PPQ

Question 1

1. A 2y/o has episodes of falling to the ground whilst tightening and stiffening his hands, accompanied by screaming and sweating. During the episodes the child is inconsolable but between episodes the child is well with normal development. What is the most likely diagnosis?
   a. Hyperactivity
   b. Reflex anoxic seizure
   c. Temper tantrum
   d. Tonic-clonic seizure
   e. Vasovagal syncope

Answer 1

c. Temper tantrum

Temper tantrums are common in young children and can involve intense emotional and physical reactions, including screaming, stiffening, and sweating. The child being inconsolable during the episodes but appearing well and developing normally between episodes supports this diagnosis.

Question 2

2. 5 y/o boy brought to GP with vague abdo pain. He has been having several loose bowel motions per day with occasional soiling of his underwear. His parents recall him passing a hard blood-streaked stool 5 days ago. Which is the most appropriate investigation?
   a. Colonoscopy with biopsies
   b. No investigations at this stage
   c. Stool microscopy, culture, and sensitivity
   d. Tissue transglutaminase antibody titres
   e. Urgent abdominal x-ray

Answer 2

b. No investigations at this stage

Initial management often includes dietary advice, hydration, and possibly the use of laxatives. If symptoms persist or worsen, further investigations may then be warranted.

Question 3

6. Boy born at 40 weeks with male phenotype, but neither testicle can be palpated on examination. What is the most likely diagnosis?
   a. Androgen insensitivity syndrome
   b. Excess in utero oestrogen exposure
   c. Klinefelter’s syndrome
   d. Physiological delay in descent
   e. Retractile testes

Answer 3

d. Physiological delay in descent

In newborn boys, it is common for the testes to not be fully descended at birth. While most boys have descended testes by the time they are born, a physiological delay in descent can occur, and the testes often descend within the first few months of life. This is a more likely and common scenario compared to other conditions listed.

NOTE: Androgen insensitivity syndrome typically presents with a phenotypically female appearance despite having a 46,XY karyotype.

Question 4

8. 22 m/o child had cough and coryza for 2 days, and is now struggling with breathing. She has subcostal and intercostal recessions and widespread wheeze. Her temperature is 37.3, HR 125, RR 45, O2 sats 98% on room air. What is the most appropriate next step in her management?
   a. 0.5L/min supplemental oxygen
   b. 2 puffs beclomethasone inhaler
   c. 10 puffs salbutamol inhaler
   d. Intravenous aminophylline
   e. Oral prednisolone

Answer 4

c. 10 puffs salbutamol inhaler

Given the clinical presentation of respiratory distress with wheezing, this likely represents an acute exacerbation of asthma or a similar reactive airway disease. Salbutamol (a bronchodilator) is the first-line treatment to relieve bronchospasm and improve breathing in such cases.

Question 5

9. 3 month old boy has 2 days of fever and crying accompanied by reduced feeding and fewer wet nappies. Temperature 38.0, HR 170, RR 38, O2 sats 97% on room air. He has reduced movement in his right leg, chest is clear, urinanalysis is normal and anterior fontanelle is slightly sunken. What is the most likely diagnosis?
   a. Developmental dysplasia of the hip
   b. Non-accidental injury
   c. Osteomyelitis
   d. Reactive arthritis
   e. Sickle cell crisis

Answer 5

c. Osteomyelitis

Osteomyelitis, an infection of the bone, is consistent with the symptoms of fever, reduced movement in the affected limb, and systemic signs of infection such as irritability and decreased feeding. The sunken fontanelle indicates dehydration, likely secondary to the fever and reduced intake. Normal urinalysis helps rule out a urinary tract infection.

Question 6

10. 3 m/o boy presents in acute respiratory failure and is diagnosed with Pneumocystis pneumonia. His parents are first cousins from Pakistan. What is the most likely underlying cause?
    a. Agammaglobulinaemia
    b. Chronic granulomatous disease
    c. Cystic fibrosis
    d. HIV infection
    e. Severe combined immunodeficiency

Answer 6

e. Severe combined immunodeficiency (SCID)

Pneumocystis pneumonia (PCP) is a rare but serious infection that typically occurs in individuals with significant immune deficiencies. The following points support SCID as the most likely underlying cause:

Question 7

14. 6 y/o boy’s parents have noticed long-standing hearing difficulties and take him to GP. Teachers have commented on poor school performance and behaviour. Speech is normal and there is no otalgia. The ear canals are narrow with non-occluding wax. Which is the most appropriate next step in his management?
    a. Aural olive oil drops
    b. Grommet insertion
    c. Pure tone audiometry
    d. Referral for hearing aids
    e. Review in 3 months

Answer 7

c. Pure tone audiometry

Pure tone audiometry is a key diagnostic test to assess the extent and nature of hearing loss. This objective assessment will help determine the severity of the hearing impairment and guide further management. Here’s why this is the best next step:

Question 8

17. 3 week old baby referred for prolonged jaundice, dark wet nappies, and pale stools. There are no developmental concerns and he is currently breastfed. Birth weight was 3.45kg and he currently weighs 3.2kg, Temperature is 37.1, HR 140, RR 45, O2 sats 98% on room air. Investigations:
    Hb 110 (normal)
    WCC 6 (normal)
    Platelets 430 (slightly high)
    Bilirubin 175 (high)
    Conjugated bilirubin 100 (high)
    ALP 160 (normal)
    ALT 35 (normal)
    Albumin 25 (lower end of normal)
    Sodium 137 (normal
    Potassium 4 (normal)
    What is the most appropriate next step in management?
    a. Feeding advice
    b. Inpatient ultrasound
    c. I.V. antibiotics
    d. Outpatient ultrasound
    e. Phototherapy

Answer 8

b. Inpatient ultrasound

The presence of prolonged jaundice with elevated conjugated bilirubin, pale stools, and dark urine raises concern for a biliary obstruction or other hepatobiliary pathology, such as biliary atresia. An inpatient ultrasound can help in the early diagnosis and management of these conditions, which is crucial for improving outcomes. Early identification and treatment of biliary atresia, for example, are essential for the effectiveness of surgical interventions like the Kasai procedure.

Question 9

18. 5 y/o boy with 2 days of fever, runny nose, cough, and sore throat. He developed a rash over the past 24 hours, temperature 39.2, HR 105, RR 30, capillary refill <2 seconds and O2 sats are 98% on room air. There is cervical lymphadenopathy, a red tongue, cracked lips, and a fine erythematous macular rash all over his body. Which is the most effective treatment?
    a. Aciclovir
    b. Aspirin
    c. Co-amoxiclav
    d. Paracetamol
    e. Phenoxymethylpenicillin

Answer 9

B. Aspirin

Given the presentation described, which strongly suggests Kawasaki disease, the most effective treatment would involve aspirin in addition to IVIG. Aspirin is used in Kawasaki disease to reduce inflammation and the risk of coronary artery complications.

Question 10

19. 18 m/o presents to GP with 1 day history of left ear pain. There is no discharge and mum reports normal number of wet nappies for that day. There is a bulging erythematous left tympanic membrane with no perforation. Temperature 38, HR 135, RR 33, O2 sats 98 on room air. What is the most appropriate management?
    a. Offer simple analgesia and an immediate prescription of amoxicillin
    b. Offer simple analgesia and ciprofloxacin ear drops
    c. Offer simple analgesia and delayed prescription of amoxicillin
    d. Offer simple analgesia and gentamicin ear drops
    e. Offer simple analgesia and reassurance

Answer 10

E

Acute otitis media is generally a self-limiting condition that does not require an antibiotic prescription. There are however some exceptions listed below. Analgesia should be given to relieve otalgia. Parents should be advised to seek medical help if the symptoms worsen or do not improve after 3 days.

ABx if > 4 days, younger than 2 with bilateral otitis media, otitis media with perf

If an antibiotic is given, a 5-7 day course of amoxicillin is first-line. In patients with penicillin allergy, erythromycin or clarithromycin should be given.

Question 11

21. A 2 y/o in GP has worsening painful rash behind the knee for 5 days. He has eczema managed with E45 cream. Temperature 37.2, HR 130, RR 30, O2 sats 98%. What is the most appropriate management?
    a. Immediate referral to Paediatric A&E
    b. Give oral Aciclovir for 1 week
    c. Give oral Flucloxacillin for 1 week
    d. Give topical dermovate
    e. Give topical fusidic acid

Answer 11

E. Give topical fusidic acid

The description of a worsening painful rash suggests a possible secondary bacterial infection, especially considering the child’s eczema, which can predispose to bacterial skin infections. Fusidic acid is an antibiotic commonly used topically for skin infections, including those caused by Staphylococcus aureus, which is often implicated in eczema-related skin infections.

Question 12

22. A 3 y/o boy in GP has left-sided neck lump on a background of 6 days of coryza, cough, and mild fever, but no systemic symptoms. Temperature 37.0, HR 105, capillary refill <1s, RR 26, O2 sats 99% on room air. ENT exam is normal and chest is clear. He has a single enlarged lymph node in the left posterior chain. What is the most appropriate next step in management?
    a. Arrange urgent ENT referral
    b. Arrange USS
    c. Arrange urgent FBC
    d. Prescribe Amoxicillin 250mg TDS for 7 days
    e. Reassurance and watchful waiting

Answer 12

e. Reassurance and watchful waiting

In a child with a recent upper respiratory tract infection (coryza, cough, mild fever) and a single enlarged lymph node in the posterior cervical chain, especially without systemic symptoms or concerning findings on examination, a conservative approach with reassurance and watchful waiting is often appropriate.

The likely diagnosis in Reactive cervical lymphadenopathy

Question 13

28. 7 y/o boy in GP with bedwetting for 2 months having previously been dry at night since age 4. Abdo exam is normal. What is the most appropriate initial investigation?
    a. Abdominal USS
    b. Abdominal x-ray
    c. Finger prick glucose test
    d. Renal function
    e. Urine dipstick

Answer 13

e. Urine dipstick

Bedwetting (nocturnal enuresis) in a previously dry child may have various causes, including urinary tract infections, diabetes, constipation, or emotional stress. However, the most common cause is primary nocturnal enuresis, which is more likely if the child has never been dry at night consistently.

Question 14

29. 35 y/o man presents to A&E agitated and requesting medication. He has mild tremor, cool and clammy skin, and goosebumps (piloerection). Ambulance staff found him in the street with an empty bottle of cider. Temperature 36.8, BP 140/100, HR 100. What is the most likely diagnosis?
    a. Alcohol intoxication
    b. Alcohol withdrawal syndrome
    c. Opiate intoxication
    d. Opiate withdrawal syndrome
    e. Tricyclic antidepressant intoxication

Answer 14

b. Alcohol withdrawal syndrome

Alcohol withdrawal syndrome typically occurs in individuals with a history of heavy or prolonged alcohol use who suddenly reduce or cease their alcohol intake. Common symptoms include agitation, tremors, autonomic hyperactivity (such as cool and clammy skin, piloerection), and in severe cases, hallucinations, seizures, or delirium tremens.

