past paper questions Flashcards
1
Q
A 19 year old man has pain in the ulnar aspect of his right hand since he threw a punch with his right fist. Which structure is most likely to have been injured?
A
Fifth metacarpal
2
Q
A 44 year old man is admitted for a day-case knee arthroscopy. He is first on the list and is scheduled for 09.00. He drank a cup of black coffee at 06.00. He has a history of oesophagitis and has suffered severe nausea and vomiting after general anaesthesia for a hernia repair. He is recovering from a cold but still has a hoarse voice.
His temperature is 37.2°C and BP 160/95 mmHg. His throat is inflamed. Which clinical feature is most likely to indicate postponing the operation?
A
Hypertension – SBP<180mmHg is ok
3
Q
A 30 year old man has 4 weeks of constipation, with rectal bleeding for the past 2 days. He describes bright red blood, separate from his stool.
His abdomen is non-tender and bowel sounds are present. Digital rectal examination is not performed as he cannot tolerate the procedure because of pain, but the anus looks normal.
Which is the most likely diagnosis?
A
Anal fissure
4
Q
The neighbours of an 80 year old man report 5 days of hearing him shouting in the middle of the night. The man lives alone and has told his neighbours that he has seen people trying to burgle him, but there is no evidence for this. He has no psychiatric history and is usually fit and well.
Which is the most likely diagnosis?
A
Delirium
5
Q
A 67 year old woman has an ulcer with a raised white margin on her left ear; it has been present for 3 years, growing slowly and never completely healing. She spent 20 years living in Australia before returning to the UK recently.
On examination, she has a small ulcerated area, 4mm x 6mm, on her left pinna.
Which is the most likely diagnosis?
A
Squamous cell carcinoma
6
Q
A 35 year old woman has an ill-defined lumpy area in the upper outer quadrant of her right breast which becomes larger and tender during the second half of her menstrual cycle.
Which is the most likely diagnosis?
A
Fibrocystic disease
7
Q
A 43 year old man is rescued from a house fire. There are no signs of burns to the face or neck, but he has soot deposits in his nose and mouth.
His temperature is 37.5°C, pulse rate 120 bpm, BP 135/86 mmHg, respiratory rate 20 breaths per minute and oxygen saturation 97% breathing air. He has widespread wheeze.
Which is the most appropriate management?
A
Non-rebreather mask and 100% oxygen
8
Q
A 28 year old man has had a painful red eye for five days.
He has a redness around the border of the sclera and cornea and the eye is watery. Fluorescein staining is normal. The pupil is irregular.
Which is the most likely diagnosis?
A
Anterior uveitis
9
Q
A 71 year old man is brought to the Emergency Department with increasing drowsiness and confusion for the past 12 hours. He is taking clozapine for schizophrenia and has a history of intravenous drug abuse.
He has a temperature of 39.8°C, pulse rate 110 bpm and BP of 110/70 mmHg, and his oxygen saturation is 91% on air. Heart sounds are normal. His GCS is 12/15 (eyes 3/4, motor 6/6, verbal 3/5). He has neck stiffness. He moves all four limbs equally. There is no rash.
Which is the most likely diagnosis?
A
Bacterial meningitis ?
Neuroleptic malignant syndrome
10
Q
A 56 year old woman with breast cancer has a mastectomy followed by adjuvant chemotherapy. Molecular profiling of the tumour is performed and further treatment with trastuzumab is considered.
When might this further treatment be indicated?
A
Tumour overexpresses HER2 protein
11
Q
A 24 year old man with long-standing atopic eczema develops a ash that is different from his usual eczema.
There are multiple eroded papules on the head and neck, in addition to excoriated eczema on the trunk and limbs.
Which is the most appropriate treatment for the acute eruption? bn
A
High-potency topical corticosteroid ointment
Oral acyclovir – HSV not impetiginized eczema apparently
?
12
Q
A 42 year old man reports that his left testicle has been swollen for the past 3 weeks. He is otherwise well. There is a firm, round swelling at the upper pole of the left testis.
Which is the most likely diagnosis?
A
Epididymal cyst
13
Q
A 64 year old man with a two year history of intermittent claudication presents with worsening lumbar back pain, not related to movement. He has type 2 diabetes mellitus.
Examination of his abdomen and spine is normal, but he has an absent right popliteal pulse and absent pulses in his left foot.
Which is the most appropriate initial investigation?
A
X-ray of lumbosacral spine
Ultrasound scan of abdomen – NOT related to movement (vascular hx🡪 AAA)
14
Q
An 80 year old woman has recurrent abdominal pain approximately 20 minutes after she has a meal. She has noticed weight loss of 14 kg over the past six months.
She is thin and has tarstained fingers. Her temperature is 36.5°C and pulse rate 85 bpm. She has an abdominal bruit.
Which is the most likely diagnosis?
A
Mesenteric angina
15
Q
A 59 year old man has a prolonged postoperative ileus after a sigmoid colectomy for diverticulitis.
Which is the most appropriate method of nutrition for this patient?
A
Intravenous total parenteral nutrition
16
Q
A 69 year old woman has constant dribbling of urine and has had to wear pads continuously for the last 12 month. She had radiotherapy for carcinoma of the cervix when she was 48 years old.
Her temperature is normal. Her bladder is not palpable or tender and neurological examination is normal.
Which is the most likely cause of her symptoms?
A
Vesicovaginal fistula
17
Q
A 65 year old woman has a hoarse voice for 4 weeks. She has lost 2 kg in weight over the past 2 months. She had a right hemithyroidectomy 10 years ago for a solitary nodule. She has an 80 pack-year smoking history.
There are no lymph nodes palpable in the neck. Chest X-ray is normal.
Which is the most important next investigation?
A
Ultrasound scan of neck
18
Q
A 23 year old woman has 8 weeks of intensely itchy transient circular weals on her trunk and limbs. Individual lesions last for less than 24 hours and resolve without any discolouration of the skin. She is otherwise fit and well.
Which is the best management advice?
A
Oral loratadine
19
Q
A 67 year old man has back pain that is not controlled by paracetamol (1 g four times daily). He is receiving palliative care for pancreatic cancer.
Which is the most appropriate next analgesic?
A
Regular codeine phosphate?? wouldnt that increase the paracetamol level past safety
Fentanyl patch
Lidocaine patch
Regular codeine phosphate
Regular controlled release morphine
Short acting morphine as required
20
Q
A 20 year old man has a painless lump arising from the lower pole of his right testis. His left testis is normal. An ultrasound scan shows a solid mass in his right testis and a radical orchidectomy is planned.
