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1

A 76 year old woman has 2 day history of pain and swelling in her left leg. She has no history of a fall and noticed the swelling first thing in the morning. Examination reveals significant swelling all over her leg from her knee to her ankle. There is redness which extends into the thigh. Her temp is 38.1. She is able to weight bear on that leg but with difficulty. What is the most likely diagnosis?

Cellulitis - acute onset and swelling with a temperature

2

A 60 year old man has a 3 month history of night sweats and fever. He has a documented temperature of 38 and has lost 3kg in weight. Clinical examination reveals a soft systolic murmur in the aortic area. Which is the likely cause of his fever?

Infective endocarditis - combination of fever and murmur

3

A newborn baby has a routine blood spot newborn screening by heel prick. Which conditions are screened for?

Hypothyroidism
Medium chain Acyl-CoA dehydrogenase deficiency
Sickle cell disease
Cystic fibrosis
Phenylketonuria

4

A 12 year old boy has a 2 day history of abdominal pain associated with nausea and vomiting. On clinical examination he has tenderness with guarding in the right iliac fossa. His temperature is 37.8. What is the most likely diagnosis?

Acute appendicitis

5

An 80 year old man has a 6 hour history of confusion, acute generalised abdominal pain and fresh PR bleeding. He has a history of poorly controlled AF. On examination his HR is 130, RR is 23 and BP is 90/50. What is the most likely cause for his presentation?

Ischaemia of the bowel
AF - risk factor for embolic disease

6

A 72 year old man living in a nursing home has had recurrent diarrhoea for the last 3 weeks. Colonoscopy shows inflammation, ulceration and a yellow membrane like material covering the mucosal surface. What is the most likely cause of his diarrhoea?

Clostridium difficile infection - pseudo membranous colitis

7

An 18 year old man has a five year history of abdominal pain, bloating and diarrhoea up to 2-3 times a day. He has weight loss of 3kg over 9 months. He has a BMI of 17. He has an itchy rash on his elbows. What is the most likely diagnosis?

Coeliac disease - growth failure and GI symptoms
The rash is dermatitis herpetiformis and is associated with coeliac

8

A 62 year old woman presents to GP with headaches, tingling in her fingers and toes and general malaise. Full blood count: Hb 103, MCV 105. What is the likely diagnosis?

Pernicious anaemia - macrocytic anaemia

9

A 45 year old man has a 6 month history of change in bowel habit, bloating and pain relieved by defecation. His weight is stable and there is no rectal bleeding, abdominal mass or relevant family history. Full blood count shows Hb 143. What is the most likely diagnosis?

Irritable bowel syndrome - commonly presents in this age group. No red flags for other more serious conditions

10

A 58 year old man presents to his GP for review of the following blood results: fasting plasma glucose 5.9 and 6.1
Oral glucose tolerance test: 10.6
HbA1c 38
What is the most likely diagnosis?

Impaired glucose tolerance
Fasting less than 7
Glucose tolerance 7.8-11.1

11

A 70 year old man presents to ED with 24 hour history of severe generalised headache, fever and neck stiffness. LP shows protein 2.2, CSF glucose 0.8, gram staining negative diplococci, blood glucose 4. What is the likely causative organism?

Neisseria meningitidis

12

A 55 year old woman is admitted to hospital with SOB, chest pain and haemoptysis. CTPA shows a blockage in the right pulmonary artery. The scan has included the upper part of the abdomen where there is evidence of ascites. What is the most important underlying diagnosis that needs to be considered?

Malignancy

13

A 62 year old man after returning from Pakistan 3 months ago has night sweats with fever and a productive cough with occasional blood streaked sputum. He has lost 4kg weight despite having a normal appetite. Chest X-ray shows bilateral upper zone shadowing. Which diagnostic approach is most appropriate?

Obtain 3 sputum samples for acid fast bacilli smear microscopy and culture
If this fails then bronchoalveolar lavage can be performed

14

An 86 year old woman has a painful red eye and blurry vision for four days and a 3 day history of vomiting. What is the most likely diagnosis?

Acute glaucoma

15

A 65 year old man with a 40 pack year history of smoking is referred with a productive cough and thick green sputum which is unresponsive to treatment for a chest infection. He has a temperature of 38.4. What is the likely diagnosis?

Pneumonia

16

A 50 year old man has acute onset central crushing chest pain. His ECG shows ST elevation in leads II, III and avF. Which coronary artery is affected?

Inferior aspect of heart - right coronary artery in 70% patients

17

Which investigation is routinely performed at the first antenatal visit for pregnant women in the uk?

Midstream urine culture

18

A 25 year old man presents to his GP with earache and some hearing loss in both ears. He has a painful pressure feeling in the ear for 24 hours. He has no discharge from the ear and no fever. He is unable to pop his ears. What is the most likely appearance through the otoscope?

A mildly retracted eardrum with fluid behind the drum - Eustachian tube dysfunction

19

A 70 year old man attends GP with a 3 week history of difficulty hearing in the left ear. It has not been associated with any pain, vertigo or discharge but he does describe some mild tinnitus. On the Weber test he reports the sound is louder in the left ear while the Rinne test is negative on the left and positive on the right. What is the most likely cause of his hearing loss?

Impacted ear wax - condition more common with age
Conductive hearing loss

20

A 30 year old man attends A and E with a one day history of sharp central chest pain radiating to the back. He reports the pain as 8/10 and is worse when he takes a deep breath in and when lying down. It is eased by leaning forwards. On auscultation there is a scratchy sound in time with the heart at the left sternal border but heart and breath sounds are otherwise normal. An ECG is performed which shows diffuse st segment elevation. Troponin t is mildly elevated. What is the most likely diagnosis?

Pericarditis - pericardial rub present

21

A 35 year old man with a past history of well controlled UC presents with general fatigue. On examination he has yellowing of his sclera, skin excoriations and tenderness in the right upper quadrant. Liver function tests show bilirubin 74, ALP 378, ALT 75, albumin 28. What is the most likely diagnosis?

Primary sclerosing colangitis
LFTs show Cholestasis: ALP greater than ALT

22

An 86 year old woman with a history of ischaemic heart disease and Hypercholesterolaemia presents with central visual loss. She is diagnosed with macular degeneration related to old age. What is the most likely finding on fundoscopy?

Drusen: tiny yellow or white accumulations of extracellular material that build up between Bruchs membrane and the retinal pigment epithelium of the retina. Seen in dry MD
Choroidal neovascularisation seem in wet MD

23

In what disease process would you see cotton wool spots on fundoscopy?

Hypertension or diabetes: caused by damage to nerve fibres, accumulation of axoplasmic material

24

What are flame haemorrhages and when would you see them?

