EMQ QUESTIONS PAPER 1 EMQ 1.

1 Treatment of cardio/respiratory emergencies; choose the most

appropriate treatment. 1. 75-year old man with crushing central chest pain for 1 hour and ST elevation in the anterior leads of his ECG. He had a previous myocardial infarction 6 months ago. 2. 82-year old female who suffers a cardiac arrest whilst in the A&E department. The monitor shows asystole. 3. 24-year old female who presents with wheeze and a rash following ingestion of shellfish 4. 36-year old male with central crushing chest pain, has a broad complex tachycardia. On examination he is clammy, tachypnoeic and has a BP of 90/30 5. 67-year old male who is brought into A&E after having an out of hospital cardiac arrest, the monitor shows ventricular fibrillation.

(A) Adrenaline 1mg IV (B) Amiodarone 300mg IV (C) Atropine 3mg (D) Coronary artery bypass grafting (E) Defibrillation 50J (F) Defibrillation 200J (G) Hydrocortisone 200mg IV (H) Primary angioplasty (I) Streptokinase 1.5 million Units IV (J) Synchronised DC cardioversion 100J

EMQ 1.2 Musculoskeletal pains; choose the SINGLE most likely diagnosis. 1. A 23-year old man with celiac disease complains of difficulty climbing stairs and generalised bone pain 2. A 50-year old woman with a history of mastectomy complains of back pain, worse at night 3. A 7-year old child presents with a 3-month history of a painful limp and swelling just above the knee. Her parents report that this is getting worse. 4. A 70-year old woman presents with kyphosis and acute on chronic thoracic pain 5. A 60-year old male smoker presents to A&E complaining of 10 hours progressively worsening but severe back pain. He has a history of poor circulation. The nurses report him to be hypotensive.

(A) Ankylosing spondylitis (B) Aortic aneurysm rupture (C) Metastases (D) Myeloma (E) Osteogenesis imperfecta (F) Osteomalacia (G) Osteomyelitis (H) Osteoporosis (I) Osteosarcoma (J) Systemic Lupus Erythematosus

EMQ 1.3 Itchy rashes; choose the most likely diagnosis 1. An 8-year old boy complains of generalised itching with an excoriated rash, mainly on the trunk, of 2-months duration. His mother has recently developed a similar rash 2. A 34-year old woman has experienced recurrent itchy weal of variable severity on her trunk and limbs on most days over a 6-month period. 3. A 2-year old child has an excoriated rash on the cheeks, trunk, antecubital and popliteal fossae, which is disturbing his sleep. 4. A chronically underweight 40 year old woman has recently developed a pruritic rash, especially affecting elbows and buttocks. There are a few small clear blisters, but most lesions are excoriations. 5. A 23-year old woman who is 35 weeks into her first pregnancy has an itchy popular eruption which began in the stretch marks but has spread to the lower limbs

(A) Acrodermatitis enteropathica (B) Atopic eczema (C) Cholestatic jaundice (D) Contact allergic dermatitis to biological washing powder (E) Dermatitis herpetiformis (F) Food allergy (G) Idiopathic urticaria (H) Iron deficiency (I) Polymorphic eruption of pregnancy (J) Scabies

EMQ 1.4 Child heath; choose the most likely diagnosis 1. A teenage girl aged 13 years with abdominal stretch marks and height tracking steadily along 50th centile since the age of 5, whose current weight is >99.6th centile. 2. A girl aged 9 years whose height has dropped from the 50th centile to below the 9th centile, but whose weight has increased to above the 75th centile. She has coarse hair and feels the cold. 3. A boy aged 5 years who eats next to nothing and whose weight and height are tracking along the 2nd centile. 4. A boy aged 14 years with no signs of secondary sexual development whose weight and height centiles have both dropped from the 50th to the 25th centile over the past 2 years. 5. A 1-year old baby who is reluctant to take solid foods, whose weight has dropped from the 75th to the 2nd centiles.

(A) Achondroplasia (B) Constitutional pubertal delay (C) Constitutional short stature (D) Craniopharygioma (E) Crohns disease (F) Cushings syndrome (G) Failure to thrive/weight faltering (H) Hypothyroidism (I) Prader-Willi syndrome (J) Simple obesity

EMQ 1.5 Management of infection; choose the most relevant statement. 1. Aciclovir 2. Gentamicin 3. Fluconazole 4. Erythromycin. 5. Penicillin

(A) Acts on bacterial cell wall synthesis (B) Acts only on gram positive bacteria (C) Levels should be monitored (D) Used as prophylaxis in close contacts of meningococcal meningitis (E) Used for treatment of norovirus (Norwalk virus/small round structured virus) infections (F) Used in the treatment of athletes foot (G) Used to treat hepatitis B infection (H) Used to treat Herpes simplex virus (HSV) infection (I) Used to treat HIV infection (J) Used to treat infection with campylobacter spp.

