LOL2

A 62-year-old man is admitted to the emergency department with abdominal pain. The patient has a past history of ischaemic heart disease and atrial fibrillation. Computed tomography scan features are highly suggestive of ischaemic bowel. The patient's blood gases are as follows: pH = 7.25, paO2 = 10, paCO2 = 2.8, HCO3 = 18, Base excess = –8. Which of the following best describes the patient's acid–base status?

You review a 33-year-old Afro-Caribbean woman in the minors bay of the emergency department. She describes a 4-day history of a sore throat (being worse on the right side) and pain on swallowing. Today, she is unable to even swallow her own saliva. She feels unwell and describes ‘ache’ in all her muscles and joints. On examination she is febrile (37.9°C), pulse rate is 100 beats/min, blood pressure is 144/90 mmHg and respiratory rate is 12 breaths/min. She is reluctant to open her mouth due to pain. Examination of the oropharynx reveals asymmetric tonsillar enlargement (right more than left) with marked tonsillar exudate. The uvula is deviated to the left. She has bilateral cervical lymphadenopathy. Which one of the following is the most appropriate management?

You see an 11-year-old boy in the emergency department who is admitted with an acute onset of abdominal pain, nausea and vomiting. There is diffuse pain around the central abdomen and right iliac fossa and is continuous in nature. On examination, the patient is febrile and there is marked tenderness and rebound in the right iliac fossa. The patient’s mother tells you that he has recently had a sore throat. You suspect mesenteric adenitis and request an ultrasound scan which is inconclusive. What is the best next step to take in managing this patient?

A 9-year-old boy is brought to the hospital by his father because he noticed that his right eye was ‘red, bulging and not moving very well’. The boy describes a headache and pain on moving his right eye. He has had multiple previous attacks of sinusitis. On examination, his temperature is 39.0°C, blood pressure 100/60 mmHg, pulse 94 beats/min, and respiratory rate 20 breaths/min. Physical assessment reveals proptosis and ophthalmoplegia of the right eye with pain to gentle palpation. The sinuses are tender, his eyelids are erythematous and the conjunctiva is markedly injected, but visual acuity is intact bilaterally. A purulent nasal discharge is additionally noted by the examining clinician. What is the most appropriate next step?

A 45-year-old woman with unexpected weight loss, loss of appetite and shortness of breath presents to you in clinic. On examination, there is reduced air entry and dullness to percussion in the right lung. A pleural tap is performed and the aspirate samples sent for analysis. You are told that the results reveal a protein content of>30 g/L. From the list below, select the most likely diagnosis:

You see a 54-year-old woman, referred to accident and emergency through her GP, with a week's history of jaundice and right upper quadrant abdominal pain. Associated symptoms include dark urine and pale stools. There is no history of weight loss and the patient does not consume alcohol. Her liver function tests reveal a bilirubin of 40 μmol/L, ALT of 40 iu/L, AST 50 iu/L and ALP of 350 iu/L. The most likely diagnosis is:

A 32-year-old builder presents in accident and emergency in a distressed state. He reports suffering from chest pain for the last 2 weeks, the pain is sharp and only occurs when he moves heavy objects. He has a family history of cardiovascular disease and is worried about a heart attack. His blood gas findings are as follows: pH= 7.47; PC02 = 3.3; P02 = 15.3; bicarbonate=
17.53. The most likely diagnosis is:

A 30-year-old man presents to his GP with a 1-week history of painful, swollen knees and a painful right heel. Further history reveals that he has been experiencing burning pains while urinating for the past 2 weeks and that his eyes have become red and itchy. What is the most
likely diagnosis?

