A 24 year old gentleman presents to the emergency department via ambulance following an accident at home. He was setting up fireworks for a birthday party celebration when one exploded unexpectedly. His clothing went on fire resulting in significant burns.

He did not suffer any inhalational injury.

On examination in the emergency department he has full thickness circumferential burns of both upper limbs and his thorax. He is dyspnoeic and hypoxic.

What is required as an emergency procedure?

A 48-year-old woman underwent modified radical mastectomy for invasive ductal carcinoma of the right breast.

The following day, she complained of shortness of breath.

On examination:

Heart rate 87 beats per minute, regular

Blood pressure 120/70 mmHg

Respiratory rate 20 breaths per minute

Temperature 37.2℃

SpO2 92% on room air

On respiratory examination, she has decreased breath sounds over the right lung field. Radiographic examination is as shown in the image.

Needle thoracentesis is performed and reveals high triglyceride levels and low cholesterol levels relative to the serum.

Cytology does not demonstrate any malignant cells.

Culture is negative.

What is the most likely cause of this lady's radiological finding?

A 18 year old male is referred to your cardiology clinic after a sports screening assessment revealed an abnormality of his ECG.

He has no past medical history. He has no family history of cardiac problems or sudden cardiac death. He is an avid runner, and is due to compete at the European Championships in 18 months.

His vitals are within normal limits and on auscultation of his chest you can appreciate an ejection systolic murmur loudest in the left lower sternal edge.

Based on auscultation what is the likely diagnosis in the young male?

You have been asked to review a patient on the ward whose oxygen saturations have decreased to 73% despite administration of 40% oxygen via a face mask.

Her past medical history includes chronic cardiac failure with an ejection fraction of 20% and GOLD Stage 2 chronic obstructive pulmonary disease (COPD) with a large left upper lobe bullae.

On examination:

She is clammy

Heart rate 92 beats per minute

Blood pressure 130/94 mmHg

Respiratory rate 18 breaths per minute

Temperature 36.7℃

On auscultation of her chest, crepitations are audible throughout both lung fields with a moist cough. She has a third heart sound.

What is the next best management step?

A 25 year old gentleman attends for excision of a lipoma from his lower back under local anaesthetic.

You intend to perform the excision using plain lignocaine (without adrenaline) as the local anaesthetic. He has no known drug allergies.

What is the maximum dose of lignocaine that you can administer?

The mother of a three year old boy reports that her son has been limping since he got out of bed yesterday morning. He was well prior to this episode.

On examination, the child appears unwell and is pyrexic (39.0℃). He is unable to weight bear on his right leg and is limping.

He cries when you try to gently internally rotate his right hip.

What is the most likely cause of the boy's hip pain and limping?

A 28 year old woman who is pregnant with her first child presents to your clinic for her 18 week check-up.

She has no past medical history.

On examination she is hypertensive and has bilateral pedal oedema.

Dipstick urinalysis shows 3+ proteinuria.

What is her most likely diagnosis?

An 8 year old girl, with known type 1 diabetes mellitus, presents to the emergency department following a two hour history of vomiting and abdominal pain.

On examination she is clinically shocked and has an unremarkable abdomen.

Preliminary laboratory investigations show the following:

Haemoglobin → 13.2 g/dL ( 11.3 - 13.4 )

WCC → 11.0 x 10^9/L ( 5.4 - 9.7 )

Platelets → 300 x 10^9/L ( 219 - 339 )

Sodium → 128 mmol/L ( 135 – 145 )

Potassium → 6.2 mmol/L ( 3.7 - 4.5 )

pH → 7.2 ( 7.35 - 7.45 )

Blood ketones → 0.6 mmol/L ( ≤ 0.6 )

Glucose → 4.1 mmol/L ( 3.0 – 6.0 )

What is the most likely diagnosis?

A 55 year old gentleman has been admitted for investigation of an episode of bleeding per rectum. He has been unwell for the past number of days with ongoing diarrhoea and poor oral intake.

He has a background history of hypertension for which he takes lisinopril 20 mg once daily.

He is haemodynamically stable and his vital signs are within normal range.

His urine output has dropped to less than 0.5 ml/kg/hour.