EMQ 1.6 Urological/abdominal problems; choose the most likely diagnosis 1. A 65-year old man attended his GP with increased difficulty in voiding over six months. He complains of hesistency, nocturia and on once occasion noticed some blood at the end of his urinary flow. He has also had backache for three weeks and on blood testing the GP noted his PSA to be 40ng/ml 2. A 73-year old man attended his GP complaining of three episodes of haematuria over the previous month. On each occasion he found it difficult to pass urine for several hours but was then relived by a sudden rush of blood stained urine. There was no pain. 3. A 55-year old woman attended her GP complaining of four episodes of dull aching pain in the left loin associated afterwards by blood mixed throughout the urinary stream. The GP checked her urine in the surgery and found blood but no leukocytes. 4. A 39-year old man attended his GP complaining of severe pain in the left loin radiating into his left testicle. There was no tenderness and on stick testing the urine the GP found traces of blood. 5. A 25-year old woman attended her GP complaining of a 6-hour history of lower abdominal pain associated with pain passing water. She was noticeable tender supra-pubically and in the right lower quadrant with some rebound tenderness at the latter site. On urine stick testing the GP found protein but no cells.

(A) Acute appendicitis (B) Acute diverticulitis (C) Acute pyelonephritis (D) Carcinoma of prostate with bony metastases (E) Localised carcinoma of prostate (F) Renal cell carcinoma of kidney (G) Testicular torsion (H) Transitional cell carcinoma of bladder (I) Ureteric calculus (J) Urinary tract infection

EMQ 1.7 Metabolic abnormalities; choose the most likely diagnosis 1. A 60-year old woman is found to have decreased bone density. Her serum calcium is 2.85mmol/L (normal range 2.1-2.5mmol/L) and her PTH level is raised. 2. A 74-year old woman has a large right breast lump and pain in her ribs severe enough to keep her awake at night. She is also found to have a raised calcium. 3. A 25-year old man is noted to have a neck swelling and a raised calcitonin. His father had an operation on his thyroid. 4. A 44-year old man has chronic renal failure and is receiving haemodialysis. He has developed painful muscles, osteopenia and some subcutaneous calcification. 5. A 30-year old man has recently developed a cough, and shortness of breath on exertion. Chest X-ray shows bilateral hilar lymphadenopathy. Routine blood tests show he is hypercalcaemic.

(A) Bone metastases (B) Follicular cancer (C) Meduallary cancer (D) Milk-alkali syndrome (E) Papillary cancer (F) Primary hyperparathyroidism (G) Sarcoid (H) Secondary hyperparathyroidism (I) Thyroid lymphoma (J) Tuberculosis

EMQ 1.8 Rectal bleeding; choose the most likely diagnosis 1. A 25-year old woman, 6 weeks post partum with rectal bleeding, pruritis and perianal pain. 2. A 65-year old man with a 6 month history of rectal bleeding, change in bowel habit, lower abdominal pain and weight loss. 3. A 21-year old lady with rectal bleeding and severe pain on defecation 4. A 30-year old male with bloody diarrhoea 20 times/day, weight loss and a colonoscopy showing inflammation from the rectum to the caecum. 5. A 90-year old lady with rectal bleeding and something coming down every time she defecated.

(A) Colon cancer (B) Crohns disease (C) Diverticular disease (D) Fissure in ano (E) Fistula in ano (F) Gastroenteritis (G) Haemorrhoids (H) Rectal prolapse (I) Sigmoid volvulus (J) Ulcerative colitis

EMQ 1.9 Obstetric conditions; choose the most likely diagnosis 1. A 30-year old multiparous woman presents with scant vaginal bleeding, severe hypotension and a tender uterus at 36 weeks gestation. Fetal heart sounds are not detected. 2. A 26-year old multiparous woman presents with irregular contractions causing discomfort only in third trimester of pregnancy 3. A 20-year old primigravid woman is brought into casualty following a fit in her 36th week of pregnancy. She is noted to have a blood pressure of 170/110mm Hg and 2+ of proteinuria. 4. A 22-year old primigravid woman is seen at clinic at 28 weeks. She is noted to have ankle oedema and a blood pressure of 160/110mmHg. Her urine demonstrates the presence of protein. 5. A 28-year old primigravid woman with lower abdominal pain and a spiking fever 24 hours after delivery of her baby.