Lie within superficial nerve fibre layer, reflect ischaemic leakage from arterioles from veins under pressure
Feature of hypertensive retinopathy

25

What features would you expect to see in the pre-proliferative stage of diabetic retinopathy?

Microaneurysms
Retinal haemorrhages
Hard exudates
Macular oedema
Macular ischaemia

26

A 3 month old baby is brought to GP by his parents with a temperature of 38. What are the red lights on the traffic light scoring system?

Colour of skin: pale/mottled/ashen/blue
Activity: no response to social cues/appears ill to HCP/does not wake or if roused does not stay awake/weak high pitched or continuous cry
Respiratory: grunting/Tachypnoea over 60/moderate or severe chest indrawing
Circulation and hydration: reduced skin turgor
Other: age less than 3 months and temp over 38/ non blanching rash/ bulging fontanelle/ neck stiffness/ status epilepticus/ focal neurological signs/ focal seizures

27

A 35 year old woman presents with weight loss. She has an increase in appetite and some increased bowel frequency. Physical examination is normal. Which is the most appropriate investigation to arrange first?

Serum TSH

28

A previously healthy 70 year old man presents with a sudden onset of weakness in the right arm and leg. Reflexes are equivocal but the right plantar is up going. Which investigation is most important in deciding the next management step?

CT head

29

A 55 year old man with diabetes phones the duty GP with a new symptom of chest pain. On questioning it is central, radiates to the back and is making him feel sick. Is has been present for 45 mins and is worsening. What is the most appropriate advice to give?

Call 999 - this is likely an acute MI or an aortic dissection

30

A 4 year old boy has a four day history of swelling of his ankles, mild abdominal pain and lethargy. On examination the swelling is confirmed, his pulse is 90 and his BP is 138/92. A urine dipstick shows protein +++. What is a likely blood test finding? What causes this change?

High cholesterol
Nephrotic syndrome, probably minimal change nephropathy
Increase in LDL and VLDL due to increase lipoprotein synthesis

31

A 23 year old woman complains of persistent sneezing and runny nose which comes each year in May and June. What is the most likely mechanism for her symptoms?

Mast cell degranulation process
Type 1 IgE mediated response to seasonal pollen antigen

32

A 24 year old man presents to the GP with a two month history of difficulty seeing at night. He has no problem in the day. His mother has similar problems. What is the most likely diagnosis?

Retinitis pigmentosa

33

A 54 year old man presents to the GP with a 3 week history of an infected cut on his hand which is failing to heal. He works on a building site and is self employed. He says he keeps it bandaged during the day but the cut remains swollen and red. What routine blood test is most likely to give the reason for his problem?

Blood glucose level - pre diabetic or diabetic

34

A 23 year old woman presents to the GP complaining of an inability to conceive over the previous year. On examination she has acne, facial hair and her BMI is 24. Further questioning on which subject is most likely to support a diagnosis?

Menstrual history - irregular periods or amenhorrea which is in keeping with a a diagnosis of Polycystic ovarian syndrome

35

A 63 year old woman presents to the GP with a 3 week history of rectal bleeding. She complains that it is associated with intermittent constipation and diarrhoea. The blood has been mixed with the stools but also on the toilet paper. Examination reveals a right lower abdominal mass. What is the most likely diagnosis?

Colorectal malignancy

36

Which rating scale can be used to assess the severity of depression in GP?

PHQ9 - patient health questionnaire 9

37

A GP discusses cv risk with a newly diagnosed hypertensive patient. Which factors would increase the patients risk?

Smoking
High LDL
Diabetes
Lack of exercise
High BMI
FH of heart disease
Ethnicity

38

A 35 year old man with well controlled asthma presents to ENT clinic with 2 year history of progressively worsening bilateral nasal obstruction. He also has excessive mucoid nasal discharge and post nasal drip. He denies any bleeding from the nose. What is the most likely diagnosis?

Nasal polyposis - related to asthma, bilateral, increases in severity over years, common in middle aged patients, no red flag symptoms - epistaxis, pain, paresthesia

39

How would a deviated nasal septum present?

In young adults once the growth of the nose and septum is complete
Would not progressively increase and one side would be more obstructed than the other - breathing difficulty
Recurrent sinus infections, nosebleeds, facial pain, headache, post nasal drip, loud breathing/snoring would all be potential symptoms

40

What is choanal atresia?

Congenital disorder where back of nasal passage, choana is blocked usually by bony or soft tissue due to failed recanalisation of the nasal fossae during foetal development
Baby with difficulty breathing unless crying - acute breathing problems, cyanosis, feeding difficulty. May need resuscitation at delivery

41

What is churg-Strauss syndrome?

Eosinophilic vasculitis causing asthma and rhinitis
Paranasal sinusitis, pulmonary infiltrates, Mononeuritis multiplex or polyneuropathy

42

What is Wegeners granulomatosis?

Multi system autoimmune disease
Necrotising granulomatous inflammation and vasculitis in small and medium blood vessels
Presentation: recurrent respiratory infection, constitutional symptoms, ophthalmic problems, ENT problems, myalgia, renal disease, Mononeuritis multiplex, palpable purpura or skin ulcers

43

What is post nasal drip?

Excess mucus production, feeling of constantly having to clear throat, cough worse at night, sore throat, ear infections from blocked Eustachian tube

44

What causes post nasal drip?

Colds, flu, allergies, sinus infection, object stuck in nose, pregnancy, medications (OCP, BP meds), deviated septum, weather, certain foods, fumes/environmental irritants

45

A 23 year old primigravida undergoes a routine 38 week antenatal check. In addition to blood pressure, what two pieces of information are important to ascertain at this stage of the pregnancy?

Presence of proteinuria and fundal height

46

A 23 year old man presents to the emergency department having been involved in a RTA. On examination he has a fracture of the shaft of the right femur. He is also assessed to be in class 1 Hypovolaemic shock. What are the features of class 1 shock?

Raised diastolic BP - minimal clinical signs due to physiological compensation - peripheral vasoconstriction and increased peripheral vascular resistance

47

A 61 year old man presents to his GP with a four week history of a sore throat which has not responded to a course of penicillin and difflam gargles. He is hypertensive and has a BMI of 34. He has a 49 pack year history. He is on ramipril for his hypertension. On examination he and an enlarged left tonsil with central ulceration and a moderately enlarged left anterior cervical lymph node. Which is the next most appropriate step in management?

