Question Bank

NICE guidelines recommend primary PCI for STEMI if it can be delivered within 120 minutes of the time when fibrinolysis could have been given. Since the PCI centre is only 60 minutes away, it is the preferred reperfusion strategy over fibrinolysis.

NICE recommends an ACE inhibitor and a beta-blocker as first-line treatment for all patients with heart failure with reduced ejection fraction (HFrEF). While furosemide treats symptoms of congestion, it does not improve mortality like beta-blockers do.

His CHA2DS2-VASc score is 3 (Age >=75 = 2 points, Diabetes = 1 point). Anticoagulation (DOAC like apixaban) is indicated for men with a score of 1 or more, and recommended for a score of 2 or more; aspirin is no longer used for stroke prevention in AF.

Staphylococcus aureus is the most common cause of acute infective endocarditis, particularly in IV drug users. The murmur described is tricuspid regurgitation (right-sided), which is characteristic of endocarditis in this patient group.

NICE guidelines recommend either a beta-blocker (e.g., atenolol/bisoprolol) or a calcium channel blocker (e.g., diltiazem/verapamil) as first-line treatment for stable angina. Long-acting nitrates and others are reserved for second-line or combination therapy.

The clinical presentation and ECG findings are classic for acute pericarditis. First-line treatment is high-dose NSAIDs (like ibuprofen) combined with colchicine to reduce symptoms and the risk of recurrence.

The patient has signs of severe aortic stenosis (syncope, slow-rising pulse, ESM radiating to carotids). Longstanding aortic stenosis leads to increased afterload and subsequent left ventricular hypertrophy (LVH).

In shockable rhythms (VF/Pulseless VT), Resus Council UK guidelines recommend 1mg adrenaline and 300mg amiodarone after the 3rd shock. For non-shockable rhythms, adrenaline is given immediately.

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.

For peripheral arterial disease (PAD), NICE recommends clopidogrel 75mg daily as the first-line antiplatelet agent for the prevention of cardiovascular events. Aspirin is used for coronary artery disease secondary prevention.

Stanford Type B dissections (descending aorta) are usually managed medically with aggressive blood pressure control (e.g., IV labetalol). Type A dissections (ascending aorta) require urgent surgery.

According to the Resuscitation Council UK tachycardia algorithm, the first-line drug for stable narrow-complex SVT after failed vagal manoeuvres is adenosine (6mg, then 12mg, then 12mg). DC cardioversion is for hemodynamically unstable patients.

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.

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.

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).

A Wells score >4 indicates that a pulmonary embolism is likely. In this clinical scenario, the patient should proceed directly to definitive imaging (CTPA) rather than a D-dimer, which is only used to rule out PE in 'unlikely' cases.

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 recommends 5 days of oral prednisolone (30mg) for COPD exacerbations and a course of antibiotics if sputum is purulent. Current guidelines have moved away from longer 10-14 day courses of steroids to reduce side effects.

For a primary spontaneous pneumothorax, if the patient is symptomatic or the rim of air is >2cm, needle aspiration is the first-line treatment. If it fails (pneumothorax remains >2cm), a chest drain is indicated.

The patient's CURB-65 score is 4 (Confusion, RR ≥30, BP <90/60, Age ≥65). A score of 3 or more indicates high risk and mandates urgent hospital admission for intravenous antibiotics and stabilization.

A pleural protein level >30 g/L is classified as an exudate. Bronchial carcinoma is a common cause of exudative effusions. Heart failure, cirrhosis, and nephrotic syndrome typically cause transudates (protein <30 g/L).

While the Epworth scale and oximetry are screening tools, multi-channel polysomnography (in a sleep lab) is the gold standard for diagnosing Obstructive Sleep Apnoea (OSA). It monitors EEG, airflow, and respiratory effort.

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.

Rifampicin causes orange/red discoloration of urine, tears, and sweat. Optic neuritis is associated with ethambutol; peripheral neuropathy with isoniazid; and hyperuricaemia with pyrazinamide.

