A 23 year old female presents with weight gain and a 4 month history of amenorrhoea. Examination reveals a BMI of 33 and mild hirsuitism. Relevant investigations reveal an oestradiol concentration of 1200 pmol/l (NR 130 - 800 pmol/l), a testosterone concentration of 2.8 nmol/l (NR less than 3 nmol/l), a prolactin concentration of 1500 mU/l (NR 50 - 450 mU/l), an LH of 1.2 u/l (NR 1.2 - 8 u/l) and a FSH of 1.5 u/l (NR 1.58 u/l).

What is the most likely diagnosis?

A 58-year-old man presents with weight loss and haemoptysis. He has smoked most of his life. On examination he is clubbed and has clinical evidence of right pleural effusion. His serum calcium is 3.2mM.

Which of the following histological type of lung cancer is he most likely to suffer from?

A 60-year-old Chinese man has been started on quinine for leg cramps by his General Practitioner. He presents, a week later, with 5 days of darkened urine and 2 days of increasing breathlessness, back pain and fatigue. Investigations show a haemoglobin of 7.0 g/dl and raised reticulocyte count.

Which of the following best explain this drug reaction? 

A breathless patient undergoes pulmonary Function testing. The following results are obtained; FEV1 = 74% predicted, FVC = 68% predicted, TLC = 77% predicted, Tlco =46% predicted, Kco = 53% predicted.

Which of the following is the most likely cause?

A 40-year-old man with a long history of alcohol abuse is admitted with a subacute illness, comprising headache, fever, meningism and ataxia. MRI brain showed patchy high signal abnormality of the brain stem. CSF analysis showed polymphonuclear pleocytosis and low glucose. He had failed to improve after 3 days of intravenous cefotaxime treatment.

The most likely diagnosis of the meningitis is?

A 25 year old lady with known SLE presents with the nephrotic syndrome. A renal biopsy is performed and this confirms diffuse proliferative glomeronephritis (WHO Class 1V).

Which of the following treatment regimes would you advise?

A 22 year old boy with known hereditary angioneurotic oedema (HAO) presents with a recurrent fever, arthralgia and a rash on the face and the upper chest.

Despite treatment for his HAO, he has always been troubled by recurrent attacks and has required adrenaline on several occasions. His C4 levels have been persistently reduced secondary to his HAO.

What is the most likely cause for his current symptoms?

50 year old Asian lady with severe rheumatoid arthritis has failed on most traditional DMARD treatments. She is currently on Methotrexate 20 mg weekly and for the last 6 months has been receiving regular infusions of the anti-TNF-alpha monoclonal antibody, Infliximab.  Her joint disease has dramatically improved. She now presents with fevers, pleuritic chest pain and a large left sided pleural effusion, but little evidence of joint synovitis.

What is the most likely diagnosis?

A 25 year old lady gives birth to a baby with complete heart block who subsequently requires pacemaker insertion.

Which of the following antibodies is most likely to be detected in the maternal serum?

A 28 year old female presents in the 24th week of pregnancy with profound tiredness and anxiety. Examination reveals a tremor, a pulse of 100 beats per minute and a soft bruit heard over the thyroid gland. Thyroid function tests show a free T4 of 32.9 pmol/l (NR 9.8 - 23.1) and a TSH of 0.04 mu/l (NR 0.5 - 4). 

Which of the following treatments would you select for this patient?

A 44-year-old woman with type 1 diabetes mellitus has not attended the diabetic clinic for 5 years. Her HbA1c is 10.1%. Examination shows no abnormalities. Her hemoglobin level is 9 g/dL, hematocrit is 28%, and mean corpuscular volume is 94 mcm3. A blood smear shows normochromic, normocytic anaemia.

Which of the following is the most likely cause?

Ten individuals are admitted to casualty with profuse vomiting after attending a retirement dinner in a chinese restaurant. They all ate at roughly 7 pm and became ill at roughly midnight. Nine ate a mixture of dishes except one female who ate vegetarian dishes with her rice.

What is the most likely infective organism?

A 36-year-old man attends clinic with his wife after failing to conceive after 10 years of marriage. Examination reveals that he his tall, thin and has bilateral gynaecomastia. Investigations show high levels of urinary gonadotrophins. What is the most likely diagnosis?

A patients' arterial blood gases give the following results; pO2 10 kPa (75mmHg), pCO2 7 kPa (52 mmHg), pH 7.47, [HCO3-] 37. Which of the following is the most likely cause?

A 50 year old man presents with a 6 week history of general malaise and a 2 day history of a right foot drop, a left ulnar nerve palsy and a widespread purpuric rash. He complains of arthralgia but has no clinical evidence of inflammatory joint disease. Echocardiogram is normal, blood cultures are negative, ESR 100 mm/hr, ANCA negative, ANA negative, rheumatoid factor strongly positive, C3 0.8 g/l (0.75 - 1.6), C4 0.02 g/l (0.14 - 0.5). Dipstick urinalysis shows blood ++ but no protein.

A 25 year old man with ankylosing spondylitis develops a DVT after a long haul flight. He is established on warfarin and his indomethacin is discontinued. He has severe spinal inflammation and is unable to cope without a NSAID. Which of the following NSAIDs would be the safest in this case?

The most likely diagnosis of the meningitis?

You are asked advice by a young professional couple, Mr and Mrs X. Mrs X is 9 weeks pregnant. Mr X’s brother and his partner had a child with cystic fibrosis. As a result, Mr X was screened and found to carry the DF508 mutation for cystic fibrosis. Mrs X declines to be tested. What are the chances of Mr and Mrs X’s child having cystic fibrosis, given that the gene frequency for this mutation in the general population is 1/20.?

A 78 year-old man is admitted to hospital having developed abnormal movements of his left side. He has longstanding hypertension, well-controlled on atenolol, but has otherwise been healthy. On xamination of his central nervous system, he exhibits sudden, violent, involuntary flinging movements of his left arm and leg. What treatment should be given?

A 54 year old female presents with a neck swelling which has been more noticeable over the last 4 months. Examination reveals a modest goitre and clinically she appears euthyroid. Investigations reveal a T4 of 13.1 pmol/l (NR 9.8 - 23) and a TSH of 5.3 mU/l (NR 0.5 - 4 mU/l). Of the thyroid auto-antibodies, anti - microsomal antibodies are detectable.

What is the most probable explanation of this patient's goitre?