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Medical Council Malta Statutory Exam study materials
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Medical Council Malta Statutory Exam practice questions

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Question 1Medical knowledge and clinical practice (provisional - source does not enumerate domains)

A 58-year-old man presents with sudden-onset crushing central chest pain radiating to the left arm, sweating and nausea. Which single investigation should be performed first?

  1. Exercise tolerance test
  2. Chest radiograph
  3. 12-lead electrocardiogram Correct answer.
  4. Troponin measurement

Explanation

In suspected acute coronary syndrome the resting 12-lead ECG is the first-line investigation because it identifies ST-elevation myocardial infarction and dictates immediate reperfusion. Troponin supports diagnosis but is not the initial triage test, and exercise testing is contraindicated in acute chest pain.

Question 2Medical knowledge and clinical practice (provisional - source does not enumerate domains)

Which finding is most characteristic of a tension pneumothorax?

  1. Hyperresonance with absent breath sounds and hypotension Correct answer.
  2. Bilateral basal crackles
  3. Tracheal deviation towards the affected side
  4. Dullness to percussion at the apex

Explanation

Tension pneumothorax produces hyperresonance, absent breath sounds and haemodynamic compromise because rising intrathoracic pressure impairs venous return. Treatment is immediate needle decompression without waiting for imaging.

Question 3Medical knowledge and clinical practice (provisional - source does not enumerate domains)

A 24-year-old woman has a fasting plasma glucose of 7.8 mmol/L on one occasion and no symptoms. What is the most appropriate next step?

  1. Start metformin immediately
  2. Reassure and discharge without follow-up
  3. Repeat the fasting glucose or perform an HbA1c Correct answer.
  4. Diagnose type 1 diabetes

Explanation

Diabetes requires confirmatory testing unless the patient is symptomatic with unequivocal hyperglycaemia; a second fasting glucose or an HbA1c is standard. A single asymptomatic value is insufficient for diagnosis.

Question 4Medical knowledge and clinical practice (provisional - source does not enumerate domains)

Which electrolyte disturbance most commonly produces peaked T waves and a widened QRS complex on ECG?

  1. Hypomagnesaemia
  2. Hyperkalaemia Correct answer.
  3. Hypokalaemia
  4. Hypercalcaemia

Explanation

Hyperkalaemia classically causes tall peaked T waves progressing to QRS widening, sine-wave morphology and cardiac arrest. Calcium gluconate stabilises the myocardium while insulin-dextrose shifts potassium intracellularly.

Question 5Medical knowledge and clinical practice (provisional - source does not enumerate domains)

A 70-year-old woman has a hip fracture after a minor fall. Which underlying condition should be actively excluded as part of her assessment?

  1. Osteomalacia
  2. Paget disease of bone
  3. Scurvy
  4. Osteoporosis Correct answer.

Explanation

Fragility fracture after low-energy trauma is the hallmark of osteoporosis, and assessment includes bone mineral density and fracture-risk evaluation. Treating the fracture without addressing bone health leaves the patient at high risk of further fractures.

Question 6Medical knowledge and clinical practice (provisional - source does not enumerate domains)

Which organism is the most frequent cause of community-acquired pneumonia in adults?

  1. Mycoplasma pneumoniae
  2. Streptococcus pneumoniae Correct answer.
  3. Pseudomonas aeruginosa
  4. Legionella pneumophila

Explanation

Streptococcus pneumoniae remains the commonest identified pathogen in community-acquired pneumonia. Empirical therapy is therefore designed to cover it, often with a beta-lactam plus a macrolide depending on severity.

Question 7Medical knowledge and clinical practice (provisional - source does not enumerate domains)

A patient presents with a painful red eye, reduced visual acuity and a fixed mid-dilated pupil. Which diagnosis must be considered?

  1. Acute angle-closure glaucoma Correct answer.
  2. Anterior uveitis
  3. Bacterial conjunctivitis
  4. Episcleritis

Explanation

Acute angle-closure glaucoma presents with severe ocular pain, halos, a fixed mid-dilated pupil and reduced acuity, and is an ophthalmological emergency. Immediate pressure-lowering treatment and urgent referral are required.

