Exam paper 1

A 28 year old female patient who works as a swimming teacher is referred to the cardiology outpatient department on account of a history of intermittent palpitations. She reports these as having a very abrupt start and stop, and that they tend to make her feel presyncopal. On a few occasions these have occurred while out running in the park, and this makes her have to stop running.

She smokes ten cigarettes per day and does not drink alcohol or use recreational drugs. Her past medical history is completely unremarkable and her only medication is the oral contraceptive pill.

On clinical examination she has a systolic murmur at the left lower sternal edge and a prominent apical impulse. Her 12 lead electrocardiogram identifies deep T wave inversion in leads V₂-V₅.

Which of the following investigations would be most likely to confirm the patient’s diagnosis?

A 53 year old male patient who works as a solicitor has an episode of paroxysmal atrial fibrillation. This caused him symptoms of shortness of breath and dizziness for approximately four hours. His initial 12 lead electrocardiogram showed fast atrial fibrillation with a rate of approximately 120 beats per minute, but he reverted to sinus rhythm while in the Emergency department prior to any treatment being administered. He is discharged on oral bisoprolol and brought back to see you the following day on ambulatory care to decide the next steps. His past medical history is completely normal and he takes no regular medications prior to this. His blood pressure is 120/70 mm Hg and his pulse is now 68 beats per minute, regular. Clinical examination of his cardiovascular, respiratory, and abdominal systems is normal. His thyroid appears clinically normal. His blood sugar level was 5.1 mmol/l and his thyroid function tests are all within normal range. He asks you how to best reduce his risk of a stroke. What do you recommend?

A 48 year old female patient who works as a carer presents with syncope, dizziness and fatigue for the past four weeks. Her past medical history is notable for hypertension, mild depression, chronic obstructive pulmonary disease and breast cancer. Her current medications include trastuzumab. She has also had a pacemaker fitted two months previously on account of bradycardia and presyncopal symptoms. Her observations reveal blood pressure 88/62, pulse 62 beats per minute (regular), respiratory rate 16 breaths per minute, oxygen saturations 97% on room air. She is apyrexial. You make a diagnosis of pacemaker syndrome. What 12 lead electrocardiogram findings are encountered in pacemaker syndrome?

A 57 year old obese male patient with a past medical history of stable angina and essential hypertension presents to the Emergency Department with central crushing chest pain of 90 minutes duration. He is started on high flow oxygen, sublingual GTN and aspirin are administered and venous access achieved. Unfortunately while he is having his 12 lead electrocardiogram monitor he loses consciousness, and the initial rhythm is confirmed as pulseless ventricular tachycardia. The defibrillator is currently in use on another patient who is also being resuscitated. What is the most appropriate immediate treatment for this patient?

A 38 year old African-Caribbean male patient presents to his general practitioner with a history of intermittent rapid palpitations. These appear to occur randomly at rest. Additionally, he has noticed episodes of rapid palpitations on exertion associated with presyncopal symptoms. On one occasion he collapsed with loss of consciousness while running. On clinical examination you suspect that has a prominent apical heave. You can also hear a systolic murmur over the left sternal edge. Clinical examination of his respiratory and abdominal systems is normal. A transthoracic echocardiogram reveals hypertrophy of the interventricular septum with a left ventricular outflow gradient of 50 mm Hg. The imaging is reported as consistent with hypertrophic obstructive cardiomyopathy. A 24 hour tape reports episodes of non-sustained ventricular tachycardia. What is the most appropriate intervention for managing his electrophysiology?

A 33 year old Caucasian female patient who is 11 weeks into her first pregnancy is seen in her primary care surgery and found to be hypertensive with a blood pressure of 162/88 mmHg. Her past medical history is completely unremarkable, she takes no regular medications and has no allergies. Clinical examination of her cardiovascular, respiratory and abdominal systems is normal. Ophthalmoscopy reveals no abnormality. An ultrasound examination of the kidneys showed equal sized kidneys of 11cm bilaterally with normal morphology. A urine dipstick reveals protein + and blood +. What is the most appropriate first line treatment for this patient?

A 68 year old retired male patient presents for review in the cardiology outpatient clinic six weeks after insertion of a dual chamber pacemaker for complete heart block . He reports feeling better because his previous symptoms of shortness of breath on exertion, fatigue and peripheral oedema have resolved. However, he has developed intermittent palpitations which seem to occur in a completely unprovoked fashion.
A 12 lead electrocardiogram to determine whether the pacemaker lead had become dislodged. What are the features in ventricular lead displacement on a 12 lead electrocardiogram?

A 30 year old male patient who works as a car park attendant presented to his general practitioner complaining of a new rash in his inguinal region. He had recently gone on a long holiday overseas to Asia, and while there purchased a treatment over the counter for the rash which he had attributed to a reaction to detergent. Unfortunately although the rash appeared beneficial temporarily, it subsequently deteriorated and returned even more symptomatic than before. The patient reports that the rash is intensely pruritic. On clinical examination he has a scaly and raised sharp red bordered rash which spreads asymmetrically down the inner aspect of his left leg. The scrotum is unaffected. There is central clearing of the rash. Which of the following investigations would be most likely to confirm the suspected diagnosis?

A 25 year old female patient who works for the police is seen by her general practitioner on account of generalised pruritus which has been ongoing for two months. Her symptoms have steadily deteriorated and are preventing her from sleeping, as the itchiness is particularly severe at night time. She has not noticed any rash. Her past medical history is completely unremarkable and she takes no regular medications. She has no allergies. She lives with her boyfriend and drinks approximately seven units per week. She smokes two cigarettes per week. On clinical examination you notice excoriations over her shoulders and arms, and can see some erythema in her interdigital webs. Clinical examination of her cardiovascular, respiratory and abdominal systems is completely normal. Which of the following treatment options is most likely to improve her symptoms?

An 80 year old retired male patient with Alzheimer’s dementia is admitted to hospital with a community acquired pneumonia in his left lung. His current medications include furosemide, bisoprolol, ramipril and spironolactone – all of which have been started in primary care for a diagnosis of congestive cardiac failure. You assess him on the ward as his pneumonia is resolving and preparations are being made for his discharge. You notice severe psoriasis covering his chest, elbows, knees and scalp. His family inform you that they have been treating this with E45 cream to reduce the symptoms, but that this has had minimal effect. What treatment would you recommend for his psoriasis?

A 53 year old male patient who works as a joiner presented to the Emergency Department with a growing rash over his shin which was causing swelling and pain. This occurred five days after returning overseas where he had travelled to have surgical removal of some varicose veins on the same leg. On clinical examination he appeared clammy and agitated. He had a temperature of 38.7 degrees centigrade and a tachycardia of 122 beats per minute, regular, with a blood pressure of 118/72 mm Hg. You examine the leg and notice a brownish discoloration over the whole area with significant swelling. On palpation of the swollen area there is a crackly character to the skin. You can see a smelly discharge from an open wound at the site of surgery. What is the most important treatment priority to organise?

You are reviewing a retired 73 year old type 2 diabetic female patient. She is currently treated with metformin modified release 1g twice daily and Humulin I at night. She started insulin at her last appointment and she has been reliably maintaining a glucose diary since then. She reports glucose levels have been in the range 9-14 mol/L when she gets up first thing in the morning. She has never had any values lower than 8.2 mol/L at this time of the day. She currently takes 16 units at night. What should you recommend that she does to improve her glycaemic control further?

