FOCP Quiz (50 Questions)

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0 [{"id":420477,"quiz_id":"21312","answer_id":null,"answerType_id":"0","created_at":"2018-03-31 11:20:45","updated_at":"2018-03-31 12:01:47","questionName":"A 55 year old woman presents to her GP with a one month history of intermittent chest pain. The pain is particularly troublesome when walking uphill, and she has to stop for five minutes approximately every 500 metres to let the pain subside. She finds the pain highly distressing, but does not experience any shortness of breath, palpitations or loss of consciousness. She has a 40 pack-year history of smoking, and consumes 15 units of alcohol weekly. What is the most likely diagnosis?","questionTimeSeconds":"0","questionTimeMinutes":"3","questionImagePath":null,"position":8,"explanation":"This is a fairly simple question covering diagnosis of stable angina \u2013 the onset of pain with exercise, duration of less than 20 minutes and significant smoking history are consistent with this. There will be questions as straightforward as this in the exam \u2013 try not to overthink them! COPD is unlikely to cause chest pain, and would produce dyspnoea as a symptom. GORD is more likely to produce pain after meals and when lying flat rather than when exercising. Panic disorder would likely produce other symptoms alongside chest pain, such as sweating and nausea, and is more likely to have unexpected onset (rather than predictably with exercise). Peripheral arterial disease could produce similar pain to this in the calves (claudication), but not in the chest. Learning outcome: chest pain (core presentation), ischaemic heart disease (core condition)","question_score_id":null,"lang":null,"questionAudioPath":null},{"id":420476,"quiz_id":"21312","answer_id":null,"answerType_id":"0","created_at":"2018-03-31 11:19:56","updated_at":"2018-03-31 12:01:47","questionName":"A 25 year old Geography student presents to her GP with a three week history of recurrent bloody diarrhoea and painful red eyes. The diarrhoea is accompanied by cramping abdominal pain, and she states that she has lost 5kg in weight since the start of her symptoms. On examination, her abdomen shows mild generalised tenderness to palpation, no masses or hepatosplenomegaly, and normal bowel sounds. Examination of the anal region reveals anal skin tags. A painful nodular erythematous eruption is noted over both of her shins. Which investigation is most likely to confirm the diagnosis?","questionTimeSeconds":"0","questionTimeMinutes":"3","questionImagePath":null,"position":7,"explanation":"This question stem is describing a patient with likely inflammatory bowel disease. The onset presence of ocular symptoms and findings of anal skin tags and erythema nodosum are particularly consistent with a diagnosis of Crohn\u2019s disease. Examiners love questions about differentiating IBD from IBS, as well as diagnosis of IBD (e.g. using biopsy findings \u2013 remember that Crohn\u2019s disease produces inflammation across the entire bowel wall whereas UC is more superficial given that it is ulcerative). Barium enemas can be used to detect diseases of the intestinal tract, but would not produce histology to confirm a diagnosis. Rheumatoid factor is not necessary in this instance, as RF- positive conditions are unlikely to cause the main presenting feature of bloody diarrhoea. Serum ACE is used to monitor sarcoidosis, and may be performed if the patient had presented with erythema nodosum alone, but the presence of IBD symptoms means this test is probably unnecessary. A stool culture would be performed in this instance, especially if the patient had had recent travel, but is less likely to confirm the diagnosis given that Crohn\u2019s disease is the most likely diagnosis (owing to the presence of extra-intestinal disease). Learning outcome: change in bowel habit (core presentation), inflammatory bowel disease (core condition), lower GI endoscope (core investigation), describe common signs of disease including inflammatory bowel disease (gastrointestinal system outcomes)","question_score_id":null,"lang":null,"questionAudioPath":null},{"id":420481,"quiz_id":"21312","answer_id":null,"answerType_id":"0","created_at":"2018-03-31 11:23:48","updated_at":"2018-03-31 12:01:47","questionName":"A 65 year old man with a history of atrial fibrillation is brought in to the Emergency Department by his wife. Two hours ago he developed sudden-onset right-sided facial and arm weakness accompanied by slurred incomprehensible speech. His wife states that three days earlier he had experienced a similar episode that lasted for five minutes before resolving. On examination, the patient had a drooping right angle of the mouth and was able to raise his eyebrows but was not able to smile. Power in the right arm was 2\/5 in all movements, with reduced tone and absent reflexes. Neurological examination of the left arm and both lower limbs is unremarkable, and gait is normal. No visual field defect is identified. What is the most likely diagnosis?","questionTimeSeconds":"0","questionTimeMinutes":"3","questionImagePath":null,"position":12,"explanation":"This question is testing your familiarity with the Oxford (Bamford) stroke classification system: TACS: unilateral weakness and\/or sensory deficit of face, arm and leg + homonymous hemianopia + higher cerebral dysfunction (e.g. dysphasia or visuospatial disorder) PACS: two out of three of the TACS criteria LACS: one of unilateral weakness and\/or sensory deficit of face and arm, arm and leg or all three + pure sensory stroke + ataxic hemiparesis POCS: one of cerebellar\/brainstem syndromes + loss of consciousness + isolated homonymous hemianopia Learning outcome: weakness (core presentation), stroke (core condition)","question_score_id":null,"lang":null,"questionAudioPath":null},{"id":420471,"quiz_id":"21312","answer_id":null,"answerType_id":"0","created_at":"2018-03-31 