Question 8Medical knowledge and clinical practice (provisional - source does not enumerate domains)

Which of the following is the most appropriate initial management for a patient with suspected anaphylaxis?

  1. Intramuscular adrenaline into the anterolateral thigh Correct answer.
  2. Oral antihistamine
  3. Intravenous corticosteroid alone
  4. Nebulised salbutamol

Explanation

Intramuscular adrenaline is the first-line treatment for anaphylaxis because it reverses airway oedema and hypotension rapidly. Antihistamines and steroids are adjuncts and must not delay adrenaline.

Question 9Medical knowledge and clinical practice (provisional - source does not enumerate domains)

A 30-year-old man has a blood pressure of 168/104 mmHg on three separate visits. Which statement best describes the correct initial approach?

  1. Refer for renal denervation
  2. Confirm with ambulatory monitoring and assess end-organ damage Correct answer.
  3. Diagnose white-coat hypertension and take no action
  4. Start three antihypertensives simultaneously

Explanation

Confirmed clinic hypertension should be verified with ambulatory or home monitoring and assessed for target-organ damage and cardiovascular risk before treatment is titrated. This avoids over-treating white-coat hypertension and guides therapy choice.

Question 10Medical knowledge and clinical practice (provisional - source does not enumerate domains)

Which feature best distinguishes an ischaemic stroke from a hypoglycaemic episode in a patient with sudden hemiparesis?

  1. Temperature
  2. Capillary blood glucose measurement Correct answer.
  3. Presence of headache
  4. Pupil size

Explanation

Hypoglycaemia can mimic stroke and is rapidly reversible, so capillary glucose must be checked in every patient with acute neurological deficit. Correction of hypoglycaemia should precede or accompany stroke imaging pathways.

Question 11Medical knowledge and clinical practice (provisional - source does not enumerate domains)

A 3-year-old child has a barking cough, inspiratory stridor and hoarse voice following a coryzal illness. What is the most likely diagnosis?

  1. Croup Correct answer.
  2. Bronchiolitis
  3. Asthma
  4. Epiglottitis

Explanation

Croup (laryngotracheobronchitis) presents with a barking cough, hoarse voice and inspiratory stridor after a viral prodrome. Most cases are mild and respond to a single dose of oral dexamethasone.

Question 12Medical knowledge and clinical practice (provisional - source does not enumerate domains)

Which of the following is the most reliable sign of dehydration in an infant?

  1. Increased appetite
  2. Dry nappy for two hours
  3. Sunken eyes with reduced skin turgor Correct answer.
  4. Mild irritability

Explanation

Reduced skin turgor and sunken eyes reflect significant extracellular fluid loss and are more reliable than parental report of nappy counts. Weight loss and prolonged capillary refill also support the assessment.

Question 13Medical knowledge and clinical practice (provisional - source does not enumerate domains)

A pregnant woman at 34 weeks presents with painless vaginal bleeding. Which diagnosis must be excluded before any digital vaginal examination?

  1. Threatened miscarriage
  2. Cervical ectropion
  3. Placenta praevia Correct answer.
  4. Urinary tract infection

Explanation

Painless antepartum bleeding suggests placenta praevia, and digital examination risks provoking catastrophic haemorrhage. Ultrasound localisation of the placenta must precede any vaginal examination.

Question 14Medical knowledge and clinical practice (provisional - source does not enumerate domains)

Which of the following is the recommended first-line treatment for a patient with newly diagnosed type 2 diabetes and no contraindications?

  1. Gliclazide
  2. Pioglitazone
  3. Metformin Correct answer.
  4. Insulin glargine

Explanation

Metformin is first-line because it is effective, weight-neutral and supported by long-term outcome data. It is started alongside lifestyle modification unless renal function is severely impaired.