Squamous cell carcinoma is often centrally located and is classically associated with paraneoplastic hypercalcaemia due to the secretion of parathyroid hormone-related protein (PTHrP).

The triad of erythema nodosum (tender nodules on shins), bilateral hilar lymphadenopathy (BHL), and dry cough/arthralgia is highly suggestive of acute sarcoidosis (Löfgren's syndrome).

HRCT is the gold standard for diagnosing bronchiectasis, showing hallmark signs such as the 'signet ring' sign (dilated bronchi wider than adjacent vessels) and lack of bronchial tapering.

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.

Low pH (<7.35) and high pCO2 (>6.0 kPa) indicate respiratory acidosis (Type 2 failure). The elevated bicarbonate (29 mmol/L) suggests the body has begun to compensate (chronic/partially compensated), but the pH remains acidotic.

For the first isolated growth of Pseudomonas aeruginosa in CF patients, the goal is eradication. NICE/UK protocols typically use a combination of oral ciprofloxacin and nebulised antibiotics (like colistimethate or tobramycin) for 3 months.

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.

The clinical picture describes Murphy's sign, suggestive of acute cholecystitis. Transabdominal ultrasound is the first-line imaging modality for suspected biliary disease as it can identify gallstones, gallbladder wall thickening, and pericholecystic fluid. CT is less sensitive for gallstones, and MRCP is used if choledocholithiasis is suspected.

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.

In patients under 55 without alarm symptoms, a trial of a full-dose PPI (e.g., Omeprazole 20mg) for 4-8 weeks is the standard first-line management for suspected GORD. OGD is reserved for older patients or those with red flags (dysphagia, weight loss, anaemia).

The primary treatment for acute pancreatitis is supportive care, with aggressive IV fluid resuscitation (crystalloids) being the most critical step to prevent organ failure and necrosis. Amylase >3x the upper limit of normal is diagnostic. Antibiotics and surgery are not indicated in the initial phase unless infection is proven.

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.

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.

In suspected variceal haemorrhage (cirrhosis history + bleeding), NICE recommends Terlipressin and prophylactic antibiotics (e.g., Ceftriaxone) before endoscopy. PPIs are used for non-variceal bleeds but have no role in acute variceal management prior to endoscopy. Propranolol is used for secondary prevention, not acute bleeds.

In the UK, patients with cirrhosis are screened for HCC every 6 months using liver ultrasound and often serum alpha-fetoprotein (AFP). CEA is for colorectal cancer, and CA19-9 is for pancreatic/biliary cancer.

The clinical picture of pain relieved by defecation, bloating, and altered bowel habit in the absence of inflammatory markers (normal CRP/ESR) or weight loss/anaemia is characteristic of Irritable Bowel Syndrome (IBS). Diagnosis is clinical once other conditions (Coeliac, IBD) are excluded.

The clinical picture of fluid loss (vomiting/diarrhoea) combined with hypotension and tachycardia suggests dehydration. The high urea-to-creatinine ratio and negative urinalysis further support a pre-renal cause rather than intrinsic or post-renal damage.

In severe hyperkalaemia (>6.5 mmol/L) or with ECG changes, the priority is to stabilise the cardiac membrane using 10% IV calcium gluconate. Insulin/dextrose and salbutamol shift potassium into cells but do not stabilise the myocardium.

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.

IgA nephropathy typically presents with 'synpharyngitic' haematuria (occurring during or shortly after an upper respiratory tract infection). Post-streptococcal glomerulonephritis usually has a longer lag period (1-3 weeks) between infection and renal symptoms.

NICE guidelines recommend an ACE inhibitor (like Ramipril) or an ARB as first-line therapy for patients with CKD and diabetes, or for those with an ACR >30 mg/mmol (or >3 if they have diabetes), due to their renoprotective effects.

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.

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).

In Minimal Change Disease (MCD), light microscopy typically appears normal. The diagnosis is confirmed via electron microscopy showing effacement of podocyte foot processes. MCD is the most common cause of nephrotic syndrome in children and is highly steroid-responsive.