A 2 week wait referral to ENT - this is likely to be a carcinoma of the tonsil with lymph node involvement. He will need a block dissection

48

A 17 year old girl presents to the GP with a six month history of amenorrhoea. She had nexplanon inserted into her left arm two years ago. She says that she is fit and healthy as she does cross country running for her school. Her BMI is 17. What is the likely cause for her amenorrhoea?

Significantly low BMI

49

A 42 year old woman attends A and E with blood dripping from her nostril for the past 10 minutes. She is assessed by the triage nurse and is found to be otherwise well with normal pulse and BP. What is the appropriate course of action for the nurse at this stage?

Suggest the patient sits forward and pinches the nostrils shut

50

A 52 year old has weight loss of 3.5kg over the last 6 months unrelated to diet and exercise. She continues to work but is becoming increasingly tired. FBC shows: Hb 75, haematocrit 0.26, MCH 24.8, MCV 55, serum ferritin 8. What type of anaemia is present?

Iron deficiency anaemia

51

A 52 year old has weight loss of 3.5kg over the last 6 months unrelated to diet and exercise. She continues to work but is becoming increasingly tired. FBC shows: Hb 75, haematocrit 0.26, MCH 24.8, MCV 55, serum ferritin 8. What would their blood film show?

Microcytic hypochromic red cells

52

A 52 year old has weight loss of 3.5kg over the last 6 months unrelated to diet and exercise. She continues to work but is becoming increasingly tired. FBC shows: Hb 75, haematocrit 0.26, MCH 24.8, MCV 55, serum ferritin 8. List 3 further questions that this patient should be asked regarding her presenting complaint

Hx of aspirin/steroids/NSAIDs
Menstrual period history
Change in bowel habit
Abdominal pain/bloating/coeliac
Hx of inflammatory bowel disease
FH of cancer in first degree relatives
Past Hx of colonic polyps
Swallowing difficulty
Dyspepsia/acid reflux
Hx of bleeding

53

List 3 clinical examination findings that may be present in iron deficiency anaemia

Pallor of the conjunctiva
Palpable mass in the abdomen/on PR examination
Tachycardia
Koilonychia
Angular stomatitis
Ankle oedema
Systolic murmur

54

A 52 year old has weight loss of 3.5kg over the last 6 months unrelated to diet and exercise. She continues to work but is becoming increasingly tired. FBC shows: Hb 75, haematocrit 0.26, MCH 24.8, MCV 55, serum ferritin 8. Excluding further blood tests, list 2 first line investigations to identify the underlying cause?

Flexible sigmoidoscopy/colonoscopy
Chest X-ray /CT chest abdo pelvis for metastasis
Upper GI endoscopy

55

A 62 year old man has chest pain which started two hours previously and woke him from sleep. It is central, radiating to his shoulders and he feels sick and dizzy. On examination he is pale, sweaty, apyrexial, his pulse is 115 and his blood pressure is 110/55 in both arms. What is the likely diagnosis?

Myocardial infarction/ACS/ angina

56

A 62 year old man has chest pain which started two hours previously and woke him from sleep. It is central, radiating to his shoulders and he feels sick and dizzy. On examination he is pale, sweaty, apyrexial, his pulse is 115 and his blood pressure is 110/55 in both arms. Other than gender and age, list 5 risk factors that should be asked about

Smoking Hx
Diabetes
Hypertension
Past Hx of cv events
Exercise levels
FH of heart disease
Ethnicity
Rheumatoid arthritis
Post code/SES
Obesity/BMI

57

A 62 year old man has chest pain which started two hours previously and woke him from sleep. It is central, radiating to his shoulders and he feels sick and dizzy. On examination he is pale, sweaty, apyrexial, his pulse is 115 and his blood pressure is 110/55 in both arms. Excluding ECG what other immediate investigation would be most useful?

Troponin T or I

58

List 3 ECG changes that would be expected in a patient with an ACS

ST elevation
ST depression
T wave inversion
Left bundle branch block
Q waves

59

A previously well 25 year old man visits his GP with a ten week Hx of generalised abdominal pain, associated with significant weight loss and diarrhoea. He also has generalised fatigue. Give 3 further questions which should be asked to aid a diagnosis?

Vomiting
Bowel habits
PR bleeding
Family Hx
Dietary Hx
Travel Hx
Medication
Sexual/STI Hx
Night sweats/fever
Polyuria/polydypsia

60

A previously well 25 year old man visits his GP with a ten week Hx of generalised abdominal pain, associated with significant weight loss and diarrhoea. He also has generalised fatigue. Examination reveals multiple mouth ulcers and red nodules over his shins. His abdomen is soft and non tender. What is the likely diagnosis?

Crohns disease

61

A previously well 25 year old man visits his GP with a ten week Hx of generalised abdominal pain, associated with significant weight loss and diarrhoea. He also has generalised fatigue. On examination he has multiple mouth ulcers and red nodules over his shins. What name is given to the nodules of the legs?

Erythema nodosum

62

A previously well 25 year old man visits his GP with a ten week Hx of generalised abdominal pain, associated with significant weight loss and diarrhoea. He also has generalised fatigue. He has multiple mouth ulcers and red nodules on his shins. List 3 investigations which should be considered in primary care

FBC
U and Es
ESR
CRP
LFTs
Coeliac screen

63

A previously well 25 year old man visits his GP with a ten week Hx of generalised abdominal pain, associated with significant weight loss and diarrhoea. He also has generalised fatigue. He has multiple mouth ulcers and red nodules over his shins. List 2 investigations which should be considered in secondary care

Sigmoidoscopy/colonoscopy
CT/MR of the abdomen
Biopsy of the bowel lesion

64

A 56 year old non smoking, obese, known hypertensive woman has a 3 month Hx of increasing thirst and nocturia. She has a Hx of recurrent candidiasis. What is the most likely diagnosis?

Type 2 diabetes Mellitus

65

A 56 year old non smoking, obese, known hypertensive woman has a 3 month Hx of increasing thirst and nocturia. She has a Hx of recurrent candidiasis. List 4 different investigations that are appropriate in this patient

Urine dip
Blood glucose: fasting or random
HbA1c
Fasting lipids
U and Es

66

A 56 year old non smoking, obese, known hypertensive woman has a 3 month Hx of increasing thirst and nocturia. She has a Hx of recurrent candidiasis. What is initial non pharmacological management in this patient?

Diet modification
Exercise

67

List 4 long term potential complications that might develop in a patient with type 2 diabetes Mellitus

Neuropathy
Nephropathy
Retinopathy
Cerebrovascular disease
Ischaemic heart disease
Peripheral vascular disease
DVT
Osteoarthritis
Recurrent infections

68

A 67 year old man is admitted to A and E with one week of cough and SOB. He is alert and well oriented. Temperature is 38.7, pulse rate 90, blood pressure 102/60, resp rate 30, sats 92%. He has right sided chest pain on deep inspiration. He chest is expanding equally but over the right lower lobe the tactile fremitus is increased, percussion is dull and bronchial breathing is present on auscultation. What is the likely diagnosis?

