A 24-year-old man is involved in a road traffic accident and rushed to accident and emergency accompanied by his mother who was unharmed. An examination shows severe abdominal injuries, peripheral cyanosis and cold extremities. The doctor on call decides a blood transfusion is necessary. The mother thinks the patient is blood group B negative but is unsure. The most appropriate blood group to give the patient is?

A 23-year-old woman complains that her right leg has become progressively stiff and clumsy over the last couple of weeks. She is worried as she has not been able to go to work for the last 4 days. On examination, tone is increased and there is a catch at the knee. She has six beats of clonus and an upgoing plantar. Power is reduced to 3-4/5 in the right leg flexors. There is no sensory involvement and the rest of the neurological exam is normal other than a pale disc on opthalmoscopy. On further questioning, she admits that she has had two episodes of blurred vision in her right eye in the last two years. Each lasted a couple of weeks from which she fully recovered. What is the most appropriate initial treatment?

A 71-year-old right-handed male is brought in by ambulance at 17:50 having suffered a collapse. His wife came home to fmd him on the floor unable to move his right arm or leg and unable to speak. Her call to the ambulance was logged at 17:30. He has a past medical history of wellcontrolled hypertension, ischaemic heart disease and atrial fibrillation for which he is on warfarin. He had a hernia repair three months ago and his brother had a 'bleed in the brain' at the age of 67. What is the absolute contraindication to thrombolysis in this male?

A 33-year-old woman attends her six-month follow-up appointment for headache. They are migrainous in nature but whereas she used to have them every few months, over the last three months she has experienced a chronic daily headache which varies in location and can be anywhere from 3-7/10 severity. Her last migraine with aura was two months ago. She takes cocodamol qds and ibuprofen tds. What is the best medical management?

A 17-year-old girl is brought into accident and emergency with generalized tonic- clonic seizure. Her mother had found her fitting in her bedroom about 20 minutes ago. The ambulance crew handover state that her sats are 96 per cent on 15 L of oxygen and they have given her two doses of rectal diazepam but she has not stopped fitting. What is the most appropriate management?

A 72-year-old man with known epilepsy and hypertension is admitted with pneumonia. His drug history includes aspirin, phenytoin, bendroflumethiazide and amlodipine. His heart rate is 67, blood pressure 170/93, sats 96 per cent on 2 L of oxygen. Neurological examination is normal. His doctor requests blood tests including phenytoin level. What is the correct indication for this test?

A 60-year-old man presents with visual problems and dizziness. The dizziness started suddenly, he sees the room spinning around and he has noticed he keeps bumping into things on his right. His blood pressure is 159/91, heart rate 72. On examination, there is nystagmus and dysdiadochokinesia. Where is his stroke?

A 62-year-old woman with metastatic breast cancer, including bone metastases, presents to accident and emergency with sudden onset back pain and difficulty walking. An urgent MRI of the spine confirms cord compression at the level of L1-L2. What is the most appropriate initial management?

A 50-year-old woman presents to accident and emergency complaining of excessive lethargy. In addition, she mentions that she has been constipated. On examination, there are clinical features of dehydration. Blood tests have revealed a corrected calcium of 3.3 mol/L. Her chest x-ray shows bilateral streaky shadowing throughout both lung fields. She is given 3 L of saline in 24 hours after admission. The following day her blood tests are repeated and her corrected calcium level is now 3.0 mmol/L. Results of parathyroid hormone levels and thyroid function tests are still awaited. What is the most appropriate management?

A 48-year-old woman with a recent diagnosis of metastatic cancer of unknown primary, including metastasis to the sacral and thoracic spine, is currently being treated for lower back pain with regular paracetamol, diclofenac and oral morphine solution. She is receiving additional oral morphine solution rescue doses for her breakthrough pain. On review of her drug chart, she has received 60 mg of oral morphine solution over the past 24 hours. Which of the following is the most appropriate escalation for this patient's pain management?

A 60-year-old man with metastatic adenocarcinoma of the lung, who has fmished two cycles of palliative cisplatin/pemetrexed chemotherapy, presents with a 2-day history of nausea and vomiting. On examination, he is tachycardic with a blood pressure of 105/60 mmHg. Blood tests show a urea of 15 mmol/L and a creatinine of 180 IJmol/L. Results from a week earlier showed a urea of 4.0 mmol/L and a creatinine of 90 IJmol/L. All other blood tests and arterial blood gas results are within the normal range. What is the most appropriate initial management of this patient?