A 51 year old male patient with a past medical history of type 2 diabetes mellitus is treated with NovoMix 30 twice daily. He asks you at his annual review to assess his blood glucose diary and advise on how he should improve his control. He currently tests his blood glucose reliably four times a day: Before breakfast, before lunch, before dinner, and at bedtime. His morning glucose readings are consistently between 5.1 and 6.4 mmol/L; pre-lunch readings are between 8.4 and 11.2 mmol/L; pre-evening meal readings are between 7.9 and 10.4 mmol/L; and bedtime readings are between 6.2 and 8.3 mmol/L. What should you recommend this patient do?

You are asked by the anaesthetist to review the case of a retired 71 year old female patient who underwent a prolonged operation earlier in the day for a complicated dental extraction. Her past medical history is only notable for stable angina and a laparoscopic cholecystectomy. Her current medications include isosorbide mononitrate, aspirin and simvastatin. She has no known allergies. You have been asked to review because she is complaining of shortness of breath and a headache. Clinical examination reveals cyanosis. An arterial blood gas on a 15 litre non-rebreathe O₂ mask is as follows:

What is the most probable explanation for her post-operative deterioration?

A 47 year old male patient who works as a life coach is referred by his general practitioner to the outpatient clinic on account of headaches. He has also noticed a very subtle and gradual change in his facial appearance with enlargement of his hands such that his wedding ring no longer fits. Clinical examination reveals enlarged digits, prognathism and a bitemporal hemianopia. His blood pressure is elevated at 152/88 mm Hg. He is referred for more investigations. An oral glucose tolerance test showed a blood glucose of 12.1 mmol/l at two hours with a failure to suppress growth hormone levels. An MRI scan of his pituitary fossa identified an adenoma that was abutting his optic chiasm. The patient did not want to attempt surgical treatment in the first instance, instead preferring to attempt medical interventions. Which of the following would be an appropriate option?

A 43 year old unemployed male patient is brought to the Emergency Department following a paracetamol overdose. He admits to having taken a total of 25 grams of paracetamol over the course of 30 minutes with half a bottle of vodka with the intention of ending his own life. This impulsive act took place approximately eight hours prior to his attendance. He was subsequently found by a friend and brought into hospital. His friend reports that he found the patient at home and there was no evidence that he had taken any other medications in the overdose. While the paramedics were bringing him to hospital the patient vomited twice and complained of new abdominal discomfort. On clinical examination the patient appeared depressed. Cardiovascular and respiratory examinations were normal, but he was tender in the right upper quadrant of his abdomen. He is not jaundiced, and his GCS is 15/15. Which of the following investigations correlates best with the severity of any liver failure in this clinical context?

A 41 year old male patient who works as a bar owner attends the diabetes outpatient clinic on account of a twenty year history of type 1 diabetes mellitus. This appointment is his annual review. Unfortunately he has developed diabetic nephropathy – his most recent creatinine is measured at 205 umol/l – and microalbuminuria. He has also required panretinal photocoagulation on the right eye due to deteriorating retinopathy. His current insulin regime comprises NovoMix 30, 12 units twice daily. His most recent HbA1c was 60.1 (7.7%). He measures his blood glucose four times a day. You review his diary and identify high postprandial glucose two hours after meals (typically in the region of 10-14 mmol/l), and attacks of hypoglycaemia late in the afternoon before his dinner. He also occasionally has hypoglycaemic attacks before breakfast. His body mass index is 21 kg/m2. The patient is happy to consider any changes to his medication regime required to improve his control. What approach would be optimal?

A 43 year old insulin-dependent male patient with poorly controlled type 1 diabetes mellitus is seen on the general medical take with an acutely swollen right mid foot which has deteriorated rapidly over the course of approximately a fortnight. He denies any trauma to the foot. On clinical examination the mid foot is warm and erythematous. His posterior tibial and dorsalis pedis pulses are intact. He has sensory loss in a glove and stocking distribution on both sides. His venous blood tests show a normal full blood count, CRP, urea and electrolytes. His plain radiograph of the affected foot is completely normal. What should you arrange to manage his foot?

A 33 year old male patient is brought to the Emergency Department by a friend. He reports feeling short of breath and generally unwell. Observations reveal pulse rate 116 beats per minute, regular, blood pressure 132/64 mm Hg, respiratory rate 26 breaths per minute. Arterial blood gases on 15 litres oxygen delivered via a non-rebreathe mask are as follows:

Other investigations are as follows:

What has the patient ingested?

An 18 year old female patient presents to the endocrinology outpatient clinic on account of a 4 months history of amenorrhoea. Further questioning reveals that she has had around a year-long history of 7kg unintentional weight loss and loose stool. Her past medical history is completely unremarkable and she takes no regular medications. On clinical examination, her body mass index is 18 kg/m². Investigations are as follows:

What is the most probable diagnosis?

An 18 year old female is referred for assessment of progressive muscle weakness and limited eye movements. She reports a long history of problems with her eyes, which began while she was at primary school when she was found to have a squint. A couple of years after this, at approximately the age of nine she developed a period of diplopia which resolved spontaneously after a few months. She has now been referred for a further opinion having again developed double vision and deteriorating generalised muscle weakness. She says that it has become difficult to climb the stairs. On clinical examination is short, has a ptosis and reduced facial expression. On cranial nerve testing she has reduced eye movements in all directions but her pupils react to light and accommodation. Her visual fields are normal. Fundoscopy is notable for pigmentary degeneration. Peripheral neurological examination detects weakness of her neck muscles and proximal muscle groups in her legs. Reflexes are generally mute. Plantar reflexes were flexor. Cerebellar testing is notable for dysdiadochokinesia and gait ataxia. Sensory examination showed preserved sensation to all primary modalities. Romberg’s testing is normal. Cardiovascular, respiratory and abdominal examinations are all normal. A 12 lead electrocardiogram is notable for Mobitz type 2 heart block. Which investigation would establish the diagnosis?

A 15 year old female patient is seen in your clinic on account of primary amenorrhoea. She attends with her mother who is very concerned because she has lost around 8 kg in weight over the last twelve months. She has also developed frequent episodes of diarrhoea. She has excellent academic performance and is high achieving in maths, music and science. She also competes frequently for the school running team and goes running every day to train for this. Her father died two years previously of oesophageal cancer. She takes no regular medication and has no allergies. On clinical examination she is underweight with a body mass index of 15.5 kg/m² and is phenotypically female. She has normal breast development. There is no galactorrhoea to expression. She has only a small amount of pubic hair. Investigations are as follows:

What is the most probable cause of her amenorrhoea?

A 56 year old unemployed female patient becomes unwell on the general medical ward with hallucinations of insects crawling on her bed, clamminess and shaking. Her symptoms follow a two day admission on account of gastroenteritis which is rapidly improving. Her past medical history is notable for excessive alcohol consumption (she admits to 42 units per week), smoking 15 cigarettes per day, and a long history of intravenous drug abuse. Her pulse rate is 130 beats per minute, regular, blood pressure 174/92 mmHg and temperature 37.8 degrees centigrade. On clinical examination she appears agitated, sweaty and is icteric. She has mild ascites with a non-tender abdomen. Clinical examination of her cardiovascular and respiratory systems is normal. She does not have asterixis. What treatment should be administered for her symptoms?

You are asked to see a 68 year old recently retired female patient on the hospital’s gynaecology ward. She was admitted with abdominal distension and constipation. Her symptoms progressively deteriorated over the course of around a month until she was no longer able to manage at home, leading her to attend the Emergency Department. An ultrasound scan arranged on her arrival revealed a large pelvic mass and gross ascites. She underwent an abdominal paracentesis to remove her ascites. The cytology report from the laboratory describes adenocarcinoma cells with psammoma bodies. Which of the following underlying diagnoses is implied by this clinical scenario?

