MRCS PART-A ONLINE PREPARATORY COURSE

MOCK EXAM-1
PAPER – 2
SBA – Single Best Answer and
EMQ – Extended Matching Questions

TOTAL MARKS – 135

DURATION – 120 MINUTES

(Please use the Answer sheet supplied by the Group Co-ordinator DR. SAKIB)

(For question number 1 – 60, please select one single best answer from the given options)

1. A newborn infant is noted to have a unilateral cleft lip only. What is the most likely explanation for
this process?

A. Incomplete fusion of the second branchial arch

B. Incomplete fusion of the nasolabial muscle rings
C. Incomplete fusion of the first branchial arch
D. Incomplete fusion of the third branchial arch
E. Incomplete fusion of the secondary palate

2. A 43 year old male with long standing chronic hepatitis is being followed up. Recently his AFP is
noted to be increased and an abdominal USS demonstrates a 2cm lesion in segment V of the liver.
What is the most appropriate course of action?

A. PET CT scan
B. Liver MRI
C. USS guided liver biopsy
D. Laparoscopic biopsy
E. Segmental resection of segment V

3. PaO2 10.0 kPa (80 mmHg) 12.0 - 14.7 (90 - 110)

PaCO2 5.8 kPa (44 mmHg) 4.5 - 6.0 (34 - 45)
pH 7.24 7.36 - 7.44
H+ 57 nmol/L 35 - 45
Bicarbonate 18 nmol/L 24 – 30 nmol/L
Base excess -7 nmol/L±2
Oxygen concentration 40%

Which of the following best describes this blood gas result?

A. Metabolic acidosis - acute with hypoxaemia

B. Metabolic alkalosis - acute, normal oxygenation
C. Normal ventilation with hypoxaemia
D. Respiratory failure – acute
E. Respiratory failure - compensated with hypoxaemia

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4. A 12-year-old boy is riding his bike. He is forced to brake suddenly and lands on his perineum on
the crossbar of his bike. When he attempts to urinate after the injury he develops marked swelling of
the scrotum. Which structure is this boy most likely to have injured?

A. Bladder
B. Prostatic urethra
C. Spongy urethra
D. Testicle
E. Testicular artery

5. A 43-year-old gentleman presents to the Accident and Emergency unit with severe stabbing type of
pain over the epigastric region. The pain started following episodes of repeated vomiting and it
worsens on swallowing. He is a heavy drinker and has been consuming 10-15 units of alcohol
everyday for the past 20 years. On examination, his blood pressure is 100/78 mmHg, and his pulse
is 124/min and thready. Chest x-ray reveals air in the mediastinum and in the subcutaneous
tissues. There is no change in the anatomical contour of the diaphragm.From the options below
choose the most appropriate cause for this patient’s signs and symptoms:

A. Acute cholecystitis
B. Boerhaave's syndrome
C. Diaphramatic rupture
D. Myocardial contusion
E. Traumatic haemothorax

6. Your crash bleep alerts you to a road traffic accident victim that has just arrived in the A&E
department.In the casualty is an 18-year-old man who is brought in by the paramedics following a
RTA. He is opening his eyes to painful stimuli, his speech is inappropriate, and he is extending his
limbs to pain.What is his Glasgow coma score?

A. 4
B. 6
C. 7
D. 8
E. 10

7. A 16-year-old female presents with a three year history of recurrent colicky loin pain. One year ago
she passed a renal calculus.24 hour urine collection showed normal levels of calcium, phosphate
and urate, but elevated levels of arginine, cystine, lysine and ornithine.Which one of the following
features is characteristic of this condition?

A. Accumulation of cystine in collecting system

B. Autosomal dominant inheritance
C. Cystine deposits within the Cornea
D. Functional defects within the glomeruli
E. Radiolucent renal stone formation

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8. In the clinical examination of the chest, accurate knowledge of the surface markings of the lungs is
essential. Which of the following corresponds to the clinical situation?

A. The apex of the lung corresponds precisely to the upper border of the medial third of the
clavicle.
B. The oblique fissure of the lung corresponds to the medial border of the scapula when the
arm is fully abducted
C. The transverse (horizontal) fissure of the right lung corresponds to the right fifth
intercostal space
D. The lower border of the lung on each side corresponds to the tenth rib in the mid-axillary
line
E. The lower border of the lung reaches the twelfth rib posteriorly

9. A 54-year-old woman has undergone some blood tests as part of an employment health screen.
She reports she is in good health and, being very health conscious, takes regular vitamin and
mineral supplements. She is taking bendrofluazide 2.5 mg for hypertension and her blood pressure
is 132/82 mmHg. The only abnormality is a serum calcium concentration of 2.94 mmol/L. Which of
the following is the most likely cause?

A. Diuretic treatment
B. High dietary calcium intake
C. High dietary vitamin D intake
D. Occult malignancy
E. Primary hyperparathyroidism

10. A 52-year-old woman undergoes investigation for jaundice. She first noticed this symptom 2
months ago, but for 4 months prior to that, she had been experiencing generalised pruritus. The
results of liver function tests are as follows:

Serum bilirubin 325 mmol/L,

Aspartate aminotransaminase 55 U/L (15–42),
Alkaline phosphatase 436 U/L (80–150),
Gamma-glutamyltransferase 82 U/L (11–51),
Albumin 3 6 g/L,
Total protein 82 g/L.

Which of the following is the most likely diagnosis?

