A 71-year-old lady with a history of one previous myocardial infarction presents to the Emergency department. She has sudden onset shortness of breath and palpitations which happened after her dinner a couple of hours earlier. A previous ECG from clinic a month earlier shows sinus rhythm. Medication includes ramipril10mg daily, amlodipine 10mg daily and aspirin 75mg. On examination her blood pressure is 100/60 mmHg, pulse is 140/min irregular and she has evidence of L VF. Bloods : Hb 14.0 gldl, WCC 6.7 x10911, PL T 190 x10911, Na+ 140 mmol/1, K+ 5.0 mmol/1, Creatinine 130 fJmol/1. ECG Fast atrial fibrillation, lateral ST depression. Which of the following is the most appropriate medication to control her AF?

A 58-year-old man with a history of hypertension managed with ramipril 10mg daily and 40 pack years of cigarette smoking presents to the Emergency department after a collapse at work. Neurological examination reveals a left sided hemiplegia. Investigations; Hb 13.8 gldl, WCC 5.4 x109!1, PLT 192 x10911, Na+ 139 mmol/1, K+ 4.9 mmol/1, Creatinine 149 J.lmol/1. CT head -No intra-cerebral haemorrhage identified. What is the time limit after presentation during within which thrombolysis should be administered?

A 62-year-old man with two previous myocardial infarctions and a history of L VF controlled with ramipril and furosemide presents to his GP with palpitations. On examination his BP is 120172 mmHg, pulse 85/min AF, with bibasal crackles consistent with heart failure. Investigations; Hb 12.1 gldl , WCC 5.4 x10911, PLT 234 x10911, Na+ 140 mmol/1, K+ 5.0 mmoVI, Creatinine 130 J.Lmol/1. ECG- Anterior Q waves, atrial fibrillation, rate 82 BPM. ECHO - Dilated left atrium and left ventricle. Which of the following would be the most appropriate agent to control his AF?

A 50-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 be 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 125177 mmHg, his pulse is 140/min, irregular. He is not in cardiac failure. Investigations; Hb 13.1 gldl, WCC 4.9 x10911, PLT 210 x10911, Na+ 139 mmol/1, K+ 4.7 mmol/1, Creatinine 120 J.LmoVI, 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 32-year-old woman is admitted in an unconscious state after an overdose of a large number of amitriptyline tablets. It is thought that she took them between 7 and 8pm and was not found by her partner until he returned from a bar some 3hrs later. When you get to see her she has already been intubated by the Emergency department consultant. Her BP is 100170 mmHg and she has a sinus tachycardia of 100 BPM. While you are watching the monitor you can see she is suffering from short unsustained runs of ventricular tachycardia. Investigations; pH 7.29, p02 = 8.1 kPa, pC02 = 4.9 kPa, HC03-= 13 mmol/l. Which of the following is the most appropriate way to initially manage the short runs of VT?

A 37-year-old male with Wolff-Parkinson-White syndrome develops a broad-complex irregular tachycardia at a rate of 200 beats per minute. He appears comfortable and has little hemodynamic impairment. Useful treatment at this point might include?

A 79-year-old woman is admitted to the coronary care unit (CCU) with unstable angina. She is started on appropriate medication to reduce her cardiac risk. She is hypertensive, fasting glucose is normal and cholesterol is 5.2. She is found to be in atrial fibriJiation. What is the most appropriate treatment?

A 49-year-old man is rushed to accident and emergency complaining of a 20-minute history of severe, crushing chest pain. After giving the patient glyceryl trinitrate (GTN) spray, he is able to tell you he suffers from hypertension and type 2 diabetes and is allergic to aspirin. The most appropriate management is:

A 21-year-old man is on his way home from a party when he experiences the sudden onset of rapid palpitations. He feels uncomfortable but not short of breath and has no chest pain. He goes to the nearest accident and emergency department, where he is found to have a supraventricular tachycardia (SVT) at a rate of 170/minute. Carotid sinus massage produced transient reversion to sinus rhythm, after which the tachycardia resumed. What would be the next step in your management?

A previously fit 19-year-old man presents with unusual shortness of breath on exertion. At times, this is also associated with central chest pain. On examination there is a loud mid-systolic murmur at the left sternal edge. Heart rate and blood pressure are normal and there is no oedema. The ECG shows left axis deviation and the voltage criteria for left ventricular hypertrophy and the echocardiogram reveals a significant thickened interventricular septum, with delayed ventricular filling during diastole. There is a family history of sudden death below the age of 50. Which of the following would be your initial therapy?

