1. A 30-year-old woman presents with shortness of breath, wheezing, and a history of asthma. Her peak expiratory flow rate is 50% of the predicted value. What is the most appropriate immediate management?

2. A 60-year-old woman presents with a severe pain deep within her left ear and dizziness. She reports that the room ‘is spinning’. Clinical examination shows vesicular lesions on the external auditory canal and pinna, and partial facial nerve palsy on the left side. What is the most likely diagnosis?

3. A 27-year-old woman presents with a fever, malaise, and a sore throat. On examination, she has cervical lymphadenopathy and splenomegaly. Her monospot test is positive. What is the most likely diagnosis?

4. A 45-year-old woman presents with chronic diarrhea, weight loss, and abdominal pain. Her anti-tissue transglutaminase antibodies are positive. What is the most likely diagnosis?

5. A 75-year-old man with a history of atrial fibrillation presents with sudden onset of unilateral weakness and aphasia. What is the most likely cause of his symptoms?

6. A 55-year-old man presents with severe epigastric pain radiating to the back, nausea, and vomiting. His serum amylase and lipase levels are significantly elevated. What is the most likely diagnosis?

7. A 42-year-old woman presents with chest pain that she describes as a stabbing sensation lasting a few seconds. The pain is reproducible with palpation of the chest wall. What is the most likely diagnosis?

8. A 70-year-old male with a history of hypertension presents with sudden severe chest pain that radiates to his back. His blood pressure is significantly higher in his right arm compared to his left arm. What is the most likely diagnosis?

9. A 28-year-old female presents with chest pain, palpitations, and shortness of breath. Her ECG shows sinus tachycardia and no other abnormalities. She is otherwise healthy with no significant medical history. What is the most likely diagnosis?

10.A 50-year-old man with a history of untreated syphilis presents with a thoracic aortic aneurysm. What is the most likely mechanism of the aneurysm formation?

11.A 58-year-old woman presents with back pain and a palpable abdominal mass. She has a history of smoking and hypercholesterolemia. What is the most likely diagnosis?

12. A 45-year-old man presents with acute chest pain and is found to have a dissection involving the ascending aorta. What is the most appropriate initial management?

13.A 75-year-old man with a history of hypertension presents with a sudden severe headache and loss of consciousness. A CT scan shows a subarachnoid hemorrhage. An aortic aneurysm is detected on further imaging. What is the most likely cause of the aneurysm?

14. A 63-year-old patient with prostate cancer presents with constipation. He was diagnosed with prostate cancer after a biopsy four months ago. Following various investigations, he was diagnosed with local and distant metastases. Despite this he has remained relatively well and is able to live independently. He has not opened his bowels for three days and has been feeling generally tired.Which of the following is the most appropriate next step?

15. A 48-year-old man is diagnosed with renal cell carcinoma. He presents to his local palliative medicine service with constipation.His drug list includes morphine sulphate modified release, 40 mg twice a day. He is assessed for the cause of his constipation and given advice on fluid intake and diet. Alongside these measures he is started on a laxative. Which would be the most appropriate initial laxative?

16.Which of the following is a recognised cause of pulmonary eosinophilia?

17. A 70-year-old male with longstanding acromegaly comes to the respiratory clinic for follow-up. He had been recently diagnosed with obstructive sleep apnoea. Despite various lifestyle modifications which he has undertaken such as losing weight and exercising regularly he still reports being tired when he comes home from work, he has restless sleep during the night with his wife often been disturbed by his loud snoring. What would be the next step to consider in the management of his obstructive sleep apnoea?

18. A 50 year old woman presented with frequent headaches associated with sweating and palpitations. On examination, her blood pressure readings were persistently high, with the systolic pressure ranging from 160 to 170 mmHg and the diastolic pressures between 100 to 110 mmHg. On further evaluation, the 24-hour urine nor-metanephrine level was found to be elevated. She had undergone thyroidectomy previously for medullary thyroid cancer, which she reports runs in the family.
What is the most likely genetic mutation?

19. A 55-year-old woman presents to her GP feeling generally unwell. For the past 1 year she has been experiencing daily frontal headaches. She has also noticed some unusual symptoms such tightening of her wedding ring and increase in her shoe size. Magnetic resonance scan has shown a pituitary macro-adenoma and she is planned for trans-nasal trans-sphenoidal surgery. What treatment is often used as an adjunct to surgery?

20. A patient with a liver mass noted on ultrasound undergoes CT scan.  The lesion is described as hypovascular with central scarring. Which  of the following is the diagnosis?

21. A63-year-old lady presents with tiredness. She has not had any periods  for the last three years and has no previous medical history.Her full blood  count shows her to have a haemoglobin of 103 g/L and her C reactive  protein is <5 mg/dL.According to the British Society of Gastroenterology  guidelines on the management of iron deficiency anaemia which of the  following is the most sensitive marker for iron deficiency?

22. A 35-year-old male presents to the emergency department with sudden onset of vomiting and diarrhea after attending a picnic where he consumed various foods, including mayonnaise-based salads and desserts. The symptoms began approximately 4 hours after the meal. Physical examination reveals a temperature of 37.5°C, heart rate of 90 bpm, and blood pressure of 120/80 mmHg. Laboratory tests show normal white blood cell count and electrolytes within normal limits. Stool cultures are negative for common bacterial pathogens. Given the patient’s rapid onset of symptoms and recent dietary history, a toxin-mediated food poisoning is suspected. Which of the following is the most likely organism responsible for this patient’s condition?

23. A 28-year-old woman presents to the clinic with concerns about increased hair growth on her face and body. She has noticed this change over the past year. On examination, you observe coarse hair on her upper lip, chin, lower abdomen, and thighs. Her BMI is 30 kg/m², and she reports irregular menstrual periods. She denies taking any medications. A Ferriman-Gallwey score assessment is performed, and she scores 18. Which of the following is the most likely underlying condition contributing to her symptoms?

24. A 23-year-old man attends with an acutely swollen and painful right knee, left elbow, and painful ankles. He describes having had burning when passing urine and gritty feeling eyes with conjunctivitis in the last week or so. You aspirate the knee. What organism is most likely to be present in the fluid?

25.  Which one of the following is most recognised as a potential complication in a patient with ankylosing spondylitis?