PLAB 1 (Professional and Linguistic Assessments Board Part 1) — Questions and Answers

Question 1: A 25-year-old woman has TFTs showing: TSH <0.01 mIU/L, free T4 35 pmol/L, free T3 12 pmol/L. What do these results indicate?

Primary hypothyroidism
Secondary hypothyroidism
Sick euthyroid syndrome
Hyperthyroidism (primary) (Correct answer)

Correct answer: Hyperthyroidism (primary)

A suppressed TSH (<0.1) with elevated free T4 and T3 indicates primary hyperthyroidism. The high thyroid hormones are suppressing TSH via negative feedback on the pituitary. In secondary hypothyroidism (pituitary failure), TSH is low but T4 is also low.

Question 2: A newborn infant is found to have bilateral undescended testes and ambiguous genitalia. What is the most important initial investigation?

Chromosomal analysis only
Reassure parents and arrange outpatient follow-up
Urgent serum 17-hydroxyprogesterone level to exclude congenital adrenal hyperplasia (CAH) (Correct answer)
Testicular ultrasound

Correct answer: Urgent serum 17-hydroxyprogesterone level to exclude congenital adrenal hyperplasia (CAH)

Bilateral undescended testes with ambiguous genitalia requires urgent investigation for congenital adrenal hyperplasia (CAH), which can cause a life-threatening salt-wasting crisis. Serum 17-hydroxyprogesterone is the key initial test. Electrolytes should also be checked urgently as hyponatraemia and hyperkalaemia can be fatal.

Question 3: What does a 'confidence interval' (CI) tell you in clinical research?

The range within which a test value is considered normal
The statistical significance of a result
The range of values that guarantee clinical significance
The range within which the true population value is likely to lie with a specified probability (e.g., 95% CI) — a wide CI indicates less precision (Correct answer)

Correct answer: The range within which the true population value is likely to lie with a specified probability (e.g., 95% CI) — a wide CI indicates less precision

A 95% CI means that if the study were repeated 100 times, 95 of the resulting CIs would contain the true population value. A wide CI reflects high uncertainty (often from small sample size); a narrow CI indicates precision. If a CI for a risk ratio includes 1.0, the result is not statistically significant at the 5% level.

Question 4: A 6-year-old boy presents with a 2-day history of high fever, sore throat, and dysphagia. On examination he has a hot-potato voice, drooling, and deviation of the uvula to the right with a bulge on the left side of the soft palate. What is the most likely diagnosis?

Tonsillitis
Retropharyngeal abscess
Epiglottitis
Peritonsillar abscess (quinsy) (Correct answer)

Correct answer: Peritonsillar abscess (quinsy)

Peritonsillar abscess (quinsy) presents with trismus (difficulty opening mouth), hot-potato voice, drooling, uvular deviation away from the abscess, and a peritonsillar bulge. It is the most common deep neck space infection and requires urgent ENT review for incision and drainage plus IV antibiotics.

Question 5: A blood film shows hypersegmented neutrophils (>5 lobes) and macro-ovalocytes. Hb 75 g/L, MCV 115 fL. What is the most likely diagnosis?

Aplastic anaemia
Megaloblastic anaemia (B12 or folate deficiency) (Correct answer)
Iron deficiency anaemia
Haemolytic anaemia

Correct answer: Megaloblastic anaemia (B12 or folate deficiency)

Megaloblastic anaemia is characterised by: macrocytosis (high MCV), macro-ovalocytes, and hypersegmented neutrophils (≥5 lobes in >5% of neutrophils, or any with ≥6 lobes). It is caused by B12 or folate deficiency, both essential for DNA synthesis. The blood film picture is pathognomonic.

Question 6: A 58-year-old woman presents with proximal limb weakness, difficulty rising from a chair, and a heliotrope (violaceous) rash around her eyelids. Serum CK is markedly elevated. What is the most likely diagnosis?

Myasthenia gravis
Polymyalgia rheumatica
Fibromyalgia
Dermatomyositis (Correct answer)

Correct answer: Dermatomyositis

Dermatomyositis presents with proximal inflammatory myopathy, markedly elevated CK, and pathognomonic skin findings including the heliotrope rash and Gottron's papules.

Question 7: A 30-year-old woman with newly diagnosed mild-to-moderate ulcerative colitis (proctosigmoiditis) should be offered which first-line treatment according to NICE guidelines?

Oral prednisolone
Azathioprine
Topical aminosalicylate (mesalazine suppository or enema) ± oral aminosalicylate (Correct answer)
Infliximab

Correct answer: Topical aminosalicylate (mesalazine suppository or enema) ± oral aminosalicylate

NICE (NG130) recommends first-line treatment for mild-to-moderate UC as topical mesalazine (suppository for proctitis, enema for proctosigmoiditis) with or without oral mesalazine. Oral steroids are used for moderate-to-severe disease or insufficient response. Immunosuppressants are for maintenance of remission or steroid-dependent disease.

Question 8: During labour, a CTG shows late decelerations with reduced variability. What does this pattern most likely indicate?

Normal fetal response to contractions
Umbilical cord compression
Fetal head compression
Uteroplacental insufficiency causing fetal hypoxia (Correct answer)

Correct answer: Uteroplacental insufficiency causing fetal hypoxia

Late decelerations (decelerations that start after the peak of a contraction and return to baseline after the contraction ends) with reduced variability indicate uteroplacental insufficiency and fetal hypoxia. This is a pathological CTG pattern requiring urgent intervention.

Question 9: A 14-year-old discloses during a consultation that she is being physically abused by a parent. She asks you to keep it confidential. What should you do?

Maintain confidentiality as promised
Tell the parents immediately
Explain that you cannot guarantee confidentiality in child protection matters, and refer to the child safeguarding team — child protection takes priority over patient confidentiality (Correct answer)
Document it but take no further action

Correct answer: Explain that you cannot guarantee confidentiality in child protection matters, and refer to the child safeguarding team — child protection takes priority over patient confidentiality

Child safeguarding must take priority over patient confidentiality. NICE, GMC, and Working Together to Safeguard Children guidance require healthcare professionals to refer safeguarding concerns. Confidentiality can be breached when there is serious risk of harm to a child. You should explain to the child what you must do and why.

Question 10: A chest X-ray shows a tracheal deviation to the right, loss of left lung volume, and a raised left hemidiaphragm. What is the most likely diagnosis?

Right pneumothorax
Left sided pleural effusion
Left sided lung collapse (atelectasis) (Correct answer)
Left pneumothorax

Correct answer: Left sided lung collapse (atelectasis)

Collapse (atelectasis) causes loss of volume on the affected side: trachea and mediastinum deviate towards the collapse, the hemidiaphragm rises, and lung volume is reduced. In tension pneumothorax or large effusion, the mediastinum deviates away from the affected side.

Question 11: A patient in A&E develops a tension pneumothorax. They are in extremis with tracheal deviation, absent breath sounds on the affected side, and hypotension. What is the immediate management?

Request an urgent chest X-ray before any intervention
Insert a chest drain in the 5th intercostal space as the first intervention
Immediate needle decompression in the 2nd intercostal space, midclavicular line, followed by chest drain insertion (Correct answer)
Administer IV fluids and wait for a senior review

Correct answer: Immediate needle decompression in the 2nd intercostal space, midclavicular line, followed by chest drain insertion

Tension pneumothorax is a clinical diagnosis — do not delay treatment for imaging. Immediate needle decompression (14-16G cannula, 2nd intercostal space, midclavicular line) converts it to a simple pneumothorax. A formal chest drain (5th intercostal space, mid-axillary line) is then inserted.

Question 12: According to NICE guidance on sepsis (NG51), what is the 'Sepsis Six' hour-1 bundle for a patient with suspected sepsis?

High-flow oxygen, blood cultures, IV broad-spectrum antibiotics, IV fluid bolus, lactate measurement, and urine output monitoring (Correct answer)
Oral antibiotics, blood cultures, catheter, and urine dipstick
IV antibiotics, chest X-ray, ECG, full blood count, CRP, and ITU referral
Blood cultures, IV antibiotics, IV fluids, urine output monitoring, blood glucose, and reassessment

Correct answer: High-flow oxygen, blood cultures, IV broad-spectrum antibiotics, IV fluid bolus, lactate measurement, and urine output monitoring

The Sepsis Six (to be completed within 1 hour): (1) High-flow O2; (2) Blood cultures; (3) IV broad-spectrum antibiotics; (4) IV fluid bolus (500ml crystalloid if hypotensive); (5) Serum lactate; (6) Urine output monitoring (catheterise if needed). Early completion reduces sepsis mortality significantly.

Question 13: A 22-year-old woman presents with heavy, regular periods (menorrhagia) but no structural abnormality on ultrasound. She does not wish to conceive. According to NICE, what is the first-line treatment?

Levonorgestrel intrauterine system (Mirena IUS) (Correct answer)
Combined oral contraceptive pill
Tranexamic acid
Endometrial ablation

Correct answer: Levonorgestrel intrauterine system (Mirena IUS)

NICE guidelines (NG88) recommend the levonorgestrel intrauterine system (LNG-IUS/Mirena) as first-line treatment for heavy menstrual bleeding. It reduces blood loss by up to 96% and provides contraception. If declined, alternatives include tranexamic acid, NSAIDs, or combined hormonal contraception.

Question 14: A 50-year-old woman presents with a painless, progressively enlarging lump in her right breast. On examination, there is skin tethering and peau d'orange. What is the most appropriate next step?

Urgent 2-week wait referral for triple assessment (clinical examination, imaging, and tissue sampling) (Correct answer)
Prescribe antibiotics for mastitis
Reassure and review in 3 months
Arrange a routine ultrasound in 6 weeks

Correct answer: Urgent 2-week wait referral for triple assessment (clinical examination, imaging, and tissue sampling)

A painless breast lump with skin tethering and peau d'orange is highly suspicious for breast cancer. NICE guidelines mandate urgent 2-week wait referral for triple assessment: clinical examination, imaging (mammography/ultrasound), and tissue sampling (core biopsy).

Question 15: A 65-year-old woman with a history of RA and chronic kidney disease develops a severe skin rash after starting allopurinol. What interaction must be warned about when prescribing allopurinol alongside azathioprine?

The combination causes severe hyperkalaemia
Allopurinol reduces azathioprine efficacy
Azathioprine reduces allopurinol absorption
Allopurinol inhibits azathioprine metabolism, causing potentially fatal toxicity (Correct answer)

Correct answer: Allopurinol inhibits azathioprine metabolism, causing potentially fatal toxicity

Allopurinol inhibits xanthine oxidase, which also metabolises azathioprine; co-administration causes azathioprine accumulation leading to severe bone marrow suppression and potentially fatal toxicity.

Question 16: A patient on metformin 1g BD develops an eGFR of 28 mL/min. According to BNF guidelines, what should be done with the metformin?

Stop metformin — it is contraindicated when eGFR falls below 30 mL/min due to the risk of lactic acidosis (Correct answer)
Switch to insulin only if HbA1c rises above 80 mmol/mol
Continue at the same dose — renal function does not affect metformin dosing
Double the dose to compensate for reduced efficacy

Correct answer: Stop metformin — it is contraindicated when eGFR falls below 30 mL/min due to the risk of lactic acidosis

Metformin should be stopped when eGFR falls below 30 mL/min/1.73m2 due to the risk of lactic acidosis from impaired renal clearance. The dose should be reviewed when eGFR falls below 45, and reduced when below 30. An alternative glucose-lowering agent should be substituted.

Question 17: A patient is prescribed trimethoprim for a UTI. They are also on methotrexate for rheumatoid arthritis. What is the key interaction?

Both are folate antagonists — co-administration markedly increases the risk of methotrexate toxicity (pancytopenia) (Correct answer)
The combination increases the risk of tendon rupture
Trimethoprim reduces efficacy of methotrexate
Trimethoprim increases methotrexate excretion

Correct answer: Both are folate antagonists — co-administration markedly increases the risk of methotrexate toxicity (pancytopenia)

Both trimethoprim and methotrexate are folate antagonists. Concurrent use markedly increases the risk of methotrexate toxicity — particularly haematological toxicity (bone marrow suppression, pancytopenia). This combination should be avoided; an alternative antibiotic should be prescribed.

Question 18: According to NICE guidelines, what is the first-line pharmacological treatment for generalised anxiety disorder (GAD) if psychological interventions have been tried?

Diazepam
Lithium
Olanzapine
Sertraline (SSRI) (Correct answer)

Correct answer: Sertraline (SSRI)

NICE recommends SSRIs (sertraline is first choice) as first-line pharmacological treatment for GAD. Benzodiazepines should not be offered beyond short-term crisis use (maximum 2-4 weeks) due to dependence risk. If the SSRI is not tolerated, an SNRI (duloxetine or venlafaxine) or pregabalin may be considered.

Question 19: A 35-year-old man is brought to A&E by police under Section 136 of the Mental Health Act 1983. He is hearing voices telling him to harm himself. Which section of the Mental Health Act allows for assessment and admission for up to 28 days?

Section 3
Section 5(2)
Section 4
Section 2 (Correct answer)

Correct answer: Section 2

Section 2 of the Mental Health Act 1983 (amended 2007) allows compulsory admission for assessment (and treatment necessary for assessment) for up to 28 days. It requires two medical recommendations and an approved mental health professional (AMHP) application.

Question 20: According to NICE guidance (NG12), which patients should be referred on a 2-week wait (suspected cancer) pathway for colorectal cancer?

