MLTC/GP

convex shape in ct brain

extradural

If a pleural effusion fluid protein/serum protein ratio is >0.5, the effusion is a

exudate

pulmonary infarct - exudate or trans

exudative

which eye condition is most likely to cause ARMD

charles bonnet

Wet ARMD

choroidal neovascularization visual acuity worse at centre of vision, vision worse at night, mode driving difficult in dark.

what gene mutation is sickle cell seen in

chromosome 11

gingival hypertrophy, hypertrichosis and nephrotoxicity

ciclosporin side effects

pts who present > 24 hours after paracetamol ingestion - if they are clearly jaundiced or have hepatic tenderness, their ALT is above normal then what

consider acetylcysteine if ALT is high or paracetamol conc is high

mx of intraductal papillomas

surgical excision

which type of access is preferred for primary PCI

radial A if fails then femoral A can be used

what injury can be caused by radiation to the lungs

radiation induced pulmonary fibrosis

if rib fracture pain is not controlled by morphine how is it managed

regional nerve block

A 10-year-old male is admitted to the orthopaedic ward with a right supracondylar fracture and has undergone close reduction and is placed in a cast. Currently, he is complaining of severe pain on his right arm which increases when his fingers are passively extended. His radial pulse is palpable. Which of the following is the next most appropriate step in managing this patient?

remove cast before urgent fasciotomy

ckd dx

A diagnosis of chronic kidney disease is made when eGFR is below 60 on two blood tests three months apart. 58%

what guage cannula for non-tension pneumothorax

16g

at what age is perthes disease likely to be present

4-8 years old.

hh3

vzv

47XXY

Klinefelter syndrome

Longitudinal splitting of the lamina densa causing a "basket-weave" appearance

alport syndrome

when to give IV iron for someone who is anaemic and going for surgery

before 6 weeks until surgery

narrow pulse pressure

AS

period of hypotension followed by renal impairment with urinary casts

ATN

SE of enteral feeding

diarrhoea

which gender is a rf for depression

female

how long do chronic fatigue syndrome symptoms last

for 3 months before making the dx

Changes to murmur in HOCM when squatting and valsava manouvre

increase in valsava decrease when squatting

normally when does a varicocele go

it goes when lying down

what happens to the sex hormone binding globulin in PCOS

it is low

sgl2 and weight

loss

myoclonic seizures mx

males: sodium valproate females: levetiracetam

what type of drug is selagiline

moa-B inhibitor for parkinsons disease

Patients ≤ 25 years who have been started on an SSRI should be reviewed after

1 week

Orbital Blow Out Fracture Treatment and Follow-Up?

1. *Forced ductions* to rule out nerve palsy one week after trauma 2. *CT scan of Orbit WITHOUT contrast* 3. *Broad Spectrum Oral Antibiotics*: Follow up at 1 week and 2 weeks after trauma Orbital fractures typically occur via blunt force trauma to the face, e.g. via assault, car accidents and sporting injuries. Blowout fractures involve fracture of the orbital wall due to the sudden increase in orbital pressure caused by impact. Blowout fractures most commonly involve the floor and/or medial orbital wall as these are the weakest points. Investigation Suspected orbital fractures are best assessed using computed tomography (CT). Management Treatment involves close ophthalmology follow up +/- antibiotics or surgery.

does an advanced decision need to be in writing

An advance decision only needs to be in writing, signed and witnessed if it is regarding refusing life-sustaining treatment. Examples include mechanical ventilation, artificial feeding and dialysis. 48%

says mama and dada

10 months

An 22 year old man is brought to the Emergency Department with a two day history of abdominal pain and vomiting. His mum says he has been waking up a lot at night to pass urine and wakes up in the morning really thirsty. His urine dip shows: Nitrites negative, Leucocytes negative, Blood negative, Ketones ++++, Glucose +++ His BM is 28 mmol/L (<11) and blood ketones are 4.2 mmol/L (<3). Blood gas shows: pH 7.25 (7.35 - 7.45), pCO2 4.3 (4.6-6.0), HCO3 11 (22-29), Na 144 mmol/L (135-145), K 4.6mmol/L (3.5-5.0) His observations are: HR 94 (60-100), RR 22 (<20), BP 110/65 (SBP <140), SpO2 100% RA What is the best initial management for this man's presentation?

1000ml 0.9% sodium chloride over 1 hour This is a classical case of diabetic ketoacidosis (DKA): abdominal pain, vomiting, polyuria, polydipsia, glucose and ketones in urine, high blood glucose and ketones, metabolic acidosis on the blood gas. Many medical students get swayed by the high glucose and think that insulin is the first step in managing DKA. However, the acute issue in these patients is severe dehydration which needs to be treated with IV fluids. This patient, despite being in DKA, is haemodynamically stable hence should initially be given 1 litre of 0.9% sodium chloride over 1 hour. After this is completed, the patient should be given another 1 litre bag but over 2 hours. The patient should also be started on a fixed rate insulin infusion at a rate of 0.1 units/kg/hr. 55% 500ml 0.9% sodium chloride over 15 minutes This is what we give as a bolus when we are fluid resuscitating a patient. This is given to patients in DKA if they are clinically unstable. This patient is conscious and has no tachycardia or hypotension so can be treated with less aggressive fluid resuscitation. 28%

A 28 year old man is brought to A&E after collapsing outside. He is very drowsy and is only mumbling sounds. His initial assessment is as follows: A - Patent airway B - Good air entry bilaterally. Nil crackles or wheeze. Saturating 98% on air C - Heart sounds normal. Nil murmurs. Slightly dry. IV access obtained and fluids started. Heart rate 64, Blood pressure 110/68. D - GCS 9, Blood glucose 2.0. E - Nil rashes. Needle marks on abdomen and fingers He has a medic alert bracelet which says that he is on insulin. Which of the following is the most appropriate initial treatment?

100ml of IV dextrose 20% This is the correct answer as this gentleman has a low blood glucose and has IV access. An alternative formulation would be 200ml of 10% dextrose. It is likely that this gentleman is a Type 1 diabetic and has either injected too much insulin or has not eaten for a long time. 67%

A 23 year old man, diagnosed with epilepsy seven years ago, has presented to his GP with a query. He would like to know about the driving regulations for people with epilepsy. His last seizure was two years ago. His epilepsy is controlled with sodium valproate, with no recent changes to medication. What is the minimum length of time he must be seizure free before driving a car?

12 months Correct. The DVLA states: "The person with epilepsy may qualify for a driving licence if they have been free from any seizure for 1 year. This needs to include being free of minor seizures and epilepsy signs such as limb jerking, auras and absences. Episodes not involving a loss of consciousness are included." 65%

says 1-3 words

12-18 m

A patient attends your clinic smelling of alcohol. He tells you that he has 3 pints (1 pint = 568ml) of White Cider (7.5%) a day and 1 litre of Vodka (37.5%) throughout the week. What is the total number of units of alcohol this patient is consuming per week?

127 units In this case, the patient drinks 21 pints of 7.5% Cider and 1L bottle of 37.5% Vodka a week. Beer: (568*7.5)/1000 = 4.26 * 21 = 89.46 Vodka: (1000ml*37.5)/1000 = 37.5 89.46 + 37.5 = 126.96 Units This is far above the recommended daily intake of 3-4 units a day for men 50%

An 11-month-old baby has a routine check-up with the health visitor. His parents are concerned because he has not yet started walking. They are wondering if there are any issues with his development. At what age will a child typically be able to walk unassisted?

13 months This is the correct answer. Toddlers will usually start to walk unassisted between the ages of 13-15 months. 43% 18 months An 18-month-old toddler should be able to walk unassisted and will likely be able to squat. If a toddler has not started walking by 18 months, a referral to paediatrics should be made to see if there are any underlying health issues. 54%

A 67-year-old female is brought to the emergency department due to an excruciating headache that started suddenly and is described as like being hit on the back of the head. She feels lethargic, sick and lightheaded. The patient has a past medical history of hypertension and polycystic kidney disease. An urgent CT scan of the head confirms a subarachnoid haemorrhage. Approximately what percentage of strokes are haemorrhagic in nature?

15% This is the correct answer. Ischaemic strokes account for approximately 85% of cases and haemorrhagic strokes for 15%. 72%

how long after giving iv alteplase for an ischaemic stroke do you give aspirin

24 hours

when can you restart the pill after surgery

2 weeks

A 37-year-old woman is reviewed by her perinatal mental health team, when concerns are raised by her partner about unusual behaviour. She has been moving rapidly between high and low mood states, laughing and crying incongruously. During the consultation she appears to be responding to unseen stimuli, and when questioned states that the baby is actually a famous politician in disguise. She has a past history of bipolar affective disorder. During which time period is postpartum psychosis most likely to be seen?

2 weeks after delivery Postpartum psychosis can include paranoia, delusions, hallucinations, mania, depression or confusion, and generally develops within the first two weeks of giving birth. 61%

when does gonorrhoea discharge usually start

2-5 days after exposure

A 34-year-old male is undergoing surgery for a ACL tear using a local anaesthetic. Following the administration, the patient has respiratory depression and a seizure ensues. What is the best treatment for this condition?

20% intralipid infusion The patient has presented with local anaesthetic toxicity. Lipids bind to the local anaesthetics and reverse effects of local anaesthetic toxicity. 68%

An 82 year old woman has been admitted onto the ward due to her seventh fall this year. She has a past medical history of anxiety and osteoporosis. Her ECG is normal, her heart rate is 70 and regular and she is afebrile. However, she has a postural drop of 25mmHg in systolic blood pressure. What is the minimum drop in systolic blood pressure required to diagnose postural hypotension?

20mmHg Correct. A drop of 20mmHg or more is required to illustrate postural hypotension 86%

what guage for tension pneumothorax

21g

A 40 year old man presents to the GP with bilateral flank pain for the past few months. He had three episodes of frank blood in his urine. His father had a sudden death due to a brain bleed. Despite being on multiple anti-hypertensive agents, blood pressure is elevated (170/100 mm Hg). Abdominal examination reveals a palpable liver and palpable kidneys in the flanks. Abdominal ultrasound shows multiple renal cysts in both kidneys. He further requests genetic testing as he wants to start a family soon. The results show that he carries heterozygous alleles while his wife is unaffected. Given the likely diagnosis, what percentage of male offspring can have the same condition?

25% His presentation of bilateral flank pain, organomegaly, hypertension, microscopic haematuria, and a family history of sudden death suggests polycystic kidney disease. About 10% of them present with a berry aneurysm in the Circle of Willis, which might have ruptured and led to his father's demise. It is an autosomal dominant disease (ADPKD), so it is found in males and females equally, and each offspring has a 50% chance of inheriting the disease. ADPKD has complete penetrance. As the chance of being a male child is 50%, therefore the possibility of having ADPKD is half among them, i.e. 25%. 18%

A 57-year-old lady attends her GP with a two week history of facial swelling and frothy-looking urine. A urine dipstick is carried out, which shows 3+ protein in the urine. Approximately how much protein is this equivalent to?

300mg/dL 3+ protein on urine dipstick is approximately equivalent to 300mg/dL of protein. 29%

A 49-year-old woman presents to her general practitioner for advice on stopping smoking. Her daughter is pregnant and has just given up smoking, and she would like to show her support by joining her daughter in quitting entirely. She started smoking when she was 15-years old and smoked 10/day for 5 years. When she was 20-years old, she smoked 30/day for 20 years, then since the age of 40, she has cut down to 5/day. What is her pack-year history?

34.75 pack-years Pack-year history is a unit used to quantify cigarette use. One pack-year is equal to 20 cigarettes per day (one pack) for a year. Therefore: 10 cigarettes per day for 5 years = 2.5 pack years (0.5 pack x 5) 30 per day for 20 years = 30 pack years (1.5 pack x 20) 5 per day for 9 years = 2.25 pack years (0.25 pack x 9) Total: 2.5 + 30 + 5 pack years = 34.75 pack-years 64%

A 45-year-old man presents to the emergency department with agitation and tremors. He denies any hallucinations. The patient admits to chronic excessive alcohol consumption.His temperature is 37.1ºC, his heart rate is 130 bpm, and his blood pressure is 168/105 mmHg. On examination, he is jaundiced and has ascites, however, the examination is limited as he experiences a generalised tonic-clonic seizure.How long has it most likely been since the patient's last drink?

36 hours symptoms: 6-12 hours seizures: 36 hours delirium tremens: 72 hours

when is earlier referral for subfertility done

36 years or older - 18 m?? According to NICE guidelines, women who are aged <40 years should be referred for specialist investigations after 2 years of trying to conceive. This may include up to one year before initial fertility investigations. Women should be advised that in those who do not conceive in the first year, about half will do so in the second year.

tool to assess delirium

4AT Correct. The 4AT is a tool to quickly assess whether a patient has delirium or not. A score of 4 and above is suggestive of possible delirum +/- cognitive impairment. 74%

A 51-year-old man visits his GP due to chest pain. It came on yesterday when he went out for a run and it was relieved after stopping to rest. He has not experienced the pain since. He describes it as a dull pain in the middle of his chest that spread to his jaw. The GP arranges an ECG. What is the correct placement of the first chest lead (V1)?

4th intercostal space, right sternal edge This is the correct placement of the first chest lead, V1. V1 and V2 visualise the septal aspect of the heart. 44%

A 49-year-old man attends his general practitioner because he would like help with his diabetes control. He has type 2 diabetes mellitus and takes metformin 500 mg three times daily. His most recent glycosylated haemoglobin (HbA1c) is 51 mmol/mol. He plans to fast for Ramadan but wants to ensure he does this correctly. He is aware that chronic conditions are exempt from fasting, but he says he would like to fast anyway. He says he eats a main meal during Ramadan after sunset (Iftar) and an early morning meal before sunrise (Suhoor). What is the most appropriate advice to give him regarding his diabetes control?

500 mg metformin in the morning before Suhoor and 1 g metformin in the night after Iftar It is a personal decision to fast for Ramadan, and patients should be provided with a Diabetes UK information leaflet and be aware that they are not required to fast if they have a chronic condition. If a patient chooses to fast, they should be supported to do this as safely as possible. As most will take their main meal after sunset (Iftar) and then have an early morning meal before sunrise (Suhoor), current guidance suggests splitting metformin into one third with Suhoor and two thirds with their main meal at Iftar. 38%

A 88-year old female presents to the emergency department unconscious after being hit by a bicycle. On examination, she has response to pain, says incomprehensible sounds and has abnormal extension to pain. What is her GCS score?

6 Response to pain: 2/4, incomprehensible sounds: 2/5, abnormal extension to pain: 2/6. 54%

Startles to loud noise

6 weeks

dose of predniolone for temporal arteritis

60mg od

when does chronic graft rejection occur

6m after transplant Hyperacute rejection (within minutes): caused by ABO incompatibility, presents with graft thrombosis/SIRS within minutes of the transplant and intra-operatively. This is managed by immediate graft removal. This can be prevented by pre-treatment ABO cross-matching. Acute rejection (within 6 months): caused by cell-mediated autoimmunity, presents with fever, pain around the graft site, and impaired renal function. This is managed with additional immunosuppressive therapy. Chronic rejection (after 6 months): the cause is unclear but it is characterised by interstitial fibrosis and tubular atrophy. This presents with a gradual reduction in renal function and hypertension. This is not responsive to immunosuppressive therapy, and is difficult to manage.

A 12-year-old boy is noted by his GP to have a low platelet count following a recent viral illness. He has no symptoms of bruising or bleeding and is otherwise completely well. A diagnosis of immune thrombocytopenia (ITP) is suspected. The GP explains that ITP is a benign and often self-limiting condition in which the platelet count is reduced due to increased break down of platelets. What is the normal lifespan of a platelet?

7-10 days The normal lifespan of a platelet is around 7-10 days. 69%

A 67-year old female presents to the emergency department unconscious after falling down a flight of stairs. On examination, she has response to pain, says inappropriate words and has flexion to pain. What is her GCS score?

8 Response to pain: 2/4, inappropriate words: 3/5, flexion to pain: 3/6. 53%

responding to own name

9-12m

A 65-year-old woman presents to her GP for a review of her long-term conditions. She has hypertension and type 2 diabetes mellitus, and she takes amlodipine and metformin. What should her target blood pressure be?

<140/90mmHg Target blood pressure is the same for those with diabetes as those without. This is the target range for those under 80 years of age. 63%

difference between type A and type B aortic dissection

A = radio-radial delay. tear is in ascending aorta B = radiofemoral delay. tear is in the descending aorta

can an advanced decision be overruled

A lasting power of attorney (LPA) may be able to override an advance decision An advance decision, often known as a "living will", is a legally binding way to refuse specific treatments in the future if a person loses mental capacity. If an advance decision is made before the LPA is appointed, the LPA may be able to override the advance decision if they have LPA for health and welfare decisions, but only if and when the patient lacks mental capacity. If an advance decision is made after the LPA is appointed, the LPA cannot consent to any treatment refused in the advance decision. 22%

A 34-year-old female presents to the emergency department at night with a single episode of haematemesis. She has a history of peptic ulcer disease. On examination, her chest is clear and she is mildly tender in the epigastric area. Her observations are as follows: Heart rate: 80 beats per minute Blood pressure: 135/90 mmHg Respiratory rate: 15 breaths per minute SpO2: 198% on room air Capillary refill time (CRT): 2 seconds Bloods, including a group and save, is requested: Haemoglobin (Hb): 96 g/L (normal 130-180 g/L) Mean cell volume (MCV): 91 fL (normal 80-96 fL) Platelets: 224 x109/mL (normal 150-400 x109/mL) White cell count: 7.9 ×109/L (normal 4.0-11.0 ×109/L) Serology testing: Anti-A: agglutination Anti-B: nil Anti-Rh: nil The decision is made to transfuse two units of packed red cells and admit her for endoscopy in the morning. What is the most appropriate blood type to administer to her?

A-negative Agglutination with anti-A demonstrates the presence of A antigen only on her red cells. Therefore, her blood type is A-negative. As she is of childbearing age, rhesus negative is most appropriate. 26%

A 61-year-old man is referred to gastroenterology after his GP found hepatosplenomegaly on examination. On questioning, he admits to feeling tired the last few months but otherwise, he feels well. He has no significant past medical history.On examination, there are purpura around both eyes and dental indentations on the underside of the tongue. Abdominal palpation confirms the presence of hepatosplenomegaly. Blood results are awaited. Urinalysis++ protein Immunoglobulin free light chain assay Abnormal kappa to lambda ratio What is the most likely diagnosis?

AL amyloidosis is the correct answer. Amyloidosis is a rare but important cause of hepatosplenomegaly. AL amyloidosis (sometimes called primary amyloidosis or immunoglobulin light chain amyloidosis) is the commonest type of amyloidosis. This patient's presentation of fatigue, weight loss, periorbital purpura, and macroglossitis is typical of AL amyloidosis. Immunoglobulin free light chain assay is one of the most sensitive diagnostic tests. AA amyloidosis is incorrect. It would not present with macroglossitis (indicated by dental indentations on the tongue) and usually occurs in patients with a past medical history of chronic inflammation e.g. rheumatoid arthritis.

A 63 year old man complains of a three month history of fatigue. He has a dull pain in his lower back that has persisted despite taking Ibuprofen. He used to work in a gas station for 40 years before retirement and he smokes 1 pack a day for 40 years. On examination, he has a flushed face but his vital signs are normal. Genital examination reveals left varicocele that persists in both supine and standing position. Laboratory studies show the following: Hb 25.1 g/dL Serum creatinine 150 umol/L Urinalysis: Protein 1+, Blood 2+ What is the next best investigation?

Abdominal CT scan with IV contrast This patient's presentation is highly suspicious of renal cell carcinoma: chronic fatigue, unilateral flank pain, secondary polycythaemia (due to paraneoplastic syndrome from excess erythropoietin production), microscopic haematuria and a left sided varicocele that fails to resolve on lying down. He also has risk factors, such as smoking and occupational exposure to gasoline. CT imaging of the abdomen with IV contrast is the gold standard to diagnose RCC. Only 15% of patients present with the classic triad of RCC (haematuria, flank pain and flank mass). 51%

CI to laparoscope?

Absolute contraindications haemodynamic instability/shock raised intracranial pressure acute intestinal obstruction with dilated bowel loops (e.g. > 4 cm) uncorrected coagulopathy Relative contraindications cardiac or respiratory failure recent laparotomy (within 4-6 weeks) abdominal aortic aneurysm (increased risk of vascular rupture) pregnancy (risk of injury to uterus) extensive adhesions from previous bowel surgery Complications of laparoscopy include: general risks of anaesthetic vasovagal reaction (e.g. bradycardia) in response to abdominal distension extra-peritoneal gas insufflation: surgical emphysema injury to gastro-intestinal tract injury to blood vessels e.g. common iliacs, deep inferior epigastric artery

experiencing prodromal symptoms of genital herpes - what should happen with sexual intercourse

Abstain from all sexual activity until asymptomatic The patient is experiencing the prodromal phase that precedes a recurrent herpes infection. This occurs in 50% of patients who experience a recurrence of herpes infection. The current guidance states that the patient should abstain from all sexual activity until symptoms from the prodromal phase and the clinical recurrence have passed dont just use condoms either

A 78-year-old woman with advanced Alzheimer's disease attends the GP surgery with increasing agitation. She no longer recognises her husband, and when she sees him in their shared home believes he is an intruder. Which of the following terms best describes this phenomenon?

Agnosia Agnosia is an inability to recognise people, objects or places that were once known to a person. This patient's distress is a result of no longer recognising her husband. 74%

A 40 year old obese man presents to his GP as he notices a lump in his scrotum on the right side, which has gradually enlarged over the past year. He does not complain of any other symptoms such as fatigue or weight loss. On examination, a soft non-reducible swelling is noted surrounding the right testicle. The testicle is palpable separately within the swelling. There are no bowel sounds on auscultation of the swelling. The transillumination test is positive. Which of the following best describes the pathology of this lump?

Accumulation of fluid within tunica vaginalis Hydrocele is a collection of peritoneal fluid between the parietal and visceral layers of the tunica vaginalis, which directly surrounds the testis and spermatic cord. It occurs due to an imbalance of secretion and reabsorption of fluid from the tunica vaginalis. 77%

A 31-year-old woman presents to the Maternity Assessment Unit (MAU) as she thinks her waters may have broken. She is 38 weeks pregnant and thus far has had an uncomplicated pregnancy. She reports no abdominal pain, no vaginal bleeding and no urinary symptoms. She is feeling well in herself and is afebrile. On speculum examination, a small amount of fluid can be seen in the posterior vaginal fornix, and the cervical os is closed. The midwife suspects a diagnosis of pre-labour rupture of membranes. What investigation can be carried out to confirm this diagnosis?

Actim-PROM vaginal swab An Actim-PROM vaginal swab detects insulin-like growth factor binding protein-1 (IGFBP-1) in vaginal fluid. The concentration of IGFBP-1 is much higher in the amniotic fluid than in the maternal blood. Therefore, a positive Actim-PROM suggests pre-labour rupture of membranes. 78% Actim-Partus vaginal swab An Actim-Partus vaginal swab detects phosphorylated insulin-like growth factor binding protein-1 (IGFBP-1) in vaginal fluid in patients presenting with suspected rupture of membranes <37 weeks gestation. It, therefore, is used to assess the risk of preterm delivery. Phosphorylated IGFBP-1 is produced by the decidua and can leak into the cervix when the decidua and chorion detach. Therefore, a positive Actim-Partus indicates a high likelihood of preterm delivery. 12%

A 26-year-old woman who is 40 weeks pregnant attends the delivery suite with reduced foetal movements. She has been placed on cardiotocography (CTG) due to multiple episodes of reduced foetal movements over the past four weeks. Her last vaginal examination was 30 minutes ago, which revealed a fully dilated cervix. She has been actively pushing for the past 20 minutes, and the baby's head is now visible. What stage of labour is this patient in?

Active second stage of labour The active second stage of labour describes the period of time when there is full cervical dilatation, defined as 10cm, active maternal pushing, and the baby is visible. 87% passive second stage is when the baby is visible at 10cm dilation but no active pushing

A 53-year-old woman presents to the GP complaining of ringing in her right ear. She says this has been ongoing for the past 2 days and yesterday the room started spinning, something she's not experienced before. She is very concerned about how dizzy she feels as it is causing a lot of nausea.Her observations are normal with a temperature of 37.6ºC. There is horizontal nystagmus towards the left and the corneal reflex is present bilaterally. Rinne's test demonstrates air conduction to be better than bone conduction bilaterally and Weber's test lateralises to the left.What is the most likely diagnosis?

Acute labyrinthitis is the correct answer. This woman has presented with vertigo, tinnitus, and hearing loss. From Rinne's and Weber's test results, it is a right-sided sensorineural hearing loss. Furthermore, acute labyrinthitis can result in horizontal nystagmus towards the unaffected side, the left in this case. Given the 2-day history, the most likely diagnosis is acute labyrinthitis. Some people will experience coryzal symptoms of an upper respiratory tract infection in the preceding week, however, this is not present in all people.

A 4-year-old boy is brought to the GP by his mother. He has had a 1-day history of irritability, restlessness, and fever. His right ear is painful and he has been tugging at it. Besides a recent viral upper respiratory tract infection, he has no other past medical history.On examination, his temperature is 38.1ºC. Otoscopy of the right ear reveals an erythematous ear canal and tympanic membrane, which is bulging and the light reflex is absent. The left ear is normal.Based on these features, what is the most likely diagnosis?

Acute otitis media (AOM) is correct. The presence of otalgia, fever, and features suggesting a middle ear effusion (such as a bulging tympanic membrane which causes the loss of the light reflex on otoscopy) makes a diagnosis of AOM likely. The presence of features suggesting a middle ear effusion is required to diagnose AOM. Otitis media with effusion is incorrect. Also known as glue ear, this describes an effusion in the middle ear without features suggesting an acute infection (e.g. fever and erythema of the ear canal and tympanic membrane). This occurs due to dysfunction of the Eustachian tube. Since this patient is febrile and his ear canal and tympanic membrane are erythematous, AOM is more likely.

A 72-year-old woman is recovering in the ward after being admitted with urinary sepsis over the last day. She has a past medical history of asthma. The patient has now started feeling breathless.Her heart rate is 95 bpm, her blood pressure is 95/65 mmHg, her respiratory rate is 31 /min, and her temperature is 37.1ºC. Chest auscultation reveals bilateral crackles and her oxygen saturations are 83% on 40% inspired oxygen. No other chest sounds are heard and her jugular venous pressure is normal.Based on these features, what is the most likely diagnosis?

Acute respiratory distress syndrome (ARDS) is correct. Bilateral chest crackles, hypotension, and tachypnoea describe pulmonary oedema. Pulmonary oedema occurring within 1 week secondary to an episode of sepsis without underlying cardiovascular disease should raise suspicion of ARDS, which describes non-cardiogenic pulmonary oedema (where pulmonary oedema occurs due to alveolar damage rather than heart failure). The presence of a decreased PaO2/FiO2 (ratio of arterial oxygen to fractional impaired oxygen) (<40 kPa or 300 mmHg) forms one of the diagnostic criteria for ARDS. This patient's PaO2/FiO2 is 83/0.4=207.5 mmHg, which satisfies this criterion. This alongside non-cardiogenic pulmonary oedema occurring within a week of an episode of sepsis meets the diagnostic criteria of ARDS.

A 55-year-old female undergoes a bilateral mastectomy for breast cancer. Six hours post-operatively, she has passed 5mls of urine in her catheter. During her surgery her blood pressure was an average of 82/50mmhg. Pre-operatively serum creatinine was 48 (45 - 84 µmol/L). Six hours post-operatively it increases to 78 µmol/L. A urine culture is negative for organisms. What is the most likely underlying cause?

Acute tubular necrosis Hypotension leads to acute tubular necrosis leading to poor urine output. The mechanism of action is damage to the tubular epithelial cells within the renal tubules of the kidney due to ischaemia. Ischaemia in this case is the result of reduced renal blood flow due to hypotension. 70%

65-year-old woman with diabetes and hypertension underwent a total hip replacement. She had massive bleeding during the operation and was infused with six units of packed red blood cells. The blood pressure dropped to 60/40 mmHg for about two hours before it was corrected with intravenous fluids and blood transfusions. Two days after the surgery, her blood results show a high serum creatinine level, which rose to 255 μmol/L from a baseline of 80 μmol/L. What is the most likely diagnosis?

Acute tubular necrosis (ATN) ATN can occur after a prolonged ischaemic event, which likely occurred here as there was a massive haemorrhage and a hypotensive shock, resulting in renal hypoperfusion and post-ischaemic injury. The increased creatinine supports this. Other causes of ATN include sepsis, nephrotoxins such as aminoglycosides, radiological contrast, and myoglobinuria in rhabdomyolysis. 80%

A 45 year old pregnant woman had a vaginal delivery complicated by a massive postpartum haemorrhage six hours ago. She was anaesthetised for hysterectomy and resuscitated with five units of packed red blood and four litres of normal saline. She now complains of an inability to pass urine. Otherwise, she has no other complaints or previous medical or surgical history. On examination, a suprapubic fullness with tenderness can be elicited. What is the most likely diagnosis?

Acute urinary retention Anaesthesia and fluid infusion are the possible risk factors for developing postoperative urinary retention. Anaesthetics decrease detrusor contraction, and a large volume of fluids causes bladder overdistension. 65%

A 2-month-old baby is brought to the GP by his parents. They are concerned as he has been very irritable for the past few days, has stopped feeding and has had fewer wet nappies. On examination, his temperature is 38.4 degrees. His urine appears dark and it has an offensive odour. The GP strongly suspects a urinary tract infection (UTI). What is the next most appropriate management?

Admit to hospital This is correct. NICE guidelines state that any infant under 3 months of age with a suspected UTI should be admitted to hospital for IV antibiotics and further investigations. In addition, a temperature of 38 degrees or above in a baby younger than three months scores red on the NICE paediatric traffic light system. Fewer wet nappies is also concerning for possible sepsis. 83%

A 38-year-old gentleman presents with a 3-day history of flu-like symptoms, intermittent abdominal pain and diarrhoea since returning from India. His observations are normal; however, there is mild icterus of the sclera. Blood tests reveal mildly deranged liver function tests and positive IgM antibodies to the hepatitis A virus (HAV). What is the most appropriate management plan?

Advice on infection control and supportive management The serology result and the presentation are in keeping with a diagnosis of hepatitis A, which is transmitted through the faecal-oral route and contaminated food and drinks. Risk factors include recent travel. Hepatitis A has an incubation period of two to six weeks, management is largely supportive, and recovery can take up to six months. It is vital to educate the patient on the importance of infection control as the disease can remain highly infectious during incubation and for approximately one week after the onset of jaundice. 70%

A 24-year-old woman presents to the GP worried about new breast changes. She says every month, she has noticed that her breasts feel swollen and tender, and when she examines them, they feel more lumpy than normal. She has no history of breast cancer in her family and has no children. Her last menstrual period was two weeks ago. On examination, there is no pain or lumpiness in her breasts. What is the most appropriate first-line management?

Advise a supportive bra and avoidance of caffeine This woman is presenting with likely fibrocystic disease of the breast. The first-line management for this is supportive, and patients should be advised to wear a supportive bra, avoid caffeine, apply heat to the area, and take simple analgesia. 91% usually resolves after menopause

A 25 year old lady attends the walk-in sexual health clinic after forgetting to take her combined oral contraceptive pill (OCP). She has missed days one and two in the packet. She had unprotected sexual intercourse (UPSI) on day one. She is due to take day three today. Which of the following is the most appropriate course of action?

Advise her to take two pills today, prescribe emergency contraception and use condoms for seven days This patient has missed the first two pills from Week one. In a traditional pill-taking regime, the week prior to this would be the pill-free interval - meaning this patient has not been taking pills for nine days. The OCP needs to be taken for seven days in a row to be effective, so she is now at risk of pregnancy due to the UPSI on day one. She needs emergency contraception, as well as barrier protection as an extra precaution until at least seven days of pill-taking is re-established 58%

A 37-year-old woman presents to the GP complaining of breast lumps. She reports that for as long as she can remember, she has had breast pain in the week before her period, and her breasts often feel swollen. She recently examined herself and became concerned with what she described as "lumpiness". All of these symptoms resolve during the beginning of her period. Which of the following is the best way to manage this patient?

Advise her to wear a supportive bra, avoid caffeine, take painkillers, and refer to a two-week wait clinic This patient is presenting with symptoms of fibrocystic disease of the breast. Typical symptoms include cyclical breast lumpiness and breast pain, which occur before a period and resolve when the period starts. Fibrocystic disease of the breast is managed conservatively; however, it is important to refer patients with new breast lumps to a two-week wait clinic to rule out breast cancer. 29%

A 56-year-old male presents to the emergency department with chest and limb pain. He is normally fit and well, but has been complaining of fatigue over the last three weeks. Examination reveals gingival bleeding and a purpuric rash. Bloods results reveal: Haemoglobin (Hb): 135 g/L (normal range 140-180g/L) Platelets: 35 x109/L (normal range 150-400x109/L) White cell count: 8.7x109/L (normal range 4-11x109/L) Prothrombin time (PT): 35.1 s (normal range 12.0-14.8 s) Activated partial thromboplastin time (APTT): 25.0 s (normal range 27.0-41.0 s) Blood film: promyelocytes with multiple Auer rods The patient continues to deteriorate, and further investigations show derangement of liver and kidney function. His purpuric rash spreads, and his limb pains considerably worsen. Based on his presentation and blood tests, which initial treatment is indicated?

All-trans retinoic acid (ATRA) The patient has disseminated intravascular coagulation (DIC), with typical symptoms and findings (thrombocytopenia, raised PT), and has a blood film showing promyelocytes with Auer rods. He likely has acute promyelocytic leukaemia, which is known to cause DIC as a complication. This is sensitive to all-trans retinoic acid (ATRA), which should be used in the first instance. 23%

An 80-year-old man is being treated for urosepsis, for which he is on day 3 of a 7 day course of IV Tazocin. He has a background of mild cognitive impairment. The patient explains that he wishes to be discharged today as he wants to be at home with his wife, who has end-stage metastatic breast cancer. He is able to understand, retain and weigh up the risks and benefits of being discharged, and communicates that he wishes to go home. Select the most appropriate action.

Allow the patient to self-discharge with oral antibiotics Whilst the patient has a background of cognitive impairment, he has the capacity to make an informed decision about discharge. He is able to self-discharge against medical advice. However, it would be appropriate to send him home with oral antibiotics and safety netting advice. 82%

alopecia areata

Alopecia areata Alopecia areata is an autoimmune condition which causes well-defined bald spots on the scalp. Short broken hairs called exclamation mark hairs are a classic feature. 43%

An 80-year-old man with Parkinson's disease is admitted to hospital after a fall. He reports feeling very dizzy after attempting to get up from his bed. He has been admitted after multiple falls within the last 12 months. He has a significant postural drop in blood pressure. The consultant has recommended starting midodrine 2.5mg three times daily. What is the mechanism of action of midodrine?

Alpha-1-agonist Midodrine is an alpha-1-adrenergic receptor agonist. Activation of alpha-1-adrenergic receptors leads to an increase in vascular tone and an increase in blood pressure. 57%

A 40-year-old man presents to the emergency department after slipping on the icy pavement and falling backwards.His past medical history includes Alport syndrome. He receives haemodialysis three times per week and his medication history includes ramipril, colecalciferol and iron replacement.On examination, he has midline pain at the base of his spine. Radiographs show a new vertebral fracture and multiple previous fractures that have now healed.Why is his risk of this injury increased?

Alport syndrome is a genetic condition caused by the defective production of type IV collagen. Features include glomerulonephritis, end-stage kidney disease, and hearing loss, and it is managed using ACE inhibitors and haemodialysis.Impaired activation of vitamin D is the correct answer. Conversion of vitamin D to its biologically active form, 1,25-dihydroxycholecalciferol, occurs in the kidneys. This function is impaired in chronic renal diseases, such as Alport syndrome. The bones of these individuals are therefore more susceptible to fracture.

A 42-year-old female presents to the GP clinic with burning pain and swelling of her left lower leg for one week. She fractured her left tibia six weeks ago and underwent surgery for intramedullary nailing. She was doing fine after her operation. On examination, her left lower leg is cold to touch and pain is elicited on light touch. There is pitting oedema up to her ankle and muscle strength is reduced compared to the right leg. There is no increased pain on passive dorsiflexion. Which of the following pharmacological management is the most appropriate for this patient's condition?

Amitriptyline This patient has Complex regional pain syndrome (CRPS) which usually occur within 4-6 weeks following a trauma. Patients with CRPS usually have pain that is excessive in duration and severity as compared to their initial injury. They would also be very sensitive to touch and may have motor symptoms (such as weakness or reduced range of movement). CRPS is a clinical diagnosis, thus, other important differentials such as compartment syndrome needs to be ruled out first. Amitriptyline is a tricyclic antidepressant which may help relieve neuropathic pain in patients with complex regional pain syndrome (CRPS). The first line of treatment for CRPS should be physical and occupational therapy. 44%

A 25-year-old woman presents to the urgent care centre with an 8-week history of diarrhoea, fever, and malaise. Her symptoms have been ongoing since returning from Mexico 9 weeks ago and today she had an episode of bloody diarrhoea. She has no other past medical history.On examination, her temperature is 38.1ºC, her pulse is 98 bpm, and her blood pressure is 127/72 mmHg. She is slightly tender in the right upper quadrant and hepatomegaly is present. No other abnormal findings are present. A liver ultrasound scan shows a homogeneous hypoechoic round lesion.What is the most likely diagnosis?

Amoebic liver abscess is correct. The presence of prolonged fever and right upper quadrant pain (RUQ) in a returning traveller should raise suspicion of an amoebic liver abscess. Many patients also have hepatomegaly and diarrhoea, which may become bloody. The duration of these symptoms makes the other diagnoses less likely. Furthermore, the liver ultrasound scan shows a homogeneous hypoechoic round lesion which is in keeping with the formation of an abscess.

A 55-year-old man visits his GP as he is concerned about new hair loss which started two weeks ago. He is finding life very stressful at the moment, due to problems at work and recently starting chemotherapy for colorectal cancer. On examination, he has diffuse alopecia. He shows the GP a photograph of himself from one month ago and the difference is quite dramatic. What is the most likely diagnosis?

Anagen effluvium Anagen effluvium is a type of alopecia which affects the anagen (growth) phase of the hair cycle. Hair stops growing prematurely and starts to shed very quickly. This is commonly due to chemotherapy. 21%

A 24-year-old man is receiving a transfusion of fresh frozen plasma (FFP). After 15 minutes into the transfusion, he develops shortness of breath. Observations are as follows: heart rate 120bpm, blood pressure 80/35 mmHg, and temperature 37.2ºC. On examination, you note bilateral expiratory wheeze. He has no past medical history.What is the most likely cause?

Anaphylactic reaction is the correct answer. The patient has features of anaphylactic shock (acute wheeze and hypotension in the absence of fever). This reaction is more common with plasma-rich blood products such as FFP, cryoprecipitate and platelets.

androgenic alopecia

Androgenic alopecia (male pattern hair loss) Androgenic alopecia refers to progressive hair loss due to various hormonal and genetic factors that tends to follow a particular pattern. In males, there is a receding hair line and hair loss mainly affecting the top and front of the head. 7%

A 65-year-old man is admitted to the stroke unit after a confirmed stroke affecting the posterior inferior cerebellar artery. On examination, the patient is found to have a broad-based ataxia and dysdiadochokinesia. During his cranial nerve examination, he is also found to have left-sided ptosis and miosis. Based on the diagnosis, which of the following signs is he most likely to display?

Anhidrosis This patient has had a confirmed stroke affecting the posterior inferior cerebellar artery. This artery supplies parts of the cerebellum and medulla oblongata. As a result of this, the patient has presented with cerebellar features (ataxia and dysdiadochokinesia) and also has signs of Horner's syndrome which can occur in lateral medullary syndrome. Ptosis, miosis and anhidrosis are signs of Horner's syndrome which occurs due to a lesion to the sympathetic trunk. 64%

A 30-year-old man is reviewed by his GP due to a three month history of lower back pain and stiffness, which wakes him up in the morning. He has also recently developed pain and redness in his right eye. On further questioning, he says he has had intermittent diarrhoea over the past year. Physical examination reveals aphthous ulcers, perianal skin tags and significantly reduced lumbar flexion. His blood tests show elevated inflammatory markers. What is the most likely cause of his presentation?

Ankylosing spondylitis His age, symptoms and blood tests are consistent with ankylosing spondylitis (a seronegative spondyloarthropathy). Extra-articular manifestations such as uveitis and inflammatory bowel disease (in this case Crohn's disease) can occur alongside ankylosing spondylitis. 84%

A 35 year old woman presents with recurrent extremely painful ulcers on her vulva. Swabs for herpes simplex virus culture and polymerase chain reaction (PCR) are negative. What is the single most appropriate investigation?

Anti-HSV antibodies The probable diagnosis in this case is genital herpes simplex. Typically, viral culture and PCR testing of a swab from the base of an ulcer are used to diagnose genital herpes. However, in certain situations, such as when there are recurrent or atypical genital ulcers with negative culture or PCR results, anti-HSV antibodies may be used to confirm the diagnosis. 31%

A 40 year old man presents with a ten day history of haemoptysis and 24 hour history of haematuria. In the last 24 hours, he has become increasingly breathless and oliguric. His blood tests are as follows: Haemoglobin: 98 g/L Serum urea: 9.5 mmol/L Serum creatinine: 350 μmol/L Sodium: 136 mmol/L Potassium: 5.9 mmol/L What is the best investigation to confirm the underlying diagnosis?

Anti-glomerular basement membrane (GBM) antibodies The likely diagnosis here is Goodpasture syndrome. The blood tests reflect an acute kidney injury. The persistent intrapulmonary bleeding can explain the slightly lower haemoglobin levels. The best initial test to confirm the diagnosis is anti-GBM antibodies. However, a renal biopsy is the gold standard investigation for diagnosis. 82%

A 23-year-old lady presents to her GP with a 2-month history of fatigue and intermittent abdominal discomfort. She denies any yellowing or itchiness of the skin or pale stool. Blood tests show a normal full blood count and thyroid function tests; however, she has a raised alanine aminotransferase (ALT) and IgG. Which autoantibodies are expected to be positive based on the most likely diagnosis?

Anti-smooth muscle antibody This woman's presentation suggests a diagnosis of autoimmune hepatitis, which typically affects young females. It is characterised by raised IgG, ALT, and positive anti-smooth muscle antibodies. 58%

An 84-year-old man is brought to his GP surgery by his wife, who is concerned that he has been acting unusually. For the past 36 hours he has been disorientated, stating that he needs to go home despite the fact that he is already at home, and expressing concerns that there are strangers in the garden. His wife confirms there is not anybody in the garden. He has also had two episodes of urinary incontinence, which is unusual for him. He is opening his bowels normally, eating and drinking well. His regular medication includes paracetamol that he takes for his osteoarthritis, amlodipine for his hypertension, and a mild corticosteroid cream for eczema. On examination his abdomen is soft and non-tender with no palpable bladder. He shows a raised temperature at 38.1 degrees, but otherwise normal observations. Which of the following is the most appropriate management to treat the underlying cause of this patient's delirium?

Antibiotics A urinary tract infection is the most likely cause of this patient's delirium. This is demonstrated by his new urinary incontinence. Therefore, antibiotics are the most appropriate management of his delirium. 74% Catheterisation Urinary retention can cause delirium. If this were the cause of this patient's delirium, catheterisation would be an appropriate management option. However this patient has been passing urine and does not have a palpable bladder, therefore catheterisation would not address his delirium. 12%

A 65 year old male presents to the emergency department with sudden onset right sided weakness which resolved completely after one hour. He denies any visual or sensory problems. Upon further questioning, he had one similar episode one month ago but did not seek further help. His past history is only significant for hypertension. On examination, his blood pressure is 150/80mmHg. Neurological examination and cardiovascular examination show no abnormalities except for a left sided carotid bruit. Blood tests and a CT head shows no abnormalities. Carotid doppler ultrasound shows 45% stenosis in the left carotid artery and 20% stenosis in the right carotid artery. What is the most appropriate next step in management?

Antiplatelet therapy In a patient with transient unilateral weakness that resolves in less than 24 hours with normal neurological examination indicate transient ischemia attack. The cause is due to carotid artery stenosis as seen from the carotid doppler ultrasound result. According to NICE guideline, symptomatic carotid stenosis of less than 50% according to the NASCET criteria, or less than 70% according to the European Carotid Surgery Trial (ECST) criteria do not have to undergo surgery, but instead they have to receive medical treatment with antiplatelet. 60%

A 54 year old man presents to the emergency department after a sudden collapse at home. His wife who is accompanying him explains he was unconscious for a few minutes and has now regained consciousness but has since been confused. She also says he had a sore throat and fever last month. On examination, the patient appears pale and sweaty. He has a bounding pulse with an evident collapsing pulse. On auscultation, there is an early diastolic murmur heard loudest at the left sternal border. Which of the following is the most likely diagnosis?

Aortic regurgitation This is an example of a patient presenting with aortic regurgitation. The question stem hints at rheumatic fever which is a risk factor for aortic regurgitation. The most common murmur heard in aortic regurgitation is an early diastolic murmur. Other examination findings include a collapsing pulse, as well as a wide pulse pressure between the systolic and diastolic pressures. 79%

A 55-year-old female presents to her GP with a 1-month history of worsening fatigue and shortness of breath. She is normally fit and well, apart from an episode of typhoid fever three months ago, diagnosed on her return to the UK from Kenya, requiring admission and intravenous chloramphenicol. She has no history of night sweats or weight loss. She is visibly pale, with a bruise on her left knee where she says she tripped. Her chest is clear and her abdomen is soft with no masses. There is no lymphadenopathy. Blood tests reveal: Haemoglobin (Hb): 67 g/L (normal 130-180 g/L) Mean cell volume (MCV): 98 fL (normal 80-96 fL) Platelets: 35 x109/mL (normal 150-400 x109/mL) White cell count: 2.2 ×109/L (normal 4.0-11.0 ×109/L) Reticulocytes: 3.2 ×109/L (normal 50-100 ×109/L A blood film does not show any blast cells or Auer rods. Based on her history and blood results, what is the most likely cause of her anaemia?

Aplastic anaemia The presence of pancytopenia should raise suspicion of aplastic anaemia. The likely cause is chloramphenicol, which is notorious for blood dyscrasia when used systemically. 77%

A 68-year-old lady presents with a four-month history of intermittent diarrhoea and dyspnea on exertion. Upon further questioning, she reveals that she also experiences episodic flushing that first started two years ago. On examination, a high-pitched, crescendo-decrescendo mid-systolic murmur is heard over the pulmonary valve. A diagnosis of carcinoid syndrome is suspected. What is the most common site of carcinoid tumour?

Appendix Carcinoid tumours are rare, slow-growing neuroendocrine malignancies arising from enterochromaffin cells. The most common site of carcinoid tumours is the appendix; other common sites include the ileum, rectum, testis, ovary, and bronchi. 31%

A 45 year old male patient presents to the emergency department with severe sudden-onset headache in the occipital region. CT scan confirms a sub-arachnoid haemorrhage. He is recovering on the wards, and 48 hours after the initial presentation complains of early morning headache and vomiting. Repeat CT head reveals dilation of the lateral, third, and fourth ventricles. Given the most likely diagnosis, where is the most likely site of the lesion?

Arachnoid granulations Subarachnoid haemorrhage may cause communicating hydrocephalus (CSF can exit the ventricular system but there is a problem with CSF absorption at the arachnoid granulations) 53%

A 55-year-old male presents to the orthopaedic clinic with a three month history of recurrent left shin pain. Five months ago, he sustained a closed left tibia fracture and underwent an open reduction and internal fixation for it. His medical history includes type 2 diabetes mellitus which he takes metformin for. On examination, he is afebrile and his vitals are within normal limits. There is warmth and tenderness upon palpation of his left mid shin, over his surgical scar. A small opening can be appreciated on the scar. What is the next most appropriate management for this patient?

Arrange for surgical removal of internal fixation This patient's presentation is suggestive of chronic osteomyelitis. Chronic osteomyelitis develops slowly over months with recurrent pain, which may be subtle, lasting weeks to months. He has a recent history of internal fixation which could be the source of infection and his medical history of diabetes mellitus is a contributing risk factor in his development of osteomyelitis. The most appropriate next step is to remove the foreign object (internal fixation) to help encourage remission of the infection. 20% Fasciotomy Fasciotomy is the definitive treatment if a patient has compartment syndrome, which is not the case for this patient. Patients with compartment syndrome would present with out-of-proportion pain and swelling of the leg and there will be pain upon light touch of the limb. 6%

A 42-year-old woman presents to the GP with severe right eye pain over the last 3 hours. She denies any changes in vision, nausea, or vomiting. She has a history of rheumatoid arthritis and takes methotrexate, and does not wear contact lenses.Her pulse is 83 bpm, her blood pressure is 133/74 mmHg, and she is afebrile. The right eye is deep red and injected throughout. Ocular palpation reveals tenderness and the injected vessels do not move. The left eye is unaffected.What is the most appropriate action for the GP to take?

