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A 55-year-old lady consults her gastroenterologist because of recent onset of intermittent dysphagia for solids. She has a history of gastrooesophageal reflux proven by endoscopy, for which she is on proton pump inhibitor therapy. Her health is otherwise good and her reflux symptoms have been well controlled. She has not lost any weight. She is a smoker, but rarely consumes alcohol. The physical examination is unremarkable.

The next most appropriate course of action is:

A 31-year-old female Cambodian refugee is found to have nephrotic syndrome. Investigations reveal:
urinary protein 7.00 g/day [<0.25]
serum albumin 23 g/L [35-50]
serum creatinine 0.07 mmol/L [0.03-0.11]
A renal biopsy shows membranous nephropathy.

Which one of the following tests is least likely to find the cause?

A 75-year-old woman presents with a three-week history of episodic severe epigastric pain and vomiting. The pain lasts for about three hours and radiates to the right upper quadrant and back. Apart from episodic nausea, she is well between attacks of pain. Past medical history includes a cholecystectomy nine years ago, peptic ulcer disease secondary to non-steroidal anti-inflammatory drugs three years ago and type 2 (non-insulin-dependent) diabetes mellitus diagnosed four years ago.

The most likely diagnosis is:

What is the most common cause of fever in a returned traveller?

A 38-year-old man with abdominal pain has the following results:

sodium 142 mmol/L [138-145]
potassium 2.9 mmol/L [3.5-5.2]
chloride 112 mmol/L [96-109]
corrected calcium 2.40 mmol/L [2.15-2.57]
creatinine 0.11 mmol/L [0.5-0.12]
bicarbonate 15 mmol/L [24-28]
albumin 42 g/L [38-48]

What is the best explanation for these results?

The long term use of omeprazole will most likely lead to which type of electrolyte disturbance?

A 25 year old nurse is brought to the emergency department by a friend who has discovered her with altered mental state.

She is found to have hypoglycemia but does not have a history of diabetes mellitus.

Lab findings:

• Blood glucose 1.7mmol/l
• serum insulin high
• serum C peptide low

What is the most likely diagnosis?

What is most important reason for measuring thyroid stimulating antibodies in the third trimester of pregnancy in a woman with Graves disease?

An 18 year old man wakes after an orthopaedic procedure on his right leg. He is noted to have a right foot drop. Examination shows weakness of the dorsiflexors of the ankle. He has normal plantar flexion at the ankle and normal knee flexion strength. His right ankle jerk is reduced. No sensory abnormality is detected.

Which nerve is most likely affected?

Which of the following condition is associated with increased levels of free testosterone?

What is the first line treatment of metastatic renal cell carcinoma?

A patient presents with TSH of > 4.5 but normal T4 levels .

When should you repeat the test?

A female patient is considering pregnancy . She was initially found to have TSH >4.5 but normal T4.

A repeat test in 3 months show a similar result.

What is the most appropriate next step in management?

A 20-year-old female presents with a one month history of malaise, nausea, abdominal pain, itch and polyarthralgia. She gives no history of recent use of prescribed or illicit drugs. Examination reveals jaundice, multiple bruises, and tender hepatomegaly. Laboratory results are consistent with an acute hepatocellular injury, with a polyclonal increase in IgG (immunoglobulin G) of 32g/L (6.1-15.5).

Serological tests for hepatitis A, B, and C viruses are negative. Histopathological findings on liver biopsy are of a periportal mixed mononuclear cell infiltrate of plasma cells, lymphocytes and eosinophils
consistent with an autoimmune hepatitis.

Which of the following autoantibodies, if present, is most predictive of a poor clinical and biochemical response to therapy?

A 14-year-old girl presents with jaundice, arthralgia and pruritus over the past week. She has recently returned from a trip to South-East Asia.

Her liver function and serology results are shown below:
bilirubin 175 μmol/L [0-15]
alanine aminotransferase (ALT) 1350 U/L [<55]
alkaline phosphatase (ALP) 687 U/L [100-350]
gamma glutamyltransferase (GGT) 425 U/L [0-40]
total protein 70 U/L [57-80]
albumin 24 g/L [33-47]
Epstein-Barr Virus (EBV)-IgG positive
Epstein-Barr Virus (EBV)-IgM negative
hepatitis A virus (HAV)-IgM negative
hepatitis B surface antigen (HBsAg) negative
anti-hepatitis B core antibody (anti-HBc) positive
anti-hepatitis C virus antibody (anti-HCV) negative
antinuclear antibody (ANA) negative
smooth muscle antibody positive

What is the most likely diagnosis?

