Dr. Hadi Edited Fawzia Sheet.PDF Medical Questions

1.The pressure within the pleural space is negative with respect to atmospheric pressure, except for which of the following? A. At end expiration B. At end inspiration C During a Valsalva maneuver D. If the patient has a tracheostomy E. When taking a deep breath 2. A 30-years-old alcoholic man pre...

1.The pressure within the pleural space is negative with respect to atmospheric pressure, except for which of the following? A. At end expiration B. At end inspiration C During a Valsalva maneuver D. If the patient has a tracheostomy E. When taking a deep breath 2. A 30-years-old alcoholic man presents with acute severe upper abdominal pain and vomiting. He is admitted to the intensive therapy unit with a diagnosis of severe acute pancreatitis Forty-eight hours later he develops peripheral paraesthesiae and carpopedal spasms. The most likely underlying metabolic abnormality is:- A. hypercalcaemia B. hypernatraemia C. hypocalcaemia D. hypokalaemia E. hyponatraemia 3. A 50-year-old woman attends her Genera) Practitioner due to a change in appearance. She finds difficulty removing her rings, reports: an increase ‘in shoe size and photographs reveal a change in her facial appearance. Visual field tests are-performed to direct confrontation. Which of the following defects is most likely to be associated with her presentation? A. Binasal hemianopia B. Bitemporal hemianopia C. Homonymous hemianopia D. Inferior quadrantanopia E. Unilateral loss of vision 4. A 24-year-old man falls off his motorbike, fracturing one arm, both femurs, and rupturing- his spleen. He required surgery and 20 units of blood. Twenty-four hours after admission he has passed 350 ml of urine. His blood pressure is 90/50 mmHg. and he has low skin turgor. Which of the following best describes the changes in the renin-angiotensin system initiated at the juxtaglomerular apparatus in the patient? Renin Angiotensin II Aldosterone Concentration concentration concentration A ↓ ↓ ↓ B ↓ ↑ ↓ C ↑ ↓ ↓ D ↑ ↓ ↑ E ↑ ↑ ↑ 5. A 35-year-old woman presents to the Emergency Department with a second attack of painful frank haematuria. What is the most likely pathology underlying this presentation? A. Gram negative urinary tract infection B. Interstitial cystitis C. Renal cell carcinoma D. Transitional cell carcinoma of bladder E. Urinary tuberculosis 6. 60-year-old man presents with a short history of pain in the right cheek and right upper teeth Maxillary sinus infection is diagnosed. This sinus is particularly prone to infection because of? A. absence of cellia on the epithelium lining the sinus B. closeness of the sinus to the nasal cavity C. poor blood supply D. Position of the sinus ostium high on the medial wall E.relationship of the front teeth to the floor of the sinus 7. A 75-year-old insulin-dependent diabetic man has undergone a hemicolectomy. On the first postoperative day he is nil-by-mouth, on subcutaneous insulin, maintenance IV infusion with-Saline and intravenous morphine via patient controlled analgesia. He is confused after a brief convulsion, has slurred speech and weakness of his right side. His pulse is 110 beats/minute, respiratory rate 25 breaths/minute, blood pressure 160/95 mmHg and Sp02 95% on room air The most likely cause of this convulsion and confusion is: A hypoglycemia B. hyponatremia C. inhibition of noradrenaline re-uptake D. stimulation of ∂ opioid receptors E. stimulation of GABA receptors 8. A 30-year-old woman presents to the general surgical clinic with a 1.5 cm cervical lymph node along the anterior border of sternocleidomastoid muscle.-Clinical examination and routine blood tests are ; unremarkable. She undergoes an excisional biopsy of the lump as a day case. The histology report reveals Encapsulated infiltrative carcinoma with marked fibrosis and cystic changes within the lymph node. What is the most likely primary pathology? A. Anaplastic thyroid carcinoma B. Follicular thyroid carcinoma C. Malignant lymphoma of the thyroid D. Medullary thyroid carcinoma E. Papillary thyroid carcinoma 9. A 37-year-old man presents with severe headache, photophobia arid neck stiffness. Karnig's sign is positive and a midline lumbar puncture is performed immediately to determine if a cerebrospinal fluid (CSF) pathogen is involved. In performing this procedure, which is 'he first of the following structures to be pierced by the lumbar puncture needle? A. Anterior longitudinal ligament B. Arachnoid mater C. Dura mater D Interspinous ligament E. Posterior longitudinal ligament 10. A 26-year-old woman presents with severe headache, photophobia and neck stiffness. Among other investigations, a lumbar puncture is earned out and cerebrospinal fluid is sent for microscopy and culture. Culture shows a growth of Neisseria meningitidis. What is likely to be the predominant-cell type in the cerebrospinal Fluid? A. Basophils B. Eosinophils C. Lymphocytes D. Macrophages E Neutrophils 11. A 70-year-old woman from a nursing home presents to the! Emergency Department with abdominal pain and vomiting. On examination, she is dehydrated and her abdomen is distended. There is a 3 cm 4 cm swelling in her right groin which is non-tender, and there is no cough impulse. At operation, a femoral Hernia found. Which of the following lies medial to the neck of the hernia? A. Femoral artery B. Femoral nerve C. Femoral vein D Lacunar ligament E. Pectineal ligament 12. A 26-year-old man presents to the Emergency Department with extensive bleeding from his arm after sustaining a glass injury. On examination there is a 7 cm transverse laceration across the anterior aspect of his elbow. On exploring the cubital fossa you would expect the brachial artery to be: A. anterior to the median nerve B. lateral to the biceps tendon C. lateral to the median nerve D. medial to the median nerve E. superficial to the bicipital aponeurosis 13. A 52-year-old man is found to have multiple myeloma. What skull X-ray appearances would be characteristic? A. Diffuse thickening of the calvarium B. Hair on end appearance. C Multiple fractures D Multiple osteolytic lesions E. Multiple osteosclerotic lesions 14. A 50-year-old woman presents with a history of right upper quadrant pain and jaundice. She reports that her urine was dark in colour and that her stools are offensive and difficult to flush Which of the following explains the dark urine? A. increase in conjugated bilirubinuria B. Increase in unconjugated bilirubinuria C. Increase in urea excretion D. Increase in urinary urobilinogen E. Reduced enterohepatic bile salt circulation 15. A 45-year-old mart presents with backache and leg pain due to a prolapsed lumbar Intervertebral disc. The pain, which is aggravated by coughing and sneezing, radiates to the lateral aspect of the foot. On examination, there is weakness of the plantar flexors of the foot, which nerve root is most likely to be involved? A. T12 B. L4 C. L5 D S1 E. S2 16. A 62-year-old woman presents to her General Practitioner with a two-week history of backpain. She has lost 8 cm in height over the last five years Investigations reveal: Findings Normal Adjusted ( corrected) Calcium 2.78 mmol/L 2.15-2.55 mmol/L Phosphate 0.84 mmol/L 0.8-1.4 Estimated GFR 0.96ml/minute More than 90 PTH 8.9 pmol/L 0.95-5.7 Which of the following is the most likely cause? A Hypoparathyroidism B Primary hypemarathyroidism C Pseudo hypoparathyroidism D Secondary hyperparathyroidism E Tertiary hyperparathyroidism 17. A 21-year-old man fractures his ulna and radius. He is treated by means of a plaster cast, which is removed after four weeks. What pathological process is most likely to have affected the immobilized muscles? A. Aplasia B Atrophy C Hyperplasia D Hypertrophy E Neoplasia 18. A 22-year-old man has been stabbed in the left fifth intercostal space at the edge of the sternum. Which structure is most likely to have been penetrated? A Left atrium B Left lobe of the liver C Left ventricle D Right atrium E Right ventricle 19. An 80-year-old man dislocates his shoulder it is reduced in the Emergency Department. At review three weeks later, he is unable to actively initiate abduction of his arm. Which muscle most likely damaged? A Clavicular head oi pectoralis major B Infraspinatus C Supraspinatus D Teres major E Trapezius 20. An 8-year-old boy is admitted for assessment of rectal blood loss. His mother describes this as bright red blood in the toilet pan. He has no pain on defalcation. There is no family history. What is the most likely cause? A. Adenomatous polyp B Familial adenomatous polyposis C Juvenile polyp D Metaplastic polyp E. Peutz-Jegher's syndrome 21. A 48-year-old woman presents with abdominal pain and five to six episodes of bloody diarrhoea each day. She also complains of pain- in the knees and elbows and recent visual problems. What is the most likely diagnosis? A. Collagenous colitis B. Diverticulitis C. Infective colitis D. intestinal tuberculosis E Ulcerative colitis 22. A 56-year-old man presents with acute epigastric pain and vomiting. On examination he has guarding in the upper abdomen. Investigations reveal: Value Normal Serum amylase 900 IU/L ≤100 Serum ALT 61 IU/l ≤50 Alkaline Phosphatase 98 IU/l 20-120 Albumin 38 g/L 35-50 Gamma GT 76 IU/L ≤60 Bilirubin 15 umol/L 0-20 Triglyceride 1.6 mmol\L ≤1.7 Corrected Calcium 3.30 mmol\L 2.20-2.70 Which of the following is the most likely etiology of this condition? A. Alcohol B Choledocholithiasis C Hyperparathyroidism D Hypertriglyceridaemia E Mumps 23. A 30-year-old man is admitted to the intensive care unit with an isolated severe head injury. A CT "can shows multiple intracerebral bleeds but no midline shift. He is intubated and ventilated. His pupils are dilated and react sluggishly to light. His heart rate is 50 beats/minute blood pressure 170,110 mmHg and his respiratory rate is set at 10 breaths/minute. The rising blood pressure is likely to be caused by: A. aortic and carotid baroreceptor stimulation B Cortisol stimulation C. renin-angiotensin stimulation D. sympathetic stimulation related to blood loss E. sympathetic stimulation related to intracranial pressure 24. A 42-year-old multiparous woman is admitted to the Emergency Department due to pelvic discomfort. The duty gynecologist diagnoses uterine prolapse. Which anatomical structure gives significant direct support to the uterus? A. Cervical ligaments B. Mesometrial part of the broad ligament C Mesosalpingial part of the broad ligament D. Round ligaments E. Transverse perinea! Muscles 25. An 80-year-old man is admitted to the surgical admission unit with central abdominal pain. His blood pressure is 100/60 mmHg and his pulse is 110 beats/minute with a respiratory rate of 25 breaths/minute. He is known to have severe chronic obstructive pulmonary disease (COPD) and has been a heavy smoker all his life. On examination he has a rigid abdomen Arterial blood gases show: PH pO2 pCo2 Bicarbonate Base Excess Finding 7.24 9 kPa 5.3 kPA 17 mmol/L -3 Normal 7.35-7.45 11.9-13.3 4.7-6.0 22-26 -2 to +2 What is the most likely diagnosis? A Hypovolemic shock complicated by COPD B Metabolic acidosis due to COPD C Metabolic acidosis due to peritonitis D Respiratory-acidosis due to COPD E Respiratory acidosis due to peritonitis 26. In describing the sino-atrial node, which one of the following statements is correct? A it is part of the somatic nervous system B It is usually supplied by the left coronary artery C If lies in the wall of the left atrium D It lies in the wall of the right ventricle E It receives fibers derived from the vagus nerves 27. A fit 21-year-old man is admitted with an acute abdomen, subsequently diagnosed as gastroenteritis. As part of the host immune response, which of the following immunoglobulins and cells are correctly paired? A. IgA-macrophage B IgD-small bowel epithelium C IgE-endothelium D IgG-plasma cell E IgM thymocyte 28. A 45-year-old man presents with fever and pain in his right loin and groin. A soft swelling was noted in his femoral triangle. Diagnosis of a psoas abscess was