Clinical Problem Solving

1. Clinical Problem Solving • This paper lasts 90 minutes. The questions present clinical scenarios and require you to exercise judgement and problem solving skills to determine appropriate diagnosis and management of patients. • This is not a test of your knowledge, but rather your ability to apply it appropriately. The topics will be taken from areas with which a Pre-Registration House Officer or Foundation Programme Year 1 doctor could be expected to be familiar. There are no questions requiring a specific knowledge of general practice. • http://www.gprecruitment.org.uk/vacancies/stage2.htm

2. Types of questions • True/false • EMQ • SBA • Other question formats may be used when appropriate e.g. Algorithms and multiple best answers. • Read the question • Timing

3. Cardiovascular Dermatology / ENT / Eyes Endocrinology / Metabolic Gastroenterology / Nutrition Infectious disease / Haematology / Immunology / Allergies / Genetics Musculoskeletal Paediatrics Pharmacology / Therapeutics Psychiatry / Neurology Reproductive (male and female) Renal / Urology Respiratory www.gprecruitment.org.uk/vacancies/stage2 Questions may relate to... Disease factors Making a diagnosis Investigations Management plans Prescribing Emergency care Clinical Problem Solving

4. True and False • 1.A raised cholesterol level is associated with increased risk of CHD. • 2. Breast feeding increases the risk of maternal breast cancer. • 3.Young maternal age is associated with SIDs • 4. Grief reaction is characterised by psychosis.

5. Options: ADepressive illness BAnaemia CHypothyroidism DHeart failure EViral illness FMalignancy 1. 30yr old female, post natal, TATT and 6/12 of increasing menorrhagia. 2. 84 yr old man, 6/52 diarrhoea and weight loss. 3. 30yr old female difficulty concentrating and TATT since throat infection 3/12 ago EMQ:TATT

6. Options: A Rosacea B Psoriasis C Cellulitis D Lupus E Impetigo F Perioral dermatitis G Eczema H Contact dermatitis 5yr old girl with erythematous rash with a golden-crusted area around her nose and mouth. She is systemically well. 40yr old woman with facial flushing. O/E erythema, pustules and telangiectasia on nose and cheeks.Worse in sun-light. 20yr old female with several months of red scaly lesions particularly around the hair line. Similar lesions are seen on her knees and elbows. EMQ: Facial Rashes

7. Options: A Lifestyle advise andrepeat Bp in 1/12 B Start amlodipine C Start frusemide D Start bendrofluazide E Start perindopril F Start atenolol G Start doxazosin F Start candesartan A 40 yr old white male with Bp 150/95. No current medications/PMH A 60yr old DM on perindopril. Past hx of gout. BP 145/90 An Asian 40yr old man, new diagnosis DM, not on any meds. BP 140/95 A 45yr old AC woman with Bp 165/90. EMQ:Hypertension management

8. Options: ARubella BMeasles CFifth disease D Chicken pox E Roseala infantum FHand foot and mouth 1. Lesions are red macules rapidly progressing to papules to vesicle to crusted lesions. 2. Illness typically causes a malar erythema followed by reticular rash on trunk and extremities. 3. Rose-pink lesions preceded by a high fever in an otherwise well child. EMQ: Childhood Infections

9. Options: A MI B Asthma C PE E Hay fever F Lung ca G COPD H Allergic alveolitis 49yr old female smoker, 2/12 of cough, wt loss of 3kg. O/E chest NAD. 34yr old on coc, sudden onset SOB and pain L side of chest. O/E tachypnoeic, sweating. Bp and ECG normal. 40yr old smoker with recurrent SOB and dry cough. Worse at night. 50yr old smoker productive white cough over 3/12. Minimal SOB EMQ:Breathlessness

10. Options: A Iron BVitamin B12 CVitamin C DVitamin D E Vitamin K FFolate 1. 76yr old female, CKD, proximal myopathy 2. 4yr old on child protection register has soft bleeding gums 3. 35 yr old female epileptic patient who is well controlled on medication is noted to have a macrocytic anaemia EMQ:Vitamin/Dietary Deficiencies

11. Options A Anxiety disorder B OCD C PTSD D Bipolar Disorder E Schizophrenia F PD G Drug-induced psychosis H Dementia 22yr old male asks for sick cert. He has been in prison and threatened suicide in the past. He can be aggressive to staff You are asked to visit a 67yr old pt with depression. He was found dancing naked in the garden and tells you he is cured. Since starting uni a 21yr old has become more withdrawn. He is dishevelled in his appearance and has had to cover all his plug sockets in his room to keep safe. A 25yr old has been having increasing problems driving to/from work for fear of a RTA. Indeed he has to go back out, retracing his steps to check he has not hit anyone despite not recalling being involved in an RTA. EMQ:Psychiatric Complaints

12. Options: ATension headache BMigraine CSubdural haemorrhage DMeningitis E Subarachnoid haemorrhage F Analgesic rebound GCluster headache 1. 36yr old female secretary, recurrent headache for few weeks. Band-like, worse in pm. 2. 45yr old male, recurrent headaches around L eye, which becomes red and watery. Lasts a few hrs daily but then disappears for a few months. 3. 85yr old c/o headaches following a fall 2/52. Her carer says she is more unsteady these days. EMQ: Headache

13. Options: ACarpel Tunnel BLateral epicondylitis CMedial epicondylitis DOA E Pulled Elbow F Ganglion GTenosynovitis H Olecranon bursitis 1. 58yr old office worker has pain and swelling in the elbow. Aspiration reveals fluid gram stain neg and no crystals. 2. 55yr old man with elbow pain getting worse over last few weeks. He has been diagnosed with golf’s elbow 3. 20yr old is worried about the painless, smooth and firm swelling she has noticed on her wrist EMQ:Elbow, Wrist and Hand problems

14. Options: A Validity B Selection Bias C Publication Bias D Information Bias E Reliability Occurs when studies with positive results are more likely to be published. Occurs when there are differences between the sample and target populations. Refers to the measure of truthfulness Refers to the measure of repeatability EMQ: Statistics 1

15. Options A Case-controlled study. B Cohort study C RCT D Cross-sectional survey E Double-blind placebo 2 or more groups to which patients are randomly allocated. 1 group is the control/non-experimental grp. Used to compare 2 groups when prevalence is low. A study in which the sample is observed at 1 particular time. It gives prevalence estimates. Follow-up of 2 or more groups with a recorded exposure to a risk factor. Provides comparative incidence estimates between exposed and non-exposed grps. EMQ:Statistics 2

16. SBA: Hormonal post-coital contraception Choose from the following: • Must be given within 48hrs of UPSI • Involves two doses 12hrs apart • Contains both oestrogens and progestogens • Is available OTC

17. SBA Which combination of the following diseases are notifiable? 1. Food poisoning, TB and mesothelioma 2. Mumps, Malaria and Measles 3. Anthrax, polio and anaphylaxis

18. SBA Which of the following statements about genital chlamydia is not correct? 1. It is asymptomatic in up to 70% of cases 2. Symptoms can include PCB 3. The incidence of the disease is stable 4. More common in an older population

19. SBA Which of the following statements about gout is true? • It is always accompanied by elevated serum uric acid levels • It is closely associated with potassium-sparing diuretics • Predominantly affect males