MRCP part 1 exam paper 1

A 34-year-old woman with a history of severe asthma is admitted with persistent symptoms despite maximal inhaled therapy. Bronchoalveolar samples show increased lymphocytes. Which statement best describes the role of specific immune cells in her airway inflammation?

A 24-year-old Afro-Caribbean woman presents with blurred vision in both eyes and complains of joint pain in her ankles and knees. Examination finds bilateral posterior uveitis and multiple tender, red swellings over the anterior aspects of her legs. Laboratory investigations reveal a significantly raised serum ACE level. What is the most likely diagnosis?

A 54-year-old man with a 30-pack-year smoking history presents with a chronic productive cough and wheeze. On examination, he has no evidence of digital clubbing. Which of the following respiratory diseases is least likely to be associated with finger clubbing?

A 19-year-old woman is referred to the hypertension clinic for evaluation of persistently high blood pressure measurements on multiple occasions. She is of short stature with a broad shield-shaped chest, widely spaced nipples, and has a webbed neck. She reports that her legs fatigue easily when walking long distances. On examination, her brachial blood pressure is 158/98 mmHg, and femoral pulses are weak and delayed compared to the radial pulses. Her menarche has not occurred. Which cardiac abnormality best explains her presentation?

A 62-year-old man with longstanding rheumatoid arthritis currently on methotrexate presents with a painful, swollen, and warm right ankle that developed overnight. He denies fever or rigors. Examination confirms a red, tender, and swollen ankle. His laboratory results reveal a CRP of 12 mg/L with normal white cell count and mild anaemia. What is the most appropriate initial investigation to undertake?

A 45-year-old man sustains a dislocated shoulder following a bicycle accident.

After reduction, he complains of difficulty abducting his arm at the shoulder and numbness over the lateral upper arm in a patch resembling a military badge. On examination, there is evident deltoid muscle weakness and sensory loss is limited to the so-called ‘regimental badge area’. Which of the following nerve lesions best explains these findings?

A 47-year-old woman presents to the clinic with persistent tiredness, mild weight gain, and dry coarse skin. On physical examination, she is found to have a small, firm, non-tender diffuse goitre. Her thyroid function tests show: TSH 22 mU/L (normal 0.5– 4.5), free T4 7 pmol/L (normal 10– 22). Her mother has a history of autoimmune thyroid disease. Which of the following is the most likely diagnosis?

A 32-year-old woman presents with a 3-month history of lethargy and vague right upper quadrant abdominal discomfort. Laboratory investigations reveal the presence of smooth muscle antibodies on autoantibody screening. Which of the following is the most appropriate investigation to undertake next?

A 54-year-old man experiences a witnessed cardiac arrest in the emergency department. Cardiopulmonary resuscitation is commenced. What is the recommended initial dose and preparation of intravenous adrenaline according to Advanced Life Support guidelines for adult cardiac arrest?

A 59-year-old woman presents with progressive unsteadiness of gait, clumsy hands, and numbness in her fingers. You suspect degenerative cervical myelopathy (DCM). Which statement best reflects the role of cervical spine radiographs in confirming the diagnosis?

A 29-year-old veterinary technician presents with a solitary lesion on her index finger.

She recalls handling goats on a farm a week ago and remembers being scratched in the process. The lesion began as a red papule but has enlarged over several days to become a nodular, ulcerated, and weeping lesion. She has no systemic symptoms. Which is the most likely diagnosis?

A 35-year-old woman is referred by her general practitioner because she noticed her fingernails are separating from the nail beds. She has experienced recent weight loss, increased appetite, and palpitations. Which underlying disorder best explains her nail findings?

A 32-year-old woman is seen in clinic for evaluation 8 weeks after delivering a healthy infant.

She complains of fatigue and mild palpitations but has no pain over her neck. Laboratory investigation reveals a suppressed TSH and elevated free T4. She did not receive any treatment during pregnancy. Her medical records show that she tested positive for thyroid peroxidase (TPO) antibodies in early pregnancy. Which statement best describes the significance of her TPO antibody positivity?

