SPECIALTIES 2021 Flashcards
(157 cards)
1
Q
A 5 year old boy in General Practice has 3 days of cough and coryza. His mother noticed a fever and a rash this morning. His temperature is 39C, pulse rate 150 bpm, respiratory rate 35 breaths per minute, and oxygen saturation 99% breathing air. His rash is found to be non-blanching. Which medication should be prescribed in this scenario?
a. IM Benzylpenicillin
b. IM Hydrocortisone
c. PO Co-Amoxiclav
d. PO Paracetamol
e. PO Penicillin V
A
IM Benzylpenicillin
2
Q
A 9 year old girl is in Paediatric Outpatients following parental concerns about her weight. During the consultation the girl reveals she is being bullied at school. Her weight is 49kg, and height is 1.37m (given growth chart with this plotted). Her thyroid function test results are as follows. TSH 3.5mU/L (0.7-4.1), free T4 16 pmol/L (12-22). Which is the most appropriate next step in her weight management?
a. Prescribe metformin
b. Prescribe orlistat
c. Refer to a paediatric dietician
d. Refer to Child and Adolescent Mental Health Services (CAMHS)
e. Refer to endocrinology
A
Refer to a paediatric dietician
3
Q
A 3 week old girl has had loose stools since day 2 of life and there are now streaks of blood in the stool. The baby examies well with normal observations, normal findings on abdominal examination, but there is dry skin on the scalp and face. Which is the most likely diagnosis?
a. Coeliac disease
b. Cow’s milk protein allergy
c. Gastroenteritis
d. Intussusception
e. Lactose intolerance
A
Cow’s milk protein allergy
4
Q
A 3 year old girl with eczema has a 2 day history of a new rash on her arms (see image). Which is the most appropriate treatment for this rash?
a. IV aciclovir
b. IV flucloxacillin
c. Topical clobetasone
d. Topical emollient
e. Topical fucidin
A
a. IV aciclovir
5
Q
An 11 year old girl has had intermittent central abdominal pain for 6 months. Her symptoms improved over the summer holidays but returned in the autumn. She also had headaches, which settled with no treatment. She opens her bowels daily with type 4 stool, and no bleeding. There is no history of fevers, vomiting or urinary frequency. Her height and weight have remained on the 75th centile. Which is the most likely diagnosis?
a. Coeliac disease
b. Constipation
c. Crohn’s disease
d. Functional abdominal pain
e. Urinary tract infection
A
Functional abdominal pain
6
Q
A 15 year old boy has 3 weeks of cough, weight loss, night sweats and fever. He moved to the UK from India 3 years ago. His chest x-ray is show in the image (can’t find exact image but showed some left upper zone shadowing I think). Which investigation is regarded as the gold standard for diagnosis for his underlying condition?
a. Blood culture
b. Gastric washings
c. Mantoux
d. QuantiFERON / IGRA
e. Sputum culture
A
Sputum culture
7
Q
The parents of a 7 year old boy are concerned about intermittent pains in his leg, which have worsened over the last few days. He has now developed a limp. His temperature is 36.5C, heart rate 80 beats per minute, respiratory rate 20 breaths per minute. Which is the most likely diagnosis?
a. Henoch Schönlein Purpura
b. Osgood Schlatter’s
c. Perthes disease
d. Reactive arthritis
e. SUFE
A
c. Perthes disease
8
Q
A 3 year old girl in the paediatric Emergency Department has conjunctival pallor, lethargy and dark urine. Last week she finished a course of nitrofurantoin for a urinary tract infection. Her blood results are as follows: Hb 70 g/L (110-140), WBC 3.2 x 10^9/L (5.0 - 12.0), platelets 520 x 10^9/L (150 - 400), albumin 37 g/L (30 - 50), bilirubin 75 umol/L (<21), ALT 18 IU/L (0 - 29), ALP 130 IU/L (60 - 425). Which is the most likely underlying diagnosis?
a. Beta Thalassaemia
b. G6PD deficiency
c. Hereditary spherocytosis
d. Iron deficiency anaemia
e. Sickle cell disease
A
b. G6PD deficiency
9
Q
A 7 year old boy has a history of recurrent chest infections, persistent sinusitis and has been prescribed multiple courses of antibiotics. He has bibasal crepitations and a right-sided apex beat. Which is the most likely underlying diagnosis?
a. Agammaglobulinaemia
b. Cystic fibrosis
c. HIV
d. Primary ciliary dyskinesia
e. Tracheo-oesophageal fistula
A
Primary ciliary dyskinesia
10
Q
A 3 day old baby girl is not feeding well. Her temperature is 36.7C, heart rate 180 bpm, respiratory rate 66 breaths per minute. There is a systolic murmur and femoral pulses are not palpable. Which is the most likely diagnosis?
a. Atrial septal defect
b. Coarctation of the aorta
c. Patent ductus arteriosus
d. Patent foramen ovale
e. Ventricular septal defect
A
Coarctation of the aorta
11
Q
A 5 year old girl in the paediatric Emergency department recently had a sore throat and now has a rash across her lower legs. She is afebrile but has abdominal pain and joint pains in both legs. Her full blood count result is as follows: Hb 110 g/L (115 - 140), WCC 10.3 x 10^9/L (3.8 - 10), neutrophils 6 x 10^9/L (150 - 400). Which is the most likely diagnosis?
a. Acute lymphoblastic leukaemia
b. Henoch Schonlein Purpura
c. Idiopathic thrombocytopenic purpura
d. Juvenile idiopathic arthritis
e. Meningococcal septicaemia
A
Henoch Schonlein Purpura
12
Q
A 15 year old girl in outpatients has no sign of breast development. Her growth is plotted in the chart below (growth chart showed short stature for age). She has widely spaced nipples and wide carrying angle of her arms. Which is the most likely diagnosis?
a. Familial short stature
b. Hypothyroidism
c. Kallmann’s syndrome
d. Noonan’s syndrome
e. Turner’s syndrome
A
Turner’s syndrome
13
Q
A 15 year old boy presents to the Emergency Department with nausea, diarrhoea and abdominal pain, jaundice, lethargy and generalised joint pains. The diarrhoea is watery, pale in colour and does not contain blood. He returned from Thailand last week.
Investigations:
Hb 150 g/L (130 -175)
WBC 12.5 x 10^9/L (3.8 - 10.0)
Platelets 380 x 10^9/L (150 - 400)
Albumin 48 g/L (30 - 50)
ALT 650 IU (0-37)
ALP 280 IU (60 - 425)
Bilirubin 110 umol/L (<21)
Gamma-GT 94 IU/L (9 - 40)
Which is the most likely diagnosis?
a. Hepatitis A infection
b. Hepatitis B infection
c. Infectious mononucleosis
d. Shigella enteritis
e. Typhoid fever
A
Hepatitis A infection
14
Q
An 8 year old boy in the Emergency Department has been unable to open his left eye for 1 day. Prior to this he had a cold one week ago. When examining the left eye, it is difficult to open, and he reports pain on all eye movements. The conjunctiva is injected. Which is the most appropriate next step in management?
a. Blood pressure
b. Blood tests
c. CT head
d. Lumbar puncture
e. Refer to specialist
A
CT head
15
Q
. A 4 year old boy has recently emigrated to the UK with a chronic persistent cough, frequent chest infections and loose stools. He has low weight, a wet cough and nasal polyps. His uncle had a similar condition, and died at age 28. Which investigation is discriminatory in this scenario?
a. Chest x-ray
b. Mantoux test
c. Pernasal swab
d. Sputum culture
e. Sweat test
A
Sweat test
16
Q
A 5 year old girl has 5 days of fever, red lips, red eyes and cervical lymphadenopathy. She has had a course of amoxicillin for a sore throat. Which is the definitive treatment in this scenario?
