UK Medical School AKT Practice Exam

The MS AKT Exam Board has put together a 200-item practice exam (2 x 100 item
papers) to help medical students prepare for the UK Medical School Applied
Knowledge Test (MS AKT). Blueprinted to the GMC Content Map this exam has
been designed to reflect the style and type of question that students will encounter
when the MS AKT goes live in 2024-25 or 2023-24 for schools that have penultimate
year exams.

The practice exam comes with and without the answer options.

We would like to recognise the contribution of medical schools, and members of the
AKT Exam Board in particular, in producing this exam which we hope students will
find a valuable resource.

Should you have any questions about the clinical content of the practice exam
please speak to the Assessment Lead in your school in the first instance.

Any redistribution or reproduction of part or all of the contents in any form is

prohibited other than for personal, educational and non-commercial use.

© Medical Schools Council 2023 Page 1 of 101

 MS AKT Practice Exam
Paper 2

1. A 25 year old man has had penile pain for two days. His most recent sexual
intercourse was one week ago.

There are multiple tender ulcers on his preputial skin. His penile and scrotal
skin does not have any other abnormality.

Which is the most likely diagnosis?

A. Genital warts
B. Gonorrhoea
C. Herpes simplex
D. Lymphogranuloma venereum
E. Syphilis

© Medical Schools Council 2023 Page 2 of 101

 2. A 60 year old man has increasing left hip pain. It is worse after exercise and
occasionally wakes him at night. He has stiffness in the mornings that lasts for
about 10 minutes. He has hypertension treated with ramipril, but is otherwise
in good health.

He has reduced internal rotation on passive movement. This also elicits pain.

Which is the most appropriate initial treatment for his pain?

A. Celecoxib
B. Codeine phosphate
C. Naproxen
D. Paracetamol
E. Tramadol

© Medical Schools Council 2023 Page 3 of 101

 3. An 18 year old woman is 19 weeks pregnant. An ultrasound scan shows her
baby has anencephaly. She wants to discuss her options with regards to
termination of pregnancy.

When will termination of this pregnancy be legally permitted?

A. After spontaneous fetal death

B. At any time during the pregnancy
C. Before 20 weeks' gestation
D. Before 24 weeks' gestation
E. Before 28 weeks' gestation

© Medical Schools Council 2023 Page 4 of 101

 4. A 65 year old man has had constant back and right knee pain for 6 months,
partially relieved by analgesia. He is an ex-smoker. He is otherwise well.

Investigations:
Haemoglobin 132 g/L (130-175)
Alkaline phosphatase 850 IU/L (25-115)
Calcium 2.3 mmol/L (2.2-2.6)
Phosphate 0.9 mmol/L (0.8-1.5)
Prostate specific antigen 5 μg/L (<4.0)

X-rays: sclerotic areas in lower right femur and lumbar spine L3

Isotope bone scan: areas of increased uptake in femur, lumbar spine and
skull

Which is the most likely diagnosis?

A. Hyperparathyroidism
B. Metastatic carcinoma of prostate
C. Metastatic small cell carcinoma of lung
D. Myeloma
E. Paget's disease of bone

© Medical Schools Council 2023 Page 5 of 101

 5. A 14 year old girl has had crampy abdominal pain and poor appetite for 24
hours. She has also had a sore throat for 3 days.

Her temperature is 38.5°C. There is cervical lymphadenopathy and

tenderness in the right iliac fossa.

Which is the most likely diagnosis?

A. Acute appendicitis
B. Crohn's ileitis
C. Meckel's diverticulum
D. Mesenteric adenitis
E. Ovarian cyst

© Medical Schools Council 2023 Page 6 of 101

 6. The links between deprivation and health inequalities are well evidenced and
widely accepted, but there are a number of explanations for that association.
One explanation proposes that ill health determines people's social class.

Which type of explanation of health inequality is this?

A. Artefact
B. Cultural/behavioural
C. Idealist
D. Materialist
E. Social selection/mobility

© Medical Schools Council 2023 Page 7 of 101

 7. A 19 year old man has 1 day of fever, muscle stiffness, palpitations and
difficulty breathing. He has a history of psychotic depression. He has been
taking fluoxetine for 6 weeks and started taking risperidone 1 week ago.

He is agitated and distressed. His temperature is 39.8°C, pulse rate 114 bpm,
BP 172/89 mmHg and respiratory rate 30 breaths per minute. Chest
examination is otherwise normal. There is increased tone globally; there are
no other neurological abnormalities.

Which test is most likely to help confirm the diagnosis?

A. CT scan of head
B. ECG
C. EEG
D. Lumbar puncture
E. Serum creatine kinase

© Medical Schools Council 2023 Page 8 of 101

 8. A 43 year old man is involved in a low speed road traffic collision. Following
this he develops pain in his lower back that it is still troublesome several
months later. The pain is worse after activity and is relieved by rest.

He has an exaggerated lumbar lordosis with a palpable depression above L5.

The range of movement of his spine is grossly normal. Neurological
examination of his lower limbs is also normal.

An MR scan is obtained (see image).

What is the diagnosis?

A. Cauda equina syndrome

B. Compression fracture
C. Herniated intervertebral disc
D. Spondylolisthesis
E. Spondylosis

© Medical Schools Council 2023 Page 9 of 101

 9. A 30 year old man goes out gambling. One night he makes a profit of
£100,000, and the following night he loses £150,000.

Which psychological process most likely occurred on the first night that led to his risk
taking on the following night?

A. Classical conditioning
B. Disinhibition
C. Modelling
D. Positive reinforcement
E. Social learning

© Medical Schools Council 2023 Page 10 of 101

 10. A 85 year old woman has a breast lump. She has hypertension, heart failure
and a previous stroke. Her medications are bisoprolol, ramipril, furosemide,
aspirin and atorvastatin.

Her pulse is 76 bpm irregularly irregular and BP 105/70 mmHg. Her jugular
venous pressure is visible 6 cm above the sternal angle. She has bibasal late
inspiratory crepitations and bilateral pedal oedema. There is a 2.5 cm
diameter, mobile, hard, non tender swelling in the upper outer quadrant of her
breast. There is no palpable lymphadenopathy.

Investigation:
Pathology report of breast biopsy: infiltrating ductal carcinoma, ER positive,
HER2 negative

She is started on an aromatase inhibitor and bisphosphonate.

Which is the most appropriate next treatment to offer?

A. Chemotherapy
B. Immunotherapy
C. No additional treatment
D. Radiotherapy
E. Surgery

© Medical Schools Council 2023 Page 11 of 101

 11. A 40 year old primigravid woman, at 28 weeks' gestation, is admitted with a
seizure. She had epigastric pain and blurred vision preceding the seizure.

Her BP is 155/105 mmHg. Reflexes are brisk with two beats of ankle clonus.
Her urinalysis shows protein 2+.

Which intravenous drug is the most appropriate immediate treatment?

A. Diazepam
B. Hydralazine
C. Levetiracetam
D. Magnesium sulfate
E. Phenytoin

© Medical Schools Council 2023 Page 12 of 101

 12. A 29 year old woman visits her GP with a heavy sensation in her vagina when
exercising. She is aware of a bulge in her vagina, sometimes associated with
a desire to void urine. She had a vaginal delivery 2 years ago.

