Organised past papers – GP

General health / palliative care / pain

- Drinking half a bottle of wine every night for years, same as friends à offer/give
advice to stop or reduce alcohol intake vs. refer to rehab counselling
o ~3.5 units per day = 24.5units/week —> recommeded for men less than
21units/week with 2 days off. Plan (from Oxford p. 161 figure 7.7):
§ - if unwilling to change: record advise given to reduce alcohol, give
patient an advice leaflet, recored advice to cut down whenever the pt
is seen in the surgery
§ - if willing to change: Dependent vs non-dependent:
• A- dependent: provide advise, refer to the community alcohol
team, Consider detoxification
• B- non-dependent: provide advise, suggest the pt keeps diary
of alcohol consumption, agree targets & follow up
- 30 y/o Macrocyctic anaemia with raised GGT- Alcohol à GI??
o causes of macrocytic anaemia e.g. folate/B12 vit deficiencies (Megaloblastic),
Alcohol, increased reticulocytes production (?e.g. in heamolytic
disease/bleeding)
o since GGT is elevated (i.e. liver dysfunction) = alcohol is the cause in this case
-
- Recurrent episodes of pancreatitis- alcohol history à GI??
o alcohol and gall stones are the commenest causes of pancreatitis
- Neurological issues from alcohol- vitamin B1
o advice to stop or reduce alcohol intake vs. refer to rehab counselling alcohol
causes thiamine deficiency which can lead to Wernicke’s
encephalopathy/Korsakoff psychosis (“neuro issues”). Another name for
thiamine = vitamin B1
- Patient on Paracetamol, NSAIDs and Tramadol and is still in pain. What would you
give next? Morphine Sulphate or Amitriptyline; MORPHINE (GOING UP TO STEP 3); IF
STILL IN PAIN, ADD AMITRIPTYLINE – pain
o weak opioid —> next step is a stronger opioid (from palliative care lecture) =
morphine sulphate/oxycodone/hydromorphone/fentanyl
o Amitryptyline is considered an adjuvant analgesia
- Obese man tired all the time, no matter how much sleep he gets, recently fell asleep
while driving, wife says he snores very loudly (all can be associated with obstructive
sleep apnae (OSA)) and has to sleep in other room sometimes. BMI 30, BP 150/95??
(hypertensive anyways) – best next step – options: lifestyle advice (lose weight, salt
restriction), refer for polysonography, start Ramipril – CVR
o From ENT: Tx:
§ - Adult OSA: lifestyle changes (e.g. reduce wt, stop smoking, stop
alcohol, avoid sedatives) // Mandibular advancement device // CPAP
// Surgery in some cases
§ - Paeds OSA: most common cause is adenotonsilar hypertrophy Tx =
surgery. // other causes: obesity (Tx ?lifestyle changes) // genetics
(e.g. down’s syndrom)
- Woman with breast cancer mets in thoracic spine confirmed on imaging. Current
management between palliative care and GP. Highest oral analgesia not adequate,
clearly distressed with the pain. What to do next – options: refer to
physio/psychologist/chemo/radiation/neurosurgeon – MSK/palliative
o initial thoughts: refer to pain management/palliative care
o ?from the options: ?psychological cause of reduced pain tolerance
o ?Refer to palliative radiotherapy
§ Oxford p.1015 bone pain palliative care:
• Consider referral for palliative radiotherapy, strontium Tx
(prostate cancer) or IV bisphosphonates (reduce pain in
myeloma, breast and prostate cancer)
- Obese women with mild osteoarthritis, doesn’t want to discuss weight loss- Come
back when ready to discuss – MSK
o ?incorrect ans.
§ Oxford p. 486/487:
§ osteoarthritis Tx:
• - MDT
• - Reduce load on joint: by wt. ANOTHER OPTION is using
walking stick in the opposite hand to the affected hip &
cushioned insoles/shoes
• - exercise & improving m. strength
• - pain control: 1- use non-pharm methods first (e.g as
mentioned above, TENS, local heat/cold Tx) // 2- regular
paracetamol (1g QDS) // 3- opioids, NSAIDs or COX2
inhibitors // 4- low dose anti-depressants (e.g. amitriptyline 10-
75mg nocte) // 5- Capsaicin cream can also help w/knee/hans
OA
• - Aspiration of joint effusion and joint injections (can help with
exacerbations)
• - Complementary therapy: e.g. CAM (Copper bracelets,
Acupuncture, food supplements, diatery Manipulation) //
chiropractic/osteopathy for back pain.
• - other drugs/supplements: glucosamine // strontium ralnelate
§ refer to:
• - rhematology —> confirm Dx
• - ortho —> if symp. severe: joint replacement
- Female with sleeping difficulties- sleep hygiene
- Insomnia mx: sleep hygiene
- Day time Sleepiness, snoring at night, HBP- advise lifestyle modifications – Cardio???
o Same answer as discussed above in the OSA Q
- Women needs to loose wt - ask to consider discussing in the future
- physio ( palliative)
- Lymph node
- Conservative? Lump in the back

- clinical scenario à Palliative care

o SE to watch for in morphine: constipation or respiratory depression
§ From tutorial:
 • common opioid toxicity signs: myotonic twitching,
sleepiness/drowseness, Altered mental state, visual
hallicination (can present as “plucking at air”)
• extreme/advanced signs: resp. depression, pupil constriction
• toxicity is not necessarly caused by increased intake/dose. it
can also be caused due to infection, dehydration, etc
o Changes to dosageà Increase dose to 80mg (She was on 60mg and still has
pain)
o Two complications of arm metastasis
o Progressive SOB IXà D-Dimer
o Ethics: doctrine of double effect
-

Cardiology
- ambulatory bp high what to give -à Ramipril
o if <55 y/o, first line Tx = ACE inhibitors (…pril) or ARB if ACE inhibitors is not
tolerated (…sartan)
o if >55 y/o or carrabian/african ethnecity, 1st line is calcium channel blocker
- DM and microalbuminuria what to give à ACE inh
o if protein in urine or ACR (albumin creatinine ratio) is elevated in urine = Tx
ACE inhibitor
- NOAC what measure- eGFR
o ?incorrect
o ?no monitoring required
o if before starting med, eGFR might be correct
- Most important parameter to check before starting NOAC – eGFR
o e.g. apixaban should not be started if eGFR <15
- Post MI-which intervention first
o from clinic: acutely given 300mg asprin and nitrate (GTN) under tounge, 15L
O2
o Acute Tx from Oxford p.1067:
§ - give pain relief (GTN or IV/IM opioid e.g. morphine)
§ - give aspirin 300mg po
§ - consider IM/IV anti-emetic
§ - Measure peripheral o2 sat —> only give o2 if sat <94% —> aim 94-
98% or 88-92% if known hypercapnic resp failure & risk of CO2
retention (e.g. COPD?)
§ - if bradycardia, consider giving 500microgram IV & further
500microgram dose if needed to a max 3mg
o Oxford p.230 meds given: modify risk factors (e.g. cholestrol, b blockers), ACE
inhibitors, antiplatelets (e.g. aspirin 75mg, clopidogrel 75mg), anticoag,
- Murmur radiating to carotids- aortic stenosis
- ECG, Valsalva manoeuvre made better - paroxysymal supraventricular tachycardia
o Valsalva manoeuvre working = thing SVT
- Hyperkalaemia secondary to medication à remove Ramipril
o an ACE inhibitor
 o from CMED prescribing lecture: drugs that can cause hyper K = e.g. potassuim
sparing diuretics (e.g. spironolactone), ACE inhibitors, b blockers, NSAIDs
o Whereas hypo can be caused by: loop/thiazide diuretics, salbutamol,
laxatives, high dose steroids
- Post-MI intervention to prioritize à diet vs. smoking vs. alcohol? I think smoking bc
cessation decreases risk of death by 50% over 15y
- Picture: ulcer on medial leg + orange-brown discoloration à venous ulcer
o Medial leg= vein (? the region is called venous gutter)
o arteries ulcers usually between toes/at pressure points e.g. heel
- Incidental finding of BP 158/85 and for two occasions her blood pressure still
remained highà ABPM (Ambulatory BP) or start ACEI? I would go with ABPM; I
would only start ACEI without ABPM if the BP has severe clinical systolic >/=180 or
diastolic >/=110
o ABPM because BP might be elevated due to white coat syndrome. ABPM
gives a more accurete estemation of BP throughout the day. IMP NOTE: BP
of >135/85 is considered hypertension in the ABPM rather than >140/90
- Calf swelling + erythema + tenderness à DVT
- 2 weeks post hemicolectomy, presents with redness and swelling in right calve,
confirm diagnosis by- right leg venous ultrasound
o think post surgery DVT
- TN on ACE-I, next drug to add à amlodipine
o add calcium channel blocker e.g. amlodipine
o if still HTN, add thiazide diuratics
o if still high:
§ K+ low —> spirnolactone
§ K+ high —> high dose thiazide-like diuretic
§ if cannot use diuretics: alpha or b blockers
- Mid-diastolic murmur louder at the apex – mitral stenosis
o Murmurs guide 101:
§ Aortic stenosi: radiate to neck, systolic murmer, best heard on
expiration
§ Mitral stenosis: best at apex, diastolic murmer, best heard on
inspiration
§ Aortic regurg: parasternal/ ask pt move forward, diastolic murmer,
best heard on inspiration
§ Mitral regurg: radiate to axilla ask pt to move forward and to the left
to best hear it, systolic murmer, best heard on expiration
- Statin most important blood test to monitor after starting – liver function
- Someone on ACEi and you’re adding a diuretic, most important to check? Renal
profile
- 42 y/o female chest and epigastric pain- confirm by ECG
o females (& elderly) can present with “atypical symptoms” with MI (“atypical
symptoms” includes GI symptoms)
- Orthostatic hypotension- BP on standing and supine. HERE?
o >20mmHg difference
- ECG: atrial fibrillation
- CHF: spironolactone
 o from Oxford:
§ diuretics are usually loop/thizide diuretics not spirolactone.
§ if hypo K Tx with amiloride or K+ supplements
- Murmur: mitral stenosis
- IHD she was asymptomatic - Statin
- Guy with collapse, mild asthma - refer for urgent cardiology, give salbutamol
- ECG, valsalval manoeuvre made better - paroxysymal supravetricular tachycardia
- Mid-diastolic murmur, heard best at apex - aortic regurg, mitral stenosis
- Drug that the person should be getting for the ischemic heart disease (was already on ace
inhibitor, aspirin etc) – put on statin (whatever the statin was)
- SVT
- Add simvastatin to woman with ischaemic heart disease
- monitor LFTs on atorvastatin
- Heart murmur mid diastolic

