eMedici Mock MCQ Flashcards by Kitty Eichner

A 57-year-old woman presents to the Emergency Department with a 20-minute history of acute onset dull central chest pain. She has no significant medical history and does not take any regular medications. She is a non-smoker. On examination, she appears well. Her pulse rate is 100/min, blood pressure 120/85 mmHg, respiratory rate 18/min, SpO2 97% on room air, and temperature 37.0°C. An ECG is performed.
Which one of the following is the most appropriate management option?
- A: Electrical cardioversion
- B: Thrombolysis
- C: Glyceryl trinitrate
- D: Percutaneous coronary intervention
- E: Dual antiplatelet therapy

= D: Percutaneous coronary intervention

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Which one of the following is the most effective intervention to prevent recurrent urinary tract infections in this patient?
- A: Daily nitrofurantoin prophylaxis
- B: Daily cranberry extract
- C: Intermittent self-catheterisation
- D: Change urinary catheter fortnightly
- E: Regular bladder irrigation with a sterile solution

= C: Intermittent self-catheterisation

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Which one of the following is the most likely diagnosis?
- A: Androgen insensitivity syndrome
- B: Congenital adrenal hyperplasia
- C: 5-alpha reductase deficiency
- D: Hyponatraemic dehydration
Ovotesticular disorder of sex development

= B: Congenital adrenal hyperplasia

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An 83-year-old man presents to the Emergency Department with a one-day history of fever, headache, drowsiness, neck stiffness and photophobia. He had an episode of severe ear ache a few days ago which his General Practitioner diagnosed as otitis media and prescribed a course of antibiotics. His medical history includes type 2 diabetes and hypertension. His medications include metformin and enalapril. On examination, he appears unwell with a pulse rate of 88/min, blood pressure 134/82 mmHg, respiratory rate 18/min, SpO2 97% on room air, and temperature 37.4°C. Neurological examination is unremarkable apart from a positive Kernig’s sign. A CT brain is arranged (Image). Which one of the following is the most likely diagnosis?
- A: Metastatic deposit
- B: Meningioma
- C: Brain abscess
- D: Hydatid cyst
- E: Glioblastoma

= C: Brain abscess

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Which one of the following is the most likely diagnosis?
- A: llness anxiety disorder
- B: Factitious disorder
- C: Somatic symptom disorder
- D: Functional neurological system disorder
- E: Malingering

= C: Somatic symptom disorder

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A 48-year-old woman presents to the Emergency Department with a two-day history of high fever, chills, malaise and a tender, erythematous and oedematous eruption with multiple pustules noted on her cheeks. She denies photosensitivity, arthralgia or sore throat and does not have any history of similar skin eruptions, but does give a history of being hit by a sharp object causing a small laceration on her cheek in the days preceding her illness. She has no significant medical history and does not take any regular medications. On examination, she appears unwell with a temperature of 39.2°C, pulse rate 110/min, blood pressure 110/70 mmHg, respiratory rate 18/min and SpO2 98% on room air. Skin examination reveals a tender, erythematous, oedematous plaque with well-demarcated borders and multiple pustules on her left cheek. Which one of the following is the most likely diagnosis?
- A: Rosacea
- B: Erysipelas
- C: Scarlet fever
- D: Systemic lupus erythematosus
- E: Erythema infectiosum

= B: Erysipelas

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Which one of the following is the most likely diagnosis?
- A: Immune thrombocytopenic purpura
- B: Henoch-Schönlein purpura
- C: Meningococcal meningitis
- D: Acute lymphoblastic leukaemia
- E: Haemolytic uraemic syndrome

= A: Immune thrombocytopenic purpura

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In these circumstances which one of the following is the most appropriate first step in management?
- A: Intravenous fluid resuscitation
- B: Obtain blood cultures
- C: Endoscopic retrograde cholangiopancreatography (ERCP) and biliary decompression
- D: Administer broad-spectrum antibiotics
- E: Upper abdominal ultrasound

= A: Intravenous fluid resuscitation

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Which one of the following is the most appropriate anti-resorptive therapy for this patient?
- A: Etidronate
- B: Alendronate
- C: Denosumab
- D: Risedronate
- E: Ibandronate

= C: Denosumab

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Which one of the following has the strongest association with the underlying disease process?
- A: Alcohol consumption
- B: Helicobacter pylori infection
- C: Cigarette smoking
- D: Older age
- E: Obesity

= C: Cigarette smoking

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Which one of the following is the most appropriate initial management?
- A: Oral cefalexin and paracetamol
- B: Admit for observation only
- C: Stat dose of trimethoprim
- D: Intravenous gentamicin and amoxicillin
- E: Nasogastric tube insertion

= D: Intravenous gentamicin and amoxicillin

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A 56-year-old man presents to his General Practice clinic after a single episode of epigastric pain which lasted several hours. The pain came on after a meal and resolved spontaneously. He has no significant medical history and does not take any regular medications. On examination, he appears well with vital signs within normal limits. Abdominal examination is unremarkable. A CT scan is performed demonstrating no changes to lungs or liver and no renal vein thrombus (Image). His renal function is normal. Which one of the following is the most appropriate next step in management?
- A: CT urogram
- B: CT-guided biopsy
- C: Active surveillance
- D: Right partial nephrectomy
- E: Right nephrectomy

= E: Right nephrectomy

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Which one of the following is the most likely diagnosis?
- A: Pulmonary embolism
- B: Acute pulmonary oedema
- C: Acute respiratory distress syndrome
- D: Acute myocardial infarction
- E: Exacerbation of COPD

= B: Acute pulmonary oedema

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Which one of the following is the most appropriate next step in management?
- A: Reassure and review in three months
- B: MRI breast
- C: Ultrasound breast
- D: Mammography
- E: Fine needle aspiration cytology of lump

= C: Ultrasound breast

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26-year-old man presents to the Emergency Department with a 24-hour history of a painful abdominal swelling at the umbilicus. He has a medical history of hypertension and type II diabetes. His medications include hydrochlorothiazide, olmesartan and metformin. On examination, he appears well with a pulse rate of 92/min, blood pressure 145/90 mmHg, respiratory rate 16/min, SpO2 98 % on room air, and temperature 37.2 °C. His BMI is 45 kg/m2. The lesion in question is shown. Which one of the following is the most likely underlying pathological process?
- A: A strangulated para-umbilical hernia
- B: Cullen’s sign
- C: A torted epiploic appendage
- D: An infected umbilical concretion
- E: A subcutaneous abscess

= A: A strangulated para-umbilical hernia

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Which one of the following disorders best explains these results?
- A: Addison’s disease
- B: Graves’ disease
- C: Conn’s syndrome
- D: Mild congenital adrenal hyperplasia
- E: Panhypopituitarism

= C: Conn’s syndrome

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An 11-year-old boy is undergoing an open reduction and internal fixation for a distal radius fracture. The anaesthetic plan is for a general anaesthetic, with sevoflurane and succinylcholine used for induction and intubation. Shortly after induction, the patient develops a tachycardia of 172 beats/minute, his skin appears mottled, and he becomes markedly febrile at 39.2°C. The end-tidal carbon dioxide is increased despite increased minute ventilation. Which one of the following is the most likely cause of this patient’s deterioration?
- A: Malignant hyperthermia
- B: Neuroleptic malignant syndrome
- C: Serotonin syndrome
- D: Anaphylaxis
- E: Pseudocholinesterase deficiency

= A: Malignant hyperthermia

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Which one of the following is the most likely diagnosis?
- A: Transposition of the great vessels
- B: Tetralogy of Fallot
- C: Ventricular septal defect
- D: Patent foramen ovale
- E: Tricuspid valve atresia

= B: Tetralogy of Fallot

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Which one of the following is the most appropriate management?
- A: Observation and supportive care
- B: Intravenous immunoglobulin
- C: Oral prednisolone
- D: Surgical decompression
- E: Intravenous acyclovir

= C: Oral prednisolone

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75-year-old woman presents to her General Practice clinic with a six-week history of a painless lump on her right lower eyelid. It has not caused any irritation, itching or bleeding. She has not had any changes to her vision. Her medical history includes hypertension and type 2 diabetes mellitus, which is diet-controlled. Her medications include amlodipine. On examination, she appears well with normal vital signs. Examination of the right eye reveals a small erythematous nodule on the lateral aspect of the lower eyelid with a pearly edge (Image). The surrounding skin appears normal. Visual acuity is 6/6 bilaterally. Pupils are equal and reactive to light. Extraocular movements are intact. Which one of the following is the most likely diagnosis?
- A: Chalazion
- B: Hordeolum
- C: Basal cell carcinoma
- D: Dacryocystitis
- E: Blepharitis

= C: Basal cell carcinoma

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Which one of the following is the most appropriate treatment?
- A: Rectal prednisolone
- B: Oral and rectal mesalazine
- C: Oral prednisolone
- D: Intravenous infliximab
- E: Surgical resection

= B: Oral and rectal mesalazine

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Which one of the following is the most appropriate treatment?
- A: Reassurance that Clostridioides difficile infection will self-resolve
- B: Repeat Clostridioides difficile toxin stool test in four weeks
- C: Oral metronidazole
- D: Oral vancomycin
- E: Referral to hospital for inpatient IV metronidazole

= C: Oral metronidazole

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Which one of the following is the most likely diagnosis?
- A: Acute lymphoblastic leukaemia
- B: Hereditary spherocytosis
- C: Gilbert syndrome
- D: G6PD deficiency
- E: Viral hepatitis

= D: G6PD deficiency

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Which one of the following is the most appropriate pharmacotherapy for this patient?
- A: Combined oral contraceptive pill
- B: Levonorgestrel-releasing intrauterine device
- C: Non-steroidal anti-inflammatory drug
- D: Oral progestogen
- E: Tranexamic acid

B: Levonorgestrel-releasing intrauterine device

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Which one of the following is the most appropriate next step in management? - A: Nurse at 45 ° head-up position - B: Intubate and ventilate - C: IV mannitol - D: High flow oxygen - E: Left temporal burr hole

= B: Intubate and ventilate

Which one of the following is the most appropriate next step in management? - A: Blood culture - B: Viral panel - C: Supportive care and close monitoring - D: Lumbar puncture - E: CT head

= E: CT Head The suspected diagnosis here is meningitis. The patient has a high fever, with symptoms and signs being consistent with this diagnosis. Other signs to be considered include the most sensitive test for meningitis: the jolt accentuation sign, in which a patient's headache intensifies after a quick head jolt. Kernig and Brudzinski signs are not sensitive, but they are fairly specific. Once a diagnosis of meningitis is suspected, a CT head should be performed first to identify contraindications for lumbar puncture including raised intracranial pressure, or to determine the presence of complications including symptomatic hydrocephalus, and cerebral abscess that would require prompt neurosurgical intervention. Performing a lumbar puncture on a patient with raised ICP would run the risk of cerebral herniation.

68-year-old man presents to his General Practice clinic with a four-week history of painful finger joints. The pain is accompanied by two hours of morning stiffness which improves with motion. He does not have any other symptoms apart from an occasional rash on his face. He has a medical history of refractory hypertension. His medications include atenolol, hydralazine, and furosemide. He does not smoke or drink alcohol. His family history is significant for scleroderma in his grandmother. On examination, he appears well with a pulse rate of 72/min and blood pressure of 138/84 mmHg. Examination reveals tender and slightly swollen DIP and PIP joints bilaterally. On examination of his back, small annular erythematous plaques can be seen. Which one of the following is the most likely diagnosis? - A: Sjogren's syndrome - B: Drug-induced lupus - C: Systemic lupus erythematosus - D: Rheumatoid arthritis - E: Osteoarthritis

= B: Drug-induced lupus

Which one of the following is the most appropriate next step in management? - A: Commence vitamin B12 - B: Cease current anti-tuberculous medications - C: Commence gabapentin - D: Commence pregabalin - E: Commence pyridoxine

= E: Commence pyridoxine

Which one of the following is the most likely diagnosis? - A: Refeeding Syndrome - B: Diabetic ketoacidosis - C: Lactic acidosis due to sepsis - D: Tumour lysis syndrome - E: Renal tubular acidosis

= **A: Refeeding Syndrome** - The most likely diagnosis is refeeding syndrome. This potentially life-threatening condition can occur in malnourished patients who receive nutrition (oral, enteral, or parenteral) after a period of starvation. During starvation, the body breaks down fat and protein stores, leading to loss of electrolytes and vitamins. When nutrition is reintroduced, there is a sudden shift from catabolism to anabolism, causing rapid uptake of phosphate, potassium, and magnesium into cells, resulting in low serum levels. Thiamine deficiency can also occur. Risk factors include malignancy, malnutrition, alcoholism, and anorexia nervosa. The patient is malnourished due to severe colitis while undergoing chemotherapy, in addition to poorly-controlled coeliac disease as a contributing factor. The occurrence of severe hypophosphatemia, hypokalaemia, hypocalcaemia, and hypomagnesemia shortly after commencing parenteral nutrition is consistent with refeeding syndrome. Arrhythmias are commonly seen due to severe electrolyte derangements.

A 34-year-old man presents to his General Practice clinic for travel vaccination advice. He is planning on travelling directly from Australia to Saudi Arabia for a pilgrimage to Mecca as part of Umrah during the Hajj season. This will be his first visit to Saudi Arabia. He has no significant medical history and does not take any regular medications. On examination, he appears well with vital signs within normal limits. Which one of the following vaccinations is required in this patient? - A: Cholera - B: Meningococcal ACWY - C: Middle East Respiratory Syndrome (MERS) coronavirus - D: Yellow fever - E: Typhoid

= B: Meningococcal ACWY

Which one of the following is the most appropriate next step in management? - A: Urinalysis and culture - B: Intravenous antibiotics - C: Full blood count and serum electrolytes - D: Scrotal ultrasound - E: Surgical exploration of scrotum

= E: Surgical exploration of scrotum

A 64-year-old man presents to the Emergency Department with a one-hour history of sudden loss of vision in his left eye. He has experienced two or three similar episodes over the last two months, but they resolved rapidly on their own. He has a medical history of aortic valve replacement, osteoarthritis and gastro-oesophageal reflux disease. His regular medications include warfarin, paracetamol, and pantoprazole. On examination, he appears well. His pulse rate is irregularly at 102/min, blood pressure 132/84 mmHg, respiratory rate 14/min, SpO2 98% on room air, and temperature 36.8°C. His right eye examination is unremarkable but there is no perception of light in his left eye. The left anterior chamber is clear and extraocular movements are normal. Fundoscopic examination of the left eye is undertaken. Which one of the following investigations is most likely to establish the underlying cause of the current problem? - A: Electrocardiogram - B: Carotid artery duplex ultrasound - C: Serum lipid profile - D: CT head with contrast - E: Temporal artery duplex ultrasound

= A: Electrocardiogram

Which one of the following additional investigations is most important to order now for this patient? - A: Vitamin D - B:Chlamydia testing - C: Oral glucose tolerance test - D: Thyroid function testing - E: CMV serology

= **C: Oral Glucose tolerance test** Generally recommended antenatal screening tests for all pregnant women at the first visit include: 1. Complete blood picture (CBP) 2. Ferritin 3. Blood group and antibody screen 4. Rubella titre 5. Syphilis serology 6. Hepatitis B and C serology 7. HIV serology 8. Midstream urine for asymptomatic bacteriuria

Which one of the following is the most appropriate advice regarding her insulin regimen? - A: Cease insulin immediately - B: Continue current insulin regimen - C: Increase insulin doses to aim for a lower HbA1c - D: Add an SGLT-2 inhibitor - E: Gradually reduce insulin dose

B: Continue current insulin regimen

A 45-year-old man presents to the Emergency Department with a three-day history of increasing upper abdominal pain, nausea and vomiting. Three months ago, he had an episode of presumed gallstone-related pancreatitis and underwent cholecystectomy. He made an uneventful recovery but has had some dull abdominal pain since then. He has no other significant medical history and takes no regular medications. He drinks three glasses of wine per day and has a 15 pack-year smoking history. On examination, he appears well with a pulse rate of 94/min, blood pressure 124/82 mmHg, and temperature 37.4°C. There is some epigastric tenderness but examination is otherwise unremarkable. Investigations reveal mildly elevated white cell count. Liver function tests, serum amylase and lipase are normal. A CT scan is performed. Which one of the following is the most likely diagnosis? - A: Adenocarcinoma of the pancreas - B: Pancreatic pseudocyst - C: Pancreatic abscess - D: Duodenal perforation - E: Acute pancreatitis

= B: Pancreatic pseudocyst

Which one of the following is the most appropriate initial treatment to improve his blood pressure? - A: Intra-aortic balloon pump - B: Noradrenaline - C: IV fluids - D: Tenecteplase - E: Glyceryl trinitrate

= C: IV fluids

A 30-year-old woman presents to the Emergency Department with a three-day history of a tender, red swelling on her buttock. She states it has become progressively more tender, making it uncomfortable to sit during her long shifts as a truck driver. She also notes feeling feverish over the last 24 hours. She has no significant medical history and does not take any regular medications. On examination, she appears well. Her pulse rate is 90/min, blood pressure 120/75 mmHg, respiratory rate 16/min, SpO2 98% on room air, and temperature 37.8°C. Examination of the buttock reveals a tender, erythematous, fluctuant swelling in the midline of the natal cleft. Which one of the following is the most likely diagnosis? - A: Bartholin cyst - B: Ischiorectal abscess - C: Perianal abscess - D: Pilonidal abscess - E: Epidermoid cyst