There is some laxity of the anterior vaginal wall, but this does not descend to
the introitus on straining. Urine culture is negative.

Which is the most appropriate management plan?

A. Oxybutinin hydrochloride
B. Pelvic floor exercises
C. Refer for urodynamic testing
D. Refer to urogynaecology clinic
E. Ultrasound scan of pelvis

© Medical Schools Council 2023 Page 13 of 101

 13. A 19 month old girl has been able to sit unsupported for 1 month. She can
speak 11 words and feeds herself. She was born at 30 weeks' gestation.

Which is the best description of her current development?

A. Fine motor delay

B. Gross developmental delay
C. Gross motor delay
D. Mild developmental delay
E. Normal development

© Medical Schools Council 2023 Page 14 of 101

 14. A 37 year old woman who is 10 weeks pregnant has had excessive vomiting
for 1 week. The fundal height is consistent with 16 weeks' gestation. Her
temperature is 37.2°C, pulse rate 100 bpm and BP 180/110 mmHg.

Which is the most likely diagnosis?

A. Gastroenteritis
B. Missed abortion
C. Molar pregnancy
D. Pre-eclampsia
E. Pregnancy-induced hypertension

© Medical Schools Council 2023 Page 15 of 101

 15. A 29 year old woman has pain and morning stiffness in her finger and wrist
joints. This improves during the day and after active movement. She has had
recurrent mouth ulcers for the last 2 years. She had an episode of pleuritic
chest pain 6 months ago which resolved without seeking help.

Her BP is 128/85 mmHg. She has no warmth or tenderness in her hands.

Urinalysis: protein 1+, blood 1+

Investigations:
Haemoglobin 109 g/L (115–150)
White cell count 3.8 × 109/L (4.0–11.0)
Lymphocytes 0.9 × 109/L (1.1–3.3)
Platelets 160 × 109/L (150–400)
Creatinine 90 µmol/L (60–120)
CRP 21 mg/L (< 5)

Which is the most likely diagnosis?

A. Behçet's disease
B. Reactive arthritis
C. Rheumatoid arthritis
D. Sjögren's syndrome
E. Systemic lupus erythematosus

© Medical Schools Council 2023 Page 16 of 101

 16. A 66 year old man has lethargy, cough and a persistent pain in the right upper
quadrant of the abdomen. He has smoked between 15 and 40 cigarettes daily
for 50 years.

He has an enlarged liver. Needle biopsy of the liver reveals adenocarcinoma,

and immunohistochemistry is positive for the marker thyroid transcription
factor-1, indicative of a primary pulmonary tumour.

Which is the most likely route by which this tumour spread to the liver?

A. Direct infiltration
B. Haematogenous spread
C. Lymphatic spread
D. Pagetoid spread
E. Transcoelomic spread

© Medical Schools Council 2023 Page 17 of 101

 17. A 63 year old woman has two days of facial swelling, early morning facial
discomfort and fullness. Nine months ago she was treated with chemotherapy
and radiotherapy for lung cancer.

Her jugular venous pressure is elevated and non pulsatile. Her face, neck and
arms are swollen, and there are prominent veins across her chest.

Which structure is most likely to be occluded?

A. Axillary vein
B. Internal jugular vein
C. Right atrium
D. Subclavian vein
E. Superior vena cava

© Medical Schools Council 2023 Page 18 of 101

 18. A 17 year old attends her GP with her mother. She has had severe
headaches, stomach aches and has vomited four times over 2 days.

She was invited to a close friend's birthday party but refused to attend. She is
extremely shy and isolated, and has very few friends. She is always worried
that others criticise her, is extremely sensitive to any rejection, and is very
attached to her mother.

Which personality disorder is she most likely to have?

A. Avoidant
B. Dependent
C. Paranoid
D. Schizoid
E. Schizotypal

© Medical Schools Council 2023 Page 19 of 101

 19. A 45 year old man visits his GP with right knee pain. He has not had any
problems with his knee before, but has had previous episodes of a severe
pain in his toe and painful swelling of the dorsum of the feet. There is no
history of trauma. He drinks 20 pints of beer a week.

His temperature is 37.5°C, and his knee is warm, diffusely tender and very
painful to flex.

What is the most likely diagnosis?

A. Gout
B. Osteoarthritis
C. Rheumatoid arthritis
D. Septic arthritis
E. Torn meniscal cartilage

© Medical Schools Council 2023 Page 20 of 101

 20. A 68 year old woman has noticed a lump in her neck for 2 months, but
otherwise feels well.

There are small lymph nodes palpable in the cervical, axillary and inguinal
regions.

Investigations:
Haemoglobin 124 g/L (115–150)
White cell count 27.2 × 109/L (3.8–10.0)
Neutrophils 2.5 × 109/L (2.0–7.5)
Lymphocytes 21.6 × 109/L (1.1–3.3)
Monocytes 0.9 × 109/L (0.2–1.0)
Eosinophils 0.4 × 109/L (0–0.4)
Basophils 0.1 × 109/L (0–0.1)
Platelets 137 × 109/L (150–400)
Blood film: increased lymphocytes with sparse cytoplasm

Which is the most likely diagnosis?

A. Acute lymphoblastic leukaemia

B. Chronic lymphocytic leukaemia
C. Infectious mononucleosis
D. Myeloma
E. Non Hodgkin's lymphoma

© Medical Schools Council 2023 Page 21 of 101

 21. A 15 year old boy has had severe anorexia nervosa for one year. He is not
currently acutely physically unwell. His weight is 75% of the expected weight
for his height, age and sex.

Which is the most appropriate treatment?

A. Cognitive-analytic therapy
B. Cognitive-behaviour therapy
C. Family therapy
D. Non-directive counselling
E. Psychodynamic psychotherapy

© Medical Schools Council 2023 Page 22 of 101

 22. A randomised controlled trial was designed to compare a new drug with a
placebo. There were 120 patients in the treatment group of which 12 patients
died within 2 years. There were 240 patients in the control group of which 48
patients died within 2 years.

Which is the number needed to treat to avoid one death within 2 years?

A. 2
B. 4
C. 8
D. 10
E. 20

© Medical Schools Council 2023 Page 23 of 101

 23. A 28 year old woman is elated in mood, has not slept for 7 days and has been
attending all-night parties. She is sexually disinhibited and believes that she is
a member of the royal family. She was previously fit and well and has no past
psychiatric history.

A urine drug screen is negative.

Which is the most appropriate medication?

A. Diazepam
B. Lithium carbonate
C. Olanzapine
D. Sodium valproate
E. Zuclopenthixol decanoate

© Medical Schools Council 2023 Page 24 of 101

 24. A 62 year old woman is seen at home because her legs feel "wobbly", and
she has been incontinent of urine once. She has been experiencing
increasing pain in her mid back over the previous fortnight. She is being
treated for metastatic breast cancer with anastrozole.

There is slight weakness, rated 4/5, in hip flexion and knee extension
bilaterally. Plantar reflexes are equivocal and tendon jerks brisk. She is tender
over the 10ththoracic vertebra.

Which is the most appropriate next course of action?