Patients with abdominal pain and bloating only
Any patient with rectal bleeding, regardless of age
Patients with haemorrhoids and rectal bleeding
Patients aged 40 or over with unexplained rectal bleeding; OR aged 60 or over with change in bowel habit; OR aged 40 or over with iron deficiency anaemia without an obvious cause (Correct answer)

Correct answer: Patients aged 40 or over with unexplained rectal bleeding; OR aged 60 or over with change in bowel habit; OR aged 40 or over with iron deficiency anaemia without an obvious cause

NICE NG12 criteria for 2WW colorectal referral include: ≥40 with unexplained rectal bleeding; ≥50 with unexplained abdominal pain or weight loss; ≥60 with change in bowel habit; ≥60 with iron deficiency anaemia; any age with rectal mass/unexplained iron deficiency anaemia. Haemorrhoids are not an automatic exclusion for referral if other criteria are met.

Question 21: A patient with rheumatoid arthritis on long-term methotrexate develops painful mouth ulcers and a macrocytic anaemia. Which supplement should be co-prescribed with methotrexate to prevent these side effects?

Folic acid (Correct answer)
Vitamin B12
Ferrous sulphate
Pyridoxine

Correct answer: Folic acid

Folic acid is routinely co-prescribed with methotrexate to reduce folate-deficiency side effects such as mucositis and macrocytic anaemia caused by methotrexate's folate antagonism.

Question 22: According to the BNF and NICE, what is the recommended first-line treatment for uncomplicated lower urinary tract infection (UTI) in a non-pregnant woman?

Co-amoxiclav for 7 days
Amoxicillin for 5 days
Ciprofloxacin for 5 days
Nitrofurantoin for 3 days (if eGFR >45) or trimethoprim for 3 days (Correct answer)

Correct answer: Nitrofurantoin for 3 days (if eGFR >45) or trimethoprim for 3 days

PHE/NICE guidelines recommend nitrofurantoin (3 days, if eGFR >45) or trimethoprim (3 days, if low local resistance) as first-line for uncomplicated lower UTI in women. Ciprofloxacin should be reserved for complicated UTIs or resistant organisms to preserve its effectiveness.

Question 23: A patient on clozapine presents with a sore throat and fever. His blood results show a white cell count of 1.2 x10^9/L and neutrophils of 0.3 x10^9/L. What is the most important immediate action?

Continue clozapine and prescribe antibiotics
Stop clozapine immediately, admit the patient, and arrange urgent haematology review (Correct answer)
Reassure the patient and repeat bloods in 1 week
Reduce the clozapine dose by half

Correct answer: Stop clozapine immediately, admit the patient, and arrange urgent haematology review

Clozapine can cause agranulocytosis (neutrophils <0.5 x10^9/L), a potentially fatal side effect. Clozapine must be stopped immediately and never restarted. The patient needs urgent admission, barrier nursing, blood cultures, and broad-spectrum antibiotics. Regular blood monitoring is mandatory for all patients on clozapine.

Question 24: A 35-year-old woman presents with post-menopausal bleeding. She is on no hormone replacement therapy. What is the most appropriate initial investigation?

Serum CA-125
Transvaginal ultrasound to assess endometrial thickness (Correct answer)
Cervical smear
CT abdomen and pelvis

Correct answer: Transvaginal ultrasound to assess endometrial thickness

Post-menopausal bleeding requires investigation to exclude endometrial cancer. NICE recommends transvaginal ultrasound as the first-line investigation. If endometrial thickness is ≥4 mm, hysteroscopy with endometrial biopsy is indicated. All women with PMB should be referred via 2-week wait.

Question 25: What is 'sensitivity' of a diagnostic test?

The proportion of people with the disease who test positive (true positive rate) — a sensitive test rarely misses disease (Correct answer)
The proportion of people without disease who test negative (true negative rate)
The probability that a positive test correctly identifies disease
The proportion of all positive tests that are true positives

Correct answer: The proportion of people with the disease who test positive (true positive rate) — a sensitive test rarely misses disease

Sensitivity = True Positives / (True Positives + False Negatives). A highly sensitive test has a low false-negative rate — it rarely misses cases of the disease. Mnemonic: SnNout — a Sensitive test, when Negative, rules OUT disease. Useful for screening tests.

Question 26: A foundation year doctor prescribes a medication and realises they have made an error that has not yet reached the patient. What should they do?

Ask a colleague to take over care to distance themselves from the error
Cancel the prescription quietly and say nothing
Report the error through the hospital incident reporting system, inform the supervising consultant, document the near-miss, and take steps to prevent recurrence (Correct answer)
Await the patient's discharge before reporting

Correct answer: Report the error through the hospital incident reporting system, inform the supervising consultant, document the near-miss, and take steps to prevent recurrence

Near misses and errors should be reported through the hospital incident reporting system (e.g., Datix). The supervising consultant must be informed. Near-miss reporting is a key patient safety mechanism that allows system improvements. GMC guidance requires openness and honesty about errors.

Question 27: A 16-year-old presents alone requesting contraception. She appears to understand the information given and the consequences of her decision. Under the Fraser guidelines, can you prescribe contraception without parental consent?

Yes — if she meets Fraser guidelines: understands advice, cannot be persuaded to involve parents, will likely have unprotected sex otherwise, her physical/mental health requires contraception, and it is in her best interests (Correct answer)
No — anyone under 18 requires parental consent
Only if she is 'Gillick competent' but only for emergency contraception
Only with a court order

Correct answer: Yes — if she meets Fraser guidelines: understands advice, cannot be persuaded to involve parents, will likely have unprotected sex otherwise, her physical/mental health requires contraception, and it is in her best interests

Fraser guidelines (from Gillick v West Norfolk, 1985) allow prescription of contraception to under-16s without parental consent if: they understand the advice; parental involvement cannot be achieved; they will likely proceed without contraception; their health requires contraception; it is in their best interests. Parental consent is not automatically required for 16–17-year-olds either.

Question 28: A woman has a primary postpartum haemorrhage (PPH) with estimated blood loss of 1,200 mL. According to UK guidelines, what are the four 'T' causes of PPH?

Transfusion, Tocolysis, Traction, Tamponade
Tachycardia, Tension, Torsion, Toxins
Temperature, Thrombosis, Trauma, Tissue
Tone, Trauma, Tissue, Thrombin (Correct answer)

Correct answer: Tone, Trauma, Tissue, Thrombin

The four T's of PPH are: Tone (uterine atony — the commonest cause, ~70%), Trauma (genital tract lacerations), Tissue (retained placenta or membranes), and Thrombin (coagulation disorders). Systematic assessment of all four causes guides management.

Question 29: A 30-year-old woman is newly diagnosed with SLE. Which medication is recommended as background therapy for virtually ALL SLE patients unless contraindicated, as it reduces flares and organ damage?

Hydroxychloroquine (Correct answer)
Azathioprine
Prednisolone
Mycophenolate mofetil

Correct answer: Hydroxychloroquine

Hydroxychloroquine is recommended for all SLE patients as it reduces disease flares, prevents organ damage, lowers cardiovascular risk, and is safe in pregnancy.

Question 30: A competent 35-year-old patient with a life-threatening condition refuses a blood transfusion on religious grounds. What should you do?

Respect the patient's decision, document it, and explore alternatives — a competent adult has the right to refuse any treatment (Correct answer)
Apply to the Court of Protection to override the decision
Delay treatment until a second opinion is obtained
Administer the blood transfusion as it is life-saving

Correct answer: Respect the patient's decision, document it, and explore alternatives — a competent adult has the right to refuse any treatment

A competent adult has an absolute right to refuse medical treatment, even if that refusal may result in death. This is enshrined in UK law (Mental Capacity Act 2005, common law). The patient must be given full information, their decision must be documented, and alternative treatments explored. Overriding consent is battery.

Question 31: What does 'best interests' decision-making require under the MCA 2005 when a patient lacks capacity?

Applying for a court order before any decision
Following the patient's family's wishes
Making the medically optimal decision regardless of personal values
Considering all relevant factors including the patient's past wishes, values, and beliefs; consulting those close to them; and choosing the least restrictive option that meets their needs (Correct answer)

Correct answer: Considering all relevant factors including the patient's past wishes, values, and beliefs; consulting those close to them; and choosing the least restrictive option that meets their needs

Best interests under the MCA 2005 requires a structured approach: consider all relevant factors, consult family/carers/advocates (IMCA if needed), consider the patient's past and present wishes/values, do not make assumptions based on age/appearance, and identify the least restrictive option. It is broader than just medical best interests.

Question 32: What is 'specificity' of a diagnostic test?

The proportion of diseased patients who test positive
The accuracy of the test across all populations
The proportion of all negative tests that are true negatives
The proportion of disease-free individuals who test negative (true negative rate) — a specific test rarely gives false positives (Correct answer)

Correct answer: The proportion of disease-free individuals who test negative (true negative rate) — a specific test rarely gives false positives

Specificity = True Negatives / (True Negatives + False Positives). A highly specific test rarely gives a positive result in people without disease. Mnemonic: SpPin — a Specific test, when Positive, rules IN disease. Useful for confirmatory tests.

Question 33: A 7-year-old child presents with periorbital oedema, generalised oedema, and frothy urine. Urine dipstick shows 4+ protein. Blood tests show low serum albumin (15 g/L) and high cholesterol. What is the most likely diagnosis?

Nephrotic syndrome (Correct answer)
Acute glomerulonephritis
Urinary tract infection
Haemolytic uraemic syndrome

Correct answer: Nephrotic syndrome

The triad of nephrotic syndrome is heavy proteinuria (>3.5 g/day), hypoalbuminaemia, and oedema. Hypercholesterolaemia is also characteristic. In children, the most common cause is minimal change disease. First-line treatment is oral corticosteroids (prednisolone), with >90% responding.

Question 34: A 60-year-old man has serum calcium 2.9 mmol/L, PTH 8.5 pmol/L (elevated), and phosphate 0.6 mmol/L. What is the most likely diagnosis?

Primary hyperparathyroidism (Correct answer)
Sarcoidosis
Malignancy-related hypercalcaemia
Secondary hyperparathyroidism

Correct answer: Primary hyperparathyroidism

Primary hyperparathyroidism: hypercalcaemia with inappropriately elevated PTH (which should be suppressed in the context of high calcium) and hypophosphataemia (PTH causes phosphate excretion). Malignancy causes hypercalcaemia with suppressed PTH. This is the classic biochemical picture of primary hyperparathyroidism.

Question 35: A 55-year-old man has the following arterial blood gas results: pH 7.28, PaCO2 3.2 kPa, PaO2 12.5 kPa, HCO3 14 mmol/L. What is the most likely acid-base disturbance?

Metabolic acidosis with respiratory compensation (Correct answer)
Respiratory alkalosis
Respiratory acidosis
Mixed metabolic and respiratory acidosis

Correct answer: Metabolic acidosis with respiratory compensation

pH 7.28 = acidosis. Low HCO3 (14) = metabolic acidosis. Low PaCO2 (3.2) = compensatory hyperventilation (blowing off CO2 to raise pH). This is metabolic acidosis with appropriate respiratory compensation. The anion gap should be calculated to determine the cause.

Question 36: A 72-year-old man has an acute exacerbation of COPD. Arterial blood gas shows: pH 7.29, PaCO2 8.5 kPa, PaO2 7.0 kPa, HCO3 26 mmol/L. His oxygen saturations are 82% on air. What is the target oxygen saturation for this patient according to BTS guidelines?

94–98%
88–92% (Correct answer)
96–98%
98–100%

Correct answer: 88–92%

BTS guidelines for COPD exacerbation recommend a target SpO2 of 88–92% for patients at risk of hypercapnic respiratory failure (type 2 respiratory failure, as shown here by elevated PaCO2). High-flow oxygen can suppress the hypoxic ventilatory drive in these patients, worsening CO2 retention.

Question 37: A patient taking an SSRI presents with agitation, tremor, hyperthermia, hyperreflexia, clonus, and diarrhoea shortly after starting tramadol. What is the most likely diagnosis?

Malignant hyperthermia
Neuroleptic malignant syndrome
Serotonin syndrome (Correct answer)
Anticholinergic toxicity

Correct answer: Serotonin syndrome

Serotonin syndrome occurs due to excess serotonergic activity, often when two serotonergic drugs are combined (SSRI + tramadol). Features include agitation, tremor, hyperthermia, hyperreflexia, clonus, and diarrhoea. It differs from neuroleptic malignant syndrome (which has rigidity and bradyreflexia). Treatment involves stopping the causative drugs and supportive care.

Question 38: What does 'intention-to-treat' (ITT) analysis mean in clinical trials?

Analysis performed before unblinding the trial
Analysis of only participants who completed the full treatment protocol
Analysis that includes all participants as originally allocated, regardless of whether they completed or received the allocated treatment — preserving the integrity of randomisation (Correct answer)
Analysis focused on the primary intention of the intervention

Correct answer: Analysis that includes all participants as originally allocated, regardless of whether they completed or received the allocated treatment — preserving the integrity of randomisation

ITT analysis maintains all participants in the groups to which they were originally randomised, regardless of non-compliance, withdrawal, or crossover. This preserves the prognostic balance of randomisation and gives a real-world estimate of treatment effect. Per-protocol analysis (completers only) may overestimate treatment benefit.

Question 39: A patient with atrial fibrillation is started on warfarin. Which of the following drugs, if added, would most significantly increase the risk of bleeding by inhibiting warfarin metabolism?

St John's Wort
Rifampicin
Fluconazole (Correct answer)
Carbamazepine

Correct answer: Fluconazole

Fluconazole is a potent inhibitor of CYP2C9, the main enzyme responsible for warfarin metabolism. This significantly increases warfarin levels and bleeding risk. Rifampicin, carbamazepine, and St John's Wort are inducers of CYP enzymes and would reduce warfarin efficacy.

