Final Mock test 2 FCPS Exam with Dr Sohrab

You are called as part of the arrest team to see a 57-year-old man who is receiving the first unit of a blood transfusion, having undergone nailing of a fractured femur. He sustained the injury in a road traffic collision. He has become extremely unwell after receiving only around 10 ml of the unit of blood. He is flushed with rigors and shortness of breath, complaining of pain in his abdomen and at the site of the transfusion cannula. His temperature is 38.0 °C, pulse is 110 bpm and regular and his blood pressure is 80/60 mmHg. Which of the following is the most likely diagnosis?

A 55-year-old woman who had rheumatic fever at the age of 13 is admitted to the Emergency Department with palpitations and exertional dyspnoea. Over the past two months, she has suffered a progressive fall in her exercise tolerance, such that she is no longer able to run for the bus. Her blood pressure is 137/82 mmHg, pulse is 75 bpm and regular. There is a pan-systolic murmur which is loudest at the apex. Which of the following is the most likely diagnosis?

A 42-year-old woman who has systemic lupus erythematosus (SLE) and takes hydroxychloroquine has well-controlled joint disease but is beginning to suffer from dry eyes and dry mucus membranes. Which of the following autoantibodies is most likely to be associated with this patient’s new symptoms?

A 45-year-old woman who has recently diagnosed hypertension and type 2 diabetes comes to the clinic for review. She has also had difficulties with swelling of the fingers of both hands and has noticed a change in the shape of her lower jaw on photographs taken over the past two to three years. An insulin-like growth factor (IGF-1) sent by her GP is markedly elevated. Her blood pressure is 155/90 mmHg, pulse is 72 bpm and regular. Her body mass index (BMI) is 24 kg/m2. Which of the following is the most appropriate next investigation?

Computed tomography (CT) abdomen
Glucose tolerance test with growth-hormone (GH) measurement
IGF-binding protein 3 (IGFBP3) measurement
Insulin tolerance test
24-hour urinary free cortisol

An 18-year-old woman comes to the Cardiology Clinic for review. She has been given a diagnosis of Turner syndrome but has not attended medical follow up in the past because of parental wishes. Over the past three to six months she has developed progressively increasing shortness of breath and decreased exercise tolerance. Her blood pressure is 155/95 mmHg, pulse is 72 bpm and regular. She has an ejection systolic murmur. Which of the following is the most likely cause of her heart murmur?

A 45-year-old chef is referred to the Orthopaedic Clinic for review. He has pain in his hands at night and feels that he is dropping things in the kitchen. Examination reveals some wasting of the thenar eminence; sensation is diminished over the fingertips of the second and third digits. Where is the most likely site of injury in this patient?

A 72-year-old man who has ischaemic cardiovascular disease and two previous transient ischaemic attacks (TIAs) comes to the Emergency Department with sudden deterioration of vision affecting his left eye. He says he awoke from sleep unable to do more than count fingers using his left eye and this has now deteriorated so that he can only perceive light and dark. Fundoscopy reveals a pale retina. Which of the following is the most likely diagnosis?

A 19-year-old man comes to the Endocrinology Clinic for review. He has emotional difficulty forming relationships and problems with his sexual function. Examination reveals a blood pressure (BP) of 110/80 mmHg, pulse is 68 bpm and regular. He is 184 cm in height and his body mass index (BMI) is 22 kg/m2. He has bilateral gynaecomastia, sparse axillary and pubic hair and small testes. Which of the following is the most likely cause of his presentation?

A 27-year-old man comes to the Respiratory Clinic for review. He has recently returned from Pakistan where he was staying with his uncle who has just been diagnosed with active tuberculosis (TB). He has no respiratory symptoms and clinical examination is unremarkable. What is the best way to confirm that he has infectious TB?

A 32-year-old woman who is a substance abuser, using nitrous oxide a number of times per week and drinking 50–60 units of alcohol, comes to the Emergency Department complaining of sudden visual loss affecting her right eye. Examination reveals an ataxic gait, bilateral loss of vibration sense and position, upgoing plantars and right optic disc pallor. Which of the following is the most likely cause of this patient’s symptoms?

A 72-year-old woman is admitted to the Emergency Department with suddenonset severe lumbar spine pain and weakness of both lower limbs. The pain began some 24 h earlier and has steadily worsened. She has a 60-pack-year smoking history and reports a chronic, worsening cough over the past six months. There is bilateral lower limb weakness (3/5) with increased tone and hyperreflexia. Decreased anal sensation is noted. Which of the following is the most likely diagnosis?