A 71 year old retired female patient is referred to the cardiology outpatient clinic on account of palpitations. She complains of episodes of “flushing” that appear to be associated with rapid palpitations in her chest. She denies any chest pain, loss of consciousness or breathlessness associated with these symptoms. She has no risk factors for ischaemic heart disease and was previously entirely fit and well. She has no allergies. She also complains of new episodes of loose stool. On clinical examination she appears well. You can see prominent V waves when you examine her JVP and can hear a pansystolic murmur at the left sternal edge. Clinical examination of her respiratory and abdominal systems is completely normal aside from a pulsatile liver edge. Which investigation would confirm the underlying diagnosis in this patient?

A 53 year old unemployed male patient has known alcoholic cirrhosis and ascites. He presents to the general medical take from the street with a three day history of abdominal discomfort. On clinical examination he is pyrexial with a temperature of 38.4 degrees centigrade. His pulse rate is 104 beats per minute, regular, and his blood pressure is 98/70 mmHg. Clinical examination of his cardiovascular and respiratory systems is unremarkable, although you note multiple stigmata of chronic liver disease. He has generalised abdominal discomfort and moderate ascites. You perform a diagnostic ascitic tap and the laboratory reports a neutrophil count of 410/microL. You inform the patient of his diagnosis of spontaneous bacterial peritonitis and commence intravenous antibiotic treatment. The patient has a number of questions about his prognosis and is keen to engage with alcohol services. What is the two year mortality of spontaneous bacterial peritonitis?

You review a 48 year old male patient who works as a journalist in the gastroenterology outpatient clinic. He has been referred by his general practitioner on account of abnormal liver function tests. His past medical history is only notable for a recent diagnosis of type 2 diabetes mellitus which he is currently attempting to control by diet alone. He does not smoke, consumes no alcohol and denies recreational drug usage. He has not travelled outside Europe in the past four years. On clinical examination he appears tanned with evidence of clubbing. You identify multiple spider naevi. Clinical examination of his cardiovascular and respiratory systems is normal, but abdominal examination reveals a 3 cm tender hepatomegaly. What is the most probable cause of his deranged liver function tests?

A 39 year old female patient who follows a vegan diet is referred to the gastroenterology outpatient clinic by her general practitioner. She complains of a six month history of fatigue and deteriorating shortness of breath on exertion. Her blood pressure is 108/76, pulse is 68 beats per minute (regular), and body mass index is 21 kg / m2. A full neurological examination is completely normal. Investigations reveal:

What is the most probable cause of symptoms?

A 18 year old female patient is referred to the general medical outpatient clinic for investigation of short stature. Discussion of her general health reveals that she experiences intermittent episodes of abdominal discomfort and loose stool over the last 18 months, although this has improved while awaiting her appointment. She was diagnosed with gastroenteritis in primary care on account of these symptoms. She also experiences occasional stiffness and pain in her right hip which occasionally makes her walk with a limp. She is otherwise fit and well and takes no regular medication. She does not smoke and consumes minimal quantities of alcohol. Her paternal uncle is under regular colonoscopy surveillance having been found to have polyps. On clinical examination she looks pale. Cardiovascular and respiratory examinations are normal. Abdominal examination detects generalised tenderness but no organomegaly. Investigations are as follows:

Other routine bloods are normal. A bone marrow aspirate reports a megaloblastic picture. A barium meal and follow through is described has showing ‘Kantor’s string sign’. What is the most probable cause of her symptoms?

A 71 year old retired male patient with a past medical history of mild depression comes to the Emergency Department complaining of dysuria, right sided flank pain, pyrexia and rigors for the past three days. His only medication is fluoxetine and he has no known allergies. His vital signs reveal a temperature of 38.9 degrees centigrade, blood pressure 102/58 mm Hg, pulse 108 beats per minute, respiration 26 breaths per minute and oxygen saturation of 98% on room air. Clinical examination of the patient’s cardiovascular, respiratory and abdominal examination was unremarkable aside from discomfort in the right renal angle. His plain chest radiograph is normal and a urine dipstick is positive for blood, protein, leucocytes and nitrites. You send blood and urine cultures to the microbiology laboratory for further analysis. What is the most appropriate next step in management?

A 79 year old retired male patient presents to the general medical outpatient department with extreme fatigue. A full systems review reveals that he has had occasional episodes of epistaxis, spontaneous bruising, and has also developed some petechiae. On clinical examination you confirm bruising and petechiae. He appears pale and has splenomegaly on abdominal examination. Clinical examination of his cardiovascular and respiratory examination is normal. Investigations reveal:

Which investigation should be arranged in order to confirm his diagnosis?

A 75 year old retired male patient is treated with warfarin for a prosthetic metallic aortic valve. He has recently been prescribed a seven day course of clarithromycin by his general practitioner for a lower respiratory tract infection, then attends for his regular INR check as usual. He is now clinically entirely well with no evidence of increased bruising or bleeding. Investigations reveal :

How should you manage his increased INR?

A 74 year old retired male patient with a long history of rheumatoid arthritis presents to the rheumatology outpatient clinic for review. He reports approximately 4 kg loss of weight and several episodes of dark discolouration of his urine. His bowel habit has remained normal. He drinks approximately 28 units of alcohol per week and does not smoke. He has no recent history of overseas travel. On clinical examination he weighs 72 kg. He has a mildly enlarged spleen, but otherwise clinical examination of his cardiovascular, respiratory and abdominal systems is completely normal. His liver function tests are within normal limits, aside from raised bilirubin. His urine analysis showed increased urobilinogen, urosiderin, but no bilirubin and no red cells. His full blood count showed his haemoglobin was reduced 9.8 g/dl and a platelet count of 98. His blood film showed an increase in spherocytes, and haptoglobins were reduced. What is the next best investigation in this case?

A 42 year old female with known type 2 diabetes mellitus is seen in the general medicine outpatient clinic and complains of a four month history of fatigue and non-specific joint pains. Clinical examination is unremarkable. On further investigation, her ferritin elevated at 1800 ng/ml with a transferrin saturation of 61%. Genetic studies show homozygosity for the HFE C282Y gene. What is the most appropriate management strategy for this patient?

A 63 year old recently retired female patient presents to the Emergency Department in the middle of the night complaining of a sudden onset of headache, right arm and leg weakness, nausea, vomiting and tiredness. A computed tomography scan of her brain identifies no intra-cranial pathology. Venous blood tests reveal haemoglobin of 69 g/L, a platelet count of 9 x 10⁹/L and a mild acute kidney injury. A blood film examination shows multiple red cell fragments and confirms true thrombocytopenia. What treatment should be arranged as soon as possible?

A 32 year old male patient who works as a plumber is seen on the general medical take with a week long history of deteriorating shortness of breath on exertion, cough and wheeze. Over a similar length of time he has also developed a new rash. These symptoms follow a recent return to the United Kingdom from a holiday spent travelling in Vietnam and Cambodia. On clinical examination he has a temperature of 38.6 degrees centigrade. You can see a linear erythematous rash on his buttocks. Clinical examination of his cardiovascular and abdominal systems is unremarkable but he has an audible wheeze throughout his precordium on auscultating his lung fields. Investigations reveal:

What is the most appropriate next step in this patient’s management?