= D: Pilonidal abscess

A 33-year-old man presents to his General Practice clinic with a two-week history of increasing breathlessness. He does not have any other respiratory symptoms. He has a medical history of pulmonary tuberculosis treated four years ago and a road traffic crash one year ago, in which he sustained some abdominal wall bruising. His last medical review was two years ago, when he was told that the tuberculosis had been completely treated. He does not take any regular medications. On examination, he appears well with a pulse rate of 90/min, blood pressure 115/75 mmHg, respiratory rate 16/min, SpO2 97% on room air, and temperature 37.4°C. There is dullness to percussion over the left lung base with reduced breath sounds. The rest of the physical examination is unremarkable. A chest X-ray is arranged Which one of the following is the most likely diagnosis? - A: Pleural effusion - B: Lung abscess - C: Diaphragmatic hernia - D: Bronchogenic cyst - E: Aspergilloma

= C: Diaphragmatic hernia

An 18-year-old woman presents to her General Practice clinic with a one-month history of lesions on her external genitalia and anal region. The lesions are not painful or itchy. She has no significant medical history and does not take any regular medications. She engages in unprotected vaginal, anal, and oral sexual intercourse with one male partner. Her partner does not have any similar lesions and there is no known history of sexually transmitted infections. On examination, she appears well with normal vital signs. Genital examination reveals multiple flat, dome-shaped, and cauliflower-shaped growths on the vulva and perianal skin.Which one of the following is the most likely causative organism? - A: Herpes simplex virus - B: Human papillomavirus - C: Treponema pallidum - D: Haemophilus ducreyi - E: Molluscum contagiosum virus

= B: Human papillomavirus

Which one of the following is the most likely diagnosis? - A: Anal fissure - B: Radiation proctitis - C: Haemorrhoids - D: Sigmoid carcinoma - E: Diverticulosis

= E: Diverticulosis

Which one of the following is the most appropriate next step in management? - A: Deep brain stimulation - B: Continuous dopaminergic pump - C: Increase dose fractionation to five times daily - D: Increase levodopa/carbidopa dose - E: Switch pramipexole to a different dopamine agonist

= C: Increase dose fractionation to five times daily

Which one of the following is the most appropriate next step in management? - A: Perform comprehensive metabolic panel - B: Refer to a psychologist - C: Administer the Edinburgh Postnatal Depression Scale (EPDS) - D: Refer for cognitive behavioural therapy (CBT) - E: Prescribe a selective serotonin reuptake inhibitor (SSRI)

= **C: Administer the Edinburgh Postnatal Depression Scale (EPDS)** - Postpartum depression is the most common complication of childbearing. However, around 80% of new mothers experience 'baby blues,' which is characterised by emotional reactivity, poor sleep, and nervousness, as possible in this case. Differentiating between baby blues and postnatal depression can be challenging. The Edinburgh Postnatal Depression Scale (EPDS) is a validated screening tool used to assess depression symptoms in women after childbirth.

Which one of the following is the most appropriate initial treatment? - A: Ceftriaxone, doxycycline and metronidazole - B: Doxycycline and azithromycin - C: Clindamycin and gentamicin - D: Amoxicillin/clavulanic acid and metronidazole - E: Cefotaxime and doxycycline

= **A: Cetriaxone, doxycycline and metronidazole** - The patient's symptoms of lower abdominal pain, pain on intercourse, and altered vaginal discharge, along with examination findings of cervical motion tenderness and bilateral adnexal tenderness, are suggestive of pelvic inflammatory disease, which is commonly a complication of sexually transmitted infections like chlamydia and gonorrhoea.

A 51-year-old man presents to the Emergency Department with a one-day history of an acutely painful and red big toe. He describes similar episodes previously, although none have been as severe. No other joints are affected. He has no significant medical history. He is a lifetime non-smoker. He drinks 10 standard alcoholic drinks per week. On examination, he appears well with vital signs within normal limits. His left great toe is swollen, erythematous and tender to touch. No other joints are inflamed. Which one of the following is the most appropriate diagnostic investigation for the swollen toe? - A: Dual-energy CT - B: Joint aspiration - C: Plain X-ray - D: Serum uric acid level - E: Ultrasound

= B: Joint aspiration

Which one of the following is the most appropriate next investigation? - A: Prostate specific antigen - B: Micturating cystourethrography - C: Sigmoidoscopy - D: Contrast enema - E: CT abdomen and pelvis

= E: CT abdomen and pelvis -

Which one of the following is the most appropriate next step in management after reassessment? - A: Repeat bronchodilators every 20 minutes for the first hour (up to three doses) - B: Increase supplemental oxygen flow rate - C: Administer intravenous corticosteroids - D: Add intravenous magnesium sulphate - E: Prepare for intubation and mechanical ventilation

= **A: Repeat bronchodilators every 20 minutes for the first hour (up to three doses)** - In the management of an acute asthma exacerbation, the priority after initial bronchodilator therapy is to reassess the patient's response and provide ongoing bronchodilator treatment. Given the severity of this patient's presentation, the most appropriate next step is to repeat the bronchodilators (salbutamol and ipratropium) every 20 minutes for the first hour (up to three doses total) or sooner if needed. This allows for individualized treatment based on the patient's response. While maintaining adequate oxygenation is important, increasing the supplemental oxygen flow rate is not the immediate next step. The initial oxygen therapy has already been started, and the focus should now be on relieving the bronchoconstriction with repeated bronchodilators. IV corticosteroids are an important component of acute asthma management, especially in moderate to severe cases. However, their anti-inflammatory effects take time, so repeating the bronchodilators is the more urgent priority to alleviate bronchoconstriction. Corticosteroids should still be given within one hour of presentation. IV magnesium sulphate can be considered for severe asthma exacerbations that are refractory to initial bronchodilator therapy. However, the immediate next step after starting treatment is to reassess and continue bronchodilators as needed. Intubation and mechanical ventilation are reserved for cases of respiratory failure that do not respond to initial management. It is not the first-line intervention for a patient with moderate respiratory distress. However, early intubation should be considered if the patient develops hypercapnia, suggesting respiratory fatigue and hypoventilation.

A 66-year-old man presents to the Emergency Department with a six-hour history of sudden onset dizziness, balance impairment, and clumsiness of his right hand. He has a medical history of hypertension and dyslipidaemia. His medications include candesartan, hydrochlorothiazide and rosuvastatin. On examination, he appears well with a pulse rate of 86/min, blood pressure 155/88 mmHg, respiratory rate 18/min, SpO2 98% on room air, and temperature 37.2°C. Neurological examination reveals right-sided ataxia, right-sided ptosis and miosis. Sensation is impaired on the left side of his body. The diagram shows the brain vasculature. Which one of the following arteries, if occluded, would lead to this presentation?

= E: posterior inferior cerebellar artery

Which one of the following is the most appropriate next step in confirming the diagnosis? - A: Arterial blood gas on room air - B: Pulmonary function tests - C: Echocardiogram - D: Chest X-ray - E: Six minute walk test

= B: Pulmonary function tests

Which one of the following is the most appropriate next step in management? - A: Cease perindopril - B: Commence levodopa - C: Cease haloperidol - D: Commence benztropine - E: Commence risperidone

= C: Cease haloperidol

Which one of the following movement combinations will most likely be affected? - A: Adduction and extension - B: Abduction and external rotation - C: Internal rotation and adduction - D: Flexion and external rotation - E: Abduction and flexion above 90 degrees

= B: Abduction and external rotation

Which one of the following is the most likely diagnosis? - A: Oral candidiasis - B: Geographic tongue - C: Oral psoriasis - D: Oral lichen planus - E: Oral leukoplakia

= B: Geographic tongue

A 12-year-old boy presents to the Emergency Department with a one-month history of diffuse abdominal swelling. He denies any pain but has discomfort in the abdomen. He has also noticed some weight loss and fatigue but attributes that to academic stress. He denies any recent infections. He has no significant medical history and does not take any regular medications. On examination, he appears well. His temperature is 38.1°C, pulse rate 100/min, blood pressure 110/70 mmHg, respiratory rate 16/min, and SpO2 99% on room air. His abdomen is diffusely enlarged and shifting dullness can be elicited. The liver and spleen are not palpable, however a large, non-tender, solid and tethering mass can be felt halfway between the umbilicus and the right costal margin. The kidneys cannot be balloted. A CT scan is performed and the report reads: A 10.4 cm diameter soft tissue mass with a hypodense centre seen in the anterior abdomen, extending from the periumbilical area to the hepatic flexure. Well circumscribed. A few other lesions of the same character, albeit much smaller, were noted around the mesenteric fat. Which one of the following is the most likely diagnosis? - A: Wilms tumour - B: Burkitt lymphoma - C: Precursor T-cell lymphoma - D: Neuroblastoma - E: Multiple myeloma

= B: Burkitt lymphoma

Which one of the following is the most likely diagnosis? - A: Cerebellar tremor - B: Dystonic tremor - C: Essential tremor - D: Parkinson's disease tremor - E: Psychogenic tremor

= C: Essential tremor

A 13-year-old boy presents to the Emergency Department with his father for a two-week history of progressive right knee pain, now causing a limp. There is no clear mechanism of injury. He has no significant medical history and does not take any regular medications. The patient trains five days per week in competitive basketball at a selective sports school. On examination, he appears well with vital signs within normal limits. There is bruising and swelling around the anterior proximal right tibia, with pain elicited on both palpation and active movement of the knee joint. An X-ray of the right knee is performed. Which one of the following structures is most likely affected in this patient's presentation? - A: Anterior cruciate ligament - B: Posterior cruciate ligament - C: Patellar ligament - D: Medial meniscus - E: Medial collateral ligament

= C: Patellar ligament

Which one of the following is the most appropriate treatment? - A: Carbimazole - B: Propranolol - C: Propylthiouracil - D: Radioactive iodine therapy - E: Levothyroxine

= B: Propranolol

A 28-year-old woman, G1P0, at 12 weeks gestation, presents to the Emergency Department with a one-day history of vaginal bleeding. She denies any abdominal pain or fevers. She has no significant medical history and does not take any regular medications. On examination, she appears well with vital signs within normal limits. Speculum examination reveals a closed cervical os with no products of conception visible. A bedside ultrasound detects a fetal heartbeat. Her 10-week antenatal blood tests show that she is blood group A, rhesus negative. Which one of the following is the most appropriate next step in management? - A: Mifepristone - B: Blood transfusion - C: Anti-D prophylaxis 625 IU - D: Dilatation and curettage - E: Reassurance

= E: Reassurance

Which one of the following is the most likely diagnosis? - A: Adult-onset Still's disease - B: Rheumatoid arthritis - C: Systemic sclerosis - D: Systemic lupus erythematosus - E: Infectious mononucleosis

= **D: Systemic Lupus Erythematosus (SLE)** - A patient presenting with fever, malar rash, and joint pain suggests the diagnosis of systemic lupus erythematosus (SLE). SLE is a chronic autoimmune disease that can affect almost any organ system, most commonly the joints, skin, kidneys, blood cells, brain, heart and lungs. It may present with a multitude of symptoms and signs including fever, photosensitive rash, alopecia, oral ulcers, Raynaud's phenomenon, weight loss, pericarditis, myocarditis, pleural effusion, pneumonitis, seizures, psychosis, autoimmune cytopenias or glomerulonephritis. A strongly positive ANA can be suggestive of SLE. The presence of a positive anti-dsDNA is highly specific for the diagnosis of SLE, and titres can be helpful for monitoring disease activity and response to treatment. Other autoantibodies can be helpful in making the diagnosis as well as predicting manifestations e.g., anti-Smith, anti-phospholipid, anti-histone, anti-nucleosome and anti-ribosomal P antibodies. Low complement levels (C3 and C4) can also occur, particularly with lupus nephritis.

Which one of the following is the most appropriate initial management of her blood pressure? - A: Lifestyle and diet advice - B: Amlodipine - C: Perindopril - D: Candesartan - E: Hydrochlorothiazide

= C: Perindopril

Which one of the following is the most appropriate next step in management? - A: Add furosemide - B: Add digoxin - C: Add empagliflozin - D: Change perindopril to sacubitril/valsartan - E: Refer for device therapy

= C: Add empagliflozin

Which one of the following is the most appropriate initial management? - A: Intravenous hydrocortisone - B: Sulfasalazine - C: Methotrexate - D: Infliximab - E: Colectomy

= A: Intravenous hydrocortisone

A 66-year-old man presents to his General Practice clinic with a two-month history of recurrent blurring of vision which affects both eyes. The symptoms tend to come on when he plays racket sports and usually resolve after a few minutes. He does not have a headache. His medical history includes type II diabetes and hypertension. His medications are metformin, gliclazide, and perindopril. On examination, he appears well with vital signs within normal limits. Fundoscopic examination of his right eye is shown. Which one of the following is the most likely diagnosis? - A: Subclavian steal syndrome - B: Migrainous aura - C: Hypertensive retinopathy - D: Diabetic retinopathy - E: Optic neuritis

= A: Subclavian steal syndrome

Which one of the following is the most appropriate initial management? - A: Methylprednisolone injection - B: Night-time wrist splinting - C: Oral ibuprofen - D: Surgical release of the flexor retinaculum - E: Therapeutic ultrasound

= **B: Night-time wrist splinting** - The patient's symptoms of numbness and tingling in the thumb, index, and middle fingers, worsening at night, and positive Tinel test suggest a diagnosis of carpal tunnel syndrome (CTS). The carpal tunnel is a narrow passageway in the wrist that is formed by the carpal bones at the base and sides, and the flexor retinaculum ligament over the top. The median nerve passes through this tunnel and provides sensation to the palmar aspect of the thumb, index, middle, and lateral half of the ring finger (the lateral three-and-a-half digits). It is also responsible for the motor function of the thenar and lateral two lumbrical muscles of the hand. Risk factors for CTS include repetitive wrist movements or vibration, rheumatoid arthritis, and pregnancy as these can cause inflammation and swelling within the tunnel, resulting in compression of the median nerve.

An 18-year-old man presents to the General Practice clinic for review of his acne. One month ago, he was prescribed adapalene which he has been using as directed, but he feels his acne is getting worse. At the previous visit he had several open and closed comedones. On examination today, he appears well with numerous inflamed comedones and a few small scattered pustules on his face. Which one of the following is the most appropriate next step in management? - A: Begin systemic retinoid therapy - B: Add topical clindamycin - C: Add benzoyl peroxide - D: Continue topical retinoids alone - E: Add oral doxycycline

= C: Add benzoyl peroxide

A 45-year-old man presents to the Emergency Department with a two-week history of bloody diarrhoea. The blood is mixed in with the stool and in the last few days he has had at least 10 bowel actions a day. He feels unwell and has noticed his abdomen becoming swollen and tender with associated crampy pain over the past 24 hours. One week prior to the onset of diarrhoea he had completed a course of antibiotics for a sore throat. He has lost eight kilograms weight over the past two weeks. He has no other significant medical history and takes no regular medications. He reports no recent travel or at-risk activities. On examination, he appears unwell with a temperature of 38.8°C, pulse rate 132/min, and blood pressure 110/70 mmHg. His abdomen is distended with widespread tenderness. Investigations reveal haemoglobin 106 g/L (130-180) and serum potassium 3.1 mmol/L (3.5-5.2). A plain abdominal X-ray is performed. Which one of the following is the most likely diagnosis? - A: Ischaemic colitis - B: Colonic pseudo-obstruction - C: Colorectal carcinoma - D: Toxic megacolon - E: Caecal volvulus

= **D: Toxic megacolon** - The clinical and radiological picture is that of toxic megacolon. The X-ray shows a massively dilated large bowel (>6 cm) with the examination and investigation findings indicating systemic toxicity, which is required for a diagnosis of toxic megacolon. Complete criteria for diagnosis include radiographic evidence of colonic dilatation >6 cm (especially in the transverse colon), plus any three of fever >38.6°C, tachycardia >120/min, leukocytosis >10.5 x 10^3/μL, or anaemia; and any of hypotension, hypovolaemia, altered mental status, or electrolyte disorders.

Which one of the following is the most appropriate contraceptive option for this patient? - A: Combined oral contraceptive pill - B: Intrauterine device - C: Medroxyprogesterone acetate injection - D: Ulipristal - E: Progestogen implant

= C: Medroxyprogesterone acetate injection

Which one of the following is the most appropriate next step in management? - A: Arterial blood gas - B: Lumbar puncture - C: Non-contrast CT head - D: MRI brain - E: IV ceftriaxone

= E: IV ceftriaxone

Which one of the following is the most likely diagnosis? - A: Uraemia - B: Renal anaemia - C: Gastrointestinal bleeding - D: Profound iron deficiency - E: Haemolysis

= **C: Gastrointestinal bleeding** - This patient's presentation and initial laboratory results are most concerning for gastrointestinal bleeding. This is evidenced by a new profound anaemia and significant rise in urea without change in creatinine or eGFR. Red blood cells in the gastrointestinal tract are broken down into proteins, which are further metabolised into urea, explaining the rise in urea levels. An acute gastrointestinal bleed should not significantly affect creatinine (a muscle breakdown product) or eGFR, unless there is a concurrent renal insult. Thus, a rise in the urea:creatinine ratio suggests gastrointestinal bleeding.

