PPQ Flashcards by ROHIT LAWRENCE (2024)

1. A 2y/o has episodes of falling to the ground whilst tightening and stiffening his hands, accompanied by screaming and sweating. During the episodes the child is inconsolable but between episodes the child is well with normal development. What is the most likely diagnosis?
   a.Hyperactivity
   b.Reflex anoxic seizure
   c.Temper tantrum
   d.Tonic-clonic seizure
   e.Vasovagal syncope

c. Temper tantrum

Temper tantrums are common in young children and can involve intense emotional and physical reactions, including screaming, stiffening, and sweating. The child being inconsolable during the episodes but appearing well and developing normally between episodes supports this diagnosis.

2. 5 y/o boy brought to GP with vague abdo pain. He has been having several loose bowel motions per day with occasional soiling of his underwear. His parents recall him passing a hard blood-streaked stool 5 days ago. Which is the most appropriate investigation?
   a.Colonoscopy with biopsies
   b.No investigations at this stage
   c.Stool microscopy, culture, and sensitivity
   d.Tissue transglutaminase antibody titres
   e.Urgent abdominal x-ray

b. No investigations at this stage

Initial management often includes dietary advice, hydration, and possibly the use of laxatives. If symptoms persist or worsen, further investigations may then be warranted.

6. Boy born at 40 weeks with male phenotype, but neither testicl* can be palpated on examination. What is the most likely diagnosis?
   a.Androgen insensitivity syndrome
   b.Excess in utero oestrogen exposure
   c.Klinefelter’s syndrome
   d.Physiological delay in descent
   e.Retractile testes

d. Physiological delay in descent

In newborn boys, it is common for the testes to not be fully descended at birth. While most boys have descended testes by the time they are born, a physiological delay in descent can occur, and the testes often descend within the first few months of life. This is a more likely and common scenario compared to other conditions listed.

NOTE: Androgen insensitivity syndrome typically presents with a phenotypically female appearance despite having a 46,XY karyotype.

8. 22 m/o child had cough and coryza for 2 days, and is now struggling with breathing. She has subcostal and intercostal recessions and widespread wheeze. Her temperature is 37.3, HR 125, RR 45, O2 sats 98% on room air. What is the most appropriate next step in her management?
   a.0.5L/min supplemental oxygen
   b.2 puffs beclomethasone inhaler
   c.10 puffs salbutamol inhaler
   d.Intravenous aminophylline
   e.Oral prednisolone

c. 10 puffs salbutamol inhaler

Given the clinical presentation of respiratory distress with wheezing, this likely represents an acute exacerbation of asthma or a similar reactive airway disease. Salbutamol (a bronchodilator) is the first-line treatment to relieve bronchospasm and improve breathing in such cases.

9. 3 month old boy has 2 days of fever and crying accompanied by reduced feeding and fewer wet nappies. Temperature 38.0, HR 170, RR 38, O2 sats 97% on room air. He has reduced movement in his right leg, chest is clear, urinanalysis is normal and anterior fontanelle is slightly sunken. What is the most likely diagnosis?
   a.Developmental dysplasia of the hip
   b.Non-accidental injury
   c.Osteomyelitis
   d.Reactive arthritis
   e.Sickle cell crisis

c. Osteomyelitis

Osteomyelitis, an infection of the bone, is consistent with the symptoms of fever, reduced movement in the affected limb, and systemic signs of infection such as irritability and decreased feeding. The sunken fontanelle indicates dehydration, likely secondary to the fever and reduced intake. Normal urinalysis helps rule out a urinary tract infection.

10. 3 m/o boy presents in acute respiratory failure and is diagnosed with Pneumocystis pneumonia. His parents are first cousins from Pakistan. What is the most likely underlying cause?
    a.Agammaglobulinaemia
    b.Chronic granulomatous disease
    c.Cystic fibrosis
    d.HIV infection
    e.Severe combined immunodeficiency

e. Severe combined immunodeficiency (SCID)

Pneumocystis pneumonia (PCP) is a rare but serious infection that typically occurs in individuals with significant immune deficiencies. The following points support SCID as the most likely underlying cause:

14. 6 y/o boy’s parents have noticed long-standing hearing difficulties and take him to GP. Teachers have commented on poor school performance and behaviour. Speech is normal and there is no otalgia. The ear canals are narrow with non-occluding wax. Which is the most appropriate next step in his management?
    a.Aural olive oil drops
    b.Grommet insertion
    c.Pure tone audiometry
    d.Referral for hearing aids
    e.Review in 3 months

c. Pure tone audiometry

Pure tone audiometry is a key diagnostic test to assess the extent and nature of hearing loss. This objective assessment will help determine the severity of the hearing impairment and guide further management. Here’s why this is the best next step:

17. 3 week old baby referred for prolonged jaundice, dark wet nappies, and pale stools. There are no developmental concerns and he is currently breastfed. Birth weight was 3.45kg and he currently weighs 3.2kg, Temperature is 37.1, HR 140, RR 45, O2 sats 98% on room air. Investigations:
    Hb 110 (normal)
    WCC 6 (normal)
    Platelets 430 (slightly high)
    Bilirubin 175 (high)
    Conjugated bilirubin 100 (high)
    ALP 160 (normal)
    ALT 35 (normal)
    Albumin 25 (lower end of normal)
    Sodium 137 (normal
    Potassium 4 (normal)
    What is the most appropriate next step in management?
    a.Feeding advice
    b.Inpatient ultrasound
    c.I.V. antibiotics
    d.Outpatient ultrasound
    e.Phototherapy

b. Inpatient ultrasound

The presence of prolonged jaundice with elevated conjugated bilirubin, pale stools, and dark urine raises concern for a biliary obstruction or other hepatobiliary pathology, such as biliary atresia. An inpatient ultrasound can help in the early diagnosis and management of these conditions, which is crucial for improving outcomes. Early identification and treatment of biliary atresia, for example, are essential for the effectiveness of surgical interventions like the Kasai procedure.

18. 5 y/o boy with 2 days of fever, runny nose, cough, and sore throat. He developed a rash over the past 24 hours, temperature 39.2, HR 105, RR 30, capillary refill <2 seconds and O2 sats are 98% on room air. There is cervical lymphadenopathy, a red tongue, cracked lips, and a fine erythematous macular rash all over his body. Which is the most effective treatment?
    a.Aciclovir
    b.Aspirin
    c.Co-amoxiclav
    d.Paracetamol
    e.Phenoxymethylpenicillin

B. Aspirin

Given the presentation described, which strongly suggests Kawasaki disease, the most effective treatment would involve aspirin in addition to IVIG. Aspirin is used in Kawasaki disease to reduce inflammation and the risk of coronary artery complications.

19. 18 m/o presents to GP with 1 day history of left ear pain. There is no discharge and mum reports normal number of wet nappies for that day. There is a bulging erythematous left tympanic membrane with no perforation. Temperature 38, HR 135, RR 33, O2 sats 98 on room air. What is the most appropriate management?
    a.Offer simple analgesia and an immediate prescription of amoxicillin
    b.Offer simple analgesia and ciprofloxacin ear drops
    c.Offer simple analgesia and delayed prescription of amoxicillin
    d.Offer simple analgesia and gentamicin ear drops
    e.Offer simple analgesia and reassurance

E

Acute otitis media is generally a self-limiting condition that does not require an antibiotic prescription. There are however some exceptions listed below. Analgesia should be given to relieve otalgia. Parents should be advised to seek medical help if the symptoms worsen or do not improve after 3 days.

ABx if > 4 days, younger than 2 with bilateral otitis media, otitis media with perf

If an antibiotic is given, a 5-7 day course of amoxicillin is first-line. In patients with penicillin allergy, erythromycin or clarithromycin should be given.

21. A 2 y/o in GP has worsening painful rash behind the knee for 5 days. He has eczema managed with E45 cream. Temperature 37.2, HR 130, RR 30, O2 sats 98%. What is the most appropriate management?
    a.Immediate referral to Paediatric A&E
    b.Give oral Aciclovir for 1 week
    c.Give oral Flucloxacillin for 1 week
    d.Give topical dermovate
    e.Give topical fusidic acid

E. Give topical fusidic acid

The description of a worsening painful rash suggests a possible secondary bacterial infection, especially considering the child’s eczema, which can predispose to bacterial skin infections. Fusidic acid is an antibiotic commonly used topically for skin infections, including those caused by Staphylococcus aureus, which is often implicated in eczema-related skin infections.

22. A 3 y/o boy in GP has left-sided neck lump on a background of 6 days of coryza, cough, and mild fever, but no systemic symptoms. Temperature 37.0, HR 105, capillary refill <1s, RR 26, O2 sats 99% on room air. ENT exam is normal and chest is clear. He has a single enlarged lymph node in the left posterior chain. What is the most appropriate next step in management?
    a.Arrange urgent ENT referral
    b.Arrange USS
    c.Arrange urgent FBC
    d.Prescribe Amoxicillin 250mg TDS for 7 days
    e.Reassurance and watchful waiting

e. Reassurance and watchful waiting

In a child with a recent upper respiratory tract infection (coryza, cough, mild fever) and a single enlarged lymph node in the posterior cervical chain, especially without systemic symptoms or concerning findings on examination, a conservative approach with reassurance and watchful waiting is often appropriate.

