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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