Which one of the following is the most likely diagnosis? - A: Rheumatoid arthritis - B: Osteoarthritis - C: Psoriatic arthritis - D: Gout - E: Septic arthritis

= **C: Psoriatic arthritis** - The patient's presentation is most consistent with a seronegative spondyloarthropathy, as suggested by key features which include dactylitis (diffuse swelling of the fingers or toes, resulting in a "sausage-like" appearance), asymmetric oligoarthritis, and inflammatory back pain. Of the options provided psoriatic arthritis, is the only spondyloarthropathy. Psoriatic arthritis can sometimes precede the onset of psoriatic skin lesions.

Which one of the following is the most appropriate next investigation? - A: Anti-nuclear antibodies (ANA) - B: Alpha-fetoprotein (AFP) - C: Anti-mitochondrial antibodies (AMA) - D: Anti-smooth muscle antibodies (ASMA) - E: Anti-neutrophil cytoplasmic antibodies (ANCA)

= A: Anti-nuclear antibodies (ANA)

Which one of the following is the most appropriate next step in management of this patient's headache? - A: 20 mL/kg intravenous fluid bolus and bed rest - B: Repeat lumbar puncture - C: Oral caffeine - D: Referral to anaesthesia for consideration of an epidural blood patch - E: Sphenopalatine ganglion block

= **C: Oral caffeine** - The patient in this stem is most likely suffering from a post-lumbar puncture (LP) or post-dural puncture headache. This type of headache is thought to be caused by the removal of cerebrospinal fluid (CSF) during lumbar puncture with continued leakage of CSF. The clinical features associated with this headache are that it is positional, aggravated by standing or sitting upright and relieved by lying down. It may be associated with nausea, photophobia, and neck stiffness.

A 25-year-old man presents to his General Practice clinic with a one-week history of weakness in the fingers of his right hand. He was doing weight training a week ago when he suddenly experienced pain in his right forearm. The pain was 6/10 in intensity and localised to his forearm. He has no significant medical history and does not take any regular medications. On examination, he appears well with normal vital signs. Examination reveals impaired flexion of his proximal interphalangeal joints in the right hand and normal flexion of the distal interphalangeal joints. Which one of the following muscles is most likely to be damaged? - A: Palmaris longus - B: Flexor carpi ulnaris - C: Flexor carpi radialis - D: Flexor digitorum superficialis - E: Flexor digitorum profundus

= **D: Flexor digitorum superficialis** - This patient has most likely damaged his flexor digitorum superficialis. This muscle originates from the medial epicondyle of the humerus and proximal anterior radius and inserts at the palmar surface of the 2nd-5th middle phalanges. It is innervated by the median nerve and is responsible for flexion of the proximal interphalangeal joints of the fingers. Isometric weight training can cause rupture of this muscle, which would also result in impaired wrist flexion in addition to impaired finger flexion.

Which one of the following is the most likely diagnosis? - A: Migraine - B: Tension-type headache - C: Medication overuse headache - D: Idiopathic intracranial hypertension - E: Giant cell arteritis

= **B: Tension-type headache** - This patient's presentation is most consistent with tension-type headache (TTH). TTH is typically characterised by bilateral headaches lasting 30 minutes to seven days, not associated with nausea or vomiting, and with at least two of the following features: bilateral location, pressing or tightening (non-pulsating) quality, mild or moderate intensity, and not aggravated by routine physical activity. The patient's description of a dull ache occurring multiple times a week, without associated nausea, vomiting, or photophobia, fits this profile. Additionally, the presence of pericranial muscle tenderness on examination is a common finding in TTH.

Which one of the following is LEAST likely to explain the elevation in troponin-T? - A: Sepsis - B: Renal impairment - C: Subdural haematoma - D: Stroke - E: Pulmonary embolism

= **C: Subdural haematoma** - Troponin-T is a highly specific and sensitive marker that, when elevated, indicates the presence of myocardial injury. Many conditions other than myocardial infarction can lead to an elevated troponin-T and should be considered in the differential diagnosis.

Which one of the following is the most likely diagnosis? - A: Hairy cell leukaemia - B: Lymphoma - C: Sarcoidosis - D: Thymoma - E: Tuberculosis

= **B: Lymphoma** - This patient has presented with constitutional symptoms (weight loss and fever), cough, itching, painless cervical lymphadenopathy which occasionally becomes painful (possibly with alcohol consumption), and splenomegaly. The chest X-ray shows a superior mediastinal mass (mediastinal lymphadenopathy). This presentation together with an elevated lactate dehydrogenase level would suggest lymphoma (likely Hodgkin lymphoma) and a biopsy is needed to provide the definitive diagnosis.

Which one of the following is the most appropriate next step in management? - A: Reassurance and follow-up in three months - B: Discharge back to her General Practice clinic - C: Digital subtraction angiography +/- angioplasty +/- stenting - D: Risk factor modification and structured exercise program - E: CT angiogram

= D: Risk factor modification and structured exercise program

A 65-year-old man presents to his GP clinic with a six-month history of progressive dyspnea associated with dry cough. He has a medical history of hypertension. His medications include ramipril. He is an ex-smoker with a 30 pack-year history who quit eight years ago. On examination, he appears well. He has a respiratory rate of 18/min, oxygen saturation of 93 % on room air, and temperature 36.8 °C. He has clubbing and bibasal fine inspiratory crackles. A chest X-ray shows diffuse interstitial opacities. Pulmonary function tests reveal a forced vital capacity (FVC) 60% predicted, forced expiratory volume in 1 second (FEV1) 71% predicted, FEV1/FVC ratio 0.84 (>0.70), and diffusing capacity for carbon monoxide (DLCO) 50% predicted. Which one of the following is the most likely diagnosis? - A: Chronic obstructive pulmonary disease - B: ACEI-induced cough - C: Hypersensitivity pneumonitis - D: Idiopathic pulmonary fibrosis - E: Sarcoidosis

= **D: Idiopathic pulmonary fibrosis** - The patient's age, smoking history, and clinical presentation with progressive dyspnea, dry cough, clubbing, and bilateral basal crackles suggest an interstitial lung disease. The chest X-ray shows diffuse interstitial opacities and pulmonary function tests reveal a restrictive ventilatory defect (decreased FVC, decreased FEV1, normal FEV1/FVC ratio) with reduced DLCO. The absence of features suggestive of a systemic disease, inhalational exposures, or drug reactions makes idiopathic pulmonary fibrosis the most likely diagnosis.

Which one of the following is the most appropriate initial management? - A: Intravenous metoprolol - B: Intravenous amiodarone - C: Electrical cardioversion - D: Intravenous diltiazem - E: Intravenous heparin

= **C: Electrical cardioversion** - The patient has presented with signs and symptoms indicating a tachyarrhythmia, specifically atrial fibrillation, as evidenced by the classical findings on the ECG and a lack of ST segment changes which likely rules out myocardial infarction. The patient has a CHA2DS2-VASc score of 0 since he has no history of cardiac issues. In this case, electrical cardioversion would be the most appropriate initial management. Electrical cardioversion is the delivery of a synchronised electrical shock to the heart, which depolarises the myocardium and interrupts the chaotic electrical activity of atrial fibrillation. It is the most appropriate initial treatment for haemodynamically unstable patients with atrial fibrillation, as it rapidly restores sinus rhythm and improves symptoms. Appropriate anticoagulation is crucial before electrical cardioversion to prevent thromboembolic events. Immediate electrical cardioversion may be contraindicated in patients with severe hypotension or acute myocardial infarction.

A 35-year-old man presents to the General Practice clinic with a six-month history of episodes of feeling hot and flushed. He has no significant medical history and does not take any regular medications. Each episode lasts about 30 minutes and is associated with diarrhoea. During these episodes he feels lightheaded when standing up, but otherwise has no other symptoms. On examination, he appears well with vital signs within normal limits. His normal appearance is shown (Image 1) and the other photograph (Image 2) was taken during one of these episodes. Which one of the following tests is most likely to confirm the diagnosis? - A: Thyroid function tests - B: Serum adrenaline and noradrenaline - C: Serum testosterone - D: Urinary 5-hydroxyindoleacetic acid (5-HIAA) - E: Anti-nuclear antibodies (ANA)

= **D: Urinary 5-hydroxyindoleacetic acid (5-HIAA)** - This patient has symptoms suggestive of carcinoid syndrome. Carcinoids are small, slow-growing neuroendocrine tumours most commonly found in the gastrointestinal tract. They secrete serotonin, bradykinin, histamine, substance P and prostaglandins. Urinary 5-HIAA over a 24-hour period is diagnostic as it is a degradation product of serotonin metabolism, one of the hormones secreted by the tumour.

A 50-year-old woman presents to her General Practice clinic with a six-week history of low-grade fever, fatigue, night sweats and coughing up sputum. She has a medical history of chronic schizophrenia. Her medications include quetiapine, though she is not always compliant. She is a lifetime non-smoker. On examination, she appears malnourished with poor dental hygiene and gingivitis. Her vital signs are within normal limits. On auscultation of her chest, a few inspiratory crackles can be heard on the right side. A chest X-ray is arranged. Which one of the following is the most likely diagnosis? - A: Tuberculosis - B: Empyema - C: Lung abscess - D: Pneumothorax - E: Lung cancer

= **C: Lung abscess** - The patient's low-grade fever, night sweats, and fatigue are suggestive of an inflammatory pathology. The presence of sputum production points towards a respiratory source. Her poor dental hygiene and gingivitis are the most likely source of the infectious agents causing her lung abscess. The chest X-ray shows a cavitation in the middle lobe of the right lung, withe the appearances of a lung abscess.

Which one of the following is the most likely medication that the patient was recently prescribed? - A: Amlodipine - B: Candesartan - C: Hydrochlorothiazide - D: Prazosin - E: Propranolol

= **C: Hydrochlorothiazide** - is the most likely medication to have caused this patient's hyponatraemia. It acts by inhibiting the sodium chloride channel in the distal convoluted tubule, thus preventing reabsorption of both sodium and chloride. As a result, sodium is lost via the urine which can lead to hyponatraemia.

Which one of the following laboratory parameters is most likely to be diagnostic? - A: Serum total bilirubin - B: Serum alkaline phosphatase (ALP) - C: Serum aspartate aminotransferase (AST) - D: Serum alanine aminotransferase (ALT) - E: Serum bile acids

= **E: Serum bile acids** - This patient has a clinical picture suggestive of intrahepatic cholestasis of pregnancy (ICP). This is a condition characterised by impaired bile flow within the liver during pregnancy, leading to the accumulation of bile acids in the blood. The most sensitive laboratory parameter for diagnosing ICP is serum bile acids. In ICP, the impaired flow of bile leads to the accumulation of bile acids in the bloodstream. Measuring serum bile acids provides a direct assessment of this abnormality. Elevated levels of serum bile acids, typically greater than 10 μmol/L, are indicative of ICP. It is an important condition in pregnancy that should not be missed because of the greater risk of perinatal mortality associated with it.

Which one of the following is the strongest indication for meningococcal vaccination in this patient? - A: Type 2 diabetes - B: Being a farmer - C: Age over 65 years - D: Asplenia - E: Frequent exposure to mosquitoes

= **D: Asplenia** - is the strongest indication for meningococcal vaccination in this patient. Individuals with asplenia or hyposplenia are at significantly increased risk of severe infections, including meningococcal disease. Meningococcal ACWY and B vaccines are funded under the National Immunisation Program for patients with asplenia.

Which one of the following is the most appropriate initial pharmacological management for this patient's acute symptoms? - A: Amlodipine - B: Clonidine - C: Olanzapine - D: Morphine sulfate - E: Glyceryl trinitrate patch

= **D: Morphine sulfate** - This patient is experiencing an episode of paroxysmal sympathetic hyperactivity, a disorder of autonomic function that occurs in up to 20% of patients with acquired brain injury, particularly traumatic brain injury, and its rapid recognition and management is essential. It is characterised by paroxysmal episodes of tachycardia, hypertension, tachypnoea, diaphoresis and/or hyperthermia, often triggered by external stimuli such as repositioning, loud noises or pain.

A 35-year-old woman presents to her General Practice clinic for a routine health check. She does not have dyspareunia, intermenstrual bleeding or post-coital bleeding. Her cervical screening test today is negative for any HPV infection. Twelve months ago, her cervical screening test (CST) was positive for HPV non-16/18 and liquid-based cytology (LBC) showed low-grade squamous intraepithelial lesion (LSIL). Her prior cervical screens have all been normal. She has no significant medical history and does not take any regular medications. Which one of the following is the most appropriate advice to provide to this woman? - A: Return to the screening program every five years - B: A further HPV negative test in 12 months before returning to the screening program every five years - C: Referral for colposcopy - D: She is now immune to HPV and no longer needs to participate in the screening program for cervical cancer - E: CST every two years

= A: Return to the screening program every five years

Which one of the following is the most likely diagnosis? - A: Meconium aspiration syndrome - B: Respiratory distress syndrome - C: Transient tachypnoea of the newborn - D: Congenital pneumonia - E: Pneumothorax

= **C: Transient tachypnoea of the newborn** is the most likely diagnosis in this late preterm infant born via Caesarean section to a mother with gestational diabetes. It is a self-limiting condition caused by delayed clearance of fetal lung fluid. Risk factors include Caesarean delivery, maternal gestational diabetes, and maternal asthma. Typical features are tachypnoea, nasal flaring, intercostal recession, and tracheal tug as seen in this baby.

Which one of the following is the most appropriate next step in investigation? - A: Carotid duplex ultrasound - B: CT angiogram of the head and neck - C: Digital subtraction angiography of the carotid arteries - D: Basic blood panel including lipid levels - E: 24-hour ECG Holter monitor

= **A: Carotid duplex ultrasound** - This patient has known coronary artery disease which is being appropriately managed with medical therapy. Literature describes at least a 50% risk of concomitant peripheral vascular disease in patients with coronary artery disease, including carotid artery stenosis. He has most likely experienced a transient ischemic attack in the form of transient monocular visual loss, also called amaurosis fugax. This is often caused by a retinal artery occlusion from an embolus originating in the ipsilateral carotid artery.

Which one of the following is the most appropriate long-term management plan? - A: Daily cranberry juice - B: Daily effervescent urinary alkaliniser sachets - C: Continuous low-dose oral cephalexin - D: Monthly renal tract ultrasound surveillance - E: No long-term preventative treatment required

= **C: Continuous low-dose oral cephalexin** - This patient has recurrent urinary tract infections (UTIs), defined as ≥2 infections in 6 months or ≥3 infections in 1 year. In an otherwise healthy woman, this can be managed in the community. However, referral to urology should be considered if there are red flags such as ongoing pain, failure to respond to antibiotics, recurrent pyelonephritis, immunocompromise, or known renal tract abnormalities.

Which one of the following is the most likely cause of his current presentation? - A: Medication side effect - B: Dehydration - C: Cardiac failure - D: Bronchogenic carcinoma - E: Wernicke's encephalopathy

= D: Bronchogenic carcinoma - This patient presents with an altered conscious state and severe hyponatraemia. Key findings on history include a 40 pack-year smoking history, recent increase in alcohol consumption, and hypertension managed by an ACE inhibitor and thiazide diuretic. Examination reveals bronchial breathing at the left lung base. Investigations show severe hyponatraemia, hypokalaemia, and low serum osmolality.

A 51-year-old man presents to his General Practice clinic with a three-month history of vague upper abdominal pain. He has no significant medical history and does not take any regular medications. On examination, he appears well with vital signs within normal limits. Abdominal examination is unremarkable. A contrast-enhanced CT abdomen is performed. Which one of the following is the most appropriate next step in management? - A: Reassurance - B: MRI abdomen - C: Fine needle aspiration biopsy - D: Percutaneous drainage - E: Albendazole

= **B: MRI abdomen** - The CT shows several discrete lesions within the liver. Three of the lesions show a characteristic appearance of hepatic haemangiomas, with peripheral nodular contrast enhancement and central low density. The larger lesion shows diffuse homogeneous enhancement. While this may also represent a haemangioma, the atypical appearance warrants further characterization with MRI to differentiate it from other benign lesions like focal nodular hyperplasia or hypervascular malignancies.

Which one of the following is the most appropriate initial investigation? - A: Serum folate - B: Complete blood count - C: Intrinsic factor antibodies - D: MRI lumbar spine - E: Serum vitamin B12

= **E: Serum vitamin B12** - This patient's clinical presentation is consistent with vitamin B12 deficiency. He is at risk of this given his total gastrectomy and thus loss of intrinsic factor, leading to impaired absorption of vitamin B12. The neurological symptoms of lower limb weakness and diminished vibratory sense are a result of subacute combined degeneration of the spinal cord secondary to B12 deficiency. The conjunctival pallor and fatigue are related to a macrocytic anaemia from B12 deficiency. Therefore serum vitamin B12 is the most appropriate initial investigation in this case. While a complete blood count may demonstrate a macrocytic anaemia, there are multiple potential causes and this alone will not confirm the specific diagnosis. Serum B12 levels are required.

Which one of the following is the most likely diagnosis? - A: Vitamin C deficiency - B: IgA vasculitis - C: Acute lymphoblastic leukaemia - D: Immune thrombocytopaenic purpura - E: Haemophilia A

= **A: Vitamin C deficiency** - This child's presentation is most consistent with vitamin C deficiency, also known as scurvy. The key features are the lower limb pain and reluctance to walk, easy bruising and bleeding, and constitutional symptoms of lethargy and weakness in the context of a restricted diet. While rare in developed countries today, scurvy can still occur in severely malnourished individuals.