Arrange referral for same-day ophthalmology assessment is correct. NICE recommends that patients with an acutely red eye where scleritis is suspected should be referred urgently for a same-day ophthalmology assessment. This is because, in secondary care, further tests can be performed relatively quickly (such as a slit-lamp examination) to confirm the diagnosis, and the type of scleritis, and guide management. Because scleritis is also associated with many systemic autoimmune conditions, if patients do not have a known history of an autoimmune condition (such as RA), investigations such as inflammatory markers, autoantibody screens, and further imaging can be carried out quickly to identify an underlying cause. dont give steroids in primary care without confirming the diagnosis

A 55 year old male presents to his GP after suffering severe pain at the base of his big toe. He describes it as 10/10 pain and the toe is red and warm to touch. It started 10 hours ago overnight. The patient has a past medical history of type 2 diabetes and hypertension for which he regularly takes ramipril and amlodipine. A diagnosis of gout is suspected. What is the initial test which should be performed?

Arthrocentesis with synovial fluid analysis Arthrocentesis is the process by which synovial fluid is removed using a needle from the joint space. The synovial fluid can then be analysed in the laboratory to diagnose conditions such as gout by identifying urate crystals which are needle-shaped with negative birefringence. 52% Joint x-ray An x-ray may be useful in identifying features of gout such as soft tissue swelling and periarticular erosions, however it is not the initial test used to confirm the diagnosis. 6%

A 60 year old man presents to the respiratory assessment unit with a three week history of increased shortness of breath on exertion and a cough. He is normally fit and well with a good exercise tolerance. He worked in a shipyard forty years ago without protective equipment and smokes 15 cigarettes daily. On examination, there are signs of clubbing, reduced chest expansion and crepitations on auscultation. Chest x-ray shows linear interstitial fibrosis and pleural plaques. What is the most likely diagnosis?

Asbestosis This is the likely diagnosis. The key indicator here is a history of asbestos exposure in a shipyard over 10 years ago. Combined with the clinical signs and chest x-ray findings, asbestosis is the correct diagnosis. 60% Mesothelioma Mesothelioma is a type of cancer that forms in mesothelial tissue around the body. Although it is also caused by asbestos exposure, one would expect red flag symptoms such as unintentional weight loss as well. It is also a rare complication of asbestos exposure, hence it is a less likely answer than asbestosis. 30%

A 45 year old man who is four months into his six month course of antibiotics for TB presents with increased shortness of breath, new productive cough with blood. His chest x-ray shows a cavitating lesion in the left upper lobe. What is the most likely cause of his haemoptysis?

Aspergilloma Aspergillomas are formed when the aspergillus fungus clumps together in the lung cavity. It usually occurs secondary to an underlying condition - TB in this case. Although there are usually no symptoms, aspergilloma is important differential to consider in patients that present with haemoptysis. 37% Lung abscess A lung abscess is a differential for haemoptysis. Risk factors for this include strokes as they can increase risk of aspiration. Patients usually bring up large amounts of blood and the signs on chest x-ray would be a central cavitation with an air fluid level. 45%

A 62 year old man attends the GP with a week history of a painful toe. He has tried paracetamol which has not helped. He takes 75mg of aspirin daily following a myocardial infarction and has a BMI of 27. On examination, his left first metacarpophalangeal joint is red, swollen and tender with reduced range of movement. Which of these modifiable risk factors for gout does the patient have?

Aspirin Medications including aspirin and thiazide diuretics are a modifiable risk factor for gout as they decrease the excretion of uric acid, causing it to build up in the body and deposit in joints. Other modifiable risk factors include obesity, medications and conditions such as hypertension, diabetes and chronic kidney disease. 20% Obesity Obesity can increase the risk of gout and is a modifiable risk factor. However, his BMI is 27, which falls under the overweight category rather than obese. The patient should be encouraged to optimise their lifestyle factors. 56%

c8/T1 radiculopathy vs cubital tunnel syndrome

C8/T1 radiculopathy is incorrect. C8/T1 radiculopathy can mimic ulnar nerve neuropathy. In this case, the preserved sensation of the forearm favours a diagnosis of cubital tunnel syndrome. The ulnar nerve does not provide sensation to the medial forearm, which is innervated by the medial antebrachial cutaneous nerve (C8 and T1).

A GP is interested in investigating the diagnosis of early primary closed angle glaucoma. What symptoms do patients with early primary closed angle glaucoma often have?

Asymptomatic Primary closed angle glaucoma is a chronic disease and patients are typically asymptomatic until the disease is more advance. This is in contrast to patients with acute angle closure glaucoma, where patients experience sudden onset symptoms. 38%

pincer grip

At 12 months, a child should have developed a pincer grip, i.e., bringing the thumb and index finger close together to hold an object, such as a pencil. It is important to remember that a delay in reaching fine motor developmental milestones may indicate a problem with vision rather than a neurological or muscular problem. 66%

A 63 year old male presents to the emergency department with severe back pain. Examination shows a pulsatile mass at the abdomen. Further imaging reveals a abdominal aortic aneurysms. She is immediately admitted for further evaluation and treatment. What is the most common cause of developing arterial aneurysms?

Atherosclerosis Atherosclerosis is the most common cause of aneurysms. The formation of plaques causes the wall of the arteries to be thick and stiff, which can weaken the aorta and cause outpouchings, named aneurysms. The risk of aneurysms include rupture which can be fatal. 52% Advancing age As people age, the walls of their blood vessels naturally become weaker and less elastic, which can cause an aneurysm. However, this is not the most common cause. 38%

A homeless man in his early 40s is brought to the emergency department by the police after they find him barely responsive on the street. He smells of vodka and has an empty bottle beside him on the pavement. During the physical examination, the patient exhibits psychomotor slowing and decreased mental function, and no further medical history can be obtained. The ECG shows an abnormal heart rhythm. What is the most likely ECG finding?

Atrial fibrillation Atrial fibrillation is a type of cardiac arrhythmia characterised by rapid, irregular contractions of the atria. It can cause symptoms such as palpitations, shortness of breath, fatigue, and dizziness. Atrial fibrillation can be due to a variety of factors, including alcohol consumption, which can lead to inflammation of the heart muscle (myocarditis) and damage to the heart's electrical conduction system. Therefore it is a reasonable consideration as it is associated with alcohol consumption and can cause symptoms such as psychomotor slowing and an abnormal heart rhythm. 48%

An 85-year-old man presents with a six month history of progressive short-term memory loss, behavioural change and functional impairment. His daughter tells you he frequently describes seeing spiders and other creatures crawling around at home. A diagnosis of dementia is suspected. Which of the following features is most specifically associated with Lewy body dementia?

Auditory and visual hallucinations Hallucinations, particularly visual hallucinations which often involve seeing animals and children, are common in Lewy body dementia. 79%

A 70 year old man attends the GP clinic complaining of obstructive urinary symptoms for the past six months. A digital rectal examination reveals a smoothly enlarged prostate. His family history is positive for prostate cancer. A prostate-specific antigen (PSA) is requested after two weeks. What is the most appropriate advice before the PSA test?

Avoid ejaculation before the test The serum PSA level rises immediately after ejaculation. If taken within 48 hours of ejaculation, it leads to a false positive result. 95%

A 19-year-old male is brought in to the emergency department with pain in his right shoulder following contact with another player in a basketball game. He has difficulty lifting his right arm over his head. On examination, the shoulder is suspected to be dislocated anteriorly and there is also reduced sensation over the deltoid muscle. Which nerve is most likely injured in this patient?

Axillary nerve Axillary nerve injury is most associated with shoulder injuries, such as dislocation. Patient with this injury may present with weakness on abduction, flexion, extension and external rotation of the shoulder. There may also be loss of sensation over the deltoid muscle (regimental patch). 91%

A 38-year-old woman presents to her general practitioner complaining of a 5-day history of an extremely painful vulva. She denies urinary symptoms or any abnormal vaginal discharge. She feels tired and not quite herself generally but has not noticed any fevers. She has no past medical history. She is sexually active and always uses condoms, but in the last 5 days has been unable to have sexual intercourse due to severe pain. She has regular periods and no intermenstrual bleeding. She works as a jockey, training racehorses, but has been unable to work since the pain began. On examination, her left labia minora is swollen, red and tender. On digital vaginal examination there is a smooth, mobile pea-sized lump on the inside of the vagina to the left at 5 o'clock which is exquisitely tender. What is the most likely diagnosis?

Bartholin's abscess Bartholin's glands are on either side of the vagina and act to provide lubrication. They are usually not palpable, but duct obstruction can lead to cyst formation, which in turn may become secondarily infected to form an abscess which is very painful. 73%

beefy appearing lesion

Beefy appearing lesion Granuloma inguinale is an infection of genital and perineal skin caused by Klebsiella granulomatis. The disease is characterised by slowly progressive skin lesions that are beefy red, raised, painless, and often ulcerated. 5%

bennet fracture

Bennett fracture Bennett fracture is a fracture of the base of the first metacarpal, usually due to a abduction or extension force on the thumb. X-ray will typically show an avulsion fracture at the base of the thumb which often extends into the carpo-metacarpal joint. 33%

A 19-year-old female presents to her GP with a 1 day history of fever, headache and vomiting. During the consultation, it is clear that the bright light in the room is affecting the patient greatly. On examination, there is neck stiffness and a non-blanching rash on the abdomen. The GP immediately calls 999 and arranges hospital transfer. The patient is usually fit and well and has no known allergies. Given the likely diagnosis, which treatment can be given whilst the patient is awaiting transfer?

Benzylpenicillin This patient has presented with features of meningitis: fever, headache, and neck stiffness. The presence of a non-blanching rash also indicates meningococcal septicaemia. In primary care, the most important step is to call 999 for hospital admission. Whilst awaiting this, a STAT dose of IM benzylpenicillin 1.2g should be given as long as it does not delay transfer. 73%

A 12-year-old boy is incidentally found to have a mild anaemia during a hospital stay for a tonsillectomy. His blood film shows microcytic, hypochromic red blood cells and target cells. Apart from recurrent episodes of tonsillitis, he has no past medical history and is otherwise well, with no symptoms of anaemia. He came to the UK six months ago with his family from Turkey. What is the most likely diagnosis?

Beta-thalassaemia trait Beta-thalassaemia trait is an inherited condition in which a person lacks one functional beta globin allele. The other allele is normal. It can cause a microcytic anaemia but patients are often asymptomatic. Target cells may also be seen on the blood film. The condition is more common in patients from Mediterranean countries, as well as the Middle East and certain parts of Asia and Africa. 69%

A 39-year-old female presents to her GP with a one month history of generalised fatigue and weakness. She has a past medical history of poorly controlled hypertension. The GP arranges some blood tests which show the following: Sodium: 152 mmol/L Potassium: 2.9 mmol/L Bicarbonate: 30 mmol/L Urea: 4.1 mmol/L Creatinine: 67 µmol/L eGFR: > 90 ml/min What is the most likely underlying cause? bilateral adrenal hyperplasia or adrenal carcinoma

Bilateral adrenal hyperplsia These blood results (hypernatraemia, hypokalaemia and raised bicarbonate) in combination with hypertension are suggestive of primary hyperaldosteronism. Causes of primary hyperaldosteronism include adrenal adenomas secreting aldosterone (Conn's syndrome), bilateral adrenal hyperplasia and very rarely, an adrenal carcinoma. 66% Adrenal carcinoma An adrenal carcinoma is a rare cause of primary hyperaldosteronism and is less likely than bilateral adrenal hyperplasia. 16%

A 65-year-old man presents with lumps in his groin and is unsure as to when they have emerged. This is the third time they have appeared. He denies any abdominal pain, discomfort, or changes to his bowel habits. He has a past medical history of hypercholesterolaemia and type 2 diabetes mellitus.His pulse is 86 bpm and his blood pressure is 143/75 mmHg. On examination, bilateral masses are seen superior and medial to the pubic tubercles. They disappear when lying down and do not transilluminate. There is no abdominal tenderness or bruising.What is the most appropriate next step in his management?

Bilateral and recurrent inguinal hernias are generally repaired laparoscopically using a mesh This patient has signs and symptoms of bilateral inguinal hernias characterised by groin lumps that disappear when lying down. The lumps being superior and medial to the pubic tubercle support this diagnosis. There are no signs of strangulation (such as pain, fever, erythema of the overlying skin etc.) and the patient is asymptomatic. Patients should be offered surgery even if inguinal hernias do not show signs of strangulation to prevent strangulation from occurring in the future, which may have associated complications such as sepsis.Refer for laparoscopic repair with a mesh is correct. Since this patient has bilateral and recurrent inguinal hernias, the most appropriate step in this patient's management is referring them for a laparoscopic repair using mesh, as this form of surgery has been shown to be efficacious in bilateral and recurrent inguinal hernias.

A 49 year old man presents to the GP with recurrent sinus infections, productive cough that contains blood and frothy urine. The GP suspects small vessel vasculitis and requests a chest x-ray. Which of these features would be consistent with a diagnosis of granulomatosis with polyangiitis (Wegener's granulomatosis)?

Bilateral nodular and cavitating infiltrates Granulomatosis with polyangiitis (Wegener's granulomatosis) is a small vessel systemic vasculitis that presents with symptoms that fall in 3 main categories- upper respiratory tract, lower respiratory tract and renal. It is common to see bilateral nodular and cavitating infiltrates on chest x-ray. 49%

A 5-day-old girl is brought to the paediatric emergency department by her parents. The community midwife asked her parents to bring her to the hospital as she looked slightly yellow. Which of the following is the most appropriate next investigation?

Bilirubin level with a transcutaneous bilirubinometer This baby has presented with neonatal jaundice after the first 24 hours of life. This is an extremely common presentation. NICE recommends a bilirubin level using a transcutaneous bilirubinometer in babies over 24 hours old. However, if this is not available, a serum bilirubin level can be taken. If the transcutaneous bilirubinometer reading is 250 micromol/L or more, a serum bilirubin level should be done and plotted on the appropriate treatment threshold graph according to the gestation of the baby at birth. 53%

A 43-year-old man is seen in the urology clinic for abdominal pain. He describes episodes of severe suprapubic pain that has been ongoing for weeks. He denies any other urinary symptoms including dysuria and polyuria. On examination, his abdomen is soft and tender suprapubically. Testicular examination is unremarkable. Urinanalysis show blood+++ with no nitrites, leucocytes or protein. What is the most likely diagnosis?

Bladder stones Bladder stones can cause severe, episodic suprapubic pain. Haematuria is also a common symptoms, either visible or, in this case, on urine dip test. 53% bladder ca doesn't cause pain

A 19-year-old woman attends her general practice for her annual check-up regarding her use of the combined oral contraceptive pill (COCP). She has no past medical history or drug history. She is a non-smoker. She takes her pill in a traditional manner, taking a pill for 21 days, followed by a 7-day pill-free interval. She has no intermenstrual bleeding. She is satisfied with this method of contraception. Which of the following is the most important parameter to monitor for this woman?

Blood pressure Women taking the combined oral contraceptive pill have a small (~2%) risk of developing hypertension. Due to the subsequent risk of myocardial infarction and stroke, it is recommended women have their blood pressure monitored annually when taking the COCP. 57%

A 62-year-old woman with invasive lobular carcinoma of the breast has undergone a left-sided mastectomy with axillary node clearance. After the surgery, she complains of generalised left-sided paraesthesia, numbness, and weakness of her left arm and hand. Which of the following complications of breast surgery has most likely occurred?

Brachial plexus injury Lymph nodes in the axilla sit close to the brachial plexus, which is therefore at risk of injury when axillary node clearance takes place alongside a mastectomy. Brachial plexus injury presents with pain, weakness, and numbness of the arm or hand along the distribution of the brachial plexus nerves. The medial cord and, therefore, the median and ulnar nerves are at particular risk. 89%

A 23-year-old female presents to her GP with a painless neck lump that has been slowly enlarging. She is otherwise well, with no medical history aside from a simple cold a few weeks ago. She has no night sweats or weight loss. On examination, there is a 3cm x 2cm mass in the anterior triangle of the neck. It moves easily, is soft to the touch, does not auscultate and does not transilluminate. It does not move on tongue protrusion or on swallowing. What is the likely diagnosis?

Branchial cyst Branchial cysts are formed due to the failure of obliteration of the second, third, and fourth branchial cleft. They are the most common cause of neck lumps in children and can also present with a fistula to the skin's surface. These are typically undetectable until the cyst swells in size, commonly due to infection. They do not move on tongue protrusion nor auscultate or transilluminate. 58%

A 68-year-old lady visits her GP because her right arm has become increasingly swollen over the past few months. On examination, her upper limb is swollen from her hand to her bicep. It is a normal temperature and normal colour. Her arm feels uncomfortable and weak, and the swelling is pitting in nature. Her observations are otherwise normal. Her medical history includes chronic obstructive pulmonary disease (COPD) and invasive ductal carcinoma of the right breast, which was surgically removed four years ago. Which of the following is most likely the cause of this presentation?

Breast surgery This patient is presenting with symptoms of lymphoedema of her right arm, which include swelling, joint stiffness, arm weakness, skin changes, and a feeling of tightness. The swelling can be normal in colour or appear slightly erythematous. This patient has had breast surgery, which is a major risk factor for developing lymphoedema, which can occur months to years after surgery. It is more common in patients who have also undergone axillary node clearance. 62%

A 67-year-old man presents with acute severe pain on the right side of his face. He has type 2 diabetes mellitus and has recently started taking antidepressant medication. On examination, there is a diffuse swelling of the right parotid region from the preauricular area extending to angle of mandible. The skin overlying the swelling is warm and red. Gentle massage of the right parotid gland results in expression of purulent material into the duct orifice intraorally. There are no signs of airway compromise. Which of the following is the most appropriate initial management plan?

Broad-spectrum antibiotics and supportive care This is the correct answer. The most likely diagnosis is acute bacterial sialadenitis of the parotid gland. The patient should begin a course of empiric broad-spectrum antibiotics after cultures (blood and pus from duct orifice) have been taken as well as supportive care, including hydration, pain relief, and sialagogues (promoting secretion of saliva) 56%

A 3-month-old girl is brought to the emergency department with a cough, poor feeding and fever. The infant is alert and responsive. She has had all routine vaccines offered. Her observations are temperature 38.1ºC, heart rate 154 bpm, respiratory rate 40/min, and oxygen saturation 91% on air. On examination, there is increased work of breathing. Coarse crackles and a wheeze can be heard across her chest. The infant's heart sounds and ECG are normal. A lumbar puncture is performed and reported as unremarkable. An hour later, the patient has a cardiac arrest.What is the most likely underlying cause of this arrest?

Bronchiolitis is the correct answer. The most common causes of cardiac arrest in children are respiratory causes that lead to hypoxia. Bronchiolitis is consistent with a history of poor feeding, cough and fever and the patient's examination findings such as crackles, wheezing and increased respiratory effort.

A 35 year old woman on a surgical ward has recently had a kidney transplant and is taking tacrolimus. She is noted to have a dry cough, spiked temperatures and reports unusual shortness of breath on mobilising to the toilet. On examination, there are end-inspiratory crackles. Which of these is the definitive diagnostic investigation given the likely diagnosis?

Bronchoscopy with bronchoalveolar lavage Pneumocystis pneumonia (PCP) is an infection caused by the pneumocystis jiroveci fungus. Patients usually present with fever, non-productive cough and breathlessness on exertion. It usually occurs in immunocompromised patients e.g. with HIV and transplants. Bronchoscopy with bronchoalveolar lavage is the definitive diagnostic investigation, as it allows a sample to be taken, which can then be tested histologically. In practice, sputum samples for polymerase chain reaction (PCR) assays are often taken, which are less invasive and are also diagnostic of the condition. 24%

A 50-year-old male presents to the emergency department with fever and lethargy. He has also complained of backache and weight loss over the last 2-3 months. He works as a farmer. On examination, he has a new heart murmur and palpable hepatosplenomegaly. An echocardiogram is performed, which reveals vegetations on the aortic valve, and initial blood cultures are negative. What is the likely organism responsible?

Brucella Brucellosis is a zoonotic infection, and high-risk occupations include farmers and vets. The symptoms are often vague, and complications include subacute and infective endocarditis, which is likely in this case. This form of infective endocarditis is often culture-negative. 45%

A 17 year old woman visits the GP. She would like to begin taking hormonal contraception. She reports that she currently uses barrier methods. On questioning, she reports she experiences heavy and painful periods. There is no other relevant medical history. Which of the following contraceptive methods is the most suitable for this patient? IUS is not an option

COCP This is the most suitable option and is recommended by the faculty of sexual and reproductive healthcare for patients who suffer from both heavy and painful periods 73%

A 74-year-old male is reviewed in the outpatient respiratory clinic due to worsening shortness of breath. On examination, he is visibly short of breath and is finding it difficult to complete his sentences. Auscultation of the chest reveals bilateral expiratory wheezing. The respiratory doctor arranges for the patient to have lung function tests and an ABG. The results show the following: pH: 7.29 Oxygen: 8 kPa Carbon dioxide: 8.1 kPa Bicarbonate: 31 mmol/L FEV1/FVC ratio: 0.66 What is the most likely explanation for these results?

COPD The pH is less than 7.35, indicating an acidosis. As the carbon dioxide is raised, this is a respiratory acidosis. Bicarbonate is raised so there is partial metabolic compensation which suggests a prolonged duration of acidosis. This ABG also shows type 2 respiratory failure (hypercapnia and hypoxia) which can be a complication of COPD. 92%

A 23-year-old man presents to his GP with a persistent runny nose. He says it started after falling off his skateboard about four hours ago, but he has been "bunged up" for the past couple of days due to seasonal allergies. He also complains of a minor headache, which is no worse when bending over. On examination, there is a thin, clear discharge from the nose. On examination of the nostrils, the nasal cavity contains dried blood. What is the most likely diagnosis?

CSF rhinorrhoea This is a classic history of someone with CSF rhinorrhoea. This occurs when there is trauma to the face (often involving the nose) which breaks the fronto-basal skull. This requires urgent imaging as a fracture in this area may allow bacteria to ascend from the nasal cavity to the meninges and neural tissues. 71%

mx of NPH

CSF taps The most likely diagnosis is normal pressure hydrocephalus. The classic triad of features is urinary incontinence, dementia and gait abnormality which develops over several months, all of which are seen in this patient. In patients who are fit for surgery, ventriculo-peritoneal shunting can be used. Otherwise conservative management with repeated CSF taps is an alternative treatment option. 56%

A 24-year-old woman presents to the emergency department with the worst headache of her life. She is also complaining of severe neck stiffness and is extremely nauseated. Analgesia is given and a CT head is requested which identifies no abnormalities. 12 hours later, her symptoms have failed to settle and a lumbar puncture is carried out which identifies the presence of xanthochromia in the cerebrospinal fluid. What is the next best investigation to carry out?

CT angiogram The presence of xanthochromia confirms the diagnosis of a subarachnoid haemorrhage. A CT angiogram is the next best investigation as it will be able to identify if the cause is due to an aneurysm and to guide subsequent management. 44%

A 70-year-old man is admitted to the surgical ward with left iliac fossa pain. He has a known history of diverticular disease. On examination, he is tachycardiac and febrile. There is a tender, palpable mass in the left iliac fossa. Blood shows an elevated white cell count and CRP. Intravenous fluid and antibiotics are started. What is the best further management option for this patient?

CT-guided percutaneous drainage This patient has a diverticular abscess secondary to divericulitis. The best approach is to drain the abscess under CT. If the patient did not improve after this, then surgery would be needed. 40%

A 35-year old female presents to her GP with a new neck swelling for the past 7 months. Her observations are as follows: HR 120 bpm, BP 192/100 mmHg, SpO2 99% on air, temperature 36.7 degrees Celsius and RR 14 breaths per minute. Thyroid function tests show the following: TSH: 3.3 mU/L(0.38-5.33mU/L) T3: 5.1 (3.8-6.0 pmol/L) T4: 10.2 (7.9-14.4 pmol/L) Which test should be carried out next?

Calcitonin levels This test is used to diagnose a medullary thyroid cancer. It needs to be done first before a biopsy. 41%

causes of systolic vs diastolic HF

Causes of systolic heart failure Ischaemic heart disease Dilated cardiomyopathy Myocarditis Infiltration (e.g. in haemochromatosis or sarcoidosis) Causes of diastolic heart failure Hypertrophic obstructive cardiomyopathy Restrictive cardiomyopathy Cardiac tamponade Constrictive pericarditis

A 75-year-old male presents to his GP after noticing that his vision has deteriorated. He has noticed that he gets blurred vision, and finds it difficult to drive at night due to the glare from street lights. His past medical history includes poorly controlled type 2 diabetes and COPD, for which he has frequent exacerbations. What is the most likely diagnosis?

Cataracts The vignette above is a classical presentation of cataracts. The patient described has various risk factors for developing cataracts: old age, diabetes, hypertension, and smoking and steroid use, suggested by his frequent exacerbations of COPD. Additionally, patients with cataracts often present with difficulty driving at night due to halos and glares. 67%

Which of the following is an AIDS-defining illness? candidiasis where??

Candidiasis of the trachea Acquired immunodeficiency syndrome (AIDS) is the advanced stage of HIV and is defined as evidence of an AIDS-defining illness alongside a CD4 count <200 cells/mm3. Candida is a common infection; however, it is classified as AIDS-defining if it affects the oesophagus, bronchi, trachea, or lungs. 23% Candidiasis of the oropharynx Candidiasis of the oropharynx is an opportunistic infection that can occur with a weakened immune system. However, it is not an AIDS-defining illness. 36%

A 70-year-old female presents with left hip pain for one week. She does not have any history of trauma to her hips. She has a past medical history of high cholesterol, type 2 diabetes mellitus and epilepsy which are all controlled with medication. Which of the following medications is most likely to have placed her at an increased risk of sustaining a non-traumatic hip fracture?

Carbamazepine Carbamazepine is found to increase the risk of osteoporosis and, subsequently, non-traumatic fractures. 38%

A 71-year-old man presents to the neurology clinic after being referred by his GP for suspected Parkinson's disease. On examination, he has bradykinesia, a shuffling gait and cogwheel rigidity. He appears to have no cognitive impairment. The neurologist decides to treat him with levodopa but explains that this will need to be combined with another medication to increase the bioavailability of levodopa. Which other medication should be given with levodopa?

Carbidopa Carbidopa is given along with levodopa (Co-careldopa) as it reduces the breakdown of levodopa peripherally, leading to a better therapeutic effect. 66% Entacapone Entacapone is a catechol-o-methyl-transferase (COMT) inhibitor which can be given as an adjunct to levodopa. 12%

A 30 year old woman with no significant medical history presents to the Emergency Department with fatigue, shortness of breath, and cough with bloody sputum. She reports that the symptoms have been progressively worsening over the past few weeks. Her vital signs are stable, but her ECG shows atrial fibrillation with a rapid ventricular response. A transthoracic echocardiogram (TTE) reveals a mass in the left atrium. Which of the following is the most likely diagnosis based on the findings?

Cardiac myxoma The ECG and TTE findings of atrial fibrillation with a rapid ventricular response and a mass in the left atrium are consistent with a diagnosis of cardiac myxoma. Cardiac myxoma is a rare type of tumour that originates from the cardiac mesenchyme and typically occurs in the left atrium. It can cause a wide range of symptoms, including fatigue, shortness of breath, and cough with bloody sputum. Cardiac myxoma can also cause atrial fibrillation and other arrhythmias due to its location in the atria. 85%

A 56-year-old patient presents complaining of a red eye. On examination, you notice that the patient's left conjunctiva is severely injected and that the left eye is displaced forwards. Additionally, when you ask the patient to look left you notice that only right eye is able to do so. What is the most likely diagnosis?

Carotid cavernous fistula This describes the abnormal communication between the carotid artery and the cavernous sinus. Key features include pulsatile proptosis, bruit and severely injected conjunctiva. The cranial nerves that run through the cavernous sinus may be affected. The vignette above describes a left abducens nerve palsy, as the patient is unable to abduct their left eye. 43%

A 62-year old woman presents to the general practice complaining of a painful, swollen and red left ankle. She said it started yesterday, and the redness has increased since then. She has a past medical history of atrial fibrillation (AF), hypertension, type 2 diabetes mellitus, diabetic neuropathy and diabetic retinopathy. She lives alone with two cats and mobilises with a frame but has been sitting down more over the last week, as she hurt her back unloading her shopping. Her drug history includes: apixaban 5 mg once daily, metformin 500 mg twice daily, linagliptin 5 mg once daily and ramipril 2.5 mg once daily. On examination, the left leg is erythematous just above her medial malleolus with associated swelling, heat and tenderness. The right leg is of normal colour and size. There are multiple cat scratches on her lower legs. The ankle has a full range of motion. What is the most likely diagnosis?

Cellulitis This patient has cellulitis of her left leg, likely caused by the introduction of infection from cat scratches. 70%

A 68-year-old woman in the intensive care unit develops a fever. She is a long-term patient and was previously making good progress in her recovery but has started to feel unwell and feverish in the last couple of days. She denies any cough, shortness of breath, abdominal pain or urinary symptoms. She is currently receiving IV fluids and parenteral nutrition through a central line. On examination, she is febrile and tachycardiac. Examination of the chest and abdomen are unremarkable. A dipstick test of a urine sample from her catheter bag shows 1+ leucocytes. What is the most likely cause of her deterioration?

Central line infection Infection is a very common complication of receiving parenteral nutrition, as the indwelling device becomes ripe for colonising pathogens. In a patient like this with a fever of unknown origin, a central with parenteral nutrition running through it would be the most likely source of infection. 64%

A 76-year-old male presents to A&E after suddenly losing his vision in his right eye when he was watching TV. He denies any pain in the right eye. The patient has a past medical history of hypertension, diabetes and COPD. What is the most likely diagnosis?

Central retinal vein occlusion Central retinal vein occlusion is when there is interuption of the venous drainage from the retinal tissue. It frequently presents as sudden, painless, unilateral vision loss. Risk factors include old age, hypertension, diabetes and atherosclerosis. This patient has hypertension and diabetes, and has COPD. Their past medical history of COPD suggests that the patient smokes, which is a cause for atherosclerosis. 38% Central retinal artery occlusion This is an incorrect answer. Central retinal artery occlusion also causes sudden unilateral vision loss due to the blockage of the blood supply to the retina. However, central retinal vein occlusion is much more common so is the most likely diagnosis. This can be confirmed with ophthalmoscopy. 55%

types of emphysema

Centriacinar - The proximal part of the airways such as the respiratory bronchioles, mainly the upper lobes. - Cigarette smoking Panacinar - The entire acini from respiratory bronchioles to alveolar duct and alveoli, mainly the lower lobes. - α1-antitrypsin deficiency Distal acinar - The distal part of the airways, mainly the paraseptal region - Fibrosis, atelectasis

dilated third and lateral ventricle and normal 4th ventricle

Cerebral aqueduct This is the correct answer. A common cause of obstructive hydrocephalus is aqueduct stenosis (commonly congenital). The aqueduct connects the third and fourth ventricles so the fourth ventricles will be of a relatively normal size 79%

A 31-year-old man presents to the GUM clinic with a genital lesion. On examination, a 2 cm lesion is seen on his penis, with pain and bleeding on contact. There is also painful lymphadenopathy in his groin. There is no urethral discharge, and he denies dysuria. He has never had an episode like this before. There are no systemic signs of infection. The man reports he recently returned from travelling in Nigeria. Which of the following is the most likely diagnosis?

Chancroid Chancroid is an infection of the genital skin and typically presents as a painful lesion that bleeds on contact. There may also be associated lymphadenopathy. It is most commonly contracted in tropical areas. 40%

A 34-year-old man presents to the sexual health clinic with an ulcer on his penis. He has also felt generally unwell for the past week with a fever and fatigue. He often has unprotected intercourse with casual male partners. On examination, he has palpable left-sided inguinal and femoral lymphadenopathy, and a single, painless, shallow ulcer is present on the coronal sulcus. Which of the following microorganisms is most likely responsible for his presentation?

Chlamydia trachomatis This patient is likely experiencing symptoms of lymphogranuloma venereum (LGV), which is a form of chlamydia infection. It often presents with a painless genital ulcer alongside systemic signs of infection such as pyrexia and malaise. Lymphadenopathy is common and is usually unilateral. Patients can also present with rectal symptoms of infection, such as rectal pain and discharge. LGV is more common in men who have sex with men (MSM). 24% Treponema pallidum Treponema pallidum is the bacteria responsible for syphilis infection. Although the first stage of syphilis presents as a single painless genital ulcer, this is less likely to be accompanied by systemic signs of infection or inguinal lymphadenopathy. 53%

A 45-year-old woman presents to the GP with a 9-month history of worsening intermittent right upper quadrant pain that is worse when eating fatty foods. Recently, she has started to have nausea, pruritus, and weight loss. She has a history of ulcerative colitis and has had these symptoms for a while and has now decided to seek help.On examination, she is afebrile, her pulse is 85 bpm, and her blood pressure is 128/75 mmHg. Scleral icterus is seen and a non-tender mass is palpable in the right upper quadrant.Based on these features, what is the most likely cause of her current presentation?

Cholangiocarcinoma is correct. The presence of slowly worsening jaundice alongside unexplained weight loss should raise suspicion of malignancy, including cholangiocarcinoma and pancreatic cancer. The presence of a palpable mass in the right upper quadrant (RUQ) supports these diagnoses, as Courvoisier's law states that a palpable mass in the RUQ is more likely to be a malignant obstruction of the common bile duct rather than obstruction due to stones. Since this patient has ulcerative colitis (UC) and has had these symptoms for a while, with her symptoms worsening recently, it is likely that they have cholangiocarcinoma, as patients with UC can develop primary sclerosing cholangitis (PSC) which can increase the risk of cholangiocarcinoma.

A 52-year-old male presents to the GP clinic with a three month history of pain in his pelvis which has been worsening. The pain is worse on the right and at night; he describes it as a dull ache. He does not have any recent trauma to the region. On examination, there is tenderness over the lateral side of his right pelvis. An x-ray of his pelvis reveals a poorly defined 4cm bone lesion in the right ilium with a moth-eaten pattern of bone destruction. Which of the following is the most likely diagnosis?

Chondrosarcoma Chondrosarcoma is a malignant bone tumour typically affecting the pelvis, proximal femur or proximal humerus and is usually seen in patients aged 50-70 years. Patients presents with progressive worsening of pain which is worst at night. On x-ray, chondrosarcomas appears as osteolytic lesions with moth-eaten pattern of bone destruction. 25%

A 33-year-old man who has recently been diagnosed with autosomal dominant polycystic kidney disease (ADPKD) attends his renal clinic appointment with some questions. He asks about how this condition is inherited. On which chromosome is the mutation affecting this patient most likely to be found?

Chromosome 16 In about 85% of cases, the mutated gene is located on chromosome 16. This is known as ADPKD-1. 50%

A 45-year-old female is seen in the emergency department with a cough. She has a history of mild bronchiectasis. On examination, there are crackles audible at the left lung base. Her observations are as follows: Heart rate: 78 beats per minute Blood pressure: 150/95 mmHg Respiratory rate: 12 breaths per minute SpO2: 98% on room air Temperature: 37.9°C Sputum microscopy reveals a gram-negative encapsulated bacillus. What is the most appropriate initial treatment?

Ciprofloxacin This patient with bronchiectasis likely has a pseudomonas infection. Given that she is systemically well, treating her in the community would be appropriate; ciprofloxacin is the only oral anti-pseudomonas antibiotic. 32%

A 75-year-old lady comes to the emergency department with a painful and swollen left wrist. Her son mentioned that she slipped in her bathroom earlier in the day and had managed to break her fall with her left hand. She has a medical history of osteoporosis which she is taking supplements for. An x-ray of her left arm shows a transverse fracture at the distal part of the radius with the distal fragment is displaced dorsally. There is no intra-articular involvement. What is the most appropriate management for this patient?

Close reduction and immobilise wrist with a cast The patient has a Colles' fracture. Colles' fracture is usually caused by a fall on the outstrethed hand and is commonly seen in osteoporotic woman. Conservative treatment should be the first choice of treatment for this patient because she has a simple fracture with no intraarticular involvement. 63% Open reduction and internal fixation Open reduction and internal fixation is not the first choice because she does not have a complex fracture (e.g communited, severely displaced or angulated, intra-articular fracture). This surgery, however, will be considered if the first-line of treatment is unsuccessful. 23%

A 55 year old male presents to the Emergency Department with a 2 month history of a persistent dry cough and breathlessness that worsens when going up the stairs. This has progressed to shortness of breath at rest over the past few days. Past medical history is relevant for a road traffic accident in rural Kenya, for which he had a splenectomy and blood transfusion. He has no recent history of illness apart from an episode of flu-like symptoms and a widespread rash 6 months ago, which has since spontaneously resolved. Observations show a temperature of 37.9 degrees Celsius, respiratory rate of 30, oxygen saturations of 86% on room air, heart rate of 77 beats per minute and blood pressure of 125/80. Arterial blood gas (ABG) showed pH 7.37, PaO2 7.1 kPa, PCO2 5.5 kPa, HCO3 25 mmol/L. What is the most appropriate initial treatment?

Co-trimoxazole and steroids This is the best treatment for Pneumocystis pneumonia (PCP). This is the most likely diagnosis given the progressive shortness of breath, exertional dyspnoea, and desaturation on ABG. He is likely to have contracted HIV from a contaminated blood transfusion in rural Kenya, which explains the seroconversion illness he experienced 6 months ago. Adjunctive steroids should be administered to patients with PaO2 ≤8 kPa and/or evidence of hypoxaemia e.g. oxygen saturations <92%. This is to reduce mortality and risk of respiratory failure

A 53 year old man attends the emergency department with shortness of breath, malaise and weight loss. He denies any urinary symptoms. On examination, there is a perforation of his nasal septum, track marks on the left arm and sinus tenderness. His vasculitic screen results are as follows: c-ANCA + anti-proteinase 3 (PR3) + human neutrophil elastase antibody + What is the most likely diagnosis?

Cocaine use Cocaine use is a differential for c-ANCA vasculitides. Users can present with respiratory symptoms, perforation of structures such as the hard palate and nasal septum and can even be positive for c-ANCA and PR3. A presentation of cocaine use can be distinguished from granulomatosis with polyangiitis (Wegener's granulomatosis) due to a positive human neutrophil elastase antibody test. This patient also has track marks which would indicate drug use. 18% Polyarteritis nodosa Polyarteritis nodosa typically presents with symptoms affecting multiple systems (renal, cardiac, musculoskeletal) and is negative for anti-nuclear cytoplasmic antibodies. 7% this nose deformity is not one that is usually seen in wegeners (here you see saddle shaped nose)

A 24-year-old male is seen by his dentist for widespread dental erosion. On further questioning, he describes intense worry about his weight and that he tries to manage this by making himself vomit when he has eaten too much. He sometimes punishes himself with a strict exercise regime after eating fatty food. On examination, his BMI is 21. Which of the following describes the first line treatment for the presentation demonstrated by this patient?

Cognitive behavioural therapy This patient has bulimia nervosa. He demonstrates binging and purging behaviour as well as anxiety around food. Cognitive behavioural therapy (CBT) is the first line treatment for bulimia nervosa. It aims to address problematic cognitions and emotions around eating, with the aim of changing the individual's thought processes and ultimately their behaviour. 94%

A 73-year-old man with a background of hypertension, type 2 diabetes, peptic ulcer disease and alcohol dependency develops a red, swollen and acutely tender right big toe. He is afebrile and has no other symptoms. He sees his GP who prescribes a new medication. A few days later, the patient returns to the GP due to stomach pain and diarrhoea. Which medication was he most likely started on?

Colchicine The first-line treatment for acute gout is a high dose non-steroid anti-inflammatory drug (NSAID) or colchicine. In this patient with a history of peptic ulcer disease, it is safer to prescribe colchicine. Abdominal pain and diarrhoea are common side-effects of colchicine. 71%

cocp and breastfeeding

Combined oral contraceptive pill This is contraindicated (UK Medical Eligibility Criteria for Contraceptive use Grade 4 - UK MEC4) in women <6 weeks postpartum who are breast-feeding. This is due to the increased risk of venous thromboembolism in the post-pregnancy state, as well as contamination of breast milk. After 6 weeks, it becomes a UK MEC2 can take pop whilst actively breastfeeding

A 24 year old model attends the sexual health clinic to discuss contraception. She has a past medical history of acne and polycystic ovary syndrome (PCOS). There is no relevant family history. Her main concern is that her periods are heavy and irregular, and she would prefer lighter and regular periods as this is currently interfering with her work. She is also keen to avoid any method that could cause her to gain weight. Which of the following is the most suitable contraceptive to offer her?

Combined oral contraceptive pill This is the preferred option in women and girls with PCOS - it helps control period regularity, as well as other manifestations of the condition like acne 56%

A 45-year-old woman is admitted to the acute medical unit with a 2-week history of headache and dizziness. During the morning ward round, she has a witnessed generalised tonic-clonic seizure which terminated after the administration of intravenous lorazepam. She is not known to suffer from seizures.On examination, she is post-ictal with a GCS of 13/15. Her observations are within normal limits.She is taken for a CT head which shows a 2cm x 2cm frontal meningioma.What is the most appropriate initial step in the management of this patient?

Commence anti-epileptic treatment is correct. This patient has had a generalised tonic-clonic seizure that has terminated following benzodiazepine use. Current guidelines from NIC state that anti-epileptic treatment should not be started after the first episode of seizure, unless in the following circumstances: the presence of a neurological deficit structural abnormality on brain imaging unequivocal epileptic activity on the EEG the patient, family or carers consider the risk of having a further seizure is unacceptable Referral to outpatient neurology team is incorrect. A neurology opinion would definitely be important given this patient's presentation. However, in this patient's case with structural abnormality and seizure activity, this should happen as an inpatient. DiscussImprove

A 39 year old man visits the HIV clinic for a follow up after routine HIV screening. His results are as follows: HCV antibody: reactive HCV RNA: identified HBsAg: negative Anti HBc: negative Anti HBs: positive HIV antibody + antigen test: positive CD4+: 353 What is the most appropriate course of action?

Commence cART and urgent Hepatology referral There is evidence of a current Hep C infection, Hep B vaccination and HIV infection. All patients with HIV should be commenced on cART irrespective of their CD4 count as this has been shown to improve overall outcomes. In this instance, due to the current Hep C infection, it is also suitable to refer to hepatology urgently to explore treatment for Hep C 59%

A 49 year old male presents to A&E with generalised weakness. He also reports difficulties initiating speech and swallowing. He is noted to be HIV positive and mentions his symptoms have come on progressively over two months. A whole brain CT scan is requested. The report states: There is a single lobulated lesion in the left frontal lobe, with solid homogenous enhancement. There is involvement of both the periventricular area and the caudate. Further, to this, a stereotactic brain biopsy is requested. The report from this investigation states: There appears to be non-cohesive malignant lymphocytes present with reduced cytoplasmic volume. There is evidence of pleiomorphic nuclei and non-cohesion Given the most likely diagnosis, what is the most appropriate treatment?

Commence cART and whole brain irradiation The most likely diagnosis is Primary CNS lymphoma. This is due to the progressive nature of the presentation, and the report of a single lobulated lesion with single homogenous enhancement. This is further supported by a positive brain biopsy, demonstrating evidence of malignant lymphocyte proliferation. In this case, cART is indicated along with whole brain irradiation 56%

A 45-year-old male presents to the orthopaedic clinic for follow-up for his right tibia shaft fracture which he sustained 4 weeks ago from an accident. He is being treated conservatively and is required to wear a cast. On examination, there is reduced sensation over the dorsum of the feet and weakness of the dorsiflexors. His foot pulses are present. Which of the following complications did this patient develop?

Common peroneal nerve injury Common peroneal nerve injury is one of the common complication in patients wearing casts sue to compression. Patient with this injury will have reduced sensation over the dorsum of the foot and weakness of the dorsiflexors (foot drop). 86%

Which of the following best describes the main aim of a phase 3 trial?

Comparing new treatment with standard treatment Phase 3 trials is also sometimes referred to as a 'comparative efficacy'. The trials compare the intervention of interest with either a standard therapy or a placebo 44%

increased risk of preterm labour or PPROM

Conditions which may cause "overstretching of the uterus" Multiple pregnancy (commonly due to assisted conception) and polyhydramnios Conditions where foetus is at risk Pre-eclampsia, intrauterine growth restriction, placental abruption etc. Problems with the uterus or cervix Fibroids, congenital uterine malformation, short or weak cervix, previous uterine or cervical surgery Infection including chorioamnionitis, maternal or neonatal sepsis, bacterial vaginosis, trichomoniasis, Group B Streptococcus, sexually transmitted infections (e.g. Chlamydia) and recurrent urinary tract infections Maternal co-morbidity (for example: Hypertension, diabetes, renal failure, thyroid disease etc.)

oral ca referral pathway

Consider a suspected cancer pathway referral (for an appointment within 2 weeks) for oral cancer in people with either:unexplained ulceration in the oral cavity lasting for more than 3 weeks or a persistent and unexplained lump in the neck. Consider an urgent referral (for an appointment within 2 weeks) for assessment for possible oral cancer by a dentist in people who have either:a lump on the lip or in the oral cavity ora red or red and white patch in the oral cavity consistent with erythroplakia or erythroleukoplakia.

An 80-year-old woman is an inpatient on the orthogeriatric ward. She was successfully operated on for a fractured neck of femur ten days ago. Her pain has been controlled with regular paracetamol and oral morphine. She has been mobilising around the ward with some assistance from physiotherapy. However, her nurse reports that she has become increasingly confused over the last two days. The patient becomes particularly agitated at night. She has no past medical history of cognitive impairment. Her observations are stable and recent blood tests show: Hb 100, MCV 80, WCC 9.0, Neutrophils 3.0, Platelets 250 Urea 5.5, Creatinine 120, Na+ 138, K+ 4.2 Ca2+ 2.25 CRP 15 On examination, the chest is clear, heart sounds are normal, and abdomen is soft and non-tender. The surgical site appears clean and dry. What is the most likely explanation for this patient's confusion?

Constipation Constipation is a common cause of delirium in elderly inpatients, particularly in those taking opiate analgesia. It would be worth checking her stool chart and performing a digital rectal examination to check for faecal impaction if she has not opened her bowels for days. 70%

A 16 year old girl is brought into GP by her mother who is worried that she has not started having her periods. All of her friends have already started having their periods. She mentions that her breasts have been growing over the past few years and she now has pubic hair. On examination, there are no obvious genital abnormalities. What is the most likely cause of delayed menarche?

Constitutional delay This young girl has developing secondary sexual characteristics (breast and pubic hair) but has not yet started her period. The most common cause of delayed puberty is constitutional delay. In cases such as these, it is important to ask if there is a family history of delayed puberty. 77%

An 18 year old woman visits the GP clinic asking about different types of contraception. Previously she has been using barrier protection, but would like hormonal contraception. She has a past medical history of epilepsy. Of the following, what is the most appropriate contraceptive method to prescribe?

Contraceptive injection The injection is the contraceptive of choice amongst the epileptic population. The injection does not interact with liver enzymes not Vaginal ring Several anti-epileptic drugs including phenobarbitone, carbomazepine and phenytoin are enzyme inducers which will increase the metabolism of the oestrogen released by the ring thereby making it less effective 18%

A 60-year-old man is brought to the emergency department with abdominal pain and vomiting. On assessment, he is confused and has a blood glucose level of 3.2mmol/L and blood pressure of 80/56. He has a past medical history of Addison's disease. The patient is treated urgently for an Addisonian crisis. His daughter is also with him and wants to know more about his condition. An Addisonian crisis is caused by the body's inability to produce which hormone?

Cortisol An Addisonian crisis is a serious condition caused by the body's inability to produce cortisol and can lead to shock and even death. 80%

Stage 4 hypertensive retinopathy

Cotton-wool spots (widespread white-ish areas resulting from ischaemia) Retinal haemorrhages (red blotches around the centre of the image) A 'macular star' composed of intraretinal lipid exudates (the radial, sunburst pattern of white streaks around the macular) The optic nerve head is swollen, which is the feature that separates grade 3 and grade 4 hypertensive retinopathy

A 34-week-old baby is born via emergency caesarean section and admitted to the neonatal unit due to prematurity. On day 7 of life, it is noted that the baby's head circumference is increasing. Which of the following is the next most appropriate investigation?

Cranial ultrasound This baby is likely to have hydrocephalus given the increasing head circumference. They also have a significant risk factor as they were born preterm. The most appropriate next investigation is a cranial ultrasound as this baby is only a week old; therefore, the anterior fontanelle is still open. Other risk factors for hydrocephalus include spina bifida and meningitis. 61% CT scan is the 2nd line ix or if the baby was older and a cranial USS is inappropriate

An 80-year-old woman has had increasing difficulty performing daily activities such as getting up from a chair and combing her hair for the past few months. Her past medical history includes rheumatoid arthritis and gout. On examination, she has reduced muscle strength bilaterally in her upper arms and legs. The sensation and reflexes in her upper and lower limbs are intact. She is also found to have dilated blood vessels around her nails, papules over her knuckles, and an erythematous rash over the back of her neck and shoulders. Which of the following is the most appropriate initial investigation given the likely diagnosis?

