2007 Formative (Core Case Paper) 1) Pnuemonia 65 yr old man: feeling unwell, right-sided chest pain, productive cough

and fever. Lifelong smoker, recent recurrent bronchitis a) Most likely diagnosis? Pneumonia (CAP) b) What 4 measures could assess severity? CARB score! Confusion, Age>65, RR>30, BP systolic<90 c) What simple measure could you do at home to assess severity? Pulse oximetry to measure Sats d) Which antibiotic would be appropriate to give? Amoxicillin or erythromycin e) What non-antibiotic measures could you use? Analgesia (eg paracetamol), ensure adequate fluid intake. f) When would you reassess the situation? 24-48hrs later

2) Hypertension (COC) 36 yr old woman: 3 kids, heavy smoker, obese, on COC. Recently found to have hypertension. a) What advice would you give to this woman? Stop the pill and use alternative method of contraception. b) What is she at increased risk of? Venous thromboembolism. c) What are her risk factors for this? Smoker, increased age, obesity, hypertension. d) What advice would you give her? Stop smoking, reduce weight etc. e) 1st line therapy? ACE inhibitor. f) 2nd line therapy? CCB and thiazide diuretic

3) Hypercalcaemia 63 yr old woman: Thirsty, losing weight, polyuria. a) 2 most likely diagnoses? - Malignancy associated hypercalcaemia/myeloma - Hyperparathyroidism b) Emergency treatment? IV saline, then IV frusemide once rehydrated. c) Whats the most important investigation to do? Measure PTH levels d) She now develops back pain. Whats the most likely diagnosis? Multiple myeloma. e) What 3 investigations would you do? Serum protein electrophoresis, urine bence jones protein, bone marrow examination.

4) DKA 23 yr old male: Thirsty lorry driver, polyuria for past few months. a) 2 most likely diagnoses? Diabetes insipidus, hypercalcaemia b) What advice would you give the pt regarding driving? Cant drive a HGV, cant drive a public services vehicle. c) What are the 4 important aspects of management? Normal saline infusion, insulin infusion, urinary catheterization, NG tubing. d) Which electrolyte would you observe closely? Potassium.

5) Miscarriage 46 yr old woman: 8 weeks pregnant, intermittent lower abdo pain and passing clots pv. a) 2 most likely diagnoses if bhCG is positive? Ectopic pregnancy, hydratiform mole. b) 3 aspects of management? Conservative, medical (antiprogesterone and prostaglandin), surgical. c) 2 most likely diagnoses if bhCG is negative? PCOS, fibroids, malignancy, hypothyroidism, perimenopausal. d) 3 appropriate investigations? FSH, oestradiol/testosterone levels, TFTs, pelvic USS

6) Nocturnal enuresis 7 yr old boy: bed wetting a) What 5 pertinent questions would you ask? Child EVER been dry at night? stressful life event?, any unusual behaviours?, h/o UTIs?, any dysuria?, any change in bowel habit/constipation? b) What 2 simple investigations would you do? Urinalysis for mc & s, urinalysis for glucose, BP, palpate for renal masses c) What are the 2 features of your management? Enuresis alarm, positive reinforcement. d) The girl is worried about spending the night at a friends house, what would you advise? Desmopressin (dDaVP) nasal spray/tablet form NB Pharmo mx (eg imipramine) is NOT 1st line for this condition.

7) Blackout 61 yr old man: blackout a) 4 most likely diagnoses? TIA/stroke, CNS tumour, epilepsy, hypercalcaemia. b) On a CXR, its found that the patients has consolidation in the right upper zone. Name two likely causes? Primary bronchial tumour, lung met, lung absess. c) What further investigations would you do? U&Es, calcium, glucose, CT head d) Which 2 individuals would be involved in this patients management in the community? Macmillan nurse, physio, OT etc. e) What benefits would he be eligible for? Attendance allowance

8) BPH 55 yr old man: 3 yr h/o nocturia a) What features would you assess on examination? Prostate size, presence of nodules, evidence of urinary retention (distended bladder.) b) What 3 conditions is this pt at risk of? UTI, acute retention, prostate cancer. c) What single important investigation would you do? PSA. d) What class of drugs would be appropriate to use? Alpha blockers (or 5 alpha reductase inhibitors). e) Name 2 aspects of surgical management? TURP, open prostatectomy, electro-vaporization etc

9) Depression 35 yr old man: his girlfriend says that hes been moody and drinking more. a) Name 5 symptoms of depression? Feelings of guilt/pessimism/hopelessness, loss of libido, loss of appetite. b) What else would you assess for in the pts history? MSE. c) What 2 non-pharmo aspects of mx could you offer? CBT, IPT. d) Name 2 drug classes that could be used in general practice? SSRIs, eg fluoxetine, TCAs, eg amitriptylline. e) When to reassess pt? 6-12 mnths later.

10) Colorectal cancer 59 yr old man: weight loss and bloody stools. a) What investigation would you do first? Flexi sig (or colonoscopy, Ba enema) b) What 3 features would you assess to stage the tumour? Lymph node involvement, spread through bowel wall, distant organs. c) What 2 aspects of management would be appropriate for a stage 2 tumour? Bowel resection, chemo with 5FU. d) What the 5 yr survival rate with treatment? 40-60%. e) What are the risk factors for this condition? Low fibre diet/high saturated fat, increased age, positive family history, ulcerative colitis, acromegaly f) What screening would you do? Faecal occult blood.