A 32-year-old man presents with photosensitive rash and arthralgia. Laboratory investigations reveal a positive anti-nuclear antibody test. Which immunoglobulin class is most commonly associated with anti-nuclear antibodies in this scenario?

A 22-year-old woman presents with recurrent episodes of painless, non-pitting swelling affecting her face and extremities. She has no urticaria, and her symptoms are often triggered by minor trauma. Laboratory studies reveal reduced levels of complement C4. Which chemical mediator is primarily responsible for the oedema in this form of hereditary angioedema?

A 28-year-old woman is planning a trekking trip to the Himalayas, where she will ascend to elevations over 3500 metres. She has previously experienced severe headaches, nausea, and insomnia during high-altitude travel. She asks about medications to help prevent recurrence of these symptoms.

Which drug would best help to prevent acute mountain sickness in this setting, and how does it work?

A 36-year-old woman who has recently returned from visiting family in Guinea develops intermittent fever, headache, and malaise. Examination reveals enlarged lymph nodes in the posterior cervical chain. Blood films identify Trypanosoma brucei gambiense. Which of the following is the most appropriate initial therapy for her condition?

A 32-year-old man of Korean descent who smokes two packs of cigarettes daily presents with persistent pain in his fingers and toes. On examination, there are dusky discoloration and necrotic ulcers at his fingertips, as well as areas of tender, cord-like swelling over superficial veins. He has no other significant past medical history. What is the most likely diagnosis?

A 29-year-old woman presents at 28 weeks of pregnancy for routine antenatal care.

She reports persistent nausea and vomiting since the first trimester. Her examination is unremarkable. Laboratory investigations reveal: Hb 6.3 g/dl, MCV 120 fl, WCC 7.3 × 10⁹/litre, platelet count 186 × 10⁹/litre. Which one of the following is most likely responsible for her anaemia?

A 29-year-old woman returns from a six-month expedition in rural Bolivia. She describes several weeks of progressive nasal stuffiness and a sore inside her nose. On examination, there is a firm, ulcerated red papule affecting the nasal septum. She reports no fever or systemic symptoms.

A 70-year-old man with a past history of chronic obstructive pulmonary disease (COPD) presents to the emergency department with worsening shortness of breath and a productive cough.

On examination, he has a respiratory rate of 24/min, oxygen saturation of 91% on room air, and blood pressure of 125/70 mmHg. An ECG reveals an irregularly irregular, narrow-complex tachycardia at a rate of 140 bpm. There are at least three different P wave morphologies visible. What is the most appropriate pharmacological strategy for controlling his heart rate?

A 36-year-old woman attends the dermatology clinic with complaints of an intensely itchy rash affecting her elbows and knees.

She reports a long-standing gluten sensitivity and chronic diarrhoea. On examination, there are clusters of small vesicles over the extensor surfaces. A skin biopsy is performed. What is the most characteristic immunofluorescence finding likely to be seen?

A 62-year-old man requires aortic valve replacement. He is concerned about the long-term function of the available prosthetic valve types. Which statement best reflects the difference between mechanical and bioprosthetic heart valves regarding durability?

A 42-year-old woman with a history of heavy alcohol use is admitted after being found confused and trembling at home. According to her housemate, she abruptly stopped drinking alcohol two days ago. In the ward, she is disorientated, restless, diaphoretic, and hypertensive, with a pulse of 104/min. During assessment, she experiences a witnessed tonic– clonic seizure. Which of the following medications should be given first to reduce the risk of further seizures?

A 65-year-old man is admitted following a stroke and is having difficulty swallowing. The medical team wishes to assess his risk of malnutrition during his hospital stay. Which tool is most appropriate to use for this purpose?

A 62-year-old woman with end-stage renal disease managed by continuous ambulatory peritoneal dialysis develops increasing abdominal discomfort, mild fever, and notices that her peritoneal dialysate has become turbid. Examination reveals diffuse abdominal tenderness. Peritonitis is suspected. Which organism is most likely to be cultured from her dialysate fluid?