In addition to β-human chorionic gonadotropin (HCG), which tumour marker should be measured before the procedure?
A
Α-Fetoprotein (AFP)
21
Q
A 62 year old woman has blurred vision and extreme pain in her right eye of sudden onset. She is nauseated, has a headache and is seeing haloes around bright lights. The ocular pressure is reduced with drugs. The ophthalmologist explains to the patient that medical management alone is likely to be insufficient to reverse the problem.
Which I the most appropriate surgical treatment?
A
Laser peripheral iridectomy
22
Q
A 55 year old man undergoes endoscopy for haematemesis. A duodenal ulcer is seen with a clot visible in its base.
Which substance is the primary factor facilitating platelet adhesion?
A
Von Willebrand factor
23
Q
A 78 year old man has a serum creatinine of 148µmol/L (60-120). Three months ago, his serum creatinine was normal. He has prostate cancer with multiple bone metastases and recently had a pathological facture of the L4 vertebral body. He also has heart failure and diabetes mellitus. He takes amlodipine, bisoprolol, gliclazide, ibuprofen and morphine.
Which drug is the most likely cause of his deteriorating renal function?
A
Ibuprofen
23
Q
A 40 year old man has an extensive rash that started 2 days ago and is worsening. He is shivering and feeling generally unwell. He has no past medical history, but has recently been treated for a chest infection.
His skin is now red over most of the body, with some large blisters and some areas of erosion. There is extensive ulceration in the mouth, and the conjunctivae are injected.
Which is the most likely diagnosis?
A
Toxic epidermal necrolysis
24
A 20 year old man has 14 weeks of cervical lymphadenopathy. He has a cough and has been sweating at night, and has lost 10% of his body weight. A lymph node biopsy reveals a proliferation of lymphoid cells, with scattered, large binucleate cells and prominent nucleoli.
Which is the most likely diagnosis?
Hodgkin lymphoma
25
A 70 year old man has 24 hours of cramping abdominal pain, bloating and complete constipation. He has had 2 months of intermittent diarrhoea.
His abdomen is distended, with lower abdominal tenderness. He has an appendicectomy scar. Abdominal X-ray shows large bowel obstruction.
Which is the most likely underlying cause for his presentation?
Colorectal cancer – more likely in large bowel obstruction
Adhesions – more likely in small bowel obstruction
26
A 53 year old woman develops pain, redness and swelling in her right calf 5 days after an operation for ovarian cancer. She has a history of type 2 diabetes mellitus. She is being treated with prophylactic dose low molecular weight heparin. Her BMI is 35 kg/m2.
Which is the most appropriate initial investigation?
Ultrasound scan of proximal leg vein
26
A 50 year old woman has suddenly become short of breath. She has found it painful to swallow for two months, and she has coughed up a small amount of blood. She is distressed and cannot lie flat.
Her temperature is 37.5°C. Her respiratory rate is 40 breaths per minute and her oxygen saturation is 78% using 15L pe minute via a re-breather mask. She has inspiratory stridor.
What is the most appropriate action to take?
Endotracheal intubation
27
A 20 year old woman has painful blisters on her vulva, associated with painful groin swellings. She has recently started a new relationship and takes the oral contraceptive pill.
She has tender blisters and erosions on the vulva, with perineal erythema and inguinal lymphadenopathy.
Which is the most likely diagnosis?
Primary genital herpes
28
A 29 year old man presents after a fall on to his outstretched left arm.
The left shoulder is deformed and there is sensory loss over the deltoid muscle. The radial pulse is palpable and the patient is able to extend his wrist.
What nerve is most likely to have been damaged?
axillary
29
An 88 year old woman has had a major stroke and has developed bilateral bronchopneumonia and acute kidney injury. Her breathing becomes noisy, with a water rattling noise with each inspiration. Her family become distressed by this noise and ask what is causing it.
Which is the most likely mechanism for this noisy breathing?
Pooling of saliva because of poor swallowing
29
A tall 28 year old man is found to be hypertensive during a routine medical examination. His pulse rate is 72 bpm and BP 210/110 mmHg. There is evidence of a radiofemoral delay.
Chest X-ray shows notching of the ribs in the mid-clavicular line.
Which is the most likely underlying diagnosis?
Coarctation of the aorta
30
A 70 year old man is brought to the Emergency Department having been found on the floor at his home by a neighbour. He is confused.
His temperature is 35.9°C, pulse rate 100 bpm, BP 110/70 mmHg and oxygen saturation 95% on high flow oxygen. He has inspiratory crackles at the right base. Urine dipstick analysis from a catheter sample shows blood 4+, protein 1+, leucocytes positive.
high urea, high creat, low calcium, high phosphate, high WBC, low Hb, high +++++ CK
Rhabdomyolysis
31
A 45 year old window cleaner falls off a ladder and sustains a comminuted closed facture of his right calcaneum.
There is gross swelling and tenderness over all aspects of his heel.
Which is the most appropriate imaging to help to plan for surgery?
CT
32
A 65 year old man receives a renal transplant. He is transferred back to the ward after four hours in recovery.
He ha a pulse rate 96 bpm and regular, BP of 115/70 mmHg, CVP +4 cmH2O and respiratory rate 18 breaths per minute. His chest is clear on auscultation. His urine output has been 15-20 mL per hour while in recovery. Drain output has been 120 mL since surgery.
Investigations:
Haemoglobin 90 g/L (130-175) (preoperative level 103 g/L)
Sodium 142 mmol/L (135-146)
Potassium 5.8 mmol/L (3.5-5.3)
Urea 31.9 mmol/L (2.5-7.8)
Creatinine 590 µmol/L (60-120)
Which is the next most appropriate management step?
Fluid challenge
33
A 56 year old man has pain and tenderness in the right upper quadrant of his abdomen, 18 hours after endoscopic retrograde cholangiopancreatography and sphincterotomy for gallstones.
His temperature is 38.9°C, pulse ate 98 bpm and BP 114/78 mmHg.
Investigations:
Bilirubin 45µmol/L (<17)
Amylase 300 U/L (<220)
Which is the most likely diagnosis?
Acute pancreatitis
34
A 70 year old woman is admitted with a one week history of worsening breathlessness.
