1) A 45 year old gentleman with cirrhosis, secondary to alcoholic liver disease, is admitted to hospital with abdominal pain and confusion. His confusion has worsened in the last twelve hours. DH: He brings with him a bag of medication, which includes furosemide 40mg once in the morning, thiamine 50mg daily and propranolol 40mg once daily. SH: His carer states that he no longer drinks alcohol but used to drink half a bottle of wine per day. She states he has been confused for about a week, and she has been with him, so he could not have drunk any alcohol in that time. On examination: Temperature 37 degrees, heart rate 77bpm, blood pressure 122/81. He is disorientated in place and time, and a left hand resting tremor. He has a hepatic flap. On abdominal examination he has hepatomegaly. PR examination shows compacted stool. Investigations: Na 139 mmol/L (135-145), K 4.8 mmol/L (3.5-4.9), Urea 4.6 (2.5-7.0), Cr 80 umol/L (60-110), albumin 21g/L (37-49), bili 76 (1-22), ALT 111 (5-35), ALP 121 U/L (45-105), Ammonia 121 mcg/dL (15-45) CT head: no acute abnormalities detected. Select the most appropriate option at this stage.

A Chlordiazepoxide high dose regime commencing at 30mg QDS

B Folic acid 5mg daily

C Hartmann’s solution IL over 6 hours

D Lactulose 30-50ml 3 times per day

E Lorazepam 1mg IV over 2 minutes

2) A 67 year old man with a background of multiple myeloma is admitted to the acute medical unit with shortness of breath. He becomes acutely dyspnoeic, with oxygen saturations of 85%. DH: He is not on any regular medications. His last chemotherapy was three months ago. SH: He lives with his wife, who has not been unwell recently. He recently injured his ankle and has not been engaging with his ADLs for the past two weeks. On examination Temperature 36.1 degrees, heart rate 131, irregularly irregular pulse. Oxygen saturations now 94% on high flow oxygen. Orientated in place in time. His chest is clear, with good air entry and no added sounds. Bilateral leg oedema, with the left leg appearing more erythematous. Weight 75kg. Investigations Na 141 mmol/L (135-145), K 4.1 mmol/L (3.5-4.9), Urea 4.4 (2.5-7.0), Cr 71 umol/L (60-110), albumin 45g/L (37-49), CRP <4, WCC 7.1 Chest X Ray: normal lung fields Select the most appropriate option at this stage.

A Enoxaparin SC injection 115mg stat

B Flucloxacillin IV 1g twice daily

C Gentimicin IV 375mg stat

D Paracetamol oral tablets 1000mg four times daily

E Piperacillin w/ tazobactam IV 4.5g 8 hourly

A 55 year old lady is admitted to the acute medical unit with nausea and vomiting of one week’s duration. She also appears confused. She has had little to no oral intake during this time, including her regular medications. She has a past medical history of asthma, Addison’s disease, fibromyalgia and diet controlled diabetes. DH: Codeine 30mg three times daily, gabapentin 100mg three times daily, fludrocortisone 250 micrograms daily, hydrocortisone 20mg daily, salbutamol CFC inhaler 2 puffs PRN SH: She works as a classroom assistant in a nursery. On examination Temperature 36.7 degrees, heart rate 88. Blood pressure 98/57. Dry mucous membranes. Appears pale and cachectic. Disoriented in place and time. Select the most appropriate option at this stage.

A Disodium pamidronate IV 30mg over 30 minutes

B Dioralyte oral powder 1 sachet QDS

C Gabapentin oral tablet 100mg stat

D Hydrocortisone IV 100mg stat

E Normal saline 0.9% IV 1L over 2 hours

4) A 67 year old man has presented with confusion and generalised aches and pains. He has not opened his bowels for five days, and he is normally very regular. He has a past medical history of recent admission for cholecystectomy, parathyroid nodule and depression. DH: He has only brought with him one box of Paracetamol, and is asking for increased pain relief. SH: He is a janitor at a local school and does not drink alcohol regularly. On examination Temperature 37.4 degrees, heart rate 71. Blood pressure 161/81. Dry mucous membranes. Orientated in place but not in time. Chest is clear, with no added sounds. Abdomen soft, with recent cholecystectomy scars noted and slightly distended abdomen. Investigations Na 140 mmol/L (135-145), K 3.7 mmol/L (3.5-4.9), Urea 2.6 (2.5-7.0), Cr 120 umol/L (60-110), bili 14 (1-22), ALT 23 (5-35), ALP 105 U/L (45-105), corrected calcium 3.40mmol/L (2.2-2.6), phosphate 1.7mmol/L (0.8-1.5) Select the most appropriate option at this stage.

