Free SMLE Medicine questions

A 21-year-old man with recurrent exertional wheeze and cough presents 30 minutes after an aerobics class with worsening breathlessness. He speaks in short phrases; respiratory rate is 26 breaths/min, heart rate 108 beats/min and oxygen saturation 94% on room air. There are diffuse expiratory wheezes with prolonged expiration. Peak expiratory flow is 55% of predicted. Which of the following is the most effective initial emergency department treatment?

A 27-year-old woman with asthma presents with 6 hours of progressive wheeze and breathlessness after a viral illness. She speaks in short phrases, respiratory rate is 28 breaths/min, and oxygen saturation is 93% on room air, with diffuse expiratory wheeze. She receives nebulised salbutamol and ipratropium plus oral prednisolone. Which of the following is the most appropriate tool to monitor her response and judge the outcome of this attack?

A 51-year-old woman is admitted with two days of severe headache, now with neck pain, fever and increasing confusion. She is drowsy with neck stiffness and a positive Kernig sign, and there is no rash. Cerebrospinal fluid is turbid with 200 cells/µL that are 90% neutrophils, protein 0.9 g/L, and glucose 1.6 mmol/L against a serum glucose of 6.0 mmol/L. Which of the following is the most likely causative organism?

A 66-year-old man with severe COPD has 2 days of worsening breathlessness. Despite an hour of controlled oxygen, bronchodilators, hydrocortisone and doxycycline, he remains distressed with a respiratory rate of 30 breaths/min and is drowsy with a flapping tremor. Arterial blood gas on 28% oxygen shows pH 7.26, PaCO2 8.6 kPa, PaO2 7.9 kPa and bicarbonate 30 mmol/L. What is the most appropriate next step in management?

A 66-year-old man with chronic obstructive pulmonary disease has 2 days of worsening breathlessness and purulent sputum, with no improvement after an hour of nebulized bronchodilators, intravenous hydrocortisone, and antibiotics. He is drowsy but rousable, follows commands, and protects his airway. Arterial blood gas shows pH 7.30, PaCO2 9.0 kPa (68 mm Hg), and PaO2 7.6 kPa (57 mm Hg). What is the most appropriate next step?

A 17-year-old male with persistent asthma presents with 6 hours of worsening breathlessness. He speaks in single words, respiratory rate is 32 breaths/min and oxygen saturation 89 % on 6 L/min of oxygen. After systemic corticosteroid, repeated nebulized bronchodilators and intravenous magnesium sulfate there is no improvement at 1 hour. Arterial blood gas shows pH 7.30 and PaCO₂ 50 mm Hg. What is the most appropriate next step in management?

A 27-year-old woman with asthma has 2 days of worsening wheeze and breathlessness. She is alert, with oxygen saturation 93 percent on 3 L/min by nasal cannula. After 1 hour of continuous nebulised salbutamol and ipratropium, intravenous magnesium, and systemic corticosteroids she remains distressed, and arterial blood gas shows pH 7.28, PCO2 8.8 kPa, and PO2 9.9 kPa. Which of the following is the best next step in management?

A 20-year-old sexually active woman has 2 days of burning on urination, frequency and suprapubic discomfort. She has no fever, no flank pain and no vaginal discharge. There is mild suprapubic tenderness with no costovertebral angle tenderness. Urine dipstick is positive for leukocyte esterase. She has no drug allergies and no previous urinary infection. What is the most appropriate next step in management?

A 63-year-old man with type 2 diabetes, hypertension, and stage 4 chronic kidney disease reports 3 months of fatigue. Blood pressure is 132/78 mm Hg with no oedema. Haemoglobin is 9.2 g/dL, MCV 88 fL, eGFR 22 mL/min/1.73 m², ferritin 480 µg/L, and transferrin saturation 32%. Vitamin B12 and folate are normal. Which is the most appropriate next step in management?

A 32-year-old woman has 3 months of low back and alternating buttock pain with morning stiffness lasting about an hour. She denies psoriasis, oral or genital ulcers, eye redness, diarrhoea, urethral discharge, and preceding gastrointestinal or genitourinary infection. Rheumatoid factor and anti-cyclic citrullinated peptide antibodies are negative, serum urate is 260 µmol/L, and pelvic radiography shows bilateral grade 3 sacroiliitis. Which of the following is the most likely diagnosis?