She looks pale. She has a temperature of 36.2°C, pulse rate 100 bpm, BP of 132/68 mmHg, JVP +8 cm above the sternal angle and oxygen saturation 94% on 40% oxygen via a face mask. She has bilateral inspiratory crepitations to the midzones. She has a pansystolic murmur at the apex.
Investigations:
Haemoglobin 52 g/L (115-150)
MCV 120 fL (80-96)
White cell count 3.0 x 109/L (3.8-10.0)
Platelets 87 x 109/L (150-400)
Which is the most likely diagnosis?
AML
35
A 35 year old man has pain in his left foot for three months; it is worse after playing football but improves when he keeps his foot still. Recently, the pain has become more persistent. He is unable to recall any specific injury that may have brough on the pain. He plays sport several times a week. He is otherwise fit and well. There is tenderness over the mid-foot.
What is the most likely diagnosis?
Metatarsal stress fracture
36
A 72 year old man with lung cancer is admitted to the respiratory ward with recurrent haemoptysis. He is known to the palliative carer team and it is felt that he is near the end of his life. He says that he wants to have his terminal care on the respiratory ward because he knows and trusts the nurses. A ‘do not attempt resuscitation’ form is completed. He subsequently has further haemoptysis and becomes more breathless, so he is treated with an opioid infusion to relieve his dyspnoea. A doctor suggests that the local hospice is better equipped to care for the patient. His son agrees with the doctor, believing that the hospice is “the right place to die”.
Which should b the most important factor influencing the decision on whether to move him to a hospice?
pt prev opinion
37
A 58 year old man has end-stage renal disease secondary to membranous nephropathy. His eGFR is 12 mL/min/1.73m2 (>60).
Options for renal replacement therapy are discussed with him.
Which treatment option is associated with the best long-term survival?
Living donor kidney transplant
38
A 77 year old woman has 2 years of increasing urinary frequency, associated with urgency and occasional incontinence and nocturia. She has vague discomfort in her lower abdomen most of the time. She has attempted bladder training with only minor improvement.
Which class of drug is most likely to be beneficial?
anti muscarinic
39
A 30 year old woman has 3 weeks of bilateral loin pain and dark urine. This was preceded by a sore throat. She had a similar less severe episode 2 years ago.
Her temperature is 37.1°C, pulse rate 80 bpm, BP 153/90 mmHg and JVP + 3 cm. She has mild ankle oedema. Heart sounds are normal and chest examination is unremarkable.
Investigations:
Sodium 136 mmol/L (135-146)
Potassium 4.8 mmol/L (3.5-5.3)
Urea 18 mmol/L (2.5-7.8)
Creatinine 250µmol/L (60-120)
Anti-neutrophil cytoplasmic antibody is negative.
Urinalysis: blood 4+, protein 3+.
Urinary albumin:creatinine ratio 192.2mg/mmol (<3.5)
Midstream urine: microscopy shows numerous red cells, no organisms on Gram stain.
Ultrasound scan shows normal sized unobstructed kidneys.
Which is the most appropriate diagnostic investigation?
renal biopsy
39
A 24 year old man is bought to the Emergency Department by friends who found him unconscious in his flat. They think that he might have been taking some drugs but do not know which. He has a history of alcohol and drug abuse and depression.
His pulse rate is 86 bpm, BP 106/64 mmHg, respiratory rate 6 breaths per minute and oxygen saturation 88% in air.
He is given high flow oxygen.
Which drug is most likely to explain his clinical condition?
diamorphine
40
A 60 year old man has been unable to hear with his left ear for 6 months.
Examination of both ear canals is normal. Tuning fork tests suggest sensorineural hearing loss in the left ear.
Which is the most likely diagnosis?
Acoustic neuroma
41
A 19 year old woman has 5 days of headache and fevers. She returned last week from a 2 month elective in Kenya.
Her temperature is 38.2°C. She does not have neck stiffness. Urine dipstick analysis shows a trace of blood only.
Which is the most important initial investigation?
blood film
42
A 40 year old man is receiving cytotoxic chemotherapy for the treatment of acute myeloid leukaemia.
While in hospital, he is noted to have a temperature of 38.5°C and a peripheral white cell count of 0.1 x 109/L (3.0-10.0), and his Hickman (central venous) line site is red and tender. Blood cultures from both the Hickman line and peripheral blood yield clumps of Gram positive cocci.
Which is the most likely organism?
Staphylococcus aureus
43
43
A 39 year old woman has worsening tiredness for two weeks. She was previously well.
She appears mildly jaundiced. She has a pulse rate 96 bpm and BP of 112/76 mmHg.
Investigations:
Haemoglobin 48 g/L (115-150)
MCV 98 fL (80-96)
White cell count 6.2 x 109/L (3.8-10.0)
Bilirubin 41 µmol/L (<17)
Aspartate aminotransferase 27 IU/L (10-40)
Alkaline phosphatase 100 IU/L (25-115)
Lactate dehydrogenase 560 IU/L (70-250)
Blood film: red cell polychromasia, occasional spherocytes, no red cell fragments
Which is the most appropriate diagnostic investigation?
DAAT
44
A 47 year old man has nausea and epigastric pain. He undergoes endoscopy and biopsy, and he is found to have a carcinoma of the lesser curve of the gastric body. His case is discussed at the multidisciplinary team meeting.
Which lymph node group is most likely to be the site of metastasis?
Coeliac
45
A 24 year old man has had a high speed motorcycle crash. A cervical spine fracture is suspected and a series of cervical spine X-rays is requested.
Which X-ray view is most likely to reveal a vertebral body crush facture?
Lateral
46
A 78 year old man has 1 month of painless haematuria.
Physical examination is unremarkable. Cystoscopy shows a tumour in the bladder. A biopsy is taken.
Which is the most likely histological diagnosis?
Transitional cell carcinoma
47
A 75 year old man develops difficulty speaking and swallowing two days after a right carotid endarterectomy.
On examination of his cranial nerves, his tongue deviates to the right on protrusion.
Which is the most likely cause of this problem?
Damage to the hypoglossal nerve
48
A 75 year old man has increased urinary frequency, nocturia (four times per night), poor urine flow and reduced urinary volumes over the past six months. Urinalysis shows glucose trace, blood and protein negative.
Investigations: electrolytes: normal
serum creatinine 387 µmol/L (60-120)
random blood glucose 5.6 mmol/L
Which is the most likely cause of his renal impairment?
Obstructive uropathy – BPH?
