiting fresh blood. Physical examination confirmed mild epigastric tendemess. A nasogastric tube was inserted and was draining bloody stained fluids. Which of the following is the most likely diagnosis?

A:

Gastritis

B:

Dieulafoy's lesion

C:

Peptic ulcer disease

D:

Mallory-weiss syndrome

Q.15. A 33 year old woman has just had an uncomplicated normal vaginal delivery. The third stage of labour was managed actively and the placenta and membranes were expelled completely soon after delivery of the baby however she continues to bleed vaginally. She has now total estimated blood loss of 1 litre. Her uterus is relaxed and is felt to be boggy and above the umbilicus. What is the most appropriate immediate step to manage this patient?

A:

Uterine massage

B:

Cross match 4 units of blood

C:

Explore the uterus for retained placental tissue under general anaesthesia

D:

Another bolus of 5 units oxytocin

Q.16. Which of the following is the most common cause of biliary colic?

A:

Cystic duct stone

B:

Gall bladder stone

C:

Gall bladder sludge

D:

Choledocholithiasis

Q.17. A 33 year old female complains of double vision which started yesterday. On examination, a fixed dilated pupil which does not accommodate and drooping eyelid can be seen on the left eye. Her left eye is displaced outward and downwards. She has no significant past medical history. There was no history of trauma. What is the most appropriate investigation to perform?

A:

Ophthalmoscopy

B:

Computed tomographic angiogra

C:

Thyroid function test

D:

Visual field test

Q.18. A 65-year-old man complains of a 2-month history of dysuria associated with the passage of cloudy urine with bubbling on micturition. He reports a 2-year history of recurrent left iliac fossa pain. Physical examination was unremarkable (see reports). Sigmoidascopy. Narrowed sigmoid colon with intact mucosa Cystoscopy: Erythematous area in the dome of the bladder. Which of the following is the most likely diagnosis?

A:

Ischemic colitis

B:

Diverticular disease

C:

Squamous cell carcinoma of the bladder

D:

Transitional cell carcinoma of the bladder

Q.19. A 3 year old boy presents with rectal prolapse. He is notd to be below the 5th percentile for weight and height. His mother is also concerned because he has a foul-smelling bulky stool that “floats”. She also states that the child has developed a repetitive cough over the last few months. What is the most appropriate initial investigation?

A:

Endomysial antibody (IgA)

B:

Sweat test

C:

Barium meal

D:

Anti-gliadin antibody (IgA or IgG)

Q.20. A 42-year-old woman presented with a right breast mass that has been present for 3 months and is not associated with other symptoms. Physical examination confirmed a 2 x 2 cm firm partially movable mass with associated skin tethering and an enlarged axillary lymph node (see report). Bilateral breast mammogram and ultrasound: i-defined lobulated dense mass that is hypoechoic on ultrasound, measuring 2 x 2 cm, not associated with speculation or suspicious microcalcifications. Coded as BI-RADS IV. Which of the following is the most appropriate next step in management?

A:

Excision biopsy

B:

Needle core biopsy

C:

Fine needle aspiration

D:

Short interval follow-up imaging

Q.21. A 75 year old man is found to be unresponsive. The ward doctor is called to the patient’s bedside. He is not breathing and has no detectable pulse. Which is the most appropriate next step?

A:

Get a defibrillator

B:

Give two rescue breaths immediately

C:

Check notes for a Do Not Attempt Resuscitation (DNAR) order

D:

Start chest compressions at a rate of 30:2

Q.22. A patient presented with severe diarrhoea. Which of the following is the most expected abnormalities?

A:

Metabolic acidosis with hypokalaemia

B:

Metabolic acidosis with hyperkalemia

C:

Metabolic alkalosis with hypokalaemia

D:

Metabolic alkalosis with hyperkalaemia

Q.23. A 66-year-old healthy man complains of rectal bleeding for 3 months. Anorectal examination confirmed 3rd degree haemorrhoids. Which of the following is the most appropriate next step in management?

A:

Colonoscopy

B:

Haemorrhoidectomy

C:

Abdominal computed tomography

D:

Submucosal injection of sclerosant

Q.24. A 54-year-old woman complains of a left breast mass that has been present for 9 months. Physical examination confirmed a 3 x 3 cm firm fixed mass at the left retro-areolar area with associated nipple retraction (see report). Bilateral breast mammogram: ‘Speculated mass at left retro-areolar region associated with suspicious clustered microcalcifications. There are multiple pathological left axillary lymph nodes. Findings coded as. BI-RADS V (Probably Malignant). Which of the following is the most appropriate next step in management?

A:

Excision biopsy

B:

Needle core biopsy

C:

Staging CT and bone scan

D:

Modified radical mastectomy

Q.25. A 55-year-old man complains of a 2-month history of central abdominal pain. Physical examination was normal (see lab result and report). Test Result Normal Value 24 hours 5-HIAA 21 mg 2-7 mg/24 h CT scan: Small bowel mass 4x5 cm, with some calcifications. Which of the following is the most likely small bowel tumour?

A:

Carcinoid

B:

Lymphoma

C:

Schwannoma

D:

Gastrointestinal stroma

Q.26. What structure passes through the deep inguinal ring?

A:

inguinal nerve

B:

Inferior epigastric artery

C:

Medical umbilical ligament

D:

Round ligament of the uterus

Q.27. A 78 year old man has a painless sudden collapse. His pulse is 120 beats/minute, blood pressure of 70/40 mmHg. Examination reveals a mottled skin of the lower body and a pulsatile abdominal mass. What is the most likely diagnosis?

A:

Aortic aneurysm

B:

Aortic aneurysm

C:

Umbilical hernia

D:

Ureteric colic

Q.28. A 25-year-old patient presented to the Emergency Department with a 6-hour history of severe periumbilical colicky abdominal pain associated with frequent vomiting, and abdominal distension. Physical examination confirmed diffuse abdominal distention with exaggerated bowel sounds. Which of the following is the most appropriate initial step in management?

A:

Ultrasound abdomen

B:

Diagnostic laparoscopy

C:

Examination of the groin

D:

Abdominal computed tomography

Q.29. A 32-year-old woman a 28-week pregnant presents with an enlarging right breast mass that has been present for 4 months and is associated with mild pain. Physical examination confirmed a 3 x2 em firm movable mass not associated with skin changes or enlarged axillary lymph nodes. Which of the following is the most appropriate next step in management?

A:

Fine needle aspiration

B:

Bilateral breast ultrasound

C:

Bilateral diagnostic mammography

D:

Reassure and reassess after delivery

Q.30. A 45-year-old presented to the Emergency Department with a 12-hour history of vomiting fresh blood. He has a 10-year history of recurrent peptic ulcers. Physical examination was normal | (see report). Upper GIT endoscopy: Esophagitis, multiple non-bleeding gastroduodenal ulcers, the distal one is in the 4th part of duodenum. Which of the following has the most diagnostic value?

A:

Calcium

B:

Fasting serum gastrin

C:

Fasting serum gastrin

D:

Fasting serum gastrin

Q.31. A 29-year-old woman presented to the Emergency Department with diffuse abdominal pain for 1 day associated with progressive abdominal distension, vomiting and constipation. Physical examination confirmed abdominal distension, diffuse mild tendemess and exaggerated bowel sounds (see report). CT scan: Distended small bowel with ileocecal intussusception causing complete small bowel obstruction. Which of the following is the most appropriate procedure?

A:

Surgical resection

B:

Surgical resection

C:

Surgical reduction

D:

Reduction by barium enema

Q.32. A 36 year old woman presents to clinic with intermittent episodes of dizziness that lasts 1 day each time for the past 6 months. Recently, she has experienced ringing and increased pressure in her eres. Her husband noticed that she has had to increase the volume of her television. MRI head is normal. What is the most likely diagnosis?

A:

Benign paroxysmal positional vertigo

B:

Vestibular schwannoma

C:

Vestibular neuronitis

D:

Meniere’s disease

Q.33. A 53-year-old man complains of a 3-month history of vague epigastric pain and weight loss. Physical examination was normal (see reports). Upper GIT endoscopy. Antral gastric mass. Multiple deep biopsies were taken. Histopathology: Mucosa associated lymphoid tissue lymphoma and positive for Helicobacter pylori Which of the following is the most appropriate initial management?

A:

Surgery

B:

Antibiotics

C:

Radiotherapy

D:

Chemotherapy

Q.34. A 48 year old man attends his GP surgery. He was started on fluoxetine 8 weeks ago for depression and is now requesting to stop his medication as he feels well and does not think he is depressed any longer. What is the most appropriate advice to give to him in regards to his treatment?

A:

Stop fluoxetine right away

B:

Continued fluoxetine for at least another 6 months

C:

Fluoxetine dose should be gradually reduced over a 4 week period

D:

Fluoxetine dose should be gradually reduced over a 1 week period

Q.35. A 75-year-old man presented with a 12-hour history of sudden lower abdominal pain, associated with progressive abdominal distension, nausea, vomiting and absolute constipation. Physical examination confirmed a grossly distended abdomen, generalized discomfort with normal bowel sounds with an empty rectum (see report). Erect abdominal X-ray: Massively distended bowel loop pointing to the right upper quadrant. Which of the following is the most likely diagnosis?