Given the presentation of agitation and physical signs such as tremor and autonomic hyperactivity, along with the history of alcohol consumption, alcohol withdrawal syndrome is the most likely diagnosis in this case.

Question 15

30. 20 y/o medical student attends A&E on the eve of an exam with difficulty breathing, palpitations, and chest tightness. She says she feels close to collapse, and feels like she is going to die. This has happened before and she was prescribed Propranolol but this is no longer effective, and she has routinely declined psychological interventions. Routine blood tests, ECG, and CXR are all normal. What is the most appropriate next step in her management?
    a. Diazepam
    b. Fluoxetine
    c. Mirtazapine
    d. Risperidone
    e. Venlafaxine

Answer 15

B. Fluoxetine

Fluoxetine is a selective serotonin reuptake inhibitor (SSRI) antidepressant commonly used in the treatment of panic disorder and other anxiety disorders. It is effective in reducing the frequency and severity of panic attacks and can provide long-term relief when taken regularly.

Question 16

31. 30 y/o white woman is on routine anti-psychotic medication for schizophrenia and has the following blood result:
    Hb 140 (normal)
    WCC (low)
    Platelets 200 (normal)
    Neutrophils 1.2 (low)
    Lymphocytes 1.3 (normal)
    Total cholesterol 5.3 (high)
    Total cholesterol: HDL ratio 4.6 (high)
    HbA1C 40 (normal)
    What medication is she most likely taking?
    a. Aripiprazole
    b. Clozapine
    c. Haloperidol
    d. Quetiapine
    e. Risperidone

Answer 16

B. Clozapine

Clozapine is an atypical antipsychotic medication commonly used in the treatment of schizophrenia, particularly in cases where other antipsychotic medications have been ineffective or poorly tolerated.

The blood results provided, specifically the low white cell count (WCC), low neutrophil count, and normal lymphocyte count, are consistent with potential hematological side effects of clozapine, such as agranulocytosis or neutropenia. Regular monitoring of blood counts is essential when using clozapine due to the risk of these adverse effects.

Question 17

33. 21 y/o woman admitted to psych ward for an acute episode. She has been prescribed Amisulpride for the past 3 weeks and is now worries she is pregnant because she has missed her period, however her pregnancy test is negative. Which blood test should be requested in addition to routine bloods?
    a. Luteinising hormone
    b. Progesterone
    c. Prolactin
    d. Thyroid stimulating hormone
    e. Triglycerides

Answer 17

c. Prolactin

Amisulpride is an antipsychotic medication that can increase prolactin levels by blocking dopamine receptors in the brain. Elevated prolactin levels can lead to amenorrhea (missed periods) and galactorrhea (milk production from the breasts) in women.

Therefore, checking serum prolactin levels can help assess whether the missed period is due to elevated prolactin levels induced by Amisulpride. If prolactin levels are found to be elevated, this could explain the amenorrhea, and appropriate management or adjustment of medication can be considered.

Question 18

34. 15 y/o girl has 12 months of irritable mood, lack of pleasure, poor sleep, poor concentration, and low appetite. She is struggling to concentrate at school and is getting into trouble for low marks. What is the most appropriate first-line treatment?
    a. Cognitive analytic therapy
    b. Cognitive behavioural therapy
    c. Family therapy
    d. Fluoxetine
    e. Sertraline

Answer 18

d. Fluoxetine

Fluoxetine is a selective serotonin reuptake inhibitor (SSRI) antidepressant commonly used in the treatment of major depressive disorder (MDD) in adolescents. It is one of the first-line pharmacological treatments for depression in this age group, as recommended by clinical guidelines.

Question 19

37. 19 y/o man with 1 day of fever, muscle stiffness, palpitations, and difficulty breathing. He has a history of psychotic depression for which he has been taking Fluoxetine for 6 weeks and Risperidone for 1 week. He is agitated with temperature of 39.8, HR 114, BP 172/89, and RR 30. Chest examination is otherwise clear, and neuro exam is normal except for globally increased tone. Which investigation would be most useful diagnostically?
    a. CT head
    b. ECG
    c. EEG
    d. Lumbar puncture
    e. Serum creatine kinase

Answer 19

e. Serum creatine kinase (CK)

The presentation is suggestive of a potential serotonin syndrome, a potentially life-threatening condition characterized by excessive serotonin activity in the central nervous system. Serotonin syndrome can occur as a result of the interaction between serotonergic medications such as Fluoxetine and Risperidone, leading to symptoms such as fever, muscle rigidity, agitation, and autonomic instability.

Serum CK levels can be elevated in serotonin syndrome due to the muscular hyperactivity and breakdown associated with the condition. Elevated CK levels can help support the diagnosis of serotonin syndrome and differentiate it from other conditions presenting with similar symptoms.

Question 20

38. 23 y/o man admitted for 3rd person auditory hallucinations, irritability, and beliefs that his neighbours are watching him. This is the first time he has experienced these symptoms and they have lasted for 3 weeks. What is the most likely diagnosis?
    a. Acute and transient psychotic disorder
    b. Adjustment disorder
    c. Paranoid personality disorder
    d. Schizoaffective disorder
    e. Schizophrenia

Answer 20

a. Acute and transient psychotic disorder

Acute and transient psychotic disorder is characterized by the sudden onset of psychotic symptoms, such as hallucinations, delusions, disorganized thinking, or grossly disorganized or catatonic behavior, lasting for at least a day but less than a month. This diagnosis is appropriate when the symptoms do not meet the criteria for other psychotic disorders like schizophrenia.

Given the brief duration of symptoms (less than a month) and the absence of a clear history of recurrent psychotic episodes or chronicity, acute and transient psychotic disorder is the most likely diagnosis in this case.

Question 21

39. 15 y/o girl in A&E after fainting at school. BMI is 16, she has been restricting calorie intake for 1 year, she exercises every day and feels she is overweight. Which additional feature would be needed for a diagnosis of anorexia nervosa?
    a. Bradycardia
    b. Fear of gaining weight
    c. Laxative abuse
    d. Muscle weakness
    e. Thinning of hair on head

Answer 21

b. Fear of gaining weight

An essential diagnostic criterion for anorexia nervosa is a persistent fear of gaining weight or becoming fat, despite being underweight. This fear may manifest in various behaviors, including restrictive eating, excessive exercise, and avoidance of calorie-dense foods.

Question 22

40. 45 y/o man presents with worsening tremor for a few weeks. Has a history of schizophrenia in remission for which he is taking Haloperidol. There is bilateral tremor and cog-wheel rigidity in upper limbs. What is the most appropriate treatment for his symptoms?
    a. Co-beneldopa
    b. Entacapone
    c. Pramipexole
    d. Procyclidine hydrochloride
    e. Selegiline hydrochloride

Answer 22

d. Procyclidine hydrochloride

The presentation of bilateral tremor and cog-wheel rigidity suggests parkinsonism, a movement disorder characterized by symptoms similar to those of Parkinson’s disease. Haloperidol, an antipsychotic medication, can induce extrapyramidal symptoms such as parkinsonism as a side effect.

Procyclidine hydrochloride is an anticholinergic medication commonly used to alleviate extrapyramidal symptoms induced by antipsychotic medications like Haloperidol. It works by blocking the action of acetylcholine in the central nervous system, which can help reduce tremor, rigidity, and other parkinsonian symptoms.

Question 23

42. 84 y/o man presents with gradual deterioration in memory for 3 years. He forgets details of conversations and to attend doctor’s appointments, though he can still manage his finances and cook and clean for himself. He regularly goes to the local shops and never gets lost. Which part of the brain is likely to be affected?
    a. Cerebellum
    b. Frontal lobe
    c. Occipital lobe
    d. Parietal lobe
    e. Temporal lobe

Answer 23

e. Temporal lobe

The temporal lobes play a crucial role in memory formation and retrieval, particularly episodic memory, which involves the recollection of specific events and experiences. Damage or degeneration in the temporal lobes can lead to difficulties in forming new memories and retrieving past memories, resulting in symptoms such as forgetfulness and memory loss.

Given that the individual is experiencing memory problems but still retains functional abilities related to daily living (such as cooking, cleaning, managing finances, and navigating familiar environments), it suggests that the memory impairment is selective and not globally disabling. This pattern of impairment is often seen in conditions affecting the temporal lobes, such as Alzheimer’s disease, which is the most common cause of age-related memory decline and dementia.

Question 24

43. A 25 y/o man has tried Olanzapine and Haloperidol but continues to experience symptoms of schizophrenia. What is the most appropriate next step in his management?
    a. Aripirazole
    b. Clonazepam
    c. Clozapine
    d. Lithium
    e. Quetiapine

Answer 24

Clozapine

Clozapine is considered the gold standard for treatment-resistant schizophrenia. It has been shown to be effective in patients who have not responded to other antipsychotic medications. However, it is typically reserved as a second-line or third-line option due to its potential for serious side effects, including agranulocytosis (a significant reduction in white blood cell count), which requires regular monitoring.

Question 25

44. 25 y/o woman has recurrent episodes of sudden onset sweating, dry mouth, “butterflies” in her stomach, difficulty breathing, and fear of impending death. These symptoms have been occurring twice weekly for the past 2 years. What is the most likely diagnosis?
    a. Dissociative disorder
    b. Generalised anxiety disorder
    c. Hypochondriasis
    d. Panic disorder
    e. Somatisation disorder

Answer 25

Panic disorder

Panic disorder is characterized by recurrent and unexpected panic attacks, which are sudden episodes of intense fear or discomfort that reach a peak within minutes. The symptoms described in the scenario, including sweating, dry mouth, gastrointestinal discomfort (“butterflies” in the stomach), difficulty breathing, and fear of impending doom, are typical features of panic attacks.

The presence of recurrent panic attacks over a period of at least several months, accompanied by persistent worry about having additional attacks, or significant behavioral changes related to the attacks, is consistent with the diagnosis of panic disorder.

While other conditions such as generalized anxiety disorder (Option b) involve excessive worry and anxiety, panic disorder specifically involves recurrent panic attacks characterized by sudden and intense fear.

Question 26

45. 19 y/o woman with OCD is prescribed Sertraline at the maximum dose but it doesn’t control her symptoms. She has been unable to attend university for 4 months, and CBT has not helped in the past. What is the most appropriate next step in her management?
    a. Add another antidepressant
    b. Change to an antidepressant of another class
    c. Refer for additional and more intensive CBT
    d. Refer for deep brain stimulation
    e. Refer for ECT

Answer 26

B. Change to an antidepressant of another class

When a patient with OCD does not respond adequately to one selective serotonin reuptake inhibitor (SSRI) such as Sertraline, switching to another antidepressant of a different class, such as a tricyclic antidepressant (TCA) or a serotonin-norepinephrine reuptake inhibitor (SNRI), may be considered.