A 34 year old male patient who recently moved to the United Kingdom from Hong Kong underwent routine blood tests from his general practitioner. His hepatitis B screen came back having detected both HBs and hepatitis-B IgG core antibodies. His anti-HBe antibody was also positive. His is found to be e-antigen and s-antigen negative. He is referred to your hepatology clinic for further advice. Other investigations sent prior to his clinic appointment are as follows:

The patient seems clinically entirely fit and well. What should you do next?

A general practitioner refers a 23 year old male university student, who had been previously fit and well to the rheumatology outpatient clinic for a second opinion. He presented on account of an eight week history of migratory arthralgia and myalgia. These symptoms followed a recent trip to Thailand. While there he had had a single unprotected sexual encounter with a female. On clinical examination there was no apparent arthritis. However, you are able to palpate bilateral cervical lymphadenopathy. Venous blood tests reveal mild anaemia, normal urea, creatinine and electrolytes, and marginally elevated liver enzymes but no hyperbilirubinaemia. Urethral swabs for chlamydia and gonococcus were normal. What is the most probable diagnosis?

A 29 year old female patient is 12 weeks pregnant. She is seen in her general practitioner’s surgery and found to have a blood pressure of 164/88 mmHg. Similar readings are achieved on two other occasions. Her past medical history is completely unremarkable and she takes no regular medications and has no allergies. This is her first ever pregnancy. Clinical examination of her cardiovascular, respiratory and abdominal systems is normal and fundoscopy is normal revealing completely clear optic discs with no evidence of papilloedema. A subsequent ultrasound scan of her kidneys, ureters and bladder showed both kidneys to be of equal size of 10 cm. A urine dipstick reveals protein + and blood +. What is the most probable cause of her hypertension?

A 40 year old unemployed male patient who is a known intravenous drug user is seen on the general medical take on account of pyrexia, shortness of breath on exertion, drenching night sweats, 5 kg weight loss and a non-productive cough. His symptoms have been deteriorating for around three weeks. On clinical examination of his respiratory system you are able to auscultate fine crepitations. A plain chest radiograph reveals bilateral diffuse interstitial infiltrates. His admission bloods identify that he is HIV-positive and has a CD4 count of 90. A sputum culture is negative for Pneumocystis jirovecii. Which investigation would confirm this patient’s diagnosis?

A 77 year old retired male patient who works as a farmer in Herefordshire was found to have slightly deranged liver function tests during a routine health check up at his primary care surgery. This was followed up with an ultrasound scan which demonstrated multiple cystic lesions in his liver. These ranged in size from 1-6 cm in diameter. Some of the cysts appeared to have some calcification. His past medical history is only notable for mild anxiety, and he takes no current medications at all. Which investigation should be arranged as the next step?

A 45 year old male patient attends the Emergency Department with his partner. He complains of a four days history of headache and 24 hour history of steadily worsening right arm weakness. His partner says that he also seems slightly “muddled”. On clinical examination, he is febrile with a temperature of 38.0 degrees centigrade, blood pressure 132/70 mm Hg. Neurological examination is notable for the presence of right arm weakness. Investigations are as follows:

What is the most probable diagnosis?

A 26 year old male patient studying postgraduate medicine returns from a month long holiday travelling in Kenya and Tanzania. Before his department he attended the travel clinic and took all relevant immunisations. He also complied with his malaria prophylaxis up until his flight home. He has now developed a ten day history of malaise, pyrexia and intermittent rigors with intermittent vomiting. On clinical examination he is drowsy. You are not able to palpate any lymphadenopathy. Cardiovascular and respiratory examinations are normal. Abdominal examination detects mild hepatosplenomegaly. Neurological examination is normal. His investigations are as follows:

What is the most probable cause of his presentation?

A 23 year old male patient who moved to the United Kingdom from Brazil eight weeks ago attends the Emergency Department with pain in his left hip. This follows his having tripped over around ten days ago, sustaining an apparently minor injury at the time. He also reports intermittent headaches and a significant loss of appetite resulting in around 12 kg weight loss over the past few months. He does not smoke and consumes minimal quantities of alcohol. On clinical examination he is underweight with a temperature of 38.1 degrees centigrade, pulse 60 beats per minute, blood pressure 124/72 mm Hg. Cardiovascular and respiratory examinations are normal, but on examination of his abdominal system you can palpate a 12 cm splenomegaly. His left hip is tender to palpation but has a full range of movement. Investigations are as follows:

Radiographs of his chest, and left hip are all unremarkable. Which of the following investigations would you predict to be diagnostic?

An 18 year old female patient who is soon starting university was brought to the neurology outpatient clinic by her father for the evaluation of intermittent unawareness that had been ongoing for approximately three years. Her father describes episodes in which she would stare and would seem unresponsive to attempts to talk to her. On some occasions she might be seen to have very subtle fluttering of her eyelids. Each episode would typically last 30 to 120 seconds before apparently resolving completely spontaneously. More recently, over the past eight months she had been observed to have intermittent sudden jerking movements of her limbs without apparent provocation. Her referral was finally prompted by a single episode in which she appeared to lose consciousness completely for two minutes and shake uncontrollably. Choose the most probable diagnosis

A 60 year old male patient who works as an engineer is seen in the neurology outpatient clinic with slowly deteriorating walking over the course of approximately four years. He reports that his walking speed has steadily slowed down, and he finds it hard to turn around quickly. More recently he has developed a tremor in his left hand which is particularly prominent when he is distracted by something else. On examination he is hypomimic with a quiet voice. He has a resting tremor of the hand apparent on his left side. His tone is increased, displaying both cog-wheeling and lead pipe rigidity on the left side. He appears to struggle with fine finger movements in his left side, although the right side appears unaffected. You examine his gait and notice reduced arm swing with a stooped posture. The rest of his clinical examination is normal. Which treatment modality is first line for this patient?

A 28 year old male patient who works as a fisherman presented to the neurology outpatient clinic with a history of intermittent headaches for the preceding six months. He reports that these occur typically twice or three times per day and can last up to one hour in duration. Around three months ago he had thought that his symptoms had completely resolved spontaneously because he went approximately four weeks without any symptoms. Unfortunately the headaches then recurred, prompting his referral to you. He reports severe right-sided pain in the right retro-orbital region, and his partner says that his eye becomes teary and red during a headache. On clinical examination his blood pressure is 118/68 mm Hg, pulse is 68 beats per minute and regular and his body mass index is 23 kg / m2. A full neurological clinical examination has no positive findings. Which of the following would be the most effective prophylactic treatment?

A 70 year old retired male patient is admitted to the Emergency Department after a sudden collapse with loss of consciousness. Just prior to his collapse he was complaining of a severe sudden occipital headache. His past medical history is notable for essential hypertension, currently controlled with amlodipine and lisinopril. On clinical examination his mean arterial pressure is 140 mm Hg. His pulse is 80 beats per minute and regular. He has bilateral papilloedema visible on ophthalmoscopy and his GCS is reduced at 13/15 (eyes 3, verbal 4, motor 6). He is moving all his limbs. A CT scan of his brain confirms a large subarachnoid haemorrhage. What cerebral perfusion pressure should be targeted in the management of his blood pressure?

A 37 year old male patient who works as a research scientist complained of a twelve month history of feeling low in mood and slight paranoia – for example, occasionally feeling suspicious that he is being followed. He had previously been completely fit and well. He is on no regular medication. He does not smoke cigarettes and consumes only around 7 units alcohol per week. However, he admits to smoking cannabis approximately once a month for the past twenty years. He suspects that his symptoms were triggered by the suicide of his mother approximately 18 months previously. On neurological examination you notice occasional facial grimacing and writhing limb movements. His tone, power and reflexes are all within normal limits. His cranial nerve examination is normal, although he struggles to stick out his tongue. What investigation is most likely to secure the diagnosis?