Which one of the following is the most significant risk factor for the development of depression in this patient? - A: BMI >30 kg/m2 - B: Age over 75 years - C: Positive family history of depression - D: Recent history of stroke - E: Male sex

= **D: Recent history of stroke** - A recent history of stroke is the most significant risk factor for the development of clinical depression in this patient. It is estimated that 30% of stroke survivors will develop depression. Post-stroke depression is associated with poorer functional outcomes, so it is important to identify and treat it effectively to optimise recovery.

Which one of the following is the most appropriate next step in management? - A: Intramuscular naloxone - B: DC cardioversion - C: Cardiopulmonary bypass - D: Intravenous atropine 1.0 mg - E: Removal of any cold/wet clothes and application of heated air blankets

= **E: Removal of any cold/wet clothes and application of air blankets** - This patient is presenting with moderate hypothermia, characterised by a core body temperature of 28-32°C. Symptoms include absence of shivering, altered conscious state, bradycardia, bradypnoea, and mydriasis. These changes typically reverse as the body temperature normalises, without other intervention.

A 68-year-old woman presents to your General Practice clinic after feeling generally unwell for four months. She complains of fatigue, mild breathlessness, joint pain, and low mood. These symptoms have been intermittent in nature. She has a medical history of type 2 diabetes mellitus, hypertension, osteoarthritis, and she was admitted to hospital four months ago with severe COVID-19. Her regular medications include metformin and amlodipine and, takes PRN paracetamol and meloxicam to manage her arthritic pain. Which one of the following is the most appropriate management for this patient? - A: Isolate for seven days - B: COVID-19 vaccination - C: Referral to mental health services - D: Maximise sleep, relaxation and nutrition - E: Commence oral antivirals

= **D: Maximise sleep, relaxation and nutrition** - This patient is presenting with typical signs and symptoms of post-COVID19 symptoms ("long COVID"). Maximising sleep, relaxation and nutrition is appropriate first-line treatment for these symptoms. Avoidance of over-investigation and emphasis on holistic care is important. Four to six weeks of mild aerobic exercise, graded to the patient's ability, may also be of benefit.

Which one of the following is the most appropriate next step in management? - A: Mirtazapine - B: Citalopram - C: Phenelzine - D: Buspirone - E: Bupropion

= **E: Bupropion** - This patient presented with a desire to quit smoking. There are several strategies that can be used to help people quit smoking, including nicotine replacement therapy, medications, behavioural therapy, Quit line telephone helplines, acupuncture and hypnotherapy.

A 62-year-old woman presents to her General Practice clinic with a one-month history of dry cough and intermittent fever. She has a medical history of rheumatoid arthritis. Her only current medication is methotrexate. On examination, she appears well with a pulse rate of 80/min, blood pressure 130/85 mmHg, respiratory rate 14/min, SpO2 98% on room air, and temperature 37.2°C. Chest examination is unremarkable. A chest X-ray is performed. Which one of the following is the most likely diagnosis? - A: Lobar pneumonia - B: Lung carcinoma - C: Rheumatoid nodule - D: Aspergilloma - E: Pulmonary tuberculosis

= **D: Aspergilloma** - The most salient finding on this chest X-ray is a rounded cavity in the right upper lobe with a radiolucent outline. The key differential diagnoses based on this finding are aspergilloma, a fungal ball composed of Aspergillus hyphae, and pulmonary tuberculosis, infection of the lungs with Mycobacterium tuberculosis.

A 20-year-old woman presents to her General Practice clinic having recently run out of her usual combined oral contraceptive pill. She has no significant medical history and does not take any other regular medications. She recently finished the seven-day course of inactive pills, and had taken two days of active pills before running out of her supply. It is now four days since she took her last pill, and she had unprotected intercourse two days ago. Which one of the following is the most appropriate advice? - A: Take two pills today, then continue as usual - B: Take two pills today, skip the next set of inactive pills, and continue the active pills instead - C: Take three pills today, then continue as usual - D: Take emergency contraception, and take two pills today then continue as usual - E: Take emergency contraception, and take three pills today then continue as usual

= D: Take emergency contraception, and take two pills today then continue as usual

Which one of the following is the most appropriate next investigation? - A: Conventional angiography - B: Repeat upper endoscopy and colonoscopy - C: Wireless video capsule endoscopy - D: CT angiography - E: Radionuclide scan

= **C: Wireless video capsule endoscopy** - This man likely has occult small bowel bleeding given his history of melaena and negative upper endoscopy and colonoscopy. In the case of obscure gastrointestinal bleeding, wireless video capsule endoscopy is indicated as the first line investigation. It may detect small bowel conditions such as angiodysplasia, tumours and ulcers.

Which one of the following is the most likely diagnosis? - A: Lewy body dementia - B: Alzheimer disease - C: Vascular dementia - D: Bipolar affective disorder - E: Frontotemporal dementia

= **E: Frontotemporal dementia** - The patient's symptoms align closely with the behavioural variant of frontotemporal dementia (FTD), a neurocognitive disorder characterised by early changes in personality and behaviour, along with disinhibited behaviours such as offensive language and inappropriate touching. This patient also exhibits classical imaging findings associated with FTD, showing atrophy in the frontal and temporal regions of the brain.

Which one of the following is the most likely diagnosis? - A: Urge incontinence - B: Overflow incontinence - C: Mixed incontinence - D: Functional incontinence - E: Stress incontinence

= **E: Stress incontinence** - The patient describes stress incontinence, which is characterised by the leakage of urine after an event that increases intra-abdominal pressure (i.e. coughing, sneezing, laughing, heavy lifting or straining). This is due to weak muscles in the pelvic floor and/or urethral sphincter. Stress incontinence usually affects females, especially after traumatic or operative vaginal delivery. Other risk factors include being overweight, post-menopausal status and advanced age.

Which one of the following is the most appropriate next step in management? - A: Gluten-free diet - B: Admission for intravenous fluids and bowel rest - C: Opioid analgesia - D: Intranasal sumatriptan - E: Reassurance that the condition is self-limiting

= **D: Intransal sumatriptan** - This child's presentation is most consistent with abdominal migraine. She meets the diagnostic criteria, which are as follows: 1. At least five attacks of abdominal pain fulfilling criteria 2-4 2. Pain has at least two of the following characteristics: midline/periumbilical/ poorly localised pain; dull pain;moderate-severe intensity 3. During attacks at least two of the following are present: anorexia, nausea, vomiting and pallor 4. Attacks last 2-72 hrs 5. Complete freedom of symptoms between attacks 6. Not associated with another disorder

Which one of the following is the most likely underlying cause of his foot ulcer? - A: Chronic venous insufficiency - B: Peripheral arterial disease - C: Peripheral neuropathy - D: Foreign body reaction - E: Plantar wart

= **C: Peripheral neuropathy** - The most likely underlying cause is peripheral neuropathy. The history and examination findings are suggestive of a diabetic foot ulcer that went undetected due to peripheral neuropathy secondary to his longstanding type 2 diabetes. The painless ulcer located on a plantar pressure point of the right foot is characteristic of a neuropathic ulcer.

Which one of the following is the most likely diagnosis? - A: Brain stem infarction - B: Vestibular migraine - C: Meniere's disease - D: Acoustic neuroma - E: Benign paroxysmal positional vertigo

= **C: Meniere's disease** - The patient's history of episodic vertigo lasting 10-25 minutes, accompanied by tinnitus, is suggestive of Meniere's disease. Meniere's disease is a peripheral cause of vertigo attributed to excess endolymphatic fluid pressure in the labyrinth of the ear. It is often associated with tinnitus and sensorineural hearing loss, although patients may not always notice the hearing impairment initially.

Which one of the following is the most appropriate next step in management? - A: Suction evacuation - B: Expectant management - C: Chemotherapy - D: Diagnostic laparoscopy - E: Exploratory laparotomy

= **A: Suction evacuation** - The clinical presentation is highly suggestive of a complete hydatidiform mole. The 'snowstorm' appearance and lack of fetal tissue on ultrasound, combined with the markedly elevated beta-hCG, are diagnostic. The most appropriate next step is suction evacuation to remove the molar tissue. Histopathology will confirm the diagnosis. The patient will require close follow-up with serial beta-hCG measurements to monitor for persistent gestational trophoblastic disease.

Which one of the following is the most likely diagnosis? - A: Croup - B: Whooping cough (Bordetella pertussis) - C: Bronchiolitis - D: Foreign body aspiration - E: Epiglottitis

= **E: Epiglottitis** - The boy is presenting with symptoms suggestive of an upper airway condition. Clinical findings of fever, stridor, drooling, dysphagia, and restlessness in paediatric patients should alert the clinician to the possibility of epiglottitis, especially in the unvaccinated population, as this is a potentially life-threatening condition. Often the result of an infection with Haemophilus influenzae type B, epiglottitis causes airway compromise as oedema of the tissues of the epiglottis may obstruct the path of oxygen. Hence, senior aid is required immediately to secure the patient's airway and antibiotic therapy initiated with cefotaxime plus dexamethasone commenced as soon as possible to reduce the infection and subsequent swelling. Examination of the throat is often limited in these patients to reduce agitation that may lead to airway compromise and cyanosis.

Which one of the following is the most appropriate screening test for spina bifida in this patient? - A: Non-invasive prenatal testing - B: Ultrasound - C: Amniocentesis - D: Carrier screening - E: Chorionic villus sampling

= **B: Ultrasound** - This patient is at increased risk of foetal spina bifida due to likely folate deficiency. She has not been taking folate supplements and has a relatively poor diet. Spina bifida is a potentially severe neural tube defect that can occur due to folate deficiencies during the first trimester. Consequences depend on lesion severity and may include hydrocephalus, neurogenic bladder, paralysis, sleep apnoea, and foetal death. Folate supplementation is recommended for all women planning pregnancy and during the first trimester to reduce the risk of neural tube defects. High-risk women, such as those on antiepileptic medications, are advised to take high-dose folate.

Which one of the following is the most appropriate hormone replacement therapy for this patient? - A: Intravaginal oestrogen therapy - B: Systemic transdermal oestrogen - C: Systemic oestrogen + progestogen therapy - D: Systemic oral oestrogen - E: Progesterone only pill

= **C: Systemic oestrogen + progestogen therapy** - This patient has presented with typical vasomotor symptoms of perimenopause, including night sweats, insomnia, and menstrual irregularity Menopause can only be diagnosed after 12 months of amenorrhea, however the perimenopause period can result in irregular and unpredictable cycles, and as such fits this patients description of symptoms. Menopause typically occurs between ages 45 to 55, also fitting with this patients age.

A girl is born via vaginal delivery at 38 weeks of gestation to a 28-year-old woman with no significant medical history. The pregnancy was uncomplicated. The mother's antenatal screening tests were positive for hepatitis B surface antigen. She does not take any regular medications. On examination, the baby appears well with vital signs within normal limits. Birth weight is 3.2 kg (50th percentile). She is active and feeding well. Which one of the following is the most appropriate management for prevention of vertical transmission of hepatitis B to the newborn? - A: Hepatitis B immunoglobulin only - B: Hepatitis B vaccine as a single dose only - C: Hepatitis B immunoglobulin and hepatitis B vaccine as a single dose - D: A full course of hepatitis B vaccine - E: A full course of hepatitis B vaccine and hepatitis B immunoglobulin

= **E: A full course of hepatitis B vaccine and hepatitis B immunoglobulin** - Hepatitis B virus (HBV) infection in a pregnant woman poses a serious risk to her infant at birth. Mother-to-child transmission occurs frequently either in the uterus, through placental leakage, or through exposure to blood or blood-contaminated fluids at or around the time of birth. The risk of perinatal transmission is associated with the hepatitis B envelope antigen (HBeAg) status of the mother. If a woman is both hepatitis B surface antigen (HBsAg) and HBeAg positive, 70–90% of her children will develop hepatitis B. If the mother is HBsAg positive but HBeAg negative, the risk is reduced.

Which one of the following is the most appropriate management? - A: Active surveillance - B: Androgen deprivation therapy - C: Radical prostatectomy - D: Brachytherapy - E: External beam radiotherapy

= **A: Active surveillance** - This patient has a PSA high enough to proceed to prostate biopsy, which shows a low-risk (Gleason ≤6) localised prostate cancer with a clinical T2 stage (tumour confined within the prostate). Active surveillance is appropriate for prostate cancers with a PSA level under 10 ng/mL, clinical stage T1-T2, and Gleason 6 or less (Grade Group 1). This patient is suitable for active surveillance, which delays and potentially avoids active definitive treatment. This spares the patient from the side effects of treatment.

Which one of the following is the most appropriate management plan? - A: Tamoxifen - B: Weight loss and lifestyle modifications - C: Abstain from alcohol - D: Discontinue lansoprazol - E: Liposuction

= **B: Weight loss and lifestyle modifications** - In this scenario, the patient is a 35-year-old man with a 12-month history of bilateral breast enlargement and tenderness. With no history of hormone therapy, drug abuse, or liver disease, and mild derangement in testosterone and oestradiol levels, the most likely contributing factor to his gynaecomastia is his BMI of 35 kg/m2, which is in the obese range. Obesity can result in increased conversion of testosterone to oestrogen in adipose tissue, leading to an imbalance in the oestrogen-testosterone ratio and the development of gynaecomastia. This patient's mildly low testosterone, and elevated oestradiol is most likely secondary to the increased conversion of testosterone to oestrogen in adipose tissues.

Which one of the following additional findings is most likely to be present? - A: Decreased sensation over the medial aspect of the forearm - B: Difficulty in supination of the forearm - C: Inability to adduct the thumb - D: Loss of sensation over the palmar aspect of the hand - E: Weakness in flexion of the wrist

= **B: Difficulty in supination of the forearm** - This patient has evidently sustained a midshaft fracture of the humerus and the scenario suggests an injury to the radial nerve. This nerve runs along the humerus and can be injured in a midshaft humeral fracture. The radial nerve innervates the muscles in the extensor compartment of the forearm, hence the difficulty in fully extending the wrist and fingers. This injury will also usually result in difficulty in supination of the forearm because the radial nerve supplies the supinator muscle. The supinator muscle is the prime supinator of the forearm. Sometimes the innervation to brachioradialis and supinator branches before the spiral groove and so this may be spared.

Which one of the following is most important for long-term management? - A: Percutaneous valvuloplasty - B: Thiazide diuretic - C: Total abstinence from alcohol consumption - D: Implantable cardioverter defibrillator - E: Beta-blocker, mineralocorticoid receptor antagonist, ACE inhibitor and SGLT2 inhibitor

= **C: Total abstinence from alcohol consumption** - This patient likely has a dilated cardiomyopathy leading to congestive cardiac failure. The history of dyspnoea and ankle oedema, as well as the bibasal crackles and elevated jugular venous pressure, suggests biventricular insufficiency. An S3 heart sound is indicative of a dilated ventricle wall. The electrocardiogram changes suggest biventricular enlargement. While there are many potential causes of dilated cardiomyopathy, in this particular case, it is most likely related to the patient's high alcohol consumption. However, other underlying aetiologies, such as previous myocardial infarction and infections, must be excluded.

Which one of the following is the most appropriate imaging investigation? - A: Digital subtraction angiography - B: Arterial duplex ultrasound - C: Computed tomography angiography - D: Magnetic resonance angiography - E: Venous duplex ultrasound

= **C: Computed tomography angiography** - This patient has acute limb ischaemia (ALI) of the right leg. It is very likely secondary to a cardioembolic source given the history of atrial fibrillation (AF). AF leads to blood stagnation in the atrial appendages, leading to thrombus formation that embolises distally. ALI typically manifests with the cardinal 6 Ps: pain, pallor, paralysis, pulselessness, paraesthesia, and poikilothermia (perishingly cold) although all six signs are rarely encountered unless a patient has severe ALI. It is a vascular emergency that requires urgent investigation and intervention.

Which one of the following is the most likely cause of this patient's acute deterioration? - A: Hypercalcaemia - B: Wernicke's encephalopathy - C: Local anaesthetic toxicity - D: Hypocalcaemia - E: Alcohol withdrawal

= **C: Local anaesthetic toxicity** - The most likely diagnosis is local anaesthetic toxicity. The patient developed perioral numbness, agitation, dizziness, and tinnitus within 30 minutes of receiving an intercostal nerve block with bupivacaine. These neurologic and cardiovascular signs of excitation progressed to a generalised seizure. Local anaesthetic toxicity occurs due to sodium channel blockade, initially causing CNS excitation (restlessness, confusion, tinnitus, muscle twitches) followed by CNS depression (coma, respiratory arrest). Cardiovascular effects begin with hypertension and tachycardia, potentially progressing to hypotension, dysrhythmias, and cardiac arrest in severe cases.

Which one of the following is the most appropriate next step in management? - A: Prednisone - B: Naproxen - C: Amitriptyline - D: Colchicine - E: Tramadol

= **C: Amitriptyline** - The patient presents with signs and symptoms consistent with a diagnosis of fibromyalgia. Fibromyalgia is more common in middle-aged women and is characterised by chronic widespread pain and allodynia (a heightened and painful response to pressure). Physical examination is typically normal except for point muscle tenderness in several areas including the mid-trapezius, lateral epicondyle, and greater trochanter, among others. Of note, fibromyalgia has no laboratory findings that are diagnostic of the condition.