made. Which of the following statements is most accurate regarding psoas major? A. It arises from the lateral borders of the bodies of T12 to L5 B. It extends the hip C. It inserts into the greater trochanter of the femur D. It is innervated from T12 and LI E. It passes posterior to the capsule of the hip joint 29. Which one of me following muscles is an extensor of the hip? A. Adductor longus B. Gracilis C. Iliopsoas D. Pectineus E. Semitendinosus 30. A tall, thin, 25-year-old woman presents to the surgical clinic with a complaint of swelling in the front of her neck for the last four months. On clinical examination she has a swelling in the left lobe of the thyroid and multiple neuromatous lesions within the oral cavity. Her blood pressure is 220/120 mmHg. Laboratory investigations show that her calcium and electrolytes are normal and serum calcitonin and urinary VMA levels are elevated, Which of the following is the most likely cause of the hypertension? A Conn's syndrome B Cushing's disease C Essential hypertension D Phaeochromocytoma E Renal artery stenosis 31. A 65-year-old man presents with haematuria and left loin pain. Computerised tomography demonstrates a left renal tumour. He undergoes a left radical nephrectomy. Where does the left renal artery lie? A. Anterior to the left gonadal vein B Anterior to the left renal vein C Anterior to the splenic vein D Posterior to the left renal vein E Superior to the superior mesenteric artery 32. Within the posterior triangle, which nerve is at particular risk of damage during surgery? A. Auricular branch of the facial B Glossopharyngeal C Phrenic D Recurrent laryngeal E Spinal accessory 33. The right and left pulmonary arteries are derived from which of the following embryological aortic arches? A Second aortic arch B Third aortic arch C Fourth aortic arch D fifth aortic arch' E Sixth aortic arch 34. A 47-year-old man presents to the Emergency Department six hours after a climbing accident initial assessment suggests that he had lost 1 L of blood. His blood pressure is 105/70 mmHg and his pulse rate is 88 beats/minute. He is catheterised and his bladder contains 120 ml of urine. Activation of which of the following transport systems best describes how aldosterone leads to maintenance of the intravascular volume and oliguria in this men? A. Na+/glucose in the proximal tubule B. Na/H+ in the descending loop of Henle C. Na+/K in the ascending loop of Henle D. Na+/Cl in the distal tubule E. Na/K in the collecting ducts 35. During arch aortography, the vertebral artery would be seen to arise directly from which of the following? A. Arch of the aorta B Brachiocephalic artery C Common carotid artery D Internal carotid artery E Subclavian artery 36. A 65-year-old man, remains, on the high dependency unit following a gastrectomy, three days previously. His urine output: has averaged 80ml/hour for the last 24 hours. He has one dry abdominal drain arid no nasogastric losses: His urea and electrolytes are normal He is to stay nil by mouth for a further 24 hours. Which of the following fluid regimes is most appropriate to his electrolyte and water requirements over the next 24 hours? A. 1 L of 0.9 % saline plus 1.5 L. of 4 % dextrose/0.18 % saline B. 1 L of 0.9 % saline plus 1.5 L of 5 % dextrose C. 1 L of 0.9 % saline plus 1.5 L of Hartmann's solution D. 2 L of 0.9% saline E. 2 L of 4 % dextrose/0,18 % saline 37. A 3-year-old boy is admitted to hospital with severe vomiting. Radiographic examination reveals that he is suffering from annular pancreas. Which of these structures is constricted? A First part of duodenum B Second part of duodenum C Third part of duodenum D Proximal jejunum E Pylorus of stomach 38. A 20-year-old man with a severe head injury is being ventilated using intermittent positive pressure. Which of the following is a physiological consequence of this? A Decreased extracellular fluid volume B Decreased cardiac preload C Increase in intrathoracic blood volume D Increased cardiac preload E Increased cardiac stroke volume 39. A 36-year-old man presents with a two-month history of low back pain radiating to his left leg After clinical examination he is referred for an MRI scan. This shows a prolapsed intervertebral disc. The clinical signs are consistent with pressure on SI roots. Which combination of clinical signs is most likely? A Weak ankle plantarfiexion; altered sensation on the dorsum of the foot; normal ankle jerk reflex B Weak ankle plantarfiexion; altered sensation on the sole of the foot; loss of ankle jerk reflex. C Weak hallux dorsiflexion; altered sensation on the anterior surface of the leg; loss-of ankle jerk reflex. D. Weak hallux dorsiflexion; altered sensation on the dorsum of the foot; normal ankle jerk reflex. E. Weak hallux dorsiflexion; altered sensation on the sole of the foot; loss of knee jerk reflex 40. 55-year-old woman undergoes a cholecystectomy; The gallbladder contains multiple dark irregular small stones. The most likely, cause of this type of gallstone is an increased blood level of: A Bile acids B calcium C cholesterol D conjugated bilirubin E unconjugated bilirubin 41. A 55-year-old man presents with a deep venous thrombosis. His full blood count shows a haemoglobin of 18.3 g/dL (normal 13.5-17.5), a white cell count of 8 x 109/L (normal 3.9- 10.0 x 109) and a platelet count of 200 x 109/L (normal 150-400 x 109) This hematological picture is most likely to be associated with: A bronchial carcinoma B pancreatic carcinoma C prostatic carcinoma D renal cell carcinoma E transitional cell carcinoma of the kidney 42. A 27-year-old has had pancolitis for the last five years. Which one of these complications is he least likely to develop? A. Arthritis B. Cholangitis C Iritis D Polyarteritis E Toxic megacolon 43. A surgeon makes a Pfannenstiel incision for access to the pelvic organs. He incises theabdominal wall down to and through the rectus sheath.-He retracts the rectus abdominis muscles laterally from the midline to expose the: A. linea alba B. peritoneum C. posterior rectus sheath D. transversalis fascia E. transversus abdominis muscle 44. A 25-year-old man undergoes splenectomy following blunt abdominal trauma. Three days postoperatively venous blood testing is likely to reveal: A. high platelet count B. high red cell count C. low platelet count D. low while cell count E. low red cell count 45. A 46-year-old woman is seen in the pre-admission clinic. She had a myocardial infarction two years ago. On examination she is in atrial fibrillation and a recent echocardiogram shows that she has a dilated left ventricle: She is on warfarin and her INR is 6.1. Warfarin inhibits which of the following? A. Antithrombin B. Kallikrein C Plasminogen D Prothrombin E. von Willebrand's factor 46. A 75-year-old man is admitted for elective repair of an abdominal aortic aneurysm. Following the operation his systolic blood pressure falls below 90 mmHg and during resuscitation he is given an infusion of fluids. There is a choice of colloid or crystalloid. Which of the following best describes why the intensive therapy unit registrar decides to administer a colloid? A Colloids are not freely filterable across semi-permeable membranes B Colloids can prevent pulmonary oedema by inducing fluid flow out of the interstitial space C Colloids decrease the transcapillary oncotic pressure gradient D Colloids expand the plasma volume by 200 ml for each liter infused E Colloids migrate from the intravascular space 47. A 35-year-old man develops septicaemia following surgery for perforated acute appendicitis He is hypotensive. Arterial blood gas analysis reveals: PH pO2 pCo2 Bicarbonate Finding 7.25 7.2 kPa 7.5 kPA 17 mmol/L Normal 7.35-7.45 11.9-13.3 4.7-6.0 22-26 What is the most likely explanation for these readings? A Compensated metabolic acidosis B Compensated respiratory acidosis C Mixed metabolic and respiratory acidosis D Uncompensated metabolic acidosis E Uncompensated respiratory acidosis 48. A.20-year-old man presents to the Emergency Department with a stab injury to the thenar eminence. On examination he is found to have a 2 cm long laceration with loss of sensation in the thumb and index finger and weakness: of the thenar muscles. Which of the following structures is most likely to have been injured? A. Anterior interosseous nerve B. Recurrent branch of median nerve C. Sensory and motor branches of median nerve D. Sensory and motor branches of radial nerve E. Sensory and motor branches of ulnar nerve 49. A 65-year-old man presents with vomiting and.weight loss. On examination he had 3 palpable epigastric mass. The transpyloric plane lies at which; vertebral level? A T11 B T12 C L1 D L2 E L3 50. A 30-year-cid motorcyclist is brought to the Emergency Department after a road traffic accident. He has an open fracture of the right femur. On arrival he is tachypnoeic and. confused, with cold and clammy skin. Which of the following physiological changes is most likely to occur? A. Decreased reabsorption of water from the collecting tubules B Decreased serum bicarbonate level C Increased pH of blood D. Increased secretion of sodium in the urine E. increased synthesis of glycogen in the liver 51. In an emergency situation what is the most appropriate surgical method of obtaining an airway? A Cutting and retracting the cricothyroid muscle B Cutting the thyrohyoid membrane. C Dividing the thyroid isthmus D Entering the trachea at the C7 level E Piercing the cricothyroid membrane 52. A 75-year-old man presents with hepatomegaly and ascites. Computerised tomography shows evidence of post hepatic portal hypertension. The inferior vena cava passes through the Diaphragm at which vertebral level? A. T8 B. T9 C. T10 D T11 E T12 53. A 20-year-old woman presents acutely with abdominal pain, imaging reveals a right ovarian cystic lesion which is excised. Histoiogicai examination shows a cyst lined by keratinizing stratified squamous epithelium. Areas of fat, muscle, thyroid and neural tissue are seen in the wall. What is the appropriate pathological designation for this lesion? A Adenocarcinoma B Cystadenoma C Dysgerminoma D Squamous cell carcinoma E Teratoma 54. A 25-year old woman who is two months post-partum, presents with a tender mass in the left breast. She is pyrexial with a raised white cell count and a raised C-reactive protein level.