A. Alcoholic cirrhosis
B. Carcinoma of the head of the pancreas
C. Cholangiocarcinoma
D. Primary biliary cirrhosis
E. Primary sclerosing cholangitis

11. A 76-year-old diabetic woman presented with a non-healing ulcer on her right foot. Blood culture
samples grew methicillin-resistant Staphylococcus aureus (MRSA). Which of the following
antibiotics may be considered in addition to iv vancomycin?

A. Flucloxacillin

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 B. Metronidazole
C. Rifampicin
D. Ticarcillin
E. Ampicillin

12. A 47-year-old man with a long history of alcohol abuse is admitted to hospital with acute
abdominal pain and is diagnosed clinically as having acute pancreatitis. This is confirmed by finding a
high serum amylase activity and by the results of an ultrasound scan. He has not had a similar illness
before. His serum is seen to be lipaemic: serum triglyceride concentration is 26 mmol/l. Which of the
following is the most likely cause of the hypertriglyceridaemia?

A. Decreased pancreatic lipase secretion

B. Deficiency of apolipoprotein C-II
C. Deficiency of LDL (low-density lipoprotein) receptors
D. Deficiency of lipoprotein lipase
E. Increased synthesis of VLDL (very low-density lipoprotein)

13. Phase 0 of the cardiac action potential relates to a:

A. Defflux of calcium
B. Rapid influx of calcium
C. Rapid influx of potassium
D. Rapid influx of sodium
E. None of the above

14. Which of the following respiratory physiology tests would be consistent with a diagnosis of
moderately established cryptogenic fibrosing alveolitis?

A. Diffusion capacity decreased, FEV1/FVC normal, total lung capacity reduced

B. Diffusion capacity increased, FEV1/FVC normal, total lung capacity increased
C. Diffusion capacity normal, FEV1/FVC reduced, total lung capacity reduced
D. Diffusion capacity decreased, FEV1/FVC normal, total lung capacity normal
E. Diffusion capacity decreased, FEV1/FVC increased, total lung capacity increased

15. The commonest histological type of invasive breast cancer is?

A. Lobular
B. Tubular
C. Mucinous
D. Medullary
E. Ductal

16. A 60-year-old previously fit and well man dies suddenly after two separate syncopal episodes. At
post mortem examination, which one of the following congenital cardiac defects that could be
associated with his sudden death would you expect to find?

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 A. Dextrocardia with situs inversus
B. Patent foramen ovale
C. Bicuspid aortic valve
D. Ventricular septal defect
E. Single coronary artery

17. A 62-year-old ex-smoker has been diagnosed with non-small cell lung carcinoma by
endobronchial biopsy. At standard mediastinoscopy, what is the least likely lymph node station to be
sampled?

A. Paratracheal nodes
B. Subcarinal nodes
C. Tracheobronchial nodes
D. Aortopulmonary nodes
E. Pretracheal nodes

18. A cut wound at the wrist affecting the median nerve will cause the following?

A. The long flexors will be affected causing wasting the front of the forearm on the long run
B. Flexor polices longus will be affected
C. The hand is held typically with the index finger straight ‘pointing finger’
D. Abduction of the thumb is affected
E. Loss of sensation over the ulnar aspect of ring finger

19. A patient diagnosed with thyroglossal cyst is going to be admitted for surgery. The most important
preoperative test is?

A. T3 and T4
B. Thyroid Stimulating Hormone (TSH) levels
C. ECG
D. Isotope scan
E. Cyst ultrasound scan

20. In a fracture of the humerus (Neer’s classification-III) the following important structure might be
affected?

A. The axillary artery

B. The axillary vein
C. The radial nerve
D. The axillary nerve
E. The profunda brachii artery

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21. A 30-year-old female attends A&E following a head injury. You assess her on arrival and her GCS
14. The nurse looking after the patient calls you back to see her 30 minutes later. The GCS is now 10,
the patient has a blown pupil, is vomiting and confused. The bleeding is most likely to be from:

A. Basillar artery
B. Berry aneurysm
C. Intrinsic cerebral vessels
D. Middle meningeal artery
E. Sigmoid sinus

22. An anxious 22-year-old female with a high respiration rate has the following arterial blood gas
results:

H
p 7.27 (7.36-7.44)
PCO2 2.6KPa (4.7-6.0)
Base deficit 12 mmol/L

What is the interpretation of the acid-base status?

A. Combined metabolic and respiratory acidosis

B. Combined metabolic and respiratory alkalosis
C. Metabolic acidosis with some compensatory respiratory alkalosis
D. Respiratory acidosis with some compensatory metabolic alkalosis
E. Respiratory alkalosis with some compensatory metabolic acidosis

23. A 22-Year-old Golf course groundsman develops sudden onset of breathlessness and right-sided
chest pain whilst maintaining the 18th hole. He is rushed to hospital but his condtion worsens when
being examined by a junior doctor who reported hearing very distant breath sounds over his right
lung. Following the intervention of a senior doctor his condition improves rapidly. What was the most
probable diagnosis?

A. Myocardial infarction
B. Pericarditis
C. Pneumonia
D. Pulmonary embolism
E. Tension Pneumothorax

24. A 32-year-old male attends A&E following an assault. He sustained multiple blows to his face and
chest. You are concerned that he may have an underlying facial fracture. On examination you note
that the right cheek is very swollen and that there is a right subconjuctival haemorrhage. There is also
sensory deficit over the right cheek. Which nerve has been damaged?

A. Inferior alveolar nerve

B. Infraorbital nerve
C. Occulomotor nerve
D. Optic nerve
E. Superior alveolar nerve

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25. A 24-year-old man has sustained significant brain injury following an assault. He is showing signs
of a raised intra-cranial pressure. Which of the cranial nerves is usally the first to be affected by a
raised intracranial pressure?