A 40-year-old woman is treated with vincristine for leukaemia. She has developed neuropathic pain. Which of the following describes the stage of the cell cycle that vincristine acts on?

A 45-year-old man presents to the Gastroenterology Clinic for review. He has suffered from multiple joint pains over the past six months, coupled with gradual weight loss and intermittent diarrhoea and bloating. He also tells you that his stool floats and is difficult to flush away. He also has a chronic cough for which his GP has prescribed a salbutamol inhaler with no significant improvement and has noticed increased skin tanning. Examination reveals increased skin pigmentation and a reduced body mass index (BMI) of 20 kg/m2. Which of the following is the most likely diagnosis?

A 74-year-old man who has type 2 diabetes, hypertension and a previous inferior myocardial infarction comes to the Emergency Department. He has suffered two episodes of loss of vision affecting his left eye in the last two weeks that he describes as like a curtain coming down, the latest episode on the morning of admission. By the time you see him in the department, his vision has recovered and fundoscopy is unremarkable. Blood pressure is raised at 155/94 mmHg. Pulse is 72 bpm and regular. Where is the likely source of the embolus which has caused his symptoms?

A 32-year-old woman who has systemic lupus erythematosus (SLE) comes to the clinic for review. Her disease is well controlled and she came off medication three months ago to try and get pregnant. She is worried about risk of venous thromboembolism in pregnancy. Which of the following antibodies is most associated with risk of venous thromboembolism?

A 38-year-old man presents to the clinic for review. Over the past year, there has been a gradual increase in his alkaline phosphatase and transaminases. He takes regular mesalazine for control of his ulcerative colitis (UC) but is otherwise well. You suspect he may be developing primary sclerosing cholangitis (PSC). Which of the following is the optimal investigation to diagnose PSC?

Autoimmune profile
Endoscopic retrograde cholangio-pancreatography (ERCP)
Liver biopsy
Magnetic resonance cholangio-pancreatography (MRCP)
Ultrasound liver

A 43-year-old woman is reviewed some 14 days post-renal transplant from a cytomegalovirus (CMV)-positive donor. She has been treated with CMV prophylaxis and a tacrolimusand prednisolone-based immunosuppressive regimen. Examination reveals a blood pressure of 142/88 mmHg, and pulse is 70 bpm and regular. There is erythema over her scar and minor tenderness over the transplanted kidney. Estimated glomerular filtration rate (eGFR) has fallen by 30 ml/min since immediately post-transplant. C-reactive protein test (CRP) is 29 mg/l. Which of the following is the most likely diagnosis?

A 32-year-old man of Chinese origin comes to the Emergency Department for review. He has recently been started on carbamazepine for complex partial epilepsy and is suffering from a severe skin rash. Examination reveals extensive annular lesions, a number of which have blistered. There is extensive cracking and blistering of the lips and a number of ulcers in the mouth. He has a temperature of 38.2 °C, his pulse is 92 bpm and regular and his blood pressure is 95/70 mmHg. Which of the following is the most likely diagnosis?

A 26-year-old woman presents to the Rheumatology Clinic with a new diagnosis of rheumatoid arthritis (RA). Her sister, mother and aunt also suffer from RA. Which of the following human leukocyte antigen (HLA) types is most likely to be found in this patient?

A 45-year-old woman presents to the Emergency Department with sudden deterioration in the vision in her right eye from waking that morning. She has type 1 diabetes mellitus and suffered a deep vein thrombosis some 10 years ago. She takes no regular medication apart from insulin and ramipril. She is anxious, with a pulse of 90 bpm and regular, and a blood pressure of 155/90 mmHg. Fundoscopy of the right eye reveals multiple flame haemorrhages over the whole fundus; she is able to perceive light and dark only with the right eye, and vision in the left eye is 6/12. Which of the following is the most likely diagnosis?

A 23-year-old woman presents to the Dermatology Clinic with an intensely itchy rash characterised by small blisters and vesicles particularly affecting her elbows, her hairline and her buttocks. The severity waxes and wanes from week to week. She has iron deficiency anaemia treated by her GP with iron tablets but is otherwise well. You confirm the presence of clusters of small vesicles and blisters, particularly over the extensor surfaces of the limbs, scalp and buttocks. Which of the following is the most likely diagnosis?