A 30-year-old man, who has recently returned from holiday in Africa, presents to accident and emergency with a 7-day history of fever, sweats, malaise and lethargy. Thick and thin blood films detect Plasmodium falciparum. What is the most appropriate treatment?

A 40-year-old man presents to accident and emergency having returned from a holiday to India a week ago. He has subsequently been unwell with nausea and reduced appetite. Over the past 2 days he has become jaundiced. On examination, he is apyrexial and there is a palpable liver edge. Liver function tests reveal a raised ALT, AST and bilirubin. A diagnosis of hepatitis A is suspected. What is the most appropriate treatment?

A 19-year-old medical student presents to his GP during fresher's fortnight. He is complaining of neck stiffness, headache and sensitivity to light. On examination, a non-blanching, petechial rash is observed on the trunk. What is the most appropriate immediate management?

Following a colonic resection, a 72-year-old woman becomes unwell with acute confusion, pyrexia, tachycardia and hypotension. The patient has had a difficult postoperative period, which has included an admission to ITU for the management of a chest infection. Blood cultures are sent and grow methicillin-resistant Staphylococcus aureus (MRSA). The patient is placed in isolation and barrier nursing is implemented. What is the most appropriate management of this patient?

A 28-year-old woman is rushed to accident and emergency in a confused state. Her partner reports seeing the patient vomiting and breathing very rapidly before falling ill, at which point he called the ambulance. Empty aspirin packets were found close to the patient, the partner estimates it has been approximately 45 minutes since the patient may have ingested the pills. The most appropriate first- line management would be:

A 22-year-old unconscious man is brought into accident and emergency. He was found lying alone on the street by passers-by who called the ambulance and the crew mention seeing needles on the floor. The patient's Glasgow Coma Scale is 12, he has a respiratory rate of 10 and blood pressure of 97/65 mmHg. During your examination you notice pinpoint pupils. The most appropriate treatment is:

A 26-year-old man with a past medical history of asthma presents to accident and emergency with difficulty breathing. He has a respiratory rate of 35 bpm, heart rate 120 bpm and difficulty in answering questions. On auscultation, a polyphonic wheeze is heard and Sp02 is 93 per cent. The patient is unable to perform a peak expiratory flow rate (PEFR). The most appropriate treatment is:

A 65-year-old Asian man with type 2 diabetes complains of central chest pain which he describes as severe and crushing in nature. On appearance, the patient appears anxious, sweaty and has difficulty breathing. The most appropriate first- line treatment is:

A 59-year-old obese woman underwent a coronary artery stent procedure. She is a wellcontrolled type 2 diabetic. The operation was successful. However, after 1 week during recovery, the patient complained of severe chest pain and shortness of breath. Her heart rate was 115 bpm and blood pressure 107/89 mHg. Following resuscitation of the airway, breathing and circulation, an electrocardiogram (EeG) showed sinus tachycardia and right axis deviation. The most appropriate treatment is:

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 74-year-old man with a known history of chronic obstructive pulmonary disease (eOPD) 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: wee 13.8 X 109/L, eRP 39.2 mg/L, P02 49 mmHg, Pe02 33.2 mmHg, Sa02 95 per cent. The most appropriate treatment is:

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 53-year-old woman with hypertension presents with muscle weakness and painful cramping. She admits some confusion with her new medication spironolactone after a recent dosage change, and may have taken more than the new prescribed dose. On examination, the patient appears well, an ECG shows absent p waves and widened QRS complexes. The most appropriate treatment is:

A 17 -year-old boy is rushed to accident and emergency after breathing difficulties in a restaurant. The parents report the patient feeling unwell after eating a cake containing nuts. The patient has swollen lips and tongue and an audible wheeze is heard. The most appropriate firstline treatment is:

A 51-year-old Caucasian male with poorly controlled hypertension presents to accident and emergency with confusion, nausea and vomiting. His daughter visits him weekly and called the ambulance on finding him in this state at home. Blood pressure measurement shows 200/140 mmHg. The most appropriate management is:

A 67-year-old woman suffered a fracture to her hip during a fall and undergoes a successful hip replacement. After 2 weeks, the patient complains of pain in her right leg, particularly on movement. On examination, the leg is swollen below the knee, erythematous and tender on palpation. The most appropriate management is:

A 17-year-old boy suffered a generalized seizure at school and is brought to accident and emergency by ambulance. His teachers report he was well during the day but has suffered from repetitive ear infections and despite taking antibiotics during the week still suffered from headaches and ear discharge. On examination, he appears well but complains of headache, his temperature is 39°C and he is neurologically intact. ACT scan confirms a cerebral abscess and rapid culture tests confirm streptococcal infection. The most appropriate management is:

You are told that a patient has been admitted to accident and emergency with jaundice and right upper quadrant pain. What levels of plasma bilirubin would this patient have in order for jaundice to be clinically visible:

A 64-year-old man suffers an anterior myocardial infarction. A few hours later, his pulse rate is noted to be 46/minute and his blood pressure 94/59 mm Hg. He is short of breath and has slight central chest pain. The monitor showed sinus bradycardia. What would be your choice of management?

A 41-year-old woman with type 2 diabetes attends a hypertension clinic. She has been doing well on metformin and has maintained good glycaemic control alongside dietary changes and regular physical exercise. She has been meeting her HbA1c targets consistently. However, her blood pressure has been poorly controlled despite lifestyle changes and is currently 157/97 mmHg. The most appropriate first- line therapy is:

A 34-year-old diabetic woman attends your hypertension clinic to discuss her blood pressure control. She is currently following lifestyle advice and has started to lose weight and maintain good glycaemic control. Her blood pressure was 155/93 mmHg at her last clinic appointment and is now 150/90 mmHg. She informs you she has recently become pregnant, which was planned, and intends to keep the baby. The most appropriate first-line therapy is:

A 69-year-old man, who is recovering from an emergency laparotomy for a ruptured duodenal ulcer, develops profuse offensive diarrhoea. His postoperative course has been complicated by chest infections and he has just been stepped down onto the main wards from the intensive care unit. Stool cultures have revealed C. Difficile toxin. What is the most appropriate treatment?

A 66-year-old man presents to accident and emergency in a confused state accompanied by his wife. She states that the patient has become increasingly obtunded in the last 3 days and has not opened his bowels for the same period of time. She mentions he has been suffering from multiple myeloma, but is otherwise healthy. On examination, the patient has brisk tendon reflexes, dry mucosal membranes, reduced skin turgor and the eyes appear sunken. The most appropriate management is:

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 60-year-old man presents to accident and emergency with sudden onset pain in the right metatarsophalangeal joint. He is unable to walk without a stick. On further questioning, the patient reports experiencing two similar episodes in the past. Blood tests reveal a raised urate. What is the most appropriate treatment?

A previously fit and well 70-year-old woman has been admitted due to a fractured neck of femur, and she has recently returned to the ward after a cemented hemiarthroplasty. You are bleeped to the ward to see her, as it is noted that she has had only 30 ml urine output in the last 3 hours. She is asleep on the ward, with a patient-controlled analgesic device in situ. Her airway is intact and her respiratory rate is 12/min with normal saturations and good air entry bilaterally. Her pulse is 125 bpm with a blood pressure of 95/68 mmHg and she has delayed capillary refill. She has pale conjunctiva and a temperature of 37.3°C. She has a 12-hourly bag of normal saline running. Her catheter is draining concentrated urine. An abdominal examination is normal. Which of the following interventions would you try first to increase the urine output?

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 70-year-old man presents to the emergency department with a cough productive of bloodstained green sputum and shortness of breath. A chest X-ray demonstrates a suspicious lesion in the right lower zone associated with consolidation. On further questioning, he admits to recent weight loss and back pain. Blood tests show: Na+ 137 mmoi!L, Corrected Ca2+ 3.0 mmoi!L, K+ 3.8 mmoi!L, P04 0.33 mmoi!L, Urea 14.5 mmoi!L, Creatinine 160 f.1moi/L, Alk Phos 450 mmoi!L. Which of the following is NOT appropriate in the management of this patient?

A 28-year-old woman with a past medical history of asthma has been using her inhaled salbutamol more frequently of late. She is currently on an inhaled short-acting beta-2 agonist and an inhaled steroid 800 flg/day. She has been compliant. What should you do?