Question 40: A patient taking co-amoxiclav develops profuse watery diarrhoea with abdominal pain 5 days into the course. Stool sample tests positive for Clostridioides difficile toxin. What is the first-line treatment?

Continue co-amoxiclav and add loperamide
Stop the causative antibiotic and start oral vancomycin (Correct answer)
No treatment needed — C. difficile resolves spontaneously
Start IV metronidazole as first-line

Correct answer: Stop the causative antibiotic and start oral vancomycin

Current UK guidelines recommend oral vancomycin as first-line treatment for C. difficile infection (replacing metronidazole, which is now second-line). The causative antibiotic should be stopped if possible. Loperamide is contraindicated as it can lead to toxic megacolon.

Question 41: A 19-year-old woman with a BMI of 14.5 presents with amenorrhoea, lanugo hair, and an intense fear of gaining weight despite being significantly underweight. What is the most likely diagnosis?

Body dysmorphic disorder
Depression with weight loss
Anorexia nervosa (Correct answer)
Bulimia nervosa

Correct answer: Anorexia nervosa

Anorexia nervosa is characterised by significantly low body weight (BMI <17.5 or <85% expected), intense fear of weight gain, and disturbed body image. Physical signs include amenorrhoea, lanugo hair, bradycardia, and hypothermia. A BMI of 14.5 indicates severe anorexia requiring urgent medical and psychiatric assessment.

Question 42: A 38-year-old woman with SLE and confirmed antiphospholipid syndrome has had two consecutive first-trimester miscarriages. What is the recommended management during her next pregnancy?

Hydroxychloroquine alone
Warfarin throughout pregnancy
Low-dose aspirin plus low molecular weight heparin (LMWH) (Correct answer)
High-dose prednisolone

Correct answer: Low-dose aspirin plus low molecular weight heparin (LMWH)

Women with antiphospholipid syndrome and recurrent pregnancy loss require low-dose aspirin and LMWH throughout pregnancy; warfarin is teratogenic in the first trimester and avoided.

Question 43: What is the principle of 'Gillick competence' and how does it apply to children under 16?

Children under 16 can never consent to medical treatment
All children under 16 need parental consent for any procedure
Gillick competence only applies to contraception decisions
A child under 16 has capacity to consent to treatment if they have sufficient maturity and understanding to fully comprehend what is proposed — the competence level must match the complexity of the decision (Correct answer)

Correct answer: A child under 16 has capacity to consent to treatment if they have sufficient maturity and understanding to fully comprehend what is proposed — the competence level must match the complexity of the decision

Gillick competence holds that a child under 16 may consent to medical treatment if they demonstrate sufficient intelligence and maturity to understand the nature and implications of the proposed treatment. The more complex or serious the decision, the higher the threshold of understanding required. Parents cannot overrule a Gillick-competent child's consent.

Question 44: Under the Mental Health Act 1983, what is a Community Treatment Order (CTO)?

A voluntary agreement between the patient and their GP
A legal framework allowing a detained patient to be discharged from hospital under supervised conditions, with the option of recall if necessary (Correct answer)
A court order requiring the patient to attend therapy sessions
An order preventing the patient from leaving their home

Correct answer: A legal framework allowing a detained patient to be discharged from hospital under supervised conditions, with the option of recall if necessary

A CTO (introduced by the 2007 amendments to the MHA) allows a patient detained under Section 3 to live in the community under specific conditions (e.g., medication compliance, contact with services). The responsible clinician can recall the patient to hospital if conditions are breached or their mental health deteriorates.

Question 45: A 20-year-old male cyclist is brought to A&E after being hit by a car. He has a GCS of 8. According to ATLS, what is the most important immediate airway intervention?

Perform endotracheal intubation with in-line cervical spine stabilisation (Correct answer)
Apply a simple face mask with high-flow oxygen
Position the patient in recovery position and observe
Insert a nasopharyngeal airway

Correct answer: Perform endotracheal intubation with in-line cervical spine stabilisation

A GCS of 8 or below indicates the patient cannot protect their own airway. ATLS guidelines recommend definitive airway management with endotracheal intubation, maintaining in-line cervical spine stabilisation until injury is excluded. A GCS ≤8 is a key threshold for intubation.

Question 46: A GP is prescribing ramipril for a patient with newly diagnosed hypertension. What monitoring is required after starting an ACE inhibitor?

No monitoring is required
Renal function and electrolytes should be checked before starting and 1-2 weeks after initiation or dose change (Correct answer)
Liver function tests should be checked monthly
Only blood pressure monitoring is needed

Correct answer: Renal function and electrolytes should be checked before starting and 1-2 weeks after initiation or dose change

ACE inhibitors can cause hyperkalaemia and deterioration of renal function, particularly in patients with renovascular disease. BNF and NICE recommend checking U&Es and eGFR before starting, 1-2 weeks after starting or dose increase, and periodically thereafter. A rise in creatinine >30% or fall in eGFR >25% requires specialist review.

Question 47: According to NICE guidelines, what is the first-line antihypertensive for a 65-year-old Caucasian man with no other comorbidities?

ACE inhibitor (e.g., ramipril)
Thiazide-like diuretic (e.g., indapamide)
Calcium channel blocker (e.g., amlodipine) (Correct answer)
Beta-blocker (e.g., atenolol)

Correct answer: Calcium channel blocker (e.g., amlodipine)

NICE hypertension guidelines (NG136): for patients aged 55 or over, or people of any age who are Black British/African/Caribbean, the first-line treatment is a calcium channel blocker (CCB). For under-55 non-Black patients, an ACE inhibitor or ARB is first line. At 65, a CCB is recommended.

Question 48: A 70-year-old woman presents with sudden onset severe headache described as 'the worst of her life', nausea and vomiting, and neck stiffness. CT head is normal. What is the most important next investigation?

Carotid Doppler
Lumbar puncture (Correct answer)
EEG
MRI brain

Correct answer: Lumbar puncture

This presentation is classic for subarachnoid haemorrhage (SAH). When CT head is negative (sensitivity ~98% within 6 hours but lower thereafter), lumbar puncture is essential to look for xanthochromia (yellow discolouration of CSF) due to haemoglobin breakdown, confirming SAH.

Question 49: What is the purpose of a 'Do Not Attempt Cardiopulmonary Resuscitation' (DNACPR) order and how should it be made?

An administrative decision made by hospital managers to allocate resources
A clinical decision that CPR would not be clinically appropriate or not in the patient's best interests, made through discussion with the patient (and family where appropriate) and senior clinician, documented clearly (Correct answer)
A form completed by the family to refuse resuscitation for their relative
A form completed by junior doctors after admission for all elderly patients

Correct answer: A clinical decision that CPR would not be clinically appropriate or not in the patient's best interests, made through discussion with the patient (and family where appropriate) and senior clinician, documented clearly

DNACPR is a clinical decision, not an administrative one. It requires: clinical assessment that CPR would be futile or not in the patient's best interests; sensitive discussion with the patient (if they have capacity) and appropriate communication with family; documentation and communication across care settings. Families cannot override a competent patient's wishes.

Question 50: Under UK law, when may a doctor breach patient confidentiality without consent?

Whenever a family member requests medical information
In specific circumstances: serious risk of harm to the patient or others that outweighs the duty of confidentiality; statutory duty to disclose (e.g., notifiable diseases); court order; or for public interest purposes (e.g., serious crime) (Correct answer)
Whenever the doctor judges it appropriate
For any research purpose with ethics approval

Correct answer: In specific circumstances: serious risk of harm to the patient or others that outweighs the duty of confidentiality; statutory duty to disclose (e.g., notifiable diseases); court order; or for public interest purposes (e.g., serious crime)

GMC confidentiality guidance permits breach without consent for: preventing serious crime or risk of serious harm; notifiable diseases; court orders; and specific statutory requirements. The decision to breach must be proportionate, and disclosure should be to an appropriate authority. Always consider whether anonymisation suffices.

Question 51: A woman at 28 weeks' gestation has a routine blood test showing she is Rhesus D negative. What is the recommended prophylactic management?

Weekly blood tests for antibodies until delivery
No action needed until after delivery
Routine antenatal anti-D immunoglobulin prophylaxis at 28 weeks (Correct answer)
Immediate delivery to prevent sensitisation

Correct answer: Routine antenatal anti-D immunoglobulin prophylaxis at 28 weeks

NICE recommends routine antenatal anti-D prophylaxis (RAADP) at 28 weeks for all RhD-negative women (single dose of 1,500 IU or two doses at 28 and 34 weeks). This prevents sensitisation and haemolytic disease of the newborn. Additional anti-D is given after sensitising events.

Question 52: A patient arrives in A&E after a road traffic collision. They are hypotensive (BP 80/50), tachycardic (HR 130), with a distended abdomen. What class of haemorrhagic shock does this represent according to ATLS?

Class II (15-30% blood loss)
Class III (30-40% blood loss) (Correct answer)
Class I (up to 15% blood loss)
Class IV (>40% blood loss)

Correct answer: Class III (30-40% blood loss)

Class III haemorrhagic shock (30-40% blood loss) presents with tachycardia >120, hypotension, tachypnoea, altered mental status, and decreased urine output. Class IV would show more profound hypotension and altered consciousness. Immediate fluid resuscitation and blood products are needed.

Question 53: An MRI of the lumbar spine shows a central disc prolapse at L4/5 compressing the cauda equina. The patient reports saddle anaesthesia and urinary retention. What is the immediate management?

Oral analgesia and physiotherapy referral
IV methylprednisolone
Emergency surgical decompression — this is cauda equina syndrome (Correct answer)
Conservative management and MRI surveillance

Correct answer: Emergency surgical decompression — this is cauda equina syndrome

Cauda equina syndrome (CES) is a surgical emergency. Features: saddle anaesthesia (perineum, genitalia, inner thighs), bladder/bowel dysfunction, bilateral leg weakness/numbness. Delays to surgical decompression cause permanent neurological damage. Once suspected clinically, emergency MRI confirms and emergency surgery is required.

Question 54: Which antibiotic is contraindicated in pregnant women due to the risk of 'grey baby syndrome' in neonates?

Cefalexin
Chloramphenicol (Correct answer)
Amoxicillin
Erythromycin

Correct answer: Chloramphenicol

Chloramphenicol inhibits mitochondrial protein synthesis. Neonates lack adequate hepatic glucuronyl transferase to metabolise it, leading to accumulation and 'grey baby syndrome' (circulatory collapse, abdominal distension, cyanosis, death). It is avoided in pregnancy and neonates.

Question 55: A 30-year-old primigravida at 34 weeks' gestation has a blood pressure of 165/110 mmHg, proteinuria of 3+, and complains of a severe headache and visual disturbances. What is the most appropriate immediate management?

Start oral methyldopa and review in the antenatal clinic next week
Prescribe bed rest at home and recheck BP in 1 week
Admit, commence IV magnesium sulphate and IV labetalol, and plan urgent delivery (Correct answer)
Discharge with oral antihypertensives and GP follow-up

Correct answer: Admit, commence IV magnesium sulphate and IV labetalol, and plan urgent delivery

This presentation — severe hypertension, significant proteinuria, headache, and visual disturbances — constitutes severe pre-eclampsia with imminent risk of eclampsia. NICE guidelines (NG133) recommend IV magnesium sulphate for seizure prevention, IV labetalol for BP control, and planned delivery.

Question 56: Which important complication must all patients with polymyalgia rheumatica be warned about and screened for?

Giant cell arteritis (Correct answer)
Peripheral neuropathy
Lupus nephritis
Aortic valve disease

Correct answer: Giant cell arteritis

Giant cell arteritis occurs in 15–20% of PMR patients and can cause irreversible ischaemic visual loss; patients must be warned to report new headache, jaw claudication, or visual symptoms urgently.

Question 57: A 6-week-old infant is brought to the GP with projectile vomiting after every feed for the past week. On examination, a small olive-shaped mass is palpable in the right upper quadrant. What is the most likely diagnosis?

Pyloric stenosis (Correct answer)
Gastro-oesophageal reflux
Duodenal atresia
Intussusception

Correct answer: Pyloric stenosis

Pyloric stenosis typically presents at 2-8 weeks of age with progressive projectile non-bilious vomiting. A palpable 'olive' in the right upper quadrant is the classic examination finding. It is more common in firstborn males. Diagnosis is confirmed by ultrasound and treated with Ramstedt's pyloromyotomy.

Question 58: A 60-year-old man with a history of heavy alcohol use presents with severe epigastric pain radiating to the back, vomiting, and a serum amylase of 1,200 U/L (normal <100). What is the most appropriate initial management?

Oral antibiotics and discharge
Emergency laparotomy
IV fluids, nil by mouth, analgesia, and monitoring using the Glasgow-Imrie score (Correct answer)
ERCP within 2 hours

Correct answer: IV fluids, nil by mouth, analgesia, and monitoring using the Glasgow-Imrie score

Acute pancreatitis management follows conservative principles: aggressive IV fluid resuscitation, nil by mouth, effective analgesia (avoiding morphine if possible), and severity scoring (Glasgow-Imrie or APACHE II). ERCP is indicated only for gallstone pancreatitis with cholangitis or persistent biliary obstruction.

Question 59: A plain abdominal X-ray shows dilated loops of large bowel (>6cm) with loss of haustral markings and a 'coffee bean' sign. What is the most likely diagnosis?

Paralytic ileus
Sigmoid volvulus (Correct answer)
Caecal volvulus
Large bowel obstruction at splenic flexure

Correct answer: Sigmoid volvulus

The coffee bean (or kidney bean) sign on AXR, with a very dilated loop of large bowel devoid of haustra, pointing to the right upper quadrant, is characteristic of sigmoid volvulus — twisting of the sigmoid colon on its mesentery. It requires urgent sigmoidoscopic decompression or surgery.