Which one of the following investigations is most appropriate to assess for deep tissue injury? - A: Lactate dehydrogenase - B: Serum creatine kinase - C: Serum potassium - D: Serum uric acid - E: Urine myoglobin

= **B: Serum creatine kinase** - The most appropriate investigation to assess the deep/skeletal muscle injury in this patient is serum creatine kinase (CK). CK is an enzyme predominantly found in skeletal muscles, and its elevation in the bloodstream signifies muscle damage. Given the nature of electrical burns, which can cause significant tissue destruction, including muscle injury, measuring serum CK levels becomes crucial in determining the extent of the damage incurred. Elevated CK levels of more than 5000 IU/L (40-250) may indicate significant muscle injury, aiding in treatment decisions and monitoring the patient's progress.

A 40-year-old man presents to the General Practice clinic with a five-week history of a solitary painless lesion on his finger. He works as a gardener and the lump is now bothering him as it prevents him from easily holding his tools while working. He does not recall any specific trigger but regularly sustains minor cuts or bruises from his work. He has no significant medical history, no history of similar lesions, and receives regular skin checks. He has never smoked cigarettes. On examination, he appears well with vital signs within normal limits. The lesion is non-tender and located on the volar surface of the left second digit. Which one of the following is the most appropriate definitive treatment? - A: Observation alone - B: Topical imiquimod - C: Cryotherapy - D: Excision - E: Pulsed dye laser therapy

= D: Excision

An 86-year-old woman presents to the Emergency Department following a fall on her right side. She has ongoing pain in the right shoulder but was able to get up after the incident. She did not hit her head and has no other injuries. She has a medical history of hypertension and osteoporosis. Her only regular medication is amlodipine. On examination, she appears well with vital signs within normal limits. Her right shoulder is tender over the proximal humerus with decreased range of motion limited by pain. Capillary refill time is <2 seconds, brachial pulse is present, and the right arm does not appear shortened. A radiograph of the right shoulder is taken. Which one of the following is the most appropriate plan of management? - A: Sling immobilisation - B: Closed reduction - C: Open reduction and internal fixation - D: Intra-medullary nailing - E: Arthroplasty

= **A: Sling immobilisation** - The X-ray shows a two-part fracture of the proximal right humerus with minimal displacement. Proximal humerus fractures are common, often seen in older patients with osteoporosis following a fall on an outstretched arm (FOOSH). Sling immobilisation is the most appropriate management plan for minimally displaced proximal humeral fractures. A cuff-and-collar sling should be worn until healing is evident at four to six weeks, with X-ray follow-up and early physical therapy to restore function.

Which one of the following is the most likely causative agent? - A: Adenovirus - B: Parainfluenza virus - C: Bordetella pertussis - D: Staphylococcus aureus - E: Respiratory syncytial virus

= B: Parainfluenza virus

Which one of the following is the most appropriate management for this patient's acute presentation? - A: Oral indomethacin - B: Oral colchicine - C: Intra-articular corticosteroid injection - D: Oral prednisolone - E: Oral febuxostat

= **D: Oral prednisolone** - This patient presents with an acute monoarticular arthritis of the right first metatarsophalangeal joint, consistent with a diagnosis of gout given the characteristic presentation and history of previous similar episodes. Treatment options for acute gout flares include nonsteroidal anti-inflammatory drugs (NSAIDs), colchicine, systemic glucocorticoids like oral prednisolone, and intra-articular corticosteroid injections. The choice of acute treatment depends on patient comorbidities and concomitant medications.

Which one of the following is the most appropriate next step in management? - A: Oral antibiotics with General Practitioner follow-up - B: Admit under gynaecology for intravenous antibiotics - C: Await vaginal swab results before commencing treatment - D: Admit under gynaecology for urgent surgical intervention - E: Reassurance and discharge with a short course of analgesia and antiemetics

= **A: Oral antibiotics with GP follow-up** - This scenario is suggestive of mild-moderate pelvic inflammatory disease (PID) complicated by a small pyosalpinx. Empirical treatment should be promptly commenced as an outpatient with oral antibiotics with GP follow-up. Safety netting is crucial; the patient should be advised to return to the Emergency Department if symptoms worsen.

Which one of the following investigations is most appropriate? - A: Serum uric acid - B: Serum parathyroid hormone - C: Serum antinuclear antibodies - D: Erythrocyte sedimentation rate - E: HLA-B27

= **B: Serum parathyroid hormone** - The patient has calcium pyrophosphate deposition (CPPD) disease, also known as pseudogout. This is confirmed by the inflammatory arthrocentesis with CPPD crystals and imaging findings showing chondrocalcinosis.

A 70-year-old woman presents to her General Practice clinic with a three-month history of a mildly pruritic rash in an abdominal skin fold. She notes that the rash started as a solitary circular red patch that has slowly spread. She has a medical history of type 2 diabetes mellitus. Her medications include metformin. On examination, she appears well with vital signs within normal limits. Examination reveals an erythematous plaque with peripheral scaling in an abdominal skin fold. Which one of the following is the most likely diagnosis? - A: Candidiasis - B: Contact dermatitis - C: Seborrhoeic dermatitis - D: Tinea corporis - E: Pityriasis rosea

= **A: Candidiasis** - This presentation is consistent with candidiasis, most often caused by Candida albicans. Candida intertrigo refers to an infection of the superficial skin fold, as in this case. It classically presents as an erythematous plaque with peripheral scaling. The areas that are most affected by candida include the skin folds under the breast or abdomen, armpits or groin, or web spaces between the fingers and toes. This infection is associated with old age, warm climates, occlusive clothing, diabetes mellitus, iron deficit, underlying skin conditions and immunodeficiency.

Which one of the following is the most likely explanation for the deterioration in this patient's condition? - A: Progressive Alzheimer's disease - B: Elder abuse - C: Pneumonia - D: Urinary tract infection - E: Recent stroke

= **B: Elder Abuse** - This is very likely to be a case of elder abuse. While fortunately not very common, it is important to recognise when it does arise. Elder abuse can manifest in many ways, including emotional/ psychological changes (fear, depression, confusion), neglect (weight loss, dehydration, poor hygiene), financial exploitation, physical abuse (unexplained bruising or injuries), social isolation, and sexual abuse.

A 72-year-old woman presents to the General Practice clinic with an eight-day history of bilateral redness, pain and mild pruritus around the corners of her mouth. She has never experienced this before and has not noticed any other symptoms recently. She is a retired chef and cooks regularly for her young pre-school grandchildren. She has a medical history of type 2 diabetes mellitus. Her medications include metformin and empagliflozin. On examination, she appears well with vital signs within normal limits. Examination reveals erythema and maceration at the corners of her mouth bilaterally. Which one of the following is the most likely cause of this patient's presentation? - A: Crohn's disease - B: Erythematous candidiasis - C: Secondary syphilis - D: Riboflavin deficiency - E: Staphylococcal infection

= **B: Erythematous candidiasis** - This patient has angular cheilitis, a common condition that can affect any adult or child. While angular cheilitis may be associated with any of the listed conditions, the most likely usual cause is an erythematous candidiasis. This is a clinical diagnosis that may require skin swabs for culturing. Candida is identified in up to 93% of cases of angular cheilitis and is more likely to occur in older age, diabetes, and immunocompromised patients.

Which one of the following is the most appropriate next investigation? - A: Bone marrow biopsy - B: MRI paranasal sinuses - C: Genetic testing - D: Total serum immunoglobulins - E: Sweat chloride test

= **D: Total serum immunoglobulins** - The child in this scenario most likely has an immunodeficiency disorder because of the presence of recurrent ear infections, pneumonia, failure to thrive, infections that do not heal with oral antibiotics and require IV Abx, along with signs most likely consistent with oral candidiasis. Various clinical instruments can be used for indicating that the child might have an immunodeficiency syndrome, of which the most widely used one is 'The Jeffrey Modell Foundation 10 warning signs of possible childhood immunodeficiency'. According to this, immunodeficiency should be suspected in a child with following features: 1. ≥4 ear infections within 12 months 2. ≥2 serious sinus infections within 12 months 3. ≥2 pneumonias within 12 months 4. ≥2 deep-seated infections including septicaemia 5. Recurrent deep skin or organ abscesses 6. Persistent oral or skin fungal infections 7. Infection does not respond to ≥2 months of standard antibiotics 8. Intravenous antibiotics needed to clear infections 9. Failure to thrive or growth retardation 10. Family history of PID

A 38-year-old man presents to his general practitioner for evaluation of subfertility. He has no significant medical history and does not take any regular medications. On examination, he appears well with vital signs within normal limits. Investigations reveal a low sperm count of 10 million/mL (>15). Which one of the following pairs of blood tests would be most helpful in identifying the potential cause of this patient's oligospermia? - A: Oestradiol and follicle-stimulating hormone - B: Testosterone and follicle-stimulating hormone - C: Oestradiol and luteinising hormone - D: Oestradiol and testosterone - E: Prolactin and follicle-stimulating hormone

= **B: Testosterone and follicle-stimulating hormone** - In this setting, measuring testosterone and follicle-stimulating hormone (FSH) levels would be most helpful in identifying the potential cause of oligospermia. Reduced FSH levels may cause oligospermia, and testosterone levels are an important indicator of sperm production.

Which one of the following is the most likely diagnosis? - A: Sertoli cell tumour - B: Leydig cell tumour - C: Seminoma - D: Non-seminomatous germ cell tumour (NSGCT) - E: Epididymal cyst

= **C: Seminoma** - The tumor markers, alpha-fetoprotein (AFP), the beta subunit of human chorionic gonadotrophin (β-hCG), and lactate dehydrogenase (LDH) have characteristic patterns in the various types of testicular cancer.

Which one of the following is the most appropriate next step in management? - A: Oral acyclovir - B: Oral prednisolone - C: Oral prednisolone and acyclovir - D: Facial nerve decompression - E: Observation

= **B: Oral prednisolone** - The patient's sudden onset of right-sided facial weakness, with difficulty closing her right eye, drooping of the right corner of her mouth, and asymmetrical smile, is highly suggestive of Bell's palsy. Bell's palsy is a diagnosis of exclusion and is typically diagnosed based on clinical presentation. Other differential diagnoses that may be considered include stroke and Ramsay Hunt syndrome. In this case, presentation of both upper and lower facial weakness rules out stroke, as stroke will result in sparing of the forehead. Additionally a normal ear examination excludes Ramsay Hunt syndrome.

Which one of the following is the most appropriate definitive management? - A: IV 5% dextrose and sodium chloride - B: Activated charcoal - C: IV furosemide - D: Haemodialysis - E: Gastric lavage

= **D: Haemodialysis** - The patient in this scenario has signs and symptoms consistent with severe lithium toxicity, including gastrointestinal symptoms (nausea and vomiting) and neurotoxicity (dysarthria, tremor, ataxia). The serum lithium level of 4.2 mmol/L is markedly elevated and confirms the diagnosis. Lithium toxicity can occur acutely in overdose or chronically with impaired renal function, as lithium is primarily eliminated by the kidneys.

Which one of the following is the most appropriate next step in management? - A: MRI brain - B: Awake and sleep EEG - C: Lumbar puncture - D: Genetic testing - E: No further investigations

= **B: Awake and sleep EEG** - This child has features suggestive of infantile spasms (IS), a type of seizure commonly seen in the context of West syndrome, the most common epilepsy syndrome in the first year of life with peak onset between 3-7 months. West syndrome is typically associated with the triad of IS, developmental regression, and hypsarrhythmia. However, not all patients have hypsarrhythmia at presentation, so a vital goal is to prevent its unfolding.

Which one of the following is the most likely key risk factor for his current presentation? - A: Low dietary fibre intake - B: Male gender - C: Family history of bowel cancer - D: Smoking history - E: Previous abdominal surgery

= **A: Low dietary fibre intake** - The history and physical findings are most suggestive of diverticulitis, characterised by left lower quadrant abdominal pain, change in bowel habits, and low-grade fever. Low dietary fibre intake and the typical Western diet of low fibre, high red meat intake and excessive sugar use have a strong association with the prevalence of diverticulosis, but its exact cause remains uncertain. With regards to the development of diverticulitis, many factors are involved, including obesity, smoking, high alcohol intake and lack of exercise, but the most important key risk factor is a low intake of fibre. In this case the patient's reliance on take-away meals suggests a diet low in fibre.

Which one of the following would best explain the patient's current low breast milk production? - A: Low human placental lactogen - B: High oxytocin - C: Low testosterone - D: High oestrogen - E: High prolactin

= **D: High oestrogen** - During pregnancy the mammary glands develop to prepare for milk production (lactogenesis). Oestrogen, progesterone, human placental lactogen and prolactin stimulate development and differentiation of the alveoli and lactiferous duct system. The alveolar epithelium matures into columnar secretory cells interspersed with myoepithelial cells. A central lumen forms in the alveoli which leads to the lactiferous ducts (branching tunnels that will carry milk to the nipple). Prolactin is the hormone required for continuing milk production, though during pregnancy is inhibited by the high levels of oestrogen and progesterone produced by the placenta.

Which one of the following is the most likely diagnosis? - A: Metastatic bone disease - B: Choledocholithiasis - C: Occult plasmacytoma - D: Paget disease of bone - E: Osteomalacia

= **D: Paget disease of bone** - The most likely explanation for the biochemical picture is Paget disease of bone. This is a disorder of an aging skeleton in which some bones grow abnormally, affecting their size and shape. Most frequently, the disease is asymptomatic and is diagnosed only when the typical sclerotic bones are incidentally detected on X-ray examinations done for other reasons or when increased alkaline phosphatase (ALP) activity is recognised during routine laboratory measurements.

Which one of the following is the most appropriate management? - A: Observation and follow-up - B: Low iron diet - C: Increase vitamin C dosage - D: Phlebotomy - E: Iron chelation therapy

= **D: Phlebotomy** - This patient has hereditary haemochromatosis (HH), diagnosed by homozygous C282Y mutation, elevated transferrin saturation and ferritin levels. This condition typically presents after the age of 40 years when iron accumulation in different organs starts to manifest (although it may present later in life in females due to monthly blood loss associated with their menses) . A critical part of management is exclusion of advanced fibrosis or cirrhosis at the time of diagnosis, which may require a liver biopsy. Missing cirrhosis can lead to development of hepatocellular carcinoma or other complications which otherwise may be avoidable with early intervention.

Which one of the following medications would be most appropriate? - A: Imipramine - B: Clomipramine - C: Atomoxetine - D: Propranolol - E: Sertraline

= **E: Sertraline** - This patient's behaviour pattern is consistent with a diagnosis of obsessive compulsive disorder (OCD), which is characterised by features of a pattern of unwanted thoughts and fears (obsessions) that lead to repetitive behaviours (compulsions). These obsessions and compulsions can interfere with daily activities and cause significant distress. Specific therapy has been encouraged but refused by the patient, as Exposure Response Prevention therapy (used in cognitive behavioural therapy for OCD) is highly effective in OCD and has lasting benefits.

A 55-year-old woman presents to the Emergency Department with a three-day history of feeling unwell, and a four-hour history of severe chest pain, productive cough and shortness of breath. The chest pain is worse when leaning forward and coughing. She has no significant medical history and takes no regular medications. She has smoked a pack of cigarettes daily for 30 years. On examination, she appears unwell with a pulse rate of 101/min, blood pressure 89/58 mmHg, respiratory rate 28/min, SpO2 88% on room air, and temperature 39.3°C. There is dullness to percussion over the right lower lung field, with decreased breath sounds in this area. The white blood cell count is 18.0 x 109/L (3.6-11.0). A chest X-ray shows right lower lobe consolidation and collapse (Image 1-2). Broad spectrum antibiotics are given immediately. Which one of the following is the most appropriate next step in management? - A: Intravenous fluid resuscitation - B: Inhaled corticosteroids - C: Non-invasive positive pressure ventilation - D: Chest physiotherapy - E: Thoracocentesis

= **A: Intravenous fluid resuscitation** - This patient's presentation is consistent with severe community-acquired pneumonia, which may potentially be an exacerbation of undiagnosed COPD, based on the lung examination findings and the chest X-ray which demonstrate right lower lobe consolidation and collapse. The patient also appears to be septic, as demonstrated by the fever, elevated white cell count, underlying infection, tachycardia, and tachypnea. In such a case, the guideline-directed provision of antibiotics must be the initial management.

Which one of the following is the most accurate diagnostic test? - A: Lumbar puncture - B: CT brain - C: Fundoscopic exam - D: MRI brain - E: EEG

= **D: MRI Brain** - This child's presenting symptoms and signs are consistent with raised intracranial pressure secondary to an intracranial mass. The most accurate diagnostic test, as well as test for surgical planning, is an MRI brain with or without contrast. An MRI provides greater detail of soft tissue structures compared to other imaging modalities, especially for infratentorial lesions. The MRI scan would likely show a heterogeneous mass with irregular margins, possibly extending through the foramen of Luschka and Magendie, consistent with an ependymoma (Images 1-2). These are glial cell tumors commonly arising from the lining cells of the ventricular system in children.

Which one of the following ECG changes is most likely to be present? - A: Atrial fibrillation - B: S1Q3T3 pattern - C: Right axis deviation - D: Right bundle branch block - E: Sinus tachycardia

= **E: Sinus tachycardia** - The patient most likely has a pulmonary embolism (PE) originating from a deep vein thrombosis. The diagnosis is usually made with a CT pulmonary angiogram or less commonly a ventilation-perfusion scan. The most common ECG abnormality in PE is sinus tachycardia, seen in up to 44% of patients with a confirmed PE. Other ECG abnormalities may be suggestive, but the absence of ECG changes has no significant predictive value as approximately 25% of patients with confirmed PE have a normal ECG.