- Clinical scenario à Brother w/ recent heart attack

o Most important CV-RF: smoking smoking cessation leads to 50% reduction in
mortality
o Drug for primary prevention: simvastatin
o Comment on ECGà Normal Rate and Regular/Normal Rhythm
o Add medicationà Aspirin

- Clinical scenario à Paroxysmal AF (Atrial Fibrillation)

o 2 medical conditions/complications: stroke/CVA, HF
o 2 reasons for high INR>6 à Alcohol and Grape Fruit Juice
o Manage high INRà Stop Warfarin (Data Interpretation Lecture)
o Systematic Reviewà Selection and Publication Bias

- Clinical Scenario à Elderly man can’t work more than 200m, gets pains in calves,
which is relieved by rest (intermittent claudication)
o Most likely diagnosis- Peripheral Arterial Disease
o Investigation of choice- Ankle Brachial Pressure Index
o What meds to add (list 2)- aspirin; diuretics
o Not compliant with meds and worse now, what features on clinical
examination (list 4) à oedematous legs; hair loss; ulceration; haemosiderin
deposition
§ DISAGREE with the hemosiderin deposition (thats venous changes)
§ hair loss, shiny, pallor (atrophic skin changes), ulceration, absent foot
pulses

Respiratory
- Monophasic wheeze and local area on CXR- lung carcinoma
- Baby with wheeze all over what do you give nebulised salbutamol
o ?bronchiolitis
o if so dont give salbutamol. Also if infent, the b reseptors might have not
developed yet so no benefit on using salbutamol (b agonist)
- Copd patient what first line SABA
o Oxford page 286
§ 1st SABA or SAMA
§ then
• LABA + inhaled corticosteroid (if asthma features)
• LABA + LAMA if no asthma features
§ then
• if asthma features / steroid responsive: cont. short acting
bronchodilator & change long acting to LAMA + LABA + inhaled
corticosteroid
- Acute severe asthma which one is a sign resp rate à 25
- 3 months history of cough in smoker who smokes 15 cigarettes per day, appropriate
investigation.
o ?COPD
o ?spirometry (Oxford p 284)
- Pleuritic chest pain + recent trip to Thailand à CXR
o ?pneumonia: CXR
o ?PE: investigations: CTPA
o ?TB: isolate, sputum culture
- 3 months history of cough in smoker who smokes 15 cigarettes per day, appropriate
investigation à spirometry, PFT, CXR ?spiromtry
- Next step in COPD RX after inhaled salbutamol with FEV 60% à LABA
o COPD Tx described earlier
- Man with SOB, left pleuritic chest pain, tachypnoeic and tachycardia, recently taken
up diving as a hobby – pneumothorax
o google:
§ Pneumothorax while diving can lead to a deadly arterial gas
embolism, but the biggest risk may come from a tension
pneumothorax that can evolve rapidly as gas expands on ascent
(?decompression sickness i.e. caisson disease, the bend)
- Man with restrictive pattern on PFTs what will auscultation likely demonstrate?
Coarse crackles? Other options: fine crackles, bronchial breathing, expiratory wheeze
or rhonci
o from JC1 ventilation lecture:
§ - obstructive pattern = FEV1 & FEV1/FVC are both redused e.g.
asthma/COPD
§ - restrictive pattern = FEV1 reduced but FEV1/FVC is normal or
increased (restrictive = due to “restrictive” expantion of alveoli i.e.
reduce compliance if alveoli) e.g. lung fibrosis, scoliosis —> google:
IPF (idiopathic pulmonary fibrosis) causes fine crackles
o crackles = too much fluid in lungs
- End of life COPD, manage dyspnoea symptoms- Morphine sulphate
o Morphine sulphate can be used as a pain killer & is also used in end stage
COPD to help with breathlessness = less likely to cause resp. depression
- COPD, cough no other symptoms- Acute bronchitis
o or could be normal in COPD to cough with no other symptoms. Right?
o 2 types of COPD (associated with smokers): chronic bronchitis & emphysema
 o - Chronic bronchitis “Blue bloaters”: blue/cyanosed & overwight. can have r.
heart failure/cor pulmonale. usually younger in age (~40-45 y/o)
o - emphysema “pink puffers”: usually are thin/fraile, breathing fast and pink in
color. usually older in age (~50-75 y/o). “berrel chest”: persed lip helps with
thier breathing; allowing air out of their lung instead of being trapped
- Smoker: COPD
- Pt w/ wheeze: CXR
- Scuba diving, left chest pain - bornholm disease / pneumothorax
o Pneumothorax as described earlier
o bornholm is caused by infection = less likely the cause?
- Tibia with breathlessness - PE
- Smoking, one side - lung carcinoma
- PE
- Coarse crackles
- Pneumothorax- diver

- Clinical scenario à Poorly controlled asthma

o Second line treatment after ACE-I for HTN (Amlodipine)
o Control questions
o Next step in RXà LABA (SABA, then inhaled corticosteroid then LABA)
§ Asthma Tx steps
• 1- SABA prn
• 2- +ICS
• 3- +LABA as combination Tx
• 4- increase ICS to medium dose OR add leukotriene agonist
(consider stoping LABA if no response to it)
• 5- refer to specialist
o Patient who quit smoking for two years and now is considering to go back to
smoke. Which stage of change? Relapse

infections
- pneumonia antibiotics- only amoxicillin – resp
o IC1 Resp micro:
§ CURB-65 to assess severity of pneumonia
• C: confusion, U: Urea >7mmol/L, R: RR ³30/min, B: BP: systolic
<90mmHg &/or diastolic <60mmHg, 65: age ³65y/o
o If 0-1 (mild) = oral amoxicillin or clarithromycin or
doxycycline
o If 2 (moderate) = IV amoxicillin + oral clarithromycin
o If 3-5 (Severe) = IV co-amoxiclav + oral clarithromycin
o Oxford p.295:
§ Tx: admission vs home
• If a decision is made to treat at home
o Advise not to smoke Take analgesia, rest, and drink
plenty of fluids
• If no intermediate features: Give antibiotics for 5d, e.g.
amoxicillin 500mg tds or doxycycline 200mg on day 1 then
 100mg od, or clarithromycin 500mg bd. Review after 3d: if
poor response, extend treatment to 7–10d
• If any intermediate features: Consider dual therapy with
amoxicillin 500mg tds + clarithromycin 500mg bd for 7–10d,
or monotherapy with doxycycline for 7–10d. Review within 3d:
if poor response, admit
• Note: Intermediate features include:
o history from patient, friend, or relative of new onset of
altered behaviour or mental state
o history of acute deterioration of functional ability
o increase respiratory rate: 21–24 breaths/min
o Systolic BP: 91–100mmHg
o increase heart rate: 91–130bpm (pregnant ♀: 100 –
130bpm) or new onset arrhythmia
o Not passed urine in 12–18h (if catheterized, passed
0.5–1mL/kg/h of urine)
o Tympanic temperature <36°C
- Baby fever, abdominal pain vomiting- first investigation urine dipstick
- Which one give antibiotics for sure centor>3???
o IC1 micro: sore throat à “consider antibiotics if 3 of 4 Centor criteria”
§ Hx of: fever, purulent tonsils, cervical adenopathy, absence of cough
or Hx of otitis media
§ Or if +ve culture results
§ Antibiotic = penicillin 10/7
- Guy with sore throat, redness of tonsils what – viral illness
o From clinic: if no apparent exudate/secretion of tonsils & no signs of otitis
media on otoscopy, less likely to be bacterial cause & more likely to be viral
cause (viruses can cause erythema of the affected areas e.g. throat/ear)
- Acute confusion in elderly à infection/geriatrics
o Dehydration/constipation are also common causes of confusion
o Ans. will depend on the Hx given in Q
o Recall: causes of delirium “PINCH ME”
§ P: pain, I: infection, N: nutritional deficiencies, C: constipation, H:
hydration (or rather dehydration), M: medications, E: environment
- HFM (Hand Food Mouth) disease à supportive RX
o HFM disease is caused by Coxsackieviruse à virus = supportive Tx (associated
with blanching rash, while sepsis is non-blanching rash)
- Hand Foot mouth disease management
- Neutropenia, otherwise well à refer to haem/repeat bloods
o From Clinic: if African ethnicity, the normal range is lower than “the normal”.
Range is ?0.9-2.5 for African ethnicity
§ Google: Approximately 25% to 50% of persons of African descent and
some ethnic groups in the Middle East have benign ethnic
neutropenia, with low leukocyte and neutrophil counts.
o Otherwise ?meds related, ?need to refer to heamatology (?acute leukaemia
Oxford p.652/653), ?post infection (the immune system can weaken after
infection which can also increase risk of shingles)
 - Boy comes in with father, you are rural GP 90+ mins from local hospital. Boy has
petechial rash, high fever – give IM benzylpenicillin IM??
o Petechial rash: ?blanching vs non-blanching à blanching = virus, non-
blanching = bacterial, possible sepsis (?meningitis)
o High fever: ?bacterial
o From peads: neonatal sepsis coverage: ?penicillin/amoxicillin +
gentamicin/cefotaxime // viral = supportive Tx
- HIV patient- encourage to discuss with husband
- Scratch on arm, develops fever, tachycardia and arm erythematous and oozing-
sepsis //infectiion symp.
- Lymphadenopathy, night sweats, weight loss: TB
o Also ?malignancy (night sweats & wt loss are B symptoms à ?lymphoma)
o ?TB à see Hx: ?occupation (e.g. taxi driver), ?recent travel to TB endemic
areas
- Hand, foot and mouth - symptomatic management
- Man from bangladesh, pancytopenia, enlarged spleen - Hodgekins / TB – RESP
o ?incorrect
o Pancytopenia à think bone marrow infiltration
o Pancytopenia + enlarged spleen à ?Chronic myeloid leukemia
o Lymphoma (e.g. Hodgekins) can infiltrate bone but that’s rare & infiltrate is usually
of focal region = ?less likely to cause pancytopenia