An 87-year-old man with a background of Alzheimer's disease, a previous stroke, and atrial fibrillation (for which he is on warfarin), is admitted with increasing amounts of painless haematuria. He is catheterised and the warfarin stopped. The haematuria reduces and then seems to stop. Problems with his residential home are delaying discharge. You note 2 days later that his creatinine level has risen to 250 J.tmoUL. When you go to see him, he seems stable, as do his observations. He does seem slightly dry with reduced skin turgor and delayed capillary refill. The urine output has not been carefully documented in the last few days, and by your calculations, 100 ml have been passed in the last 24 hours. On examination he appears to have a mass in his central lower abdomen. What should be your next step?

A 79 year-old-man known to have chronic congestive heart failure is readmitted with worsening heart failure. His furosemide (frusemide) dosage is increased to 200 mglday to aid the relief of his symptoms. His other medications are bendrofluazide, ramipril and bisoprolol. Which of the following effects can be encountered?

A 25-year-old primigravida who is 26 weeks' pregnant, presents to the casualty department with symptoms of headache, flashing lights and vomiting. Her blood pressure was recorded at 140/100 mmHg and her antenatal diary showed consistent systolic readings of 110- 120 mmHg and consistent diastolic readings of less than 80 mmHg. She has a history of mild asthma but was otherwise in good health prior to pregnancy, and there is no family history of note. Which of the following would be the drug of first choice?

A 60-year-old man with NYHA (New York Heart Association) class II heart failure, is taking angiotensin-converting enzyme (ACE) inhibitors and 6-blockers for his heart failure. He is generally well in himself. On direct questioning at his routine outpatient visit, it is noticed that his exercise tolerance has decreased over the last year. Which of the following drugs should be added to his list of medications?

A 68-year-old man is admitted with syncope. He is known to have ischaemic cardiomyopathy. His medications include: aspirin 75 mg od, frusemide 80 mg bd and lisinopri110 mg od. An initial ECG shows sinus bradycardia (50 bpm) and RBBB. Results of blood tests are as follows: sodium, 134 mmol/1; potassium, 3.5 mmol/1; creatinine 124 mmol/1. He has recurrent syncopal episodes on the CCU, where monitoring shows episodes of non-sustained torsades de pointes (polymorphic VT). Which of the following would be your initial line of treatment?

A 72-year-old diabetic man is admitted to AE with a 40 minute history of central, crushing chest pain. The pain eases after an hour with bedrest, oxygen and morphine. ECG shows mild anterior ST flattening. The troponin T level is slightly raised. What would be the optimal management of the underlying cause of his chest pain be besides usual medical measures?

A 64-year-old man with Wolff-Parkinson-White syndrome presents with uneasiness and palpitations. The ECG shows fine oscillations of the baseline and no clear P waves. The QRS rhythm is rapid and irregular. The ventricular rate is 120 beats per minute. His blood pressure is 90/60 mmHg. Which of the following interventions would be most appropriate in this case?

A 19-year-old patient with Wolff-Parkinson-White syndrome presents to the emergency department with a two-hour history of rapid palpitations. The heart rate is 180 beats/min (bpm). Blood pressure is 130/80 mmHg. The electrocardiogram (ECG) shows a regular broad complex tachycardia. What is the best treatment for the tachycardia?

A 41-year-old man with a family history of sudden death presents to casualty with a second episode of collapse. On this occasion he is referred to the Cardiology Department for review. Echocardiography reveals asymmetrical septal hypertrophy, abnormal systolic motion of the anterior mitral valve leaflet and narrowing of the left ventricular outflow tract. The 24-h electrocardiogram (ECG) monitoring as an outpatient reveals several periods of non-sustained ventricular tachycardia. Which of the following would be most appropriate for the management of his arrhythmia?

A 70-year-old lady with a history of asthma presents with shortness of breath for some days. She is also treated with ramipril10mg daily. On examination her blood pressure is 135/85 mmHg, pulse is 100/min (atrial fibrillation). She is not in cardiac failure. Examination of the respiratory system reveals wheeze consistent with asthma. Results; Hb 13.2 gldl, WCC 6.1 x10911, PLT 240 x1091l, Na+ 138 mmol/1, K+ 4.7 mmol/1, Creatinine 125 JliDOVI. CXR Cardiomegaly consistent with longstanding hypertensive heart disease. Which of the following is the most appropriate treatment for her atrial fibrillation?