A 75-year-old woman presents for follow-up after a recent fall at home, during which she briefly lost balance but did not lose consciousness. Over the last two weeks she has experienced intermittent mild headaches but remains independent and alert. She has a history of hypertension and paroxysmal atrial fibrillation managed without anticoagulation. On examination, vital signs are stable, and there are no focal neurological deficits. A CT head reveals a 1.5 cm chronic frontoparietal subdural haematoma without mass effect. What is the most appropriate next step in management?

A junior doctor sustains a needlestick injury while suturing a patient known to be HIV positive. After immediate first aid, the occupational health team reviews the incident. In assessing the risk of HIV transmission, which patient factor most significantly increases the risk following this exposure?

A pharmaceutical company is testing a new medication intended to slow the progression of metastatic melanoma. During which phase of the clinical trial is the primary objective to assess whether the drug effectively slows disease progression in patients who have the condition?

A gardener presents with several painless, ulcerated nodules ascending from his left hand up the forearm in a linear distribution. He reports pricking his finger on a rosebush 5 weeks ago. He has no systemic symptoms. A skin biopsy is sent and cultured on Sabouraud dextrose agar, producing colonies of a dimorphic fungus. Which infectious agent is most likely responsible for this clinical picture?

A 60 year old man presents with confusion and constipation. He has a history of dyspepsia and admits to regularly self-medicating with large amounts of over-the-counter calcium carbonate tablets for heartburn. On examination, he appears dehydrated, with a blood pressure of 108/68 mmHg and dry mucous membranes.

Investigations:

What is the most likely diagnosis?

A 55-year-old man with type 2 diabetes mellitus is being evaluated for exenatide as an addition to his therapy. According to NICE guidelines, which of the following is NOT a required criterion for initiation or ongoing use of exenatide?

A 62-year-old woman arrives at the emergency department with severe chest pain that began shortly after hearing distressing news about her granddaughter. Her ECG demonstrates ST-segment elevation in the anterior leads, and serum troponin is modestly increased. Emergent coronary angiography reveals no significant coronary artery obstruction. Echocardiography identifies marked hypokinesis and ballooning of the left ventricular apex while basal contraction is preserved. She reports no previous cardiac issues. What is the most likely diagnosis?

A 30-year-old woman seeks genetic counselling due to a strong family history of breast and ovarian cancer.

Her sister was diagnosed with breast cancer at age 34, and her mother died from ovarian cancer at age 48. The patient is currently healthy and examination is unremarkable. The genetics team decides to investigate whether she carries a hereditary mutation commonly associated with breast and ovarian cancer. Which laboratory technique is most appropriate to directly identify BRCA1 or BRCA2 mutations in her DNA sample?

A 36-year-old man with a known history of ulcerative colitis attends clinic for investigation of worsening fatigue and pruritus. On examination, he appears icteric and his liver function tests reveal a raised alkaline phosphatase with a mild elevation of transaminases. Serological testing shows a positive perinuclear antineutrophil cytoplasmic antibody (p-ANCA). What is the most likely diagnosis?

A 58-year-old woman with recently diagnosed hyperprolactinaemia is commenced on cabergoline. Several months later, she presents with breathlessness and a non-productive cough. Which of the following adverse effects is cabergoline most strongly linked to in this scenario?

A 72-year-old woman reports an 11-week history of painless, watery diarrhoea, occurring up to 7 times daily without blood or mucus.

She denies abdominal pain but has noticed unintentional weight loss of 3 kg. Past history is notable for hypertension and longstanding gastro-oesophageal reflux managed with omeprazole. She does not drink alcohol or smoke. Physical examination is unremarkable. Laboratory investigations show mild anaemia, a raised ESR, and a modestly increased faecal calprotectin. Infectious stool studies are unremarkable. Colonoscopy reveals a macroscopically normal colon throughout. Which investigation is necessary to establish the underlying diagnosis?

A 65-year-old man presents with a three-day history of walking into objects on his right side. He denies headache or visual aura. On examination, his visual fields reveal a complete right homonymous hemianopia. Pupillary reflexes and ocular movements are normal. No weakness or sensory loss is found.
Which of the following lesions best explains this visual field defect?

A 73-year-old woman presents with fatigue and exertional breathlessness.