a. IV aciclovir
b. IV ceftriaxone
c. IV clindamycin
d. IV IG
e. IV remdesivir
A
IV IG
17
Q
A 7 year old girl has breast buds but no pubic hair. Her height is on the 98th centile and her weight is on the 75th centile. She is otherwise fit and well. There is no significant family history. Investigations show: bone age of 10 years, FSH 3.2 IU/L (<1), LH 3.4 IU/L (<1). Which is the most likely diagnosis?
a. Adrenarche
b. Central precocious puberty
c. Congenital adrenal hyperplasia
d. Normal variant
e. Thelarche
A
Central precocious puberty
18
Q
A 4 year old boy is in the Emergency Department has 1 week of tiredness. His mother reports that he has generalised swelling, mostly around the eyes and lower legs. His abdomen also seems bigger than normal. Which is the most appropriate first line investigation in this scenario?
a. 24 hour urine collection
b. Abdominal ultrasound
c. Abdominal x-ray
d. Blood tests
e. Urine dipstick
A
Urine dipstick
19
Q
A 2 year old boy has daily loose stools for 2 weeks, containing visibly undigested food matter, such as peas and carrots. He is growing along the 50th centile. Which is the most likely diagnosis?
a. Constipation with overflow
b. Food poisoning
c. Gastroenteritis
d. Inflammatory bowel disease
e. Toddler diarrhoea
A
Toddler diarrhoea
20
Q
A 4 year old boy has abdominal pain for 2 weeks and noticed some blood in his urine. He has a palpable abdominal mass on the left side, extending below the umbilicus. Which is the most likely diagnosis?
a. Constipation
b. EBV
c. Horseshoe kidney
d. Neuroblastoma
e. Wilms tumour
A
Wilms tumour
21
Q
A 3 year old boy attends the Emergency Department after an episode of sudden onset jerky movements of both arms and legs for 5 minutes, which stopped before the ambulance arrived. His current observations are: temperature 38.5C, pulse 130 bpm, blood pressure 100/90 mmHg, respiratory rate 25 breaths per minute, oxygen saturation 98% breathing air. He has had a coryzal illness for 24 hours and is otherwise fit and well. He is alert, with a blood glucose of 4.5 mmol/L (3.0 - 6.0) and neurological examination is normal. Which is the most appropriate next step in management?
a. Order a CT brain and observe
b. Prescribe buccal midazolam and discharge
c. Prescribe IV ceftriaxone and admit
d. Prescribe oral antipyretics and observe
e. Prescribe oral co-amoxiclav and discharge
A
Prescribe oral antipyretics and observe
22
Q
. A term infant born to a diabetic mother is 4 hours old on the postnatal ward and is noted to be jittery. The capillary blood gas result is as follows: pH 7.37 (7.35 - 7.45), PCO2 5.5 kPa (4.6 - 6.4), PO2 4.9 kPa (8 - 12), glucose 2.4 mmol/L (3 - 6), lactate 2.0 mmol/L (1 - 2). Which is the most appropriate treatment for the baby in this scenario?
a. Buccal midazolam
b. Feed the baby
c. IV dextrose
d. IV lorazepam
e. Oxygen
A
IV dextrose
23
Q
A 2 year old boy has acute onset of cough and drooling, with inspiratory upper airway noises. His vaccinations are up to date. His examination is otherwise normal. His temperature is 36.8C, pulse 120 bpm, blood pressure 100/60 mmHg, respiratory rate 26 breaths per minute and oxygen saturation 98% breathing air. Which is the most likely diagnosis?
a. Anaphylaxis
b. Croup (parainfluenza)
c. Epiglottitis (HiB)
d. Inhaled foreign body
e. Laryngomalacia (weakened larynx cartilage, inspiratory stridor)
A
Inhaled foreign body
24
Q
A 14 year old girl attends Paediatric Outpatients with ongoing headaches. These are associated with nausea and vomiting and she is missing school. They are occurring once per month and at any time of day. The headaches eventually settle after lying down in a dark room. She has tried NSAIDs, which do not help. Neurological examination is normal. Which is the most appropriate treatment?
a. Aspirin once daily
b. Metoclopramide when required
c. Nasal sumatriptan when required
d. Pizotifen when required
e. Propanolol once daily
A
Nasal sumatriptan when required
25
12 year old boy in GP complains of ongoing headaches for the last 4 months. The headaches are severe and throbbing in nature and often associated with nausea and vomiting. The headaches are worse in the morning. His father has noticed he is more tired than usual and has been more irritable. His weight is 62 kg. Which is the most likely diagnosis?
a. Benign intracranial hypertension
b. Insomnia
c. Low mood
d. Migraine
e. Tension headaches
Migraine
26
A 5 year old boy in General Practice has bright red blood when opening his bowels for 1 week. He opens his bowels every 3 days. He has no past medical history and is thriving. He has a well-balanced diet and has good fluid intake. There are no safeguarding concerns. Abdominal examination is unremarkable. Rectal inspection reveals a fissure. Which is the most appropriate management?
a. Dietary advice
b. Osmotic laxative
c. Phosphate enema
d. Stimulant laxative
e. Toilet training
Osmotic laxative
27
A 7 year old boy in General Practice has a sore throat, fever and pain on swallowing for 1 day. His temperature is 38.5C, pulse rate 110 bpm, respiratory rate 24 breaths per minute, and oxygen saturation 99% breathing air. He has bilateral tonsillar enlargement with exudate and bilateral cervical lymphadenopathy. He is talking in full sentences without using accessory muscles. Which is the most appropriate management?
a. Admit to hospital
b. Continue supportive measures
c. Prescribe amoxicillin
d. Prescribe phenoxymethylpenicillin
e. Review in 48 hours
Prescribe phenoxymethylpenicillin
28
14 year old has a 2 day history of worsening abdominal pain, reduced appetite and constipation. His temperature is 38.1C. He is tender in his right lower quadrant. Which is the most appropriate action?
a. Admit to hospital for assessment
b. Encourage oral fluids
c. Prescribe analgesia and follow up next week
d. Prescribe movicol
e. Refer to paediatric 2 week wait
Admit to hospital for assessment
29
A 6 week old baby is seen for his routine baby check in General Practice with his mother. She has no concerns. A soft systolic murmur is heard on examination. It varies with posture and does not radiate. The child appears well. Which is the most likely diagnosis?
a. Coarctation of the aorta
b. Innocent murmur
c. Patent ductus arteriosus
d. Pulmonary stenosis
e. Ventricular septal defect
Innocent murmur
30
A 7 year old boy in General Practice has ongoing night time bed-wetting. He is dry during the day but has never been dry at night. His mother has tried managing his fluid intake, regular toileting and a star chart for 6 months with no success. He has no past medical history and takes no regular medication. He is doing well at school and at home. Abdominal examination is unremarkable.