Right lower lobe pneumonia

69

A 67 year old man is admitted to A and E with one week of cough and SOB. He is alert and well oriented. Temperature is 38.7, pulse rate 90, blood pressure 102/60, resp rate 30, sats 92%. He has right sided chest pain on deep inspiration. He chest is expanding equally but over the right lower lobe the tactile fremitus is increased, percussion is dull and bronchial breathing is present on auscultation. What is the expected finding on the chest X-ray?

Right lower lobe consolidation

70

List the 4 history and examination features that are used to assess the severity of pneumonia

Confusion
Respiratory rate
Blood pressure
Age

71

Which blood test is used to assess the severity of pneumonia?

Urea
CRP

72

A 67 year old man is admitted to A and E with one week of cough and SOB. He is alert and well oriented. Temperature is 38.7, pulse rate 90, blood pressure 102/60, resp rate 30, sats 92%. He has right sided chest pain on deep inspiration. He chest is expanding equally but over the right lower lobe the tactile fremitus is increased, percussion is dull and bronchial breathing is present on auscultation. Excluding death, list 3 complications which could develop in this patient

Pleural effusion
Empyema
Lung abscess
Pneumothorax
Sepsis
Respiratory failure

73

An 8 week old infant is brought to go for a routine baby check. He was born by normal delivery at term following an uneventful pregnancy. The GP checks that the results of the heel prick test have been received. State 3 conditions which are tested for and for each state their genetic heritability

Maple syrup urine disease: AR
Glutaric aciduria type 1: AR
Homocystinuria: AR
Isovaleric acidaemia: AR
Long chain 3-hydroxyacyl-CoA dehydrogenase deficiency: AR
Phenylketonuria: AR
Congenital hypothyroidism: can be AD, AR or spontaneous
Sickle cell disease: AR
Cystic fibrosis: AR
Medium chain Acyl-CoA dehydrogenase deficiency: AR

74

A GP commences a baby check with a physical examination of the eyes. What specific sign are they looking for?

Red reflex

75

State 2 conditions which can cause the red reflex to be absent in a baby

Retinoblastoma
Congenital cataract

76

In a baby check, the GP checks the baby's hips for developmental hip dysplasia. State one observation and one clinical examination test which can be used to check for this condition

Symmetry of hips and legs/symmetry of skin folds
Ortolani/Barlow test

77

What are ortolani and Barlow tests?

Barlow: adducting hip while applying pressure on knee posteriorly, hip dysplasia - hip will dislocate
Ortolani: relocates dislocation. Flex hips and knees to 90 degrees, anterior pressure on greater trochanter and abducting leg. Positive sign - clunk as femoral head relocates anteriorly

78

List 2 factors which increase the risk of developmental dysplasia of the hip

Breech presentation
Family Hx
Female gender
1st born infant
Oligohydramnios
Developmental abnormalities: spina bifida/Down's
Postnatal posture: swaddling

79

An 8 year old is brought in by her mother to the GP with a midline swelling in the neck. Which is it most likely to be: dental abscess, thyroglossal cyst, branchial cyst, cystic hygroma, lymphadenopathy from a viral infection?

Thyroglossal cyst

80

Where would you find a cystic hygroma?

Posterior triangle of the neck, congenital abnormality of lymphoid tissue

81

What is the specific indicator for the diagnosis of peripheral artery disease?

Abnormal ankle brachial pressure index

82

69 year old man has a 23 year history of HTN and kidney stones. He takes anti hypertensives and anti platelet drugs. Examination is normal. Investigation: Hb 120, creatinine 168. EGFR 37, urinalysis 2+ protein. What is the appropriate investigation in this patient?

Renal USS

83

Why should an abdo CT with contrast not be done on a patient with a GFR less than 60?

Contrast induced nephropathy risk

84

74 year old has a history of feeling faint and passing black and sticky motions. She has RA and has been taking an NSAID for pain relief. What is the most likely cause of her blood loss?

Gastric ulcer

85

An 18 year old man developed left sided anterior chest pain, breathlessness and a cough the previous evening. Pain is aggravated by breathing in. He is apyrexial. Breath sounds reduced over upper half of left side of chest. What is the most likely diagnosis?

Spontaneous pneumothorax

86

75 year old man admitted to hospital for knee surgery. Two days later his behaviour is bizarre. He is agitated and shouts at the sink by his bed. When questioned his is frightened and says he can hear someone whispering in the sink. What is the most likely diagnosis?

Delirium

87

73 year old man presents with confusion and dribbling urinary incontinence. He is disoriented and has a large suprapubic mass. Urine dip positive for blood. What is the likely cause of confusion?

Acute retention of urine

88

75 year old chronically ill man with long history of alcoholism suddenly develops shortness of breath. Lung scan shows large perfusion defect in right lower lobe with normal ventilation. Which is the most likely factor to have initiated this event?

Venostasis from inactivity

89

75 year old man presents with some confusion and prominent hiccups. He looks pale and sallow. In the abdomen there are masses palpable bilaterally which do not cross the midline. Hb 101, urea 36, creatinine 350. What is the most appropriate next investigation?

USS KUB
Likely enlarged kidneys from hydronephrosis

90

Which type of lung cancer is most commonly associated with paraneoplastic hypercalcaemia?

Squamous cell carcinoma
PTH or calcitriol ectopic release

91

A 33 year old woman asks to change from COCP to POP. She asks how to change pills to ensure ongoing contraception effectiveness. What advice should be given?

Start on the day following completion of the COCP 21 day course without a break

92

How long does the POP take to become effective?

2 days

93

A 35 year old woman presents to gp with fatigue. Blood is taken and results reviewed. Which result might be most suggestive of an alcohol problem?

Raised MCV
Raised gamma GT

94

60 year old man with a hx of type 1 diabetes is found unconscious by his daughter at 6am. He has been generally unwell for 3 days with nausea and vomiting. Urine dip shows ketones +++
What is the likely diagnosis?

Diabetic ketoacidosis

95

68 year old lead singer in a rock band presents to gp with hoarseness of his voice. He has a 50 pack year hx of smoking and longstanding excess alcohol use. Examination shows a hard mode in the lower deep cervical chain. What is the most likely diagnosis?

Squamous carcinoma of the larynx

96

76 year old man with severe memory loss is referred to dermatology with a pigmented lesion on his back. He attends with a carer from his residential home. Dermatologist suspects melanoma and recommends a wide local excision of the lesion. She assesses that the man lacks capacity to consent to treatments. What is the appropriate next step?