-A diagnosis of lactational mastitis with abscess is made. Which of the following is the most likely causative organism? A Aeromonas hydrophilia B Escherichia coli C Streptococcus' miileri D Lactobacillus caseii E Staphylococcus aureus 55. A 62-year-oid alcoholic man is admitted with severe acute pancreatitis. Three days after admission he becomes hypoxic (pOa is 7.5 kPa) and confused. Chest X-ray shows a uniform opacification of both lung fields. Which of the following is the most likely clinical diagnosis? A Acute left ventricular failure B Adult respiratory distress syndrome C. Bilateral bronchopneumonia D. Bilateral lobar pneumonia E. Massive pulmonary embolism 56. A 58-year-oid woman presented to the Emergency Department with a large fluctuant swelling the site of a recent insect bite. She is anxious, tachycardic, and pyrexial. An ECG shows critical fibrillation. She is noted to have a goiter. The swelling at the site of the bite requires surgical drainage. Which of the following classes of drug would be most appropriate as part of her preoperative preparation for surgery? A. Alpha-1 adrenoceptor agonist B Alpha-2 adrenoceptor agonist C Alpha adrenoceptor blocker D Beta adrenoceptor agonist E Beta adrenoceptor blocker 57. A nulliparous 30-year-old Woman presents with a recurrent painful red area in the areola. She gives a history of smoking cigarettes. The lesion is excised and the histology shows squamous metaplasia of lactiferous ducts. Microbiological culture does not grow any organism. Which of the following is the most likely diagnosis? A Breast abscess B Carcinoma of the breast C Fibroadenoma D Galactorrhea E Subareolar abscess 58. A 65-year-old man undergoes right hemicolectomy; On the second postoperative day he is afebrile, nauseous has a distended abdomen but very little pain. He is on intravenous morphine via a patient-controlled analgesia pump. Plain X-ray confirms distended loops of small intestine. The physiologic basis of postoperative paralytic ileus involves: A. stimulation of dopaminergic receptors B. stimulation of reversed migrating motor complexes C. stimulation of p receptors D. suppression of muscarinic receptors. E. suppression of motilin due to starvation 59. A 42-year-old woman has a cholecystectomy arid develops a self-limiting postoperative wound infection. By what process would bacterial ingestion have been enhanced? A Apoptosis B Autophagy C Metaplasia D Opsonisation E Phagocytosis 60. A 60-year-old non-smoker presents with three-month history of loss of weight, malaise and breathlessness. On examination he has left supraclavicular lymph node enlargement. Chest radiograph reveals multiple bilateral opacities. What abnormality would a biopsy of a left supra-clavicular lymph node most probably show? A. Chronic inflammatory cells B. Granuloma C. Langerhan's type giant cells D. Multiple abnormal mitotic figures in cells E. Reed Sternberg cells 61. A 78-year-old woman with emphysema receiving 28% oxygen by mask has the following blood gas results The most likely interpretation is: PH pO2 pCo2 Bicarbonate Base Excess Finding 7.28 6.2 kPa 8 kPA 36 mmol/L +5 Normal 7.35-7.45 11.9-13.3 4.7-6.0 22-26 -2 to +2 A. mixed respiratory and metabolic acidosis B. partially compensated metabolic acidosis C. partially compensated respiratory acidosis D. uncompensated metabolic acidosis E. uncompensated respiratory acidosis 62. A 2-year-old child is referred because of an impalpable testis in the left scrotum. Which of the following positions describes an ectopic testis? A At the deep inguinal ring B At the root of the penis C At the superficial inguinal ring D In the inguinal canal. E in the upper part of the scrotum 63. A 60-year-oid man is found to have a 2 cm diameter mass in the upper lobe of his left lung.The lesion is excised and it is found that the lesion includes connective tissue, mature cartilage and ciliated epithelium. What is the most likely diagnosis? A. Adenoma B. Carcinoma C. Chondroma D. Hamartoma E. Sarcoma 64. A 23-year-oid man presents three months following extraction of carious teeth with a plaque like infiltration over the upper jaw with sinus formation. Yellow granules are present in the discharging pus. What is the most likely causative organism? A Actinomyces B. Aspergillus C. Blastomyces D. Cryptococcus E. Histoplasma 65. An 82-year-old man has complete occlusion of his inferior mesenteric artery on angiography but no symptoms or signs of colonic ischemia. Which of the following arteries is the most likely additional source of blood supply to the territory of the inferior mesenteric artery? A Left colic B Left gastroepiploic C Middle colic D Splenic E Superior rectal 66. An intravenous drug abuser is having an echocardiogram for suspected endocarditis. Closure of the tricuspid valve occurs at the onset of which phase of the cardiac cycle? A. Atrial systole B Isovolumetric contraction C Isovolumetric relaxation D Rapid ejection E Rapid ventricular filling 67. After being stabbed in the the left groin, a previously healthy 20-year-old man was admitted to The emergency Department. He developed hemorrhagic shock. During resuscitation, 10 units of type O negative red cells and 6 L of colloid were administered; Twenty-four hours later, he noted to have severe dyspnoea for which he required intubation and ventilation on the intensive care unit. Which of the following would be the most likely cause of his respiratory insufficiency? A. ABO blood incompatibility B. Adult respiratory distress syndrome (ARDS) C. Congestive cardiac failure D. Tension pneumothorax E. Viral pneumonitis 68. An 80-year-old man with a history of hypertension, controlled with thiazide diuretics. undergoes transurethral resection of prostate under general anaesthetic. The surgery.is prolonged and in the recovery room he complains of nausea and a headache. He later becomes agitated and confused. Which of the following is the most likely diagnosis? A Hypercalcaemia B Hyperuricaemia C Hypoglycaemia D Hypokalaemia E Hyponatremia 69. A 35-year-old man is admitted to hospital with vomiting, nausea and severe headaches. An MRI scan reveals a tumour of the cerebellopontine angle. Which one of the following pairs of cranial nerves is most likely to be compressed by this tumour? A Accessory and vagus B Facial and vagus C Facial and vestibulocochlear D Glossopharyngeal and vestibulocochlear E Vagus and vestibulocochlear 70. After resection of d rectal tumour a patient experiences erectile dysfunction. Which of the following nerves is most likely to have been damaged in surgery? A Genitofemoral nerve B Lumbosacral plexus C Pelvic splanchnic nerves D Perineal branch of S4 E Pudendal nerve 71. A 45-year-old woman presents with pain, swelling and stiffness affecting all her metacarpophalangeal joints. She has noticed weakness in her grip and her handwriting has changed. She is unable to extend her fingers fully. The index, middle and ring fingers in both hands show an ulnar deviation. The most likely diagnosis is: A Dupuytren's contracture B gouty arthritis C osteoarthritis D radial nerve palsy E rheumatoid arthritis 72. A 22-year-old man arrives to the Emergency Department with sudden breath less ness due to a large pneumothorax. A chest drain is inserted into the fifth left intercostal space in 5th mid-axillary line. There is haemorrhape into the drainage bottle. Which of the following structures is the most likely cause of this acute haemorrhage? A Intercostal artery B Left pericardiophrenic artery C Lingula of the lung D Right ventricle of the heart E Spleen 73. 65-year-old woman collapses after a total hip replacement. A pulmonary embolism is suspected. Which of the following electrocardiogram changes would support this diagnosis? A Dominant R wave in V6 B Left axis deviation C Left bundle branch block D ST elevation in V1-V3 / E T wave inversion in V1-V3 74. 40-year-old woman had the anterior lobe of the pituitary removed because of a tumour. Without postoperative supplements, which of the following could occur? A Failure to produce adequate amounts of thyroxine B Fail to produce parathyroid hormone in response to hypocalcaemia C Failure to secrete catecholamine in response to stress D Failure to secrete insulin in hyperglycemia E inability to concentrate urine in response to water deprivation 75. A 38-year-oid man in end-stage renal failure resulting from polycystic kidney disease receives a cadaveric renal transplant. Good renal function is established but four weeks later deteriorates, the serum creatinine rising by 25%. Which of the following processes is most likely to be responsible for this deterioration? A B-cell mediated rejection B Circulating immune complex disease C IgG antibody mediated rejection D Post-transplant lymphoproliferative disorder E T-cell mediated rejection 76. In order to expose the right axillary artery, a transverse skin incision is typically made below the clavicle from a point just lateral to the sternal end of the clavicle to the deltopectoral groove. Which of the following structures would be encountered in the dissection down to the vessel? A Lateral thoracic artery B Phrenic nerve C Suprascapular artery D Thoracic duct E Thoraco-acromial artery 77. A 4-year-old boy presents to the Emergency Department with a two-day history of headache vomiting and drowsiness. A CT scan reveals dilatation of both his lateral ventricles and his third cerebral ventricle. His fourth ventricle was of normal size. It is suspected that he has an obstruction to his cerebrospinal fluid flow. At which of the following sites is the obstruction most likely to be? A Cerebral aqueduct (of Sylvius) B Infundibular recess C Interventricular foramen (of Monro) D Lateral foramen of fourth ventricle (foramen of Luschka) E Median foramen of fourth ventricle (foramen of Magendie) 78. A 12-year-old boy presents to the Emergency Department two hours after helping his father cut the grass. He complains of rhinorrhea, itchy eyes, sneezing and a blocked nose. He is apyrexial with a haemoglobin of 12.2 g/dl and white blood cell count of 6.8 * 109/L with a raised eosinophil count. Chest X-ray is clear. Which immunoglobulin is most likely to cause this reaction? A IgA B IgD C IgE D IgG E IgM 79. A 35-year-old woman undergoes gastric bypass surgery for morbid obesity. At a subesequent surgical clinic review she complains of dizziness, sweating, palpitation and collapsing episodes after big meals without any vomiting or pain. she is otherwise well and has no medical problems. What is the most likely explanation for her symptoms? A. Operative denervation of stomach B. Release of gastrin C. Release of glucagon D. Release of insulin E. Vasovagal syncope 80. A 56-year-old man with chronic emphysema is on the high dependency unit (HDU), ten days after anterior resection. He has developed acute shortness of breath' and hypotension): Which of the following landmarks would be the most appropriate to use to obtain a femoral arterial blood gas sample? A. A point midway between the anterior superior iliac spine and the pubic tubercle B. A point midway between the anterior superior iliac-spine and the' pubic symphysis C. A point midway between the greater trochanter and the pubic symphysis D. A point 1 cm inferior and 4 cm lateral to the pubic tubercle E. A point 2 cm lateral to the midway point between the anterior superior iliac spine and pubic symphysis 81. A 70-year-old man complains of persistent numbness since.an inguinal hernia repair one year previously. The numbness affects the top of the scrotum, root of penis, and a small area below the medial part of the inguinal ligament. Which nerve is likely to have been damaged? A. Femoral branch of the genitofemoral nerve B. Genital branch of the genitofemoral nerve C. lliohypogastric nerve D Ilioinguinal nerve E. Medial cutaneous branch of the femoral nerve 82. A 12-year-old girl has a diastolic murmur. It is maximally audible in the second left intercostal space. Pathology of which structure is the most likely cause? A. Aortic valve B. Ductus arteriosus C. Mitral valve D. Pulmonary valve E. Tricuspid valve 83. A 34-year-old pregnant woman develops a swollen leg. Her mother and maternal aunt also had similar problems during their pregnancies. Which of the following tests is likely to be positive? A. Antiendomysial antibodies B. Antimitochondrial, antibodies C. Antinuclear antibodies D Antiphospholipid antibodies E. Antithyroglobuiin antibodies 84. The "fight or flight", response produces a release of epinephrine (adrenaline). What is the primary metabolic effect of epinephrine? A. Alanine shunt activation B. Cortisol release C. Glycolysis D Tachycardia E Vasoconstriction 85. A 58-year-old-man underwent an emergency appendectomy. Which of the following physiological parameters are consistent with sepsis? Heart Rate Systemic Vascular Cardiac Resistance output A ↓ ↓ ↑ B ↑ ↑ ↓ C ↑ ↓ ↑ D ↓ ↑ ↓ E ↑ ↓ ↓ 83. A 50-year-old man with a 30-year history of pancolitis undergoes surveillance colonoscopy which reveals a plaque-like lesion in the descending colon. Biopsy reveals a pre-malignant change. What is the name of this pre-malignant change? A Anaplasia B Dysplasia C. Hyperplasia D. Metaplasia E. Neoplasia 87. A 60-year-old man undergoes cystectomy for a bladder carcinoma. During surgery, the ureters are identified. On which region of the bladder do the ureters pierce the bladder wall? A. Anterior surface B Apex C Lateral surfaces D Neck E Posterior surface 88. A year-old patient in the intensive care unit has a tracheostomy performed via the second, third and fourth tracheal rings. Which intervening structure is most likely to require transection? A Anterior jugular vein B Inferior thyroid veins C Sternothyroid muscle D Thymus E Thyroid isthmus 