Creatine kinase Patients with idiopathic inflammatory myopathy (IIM) present with muscle weakness and have elevated creatine kinase. IIM is a group of disorders characterised by muscle weakness and inflammation, of which dermatomyositis is one of them. The cutaneous findings (periungual telangiectasia, Gottron's papules, shawl sign) and bilateral proximal muscle weakness support the diagnosis of dermatomyositis. Testing for creatine kinase helps to guide further diagnostic studies. 51% ESR is first line for temporal arteritis

A 50 year old man presents to the GP with muscle weakness. He reports his arms becoming fatigued earlier than usual and he has been squatting less and less weights at the gym over the last few months. He has had no change in his diet or exercise routine. On examination, he has lilac discolouration of the eyelid, periorbital oedema and scaly erythematous papules on his knuckles. The GP requests some blood tests. Given the likely diagnosis, which key test should the GP include?

Creatinine kinase The likely diagnosis here is dermatomyositis. The patient is experiencing progressive proximal muscle weakness, along with dermatological features of a heliotrope rash and Gottron's papules. Creatinine kinase is the most sensitive indicator of disease and can give an idea of disease activity. 54%

A 27-year-old man attends his GP reporting haemoptysis and haematuria. A diagnosis of Goodpasture syndrome is suspected so he is referred for a renal biopsy. What would the renal biopsy show if this was the diagnosis?

Crescent formation and linear deposition of antibodies along the glomerular basement membrane This is the typical histological finding in Goodpasture syndrome. It is caused by anti-glomerular basement membrane antibodies, which is why you see deposition of the antibodies along the membrane. 64%

A 3-year-old boy is brought to the paediatric emergency department by his mother in the middle of the night as she is concerned about his breathing. He has been making a noisy high-pitched sound when breathing in for the last few hours. She explains he has been coughing and had a runny nose for the last few days; however, it gets much worse at night. The coughing sounds like a 'barking' noise. He is afebrile on examination. Which of the following is the most likely diagnosis?

Croup This child has presented with stridor on a background of a barking cough and coryzal symptoms, which worsen at night. Although there are many causes of stridor in children, this pattern of symptoms fits with a diagnosis of croup. Children are more likely to present with stridor than adults because their upper airway is shorter and narrower than an adult's and is, therefore, more likely to get blocked. 96%

A 30 year old pregnant lady complains of itching and pain in the perineal area. On examination, there are raised plaques over the external surface of the vulva. A biopsy of the genital lesions revealed hyperplastic squamous epithelium with koilocytes and squamous cells containing a hyperchromatic nucleus displaced by a large perinuclear vacuole. What is the best step in the management of this patient?

Cryotherapy Liquid nitrogen, also known as cryotherapy, can be used to destroy abnormal skin cells by freezing them. It is a relatively simple and non-invasive procedure that can be performed in a outpatient setting, and it is safe and effective in treating genital warts caused by HPV. Delaying treatment until after delivery is common practice. 29% topical imiquimod and podophyllotoxin are CI in pregnancies

A 25-year-old man attends with a 3-month history of numbness in his right hand. On examination, you note the loss of sensation to the palmar and dorsal aspect of the 5th digit. Sensation of the forearm is preserved.What is the most likely diagnosis?

Cubital tunnel syndrome is correct. This is a classical description of ulnar nerve neuropathy. The ulnar nerve supplies sensory innervation to the palmar and dorsal aspects of 1.5 fingers medially. It has a motor component which can result in wasting and paralysis of intrinsic hand muscles (except lateral two lumbricals) and the hypothenar muscles. Froment's test can be used to test the function of the adductor pollicis muscle which is often weak in ulnar neuropathy.

An 18-year-old girl presents to the GP with ongoing breast pain. She says her breasts feel heavy and tender for around 10 days each month. This usually resolves by the end of her menstrual period. There is no lumpiness or overlying skin changes. She has no children; her last menstrual period was two weeks ago. What is the most likely diagnosis?

Cyclical mastalgia Cyclical mastalgia is breast pain that occurs with the fluctuations of hormones during the menstrual cycle. This most commonly occurs in the luteal phase of the menstrual cycle and resolves during the menstruation phase. 85%

A newborn baby girl, born at term, has not passed meconium in the first 48 hours of birth. She is irritable, has a distended abdomen and has started vomiting green fluid. An abdominal x-ray shows a 'bubbly' appearance of the intestines with a lack of air-fluid levels. Which of the following conditions is the most likely underlying cause of this condition?

Cystic fibrosis This baby has presented with meconium ileus, where the first stool (also known as meconium) is too thick and sticky, resulting in intestinal obstruction. The radiological findings, in this case, are classically found in meconium ileus. Cystic fibrosis is the most likely cause of meconium ileus, as the disruption in chloride transportation causes the meconium to become very thick. 28% Necrotising enterocolitis (NEC) Necrotising enterocolitis (NEC) is a common cause of bilious vomiting in preterm babies. The main investigation in NEC is a supine abdominal x-ray which shows dilated asymmetrical bowel loops, bowel wall oedema with 'thumbprinting' and pneumatosis intestinalis (gas within the bowel wall). This baby's presentation is more consistent with meconium ileus, where the first stool (also known as meconium) is too thick and sticky resulting in intestinal obstruction. The radiological findings, in this case, are classically found in meconium ileus. Cystic fibrosis is the most likely cause of meconium ileus, as the disruption in chloride transportation causes the meconium to become very thick. 26%

A 52 year old man underwent a transurethral resection of prostate (TURP) and went home after 1 day following a successful trial without catheter. He presents to the casualty after 3 days with frank haematuria and increasing difficulty in passing urine after lifting heavy weights at home. An urgent bedside ultrasound scan of the bladder reveals clot retention. What is the definitive management?

Cystoscopy and evacuation of blood clots This patient presents with clot retention after transurethral resection of prostate (TURP). It is a common complication following the procedure, hence most patients are advised to refrain from walking and lifting heavy weights for at least one week post-surgery. In the event of clot retention, an emergency clot evacuation and diathermy to the bleeding point is the definitive management. 51%

DM or HTN on fundoscopy

DM = maculopathy HTN = would see vessel changes

mx of gas gangrene

Debridement should be urgently carried out, alongside antibiotics as an adjunct therapy. Amputation may be required. If amputating, a large margin must be given around the site of infection or else there will be a further development of gas gangrene and loss of far more tissue. Hyperbaric oxygen therapy may have some benefits since the bacteria are anaerobic and therefore oxygen may be lethal to them; however, it is not routinely used.

An 80-year-old man presents to his GP with bradykinesia, rigidity, tremor and recurrent falls. He is diagnosed with Parkinson's disease and prescribed co-beneldopa 12.5g/50mg three times daily. Each capsule contains levodopa 50mg and benserazide 12.5mg. What is the mechanism of action of benserazide?

Decarboxylase inhibitor Benserazide is a decarboxylase inhibitor which prevents the peripheral breakdown of levodopa. This means that levodopa is decarboxylated into dopamine in the brain, enabling the full therapeutic dose to take effect. 52%

A 20 year old male presents to the GP clinic with a genital lesion for the past two weeks. It began as an erythematous papule, which became a pustule and subsequently a severely painful ulceration. There are enlarged nodes around the lesion. He is sexually active and does not use condoms regularly. Vital signs are normal. Penile swab reveals Gram-negative rods in a typical "school of fish" pattern. Given the current clinical picture, how would the lesion appear on examination?

Deep ulcer with a soft, irregular border and a friable base Chancroid is a sexually transmitted infection characterised by multiple painful ulcers on the genitals and inguinal lymphadenopathy. Haemophilus ducreyi, a Gram-negative anaerobic bacteria, causes chancroid by generating a toxin that forms ulcers. Typically, an erythematous papule forms at the site of inoculation, which soon develops into a pustule and then into an excruciatingly painful ulcer, which has a friable base and yellow-grey exudate. 35%

A 10-year-old female has a history of numerous long bone fractures. On examination, she has blue sclera and her lower extremities has a bilateral varus deformity. Her father has a similar history of having multiple fractures during his childhood. Which of the following is the mechanism behind this patient's disorder?

Defect of type 1 collagen synthesis This patient has osteogenesis imperfecta, which is a condition caused by a qualitative defect in collagen type 1 synthesis. Patients typically have a history of multiple fractures in their childhood and may have sclera (blue) and dental abnormalities. Some patients will also have hearing defects as they grow older. 69%

lung abscess

Definition A lung abscess is liquefactive necrosis of lung parenchyma as a result of infection by a pathogen, creating a cavity consisting of fluid and debris. The most common responsible organisms are anaerobic flora. Conditions that increase the likelihood of developing a lung abscess include: Aspiration of oropharyngeal secretions Lung malignancy Pneumonia Presentation of a lung abscess Symptoms: Fever Productive cough: foul-smelling purulent mucus Dyspnoea Lethargy Night sweats Weight loss/ cachexia Signs: Finger clubbing Dental Erosions/ periodontal disease Localised dull percussion note Bronchial breathing Investigations (and results) Blood: raised inflammatory markers of CRP and ESR; leukocytosis Sputum culture Chest X-ray: an abscess affects one side, commonly the posterior segment of the upper lobe and the apex of the lower lobe CT scan Bronchoscopy: aspirates can be obtained for culture and for drainage Management Conservative management: Chest physiotherapy for postural drainage Smoking cessation therapy if necessary Medical management: Supportive treatment: Oxygen; fluid Regime; analgesia Antibiotic treatment: Intravenous therapy for 3 weeks followed by oral antibiotics for 1-2 months. Surgical management: CT-guided percutaneous drainage or pulmonary resection

Schistosomiasis

Definition Also known as Bilharzia This is a tropical parasitic disease caused by infection with blood-dwelling trematodes (flukes). Most cases occur in Sub-Saharan Africa, but South-East Asia and the Middle East are also affected. Pathogenesis Female worms lay thousands of eggs per day in the capillaries of infected patients (mammals are definitive hosts). Eggs migrate from blood vessels to the bladder lumen (for Schistosoma haemotobium) or intestine (for S. mansoni and japonicum). 1/3 are excreted in the urine and faeces, while the rest remain in the target organ tissues or get trapped in the liver. Excreted eggs hatch when they contact fresh water, and release swimming miracidia The miracidia infect freshwater snails (the intermediate host), and develop into cercariae over 4-6 weeks. Sunlight stimulates cercariae release, and they have 12-24 hours to find a mammalian host. The cercariae penetrate the dermis of a new host and migrate as schistosomulae through the bloodstream (may pass via lungs and be retained there in some cases). The schistosomulae mature to schistosomes in the portal or vestibular veins over 4-6 weeks, and male and female form a mating pair. The mating pair migrates up into the mesenteric veins where they may live for many years. Disease Types Local urticaria or 'Swimmer's itch' after cercariae penetration of the dermis. Acute schistosomiasis or 'Katayama fever': due to a hypersensitivity reaction to circulating and maturing schistosomulae. Chronic schistosomiasis: caused by eggs getting trapped in host tissues, leading to inflammation and formation of granulomas.In urinary schistosomiasis, deposition of eggs in the bladder and ureter walls can cause haematuria, UTIs, fibrosis and calcification, and is a risk factor for Squamous Cell Carcinoma of the bladder.Intestinal/hepatosplenic deposition of eggs leads to blood in the stool, diarrhoea and strictures of the colon or rectum. Liver fibrosis can occur and lead to portal hypertension, ascites and chronic liver disease in the long term.Neuroschistosomiasis occurs due to aberrant migration of adult schistosomes, leading to egg deposition in the brain or spinal cord.Pulmonary disease can cause pulmonary hypertension and cor pulmonale. Risk Factors Contact with fresh water, such as lakes, ponds, streams, or irrigation and drainage canals in endemic countries Activities associated with this include: Swimming Bathing Fishing Farming Washing clothes Important sites: Lake Malawi Lake Victoria Zambezi Delta Niger delta Lake resorts in South Africa Mekong River in Laos Diagnosis Identification of eggs on microscopic examination of urine or stool. Serology if within 2 months of exposure, as eggs may not be detected this early Histopathological analysis of affected tissue, not often used. Management Praziquantel is the drug of choice.Kills adults but not the eggs or migrating schistosomulaHence needs to be given again 2-3 months after exposure to allow for the development of the worms. Steroids are needed in acute Katayama Fever to suppress hypersensitivity reaction.

bacterial vaginosis

Definition Bacterial vaginosis is a bacterial imbalance of the vagina caused by an overgrowth of anaerobic bacteria and a loss of lactobacilli. # Clinical features Increased vaginal discharge Grey-white watery discharge Characteristic "fishy" smelling discharge, particularly after intercourse Epidemiology Bacterial vaginosis is the most common cause of abnormal vaginal discharge in women of childbearing age, with a prevalence as high as 50% in some communities. Diagnosis In order to diagnose bacterial vaginosis, the Amstel criteria are often used. Three out of four features are needed to confer a diagnosis: Vaginal pH >4.5 Homogenous grey or milky discharge Positive whiff test (addition of 10% potassium hydroxide produces fishy odour) Clue cells present on wet mount Management The treatment of choice is usually either Metronidazole or Clindamycin, which can be administered orally or intravaginally.

mx of carpal tunnel syndrome

Definition Carpal tunnel syndrome arises from median nerve entrapment in the anatomically closed space of the carpal tunnel. Causes It is more common in women and may be primary/idiopathic or secondary to the following causes: Diabetes Pregnancy Hypothyroidism Acromegaly Radial fracture Rheumatoid arthritis Clinical features The symptoms are tingling/pain in the first three digits, worse at night and relieved by shaking/ hanging out the hand at night. There may also be clumsiness in hand movements and decreases sensation in the first three digits. Management Carpal tunnel syndrome can be treated through splinting, local steroid injections and treatment of the underlying cause if it is secondary. If these fail, then decompression surgery is used- performed by dividing the tunnel roof (flexor retinaculum).

gout

Definition Gout is a form of arthritis caused by the deposition of monosodium urate crystals in and around the joints. Epidemiology The reported prevalence of gout worldwide ranges from 0.1% to approximately 10%, and the incidence from 0.3 to 6 cases per 1,000 person-years. Developed countries have a much higher prevalence than less developed countries. Presentation Acute gout commonly presents with arthritis of the 1st MTP (metatarsophalangeal) joint. It is characterised by sudden, severe attacks of pain, swelling, redness and tenderness in the joints, often the joint at the base of the big toe. Causes Gout is caused by the precipitation of uric acid crystals within the joint leading to an acute inflammatory response. Non-modifiable risk factors Male gender Age over 50 years Family history of gout Modifiable risk factors Obesity Hypertension Chronic kidney disease Diabetes Metabolic syndrome Medications: thiazide diuretics, ACE inhibitors and aspirin Triggers Gout has a number of triggers/ precipitating factors which can cause an acute flare, these are generally due to increased production of uric acid, either through digestion of protein or increased cell turnover and protein degradation. Seafood/ protein binges - eating lots of high protein foods raises levels of uric acid Chemotherapy - increases cell break down Trauma and surgery - increases cell break down Symptoms Excruciating, sudden, burning pain in the affected joint Swelling, redness, warmth, and stiffness in the affected joint Asymmetric joint distribution Mild fever Tachycardia as a transient sympathetic response to the pain of an acute attack Differentials of monoarthropathy The most important differentials of a monoarthropathy are: Septic arthritis Crystal arthropathy - gout/ pseudogout Inflammatory arthritis - rheumatoid arthritis and seronegative arthritis Septic arthritis should be excluded in any patient presenting with an acute, hot swollen joint, especially if they are systemically unwell. Diagnosis is made by aspirating the joint and sending the fluid for microscopy, culture and sensitivity. Investigations Initial tests that should be performed in a patient with suspected gout is arthrocentesis with synovial fluid analysis. Needle-shaped monosodium urate crystals with negative birefringence confirm gout and differentiate it from pseudogout, and the fluid should also be sent for gram stain and culture to rule out septic arthritis. Other investigations can be considered: The uric acid level should be obtained at least 2 weeks after the attack as it may be low or falsely normal during the attack. Additionally, gout can develop with serum uric acid levels with the normal range. X rays of affected joints: The radiological features of gout includes normal joint space, soft tissue swelling and periarticular erosions. Ultrasound of affected joints Management of an acute gout attack Gout is managed in terms of the acute attack, and then the ongoing management. NSAIDs, colchicine, steroids and paracetamol may all be used acutely, according to the patient's co-morbidities. The NSAID indomethacin is traditionally used first-line. For patients with a high risk of gastro-intestinal side effects, past medical history of chronic kidney disease or heart failure, colchicine may be used. Diarrhoea is a side effect of colchicine and if intolerable to patients, intra articular administration of steroids may be considered. Importantly, intra-articular administration of steroids should not be undertaken if septic arthritis is suspected. Lifestyle changes for the prevention of gout Following this, it is important to give the patient lifestyle advice regarding ways of preventing another attack: Reduction of alcohol consumption Reduction of purine-based foods- meat and seafood Medications should be reviewed as the following drugs may cause hyperuricaemia Thiazides and loop diuretics Low dose salicylates Chemotherapy Indications for allopurinol in the prevention of gout Allopurinol should be commenced at a low dose at least 2 weeks following an attack. Criteria for commencing prophylactic allopurinol: More than 2/3 attacks per year Tophaceous gout X-ray changes showing chronic destructive joint disease Urate nephrolithiasis Patient experiencing severe and disabling polyarticular attacks If allopurinol fails or is contraindicated, febuxostat can be used instead. It is important to remember that urate lowering therapy should be only be started at least one week after an acute episode has resolved as it may worsen the acute episode. In addition starting or increasing urate lowering therapy can itself cause a gout flare. For this reason, the first 3-6 months of urate lowering therapy are often covered with an NSAID or colchicine until the effective dose is reached. If the patient experiences an acute flare while on urate lowering therapy, they should continue the drug.

haemorrhoids

Definition Haemorrhoids occur when cushions within the anal canal expand and protrude outside the anal canal. Clinical features Patients typically present with bright red PR bleeding associated with defecatation. Pain is not a typical feature, and if present suggests a thrombosed external haemorrhoid or an alternative diagnosis (such as an anal fissure). Patients may also report anal pruritus or a protruding mass. On examination, a palpable anal mass may be present with prolapsing haemorrhoids. Risk factors Risk factors for haemorrhoids include constipation, pregnancy, and other factors which increase intra-abdominal pressure (such as a space-occupying lesion). Portal hypertension secondary to cirrhosis also increases the risk of haemorrhoids (due to increased pressure at the rectal porto-systemic anastomosis). Diagnosis Diagnosis is with anoscopic examination. Management of haemorrhoids Grade 1 haemorrhoids (i.e. no prolapse) can be managed conservatively, ± topical corticosteroids to alleviate pruritus. Grade 2 haemorrhoids (i.e. prolapse on straining which spontaneously reduces) can be managed with rubber band ligation (preferred), sclerotherapy, or infrared photocoagulation. Grade 3 haemorrhoids (i.e. prolapse on straining and require manual reduction) are managed with rubber band ligation. Grade 4 haemorrhoids (i.e. prolapse on straining and can't be manually reduced), external haemorrhoids, or lower grade haemorrhoids failing to respond to less invasive measures are managed with surgical haemorrhoidectomy. All patients should be advised to consume a diet rich in fibre and fluids, to reduce the risk of constipation. Management of thrombosed haemorrhoids Thrombosed haemorrhoids (which present as a painful purple protrusion) can be managed conservatively with ice packs, laxatives, and lidocaine gel. Patients require haemorrhoidectomy if conservative measures fail.

microscopic polyangitis

Definition Microscopic polyangitis is one of the more common forms of arteritis affecting smaller arteries, characterised by renal disease, pulmonary disease and pANCA directed against myeloperoxidase. Symptoms The most common clinical manifestations of microscopic polyangiitis are: Constitutional symptoms (weight loss, fevers, malaise, joint and muscle aches) Kidney inflammation (necrotising glomerulonephritis) Skin lesions (most commonly palpable purpura of the lower extremities) Peripheral nerve damage (mononeuritis multiplex: damage to two or more separate peripheral nerves) Lung involvement (pulmonary capillaritis leading to alveolar haemorrhage and haemoptysis)

acute myocarditis

Definition Myocarditis is an inflammatory disease of the myocardium. It is sometimes concurrent with inflammation of the pericardium, in which case it is referred to as myopericarditis. Clinical Features The range of signs and symptoms is broad, reflecting the variability in extent of myocardial involvement. Typically, patients present with cardiac-type chest pain, fatigue, palpitations, and symptoms of heart failure. Myocarditis can in some cases present with sudden unexplained cardiac death. Examination findings are non-specific. Signs of heart failure may be evident (along with S3 and S4 gallops). If pericarditis is associated, auscultation can reveal a pericardial friction rub. Investigations ECG demonstrates non-specific ST segment and T wave changes (which may be regional, depending on degree and location of myocardial involvement), along with ectopic beats and arrhythmias if present. Troponin enzymes can be markedly elevated. Echocardiogram can reveal ventricular dysfunction if present, in the form of diastolic dysfunction or regional wall motion abnormalities. Cardiac MRI findings can help confirm the diagnosis of myocarditis by showing the presence and extent of inflammation. Endomyocardial biopsy via cardiac catheterisation is the gold standard diagnostic tool, but is associated with its own risks as it is an invasive test. Management Treatment involves addressing the underlying cause alongside supportive management. ITU support may be required as patients may require vasopressors. Corticosteroids are sometimes considered in a select group of patients with viral myocarditis. After recovery, patients should be advised to limit activity for a few months.

pid

Definition Pelvic inflammatory disease (PID) occurs when infection spreads from the vagina through into the cervix and then into the upper genital tract. Epidemiology The largest UK study, based on only 147 women at one location, indicated that 39% (95% CL 29% to 49%) of PID cases were caused by C trachomatis and 14% were caused by gonorrhoea. Aetiology It is spread sexually but sometimes no pathogen can be isolated. Gonorrhoea and Chlamydia cause 20% but there are also numerous anaerobic bacteria involved. Clinical features The diagnosis is made clinically. Symptoms include: bilateral abdominal pain, discharge, post coital bleeding. Signs include: Adnexal tenderness, cervical motion tenderness on bi-manual, fever 10% of patients present with RUQ, which is secondary to inflammation of the liver capsule, also known as Fitz Hugh Curtis syndrome Investigations Investigations include pelvic examination, pregnancy test, swabs for gonorrhoea and chlamydia, bloods and transvaginal ultrasound Management Treatment occurs in the outpatient setting, and involves ofloxacin + metronidazole Analgesia may also be required, and the patient is reviewed in 4 weeks All young sexually active women complaining of bilateral lower abdominal pain with adnexal tenderness are given empirical treatment for PID, due to the significant number of women that are not diagnosed. Complications of PID The complications of PID include: Chronic pelvic pain (40%) Infertility (15%) Ectopic pregnancy (1%) Fitz-Hugh-Curtis syndrome features Fitz-Hugh-Curtis syndrome occurs when adhesions form between the anterior liver capsule to the anterior abdominal wall or diaphragm, on a background of pelvic inflammatory disease. Liver function tests are often normal. An abdominal ultrasound should be used to exclude stones. Laparoscopy is required for a definitive diagnosis and treatment involves the use of antibiotics.

pjp

Definition Pneumocystis Pneumonia (PCP) is an infection with the fungus Pneumocystis Jiroveci. It is a common presentation associated with individuals with HIV who are noncompliant with their cART regimens or antibiotic prophylaxis. Clinical features The patient can present with: Fever Non productive cough (however can have superimposed bacterial infection causing a productive cough) Exertional breathlessness associated with onset of infection Exertional breathlessness is a specific sign for PCP, and is used to stratify severity. On examination, the chest is often clear, however sometimes there are end inspiratory crackles present. Investigations Chest x-ray commonly shows bilateral bihilar interstitial infiltrates. In 10% of cases, the chest x-ray is normal. If a chest x-ray is normal and PCP is suspected, a high resolution CT can be requested, to look for cysts and nodules. The definitive diagnostic investigation is bronchoscopy with bronchoalveolar lavage. Induced sputum samples can be used, but this is a less specific diagnostic investigation. Samples are stained using Grocott's silver stain, which shows a characteristic "Mexican hat" appearance. Blood gas measurements are used to define severity of disease. If the patient has a p02 <9.3kPa and an arterial alveolar 02 gradient >4.7kPa, is it important to consider adjuvant corticosteroids. This has a proven reduction of mortality. Management Treatment is based on clinical or radiological evidence of infection or clinical indicators of general immune deficiency. PCP is treated with antibiotics such as co-trimoxazole. Alternative therapy can be used if co-trimoxazole does not eliminate infection. This includes clindamycin-primaquine, dapsone, IV pentamidine.

primary hiv infection

Definition Primary HIV infection is the period immediately after initial exposure to the virus. Clinical features Most people with primary HIV infection clinical experience a mild flu-like illness 2-6 weeks after infection, which can range from a mild glandular fever to an evolving encephalopathy Classically, patients present with fever and lymphadenopathy. Other common features are a maculopapular rash, found commonly on the upper chest, and mucosal ulcers. Other symptoms may include myalgia, arthralgia and fatigue. Onset of symptoms within 3 weeks of infection that last for longer than 2 weeks or that involve the CNS are associated with a rapid progression to AIDS. Asymptomatic infection may also occur. Diagnosis and management Diagnosis is via serum HIV enzyme-linked immunosorbent assay (ELISA), with a positive result confirmed using a second test. Additional tests should include a HIV viral load, full blood count, lymphocyte subset panel including CD4 count, screening for other sexually transmitted infections such as chlamydia, gonorrhoea and syphilis, screening for viral hepatitis, kidney function, liver function, glucose, lipids. All patients should be offered combination antiretroviral therapy (cART), regardless of CD4 count. Contact tracing is also required.

whipple's disease

Definition Whipple's disease is a rare, systemic condition caused by Tropheryma whipplei. Presentation The disease primarily presents with diarrhoea, abdominal pain and joint pain, but can affect any part of the body including the cardiac and nervous systems. Investigations Whipple's disease is more common in males. Diagnosis is with a small bowel biopsy, which shows the presence of acid-Schiff (PAS)-positive macrophages, which are seen to contain the causative bacteria on electron microscopy. Management Treatment is with a long term course of co-trimoxazole.

bartholins gland

Definitions Bartholin's glands are situated within the vestibule, just lateral to the introitus and normally function to secrete a lubricating fluid. Bartholin's gland cyst: occurs when the duct from the gland becomes blocked, resulting in palpable swelling and pain at the site of the Bartholin's gland Bartholin's gland abscess: occurs when a cyst becomes infected, resulting in extreme pain, lymphadenopathy, erythema and in rare cases, systemic upset. Management of Bartholin's gland cyst Incision and drainage: under local anaesthetic, the swollen gland is incised and allowed to drain. A Word catheter may also be inserted to promote continued drainage Antibiotics in cases of abscess Salt water baths may relieve pain Surgery may be required in recurrent cases

pathophysiology of achalasia

Degeneration of ganglion cells in myenteric plexus The statement described above suggests a diagnosis of achalasia which is characterised by failure of relaxation of the lower oesophageal sphincter due to progressive degenerative of the ganglion cells in the myenteric plexus. The management of achalasia may include pneumatic dilation, Heller myotomy, botulinum toxin injections, calcium channel blockers and nitrates. 57%

duodenal atresia x-ray

Duodenal atresia There are many causes of bilious vomiting in a newborn; however, this case's radiological findings and treatment are consistent with intestinal malrotation, which has led to volvulus. Duodenal atresia is another congenital malformation, which classically causes a 'double bubble' sign on abdominal x-ray. 25%

A 45-year-old male is admitted to the acute medical unit with lethargy and dehydration secondary to severe gastroenteritis. He is normally fit and well, but has recently had reduced mobility, given his condition. He discloses that his grandfather suffered from a pulmonary embolism (PE) some years back. He is started on prophylactic enoxaparin to prevent a deep venous thrombosis (DVT). Which history or examination finding has indicated thromboprophylaxis is necessary?

Dehydration As a medical patient with reduced mobility, he requires further assessment, where thrombosis risk is weighed against bleeding risk. Dehydration is a thrombosis risk, and thromboprophylaxis is indicated in the absence of any bleeding risks. 13%

deprivation of liberty

Deprivation of Liberty Article 5 of the Human Rights Act states that 'everyone has the right to liberty and security of person. No one shall be deprived of his or her liberty [unless] in accordance with a procedure prescribed in law'. There is likely a deprivation of liberty if: The person is subject to continuous supervision and control and The person is not free to leave The Deprivation of Liberty Safeguards The Deprivation of Liberty Safeguards is the procedure in law used where it is necessary to deprive a patient or resident of their liberty as they lack capacity to consent to treatment or care to keep them safe from harm. These procedures must be authorised by a supervisory authority e.g. local authority. The following conditions must be met to allow a person to be deprived of their liberty under the safeguards: The person must be 18 or over. The person must be suffering from a mental disorder. The person must be a patient in hospital or a resident in a care home. The person lacks capacity to decide for themselves about the restrictions which are proposed so they can receive the necessary care and treatment. The proposed restrictions would deprive the person of their liberty. The proposed restrictions would be in the person's best interests. Whether the person should instead be considered for detention under the Mental Health Act. There is no valid advance decision to refuse treatment or support that would be overridden by any DoLS process. Capacity All patients are initially assumed to have capacity Capacity is decision-specific e.g. a patient may be able to decide which clothes to wear, but not where is safest to live Capacity can be impaired permanently, temporarily, or can fluctuate Patients deemed to have capacity are freely able to make decisions that the healthcare provider thinks unwise or dangerous The Mental Capacity Act The mental capacity act haas five key principles: Every adult is assumed to have capacity unless proved otherwise A person must be given all practicable help to make their own decisions before they are deemed to lack capacity Unwise, unsafe or dangerous decisions does not mean that person does not have capacity. All treatment given to a person who lacks capacity must be in the patients best interests Anything done for a person who lacks capacity must be done in the least restrictive way possible Power of attorney This is a legal document drawn up by a competent adult that nominates another person to make decisions on their behalf. This can be related to financial and property, or health and welfare. It can only be used when that adult has lost capacity. # Advance directives An advance directive is a medical decision made by a patient with capacity, regarding their future wishes for treatment. It only comes into force if a patient subsequently lacks capacity.

where are dermoids found

Dermoid cyst A dermoid cyst is a small, often painless, lump which contains epithelial lining so can grow hair or teeth. They are typically found in the head and neck, most commonly affecting frontal, occipital, and supraorbital areas. The outer third of the eyebrow is the most common place for these cysts. They have a yellow tinge to them and are often diagnosed at birth. The cyst in this scenario presents in the wrong area of the head to be a dermoid cyst. 16%

A 55-year old male presents to the emergency department with acute back pain and reports that he has been struggling to walk. He has tried analgesia which did not help. He has a background of prostate cancer, treated via the 'watch-and-wait' approach. On examination, he has bilateral weakness in his lower limbs and is unable to walk. He informs you with embarrassment that he lost control of his bowels within the toilet and soiled himself. What would be the next best step in the management for this patient?

Dexamethasone This is a likely case of spinal cord compression. It needs to be treated with IV steroids before an MRI. 43%

A 45-year-old male presents to the emergency department with severe shortness of breath and hypoxia, requiring supplemental oxygen. He is obese and has type 2 diabetes. He reports a cough and high fever for the last 4 days, associated with myalgia and anosmia. What is the most appropriate initial treatment?

Dexamethasone and remdesivir This patient is likely suffering from Covid-19 and requires supplemental oxygen; such patients should be treated with a combination of dexamethasone and remdesivir. 50%

when to add dex to dka mx

Diabetic ketoacidosis: once blood glucose is < 14 mmol/l an infusion of 10% dextrose should be started at 125 mls/hr in addition to the saline regime

A 26-year-old woman presents to her GP with a history of infrequent menstruation. She uses a period tracking app on her phone, which demonstrates that she had five periods in the last 12-month period, each at random intervals.On further questioning, she describes the growth of thick, dark hair on her upper lip and neck. She has been suffering from worsening acne for several years.Given the likely diagnosis and assuming other causes are ruled out, what is required in order for the patient to meet the diagnostic criteria?

Diagnosis can be made clinically based on her symptoms is correct. The patient is likely to be suffering from polycystic ovary syndrome (PCOS). For a diagnosis of PCOS to be made, 2 out of 3 of the following must be present: Infrequent or no ovulation (usually manifested as infrequent or no menstruation). Clinical and/or biochemical signs of hyperandrogenism (such as hirsutism, acne or elevated levels of total or free testosterone). Polycystic ovaries on ultrasound scan.

A 75-year-old lady with newly diagnosed end-stage renal failure has her first haemodialysis session. During the dialysis, she rings the nursing bell due to a new headache and vomiting. The nurse checks her observations which show a heart rate of 45 and a blood pressure of 190/92. She rapidly deteriorates and develops irregular breathing. What is the most likely diagnosis?

Dialysis disequilibrium syndrome Dialysis disequilibrium syndrome is a rare but potentially fatal complication of haemodialysis, particularly in patients who are starting it. Patients may develop cerebral oedema. This is thought to be due to rapid shifts in urea, an osmotically active substance, between different fluid compartments during haemodialysis. In cerebral oedema, there is raised intracranial pressure, which is suggested here by the headache, vomiting and Cushing's triad - low heart rate, raised blood pressure (with wide pulse pressure) and irregular breathing. 84%

An 80-year-old female has just been diagnosed with dry age-related macular degeneration. Which complaint is she likely to have presented with?

Difficulty reading text This is the correct answer. It is the typical finding in dry AMD, which is what this patient has. Difficulty in reading text and recognising faces, and problems with vision in dim light are typical features of dry AMD. 66%

A 64 year old lady is brought to A&E with nausea and vomiting. Her daughter says that she complained of some palpitations earlier and has become quite confused which is abnormal for her. Her ECG shows bradycardia with prolonged PR interval and QRS complexes. A blood gas shows a high serum potassium. She has a background of atrial fibrillation, chronic heart failure and recently diagnosed dementia. She is on furosemide, apixaban, bisoprolol and digoxin. What is the most likely cause for this lady's presentation?

Digoxin toxicity There are many aspects of this case which point towards a diagnosis of digoxin toxicity: nausea and vomiting, bradycardia with prolonged PR intervals and QRS complexes on ECG, and high serum potassium. It is likely that this lady forgot that she took her digoxin due to her dementia and accidently took an overdose. The treatment for digoxin toxicity is a monoclonal antibody which can bind to and remove digoxin from the body. 89%

A 66-year-old man attends his GP with a painful lump in his scrotum. The lump first appeared 3 days ago and has been growing in size and becoming increasingly painful. He denies urinary symptoms, fever, weight loss and night sweats. His past medical history includes hypertension and COPD. On examination, there is a tender, erythematous mass in the right hemi-scrotum. It is not possible to get above the mass and transillumination test is negative. What is the most likely diagnosis?

Direct inguinal hernia Any scrotal lump that you cannot get above on examination immediately points towards an inguinal hernia as a likely diagnosis. Occasionally, a hydrocele extending proximally may also present like this, but this would be positive for transillumination. In this case, the patient most likely has a direct inguinal hernia as he is elderly and likely has a chronic cough due to his COPD. As the hernia is erythematous and tender, it has likely become incarcerated. 34% Indirect inguinal hernia Indirect inguinal hernias would have similar examination findings, but are usually congenital and would rarely present in a patient this age. 34%

Discitis

Discitis is an infection in the intervertebral disc space. It can lead to serious complications such as sepsis or an epidural abscess.Features Back pain General featurespyrexia,rigorssepsis Neurological featurese.g. changing lower limb neurologyif epidural abscess develops Causes BacterialStaphylococcus aureus is the most common cause of discitis Viral TB Aseptic Diagnosis Imaging: MRI has the highest sensitivity CT guided biopsy may be required to guide antimicrobial treatment Treatment The standard therapy requires six to eight weeks of intravenous antibiotic therapy Choice of antibiotic is dependent on a variety of factors. The most important factor is to identify the organism with a positive culture (e.g. blood culture, or CT guided biopsy) the patient should be assessed for endocarditis e.g. with transthoracic echo or transesophageal echo. Discitis is usually due to haematogenous seeding of the vertebrae implying that the patient has had a bacteraemia and seeding could have occurred elsewhere Complications sepsis epidural abscess

A 73-year-old woman is seen in the emergency department with abdominal pain. She has had difficulty moving her bowels for the past couple of days and has been feeling increasingly unwell with pain in her lower abdomen that is worse on the left side. She was due to be seen in the general surgery outpatient clinic for chronic PR bleeding. On examination, she is febrile and tachycardiac. Her abdomen is peritonitic and there is a firm, tender mass in the left iliac fossa. PR examination is unremarkable. What is the most likely diagnosis?

Diverticular abscess A tender mass in the left iliac fossa, in the context of a history of PR bleeding, is most likely a diverticular abscess. This patient has become increasingly well unwell with diverticulitis and an abscess has formed. She will need prompt treatment for sepsis and most likely require emergency surgery. 69%

A 25 year old man attends the GUM clinic. He comments that he noticed a cloudy genital discharge that started this morning. An urethral swab is taken and the microscopy results show 6 polymorphs per high power field. Given the most likely diagnosis, what is the appropriate management for this patient?

Doxycycline This is the correct answer. If a smear displays 5 or more polymorphs per high power field, with no evidence of gram negative diplococci, the current guidance is to treat for chlamydia infection empirically with Doxycycline. If Doxycycline is contraindicated then azithromycin, ofloxacin and erythromycin are possible alternatives If you have a bloke with urethritis the two most common causes are Chlamydia (which doesn't show up on gram stain) and Gonorrhoea (gram neg diplococci). If on gram staining you only see polymorphs and no organism, it's probably not gonorrhoea. We call this NGU (non-gonococcal urethritis). The most likely cause of this is Chlamydia but other bugs like Mycoplasma genitalium can cause it too. Thankfully they both respond to Doxycycline so we prescribe this empirically, and wait for further NAAT testing to confirm the actual organism. If it turns out to be M Gen we'll call them back after a week for a further course of azithromycin. Hope this helps :)

A 20 year old female attends her local sexual health drop in service for a routine asymptomatic sexual health screen. She is currently sexually active with one male partner and has a Mirena intrauterine system in situ for contraception. Her self-taken vaginal swab reveals infection with Chlamydia trachomatis What is the most appropriate action?

Doxycycline 100 mg twice a day for 7 days, leave Mirena in situ There is no need to remove an intrauterine device in cases of uncomplicated asymptomatic chlamydia infection. Treatment is the same regardless of if an intrauterine device is in situ or not 48%

An 85 year old woman presents to the GP with a six week history of pain and early morning stiffness in the shoulders and hips. She is diagnosed with polymyalgia rheumatica and started on steroids. What further scan should the GP consider doing?

Dual-energy X-ray absorptiometry (DEXA) Polymyalgia rheumatica is an inflammatory condition that classically presents as morning shoulder and hip girdle stiffness in patients over 50. It is treated with long term steroids, which can lead to loss of bone density, osteoporosis and even fractures. Therefore, following initial investigations, a DEXA scan should be considered to assess fracture risk. This is advised for patients with major risk factors for osteoporosis, including age (>65 years for women and >75 years for men), previous fragility fracture, long-term steroid use, low body mass index, or other risk factors for secondary osteoporosis. 78%

A 55-year-old lady presents to the GP with nipple changes. Over the past two months, she has noticed that her left nipple has developed an itchy rash. On examination, there is a dry, erythematous rash around the left nipple. On palpation, there is a lump underneath the nipple. Which of the following is most likely to be the underlying diagnosis?

Ductal carcinoma in situ (DCIS) This patient presents with symptoms of Paget's disease of the nipple. Symptoms include an erythematous, scaly, itchy rash that resembles eczema. In addition, the nipple may be retracted or inverted, and there may be a breast lump. Although not cancerous itself, Paget's disease of the nipple is commonly associated with underlying breast cancer, the most common of which is ductal carcinoma in situ (DCIS). 57%

A 55 year old female presents with persistent swelling, discomfort and itchiness of her legs for six months. The pain is worse at the end of the day and is relieved by elevating the leg. She has a background of hypertension and coronary artery disease. Examination shows bilateral pitting oedema to the mid-shin. There are scratch marks and brown discoloration across the lower limbs. Several dilated, tortuous veins are found on the posterolateral part of the legs. Peripheral pulses are palpable bilaterally. Which of the following is most likely to establish the diagnosis?

Duplex ultrasonography Chronic dull pain, discomfort, pruritus with skin changes (hemosiderin, oedema) suggest chronic venous insufficiency. The dilated tortuous veins are suggestive of varicose veins due to venous valve incompetence. As venous pressure rises, the veins become varicose and leak inflammatory substances into the interstitium. Duplex ultrasonography can pick up bidirectional blood flow in the superficial veins instead of unilateral blood flow from the superficial to the deep system. 73%

A 69-year-old male presents to the emergency department with a two hour history of tearing central chest pain. He has a background of hypertension, type 2 diabetes and COPD. His observations are: respiratory rate 33, oxygen saturations 95% on room air, heart rate 153, blood pressure 88/68, temperature 37.2. On examination, there is a diastolic murmur, heard loudest over the 2nd intercostal space at the right sternal edge. The patient has a chest x-ray which shows a widened mediastinum. Which of the following investigations would be most appropriate for this patient?

Echocardiogram The patient is presenting with a suspected aortic dissection. He has a diastolic murmur (suggesting aortic regurgitation) and a widened mediastinum on his chest x-ray. As the patient is haemodynamically unstable, an immediate echocardiogram is required to provide the diagnosis. This can be done at the bedside. If he were stable, an urgent CT angiogram of the chest, abdomen and pelvis would be the first-line imaging test. 36%

A newborn baby is examined by the paediatrician after birth. The main findings on examination are low-set ears, microcephaly and omphalocele. What is the most likely diagnosis?

Edwards syndrome Edwards syndrome is caused by trisomy 18. Patients may have structural heart defects such as a ventricular septal defect. Other features include oesophageal atresia, omphalocele (intestines protruding outside the body), microcephaly (a small head), low-set ears and overlapping digits. 30% Patau syndrome Patau syndrome is caused by trisomy 13. Common features include microcephaly, intellectual disability, cleft palate and polydactyly (extra digits). The features mentioned in this case are more in line with a diagnosis of Edwards syndrome. 29%

A 26 year old woman presents to the sexual health clinic requesting emergency contraception after an episode of unprotected sexual intercourse (UPSI) the previous evening. She has no significant past medical history. She is on day 19 of a regular 26-day cycle. She has had one other episode of unprotected sexual intercourse on day 13 of her cycle. Which of the following is the most appropriate management plan for her?

Ella One The patient has had 2 UPSI's. The first UPSI is over 5 days ago, therefore no emergency contraception can be given. However, for the 2nd UPSI, the patient can have Ella One and it will not harm the existing pregnancy. The patient should still be advised to take a pregnancy test for the first UPSI. preg test in 3 weeks time

A 62 year old male with a history of hypertension presents to the Emergency Department with sudden onset of severe chest pain. He reports that the pain radiates to his back and is associated with shortness of breath and diaphoresis. Physical examination reveals a pulse deficit and a blood pressure difference between the right and left arms. A chest x-ray shows double aortic contour. Which of the following is the most appropriate management for this patient?

Emergency surgical intervention Aortic dissection is a life-threatening condition that occurs when there is a tear in the inner layer of the aorta, leading to the formation of a false lumen. This can cause the aorta to expand and potentially rupture, leading to severe bleeding and death. Management depends on the type of dissection. The patient here displays signs of a type A dissection (involving the ascending aorta) with features of an upper extremity pulse deficit. This usually requires surgical management with the use of stents or grafts to repair the damaged aorta. 84%

A 49-year-old male presents following a road traffic accident and is undergoing surgery via rapid sequence induction. What reading is used to confirm intubation?

End-tidal CO2 This is confirmation that the tube is in the right location. It measures the partial pressure of CO2 at the end of expiration. It is built into the ventilators used in anaesthetics. 82%

what cancers are you at increased risk of developing with lynch syndrome

Endometrial Patients with Lynch syndrome, as well as having a high risk of colorectal cancer, are at a higher risk of developing endometrial cancer. They are also at risk of developing breast, prostate and gastric cancer. 63%

A 28-year-old man attends following the consumption of half a bottle of bleach in an attempt to end his own life. On examination, he has a hoarse voice and a visibly red and ulcerated oropharyngeal mucosa.How should this patient be managed?

Endoscopy is correct. The patient has had a significant injury due to the ingestion of a corrosive substance. Drooling, dysphagia, vomiting, severe pain, haematemesis, stridor and extensive oropharyngeal burns are associated with more severe injuries and indicate the need for urgent imaging/endoscopy. Both CT scan and fibreoptic endoscopy are useful in assessing the severity of injury, risk of mortality, and risk of subsequent stricture formation. These 2 imaging modalities are complementary and provide the best understanding of the injury and risk when combined. If there are severe clinical features, then endoscopy is best performed by a surgeon capable of undertaking definitive treatment.

A 24-year-old man presents to the general practice with a 1-day history of diarrhoea and abdominal pain. He says the diarrhoea is profuse and watery with associated abdominal pain. He arrived back from Senegal last night. What is the most likely responsible pathogen?

Enterotoxigenic Escherichia coli Enterotoxigenic E. Coli, also known as traveller's diarrhoea, usually presents within 12-24 h of exposure to the pathogen and presents with crampy abdominal pain and profuse watery diarrhoea. It has a higher incidence in many countries particularly across Africa and Asia. 44%

A 67 year old homeless man presents to the Emergency Depratment after a sudden onset weakness of his right arm and leg. He is currently alert but unable to recall the events leading up to his admission. Neurological examination also reveals a positive Romberg's sign, bilateral hyporeflexia of his lower limbs and upgoing plantars. He has reduced vibration and joint position sensation of both lower limbs. Cardiovascular examination reveals an early diastolic murmur loudest over the upper right sternal edge. He has multiple hyperpigmented lesions on his shins with central necrosis. Which of the following investigations is most likely to confirm the underlying diagnosis?

Enzyme immunosorbent assay (EIA) This is the initial screening tool used for syphilis. This patient has features of tertiary syphilis, as seen from his neurological signs (stroke, sensory ataxia, proprioceptive loss, mixed upper and lower motor neuron signs), cardiac signs (aortic regurgitation), cutaneous granulomas and dementia Echocardiogram This can be used to investigate the severity of aortic valve regurgitation and to exclude features of infective endocarditis. However, the additional presence of dementia, cardiac and skin signs point to an overarching diagnosis of tertiary syphilis 12%

genital herpes

Epidemiology In England, there were 31,777 diagnoses of first episode genital herpes in 2014. This represented 7% of new diagnoses of a sexually transmitted infection (STI). 42% of those diagnosed with genital herpes are 15-24 years of age. Aetiology Genital herpes is an infection caused by one of the herpes simplex viruses: HSV-1 (the usual cause of oral herpes and now the most common cause of genital herpes in the UK) HSV-2 (historically the most common cause of genital herpes in the UK, more likely to cause recurrent anogenital symptoms) Clinical features of HSV Infections caused by HSV1 and HSV2 are clinically indistinguishable. Not all individuals will display symptoms at the time of acquisition. May be entirely asymptomatic Multiple painful genital ulcers Dysuria Vaginal or urethral discharge Lesions typically crust and heal, at which point virus ceases to be shed from the lesions. In some cases may have symptoms of fever, malaise, headache and urinary retention. Recurrent episodes are usually less severe than a primary episode. There may not be a clearly identifiable trigger. The recurrent episode may have a prodromal phase, such as tingling. Diagnosis Diagnosis can be made clinically from history and examination The most effective method of diagnosis is to obtain a swab from the base of the ulcer and analyse using nucleic acid amplification tests (NAATs). Transmission of herpes simplex HSV is transmitted from skin-to-skin. The virus can be shed in the prodromal phase and during phases of recurrence or when displaying clinical symptoms for the first time. Virus can also be shed when the patient is asymptomatic The current guidance advises patients to abstain from sex during clinical recurrence or when they are experiencing prodromal symptoms. Management Oral antivirals are the primary treatment for genital herpes simplex infection — treatment should commence within 5 days of the start of the episode, or while new lesions are forming for people with a first clinical episode of genital herpes simplex virus (HSV). Common regimes: Aciclovir 400 mg three times daily for 5 days Valaciclovir 500 mg twice daily for 5 days Aciclovir 200 mg five times daily for 5 days Famciclovir 250 mg three times daily for 5 days Analgesia such as topical lidocaine may be required for symptomatic relief.

hh4

Epstein-Barr virus

rheumatic fever mx

Eradication of group-A beta-haemolytic streptococcal infection STAT dose of IV Benzylpenicillin, with a ten day course of Phenoxymethylpenicillin to follow Analgesia for arthritic symptoms Aspirin or non-steroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen or naproxen. Aspirin should be used with caution in young children due to the small risk of Reye syndrome. There is no evidence to suggest that NSAIDs help with outcomes related to carditis. If carditis is complicated by heart failure Glucocorticoids (e.g. Prednisolone) can provide benefit (NSAIDs should be stopped concurrently). Diuretic treatment may also be necessary, and valve surgery if severe. Sydenham's chorea is self-limiting and does not require treatment, however Haloperidol or Diazepam may be used for distressing symptoms or risk of harm. Erythema marginatum is associated with rheumatic fever is temporary and doesn't require treatment, although antihistamines can help with pruritus.