- Clinical Scenario
o Diagnosis- acute pharyngitis
o Treat (SBA- choose 2)- oral paracetamol & oral ibuprofen
§ Commonly viral origin: supportive Tx (e.g. analgesia, hydration, rest)
o Brother has EBV; Management give 2 options- Analgesia; bed rest
§ EBV = DO NOT give amoxicillin or penicillin derived drugs (causes
hypersensitivity leading to a rash (maculopapular))
o What would you find on bloods, choose 4- EBV antibodies; raised
transaminases; lymphocytic leucocytosis
§ Sketchy micro: ?Lymphocytosis, monospot IgG test

Gastroenterology
- Anal fissure at 6 o clock what do you do stool softner
o Anal fissures might be caused by constipation. Hence, giving laxatives can
help
- Loose stools exam normal – IBS
o Recall from psych: IBS is basically psychological stress converted into physical
symptoms due to sympathetic overactivation (can think of it as a type of
somatisation that is related to the GI system). Hence, investigations are
normal
- IBS question
- 22 y/o women with abdominal pain and diarrhoea, all tests normal- Irritable bowel
syndrome (IBS)
- Get pain after eating- peptic ulcer disease
 o Pain after eating à gastric ulcer
o Pain relieved after eating à duodenal ulcer
- Abdominal cramps + loose stools, no bleeding, IX à abdominal CT/US/PFA
o ?gastroenteritis
o I’d say maybe PFA is the most appropriate of these options in this case? Or no
imaging is required as gastroenteritis is most likely to be caused by viral
infections (can also be caused by bacterial e.g. C. Jejuni
- High GGT and MCV+ macrocytic anaemia à alcohol liver disease
o Discussed above: (repeat):
§ causes of macrocytic anaemia e.g. folate/B12 vit deficiencies
(Megaloblastic), Alcohol, increased reticulocytes production (?e.g. in
heamolytic disease/bleeding)
§ since GGT is elevated (i.e. liver dysfunction) = alcohol is the cause in
this case
- Woman in elderly home w/ incontinence x2w + not taking fiber for last 1m à
catheter vs. laxative; I would go with the laxative bc constipation can cause
incontinence due to faecal impaction
o Agree à laxative for similar reasons (options senna = stimulant laxative &/or
Movicol = osmotic laxative)
- Mass in RUQ, pale w/ attacks à intussusception
o Oxford page 869:
§ Intussusception:
• Abdominal colic: paroxysms of pain during which child draw up
their legs. The child often screams w/pain & become pale.
Episodic: usually last 2-3min and 10-15min apart but become
more frequent w/time
• Vomiting is an early symptom while rectal bleeding is a late
sign
• “sausage-shaped” mass in the abdomen: usually RUQ but not
always present
- Anemia + pallor + dyspepsia à refer for upper GI endoscopy
o ?bleeding PUD causing anaemia/pallor à therefore, refer for OGD
- Reason to refer- Frank bleeding PR??
- Pt w/ jaundice: pancreatic ca
o Pancreatic head tumour can press on/obstruct bile duct outflow leading to
jaundice. Also recall “Courvoisier’s Law” from IC2 GI surgery lecture:
“palpable gallbladder in a jaundiced patient is unlikely to be due to gallstone
disease” but rather more likely to be pancreatic cancer
- child with peri-umbilical pain that localised to the right lower abdo- probably
appendicitis
o ?appendicitis, ?Meckel’s diverticulum à see Hx in Q
- lady with vomiting and upper abdominal pain with tenderness in the RUQ -probably
acute cholecystitia
o see Hx in Q (?pain worse with fatty food, etc). pancreatitis (relived by moving
forward, radiate to back à AAA also radiate to back), gastritis, PUD (relation
with food), inflammation/association of other organs in surrounding this area
 (e.g. intestine/liver/kidneys, etc) can also present with RUQ pain. Therefore,
Hx imp.
- 30 units of alcohol, dyspepsia - gastric cancer
o ?correct/incorrect
o ?Alcohol can cause gastric damage & increase acid production (causing PUD??)
o Google: Gastric cancer Alcohol: Stomach cancer risk is higher in people who drink 3
or more units of alcohol each day
o Oxford text related to stomach ulcer (alcohol is not specifically mentioned as rist
factor) p.362/363:
§ Stomach cancer: Stomach cancer causes ~5000 deaths/y in the UK; 95% are
adenocarcinomas. Disease affecting older people with 92% diag- nosed
>55y; ♂ > ♀ (5:3). Incidence has more than halved over the past 30y in the
UK probably due to improved diet.Other risk factors:
• Geography—common in Japan
• Blood group A
• H. pylori infection (not clear if eradication decreased risk)
• Atrophic gastritis
• Pernicious anaemia
• Smoking
• Adenomatous polyps
• Social class
• Previous partial gastrectomy
§ Presentation Often non-specific. Presents with dyspepsia, weight loss,
anorexia or early satiety, vomiting, dysphagia, anaemia, and/or GI bleeding.
Suspect in any patient >55y with recent-onset dyspepsia (within 1y) and/ or
other risk factors. examination is usually normal until incurable. Look for
epigastric mass, hepatomegaly, jaundice, ascites, enlarged supraclavicular Ln
(Virchow’s node), acanthosis nigricans.
§ Management If suspected refer for urgent endoscopy. In early stages total/
partial gastrectomy may be curative. Most present at later stage. Overall 5y
survival is 15%.
- Hyperglycaemia, pancreatitis - alcohol hx
o Alcohol can cause pancreatitis/pancreatic damage
o Pancreatic damage= less insulin production = hyperglycaemia
- Supraclavicular lump, feeling sick, so small intake - gastric cancer (see note on gastric cancer
above à “feeling sick” =?dypepsia/heartburn, “so small intake” = ?anorexia/early satiety)
- Cut in the perianal lesion - anal fissues - stool softener
- Person with anal fissure at 6 oclock – stool softener
- Man with previous haemorrhoids, DRE normal - iron def tests or colonoscopy?
o Oxford p. 374:
§ if piles are not obvious on exam, arrange protoscopy +/- sigmoidoscopy for
all pt >40 y/o
§ Tx: soften stool (bran, ispaghula husk) & recommended topical analgesia
(e.g. lidocaine 5% ointment or OTC preperation). if not
responding/uncertainityover Dx or severe symp. —> refer for surgical
assessment
- Person with blood covered stool, 60 year old man – refer for colonscopy
o To rule out: colorectal cancer as the cause of the bleeding esp. cuz elderly (recall
from IC2 GI, even if pt present with just iron deficiency anaemia & age is over 40,
they will need GIT upper and lower endoscopy if there is no obvious cause of the
anaemia)
 - Gastric cancer
- Laryngeal cancer