A:

Sigmoid volvulus

B:

Rectosigmoid cancer

C:

Closed loop obstruction

D:

Acute sigmoid diverticulitis

Q.36. A 6 year old boy was playing at home alone when he stuck super glue into his ear. His mother has brought him to A&E and is extremely concerned. On inspection, the adhesive is in contact with the tympanic membrane. What is the most appropriate management?

A:

Reassure

B:

Ear irrigation

C:

Refer to an Ear Nose and Throat specialist

D:

Suction with a small catheter

Q.37. A 67 year old man with history of weight loss complains of hoarseness of voice. Chest x-ray reveals opacity in the right upper mediastinum. He denies any history of difficulty breathing. What is the most appropriate investigation?

A:

Laryngoscopy

B:

Bronchoscopy

C:

Lymph node biopsy

D:

Bronchoalveolar lavage

Q.38. A 25-year-old man presented to the Emergency Department with severe pain during and after defecation for 3 days associated with passage of a small amount of fresh blood after defecation. Physical examination confirmed an acute posterior anal fissure. Digital and proctoscopic examination were not performed due to the anal pain. Which of the following is the most appropriate management?

A:

Examination under anaesthesia

B:

Lateral internal anal sphincterotomy

C:

Chemical sphincterotomy with diltiazem

D:

Botulinus toxin paralysis of anal sphincter

Q.39. A 69 year old woman with a medical history of rheumatoid arthritis for 25 years presents with left shoulder pain and swelling for 3 days. She has a low grade fever. On examination, there is decreased range of motion of the left shoulder joint and movement elicits pain. She takes regular low dose steroids for the past year to manage her flare of rheumatoid arthritis. She has no known drug allergies. Joint aspiration has been sent for microscopy and culture. Her blood results show: CRP 168 mg/L White cell count 14 x 109/L What is the most appropriate management?

A:

Wait for results of culture prior to starting antibiotic therapy

B:

Intravenous flucloxacillin

C:

Oral flucloxacillin

D:

Intravenous clindamycin

Q.40. A 21-year-old man was brought to the Emergency Department following a motorbike crash, complaining of difficulty in breathing. On examination, he was conscious, oriented, dyspoeic with reduced breath sounds and tympanic percussion over the left hemithorax. Blood pressure 90/55 mmHg Heart rate 110 /min Which of the following is the most appropriate next step in management?

A:

Plain chest X-ray

B:

Endotracheal intubation and ventiation

C:

Needle decompression of left hemithorax

D:

Chest tube insertion in the left hemithorax

Q.41. A 60 year old presents with non-healing ulcers on his calves and a cramp-like pain in the calves relieved by rest. His past medical history includes hypertension, diabetes, and hypercholesterolaemia. He also smokes 15 cigarettes a day. Physical examination shows cold extremities, absent distal pulses. Which advice is unlikely to prevent disease progression?

A:

Quit smoking

B:

Treat hypertension

C:

Treat high cholesterol

D:

Omega 3 oils

Q.42. A 55-year-old man presented with a 4-month history of vague epigastric pain associated with 15 kg weight loss. Physical examination confirmed enlarged left supractavicular lymph nodes and gross ascites. Which of the following is the most appropriate next step in management?

A:

Abdominal ultrasound

B:

Diagnostic laparoscopy

C:

Abdominal paracentesis

D:

Upper gastrointestinal endoscopy

Q.43. A 19-year-old woman complains of a 4-month history of a left breast mass. Breast examination confirmed a well-circumscribed, firm, smooth mobile lump, 2x2 cm in size, in the lateral upper quadrant of the left breast. Which of the following is the most likely diagnosis?

A:

Sclerosis

B:

Galactocele

C:

Duct ectasia

D:

Fibroadenoma

Q.44. A 22-year-old man underwent an open left inguinal hernia mesh repair 2 weeks ago, presented with continuous discharge from the surgical wound. Examination confirmed a 2 x 3 cm pus- discharging wound with part of the mesh exposed. Which of the following is the most appropriate management?

A:

Systemic antibiotic

B:

B. Wound debridement

C:

Wound drainage and mesh removal

D:

Open entire wound for daily dressing

Q.45. A 39 year old woman has been having tingling and numbness of her thumb, index and middle fingers for a while. She has been treated with local steroids but there was no improvement. She has planned to undergo a surgical procedure. What is the most likely structure to be incised?

A:

Flexor digitorum profundus

B:

Transverse carpal ligament

C:

Palmar aponeurosis

D:

Extensor retinaculum

Q.46. A 40-year-old woman presented for her first screening mammography. She has no past medical history, and no family history of cancer (see reports). Bilateral breast mammogram: Bilateral dense breast with multiple fibro glandular opacities, no suspicious microcalcifications or speculated lesions. Breast ultrasound: Bilateral multiple variable sizes cysts. Findings coded as BI-RADS Ill (Probably benign). Which of the following is the most appropriate next step in management?

A:

Annual screening

B:

Needle core biopsy

C:

Short interval follow-up imaging

D:

Magnetic resonant mammography

Q.47. A 26-year-old man presented 3 days after a sleeve gastrectomy with left upper abdominal pain. Physical examination confirmed only mild upper abdominal tenderness with no sign of peritonitis. Blood pressure 100/70 mmHg Heart rate 116 /min Which of the following is the most likely explanation?

A:

Dehydration

B:

Gastric leak

C:

Pulmonary embolism

D:

Inadequate analgesia

Q.48. A 28-year-old man presented with a 2-year history of reducible right inguinal hernia that became painful for 16 hours. It is associated with progressive abdominal distension, and vomiting. Physical examination confirmed a distended abdomen, exaggerated bowel sound, and a tender right inguinal swelling with red discoloration of the overlying skin (see lab result and report). Test Result Normal Value WBC 9.8 4510.5 x 109 Erect abdominal X-ray: Multiple air fuid levels. Which of the following is the most likely hernia complication?

A:

Irreducible

B:

Obstructed

C:

Incarcerated

D:

Strangulated

Q.49. A 36 year old lady has diarrhoea for the last 2 months. She has lost 8 kg in that time period. A colonoscopy was performed which showed fistulas. Perianal fistulas are also noticed. What is the most likely diagnosis?

A:

Crohn’s disease

B:

Irritable bowel syndrome

C:

Coeliac disease

D:

Diverticulitis

Q.50. A 48-year-old woman presented with a 12-hour history of a painful swelling in the right groin. Physical examination confirmed an irreducible tender swelling in the groin area that is 3 x 4cm. Surgical exploration confirmed a strangulated hernia and the neck is lateral and inferior to the pubic tubercle. Which of the following is the most likely hernia?

A:

Femoral

B:

Obturator

C:

Direct inguinal

D:

Indirect inguinal

Q.51. A 36-year-old man presented to the Emergency Department with a 24-hour history of central abdominal pain associated with abdominal distension, vomiting and constipation. He had an appendectomy 7 years ago. Physical examination confirmed diffuse abdominal distension, mild ‘abdominal tenderness with exaggerated bowel sounds (see lab results and report). Test Result Normal Values Amylase 288 24-151 IUL WBC 11.4 45-105 x 1091L Erect X-ray: Multiple air fluid with dilated small bowel. Which of the following is the most appropriate investigation?

A:

Abdominal ultrasound

B:

Exploratory laparotomy

C:

Abdominal computed tomography

D:

Laparoscopic abdominal exploration

Q.52. A 25-year-old man was admitted through the Emergency Department complaining of a 5-day history of right iliac fossa pain. Physical examination confirmed a tender mass in the right ac: fossa with sluggish bowel sounds (see report). CT scan: Acute appendicitis, appendicolith, with 10x15 cm abscess, extending from the right iliac fossa. the abdominal wall. Which of the following is the most appropriate intervention?

A:

Open drainage of the collection

B:

Percutaneous drainage of the collection

C:

Open appendectomy with drainage of the collection

D:

Laparoscopic appendectomy with drainage of collection

Q.53. A 48 year old man after surgical removal of mandibular cancer presents with perioral paresthesia and severe perioral pain which is not relieved by oral morphne and ibuprofen. The skin is also very tender to touch. What is the most appropriate next step in management to relieve the pain?

A:

Gabapentin

B:

Oral oxycodone

C:

Patient controlled analgesia

D:

Intravenous morphine

Q.54. A 64 year old diabetic woman presents to the GP surgery with an acutely painful, swollen and hot right knee joint. There is limited range of movement and movements are painful in all directions. There is redness around the joint. An effusion surrounding the entire joint is obvious. There is no history of trauma. She has a pulse rate of 70 beats/minute, and a temperature of 37.8 C. What is the most likely diagnosis?

A:

Reactive arthritis

B:

Septic arthritis

C:

Viral arthritis

D:

Bursitis

Q.55. A 52 year old man who underwent a partial gastrectomy 10 months ago presents with increasing fatigue. A yellow tinge is noted on his skin and he has a red sore tongue. What is the most likely diagnosis?