A. The abducent nerve

B. The facial nerve
C. The hypoglossal nerve
D. The vagus nerve
E. The vestibulocochlear nerve

26. Which one of the following is true regarding acute pulmonary embolism?

A. A normal ECG excludes the diagnosis

B. Embolectomy is more effective than thrombolysis in improving survival
C. Heparin is as effective as thrombolytic therapy
D. The presence of hypoxaemia is an indication for thrombolysis
E. Thrombolysis administered through a peripheral vein is as effective as through a
pulmonary artery catheter

27. A 16-year-old girl presents with bilateral cervical lymphadenopathy. Her lymph node biopsy
reveals a nodular sclerosing Hodgkin’s disease. Which one of the following features indicates a
poorer prognosis?

A. Fatigue
B. Mediastinal mass of 3cm
C. Night sweats
D. Pruritis
E. Recent Epstein-Barr virus infection

28. An 18-year-old with Cerebral Palsy is admitted after a respiratory arrest having been intubated by
paramedics. Nobody can gain intravenous access as the patient is too shut down. A femoral line is
not possible due to contractures. You don’t have the experience to perform central venous
cannulation. Which of the following is the best option for administering intravenous fluids/emergency
drugs in this situation of inability to gain venous access?

A. Down the endotracheal tube

B. Interosseus
C. Intramuscular
D. Nasogastric
E. Subcutaneous

29. A 24-year-old woman develops infective endocarditis involving the aortic valve. She receives a
porcine bioprosthesis because of her desire to have children and not to take anticoagulant
medication. After ten years, she must have this prosthetic valve replaced. Which of the following
pathologic findings in the bioprosthesis has most likely led to the need for replacement?

A. Calcification with stenosis

B. Dehiscence

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 C. Infective endocarditis
D. Strut failure
E. Thrombosis

30. A 25-year-old female with a history of type 1 Von Willebrand’s disease is referred for an opinion.
She is to have a cervical cone biopsy and the admitting team are concerned about her clotting.You
find that she has a past history menorrhagia and has had two dental extractions as an adolescent that
were uncomplicated. What is the most useful test to assess her bleeding tendency?

A. Activated partial thromboplastin time

B. Bleeding time
C. Plasma factor VIII activity
D. Platelet aggregation
E. Prothrombin time

31. A 78-year-old lady with chronic venous ulcers is reviewed in clinic and is found to have a new
nodule on the edge of the ulcer. This is biopsied and found to be malignant. What is the name given
to this condition?

A. Bowen’s disease
B. Curling’s ulcer
C. Cushing’s ulcer
D. Marjolin’s ulcer
E. Rodent ulcer

32. A 36-year-old man presents on the emergency intake with a perianal abscess. He is taken to
theatre and an EUA demonstrates the presence of a fistula to the abscess cavity. The abscess is
situated to the left and posterior to the anus (5 o’clock position in the lithotomy position). Where would
you expect the internal opening to be located?

A. Directly anterior to the centre of the anus (12 o’clock)

B. Directly posterior to the centre of the anus (6 o’clock )
C. To the left and posterior to the centre of the anus (5 o’clock)
D.To the left of the centre of the anus (3 o’clock)
E.To the right of the centre of the anus (9 o’clock)

33. Which of the following regarding Helicobacter pylori is false?

A. Infection may elevate serum gastrin

B. It is the cause of > 90% of duodenal ulceration
C. It is associated with gastric adenocarcinoma
D. Eradication of the infection is curative in gastric mucosa associated lymphoid tissue
(MALT) lymphoma
E. It is a Gram positive spiral flagellated organism

34. An 87-year-old lady is admitted to the orthopaedic ward following a fall in which she sustained a
fractured neck of femur. She has no past medical or surgical history. She undergoes hemiarthroplasty

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and on her second post-operative day she is noted to have a warm, red wound and is started on an
intravenous cephalosporin. This is continued for 12 days following which she develops abdominal
distension and profuse diarrhoea. Plain abdominal x-ray shows a dilated large bowel. Ridgid
sigmoidoscopy shows an inflamed rectal mucosa with pseudomembranous patches. What is the most
useful next investigation?

A. Barium enema
B. Colonoscopy
C. CT Abdomen/Pelvis
D. Gastrograffin enema
E. Stool sample

35. Apoptosis is induced by

A., Activation of caspases

B. The MAP kinase pathway
C. DNA synthesis
D. Antibodies
E. Necrosis

36. A 42-year-old man is seen in the clinic reporting lethargy, nausea and vomiting and weight loss.
On examination he is hypotensive and there is pigmentation of his palmar skin creases and of an old
appendicectomy scar. Routine biochemistry reveals:

Potassium 5.8 mmol/L (3.5-4.9)

Sodium 131 mmol/L (137-144)

What is the likely diagnosis?

A. Addison’s disease
B. Conn’s syndrome
C. Cushing’s syndrome
D. Hypopituitarism
E. Waterhouse-Friderichsen syndrome

37. A 76-year-old man is admitted on the surgical intake complaining of colicky lower abdominal pain,
absolute constipation and abdominal distension of 2 days duration. On examination he has a grossly
distended soft abdomen. Plain abdominal x-ray demonstrates large bowel dilation throughout the
colon. Routine bloods are requested and he is placed nil by mouth. What is the most appropriate next
management step for this gentleman?