A 50-year-old male presents to his GP with polyarthritis, malaise and myalgia, which started following a hiking trip two months ago. He remembers having a rash on his arm during the trip, but this has disappeared. He has a background of type 2 diabetes but is otherwise normally fit and well. What type of rash did he most likely have?

Erythema migrans This patient likely has borreliosis (Lyme disease). This tick-borne disease usually presents with flu-like symptoms in the early stages before progressing to disseminated disease, of which arthritis is an early symptom. Erythema migrans is a classic finding in the early localised phase of Lyme disease (although not every patient will have or remember it). 56%

A 56-year-old gentleman with a background of alcohol dependence and liver cirrhosis is brought urgently to the emergency department following a two-hour history of abdominal pain and fever. On examination, mild abdominal tenderness is evident. A diagnosis of spontaneous bacterial peritonitis is suspected. Which of the following organisms is most likely to be found in the ascitic fluid culture?

Escherichia coli Gram-negative rods such as Escherichia coli and Klebsiella pneumoniae are the most common bacteria associated with spontaneous bacterial peritonitis. 65%

A 25-year-old woman presents to the delivery suite with regular painful contractions. She is 39 weeks pregnant with her first baby and has had no complications so far in her pregnancy. A vaginal examination is performed by one of the midwives, which reveals cervical dilatation of 8cm. She is getting contractions every 5-6 minutes and describes these as painful. What stage of labour is this patient in?

Established first stage of labour Established first stage of labour describes the period when there are regular painful contractions and progressive cervical dilatation from 4cm. 60%

A 32-year-old female has been diagnosed with tuberculosis and started on a medication regimen. She is now complaining of changes to her red-green colour vision. Which medication is responsible for this?

Ethambutol Ethambutol may cause disturbances in vision, in particular red-green colour detection. 79%

A 55-year-old female presents to the emergency department with a mild haematoma to her right thigh following a fall. Blood testing reveals the following: Prothrombin time (PT): 13.1s (normal 12.0-14.8s) Activated partial thromboplastin time (APTT): 52s (normal 27.0-41.0s) She mentions she is on "blood thinners," and that her father also has easy bruising. What assays will definitively reveal the diagnosis?

Factor XI assays The highly likely non-X-linked nature of this condition points to haemophilia C rather than haemophilia A or B. NaN%

A 59-year-woman presents to her General Practitioner with an eight-month history of vaginal bleeding. She says this occurs almost daily and has progressed from a brown discharge to dark red blood. She has also lost approximately 3kg in weight in the past six months, with no major changes to her diet. An endometrial biopsy confirms endometrial cancer, and she is referred for further investigations. Which of the following is used to stage endometrial cancer?

FIGO staging The FIGO staging system is used to stage endometrial and ovarian cancers. It ranges from stage 0, which refers to carcinoma in situ, to stage 4, which refers to cancer associated with distant metastases. 52%

A 52-year-old gentleman with recurrent peptic ulcer disease presents to the general practitioner with a 3-month history of worsening epigastric pain, acid reflux and diarrhoea. He has been taking omeprazole for the past 2 months, which unfortunately has not helped to resolve his symptoms. A provisional underlying diagnosis of Zollinger-Ellison syndrome is suspected. Which of the following is used as a screening test for Zollinger-Ellison syndrome?

Fasting serum gastrin level Fasting serum gastrin level is used as a screening test for Zollinger-Ellison syndrome. A raised fasting serum gastrin level suggests a diagnosis of Zollinger-Ellison syndrome. 65% Somatostatin receptor scintigraphy Somatostatin receptor scintigraphy is the best imaging modality for Zollinger-Ellison syndrome, as a small adenoma is often difficult to image via computed tomography (CT) scan. 13%

A 27-year-old woman presents to the GP with a new breast lump. She noticed it first after a mild car accident a few weeks ago. On examination, a small, painless lump is present in her right breast. It feels irregular to touch and appears immobile and fixed to the underlying tissues. There is no history of breast cancer in her family, and she has never had children. She is referred to the breast clinic. What is the most likely diagnosis?

Fat necrosis of the breast Fat necrosis of the breast is a benign lump caused by inflammation of the breast lump following trauma. It can present as a firm round lump but can also be irregular and tethered. It can sometimes be hard to distinguish between fat necrosis and breast cancer, so a referral to a breast clinic for histology is vital. 87%

A 74-year-old female presents to her GP with a 4-month history of progressive facial swelling and weight loss. On examination, there is obvious macroglossia and a mild purpuric rash concentrated around the periorbital regions. The liver edge is palpable 2cm below the costal margin. She also has pedal oedema, and urinalysis reveals +++ protein. Which test will confirm the likely primary diagnosis?

Fat pad biopsy with Congo-red staining The patient likely has primary amyloidosis, characterised by the deposition of abnormal amyloid proteins. As a result, she has symptoms of nephrotic syndrome. Periorbital purpura is not always seen, and macroglossia is not a feature of secondary amyloidosis but is often a result of inflammatory bowel disease or rheumatoid arthritis. Diagnosis of amyloidosis is by tissue biopsy (most often the abdominal fat pad) and Congo-red staining under polarised light; the amyloid proteins will appear "apple green." 33%

A 70 year old man notices a painless lump in his right groin associated with pressuring sensation. His past medical history is significant with hypertension. Examination shows a lump right below the inguinal ligament and it is pulsatile. What is the most likely diagnosis?

Femoral artery aneurysm A painless lump in the groin that is pulsating suggests femoral artery aneurysm. It is the second most common aneurysms of the peripheries after popliteal aneurysms. 62% Saphena varix Saphena varix is caused by varicose dilatation of the saphenous vein at the saphenofemoral junction of the groin. Signs of varicosities may be appreciated at the other parts of the legs, which is not mentioned here. 17%

A 39-year-old lady attends a follow-up appointment after being started on ramipril for a new diagnosis of hypertension. Her baseline blood pressure before starting ramipril was 155/98 and a blood test showed normal renal function. Today, her blood pressure is 158/102 and repeat blood tests show significantly worsening renal function. What is the most likely underlying cause of her hypertension?

Fibromuscular dysplasia Fibromuscular dysplasia most commonly occurs in women under the age of 50. It occurs when there is thickening and narrowing within the walls of arteries which can lead to renal artery stenosis. It often presents as treatment-resistant hypertension and deteriorating renal function after the patient is started on an ACE inhibitor. 28% Atherosclerotic renal artery stenosis The treatment-resistant hypertension and worsening renal function after starting an ACE inhibitor is suggestive of renal artery stenosis. In most cases, atherosclerosis is the cause. However, in young women under 50, fibromuscular dysplasia is most common. 52%

A 23 year old female presents to her GP complaining of a 3 day history of abdominal pain, purulent vaginal discharge and dyspareunia. A vaginal swab is sent for culture, which grows gram negative cocci which appear in pairs. NAAT testing is negative for Chlamydia trachomatis. Which of the following is a rare but potentially serious complication of this disease?

Fitz-Hugh-Curtis syndrome Fitz-Hugh-Curtis syndrome is a type of peri-hepatitis that causes inflammation of the liver capsule, resulting in adhesions. It may occur secondary to Neisseria gonorrhoeae infection, and more rarely Chlamydia trachomatis infection 52%

A 59 year old male comes to the emergency department with severe abdominal and lower back pain. He has a background of type 2 diabetes mellitus and hypertension. He is a lifelong smoker. Observations shows that his pulse rate is 120 beats per min, blood pressure 70/50 mmHg, SpO2 92% on air and temperature of 37.5 degrees Celsius. There are no airway noises and the chest sounds clear. Abdominal examination reveals an expansile and pulsatile mass. His calves are soft and non-tender. What is the most appropriate initial management?

Fluid resuscitation to bring systolic blood pressure to 90mmHg This patient's presentation is typical for ruptured abdominal aortic aneurysms (severe abdominal and lower back pain, tachycardia, hypotension, expansile mass). Immediate fluid resuscitation with 0.9% normal saline to raise blood pressure to 90mmHg (permissive hypotension) is immediate first line treatment to keep vital organs perfused until definitive measures can be done. 39% Urgent operative repair In patients with ruptured abdominal aortic aneurysms, the vascular team will be summoned for emergency operation. Appropriate resuscitative measures are usually initiated first. 35%

A 47-year-old male presents to his GP with swelling of his legs which he first noticed two months ago. Recently, he has been feeling very fatigued and tired. On examination, there is xanthelasma on the eyelids and the patient has bilateral peripheral oedema. The GP arranges blood tests and a urine dipstick. His blood results show the following: FBC: Hb 120, MCV 82, WCC 6.7, platelets 289 U+Es: sodium 133, potassium 4.7, urea 11.9, creatinine 187 LFTs: bilirubin 3, ALT 26, ALP 57, albumin 19 The urine dipstick is positive +++ for protein. What is the most likely diagnosis?

Focal segmental glomerulosclerosis (FSGS) FSGS is a type of nephrotic syndrome. Key features of nephrotic syndrome are proteinuria, hypoalbuminemia, and peripheral oedema. Patients may also have hypercholesterolaemia (suggested by the xanthelasma). A renal biopsy would provide the definitive diagnosis. 68%

A 3 year old boy is brought into the Emergency Department by his father. He was found choking and back slaps did not help. On examination, his nostrils are flaring his lips are blue. A chest x-ray shows a round, symmetrical opacity in the right main bronchus. What is the most likely cause of this presentation?

Foreign body A foreign body is the most common cause of this presentation, as toddlers are known to ingest all sorts of objects. Based on the chest x-ray findings, it is likely that they have swallowed a small, round object such as a coin. The right main bronchus is the commoner site for ingested foreign bodies compared to the left, as it is wider and straighter. 94%

A 32-year-old female is playing cricket when the ball is hit into her eye. She presents to you with pain, diplopia and limitation of her eye movement. On examination, you note enophthalmos. What is the most likely diagnosis?

Fracture of the ethmoid bone The vignette above describes a orbital blow out fracture. This is commonly caused by sports injuries, as in the case described. The pressure from the force causes fracture of the orbital floor. The ethmoid bone forms the medial wall of the orbit, which is commonly fractured as it is very thin. 44% Globe laceration This describes a penetrating injury to the eye, which is not the mechanism of injury described above. 7% Globe rupture Globe rupture is another consequence of trauma to the eye. However, it presents differently e.g. thick subconjunctival haemorrhage, teardrop pupil. 27% Retrobulbar haematoma This is another consequence of trauma to the eye. However, the vignette above does not describe this. 18%

A 21 year old woman presents to clinic with vaginal discharge that increases around her menses. Upon bimanual and speculum examination an, an ectropion is observed and there is noted to be a fishy odour. What is the most likely causative organism for this presentation?

Gardnerella Vaginalis This is the answer, as the most likely condition is Bacterial Vaginosis. This often presents with a vaginal discharge worse after bleeds, and an associated fishy odour Trichomonas Vaginalis You would expect a profuse, frothy, yellow, vaginal discharge. There is also no mention of vulval irritation and dyspareunia. Strawberry cervix is strongly associated with Trichomoniasis but is uncommon 25%

A 69-year-old man is concerned about new 'moles' on his back which have increased in number over the past month. He has also had intermittent stomach pain and thinks he has lost some weight recently. His father had malignant melanoma and the patient is very worried that he also has this. On examination, there are many well-demarcated raised brown lesions all over his back. They feel smooth and waxy to touch. The patient says they itch slightly but are not painful and have never bled. They have a 'stuck-on' appearance. Given the most likely diagnosis, which of the following conditions is most associated with it?

Gastric adenocarcinoma These lesions have the typical description of seborrheic keratosis, rather than malignant melanoma. Seborrheic keratoses are common and benign skin growths which can usually be managed conservatively. However, a sudden eruption of many seborrheic keratoses is called Leser-Trélat sign. This is a paraneoplastic process which is associated with various malignancies, most commonly gastric or colorectal adenocarcinoma. 41%

A 52-year-old man is seen in clinic for haematemesis. He describes a 3-week history of vomiting fresh blood every morning, with no abdominal pain. He cannot recall if he has lost weight, but reports his clothes feel more loose. He denies dysphagia, fever, drug use and foreign travel. He has a history of excessive alcohol use. On examination, he appears pale and cachexic. There is no evidence of hepatomegaly or other signs of liver disease. What is the most likely diagnosis?

Gastric cancer This patient has chronic haematemesis, weight loss and assumed anaemia (bleeding + pallor), pointing to a diagnosis of gastric cancer. High alcohol intake is a known risk factor for gastric cancer. 51% Oesophageal varices Variceal bleeding is acute and often life-threatening, and this patient's bleeding is more chronic. Furthermore, weight loss does not fit with variceal bleeding and there are no examination findings suggesting liver disease. 30%

65-year-old man with poorly controlled type 2 diabetes mellitus presents to his GP with nausea which he has been experiencing every morning for several weeks. He also reports feeling full after eating only a small amount of food and has offensive burps that smell like eggs. What complication of type 2 diabetes mellitus is this patient most likely to be experiencing?

Gastroparesis Gastroparesis is caused by autonomic dysfunction of the vagus nerve leading to delayed gastric emptying and presents with the symptoms described above. Treatment includes pro-motility medications such as metoclopramide or domperidone. Symptoms are also sometimes caused by bacterial overgrowth, so antibiotics such as erythromycin are sometimes indicated. 99%

chlamydial infection

Genital chlamydia infection is caused by the Chlamydia trachomatis bacterium which is the most common bacterial sexually transmitted infection in the UK. The prevalence of infection is highest in young sexually active adults (15 to 24 years olds). Aetiology Genital chlamydia infection is caused by Chlamydia trachomatis, an obligate intracellular bacterium. Clinical features Asymptomatic infections are common, particularly in women The most common symptoms in men are urethral discharge and dysuria The most common symptoms in women are dysuria, intermenstrual bleeding and vaginal discharge Anal infection may present with discharge or anorectal discomfort Neonates can be affected with pneumonia and conjunctivitis resulting from exposure to an infected mother's genital tract during delivery # Diagnosis For vaginal: vulvovaginal swab (either self-taken or clinician-taken) or endocervical swab analysed using nucleic acid amplification tests (NAATs) For penile: urine or urethral swab, analysed in a similar manner. For anal: anal swab, analysed as above Management Treatment is with oral Doxycycline twice daily for 7 days. A test of cure is normally recommended for rectal infections

A 35-year-old gentleman presents to the emergency department with a four-day history of explosive diarrhoea. He denies vomiting or the presence of blood or mucus in his stool. On further questioning, he reveals that he had returned from a conference in India one week ago and had tried out local food during his trip. Physical examination is unremarkable. Which of the following is the most likely diagnosis?

Giardiasis Giardia infection is caused by Giardia lamblia which is transmitted through the faecal-oral route. It is characterised by explosive, non-bloody diarrhoea with an incubation period of one to three weeks. 70%

what type of laxative is glycyrel suppository

Glycerin suppository A glycerin suppository works by pulling water into the stool and softening it. It is not a stimulant laxative. Also, in general, oral methods to treat constipation should be trialled before rectal methods. 2%

viral assays in HIV

Gold Standard diagnosis of HIV The gold standard for diagnosis of HIV infection is a serum HIV enzyme-linked immunosorbent assay (ELISA) which tests for both HIV-1 and HIV-2 antibodies and HIV-1 p24 antigen. p24 antigen is usually detectable earlier than HIV antibody, and can be detectable as early as 14 days after exposure. Fourth generation ELISA tests are accurate from 45 days post-exposure. Point of care test Current "point of care" (POC) tests or "finger prick" tests are third generation tests, and test for HIV antibody. The antibody can be detectable as early as 21-25 days after infection. Third generation POC tests are accurate from 90 days post-exposure. How soon after infection can HIV be detected? A window period is the time between HIV transmission and the ability to detect infection in the blood on testing. The window period for ELISA tests for HIV antigen and antibody is 45 days, however many infections will produce a positive result at 4 weeks. If the infection occurred less than 45 days ago, the patient will require retesting for an accurate result.

A 28-year-old male presents to his GP with abnormal changes in behaviour, fatigue and uncontrolled movements. He reports struggling to speak and swallow, and you notice that his skin and eyes appear yellow in colour. An electrolyte panel shows an iron level of 90 mcg/dL and a caeruloplasmin level of 8mg/dL (normal: 4 to 40 mg/dL). Given the most likely diagnosis, what might you see on examination of the patient?

Golden-brown eye discoloration The vignette above describes Wilson's disease. This is when copper builds up in a patients body, often the brain and the liver. Consequently, patients often presents with neurological symptoms (difficulty with speech and swallowing and uncontrolled movement in this vignette) and hepatological symptoms (jaundice in this vignette). Another common place for copper deposits is in the eye. These are called Kayser-Fleischer rings and appear as golden-brown eye discoloration. 79%

A 68-year-old-man attends his GP reporting a two week history of worsening haematuria and haemoptysis. He has a past medical history of hypertension and osteoarthritis, and is a retired dry cleaner. His blood tests are suggestive of renal failure and spirometry reveals restrictive lung disease. What is the most likely diagnosis?

Goodpasture's disease This is a classic presentation of Goodpasture syndrome, with haemoptysis and haematuria. It is also known as anti-glomerular basement membrane disease. It occurs when anti-glomerular basement membrane antibodies attack type IV collagen in the kidneys and lungs. In addition, a unique risk factor for this patient is his occupation. Exposure to solvents is a risk factor for Goodpasture syndrome, so people who have worked in dry cleaners or laboratories are at higher risk. 79%

A 23-year-old woman presents to the sexual health clinic with pelvic discomfort, dysuria, abnormal vaginal discharge and rectal pain since having unprotected intercourse with a casual male partner. On examination, there is a green-yellow vaginal discharge present. Proctoscopy reveals proctitis with a mucopurulent discharge. Which of the following investigations would confirm the likely diagnosis?

Gram-negative diplococci on microscopy This patient likely has Neisseria gonorrhoea infection. This is a bacterial sexually transmitted infection that most commonly affects those between the ages of 15 and 24. It typically presents in women with abnormal vaginal discharge, unexpected bleeding, and dysuria; however, it can also infect the rectum, causing rectal pain, bleeding and discharge. It can be diagnosed where there are Gram-negative diplococci seen on microscopy. 50% chlamydia does not cause rectal sx

A 45-year-old man is referred by his GP to rheumatology due to late-onset asthma, persistent sinusitis and eosinophilia. He goes on to have further blood tests which show that he is positive for perinuclear anti-neutrophil cytoplasmic antibodies (p-ANCA), and a tissue biopsy, the results of which are also in line with the suspected diagnosis. Which of the following biopsy findings is most expected?

Granuloma This patient's symptoms, combined with eosinophilia and positive p-ANCA, are strongly suggestive of eosinophilic granulomatosis with polyangiitis (Churg-Strauss syndrome). This is a rare vasculitis which causes granulomatous inflammation. 63%

A 35-year-old man presents to his GP with neck swelling and anxiety. On examination, he has a fine tremor and a small but smooth palpable lump in the centre of his neck, which is not painful to touch. What is the most likely diagnosis?

Grave's disease Grave's disease is the most common cause of hyperthyroidism. It is an autoimmune condition where autoantibodies are produced against the thyroid gland, causing it to become overactive. Grave's disease typically presents with a smooth goitre. 55% Toxic multinodular goitre produce a nodular goitre

A 5-month-old baby is brought to the GP by his parents. They are concerned because he has had two episodes of vomiting. The vomit is green in colour and both episodes have been after feeding. They say he is gaining weight as expected and has otherwise been well up until now. Which part of the history would cause immediate concern?

Green vomit Green or bilious vomit is a feature of intestinal obstruction, specifically obstruction distal to the second part of the duodenum which is where bile is secreted into the small intestine. Causes of bilious vomiting include malrotation, duodenal atresia and meconium ileus. This is a red flag symptom and warrants immediate hospital admission. 81%

A 35-year-old woman undergoes routine antenatal screening and is found to be positive for hepatitis B. Her serology is reviewed, and she is identified as high risk for vertical transmission. She is informed her baby will receive intravenous immunoglobulin and a hepatitis B vaccine at birth. Which of the following has been detected in her serology?

HBe antigen 90% of mothers who are hepatitis B e antigen-positive will transmit the disease vertically; these patients are the most infectious. 41%

A 22-year-old woman was bitten by her partner during a domestic argument. She mentions that her partner is HIV-positive and has been on antiretrovirals for a long time. She is normally fit and well but is now worried about contracting HIV as she noticed a slight wound over the bite mark.What is the recommended post-exposure prophylaxis for this patient?

HIV prophylaxis is not needed following human bites

What is the mechanism of action of metformin?

Increases peripheral insulin sensitivity and hepatic glucose uptake. Metformin is a biguanide that increases peripheral insulin sensitivity and hepatic glucose uptake. 92%

high risk tarffic light system for HR and RR in paeds

HR more than 160 RR more than 50

A 55 year old male presents to A&E with right-sided eye pain, watering and blurred vision for the past day. He also complains of sensitivity to bright lights. He is a known HIV positive patient. On inspection, there is conjunctival redness and watery discharge. Fluorescein stain reveals a branch-like pattern on the cornea. Which is the most likely diagnosis?

HSV keratitis This is an infection of the superficial layer of the cornea. HIV patients are at increased risk. It shows up as a dendritic cell ulcer on fluorescein stain, which has a characteristic branched appearance. Blindness may result from corneal scarring and opacity 56%

A 47-year-old woman presents to her general practitioner complaining of blood in her stool. She says it is a small amount of fresh red blood and is also present on the toilet tissue upon wiping. She also finds that she has increased mucous on wiping. Otherwise, she is well and does not report any new change in bowel habit. Past medical history and family history are unremarkable. What is the most likely diagnosis?

Haemorrhoids Haemorrhoids are engorged blood vessels around the anus and generally present with painless fresh red bleeding that is not mixed in with the stool (the stool gets blood on it as it passes the haemorrhoid at the end of the gastrointestinal tract). Haemorrhoids also often present with increased mucous and itching. 63%

A 38-year-old lady presents to the emergency department with pain over her right wrist. She does not remember having any trauma on her wrist but mentions that she is a frequent tennis player. On examination, there is tenderness over the ulnar aspect of the wrist and weakened grip strength. Active flexion of the fourth and fifth finger causes pain. There is no numbness or tingling sensation. Which of the following is the most likely diagnosis?

Hamate fracture This patient likely has a hook of hamate fracture which can occur due to repeated impact against the hamate, which in this case, can be a result from tennis. Patients with hamate fracture typically have pain over the ulnar aspect of the wrist and have weakened grip. Pain on active flexion of fourth and fifth fingers (pull test) is also supportive of this diagnosis. 26%

A 55-year-old woman is triaged to the surgeons following an emergency admission with severe diverticulitis. She is haemodynamically unstable with high inflammatory markers. She is taken to theatre for emergency surgery where her sigmoid colon is removed and a colostomy is created. What operation has this patient received?

Hartmann's procedure This is a Hartmann's procedure, where the sigmoid colon is removed and a colostomy is formed. The stoma can be reversed at a later date if desired. This operation is used in emergencies, particularly in diverticulitis as the sigmoid colon is the most commonly affected site. 75% Abdomino-perineal resection An abdomino-perineal resection involves removing the proximal sigmoid colon, rectum and anus, resulting in a permanent end colostomy. This is used for very lower rectal cancers. This patient has only had their sigmoid colon removed and thereofore has had a Hartmann's rather than an abdomino-perineal resection. 3% Anterior resection An anterior resection involves removing part of the sigmoid colon and rectum and creating an anastomosis. A temporary ileostomy is also often created to help the anastomosis heal. As this patient has a colostomy rather than an ileostomy, she has had a Hartmann's and not an anterior resection. 12%

A 60-year-old woman sees her doctor due to difficulty going up stairs for the past six months. Physical examination reveals significantly reduced strength in the deltoid and quadriceps muscles bilaterally. She is also noted to have scaly papules over the interphalangeal joints of her hands. Which of the following skin features is most associated with the suspected diagnosis?

Heliotrope rash This patient has bilateral proximal muscle weakness and Gottron's papules which strongly suggest dermatomyositis. Another characteristic sign of this condition is a heliotrope rash which is a periorbital rash. 77%

A 64-year-old man attends his GP reporting a three-week history of swollen ankles and urine which he describes as "frothy-looking". His renal function tests are grossly deranged and he has hypoalbuminaemia. The patient is referred to nephrology for further assessment and subsequently has a renal biopsy which confirms membranous nephropathy. Given the diagnosis, which of the following tests should be considered for this patient?

Hepatitis B testing Membranous nephropathy can be idiopathic or secondary to other conditions or infections. Hepatitis B is a known possible cause of membranous nephropathy. For this reason, a hepatitis B test should be considered. 47%

A 27-year-old man is referred to neurology with worsening spasms in both legs over the past 9 months. On examination, he walks with a scissor gait and has increased muscle tone in both lower limbs. He has notable muscle weakness and when testing the knee reflex, hyperreflexia is noted. There is also reduced vibration sensation in the lower limbs. What is the most likely diagnosis?

Hereditary spastic paraparesis This patient's symptoms are suggestive of hereditary spastic paraparesis which causes degeneration of mainly the corticospinal tracts and, in some patients, the dorsal column. Patients present with spasticity, hyperreflexia and gait disturbance. The scissor gait is seen due to increased muscle tone in the adductor muscles. 40%

A 21-year-old man visits the GP due to a new rash on his hands which started four days ago. He also has a couple of mouth ulcers and says he has felt more tired and run down recently. However, he is apyrexial and managing to eat and drink normally. On examination, the patient has multiple skin lesions on the palms of both hands. The lesions are circular, raised and erythematous, with darker centres resembling a target. Given the most likely diagnosis, what is the most common infectious cause?

Herpes simplex virus This is a typical description of erythema multiforme which is characterised by target lesions that usually appear on the peripheries. In more severe cases, there can be mucosal involvement of the mouth, eyes or genitals. The vast majority of cases are due to infection, of which herpes simplex virus is the most common infectious cause. 52%

A 64-year-old man is brought to the emergency department by his wife with new onset confusion. His wife states that he has been generally unwell over the past few days with a headache and sore throat. This morning, he has become more disorientated and agitated which is very unusual for him. His observations are recorded and his temperature is found to be 39.8 degrees Celsius. His past medical history is only significant for type 2 diabetes. Given the suspected diagnosis, what is the most likely causative organism?

Herpes simplex virus type 1 This patient has presented with features of encephalitis - a prodromal illness followed by fever and altered mental status. Encephalitis is typically viral with herpes simplex virus type 1 being the most common cause. 51%

A 62-year-old gentleman with a twenty-pack-year smoking history presented to the general practitioner with a two-month history of worsening dyspepsia and heartburn. He denies any unintentional weight loss or change in appetite. His recent endoscopy confirmed a finding of low-grade dysplasia. What is the best management plan for this patient?

High-dose proton pump inhibitor (PPI) and six monthly endoscopic surveillance Low-grade dysplasia is generally managed with a high-dose proton pump inhibitor (PPI) with six monthly endoscopic surveillance. In addition, lifestyle interventions such as smoking cessation should be advised, as smoking is a risk factor for Barrett's oesophagus and oesophageal cancer. 66%

A newborn baby girl is undergoing a newborn baby check. Examination of the hips reveals a positive Barlow's and Ortolani's test. On closer examination of the notes, she is a firstborn child and was a breech delivery. Which of the following is the next best investigation?

Hip ultrasound A positive Barlow's and Ortolani's test is highly suspicious for developmental dysplasia of the hip (DDH). Furthermore, this baby has 3 risk factors for DDH: female, firstborn and breech. A hip ultrasound is the most appropriate investigation to evaluate the presence and severity of DDH. This should happen when the baby is between 4-6 weeks old. 82%

A 37-year-old man is reviewed by his mental health team after demonstrating inappropriate sexual behaviour towards a work colleague. During the consultation he is extremely tearful, commenting that he has been unjustly treated. He reports that he and the work colleague were soul mates, and he cannot understand where the accusation of inappropriate behaviour came from. Which of the following personality disorders best describes the behaviour of this patient?

Histrionic personality disorder This patient demonstrates Histrionic personality disorder. Histrionic personality disorder is characterised by excessive displays of emotions and attention seeking behaviours. They can be sexually inappropriate, and may consider relationships more intimate than they really are. This is demonstrated by the patient's behaviour towards the work colleague, and subsequent denial of the accusation. 73%

A 73 year old man with a 50 pack year smoking history presents with a longstanding dry cough, shortness of breath and fatigue. On examination, his fingers are clubbed and there are fine end-inspiratory crackles heard on the lung bases. Chest x-ray shows bilateral lower zone reticulo-nodular shadowing. A high resolution CT is ordered for further investigation. Which CT finding would be most consistent with the likely diagnosis?

Honeycomb lung The most likely diagnosis is pulmonary fibrosis. It typically presents with a dry cough, shortness of breath, fatigue and muscle pains. Examination findings include cyanosis, clubbing and fine-end inspiratory crackles and x-ray findings supports the diagnosis. Honeycombing on CT is a visual representation of fibrotic lung parenchyma with cystic airspaces contained by fibrotic walls. It is a common feature of pulmonary fibrosis. 63% Diffuse ground-glass opacities This is the most common finding on CT scans of patients with pneumocystis pneumonia. High-resolution CT scans are helpful in cases where chest x-ray is normal but there is a high suspicion of pneumocystis pneumonia (PCP). This is unlikely here as the patient is not immunocompromised and is not presenting with fever or desaturation, as would be expected with PCP. 23%

A 3-year-old boy is brought into the general practice with a rash, by his mother. His mother describes him feeling hot and sweaty two nights ago, and since then, he has not been himself and has been off of his food. Yesterday, he developed an itchy red rash which began on his tummy but then spread over the rest of his body. On examination, there is a mixture of erythematous papules and crusting vesicles with associated excoriation marks. What is the most likely virus causing this child's rash

Human herpesvirus 3 (HHV-3) This child is presenting with chickenpox, caused by HHV-3, also known as the varicella zoster virus (VZV). Chickenpox initially has a febrile prodrome, and then a macular-papular rash develops, typically starting on the head and trunk and spreading to the whole body. The papules then progress to vesicles and begin crusting. Chickenpox is intensely itchy, hence the excoriation marks. 31%

A 50 year old man presents to the sexual health clinic with oral ulcers for the past three months. There is no history of recent trauma. However, he stopped taking medications for acquired immunodeficiency syndrome (AIDS) recently. Examination shows multiple violaceous plaques in the oral cavity, cervical lymphadenopathy, and a purplish-coloured lesion on the left lower leg. Immunohistochemistry of the lesion on the leg is positive for LANA1. Given the likely diagnosis, what is the most likely causative organism?

Human herpesvirus-8 Kaposi sarcoma (KS) is a multicentric vascular tumour caused by human herpesvirus-8. It is common in immunosuppressed persons such as those with AIDS or organ transplants. The risk increases in patients with low CD4 counts of less than 200, which is likely in this case as he has been non-compliant with his therapy. Cutaneous lesions are asymptomatic purple macules that coalesce into violet to black-coloured plaques and nodules. LANA1 (latent nuclear antigen 1) is usually expressed by Kaposi's sarcoma-associated herpesvirus (KSHV), also known as human herpesvirus 8 (HHV-8). 56%

A 45 year old female has been brought into A & E by ambulance with shortness of breath and chest tightness. The patient has a past medical history of asthma and eczema. The patient's husband informs you she did a peak flow test at home which was 60% of her normal reading. On examination, the patient is struggling to answer questions in one breath. Her observations show a respiratory rate of 26, a heart rate of 120 and oxygen saturations of 94% on room air. Initial management is initiated in the department. A cannula is inserted, the patient is sat up and started on 15L of high flow oxygen via a non-rebreather mask. 5mg of nebulised salbutamol and 0.5mg of ipratropium bromide are also given. What steroid-based medication is appropriate to give this patient?

Hydrocortisone 100mg IV According to guidelines published by the British Thoracic Society, appropriate steroids should be given in acute asthma attacks. As this patient has a cannula in situ and is struggling to breathe, IV hydrocortisone would be the most appropriate medication to give. 44% Prednisolone 50mg PO According to guidelines published by the British Thoracic Society, appropriate steroids should be given in acute asthma attacks. Oral prednisolone is an appropriate management option, however, as this patient has a cannula in situ and is struggling to breathe, IV hydrocortisone would be the most appropriate medication to give at this point. IV medications can be changed to oral when the clinical condition improves. 25%

An 80-year old male is brought into Accident and Emergency complaining of severe shortness of breath. He has a past medical history of chronic obstructive pulmonary disease (COPD) and hypertension. On examination, he has increased work of breathing and a bilateral expiratory wheeze. His temperature is 37.5C, respiratory rate is 25, heart rate is 90, blood pressure is 123/75 and oxygen saturations are 84% on room air. He is treated with oxygen via a Venturi mask and has nebulised salbutamol, however his condition does not improve. Which of the following is the most appropriate treatment to give this patient next?

Hydrocortisone 200mg IV This is the correct answer. This patient is presenting with features of an acute exacerbation of COPD which has not improved despite nebulised salbutamol. Therefore, hydrocortisone 200mg IV is the next best option. 42% pred 30mg OD for 7-14 days once the pt is clinically stable

A 5-year-old boy is brought to the GP by his mother. She has noticed a rash on the creases of his elbows and behind his knees. It has been worsening over the past few weeks. The rash is very itchy and there are a number of excoriations on the affected areas. The patient has no past medical history. On examination, there is flaking and erythema at the flexures of the elbows and knees. There is no bleeding, altered pigmentation or signs of infection. Which of the following is the best treatment option?

Hydromol cream and topical clobetasone butyrate 0.05% The likely diagnosis here is atopic dermatitis (eczema). Eczema usually begins in infancy and most affected children develop symptoms by the age of six years old. Pruritus is a key feature of eczema and it typically affects the face and flexural surfaces. The mainstay treatment for eczema is emollients with or without topical steroids. Given this patient's skin inflammation and itching which is severe enough to cause excoriations, he should be treated for moderate eczema. This includes frequent and generous use of emollients such as Hydromol, as well as short-term use of a topical corticosteroid such as clobetasone butyrate 0.05%. 58%

A 55-year old with a known background of colorectal cancer with bony metastases presents with a 1 day history of vomiting, confusion and a generalised abdominal pain. Her carer reports that she is passing flatus and opening her bowels, although it looks like rabbit droppings. Her mood has been variable, often on the lower side, and she has been feeling more tired. On examination, her abdomen is soft and diffusely tender, bowel sounds are normal. What is the most likely cause of her nausea and vomiting?

Hypercalcaemia This is a common electrolyte imbalance in patients with cancer, especially those with bony metastases. The patient's symptoms are acute and fit more with hypercalcaemia rather than more chronic conditions. 75%

A 5-year-old boy is admitted to the paediatric haematology ward for treatment of acute lymphoblastic leukaemia (ALL). He is due to receive chemotherapy. Which of the following is a good prognostic factor in ALL?

Hyperdiploid blast cells Hyperdiploidy (the presence of extra chromosomes in blast cells compared to the normal 46 in somatic cells) is associated with a better prognosis. 31%

A 27-year-old woman is rushed to the emergency department following a RTA. On presentation, she has a GCS of 8 and is subsequently intubated. Her heart rate is 42 beats per minute and her blood pressure is 180/100. An urgent CT head shows an intracranial haematoma causing a midline shift. The patient is managed whilst awaiting neurosurgical intervention. What treatment would be useful in the meantime?

Hypertonic saline This patient has suffered a traumatic brain injury. Her observations show a widened pulse pressure and bradycardia (components of the Cushing's reflex) which is indicative of raised intracranial pressure (secondary to the haematoma). Evidence has suggested that hypertonic saline is an appropriate short-term treatment to help reduce intracranial pressure. 15% Mannitol Mannitol has been widely used to reduce intracranial pressure but due to the additional risks associated with it, hypertonic saline is considered the better option. 54%

A newborn baby boy is brought to the Paediatric Emergency department by his mother who is concerned as he has been vomiting, and the community midwife expressed concerns about him not gaining weight appropriately. He is being investigated for congenital adrenal hyperplasia. Which of the following are the most likely electrolyte findings in congenital adrenal hyperplasia?

Hyponatraemia and hyperkalaemia Congenital adrenal hyperplasia is characterised by a deficiency of 21-hydroxylase. This enzyme is responsible for key steps in the glucocorticoid and mineralocorticoid pathways; therefore, a deficiency leads to reduced cortisol and aldosterone. Aldosterone normally facilitates sodium absorption and potassium excretion in the kidneys; therefore, reduced aldosterone leads to hyponatraemia and hyperkalaemia. This is known as a salt-wasting crisis. 47%

ann arbor staging

I: single lymph node II: 2 or more lymph nodes/regions on the same side of the diaphragm III: nodes on both sides of the diaphragm IV: spread beyond lymph nodes

brugada mx

ICD

how long is acetylcysteine tranfused over

IV N-acetylcysteine over 1 hour is correct. Guidelines recommend continuing acetylcysteine treatment if there is jaundice, hepatic tenderness or ALT level above the normal limit (all of which the patient has above).

A 41-year-old man is brought into the emergency department by a family member with new confusion and difficulties with balance. On further questioning, he is disoriented to time and place and appears agitated. On examination, you note that he has an ataxic gait and a horizontal nystagmus when looking to the left. He has a past medical history of chronic drug and alcohol misuse. What is the most appropriate treatment?

IV Pabrinex This patient has presented with the triad of symptoms caused by Wernicke's encephalopathy (confusion, ataxia and nystagmus). This is caused by thiamine deficiency with excessive alcohol intake being the likely cause in this patient. It is a reversible condition and is treated with IV Pabrinex which replaces thiamine. Korsakoff syndrome is a serious and potentially irreversible complication that can develop if Wernicke's encephalopathy is left untreated. 78%

A 22 year old woman is brought into A&E after having a seizure at home. The paramedics mention that she has now returned back to her baseline and they have managed to insert a cannula into her right arm. Whilst being assessed, she has a second seizure. She is moved onto her side and a timer is started. A nurse asks if there is any medication that will need to be given to help stop the seizure and when it should be given. What is the most appropriate treatment for this lady and when should it be given?

IV lorazepam at 5 minutes This is the correct answer. Status epilepticus is defined as a seizure that does not self-terminate within 5 minutes, or 2 seizures between which a patient does not return to baseline. The initial treatment for status epilepticus is a benzodiazepine which is given at 5 minutes. Since this lady has IV access, the most appropriate benzodiazepine is IV lorazepam. 53%

A 45-year old male has been in a road traffic accident with multiple rib fractures and a femur fracture. He arrives in the emergency department with excruciating pain. What is the best way to manage his pain?

IV morphine According to the NICE guidelines for major trauma, pain needs to be managed effectively because it can lead to a rise in intracranial pressure. Significant pain needs to be treated with small doses of intravenous opioids titrated against clinical response and baseline cardiorespiratory measurements. 85%

A 67-year old man with hepatocellular carcinoma is complaining of pain and is not on any painkillers. What would be the first line treatment for his pain?

Ibuprofen 400mg, four times a day Step 1 of the WHO pain ladder is paracetamol or a NSAID. Paracetamol is given in caution to those with hepatic impairment, hence, an NSAID is the first choice. 20%

when to recommend levo in subclinical hypothyroidism

If a patient's TSH level is elevated but less than 10 mU/L on two separate occasions three months apart and symptoms of hypothyroidism are present (such as fatigue and cold intolerance in this case), NICE recommends a 6-month trial of levothyroxine and rechecking TFTs after.

A 52-year-old man with known Marfan syndrome, ischaemic heart disease and COPD presents with chest discomfort over a 6-8-hour period which is not improved by his GTN spray. He denies any other symptoms.On examination, he has a reduced air entry on the left side and a chest x-ray reveals a pneumothorax measuring 3cm. He has never had a pneumothorax before.What treatment should be performed for this patient?

If a secondary pneumothorax > 2cm and/or the patient is short of breath then patient should be treated with chest drain (not aspiration) as first-line

erbs palsy

Impaired wrist extension and elbow flexion Erb's palsy describes an injury to the C5 and C6 myotomes. Patients often present with a characteristic "waiter's tip" which involves a flexed wrist, extended forearm and internally rotated, adducted arm. 54%

A 45-year-old male undergoes a hemicolectomy for severe ulcerative colitis. Post-operatively, he develops extreme nausea. Which needs to be avoided?

Metoclopramide It is contraindicated in gastrointestinal obstruction and needs to be avoided post-gastrointestinal surgery 63%

A couple visits their GP worried that they have not been able to conceive a child despite trying for eight months. The husband and wife's ages are 38 and 37 respectively, and they have sexual intercourse once a week. They smoked cigarettes when they were in their early 20s but have not smoked in the past five years. They drink two to three small glasses of wine per week. The wife has a family history of fibroids and the husband has asthma. Which aspect of this couple's history is a risk factor for infertility?

Increased age Increased age (>35) is a risk factor for infertility. It is also associated with an increased risk of complications during pregnancy. 68%

A woman brings her six-week-old son to see his general practitioner. The boy has been vomiting white 'stuff' after feeds, and also often cries whilst being breastfed. He has no diarrhoea or bloody stools. He was born at 35 weeks by ventouse delivery. What is the most likely diagnosis?

Infant < 8 weeks, presents with milky vomits after feeds, often after being laid flat, excessive crying → ? GORD

A 62-year-old obese man previously diagnosed with renal cancer complains of bilateral swelling of both legs. Otherwise, his past medical history is unremarkable, and he does not smoke. His vital signs are within normal limits. What is the most likely cause of his presentation?

Inferior vena cava occlusion Renal cell carcinoma tends to invade major blood vessels through renal veins, extending from the inferior vena cava to the right atrium. It leads to reduced venous drainage and the development of bilateral pedal oedema. 57%

dx of infertility

Infertility is defined as an inability to conceive after: 1 year in couples who are having regular penetrative intercourse 2 years in couples who are having regular penetrative intercourse and have a pre-diagnosed condition that can impact fertility (e.g. polycystic ovarian syndrome) This couple does not meet any of these criteria. 3%

A 28 year old male presents with throbbing right scrotal pain for one day associated with mild penile discharge and fever. He is sexually active with a few partners of both sexes. Examination shows tender and swollen right scrotum. Ultrasound doppler of the right testes reveals increased vascularity. Which of the following is the likely cause for his symptoms?

Inflammation of the epididymis as a result of a sexually transmitted infection This patient's symptoms and ultrasound findings suggest acute epididymo-orchitis (scrotal pain, penile discharge, acute and swollen scrotum and increased perfusion on ultrasound). In a sexually active young man, the most common causes of infectious epididymo-orchitis are Chlamydia Trachomatis and Neiserria Gonorrhea. 94%

A 24-year-old Turkish man presents to his GP with painful oral and genital ulcers which have been recurrent for the past six months. He also complains of blurred vision and photophobia, as well as painful lumps on his shins. Upon suspicion of Behcet's disease, he is referred for a pathergy test. What is likely to be the skin response to this test?

Inflammatory papule Pathergy is a commonly observed feature in Behcet's disease and refers to an exaggerated skin reaction, typically the appearance of an inflammatory papule or pustule, after mild skin trauma. It is tested for with a needle prick and skin changes are usually seen at the site of the needle injury within 24-48 hours. 61%

A 4-month-old baby girl is brought to the paediatric emergency department in the evening by her father. Her father is worried as she rolled off the bed in the morning while he was in the bathroom brushing his teeth, and has been crying ever since. On examination, there are bruises of varying ages on her arms and legs. Which of the following is the next best step in management?

Inform a senior This case is highly suspicious of non-accidental injury. There are a number of red flags: 4-month-old babies cannot roll over yet; therefore the history is implausible The mechanism of injury does not match the clinical presentation of injuries There is a delayed presentation Unwitnessed injury Bruises of varying ages This case should be immediately discussed with a senior and/or safeguarding lead. 61%

A 52-year-old man present to his GP with a lump in his groin. He says it has been there for a few months and has never caused him problems, but recently has been growing in size. He is generally fit and well. He is a lifelong smoker. On examination, there is a soft, fluctuant mass superior and medial to the pubic tubercle. It is not possible to get above the lump and cough impulse test is positive. There are multiple varicose veins present throughout the legs. What is the most likely diagnosis?

Inguinal hernia This is most likely a direct inguinal hernia due to its location and positive cough impulse. The pubic tubercle is a good landmark when assessing hernias, with anything superior and medial to it being classed as an inguinal hernia, and anything lateral and inferior being a femoral hernia. 63%

An 18-hour-old newborn baby, born at term, starts vomiting green liquid on the postnatal ward. An upper gastrointestinal contrast study shows an obstruction where the proximal bowel looks like a 'corkscrew', and the duodenojejunal junction is in an abnormal location. The baby is treated with a Ladd's surgical procedure. Which of the following is the most likely diagnosis?

Intestinal malrotation There are many causes of bilious vomiting in a newborn; however, this case's radiological findings and treatment are consistent with intestinal malrotation, which has led to volvulus. Intestinal malrotation is where the midgut rotates and fixes in an abnormal position while the baby is developing in the womb. This abnormal position makes it more likely for the bowel to twist on itself and cut off its own blood supply. This is known as volvulus. Ladd's procedure is where the surgeon straightens out the bowel and divides any abnormal peritoneal bands (Ladd bands). 66%

A 29 year old woman presents to the GUM clinic. She is asking about different types of contraception available to her. She has recently stopped the combined oral contraceptive pill. It is noted that she suffers with fibroids associated with heavy menstrual bleeding. There is no other relevant medical history. What is the most appropriate method of contraception to prescribe?

Intra-uterine system (IUS) This is the current guidance, as insertion of the IUS can lead to a reduction in bleeding 6 months after insertion, thus alleviating symptoms of heavy periods 47%

A 33 year old woman attends the GP to discuss ongoing contraception following the recent birth of her child. She gave birth five weeks ago and is currently breast-feeding. She plans to breast-feed for at least six months. She has no other medical history and takes no medication. She is keen on a long-term method of contraception, expressing that she would like more children in the next few years, but has no immediate plans. What is the most appropriate contraceptive method to recommend?

Intrauterine device (IUD) This is a very effective long-acting reversible contraceptive (LARC). It can be inserted either 48 hours within giving birth or four weeks postpartum, is effective immediately, and can be reversed with immediate return to fertility, making it suitable for this patient's needs LAM is only 98% effective and is not a long term solution

A 32-year-old gentleman is admitted to the medical ward due to a flare-up of his ulcerative colitis. He reports that he opened his bowels seven times yesterday with notable blood in his stool. On examination, he has a temperature of 38.1°C with a pulse rate of 91 beats per minute. Routine blood tests show a raised erythrocyte sedimentation rate (ESR). What is the most appropriate management plan?

Intravenous corticosteroids According to Truelove and Witt's severity score, this exacerbation of ulcerative colitis is classified as severe. Hence, intravenous corticosteroids should be considered as first-line management. 75%

A 49 year old woman presents to the emergency department with sudden excruciating pain of the left arm associated with numbness while she was doing house chores this morning. There is no previous history of trauma to the arm. On further questioning, she has intermittent episodes of palpitations over the last few weeks. Examination shows cyanosis to the level of the elbow and her left hand feels cold to touch. The radial and ulnar pulses are absent. She has active range of movement in the hand but the sensation is mildly reduced. Her right upper extremities are normal. Following initial resuscitation with high flow oxygen, fluids and analgesia, what is the next best step of management?

Intravenous heparin bolus followed by continuous infusion This patient has an acute ischaemic arm (acute pain, paraesthesia, pallor, cold) likely secondary to arterial embolism. She has minimal sensory loss without any motor deficit, putting her at category 2a- marginally threatened limb according to Rutherford criteria. For patients with category 2a and below, conservative management with prolonged course of heparin may be attempted first. 37%

A 56-year-old gentleman is brought into accident and emergency by a friend following a paracetamol overdose. On examination, he is drowsy but rousable to voice. Bloods reveal deranged liver function tests and a raised international normalised ratio (INR). Which of the following is indicated to reduce cerebral oedema in hepatic encephalopathy?

Intravenous mannitol Intravenous mannitol is used to reduce cerebral oedema in hepatic encephalopathy. It is advised to assess cardiac function before treatment, as side effects such as arrhythmia are associated with intravenous mannitol. 46%

An 18-year-old female presents to the GP with a 6-month history of fatigue and shortness of breath. She is currently suffering from a viral upper respiratory tract infection. Her medical history is of heavy periods, but she is normally fit and well. Routine bloods are as follows: Haemoglobin (Hb): 98 g/L (normal 130-180 g/L) Mean cell volume (MCV): 65 fL (normal 80-96 fL) Platelets: 395 x109/mL (normal 150-400 x109/mL) White cell count: 12.7 ×109/L (normal 4.0-11.0 ×109/L) Ferritin: 35 mcg/L (normal 24-336 mcg/L) What is the most likely diagnosis?