(A) Abruptio placentae (B) Braxton-Hicks contractions (C) Endometriosis (D) Early pregnancy (E) Eclampsia (F) Ectopic pregnancy (G) Endometritis (H) Placenta praevia (I) Pre-eclampsia (J) Quickening

EMQ 1.10 Hepatomegaly; select the most likely diagnosis 1. A 76-year old lady is admitted with dyspnoea 3 days post MI, I found to have a palpable tender liver. 2. A male of 50 years of age with known non-insulin dependent diabetes mellitus is found to have Hepatomegaly at routine follow up. 3. At an insurance Medical Examination a lady of 50 years of age is noted to have xanthelasma, skin pigmentation and a palpable liver. 4. A 45-year old Publican, who attends to the Dermatology clinic with severe psoriasis, is noted to be jaundiced and have a large liver. 5. A 70-year old lady with constant upper abdominal pain and anorexia is found to have an enlarged irregular liver.

(A) Alcoholic liver disease (B) Auto-immune hepatitis (C) Chronic obstructive pulmonary disease (D) Congestive cardiac failure (E) Infective hepatitis (F) Lymphoma (G) Metastatic liver disease (H) Polycystic liver (I) Primary biliary cirrhosis

PAPER 2 EMQ 1.1 Psychiatric disorders; choose the most likely diagnosis. 6. 16-year old girl with paracetamol overdose following the break up of a relationship one week earlier Adjustment disorder 7. 75-year old woman with low mood and beliefs that her bowels have stopped working and her heart is no longer beating Depressive episode with psychotic features 8. 36-year old fireman with low mood, anxiety and flashbacks of disturbing work experiences Post-traumatic stress disorder 9. 24-year old woman with repeated self-injury, depressed mood and difficulty sustaining relationships Emotionally unstable personality disorder borderline type 10. 34-year old man with disinhibition, over activity and the belief that he has a mission to bring peace to the world. Manic episode (more severe episodes may have grandiose delusions)

(A) Adjustment disorder (B) Depressive episode with psychotic features (C) Emotionally unstable personality disorder borderline type (D) Generalised anxiety disorder (E) Manic episode (F) Non-psychotic depression (G) Post-traumatic stress disorder (H) Schizoaffective disorder depressive type (I) Schizoaffective disorder manic type

EMQ 1.2 The management of dysfunctional uterine bleeding; choose the SINGLE most appropriate answer. 6. A 25-year old married woman who presents with irregular menstrual cycles and menorrhagia. She would not like to start a family yet Oral contraceptives 7. A 50-year old woman present with irregular uterine bleeding. Hysteroscopy 8. A 14-year old female complains of heavy periods and pain. She is not sexually active. Oral contraceptives 9. A 40-year old woman presents with heavy, regular periods Mefenamic acid 10. A 33-year old woman presents with intermenstrual bleeding that is not controlled with oral contraceptives. Hysteroscopy

(A) Clomiphene citrate x (B) Ethinylestradiol x (C) Hysterectomy (D) Hysteroscopy (E) Measure progesterone levels at day 21 x (F) Mefenamic acid (G) Pipelle endometrial sampling (H) Provera (I) Oral contraceptives

EMQ 1.3 Genetics; choose the most appropriate mode of inheritance 6. Type II diabetes 7. Duchenne Muscular dystrophy 8. Cystic Fibrosis 9. Huntingtons disease 10. Myotonic dystrophy

(A) Autosomal Dominant (B) Autosomal recessive (C) X-Linked Dominant (D) X-Linked recessive (E) Mitochondrial (F) Mutlifactorial (G) Polygenic (H) No genetic factor involved

EMQ 1.4 Diarrhoea; choose the most likely diagnosis 6. A 32-year old woman presents with recurrent lower abdominal pain. Her bowels are all over the place with intermittent constipation and diarrhoea. The pain is often after eating and lasts for up to an hour. She is other wise well, and has lost no weight. Examination and barium enema are normal 7. A 28-year old woman presents with a history of sudden onset of vomiting and frequent watery stools 2 days previously. The vomiting has settled but the diarrhoea persists. A stool specimen taken at the time reveals no bacterial growth. 8. A 40-year old man presents with a 3 year history of weight loss, lassitude and the passage of bulky stools that are offensive and difficult to flush away. 9. A 73-year old woman develops intractable diarrhoea after leaving hospital where she was treated for pneumonia 10. A 26-year old man presents with a 6 day history of up to 10 episodes of watery diarrhoea containing both blood and mucus. He has had some looseness of his stools in the last 6 weeks, associated with cramping lower abdominal pain. He has previously been well. On examination he is afebrile, mildly dehydrated and tender in the LIF.