A 18 year old female patient is referred to the neurology outpatient department after experiencing a one year history of upper limb jerking on waking up in the morning. She reports that these symptoms typically last for a few seconds. She has noticed similar episodes on a few occasions at other times of the day, too – but says that the symptoms are most apparent first thing in the morning. She attends the clinic with her father, who also reported multiple episodes in the last three months where she would stare into the distance for up to 10 seconds, and not respond to attempts to talk to her. Her past medical history is completely unremarkable and she takes no regular medications. She is currently waiting to begin studying maths at university. Her body mass index is 20 kg / m2 and her blood pressure is 108/20 mm Hg. A full neurological examination is normal. Which anti-epileptic drug would be most suitable for this patient?

A 51 year old female patient who works as an occupational therapist complains of incoordination in her right hand with a deterioration in her handwriting. She estimates that the symptoms have persisted for around four months and appeared to follow a viral illness. In the last couple of weeks she has also developed vertiginous symptoms. A cranial nerve examination detects reduced hearing in the right ear with diminished sensation on the right side of the face. She also has an absent corneal blink reflex. On clinical examination of her limbs she had impaired finger-nose coordination in the right side with impaired dysdiadochokinesis on the same side. Her blood pressure is recorded as 132/76 mm Hg, with a pulse rate of 74 beats per minute and regular. Which of the following investigations would be most useful?

A 63 year old male patient is referred to a the neurology outpatient clinic on account of a twelve week history of deteriorating forgetfulness, agitation and problems with his speech. He works on a factory production line assembling electrical components but has recently been sacked due to clumsiness. He has become progressively depressed since losing his job. His past medical history is notable only for essential hypertension, treated with indapamide and ramipril. On clinical examination his observations are entirely within normal limits. He looks depressed and exhibits a moderate expressive dysphasia. His mini-mental state examination score is 19/30. You detect a right palmomental reflex. Peripheral neurological examination is notable for myoclonic movements throughout all limbs and an intention tremor in both arms. He has an ataxic, broad-based gait. Investigations are as follows:

What is the most probable diagnosis?

A 29 year old female patient was admitted to the Emergency Department complaining of headaches and double vision. She describes a generalised, throbbing headache which is associated with nausea and worse on getting up in the morning. This has been ongoing for some time, but deteriorating recently. Today she noticed double vision and some difficulty opening her eyelid on the left. She denies any paraesthesia or symptoms in her limbs. Her past medical history is only notable for episodic migraine, for which she occasionally takes sumatriptan that she purchases over the counter. She has no other medications. She does not smoke and typically consumes around 14 units alcohol each week. On clinical examination she is alert and orientated to time, place and person. Blood pressure 130/74 mmHg, pulse 72 beats per minute, regular. She has some mild neck stiffness and is mildly photophobic. Fundoscopy is normal. Cranial nerve examination confirms the presence of a left third nerve palsy. Peripheral nervous system examination is completely normal. Investigations are as follows:

Which investigation is most likely to be diagnostic?

A 58 year old male patient is referred to your general medical outpatient clinic for investigation of bilateral hand weakness which has been deteriorating for approximately eight months. This has made his work on a factory production line extremely difficult to manage, and he has had numerous occasions where he has made mistakes as a result. He also complains of general aches and pains in his neck and calf muscles that appears to deteriorate in the evening. His partner is very concerned because he has exhibited some episodes of erratic behaviour and he seems to be getting forgetful. His past medical history is completely unremarkable and he takes no regular medications and has no allergies. He does not drink alcohol or smoke cigarettes. On clinical examination he scores 10/10 on his abbreviated mental test. He has wasting of the small muscles of his hands both sides and you see occasional fasciculations in his quadriceps. On testing his tone you elicit generalised mild spasticity and 4/5 weakness in his hands. Sensation is normal throughout. An MRI scan of his brain and spinal cord is completely normal. Which investigation would you expect to be diagnostic?

A 56 year old female patient with a past medical history of essential hypertension, type 2 diabetes mellitus and an ovarian cancer resected two years previously, presents to the Emergency Department on account of a seven day history of shortness of breath and cough. She reports a moderate left sided earache with discharge and associated headache although no photophobia or neck stiffness. She has also had some hoarseness of her voice in the past few days. On clinical examination her observations are all within normal limits. Cranial nerve examination is notable for deviation of uvula to the right and her right palatolingual fold appears raised compared to the left. Her tongue deviates to the left when she sticks it out. Peripheral neurological assessment is completely normal. Investigations are as follows:

What is the most probable cause of her symptoms?

A 53 year old postmenopausal female patient who works as a hairdresser is admitted to the hospital on account of right sided abdominal discomfort. On clinical examination she is noted to be haemodynamically stable. She has an adnexal mass on pelvic examination. An ultrasound examination appears to demonstrate torsion of the right ovary, so she is referred to the gynaecologists who arrange a right sided oophorectomy. Intra-operatively she is found to have an ovarian malignancy. The cancer appears to be confined to her right ovary, and the capsule of the ovary is intact. There is no evidence of metastatic spread and she has no ascites. Post-operatively, a staging CT chest, abdomen and pelvis shows no evidence of metastatic disease. What management should be offered to the patient?

A 40 year old female patient who works as a music teacher underwent resection of a carcinoma of her right breast three years previously. Postoperatively she was also treated with radiotherapy. She is referred to the neurology outpatient clinic on account of deteriorating right hand weakness. On clinical examination in the outpatient clinic she appears well. Her right palpebral fissure is slightly smaller than the left. She has normal eye movements in all directions. There is right sided meiosis. Her facial expression is normal. On examining her right hand you notice that the small muscles are wasted and weak, with some clawing apparent. She has reduced sensation on the ulnar border of the right hand and forearm when you conduct pin-prick testing. What is the most probable underlying cause of her presentation to your clinic?

A 69 year old male patient with palliative metastatic non-small cell lung cancer is seen on the general medical take on account of right sided hip and chest pain. He has already been found to have multiple metastatic deposits in his spine and ribs which appear to be the cause of his pain. His past medical history includes a previous appendicectomy and a non-ST elevation myocardial infarction four years previously. His current medication only comprises regular dose paracetamol. He also uses a TENS machine. What is the most appropriate medication to prescribe for this patient next?

A 78 year old retired male patient is seen on the general medical take with a three month history of 4 kg weight loss, altered bowel habit and fatigue. A colonoscopy reveals a large mass in his descending colon consistent with a malignancy. After discussion at the colorectal multidisciplinary meeting, the patient undergoes a left hemicolectomy which is graded as Dukes C. He is found to have evidence of metastatic adenocarcinoma in 2 out of 14 lymph nodes. His post-operative staging CT scan shows no evidence of residual disease or metastases. What is the approximate five year survival for patients with a Dukes C adenocarcinoma?

A 41 year old female patient is referred to the general medical take by her general practitioner on account of uncontrolled pain and vomiting. Unfortunately, she has known metastatic incurable carcinoma of the cervix which has been actively managed for the past four years by the oncologists. They have recently decided that her disease has progressed, and referred her to palliative care services. She has resigned herself to her limited prognosis, and is aiming to spend as much time as possible with her husband and two teenage children. Her admission has been prompted by deteriorating pelvic and leg pain. She describes a deep pain in her abdomen and pelvis with back pain which is exacerbated by walking. She also has sudden shooting pains that radiate down the posterior aspect of her right leg. She denies any change in her bowel habit or urinary symptoms. Her community palliative care nurse has already prescribed co-codamol 30/500 up to four times a day if required and cyclizine 50mg orally as required. She initially found the cyclizine helpful but complains of drowsiness from the co-codamol. In the past 36 hours she has become unable to retain any oral medications due to vomiting. On examination she is moderately dehydrated and in obvious pain. Her temperature is 37.1 degrees centigrade, pulse 88 beats per minute, blood pressure 98/60 mm Hg. Cardiovascular and respiratory examinations are unremarkable. Her abdomen is soft with a mass arising from her pelvis. Investigations are as follows:

How should you manage her pain?