Arrange a best interests meeting

97

A 48 year old woman has a hx of 2 episodes severe abdomen pain which have lasted half an hour. Deeply jaundiced but has no signs of chronic liver disease. Which investigation joe be most helpful to find out the cause of her jaundice?

Abdominal USS
Likely biliary colic

98

Prior to what age is the menopause defined as premature?

40 years old

99

Why do women with premature menopause require HRT until they are 51/52?

Protect against risks of osteoporosis

100

85 year old man has acute confusion. He lives alone and is unable to give any hx. HR 85, irregularly irregular, BP 135/75, resp rate 16, sats 96%. He is on simvastatin, aspirin, ramipril, furosemide, warfarin. He has multiple bruises on his arms and legs. What is the appropriate diagnostic investigation for his confusion.

CT head - patient on warfarin is likely to have a subdural haematoma

101

25 year old woman presents to GP with dysuria and frequency of micturition. GP suggests UTI. What is the most likely causative organism?

E. coli

102

To which class of drugs do most anti dementia drugs belong?

Acetyl cholinesterase inhibitors

103

50 year old man has a firm lump in his right groin. He had a skin lesion removed from his right calf 2 years ago. Fine needle aspirate of the lump shows "abundant highly atypical cells with pleomorphic nuclei, cherry red nuclei and brown pigment within the cells. Mitoses are frequent and some are abnormal in morphology". What is the most likely diagnosis?

Metastatic malignant melanoma

104

20 year old consumes 4 330ml bottles of lager (5%) on a night out. How many units is this?

6.6

105

20 year old man noticed a swelling in his right testis for the past 6 weeks. It is not painful. GP suspects a primary testicular tumour and refers urgently to urology 2 week wait clinic. What is the most common primary testicular neoplasm in this age group?

Teratoma

106

65 year old man presents with weak urinary stream, prolonged emptying of bladder, hesitancy, post urination dribbling, frequent urination, nocturia. What class of drugs is most likely to be of use?

Alpha antagonists

107

51 year old woman presents with irregular periods, flushing and rapid mood changes. GP discusses combined hormone replacement therapy. Which is the most frequent unwanted effect to consider with her?

Venous thromboembolism

108

The first stage of labour begins with the onset of contractions and ends when?

Complete cervical dilation

109

A 40 year old man presents to ED with 4cm painful red hot swelling on the back of his neck. It has developed in the last 4 days. He is otherwise well. An abscess is diagnosed and an incision and drainage is performed. Abundant sticky yellow fluid is drained. What type of inflammatory cell is likely to be present in large numbers?

Neutrophils

110

Why is folic acid supplementation of 400 micrograms routinely recommended to all women pre conception and up to 12 weeks of pregnancy?

Reduces risk of neural tube defects in the foetus in the first trimester

111

Which is correct concerning cervical screening in primary care in England: samples are smeared onto a slide before transport to lab, samples are taken with a charcoal swab, samples are tested for HPV, testing is offered every 3 years for women of screening age, women age 20-70 are invited?

Samples are tested for HPV
Invited every 3 years from 25-49 and every 5 years from 50-65

112

68 year old man with hx of T2DM presents to GP with 2 month hx chest pain, weight loss and non productive cough. He has enlarged supraclavicular lymph nodes on the left. His serum sodium is 120. What is the most likely cause for the low sodium?

Carcinoma of the lung
SIADH

113

A 54 year old woman diagnosed with epilepsy secondary to MS. She lives alone in a village, not well served by public transport and lost her driving licence due to fits. She works 15 miles away from home. What is the most appropriate action to take?

Refer her to disability MDT

114

A 28 year old woman presents to community midwife after a missed period and a positive pregnancy test. On examination her height is 158cm and her weight is 90kg. How would these measurements be characterised?

BMI 36
Class 2 obesity according to NICE guidance

115

33 year old woman presents to GP with 4 day hx white vaginal discharge and vulval itching. She has recently finished a course of abx for chest infection. On examination the vulva is red and swollen. There is a thick white discharge which does not smell offensive. What is the most likely cause?

Candidiasis

116

43 year old man has breathlessness which worsens on exercise and lying down. On auscultation of the chest a mid systolic click at the apex is heard. What is the most likely cause of this abnormal heart sound?

Mitral valve prolapse

117

73 year old man has a yellow tinge to his eyes and unintentional weight loss or 8kg in 3 months. He has no abdo pain or change in bowel habit. His bilirubin 280 and USS abdomen shows a dilated common bile duct. What is the likely diagnosis?

Carcinoma of the pancreas

118

65 year old woman has pain around her right knee and calf for past 6 months. Cramp which comes on when she walks for 100 yards. Pain is relieved with rest. She used to smoke 30 cigarettes a day but has now given up. The pain does not wake her from sleep. What is the most appropriate diagnosis?

Vascular claudication

119

29 year old man who is a recent immigrant to the uk from India presents with weight loss, fever and neck lymphadenopathy. A trucut needle biopsy of the lymphadenopathy shows multiple granulomas with caseous necrosis. A Ziehl neelsen stain for acid alcohol fast bacilli is negative. What is the most likely diagnosis?

TB

120

A 35 year old woman undergoes surgery for parathyroid adenoma. In the post op period which ion is likely to low in the extracellular compartment?

Calcium

121

63 year old man presents to ED with sudden onset very severe central chest pain radiating to his back. His past medical hx includes HTN. Extremities are cold to touch. RR is 20, sats 94% on air, HR 100, BP 95/30, chest auscultation reveals fine crackles over lung bases and a diastolic mumur loudest in 3rd left parasternal intercostal space and radiating along left eternal border. What is the most likely diagnosis?

Aortic dissection
Aortic regurgitation murmur, wide pulse pressure

122

What characterises the latent phase of labour?

Cervical effacement
Early dilation up to 3cm

123

Name screening tools for dementia which can be used in primary care

GPCOG
MMSE
6-CIT
Mini COG
MIS

124

List the diagnostic features of delirium

Confusion develops over a short period and fluctuates
Disturbance of consciousness
Change in cognition
Evidence from hx, examination or lab findings that disturbance is caused by direct physiologic consequences of a medical condition

125

List conditions apart from delirium which can mimic dementia in the elderly

Depression
Hypothyroidism
B12 deficiency
Alcohol
Medication
Hydrocephalus
Subdural haematoma
Brain tumour

126

List common causes of delirium in the elderly

Medication
Infection
Constipation
Urinary retention
Pain
Alcohol
Hypoxia
Subdural haematoma
Subtle organ failure
Dehydration

127

What advice should the GP give about driving to a patient with delirium?