(A) Carcinoma of the colon (B) Diverticulitis (C) Irritable bowel syndrome (D) Ischaemic colitis (E) Laxative abuse (F) Malabsorption syndrome (G) Pseudomembranous colitis (H) Salmonella infection (I) Ulcerative colitis (J) Viral gastroenteritis

EMQ 1.5 Therapeutics; choose the most likely treatment. 6. A 62-year old man with an 8-week history of angina of effort, occurring several times per week. He has a past history of asthma. 7. A 22-year old woman with a 2 month history of weight loss, increased sweating, palpitation, and anterior neck swelling. 8. A 73-year old man with acute exacerbation of COPD associated with a purulent spit. He is known to have a penicillin allergy. 9. A 43-year old woman with a 4 month history of increasing pain and stiffness in both hands. Examination shows swelling and tenderness of the PIP and MCP joints of both hands. 10. A 40-year old man with a 20 year history of insulin dependent diabetes mellitus who has developed sustained, moderate hypertension (BP 140/105)

(A) Ampicllin (B) Atenolol (C) Benzhexol (D) Carbamazepine (E) Carbimazole (F) Enalapril (G) Erythromycin (H) Gentamicin (I) Ibuprofen (J) Isosorbide Mononitrate (K) Paracetamol

EMQ 1.6 Jaundice; choose the most likely diagnosis 6. A 40-year old woman presents with progressive jaundice and severe discomfort in the epigasgtrium. She is apyrexial. 10 months before she had undergone laparascopic cholecystectomy. 7. A diabetic 47-year old man presents with severe weight loss and painless progressive jaundice. His gallbladder is palpable on examination. 8. A 25-year old intravenous drug abuser in hospital with suspected appendicitis becomes suddenly unwell with a high swinging temperature, jaundice, and palpable tender hepatomegaly 9. A 53-year old hotel worker has a 10-day history of increasing jaundice and confusion. On examination he has spider naevi and palmar Erythema. The liver is not palpable. He also has glove and stocking loss of sensation 10. A 29-year old woman has a 2 week history of mild jaundice and pallor, dating from an upper respiratory infection. On examination the spleen tip is just palpable. Urinanalysis shows excess urobilinogen, but no bilirubin.

(A) Acute cholecystitis (B) Alcoholic liver disease (C) Carcinoma of the head of the pancreas (D) Choledocholthiasis (E) Haemolytic anaemia (F) Hepatic abcess (G) Metastatic hepatic disease (H) Pancreatitis (I) Portal vein thrombosis

EMQ 1.7 Trauma; choose the most likely diagnosis 6. A 70-year old woman presents with breathlessness, having fallen down stairs onto her left side. She has resonance over the left chest with absent breath sounds. 7. A 75-year old man falls 20 meters from a window and presents by ambulance 2 weeks later with a Glasgow Coma Scale of 7. 8. A child is struck by a car and presents with a Glasgow Coma Score of 4 and a fixed dilated right pupil. 9. A footballer is brought to casualty following a heavy challenge. He has a painful swelling in his upper thigh with limb shortning. 10. A student is brought to casualty following a road traffic accident. He is hypotensive and tachycardic with a swollen rigid abdomen and no bowel sounds.

(A) Extradural haematoma (B) Femoral fracture (C) Fractured rib (D) Haemothorax (E) Hip dislocation (F) Liver rupture (G) Pelvic fracture (H) Pneumothorax (I) Renal haematoma (J) Subdural haematoma

EMQ 1.8 Headache; choose the most likely diagnosis 6. An 80-year old woman has pains over her forehead which was previously the site of an episode of shingles 7. A 40-year old man presents with a 2-day history of pain in the mandible at the site of a recent tooth filling 8. A 75-year old woman complains of severe dull headache with scalp tenderness when she combs her hair 9. A 16-year old girl give a 2 year history of episodic unilateral throbbing headache associated with vomiting and photophobia 10. A 60-year old woman presents with a 2-week history of gradually worsening occipital headache. The pain is made worse by coughing, and tends to improve as the day goes on.