Question 15Medical knowledge and clinical practice (provisional - source does not enumerate domains)

A patient on warfarin has an INR of 8.0 with no bleeding. Which is the most appropriate management?

  1. Stop warfarin and give oral vitamin K Correct answer.
  2. Give fresh frozen plasma immediately
  3. Give protamine sulfate
  4. Continue the same dose and recheck in one week

Explanation

A markedly elevated INR without bleeding is managed by withholding warfarin and giving low-dose oral vitamin K, with repeat INR monitoring. Prothrombin complex concentrate or plasma is reserved for major bleeding.

Question 16Medical knowledge and clinical practice (provisional - source does not enumerate domains)

Which of the following best describes the mechanism of action of beta-blockers in heart failure with reduced ejection fraction?

  1. They directly increase myocardial contractility
  2. They reduce preload by venodilation
  3. They block aldosterone receptors
  4. They blunt sympathetic overactivity and reduce adverse remodelling Correct answer.

Explanation

Beta-blockers reduce sympathetic drive, lower heart rate and improve reverse remodelling, producing a mortality benefit in reduced ejection fraction. They must be started at low dose and titrated slowly.

Question 17Medical knowledge and clinical practice (provisional - source does not enumerate domains)

A 45-year-old man has a serum creatinine of 180 micromol/L and a urine output of 0.2 mL/kg/h for 12 hours despite fluid resuscitation. Which classification best fits?

  1. Chronic kidney disease stage 2
  2. Normal renal function
  3. Acute kidney injury stage 3 Correct answer.
  4. Acute kidney injury stage 1

Explanation

Urine output below 0.3 mL/kg/h for 24 hours or anuria for 12 hours defines stage 3 AKI by KDIGO criteria. This warrants urgent nephrology assessment and consideration of renal replacement therapy.

Question 18Medical knowledge and clinical practice (provisional - source does not enumerate domains)

Which of the following is a recognised risk factor for the development of pressure ulcers?

  1. Adequate protein intake
  2. Normal body mass index
  3. Immobility with reduced sensory perception Correct answer.
  4. Regular repositioning

Explanation

Immobility and impaired sensation lead to sustained pressure over bony prominences and are key modifiable risk factors. Risk assessment tools such as the Braden scale guide preventive interventions.

Question 19Medical knowledge and clinical practice (provisional - source does not enumerate domains)

A 65-year-old smoker presents with a painless haematuria. What is the most important diagnosis to exclude?

  1. Urinary tract infection
  2. Bladder carcinoma Correct answer.
  3. Benign prostatic hyperplasia
  4. Renal colic

Explanation

Painless visible haematuria in an older smoker is a red flag for urothelial malignancy and requires urgent cystoscopy and upper tract imaging. Smoking is the strongest modifiable risk factor.

Question 20Medical knowledge and clinical practice (provisional - source does not enumerate domains)

Which of the following is the most appropriate initial imaging for suspected acute appendicitis in a young adult?

  1. Intravenous pyelogram
  2. Ultrasound of the abdomen Correct answer.
  3. Barium enema
  4. Erect chest radiograph

Explanation

Ultrasound is often first-line in younger patients and women of childbearing age because it avoids ionising radiation and can assess alternative pelvic pathology. CT is used when ultrasound is inconclusive.

Question 21Medical knowledge and clinical practice (provisional - source does not enumerate domains)

A patient has a serum sodium of 118 mmol/L with confusion following excessive water intake. What is the key principle in correction?

  1. Give hypertonic saline irrespective of symptoms
  2. Correct rapidly to normal within two hours
  3. Correct slowly to avoid osmotic demyelination Correct answer.
  4. Restrict all fluids indefinitely

Explanation

Severe hyponatraemia with neurological symptoms requires careful hypertonic saline with a controlled rise, usually no more than 8 to 10 mmol/L in 24 hours, to avoid osmotic demyelination. Symptomatic patients need closer monitoring rather than unlimited rapid correction.