A Aluminium hydroxide oral capsules 4-20 capsules daily in divided doses with meals

B Disodium pamidronate IV 15mg over 30 minutes

C Disodium pamidronate IV 60mg over 30 minutes

D Hartmann’s solution IV 1L over 2 hours

E Sodium chloride 0.9% IV 1L over 2 hours

An 87 year old lady is admitted to the surgical ward with severe abdominal pain. On abdominal CT, she is found to have evidence of ischaemic bowel, which is deemed inoperable. She deteriorates rapidly, and she is reviewed by the palliative care team, who, in conjunction with the ward team, recognise that this patient is reaching end of life. She is orientated in place and time, however appears uncomfortable due to excess respiratory secretions. Her pain is presently under control with oromorph, whilst she has not felt nauseous. Select the most appropriate option at this stage.

A Cyclizine 50mg PO TDS

B Haloperidol 2.5mg SC 2 hourly PRN

C Hyoscine hydrobromide 400micrograms SC 2 hourly PRN

D Levomepromazine 6.25mg SC 2 hourly PRN

E Midazolam 10mg SC 2hourly PRN

A 72 year old homeless man is admitted with shortness of breath and a productive cough. He is diagnosed with an infective exacerbation of COPD, and commenced on Amoxicillin 1g IV. Soon after, he becomes more acutely breathless, and you are asked to review him. DH: He states he does not take any regular medication, however admits to occasionally using cocaine. On examination Temperature 37.7 degrees, heart rate 154bpm, regular. Blood pressure 87/44. Oxygen saturations 89% on 2L oxygen. Appears uncomfortable and breathless. Angioedema noted. Wheeze and stridor on chest examination. Select the most appropriate option at this stage.

A Adrenaline IM 0.5mg stat

B Adrenaline IV 0.5mg stat

C Chlorphenamine oral 10mg stat

D Hydrocortisone IV 200mg stat

E Piperacillin w/ tazobactam IV 4.5g 8 hourly

Mrs Smith is a 72yr old lady admitted with a distal wrist fracture following a fall, which has been managed conservatively with strong analgesia. During the night you are called to see her because she has become very drowsy and is ‘not herself. Following ABCDE assessment, she is clinically dehydrated, responsive to voice with bilaterally constricted pupils. RR 10, sO2 98%. Obs are otherwise stable. Select the most appropriate initial management for this lady.

A) Naloxone 800microgram, followed by 400microgram (up to a further 2 doses) and stop all opiates

B) Naloxone infusion 1.6mg/hr

C) Flumazenil 200micrograms

D) Naltrexone 25mg OD

E) Naloxone 400microgram, followed by 800microgram (up to a further 2 doses) and review renal function prior to prescribing further analgesia

A 19yr old woman is pregnant with her second child. She is suffering with persistent nausea and vomiting despite conservative measures. You are concerned she may become dehydrated, what antiemetic would be a suitable first line treatment?

A) Domperidone

B) Cyclizine

C) Metoclopramide

D) Dexamethasone

E) Ondansetron

Mabel is 82 years old. She has struggled to open her bowels for the last few months. She has seen her GP who discussed conservative measures and started her on ispaghula husk. Unfortunately she remains constipated, and her bowel motions are hard. What is the next most appropriate medication to offer?

A) Movicol 2 sachets BD

B) Senna 15mg ON

C) Bisacodyl 10mg OD

D) Phosphate enema PR

E) Lactulose 50ml TDS

Mr Jones was admitted with coffee ground vomiting. After initial fluid resus he was sent for endoscopy which shows a small gastric ulcer. Biopsies were taken and are CLO negative. What is the most appropriate first line management in this patient?

A) Amoxicillin 1 g BD, clarithromycin 500 mg BD and lansoprazole 30 mg BD

B) Ranitidine 150mg BD

C) Lansoprazole 15mg OD

D) Lansoprazole 30mg BD for 4-6 weeks then arrange a repeat endoscopy

E) Clarithromycin 250 mg BD, metronidazole 400 mg BD and lansoprazole 30 mg BD

Mr Ali is brought to A&E with fresh PR bleeding and a Hb of 74g/l. The rest of his bloods are grossly normal. He is on warfarin and his INR is found to be 7. Which of the following medication is most likely to have resulted in his deranged INR?