A. Admission to the local hospice

B. Advise bed rest until pain resolves
C. Arrange domiciliary physiotherapy
D. Emergency admission for MR scan of spine
E. Give analgesia and re-examine her in the morning

© Medical Schools Council 2023 Page 25 of 101

 25. A 3 year old boy has 6 months of diarrhoea. He has 4-5 watery stools per day
that contain visible pieces of sweetcorn and other vegetables. He is thriving
and developing well.

Which is the most likely diagnosis?

A. Coeliac disease
B. Gastroenteritis
C. Inflammatory bowel disease
D. Lactose intolerance
E. Toddler diarrhoea

© Medical Schools Council 2023 Page 26 of 101

 26. A mother gives her 6 month old baby girl formula milk for the first time. Within
minutes, the baby vomits and develops an erythematous rash over her lips
and chin, which takes 1 hour to subside. The following week, the mother drips
a couple of drops of formula milk onto the baby's arm. The baby develops an
erythematous rash over the arm within 1 minute.

The mother is returning to work and does not wish to continue breastfeeding
or expressing milk.

Which is the best management option?

A. Goat's milk
B. Hydrolysed formula
C. Lactose free formula
D. Latex free teat
E. Soya milk

© Medical Schools Council 2023 Page 27 of 101

 27. A 28 year old woman is admitted with a sudden onset of abdominal pain and
vaginal bleeding. She is 38 weeks pregnant.

Her pulse rate is 120 bpm and BP 110/80 mmHg. She has a tender abdomen.
The fetal heart rate is 170 bpm.

Which is the most likely diagnosis?

A. Necrosis of a fibroid
B. Placenta praevia
C. Placental abruption
D. Pre-term labour
E. Uterine rupture

© Medical Schools Council 2023 Page 28 of 101

 28. A 52 year old woman has had two days of worsening confusion. She has
chronic liver disease secondary to alcohol and has been abstinent for six
months. She has had a previous admission due to acute hepatic
encephalopathy.

She is disoriented in time and place, and is unable to hold a conversation. Her
temperature is 37.1°C, pulse 90 bpm and BP 119/80 mmHg. She has a
distended abdomen, widespread spider naevi and a flapping tremor.

She is given intravenous vitamin supplements.

Which is the most appropriate additional management of her acute confusion?

A. Ciprofloxacin
B. Furosemide
C. Lactulose
D. Lorazepam
E. Restrict dietary protein intake to 60 g/day

© Medical Schools Council 2023 Page 29 of 101

 29. A 25 year old nulliparous woman with an uncomplicated pregnancy attends
for induction of labour at 41 weeks.

Examination reveals the head is engaged; the cervix is posterior, 2cm long
and the os is closed.

Which is the most appropriate method of induction?

A. Endovaginal prostaglandin gel

B. Membrane sweep
C. Oxytocin infusion
D. Oxytocin infusion and amniotomy
E. Progesterone suppository

© Medical Schools Council 2023 Page 30 of 101

 30. A 60 year old man believes that the government has been monitoring him for
10 years, despite him repeatedly writing to the Prime Minister. His beliefs are
present whatever his mood, and he has never heard voices when nobody else
is around.

Which is the most likely diagnosis?

A. Anankastic personality disorder

B. Delusional disorder
C. Depression with psychosis
D. Paranoid schizophrenia
E. Schizoid personality disorder

© Medical Schools Council 2023 Page 31 of 101

 31. A woman develops a temperature of 38.5°C, 15 minutes after a transfusion of
red blood cells.

What is the most likely cause of her high temperature?

A. Donor blood not screened for infective agents

B. Patient identified incorrectly
C. Pre-labelled sample used
D. Sample not labelled at the bedside
E. Sample not labelled by the person taking the blood

© Medical Schools Council 2023 Page 32 of 101

 32. A 94 year old woman has a deep gnawing pain in her left arm. She has had
10 kg weight loss in the past year.

Her temperature is 37.3°C. She has localised tenderness over the left upper
arm.

Investigations:
X-ray left arm (see image).

Which is the most likely cause of her pain?

A. Metastatic carcinoma
B. Osteomyelitis
C. Osteoporosis
D. Osteosarcoma
E. Paget's disease

© Medical Schools Council 2023 Page 33 of 101

 33. A 45 year old man has a 5 month history of chronic sinusitis and unresolving
headaches. When he bends forward, purulent fluid pours from his nose.

Which anatomical structure is most likely to be the source of this fluid?

A. Anterior ethmoid air cells

B. Frontal sinus
C. Lacrimal sac
D. Maxillary sinus
E. Posterior ethmoid air cells

© Medical Schools Council 2023 Page 34 of 101

 34. A 6 hour old term baby boy is grunting and cyanosed. He has been struggling
to feed.

His temperature is 36.8°C, pulse rate 190 bpm (120-160), respiratory rate 60
breaths per minute (30-60) and oxygen saturation 82% breathing air. His
oxygen saturation does not improve significantly breathing high flow oxygen.
He has a loud single second heart sound and a systolic murmur.

He is treated with intravenous fluids and antibiotics.

Which is the most appropriate next medication?

A. Alprostadil
B. Ibuprofen
C. Indometacin
D. Sildenafil
E. Surfactant

© Medical Schools Council 2023 Page 35 of 101

 35. A 5 year old girl is brought to her GP with a rash over her arms that has been
gradually worsening over the past month. Her mother reports that she seems
more tired than usual.

She has a petechial rash over both forearms, with some petechiae over her
left anterior chest. She is pale and has hepatosplenomegaly.

Which is the most appropriate management option?

A. Administer intramuscular benzylpenicillin sodium and send her to hospital in

an ambulance
B. Prescribe a course of prednisolone and review in 3 days
C. Refer her for a routine appointment in the general paediatric clinic
D. Refer her urgently to the paediatric assessment unit
E. Take a full blood count and blood film and see her within 48 h

© Medical Schools Council 2023 Page 36 of 101

 36. A 62 year old man attends the outpatients clinic with his wife. He has had
reduced energy and lack of interest in his work and poor sleep for six weeks.
He has lost weight. There is evidence of self-neglect and reduced eye
contact. He is known to have benign prostatic enlargement.

What is the single most appropriate drug treatment?

A. Benzodiazepine
B. Selective serotonin re-uptake inhibitor
C. Serotonin noradrenaline re-uptake inhibitor
D. Tricyclic antidepressant
E. Z-drug

© Medical Schools Council 2023 Page 37 of 101

 37. A doctor is approached by their neighbour who is aware that another person
on their street has been admitted to the ward the doctor is working on. They
wish to know how the patient is doing. The doctor is aware the patient is
stable but the prognosis is uncertain.

Which is the most appropriate response by the doctor?

A. They can confirm they are caring for him and that he is unwell but stable
B. They can confirm they are caring for him but cannot comment on his condition
C. They can confirm they are caring for him and that he is making good progress
D. They cannot confirm they are caring for him but have heard he is unwell but
stable
E. They cannot confirm who is caring for him and cannot comment on his
condition

© Medical Schools Council 2023 Page 38 of 101

 38. A 40 year old woman has had right-sided facial weakness for the past 12
hours.

She has weakness of all of the muscles on the right side of her face. There is
no limb weakness and speech is normal. Examination of her ears is normal.

