An 87 year old NZ European male has presented via ambulance due to collapsing at home with sudden onset left-sided weakness. His partner explains that he has not been making sense when he speaks and seems to ignore everything on the left side. What is the most appropriate initial action?

A 3-year-old child presents to the emergency department with a 6-day history of fever, irritability and a rash that started on the trunk and has spread distally. On examination, the child has red, bloodshot eyes, dry cracked lips, and a strawberry tongue with peeling skin. The parents report a recent URTI and mention having autoimmune conditions themselves. The child has no significant past medical history.

A 48-year-old woman is admitted to the ward with jaundice of unknown cause. She first noticed yellow sclera a week or so ago. She denies any pain, but admits to feeling itchy lately. She has not travelled recently, and cannot recall any recent gastrointestinal illness. Some of her investigations are shown below:

Hb 117 g/L (115-155 women); WCC 9.0 x 10⁹/L (4.0 – 11.0) ; Total bilirubin 124 µmol/L (< 25); LDH 75 U/L (120-250); Haptoglobin 4.5 g/L (0.3-2.5); ALP 324 U/L (30-105); AST 26 U/L (10-35)

Examination of the abdomen reveals a palpable mass in the right upper quadrant, and she has yellow discoloration of the sclera and skin. There are no other positive findings. Urine dipstick analysis shows high levels of conjugated bilirubin in the urine. What is the most likely diagnosis?

A 38-year-old Indian female G4P3 has just given birth to a healthy baby via caesarian section. There is difficulty delivering the placenta and Mum is noted to an estimated blood loss of 1.5L. Which of the following would not be part of immediate management of Primary Postpartum Haemorrhage?

What is NOT true about the difference between Tamoxifen and Letrozole?

A 1-year-old Indian girl is noted to have a continuous murmur, loudest at the left sternal edge. She is not cyanosed. A diagnosis of patent ductus arteriosus is suspected. What pulse abnormality is most associated with this condition?

A 26-year-old NZ European man is brought to your GP clinic by his girlfriend, who reports that he has been displaying increasingly unusual, concerning behaviour over the past 5 days. He has suddenly become obsessed with cryptocurrency and has invested thousands of dollars online, staying up late into the night on trading sites. However he seems to have lots of energy and is still going to work as a PE teacher. During your history and exam, his speech is quite loud and his mood is elevated. He says there is nothing wrong with him, and denies using any substances. His past medical history is significant only for previous depression. What mood symptom is this patient exhibiting?

A 24 year old female presented to the ED with a 2 day history of nausea, diarrhoea, bloating and intermittent upper abdominal pain. She mentioned she had a gastric bypass done 6 weeks ago. What post operative complication would you be most concerned about in this patient and how would you investigate it?

A 56-year-old man is brought to the emergency department by friends because he has become confused over the past day. He has a known history of heavy alcohol use. On examination, he is disoriented and inattentive. His gait is unsteady and wide-based. He has horizontal nystagmus. Pupils are equal and reactive. There is no tremor noted. Vital signs are stable. Considering the likely diagnosis, what is the most important initial IV medication to administer?

A 34 year old Māori female presents to her GP with tingling in her right hand. She is currently 30 weeks pregnant. She has no significant past medical history. She reports 3 months of intermittent tingling and pain in her thumb, index finger and middle fingers of her right hand. Her symptoms are worse at night. You do a Phalen's test and it is positive. Her neurological examination is otherwise normal, and there is no muscle wasting. Which nerve is affected and what is the recommended treatment?

A 67 year old man presents to your GP clinic with 2 months of intermittent palpitations, breathlessness and dizziness that began infrequently, but now occur on average once every other day. The episodes usually last for a few minutes before self resolving. He does not describe any associated chest or back pain. A baseline ECG in clinic is normal. He has no significant past medical history. His vital signs are grossly normal on assessment apart from his blood pressure which currently sits at 141/92. What is the most appropriate next step in his management?

A 12-year-old Māori girl presents to her GP with a 4-month history of a dull, aching pain and swelling in the distal aspect of her right thigh. She is otherwise well and blood tests are unremarkable. There is a family history of retinoblastoma. A knee radiograph identifies a triangular area of new subperiosteal bone in the metaphyseal region of the femur, with a 'sunburst' pattern. Which of the following is the most likely diagnosis?

A 68 year old NZ European woman presents to ED with a 2 day history of a temporal headache with some transient blurry vision. She also complains of pain in her jaw when she chews. She has a long history of arthritis in her knees, but notes that recently she has also been getting worsening pain around her shoulders. What investigation will confirm the most likely diagnosis?

A 72-year-old Māori man presents to the Emergency Department with progressive shortness of breath, productive cough, and pleuritic chest pain for 3 days. He has a 50-pack-year smoking history. He was diagnosed with COPD 5 years ago. His medications include regular tiotropium (Spiriva Respimat) and PRN salbutamol. He has no known allergies.

On examination he seems slightly confused. His observations are: HR 110 bpm, RR 31, SpO₂ 88% on room air, BP 122/76, Temp 38.3°C. He has decreased breath sounds with dullness to percussion at the right lower lung zone.

Oxygen administration improved SpO₂ to 92%.

A chest X-ray shows a right lower lobe opacity with a small pleural effusion.

Which of the following is the most appropriate next step in investigation/management?

A 40 year old woman presents to ED with a 2 day history of worsening dyspnoea following an influenza infection two weeks ago. She has a history of type 1 diabetes mellitus, psoriasis, and myasthenia gravis. Her recent dyspnoea has been paired with increasing difficulty with swallowing and talking, as well as increasing proximal limb weakness. What is the appropriate treatment for this condition?