A) Carbamazepine

B) Naproxen

C) Erythromycin

D) Amlodipine

E) Paracetamol

A 76yr old man presents to his GP complaing of severe right orbital headaches. He has had multiple episodes of these headaches over the past few days, each episode lasting around an hour. They most commonly happen at night, and he describes feeling restless, pacing the room and occasionaly banging his head off the wall. It is also associated with right sided runny nose and watery eye. He has a PMH of IHD and hypertension.What would be the most appropriate management for his headache symptoms?

A) Sumatriptan nasal spray 10-20mg

B) Oral sumatriptan 50-100g

C) Verapamil 80mg TDS

D) Naproxen 500mg BD

E) Home oxygen

A patient is admitted with a significant AKI due to dehydration. His potassium is found to be 6.6mmol/l. What is the most suitable initial treatment to lower her postassium?

A) Calcium gluconate 10% 10mls IV

B) 10 units of actrapid in 50ml 50% dextrose

C) Sodium polystyrene sulfonate 30g

D) Spironalactone 200mg OD

E) Dialysis

A 62 year old man has known hypertension. He was previously treated with lisinopril 20mg OD for a number of years which had well controlled his blood pressure. His blood pressure has increased over the last few months, and has consistently read over his target blood pressure. What would be the next most appropriate stage in management?

A) Amlodipine 5mg

B) Candesartan 8mg

C) Bendroflumethiazide 2.5mg

D) Bisoprolol 5mg

E) Simvastatin 40mg

A 75 year old man with heart failure and diabetes is admitted with increased shortness of breath and is treated for a pneumonia. He remains an inpatient for two weeks. A blood test is undertaken to identify resolution of infection, in which he is noted to have an ALT of 1145. Which of the following medications from his kardex should be discontinued?

a) Amoxicillin

b) Atorvastatin

c) Furosemide

d) Gabapentin

e) Spironolactone

A patient is admitted to the acute medical unit feeling generally unwell. They have a background of complex rheumatoid arthritis which has been resistant to treatment, as well as bipolar disorder and epilepsy. As an FY1 doctor, you are asked to rewrite their regular medications. Which of the following medications require consultant prescription?

A Celecoxib

B Gabapentin

C Lithium

D Methotrexate

E Sodium Valproate

An 89 year old lady is admitted to the ward with pyrexia and a productive cough. She is found to have sepsis of respiratory source. Unfortunately, treatment with IV antibiotics proves to be unsuccessful, and your consultant discussed the situation with their family. All are in agreement that the patient is coming to the end of her life. Unfortunately the lady is becoming increasingly agitated, and the family ask you to prescribe some medication to treat this. What is the most appropriate prescription in this case?

A Cyclizine 50mg subcutaneously

B Hyoscine butylbromide 20mg subcutaneously

C Hyoscine hydrobromide 400micrograms subcutaneously

D Midazolam 2.5mg subcutaneously

A 75 year old man is admitted to the ward with weight loss and haemoptysis. He states he previously weighed 92kg 6 months ago but now weighs 80kg. Chest X ray shows a mass and lung cancer is suspected. He begins to complain of leg pain, and on examination his left leg is erythematous, tense and warm. The entire limb is swollen and he has pitting oedema, with dilated superficial vessels. What is the most appropriate prescription?

A Apixaban 5mg BD oral

B Enoxaparin 120mg subcutaneously STAT

C Enoxaparin 240mg subcutaneously STAT

D Flucloxacillin 500mg QDS IV

E Warfarin 5mg once daily oral then adjusted for INR

A 41 year old man is brought to A&E by ambulance. He is largely unresponsive when assessed, with GCS 10. His partner is present and is concerned that he has taken an overdose of diazepam tablets kept at home for his mother’s anxiety. He has apparently been unconscious for more than 3 hours. Which of the following medications may reverse the effect of this overdose?

A Activated charcoal

B Ethanol

C Flumazenil

D N-Aceylcisteine

E Naloxone

An 81 year old man is reviewed on the ward because they appear generally unwell. He has a background of heart failure and chronic kidney disease. His eGFR is 29. He appears confused and is complaining of dysuria. An MSU is requested, which grows e.coli, sensitive to a number of medications. Which of the following antibiotics would be least appropriate in management?

A Amoxicillin

B Co-amoxiclav

C Fosfomycin

D Nitrofurantoin

E Trimethoprim