Stop driving until they have been fully assessed

128

28 year old man presents to GUM clinic with 2 day hx of urethral discharge and dysuria. He had unprotected sex with a regular female partner 3 days prior and also with a different casual partner 7 days prior. On genital examination he has meatitis and a profuse purulent looking urethral discharge. A urethral slide shows gram negative diplococci with polymorphonuclear leukocytes. What is the diagnosis?

Gonorrhoea

129

List systemic manifestations of gonorrhoea

Skin rash: erythema nodosum
Eye: keratoconjunctivitis
Joint: reactive arthritis

130

Name other diagnoses which should be screened for in a patient with gonorrhoea

Syphilis
HIV
Chlamydia
Non specific urethritis

131

Name other organisms which should be tested for in a patient with suspected gonorrhoea

Chlamydia trachomatis
Neisseria gonorrhoea
Treponema pallidum
HIV virus

132

What class of antibiotics should be used in a patient with gonorrhoea?

Macrolides
Cephalosporins

133

Name public health processes that should be followed after making a diagnosis of gonorrhoea to reduce spread

Contact tracing
Abstinence or condoms
Test of cure

134

List complications of a paracetamol overdose

Abnormal bleeding/clotting
Acute liver failure
Hepatic encephalopathy
Renal failure
Hypoglycaemia
Vomiting and dehydration
Metabolic acidosis
Death

135

Give investigations which should be done in a patient who has taken a paracetamol overdose

INR/coagulation screen/PT
Paracetamol levels
Liver function tests
Blood glucose
Arterial blood gases
U and Es

136

Name the drug used in the management of paracetamol overdose

N-acetylcysteine IV

137

When should n acetylcysteine be administered after paracetamol overdose to be most effective?

Within 8 hours of ingestion

138

List health care staff who may be involved in the care of a patient who has taken a paracetamol overdose

Outreach/acute intensive care staff
Liver transplant services/acute liver unit
Mental health services
Gastroenterologist/hepatologist
GP

139

A 78 year old man presents to GP compliant of passing bright red blood in his urine. What is the specific name for this symptom?

Visible/macroscopic haematuria

140

List most likely pathological processes that can present with visible haematuria

Urinary tract cancer
Renal stone disease
Urinary tract infection

141

What action should a GP take when seeing a 78 year old patient presenting with visible haematuria?

Refer to haematuria clinic (urology) to exclude urinary tract malignancy on 2 week wait with cystoscopy/further investigation

142

List investigations which should be doe to exclude significant pathology in a patient with visible haematuria

MSU
Flexible cystoscopy (possibly biopsy)
Urine cytology
Imaging of kidney (USS or CT)

143

What is the single most important risk factor for transitional cell carcinoma of the urinary tract?

Smoking

144

A 25 year old woman attends her GP with a 2 week hx of a painless lump in the right lower anterior cervical region. Apart from this group, list other node groups which should be palpated by the GP

Posterior cervical
Cervical
Axillary
Inguinal
Epitrochlear
Submandibular
Sub mental
Pre and post auricular
Supraclavicular

145

Name symptoms which are relevant in staging of lymphoma (B symptoms)

Fever
Night sweats
Weight loss
Persistent lethargy
Nausea and vomiting/loss of appetite

146

Give clinical features which would be relevant to a diagnosis of lymphoma

Multiple palpable lymph nodes
Hepatomegaly
Splenomegaly
Anaemia
Systemic features: anorexia, fever

147

List early complications of chemotherapy

Nausea and vomiting
Mucositis
Alopecia
Infections/neutropenia
Thrombocytopenia
Diarrhoea/GI upset
Anaemia

148

Name long term complications of chemotherapy

Second malignancy
Pulmonary fibrosis
Cardiotoxicity
Infertility
Peripheral neuropathy
Early menopause
Failure of treatment/disease progression

149

Name features of a breast lump which on examination may be indicative of malignancy

Firmness or hard/irregular
Immobile/skin dimpling/tethering
Lymphadenopathy
Nipple change/bleeding from nipple/inversion
Liver mass/hepatomegaly
Ulceration of breast
Peau d'orange

150

Name the components of the triple assessment of the breast

Clinical examination
Imaging/radiology
Cytology/biopsy

151

Name components that constitute a breast conserving surgical approach

Lumpectomy and axillary node dissection or sentinel node biopsy

152

Name the adjuvant treatment that is routinely offered alongside a wide local excision of the breast

Radiotherapy

153

A breast lump is found to be T2 N0 oestrogen receptor positive, HER2 negative. What class of drug is indicated?

ER antagonist, aromatase inhibitor

154

What does N0 mean in terms of breast cancer staging?

Node negative, no lymph node involvement

155

A young woman reports that since stumbling over some paving stones and hurting her knee six months ago she is struggling to leave the house. She is largely anxiety free at home although can get anticipatory anxiety. She has severe anxiety when she leaves the house. Supermarkets are particularly difficult. Her anxiety is less if she travels with someone else. What is the most likely diagnosis?

Agoraphobia

156

A 50 year old woman has a subcutaneous module removed from the shoulder area. The microscopic pathology description reads as follows: the lesion is composed of mature fat with a well defined capsule. No lipoblasts are seen. There is no evidence of malignancy. What pathological process has given rise to this appearance?

Neoplasia

157

A 72 year old man visits his GP complaining of upper abdo discomfort after eating. It started 8 weeks ago and has not improved with antacids. As a result his appetite has reduced and he has lost 2kg in weight. He has never had indigestion before. What is the most appropriate management?

Refer on 2 week wait to upper GI team

158

A 34 year old man presents to GP with 24 hr hx of dizziness and vomiting, worse when moving his head. He is experiencing rotational vertigo. He has no deafness or tinnitus. On examination nystagmus is elicited. What is the most likely diagnosis?

Labyrinthitis

159

A 24 year old man complains of intense itching between fingers especially at night. On examination, burrows are visible. What is the likely diagnosis?

Scabies

160

A 54 year old woman has a 1 week hx of irregular heart rhythm. She has not experienced chest discomfort, light headedness, syncope, orthopnoea, PND or oedema. On examination she has a pan systolic mumur radiating to axilla. What is the likely diagnosis?

Mitral regurgitation

161

A 55 year old woman has post menopausal bleeding. Investigations reveal a thickened endometrium. A pipelle biopsy shows a well differentiated endometroid adenocarcinoma. What is the most important risk factor for this type of malignancy?

Excess oestrogen

162

What molecule does HIV use as the primary receptor for entry into T cells?