Iron deficiency anaemia The presence of microcytic anaemia with this history makes iron deficiency highly likely. In addition, although her ferritin levels are within normal range, ferritin is an acute phase reactant and may be falsely elevated due to her viral illness. 64% Thalassemia It would be very unusual to present at this age with thalassemia, and the history of heavy periods makes this unlikely. 19%

incarcerated hernia

Irreducible. The intestine swells in the hernia sac and becomes trapped, the intestine can no longer be pushed back into the abdomen.

incarcerated hernia

Irreducible. The intestine swells in the hernia sac and becomes trapped, the intestine can no longer be pushed back into the abdomen. doesnt present with pain

A 63-year-old female presents to the emergency department with melena. She has no previous medical history. Examination findings reveal splenomegaly and erythromelalgia. A full blood count is ordered, which can be seen below. Haemoglobin (Hb): 138 g/L (normal range 140-180g/L) Platelets: 652 x109/L (normal range 150-400x109/L) White cell count: 9.0x109/L (normal range 4-11x109/L) What is the most likely genetic cause of her symptoms?

JAK2 V617F The patient is suffering from essential thrombocytosis. This is a myeloproliferative disorder affecting megakaryocytes. While 50% of patients are asymptomatic at diagnosis, symptoms may include bleeding due to dysfunctional platelets. JAK2 V617F is found in more than half of all cases. 77%

jejunal atresia x-ray vs duodenal atresia

Jejunal atresia There are many causes of bilious vomiting in a newborn; however, this case's radiological findings and treatment are consistent with intestinal malrotation, which has led to volvulus. Jejunal atresia is another congenital malformation which presents clinically in the same way as duodenal atresia, with abdominal distension and bilious vomiting. However, it is distinguished from duodenal atresia on abdominal x-ray as jejunal atresia has a 'triple bubble' appearance as opposed to a 'double bubble'. 4%

UKMEC 4 COCP CI

Known or suspected pregnancy, smoker over the age of 35 who smokes >15 cigarettes, obesity, breast feeding <6 weeks post partum, fhx of thrombosis before 45 years old, breast cancer or cancer within last few years, BRCA genes

syphilis vs lgv

LGV - painless ulcer + tender lymphadenopathy Syphilis - painless ulcer + non-tender lymphadenopathy

A 40 year old male presents with a localised testicular swelling that has been growing slowly over the past year and was noticed by his partner. He has been having a dull ache in the scrotum. Past history is remarkable for surgical correction of undescended testis at five years of age. Physical examination reveals a right sided painless testicular mass that is indistinguishable from the testicle. Given the history, which tumour marker is likely to be raised?

Lactate dehydrogenase (LDH) The most common type of testicular cancer occurring in undescended testes is a seminoma. They are more likely to present with localised disease, have indolent growth and rarely metastasise to other organs. In contrast, non-seminomatous germ cell tumours frequently spread to other areas, including the lung, liver, bone and brain. A rise in serum LDH levels helps to monitor growth in seminomas. 15% afp and betahcg are increased in non seminomas

A 23-year-old primiparous woman who is six weeks postpartum presents to the GP with ongoing breast pain. She is currently being treated for puerperal mastitis and now presents with further pain and erythema over her right breast. On examination, there is a palpable, fluctuant mass lateral to the areolar. What is the most likely diagnosis?

Lactational Breast abscess Definition Infectious mastitis may lead to an accumulation of pus in an area of the breast, leading to the development of a lactational breast abscess. Causes The most common causative agent is Staphylococcus aureus, which enters via a crack in the nipple skin or through a milk duct. Clinical Features Fever or rigors Malaise Pain and erythema over an area of the breast There may be a fluctuant mass present, but this is not always palpable. History of recent or current mastitis Management Incision and drainage or needle aspiration (with or without diagnostic ultrasound) Oral or intravenous antibiotics according to local protocol

A 54-year-old Caucasian agricultural worker presents to the general practitioner with a one-week history of colicky abdominal pain and diarrhoea. On further questioning, he reveals that he has also experienced migratory joint pain over his knee, shoulder, and ankle over the past month. He returned from a work trip to Italy a month ago. He denies any intravenous drug use or unprotected sexual intercourse. On examination, hyperpigmentation of the skin is evident. Routine blood tests are unremarkable. A diagnosis of Whipple's disease is suspected, and he is sent for a gastrointestinal biopsy. Which of the following is suggestive of a diagnosis of Whipple's disease?

Lamina propria infiltration with periodic acid-Schiff (PAS) positive macrophages The biopsy findings of lamina propria infiltration with periodic acid-Schiff stain (PAS)- positive macrophages and intracellular clumps of Tropheryma whipplei are in keeping with a diagnosis of Whipple's disease. 84%

A 29 year old woman presents with a left sided facial droop and left sided mild headache. On examination, she is unable to smile, frown or close her eye fully on the left side of her face. She has no upper or lower limb weakness or sensory changes. What is the most likely cause of this presentation?

Left cranial nerve VII lower motor neuron (LMN) lesion Correct. This patient is likely experiencing Bell's palsy, which is caused by a LMN lesion. LMN lesions cause ipsilateral manifestations, so the left sided symptoms are due to a left sided lesion. The whole side of the face is affected (not forehead sparing), which further indicates a LMN lesion. 56%

deep femoral A occlusion

Left deep femoral artery The deep femoral artery is a branch from the common femoral artery that supplies the thigh. Patients may present with thigh pain, instead of below knee pain. 13%

ext iliac occlusion

Left external iliac artery The external iliac artery becomes the femoral artery after it passes under the inguinal ligament. Patients will have pain that starts just above the inguinal ligament. 7%

A 58 year old male presents with acute severe left foot and leg pain. The pain starts from the level below his knee. His past medical history includes hypertension and type 2 diabetes mellitus. On examination, his left leg is cold to touch. The left dorsalis pedis, posterior tibialis and popliteal pulse are not felt. Gross motor and sensory functions are intact. The right leg is normal. What is the single most likely occluded artery?

Left femoro-popliteal artery To answer this question, it is important to know the blood supplies of the lower limb. This patient presents with an acute onset leg pain with findings consistent with acute limb ischemia. Occlusion at the femoral-popliteal artery is the most likely as the pain starts below the knee. Remember, symptoms of occlusion occurs distal to the site of occlusion. 45% Left common femoral artery The left common femoral artery starts after the level of inguinal ligament. Occlusion of the common femoral artery is less likely as the pain would start below the inguinal ligament. 29%

What is the conduit of choice for the left anterior descending artery while performing coronary artery bypass grafting?

Left internal mammary artery The left internal mammary artery is the conduit of choice for the left anterior descending coronary artery. It depends upon the graft patency which is highest in it. 27%

A 34-year-old woman with a background of multiple sclerosis attends the neurology clinic for a follow-up. On examination, when performing the H test and looking to her right, the patient is unable to adduct her left eye and nystagmus is noted in the right eye on abduction. Which option best describes this abnormality?

Left internuclear ophthalmoplegia Internuclear ophthalmoplegia presents with ipsilateral impairment of the adducting eye and nystagmus in the abducting eye as demonstrated by this patient. This would be due to a lesion affecting her left medial longitudinal fasciculus causing a left internuclear ophthalmoplegia. Multiple sclerosis is a cause, particularly in younger patients. 58%

A 48 year old man is brought to A&E. He struggles to articulate, but tells you that he woke up this morning with right sided weakness. He has been taking cART for the past 10 years. Given the clinical picture, what is the most likely diagnosis?

Left sided middle cerebral artery infarct This is the correct diagnosis. Patients with HIV on long term cART are at a significantly increased risk of both ischaemic and haemorrhagic stroke. This is due to the increase in vascular risk factors conferred by both anti retroviral medications and the presence of HIV within the blood 56%

which emergency contraception dose increases based on weight

Levonelle, double dose In women with a BMI >26 or a weight >70kg, the dose of Levonelle must be doubled in order to be effective. This patient's BMI is 32 so she falls within this category 48%

lichen planus

Lichen planus Lichen planus is an autoimmune T-cell mediated condition that can affect the vulva, vagina and mouth with erosive, hypertrophic lesions. It leads to scarring and loss of vulval architecture. It causes pain, but the rash is not itchy. It is associated with an increased risk of malignancy. 14%

A 56-year-old woman presents to her General Practitioner (GP) with a two month history of vulval pruritis and dyspareunia. She went through the menopause six years ago and has not had any vaginal bleeding since. She reports no abnormal vaginal discharge and no urinary symptoms. Her past medical history includes type 1 diabetes, for which she is compliant with her insulin therapy. On examination, there are two patches of white atrophic vulval skin. On bimanual examination, her uterus is non-tender, and no masses are palpable. What is the most likely diagnosis?

Lichen sclerosis This is a typical presentation of lichen sclerosus; vulval pruritis and white atrophic patches of skin on the vulva. The condition is characterised by chronic anogenital inflammation. The cause is not well understood but is thought to have an autoimmune aetiology. The main risk factors include genetics and the presence of other autoimmune conditions. It can potentially progress into squamous cell carcinoma in post-menopausal women. 70% Atrophic vaginitis Atrophic vaginitis occurs in post-menopausal women and is caused by low levels of circulating oestrogen. This leads to thinning and dryness of the vulval skin and vaginal epithelium. It typically presents with vulval irritation, soreness and superficial dyspareunia. Some women also report vaginal discharge changes. This common condition can be managed with topical lubricants or topical or vaginal oestrogen. The white atrophic patches seen on examination in this patient make lichen sclerosus a more likely diagnosis. 22%

A 79-year-old woman presents to her general practitioner complaining of vulval pain and itching, and she says the area occasionally bleeds. She also suffers from urinary incontinence, which has worsened over the last few years. She is widowed and no longer has sexual intercourse. She denies any weight loss or night sweats. Her last menstrual period was aged 51. On examination, the vulva is pale and stiff with crinkled atrophic tight skin. There are generalised excoriation marks with associated minor bleeding points and regions of hyperkeratosis.

Lichen sclerosus Lichen sclerosus is most common in postmenopausal women and presents with pale atrophic skin with loss of vulval architecture. It is often associated with urinary incontinence, as in this woman. It increases the risk of vulval malignancy. 61%

lichen simplex chronicus

Lichen simplex chronicus Lichen simplex chronicus or vulval eczema is an appropriate differential for thickened vulval skin with excoriation and bleeding. Importantly, it has no loss of architecture, and pathology is due to the itch-scratch cycle. 9%

A 66-year-old man is diagnosed with a 3cm sliding hiatus hernia during an oesophagogastroduodenoscopy. He initially presented with 'burning' chest pain, halitosis and frequent belching. The patient does not smoke or drink alcohol and has a BMI of 34 kg/m².What is the most appropriate management plan for this patient?

Lifestyle advice and omeprazole is the correct answer. The patient's symptoms are best managed with lifestyle advice and proton pump inhibitors because they have a symptomatic hiatus hernia (acid reflux, 'burning' pain, halitosis and frequent belching).

A 24-years-old male football player presents to the emergency department with right foot pain which started an hour ago during training. He claims that the pain started right after he made a sudden change in direction. He is unable to weight bear on the affected foot. On examination, there is a slight swelling and tenderness over the right midfoot. An x-ray of the foot reveals a lateral displacement of the second metatarsal on AP view. Which of the following is the most likely diagnosis?

Lisfranc injury Lisfranc's injury is a dislocation of the base of the second metatarsal and the medial cuneiform in the midfoot. The injury usually occurs due to a direct force, such as a sudden rotation of the joint during such as changing direction or a forced plantar flexion. This patient's presentation and mechanism of injury is typical for this injury and it is confirmed by the finding on his x-ray. 48% Stress fracture Stress fractures usually occur due to repetitive force on the bone. Although fracture line may not be appreciated on initial x-ray, dislocation of the tarsometatarsal joint will not be present as well. 28%

A 32-year-old female is seen on the neurology ward. She was hospitalised following a fall which led to a subarachnoid haemorrhage. On examination today, she appears alert and well. Her observations are normal. However, she states that since her admission she has been going to the toilet much more often and has been feeling very thirsty. She has a past medical history of bipolar disorder, depression and dyspepsia. The patient has several blood and urine tests which show hypernatraemia, high serum osmolality and low urine osmolality. What is the most likely cause of her condition?

Lithium This patient's symptoms and investigations point towards diabetes insipidus. Lithium is a known cause of nephrogenic diabetes insipidus, in which the kidneys do not respond appropriately to antidiuretic hormone. As this patient has a past medical history of bipolar disorder, there is a reason for her taking lithium. 45%

A 74-year old male with colorectal cancer attends his oncology appointment. He asks questions about metastasis of the cancer. Which site is it most likely to spread to?

Liver This is the most common site for metastasis for colon cancers. The spread is via the portal circulation. 71%

A 24-year-old male attends his GP surgery feeling generally unwell. He is a regular user of heroin, but has recently run out of money and so has not taken any heroin for the last 24 hours. During the consultation he reports feeling extremely anxious, with watering eyes and a stomach ache. His most troubling symptom is the diarrhoea, which has occurred five times already since waking. Which of the following is the most appropriate first line management?

Loperamide In acute heroin withdrawal, NICE specifically advises against prescribing opiates and instead recommends symptomatic management. As this man's most troubling symptom is diarrhoea, loperamide is the most appropriate option. Alternatively lofexidine (an alpha 2 receptor agonist) can be used to help relieve physical symptoms, and benzodiazepines can be given for agitation. 48%

A 32-year-old woman presents to the emergency department with a severe, throbbing headache occurring all across her head. She also feels nauseated and has vomited several times. On examination, you note bilateral papilloedema and she appears confused. A non-contrast CT head is requested which shows hyperdensity in the superior sagittal sinus. Given the most likely diagnosis, what is the most appropriate treatment?

Low molecular weight heparin (LMWH) This patient has presented with features of intracranial venous thrombosis. The presenting symptoms are typically very non-specific (confusion, nausea, headache), therefore often a non-contrast CT head is the first imaging test performed. A non-contrast CT head would typically show hyperdensity in the affected sinus. The addition of contrast can identify the filling defect. In the superior sagittal sinus, the filling defect is known as the empty delta sign. LMWH is the first-line treatment for intracranial venous thrombosis. 25% NOT DOAC

A 58 year old woman presents to the Emergency Department with shortness of breath. She has been experiencing bilateral hip and shoulder weakness over the past year which she put down to aging. On examination, she is visibly short of breath, there is no obvious loss of muscle bulk and reflexes are present but power is 3/5. Bloods show elevated creatinine kinase and liver enzymes, Chest x-ray is normal. A blood gas is taken as well. What is the blood gas likely to show?

Low oxygen, high carbon dioxide Low oxygen and high carbon dioxide means that the patient is in type 2 respiratory failure. They have presented with features of polymyositis, the main symptom being bilateral girdle weakness without loss of muscle bulk and elevated serum enzymes. Polymyositis is more prevalent in females and 40-60 year olds. As the condition progresses, it can lead to neuromuscular weakness such as in the respiratory muscles, which leads to poor ventilation and type 2 respiratory failure. 54%

A 58-year-old man is treated for a right head of radius fracture conservatively with a cast and arm sling. A week later, he complains of difficulty using his right hand to pick up objects, but is fine when holding objects. On examination, he is unable to extend his fingers. There is no sensory loss. Which of the following nerve injury has this patient develop?

Low radial nerve injury Low radial nerve injury happens at the forearm. The fracture at the head of radius fracture has cause the patient to develop low radial nerve injury. Patient would have difficulty extending fingers (finger drop) but sensation would be intact. 44% High radial nerve injury High radial nerve injury happens at the shaft of the humerus. Patient will have difficulty extending his wrist (wrist drop) on top of having finger drop. 32% Very high radial nerve injury Very high radial nerve injury happens at the level of the axilla and is usually due to impingement. Patient will have tricep weakness on top of having wrist and finger drop. 7%

what organ is spared in polyarteritis nodosa

Lungs This patient has signs and symptoms of polyarteritis nodosa. This is a rare small and medium vessel vasculitis which causes systemic symptoms and is strongly associated with hepatitis B infection. It most commonly affects the skin, kidneys, heart, nervous system and gastrointestinal tract. The lungs are usually spared in this condition and patients do not tend to have respiratory symptoms. 38%

A 39-year-old woman attends her general practitioner, as she has been trying to get pregnant for the last 10 months. In an attempt to increase her success, she has started using ovulation test strips to work out when she is most likely to conceive. What hormone do ovulation test strips most likely detect?

Luteinising hormone (LH) LH spikes just prior to ovulation. Women may use daily ovulation test strips to detect LH and alert them to when they are about to ovulate so they can time their sexual intercourse with this. Day 3 LH is sometimes used to investigate subfertility. 54%

A 24-year-old female is referred to haematology by her GP. She had presented with night sweats, fatigue, and weight loss and was found to have cervical lymphadenopathy. She has no medical history of note. What investigation will give a definitive diagnosis?

Lymph node biopsy The patient has all the symptoms of lymphoma. A lymph node biopsy will determine the presence of Reed-Sternberg cells, and distinguish Hodgkin's lymphoma from non-Hodgkin's lymphoma. 76%

A 35 year old male presents to the sexual health clinic with a painless penile ulcer that he first noticed 2 weeks ago. He has had 5 casual partners in the last month and reports that he has sex with both men and women. He reports having fever and malaise for the past few days. Examination reveals bilateral tender groin swellings. Which of the following is the most likely diagnosis?

Lymphogranuloma venereum (LGV) This begins with a painless ulcer which progresses to form painful inguinal buboes, causing the characteristic "groove" sign. This may be accompanied by fever and malaise. Men who have sex with men (MSM) are at higher risk of LGV 44%

first line mx of myoclonic seizures in M and F

M = sodium valproate F = Levetiracetam

median nerve injury is associated with which fractures (so is ulnar nerve)

Median nerve Median nerve injury is most associated with supracondylar fractures and more distal injuries. Patient would have impaired flexion of the wrist, thumb, index and middle fingers and loss of sensation over the thenar eminence. Shoulder movements will not be affected. 0%

A 20-year-old man presents to his GP with polydipsia, polyuria, headache, and a new visual field defect. He is clinically diagnosed with diabetes insipidus. Which of the following would be indicated to investigate the cause of his diabetes insipidus (DI)?

MRI brain A potential cause of his symptoms and DI could be a pituitary adenoma which could lead to DI if there is suppression of antidiuretic hormone (ADH) secretion and can cause headaches and visual field defects (classically bitemporal hemianopia) from mass effect compression on the optic nerve. 60%

28-year-old lady attends the emergency department with left-sided pain in her back that radiates to her groin. The pain started two hours ago. She has a past medical history of recurrent urinary tract infections. A CT scan of the kidneys, ureters and bladder shows a staghorn calculus in the left kidney. What is the most likely composition of this stone?

Magnesium ammonium phosphate (struvite) Staghorn calculi are usually made up of struvite. Struvite is a substance that grows very quickly, explaining why staghorn calculi are so large. Struvite stones are also associated with recurrent urinary tract infections caused by Proteus bacteria. 62%

A woman with known pregnancy-induced hypertension presents at 36 weeks gestation with chest pain, leg swelling, and a headache. A urine dip confirms proteinuria.Before management can be commenced the patient collapses and starts to have a tonic-clonic seizure.What adverse effect should be monitored for while providing the first-line treatment indicated?

Magnesium sulphate - monitor reflexes + respiratory rate

A 68 year old male presents with intermittent calf pain exacerbated by walking and relieved by resting. He smokes 20 cigarettes a day and has done for more than 40 years. His past history is significant for hypertension, type 2 diabetes mellitus, hypercholesterolemia and stage 4 chronic kidney disease. On examination, his lower limbs are dry, shiny and hairless. Buerger's test reveals pallor upon limb elevation and reactive hyperaemia following limb dependence. Which of the following is the best definitive investigation for this patient?

Magnetic resonance angiography (MRA) Symptoms of intermittent claudication, lower limb signs and positive Buerger's test in this patient reveal peripheral artery disease. The gold standard of diagnosis modality is angiography, which can be used to assess the location of the occlusion. MRA does not require administering a contrast agent and does not expose the patient to radiation, hence it is the most suitable for this patient with chronic kidney disease. 20% he has renal disease so dont do CT as we dont want to expose to contrast

A 38-year-old woman presents to the emergency department with abdominal pain. She reports feeling increasingly unwell over the last 3 days. On examination, she is febrile with a temperature of 38.2 degrees Celsius. She appears jaundiced and is tender in the right upper quadrant. She is Murphy's sign is positive. What investigation is most likely to confirm the diagnosis?

Magnetic resonance cholangiopancreatography (MRCP) This patient has ascending cholangitis, presenting with Charcot's triad (right upper quadrant pain, fever and jaundice). This indicates blockage of the common bile duct and infection, most likely due to an impact gallstone. MRCP is the gold-standard diagnostic test for confirming ascending cholangitis. 46% MRCP first to confirm diagnosis. Not ERCP - this is used to dislodge the stone

A 30-year-old female presents to the emergency department following a road-traffic accident. She is alert and responsive however complains of bilateral limb numbness & weakness. What is the next best step in management for this patient?

Maintain neutral neck position and CT spine This patient is at risk of having a C-spine injury. A neutral neck position is needed to stabilise the C-spine. A CT scan of the spine is the best diagnostic tool for this injury. 67%

A 34-year-old female presents after a fall and is unable to bear weight on her right leg. An x-ray of her right leg shows a medial malleolus fracture with widening of the distal tibiofibular syndesmosis and a fibular neck fracture. What is the name given for this injury?

Maisonneuve fracture Maisonneuve fracture is a combination of proximal fibula fracture with a ligamentous injury (deltoid ligament, distal tibiofibular syndesmosis) and/or a medial malleolus fracture. 43%

A 68 year old woman with a history of osteoarthritis presents to the respiratory assessment unit with a six month history of increasing shortness of breath, haemoptysis, reduced exercise tolerance and weight loss. She does not have a history of recent travel. On examination, there are reduced breath sounds and dullness to percussion in the left base. Pleural fluid shows a pleural fluid to serum protein ratio of 0.7, LDH of 0.65 and pH of 7.3. Which of these is the most likely underlying cause?

Malignancy Malignancy is something to rule out in unilateral pleural effusion. The pleural fluid findings show an exudative pattern and in addition to symptoms of haemoptysis and weight loss, malignancy would be the most likely underlying diagnosis. 75%

A 45-year old male is undergoing knee surgery for a meniscal tear. Sevoflurane is being used as the anaesthetic agent. The surgeon states his muscles have become rigid. The anaesthetist reviews his observation and notes that his heart rate is 130bpm and respiratory rate is 30 breaths per minute. What is the most likely diagnosis?

Malignant hyperthermia The most common cause of malignant hyperthermia is an autosomal dominant mutation in the ryanodine receptor 1, increasing calcium levels in the sarcoplasmic reticulum and increasing metabolic rate. It presents with features such as rigidity, tachycardia and tachypnoea. 94%

A 19-year-old girl attends her GP surgery. She is distressed as she had a helix piercing six months ago, and despite removing the piercing and daily washing she still has a painless lump on her ear. The patient has never had this reaction to any piercings before. It is not painful.On examination of the ear, there is a flesh-coloured lump approximately 1cm by 1cm beside the site of the piercing.The patient is afebrile and has no known drug allergies.What would be an appropriate management option for this patient?

Management is with intra-lesional steroids or excision, although the latter may lead to further keloid scarring.

do people normally respond to donepezil

Many patients with Alzheimer's disease do not benefit from donepezil Around half of patients with Alzheimer's disease do not benefit from taking donepezil. In some cases, donepezil even causes worsening of cognition or agitation. 17%

A 34-year-old female presents to the orthopaedic clinic with a three day history of right knee pain. The pain started after she twisted her knee during a frisbee game. On examination, there is effusion of the right knee and there is tenderness along the medial joint line. Her MRI of the knee shows a hyperintense line in the medial meniscus. Other structures of the knee on the MRI appear to be normal. Which of the following tests is likely to be positive for this patient?

McMurray test This patient's presentation and examination findings are suggestive of a diagnosis of medial meniscus injury and is confirmed by the hyperintense medial meniscus seen on her MRI. McMurray test refers to the manoeuvre of passive external rotation of the patient's tibia with valgus stress (for medial meniscus) or passive internal rotation of the patient's tibia with varus stress (for lateral meniscus) while extending the knee. The test is positive if pain or audible pop/click sound is elicited on performing the manoeuvre which is suggestive of a meniscus injury. 51%

A 4-year-old female is brought into the emergency department by her parents with a fever of 40°C for nearly three days. She has also been coughing and sneezing. She has no medical history. On examination, bilateral conjunctivitis is noted, and a maculopapular rash is seen on the back of the head and ears. What is the likely illness?

Measles The characteristic rash of measles does not normally start until after a few days of fever, where it begins on the back of the head and behind the ears. The early course of measles can be thought of as the 4Ds (4 days of fever) and the 3Cs (cough, coryza, conjunctivitis). 47% Rubella virus Rubella typically causes a low-grade fever and a characteristic rash which initially presents on the face. 21%

meconium ileus on x-ray

Meconium ileus There are many causes of bilious vomiting in a newborn; however, this case's radiological findings and treatment are consistent with intestinal malrotation, which has led to volvulus. Meconium ileus is where the distal ileum is obstructed due to thick and impacted meconium. This appears on abdominal x-ray as an absence of air-fluid levels in the bowel and a 'bubbly' appearance of the distended intestinal loops. Contrast studies will show filling defects caused by the meconium. 3%

A 46-year-old man attends his general practitioner with elbow pain. He has just returned from a trip with friends in Cornwall, and he is concerned he 'overdid it' when playing tennis and Crazy Golf during the trip. He described pain in his elbow with a tingling sensation in his fourth and fifth fingers. On examination, the pain is worse on pronation of the forearm and wrist flexion. What is the most likely diagnosis?

Medial epicondylitis Medial epicondylitis, or golfer's elbow, is pain in the medial epicondyle, exacerbated by wrist flexion/pronation. If there is involvement of the ulnar nerve, there may also be paraesthesia of the fourth and fifth digits. Commonly confused with lateral epicondylitis or tennis elbow, where pain is worse on wrist extension and forearm supination. Pronation = Putt (golf) Supination = Serve (tennis) 49%

mx of bells palsy - for how long is pred given

Prednisolone 1 mg/kg for 10 days This patient has a Bell's palsy - a unilateral idiopathic lower motor neurone facial nerve palsy. She also has associated symptoms such as post-auricular pain and hyperacusis. Pregnancy is a risk factor for Bell's palsy. 59%

A 40-year-old woman presents with complaints of fatigue and oedema. Her past medical history is significant for chronic hepatitis C infection. She is a smoker and has been taking intravenous drugs for the past 20 years. Urinalysis reveals protein +, blood +, and red blood cell casts. Other investigations are as follows: Albumin: 8 g/dL Creatinine: 220 µmol/L C3: 0.68 g/L C4: 0.09 g/L Serum creatinine level a week ago was normal (100 µmol/L). A renal biopsy shows glomerular crescent formation. Antinuclear cytoplasmic antibody, Antinuclear antibody, and anti-glomerular basement membrane antibody testing are negative. What is the most likely diagnosis?

Membranoproliferative glomerulonephritis A rapid decrease in glomerular filtration rate, as evidenced by increased serum creatinine over a short period of time, red blood cell casts on urinalysis, and crescent formation on a renal biopsy, suggests that she is suffering from rapidly progressive glomerulonephritis (RPGN). The most likely cause of her diagnosis is chronic hepatitis C infection. 62%

A 27-year-old woman attends her GP reporting a two-week history of swollen ankles and "frothy-looking" urine. She is referred to nephrology and after further assessment undergoes a renal biopsy. The biopsy report describes subepithelial immunoglobulin and complement deposits on the glomerular basement membrane. The basement membrane is also thickened. What is the most likely diagnosis?

Membranous nephropathy The renal biopsy findings in this case are typical of membranous nephropathy. A tip for remembering the names of the various glomerulonephritides and their biopsy findings is to know that their names often relate to their histological appearances. For example, in membranous nephropathy there is thickening of the glomerular basement membrane. Likewise, minimal change disease gets its name from the fact that there is minimal or no abnormality seen on light microscopy in this condition. 50%

An 8 year old girl is brought to the GP by her mother with a sore throat for the past five days. Incidentally, on examination, a harsh pansystolic murmur is heard during cardiac auscultation at the left lower sternal region. Echocardiogram reveals a small septal defect located apical to the aortic annulus but below the crista supraventricularis. Which of the following best describes the type of ventricular septal defect?

Membranous ventricular septal defect Ventricular septal defect (VSD) is the most common congenital cardiac anomaly in children. The interventricular septum is an asymmetric curved structure due to the pressure difference in ventricular chambers. It is composed of five parts: the membranous, muscular (frequently referred to as trabecular), infundibular, atrioventricular, and inlet. Failure of development or fusion of one of the above components during morphogenesis of the embryonic heart results in a VSD in the corresponding component. Type 2 (membranous) VSD is the most common type (80% of all defects). It is located in the membranous septum inferior to the crista supraventricularis. It often involves the muscular septum, which is commonly known as perimembranous. 28% Muscular ventricular septal defect This is an incorrect answer. Type 4 (muscular, trabecular) VSD is located in the muscular septum, bordered by muscle, usually in the apical, central, and outlet parts of the interventricular septum. 18% Infundibular ventricular septal defect This is an incorrect answer. Type 1 (infundibular, outlet) VSD is located below the semilunar valves (aortic and pulmonary) in the outlet septum of the right ventricle above the crista supraventricularis. 19% Inlet ventricular septal defect This is an incorrect answer. Type 3 (inlet or atrioventricular canal) VSD is located just inferior to the inlet valves (tricuspid and mitral) within the inlet part of the right ventricular septum. 13%

A 92-year-old is in the general medical ward awaiting a package of care for discharge. Unfortunately, she becomes unwell with a productive cough, tachycardia and hypotension. A hospital-acquired pneumonia is suspected, and she is commenced on empirical antibiotics. A sputum culture shows extended-spectrum beta-lactamase (ESBL) producing Klebsiella pnuemoniae. Based on this, what is the most appropriate antibiotic?

Meropenem Carbapenems are indicated for infections with extended-spectrum beta-lactamase (ESBL)-producing bacteria. Due to rising resistance, this is the last class of antibiotic available for ESBL-producing bacteria, and the situation is getting worse with the rise of carbapenemase-producing enterococcus (CPE). 52%

is barrets dysplasia or metaplasia

Metaplasia Barrett's oesophagus involves metaplasia of the epithelial lining, which is characterised by the replacement of normal stratified squamous epithelium by simple columnar epithelium. Metaplasia refers to a reversible, abnormal change of cell type to another. 64%

A 35-year-old woman presents to the emergency department with a 2-week history of shortness of breath, dry cough, and rigours. She has a 1-month history of rheumatoid arthritis for which she started taking methotrexate and diclofenac when needed, a 5-year-history of hypertension controlled with amlodipine, and a urinary tract infection treated 2 weeks ago with nitrofurantoin. She does not smoke.On examination, her temperature is 38.1ºC, her pulse is 98 bpm, and her blood pressure is 135/75 mmHg. Bilateral fine inspiratory crackles are heard.Out of the options listed, what is the most likely cause?

Methotrexate may cause pneumonitis - typically presents with cough, dyspnoea and fever

A 24-year-old man is playing for his local football team when he collides head first with an opposing player. Although initially shaken up and appearing dazed, he quickly recovers and continues the rest of the game. However, shortly afterwards he starts complaining of a worsening headache and starts to become distressed and confused. His teammates bring him into the emergency department where his GCS is found to be 12 and an urgent CT head is arranged. His CT head shows a biconvex, hyperdense collection which does not cross suture lines. Based on the likely diagnosis, which artery has most likely been affected?

Middle meningeal artery This is a classical presentation of an extradural haemorrhage - head injury causing an initial loss of consciousness, followed by a lucid interval where the patient appears to have recovered which is then followed by a deterioration in GCS. The most common source of extradural bleeding is the middle meningeal artery which runs behind the pterion (the weakest part of the skull which is particularly vulnerable to traumatic impact). 80%

A 61-year-old male who is currently an inpatient on the cardiology ward becomes acutely short of breath and hypotensive. He was admitted three days prior with central chest pain and was found to have ST elevation in leads II, III and aVF. He was subsequently treated for an inferior ST-elevation myocardial infarction. Now the patient has become tachypnoeic and hypoxic. On examination, a pan-systolic murmur is heard in the fifth intercostal space at the mid-clavicular line and the patient has bilateral coarse crackles on auscultation. Given the probable diagnosis, which complication has most likely occurred?

Mitral regurgitation This patient is presenting with acute mitral regurgitation following a myocardial infarction. He is experiencing breathlessness, which is most likely a result of pulmonary oedema. A pan-systolic murmur is also characteristic of mitral regurgitation. Acute mitral regurgitation can occur after a myocardial infarction due to rupture of the papillary muscles. 71% Ventricular septal defect A ventricular septal defect is another possible complication of a myocardial infarction and can also cause a pan-systolic murmur. It presents similarly to acute mitral regurgitation, however it is much less common. 11%

eligibility for lung vol reduction surgery

Predominant upper lobe emphysema is a factor that would make her eligible for lung reduction surgery FEV1<50% predicted, PaCO2 <7 and Transfer capacity of the lung for carbon monoxide (TlCO) >20%.

A 58-year-old woman with a background of diabetes presents with right leg pain. She describes the pain as a deep ache in her thigh. She also mentions experiencing weakness and a tingling sensation in her fourth and fifth fingers around two months ago and has not fully regained function. On examination of her right leg, a strong popliteal pulse can be felt but the right knee reflex cannot be elicited. What is the most likely diagnosis?

Mononeuritis multiplex This patient has presented with mononeuritis multiplex which is a peripheral neuropathy, with one of the strongest risk factors being diabetes. It is characterised by the involvement of multiple, isolated nerve regions affecting sensory and motor function. Symptoms tend to arise subacutely. 65% Sciatica This would present with back pain that can shoot down to the posterior thigh and would not explain the paraesthesia in the hand. 2% Meralgia paraesthetica This is caused by compression of the lateral femoral cutaneous nerve and would present with abnormal sensations on the lateral aspect of the thigh. This does not correspond with this patient's presenting complaint. 13%

A 20-year-old male presents to his GP with a severe sore throat. He is normally fit and well. He has also been suffering from malaise and fatigue for 10 days. On examination, his chest is clear. His abdomen is soft with mild splenomegaly. His tonsils appear enlarged. His observations are as follows: Heart rate: 80 beats per minute Blood pressure: 135/85 mmHg SpO2: 95% on room air Temperature: 38°C What is the most appropriate next test to perform?

Monospot test This is likely a case of infective mononucleosis caused by the Epstein-Barr virus (EBV). The monospot test is the most appropriate next test given its speed of results and cost; if this yields a negative result in the context of high clinical suspicion, serology testing may then be indicated. 48% Epstein-Barr virus (EBV) serology Epstein-Barr virus (EBV) serology is the most accurate test for EBV infection. It is used in the context of high clinical suspicion with a negative monospot or with immunocompromised patients. 38%

A 5-year-old boy is brought into the general practice by his mother with a 2-week history of abdominal pain. On further questioning, his mother explains that he has been scared of using the toilet for the last week and has been straining excessively. He has not opened his bowels in 4 days. Which of the following is the most appropriate management for this case? movicol disimpaction or movicol maintenance regime

Movicol disimpaction regimen This case is suggestive of chronic constipation, which has escalated to faecal impaction. NICE recommends an escalating dose regimen on a macrogol such as Movicol in the first instance. 78%

differnece between men 2a and men 2b

Multiple endocrine neoplasia-2a (MEN-2a) MEN-2a is associated with medullary thyroid cancer, pheochromocytoma and parathyroid hyperplasia/adenoma. 18% Multiple endocrine neoplasia-2b (MEN-2b) MEN-2b is associated with medullary thyroid cancer, pheochromocytoma, parathyroid hyperplasia/adenoma and mucosal neuromas. 15%

A 40 year old male presents to A&E with an acute onset of severe, generalised abdominal pain that began this morning. He has been experiencing fevers, night sweats and non-bloody diarrhoea for the past 1 week. He has no recent travel history. He is a known HIV positive patient currently on antiretroviral therapy. Liver function tests show: Bilirubin 11 µmol/L ALT 32 iU/L AST 35 iU/L ALP 358 iU/L GGT 15 U/L LDH was 410 iu/L What is the most likely causative organism?

Mycobacterium avium intracellulare This usually occurs in the immunocompromised, and causes abdominal pain due to intra-abdominal lymph node enlargement. ALP and LDH are typically elevated. It may cause pulmonary, gastrointestinal and disseminated disease (particularly in HIV patients) 18% cryposporidium parvum causes chronic secretory diarrhoea in HIV pts and is more severe in those with low CD4 counts

A 64-year-old man is undergoing investigations prior to receiving a renal transplant. He is informed that he will need to have a viral and bacterial screen before receiving the transplant. Which bacterial infection is routinely screened for prior to a renal transplant

Mycobacterium tuberculosis Patients are routinely tested for mycobacterium tuberculosis infection prior to renal transplantation. They are tested for active infection that needs treatment before the transplant, and also for latent infection that may reactivate once the person begins immunosuppressant therapy. 65%

A 21-year-old male is brought to the emergency department with sudden onset chest pain that started during a university lecture. He describes it as a sharp central pain which is worse when he breathes in. He is also feeling very breathless. This is the first time he has every felt like this. He has no past medical history and is normally very active. He takes no regular medications or recreational drugs. On further questioning, he says he has been feeling very rough for the past week with a cold. On assessment, he has a heart rate of 122 but his other observations are normal. There are no abnormalities detected on physical examination. An ECG shows sinus tachycardia and T wave inversion. What is the most likely diagnosis?

Myocarditis Myocarditis is the correct answer. The symptoms, ECG findings and history of a recent viral illness are all in keeping with myocarditis. ECG changes that may be seen in myocarditis include sinus tachycardia, ST changes and T wave inversion. 42%

A 30 year old lady attends A&E with chest pain and difficulty breathing. She says the pain started two hours ago and is in the middle of her chest, radiating to the left arm and worsened with exertion. She has been feeling more and more breathless since the pain started. She works as a long-haul lorry driver but has been on leave for the past-week. She mentions that she has been feeling a bit under the weather lately with flu-like symptoms. Her NEWS score is 1 due to a HR of 105. Her troponin I comes back as 106ng/L (<18). Electrocardiogram shows normal sinus rhythm with no ischaemic changes. What is the most likely cause of her symptoms?

Myocarditis There are many causes of a raised troponin, not just a myocardial infarction. It is therefore very important to consider alternative differentials whenever you see a high troponin. In this case, we have a young lady with a recent history of what sounds like a viral illness and new-onset cardiac symptoms. This is highly suggestive of myocarditis - inflammation of the myocardium of the heart. It usually resolves by itself over time, but can require supportive care and monitoring in the acute phase. 58%

A 65-year-old woman presents to the emergency department with sudden onset loss of vision in her left eye. She denies recent trauma and does not complain of pain. In the last 2-3 days she reports noticing flashes in the peripheries of her vision.On examination, her left eye is erythematous with an absent red reflex. The cornea appears hazy.What is a risk factor for the underlying diagnosis?

Myopia is correct. This patient has a diagnosis of retinal detachment given the history of flashes in the peripheral field of vision followed by a sudden and painless loss of vision. Examination findings in retinal detachment include reduced visual acuity and loss of the red reflex, as seen here. Other clinical findings include a relative afferent pupillary defect and visual field defects. Risk factors for retinal detachment include age > 40 years, previous eye surgery, trauma and myopia (short-sightedness).

Achilles tendonitis mx

NSAIDs, physio, rest if sx persist beyond 7 days

anti-gbm on renal biopsy

Necrosis with epithelial cell crescents The likely diagnosis here is Goodpasture syndrome. The blood tests reflect an acute kidney injury. The development of alveolar haemorrhage can explain the slightly lower haemoglobin levels. A kidney biopsy is the gold standard for diagnosis but is not required to begin treatment. Crescent formation is the histopathologic hallmark of the anti-GBM disease. 31%

A 45-year-old woman is admitted to the medical ward with a 2-day history of leg swelling. She has a background of breast cancer, treated via chemotherapy. On examination, she is febrile and tachycardiac. She has unilateral swelling of the right thigh and a well-demarcated patch of blistering erythema. A subsequent USS shows fluid and air accumulating between the fascial layers of the right thigh. What is the most likely diagnosis?

Necrotising Fasciitis This patient has necrotising fasciitis, as evidenced by her fever, tachycardia and signs of a soft tissue infection in the leg (erythema, blistering and swelling). The ultrasound scan showing fluids and air between the fascial layers indicates the infection has penetrated deeper soft tissues and is diagnostic of necrotising fasciitis. This has likely developed because the patient is immunosuppressed due to her chemotherapy. 74%

NEC x-ray

Necrotising enterocolitis (NEC) There are many causes of bilious vomiting in a newborn; however, this case's radiological findings and treatment are consistent with intestinal malrotation, which has led to volvulus. Necrotising enterocolitis (NEC) is a common gastrointestinal condition in preterm neonates. The main investigation in NEC is a supine abdominal x-ray which shows dilated asymmetrical bowel loops, bowel wall oedema with 'thumbprinting' and pneumatosis intestinalis (gas within the bowel wall). 2%

2-week-old neonate, born at 34 weeks, in the neonatal unit starts to vomit green fluid and develop bloody stools. On examination, there are no bowel sounds heard. A capillary blood gas shows a metabolic acidosis. An abdominal x-ray is performed, which shows dilated bowel loops with gas within the bowel wall. Which of the following is the most likely diagnosis?

Necrotising enterocolitis (NEC) This baby is preterm and has presented with signs of necrotising enterocolitis (NEC)(bilious vomiting, bloody stools, absent bowel sounds, systemic compromise with metabolic acidosis). NEC is a common gastrointestinal condition in preterm neonates. The main investigation in NEC is a supine abdominal x-ray which shows dilated asymmetrical bowel loops, bowel wall oedema with 'thumbprinting' and pneumatosis intestinalis (gas within the bowel wall). 81%

A 52 year old man presents to his GP with a twenty-four hour history of a left-sided red, hot and swollen first metatarsophalangeal joint (big toe). This is his first episode. He has a past medical history of hypercholesterolaemia and takes atorvastatin for it. He has no known drug allergies or previous surgeries and no family history of note. He does not drink alcohol and stopped smoking thirty years ago. He smoked 5 cigarettes per day for three years. He has recently taken up running 5km twice a week and commenced a strict high-protein pescatarian diet one month ago to try and improve his health. Which part of his history has most likely contributed to his acute flare of gout?

New pescatarian diet Correct. Common triggers of acute flares of gout include seafood/ protein binges, chemotherapy, trauma and surgery. Common risk factors for gout are obesity, hypertension, diabetes, chronic kidney disease, diabetes, metabolic syndromes, some medications, being male, being over 50 years old and having a family history of gout. With this information in mind, this patient's possible risk factors and triggeres include him being over 50, being male and his new high protein seafood diet. From the options listed in the answers, his most likely reason for this acute flare is his new pescatarian diet (a diet where individuals eat fish and seafood but no other meat or poultry). 66%

A 57 year old man with lung cancer is referred to smoking cessation clinic. He has a 35 pack year history of smoking cigarettes, a history of epilepsy and suicidal ideation. Which of these would be the most appropriate choice of medical management for smoking cessation?

Nicotine replacement therapy All patients should be encouraged to stop smoking and should be referred to smoking cessation services for support if they are willing to quit. There are a number of behavioural and therapy options available. Nicotine replacement therapy is the most appropriate form of medical management in this case, given the patient's past medical history of epilepsy and suicidal ideation. There are multiple formulations including patches and gums. 78% cant use varencline as it can increase suicidal ideations bupropion is CI in epilepsy

A 42-year-old woman attends her GP surgery after an episode of memory loss. Her partner reports that for around 12 hours she seemed to have no memory of recent or more distant events. After this period her symptoms completely resolved. She is diagnosed with transient global amnesia. Which of the following is the most appropriate management of transient global amnesia?

No action needed Transient global amnesia is a neurological condition characterised by a temporary but total disruption of both short and long term memory. Other cognitive functions are preserved. Patients normally make a full recovery without treatment, and the phenomenon is unlikely to recur. 81%

A 22-year-old woman books a doctor's appointment because she is worried about a pink bump which she has recently noticed on her left shin. It is not causing her any physical symptoms and she denies any recent trauma or insect bites to the leg. On examination, the lesion is 1cm in diameter, has smooth round borders and the overlying skin dimples when it is squeezed. Given the likely diagnosis, what is the most common associated complication?

No complications A dermatofibroma is a benign fibrous nodule which most commonly appears on the legs. It usually presents as an asymptomatic papule which dimples when squeezed (the dimple sign). They persist for life but patients can be reassured that they are harmless. 53%

is Phaeochromocytoma in MEN 1

No it is in MEN 2a/b MEN 1 = is a combination of parathyroid, pituitary and pancreatic tumours in MEN1 syndrome. 51%

Types of Hodgkin's lymphoma

Nodular sclerosis (vs. mixed cellularity, lymphocytic predominance, lymphocytic depletion)

A 60-year-old woman is seen in the liver clinic after recently being diagnosed with primary liver cancer. Her past medical history is notable for hypertension, type 2 diabetes and ulcerative colitis. Her BMI is 38 and she drinks around 15 units of alcohol per week. What is the most likely underlying cause of her liver cancer?

Non-alcoholic fatty liver disease This patient's obesity and type 2 diabetes puts them at high risk of having non-alcoholic fatty liver disease (NAFLD). It is one of the most common chronic diseases in the western world with estimated around 1 in 3 people in the UK affected. In the context of this patient's new diagnosis of liver cancer, NAFLD is therefore the most likely cause. 40%

A 45-year-old woman presents to her GP with a new rash which developed shortly after a bee sting yesterday.She has a widespread, raised, erythematous rash that covers her back and chest in patches. The patches developed not long after the bee sting. She is finding it incredibly itchy, particularly at night time.Apart from the rash, the patient is well and has no swelling of the lips or tongue and no breathing difficulties.Given the likely diagnosis, what is the most appropriate first-line treatment option?

Non-sedating antihistamines are first-line for acute urticaria This patient is describing a typical acute urticarial rash in response to a bee sting. Other common triggers include food allergies, infections, heat or cold exposure or some drugs such as NSAIDs or antibiotics.The correct answer isloratadinewhich is a non-sedating antihistamine. These are the first-line management of urticaria.

A 52-year-old gentleman with a past medical history of cirrhosis secondary to alcohol-related liver disease undergoes an endoscopy to screen for oesophageal varices. His endoscopy result confirms a finding of grade 2 varices. Which of the following is used as a primary prophylaxis of oesophageal variceal bleeding?

Non-selective beta blocker For those with grade 2 or 3 oesophageal varices, prevention of variceal bleeding through modalities such as non-selective beta blocker and variceal band ligation is recommended. 57% terlipressin is used for acute variceal haemorrhage

mx of hsp

Non-steroidal anti-inflammatory drugs (NSAIDs) This is a case of Henoch-Schonlein purpura (HSP). It commonly presents with a triad of purpura/petechiae on the buttocks and lower limbs, abdominal pain and arthralgia. Other features include haematuria, proteinuria, pyrexia and hypertension. The majority of HSP cases are self-limiting and resolve completely. Therefore, simple analgesia such as NSAIDs and/or paracetamol can be used. In severe cases, steroids may be indicated. If hypertension is present, antihypertensives may also be indicated. 43%

Which of the following is the most common cause of Down syndrome?

Nondisjunction mutation Nondisjunction mutation is the cause for 95% of cases of Down syndrome. Nondisjunction occurs during mitosis when the chromosomes do not split correctly, leading to a trisomy (three of chromosome 21) and a monosomy (one chromosome of 21). The monosomic cell dies, and the trisomic cell results in a Down syndrome phenotype. This is the result of a random mutation and is not inherited. 59%

A 50-year-old man of black African origin has recently been diagnosed with essential hypertension and is started on amlodipine. A routine blood test reveals a neutrophil count of 1.2 x 10^9/L and no other abnormalities. His observations are normal and he feels completely well. He denies any recent illnesses. What is the most likely cause of his neutropenia?

Normal variant Neutropenia is a normal variant in black people and Middle Eastern people. It is usually mild (between 1.0-1.5 x 10^9/L) with no increased risk of infection. 35%

onjective signs of poor asthma control

Objective signs of poor asthma control include: reduced effectiveness of bronchodilator reduce exercise tolerance asthma attack within the last two years history of waking up at night with wheeze/cough/chest pain or daytime asthma symptoms (three times a week or more) This patient describes reduced effectiveness of her bronchodilator. 57%

mx of asx ganglion cysts

Observation Observation is the first line treatment for asymptomatic ganglion cysts. Patient's modified allen test is also normal which suggest that the ulnar artery is not compromised, a complication that can occur if the cyst is found on the volar aspect of the wrist. 57%

risk factors for ovarian ca

Older age Smoking Greater number of ovulations (early menarche, late menopause) Obesity Hormone replacement therapy (HRT) BRCA 1 and 2 genes

A 26 year old lady attends her GP practice with elbow pain for the past week followed by a lump appearing on her elbow 2 days ago. This lump has got bigger and is now stopping her fully extending her arm. She has not injured her arm and she is frustrated as she has been taking part in a 'plank competition' at the gym and she can no longer do this as she can't lean on her elbow. On examination there is a lump over the olecranon, it is not painful, red or hot to touch. She is systemically well and has no other joint abnormalities. What is the most likely diagnosis?

