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A 70 year old woman attends her GP surgery for an NHS health check. She has no medical history of note and describes herself as being well.

Her pulse rate is 80 bpm and irregularly irregular. An ECG confirms atrial fibrillation.

Which is the most appropriate immediate management strategy?

a.  Amiodarone hydrochloride

b. Apixaban

c. Aspirin

d. Bisoprolol fumarate

e. Digoxin



An 89 year old man is brought to the Emergency Department by his nursing home carers who report that he has been unwell for 24 hours. No history is available from the patient as he has advanced dementia, but his carers state that he had chest pain 24 hours previously.

His pulse rate is 34 bpm, BP 95/50 mmHg, respiratory rate 22 breaths per minute and oxygen saturation 95% breathing air. An ECG shows complete heart block with ventricular escape rhythm.

Which drug should be given immediately?



a. Adrenaline/epinephrine


b. Aminophylline


c. Atropine sulfate


d. Isoprenaline


e. Oxygen


Atropine sulphate


A 67 year old man is admitted with a right basal pneumonia, and a subclavian central line is inserted. He has chest pain and difficulty in breathing of sudden onset.

He looks distressed and blue. The right side of his chest is not expanding as well as the left, and the trachea is deviated to the left. Breath sounds are absent on the right, and there is hyperresonance to percussion, also on the right side of the chest.

Which is the most appropriate immediate management?

a. Insert a chest drain in the 5th intercostal space anterior axillary line on the left side


b. Insert a chest drain in the 5th intercostal space anterior axillary line on the right side


c. Insert a large-bore cannula in the 2nd intercostal space midclavicular line on the left side


d. Insert a large-bore cannula in the 2nd intercostal space midclavicular line on the right side


e. Order an urgent portable chest X-ray

d. large-bore cannula 2nd intercostal space midclavicular line on the R side



A 42 year old man has 1 week of chest pain and shortness of breath.

His pulse rate is 125 bpm, BP 77/42 mmHg and oxygen saturation 85% breathing air.

Investigations: Chest X-ray: no abnormality CT pulmonary angiogram: massive pulmonary embolus

Which is the most appropriate immediate treatment?

a. Intravenous alteplase


b. Intravenous heparin (unfractionated)


c. Oral dabigatran etexilate


d. Oral warfarin sodium


e. Subcutaneous low molecular weight heparin



a. IV alteplase 



A 19 year old woman has increasing wheeze and breathlessness over the past 12 hours. She has a history of asthma.

She is drowsy and unable to cooperate. Her temperature is 37.8°C, pulse rate 110 bpm, respiratory rate 34 breaths per minute and oxygen saturation 91% on 60% oxygen. She has quiet breath sounds. She has received nebulised salbutamol and intravenous steroids and magnesium.

Arterial blood gases on 60% oxygen

pH                   7.1             (7.35–7.45)

PO2                7.9 kPa      (11–15)

PCO2              8.9 kPa      (4.6–6.4)

Bicarbonate    19 mmol/L  (22–30)


Which is the most appropriate next step in management?



a. Give intravenous aminophylline


b. Give intravenous salbutamol infusion


c. Intubate and ventilate


d. Start bilevel positive airways pressure (BIPAP)


e. Start continuous positive airway pressure



c. intubate and ventilate


A 76 year old woman is reviewed in the stroke clinic. She was discharged three weeks earlier following a stroke that caused left arm and left facial weakness. She is taking clopidogrel and simvastatin. She has had no new symptoms since discharge.

Her pulse is 84 bpm and BP of 163/98 mmHg (average of six readings). She has pyramidal weakness of the left arm and left upper motor neurone VIIth nerve palsy.


Investigations: Urea 4.8 mmol/L (2.5–7.8)

Creatinine 75 µmol/L (60–120)

Cholesterol 4.2 mmol/L (<5.0)

ECG: sinus rhythm with occasional ectopic beats

Carotid duplex ultrasound: 50% stenosis of the right carotid artery, 50% stenosis of the left carotid artery

What is the most appropriate further management?

a. Add atenolol


b. Add ezetimibe


c. Add perindopril


d. Refer for carotid artery stenting


e. Switch clopidogrel to aspirin


c. add perindopril 



A six year old boy has frequent episodes when he stops playing, stares straight ahead and has a blank facial expression for 20 seconds before returning to normal activity. His teacher has noticed similar episodes in school.

His EEG reveals a 3 per second spike-and-wave pattern.

Which is the most appropriate treatment?

a. Carbamazepine


b. Clonazepam


c. Lamotrigine


d. Sodium valproate


e. Vigabatrin





d. Sodium valproate 



A 72 year old man has 6 months of malaise and intermittent tremor in his right arm of gradual onset. The tremor is now also affecting his left arm and is exacerbated by anxiety.

He is slow to initiate movements. There is increased tone in the arms with superimposed tremor.

Which is the most likely diagnosis?


a. Corticobasal degeneration


b. Essential tremor


c. Multiple system atrophy


d. Parkinson's disease


e. Progressive supranuclear palsy





d. Parkinson's disease


A 23 year old man visits his GP with 2 months of low mood, lack of pleasure, persistent tiredness, poor sleep, poor appetite and low self-esteem. He sometimes has thoughts of taking his life, with no specific plans. There is no past psychiatric history.

The GP diagnoses depression and starts an antidepressant.

Which is the most appropriate follow-up?

a. Admit to psychiatric unit


b. GP review in 1 month


c. GP review in 1 week


d. No routine follow-up


e. Referral to a psychiatrist



c. review in 1 week


A four year old boy has 2 days of a sore throat. He has been febrile but has had no symptoms of cough or cold. This is his fourth sore throat in the past year.