Question 22Medical knowledge and clinical practice (provisional - source does not enumerate domains)

Which vaccination is contraindicated in a patient receiving high-dose immunosuppressive therapy?

  1. Tetanus toxoid
  2. Inactivated influenza vaccine
  3. Hepatitis B vaccine
  4. Live attenuated influenza vaccine Correct answer.

Explanation

Live attenuated vaccines can cause disseminated infection in significantly immunocompromised patients and are avoided. Inactivated vaccines are safe and should still be given, though responses may be reduced.

Question 23Medical knowledge and clinical practice (provisional - source does not enumerate domains)

A 22-year-old presents with a painless ulcer on the genitalia and regional lymphadenopathy. Which diagnosis is most consistent with this presentation?

  1. Genital warts
  2. Chancroid
  3. Herpes simplex infection
  4. Primary syphilis Correct answer.

Explanation

Primary syphilis presents with a painless chancre and painless regional lymphadenopathy, which distinguishes it from painful ulcerative infections. Serology and dark-ground microscopy confirm the diagnosis.

Question 24Medical knowledge and clinical practice (provisional - source does not enumerate domains)

Which of the following is the most important initial step in managing a patient with acute severe asthma?

  1. Chest physiotherapy
  2. Sedation for agitation
  3. Oral antibiotics
  4. High-flow oxygen with nebulised salbutamol and ipratropium Correct answer.

Explanation

Acute severe asthma is managed with oxygen to maintain saturation, repeated inhaled short-acting beta-agonists and ipratropium, plus systemic corticosteroids. Sedation is dangerous as it masks deterioration and depresses respiration.

Question 25Medical knowledge and clinical practice (provisional - source does not enumerate domains)

A patient with known atrial fibrillation has a CHA2DS2-VASc score of 3. What is the recommended antithrombotic strategy?

  1. Aspirin alone
  2. Dual antiplatelet therapy
  3. No antithrombotic therapy
  4. Oral anticoagulation Correct answer.

Explanation

A CHA2DS2-VASc score of 2 or more in men indicates sufficient stroke risk to recommend oral anticoagulation, preferably a direct oral anticoagulant. Antiplatelet therapy is inferior for stroke prevention in atrial fibrillation.

Question 26Medical knowledge and clinical practice (provisional - source does not enumerate domains)

A 58-year-old man collapses in the emergency department and a rhythm strip shows a chaotic, irregular waveform with no identifiable QRS complexes. What is the single most appropriate immediate action?

  1. Begin chest compressions and deliver an unsynchronised shock as soon as the defibrillator is available Correct answer.
  2. Give intravenous amiodarone and reassess the rhythm after two minutes
  3. Give intravenous atropine 500 micrograms and reassess
  4. Perform synchronised cardioversion at 100 joules

Explanation

Ventricular fibrillation is a shockable cardiac arrest rhythm, so the priority is immediate high-quality chest compressions with early unsynchronised defibrillation. Synchronisation is impossible because there is no organised QRS to track. Antiarrhythmic drugs are adjuncts given after defibrillation attempts, not instead of them.

Question 27Medical knowledge and clinical practice (provisional - source does not enumerate domains)

A 70-year-old woman has a painful, blistering rash in a band-like distribution over the left T8 dermatome that does not cross the midline. Which causative agent is responsible?

  1. Human papillomavirus
  2. Coxsackievirus
  3. Varicella-zoster virus Correct answer.
  4. Herpes simplex virus type 1

Explanation

Reactivation of latent varicella-zoster virus in a dorsal root ganglion produces herpes zoster, which classically causes a unilateral dermatomal vesicular rash that respects the midline. Herpes simplex causes grouped vesicles usually at mucocutaneous sites, not a dermatomal band.

Question 28Medical knowledge and clinical practice (provisional - source does not enumerate domains)

A 24-year-old woman has a body mass index of 17 kg/m2, amenorrhoea for eight months and a fear of gaining weight. Which finding is most characteristic of this condition?

