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3,531 questions
A 61-year-old woman presents to the walk-in clinic with a history of tight, sternal chest pain ''appearing out of the blue''. Such episodes have occurred at different times throughout the day and rarely last longer than a few minutes. They do not correspond to hard exercise. The patient has no cardiac history to date. Her electrocardiogram (ECG) has not detected any abnormalities and 2 days have passed since the last episode. Which of the following is the next best step in her management?
A 45-year-old man presents with a 1-day history of severe, excruciating pain in his right flank, vomiting and fever. He describes the pain as 'needle-like' and it moves towards his groin. He has tried diclofenac which has had little effect. When passing urine, the pain increased and his urine was blood-tinged. He denies any other symptoms or medical problems. The patient's temperature is 38°C and a CT scan shows a renal staghorn calculus. The most appropriate treatment is:
pH 7.51, p02 18, pC02 2.3, HC03-24 A 65-year-old man presents to the GP with chest pain, increasing shortness of breath and weight loss. He describes the pain as dull and worse on inhalation. He notices that he has lost 1 stone in 3 weeks. He has never smoked and has no other significant past medical history. He used to work in a shipyard. Observations include temperature 36.8°C, pulse rate 80 bpm, blood pressure 140/95 mmHg and respiratory rate 18/min. On examination, there is dullness to percussion over the left lower lung zone. What is the most likely diagnosis?
A 60-year-old man presents to the emergency department with shortness of breath for 3 hours and chest pain. He also complains of a right calf pain that he has had for 2 week.s. He has a past medical history of hypertension, recent stroke and disseminated lung cancer. His observations include temperature 37.0°C, pulse rate 112 bpm, blood pressure 100/54 mmHg, respiratory rate 26/min and saturations 87°/o on room air. There is no significant finding on chest examination. An electrocardiogram (ECG) shows sinus tachycardia and new right bundle branch block. A computed tomography (CT) pulmonary angiography confirmed massive pulmonary embolism. What is the most appropriate initial treatment?
A 35-year-old man presents to the GP with increasing fatigue for 3 months. He fmds himself waking up choking a few times at night. He was told by his partner that he snores quite loudly most nights. He denies any weight loss. He smokes 30 cigarettes/day, drinks 2 pints of beer every night and bas a body mass index of 32. What is the most likely differential diagnosis?
A 55-year-old man is found to have a gastric ulcer following an endoscopy for left upper quadrant pain. A rapid urease test is positive for H. pylori infection. What treatment does this man need?
A 78-year-old woman, who bas recently been feeling under the weather and losing some weight, develops a severe left-sided headache with jaw pain on eating. She also complains of USMLE IM2e/Diagnostic blurred vision on the left side. Which of the following investigations is needed to give a defmitive diagnosis?
A 70-year-old man presents with multiple widespread tense blisters measuring between 0.5 cm and 5 cm in diameter. They are localised mainly to the arms and legs, with some lesions on the chest. They appeared over weeks, preceded by itchy urticarial lesions. A few lesions have burst and have left not much behind. There is a history of osteoarthritis of the knees for which he takes diclofenac, and he has not changed any medication in the past year. A subsequent biopsy of a bulla shows splitting at the dermoepidermal junction. What is the diagnosis?
A type 2 diabetic patient has been taking metformin with good effect for the last four months. He has started to lose weight and maintained good glucose control. In the last two months, however, the patient has been persistently hyperglycaemic despite increased metformin dosage and HbAlc targets have not been achieved. The most appropriate management is:
An 81-year-old retired farmer presents with a 1.5 cm raised lesion on his left temple that has slowly grown over the past year and occasionally bleeds. He has had a basal cell carcinoma removed from his right temple previously, and he has had cryotherapy for actinic keratoses on his temples and head several times at his GP surgery. On examination, the lesion has a rolled edge and is translucent with telangiectasia. Which of the following treatment options is NOT recommended for this lesion?