A 43-year-old woman presents to the clinic with Raynaud’s phenomenon and has skin thickening with areas of calcinosis affecting her hands and feet, with areas of digital ulceration affecting her toes. You also notice some telangiectasias around her lips, although microstomia appears not to be present. Blood workup is unremarkable with normal renal function. Pulmonary function tests are in the normal range for her age. Which of the following auto-antibodies is most likely to be present?

A 52-year-old woman presents to the Oncology Clinic to discuss her prognosis following lumpectomy, chemotherapy and radiotherapy for left breast cancer. She’s interested in whether blood tests can be used to monitor for recurrence of her tumour. Which of the following markers would be a useful blood test for monitoring breast cancer recurrence?

An 18-year-old woman comes to the Endocrine Clinic for review. She is concerned, as she has yet to begin her periods. Her only past medical history of note is bilateral inguinal hernia repair while still a neonate. Her blood pressure is normal at 105/80 mmHg, her pulse is 65 bpm and regular, her height is 1.78 m, with a body mass index of 22 kg/m2. She has normal breasts and external genitalia, although you note an absence of pubic hair. Which of the following is the most likely diagnosis?

Androgen insensitivity syndrome (AIS)
Classical congenital adrenal hyperplasia (CCAH)
Klinefelter syndrome
Non-classical adrenal hyperplasia (NCAH)
Turner syndrome

A 27-year-old man is admitted to the Emergency Department having tried to slit his throat with a knife. He is successfully resuscitated and you review him later. He has had numerous previous admissions with both alcohol and drug intoxication. When you ask him why he did it, he tells you that he could hear people talking about him, providing a commentary that he was planning to slit his throat and that the television is inserting thoughts into his brain. Which of the following is the most likely diagnosis?

An 18-year-old man is admitted to the Emergency Department having suffered a seizure. He has had a number of previous seizures over the past few years but has always selfdischarged from hospital before being investigated futher. He tells you that he suffered a dislocated shoulder after one previous seizure. You note a number of small reddish spots around his nose and cheeks, a number of skin tags, and some smooth fleshy growths adjacent to his fingernails. He has patches of skin depigmentation over his trunk. Fundoscopy reveals a number of translucent rounded lesions in the periphery of the retina. Which of the following is the most likely diagnosis?

A 65-year-old man who has suffered from chronic back pain over the last six months comes to the Emergency Department with weakness of his left leg. He smokes 20 cigarettes per day and has been diagnosed with chronic obstructive pulmonary disease (COPD) some ten years earlier. He admits to a worsening cough with occasional haemoptysis over recent months. Examination confirms weakness of the left leg, there is loss of vibration and position sense over the lower left portion of the abdomen and leg and loss of pain and temperature sensation on the right-hand side. Which of the following is the most likely cause of his neurological symptoms?

A 64-year-old man who has type II diabetes has been helping his daughter move house, lifting a number of heavy boxes. Over the past two days, he has suffered progressively increasing pain over his left shoulder and global limitation of movement. He is unable to sleep on the lefthand side and still has pain despite maximal doses of paracetamol and ibuprofen. Examination reveals global restriction of all movements, passive and active, of the left shoulder. Which of the following is the most likely diagnosis?

A 19-year-old man comes to the Emergency Department with symptoms of a severe sore throat, neck stiffness, headache, and pyrexia. He says these symptoms have significantly worsened over the past 36 h. He did not receive routine vaccinations as a child as his parents were against vaccination. He is pyrexial at 38.9°C, there is evidence of pharyngitis, bilateral parotitis and meningism. A lumbar puncture reveals a lymphocytosis, and routine blood tests reveal evidence of hepatitis. Which of the following is the most likely diagnosis?

A 19-year-old man presents to the Neurology Clinic for review. He has suffered from progressive weakness including foot drop which has been causing him to fall frequently, and he is unable to continue his job at a warehouse selling car parts. On examination, there is obvious weakness of the levator palpebrae superficialis and temporalis muscles. His sternocleidomastoids are also weak, as are the distal muscles of the forearm, intrinsic muscles of the hands, and ankle dorsiflexors (leading to bilateral foot drop). You note he has a high-arched palate. Which of the following is the most likely diagnosis?