A 68 year old retired female patient with a past medical history of rheumatoid arthritis (RF positive, anti-CCP positive) is seen on the general medical take on account of a headache and right eye visual blurring. Her medications include methotrexate weekly and folic acid daily. She has no allergies and does not smoke or drink alcohol. Her arthritis is currently well controlled and she has no swollen or tender joints. On clinical examination she has a red right eye with a corneal opacity and intense photophobia. Her full blood count, renal function tests, and liver function tests are all normal. Her CRP is 104 mg/L. A corneal swab did not grow any organisms. What is the most probable cause of her symptoms?

You are asked to see a 43 year old unemployed female patient on the hospital’s psychiatry ward. She has a long history of schizophrenia resulting in multiple hospitalisations previously. She reports a four week history of feeling general malaise with increasing stiffness of her jaw and arms. She has been stably established on haloperidol for the past four years with no dose changes in the past 12 months. On clinical examination, her temperature is 38.9 degrees centigrade and her blood pressure is 172/90 mmHg. Her pulse rate is 96 beats per minute, regular. What treatment do you recommend in this scenario?

A 66 year old retired male patient is referred by his general practitioner to the renal outpatient clinic. He has recently started treatment with ramipril for essential hypertension, but on a routine review of his renal function seven days later the general practitioner detected a significant deterioration in his creatinine. An magnetic resonance angiogram is arranged with reports a patent right renal artery and additional stenosis of the left renal artery. On clinical examination the patient’s blood pressure is 152/92 mmHg, pulse 78 beats per minute (regular). Clinical examination of the cardiovascular, respiratory, abdominal systems is completely normal. A urine dipstick is also normal. What should you do?

A 61 year old female patient who works as a librarian presents with tiredness, disorientation and vomiting. She has no previous medical records on file and has not consulted with her general practitioners for over ten years. Her only medication comprises occasional paracetamol for headaches in the past. She also takes bendroflumethiazide for the past 12 years for the management of essential hypertension. On clinical examination her blood pressure is 162/82 mm Hg and she is confused. You elicit evidence of nystagmus, brisk reflexes and several beats of clonus. She also has some evidence of vaginal bleeding. Blood tests are as follows:

What has caused her presentation?

A 23 year old female patient who works as an office administrator is admitted to the Emergency Department after collapsing unconscious at work. Her co-workers brought her for further assessment. The patient attributes her collapse to a faint, saying that it was a very hot day and the air conditioning system had malfunctioned and was awaiting repair. On systems review, however, she admits to significant fatigue and myalgia on minimal levels of exercise. She says that she has had this lifelong. She struggled throughout school to keep up in sports for this reason, although performed academically extremely well. Clinical examination is notable for a blood pressure of 104/75 mm Hg, pulse rate 80 beats per minute, regular. Her body mass index is 24 kg/m2. Investigations are as follows:

What is the most probable diagnosis?

A 27 year old male patient is referred to the renal outpatient clinic for investigation of an abnormal urine dipstick result that was detected at a routine check-up. He was also found to be hypertensive with a blood pressure of 154/94 mm Hg. His urine dipstick has repeatedly tested positive for 2+ blood and 1+ protein. The patient is completely fit and well and takes no regular medications. He was adopted at birth and a family history is unavailable. On clinical examination, blood pressure is 152/90 mm Hg. His other observations are within normal limits and examination of cardiovascular, respiratory and abdominal systems is completely normal. Investigations are as follows:

Ultrasound scan of kidneys:

What should you do?

A 43 year old male patient is attends the Emergency Department with on account of acute severe right flank pain. His past medical history is completely unremarkable and he takes no regular medications. On clinical examination, body mass index is 29 kg/m², pulse rate 74 beats per minute, regular. His abdominal examination is notable for a ballotable mass in his right flank. Investigations are as follows:

Which of the following findings do you expect to find?

A 68 year old retired female patient is admitted as an emergency after a choking episode at a restaurant. She is short of breath on exertion and has a pyrexia of 38.1 degrees centigrade. She is a lifelong smoker of 15 cigarettes per day, but has no history of respiratory diagnoses. However, she was admitted around nine months ago following a stroke. A plain chest radiograph reveals a homogenous opacity at the right base of her lung with the right hilum pulled inferiorly. What investigation should be organised next?

A 36 year old male patient who works in a factory is seen on the general medical take with a three week history of pain, swelling, and stiffness in his ankles. He also reports a cough and shortness of breath on exertion. On clinical examination his ankles are warm, tender to palpation, and swollen with evidence of joint effusions. Clinical examination of his cardiovascular, respiratory and abdominal systems was completely normal. His venous blood tests reveal normal FBC, U&E, and LFTs. He tests negative for anti-CCP antibodies and rheumatoid factor. However, his CRP is elevated at 42 mg/L. Serum ACE is elevated at 145 (normal 0-70). A plain chest radiograph reveals bilateral hilar lymphadenopathy and reticulo-nodular shadows in lung fields. What is the most probable cause of his presentation?

A 30 year old female patient who works as a nursery supervisor presents with acute severe asthma. She complains of worsening shortness of breath on exertion and wheeze over the preceding two days. On reviewing her previous case notes you can see a couple of previous admissions to general medical wards, although she has never had to be transferred to intensive care. The Emergency Department has already treated her with nebulised salbutamol and ipratropium plus intravenous hydrocortisone and magnesium. Unfortunately in spite of these interventions she struggles to perform a peak flow test and remains unable to complete a sentence. You are concerned because she appears to be tiring. An arterial blood gas is performed and her PaCO₂ is 6.9 kPa with a PaO₂ of 7.9 kPa. What is the severity of this patient’s asthma?

A 59 year old male patient who works as a carpenter is seen on the general medical take with cough and shortness of breath on exertion. His past medical history is notable for chronic obstructive pulmonary disease and Crohn’s disease. He still smokes 20 cigarettes a day in spite of these diagnoses, and consumes approximately 28 units alcohol per week. His cough is productive of clear sputum in large volumes. He reports expectorating around a pint of this sputum each day. He denies ever seeing any blood mixed with his sputum. Unfortunately his symptoms have deteriorated to the point that he now gets short of breath climbing the stairs, even though a year previously he had no problems with this. Over the past eight weeks he has lost 5 kg in weight unintentionally. Clinical examination reveals dullness to percussion at his right lung base. His abdomen was generally tender but there was no guarding. What is the most probable diagnosis?

A 25 year old female patient who works as a teacher’s assistant is seen in the respiratory outpatient clinic on account of recurrent episodes of shortness of breath on exertion and a longstanding cough productive of copious malodourous sputum. Her past medical history is also notable for a small number of attendances to the Emergency Department over the past few years on account of colicky abdominal pain. Investigations reveal:

What is the most probable explanation for her presentation to clinic?