The likely diagnosis in Reactive cervical lymphadenopathy

28. 7 y/o boy in GP with bedwetting for 2 months having previously been dry at night since age 4. Abdo exam is normal. What is the most appropriate initial investigation?
    a.Abdominal USS
    b.Abdominal x-ray
    c.Finger prick glucose test
    d.Renal function
    e.Urine dipstick

e. Urine dipstick

Bedwetting (nocturnal enuresis) in a previously dry child may have various causes, including urinary tract infections, diabetes, constipation, or emotional stress. However, the most common cause is primary nocturnal enuresis, which is more likely if the child has never been dry at night consistently.

29. 35 y/o man presents to A&E agitated and requesting medication. He has mild tremor, cool and clammy skin, and goosebumps (piloerection). Ambulance staff found him in the street with an empty bottle of cider. Temperature 36.8, BP 140/100, HR 100. What is the most likely diagnosis?
    a.Alcohol intoxication
    b.Alcohol withdrawal syndrome
    c.Opiate intoxication
    d.Opiate withdrawal syndrome
    e.Tricyclic antidepressant intoxication

b. Alcohol withdrawal syndrome

Alcohol withdrawal syndrome typically occurs in individuals with a history of heavy or prolonged alcohol use who suddenly reduce or cease their alcohol intake. Common symptoms include agitation, tremors, autonomic hyperactivity (such as cool and clammy skin, piloerection), and in severe cases, hallucinations, seizures, or delirium tremens.

Given the presentation of agitation and physical signs such as tremor and autonomic hyperactivity, along with the history of alcohol consumption, alcohol withdrawal syndrome is the most likely diagnosis in this case.

30. 20 y/o medical student attends A&E on the eve of an exam with difficulty breathing, palpitations, and chest tightness. She says she feels close to collapse, and feels like she is going to die. This has happened before and she was prescribed Propranolol but this is no longer effective, and she has routinely declined psychological interventions. Routine blood tests, ECG, and CXR are all normal. What is the most appropriate next step in her management?
    a.Diazepam
    b.Fluoxetine
    c.Mirtazapine
    d.Risperidone
    e.Venlafaxine

B. Fluoxetine

Fluoxetine is a selective serotonin reuptake inhibitor (SSRI) antidepressant commonly used in the treatment of panic disorder and other anxiety disorders. It is effective in reducing the frequency and severity of panic attacks and can provide long-term relief when taken regularly.

31. 30 y/o white woman is on routine anti-psychotic medication for schizophrenia and has the following blood result:
    Hb 140 (normal)
    WCC (low)
    Platelets 200 (normal)
    Neutrophils 1.2 (low)
    Lymphocytes 1.3 (normal)
    Total cholesterol 5.3 (high)
    Total cholesterol: HDL ratio 4.6 (high)
    HbA1C 40 (normal)
    What medication is she most likely taking?
    a.Aripiprazole
    b.Clozapine
    c.Haloperidol
    d.Quetiapine
    e.Risperidone

B. Clozapine

Clozapine is an atypical antipsychotic medication commonly used in the treatment of schizophrenia, particularly in cases where other antipsychotic medications have been ineffective or poorly tolerated.

The blood results provided, specifically the low white cell count (WCC), low neutrophil count, and normal lymphocyte count, are consistent with potential hematological side effects of clozapine, such as agranulocytosis or neutropenia. Regular monitoring of blood counts is essential when using clozapine due to the risk of these adverse effects.

33. 21 y/o woman admitted to psych ward for an acute episode. She has been prescribed Amisulpride for the past 3 weeks and is now worries she is pregnant because she has missed her period, however her pregnancy test is negative. Which blood test should be requested in addition to routine bloods?
    a.Luteinising hormone
    b.Progesterone
    c.Prolactin
    d.Thyroid stimulating hormone
    e.Triglycerides

c. Prolactin

Amisulpride is an antipsychotic medication that can increase prolactin levels by blocking dopamine receptors in the brain. Elevated prolactin levels can lead to amenorrhea (missed periods) and galactorrhea (milk production from the breasts) in women.

Therefore, checking serum prolactin levels can help assess whether the missed period is due to elevated prolactin levels induced by Amisulpride. If prolactin levels are found to be elevated, this could explain the amenorrhea, and appropriate management or adjustment of medication can be considered.

34. 15 y/o girl has 12 months of irritable mood, lack of pleasure, poor sleep, poor concentration, and low appetite. She is struggling to concentrate at school and is getting into trouble for low marks. What is the most appropriate first-line treatment?
    a.Cognitive analytic therapy
    b.Cognitive behavioural therapy
    c.Family therapy
    d.Fluoxetine
    e.Sertraline

d. Fluoxetine

Fluoxetine is a selective serotonin reuptake inhibitor (SSRI) antidepressant commonly used in the treatment of major depressive disorder (MDD) in adolescents. It is one of the first-line pharmacological treatments for depression in this age group, as recommended by clinical guidelines.

37. 19 y/o man with 1 day of fever, muscle stiffness, palpitations, and difficulty breathing. He has a history of psychotic depression for which he has been taking Fluoxetine for 6 weeks and Risperidone for 1 week. He is agitated with temperature of 39.8, HR 114, BP 172/89, and RR 30. Chest examination is otherwise clear, and neuro exam is normal except for globally increased tone. Which investigation would be most useful diagnostically?
    a.CT head
    b.ECG
    c.EEG
    d.Lumbar puncture
    e.Serum creatine kinase

e. Serum creatine kinase (CK)

The presentation is suggestive of a potential serotonin syndrome, a potentially life-threatening condition characterized by excessive serotonin activity in the central nervous system. Serotonin syndrome can occur as a result of the interaction between serotonergic medications such as Fluoxetine and Risperidone, leading to symptoms such as fever, muscle rigidity, agitation, and autonomic instability.

Serum CK levels can be elevated in serotonin syndrome due to the muscular hyperactivity and breakdown associated with the condition. Elevated CK levels can help support the diagnosis of serotonin syndrome and differentiate it from other conditions presenting with similar symptoms.

38. 23 y/o man admitted for 3rd person auditory hallucinations, irritability, and beliefs that his neighbours are watching him. This is the first time he has experienced these symptoms and they have lasted for 3 weeks. What is the most likely diagnosis?
    a.Acute and transient psychotic disorder
    b.Adjustment disorder
    c.Paranoid personality disorder
    d.Schizoaffective disorder
    e.Schizophrenia

a. Acute and transient psychotic disorder

Acute and transient psychotic disorder is characterized by the sudden onset of psychotic symptoms, such as hallucinations, delusions, disorganized thinking, or grossly disorganized or catatonic behavior, lasting for at least a day but less than a month. This diagnosis is appropriate when the symptoms do not meet the criteria for other psychotic disorders like schizophrenia.

Given the brief duration of symptoms (less than a month) and the absence of a clear history of recurrent psychotic episodes or chronicity, acute and transient psychotic disorder is the most likely diagnosis in this case.

39. 15 y/o girl in A&E after fainting at school. BMI is 16, she has been restricting calorie intake for 1 year, she exercises every day and feels she is overweight. Which additional feature would be needed for a diagnosis of anorexia nervosa?
    a.Bradycardia
    b.Fear of gaining weight
    c.Laxative abuse
    d.Muscle weakness
    e.Thinning of hair on head

b. Fear of gaining weight

An essential diagnostic criterion for anorexia nervosa is a persistent fear of gaining weight or becoming fat, despite being underweight. This fear may manifest in various behaviors, including restrictive eating, excessive exercise, and avoidance of calorie-dense foods.

40. 45 y/o man presents with worsening tremor for a few weeks. Has a history of schizophrenia in remission for which he is taking Haloperidol. There is bilateral tremor and cog-wheel rigidity in upper limbs. What is the most appropriate treatment for his symptoms?
    a.Co-beneldopa
    b.Entacapone
    c.Pramipexole
    d.Procyclidine hydrochloride
    e.Selegiline hydrochloride

d. Procyclidine hydrochloride

The presentation of bilateral tremor and cog-wheel rigidity suggests parkinsonism, a movement disorder characterized by symptoms similar to those of Parkinson’s disease. Haloperidol, an antipsychotic medication, can induce extrapyramidal symptoms such as parkinsonism as a side effect.

Procyclidine hydrochloride is an anticholinergic medication commonly used to alleviate extrapyramidal symptoms induced by antipsychotic medications like Haloperidol. It works by blocking the action of acetylcholine in the central nervous system, which can help reduce tremor, rigidity, and other parkinsonian symptoms.

42. 84 y/o man presents with gradual deterioration in memory for 3 years. He forgets details of conversations and to attend doctor’s appointments, though he can still manage his finances and cook and clean for himself. He regularly goes to the local shops and never gets lost. Which part of the brain is likely to be affected?
    a.Cerebellum
    b.Frontal lobe
    c.Occipital lobe
    d.Parietal lobe
    e.Temporal lobe

e. Temporal lobe

The temporal lobes play a crucial role in memory formation and retrieval, particularly episodic memory, which involves the recollection of specific events and experiences. Damage or degeneration in the temporal lobes can lead to difficulties in forming new memories and retrieving past memories, resulting in symptoms such as forgetfulness and memory loss.

Given that the individual is experiencing memory problems but still retains functional abilities related to daily living (such as cooking, cleaning, managing finances, and navigating familiar environments), it suggests that the memory impairment is selective and not globally disabling. This pattern of impairment is often seen in conditions affecting the temporal lobes, such as Alzheimer’s disease, which is the most common cause of age-related memory decline and dementia.