Which one of the following would be the most appropriate initial medication? - A: Clomipramine - B: Fluoxetine - C: Lamotrigine - D: Paroxetine - E: Olanzapine

= **B: Fluoxetine** - The patient has presented with signs and symptoms characteristic of obsessive-compulsive disorder (OCD). OCD is often a disabling condition consisting of repetitive intrusive thoughts or images (obsessions) that elicit anxiety and distress. To reduce this, the patient may employ rituals (compulsions). Cognitive behavioural therapy (CBT) with exposure and response prevention is the first line treatment for all ages. Medication is considered if CBT is unavailable, unacceptable to the patient, or ineffective. Although all the listed medications can be used for OCD, fluoxetine is the best and safest first-line option approved for treating OCD in this age group.

Which one of the following is the most likely diagnosis? - A: Hypothyroidism - B: Depression - C: Obstructive sleep apnoea - D: Migraine - E: Colorectal carcinoma

= **C: Obstructive sleep apnoea** - The clinical presentation fits with obstructive sleep apnoea (OSA). OSA can cause daytime fatigue, sleepiness, morning headaches and snoring. Obesity, increased neck circumference (>35 cm) and hypertension are significant risk factors for OSA. To further evaluate the patient, questionnaires can be completed (e.g. STOP-BANG score or Epworth Sleepiness Scale) and polysomnography (sleep study) arranged. The gold standard treatment for OSA is continuous positive airway pressure (CPAP). Oral appliances can also be considered.

Which one of the following is the most appropriate treatment? - A: Immune checkpoint modulation - B: Surgery followed by chemoradiation therapy - C: Surgical resection only - D: Palliative care - E: Radiation and chemotherapy

= **E: Radiation and chemotherapy** - The diagnosis in this patient is Cushing's syndrome caused by an ectopic small cell lung carcinoma. The presence of a lung mass, elevated cortisol which is not suppressed by exogenous dexamethasone (indicating an external source of cortisol secretion), and an elevated ACTH despite a normal pituitary MRI is suspicious for a paraneoplastic syndrome. The lung biopsy findings of tumour cells with small size, round-to-fusiform shape, scant cytoplasm, finely granular nuclear chromatin and absent or inconspicuous nucleoli meet the WHO criteria for small cell lung cancer.

Which one of the following is the most appropriate course of action? - A: Refer to the hospital's legal department - B: Certify the death - C: Refer the case to the coroner - D: Decline to certify the death and await consultant review - E: Arrange a multidisciplinary team meeting

= **C: Refer the case to the coroner** - The criteria for reporting to the coroner are unique to each state and territory in Australia. It is important that you are familiar with the reporting criteria in your jurisdiction. All states and territories in Australia have reporting criteria that would capture the circumstance described. Excerpted reporting criteria from each jurisdiction in Australia: Western Australia: the person died during or as a result of an anaesthetic. All jurisdictions also require that deaths are reported to the coroner when the cause of death is unclear. This is the case here. Failure to report a reportable death is punishable by large fines. In the Australian Capital Territory and South Australia it is possible to be sentenced to a term in prison.

Which one of the following is the most likely diagnosis? - A: Corticobasal syndrome - B: Dementia with Lewy bodies - C: Multiple system atrophy - D: Parkinson disease dementia - E: Alzheimer disease

= **D: Parkinson disease dementia** - The patient presents with symptoms and signs of parkinsonism (bradykinesia, rigidity, postural instability) and cognitive impairment (executive and visuospatial functions). This is suggestive of Parkinson disease dementia (PDD) or dementia with Lewy bodies (DLB). Both show notable overlap in their clinical, morphological, and pathogenic features. Their diagnosis is based on an arbitrary distinction between the time of onset of motor and cognitive symptoms, known as the 'one-year rule'; dementia preceding parkinsonism in DLB, while it develops after the onset of parkinsonism in PDD.

Which one of the following is the most important contraindication for renal transplantation in this patient? - A: Active uncontrolled infection - B: Age > 60 years - C: Poorly controlled hypertension - D: Active malignancy - E: BMI 35 kg/m2

= **A: Active uncontrolled infection** - Renal transplantation is a well-established treatment option for patients with end-stage renal disease. Although it provides numerous benefits, it also has many risks. Patients must undergo a thorough evaluation process to ensure that they are suitable candidates for transplantation. Active uncontrolled infection is a relative yet important contraindication because it can increase the risk of surgical site infection and may also worsen the function of the transplanted kidney. Even while this may be a mild infection, the immunosuppressive drugs required following an organ transplant increase the risk of severe infection. In this case, the patient has radiological evidence suggestive of underlying osteomyelitis, which would preclude transplantation if confirmed.

Which one of the following is the most likely diagnosis? - A: Chancroid - B: Herpes simplex - C: Human papillomavirus - D: Lymphogranuloma venereum - E: Syphilis

= **B: Herpes Simplex** - This presentation is consistent with herpes simplex. Multiple painful vesicular lesions of the genitals, particularly when preceded by characteristic paraesthesia, are typical of herpes simplex virus (HSV) infection. HSV is a sexually transmitted infection that has an incubation time of 3-7 days and the first outbreak is often associated with lymphadenopathy and systemic features, as in this case.

Which one of the following is the most likely trigger for this presentation? - A: Empagliflozin - B: Metformin - C: Paracetamol - D: Topical steroids - E: Oxymetholone

= **A. Empagliflozin** - The patient presented with nausea and abdominal pain on a background of known type 2 diabetes mellitus treated with metformin and empagliflozin.

Which one of the following is the most likely underlying cause of his current presentation? - A: Autoimmune haemolytic anaemia - B: Hereditary spherocytosis - C: G6PD deficiency - D: Sickle cell anaemia - E: Thalassaemia

= **C: G6PD deficiency** - This child most likely has G6PD deficiency. G6PD deficiency is an X-linked inherited disorder caused by a genetic defect in the red blood cell enzyme G6PD, which generates NADPH and protects red blood cells from oxidative injury. Individuals with G6PD deficiency have episodes of acute haemolysis in the setting of oxidant injury that can occur from use of certain medications (such as antimalarials like primaquine), acute illnesses or infections, and certain foods such as fava beans.

Which one of the following is the most likely diagnosis? - A: Sickle cell disease - B: Thalassaemia - C: Infectious mononucleosis - D: Vitamin B12 deficiency anaemia - E: Aplastic anaemia

= **B: Thalassaemia** - The symptoms of fatigue, shortness of breath, and pale appearance, along with the examination finding of splenomegaly and laboratory findings of microcytic anemia (low hemoglobin, low MCV, low MCH), reticulocytosis, and evidence of ineffective erythropoiesis on bone marrow biopsy, are most consistent with a diagnosis of thalassaemia. Thalassemia is an inherited blood disorder that affects the production of hemoglobin, resulting in fewer healthy red blood cells that have a shorter lifespan, leading to anemia and other symptoms. The patient's Mediterranean descent further supports this diagnosis, as thalassemia is more common in people of Mediterranean, Middle Eastern, and Asian ancestry.

Which one of the following is the most likely diagnosis? - A: Epiglottitis - B: Foreign body aspiration - C: Vocal cord paralysis - D: Acute extrinsic upper airway obstruction - E: Retropharyngeal abscess

= **D: Acute extrinsic upper airway obstruction** - The clinical scenario and examination findings are most suggestive of acute extrinsic upper airway obstruction, characterized by the collapse or narrowing of the larynx and trachea during inspiration due to weak cartilage. The history of an upper respiratory tract infection triggering her symptoms is consistent with this condition, as infections can exacerbate acute extrinsic upper airway obstruction. In this case, it is most likely due to extrinsic compression by an expanding goiter in the setting of non-compliance with antithyroid medication.

Which one of the following is the most appropriate in management? - A: Abdominoperineal resection + adjuvant chemotherapy - B: Short-course radiotherapy + resection + adjuvant chemotherapy - C: Transanal excision and surveillance - D: Low anterior resection and surveillance - E: Total neoadjuvant therapy (TNT)

= **E: Total neoadjuvant therapy (TNT)** has emerged as the preferred initial approach for locally advanced rectal carcinomas. It typically involves three stages: chemotherapy (induction - prior to chemoradiation or consolidation - after chemoradiotherapy), chemoradiation therapy and total mesorectal excision (TME). This approach would be suitable for the patient described in this scenario. TNT has gained favour in recent years due to its potential advantages over traditional approaches. These include improved tumour downsizing and downstaging, increased rates of pathologic complete response, and improved delivery and completion rate of systemic therapy. After TNT, patients may proceed to surgical resection or, in cases of complete clinical response, a 'wait and watch' approach may be adopted.

Which one of the following is the most appropriate next step in management? - A: Vaginal swabs for chlamydia and gonorrhoea - B: Kleihauer-Betke test - C: Complete blood count and iron studies - D: Digital vaginal examination - E: Ultrasound

= **E: Ultrasound** - The most common cause of painless vaginal bleeding in the third trimester is placenta praevia. Ultrasound is essential to assess fetal viability and locate the placenta. If the placenta is found to be covering the cervical os, placenta praevia is diagnosed. Placenta praevia is associated with an increased risk of postpartum haemorrhage and maternal iron deficiency anaemia.

Which one of the following is the most appropriate initial management? - A: Bladder lavage with cooled fluids - B: Cooled intravenous fluids - C: Cold water immersion - D: Gastric lavage with cooled fluids - E: Evaporative cooling

= **E: Evaporative cooling** - This patient presents with heatstroke, which is defined by a core body temperature greater than 40°C with associated central nervous system dysfunction. There are two forms of heatstroke: classic heatstroke, which typically affects older patients with chronic medical conditions; and exertional heatstroke, which affects healthy individuals engaging in strenuous physical activity or exposed to hot environmental conditions, as seen in this case. Early clinical features of heatstroke can include headache, muscle cramps, fatigue, dizziness, nausea and vomiting. As the condition progresses, end-organ damage may occur. Management of heatstroke focuses on early recognition, rapid cooling, and supportive care.

Which one of the following is the most likely diagnosis? - A: Bladder calculus - B: Phlebolith of the left common iliac vein - C: Small bowel carcinoid tumour - D: Gallstone ileus - E: Faecolith of the appendix

= **D: Gallstone ileus** - There is a calcified structure in the pelvis which is spherical and laminated. Whilst many structures in the pelvis can calcify, this pattern of calcification is characteristic of a gallstone. Taken together with the gas visible in the biliary tree (pneumobilia), and history and examination findings consistent with a small bowel obstruction (Rigler's triad) this adds up to a diagnosis of gallstone ileus.

Which one of the following is the most likely diagnosis? - A: Congestive cardiac failure - B: Pericarditis - C: Pericardial effusion - D: Acute coronary syndrome - E: Atrial fibrillation

= **B: Pericarditis** - The patient's presentation is most consistent with pericarditis. She has the classic features of pleuritic chest pain relieved by sitting forward, fever, and a pericardial friction rub on auscultation. The ECG shows diffuse ST segment elevation, which is the most common ECG finding in pericarditis. Importantly, there is no reciprocal ST depression, helping to distinguish it from acute coronary syndrome. While a pericardial effusion can occur as a complication of pericarditis, there are no signs of this yet, such as elevated JVP or muffled heart sounds. Pericardial effusions are more common after conditions that directly injure the myocardium, like myocardial infarction or cardiac surgery. The patient does not have the typical signs of congestive cardiac failure such as peripheral edema, ascites, or elevated JVP. Her presentation would be atypical for new onset heart failure. The ECG is not consistent with atrial fibrillation, which would show an irregularly irregular rhythm and absence of P waves. Atrial fibrillation also does not typically cause chest pain. Pericarditis classically presents with pleuritic chest pain that is relieved by sitting forward. The most common ECG finding in pericarditis is diffuse ST segment elevation without reciprocal ST depression A pericardial friction rub is often present on auscultation in pericarditis.

Which one of the following is the most appropriate electrolyte to administer at this stage? - A: Bicarbonate - B: Potassium - C: Magnesium - D: Calcium - E: Phosphate

= **B: Potassium** - his patient is presenting with diabetic ketoacidosis (DKA), likely triggered by infection. The criteria for DKA are hyperglycaemia, metabolic acidosis, and the presence of ketones, which are all present in this case. The management of DKA involves aggressive rehydration with IV fluids (normal saline), an IV insulin infusion (which involves giving IV insulin either with normal saline or dextrose - choice is dependent on BGL levels), maintaining normal potassium levels, and treating the precipitant.

Which one of the following is the most likely diagnosis? - A: Gestational diabetes mellitus - B: Diabetes in pregnancy - C: Type 1 diabetes mellitus - D: Type 2 diabetes mellitus - E: Pregestational diabetes

= **A: Gestational diabetes mellitus** - This patient has gestational diabetes mellitus (GDM). Routine testing for GDM using the oral glucose tolerance test (OGTT) is recommended for all women at 24-28 weeks gestation. A diagnosis of GDM is made based on the 75 g OGTT with one or more of the following values: fasting plasma glucose ≥5.1 mmol/L, 1-hour post 75 g oral glucose load ≥10.0 mmol/L, 2-hour post 75 g oral glucose load ≥8.5 mmol/L. In this case, the patient's fasting plasma glucose of 6.4 mmol/L exceeds the threshold, confirming the diagnosis of GDM. GDM occurs due to the insulin-antagonising effects of pregnancy hormones, particularly human placental lactogen, cortisol, and progesterone. These hormones cause insulin resistance, which can lead to hyperglycaemia if the pancreas cannot produce enough insulin to compensate.

A seven-year-old girl presents to the General Practice clinic with her mother with a three-day history of painless small lumps over her neck and arms associated with itching. The lumps have increased in number since they first appeared. She has no significant medical history, takes no regular medications and is up to date with all her vaccinations. On examination, she appears well with a temperature of 37.0°C, pulse rate 110/min, respiratory rate 20/min, blood pressure 100/60 mmHg, and SpO2 99% on room air. Skin examination reveals a collection of pearly-white dome-shaped umbilicated painless lesions with a central punctum. Which one of the following is the most likely diagnosis? - A: Chickenpox - B: Herpes simplex - C: Molluscum contagiosum - D: Viral warts - E: Milia

= **C: Molluscum contagiosum** - The clinical presentation is consistent with molluscum contagiosum. Molluscum contagiosum is a viral infection caused by a pox virus. It is contagious, found commonly in children, and often spread by direct skin-to-skin contact or by sharing clothes, towels etc. It characteristically presents with painless pearly-white dome-shaped lesions with an umbilicated centre.

Which one of the following is the most likely underlying cause of this clinical syndrome? - A: Non-small cell lung cancer - B: Small cell lung cancer - C: Breast cancer - D: Non-Hodgkin lymphoma - E: Colon cancer

= **C: Breast Cancer** - The clinical presentation of subacute cerebellar ataxia in a middle-aged woman, along with bilateral cerebellar atrophy on MRI and positive anti-Yo antibodies, is highly suggestive of paraneoplastic cerebellar degeneration (PCD). Breast cancer is the most common malignancy associated with anti-Yo positive PCD, accounting for over half of cases. Gynecologic cancers, especially ovarian, are the next most common.

Which one of the following ankle brachial index (ABI) values is most likely to be obtained in the right leg? - A: 0.1 - B: 0.3 - C: 0.7 - D: 0.95 - E: 1.4

= **C: 0.7** - The symptoms this patient describes are those of intermittent claudication. ABIs <0.5 (e.g. 0.1 and 0.3) would be suggestive of critical limb ischaemia - and in this case the patient's symptoms are not suggestive of such a diagnosis. - Values in the range of 0.50 to 0.80 (e.g. 0.7) indicate non-critical limb ischaemia due to intermittent claudication as is evident from this patient's presentation. - Values >0.95 would be normal and those >1.3 (e.g. 1.4) would indicate arterial calcification due to diabetes, which this patient does not suffer from. - Measurement of the ankle-brachial index helps determine the severity of peripheral limb ischaemia.

Which one of the following is the most appropriate next step in management? - A: Sertraline - B: Propranolol - C: Electroconvulsive therapy - D: Quetiapine - E: Cognitive behavioural therapy

= **E: Cognitive behavioural therapy**. - The patient in the stem is suffering from panic disorder, a condition which affects approximately 2-3% of the world's population and is three times more common in women. It is characterised by recurrent panic attacks with no associated trigger, although over time panic may be triggered by people, places and situations that have previously been associated with spontaneous attacks. CBT is first-line treatment for panic disorder. It is targeted towards challenging misattributions about the physiological symptoms of panic and establishing strategies to manage them.

Which one of the following is the most appropriate next investigation? - A: Serum angiotensin-converting enzyme - B: Serum parathyroid hormone - C: Serum prostate-specific antigen - D: Serum protein electrophoresis - E: Serum vitamin D

= **D: Serum protein electrophoresis** - The patient is suffering from multiple myeloma, which is a clonal plasma cell proliferative disorder characterized by the abnormal increase of monoclonal immunoglobulins. Calcium elevation, renal dysfunction, anemia, and bone disease (CRAB criteria) are usually seen in multiple myeloma. Serum protein electrophoresis is used to identify patients with multiple myeloma and other serum protein disorders. Electrophoresis separates proteins based on their physical properties, and the subsets of these proteins are used in interpreting the results. A homogeneous spike-like peak in a focal region of the gamma-globulin zone indicates a monoclonal gammopathy. Monoclonal gammopathies are associated with a clonal process that is malignant or potentially malignant, including multiple myeloma, Waldenström's macroglobulinemia, solitary plasmacytoma, smoldering multiple myeloma, monoclonal gammopathy of undetermined significance, plasma cell leukemia, heavy chain disease, and amyloidosis. The quantity of M protein, the results of bone marrow biopsy, and other characteristics can help differentiate multiple myeloma from the other causes of monoclonal gammopathy.