Urinalysis:
Glucose - negative
Protein - negative
Ketone - negative
Blood - negative
Nitrites - negative
Leukocytes - negative
Which is the most suitable management option?
a. Continue star chart
b. Desmopressin
c. Enuresis alarm
d. Imipramine
e. Oxybutynin
Enuresis alarm
31
43. The father of a 3 year old is concerned about her weight. She is always hungry and has put on a lot of weight this year due to overeating. The child is short in stature, has almond-shaped eyes and a narrow forehead. Which is the most likely diagnosis?
a. Edward’s syndrome
b. Fragile X syndrome
c. Pierre-Robin syndrome
d. Prader-Willi syndrome
e. William’s syndrome
Prader-Willi syndrome
32
A 2 year old in General Practice has a cough. He has reached all of his developmental milestones at the right time so far. Which motor skill would this child have most recently acquired?
a. Crawling
b. Draw a circle
c. Draw a square
d. Transfers objects from one hand to the other
e. Turning one page in a book
Turning one page in a book
33
A 72 year old man has a 6 month history of low mood, poor sleep and poor appetite. His wife died 1 year ago. He complains of poor memory, forgetting to take his medication and forgetting appointment dates and neglecting to pay bills. He used to attend the community centre but no longer enjoys doing so. He feels hopeless about the future. He denies social ideation. Which is the most likely diagnosis?
a. Abnormal grief reaction
b. Adjustment disorder with depressed mood
c. Alzheimer’s disease
d. Severe depressive episode without psychotic features
e. Vascular dementia
Severe depressive episode without psychotic features
34
. A 28 year old man attends the clinic with his mother. He states that he has ‘had enough’ because his flatmates are Russian spies who are after him, follow him wherever he goes and he can hear them comment on his actions when they are not in the room with him. As a result of this, he has stopped going out and has limited his contact with his family and friends in recent months. Which of the features described is a negative symptom?
a. He believes that he is being followed
b. He believes that his flatmates are Russian spies
c. He has limited social contacts
d. He hears the voices of his flat mates
e. His flatmates' voices comment on his actions
He has limited social contacts
35
A 35-year-old man has been feeling low in mood and has disturbed sleep. He has been taking fluoxetine 40 mg daily for 3 months, with no improvement. His treating doctor intends to commence him on citalopram 20 mg daily. Which is the most appropriate next step in regards to changing his medication?
a. Add citalopram to fluoxetine at the current dose, withdrawing fluoxetine only if patient’s syndrome improve
b. Cross taper, i.e. reduce the fluoxetine dose, simultaneously adding citalopram
c. Reduce fluoxetine dose to 20mg daily, discontinue it after 1 week and then immediately initiate citalopram
d. Reduce fluoxetine dose to 20mg daily and start citalopram after a 1 week washout period
e. Reduce fluoxetine dose to 20 mg daily and start citalopram after a 6 week washout period
Reduce fluoxetine dose to 20mg daily and start citalopram after a 1 week washout period
36
An 18 year old woman has not eaten any solid food over the past week and has been limiting her liquid intake to 500 mL per day. She is preoccupied about being significantly overweight. Which blood test parameter is most likely to be raised in this scenario?
a. Cholesterol
b. Haemoglobin
c. Phosphate
d. Potassium
e. Triiodothyronine (T3)
Cholesterol
37
A 46 year old woman attends a follow up appointment with the community mental health team. She has been taking venlafaxine 150mg daily for the past 3 months. She is feeling more energetic, requiring very little sleep, has been going out most evenings and is overspending. Which is the most appropriate next step in regards to her management?
a. Refer to the community mental health team
b. Start lithium
c. Start risperidone
d. Start sodium valproate
e. Stop venlafaxine
e. Stop venlafaxine
38
A 30 year old woman is admitted to the mental health unit from the Emergency Department. She appears elated, apparently unconcerned that she has hardly slept in recent days and is talking about flying to the USA to assume the presidency. She was reported by her companion to have eaten soap. Her past psychiatric and medical history is unremarkable. Which is the most appropriate pharmacological intervention for this acute presentation?
a. Carbamazepine
b. Lithium
c. Olanzapine
d. Sertraline
e. Sodium valproate
Olanzapine
39
The family of a 72 year old man have raised concerns about his memory, which has recently deteriorated. He has had a number of similar presentations over the past 3 years. Following each episode, his ability to communicate and care for himself has declined. His medical history includes diabetes, hypertension, hyperlipidaemia and transient ischaemic attacks. Which is the most likely diagnosis?
a. Alzheimer’s disease
b. Creutzfeld-Jakob disease
c. Frontotemporal dementia
d. Lewy body dementia
e. Vascular dementia
Vascular dementia
40
A 20 year old woman attends the outpatient clinic following concerns by her GP about her eating habits. She significantly restricts her food intake and induces vomiting when she feels that she has overeaten. She speaks a lot about food and has started baking cakes, although she does not appear to eat them. She has not had a period for over 3 months. Her BMI is 18.5 kg/m2. She appears anxious when her diet is discussed. Which presenting feature most characteristically indicates a diagnosis of anorexia nervosa?
a. Amenorrhoea
b. Anxiety when discussing food
c. BMI of 18.5 kg/m2
d. Preoccupation with food
e. Purging behaviour
a. Amenorrhoea
41
A 30 year old woman with type I diabetes mellitus has developed end-stage renal failure and requires dialysis. She believes that the hospital (where she is admitted) has conspired to intentionally give her diabetes. She is therefore refusing to have dialysis and is actively attempting to leave the hospital. She is able to retain the relevant information and communicate her decision to refuse dialysis, which she justifies based on her thoughts that dialysis will cause her further harm. Blood investigations: potassium 6.7 mmol/L (3.5 - 5.3), Urea 50 mmol/L (2.5 - 7.8), creatinine 1200 micromol/L (60 - 120). Which is the most appropriate next step in regards to her management?
a. Detain the patient under Section 5(2) of the Mental Health Act and provide emergency dialysis
b. Facilitate a Mental Health Act assessment
c. Facilitate an urgent best interests assessment
d. Facilitate dialysis under common law, using sedation if required
e. Facilitate discharge and continue discussions with the patient in the community
Facilitate an urgent best interests assessment
42
A 27 year old woman with diabetes reports not sleeping for 1 week. She has recently ended her relationship with her partner of 5 years because she believes that he is a member of the CIA and has been uncharacteristically promiscuous. She states that she hears his voice even when she is not with him in the room. Which medication combination is most appropriate in this scenario?
a. Aripiprazole and sodium valproate
b. Clozapine and lithium
c. Olanzapine and carbamazepine
d. Quetiapine and lithium
e. Risperidone and lamotrigine
Quetiapine and lithium
43
A 35 year old woman is referred to the mental health nurse based in her GP surgery, following multiple presentations over the last year with gynaecological symptoms. She has a regular menstrual cycle, but with the onset of menstruation, she becomes increasingly anxious that she has developed life-threatening internal bleeding. She is worried that she may have cancer of the uterus. Blood tests, including a full blood count, are within normal limits. Her blood pressure is normal. Which is the most likely diagnosis?
a. Conversion disorder
b. Factitious disorder
c. Hypochondrial disorder
d. Malingering
e. Somatisation disorder
Hypochondrial disorder
44
A 19 year old woman writes to her new GP to profess her love for him. In the letter, she describes her belief that they are destined to marry, which she knew to be true after seeing his picture on the surgery’s website. Police have been contacted by her GP after she was seen to be following him home late at night. Which is the most likely diagnosis?
a. Acute stress reaction
b. De Clerambault syndrome (erotomanic delusions)
c. Emotionally unstable personality disorder
d. Normal adolescent development
e. Schizophrenia
De Clerambault syndrome
45
. A 50 year old man has been feeling low in mood and describes ‘not enjoying anything’ in recent weeks. He has difficulties concentrating at work, where his performance has been declining. He is unkempt and losing weight. He has seen his GP who initiated sertraline 100mg daily 1 month ago and referred him to the community mental health team. Which is the most appropriate next step in his management?
a. Add lithium
b. Add mirtazapine
c. Add olanzapine
d. Increase the dose of sertraline
e. Switch to dosulepin (a TCA)
Increase the dose of sertraline
46
A 19 year old university student presents with a 3 week history of thinking that MI6 are out to get him. He believes that he is being monitored and checks his locks up to 20 times per day. He last used cannabis 3 years ago. At present he is euthymic. Which is the most likely diagnosis?
a. Acute psychotic disorder
b. Delusional disorder
c. Obsessive compulsive disorder
d. Paranoid schizophrenia
e. Schizoaffective disorder
Acute psychotic disorder
47
A 28 year old man is prescribed regular medication for bipolar disorder. He has also been taking naproxen for a sports injury. He presents to the Emergency Department with ataxia, confusion and tremor. Which medication is most likely to have resulted in his symptoms?
