I85PREP
⌘ K
MRCPI GM Part II Written study materials
MRCPI GM Part II Written study resources

MRCPI GM Part II Written practice questions

One question at a time. Build your MRCPI GM Part II Written understanding.

First 50 of 200 questions. Each one lists the choices, the correct answer, and an explanation. The checker at the top of this page saves progress in this browser when it is available.

Continue in the practice tool above to load more questions, 50 at a time.

Question 1General (internal) medicine - clinical sciences and core topics

A 24-year-old woman presents with palpitations. Her ECG shows a narrow-complex tachycardia at 180 bpm that terminates abruptly with intravenous adenosine. Which mechanism best explains this arrhythmia?

  1. Delayed afterdepolarisations triggered by digoxin toxicity
  2. Re-entry around a scar in the left ventricle
  3. Re-entry involving the atrioventricular node Correct answer.
  4. Enhanced automaticity of the sinus node

Explanation

AV nodal re-entrant tachycardia is the commonest paroxysmal narrow-complex tachycardia in young adults and characteristically terminates with adenosine, which transiently blocks AV nodal conduction and breaks the circuit.

Question 2General (internal) medicine - clinical sciences and core topics

Which finding on arterial blood gas most strongly suggests a primary respiratory alkalosis rather than a metabolic acidosis with respiratory compensation?

  1. Raised bicarbonate with a raised PaCO2
  2. Low PaCO2 with a normal or raised bicarbonate
  3. Normal pH with a low PaCO2 and low bicarbonate
  4. Low PaCO2 with a low bicarbonate Correct answer.

Explanation

In a primary respiratory alkalosis the fall in PaCO2 drives a compensatory renal excretion of bicarbonate, so bicarbonate is low but the pH remains alkalotic. A metabolic acidosis with hyperventilation shows low bicarbonate as the primary abnormality with a low PaCO2 and acid pH.

Question 3General (internal) medicine - clinical sciences and core topics

A 68-year-old man with type 2 diabetes and an eGFR of 28 mL/min/1.73m² is being started on a glucose-lowering agent. Which drug requires dose reduction or avoidance because of reduced renal clearance and risk of lactic acidosis?

  1. Empagliflozin
  2. Sitagliptin
  3. Metformin Correct answer.
  4. Gliclazide

Explanation

Metformin is renally excreted and accumulates when eGFR falls, increasing the risk of lactic acidosis; most guidelines advise stopping it below an eGFR of 30 and reducing the dose between 30 and 45.

Question 4General (internal) medicine - clinical sciences and core topics

A 55-year-old woman has a 6-month history of fatigue, weight gain and cold intolerance. TSH is elevated and free T4 is low. Which antibody is most specific for the underlying cause?

  1. Anti-thyroid peroxidase antibody Correct answer.
  2. TSH receptor stimulating antibody
  3. Anti-smooth muscle antibody
  4. Anti-thyroglobulin antibody

Explanation

Hashimoto thyroiditis is the commonest cause of primary hypothyroidism in iodine-replete populations, and anti-thyroid peroxidase antibodies are the most sensitive and specific serological marker.

Question 5General (internal) medicine - clinical sciences and core topics

A 70-year-old man with atrial fibrillation on warfarin is admitted with melaena. His INR is 6.8 and he is haemodynamically stable. Which is the most appropriate immediate management?

  1. Fresh frozen plasma alone
  2. Intravenous vitamin K alone
  3. Four-factor prothrombin complex concentrate plus intravenous vitamin K Correct answer.
  4. Protamine sulphate

Explanation

For major bleeding with a markedly elevated INR, guidelines recommend urgent reversal with a prothrombin complex concentrate together with intravenous vitamin K to correct the coagulopathy and sustain reversal.

Question 6General (internal) medicine - clinical sciences and core topics

A 32-year-old man presents with sudden-onset pleuritic chest pain and breathlessness after a long-haul flight. Which ECG finding is most characteristic of acute right heart strain from pulmonary embolism?

  1. Delta wave with a short PR interval
  2. Sinus tachycardia with T-wave inversion in lead III Correct answer.
  3. T-wave inversion in leads V1 to V4
  4. ST elevation in leads II, III and aVF

Explanation

The classic described pattern of pulmonary embolism is sinus tachycardia with an S wave in lead I, a Q wave in lead III and T-wave inversion in lead III (S1Q3T3), reflecting acute right ventricular strain.