She has a history of known aortic stenosis. Examination reveals a systolic murmur at the right second intercostal space and her laboratory tests show haemoglobin 9.1 g/dl, MCV 72 fL, platelet count 290 × 10⁹/L, and normal white cell count. She denies any haematuria or menstrual losses, and has no dyspeptic symptoms. Which of the following is the most likely underlying cause of her iron deficiency anaemia?

A 52-year-old woman presents with progressive proximal muscle weakness, difficulty climbing stairs, and a violaceous rash on her upper eyelids.

Physical examination reveals Gottron’s papules over the knuckles and erythema over her shoulders (shawl sign). Routine laboratory tests show elevated creatine kinase. Given her diagnosis, which other condition should be carefully considered and screened for as a possible underlying etiology?

An 82-year-old woman is started on digoxin for the management of atrial fibrillation. You notice that the prescribed dose is lower than what is typically given to younger adults. What is the principal pharmacokinetic factor necessitating a lower maintenance dose of digoxin in elderly patients compared to younger individuals?

A 34-year-old woman presents with persistent, well-demarcated hyperkeratotic scaly plaques over her knees, elbows, and along the hairline.

She reports mild itching but no significant pain. A skin scraping sent for fungal culture is negative. Laboratory investigations show all parameters within normal limits except for a mildly elevated ESR. There is no past history of atopy. Which is the most likely diagnosis?

A 72-year-old male with a diagnosis of Parkinson’s disease complains of persistent itching and flaking around the scalp, eyebrows, and upper chest. On examination, there are erythematous patches with greasy scales affecting these areas. Which of the following skin conditions is he at increased risk of developing due to his underlying neurological disorder?

A 14-year-old boy is seen for delayed puberty. He is noted to be shorter than his peers and has underdeveloped secondary sexual characteristics, including minimal pubic and axillary hair, small testes, and absence of voice deepening. He also reports an inability to smell since childhood. Laboratory studies reveal decreased levels of follicle stimulating hormone (FSH), luteinizing hormone (LH), and testosterone. Imaging reveals no pituitary abnormalities. What is the most likely diagnosis?

A 72-year-old woman presents with recurrent episodes of dizziness and palpitations.

Her ECG shows complete atrioventricular (AV) dissociation, with independent atrial and ventricular rates. On cardiovascular examination, her pulse is slow and irregular. Which finding is most likely to be heard when listening to her heart sounds?

A 70-year-old woman with atrial fibrillation and hypertension presents for review.

She reports new-onset constipation since her medication regimen was changed last month. Her current medications include digoxin, diltiazem, bisoprolol, and simvastatin. Laboratory investigations are unremarkable. Which of her medications is most likely responsible for her constipation?

A 28 year old man is admitted with sudden onset haemoptysis, breathlessness and dark coloured urine. Examination reveals bilateral lung crackles. Blood results show elevated creatinine and urea, while urinalysis demonstrates red cell casts and proteinuria. Testing identifies the presence of circulating anti-glomerular basement membrane (anti-GBM) antibodies. Chest imaging shows diffuse airspace shadowing. Which diagnosis most likely accounts for these findings?

A 34-year-old man presents to the emergency department with intermittent fever, headache, and rigors five days after returning from a business trip to West Africa. Laboratory investigations confirm the diagnosis. The admitting team discusses the case and queries whether any diseases require mandatory notification to public health authorities in the UK.
Which one of the following infections is legally notifiable, requiring prompt reporting to public health authorities in the UK?

A 59-year-old man with a BMI of 29 kg/m² and a 2-year history of type 2 diabetes mellitus is seen for routine follow-up.

He has persistent hyperglycaemia (HbA1c 68 mmol/mol) despite being on the maximum tolerated dose of metformin. He was previously trialled on gliclazide but developed severe hypoglycaemia and had to stop it. Which of the following is the most appropriate pharmacological management to improve his glycaemic control?

A 27-year-old woman attends the endocrine clinic with concerns about irregular periods and increased facial hair growth. She is found to be overweight, and her blood tests reveal biochemical evidence of hyperandrogenism. Which of the following laboratory findings is most characteristic of polycystic ovarian syndrome (PCOS)?