a. Carbamazepine
b. Lithium
c. Olanzapine
d. Sertraline
e. Sodium valproate
Lithium
48
A 25 year old woman is currently an informal inpatient on a mental health ward for management of a depressive episode. She has intent to end her life. She wants to leave the ward. She is deemed to have capacity to make a decision to leave hospital. Which is the next most appropriate step in management?
a. Allow her to self discharge
b. Detain her under the Deprivation of Liberty Safeguards
c. Detain her under the Mental Capacity Act
d. Detain her under the Section 2 of the Mental Health Act
e. Detain her under the Section 5(2) of the Mental Health Act
Detain her under the Section 5(2) of the Mental Health Act
49
A 85 year old man in the memory clinic has concerns about being unable to recall what he ate for breakfast that morning or provide detail regarding his activities today and yesterday. He has difficulties concentrating. He has a tremor and poor balance. Which is the most appropriate initial step in his work-up?
a. Blood tests
b. CT brain
c. MoCA (Montreal Cognitive Assessment)
d. MRI brain
e. Neuropsychological testing
MoCA
50
A 22 year old woman in the Emergency Department describes an episode when she saw an unfamiliar man in her house at sunset. Her boyfriend, who was with her at the time, did not see this man in her house, but noted that she was disoriented to time and place. She reported no other difficulties at the time and she has no previous psychiatric history. Her AMTS is 6/10 and her temperature 37.9C. Investigations: GGT 11 IU/L (9 - 40), CRP 70 mg/L (<5); urine drug screen - negative for all substances. Which is the most likely diagnosis?
a. Alcoholic hallucinosis
b. Delirium
c. First episode psychotic disorder
d. Temporal lobe epilepsy
e. Young onset dementia
Delirium
51
A 48 year old woman with Down syndrome has worsening memory impairment which is affecting her activities of daily living. Which is the most likely diagnosis?
a. Alzheimer’s disease
b. Frontotemporal dementia
c. Lewy body dementia
d. Pseudodementia
e. Vascular dementia
Alzheimer’s disease
52
A 30 year old woman is assessed at the addictions treatment clinic for her heroin addiction, having never had treatment previously. Which is the most appropriate pharmacological treatment to initiate?
a. Diazepam
b. Disulfiram
c. Methadone
d. Naloxone
e. Naltrexone
Methadone
53
A 30 year old woman attends the Urgent Treatment Centre after cutting her wrists superficially. She suffers from depression and is taking sertraline 50mg daily. Her partner walked out on her this morning. She feels distressed but her sister has offered to stay with her. She has previously cut her wrists with no threat to her life. She has no thoughts of suicide. She intends to attend her appointment with the psychiatrist tomorrow. Which is the next most appropriate step in management?
a. Arrange a Mental Health Act assessment
b. Call an ambulance
c. Call the duty psychiatrist for an urgent assessment
d. Give her the 24 hour mental health crisis number
e. Increase her dose of sertraline
Give her the 24 hour mental health crisis number
54
A 24 year old paramedic is referred to see a psychiatrist by her GP. She reports that she has not been herself after attending a call last month when the patient ultimately died. She complains of low mood and difficulty falling asleep on most nights. Her appetite is not affected and she has not lost any weight. Blood test results including full blood count and thyroid function tests are unremarkable. Which is her most likely diagnosis?
a. Acute stress reaction
b. Adjustment disorder
c. Depressive episode
d. Generalised anxiety disorder
e. Post-traumatic stress disorder
Adjustment disorder?
55
A 25 year old man in the outpatient clinic is asked what prompted his GP to refer him. He responds as follows: ‘Doctor, that’s a difficult question. When I woke up at 7am, I thought about how much I’d like to make myself a boiled egg. I watched the news for a bit, and then found my favourite leather shoes. Later on I popped over to Tesco to get some fruit, and after that I came here to discuss a change in my medication’. Which thought disorder is exhibited by the man in this scenario?
a. Circumstantiality
b. Derailment (loosening of associations)
c. Flight of ideas
d. Pressure of speech
e. Tangentiality
Circumstantiality
56
A 44 year old man has a 10 year history of using crack cocaine and heroin. He uses both substances once or twice per week and often feels depressed following episodes of excessive use. He developed hepatitis C after sharing needles. He does not describe a strong desire to use these substances, but nonetheless continues to do so. Which diagnosis best describes his presentation?
a. Acute intoxication
b. Dependence
c. Depressive disorder
d. Harmful use
e. Withdrawal syndrome
harmful use
57
A 35 year old man in General Practice has obsessive compulsive disorder. He has not engaged with psychological treatment. Initiation of which class of medication is most appropriate in this scenario?
a. Acetylcholinesterase inhibitor
b. Benzodiazepine
c. Monoamine oxidase inhibitor
d. Selective serotonin reuptake inhibitor
e. Tricyclic antidepressant
Selective serotonin reuptake inhibitor
58
A 55 year old woman in General Practice has a history of recurrent depression. She has previously had cognitive behavioural therapy and antidepressant medication. She is currently well but her work has been stressful and she is worried her depression may recur. Which is the most appropriate next management option?
a. Group based CBT
b. Mindfulness-based cognitive therapy
c. Prescribe prophylactic SSRI
d. Prescribe zopiclone
e. Regular follow up with GP and screening for depression
Mindfulness-based cognitive therapy
59
. The mother of a 7 year old boy is concerned that he has always struggled to focus in class, wait for his turn and has lots of energy in comparison to his peers. He has few friends and has only been in one physical fight in his life. Which is the most likely diagnosis?
a. Attention deficit hyperactivity disorder
b. Conduct disorder
c. Depression
d. Psychosis
e. Social anxiety
ADHD
60
A 34 year old woman with borderline personality disorder has taken a spontaneous paracetamol overdose after breaking up with her boyfriend. She had texted her friend afterwards because she worried about who would care for her children. She had locked herself in the bathroom before taking the overdose but had not stocked up on tablets. Which of the following would cause the most concern?
a. Admitting the overdose was a spontaneous decision
b. Expressing worry about who would look after her children if she was not around
c. Locking the bathroom door before taking the overdose
d. Not stocking up on tablets
e. Texting her friend after taking the overdose
Locking the bathroom door before taking the overdose
61
A 45 year old man in General Practice is requesting help with his alcohol consumption. He drinks one bottle of vodka a day. He begins shaking as if he has not had an alcoholic drink first thing in the morning. Previously, when he tried stopping drinking suddenly 2 years ago, he had a seizure. Which is the most appropriate management plan?
a. Offer self-help guides
b. Prescribe a reducing dose of chlordiazepoxide
c. Prescribe acamprosate
d. Prescribe thiamine
e. Refer for inpatient detoxification
Refer for inpatient detoxification
62
. A 55 year old man attends for a routine health review. He was seen on a few occasions last year after he was made redundant from his job as an IT technician. At the time he had low mood, anhedonia, insomnia and hopelessness, which all resolved after he found a new job. Which is the most likely diagnosis?
a. Adjustment disorder
b. Bipolar affective disorder
c. Personality disorder
d. Post-traumatic stress disorder
e. Severe depressive disorder
Adjustment disorder
63
A 33 year old woman takes omeprazole, paroxetine, aripiprazole, and zopiclone for gastro-oesophageal reflux and bipolar affective disorder. She also takes the combined oral contraceptive pill. Her annual blood test show: sodium 135 mmol/L (135 - 145), potassium 4.2 mmol/L (3.5 - 5.3), urea 5.1 mmol/L (2.5 - 7.8), creatinine 63 umol/L (60 - 120), eGFR 90 (>60) and prolactin 622 UI/L (100 - 500). Which medication is most likely responsible?