Question 7General (internal) medicine - clinical sciences and core topics

A 45-year-old woman with known systemic lupus erythematosus presents with haematuria and proteinuria. Which serological finding would most support active lupus nephritis?

  1. High anti-histone antibodies with normal complement
  2. Low anti-double-stranded DNA titre with low complement
  3. Positive anti-centromere antibodies
  4. High anti-double-stranded DNA titre with low C3 and C4 Correct answer.

Explanation

Rising anti-double-stranded DNA titres and falling complement (C3 and C4) reflect immune complex consumption and correlate with active lupus nephritis.

Question 8General (internal) medicine - clinical sciences and core topics

A 60-year-old man has a serum sodium of 118 mmol/L after several days of poor oral intake and excessive water drinking. He is asymptomatic with no neurological signs. Which is the safest initial approach?

  1. Intravenous furosemide without fluid restriction
  2. Fluid restriction with cautious correction of no more than 8-10 mmol/L in 24 hours Correct answer.
  3. Rapid correction with hypertonic 3% saline to 135 mmol/L within 6 hours
  4. Free water restriction alone with no monitoring of sodium

Explanation

In asymptomatic chronic hyponatraemia, the priority is slow correction to avoid osmotic demyelination; a rise of no more than 8-10 mmol/L per 24 hours is recommended in high-risk patients.

Question 9General (internal) medicine - clinical sciences and core topics

Which finding best distinguishes nephrotic from nephritic syndrome in a patient with new proteinuria?

  1. Haematuria with red cell casts
  2. Hypertension and oliguria
  3. Heavy proteinuria with hypoalbuminaemia and oedema Correct answer.
  4. Raised creatinine with a fall in urine output

Explanation

Nephrotic syndrome is defined by heavy proteinuria (usually >3.5 g/day), hypoalbuminaemia and oedema, whereas nephritic syndrome is characterised by haematuria, hypertension and variable renal impairment.

Question 10General (internal) medicine - clinical sciences and core topics

A 58-year-old smoker has a right upper lobe mass and a serum sodium of 124 mmol/L. Which mechanism best explains the hyponatraemia?

  1. Excess atrial natriuretic peptide secretion
  2. Adrenal insufficiency from metastasis
  3. Primary polydipsia
  4. Ectopic secretion of antidiuretic hormone Correct answer.

Explanation

Small cell lung cancer commonly secretes antidiuretic hormone ectopically, producing SIADH with euvolaemic hyponatraemia, low serum osmolality and inappropriately concentrated urine.

Question 11General (internal) medicine - clinical sciences and core topics

A 30-year-old man has recurrent episodes of severe abdominal pain, hypertension and palpitations. Which investigation is most appropriate to confirm the diagnosis?

  1. Plasma renin and aldosterone ratio
  2. Serum cortisol after overnight dexamethasone
  3. 24-hour urinary fractionated metanephrines Correct answer.
  4. Serum gastrin after fasting

Explanation

The triad of paroxysmal headache, sweating and palpitations with hypertension suggests phaeochromocytoma, and measurement of plasma free or 24-hour urinary fractionated metanephrines is the recommended initial test.

Question 12General (internal) medicine - clinical sciences and core topics

Which clinical feature is most suggestive of a diagnosis of Parkinson disease rather than a Parkinson-plus syndrome?

  1. Early falls within the first year
  2. Asymmetrical resting tremor with good response to levodopa Correct answer.
  3. Prominent early autonomic failure
  4. Vertical supranuclear gaze palsy

Explanation

Idiopathic Parkinson disease typically begins asymmetrically with a resting tremor and responds well to levodopa, whereas Parkinson-plus syndromes often show early falls, gaze palsy or severe autonomic dysfunction.

Question 13General (internal) medicine - clinical sciences and core topics

A 28-year-old woman has a generalised tonic-clonic seizure. She is 30 weeks pregnant and has been taking sodium valproate. Which drug should replace valproate as the preferred antiepileptic in pregnancy?

  1. Phenytoin
  2. Sodium valproate at a lower dose
  3. Topiramate
  4. Levetiracetam Correct answer.

Explanation

Sodium valproate carries the highest risk of major congenital malformations and neurodevelopmental harm. Levetiracetam is considered one of the safest options in pregnancy, with extensive reassuring data.

Question 14General (internal) medicine - clinical sciences and core topics

A 65-year-old woman has a sudden painless loss of vision in one eye described as a curtain descending. Which is the most appropriate immediate action?