A. Barium enema
B. Barium small bowel follow through
C. Colonoscopy
D. Laparotomy
E. Water soluble contrast enema

38. A 31-year-old woman is seen in the clinic complaining of weight loss and palpitations. On
examination she has a tremor and an irregularly irregular pulse. She has a smooth goitre which has a

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bruit and there is exophthalmos. Thyroid function tests are requested. Which of the following
combinations represents the clinical condition?

A. T4 ↑; T3 ↑; TSH ↓
B. T4 ↑; T3 N; TSH ↓
C. T4 ↑; T3 ↑; TSH ↑
D. T4 ↓; T3 ↓; TSH ↑
E. T4 ↓; T3 ↓; TSH ↓

39. A 58-year-old woman presents to the neurosurgical clinic having been investigated for new onset
epilepsy, accompanied with severe headaches. CT and MRI have shown a space occupying lesion in
the frontal lobe that has an enhancing ring around an area of necrosis. What is the most likely
diagnosis from the list below?

A. Astrocytoma
B. Ependymoma
C. Glioblastoma
D. Meningioma
E. Oligodendroglioma

40. A 69-year-old woman presented with an ulcer over the left ankle, which had developed over the
previous 9 months. She had a history of right deep vein thrombosis five years previously. On
examination she had a superficial slough-based ulcer, 6cms in diameter, over the medial malleolus
with no evidence of cellulitis.Which one of the following is the most appropriate next investigation?

A. Ankle-brachial pressure index

B. Bacteriological swab of the ulcer
C. Bilateral lower limb arteriogram
D. Right leg venogram
E. Venous duplex ultrasound scan

41. A 58-year-old lady undergoes an anterior resection for colorectal cancer. After radiological and
pathological staging her disease is staged as a Duke stage C. She is given post-operative
chemotherapy. At her surgical out-patient review, at 1 year post-op, she asks you what is her
prognosis over the next 4 years. Which of the following would be the most accurate answer?

A. <5%
B. 10-20%
C. 25-35%
D. 55-65%
E. 80-90%

42. A 23-year-old female is seen in the accident and emergency department. She has suffered severe
vomiting and diarrhoea over the last four days. She states that she has been unable to keep down
any fluids. Clinically she is dehydrated and she is started on an intravenous infusion. Investigations
reveal a potassium of 2.6 mmol/L (3.5-4.9). Which of the following abnormalities would you expect to
see on her ECG?

A. Shortened P-R interval

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 B. Small P waves
C. S-T segment depression
D.Tall, tented T waves
E. Wide QRS complexes

43. A 34-year-old man with a known history of Crohn’s disease was admitted to hospital with
abdominal pain and features of perforation. He underwent laparotomy and a perforation of the
terminal ileum was found with free faecal fluid in the abdominal cavity. He was transferred to the
Intensive Care Unit. Together with traditional antimicrobial and supportive ITU therapy, which of the
following therapeutic measures is most likely to improve this patient’s outcome?

A. High-dose intravenous corticosteroids

B. Low-dose intravenous corticosteroids
C. Recombinant anti-endotoxin antibody
D. Recombinant human antithrombin III
E. Recombinant human tissue-factor pathway inhibitor

44. A 56-year-old man with septic shock is fully ventilated, on Continuous Veno-Venous
Haemofiltration receiving noradrenaline, Vancomycin and Ciprofloxacin. He has a blood pressure of
80/60 mmHg despite 1mcg/kg/min of noradrenaline.Which of the following would be the most
appropriate next step in managing this patient?

A. A short synacthen test

B. Activated Protein C
C. Change of inotropes
D. Hydrocortisone
E. Nitric Oxide

45. A 67-year-old man is 3 days post-operative following a sigmoid colectomy. He has insulin
dependent diabetes mellitus. He complains of dizziness and faintness. His blood pressure is 80/50
mmHg, his pulse 110 beats per min, respiratory rate 24/min, and he has SpO2 99% on air. His plasma
glucose concentration is 18 mmol/L (3.0-6.0 Fasting) Which of the following is the most appropriate
investigation for this patient?

A. Arterial blood gas

B. Chest X-ray
C. Electrocardiogram
D. Serum Lactate
E. Urine ketones

46. A 56-year-old man is admitted with epigastric pain after drinking heavily. He has a temperature of
o
36.9 C, a pulse of 95/min, a blood pressure of 85/60 mmHg, and a respiratory rate of 32/min.
Investigations reveal:

Haemoglobin 12.6 g/dL (13.0-18.0)

Platelets 169 x109/L (150-400 x109)
9 9
White cell count 3.9 x10 /L (4-11 x10 )

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Which of the following is the diagnosis?
A. Leaking aortic aneurysm
B. Multi-organ dysfunction syndrome
C. Pancreatitis
D. Septic shock
E. Systemic Inflammatory Response Syndrome

47. A 65-year-old gentleman was admitted with a two month history of jaundice, pale stool, dark urine
and bruising following minimal trauma. A coagulation screen revealed a prolonged APTT and PT.

A. Haemophilia A
B. DIC
C. Ehlors-Danlos Syndrome
D. Von Willebrand Disease
E. Vit K Deficiency

48. A 75-year-old lady presents on the acute general surgical take with severe left iliac fossa pain.
Examination reveals a pyrexia and localised tenderness in the left iliac fossa. She is treated
conservatively with broad spectrum antibiotics and settles over the next 1 week. On review in the out-
patient department 3 months later she reports that she has had recurrent urinary tract infections and
has pneumaturia. What is the most likely underlying diagnosis?