A 25-year-old man presents six weeks after a trip to central Africa with fever, chills and rigors. Stool examination is positive for Entamoeba histolytica. An ultrasound reveals a 7.5 cm liver abscess. The most appropriate next step in this patient’s management is:

. In a subject taking part in a bioavailability study, the area under the plasma concentration versus time curve (AUC) achieved after an intravenous dose of 20 mg is 100 mg/hr/L, compared with an AUC of 200 mg/hr/L after an oral dose of 50 mg. The oral bioavailability of the drug in this subject is:

A 25-year-old woman is evaluated for a 5-year history of difficult-totreat hypertension. Medical history is unremarkable. Her only medication is diltiazem. There is no family history of hypertension.

On physical examination, blood pressure is 180/115 mm Hg, pulse rate is 88/min, and respiration rate is 16/min. Cardiopulmonary examination reveals a prominent precordial heave and an abdominal bruit. Funduscopic examination reveals grade 2 hypertensive retinopathy.

Laboratory studies:
Sodium 140 mmol/L
Potassium 3.7 mmol/L
Chloride 100 mmol/L
Bicarbonate 28 mmol/L
Blood urea nitrogen 6.4 mmol/L
Serum creatinine 88.4 mmol/L
Plasma renin activity 10 ng/mL/h (normal 0.6-4.3 ng/mL/h)

Which of the following diagnostic studies of the renal arteries should be performed next?

A 57-year-old man with type 2 (non-insulin-dependent) diabetes mellitus presents with a right foot drop. On examination there is mild weakness of right ankle dorsiflexion and toe extension with other muscle groups being normal. Reflexes are symmetrical with bilaterally downgoing plantar responses. Sensory examination is normal. Electromyography (EMG) and nerve conduction studies are shown in the table below.

Needle examination reveals enlarged motor unit potentials in the right tibialis anterior, flexor digitorum longus , and gluteus medius muscles.

The most likely diagnosis is:

A 72 year old man with background of hypertension, previous AAA repair, diabetes, hyperlipidemia and previous stroke presents with acute pulmonary edema. Inpatient ECHO showed normal LV and RV function.EF >65%.A captopril renogram is performed and shows the following:

What is the most likely diagnosis?

What is the leading cause of death for survivors of testicular tumors following successful chemotherapy?

A drug has a fraction excreted unchanged of 0.1 and a total body clearance of 50L/hr. Liver blood flow is 90/L.

What is its maximum oral bioavailability?

Clostridium difficile is a:

Which of the following is the best diagnostic tool to detect early lung toxicity secondary to Bleomycin?

A 60 year old man presents with urinary retention. On examination he has brisk reflexes bilaterally in the lower limbs with up going plantars. Examination of the upper limb is normal.

Where is the lesion?

3. Which of the following pathogen associated molecular patterns (PAMPs) is expressed by gram negative bacteria?

A 60 year old man presents to the emergency department with sudden onset of right arm weakness. When you asked him what happened he replied “fudden in a hair, still larging OK”.

Which of the following best describes this man’s speech abnormality?

Which of the following cells of the immune system is the first to deal with a pathogen that have crossed the epithelial barrier?

A 32 year old woman who is currently 20 weeks pregnant, presents to the Emergency department with a new onset of severe headache associated with ptosis on her right eye but without evidence of fatigability on eye movements. Her pupil size are equal and fundoscopy shows mild bilateral papilloedema.

Her CT head is normal.

Which of the following intervention is least likely to be beneficial in this patient’s management?

Drugs A and B have the following properties in healthy individuals:

In such healthy individuals, haemodialysis shortens the half-life of drug A much more than it shortens the half-life of drug B. This difference is best explained by which of the following characteristics of drug B?

Failure of signalling through the interleukin 7 receptor (IL-7 R), due to inherited deficiency of either the common interleukin receptor γ chain (γc) or Janus kinase 3 (JAK3 protein kinase), produces a severe combined immune deficiency (SCID) state, the features of which are best explained by the loss of expansion of which one of the following cell types?

A 65-year-old man with cirrhosis has significant (grade 2 of 3) oesophageal varices detected on screening endoscopy.

Which of the following is the most appropriate initial management?

Oral medications, Drugs A and B, have the following properties in healthy individuals.

Compared to healthy individuals. patients with cirrhosis have a much higher concentration of drug A than drug B. The best explanation for this is the difference in:

Which of the following immunoglobulins binds with low affinity and high avidity when exposed to antigen?

The following results were obtained from a randomized controlled trial of a new artificial surfactant called “S”.

The number of babies that you would need to treat with S to prevent one case of chronic lung disease is:

The use of sirolimus in renal transplant recipient is most likely to reduce which type of malignancy?