Which is the most appropriate drug treatment?

A. Aciclovir
B. Aspirin
C. Cinnarizine
D. None
E. Prednisolone

© Medical Schools Council 2023 Page 39 of 101

 39. A 35 year old woman with gestational hypertension is induced at 40 weeks.
She has a normal vaginal delivery, but following delivery of the placenta she
bleeds heavily.

Which is the most appropriate management?

A. Carboprost
B. Ergometrine
C. Oxytocin
D. Misoprostol
E. Tranexamic acid

© Medical Schools Council 2023 Page 40 of 101

 40. A 19 year old man has had two days of a burning sensation when passing
urine and a penile discharge. This developed three days after he had
unprotected sex with a new female partner.

Which is the most appropriate treatment?

A. Azithromycin and ceftriaxone

B. Ciprofloxacin and metronidazole
C. Fluconazole and penicillin V
D. Metronidazole and fluconazole
E. Penicillin V and azithromycin

© Medical Schools Council 2023 Page 41 of 101

 41. A 9 month old baby boy is brought to his GP with 4 days of coryzal symptoms,
intermittent fever, coughing and wheezing. He has been taking smaller feeds
for the past 2 days and was unsettled last night. He is alert, there is no rash
and he is drooling. He has adequate oral intake. His mother has given him
paracetamol suspension.

His temperature is 38.2°C, capillary return 1 second, pulse rate 148 bpm (80-
160), respiratory rate 60 breaths per minute (30-60) and oxygen saturation
97% in air. He has widespread wheeze and crackles, and his ears and throat
are normal.

Which is the most appropriate next step in management?

A. Admission to paediatric ward

B. Prescribe oral doxycycline
C. Prescribe oral co-amoxiclav
D. Reassure and give safety netting advice
E. Give nebulised salbutamol and review

© Medical Schools Council 2023 Page 42 of 101

 42. A 23 year old woman has barricaded herself with her baby in the bathroom,
shouting that it is unsafe to come out because the house is infected. She
thinks that someone is trying to kill her and her baby. She is four days post-
caesarean section. Her mood has not been low at any stage. She was not on
any medication during her pregnancy, but drank 20 units of alcohol a week.
Her physical recovery from caesarean section has been uncomplicated. She
is orientated in time and place.

Which is the most likely diagnosis?

A. Alcohol withdrawal
B. Delirium
C. Obsessive-compulsive disorder
D. Post-natal depression
E. Puerperal psychosis

© Medical Schools Council 2023 Page 43 of 101

 43. A 20 year old woman seeks contraceptive advice. She had unprotected
sexual intercourse four days ago.

Which is the most appropriate method of contraception?

A. Combined oral contraceptive pill

B. Copper-containing intrauterine device
C. Depot progestogen injection
D. High dose oral progestogen
E. Intrauterine progestogen system (Mirena coil)

© Medical Schools Council 2023 Page 44 of 101

 44. A 60 year old man feels tired, but has no specific symptoms. He is a non-
smoker and drinks eight units of alcohol per week.

Investigations:
Haemoglobin 120 g/L (130–175)
White cell count 5.8 × 109/L (3.0–10.0)
Platelets 170 × 109/L (150–400)
MCV 110 fL (80–96)
TSH 2.0 mU/L (0.3–4.2)

Which additional investigation is most likely to help with the diagnosis?

A. Erythrocyte sedimentation rate

B. Ferritin
C. Folate and vitamin B 12
D. Haptoglobin
E. Protein electrophoresis

© Medical Schools Council 2023 Page 45 of 101

 45. A 15 year old girl has delayed puberty. She has always been short for her age
(height <0.4th centile for age). She has no dysmorphic facial features but
does have a webbed neck and widely spaced nipples. She has no breast
development, and has not started her periods yet.

Which chromosomal abnormality is most likely to cause her clinical presentation?

A. 45X0
B. 47XXX
C. 47XXY
D. Trisomy 13
E. Trisomy 21

© Medical Schools Council 2023 Page 46 of 101

 46. A 36 year old man is brought to the Emergency Department with a head injury
after a fall from 10 metres. He was unconscious for a minute but recovered
and seemed fully alert and orientated. Four hours later he becomes drowsy
and confused, and then collapses.

His GCS is 7/15.

Which is the most likely diagnosis?

A. Cerebral contusions
B. Compound depressed skull fracture
C. Diffuse axonal injury
D. Extradural haematoma
E. Subarachnoid haemorrhage

© Medical Schools Council 2023 Page 47 of 101

 47. A 3 year old boy has had multiple skin lesions on his chest wall for 2 weeks
(see image). The lesions are not itchy, and he is apyrexial and otherwise well.

Which is the most likely diagnosis?

A. Chickenpox
B. Discoid eczema
C. Hand, foot and mouth disease
D. Molluscum contagiosum
E. Rubella

© Medical Schools Council 2023 Page 48 of 101

 48. A 42 year old woman has 6 months of a painful right shoulder. Her pain keeps
her awake at night and is worsened by movement. She is otherwise well.
There is no history of trauma.

She has pain on shoulder abduction between 80° and 120°. Her shoulder
movements are otherwise normal. There is no joint effusion. X-ray of right
shoulder is normal.

Which is the most likely diagnosis?

A. Cervical radiculopathy
B. Osteoarthritis of glenohumeral joint
C. Polymyalgia rheumatica
D. Pseudogout
E. Subacromial bursitis

© Medical Schools Council 2023 Page 49 of 101

 49. A 45 year old man has his BMI measured as part of a clinical trial for type 2
diabetes.

Which is the most appropriate classification of data on this parameter?

A. Categorical
B. Continuous
C. Discrete
D. Nominal
E. Subjective

© Medical Schools Council 2023 Page 50 of 101

 50. A 75 year old man with metastatic bowel cancer is dying. He is semi-
conscious. He is being treated with morphine and haloperidol via a syringe
driver. His breathing is becoming increasingly rattly.

Which is the most appropriate drug management?

A. Amoxicillin
B. Furosemide
C. Hyoscine
D. Levomepromazine
E. Midazolam

© Medical Schools Council 2023 Page 51 of 101

 51. A 67 year old man has had 24 hours of a painful swollen left knee. He went
hill walking 3 days ago.

His temperature is 37.6°C, pulse rate 104 bpm and BP 116/80 mmHg. His left
knee is red, swollen and hot to touch. He has a reduced range of movement
in his knee and is unable to weight bear due to pain.

Investigations:
Haemoglobin 145 g/L (130–175)
White cell count 23.4 × 109/L (4.0–11.0)
Platelets 546 × 109/L (150–400)
Neutrophils 19.2 × 109/L (2.0–7.5)
CRP 122 mg/L (<5)

Which is the most appropriate next investigation?

A. Aspiration of left knee joint for microscopy and culture

B. MR imaging of left knee
C. Serum anti-cyclic citrullinated peptide antibody
D. Serum uric acid
E. X-ray of left knee

© Medical Schools Council 2023 Page 52 of 101

 52. A 36 year old woman and her partner have been trying to conceive for the last
18 months. Neither has ever attained a pregnancy before. Both are medically
fit and well and have no surgical history. Her periods are every 38-45 days.
Both smoke 5-10 cigarettes per day and drink occasionally at the weekend.
Examination is unremarkable in both.