A 32-year-old man of Southeast Asian descent is started on carbamazepine for trigeminal neuralgia. Genetic screening reveals he is positive for HLA-B*1502. Ten days after beginning the medication, he develops widespread blistering skin lesions, mucosal ulceration, and full-thickness skin detachment consistent with toxic epidermal necrolysis. Which of the following best describes the principal immunological mechanism responsible for this reaction?

A 45-year-old previously healthy woman presents with a 3-day history of fever, pleuritic chest pain, and a productive cough with purulent sputum. She reports that two weeks ago she experienced a severe episode of influenza. On examination, she is tachypnoeic and hypoxic. Chest auscultation reveals bronchial breathing with coarse crackles over the left upper zone. A chest radiograph demonstrates a cavitating lesion with surrounding consolidation in the left upper lobe.

What is the most likely causative organism in this scenario?

A 59-year-old man with a history of coronary artery disease is started on atorvastatin. He asks about any foods or drinks he should avoid while taking this medication. Which one of the following beverages is most likely to increase his risk of statin toxicity through a drug interaction?

A 52-year-old woman presents with a 2-month history of a painless lump in the neck, persistent hoarseness, and difficulty swallowing. She is a non-smoker and drinks alcohol occasionally. Examination reveals a firm, enlarged left cervical lymph node and a mass involving the left tonsillar region. Imaging suggests a primary tumour in the oropharynx. Biopsy confirms squamous cell carcinoma. Which viral infection is most strongly associated with her diagnosis?

A 22-year-old man presents with recurrent episodes of swollen, painful joints after minor injuries. Laboratory evaluation shows a prolonged activated partial thromboplastin time (APTT), prolonged bleeding time, and a normal prothrombin time (PT). Further testing reveals an almost complete absence of von Willebrand factor. What is the most likely diagnosis?

A 68-year-old man presents with lower back discomfort and heaviness in both legs after walking short distances. He notices that his symptoms improve when he sits or bends forward, but worsen when he stands upright or leans backwards. Neurological examination of the legs reveals no abnormalities. Lumbar spine radiographs are unremarkable. Which diagnosis best explains his symptoms?

A 59-year-old man presents to the emergency department with sudden-onset breathlessness and pleuritic chest pain. He has a history of recent major orthopaedic surgery. On examination, he is pale, clammy, and confused with a blood pressure of 75/45 mmHg despite receiving two litres of intravenous normal saline. His oxygen saturation is 90% on high-flow oxygen. An urgent CT pulmonary angiogram confirms a large pulmonary embolism. What is the most appropriate next management step?

An 8-year-old girl is brought to the clinic by her parents due to poor academic performance and growing social isolation. They note she has been asking them to repeat themselves more often over the past year. Examination reveals bilateral sensorineural hearing loss, as well as an enlarged, non-tender thyroid gland. The child’s growth charts show a decreasing percentile for height and recent weight gain. On questioning, her parents state she is often lethargic and constipated. Laboratory tests reveal elevated TSH and decreased free T4 levels. Which of the following conditions is most likely responsible for her presentation?

Which of the following is NOT a recognized clinical feature or association of Friedreich’s ataxia?

A 53-year-old man with poorly controlled type 2 diabetes attends clinic for a routine review. He asks about skin changes that may be related to his condition. Which of the following skin disorders is NOT commonly associated with diabetes mellitus?

A 48-year-old man presents with jaundice and pruritus two weeks after starting a new medication. Laboratory tests reveal a cholestatic pattern of liver enzyme derangement. Which of the following medications is least likely to be associated with drug-induced cholestatic liver injury?

A 30-year-old man undergoes an electroencephalogram as part of an evaluation for episodic loss of consciousness. Which of the following frequency ranges is characteristic of alpha wave activity on an EEG?

A 64-year-old woman with a history of persistent atrial fibrillation is started on amiodarone to prevent further arrhythmias. What is the principal cardiac electrophysiological action of amiodarone?