A double blinded randomized control trial for a new drug for prevention of Alzheimer’s disease in a group of at risk patients was conducted over a 10 year follow up period.The absolute risk of developing Alzheimer’s disease in the group receiving placebo was 10%.The relative risk of those with the new medication was 0.8.

What number of patients will need to be treated with active drug for 10 years to prevent one new case of Alzheimer’s disease?

26 year old man has been treated with two previous chemotherapy regimens for metastatic sarcoma. On assessment, he appears tired and requiring regular opioid analgesia. He needs to rest more than half the day in bed.

What is the patient’s ECOG performance status?

Which of the following immunosuppressant is safe for use in pregnancy?

An 84-year-old man is evaluated for a 5-year history of a gradually worsening gait and a 2-year history of cognitive impairment and urinary incontinence. Twelve years ago, he sustained a closed head injury that caused a mild traumatic subarachnoid hemorrhage and a 5-hour loss of consciousness. Medications include zolpidem (when needed as a sleep aid) and a daily multivitamin.

On physical examination, temperature is 36.2 C, blood pressure is 128/78 mm Hg, pulse rate is 76/min, respiration rate is 14/min, and BMI is 27. The patient’s gait is slow and unsteady and is marked by small, shuffling steps. His level of alertness, speech, posture, arm swing, and muscle tone are all normal, and he has no tremor. He scores 24/30 on the Folstein Mini-Mental State Examination, losing one point in the orientation portion for incorrectly stating today’s date, three points in the serial calculation portion, and two points in the recall portion.

Results of a complete blood count, a basic metabolic panel, serum vitamin B12 measurement, thyroid function tests, and a urinalysis are normal.

What is the most likely diagnosis?

FDG-PET is least likely to be useful in the staging of which type of malignancy?

Which of the following is the most common life-threatening hospitalacquired infection?

Which of the following is the strongest visual risk factor for falls in the elderly population?

Which of the following cancers have the best chance of long term survival even with the presence of metastasis?

Which of the following medication has been proven in the HYVET trial to reduce stroke and all cause mortality when given with or without perindopril to people over the age of 80 for the treatment of hypertension?

Which class of drug has strong evidence for association with the risk of falling in older people?

When administered to a 70 year old man, which of the following drugs is most likely to cause urinary retention?

A 25 year old renal transplant patient on mycophenolate and sirolimus visits your practice to get some advice on pre-travel vaccination.

Which of the following vaccines are contraindicated?

What is the most common cause of blindness in the elderly population?

A couple seeks your advice regarding the recurrence risk of the NARP (neuropathy, ataxia, retinitis pigmentosa) syndrome, a disorder with mitochondrial inheritance. They are first cousins and have a family history of the condition.

What is the impact of their consanguinity on the risk of having an affected child?

Which of the following type of mutation results in a single amino acid change in the gene product?

Different mutations in the DMD (Duchenne muscular dystrophy) gene cause three clinically distinct syndromes in males. The table below lists the three conditions, the degree of skeletal muscle weakness, and a number of different abnormal genotypes involving the DMD gene.

Which of the following represents the most likely relationship between the genotypes and phenotypes?

A 55-year-old man has the following lung function test results: FEV1 2.0 L (61% predicted) FVC 2.6 L (68% predicted) FEV1/FVC 77% (85% predicted) TLC 72% predicted RV 75% predicted DLCO 64% predicted
KCO 110% predicted His body mass index (BMI) is 31 kg/m2 [18-25].

Which of the following is the best explanation for these results?

A 55-year-old man has the following lung function test results: FEV1 2.0 L (61% predicted) FVC 2.6 L (68% predicted) FEV1/FVC 77% (80% predicted) TLC 70% predicted RV 75% predicted DLCO 48% predicted
His body mass index (BMI) is 31 kg/m2 [18-25]. No bronchodilator response. Normal CXR.

Which of the following is the best explanation for these results?

The mechanism of hypoxemia in interstitial lung disease is mainly due to?

The following medications causes reduce REM sleep except?

A patient with background of left ventricular failure undergoes a polysomnographic sleep study.
It was noted in this study that during the episodes of reduced oxygen saturation, there was no attempt at breathing.

What could be the underlying cause for this?

Which one of the following condition causes high titers of rheumatoid factor?

Which of the following marker is highly predictive of RA in asymptomatic and early undifferentiated arthritis?

Which of the following are risk factors for RA development?

Which one of the following statements concerning discoid lupus is correct?

Which one of the following is least recognised as a risk factor for developing osteoporosis?

What level of evidence does a randomized control trial offer?

In a particular population, the risk of a healthy 70-year-old person developing dementia over the next five years is 5%. 10% of the total population carry one or two ApoE4 alleles and have a threefold increased risk of developing dementia during this interval.

What is the best estimate of the proportion of people developing dementia during this interval who do not have one or two ApoE4 alleles?