89. A 23-year old man is assaulted and sustains a stabbing injury to the left groin. The wound- is cleaned and a simple dressing applied; Six months later the patient returns with pulsatile swelling at the site of the injury. The most probable: lesion present is: A Abscess B False aneurysm of the femoral artery C Lymphocoele D Mycotic aneurysm of the femoral artery E. Saphena varix 90. A 72-year-old man with a body mass index of 18.4 has not eaten for four days following the removal of an adenocarcinoma from his descending colon. His urea is found to be 12 mmol/L (normal 3.2-7.5) and creatinine 346 umol/L (normal 35-110). A blood gas profile is ordered. The most likely set of results would be: PH pO2 pCo2 Bicarbonate A 7.23 13.6 kPa 3.8 kPA 13.5 mmol/L B 7.30 8.8 kPa 8.3 kPa 30.5 mmol/L C 7.36 11.5 kPa 5.3 kPa 30.5 mmol/L D 7.43 16.4 kPa 3.7 kPa 21.0 mmol/L E 7.49 12.6 kPa 3.9 kPa 24.0 mmol/L Normal 7.35-7.45 11.9-13.3 4.7-6.0 22-26 91. A 16-year-old boy is hit on the left side of the face by a ball. There are no broken bones but the boy complains of numbness of the face below the eye. Which nerve has most likely been compromised? A Abducens nerve. B Facial nerve C Glossopharyngeal nerve. D infra-orbital nerve E Zygomatic nerve 92. A 74-year-old man, who has undergone emergency major abdominal surgery two-days previously, is noted to be confused. He has been on furosemide for mild heart failure. The plasma sodium is 122 mmol/L Inspection of the fluid chart shows that he has been written- up for 1L, four-hourly intravenous 5% glucose infusions. What is the most likely cause for the hyponatremia? A. An ACTH (Adrenocorticotrophic hormone) response to surgery B. Excessive sodium-free intravenous fluid administration C. Osmotic effect of hyperglycemia induced by glucose infusions D. Syndrome of inappropriate antidiuretic hormone E. Use of loop diuretic in the long term 93. The Cori cycle is important in lactate metabolism in the Septic surgical patient It is used to describe a pathway in which glucose is metabolised anaerobically to lactate in one tissue and the lactate is converted back to glucose in another; Which one of the following relies on this cycle to meet all of its energy needs? A. Erythrocyte B. Hepatocyte C. Leukocyte D. Osleocyte E. Pneumocyte 94. After receiving an intermascular Injection in the buttock, a 25 year-old man complains of inability to evert his foot Which nerve is most likely to have been injured? A Common peroneal (fibular) component of sciatic B Inferior gluteal C Pudendal D Superior gluteal E Tibial component of sciatic 95. A 73-year-old man with a history of irregular bowel movements presents with dysuria, pneumaturia and an Escherichia ccli urinary tract Infection. CT scans show a mass involving the sigmoid colon and the bladder. What is the commonest cause of this presentation? A. Adenocarcinoma of the sigmoid colon B Colonic diverticular disease C Crohn's disease D Transitional cell carcinoma of the bladder E Ulcerative colitis 96. A 7 year-old woman is in the recovery area arid receives 28% oxygen by mask. Blood Gas Shows PH pO2 pCo2 Finding 7.2 12 kPa 10 kPA Normal 7.35-7.45 11.9-13.3 4.7-6.0 Reduced sensitivity of which receptors is most likely to be responsible for this blood gas picture? A. Adrenergic receptors B. Baro receptors C Central chemo-receptors D J receptors E Lung stretch-receptors 97. A 76-year-old woman falls and sustains an inter-trochanteric fractured neck of femur Following operative fixation her recovery is prolonged and she is discharged to a rehabilitation unit Six weeks after her original operation she is readmitted. She is drowsy, hypotensive and bradycardic. An ECG shows low voltage complexes and a prolonged QT interval Under-activity of which of the following glands gives the best explanation of the clinical picture? A. Adrenal B Pancreas C Parathyroid D Pituitary E Thyroid 98. A 36-year-old man falls on his outstretched right hand. Examination reveals tenderness in the anatomical snuff box. Which one of the following tendons form a boundary of the anatomical snuff box? A Abductor pollicis brevis B Extensor carpi radialis brevis C Extensor carpi radialis longus D Extensor indicis E Extensor pollicis longus 99. A 65-year-old woman with metastatic breast cancer is admitted to hospital confused and acutely unwell, with nausea and vomiting. Her vital signs are within normal limits. What abnormality is most likely to contribute to her clinical condition? A Hypercalcaemia B Hyperkalemia C Hypocalcaemia D Hypokalemia. E Hyponatremia' 100. A 4-year-old boy presents to the Emergency Department with a two-day history of fever, difficulty walking and is unable to weight bear on the right leg. He has been on oral Amoxycillin 250 mg three times a day for a chest infection over the last five days. He is irritable with a temperature of 39.4°C. He does not allow examination and keeps his right hip flexed and abducted. Blood tests are: white blood cell count; (WBC) 12.3 x -109/dL, C-Reactive protein (CRP) 146, haemoglobin 11.3 g/dL What is the most likely diagnosis? A. Acute avascular necrosis of hip B. Dislocation of hip C. Perthes disease D Septic arthritis E. Slipped upper femoral epiphysis 101. A 35-year-old woman presents with recurrent peptic ulceration. She is on proton pump inhibitors and previously received Helicobacter pylori eradication therapy three months ago. Which of the following is likely to be raised on venous blood testing? A Cholecystokinin B Gastrin C Histamine D Pancreozymin E Secretin 102. A 55-year-old man presents with back ache. Neurological examination reveals lack of extension of the left great toe.; Which of the following spinal cord segments are likely to be involved? A L1, L2 & L3 B L2, L3 & L4 C L4, L5 & S1 D S1, S2, & S3 E S3, S4 & S5 103. A 34-year-old man is seen in the Emergency Department with a fibular fracture following football match. On examination he is noted to have loss of foot eversion. Which area of skin should be examined to confirm. loss of the cutaneous distribution of the affected-nerve? A. Along the lateral aspect of the foot B. Along the medial aspect of the foot C. Cross the dorsal surface of the foot D. On the plantar Surface of the foot E. Over the heel 104. A 68-year-old man with insulin-dependent diabetes presents to the preadmission clinic prior to surgery for rectal carcinoma. His creatinine is found to be 590 pmol/L. He is referred to a renal unit where a measure of his glomerular filtration rate (GFR) is made. Which of the following best describes why inulin could be used to measure his GFR? A It is filtered and not reabsorbed B It is filtered and reabsorbed C It is filtered, secreted and reabsorbed' D It is filtered, secreted but not reabsorbed E It is not filtered but is secreted and not reabsorbed 105. A 60-year-old man presents with a one-month history of headache, confusion and recent onset of right sided hemiparesis. A CT scan demonstrates a 4 cm >- 4 cm lesion with central necrosis in the left frontal lobe. It is seen extending across the midline along the corpus callosum. There is extensive oedema around the lesion. Which of the following is the most likely diagnosis of this lesion? A Central neurocytoma B. Ependymoma C. Glioblastoma D. Meningioma E. Oligodendroglioma 106. A 65-year-old woman presents with a 2.5 cm diameter mass in the upper outer quadrant of the left breast with associated axillary lymphadenopathy. A core biopsy is taken which confirms the presence of carcinoma. Which of the following types of carcinoma is this most likely to be? A Invasive ductal carcinoma B Invasive lobular carcinoma C Medullary carcinoma D Mucinous carcinoma E Tubular carcinoma 107. A 26-year-old man is admitted to the Emergency Department with multiple peripheral fractures. He is clinically shocked. Which is the structure responsible for the first; hemostatic response to a fall in systemic arterial blood pressure? A. Adenohypophysis B. Baroreceptor C. Chemoreceptor D. Kidney E. Neurohypophysis 108. Vitamin K is required for normal blood clotting. Which one of the following statements is true about the effects and availability of vitamin K? A Affects platelet function B Causes bleeding if taken in excess C Is provided only by fresh food D Is depleted by broad spectrum oral antibiotics E Vitamin K absorption is affected by resection of the terminal ileum 109. In septic shock, norepinephrine (noradrenaline) is used to increase the systemic vascular resistance. This action is a result of the stimulation of which of the following receptors? A α1 B α2 C β1 D β2 E. ∂1 110. A 10-year-old child presents with progressive facial weakness and a squint. On examination there is a lower motor neuron facial weakness and failure of abduction of one eye. An MRI scan shows a small, intrinsic mass lesion within the central nervous system. Where is this most likely to be located? A The cerebellar vermis B The cerebellar tonsil C The medulla D The midbrain E The pons 111. A 65-year-old man, with a history of ischaemic heart disease, has an abdomino- perineal excision of the rectum after which he is stable. Two days later he is clammy, has cool peripheries, a tachycardia and a blood pressure of 80/60 mmHg. His temperature is normal. What is the most likely cause? A. Anaphylactic shock B. Cardiogenic shock C. Hypovolaemic shock D. Neurogenic shock E. Septic shock 112. A 55-year-old1 man presents to his General Practitioner with a four-month history of feeling tired. The General Practitioner notes breast enlargement. Investigations reveal: Result Normal TSH 0.2 mIU/L 0.4-4.3 Free T4 6 mmol/L 9-23 Which of the following is the most likely cause? A Primary hyperthyroidism B Primary hypothyroidism C Secondary hyperthyroidism D Secondary hypothyroidism E Sick euthyroid syndrome 113. A 40-year-old woman presents with a parotid tumour. A biopsy reveals extensive perineural invasion. Which is the most likely pathology? A. Acinic cell carcinoma B. Adenocarcinoma C Adenoid cystic carcinoma D. Lymphoma E. Pleomorphic salivary adenoma 114. A 50-year-old man presents with malaise, abdominal pain, weight loss, fever and myalgia Polyarteritis nodosa is associated with all of the following except: A. Erythema nodosum B. livedo reticularis C mononeuritis multiplex D nailfold infarcts E palpable purpura. 