Question Bank

In accordance with NICE and British Society of Gastroenterology guidelines, any male or post-menopausal female with unexplained iron deficiency anaemia must be referred for urgent (2-week wait) GI investigation to exclude malignancy. While iron supplementation is needed, it must not delay diagnostic investigations. Bone marrow biopsy is not indicated for simple microcytic anaemia.

The patient has cluster headaches. Verapamil is the first-line prophylactic agent (NICE CG150). High-flow oxygen and SC sumatriptan are used for the management of acute attacks, not for prevention. Propranolol and amitriptyline are used for migraine prophylaxis.

NICE (NG12) guidelines mandate a 2-week wait (2WW) referral for colonoscopy in patients aged 60+ with a change in bowel habit or iron deficiency anaemia. While FIT is used for lower-risk scenarios or primary care screening, this patient meets the criteria for direct urgent referral for suspected colorectal cancer.

Unilateral sensorineural hearing loss and tinnitus are red flags for a vestibular schwannoma (acoustic neuroma). Gadolinium-enhanced MRI of the internal auditory meatus is the gold-standard investigation. CT is less sensitive for small lesions in the cerebellopontine angle.

NICE guidelines state that the gold standard for diagnosing coeliac disease in adults is an OGD with duodenal biopsies showing villous atrophy. Serology (anti-tTG) is a screening tool, and biopsies must be performed while the patient is still consuming gluten. Colonoscopy is used for IBD, not coeliac disease.

Severe asthma is defined by any one of: PEF 33-50% predicted, respiratory rate ≥25/min, heart rate ≥110/bpm, or inability to complete sentences in one breath. Life-threatening features would include a silent chest, cyanosis, or PEF <33%.

NICE guidelines recommend referral to a specialist for oral isotretinoin when there is a risk of scarring or if moderate-to-severe acne has failed to respond to two courses of treatment (including an oral antibiotic). This patient has nodules, early scarring, and has failed a standard course of oral lymecycline.

Refeeding syndrome occurs when nutrition is reintroduced to a malnourished patient, leading to insulin release. Insulin causes an intracellular shift of potassium, magnesium, and phosphate, which can lead to cardiac arrhythmias and respiratory failure.

Idiopathic Pulmonary Fibrosis typically presents with clubbing and bi-basal fine crackles. HRCT characteristically shows a 'usual interstitial pneumonia' (UIP) pattern, featuring subpleural honeycombing and traction bronchiectasis.

Oesophageal manometry is the gold standard for diagnosing achalasia, classically showing a failure of the lower oesophageal sphincter to relax and lacked peristalsis in the distal oesophagus. Barium swallow provides characteristic signs but is not confirmatory. OGD is necessary to rule out pseudoachalasia/malignancy.

NICE recommends adding a low-dose ICS if a patient has symptoms ≥3 times a week or is waking at night. If symptoms are uncontrolled on SABA + ICS, the next step would be adding an LTRA.

Metamorphopsia (distortion of straight lines) and loss of central vision are hallmark symptoms of age-related macular degeneration (AMD). Glaucoma typically causes peripheral vision loss first. Cataracts cause generalized blurring and glare without specific distortion.

The classic ECG findings (short PR interval and delta wave) describe Wolff-Parkinson-White (WPW) syndrome, which is caused by the presence of an accessory conduction pathway known as the Bundle of Kent, bypassing the AV node.

A pan-systolic murmur at the apex radiating to the axilla indicates mitral regurgitation. Chronic mitral regurgitation leads to volume overload of the left atrium and left ventricle, causing left atrial enlargement.

For patients of Black African or African Caribbean family origin of any age, or patients over 55 who are not of Black African/Caribbean origin, the first-line treatment for hypertension is a Calcium Channel Blocker (CCB) such as amlodipine.

The patient likely has Autosomal Dominant Polycystic Kidney Disease (ADPKD). There is a significant association between ADPKD and intracranial berry aneurysms, which can lead to subarachnoid haemorrhage (explaining her father's early death).

A significant rise in creatinine (usually >20-30%) after starting an ACE inhibitor is a classic indicator of bilateral renal artery stenosis. ACE inhibitors reduce efferent arteriolar pressure, which in the presence of stenosis, leads to a drop in glomerular filtration pressure.

Bullous pemphigoid is an autoimmune blistering disease common in the elderly; the bullae are tense because they are subepidermal. High-potency topical steroids (e.g., clobetasol propionate) are first-line for localized or moderate disease and are associated with fewer side effects than oral steroids in this age group.

For distal ulcerative colitis (proctitis or proctosigmoiditis), NICE recommends a topical (rectal) 5-ASA as first-line induction therapy. If remission is not achieved within 4 weeks, an oral 5-ASA may be added. Steroids are used for flares but are not the preferred first-line for mild distal disease.

Cotard syndrome is a nihilistic delusion where patients believe they are dead, do not exist, or have lost internal organs. Capgras and Fregoli are delusional misidentification syndromes, while De Clerambault is the delusion that another person is in love with the patient.

Hypertrophic Cardiomyopathy (HCM) is the most common cause of sudden cardiac death in young athletes. It is typically inherited in an autosomal dominant fashion, usually due to mutations in genes encoding sarcomere proteins (e.g., MYH7 or MYBPC3).

His CHA₂DS₂-VASc score is 4: Age ≥75 scores 2 points; Hypertension (BP 135/82 mmHg qualifies as hypertension or treated hypertension) scores 1 point; Type 2 Diabetes scores 1 point. For male patients with a score of 2 or more, anticoagulation with a DOAC (such as apixaban) is recommended by NICE and the 2020 ESC AF guidelines. Aspirin is no longer recommended for stroke prevention in AF. Warfarin with a target INR of 3.5 is not indicated; standard INR target for AF is 2.0–3.0, and DOACs are preferred over warfarin for non-valvular AF.

This patient presents with the nephrotic triad (proteinuria >3.5g/day, hypoalbuminaemia, and oedema). In adults, membranous nephropathy is the most common primary cause, whereas minimal change disease is most common in children.

NICE NG185 recommends primary PCI as the preferred reperfusion strategy for STEMI when it can be delivered within 120 minutes of the time at which fibrinolysis could have been given (i.e. door-to-balloon time). With the PCI centre only 60 minutes away, this criterion is met and primary PCI is strongly preferred over fibrinolysis. If the expected door-to-balloon time exceeds 120 minutes — for example due to transfer delays — fibrinolysis should be offered immediately instead, followed by angiography within 3–24 hours. Aspirin 300 mg and anticoagulation should be given to all STEMI patients regardless of reperfusion strategy.

According to the Resus Council and NICE, the first-line treatment for status epilepticus (seizure > 5 mins) in a hospital setting with IV access is IV lorazepam 4mg, which can be repeated once after 10-20 mins. IM midazolam is preferred if IV access is not available. Phenytoin or levetiracetam are second-line agents.