A 24 year old NZ European woman presents to your GP clinic with pallor, shortness of breath on exertion, and a 2-month history of increasing fatigue. She does not have any cough or chest pain. Her medical history includes raised BMI, hypertension, and asthma. She tells you she has been on a vegan diet for around 12 months. She has a Mirena in situ and has been amenorrheic for 2 years.

Bloods tests reveal: Hb 95; MCV 72 fL; MCH 23 pg; RDW 18%; Platelets 450 ×10⁹/L; WBC 6 ×10⁹/L. CRP 10.

Serum ferritin 8 µg/L, TIBC 80 µmol/L; Transferrin saturation 6%.

What is the most likely reason for her shortness of breath and fatigue?

A 72 year old Pākehā man is brought to Auckland ED by his wife, with a 24-hour history of inability to pass urine. Prior to this, he had mild difficulty initiating urination and a weak stream for a few years. Past medical history is significant for depression treated with amitriptyline for many years; and seasonal allergies that have been quite bad recently. treated with promethazine. On examination, you note a distended lower abdomen and a smooth, enlarged prostate. You notice that he looks quite flushed and at times seems confused.

A bladder scan reveals a volume of 1300 mL. A cathether is then inserted, draining 1200 mL of clear yellow urine. Over the next 6 hours, he continues to pass large volumes of urine (300-400 mL per hour). What has most likely contributed to the patient’s presentation and what is the most appropriate next step in his management?

A 72-year-old Samoan man presents to his GP with progressive shortness of breath over the past 3 months. He reports needing two pillows at night to sleep comfortably and has noticed swelling in both ankles. On examination, his blood pressure is 145/85 mmHg, his pulse is 96 bpm, RR is 22/min and oxygen saturation is 95% on room air. He has some bibasal inspiratory crackles and bilateral pitting oedema to the mid-shin. Question: What is the most appropriate initial investigation to confirm the diagnosis of heart failure?

A 37 year old NZ European auto mechanic presents to the ED with severe back pain radiating down the legs, and new onset this evening of bilateral leg weakness. The back pain has been present and worsening for over a week, since injuring himself at work. He also mentions that he soiled himself on the car ride in, which has never happened before. What is the likely diagnosis?

A 32 year old woman, with a 10 pack year smoking history, presents to your GP clinic complaining of a fishy-smelling grey vaginal discharge. She has received multiple courses of antibiotics recently for urinary tract infections. There is no itching or dysuria, and no post-coital or intermenstrual bleeding. She is up to date with cervical screening (normal) and has had the same sexual partner for 7 years. She states that she has had this before a couple of times, and it cleared up with treatment. Which of the following is the most likely causative organism of her presentation?

A 65 year old Chinese man presents with their left eye appearing depressed and abducted. What is the likely cranial nerve affected?

A 46-year-old woman with no significant medical history presents with weight gain, purple abdominal striae, proximal muscle weakness, and new-onset diabetes. Her serum cortisol is elevated and not suppressed by a low-dose dexamethasone test. Her ACTH is also elevated. A high-dose dexamethasone test shows suppression of cortisol levels. What is the most likely diagnosis?

A 84 year old man presents to his GP with mild back pain over the past month with severe constipation. He is an ex-smoker of 30 years. Generally fit and well.

Bloods: Hb: 116 (Men: 135-180 g/L); MCV: 90 (82-100 fL) Platelets: 160 (150-400 x 10⁹/L); WBC: 4.2 (4.0-11.0 x 10⁹/L) Neutrophils 5.5 (2.0-7.0 x 10⁹/L) Lymphocytes 2.5 (1.0-3.0 x 10⁹/L); Ca+: 3.1 (2.1-2.6 mmol/L); ESR 78 (Men: < (age / 2) mm/hr); Urine dipstick: +++ protein - nitrites + blood +++ leucocytes

Based on these results and his presenting complaints, what would be the most likely diagnosis?

A 61 year old Cook Island Māori woman presents to her GP complaining of dizziness. On further history, she experiences recurrent episodes of vertigo after rolling over in bed or looking up, lasting under a minute. During these episodes she feels nauseous and unsteady on her feet. Her cranial nerve exam and hearing is normal. Which test is diagnostic of her presumed condition?

A 45 year old NZ European man has come to his psychiatric review. Throughout the session he is alert and co-operative, very talkative, and goes into intense detail when asked questions. When asked about his mood he responds that his mom has recently been making yummy apple pies, when he was little she used to make him meat pies that weren't nice. He doesn't like eating meat at all. But he loves apple pie so much, and that is why he has been so happy lately. Based on the description above how would you describe his response to the question about his mood?

A 12-year-old Korean girl presents with progressive pain and swelling in the proximal tibia. X-ray reveals an eccentric, expansile, lytic lesion with a "blow-out" appearance and thin cortical rim. MRI shows multiple fluid-fluid levels within the lesion. Histology demonstrates blood-filled spaces separated by fibrous septa containing osteoclast-type giant cells. What is this most in keeping with?

A 45 year old man presents to his GP with 1 month long back pain and fatigue. He is very pale and has visible bruising on his legs. His bloods reveal: ***Hb 78 (135-180 g/l), MCV 92 (82-100 fl), WBC 7.4 (4.0-11.0 * 109/l), Na 142 (135-145 mmol/l) ***Ca 4.5 (2.1-2.6 mmol/l) K 3.8 (3.5 - 5.0 mmol/l) ***Cr 324 (55-120 umol/l). With the most likely diagnosis the GP orders a serum electrophoresis, what would you expect to see on this?

A 76-year-old New Zealand European woman presents to the Emergency Department with sudden onset chest pain and shortness of breath. She has a history of hypertension and is currently taking ramipril. On examination, she is tachypnoeic and hypoxic. An ECG shows new atrial fibrillation. You suspect a pulmonary embolism. Which of the following is the least common feature of pulmonary embolism?