A 29-year-old woman presents to her GP with painful, red lumps on the fronts of both shins that have developed over the past ten days. She also reports recent fatigue and mild aches in her ankles and knees. She has no cough, weight loss, or night sweats. Examination reveals multiple tender, raised, erythematous nodules on the anterior aspects of both lower legs. Her blood tests are unremarkable. A chest X-ray is performed and described as showing clear lung fields with bilateral hilar lymphadenopathy but no consolidation. What is the most likely diagnosis?

A 68-year-old woman with a history of primary biliary cholangitis presents to clinic complaining of persistent lower back discomfort. Her examination reveals localised tenderness over the lumbar spine but no neurological deficits. Laboratory studies show alkaline phosphatase is elevated, but no evidence of infection or malignancy is found. Which of the following is the most likely explanation for her symptoms?

A 38-year-old man who recently immigrated from Southeast Asia presents with several months of numbness affecting the lateral aspect of his left hand and forearm. He also reports the appearance of pale, slightly raised skin patches on his trunk and upper arm. On examination, there is thickening of the ulnar and radial nerves bilaterally. Which investigation is most definitive in confirming the diagnosis of leprosy by identifying Mycobacterium leprae?

A 72-year-old woman with a background of atrial fibrillation and type 2 diabetes is brought to hospital after developing sudden right-sided weakness and expressive aphasia over the past 2 hours. Her observations are stable. Blood tests are unremarkable, and an urgent CT head excludes intracranial haemorrhage. She is diagnosed with an acute ischaemic stroke. According to national guidelines, what is the maximum allowable interval from symptom onset for the administration of intravenous thrombolysis (alteplase) in this setting?

A 67-year-old man is rescued from a lake in winter after prolonged exposure to cold water. On arrival at hospital, he is found to be shivering and drowsy, with a core temperature measured at 30ºC. An ECG is performed to evaluate his cardiovascular status.

Which of the following findings is most characteristic of hypothermia on ECG?

A 27-year-old man with no history of smoking or respiratory disease presents to the Emergency Department after experiencing mild pleuritic chest pain that began while at rest. He has no shortness of breath and is haemodynamically stable. Chest x-ray demonstrates a left-sided pneumothorax with a 1.2 cm rim of air visible at the hilum. What is the most appropriate initial management for this patient?

A 28-year-old man reports recurrent episodes where his fingers become pale and painful in cold weather, sometimes followed by a bluish discoloration and later redness as they warm. He finds that non-pharmacological measures, such as wearing thick gloves, have provided little relief. His hand examination reveals no abnormalities, and his medical history is unremarkable. Which pharmacological agent is most appropriate to alleviate his Raynaud’s phenomenon?

A 70-year-old woman taking warfarin for a mechanical heart valve is admitted with spontaneous gum bleeding. Her INR is found to be 7.2. She recently completed a course of antibiotics for a urinary tract infection. Which of the following antibiotics, when used with warfarin, is most likely to have caused her elevated INR?

A 68-year-old woman with a previous diagnosis of dilated cardiomyopathy presents to clinic with worsening symptoms. She describes episodes where she awakens suddenly at night, gasping for air a few hours after going to bed. These episodes are partially relieved when she sits upright. On examination, she has fine inspiratory basal crackles and mild ankle swelling. Which symptom is most characteristic of poorly controlled left-sided heart failure?

A 25-year-old woman is found at home confused and excessively sweating. On arrival to the emergency department, her vital signs show a temperature of 38.3ºC, pulse 112/min, BP 125/80 mmHg, and respiratory rate 32/min. Physical examination finds bibasal inspiratory crackles in the lungs. Arterial blood gas reveals: pH 7.33, pCO2 3.2 kPa, pO2 13.6 kPa. Which is the most likely explanation for her presentation?

A 72-year-old man with known cervical spondylosis presents with progressive numbness and tingling in both hands, as well as difficulty walking. On examination, his gait is unsteady, muscle tone is increased in both lower limbs, and plantar reflexes are extensor bilaterally. What is the most appropriate next step in his management?

A 55-year-old woman, recently treated for breast cancer, presents with symptoms of exertional dyspnoea and fatigue over the past two months. Echocardiography reveals global left ventricular dilatation and reduced ejection fraction. Her past medical history is notable for receiving multiple cycles of doxorubicin-containing chemotherapy. Which one of the following statements is correct concerning her cardiac status?