Goodpasture's syndrome (Anti-GBM disease) presents with the combination of pulmonary haemorrhage and rapidly progressive glomerulonephritis. It is characterised by anti-GBM antibodies and a linear pattern of IgG deposition.

Acute Tubular Necrosis (ATN) is often caused by prolonged ischaemia (e.g., hypotension/shock during surgery). The presence of 'muddy brown' casts in the urine is highly pathognomonic for ATN compared to simple pre-renal azotaemia.

NICE guidelines (CG150) recommend combination therapy with an oral triptan and an NSAID (or paracetamol) for the acute treatment of migraine. Propranolol and amitriptyline are used for prophylaxis, not acute treatment. Subcutaneous triptans are usually reserved for patients with severe vomiting or those who fail oral therapy.

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.

This patient has symptoms disseminated in time (previous weakness, current optic neuritis) and space, suggesting Multiple Sclerosis (MS). MRI is the gold-standard investigation to demonstrate demyelinating plaques; gadolinium enhancement indicates active lesions. Lumbar puncture for oligoclonal bands is supportive but MRI is the primary tool.

The clinical triad of tremor, bradykinesia, and rigidity is characteristic of Parkinson's Disease. The pathological hallmark is the presence of Lewy bodies (alpha-synuclein aggregates) and the loss of dopaminergic neurons in the substantia nigra pars compacta. Atrophy of the caudate is seen in Huntington's disease.

If a CT head is negative for suspected subarachnoid haemorrhage, a lumbar puncture (LP) must be performed at least 12 hours after symptom onset to look for xanthochromia. While CT sensitivity is high in the first 6 hours, a negative scan cannot definitively rule out SAH. CT angiogram is used to identify the source once SAH is confirmed.

Myasthenia Gravis is an autoimmune condition characterized by fatiguable muscle weakness due to autoantibodies against the postsynaptic nicotinic acetylcholine receptors at the neuromuscular junction. Antibodies against voltage-gated calcium channels are seen in Lambert-Eaton Myasthenic Syndrome.

The presentation is classic for Guillain-Barré Syndrome (GBS), often preceded by Campylobacter jejuni infections. Treatment is IVIG or plasma exchange. Corticosteroids are not effective in GBS. Monitoring FVC is crucial as respiratory failure is a major complication requiring ICU admission.

For patients with ischaemic stroke presenting within 4.5 hours of symptom onset, thrombolysis with Alteplase is the first-line treatment if haemorrhage is excluded and no contraindications exist. Aspirin 300mg should be given 24 hours after thrombolysis. BP should only be lowered aggressively if >220/120 mmHg unless thrombolysis is planned (where the limit is <185/110 mmHg).

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.

MND (specifically Amyotrophic Lateral Sclerosis) typically presents with a combination of upper motor neurone signs (brisk reflexes, increased tone) and lower motor neurone signs (wasting, fasciculations) in the absence of sensory loss. Tongue fasciculations (bulbar involvement) are a specific sign of MND.

Primary hyperparathyroidism is characterized by elevated calcium and inappropriately elevated (or high-normal) PTH, often due to a solitary adenoma. Secondary hyperparathyroidism features high PTH but low/normal calcium (usually renal failure). Malignancy typically causes suppressed PTH due to PTHrP production.

According to UK national DKA guidelines, resolution is defined by pH >7.3, bicarbonate >18 mmol/L, and ketones <0.6 mmol/L. Glucose often normalizes before the metabolic acidosis resolves; therefore, glucose monitoring alone is insufficient for stopping the insulin infusion.

The Short Synacthen test (ACTH stimulation test) is the gold standard for diagnosing primary adrenal insufficiency (Addison's). A failure of cortisol to rise above 425-500 nmol/L (depending on the assay) 30 minutes after synthetic ACTH administration is diagnostic.

Agranulocytosis is a rare but life-threatening side effect of thionamides like Carbimazole. Patients must be warned to have an urgent Full Blood Count if they develop signs of infection, such as a sore throat or fever.