CD4

163

Which joint is most commonly affected by OA?

Knee

164

A 75 year old woman has a 3 week hx of increasing abdo distension. She has lost 10kg in weight unintentionally over 12 weeks. On examination the abdomen is distended and there is a fluid thrill. She is apyrexial. USS confirms ascites and a mass emerging from the pelvis. Serum Ca125 is greatly raised. A sample of ascitic fluid shows abundant adenocarcinoma cells, some in papillary clusters. To which team should an urgent request for review be addressed?

Gynaecological

165

A 65 year old man presents with increasing lower back pain not relieved by analgesia. Examination is unremarkable apart from tenderness overlying L2-4. ESR raised, WCC normal, platelets normal, blood film normal, calcium raised, serum bone electrophoresis shows monoclonal IgG. A bone marrow aspirate sample is taken, which abnormal cells are likely to be present?

Plasma cells

166

A 67 year old woman has a 2 year hx of shin lesions on right medial distal leg. The margins are uneven, there is dry skin around it and there are brown deposits in the skin. What is the most likely cause?

Venous ulcer

167

A man reports that he believes someone has inserted a bug inside his brain which is transmitting waves. On questioning this belief is unshakeable. How is this psychopathology best described?

Paranoid delusion

168

A 31 year old asthmatic woman is admitted to the ED with SOB, palpitations and dizziness of 30 mins duration. Her only medication is inhaled short acting beta acting as needed. The ECG shows a rapid irregular wide complex tachycardia with slight variations in QRS morphology, no p waves are present and a delta wave is seen in leads V2 to V5. What is the likely diagnosis?

Atrial fibrillation

169

An 18 year old woman has a 5 year hx of severe menorrhagia. Her mother and 16 year old sister also have menorrhagia. Coagulation studies show: normal prothrombin time, prolonged APTT. What is the likely diagnosis?

Von Willebrands disease

170

A 52 year old man has an 8 week hx of pain and 2 hours morning stiffness of hands that improves with activity. He has no pertinent personal or family hx and takes no meds. On examination synovitis is noted at metacarpophalangeal joints of second through to fifth digits bilaterally with swelling, tenderness and pain on range of motion. What is the most appropriate diagnostic investigation?

Anti cyclic citrullinated peptide antibodies

171

A 14 year old is admitted to ED with chest tightness and sudden onset wheezing after being at a party. He is sat up on the trolley and unable to speak in full sentences. His respiration rate is 40 and he has wide spread wheeze. Arterial blood gas on air. What would you expect this to show?

Low PaCO2

172

What is the viral cause of verrucas and warts?

Human papilloma virus

173

A 48 year old man is evaluated for pain on his right lateral thigh. He describes it as a burning sensation present for 3 weeks. He has never had this pain before and has no associated leg weakness or back pain. His BMI is 34 and dysesthesia is present in anterolateral thigh. There is no tenderness to palpation of lateral femoral epicondyle. Knee and hip exam normal. Straight leg raising test negative bilaterally and strength is 5/5. What is the most likely diagnosis?

Meralgia paresthetica

174

A young woman reports that since stumbling over some paving stones and hurting her knee six months ago she is struggling to leave the house. She is largely anxiety free at home although can get anticipatory anxiety. She has severe anxiety when she leaves the house. Supermarkets are particularly difficult. Her anxiety is less if she travels with someone else. What is the most likely diagnosis?

Agoraphobia

175

A 50 year old woman has a subcutaneous module removed from the shoulder area. The microscopic pathology description reads as follows: the lesion is composed of mature fat with a well defined capsule. No lipoblasts are seen. There is no evidence of malignancy. What pathological process has given rise to this appearance?

Neoplasia

176

A 72 year old man visits his GP complaining of upper abdo discomfort after eating. It started 8 weeks ago and has not improved with antacids. As a result his appetite has reduced and he has lost 2kg in weight. He has never had indigestion before. What is the most appropriate management?

Refer on 2 week wait to upper GI team

177

A 34 year old man presents to GP with 24 hr hx of dizziness and vomiting, worse when moving his head. He is experiencing rotational vertigo. He has no deafness or tinnitus. On examination nystagmus is elicited. What is the most likely diagnosis?

Labyrinthitis

178

A 24 year old man complains of intense itching between fingers especially at night. On examination, burrows are visible. What is the likely diagnosis?

Scabies

179

A 54 year old woman has a 1 week hx of irregular heart rhythm. She has not experienced chest discomfort, light headedness, syncope, orthopnoea, PND or oedema. On examination she has a pan systolic mumur radiating to axilla. What is the likely diagnosis?

Mitral regurgitation

180

A 55 year old woman has post menopausal bleeding. Investigations reveal a thickened endometrium. A pipelle biopsy shows a well differentiated endometroid adenocarcinoma. What is the most important risk factor for this type of malignancy?

Excess oestrogen

181

What molecule does HIV use as the primary receptor for entry into T cells?

CD4

182

Which joint is most commonly affected by OA?

Knee

183

A 75 year old woman has a 3 week hx of increasing abdo distension. She has lost 10kg in weight unintentionally over 12 weeks. On examination the abdomen is distended and there is a fluid thrill. She is apyrexial. USS confirms ascites and a mass emerging from the pelvis. Serum Ca125 is greatly raised. A sample of ascitic fluid shows abundant adenocarcinoma cells, some in papillary clusters. To which team should an urgent request for review be addressed?

Gynaecological

184

A 65 year old man presents with increasing lower back pain not relieved by analgesia. Examination is unremarkable apart from tenderness overlying L2-4. ESR raised, WCC normal, platelets normal, blood film normal, calcium raised, serum bone electrophoresis shows monoclonal IgG. A bone marrow aspirate sample is taken, which abnormal cells are likely to be present?

Plasma cells

185

A 67 year old woman has a 2 year hx of shin lesions on right medial distal leg. The margins are uneven, there is dry skin around it and there are brown deposits in the skin. What is the most likely cause?

Venous ulcer

186

A man reports that he believes someone has inserted a bug inside his brain which is transmitting waves. On questioning this belief is unshakeable. How is this psychopathology best described?

Paranoid delusion

187

A 31 year old asthmatic woman is admitted to the ED with SOB, palpitations and dizziness of 30 mins duration. Her only medication is inhaled short acting beta acting as needed. The ECG shows a rapid irregular wide complex tachycardia with slight variations in QRS morphology, no p waves are present and a delta wave is seen in leads V2 to V5. What is the likely diagnosis?

Atrial fibrillation

188

An 18 year old woman has a 5 year hx of severe menorrhagia. Her mother and 16 year old sister also have menorrhagia. Coagulation studies show: normal prothrombin time, prolonged APTT. What is the likely diagnosis?