a. Aripiprazole
b. Combined oral contraceptive pill
c. Omeprazole
d. Paroxetine
e. Zopiclone
Combined oral contraceptive pill
64
. A 63 year old man is in General Practice for his annual medication review. His past medical history includes ischaemic heart disease, depression and rheumatoid arthritis. He is taking citalopram (10 mg once daily), bisoprolol (5 mg once daily), atorvastatin (40 mg once daily), methotrexate (15 mg once weekly) and aspirin (75 mg once daily). His blood results are as follows: sodium 130 mmol/L (135 - 145), potassium 4.2 mmol/L (3.5 - 5.3), urea 4.2 mmol/L (2.5 - 7.8), creatinine 93 umol/L (60 - 120). Which of his medications is the most likely cause of this derangement?
a. Aspirin
b. Atorvastatin
c. Bisoprolol
d. Citalopram
e. Methotrexate
Citalopram
65
A 39 year old woman, gravidity 2 parity 0 at 39 + 3 weeks’ gestation is on the labour ward. She presented in spontaneous labour with a history of regular contractions every 4-5 minutes, lasting 30 seconds. Her MEWS (maternity early warning score) is 0. The foetal heart rate is reassuring. At 09:00 she was 2 centimetres dilated on vaginal examination. At 13:00 she was 5 centimetres dilated and at 17:00 she was 6 centimetres dilated. What is the most appropriate next step in management?
a. Artificial rupture of membranes
b. Commence oxytocin
c. Perform a caesarian section
d. Perform a membrane sweep
e. Wait for 2 hours and reassess
Artificial rupture of membranes
66
A 35 year old woman and her male partner have been trying to conceive for 5 months. They have no underlying medical conditions and do not smoke. They have regular sexual intercourse. The woman has regular 31 day menstrual cycles. Which is the most appropriate next step in management?
a. Perform a female hormone profile
b. Perform a pelvic ultrasound scan
c. Perform a semen analysis
d. Reassure and advise to return in 7 months if not pregnant
e. Reassure and advise to return in 19 months if not pregnant
Reassure and advise to return in 7 months if not pregnant
67
24 year old woman in her first pregnancy, is in spontaneous labour on the labour ward. She is using Entonox for analgesia and has now been in the second stage for 3 hours. She has been in good descent from pushing for 2 hours. The baby is in the cephalic presentation in an occipito-anterior position, vertex below the ischial spines. The foetal heart rate has been suspicious for 30 minutes. Which is the most appropriate management in this scenario?
a. Caesarean section
b. Epidural analgesia
c. Episiotomy
d. Forceps delivery
e. Ventouse delivery
Episiotomy
68
. A 27 year old woman is seen in the antenatal clinic for a routine appointment. She has a black eye which has been covered with makeup. When asked, she does not provide a clear cause for her injury. Which is the most appropriate initial course of action.
a. Refer to safeguarding midwife
b. Refer to the Caldicott guardian
c. Refer to the Emergency Department
d. Refer to the police
e. Refer to women’s aid
Refer to safeguarding midwife
69
. A 39 year old woman has a transvaginal ultrasound scan at 6 weeks of pregnancy, in which an intrauterine gestational sac was seen. She attends the Emergency Department 2 weeks later with 2 days of heavy vaginal bleeding. A transvaginal scan shows a normal endometrium. Both ovaries appear normal. There is no adnexal mass but there is a small amount of free fluid in the Pouch of Douglas. Which is the most likely diagnosis?
a. Complete miscarriage
b. Ectopic pregnancy
c. Incomplete miscarriage
d. Molar pregnancy
e. Pregnancy of unknown viability
Complete miscarriage
70
A 42 year old woman is 12 weeks into her third pregnancy. She would like to have screening for Trisomy 21. Which is the most sensitive screening test?
a. Amniocentesis
b. Chorionic villous sampling
c. Non-invasive pre-natal testing (cell free DNA)
d. Nuchal translucency
e. Quadruple test
Non-invasive pre-natal testing (cell free DNA)
71
A 27 year old woman in the early pregnancy unit has light vaginal bleeding, 6 weeks after her last menstrual period. Transvaginal ultrasound scan (USS) shows an intrauterine gestation sac. There was no visible yolk sac or foetal pole. Which is the recommended management?
a. Arrange a repeat USS in 10-14 days
b. Arrange a repeat USS in 48 hours
c. Offer management for miscarriage
d. Reassure and discharge
e. Take beta-HCG and repeat in 48 hours
Arrange a repeat USS in 10-14 days
72
A 38 year old woman has a total abdominal hysterectomy for dysmenorrhoea. Histology shows that there were CIN 1 changes in the cervix, which were completely excised. Which is the most appropriate follow-up?
a. Back to routine smear recall
b. Colposcopy in 6 months
c. No follow up required
d. Vault smear in 6 months
e. Vault smear in 12 months
d. Vault smear in 6 months
73
A 35 year old woman has a severe headache 24 hours following an elective cesarean section for placenta praevia under regional anaesthesia. It is worse on sitting up and better when she is lying down. Her temperature is 37.3C, heart rate 90 bpm, blood pressure 124/64 mmHg, respiratory rate 12 breaths per minute, oxygen saturation 98% breathing room air. Which is the most likely cause of her headache?
a. Cerebral venous sinus thrombosis (imitates SAH with thunderclap)
b. Meningitis
c. Migraine
d. Post-dural tap headache
e. Pre-eclampsia
Post-dural tap headache
74
A woman sees her GP at 12 weeks gestation. Which vaccines should she be recommended?
a. BCG and pertussis
b. Influenza and pertussis
c. Influenza and rubella
d. Pertussis and varicella zoster
e. Rubella and varicella zoster
Influenza and pertussis
75
A 32 year old woman is mixed feeding her 3 week old baby and complains of a tender left breast, which is more swollen than the right. She does not have a fever and is otherwise well, but reports some redness to the skin. Which advice should she be given as regards to infant feeding?
a. Continue feeding from both breasts
b. Express milk from the left breast and discard
c. Feed only from the left breast
d. Feed only from the right breast
e. Switch to formula feeding
Continue feeding from both breasts
76
. A 37 year old woman on the Maternity Assessment Unit is 28 weeks pregnant. She has a sudden onset of chest pain. She reports some shortness of breath on minimal exertion. She smokes 2 cigarettes per day and has a BMI of 30 kg/m2. She has known hypercholesterolaemia. She needs to use 3 pillows to sleep comfortably at night. She works long hours at her desk from home. Which is the most likely diagnosis?
a. Cardiomyopathy
b. MI
c. Musculoskeletal pain
d. Oesophageal reflux
e. PE
PE
77
A 22 year old woman with cystic fibrosis attends the obstetric medicine clinic for preconception counselling. Development of which obstetric complication is she at greatest risk, given her pre-existing disease?
a. Foetal congenital malformation
b. Gestational diabetes
c. Obstetric cholestasis
d. Pregnancy induced hypertension
e. Spontaneous miscarriage
Gestational diabetes
78
A 24 year old vegan woman with alpha thalassemia trait has a booking haemoglobin of 115 g/L (115 - 150), WCC 7.9 x 10^9/L (3.8 - 10), platelets 230 x 10^9/L (150 - 400). At her 28 week appointment her Hb is 106 g/L, WCC 8.9 x 10^9/L, platelets 195 x 10^9/L. Which is the most likely cause for these test results?
a. Alpha thalassaemia
b. Diet
c. Myeloproliferative disorder
d. Physiological change
e. Retroplacental bleeding
Physiological change
79
. A 20 year old woman has abdominal discomfort for 3 months. A pregnancy test is negative. An ultrasound scan shows a complex cystic pelvic mass with solid components. Which is the most likely diagnosis?
a. Endometriosis
b. Epithelial ovarian cancer
c. Fibroids
d. Germ cell tumour of the ovary
e. Uterine sarcoma
Germ cell tumour of the ovary
80
. A 10 year old girl with BMI 28 kg/m2 is seen in adolescent gynaecology outpatients. She has breast bud development and some axillary hair. There are no other features of secondary sexual characteristics or galactorrhoea. Which is the most appropriate next step in management?