He is alert and well. His temperature is 38.1°C. His tonsils appear red and inflamed with exudates. He has enlarged cervical lymph nodes.

Which is the most appropriate management?


a. Advise symptomatic treatment only


b. Prescribe an antiviral


c. Prescribe an appropriate antibiotic


d. Routine ENT referral


e. Urgent paediatric referral


c. prescribe appropriate antibiotic 



A 63 year old woman visits her GP with a painless neck lump that has been present for over 2 months.

The lump is 1 cm × 2 cm and non-pulsatile. It is anterior to the sternocleidomastoid muscle on the right hand side and does not cross the midline. It moves with swallowing but not with tongue protrusion and there are no overlying skin changes.

Which is the most likely diagnosis?


a. Branchial cyst


b. Carotid artery aneurysm


c. Cervical rib


d. Thyroglossal cyst


e. Thyroid nodule   



e. thyroid nodule 



A 65 year old woman has 4 weeks of stiffness and swelling of her fingers and forearm after an insect bite to her left arm. She was treated 5 years ago for left breast cancer with lumpectomy, lymph node sampling and local radiotherapy.

Her left hand, forearm and upper arm are swollen. There is no discoloration of the skin. There are no abnormal masses.

Which is the most likely cause of her arm swelling?

a. Ascending lymphangitis


b. Hypoalbuminaemia


c. Lymphoedema


d. Pathological fracture


e. Recurrent breast cancer



c. lymphoedema 



A 50 year old man is brought to the Emergency Department with a rash. He also has genital and oral ulcers which appeared two days ago. He has sore red eyes and a generalised dusky red rash. Some areas of the rash have developed large blisters. The patient is normally in good health but started taking treatment for a chest infection 10 days ago.

What is the most likely diagnosis?


a. Bullous pemphigoid


b. Eczema with secondary infection


c. Herpes simplex


d. Pemphigus vulgaris


e. Toxic epidermal necrolysis




e. Toxic Epidermal Necrosis 



A 38 year old woman walks into the Emergency Department feeling unwell. She has a history of type 1 diabetes.

Her capillary blood glucose is 1.9 mmol/L (3.0–6.0).

Which is the most appropriate immediate treatment to offer?

a. 10% glucose 150 mL IV

b. 20% dextrose 150 mL IV

c. A piece of toast

d. Glucagon 1 mg IM

e. Lucozade 100–200 mL orally



e. Lucozade



A three month old boy has a three day history of coryzal symptoms, increasing cough and difficulty with feeding. He received his first round of immunizations two weeks previously.

He is not pale or centrally cyanosed, but is irritable and has marked intercostal recession. He has a temperature of 38.5°C, pulse rate 140 bpm (110–160) and respiratory rate 60 breaths (30-40) per minute, and his oxygen saturation is 88% breathing air. A 2 cm liver edge is palpable. Widespread bilateral crackles are heard on auscultation, with reduced breath sounds.


Which is the most likely diagnosis?


a. Acute bronchiolitis


b. Acute laryngotracheobronchitis (croup)


c. Bronchopneumonia


d. Ventricular septal defect


e. Viral exacerbation of asthma



a. acute bronchiolitis 


A 73 year old man has increasing breathlessness over 1 week. He has a history of chronic kidney disease and ischaemic heart disease. He takes alfacalcidol, aspirin, atorvastatin, bisoprolol fumarate, furosemide and irbesartan.

There are bibasal inspiratory crepitations and mild peripheral oedema.
Sodium        134 mmol/L                       (135–146)
Potassium   6.7 mmol/L                        (3.5–5.3)
Urea            19 mmol/L                         (2.5–7.8)
Creatinine   259 µmol/L                        (60–120)
eGFR        23 mL/min/1.73 m2                  (>60)

Which is the most likely cause of the hyperkalaemia?


a. Alfacalcidol


b. Aspirin


c. Bisoprolol fumarate


d. Furosemide


e. Irbesartan




e. Irbesartan 


A 46 year old woman has menorrhagia. She also has urinary frequency, abdominal pain and bloating. She has anaemia, despite iron supplementation.

The uterus can be palpated above the umbilicus. An ultrasound scan shows that her uterus measures 200 × 150 × 100 mm. There are multiple fibroids, with the largest measuring 100 mm in diameter.

Which is the most appropriate management?

a. Endometrial ablation


b. Laparoscopic myomectomy


c. Open myomectomy


d. Total abdominal hysterectomy


e. Transvaginal resection of fibroids


d. total abdominal hysterectomy 


A 24 year old woman is admitted for induction of labour at 42 weeks in an otherwise uncomplicated pregnancy. The cervix is long, closed, posterior and firm. This is her first child.

Which is the most suitable method of induction for this patient?


a. Artificial rupture of membranes


b. Ergometrine


c. Oxytocin


d. Progesterone


e. Prostaglandins


e. prostaglandins 


A 35 year old woman has a routine cervical smear and further investigations.


Investigations: Cervical smear severely dyskaryotic and highly keratinized cells suspicious of malignancy

Colposcopy 2 cm ulcerated mass on ectocervix

She undergoes a cervical biopsy.

Which is the most likely pathological diagnosis?

a. Adenocarcinoma


b. Leiomyosarcoma


c. Small cell carcinoma


d. Squamous cell carcinoma


e. Transitional cell carcinoma



d. squamous cell carcinoma