Chronic pyelonephritis
Diabetic nephropathy
Obstructive uropathy – BPH?
Polycystic kidney disease
Renovascular disease
49
An 18 year old man attends the Emergency Department after cutting the volar radial border of his left index finger with a knife while cutting up an apple. There was immediate arterial bleeding.
Other than the digital artery, which is the most likely structure to have been damaged?
digital nerve
50
An 82 year old man is confused and agitated in the recovery room following a transurethral resection for benign prostatic hyperplasia. He had a spinal anaesthetic containing bupivacaine and diamorphine hydrochloride. Hypotonic glycine was used for irrigation for the procedure, and he absorbed 1200 mL of glycine fluid. He was given prophylactic gentamicin at the start of the procedure.
His temperature is 36.2°C, pulse rate 82 bpm, BP 178/92 mmHg, respiratory rate 20 breaths per minute and oxygen saturation 96% breathing 28% oxygen.
Which is the most likely cause of his confusion?
hyponatremia
50
A 20 year old woman presents to the Emergency Department complaining of muscle pain, malaise and headache. She visited her father’s family in India 2 weeks ago where she suffered a bout of diarrhoea. She took appropriate malarial prophylaxis medication.
Her temperature is 39.5°C and pulse rate 62 bpm.
Which I the most likely diagnosis?
enteric fever
51
While playing squash, a 30 year old man was hit by a racquet just below his left knee. Since then he can neither evert nor dorsiflex his left foot. There is a loss of sensation over the front and outer half of his left leg and the dorsum of his left foot. The knee and ankle reflexes are normal.
Which nerve is most likely to be injured?
common peroneal
52
A 71 year old man dies in hospital 36 hours after admission with a chest infection. He was an inpatient briefly 2 weeks ago, when he had an inconclusive bronchoscopy and pleural biopsy. He had been receiving an occupational pension for pneumoconiosis and was living alone, refusing help from social services.
Which is the most important reason for referring to the coroner/procurator fiscal?
Death due to industrial disease
53
A 67 year old woman has weakness in her left arm and shoulder. She has recently undergone a left mastectomy and lymph node dissection for breast carcinoma.
She has reduced abduction in her left shoulder and winging of the scapula.
Which nerve is most likely to have been damaged?
Long thoracic nerve
54
A 67 year old man with lung cancer requires 60 mL of 10 mg/5 mL oral morphine solution per day to control his pain. His GP would like to convert this to regular controlled release morphine.
Which is the correct dose of controlled release morphine required to manage his pain?
60 mg twice daily
55
A 21 year old man presents to his GP with an erythematous rash on his glans penis. He also reports tiredness and increased thirst over the past 1 month. He has been waking up to pass urine three or four times per night and also has daytime urinary frequency but no other urinary symptoms.
Which is the most likely diagnosis?
DM
56
A 72 year old woman has severe lower gastrointestinal haemorrhage. Colonoscopy shows active bleeding from a caecal carcinoma that cannot be controlled endoscopically. A decision is made to proceed to embolisation.
Which artery must be accessed for embolisation?
Superior mesenteric
57
A 63 year old man has right-sided weakness and difficulty speaking that lasts for 25 minutes and resolves completely. He has a history of hypertension and is an ex-smoker.
He has an audible bruit high on the left side of his neck. Ct scan of the head is normal.
Which is the most appropriate next imaging?
Carotid Doppler ultrasonography
58
A 65 year old woman attend for routine breast screening. She has no symptoms of breast disease, no relevant family history and is not on any medication. She has a normal breast examination. The mammogram shows and area of focal microcalcification.
Which is the most common pathological cause?
Ductal carcinoma in situ (DCIS)
59
A 70 year old man attends his general practitioner with pain in his left foot. He has pain in his left calf when walking that has been progressively worsening over the past three months. Now he has pain at night. He has a past medical history of ischaemic heart disease and stopped smoking six years ago after a myocardial infarction.
He has a pulse rate 88 bpm and BP of 160/88 mmHg. His left foot is cold and there are no palpable pulses below the femoral artery.
Which is the most likely diagnosis?
acute limb ischaemia
60
A 64 year old woman collapses on the ward. The nurses repot that she had breathlessness just before her collapse. She was admitted that morning with cellulitis and had received her first dose of antibiotics in the Emergency Department.
Her pulse rate is 100 bpm, BP 80/40 mmHg, respiratory rate 32 beaths per minute and oxygen saturation 94% on 10 L/min oxygen.
Which is the most appropriate immediate treatment?
0.9% Sodium chloride fluid bolus
Adrenaline – lol silly
61
A 62 year old man becomes progressively hypotensive six hours after a right hemicolectomy. He has a past history of type 2 diabetes and hypertension. He received prophylactic antibiotics per-operatively. His observation charts show a rising heart rate before his BP started to fall.
He now has a pulse rate of 120 bpm and BP of 80/54 mmHg. He looks pale and his peripheries are cool. A fluid bolus of 500 mL of 0.9% sodium chloride results in a rise in systolic blood pressure to 100 mmHg and a reduction of his heart rate to 96bpm. His urine output in his catheter bag is <30mL/h.
Which type of shock is most likely in this case?
hypovolaemic
62
A 72 year old woman is admitted with three days of cough and fever. She has been unwell for the past two to three months with lethargy, arthralgia and anorexia. She has hypertension. Her creatinine concentration two months previously was 71 µmol/L (60-120).
She has a temperature of 38°C, pulse rate 87 bpm and BP of 132/70 mmHg, and her oxygen saturation is 98% on 40% oxygen via a face mask. She has coarse inspiratory crackles at the right base. Urinalysis shows protein 4+, blood 1+.
Investigations:
sodium 132 mmol/L (135-146)
potassium 5.3 mmol/L (3.5-5.3)
urea 14.7 mmol/L (2.5-7.8)
creatinine 275 µmol/L (60-120)
eGFR 25/mL/min/1.73 m2 (>60)
albumin 28 g/L (35-50)
urinary protein:creatinine ratio 340 mg/mmol (<20)
urinary sodium 18 mmol/L
Ultrasound scan shows that both kidneys are 11 cm in diameter and not obstructed.
Which feature favours an intrarenal, as opposed to a prerenal, cause for her acute kidney injury?
Systolic BP >130 mmHg
63
A 60 year old man has reduced urine output 24 hours after gastrectomy and splenectomy for a gastric tumour. He is receiving 0.18% sodium chloride/4% glucose at 80 mL/h.