Olecranon Bursitis The common presentation of pain and swelling localised to the olecranon following a repetitive injury makes this the most likely diagnosis 83%

dose of oral antiviral to treat hsv - when pregnant and not pregnant

Oral Aciclovir 400mg three times a day This woman has a primary herpes simplex virus (HSV) genital infection. Treatment with oral Aciclovir should be given immediately following clinical diagnosis. A higher dose of 400mg three times a day is required due to the higher circulating blood volume found in pregnancy. Acquisition of primary genital herpes simplex in the first or second trimester does not preclude vaginal delivery, however suppressive therapy with oral Aciclovir may be given from week 36 to reduce the risk of HSV lesions at term. If this woman has HSV lesions at term, delivery via caesarean section is recommended to reduce the risk of vertical transmission to the newborn 49%

A 27 year old man presents to his GP complaining of penile soreness, pruritus, redness. On examination he has dry, red glazed plaques and papules on his penis. He has one sexual partner of seven years and does not use condoms. He has no other past medical history of note. He is otherwise fit and well. Which medication should be prescribed given the most likely diagnosis?

Oral Fluconazole This is the correct answer. This man has genital candidiasis which is deducible from his history. The most common cause of Candidiasis is Candida Albicans. It is generally not sexually transmitted, can be caused by poor hygiene and predisposed by diabetes. An alternative treatment would be an imidazole cream for up to 14 days, such as clotrimazole. 26%

A 79 year old woman presents to her GP complaining of tenderness and pain in her mouth. She has reported a fever of 38 degrees for the past 2 days. On examination there is a diffuse swelling in the submandibular region with associated lymphadenopathy. What is the single most appropriate management of this patient?

Oral antibiotics and oral hygiene advice This is the correct answer. Antibiotics should be given to this patient who is systemically unwell 83%

A 56-year-old gentleman with a past medical history of cirrhosis secondary to alcohol-related liver disease is admitted with a two-day history of fever and abdominal pain. He had a previous episode of spontaneous bacterial peritonitis earlier this year. On examination, there is marked abdominal distension with guarding and rebound tenderness. Ascitic tap shows an elevated neutrophil count of 350 cells/μL and protein of 13 g/L. Which of the following is offered for prophylaxis of spontaneous bacterial peritonitis?

Oral ciprofloxacin Prophylactic ciprofloxacin or norfloxacin is recommended as per NICE guidelines for those at high risk of spontaneous bacterial peritonitis, including those with cirrhosis and ascites with a level of ascitic protein of 15 g/L or less, until the resolution of ascites. 59%

A 24-year-old woman presents to her GP with a two-week history of dysuria and vaginal discharge. She describes the discharge as thin and white-yellow, with a slight smell. Her last menstrual period was three weeks ago, and a pregnancy test is negative. There is no itching or vaginal pain. Urinalysis is negative. She had unprotected sex with a new sexual partner two weeks ago. Which of the following is the most appropriate management?

Oral doxycycline This patient most likely has a diagnosis of chlamydia infection following unprotected sex two weeks ago. Symptoms of chlamydia in women include vaginal discharge, dysuria, and intermenstrual bleeding. Chlamydia is treated with oral doxycycline twice a day for one week. 55% Intravaginal metronidazole gel Intravaginal metronidazole gel is used to treat bacterial vaginosis, which typically presents with a grey-white watery discharge with a characteristic fishy smell. 33%

A 37-year-old woman with a background of multiple sclerosis presents to the GP with blurred and double vision for the past two days. On examination, when she moves her eyes to either side there is limited movement of the adducting eye and nystagmus in the abducting eye. The patient feels well in herself otherwise and has normal observations. What would be the best management of her symptoms?

Oral methylprednisolone As this patient has a background of multiple sclerosis (MS), she is most likely experiencing an acute relapse and has presented with signs of internuclear ophthalmoplegia. This is a complication associated with MS. Before diagnosing a relapse it is important to rule out an infective cause, however this is unlikely as her observations are normal and she has no other symptoms. Oral methylprednisolone is typically the treatment of choice but this should be discussed with an MS specialist before being initiated. 72%

A father brings in his 8-year-old daughter who has got a swollen and red right eye. He says that his daughter has no other health conditions but is currently recovering from a sinus infection. On examination, the right eye is severely red, and you are unable to touch the eye as she screams out in pain when you try to. There are no pupil abnormalities and no photophobia. What is the most likely diagnosis?

Orbital cellulitis This is the correct answer. The vignette above describes a patient who has the symptoms and risk factors of orbital cellulitis. Orbital cellulitis is the infection fo the muscles and fat within the orbit. It is often caused by spread from a neighbouring sinusitis. 61%

A 87-year-old female presents to the emergency department unresponsive following a fall with suspected head trauma. Her pulse can be felt and she has a community DNACPR in situ. A jaw thrust does not help and she is still unresponsive. What is the next best step in airway management?

Oropharyngeal airway insertion Oropharyngeal airways are used in unconscious patients with an airway obstruction after basic manoeuvres. 62% this is done before LMA

A 20-year-old male presents to the GP clinic with pain in the left knee for 3 weeks which worsens whenever he plays football. He also reports his knee being stuck on a few occasions. He does not have a history of trauma to his knee. On examination, there is tenderness and slight swelling over his medial femoral condyle when the knee is flexed. The range of movement is full. Given the history and examination findings, what is the likely diagnosis?

Osteochondritis dissecans Osteochondritis dissecans is the necrosis and displacement of a fragment of bone and cartilage in the joint due to overuse and repetitive microtrauma of the joint. It commonly affects young adults and is worsened by physical activity. Patients may experience joint locking and stiffness. 44% Osgood-schlatter disease Osgood-schlatter disease presents similarly with knee pain which is exacerbated by physical activity. However, it is more commonly found in children. Moreover, the pain and swelling will be localised at the tibial tuberosity instead of the femoral condyle. 26%

A 20-year-old male presents to the GP with hearing problems in his right ear. He first noticed this when he found his headphones sounded out of balance. He also often finds he hears better when there is background noise and is often asked to speak louder, even though he feels he is talking at a normal volume. He reports no fevers, no discharge from the ear and no dizziness. Otoscopy is normal. What is the most likely diagnosis?

Otosclerosis Otosclerosis is the thickening of the trabecular part of the bone. This causes hearing loss as the stapes bone (which transmits sound through the oval window) becomes fused with the surrounding bone removing its ability to move. The hearing loss caused is characteristically better when there is background noise. A common sign is patients speaking quietly as their voice sounds louder in their head. Otosclerosis is treated with hearing aids or surgery to replace the stapes bone with a metal version. 67%

death confirmation

Overview Confirming, or verifying, death is a common request in hospital and in primary care. Legally in the UK, verifying death does not require a doctor to confirm that death has occurred. It is however a doctor's legal duty to notify the cause of death by issuing a death certificate. Steps There is also no legal definition to confirm death in the UK. However, it is generally accepted that confirming death consists of: Confirming the patients identity Checking for any obvious signs of life Checking response to verbal and painful stimuli Assessing pupils - they should be fixed and dilated Feeling a central pulse Listening for heart sounds and respiratory sounds for a total of 5 minutes.

suitability for pep

Overview PEP stands for post-exposure prophylaxis. If a patient is thought to have been exposed to HIV, they can be prescribed a course of drugs that can prevent infection, should the drugs be administered within 72 hours. The suitability of prescribing these drugs is dependent on the circumstances of the exposure. The two drugs used are Raltegravir and Truvada. These are prescribed for 28 days How is suitability for PEP assessed? The suitability for PEP is evaluated using a risk versus benefit analysis. Where risk of transmission is low (less than 1 in 10,000) PEP is not recommended. Situations where PEP is recommended: Receptive anal intercourse with a HIV positive individual Receptive anal intercourse with an individual of unknown HIV status, from a high prevalence area Insertive anal intercourse with a with a HIV positive individual with a detectable viral load Receptive vaginal intercourse with a HIV positive individual with a detectable viral load Insertive vaginal intercourse with a HIV positive individual with a detectable viral load Sharing injecting equipment with a HIV positive individual with a detectable viral load Situations where PEP can be considered (i.e. if there are additional factors that may increase the likelihood of transmission) Insertive anal intercourse with an individual of unknown HIV status, from a high prevalence area Receptive vaginal intercourse with an individual of unknown HIV status, from a high prevalence area Insertive vaginal intercourse with an individual of unknown HIV status, from a high prevalence area Oral sex with ejaculation with a HIV positive individual with a detectable viral load Ejaculate in the eye if individual is HIV positive Sharing equipment with with an individual of unknown HIV status, from a high prevalence area

parental responsibility

Overview Parental responsibility (PR) is a legal term. It is not the same as 'next of kin' and does not necessarily have to be the child's biological parents. It also differs from somebody who may play a day-to-day parental role for the child. Those who have PR have the right to consent to treatment on behalf of their children. It is thus important to check if the person accompanying children to the hospital/GP have parental responsibility, otherwise they cannot give valid consent if unable to obtain it from the patient. Note: Each of the devolved nations has slightly different criteria on PR so it is important to check the precise criteria as per your local setting. Who has parental responsibility? A biological mother automatically has PR upon the child's birth. This status remains in place unless it is removed by the courts (see below). If somebody does not have PR, one has to either enter into a parenting responsibility agreement with a person who has PR or formally apply to be awarded PR. A father usually has PR if he is: Married to the child's mother at the time of birth Listed on the birth certificate In a parental responsibility agreement Adoption: If the parents if they've jointly adopted a child, they both have PR Same-sex partners: If civil partners: both have parental responsibility if they were civil partners at the time of fertility treatment If not civil partners: the second parent can gain parental responsibility by either:applying for parental responsibilitybecoming a civil partner and jointly registering the birthbecoming a civil partner and forming a parental responsibility agreement Married step-parents: Obtain PR via parental agreements or applying for PR via the courts Registered civil partners: Obtain PR via parental agreements or applying for PR via the courts Losing parental responsibility Parental responsibility awarded by the courts can only be removed by the courts Parental responsibility is not lost by divorce or separation Parental responsibility is not lost even if the parent has no contact with the child Parental responsibility is not lost even if there is no financial contribution

PNH

Overview Paroxysmal nocturnal haemoglobinuria (also known as Marchiafava Micheli syndrome) is a rare acquired stem cell disorder of unknown aetiology. An abnormal surface glycoprotein expressed on a subclone of red blood cells marks these cells for complement mediated haemolysis - severity depends on the size of this subclone. Presentation Patients present in early adulthood with nocturnal episodes of intravascular haemolysis (it is not known why this occurs at night), and may be associated with other stem cell defects and increased risk of thrombosis (via an effect on complement mediated platelet aggregation). Diagnosis Diagnosis is with flow cytometry. Management The monoclonal antibody eculizumab, which inhibits formation of the membrane attack complex of the complement cascade, has been used in some subjective success in these patients (improves quality of life, but does not appear to affect mortality rates).

ocular differentials for HIV

Overview When considering ocular disease in HIV patients, it is important to be aware of key differential diagnoses. There is a general increase in all bacterial ocular infections. These include: Retinitis Conjunctivitis Keratitis Episcleritis Cytomegalovirus (CMV) retinitis features CMV is the most common ocular opportunistic infection. It presents with reduced visual acuity. On fundoscopy,there may be a classic "pizza pie" appearance. Treatment involves using intraocular injections of ganciclovir and systemic oral valganciclovir. Herpes simplex virus (HSV) infection (eye features) HSV infection may affect the anterior or posterior segment of the eye. If the central area of the cornea is involved, vision may be permanently affected. Topical aciclovir is used in this instance Varicella Zoster (VSV) infection (eye features) Can cause multiple ophthalmic disorders. These include: Herpes zoster ophthalmicus - eyelids become red and swollen Keratitis Uveitis Progressive outer retinal necrosis Cerebral vasculitis Tuberculosis Can cause either uveitis or discrete ocular granulomas within the retina. Both manifestations respond to regular TB treatment. Ocular malignancies Associated with HIV include Kaposi's sarcoma of the eye. Discrete lesions are found on the eyelid or growing within the conjunctiva. These respond primarily to cART.

A 30-year-old female presents to the emergency department with a one day history of nausea, abdominal pain and confusion. She has a past medical history of hyperthyroidism and is currently five months pregnant. Her husband says that recently she has not been very compliant with her medications and stopped taking them altogether a few days ago. Observations show a heart rate of 150, blood pressure of 135/80 and a temperature of 38.8 degrees. The patient has a set of blood tests which show very high T3 and T4 levels and a low TSH. Her other blood tests including inflammatory markers are normal. Based on the presentation and the deranged thyroid function tests, the patient is diagnosed with a thyrotoxic storm. What is the most appropriate antithyroid medication to prescribe?

PO propylthiouracil This is the correct answer. Propylthiouracil is the first-line treatment for a thyrotoxic storm and is also the preferred antithyroid medication during pregnancy. 54% IV propranolol Propranolol is a beta blocker which may be given to relieve symptoms of hyperthyroidism such as anxiety and palpitations. However, it would be given as an adjunct to an antithyroid medication such as propylthiouracil, rather than as the sole treatment. 29%

A 43-year-old gentleman attends the emergency department with a six hour history of right-sided back pain that radiates towards his groin. The pain comes in waves and he is struggling to sit still because of it. He has no urinary symptoms but a urine dipstick shows microscopic haematuria. His observations are within normal ranges. A CT scan of the kidneys, ureters and bladder is requested. What is the most appropriate analgesia to give this patient whilst he is waiting?

PR diclofenac Diclofenac, either PR or IM, provides effective pain relief in renal colic and is usually offered first-line. 67%

A 69-year-old man presents to his GP with left leg pain. He complains of mild pain when walking but has no pain elsewhere. On examination, he stands in a bow-legged position. The GP decides to order some blood tests. His blood results show a raised alkaline phosphate. Phosphate and vitamin D levels are normal. What is the most likely diagnosis?

Paget's disease Paget's disease is correct. This is a bone disorder which most commonly causes deformities of the femur, tibia and skull. Bone bowing is a common examination finding. The typical history will be an elderly patient with generic leg or back pain. Bloods will show a raised ALP, but phosphate and vitamin D levels will be normal. 69%

increased oestrogen effects in cirrhosis

Palmar erythema In liver cirrhosis, an increased oestrogen level induces vascularisation and leads to palmar erythema, a red colouration, particularly in hypothenar and thenar eminences. Other features of increased oestrogen include the development of gynaecomastia and spider naevi. 56%

A 72 year old woman with a forty pack-year smoking history presents to the GP complaining of a decreased field of vision. She states that she can only see the lower half of objects unless she tilts her head back. She attends bi-weekly zumba classes and has also noticed she is not sweating as much despite no changes in exertion. On further questioning, she reports pain in her right shoulder that radiates to the back and weakness in her right arm. On examination, the GP notices considerable drooping of the right upper eyelid and constriction of the right pupil. What is the likely underlying diagnosis?

Pancoast tumour A right-sided Pancoast tumour can interrupt the sympathetic nerve, and thus supply to the eye and facial muscles. It is an underlying cause of Horner's syndrome which is described through the symptoms above (ptosis, miosis and anhidrosis). Smoking is a risk factor for the development of Pancoast tumours. 90%

A 78-year-old man is seen in clinic with his daughter. She mentions that over the last 7 months, his memory has become poor and his attention and consciousness are fluctuating. Occasionally, he has seen dogs and children running around in the living room. His medical history includes an 8-year history of resting tremors, rigidity and shuffling when he walks, and he generally moves very slowly.His daughter denies any mood lability, or urinary or bowel incontinence, and on examination, no postural changes in his blood pressure are noted.What is the most likely diagnosis?

Parkinson's disease dementia (PDD) is correct. PDD and dementia with Lewy bodies (DLB) both have overlapping features (such as tremors, rigidity, postural instability, fluctuating cognition, and hallucinations), however, they can be differentiated by the time of onset of dementia compared to motor symptoms. PDD is diagnosed if a patient had a Parkinson's disease diagnosis for at least 1 year. Given that this patient has had motor symptoms ongoing for 8 years before the emergence of dementia, this patient is more likely to have PDD. This difference is important to note as the management of PDD and DLB varies massively. In many cases of PDD, levodopa is the mainstay of treatment, whereas, in DLB, rivastigmine is the drug of choice. Levodopa may be used in DLB if there are significant motor symptoms.

A 6-year-old girl is seen by her GP. Her mother is concerned that her daughter is not her usual self. She has been more tired with coryzal symptoms and feels warm to touch. On examination, she has a mild fever, a maculopapular rash on her torso and her cheeks appear very erythematous. Based on the most likely diagnosis, what is the causative organism?

Parvovirus B19 The history and examination findings point towards a diagnosis of fifth disease (also known as slapped cheek syndrome). This is caused by parvovirus B19 and presents with a rash, cheek erythema and a mild fever. It is a clinical diagnosis and no specific treatment is required as it is usually a self-limiting condition. 80%

A 45-year-old man presents to the emergency department with agitation, confusion, and tremors. Despite none being present, he is complaining of severe itching due to a termite infestation affecting his skin and is insistent on their presence. The patient admits to chronic excessive alcohol consumption.His temperature is 38.1ºC, his heart rate is 132 bpm, and his blood pressure is 168/105 mmHg. On examination, he is jaundiced and has ascites, and a coarse tremor is noted.How long has it most likely been since the patient's last drink?

Patient admitted to hospital - hallucinations, confusion, delusions 48-72 hours after admission → ?delirium tremens

A 38-year-old woman presents to her GP with lower abdominal pain which she describes as like a band across the front of her lower abdomen. She also complains of inter-menstrual bleeding. She has 4 children and is taking the oral contraceptive pill to prevent any further pregnancies. She has been treated for gonorrhoea and chlamydia in the past but is otherwise well. The GP performs a serum Ca-125 test which comes back as high. Which of the following is the most likely diagnosis?

Pelvic inflammatory disease This is the correct answer. Pelvic inflammatory disease can cause raised Ca-125; a raised Ca-125 is not specific for ovarian cancer. Pelvic inflammatory disease can present with bilateral abdominal pain and inter-menstrual bleeding. As she has had sexually transmitted infections (gonorrhoea and chlamydia in this case) in the past she is at increased risk of developing pelvic inflammatory disease 41%

A 61-year-old man presents to the emergency department with central crushing chest pain radiating to his left jaw. The pain began one hour ago whilst he was watching TV and he also feels sick and sweaty. He has a past medical history of hypertension and type 2 diabetes. An ECG reveals ST elevation in V1, V2, V3 and V4. He has an elevated troponin and mildly increased inflammatory markers. The patient receives medical treatment for an ST-elevation myocardial infarction (STEMI) and is discussed with the cardiology registrar on call. The hospital has a catheterisation laboratory (cath lab). What is the most appropriate next step in his management?

Percutaneous coronary intervention (PCI) The patient is suffering a STEMI and requires urgent management. As he is presenting within 12 hours of symptom onset and will be able to have a PCI within 2 hours, he should receive an urgent PCI. 73% Aspirin 300mg STAT The question mentions that the patient has already received medical management for a STEMI. Therefore, another dose of aspirin would not be appropriate and is not the definitive treatment for coronary vessel occlusion. 18%

A 45-year-old male presents to the Emergency Department with a sudden onset of right loin pain, haematuria, nausea and vomiting. An ultrasound scan reveals right sided hydronephrosis and presence of a large stone measuring 4cm in the right ureter. Renal function test indicates acute kidney injury (AKI). What is the most appropriate next step in the management of this patient?

Percutaneous nephrostomy Acute kidney injury and hydronephrosis are indicative of obstructive uropathy. Percutaneous nephrostomy would be the best intervention to temporarily decompress the renal collecting system by placing a catheter through the skin into the kidney. This catheter allows the urine to drain from the kidney into a collecting bag outside the body. Therefore, it bypasses the ureteric obstruction and relieves the pain associated with it. A forceps is used to extract the stones. This is usually done for large (>2cm) stones or complex calculi. 51%

A 45-year-old woman is being reviewed on the surgical ward. She is recently underwent an elective laparoscopic cholecystectomy for biliary colic. She has felt unwell since the procedure, with colicky abdominal pain and diarrhoea. She denies any urinary symptoms. On examination, the patient is newly jaundiced. Vital signs are within normal limits and her abdomen is soft with tenderness around her wounds. What is the most likely cause of her symptoms?

Post-cholecystectomy syndrome This is a typical description of what is known as post-cholecystectomy syndrome- colicky abdominal pain, diarrhoea and new jaundice. It is thought to be due to the lost of the gall bladder as a reservoir for bile moving through the biliary system. It is a common complication of the procedure and is often transient. 62% Bile duct injury Bile duct injury is a potential complication of a cholecystectomy. However, it would present either with dark urine and pale stools, or with the patient being systemically unwell, neither of which applies to this patient. 30%

A 25-year-old football player is brought to the emergency department for pain and swelling of his right knee following a match. He recalls slipping on the field and landing on the anterior aspect of his knee during a sprint. On examination, his left tibia is displaced posteriorly when posterior drawer test is performed. Which of the following is most likely the diagnosis?

Posterior cruciate ligament injury Posterior cruciate ligament injury usually occurs from a blow to a flexed knee, often seen in motor vehicle accidents or athletes. The positive posterior sag makes this the most likely diagnosis. 80%

A 24-year-old medical student presents to the emergency department with a single episode of bloody diarrhoea. She also reports dysuria and haematuria since returning from her elective in Tanzania one week prior. What is the most appropriate treatment?

Praziquantel This patient likely has schistosomiasis. Therefore, praziquantel should be given now and again in 2 months to destroy the flukes responsible. Of note, corticosteroids would also be indicated if she presented with Katayama fever, a hypersensitivity reaction. 49%

phases of a clinical trial

Pre-clinical: Animal/cell testing to gather information about efficacy and toxicity. Phase 0 (sometimes not done): small group of volunteers, used to assess pharmacodynamics and pharmacokinetics Phase 1: Testing of drug on healthy volunteers to find appropriate dosing Phase 2: Testing of drug on large group of patients to assess efficacy and safety Phase 3: Testing of drug on a large group of patients to confirm effectiveness, safety and comparing to existing interventions Post-marketing surveillance after release of the drug

A 52-year-old female attends her GP for a routine check-up. A fasting glucose is 6.5mmol/L (normal 4.0-6.0 mmol/L). Given her fasting glucose result, which is the correct diagnosis?

Pre-diabetes A fasting glucose between 6.1-7 mmol/L is a pre-diabetic state meaning the patient is at high risk of developing type 2 diabetes in the future. 2h glucose >7.8mmol/L but <11.1mmol/L

A 31-year-old woman presents to the maternity assessment unit with a new onset headache and visual disturbance. She is currently 35 weeks pregnant and has had no complications so far in her pregnancy. She has also noticed pain on the right side of her abdomen and swelling in her hands and feet. She reports no vaginal bleeding and no urinary symptoms. On examination, she has moderate tenderness in the right upper quadrant of her abdomen and peripheral oedema to just above her ankles bilaterally. Her blood pressure is 152/98 mmHg, and urinalysis reveals 3+ of protein. Her blood tests, including full blood count, urea & electrolytes and liver function tests, are normal. Cardiotocography (CTG) shows a normal trace with no signs of foetal distress. What is the most likely diagnosis?

Pre-eclampsia Pre-eclampsia is defined as new onset hypertension that occurs after 20 weeks gestation and the co-existence of ≥1 of the following conditions: proteinuria, maternal organ dysfunction, neurological complications, haematological complications or uteroplacental dysfunction. 85% Eclampsia Eclampsia is the occurrence of one or more seizures in a woman with pre-eclampsia. There is no mention of seizure activity in this patient. 5%

A 27 year old gentleman presents to the GUM clinic with a painful lesion on his penis. He has recently returned from a holiday in the Gambia. Given the most likely diagnosis, what is the most appropriate management?

Prescribe Ciprofloxacin and Ceftriaxone Chancroid presents with a painful ulcer on the penis. It is common in the tropics, and a travel history should be explored if any patient presents with a painful lesion on their penis. Given the travel history and the symptoms, a clinical diagnosis of Chancroid can be made. Treatment involves Ciprofloxacin and Ceftriaxone Prescribe Aciclovir This would be suitable in serious Herpes Simplex infection. Although this is a very good differential diagnosis, in this case the patient's travel history makes a diagnosis of Chancroid more likely

A 32 year old man visits the GUM clinic. He comments that he had receptive anal sex 48 hours ago and is concerned that he has contracted HIV. He is unaware of the HIV status of his partner. What is the most appropriate initial management of this patient?

Prescribe Post Exposure Prophylaxis The current guidelines recommend prescribing PEP to anyone who has engaged in receptive anal sex, regardless of whether the HIV status of the partner is known or not 79%

An 8-year-old girl is brought to the GP by her mother. She has had itching around her vulva and anus for the last 3 days. Her mother has noticed redness and the skin has broken in the affected areas due to intense itching. The itching does not resolve with over-the-counter topical clotrimazole and emollients. She has no other past medical history. Given the likely diagnosis, what is the most appropriate step for the GP to take?

Prescribe a single dose of mebendazole to her and the whole household is correct. Perianal itching and vulval irritation in a young child should raise suspicion of threadworms, which is a common infection in children. NICE recommends prescribing a single dose of mebendazole to the patient and the whole household as threadworms are highly transmissible and many patients can remain asymptomatic but remain infectious. Although the 'Scotch tape test' (sticking tape on an affected area to identify worms or eggs), many patients are now treated based on clinical features if they are characteristic.

A 27-year-old woman presents to her GP complaining of a three day history of a painful right ear. She is otherwise normally fit and well. On otoscopic examination, the GP notices erythema in the right auditory canal, although there is no discharge, wax or oedema. The tympanic membrane appears normal and there is no evidence of mastoid tenderness. Her temperature is 36.8C. Given the most likely diagnosis, which of the following is the next best step in management?

Prescribe topical acetic acid This patient is presenting with symptoms suggestive of a diagnosis of acute otitis externa which can often be treated with acetic acid spray applied to the affected ear. Acetic acid can limit bacterial and fungal growth. If this is ineffective or there are signs of more severe infection such as discharge or oedema, antibiotic and steroid ear drops can be given. 32%

A 52-year-old male is referred through the suspected cancer pathway for weight loss and abdominal discomfort. A CT scan of his abdomen shows a focal lesion in his liver. Blood tests show a grossly elevated alpha fetoprotein (AFP). Which of the following is a risk factor for this patient's condition?

Primary biliary cirrhosis This patient likely has hepatocellular carcinoma, as strongly indicated by the lesion in his liver and elevated tumour marker. Primary biliary cirrhosis is an autoimmune condition that leads to hepatocellular damage, and like any form of cirrhosis can lead to liver cancer. 30% Primary sclerosing cholangitis Primary sclerosing cholangitis is another autoimmune biliary condition. It is associated with ulcerative colitis and can cause cholangiocarcinoma. However, it affects the common bile duct rather than the liver and therefore is not associated with liver cancer. 35%

6-year-old boy is brought to general practice by his mother. His mother is worried as he is still wetting the bed at night at least 3 times a week. He has never had more than a week without wetting the bed. He passes urine frequently during the day, often up to 10 times, but has not wet himself during the day. Which of the following is the most likely diagnosis?

Primary enuresis with daytime symptoms This child has presented with primary enuresis as he has never had a 6-month period of being dry at night. He is also experiencing daytime symptoms of frequency as he is passing urine more than 7 times a day. He should be referred to secondary care/enuresis clinic for further investigations. 25%

syphilis stages

Primary syphilis features Infection occurs 9-90 days (typically around 21 days) after exposure. Lesions are found at the site of inoculation and are often genital or perianal. Lesions tend to be painless and solitary in nature. They are round with an indurated base, and heal within 3-8 weeks. Secondary Syphilis features Occurs 4-10 weeks after primary infection. It typically presents with a maculopapular symmetrical rash on the palms, legs, soles and face. There also may be lymphadenopathy mucosal ulcers. Other less common features include malaise, fever, hepatitis, glomerulonephritis and neurological complications. Tertiary Syphilis features Tertiary or late disease occurs in approximately 1/3 of untreated patients, and manifests 20-40 years after primary infection. It is rare due to the advent of penicillin, but if found it must be treated with urgently. Features can be categorised into gummatous (15% of patients); cardiovascular (10%) and neurological complications (7%). Gummatous disease is the presence of granulomatous-type lesions on the skin. Cardiovascular complications may include aortitis, arteritis and aortic valve regurgitation. Neurological complications include meningovascular syphilis, paresis, dementia, tabes dorsalis and pupil abnormalities e.g. Argyll-Robertson pupil. If Tertiary Syphilis is confirmed, a CSF examination is indicated in order to test for CNS involvement.

A 27-year-old woman presents to her local sexual health clinic requesting contraception. She has recently entered into a regular sexual relationship with a man and would like to prevent pregnancy. She would like contraception that she can stop at any point should the relationship cease. Her past medical history includes depression and migraines with aura. She takes no regular medication. Her BMI is 23 kg/m2. What is the most appropriate contraception to offer her?

Progestogen-only pill This patient would like a contraceptive she can stop at any point, therefore a pill is most appropriate. Her past medical history of migraine with aura contraindicates the use of the combined oral contraceptive pill, so the progestogen-only pill is the most suitable choice for her. 69%

A 69 year old man is brought to the casualty with progressively worsening lower back pain for two months, not relieved with Ibuprofen. He has also reports weakness of his legs and urinary incontinence for the past one week. On examination, he has tenderness of the lumbar spine with reduced power in bilateral lower limbs. X ray of the lumbar spine shows multiple sclerotic lesion in the lumbar vertebrae. What is the most likely cause of his symptoms?

Prostate cancer Male patient with advanced age (>50 years old), and osteoblastic bone lesion strongly suggests prostate cancer. Advanced stage prostate cancer commonly metastasize to the spine, which causes metastatic spinal cord compression (limb weakness, difficulty in walking, sensory loss or bladder or bowel dysfunction). X ray findings of the spine suggest osteoblastic metastasis. It is an oncology emergency of which urgent MRI of the spine should be carried out next and surgical decompression may be required. 61% Multiple myeloma Multiple myeloma is the most common primary tumour of the spine and can manifests as cord compression. However, it causes lytic bone lesion instead of sclerotic bone lesion on the X ray. In addition, multiple myeloma may present with other symptoms, such as features of anaemia, hypercalcemia and renal failure. 18%

A 25-year-old woman (G1P1) undergoes a vaginal delivery at 39 weeks gestation, followed by a physiological third stage of labour. In the hours following, she has some brown mucousy vaginal discharge with blood in it, producing approximately 100ml of blood.On examination, the patient has a GCS of 15, a soft but tender abdomen. Her blood pressure is 132/83 mmHg, her pulse is 86 bpm, her temperature is 36.5C.What is the most appropriate next step in her management?

Provide sanitary pads is correct. This patient has lost <500 ml of blood within 24 hours of delivery and is showing no signs of circulatory shock making it unlikely for the diagnosis to be a primary postpartum haemorrhage (PPH). The patient is more likely to be producing lochia, a combination of mucus, uterine tissue, and blood that is common after childbirth. This should reduce over the following days but can continue for up to 12 weeks.

A 45-year-old male presents to the GP after noticing a prominent bulge over his right biceps which appeared suddenly 4 days ago. There is no pain and there is no limitation to his movements. He is a frequent weight-lifter and has a history of injury to his shoulder 5 years ago. What is the most possible diagnosis?

Proximal bicep tenden rupture Patient with bicep tendon rupture will present with sudden bulge at the biceps, commonly termed the pop-eye sign. Proximal bicep tendon rupture is often painless and may not present with significant loss of function if one of the two proximal heads (short head and long head) is still intact. Repetitive weight lifting and history of shoulder pathology are risk factors for proximal bicep tendon rupture. 40% Distal bicep tendon rupture Patients with distal bicep tendon rupture presents with acute pain and limitation of flexion and supination of the elbow joint. 23%

multinucleated giant cell on pleural aspirate

RA

scleritis

RA acutely painful red eye, photophobia, scleral vessel injection and region of blue/violet hue. same day referral for ophthalmology

A 50-year-old man is referred to the clinical genetics clinic following a diagnosis of suspected multiple endocrine neoplasia-2a (MEN-2a). An inherited mutation in which gene is associated with MEN-2a?

RET gene The RET gene is a proto-oncogene involved in kinase activation. MEN-2a is associated with medullary thyroid cancers, phaeochromocytoma, and parathyroid hyperplasia and adenomas. 59%

A 3-year-old male infant presents to the GP feeling generally unwell with coryzal symptoms. His father reports that he has been more quiet recently. His heart rate is 130 beats per minute, respiratory rate is 43 breaths per minute, he has pallor of the tongue and reduced urine output. His capillary refill time is above 3 seconds. Which of these features fits the criteria for a referral to the hospital?

RR: 43 This meets the criteria for a referral according to the NICE traffic light system for unwell children. 27%

A 60-year old male with a history of prostate cancer is undergoing radiotherapy. He presents to the emergency department with rectal pain, diarrhoea and tenesmus for one week following radiotherapy 3 months ago. He admits he had sexual intercourse with a new partner last week. He denies discharge, dysuria, haematuria and abdominal pain. What is the most likely underlying cause?

Radiation therapy Radiation to the pelvis when treating prostate cancer can lead to radiation proctitis. 84%

A 68-year-old man attends his GP for routine follow-up for chronic kidney disease. His urine sample reveals an albumin:creatinine ratio of 5.5mg/mmol (<1mg/mmol). His current medications include metformin, gliclazide, amlodipine and paracetamol. Given his albumin:creatinine ratio, what medication should be added?

Ramipril All patients with diabetes should have regular albumin:creatinine ratio screening. If the value is >2.5mg/mmol in men or >3.5mg/mmol in women, they should be started on an ACE inhibitor. 67%

A 64-year-old man sees his GP as he is very concerned about seeing blood in his urine. Other than type 2 diabetes, he has no past medical history. His observations show a blood pressure of 162/92 and his eGFR is 58 (a blood test three months ago showed normal renal function). He is referred to nephrology and has a repeat blood test a few weeks later which shows an eGFR of 21. A renal biopsy reveals epithelial crescents in the glomeruli. What is the most likely diagnosis?

Rapidly progressive glomerulonephritis The biopsy findings and rapid decline of more than 50% in eGFR are suggestive of rapidly progressive glomerulonephritis. Rapidly progressive glomerulonephritis, also called cresenteric glomerulonephritis, is a glomerulonephritis that can occur idiopathically or secondary to other conditions such as systemic lupus erythematosus and Goodpasture syndrome. The biopsy findings would show epithelial crescents (crescent-shaped scars) in most glomeruli. 64%

A 23 year old male attends the GUM clinic for results of his syphilis serology tests. He has been treated empirically for infection. The results of his initial serology at diagnosis and current serology are given below. Initial serology at diagnosis: EIA: positive, TPPA: positive, RPR: 1:32 Current serology: EIA: positive, TPPA: positive, RPR: 1:8 Given the serology results, what is the most appropriate next step?

Reassure and discharge There has been a four-fold decrease in RPR from initial diagnosis to the current moment, thus this is indicative of a successful treatment protocol, and at this point no other management is required. The patient can be discharged 1 in 32 means it takes 32 dilutions for the RPR to become negative. 1 in 8 means it only takes 8 dilutions so the titre is lower. The higher the second number, the higher the titre.

A 28 year old woman who is 20 weeks pregnant has come to the clinic for a follow-up appointment. Two weeks ago, an obstetric ultrasound showed no abnormalities. However, she has a history of a recurrent painful vesicular rash on her vagina. The rash started again two days ago. On examination, there are multiple small vesicles on the vulva and labia, as well as tender lymph nodes in the groin area. A swab reveals the presence of ballooned multinucleated giant cells and eosinophilic inclusion bodies. Which of the following is the next best step in the management of this patient?

Reassure and offer supportive treatment The patient's symptoms suggest a diagnosis of genital herpes simplex 2 infection. Most episodes of recurrent genital herpes are brief and resolve within 7 to 10 days without antiviral treatment. Supportive management include using saline bathing and analgesia (topical lidocaine 2% gel) with standard doses of paracetamol alone will usually suffice. 10% if recurrent oral aciclovir from 36 w onwards

A 27-year-old visits her GP with irregular vaginal bleeding, reporting 4-weeks of intermittent light 'spotting'. She denies pelvic pain, vaginal discharge, dyspareunia or post-coital bleeding. A pregnancy test is negative and a pelvic and speculum examination is normal.The patient had a smear test 2-years ago which was HPV negative and is sexually active with one partner. They have both been screened for sexually transmitted infections. She started taking desogestrel for contraception one and a half months ago.What is the most appropriate action?

Reassure and re-assess in 2 months is the correct answer. This is because irregular vaginal bleeding is the most common side effect of progestogen-only pills (POPs), which is the class that desogestrel belongs to. NICE advises that further investigation is not needed if this bleeding is present in the first 3-months, so long as a pregnancy and sexually transmitted infections are excluded, there is an up-to-date smear and there are no symptoms suggesting another underlying disease. This patient meets all these criteria and has normal examination findings, so can continue her contraception with reassurance if she desires.

The parents of a newborn baby girl are worried about a red spot on her neck. The baby had an uncomplicated birth and there are no other health concerns. On examination, there is a small erythematous papule on the right side of her neck. It is non-blanching. What is the most appropriate action to take?

Reassure the parents Infantile haemangiomas (or strawberry naevi) are common and benign vascular growths which can be present at birth. They are often small, harmless and require no treatment. They may get smaller with age. 73%

A newborn baby boy is being examined by his paediatrician. His examination is unremarkable except for a 1x1cm dark brown oval-shaped lesion on his left forearm. It is flat and has a regular border. Which of the following is the most appropriate action to take?

Reassure the parents The clinical vignette describes a single melanocytic naevus. These are benign skin lesions which may be congenital. They are due to a local proliferation of melanocytes. Most can be left alone and the patient can be reassured, especially if they are young. In older people, particularly if there are atypical features or if there is doubt about the diagnosis, further assessment may be required to exclude malignant melanoma. 77%

mx of bleeding in haemophilia A

Recombinant factor VIII Haemophilia A affects factor VIII levels, and in major or life-threatening bleeds, recombinant factor VIII is the most appropriate treatment. 69%

A 40-year old male with a background of lung cancer presents to his GP with new bilateral leg numbness. He is unable to feel anything below his back and has new back pain that started this morning. He has been unable to pass urine since this morning as well. He denies urinary and bowel incontinence. What would be the next first-line measure to take within a GP practice setting?

Rectal examination To rule out any spinal compression, it is important to check for perianal numbness and saddle anaesthesia with a rectal examination. 40%

A 65 year old man presents to the district nurse clinic with acute urinary retention secondary to an enlarged prostate. An immediate urinary catheterisation is attempted and the volume post-catheterisation is recorded as 1200ml. What is the most appropriate management?

Refer for hospital admission This patient has a large retention volume of >1000ml. He should be admitted to monitor for post-obstructive diuresis. Post-obstructive diuresis occurs following rapid decompression of urinary retention. Patients will be at risk for dehydration and should be monitored closely for their urine output in the hospital and if >200ml/hr urine is being produced, they should be replaced with intravenous fluids to avoid acute kidney injury. 28% Keep catheter in-situ and urgent referral to urology outpatient clinic For patients with high pressure urinary retention (evidence of hydronephrosis or hydroureter and worsened kidney function), a catheter should be kept in place following retention. There is no mention of high pressure urinary retention in this patient. Instead, he has a large volume of retention and hence should be admitted immediately. 47%

A 14 year old male revisits his GP with persistent symptoms despite treatment with hydrocortisone 1% cream. He now presents with itchy, painful, and white patches on the tip of his penis. He denies being sexually active. On examination, white atrophic plaques and haemorrhagic vesicles are present on the glans penis and prepuce. New onset phimosis is visible. What is the most appropriate step in management?

Refer to a paediatric specialist This boy presented with balanoposthitis caused by lichen sclerosus (balanitis xerotica obliterans), a chronic inflammatory dermatosis. Haemorrhagic vesicles and phimosis point toward its diagnosis. Referral to a paediatric urologist or surgeon is required to correct phimosis by circumcision. 49%

A 7-year-old boy is admitted to the ward with a three-day history of a rash over his lower limbs. On further questioning, his carer reveals that he reported blood in his urine this morning. He has also experienced joint pains and colicky abdominal pain for the past two days. The carer denies any past medical history, previous hospital admission and recent travel history. He had recovered from an upper respiratory tract infection two weeks ago. On examination, non-blanching purpura is visible over his buttock and the extensor surface of his bilateral lower limbs. Routine blood tests are unremarkable. What is the most appropriate post-recovery follow-up plan based on the most likely diagnosis?

Regular urine dips for 12 months The presentation above suggests a diagnosis of Henoch-Schonlein purpura (HSP), which is characterised by a tetrad of non-thrombocytopenia palpable purpura, arthralgia, haematuria, and abdominal pain. All children with HSP should be followed up for a year to detect the presence of any persisting haematuria or proteinuria. 51%

A 58 year old male is under close monitoring in the intensive care unit following an urgent embolectomy for acute limb ischemia six hours ago. The nurse in charge notices that he has not been passing enough urine in the last few hours. His urine colour appears reddish brown. What is the cause for his acute kidney injury?

Release of myoglobin Reperfusion injury is the tissue damage that takes place following restoration of blood flow after a period of ischemia. In the event of acute limb ischemia, there is release of myoglobin from the damaged muscle cells causing myoglobinuria, which is responsible for the reddish brown urine discolouration. This could lead to acute kidney injury which manifests as oliguria in this patient. 81%

A 4-year-old boy is brought to his GP by his mother. She is concerned because her son is very distressed and is continuously complaining of tummy pain. On examination, a large firm abdominal mass is felt in the right lower quadrant. The mass does not cross the midline. Based on the most likely diagnosis, what is the gold standard investigation to confirm this?

Renal biopsy The history and examination point towards a diagnosis of nephroblastoma (Wilms's tumour). Nephroblastoma is a kidney tumour that is most commonly found in children under the age of 5. The gold standard investigation is a renal biopsy to confirm the diagnosis and help stage the tumour. Treatment is with radiotherapy and surgery. 20%

what test to do in systemic sclerosis

Renal function tests The likely diagnosis is limited cutaneous systemic sclerosis. This patient has 3 of the 5 CREST syndrome features - Raynaud's phenomenon, oesophageal dysmotility and sclerodactyly. Anti-centromere antibodies are also specific to limited cutaneous systemic sclerosis. Systemic sclerosis can cause a renal crisis through rapidly progressive renal failure (usually with hypertension) so blood pressure and renal function tests should be monitored regularly for early detection of renal involvement. 66%

An eight-year-old boy with Fanconi's syndrome attends his renal follow-up appointment. His parents report that he has been getting muscle cramps and fatigue. They also say he is not growing like other children in his class. A venous blood gas is carried out. It shows a metabolic acidosis and hypokalaemia. A urine sample shows a high urinary pH. What is the most likely diagnosis?

Renal tubular acidosis type 2 Renal tubular acidosis type 2 occurs when the proximal convoluted tubule does not reabsorb bicarbonate into the blood so it passes out in the urine. This leads to metabolic acidosis, as well as hypokalaemia and a high urinary pH. The main cause of renal tubular acidosis type 2 is Fanconi's syndrome. 43%

A 27 year old man is brought in by his girlfriend to A&E. He is drowsy, confused and has vomited twice in the emergency department. She thinks something happened 30 minutes ago while she was out. His observations are as follows: Heart rate of 117, respiratory rate of 32, temperature of 38.6, blood pressure of 115/63 and oxygen saturations of 93% on room air. Salicylate levels return elevated and an arterial blood gas is being processed. Given the likely diagnosis, what would we expect to see on the initial blood gas?

Respiratory alkalosis This is a classic presentation of aspirin overdose. We would expect to see an initial respiratory alkalosis as the high salicylate levels activate the brain's respiratory centres. Later on, metabolic acidosis would develop due to the ingested salicylic acid load. 34%

A 86-year-old female presents after suddenly experiencing visual changes. She has noticed that her vision has become blurred, and that she is experiencing flashes of lights, dots and lines in her vision. The patient requires glasses for myopia, and has bilateral cataracts, for which she had surgery for. What is the most likely diagnosis?

Retinal detachment Retinal detachment is when the retina is displaced from its usual position. Consequently, the retinal cells are no longer provided with a sufficient blood supply. Risk factors for retinal detachment include myopia and previous surgeries, which the patient in the vignette has. Additionally, the patient is experiencing the classic symptoms of retinal detachment, making this the most likely diagnosis. 45% Posterior vitreous detachment Posterior vitreous detachment is when the vitreous humour comes away from the retina. It can also presents with flashes and floaters. However, it does not cause visual loss, which the patient in the vignette has (blurring of vision). 52%

RF vs anti-CCP

Rheumatoid factor (RF) is incorrect as this is a sensitive test for RA, but not specific. This means it is useful as a screening test, as it is positive in 70-80% of patients with RA, but non-specific to RA as other conditions may also have positive RF findings, such as Sjogren's syndrome (around 50%), infective endocarditis (around 50%), systemic sclerosis (around 30%), and around 5% of the general population have positive RF findings. As mentioned above, a helpful way of remembering when to use either is SPin and SNout. SPecific is helpful for ruling in (confirming a diagnosis), SeNsitive is helpful for ruling out. RF is good for ruling out and anti-CCP is good for confirming the diagnosis. Anti-cyclic citrullinated peptide antibodies (anti-CCP) is correct as these are the most specific autoantibodies for patients with RA. Specific tests are useful for confirming a diagnosis as they reflect the true negative rate of a condition (if a specific test is negative for a patient, they most likely do not have the disease and it is positive in very few diseases). Sensitive tests are useful for identifying those who may have the disease, but cannot confirm its presence, and is often used in screening (as they can be positive in many different diseases). A helpful way of remembering when to use either is SPin and SNout. SPecific is helpful for ruling in (confirming a diagnosis), SeNsitive is helpful for ruling out.

rf for types of bladder ca

Risk factors for Transitional Cell Carcinoma Smoking Aromatic amines (rubber, dyes and chemical industry) Cyclophosphamide Risk factors for Squamous cell carcinoma Schistosomiasis infection Long term catheterisation (10+ years) Risk factors for Adenocarcinoma Other types bladder cancer Local bowel cancer Risk factors for Small cell bladder cancer Associated with other types of bladder cancer

A 4-year-old boy is brought to the GP by his father. He has a three day history of a high fever, after which he developed a rash. On examination, a wide-spread macular rash is noted on his torso, face and arms. The rest of his examination is normal and he is up to date with all of his vaccines. What is the most likely diagnosis?

Roseola infantum This is caused by human herpes virus 6 and is also called sixth disease. It presents as a pinkish rash across the body which is usually preceded by a high fever. It is a clinical diagnosis and the mainstay of treatment is supportive care. 73%

A 70-year-old man books a GP appointment due to a spot on his cheek which he first noticed a few months ago and which has grown in size. It is slightly tender but not itchy and it has never bled. On examination, he has a single erythematous nodule with a central depression and rolled edges on his right cheek. It has a shiny appearance and there is associated telangiectasia. Given the likely diagnosis, what is the most appropriate management option?

Routine referral to dermatology This patient likely has basal cell carcinoma. According to NICE guidelines, most suspected cases can be referred routinely to dermatology due to the slow growing nature of the lesion. An urgent two week wait referral is only indicated if there are specific concerns, such as lesions in problematic sites like the eyelids, large lesions > 1cm, or if there is diagnostic uncertainty. 22%

A 29-year-old woman presents to the GP with a new breast lump. On examination, there is a firm, smooth, 2 cm lump in the upper outer quadrant of her left breast. It is highly mobile with well-defined borders. It is not painful, and there are no overlying skin changes. Which is the most appropriate management?

Routine referral to the outpatient breast clinic This patient presents with symptoms of a benign fibroadenoma. For patients under 30, a routine referral to the breast clinic for further assessment or imaging is indicated. If the patient is over 30, this should be an urgent referral. 81%

decreased int rotation of leg in flexion in paediatrics

SUFE

A 62 year old gentleman presents to Accident & Emergency (A&E) with worsening shortness of breath. He has been coughing up yellow/green sputum for the last three days. He has a forty pack year smoking history. He says his GP started him on some inhalers last year but he cannot remember why or which ones. His observations are as follows: HR 100, RR 24, BP 140/90, T 37.9, SpO2 92% Venturi Mask. His CXR shows a hyperexpanded chest with left lower lobe consolidation. Which of the following is the most appropriate initial treatment for this gentleman?