Question 60: A 5-year-old child presents with a widespread erythematous rash that started on the face ('slapped cheek' appearance) and has spread to the trunk and limbs in a lace-like pattern. What is the causative organism?

Parvovirus B19 (Correct answer)
Human herpesvirus 6
Measles virus
Group A Streptococcus

Correct answer: Parvovirus B19

Parvovirus B19 causes erythema infectiosum (fifth disease/slapped cheek syndrome). The characteristic 'slapped cheek' facial rash is followed by a lace-like reticular rash on the trunk and limbs. The child is no longer infectious once the rash appears. It can cause aplastic crisis in sickle cell disease and hydrops fetalis in pregnancy.

Question 61: A patient asks you to provide them with a medical certificate stating they are unfit for work for a month when you believe they are fit for work in two weeks. What should you do?

Compromise and issue a 3-week certificate
Provide the certificate as the patient is the expert on their own health
Decline to certify a longer period than clinically justified — issuing a dishonest certificate is professional misconduct and may constitute fraud (Correct answer)
Refer to a colleague to avoid conflict

Correct answer: Decline to certify a longer period than clinically justified — issuing a dishonest certificate is professional misconduct and may constitute fraud

GMC Good Medical Practice requires honesty and integrity in all aspects of medical practice, including documentation and certification. Issuing an inaccurate medical certificate is dishonest, potentially fraudulent, and constitutes serious professional misconduct. You must only certify what you genuinely believe to be clinically justified.

Question 62: A 70-year-old man with Alzheimer's disease is prescribed donepezil. What is the mechanism of action of this drug?

Dopamine agonist
NMDA receptor antagonist
GABA receptor modulator
Acetylcholinesterase inhibitor — it increases acetylcholine levels in the brain (Correct answer)

Correct answer: Acetylcholinesterase inhibitor — it increases acetylcholine levels in the brain

Donepezil is an acetylcholinesterase inhibitor that prevents the breakdown of acetylcholine in the brain, thereby increasing cholinergic transmission. NICE recommends it for mild-to-moderate Alzheimer's disease. Other AChE inhibitors include rivastigmine and galantamine. Memantine (NMDA antagonist) is used for moderate-to-severe disease.

Question 63: Under the Mental Capacity Act 2005 (England and Wales), what are the five principles that underpin the Act?

Presumption of capacity; support to make decisions; right to make unwise decisions; best interests; least restrictive option (Correct answer)
Informed consent, autonomy, confidentiality, beneficence, and justice
Competence, disclosure, understanding, voluntariness, and decision-making
Beneficence, non-maleficence, autonomy, justice, and veracity

Correct answer: Presumption of capacity; support to make decisions; right to make unwise decisions; best interests; least restrictive option

The MCA 2005 five principles: (1) Presume capacity unless proven otherwise; (2) Support people to make decisions; (3) Respect the right to make unwise decisions; (4) Any action/decision for those lacking capacity must be in their best interests; (5) Choose the least restrictive option. These apply to all healthcare decisions.

Question 64: A 30-year-old woman has blood test results showing: Hb 88 g/L, MCV 70 fL, serum ferritin 6 µg/L, transferrin saturation 8%. What is the most likely diagnosis?

Folate deficiency anaemia
Anaemia of chronic disease
Thalassaemia trait
Iron deficiency anaemia (Correct answer)

Correct answer: Iron deficiency anaemia

Iron deficiency anaemia is characterised by low Hb, microcytic anaemia (low MCV <80 fL), low ferritin (the most sensitive indicator of iron stores), and low transferrin saturation. Ferritin of 6 µg/L confirms depleted iron stores. Anaemia of chronic disease has normal/raised ferritin.

Question 65: A 50-year-old man presents with a 6-month history of exertional chest pain that is relieved by rest, occurring after walking 200 metres uphill. ECG at rest is normal. What is the most appropriate investigation to confirm the diagnosis?

24-hour ECG (Holter monitor)
Chest X-ray
Echocardiogram
Exercise tolerance test (ETT) or CT coronary angiogram (Correct answer)

Correct answer: Exercise tolerance test (ETT) or CT coronary angiogram

This is a classic presentation of stable angina. NICE guidelines (CG95) recommend CT coronary angiography as the first-line investigation for suspected stable angina. Exercise tolerance testing is an alternative. The resting ECG is often normal in stable angina.

Question 66: According to NICE guidelines, what is the first-line antihypertensive for a 60-year-old Caucasian patient with no comorbidities?

Calcium channel blocker (e.g., amlodipine) (Correct answer)
Beta-blocker (e.g., bisoprolol)
Thiazide-like diuretic (e.g., indapamide)
ACE inhibitor (e.g., ramipril)

Correct answer: Calcium channel blocker (e.g., amlodipine)

NICE hypertension guidelines (NG136) recommend a calcium channel blocker (CCB) as first-line for patients aged ≥55 or of African/Caribbean descent. ACE inhibitors/ARBs are first-line for patients aged <55 (non-African/Caribbean). At age 60 without comorbidities, amlodipine would be appropriate.

Question 67: A patient on warfarin develops a DVT and is found to have a supratherapeutic INR of 8.5 with minor bleeding from the gums. What is the most appropriate management?

Stop warfarin, give IV vitamin K 5mg, and transfuse FFP
Stop warfarin and give oral vitamin K 1–2mg; review in 24 hours (Correct answer)
Stop warfarin and give idarucizumab
Continue warfarin and observe

Correct answer: Stop warfarin and give oral vitamin K 1–2mg; review in 24 hours

For INR 5–8 with minor bleeding (BCSH guidelines): stop warfarin, give low-dose oral vitamin K (1–2mg). This will partially reverse anticoagulation within 6–12 hours without fully reversing it (important if anticoagulation is needed ongoing). IV vitamin K and FFP are reserved for serious/life-threatening bleeding.

Question 68: A patient is prescribed amoxicillin for a chest infection. They mention they are also taking the combined oral contraceptive pill. According to current BNF guidance, does amoxicillin interact with the combined oral contraceptive?

Yes — amoxicillin specifically destroys oestrogen in the gut
Antibiotics only interact with the progesterone-only pill
Yes — all antibiotics reduce the efficacy of the pill and additional contraception is always needed
No — non-enzyme-inducing antibiotics like amoxicillin do not reduce the efficacy of the combined oral contraceptive according to current evidence and BNF guidance (Correct answer)

Correct answer: No — non-enzyme-inducing antibiotics like amoxicillin do not reduce the efficacy of the combined oral contraceptive according to current evidence and BNF guidance

Current BNF and FSRH guidance states that non-enzyme-inducing antibiotics (including amoxicillin) do not reduce the efficacy of the combined oral contraceptive. Only enzyme-inducing drugs (e.g., rifampicin, carbamazepine, phenytoin) require additional contraceptive precautions.

Question 69: A 45-year-old woman presents with a 6-hour history of severe colicky right upper quadrant pain radiating to the right shoulder tip, nausea, and vomiting. She is febrile at 38.5°C. Murphy's sign is positive. What is the most likely diagnosis?

Acute cholecystitis (Correct answer)
Acute pancreatitis
Biliary colic
Hepatitis

Correct answer: Acute cholecystitis

RUQ pain with fever and a positive Murphy's sign (inspiratory arrest on palpation of the RUQ) is diagnostic of acute cholecystitis. Biliary colic alone does not cause fever or Murphy's sign. Management includes IV antibiotics and cholecystectomy (ideally within 72 hours per NICE guidelines).

Question 70: A 45-year-old man with a history of peptic ulcer disease requires an NSAID for acute gout. What should be co-prescribed to reduce the risk of GI complications?

An antihistamine (H1 blocker)
Metronidazole
Misoprostol is preferred over PPI
A proton pump inhibitor (PPI) (Correct answer)

Correct answer: A proton pump inhibitor (PPI)

NSAIDs inhibit COX-1 and COX-2, reducing gastric mucosal protection and increasing the risk of peptic ulcers and GI bleeding. PPI co-prescription is recommended by NICE for patients on NSAIDs who have risk factors (previous ulcer, age >65, oral steroids, anticoagulants). A PPI reduces GI complications significantly.

Question 71: A 9-month-old infant presents with paroxysmal colicky abdominal pain, drawing up of the legs, a sausage-shaped mass in the right upper quadrant, and 'redcurrant jelly' stools. What is the most likely diagnosis?

Meckel's diverticulum
Hirschsprung's disease
Appendicitis
Intussusception (Correct answer)

Correct answer: Intussusception

Intussusception typically presents in infants aged 6-18 months with paroxysmal colicky pain (episodes of screaming with legs drawn up), a sausage-shaped mass (usually RUQ), and redcurrant jelly stools (blood and mucus). First-line treatment is air or contrast enema reduction.

Question 72: A 28-year-old woman of childbearing age with epilepsy is prescribed valproate. What is the most important counselling point?

She must avoid dairy products
She should double the dose if she misses one tablet
Valproate is highly teratogenic (risk of neural tube defects, neurodevelopmental effects) and must not be used in women who may become pregnant without specialist review and the Pregnancy Prevention Programme (Correct answer)
She must avoid alcohol completely

Correct answer: Valproate is highly teratogenic (risk of neural tube defects, neurodevelopmental effects) and must not be used in women who may become pregnant without specialist review and the Pregnancy Prevention Programme

Sodium valproate has high teratogenic risk — 10% risk of congenital malformations (especially neural tube defects) and 30–40% risk of neurodevelopmental problems. UK MHRA requires implementation of the Pregnancy Prevention Programme (contraception, annual review, patient card) for all women of childbearing potential on valproate.

Question 73: A 28-year-old woman presents at 32 weeks gestation with severe headache, visual disturbances, BP 165/110, and 3+ proteinuria on dipstick. She has pitting oedema. What is the most likely diagnosis?

Pre-eclampsia (Correct answer)
Gestational hypertension
Chronic hypertension
Migraine

Correct answer: Pre-eclampsia

Pre-eclampsia is defined as hypertension (≥140/90) with proteinuria after 20 weeks gestation, or hypertension with other features (headache, visual disturbances, liver tenderness, thrombocytopenia). This patient has severe features (BP 165/110, severe headache, visual disturbance) indicating severe pre-eclampsia requiring urgent management.

Question 74: A 72-year-old man presents with sudden-onset unilateral weakness affecting the face, arm, and leg, slurred speech, and left homonymous hemianopia. Symptoms began 3 hours ago. CT head is normal. What is the most appropriate immediate management?

Aspirin 300mg orally and urgent neurology referral
CT angiography only, then discharge
Anticoagulation with heparin
IV alteplase (thrombolysis) after confirming no contraindications (Correct answer)

Correct answer: IV alteplase (thrombolysis) after confirming no contraindications

This is an acute ischaemic stroke presenting within 4.5 hours. With a normal CT head (excluding haemorrhage) and no contraindications, IV alteplase thrombolysis should be given. The time window is critical — 'time is brain'. NICE recommends thrombolysis within 4.5 hours of onset.

Question 75: A patient in A&E who smells of alcohol is being verbally abusive and trying to leave before assessment. He has a head injury. What is the most important consideration?

Physically restrain him regardless of capacity
Carefully assess his capacity — intoxication may impair capacity; if he lacks capacity, he can be detained in his best interests under the MCA; if he has capacity, he has the right to leave but should sign a self-discharge form (Correct answer)
Discharge him immediately to avoid conflict
Call police to detain him

Correct answer: Carefully assess his capacity — intoxication may impair capacity; if he lacks capacity, he can be detained in his best interests under the MCA; if he has capacity, he has the right to leave but should sign a self-discharge form

Intoxication may impair capacity — the capacity assessment must be made at that time, considering whether he can understand, retain, weigh, and communicate information about his condition and the risks of leaving. If capacity is absent, best interests (MCA) applies and treatment/retention may be justified. If he has capacity, you cannot detain him but must document risks.

Question 76: A 3-year-old child presents to A&E with a barking cough, stridor at rest, and mild chest wall recession. According to NICE guidelines, what is the most appropriate initial management?

Single dose of oral dexamethasone (0.15 mg/kg) (Correct answer)
Immediate intubation
IV antibiotics and admission to intensive care
Salbutamol nebuliser

Correct answer: Single dose of oral dexamethasone (0.15 mg/kg)

This presentation is consistent with moderate croup (viral laryngotracheobronchitis). NICE recommends a single dose of oral dexamethasone (0.15 mg/kg) for all children presenting with croup. Nebulised adrenaline is reserved for severe croup with significant respiratory distress.

Question 77: According to NICE guidelines (NG28), which of the following patients with type 2 diabetes should be started on metformin as first-line therapy?

A patient with recurrent hypoglycaemia on other agents
A patient with type 1 diabetes
A patient with eGFR 25 ml/min/1.73m²
A patient with no contraindications to metformin and HbA1c above the agreed target (Correct answer)

Correct answer: A patient with no contraindications to metformin and HbA1c above the agreed target

NICE recommends metformin as first-line pharmacological therapy for type 2 diabetes in patients who have no contraindications (renal impairment eGFR<30, hepatic failure, alcohol excess) and whose HbA1c is above their agreed target after lifestyle modification. It does not cause hypoglycaemia and aids weight neutrality.

Question 78: A 30-year-old woman presents with episodes of binge eating followed by self-induced vomiting, occurring at least twice per week for the past 3 months. Her BMI is 22. What is the most likely diagnosis?