  1. Topical antibiotic drops and review in 24 hours
  2. Urgent ophthalmology referral for assessment of retinal artery occlusion Correct answer.
  3. Reassurance and outpatient review in 2 weeks
  4. Prescription of new glasses

Explanation

Amaurosis fugax or sudden painless visual loss suggests retinal artery occlusion or transient ischaemia, which is a medical emergency requiring urgent ophthalmological and stroke assessment.

Question 15General (internal) medicine - clinical sciences and core topics

Which laboratory finding is most typical of haemolytic anaemia due to red cell destruction?

  1. Low haptoglobin with raised reticulocyte count and raised lactate dehydrogenase Correct answer.
  2. Low reticulocyte count with normal bilirubin
  3. Raised haptoglobin with low reticulocyte count
  4. Isolated thrombocytopenia with normal bilirubin

Explanation

Haemolysis consumes haptoglobin, raises lactate dehydrogenase and unconjugated bilirubin, and drives a reticulocytosis as the marrow compensates.

Question 16General (internal) medicine - clinical sciences and core topics

A 72-year-old man with chronic kidney disease stage 4 has a haemoglobin of 82 g/L. Which cause of anaemia is most likely in this context?

  1. Autoimmune haemolysis
  2. Vitamin B12 deficiency
  3. Erythropoietin deficiency Correct answer.
  4. Iron deficiency from dietary insufficiency

Explanation

The kidneys produce erythropoietin, and advanced chronic kidney disease is a common cause of normocytic normochromic anaemia due to reduced erythropoietin production.

Question 17General (internal) medicine - clinical sciences and core topics

A 48-year-old man has a serum calcium of 3.05 mmol/L with a raised parathyroid hormone. Which finding would best localise a parathyroid adenoma pre-operatively?

  1. Neck ultrasound and sestamibi scan Correct answer.
  2. Serum phosphate measurement
  3. 24-hour urinary calcium
  4. Bone densitometry

Explanation

Primary hyperparathyroidism is usually caused by a single adenoma, and combined neck ultrasound with sestamibi scintigraphy is the standard pre-operative localisation strategy.

Question 18General (internal) medicine - clinical sciences and core topics

A 21-year-old student has a 3-day history of fever, sore throat and cervical lymphadenopathy. Blood film shows atypical lymphocytes, and a heterophile antibody test is positive. Which advice is most appropriate?

  1. Immediate treatment with high-dose amoxicillin
  2. Urgent bone marrow biopsy
  3. Supportive care and avoidance of contact sports for several weeks Correct answer.
  4. Long-term corticosteroids

Explanation

Infectious mononucleosis due to Epstein-Barr virus is usually self-limiting and managed supportively; splenomegaly carries a risk of rupture, so contact sports should be avoided for around four to six weeks.

Question 19General (internal) medicine - clinical sciences and core topics

Which organism is the commonest cause of community-acquired pneumonia requiring hospital admission in adults in the UK?

  1. Streptococcus pneumoniae Correct answer.
  2. Legionella pneumophila
  3. Mycoplasma pneumoniae
  4. Pneumocystis jirovecii

Explanation

Streptococcus pneumoniae remains the single commonest cause of community-acquired pneumonia across all severities, including patients requiring hospital admission.

Question 20General (internal) medicine - clinical sciences and core topics

A 40-year-old man has a blood pressure of 168/104 mmHg on three occasions. Which secondary cause should be screened for first if he has resistant hypertension with hypokalaemia?

  1. Primary aldosteronism Correct answer.
  2. Cushing syndrome
  3. Renal artery stenosis
  4. Phaeochromocytoma

Explanation

Resistant hypertension with spontaneous or diuretic-induced hypokalaemia is a classic clue to primary aldosteronism, screened with a plasma aldosterone-to-renin ratio.

Question 21General (internal) medicine - clinical sciences and core topics

A 66-year-old man with heart failure with reduced ejection fraction remains symptomatic despite an ACE inhibitor and beta-blocker. Which addition has the strongest evidence for reducing mortality?

  1. An alpha blocker
  2. A loop diuretic
  3. Digoxin
  4. A mineralocorticoid receptor antagonist Correct answer.

Explanation

Mineralocorticoid receptor antagonists such as spironolactone reduce mortality in heart failure with reduced ejection fraction and are recommended in addition to an ACE inhibitor and beta-blocker.

Question 22General (internal) medicine - clinical sciences and core topics

Which feature is most consistent with a diagnosis of stable angina rather than acute coronary syndrome?