(A) Acute bacterial meningitis (B) Cervical disc protrusion at C5/6 (C) Dental abscess (D) Migraine (E) Post herpetic neuralgia (F) Raised intracranial pressure (G) Sub-arachnoid haemorrhage (H) Temporal arteritis (I) Tension headache (J) Trigeminal neuralgia

EMQ 1.9 Patients presenting as an emergency with abdominal pain; choose the SINGLE most likely diagnosis 6. A 74-year old man presents with sudden onset of severe abdominal pain radiating to his back. On examination he is profoundly shocked and has a distended tender abdomen 7. A 40-year old woman present with right upper quadrant pain and vomiting. On examination she is afebrile and has localised tenderness below the right costal margin 8. A 67-year old woman presents with upper abdominal pain and rigors. On examination she is jaundiced and has a temperature of 40oC 9. A 23-year old medical student presents with epigastric pain and vomiting of altered blood following a weekend of heavy drinking after passing his final exam. 10. A 56-year old man with a history of several previous operations for Crohns disease presents with colicky abdominal pain and bilious vomiting

(A) Acute cholecystitis (B) Acute pancreatitis (C) Ascending cholangitis (D) Empyema of gallbladder (E) Gastritis (F) Perforated peptic ulcer (G) Ruptured aortic aneurysm (H) Sclerosing cholangitis (I) Small bowel obstruction (J) Viral hepatitis

EMQ 1.10 Respiratory problems in childhood; select the SINGLE most likely diagnosis 6. A 16-month old boy is admitted with a weeks history of wheeze, not helped with salbutamol (ventolin) administration. On examination he has dyspnoea, and a pyrexia of 38.2oC. The right hemithorax is hyperinflated compared with the left. 7. A newborn infant is admitted to the special care baby unit aged 12 hours with tachypnoea, grunting and poor feeding. He is the first baby of a 19-year old mother, in good health, whose membranes ruptured 48 hours before delivery. The birth was normal and the baby weight 3.5kg at 41 weeks gestation. 8. An 8-year old girl is admitted with a one week history of cough and pyrexia with no clinical improvement following a 5 day course of amoxicillin. On examination she looks well, but chest auscultation shows bilateral basal crepitations. 9. A 2-year old boy in admitted with a history of coryzal symptoms for two days followed by a sudden onset of difficult breathing at night. On examination he is pyrexial (38.5oC) but alert, and has inspiratory stridor with intercostals and subcostal recession 10. A 3-year old girl is readmitted with her third episode of cough and wheeze in 6 months. Her mother says that she eats reasonably well but has loose stools and is not putting on weight. Examination shows a thin child with no finger clubbing, a hyper-inflated chest with widespread wheeze and crepitations, and some abdominal distension.

(A) Asthma (B) Atypical pneumonia (C) Bronchitis (D) Croup (E) Cystic Fibrosis (F) Epiglottitis (G) Inhaled foreign body (H) Lobar pneumonia (I) Meconium aspiration (J) Neonatal pneumonia

(K) Respiratory distress syndrome ANSWERS: - Check against a book (I have not check the accuracy of these.