- Clinical Scenario à 20y/o complaining of abdominal pain. Needs to empty bowels

very often. Pain is quite bad, needs to miss school
o DDx- Irritable bowel syndrome; inflammatory bowel disease
o What investigation you would do (choose 2)- colonoscopy; FBC
o On OCP, get headaches, photophobia and tingling sensation in arm; what
features worrying of pathology if present (choose 3)- petechial rash;
o Treatment for headaches (choose 2)- topiramte and sumitriptan

Endocrinology
- Subclinical hypothyroidism bloods – eltroxin (from moodle SBA)
o Eltroxin = thyroxine
o Subclinical hypo = normal T4 but persistently raised TSH
o Oxford p.334:
§ If any sump (including depression, non-spec symp.,
hypercholestolaemia) à trial of Tx
§ If no symptoms à repeat after 3-6/12 and then monitor annually
- Lab results showing subclinical hypothyroidism à refer to endocrinology vs measure
after 6 months vs measure after 12 months; if no symptoms, repeat after 3-6 months
then annually (see answer above)
- Chronic steroid use can lead to à Cushing’s syndrome
- Tremors, weight loss, palpitations à Elevated T4 and Low TSH
o = symptoms of hyperthyroidism = T4 is elevated = negative feedback on TSH
production. Hence, TSH will be low
- Women on eltroxin (thyroxine med) for hypothyroidism, bloods show raised T4 and
raised TSH- over medication
o from clinic, over medication is usually associated with low TSH (due to
increased negative feedback of TSH production) NOT high TSH.
o check clinical presentation of pt i.e. is displaying symp of hyperthyroidisim or
not (recall: treat pt not blood from IC2 REGUB)
- Poorly controlled diabetes, complication seen on urine dipstick- proteins
o also urine test can show elevated ACR (albumin creatinine ratio)
o Why? due to renal damage due to the DM
- Hyperglycaemia: T2DM
- Subclinical hypothyroidism - TSH 6 and T4 12
o From IC2 REGUB med: normal TFTs resaults:
§ Free T4 à 7-16 pmol/L
§ Total T3 à 1-3 nmol/L
§ Thyrotrophin/TSH à 0.4-5 mu/L
- Women with hypothroid on levothyroxine - what now - increase the level
o If dose is not adequate , increase Tx by 25mg
- Tsh elevated, normal thyroid levels – subclinical hypothyroidism
- Continue levothyroxine
 - Clinical Scenario à Elderly man with new onset blurred vision and tingling
sensations in hands and legs (?DM related)

o Investigation- OGTT
o Features from history that leads to diagnosis (list 2)- blurred vision; tingling
sensation
o First line therapy- Metformin

- Clinical Scenario à Came in with mom. 22 y/o very edgy and panicky. Tremor,
weight loss and heart palpitations. Cardiovascular and respiratory examinations
normal.

o Single most important investigation- TFTs (right)

o 2 management options- carbimazole; fluoxetine
o ?fluxetine incorrect
o Oxford management of hyperthyroidism (p.334)
§ B blocker (symp. control), Carbimazole (inhibit thyroid
hormone synthesis), radioactive iodine (131I), surgery

Genitourinary / renal
- SA test what do explain risk and benefit then give ??
- Ph 6 and vaginal discharge – bacterial vaginosis
o IC2 Trop med: vaginal discharge (watery/white discharge with fishy odour) &
increased vaginal pH (>4.5), associated with sexual activity but not STI.
However, it can increase risk of STI (coats epithelial cells à “clue cells”). Tx
Metronidazole 500mg BD for 7/7
o Oxford p.713 similar info to above. 50% remit spontaneously. No need to Tx
partner. Tx metronidazole 400mg bd for5-7/7 or 2g single dose or
clindamycin 2% cream 5g nocte PV for 1/52
- Hard swollen testes- USS
o See answer in the below Q
- Scrotal lump- reassure and non-urgent ultrasound??
o (from general knowledge/what I learned in clinic)
§ ?scrotal lump/swelling present, can:
• A- ?scrotal extentions
o - feel if the area is compessable or not
o - if not compressable: do transillumenation to see
whether the content is fluid (light can pass) or if ?bowel
content (light cant pass)
§ ?recent injury: ?epididymitis
§ ?torsion: if at puberty age and presenting with severe pain in scrotum
- Swollen and tender mass in the testicles. Diagnosis? Acute Epididymo-orchitis
o See answer above. Also ?torsion if at puberty
- Incontinence want do use medication – oxybutin
o Oxford p.425 (under Urge incontinence):
§ First-line med = oxybutynin (alternatives: solifenacin, tolerodine,
trospium, duloxetine)
- Guy having intercourse with men 10 days ago, urethritis and discharge what test –
renal
o Oxford p.715 (under urethritis)
§ Sexually acquired. Characterised by discharge and/or dysuria although
may be assympt.. Found when a swab is taken following contact
tracing. Tx (see table for details): 1st line à doxycycline, azithromycin,
ofloxacin. See table for meds added when persistent/recurrent
(metronidazole key)
- Renal flank pain what test to confirm diagnosis urine analysis
o From IC2 REGUB micro UTI à location of pain and DDx:
§ Suprapubic à cystitis (bladder inflame.)
§ Flank pain à pyelonephritis (kidney inflam.)
o If urine dipstick +ve nitrate/lactate à think infection
o Haematuria causes (IC2 REGUB path) à think systemic cause or something
obstructing urinary tract
§ Systemic cause: clotting disorders, low platelets, warfarin
§ Obstruction à in/of: kidney ureter, bladder, urethra (see pic below
from lecture)

- 26yo F w/ loin pain radiating to groin + haematuria à renal colic

- Haematuria, renal angle tenderness, rigors, dipstick blood + nitrates + and White
cells + - what treatment? Ciprofloxacin
o IC2 REGUB micro:
§ ?UTI: nitrofurantoin/trimethoprim
§ ?pyelonephritis: cefuroxime & gentamicin?
o ?Renal Colic (Oxford p.418): stones pass spontaneously. Give pain killers
(diclofenac (NSAID)) +/- anti-emetic. Consider admission in some cases (see
p.418 for details)
- 30 something year old man presents with solid 2cm right testicular mass – best next
step – USS? Other option – CT pelvis, biopsy
 o From google: An ultrasound is often the first test done if the doctor thinks
you might have testicular cancer.
o From IC2 REGUB male GU: types of testicular tumours:
§ Germ cell tumour (most common 90%. Divided into seminoma & non-
seminoma), Sex cord/stromal tumours (<10%. Leydig cell tumour
most common and most of them are benign), Other rare (lymphomas,
mets).
§ NOTE: not all testis lumps are tumours (could be infection, cysts, ect)
§ à Tumour markers in blood can also be imp (e.g. non-seminoma
types like yolk sac (produce AFP) & Choriocarcinoma (produce hCG))
- Boy with nocturnal frequency, lost weight, has RTI taking ibuprofen- AKI
o Drugs that can cause AKI (from IC2 med lecture): Renal type - NSAIDS,
ACEi, ARBs, Gentamicin, contrast, rhabdomyolysis (?e.g. statin related drug
interaction e.g. w/macrolides)
- Prostate symptoms- reassure, advise self-help and follow up
o From clinic: if presenting with prostate symp. DRE should be performed.
Also, bloods can be taking before doing the DRE to check PSA (Note: taking
the bloods soon after doing the DRE can cause “false” elevation of PSA).
o why DRE is imp. to perform: rule out prostate cancer (irregular
nodules/bumps felts on DRE)
- Renal colic- refer for X-ray of kidney ureter and bladder??
o ?I believe US would be the 1st line imaging for suspected renal colic rather
than x-ray (look for dilatation above blockage)
o Oxford p.418:
§ - immediate investigation: urine dipstick —> note: absence of RBCs
does NOT exclude renal colic
§ - immediate management: usually resolve spontaniously —> give pain
relief (e.g diclofenac [an NSAID]) // if not admitted: encourage
increase fluid intake & monitor/review pain relief & for complications
- Pt w/ testicular tumour: US see above
- Blood in urine: refer to urology if ?Renal colic, might resolve spontaneously & not
need referal
- Pyelonephiritis - ciprofloxacin
- Stress incontinence - pelvic floor
o Oxford page.424. Tx stress incon = pelvic floor exercises
- Man with right testicular mass, 2 cm in size – ultrasound?
- Man with the stone – ultrasound?
- Man with pyelonephritis – give ciprofloxacin
- Urinalysis- RENAL STONES