His temperature is 37.0°C, pulse rate 88 bpm, BP 121/67 mmHg and CVP 4 cmH20. His urine output has been 10-20 mL/h for the past 4 hours. Clinical examination is normal.
Which is the most appropriate immediate management?
Replace urinary catheter
64
An 87 year old man falls and fractures his left neck of femur. He is admitted to hospital, and told that he needs to undergo a hemiarthroplasty. The doctor taking consent from him explains what the operation involves.
Which is the best description of this procedure?
Replacement of the head and neck of the femur
65
A 75 year old woman has a 1.5cm left breast lump. She has a history of hypertension and COPD.
Investigations:
Core biopsy: grade 3 invasive ductal carcinoma that is oestrogen receptor negative
Ultrasound scan of axillary: negative
Which is the most appropriate initial treatment?
Wide local excision and sentinel node biopsy – grade 3 not stage 3
66
A 19 year old man is admitted to hospital following a motor bike collision where he sustained a severe head injury.
He is on a ventilator and his brain scan shows extensive damage. His pupils are fixed, dilated and non responsive. He is not sedated.
Which investigation needs to be performed before he becomes a heart beating organ donor?
brain stem death tests
67
An 84 year old woman has cut her leg following a fall in the garden. She cannot provide any immunisation history.
There is a deep laceration. The laceration is cleaned and sutured, and she is given analgesia and antibiotics.
Which is the most appropriate additional treatment?
immunoglobulin
68
A 72 year old man had a laparotomy for a perforated colonic diverticulum 4 hours ago. He has been given 1 g of paracetamol and 10 mg of morphine sulfate within the past hour.
His temperature is 37.2°C, pulse rate 108 bpm, BP 96/62 mmHg, respiratory rate 6 breaths per minute and oxygen saturation 87% breathing 40% oxygen. He is drowsy but easily rousable and talking coherently.
His inspired oxygen is increased.
Which is the most appropriate immediate management?
naloxone
68
A 64 year old man has weight loss of 10kg over the last three months. He drinks six units of alcohol and smokes 20 cigarettes per day. He is jaundiced and has 2 cm hepatomegaly.
What is the most likely primary site of malignancy?
Liver? oesopjhagus? stomach?
69
A 55 year old man is rescued from a collapsed building where he has been trapped for 12 hours without water.
He has a temperature of 35.6°C, pulse ate 100 bpm and BP of 90/42 mmHg. His JVP is not visible. His abdomen is non tender.
Investigations:
Haemoglobin 168 g/L (130-175)
Sodium 148 mmol/L (135-146)
Potassium 6.22 mmol/L (3.5-5.3)
Urea 25.1 mmol/L (2.5-7.8)
Creatinine 184 µmol/L (60-120)
Creatine kinase 840 U/L (25-200)
Which is the most likely cause of this biochemical picture?
hypovolaemia
70
A 35 year old man has a gradual onset of hesitancy and poor urinary flow. He has a past history of urinary tract infection, which he developed while on holiday. Urinalysis is normal. Digital rectal examination reveals a small, firm, non-tender prostate.
Which is the most likely underlying cause for his symptoms?
Urethral stricture
71
A 21 year old man has 4 days of a widespread rash and malaise. He has had several male sexual partners over the past few months.
There is a macular rash over his body, including his palms, soles and scalp, a few palpable lymph nodes in his groin and a small popular lesion on the glans of his penis.
Which is the most likely diagnosis?
Syphilis
71
A 68 year old man is receiving palliative care for bone metastases. He complains of pain in his right arm which paracetamol and ibuprofen fail to relieve. Morphine sulphate is suggested to him, but he is concerned about the side effects of morphine.
Which is the most frequent side effect?
Constipation
72
A 66 year old man has had left sided abdominal discomfort for the pat 1 month.
He has widespread purpura and a palpable spleen measuring 17 cm from the left costal margin. There is no hepatomegaly or lymphadenopathy.
Investigations:
Haemoglobin 85 g/L (130-175)
White cell count 0.5 x 109/L (3.0-10.0)
Platelet count 38 x 109/L (150-400)
INR 1.0 (1.0)
Activated partial thromboplastin time 31 s (22-41)
Which is the most likely diagnosis?
Myelofibrosis
73
An 18 year old man is worried about his cancer risk. His paternal grandfather died of colorectal cancer at 42 years of age and his 36 year old father has just been diagnosed with colorectal cancer. The son’s colonoscopy shows hundreds of colonic polyps, and biopsies from several of the polyps show adenomatous change with low grade dysplasia.
Which is the most appropriate strategy to prevent colon cancer in this situation?
Panproctocolectomy
74
A 75 yar old man is found collapsed at home and is brought to the Emergency Department. He has right sided weakness and reduced consciousness. He has a history of type 2 diabetes mellitus, atrial fibrillation and hypertension. He is taking warfarin.
Investigations:
INR is 4.6 (<1.0).
CT scan of the head shows a large intracranial haemorrhage. His is given intravenous vitamin K.
Which is the most appropriate next additional treatment?
Prothrombin complex concentrate
75
A 70 year old man has bright red rectal bleeding. Rigid sigmoidoscopy reveals a smooth and pedunculated polyp, 1 cm in diameter and 3 cm from the anal margin.
Which type of tumour is this polyp most likely to be?
Adenoma
76
A 55 year old woman ha two months of increasing ankle oedema. She has felt tied and lethargic and has also noticed occasional blood and mucus in her stools.
Her BP is 168/90 mmHg and JVP +2 cm above the sternal angle. She has oedema to mid-calf bilaterally.
Investigations:
Urea 8.0 mmol/L (2.5-7.8)
Creatinine 124 µmol/L (60-120)
Albumin 22 g/L (35-50)
Urinary protein: creatinine ratio 754 mg/mmol (<30)
Which is the most likely diagnosis?
Membranous nephropathy
77
77
A 77 year old man has been unable to pass urine for 12 hours and has severe suprapubic pain.
His bladder is palpable to the level of the umbilicus. He is catheterised and 1.5 L of urine is drained. A digital rectal examination shows an enlarged prostate and empty rectum.
Which is the most appropriate first-line class of drug to prescribe?
α-Adrenoceptor blocker
78
A 25 year old man has urinary hesitancy and a sensation of incomplete voiding, just after recovering from a severe urinary infection. He has primary progressive multiple sclerosis but lives independently.