  1. Raised serum leptin with insulin resistance
  2. Hypertension with truncal obesity
  3. Low bone mineral density with bradycardia and hypothermia Correct answer.
  4. Elevated serum luteinising hormone with polycystic ovaries

Explanation

Anorexia nervosa produces a starvation state with low gonadotrophins causing amenorrhoea, reduced bone density, bradycardia and hypothermia from increased vagal tone and low metabolic rate. Leptin is low rather than raised in starvation.

Question 29Medical knowledge and clinical practice (provisional - source does not enumerate domains)

A 62-year-old man presents with sudden painless loss of vision in one eye described as a curtain descending. Fundoscopy is initially normal. What is the most likely underlying mechanism?

  1. Optic neuritis related to demyelination
  2. Acute angle closure glaucoma
  3. Vitreous haemorrhage from a retinal tear
  4. Embolic occlusion of a retinal artery branch Correct answer.

Explanation

Amaurosis fugax reflects transient retinal ischaemia, most often from an embolus arising from the carotid artery, and produces a curtain-like visual loss with a normal fundus between episodes. Vitreous haemorrhage obscures the red reflex, and optic neuritis causes painful visual loss with a relative afferent pupillary defect.

Question 30Medical knowledge and clinical practice (provisional - source does not enumerate domains)

A 34-year-old woman has recurrent episodes of palpitations, sweating and headache. Biochemistry shows elevated plasma metanephrines. Which investigation is the most appropriate next step to localise the lesion?

  1. CT of the adrenal glands Correct answer.
  2. Renal artery Doppler ultrasound
  3. Overnight dexamethasone suppression test
  4. Serum thyroid function tests

Explanation

Biochemical confirmation of a phaeochromocytoma with elevated metanephrines is followed by anatomical imaging, usually CT or MRI of the adrenals and abdomen, to localise the tumour. Thyroid function and dexamethasone suppression test alternative diagnoses rather than localise a confirmed catecholamine-secreting tumour.

Question 31Medical knowledge and clinical practice (provisional - source does not enumerate domains)

A 68-year-old man has a haemoglobin of 92 g/L with a mean corpuscular volume of 72 fL and a ferritin of 8 micrograms/L. Which is the most appropriate next investigation?

  1. Serum electrophoresis
  2. Bone marrow aspiration
  3. Upper and lower gastrointestinal endoscopy Correct answer.
  4. Serum vitamin B12 assay

Explanation

A microcytic anaemia with a very low ferritin confirms iron deficiency, and in an older man this requires investigation of the gastrointestinal tract for a source of chronic blood loss, including malignancy. Vitamin B12 deficiency causes a macrocytic anaemia, and bone marrow examination is not the initial step.

Question 32Medical knowledge and clinical practice (provisional - source does not enumerate domains)

A 5-year-old child develops a generalised tonic-clonic seizure lasting six minutes at home. Which is the most appropriate first-line drug once intravenous access is secured?

  1. Intravenous lorazepam Correct answer.
  2. Oral carbamazepine
  3. Intravenous phenytoin
  4. Intravenous mannitol

Explanation

A benzodiazepine such as intravenous lorazepam is first-line for terminating a convulsive seizure that has lasted beyond five minutes. Phenytoin is a second-line agent used after benzodiazepines have failed. Oral therapy is inappropriate in an actively seizing child.

Question 33Medical knowledge and clinical practice (provisional - source does not enumerate domains)

A 28-year-old woman at 10 weeks' gestation has a positive urine pregnancy test, lower abdominal pain and vaginal spotting. Transvaginal ultrasound shows no intrauterine sac and a serum beta-hCG of 1800 IU/L. What is the most likely diagnosis?

  1. Threatened miscarriage
  2. Ectopic pregnancy Correct answer.
  3. Molar pregnancy
  4. Complete miscarriage

Explanation

An empty uterus on transvaginal ultrasound with a beta-hCG above the discriminatory zone of roughly 1000-2000 IU/L strongly suggests an ectopic pregnancy, especially with pain and bleeding. A complete miscarriage would usually show a falling beta-hCG and a history of passing tissue.