In phaeochromocytoma, alpha-blockade must be achieved before starting beta-blockers. Failure to do so can lead to unopposed alpha-adrenergic stimulation, causing a hypertensive crisis.

A suppressed ACTH in the presence of hypercortisolism indicates ACTH-independent Cushing's Syndrome, most commonly caused by an autonomous adrenal adenoma or exogenous steroids. If exogenous use is ruled out, an adrenal source is most likely.

In elderly patients or those with underlying ischaemic heart disease, Levothyroxine should be started at 12.5–25 micrograms to avoid precipitating a myocardial infarction or angina through sudden increases in metabolic demand.

In cranial DI, the kidneys can concentrate urine when exogenous ADH (Desmopressin) is provided. In nephrogenic DI, the kidneys fail to respond to Desmopressin, and in primary polydipsia, the urine should concentrate during the deprivation phase.

Primary hyperaldosteronism (Conn's Syndrome) presents with hypertension, hypokalaemia, and a high ARR. The first-line imaging to differentiate between an adrenal adenoma and bilateral adrenal hyperplasia is a CT Adrenal scan.

For a patient with hypoglycaemia who is conscious but cannot safely swallow (no safe swallow or uncooperative), IM Glucagon is the treatment of choice in the community. Oral options are unsafe due to aspiration risk, and IV access is rarely available outside a hospital setting.

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 clinical picture is consistent with Immune Thrombocytopenic Purpura (ITP). First-line treatment for patients with a platelet count <30 x 10^9/L or significant bleeding is oral corticosteroids (prednisolone). IVIg is typically reserved for patients requiring a rapid rise in platelets or those refractory to steroids. Platelet transfusions are ineffective as the antibodies will destroy the donor platelets immediately.

Acute Chest Syndrome (ACS) is defined in Sickle Cell patients as a new infiltrate on CXR accompanied by fever and/or respiratory symptoms (hypoxia, cough, tachypnoea). It is a medical emergency requiring oxygen, analgesia, antibiotics, and often exchange transfusion. While infection often triggers ACS, the clinical constellation defines the syndrome rather than simple pneumonia.

The patient has Subacute Combined Degeneration of the Cord due to B12 deficiency (Pernicious Anaemia). For patients with B12 deficiency and neurological involvement, the BNF/NICE guidance recommends 1mg IM hydroxocobalamin every other day until there is no further improvement in symptoms. The standard maintenance dose of 1mg every 3 months is only for those without neurological symptoms.

The clinical triad of CRAB features (Calcium, Renal failure, Anaemia, Bone pain) suggests Multiple Myeloma. The first step involves screening for a monoclonal (M) protein via serum protein electrophoresis and serum free light chain assay. Isotope bone scans are often falsely negative in myeloma because they detect osteoblastic activity, whereas myeloma lesions are purely osteolytic.

NICE recommends NSAIDs (like naproxen) or colchicine as first-line for acute gout. While colchicine is an option, NSAIDs are often preferred if there are no contraindications; Allopurinol and Febuxostat are urate-lowering therapies (ULT) and should not be initiated during an acute flare.

NICE NG100 recommends offering first-line conventional DMARDS (cDMARDs) monotherapy, with methotrexate being the standard first choice. Steroids are used as 'bridging therapy' but do not replace DMARDs. Biologics like Infliximab are reserved for patients failing dual cDMARD therapy.

Septic arthritis is a surgical emergency; joint aspiration for synovial fluid analysis (Gram stain and culture) is the gold standard for diagnosis. Imaging and bloods are supportive but cannot definitively rule in or out infection as quickly or accurately as aspiration.

First-line management for ankylosing spondylitis (axial spondyloarthritis) is regular NSAIDs and structured exercise/physiotherapy. DMARDs like methotrexate are not effective for purely axial disease. TNF-alpha inhibitors like Etanercept are only used if NSAIDs fail.