His laboratory investigations show that his potassium (K+) is 6.1 mmol/L, ref: 3.5 - 5.0 mmol/L (US value 6.1 mEq/L, ref: 3.5 - 5.1 mEq/L)

An electrocardiogram (ECG) performed shows tall tented T waves and flat P waves.

What is your first pharmacological management?

A 54 year old female is brought to the emergency department following a petrol burn to her left arm and leg.

There is no evidence of an inhalation injury and her airway is patent.

On examination she has full-thickness burns to her anterior right arm, and full-thickness burns to her anterior and posterior right leg.

There is also a large superficial burn to her anterior chest.

You want to commence intravenous fluids at the appropriate rate.

Using the ‘rule of nines’, calculate the total body surface area of burns so adequate fluid resuscitation can be determined.

A 74 year old gentleman presents to the emergency department with a two month history of feeling tired all the time with breathlessness on minimal exertion. His daughter reports that he is very pale.

On further questioning he reports that his bowel habit has changed over the past 4-6 weeks associated with intermittent colicky abdominal pain.

On examination he has conjunctival pallor. His abdomen is soft and there are no palpable abdominal masses.

His haemoglobin is 6.2 g/dL, his MCV is low (microcytic). His white cell count and platelets are within normal parameters. Renal and liver profiles are unremarkable.

What investigation should be prioritised to diagnose this gentleman?

A 40 year old woman presents with a five week history of a palpable breast lump.

She has had multiple biopsies for breast lumps in the past and they have all been reported as “benign fibrocystic disease”.

Her medical history is notable for type 1 diabetes mellitus.

She has no family history of cancer.

What is the most appropriate management of this patient?

Jane is a 45 year old woman who presents to the symptomatic breast unit for assessment based on her positive family history of breast malignancy.

Jane is eager to be tested for “the gene”.

Her sister, Marie, had breast cancer fifteen years ago, at 35 years of age, and is also under your care. Her mother died from ovarian cancer at 50 years of age and her maternal first cousin had breast cancer two years ago, at 46 years of age.

At the time of Marie's diagnosis, her cousin had not yet been diagnosed and she had been unsure of her mother’s diagnosis.

What is the most appropriate next step?

This 32 year old gentleman presented to his general practitioner with a lesion on his neck. He reports that it is increasing in size.

In the context of an examination/assessment, describe the lesion you see in these two photographs and select the single best answer.

A 55 year old woman attends your medical practice complaining of dizziness.

She is flustered as she was running late.

Her blood pressure (BP) is 160/90 mmHg.

You recheck it again from the other arm five minutes later and it is 155/90 mmHg.

What is the next best course of action?

A 62 year old man presents to the emergency department with chest pain on exertion.

He reports swelling of his ankles bilaterally over the past number of months with some shortness of breath on exertion. He has had 4-5 “dizzy spells” over the past two weeks, one of which resulted in collapse.

The nurse reports that he is haemodynamically stable and has no neurological deficits.

Before you examine this man and listen to his chest, what do you think is the most likely diagnosis?

A 38 year old man presents with a history of acute back pain radiating to his left buttock and calf. The pain is severe and has been ongoing for the past five days.

You are concerned that he may have an acute S1 radiculopathy secondary to vertebral disc herniation.

On examination there are no sensory or motor deficits and sphincter control is normal.

Which of the following is the most appropriate plan for early management of this case?

A 65 year-old man attends your surgery to seek advice on a symptom that has been waking him from sleep for the past two years with increasing frequency.

He reports that he wakes with paraesthesiae of both hands, which is more frequent in the right hand.

This discomfort resolves after a number of minutes, during which time he will shake his hands out or hold his hands in the air.

He has also been aware of reduced strength in his hands for approximately six months, particularly for tasks such as opening jars.

On examination he is obese with evident weakness of abductor pollicis brevis muscle (APB) on the right hand side.

What is the most likely cause of this man’s symptoms?

This 27 year old man has been referred to the dermatology outpatient department for an opinion regarding a friable lesion on the sole of his foot.

You see him and are concerned.

Describe this lesion to the dermatology consultant and select the most likely diagnosis from the list below.