A:

B12 deficiency

B:

Cancer of the colon

C:

Alcoholism

D:

Coeliac disease

Q.56. A morbidly obese 23-year-old man complains of gastroesophageal reflux disease (see report). Upper GI endoscopy: Large hiatus hernia with grade Ill reflux. Which of the following is the most appropriate weight reduction procedure?

A:

Sleeve gastrectomy

B:

Intra-gastric balloon

C:

Bilo-pancreatic bypass

D:

Roux-en-y gastric bypass

Q.57. A 4 year old child is taken by his mother to the Emergency Department as he is having pain around his right eye. He is febrile with a temperature of 38.5 C. This swelling started two days ago with a gradual onset. On examination, there is a tender, erythematous swelling around his right eye. What is the most likely diagnosis?

A:

Allergic reaction

B:

Foreign body

C:

Conjunctivitis

D:

Periorbital cellulitis

Q.58. A 52 year old woman with a history of systemic lupus erythematosus complains of dry eyes and altered sense of taste. Her voice becomes hoarse when she speaks for long periods of time. What is the most likely diagnosis?

A:

Acquired Angioedema

B:

Sjogren’s syndrome

C:

Herpes zoster ophthalmicus

D:

Sarcoidosis

Q.59. A 32-year-old man presented to the Emergency Department with a 6-hour history severe sudden epigastric pain. Physical examination confirmed diffuse severe abdominal tendemess with sluggish bowel sounds (see lab results). Test Result Normal Values WBC 13.8 45-105 x 1091L Amylase 300 24-151 IUL Which of the following is the most appropriate next step in management?

A:

Erect chest X-ray

B:

Abdominal X ray

C:

CT scan abdomen

D:

Ultrasound abdomen

Q.60. A 52-year-old man presented to the Emergency Department complaining of a 5-day history of right upper quadrant abdominal pain associated with fever, and yellowish discoloration of sclera On examination, he was jaundiced with mild right upper quadrant abdominal tenderness (see lab results). Test Result Normal Values Alkaline phosphatase 389 39-117 IU/L Alanine aminotransferase 85 5-40 IU/L Aspartate aminotransferase 78 12-40 IU/L Direct bilirubin 55 1.5-6.5 mol/L Total bilirubin 66 3.5-16.5 pmol/L Which of the following is the most appropriate next investigation?

A:

Abdominal computed tomography

B:

Trans-abdominal ultrasonography

C:

Magnetic resonant cholangiopancreatography

D:

Endoscopic retrograde Cholangiopancreatigraphy

Q.61. A 28-year-old woman was admitted through the Emergency Department with a 12-hour history of epigastric pain. Physical examination confined epigastric tendemess. Over the next 3 days during the hospitalization, the patient completely recovered clinically and biochemically (see lab results and report). Test Result Normal Values Alkaline phosphatase 110 39-117 IU/L Amylase 250 24-151 IUL Ultrasound: Multiple gallstones with mild extrahepatic biliary dilatation. Which of the following is the most appropriate intervention?

A:

Abdominal computed tomography

B:

Cholecystectomy before discharge

C:

Interval cholecystectomy in 6-8 weeks

D:

Endoscopic retrograde cholangiopancreatography

Q.62. A 52-year-old woman presented with a 3-month history of a progressive anterior neck swelling with stridor. She has a 12-year history of Hashimoto's thyroiditis. Physical examination confirmed a diffuse, large, non-tender thyroid swelling with retrosternal extension. A core needle biopsy was ordered (see reports). Ultrasound: Diffuse thyroid enlargement, encasing bilateral carotid sheaths. Histopathology: Malignant thyroid tumour. Which of the following is the most likely tumour?

A:

Follicular

B:

Medullary

C:

Anaplastic

D:

Lymphoma

Q.63. A 65 year old man with a body mass index is 33 kg/m2 has been diagnosed with Type 2 diabetes mellitus. Diet and lifestyle modifications have failed to control his blood sugar over the last three months. He has no known allergies and does not take any regular medications. His blood results are as follows: Serum urea 3.6mmol/L Creatinine 82 mmol/L eGFR 79 ml/min What is the most appropriate pharmacological management?

A:

Biguanide

B:

Sulfonylurea

C:

Sodium glucose co-transporter 2 (SGLT2) inhibitors

D:

Glitazone

Q.64. A 28-year-old man presented with a 2-month history of frequent attacks of bloody stools. Physical examination was unremarkable. Proctoscopic examination showed multiple rectal polyps (see report). Colonoscopy: Colon and rectum were carpeted with polyps, multiple biopsies were taken. Which of the following is the most likely diagnosis?

A:

Ulcerative colitis

B:

Diverticulosis coli

C:

Familial adenomatous polyposis

D:

Human Papilloma virus proctitis

Q.65. A d6-year-old man underwent an ERCP for biliary obstruction; the procedure was prolonged ~~: and difficult. 4 hours later, he developed extensive surgical emphysema of the abdomen, chest and neck. Where is the most likely injury?

A:

Gastric

B:

Tracheal

C:

Duodenal

D:

Oesophageal

Q.66. A 28 year old woman presented to her GP with the complaint of amenorrhoea. On further questioning, she reveals that her last menstrual period was approximately twelve months ago and that she has not had a period since. Her menarche was at the age of twelve years. She reports no symptoms regarding the halt of her menses but claims that her menses have always been rather “light”. She has never had any children and does not think that she could be pregnant as she is not in a current relationship. She has lost 2.3 kilograms (around 5 pounds) of body weight over the past three months and reports a two week history of unilateral foot pain. She is a professional athlete and is currently training hard for the 10 km long distance race in the Olympics. She typically runs around twelve kilometres per day, at least five times per week. She has a very healthy lifestyle and does not smoke or drink alcohol. On physical examination, her body mass index is 19 kg/m2. There is dull pain on palpation along the fourth and fifth metatarsal of her left foot. The physical examination was otherwise normal. A blood sample was taken from the patient and her results are as follows: Follicle stimulating hormone (FSH) 10 U/L Luteinizing horome (LH) 5 U/L Prolactin 750 mU/L Oestradiol 120 pmol/L What is the most likely diagnosis for this patient?

A:

Polycystic ovarian syndrome

B:

Hypothalamic amenorrhoea

C:

Premature ovarian failure

D:

Coeliac disease

Q.67. A 56-year-old woman complains of a 4-month history of a right breast lump, increasing in size, associated with bloody nipple discharge. Physical examination confirmed a dcm central hard mass with ill-defined edges. The right nipple was inverted with enlarged axilary lymph nodes (see repor). Mammogram: Sub-areolar dense irregular density with microcalcification and thickening of overlying skin. Which of the following is the most appropriate next step in management?

A:

Excisional biopsy

B:

Needle core biopsy

C:

Discharge cytology

D:

Fine needle aspiration

Q.68. A 58-year-old man presented with a 3-month history of vague epigastric pain associated with weight loss and loss of appetite. Physical examination was normal. Which of the following is the most appropriate investigation?

A:

Plain abdominal CT

B:

Gastroduodenoscopy

C:

Abdominal ultrasound

D:

Gastrografin swallow

Q.69. A 22-year-old woman presented 1 week after a laparoscopic appendectomy with mild abdominal pain not associated with nausea or vomiting, she reports passing infrequent loose stool. Physical examination confirmed a soft abdomen with mild tenderness at the wound site (see report). CT scan of abdomen 2x2 cm retrocaecal collection. Which of the following is the most appropriate next step in management?

A:

Percutaneous drainage

B:

Open surgical drainage

C:

Diagnostic laparoscopy

D:

Conservative management

Q.70. A 72-year-old diabetic presented to the Emergency Department with a 2-day history of lower abdominal pain, nausea, vomiting and bloody diarrhoea. Physical examination confirmed tenderness in the left lower quadrant (see lab result and report). Test Result Normal Value WBC 17.44.5105 x 1091L Plain abdominal x-ray: Thickened descending and sigmoid colon with thumb printing appearance. Which of the following is the most likely diagnosis?

A:

Crohn's disease

B:

Ischemic colitis

C:

Ulcerative colitis

D:

Acute diverticulitis

Q.71. A 25-year-old breastfeeding mother presented with right breast pain for 24-hours. Examination confirmed a tender swelling with skin redness in the outer lower quadrant of the right breast, ‘with warm skin, but no fluctuation. Which of the following is the most appropriate initial management?

A:

Aspiration

B:

Flucloxacillin

C:

Prolactin antagonist

D:

Incision and drainage

Q.72. A 30 year old woman complains of decreased appetite and weight gain. She has been having irregular, infrequent periods in the last 10 months. She also feels tired and lethargic majority of the day. On inspection, she has a dry coarse skin. What is the most likely diagnosis?

A:

Hypothyroidism

B:

Hyperthyroidism

C:

Polycystic ovary syndrome

D:

Addison’s disease

Q.73. A 74-year-old man presented with a 2-month history of vague upper abdominal pain associated with progressive yellowish discoloration of his skin and sclera and dark urine. On examination, he was jaundiced (see lab result and report). Test Result Normal Values Alkaline phosphatase 312 39-117 ULL Direct bilirubin 87 1.5-6.5 mol/L Total bilirubin 97 3.5-16.5 umol/L. Ultrasound: Dilated intrahepatic biliary tree with collapsed gallbladder. Which of the following is the most likely diagnosis?