  1. Chest tightness provoked by exertion and relieved within minutes by rest Correct answer.
  2. Pain associated with a raised troponin
  3. Pain that is new and crescendo in nature
  4. Chest pain at rest with ST elevation on ECG

Explanation

Stable angina is characterised by predictable exertional chest discomfort relieved by rest or nitrates, with no rise in cardiac biomarkers and no acute ECG changes.

Question 23General (internal) medicine - clinical sciences and core topics

A 55-year-old woman has a 6-week history of proximal muscle weakness and a raised creatine kinase. Which autoantibody is most specific for polymyositis or dermatomyositis?

  1. Anti-nuclear antibody
  2. Anti-CCP
  3. Anti-Jo-1 Correct answer.
  4. Rheumatoid factor

Explanation

Anti-Jo-1 (anti-histidyl-tRNA synthetase) is the commonest myositis-specific antibody and is associated with antisynthetase syndrome, myositis and interstitial lung disease.

Question 24General (internal) medicine - clinical sciences and core topics

A 34-year-old woman has a 3-week history of bloody diarrhoea with urgency. She is haemodynamically stable with a haemoglobin of 105 g/L. Which initial investigation is most appropriate to confirm ulcerative colitis?

  1. Faecal calprotectin alone
  2. Barium enema
  3. Colonoscopy with biopsy Correct answer.
  4. Abdominal ultrasound

Explanation

Colonoscopy with mucosal biopsy is the gold standard for diagnosing ulcerative colitis, allowing assessment of extent and histological confirmation, and is safe in a stable patient.

Question 25General (internal) medicine - clinical sciences and core topics

A 70-year-old man has a creatinine of 250 micromol/L after a recent course of an NSAID. Which finding would best support a diagnosis of acute tubular necrosis rather than pre-renal injury?

  1. Brisk response to a fluid challenge
  2. Muddy brown casts with a fractional excretion of sodium above 2% Correct answer.
  3. A rise in creatinine after volume repletion
  4. Urinary sodium below 20 mmol/L with a fractional excretion below 1%

Explanation

Acute tubular necrosis causes impaired tubular reabsorption, producing a high urinary sodium, a fractional excretion above 2% and muddy brown granular casts, unlike the sodium-avid pre-renal state.

Question 26General (internal) medicine - clinical sciences and core topics

A 68-year-old man with type 2 diabetes and a history of myocardial infarction presents with a 2-week history of progressive exertional breathlessness. Examination reveals bibasal crackles, a raised JVP and bilateral ankle oedema. Which single finding on echocardiography would most strongly support a diagnosis of heart failure with reduced ejection fraction rather than heart failure with preserved ejection fraction?

  1. Left ventricular ejection fraction of 35% Correct answer.
  2. Left ventricular wall thickness of 14 mm
  3. Left atrial volume index of 40 mL/m²
  4. E/e' ratio of 15 on tissue Doppler

Explanation

Heart failure with reduced ejection fraction is defined by a left ventricular ejection fraction of 40% or less, and a value of 35% is therefore diagnostic. The other listed findings are markers of diastolic dysfunction or left ventricular hypertrophy that are more typical of heart failure with preserved ejection fraction.

Question 27General (internal) medicine - clinical sciences and core topics

A 24-year-old woman presents with a 3-day history of pleuritic chest pain that is worse on inspiration and relieved by sitting forward. She has a low-grade fever and a pericardial friction rub. ECG shows widespread concave ST-segment elevation with PR-segment depression. Which is the most appropriate initial management?

  1. Oral prednisolone 60 mg daily
  2. Intravenous thrombolysis
  3. High-dose aspirin and colchicine Correct answer.
  4. Urgent pericardiocentesis

Explanation

The presentation is typical of acute idiopathic pericarditis, for which first-line treatment is an NSAID such as high-dose aspirin or ibuprofen plus colchicine to reduce symptoms and recurrence. Thrombolysis, high-dose steroids and pericardiocentesis are reserved for specific complications or contraindications and are not initial therapy here.

Question 28General (internal) medicine - clinical sciences and core topics

A 62-year-old man with chronic obstructive pulmonary disease has a resting oxygen saturation of 89% on room air when clinically stable. He has no evidence of right heart failure. According to standard criteria for long-term oxygen therapy, which measurement is required to confirm eligibility?