Which is the most likely cause of their inability to conceive?

A. Abnormal semen
B. Anovulatory cycles
C. Parental smoking
D. Unexplained subfertility
E. Uterine tube blockage

© Medical Schools Council 2023 Page 53 of 101

 53. A 45 year old man has a lump in the right side of his neck. He has never
smoked and takes no regular medications. Fine needle aspiration of the mass
reveals squamous cell carcinoma, and subsequent investigations identify the
primary tumour in the right tonsil.

Which virus is associated with this malignancy?

A. Cytomegalovirus
B. Epstein–Barr virus
C. Human immunodeficiency virus
D. Human papilloma virus
E. Human T-lymphotropic virus

© Medical Schools Council 2023 Page 54 of 101

 54. A 78 year old man has worsening breathlessness. He has heart failure that
has been worsening progressively over the past 12 months. He has been bed
bound for the past 2 weeks. He was recently found to have probable lung
carcinoma but was not fit for further investigation.

He is dyspnoeic, cyanosed and confused. His temperature is 36.1°C, pulse

rate 100 bpm, BP 92/60 mmHg, respiratory rate 30 breaths per minute and
oxygen saturation 88% on 15 L/min via a Venturi mask. He has inspiratory
crackles in both bases.

He is treated with intravenous furosemide.

Which additional treatment is most likely to reduce his breathlessness?

A. Intramuscular haloperidol
B. Intravenous glyceryl trinitrate
C. Intravenous morphine
D. Nasal intermittent positive pressure ventilation
E. Nebulised salbutamol

© Medical Schools Council 2023 Page 55 of 101

 55. An 18 year old woman has a sudden sharp stabbing pain in her abdomen,
lasting only a few minutes. It is 14 days since her last period started. She
indicates that the pain is localised to the left iliac fossa.

A surge in which hormone is most likely to coincide with her pain?

A. Follicle stimulating hormone

B. Luteinising hormone
C. Oestrogen
D. Progesterone
E. Prolactin

© Medical Schools Council 2023 Page 56 of 101

 56. A 72 year old man with lung cancer is admitted to the respiratory ward with
recurrent haemoptysis. He is known to the palliative care team and it is felt
that he is near the end of his life. He says that he wants to have his terminal
care on the respiratory ward because he knows and trusts the nurses. A 'do
not attempt resuscitation' form is completed. He subsequently has further
haemoptysis and becomes more breathless, so he is treated with an opioid
infusion to relieve his dyspnoea. A doctor suggests that the local hospice is
better equipped to care for the patient. His son agrees with the doctor,
believing that the hospice is "the right place to die".

What should be the most important factor influencing the decision on whether to
move him to a hospice?

A. Consultant's view of patient's best interests

B. Hospital bed state
C. Local policy on end of life care
D. Patient's previous opinion
E. Son's wishes

© Medical Schools Council 2023 Page 57 of 101

 57. A 74 year old woman has had left sided headache and discomfort when
chewing food for 3 months. She experiences a sensation of pressure and pain
in her jaw, even when talking. She has lost 8 kg in weight over the same time
period.

Investigations:
CRP 45 mg/L (<5)

Which investigation is most likely to establish the diagnosis?

A. CT scan of head
B. Parotid sialogram
C. Serum anti-neutrophil cytoplasmic antibodies
D. Temporal artery biopsy
E. X-ray of temporomandibular joint

© Medical Schools Council 2023 Page 58 of 101

 58. A group of 75 men and a group of 75 women performed a standardised
exercise test and had their pulse rate measured at the end.

The data from the two groups were compared. The data is normally
distributed with equal variance.

Which is the most appropriate statistical test to compare these groups?

A. Analysis of variance
B. Friedman's test
C. Mann–Whitney test
D. Paired Student's t-test
E. Unpaired Student's t-test

© Medical Schools Council 2023 Page 59 of 101

 59. A 45 year old man has a tremor that has worsened over several weeks. He
has a history of schizophrenia and is taking haloperidol.

He has bilateral tremor and cog-wheel rigidity in his upper limbs.

Which is the most appropriate treatment to manage his symptoms?

A. Co-beneldopa
B. Entacapone
C. Pramipexole
D. Procyclidine hydrochloride
E. Selegiline hydrochloride

© Medical Schools Council 2023 Page 60 of 101

 60. A 30 year old man is unable to straighten his right middle finger after an injury.

He has a flexion deformity of the finger at the distal interphalangeal joint and
is unable to actively extend his finger.

Which is the most appropriate management option?

A. External finger fixation

B. Finger splint
C. Internal finger fixation
D. Reassurance
E. Steroid injection

© Medical Schools Council 2023 Page 61 of 101

 61. A previously well 20 year old man has had 2 months of night sweats and 5 kg
weight loss.

His temperature is 37.6°C. He has palpable neck lymph nodes and

splenomegaly.

Investigations:
CT scan chest, abdomen and pelvis: enlarged mediatinal lymph nodes and
splenomegaly
Lymph node biopsy: Hodgkin/Reed-Sternberg (HRS) cells admixed with a
polymorphous inflammatory infiltrate

Which is the most appropriate first line treatment?

A. Chemotherapy
B. Corticosteroids
C. Immunotherapy
D. Radiotherapy
E. Surgical excision of mediastinal lymph nodes

© Medical Schools Council 2023 Page 62 of 101

 62. A 72 year old man is admitted with cough, breathlessness and confusion. He
has metastatic adenocarcinoma and is being treated with chemotherapy. His
wife reports that he has had enough of his treatment and planned to
discontinue active treatment.

He is drowsy and unable to answer questions. He has bronchial breathing at

the left base. He is given 0.9% sodium chloride and broad spectrum
antibiotics intravenously.

Which is the most appropriate way to determine his cardiopulmonary resuscitation

status on this admission?

A. Admitting team should decide

B. Ask an independent advocate to decide
C. Ask consultant oncologist to decide
D. Ask his wife to decide
E. Wait 24 hours to see if patient regains capacity to decide

© Medical Schools Council 2023 Page 63 of 101

 63. A 36 year old man with type 1 diabetes mellitus has a pilonidal sinus. He
takes 14 units long-acting insulin at night, and short-acting insulin three times
daily at mealtimes (typically 6-8 units with each meal). He is scheduled for
excision of the sinus under general anaesthesia, first on a morning operating
list. He is asked to fast from midnight the night before.

His HbA1c is 58 mmol/mol (20-42).

Which is the most appropriate plan for managing his insulin pre-operatively?

A. Omit evening and morning insulin doses

B. Start a variable-rate insulin infusion on the morning of surgery
C. Start a variable-rate insulin infusion the evening before surgery
D. Take evening and morning insulin doses, as usual
E. Take usual evening insulin and omit morning insulin

© Medical Schools Council 2023 Page 64 of 101

 64. A 3 year old girl has had a fever and a runny nose for the past 2 days. She is
alert but miserable.

Her temperature is 39.6°C, pulse rate 150 bpm (95-140), BP 105/62

mmHg (90/50-120/180), respiratory rate 36 breaths per minute (20-30) and
oxygen saturation 97% in air. She has a red throat and looks flushed with a
flat, erythematous rash across her trunk and face that feels rough. There is no
rash around her mouth.