A 55-year-old man complains of a 4-week history of general malaise and fatigue, he has also noticed his trousers have become more loose fitting. A blood test shows the following results: Haemoglobin 12 g/dL, MCV 90 fL, Platelet count 250 x 109/L, WBC 10 x 109/L, Serum iron 10 μmoVL, Total iron-binding capacity 40 μmoVL, Serum ferritin 160 μg/L. The most likely diagnosis is:

A 52-year-old woman presents complaining of a two-month history of increasing fatigue and numbness in both of her arms and legs. She lives at home with her husband and has found it difficult coping with the daily activities of living. She suffers from hypothyroidism which is well controlled with thyroid replacement medication. A peripheral blood smear shows hypersegmented neutrophils. A blood test reveals the following: Haemoglobin 10 g/dL, Mean corpuscular volume 110 fL, Platelets 150 x 109/L. Liver function tests: ALT 25 IU/L, AST 27 IU/L, GGT 22 IU/L, ALP 100 IU/L, Urea 5 mmol/L, Creatinine 100 μmol/L. The most likely diagnosis is:

A 47-year-old woman presents to clinic concerned about her recent ill health. She has noticed over the last three months that she has been suffering from headaches, fatigue and recurrent infections. She notes she has rarely been to the doctor before and otherwise leads a healthy lifestyle. She decided to see a doctor when she noticed petechial rashes appearing on her arms. On examination there is no organomegaly and blood tests reveal an MCV of 105, a pancytopenia
with the bone marrow appearing hypocellular on biopsy.

A 51-year-old man presents to accident and emergency with a lesion on his forearm. He mentions that he has spent the past three months travelling around South Americ.a and only returned home 3 days ago. While his lesion has been present for a few weeks he was reluctant to
see a doctor in South America. On examination, there is a 3 x 3 cm erythematous ulcer on the
left forearm with a raised edge. What is the most likely diagnosis?

A 42-year-old man presents to accident and emergency with a 1-day history of headache and fevers. He presents with his partner who says he has been becoming increasingly confused and disorientated. On examination, his temperature is 38.5° C. On cranial nerve examination there is a right-sided superior quadrantanopia. An urgent CT scan of the head is organized which shows multiple ring enhancing lesions. What is the most likely diagnosis?

You are asked to review an electrocardiogram (ECG) in the emergency department. Helpfully, a summary of details is printed at the top as follows: rate 88/min, regular rhythm, axis -20° , PR duration 0.26 seconds (constant), QRS complex 0.08 seconds, QT interval 0.2 seconds. You note that P-waves are only present before each QRS and that the rhythm is regular. Which of the following would be the best summary?

To establish the aetiology of pulmonary hypertension, a cardiac catheter study was performed. The wedge pressure was normal and the mean mitral valve diastolic pressure gradient was > 3 mmHg at rest, both of which increased with exercise. From this data, what is the probable diagnosis?

A 54-year-old man with a history of smoking and hypertension presents to the Emergency room with central crushing chest pain, nausea and sweating. On examination his BP is 104/70 mmHg, his pulse 85/min regular and he looks pale, grey and sweaty. There are no murmurs on auscultation but he has crackles at both lung bases consistent with heart failure. Investigations; Hb 12.8 g/dl, WCC 5.9 x109/l, PLT 190 x109/l, Na+ 141 mmol/1, K+ 5.0 mmol/1, Creatinine 110 μmol/1, ECG ST elevation Vl-V 4, ST depression II, III and a VL. Which of the following is the most likely finding on angiography?

A 29-year-old woman complains of a 1-week history of weakness and malaise, she has 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 59-year-old man, who has completed five cycles of chemotherapy for metastatic colorectal carcinoma, presents to accident and emergency complaining of feeling generally unwell. On examination, he is pyrexial at 38.9°C and there are crepitations in the right lung base. What is the most urgent investigation?

A 49-year-old man presents with right upper quadrant abdominal pain that began 8 hours ago. The pain is constant and is associated with nausea, vomiting, and fever. Over the past few months, he has had intermittent episodes of similar pain, but those were less intense, resolved spontaneously within 1 or 2 hours, and were never associated with vomiting or fever. Results of
physical examination are as follows: temperature, 101.3° F (38.5° C); blood pressu.re, 130/90 mm
Hg; pulse, 90 beats/min; and respirations, 16breaths/min. The patient looks tired and
moderately uncomfortable. Bowel sounds are present, but he has right upper quadrant
tenderness. There is no palpable liver or gallbladder. Laboratory results are remarkable for a
white blood cell count of 14,000, with a left shift. Bilirubin, amylase, and alkaline phosphatase
levels are normal. Which of the following is the best diagnostic imaging test for this patient?