A 21 year old male student was admitted to the Emergency department on account of sudden onset chest pain and shortness of breath. He was promptly diagnosed with a large right sided pneumothorax which was successfully treated with a Seldinger chest drain. This episode follows a similar occurrence one year previously when he presented with a pneumothorax on the contralateral side which also required treatment with a chest drain. He is a non-smoker, consumes no alcohol and has no other past medical history of relevance. He clinically improves on the ward over the following 36 hours with re-expansion of his lungs. What should be arranged next?

A 68 year old retired male patient has been admitted in extremis to the resuscitation room in the Emergency Department on account of shortness of breath. His plain chest radiograph is consistent with a diagnosis of heart failure, showing bats-winging of the hilar, upper lobe blood diversion and small pleural effusions. The Emergency Department junior doctor has already administered a bolus of furosemide intravenously to the patient, and then subsequently commenced a GTN infusion to continue his management. The patient’s blood pressure is 94/68 mmHg, pulse is 82 beats per minute (regular). Despite initial treatment, the patient remains significantly unwell with oxygen saturations of 89% on 15 litres of oxygen delivered via a non-rebreathe mask. What treatment should you consider next to improve his clinical status?

A 65 year old recently retired female patient with a known diagnosis of osteoarthritis of the knee and a past medical history of peptic ulcer disease, presents with a seven day history of deteriorating right knee pain. She finds the pain incapacitating, and is having significant difficulties climbing the stairs at home. She denies any trauma and has not noticed any swelling in the joint. She is able to get partial pain relief with maximal doses of co-codamol, ibuprofen gel, and more recently has started fentanyl patches provided by her general practitioner. On clinical examination she is obese. She has crepitus in her right knee but no palpable joint effusion. What is the next management step?

A 50 year old female patient with a 30 year history of type 1 diabetes mellitus is seen on the general medical take on account of a painful, stiff right shoulder for the past month. She reports her pain is present at rest and continuous. Her shoulder movements are reduced in all directions. She denies any pyrexia or recent trauma to the joint, and denies any recent heavy lifting. On clinical examination her shoulder movements are restricted in all directions. You are not able to detect a joint effusion clinically. Her cervical spine movements are completely normal. Her venous blood tests (including full blood count, liver function tests, urea, electrolytes, creatinine and CRP) are all normal. What is the most probable cause of her symptoms?

A 66 year old recently retired male patient with a past medical history of chronic obstructive pulmonary disease is reviewed in the general medical outpatient clinic. He reports deteriorating symptoms in keeping with indigestion. His current medications include low dose prednisolone (for polymyalgia rheumatica), aminophylline (for depression) and a Symbicort inhaler. He also takes weekly alendronate since starting treatment for his polymyalgia rheumatica. He takes nifedipine for essential hypertension and allopurinol for gout. Which of his oral medications is the least likely to be contributing to his symptoms?

The following arterial blood gases were sampled from a cerebrally obtunded 48 year old male patient who presented to the Emergency department. The sample was taken on room air:

What does this arterial blood gas reveal?

A 26 year old female patient presents to her general practitioner with symptoms of hay fever. She reports a seasonal itchy nose and runny eyes. She says this interferes with her routine daily tasks and makes it extremely hard to concentrate on her work. The general practitioner prescribes an antihistamine with good symptomatic effect. However, she returns a fortnight later because now she is having significant drowsiness and almost crashed her car while driving to work. Which antihistamine is most prone to causing sedative side effects?

An 18 year old male patient is brought to the Emergency Department on account of a three hour history of confusion and disorientation. He attends with his parents who report that he has been trying to lose weight and had joined a local gym. He had acquired a powder off some friends there which she suspected was a muscle building substance purchased over the internet. On examination the patient is visibly agitated. His pulse is 42 beats per minute, blood pressure 94/72 mm Hg. Clinical examination of his cardiovascular, respiratory and abdominal systems is completely normal. However, over the next two hours he becomes increasingly unresponsive then develops Cheyne-Stokes breathing. You call intensive care, and he is intubated and ventilated and transferred for ongoing level three care. Two hours after admission to intensive care he recovers fully and pulls out his endotracheal tube. Investigations are as follows:

What is the most probable cause of his presentation?

An 18 year old female patient is brought to the Emergency Department following a collapse at an illegal rave. She had been out celebrating finishing school with friends and was looking for water to drink. Her friends say that she does not drink alcohol but appeared confused just prior to losing consciousness. On clinical examination temperature is 40.4 degrees centigrade and she is unconscious. She has dilated pupils. Blood pressure is 160/90 mm Hg, pulse rate 115 beats per minute, regular. Investigations are as follows:

What is the most probable cause of her presentation?

An 18 year old female is brought to the Emergency Department on account of abdominal discomfort and vomiting. She smells strongly of alcohol and appears confused. Her partner her reports that he received an emotionally charged telephone call from her eight hours prior to her presentation when she had threatened taking an overdose. Her past medical history is notable for depression and deliberate self-harm. On clinical examination, pulse rate is 68 beats per minute, regular, blood pressure 104/52 mmHg. She has diffuse abdominal discomfort. You can see she has vomited coffee-ground vomit. A pregnancy test is negative. Her plain abdominal radiograph is notable for multiple radiopaque shadows in her abdomen. Investigations are as follows:

What is the most probable cause of her presentation?

A 52 year old female patient who works as a psychiatrist has a past medical history of asthma and severe depression. She presents to the Emergency Department feeling unwell. She complains of agitation, profuse vomiting, polyuria and polydipsia. On clinical examination she is hyperventilating. Blood pressure is 98/68 mm Hg, pulse 108 beats per minute, regular. Clinical examination of her cardiovascular, respiratory and abdominal systems is otherwise unremarkable. Later, her partner arrives who says that he thinks she has taken an overdose of multiple medications. Investigations are as follows:

Which medication overdose is accounting for her presentation?

An 86 year old male patient requires review on the orthopaedic ward following a collapse. He has been transferred to the ward post-operatively following a hemiarthroplasty for a fractured neck of femur on the right hand side. He has been increasingly disorientated and intermittently drowsy over the last two days following his operation and has had significant problems mobilising with the physiotherapy team. His medications include prophylactic low molecular weight heparin, ramipril, bisoprolol, salbutamol PRN, codeine PRN, paracetamol, simvastatin and haloperidol. His 12 lead electrocardiogram is depicted:

What is the most appropriate initial management step?

A 29 year old male patient who works as a facilities manager presents to the rheumatology outpatient clinic. He has recently changed his general practitioner following a house move, and at his booking visit the GP noticed that the inside of the patient’s mouth appeared unusual. He was then referred to your clinic in order to exclude any abnormal cause. The patient feels entirely clinically well and denies any relevant past medical history. He has a family history of ischaemic heart disease and ovarian cancer. He takes no regular medication and has no allergies. On clinical examination he found to be a tall and thin male patient with pectus excavatum. He has arachnodactyly. When he holds his own wrist he can reach around and cover his thumb with his fingers. A photograph of the patient is depicted here:

Which investigation is would help establish the diagnosis?

You review a 39 year old female patient who works as an actress in the general medicine outpatient clinic. She has been referred on account of generalised weakness and lethargy. Clinical examination of the patient reveals a normal body habitus with a body mass index of 21 kg/m²Her 12 lead electrocardiogram is depicted here:

Based on the 12 lead electrocardiogram and limited history available, what is the most probable underlying electrolyte abnormality?

A 48 year old African-Caribbean female patient has been referred to you by her general practitioner after attending their clinic for a check-up. Her general practitioner is concerned that she may have hypertension. Two blood pressure readings are 164/92 mm Hg (right arm) and 172/88 mm Hg (left arm). The patient is clinically well and symptom-free. Her family history is only notable for the fact that her sister developed pancreatic cancer at a young age and died of this. Her 12 lead electrocardiogram is depicted. Her full blood count, renal function and liver function are all completely normal.