Neurology
- hit head, headache chronic subdural haemorrhage
o Recall from CMED: different types of brain haemorrhage:
§ subdural haemorrhage à rupture of bridging veins, Elderly/Alcohol
abuse/Trauma, Convex on CT
§ Epidural à Arterial bleed, Trauma/Skull fracture (of squamous
temporal), lucid interval (i.e. lose consciousness then wakes up),
Biconcave on CT
 § Intraparenchymal à Hypertension, Bleeding lesion (tumour, vascular
malformation), Trauma
§ Subarachnoid à severe headache “worst headache on my life”/“like
an axe”/N&V/Loss of consciousness/Drowsiness/Neurological deficit,
Traumatic vs non-traumatic (e.g. aneurysm rupture)
- fall risk with Doxazosin thingy
o ?incorrect
o Oxford elderly risk of fall p.192. in terms of meds mentioned = psychotropic
drugs, sedatives, diuretics, b blockers
§ Google: Citalopram one of the “most frequently prescribed
psychotropic drugs”
- status epilepticus what do you give- IV midazolam
o ?incorrect cuz midazolam is not given IV (it’s given buccal)
o Options: buccal midazolam, rectal diazepam, IV lorazepam/diazepam
- Symptoms of cauda equine- refer to ED
o Oxford p.453: management refer/admit as neurological emergency. Rapid
surgical Tx increses chance of full motor & sphincter recovery
- Slept on arm, decreased sensation over first webspace- which action reduce
o 1st webspace sensory innervation = median nerve
o Median nerve motor innervation = thumb movement/grasp (Oxford p.459)
- Meningitis à IM penicillin (benzylpenicllin; cefotaxime if anaphylaxis against
penicillin) ??IM
o From above (repeated ans.): Q: Boy comes in with father, you are rural GP
90+ mins from local hospital. Boy has petechial rash, high fever – give IM
benzylpenicillin IM??
§ Petechial rash: ?blanching vs non-blanching à blanching = virus, non-
blanching = bacterial, possible sepsis (?meningitis)
§ High fever: ?bacterial
§ From peads: neonatal sepsis coverage: ?penicillin/amoxicillin +
gentamicin/cefotaxime // viral = supportive Tx
- Band headache, worse at work à tension headache
- 4-month headache, HX of fall, 1w HX of paracetamol & codeine à chronic subdural
hemorrhage? I believe so
o if elderly & Hx of fall à ?subdural haemorrhage of bridging veins
o the 1/52 Hx of meds à ?Medication overuse headache à from Oxford red
book: (5x in women than men). Meds that can cause it: migraines meds,
analgesics. The headache resembles migranes or tension-type headaches
- Seizure in waiting room, airway cleared à diazepam/midazolam/loosen clothes/turn
the patient into the recovery position/check glucose
o If actively seizing/status epilepticus:
§ and there is IV access: IV lorazepam
§ No IV access: buccal midazolam or rectal diazepam
§ If still seizing >5min after med, call ambulance & drug can be
readministered after 10-15min
o If not actively seizing/post seizure à turn pt into recovery position
o Glucose is usually checked in infants/paeds who present with seizures as
hypoglycemia can cause seizures in infants
- Vascular dementia + bilateral tingling in LL à ECG/Vitamin B12/electrophoresis
o ?Vitamin B12?
§ From IC1 pathology lecture haematology & anaemia à important
clinical features of B12 deficiency:
• Anaemia (low Hb, high MCV, low serum B12), peripheral
neuropathy, subacute combined degeneration of the cord,
optic atrophy, psychiatric disorder, atophic glossitis.
- Woman brought in by her husband hx of fall ~ week ago, forgetful, headaches
resistant to analgesia, most likely dx? – chronic subdural haematoma
- In GP practice you call next patient in you notice she is slow to start walking,
unsteady, wide based gait, nearly falls as she turns the corner – cerebellar disease
other options: parkinsonism
o Recall DANISH for cerebeller injury:
§ D: Dysdiadochokinesia
§ A: Ataxia
§ N: Nystagmus
§ I: Intension tremor
§ S: Slurred Speach (dyasthria)
§ H: heel-shin test/hypotonia
- 23 year old male with back pain, radiates down to his thigh no further than that.
Happened 24 hours ago? Localised pain to L4 with associated muscle spasm. No
neurological impairment. How to treat – advise bed rest for 2 days/MRI lumbar
spine/take analgesia and back to work
o ?take analgesia & back to work (see oxford pic p.452: simple (mechanical)
backache = specialist referral is NOT required)
o Oxford p.450 management of acute back pain:
§ Who do not require immediate referrel: analgesia (e.g. NSAIDs short-
term + gastroprotection // weak opioids+/-paracetamol), use keels
STarT Back screening tool:
• If score £3: likely natural Hx of back pain = AVOID bed rest &
maintain normal activities
• If ³4 not resolved in 4/52 à refer for specialist
§ STarT Back screening tool:
• 1. My back pain has spread down my leg(s) at some time in the
last 2wk
• 2. I have had pain in the shoulder or neck at some time in the
last 2wk
• 3. I have only walked short distances because of my back pain
• 4. In the last 2wk, I have dressed more slowly than usual
because of back pain
• 5. It’s not really safe for a person with a condition like mine to
be physically active
• 6. Worrying thoughts have been going through my mind a lot
of the time
• 7. I feel that my back pain is terrible and it’s never going to get
any better
• 8. In general I have not enjoyed all the things I used to enjoy
 • If the patient agrees with a statement, score 1; if disagrees,
score 0.
• 9. Overall, how bothersome has your back pain been in the
last 2wk?
o Not at all, slightly or moderately—score 0
o Very much or extremely—score 1
- Intension tremor, wide based gait, slurred speech- Cerebellar disease (see DANISH
above)
- Resting tremor, shuffling gait- Lewy body dementia
o From psych:
§ = features of parkinson’s, fluctuating cognative function, visual
hallucinations, sensitivity to antipsycotics
- 17 y/o with collapse and jerking movements with immediate recovery- reassure as
vasovagal syncope
o if loss of consiousness/focal or tonic-clonic features think epilepsy/seizures
- Tension type headache- advise relaxation techniques
o Oxford P. 530
§ Tension headaches are usually stress/anxiety related or func./structural
abnormality
§ Tx:
• - reassurance
• - Acutely: simple analgesia (e.g. paracet, NSAIDs). AVOID
codeine-containing preparations & other opioids
• - try to alleviate stress: relaxation; massage, yoga, excercise
• - Tx MSK symp.: physio
• - consider referral for prophylaxis with acupuncture
- 90y/o women with many falls, poorly controlled T2DM, metatarsal ulcer norm
noticed by her, fall caused by- Peripheral neuropathy??
- lady with eye pain that started in the shower -probably MS
o pt with MS can experience worsening of symptoms with hot water/whether
- Elderly man with falls - doxizosan - causes postural hypotension
o As discussed above
- Women walking with wide based gait - cerebellar
o As discussed above (DANISH)
- Women walks in acutely ill and collapses - lie down and call an ambulance – drowsiness
o Didn’t understand the Q
- Women who fell 4 weeks ago - chronic subdural haematoma
- Woman who had a fall one month ago, has had a headache ever since – chronic subdural
haematoma
- Cerebellar disease
- Vasovagal syncope

- Vascular dementia
o Vascular dementia
o Ischemic stroke- change meds (Warfarin)

MSK
- Tennis history of OA painful arc test – impingement
 o Oxford p.455: rotator cuff injury
§ Acute tendinitis: often from overuse/trauma <40 y/o
§ Rotator cuff tears: may accompany subacromial impingement à
suspect if recurrent impingement or +ve drop arm test (abduct arm
90o then lower slowly to side)
§ subacromial impingement à pain occur on limited arc of abduction
(60-120o painful arc syndrome)
o Tx: Rest & NSAIDs followed by physio and/or subacromial steroid injection. If
fails, refer
- Shoulder pain: impingement
- Shoulder pain + FHX of OA + painful arc à IA injection/refer to ortho/MRI/X-ray
o See Tx above (Intra-articular injection from these options is the correct one?)
(PAINFUL ARC= SHOULDER IMPINGEMENT à REST, NSAIDS, THEN PHYSIO THEN
SUBACROMIAL STEROID INJECTION)
- Lower back pain after carrying heavy box + focal tenderness + (+) straight leg raise
o This = sciatica (?due to protrusion of nucleus fibrosis of vertebra and
impingement on nerve)
- First thing to prescribe for osteoporosis- alendronate
o = Alendronic acid see below (repeated: bisphosphenate (due to osteoporosis)
o ?can also give calcichew (Calcium & Vit D)
- Guy comes in neck brace says that pain in neck since yesterday- on exam reduced
neck movements what do you do – neuro
o ?not sure if correct or incorrect
o Oxford p.449: management of neck pain:
§ Examine to exclude bone tenderness à require x-ray
§ Tx with analgesia & early mobilization. Collar can help initially but
avoid long-term use. Recovery often slow. General rule: the quiker the
symp. develop, the longer they take to disappear.
§ Early physiotherapy increase recovery rate
- Ankylosing spondylitis à HLA-B27
- Gout secondary to medication à remove thiazide – MSK/renal
o From IC2 CNS joint lecture: Meds that can cause 2o gout: diuretics drugs,
salicylate (e.g. aspirin?), ethanol (i.e. alcohol)
- Lower back pain after carrying heavy box + focal tenderness + (+) straight leg raise à
MRI spine/X-ray spine/analgesia/bed rest
o See Oxford pic p.452 à specialist referral is not needed in the first 4/52
assuming signs of resolution
- Runner w/ foot pain, unable to run, worse in morning à Achilles vs. plantar fasciitis
o Ans. = plantar fasciitis
o Oxford p.472: Plantar fasciitis/bursitis: Common cause of inferior heel pain
especially among runners. Pain is worst when taking the first few steps after
getting out of bed. usually unilateral and generally settles in <6wk.
o Tx: Advise shoes with arch support, soft heels, and heel padding (e.g.
trainers). Achilles tendon stretching exercises can help; NSAIDs and steroid
injection are also helpful.
o In persistent cases refer to podiatry (for fitting of an insole) ± orthopaedics.
- Pregnant patient with lower abdominal pain radiating to the back. What is the best
next step of management? Lignocaine Patch OR Refer to Physiotherapy OR Refer to
Orthopaedics or Heat Patches ???
o ?Ans simple analgesia if an option or refer to physio if no other options
o Oxford p.464: Pubic symphysis dehiscence: occur late in pregnancy, may
persist after delivery. Symp.: low abdo pain radiating down both thighs +/-
lower back, pain is content & worse with movement. Resolves on rest
§ Tx simple analgesia (e.g. paracetamol). Rest in a semi-recumbent
position when in pain
§ Refer to physio esp if still a problem in puerperium (i.e. 6/52 after
delivery). Most resolve spontan. within several months of delivery.
Some persist & need specialist referral
- Woman post tibial fracture discharged from hospital 1 week ago – now short of
breath, tachypnoeic and tachycardic – most likely dx PE
- Lower back pain with decreased sensation on shin and dorsum of foot, weakened
dorsiflexion of big toe, knee and ankle reflex intact. What nerve root? L5
o Imingement - lack of sensation on the shin and over the foot, present reflexes in
knee and ankle - L5 Oxford p.451

