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3,531 questions
A 75-year-old woman presents to accident and emergency with severe left-sided headache. She also mentions that the vision in her left eye is blurred. She has previously been fit and well but has been feeling increasing worn down in the last few months with aching, weak shoulders and legs. On examination, the left side of her scalp is painful to touch. Blood tests reveal a raised ESR. What is the most appropriate immediate management?
A 54-year-old woman presents to her GP complaining of repeated incidents of burning central chest pain. It mainly occurs when she lies down to go to bed at night. She is overweight with a body mass index of 40. She uses glyceryl trinitrate (GTN) occasionally but it doesn't always relieve her symptoms. She doesn't report any shortness of breath or palpitations and examination is unremarkable. What is the most likely diagnosis?
An 18-year-old African man presents with worries about his general health stating that hypertension and sickle cell anaemia are present in his family history. The patient denies any shortness of breath, chest pain, digit or limb changes. Blood pressure is 124/77 mmHg. What test would be appropriate to investigate sickle cell anaemia?
A 44-year-old woman is brought to accident and emergency after becoming ill at the airport after a flight from Australia. She presents with mild pain that causes her to catch her breath and has been coughing blood-stained sputum. On examination, her respiratory rate is 25, heart rate 100 bpm and blood pressure is 130/85 mmHg. The most appropriate management is:
A 29-year-old man is brought to the emergency department having been found unresponsive on a park bench. On examination, his airway is patent and he has a spontaneous respiratory rate of 7, with a saturation rate of 92% on air. There is no abnormality on examination or auscultation of the chest. He has a pulse of 70 bpm and a blood pressure of 110/80 mmHg. The ECG is normal. He has a Glasgow Coma Score (GCS) of 3 and has pinpoint pupils. He has a temperature of 36.8°C and a blood sugar reading of 6. Basic initial management steps include high-flow oxygen administration and intravenous access. Which of the following might you also implement?
A 21-year-old student on an internship with The Guardian travel section has recently returned from a backpacking holiday in West Africa. For the last few days he has been having headaches, flu-like symptoms and muscle aches, and now he has started rigoring. Which investigation should be performed to rule out malaria?
A 29-year-old woman complains of tiredness, especially during activity. On examination the patient appears pale. Auer rods and schistocytes can be seen on peripheral blood smear. The patient is referred for a bone marrow biopsy and the extracted cells are sent for cytogenetic analysis. The most likely results are:
A 65-year-old woman presents to hospital with left-sided weakness of sudden onset. She is a type II diabetic, smokes 20 cigarettes/day and has high blood pressure. On examination, power in the left arm is O throughout although the left leg shows a power of 3 at the hip and knee and 4 at the foot. Her reflexes are reduced throughout, and sensation is absent in the arm and reduced in the leg. In the cranial nerve examination she is unable to see on her left-hand side, and the lower half of her left face is weak (she can raise her eyebrow). Tl1ere is no dysphasia. Which vascular territory is affected?
A 68-year-old woman is admitted to accident and emergency with shortness of breath and cough. She bas been a smoker for 25 years, smoking on average 20 cigarettes a day, and is a known COPD patient with home oxygen. The observations read a pulse rate of 101, blood pressure of 100/60, respiratory rate of 20, oxygen saturations of 88 per cent on air and temperature of 37.2°C. On auscultation you hear bilateral expiratory wheeze. She is prescribed nebulizers (salbutamol 5 mg+ ipratropium 500 µg) with oxygen and chest x-ray requested. Intravenous access has been established and bloods sent for analysis. From the list below, select the most appropriate next step in this patient's management plan?
A 29-year-old woman complains of a 1-week history of weakness and malaise, she bas recently become a vegetarian and eats mostly green vegetables and drinks lots of tea during the day. She is apyrexial and has a C-reactive protein (CRP) < 5. You suspect an abnormality of the patient's iron stores. What is the most appropriate investigation to determine iron store levels?
A 33-year-old woman with multiple sclerosis (MS) is having problems with painful spasms and disabling spasticity in her left leg. Which of the following medications is most likely to help?