  1. Nocturnal oximetry showing desaturation below 90% for 30% of the night
  2. Peak expiratory flow of less than 50% predicted
  3. Arterial partial pressure of oxygen of 7.5 kPa or less on two occasions when stable Correct answer.
  4. Six-minute walk distance of less than 200 metres

Explanation

Long-term oxygen therapy in COPD is offered when the arterial partial pressure of oxygen is 7.3 kPa or less, or 8.0 kPa or less with polycythaemia or pulmonary hypertension, measured on two stable occasions. Nocturnal desaturation alone, spirometric severity and walk distance are not qualifying criteria.

Question 29General (internal) medicine - clinical sciences and core topics

A 45-year-old woman has a 6-month history of fatigue, weight gain and cold intolerance. Examination shows dry skin, bradycardia and delayed relaxation of the ankle reflex. Which laboratory pattern is most consistent with primary hypothyroidism?

  1. Low free T4 with low thyroid-stimulating hormone
  2. Normal free T4 with low thyroid-stimulating hormone
  3. Raised free T4 with raised thyroid-stimulating hormone
  4. Low free T4 with raised thyroid-stimulating hormone Correct answer.

Explanation

Primary hypothyroidism is characterised by a low free thyroxine level with a compensatory rise in thyroid-stimulating hormone. A low TSH with low free T4 indicates central hypothyroidism, whereas a normal free T4 with low TSH suggests subclinical hyperthyroidism or pituitary disease.

Question 30General (internal) medicine - clinical sciences and core topics

A 58-year-old man with type 2 diabetes has a serum creatinine of 180 micromol/L and an estimated glomerular filtration rate of 32 mL/min/1.73 m². He has persistent albuminuria. Which additional finding would best support a diagnosis of diabetic nephropathy rather than an alternative cause of chronic kidney disease?

  1. Haematuria with red cell casts on urine microscopy
  2. A kidney biopsy showing mesangial IgA deposits
  3. A history of diabetes for 12 years with coexisting retinopathy Correct answer.
  4. Rapid loss of kidney function over 3 months

Explanation

Diabetic nephropathy typically develops after a long duration of diabetes and is commonly accompanied by diabetic retinopathy, which supports the diagnosis. Red cell casts, IgA deposits and a rapid decline in function suggest glomerulonephritis or another renal disease rather than diabetic nephropathy.

Question 31General (internal) medicine - clinical sciences and core topics

A 70-year-old woman is admitted with confusion and a urinary tract infection. She is found to have a serum sodium of 122 mmol/L. She is clinically euvolaemic. Which initial fluid strategy is most appropriate?

  1. Fluid restriction and slow correction with hypertonic saline only if symptomatic
  2. Intravenous furosemide with free water replacement
  3. Intravenous 0.9% sodium chloride Correct answer.
  4. Rapid correction with 3% sodium chloride to a normal sodium within 6 hours

Explanation

In euvolaemic hyponatraemia, often due to syndrome of inappropriate antidiuretic hormone secretion, the priority is to treat the underlying cause and avoid rapid correction. Hypertonic saline is reserved for severe symptomatic hyponatraemia, and correction should generally not exceed 8–10 mmol/L in 24 hours to reduce the risk of osmotic demyelination.

Question 32General (internal) medicine - clinical sciences and core topics

A 34-year-old man has a 6-week history of progressive weakness and areflexia after a diarrhoeal illness. He has a symmetrical ascending flaccid paralysis. Which investigation is most likely to confirm the diagnosis?

  1. Serum creatine kinase elevated more than 10 times the upper limit of normal
  2. Anti-acetylcholine receptor antibodies
  3. Cerebrospinal fluid showing albuminocytological dissociation Correct answer.
  4. Nerve conduction studies showing a sensory axonal neuropathy

Explanation

The clinical picture is consistent with Guillain–Barré syndrome, in which cerebrospinal fluid typically shows a raised protein with a normal cell count, known as albuminocytological dissociation. Anti-acetylcholine receptor antibodies are used for myasthenia gravis, and sensory axonal neuropathy is not the typical pattern.

Question 33General (internal) medicine - clinical sciences and core topics

A 29-year-old woman has a 3-day history of fever, headache and neck stiffness. A lumbar puncture shows a neutrophil-predominant pleocytosis with a low glucose and a raised protein. Which organism is the most likely cause?