Salbutamol nebuliser, ipratropium bromide nebuliser, oral prednisolone, antibiotics This gentleman has come in with an acute infective exacerbation of COPD (IECOPD). Whilst the question does not specifically give the diagnosis, it provides many clues to point us in the right direction: 40 pack year smoking history, started on inhalers, old age, hyperexpanded chest, yellow/green sputum, consolidation on CXR. The first line management for an IECOPD is: salbutamol and ipratropium nebulisers - these help open up the airways so that patients can breathe better. corticosteroids - This helps reduce the inflammation in the lungs. Either oral prednisolone or IV hydrocortisone can be given - both are equally effective. antibiotics - There are clear signs of infection in the scenario, therefore we need to give antibiotics to help the patient clear it. 57%

A 38-year-old gentleman presents to the emergency department with abdominal cramps and diarrhoea that first started this morning. He denies any presence of mucus or blood in his stool. There is no recent travel history, and he reports that he had poached egg with toast yesterday morning. What is the most likely causative organism for this presentation?

Salmonella enteritidis Salmonella enteritidis is the second most common cause of food poisoning in the UK. The common source of infection includes raw or undercooked eggs. 77%

A 26-year-old woman has 3 weeks of shortness of breath and fatigue on exertion and a new skin rash over her face and nose. During this time, she has felt generally unwell and has had a dry cough and malaise. She has never smoked.She has cervical and submandibular lymphadenopathy and dark indurated plaques are noted around the eyes, nose, and cheeks.

Sarcoidosis is correct in this case. This patient is young and female presenting with shortness of breath, fatigue on exertion, a facial rash and lymphadenopathy which should raise suspicion of sarcoidosis. The elevated serum calcium supports this diagnosis, as sarcoidosis can lead to hypercalcaemia due to the increased production of 1,25-dihydroxy vitamin D3 by activated macrophages and granulomas. The rash described in this patient is known as lupus pernio, which describes dark indurated plaques that can involve the face and extremities.

An 18-year-old university student attends the GP with a one week history of a very itchy rash. It is mainly on her lower abdomen, groin and thighs. She says the rash is particularly severe at night and is interfering with her sleep. She has been scratching so much that she has caused bleeding. The patient has tried taking over the counter antihistamines but they have not helped. She lives with her partner who has also had similar symptoms. On examination, she has small erythematous papules on the affected areas with excoriations and linear marks. What is the most likely diagnosis?

Scabies This presentation is suggestive of scabies, a very contagious skin condition caused by skin infestation with parasitic mites. It causes intense itching which is classically worse at night and often affects the hands and feet, although it can also affect other areas such as the abdomen, thighs and groin. 86% atopic dermatitis is usually on the face and flexure s

vaccines - esp CI

Schedules and further information: The UK schedule regularly changes. Always use the authoritative summary provided from the UK Gov website for the latest schedule For any information, refer to the 'Green Book' - also found on the UK Gov website. It contains information on indications for different vaccines, including catch-up schedules for people who have missed vaccines or were not immunsed Common side effects of vaccinations Vaccinations are generally very safe and effective. Any vaccination can cause side effects from a local and systemic immune response: Locally, there may be tenderness and aches around the injection site Systemically, the patient may have a fever and feel unwell for a few hours Fever is particularly common with the meningococcal vaccine; parents should be asked to give prophylactic paracetamol to their child and warned that a fever is very likely. This will help to reduce unnecessary worry, A&E attendance and unnecessary investigations. Rare side effects of vaccinations Anaphylaxis Rotavirus vaccination can rarely cause intussusception. The MMR vaccine can cause seizures (1/1000 doses) and ITP (idiopathic thrombocytopenic purpura) (1/24,000 doses). Contra-indications to vaccinations Egg allergychildren with egg allergy should not receive yellow fever vaccinationthe standard preparation of the influenza vaccine is only contraindicated in children who have been admitted to PICU as a result of their egg allergy. All other cases of children with egg allergy can safely have the standard vaccine in primary care settings.The MMR vaccine is safe for children with an egg allergy. It is a common misconception that it contains components from eggs. Previous proven anaphylaxis to vaccine components - children with serology confirming allergy to vaccine components should not receive further doses of that particular vaccine. Immunosuppression - children with immunosuppression (e.g. from confirmed severe primary immunodeficiencies, chemotherapy or other immunosuppressive medications, or radiotherapy) should not receive live attenuated vaccines, such as the MMR vaccine, inhaled influenza vaccine or the varicella vaccine. Intussusception - children with a history of intussusception cannot have the rotavirus vaccination

A 28-year-old female attends the cardiology clinic for a routine follow-up. She suffered from severe infective endocarditis aged 24, requiring mitral valve replacement with a mechanical valve. Routine bloods, including a peripheral blood film, is taken. Which finding would be expected based on her history?

Schistocytes Schistocytes are fragmented red cells seen in intravascular haemolysis, such as haemolytic anaemia. They are also seen in patients with mechanical heart valves due to mechanical haemolysis of the cells. 64%

A 21-year-old female professional ballet dancer presents to her GP with three months of right midfoot pain which is getting worse. She has no history of trauma to her ankle or foot. Her medical history involves periods of amenorrhea. Which of the following is the most probable diagnosis?

Second metatarsal base stress fracture This patient has a stress fracture from repetitive microtrauma sustained from her training. The onset is gradual and may be associated with amenorrhea. Stress fracture in ballet dancers occurs most commonly at the second metatarsal base. 49%

sequestration crisis in sickle cell

Sequestration crisis is incorrect. Sequestration crisis is characterized by sickling within organs such as the spleen or lungs, causing the pooling of blood with worsening of the anaemia, and is associated with an increased reticulocyte count. However, in the given case, there is no mention of an increased reticulocyte count, which makes the diagnosis of sequestration crisis less likely. Additionally, the pain and swelling are predominantly in the hands and feet rather than the abdomen (in the case of spleen sequestration) or the chest (in the case of pulmonary sequestration). DiscussImprove

A 3-year-old girl is brought to the GP by her father. He is concerned as she has been unwell for a few days with a fever and a runny nose. Yesterday, a rash started on her face. On examination, a widespread rash is noted across the body and she has enlarged lymph nodes behind her right ear. The GP suspects rubella. What is the definitive investigation to confirm the diagnosis?

Serological testing Rubella is a viral infection, the diagnosis of which can be confirmed using serological testing looking for rubella-specific IgM antibodies. 81%

syphilis serology explained

Serology principles Syphilis serology aids diagnosis and treatment. Serology can be divided into treponemal and non-treponemal. Non treponemal tests include the venereal disease research laboratory (VDRL) and rapid plasma reagin (RPR), and detect biomarkers released after infection. False positives can occur due to spirochaetes such yaws and pinta, pregnancy, and autoimmune disorders. If the RPR is positive and the titre is greater than 1:8,and there is no history of treatment, a diagnosis of syphilis is made and the patient should begin treatment. If the RPR decreases fourfold (i.e. from 1:32 to 1:8), or decreases below 1:8, this is considered adequately treated Treponemal tests include T pallidum particle agglutination assay (TPPA) and Treponemal enzyme immunoassay (EIA). These work by detecting antibodies to the Treponema pallidum and therefore remain active for life, even in adequately treated patients. Interpretation A positive EIA with a non reactive RPR and a non reactive TPPA is a most likely a false positive EIA result. If clinical history suggests a risk for syphilis the EIA should be repeated in 3-4 weeks. A positive EIA with a non reactive RPR and a positive TPPA is consistent with treated syphilis. The diagnosis should not be made on the basis of one clinical test result. The entire clinical picture should be considered, including symptoms and history.

An 80 year old man diagnosed with prostate cancer a few years ago attends the clinic for a regular follow-up. He is currently on a gonadotropin-releasing hormone (GnRH) antagonist. What is the most appropriate follow-up investigation to do for this patient?

Serum Prostate-specific antigen (PSA) Prostate-specific antigen is helpful in monitoring response to treatment. The level of PSA over time would determine the subsequent management of prostate cancer, factoring in the age and race according to test results. 75%

An 8-year-old boy is brought to the paediatric outpatient clinic with a two-day history of dramatic weight gain and swelling of his legs. His mother noted puffy eyes a few days ago, which did not subside even after giving him antihistamine syrup. He has no medical problems and is in the 50th percentile on all his growth charts. There is no significant family history of renal disorders. Urine analysis reveals marked proteinuria. What is the most appropriate investigation to confirm his diagnosis?

Serum albumin The patient's urinalysis shows significant proteinuria, which is most likely to be a minimal change disease. It nearly always presents as nephrotic syndrome, accounting for the majority of cases in children. The next best step would be to check the serum albumin level to confirm the diagnosis of nephrotic syndrome. The weight gain and limb swelling are due to oedema (extravasation of fluid into interstitial space). Oedema may progress to involve the whole body. 69%

A 25-year-old man is reviewed in clinic for a 4-month history of itchy skin rashes described as 'hives' which occur after eating certain foods and on exposure to dust. He was given cetirizine which initially helped his symptoms, however, his episodes are getting worse and it is not currently working as well.His temperature is 37.3ºC, his heart rate is 89 bpm, and his blood pressure is 135/78 mmHg. On examination, there are diffuse erythematous lesions on his arms, legs, and chest which are intensely itchy.What is the most appropriate next step in his management?

Severe urticaria - A short course of an oral corticosteroid may required in addition to a non-sedating antihistamine so continue citirizine and prescribe a 5 day course of oral pred

A 55 year old man complains of pain in the right side of his mouth when eating. His wife has noticed that sometimes she sees a lump under his right jaw during an episode. ENT examination is normal. Which of the following investigations should confirm the most likely diagnosis?

Sialogram This patient has a calculus (stone) within the right salivary gland. This can cause pain and salivary gland swelling while eating, due to build up of blocked saliva within the gland. Diagnosis can be confirmed using plain X-ray or sialogram. A sialogram involves injection of contrast material into the salivary duct under fluoroscopy. Definitive treatment depends on the location of the stone. If the stone were easily visible and palpable, simple surgical removal of the stone can be performed. In this case, the stone is likely deep within the salivary gland (because the stone was not palpable on examination), so definitive treatment would entail excision of the entire gland 49%

Causes low HbA1c

Sickle-cell anaemia GP6D deficiency Hereditary spherocytosis Haemodialysis

A 14 year old female presents to the clinic with concerns about new onset vaginal spotting. She reports that she has been started on the combined oral contraceptive pill (COCP) for the past three weeks, according to the instructions provided by her doctor. She takes the pill at the same time every day and has not missed any doses. Her menstrual cycle is typically regular, with periods occurring every 28 days. A pregnancy test is negative. What is the most likely cause of the patient's symptom of vaginal spotting?

Side effect of the COCP Vaginal spotting or bleeding is a common side effect of the COCP, especially during the first few months of use. It is often caused by hormonal changes and can resolve on its own after a few cycles. In this case, the patient has only been taking the COCP for a few weeks and is experiencing vaginal spotting, making it the most likely cause of the symptom. 95%

syphilis ulcer

Single, indurated, undermined ulcer with a clean base A single, indurated ulcer with a clean base is a chancre caused by Treponema pallidum. It usually appears as a single painless lesion with non-tender inguinal lymphadenopathy. 33%

A 70 year old man presents with visible blood noted when he is passing urine for the past two weeks. It happens intermittently and he experiences no pain. He is a lifelong smoker and prior to retirement, worked in the fabric industry. His father died of prostate cancer at the age of 80. Cystoscopy reveals a friable mass near the neck of the bladder and histology reveals transitional cell carcinoma of the bladder. What is the single most important risk factor for the development of bladder cancer in this patient?

Smoking Smoking is the single biggest risk factor for the development of bladder cancer. Exposure of the chemicals in tobacco in the form of urine cause changes to the lining of the bladder. 59%

A 30 year old male smoker with a history of familial hypercholesterolemia presents with pain in his legs during activities such as walking and climbing the stairs for the past few months. The pain usually subsides with resting. Upon examination, he is found to have diminished pulses in his lower extremities and coldness in his toes. Ankle brachial pressure index is 0.5 bilaterally. Blood test shows normal ESR and CRP. Further imaging reveals non- atherosclerotic segmental lesions that occlude the distal vessels of lower limbs with 'corkscrew shaped' collateral vessles. What is the most important intervention for this patient?

Smoking cessation Claudication pain, decreased peripheral pulses, cold extremities, low ankle brachial pressure index and non atherosclerotic lesion with cork screw collateral vessels on imaging in a young, male patient indicate thromboangiitis obliterans. It is an inflammatory and non atherosclerotic condition that affects small and medium vessels. First line of management is to advice for smoking cessation, as it causes vessel inflammation and thrombotic occlusion. It must be stopped completely as even a single cigarette a day or exposure to second hand smoking can reactivate the disease. Smoking cessation can also prevent gangrene and amputation. 74%

A 75-year-old male presents to his GP for a routine checkup of his hypertension, which is well-controlled. Routine bloods are as follows: Haemoglobin (Hb): 164 g/L (normal 130-180 g/L) White cell count: 8.3 ×109/L (normal 4.0-11.0 ×109/L) Platelets: 360 x109/mL (normal 150-400 x109/mL) Mean cell volume (MCV): 93 fL (normal 80-96 fL) Creatinine: 82 μmol/L (normal 60-100 μmol/L) eGFR: >90 mL/min (normal >60mL/min) Calcium (adjusted): 2.25 mmol/L (normal 2.20-2.60 mmol/L) Phosphate: 1.2 mmol/L (normal 0.8-1.45 mmol/L) Serum total protein: 90 g/L (normal 60 to 83 g/L) Further investigation with protein electrophoresis reveals an M protein spike of 40 g/L, composed primarily of IgG. No Bence-Jones proteins are seen. He is referred to haematology. Imaging is unremarkable, and a bone marrow biopsy reveals a clonal plasma cell level of 24%. Given the results of his investigations, what is the diagnosis?

Smouldering myeloma A raised M protein, with raised clonal plasma cells 10-60% without a myeloma-defining event (such as a CRAB feature - calcium elevation, renal insufficiency, anaemia, or bone lesions) is a feature of smouldering myeloma. This is a precancerous condition, and 50% of patients will develop multiple myeloma within the next 5 years. 18% Monoclonal gammopathy of unknown significance (MGUS) MGUS is a common disease of the elderly, which resembles multiple myeloma, but is usually asymptomatic with a lower level of paraproteins. MGUS can transform into multiple myeloma, and yearly surveillance is recommended 42% Waldenström macroglobulinaemia Waldenström macroglobulinaemia often presents with fatigue and weight loss, however, the hallmark of this condition is an IgM monoclonal paraprotein with decreased IgG and IgA. 16%

A 36-year-old woman is seen by her GP with ongoing concerns around her abdominal pain, which has been present for the last 12 months. The pain is present all of the time, however she notes it can become worse in times of psychological stress. She has undergone extensive physical examinations, and investigations including blood tests and a CT thorax, abdomen and pelvis, which have all been normal. Although she is not particularly concerned about any serious underlying cause, she finds the pain disrupts her social life and can make it difficult to concentrate at work. She is otherwise well, with no medical conditions other than depression, for which she takes sertraline. Which of the following is the most likely underlying diagnosis?

Somatoform disorder Somatoform disorder describes the presence of physical symptoms that cannot be explained by a physical medical condition. It is an unconscious process, and patients are not fabricating their symptoms. Common presenting symptoms are gastrointestinal symptoms, fatigue, weakness, musculoskeletal symptoms and, as in this patient's case, abdominal pain. 75%

A 22-year-old woman who has recently moved from India presents to her GP with haemoptysis. Over the last 4 weeks, she has suffered from a cough. During the last week, she has also noticed blood in her sputum. In the same period, she reports unintentional weight loss and fatigue. Her father in India had similar symptoms before she left. She has no past medical history and doesn't smoke.Given the likely diagnosis, what is the most sensitive diagnostic test?

Sputum culture is more sensitive than both sputum AFB smear and nucleic acid amplification tests

A 46-year-old lady presents to the general practitioner with a one-month history of painless, intermittent difficulty swallowing solid food. She denies any recent weight loss, haematemesis, melaena and hoarseness of voice. On examination, angular stomatitis is evident. Routine blood tests show iron deficiency anaemia. A diagnosis of Plummer-Vinson syndrome is suspected. Which of the following is the most likely complication of Plummer-Vinson syndrome?

Squamous cell carcinoma of the oesophagus Plummer-Vinson syndrome is characterised by a triad of post-cricoid dysphagia, iron deficiency anaemia and upper oesophageal web. There is a strong association between Plummer-Vinson syndrome and squamous cell carcinoma of the oesophagus. 58%

copd staging

Stage 1 Mild FEV1 ≥ 80% predicted Stage 2 Moderate FEV1 50-79% of predicted Stage 3 Severe FEV1 30-49% of predicted Stage 4 Very Severe FEV1 <30% of predicted

A 21 year old male has presented to his GP with a two hour history of profuse vomiting and watery diarrhoea following a creamy carbonara (creamy pasta dish with meat) he had for lunch five hours ago. What is the most likely responsible pathogen?

Staphylococcus aureus Correct. This patient is presenting with symptoms of gastroenteritis following a meal 5 hours ago. The short incubation period and history of the type of meal he had (containing cream and meat) should make you think of Staphylococcus aureus which has a short incubation period (1-6h) and presents with profuse vomiting and watery diarrhoea. 31% Escherichia coli Incorrect. Escherichia coli, also known as traveller's diarrhoea, usually presents within 12-24 h of exposure to the pathogen and presents with crampy abdominal pain and profuse watery diarrhoea. It has a higher incidence in many countries particularly across Africa and Asia. This patient's history illustrates a much shorter incubation period and does not mention the presence of foreign travel. Therefore, this makes Escherichia coli a less likely cause. 27%

A 75-year-old female presents to the emergency department with a cough and shortness of breath, which has worsened over the last week. She has a past medical history of hypertension and has recently had a viral "chest infection." On examination, she is pyrexial, and a chest x-ray shows a cavitating lung lesion in the right lower zone. What is the most likely causative organism

Staphylococcus aureus Staphylococcus aureus tends to follow viral pneumonia. The young and the old are at increased risk compared to the rest of the population. 37%

A 65-year-old man with a background of CKD stage 5 attends the emergency department with a two day history of worsening abdominal pain and rigors. His observations show a temperature of 38.5. On examination, he has rebound abdominal tenderness. A peritoneal dialysis bag is noted, the contents of which appear cloudy. What is the most likely causative organism?

Staphylococcus epidermidis The most likely diagnosis here is peritoneal dialysis peritonitis. S. epidermidis is a commensal organism of the skin, but it can cause peritonitis and sepsis if it enters the body via the peritoneal dialysis catheter. 55%

A 38-year-old male is brought to A&E by police after being found disorientated in another person's garden. He was reportedly very agitated when first found, but since being brought to hospital appears to be in good spirits, with no recollection of the day's events. Neurological examination finds dystonia, gait ataxia and dysdiadochokinesia. He later seizes in his hospital. He has no significant past medical history. He does not drink alcohol or use drugs. After extensive investigation, he is deemed to have autoimmune encephalitis. Which of the following is the first line treatment for autoimmune encephalitis?

Steroids and IV immunoglobulin Autoimmune encephalitis is a form of non-infectious neuroinflammation that can lead to acute mental state and behavioural change. Steroids and IV immunoglobulins are the first line management of autoimmune encephalitis. Plasma exchange can also be used as an adjunctive treatment 90%

diagnostic tests for coeliac remember can be a duodenal biopsy

Stool culture is necessary to exclude infection. The gold standard diagnostic test is with OGD and duodenal/jejunal biopsy. Patients should be referred for this after positive serological testing (or negative serological testing but high clinical suspicion). Ideally this should be carried out before gluten is withdrawn from the diet and repeated after gluten withdrawal (to demonstrate resolution). Histology reveals sub-total villous atrophy, crypt hyperplasia, and intra-epithelial lymphocytes.

A 75-year-old male has recently been diagnosed with pancreatic cancer. He takes 1g of paracetamol four times a day and codeine 60mg four times a day which is not helping. What is the next best treatment for his pain?

Stop codeine and add oral morphine sulphate solution 5mg, four hourly The WHO pain ladder recommends a strong opioid at step 3. Any step 2 opioid must be stopped. Morphine is the first line analgesic at step 3. 75%

A 20-year-old man with a background of sickle cell disease attends the emergency department with a one day history of a fever and feeling generally unwell. He has a history of multiple sickle cell crises. Which of the following pathogens is the patient most susceptible to?

Streptococcus pneumoniae Patients with sickle cell disease may have reduced splenic function due to repeated splenic infarctions. The spleen plays a very important role in the immune response against infection, particularly against encapsulated organisms which are phagocytosed there. Therefore, patients with sickle cell disease and hyposplenism are at increased risk of severe infections from encapsulated organisms. Examples of such organisms include Streptococcus pneumoniae, Pseudomonas aeruginosa and Haemophilus influenzae. 47%

A 76-year-old lady with a recent history of stroke is being treated for a non-infective exacerbation of COPD on a respiratory ward. Nurses have noted that she seems to be struggling to swallow her meals and has choked on a few occasions. Whilst awaiting a Speech and Language assessment, she becomes more unwell with an increased oxygen requirement. Chest x-ray shows new consolidation in the right lung. Sputum cultures grow a Gram positive aerobic bacteria. It is suspected that she has developed aspiration pneumonia. What is the most likely causative organism?

Streptococcus pneumoniae Streptococcus pneumoniae is a gram positive aerobic bacteria that is a common cause of aspiration pneumonia. 66%

A six-year-old boy is brought to the emergency department by his parents who have seen blood in his urine. After a history and examination, a diagnosis of post-streptococcal glomerulonephritis is suspected. What would be the expected histological finding on renal biopsy in this condition?

Subepithelial humps in the glomeruli Post-streptococcal glomerulonephritis can occur a couple of weeks after a group A streptococcal infection. In this condition, damage to the kidneys is caused by deposition of streptococcal antigen deposits in the glomeruli and immune complex formation. This appears as 'hump' shaped subepithelial deposits on immunofluorescence. 31%

A 65 year old man presents to his GP complaining of a lump on his neck. On further questioning, the lump has been there for 4 months, and he thinks it is increasing in size. It is non-painful, and there are no other lumps present. He does feel more tired than usual, and has been avoiding eating meat recently as he finds it difficult to swallow, and he thinks he's lost a little weight. On examination, there is a 2.5cm firm lump in the anterior triangle of the neck just below the mandible. It is not tender on palpation and is not mobile. It does not move with swallowing. There is no lymphadenopathy and the oropharynx appears unremarkable. What is the most likely diagnosis?

Submandibular salivary gland tumour This gentleman has a painless neck lump of several months duration, along with some red flag symptoms (weight loss, swallowing difficulty). The location of the lump is in line with the submandibular salivary gland. This combination of history and examination findings should prompt urgent referral for investigation of a neck cancer. 54%

Telogen effluvium

Telogen effluvium is a type of alopecia which affects the telogen (resting) phase of the hair cycle. It can be triggered by many things, including stress, childbirth, recent surgery, thyroid dysfunction and iron deficiency. Symptoms include hair thinning and shedding hair more easily. However, it tends to be less severe than anagen effluvium and given the patient's recent chemotherapy, anagen effluvium is more likely. 26%

An 18-year-old man presents to the emergency department with irritability and dizziness. He has a past medical history of asthma and type 1 diabetes mellitus. On examination, he is sweaty and clammy and has a GCS of 15. A venous blood demonstrates a blood glucose of 3.2 mmol/L (normal 4.0-11.0 mmol/L), with all other parameters within the normal range. What is the best first management step for this patient?

Sugary drink This patient is alert and talking and can swallow a sugary drink safely. A blood glucose of 3.2 mmol/L would explain his irritability, dizziness and clamminess, and a sugary drink is an appropriate first step in managing his hypoglycaemia. 79%

A 40 year old woman presents with pain over the lateral surface of her left leg. Her past history is significant for varicose veins for 5 years. Her BMI is 35 kg/m^2 and has a mild pyrexia of 37.3 degrees Celsius. Examination shows an erythematous area from below her knee down to the lateral aspect of left leg associated with swelling. A cord like superficial vein is palpable. A doppler ultrasonography shows a non-compressible superficial vein. Which of the following is the most likely diagnosis?

Superficial thrombophlebitis A painful, erythematous and palpable vein coupled with background history of varicose veins point towards superficial thrombophlebitis. The diagnosis is further confirmed by doppler ultrasonography, which reveals a non compressible superficial vein that is likely due to a thrombosis. The risk factor for developing superficial thrombophlebitis in this patient is obesity. 80%

mx of keratoachanthoma

Surgical excision Keratoacanthoma is a benign yet locally invasive skin growth which can be indistinguishable from squamous cell carcinoma clinically. It may spontaneously resolve within a few months, however surgical excision is usually recommended first-line. Other options if surgery is not appropriate or declined include cryotherapy, curettage or medical treatment with topical imiquimod or 5-fluorouracil. 50%

A 22-year-old man attends the emergency department with an increasing headache. This has been going on for a couple of days but has gotten particularly worse over the last day. He is also experiencing photophobia. He does not have any other symptoms and does not suffer from any other medical conditions.On examination, he is warm to the touch and there is flexion of his hips and knees when he tries to flex his neck. There is no evidence of a raised intracranial pressure.Assuming things at this hospital are carried out quickly, what would be the most appropriate next step in his management?

Suspected bacterial meningitis: an LP should be done before IV antibiotics, unless: cannot be done within 1 hour signs of severe sepsis or a rapidly evolving rash significant bleeding risk signs of raised intracranial pressure

A 28-year-old woman with multiple sclerosis presents to the emergency department with new onset vision loss affecting her left eye, associated with pain when moving her eyes. She has no other past medical history.Neurological examination of the limbs is normal.What imaging is recommended?

Suspected optic neuritis: MRI of the brain and orbits with gadolinium contrast is the investigation of choice

A 35-year-old male undergoes surgery for pancreatic cancer. He is induced with IV propofol and suxamethonium to aid intubation. He has a family history of difficult intubations. He is given IV morphine for pain relief. One hour into the surgery, the patient becomes hypoxic with an oxygen saturation of 70% and his respiratory rate is 8 breaths per minute. The surgeons mention his abdominal muscles are paralysed. What is the most likely diagnosis?

Suxamethonium apnoea Suxamethonium apnoea occurs in individuals who have a defect in the plasma cholinesterase enzyme which normally breaks down suxamethonium. They are unable to break down suxamethonium and the patient will struggle to breathe on their own due to relaxation of the respiratory muscles. 83%

A 72 year old man presents to Rheumatology clinic for a routine follow up of his rheumatoid arthritis. On examination, the patient's right index finger is flexed at the metacarpophalangeal joint (MCPJ), hyperextended at the proximal interphalangeal joints (PIPJ) and hyperflexed at the distal interphalangeal joints (DIPJ). Which of the following deformities best describes the changes to the patient's hand?

Swan-neck deformity Inflammation of the joints in rheumatoid arthritis can lead to damage of tendons, ligaments and joint capsule. This can create a range of characteristic deformities in the hands and feet. MCPJ flexion, PIPJ hyperextension and DIPJ hyperflexion are features of swan-neck deformity. 80% Boutonniere deformity Boutonniere deformity presents as PIPJ flexion and DIPJ hyperextension - it can be thought of as the opposite of swan-neck deformity without involvement of the MCPJs. 18%

A 26 year old woman presents to the GP with a year's history of lower back stiffness and buttock pain that impedes her getting dressed in the morning. She is a personal trainer and has noticed that the stiffness gets better after a few hours at work. On further questioning, she reports having a painful, red eye a few months ago. The GP suspects ankylosing spondylitis and given that the x-ray also shows bony bridges between adjacent vertebrae. Which of the following options best describes the x-ray findings?

Syndesmophytes Syndesmophytes are bony growths within the spinal ligaments and can form bony bridges between adjacent vertebrae. They can develop in patients with later stages of ankylosing spondylitis.

single penile ulcer causes

Syphilis (Treponema pallidum) - typically painless in nature, with an indurated base Herpes simplex virus - tends to cause multiple painful ulcers Chancroid (Haemophilus ducreyi) - tends to be multiple and painful Lymphogranuloma venereum (LGV) (Chlamydia trachomatis L1, L2, L3) - typically one ulcer, tender Granuloma inguinale/donovanosis (Klebsiella granulomatis) - typically painless, may be single or multiple Carcinoma Circinate balanitis - ring-shaped dermatitis caused by a reactive arthritis Lichen sclerosis Trauma

A 24-year-old female presents to the GP with an itchy rash on her neck. She first noticed it when she started wearing a new necklace three days ago. She has no history of any skin conditions. On examination, there is an erythematous rash encircling her neck. Given the most likely cause of her symptoms, which type of white blood cell is associated with this condition?

T lymphocytes This is a classic history of allergic contact dermatitis, in which skin irritation is triggered by contact with an allergen. Nickel is a common allergen and can be found in jewellery. Allergic contact dermatitis is a delayed type IV hypersensitivity reaction which is mediated by T lymphocytes. 24%

A 7 year old girl has been diagnosed with coeliac disease. Her parents would like to know more about how coeliac disease works. What is the pathophysiology behind the inflammatory response in coeliac disease?

T-Cell Mediated Correct. Coeliac disease is a T cell-mediated inflammatory autoimmune disease. 27%

48-year-old woman attends her annual diabetic screening with the local practice nurse. The patient reports feeling generally fit and well, and has been actively trying to lose weight and increase exercise levels. She reports good coherence with prescribed medications. QRISK2 score = 8.2%.Past medical history includes type 2 diabetes mellitus and hypertension. Current medications include metformin 1g BD and ramipril 10mg OD.A blood test is performed. HbA1c58 mmol/mol (7.5%) How should glycaemic control be managed?

T2DM on metformin, if HbA1c has risen to 58 mmol/mol then one of the following should be offered depending on the individual clinical scenario: DPP-4 inhibitor pioglitazone sulfonylurea SGLT-2 inhibitor (if NICE criteria met)

tnm bc staging

TX (tumour size unable to be assessed) T0 (there is no evidence of tumour in the breast) Tis (tumour is in situ) T1 (tumour is ≤2cm in size)T1mi (tumour is ≤1mm in size)T1a (tumour is >1mm but ≤5mm in size)T1b (tumour is >5mm but ≤10mm)T1c (tumour is >10mm but ≤20mm) T2 (tumour is 2-5cm in size) T3 (tumour is >5cm in size) T4 is subcategorised according to the spread of the tumour:T4a (spread into the chest wall)T4b (spread into the skin)T4c (spread to both skin and chest wall)T4d (inflammatory carcinoma - the overlying skin is inflamed and painful) Node (N) describes spread to the lymph nodes. Evaluation of this component may include clinical examination, sentinel lymph node biopsy or axillary lymph node dissection. NX (lymph nodes unable to be assessed) N0 (no spread to nearby nodes) N1 (spread to 1-3 axillary lymph nodes and/or internal mammary lymph nodes) N2 (spread to 4-9 axillary lymph nodes and/or internal mammary lymph nodes) N3 (spread to 10 or more axillary lymph nodes; or spread to supraclavicular or infraclavicular lymph nodes) Recently, staging has been updated to also incorporate biological factors such as oestrogen/progesterone receptor expression and HER2 receptor status. Metastasis (M) describes the spread to other parts of the body. Investigations to assess metastasis may include bone scan, chest x-ray, full blood count, liver function tests, calcium levels and/or computed tomography. M0 (no metastasis) M1 (metastasis present)

A 33 year old woman is brought to the Emergency Department with sudden onset right-sided weakness, slurred speech and visual changes by her mother. Collateral history reveals that the patient is normally fit and well besides a sinus infection and complaints of pains in her left arm for the last few weeks, especially after exercise. She has just finished a course of aciclovir for genital ulcers. On examination, her left radial pulse is weak and her blood pressure is 135/70 on one arm and 170/100 on the other. CT head reveals a hypodense area on the left hemisphere. What is the likely underlying cause for this presentation of stroke?

Takayasu's arteritis Takayasu's arteritis is a large vessel vasculitis that usually affects young women. It typically affects the aorta, causing limb claudication, abnormal or absent pulses and differential blood pressure measurements. Takayasu's arteritis can cause a stroke and should be considered in young women presenting with stroke. 54%

A 37 year old lady attends the walk-in sexual health clinic after forgetting to take her last Progesterone-only pill. She usually takes Micronor (Norethisterone) once a day. Her last pill was due four hours ago. She has not had any unprotected sexual intercourse this month. What is the most appropriate advice to give?

Take the missed pill, continue the pack as usual, and use condoms for the next two days Be aware of the two types of progesterone-only pills (POP): 'traditional' Norethisterone-containing pills, and newer Desogestrel ones. Desogestrel POPs are considered missed after 12 hours of being late to take them, whilst norethisterone POPs are missed after 3 hours - this patient is four hours late, therefore has missed a pill and needs added protection. POPs are only effective on the day taken - missing even one day reduces effectiveness. Patient should be advised to use condoms for the next two days FOR POP MISSING 1 IS BAD. FOR COCP MISSING 2 IS BAD

A 25 year old lady attends the walk-in sexual health clinic after forgetting to take her Progesterone only pill yesterday. She usually takes Cerazette (desogesterel) once a day. Her last pill was due 15 hours ago. She has not had any unprotected sexual intercourse this month. What is the most appropriate advice to give

Take the missed pill, continue the pack as usual, and use condoms for the next two days Progesterone only pills are only effective on the day taken - missing even one day reduces effectiveness. Patient should be advised to use condoms for the next two days, and if unprotected sexual intercourse happens in these two days, emergency contraception must be offered 56%

A 40 year old female presents to her GP with abnormal vaginal spotting for 10 weeks. She has a history of breast cancer. Which medication commonly used in the treatment of breast cancer is responsible for her symptoms?

Tamoxifen Tamoxifen is a oestrogen antagonist, commonly indicated for ER+ positive breast cancers. However, it also works as an agonist on endometrial tissue which can result in endometrial proliferation and cause abnormal vaginal bleeding. 87%

A 25-year-old man is seen in the acute mental health unit. He appears drowsy. When asked about his mood, he says, 'I should start by telling you about how my car broke down last week, which was annoying. After my car broke down, I had to wait a long time for a recovery vehicle. The driver was nice, and we talked about lots of things. I hope I get my car sorted out soon; I really need it for work, and I have a new project upcoming.' and he continues to talk about work.When asked further questions, he demonstrates similar behaviour and talks slowly throughout.What is the best description of his behaviour?

Tangentiality is correct. This patient was asked about his mood before he talked about the events leading up to the consultation, then talked about his car and its recovery, then moved on to his work project, and did not answer the question regarding his mood. This is an example of tangentiality, where patients wander (or tangent) from a topic without returning to it. Circumstantiality is incorrect, as this is where patients cannot answer questions without excessive and unnecessary detail. This would be the case if the patient eventually answered the question about his mood, however, he does not do so.Clang associations is incorrect. This is where patients say sentences that are only linked together by the fact they sound similar or rhyme, which is not seen here.Flight of ideas is incorrect. Despite the fact that this patient jumps from topic to topic with discernible links, this is usually associated with mania and pressured thoughts. The patient is drowsy and speaking slowly, making this option less likely, and they tangent from the initial topic onto related topics, rather than jumping from one thing to another. In flight of ideas, the derailment typically happens after answering the question. An example that would make flight of ideas more likely would be something similar to 'I am feeling awful, my car broke down last week, I hate my car's colour, my favourite colour is orange, oranges are a good fruit, fruits are tasty.' They would have answered the question, and each derailment is slightly linked to the previous topic.Knight's move is incorrect, as this is where the patient jumps from topic to topic without any clear or logical link between each sentence. This is not seen in this patient.

An 85-year-old man with a history of polycythaemia vera (PV) presents to the GP with recurrent fevers, weight loss and abdominal discomfort. On examination, he has massive splenomegaly. A full blood count reveals anaemia, leucocytosis and thrombocytosis. Based on the most likely diagnosis, which of the following would be expected on his blood film?

Teardrop poikilocytes The most likely diagnosis here is myelofibrosis, which can occur as a complication of PV and is a cause of massive splenomegaly. Teardrop poikilocytes are the characteristic blood film finding. 51%

A 30 year old man presents to his GP with a painless right testicular enlargement. He first noticed it ten months ago, and has gradually increased in size since then. On examination, the right testicle is significantly larger than the left one. A 3 mm firm, non-tender lump is felt within the body of the right testicle. It does not transilluminate. What is the single most likely diagnosis?

Testicular cancer It is important to note that the enlargement is of the testicle, not the scrotum. So the lump palpated within the body of the right testicle is suggestive of testicular cancer. Accompanied with the history of slow growth over a long period of time, this is typical of testicular cancer. 76% epididymal cysts are extra-testicular

A 48-year-old man with a background of Huntington's disease presents to his GP. He appears distressed and says he has been experiencing increasing sudden, involuntary movements in his hands and neck. He is hoping to see if anything can be done to help control these symptoms. What is the most suitable treatment option?

Tetrabenazine The involuntary, sudden movements the patient is describing are known as choreoathetosis. Tetrabenazine is useful for managing choreoathetosis. It works by reducing the uptake of monoamines such as dopamine which have been found to cause these movements. 41%

A 1-month-old baby suffers from intermittent episodes of cyanosis and tachypnoea, particularly when distressed. An examination reveals a harsh ejection-systolic murmur.Given the likely diagnosis, what is the best predictor of the clinical severity of this condition?

Tetralogy of Fallot: the severity of the right ventricular outflow tract obstruction (pulmonary stenosis) determines the degree of cyanosis and clinical severityImportant for meLess important The degree of pulmonary stenosisis correct. The presence of intermittent cyanotic episodes and tachypnoea associated with distress and the presence of a harsh ejection-systolic murmur should raise suspicion of tetralogy of Fallot (TOF), a congenital heart defect which often presents at around 1-2 months of age. TOF is characterised by four defects: Ventricular septal defect (VSD) Right ventricular hypertrophy Right ventricular outflow tract obstruction (pulmonary stenosis) Overriding aorta

meningitis in >50

The BNF recommend IV cefotaxime (or ceftriaxone) + amoxicillin (or ampicillin) as empirical therapy for adults > 50 years with suspected bacterial meningitis

A 22 year old dancer attends the sexual health clinic to discuss contraception. She is unhappy on her current contraceptive, the Nexplanon implant, as it has made her periods erratic. She also experiences spotting throughout her cycle. The irregular bleeding interferes with her work and she requests a method that will bring back regularity of her periods as soon as possible. Her past medical history includes acne, for which she uses topical Benzoyl peroxide. There is no relevant family history. She is a non-smoker and has a normal blood pressure. Which of the following is the most suitable option to offer?

The combined oral contraceptive pill (OCP) This is the most suitable option for a young woman with no contraindications, whose main concern is irregularity. The OCP is well known for improving regularity of cycles, as well as lighter, less painful periods (including, sometimes, complete cessation of periods). It also has the benefit of improving acne 77%

Primary amenorrhoea, little or no axillary and pubic hair, elevated testosterone

The correct answer is Androgen insensitivity syndrome . Androgen insensitivity syndrome in its complete form is a disorder of hormone resistance characterised by a female phenotype in an individual with an XY karyotype and testes producing age-appropriate normal concentrations of androgens. This patient is showing breast development as a result of the conversion of testosterone to oestradiol, lack of axillary and pubic hair and elevated testosterone all in keeping with this diagnosis.

A 19-year-old medical student attends her GP surgery with a one-day history of increased urinary frequency, dysuria and cloudy urine. There is no significant past medical history and the patient is on the combined oral contraceptive pill for contraception. She has no allergies and takes no other medications, and is systemically well.A urine dip is positive for leucocytes and blood, and is negative for nitrites.What is the most appropriate management of this patient?

The correct answer is Trimethoprim 3 days, send MSU . All UTIs with visible or non-visible haematuria should have a MSU sent. Three days is the correct length of antibiotic prescription for a woman. If this patient were male, a seven-day course would be appropriate.

A 45-year-old man presents to the GP complaining of skin thickening in his hands over the past 3 months. He complains that this has led to his fingers becoming fixed in a flexed position. Over the same period, she's noticed his fingers turn white and then blue in cold weather.On further questioning, he complains of exertional dyspnoea and cough when he goes running, as well as erectile dysfunction.Given the likely diagnosis, which autoantibody blood test is most likely to be positive?

The correct answer is anti-scl-70. The patient is presenting with diffuse systemic sclerosis. This is evident from the symptoms of skin thickening around the fingers, Raynaud's phenomenon, and symptoms of respiratory involvement (pulmonary fibrosis) and erectile dysfunction. The autoantibody most commonly associated with diffuse systemic sclerosis is anti-scl-70. Anti-topoisomerase I is another antibody often used in the diagnosis of diffuse systemic sclerosis.

A 35-year-old with asthma attends her GP surgery with increasing shortness of breath over the last two days.On examination her respiratory rate is 22 breaths/min, her heart rate is 76 beats/min, her saturations are 100% and her peak flow is 280L/min. Previously, her best peak flow was 400L/min. She is speaking in full sentences. Chest auscultation reveals a fine end expiratory wheeze and right basal crackles. She was admitted to the hospital with her asthma last winter, during which she required mechanical ventilation.What would be the most appropriate management plan for this patient?

The correct answer is arrange admission to hospital .As this patient had a previous near-fatal attack and is currently presenting with features of moderate acute asthma (as illustrated by PEFR 70% of her best, normal speech, RR <25 and pulse <110) she requires admission to the hospital.

A 32-year-old man with a known history of Crohn's disease presents to the emergency department with a history of acute, colicky abdominal pain over the last 24 hours. Further questioning reveals nausea and absolute constipation over the same period. He has an ileostomy.CT reveals small bowel obstruction with 5cm dilated loops of the small bowel and extensive adhesions from previous surgery. His blood pressure is 95/60 mmHg, heart rate 110 bpm, respiratory rate 23/min, and temperature is 37.9 ºC.What management option is contraindicated in this patient?

The correct answer is laparoscopic surgery. This patient is presenting with small bowel obstruction, as shown by the patient's abdominal pain, nausea, and constipation. Laparoscopic surgery can form part of the treatment algorithm for this. However, laparoscopic surgery is contraindicated in this situation as the patient has dilated loops of bowel on CT larger than 4cm.

An 82-year-old man presents to the emergency department with sudden onset of blurred vision and weakness in his right arm and leg.He has a past medical history of hypertension and type 2 diabetes for which he takes ramipril and metformin.On examination, his left pupil is dilated and both consensual and direct light reflexes are absent. In the right pupil, both direct and consensual light reflexes are intact. Power is 3/5 bilaterally in both upper and low limbs.Given this presentation what is the most likely location of this patient's stroke?

The correct answer is midbrain, also known as Weber's syndrome. This type of stroke affects the branches of the posterior cerebral artery that supply the midbrain. The midbrain contains the ocular motor nucleus so a stroke here causes ipsilateral CN III palsy but also because the cortical spinal tracts run through the midbrain before they cross over a midbrain stroke causes contralateral weakness of the upper and lower limbs.

A 37-year-old man presents to the GP complaining of flushing over the past two months. He complains that this has been getting progressively worse and his face is now red most of the time.On examination, there are multiple pustules and papules on a base of erythema covering the cheeks and nose. His nose is swollen with thickened skin. He has no significant past medical history or drug allergies.Given the likely diagnosis, what is the first-line treatment?

The correct answer is oral doxycycline and topical ivermectin. This patient is presenting with classic signs of rosacea: pustules and papules on a base of erythema over the nose and cheeks, as well as rhinophyma. Due to the severity of this presentation, NICE recommends a combination of topical ivermectin and oral doxycycline as the first-line treatment.

A six-year-old presents to the GP with his mother, who describes a stubborn patch of eczema on the boy's left cheek which has worsened despite his usual emollient and topical hydrocortisone treatment. Overnight, the patch has become extremely painful and spread to his chin. He has had eczema since infancy but is otherwise well.Examination reveals a patch of dry erythematous skin on the right cheek and a larger, more erythematous patch on the left, extending to the chin. The area is hot and tender on palpation. Vital signs are normal.What is the most appropriate action?

The correct answer is same-day referral to paediatrics . This child is presenting with an area of rapidly worsening and painful eczema, that is not responding to the usual treatment. This raises suspicion of and should be treated as, eczema herpeticum. Eczema herpeticum is treated as a medical emergency. It can rapidly worsen and lead to systemic complications. Urgent assessment and treatment with antivirals are indicated to prevent eye and meningeal involvement.

An 83-year-old woman has collapsed in her room and you are responding to the medical emergency call.Just before you arrived, she suddenly collapsed and the nurses managed to get her back into bed and attach monitoring equipment.She was originally admitted with sinus bradycardia and her bisoprolol has been stopped.She is barely conscious and you note on the monitor a heart rate of 28/min and a BP of 84/51mmHg.What is the most appropriate immediate management?

The correct answer is to give atropine which is the first-line temporising measure. This works as an anti-cholinergic to block the parasympathetic nervous system and thus increases heart rate. It only lasts a short time so there are more definitive measures that can be used to treat bradycardia such as isoprenaline infusions, temporary pacing or a permanent pacemaker.

A 32-year-old man presents to a sexual health clinic with a single painless ulcer on the tongue.On examination, the lesion is circular, 1cm in diameter, and has an indurated centre. Non-tender lymphadenopathy to the neck bilaterally is also noted.The patient is bisexual and has had unprotected oral and penetrative anal and vaginal intercourse with three male and four female partners in the past three months.What is the likely causative organism?

The correct response is Treponema pallidum. The lesion described is consistent with a chancre (lesion characteristic of the primary stage of syphilis). Chancres are typically singular, painless, indurated genital ulcers. They are found at the transmission site, typically the anus, mouth, penis or vagina. Syphilis is caused by the bacteria Treponema pallidum. Men who have sex with men (MSM) and those who engage in unprotected sexual intercourse with multiple partners are at increased risk of developing syphilis. HIV is incorrect. Primary HIV infection and seroconversion are associated with dermatological features, but this is typically a generalised maculopapular eruption with systemic 'flu-like' features.

A 65-year-old man presents with a progressive history of headaches, fatigue and generalised bone pain. Base-level blood tests are performed and identify normocytic anaemia, raised calcium and renal impairment therefore a diagnosis of multiple myeloma is suspected.The patient is admitted for corrects of his electrolyte imbalance and a plan for bone marrow biopsy is considered.What imaging should be conducted as the first line for this patient's suspected diagnosis?

The patient in the vignette has presented with features of a neoplasm of the bone marrow plasma cells, multiple myeloma (MM). Whole-body MRI is now the recommended imaging modality for suspected MM, identifying both focal and diffusion bone marrow infiltration. MRI is advised as the first line, as it has a high sensitivity for detecting osseous and extraosseous lesions without ionizing radiation.

A 90 year old man is admitted to hospital for end-stage liver disease and then develops hospital acquired pneumonia. He has a past medical history of schizophrenia, non-alcoholic fatty liver disease and hypertension. He is not compliant with treatment for any of his conditions. He develops delirium, which makes him agitated and he starts to remove his nasogastric tube (NGT), expressing a wish to leave. You assess his capacity and deem that he is lacking capacity to make a decision about his current treatment. You are considering issuing a deprivation of liberty safeguards (DoLS) to keep him in the hospital to complete the treatment. Which of the following reasons are would allow you to issue a DoLS?

The patient lacks capacity to consent to treatment or care to keep them safe from harm Correct. The Deprivation of Liberty Safeguards (DoLS) is used where it is necessary to deprive a patient or resident of their liberty as they lack capacity to consent to treatment or care to keep them safe from harm. DoLS is an amendment to restrict/restraint a patient and deprive them of their liberty. This patients lack of capacity in this situation is the key criteria to be able to issue a DoLS. 96% The patient has schizophrenia and is non-compliant with treatment Incorrect. Having a mental health issue, such as schizophrenia, alone is not the key criteria. There must be evidence of a lack of capacity for decision making for a person to be deprived of their liberty. Even though he has a history of schizophrenia, he must be presumed to have capacity until proven otherwise. Therefore, a capacity assessment should be done first. 2%

when is peritoneal dialysis preferred

The success is dependent on the presence of residual renal function. This is true of peritoneal dialysis. Peritoneal dialysis is preferred when the patients are younger and still have some residual renal function. Haemodialysis is not dependent on existing renal function, so it can be used when there is no renal function. 31%

endometriosis mx

The treatment for endometriosis depends on the symptoms, and the severity of these symptoms. Analgesia e.g. paracetamol or non-steroidal anti-inflammatory drugs Hormonal therapiesCombined oral contraceptive pillMedroxyprogesterone acetateGonadotrophin-releasing hormone agonists Surgical Management Diathermy of lesions Ovarian cystectomy (for endometriomas) Adhesiolysis Bilateral oophorectomy (sometimes with a hysterectomy) For managing infertility, menstrual suppression would be unsuitable, and so ablation or surgery is more appropriate.

when to screen for breast cancer

There are specific conditions in a patient's family history that may consider them at higher risk for breast cancer, which warrant referral from primary care. These include: Breast cancer in a first-degree male relative of any age Breast cancer in a first-degree relative under the age of 40 Bilateral breast cancer in a first-degree relative under the age of 50 Breast cancer in two first-degree relatives 36%

A 35-year-old man presents to his GP with weakness in his legs which is impacting his walking. He also describes tingling sensations in his feet and episodes where his feet feel numb. He has no significant past medical history and takes no regular medications. He has smoked 5 cigarettes a day for the past 3 years and drinks around 30 units of alcohol per week. On examination, you note significant muscle atrophy and reduced lower limb reflexes bilaterally. When assessing proprioception and vibration, this is also found to be impaired. What is the likely diagnosis?