A 25-year-old man attends a pre-employment check-up. He is 192 cm tall with hyperextensible joints. Blood pressure is 148/52 mm Hg with a collapsing radial pulse. Cardiac auscultation reveals a soft, high-pitched, early diastolic decrescendo murmur at the left sternal edge, louder when he sits up, leans forward and holds his breath in full expiration. The apex beat is displaced laterally. Which of the following is the most likely diagnosis?

A 73-year-old man has exertional dyspnea and two episodes of syncope while walking uphill. A harsh mid-systolic ejection murmur is heard at the right second intercostal space, radiating to both carotids. The carotid upstroke is delayed and low in volume, and the second heart sound is soft. Blood pressure is 112/78 mm Hg. What is the most likely diagnosis?

A 68-year-old man has 6 weeks of progressive abdominal distension and ankle swelling, with no history of liver disease or alcohol use. The jugular venous pressure is elevated, with a third heart sound, bibasilar crackles, shifting dullness, and pitting oedema. Ascitic albumin is 2.0 g/dL with serum albumin 3.6 g/dL, ascitic total protein 3.5 g/dL, and 60 polymorphonuclear cells/mm³. Which is the most likely cause of his ascites?

A 68-year-old woman attends pre-operative assessment before elective knee arthroplasty. She has no dysuria, frequency, urgency, suprapubic or flank pain, and is afebrile. Urinalysis shows 30 leukocytes per high-power field with positive nitrites, and clean-catch midstream culture grows more than 10⁵ colony-forming units/mL of Klebsiella pneumoniae. She is not pregnant and no urological procedure is planned. What is the most appropriate management?

A 26-year-old woman is referred with 6 months of exertional dyspnea and palpitations. There is a grade 2/6 systolic ejection murmur at the left upper sternal border and a soft mid-diastolic rumble at the lower left sternal border. Electrocardiography shows right axis deviation with incomplete right bundle branch block. Echocardiography demonstrates a 15 mm secundum atrial septal defect with left-to-right shunting. Which auscultatory finding is characteristic of this lesion?

A 60-year-old man with a 12-year history of nightly heartburn and acid regurgitation presents after two episodes of vomiting small amounts of fresh blood. Haemoglobin is 121 g/L and he is haemodynamically stable. Upper gastrointestinal endoscopy shows salmon-coloured mucosa extending 4 cm proximally from the gastro-oesophageal junction, and biopsies reveal intestinal-type columnar epithelium with goblet cells and no dysplasia. Which of the following is the most likely diagnosis?

A 55-year-old man with 20 years of daily heartburn undergoes upper endoscopy. It shows a 4 cm segment of salmon-colored mucosa above the gastroesophageal junction, a 2 cm sliding hiatal hernia, a short benign peptic stricture, and linear erosions in the distal esophagus. Biopsies of the salmon-colored segment show intestinal metaplasia with goblet cells and no dysplasia. Which of these findings carries the greatest risk of progression to esophageal adenocarcinoma?

A 35-year-old shepherd from Aseer has four months of fever, drenching night sweats and low back pain. He regularly drinks unpasteurised camel milk. The right knee is swollen with an effusion and lumbar movement is limited. Knee aspiration yields 15,000 white cells/µL with no organisms on Gram stain, and two sets of blood cultures held for 5 days are negative. Which of the following is the most appropriate next action?

A 44-year-old Saudi farmer has 3 months of undulating fever, night sweats, and low back pain radiating to both legs. He drinks unpasteurised camel milk. There is bony tenderness over the lumbar spine, and MRI shows L4 to L5 spondylodiscitis. Blood cultures grow slow-growing gram-negative coccobacilli. Which of the following is the most likely diagnosis?

A 59-year-old man develops progressive dyspnea and hypoxemia 20 hours after laparotomy for colonic adenocarcinoma with liver metastases. Blood pressure is 122/76 mm Hg, heart rate 108 beats/min, respiratory rate 24 breaths/min, oxygen saturation 88% on room air. CT pulmonary angiography shows a right lower lobe embolus. Hemoglobin is 11.2 g/dL. Which of the following is the most appropriate initial treatment?