a. Follow-up in 2 years
b. Hormone profile
c. MRI brain
d. Pelvic ultrasound scan
e. Reassure and discharge
Reassure and discharge
81
48 year old woman has a progesterone IUS in place. She complains of a 1 year history of palpitations, night sweats, fatigue, irritability and vaginal dryness. What is the most appropriate treatment?
a. Oral oestrogen
b. SSRIs
c. Tibolone
d. Transdermal oestrogen
e. Vaginal oestrogen
Transdermal oestrogen
82
A 40 year old woman with uterine fibroids require the active management of the third stage of labour. At which point in labour should IM syntocinon (oxytocin) be administered?
a. When the anterior shoulder has been delivered
b. When the head has been delivered
c. When the neonate has been delivered
d. When the trunk has been delivered
e. When the vertex is crowning
When the anterior shoulder has been delivered
83
A 55 year old woman in gynaecology outpatients has a BMI of 23.5 kg/m2 and a history of stress incontinence. Pelvic floor exercises have not improved her symptoms. Which is the most appropriate next step in management?
a. Hysterectomy
b. Intra urethral bulking
c. Ring pessary
d. Surgical repair
e. Weight loss
Surgical repair
84
A 34 year old woman has an evacuation of retained products of conception, which are sent for cytogenetics. She is told she had a molar pregnancy. Which is the most appropriate follow up?
a. Chest x-ray
b. CT pelvis
c. Serial pipelle endometrial biopsy
d. Serial quantitative beta-HCG
e. Serial ultrasound scans
Serial quantitative beta-HCG
85
. A 23 year old woman has superficial dyspareunia and type 3 female genital mutilation. Which is the most appropriate next step in management?
a. Make a safeguarding risk assessment
b. Offer reversal surgery
c. Refer for psychosexual counselling
d. Refer to police
e. Refer to social services
Offer reversal surgery
86
A 56 year old woman has a 6 month history of urinary incontinence and urgency, which is affecting her personal life. Urine microscopy is negative. Which is the most appropriate first investigation?
a. Bladder diary
b. Cystoscopy
c. Pad tests
d. Pelvic ultrasound
e. Urodynamics
Bladder diary
87
A 23 year old woman complains of severe dysmenorrhoea every month for the last 6 months, lasting 3-4 days after her period ends. It is not relieved by regular paracetamol and a hot water bottle. Which is the most appropriate next step in management?
a. List for laparoscopy
b. Organise a pelvic CT scan
c. Organise a pelvic ultrasound scan
d. Perform a hormone profile
e. Perform a sexual health screen
Organise a pelvic ultrasound scan
88
. A 19 year old woman presents with an acutely painful large swelling near the opening of the vagina. She is unable to sit and passing urine is uncomfortable. Her last menstrual period started 2 days ago. Which is the most likely diagnosis?
a. Bartholin’s abscess
b. Bartholin’s cyst
c. Congenital urethral cyst
d. Urinary tract infection
e. Vaginal endometriosis
Bartholin’s abscess
89
A 57 year old woman in General Practice has vulval itching and passes urine more frequently. She denies any vaginal discharge. The vulval area looks dry with evidence of excoriation marks. There is an area of paler skin near the introitus. Urinalysis showed 1+ leukocytes only. Which is the most likely diagnosis?
a. Atrophic vaginitis
b. Lichen sclerosus
c. Urinary tract infection
d. Vaginal candida
e. Vaginal malignancy
Lichen sclerosus
90
A 34 year old woman attends her GP for her 32 week antenatal appointment. She feels well in herself and has regular foetal movements. She has had normal scans to date and an uncomplicated pregnancy. Her temperature is 36.8C, pulse 93 bpm, blood pressure 113/72 mmHg, and oxygen saturation 98% breathing air. Her booking blood pressure was 110/68 mmHg.
Urinalysis - negative
Ketones - negative
Blood - negative
Protein - 2+
Nitrites - negative
Leukocytes - negative
Which is the most appropriate next step in management?
a. Ask midwife to review in 2 weeks
b. Reassure and review at 36 week antenatal appointment
c. Refer for antenatal same day assessment
d. Send a mid-stream urine for microscopy, culture and sensitivity
e. Send a protein creatinine ratio
Refer for antenatal same day assessment
91
. A 30 year old woman presents to General Practice 2 weeks after delivery of her first baby. She has low mood, exhaustion, difficulty sleeping, and is very tearful for the last week. She felt well during her pregnancy. She is bonding well with her baby and has good support at home. She has a history of depression but has been stable for the last 2 years. She has no thoughts of self-harm or suicide. Which is the most likely diagnosis?
a. Adjustment disorder
b. Baby blues
c. Dysthymia
d. Postnatal depression
e. Recurrent depression
Baby blues
92
A 35 year old woman in General Practice is 10 weeks pregnant and has worsening nausea and vomiting daily for 3 weeks. She is now struggling to keep down fluids but still passing urine.
Urinalysis:
Glucose - negative
Protein - negative
Ketone - negative
Blood - negative
Nitrites - negative
Leukocyte - negative
Which is the most suitable management option?
a. Admit to hospital
b. Advise ginger tea
c. Avoid heavy meals
d. Offer cyclizine
e. Offer ondansetron
Offer cyclizine
93
A 21 year old woman in General Practice has a 6 month history of irregular periods. She has gained 3 kg in weight over the last 4 months. Her BMI is 28 kg/m2 and she has cystic acne on her back. Which blood tests could support the most likely diagnosis?
a. Cortisol, fasting glucose
b. HbA1C, fasting lipids
c. LH, FSH, SHBG, testosterone
d. Prolactin, growth hormone
e. TSH, free T4
LH, FSH, SHBG, testosterone
94
42 year old woman in General Practice has 6 weeks of intermenstrual and post-coital bleeding. She is married with two children. She has no vaginal discharge. She has not previously taken hormonal contraception. Her last smear was normal 2 years ago. Which is the most likely diagnosis?
a. Cervical cancer
b. Endometrial cancer
c. Endometrial polyp
d. Ovarian cancer
e. Sexually transmitted infection
Endometrial polyp
95
A 35 year old woman in General Practice has epilepsy and is currently taking sodium valproate and desogestrel. She has not had a seizure for 13 months. She and her boyfriend would like to conceive a child. Which is the most appropriate management option?
a. Perform blood tests to check sodium valproate levels
b. Reduce sodium valproate dose
c. Refer to epilepsy clinic, continue current medication in the meantime
d. Refer to epilepsy clinic, meanwhile switch to a different anti-epileptic
e. Stop all medication now and refer to epilepsy clinic
Refer to epilepsy clinic, continue current medication in the meantime
96
A 60 year old woman in General Practice has 4 months of urinary frequency, nocturia, and urgency with occasional leaking of urine. She has no abdominal or back pain. Her temperature is 36.8C. Which is the most appropriate initial investigation?
a. HbA1C
b. Renal USS
c. Urea and electrolytes
d. Urinalysis
e. Urodynamics
Urinalysis
97
An 8 month old baby is seen in clinic with widespread rash localised to his flexures, cheek and neck. There is a strong family history of atopy. What is the most appropriate first line treatment?
topical emollients
98
A 5 month old baby who is unvaccinated is in the Paediatric Emergency Department following apnoeic episodes with coughing at home. What is the most likely causative organism?
Bordatella pertussis
99
A widespread rash is found on a 2 day old baby at his newborn check (see image). He is feeding well, is active and has no fever. What is the most appropriate management?
reassure and discharge (erythema toxicum)
100
A 9 month old boy in the Paediatric Emergency Department has left cheek bruising. He had multiple bruises on both thighs and buttocks. Full blood count and clotting screens were unremarkable. What is the most likely cause for his presentation?