- Woman with hx of carpal tunnel, now with bilateral wrist pain worse in morning,
can’t remember other clinical details – question most likely dx – RA
o Pain worse in morning i.e. worse when rest/improve with movement =
inflame. Condition e.g. RA
- DEXA Scan -2.6 - Alendronic acid
o bisphosphenate (due to osteoporosis)
o ?can also give calcichew (Calcium & Vit D)
- Sciatica- absent ankle reflex and normal knee reflex?? – neuro???
o Causes shooting pain on straight leg raise
- Golfers elbow- wrist pronation
o Epicondylitis —> tennis & Golfers elbow
§ Tennis = LaTeral epicondylitis
§ Golfers = Medial epicondylitis
• Golfers: pronator teres is one of the m. attached to medial
epicondyls
- Man with right thumb and knee pain, worse after activity- Pseudogout??
o ?incorrect
 § worse after activity = NOT inflammatory cause
§ ?sympt. for cosistant with osteoarthritis (OA):
• - knee/wt bearing join pain
• - OA can also affect 1st CMC joint (under thumb)
• - other features: Heberden’s node (at DIP) & Bouchard nodes
(at PIP)
• - WORSE AFETER ACTIVITY
- Knee and finger pain, raised LFTs and hyperglycaemia- rheumatoid factor??
o joint pain + raised LFT (acute phase reactant) + hyperglysemia (due to stress
on the body) = ?infection/inflammation excerebation
§ ?Septic arthritis: joint aspirite?
§ ?reactive arthritis: Hx GI/GU infection, “cant see, cant pee, cant climb
a tree”. HLA-B27 in 80% (from IC2 lecture)
§ ?psoriasis arthritis affect DIP joints of hands & toes & spine, knees and
ankle. affects 5-10% of pt with psoriasis (chech Hx of psoriasis). HLA-
B27
- Back pain: degenerative lumbar
o Oxford p.451 age & back pain cause

- Old lady, externally rotated and shortened - right hip fracture

- Rheumatoid arthritis - woke with pain, got better throughout the day with dry eyes
- Carpal tunnel - sensation of the ring finger and baby finger
o Oxford p.460: carpal tunnel syndrome
§ pain in the radial 3 and half digits of hand± numbness, pins and needles, and
thenar wasting. Due to compression of the median nerve as it passes under
the flexor retinaculum. Worse at night. Symptoms are improved by shaking
the wrist. Associations: pregnancy, hypothyroidism, DM, obesity, and carpal
arthritis.
§ Investigations: Phalen’s test (hyperflexion), Tinel’s (Tapping)
§ Management by GP: splint +/- carpal tunnel steroid injection
- Painful arc syndrome - Sub acromial inpingement discussed previously
- Bilateral wrist swelling, history of dry eyes – rheumatoid arthritis
o Dry eye & mouth = sjogrens syndrome which is associated with RA
- Woman who had a fall and hip externally rotated – hip fracture
- Back pain with change in dorsiflexion of big toe and reduce sensation over shin area what
nerve root impingement (L5?) discussed previously & pic inserted
- Lower back pain what impingeent ?
- Subacromial impingement
- Lower back pain physio
- Carpel tunnel tips?
 - carpal tunnel syndrome wasting of hyperthenar eminence ? nope. it can be associated with
thenar wasting but not hypothenar
- lady with bilateral carpal tunnel worse in morning
- L5

Mental health
- guy inappropriate, delusional, does not want to go for psych (increase lithium or
olanzapine??) increase olanzapine? (dude has schizophrenia)
o ?olanzapine is antipsychotic so inc it (lithium is just a mood stabiliser)
- Guy on citalopram thinks mood better and thinks med affecting libido what do you
do ?educate à not sure
- Suicidal tendencies in 14-year-old what do- psych referral
- Women fainted, pinpoint pupils, 6 breaths/minute (i.e. respiratory depression)-
Opioid overdose X2
- anxious patient comes again and again what do you do
o ?GAD, ?Somatisation, ?psychosocial stressors, identify cause
o Oxford p.971 (pic of GAD):
§ step 1: identification & assessment, education and active monitoring
§ 2: offer low intensity (e.g. CBT: self-help or computerised)
§ 3: high intensity psych tx (e.g. face to face/group CBT) or IPT (Rx)
§ 4: offer referral to specialist
- Depression 1y ago, complaining of decreased libido à taper/titer the dose of SSRI to
avoid withdrawal symptoms vs. specialist referral ?titre down
- Known depression + HX of self-harm + wants to drink bleach à refer same
day/immediately for psych review
- Schizophrenic on olanzapine + lithium à increase dose, forced admission, refer to
psych OPD depend on risk assessment
- Elderly on multiple medications, fall risk, which to review immediately à
citalopram/aspirin/doxazosin. CITALOPRAM
o Oxford elderly risk of fall p.192. in terms of meds mentioned = psychotropic
drugs, sedatives, diuretics, b blockers
§ Google: Citalopram one of the “most frequently prescribed
psychotropic drugs”
- 14 y/o overdose- psych referral??
- Panic Attack 3 to 5 times per week- refer for CBT??
o 3-5 attackes per week = ?panic disorder (?is the pt fearful of when the next
attack will unfold) —> Tx of panic disorder (Oxford p. 972): step wise
approach:
§ - step 1: Dx, educate, support community & discuss Tx options.
§ - 2: Tx in primary care = offer e.g. CBT, Drug Tx or Self help. choice
depend on severity/co-morbidities/pt preference
§ - 3: consider alternitive from step 2
§ - 4: offer referral if 2 or more primary care Tx have failed
- Women started on escitalopram (anti-depressent (SSRI)), but complaining of worse
mood and increased anxiety, what do you do- continue with the medication at same
dose
o SSRI take few weeks until they show their full effect & can cause intial
anxiety on starting med
 - Pregnant lady w/ depression: fluoxetine
- Lady w/ depression: SSRI
- Pt w/ bipolar: involuntary admission
- old lady with sudden onset confusion and agitation worse in the evening. Also seeing
her dead husband- I don’t know. Options were dementia, infection, psychosis and 2
more that I can’t remember; INFECTION à DELIRIUM
o from psych: the symptoms of delirium are usually worse at night compared to
other times of the day (causes discussed above à “PINCH ME”)
o also ?PTSD (less likely)
- Women with delirium, worried about neighbours - urine dipstick – delirium à infectious
cause
- FBC - delirium
- Man separated from wife, with alcoholism and some suicide intent - adjustment disorder
o Also consider depression
o Hx imp.
- Woman with the 1 month history of anxiety, hence nausea? Etc – commence anxiety
treatment
- Bb blue/ psychosis (elation after delivery) à Reassure-baby blues
o Recall from psych: baby blues happen due to the rapid hormone changes after delivery
of baby + placenta à resolves spontaneously
- Anxiety management
- Substance misuse/depression
- Alcohol history

- Clinical scenario à Psych: anxiety symptoms

o Two investigationsà ECG and TFT
§ Oxford assessment of GAD (p.970): TFTs & use GAD-2 score
o One diagnosisà Generalized Anxiety Disorder
o One managementà CBT

- Clinical Scenario à 42y/o man depressed. Lost job recently. Drinking more than
usual (30 units a day).
o 2 important depression questions- how is your mood?; loss of appetite?
§ Nope: mood & interest/pleasure (rather than appetite)
o 4 management options- start SSRI, refer to CBT; advice on alcohol reduction;
do FBC before prescribing medications
o ECG abnormality- RBBB