The impact of an intervention in clinical trials and in systematic reviews can be expressed in a number of ways. One increasingly used format is the number needed to treat (NNT) which indicates how many patients have to be treated with the intervention of interest compared to the control intervention in order to achieve one successful outcome.

In a recent systematic review of optimal self-management for adult asthma, the intervention was found to produce a 50% reduction in hospitalisation for asthma. Approximately 10% of patients in the control group required hospitalisation compared to approximately 5% of those who received optimal self-management.

Which one of the following is the best estimate of the number needed to treat for this intervention?

A new diagnostic test for a certain disease has been evaluated.Compared with the definitive diagnostic standard, this test has asensitivity of 100% and a specificity of 95%. The prevalence of thedisorder in the population to be tested is 0.1%.

What is the best estimate of the positive predictive value of the new test?

A pregnant patient is noted to have moderate hypertension.

Treatment with anti-hypertensive will reduce the risk of all the following except?

A 29-year-old primigravida at 29 weeks gestation presents with drowsiness and right upper quadrant pain and vomiting. Physical examination reveals poor peripheral perfusion, a pulse rate of 96/minute and blood pressure of 170/110 mmHg. There is tenderness in the right upper quadrant and brisk reflexes.

Liver function tests show:

• bilirubin 14 μmol/L [2-14]
• alkaline phosphatase (ALP) 200 U/L [40-130]
• gamma glutamyltranspeptidase (GGT) 15 U/L [1-35]
• aspartate transaminase (AST) 630 U/L [8-35]
• alanine transaminase (ALT) 550 U/L [8-40]
• urine dipstick 1+ proteinuria Serum creatinine is 150

Which of the following is the most appropriate intervention?

Which of the following is least consistent with a drug seeking behaviour?

With regards to the management of opioid induced constipation in a patient with advanced metastatic disease currently in hospice care, which of the following is least likely to be useful?

A 70-year-old man with chronic kidney disease stage 4 and metastatic prostate cancer presents to hospital as his pain is not controlled with ParaCode (paracetamol and codeine phosphate).

Which one of the following opioid is the most appropriate to use given his impaired renal function?

A 57-year-old man with lung cancer is currently taking Sevredol 10mg Q4hrly for pain relief.

What dose of oral morphine solution should he be prescribed for breakthrough pain?

A 25-year-old man demands a CT scan of his abdomen in clinic. He states it is ‘obvious’ he has cancer despite previous negative investigations. This is an example of a:

A 23-year-old male presents to his GP two weeks after a road traffic accident concerned about increased anxiety levels, lethargy and headache. At the time he had a CT brain after banging his head on thesteering wheel, which revealed no abnormality. Six months following this episode his symptoms have resolved.
What did hisoriginal symptoms likely represent?

A 24-year-old male is admitted to the Emergency Departmentcomplaining of severe abdominal pain. On examination he is shivering and rolling around the trolley. He has previously been investigated for abdominal pain and no cause has been found. He states that unless he is given morphine for the pain he will kill himself.
This is an example of:

An 18-year-old woman is admitted following an episode of loss of consciousness at college. She has a two-day history of fever. The day after admission she requires fluid resuscitation and admission to the intensive care unit after an episode of cardiovascular collapse on the ward. Her electrocardiogram (ECG) is shown above.

What is the most likely diagnosis?

A 45-year-old man with a long history of asthma presents to hospital with acute shortness of breath, requiring intubation and ventilation for respiratory support. A chest X-ray reveals right upper lobe consolidation. He is treated with intravenous methylprednis(ol)one, metronidazole, and ceftriaxone with his clinical course complicated by renal and cardiac failure requiring inotropic support and a short period of dialysis. Attempts to wean ventilation support are unsuccessful. Nerve conduction studies reveal the following: Needle examination reveals fibrillation potentials with small motor unit potentials in all muscles examined.

The most likely diagnosis is:

A 62-year-old man is admitted to the intensive care unit with community-acquired pneumonia and severe respiratory failure for which he is intubated and given mechanical ventilation. He becomes progressively hypoxaemic, hypotensive and oliguric. Assessment at this stage shows: arterial blood pressure 93/55 mmHg arterial blood gases on 60% inspired oxygen PaO2 53 mmHg PaCO2 34 mmHg pH 7.31 oxygen saturation 83% haemoglobin concentration 105 g/L [125-180] pulmonary capillary wedge pressure 5 mmHg [3-12] cardiac output 3.0 L/min [predicted cardiac output 4.5]

The most appropriate intervention to achieve an increase in oxygen delivery to his tissues is:

Which one of the following therapeutic strategies can improve the survival of patients with adult respiratory distress syndrome and acute lung injury?