Question 34Medical knowledge and clinical practice (provisional - source does not enumerate domains)

Which single intervention reduces the risk of ventilator-associated pneumonia most reliably in an intubated patient?

  1. Daily chest physiotherapy
  2. Changing the endotracheal tube every 48 hours
  3. Elevating the head of the bed to 30-45 degrees Correct answer.
  4. Routine prophylactic broad-spectrum antibiotics

Explanation

Semi-recumbent positioning at 30-45 degrees reduces aspiration of gastric contents and is a core element of the ventilator-associated pneumonia prevention bundle, alongside sedation holds and oral care. Prophylactic antibiotics are not recommended because they promote resistance.

Question 35Medical knowledge and clinical practice (provisional - source does not enumerate domains)

A 40-year-old man has a deep laceration to the forearm with brisk bleeding that is not controlled by direct pressure. Which vessel is most likely injured if the bleeding is bright red and pulsatile?

  1. Median nerve
  2. Radial vein
  3. Radial artery Correct answer.
  4. Cephalic vein

Explanation

Bright red pulsatile bleeding indicates arterial injury, and the radial artery is a common site in forearm lacerations. Veins bleed dark red and non-pulsatile, and nerves do not bleed in this manner.

Question 36Medical knowledge and clinical practice (provisional - source does not enumerate domains)

A 52-year-old woman has a thyroid swelling. Fine-needle aspiration cytology is reported as suspicious for malignancy. Which is the most appropriate next step in management?

  1. Radioiodine ablation
  2. Repeat fine-needle aspiration in six months
  3. Total thyroidectomy after discussion at a multidisciplinary team meeting Correct answer.
  4. Lifelong levothyroxine suppression alone

Explanation

A cytologically suspicious thyroid nodule warrants surgical referral, usually total thyroidectomy, after multidisciplinary discussion, because the risk of malignancy is substantial. Repeat aspiration delays definitive treatment, and radioiodine is used after surgery for differentiated cancer, not as primary therapy for an undiagnosed nodule.

Question 37Medical knowledge and clinical practice (provisional - source does not enumerate domains)

A 19-year-old student has a two-day history of sore throat, fever and tonsillar exudate. Which finding would most support a bacterial rather than viral cause?

  1. Anterior cervical lymphadenopathy with tender nodes
  2. Tonsillar exudate with tender anterior cervical nodes and fever, without cough Correct answer.
  3. Hoarseness and conjunctivitis
  4. Cough and coryza

Explanation

The Centor criteria combine tonsillar exudate, tender anterior cervical lymphadenopathy, fever and absence of cough to estimate the likelihood of streptococcal pharyngitis. Cough, coryza, hoarseness and conjunctivitis are features of viral infection.

Question 38Medical knowledge and clinical practice (provisional - source does not enumerate domains)

A 72-year-old man has a serum potassium of 6.9 mmol/L with peaked T waves on the ECG. Which is the most appropriate immediate treatment to protect the myocardium?

  1. Intravenous furosemide
  2. Intravenous calcium gluconate Correct answer.
  3. Oral potassium binder
  4. Oral sodium bicarbonate

Explanation

Intravenous calcium stabilises the myocardial membrane and is the first-line treatment for hyperkalaemia with ECG changes, acting within minutes without lowering serum potassium. Measures that shift or remove potassium, such as insulin-dextrose, salbutamol or binders, follow but act more slowly.

Question 39Medical knowledge and clinical practice (provisional - source does not enumerate domains)

A 30-year-old woman has a butterfly rash, arthralgia and a positive antinuclear antibody test. Which additional antibody is most specific for systemic lupus erythematosus?

  1. Anti-double-stranded DNA Correct answer.
  2. Anti-mitochondrial antibody
  3. Rheumatoid factor
  4. Anti-transglutaminase antibody

Explanation

Anti-double-stranded DNA is highly specific for systemic lupus erythematosus and correlates with disease activity and renal involvement. Rheumatoid factor is non-specific and anti-mitochondrial antibodies point to primary biliary cholangitis.