A 65 year old woman with known multiple myeloma presents with nephrotic-range proteinuria and progressive kidney dysfunction. A renal biopsy is performed, and Congo red staining shows apple-green birefringence under polarized light. What is the most likely type of amyloid protein involved in the pathogenesis of her renal disease?

A research group is evaluating a new blood biomarker for the diagnosis of early-stage pancreatic cancer. In a cohort of 1800 patients, 300 had a positive biomarker result. Later, 240 of these 300 patients were found to have pancreatic cancer on biopsy. Of the 1500 patients with a negative biomarker, 60 were subsequently diagnosed with pancreatic cancer. Based on this information, what is the specificity of the blood biomarker test?

A 52-year-old man undergoes renal transplantation for chronic kidney disease secondary to hypertension. He is commenced on standard immunosuppressive therapy. At his annual review, cancer surveillance is discussed as part of his long-term management. Which malignancy is he at greatest risk of developing as a result of his immunosuppressive therapy?

A 34-year-old woman presents with involuntary, dance-like movements affecting her face and limbs. She has a history of systemic lupus erythematosus (SLE) and is currently 12 weeks pregnant. Which of the following is least likely to be a cause of her chorea?

A 56-year-old woman with a history of prolonged neutropenia following chemotherapy presents with painful, necrotic cutaneous nodules and fever. Punch biopsy of a lesion is performed for Gram stain and histopathology. Microscopy reveals acute angle branching, septate hyphae. Which of the following is the most likely causative organism?

A 45-year-old man has a 3-year history of slowly progressive weakness affecting his left hand and right foot. There is no sensory loss or sphincter involvement. Examination reveals marked weakness of the left wrist extensors and right ankle dorsiflexors, with preserved sensation and normal tendon reflexes. Nerve conduction studies demonstrate motor conduction block in the affected nerves, but sensory nerve action potentials remain within normal limits. What is the most appropriate treatment to initiate?

A 21-year-old woman is referred to nephrology with persistent microscopic haematuria identified during routine health checks. She has recently begun to notice gradual hearing loss, particularly struggling to hear conversations in noisy environments. Her past medical history is notable for no previous hospital admissions. On further questioning, she reports that her father required a kidney transplant in his 40s and wore hearing aids from a similar age. Which of the following clinical findings would best support the suspected diagnosis?

A 56 year old man with a 10-year history of type 2 diabetes presents for review. His BMI is 35 kg/m² and his blood pressure is 150/96 mmHg. His medical history includes a non-ST elevation myocardial infarction three years ago. He is currently taking metformin 1 g twice daily. His latest HbA1c is 68 mmol/mol (8.4%). Which medication would be the most suitable next addition to his diabetes regimen?

A 72-year-old woman with osteoarthritis and hypertension presents with new onset confusion and reduced urine output. Blood tests reveal: Sodium 140 mmol/l, Potassium 6.1 mmol/l, Urea 25.0 mmol/l, Creatinine 390 µmol/l. Six months prior, her renal function was within normal limits. Her regular medications are listed below. Which of these should be discontinued immediately due to its potential to directly precipitate or worsen her acute kidney injury?

A 35-year-old man with a history of a congenital ventricular septal defect (VSD) that was never surgically repaired presents with increasing fatigue and shortness of breath. Clinical examination reveals central cyanosis, digital clubbing, and a loud pulmonary component of the second heart sound. Echocardiography shows significantly elevated pulmonary artery pressures and a right-to-left shunt across the ventricular septum. What is the most likely diagnosis?

A 30-year-old woman, 12 weeks pregnant, attends her first antenatal visit. She is well with no urinary symptoms. A routine midstream urine culture grows >100,000 CFU/mL of Enterococcus faecalis. She has no known drug allergies. What is the most appropriate next step in her management?