43. A 25 y/o man has tried Olanzapine and Haloperidol but continues to experience symptoms of schizophrenia. What is the most appropriate next step in his management?
    a.Aripirazole
    b.Clonazepam
    c.Clozapine
    d.Lithium
    e.Quetiapine

Clozapine

Clozapine is considered the gold standard for treatment-resistant schizophrenia. It has been shown to be effective in patients who have not responded to other antipsychotic medications. However, it is typically reserved as a second-line or third-line option due to its potential for serious side effects, including agranulocytosis (a significant reduction in white blood cell count), which requires regular monitoring.

44. 25 y/o woman has recurrent episodes of sudden onset sweating, dry mouth, “butterflies” in her stomach, difficulty breathing, and fear of impending death. These symptoms have been occurring twice weekly for the past 2 years. What is the most likely diagnosis?
    a.Dissociative disorder
    b.Generalised anxiety disorder
    c.Hypochondriasis
    d.Panic disorder
    e.Somatisation disorder

Panic disorder

Panic disorder is characterized by recurrent and unexpected panic attacks, which are sudden episodes of intense fear or discomfort that reach a peak within minutes. The symptoms described in the scenario, including sweating, dry mouth, gastrointestinal discomfort (“butterflies” in the stomach), difficulty breathing, and fear of impending doom, are typical features of panic attacks.

The presence of recurrent panic attacks over a period of at least several months, accompanied by persistent worry about having additional attacks, or significant behavioral changes related to the attacks, is consistent with the diagnosis of panic disorder.

While other conditions such as generalized anxiety disorder (Option b) involve excessive worry and anxiety, panic disorder specifically involves recurrent panic attacks characterized by sudden and intense fear.

45. 19 y/o woman with OCD is prescribed Sertraline at the maximum dose but it doesn’t control her symptoms. She has been unable to attend university for 4 months, and CBT has not helped in the past. What is the most appropriate next step in her management?
    a.Add another antidepressant
    b.Change to an antidepressant of another class
    c.Refer for additional and more intensive CBT
    d.Refer for deep brain stimulation
    e.Refer for ECT

B. Change to an antidepressant of another class

When a patient with OCD does not respond adequately to one selective serotonin reuptake inhibitor (SSRI) such as Sertraline, switching to another antidepressant of a different class, such as a tricyclic antidepressant (TCA) or a serotonin-norepinephrine reuptake inhibitor (SNRI), may be considered.

49. 25 y/o man attends A&E with headache. He is speaking rapidly and smiling as he talks. He scratches his skin constantly and claims to feel insects crawling up him. His temperature is 36.5, HR 130, and BP 154/84. What is the most likely diagnosis?
    a.Alcohol withdrawal
    b.Benzodiazepine withdrawal
    c.Cannabis intoxication
    d.Cocaine intoxication
    e.Heroin withdrawal

d. Cocaine intoxication

Cocaine is a stimulant drug that can cause a range of physiological and psychological effects, including euphoria, increased energy, rapid speech, tactile hallucinations (such as the sensation of insects crawling on or under the skin, known as formication), and heightened sympathetic activity leading to elevated heart rate and blood pressure.

Scratching behavior, often described as “cocaine bugs” or “cocaine psychosis,” is a common phenomenon associated with cocaine use, where individuals experiencing tactile hallucinations may scratch or pick at their skin in an attempt to alleviate the sensation of insects crawling on or under the skin.

51. 45 y/o man is taken to A&E by police who are concerned for his health after being in custody for 20 hours. He is known to consume alcohol to excess, and appears dishevelled, agitated, and is tremulous. Blood tests are unremarkable except for moderately deranged LFTs. What is the most likely diagnosis?
    a.Alcohol withdrawal syndrome
    b.Alcohol induced hepatitis
    c.Hepatic encephalopathy
    d.Opioid withdrawal syndrome
    e.Wernicke’s encephalopathy

Alcohol withdrawal syndrome

Alcohol withdrawal syndrome typically occurs in individuals with a history of chronic alcohol abuse who suddenly decrease or stop their alcohol consumption. Symptoms may include agitation, tremors, anxiety, sweating, nausea, vomiting, insomnia, and occasionally hallucinations or seizures.

The presentation described, including agitation, tremors, and elevated LFTs, is consistent with alcohol withdrawal syndrome. The tremulousness and agitation suggest autonomic hyperactivity, which is characteristic of alcohol withdrawal.

53. 58 y/o man attends addiction services for initial alcohol dependence assessment. He regularly attends A&E following overdose attempts. He requests detoxification. He lives alone with few social contacts and has poorly controlled asthma. What is the most appropriate next step in management?
    a.CBT
    b.Community detoxification
    c.Disulfiram
    d.Inpatient detoxification
    e.Motivational interviewing

d. Inpatient detoxification

Inpatient detoxification offers a structured and supervised environment where the patient can receive medical care and support during the withdrawal process. This setting is particularly important for individuals with severe alcohol dependence and those at risk of complications such as overdose attempts, as it allows for close monitoring of symptoms and medical management of any complications that may arise.

Inpatient detoxification also provides an opportunity for comprehensive assessment, including evaluation of the patient’s asthma and optimization of asthma management during detoxification.

54. 30 y/o man attends A&E with palpitations, dizziness, and chest pain – he is worried that he has had a heart attack. The chest pain is sharp and variable in location, and he gives a history of 6 months of low mood following being laid off from work. He has attended multiple local hospitals for several years and has reported a variety of different symptoms including headaches over the right ear, difficulty swallowing, and griping stomach pains, but says “the doctor’s haven’t been able to find out what’s wrong with me”. His ECG is normal. What is the most likely diagnosis?
    a.Borderline personality disorder
    b.Factitious disorder
    c.Generalised anxiety disorder
    d.Panic disorder
    e.Somatisation disorder

e. Somatization disorder

Somatization disorder is characterized by the presence of multiple physical symptoms that cannot be explained by a medical condition. These symptoms often lead to frequent medical visits and investigations, as the individual believes them to be indicative of a serious illness despite medical reassurance. The symptoms are typically varied and may involve different organ systems.

The patient’s history of chest pain, dizziness, palpitations, headaches over the right ear, difficulty swallowing, and griping stomach pains, along with normal findings on ECG and a history of low mood following job loss, are consistent with the diagnosis of somatization disorder.

55. A 35 y/o man with Fragile X syndrome lives alone, does voluntary work, and travels independently to familiar places, though he needs help planning travel to new areas. He attended a special needs school and has a carer supporting him by helping him to pay his bills. What is his most likely IQ?
    a.20
    b.40
    c.65
    d.80
    e.110

65

Individuals with Fragile X syndrome typically exhibit a wide range of intellectual abilities, but the majority fall within the mild to moderate range of intellectual disability. An IQ of around 65 would be consistent with the level of independence described in the scenario, where the individual can perform some tasks independently but may require support with more complex activities and decision-making.

59. 48 y/o man has hypertension, anxiety, gout, and back pain. His routine ECG shows a QT interval of 460ms (380-440 normal range). Which is the most likely causative medication?
    a.Allopurinol
    b.Amitriptyline
    c.Co-codamol
    d.Diazepam
    e.Ramipril

b. Amitriptyline

Amitriptyline is a tricyclic antidepressant (TCA) known to prolong the QT interval. Prolongation of the QT interval can predispose individuals to a type of arrhythmia called torsades de pointes, which can be life-threatening.

62. A 29 y/o woman in GP is complaining of palpitations, sweating, dry mouth, and paraesthesia each time she leaves the house. She has a PMHx of asthma. Which is the most appropriate drug class to use?
    a.Atypical anti-psychotic
    b.Benzodiazepine
    c.Beta blocker
    d.Sedating antihistamine
    e.SSRI

Beta blocker

These symptoms are suggestive of anxiety or panic attacks, especially given their occurrence in specific situations (leaving the house), and beta blockers are commonly used to manage the physical symptoms associated with anxiety or panic disorders. Beta blockers can help alleviate symptoms such as palpitations, sweating, and tremors by blocking the effects of adrenaline on the heart and peripheral vasculature, thus reducing sympathetic nervous system activity.

63. 38 y/o woman in GP has 8 months of amenorrhea on a background of T2DM and BPAD. Her pregnancy test is negative. Investigations:
    Luteal LH 2.0 (normal)
    Luteal FSH 2.0 (normal)
    TSH 2.3 (normal)
    Testosterone 1.0 (normal)
    SHBG 80.0 (normal)
    Prolactin 821 (high)
    Which medication is most likely to have caused this?
    a.Diazepam
    b.Metformin
    c.Risperidone
    d.Sertraline
    e.Zopiclone

c. Risperidone

Risperidone is an atypical antipsychotic medication commonly used to treat conditions like bipolar affective disorder. It is known to increase prolactin levels through its dopamine receptor-blocking effects, particularly at higher doses. Elevated prolactin levels can lead to amenorrhea or irregular menstrual cycles in women due to the suppression of gonadotropin-releasing hormone (GnRH) from the hypothalamus, which in turn inhibits ovulation.

65. 28 y/o woman attends GP for 6 week post-natal check following emergency C-section. She is feeling tired, low in energy, has poor appetite, and is having some frightening thoughts or about hurting her baby. Which is the most likely diagnosis?
    a.Adjustment disorder
    b.Baby blues
    c.PTSD
    d.Post-natal depression
    e.Puerperal psychosis

d. Post-natal depression

Post-natal depression is a mood disorder that can occur after childbirth, typically within the first few weeks to months. It is characterized by symptoms such as low mood, tearfulness, irritability, fatigue, changes in appetite, and difficulty bonding with the baby. Frightening thoughts about harming the baby can also occur in post-natal depression, although it’s important to note that these thoughts are distressing to the mother and are not acted upon

67. 24 y/o seen in GP for 6 months of low mood, poor concentration, and trouble sleeping. He denies suicidal ideation or self-harm. He denies drinking excessively, smoking at all, and using recreational drugs. He is a waiter and is struggling at work and has a PHQ-9 of 6 (mild severity). What is the most appropriate course of action?
    a.Advise mindfulness classes
    b.Refer for CBT
    c.Start Citalopram
    d.Start Fluoxetine
    e.Write a fit note (medical certificate) for 4 weeks

Advise mindfulness classes

Mindfulness-based interventions, such as mindfulness classes, have been shown to be effective in reducing symptoms of depression, particularly in individuals with mild-to-moderate depression. They provide techniques for managing stress, enhancing self-awareness, and promoting emotional regulation, which can be beneficial for individuals experiencing low mood and other depressive symptoms.