115. A 30-year-old woman undergoes subtotal thyroidectomy. Five days later the wound appears red and inflamed. Which of the following is the most likely causative organism? A. Haemophilus influenzae B. Proteus-mirabilis C. Pseudomonas aeruginosa D. Staphylococcus aureus E. Streptococcus pyogenes 116. A 50-year-old man complains of recent onset diplopia. On examination he is unable to lookinwards and downwards with his right eye; The most likely diagnosis is a lesion of the? A. abducens nerve B. ciliary ganglion C. nasociliary nerve D. oculomotor nerve E. trochlear nerve 117. A 57-year-old heart transplant recipient is keen-to join the cardiac, rehabilitation programme Which of the following factors is most likely to increase cardiac output in this patient during moderate exercise? A. Decreased negative intrathoracic pressure B. Decreased venous tone C Decreased ventricular compliance D Increased atrial filling ITS E. Increased intrapericardial Pressure 118. A 69-year man with recta! cancer undergoes low anterior resection. The liver is disease free. The pathology of his tumour was reported as a large tumour invading from the rectum into the mesorectum. Two nodes of 24 lymph nodes, close to the tumour were carcinoma on histology. The tumour was completely excised. What is the correct pathological staging of his tumour? A Dukes' A B Dukes' B C Dukes' C D Dukes' D E T2 N1 119. A 21 -year-old man is admitted to the Emergency Department with a stab injury to his right chest. Pulse rate is 110 beats/minute and blood pressure is 85/40 mmHg. Chest X-ray shows a large right haemothorax. and a very small light apical pneumothorax. Which is the first substance secreted in the process leading to increased renal reabsorption of sodium in response to the above injury? A. Angiotensin I B. Angiotensin 11 C. Angiotensinogen D. Antidiuretic hormone. E. Renin 120. During the second (proliferative) phase of wound healing the predominant cells in the wound site are fibroblasts. This cell is of mesenchymal origin and produces the matrix and collagen needed to strengthen the scar. Cross linkage of collagen requires hydroxy-proline and hydroxy-lysine residues, which requires a specific vitamin to be available in sufficient quantities. Deficiency of which vitamin results in collagen that is unstable? A Vitamin B2 (riboflavine) B Vitamin B6 (pyridoxine) C Vitamin C (ascorbic acid) D Vitamin D (cholecalciferol) E Vitamin E (tocopherol) 121. A 62-year-old woman presents with a firm irregular mass in the upper outer quadrant of the right breast. This appears malignant on mammography, and fine needle aspiration cytology is reported as Co. Which is the first lymph node to which the tumour is most likely to metastasise? A Initial node B Primary riode C Secondary node D Sentinel node E Virchow's node 122. Which of the following statements is true with relation to cardiac muscle? A Contraction does not involve release of Ca by the sarcoplasmic reticulum B. Contraction is triggered by an influx of Ca through the sarcolemma C. Excitation is passed from one cardiac cell to another through desmosomes D. Hypertrophy is brought about by division of existing cardiac cells E. There is capacity for regeneration 123. A 70-year-old retired farm worker presents with a scaly lesion on the back of his left wrist. Biopsy shows enlarged pleomorphic squamous cells with mitoses that have breached the basement membrane. What is the name of this process? A. Dysplasia B. Hyperplasia C. Hypertrophy D Metaplasia E Neoplasia 124. A 45-year-old man has established cirrhosis. At a follow-up appointment a palpable spleen four fingers breadths below the costal margin, is noticed. Full blood counts have shown a persistent thrombocytopaenia. Bone marrow examination shows megakaryocyte hyperplasia. What is the most likely cause of the thrombocytopaenia? A. Ineffective production in the bone marrow B. Platelet destruction in the bone marrow C. Platelet destruction in the liver D Platelet destruction in the spleen E Platelet storage in the spleen 125. A surgeon is carrying out an elective splenectomy for congenital spherocytosis. Which structure will be divided in order to mobilize the spleen from the posterior abdominal wall? A Gastrosplenic ligament B Lesser omentum C Lienorenal ligament D Phrenicocolic ligament E. Short gastric vessels 126. A 50-year-old man is admitted with epigastric pain and a rigid abdomen He is diagnosed with, a perforated duodenal ulcer. Ulceration due to excessive gastrin activity may be: caused by increased levels of? A. adrenaline (epinephrine) B. calcitonin C glucagon D secretin E. somatostatin 127. A 66-year-old woman with known tumour of her spine has started to retain urine and is experiencing decreased anal and rectal tone. The tumour is pressing directly on the conus medullaris. At which one of the following vertebral levels is the tumour most likely to be located? A. T9/T10 B T11/T12 C L1/L2 D L3/C4 E L5/S1 128. A 26-year-old man presents with a two-month history of unilateral testicular swelling. An ultrasound scan shows a heterogeneous mass within the testis with surrounding fluid. His blood test show- an elevated alpha fetoprotein level. Which of the following is the most likely diagnosis? A Lymphoma B Orchitis C Seminoma D Teratoma E Tuberculosis 129. A 50-year-old woman presents with a history of faecal incontinence over the past few year She had a prolonged and difficult first stage of labor 20 years previously. Physical examination reveals a relatively lax anal sphincter. Which nerve is likely to have been damaged in labour? A Autonomic nerves to the rectum B Genitofemoral nerve C Lumbosacral trunk D Obturator nerve E Pudendal nerve 130. A 70-year-old man is admitted to hospital with a 12-hour history of a painful white leg. Afemoral artery embolus is shown on angiography. He is an insulin-controlled diabetic and takes ibuprofen for longstanding osteoarthritis. Twenty-four hours after emergency embolectomy his blood pressure is 90/60 mmHg and he passes very dark brown urine. A dipstick shows myoglobin and traces of blood. His blood glucose is 15 mmol/L (normal- 4.0-6.0), urea 12 mmol/L (normal 3.2-7.5) and creatinine 180 mmol/L (normal 35-110). What is the most likely cause of his abnormal renal function? A Drug induced nephropathy B Hypovoiaemia C Methaemoglobinuria D Rhabdornyolysis E. Uncontrolled diabetes 131. An 86-year-old woman, with a history of partial gastrectomy, is in the high dependency unit for a chest infection that is being treated with antibiotics. She complains of difficulty swallowing. Endoscopy shows multiple white plaques on the mucosal surface of the oesophagus. Biopsy is most likely to show: A. acid reflux oesophagitis B Barrett's oesophagitis C candida oesophagitis : D eosinophilic oesophagitis E. herpes oesophagitis 132. A 65-year-old woman has been given a total of 15 mg of morphine/over a 30-minute period for pain relief following a femoral neck fracture, mellowing observations are found: Sp02 on 80% oxygen is 80%; blood pressure 90/60 respiratory rate 6 breaths/minute.-The immediate intervention should be: A. high flow oxygen B, intravenous fluid replacement C intravenous Naloxone D. monitor her ECG E. tracheal intubation 133. The following drugs are used to treat patients with peripheral vascular disease. They all reduce the rate of myocardial infarction and stroke except: A. A.C.E inhibitors B. antihypertensive medication C. aspirin D. cholesterol lowering drugs E. oxypentifylline 134. A 4-year-old boy, is brought to the Emergency Department with a painful right elbow. His father stales that he was swinging his son by his arms when the pain came on suddenly An X-ray shows that the radial head is displaced from its usual position. What is the ligament (of the proximal radio-ulnar joint) that holds the radial head in place? A Annular ligament B Conoid ligament C Quadrate ligament D Radial ligament E Ulnar ligament 135. A 35-year-old man presents with a three-week history of low back pain and a three- day history of pain and weakness in his left leg. Physical examination demonstrates numbness over the posterior aspect of the left calf extending to the lateral aspect of the foot. Left ankle reflex is absent. A magnetic resonance scan shows compression of the left S1 nerve root. What is the most likely responsible structure? A. Annulus fibrosus B. Anterior longitudinal ligament C. Nucleus pulposus D. posterior longitudinal ligament E. Vertebral end plate End of paper 1 1. A 26 years old man motorcyclist loses 1 L of blood secondary to an open fracture of the femur sustained in RTA. Which of the following is the most likely earliest compensatory response in hypovolemeia in the this patient? A. Baroreceptors induced venoconstriction B Capillary fluid shifts C Decreased atrial natriuretic peptide (AMP),secretion D Renal fluid retention E Renin Angiotensin system activation 2. Histology of a discrete palpable lump in the breast o 1 a 34-year-oM woman has shown Apocrine metaplasia, epithelial overgrowth and papillary projections. What is the most Likely pathological process ? A Benign breast cyst B Carcinoma of the breast C Fibroadenoma D Phylloids tumor E Plasma mastiditis 3. A 35 -year-old woman 'presents with recurrent peptic ulceration. She is on a proton pump inhibitor previously received Helicobacter pylori eradication therapy three months ago. Which of the following is likely to be raised on venous blood testing? A Cholecystokinin B Gastrin C Histamine D Pancreozymin R Secretin 4. 3 Year old male boy presented with his mother for rectal blood loss, his mother describes it as a bright red blood in the toilet pan. He has no pain on defecation with negative family history. What is the most likely cause? A-Adenomatous polyp B Juvenile polyp C Metastatic polyp D Multiple polyposis coli E peutz jegher syndrome 5. A 32-years old man presents with a painful torticollis there is no past medical history and his only complaint is that he has been feeling rather tired over the last 4 nights. On examination, he has large rubbery mass in the lateral aspect of his neck as well as a few smaller masses along his internal jugular vein. You correctly assume that the muscular neck spasm and the large mass are connected. The most likely cause of his torticollis is due to pressure on? A. Ansa cervicalis B. Cervical plexus branch C. Cranial accessory nerve D. Spinal accessory nerve E. Vagus nerve 6. A thin menopausal 52-vear-frld woman is diagnosed with breast cancer. Her menarche was at the age of 14. she had her first child at age40 years. During lactation, she developed breast abscess that necessitated surgical intervention. She has no family history of breast cancer. Which of the following is the most significant risk factor for this patient? A Age at first full term pregnancy B Familial predisposition C History of breast abscess D Interval between in menarche and menopause E Physical stature 7. A 30-ycar-old woman is sent to the outpatient clinic with weight loss of 5 kg over the Last 6 months, She also complains of anxiety, panic attacks and palpations. On Examination. There is a swelling in the anterior neck which moves on swallowing Which of the following is most likely pathology underlying this presentation? A Graves disease B Hasliimoto's thyroiditis C Metastasis to the thyroid D. Papillary carcinoma E Undifferentiated carcinoma 8. A 69-yeac-oJd man has been admitted to the high dependency unit following an anterior resection under general anesthesia. He was given 2 mg of intrathecal morphine. On examination, he looks pale and drowsy. Arterial blood gasses results are: PH pCo2 pO2 Base Gluose Lactate Excess Finding 7.28 8.1 kPA 10.2 kPa -2.1 21 mmol/L 4.0 mmol/L Normal 7.35-7.45 4.7-6.0 11.9-13.3 -2 to +2 4-7 0.5-2.2 Which o f the following is the most likely diagnosis? A. Diabetic ketoacidosis B. Metabolic acidosis C. Metabolic alkalosis D Respiratory acidosis E Respiratory Alkalosis 9. A 32 year-old woman has a pigmented lesion excised from her left calf. The histopathological diagnosis is melanoma in situ, which is completely excised with a- 1 cm margin. What is the next most appropriate management? A Education about skin self-examination and discharge from follow up B. Elective inguinal lymph node dissection C Re excision with 2 cm margin D. Removal of any other pigmented lesions E. Sentinel lymph node biopsy 10. A 60-year-old man with a past history of angina undergoes an uncomplicated operation, for an inguinal hernia. Postoperatively he is found to be hypotensive, tachycardic, and has a raised jugular venous pressure. What is the most likely Underlying cause Of his hypotension? A. Reduced afterload B. Reduced parasympathetic tone G Reduced preload D. Reduced stroke volume E. Reduced sympathetic tone 11. A 4-years old boy presents to the Emergency Department with a two-day history of fever, difficulty walking and is unable to weight bear on the right leg. He has been on oral Amoxycillin 250 mg three times a day for a chest infection over the last five days. He is irritable with a temperature of 39.4°C. He does not allow examination and keeps his right hip flexed and adducted. Blood tests are, (WBC) 18.3 (CRP) 146, haemoglobin 11.3 g/dL. What is the most likely diagnosis? A Acute avascular necrosis of hip B Dislocation of hip C Perthes disease D Septic arthritis E. Slipped upper femoral epiphysis 12. A 34-year-oid man is admitted to-the Emergency Department with a head injury. On examination his Glasgow coma scale is 9. A CT scan of the brain demonstrates an extra dural haemorrhage. Which of the following arteries is the most likely source of this? A. Anterior cerebral B. Middle cerebral C. Middle meningeal D Posterior cerebral H. Superficial temporal 13. A 65-year-old man has a history of