A 62-year-old female with a history of type 2 diabetes presents complaining of progressive left shoulder discomfort and increasing stiffness over the past 3 months. She notes difficulty reaching above her head and struggles especially when trying to fasten her seatbelt. There is no history of trauma. On examination, both active and passive external rotation of the shoulder are markedly limited, with pain at the end of range. Abduction and internal rotation are also restricted, but to a lesser extent. There is no localized swelling, deformity, or tenderness over the bony prominences. What is the most likely diagnosis?

A 60-year-old man with a history of previous myocardial infarction is prescribed clopidogrel for secondary prevention. He also requires long-term gastric acid suppression for peptic ulcer disease. Which drug, if prescribed alongside clopidogrel, is most likely to reduce its effectiveness due to CYP2C19 inhibition?

A 65-year-old man with chronic kidney disease is treated for methicillin-resistant Staphylococcus aureus (MRSA) sepsis. Which of the following antimicrobial agents requires routine measurement of plasma concentrations due to its narrow therapeutic index and risk of nephrotoxicity?

A 35-year-old patient has recently been diagnosed with multiple sclerosis. You are counselling them regarding factors that may predict a more aggressive disease course. Which of the following is associated with a worse prognosis in multiple sclerosis?

A 38-year-old woman is referred for cardiovascular risk assessment. Routine blood tests reveal a fasting cholesterol level of 10 mmol/l. She reports a strong family history of premature coronary artery disease. On examination, which of the following physical findings would be most specific for familial hypercholesterolaemia?

A 35-year-old woman presents to the emergency department with a sudden, severe headache described as the worst of her life, along with photophobia and nausea. Neurological examination is normal. CT brain performed 7 hours after symptom onset is reported as normal. You suspect subarachnoid haemorrhage and plan a lumbar puncture to look for xanthochromia. After how many hours from the onset of headache should the lumbar puncture be performed to maximise the sensitivity for xanthochromia detection?

A 19-year-old woman is evaluated for multiple hyperpigmented macules on her torso and thighs, each greater than 15 mm in diameter. She has noticed several painless, soft cutaneous nodules in recent years. On examination, there is evidence of axillary freckling, but no family history of neurological disease is reported. To support a clinical diagnosis of neurofibromatosis type 1, which investigation would be most useful to detect a specific ocular diagnostic criterion?

A 35-year-old woman is admitted following a knife injury to the right side of her back at the T8 level. On neurological examination, she has marked weakness in her right leg, absent proprioception and vibration sense in the right leg below T8, and loss of pain and temperature sensation in the left leg beginning several levels below T8. Reflexes are brisk in the right lower limb. Which of the following syndromes best explains her neurological findings?

A 52-year-old woman with treatment-resistant depression is being assessed for a change in her antidepressant medication. She has a history of previous medication overdoses. When considering the safety profile of tricyclic antidepressants, which is considered most dangerous in overdose situations?

Which of the following best describes the molecular class of adrenergic receptors involved in cellular signal transduction following adrenaline binding?

A 3-year-old girl presents with profound developmental delay, multiple congenital anomalies, and failure to thrive. She has recently been diagnosed with a chromosomal abnormality following comparative genomic hybridization. Which chromosomal abnormality is most likely responsible for such a severe clinical presentation due to the greatest genetic imbalance?

A 72-year-old man presents to his GP complaining of sudden onset flashes of light and moving black spots in his right eye. He denies any pain or loss of central vision. On further questioning, he reports these symptoms started two days ago and have persisted. What is the most likely underlying diagnosis?

A 62-year-old man presents to his general practitioner reporting ongoing loose stools and mild cramping lower abdominal pain that have persisted since his elective laparoscopic cholecystectomy performed 2 months ago. He has no fever, and his physical examination is unremarkable apart from mild peri-umbilical tenderness. Blood tests, including full blood count and inflammatory markers, are within normal limits, and stool cultures are negative. Which of the following is the most likely cause of his symptoms?

A 25-year-old woman presents with a two-year history of gradually worsening hearing loss in both ears. She also experiences persistent tinnitus, but denies vertigo or recurrent ear infections. Her family history is significant for her mother and maternal uncle both requiring hearing aids for ‘early onset hearing problems.’ On examination, her ear canals and tympanic membranes are normal. Audiometry confirms a bilateral conductive hearing loss. What is the most likely diagnosis?