Which is the most likely diagnosis?

A. Kawasaki disease
B. Measles
C. Parvovirus infection
D. Rhinovirus infection
E. Scarlet fever

© Medical Schools Council 2023 Page 65 of 101

 65. A one week old fully breastfed baby girl has pale stools in her nappy, with
streaks of dark urine (see image). She has lost 8.2% of her birth weight. She
was born at term.

She is apyrexial. She is alert and has jaundice.

Which is the most appropriate investigation?

A. Coombs (direct antiglobulin) test

B. Full blood count and film
C. Plasma glucose
D. Split bilirubin
E. Urea and electrolytes

© Medical Schools Council 2023 Page 66 of 101

 66. A 36 year old woman attends for an asthma review.

She requires a long-acting β-agonist and steroid combination inhaler. The

guidelines suggest either a metered dose inhaler or a dry powder. They are
the same price. This patient asks which is better for the environment.

Which component of these inhalers has the highest carbon footprint?

A. Hydrofluorocarbon propellant in the metered dose inhaler

B. Packaging of the dry powder inhaler
C. Plastic component of the dry powder inhaler
D. Plastic component of the metered dose inhaler
E. Powder component of the dry powder inhaler

© Medical Schools Council 2023 Page 67 of 101

 67. A 18 year old man is worried about his cancer risk. His paternal grandfather
died of colorectal cancer at 42 years of age and his 36 year old father has just
been diagnosed with colorectal cancer. The son's colonoscopy shows
hundreds of colonic polyps, and biopsies from several of the polyps show
adenomatous change with low grade dysplasia.

Which is the most appropriate strategy to prevent colon cancer in this situation?

A. Daily low dose aspirin

B. Diet rich in fruit and vegetables
C. Panproctocolectomy
D. Annual faecal immunochemical test (FIT)
E. Annual colonoscopy and biopsy

© Medical Schools Council 2023 Page 68 of 101

 68. A 21 year old man has a fear of public speaking. He is a student and has to
give an oral presentation, and he feels unable to manage this. He fears that
he will do something to embarrass himself or even vomit. The thought of
giving his presentation gives him palpitations and makes him breathless and
dizzy.

He has avoided his tutor for 3 months and has not left his flat for several
weeks. He recognises that his fears are irrational but feels overwhelmed.

Which is the most likely diagnosis?

A. Agoraphobia
B. Anxious avoidant personality disorder
C. Emetophobia
D. Panic disorder
E. Social phobia

© Medical Schools Council 2023 Page 69 of 101

 69. A 46 year old man has sudden onset and intense lower back pain. He has no
pain or numbness in his buttocks or legs. He is diagnosed with mechanical
back pain. He has no drug contra-indications.

Which is the most appropriate initial medication?

A. Amitriptyline
B. Fentanyl
C. Ibuprofen
D. Paracetamol
E. Triamcinolone

© Medical Schools Council 2023 Page 70 of 101

 70. A 56 year old woman has had 2 months of intermittent vertigo, which typically
occurs when turning over in bed or looking over her shoulder while driving.
Each episode lasts for up to 1 minute. She has no hearing loss, tinnitus or ear
pain.

Which test is most likely to confirm the diagnosis?

A. Audiometry
B. Carotid doppler ultrasonography
C. CT scan of head
D. Dix–Hallpike manoeuvre
E. MR of internal auditory meatus

© Medical Schools Council 2023 Page 71 of 101

 71. A 62 year old man is brought to the operating theatre recovery room after a
laryngoscopy and vocal cord biopsy. He appears to be conscious, but his
breathing is shallow and respiratory rate 28 breaths per minute. His voice is
weak and, when the recovery nurse asks him to squeeze her fingers with his
hand, the grip is not sustained.

Which drug will reverse these signs?

A. Doxapram
B. Glycopyrronium
C. Naloxone
D. Neostigmine
E. Rocuronium

© Medical Schools Council 2023 Page 72 of 101

 72. A 50 year old woman has broken her right radius after tripping at home. She
has been experiencing hot flushes and night sweats for the past six months,
with irregular menstruation. She has been taking salbutamol and
beclometasone regularly for more than five years to treat asthma. Her fracture
heals with no complications.

Which investigation will most effectively evaluate her future risk of fractures?

A. 99m-technetium bone scintigraphy

B. Dual energy X-ray absorptiometry
C. MR scan of spine and hip
D. Plain X-ray lumbar spine and pelvis
E. Quantitative CT scan of spine and hip

© Medical Schools Council 2023 Page 73 of 101

 73. A 72 year old man has had difficulty swallowing solids. He has cancer of the
middle third of the oesophagus and hepatic metastases.

Which is the most appropriate initial management of his dysphagia?

A. Chemotherapy
B. Excision of tumour
C. Gastrostomy feeding tube
D. Oesophageal stent
E. Radiotherapy

© Medical Schools Council 2023 Page 74 of 101

 74. A 64 year old man has low thoracic back pain and has been tired for the past
6 weeks. He is a non-smoker. He has hypertension and takes amlodipine.

His urinalysis is normal.

Investigations:
Haemoglobin 81 g/L (135–175)
MCV 82 fL (80–96)
White cell count 4.3 × 109/L (3.0–10.0)
Platelets 74 × 109/L (150–400)

Creatinine 203 µmol/L (60–120)

Which initial investigation is most likely to help establish the diagnosis?

A. Anti-neutrophil cytoplasmic antibody

B. Antinuclear antibody
C. Complement levels (C3 and C4)
D. Coagulation screen
E. Urine and serum protein electrophoresis

© Medical Schools Council 2023 Page 75 of 101

 75. A 66 year old woman has become forgetful, does not sleep well and has lost
her appetite over the last few weeks. She has been getting up early in the
morning because she cannot sleep. She feels that she is no longer of any use
to the rest of her family.

Mini Mental State Examination is 27/30.

Which is the most likely diagnosis?

A. Age-associated memory impairment

B. Alzheimer’s disease
C. Depression
D. Frontotemporal dementia
E. Vascular dementia

© Medical Schools Council 2023 Page 76 of 101

 76. A consultant is looking to find published evidence on reducing the incidence of
deep venous thrombosis.

Which type of study would provide the highest quality evidence?

A. Case control study

B. Case series
C. Cohort study
D. Meta-analysis of trials
E. Randomised controlled trial

© Medical Schools Council 2023 Page 77 of 101

 77. A 62 year old man has had 3 months of general weakness, fatigue, 10 kg
weight loss and mild abdominal discomfort over the right hypochondrium. He
was found to have liver cirrhosis 10 years ago and has abstained from alcohol
since the diagnosis.

He has a non-tender, fixed hard mass in the right upper quadrant.

Which serum investigation is most appropriate to aid diagnosis?

A. α-Fetoprotein
B. β-Human chorionic gonadotropin
C. CA 125
D. CA 19-9
E. Carcinoembryonic antigen

© Medical Schools Council 2023 Page 78 of 101

 78. A 7 year old boy has intermittent pain in his left groin when playing football
and climbing stairs. This has worsened over the past 4 weeks. He has now
developed a painless limp.