An ultrasound scan of his bladder indicates 400 mL of urine after voiding. Urinalysis reveals heavy growth of Proteus species.
Which is the most appropriate long term management?
Intermittent self catheterisation?? what about his MS
Suprapubic catheterisation
78
A 40 year old woman attends the ear, nose and throat clinic with a series of episodes of vertigo over the past 3 years. Each episode is preceded by a feeling of fullness in her left ear. The attacks last several hours and leave her with left sided tinnitus and deafness. She sometimes vomits during the attacks. An audiogram shows a left sided sensorineural hearing loss.
Which is the most likely diagnosis?
Ménière’s disease
79
A 60 year old man presents with weight loss and a cough productive of mucus mixed with blood. He is a smoker and has a history of chronic cough. His voice has recently become very weak. On examination, his left vocal cord is paralysed but the rest of the larynx is normal.
What is the most likely cause of the vocal cord paralysis?
Carcinoma of the left main bronchus
80
A 64 year old man had a mitral valve replacement two years ago. He attends the Anticoagulant Clinic three days after his son’s wedding where he consumed 30 units of alcohol. He has a previous history of excess alcohol consumption.
His international normalised ratio (INR) is 8.5 (1.0) and he has a few old bruises on his legs. There is no haematuria and no epistaxis or other evidence of bleeding. Abdominal examination shows mild tenderness with sparse bowel sounds.
His warfarin has been temporarily discontinued.
Which is the most appropriate treatment?
Vitamin K orally
81
A 22 year old woman has a painless swelling in the left side of her neck. She first discovered the lump several months ago and noticed that it became slightly more prominent after a recent cold.
She looks well. Her temperature is 37.2°C. There is a 3 cm x 4 cm oval, non-tender, fluctuant mass along the lower third of the anteromedial border of the sternocleidomastoid muscle.
Which is the most likely diagnosis?
branchial cyst
82
A 28 year old man has a headache, intermittent fever, sore throat and diarrhoea.
He has a temperature of 37.7°C. His facies are red and there are two small aphthous ulcers on his left buccal mucosa. He also has a maculopapular erythematous rash on his upper trunk, red hands and folliculitis on his chest. His liver and spleen are just palpable and he has mild neck stiffness.
Investigations:
haemoglobin 135 g/L (130-175)
white cell count 3.3 x 109/L (3.0-10.0)
platelets 84 x 109/L (150-400)
Which next investigation is most likely to lead to a diagnosis?
HIV serology
83
A 23 year old woman has 2 days of localised right-sided loin pain, and visible haematuria but no dysuria.
Her temperature is 36.5°C and BP 158/86 mmHg. There is a mass that is just palpable in the right loin. Urinalysis shows blood 4+, protein 1+, leucocytes 1+ and nitrites negative.
Investigations:
Haemoglobin 135 g/L (115-150)
Urea 6.2 mmol/L (2.5-7.8)
Serum creatinine 98 µmol/L (60-120)
Which is the most likely diagnosis?
Adult polycystic kidney disease
or
Renal cell carcinoma. ( single mass?)
84
A 27 year old man is brought to the Emergency Department having fallen from a ladder. He has a compound fracture of his right femur.
He is maintaining his airway and has cold peripheries with a capillary refill time of 4 seconds. His pulse rate is 135 bpm, BP 89/55 mmHg, respiratory rate 32 breaths per minute and oxygen saturation 98% breathing 15 L/min oxygen via a non-rebreathing mask.
Fluid resuscitation is started with Hartmann’s solution.
Which is the most appropriate initial treatment for his pain?
Intravenous paracetamol?
IV morphine?
84
A 90 year old woman is admitted with a urinary tract infection and acute kidney injury. She has a history of peripheral vascular disease, hypertension, CKD stage and osteoarthritis. She takes amlodipine (5 mg once daily), clopidogrel (75 mg once daily), docusate sodium (100 mg three times daily), morphine sulfate (20 mg twice daily), and paracetamol (1 g four times daily).
Her temperature is 37.5°C, pulse rate 90 bpm and BP 130/85 mmHg.
Investigations:
Creatinine 201 µmol/L (60-120)
eGFR 18 mL/min/1.73m2 (>60)
Which of her medications is most likely to accumulate?
Morphine sulfate
85
A 68 year old woman develops a temperature while receiving a blood transfusion. She was admitted eight hours previously with one month of lethargy and breathlessness on exertion. She has ischaemic heart disease.
Admission investigations:
Haemoglobin 56 g/L (115-150)
MCV 76 fL (80-96)
She was advised to have a two unit blood transfusion. The first unit was prescribed over two hours with furosemide 20 mg orally.
Her temperature is 38.0°C, pulse rate 76 bpm, BP 137/80 mmHg, and oxygen saturation 95% breathing air.
The nurses have stopped the transfusion and given the patient paracetamol. The patient has no other symptoms.
Which is the most appropriate next step?
Check identity of patient and details of the unit of blood
86
A 34 year old man has fevers, rigors and collapse.
His temperature is 39.1°C, pulse rate 105 bpm, BP 92/56 mmHg and respiratory rate 25 breaths per minute. He has widespread purpura and evidence of papilloedema.
He is treated with fluids and broad-spectrum antibiotics.
Investigations:
Haemoglobin 85 g/L (130-175)
White cell count 75.2 x 109/L (3.0-10.0)
Platelets 38 x 109/L (150-400)
Neutrophils 73.2 x 109/L (2.0-7.5)
Blood culture Escherichia coli isolated
Which is the most likely cause of his high white cell count?
Acute leukaemia
87
A 40 year old woman with a malignant brain tumour is invited to consider participation in a phase 3 clinical trial of a new agent. She asks the purpose of phase 3 clinical trials.
Which is the key purpose of a phase 3 clinical trial?
To test efficacy of the new agent compared with standard care
88
A 19 year old man presents to the Emergency Department with 48 hours of fever, sore throat and a generalised rash that began on his face and has spread downwards.
His temperature is 39.1°C, pulse rate 112 bpm and BP 106/65 mmHg. He has a widespread blanching rash and conjunctivitis. There are white spots in his mouth.
Which is the major mode of transmission of the pathogen?
Respiratory droplet
89
A 38 year old woman is scheduled to have an elective hysterectomy for menorrhagia. She smokes 20 cigarettes a day and is not taking any medications.
Her haemoglobin concentration is 98 g/L (115-150).
Which preoperative test is it essential to undertake?