A 28-year-old woman has had chronic diarrhea, bloating, and 6 kg weight loss for one year. Hemoglobin is 9.8 g/dL with ferritin 6 µg/L despite oral iron. Anti-tissue transglutaminase IgA is strongly positive with normal total IgA. She continues a normal gluten-containing diet. Which statement about establishing her diagnosis is correct?

A 30-year-old previously healthy man has three days of fever, productive cough and pleuritic pain. Temperature is 39.1 °C, respiratory rate 26 breaths/min, blood pressure 118/70 mm Hg, oxygen saturation 91% on room air, and white cell count 18 × 10⁹/L. Chest radiography shows right middle lobe consolidation. He is admitted to a general ward. Which antibiotic regimen is most appropriate?

A 45-year-old man who smokes and has type 2 diabetes mellitus has three days of fever and productive cough. He is fully alert and oriented. Temperature is 38.3 °C, blood pressure 128/76 mm Hg, respiratory rate 20 breaths/min, and oxygen saturation 96% on room air. Blood urea is 5.1 mmol/L and chest radiography shows a right lower lobe infiltrate. Which of the following is the most appropriate management?

A 66-year-old woman with severe chronic obstructive pulmonary disease presents with worsening dyspnoea and purulent cough. She is alert and cooperative, with accessory muscle use. Oxygen saturation is 93 percent on 3 L/min. Chest radiograph shows hyperinflation without pneumothorax. After 1 hour of nebulised bronchodilators, corticosteroids, and antibiotics, arterial blood gas shows pH 7.28 and PaCO2 66 mm Hg. Which of the following is the best next step in management?

A 55-year-old man who smokes 30 cigarettes daily presents with one hour of retrosternal chest pain radiating to the neck. He has no diabetes or family history of premature coronary disease. Blood pressure is 128/78 mm Hg and body mass index is 26 kg/m². ECG shows 1 mm ST depression in leads II, III, and aVF, and troponin is elevated. Which factor contributed most to his coronary event?

A 49-year-old woman has 4 months of paroxysmal dry coughing spells that interrupt conversation. A glucocorticoid nasal spray for presumed allergic rhinitis gave no benefit. She has dust allergy. Examination shows slight nasal congestion and a dry cough, and the chest is clear. Chest radiograph is normal, and spirometry shows FEV1/FVC 0.78 with 6% change after bronchodilator. Which diagnostic test is most appropriate next?

An 18-year-old woman has 10 months of loose non-bloody stools with crampy right lower quadrant pain, and she has lost 6 kg. She has had no rectal bleeding. There is tenderness in the right iliac fossa. Haemoglobin is 100 g/L, mean corpuscular volume 100 fL, platelets 540 × 10⁹/L, vitamin B12 74 pmol/L (reference 120 to 660), and folate is low. Which of the following is the most likely diagnosis?

An 82-year-old man with heart failure and permanent atrial fibrillation taking digoxin presents with three days of worsening orthopnoea and leg swelling. Blood pressure is 128/76 mm Hg, ventricular rate 96 beats/min, jugular venous pressure 8 cm, with bibasal crackles and a right pleural effusion on chest radiograph. Serum digoxin is 1.4 ng/mL. Which is the most appropriate next step?

A 71-year-old woman has 2 days of fever, dysuria, and suprapubic pain, and since this morning has been disoriented with fluctuating attention; last week she was fully alert and independent. Temperature is 38.6 °C. Urinalysis shows nitrites and 60 white cells per high-power field. Leukocytes are 16.5 × 10⁹/L, sodium 132 mmol/L, and corrected calcium 2.06 mmol/L. Which of the following is the most appropriate next step in management?

A 66-year-old man with type 2 diabetes, hypertension, and heart failure takes lisinopril, furosemide, and insulin. Heparin and warfarin were started for deep vein thrombosis. He now has worsening leg edema. Potassium is 6.5 mmol/L, creatinine 168 µmol/L, activated partial thromboplastin time prolonged, and prothrombin time normal. Which medication should be stopped?