A SO-year-old man with no previous cardiovascular history comes to the Emergency room after referral from his GP. He attended the GP surgery with palpitations, which were extremely rapid and irregular. It is now 9am and he tells you the palpitations began the previous morning after a heavy drinking session with a friend from work. There is no history of smoking, cardiovascular disease or previous myocardial infarction, he plays squash twice per week and cycles to work. On examination his BP is 125/77 mmHg, his pulse is 140/min, irregular. He is not in cardiac failure. Investigations; Hb 13.1 g/dl, WCC 4.9 x109/l, PLT 210 x109/l, Na+ 139 mmol/1, K+ 4.7 mmol/1, Creatinine 120 µmol/1, CXR No cardiomegaly, no LVF, ECG Fast atrial fibrillation, no Q waves. Which of the following is the most appropriate therapy to chemically cardiovert him?
A 68-year-old obese woman is not coping at home and presents to the emergency department foilowing a fall. On examination, she has a weak, regular pulse and an ejection systolic murmur. You try to lean her forward and palpate her apex beat in expiration but she gets flustered and complains of a sore back and shortness of breath. A neurological examination is unremarkable and her haemoglobin level is 13.2 g/dl. What is most likely wrong with her?
A 32-year-old man is diagnosed with Hodgkin's lymphoma following a recent history of weight loss and night sweats. Computed tomography (CT) staging scan shows disease in the mediastinum bilaterally and some abdominal lympbadenopathy, including the spleen, but no evidence of disease in extranodal sites. What is his stage of disease?
A 32-year-old man presents to the GP 4 days after an episode of painless haematuria, 2 weeks following a sore throat. He says he now feels he is producing less urine than usual and that it is brown. He denies any weight loss or fatigue, and has no family history of urological malignancy. On examination, he has a blood pressure of 155/90 mmHg, +++ blood on urine USMLE IM2e/Diagnostic dipstick, and blood tests reveal a creatinine of 170 µmol/L and normal electrolytes. What is the clinical picture most consistent with?
A 24-year-old woman presents with increasing breathlessness on exertion, which has been developing over several months. There are no abnormal physical signs on examination. On the ECG, there is right axis deviation and an R wave in Vl, with peaked P waves. Chest x-ray showed prominent hilar vessels with sparse vasculature peripherally in the lungs. Doppler echocardiography revealed a pulmonary artery pressure of 60 mmHg and primary pulmonary hypertension was diagnosed. Which of the following medications would not be appropriate in managing this patient?
A 67-year-old man is discharged from hospital following an incision and drainage of a large abdominal wall abscess. He needs someone to help change his wound packing regularly, however he is immobile and lives alone. Which member of the multidisciplinary team would be most appropriate to help?
An 18-year-old man presents with a 3-day history of fever, vomiting and headaches on waking in the morning. He has recently started at university and denies taking any illicit substances prior to or during his time at university. He has tried paracetamol but they have not helped. He decided to see a doctor when his neck became painful and stiff to move. On further examination, a non-blanching petechial rash is discovered. The most appropriate management is:
A 19-year-old female university student presents with problems in both arms and difficulty walking. Since starting her course she has bad difficulty writing, typing, and other such activities, and thus has struggled to keep up with the workload. She says the arms have ''felt unusual'' for around 6 months. She describes finding small burns and blisters on her arms that she can't remember getting in the first place. In the last few weeks she has also fallen twice when walking up the stairs. The only other thing she describes is some mild occipital headaches that have increased in frequency lately. She is otherwise fit and well. On examination, there is a loss of pinprick sensation found throughout the arms and on the back to around T3 level. Her hands appear to have some element of small muscle wasting and there is some loss of power throughout the arms. Reflexes are hard to elicit or possibly absent. In the legs, there is some mild symmetrical weakness, and the knee reflexes appear brisk. Plaotars appear equivocal. What is the most likely diagnosis?
A 56-year old man has a myocardial infarction the day after a hernia repair. You request an ECG and then compare it to his pre-admission trace. You notice ST-segment changes in leads II, ID and aVF. In which part of the myocardium is the infarct?
A 78-year-old retired groundskeeper presents with a 2 cm skin lump on his temple. He is unsure how long it has been there. It appears to have a rolled, shiny edge with telangiectasia and a central ulcerated area. Which of the following is the most likely diagnosis?