Thiamine deficiency This patient has presented with symptoms suggestive of peripheral neuropathy secondary to excessive alcohol consumption. He has lower motor neuron signs (atrophy and hyporeflexia) which supports a peripheral nervous system cause. Excessive alcohol leads to thiamine deficiency which has a key function in providing energy to nerve cells. 32%

Longitudinal splitting of the lamina densa of the glomerular basement membrane

This describes a "basket-weave appearance" and is the characteristic histological finding in Alport syndrome. 7%

Linear deposition of antibodies along the glomerular basement membrane

This describes what is seen in Goodpasture syndrome. 37%

Bilateral fine reticulonodular shadowing

This is commonly found in idiopathic pulmonary fibrosis, although it is non-specific and can also be seen in other interstitial lung diseases. 28%

what is Pyrimethiamine and Sulfadiazine used to treat

This is the treatment for toxoplasmosis. Should the presentation have been more rapid, and the lesion reported as ring enhancing, this would have been a more appropriate treatment 19%

what is Amphotericin B and Flucytosine used to tx

This is the treatment of choice for meningitis in HIV, but there is no evidence of meningism 13%

Multiple ring enhancing lesions on MRI

This is the typical finding in a Toxoplasmosis gondii infection 34%

Encapsulated yeast organisms on India ink stain

This is the typical finding in cryptococcal meningitis, which is the most likely diagnosis in a HIV positive patient with a raised opening pressure on lumbar puncture. Approximately 25-30% of patients with cryptococcal meningitis have a normal CSF profile 29%

Periventricular ring enhancing lesions on MRI

This is the typical finding in primary cerebral lymphoma, which is caused by the Epstein-Barr virus 20%

Asymmetrical demyelinating white matter lesions on MRI

This is the typical finding in progressive multifocal leukoencephalopathy, which occurs due to the reactivation of the John Cunningham (JC) virus in immunosuppressed patients 11%

IgG and C3 subepithelial deposit spikes

This is what is seen in membranous glomerulonephritis. 15%

Subepithelial humps in the glomeruli

This is what is seen in post-streptococcal glomerulonephritis when the renal biopsy tissue is analysed under immunofluorescence.

what type of dialysis needs a restricted diet

This type of dialysis requires a more restricted diet. Patients on haemodialysis must have a more restricted diet. However, those on peritoneal dialysis can eat more freely.

A 45-year-old woman presents to her GP with visual problems. She states she has been experiencing double vision which is fine in the morning but as the day continues, gets progressively worse. She has also been feeling weak and fatigued by the end of the day. On examination, you notice she has a right-sided ptosis and some mild facial weakness compared to the left side. Which condition is most commonly associated with the suspected diagnosis?

Thymic hyperplasia This patient has presented with symptoms suggestive of myasthenia gravis - muscle weakness which is worse after repetitive use and by the end of the day. Ptosis, diplopia and facial weakness are also common features. Thymic hyperplasia is a benign condition which occurs in around 65% of patients with myasthenia gravis, making it the most commonly associated condition. 16% Thymoma Although this is a recognised complication of myasthenia gravis, thymic hyperplasia is more common in these patients. However, it is very important to rule out a thymoma in patients with suspected myasthenia gravis as they can be eligible for a thymectomy which can result in a significant improvement in symptoms. 66%

An 80 year old woman is brought to the A&E from a care home as she appeared confused. Past medical history is remarkable for pernicious anaemia, type II diabetes and vitiligo. On examination she is disorientated, bradycardic at 48 bpm with a blood pressure of 147/89 mmHg and hypothermic at 34.9ºC. Blood glucose is 3.9mmol/L. Which test is most likely to provide a diagnosis?

Thyroid function tests Hypothyroidism can cause constipation, bradycardia, hypothermia, and confusion. When evaluating an elderly patient who is experiencing confusion and is not known to have a history of confusion, it is important to consider the possibility of hypothyroidism and to obtain thyroid function tests. 41% Short synacthen test This is an incorrect answer. Addison's disease may present as hypotension, hyperkalaemia, hyponatraemia with nausea and vomiting. The short synacthen test is a specific test for Addison's disease. 19%

tibial plate fractures

Tibial plateau fractures commonly occur as a result of high energy impact. Diagnosis is via plain x-ray. Plateau fractures may be managed conservatively with immobilisation in a hinged knee brace for 8-12 weeks. Displaced or open fractures may require surgical fixation. External links see schatzker classification

A 25-year-old man attends the emergency department accompanied by his partner, after sustaining a head injury. His partner states he was making breakfast this morning when suddenly he went floppy and fell to the floor. She goes on to add, that he has experienced an episode like this previously but did not sustain any injuries.A CT scan shows no abnormalities detected, however, the attending clinician suggests the patient is referred to an epilepsy clinic.What medication may be started for this man's presentation?

Tonic or atonic seizures males: sodium valproate females: lamotrigine

A 40 year old man attends the GP having had a couple of episodes of rectal bleeding. On further questioning, the bleeding is painless, and apparent only on wiping following defecation. There are no other symptoms, aside from the occasional period of constipation, which he manages with prune juice. On examination, his abdomen is soft and non-tender. The anus appears normal, with no swellings, masses or bleeding apparent. On digital rectal examination, there are several non-tender small swellings palpable just inside the external anal sphincter. There is no protrusion of the swellings on straining. Anal tone is intact. What is the most appropriate management for this man?

Topical Corticosteroid cream This man has haemorrhoids (piles). Haemorrhoids typically present with painless rectal bleeding following defecation and/or straining and may be accompanied by rectal discomfort +/- pruritus. All patients with haemorrhoids should be given advice regarding increasing the amount of fibre in the diet, and keeping well hydrated to avoid constipation. Haemorrhoids are graded as follows: Grade 1 haemorrhoids: these are internal haemorrhoids which do not prolapse on straining. These can be managed conservatively with topical corticosteroids. Grade 2 haemorrhoids: these are internal haemorrhoids which prolapse on straining, but spontaneously reduce. These are typically treated with rubber band ligation, sclerotherapy, or infrared photocoagulation. Grade 3 haemorrhoids: these are internal haemorrhoids that prolapse on straining and require manual reduction. These are best managed with rubber band ligation. Grade 4 haemorrhoids: these are internal or external haemorrhoids that prolapse on straining and cannot be reduced. These are normally treated surgically with haemorrhoidectomy. This gentleman sounds like he has grade 1 haemorrhoids. There is no evidence of prolapse, and therefore he can be managed with topical corticosteroids along with dietary advice. 45%

A 47-year-old woman is referred to the dermatology clinic due to rosacea. She has tried lifestyle changes such as avoiding hot environments which have helped somewhat however she is still not happy with her appearance.On examination, she has Fitzpatrick skin type I and there is fixed erythema around her nose and upper cheeks. There are no visible blood vessels, papules or pustules. She has no other medical conditions and takes no regular medication.What is the most appropriate next step in her management?

Topical brimonidine is correct. This patient has rosacea with fixed centrofacial flushing despite lifestyle changes. The best treatment for this is a topical alpha agonist like brimonidine or oxymetazoline. This patient does not have telangiectasia but patients with telangiectasia should be advised that these will become more prominent with alpha agonist treatment.

A 55-year-old woman with a background of ulcerative colitis attends a gastroenterology follow-up appointment. Her gastrointestinal symptoms are currently well controlled, however she asks the consultant if they can look at a sore on her leg which has developed over the past few days. On examination, there is a 2x3cm ulcer on the left shin which is malodorous with a purulent base and an irregular, erythematous border. The patient is afebrile and otherwise well. What is the most appropriate treatment option for this condition?

Topical corticosteroids This patient's condition is consistent with pyoderma gangrenosum, in which painful ulcers develop most commonly on the legs. It is associated with inflammatory bowel disease, although it is an uncommon complication. A skin biopsy may be done to exclude other causes of ulceration. Small ulcers are often treated with potent topical corticosteroids. For large ulcers or if the patient is systemically unwell, oral corticosteroids or other immunosuppressants may be considered. Severe cases may also require surgical management, however this is avoided during acute flare-ups as there is a risk of worsening the ulceration as a consequence of surgical trauma. 52% Surgical debridement Severe cases may require surgical management, however this is avoided during acute flare-ups as there is a risk of worsening the ulceration as a consequence of surgical trauma. 33%

An 18-year-old female visits the GP with a two month history of comedones, papules and pustules on her forehead, cheeks and jawline. They first appeared on her chin then progressed to involve most of the face. She has no history of any skin conditions and takes no regular medications. Based on the appearance of her skin and the presence of several nodules, the GP decides to prescribe treatment for severe acne. Which of the following is the most appropriate treatment option?

Topical retinoid, topical benzoyl peroxide and oral doxycycline Acne vulgaris is an inflammatory skin condition. It is characterised by the presence of comedones, papules and pustules which arise as a consequence of pilosebaceous unit blockage and inflammation. Oral antibiotics such as doxycycline and lymecycline are reserved for moderate or severe acne. However, they are always prescribed with topical treatments in order to reduce the risk of antibiotic resistance. 52% dont prescribe oral abx by themselves

A 23-year-old man presents to A&E after recently immigrating to the UK from Sudan. He is complaining of discharge from his eye which is green and white. He also feels like his eyelashes have turned inwards and this is quite painful. On examination of the eye there are follicles and papillae on the lid. What is the most likely diagnosis?

Trachoma This is a classical description of Trachoma which is the leading cause of blindness worldwide. It is caused by Chlamydia trachomatis. It is particularly endemic in Africa and this gentleman has recently moved to the UK from Sudan. It is spread via human to human transmission, as well as flies landing on the nose and eyes. It is treated with antibiotics and surgery if damage to the cornea has occurred. Damage to the cornea occurs when the eyelid turns inwards (called an entropion). This is a serious manifestation of the condition as it causes blindness 51%

A 16-year-old teenager visits the GP for a routine health check-up as she is currently training for a triathlon. She has no past medical history, takes no medications, and denies any current symptoms. Her vitals and physical examination are entirely normal; however, a urine dipstick is positive for 1+ protein. A urine protein-to-creatinine ratio estimates 100 mg of protein excretion per day. After a week, another urine sample revealed similar results. What is the most likely diagnosis?

Transient proteinuria Fever, exercise, stress, seizures, and hypovolemia are some of the causes of transient proteinuria, which is relatively prevalent in this age range and disappears after the underlying cause is eliminated. In the provided scenario, it might have been the case as she is involved in rigorous physical activity. 56%

A 27 year old lady attends GP complaining of heavy and painful periods. She says that she normally soaks through almost ten sanitary towels per day during her period. PV examination reveals a bulky uterus. What investigation is most appropriate for identifying the cause of this lady's bleeding?

Transvaginal ultrasound A bulky uterus in a young lady is most likely due to fibroids. These are non-cancerous growths of fibroepithelial tissue within the uterus. The most appropriate investigation to visualise fibroids is a transvaginal ultrasound as it can pick up fibroids in various locations (submucosal, intramural, subserosal). If further detail is required, hysteroscopy can be performed for small polyps not seen on ultrasound or for planning resection of submucosal fibroids. 78%

A 23 year old woman presents to the Emergency Department with severe abdominal pain. She has a history of pelvic inflammatory disease (PID) three years ago, which was successfully treated with antibiotics. Her blood pressure is 120/85 mmHg and her temperature is 39.4 degrees Celsius. The abdomen is rigid. Vaginal examination elicits cervical excitation. What is the single most appropriate investigation?

Transvaginal ultrasound The patient's symptoms, including severe abdominal pain, fever, and cervical excitation during a vaginal examination, are consistent with a possible recurrent or persistent pelvic infection. The presence of abdominal rigidity also suggests an acute abdomen. In this scenario, ultrasound is non-invasive and can be performed quickly, making it a useful tool for diagnosing acute PID and its sequelae (including pyosalpinx and tubo-ovarian abscess). 36%

A 50 year old man presents with painful and persistent erection for more than 4 hours. His past medical history includes hypertension, anxiety, and depression for which he is taking propranolol, trazodone and citalopram. He drinks 1-2 cans of beer a week and smokes cannabis. Which of the following is the most likely cause of his condition?

Trazodone A sustained erection for more than 4 hours indicates priapism in this patient. Trazodone, a medication used to treat depression is known to have an increased risk of priapism. Low flow priapism is an emergency which requires prompt treatment with aspiration of the corpus cavernosum. 46%

A 40-year-old man presents to the Emergency Department with a spontaneous and painful erection for the past six hours. He denies taking illicit drugs or being sexually active. He is taking medication for diabetes mellitus, hypertension, hyperlipidemia, and depression. Which of the following medication would have led to his condition?

Trazodone Trazodone is a serotonin receptor antagonist and reuptake inhibitor, which can cause priapism as a side effect. Trazodone-induced priapism is through its α-adrenergic blocking activity. 63%

mx of cmv retinitis

Treatment involves using intraocular injections of ganciclovir and systemic oral valganciclovir.

A 39-year-old lady with a past medical history of hiatal hernia and a body mass index (BMI) of 37 presents to the general practitioner with a three-month history of heartburn and acid reflux. She denies any recent weight loss, haematemesis or melaena. Blood tests are unremarkable. Which of the following is the most appropriate management plan?

Trial of omeprazole for 8 weeks and lifestyle interventions Trial of proton pump inhibitor (PPI) therapy such as omeprazole in combination with lifestyle interventions should be the first line management plan for this patient with likely gastro-oesophageal reflux disease (GERD) in the absence of red flags features. 84% Two-week wait referral for upper gastrointestinal endoscopy Urgent two-week wait referral for upper gastrointestinal endoscopy is indicated for those with dysphagia or those aged 55 years and over with weight loss accompanied by reflux, dyspepsia, or upper abdominal pain. 5%

A 6-month-old girl is brought into general practice by her father. Her father is concerned about her speech development and wants to know what hearing, speech and language milestones a 6-month-old should be reaching. Which of the following is a hearing, speech and language milestone for a 6-month-old baby?

Turns head towards loud sounds 6-month-old babies should be turning their head towards loud sounds and starting to babble, coo and laugh. They should also start understanding 'bye-bye'. 40%

A 50-year-old man complains of dizziness and infrequent urination. Past history is significant for chronic kidney disease (CKD) a few months ago. Investigations reveal metabolic acidosis with hyperkalaemia. What is the most likely diagnosis?

Type 4 renal tubular acidosis Hyperkalaemia is the characteristic feature of type 4 or generalised distal renal tubular acidosis. It commonly occurs in patients with chronic kidney disease. In CKD, volume overload leads to low renin and aldosterone levels, which causes sodium and potassium ions retention in the distal tubule. Therefore, the resultant hyperkalaemia causes H+ ions to retain in the proximal tubule, causing acidosis. 35%

Which of the following terms best describes the rejection of the null hypothesis when it is true?

Type I error A type 1 error is a false positive finding (incorrect rejection of the null hypothesis), which means that the results falsely suggest the existence of a statistical significance that is not there. For example, a clinical trial of a medical treatment showing that the treatment works when it really doesn't 49%

A 5-day-old premature female neonate in the intensive care unit suddenly becomes unwell with increased oxygen requirement and heart rate. She was born at 27 weeks gestation and is currently intubated with an umbilical venous catheter (UVC) in situ. She is treated empirically for sepsis. Blood cultures grow coagulase-negative staphylococcus (COnS) which is determined to be Staphylococcus epidermidis. What is the definitive treatment for this illness?

UVC removal Commonly found on the skin, S. epidermidis can form biofilms on plastic devices inserted centrally. In this case, the neonate has a central venous catheter inserted through the umbilical vein, which is the likely source of her sepsis. While antibiotics may provide some clinical benefit, the definitive treatment is removing the affected device. 26%

A 52-year-old male visits his GP with chest pain that came on suddenly 2 hours ago while he was watching TV. He describes the pain as central and crushing. The patient has a past medical history of hypertension and hypercholesterolaemia and is currently taking ramipril 2.5mg and atorvastatin 20mg daily. He admits he has been forgetting to take his medications regularly. An ECG is done which is normal. What is the most likely diagnosis?

Unstable angina This is correct, as the patient presents with chest pain which started at rest. The ECG may be normal in unstable angina. 64%

A 60-year old female with ovarian cancer attends her GP appointment. She is being started on cisplatin. What investigations would the patient need regularly?

Urea & electrolytes Cisplatin can cause nephrotoxicity and ototoxicity, it is important to monitor kidney function. 47%

A 45 year old woman presents to the emergency department with severe left flank pain. She describes the pain as colicky in nature and 9/10 in intensity. She has no similar episodes in the past. She has a BMI of 40kg/m^2. Her temperature is 37.3C, pulse rate 80/min, respiratory rate 16/min and blood pressure 130/80mmHg. There is mildly elevated leucocytosis, raised urea and creatinine on blood test. A non-contrast CTKUB reveals 14mm stone in the left vesico-uteric junction with left hydroureter and hydronephrosis. She is given intramuscular NSAIDS. Which of the following is the most appropriate for her treatment?

Ureteroscopic (URS) stone removal Ureteroscopic (URS) stone removal is the first line treatment for mid ureter or distal stones that are more than 10mm. This patient's blood test shows acute kidney injury and obtructive uropathy as evident on the CT scan and warrants immediate relieve to avoid further renal damage. In this procedure, a scope is inserted retrograde via the urethra, and laser carried out to fragment the stones. A temporary retrograde stenting usually follows to keep the ureter patent and allow healing. 28% Percutaneous Nephrolithotomy (PCNL) PCNL is usually carried out in patients with large renal stones (including staghorn calculi). An incision is made over the flank area and a tube is placed inside the kidney through X ray guidance. This patient has a calculi in the distal ureter and hence this procedure is not appropriate. 38%

An 18-year-old man is seen in the emergency department after suffering a hard tackle during a rugby match. He feels well, has no abdominal pain and and would like to be discharged. On examination, observations are Sp02 99%, HR 105/bpm, BP 132/80 mmHg, temperature 36.9 degrees Celsius. On examination, he is surprisingly tender in the left upper quadrant. What is the best management option for this patient?

Urgent abdominal CT scan Left-sided abdominal tenderness in the context of blunt trauma should be treated as a splenic rupture until proven otherwise and this patient needs an urgent CT scan. His mild tachycardia could also be an early sign of haemodynamic compromise. 42%

A six-year-old boy is brought to the paediatric assessment unit with an eight day history of abdominal pain, bloody stools and bruising. His blood tests show a low haemoglobin (with a normal MCV), a low platelet count, raised white cell count and raised creatinine. Given the likely diagnosis, what is the most appropriate management of this patient?

Urgent admission for supportive care The most likely diagnosis is haemolytic uraemic syndrome. This is a potentially life-threatening condition that requires immediate hospital admission. The treatment is supportive and likely to include IV fluids, analgesia, nutritional support, and antihypertensives. In some cases, blood transfusions are required for severe anaemia and dialysis is indicated if there are signs of renal failure. 60%

A 4-year-old girl is brought to the paediatric emergency department by her father. He is extremely worried as she was playing alone in the living room and suddenly started coughing. He is worried that she may have swallowed something by accident. She is no longer coughing and looks well now. A chest x-ray shows a circular radio-opaque region with a 'halo sign' in the oesophagus. Which of the following is the most appropriate next step of management?

Urgent endoscopy The x-ray findings (halo sign) suggest that this child has swallowed a button battery. Ingestion of button batteries is extremely dangerous as the battery can react with bodily fluids such as saliva, which allows the battery to leak a strong alkaline fluid which can burn through the tissue. The next best management step is to perform an urgent endoscopy under general anaesthetic to remove the battery and decide if further treatment is needed, for example, if the battery has caused a tracheo-oesophageal fistula. 78%

A 18 year old male presents with severe pain in the left scrotum lasting for 4 hours. He had a similar episode of pain a year ago but this resolved spontaneously. He denies all urinary symptoms, including dysuria, discharge and haematuria. He is sexually active with 2 partners, however remains insistent that he always uses condoms. His most recent STI screen was negative. On examination, his scrotum is extremely tender and examination is not possible because of the pain. Given the likely diagnosis, what is the most appropriate next step in management?

Urgent surgical exploration Even though no further tests can be performed due to the intense pain, a sudden, acute onset testicular pain is testicular torsion until proven otherwise. His past episode of similar presentation suggests that the testicles twist and untwist spontaneously on its own. Testicular torsion is a surgical emergency and should be treated immediately with detorsion of the affected testis and bilateral orchidopexy to prevent further episodes of torsion. Urgent referral to the urologist should be made, and the patient be kept nil by mouth with maintenance fluids, analgesia and anti-emetics. 74%

An 80 year old man was admitted for cellulitis and started on antibiotics. He was prescribed regular diphenhydramine when he developed a rash as a side effect of antibiotics. A week later, he developed oliguria. Serum creatinine level is raised, and a renal ultrasound reveals dilation of the pelvicalyceal system. Where would be the most likely site of obstruction in this scenario?

Urinary bladder The abrupt onset of oliguria and raised creatinine indicates acute kidney injury, and ultrasound points towards obstructive nephropathy. Diphenhydramine is a 1st generation anti-histamine, which has greater risk of anticholinergic side effects compared to 2nd generation drugs. This causes urinary retention in the elderly through reduced contractility of detrusor muscle in the bladder. 11% Ureteropelvic junction Dislodging of renal calculi at the ureteropelvic junction could cause ipsilateral hydronephrosis. Renal calculi would usually present with loin pain, haematuria and dysuria. This is not seen here. 53%

A 26-year-old lady is sent to the emergency department after a seizure lasting for 2 minutes. Her carer is extremely worried about her as she is described as not being herself, with some odd behaviours noted over the past few days. A collateral history reveals that she had recently finished a course of antibiotics for a urinary tract infection. Her observations are as follows: Heart rate: 112 beats per minute Blood pressure: 141/85 mmHg Temperature: 36.7°C On examination, there is no rash. A power of 4/5 is noted in both upper and lower limbs. Blood results reveal glucose of 7.1 mmol/L (normal 4.0-11.0 mmol/L) and sodium of 124 mmol/L (normal 137-144 mmol/L); however, are otherwise unremarkable. A diagnosis of acute porphyria is suspected. Which of the following is used to confirm the diagnosis of acute porphyria?

Urine porphobilinogen level Acute porphyria can manifest with gastrointestinal symptoms, e.g. abdominal pain, vomiting or neuropsychiatric features (peripheral neuropathy, psychosis, and seizure). Due to the overactivity of the sympathetic system, acute porphyria can also result in hypertension and bradycardia. Urine porphobilinogens are raised during an acute attack. Possible triggers of acute porphyria include antibiotics such as trimethoprim and nitrofurantoin and anaesthetic agents. 71%

An 18-year-old female presents to the emergency department with fever. She is normally fit and well but suffered a bad sore throat three weeks ago. On examination, her chest is clear, and her abdomen is soft and non-tender. She displays choreatic movements and complains of pain in her left wrist and right ankle. She is tachycardic and pyrexial. What is the most important complication of this disease to prevent?

Valvulopathy The patient meets the Jones criteria for rheumatic fever; this is associated with valve defects, of which the most common is mitral stenosis. 43%

A 57-year-old man is seen in clinic with a 4-month history of aches, swellings in his legs, and itchy, dry skin. His symptoms are worse on exertion and when standing, especially towards the end of the day when his swelling is most prominent. He has a past medical history of obesity and smokes 30 cigarettes daily.His lower limbs appear eczematous with hyperpigmentation, and shallow, irregular ulcers are present. The skin around his ankles is hardened and tight. An ankle-brachial pressure index measurement is normal.Given the likely diagnosis, if any, what is the diagnostic investigation of choice?

Venous duplex ultrasound is correct. This patient has evidence of chronic venous insufficiency (CVI) given their history of obesity and lower limb swelling that is worse at the end of the day. Lipodermatosclerosis (tightened, hardened skin), venous ulcers (shallow and irregular ulcers), and haemosiderin deposition (skin hyperpigmentation) support a diagnosis of CVI. The investigation of choice of CVI is a venous duplex ultrasound scan, which would show retrograde venous flow due to incompetent venous valves.

which type of polyps cause hypokalaemia and are more likely to cause crc

Villous polyp Villous polyps tend to be larger than other polyps and are more likely to progress to colorectal cancer. Crucially for this question, they are also associated with hypokalemia. This is thought to be due to the polyp secreting insulin. 48%

causes of a high hba1c

Vitamin B12/folic acid deficiency Iron-deficiency anaemia Splenectomy

A 25-year-old woman presents to the GP with a 1-year history of lethargy, tiredness, and joint pain. During this time, she has also had some easy bruising, as well as prolonged bleeding from her gums when brushing her teeth. She is generally fit and well, although admits her appetite has been poor recently, and her diet consists nearly entirely of white rice because of this. She does not smoke and drinks 12 units of alcohol weekly.An abdominal examination is unremarkable, there are bruises on her arms and calves, and her gums are slowly bleeding.What is the most likely cause of her presentation?

Vitamin C deficiency is correct. As the presence of easy bruising, prolonged gum bleeding, lethargy, tiredness, anorexia, and joint pain on a background of poor diet point towards a nutritional deficiency, more specifically a vitamin C deficiency, as easy bruising and bleeding gums are characteristic symptoms.

vulvodynia

Vulvodynia Vulvodynia is persistent and unexplained pain in the vulva. This woman's pain is secondary to skin scarring and atrophy due to lichen sclerosus and so is therefore not unexplained. 8%

A randomized control trial comparing treatment with Ramipril to a control group shows that the relative risk of death from a non-cardiovascular cause is 1.03 (95% CI: 0.85-1.26). Given the information available, which of the following is the most appropriate interpretation of the above statement?

We are 95% confident that true value can be anything from 15% reduction in deaths to 26% increase in deaths A 95% confidence interval means that we would expect 95% of the interval estimates (in this case 0.85 to 1.26) to include the population parameter (in this case, relative risk of death from a non-cardiovascular cause). Note that a figure less than 1 indicates a lower risk compared to the control, and vice versa 53%

A 68 year old man presents to the emergency department with fever and feeling generally unwell since a day before. He has uncontrolled type 2 diabetes and hypertension. He reports pain on his left foot. Observations show temperature 38.6 degrees Celsius, blood pressure 100/70mmHg, pulse rate 102 beats per minute and respiratory rate 25 breaths per minute. There are no abnormalities to cardiovascular examination. Examination of the left foot shows erythema and oedema up to the ankle. The left big and second toes appear moist with blackish discolouration and blisters. The dorsalis pedis pulse is absent. The right foot is dry and shiny with no hair. Sepsis six protocol is initiated. Which of the following is the contributing factor of sepsis in this patient?

Wet gangrene In patients with peripheral arterial disease (absent pulses and skin changes), blackish, moist and blistering distal extremities raise concern for wet gangrene. In wet gangrene, patients may went on to develop sepsis due to superimposed infection, which needs to be urgently treated with IV antibiotics followed by surgical debridement or in most scenarios, amputation. 72%

genital herpes mx in pregnancy

What if I have recurrent flare-ups? If you have caught genital herpes before you become pregnant, your immune system will provide protection to your baby in pregnancy. Flare-ups of genital herpes during pregnancy do not affect your baby. Even if you have a flare-up when you go into labour and give birth, the risk to your baby is extremely low. Most women who have recurrent genital herpes can have a vaginal birth. Your doctor or midwife will discuss this with you. If you have frequent flare-ups during pregnancy, you may be offered continuous antiviral treatment from 36 weeks of pregnancy to birth. What if I get genital herpes for the first time in pregnancy? What treatment will I be offered? You should be referred to a specialist genitourinary medicine clinic. You will be offered testing, treatment and support. You may be admitted to hospital if this first episode is very painful or you cannot pass urine. Genital herpes can be safely treated during pregnancy. You will be offered a course of antiviral tablets. This medication is safe to take in pregnancy and while breastfeeding.

HIV transmission - mother to child

Without intervention, the likelihood of passing HIV from mother to child is around 25-40%, 90% of which occurs during delivery. Infection is rarely passed in utero. Management It is imperative to start the mother on combination antiretroviral therapy (cART) as soon as a diagnosis is confirmed. If the mother's viral load is <50, a normal vaginal delivery can be recommended and supported. If the viral load is greater than 50, an elective caesarean section is recommended The baby will be recommended infant post exposure prophylaxis (PEP) with either zidovudine monotherapy or cART. The duration and choice of therapy depends on the risk of transmission (e.g. maternal viral load, resistance patterns) In the UK, the safest way to feed infants born to women with HIV is with formula milk, as there is no on-going risk of HIV exposure after birth However women with a low viral load on cART who choose to breastfeed should be informed of the risk of transmission, but supported to breastfeed if they wish, alongside additional monitoring.

A 26-year-old pregnant woman comes to the GP for her prenatal visit. She is currently at 26 weeks' gestation. She complains of numbness and tingling sensation over her right hand for the last few weeks. The symptoms can be relieved by shaking her hand but it soon recur. She also noticed weakness when grasping objects using her right hand. On examination, there is worsening of numbness and tingling sensation on her right wrist when it is held in full flexion passively. Which of the following is the most appropriate first-line management for this patient?

Wrist splint This patient is having carpal tunnel syndrome on her right wrist. Pregnancy is a risk factor for carpal tunnel syndrome because of physiological fluid retention that occurs during pregnancy. She also has a positive Phalen test (numbness and tingling on passive wrist flexion). Conservative management by splinting the wrist would usually help resolve her symptoms. 75% Corticosteroid injection Corticosteroid injection is often used in patient with mild to moderate carpal tunnel syndrome. However, most carpal tunnel syndrome caused by pregnancy usually resolve after delivery and can be manage by splinting. Therefore, corticosteroid injection is not the most suitable first line treatment for this patient. 5%

A 55-year-old man presents to the emergency department with a fever and yellow skin and eyes. He has recently had an illness characterized by fever, chills, headache, and myalgia after returning from Angola. He seemed to recover from the illness and was well for a period of 48 hours before deteriorating. He has a past medical history of rheumatoid arthritis and is on tocilizumab.On examination, there is bleeding from his eyes and mucus membranes and he is visibly jaundiced. The temperature is 38.5ºC.What is the likely diagnosis?

Yellow fever typically presents with flu like illness → brief remission→ followed by jaundice and haematemesisImportant for meLess important Yellow feveris the correct answer. The patient presents with a flu-like illness after returning from Nigeria, followed by a brief period of remission with subsequent recrudescence of fever and the development of jaundice and haemorrhage from the eyes and mucus membranes. This presentation is typical of yellow fever (and the brief period of remission is characteristic). Tocilizumab treatment for rheumatoid arthritis means the yellow fever vaccine is contraindicated and would put the patient at increased risk of developing the illness.

femoral artery in femoro-popliteal stenosis

absent femoral pulse

criteria for ARDS

acute onset (within 1 week of a known risk factor) pulmonary oedema: bilateral infiltrates on chest x-ray ('not fully explained by effusions, lobar/lung collapse or nodules) non-cardiogenic (pulmonary artery wedge pressure needed if doubt) pO2/FiO2 < 40kPa (300 mmHg)

how to determine if someone requires anticoag in afib

cha2ds2 vasc

which ethnicity is likely to develop fibroids

african american

AST/ALT >2

alcohol hepatitis

mx of hiatus hernia

all patients benefit from conservative management e.g. weight loss medical management: proton pump inhibitor therapy surgical management: only really has a role in symptomatic paraesophageal hernias

meningitis >50

amoxicillin and iv cefotaxime

uti mx in pregnant women in 3rd trimester

amoxicillin or cefalexin

uti third trimester

amoxicillin or cefalexin

diagnosis of AIDS requires what

an AIDS defining illness as well as a cd4 less than 200

46 XY

androgen insensitivity syndrome can palpate pelvic masses.

A 22-year-old man presents with a 12-month history of progressively worsening back pain. The pain and stiffness are worse in the morning and improve with exercise. You note the presence of a flexural rash with poorly defined areas of erythema, dry skin and lichenification. Observations are normal. what is the most likely diagnosis

ankylosing spondylitis

common non-motor symptom of PD

anosmia

mx of jarisch herischmer reaction

antipyretics and supportive mx

A 30-year-old female presents to her GP with a swollen left leg; she noticed this a few days after returning from a vacation in Tokyo. A Doppler ultrasound confirms a deep venous thrombosis (DVT), and she is started on apixaban. A few days later, she presents to the emergency department with epistaxis. What is the mechanism of action of apixaban?

apixaban is a factor 10 inhibitor dabigatran is a thrombin inhibitor

inhernitance pattern of vwd

autosomal dominant

where does lesion occur in dyskinetic/athetoid cerebral palsy

basal ganglia and substantia nigra

A 24-year-old man presents to the emergency department after falling off his bike without a helmet yesterday. He initially felt fine but today has developed a worsening headache. On examination, he is found to have extensive bruising over the mastoid process. What is the term given for this examination finding?

battles sign haemotypanum is blood in the middle ear

which tremor is improved by alcohol

benign essential tremor

where does renal cell carcinoma spread to first

blood vessels

most common place that lung ca can mets too

brain

home exercises for bppv

brandt daroff

gold standard ix for diagnosing pjp

bronchoalveolar lavage

methotrexate toxicity

bruising, mouth ulcers and abdominal pain

levodopa side effects

can cause dysnkinesia at high doses dystonia, chorea or athetosis

fungal nail infection

candida - intraconazole dermatophyte - amorolfine nail liquor, oral terbinafine.

for meningitis - when to give abx and not do LP

cant be done in 1 hour signs of severe sepsis or rapidly evolving rash significant bleeding risk signs of high ICP

ix before starting transtuzumab

cardiac toxicity so do an echo

over 55 and htn

ccb

rapidly correcting hypernatraemia gives you

cerebral oedema

lung collapse

common due to cancers

sah cause what type of hydrocephalus

communicating (not obstructive)

what type of diabetes insipidus does sarcoidosis cause

cranial

A 48 year old woman attends the sexual health clinic to discuss contraception. She tells you she thinks she's going through 'the change', as she stopped having periods 12 months ago, and asks whether she still needs contraception. She has a past medical history of breast cancer, which was successfully treated two years ago. Her medications include Atorvastatin and Cetirizine as required. She smokes five cigarettes a day and consumes three units of alcohol a week. Her observations in clinic today are normal. Which of the following advice is most appropriate?

cu iud is the only suitable choice in someone with a history of breast cancer

what happens to murmur in AS when doing valsava

decreases murmur (same as MR)

bowel effects of metoclopramide

diarrhoea

CCB IN HTN

dihydropyridines

type of ccb for afib

dihydropyridines

dvt anticoag

doac

general advice for someone with oral hsv

dont kiss babies - they can develop neonatal herpes

CT head within 6 hours for a SAH is normal now what what if it is normal after 6 hours GUIDELINE CHANGED IN 2022

dont need to do LP - consider an alternative diagnosis if after 6 hours CT is normal then do LP.

in hyperkalaemia what resuscitation fluid can you not use

dont use hartmanns as it has K use saline

levenogestrol pill in epilepsy

double dose

47XX

downs

do you get dysphasia or dysarthria in cerebellar problems

dysarthria

An 18-year-old man presents to the emergency department with 1-hour history of sudden-onset right-sided groin pain over the last hour. He describes it as 10/10 and has associated nausea and vomiting.On examination, the right testis is retracted and elevation of the testis does not ease the pain. The left testis is unaffected. He is subsequently admitted. There are no anticipated delays in treatment.What is the most appropriate step in his management?

emergency bilateral orchdopexy Testicular torsion surgery should involve fixation of both testes to prevent torsion of the other testes

A 42 year HIV-positive old man presents to the GP. He is concerned as he has noticed multiple palpable purple nodular lesions on his back. What is the most appropriate first step?

ensure the pt is complaint with their HIV medication first as this is effective tx for kaposi's sarcoma. if they are then urgent dermatology referral is warranted.

example of COMT inhibitor

entacapone

cysts on silver stain

finding in PJP in immunocompromised pts

A 27-year old female presents with right upper quadrant (RUQ) pain and fever. Her last menstrual period was 2 weeks ago, and she was last sexually active 10 weeks ago. They did not use a condom, but she is on the oral contraceptive pill. Her past medical history includes an appendectomy only. She is febrile but other observations are stable. On abdominal examination she is tender in the right upper quadrant. Bimanual vaginal exam reveals cervical excitation. Urine dip shows leucocytes but is negative on a pregnancy test. Bloods show a leucocytosis but are otherwise entirely normal. What is the most likely diagnosis? ruptured ectopic or fitz hugh curtis

fitz hugh curtis

anorectal abscess - incision and drainage vis general or local anaesthetic

general

HIV neurocomplications

generalised vs focal disease. Focal disease = toxo and lymphoma. Generalised = encephalitis, cryptococcus, PML, AIDs dementia complex. Toxo (CT) shows ring-enhancing lesion(s) Lymphoma shows homogenous enhancing lesion(s) and is associated with EBV.

what type of memory loss does pseudodementia have

global memory

pseudogout vs gout joints

gout = foot and knee pseudogout = knee and wrists

bronchiectasis most common organism

h influenza

triad of HUS

haemolytic anaemia Thrombocytopenia AKI features (e.g. creatinine raised x2 normal)

arthritis in which bones can you apply topical nsaid too

hands and knee elbows ankles

A 34 year old male presents with numerous lesions on his face. These are small, smooth in nature with a central area of umbilication. He is concerned about his appearance. He is currently being treated with cART. Given the most likely diagnosis, what is the most appropriate treatment?

he has molluscum contagiosum. Normally these pts are reassured, however because he is immunocompromised he requires cryotherapy

ccb se

headache, flushing, ankle oedema

mx of hypoCa

high QT IV calcium gluconate

how much pth is a risk factor for gout

hyperparathyroidism

when to start oral flucloxacillin in lactational mastitis

if after 12-24 hours of breast milk removal has not worked use oral flucloxacillin

when can pp depression be dx

if it occurs in the 12 months of birth

when is doxy ci for sti

if pregnant

lights crteria - for exudative

if the protein level is between 25-35 g/L, Light's criteria should be applied. An exudate is likely if at least one of the following criteria are met:pleural fluid protein divided by serum protein >0.5pleural fluid LDH divided by serum LDH >0.6pleural fluid LDH more than two-thirds the upper limits of normal serum LDH

igA or igG for coeliac

igA

high 2 hour glucose

impaired glucose tolerance

discitis cause and sx

infective endocarditis severe back pain over specific vertebrae limited movement

mx of keloid scars

intra-lesional steroids,

strangulated hernia

irreducible and pain

POP side effect

irregular bleeding

haemodialysis does what to HBA1c

it creates a falsely low HBA1c

how to diagnose DM based on random glucose

it should be 11mmol/l or more

how to diagnose DM based on HBA1c

it should be 48mmol/l or above

how to diagnose DM based on fasting glucose

it should be 7mmol/l or more

iv for hypoca

iv calcium gluconate

l5 radiculopathy vs common peroneal nerve lesion

l5 has weakness in foot inversion common peroneal is weakness in eversion

where is saphena varix

lat and inf to pubic tubercle like femoral hernia

which drug for breast cancer causes osteoporosis

letrazole (aromatase inhibiters)

side effect of GnRH analogues

loss of BMD

levels of sex hormones - FSH, LH, testosterone in anorexia

low

asbestos - upper or lower zone fibrosis

lower

bells palsy - upper or lower

lower affects forehead

upper third or middle of thigh for adrenaline injection

mddle

aggravated by wrist flexion and pronation

medial epicondylitis

colles fracture affects which nerve

median N injury

An 84-year-old woman attends her general practice with her daughter. Her daughter is concerned regarding her mother's increasing frailty and reducing mobility. She lives alone and can perform most of her activities of daily living independently. She has recently struggled to get to the toilet in time to pass urine and has been having more accidents. The daughter wonders if there is some way to help with these symptoms, as she finds it challenging to help her remain independent following these accidents. Her past medical history includes glaucoma and cataracts. Which of the following options is the most appropriate management for the likely underlying condition?

mirabegron anticholinergics (oxybutinin) would be CI in people with glaucoma

monitor MgSO4 effects in pregnancy

monItor reflexes and RR Give calcium gluconate

what level of CK means statins should be stopped

more than 5 times the upper limit

Cauda equina Ix

mri whole spine

dx hsv

naat

gout - N&N

needle shaped negative birefringement

nephrotic or nephritis fsgs membranous nephropathy post-strep gn minimal change disease renal amyloidosis

nephrotic nephrotic nephritic nephrotic nephrotic

do epidydimal cysts trans-illuminate

no

is atenolol cardioselective

no

is nulliparity associated with fibroids

no

is papilloedema seen in diabetic retinopathy

no

can basic care be refused in an advanced statement

no - e.g. eating and drinking

can DOLS be used in capacitatous patients

no - it is used in patients who cant consent

does donepezil affect disease progression

no it works symptomatically

are all down syndrome screening tests for edwards and pataus too

no only the combined test not all of them.

type of CT head in SAH

non-contrast CT head

hh6 rash (roseala infantum)

not itchy

where is optic disc on fundoscopy

on nasal side

when is prothrombin complex concentrate given for people with high INR and bleeding when on warfarin

only if it is major bleeding = not bleeding gums

what type of laxative is lactulose

osmotic laxative

what type of laxative is macrogol

osmotic laxative

post menopausal se of levothyroxine

osteoporosis

ckd causes what bone condition

osteoporosis osteomalacia

A 69-year-old man is brought into the emergency department with sepsis due to a urinary source. His renal function tests indicate that he has an acute kidney injury. Which of the following investigation findings in acute kidney injury would indicate the need for dialysis?

pH 7.15 on venous blood gas Severe and refractory acidosis (pH <7.2) is an indication for dialysis. 62%

An 18 year old man presents to the GP. He describes multiple lesions on his penis. On examination, there are multiple uniform smooth lesions present around the coronal margin of the glans. Given the likely diagnosis, what is the most appropriate management?

pearly penile papules - reassure and discharge dont need GUM referral as it is not an sti

what is seen on peripheral blood smear and bone marrow aspirate for Multiple myeloma

peripheral blood smear = rouleaux formation bone marrow aspirate = increased number of plasma cells

orchidopexy vs orchidectomy

pexy = correct twist dectomy - remove

methotrexate chest SE

pneumonitis - cough, dyspnoea and fever

rf for breech delivery

polyhydramnios multiparity multiple preg

high Ca sx

polyuria constipation loss of appetite

low GCS paralysis bilateral pinpoint pupils HTN

pontine haemorrhage

reduced GCS Paralysis bilateral pin point pupils

pontine haemorrhage

thrombotic/painful crisis in sickle cell

precipitated by infection, dehydration or deoxygenated Painful crisis (also known as a thrombotic crisis) is the most likely diagnosis in this case given the typical presentation of sudden onset of severe pain in the hands and feet, along with mild swelling and tenderness in both feet, which is consistent with a painful crisis. Painful crises are caused by the sickling of red blood cells leading to vaso-occlusion and tissue ischemia. In this case, the recent coryzal infection may have contributed to the thrombotic crisis, as infections are known to be a common precipitating factor for thrombotic crises in sickle cell disease.

risks in pregnancy of a bv infection

preterm rupture of membranes premature labour

Calcium 2.85 mmol/L (2.1-2.6) Phosphate 0.62 mmol/L (0.8-1.4) PTH 4.8 pmol/L (1.6 - 6.9)

primary hyperparathyroidism pth is usually normal

A 'drug rep' tells you that the relative risk reduction of mortality after using Drug X is 50%. Which of the following is true regarding relative risk reduction?

risk in intervention - risk in control It can lead to over-estimation of treatment effect For example, if the risk of an adverse event (e.g. a cardiovascular event) on drug X is 2% and the risk is 4% on the control drug, then the absolute risk reduction would be 2%. However, the relative risk reduction would be 50% (2/4), which sounds like a greater treatment effect compared to a modest 2% ARR 34%

facial rash + lymphadenopathy

sarcoidosis

A 35-year-old woman is being treated for diffuse scleroderma. She tells her rheumatologist she has had intermittent diarrhoea, nausea and bloating for the last three months. She has symptoms 2-3 times per week with no change after eating any particular food. Her symptoms improved after taking oral antibiotics two weeks ago. She has no history of recent foreign travel. what is the most likely diagnosis

scleroderma - risk factor for small bacterial overgrowth syndrome.

marfans - primary or secondary pneumothorax

secondary

high TSH High T3 High T4 diagnosis?

secondary hyperthyroidism in primary the TSH will be low

digoxin and QT

short QT interval

A 37-year-old man attends his GP surgery to discuss his low mood. He is losing interest in golf, which he used to enjoy, and sometimes has thoughts about not wanting to be alive anymore. He is currently in full-time employment, although he has had to take some time off recently for bowel cancer treatment. He has not spoken to his wife about how he is feeling. He is otherwise fit and well, with no history of mental health problems. Which of the following is a risk factor for the development of depression?

significant physical illness

tertiary hyperparathyroidism labs

similar to primary hyperparathyroidism (inc Ca, dec PO4, HCO3 secreted in urine Cl to PO4 ratio >33, inc renal cAMP) however renal impairment should be bad

strongest risk factor for AAA

smoking

first line mx for atonic/focal seizures in males

sodium valproate

what infection is most likely to cause discitis

staph aureus

when managing DKA and blood glucose is less than 14 what should happen

start an infusion of 10% dextrose at 125mls/hr and saline regime

mx of behcets disease

steroids and colchicine

investigate mesothelioma

suspicion is normally raised by a chest x-ray showing either a pleural effusion or pleural thickening the next step is normally a pleural CT if a pleural effusion is present fluid should be sent for MC&S, biochemistry and cytology (but cytology is only helpful in 20-30% of cases) local anaesthetic thoracoscopy is increasingly used to investigate cytology negative exudative effusions as it has a high diagnostic yield (around 95%) if an area of pleural nodularity is seen on CT then an image-guided pleural biopsy may be used

refer for acne rosacea

symptoms have not improved with optimal management in primary carelaser therapy may be appropriate for patients with prominent telangiectasia patients with a rhinophyma Red, inflamed eyes and eyelids are the correct answer. In this patient, it would indicate ocular involvement, which requires prompt escalation to prevent corneal scarring. Although none is immediately evident from the image, a proper examination would be required.

most common abnormalities in boys in NIPE

testes

cmv retinitis

the most common cause of retinits in HIV-positive patietns. Uusally affects patients with CD4 counts less than 50. It is best treated with ganciclovir.

OCD severe functional impairment mx

this means it is having a huge impact on the persons day to day life. SSRI, CBT, ERP and urgent secondary care referral

A 12-year-old boy is brought into the GP with a new rash on his forearm. The rash is ring-like with a clear centre and is red and pruritic. The patient is otherwise well. What treatment should be given?

top clotrimazole = ring worm

what can hypomagnesaemia cause on an ecg

torsades de pointes

hypothyroidism - transudative or exudative

trans

meigs syndrome - trans or exudative

trans

heart failure - exudate vs transudative

transudative

progesterone containing contraceptives and bc

ukmec 3

what type of lesion causes ataxic cerebral palsy

upper motor neuron lesion in the cerebellum.

what type of lesion causes spastic cerebral palsy

upper motor neuron of the periventricular grey matter.

hand prefernce before 12m - urgent or routine referral

urgent

79-year-old man presents to his GP with a 3-day history of testicular pain and swelling. He has also noticed a purulent discharge from his urethra with mild dysuria. His past medical history includes hypertension for which he takes amlodipine and ramipril.On examination, he has a temperature of 38.1ºC with a heart rate of 89 beats/min and blood pressure of 135/90mmHg. His left testicle is swollen, erythematous and warm to the touch. There are no palpable lumps, although he winces in pain during the examination.What is the recommended investigation of choice for the underlying diagnosis?

urine mcs Investigations for suspected epididymo-orchitis are guided by age: sexually active younger adults: NAAT for STIs older adults with a low-risk sexual history: MSSU

Musculocutaneous nerve injury causes what

usculocutaneous nerve Although patients with musculocutaneous injury can have impaired shoulder flexion, there will not be loss of sensation over the deltoid muscle. They may also present with impaired elbow flexion and supination of the forearm. 7%M

most common cause of PMB

vaginal atrophy

abx to treat MRSA

vancomycin

Mx of haemochromatosis

venesection and desfurrioxime

Cause of Raynaud's Disease

vibrating tools Secondary causes of Raynaud's phenomenon connective tissue disorders - scleroderma (most common) - rheumatoid arthritis - systemic lupus erythematosus leukaemia type I cryoglobulinaemia, cold agglutinins use of vibrating tools drugs: oral contraceptive pill, ergot cervical rib

pregnant with varicose veins mx

watchful waiting and compression stockings

inheritance pattern of sideroblastic anaemia

x-linked

can pregnant women take metronidazole

yes

is reiters autoimmune

yes

are people with pseudodementia aware of their memory impairment

yes people with actual dementia usually lack insight

can cerebral palsy patients be hypotonic?

yes - the hypotonia can precede the spasticity

does 2hr OGTT count as diabetes if 7.8

yes it includes 7.8 and above