A 58-year-old man presents with 3 days of fever, rigors and productive cough. He has not been hospitalised or received antibiotics in the past year. Temperature is 38.9 °C and oxygen saturation is 92% on room air. He is fully orientated, and chest radiography shows right lower lobe consolidation. He is admitted to a general medical ward. Which of the following is the most appropriate empirical antibiotic regimen?

A 71-year-old man with known chronic obstructive pulmonary disease presents with severe respiratory distress and drowsiness. He responds only to painful stimuli, cannot cooperate with instructions, and his upper airway is full of copious purulent secretions. Respiratory rate is 8 breaths/min and shallow, and oxygen saturation is 74%. Arterial blood gas shows pH 7.18 and PaCO2 10.6 kPa. Which of the following is the best next step in management?

A 35-year-old woman is diagnosed with Graves disease after 5 kg weight loss, palpitations, heat intolerance, and a diffuse goitre with a bruit. Thyroid-stimulating hormone is undetectable, free thyroxine 42 pmol/L, and thyrotropin receptor antibodies strongly positive. She has mild eyelid retraction and proptosis of 20 mm bilaterally without diplopia. She smokes 20 cigarettes daily. Which factor most increases her risk of progressive orbitopathy?

A 45-year-old man who emigrated from Southeast Asia is screened before hospital work. He feels well and alanine aminotransferase is 28 U/L. Serology shows hepatitis B surface antigen positive, anti-hepatitis B core IgG positive, anti-core IgM negative, hepatitis B e antigen negative, anti-hepatitis B e positive, and anti-hepatitis B surface antibody negative, with hepatitis B virus DNA 1,500 IU/mL. Which is the most likely interpretation?

A 58-year-old man with compensated cirrhosis from chronic hepatitis C, cured with direct-acting antivirals two years ago, attends the hepatology clinic. He is asymptomatic, with a firm liver edge, no ascites and no encephalopathy. His Child-Pugh score is A, platelet count 96 x 10⁹/L, albumin 38 g/L, and the international normalised ratio is 1.1. Which of the following is the most appropriate strategy for hepatocellular carcinoma surveillance?

A 47-year-old man has 6 months of fatigue, right upper quadrant discomfort and darkening bronze skin. He also reports reduced libido and aching second and third metacarpophalangeal joints. He drinks no alcohol. Fasting glucose is 9.1 mmol/L, ALT 78 U/L, serum ferritin 1450 µg/L and transferrin saturation 62 percent. His father died of liver cirrhosis. What is the most appropriate confirmatory test?

A 22-year-old man has 4 days of fever, severe frontal headache, and progressive confusion. Yesterday he was unable to name familiar objects and had a brief episode of lip smacking with unresponsiveness. Lumbar puncture shows 380 cells/µL with 90 percent lymphocytes, protein 0.8 g/L, cerebrospinal fluid glucose 3.7 mmol/L with a normal serum glucose, and a negative Gram stain. Which of the following is the most appropriate intravenous treatment?

A 19-year-old competitive footballer attends after his brother died suddenly at 24 and a paternal uncle at 30. He has had 2 episodes of light-headedness and one near-syncope while sprinting. A grade 3 out of 6 systolic murmur at the left lower sternal border becomes louder on standing and during Valsalva, and softer on squatting. There is a fourth heart sound. Which condition should he be screened for?

A 27-year-old man has exertional dyspnea and two episodes of near syncope while playing football. A harsh systolic murmur at the left sternal border increases with Valsalva. Echocardiography shows asymmetric septal hypertrophy of 19 mm, systolic anterior motion of the mitral valve, and a resting left ventricular outflow gradient of 60 mm Hg. What is the most appropriate initial therapy?

A 61-year-old woman is referred after a solid left upper lobe pulmonary nodule was found incidentally on CT for renal colic. She is asymptomatic. She has never smoked and has no occupational dust or asbestos exposure, no family history of lung cancer, and no prior malignancy. The nodule measures 8 mm with smooth margins and no calcification. Which of the following is the most appropriate next step in management?

A 19-year-old man is newly diagnosed with type 1 diabetes after 4 weeks of polyuria, polydipsia, and 6 kg of weight loss. His mild diabetic ketoacidosis has resolved. He is a university student whose meal times vary from day to day and he plays football three evenings a week. HbA1c is 11.4 % (101 mmol/mol). Which of the following is the most appropriate outpatient insulin regimen?