He has reduced range of movement and pain on internal rotation and

abduction.

His temperature is 37.1°C.

Which is the most likely diagnosis?

A. Osgood–Schlatter disease
B. Perthes' disease
C. Septic arthritis
D. Slipped upper femoral epiphysis
E. Transient synovitis

© Medical Schools Council 2023 Page 79 of 101

 79. A 28 year old primigravida attends the antenatal clinic at 35 weeks' gestation.
She has 2 weeks of persistent itching of her palms, soles and abdomen. Her
pregnancy has been uncomplicated to date, and she is feeling good fetal
movements.

She has red scratch marks on her abdomen with no rash.

Which is the most appropriate investigation?

A. Anti-mitochondrial antibody
B. Iron studies
C. Liver function tests
D. Thyroid function tests
E. Urea and electrolytes

© Medical Schools Council 2023 Page 80 of 101

 80. A 23 year old woman commenced chemotherapy for Burkitt's lymphoma
yesterday. Since then she has been feeling increasingly nauseated. Urine
output has been 40 mL in the last 12 hours.

Her temperature is 36.8°C, pulse rate 96 bpm and BP 112/80 mmHg.

Investigations on admission were normal.

Investigations today:
Potassium 6.2 mmol/L (3.5–5.3)
Urea 9 mmol/L (2.5–7.8)
Creatinine 410 µmol/L (60–120)

Which investigation is most likely to identify the cause of her acute deterioration?

A. Blood cultures
B. C reactive protein
C. Creatine kinase
D. Phosphate
E. Urate

© Medical Schools Council 2023 Page 81 of 101

 81. A 44 year old woman is increasingly hypotensive in the high dependency unit.
She was admitted 12 hours earlier with loin pain, dysuria and rigors, and was
treated with intravenous broad spectrum antibiotics.

Her temperature is 37.8°C, pulse rate 112 bpm, BP 91/60 mmHg, central
venous pressure +12 mmHg and oxygen saturation 95% on 60% oxygen.

Investigations:
Sodium 139 mmol/L (135–146)
Potassium 5.1 mmol/L (3.5-5.3)
Urea 10.3 mmol/L (2.5-7.8)
Creatinine 159 μmol/L (60–120)

She has been treated with 3 L of 0.9% sodium chloride since admission, with
a urine output of 400 mL in total and 10–20 mL/hr for the past 4 hours.

Which is the most appropriate next step in management?

A. Haemofiltration
B. Intravenous 500 mL gelatin over 30 minutes
C. Intravenous 500 mL 0.9% sodium chloride over 30 minutes
D. Intravenous furosemide bolus
E. Intravenous noradrenaline/norepinephrine infusion

© Medical Schools Council 2023 Page 82 of 101

 82. A 43 year old man has inoperable cancer of the bowel with hepatic and
peritoneal metastases. He has back pain due to tumour infiltration. The pain
has been controlled with regular codeine phosphate at maximum dosage. He
now has bowel obstruction with vomiting and his pain has recurred because
he cannot take oral medication.

Investigations: Creatinine 85 µmol/L (60–120)

Which is the most effective drug to control his pain?

A. Buprenorphine transcutaneous patch

B. Codeine phosphate intramuscular injection
C. Fentanyl transcutaneous patch
D. Morphine sulfate continuous subcutaneous infusion
E. Tramadol hydrochloride intramuscular injection

© Medical Schools Council 2023 Page 83 of 101

 83. A full term newborn boy is discharged home 48 hours after birth. The next
day, his 2 year old sibling develops a florid chickenpox rash. His mother has
detectable varicella antibodies. The newborn remains clinically well.

Which is the most appropriate management decision?

A. Admit for observation

B. Check antibody status for varicella antibodies
C. No action is necessary
D. Treat with aciclovir
E. Treat with zoster immune globulin

© Medical Schools Council 2023 Page 84 of 101

 84. A 35 year old woman finds a small firm lump on self examination of her
breast. It is excised and is a firm, well-circumscribed solid mass, 2.5 cm in
diameter.

Histology shows duct-like structures lined by regular, low columnar cells,

separated by loose fibrous tissue. The margins are well defined.

Which is the most likely diagnosis?

A. Carcinoma in situ
B. Ductal carcinoma
C. Fibroadenoma
D. Intraductal papilloma
E. Paget's disease of the breast

© Medical Schools Council 2023 Page 85 of 101

 85. A 22 year old woman has intense itching and pain in her right ear that has
gradually worsened over several days. She says that her hearing appears to
be affected. She is a surfer.

She has debris in the right ear canal, and the tympanic membrane is not
visible. There is pain on pulling the pinna.

Which is the most likely diagnosis?

A. Cholesteatoma
B. Mastoiditis
C. Otitis externa
D. Otitis media
E. Ruptured tympanic membrane

© Medical Schools Council 2023 Page 86 of 101

 86. A 35 year old woman has a painful lump in her breast. Her mother had breast
cancer at the age of 65 years. She is 32 weeks pregnant with no past medical
history. She is not taking any medication. She smokes 5 cigarettes per day.

There is a 2 cm lump in her right breast that is tender on palpation. There is

redness of the overlying skin.

Which is the most appropriate management?

A. Bilateral mammogram
B. No further investigations until after delivery
C. Start oral cefalexin
D. Surgical excision of lump
E. Triple assessment

© Medical Schools Council 2023 Page 87 of 101

 87. A 35 year old woman is admitted unconscious to the Emergency Department
after being found collapsed outside a pub. There was an empty vodka bottle
lying next to her.

Her pulse is 86 bpm, BP 112/62 mmHg, respiratory rate 12 breaths per

minute and oxygen saturation is 98% breathing air.

Which is the most important immediate investigation?

A. Arterial blood gas

B. Blood alcohol level
C. Capillary blood glucose
D. Urea and electrolytes
E. Urinary drug screen

© Medical Schools Council 2023 Page 88 of 101

 88. A 28 year old woman has a lobar pneumonia and is treated with intravenous
amoxicillin. A few minutes after she is given the antibiotic therapy, she
develops an itchy skin eruption and increased breathlessness.

Which is the most likely mechanism of this reaction?

A. Antibody binding to cell-bound antigen

B. Complement activation
C. Delayed-type hypersensitivity
D. Immediate hypersensitivity
E. Immune complex hypersensitivity

© Medical Schools Council 2023 Page 89 of 101

 89. A 39 year old woman has had worsening tiredness for 2 weeks. She was
previously well. She is mildly jaundiced. Her pulse rate is 96 bpm and
BP 112/76 mmHg.

Investigations:
Haemoglobin 48 g/L (115–150)
White cell count 6.2 × 109/L (4.0–11.0)
Platelets 165 × 109/L (150–400)
Mean cell volume (MCV) 98 fL (80–96)
Alkaline phosphatase 100 IU/L (25–115)
Aspartate aminotransferase (AST) 27 IU/L (10–40)
Bilirubin (total) 41 µmol/L (< 21)
Lactate dehydrogenase 560 IU/L (70–250)
Blood film: red cell polychromasia, occasional spherocytes, no red cell
fragments

Which is the most appropriate diagnostic investigation?