A. Colorectal cancer
B. Diverticular disease
C. Ulcerative colitis
D. Crohn’s disease
E. Fistula in ano

49. A 23-year-old gentleman presents to clinic complaining of multiple swellings over the torso, thigh
and head. Each of the swellings is found to have similar characteristics being: soft, 2-4cm in size,
non-pulsatile, non-reducible and not fixed to skin or deep tissues. His brother has similar swellings.
Which one of the following conditions is the most likely?

A. Cambell de Morgan spots

B. Dercum’s disease
C. Dermatofibroma
D. Osler-Weber-Rendu syndrome
E. Von recklinghausen’s disease

50. A 23-year-old gentleman presents to clinic complaining of multiple swellings over the torso, thigh
and head. Each of the swellings is found to have similar characteristics being: soft, 2-4cm in size,
non-pulsatile, non-reducible and not fixed to skin or deep tissues. His brother has similar swellings.
Which one of the following conditions is the most likely?

A. Cambell de Morgan spots

B. Dercum’s disease
C. Dermatofibroma
D. Osler-Weber-Rendu syndrome

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 E. Von recklinghausen’s disease

51. In relation to the oxygen dissociation curve, which of the following factors shifts the curve to the
right?

A. Carbon monoxide poisoning

B. Fall in 2,3 DPG
C. Fall in pH
D. Fall in temperature
E. Rise in Ph

52. An 80-year-old lady is admitted on the emergency intake and is noted to have facial flushing
which she says is long-term and related to her “heart tablets”. Which of the following is likely to be
responsible for this affect?

A. Atenolol
B. Digoxin
C.Nifedipine
D. Simvastatin
E. Spironolactone

53. A 37-year-old lady who has had low back pain radiating to her calf for six weeks presents to the
A&E department. She reports severe abdominal pain and in the last 12 hours she has been unable to
micturate. Rectal examination reveals an empty rectum and altered peri-anal sensation. Neurological
examination of her limbs reveals weakness in both legs but upper limbs are normal. What is the most
likely diagnosis from the following list?

A. Central disc prolapse at C6/7

B. Central disc prolapse at L4/5
C. Constipation
D. Lateral disc prolapse at C6/7
E. Multiple sclerosis

54. A 75-year-old lady presents on the acute general surgical take with severe left iliac fossa pain.
Examination reveals a pyrexia and localised tenderness in the left iliac fossa. She is treated
conservatively with broad spectrum antibiotics and settles over the next 1 week. On review in the out-
patient department 3 months later she reports that she has had recurrent urinary tract infections and
has pneumaturia.What is the most likely underlying diagnosis?

A. Colorectal cancer
B. Diverticular disease
C. Ulcerative colitis
D. Crohn’s disease
E. Fistula in ano

55. Which of the following statements regarding the subclavian vein and its relations is correct?

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 A. Forms the axillary vein
B. Begins at the lateral border of the first rib
C. Joins the superior vena cava
D. The subclavian vein and internal jugular vein form the brachiocephalic trunk
E. The subclavian vein passes posterior to scalenus anterior.

56. A study reports on the results of a large study of the primary prevention of stroke in a diabetic
population using a new antiplatelet agent versus aspirin. The results of the study reveal that over a 5
year period the incidence of stroke in the aspirin treated group is 3% compared to a rate of 1.5% in
the group treated with the new antiplatelet agent (p<0.001). What is the relative risk reduction in
stroke associated with the new drug?

A. 1.5%
B. 15%
C. 30%
D. 40%
E. 50%

57. A 72-year-old male presented to his GP with depression after the death of his wife. His notes also
reveal that he has a two-year history of urinary hesitancy and poor stream. His GP prescribed him
some medication and the following day he developed acute urinary retention. Which of the
following drugs is most likely to have precipitated the urinary retention?

A. Amitriptyline
B. Diazepam
C. Fluoxetine
D. Venlafaxine
E. Zopiclone

58. Which of the following are true? Small cell cancer of the lung –

A. Accounts for more than 50% of all lung cancers

B. Is common in elderly non-smokers
C. Is frequently benign and localised at presentation
D. May be associated with hypercalcemia
E. Has a median survival of 5 years if treated appropriately

59. . In the investigation of a woman presenting with jaundice and itching, which one of the following
would most strongly support the diagnosis of primary biliary cirrhosis (PBC)?

A. Raised serum IgM

B. Positive antinuclear antibodies
C. Antimitochondrial antibodies (M2 pattern)
D. Raised serum IgA
E. Anti-smooth muscle antibodies

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60. A 60-year-old female presents with a 4 week history of low grade fever, dyspnoea and fatigue.
Two months ago she received a prosthetic valve replacement for mitral regurgitation. On examination
she has a temperature of 37.7oC. At trans-oesophageal echocardiography vegetations are seen.A
clinical diagnosis of prosthetic valve endocarditis is made. Which of the following is the most likely
causative organism?

A. Actinomycoses
B. Candida albicans
C. Enterococci
D. Staphylococcus epidermidis
E. Streptococcus viridans

(From question number 61-135, all are Extended Matching Questions. Each option can be used
once or more than once or not at all)

Lower dermatomes

Options

A. S4
B. S5
C. L3
D. L4
E. L5

For each of the following regions select the most appropriate dermatomal level. Each option can be
used once or more than once or not at all.

61. Patella.

62. Great toe.

63. Anus.

Branches of the abdominal aorta

Options

A. Common Iliac Arteries

B. Celiak trunk
C. Inferior Mesenteric Artery
D. Superior Mesenteric Artery
E. Median Sacral Artery

For each of the following, please choose the correct arterial option from above. Each option can be
used once or more than once or not at all.