Question 27

49. 25 y/o man attends A&E with headache. He is speaking rapidly and smiling as he talks. He scratches his skin constantly and claims to feel insects crawling up him. His temperature is 36.5, HR 130, and BP 154/84. What is the most likely diagnosis?
    a. Alcohol withdrawal
    b. Benzodiazepine withdrawal
    c. Cannabis intoxication
    d. Cocaine intoxication
    e. Heroin withdrawal

Answer 27

d. Cocaine intoxication

Cocaine is a stimulant drug that can cause a range of physiological and psychological effects, including euphoria, increased energy, rapid speech, tactile hallucinations (such as the sensation of insects crawling on or under the skin, known as formication), and heightened sympathetic activity leading to elevated heart rate and blood pressure.

Scratching behavior, often described as “cocaine bugs” or “cocaine psychosis,” is a common phenomenon associated with cocaine use, where individuals experiencing tactile hallucinations may scratch or pick at their skin in an attempt to alleviate the sensation of insects crawling on or under the skin.

Question 28

51. 45 y/o man is taken to A&E by police who are concerned for his health after being in custody for 20 hours. He is known to consume alcohol to excess, and appears dishevelled, agitated, and is tremulous. Blood tests are unremarkable except for moderately deranged LFTs. What is the most likely diagnosis?
    a. Alcohol withdrawal syndrome
    b. Alcohol induced hepatitis
    c. Hepatic encephalopathy
    d. Opioid withdrawal syndrome
    e. Wernicke’s encephalopathy

Answer 28

Alcohol withdrawal syndrome

Alcohol withdrawal syndrome typically occurs in individuals with a history of chronic alcohol abuse who suddenly decrease or stop their alcohol consumption. Symptoms may include agitation, tremors, anxiety, sweating, nausea, vomiting, insomnia, and occasionally hallucinations or seizures.

The presentation described, including agitation, tremors, and elevated LFTs, is consistent with alcohol withdrawal syndrome. The tremulousness and agitation suggest autonomic hyperactivity, which is characteristic of alcohol withdrawal.

Question 29

53. 58 y/o man attends addiction services for initial alcohol dependence assessment. He regularly attends A&E following overdose attempts. He requests detoxification. He lives alone with few social contacts and has poorly controlled asthma. What is the most appropriate next step in management?
    a. CBT
    b. Community detoxification
    c. Disulfiram
    d. Inpatient detoxification
    e. Motivational interviewing

Answer 29

d. Inpatient detoxification

Inpatient detoxification offers a structured and supervised environment where the patient can receive medical care and support during the withdrawal process. This setting is particularly important for individuals with severe alcohol dependence and those at risk of complications such as overdose attempts, as it allows for close monitoring of symptoms and medical management of any complications that may arise.

Inpatient detoxification also provides an opportunity for comprehensive assessment, including evaluation of the patient’s asthma and optimization of asthma management during detoxification.

Question 30

54. 30 y/o man attends A&E with palpitations, dizziness, and chest pain – he is worried that he has had a heart attack. The chest pain is sharp and variable in location, and he gives a history of 6 months of low mood following being laid off from work. He has attended multiple local hospitals for several years and has reported a variety of different symptoms including headaches over the right ear, difficulty swallowing, and griping stomach pains, but says “the doctor’s haven’t been able to find out what’s wrong with me”. His ECG is normal. What is the most likely diagnosis?
    a. Borderline personality disorder
    b. Factitious disorder
    c. Generalised anxiety disorder
    d. Panic disorder
    e. Somatisation disorder

Answer 30

e. Somatization disorder

Somatization disorder is characterized by the presence of multiple physical symptoms that cannot be explained by a medical condition. These symptoms often lead to frequent medical visits and investigations, as the individual believes them to be indicative of a serious illness despite medical reassurance. The symptoms are typically varied and may involve different organ systems.

The patient’s history of chest pain, dizziness, palpitations, headaches over the right ear, difficulty swallowing, and griping stomach pains, along with normal findings on ECG and a history of low mood following job loss, are consistent with the diagnosis of somatization disorder.

Question 31

55. A 35 y/o man with Fragile X syndrome lives alone, does voluntary work, and travels independently to familiar places, though he needs help planning travel to new areas. He attended a special needs school and has a carer supporting him by helping him to pay his bills. What is his most likely IQ?
    a. 20
    b. 40
    c. 65
    d. 80
    e. 110

Answer 31

65

Individuals with Fragile X syndrome typically exhibit a wide range of intellectual abilities, but the majority fall within the mild to moderate range of intellectual disability. An IQ of around 65 would be consistent with the level of independence described in the scenario, where the individual can perform some tasks independently but may require support with more complex activities and decision-making.

Question 32

59. 48 y/o man has hypertension, anxiety, gout, and back pain. His routine ECG shows a QT interval of 460ms (380-440 normal range). Which is the most likely causative medication?
    a. Allopurinol
    b. Amitriptyline
    c. Co-codamol
    d. Diazepam
    e. Ramipril

Answer 32

b. Amitriptyline

Amitriptyline is a tricyclic antidepressant (TCA) known to prolong the QT interval. Prolongation of the QT interval can predispose individuals to a type of arrhythmia called torsades de pointes, which can be life-threatening.

Question 33

62. A 29 y/o woman in GP is complaining of palpitations, sweating, dry mouth, and paraesthesia each time she leaves the house. She has a PMHx of asthma. Which is the most appropriate drug class to use?
    a. Atypical anti-psychotic
    b. Benzodiazepine
    c. Beta blocker
    d. Sedating antihistamine
    e. SSRI

Answer 33

Beta blocker

These symptoms are suggestive of anxiety or panic attacks, especially given their occurrence in specific situations (leaving the house), and beta blockers are commonly used to manage the physical symptoms associated with anxiety or panic disorders. Beta blockers can help alleviate symptoms such as palpitations, sweating, and tremors by blocking the effects of adrenaline on the heart and peripheral vasculature, thus reducing sympathetic nervous system activity.

Question 34

63. 38 y/o woman in GP has 8 months of amenorrhea on a background of T2DM and BPAD. Her pregnancy test is negative. Investigations:
    Luteal LH 2.0 (normal)
    Luteal FSH 2.0 (normal)
    TSH 2.3 (normal)
    Testosterone 1.0 (normal)
    SHBG 80.0 (normal)
    Prolactin 821 (high)
    Which medication is most likely to have caused this?
    a. Diazepam
    b. Metformin
    c. Risperidone
    d. Sertraline
    e. Zopiclone

Answer 34

c. Risperidone

Risperidone is an atypical antipsychotic medication commonly used to treat conditions like bipolar affective disorder. It is known to increase prolactin levels through its dopamine receptor-blocking effects, particularly at higher doses. Elevated prolactin levels can lead to amenorrhea or irregular menstrual cycles in women due to the suppression of gonadotropin-releasing hormone (GnRH) from the hypothalamus, which in turn inhibits ovulation.

Question 35

65. 28 y/o woman attends GP for 6 week post-natal check following emergency C-section. She is feeling tired, low in energy, has poor appetite, and is having some frightening thoughts or about hurting her baby. Which is the most likely diagnosis?
    a. Adjustment disorder
    b. Baby blues
    c. PTSD
    d. Post-natal depression
    e. Puerperal psychosis

Answer 35

d. Post-natal depression

Post-natal depression is a mood disorder that can occur after childbirth, typically within the first few weeks to months. It is characterized by symptoms such as low mood, tearfulness, irritability, fatigue, changes in appetite, and difficulty bonding with the baby. Frightening thoughts about harming the baby can also occur in post-natal depression, although it’s important to note that these thoughts are distressing to the mother and are not acted upon

Question 36

67. 24 y/o seen in GP for 6 months of low mood, poor concentration, and trouble sleeping. He denies suicidal ideation or self-harm. He denies drinking excessively, smoking at all, and using recreational drugs. He is a waiter and is struggling at work and has a PHQ-9 of 6 (mild severity). What is the most appropriate course of action?
    a. Advise mindfulness classes
    b. Refer for CBT
    c. Start Citalopram
    d. Start Fluoxetine
    e. Write a fit note (medical certificate) for 4 weeks

Answer 36

Advise mindfulness classes

Mindfulness-based interventions, such as mindfulness classes, have been shown to be effective in reducing symptoms of depression, particularly in individuals with mild-to-moderate depression. They provide techniques for managing stress, enhancing self-awareness, and promoting emotional regulation, which can be beneficial for individuals experiencing low mood and other depressive symptoms.

Question 37

69. 29 y/o woman visits GP with heavy sensation in her vagina when exercising. She is aware of a bulge in her vagina, sometimes associated with a desire to urinate. She had a vaginal delivery 2 years ago. O/E there is some laxity of the anterior vaginal wall but this does not descend to the introitus on straining. Urine culture is negative. What is the most appropriate management plan?
    a. Oxybutynin hydrochloride
    b. Pelvic floor exercises
    c. Refer for urodynamic testing
    d. Refer to urogynaecology clinic
    e. USS of pelvis

Answer 37

b. Pelvic floor exercises

Pelvic floor exercises, also known as Kegel exercises, are commonly recommended as the first-line treatment for mild to moderate symptoms of pelvic organ prolapse, which appears to be the likely diagnosis in this case. These exercises aim to strengthen the muscles supporting the pelvic organs and can help improve symptoms of pelvic floor dysfunction, including sensations of heaviness or bulging in the vagina and urinary symptoms

Question 38

70. 42 y/o woman is 34 weeks pregnant and has had repeat admissions for severe abdominal pain. She currently needs opiate analgesia but is still struggling with the pain. USS shows a sub-serosal fibroid measuring 7cm x 9cm. What is the best management option for her pain?
    a. Continuous regular opiates
    b. Epidural anaesthesia
    c. NSAIDs
    d. Remifentanyl patient-controlled analgesia
    e. Uterine artery embolisation

Answer 38

NSAIDs

Nonsteroidal anti-inflammatory drugs (NSAIDs) can be considered as the best management option for her pain in this situation. NSAIDs are effective for managing pain associated with fibroids and are relatively safe to use during pregnancy, especially in the third trimester. However, they should be avoided earlier in pregnancy due to potential risks to the fetus, such as premature closure of the ductus arteriosus and oligohydramnios.

Question 39

72. 33 y/o woman 32 weeks pregnant has glycosuria for the second time. Fundal height is 36cm and the fetal parts are difficult to palpate. Her routine glucose testing at 27 weeks was normal. What is the most appropriate next step in her management?
    a. Advise low glycaemic index diet
    b. Perform 75g glucose tolerance test
    c. Send HbA1c
    d. Start Insulin
    e. Start Metformin

Answer 39

b. Perform 75g glucose tolerance test

The presence of glycosuria, increased fundal height, and difficulty palpating fetal parts suggest the possibility of gestational diabetes mellitus (GDM) or macrosomia (large fetal size). While routine glucose testing at 27 weeks was normal, the development of glycosuria at 32 weeks raises concerns for glucose intolerance that may have developed later in pregnancy.