Which one of the following is the most likely diagnosis? - A: Hydatid cyst - B: Metastatic melanoma - C: Astrocytoma - D: Meningioma - E: Glioblastoma

= **D: Meningioma** - This patient's presentation is suggestive of an intracranial space-occupying lesion, with symptoms including headache, unilateral weakness, and papilledema. While all the options listed are potential intracranial lesions, meningiomas are the most common primary brain tumour in adults, accounting for over a third of cases. They are typically slow-growing, benign tumours that arise from the meninges, which aligns with the gradual onset of this patient's symptoms over several months to years.

Which one of the following is the most likely diagnosis? - A: Schizophreniform disorder - B: Schizoaffective disorder - C: Schizophrenia - D: Delusional disorder - E: Post-traumatic stress disorder

= **C: Schizophrenia** - The patient exhibits many symptoms, historical features and signs of schizophrenia, which is a psychotic disorder. The patient is a young adult who went through a major stressor in his life (loss of his mother). Schizophrenia may present after a major stressor in life like moving out from home, separation of parents, breakups, etc. He has persecutory delusions (staff trying to kill him) and auditory hallucinations (mysterious voice), and signs of disorganisation (faeces and urine in the room), these all are the positive symptoms of schizophrenia. Blunted affect during the interview is a negative symptom of schizophrenia and the presence of these positive and negative symptoms for more than six months without major disturbance of mood and in the absence of substance use makes the diagnosis of schizophrenia most likely. One would need to exclude organic causes of these symptoms to confirm the diagnosis.

Which one of the following is the most likely cause of the patient's deterioration? - A: Sepsis - B: Transfusion associated circulatory overload (TACO) - C: Transfusion related acute lung injury (TRALI) - D: Acute myocardial infarction (AMI) - E: Haemolytic transfusion reaction

= **B: Transfusion related acute lung injury (TRALI)** - The patient in the stem is suffering from transfusion related acute lung injury (TRALI). This diagnosis should always be considered in any patient developing hypoxia and pulmonary oedema within a few hours of transfusion of any blood product containing plasma or plasma derivative. The pathophysiology is believed to be secondary to activation of recipient leucocytes by donor anti-leucocyte antibodies and usually occurs within the first six hours following a transfusion of plasma containing blood products.

Which one of the following is the most appropriate next step in management? - A: Mesalamine - B: Prednisolone - C: Low-FODMAP diet - D: Metronidazole - E: Watchful waiting

= **C: Low-FODMAP diet** - Based on the clinical presentation and normal laboratory values, the most likely diagnosis in this patient is irritable bowel syndrome, which is a diagnosis of exclusion. The patient meets the ROME IV diagnostic criteria for IBS, which includes recurrent abdominal pain on average at least one day per week in the previous three months, associated with two or more of the following criteria: 1) related to defecation, 2) associated with a change in frequency of stool, and 3) associated with a change in form (appearance) of stool.

Which one of the following is the most appropriate next step in assessment? - A: Creatine kinase (CK) estimation - B: Passive stretching of calf muscles - C: Pulse oximetry of toes - D: Urine test for myoglobinuria - E: Venous doppler ultrasonography

= **B: Passive stretching of calf muscles** - Acute compartment syndrome is diagnosed on a clinical basis. Passive stretching of calf muscles is a key clinical maneouvre in diagnosing compartment syndrome. If pain is elicited, this is an almost certain diagnostic sign and no further investigations are required; the next step is emergency fasciotomy. In compartment syndrome, the affected muscle compartments become swollen and pressure builds up within the closed space, leading to ischaemia and pain. Passive stretching of the affected muscles exacerbates the pain due to increased pressure within the compartment. Therefore the presence of severe pain on passive stretching is a hallmark sign of compartment syndrome.

Which one of the following is the most likely diagnosis? - A: Osteomyelitis - B: Slipped capital femoral epiphysis - C: Transient synovitis - D: Septic arthritis - E: Legg-Calve-Perthes disease

Transient synovitis is a common cause of hip pain in children between three and 10 years of age. The hallmark symptoms include hip pain, decreased hip range of motion (particularly internal rotation), and a limp. Children with transient synovitis may also have a low-grade fever. The exact cause is not always clear, but it is thought to be triggered by a viral infection, trauma to the joint, or an autoimmune reaction. On examination, there may be tenderness over the affected hip. Ultrasound may detect a joint effusion. Transient synovitis is typically self-limiting and resolves on its own within a few days to a week. Simple analgesia such as paracetamol and short-term NSAIDs can be used for symptomatic relief.

Which one of the following is the most likely cause of his presentation? - A: Post infectious glomerulonephritis - B: IgA nephropathy - C: Henoch-Schönlein purpura - D: Carcinoma of the bladder - E: Urinary tract infection

= **A: Post infectious glomerulonephritis** - In considering haematuria, a classification into pre-renal, intra-renal and post-renal (obstructive) causes can be helpful. In the given scenario, the clinical presentation of gross haematuria, ankle swelling and severe hypertension, preceded by a unilateral well-demarcated red rash, is most suggestive of post infectious glomerulonephritis (PIGN) preceded by cellulitis. Group A streptococcus is one of the most common causes of cellulitis. PIGN is an immune-mediated condition, which is fairly common among the indigenous population, and is more often seen in males rather than females. It typically occurs in children between the ages of two and 12.

A 76-year-old woman presents to her General Practice clinic with a six-week history of a rapidly growing lesion on her right cheek. It is slightly painful and tender to touch. She has no other visible lesions. She has no significant medical history and does not take any regular medications. On examination, she appears well with a pulse rate of 72/min, blood pressure 130/85 mmHg, respiratory rate 14/min, SpO2 98% on room air, and temperature 36.8°C. The lesion on her right cheek is a 1.5 cm dome-shaped nodule with a central keratin-filled crater. Which one of the following would be the most likely finding if the lesion was left untreated and reviewed again in four months? - A: Involution - B: Increase in size - C: Nodal metastases in the neck - D: Distant metastases - E: Satellite lesions

= **A: Involution** - The rapid growth and physical characteristics of this lesion are most suggestive of a keratoacanthoma. Keratoacanthomas are a form of well-differentiated squamous cell carcinoma with a self-limiting nature. They have a dome-shape with a central keratin crater and progress through three phases: proliferation, maturation, and involution.

Which one of the following is the most likely diagnosis? - A: Schizoid personality disorder - B: Antisocial personality disorder - C: Schizophrenia - D: Avoidant personality disorder - E: Paranoid personality disorder

= **A: Schizoid personality disorder** - The age of the patient and her symptoms are suggestive of schizoid personality disorder, a personality disorder common in late childhood and early adolescence. The patient neither desires nor enjoys close relationships, likes solitary activities, lacks close friends, appears indifferent to the praise or criticism of others, and shows emotional coldness, detachment, or flattened affectivity. A closer examination might be needed to rule out autism spectrum disorder. Adolescents with schizoid personality may actually have the prodromal phase of schizophrenia, so monitoring for early psychotic symptoms over time can help differentiate.

A 77-year-old man presents to the General Practice clinic for a pre-operative assessment. He is scheduled for surgical repair of a large para-oesophageal hernia causing iron-deficiency anaemia secondary to Cameron's ulcers. He has a medical history of a myocardial infarction two years ago, with insertion of two drug-eluting coronary artery stents. His medications are clopidogrel and aspirin. On examination, he appears well with vital signs within normal limits. Which one of the following is the most appropriate plan for his antiplatelet medications prior to surgery? - A: Cease aspirin only - B: Cease both clopidogrel and aspirin - C: Proceed to surgery on the current medications - D: Stop both medications and start enoxaparin - E: Cease clopidogrel only

= **E: Cease clopidogrel only** - This patient requires surgical repair of a para-oesophageal hernia to allow healing of the traumatic Cameron's ulcers, which are the cause of his iron-deficiency anaemia. Proton pump inhibitors are unlikely to be effective as the ulcers are not primarily due to acid hypersecretion.

Which one of the following types of hearing loss does this patient most likely have? - A: Sensorineural hearing loss in left ear - B: Bilateral conductive hearing loss - C: Conductive hearing loss in the left ear - D: Conductive hearing loss in right ear - E: Bilateral sensorineural hearing loss, worse in the right ear

= **E: Bilateral sensorineural hearing loss, worse in the right ear** - The results of the Weber and Rinne tests indicate hearing loss is present. The Weber test lateralising to the left ear suggests the left ear has better hearing than the right. Positive Rinne tests bilaterally indicate air conduction is better than bone conduction in both ears, consistent with sensorineural rather than conductive hearing loss. Taken together with the history of worsening hearing and occupational noise exposure, the most likely diagnosis is bilateral sensorineural hearing loss, worse in the right ear.

Which one of the following is the most appropriate management? - A: Inhaled ipratropium bromide - B: Inhaled beclomethasone every morning - C: Reassurance - D: Inhaled salbutamol as needed - E: Inhaled salmeterol every morning

= **D: Inhaled salbutamol as needed** - This patient presents with classic symptoms of exercise-induced bronchoconstriction. Her symptoms occur only during physical activity and resolve with rest, which is characteristic of this condition. Inhaled salbutamol as needed is the most appropriate initial management for exercise-induced bronchoconstriction. Short-acting beta-agonists like salbutamol provide rapid bronchodilation and can be used prophylactically before exercise to prevent symptoms in patients with mild, intermittent exercise-induced bronchoconstriction. The patient should be instructed to use the inhaler 15-30 minutes before exercise.

Which one of the following is the most likely diagnosis? - A: Exercise-induced asthma - B: Pulmonary embolism - C: Spontaneous pneumothorax - D: Costochondritis - E: Pericarditis

= **C: Spontaneous pneumothorax** - This patient's presentation is most consistent with a spontaneous pneumothorax. He fits the classic demographic, being a young tall thin male. Pneumothorax typically presents with sudden onset pleuritic chest pain and shortness of breath. The key examination findings of reduced chest expansion, hyper-resonance to percussion, and reduced breath sounds on the affected side strongly point towards this diagnosis in this clinical context.

Which one of the following is the most likely diagnosis? - A: Benign paroxysmal positional vertigo - B: Cerebellar stroke - C: Orthostatic hypotension - D: Normal pressure hydrocephalus - E: Peripheral neuropathy

= **D: Normal pressure hydrocephalus** - Normal pressure hydrocephalus is characterised by the classic triad of magnetic or apraxic gait disturbance, urinary incontinence, and dementia. This patient's progressive unsteady gait with a tendency to veer to one side is consistent with the gait disturbance seen in NPH. Normal pressure hydrocephalus is caused by impaired absorption of cerebrospinal fluid, leading to enlarged ventricles and increased intracranial pressure despite a normal lumbar puncture opening pressure. Further evaluation with brain imaging and possibly cerebrospinal fluid studies would be necessary to confirm the diagnosis.

Which one of the following is the most appropriate first-line analgesic option? - A: Fentanyl patch 25 mcg/hr - B: Hydromorphone 4 mg SC PRN Q2h - C: Ibuprofen 400 mg PO TDS - D: Morphine 1 mg SC QID - E: Morphine 2-5 mg PO PRN Q2h

= **E: Morphine 2-5 mg PO PRN Q2h** - Morphine is the first-line opioid to consider for pain control in opioid-naïve palliative care patients. The oral dose range of 2-5 mg PRN allows titration to effect. Opioids are generally started as needed, with these doses used as a baseline for sustained-release formulations if required.

A 22-year-old man presents to the Emergency Department with a two-hour history of right shoulder pain and limited movement after a football injury. He has no significant medical history, including no previous shoulder injuries, and does not take any regular medications. On examination, he appears well with a pulse rate of 88/min, blood pressure 128/76 mmHg, respiratory rate 16/min, SpO2 99% on room air, and temperature 36.8°C. There is tenderness over the right shoulder, and he cannot abduct or rotate his arm. He has an apparent deformity in the region of his right shoulder. Which one of the following is the most appropriate next step in management? - A: Intra-articular lignocaine injection - B: Closed reduction - C: X-ray of right shoulder - D: Open Latarjet procedure - E: Arthroscopic Bankart repair

= **C: X-ray of right shoulder** - Based on the provided information and image, the most likely diagnosis for this 22-year-old man with pain, limited movement, tenderness, and a deformity in the region of his right shoulder after an injury is glenohumeral dislocation. The acromion appears prominent, further pointing towards an anterior glenohumeral dislocation. It refers to the dislocation of the ball-and-socket joint formed by the humerus and the glenoid fossa of the scapula. It commonly occurs due to trauma, such as a fall or forceful impact.

A 37-year-old man presents to the ophthalmology clinic with a few months history of a lump on his right eye. It occasionally causes mild itching and a gritty sensation, but no pain, lacrimation, discharge or redness. He has no history of allergies. His medical history is unremarkable and he takes no regular medications. He works as a security guard on a building site, which is a dusty environment with prolonged sun exposure. On examination, a lesion on his right eye is visible (Image). Visual acuity is 6/6 in both eyes. The remainder of the eye examination is normal. Which one of the following is the most likely diagnosis? - A: Pinguecula - B: Limbal dermoid - C: Phlyctenular conjunctivitis - D: Corneal intraepithelial neoplasia - E: Nodular scleritis

= **A: Pinguecula** - The image shows a yellowish-white, slightly elevated, avascular mass on the nasal conjunctiva near the cornea of the right eye. This is characteristic of a pinguecula. Pingueculae are benign, non-cancerous growths that develop on the conjunctiva, usually on the nasal side. They are avascular and do not involve the cornea. Pingueculae can occur at any age but are most common in middle-aged and older people. The degenerative changes leading to pingueculae are related to chronic sun exposure, which damages the abundant elastin fibers in the conjunctiva. High exposure to dryness, dust, and wind are additional risk factors, consistent with this patient's occupational history. Pingueculae are usually asymptomatic but can occasionally cause mild irritation, itching, or a foreign body sensation as described. Overall, they are an extremely common and essentially normal finding in older adults.

A 25-year-old woman presents to the General Practice clinic with a two-week history of itchy lumps in her genital region. Three months ago she started a new relationship with someone who had several previous sexual partners. She has no significant medical history and does not take any regular medications. On examination, she appears well with vital signs within normal limits. There are multiple, smooth nodules of varying diameter on her vulva (Image). The lesions are not tender to palpation. The remainder of the physical examination is unremarkable. Which one of the following is the most likely diagnosis? - A: Anogenital warts - B: Herpes simplex - C: Mpox (monkeypox) - D: Condylomata lata - E: Herpes vegetans

= **D: Condylomata lata** - The vulval lesions present in this patient are those of condylomata lata, which are painless, smooth nodules with a moist surface and which are usually covered with a whitish exudate. These lesions are characteristic of secondary syphilis. Whilst most patients have systemic manifestations during the secondary stage of syphilis infection, these symptoms and signs may not always be apparent and sometimes the associated rash can be so faint it is not noticed.

A 72-year-old woman presents with fatigue for the past year. This is accompanied with difficulty sleeping due to night sweats and lower back pain. She also mentioned that she has been constipated for the past few months, only passing stools once every five days. Physical examination reveals pallor of the conjunctivae. Her lumbar spine is tender upon palpation, with limited flexion and extension due to the pain. Complete blood examination shows normochromic normocytic anaemia and a platelet count of 110x10^9/L. Biochemistry test demonstrates elevated calcium of 3.4 mmol/L with a low parathyroid hormone level. Urine dipstick is positive for protein. Which one of the following is the most urgent investigation? - A: Serum protein electrophoresis for monoclonal paraprotein - B: Kidney ultrasound - C: Iron studies - D: (99m)Tc sestamibi scintigraphy - E: Bone marrow biopsy

= **A: Serum protein electrophoresis for monoclonal paraprotein** - The most concerning diagnosis is multiple myeloma, with the major differential being a non-haematological metastatic cancer. Symptoms of multiple myeloma can be remembered using the acronym CRAB - Calcium elevation, Renal dysfunction, Anaemia, and Bone disease. However, it is important to note that initial presentation of multiple myeloma can vary in different patients. The most common presenting symptom of multiple myeloma is anaemia, with patients presenting with fatigue and shortness of breath upon exertion. Back pain is also a common presentation, reported in more than 50% of patients. Lytic lesions may also be present on X-ray films. Renal dysfunction due to multiple myeloma leads to the kidney's inability to clear excess calcium, increasing the serum calcium levels subsequently.