A 22-year-old man arrives in the emergency department with vomiting and drowsiness. Glucose is 28 mmol/L, arterial pH 7.10, bicarbonate 8 mmol/L, potassium 4.2 mmol/L, and urine ketones strongly positive. Blood pressure is 96/58 mm Hg and he is clinically dehydrated. After intravenous fluid resuscitation is started, how should insulin be administered?

A 45-year-old man receiving induction chemotherapy for acute myeloid leukemia has been neutropenic for 18 days with persistent fever of 38.9 °C despite 7 days of meropenem and vancomycin. He now has right-sided pleuritic chest pain and small-volume hemoptysis. Computed tomography shows two peripheral nodules with surrounding ground-glass halos. Serum galactomannan index is 1.8 and bronchoalveolar lavage grows Aspergillus fumigatus. What is the most appropriate first-line treatment?

A 66-year-old man taking ibuprofen daily for osteoarthritis has 2 months of dyspepsia and fatigue. Endoscopy shows erosive gastritis with no active bleeding, and biopsies are negative for Helicobacter pylori. Hemoglobin is 90 g/L, mean corpuscular volume 72 fL, and ferritin 8 µg/L. Pulse is 78 beats/min and blood pressure 128/76 mm Hg. What is the most appropriate treatment for his anemia?

A 28-year-old woman with systemic lupus erythematosus on hydroxychloroquine, prednisone 5 mg daily, and azathioprine presents with weakness of both legs and urinary incontinence developing over 6 hours. Power is 2/5 in both lower limbs with hyperreflexia, extensor plantars, and a sensory level at T8. She has no headache, seizures, or confusion. Which investigation is most appropriate immediately?

A 22-year-old man reports two days of dysuria and mucopurulent urethral discharge after unprotected intercourse with a new partner. He is afebrile at 37.0 °C with no testicular tenderness or skin lesions. Gram stain of the discharge shows numerous neutrophils with intracellular gram-negative diplococci. Nucleic acid amplification testing is pending. Which of the following is the most appropriate empirical treatment?

A 50-year-old man attends for a routine health check. He has no history of cardiovascular disease, diabetes, hypertension or pancreatitis, has never smoked, takes no medication and has no family history of premature coronary disease. His body mass index is 31 kg/m2, waist circumference 106 cm, blood pressure 124/78 mm Hg, and he reports drinking two sugar-sweetened soft drinks daily with minimal physical activity. Fasting lipids show LDL cholesterol 108 mg/dL, HDL cholesterol 38 mg/dL and triglycerides 281 mg/dL. Fasting glucose, TSH, creatinine, urine protein and liver enzymes are all normal, and his estimated 10-year atherosclerotic cardiovascular risk is 4%. Which of the following is the most appropriate next step in management?

A 58-year-old woman has wheezing and breathlessness most days during allergy season, limiting her activities several times a week, plus nocturnal waking twice weekly. She uses loratadine and antihistamine eye drops only. Examination shows conjunctival injection and expiratory wheeze. Chest radiograph is normal. FEV1 is 74% of predicted and rises 18% after bronchodilator. Which treatment is most appropriate?

A 19-year-old woman has 5 days of blurred vision with pain on moving the right eye and 2 weeks of left leg numbness and weakness. Three months earlier she had double vision for 10 days. Right visual acuity is 6/36, with reduced left leg pinprick sensation and an extensor plantar response. MRI shows multiple periventricular and juxtacortical T2-hyperintense lesions, one enhancing with gadolinium. What is the most likely diagnosis?

A 72-year-old man with chronic obstructive pulmonary disease presents with increasing dyspnoea and purulent sputum. He is drowsy but rousable and follows commands, with no vomiting and an intact cough. Oxygen saturation is 94 percent on 4 L/min. After an hour of nebulised bronchodilators, corticosteroids, and antibiotics, arterial blood gas shows pH 7.26 and PaCO2 72 mm Hg. Which of the following is the most appropriate next step in management?