Blood group and save serum
90
A 65 year old man has 3 weeks of progressive ankle oedema.
His BP is 125/85 mmHg and oxygen saturation 98% breathing air. He has marked bilateral pitting ankle oedema and reduced chest expansion.
Investigations:
Creatinine 85 µmol/L (60-120)
Urinary protein: creatinine ratio 300 mg/mmol (<30)
Fasting glucose 5.7 mmol/L (3.0-6.0)
Albumin 22 g/L (35-50)
Total cholesterol 9 mmol/L (<5.0)
Which treatment is most likely to reduce the amount of urinary protein?
ramipril?
91
74 y/o patient on an assortment of medications for the past 10 years, presents with a #NOF low impact (think she kicks a football to her grandson and has a fracture) subtrochanteric femur #. Which drug is the most likely cause
Alendronic acid – Bisphosphonates associated with atypical femur fractures
92
Bradycardia during cystoscopy
atropine
93
A 60 year old male with B symptoms with lymphadenopathy, anaemia raised neutrophils but no raised lymphocytes, raised LDH
Lymphoma
94
Patient has hyperkeratosis suggesting Tinea pedis, what is the causative organism?
Trichophyton rubreum – aka athletes foot
95
Patient had anaemia with normal ferritin in male with CKD, what do you do next?
EPO
96
SVC symptoms with lung mass in right upper lung. What is diagnostic investigation?
CT chest
97
DEEP abdominal pain and right loin pain, vomiting 1 hour, now hypotensive, cap refill 5s. pmhx hypertension and hypercholesteremia
Ruptured AAA
98
Epigastric pain in the mornings, settles with a morning cup of milk. Tender on palpation. Low Hb and low MCV
duodenal ulcer
99
Immunosuppressed patient with hx radiotherapy to lumbar spine/abdo, pain on swallowing. No regurgitation. Blood tests show neutropaenia.
oes stricture
100
Partygoer vomited 3 times, 4th time vomited a cup of bright red blood. What is the most likely cause?
mallory weiss
101
Prostate metastases to the spine, sclerotic, back pain, no nerve impingement, no fractures, PO morphine is not working.
radiotherapy
102
Overdose, dilated pupils with widened QRS. Patient refuses to disclose what medication was overdosed. What was the agent?
amitriptyline
103
History of atopy, with pollen being the trigger. Now spring and both eyes are watery, red and sore. – allergic conjunctivitis v
Antihistamine eye drop
104
Main DMARD for rheumatoid arthritis (yes they said dmard in the question)
methotrexate
105
Correct statin target 3 months after starting treatment:
>40% reduction in non-HDL cholesterol
106
Bilateral resting tremor, falls, shuffling (small stepping) gait, no bradykinesia, bilateral cogwheel rigidity, increase tone at the wrists. Taking chlorpromazine, statin and antihypertensive.
Drug induced
107
Delirium and usually well, patient wandering the wards at night and refuses to go to bed - mx
Orientation techniques
108
24hrs post MI, new mid systolic murmur, raised JVP, breathless, afebrile
pericarditis
109
URTI a week ago, presents with flushing, diarrhoea and palpitations. Tender enlarged mass at neck, isotope shows diffusely reduced uptake. TSH is low, T4 and T3 are raised.
Viral (subacte/dq) thyroiditis
110
Insulin before surgery. Patient with type 1 diabetes and taking both long acting and short acting. What should be done to prepare them for surgery?
usually can just adjust
if poor control/long surgery - VRII
111
82 year old female had stroke, found to have AF, currently taking aspirin 75mg for previous MI.
Change aspirin to apixaban
112
Transfusion reaction. 10 minutes, pyrexia, loin pain, normotensive
ABO incompatibility
113
A female patient woke up with leg weakness at 0700, daughter saw them last at 2300 and she was normal. Now 0800 she has progressive aphasia. 0830 CT scan shows infarct and no haemorrhage. She has a past history of AF.
Give alteplase
114
A male and young patient in his 20s presents with sudden and painful vision loss however notes that this has happened before a few weeks ago and recovered after four weeks.
Optic neuritis –
115
Patient with diabetes, only controlled on diet, and presents with visual loss.
Send to ophthalmologist
116
Old man had a 3/7 hx of a fall, since then unable to weight bear. Physiotherapist unable to assess him due to patient being in pain when touched, but x-ray only showed minor degenerative changes only. What do you do?
CT hip and pelvis
117
House fire inhaled. Patient needs increased ventilatory pressures, what is the reason?
surfactant insufficency
118
House fire inhaled. Patient needs increased ventilatory pressures, what is the reason?
Wrist extensors
119
Breastfeeding female patient with 2cm breast abscess for 48 hours. Normal observations. Patient was told to keep feeding as normal. Abscess was drained with needle and sent for MC&S. What to do now?
Flucloxacillin – antibiotics are needed after abscess
120
CKD patient with raised calcium, low phosphate (does not give PTH – was phosphate given to us in this Q?). 6 years ago, her blood tests also showed a raised calcium.
Primary hyperparathyroidism-
121
Patient with BPH symptoms in hospital, what do you start him on?
Catheterise
122
A 40 year old patient worried about getting cancer. Mum received a diagnosis of unilateral breast cancer at 67, brother has metastatic melanoma 5 years ago, uncle with lung cancer at XX age, grandparent with colorectal cancer at 82
Send for BRCA1
123
Parkinson’s patient with recurrent pneumonia, on multiple medications for 10 years, which HCP to refer to
Speech and language therapy
124
A middle-aged man with headache, intermittent left-sided claudication, history of a TIA. He has 220/80 BP and has AKI. Biochemistry (presumably U&E) is normal. Ultrasound showing one kidney is 10cm and the other is 7cm. A scan also showed no obstruction in the ureters.
Urine metanephrines
125
Pleural effusion with cancer – palliative female patient who had mesothelioma and was only going to live for a few more weeks.
Aspiration (thoracocentesis)
126
Difficult to control epistaxis in a patient with recent chemotherapy. Hb 79 platelets 2, low BP
platelet transfusion
127
Patient who was 62 years old and had hypertension on amlodipine, and the ECG was positive according to the voltage criteria for LVH. What to add next?
Bisoprolol
128
Fluid replacement for a female patient 62kg. How much maintenance potassium to add to their fluids in a day?
60mmol
129
Male and young patient with painful left testes pain all through with swelling. Cremasteric reflex is present.