A:

Klatskin tumour

B:

Mirizzi's syndrome

C:

Gallbladder cancer

D:

Periampullary tumour

Q.74. A 24-year-old man presented with neck pain for 4 months. Physical examination of the neck was normal (see lab results and report). Test Result Normal Values Thyroid-Stimulating Hormone 3.6 0.4 - 5.0 U/mL Thyroxine (T4 free serum) 118.5 - 15.2 pmoliL Neck Ultrasound: Normal size thyroid gland with a solitary sold left thyroid nodule measure 9 x 7 mm. Benign looking bilateral cervical lymph nodes. Which of the following is the most appropriate management?

A:

Thyroid scan

B:

Follow up imaging

C:

Fine needle aspiration

D:

Left thyroid lobectomy

Q.75. A 13 year old girl presents to the clinic requesting morning pills. She says the condom she used with her 13 year old boyfriend splint into two while having intercourse. What is the most appropriate action?

A:

Inform the police and then give patient contraception

B:

Inform patient’s General practitioner

C:

Inform patient’s mother and the police immediately

D:

Give contraception

Q.76. ‘A morbidly obese 35-year-old with no relevant past medical history consults for weight reduction. Which of the following is the most useful to determine the most appropriate procedure?

A:

Barium swallow

B:

Upper GI endoscopy

C:

CT scan of abdomen

D:

Ultrasound abdomen

Q.77. A 27-year-old man presented with a 10-day history of right upper quadrant abdominal pain associated with fever. Physical examination confirmed tendemess in the right upper quadrant. (see reports). Enzyme-linked immunosorbent assay: Positive for Entamoeba histolytica. CT scan: Large (10 x15 cm), septated abscess in the right lobe of the liver with poorly defined margin. Which of the following is the most appropriate initial management?

A:

Cephalosporin

B:

Metronidazole

C:

Percutaneous drainage

D:

Percutaneous aspiration

Q.78. A 29 year-old patient presented with a 3-year history of frequent attacks of bloody diarrhoea. On examination, he was pale with a normal abdominal examination (see reports) Barium enema: Featureless “lead-pipe” colon. Colonoscopy: Diffusely inflamed colon with pseudopolyps, featureless terminal ileum and backwash ileiis. Which of the following is the most likely type of colitis?

A:

Crohn's

B:

Amebic

C:

Ischemic

D:

Ulcerative

Q.79. Each yeatr 950,000 people develop myocardial infarction in a population of 250,000,000. Out of these 215,000 die and 112,500 in the first hour. Which of the following is the most likely value for the incidence of myocardial infarction?

A:

112,500 in 250,000,000

B:

112,500 in 215,000,000

C:

215,000 in 250,000,000

D:

950,000 in 250,000,000

Q.80. A 19-year-old man presented with a 3-day history of frequent attacks of per-rectal fresh bleeding. Physical examination confirmed clotted blood in the rectum. Nasogastric tube was draining greenish coloured fluids (see lab result and report). Test Result Normal Value Hb 85 130-170 g/L (Male) 120-160 g/L (Female) Colonoscopy: No colorectal pathology. Which of the following is the most appropriate diagnostic tool to localize source of bleeding?

A:

Diagnostic laparoscopy

B:

Gastrografin follow through

C:

Upper gastrointestinal endoscopy

D:

99mTc labelled sodium pertechnetate

Q.81. A 27-year-old obese woman presented to the Emergency Department with a 6-day history of ightliac fossa pain associated with nausea, vomiting, and loss of appetite. Physical examination confirmed tenderness in the right iliac fossa (see lab result). Test Result Normal Value WBC 134.5-10.5 x 109/L Which of the following is the most appropriate next step in management?

A:

Open surgery

B:

Abdominal CT scan

C:

Abdominal ultrasound

D:

Diagnostic laparoscopy

Q.82. A 60 year old female has pain and stiffness in her right hip joint. The pain has been worsening over the past 6 months. The pain increases in intensity as the day progresses and it is usually least pain in the morning. She has noticed nodules in the joints of the fingers of her hands. A recent blood test shows: Haemoglobin 92 g/L White cell count 9.8 x 109/L Platelets 250 x 109/L What is the most likely diagnosis?

A:

Rheumatoid arthritis

B:

Osteoarthritis

C:

Gout

D:

Pseudogout

Q.83. A 28-year-old is 4-days post-exploratory laparotomy for a perforated acute appendicitis and is complaining of generalized abdominal discomfort and vomiting. Physical examination confirmed a distended abdomen, mild generalized tenderness, and sluggish bowel sounds (see lab resuit and report) Test Result Normal Value WBC 12.5 45-105 x 1091L Abdominal X-ray: Multiple air-fiuid levels. Which of the following is the most likely diagnosis?

A:

Paralytic ileus

B:

Volvulus of small bowel

C:

intra-abdominal collection

D:

Adhesive small bowel obstruction

Q.84. A 68-year-old man was admitted through the Emergency Department with a 24-hour history of sudden severe lower abdominal pain, associated with progressive abdominal distension and constipation. On examination, the abdomen was hugely distended, tympanic with tenderness over the left iliac fossa. A digital rectal examination confirmed an empty rectum (see lab result and report). Test Result Normal Value WBC 224.5-10.5 x 109L Abdominal plain X-ray: Y-shaped shadow surrounded by a hugely distended colon arising from the pelvis. Which of the following is the most appropriate intervention?

A:

Fleet enema

B:

Colonoscopy

C:

CT with double contrast

D:

Sigmoid colectomy with end colostomy

Q.85. A 45-year-old patient complains of frequent anal itching, and post defecation pain. Which of the following is the most likely diagnosis?

A:

Anal fissure

B:

Perianal fistula

C:

Perianal hematoma

D:

Internal hemorrhoids

Q.86. A 65-year-old man presented to the Emergency Department with an 8-hour history of severe, sudden central abdominal pain associated with vomiting. He has a history of cardiomyopathy. He reports having passed loose stools once. On examination, the abdomen was soft with exaggerated bowel sounds (see lab results). Test Result Normal Values WBC 26.7 4.5-10.5 x 100/L Amylase 155 24-151 IUL Which of the following Is the most likely diagnosis?

A:

Acute pancreatitis

B:

Small bowel obstruction

C:

Dissecting aortic aneurysm

D:

Mesenteric vascular occlusion

Q.87. A 33-year-old man presented to the Emergency Department with a 24-hour history of epigastric pain. Physical examination confirmed tenderness in the epigastric area with normal bowel sounds (see lab results and report) Blood pressure 100/60 mmHg Heart rate 110 /min Temperature 37.7 °C Test Result Normal Values WBC 144.5105 x 1091 Amylase 223 24-151 IUL Erect chest x-ray: Free air under diaphragm. Which of the following is the most appropriate next step in management?

A:

Gastrografin swallow

B:

Gastroduodenoscopy

C:

Exploratory laparotomy

D:

Conservative treatment

Q.88. A 38-year-old woman presented to the Emergency Department with epigastric pain for 6-days, radiating to the back, associated with frequent vomiting. She is known to have multiple small gallstones. Physical examination confirmed diffuse abdominal distention, epigastric tendemess with sluggish bowel sounds (see lab results and report). Test Result Normal Values Alkaline phosphatase 115 33-117 IU/L Amylase 149 24-151 UL Direct bilirubin 5.6 1.56.5 pmol/L Total bilirubin 15.8 3.5-16.5 pmol/L Erect chest X-ray: Left pleural effusion. Which of the following is the most appropriate initial investigation?

A:

Trans-abdominal ultrasound

B:

Urine analysis for amylase level

C:

Abdominal computed tomography

D:

Analysis of gastrointestinal aspirated fluids

Q.89. A 36-year-old patient presented with a left neck mass. Examination confirmed a 2 x 2 cm mass at the posterior triangle just below the angle of the mandible (see reports). Ultrasound of the neck Normal thyroid gland, large left cervical lymph node with cystic changes. Fine needle aspiration: The entire smear consists of follicular thyroid cells. Which of the following is the most likely diagnosis?

A:

Thyroglossal cyst

B:

Ectopic thyroid gland

C:

Apparent thyroid gland

D:

Metastatic thyroid cancer

Q.90. A 33 year old man presents with an erythematous patch on his thigh, which has been enlarging in the last few days. He went for a camping trip a week ago. He has no allergies to any known medication. He is otherwise asymptomatic. What is the most appropriate management?

A:

Erythromycin

B:

Doxycycline

C:

Penicillin

D:

Ceftriaxone

Q.91. A 55 year old man has a firm belief that the headlines in the newspapers are written especially for him. He believes that the authors of the newspaper articles whom he has never met are sending secret and significant messages that only he can understand. What is the most likely type of delusion that this man is suffering from?

A:

Persecutory delusions

B:

Grandiose delusions

C:

Delusion of control

D:

Delusion of reference

Q.92. A 20-year-old patient underwent a right hemithyroidectomy for a symptomatic right thyroid nodule (see report). Histopathology: A 3x4 cm colloid nodule. There was a focal will differentiated papillary carcinoma measured 8 mm away from the main lesion, there was no extrathyroidal extension, and no lymphovascular invasion. Which of the following is the most appropriate management?