69. 29 y/o woman visits GP with heavy sensation in her vagin* when exercising. She is aware of a bulge in her vagin*, sometimes associated with a desire to urinate. She had a vagin*l delivery 2 years ago. O/E there is some laxity of the anterior vagin*l wall but this does not descend to the introitus on straining. Urine culture is negative. What is the most appropriate management plan?
    a.Oxybutynin hydrochloride
    b.Pelvic floor exercises
    c.Refer for urodynamic testing
    d.Refer to urogynaecology clinic
    e.USS of pelvis

b. Pelvic floor exercises

Pelvic floor exercises, also known as Kegel exercises, are commonly recommended as the first-line treatment for mild to moderate symptoms of pelvic organ prolapse, which appears to be the likely diagnosis in this case. These exercises aim to strengthen the muscles supporting the pelvic organs and can help improve symptoms of pelvic floor dysfunction, including sensations of heaviness or bulging in the vagin* and urinary symptoms

70. 42 y/o woman is 34 weeks pregnant and has had repeat admissions for severe abdominal pain. She currently needs opiate analgesia but is still struggling with the pain. USS shows a sub-serosal fibroid measuring 7cm x 9cm. What is the best management option for her pain?
    a.Continuous regular opiates
    b.Epidural anaesthesia
    c.NSAIDs
    d.Remifentanyl patient-controlled analgesia
    e.Uterine artery embolisation

NSAIDs

Nonsteroidal anti-inflammatory drugs (NSAIDs) can be considered as the best management option for her pain in this situation. NSAIDs are effective for managing pain associated with fibroids and are relatively safe to use during pregnancy, especially in the third trimester. However, they should be avoided earlier in pregnancy due to potential risks to the fetus, such as premature closure of the ductus arteriosus and oligohydramnios.

72. 33 y/o woman 32 weeks pregnant has glycosuria for the second time. Fundal height is 36cm and the fetal parts are difficult to palpate. Her routine glucose testing at 27 weeks was normal. What is the most appropriate next step in her management?
    a.Advise low glycaemic index diet
    b.Perform 75g glucose tolerance test
    c.Send HbA1c
    d.Start Insulin
    e.Start Metformin

b. Perform 75g glucose tolerance test

The presence of glycosuria, increased fundal height, and difficulty palpating fetal parts suggest the possibility of gestational diabetes mellitus (GDM) or macrosomia (large fetal size). While routine glucose testing at 27 weeks was normal, the development of glycosuria at 32 weeks raises concerns for glucose intolerance that may have developed later in pregnancy.

Performing a 75g glucose tolerance test (GTT) would help to accurately diagnose gestational diabetes mellitus (GDM) and guide appropriate management. This test is the gold standard for diagnosing GDM and involves measuring blood glucose levels at fasting and at specific time intervals after a glucose load.

75. 40 y/o woman is successfully treated for ectopic pregnancy with methotrexate. After what interval may she safely conceive again?
    a.1 year
    b.3 months
    c.6 months
    d.Her next menses
    e.Immediately

c. 6 months

Waiting for at least 6 months after methotrexate treatment for an ectopic pregnancy before attempting to conceive again is often recommended. This allows time for the methotrexate to clear from the body and reduces the risk of potential complications or adverse effects on a subsequent pregnancy.

77. A woman is having a repeat USS at 32 weeks gestation for a previously low-lying placenta. The USS shows the placenta is clear of the cervical os and an additional succenturiate lobe is seen. Which condition needs to be excluded in the USS?
    a.Cervical shortening
    b.Fetal growth restriction
    c.Placenta praevia
    d.Vasa praevia
    e.Velamentous cord insertion

d. Vasa praevia

Vasa praevia is a rare but potentially life-threatening condition where fetal blood vessels, unprotected by Wharton’s jelly, run across the internal os of the cervix or between the placental lobes. This condition can lead to vessel rupture and severe fetal hemorrhage during labor or rupture of membranes.

While the presence of a low-lying placenta (placenta previa) was previously a concern, the current ultrasound showing the placenta clear of the cervical os eliminates this as a primary concern. The additional finding of a succenturiate lobe indicates the presence of an accessory placental lobe, which is typically not associated with significant risks.

80. 63 y/o woman presents with a 2 week history of post-menopausal vagin*l bleeding. BMI is 39.2. Pelvic USS shows irregular endometrial thickening (14mm). Outpatient endometrial sampling fails because of cervical stenosis. What is the most appropriate management?
    a.CT abdomen and pelvis
    b.Hysteroscopy with dilatation and curettage
    c.Repeat USS in 2 weeks
    d.Total abdominal hysterectomy + bilateral salpingo-oopherectomy
    e.Total laparoscopic hysterectomy + bilateral salpingo-oopherectomy

b. Hysteroscopy with dilatation and curettage

Hysteroscopy with dilatation and curettage (D&C) is the most appropriate next step in this situation. It allows direct visualization of the endometrial cavity and enables targeted biopsy or removal of any suspicious tissue. Additionally, cervical stenosis can often be managed during hysteroscopy by dilating the cervix, allowing for successful sampling or biopsy.

81. 32 y/o nulliparous woman is 8 weeks pregnant and experiencing severe nausea and vomiting that makes it impossible for her to work. She is taking 50mg cyclizine OD (once daily) with no effect. What is the best next management option?
    a.Admit for I.V. fluids
    b.Change to prochlorperazine
    c.Increase frequency of cyclizine to TDS (three times daily)
    d.Add a PPI
    e.Add Prochlorperazine

B. Change to prochlorperazine

Switching to prochlorperazine (Option b) is indeed a reasonable next step in the management of severe nausea and vomiting (hyperemesis gravidarum) in pregnancy if cyclizine is ineffective. Prochlorperazine is another commonly used antiemetic medication that may be more effective for some individuals.

82. 29 y/o woman with past history of cocaine and cannabis use denies using for the past 3 years. Which additional test should be done for this patient at booking?
    a.Hair toxicology screen
    b.Hepatitis C
    c.Hepatitis E
    d.Serum toxicology screen
    e.Urine toxicology screen

e. Urine toxicology screen

Urine toxicology screening is a common method used to detect recent drug use. It can detect the presence of various substances, including cocaine and cannabis, typically within a few days to a week after use, depending on factors such as the frequency and amount of drug use.

83. 33 y/o woman has Ventouse delivery at 39 weeks gestation and requires manual removal of placenta. The removal is uncomplicated with an EBL of 600ml. She plans to mix feed her baby for the first 6 months. When can she expect her menstrual cycle to return?
    a.Cannot be predicted
    b.When she is more than 50% bottle feeding
    c.When she stops breastfeeding
    d.Within 6 months
    e.Within 6 weeks

a. Cannot be predicted

After a vagin*l delivery, the return of menstruation can vary from woman to woman, and it is influenced by factors such as breastfeeding, hormonal changes, and individual physiology.

In the case of mixed feeding, where the mother is both breastfeeding and supplementing with formula, the return of menstruation can be more variable compared to exclusive breastfeeding. Breastfeeding typically delays the return of menstruation due to the suppression of ovulation caused by the hormone prolactin.

Given that the woman plans to mix feed her baby for the first 6 months, it’s likely that she may experience a delay in the return of her menstrual cycle compared to if she were exclusively bottle feeding. However, the return of menstruation cannot be predicted with certainty, as it varies among individuals.

85. 20 y/o woman attends A&E. She realised 4 days after her menses finished that she had forgotten to remove her tampon. She has now removed it and is asymptomatic but concerned about the possible consequences. What is the most appropriate management?
    a.Advise vagin*l douching
    b.Arrange USS pelvis
    c.Perform high vagin*l swabs
    d.Prescribe prophylactic antibiotics
    e.Reassure and discharge

e. Reassure and discharge

If the woman has removed the forgotten tampon and is asymptomatic, there is typically no need for further intervention

86. 60 y/o woman presents with discomfort during sex and vagin*l dryness. What is the best management option?
    a.Commence oral HRT
    b.Commence SSRI
    c.Commence topical vagin*l oestrogen
    d.Commence transdermal HRT
    e.Commence vagin*l lubricants

c. Commence topical vagin*l estrogen

Topical vagin*l estrogen therapy is often considered the first-line treatment for symptoms of vagin*l dryness and discomfort during intercourse in postmenopausal women. It works by replenishing estrogen levels in the vagin*l tissues, restoring moisture and elasticity, and improving symptoms of vagin*l atrophy.

88. 17 y/o girl has delayed menarche and short stature. Investigations:
    FSH 70 (very high)
    LH 40 (very high)
    Which investigation is likely to produce a definitive diagnosis?
    a.Karyotyping
    b.MRI scan of pituitary fossa
    c.Serum oestradiol
    d.Thyroid function tests
    e.Pelvic USS

a. Karyotyping

Karyotyping can help identify any chromosomal abnormalities, such as Turner syndrome (45,X), which is a common cause of POI in young females. Turner syndrome is associated with short stature, delayed puberty, and ovarian dysgenesis.