What treatment do you recommend for this patient?

A 69 year old retired female patient is admitted through the general medical take on account of a lower respiratory tract infection. While being treated with intravenous antibiotics develops the depicted appearances in her legs.

Her past medical history is notable for venous ulceration of her legs, which he previously been managed in the community by district nurses who dress the legs with three layer compression bandages. These are changed weekly. Unfortunately, while an inpatient the dressings were removed and the tissue viability nursing team have not yet replaced them. She is afebrile and clinically well. On examination her pedal pulses are all present. There is some lower limb oedema but no exudate. Her legs are malodourous. Her skin is completely normal above the knees. Venous blood tests have normalised as she has been treated for her lower respiratory tract infection. How should you manage her legs?

A 71 year old female patient books to see her general practitioner on account of extensive blisters and erosions on her trunk and limbs which started approximately 4 weeks previously.

She takes no prescribed or over the counter medication. On clinical examination her oropharynx and mucosa appear completely normal. What is the first treatment option for this patient?

A 73 year old retired male patient attends the Emergency Department on account of a 48 hour history of deteriorating abdominal discomfort and a one day history of diarrhoea with blood mixed in the stool. His past medical history is only notable for essential hypertension and mild depression. His medications include indapamide, ramipril and citalopram. He has no known allergies. On clinical examination, he is in significant discomfort. He is pyrexial (temperature 38.3 degrees centigrade). He has a distended and diffusely tender abdomen. His plain abdominal radiograph is depicted here:

What investigation should you arrange as a next step?

An 80 year old retired male patient was reviewed in the general medical outpatients department following a recent admission on account of a right lower lobe pneumonia. He has had two previous episodes which were managed by his general practitioner over the preceding twelve months. His past medical history is otherwise only notable for mild stable angina, treated with aspirin and bisoprolol. On direct questioning he also reports problems swallowing that he has never sought advice about before. His past medical history is otherwise unremarkable. He smoked twenty cigarettes a day for the past 60 years, but does not drink alcohol. He has travelled extensively to foreign countries since retirement on account of having an excellent pension and plenty of energy. Clinical examination and venous blood tests are completely normal. A plain chest radiograph is depicted:

What is the most probable cause of the patient’s recurrent respiratory tract infections?

A 32 year old female patient who works as a software engineer is admitted to hospital on account of vomiting and severe epigastric pain. On the most recent occasion that she vomited she noticed some blood mixed in with the vomitus. Her past medical history is notable for gastritis and drinking alcohol to excess – typically she consumes around 45 units per week. Clinical examination reveals tenderness in the epigastrium but is otherwise unremarkable. An ultrasound scan of her abdomen is normal. She is referred for an oesophagogastroduodenoscopy, which identifies the pathology depicted. What is the diagnosis?

A 30 year old female patient who works for the armed forces presents to the Emergency Department with agitation and anxiety and complaining of abdominal discomfort. Your attention is drawn to the fact that she has had eight similar admissions in the past year under nearly identical circumstances – on one occasion she underwent a laparoscopy which was unremarkable. Today, her blood pressure is elevated at 152/92 mm Hg and her pulse is 98 beats per minute and regular. Her body mass index is 23 kg/m². Clinical examination of her cardiovascular and respiratory systems is normal. Her abdomen is soft, but you are able to elicit generalised tenderness on palpation. Her admission venous bloods are largely unremarkable although you note a mild hyponatraemia of 131mM. Her abdomen is depicted here:

Which diagnosis should be considered in this clinical scenario?

A 31 year old female patient who has moved to the United Kingdom from Uganda presents to the Emergency Department complaining of a month-long history of weakness, loss of appetite and around 5 kg unintentional weight loss. This has been associated with headaches and more recently shortness of breath on exertion. She denies any history of blood transfusions. On clinical examination she is cachectic, temperature 36.3 degrees centigrade, pulse 80 beats per minute, regular, blood pressure 126/74 mm Hg. Cardiovascular, respiratory and abdominal examinations are all normal. Investigations are as follows:

The histopathology of a renal biopsy is depicted:

What is the most probable cause of her presentation?

A 30 year old female patient attends the neurology outpatient clinic on account of deteriorating headaches. These are particularly bad when she strains at stool and also when she first gets up in the morning. While symptomatic with the headache she frequently also experiences blurring of her vision. She is previously fit and well, and her only medication is the oral contraceptive pill. She has no allergies. On clinical examination her blood pressure is 148/88 mm Hg, pulse rate is 68 beats per minute and regular, and her body mass index is 34 kg/m². A full neurological examination is unremarkable. A picture of her retina is depicted here:

She has similar appearances in both eyes. A computed tomography scan of her brain is completely normal. Cerebrospinal fluid opening pressure is 30 cm H₂O. You test her vision with a Snellen chart and detect no impairment. Which of the following is the most appropriate next step?

A 66 year old retired male patient is seen on the general medical take on account of shortness of breath on exertion and a new productive cough. He is febrile at 38.9 degrees centigrade, has a blood pressure of 88/58 mm Hg, and is tachycardic at 104 beats per minute, regular. The nursing staff at triage are concerned that he has sepsis, and you begin treatment with piperacillin/Tazobactam and a normal saline fluid bolus. Initially, he responds well to this. However, you are called back to see him again as his oxygen saturations have dropped to 83% on 15 litres of high-flow oxygen delivered by a non-rebreathe mask. On arterial blood gas testing his p_a(O₂) is 7.9 kPa. His past medical history is notable only for obesity and obstructive sleep apnoea, for which he is treated with nasal CPAP. His plain chest radiograph is depicted:

What should you do as a next step?

With which of the following is the depicted condition associated?

A 70 year old retired female patient presents to the general medical outpatient clinic with long-standing pain and stiffness in her hands. This has been associated with deteriorating deformity and swelling. She is otherwise entirely systemically well. She previously managed to just about continue her normal activities by self-medicating with paracetamol and ibuprofen that she purchased over the counter, but this is no longer sufficient for her needs. Her past medical history is only notable for essential hypertension, a laparoscopy cholecystectomy and mild anxiety. On clinical examination of her hands she has swelling of her wrists and metacarpophalangeal joints. Her hands are depicted here:

You arrange for appropriate venous blood tests to be sent to the laboratory to guide future steps. What should you do next?

A 37 year old male patient who works as a farmer presents to the Emergency Department with non-specific malaise and a painful red eye. He complains of a dull, severe aching sensation in the eye and around his orbit. He says that his vision has also become very blurred. Over the past seven days, he has been treated with a course of phenoxymethylpenicillin by his general practitioner for pharyngitis. He subsequently developed painful, swollen knees and ankles with a tender purplish rash over his shins. His visual acuity is 6/6 in the left eye and 6/24 in the right eye. On clinical examination you observe the following appearance to his eye:

What is the most probable ophthalmological diagnosis?

A 43 year old male patient who works as a porter attends the rheumatology outpatient clinic because of a six month history of pain and stiffness in his hands. He denies any rash, dry mouth or sore eyes. On direct questioning, he also reports that he has not had unprotected sexual intercourse. He reports a completely normal bowel habit. His regular medications include co-codamol for joint pain, which he purchases over the counter, and lisinopril for his essential hypertension. On clinical examination he has tenderness in his right wrist. The distal interphalangeal joints exhibit particularly severe tenderness to palpation and mild swelling. A photograph of his hands is depicted here:

What is the most probable diagnosis?