A:

Follow-up

B:

Whole body iodine scan

C:

Radioactive iodine ablation

D:

Completion of thyroidectomy

Q.93. A 44-year-old patient presented with an anterior neck swelling for 2 months. Physical examination confirmed a hard lump in the left side of the anterior triangle of the neck moving up ‘with swallowing but no palpable cervical lymph nodes (see reports). Ultrasound Mildly enlarged thyroid, with 1.5 cm solid nodule in the left lobe. Normal right lobe Fine needle aspiration cytology: Medullary thyroid cancer. Which of the following is the most appropriate procedure?

A:

Nodule enucleation

B:

Total thyroidectomy

C:

Subtotal thyroidectomy

D:

Left hemithyroidectomy

Q.94. Which of the following is most commonly associated with biliary colic?

A:

Bilirubin

B:

Amylase

C:

Cholecystokinase

D:

Alkaline phosphatase

Q.95. A 33-year-old woman presented with a lump in her neck. Physical examination confirmed enlarged right cervical lymph nodes with normal thyroid gland. She underwent percutaneous biopsy of the lymph nodes (see report). Histopathology: Normal follicular thyroid cells. Which of the following is the most likely diagnosis?

A:

Ectopic thyroid

B:

Thyroid lymphoma

C:

Papillary thyroid cancer

D:

Follicular thyroid cancer

Q.96. A 37-year-old complained of a right breast lump for 3 months. She has family history of breast cancer. Physical examination confirmed a hard lump in the upper outer quadrant of the right breast with il-defined edge and skin tethering and no palpable axilary lymph node. Which of the following is the most appropriate next step in management?

A:

MRI breast

B:

Core needle biopsy

C:

Bilateral mammography

D:

Fine needle aspiration cytology

Q.97. A 62-year-old man presented with a 3-month history of early satiety and 11 kg weightloss. | Physical examination was normal (see reports). Upper GIT endoscopy: Ulcerating mass in the antrum. Multiple biopsies were taken. Histopathology: Invasive adenocarcinoma. Which of the following is the most appropriate next investigation?

A:

Abdominal ultrasound

B:

Endoscopic ultrasound

C:

Diagnostic laparoscopy

D:

CT scan chest, abdomen and pelvis

Q.98. A 28-year-old woman presented to the Emergency Department with 18-hour history of severe epigastric pain associated with vomiting. She is known to have multiple small gallstones. Physical examination confirmed upper abdominal tendemess (see lab results). Test Result Normal Values WBC 13.4 45-105 x 1091L Alkaline phosphatase 289 39-117 IUL Amylase 488 24-151 IUL Direct bilirubin 19 1.56.5 mol/L Total bilirubin 34 3.5-16.5 mol/L Which of the following is the most appropriate initial management?

A:

Abdominal ultrasound

B:

Intravenous crystalloid infusion

C:

Intravenous broad spectrum antibiotics

D:

Endoscopic retrograde cholangiopancreatography

Q.99. A 65-year-old man presented to the outpatient department complaining of alternating constipation and diarrhoea for 4 months. Physical examination was normal (see reports) Rigid Sigmoidoscopy: Circumferential, uicerating mass in the distal part of sigmoid colon. Multiple biopsies were taken. Histopathology: Adenocarcinoma. Which of the following is the most appropriate next step in management?

A:

Abdominal CT scan

B:

Sigmoidectomy

C:

Colonoscopy

D:

Pelvic MRI

Q.100. A 79 year old man has a diagnosis of lung cancer. He has a sodium level of 122 mmol/L but remains asymptomatic for hyponatraemia. What is the most appropriate management?

A:

Demclocycline

B:

Vasopressin

C:

Fluid restriction

D:

Reassure

Q.101. A 58-year-old woman presented to the Emergency Department with a 2-day history of central abdominal pain, associated with abdominal distension, vomiting and constipation. She has no | history of abdominal surgery. Physical examination confirmed a distended, tympanic abdomen, with exaggerated bowel sounds (see report). Erect abdominal X-ray: Multiple air-fiuid levels with pneumobilia Which of the following is the most likely diagnosis?

A:

Gallstone ileus

B:

Intussusception

C:

Small bowel volvulus

D:

Small bowel ischemia

Q.102. A 33 year old lady who has been traveling around Europe for a few months now returns to the United Kingdom with lethargy, abdominal pain, loose watery diarrhoea and bloating. She has lost a few kilograms since coming back from the trip. Her physical examination remains unremarkable with abdominal examination having mild generalised tenderness. What is the most likely organism causing her symptoms?

A:

Campylobacter jejuni

B:

Salmonella enterica

C:

Shigella dysentry

D:

Giardia lamblia

Q.103. A 5 month old child is unable to speak but makes sounds. She can hold things with her palm, but not with her fingers. She smiles and laughs and is not shy. She cannot sit independently but can hold her hand and sit when propped up against pillows. What is the best development stage to describe this child?

A:

Normal

B:

Delayed speech and language development

C:

Delayed speech and language development

D:

Delayed fine motor development

Q.104. A 29 year old male presents to Accident & Emergency with the complaint of neck stiffness. The patient’s past medical history is significant for schizophrenia, diagnosed a few months ago. His notes mention that his psychiatrist had just started him on a new drug called clozapine due to his previous medication not working. He is on no other medication and denies the use of over the counter medications or illicit drugs. He smokes around five cigarettes a day but does not drink alcohol. Upon physical examination, the patient appears to be working hard to breath. Active and passive flexion and extension of his neck is extremely difficulty to achieve. The patient’s face also appears red and flushed. He also appears to be confused. His vital signs are as follows: Blood pressure 168/98 mmHg Heart rate 114 beats per minute Temperature 39.2 C Oxygen saturation on room air 95% What is the most likely diagnosis?

A:

Bacterial meningitis

B:

Drug overdose

C:

Encephalitis

D:

Neuroleptic malignant syndrome

Q.105. A 36-year-old presented to the Emergency Department with a 9-day history of right iliac fossa pain, diarrhoea and fever. He was diagnosed with Crohn's disease 10 years ago. Physical examination confirmed a tender mass in the right liac fossa (see lab result and report). Test Result Normal Value WBC 17.6 4.5-10.5 x 109/L CT scan: Collection in the right iliac fossa (12x15 cm) with jejune-ileal fistula Which of the following is the most appropriate initial treatment?

A:

Laparoscopic drainage

B:

Percutaneous drainage

C:

Open surgical drainage

D:

Open drainage with resection of fistula

Q.106. A 20 year old man presents to A&E after having severe injuries from a road traffic accident. On presentation he is breathless and has severe chest pain. Paradoxical respiration with shortness of breath is seen. His systolic blood pressure is 85 mmHg, respiratory rate is 25 breaths/min, oxygen saturation of 88% and his pulse rate is 110/min. What is the most appropriate initial action?

A:

Chest X-ray

B:

Analgesia

C:

High flow oxygen

D:

Secure venous access

Q.107. An 8 year old child is brought into A&E with a fractured leg. The parents are unable to explain how the leg fractured. X-rays reveal several other fractures in various stages of healing. The parents cannot explain what might have caused them. On examination, the child has a blue sclerae and difficulty hearing. What is the most likely diagnosis?

A:

Osteogenesis imperfecta

B:

Non accidental injury

C:

Haemophilia

D:

Achondrogenesis

Q.108. A 65-year-old man was admitted and ventilated in the Intensive Care Unit following a major burn injury. He was referred to surgery due to a 24-hour history of right upper quadrant abdominal pain. Physical examination confirmed tenderness in right upper quadrant (see reports). Erect chest X-ray: Normal. Ultrasound: Distended gallbladder with thick wall and pericholecystic fluid but no gallstone. Which of the following is the most appropriate next step?

A:

Open cholecystectomy

B:

Cholecystostomy tube insertion

C:

Abdominal computed tomography

D:

Magnetic resonant cholangiopancreatography

Q.109. A 30-year-old underwent a laparoscopic appendectomy 2 weeks ago (see report). | Histology: Carcinoid tumor at the tip of the appendix measuring 0.5 cm Which of the following is the most appropriate management?

A:

Colonoscopy

B:

No further action needed

C:

Limited right hemicolectomy

D:

CT scan of chest abdomen and pelvis

Q.110. A 33-year-old women presented with 1-day history of right upper quadrant abdominal pain associated with fever, nausea and vomiting. Physical examination confirmed marked tendemess in the right upper quadrant of the abdomen (see report). Uttrasound: Thick wall gallbladder, pericholecystic fluids and multiple gallstones. Which of the following is the most appropriate management?

A:

Early open cholecystectomy

B:

Early laparoscopic cholecystectomy

C:

Delayed cholecystectomy in 2-3 months

D:

Emergency cholecystectomy tube insertion

Q.111. A 58-year-old man presented with a 4-month history of generalized fatigabilty and shortness of | breath. Physical examination confirmed a non-tender mass in the right iliac fossa (see lab result). Test Result Normal Value Hb 66 130-170 g/L Which of the following is the most important step in management?