Non-accidental injury
101
A 4 year old boy in paediatric outpatients is unsettled with abdominal pain. He is scratching his bottom, worse at night, He has small white threads seen in his stool. What is the most appropriate treatment for this condition?
oral mebendazole
102
A 6 year old girl with known sickle cell disease is in the Emergency Department with lethargy and shortness of breath. This is in the context of a recent febrile illness with a rash that has now resolved. Her blood results show: Hb 45 g/L (115 - 140), WBC 2.8 x 10^9/L (3.8 - 10), platelets 55 x 10^9/L (150 - 400). What pathogen is likely to have caused this presentation?
parvovirus b19
103
A 3 year old non-verbal girl is seen in outpatients. She is noted to have ritualistic behaviours, poor eye contact and a lack of pretend play. She has significant sensory issues. What is the most likely diagnosis?
Autism spectrum disorder
104
. A 2 year old boy in the Paediatric Emergency Department has a barking cough and difficulty breathing. He has inspiratory stridor on crying and mild intercostal and subcostal recessions. He is alert and playing. There is no drooling. His temperature is 38.2C, pulse rate 130 bpm, respiratory rate 34 breaths per minute, oxygen saturation 98% breathing air. What is the most appropriate first line treatment?
oral dexamethasone
105
A 6 month old boy presents with abdominal distension, bilious vomiting, excessive crying and drawing her legs up to his chest. He has recently been weaned off breastfeeding. He has blood in his stools. What is the most likely diagnosis?
intussuception
106
A 12 year old girl develops discolouration of her urine and tears after starting medication for persistent chronic cough and fever. What medication commonly used for this condition is causing her symptoms?
rifamcipin
107
. A 6 week old girl in the Paediatric Emergency Department has jaundice which has been present since 1 week of age. She has pale stools and dark urine. She has dropped two centiles for weight. What is the most likely diagnosis?
biliary atresia
108
A 6 year old girl in clinic has asthma, and is currently on treatment with salbutamol and Clenil inhalers. What device is most suitable for delivering these medications?
spacer
109
A small for gestational age baby is born following an unremarkable pregnancy. He has low set ears, micrognathia, microcephaly, rocker bottom feet, overlapping digits, cleft lip and palate. What is the most likely diagnosis following chromosomal analysis?
Edwards
110
A previously well 4 year old boy is in the Paediatric Emergency Department with his mother. She saw him swallow a 20p coin while playing outside 30 minutes ago. She reports no coughing, choking or difficulty in breathing since. What is the investigation of choice in this scenario?
Chest x ray
111
A 3 year old boy has 3 days of fever and a sore throat. He has red tonsils with exudate and a coarse, sandpaper rash on his abdomen. His temperature is 38.5C, pulse rate 125 bpm, respiratory rate 26 breaths per minute, oxygen saturation 98% breathing air. What is the most likely diagnosis?
scarlet fever
112
A 13 year old girl in General Practice has 3 weeks of left knee pain. The pain feels worse after running. She is very active and does a lot of sport. There is tenderness at the left tibial tuberosity. She is systemically well. What is the most likely diagnosis?
Osgood Schlatter disease
113
The mother of a 3 year old boy in General Practice has noticed that her son’s foreskin is ballooning on urination. The foreskin is non-retractile. There is no redness or discomfort. What is the most likely diagnosis?
phimosis
114
A 5 month old girl in General Practice has a worsening nappy rash for the last 2 weeks despite regular nappy changes, barrier cream and nappy-free time. She is feeding normally and otherwise well. Her temperature is 36.8C, and pulse rate 128 bpm. The rash is depicted in the image provided. What is the most appropriate management option?
CLOTRIMAZOLE
115
. A 6 year old boy in General Practice has a new petechial rash on his legs and a bruise on his left knee, after knocking it on a table. He had a cold last week but fully recovered and was back to his normal self after a few days. There are no safeguarding concerns. He is well on examination and vital signs are normal. Investigations: Hb 123 g/L (115 - 140), WCC 6.2 x 10^9/L (3.8 - 10.0), platelets 15 x 10^9/L (150 - 400), normal blood film and normal coagulation screen. What is the most likely diagnosis?
ITP
116
A 5 month old boy in General Practice is found to have developmental delay and recurrent spasms. An EEG has shown hypsarrhythmia. What is the most likely diagnosis?
infantile spasms
117
A 30 year old man with a brain injury following a road traffic accident reports experiencing an odd smell of burnt plastic. He is surprised that this is not bothering his flatmates. He recently reported seeing an image of Jesus on the walls of his bedroom reciting the ten commandments. What is the most likely diagnosis?
temporal lobe epilepsy
118
A 17 year old girl in the Emergency Department has experienced a seizure. She appears confused and fatigued, and has an irregular heart rhythm. Her blood pressure is 170/90 mmHg. Her mother reports that she has anorexia nervosa and her father has been trying to force feed her. What diagnosis would most likely explain her clinical presentation?
refeeding syndrome
119
A 56 year old man is brought to the Emergency Department by ambulance after he was found collapsed in a park. His pupils are constricted and his respiratory rate is 6 breaths per minute. What emergency medication should be administered in this scenario?
naloxone
120
A 21 year old man with a history of drug use is detained under the Mental Health Act (1983) for treatment of an acute psychotic episode. He has been administered an initial dose of zuclopenthixol depot 2 days ago. His urine drug screen is positive for cannabis. He is confused, has muscle rigidity, fever and hyporeflexia. His temperature is 38.4C, pulse rate 113 bpm, BP 135/80 mmHg, respiratory rate 26 breaths per minute and oxygen saturation 96% breathing air. What is the most likely cause for the change in presentation?
NEUROLEPTIC MALIGNANT SYNDROME
121
122
A 75 year old man with recurrent depressive disorder stopped taking his medication 1 month ago. He now has significant low mood and suicidal thoughts. He is admitted informally following an apparent attempt to hang himself. His wife died of cancer 2 years ago and he has no children. What level of observation should be provided by the ward nursing staff in this scenario?
one to one
123
A 30 year old woman is admitted to the Mental Health Unit. She has reportedly been spending her savings on expensive items of clothing. Her named nurse reports that she hardly sleeps at night and seems unable to settle down. She is overfamiliar and labile in mood. A urine drug screen is negative for all substances and all blood test parameters are within normal limits. What is the likely diagnosis?
acute manic episode
124
A 76 year old man who lives independently is admitted to the mental health unit with a severe depressive episode. He was managed in the community with multiple antidepressants at various times, but none have really benefited him. He completed a course of ECT treatment a few days ago. His family members visit him on the ward but he is unable to recognise them. What type of memory impairment is demonstrated?
retrograde
125
A 35 year old woman who is 7 weeks postpartum, presents with low mood, anhedonia, poor energy levels, insomnia and fleeting suicidal thoughts. She has no previous history of mental illness. She is breastfeeding. Initiation of what medication class is most appropriate in this scenario?
Paroxetine
126
A 24 year old man is brought to the Emergency Department by police. A neighbour had reported him shouting in his house, following which, he ran onto the street and began throwing rocks at passing cars. The police arrested him and brought him to hospital. Under what section of the Mental Health Act (1983) was he most likely detained?
Section 136
127
A 30 year old male with paranoid schizophrenia has been treated unsuccessfully with aripiprazole and later, olanzapine. He has ongoing delusions that his family and nursing staff are poisoning his food and medication. He hears two men arguing and commenting on his actions. What is next most appropriate pharmacological treatment option?
Clozapine
128
A 61 year old man with alcohol dependence is brought to the Emergency Department by ambulance following concerns by neighbours. He presents with confusion and disorientation. He is irritable, tremulous and sweating. He appears to be responding to external visual stimuli. His temperature is 37.9C, pulse rate 125 bpm, BP 140/95 mmHg, respiratory rate 20 breaths per minute and oxygen saturation 95% breathing air. His breathalyser reading is 80 microgram alcohol / 100 mL of breath (legal limit for drivers <35). What is the most likely diagnosis?