  1. Streptococcus pneumoniae Correct answer.
  2. Listeria monocytogenes
  3. Neisseria meningitidis
  4. Herpes simplex virus

Explanation

Bacterial meningitis in adults is most commonly caused by Streptococcus pneumoniae, followed by Neisseria meningitidis. The cerebrospinal fluid profile of neutrophilic pleocytosis with low glucose and high protein is typical of bacterial meningitis, and pneumococcus is the leading pathogen in adults.

Question 34General (internal) medicine - clinical sciences and core topics

A 55-year-old man presents with a 3-month history of progressive dyspnoea, dry cough and fatigue. Examination reveals fine bibasal crackles and clubbing. High-resolution CT shows usual interstitial pneumonia. Which autoantibody is most strongly associated with idiopathic pulmonary fibrosis?

  1. Anti-nuclear antibody Correct answer.
  2. Rheumatoid factor
  3. Anti-neutrophil cytoplasmic antibody
  4. Anti-cyclic citrullinated peptide

Explanation

Idiopathic pulmonary fibrosis is not defined by a specific autoantibody, but a positive antinuclear antibody is common and may support an autoimmune contribution. Rheumatoid factor and anti-cyclic citrullinated peptide are associated with rheumatoid arthritis, and anti-neutrophil cytoplasmic antibody is associated with vasculitis.

Question 35General (internal) medicine - clinical sciences and core topics

A 62-year-old man is admitted with a 2-day history of severe epigastric pain radiating to the back, vomiting and fever. Serum amylase is three times the upper limit of normal. He is tachycardic and hypotensive. Which initial fluid resuscitation strategy is most appropriate?

  1. Intravenous colloid at 10 mL/kg/hour for 24 hours
  2. Rapid intravenous crystalloid boluses with regular reassessment Correct answer.
  3. Fluid restriction to 1 litre per day
  4. Oral rehydration with small frequent sips

Explanation

Acute pancreatitis with haemodynamic compromise requires prompt intravenous crystalloid resuscitation, typically with balanced crystalloid and frequent reassessment of response. Oral fluids, colloid and fluid restriction are inadequate or potentially harmful in this setting.

Question 36General (internal) medicine - clinical sciences and core topics

A 48-year-old woman has a 4-week history of painless jaundice, pruritus and pale stools. Examination reveals scratch marks but no hepatomegaly. Liver tests show a raised alkaline phosphatase and bilirubin with a normal albumin. Which investigation is most likely to establish the diagnosis?

  1. Anti-nuclear antibody
  2. Anti-smooth muscle antibody
  3. Anti-liver kidney microsomal antibody
  4. Anti-mitochondrial antibody Correct answer.

Explanation

The presentation is typical of primary biliary cholangitis, which is characterised by anti-mitochondrial antibodies in the majority of patients. Anti-smooth muscle antibody is associated with autoimmune hepatitis, and anti-liver kidney microsomal antibody is associated with type 2 autoimmune hepatitis.

Question 37General (internal) medicine - clinical sciences and core topics

A 35-year-old man has a 2-day history of severe pain and swelling of the right first metatarsophalangeal joint. He has a history of hypertension and takes bendroflumethiazide. Joint aspiration shows needle-shaped negatively birefringent crystals. Which is the most appropriate treatment for the acute attack?

  1. Intra-articular steroid plus allopurinol
  2. Allopurinol 300 mg daily
  3. Probenecid
  4. Oral colchicine Correct answer.

Explanation

Acute gout is treated with an NSAID, colchicine or a corticosteroid, and colchicine is an appropriate choice. Allopurinol and probenecid are urate-lowering therapies that should not be started during an acute attack because they can prolong or precipitate symptoms.

Question 38General (internal) medicine - clinical sciences and core topics

A 58-year-old man with a history of hypertension presents with sudden-onset severe tearing chest pain radiating to the back. Blood pressure is 180/100 mmHg in the right arm and 140/90 mmHg in the left arm. Chest radiograph shows a widened mediastinum. Which is the most appropriate immediate investigation?

  1. Contrast-enhanced computed tomography of the aorta Correct answer.
  2. Exercise stress testing
  3. Transthoracic echocardiography
  4. D-dimer assay

Explanation

The presentation is highly suggestive of acute aortic dissection, and contrast-enhanced computed tomography is the investigation of choice in a stable patient. Transthoracic echocardiography may miss a dissection and exercise testing is contraindicated, while D-dimer is not sufficiently specific.

Question 39General (internal) medicine - clinical sciences and core topics

A 72-year-old woman is found to have a haemoglobin of 105 g/L and a mean corpuscular volume of 72 fL. She has a long-standing history of rheumatoid arthritis and takes regular ibuprofen. Which additional test is most likely to identify the cause of her anaemia?