Rumination disorder
Anorexia nervosa, binge-purge subtype
Bulimia nervosa (Correct answer)
Binge eating disorder

Correct answer: Bulimia nervosa

Bulimia nervosa is characterised by recurrent episodes of binge eating followed by compensatory behaviours (self-induced vomiting, laxative misuse, excessive exercise) at least once per week for 3 months. Unlike anorexia nervosa, BMI is typically normal or above normal. NICE recommends CBT-ED as first-line treatment.

Question 79: According to the GMC's Good Medical Practice, what are the four domains of Good Medical Practice?

Clinical competence, communication, ethics, and research
Patient care, self-care, team care, and organisational care
Clinical expertise, professionalism, leadership, and education
Knowledge, skills, and performance; safety and quality; communication, partnership, and teamwork; maintaining trust (Correct answer)

Correct answer: Knowledge, skills, and performance; safety and quality; communication, partnership, and teamwork; maintaining trust

GMC Good Medical Practice is organised around four domains: (1) Knowledge, skills, and performance; (2) Safety and quality; (3) Communication, partnership, and teamwork; (4) Maintaining trust. All registered doctors must meet the standards in all four domains.

Question 80: Which investigation is most SPECIFIC for diagnosing rheumatoid arthritis?

ESR
CRP
Rheumatoid factor (RF)
Anti-CCP antibodies (Correct answer)

Correct answer: Anti-CCP antibodies

Anti-CCP (anti-cyclic citrullinated peptide) antibodies have >95% specificity for rheumatoid arthritis, making them more diagnostically specific than rheumatoid factor.

Question 81: A patient's relative calls demanding information about the patient's condition. The patient is an adult with capacity and has not given consent to share information with their family. What should you do?

Ask the consultant to decide
Provide general information without specific details
Decline to confirm or deny any information — confidentiality belongs to the patient and they have not consented to disclosure (Correct answer)
Provide the information as the relative is clearly concerned

Correct answer: Decline to confirm or deny any information — confidentiality belongs to the patient and they have not consented to disclosure

Confidentiality belongs to the patient. An adult patient with capacity must specifically authorise disclosure to third parties, including family. Without that consent, you should not confirm or deny details of their condition or treatment. This applies even to close relatives, unless there is a specific lawful basis for disclosure.

Question 82: A 25-year-old woman presents 2 hours after taking 20 paracetamol tablets (10g). She is asymptomatic. Serum paracetamol level is above the treatment line on the nomogram. What is the most appropriate treatment?

Supportive care and monitoring only
Oral methionine
IV N-acetylcysteine (NAC) (Correct answer)
Activated charcoal only

Correct answer: IV N-acetylcysteine (NAC)

IV N-acetylcysteine (NAC) is the antidote for paracetamol overdose. It replenishes glutathione, which is depleted by the toxic metabolite NAPQI, preventing hepatocellular damage. Treatment should be started when the level plots above the treatment line on the Rumack-Matthew nomogram. Activated charcoal may also be given within 1 hour of ingestion.

Question 83: A 68-year-old man has a serum sodium of 122 mmol/L. He has gained weight, has peripheral oedema, and his urine sodium is 10 mmol/L. What is the most likely cause?

Addison's disease
Diuretic therapy
Cardiac failure or nephrotic syndrome causing dilutional hyponatraemia (Correct answer)
SIADH (syndrome of inappropriate ADH)

Correct answer: Cardiac failure or nephrotic syndrome causing dilutional hyponatraemia

Dilutional hyponatraemia in a hypervolaemic patient (oedema, weight gain) with low urine sodium (the kidney is avidly retaining sodium) points to cardiac failure, cirrhosis, or nephrotic syndrome. In SIADH, patients are euvolaemic with urine sodium >20 mmol/L. The kidneys are working normally but the total body water is excessive.

Question 84: A patient is started on warfarin for atrial fibrillation. According to NICE guidelines, what is the target INR range for non-valvular AF?

4.0-5.0
3.0-4.0
2.0-3.0 (Correct answer)
1.0-1.5

Correct answer: 2.0-3.0

The target INR for warfarin in non-valvular atrial fibrillation is 2.0-3.0. A higher range (2.5-3.5) is used for mechanical heart valves. DOACs (e.g., apixaban, rivarelbaan) are now recommended first-line for non-valvular AF by NICE, as they do not require INR monitoring.

Question 85: A patient with chronic kidney disease stage 4 is found to have a potassium level of 6.8 mmol/L. ECG shows peaked T waves. What is the most important immediate treatment?

Oral calcium supplements
IV calcium gluconate 10% to stabilise the myocardium, followed by insulin-dextrose infusion to reduce serum potassium (Correct answer)
Oral sodium polystyrene sulfonate (Calcium Resonium)
Withhold all medications and recheck potassium in 24 hours

Correct answer: IV calcium gluconate 10% to stabilise the myocardium, followed by insulin-dextrose infusion to reduce serum potassium

Severe hyperkalaemia (>6.5 mmol/L) with ECG changes is a medical emergency. IV calcium gluconate is given first to stabilise the myocardium (does not reduce potassium). Insulin-dextrose drives potassium intracellularly. Nebulised salbutamol can also help. Calcium Resonium removes potassium but acts too slowly for acute management.

Question 86: A patient with asthma develops worsening bronchoconstriction after being prescribed a new medication for hypertension. Which class of drug is most likely responsible?

Beta-blocker (Correct answer)
ACE inhibitor
Calcium channel blocker
Thiazide diuretic

Correct answer: Beta-blocker

Beta-blockers (even cardioselective ones like atenolol) are contraindicated in asthma because they can cause bronchospasm by blocking beta-2 receptors in bronchial smooth muscle. Non-selective beta-blockers (propranolol) carry greater risk. This is a key prescribing safety rule.

Question 87: What are the four components of valid informed consent?

Written form, two witnesses, patient's signature, and consultant approval
Signature, witness, medical assessment, and doctor's agreement
Voluntary decision, capacity, adequate information/disclosure, and the ability to communicate the decision (Correct answer)
Patient request, clinical indication, family agreement, and legal approval

Correct answer: Voluntary decision, capacity, adequate information/disclosure, and the ability to communicate the decision

Valid consent requires: (1) voluntariness — free from undue pressure; (2) capacity — the ability to understand, retain, weigh, and communicate information; (3) adequate information — enough to make an informed decision including risks, benefits, and alternatives; (4) communication of the decision. All four must be present.

Question 88: According to UK guidelines, at what age should a child be referred for further assessment if they are not walking independently?

15 months
24 months
12 months
18 months (Correct answer)

Correct answer: 18 months

While most children walk independently between 12-15 months, the threshold for referral for developmental assessment is 18 months if a child is not walking independently. This may indicate developmental delay, neurological conditions (e.g., cerebral palsy), or other causes requiring investigation.

Question 89: What is the definition of a 'notifiable disease' in the UK and what are your obligations?

Diseases requiring mandatory treatment under the Mental Health Act
Specified infectious diseases that doctors have a statutory duty to notify to the local authority proper officer (usually the local UKHSA health protection team) — failure to notify is an offence (Correct answer)
Any serious illness requiring hospital admission
Any disease that must be disclosed to the patient's family

Correct answer: Specified infectious diseases that doctors have a statutory duty to notify to the local authority proper officer (usually the local UKHSA health protection team) — failure to notify is an offence

Under the Health Security (Notification) Regulations 2010, doctors must notify the local authority's proper officer (usually Health Protection Team) of specified notifiable diseases (e.g., TB, measles, meningitis, COVID-19). This statutory obligation exists regardless of patient consent and supports public health surveillance and outbreak management.

Question 90: A 35-year-old man sustains a stab wound to the left chest at the 5th intercostal space, midclavicular line. He is hypotensive with muffled heart sounds and distended neck veins. What is the most likely diagnosis?

Cardiac tamponade (Correct answer)
Tension pneumothorax
Massive haemothorax
Aortic dissection

Correct answer: Cardiac tamponade

Beck's triad — hypotension, muffled heart sounds, and distended neck veins (raised JVP) — is classic for cardiac tamponade. Penetrating trauma at this location can injure the heart. Emergency management includes pericardiocentesis or emergency thoracotomy.

Question 91: A 70-year-old woman with heart failure is started on spironolactone. Which electrolyte abnormality must be monitored closely?

Hyperkalaemia (Correct answer)
Hypercalcaemia
Hypokalaemia
Hyponatraemia

Correct answer: Hyperkalaemia

Spironolactone is a potassium-sparing diuretic (aldosterone antagonist). It causes potassium retention, risking hyperkalaemia, which can cause life-threatening arrhythmias. Regular U&E monitoring is essential, especially if the patient is also on ACE inhibitors or ARBs which also raise potassium.

Question 92: Which DMARD requires regular monitoring of full blood count, liver function tests, and renal function every 2–3 months due to risks of hepatotoxicity and bone marrow suppression?

Methotrexate (Correct answer)
Leflunomide
Sulfasalazine
Hydroxychloroquine

Correct answer: Methotrexate

Methotrexate requires regular FBC, LFTs, and renal function monitoring due to risks of hepatotoxicity, pulmonary toxicity, and bone marrow suppression; folic acid must be co-prescribed.

Question 93: A 68-year-old man presents with sudden onset severe pain, erythema, and swelling of the first metatarsophalangeal joint. Serum uric acid is elevated at 560 µmol/L. What is the most likely diagnosis?

Reactive arthritis
Gout (Correct answer)
Septic arthritis
Pseudogout

Correct answer: Gout

Gout classically presents with acute monoarthritis of the first MTP joint (podagra) with hyperuricaemia, often triggered by alcohol, dehydration, or diuretics.

Question 94: A 75-year-old man presents with absolute constipation (no flatus or faeces for 3 days), colicky abdominal pain, and vomiting. Abdominal X-ray shows dilated large bowel with a 'coffee bean' sign. What is the most likely diagnosis?

Caecal carcinoma
Small bowel obstruction
Sigmoid volvulus (Correct answer)
Paralytic ileus

Correct answer: Sigmoid volvulus

The 'coffee bean' sign on abdominal X-ray is pathognomonic for sigmoid volvulus — a twisting of the sigmoid colon on its mesentery. It is more common in elderly, institutionalised, or psychiatric patients. Initial management is sigmoidoscopic decompression with a flatus tube.

Question 95: A patient presents with an acute severe asthma attack (SpO2 91%, PEFR 35% predicted, RR 30, pulse 125). According to BTS guidelines, what is the most appropriate immediate management?

IV magnesium sulphate alone
Nebulised salbutamol only and discharge with oral prednisolone
High-flow oxygen, back-to-back nebulised salbutamol + ipratropium, oral/IV prednisolone, and hospital admission (Correct answer)
Intubation and ventilation immediately

Correct answer: High-flow oxygen, back-to-back nebulised salbutamol + ipratropium, oral/IV prednisolone, and hospital admission

BTS/SIGN asthma guidelines for acute severe attack: high-flow O2 (target SpO2 94–98%), back-to-back (or continuous) nebulised salbutamol + ipratropium bromide every 20–30 minutes, systemic steroids (prednisolone 40–50mg oral or IV hydrocortisone 100mg), and admission. IV magnesium sulphate is added for life-threatening features.

Question 96: A patient on long-term prednisolone 20 mg daily for rheumatoid arthritis wants to stop the medication. What is the correct approach?

Halve the dose once and then stop
Gradual dose reduction is essential to avoid adrenal crisis, as long-term corticosteroids suppress the hypothalamic-pituitary-adrenal (HPA) axis (Correct answer)
Switch to a different steroid at the same dose before stopping
Stop immediately — there is no need for gradual withdrawal

Correct answer: Gradual dose reduction is essential to avoid adrenal crisis, as long-term corticosteroids suppress the hypothalamic-pituitary-adrenal (HPA) axis

Long-term corticosteroid use (>3 weeks) suppresses the HPA axis. Abrupt withdrawal can cause adrenal crisis (hypotension, shock, death). The BNF recommends gradual dose tapering, typically reducing by 1-2.5 mg every 2-4 weeks, with monitoring for symptoms of adrenal insufficiency.

Question 97: A 45-year-old man with type 2 diabetes presents with a painless, non-healing ulcer on the plantar surface of his right foot. The foot is warm and pulses are palpable. Sensation to 10g monofilament is absent. What type of ulcer is this?

Venous ulcer
Neuropathic diabetic ulcer (Correct answer)
Pressure ulcer
Arterial (ischaemic) ulcer

Correct answer: Neuropathic diabetic ulcer

A neuropathic diabetic ulcer is characterised by: location on a pressure point (plantar surface), painlessness (due to peripheral neuropathy), absent sensation to monofilament, but warm foot with intact pulses (good circulation). Arterial ulcers are painful, cold, with absent pulses.

Question 98: A 72-year-old man with heart failure is prescribed spironolactone in addition to ramipril. What is the most important electrolyte to monitor closely with this combination?

Potassium — both drugs can cause hyperkalaemia, and the combination significantly increases this risk (Correct answer)
Sodium
Magnesium
Calcium

Correct answer: Potassium — both drugs can cause hyperkalaemia, and the combination significantly increases this risk

Both ACE inhibitors (ramipril) and aldosterone antagonists (spironolactone) can cause hyperkalaemia. The combination significantly increases the risk. NICE recommends checking potassium and renal function within 1 week of starting spironolactone, then regularly thereafter. Potassium >5.5 mmol/L requires dose adjustment or cessation.

Question 99: According to NICE guidelines, what is the recommended method of induction of labour when the cervix is unfavourable (Bishop score <6)?