OBSGY
- Heavy menses what contraception- IUD levoprogesterone
o Oxford p.727 table 21.2: progesterone containing intrauterine systems
advantage à reduce bleeding and dysmenorrhoea
- Obese, smoker what contraception- POP
o Oxford p.736: POP (progestron-only pill) is an alternative to Combined OCP in
cases such as smokers age >35y/o
 o ?Obese = cardiovascular risk due to high BMI = Combined OCP containdicated
- 40+ year old woman new partner, doesn’t want children, smoker, obese, mother had
osteoporosis, what contraception? POP
o See above ans
- Pregnant lady with blood showing low haemoglobin what test next FBC with iron
studies
o ?Start iron & folate
o Iron deficiency is the most common cause but if persistent check haematinics
(e.g. folate, B12)
o Oxford p.800 anaemia in pregnancy:
§ Defined as Hb <11g/dL early in pregnancy, or <10.5g/dL after 28wk.
Common in pregnancy (20%). Some d in Hb is physiological due to i in
plasma volume, however iron requirements i ×2–3 and folate i ×10–20
during pregnancy. Anaemia is usually due to iron deficiency.
Complications include excessive fatigue and poorer fetal outcome.
Risk factors:
• Multiple pregnancy
• Frequent pregnancies
• Poor diet
• Starting pregnancy anaemic
• Haemoglobinopathy
§ Screening Hb is routinely screened at booking and again at 28wk.
§ Management Routine use of oral iron for all pregnant women is of no
proven benefit and may cause harm. Women in high-risk groups (e.g.
mul- tiple pregnancy) may routinely be given prophylaxis—follow
local policies.
• If Hb is <11g/dL at booking or <10.5g/dL at 28wk, start iron
(e.g. ferrous sulfate 200mg tds) and folic acid (5mg od).
Repeat Hb in 2wk. If there is no response to oral iron, exclude
occult infection (e.g. UtI); check haematinics; consider referral
for parenteral iron.
- IMB + PCB + on OCP à stop pill
o ?not sure of the ans.
o IMB = intermenstrual bleeding, PCB = Postcoital bleedin (i.e. bleeding after
intercourse)
- Contraception 6w post-CS à lactational amenorrhea, POP, COCP, IUCD; lactational
amenorrhea up until 21 days (no contraception needed during this time); COCP
shouldn’t be used if breastfeeding, have increased risk of VTE, or if CS; IUCD only if
CS uncomplicated; POP probably the best option
- PM woman w/ stress incontinence + mild cystocele à ring pessary vs. vaginal
pessary. A ring pessary is a vaginal pessary (not sure)
- PM woman w/ recurrent dysuria + vaginal dryness à topical estrogen (not sure)
- Pregnant woman w/ white vaginal discharge (?bacterial vaginosis) after course of
amoxicillin à topical antifungal; I think this is Bacterial vaginosis (treat w/
metronidazole esp in pregnancy bc there is high risk of preterm delivery)
- Breast cancer with metastasis to thoracic spine, max analgesia à refer to
chemo/radio/psych/physio
 o ?Refer to palliative radiotherapy
§ Oxford p.1015 bone pain palliative care:
• Consider referral for palliative radiotherapy, strontium Tx
(prostate cancer) or IV bisphosphonates (reduce pain in
myeloma, breast and prostate cancer)
- Breast cancer post-palliative radio on 10mg morphine, now drowsy and over sedated
à increase dose/reduce/lower the dose to 5mg morphine sulphate/same and
monitor/switch to patches/add fentanyl; I would reduce the dose
o Oxford p.186: Drowsiness/cognative impairment à usually improves within
the first week. Advise pt not to drive, perform other skilled tasks, or work
with dangerous machinery if affected. If not improving, consider an
alternative opioid or refer for specialist help
§ From palliative care tutorial: other e.g. of strong opioids include
oxycodone/hydromorphone/fentanyl
- Pregnant women + slapped cheek à check parvovirus AB vs. refer for IVIG
o Oxford p. 792/793: Check for parvovirus B19 AB (IgG, IgM i.e. bloods for
serology). If infection detected à refer for specialist advise
- Pregnant woman w/ Hb 11.3, WBC N, platelets 440 à continue routine/refer to
haem/investigate low platelets
- Obese woman with heavy menstrual bleeding (flooding every month), over 35 years,
smoker – mirena coil (i.e. progesterone releasing IUS à used for heavy bleeding)
- Women - obese, smoking - POP
- Girl with menorrhagia and anaemic on blood test, what is most likely appearance on
blood film? Microcytic hypochromic
o Because menorrhage can cause iron deficiency anaemia from bleeding
o Iron deficiency = microcytic, hypochromic
- Breast feeding women with migraine with aura- COCP contraindicated
o Combined OCP is avoided in postpartum & breastfeeding women
- Nipple hyperpigmentation, breast soreness and urinary frequency- Beta HCG
o ?pregnent
§ nipples darken & enlarge at around 12 weeks gestation
§ During pregnency, breast lobules undergo hyperplasia driven by
increased estrogen & progestrone. increase of estrogen can lead to
breast tenderness
§ urinary frequency —> as baby grow in pelvic region, it will press on
other organs in pelvis e.g. bladder. Hence, urinary frequency
- Bilateral breast pain starting pre-menstruation and relieved with period- cyclical
breast pain
o e.g. due to hormonal changes (e.g. increase of estrogen).
o a lump that change in size with the menestral cycle = benign cystic breast
- Breast cancer, mets to spine - give radiotherapy
- Vaginal discharge and pain after intercourse with new partner- Swab for
chlamydia/gonorrhoea
o Discharge + pain post intercourse = worry about STI
- Women with PMB (postmenopausal bleeding)- endometrial biopsy
o from google:
§ Postmenopausal bleeding is vaginal bleeding that occurs a year or
more after your last menstrual period. It can be a symptom of vaginal
 dryness, polyps (noncancerous growths) or other changes in your
reproductive system. In about 10% of women, bleeding after
menopause is a sign of uterine cancer.
- Heavy menses - intrauterine levonergestrel
- Heavy menses, fatigue and SOB - microcytic, hypochromic and normocytic normochromic
o Iron deficiency from menorrhea and the fatigue/SOB are symp of iron deficiency
- Pregnant 22 weeks elevated platelets, low Hb - do bloods FBC with iron studies or just
continue because it is physiological.
o ?How low is iron? <11 might consider giving iron supplement + folate
- Woman who was a smoker, aged 43, looking for contraception, had no history of excessive
bleeding etc – progesterone only pill
- Woman who was 43 with the excessive bleeding – intrauterine system (e.g. progesterone
releasing IUS)
- Woman who comes into GP, not feeling the best, collapses – lie supine and call ambulance
- 70yo banged her head a month ago now unsteady on her feet
- Menorrhagia tx
- Contraception for a smoker (progesterone only)

- Clinical scenario à Antenatal care

o 3-4 health promotion for her current pregnancy
o Treatment of abdominal pain in pregnancyà Heat patches or Lignocaine
Therapy or Physiotherapy
§ Management of acute abdominal pain (in general) p.1078: Tx cause, if
unsure admit as surgical emergency. If possible, give analgesia prior to
transfer.
o 2 symptoms of pre-eclampsia: vomiting, epigastric pain, headache, visual
disturbance, decreased fetal movements, small for gestational age fetus all
correct
§ Oxford p.805: significant pre-eclampsia symp:
• Epigastric pain, vomiting, headache, visial disturbance, reduse
fetal movement, small for gestational age
o Breast engorgement

- Clinical Scenario à 42 y/o women with vaginal discharge, vulval soreness and
pruritis
o Most likely diagnosis- candida
o Treatment- fluconazole
o Still having discharge after medications; choose 3 investigations- endocervical
swab
o Wants contraception, bloods shows microcytic anaemia- Intrauterine coil

Paediatrics
- Baby wants more feeds, mom feels breast empty, weight from 3.1 to 3.4kg in 2w à
add extra bottle feed and re-weigh or have feeding schedule
 - 18 month old child with 24 hours vomiting, diarrhoea, no fever, appears well, good
form, wet nappies, cap refill <2secs à oral rehydration? Other options: oral
domperidone, loperamide, abx
- 10 y/o 38.7 temp, creps- Amoxicillin
o Temp. + creps on auscultation = ?pneamonia = Tx amoxicillin
- Child with bronchiolitis- symptomatic management
o correct + can consider prophylactic pavilizumab (protect against RSV)
- Child with vomiting and diarrhoea- rotavirus
o commonest cause of gastroenteritis
- child with abdominal distension, constipation and pallor- probably intussusception
- Child with mastoiditis - refer to A+E
- Child with lone playing, repeated words - ASD
- 18 month old with abdominal pain - FBC / Urine dipstick
- Child well, vomiting and diarrhoea - oral rehydration
- Child with lump in the neck, anterior to SCM and after a viral illness - branchial cyst
- Child with purpuric petechiae, GP 70 mins from hospital – im benzylpenicillin
- 18 month old child with the very heavy offensive diarrhea – oral rehydration
- lateral neck mass on three yo

- Clinical scenario à Paediatrics question

o Diagnosisà Acute otitis media
o Antibioticà Amoxicillin
o 2 DX to rule-out in nocturnal enuresisà UTI and Diabetes Mellitus
o 3 advice/non-pharmacological interventionsà Star Chart, Stop Fluid Intake
before Sleep and Use Bathroom before sleep