Von Willebrands disease

189

A 52 year old man has an 8 week hx of pain and 2 hours morning stiffness of hands that improves with activity. He has no pertinent personal or family hx and takes no meds. On examination synovitis is noted at metacarpophalangeal joints of second through to fifth digits bilaterally with swelling, tenderness and pain on range of motion. What is the most appropriate diagnostic investigation?

Anti cyclic citrullinated peptide antibodies

190

A 14 year old is admitted to ED with chest tightness and sudden onset wheezing after being at a party. He is sat up on the trolley and unable to speak in full sentences. His respiration rate is 40 and he has wide spread wheeze. Arterial blood gas on air. What would you expect this to show?

Low PaCO2

191

What is the viral cause of verrucas and warts?

Human papilloma virus

192

A 48 year old man is evaluated for pain on his right lateral thigh. He describes it as a burning sensation present for 3 weeks. He has never had this pain before and has no associated leg weakness or back pain. His BMI is 34 and dysesthesia is present in anterolateral thigh. There is no tenderness to palpation of lateral femoral epicondyle. Knee and hip exam normal. Straight leg raising test negative bilaterally and strength is 5/5. What is the most likely diagnosis?

Meralgia paresthetica

193

A 25 year old woman has a one day hx of epistaxis and new onset rash on her shins. Last week her menses were abnormally heavy. Her complete blood count from one year ago was normal. On examination vitals are normal. She has bruising over shins and wrists and a petechial rash over shins and abdomen. Dried blood visible in nares. No splenomegaly. Hb normal, leukocyte normal, MCV normal, platelet count low. What is the most likely diagnosis?

Idiopathic thrombocytopenic purpura

194

A 35 year old man attends ED with a 3 day hx of SOB, dry cough and wheeze. He has a known hx of bronchial asthma and takes 2 inhalers for this. He is a non smoker. He was not able to complete sentences. Pulse 105, BP 125/76, SpO2 97% on air, resp rate 26, peak flow 50% best, bilateral wheeze. What is the severity of his attack?

Acute severe asthma

195

What defines moderate asthma as per BTS guidelines?

Increasing symptoms
PEF 50-75% best
No features of severe

196

What features characterise acute severe asthma?

PEF 33-55% best
Resp rate >25
Heart rate >110
Inability to complete sentences

197

What are features of near fatal asthma?

Raised PCO2 and or requiring mechanical ventilation with raised inflation pressures

198

A 26 year old man is taking lithium for bipolar disorder. Regular blood tests are required in order to detect serious side-effects. Other than U and Es, what test is required?

TFTs

198

A 32 year old recently arrived from sub Saharan Africa is diagnosed with HIV. He has pain on swallowing and on occasions food is sticking in his throat. His CD4 is 80 cells per mm3. What is the most likely cause of his symptoms?

Candida infection

199

A 4 year old boy has dry itchy skin worse in the flexures, the GP diagnoses mild eczema. What treatment is appropriate first line?

Emollient cream

200

A 65 year old woman is on multiple medications for high BP, T2DM, Hypercholesterolaemia and chronic stable angina. She complains of severe intermittent headache. GP suspects it's a side effect of one of her medications. Which is the most likely cause?

Nitrate

201

A 4 year old girl has a 3 day Hx of an itchy vesicular rash which her GP diagnoses as chicken pox. When is it appropriate for her to return to school?

Once all of the lesions have crusted over

202

A 46 year old man has a non traumatic 3 month Hx of a dull aching right groin pain and limp. It was initially severe, improved for a few weeks but has been slowly worsening since then. He drinks 10 units alcohol and is a current smoker with a 30 year pack Hx. He is afebrile and has limited internal and external rotation of the right hip. Internal rotation is limited to a greater degree. Pain is present on leg rolling. Radiographs of the hip are normal. What is the most likely diagnosis?

Osteonecrosis of the femoral head

203

Which part of the GI tract is most commonly affected by diverticular disease?

Sigmoid colon

204

A 35 year old patient with asthma and GORD has been requiring more of their regular meds to the point where they have developed a tachycardia. An ECG shows sinus Tachy. Which of their meds is the likely cause?

Beta agonist

205

A 70 year old man is seen by dermatologist for generalised itchiness. This is worse when skin comes into contact with water. No dermatological cause is found, haematological cause is suspected. Which condition could it be?

Polycythaemia Vera

206

A 68 year old woman scheduled for total hip replacement attends pre op clinic. On examination she has an ejection systolic murmur heard at the left second intercostal space. Which investigation is most useful in diagnosing the specific pathology?

Echocardiography

207

A 45 year old man is being treated with systemic chemotherapy for acute leukaemia. He sees his GP because he feels non specifically unwell. Under what circumstances should GP immediately refer to secondary or tertiary care?

No additional circumstance necessary - neutropenic sepsis

208

A 32 year old woman has a routine cervical smear screening test. The result is reported as CIN1. What is the best description of this?

Mild epithelial dysplasia

209

A 52 year old woman presents to GP with facial flushing. On examination she has an erythematous rash across both cheeks with telangiectasia and pustules, what is the most likely cause?

Acne Rosacea

210

A 16 month old girl is not pulling to stand and is unable to stand unsupported, developmental assessment is as follows: gross motor - can roll, sit, low tone, fine motor - immature pincer grasp, unable to produce a tower of 2 bricks, speech and language - unclear vocalisations and consonant babble, social - good eye contact, no evidence of stranger anxiety
Examination reveals brachycephaly, epicanthic folds and macroglossia. Growth is on tenth centile. What is the most likely diagnosis?

Trisomy 21

211

Which protein is involved in the formation of a stable blood clot? Plasminogen, protein c, protein s, thrombomodulin or tissue factor

Tissue factor

212

A 63 year old man with a Hx of non insulin dependent diabetes Mellitus presents to diabetic clinic with 6 month Hx tingling and burning in his feet. He describes increased sensitivity to touch particularly at night, his GP diagnoses neuropathic pain. He takes paracetamol, ibuprofen and oromorph with limited success. What is the most appropriate first line therapy to add?

Duloxetine

213

A 67 year old woman presents with chronic rash under breasts and in groin, intermittent and worse in summer. What is the most likely diagnosis?

Intertrigo

214

A 19 year old woman presents with heavy menses since menarche that last 8 days. She has abonormal bleeding with wisdom tooth extraction. Her mother and sister have heavy menses. She appears pale. Haematocrit low, leukocytes normal, MCV low, platelets slightly raised, APTT low normal, PT normal. What is the most likely diagnosis?

Von willebrand disease