A 30-year-old woman attends an obesity clinic. Body mass index is 32 kg/m², waist circumference 96 cm, fasting glucose 5.4 mmol/L and blood pressure 124/76 mm Hg. She works long hours, eats mostly takeaway meals and takes no physical activity. She wants durable weight loss. Which of the following is the most important factor for achieving it?

A 26-year-old man is found unresponsive; his friend reports heroin use. He responds only to painful stimulus with a Glasgow Coma Scale score of 7. Respiratory rate is 6 breaths/min and oxygen saturation is 84% on room air. Pupils are constricted to 1 mm, there are needle marks in the left antecubital fossa, and capillary blood glucose is 6.1 mmol/L. Which of the following is the most appropriate antidote?

A 68-year-old man has an 18-month history of slowing movement and a right-hand tremor that is most obvious at rest and disappears when he reaches for a cup. Examination shows a 4 Hz pill-rolling rest tremor, cogwheel rigidity at the right wrist, decrementing amplitude on repetitive finger tapping, a stooped shuffling gait with reduced right arm swing, and normal ocular movements. Degeneration of which structure explains these findings?

A 63-year-old woman presents with cola-coloured urine and facial puffiness. Two weeks earlier she had a sore throat treated with penicillin V. Blood pressure is 150/94 mm Hg, with periorbital oedema and pitting ankle oedema. Urinalysis shows 3+ blood and 2+ protein with red cell casts. C3 is low and the antistreptolysin O titre is elevated. Which of the following is the most appropriate treatment at this time?

A 66-year-old woman with stage 5 chronic kidney disease not on dialysis, estimated glomerular filtration rate 18 mL/min/1.73 m², develops sudden pleuritic chest pain and breathlessness 5 days after elective total hip replacement. CT pulmonary angiography confirms bilateral segmental pulmonary emboli, and echocardiography shows normal right ventricular size and function with a normal troponin. The surgical wound is dry. What is the most appropriate initial anticoagulation?

A 62-year-old man had ultrasonography confirming a femoropopliteal deep vein thrombosis, and no treatment has been started. Two hours later he develops pleuritic chest pain and breathlessness. Blood pressure is 126/78 mm Hg and oxygen saturation 92% on room air. CT pulmonary angiography shows filling defects in segmental pulmonary arteries with a normal-sized right ventricle, and high-sensitivity troponin is normal. What is the most appropriate next step in management?

A 62-year-old woman diagnosed 5 days ago with a proximal deep vein thrombosis is adherent to therapeutic low molecular weight heparin. She now has pleuritic chest pain and breathlessness. She is normotensive with oxygen saturation 94% on room air. Computed tomography pulmonary angiography shows bilateral segmental filling defects with a right to left ventricular ratio of 0.8. Troponin and natriuretic peptide are normal. Which is the most appropriate next step?

A 38-year-old woman has bilateral hilar shadows on a screening chest radiograph. She has an occasional dry cough but no dyspnoea, fever, weight loss, or eye symptoms. Spirometry and diffusing capacity are normal. CT confirms bilateral hilar lymphadenopathy with clear parenchyma, and lymph node biopsy shows non-caseating granulomas with negative stains and cultures for mycobacteria and fungi. Which of the following is the most appropriate next step in management?

A 68-year-old woman with persistent atrial fibrillation and moderate persistent asthma attends with palpitations and breathlessness on climbing one flight of stairs. Heart rate is 132 beats/min and irregularly irregular, with no wheeze at rest. An electrocardiogram confirms atrial fibrillation with no pre-excitation, and echocardiography shows a left ventricular ejection fraction of 58 per cent. Thyroid function and electrolytes are normal. What is the most appropriate rate-control agent?

A 32-year-old man has had continuous generalized tonic-clonic seizures for 35 minutes. He received intravenous diazepam 10 mg twice without response. The airway is secured, oxygen saturation is 96 percent, capillary glucose is 6.1 mmol/L, and temperature is 37.1 °C. Which of the following is the most appropriate next step in management?

A 62-year-old woman with diabetes, hypertension, and an ischaemic stroke one month ago has three hours of central chest pain. She takes aspirin, lisinopril, and metoprolol. Pain persists after oxygen, morphine, and sublingual nitroglycerin. Blood pressure is 142/86 mm Hg, and ECG shows 3 mm ST elevation in leads V2 to V5. A catheterisation laboratory is available on site. Which of the following is the most appropriate next step?