Performing a 75g glucose tolerance test (GTT) would help to accurately diagnose gestational diabetes mellitus (GDM) and guide appropriate management. This test is the gold standard for diagnosing GDM and involves measuring blood glucose levels at fasting and at specific time intervals after a glucose load.

Question 40

75. 40 y/o woman is successfully treated for ectopic pregnancy with methotrexate. After what interval may she safely conceive again?
    a. 1 year
    b. 3 months
    c. 6 months
    d. Her next menses
    e. Immediately

Answer 40

c. 6 months

Waiting for at least 6 months after methotrexate treatment for an ectopic pregnancy before attempting to conceive again is often recommended. This allows time for the methotrexate to clear from the body and reduces the risk of potential complications or adverse effects on a subsequent pregnancy.

Question 41

77. A woman is having a repeat USS at 32 weeks gestation for a previously low-lying placenta. The USS shows the placenta is clear of the cervical os and an additional succenturiate lobe is seen. Which condition needs to be excluded in the USS?
    a. Cervical shortening
    b. Fetal growth restriction
    c. Placenta praevia
    d. Vasa praevia
    e. Velamentous cord insertion

Answer 41

d. Vasa praevia

Vasa praevia is a rare but potentially life-threatening condition where fetal blood vessels, unprotected by Wharton’s jelly, run across the internal os of the cervix or between the placental lobes. This condition can lead to vessel rupture and severe fetal hemorrhage during labor or rupture of membranes.

While the presence of a low-lying placenta (placenta previa) was previously a concern, the current ultrasound showing the placenta clear of the cervical os eliminates this as a primary concern. The additional finding of a succenturiate lobe indicates the presence of an accessory placental lobe, which is typically not associated with significant risks.

Question 42

80. 63 y/o woman presents with a 2 week history of post-menopausal vaginal bleeding. BMI is 39.2. Pelvic USS shows irregular endometrial thickening (14mm). Outpatient endometrial sampling fails because of cervical stenosis. What is the most appropriate management?
    a. CT abdomen and pelvis
    b. Hysteroscopy with dilatation and curettage
    c. Repeat USS in 2 weeks
    d. Total abdominal hysterectomy + bilateral salpingo-oopherectomy
    e. Total laparoscopic hysterectomy + bilateral salpingo-oopherectomy

Answer 42

b. Hysteroscopy with dilatation and curettage

Hysteroscopy with dilatation and curettage (D&C) is the most appropriate next step in this situation. It allows direct visualization of the endometrial cavity and enables targeted biopsy or removal of any suspicious tissue. Additionally, cervical stenosis can often be managed during hysteroscopy by dilating the cervix, allowing for successful sampling or biopsy.

Question 43

81. 32 y/o nulliparous woman is 8 weeks pregnant and experiencing severe nausea and vomiting that makes it impossible for her to work. She is taking 50mg cyclizine OD (once daily) with no effect. What is the best next management option?
    a. Admit for I.V. fluids
    b. Change to prochlorperazine
    c. Increase frequency of cyclizine to TDS (three times daily)
    d. Add a PPI
    e. Add Prochlorperazine

Answer 43

B. Change to prochlorperazine

Switching to prochlorperazine (Option b) is indeed a reasonable next step in the management of severe nausea and vomiting (hyperemesis gravidarum) in pregnancy if cyclizine is ineffective. Prochlorperazine is another commonly used antiemetic medication that may be more effective for some individuals.

Question 44

82. 29 y/o woman with past history of cocaine and cannabis use denies using for the past 3 years. Which additional test should be done for this patient at booking?
    a. Hair toxicology screen
    b. Hepatitis C
    c. Hepatitis E
    d. Serum toxicology screen
    e. Urine toxicology screen

Answer 44

e. Urine toxicology screen

Urine toxicology screening is a common method used to detect recent drug use. It can detect the presence of various substances, including cocaine and cannabis, typically within a few days to a week after use, depending on factors such as the frequency and amount of drug use.

Question 45

83. 33 y/o woman has Ventouse delivery at 39 weeks gestation and requires manual removal of placenta. The removal is uncomplicated with an EBL of 600ml. She plans to mix feed her baby for the first 6 months. When can she expect her menstrual cycle to return?
    a. Cannot be predicted
    b. When she is more than 50% bottle feeding
    c. When she stops breastfeeding
    d. Within 6 months
    e. Within 6 weeks

Answer 45

a. Cannot be predicted

After a vaginal delivery, the return of menstruation can vary from woman to woman, and it is influenced by factors such as breastfeeding, hormonal changes, and individual physiology.

In the case of mixed feeding, where the mother is both breastfeeding and supplementing with formula, the return of menstruation can be more variable compared to exclusive breastfeeding. Breastfeeding typically delays the return of menstruation due to the suppression of ovulation caused by the hormone prolactin.

Given that the woman plans to mix feed her baby for the first 6 months, it’s likely that she may experience a delay in the return of her menstrual cycle compared to if she were exclusively bottle feeding. However, the return of menstruation cannot be predicted with certainty, as it varies among individuals.

Question 46

85. 20 y/o woman attends A&E. She realised 4 days after her menses finished that she had forgotten to remove her tampon. She has now removed it and is asymptomatic but concerned about the possible consequences. What is the most appropriate management?
    a. Advise vaginal douching
    b. Arrange USS pelvis
    c. Perform high vaginal swabs
    d. Prescribe prophylactic antibiotics
    e. Reassure and discharge

Answer 46

e. Reassure and discharge

If the woman has removed the forgotten tampon and is asymptomatic, there is typically no need for further intervention

Question 47

86. 60 y/o woman presents with discomfort during sex and vaginal dryness. What is the best management option?
    a. Commence oral HRT
    b. Commence SSRI
    c. Commence topical vaginal oestrogen
    d. Commence transdermal HRT
    e. Commence vaginal lubricants

Answer 47

c. Commence topical vaginal estrogen

Topical vaginal estrogen therapy is often considered the first-line treatment for symptoms of vaginal dryness and discomfort during intercourse in postmenopausal women. It works by replenishing estrogen levels in the vaginal tissues, restoring moisture and elasticity, and improving symptoms of vaginal atrophy.

Question 48

88. 17 y/o girl has delayed menarche and short stature. Investigations:
    FSH 70 (very high)
    LH 40 (very high)
    Which investigation is likely to produce a definitive diagnosis?
    a. Karyotyping
    b. MRI scan of pituitary fossa
    c. Serum oestradiol
    d. Thyroid function tests
    e. Pelvic USS

Answer 48

a. Karyotyping

Karyotyping can help identify any chromosomal abnormalities, such as Turner syndrome (45,X), which is a common cause of POI in young females. Turner syndrome is associated with short stature, delayed puberty, and ovarian dysgenesis.

Question 49

89. 40 y/o woman is having a normal vaginal delivery with planned active management of third stage. She has a history of essential hypertension. Which is the most appropriate drug to reduce risk of post-partum haemorrhage?
    a. Dinoprostone (prostaglandin E2)
    b. Ergometrine maleate
    c. Labetalol hydrochloride
    d. Magnesium sulphate
    e. Oxytocin (Syntocinon)

Answer 49

e. Oxytocin (Syntocinon)

Oxytocin is the preferred uterotonic agent for preventing postpartum hemorrhage during the third stage of labor. It is a synthetic form of the natural hormone oxytocin, which stimulates uterine contractions and helps to prevent excessive bleeding after delivery by promoting the contraction of the uterine muscles and reducing the risk of uterine atony.

Question 50

90. 32 y/o woman has diagnostic laparoscopy to investigate pelvic pain, and has a catheter inserted in recovery for urinary retention. The catheter is removed the next morning. When can she be safely discharged home?
    a. When she has voided more than 200ml
    b. Straight away with advice to return if she has problems voiding
    c. When her post-void residual volume is 0ml
    d. When her post-void residual volume is 100ml
    e. When her post-void residual volume is 300ml

Answer 50

c. When her post-void residual volume is 0ml

Question 51

92. 25 y/o woman who is 38 weeks pregnant is seen in triage for irregular painful contractions lasting 6 hours. She took paracetamol 6 hours ago. She is examined and found to be 2cm dilated. Which analgesia is most appropriate?
    a. Co-dydramol
    b. Epidural analgesia
    c. Nitrous oxide
    d. NSAID
    e. Warm bath

Answer 51

b. Epidural analgesia

Epidural analgesia is commonly used during labor to provide effective pain relief while allowing the woman to remain awake and alert. It can provide continuous pain relief throughout labor and delivery, making it suitable for women experiencing prolonged or intense pain during labor.

Question 52

93. 41 y/o women attends her dating scan. LMP dates make her 12 weeks pregnant. An intrauterine pregnancy is seen with no fetal heartbeat. CRL is equivalent to a fetus of 9 weeks gestation. What is the best next step?
    a. Admit her for laparoscopy
    b. Counsel her on management options for miscarriage
    c. Offer her a repeat USS in 1 week
    d. Offer treatment with methotrexate
    e. Serum beta-hCG now and repeat in 48 hours

Answer 52

b. Counsel her on management options for miscarriage.

In this case, the woman should be informed about the diagnosis of a missed miscarriage and offered options for management, which may include expectant management (allowing the miscarriage to occur naturally), medical management (using medication to induce miscarriage), or surgical management (such as dilation and curettage). The choice of management option should be based on the woman’s preferences, clinical condition, and any medical indications.

Question 53

94. 37 y/o woman has her anomaly scan at 20+3 weeks of pregnancy, and it reveals echogenic bowel. What is the most likely cause?
    a. Duodenal atresia
    b. Incidental finding
    c. Male gender
    d. Trisomy 18
    e. Trisomy 21

Answer 53

b. Incidental finding.

Echogenic bowel can sometimes be seen as an incidental finding on ultrasound and may not necessarily indicate a specific abnormality or pathology. However, it can also be associated with certain conditions such as infections, genetic abnormalities (such as trisomy 21 or 18), fetal bowel obstruction (like duodenal atresia), or other gastrointestinal issues. While trisomy 21 can sometimes present with echogenic bowel, trisomy 18 is more strongly associated with this finding.