89. 40 y/o woman is having a normal vagin*l delivery with planned active management of third stage. She has a history of essential hypertension. Which is the most appropriate drug to reduce risk of post-partum haemorrhage?
    a.Dinoprostone (prostaglandin E2)
    b.Ergometrine maleate
    c.Labetalol hydrochloride
    d.Magnesium sulphate
    e.Oxytocin (Syntocinon)

e. Oxytocin (Syntocinon)

Oxytocin is the preferred uterotonic agent for preventing postpartum hemorrhage during the third stage of labor. It is a synthetic form of the natural hormone oxytocin, which stimulates uterine contractions and helps to prevent excessive bleeding after delivery by promoting the contraction of the uterine muscles and reducing the risk of uterine atony.

90. 32 y/o woman has diagnostic laparoscopy to investigate pelvic pain, and has a catheter inserted in recovery for urinary retention. The catheter is removed the next morning. When can she be safely discharged home?
    a.When she has voided more than 200ml
    b.Straight away with advice to return if she has problems voiding
    c.When her post-void residual volume is 0ml
    d.When her post-void residual volume is 100ml
    e.When her post-void residual volume is 300ml

92. 25 y/o woman who is 38 weeks pregnant is seen in triage for irregular painful contractions lasting 6 hours. She took paracetamol 6 hours ago. She is examined and found to be 2cm dilated. Which analgesia is most appropriate?
    a.Co-dydramol
    b.Epidural analgesia
    c.Nitrous oxide
    d.NSAID
    e.Warm bath

b. Epidural analgesia

Epidural analgesia is commonly used during labor to provide effective pain relief while allowing the woman to remain awake and alert. It can provide continuous pain relief throughout labor and delivery, making it suitable for women experiencing prolonged or intense pain during labor.

93. 41 y/o women attends her dating scan. LMP dates make her 12 weeks pregnant. An intrauterine pregnancy is seen with no fetal heartbeat. CRL is equivalent to a fetus of 9 weeks gestation. What is the best next step?
    a.Admit her for laparoscopy
    b.Counsel her on management options for miscarriage
    c.Offer her a repeat USS in 1 week
    d.Offer treatment with methotrexate
    e.Serum beta-hCG now and repeat in 48 hours

b. Counsel her on management options for miscarriage.

In this case, the woman should be informed about the diagnosis of a missed miscarriage and offered options for management, which may include expectant management (allowing the miscarriage to occur naturally), medical management (using medication to induce miscarriage), or surgical management (such as dilation and curettage). The choice of management option should be based on the woman’s preferences, clinical condition, and any medical indications.

94. 37 y/o woman has her anomaly scan at 20+3 weeks of pregnancy, and it reveals echogenic bowel. What is the most likely cause?
    a.Duodenal atresia
    b.Incidental finding
    c.Male gender
    d.Trisomy 18
    e.Trisomy 21

b. Incidental finding.

Echogenic bowel can sometimes be seen as an incidental finding on ultrasound and may not necessarily indicate a specific abnormality or pathology. However, it can also be associated with certain conditions such as infections, genetic abnormalities (such as trisomy 21 or 18), fetal bowel obstruction (like duodenal atresia), or other gastrointestinal issues. While trisomy 21 can sometimes present with echogenic bowel, trisomy 18 is more strongly associated with this finding.

95. 29 y/o woman had had intermittent vagin*l bleeding since insertion of the Mirena coil 6 weeks ago. What is the most appropriate investigation?
    a.Cervical smear
    b.Colposcopy
    c.High vagin*l swab
    d.No investigation required
    e.Transvagin*l pelvic USS

e. Transvagin*l pelvic ultrasound (USS)

Transvagin*l pelvic ultrasound would help assess the position of the Mirena coil, ensuring it’s properly placed within the uterine cavity and ruling out any complications, such as uterine perforation or abnormal positioning, which could be causing the vagin*l bleeding. Additionally, it can help evaluate the endometrial lining and identify any other potential causes of the bleeding. Therefore, this investigation is crucial in determining the cause of the symptoms and guiding further management.

96. A woman with sickle cell trait is 8 weeks into an unplanned pregnancy. Which investigation should be offered first?
    a.Chorionic villus sampling
    b.Free fetal DNA testing
    c.Partner FBC
    d.Partner haemoglobin electrophoresis
    e.Partner karyotyping

d. Partner haemoglobin electrophoresis.

This investigation is essential because if the partner is found to have sickle cell trait or another hemoglobinopathy, it could increase the risk of the unborn child inheriting a more severe form of the disease, such as sickle cell disease or another hemoglobinopathy. Identifying the partner’s hemoglobin status allows for informed genetic counseling and consideration of further testing or interventions to assess the risk to the fetus.

97. A Rh negative woman has light vagin*l bleeding and pain at 9 weeks gestation. USS shows a viable 9 week intrauterine pregnancy. The bleeding resolves 48 hours later. What further treatment does she require?
    a.250IU Anti-D prophylaxis immediately
    b.Kleihauer test
    c.No further action
    d.Progesterone pessaries
    e.Repeat scan in 2 weeks

c. No further action.

Since the woman’s Rh status is negative and there are no signs of miscarriage or complications following the bleeding episode, further treatment, such as Anti-D prophylaxis or progesterone pessaries, is not indicated at this time.

100. 24 y/o woman has urge incontinence causing low mood. She previously had a cl*toridectomy aged 7 years old in Somalia. She is nulliparous. She has two younger brothers. What is the most appropriate next step in her management?
     a.Referral to FGM clinic
     b.Referral to mental health team
     c.Referral to police
     d.Referral to social services
     e.Referral to uro-gynaecology

102. 36 y/o woman sees GP for routine appointment at 32 weeks pregnancy. This is her first pregnancy and has so far been uncomplicated. She has normal fetal movements and is generally well with temperature 36.3, HR 90, BP 128/82, RR 13, O2 sats 96% on room air. Fundal height is 32cm and fetal HR is normal. Urine dipstick shows ++ protein but no other abnormalities. What is the most appropriate management?
     a.Immediate referral to obstetrics
     b.Repeat urinanalysis in 1 day
     c.Repeat urinanalysis in 1 week
     d.Send urine for MC&S and start Nitrofurantoin
     e.Send urine for MC&S and start Trimethoprim

a. Immediate referral to obstetrics.

Proteinuria in pregnancy can be an indication of various conditions, including preeclampsia. Preeclampsia is a serious condition characterized by hypertension and proteinuria after 20 weeks of gestation. Given the presence of proteinuria along with the gestational age of 32 weeks, immediate referral to obstetrics for further evaluation and management is warranted to assess for preeclampsia and ensure the well-being of both the woman and the fetus.

103. 19 y/o woman in GP has a 3 week history of post-coital vagin*l bleeding. She had a Nexplanon (Progesterone-only subdermal implant) inserted 18 months ago and has been amenorrhoeic for the last 12 months. vagin*l and speculum exams are normal and urine pregnancy test is normal. What is the most appropriate next investigation?
     a.Blood test for clotting screen
     b.Cervical cytology
     c.Endocervical, chlamydial, and high vagin*l swabs
     d.Transvagin*l USS
     e.Urine for microscopy, culture, and sensitivities

104. 19 y/o woman attends GP for contraception review. She started Microgynon-30 14 months ago and reports a recent migraine without aura which lasted 2 days (which she has never experienced before). She is currently a smoker but has no other CVS disease or VTE risk factors. Her temperature is 36.5, HR 70, BP 115/63, RR 14, O2 sats 97% on room air, and her BMI is 21. What is the most appropriate next step in management?
     a.Continue Microgynon-30 and offer smoking cessation
     b.Continue Microgynon-30 and start Sumitriptan
     c.Stop Microgynon-30 and offer Microgynon-20
     d.Stop Microgynon-30 and offer progesterone-only contraception
     e.Stop Microgynon-30 and start NuvaRing

d. Stop Microgynon-30 and offer progesterone-only contraception.

Migraine with aura is a contraindication to combined hormonal contraceptives (CHCs), such as Microgynon-30, due to the increased risk of ischemic stroke. While the woman’s recent migraine was without aura, the presence of any migraine headache while using CHCs is still considered a precaution, especially in combination with smoking, which further increases the risk of vascular events.

Therefore, the most appropriate action would be to discontinue Microgynon-30 and offer progesterone-only contraception, which does not carry the same increased risk of ischemic stroke in women with migraine headaches, even in the absence of aura. This would help minimize the risk of adverse cardiovascular events while still providing effective contraception.

105. 26 y/o woman has 24 hours of vulval rash and painful urination. What is the most appropriate treatment?
     a.Oral aciclovir
     b.Oral flucloxacillin
     c.Topical aciclovir
     d.Topical clotrimazole
     e.Topical fusidic acid

a. Oral aciclovir.

The symptoms are suggestive of genital herpes, a common sexually transmitted infection characterized by painful genital ulcers and rash, along with dysuria. Oral aciclovir is the standard treatment for genital herpes and can help reduce the severity and duration of symptoms, speed up healing of lesions, and decrease the risk of recurrent outbreaks.