Emergency caesarean section
Vaginal prostaglandin E2 (dinoprostone) or oral misoprostol to ripen the cervix (Correct answer)
Immediate ARM (artificial rupture of membranes)
IV oxytocin infusion

Correct answer: Vaginal prostaglandin E2 (dinoprostone) or oral misoprostol to ripen the cervix

NICE recommends cervical ripening with vaginal prostaglandin E2 (dinoprostone) or oral misoprostol when the cervix is unfavourable (Bishop score <6). ARM and oxytocin are used once the cervix is favourable. Mechanical methods (balloon catheter) are also options.

Question 100: A 45-year-old woman with known rheumatoid arthritis on methotrexate presents with a 2-week history of dry cough and progressive breathlessness. CXR shows bilateral interstitial shadowing. What is the most likely diagnosis?

Cardiac failure
Community-acquired pneumonia
Pulmonary embolism
Methotrexate-induced pneumonitis (Correct answer)

Correct answer: Methotrexate-induced pneumonitis

Methotrexate pneumonitis is a well-recognised and potentially serious complication of methotrexate therapy. It presents with dry cough, progressive dyspnoea, and bilateral interstitial shadowing on CXR. Methotrexate should be stopped immediately and the patient referred urgently.

Question 101: A 35-year-old woman presents with palpitations, heat intolerance, weight loss despite increased appetite, tremor, and diarrhoea. On examination she has lid lag, exophthalmos, and a diffuse goitre. TFTs show suppressed TSH and elevated free T4. What is the most likely diagnosis?

De Quervain's thyroiditis
Thyroid carcinoma
Graves' disease (Correct answer)
Toxic multinodular goitre

Correct answer: Graves' disease

Graves' disease is the most common cause of hyperthyroidism in young women. The specific features here are exophthalmos (pretibial myxoedema if present) and diffuse goitre, pointing to Graves' disease rather than other causes. It is an autoimmune condition mediated by TSH receptor antibodies.

Question 102: A 42-year-old woman presents with dry eyes, dry mouth, difficulty swallowing, and symmetrical arthralgia. Blood tests show positive Anti-Ro and Anti-La antibodies. What is the most likely diagnosis?

Sjögren's syndrome (Correct answer)
Systemic lupus erythematosus
Systemic sclerosis
Rheumatoid arthritis

Correct answer: Sjögren's syndrome

Sjögren's syndrome presents with sicca symptoms (dry eyes and mouth) caused by exocrine gland lymphocytic infiltration and is characterised by Anti-Ro (SSA) and Anti-La (SSB) antibodies.

Question 103: A patient with SLE develops a butterfly facial rash, joint pains, and proteinuria with red cell casts on urine microscopy. Which antibody best correlates with disease activity and renal involvement in SLE?

Anti-Smith
Anti-dsDNA (Correct answer)
Anti-Ro (SSA)
Anti-La (SSB)

Correct answer: Anti-dsDNA

Anti-dsDNA antibody titres correlate with SLE disease activity, particularly lupus nephritis, and rising titres predict disease flares.

Question 104: A 60-year-old man with a history of alcohol excess presents with haematemesis. On examination he has spider naevi, palmar erythema, and ascites. OGD shows oesophageal varices with active bleeding. What is the most appropriate initial management?

Oral propranolol
Terlipressin IV plus urgent endoscopic band ligation (Correct answer)
Urgent surgical ligation of varices
IV omeprazole infusion

Correct answer: Terlipressin IV plus urgent endoscopic band ligation

Acute variceal bleeding is managed with: (1) terlipressin (vasopressin analogue that reduces portal pressure) started immediately; (2) prophylactic IV antibiotics (ciprofloxacin or tazobactam); (3) urgent endoscopic band ligation within 12 hours. Terlipressin reduces mortality when started before endoscopy.

Question 105: According to ATLS principles, what is the correct sequence of the primary survey?

Exposure, Disability, Circulation, Breathing, Airway
Breathing, Airway, Circulation, Disability, Exposure
Airway with cervical spine protection, Breathing, Circulation, Disability, Exposure (ABCDE) (Correct answer)
Circulation, Airway, Breathing, Disability, Exposure

Correct answer: Airway with cervical spine protection, Breathing, Circulation, Disability, Exposure (ABCDE)

The ATLS primary survey follows the ABCDE approach: Airway (with cervical spine protection), Breathing, Circulation (with haemorrhage control), Disability (neurological status), and Exposure (fully expose the patient while preventing hypothermia).

Question 106: A patient with epilepsy controlled on sodium valproate discovers she is pregnant. What is the most important concern regarding sodium valproate in pregnancy?

Sodium valproate has no effect on pregnancy outcomes
Sodium valproate is a known teratogen with a 10% risk of major congenital malformations and up to 40% risk of neurodevelopmental disorders — the Pregnancy Prevention Programme must be followed (Correct answer)
Sodium valproate is safe in the first trimester but should be stopped in the third
Sodium valproate only causes minor cosmetic abnormalities

Correct answer: Sodium valproate is a known teratogen with a 10% risk of major congenital malformations and up to 40% risk of neurodevelopmental disorders — the Pregnancy Prevention Programme must be followed

Sodium valproate is a major teratogen associated with neural tube defects, congenital malformations (10%), and neurodevelopmental disorders including autism and reduced IQ (up to 40%). The MHRA Pregnancy Prevention Programme requires two forms of contraception and annual risk acknowledgement forms for all women of childbearing potential.

Question 107: What is the mechanism of action of allopurinol in the management of gout?

Promotes dissolution of urate crystals in joints
Increases renal excretion of uric acid via uricosuric effect
Inhibits xanthine oxidase, reducing uric acid production (Correct answer)
Blocks intestinal absorption of purines

Correct answer: Inhibits xanthine oxidase, reducing uric acid production

Allopurinol inhibits xanthine oxidase, the enzyme that converts hypoxanthine and xanthine to uric acid, thereby reducing urate production and serum uric acid levels.

Question 108: A 30-year-old man presents with bloody diarrhoea 8 times per day, abdominal cramps, and fever. He has a history of recurrent attacks since age 22. Sigmoidoscopy shows continuous mucosal inflammation from the rectum extending proximally. Biopsy shows crypt abscesses. What is the most likely diagnosis?

Crohn's disease
Ischaemic colitis
Ulcerative colitis (Correct answer)
Infective colitis

Correct answer: Ulcerative colitis

Ulcerative colitis is characterised by continuous mucosal inflammation starting from the rectum extending proximally, crypt abscesses on histology, rectal bleeding, and diarrhoea. Crohn's disease is typically patchy (skip lesions), transmural, and can affect any part of the GI tract.

Question 109: A 55-year-old woman presents with progressive dysphagia, initially to solids and now to liquids, weight loss of 8kg over 3 months, and iron deficiency anaemia. What is the most important investigation?

Barium swallow
Upper GI endoscopy (OGD) and biopsy (Correct answer)
CT chest/abdomen
H. pylori breath test

Correct answer: Upper GI endoscopy (OGD) and biopsy

Progressive dysphagia (solids then liquids), weight loss, and iron deficiency anaemia are alarm symptoms suggesting oesophageal carcinoma. OGD with biopsy is essential for direct visualisation and tissue diagnosis. Barium swallow may show the lesion but does not provide histology.

Question 110: A 62-year-old man presents with acute knee pain and swelling. Joint aspiration reveals positively birefringent rhomboid-shaped crystals under polarised light microscopy. What is the diagnosis?

Pseudogout (calcium pyrophosphate deposition) (Correct answer)
Haemarthrosis
Gout
Septic arthritis

Correct answer: Pseudogout (calcium pyrophosphate deposition)

Pseudogout is caused by calcium pyrophosphate dihydrate (CPPD) crystals, which appear positively birefringent and rhomboid-shaped under polarised light, unlike the negatively birefringent needle-shaped urate crystals of gout.

Question 111: According to the UK immunisation schedule, at what age should a child receive their first dose of the MMR vaccine?

18 months
12 months (on or after their first birthday) (Correct answer)
6 months
2 years

Correct answer: 12 months (on or after their first birthday)

The UK childhood immunisation schedule recommends the first dose of MMR vaccine at 12 months of age (on or after the first birthday). The second dose is given at 3 years 4 months (pre-school booster). MMR protects against measles, mumps, and rubella.

Question 112: A 70-year-old woman with osteoporosis has a T-score of -2.8 on DXA scan and has had one vertebral fracture. According to NICE guidelines, what is the most appropriate treatment?

Bisphosphonate (e.g., alendronate) plus calcium and vitamin D (Correct answer)
Calcium and vitamin D supplementation alone
Denosumab as first-line therapy
HRT

Correct answer: Bisphosphonate (e.g., alendronate) plus calcium and vitamin D

NICE (TA160/TA161) recommends bisphosphonates (alendronate is first-line) for women with osteoporosis (T-score ≤-2.5) confirmed on DXA scan, particularly those with a prior fragility fracture. Calcium and vitamin D should be co-prescribed. Denosumab or other agents are second-line if bisphosphonates are not tolerated or contraindicated.

Question 113: A 28-year-old woman at 32 weeks' gestation presents with painless bright red vaginal bleeding. On examination, the uterus is soft and non-tender. What is the most likely diagnosis?

Cervical ectropion
Placental abruption
Uterine rupture
Placenta praevia (Correct answer)

Correct answer: Placenta praevia

Painless, bright red vaginal bleeding in the third trimester is the hallmark presentation of placenta praevia. The soft, non-tender uterus distinguishes it from placental abruption, which typically presents with constant pain and a woody-hard uterus. Digital vaginal examination is contraindicated.

Question 114: A 55-year-old man presents with a pulsatile, expansile abdominal mass. He is haemodynamically stable. An ultrasound shows a 5.8 cm infrarenal abdominal aortic aneurysm. What is the recommended management?

Conservative management with annual ultrasound surveillance
Emergency open surgical repair
Urgent referral to vascular surgery for consideration of elective repair (Correct answer)
Prescribe aspirin and discharge

Correct answer: Urgent referral to vascular surgery for consideration of elective repair

NICE guidelines recommend referral for consideration of elective repair for AAA ≥5.5 cm due to the significant risk of rupture. Aneurysms 3.0-4.4 cm are monitored annually, and 4.5-5.4 cm are monitored 3-monthly. At 5.8 cm, the benefit of elective repair outweighs surgical risk.

Question 115: What is a 'double-blind randomised controlled trial' (RCT) and why is it considered the gold standard for establishing therapeutic efficacy?

A trial conducted across two different hospital sites
A trial where two different treatments are compared without any controls
A trial where neither participants nor investigators know which group receives treatment or placebo, eliminating allocation bias and expectation bias — the best evidence for causality (Correct answer)
A trial examining two different outcomes simultaneously

Correct answer: A trial where neither participants nor investigators know which group receives treatment or placebo, eliminating allocation bias and expectation bias — the best evidence for causality

A double-blind RCT: random allocation prevents selection bias and balances confounders; blinding participants prevents placebo effect; blinding investigators prevents observer bias. The combination of randomisation and blinding provides the most robust evidence for causality in therapeutic research.

Question 116: According to NICE stroke guidelines, which antiplatelet regimen should be started within 24 hours of a confirmed ischaemic stroke (not thrombolysed)?

Anticoagulation with apixaban immediately
Aspirin 75mg indefinitely
Dual antiplatelet therapy: aspirin 300mg for 2 weeks, then clopidogrel 75mg monotherapy (Correct answer)
Clopidogrel 75mg daily for life

Correct answer: Dual antiplatelet therapy: aspirin 300mg for 2 weeks, then clopidogrel 75mg monotherapy

NICE NG128: After ischaemic stroke, start aspirin 300mg immediately (if haemorrhage excluded), continue for 2 weeks, then switch to clopidogrel 75mg monotherapy for long-term secondary prevention. NICE (2023) updated guidance recommends clopidogrel as first-line long-term antiplatelet over aspirin.

Question 117: A 55-year-old man presents with an acute ST-elevation myocardial infarction (STEMI). According to NICE and UK guidelines, which combination of antiplatelet drugs should be given immediately?

Warfarin and aspirin
Clopidogrel alone
Aspirin alone
Aspirin 300 mg plus a P2Y12 inhibitor (e.g., ticagrelor or clopidogrel) (Correct answer)

Correct answer: Aspirin 300 mg plus a P2Y12 inhibitor (e.g., ticagrelor or clopidogrel)

UK guidelines for STEMI recommend dual antiplatelet therapy (DAPT): aspirin 300 mg loading dose plus a P2Y12 inhibitor. Ticagrelor is preferred over clopidogrel for STEMI patients undergoing primary PCI. DAPT is continued for 12 months post-MI.

Question 118: A clinical trial reports that a new drug reduces the relative risk of myocardial infarction by 50% compared to placebo. The absolute event rates are 2% (treatment) and 4% (control). What is the Number Needed to Treat (NNT)?

100
50 (Correct answer)
2
25

Correct answer: 50

NNT = 1 / Absolute Risk Reduction (ARR). ARR = 4% - 2% = 2% = 0.02. NNT = 1/0.02 = 50. The NNT of 50 means you need to treat 50 patients to prevent one MI. While the relative risk reduction (50%) sounds impressive, the NNT provides more clinically meaningful information.

Question 119: A 68-year-old woman presents with worsening confusion over 3 days, pyrexia, dysuria, and frequency. Her urine is cloudy and malodorous. What is the most likely diagnosis causing confusion in this elderly patient?

Hyponatraemia
Urinary tract infection causing acute delirium (Correct answer)
New stroke
Dementia exacerbation

Correct answer: Urinary tract infection causing acute delirium

UTI is a very common cause of acute delirium (acute confusional state) in elderly patients. Classic urinary symptoms may be less prominent in the elderly. The confusion is acute onset (over days), fever is present, and urinary symptoms/signs are evident. This is acute delirium, not worsening dementia.