Question 54

95. 29 y/o woman had had intermittent vaginal bleeding since insertion of the Mirena coil 6 weeks ago. What is the most appropriate investigation?
    a. Cervical smear
    b. Colposcopy
    c. High vaginal swab
    d. No investigation required
    e. Transvaginal pelvic USS

Answer 54

e. Transvaginal pelvic ultrasound (USS)

Transvaginal pelvic ultrasound would help assess the position of the Mirena coil, ensuring it’s properly placed within the uterine cavity and ruling out any complications, such as uterine perforation or abnormal positioning, which could be causing the vaginal bleeding. Additionally, it can help evaluate the endometrial lining and identify any other potential causes of the bleeding. Therefore, this investigation is crucial in determining the cause of the symptoms and guiding further management.

Question 55

96. A woman with sickle cell trait is 8 weeks into an unplanned pregnancy. Which investigation should be offered first?
    a. Chorionic villus sampling
    b. Free fetal DNA testing
    c. Partner FBC
    d. Partner haemoglobin electrophoresis
    e. Partner karyotyping

Answer 55

d. Partner haemoglobin electrophoresis.

This investigation is essential because if the partner is found to have sickle cell trait or another hemoglobinopathy, it could increase the risk of the unborn child inheriting a more severe form of the disease, such as sickle cell disease or another hemoglobinopathy. Identifying the partner’s hemoglobin status allows for informed genetic counseling and consideration of further testing or interventions to assess the risk to the fetus.

Question 56

97. A Rh negative woman has light vaginal bleeding and pain at 9 weeks gestation. USS shows a viable 9 week intrauterine pregnancy. The bleeding resolves 48 hours later. What further treatment does she require?
    a. 250IU Anti-D prophylaxis immediately
    b. Kleihauer test
    c. No further action
    d. Progesterone pessaries
    e. Repeat scan in 2 weeks

Answer 56

c. No further action.

Since the woman’s Rh status is negative and there are no signs of miscarriage or complications following the bleeding episode, further treatment, such as Anti-D prophylaxis or progesterone pessaries, is not indicated at this time.

Question 57

100. 24 y/o woman has urge incontinence causing low mood. She previously had a clitoridectomy aged 7 years old in Somalia. She is nulliparous. She has two younger brothers. What is the most appropriate next step in her management?
     a. Referral to FGM clinic
     b. Referral to mental health team
     c. Referral to police
     d. Referral to social services
     e. Referral to uro-gynaecology

Answer 57

A. Referral to FGM clinic

Question 58

102. 36 y/o woman sees GP for routine appointment at 32 weeks pregnancy. This is her first pregnancy and has so far been uncomplicated. She has normal fetal movements and is generally well with temperature 36.3, HR 90, BP 128/82, RR 13, O2 sats 96% on room air. Fundal height is 32cm and fetal HR is normal. Urine dipstick shows ++ protein but no other abnormalities. What is the most appropriate management?
     a. Immediate referral to obstetrics
     b. Repeat urinanalysis in 1 day
     c. Repeat urinanalysis in 1 week
     d. Send urine for MC&S and start Nitrofurantoin
     e. Send urine for MC&S and start Trimethoprim

Answer 58

a. Immediate referral to obstetrics.

Proteinuria in pregnancy can be an indication of various conditions, including preeclampsia. Preeclampsia is a serious condition characterized by hypertension and proteinuria after 20 weeks of gestation. Given the presence of proteinuria along with the gestational age of 32 weeks, immediate referral to obstetrics for further evaluation and management is warranted to assess for preeclampsia and ensure the well-being of both the woman and the fetus.

Question 59

103. 19 y/o woman in GP has a 3 week history of post-coital vaginal bleeding. She had a Nexplanon (Progesterone-only subdermal implant) inserted 18 months ago and has been amenorrhoeic for the last 12 months. Vaginal and speculum exams are normal and urine pregnancy test is normal. What is the most appropriate next investigation?
     a. Blood test for clotting screen
     b. Cervical cytology
     c. Endocervical, chlamydial, and high vaginal swabs
     d. Transvaginal USS
     e. Urine for microscopy, culture, and sensitivities

Answer 59

C. Endocervical, chlamydial, and high vaginal swabs

Question 60

104. 19 y/o woman attends GP for contraception review. She started Microgynon-30 14 months ago and reports a recent migraine without aura which lasted 2 days (which she has never experienced before). She is currently a smoker but has no other CVS disease or VTE risk factors. Her temperature is 36.5, HR 70, BP 115/63, RR 14, O2 sats 97% on room air, and her BMI is 21. What is the most appropriate next step in management?
     a. Continue Microgynon-30 and offer smoking cessation
     b. Continue Microgynon-30 and start Sumitriptan
     c. Stop Microgynon-30 and offer Microgynon-20
     d. Stop Microgynon-30 and offer progesterone-only contraception
     e. Stop Microgynon-30 and start NuvaRing

Answer 60

d. Stop Microgynon-30 and offer progesterone-only contraception.

Migraine with aura is a contraindication to combined hormonal contraceptives (CHCs), such as Microgynon-30, due to the increased risk of ischemic stroke. While the woman’s recent migraine was without aura, the presence of any migraine headache while using CHCs is still considered a precaution, especially in combination with smoking, which further increases the risk of vascular events.

Therefore, the most appropriate action would be to discontinue Microgynon-30 and offer progesterone-only contraception, which does not carry the same increased risk of ischemic stroke in women with migraine headaches, even in the absence of aura. This would help minimize the risk of adverse cardiovascular events while still providing effective contraception.

Question 61

105. 26 y/o woman has 24 hours of vulval rash and painful urination. What is the most appropriate treatment?
     a. Oral aciclovir
     b. Oral flucloxacillin
     c. Topical aciclovir
     d. Topical clotrimazole
     e. Topical fusidic acid

Answer 61

a. Oral aciclovir.

The symptoms are suggestive of genital herpes, a common sexually transmitted infection characterized by painful genital ulcers and rash, along with dysuria. Oral aciclovir is the standard treatment for genital herpes and can help reduce the severity and duration of symptoms, speed up healing of lesions, and decrease the risk of recurrent outbreaks.

Question 62

106. 29 y/o seen in GP wanting to conceive. She has epilepsy and her last seizure was 18 months ago. She currently has a copper IUD in situ and is taking sodium valproate 1000mg BD. What is the most appropriate management?
     a. Leave IUD in situ, continue sodium valproate, and refer her for specialist advice
     b. Remove IUD, continue sodium valproate 1000mg BD and start folic acid 5mg OD
     c. Remove IUD, stop sodium valproate 1000mg and start carbamazepine 600mg BD and folic acid 5mg OD
     d. Remove ID, stop sodium valproate, and start folic acid 400mcg OD

Answer 62

b. Remove IUD, continue sodium valproate 1000mg BD, and start folic acid 5mg OD.

While planning for pregnancy, it’s essential to consider both the woman’s epilepsy management and the potential impact of antiepileptic drugs (AEDs) on pregnancy outcomes. Sodium valproate is associated with an increased risk of congenital malformations and neurodevelopmental disorders in babies born to mothers taking it during pregnancy, especially at higher doses.

However, abruptly stopping sodium valproate can increase the risk of seizures, which can also be harmful during pregnancy. Therefore, the recommendation is typically to continue sodium valproate if it is the most effective treatment for controlling seizures, but to use the lowest effective dose and add folic acid supplementation at a higher dose (5mg daily) to reduce the risk of neural tube defects in the baby.

Question 63

107. 31 y/o woman in GP is 34 weeks pregnant and presents with dysuria, frequency, and urgency. Temperature 37.2, HR 80, BP 126/78, RR 18, O2 sats 99% on room air. She has mild suprapubic pain with no rebound or tenderness. What is the most appropriate initial management plan?
     a. Arrange clinical review in 24 hours
     b. No investigation required, treat empirically with antibiotics
     c. Reassure, no treatment needed
     d. Send urine for MC&S and treat empirically with antibiotics without waiting for results
     e. Send urine for MC&S and treat with antibiotics based on the results

Answer 63

d. Send urine for MC&S (Microscopy, Culture, and Sensitivity) and treat empirically with antibiotics without waiting for results.

Urinary tract infections (UTIs) are common during pregnancy and can have serious implications if left untreated. Pregnant women are at higher risk of complications from UTIs, including pyelonephritis and preterm labor.

Empirical treatment with antibiotics without waiting for culture results is typically recommended in pregnant women with symptoms suggestive of a UTI, especially in the third trimester, to promptly alleviate symptoms and reduce the risk of complications.

Question 64

2. A baby is born with 45XO karyotype. What is the most likely cardiac abnormality associated with this syndrome?

Answer 64

Bicuspid aortic valve

Question 65

4. 15 y/o boy has worsening severe headaches for 1 month and has been vomiting in the morning. There is no history of trauma and he is afebrile. What definitive investigation should now be requested?

Answer 65

Brain MRI

Question 66

5. 5 y/o boy has a systolic murmur which is soft and audible at the left sternal edge. The boy is asymptomatic. What is the most likely diagnosis?

Answer 66

Innocent murmur

Question 67

7. Child has symptoms of perennial rhinitis (blocked nose, nasal voice, running eyes). What is the most likely causative allergen in this scenario?

Answer 67

Dust mites

Question 68

8. 2 y/o girl has a fever of 39.7 and a painful, swollen right eye with preserved eye movements (see picture below). What is the most appropriate first-line treatment?

Answer 68

Oral co-amox

Question 69

13. 15 y/o girl weighs 100kg. She has striae and darker skin in her armpits and neck. She has been feeling tired and has had episodes of vulval thrush, but is otherwise well. A blood test shows a fasting blood glucose of 7.6mmol/L (3-6 normal range). What pharmacological treatment should be considered?

Answer 69

Metformin

Question 70

14. Mother with SLE has a baby who is born with a slow heartbeat. What is the most likely diagnosis?

Answer 70

Congenital heart block

Question 71

15. 2 y/o boy has suddenly started crying and intermittently pulling his legs up. He has vomited several times, and the last vomitus was green. He has not opened his bowels for several hours. He is resuscitated appropriately. What is the definitive management for this condition?

Answer 71

Rectal air insufflation

Question 72

16. 13 y/o girl seen in GP with fever, sore throat, and cervical lymphadenopathy. Her temperature is 37.9 and she has white exudates on enlarged tonsils. She is prescribed Amoxicillin 500mg TDS, then 7 days later re-presents with a widespread rash. What is the most likely causative organism?

Answer 72

Epstein-Barr virus

Question 73

19. 2 week old boy in GP has bilateral red eyes with purulent discharge since birth. What is the most likely causative organism?

Answer 73

Chlamydia trachomatis

Question 74

22. 20 y/o woman presents to A&E with agitation, confusion, high temperature, sweating, muscle twitches, and diarrhoea. She was recently started on medication for depression. What is the most likely diagnosis?

Answer 74

Serotonin syndrome

Question 75

23. 60 y/o man with schizophrenia is taking haloperidol and has developed uncontrolled repetitive movements of his jaw with grimacing and protrusion of his tongue. What phenomenon is this?