transient ischemic attacks. He is due to undergo carotid endarterectomy. Which one of the following is true of the internal carotid artery? A. Begins at the level of the sixth cervical vertebra B. Divides into the anterior, middle and posterior cerebral arteries C. Gives off the ophthalmic artery D. Is accompanied within the skull by preganglionic sympathetic nerves E. Passes through the foramen ovale 14. A 25-year-old male athlete is in training. At rest, how many liters of blood per minute does his heart pump out? A. 0.9 B. 2 to 3 C 5 to 6 D 8 to 10 E 15 to 20 15. A 26-year-oJd man presents to the Emergency Department after sustaining a glass cut to his arm. On examination there is a 10 cm longitudinal laceration on the anterior aspect of his upper arm. He has symptoms suggestive of ulnar nerve injury. On exploring the upper part of the arm we would expect the ulnar nerve to be: A. anterior then medial to the brachial artery B. medial then anterior to the brachial artery C medial to the brachial artery D. posterior then medial to the brachial artery E. posterior to the brachial artery 16. A 55-year-old man presents with acute back pain following a severe road traffic accident. Neurological examination reveals lack of sensation of the umbilicus and below. What is the spinal level of the neurological deficit likely to be? A T8 B T9 C T10 D T11 E T12 17. A- 65-year-oid man complains of being thirsty and getting up in the middle of the night to get to the toilet. His weight is 95.5 kg. height 1.65 in and blood pressure 167/94 mmHg. An oral glucose tolerance test was performed and produced the following results: The most likely diagnosis: Fasting plasma glucose 5.9 mmol/L A Diabetes insipidus Two hours plasma 11.3 mmol/L B Diabetes mellitus glucose C Impaired fasting Glycemia D impaired glucose tolerance E Normoglycemia 18. in a 9-year-old child with cellulitis of the hand, which chronological sequence of immunoglobulin production is correct? A. IgD precedes IgE production B IgG precedes IgA production C IgG precedes IgE production D IgM precedes IgA production E IgM precedes IgG production 19. A 60-year»old man presents to the-Emergency Department with epistaxis. The source 0f the bleeding is identified as Little's area and resolves with direct cautery. Which vessel is most likely responsible for the bleeding? A. Anterior ethmoidal artery B. Infraorbital artery C. Middle meningeal artery D Sphenopalatine artery E. Supratrochlear artery 20. A 75-year-old man presents with esophageal reflux. Endoscopy confirms the Presence of a hiatus hernia. The esophagus passes through the diaphragm at which level? A T8 B T9 C T10 D T11 E T12 21. A 78-year-ojd woman with emphysema receiving 28% oxygen by mask has the Following blood gas results PH pO2 pCo2 Bicarbonate Base Excess Finding 7.28 6.2 kPa 8 kPA 36 mmol/L +5 Normal 7.35-7.45 11.9-13.3 4.7-6.0 22-26 -2 to +2 Which of the following is the most likely interpretation? A Mixed respiratory and metabolic Acidosis B Partially compensated metabolic acidosis C Partially compensated respiratory acidosis D Uncompensated metabolic acidosis E Uncompensated respiratory acidosis 22, A 26-year-old man is having a stereotactic frame fitted to his skull prior to radiosurgery on a cerebral arteriovenous malformation. Four pins secure the frame tightly through the scalp to the outer table of the skull, two anteriorly, two posteriorly. On insertion of one of the-posterior pins, arterial haemorrhage is encountered. Which artery is most likely to have been punctured? A The ascending pharyngeal artery B The middle meningeal artery C The occipital artery D The posterior cerebral artery E The posterior communicating artery 23. A. 2.6-year-old man presents with a two-month history of unilateral testicular swelling. An ultrasound scan shows a heterogeneous mass within the testis with surrounding fluid. His blood test shows an elevated alpha fetoprotein level Which of the following is the most likely diagnosis? A Lymphoma B Orchitis C Seminoma D Teratoma E Tuberculosis 24. A 2 day old baby presents with increasing respiratory distress. He was born at term By normal vaginal delivery. On examination he has cyanosis of the lower limbs and marked respiratory in drawing of the chest His femoral pulses ate absent bilaterally and he has been anuric for the last 2 hours. Pulse rate is 140 beats/minute, regular, and his blood pressure is 60/30 mmhg in both upper limbs. What is the most likely diagnosis? A. Hypoplastic left heart syndrome B. Interrupted aortic arch C. Pulmonary atresia and ventricular septal defect D. Transposition of the great arteries E. Tricuspid atresia 25. A 50-years old woman presents with a history of right upper quadrant pain and jaundice. She reports that her urine was dark in colour and that her stools are offensive and difficult to flush. Which of the following explains the dark urine? A. Increase in conjugated bilirubinuria B. Increase in unconjugated bilirubinuria C. increase in urea excretion D Increase in urinary urobilinogen H. Reduced enterohepatic bile salt circulation 26. An 80-year-old woman, who has suffered a fall, is found lying on the floor, where, she has-been for over 12 hours. Initial assessment shows that she has a core temperature of 28°C. What would the expected early physiological response to her body temperature be? A. Increased fat metabolism B. Increased constriction of peripheral blood vessels C. Increased hypothalamic set-point D. Increased metabolic rate. E. Increased thyroid activity 27. A -12-year-old boy presents to the Emergency Department two hours after helping his father cut the grass. He complains of rhinorrhoea, itchy eyes, sneezing and a a blocked nose. He is apyrexial with a haemoglobin of 12.2 g/dL and white blood cell count of 6.8 * I09/L with a raised eosinophil count. Chest X-ray is; clear. Which immunoglobulin is most likely to cause this reaction? A. IgA B. JgD C. IgE D. IgG E. IgM 28. A 45-year-old man presented with backache and leg pain due to –prolapsed lumbar intervertebral' disc. The pain, which is aggravated by coughing and sneezing; radiates to the dorsum of the foot On examination there is weakness, of the dorsiflexion of the foot. Which nerve root is most likely to be involved? A. T12 8- L3 C. L5 D. S1 E. S2 29. A 75-year-old woman, who has a carcinoma of the upper rectum, undergoes anterior resection. The arterial blood supply of the upper rectum arises from which of the following? A. Coeliac artery B. Iliocolic artery C. Inferior mesenteric artery D. Internal iliac artery E. Superior mesenteric artery 30. A 65-year-old man is undergoing an abdominal aortogram, A stenosis is demonstrated in a lateral aortic branch, arising at the level of the body of the second lumbar vertebra. The stenosed vessel is most likely to be the: A. coeliac artery B. inferior mesenteric artery C. left renal artery D. second left lumbar artery E. superior mesenteric artery 31. A 40-year-old man is admitted tc the surgical day case unit for repair of his left inguinal hernia. On examination he is noted to have diffuse skin tanning, spotty pigmentation of the elbows, nipples and buttocks, and pigmentation of the scar from A previous right inguinal hernia repair. Three hours after the operation be becomes severely hypotensive. 'What is the most likely cause? A. ACTH deficiency B. Adrenal insufficiency C. Growth hormone deficiency D. Potassium deficiency E. Thyroxine deficiency 32. A 19-year-old woman presents to the Emergency.Department profoundly hypovolemic having fallen from a horse. A postero-anterior (PA) chest radiograph shows a fracture to the medial third of the left clavicle. Which of the following vessels was-most likely damaged? A Brachiocephalic trunk B Left axillary artery C Left common carotid artery D Left subclavian artery E Left vertebral artery 33. 65 years old man presented with an inguino-scrotal swelling in the right groin which is non tender. A cough impulses is elicited, At operation, an indirect inguinal hernia is repaired. The cremasteric muscle is derived from which of the following A. External oblique aponeurosis B Internal oblique muscle C. Rectus abdaminis muscle D. Rectus sheath E. Trsusversalis fascia 34. A 70-y ear-old woman is in the recovery area and receives 28% oxygen by mask. Blood gas shows: PH Pco2 Po2 Findings 7.1 10.0 kPa 12 kPa Normal 7.35-7.45 4.7-6.0 11.9-13.3 Reduced sensitivity of which receptors is most likely to be responsible for this blood gasses picture? A. Adrenergic receptors B. Baro receptors C Central chemo receptors D. J receptors E Lung stretch-receptors 35. A 28-year-old man presents with pain in his left scrotum. A diagnosis of varicocele is made. Which vessel is involved? A Femoral vein E. Inferior epigastric vein C. Long saphenous vein D Internal pudendal vein E Testicular vein 36. A 60-year-old man, who is a heavy smoker, presents with a 10-day history of frank painless haematuria. His prostate is slightly enlarged on rectal examination. his haemoglobin is 11.3 g/dL. creatinine 84 pmol/L and prostate specific antigen (PSA.) is 3,1 mg/dL. What is the most likely pathological process? A. Benign prostatic hyperplasia B. Prostate cancer C. Renal cell carcinoma D. Transitional cell carcinoma of bladder E. Urinary tract infection 37-. A 34-year-old woman presents with an irregular mass in the right breast which is clinically. radiologically and histologically malignant. Her mother died of breast cancer at the age of 58 and her grandmother died of ovarian- cancer at the age of 55. Which gene is most likely to be involved in the development of this woman tumor? A BRCA1 B. hMLH1 C. KRAS D. p53 E. PTEN 38. 65-year-old man presents with a non-tender swelling in the right hemi-scrotum. At operation, the hydrocele sac is opened and 400 ml of fluid is drained. Which anatomical structure surrounds the fluid? A. Dartos muscle B. Patent processus vaginalis C. Testicular capsule D. Tunica albuginea E. Tunica vaginalis 39. A 24 years old man is brought to the Emergency Department following a road traffic accident. He has obvious airway compromise due to mouth/ facial haemorrhage which requires a surgical airway. The surface landmarks used to localise, the optimal site for a tracheostomy incision are midway between the suprasternal notch and which of the following? A Cricoid B Hyoid C Mastoid D Laryngeal prominence E Thyroid 40. A 60-year-old man has -an anterior resection for a high rectal carcinoma. The histopathology report indicates the lesion is Dukes' stage B. What is the approximate average five years survival rate for patients with these lesions? A. 10% B. 20% C. 35% D 70% E 90% 41. A 20-years man presents to the Emergency Department after accidentally tripping over and lacerating his hand on a glass bottle. On examination there is a 2 cm laceration on the hypothenar eminence with loss of flexion in the distal interphalangeal joint of the little finger. What is the most likely tendon to be injured? A Flexor digiti minimi brevis B Flexor digitorum profundus C Flexor digitorum superficialis D Fourth palmar interosseous E Lumbirical 42 A 75-year-old man, who smokes heavily, underwent coronary artery bypass grafting six months ago. A left internal-mammary artery graft was used. He now complains of angina on pegging his laundry on the washing line to dry. Which of the following lesions best explains his symptoms? A..Micro-emboli from the left common carotid artery B. Micro-emboli from the le\t internal carotid artery C. Stenosis.of the subclavian artery at the level of the costo-cervical trunk D. Stenosis of the subclavian artery distal to the insertion of scalenus anterior E. Stenosis of the subclavian artery proximal to the first branch 45. A 50-year-old alcoholic man presents-to the Emergency Department and is found to be unable to extend his wrist, thumb and fingers of his right hand. He is also found to have weak extension of the right elbow joint and loss of sensation on the dorsum of the first web space. Which nerve is most likely to have been injured? A Median nerve