A 54-year-old man with asthma reports 6 months of progressive breathlessness that is worse lying flat. A firm swelling in the lower anterior neck moves upward on swallowing but not on tongue protrusion, and raising both arms produces facial plethora and neck vein distension. CT shows a midline mass extending from the thyroid bed into the superior mediastinum with tracheal compression. What is the most likely diagnosis?

A 30-year-old woman with 8 months of rapidly progressive skin thickening, Raynaud phenomenon, and positive anti-RNA polymerase III antibodies has 4 days of severe headache and blurred vision. Blood pressure is 196/114 mm Hg, having been 120/70 mm Hg 2 months ago. Serum creatinine is 238 µmol/L, up from 68 µmol/L, hemoglobin 9.2 g/dL with schistocytes, and platelets 88 × 10⁹/L. What is the most appropriate treatment?

A 54-year-old man with hepatitis C infection has progressive abdominal distension over six weeks. Examination shows spider naevi, splenomegaly, and shifting dullness. Diagnostic paracentesis is performed with a simultaneous blood sample. The ascitic albumin is 8 g/L, the serum albumin is 27 g/L, and the ascitic total protein is 12 g/L. How is the serum-ascites albumin gradient calculated and what does his value indicate?

A 57-year-old man with hepatitis C cirrhosis has progressive abdominal distension and ankle swelling. Examination shows spider angiomas, shifting dullness and pitting pedal edema, with no jugular venous distension. The serum-ascites albumin gradient is 16 g/L, ascitic total protein is 14 g/L, the polymorphonuclear count is 90 cells/mm³, cytology is negative and adenosine deaminase is not elevated. What does this ascitic fluid profile most strongly indicate?

A 60-year-old man reports 6 months of exertional dyspnoea. He has a collapsing pulse, blood pressure 160/45 mm Hg, an early diastolic murmur at the left upper sternal border, and bilateral fine basal crackles. Echocardiography shows severe aortic regurgitation with a left ventricular ejection fraction of 40%. Which of the following is the most appropriate treatment?

A 38-year-old woman with asthma remains symptomatic on a medium-dose budesonide-formoterol inhaler twice daily, with daytime wheeze four days a week, night waking twice weekly, and salbutamol use four times a week. Inhaler technique is correct, adherence is confirmed, she has no rhinosinusitis or reflux, and she does not smoke. Spirometry shows an FEV1 of 68 percent predicted, and blood eosinophils are 0.18 × 10⁹/L. Which addition is most appropriate?

A 38-year-old man undergoes computed tomography after a minor road traffic collision. He has no cough, haemoptysis, fever, night sweats or weight loss. The scan incidentally shows a solitary nodule in the right upper lobe measuring 2.8 cm in diameter with spiculated, irregular margins and no visible calcification. Serum calcium is 2.35 mmol/L. Which of the following features most strongly suggests that this nodule is malignant?

A 61-year-old man with high-grade non-Hodgkin lymphoma and bulky lymphadenopathy was to start chemotherapy the following week. He had poorly controlled type 2 diabetes. He was found collapsed at home and died. Blood on arrival showed potassium 7.4 mmol/L, uric acid 16 mg/dL, phosphate 2.6 mmol/L, corrected calcium 1.7 mmol/L, creatinine 310 µmol/L and lactate dehydrogenase 2100 U/L. Which of the following is the most likely cause of death?

A 33-year-old woman with bronchial asthma and chronic rhinosinusitis reports worsening breathlessness and a cough that wakes her three nights per week. She uses her salbutamol inhaler about five times per week during the day. Oxygen saturation is 97% on room air, with bilateral expiratory wheezes. Spirometry shows an FEV1 of 74% predicted that improves by 14% after bronchodilator. Which of the following should be added to her management plan?

A 34-year-old woman has 10 days of fever and anterior neck pain that began two weeks after an upper respiratory tract infection. The thyroid is diffusely enlarged and exquisitely tender to light palpation, with no eye signs. TSH is 9.8 mIU/L, free T4 is low, anti-thyroid peroxidase antibody is 10 IU/mL, erythrocyte sedimentation rate 78 mm/h and C-reactive protein 62 mg/L. What is the most likely diagnosis?