A 28-year-old woman is brought in by ambulance to the Emergency Department with a reduced level of consciousness following suspected polypharmacy overdose. The ambulance officers have brought in a number of opened medication containers they found beside the patient. She has an extensive mental health history. As part of her initial workup, an ECG is performed. Which one of the following medications has the closest association with the changes shown on the ECG? - A: Valproate - B: Propranolol - C: Diazepam - D: Quetiapine - E: Paracetamol

= D: Quetiapine

A 73-year-old woman is brought into the Emergency Department with a 24 hour history of increasing, generalised abdominal pain. The pain is constant and she has never had anything like this before. She has not had any abdominal surgery and her only medical history of note is atrial fibrillation, for which she in on warfarin. On examination her blood pressure is 100/70 mmHg, pulse rate 100/min and temperature 37.2C. There is widespread abdominal tenderness and a plain abdominal X-ray shows gas in the portal venous system. Which one of the following is the most likely underlying pathological process? - A: Diverticulitis - B: Necrotising pancreatitis - C: Retroperitoneal haemorrhage - D: Mesenteric ischaemia - E; Perforated appendicitis

= D; Mesenteric ischaemia

A 14-year-old girl presents concerned that her periods have not started yet. She is accompanied by her mother, because the girl is known to have an intellectual disability. On examination she has webbing of the neck, a broad chest, and a short stature. Which one of the following is the most likely underlying genetic abnormality? - A: Trisomy 21 - B: Trisomy 18 - C: 45, XO - D: 15q21.1 mutation - E; 22q11.2 deletion

= **C: 45, XO** (Turner Syndrome) - This girl is suffering from a chromosomal condition called Turner syndrome, characterised by the karyotype of 45, XO (partly or completely missing an X-chromosome). This results in impaired ovarian development, leading to deficiencies in oestrogen and progesterone secretion. They have a female phenotype. They often present with symptoms of primary ovarian insufficiency with delayed puberty, primary amenorrhoea and infertility. This is due to “streak gonads” - where their ovaries mainly consisting of connective tissue.

Which one of the following substances may be responsible for his symptoms? - A: St. John’s Wort - B: Alcohol - C: Haloperidol - D: Amiodarone - E: Phenytoin

= **A: St John's Wort** - This man’s symptoms are consistent with serotonin syndrome. Serotonin syndrome is a life-threatening drug-induced complication associated with increased serotonergic activity in both the peripheral and central nervous systems. Findings of serotonin syndrome include neuromuscular changes (rigidity, hyperreflexia, tremor, myoclonus), autonomic hyperactivity (diaphoresis, hyperthermia, vomiting) and mental state changes.

Which one of the following structures is most likely involved in this presentation? - A: Appendix - B: Round ligament - C: Infundibulopelvic ligament - D: Fallopian tube - E: Ovarian ligament

= **C: Infundibulopelvic ligament** - This is a case of ovarian torsion - a gynaecological emergency in a woman of reproductive age. Whilst all structures listed can be involved, the most likely structure involved is the infundibular pelvic ligament as the ovary has twists on the ovarian cyst (the cyst is the Lynch point) and then the IP has twists on itself. The infundibulopelvic (IP) ligament (suspensory ligament) runs from the pelvic side wall to the ovary. It is mobile and contains the ovarian artery, vein and lymphatic vessels. In ovarian torsion involving the IP ligament, blood flow and lymphatic drainage is obstructed causing ischaemia and pain. The incidence of ovarian torsion is approximately 2-15% in reproductive aged women with 80% of cases involving an ovarian cyst >5cm. A high index of clinical suspicion is important and pelvic ultrasound, when readily available, is often used to aid in diagnosis. It is important to avoid prolonged delay and irreversible ovarian ischaemia.

A 7-year-old boy presents with a one-day history of right ear discharge. This was preceded by nasal congestion, rhinorrhoea, mild febrile illness and significant ear pain. The pain improved last night and the boy noted ear discharge. He is currently afebrile, appears well, and there is purulent discharge from the right ear canal. The left tympanic membrane appears erythematous but mobile with no effusion. His Weber test lateralises to his right ear, Rinne is abnormal on the right and normal on the left. In addition to simple analgesia, which one of the following is the most appropriate treatment? - A: Oral amoxicillin and further review - B: Amoxicillin and clavulanic acid and further review - C: Ear toilet and further review - D: Ear toilet, Ciprofloxacin ear drops, and further review - E: Systemic amoxicillin, ear toilet and admission

= **D: Ear toilet, Ciprofloxacin ear drops, and further review** - Otitis media involves infection of the middle ear by pathogens ranging from viruses to various bacteria, most commonly Streptococcus pneumoniae, Haemophilus influenzae and Moraxella catarrhalis. Otitis media most commonly presents in younger children with fever and ear pain manifested by grasping of the ear. It can follow an upper respiratory tract infection and the build up of purulent fluid can lead to conductive hearing loss of the affected ear. When there is a spontaneous resolution of otalgia followed by release of purulent fluid, a tympanic membrane perforation must be suspected.

Which one of the following is the most appropriate diagnostic investigation? - A: Nasopharyngeal viral PCR - B: Chest X-ray - C: D-dimer - D: V/Q scan - E: CT pulmonary angiogram

= E: CT pulmonary angiogram - Selecting the most appropriate investigation requires identifying the most likely differential diagnosis, which in this case is a pulmonary embolism (PE). The patient's symptoms, along with the patient's recent COVID infection make this the most likely diagnosis. Risk of a PE is increased in people who have had COVID for up to 6 months post infection. This patient's other risk factor is that she take the combined oral contraceptive pill. Even without applying the Well's criteria, this patient is at significant risk of having a PE.

A 26-year-old man presents to his general practitioner with a two day history of dark red urine. He has also had a sore throat, runny nose and non-productive cough for the last three days. He has had a few similar episodes over the past few years, with the most recent episode occurring last winter and resolving spontaneously. His blood pressure is 160/105 mmHg, pulse 90/min and temperature 37.2oC. Urinalysis reveals 3+ blood and 1+ protein. Which one of the following is the most likely diagnosis? - A: Henoch-Schonlein purpura - B: IgA nephropathy - C: Post-streptococcal glomerulonephritis - D: Goodpasture's syndrome - E; Alport syndrome

= B: IgA nephropathy

A 62-year-old woman presents to the Emergency Department with a 24 hour history of worsening colicky abdominal pain. During this time she has had minimal food intake due to nausea and one episode of a bilious vomit shortly before her presentation. Her last bowel movement was yesterday and she is unsure if she has passed any gas. Her medical history includes treatment for hypothyroidism (levothyroxine) and a hysterectomy 10 years ago. On examination she appears to be in obvious discomfort with a greatly distended abdomen. The abdomen is diffusely tender on light palpation and bowel sounds are reduced. An abdominal X-ray is performed. Which one of the following is the most likely diagnosis? - A: Gastric outlet obstruction - B: Small bowel obstruction - C: Large bowel obstruction - D: Caecal volvulus - E: Sigmoid volvulus

= **D: Caecal volvulus** - This patient's clinical picture is consistent with intestinal obstruction. A history of abdominal surgery is often associated with small bowel adhesive-obstruction. The key to the diagnosis is interpreting the gas patterns seen on the X-ray. This patient has a caecal volvulus. The X-ray shows the characteristic 'comma' shaped caecum seen in caecal volvulus which is displaced superiorly and medially from its normal anatomical position. There are visible plicae circularis/haustra on the dilated bowel, unlike the appearance of a sigmoid volvulus.

A 26-year-old man presents to the General Practice clinic with concerns regarding his nails. He reports that this condition has gradually developed over the course of several months and affects a number of his fingernails. His nails are not particularly itchy or painful. He has no significant medical history and does not take any regular medications. He reports that he is a vegetarian. On examination, he appears well with vital signs within normal limits. Inspection of his nails reveals thickening and distal separation of the nail plate from the nail bed. Which one of the following is the most likely diagnosis? - A: Subungual melanoma - B: Onychogryphosis - C: Onychomycosis - D: Koilonychia - E: Psoriatic nail changes

= **C: Onychomycosis** - The image shows nail thickening (hyperkeratosis) and distal onycholysis, which are classic features of onychomycosis. Onychomycosis is a chronic fungal nail infection that can affect both fingernails and toenails. It is most commonly caused by dermatophytes, particularly Trichophyton rubrum and T. interdigitale, but can also be caused by yeasts such as Candida albicans or molds. The condition typically develops gradually over months, as seen in this patient. Subungual melanoma usually presents as a pigmented band in the nail that becomes wider over time. It would be an unlikely diagnosis given the multiple nail involvement and lack of pigmentation described in this case.

A 72-year-old woman presents with a two-day history of increasing crampy and generalised abdominal pain. This is associated with nausea, abdominal distension and constipation. Her medical history includes an hysterectomy. Her abdomen is distended and soft. On auscultation, increased and high-pitched bowel sounds are audible. Some faecal pellets are felt on rectal examination. A plain X-ray is performed. Which one of the following is the most likely diagnosis? - A: Adhesive-obstruction - B: Gallstone ileus - C: Pseudo-obstruction - D: Appendicitis - E; Renal colic

= B: Gallstone ileus

A 42-year-old man presents to the Emergency Department with a two-hour history of increasing chest pain which radiates into his neck. The pain came on after an evening spent with his friends, eating pizza, drinking, and snorting cocaine. He has not had any nausea or vomiting but indicated that he felt like coughing after his cocaine use. He does not report any other health issues and is not on any medications. He does not have any allergies. On examination, his blood pressure is 100/72 mmHg, pulse 104/min, temperature 37.2oC, respiratory rate 24/min, and pO2 of 96% on room air. Precordial examination reveals systolic crepitations and reduced heart sounds. There were no palpable masses and no signs of airway compromise. An ECG is unremarkable, and a chest X-ray is performed. Which one of the following is the most likely diagnosis? - A: Left-sided pneumothorax - B: Right-sided pneumothorax - C: Pulmonary embolism - D: Pneumomediastinum - E: Cocaine-induced myocarditis

= **D: Pneumomediastinum** - This patient presents with a recent history of chest pain which radiates into his neck, mild hypotension, tachypnoea, and tachycardia on a background of drug use. Exam findings also reveal the ‘Hamman sign’ which is an auscultatory finding associated with mediastinal emphysema. This clinical picture is suggestive of a diagnosis of pneumomediastinum. The diagnosis is confirmed by the presence of radiolucent streaks in the mediastinum and free air tracking along with normal anatomic structures and extending into the neck. Both spontaneous pneumothorax and pneumomediastinum have been identified in users of cocaine (both intranasal users and smokers). This kind of barotrauma is theorized to be the result of habitual practices like performing a Valsalva manoeuvre after inhalation or forcefully exhaling forcefully into each other's mouths paired with inflammation and fibrotic parenchymal changes which result from routine drug use.

Which one of the following is the most appropriate next step in management? - A: Oral antibiotics and review in outpatient clinic - B: Intravenous antibiotics and gut rest - C: Colonoscopy - D: Laparoscopy and peritoneal washout - E: Analgesia and review in clinic in four day's time

= **A: Oral antibiotics and review in outpatient clinic** - This patient has uncomplicated or simple diverticulitis. This term describes inflammation without any evidence of a complication such as abscess, stricture, fistula or perforation. Some 75% of cases of diverticulitis are uncomplicated. In most circumstances such a patient can be managed at home. Whether or not he needs antibiotics is debatable and in most low risk cases are not necessary. Current guidelines recommend a clear liquid diet and antibiotics on a selective case-by-case basis. Antibiotics would be appropriate for patients with substantial co-morbidities, signs of systemic infection, or immunosuppression.

Which of the following is the most appropriate investigation to assist with diagnosis? - A: ECG - B: High-sensitivity troponin - C: Anti-streptolysin O titre - D: Blood culture - E: Pericardiocentesis

= C: This patient most likely has rheumatic fever given his joint pain, soft nodules in his elbows, rash, early diastolic murmur indicating aortic regurgitation, and recent upper respiratory infection. Anti-streptolysin O titre is a blood test that is useful in recognising recent infection with Streptococcus Pyogenes, the bacteria that precedes rheumatic fever, thus, is very useful in the diagnosis of rheumatic fever.

Which one of the following is the most appropriate plan of management? - A: No follow-up required - B: Endoscopic re-assessment in one week - C: Endoscopy and re-biopsy of the ulcer in two weeks - D: Helicobacter pylori serology at four weeks - E: Urea breath test or H.pylori stool antigen at six weeks

= E: Urea breath test or H.pylori stool antigen at six weeks

Which one of the following structures is most likely to be involved? - A: Vertebrobasilar artery - B: Right anterior cerebral artery - C: Left anterior cerebral artery - D: Right middle cerebral artery - E: Left middle cerebral artery

= **E: Left middle cerebral artery** - In this case scenario, the patient’s stroke may be secondary to a new onset atrial fibrillation given the irregular pulse, but further investigations such as an ECG will be required to confirm the diagnosis. The clinical picture presented by this patient suggests a cerebrovascular event. Her right-sided upper limb and facial hemiparesis suggests left brain involvement, given that the left hemisphere controls right-sided movement, and vice versa. The expressive aphasia suggests involvement of the dominant hemisphere of the brain, which is responsible for speech and language. Most individuals are left brain dominant irrespective of their handedness.

Given the most likely diagnosis, which one of the following medications is most suitable? - A: Haloperidol - B: Aripiprazole - C: Zuclopenthixol - D: Clozapine - E: Sodium valproate

= B: **Aripiprazole** - This patient appears to be suffering first episode psychosis (FEP). The definitive diagnosis may not be clear at this point in time, however a primary psychosis (e.g. schizophreniform disorder) seems more likely than psychosis related to drugs or organic illness. Intervention is therefore warranted and in young people with FEP, pharmacotherapy is first-line (following a 24-48hr period of observation and assessment).

A 35-year-old woman presents with a painless lump in her neck (Image). She is unsure of the timeframe of the lump but first noticed it several months ago. Over this period it has not changed in size. She reports some weight loss recently, although attributes this to a new diet. She denies palpitations, heat intolerance and tremor. Her medical history is significant for the surgical removal of a lipoma from her back last year as well as a recent diagnosis of Sjögren's syndrome. She has a family history of Graves disease in her sister. On examination, she is haemodynamically stable and clinically euthyroid. The lump is found to rise with tongue protrusion and is smooth, symmetrical and non-tender on palpation. Which one of the following is the most likely diagnosis? - A: Thyroglossal duct cyst - B: Thyroid nodule - C: Branchial cleft cyst - D: Submandibular sialadenosis - E: Lipoma

= **A: Thyroglossal duct cyst** - This smooth-surfaced, midline swelling is most likely to be a thyroglossal duct cyst. A thyroglossal duct cyst is a congenital anomaly due to an embryonic remnant that forms with the failed closure of the thyroglossal duct. The cyst can form anywhere along the thyroid's route of migration extending from the foramen caecum in the tongue to the thyroid's final location in the neck. The thyroglossal duct usually involutes by the 10th week of gestation, failure to do so results in secretion from the epithelial lining leading to inflammation and cyst formation.

A 32-year-old man is involved in a fight and receives a blow to the head. Later that day he reports double vision when looking to left. He is asked to look directly ahead. Which one of the following is the most likely explanation for his symptoms? - A: Right fourth nerve palsy - B: Left fourth nerve palsy - C: Right sixth nerve palsy - D: Left sixth nerve palsy - E: Right third nerve palsy

= E: Right third nerve palsy

A 66-year-old man presents with a three day history of a dull, gnawing headache. Four weeks previously he had started adjuvant chemotherapy after colonic resection for a Stage IIIB carcinoma. A peripherally-inserted central catheter (PICC) line had been inserted in his right arm which was complicated by an axillary vein thrombosis, resulting in the line being removed and warfarin started. On examination, there is some tenderness and swelling in the right arm, but no other abnormalities are found. His investigations show: Haemoglobin 139 g/L (135 - 180), white cell count 6.7x109 /L (4.0 – 11.0) and INR 5.6 (1.0 - 1.2). A CT of his head is performed. Which one of the following is the most likely diagnosis? - A: Metastatic deposit - B: Extradural haematoma - C: Subdural haematoma - D: Intraparenchymal bleed - E: Cerebral abscess

= **C: Subdural haematoma** - The CT demonstrates a subdural haematoma, with a crescentic extra-axial collection of venous blood that is not constrained by cranial sutures. (Image) Its mixed density reflects chronicity: some of the clot has begun to liquefy and so when the patient lies supine for a CT scan, the more liquid components rise to the top while the denser proteinaceous components sink to the bottom. This bleed has resulted from over-anticoagulation.

Which one of the following is the most appropriate management? - A: Provide alcohol cessation counselling - B: Cease amiodarone - C: Increase dose of amiodarone - D: Prescribe thyroid hormone replacement - E: Prescribe iron tablets

= **D: Prescribe thyroid hormone replacement** - The clinical symptoms are consistent with hypothyroidism, which is supported by obesity and bradycardia on examination. This diagnosis is confirmed with a raised TSH level with low T4, suggesting likely primary hypothyroidism. The level of anti-thyroid peroxidase antibodies (anti-TPO) suggests a high likelihood of Hashimoto's thyroiditis. Primary hypothyroidism is treated with thyroid hormone replacement (levothyroxine).

Which one of the following would be the most appropriate management for this presentation? - A: Expectant management - B: Misoprostol/mifepristone - C: Methotrexate - D: Dilation and curettage - E: Emergency salpingectomy/salpingostomy

= **A: Expectant management** - This patient has presented to ED with an incomplete miscarriage. Diagnosis of this is based on the history of a viable intrauterine pregnancy one week previously, ongoing vaginal bleeding, open os and presence of products of conception in the cervical canal. Other differentials include an inevitable miscarriage (intrauterine pregnancy and an open cervical os) or a complete miscarriage (no evidence of remaining POC and a closed cervical os).

eMedici Mock MCQ Flashcards

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