B Musculocutaneous nerve C Posterior interosseous nerve D Radial nerve B. Ulnar nerve 44. A 55 year-old man presents with acute back pain following a severe road traffic accident. Neurological examination reveals lack of dorsi-flexion of the left ankle joint. Which of the following spinal cord, segments are most likely to be injured? A. L1, L2 & L3 B. L2, L3 & L4 C L4, L5 & S1 D. S1, S2& S3 E. S3, S4 & S5 45. A 21 -year-old man is admitted to the Emergency Department with a stab injury to his right chest. Pulse rate is 110 beats/minute and blood pressure is 85/40 mmhg Chest X-ray shows a large right haemothorax and a very small right apical pneumothorax. Which is the first substance secreted in the process leading to increased renal reabsorption of sodium in response to the above injury? A. Angiotensin I B Angiotensin II C Angiotensinogen D Antidiuretic hormone E Renin 46. A 21-year-old man has been stabbed in the back of the knee, dividing the popliteal artery, and is undergoing repair via a posterior approach. Which of the following structures is most likely to be encountered first, when dissecting deep from the skin „ incision? A Popliteal artery B Popliteus muscle C Popliteal vein D Tibial nerve E Soleus muscle 47. A 78-year-old woman presents with urinary urgency and incontinence. The external urethral sphincter is innervated by which of the following nerve roots? A. L 3, 4 & 5 B. L4, 5 & SI C. L 5, S1 & 2 D. S1, 2 & 3 E. S2.3& 4 48. A 40-.year-Qld woman presents with a parotid tumour. A biopsy reveals perineural invasion. Which is the most likely pathology? A. Acinic cell.carcinoma B. Adenocarcinoma C. Adenoid cystic carcinoma D. Lymphoma E. Pleomorphic salivary adenoma 49. A 19-year-old man was assaulted and sustained injuries to the right side of his head. After two weeks he notices dial his right eye is dry and it could not produce tears. from which ganglion is post synaptic fibers arise to supply lacrimal gland? A. Geniculate ganglion B. Inferior ganglion of the vagus nerve C. Otic ganglion D. Pterygopalatine ganglion E. Superior cervical ganglion 50. A 35-year-old man undergoes a right inguinal hernia repair under genera! anaesthetic as a day patient. He has a nerve block after the procedure. On recovery he has weakness of the right leg. Which nerve has been affected? A. Femoral nerve B. Genitofemoral nerve C Ilioinguinal nerve D Lateral cutaneous nerve E Sciatic nerve 51. A man suffers a brachial plexus injury. On examination, he has a Horner's syndrome in association with upper limb paralysis. Which nerve roots does the Homer's syndrome suggest involvement of? A. C2 & C3 roots B. C4 & C5 roots C. C6 & C7 roots D C8 & T1 roots E. T2 & T3 roots 52. A 60-year-old woman with breast carcinoma complains of difficulty chewing her.. food and is found to have numbness of the lower lip on one side. CT scanning shows a small metastatic lesion affecting the bony skull base on. The same side as the lip numbness. Which foramen is the most likely to involve? A. Foramen caecum B Foramen magnum C Foramen ovale D. Foramen rotundum E. Foramen spinosum 53. Which one of the following muscles is an extensor of the hip? A. Adductor longus B. Gracilis C. Iliopsoas D. Pectineus E. Semitendinosus 54. In order to expose the right axillary artery, a transverse skin incision is typically made below the clavicle from a point just lateral- to the sternal end of the clavicle to the deltopectoral groove. Which of the following structures would be encountered in the dissection down to the vessel? A. Lateral thoracic artery B. Phrenic nerve C. Suprascapular artery D. Thoracic duct E. Thoraco-acromial artery 55. A 55-year-bld man presents to the-Emergency Department after collapsing. On examination his pulse is 124 beats/minute, blood pressure is 60/30 mmHg, respiratory rate is 34 breaths/minute and his peripheries are warm. What is the most likely diagnosis, for this patient? A. Cardiac failure B. Haemorrhage C Hypovolemia D. Pulmonary embolus E. Sepsis 56. In the posterolateral approach to a posterior malleolar fracture, an incision is made between the calcaneal (Achilles) tendon and the distal-.fibula. Which of the following structures is at risk? A. Deep peroneal (fibular) nerve B. Saphenous nerve C. Superficial peroneal, (fibular) nerve D Sural nerve E. Tibial nerve 57. A 25-year-old woman undergoes.an elective right thoracoscopic procedure for treatment of right palmar hyperhidrosis. Diathermy is applied to a neural structure lying anterior to-the neck of tire right first rib. What is the most likely complication to occur as a result of this procedure? A. Bradycardia B. Hoarseness C. Homer's syndrome D. Raised right hemi diaphragm E. Reduced right biceps tendon reflex 58 / A 33-year-old man presents to the orthopedic outpatient clinic with a six-month history of low back pain radiating to the lateral aspect of the left upper thigh. Micturition and defecation are normal and there is no history of previous Injury. On examination, left lateral flexion of the spine is limited but a full range of hip movements are observed, although it is painful. Sensation is altered over the front of the knee. Left knee reflex is reduced. Which spinal nerve-is most likely to have been compressed? A. L1 B. L2 C. L3 D. L4 E. L5 59. A 2S-year old motorcyclist is admitted following a road traffic accident, having sustained- bilateral femoral fractures and a ruptured spleen. Three days postoperatively lie is noted to be confused, hypoxemic and difficult to ventilate. His observations show a blood pressure, of 120/8O.mmHg, regular pulse of 88 beats/minute and he is apyrexial. A chest X-ray shows bilateral diffuse lung infiltrates. What is the most likely underlying diagnosis? A. Adult respiratory distress syndrome B Atelectasis C Bronchopneumonia D. Pulmonary oedema E: Pulmonary thrombo-emboilism 60. On-an ultrasound scan of the popliteal fossa when investigating-a swelling, which of the following structures is closest to the capsule of the knee joint? A Great (long) saphenous vein B Popliteal artery C Popliteal vein D. Small (short) saphenous vein E. Tibial nerve 61. A 25 years old man sustains a twisting injury while playing football. He develops immediate swelling of the knee and he can not continue the game. Six months later, he Is still not able to play football. His knee feels unsteady and tends to give way. On examination, he has a full range of knee motion. There is a positive anterior draw test and a small effusion. What is the most likely structure damaged? A Anterior cruciate ligament B. Lateral collateral ligament C. Medial collateral ligament - D. Oblique popliteal ligament E. Posterior cruciate ligament 62. A 62-year-old man required a partial gastrectomy for a large benign ulcer in his gastric antrum. When he is reviewed in clinic, six months later he complains of palpitations, weakness and sweating along with a cramp-like abdominal pain which occurs within an hour of eating n meal. Usually, he has to lie down for 30-40 minutes until the symptoms subside. What is the most likely cause of his symptom pattern? A Chronic gastroparesis B Dumping syndrome C. Delayed gastric emptying D Reflux gastritis E Recurrent ulceration 63. in septic shock, noradrenaline is used to increase the systemic vascular resistance This action is a result of the stimulation of which of the following ? A α1 B α2 C β1 D β2 E. ∂1 64. A 56-year-old man presents with acute epigastric pain and vomiting. On examination he has guarding in the upper abdomen His test results are: Value Normal Serum amylase 900 IU/L ≤100 Serum ALT 61 IU/l ≤50 Alkaline Phosphatase 93 IU/l 20-120 Albumin 38 g/L 35-50 Gamma GT 500 IU/L ≤60 Bilirubin 15 umol/L 0-20 Triglyceride 2.9 mmol\L ≤1.7 Which of the following is the most likely etiology of this condition? A. Alcohol B. Choledocholithiasis C. Hypertriglyceridemia D. Hypocalcaemia E. Mump 65. A 47-year-old woman with end stage renal failure requires an elective cholecystectomy for symptomatic gallstone disease. Her hemoglobin preoperatively is 7.2 g/dL. What is the major cause of her anaemia? A. Calcium deficiency B. Erythropoietin deficiency C Folate deficiency D Iron deficiency E. Vitamin B12 deficiency 66. A 60-year-old man undergoes cystectomy a bladder carcinoma. During surgery, the ureters are identified. On which region of the bladder do the ureters pierce the bladder wall? A. Anterior surface B. Apex C. Lateral surfaces D. Neck E. Posterior surface 67. A 65 year-old man had a colonic resection for carcinoma 12 hours ago. He is now passing concentrated urine at a rale of 0,5 ml/kg/hr. Which endocrine response is most likely to have caused this? A. Decreased aldosterone release B. Decreased insulin release C. Decreased thyroxine release D Increased adreno-coriticotrophic hormone (ACTH) release E Increased Vassopressin release 68. A 28-year-old man presents with an ischiorectal abscess. Where is ths abscess cavity likely to be sited? A. Above the levator ani B. Between external and internal anal sphincter C. Lateral to the obturator internus D Medial to the internal anal-sphincter E Medial to the pudendal canal 69. A 36-year-pld man falls on his outstretched right hand.-Examination reveals tenderness in the anatomical snuffbox. Which one of the following tendons form a boundary of the anatomical snuff box? A. Abductor pollicus brevis. B Extensor carpi radialis brevis C. Extensor cairpi radialis longus D. Extensor indicis E. Extensor poliicis longus 70. A 55-year-old- woman complains of cramps and tingling in her legs and arms 48 hours following a sub total thyroidectomy. Her vital signs, are stable. Investigations reveals a normal white-cell count and normal haemoglobin. The NA is 132 mmol/L K+3.2 mmoI/L and Ca 1.60 mmol/L. Serum albumin is normal The next appropriate step is intravenous infusion of? A. Calcium chloride B. Magnesium sulphate C. Potassium chloride D. Sodium bicarbonate E. Sodium chloride 71. A 40-year-old. woman presents with faecal incontinence and; anatomically intact internal and external anal- sphincters. Which structure is most likely to have been damaged? A. First sacral nerve-root B. Obturator nerve: C. Pelvic splanchnic nerves D. perineal nerve E. Pudendal nerve 72. Abdominal free fluid will collect in the lowest part of the peritoneal cavity. At operation with the patient supine, in which of the following will the fluid collect first? A Hepatorenal pouch B. Left subphrenic space C. Lesser sac D. Right paracolic gutter E. Right subphrenic space 73. A 45-year-old homeless man presents with a cough and weight loss over three months. On examination his BMI (Body Mass Index) is 19 and he has reduced breath sounds in the right upper zone. His chest X-ray shows a cavitaing lesion in the right upper lobe. He undergoes a bronchoscopy and a brornchial biopsy. The biopsy shows featureless necrosis surrounded by epithelioid macophages and giant cells. Which of the following is the most likely diagnosis? A.. Actinomycosis B Bronchiectasis C Sarcoidosis D Squamous cell carcinoma E. Tuberculosis 74. A healthy 36 years old man is being assessed with a view to being a life related kidney donor which are of following investigations is most accurate for measuring the GFR? A Creatinine clearance B Glucose Clarence C Inulin Clarence D PAH E Urea clearance 75. A 34-year-old pregnant woman develops a swollen leg. Her mother and maternal aunt also had a similar problem during their pregnancies. Which of the following tests is likely to be positive? A. Antiendomysial antibodies B. Antimitochondrial antibodies C. Antinulear antibodies D. Antiphospholipid antibodies E. Antithyroglobulin antibodies 76. A 72-year-old alcoholic man is known to suffer from chronic obstructive pulmonary disease (COPD). He has now been diagnosed with carcinoma of the urinary bladder and-has a history of a gastric ulcer. Which of the following agents is most likely to be responsible for all these problems? A. Alcohol B Cigarette smoking C. Drugs D. Dust E. Virus 77. A 3-year-old boy is admitted to hospital with severe