A 21-year-old man reports three episodes of abrupt palpitations with brief loss of consciousness. During an episode his blood pressure is 105/70 mm Hg and the monitor shows a regular narrow QRS complex tachycardia at 230 beats/min with no discernible P waves and no beat-to-beat variability. The rhythm terminates suddenly with carotid sinus massage. Which is the most likely diagnosis?

A 22-year-old woman is admitted after two generalised tonic-clonic seizures. MRI shows a ring-enhancing right temporal mass, and biopsy confirms glioblastoma multiforme. There is no postural blood pressure drop and no peripheral oedema. Serum sodium is 118 mmol/L, serum osmolality 250 mosmol/kg, urine osmolality 620 mosmol/kg, urine sodium 65 mmol/L, and serum uric acid 130 µmol/L. Which of the following is the most likely cause of her hyponatraemia?

A 29-year-old woman with systemic lupus erythematosus has taken hydroxychloroquine 400 mg daily for 12 months. She has persistent symmetrical swelling of the metacarpophalangeal and proximal interphalangeal joints and wrists with 90 minutes of morning stiffness, and has needed three courses of oral prednisolone this year. Urinalysis shows no protein or casts, complement is normal, and anti-double-stranded DNA is negative. Which is the most appropriate next step in management?

A 29-year-old woman with systemic lupus erythematosus taking mycophenolate mofetil develops a malar rash, temperature 38.1 °C, and painful swelling of both wrists over one week. Blood and urine cultures are negative, creatinine is 68 µmol/L, urinalysis shows no protein or cellular casts, C3 and C4 are mildly reduced, and anti-double-stranded DNA titres are rising. Which is the most appropriate addition to her treatment?

A 30-year-old primigravida at 20 weeks gestation has systemic lupus erythematosus that has been in remission for 2 years on hydroxychloroquine. Blood pressure is 112/70 mm Hg, urine protein is negative, complement levels are normal, and anti-double-stranded DNA is negative. She asks whether to keep taking her medication. Which of the following is the most appropriate management?

A 34-year-old man whose father was treated for pulmonary tuberculosis last year has 6 weeks of fever, night sweats, 7 kg weight loss, and blood-streaked sputum. He has never smoked. There is stony dullness and absent breath sounds over the right lower chest, with a central trachea. Pleural aspirate is straw coloured and lymphocyte predominant, with protein 52 g/L and adenosine deaminase 78 U/L. What is the most likely diagnosis?

A 47-year-old man with newly diagnosed Burkitt lymphoma developed laboratory tumor lysis syndrome 2 days after his first cycle of chemotherapy and was treated with aggressive intravenous hydration and a single dose of rasburicase. Five days later he is alert, has no cramps, tetany or arrhythmia, and urine output is 1.5 mL/kg per hour. Blood pressure is 124/76 mm Hg and heart rate is 84 beats/min. Laboratory studies now show uric acid 250 µmol/L, creatinine 105 µmol/L, potassium 4.2 mmol/L, phosphate 1.3 mmol/L, corrected calcium 2.30 mmol/L, bicarbonate 24 mmol/L and a falling lactate dehydrogenase. The oncology team is deciding whether the metabolic picture has recovered enough to give the next cycle. Which of the following sets of criteria best indicates readiness to resume chemotherapy?

A 19-year-old man is newly diagnosed with type 1 diabetes after presenting with weight loss and ketonuria. He has recovered from diabetic ketoacidosis, is eating normally, and glutamic acid decarboxylase antibodies are positive. C-peptide is low and his body mass index is 21 kg/m². He wants flexible meal timing at university. Which insulin regimen is most appropriate?

A 58-year-old woman has 3 months of epigastric pain with intermittent vomiting and 5 kg weight loss. Hemoglobin is 13.2 g/dL, MCV 92 fL, serum vitamin B12 is 90 pg/mL, and serum folate is normal. She has no diarrhea, takes no metformin, and drinks no alcohol. What is the most appropriate next investigation?