A:

Colonoscopy

B:

Abdominal ultrasound

C:

Percutaneous biopsy of the mass

D:

Abdominal computed tomography

Q.112. A 52-year-old complains of left lower abdominal pain associated with passing loose stool and a loss of appetite. Examination confirmed left iliac fossa guarding and rebound tenderness (see : lab result). Blood pressure 110/70 mmHg Heart rate 98 /min Test Result Normal Value WBC 194.5-10.5 x 1091 Which of the following is the most likely diagnosis?

A:

Diverticulitis

B:

Pyelonephritis

C:

Sigmoid malignancy

D:

Ruptured ovarian cyst

Q.113. A 32-year-old woman presented with a 2-month history of left breast pain associated with bloody nipple discharge. Physical examination confirmed a normal left breast and axilla Which of the following is the most appropriate initial breast investigation?

A:

MRI

B:

CTscan

C:

Ultrasound

D:

Mammogram

Q.114. A 25-year-old presented to the Emergency Department with a 2-day history of diffuse colicky abdominal pain, associated with abdominal distension, vomiting and constipation. Physical examination confirmed diffuse abdominal discomfort with exaggerated bowel sounds (see reports). CT scan: Distended proximal small bowel with complete obstruction at the proximal ileum. Exploratory laparotomy: 3 strictures over 60 cm of the ileum, the proximal one was the cause of small bowel obstruction. Which of the following is the most likely diagnosis?

A:

TB enteritis

B:

Crohn's disease

C:

Small bowel lymphoma

D:

Gastrointestinal stromal tumour

Q.115. A 21 year old man presents with mild jaundice. Haemoglobin 75 g/L Reticulocytes 7% There are spherocytes seen on the blood film. He has no past medical history of any significance. What is the most appropriate investigation?

A:

G6PD enzyme assay

B:

Direct Coombs test

C:

Indirect Coombs test

D:

Bone marrow biopsy

Q.116. A 41-year-old woman presented to the Emergency Department complaining of a 2-week history of upper abdominal pain associated with vomiting and fever. History reveals she underwent conservative treatment of acute hyperlipidaemia induced pancreatitis 6 weeks ago. Physical examination confirmed tenderness in the epigastric region (see lab result and report). Blood pressure 110/70 mmHg Heart rate 100 /min Temperature 38.1 °C Test Result Normal Values WBC 202 4.5-10.5 x 109/L Amylase 245 24-151 IUL Ultrasound: Well circumscribed collection (15 x 17 cm) in the lesser sac.Which of the following is the most appropriate initial method of drainage?

A:

Endoscopic

B:

Percutaneous

C:

Percutaneous

D:

Open surgical

Q.117. Which of the following is the most common cause of fever in the first 24-hours after abdominal surgery?

A:

Atelectasis

B:

Wound infection

C:

Blood transfusion

D:

intra-abdominal collection

Q.118. A 31-year-old patient presented with a 12-hour history of severe epigastric abdominal pain. Physical examination confirmed a tender abdomen with sluggish bowel sounds (see reports). Erect chest X-ray: Air under the diaphragm. Exploratory laparotomy: A 5x5 mm perforation in the anterior aspect of the 1st part of duodenum with peritoneal soiling. Which of the following is the most appropriate management?

A:

Distal gastrectomy

B:

Pyloroplasty with truncal vagotomy

C:

Simple closure with omental patching

D:

Pyloroplasty with high selective vagotomy

Q.119. A 38-year-old woman presented to Emergency Department complaining of epigastric pain and post-prandial vomiting. She was conservatively treated for acute pancreatitis 4 weeks ago. Physical examination confirmed tendemess and fullness in the epigastric region (see lab resuits and report) Test Result Normal Values Amylase 413 24-151 UL WBC 15.94.5-10.5 x 109/L Abdominal ultrasound The fluid collection is surrounded by a thick wall in the lesser sac 15 x 17 cm in size. Which of the following is the most likely diagnosis?

A:

Abscess

B:

Phlegmon

C:

Pseudocyst

D:

Walled off necrosis

Q.120. A 20 year old man suddenly develops shortness of breath over the last day. It started when he was playing football. The shortness of breath was associated with right sided pleuritic chest pain. On examination, reduced air entry with hyper-resonance was noted over the right lung field. His oxygen saturation was 91% on room air. What is the most likely diagnosis?

A:

Asthma

B:

Spontaneous pneumothorax

C:

Tension pneumothorax

D:

Chronic obstructive pulmonary disease (COPD)

Q.121. A 5 year old boy was rushed to the emergency department unconscious after he had taken methadone belonging to his sister. He was given naloxone and he regained consciousness. After a while he started getting drowsy again. What is the most likely reason for his drop in level of consciousness?

A:

Naloxone is absorbed faster than methadone

B:

Methadone is absorbed faster than naloxone

C:

Methadone increases elimination of naloxone

D:

Naloxone has a shorter half life compared to methadone

Q.122. A 65-year-old man presented with a 3-month history of vague upper abdominal pain associated with progressive yellowish discoloration of his sclera, dark urine and weight loss. On examination, he was jaundiced with a palpable, distended non-tender gallbladder (see lab results). Test Result Normal Values Alkaline phosphatase 320 39-117 IU/L Direct bilirubin 77 1.5-6.5 pmol/L. Total bilirubin 88 3.5-16.5 pmol/L Which of the following is the most likely diagnosis?

A:

Kiatskin tumour

B:

Periampullary tumour

C:

Common bile duct stone

D:

Hepatocellular carcinoma

Q.123. A 42 year old woman is 16 weeks pregnant. She was late in booking her antenatal appointments and missed her first trimester scan. She is extremely worried about an abnormal chromosomal anomaly in her unborn baby as her first child was born with Down Syndrome. What is the most definitive investigations at this stage?

A:

Amniocentesis

B:

Chorionic villous sampling

C:

Parents karyotyping

D:

Parents karyotyping

Q.124. A 58 year old man with a history of type 1 diabetes mellitus and hypertension for 13 years develops sudden central chest pain and abdominal pain for 45 minutes. The pain radiates to his jaw. It started while he was driving and it was associated with cold sweating and dyspnoea. He describes the pain as a burning pain. What is the most likely diagnosis?

A:

Myocardial infarction

B:

Pericarditis

C:

Pulmonary embolism

D:

Costochondritis

Q.125. A 28-year-old presents with a neck mass that has been present for 1 year and is not associated with pressure symptoms. Physical examination confirmed a diffuse thyroid enlargement (see lab results and report) Blood pressure 120/70 mmHg Heart rate 90 /min Temperature 36.7 °C Test Result Normal Values Thyroid-Stimulating Hormone 0.001 0.4 - 5.0 uU/mL Thyroxine (T4 free serum) 21 8.5 - 15.2 pmollL Ultrasound thyroid: Enlarged both thyroid lobes, with a solid nodule on the left side measure 1 x 2 cm and another nodule at the right side measure 4 x 3 cm. Which of the following is the most appropriate next step in management?

A:

Thyroid scan

B:

Total thyroidectomy

C:

Fine needle aspiration of both nodules

D:

Fine neede aspiration

Q.126. A 33-year-old presented with a lump in her neck. Physical examination confirmed enlarged right cervical lymph nodes with normal thyroid gland. She underwent percutaneous biopsy of the lymph nodes (see report). Histopathology: Normal follicular thyroid cells. Which of the following is the most appropriate next step?

A:

Reassurance

B:

Surgical referral

C:

Lymph node excision

D:

3 months follow up ultrasound

Q.127. An 18 year old male washes his hands 6 times every time he uses the toilet. On his way out of the toilet, he has to switch off the light, turn it back on and turn it off once more. What is the most appropriate management?

A:

Psychodynamic therapy

B:

Electroconvulsive therapy (ECT)

C:

Antipsychotics

D:

Cognitive behavioural therapy (CBT)

Q.128. A patient presented with severe maxillofacial injury with mandibular fracture dislocation and profuse oral bleeding. Which of the following is the most appropriate way to secure the airway?

A:

Laryngeal mask

B:

Orotracheal tube

C:

Nasotracheal tube

D:

Cricothyroidotomy

Q.129. A 33 year old schizophrenic says the following. “Life is unfair, I eat air, law chair, I like fairs, fairs have foot, it must be good, in adulthood, I misunderstood”. What term describes this patient’s speech?

A:

Neologism

B:

Pressure of speech

C:

Broca’s aphasia

D:

Clang association

Q.130. A 32-year-old woman presented to the Emergency Department with severe pain in the right upper quadrant of the abdomen following a fatty meal 6-hours ago. This pain has decreased in severity over the last 2 hours. The pain was radiating to the right subscapular area associated with vomiting. Physical examination was normal (see lab results and report). Test Result Normal Values WBC 8.24.5-10.5 x 109/L Amylase 134 24-151 IUL Ultrasound: Multiple gallstone with normal gallbladder wall. Which of the following is the most appropriate management?