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64. Gives rise to the middle colic arteries.

65. This artery supplies parts of the gut which are derived from the hindgut.

66. An unpaired branch that arises from the aortic bifurcation.

Abnormal movements

Options

A Tardive dyskinesia
B Hemiballismus
C Dysmetria
D Chorea
E Asterixis

Choose from options above the term that describes the types of movement in following clinical
situations. Each option can be used once or more than once or not at all.

67. A jerky tremor of outstretched hands in an alcoholic with decompensated liver disease.

68. Non-rhythmic jerky purposeless movements in the hands of a 55-year-old man.

69. A 75-year-old man with poorly controlled diabetes is distressed by wild flinging of his right arm
and right leg.

70. Grimacing and involuntary chewing in a 75-year-old woman on long-term treatment with
neuroleptics.

71. Past-pointing in a 60-year-old woman being investigated for unsteady gait.

Abdominal mass

Options

A Pancreatic pseudocyst
B Ovarian carcinoma
C Gastric carcinoma
D Sigmoid carcinoma
E Caecal carcinoma

For each clinical scenario below, give the most likely cause for the clinical findings. Each option can
be used once or more than once or not at all.

72. A 75-year-old man with a 3-month history of dyspepsia presents with weight loss and abdominal

16
 distension. On examination a 3.5 cm, hard, irregular, tender epigastric mass can be felt which
moves on respiration. Percussion of the distended abdomen reveals shifting dullness. The left
supraclavicular node is palpable.

73. A 70-year-old woman presents with a mass in the right iliac fossa and severe microcytic anaemia.
On examination the mass is firm, irregular and 4 cm in diameter. The lower edge is palpable.

Swelling in the neck

Options

A branchial cyst
B sternomastoid tumour
C cervical rib
D lymphoma
E chemodectoma

For each clinical scenario below give the most likely cause for the clinical findings. Each option can be
used once or more than once or not at all.

74. A 43-year-old man presents to his GP with a 6-month history of a painless pulsatile mass at the
angle of the jaw.

75. A 23-year-old girl complains of intermittent numbness and paraesthesiae in her right hand for the
past 2 months. On examination there is a fixed, hard, 1cm x 2 cm swelling in the right
supraclavicular fossa.

76. A 32-year-old woman presents to her GP with a neck lump enlarging for the last 3 years. It
measures 1 cm x1.5 cm and is located behind the junction of the upper and middle thirds of left
sternocleidomastoid muscle.The lump has the history of infection and resolving with oral
antibiotics.

77. A 23-year-old man presents to his GP with a 2 cm 3 cm painless lump at the angle of the jaw; it
has been there for 2 months. He also complains of weight loss, night sweats and fever, over the
same period. Hepatosplenomegaly is detected on examination of the abdomen.

Skin cover

Options

A. Split-thickness skin graft

B. Full-thickness skin graft
C. Sterile skin closure strips
D. Local flap
E. Free flap

For each clinical scenario below choose the most appropriate means of reconstruction. Each option
can be used once or more than once or not at all.

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78. A 74-year-old woman presents to A&E with a small proximally based pretibial laceration with no
soft tissue loss. She is known to have ischaemic heart disease, COPD and diabetes.

79. A 44-year-old woman would like breast reconstruction surgery following a rightsided mastectomy
and postoperative radiotherapy. She is known to be a noninsulin-dependent diabetic and
previously smoked 20 cigarettes a day.

80. A 25-year-old patient has suffered a full-thickness burn over the posterior aspect of her trunk.

81. A 43-year-old woman presents with a biopsy-proven 3 cm 3 cm squamous cell carcinoma over
the right side of her forehead. Tumour excision included the periosteum of the skull. The patient is
particularly concerned about the cosmetic outcome.

Clinical Audit

Opions

A. Data analysis
B. Data collection
C. Identify standards
D. Implement changes
E. Needs assessment

From the given list for the following teams who are undertaking audits. Each option can be used once
or more than once or not at all.

82. A surgical team presented their data demonstrating an increased rate of post-surgical wound
infection following gastrointestinal surgery compared with published standards from the Royal
College of Surgeons.

83. A vascular team intend to compare their future results for aortic aneurysm repair with national
standards.

84. A team wish to audit their departmental results on the use of anticoagulation in patients with atrial
fibrillation.

Shoulder condition

Options

A posterior dislocation of shoulder

B anterior dislocation of shoulder
C. adhesive capsulitis
D osteoarthritis
E impingement syndrome

18
For each clinical scenario below give the most likely cause for the clinical findings. Each option can be
used once or more than once or not at all.

85. A 21-year-old woman presents with a very painful shoulder locked in adduction and internal
rotation following an epileptic fit.

86. A 55-year-old man complains of shoulder pain aggravated in abduction of the arm between 60°
and 120°.

87. A 65-year-old woman presents with shoulder pain and restricted movement in all directions for last
couple of years.

Diarrhoea

Options

A. Vibrio cholerae
B. Yersinia enterocolitica
C. E. coli (Enterohaemorrhagic)
D. E.Coli (Enteroinvasive)
E. Campylobacter jejuni.

What is the most likely infective organism for the scenario given? Each option can be used once or
more than once or not at all.

88. A 22 year old chef presents to the medical team with profuse bloody diarrhoea. On further
questioning he describes tenesmus. They arrange a sigmoidoscopy which reveals necrosis and
ulceration of the descending colon mucosa.