Question 120: A 55-year-old man has had a myocardial infarction. According to NICE guidelines (NG185), which combination of medications should he be prescribed for secondary prevention?

Clopidogrel + statin only
Aspirin alone
Warfarin + statin + beta-blocker
Aspirin + P2Y12 inhibitor (e.g., ticagrelor) + high-intensity statin + ACE inhibitor + beta-blocker (Correct answer)

Correct answer: Aspirin + P2Y12 inhibitor (e.g., ticagrelor) + high-intensity statin + ACE inhibitor + beta-blocker

Post-MI secondary prevention (NICE NG185): dual antiplatelet (aspirin + ticagrelor/clopidogrel/prasugrel for 12 months), high-intensity statin (atorvastatin 80mg), ACE inhibitor (or ARB if intolerant), and beta-blocker. All four classes are indicated unless contraindicated.

Question 121: A 4-year-old child is brought to A&E with sudden onset of drooling, high fever, and sitting in a tripod position. The child appears toxic and has a muffled voice. What is the most likely diagnosis and immediate priority?

Viral pharyngitis — prescribe paracetamol and discharge
Peritonsillar abscess — arrange incision and drainage
Croup — administer nebulised adrenaline
Acute epiglottitis — do not examine the throat; call senior anaesthetist for airway management (Correct answer)

Correct answer: Acute epiglottitis — do not examine the throat; call senior anaesthetist for airway management

Acute epiglottitis presents with the 4 D's: Drooling, Dysphagia, Dysphonia, and Distress. The child often adopts a tripod position. It is a life-threatening airway emergency. Do NOT examine the throat (risk of complete airway obstruction). Call a senior anaesthetist immediately for controlled airway management.

Question 122: A 65-year-old man is prescribed gentamicin for a Gram-negative infection. Which of the following side effects must be specifically monitored?

Nephrotoxicity and ototoxicity (Correct answer)
Hepatotoxicity and jaundice
Pulmonary fibrosis
QT prolongation

Correct answer: Nephrotoxicity and ototoxicity

Aminoglycosides (gentamicin, amikacin) cause nephrotoxicity (tubular damage) and ototoxicity (vestibular and cochlear damage), particularly with prolonged use or high trough levels. Regular monitoring of renal function and gentamicin levels (trough and peak, or once-daily AUC monitoring) is essential.

Question 123: Which set of X-ray findings is characteristic of osteoarthritis, distinguishing it from inflammatory arthritis?

Periarticular osteoporosis and soft tissue swelling
Joint space narrowing, osteophytes, subchondral sclerosis, and cysts (Correct answer)
Marginal erosions and periosteal reaction
Chondrocalcinosis and uniform joint space loss

Correct answer: Joint space narrowing, osteophytes, subchondral sclerosis, and cysts

Osteoarthritis shows asymmetric joint space narrowing, osteophyte formation, subchondral sclerosis, and subchondral cysts — degenerative rather than erosive or inflammatory changes.

Question 124: A 20-year-old man presents with a 6-month history of auditory hallucinations (third-person commentary), thought insertion, and social withdrawal. There is no history of substance misuse. What is the most likely diagnosis?

Schizophrenia (Correct answer)
Drug-induced psychosis
Schizoaffective disorder
Bipolar affective disorder

Correct answer: Schizophrenia

First-rank symptoms (Schneider's) — including third-person auditory hallucinations and thought insertion — persisting for over one month in the absence of substance misuse or organic cause, are characteristic of schizophrenia. The 6-month duration with social decline supports this diagnosis under ICD-11 criteria.

Question 125: A 60-year-old woman is started on lithium for bipolar disorder. What monitoring is essential before and during lithium treatment?

Annual liver function tests only
Only serum lithium levels need to be checked once at the start
No monitoring is required — lithium is a safe medication
Baseline renal function, thyroid function, and ECG, with regular serum lithium levels maintained at 0.6-0.8 mmol/L (maintenance) (Correct answer)

Correct answer: Baseline renal function, thyroid function, and ECG, with regular serum lithium levels maintained at 0.6-0.8 mmol/L (maintenance)

Lithium has a narrow therapeutic index. NICE requires baseline renal function (U&Es, eGFR), thyroid function (lithium can cause hypothyroidism), calcium, and ECG. Serum lithium levels should be checked 12 hours post-dose, weekly until stable, then every 3 months. Target range for maintenance is 0.6-0.8 mmol/L.

Question 126: A patient with type 2 diabetes has an eGFR of 25 ml/min/1.73m². Which diabetes medication must be stopped or dose-reduced due to risk of lactic acidosis?

Sitagliptin
Gliclazide
Metformin (Correct answer)
Insulin

Correct answer: Metformin

Metformin is contraindicated when eGFR falls below 30 ml/min/1.73m² due to the risk of lactic acidosis (accumulation of metformin due to impaired renal excretion). NICE guidelines recommend stopping metformin if eGFR < 30 and dose reduction if eGFR 30–45.

Question 127: A junior doctor on night shift is the only available doctor for the ward. They are asked to perform a procedure they have not been trained to do and feel unsafe. What is the most appropriate action?

Decline to perform the procedure, explain your competence limits, seek urgent senior/on-call specialist help, and inform the patient of the delay (Correct answer)
Document that the procedure was refused and leave for morning team
Perform the procedure with a nurse supervising
Attempt the procedure — patient need comes first

Correct answer: Decline to perform the procedure, explain your competence limits, seek urgent senior/on-call specialist help, and inform the patient of the delay

GMC Good Medical Practice: you must recognise and work within your competence. Attempting procedures beyond your competence puts patients at risk. You must ask for help from a competent colleague urgently. Patient safety requires honesty about limitations, not false heroism.

Question 128: A 45-year-old woman has a urinalysis showing: blood 3+, protein 2+, red cell casts on microscopy. What does the presence of red cell casts indicate?

Bladder carcinoma
Glomerulonephritis (Correct answer)
UTI
Renal calculi

Correct answer: Glomerulonephritis

Red cell casts form in the renal tubules when red cells leak through a damaged glomerular basement membrane into the tubular lumen. Their presence is pathognomonic of glomerulonephritis (glomerular inflammation). Haematuria with red cell casts always requires urgent nephrology investigation.

Question 129: A 3-year-old child presents to A&E with a non-blanching purpuric rash, fever, and altered consciousness. What is the most important immediate action?

Apply EMLA cream and obtain IV access before treatment
Request an urgent CT head
Administer IV/IM benzylpenicillin or ceftriaxone immediately without waiting for investigation results (Correct answer)
Take blood cultures before doing anything else

Correct answer: Administer IV/IM benzylpenicillin or ceftriaxone immediately without waiting for investigation results

A non-blanching purpuric rash with fever and altered consciousness strongly suggests meningococcal septicaemia. This is a medical emergency — antibiotics (IV ceftriaxone or benzylpenicillin) must be given immediately. Do not delay treatment for investigations. Blood cultures can be taken alongside but must not delay antibiotics.

Question 130: A patient on simvastatin 40 mg reports new-onset muscle pain and weakness. Blood tests show a creatine kinase (CK) level 10 times the upper limit of normal. What is the most appropriate action?

Stop simvastatin immediately — the elevated CK indicates rhabdomyolysis/myopathy, a serious adverse effect of statins (Correct answer)
Continue simvastatin and reassure the patient
Increase the dose of simvastatin
Add a fibrate to the simvastatin

Correct answer: Stop simvastatin immediately — the elevated CK indicates rhabdomyolysis/myopathy, a serious adverse effect of statins

Statin-induced myopathy with CK >10x ULN is a serious adverse effect that can progress to rhabdomyolysis and acute kidney injury. The statin must be stopped immediately. After CK normalises, a different statin at a low dose (e.g., pravastatin) may be tried cautiously, or an alternative lipid-lowering agent used.

Question 131: A 72-year-old woman presents with 3 months of bilateral shoulder and pelvic girdle aching and stiffness worse in the mornings, ESR 85 mm/hr, and CRP 45 mg/L. She responds dramatically to 15 mg prednisolone. What is the most likely diagnosis?

Polymyositis
Polymyalgia rheumatica (Correct answer)
Fibromyalgia
Rheumatoid arthritis

Correct answer: Polymyalgia rheumatica

Polymyalgia rheumatica presents in patients >50 years with bilateral girdle pain and stiffness, markedly elevated inflammatory markers, and a dramatic response to low-dose corticosteroids.

Question 132: A patient's ECG shows: heart rate 150 bpm, narrow complex, no visible P waves, irregularly irregular rhythm. What is the most likely diagnosis?

SVT (AVNRT)
Atrial fibrillation (Correct answer)
Sinus tachycardia
Atrial flutter with 2:1 block

Correct answer: Atrial fibrillation

Atrial fibrillation (AF) is characterised by: (1) irregularly irregular rhythm — the most important feature; (2) absence of distinct P waves (replaced by fibrillatory baseline); (3) narrow complexes (unless aberrant conduction). SVT is regular; atrial flutter is typically regular at 150 bpm with flutter waves.

Question 133: A 2-year-old child presents with a 5-day history of high fever (>39°C), bilateral non-purulent conjunctival injection, strawberry tongue, cervical lymphadenopathy, and a polymorphous rash. What is the most likely diagnosis?

Measles
Scarlet fever
Meningococcal septicaemia
Kawasaki disease (Correct answer)

Correct answer: Kawasaki disease

Kawasaki disease requires fever for ≥5 days plus at least 4 of 5 criteria: bilateral conjunctival injection, oral mucosal changes (strawberry tongue, cracked lips), polymorphous rash, cervical lymphadenopathy, and extremity changes. Treatment with IV immunoglobulin and aspirin reduces the risk of coronary artery aneurysms.

Question 134: A primigravida at 41+3 weeks' gestation is offered a membrane sweep. She asks about the evidence. What should you tell her about the purpose of a membrane sweep?

It is a form of artificial rupture of membranes
It has no evidence base and is not recommended by NICE
It can help stimulate the onset of spontaneous labour by releasing prostaglandins, reducing the need for formal induction (Correct answer)
It guarantees labour will start within 24 hours

Correct answer: It can help stimulate the onset of spontaneous labour by releasing prostaglandins, reducing the need for formal induction

Membrane sweeping involves separating the membranes from the lower uterine segment, which stimulates local prostaglandin release. NICE recommends offering sweeps from 40 weeks in nulliparous women and 41 weeks in multiparous women to reduce the need for formal induction of labour.

Question 135: A 25-year-old woman presents with low mood, anhedonia, early morning wakening, poor concentration, and feelings of worthlessness for the past 4 weeks. She has no suicidal ideation. According to NICE guidelines, what is the first-line treatment for moderate depression?

A high-intensity psychological intervention (CBT) or an SSRI antidepressant such as sertraline (Correct answer)
Immediate referral to secondary care psychiatry
Electroconvulsive therapy
Benzodiazepines for anxiety and sleep

Correct answer: A high-intensity psychological intervention (CBT) or an SSRI antidepressant such as sertraline

NICE guidelines (NG222) recommend offering either a high-intensity psychological therapy (such as CBT) or an SSRI antidepressant (sertraline or fluoxetine as first choice) for moderate depression. The choice should be based on shared decision-making with the patient.

Question 136: Which of the following best describes the GMC's guidance on social media use for doctors?

All social media posts about medicine must be peer-reviewed
Doctors must maintain professional standards, protect patient confidentiality, clearly identify themselves as doctors where relevant, and not post anything that could bring the profession into disrepute (Correct answer)
Doctors should not use any social media
Doctors can share anonymised case details on social media without restriction

Correct answer: Doctors must maintain professional standards, protect patient confidentiality, clearly identify themselves as doctors where relevant, and not post anything that could bring the profession into disrepute

GMC guidance on social media: maintain professional boundaries, protect patient confidentiality (even with apparent anonymisation), treat people with respect, do not make misleading statements about treatments, and maintain standards regardless of the platform. Even personal accounts reflect on the profession.

Question 137: A 28-year-old man presents with low back pain and stiffness worse in the morning and improving with exercise. HLA-B27 is positive and MRI shows bilateral sacroiliitis. What is the most likely diagnosis?

Rheumatoid arthritis
Psoriatic arthritis
Ankylosing spondylitis (Correct answer)
Reactive arthritis

Correct answer: Ankylosing spondylitis

Ankylosing spondylitis presents in young males with inflammatory back pain, HLA-B27 positivity, and sacroiliitis on imaging, with characteristic improvement with exercise.

Question 138: A 55-year-old man with long-standing GORD presents for review. He reports dysphagia to solids, odynophagia, and a 5kg weight loss over 2 months. What is the most appropriate next step?

Barium swallow
Urgent 2-week wait (2WW) OGD referral (Correct answer)
Increase PPI dose and review in 4 weeks
H. pylori testing

Correct answer: Urgent 2-week wait (2WW) OGD referral

New dysphagia, odynophagia, and weight loss in a patient with long-standing GORD are urgent alarm symptoms suggesting possible oesophageal malignancy. NICE guidelines mandate an urgent 2-week wait referral for OGD. Barrett's oesophagus (a complication of GORD) is a risk factor for oesophageal adenocarcinoma.

Question 139: A 70-year-old woman presents with sudden-onset severe abdominal pain, bloody diarrhoea, and abdominal distension. She has a history of atrial fibrillation. What is the most likely diagnosis?

Sigmoid volvulus
Gastroenteritis
Diverticulitis
Acute mesenteric ischaemia (Correct answer)

Correct answer: Acute mesenteric ischaemia

Sudden severe abdominal pain with bloody stools in a patient with AF strongly suggests acute mesenteric ischaemia due to arterial embolism. AF is a major risk factor. This is a surgical emergency with high mortality if not treated promptly with CT angiography and possible surgical or interventional management.