Haematology
- Nose bleeding, gum bleeding and bruising- thrombocytopenia
- 64 yr old with iron def anaemia- colonoscop
- 63yo M w/ fatigue + Hb/MCV/MCH/haematocrit low à colonoscopy vs. Vitamin B12
levels
- Elderly man with haemorrhoids, minimal bleeding every time with bowel movement,
normal PR exam- FBC to check for Fe deficiency anaemia??
o Oxford p. 374:
§ if piles are not obvious on exam, arrange protoscopy +/-
sigmoidoscopy for all pt >40 y/o
§ Tx: soften stool (bran, ispaghula husk) & recommended topical
analgesia (e.g. lidocaine 5% ointment or OTC preperation). if not
responding/uncertainityover Dx or severe symp. —> refer for surgical
assessment
- Low MCV: iron def
- Hypo microcytic
- FBC and iron studies?
- Investigate platelet/ go to clinic (high platelet)
Oncology
- 22 yr old with itching mild splenomegaly, night sweats, weight loss, non-tender
lymphadenopathy in axilla and neck – lymphoma
- appropriate management for a 54 year old lady with post-menopausal bleeding-
options were CA125, abdominal US, and endometrial biopsy. I would start with
abdominal US, then do endometrial biopsy. (ddx: cervical cancer; ca125 points
towards ovarian cancer and she doesn’t present those symptoms) – gynae
- Supraclavicular lump, feeling sick so small intake - gastric cance

ENT
- Benign paroxysmal positional vertigo - epleys maneuver
o from ENT:
§ Dx = dix-hallpike manuver
§ Tx = epley’s manuver
o Oxford (p. 929): usually self limiting, reassure pt, educate pt: sitting and lying
in stages. if not setteling = perform/refer to ENT for epley’s manauver and/or
refer to physiotherapy for exercise/vestibular rehabilitation
- BPPH- refer for Epley manuevre (see above)
- 60 something year old with hoarsness- refer to ENT
- Opera singer with hoarseness- vocal nodules
o Hoarsness = vocal cord affected
- Child with unilateral offensive nose bleed- foreign bod
- 19 y/o with nasal congestion- Intranasal fluticasone
o From Oxford p. 918:
§ nasal obstruction is a common symp. usually short in duration and
bilateral (if persistant unilateral blockage = assume neoplasm = refer
urgently to ENT)
o From clinic: nasal congestion can be Tx with saline/nasal spray
- Mastoiditis with ear painà refer to ER
- Hoarseness + HX of smoking à refer to ENT
- Girl with recent ear infection tx with Abx not resolved, now has protruding ear with
bony tender prominence behind the ear, what is best next step – refer to ED
- 19 y/o with nasal congestion- Intranasal fluticasone
o Fluticasone (steroid) nasal spray à used to treat nasal polyps (swelling of the
lining of the nose)
o Should NOT be used to teat symptoms (e.g. sneezing, stuffy, runny, itchy nose)
caused by common cold
- Submandibular swelling: reassure pt
- Hearing loss, previous otitis media, retracted ear drum - with effusion
- Smoking, alcohol, pharynx fine, hoarse 8 weeks - laryngeal cancer
- Obstructive sleep apnoea - lifestyle advise vs. polysonography
- Glue ear
- Refer to ED Mastoiditis
Ophthalmology
- headache, hazy eye, right eye pain, decreased visual acuity what does he have
(options migraine, acute angle closure glaucoma, giant cell arteritis)
- Pic of blood in eyes and high bp- reassure
- Picture: conjunctivitis à warm compresses vs. chloramphenicol
- Picture: haemorrhage with no traumaà refer to ophthalmology à (I DISAGREE, I
THINK IF THERE IS NOT HISTORY OF TRAUMA, IT WILL CLEAR SPONTANEOUSLY;
REFER IF HX OF TRAUMA) à CHECK
- Red eye, no trauma, young woman - reassure
- “Curtain coming down on eyes”, fine next day, examination N à refer to
optometrist/neuro/ophthalmology evaluation
- Blepharitis- wash with baby shampoo
o from optho red eye lecture: Tx = Warm lid compression, lid hygiene,
chloramphenicol ointment BD, Doxycyclin 50-100mg OD x 3/12, Artificial
tears (for symp. relief)
o from Oxford (look at p. 942 for details): Warmth (e.g. facial sauna), massage
(with cotton bud), clean (using diluted tea-tree oil baby shampoo)
- Bitemporal hemianopia- pituitary tumor
o pressing on optic chiasm
- End organ damage for eye- retinal haemorrhage and cotton wool spots??
o nope thats signs of pre-proliferative stage of eye disease which can be Tx
o ?other options:
o ? something that can lead to irreversable damage of eye/optic N.
- Male with joint pains and presenting with sudden vision loss in left eye- prednisone
60mg and refer urgently for temporal artery biopsy
o Joint pain + sudden loss of vision = WORRY about: Temporal arteritis —> Tx
steroids & Dx biopsy
- 6 week check, absent red reflex- urgent referral to ophthalmology
o Cuz ?retinoblastoma/?congenetal cataract
- Red eye picture - uveitis
- Photophobia with the red looking conjunctiva – episcleritis
- Other red eye, looked like subconjunctival haemorrhage – reassure the patient
- - bloody eye
- red eye with photophobia and pain

Geriatrics
- Woman in elderly home w/ incontinence x2w + not taking fiber for last 1m- what do
- Elderly woman brought in by her daughter, change in behaviour for last week. Thinks
neighbours stealing food from her fridge and can see them hiding in the garden.
Drowsiness or some clouded consciousness?? What test – options: FBC, random
glucose, urine dipstick, MRI brain
-

Medication related
- Man with ischaemic heart disease, well controlled ACEi, aspirin, beta blocker, what
would be most beneficial to add – simvastatin. Other options: diuretic,
antidepressant
 - Medication review: on anti-HTN, thiazide, aspirin, triptan PRN à which to remove? I
would remove Triptan
- Elderly man with polypharmacy, having falls lately, what medication most likely
causing them? Doxazosin. Other options: citalopram
- Diuretic started - what blood test - renal?
- Statin - LFTs
- NOAC - eGFR, APTT, monitor for signs of anaemia?
- Drug causing the mans postural hypotension – doxazosin (or whatever the alpha adrenegric
antagonist was)
- Renal function
- Aptt
- Iv benzylpenicillin?
- Statins- LFTs

Statistics
- NNT 4% and 2%
- Prognosis which study- cohort

Emergency
- Patient came in with anaphylactic shock, treated appropriately, fine now, next step-
send to ED
- Hemmorhage? Refer?

- Clinical Scenario à a patient Came in with angioedema, strider, wheeze can’t

breathe (anaphylaxis)
o Diagnosis- Anaphylactic shock
o Priority (SBA)- call ambulance
o Medication- adrenaline
o Route- IM
o 4 therapeutic indications- antihistamine; corticosteroid; observe for late
phase reaction; recognise trigger
o After, what to prescribe- Epi Pen

Dermatology
- Pic of lesion on mouth and smoker- SCC
- Vesicular rash itching all over- chicken pox
- Child with vesicular rash on hands, feet and mouth. Tx – supportive
- Picture of child with crusty golden lesion around nose and mouth – Impetigo (same
as tutorial)
- Impetigo - child with lesions
- Picture of BCC (same as in tutorial)
- Basal cell ca - red pearly lesion
- Picture- keratoacanthoma??
 o keratoacanthoma: “thought to be a type of squamous cell skin cancer”, which
is “self-healing”
o basically look up the shape of different skin lesions or access IC2 skin lecture
of CNS “L11 skin pathology” pathology // “L2 Skin cancer” surgery
- Picture- Comedonic acne
o small flesh-colored acne papules usually develop on forhead & chin
(blackheads & whiteheads are the most common forms of comedonal acne)
- Women with acne rosacea- metronidazole
o acne with redness & pimples that contain pus.
o Tx is oral antibiotics e.g. doxycycline // Best Tx: Topical metronidazole,
sulfacetamide/sulfur and azelaic acid. for moderate papulopustular rosacea,
combination therapy with oral tetracyclines and topical agents is the first-line
choice.
- Picture: seborrheic keratosis à cryotherapy or refer to dermatology or reassurance
- Picture- scabies
o Pro tip: google the pic XD
o Description of rash from google:
§ “little bumps that often form a line. The bumps can look like hives,
tiny bites, knots under the skin, or pimples. Some people develop scaly
patches that look like eczema”
- Scabies - women working in residential care, 2 week history of itching
- Picture: skin tags
- Picture: acne
- Picture: uveitis
- Picture: chicken pox
- Acantinic keratosis - women with sun exposure
- Sebacous cyst - biopsy / reassure
- Woman with rash on the back 2 weeks previously, not pain in the same area - neuropathy
answer???
- Diagnosis of skin lesion on nose – actinic keratosis
- Picture of lesion on mans forhead – basal cell carcinoma
- The other lesion with a blackhead top and was growing in size – biopsy lesion
- Post shingle neuralgia
- Scabies picture
- Management of cyst picture
- Cocksaxki supportive tx
- Impetigo
- Scabies
- Acetenic keratosis
- Basal cell carcinoma
- Pic of sebaceous cyst- conservative treatment

- pic of rosacea- metronidazole

- atopic dermatitis pic of infant

- Skin lesion + recent horse ridingà Tinea cruris

- Picture: molloscum contagiosum