EMQ 1.1
1. 2. 3. 4. 5. A B G C E

EMQ 1.6
1. 2. 3. 4. 5. D C F B E

EMQ 1.2
1. 2. 3. 4. 5. I J I F D

EMQ 1.7
1. 2. 3. 4. 5. H J A E F

EMQ 1.3
1. 2. 3. 4. 5. F D B A A

EMQ 1.8
1. 2. 3. 4. 5. E C H D F

EMQ 1.4
1. 2. 3. 4. 5. C J F G I

EMQ 1.9
1. 2. 3. 4. 5. G A C E I

EMQ 1.5

EMQ 1.10

PAPER 3 EMQ 1.1 Findings on cardiovascular system examination; choose the most likely diagnosis. 11. 55-year old lady with a ten-year history of scleroderma with lung fibrosis attends your clinic for routine follow-up. Her blood pressure is 140/88, the apex beat is in the normal position, JVP is not elevated but her second heart sound is loud in the 3rd left intercostal space. 12. A 75-year old lady is found to have an irregularly irregular pulse. Her blood pressure is 150/85. The JVP is not elevated, she has a pan systolic murmur, loudest at the apex beat radiating into the axilla. Chest X-ray shows pulmonary oedema 13. A 25-year old man is found to have a systolic murmur at routine health screening. His blood pressure is 125/75, he has no elevation of JVP or ankle swelling. The apex beat is in the 5th intercostal space and he has no basal crepitations. The systolic murmur is loudest in the 2nd right intercostals space and radiates to the carotids. 14. A 55-year old man presents with crescendo angina. His blood pressure is 110/90. His JVP is not elevated and there is no ankle swelling. The apex beat is in the mid-clavicular line in the 6th intercostal space. He has no evidence of left ventricular cardiac failure. There is a systolic murmur loudest in the 2nd right intercostal space radiating to the carotids. 15. A 45-year old lady with previous rheumatic fever presents with increasing shortness of breath. She has a collapsing pulse, blood pressure is 160/60 and, although there are no signs or right ventricular failure, she has bilateral basal crepitations. There are no systolic murmurs to be heard but on sitting the patient forward you can hear a diastolic murmur in the 2nd right intercostal space and down the left sternal edge. (A) Aortic incompetence (B) Aortic Stenosis (C) Atrial septal defect (D) Bicuspid aortic valve (E) Mitral incompetence (F) Mitral stenosis (G) Pericarditis (H) Pulmonary artery hypertension (I) Pulmonary stenosis (J) Tricuspid stenosis

EMQ 1.2 Child and adolescent psychiatry; choose the most likely diagnosis. 11. Amanda, an eight-year old, complains of epigastric abdominal pain that is usually worse at about 0800 hours in the morning. Extensive investigation was normal. This confines her to the home. 12. Helen was well until 2 years ago following an off chance remark in the school gym about her size started obsessive dieting. She weighs less than the 3rd percentile and exercises vigorously. Family meal times are a nightmare. 13. Adam is a 3-year old, he wets the bed most nights however, he is dry during the day. He has no development problems. His parents are very anxious that he is not yet dry. 14. A 15-year old girl was brought to the A&E unit at 10.00pm swearing, cursing and swaggering. There was a disagreement the previous night because parents disapprove of her new-found friend. Fifteen minutes later she collapsed. 15. Ryan is 9-years old, he has few friends because of his emphasis on exactitude. He lacks warmth towards his siblings. He does not miss friends as he spends most of his time obsessively studying his special interest in local bus services. Intellectual functioning is normal.

(A) Accidental poisoning (B) Anorexia nervosa (C) Aspergers syndrome (one of the autism disorders) (D) Bulimia nervosa (E) Nocturnal enuresis (F) Obsessive compulsive disorder (G) Physiological immaturity (H) School refusal (I) Substance abuse (J) Truancy

EMQ 1.3 Endocrinology (thyroid disease); choose the most likely diagnosis 11. A 14-year old girl presents with a smooth, enlarged goitre. Her weight is normal, pulse is 75/min and she has no heat or cold intolerance. 12. A 35-year old patient presents with weight loss, diarrhoea and a defined tremor. She has exophthalmos but no lid lag. 13. A lady with proven thyrotoxicosis with exophthalmos complains to you of a skin rash on the lower limbs. Examination demonstrates a thickened area of skin, which is raised on the anterior aspect of the lower limb. 14. Five years after radioactive iodine treatment for thyrotoxicosis, a patient complains of weight gain and an increased sensitivity to cold. You find her bradycardic. 15. A 75-year old lady presents with a rapidly developing swelling in her neck, together with some hoarseness and some difficulty with swallowing. Examination reveals a goitre and some skin tethering to the underlying lesion.

(A) Anaplastic carcinoma of the thyroid (B) Juvenile myxoedema (C) Myxoedema madness (D) Papillary carcinoma of the thyroid (E) Post radiation myxoedema (F) Pretibial myoedema (G) Riedels woody thyroiditis (H) Simple non-toxic goitre (I) Thyroid crisis (J) Thyrotoxicois

EMQ 1.4 Infections (viral); choose the most likely , causative or predisposing virus from the options listed. 11. A two year old child with croup 12. A 56-year old man with cirrhosis and liver failure he was an intravenous drugs used in the 1970s 13. A 45-year old homosexual man who has always lived in Scotland with Pneumocytis carinii in a broncoalveolar lavage. 14. A 19-year old student with warts on his fingers 15. A 19-year old man with a painful sore on his lower lip