Question 140: A 40-year-old woman with limited cutaneous systemic sclerosis develops severe Raynaud's phenomenon and is found to have pulmonary arterial hypertension on echocardiography. Which antibody is most associated with this presentation?

Anti-dsDNA
Anti-Scl-70 (anti-topoisomerase I)
Anti-centromere antibody (Correct answer)
Anti-Jo-1

Correct answer: Anti-centromere antibody

Anti-centromere antibody is associated with limited cutaneous systemic sclerosis (CREST syndrome) and carries significantly increased risk of pulmonary arterial hypertension.

Question 141: A 25-year-old man presents to A&E with sudden-onset right iliac fossa pain. On examination, he has rebound tenderness and guarding. His temperature is 38.2°C. Blood tests show WCC 15 x10^9/L and CRP 85 mg/L. What is the most likely diagnosis?

Crohn's disease flare
Mesenteric adenitis
Right ureteric colic
Acute appendicitis (Correct answer)

Correct answer: Acute appendicitis

Right iliac fossa pain with rebound tenderness, guarding, fever, and raised inflammatory markers is classic for acute appendicitis. This requires urgent surgical assessment and likely appendicectomy. The Alvarado score can aid clinical assessment.

Question 142: A 55-year-old woman presents with pain and stiffness in both hands worse in the morning lasting over 1 hour. X-ray shows erosions and joint space narrowing at the MCP and PIP joints. What is the most likely diagnosis?

Rheumatoid arthritis (Correct answer)
Osteoarthritis
Psoriatic arthritis
Gout

Correct answer: Rheumatoid arthritis

Rheumatoid arthritis typically presents with symmetrical small joint involvement, prolonged morning stiffness (>1 hour), and erosive changes on X-ray at MCP and PIP joints.

Question 143: A patient on long-term oral steroids (prednisolone) requires co-prescription of which of the following to prevent a common serious side effect?

Calcium and vitamin D supplementation plus bisphosphonate (Correct answer)
Anticoagulation with warfarin
Prophylactic antifungal therapy
H2 receptor antagonist for gastric protection only

Correct answer: Calcium and vitamin D supplementation plus bisphosphonate

Long-term corticosteroids cause significant bone loss (osteoporosis) through multiple mechanisms. NICE guidelines (CG146) recommend calcium and vitamin D for all patients on steroids, and bisphosphonates (e.g., alendronate) for patients at moderate/high risk of fracture. This is one of the most important co-prescriptions in clinical practice.

Question 144: A patient under your care develops a serious unexpected complication after surgery that may have been caused by a system failure. What is the most appropriate action under NHS duty of candour?

Inform the ward sister but not the patient until an internal review is completed
Be open and honest with the patient and family, acknowledge what happened, offer an apology, provide information about any investigation, and explain what steps are taken to prevent recurrence (Correct answer)
Document the complication in the notes and await the patient's complaint
Seek legal advice before disclosing anything to the patient

Correct answer: Be open and honest with the patient and family, acknowledge what happened, offer an apology, provide information about any investigation, and explain what steps are taken to prevent recurrence

Duty of Candour (statutory for NHS organisations under regulation 20 of the Health and Social Care Act 2008, and a professional duty for individual practitioners under GMC Good Medical Practice) requires openness, honesty, and transparency when something goes wrong that causes or may cause harm, including a meaningful apology.

Question 145: A patient with a known diagnosis of rheumatoid arthritis is to be started on an anti-TNF biologic agent. Which pre-treatment screening is MOST important before initiating therapy?

Hepatitis C antibody
Tuberculosis screening (IGRA or Mantoux) (Correct answer)
MRSA nasal swab
HIV serology

Correct answer: Tuberculosis screening (IGRA or Mantoux)

TB screening with an interferon-gamma release assay (IGRA) or Mantoux test is mandatory before starting anti-TNF therapy, as these agents can reactivate latent tuberculosis causing life-threatening disease.

Question 146: A 65-year-old man presents with crushing central chest pain radiating to the left arm, sweating, and nausea for 2 hours. ECG shows ST elevation in leads II, III, and aVF. What is the most likely diagnosis?

Pericarditis
Unstable angina
Anterior STEMI
Inferior STEMI (Correct answer)

Correct answer: Inferior STEMI

ST elevation in leads II, III, and aVF indicates inferior STEMI, reflecting occlusion of the right coronary artery (RCA) in most patients. The clinical picture — crushing central chest pain with radiation, diaphoresis and nausea — is classic for acute MI.

Question 147: A 25-year-old woman presents at 7 weeks' gestation with vaginal bleeding and left iliac fossa pain. Her serum beta-hCG is 1,500 IU/L and transvaginal ultrasound shows an empty uterus. What is the most likely diagnosis?

Threatened miscarriage
Molar pregnancy
Complete miscarriage
Ectopic pregnancy (Correct answer)

Correct answer: Ectopic pregnancy

An empty uterus on transvaginal ultrasound with a beta-hCG above the discriminatory level (usually 1,500-2,000 IU/L), combined with pain and bleeding, is highly suspicious for ectopic pregnancy until proven otherwise. This requires urgent gynaecological assessment.

Question 148: According to NICE guidance, which patients with community-acquired pneumonia should be considered for hospital admission using the CRB-65 score?

Patients with CRB-65 score ≥2 should be considered for hospital admission; score of 1 requires clinical judgement (Correct answer)
All patients with pneumonia, regardless of severity
Only patients with SpO2 below 90%
Only elderly patients over 65

Correct answer: Patients with CRB-65 score ≥2 should be considered for hospital admission; score of 1 requires clinical judgement

CRB-65 (Confusion, Respiratory rate ≥30, BP systolic <90 or diastolic ≤60, age 65+): 0 = low risk, consider home treatment; 1–2 = moderate risk, hospital assessment considered; 3–4 = high severity, urgent hospital admission. CURB-65 adds urea >7 mmol/L and is used in hospital settings.

Question 149: A 32-year-old woman in established labour has a cervical dilatation rate of 0.3 cm/hour after 4 hours despite adequate contractions. According to NICE intrapartum care guidelines, what is this called and what is the next step?

Normal progress — continue observation
Failure to progress — immediate caesarean section
Delay in the first stage — consider amniotomy if membranes are intact, and/or oxytocin augmentation (Correct answer)
Precipitate labour — slow down contractions with tocolytics

Correct answer: Delay in the first stage — consider amniotomy if membranes are intact, and/or oxytocin augmentation

NICE defines delay in the first stage as cervical dilatation of less than 0.5 cm/hour over 4 hours. Management includes amniotomy (ARM) if membranes are intact, followed by oxytocin augmentation if progress remains slow. Caesarean section is considered if these measures fail.

Question 150: A 40-year-old woman presents with increasing proximal muscle weakness, difficulty climbing stairs, and a purple discolouration around her eyes and on her knuckles. CK is markedly elevated. What is the most likely diagnosis?

Myasthenia gravis
Polymyalgia rheumatica
Dermatomyositis (Correct answer)
Duchenne muscular dystrophy

Correct answer: Dermatomyositis

Dermatomyositis presents with proximal muscle weakness, markedly elevated CK, and characteristic skin changes: heliotrope rash (purple periorbital discolouration) and Gottron's papules (purple papules over knuckles). It is an important diagnosis as it may be a paraneoplastic phenomenon in adults over 40.

Question 151: A 26-year-old man develops asymmetrical oligoarthritis, urethritis, and conjunctivitis 3 weeks after a confirmed Chlamydia trachomatis infection. What is this condition?

Psoriatic arthritis
Ankylosing spondylitis
Reactive arthritis (Correct answer)
Septic arthritis

Correct answer: Reactive arthritis

Reactive arthritis (formerly Reiter's syndrome) is a sterile inflammatory arthritis triggered by genitourinary or gastrointestinal infection, classically causing the triad of arthritis, urethritis, and conjunctivitis.

Question 152: A 50-year-old man has an elevated ALP with normal ALT, AST, and GGT. Bone scan shows increased uptake in multiple areas of the pelvis and skull. What is the most likely diagnosis?

Liver metastases
Myeloma
Paget's disease of bone (Correct answer)
Primary hyperparathyroidism

Correct answer: Paget's disease of bone

Paget's disease of bone causes isolated elevation of ALP (from increased osteoblast activity) with normal liver function (GGT is normal, distinguishing it from liver disease). Bone scan shows characteristic intense uptake in affected bones. The skull and pelvis are commonly affected.

Question 153: A 10-year-old child presents 2 weeks after a sore throat with haematuria, facial oedema, hypertension, and dark ('cola-coloured') urine. What is the most likely diagnosis?

Wilms' tumour
Nephrotic syndrome
Post-streptococcal glomerulonephritis (Correct answer)
IgA nephropathy

Correct answer: Post-streptococcal glomerulonephritis

Post-streptococcal glomerulonephritis typically presents 1-3 weeks after a Group A streptococcal pharyngitis or skin infection. Features include haematuria (cola-coloured urine), hypertension, oedema, and reduced urine output. Anti-streptolysin O (ASO) titre is elevated and complement C3 is low.

Question 154: A 70-year-old man presents with back pain, weight loss, and fatigue. Blood tests show: Hb 85g/L, calcium 3.1 mmol/L, creatinine 185 µmol/L. X-ray of the spine shows lytic lesions. Serum protein electrophoresis shows a monoclonal band. What is the most likely diagnosis?

Multiple myeloma (Correct answer)
Metastatic prostate cancer
Lymphoma
Primary hyperparathyroidism

Correct answer: Multiple myeloma

Multiple myeloma classically presents with the CRAB criteria: hyperCalcaemia, Renal impairment, Anaemia, and Bone lesions (lytic). The monoclonal (M) band on serum protein electrophoresis confirms paraproteinaemia. All four CRAB criteria are present here.

Question 155: A 45-year-old man presents after a suicide attempt by overdose. He has a clear plan, wrote a suicide note, and took steps to avoid being found. According to UK risk assessment guidelines, which features indicate the highest risk?

The method used was an overdose rather than a violent method
Evidence of planning, a suicide note, and precautions against discovery indicate high intent and high risk (Correct answer)
The time of day the attempt was made
The patient's age — younger patients are always higher risk

Correct answer: Evidence of planning, a suicide note, and precautions against discovery indicate high intent and high risk

High-risk features for completed suicide include: evidence of planning (not impulsive), writing a suicide note or final arrangements, precautions against discovery, use of a violent method, and ongoing suicidal intent. These features indicate high intent and require urgent psychiatric assessment and safety planning.

Question 156: A 25-year-old woman presents with a 3-month history of fatigue, weight loss, mouth ulcers, and a butterfly-shaped facial rash worsened by sunlight. Blood tests show positive ANA and anti-dsDNA antibodies, lymphopenia, and proteinuria. What is the most likely diagnosis?

Sjögren's syndrome
Systemic lupus erythematosus (SLE) (Correct answer)
Dermatomyositis
Systemic sclerosis

Correct answer: Systemic lupus erythematosus (SLE)

This is a classic presentation of SLE: the malar (butterfly) rash, photosensitivity, oral ulcers, positive ANA and anti-dsDNA (highly specific for SLE), lymphopenia, and renal involvement (proteinuria). Anti-dsDNA antibodies are highly specific for SLE.

Question 157: A 40-year-old woman presents with a 3 cm complex ovarian cyst found incidentally on ultrasound. Her CA-125 is 85 U/mL (normal <35). Using the Risk of Malignancy Index (RMI), which factors are included in the calculation?

Ultrasound score, menopausal status, and CA-125 level (Correct answer)
Ethnicity, smoking status, and hormone use
Tumour size, blood pressure, and parity
Age, BMI, and family history

Correct answer: Ultrasound score, menopausal status, and CA-125 level

The Risk of Malignancy Index (RMI) = Ultrasound score (U) x Menopausal status (M) x CA-125 level. An RMI ≥250 warrants referral to a specialist gynaecological oncology centre. This woman's elevated CA-125 and postmenopausal status increase her RMI significantly.

Question 158: A 3-year-old child presents with a 2-day history of barking cough, hoarse voice, and inspiratory stridor, worse at night. He is mildly distressed but maintaining oxygen saturations. What is the most likely diagnosis and management?

Foreign body inhalation — bronchoscopy
Croup (laryngotracheobronchitis) — single dose oral/IM dexamethasone (Correct answer)
Bacterial tracheitis — IV antibiotics
Epiglottitis — call anaesthetics urgently

Correct answer: Croup (laryngotracheobronchitis) — single dose oral/IM dexamethasone

Croup (viral laryngotracheobronchitis) classically presents in children aged 6 months to 3 years with a barking 'seal-like' cough, hoarse voice, and inspiratory stridor, typically worse at night and following a viral URTI. Oral or IM dexamethasone (single dose) reduces inflammation and hospital admission rates. Epiglottitis is rarer and presents with a much more toxic child who is drooling and cannot swallow.

Question 159: According to UK guidelines, what is the first-line treatment for an acute attack of gout?

Prednisolone
Colchicine or NSAIDs (Correct answer)
Allopurinol
Febuxostat

Correct answer: Colchicine or NSAIDs

NSAIDs (e.g. naproxen) or colchicine are first-line for acute gout; allopurinol and febuxostat are urate-lowering agents used for prophylaxis, not acute attacks.

PLAB 1 (Professional and Linguistic Assessments Board Part 1)

The PLAB 1 is a written examination administered by the UK General Medical Council (GMC) that assesses whether international medical graduates have the knowledge and clinical reasoning to practise medicine safely in the UK at the level of a Foundation Year 2 doctor.

180

Questions

180 min

Time Limit

64%

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