Delirium tremens
129
A 13 year old boy attends the child psychiatry clinic with his parents, who describe a 7 month history of overeating. He frequently rummages through the cupboards at odd times of the day. He has said at times that he feels fat. His BMI is 18.5 kg/m2 (just under the 50th centile for his age). He has calluses on his knuckles. He performs well academically. What is the most likely diagnosis?
bulimia nervosa
130
A 20 year old medical student has become increasingly isolated and has stopped attending lectures for the past 7 months. Concerns have been raised by his friends that he has been locking himself in his room and talking to himself. He believes that the government is spying on him and trying to steal his intelligence. He reports hearing female voices commenting on his actions. What is the most likely diagnosis?
paranoid schizophrenia
131
20 year old woman in the outpatient clinic has sudden episodes of palpitations, shortness of breath, sweating, chest pain and dry mouth. These episodes started 6 months ago, occur randomly and last for about 15 minutes. Education and lifestyle modification advice have not been helpful. What is the most appropriate next step in regards to her management?
CBT
132
. A 55 year old man in the outpatient clinic has been experiencing frequent thoughts of jumping onto the train tracks during his daily commute. This is very distressing for him as he does not consider himself to be suicidal. He has stopped taking the train and instead takes three buses to work, adding 1 hour to his journey time. He has received a warning for attending late. What is the most likely diagnosis?
OCD
133
A 32 year old woman attends her GP surgery for her 6 week postnatal check. She has low mood, feels exhausted, is unable to sleep and is struggling to bond with her baby. She has lost her appetite and looks dishevelled. Her partner stated that she worries excessively about her baby. She has no previous psychiatric history. What is the most likely diagnosis?
postnatal depression
134
. A 20 year old man has never been able to hold down a job for longer than a few months at a time. His relationships have also been affected by his symptoms. He has recently been diagnosed with ADHD by his psychiatrist. What medication would the psychiatrist most likely recommend in this scenario?
methylphenidate
135
An 18 year old girl in General Practice has had no periods for the previous 4 months. She had the contraceptive implant inserted 2 years ago. She reports missing meals as she has been stressed for her university exams. She admits to making herself vomit occasionally when she is stressed. Her temperature is 36.8C, pulse rate 65 bpm, BP 109/70 mmHg, BMI 17.5 kg/m2. A pregnancy test is negative. What is the most likely diagnosis?
Anorexia
136
A 55 year old woman in General Practice is in a tearful state and reports feeling low. She advises that she gets cold easily and has been gaining weight. What investigation will likely be discriminatory in this scenario?
TFTs
137
A 28 year old woman in General Practice is agitated. She had a healthy baby boy via normal spontaneous vaginal delivery 7 days ago. The birth and pregnancy were uncomplicated. She mentions her thoughts have been racing for the last few days and she has been hearing a voice telling her that her food is being poisoned by her husband. What is the most likely diagnosis?
Puerperal psychosis
138
A 28 year old woman with a twin IVF pregnancy has a scan at 18 weeks gestation. This shows a marked difference in foetal size with oligohydramnios in one twin and polyhydramnios in the other twin. What is the most likely diagnosis?
tts
139
A 36 year old woman presents with spontaneous rupture of membranes at 33 weeks’ gestation. She has no abdominal pain. Speculum examination confirms a <1cm dilated cervix. She has no allergies. Her temperature is 36.6C, pulse 88 bpm, BP 110/55 mmHg, respiratory rate 16 breaths per minute, oxygen saturation 99% breathing air. What antibiotic should be prescribed in this scenario?
oral erythromycin
140
An active 50 year old who has no medical problems has a total abdominal hysterectomy for large multiple fibroids. She loses 300mls of blood. The procedure is uncomplicated. For how long should she be advised to take bed rest following discharge home?
2 weeks
141
A 36 year old woman with a long history of dysmenorrhoea and cyclical rectal bleeding presents with worsening abdominal pain. Regular paracetamol has not eased her symptoms. She has been trying to conceive for 8 months. Her LMP was 3 weeks ago. What is the most likely diagnosis?
endometriosis
142
A woman is admitted at 12 weeks with severe nausea and vomiting. She requires three different anti-emetic treatments and IV fluids. What supplement must also be prescribed in this scenario?
thiamine
143
A 27 year old woman who is low risk at booking has her booking blood tests taken by her midwife. Her results show she is HIV negative and syphilis negative. For what other virus must she be tested?
Hep B
144
A 33 year old woman is seen at 7 weeks of pregnancy for booking. She has a history of ectopic pregnancy and salpingectomy, two first trimester miscarriages, a miscarriage at 23+5 weeks’ gestation, two failed IVF cycles and a premature delivery at 27 weeks’ gestation. The infant died of complications related to prematurity four weeks later. What is her gravidity and parity?
G6P1
145
A woman is due to have an elective caesarean section for breech presentation at 39 weeks’ gestation. For how many hours should she be fasted for solids prior to the operation? Your answer should be expressed numerically in the form
6 hours
146
A 20 year old woman with epilepsy presents with an unplanned pregnancy at 12 weeks’ gestation. She takes sodium valproate for seizure control. Which congenital abnormality is she most at risk of developing?
spina bifida
147
. A 27 year old woman has a non-viable pregnancy at 6 weeks with a beta-HCG of 28,000 IU/L. What malignancy is she at greatest risk of developing?
choriocarcinoma
148
A midwife is on her own with a patient on the labour ward. She states that the head has been delivered for 4 minutes but the body is not coming. The woman is lying flat on her back at the end of the bed. Name the first manoeuvre that should be performed in this scenario
McRoberts
149
A 19 year old woman complains of irritability, aggression and low mood every month. She has no other medical conditions, takes no regular medication and is sexually active. The symptom diary shows that her work and social life are being affected in a cyclical way. What, specifically, is the aim of the hormonal management in this scenario?
Symptom control
150
A 27 year old woman has a complete molar pregnancy and only receives surgical management. She subsequently has regular serum beta-HCG monitoring. For how long should she be told to avoid pregnancy after the beta-HCG has returned to normal?
6 months
151
A 65 year old woman presents with a lump in her vagina, which has been getting worse over many years. She finds it difficult to evacuate her bowels and now needs to digitate her vagina to do so. What is the most likely diagnosis?
Rectocele
152
. A 24 year old woman with a BMI of 22 kg/m2, has an elective, uncomplicated laparoscopic procedure for removal of a 6 cm simple ovarian cyst. Assuming good postoperative recovery, after how long would she be appropriate to be discharged?
4 hours
153
. A 30 year old woman in the third trimester of her first pregnancy develops an itchy, bumpy rash on her abdomen, with sparing of the periumbilical area. She is usually fit and well and has had an uneventful pregnancy so far. What is the most likely diagnosis?
polymorphic eruption of pregnancy
154
A baby girl is seen for her 6 week baby check in General Practice, with resolving yellow discolouration of the skin. She was born at term and is following the 25th centile for height and weight. She is breastfeeding well and stools are normal. What is the most likely diagnosis?
physiological jaundice
155
A 36 year old woman presents with a 4 day history of lower abdominal pain, dyspareunia and offensive vaginal discharge. She denies any bowel or urinary symptoms. She takes the combined oral contraceptive pill only and denies any missed pills. Her temperature is 38.2C. Her lower abdomen is mildly tender on palpation. Vaginal and speculum examinations are normal and pelvic swabs are taken. Her urine dipstick is normal. What is the most likely diagnosis?
Pelvic inflammatory disease
156
A 9 week pregnant woman has a routine urine dipstick during an antenatal check. The urine is positive for leukocytes and nitrites. She is asymptomatic. She has no previous past medical history. She is allergic to penicillin. What medication should be prescribed in this scenario?
Nitrofurantoin
157
A 25 year old woman is having her first smear in General Practice. The nurse notices an absent clitoris and labia minora with surrounding scarring. What is the most likely diagnosis?
Type 2