Question 40Medical knowledge and clinical practice (provisional - source does not enumerate domains)

A 55-year-old man has a history of duodenal ulcer disease and now presents with recurrent vomiting of large volumes of food. Which acid-base disturbance is most likely?

  1. Metabolic acidosis with a normal anion gap
  2. Metabolic alkalosis with hypokalaemia Correct answer.
  3. Metabolic acidosis with hyperkalaemia
  4. Respiratory acidosis

Explanation

Gastric outlet obstruction causes loss of hydrogen and chloride ions through vomiting, generating a hypochloraemic metabolic alkalosis, while renal compensation and aldosterone effects cause hypokalaemia. Metabolic acidosis would be expected with diarrhoea or renal tubular losses, not gastric obstruction.

Question 41Medical knowledge and clinical practice (provisional - source does not enumerate domains)

A 70-year-old woman has had a left-sided weakness and facial droop for 45 minutes. Her blood pressure is 175/95 mmHg and she is not on any blood pressure medication. What is the most appropriate initial management?

  1. Immediate intravenous labetalol to lower blood pressure to 120/80 mmHg
  2. Urgent non-contrast CT head and thrombolysis assessment Correct answer.
  3. Oral aspirin 300 mg without imaging
  4. Reassurance and outpatient follow-up

Explanation

Acute stroke requires urgent neuroimaging to distinguish ischaemic from haemorrhagic stroke before thrombolysis or antiplatelet therapy can be given. Blood pressure is usually left untreated in the acute phase unless above 185/110 mmHg before thrombolysis or very high, because aggressive lowering can worsen cerebral perfusion.

Question 42Medical knowledge and clinical practice (provisional - source does not enumerate domains)

A 26-year-old woman with a history of asthma has an acute exacerbation with a peak expiratory flow at 40% of predicted and inability to complete sentences. Which finding would indicate a life-threatening attack?

  1. Respiratory rate of 22 breaths per minute
  2. Pulsus paradoxus of 12 mmHg
  3. Peak expiratory flow of 55% predicted
  4. Silent chest with cyanosis Correct answer.

Explanation

A silent chest, cyanosis, exhaustion and a normal or raised carbon dioxide level signify a life-threatening asthma attack where airflow is so poor that wheeze is inaudible. A moderate tachycardia or tachypnoea alone indicates a non-life-threatening exacerbation.

Question 43Medical knowledge and clinical practice (provisional - source does not enumerate domains)

A 60-year-old man with chronic kidney disease is reviewed. Which of the following is the most appropriate method for estimating glomerular filtration rate in this patient?

  1. The CKD-EPI creatinine equation Correct answer.
  2. Cockcroft-Gault creatinine clearance
  3. Serum cystatin C alone without creatinine
  4. Twenty-four-hour urine creatinine clearance only

Explanation

The CKD-EPI creatinine equation is the recommended tool for estimating GFR in adults for staging chronic kidney disease. Cockcroft-Gault estimates creatinine clearance and is used for drug dosing rather than for CKD staging.

Question 44Medical knowledge and clinical practice (provisional - source does not enumerate domains)

A 3-week-old infant has projectile non-bilious vomiting after feeds and a palpable olive-shaped mass in the right upper abdomen. Which is the most likely diagnosis?

  1. Duodenal atresia
  2. Gastro-oesophageal reflux
  3. Intussusception
  4. Pyloric stenosis Correct answer.

Explanation

Projectile non-bilious vomiting in a 3-6 week old with a palpable olive-shaped mass is classic for hypertrophic pyloric stenosis, confirmed by ultrasound showing a thickened pyloric muscle. Duodenal atresia presents in the first days of life with bilious vomiting and a double-bubble sign.

Question 45Medical knowledge and clinical practice (provisional - source does not enumerate domains)

A 45-year-old woman reports a two-year history of low mood, anhedonia and early morning waking. She has not responded to two adequate trials of different antidepressants. Which is the most appropriate next step in management?