A. Bone marrow aspiration

B. Direct antiglobulin test
C. Serum antinuclear antibody
D. Serum folate
E. Serum vitamin B₁₂

© Medical Schools Council 2023 Page 90 of 101

 90. A 65 year old woman has two episodes of vaginal bleeding. Her last
menstrual period was 12 years ago. Abdominal and pelvic examination are
normal. Pelvic ultrasound scan shows an endometrial thickness of 10 mm.

Which is the most appropriate next investigation?

A. CA 125
B. Cervical cytology
C. CT scan of pelvis, abdomen and chest
D. Hysteroscopy and endometrial biopsy
E. MR scan of pelvis

© Medical Schools Council 2023 Page 91 of 101

 91. A 25 year old man develops a muscle contraction in his neck causing pain
and an involuntary rotation of his neck. He was admitted to the psychiatric unit
24 hours ago with persecutory delusions, agitation, and auditory
hallucinations. He has been given risperidone since admission.

Which side effect is he experiencing?

A. Akathisia
B. Autonomic instability
C. Dystonia
D. Parkinsonism
E. Tardive dyskinesia

© Medical Schools Council 2023 Page 92 of 101

 92. An 18 year old woman with sickle cell disease attends the Emergency
Department with severe pain in her left leg. She rates her pain score as 8/10.

Her temperature is 36.9°C, pulse rate 110 bpm, BP 120/80 mmHg, respiratory
rate 16 breaths per minute and oxygen saturation 96% breathing air.

Investigations:
White cell count 7.1 x 109/L (4.0–11.0)
Haemoglobin 71 g/L (115–150)
Platelets 190 × 109/L (150–400)

Which is the next management step?

A. Intravenous co-amoxiclav
B. Oral prednisolone
C. Red cell transfusion
D. Subcutaneous morphine
E. Treatment dose dalteparin

© Medical Schools Council 2023 Page 93 of 101

 93. A 79 year old woman has had malaise and pain in the arms and legs for 4
weeks, with morning stiffness that lasts for 3 hours each day. She
has difficulty washing and dressing.

She cannot lift her arms above her head due to pain, but there is no objective
muscle weakness. She has Heberden's nodes in her hands.

Investigations:
Haemoglobin 112 g/L (115–150)
White cell count 9.8 × 109/L (4.0–11.0)
Platelets 365 × 109/L (150–400)Mean cell volume (MCV) 89 fL (80–96)
CRP 67 mg/L (<5)

Which is the most likely diagnosis?

A. Osteoarthritis
B. Osteomalacia
C. Polymyalgia rheumatica
D. Polymyositis
E. Rheumatoid arthritis

© Medical Schools Council 2023 Page 94 of 101

 94. A 30 year old woman becomes acutely short of breath. She was admitted to
hospital 3 hours ago with an acute exacerbation of asthma. She improved
following treatment with oxygen, nebulised salbutamol and oral prednisolone.
Her chest X-ray on admission was clear.

Her pulse rate is 122 bpm, BP 88/50 mmHg, respiratory rate 30 breaths per
minute and oxygen saturation 88% breathing 40% oxygen via a face mask.
She has reduced expansion of the upper left chest. She has mild wheeze
throughout the chest with reduced breath sounds over the left apex.

Which is the most likely explanation for her deterioration?

A. Anaphylaxis
B. Increasing severity of asthma
C. Lobar collapse
D. Pneumothorax
E. Pulmonary embolus

© Medical Schools Council 2023 Page 95 of 101

 95. A 40 year old man had a laparotomy for intestinal obstruction 12 hours ago.
He has an epidural for analgesia and has been given a 500 mL intravenous
crystalloid bolus. He has no pain. He has no pre-existing medical problems.
His pulse rate is 120 bpm and BP 80/62 mmHg. He has passed 10 mL of
urine in the past 4 hours. He shows no sign of heart failure.

Which is the most appropriate first line of management?

A. IV diuretic
B. IV fluid bolus
C. IV vasoconstrictor
D. Place bed head down
E. Stop epidural analgesia

© Medical Schools Council 2023 Page 96 of 101

 96. A 23 year old man has had joint pains for the last 6 months. He thinks he may
have contracted hepatitis B following unprotected sex 6 months ago and is
unsure of his hepatitis B vaccination status.

Investigations:
HBsAg –ve
anti-HBc IgG +ve
anti-HBs IgG +ve

What is the best description of his hepatitis B status?

A. Acute infection
B. Chronic infection
C. Immune due to naturally resolved infection
D. Immune due to previous vaccination for hepatitis B
E. Not infected but susceptible to further infection

© Medical Schools Council 2023 Page 97 of 101

 97. A 65 year old woman has had headaches for 3 months. She was treated for
cancer of the right breast 12 years ago. There is no evidence of local or
regional recurrence.

Examination of the central nervous system is normal.

CT scan of brain shows an isolated metastasis with cerebral oedema.

Which is the most appropriate immediate treatment?

A. Anastrozole
B. Chemotherapy
C. Dexamethasone
D. Radiotherapy
E. Surgical decompression

© Medical Schools Council 2023 Page 98 of 101

 98. A 45 year old man has had two hours of colicky left sided abdominal pain
radiating to his groin. The pain started abruptly and is associated with nausea
and vomiting.

He is restless and writhing in pain. There is tenderness on palpation of the left

costovertebral angle. Abdominal examination is normal. Bowel sounds are
present but scanty. His urinalysis has 3+.

Which is the most appropriate initial analgesic agent?

A. Aspirin
B. Diclofenac
C. Oxycodone
D. Paracetamol
E. Tramadol

© Medical Schools Council 2023 Page 99 of 101

 99. A 70 year old man has had 1 day of cough and breathlessness. He has a
history of COPD and heart failure. His normal exercise tolerance is 100 m. He
has had no previous hospital admissions. He has a 35 pack-year smoking
history. He is taking lisinopril and uses a tiotropium inhaler.

He is cyanosed and dyspnoeic. His pulse rate is 100 bpm, BP 105/78 mmHg,
respiratory rate 30 breaths per minute and oxygen saturation 84% breathing
28% oxygen. He has scattered wheeze and crackles bilaterally. He has been
given nebulised salbutamol.

Investigations:
Arterial blood gas on 28% oxygen
pH 7.25 (7.35-7.45)
PO2 6.9 kPa (11-15)
PCO2 7.8 kPa (4.6-6.4)
Bicarbonate 34 mmol/L (22-30)

Which is the most appropriate next step in management?

A. Increase oxygen to 40% via a Venturi mask

B. Intravenous amoxicillin
C. Intravenous furosemide
D. Non-invasive ventilation
E. Reduce oxygen to 2 L/min via a nasal cannula

© Medical Schools Council 2023 Page 100 of 101

 100. A 2 day old baby boy undergoes his routine neonatal hearing screen. His
mother has been deaf since early childhood and has bilateral hearing aids.
She asks whether her baby will be deaf.

Which is the most appropriate additional assessment?

A. Brainstem evoked response test

B. Cytomegalovirus serology
C. Distraction testing
D. MR scan of brain
E. Weber's test

© Medical Schools Council 2023 Page 101 of 101