Answer 75

Tardive dyskinesia

Question 76

24. 97 y/o woman has dementia and frequently tries to leave her nursing home an 03:00 in her nightgown to feed the swans. What legal framework may be considered in order to prevent her from leaving?

Answer 76

Deprivation of Liberty Safeguards

Question 77

26. 27 y/o woman reviewed by community mental health team for schizophrenia follow-up. She describes experiences where she thinks she isn’t real. What phenomenon is this?

Answer 77

Depersonalisation

Question 78

30. 36 y/o man started on lithium for BPAD. He is scheduled to have regular monitoring of lithium levels, renal function, calcium, and glucose. Which other blood test should be monitored?

Answer 78

TFTs

Question 79

31. 50 y/o man believes wife is cheating on him, gathering evidence by repeated obsessive examination of her underwear. What is the most likely psychiatric diagnosis?

Answer 79

Othello syndrome

Question 80

32. 40 y/o woman attends A&E after her mother’s funeral with sudden onset blindness, but seems largely unconcerned about this new development. Physical examination and investigations are normal. What is the most likely disorder?

Answer 80

Conversion disorder

Question 81

34. 20 y/o man with schizophrenia tells his support worker that the TV news presenter talks about him. What psychotic phenomenon is he describing?

Answer 81

Ideas of reference

Question 82

35. 56 y/o man brought to A&E by ambulance after he’s found collapsed in a park. His pupils are constricted and his RR is 6. Which mediation should be urgently administered?

Answer 82

Nalaxone

Question 83

36. 78 y/o woman has 2 weeks of progressive lethargy, nausea, and dizziness. She has depression and has recently increased her dose of Citalopram. What is the most likely biochemical abnormality?

Answer 83

Hyponatraemia

Question 84

37. 22 y/o female with diagnosis of OCD presents to her GP for a repeat prescription of her medication. Which class of drug is first line for OCD?

Answer 84

SSRI

Question 85

38. 40 y/o doctor has central chest pain but a normal ECG. 3 months ag he attended rapid access chest pain clinic but was discharged after normal exercise stress test. His only PMHx is chronic rhinitis. What is the most likely drug of abuse in this case?

Answer 85

Cocaine

Question 86

39. 22 y/o woman has 6 months of restricted eating, amenorrhea, social anxiety, and low mood. She has fine hair on her face and her BMI is 16.8. Her observations are otherwise normal. What is the most appropriate first-line pharmacological intervention?

Answer 86

SSRI (Fluoxetine)

Question 87

40. 16 y/o attends GP with difficulties at college: she fears sitting on public transport and feels scared to leave her house. She avoids the supermarket and now does her grocery shopping online. What is the most likely diagnosis?

Answer 87

Social phobia

Question 88

42. 22 y/0 woman is planning a water birth. She is low risk with no medical problems. What complication of normal delivery is increased by a water birth?

Answer 88

Infection

Question 89

47. 80 y/o woman with a BMI of 25, COPD, and angina complains of back pain and a dragging sensation in her vagina. She has a uterine prolapse and a normal pelvic USS. What is the most appropriate treatment option?

Answer 89

Pelvic floor muscle training

Question 90

48. 8 y/o girl brought to gynaecology clinic with offensive vaginal discharge, but is otherwise well. What is the most likely cause?

Answer 90

Foreign body

Question 91

51. 49 y/o woman has heavy, irregular menstrual bleeding. TVUSS shows a thickened endometrium with cystic spaces. What investigation would be diagnostic in this scenario?

Answer 91

Biopsy

Question 92

52. 32 y/o with mild asthma has unexplained intra-uterine death at 37 weeks gestation. She is induced and has epidural analgesia and a spontaneous vaginal delivery. She is very distressed and would like to go home. What should be given to prevent her from expressing breast milk in this scenario?

Answer 92

Cabergoline

Question 93

53. 21 y/o woman is 5 weeks pregnant with abdominal pain. USS shows no evidence of an intrauterine pregnancy, a corpus luteum in the left ovary, and otherwise normal adenexae. Her serum b-hCG is 700 (<18 normal range). How should this pregnancy be classified?

Answer 93

Pregnancy of Unknown Location

Question 94

54. A low risk woman would like to have epidural anaesthesia but is concerned about the risks. What is the risk of permanent paralysis (give as 1:X)

Answer 94

1 in 100,000 to 1 in 250,000 epidurals administered

Question 95

56. 31 y/o woman is 37 weeks pregnant and attends GP with itchy rash, though she is systemically well. Temperature 36.8, HR 80, BP 116/78, RR 18, O2 sats 99% on room air. She has the rash depicted below. What is the most likely diagnosis?

Answer 95

Pruritic urticarial papules and plaques of pregnancy (PUPPP)

Question 96

57. 19 y/o woman with intra uterine device in situ presents to GP with new onset low abdominal pain and spotting. Temperature 36.3, HR 83, BP 110/90, RR 18, O2 sats 98% on room air. What is the most appropriate initial investigation?

Answer 96

Urinary B-HcG

Question 97

58. 34 y/o woman in GP is 28 weeks pregnant. She had normal antenatal screening and scans, and her pregnancy is uncomplicated. She has already had the influenza vaccination. Which other immunisation does she require?

Answer 97

Whooping cough

Question 98

59. 28 y/o woman attends GP requesting emergency contraception 5 days after unprotected intercourse. What is the most effective option available to her?

Answer 98

Copper IUD

Question 99

60. 38 y/o woman in GP requests contraception. She has severe menorrhagia and had a gastric sleeve bypass 12 months ago. What is the first line contraceptive management in this scenario?

Answer 99

Progestogen-only intrauterine system

Question 100

1. A 13 year old girl in the Paediatric Emergency Department has drowsiness, weight loss and tiredness over the last 10 days. Her capillary blood gas results on arrival shows:
   pH 7.01 (7.35 - 7.45)
   PCO2 2.9 kPa (4.6 - 6.4)
   HCO3 9 mmol/L (22 - 30)
   Glucose 24 mmol/L (3.0 - 6.0)
   Blood ketones 6 mmol/L

Following an initial ABC assessment, bloods were taken. Her latest observations are: temperature 37C, pulse rate 118 bpm, BP 105/74 mmHg, capillary refill time 3 seconds, respiratory rate 27 breaths per minute, oxygen saturation 96% breathing air.

Rank the following subsequent management steps in order of priority with (1) being performed first and (5) being performed last
a. SC insulin
b. Repeat blood gas
c. Administer a fluid bolus
d. IV insulin
e. Calculate IV fluid requirement

Answer 100

a. SC insulin 5
b. Repeat blood gas 4
c. Administer a fluid bolus 1
d. IV insulin 3
e. Calculate IV fluid requirement 2

Question 101

A previously well, fully immunised, 2 year old girl, has a fever, irritability and vomiting for the last 3 days. A lumbar puncture is performed, and her CSF results are as follows:
CSF protein 0.8 g/L (0.15 - 0.45)
Glucose 2.9 mmol/L (2.2 - 2.4) (blood glucose 7 mmol/L)
Polymorphonuclear cells 95%
Mononuclear cells 5%

Rank the following causative organisms in order of likelihood with (1) being the most likely and (5) being the least likely.
a. Streptococcus pneumoniae
b. Cryptococcus
c. Haemophilus influenzae type B
d. Staphylococcus aureus
e. Enterovirus

Answer 101

a. Streptococcus pneumoniae 1
b. Cryptococcus 4
c. Haemophilus influenzae type B 2
d. Staphylococcus aureus 3
e. Enterovirus 5

Question 102

. A 2 week old baby has been recently diagnosed with trisomy 21. Rank the following cardiac defects in order of likelihood
a. ASD
b. Pulmonary atresia
c. Mild coarctation of the aorta
d. AVSD
e. VSD

Answer 102

a. ASD 3
b. Pulmonary atresia 5
c. Mild coarctation of the aorta 4
d. AVSD 1
e. VSD 2

Question 103

A 4 month old boy in General Practice has 2 months of slowly worsening vomiting after feeding. He frequently cries and arches his back after feeding and refuses feeds. He is formula fed. He was just below the 50th centile for weight at birth and is now just above the 25th percentile.

Rank the following interventions according to the sequence in which they should be implemented with (1) being carried out first and (5) being carried out last.
a. Refer to paediatrics team
b. Trial smaller and more frequent feeds
c. Trial of proton pump inhibitor treatment
d. Trial of feed thickener
e. Prescribe alginate therapy with feeds

Answer 103

a. Refer to paediatrics team 5
b. Trial smaller and more frequent feeds 1
c. Trial of proton pump inhibitor treatment 4
d. Trial of feed thickener 2
e. Prescribe alginate therapy with feeds 3

Question 104

A 32 year old woman with bipolar affective disorder is in the 11th week of her first pregnancy. She has not been taking medication for the last 3 months and wants to remain medication free throughout the pregnancy and postnatal period.

Rank the following disorders in order of likelihood of occurrence in this woman with (1) being the most likely and (5) being the least likely.
a. Post-traumatic stress disorder
b. Puerperal psychosis
c. Postnatal depression
d. Alcohol use disorder
e. Generalised anxiety disorder

Answer 104

a. Post-traumatic stress disorder 5
b. Puerperal psychosis 2
c. Postnatal depression 1
d. Alcohol use disorder 4
e. Generalised anxiety disorder 3

Question 105

A 21 year old woman in the Emergency Department states that she is going to kill herself because the voices in her head are telling her to do so. Her feelings reportedly intensified following an argument with her mother earlier in the day. She demands to be admitted to the mental health unit, saying ‘it will all be your fault when I commit suicide”. She has a history of cutting and is well known to mental health services from previous crisis presentations.

Rank the following differential diagnoses in order of likelihood, with (1) being the most likely and (5) being the least likely.
a. Dissocial personality disorder
b. Paranoid schizophrenia
c. Depressive episode of moderate severity
d. Severe depressive episode with psychotic features
e. Emotionally unstable personality disorder

Answer 105

a. Dissocial personality disorder 5
b. Paranoid schizophrenia 4
c. Depressive episode of moderate severity 3
d. Severe depressive episode with psychotic features 1
e. Emotionally unstable personality disorder 2

Question 106

A 37 year old woman in the Emergency Department has low mood, insomnia, an inability to concentrate and hopelessness for the past 6 weeks. She recently lost her job as a corporate lawyer. She had an episode of depression at the age of 26 years, which was treated with fluoxetine for 6 months. She reports being a social drinker (average consumption is 2 glasses of wine per week).

Rank the following risk factors for depression in order of significance for this woman, with (1) being the most significant and (5) being the least significant.
a. Alcohol intake
b. Gender
c. Age
d. Previous depressive episode
e. Recent unemployment

Answer 106

A 37 year old woman in the Emergency Department has low mood, insomnia, an inability to concentrate and hopelessness for the past 6 weeks. She recently lost her job as a corporate lawyer. She had an episode of depression at the age of 26 years, which was treated with fluoxetine for 6 months. She reports being a social drinker (average consumption is 2 glasses of wine per week).