vomiting. Radiographic examination and history reveals that he is suffering from annular pancreas. Which of these structures is constricted? A. First part of duodenum B Second part of duodenum C. Third part of duodenum D. Proximal jejunum E. Pylorus of stomach 78. A 45 year-old man presents with a 3 cm * 4 cm swelling in the right groin which is non-tender. A cough impulse is elicited. At operation, an indirect inguinal hernia is found. The external inguinal ring is a defect in which of the following abdominal A. External oblique aponeurosis B. External oblique muscle C. Internal oblique muscle D Transversus abdominis muscle E Transversalis fascia 79. A 45-year-old woman suffers from spina bifida and is confined to a wheelchair. Her legs are not fully developed. What is the pathological process which has occurred in the legs? A. Apoptosis B Atrophy C. Hyperplasia D. Hypertrophy E. Hypoplasia 80. A 23-year-old man presents to the Emergency Department-with non-specific: chest pains. A postero-anterior (PA) chest radiograph is performed and is normal. Immediately inferior cauidal to the outline of the aortic knuckle was a farther structure with a convex border. What is this structure? A. The left atrium B. The pulmonary trunk C. The oesophagus D. The right atrium E. The superior vena cava 8I. A 45-year-old woman presents to the hospital with jaundice. She- undergoes an ultrasound scan and is diagnosed with a hepatocellular carcinoma affecting the left lobe of her liver. Which virus is the most likely to be implicated? A. Epstein Bar virus (EBV) B. Hepatitis B virus (HBV) C. HIV D. Human papilloma virus (HPV) E. Human T cell lymph a trophic virus-1 (HTLV1) 82. An 82-year-old man has complete occlusion of his inferior mesenteric artery on angiography but no symptoms or.signs of colonic ischaemia. Which of the following arteries is the.most likely additional source of blood supply to the territory of the inferior mesenteric artery? A Left colic artery B Left gastroepiploic C. Middle colic D. Splenic E. Superior rectal 83. A 56-year-old man with documented Type 1 diabetes mellitus presents to the Surgical outpatient clinic with 3 months history of right leg pain brought on by walking 50 meters. He has no history of back pain. He has been a smoker for 10 years (10 cigarettes a day);-He stales his alcohol consumption to be 30 units per week. On clinical examination, significant findings include weak right foot pulses with altered sensation on dorsum of the right toot. What is the most likely diagnosis D from the following list? A. Autonomic neuropathy B. Femro popliteal stenosis C. Neuropathic joint disease D. Polyneuropathy E. Radiculopathy 84. A 35-year-old man presents with a three-week history of low back pain and a three day history of pain and weakness in his left leg. Physical examination demonstrates numbness over the posterior aspect of the left calf extending to the lateral aspect, of the foot. Left ankle reflex is absent. A magnetic resonance scan shows compression of the left S1. nerve root. What is the most likely structure compressing the nerve? A. Annulus fibrosus B Anterior longitudinal ligament C. Nucleus pulposus D. posterior longitudinal ligament E Vertebral end plate 85. A 72-year-old man who is a smoker presents to his doctor with a second episode of frank hematuria. When an ultrasound scan of his urinary tract was performed it a solid lesion in the right kidney. What is the most likely pathology underlying this presentation? A. Angiomyolipoma B Renal cell carcinoma, C Renal cyst D Renal oncocytoma E. Transitional cell carcinoma 86. A 20-years old man presents with abdominal pain and shock. He is found to have hemoperotonium Due to a ruptured spleen. He denies any history of trauma what is the most likely predisposing cause of his splenic rupture? A. Epstein Barr virus infection B. Human immunodeficiency virus (HIV) infection C. Measles virus infection D. Mumps virus infection E. Varicella zoster virus infection 87. A 30-year-old woman presents to the outpatient' clinic witlr a three-month history of diarrhoea, which is intermittently bloody. On rectal biopsy, the histology has shown' a granulomatous inflammation. What is the most likely diagnosis? A. Ameobiasis D. Crohn's disease C. Sarcoidosis D. Tuberculosis E. Ulcerative colitis 88. A 56 year-old motorcyclist presents to the Emergency Department after being involved in a road traffic accident. He is a smoker and known to have hypertension. He is conscious (Glasgow coma score of 1-3/15), and maintaining his own airway and breathing. He is found to have an open right femoral fracture With normal distal pulses and- sensation. Resuscitation is started. Urethral catheterisation drained 250 ml. immediately but over the following 60 minutes he drained only 10 ml. Which of the following is the most likely cause of his low urine output? A. Blocked catheter B. Cardiogenic shock C. Hypovolemic shock D. Ruptured bladder E. Septic shock 89. A 35-year-old man is admitted with pancreatitis, which leads to admission to the surgical high dependency unit. After 48 hours, he develops breathing difficulties with elevated, respiratory rate and increasing hypoxia. You suspect he is developing respiratory failure. Which of the following mechanisms is responsible for the regulation of respiration? A Brainstem receptors producing voluntary breathing. B CO2 concentration in medulla C Elevated bicarbonate levels in cerebrospinal fluid D. Hydrogen ion diffusion across blood brain barrier E. Hypoxic stimulation' of chemoreceptors 90. A 70-year-old man undergoes transurethral resection of bladder uimonr (TURBT). The tumour lies over the lateral side wall of the bladder just above the opening of the right ureteric orifice. Use of the diathermy suddenly causes the patient to 'kick' because of contraction of the hip adductors muscles. Which nerve has been stimulated? A Femoral nerve B Genitofemoral nerve C Lateral femoral cutaneous nerve D Obturator nerve E Sciatic nerve 91. Witch of the following statements is true with relation to cardiac muscle? A. Contraction does not involve-release of Ca 2 + by the sarcoplasmic reticulum B. Contraction is triggered by an influx of Ca 2+ through the sacrolemma C. Excitation is passed from one cardiac cell to another through desmoses D. Hypertrophy is brought about by division of existing cardiac cells E. There is capacity for regeneration 92. A 39-year-old man presents with searing left-sided loin to groin pain. Investigation. reveals a radiodense opacity, confirmed to be in the ureter on intravenous urography. What is the most likely composition of this man's ureteric stone? A. Ammonium magnesium phosphate B. Calcium oxalate C. Cholesterol D. Cysteine E. Urate 93. A 25-year-oid man is playing football when he complains of posterior thigh pain whilst sprinting with the ball. On examination he has tenderness in the lower lateral posterior thigh. He is unable to fully extend the knee due to pain. What is the most likely injury? A Biceps femoris tear B. Gracilis tear C. Gastrocnemius tear D. Semimembranosus tear E Semiteodinosus tear 94. A 23 years old man is assaulted and sustains a stab injury to the left groin. The wound is cleaned and a simple dressing applied. Six months later the patient returns- with a pulsatile swelling in the site of the injury. The most probable lesion present is: A. Abscess 8. False aneurysm of the femoral artery C. lymphocele D. mycotic aneurysm of the femoral artery E Saphena varix 95. 12 years old girl has a diastolic murmur it is maximally audible in the 2nd left intercostal space. Pathology of which structure is the most likely cause ? A. Aortic valve B. Ductus arteriosus C Mitral valve D. Pulmonary valve E. Tricuspid valve 96. A 25-year-old man is admitted having been stabbed in the interior chest. On examination he is alert and coherent. He has congested neck veins. His pulse is 140 beats/minute and his blood pressure 90/60 mmHg. He has normal breath sounds. What is the most likely cause of his cardiac arrest 15 minutes later? A. Cardiac tamponade B. Congestive cardiac failure C. Hypovolemia D Tension pneumothorax E Ventricular arrhythmia 97. A 20-year-old woman presents acutely with abdominal pain. Imaging reveals a right ovarian cystic lesion which is excised. Histological examination shows a cyst lined by keratinising stratified squamous epithelium. Areas of fat,muscle, thyroid and neural tissue are seen in the wall. What is the appropriate pathological designation for this lesion? A. Cystadenoma B. Dysgerminoma. C. Mesenchymoma, D. Squamous cell carcinoma E. Teratoma 98. A 21-year-old map comes into the Emergency Department with a severe headache and neck stiffness of recent onset. You suspect acute meningitis and decide immediately to treat with antibiotics and perform a lumbar puncture. After your third attempt to obtain for cerebrospinal fluid (CSF) you notice that the fluid obtained is stained red. However during the collection of CSF into three containers it is noted that the final bottle is now cleared of any blood. Which anatomical structure is the most likely to be responsible for this bleeding? A.. Anterior spinal artery B. Epidural artery C. Subarachnoid vein D. Veins within the erector spinae muscles E. Vertebral venous plexus 99. A 25-year-old woman presented in the surgical clinic with a three-month history of diarrhoea. On examination she is found to have a smooth 2 cm swelling in the front of her neck her sister has a similar swelling which was operated on 2 years ago The swelling moves on swallowing and the patient is clinically euthyroid Fine needle aspiration cytology of the swelling shows amyloid stroma and serum calcitonin levels are elevated. Which of the following is the most likely diagnosis? A. Anaplastic thyroid carcinoma B Follicular thyroid carcinoma C. Medullary thyroid carcinoma D. Metastatic thyroid carcinoma E Papillary thyroid carcinoma. 100. A 74-year-old man with known prostatic hyperplasia presents to the Emergency Department with acute urinary obstruction. Thirty minutes after urinary catheterization he Collapses with a blood pressure of 74/34 mmhg a heart rate of 128 beats/minute. What is the most likely diagnosis? A. Cardiac failure B. Haemorrhagic shock C. Latex allergy D. Septic shook E. Vasovagal syncope 101. A 70-year-old man has a basal cell carcinoma resected from his left temple. What is the most important prognostic indicator? A Clinical pathological type B. Completeness of excision C. intensity of the lymphocytic infiltrate D Lymphovascular space invasion E. Mitotic index in the tumour islands 102. A 68-year-old man has undergone emergency surgery to repair a leaking aortic abdominal aneurysm. He underwent transfusion with 6 units of packed red cells, Blood tests were performed two hours postoperatively: haemoglobin 10.1 g/dl WBC 12.3 x 109/L , platelets 40 x109 /L, APTT 36 seconds, INR 2.2, fibrinogen 1.5 g/L, fibrin degradation products 25 mg/mi. What will these results be consistent with? A Disseminated intravascular coagulation B Inactivation of Antithrombin III C increased level of vitamin K dependent D Plasminogen inactivation E Protein C deficiency 103. A 46-year-old woman is seen in the pre-admission.clinic. She had a myocardial infarction two years ago. On examination she is in atrial fibrillation and a recent.. echocardiogram show that she had a dilated left ventricle. She is on warfarin and her INR. (International Normalized Ratio) is 6.1 Warfarin inhibits which of the A Antithrombin B. Kallikrein C. Plasminogen D. Prothrombin E. von Willebrand factor 104. A 29 year oId pregnant woman is having uncontrolled labor pains. She has an epidural for pain relief. Which of the following is true? A. An epidural puncture should only be performed below the L1 level to avoid damage to the spinal cord B. An epidural puncture should only be performed below the L4 level to avoid the spinal cord C.The epidural space (also known as the extradural space) contains numerous nerve roots and a venous plexus D. The liganientum flavum is ra