106. 29 y/o seen in GP wanting to conceive. She has epilepsy and her last seizure was 18 months ago. She currently has a copper IUD in situ and is taking sodium valproate 1000mg BD. What is the most appropriate management?
     a.Leave IUD in situ, continue sodium valproate, and refer her for specialist advice
     b.Remove IUD, continue sodium valproate 1000mg BD and start folic acid 5mg OD
     c.Remove IUD, stop sodium valproate 1000mg and start carbamazepine 600mg BD and folic acid 5mg OD
     d.Remove ID, stop sodium valproate, and start folic acid 400mcg OD

b. Remove IUD, continue sodium valproate 1000mg BD, and start folic acid 5mg OD.

While planning for pregnancy, it’s essential to consider both the woman’s epilepsy management and the potential impact of antiepileptic drugs (AEDs) on pregnancy outcomes. Sodium valproate is associated with an increased risk of congenital malformations and neurodevelopmental disorders in babies born to mothers taking it during pregnancy, especially at higher doses.

However, abruptly stopping sodium valproate can increase the risk of seizures, which can also be harmful during pregnancy. Therefore, the recommendation is typically to continue sodium valproate if it is the most effective treatment for controlling seizures, but to use the lowest effective dose and add folic acid supplementation at a higher dose (5mg daily) to reduce the risk of neural tube defects in the baby.

107. 31 y/o woman in GP is 34 weeks pregnant and presents with dysuria, frequency, and urgency. Temperature 37.2, HR 80, BP 126/78, RR 18, O2 sats 99% on room air. She has mild suprapubic pain with no rebound or tenderness. What is the most appropriate initial management plan?
     a.Arrange clinical review in 24 hours
     b.No investigation required, treat empirically with antibiotics
     c.Reassure, no treatment needed
     d.Send urine for MC&S and treat empirically with antibiotics without waiting for results
     e.Send urine for MC&S and treat with antibiotics based on the results

d. Send urine for MC&S (Microscopy, Culture, and Sensitivity) and treat empirically with antibiotics without waiting for results.

Urinary tract infections (UTIs) are common during pregnancy and can have serious implications if left untreated. Pregnant women are at higher risk of complications from UTIs, including pyelonephritis and preterm labor.

Empirical treatment with antibiotics without waiting for culture results is typically recommended in pregnant women with symptoms suggestive of a UTI, especially in the third trimester, to promptly alleviate symptoms and reduce the risk of complications.

2. A baby is born with 45XO karyotype. What is the most likely cardiac abnormality associated with this syndrome?

4. 15 y/o boy has worsening severe headaches for 1 month and has been vomiting in the morning. There is no history of trauma and he is afebrile. What definitive investigation should now be requested?

5. 5 y/o boy has a systolic murmur which is soft and audible at the left sternal edge. The boy is asymptomatic. What is the most likely diagnosis?

7. Child has symptoms of perennial rhinitis (blocked nose, nasal voice, running eyes). What is the most likely causative allergen in this scenario?

8. 2 y/o girl has a fever of 39.7 and a painful, swollen right eye with preserved eye movements (see picture below). What is the most appropriate first-line treatment?

13. 15 y/o girl weighs 100kg. She has striae and darker skin in her armpits and neck. She has been feeling tired and has had episodes of vulval thrush, but is otherwise well. A blood test shows a fasting blood glucose of 7.6mmol/L (3-6 normal range). What pharmacological treatment should be considered?

14. Mother with SLE has a baby who is born with a slow heartbeat. What is the most likely diagnosis?

15. 2 y/o boy has suddenly started crying and intermittently pulling his legs up. He has vomited several times, and the last vomitus was green. He has not opened his bowels for several hours. He is resuscitated appropriately. What is the definitive management for this condition?

16. 13 y/o girl seen in GP with fever, sore throat, and cervical lymphadenopathy. Her temperature is 37.9 and she has white exudates on enlarged tonsils. She is prescribed Amoxicillin 500mg TDS, then 7 days later re-presents with a widespread rash. What is the most likely causative organism?

19. 2 week old boy in GP has bilateral red eyes with purulent discharge since birth. What is the most likely causative organism?

22. 20 y/o woman presents to A&E with agitation, confusion, high temperature, sweating, muscle twitches, and diarrhoea. She was recently started on medication for depression. What is the most likely diagnosis?

23. 60 y/o man with schizophrenia is taking haloperidol and has developed uncontrolled repetitive movements of his jaw with grimacing and protrusion of his tongue. What phenomenon is this?

24. 97 y/o woman has dementia and frequently tries to leave her nursing home an 03:00 in her nightgown to feed the swans. What legal framework may be considered in order to prevent her from leaving?

26. 27 y/o woman reviewed by community mental health team for schizophrenia follow-up. She describes experiences where she thinks she isn’t real. What phenomenon is this?

30. 36 y/o man started on lithium for BPAD. He is scheduled to have regular monitoring of lithium levels, renal function, calcium, and glucose. Which other blood test should be monitored?

31. 50 y/o man believes wife is cheating on him, gathering evidence by repeated obsessive examination of her underwear. What is the most likely psychiatric diagnosis?

32. 40 y/o woman attends A&E after her mother’s funeral with sudden onset blindness, but seems largely unconcerned about this new development. Physical examination and investigations are normal. What is the most likely disorder?

34. 20 y/o man with schizophrenia tells his support worker that the TV news presenter talks about him. What psychotic phenomenon is he describing?

35. 56 y/o man brought to A&E by ambulance after he’s found collapsed in a park. His pupils are constricted and his RR is 6. Which mediation should be urgently administered?

36. 78 y/o woman has 2 weeks of progressive lethargy, nausea, and dizziness. She has depression and has recently increased her dose of Citalopram. What is the most likely biochemical abnormality?

37. 22 y/o female with diagnosis of OCD presents to her GP for a repeat prescription of her medication. Which class of drug is first line for OCD?

38. 40 y/o doctor has central chest pain but a normal ECG. 3 months ag he attended rapid access chest pain clinic but was discharged after normal exercise stress test. His only PMHx is chronic rhinitis. What is the most likely drug of abuse in this case?

39. 22 y/o woman has 6 months of restricted eating, amenorrhea, social anxiety, and low mood. She has fine hair on her face and her BMI is 16.8. Her observations are otherwise normal. What is the most appropriate first-line pharmacological intervention?

40. 16 y/o attends GP with difficulties at college: she fears sitting on public transport and feels scared to leave her house. She avoids the supermarket and now does her grocery shopping online. What is the most likely diagnosis?

42. 22 y/0 woman is planning a water birth. She is low risk with no medical problems. What complication of normal delivery is increased by a water birth?

47. 80 y/o woman with a BMI of 25, COPD, and angina complains of back pain and a dragging sensation in her vagin*. She has a uterine prolapse and a normal pelvic USS. What is the most appropriate treatment option?

48. 8 y/o girl brought to gynaecology clinic with offensive vagin*l discharge, but is otherwise well. What is the most likely cause?

51. 49 y/o woman has heavy, irregular menstrual bleeding. TVUSS shows a thickened endometrium with cystic spaces. What investigation would be diagnostic in this scenario?

52. 32 y/o with mild asthma has unexplained intra-uterine death at 37 weeks gestation. She is induced and has epidural analgesia and a spontaneous vagin*l delivery. She is very distressed and would like to go home. What should be given to prevent her from expressing breast milk in this scenario?

53. 21 y/o woman is 5 weeks pregnant with abdominal pain. USS shows no evidence of an intrauterine pregnancy, a corpus luteum in the left ovary, and otherwise normal adenexae. Her serum b-hCG is 700 (<18 normal range). How should this pregnancy be classified?

54. A low risk woman would like to have epidural anaesthesia but is concerned about the risks. What is the risk of permanent paralysis (give as 1:X)

56. 31 y/o woman is 37 weeks pregnant and attends GP with itchy rash, though she is systemically well. Temperature 36.8, HR 80, BP 116/78, RR 18, O2 sats 99% on room air. She has the rash depicted below. What is the most likely diagnosis?

57. 19 y/o woman with intra uterine device in situ presents to GP with new onset low abdominal pain and spotting. Temperature 36.3, HR 83, BP 110/90, RR 18, O2 sats 98% on room air. What is the most appropriate initial investigation?

58. 34 y/o woman in GP is 28 weeks pregnant. She had normal antenatal screening and scans, and her pregnancy is uncomplicated. She has already had the influenza vaccination. Which other immunisation does she require?

59. 28 y/o woman attends GP requesting emergency contraception 5 days after unprotected intercourse. What is the most effective option available to her?

60. 38 y/o woman in GP requests contraception. She has severe menorrhagia and had a gastric sleeve bypass 12 months ago. What is the first line contraceptive management in this scenario?

1. A 13 year old girl in the Paediatric Emergency Department has drowsiness, weight loss and tiredness over the last 10 days. Her capillary blood gas results on arrival shows:
   pH 7.01 (7.35 - 7.45)
   PCO2 2.9 kPa (4.6 - 6.4)
   HCO3 9 mmol/L (22 - 30)
   Glucose 24 mmol/L (3.0 - 6.0)
   Blood ketones 6 mmol/L

Following an initial ABC assessment, bloods were taken. Her latest observations are: temperature 37C, pulse rate 118 bpm, BP 105/74 mmHg, capillary refill time 3 seconds, respiratory rate 27 breaths per minute, oxygen saturation 96% breathing air.

