Question 12
A 72-year-old man develops sudden left-sided weakness and slurred speech 90 minutes ago. CT brain shows no haemorrhage. There are no contraindications. What is the most appropriate next step?
A. IV thrombolysis (alteplase/tenecteplase) if within the eligible time window ✓ Correct
B. Aspirin only, thrombolysis not indicated
C. Immediate anticoagulation with warfarin
D. Wait 24 hours before any treatment or imaging
E. Discharge home with GP follow-up
Explanation
For acute ischaemic stroke presenting within the thrombolysis window (generally up to 4.5 hours from onset, subject to eligibility criteria) with no haemorrhage on CT, IV thrombolysis is indicated. Large vessel occlusion should also prompt consideration of endovascular clot retrieval.
Question 13
A 45-year-old man has 3 months of retrosternal burning worse after meals and when lying flat, with no red flag symptoms (no dysphagia, weight loss, or GI bleeding). What is the most appropriate initial management?
A. Urgent endoscopy before any treatment
B. Trial of a proton pump inhibitor plus lifestyle advice ✓ Correct
C. Long-term antibiotics for H. pylori regardless of testing
D. Barium swallow as first-line investigation
E. Immediate referral for antireflux surgery
Explanation
In a patient with typical GORD symptoms and no alarm features, empirical treatment with a PPI trial and lifestyle modification (weight loss, avoiding late meals, elevating the head of bed) is appropriate first-line management; endoscopy is reserved for red flags or treatment failure.
Question 14
A 30-year-old woman has fatigue and pallor. Investigations show microcytic hypochromic anaemia, low ferritin, and low serum iron with high total iron-binding capacity. What is the most appropriate next step?
A. Start oral iron supplementation and investigate the underlying cause of iron deficiency ✓ Correct
B. Start vitamin B12 injections
C. Immediate blood transfusion regardless of symptoms
D. Start folic acid alone
E. No treatment needed, recheck in 1 year
Explanation
Low ferritin with microcytic anaemia confirms iron deficiency. Management includes oral iron replacement and, importantly, investigating the underlying cause (e.g. menstrual loss, GI blood loss, dietary deficiency) rather than treating iron deficiency in isolation.
Question 15
A 55-year-old man with no significant renal or GI comorbidity presents with sudden severe pain and swelling of the first metatarsophalangeal joint. Serum urate is elevated. What is the most appropriate first-line treatment for this acute episode?
A. Allopurinol started immediately during the acute attack
B. NSAID (e.g. naproxen) or colchicine ✓ Correct
C. IV antibiotics
D. Immediate joint replacement
E. Long-term low-dose aspirin
Explanation
Acute gout is treated with NSAIDs, colchicine, or corticosteroids (oral or intra-articular), chosen based on comorbidities. Urate-lowering therapy such as allopurinol is not started during an acute flare, as it can prolong or worsen the attack, but is introduced later once the flare has settled.
Question 16
A 60-year-old woman presents with sudden severe unilateral eye pain, blurred vision, haloes around lights, a fixed mid-dilated pupil, and a red eye with a hard globe on palpation. What is the most likely diagnosis?
A. Acute angle-closure glaucoma ✓ Correct
B. Anterior uveitis
C. Bacterial conjunctivitis
D. Retinal detachment
E. Corneal abrasion
Explanation
The combination of severe pain, haloes around lights, a fixed mid-dilated pupil, and a firm globe is classic for acute angle-closure glaucoma, an ophthalmic emergency requiring urgent IOP-lowering treatment and same-day ophthalmology referral.
Question 17
A 3-year-old has ear pain, fever, and irritability. Otoscopy shows a bulging, erythematous tympanic membrane with loss of light reflex. The child is systemically well otherwise.