Epididymo-orchitis
130
3 month history of left sided testicular mass and a recent onset of abdominal pain/swelling (can’t remember), which is most likely to be raised? (I think afp was already mentioned to be raised)
bHCG
131
Patient started medication for tuberculosis, on rifampicin, isoniazid, pyrazinamide and ethambutol. What else should be prescribed prophylactically?
Pyridoxine
132
Displaced intracapsular NOF fracture, in a 68 year old man who fell off motorbike, controlled HTN, no other health issues. Most appropriate surgery?
total hip arthroplasty
133
Patient had trauma and initially was speaking to the ambulance staff but deteriorates and on arrival to ED, they present with low GCS. On pain, they would groan, move to localised pain, and have no eye movement. They have no facial trauma.
Oropharyngeal
134
Parotid gland swelling 6 months, not tethered to skin, face weakness and numbness, dribbling fluids.
Pleomorphic adenoma
135
Asthma with RR 30, Exhaustion, PEF 45%, HR 120 what is a sign of life-threatening asthma from the above?
Exhaustion
136
A COPD patient is breathless with 86% oxygen saturations, what should be given initially?
15L/minute via non-rebreathe
137
Patient had SBP with shifting dullness and was treated. Patient currently on furosemide and spironolactone. What other medication should be given?
drain? they put pred but i cnt find anygthing
138
Patient is tired, can’t finish food. This happens at end of the day. 6-month history. Diagnosis?
myasthenia gravis
139
Photosensitive rash with purple dusky colour on both eyelids, photosensitive. 4-month history of progressive weakness, can’t climb stairs and get out of a chair
dermatomyositis
140
T1DM patient went out, boozed, collapsed at home, then had seizure in emergency department. What are your next investigations?
Capillary Glucose
141
UC involving only the rectum and sigmoid colon. 4 month history of bloody diarrhoea. What is initial treatment? (doesn’t specify how often)
topical mesalazine
142
Patient 8 weeks pregnant, wants an abortion and you as the GP agree to this. Patient is HIV positive however does not wish to disclose her HIV status in the referral.
Accept her wish and refer her
143
Patient with Diabetes started metformin 4 weeks ago, since starting she has been having diarrhoea, bloods sugars are still unchecked (didn’t specify values).
Change to modified-release metformin
144
Painless end-of-stream haematuria in a 68 year old patient. Normal observations. Where is the pathology?
Bladder cancer
145
A 66 year old man 5 cm Scalp laceration after hitting head and was on rivaroxaban, he can’t remember how he hurt himself.
CT head
146
Young constipated patient, pain after defaecation, bright red blood
anal fissure
147
Patient with a painless ulcer after unprotected MSM sex
Treponema pallidum
148
Cord compression syndrome, loss of sensation around the mid abdomen (it said around umbilicus specifically), and bilateral weakness and brisk reflexes, UMN signs in both lower limbs, incontinence. Where is the lesion?
above L1 = UMN sx in legs
149
Dermatology psoriasis picture. What management. Now using emollients
Vit d analogue and topical potent steroids
150
Patient has Multiple sclerosis, is complaining of spasticity.
Carbamazepine
151
RUQ pain, known biliary stones, with previous colic, now constant, temp 38.2, raised bilirubin, mildly raised amylase
Cholecystitis
152
38 yo patient with bilateral conductive hearing loss, worsened during pregnancy. Especially at 2000 Hz
otosclerosis
153
Patient comes to GP with vaginal discharge, fishy odour. She is going away on a wine tasting weekend tomorrow. What treatment?
Topical clindamycin
154
Paracetamol overdose. Patient took it 18 hours ago, took 32 500mg tablets. 80kg male. What is your next step?
IV N-acetylcysteine immediately
155
Patient on long term steroids, now presents with progressive bilateral visual disturbances. Loss of the red reflex bilaterally.
cataracts
156
Patient with pale stool, floats on pan and difficult to flush. Xray showed epigastric calcifications. Has been hospitalised many times for epigastric pain.
Impaired exocrine function of the pancreas
157
Patient had splenectomy, on long-term penicillin now. What infection are they most susceptible to?
Strep pneumoniae
158
Alcoholic patient with purpura. APTT extremely raised, 5x upper limit. PT 1x upper limit, reduced fibrinogen and raised d-dimer.
DIC
159
Warfarin patient, had a fall. INR 5.3 and has orbital bleeding. Vit K has been given, what is your next step?
prothrombin complex concentre
160
Shoulder and hip stiffness and pain. Hard to get out of chair. Can’t remember if CK normal or high. (was normal)
PMR
161
Diabetes and 3 day hx of 4/5 strength in the upper limbs, 3/5 strength in the hips, 4/5 in the lower limbs and tingling all throughout. Reduced ankle reflexes. Normal sensation. Patient unable to keep eyes closed against resistance.
GBS
162
18 yo female walked into A&E and feels unwell. Definitely no mention of an IV port. Known diabetic, BM 1.9. What do you give her?
oral cos awake? then IM then IV
163
Patient due for colonic resection surgery, when do you give prophylactic antibiotics
4-8 hours before
164
Pt 5 days post-op on epidural pain relief, was feeling well in bed, had clammy hands, warm feet, BP 90/60, normal HR. 30ml urine produced in past 2 hours
Saline 500ml challenge
165
Man returned from India with meningism. LP showed low opening pressure, normal glucose, high protein, lymphocyte predominant cells 90%.
viral
166
A patient with XXX symptoms, had a lung biopsy of a peripheral lesion, with histology results of: glandular cells with cellular atypia, something about nuclei and something else.
adenocarcinoma
167
Stable angina patient, relieved by her sublingual GTN and was on statin?. What else do you add?
Beta blocker
168
Hyponatraemia question with urinary sodium >20, serum sodium 122 and JVP was not raised, BP was normal.
Fluid restrict
169
Went on holiday and swam in the ocean, now pain when pressing on tragus and canal looks macerated. Nothing wrong with tympanic membrane. What’s the treatment?
Steroid and abx drops
170
Patient has stroke, impacted mobility a lot. Son wants them to go to care home, patient wants to go back home. What do you do next?
assess capacity
171
Patient had stage IIIB colon cancer removed. 1cm margin clear of cancer cells. 1/16 LNs removed positive. What do you do now?
chemo
172
Patient with #NOF with pain uncontrolled pain. Was on IV paracetamol but it did not relieve pain. What is the next analgesia to offer?
IV morphine