PMR typically shows a rapid and dramatic response to low-dose steroids. NICE and BSR guidelines suggest reviewing response within 1 week; failure to see significant improvement in symptoms (usually >70% within 1 week) should prompt reconsideration of the diagnosis.

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.

NICE guidelines recommend an antipsychotic (e.g., haloperidol, olanzapine, risperidone, or quetiapine) as first-line treatment for an acute manic episode. Lithium alone may not be sufficient for acute control, and antidepressants like amitriptyline are contraindicated as they can worsen mania.

Clozapine carries a risk of agranulocytosis; therefore, a Full Blood Count (FBC) must be monitored regularly (weekly for 18 weeks, then fortnightly until one year, then monthly). While blood glucose and lipids are also monitored due to metabolic syndrome risk, FBC is the mandatory safety monitoring required by the clozapine monitoring service.

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.

This patient is experiencing delirium tremens, a severe form of alcohol withdrawal. NICE recommends a symptom-triggered or fixed-dose regimen of a benzodiazepine, such as chlordiazepoxide or diazepam, to manage withdrawal symptoms and prevent seizures.

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.

The 'pearly' appearance, telangiectasia, and central ulceration (rodent ulcer) are classic features of a nodular basal cell carcinoma, the most common skin cancer. Squamous cell carcinoma typically presents with more keratotic scale and faster growth, while seborrheic keratoses have a 'stuck-on' appearance.

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.

Eczema herpeticum is a dermatological emergency caused by HSV infection on top of eczema, characterized by punched-out erosions. Due to the risk of systemic dissemination and ophthalmic involvement, patients (especially children) should be admitted for IV aciclovir; steroids should be avoided as they can worsen the infection.

The Auspitz sign is the appearance of punctate bleeding points after the removal of a psoriasis scale, reflecting the thinning of the epidermis over elongated dermal papillae. The Koebner phenomenon refers to the development of lesions at sites of trauma, and Wickham striae are seen in Lichen Planus.

Intravenous acetazolamide is the first-line systemic treatment to rapidly reduce intraocular pressure in acute angle-closure glaucoma (AACG). Pilocarpine is used once the pressure has dropped slightly but is ineffective if the pressure is too high due to iris ischaemia. Latanoprost is used for chronic open-angle glaucoma.

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.

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.

If a bleeding point is clearly visualized in anterior epistaxis (Little's area) and simple pressure fails, silver nitrate cautery is the treatment of choice after applying local anaesthetic. Nasal packing is reserved for cases where the bleeding point cannot be identified or cautery is unsuccessful.

Orbital cellulitis (infection posterior to the orbital septum) is distinguished from preseptal cellulitis by signs of orbital involvement: proptosis, painful eye movements (ophthalmoplegia), and reduced visual acuity. Both conditions may present with eyelid swelling, redness, and fever.

NICE NG89 recommends that for elective total hip replacement, pharmacological VTE prophylaxis should be offered for 35 days. Options include oral anticoagulants like rivaroxaban or apixaban, or LMWH for 10 days followed by aspirin for 28 days. Aspirin alone for 14 days is insufficient duration and not first-line.

This patient has acute severe asthma. For all patients with acute asthma, NICE/BTS guidelines require the early administration of systemic steroids (40-50mg prednisolone orally). IV steroids are reserved for those unable to swallow or vomit; oral is equally effective.

ACE inhibitors (like ramipril) should be withheld during an AKI as they can impair autoregulation of glomerular blood flow and exacerbate hyperkalaemia, which is already present here. Bisoprolol and statins are generally continued unless there is severe hypotension or rhabdomyolysis.

NICE NG28 suggests that for patients with T2DM and chronic heart failure, an SGLT2 inhibitor with proven cardiovascular benefit should be added to metformin once glucose targets are not met. Pioglitazone is contraindicated in heart failure due to fluid retention.

The standard breakthrough dose of an opioid is 1/10th to 1/6th of the total daily dose. This patient's total daily dose is 120mg (60mg x 2); 1/6th of 120mg is 20mg. 5mg or 10mg would likely be sub-therapeutic.