A:

Observation

B:

Ursodeoxycholic

C:

Laparoscopic cholecystectomy

D:

Magnetic resonant cholangiopancreatography

Q.131. A 60-year-old woman complains of left nipple discharge that is spontaneous, blood stained and recurrent for the past 6 months. Physical examination was normal (see reports). Bilateral Breast Mammogram: Normal, Breast Ultrasound: Bilateral ductal dilatation, there is a 12 mm left intraductal lesion, suggestive of intraductal papiloma Which of the following is the most appropriate next step in management?

A:

Discharge fluid cytology

B:

Left central duct excision

C:

Image-guided core biopsy

D:

Short-interval follow-up imaging

Q.132. A 37 year old man has a nonhealing ulcer on the skin of the right medial malleolus. Which lymph node is likely to be involved?

A:

Axillary lymph nodes

B:

Pre-aortic lymph node

C:

Aortic lymph node

D:

Inguinal lymph node

Q.133. Which of the following is the most preferred mesh placement for a ventral hernia repair?

A:

Inlay

B:

Inlay

C:

Sublay

D:

Undertay

Q.134. A 60 year old woman has lower abdominal discomfort and mild abdominal distension. On pelvic examination, a nontender, solid irregular right adnexal mass is felt. Her Pap smear done a year ago was normal. What is the most appropriate tumour marker to request for?

A:

CA 125

B:

CA 15-3

C:

CA 19-9

D:

Carcinoembryonic antigen (CEA)

Q.135. A 25-year-old man underwent an exploratory laparotomy 5-days ago, for a perforated peptic ulcer. He continues to have abdominal distension and vomiting. Physical examination confirmed a distended non-tender abdomen with sluggish bowel sounds (see report). Abdominal X-ray Dilated small and large bowel with multiple air-fluid levels. Which of the following Is the most appropriate next step in management?

A:

Abdominal ultrasound

B:

Gastrografin follow-through

C:

Check serum potassium level

D:

Abdominal computed tomography

Q.136. A 45-year-old woman presents to the Emergency Department with severe continuous mid- abdominal pain for 16 hours, associated with nausea and vomiting. She is known to have cholelithiasis. Physical examination confirmed epigastric tendemess (see lab results). Test Result Normal Values WBC 134.5-10.5x 1091. Amylase 650 24-151 ULL Which of the following is the most likely diagnosis?

A:

Hepatitis

B:

Acute pancreatitis

C:

Acute cholecystitis

D:

Perforated peptic ulcer disease

Q.137. A 29-year-old woman presented to the Emergency Department with an 8-hour history of severe epigastric pain radiating to the back associated with vomiting. She underwent a sleeve gastrectomy 3 months ago for morbid obesity. Physical examination confirmed mild epigastric tenderness (see lab results and report). Test Result Normal Values WBC 9.8 4.5-10.5 x 109/L Amylase 700 24-151 ULL Uttrasound: Biliary sludge but no gallstone. Normal bile ducts. Which of the following is the most appropriate intervention?

A:

Endoscopic ultrasound

B:

Endoscopic sphincterotomy

C:

Laparoscopic cholecystectomy

D:

Percutaneous cholecystostomy

Q.138. A 33 year old man is brought into the emergency department following a road traffic accident. He is seen to be very short of breath. He has no breath sounds over the right side of his chest. On percussion, the right chest is noted to be hyper-resonant. On examination, his trachea is deviated to the left. His heart rate is 120 beats/minute. His blood pressure is 90/65 mmHg, and has an oxygen saturation of 85% on 15 L of oxygen. What is the most appropriate course of action?

A:

Arterial blood gas

B:

Urgent chest X-ray

C:

Needle decompression

D:

Urgent computed tomography scan of chest

Q.139. A 42-year-old woman presented with a 4-month history of an anterior neck swelling. Physical examination confirmed a solitary nodule in the right lobe of thyroid (see lab results and report) Test Result Normal Values Thyroid-Stimulating Hormone 0.05 0.4 - 5.0 U/mL Thyroxine (4 free serum) 37 8.5 - 15.2 pmol Ultrasound: Right thyroid lobe solitary solid nodule 2 x 3 cm. Which of the following is the most appropriate next step in management?

A:

Thyroid CT scan

B:

Right hemithyroidectomy

C:

Thyroid isotope scintigraphy

D:

Fine needle aspiration cytology

Q.140. A 28-year-old married woman presented to the Emergency Department complaining of a 6-hour history of right iliac fossa pain associated with drowsiness. Physical examination confirmed tenderness over the lower abdomen with sluggish bowel sounds. Which of the following is the most ikely diagnosis?

A:

Septic shock

B:

Ectopic pregnancy

C:

Ectopic pregnancy

D:

Pelvic inflammatory disease

Q.141. A 54 year old man has just had a cardiac arrest. He is currently being managed in the Intensive Care Unit (ICU). He is on a ventilator. His vitals were taken and are as follows: Pulse 120 beats/minute Blood pressure 100/50 mmHg An arterial blood gas was also done for this patient and the results are as follows: pH 7.03 pCO2 9.8 kPa PaO2 12 kPa HCO3 18 mmol/L What is the most appropriate next step in management of this patient?

A:

Bicarbonate

B:

Intravenous fluid

C:

Inotropic drugs

D:

Increase ventilation

Q.142. A 29 year old diabetic woman presents to her GP surgery with a history of gradual worsening pain in the left ear for the past 5 days. She denies hearing loss. On examination, there is a small, red, tender mass at the outer third of the external canal. Insertion of the otoscope causes severe localized pain. There is no discharge seen. What is the most likely diagnosis?

A:

Chondromalacia

B:

Furuncle

C:

Myringitis

D:

Cholesteatoma

Q.143. A 33 year old woman who is rhesus negative had just delivered vaginally 3 hours ago. She would like to know when is the best time for anti-D immunoglobulins to be administered. What is the recommended time to administer anti-D immunoglobulins to a previously non-sensitised rhesus negative mother after delivery?

A:

As soon as possible and always within 24 hours

B:

Anytime in the time frame of 48 hours

C:

As soon as possible and always within 72 hours

D:

Up to 10 days

Q.144. A 60 year old man was screwing his cupboard to the wall when he suddenly felt a rupture at the cubital fossa resulting in a swollen elbow with weakness on flexion and supination. A lump in the distal arm is seen. What is the most likely diagnosis?

A:

Hand flexor tendon rupture

B:

De Quervain’s disease

C:

Biceps tendon rupture

D:

Tennis elbow

Q.145. A 58-year-old man presented to the Emergency Department complaining of right ac fossa pain for 5 days. Physical examination confirmed a tender mass in the right iiac fossa. The patient was admitted, treated non-operatively and discharged from the hospital after 7 days with complete recovery (See report) Ultrasound: Appendiceal mass without collection. Which of the following is the most appropriate next step?

A:

No further intervention

B:

Colonoscopy in 6 weeks

C:

Open appendectomy in 12 weeks

D:

Laparoscopic appendectomy in 12 weeks

Q.146. Which of the following hormones reduces the water loss through the kidneys?

A:

Vasopressin

B:

Angiotensin

C:

Cortisone

D:

Rennin

Q.147. A 41 year old lady is suffering from fever, sore throat and loss of appetite. Her symptoms have been persistent and worsening over the past few weeks. She has had a recent renal transplant and is currently on immunosuppressive medication. Serology was taken for toxoplasmosis and has returned with the presence of IgE antibodies which is interpreted as having a recent acquired infection. Her renal function is satisfactory. What is the most appropriate treatment?

A:

Pyrimethamine

B:

Pyrimethamine + sulfadiazine

C:

Clindamycin

D:

Spiramycin

Q.148. A 38-year-old man with a history of recurrent acute pancreatitis over the last 10 years, presents EE with a 12-hour history of frequent episodes of vomiting fresh blood. Intravenous fluid resuscitation was initiated (see reports). Upper gastrointestinal endoscopy: Isolated bleeding fundal varices which has been controlled by injection sclerotherapy. Ultrasound Splenomegaly, normal portal vein and thrombosed splenic vein. Which of the following is the most appropriate management?

A:

Splenectomy

B:

Portacaval shunt

C:

Distal splenorenal shunt

D:

Sengstaken blakmore tube

Q.149. A 34 year old pregnant woman was involved in a road traffic accident and presents to the hospital with circulatory collapse. She is a Jehovah’s Witness and carrying a witnessed written directive refusing blood and all blood products. She is taken to the operating table where the surgical team is finding it difficult to stop the bleeding. Her haemoglobin is 40 g/L. She urgently requires blood transfusion. What is the most appropriate action?