Rank the following risk factors for depression in order of significance for this woman, with (1) being the most significant and (5) being the least significant.
a. Alcohol intake 5
b. Gender 3
c. Age 4
d. Previous depressive episode 1
e. Recent unemployment 2

Question 107

. The son of an 81 year old man in General Practice is concerned about his father. His father lives alone and has become more forgetful over the past 3 months. He has left his house without shutting the door several times and has been getting lost on the way to the shops. He has well-controlled hypertension and diet-controlled Type 2 Diabetes Mellitus.

Rank the following management steps according to the sequence in which they should be implemented with (1) being carried out first and (5) being carried out last.
a. Arrange joint consultation with father and son
b. Refer to local Memory Clinic
c. Perform an assessment of cognition with a cognitive assessment tool
d. Arrange confusion screen blood tests
e. Assess for acute reversible causes of confusion

Answer 107

a. Arrange joint consultation with father and son 1
b. Refer to local Memory Clinic 5
c. Perform an assessment of cognition with a cognitive assessment tool 3
d. Arrange confusion screen blood tests 4
e. Assess for acute reversible causes of confusion 2

Question 108

A 24 year old woman presents with a 2 day history of worsening right-sided lower abdominal pain. She is sexually active and normally uses condoms. She has a 28 day cycle and her last period was 6 weeks ago. One day ago she had loose stools and attributed this to a bad take away. She has nausea and loss of appetite but no vomiting. Her temperature is 37.3C, pulse 96 bpm, BP 110/64 mmHg, respiratory rate 18 breaths per minute, oxygen saturation 98% breathing room air.

Urine dip: blood 1+ only
Blood test results: Hb 85 g/L (115 - 150), CRP 10 mg/L (<5)

Rank the following diagnoses in order of likelihood with (1) being the most likely and (5) being the least likely.
a. Appendicitis
b. Urinary tract infection
c. Pyelonephritis
d. Ectopic pregnancy
e. Ovarian cyst accident

Answer 108

a. Appendicitis 3
b. Urinary tract infection 5
c. Pyelonephritis 4
d. Ectopic pregnancy 1
e. Ovarian cyst accident 2

Question 109

A 25 year old woman in the Emergency Department is 8 days post delivery. She was induced at 38 weeks’ gestation for pre-labour rupture of membranes. She had a forceps delivery for foetal distress and a postpartum haemorrhage of 700mls. She was discharged on day 4 post delivery. She says she is finding it hard to cope, worries about the baby all the time and is unable to sleep because she feels she needs to watch the baby. She cries every day and is worried someone will take the baby from her. She is concerned her breast milk is inadequate. She has been sweating at night but has not checked her temperature. She also has a constant headache.

Rank the following differential diagnoses in order of likelihood with (1) being the most likely and (5) being the least likely.
a. Postnatal depression
b. Sepsis
c. Schizophrenia
d. Baby blues
e. Pre-eclampsia

Answer 109

a. Postnatal depression 2
b. Sepsis 3
c. Schizophrenia 4
d. Baby blues 1
e. Pre-eclampsia 5

Question 110

A 36 year old mother of three young children is not using any contraception. She had a recent unplanned pregnancy and opted for a termination. She occasionally experiences headaches and smokes five cigarettes per day. Her BMI is 30 kg/m2. She has been in a relationship for 18 months.

Rank the following contraceptive choices for this woman in order of appropriateness, with (1) being the most appropriate and (5) being the least appropriate.
a. Combined oral contraceptive pill
b. Nexplanon implant
c. Sterilisation
d. Mirena IUS
e. Condoms

Answer 110

a. Combined oral contraceptive pill 4
b. Nexplanon implant 2
c. Sterilization 5
d. Mirena IUS 1
e. Condoms 3

Question 111

A heterosexual couple in their early 30s have been trying to conceive for more than 1 year without success. Neither has any children.

Rank the following potential causes of their infertility in order of likelihood with (1) being the most likely and (5) being the least likely.
a. Gamete defects
b. Male infertility
c. Uterine or peritoneal disorders
d. Tubal damage
e. Ovulatory disorders

Answer 111

a. Gamete defects 5
b. Male infertility 2
c. Uterine or peritoneal disorders 3
d. Tubal damage 4
e. Ovulatory disorders 1

Question 112

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

Answer 112

Refer to a paediatric dietician

Question 113

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

Answer 113

Cow’s milk protein allergy – allergy symptoms and GI symptoms. If breast tell mum to avoid dairy. If bottle use hydrolyzed. Start on milk ladder after 1 year of age

Question 114

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?

Blood culture

Gastric washings

Mantoux

QuantiFERON / IGRA

Sputum culture

Answer 114

Sputum culture

Question 115

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?

Beta Thalassaemia

G6PD deficiency

Hereditary spherocytosis

Iron deficiency anaemia

Sickle cell disease

Answer 115

G6PD deficiency - Nitrofurantoin can cause it

Question 116

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?

Agammaglobulinaemia

Cystic fibrosis

HIV

Primary ciliary dyskinesia – people commonly also have consanguity (left and right flipped inside)

Tracheo-oesophageal fistula

Answer 116

Primary ciliary dyskinesia (PCD)

This is because

Recurrent Respiratory Infections and Sinusitis: PCD is characterized by recurrent respiratory tract infections due to defective ciliary function, which impairs mucociliary clearance.

Bibasal Crepitations: These are common in conditions that affect the lower respiratory tract chronically, such as PCD.

Right-Sided Apex Beat (Situs Inversus): PCD is often associated with situs inversus (a condition where the major visceral organs are mirrored from their normal positions), which can result in a right-sided apex beat.

Question 117

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?

Atrial septal defect

Coarctation of the aorta

Patent ductus arteriosus

Patent foramen ovale

Ventricular septal defect

Answer 117

Coarctation of the aorta

Question 118

. A 5 year old boy 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 inboth 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

Answer 118

b. Henoch Schonlein Purpura

Question 119

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

Answer 119

Hepatitis A infection

Question 120

. 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

Answer 120

Refer to specialist

NOTE: Do a CT head if you are between orbital and periorbital cellullitis

Question 121

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

Answer 121

Sweat test

Question 122

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

Answer 122

Central precocious puberty

This is because:

Clinical Presentation:
Breast buds (thelarche): This indicates the beginning of puberty.
No pubic hair: Pubic hair development typically follows breast development in the sequence of puberty.

Growth Metrics:
Height on the 98th centile: Advanced growth may be associated with early puberty.
Weight on the 75th centile: Consistent with overall increased growth velocity.
Bone Age:

Bone age of 10 years: Advanced bone age suggests early onset of puberty.

Hormonal Findings:
Elevated FSH (3.2 IU/L) and LH (3.4 IU/L): Elevated gonadotropins are indicative of activation of the hypothalamic-pituitary-gonadal axis, which is a hallmark of central precocious puberty.

Question 123

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

Answer 123

Urine dipstick - minimal change disease - check dipstick for nephrotic syndrome

Question 124

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

Answer 124

Prescribe oral antipyretics and observe

NOTE: Wouldn’t prescribe buccal midazolam. ALWAYS OBSERVE FIRST EPISODE OF CONVULSIONS. anti-pyretic for symptomatic relief.

Question 125

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

Answer 125

b. Feed the baby

If feeding the baby does not resolve the hypoglycemia or if the infant is unable to feed, the next step would be to consider intravenous dextrose (option c). However, initial management typically involves an attempt to feed the baby.

Question 126

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
c. Epiglottitis
d. Inhaled foreign body
e. Laryngomalacia

Answer 126

d. Inhaled foreign body

Acute Onset of Symptoms: The sudden onset of cough and drooling is highly suggestive of an inhaled foreign body. This is often seen when a child suddenly develops respiratory symptoms without a preceding illness.

Inspiratory Upper Airway Noises: Stridor, which is an inspiratory noise, is commonly associated with an obstruction in the upper airway, which can occur with an inhaled foreign body.

Drooling: This is a key symptom that suggests the child is having difficulty swallowing saliva, which can be due to a partial obstruction in the airway or esophagus caused by a foreign body.

Normal Vital Signs and Examination: The child’s normal temperature and other stable vital signs make infectious causes like croup and epiglottitis less likely. Both of these conditions often present with fever and more severe respiratory distress.

Vaccinations Up to Date: This reduces the likelihood of epiglottitis, especially if the child has received the Haemophilus influenzae type b (Hib) vaccine, which significantly reduces the incidence of epiglottitis caused by Hib.

Question 127

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

Answer 127

Nasal sumatriptan when required – it’s the normal treatment ladder, however after triptans should be managed by specialist; ask for abdominal migraine in children

Question 128

A 12 year old girl 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

Answer 128

a. Benign intracranial hypertension (also known as idiopathic intracranial hypertension)

Here’s the reasoning:

Headache Characteristics: Severe, throbbing headaches that are worse in the morning are a red flag for increased intracranial pressure (ICP).

Morning Headaches: Headaches that are worse in the morning suggest a possible increase in ICP because intracranial pressure is often higher when lying down.

Nausea and Vomiting: These symptoms are commonly associated with increased ICP.

Additional Symptoms: Increased tiredness and irritability can be related to increased ICP.

Weight: The girl’s weight (62 kg) may suggest obesity, which is a known risk factor for benign intracranial hypertension.

Question 129

38. 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

Answer 129

Offer an osmotic laxative as there is a fissure

Question 130

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

Answer 130

D. Prescribe phenoxymethylpenicillin

NOTE: FeverPAIN criteria

Fever (during previous 24 hours)

Purulence (pus on tonsils)

Attend rapidly (within 3 days after onset of symptoms)

Severely Inflamed tonsils

No cough or coryza (inflammation of mucus membranes in the nose)

Each of the FeverPAIN criteria score 1 point (maximum score of 5). Higher scores suggest more severe symptoms and likely bacterial (streptococcal) cause. A score of 0 or 1 is thought to be associated with a 13 to 18% likelihood of isolating streptococcus. A score of 2 or 3 is thought to be associated with a 34 to 40% likelihood of isolating streptococcus. A score of 4 or 5 is thought to be associated with a 62 to 65% likelihood of isolating streptococcus.

Question 131

A 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

Answer 131

A. admit to hospital for assessment

THIS IS LIKELY APPENDICITIS

Question 132

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

Answer 132

e. Turning one page in a book

Crawling (3 months head, 6 months upright, 9 months crawl, 12 months walk (18 is red flag))

Draw a circle (3 years)

Draw a square (4 years)

Transfers objects from one hand to the other (6 months)

Turning one page in a book (Several pages at 2 years, one page at 3 years) Casting bricks should stop by 18 months

Question 133

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

Answer 133

c. He has limited social contacts

Negative symptoms in schizophrenia refer to deficits or reductions in normal emotional and behavioral functions. Limited social contacts indicate a reduction in social interactions, which is a negative symptom.