(A) Astrovirus (B) Hepatitis A virus (C) Hepatitis C virus (D) Herpes simplex virus 1 (E) Human immunodeficiency virus type 1 (F) Human immunodeficiency virus type 2 (G) Human papillomavirus type 1 (H) Human papillomavirus type 16 (I) Parainfluenza virus (J) Measles virus

EMQ 1.5 Obstetrics and Gynaecology: Problems in pregnancy; choose the most likely diagnosis. 11. A 16-year old unbooked nullipara presents at 33 weeks gestation (by her dates). Abdominal examination shows a fundal height measurement of 37cm with a cephalic presentation. 12. A 26-year old para 3 presents with a light painless bleed at 30 weeks gestation. Examination reveals her to be undistressed, with no signs of shock, and a non-tender abdomen. The fetal lie is transverse. 13. A 40-year old primigravida, with a twin pregnancy at 36 weeks gestation, gives a two-day history of troublesome itch of the palms and soles. There is no obvious rash and no jaundice, although her transaminases levels and serum bilirubin are elevated. 14. An 18-year old primigravida, estimated to be 30 weeks gestation, is admitted with acute onset of lower abdominal pain and slight vaginal bleeding. Her blood pressure 100/60 and she has a tense, tender abdomen and the fetal heart cannot be heard. 15. A 28-year old para 1 has has an uneventful pregnancy and a normal detailed US scan at 18 weeks gestation. At 35 weeks, the fundal height measures 28cm and the liquor volume is clinically reduced.

(A) Abruptio placentae (B) Cervical cancer in pregnancy (C) Cholestasis of pregnancy (D) Fatty liver of pregnancy (E) Hepatitis C in pregnancy (F) Hydatidiform mole (G) Placenta praevia (H) Placental insufficiency (I) twin-to-twin transfusion syndrome (J) Wrong dates

EMQ 1.6 Drug side effects; choose the most likely culprit drug 11. Bronchospasm 12. Pneumonitis 13. Jaundice 14. Anaphylaxis 15. Retroperitoneal fibrosis

(A) Aminophylline (B) Amiodarone (C) Captopril (D) Chlorpromazine (E) Insulin (F) Methysergide (G) Metoclopramide (H) Penicillin (I) Pizotifen (J) Propanolol

EMQ 1.7 Anorectal symptoms; choose the most likely diagnosis 11. A 35-year old man presents with fresh rectal bleeding at the time of defecation. This is accompanied by a sense of local itch and irritation, but no alteration in bowel habit and no systemic upset 12. A 15-year old boy presents acutely with blood stained perianal discharge. He has a two year history of episodes of mouth ulceration, colicky abdominal pain and intermittent bloody diarrhoea. He is on the 10th centile for growth. 13. A 40-year old lady presents with a history of severe pain at the time of defaecation which typically lasts for 45 minutes thereafter. Her bowel habit has become sluggish. 14. A 55-year old female present with a history of intermittent abdominal bloating, crampy left-sided abdominal pain and the discharge of mucus per rectum. Sigmoidscopy and colonoscopy are both normal. 15. A 25-year old man presents with a sudden onset of an acutely painful swelling at the anal verge. There is no history of discharge and no rectal bleeding.

(A) Anal fissure (B) Clotted venous sacule (C) Crohns disease (D) Fistula in ano (E) Internal haemorrhoids (F) Irritable bowel syndrome (G) Proctalgia fugax (H) Prolapsing haemorrhoids (I) Rectal adenoma (J) Ulcerative colitis

EMQ 1.8 Neurological problems in the upper limbs; choose the most likely diagnosis 11. A 34-year old lady presents to her General Practitioner with a 6-month history of pins and needle in her right hand and she has some diminished sensation in the thumb and index finger. Thumb movements appear normal but there is slight muscle wasting of the thenar eminence on the right. 12. A 65-year old lady presents complaining of numbness in both her hands. She admits to a high alcohol intake. On clinical examination there is no wasting of musculature in the forearm of hands. Her reflexes are normal. She has a sensory disturbance to pinprick sensation affecting the thumb and all the fingers of both hands to the level of the metacarpophalangeal joints. 13. A 47-year old woman is admitted to hospital for major abdominal surgery. On discharge two weeks after the operation she complains to the House Officer that she has developed paraesthesia affecting the ring and little finger of her left hand. There is some numbness and weakness of flexion in these two fingers. 14. A 65-year old smoker presents with progressive weakness in the right hand, which has been going on for the last 6 weeks. Clinical examination reveals generalised wasting of the small muscles of the hand and she has an area of diminished sensation in the inner aspect of the upper arm. 15. A 42-year old accountant presents with paraesthesiae in the fingers and weakness at the wrist. Examination shows Grade 3/5 wrist extension and Grade 4/5 elbow extension and the triceps jerk is absent. He gives a history of acute neck pain about 10 days prior to his attendance in surgery.