Rank the following subsequent management steps in order of priority with (1) being performed first and (5) being performed last
a.SC insulin
b.Repeat blood gas
c.Administer a fluid bolus
d.IV insulin
e.Calculate IV fluid requirement

A previously well, fully immunised, 2 year old girl, has a fever, irritability and vomiting for the last 3 days. A lumbar puncture is performed, and her CSF results are as follows:
CSF protein 0.8 g/L (0.15 - 0.45)
Glucose 2.9 mmol/L (2.2 - 2.4) (blood glucose 7 mmol/L)
Polymorphonuclear cells 95%
Mononuclear cells 5%

Rank the following causative organisms in order of likelihood with (1) being the most likely and (5) being the least likely.
a.Streptococcus pneumoniae
b.Cryptococcus
c.Haemophilus influenzae type B
d.Staphylococcus aureus
e.Enterovirus

A 4 month old boy in General Practice has 2 months of slowly worsening vomiting after feeding. He frequently cries and arches his back after feeding and refuses feeds. He is formula fed. He was just below the 50th centile for weight at birth and is now just above the 25th percentile.

Rank the following interventions according to the sequence in which they should be implemented with (1) being carried out first and (5) being carried out last.
a.Refer to paediatrics team
b.Trial smaller and more frequent feeds
c.Trial of proton pump inhibitor treatment
d.Trial of feed thickener
e.Prescribe alginate therapy with feeds

A 32 year old woman with bipolar affective disorder is in the 11th week of her first pregnancy. She has not been taking medication for the last 3 months and wants to remain medication free throughout the pregnancy and postnatal period.

Rank the following disorders in order of likelihood of occurrence in this woman with (1) being the most likely and (5) being the least likely.
a.Post-traumatic stress disorder
b.Puerperal psychosis
c.Postnatal depression
d.Alcohol use disorder
e.Generalised anxiety disorder

A 21 year old woman in the Emergency Department states that she is going to kill herself because the voices in her head are telling her to do so. Her feelings reportedly intensified following an argument with her mother earlier in the day. She demands to be admitted to the mental health unit, saying ‘it will all be your fault when I commit suicide”. She has a history of cutting and is well known to mental health services from previous crisis presentations.

Rank the following differential diagnoses in order of likelihood, with (1) being the most likely and (5) being the least likely.
a.Dissocial personality disorder
b.Paranoid schizophrenia
c.Depressive episode of moderate severity
d.Severe depressive episode with psychotic features
e.Emotionally unstable personality disorder

A 37 year old woman in the Emergency Department has low mood, insomnia, an inability to concentrate and hopelessness for the past 6 weeks. She recently lost her job as a corporate lawyer. She had an episode of depression at the age of 26 years, which was treated with fluoxetine for 6 months. She reports being a social drinker (average consumption is 2 glasses of wine per week).

Rank the following risk factors for depression in order of significance for this woman, with (1) being the most significant and (5) being the least significant.
a.Alcohol intake
b.Gender
c.Age
d.Previous depressive episode
e.Recent unemployment

A 37 year old woman in the Emergency Department has low mood, insomnia, an inability to concentrate and hopelessness for the past 6 weeks. She recently lost her job as a corporate lawyer. She had an episode of depression at the age of 26 years, which was treated with fluoxetine for 6 months. She reports being a social drinker (average consumption is 2 glasses of wine per week).

Rank the following risk factors for depression in order of significance for this woman, with (1) being the most significant and (5) being the least significant.
a.Alcohol intake 5
b.Gender 3
c.Age 4
d.Previous depressive episode 1
e.Recent unemployment 2

. The son of an 81 year old man in General Practice is concerned about his father. His father lives alone and has become more forgetful over the past 3 months. He has left his house without shutting the door several times and has been getting lost on the way to the shops. He has well-controlled hypertension and diet-controlled Type 2 Diabetes Mellitus.

Rank the following management steps according to the sequence in which they should be implemented with (1) being carried out first and (5) being carried out last.
a.Arrange joint consultation with father and son
b.Refer to local Memory Clinic
c.Perform an assessment of cognition with a cognitive assessment tool
d.Arrange confusion screen blood tests
e.Assess for acute reversible causes of confusion

A 24 year old woman presents with a 2 day history of worsening right-sided lower abdominal pain. She is sexually active and normally uses condoms. She has a 28 day cycle and her last period was 6 weeks ago. One day ago she had loose stools and attributed this to a bad take away. She has nausea and loss of appetite but no vomiting. Her temperature is 37.3C, pulse 96 bpm, BP 110/64 mmHg, respiratory rate 18 breaths per minute, oxygen saturation 98% breathing room air.

Urine dip: blood 1+ only
Blood test results: Hb 85 g/L (115 - 150), CRP 10 mg/L (<5)

Rank the following diagnoses in order of likelihood with (1) being the most likely and (5) being the least likely.
a.Appendicitis
b.Urinary tract infection
c.Pyelonephritis
d.Ectopic pregnancy
e.Ovarian cyst accident

A 25 year old woman in the Emergency Department is 8 days post delivery. She was induced at 38 weeks’ gestation for pre-labour rupture of membranes. She had a forceps delivery for foetal distress and a postpartum haemorrhage of 700mls. She was discharged on day 4 post delivery. She says she is finding it hard to cope, worries about the baby all the time and is unable to sleep because she feels she needs to watch the baby. She cries every day and is worried someone will take the baby from her. She is concerned her breast milk is inadequate. She has been sweating at night but has not checked her temperature. She also has a constant headache.

Rank the following differential diagnoses in order of likelihood with (1) being the most likely and (5) being the least likely.
a.Postnatal depression
b.Sepsis
c.Schizophrenia
d.Baby blues
e.Pre-eclampsia

A 36 year old mother of three young children is not using any contraception. She had a recent unplanned pregnancy and opted for a termination. She occasionally experiences headaches and smokes five cigarettes per day. Her BMI is 30 kg/m2. She has been in a relationship for 18 months.

Rank the following contraceptive choices for this woman in order of appropriateness, with (1) being the most appropriate and (5) being the least appropriate.
a.Combined oral contraceptive pill
b.Nexplanon implant
c.Sterilisation
d.Mirena IUS
e.Condoms

A heterosexual couple in their early 30s have been trying to conceive for more than 1 year without success. Neither has any children.

Rank the following potential causes of their infertility in order of likelihood with (1) being the most likely and (5) being the least likely.
a.Gamete defects
b.Male infertility
c.Uterine or peritoneal disorders
d.Tubal damage
e.Ovulatory disorders

A 15 year old boy has 3 weeks of cough, weight loss, night sweats and fever. He moved to the UK from India 3 years ago. His chest x-ray is show in the image (can’t find exact image but showed some left upper zone shadowing I think). Which investigation is regarded as the gold standard for diagnosis for his underlying condition?

Blood culture

Gastric washings

Mantoux

QuantiFERON / IGRA

Sputum culture

and dark urine. Last week she finished a course of nitrofurantoin for a urinary tract infection. Her blood results are as follows: Hb 70 g/L (110-140), WBC 3.2 x 10^9/L (5.0 - 12.0), platelets 520 x 10^9/L (150 - 400), albumin 37 g/L (30 - 50), bilirubin 75 umol/L (<21), ALT 18 IU/L (0 - 29), ALP 130 IU/L (60 - 425). Which is the most likely underlying diagnosis?

Beta Thalassaemia

G6PD deficiency

Hereditary spherocytosis

Iron deficiency anaemia

Sickle cell disease

A 7 year old boy has a history of recurrent chest infections, persistent sinusitis and has been prescribed multiple courses of antibiotics. He has bibasal crepitations and a right-sided apex beat. Which is the most likely underlying diagnosis?

Agammaglobulinaemia

Cystic fibrosis

HIV

Primary ciliary dyskinesia – people commonly also have consanguity (left and right flipped inside)

Tracheo-oesophageal fistula

Primary ciliary dyskinesia (PCD)

This is because

Recurrent Respiratory Infections and Sinusitis: PCD is characterized by recurrent respiratory tract infections due to defective ciliary function, which impairs mucociliary clearance.

Bibasal Crepitations: These are common in conditions that affect the lower respiratory tract chronically, such as PCD.

Right-Sided Apex Beat (Situs Inversus): PCD is often associated with situs inversus (a condition where the major visceral organs are mirrored from their normal positions), which can result in a right-sided apex beat.

A 3 day old baby girl is not feeding well. Her temperature is 36.7C, heart rate 180 bpm, respiratory rate 66 breaths per minute. There is a systolic murmur and femoral pulses are not palpable. Which is the most likely diagnosis?

Atrial septal defect

Coarctation of the aorta

Patent ductus arteriosus

Patent foramen ovale

Ventricular septal defect

Refer to specialist

NOTE: Do a CT head if you are between orbital and periorbital cellullitis

Central precocious puberty

This is because:

Clinical Presentation:
Breast buds (thelarche): This indicates the beginning of puberty.
No pubic hair: Pubic hair development typically follows breast development in the sequence of puberty.

Growth Metrics:
Height on the 98th centile: Advanced growth may be associated with early puberty.
Weight on the 75th centile: Consistent with overall increased growth velocity.
Bone Age:

Bone age of 10 years: Advanced bone age suggests early onset of puberty.

Hormonal Findings:
Elevated FSH (3.2 IU/L) and LH (3.4 IU/L): Elevated gonadotropins are indicative of activation of the hypothalamic-pituitary-gonadal axis, which is a hallmark of central precocious puberty.

Prescribe oral antipyretics and observe

NOTE: Wouldn’t prescribe buccal midazolam. ALWAYS OBSERVE FIRST EPISODE OF CONVULSIONS. anti-pyretic for symptomatic relief.

b. Feed the baby

If feeding the baby does not resolve the hypoglycemia or if the infant is unable to feed, the next step would be to consider intravenous dextrose (option c). However, initial management typically involves an attempt to feed the baby.

d. Inhaled foreign body

Acute Onset of Symptoms: The sudden onset of cough and drooling is highly suggestive of an inhaled foreign body. This is often seen when a child suddenly develops respiratory symptoms without a preceding illness.