A 58-year-old man has made an excellent functional recovery after an anterior MI. He is entirely asymptomatic and there is no abnormality on physical examination. His blood pressure is 134178 mmHg and he is undertaking a cardiac rehabilitation programme. Which of the following would you not recommend as part of his secondary prevention planning?

A 69-year-old woman complains of intermittent palpitations, lasting several hours, which then stop spontaneously. She also suffers from asthma. Holter monitoring confirms paroxysmal atrial fibrillation. Which of the following statements is correct regarding the management of this patient?

A 57-year-old man is reviewed in a hypertension clinic, where it is found that his blood pressure is 165/105 mmHg despite standard doses of amlodipine, perindopril, doxazosin and bendroflumethiazide. Electrolytes and physical examination have been, and remain, normal. Which of the following would be your next stage in his management?

A 68-year-old woman has presented with acute onset shortness of breath 24 hours after a long haul flight. Her blood results show a raised D-dimer level and the arterial blood gas shows a P02 of 8.3 kPa and PC02 of 5.4 kPa. Your consultant suspects a pulmonary embolism and the patient needs to be started on treatment while aCT-PAis awaited. From the list below, please select the most appropriate treatment regime?

A 55-year-old man, who has never smoked and with no past medical history, has been diagnosed with right basal community-acquired pneumonia. There are minimal changes on his chest x-ray and bloods reveal a neutrophil count of 8.2 and a C-reactive protein (CRP) of 15. He has no drug allergies. Although he has a productive cough of green sputum, his respiratory rate is 16, oxygen saturations are 97 per cent on room air and his temperature is 37.4°C. You are asked to place him on treatment. Which of the following treatment options would be appropriate for this patient?

A 68-year-old woman is admitted to accident and emergency with shortness of breath and cough. She has 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 f.lg) 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 58-year-old man with known COPD, diagnosed eight months ago, attends your clinic with persistent shortness of breath despite stopping smoking and using his salbutamol inhaler (given to him at the time of diagnosis), which he finds he is using more frequently. You assess the patient's lung function tests that have been recorded just before he saw you in clinic on this occasion. His FEV1 = 65 per cent of the predicted value. Oxygen saturations are 95 per cent on room air, respiratory rate in 18, and his temperature is 37.1°C. From the list below, select the next most appropriate step in this patient's management?

Your clinic patient has been diagnosed with pulmonary tuberculosis (TB) following a threemonth history of haemoptysis and fever. The patient is due to start on treatment and you are asked by your registrar which of the following regimes is the most suitable. The patient has no known drug allergies and, in addition, liver function tests and urea and electrolytes results are all within normal ranges. From the list below, which of the following answers is the most appropriate and recommended treatment regimen for this patient?

You see a 76-year-old woman in accident and emergency who has been admitted with a 1-day history of shortness of breath and pyrexia (38.4°C). The patient's past medical history includes hypertension, stroke and insulin-dependent diabetes. She has no known drug allergies. The nursing staff report that the patient vomited after her lunchtime meal yesterday. On examination the patient's respiratory rate is 26, oxygen saturations 93 per cent on room air. On auscultation of the chest, you hear right basal crackles. You suspect that this patient is suffering from aspiration pneumonia. From the list below, which is the most appropriate antibiotic regimen for this patient?

A 55-year-old woman is referred by her GP for upper gastrointestinal (GI) endoscopy following a four-month history of epigastric pain despite treatment with antacids and proton pump inhibitors (PPis). The results demonstrate a duodenal ulcer coupled with a positive campylobacter-like organism (CLO) test. The patient has n

A 35-year-old woman presents with a 24-hour history of watery diarrhoea. She has opened her bowels nine times since the onset of her symptoms. You diagnose gastroenteritis after learning that the patient and her family all ate at a new restaurant and the rest of her family have had similar problems. The most appropriate management is:

You see a 19-year-old Caucasian man in your clinic who presents with a history of transient jaundice. On direct questioning, you ascertain that the jaundice is noticeable after periods of increased physical activity and subsides after a few days. The patient has no other symptoms and physical examination is unremarkable. Full blood count is normal (with a normal reticulocyte count) and liver function tests reveal a bilirubin of 37 JJmoVL. The most appropriate management is

During your on-call, you are bleeped to see an 80-year-old woman on the ward who has not opened her bowels for the last 4 days. She is not known to have a history of constipation. On examination, her observations are within normal range, the abdomen is soft and there is mild discomfort at the left iliac fossa. Bowel sounds are present and on PR examination, the rectum is empty. You consult your registrar who asks you to prescribe an osmotic laxative. What is the most appropriate treatment?