Dystrophia myotonica type 1 (DM1)
Dystrophia myotonica type 2 (DM2)
Hereditary spastic paraplegia (HSP)
Hereditary sensory and autonomic neuropathy type 1 (HSAN1)
Hereditary sensory and autonomic neuropathy type 2 (HSAN2)

A 43-year-old woman presents to the clinic for review with rapidly worsening rheumatoid arthritis. She is interested in finding more out about the disease, as she, her mother and sister also suffer from severe arthritis. Which of the following human leukocyte antigen (HLA) types is most associated with her disease?

A 61-year-old man with a 50-pack-year smoking history comes to the Emergency Department following a fall. He has developed progressive unsteadiness over the past 3–4 weeks and is now unable to mobilise even around his flat. He admits to a cough with haemoptysis that has been present for 4–5 months. On examination, his blood pressure is 132/82 mmHg, auscultation of the chest reveals bilateral poor air entry consistent with chronic obstructive pulmonary disease and marked wheeze. Neurological assessment reveals obvious cerebellar dysfunction. He is unable to mobilise. Chest X-ray reveals a right hilar mass. Which of the following is the most likely diagnosis?

A 39-year-old woman with a diagnosis of systemic sclerosis comes to the clinic for review. She has been previously diagnosed with gastro-oesophageal reflux disease which is thought to relate to her underlying disease, and she takes long-term omeprazole therapy. Over the last few months, she has started to lose weight, and suffers from eructation, abdominal bloating and intermittent diarrhoea. She is slim with a mildly distended abdomen, and her body mass index is 20.5 kg/m2. Which of the following is the most appropriate next investigation?

A 29-year-old soldier who spends many hours doing guard duty comes to the clinic for review. He complains of pains in his legs and difficulties falling forward on standing for long periods of time. Which of the following muscles stops him falling forwards?

A 29-year-old woman who is working in an electronics factory comes to the Respiratory Clinic for review. She is a non-smoker; her main complaint is of gradually worsening shortness of breath and wheeze during the course of the working week, which improves during time off and at the weekends. Her GP has trialled a salbutamol inhaler and low-dose inhaled beclomethasone without any significant improvement. Which of the following is the most appropriate next step?

A 45-year-old man with a history of chronic pancreatitis related to alcohol consumption comes to the clinic complaining of diarrhoea. He has lost 5 kg in weight over the last 3 months and has chronic abdominal pain. His body mass index is 19.5 kg/m2. You suspect malabsorption related to pancreatic exocrine insufficiency. Which of the following is the most appropriate next investigation?

A 42-year-old woman with a previous history of rheumatoid arthritis presents to the clinic for review. Over the past 1–2 years she has begun to develop features consistent with Raynaud’s phenomenon and oesophageal reflux. There has also been a problem with digital ulceration and calcium deposits in the fingers. Examination reveals features of active rheumatoid and systemic sclerosis. You suspect she is developing mixed connective tissue disease. Which of the following antibodies is most likely to be found?

A 67-year-old man with a history of type 2 diabetes comes to Emergency Department complaining of double vision since waking that morning. Examination reveals a conjugate gaze palsy with diplopia on looking to the left. Where is the site of the underlying neurological lesion?

A 63-year-old man who has been diagnosed with post-viral cardiomyopathy comes to the clinic for review. He is still short of breath despite therapy with ramipril 10 mg daily, bisoprolol 10 mg daily, spironolactone 25 mg daily, and furosemide 40 mg daily. He can walk only 50–60 yards and cannot help his wife with even minimal chores around the house. On examination, his blood pressure is 132/82 mmHg, pulse is 68 bpm and regular. There are bibasal crackles on auscultation of the chest; there is no ankle swelling. His ejection fraction is measured at 24%, and his creatinine is 102 µmol/l. Which of the following is the most appropriate next step?

A 36-year-old man with familial hypercholesterolaemia treated with atorvastatin 80 mg daily and ezetimibe 10 mg comes to the clinic for review. He has received two stents some 3 months earlier, having suffered an episode of unstable angina. On examination, his blood pressure is 132/84 mmHg, pulse is 67 bpm and regular. Chest is clear, heart sounds are normal and there is no ankle swelling. A fasting cholesterol is measured at 7.2 mmol/l. Which of the following is the most appropriate next step?

You are reviewing a patient with a history of cranial diabetes insipidus. He is passing 4–6 litres of urine per day. Expression of which channel is likely to be decreased most in the collecting duct?