(A) C5 radiculopathy (B) C7 radiculopathy (C) Carpal tunnel syndrome (D) Infective polyneuropathy (E) Motor neurone disease (F) Multiple sclerosis (G) Pancoasts tumour (apical tumour in the lung) (H) Peripheral neuropathy (I) Radial nerve palsy (J) Ulnar nerve entrapment at the elbow.

EMQ 1.9 Jaundice; choose the most likely cause; ALL the patients have a mild jaundice with a serum bilirubin of <80umol/L 11. A 72-year old lady complains of upper quadrant abdominal pain, fever and rigors. She is tender in the right upper quadrant but no mass is palpable. Serum alkaline phosphatase is 950U/L (normal <280U/L), AST 76U/L (normal <35U/L) and ALT 65U/L (normal <50U/L) 12. A 29-year old male attends his GP with a 48-hour history of influenza-like symptoms. He has not eaten much recently and physical examination is normal. His GP noticed mild jaundice. His liver function tests are otherwise normal. 13. A 55-year old man with a previous history of lung resection for carcinoma of the bronchus presents with weight loss, upper abdominal pain and 2cm enlarged liver. His alkaline alkaline phosphatase is 670U/L (normal <280U/L), the AST 48U/L (normal <35U/L) and ALT 55U/L (normal <50U/L) 14. A 40-year old female health care worker presents with anorexia, nausea and mild jaundice. She has a liver edge two fingers palpable and slight ankle oedema. Her serum transaminases are elevated AST 560U/L (normal <35U/L), ALT 742U/L (normal <50U/L), IgG was 35g/L and anti HBs positive. Prothrombin time is prolonged to 18 seconds. Her liver function test had been recorded as mildly abnormal 3 months ago. 15. A 73-year old woman complains of pruritis, anorexia and weight loss of 5kg. She denies significant abdominal pain. On physical examination there is a mass palpable in the right upper quadrant.

(A) Acute viral hepatitis (B) Alcoholic hepatitis (C) Auto-immune hepatitis (D) Budd-Chiari Syndrome (hepatic vein thrombosis) (E) Carcinoma head of pancreas (F) Common bile duct stone (G) Drug cholestasis (H) Gilberts disease (defective UDP-glucuronyl transferase) (I) Primary biliary cirrhosis (J) Secondary deposits in the liver

EMQ 1.10 Abdominal pain; select the most likely diagnosis 11. A 48-year old man with a past history of alcohol abuse presents with a 12 hour history of vomiting and epigastric pain radiating to his back 12. A 15-year old girl gives a 24-hour history of central abdominal pain. On examination she is tender in her right iliac fossa with guarding and rebound. 13. A 40-year old woman underwent a total abdominal hysterectomy 12 months ago. She now presents with a 36-hour history of colickly central abdominal pain and profuse vomiting. Clinical examination reveals a distended tympanic abdomen. 14. A 64-year old woman present with a 12-hour history of severe epigastric pain. On examination she is pyrexial with tenderness in the right upper quadrant 15. A 12-year old girl has a sore throat and a cough and she present with right iliac fossa pain. Clinically she is mildly tender in the right iliac fossa.

(A) Acute appendicitis (B) Acute cholecytitis (C) Acute pancreatitis (D) Adhesive small bowel obstruction (E) Large bowel obstruction (F) Mesenteric adenitis (G) Obstructed femoral hernia (H) Perforated peptic ulcer (I) Renal colic (J) Torsion of ovarian cyst.

ANSWERS: - Check against a book (I have not check the accuracy of these.

EMQ 1.1
6. H 7. E 8. B 9. B 10. A

EMQ 1.6
6. J 7. F 8. I 9. E 10. A

EMQ 1.2
6. H 7. B 8. E 9. I 10. C

EMQ 1.7
6. E 7. C 8. A 9. F 10. B

EMQ 1.3
6. H 7. J 8. F 9. E 10. A

EMQ 1.8
6. C 7. H 8. J 9. G 10. B

EMQ 1.4
6. I 7. C 8. E 9. G 10. D

EMQ 1.9
6. F 7. H 8. J 9. A 10. J

EMQ 1.5

EMQ 1.10