89. A 22 year old Chef presents with abdominal pain in the right iliac fossa. There is an associated
temperature and diarrhoea. The SHO takes the patient to theatre for an appendicectomy, but the
appendix appears normal. The terminal ileum appears thickened and engorged.

90. A 30 year old aid worker becomes unwell whilst helping at the scene of a recent earthquake. He
develops vomiting and soon afterwards a diarrhoea that is loose and extremely watery.

Disorders of the hip

Options

A. Perthes disease
B. Developmental dysplasia of the hip
C. Intra capsular fracture of the femoral neck
D. Slipped upper femoral epiphysis
E. Adhesive capsulitis

Please select the most likely diagnosis for the scenario given. Each option can be used once or more
than once or not at all.

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91. An obese 14 year old boy presents with difficulty running and mild knee and hip pain. There is no
antecedent history of trauma. On examination internal rotation is restricted but the knee is normal with
full range of passive movement possible and no evidence of effusions. Both the C-reactive protein
and white cell count are normal.

92. A 6 year old boy presents with pain in the hip it is present on activity and has been worsening
over the past few weeks. There is no history of trauma. He was born by normal vaginal delivery at 38
weeks gestation On examination he has an antalgic gait and limitation of active and passive
movement of the hip joint in all directions. C-reactive protein is mildly elevated at 10 but the white cell
count is normal.

93. A 30 year old man presents with severe pain in the left hip it has been present on and off for
many years. He was born at 39 weeks gestation by emergency caesarean section after a long
obstructed breech delivery. He was slow to walk and as a child was noted to have an antalgic gait. He
was a frequent attender at the primary care centre and the pains dismissed as growing pains. X-rays
show almost complete destruction of the femoral head and a narrow acetabulum.

Types of tissue transplantation

Options

A Autograft
B Allograft
C Monograft
D Isograft
E Xenograft

For each of the clinical scenarios listed below, select the most appropriate description of the
transplanted tissue. Each option may be used once, more than once, or not at all.

94. A patient receives a porcine aortic valve replacement

.
95. A 25-year-old woman with end-stage renal failure receives a kidney for transplantation from her
identical twin sister.

96. A woman undergoes renal transplantation. The kidney had been harvested from a patient with
confirmed brainstem death.

97. A 16 year-old boy suffers burns to h is chest. A partial thickness skin graft is harvested from his
thigh and used to cover part of his chest.

Complications following renal transplant

Options

A. Lymphocele
B. Renal vein thrombosis
C. Chronic allograft nephropathy

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D. Renal artery stenosis
E. Renal artery thrombosis

For each of the clinical scenarios listed below, select the most appropriate complication of the renal
transplant. Each option may be used once, more than once, or not at all.

98. A 45 year old lady undergoes a renal transplant from a living related donor. She is well for several
months but on review in the outpatient department is noted to have persistent hypertension and a
slight deterioration in renal function.

99. A 43 year old lady undergoes a live related renal transplant. At the conclusion of the operation she
has a good urine output and the graft appeared well perfused. On the ward she suddenly becomes
anuric.

100. A 39 year old lady undergoes a live related renal transplant. She progresses well. Two weeks
following the transplant she is noted to have swelling overlying the transplant site and swelling of the
ipsilateral limb.Urine output is acceptable and creatinine unchanged.

Theme: Statistics

Options

A. Fishers exact test

B. Bonferroni test
C.Mann Whitney U test
D.Paired T test
E. Unpaired T Test

For each of the clinical scenarios listed below, select the most appropriate statistical test. Each option
may be used once, more than once, or not at all.

101. A surgeon has conducted a piece of research and is try to make his data appear interesting for
publication. To do this he is conducting multiple analyses of sub group data using multiple tests.

102. A surgical unit are conducting a study to determine whether patients who have bowel preparation
have a lower risk of colonic anastomotic leakage than those having none. The planned sample
size is 25.

103. A surgeon wishes to conduct a national study relating patient weight to the length of inpatient
stay following all major operations.

Breast Lump

Options

A Fibroadenoma
B Paget's disease
C Fat necrosis
D Carcinoma

21
E Ductal papilloma

For each of the patients described below, select the single most likely diagnosis from the options
listed above. Each option may be used once, more than once, or not at all.

104. A 54-year-old woman presents with chest trauma. 10 days earlier she had noticed some
bruising, and now there is a painful mass in her breast.

105. A 27-year-old woman presents with bloody discharge from her nipple.

106. A 46-year-old woman presents with a scaly rash around her nipple.

Jaundice

Options

A Autoimmune hepatitis
B Primary sclerosing cholangitis
C hepatitis A
D Dubin–Johnson syndrome
E primary biliary cirrhosis

For each clinical scenario below, give the most likely cause for the clinical findings. Each option may
be used once, more than once, or not at all.

107. A 24 year old presents with nausea, malaise and jaundice. He returned 3 weeks ago from a
holiday abroad. On examination he has a moderate hepatosplenomegaly and tender cervical
lymphadenopathy. He has dark urine and pale stools..

108. A 35-year-old woman presents with fever, malaise and jaundice. On examination she has
moderate hepatomegaly. She is anti-smooth muscle antibody and antinuclear antibody positive.

109. A 45-year-old man with ulcerative colitis presents with jaundice, pruritus and abdominal pain.
Alkaline phosphatase (ALP) is raised and anti-mitochondrial antibodies negative.

Lump in the scrotum

Options

A Epididymal cyst
B Epididymo-orchitis
C Seminoma
D Teratoma
E torsion of testis

For each clinical scenario below, give the most likely cause for the clinical findings. Each option may
be used once, more than once, or not at all.