A:

Respect patient wishes and proceed with fluid resuscitation

B:

Do not transfuse packed cells but infuse platelets

C:

Transfuse anyway as this is a life-threatening emergency

D:

Obtain written consent from husband and transfuse blood

Q.150. A 51 year old man presents to the medical out-patient clinic with the complaint of difficulty in climbing up stairs. He has been having these symptoms for a few months and has complaint to his general practitioner before of diffuse muscular aches in the limbs and back. He describes difficulty in getting up from a seated position and general weakness of his quadriceps. He has a poor diet and drinks about 3-4 units of alcohol a week. He gives a history that he does not go out much. He takes oral steroids during his COPD exacerbations which usually occurs three times a year. A full blood count, urea and electrolytes and a liver function test were done, and they show: Haemoglobin: 13.2 g/dL Platelets: 220 x 109/L White cell count: 5.8 x 109/L Sodium: 138 mmol/L Potassium: 4.1 mmol/L Bilirubin: 13 micromol/L Alanine transferase (ALT): 24 U/L Asparate transaminase (AST): 19 U/L Alkaline phosphatase (ALP): 391 U/L Gamma glutamyl transferase (Gamma-GT): 34 U/L Creatine kinase: 192 U/L What is the most likely diagnosis?

A:

Polymyalgia rheumatica

B:

Osteomalacia

C:

Steroid myopathy

D:

Polymyositis

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MOCK TEST 7

Q.6. A 36-year-old woman complaining of per-rectal bleeding and prolapsed tissue masses through the anal verge. Anorectal examination confirmed grade IV haemorthoids at 3, 7, and 11 clock | positions. Which of the following is the most appropriate management?

Q.7. This is the likelihood of a test reporting positive when the condition being tested is actually present. What is the most likely term?

Q.12. A 50-year-old man underwent an open mesh repair of a left inguinal hernia. He presented 2 months later because he noticed that the left testes had become smaller in size. Which of the following is the most likely cause?

Q.16. Which of the following is the most common cause of biliary colic?

Q.21. A 75 year old man is found to be unresponsive. The ward doctor is called to the patient’s bedside. He is not breathing and has no detectable pulse. Which is the most appropriate next step?

Q.22. A patient presented with severe diarrhoea. Which of the following is the most expected abnormalities?

Q.23. A 66-year-old healthy man complains of rectal bleeding for 3 months. Anorectal examination confirmed 3rd degree haemorrhoids. Which of the following is the most appropriate next step in management?

Q.26. What structure passes through the deep inguinal ring?

Q.27. A 78 year old man has a painless sudden collapse. His pulse is 120 beats/minute, blood pressure of 70/40 mmHg. Examination reveals a mottled skin of the lower body and a pulsatile abdominal mass. What is the most likely diagnosis?

Q.34. A 48 year old man attends his GP surgery. He was started on fluoxetine 8 weeks ago for depression and is now requesting to stop his medication as he feels well and does not think he is depressed any longer. What is the most appropriate advice to give to him in regards to his treatment?

Q.36. A 6 year old boy was playing at home alone when he stuck super glue into his ear. His mother has brought him to A&E and is extremely concerned. On inspection, the adhesive is in contact with the tympanic membrane. What is the most appropriate management?

Q.37. A 67 year old man with history of weight loss complains of hoarseness of voice. Chest x-ray reveals opacity in the right upper mediastinum. He denies any history of difficulty breathing. What is the most appropriate investigation?

Q.42. A 55-year-old man presented with a 4-month history of vague epigastric pain associated with 15 kg weight loss. Physical examination confirmed enlarged left supractavicular lymph nodes and gross ascites. Which of the following is the most appropriate next step in management?

Q.43. A 19-year-old woman complains of a 4-month history of a left breast mass. Breast examination confirmed a well-circumscribed, firm, smooth mobile lump, 2x2 cm in size, in the lateral upper quadrant of the left breast. Which of the following is the most likely diagnosis?

Q.44. A 22-year-old man underwent an open left inguinal hernia mesh repair 2 weeks ago, presented with continuous discharge from the surgical wound. Examination confirmed a 2 x 3 cm pus- discharging wound with part of the mesh exposed. Which of the following is the most appropriate management?

Q.45. A 39 year old woman has been having tingling and numbness of her thumb, index and middle fingers for a while. She has been treated with local steroids but there was no improvement. She has planned to undergo a surgical procedure. What is the most likely structure to be incised?

Q.47. A 26-year-old man presented 3 days after a sleeve gastrectomy with left upper abdominal pain. Physical examination confirmed only mild upper abdominal tenderness with no sign of peritonitis. Blood pressure 100/70 mmHg Heart rate 116 /min Which of the following is the most likely explanation?

Q.49. A 36 year old lady has diarrhoea for the last 2 months. She has lost 8 kg in that time period. A colonoscopy was performed which showed fistulas. Perianal fistulas are also noticed. What is the most likely diagnosis?

Q.53. A 48 year old man after surgical removal of mandibular cancer presents with perioral paresthesia and severe perioral pain which is not relieved by oral morphne and ibuprofen. The skin is also very tender to touch. What is the most appropriate next step in management to relieve the pain?

Q.55. A 52 year old man who underwent a partial gastrectomy 10 months ago presents with increasing fatigue. A yellow tinge is noted on his skin and he has a red sore tongue. What is the most likely diagnosis?

Q.56. A morbidly obese 23-year-old man complains of gastroesophageal reflux disease (see report). Upper GI endoscopy: Large hiatus hernia with grade Ill reflux. Which of the following is the most appropriate weight reduction procedure?

Q.58. A 52 year old woman with a history of systemic lupus erythematosus complains of dry eyes and altered sense of taste. Her voice becomes hoarse when she speaks for long periods of time. What is the most likely diagnosis?

Q.65. A d6-year-old man underwent an ERCP for biliary obstruction; the procedure was prolonged ~~: and difficult. 4 hours later, he developed extensive surgical emphysema of the abdomen, chest and neck. Where is the most likely injury?

Q.68. A 58-year-old man presented with a 3-month history of vague epigastric pain associated with weight loss and loss of appetite. Physical examination was normal. Which of the following is the most appropriate investigation?

Q.72. A 30 year old woman complains of decreased appetite and weight gain. She has been having irregular, infrequent periods in the last 10 months. She also feels tired and lethargic majority of the day. On inspection, she has a dry coarse skin. What is the most likely diagnosis?

Q.75. A 13 year old girl presents to the clinic requesting morning pills. She says the condom she used with her 13 year old boyfriend splint into two while having intercourse. What is the most appropriate action?

Q.76. ‘A morbidly obese 35-year-old with no relevant past medical history consults for weight reduction. Which of the following is the most useful to determine the most appropriate procedure?

Q.79. Each yeatr 950,000 people develop myocardial infarction in a population of 250,000,000. Out of these 215,000 die and 112,500 in the first hour. Which of the following is the most likely value for the incidence of myocardial infarction?

Q.85. A 45-year-old patient complains of frequent anal itching, and post defecation pain. Which of the following is the most likely diagnosis?

Q.90. A 33 year old man presents with an erythematous patch on his thigh, which has been enlarging in the last few days. He went for a camping trip a week ago. He has no allergies to any known medication. He is otherwise asymptomatic. What is the most appropriate management?

Q.94. Which of the following is most commonly associated with biliary colic?

Q.100. A 79 year old man has a diagnosis of lung cancer. He has a sodium level of 122 mmol/L but remains asymptomatic for hyponatraemia. What is the most appropriate management?

Q.109. A 30-year-old underwent a laparoscopic appendectomy 2 weeks ago (see report). | Histology: Carcinoid tumor at the tip of the appendix measuring 0.5 cm Which of the following is the most appropriate management?

Q.113. A 32-year-old woman presented with a 2-month history of left breast pain associated with bloody nipple discharge. Physical examination confirmed a normal left breast and axilla Which of the following is the most appropriate initial breast investigation?

Q.115. A 21 year old man presents with mild jaundice. Haemoglobin 75 g/L Reticulocytes 7% There are spherocytes seen on the blood film. He has no past medical history of any significance. What is the most appropriate investigation?

Q.117. Which of the following is the most common cause of fever in the first 24-hours after abdominal surgery?

Q.121. A 5 year old boy was rushed to the emergency department unconscious after he had taken methadone belonging to his sister. He was given naloxone and he regained consciousness. After a while he started getting drowsy again. What is the most likely reason for his drop in level of consciousness?

Q.127. An 18 year old male washes his hands 6 times every time he uses the toilet. On his way out of the toilet, he has to switch off the light, turn it back on and turn it off once more. What is the most appropriate management?

Q.128. A patient presented with severe maxillofacial injury with mandibular fracture dislocation and profuse oral bleeding. Which of the following is the most appropriate way to secure the airway?

Q.129. A 33 year old schizophrenic says the following. “Life is unfair, I eat air, law chair, I like fairs, fairs have foot, it must be good, in adulthood, I misunderstood”. What term describes this patient’s speech?

Q.132. A 37 year old man has a nonhealing ulcer on the skin of the right medial malleolus. Which lymph node is likely to be involved?

Q.133. Which of the following is the most preferred mesh placement for a ventral hernia repair?

Q.134. A 60 year old woman has lower abdominal discomfort and mild abdominal distension. On pelvic examination, a nontender, solid irregular right adnexal mass is felt. Her Pap smear done a year ago was normal. What is the most appropriate tumour marker to request for?

Q.144. A 60 year old man was screwing his cupboard to the wall when he suddenly felt a rupture at the cubital fossa resulting in a swollen elbow with weakness on flexion and supination. A lump in the distal arm is seen. What is the most likely diagnosis?

Q.146. Which of the following hormones reduces the water loss through the kidneys?