Inspiratory Upper Airway Noises: Stridor, which is an inspiratory noise, is commonly associated with an obstruction in the upper airway, which can occur with an inhaled foreign body.

Drooling: This is a key symptom that suggests the child is having difficulty swallowing saliva, which can be due to a partial obstruction in the airway or esophagus caused by a foreign body.

Normal Vital Signs and Examination: The child’s normal temperature and other stable vital signs make infectious causes like croup and epiglottitis less likely. Both of these conditions often present with fever and more severe respiratory distress.

Vaccinations Up to Date: This reduces the likelihood of epiglottitis, especially if the child has received the Haemophilus influenzae type b (Hib) vaccine, which significantly reduces the incidence of epiglottitis caused by Hib.

a. Benign intracranial hypertension (also known as idiopathic intracranial hypertension)

Here’s the reasoning:

Headache Characteristics: Severe, throbbing headaches that are worse in the morning are a red flag for increased intracranial pressure (ICP).

Morning Headaches: Headaches that are worse in the morning suggest a possible increase in ICP because intracranial pressure is often higher when lying down.

Nausea and Vomiting: These symptoms are commonly associated with increased ICP.

Additional Symptoms: Increased tiredness and irritability can be related to increased ICP.

Weight: The girl’s weight (62 kg) may suggest obesity, which is a known risk factor for benign intracranial hypertension.

38. A 5 year old boy in General Practice has bright red blood when opening his bowels for 1 week. He opens his bowels every 3 days. He has no past medical history and is thriving. He has a well-balanced diet and has good fluid intake. There are no safeguarding concerns. Abdominal examination is unremarkable. Rectal inspection reveals a fissure. Which is the most appropriate management?
    a.Dietary advice
    b.Osmotic laxative
    c.Phosphate enema
    d.Stimulant laxative
    e.Toilet training

D. Prescribe phenoxymethylpenicillin

NOTE: FeverPAIN criteria

Fever (during previous 24 hours)

Purulence (pus on tonsils)

Attend rapidly (within 3 days after onset of symptoms)

Severely Inflamed tonsils

No cough or coryza (inflammation of mucus membranes in the nose)

Each of the FeverPAIN criteria score 1 point (maximum score of 5). Higher scores suggest more severe symptoms and likely bacterial (streptococcal) cause. A score of 0 or 1 is thought to be associated with a 13 to 18% likelihood of isolating streptococcus. A score of 2 or 3 is thought to be associated with a 34 to 40% likelihood of isolating streptococcus. A score of 4 or 5 is thought to be associated with a 62 to 65% likelihood of isolating streptococcus.

A. admit to hospital for assessment

THIS IS LIKELY APPENDICITIS

e. Turning one page in a book

Crawling (3 months head, 6 months upright, 9 months crawl, 12 months walk (18 is red flag))

Draw a circle (3 years)

Draw a square (4 years)

Transfers objects from one hand to the other (6 months)

Turning one page in a book (Several pages at 2 years, one page at 3 years) Casting bricks should stop by 18 months

c. He has limited social contacts

Negative symptoms in schizophrenia refer to deficits or reductions in normal emotional and behavioral functions. Limited social contacts indicate a reduction in social interactions, which is a negative symptom.

47. A 35 year old man has been feeling low in mood and has disturbed sleep. He has been taking fluoxetine 40 mg daily for 3 months, with no improvement. His treating doctor intends to commence him on citalopram 20 mg daily. Which is the most appropriate next step in regards to changing his medication?
    a.Add citalopram to fluoxetine at the current dose, withdrawing fluoxetine only if patient’s syndrome improve
    b.Cross taper, i.e. reduce the fluoxetine dose, simultaneously adding citalopram
    c.Reduce fluoxetine dose to 20mg daily, discontinue it after 1 week and then immediately initiate citalopram
    d.Reduce fluoxetine dose to 20mg daily and start citalopram after a 1 week washout period
    e.Reduce fluoxetine dose to 20 mg daily and start citalopram after a 6 week washout period

Option d. Reduce fluoxetine dose to 20mg daily and start citalopram after a 1-week washout period could indeed be a valid approach, especially considering the half-life of fluoxetine, which is around 4 to 6 days, and the potential risk of serotonin syndrome.

This approach allows for a gradual reduction of fluoxetine while minimizing the risk of adverse effects from the combination of SSRIs.

Stop venlafaxine

Venlafaxine: Venlafaxine is an antidepressant medication that belongs to the class of serotonin-norepinepherine reuptake inhibitors (SNRIs). It can induce or exacerbate manic or hypomanic symptoms, especially in individuals with bipolar disorder.

Harmful use – substance use causing harm to health

Dependence – strong desire to take substance
Withdrawal syndrome – symptoms result after stopping substance

Artificial rupture of membranes – this is the first line in failure to progress (if this doesn’t work then needs to be obstetric-led care). Next step or if membranes are already ruptured, oxytocin (Failure to progress is <2cm in 4 hours)

NOTE: Perform a membrane sweep – first step for induction of labour (done around 40 weeks), followed by vagin*l prostaglandin, followed by oral, followed by oxytocin

Episiotomy – this is going to be done first to make instrumental delivery easier

Forceps delivery – need to expedite the delivery since its been 2 hours and signs of fetal distress. This is quicker then ventouse

Amniocentesis – this is actually most sensitive >15 weeks

Chorionic villous sampling - less sensitive done around 11-14 weeks

Non-invasive pre-natal testing (cell free DNA) –slightly less sensitive, is now on the NHS

NOTE: Depends on question, think about risk to baby, mothers wishes etc

Arrange a repeat ultrasound scan (USS) in 10-14 days

Here’s why:

Intrauterine Gestation Sac: The presence of an intrauterine gestational sac indicates a pregnancy is located within the uterus, which is reassuring.

Absence of Yolk Sac or Fetal Pole: At 6 weeks of gestation, the absence of a visible yolk sac or fetal pole may not be definitive evidence of a non-viable pregnancy. In some cases, these structures may not yet be visible due to the early stage of pregnancy.

85. A 35 year old woman has a severe headache 24 hours following an elective cesarean section for placenta praevia under regional anaesthesia. It is worse on sitting up and better when she is lying down. Her temperature is 37.3C, heart rate 90 bpm, blood pressure 124/64 mmHg, respiratory rate 12 breaths per minute, oxygen saturation 98% breathing room air. Which is the most likely cause of her headache?
    a.Cerebral venous sinus thrombosis
    b.Meningitis
    c.Migraine
    d.Post-dural tap headache
    e.Pre-eclampsia

d. Germ cell tumor of the ovary

Germ cell tumors of the ovary are neoplasms derived from germ cells and can present as complex cystic masses with solid components on ultrasound. These tumors are more common in young women, typically in their second or third decade of life. While they can be benign or malignant, the presence of solid components within the cystic mass raises concern for malignancy.

Surgical repair

NOTE: Intraurethral bulking (option b) is often considered before surgical repair because it is a minimally invasive procedure that can be effective for treating stress incontinence and carries fewer risks compared to surgery. If intraurethral bulking fails to adequately address the symptoms, then surgical repair may be pursued

Bladder diary

Here’s why:

Bladder Diary: A bladder diary is a simple and non-invasive tool used to assess the frequency, volume, and pattern of urinary symptoms over a specific period. It typically involves recording fluid intake, voiding frequency, urine volume, episodes of urinary incontinence, and any associated factors such as urgency or nocturia. A bladder diary can provide valuable information about the nature and severity of the patient’s symptoms, as well as potential triggers or patterns.

. A 34 year old woman attends her GP for her 32 week antenatal appointment. She feels well in herself and has regular foetal movements. She has had normal scans to date and an uncomplicated pregnancy. Her temperature is 36.8C, pulse 93 bpm, blood pressure 113/72 mmHg, and oxygen saturation 98% breathing air. Her booking blood pressure was 110/68 mmHg.

Urinalysis - negative
Ketones - negative
Blood - negative
Protein - 2+
Nitrites - negative
Leukocytes - negative
Which is the most appropriate next step in management?
a.Ask midwife to review in 2 weeks
b.Reassure and review at 36 week antenatal appointment
c.Refer for antenatal same day assessment
d.Send a mid-stream urine for microscopy, culture and sensitivity
e.Send a protein creatinine ratio

Refer for antenatal same day assessment - 2+ protein needs urgent same day assessment. 1+ and other symptoms of pre-eclampsia same day assessment as well

NOTE: Send a protein creatinine ratio – do this 1 week later if it was 1+ and no other symptoms

A 35 year old woman in General Practice is 10 weeks pregnant and has worsening nausea and vomiting daily for 3 weeks. She is now struggling to keep down fluids but still passing urine.

Urinalysis:
Glucose - negative
Protein - negative
Ketone - negative
Blood - negative
Nitrites - negative
Leukocyte - negative
Which is the most suitable management option?
a.Admit to hospital
b.Advise ginger tea
c.Avoid heavy meals
d.Offer cyclizine
e.Offer ondansetron

Admit to hospital

NOTE: Offer cyclizine – do this if she can swallow. Offer ondansetron – this is second line as associated with increased risk of cleft palate.

Post-traumatic psychosis

Post-traumatic psychosis can occur following a traumatic brain injury and is characterized by the presence of hallucinations, delusions, disorganized thinking, or other psychotic symptoms. These symptoms may develop weeks to months after the injury and can be distressing and impairing for the individual.