  1. Discontinuing all medication and starting a benzodiazepine
  2. Referral for specialist assessment including consideration of augmentation or psychotherapy Correct answer.
  3. Reassuring her that the condition will resolve with time
  4. Adding a third antidepressant of the same class

Explanation

Treatment-resistant depression, defined as failure of two adequate antidepressant trials, warrants specialist psychiatric assessment for augmentation strategies, psychological therapy or other interventions. Simply adding another agent of the same class is not evidence-based.

Question 46Medical knowledge and clinical practice (provisional - source does not enumerate domains)

A 35-year-old man is brought in after a fall from height. His blood pressure is 85/50 mmHg and heart rate 120 beats per minute. He has distended neck veins and muffled heart sounds. What is the most likely diagnosis?

  1. Cardiac tamponade Correct answer.
  2. Neurogenic shock
  3. Tension pneumothorax
  4. Hypovolaemic shock from a pelvic fracture

Explanation

Beck's triad of hypotension, distended neck veins and muffled heart sounds points to cardiac tamponade, in which pericardial fluid impairs ventricular filling. Hypovolaemic shock would produce collapsed neck veins, and neurogenic shock causes bradycardia rather than tachycardia.

Question 47Medical knowledge and clinical practice (provisional - source does not enumerate domains)

A 65-year-old man has a painful, swollen right calf after a long-haul flight. Which is the most appropriate initial investigation to confirm the suspected diagnosis?

  1. D-dimer assay
  2. Magnetic resonance venography
  3. Compression ultrasound of the leg veins Correct answer.
  4. Plain radiograph of the calf

Explanation

Compression ultrasound is the imaging investigation of choice for suspected deep vein thrombosis and is both sensitive and specific for proximal thrombi. D-dimer is useful to exclude the diagnosis in low-probability cases but is not confirmatory, and plain radiographs do not assess veins.

Question 48Medical knowledge and clinical practice (provisional - source does not enumerate domains)

A 50-year-old man has a serum calcium of 2.95 mmol/L and a raised parathyroid hormone level. Which is the most likely cause?

  1. Primary hyperparathyroidism Correct answer.
  2. Vitamin D deficiency
  3. Hypoparathyroidism
  4. Chronic kidney disease with secondary hyperparathyroidism

Explanation

Hypercalcaemia with an inappropriately raised or normal parathyroid hormone indicates primary hyperparathyroidism, most often from a parathyroid adenoma. Vitamin D deficiency and chronic kidney disease cause low or low-normal calcium with secondary parathyroid hormone elevation.

Question 49Medical knowledge and clinical practice (provisional - source does not enumerate domains)

A 70-year-old woman has a wrist fracture after a fall from standing height. Which is the most appropriate initial approach to reduce her future fracture risk?

  1. Routine calcium and vitamin D alone without further assessment
  2. Immediate initiation of hormone replacement therapy
  3. Reassurance that this is a normal age-related event
  4. Bone densitometry and assessment for osteoporosis treatment Correct answer.

Explanation

A fragility fracture in an older adult warrants bone densitometry and assessment for osteoporosis treatment, including lifestyle measures and pharmacological therapy such as bisphosphonates. Hormone replacement therapy is not first-line in older women because of cardiovascular and breast cancer risks.

Question 50Medical knowledge and clinical practice (provisional - source does not enumerate domains)

A 4-year-old child has a fever, sore throat and a sandpaper-like rash with a strawberry tongue. Which organism is the most likely cause?

  1. Epstein-Barr virus
  2. Neisseria meningitidis
  3. Staphylococcus aureus
  4. Streptococcus pyogenes Correct answer.

Explanation

Scarlet fever is caused by group A beta-haemolytic Streptococcus pyogenes and presents with fever, pharyngitis, a sandpapery rash and a strawberry tongue. Staphylococcus aureus causes toxic shock syndrome, which has a different clinical picture.