  1. Serum folate
  2. Serum vitamin B12
  3. Serum ferritin Correct answer.
  4. Reticulocyte count

Explanation

A microcytic anaemia in a patient with chronic inflammatory disease and NSAID use is most likely due to iron deficiency, and serum ferritin is the key initial test. Vitamin B12 and folate deficiency cause macrocytic anaemia, and reticulocyte count assesses marrow response rather than the underlying cause.

Question 40General (internal) medicine - clinical sciences and core topics

A 40-year-old woman presents with a 6-week history of fatigue, weight loss and palpitations. She has a diffuse goitre and fine tremor. Thyroid function tests show a suppressed thyroid-stimulating hormone and raised free T4. Which antibody is most specific for Graves disease?

  1. Thyroid-stimulating hormone receptor antibody Correct answer.
  2. Anti-nuclear antibody
  3. Anti-thyroglobulin antibody
  4. Anti-thyroid peroxidase antibody

Explanation

Graves disease is caused by thyroid-stimulating immunoglobulins that bind the thyroid-stimulating hormone receptor, and receptor antibodies are the most specific marker. Anti-thyroglobulin and anti-thyroid peroxidase antibodies occur in Hashimoto thyroiditis and other autoimmune thyroid disease but are not specific for Graves disease.

Question 41General (internal) medicine - clinical sciences and core topics

A 68-year-old man with atrial fibrillation is started on warfarin. Three days later he develops painful purple discolouration of the toes and a raised international normalised ratio. Which is the most appropriate immediate treatment?

  1. Intravenous heparin
  2. Platelet transfusion
  3. Oral vitamin K
  4. Intravenous vitamin K and fresh frozen plasma Correct answer.

Explanation

Warfarin-induced skin necrosis is caused by transient protein C deficiency and presents with painful purpuric lesions and a raised INR. Treatment is to stop warfarin and give vitamin K with fresh frozen plasma or prothrombin complex concentrate to restore clotting factors rapidly.

Question 42General (internal) medicine - clinical sciences and core topics

A 25-year-old woman has a 4-week history of episodic palpitations, sweating and tremor. She has a blood pressure of 160/95 mmHg and a pulse of 110 beats per minute. Which initial biochemical test is most appropriate to screen for phaeochromocytoma?

  1. Plasma renin activity
  2. Plasma free metanephrines Correct answer.
  3. Serum aldosterone
  4. Serum cortisol

Explanation

Phaeochromocytoma is best screened for with plasma free metanephrines or 24-hour urinary fractionated metanephrines, which have high sensitivity. Cortisol, renin and aldosterone are used to investigate other causes of hypertension such as Cushing syndrome or primary aldosteronism.

Question 43General (internal) medicine - clinical sciences and core topics

A 62-year-old man with type 2 diabetes has a glycated haemoglobin of 58 mmol/mol and a body mass index of 31 kg/m². He is already on metformin. Which additional agent is most appropriate to reduce cardiovascular risk?

  1. Sitagliptin
  2. Pioglitazone
  3. Gliclazide
  4. Empagliflozin Correct answer.

Explanation

Sodium-glucose cotransporter-2 inhibitors such as empagliflozin have demonstrated cardiovascular benefit in patients with type 2 diabetes and established or high risk of cardiovascular disease. Gliclazide, pioglitazone and sitagliptin do not have the same level of evidence for cardiovascular risk reduction.

Question 44General (internal) medicine - clinical sciences and core topics

A 72-year-old woman presents with a 2-day history of confusion and a urinary tract infection. She is found to have a serum sodium of 122 mmol/L. She is clinically euvolaemic. Which initial fluid strategy is most appropriate?

  1. Fluid restriction and slow correction with hypertonic saline only if symptomatic
  2. Intravenous 0.9% sodium chloride Correct answer.
  3. Intravenous furosemide with free water replacement
  4. Rapid correction with 3% sodium chloride to a normal sodium within 6 hours

Explanation

In euvolaemic hyponatraemia, often due to syndrome of inappropriate antidiuretic hormone secretion, the priority is to treat the underlying cause and avoid rapid correction. Hypertonic saline is reserved for severe symptomatic hyponatraemia, and correction should generally not exceed 8–10 mmol/L in 24 hours to reduce the risk of osmotic demyelination.