A 19-year-old woman is referred to the Renal Clinic with difficult-to-control hypertension and an elevated serum creatinine. Her current medication for blood pressure control is ramipril 10 mg and indapamide 2.5 mg once a day. Her only past medical history of note is a number of urinary tract infections as a child. On examination, her blood pressure is 152/89 mmHg, pulse is 70 bpm and regular. Her body mass index is 21 kg/m2, abdomen is soft and non-tender. You note her creatinine is elevated at 189 mmol/l. An ultrasound scan (USS) of the kidneys reveals a normal-sized right kidney, although the left kidney shows marked parenchymal thinning. Urine dipstick reveals 1+ of protein. Which of the following is the most likely cause of her hypertension?

A 62-year-old man is admitted to the Acute Medical Ward with suspected endocarditis. He has felt unwell for the past few weeks with night sweats, lethargy and gradual weight loss. He has no significant medical illnesses. He has developed a pansystolic murmur, loudest at the apex, and an echocardiogram has revealed vegetations on the valve. Blood cultures have confirmed the presence of Streptococcus gallolyticus (Streptococcus bovis) infection. Which of the following is the most important investigation?

You are reviewing the distribution of bodyweight in a group of men vs a group of women who have non-alcoholic steatohepatitis (NASH). Which of the following is the most appropriate statistical test to look for differences in the weight distribution between the two groups?

You are asked to take part in a clinical trial of an agent that moves the oxygen dissociation curve to the right, making increased oxygen available for tissues in times of sepsis. Which of the following conditions is known to do this?

A 23-year-old woman is referred to the Cardiology Clinic in the twelfth week of pregnancy. She has been noted to have a systolic murmur, and the general practitioner (GP) is requesting advice on diagnosis and further management. She has no past medical history of note and regularly plays squash. Examination in the clinic reveals a loud pan-systolic murmur, best heard in the third left intercostal space where there is also a palpable thrill. There are no signs of cyanosis or associated cardiac failure. Her blood pressure is 115/82 mmHg, and her pulse is 65 bpm and regular. Oxygen saturation is 93% on air. What is the best advice with respect to her pregnancy?

She has a high risk of complications and should be offered a termination
She can be reassured that no intervention is likely to be required
She should be started on an angiotensin-converting enzyme (ACE) inhibitor
She should be started on methyldopa
She will require percutaneous valvotomy

A 72-year-old woman comes to the Urology Clinic for review. She tells you that she suffers from incontinence two to three times per day where she has an uncontrollable urge to pass urine. She often does not make it to the toilet in time. She has osteoarthritis of both hips and is awaiting bilateral elective hip replacements. Her body mass index is 23 kg/m2. Which of the following is the most likely cause of her symptoms?

A 76-year-old man has been admitted to the Elderly Care Ward with acute confusion. He has been diagnosed with a urinary tract infection, for which he is being treated with intravenous (IV) coamoxiclav. You are asked to see him because he has become agitated and aggressive. He has hypertension and ischaemic heart disease and takes a range of medications. He drinks alcohol only on special occasions. When you examine him at the request of nursing staff, he is agitated and aggressive, trying to get out of bed, and he attempts to bite you. Which of the following is the most appropriate intervention?

A 52-year-old woman has recovered from a bowel resection for Duke’s C colon cancer. She works as a local biomedical researcher and asks if any biochemical markers are useful in monitoring for recurrence of disease. Monitoring of which of the following has a role in colon cancer surveillance?

A 53-year-old man with type 2 diabetes comes to the Endocrine Clinic for review. His type 2 diabetes was diagnosed some five years ago, and current therapy is metformin 1 g twice daily (bd). He has recently suffered an inferior myocardial infarction and has been left with residual shortness of breath. His blood pressure is 139/85 mmHg, and pulse 78 bpm and regular. There is pitting oedema of both ankles. His HbA1c is measured at 66 mmol/mol. A decision is made to commence dapagliflozin therapy. Which of the following is the mode of action of dapagliflozin?

Alpha-glucosidase inhibition
Dipeptidyl peptidase-IV (DPPIV) inhibition
Glucagon-like peptide-1 (GLP-1) agonism
Glucokinase activation
Sodium–glucose co-transporter-2 (SGLT-2) inhibition

A 72-year-old man is reviewed on the Acute Medical Ward the morning after admission for a suspected ischaemic stroke. He appears to be neglecting his left-hand side, and when you ask him to copy an object on a piece of paper, he only copies the right-hand side of the object. Where is the most likely site of his infarct?

Final Mock test 2 FCPS Exam with Dr Sohrab

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