22
110. A 34-year-old man with a history of undescended testes presents with weight loss and a hard
painless testicular lump.

111. A 12-year-old boy presents with severe pain in the testis associated with vomiting after jumping
on his bicycle.

112. A 45-year-old man presenting with a scrotal swelling is worried that he is growing a third
testicle. On examination there is a smooth fluctuant swelling within the scrotum. Both left and right
testes are palpable.

Acute paediatric airway obstruction

Options

A. Laryngeal papillomatosis
B. Childhood asthma
C. Acute epiglottitis
D. Acute laryngotracheobronchitis
E. Laryngomalacia

113. A 3-year-old boy presents with sudden-onset noisy breathing and drooling. He had a preceding
upper respiratory tract infection and pyrexia. On examination the child appears frightened, flushed in
the face, with inspiratory and expiratory stridor. There is in-drawing of neck muscles and intercostals.

114. A 4-month-old baby presents with gradually worsening noisy breathing which is especially
noticeable when she eats. She is on a lower centile for weight gain and has poor food intake.

Thyroid conditions

Options

A. Follicular carcinoma
B Hashimoto’s disease
C Anaplastic carcinoma
D de Quervain’s thyroiditis
E Graves’ disease

For each clinical scenario below give the most likely cause for the clinical findings. Each option may
be used once, more than once, or not at all.

115. A 75-year-old woman presents with acute airway obstruction and a thyroid mass after several
weeks of worsening shortness of breath. Postmortem reveals a thyroid mass that has invaded the
trachea and surrounding structures. Histology shows giant cells containing pleomorphic
hyperchromatic nuclei.

116. A 36-year-old woman presents with a history of increasing weight gain and neck swelling. Fine
needle aspiration shows a diffuse lymphocytic and plasma cell infiltrate. The report also mentions the
presence of lymphoid follicles and parenchymal atrophy.

23
117. A 45-year-old woman presents with a painless, firm, left-sided neck swelling. Fine needle
aspiration reveals the presence of multiple compact follicles. Histology shows evidence of capsular
and blood vessel invasion.

Jugular venous pressure

Options

A. Tricuspid stenosis
B. Single chamber ventricular pacing
C. Tricuspid regurgitation
D. Aortic stenosis
E. Aortic regurgitation

For each set of signs give the most likely cause for the particular JVP observed. Each option may be
used once, more than once, or not at all.

118. Giant systolic ‘v’ waves.

119. Cannon ‘a’ waves.

Abdominal pain

Options

A Duodenal ulcer
B Irritable bowel syndrome
C Gastric ulcer
D Chron’s disease
E Diverticulosis

For each clinical scenario below, give the most likely cause for the clinical findings. Each option can
be used once or more than once or not at all.

120. A 50-year-old man presents with epigastric pain worse at night and relieved by eating or drinking
milk.

121. A 35-year-old man presents with weight loss, diarrhoea and abdominal pain. On examination,
he has aphthous ulcers in the mouth and a mass is palpable in the right iliac fossa. Blood tests
reveal low serum vitamin B12 and folate.

122. A 21-year-old student presents with a cramping diffuse abdominal pain associated with lternating
constipation and diarrhoea. Investigations are normal.

Nerve Lesion

24
Options

A. C8, T1
B. Sprascapular nerve
C. L1
D. Nerve of Bell
E. T10

Choose the most likely location of lesion that gives rise to the symptoms below. Each option can be
used once or more than once or not at all.

123. A 25-year-old man presents with a winged scapula and the inability to raise his arm above the
horizontal.

124. Sensory loss bilaterally below the level of the umbilicus.

125. Right-sided ptosis, miosis and wasting of small muscles of the right hand.

Tumour Markers

Options

A. Prostate Specific Antigen

B. L Carcinoembryonic antigen
C. G α-fetoprotein
D. β-human chorionic gonadotrophin
E. CA 19-9

For each of the presentations of cancer below, suggest the tumour marker that is most likely to be
elevated. Each option can be used once or more than once or not at all.

126. A 60-year-old man presents with poor stream, weight loss and back pain. Digital rectal
examination reveals a hard irregular prostate gland.

127. A 65-year-old woman with weight loss and painless jaundice. There is evidence of
thrombophlebitis migrans and computed tomography (CT) shows a mass in the pancreatic head.

128. A 70-year-old man presenting with a suspected recurrence of colorectal carcinoma.

129. A 68-year-old person with chronic alcohol problems and hepatocellular carcinoma.

130. A 34-year-old man is referred to radiotherapy with seminoma.

Anorectal conditions

Options

A. Syphilitic gumma
B. Perianal warts

25
C. Pilinoidal sinus
D. Second-degree haemorrhoids
E. Anal carcinoma

For each clinical scenario below, give the most likely cause for the clinical findings. Each option can
be used once or more than once or not at all.

131. A 30-year-old builder complains of a pain and discharge from an area in the midline of the natal
cleft about 4 cm above the anus. This problem has been remitting and recurring for 2 years.

132. A 19-year-old woman presents with multiple papilliferous lesions around the anus.

Gait

Options

A Spastic gait
B Cerebellar ataxia
C Femoral nerve injury
D Sciatic nerve injury
E Parkinson’s disease

For each clinical scenario below, give the most likely cause for the gait that is observed.

133. A 60-year-old woman walks with a drop foot and high-stepping gait shortly after hip replacement.

134. A 65-year-old man presents after a stroke with a stiff right leg that drags forward in an arc.

135. A broad-based unstable gait with veering to the right side.

End of the Paper

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