Question 134

47. 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

Answer 134

Option d. Reduce fluoxetine dose to 20mg daily and start citalopram after a 1-week washout period could indeed be a valid approach, especially considering the half-life of fluoxetine, which is around 4 to 6 days, and the potential risk of serotonin syndrome.

This approach allows for a gradual reduction of fluoxetine while minimizing the risk of adverse effects from the combination of SSRIs.

Question 135

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)

Answer 135

Cholesterol: When the body is in a state of severe malnutrition and fasting, such as in this scenario, there can be alterations in lipid metabolism. Specifically, levels of cholesterol can increase due to the body mobilizing fat stores for energy. This can result in elevated serum cholesterol levels.

Question 136

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

Answer 136

Stop venlafaxine

Venlafaxine: Venlafaxine is an antidepressant medication that belongs to the class of serotonin-norepinepherine reuptake inhibitors (SNRIs). It can induce or exacerbate manic or hypomanic symptoms, especially in individuals with bipolar disorder.

Question 137

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

Answer 137

Amenorrhea: In females, the absence of menstrual periods (amenorrhea) is a common feature of anorexia nervosa, particularly when the disorder is severe and accompanied by significant weight loss. It typically occurs due to hormonal disruptions caused by malnutrition and low body weight.

Question 138

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

Answer 138

Quetiapine and lithium antipsychotic and mood stabiliser. During depression the SSRI of choice is fluoxetine.

Question 139

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

Answer 139

Hypochondrial disorder

Question 140

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)

Answer 140

d. Increase the dose of sertraline

Question 141

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

Answer 141

Detain her under Section 5(2) of the Mental Health Act

Question 142

. 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

Answer 142

c. MoCA (Montreal Cognitive Assessment)

Question 143

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

Answer 143

B. Delirium as she is unoriented to time and place

Question 144

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

Answer 144

Methadone

Question 145

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

Answer 145

d. Give her the 24 hour mental health crisis number

Question 146

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

Answer 146

Acute stress reaction

Question 147

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

Answer 147

Harmful use – substance use causing harm to health

Dependence – strong desire to take substance
Withdrawal syndrome – symptoms result after stopping substance

Question 148

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

Answer 148

Mindfulness-based cognitive therapy – this can be used for prevention

Question 149

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

Answer 149

Adjustment disorder

Question 150

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

Answer 150

a. Aripiprazole

Question 151

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

Answer 151

Artificial rupture of membranes – this is the first line in failure to progress (if this doesn’t work then needs to be obstetric-led care). Next step or if membranes are already ruptured, oxytocin (Failure to progress is <2cm in 4 hours)

NOTE: Perform a membrane sweep – first step for induction of labour (done around 40 weeks), followed by vaginal prostaglandin, followed by oral, followed by oxytocin

Question 152

. A 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

Answer 152

Episiotomy – this is going to be done first to make instrumental delivery easier

Forceps delivery – need to expedite the delivery since its been 2 hours and signs of fetal distress. This is quicker then ventouse

Question 153

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

Answer 153

Complete miscarriage

Question 154

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 (99.4-100%)
b. Chorionic villous sampling (85%)
c. Non-invasive pre-natal testing (cell free DNA) (99.17-100%)
d. Nuchal translucency
e. Quadruple test

Answer 154

Amniocentesis – this is actually most sensitive >15 weeks

Chorionic villous sampling - less sensitive done around 11-14 weeks

Non-invasive pre-natal testing (cell free DNA) –slightly less sensitive, is now on the NHS

NOTE: Depends on question, think about risk to baby, mothers wishes etc

Question 155

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

Answer 155

Arrange a repeat ultrasound scan (USS) in 10-14 days

Here’s why:

Intrauterine Gestation Sac: The presence of an intrauterine gestational sac indicates a pregnancy is located within the uterus, which is reassuring.

Absence of Yolk Sac or Fetal Pole: At 6 weeks of gestation, the absence of a visible yolk sac or fetal pole may not be definitive evidence of a non-viable pregnancy. In some cases, these structures may not yet be visible due to the early stage of pregnancy.

Question 156

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

Answer 156

No follow up required

Question 157

85. 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
    b. Meningitis
    c. Migraine
    d. Post-dural tap headache
    e. Pre-eclampsia

Answer 157

Post-dural tap headache - side-effect of epidural, headache that is worst when standing and better on lying flat. Get them to lie flat as long as possible and paracetamol. If persisits epidural blood patch

Question 158

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

Answer 158

Influenza and pertussis - (+COVID-19), also tested for HIV, Hep B and Syphillis.

Question 159

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

Answer 159

Gestational diabetes – you are at increased risk for diabetes anyways

Question 160

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

Answer 160

Physiological change

Question 161

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

Answer 161

d. Germ cell tumor of the ovary

Germ cell tumors of the ovary are neoplasms derived from germ cells and can present as complex cystic masses with solid components on ultrasound. These tumors are more common in young women, typically in their second or third decade of life. While they can be benign or malignant, the presence of solid components within the cystic mass raises concern for malignancy.

Question 162

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

Answer 162

Reassure and discharge – order of puberty breast buds, pubic hair, menarche; for boys testis, penis, pubic hair voice

Question 163

. A 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

Answer 163

Transdermal oestrogen

Question 164

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

Answer 164

Surgical repair

NOTE: Intraurethral bulking (option b) is often considered before surgical repair because it is a minimally invasive procedure that can be effective for treating stress incontinence and carries fewer risks compared to surgery. If intraurethral bulking fails to adequately address the symptoms, then surgical repair may be pursued

Question 165

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

Answer 165

d. Serial quantitative beta-HCG

Question 166

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

Answer 166

a. Make a safeguarding risk assessment

Question 167

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

Answer 167

Bladder diary

Here’s why:

Bladder Diary: A bladder diary is a simple and non-invasive tool used to assess the frequency, volume, and pattern of urinary symptoms over a specific period. It typically involves recording fluid intake, voiding frequency, urine volume, episodes of urinary incontinence, and any associated factors such as urgency or nocturia. A bladder diary can provide valuable information about the nature and severity of the patient’s symptoms, as well as potential triggers or patterns.

Question 168

. 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

Answer 168

c. Organise a pelvic ultrasound scan

Question 169

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

Answer 169

Bartholin’s abscess

Question 170

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

Answer 170

Lichen sclerosus – atrophy of epidermis with white patches, presents with itching and pain during sex/urination

Question 171

. 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

Answer 171

Refer for antenatal same day assessment - 2+ protein needs urgent same day assessment. 1+ and other symptoms of pre-eclampsia same day assessment as well

NOTE: Send a protein creatinine ratio – do this 1 week later if it was 1+ and no other symptoms

Question 172

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

Answer 172

Postnatal depression

Question 173

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

Answer 173

Admit to hospital

NOTE: Offer cyclizine – do this if she can swallow. Offer ondansetron – this is second line as associated with increased risk of cleft palate.

Question 174

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

Answer 174

c. LH, FSH, SHBG, testosterone

Question 175

A 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

Answer 175

Endometrial polyp

Question 176

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

Answer 176

Refer to epilepsy clinic, continue current medication in the meantime – you do not want to change any of her medication, only epilepsy clinic can do this (sodium valporate teratogenic)

Question 177

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?

Answer 177

Emollients, topical steroids if severe

Question 178

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?

Answer 178

Milia (LOOK UP WHAT THIS LOOKS LIKE) - do nothing

Question 179

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?

Answer 179

Non-accidental injury

Question 180

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

Answer 180

Parvovirus B19

Question 181

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?

Answer 181

Biliary atresia

Question 182

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?

Answer 182

rifampicin

Question 183

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?

Answer 183

spacer

Question 184

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?

Answer 184

Trisomy 18

Question 185

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 in this scenario?

Answer 185

mild steroid eg hydrocortisone, imicazole if this is candida

Question 186

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?

Answer 186

Post-traumatic psychosis

Post-traumatic psychosis can occur following a traumatic brain injury and is characterized by the presence of hallucinations, delusions, disorganized thinking, or other psychotic symptoms. These symptoms may develop weeks to months after the injury and can be distressing and impairing for the individual.

Question 187

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?

Answer 187

Refeeding syndrome - hypophosphotaemia

Question 188

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?

Answer 188

Nalaxone

Question 189

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?

Answer 189

Neuroleptic malignant syndrome

Question 190

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?

Answer 190

1:1

Question 191

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?

Answer 191

Manix episode, This could be hypomania if she is functional.

Question 192

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?

Answer 192

Retrograde amnesia

Question 193

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?

Answer 193

Clozapine - for treatment resistant schizo

Question 194

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?

Answer 194

SSRI - sertraline and paroxetine given in breastfeeding

Question 195

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?

Answer 195

Delirium tremens

Question 196

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?

Answer 196

Bulimia nervosa

Question 197

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?

Answer 197

Paranoid schizophrenia

Question 198

A 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

Answer 198

CBT or SSRIs can be used in panic disorder or GAD after self help/education

Question 199

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?

Answer 199

Methylphenidate (lisdexamphetamine is second line, both are cardiotoxic so do baseline ECG)

Question 200

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?

Answer 200

Anorexia nervosa

Question 201

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?

Answer 201

TFTs can cause depression, cold and weight gain

Question 202

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

Answer 202

Twin to twin transfusion syndrome - treated with a tertiary care laser to stop blood supply

Question 203

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?

Answer 203

Erythromycin, would give benpen if GBS confirmed or fever during labour

Question 204

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?

Answer 204

4-6 weeks

Question 205

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?

Answer 205

Endometriosis, pain on defecation is due to dyschezia

Question 206

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?

Answer 206

Thiamine

Question 207

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? (Your answer should be expressed in the format: GX PX

Answer 207

G5P1 (Gravidity is number of pregnancies and Parity is number of viable pregnancies >24 weeks)

Question 208

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: X hours

Answer 208

6 hrs food and 2 hrs clear liquids

Question 209

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?

Answer 209

Choriocarcinoma

Question 210

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?

Answer 210

McRoberts’s maneuvere

Question 211

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?

Answer 211

Reduce PMS symptoms

Question 212

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? (Your answer should be expressed numerically in the form: X months)

Answer 212

6-12 months

Question 213

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?

Answer 213

Rectocele

Question 214

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? (Your answer should be expressed numerically in the form: X hours

Answer 214

6 hours

Question 215

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?

Answer 215

Pruritic urticarial papules and plaques of pregnancy (PUPPP)

Question 216

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?

Answer 216

Physiological jaundice presents around day 3-4 and resolves by week 2. Above week 2 is prolonged jaundice. Since he is good most likely thing is breast milk jaundice

Question 217

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?

Answer 217

T2FGM