Question 45General (internal) medicine - clinical sciences and core topics

A 45-year-old woman with known systemic lupus erythematosus presents with haematuria and proteinuria. Which serological test is most useful in monitoring disease activity in lupus nephritis?

  1. Anti-centromere antibody
  2. Anti-histone antibody
  3. Anti-Ro antibody
  4. Anti-double-stranded DNA antibody titre Correct answer.

Explanation

Anti-double-stranded DNA antibodies correlate with disease activity in systemic lupus erythematosus and are particularly associated with lupus nephritis. Anti-histone antibodies are associated with drug-induced lupus, anti-centromere antibodies with limited cutaneous systemic sclerosis, and anti-Ro antibodies with Sjögren syndrome and neonatal lupus.

Question 46General (internal) medicine - clinical sciences and core topics

A 58-year-old man with a history of alcohol excess presents with confusion, ataxia and ophthalmoplegia. He is given intravenous glucose without thiamine. Which complication is most likely to develop?

  1. Wernicke encephalopathy Correct answer.
  2. Hepatic encephalopathy
  3. Delirium tremens
  4. Korsakoff psychosis

Explanation

Thiamine deficiency causes Wernicke encephalopathy, which is characterised by the triad of confusion, ataxia and ophthalmoplegia. Glucose administration without thiamine can precipitate or worsen Wernicke encephalopathy by increasing thiamine demand, so thiamine should be given before or with glucose.

Question 47General (internal) medicine - clinical sciences and core topics

A 30-year-old man has recurrent episodes of severe abdominal pain, hypertension and palpitations. Which investigation is most likely to establish the diagnosis?

  1. 24-hour urinary fractionated metanephrines Correct answer.
  2. Plasma cortisol
  3. Serum calcium
  4. Serum gastrin

Explanation

The episodic triad of abdominal pain, hypertension and palpitations suggests phaeochromocytoma, which is diagnosed by demonstrating raised metanephrines in plasma or urine. Serum gastrin, cortisol and calcium are used to investigate other neuroendocrine or metabolic causes and would not confirm phaeochromocytoma.

Question 48General (internal) medicine - clinical sciences and core topics

A 66-year-old man with heart failure with reduced ejection fraction remains symptomatic despite an ACE inhibitor and beta-blocker. His ejection fraction is 30% and he is in sinus rhythm with a QRS duration of 130 ms. Which additional treatment is most likely to improve his symptoms and prognosis?

  1. Implantable cardioverter-defibrillator alone
  2. Ivabradine
  3. Cardiac resynchronisation therapy Correct answer.
  4. Digoxin

Explanation

Cardiac resynchronisation therapy is indicated in symptomatic heart failure with reduced ejection fraction and a broad QRS complex, particularly with left bundle branch block, and improves symptoms and survival. An implantable cardioverter-defibrillator alone does not improve symptoms, and digoxin and ivabradine are not first-line for this indication.

Question 49General (internal) medicine - clinical sciences and core topics

A 55-year-old woman has a 6-week history of proximal muscle weakness and a raised creatine kinase. She has a heliotrope rash and Gottron papules. Which autoantibody is most strongly associated with this condition?

  1. Anti-double-stranded DNA antibody
  2. Anti-Scl-70 antibody
  3. Anti-centromere antibody
  4. Anti-Jo-1 antibody Correct answer.

Explanation

The presentation is typical of dermatomyositis, which is associated with anti-Jo-1 antibodies, particularly when interstitial lung disease is present. Anti-double-stranded DNA is associated with systemic lupus erythematosus, anti-centromere with limited cutaneous systemic sclerosis, and anti-Scl-70 with diffuse cutaneous systemic sclerosis.

Question 50General (internal) medicine - clinical sciences and core topics

A 34-year-old woman has a 3-week history of bloody diarrhoea with urgency. She is haemodynamically stable with a haemoglobin of 105 g/L. Stool cultures are negative. Which is the most appropriate initial investigation to confirm the diagnosis?

  1. Flexible sigmoidoscopy with biopsy Correct answer.
  2. Abdominal computed tomography
  3. Faecal calprotectin
  4. Colonoscopy with biopsy

Explanation

In suspected ulcerative colitis, flexible sigmoidoscopy with biopsy is the preferred initial investigation because it is less invasive and usually sufficient to establish the diagnosis. Colonoscopy is reserved for cases where sigmoidoscopy is inconclusive or to assess disease extent, and faecal calprotectin supports inflammation but is not diagnostic.