A 60-year-old man with alcoholic liver disease was admitted with an upper GI bleed secondary to oesophageal varices. The patient undergoes endoscopic variceal banding and is discharged after 2 weeks in-hospital stay. Which of the following medications would act as prophylaxis in preventing are bleed from his oesophageal varices?

You see a 56-year-old woman who presents with a two-month history of jaundice. Associated symptoms include lethargy and polyarthralgia. Her LFTs reveal a bilirubin of 46 iu!L, AST 200, ALT 175, ALP 104. On examination, the patient is jaundiced and has finger clubbing. There are several spider naevi on the front and back of the trunk. Her abdomen is soft and there is a smooth hepatomegaly. Prior to her onset of symptoms, the patient has been fit and well. Viral serology is normal and anti-soluble liver antigen (SLA) is detected. You decide to start this patient on treatment. The most appropriate treatment is

You are asked to see a 29-year-old woman diagnosed with ulcerative colitis 18 months ago. Over the last 4 days she has been experiencing slight abdominal cramps, opening her bowels approximately 4-5 times a day and has been passing small amounts of blood per rectum. The patient is alert and orientated and on examination her pulse is 67, blood pressure 127170, temperature 37.3°C and her abdomen is soft with mild central tenderness. PR examination is nil of note. Blood tests reveal haemoglobin of 13.5 gldL and a CRP of 9 mg!L. The most appropriate management plan for this patient is:

A 65-year-old man attends your clinic with a three-month history of weight loss of approximately 9 kg despite a normal appetite. A full blood count reveals that his haemoglobin is 9.0 gldL (previous haemoglobin was 13.5 gldL one year ago) and the MCV is 71 fL. Abdominal examination is unremarkable and per rectum exam is nil of note. The patient states that he has normal bowel habits and has been feeling quite tired lately. The most appropriate management is:

A 58-year-old African man presents with pitting oedema of his ankles. He suffers from recently diagnosed hypertension, but is otherwise healthy. Blood results show low albumin and a urine dipstick is positive for protein. The most appropriate initial treatment is:

A 28-year-old woman patient who is 13 weeks pregnant presents for an antenatal clinic appointment. The patient feels embarrassed when asked to provide a urine sample and produces enough for a urine dipstick test only which is positive for leukocytes and nitrites. The patient denies any symptoms. The most appropriate treatment is:

A 55-year-old woman is seen in clinic, she has a ten-year history of type 2 diabetes treated with glibenclamide. Her blood pressure is 148/93 with new onset proteinuria, her serum results show elevated lipid levels, glycated haemoglobin of 5.5 per cent and fasting glucose of 6.0 mmoVL. A renal biopsy shows the presence of Kimmelstiel-Wilson lesions. The most appropriate management is:

A 21-year-old man presents with lethargy over the last week, he has periorbital oedema and proteinuria. The patient mentions he has been to hospital a number of times in the past due to the same symptoms as well as mild eczema. Light microscopy of a renal biopsy showed normal morphology. Electron microscopy of the renal biopsy reveals the diffuse effacement of the epithelial podocytes. The most appropriate treatment is:

A 65-year-old woman complains of panic attacks. She has recently retired as a school teacher, but 2-3 times a week she suffers extreme anxiety, becomes short of breath and sweats excessively. Elevated catecholamines are detected in the urine. The most appropriate medical treatment is:

A 50-year-old Asian man is referred to the diabetes clinic after presenting with polyuria and polydipsia. He has a BMI of 30, a blood pressure measurement of 137/88 and a fasting plasma glucose of 7.7 mmoVL. The most appropriate first-line treatment is:

A 41-year-old man has been recently diagnosed with type 2 diabetes and has been following a plan of lifestyle measures to improve his diet and increase his level of exercise. On returning to clinic, his BMI is 23, fasting plasma glucose 9.0 mmoVL, blood pressure 133/84 mmHg and HbA1c of7.1 per cent. The most appropriate treatment option is:

A 19-year-old woman presents with concerns about changes to her facial appearance, in particular her nose and jaw seem quite large, she is also quite sweaty and despite using antiperspirants is finding it difficult to control and is afraid of embarrassment at university. A glucose tolerance test is performed and found to be raised. The most appropriate management would be:

A 40-year-old woman presents to the rheumatology outpatient clinic with a three- month history of stiff hands and wrists. She mentions that the pain is particularly bad first thing in the morning. On examination, the wrists, metacarpophalangeal joints and proximal interphalangeal joints are swollen and warm. A diagnosis of rheumatoid arthritis is suspected. Blood tests for rheumatoid factor return as positive. What is the most appropriate management?