A 27-year-old woman who works in the city as an investment banker presents with difficulty walking, and a tremor in the right hand. It has come on over the last 4 days and she is now unable to get to work safely. She denies any preceding respiratory or gastrointestinal infection or any abnormal stress at work or in her personal life; however, she says that 5 months ago she had some pain and blurring in the left eye for about 10 days, but she put that down to ''sinusitis'', kept working, and things returned to normal. Her grandfather, who died 2 years ago, bad Parkinson's disease for some time, and she is concerned that this could be the same thing. On examination, in her arms, there is normal tone, power and sensation, but there is indeed a tremor in the right hand on testing coordination, which gets worse on approaching the target, and is absent at rest. In the legs, there is normal power, but decreased light touch sensation bilaterally and a loss of vibration sense and proprioception up to the ankles. What are you most concerned is the diagnosis?
A 74-year-old man with a known history of chronic obstructive pulmonary disease (COPD) presents with a 3-day history of worsening shortness of breath, wheeze, non-purulent cough and fever. He appears unwell and the following blood results were obtained: WCC 13.8 x 109/L, CRP 39.2 mg/L, PO2 49 mmHg, PCO2 33.2 mmHg, SaO2 95 per cent. The most appropriate treatment is:
A 60-year-old man presents with a history of recurrent dizzy spells for the past 4 months, which occur daily. The dizzy spells last a few minutes and seem to occur if he moves his head, as a result of which he keeps bis bead as still as possible. The attacks are not associated with any deafness or tinnitus and a neurological examination is entirely normal. You favour a diagnosis of benign paroxysmal positional vertigo. Which of the following descriptions of findings on Hallpike's manoeuvre would confirm this diagnosis?
A 56-year-old man who has been recently diagnosed with sigmoid cancer and had a Hartmann 's procedure is admitted to hospital with acute-onset shortness of breath. He denies any collapse or fainting. He has a past medical history of chronic obstructive pulmonary disease, hypertension, stroke and gout. His observations include temperature 37.2°C, pulse rate 106 bpm, blood pressure 110/74 mmHg, respiratory rate 25/min and saturations 87% on room air. There is no significant finding on chest examination. An electrocardiogram (ECG) shows sinus tachyc.ardia with no ST elevation. A plain chest X-ray shows a small left pleural effusion. Which of the following is the most appropriate diagnostic investigation?
A 27-year-old woman presents to accident and emergency complaining of sudden onset shortness of breath, right-sided pleuritic chest pain and haemoptysis. She has a past medical history of three miscarriages and a deep venous thrombosis in the right leg. CTPA confirms a large pulmonary embolism. A diagnosis of anti-phospholipid syndrome is suspected and a full autoantibody screen is sent. Which of the following auto-antibodies would confirm the diagnosis if detected?
A 27-year-old woman presents to accident and emergency complaining of sudden onset shortness of breath and right-sided pleuritic chest pain. She has a past medical history of three miscarriages and a deep venous thrombosis in the right leg. On examination, pulse is 110 bpm, respiratory rate is 24 bpm, oxygen saturation is 88 per cent on room air. An arterial blood gas shows pH 7.40, P02 8.0, PC02 3.1. What is the diagnostic investigation of choice?
A 17-year-old male is brought unconscious to accident and emergency. His friends report they were at a nightclub while celebrating his birthday, they deny having any alcohol or recreational drugs. The club has strobe light effects and while these were on he suffered a seizure. The friends called an ambulance and while waiting the patient suffered another seizure shortly after the first, he was not conscious during any of the attacks. The most appropriate treatment is:
A 70-year-old woman with a history of vertebral crush fractures presents to the osteoporosis outpatient clinic. Which of the following investigations is most useful to assess the extent of her osteoporosis?
A 32-year-old man presents to the minor injuries walk-in clinic, complaining of back pain. This had started suddenly that morning after he had lifted a heavy box at home. He mentions that the pain has been shooting down his left leg and he cannot walk without the support of his friend. He has not passed urine since the onset of pain. On neurological examination of the lower limbs, tone and power cannot be assessed doe to pain but there are decreased ankle reflexes and a sacral anaesthesia. What is the most appropriate next step?