A 76-year-old man presents to accident and emergency with pain in his knees. It is worse in the right knee. He describes the pain as being worse in the evening and after exertion. On examination, bony nodules are palpable on the distal interphalangeal joints of both his hands. The right knee is swollen and there is a reduced range of active movement. X-rays show reduction in the joint space, subchondral sclerosis and osteophyte formation. What is the most appropriate treatment?

A 23-year-old man presents to the rheumatology clinic with lower back and hip pain. These have been occurring every day for the past two months. Pain and stiffness are worse in the mornings. He also mentions that his right heel bas been hurting. He is previously fit and well, but had occasions of lower back pain when he was a teenager. His symptoms have stopped him from playing tennis. Recent blood tests organized by his GP have shown a raised C-reactive protein (CRP) and erythrocyte sedimentation rate (ESR). What is the most appropriate treatment?

A 24-year-old woman presents to her GP complaining of cold hands and feet. This has been ongoing for the past three months and is especially bad when she goes out in the mornings and may last for hours. On further questioning, she mentions that her hands sometimes turn blue or red and that gloves are unhelpful. She has otherwise been feeling well and has no past medical history. What is the most appropriate treatment?

A 59-year-old man presents to his GP with sudden onset severe pain, tenderness and swelling of the first metatarsophalangeal joint. He is known to suffer from acute gout and has had several previous similar episodes. What is the most appropriate treatment?

A 70-year-old woman complains of tiredness, fatigue and weight loss. Blood tests reveal an elevated WCC and on examination splenomegaly is palpated. Cytogenetics are positive for the Philadelphia chromosome and the patient is diagnosed with chronic myeloid leukaemia. The most appropriate treatment is:

A 50-year-old woman with T2N2Ml squamous cell carcinoma of the tongue has been electively admitted for her third cycle of palliative cisplatin/5-fluorouracil chemotherapy. She has known metastasis to the T3 vertebrae and the ribs. Since her last cycle of chemotherapy she has been very lethargic and constipated. Upon checking her bloods you discover that her corrected calcium levels are 2.95 mmol/L. The most appropriate treatment is:

A 22-year-old man with testicular cancer has undergone an inguinal orchidectomy. Histology has confirmed teratoma. A preoperative CT staging scan has shown involvement of the paraaortic lymph nodes. Which of the following treatments is the best post-operative option?

A 51-year-old man with a recent diagnosis of pancreatic carcinoma with metastases to the liver and omentum is about to commence gemcitabine chemotherapy. Prior to his first cycle he mentions that he is getting increasing severe abdominal pains. He is currently taking paracetemol for this, which eases the pain but is now becoming less effective. The most appropriate analgesia for this patient is:

A 57-year-old man with metastatic adenocarcinoma of the lung is attending for cycle three of his palliative pemetrexed/cisplatin chemotherapy. During his cisplatin infusion, he noticed his arm becoming painful, swollen and red at the cannula site. The most likely cause of this is:

A 55-year-old woman with metastatic pancreatic cancer attends the oncology clinic prior to her second cycle of chemotherapy. She tolerated her first cycle well, but her husband mentions that there have been occasions where she has been confused. Her urea and electrolytes on this occasion reveal a serum sodium of 116 mmol!L. All other results were within the normal range. The chemotherapy is delayed and a urine specimen is sent off. This confirms a diagnosis of syndrome of inappropriate ADH (SIADH). The most appropriate treatment is:

A 56-year-old man, diagnosed with psoriasis three years ago, presents to your clinic with pruritus. His symptoms are not improving despite being prescribed conventional therapy. On examination, you note the presence of erythematous scaly plaques on the extensor surfaces of the knee and elbows. There is no evidence of flexural involvement. The most appropriate treatment is:

A 68-year-old man is diagnosed with right forearm cellulitis. You are asked to start the patient on treatment and he has no known drug allergies. Which one of the following antibiotics would be the most appropriate choice in this scenario?

A 56-year-old man presents with two lesions on his neck which have been increasing in size over the last three months. On examination you notice two firm brown-coloured nodular lesions on the anterior aspect of the neck. The nodules give an ' apple-jelly' appearance on diascopy. The patient is systemically well. The most appropriate treatment is:

An 18-year-old man presents to you with an itchy scalp which has been present for 2 weeks following a visit at the barber shop. On examination, you notice a 3 x 3 em oval area of patchy hair loss in the crown area of the scalp with a ring of erythema. You suspect that the patient has a dermatophytic infection. Which one of the following options would be the most appropriate in treating this condition?