11:13:51","updated_at":"2018-03-31 12:01:47","questionName":"A 72 year old woman presents to the Emergency Department with a three day history of abdominal pain and dysuria. Her airway is patent and her chest is clear with respiratory rate of 28 cycles\/min and O2 saturation 97% on room air. Her heart rate is 128bpm and her BP is 102\/82, with peripheral capillary refill time of less than 2 seconds. She is alert but mildly confused with equal pupils. Her temperature is 39.2\u00b0C, and she has no rashes. On abdominal examination she has renal angle tenderness with positive urine dipstick for blood, leukocytes and nitrites. Her initial bloods show a leucocytosis with neutrophilia, CRP 128 (normal range <5), normal lactate and evidence of an acute kidney injury. The F1 has commenced the patient on 15L high-flow O2 via a non-rebreather mask and 500ml normal saline. What is the next step in managing this patient?","questionTimeSeconds":"0","questionTimeMinutes":"2","questionImagePath":null,"position":2,"explanation":"This question stem is describing a patient with features of sepsis, likely secondary to pyelonephritis given the symptoms, renal angle tenderness (a good buzzword for pyelonephritis) and inflammatory urine dipstick result. In this question, the F1 has commenced their management of sepsis and you are expected to complete the remaining steps in an appropriate order. The sepsis 6 describes actions to be taken within one hour of identifying a patient with sepsis, and can be split into \u201cgive 3 and take 3\u201d: \u2022 Take lactate (plus other necessary bloods) \u2022 Take urine (monitor hourly urine output e.g. through urinary catheterisation) \u2022 Take blood cultures \u2022 Give intravenous fluids \u2022 Give high-flow oxygen \u2022 Give intravenous antibiotics (within one hour of identification of sepsis) In this patient, the lactate has already been checked and fluids and oxygen have already been given. Urine output monitoring is not given as an option, leaving blood cultures and antibiotic therapy as the remaining options. Wherever possible, blood cultures should be taken before initiating intravenous antibiotic therapy, and so this is the best next step. Urine cultures are a very sensible option and would be performed, but given that the infection has progressed to sepsis the blood cultures should be prioritised. A CXR is useful in evaluation of sepsis of unclear source, but in this case the normal respiratory examination versus the obvious urinary symptoms\/signs makes this a low-priority investigation. Co-amoxiclav and gentamicin are both appropriate options for the management of suspected urosepsis. Learning outcome: septic shock (core condition), urinary tract infection (core condition)","question_score_id":null,"lang":null,"questionAudioPath":null},{"id":420474,"quiz_id":"21312","answer_id":null,"answerType_id":"0","created_at":"2018-03-31 11:18:23","updated_at":"2018-03-31 12:01:47","questionName":"A 20 year old medical student presents to the Dermatology clinic for review of her atopic eczema. She currently has two large patches of erythema and lichenification over both antecubital fossae, with several excoriation marks and breaks in the skin barrier. She has been using regular emollients as well as a moderate topical steroid ointment (Eumovate, clobetasone butyrate 0.06%) for the past five days. There are no signs of infection over the skin lesions. The patient is concerned that she will be starting a ward placement in one weeks\u2019 time and that her ongoing eczema may pose an infection risk. What is the most appropriate management?","questionTimeSeconds":"0","questionTimeMinutes":"3","questionImagePath":null,"position":5,"explanation":"This question is testing your knowledge of eczema management, which comes under both FoCP and LTC learning outcomes. Emollients should always be used for atopic eczema, including between flares, hence why they are included in every answer \u2013 oil-based ointments are most effective but are often found to be unpleasant by patients due to their greasy nature and marking of clothing, so creams are often used as well. Steroid therapy in eczema is very simple \u2013 mild topical steroids (e.g. hydrocortisone) are available over the counter, and are the highest strength steroid that should be used on the face (especially on the skin around the eyes) without Dermatology advice. Steroids are then stepped up gradually until adequate control is achieved (typically to Eumovate, then Betnovate RD (optional), then Betnovate, then Dermovate). Brand names are often used as the names of the steroids themselves are confusing and easily mixed up. In this patient, she does not have adequate control on Eumovate and so should be stepped up to Betnovate. Potent steroids are also useful for treating the lichenification (thickened skin) that occurs in chronic atopic eczema. Oral steroids are only used for severe refractory eczema, as are other immunomodulatory therapies. Learning outcome: eczema (core condition)","question_score_id":null,"lang":null,"questionAudioPath":null},{"id":420479,"quiz_id":"21312","answer_id":null,"answerType_id":"0","created_at":"2018-03-31 11:22:16","updated_at":"2018-03-31 12:01:47","questionName":"A 76 year old man presents to his GP complaining of difficulty passing urine. He describes a six month history of increasing difficulty initiating urination associated with increased frequency and weak urinary stream. He describes waking 4-5 times a night to go to the toilet, which his starting to bother his wife. He is also restless in bed at night owing to new- onset lumbar pain, which is producing no other symptoms. On rectal examination, a solid irregularly enlarged prostate is palpated. Neurological examination of the lower limbs is unremarkable. What is the most likely diagnosis?","questionTimeSeconds":"0","questionTimeMinutes":"3","questionImagePath":null,"position":10,"explanation":"Clues towards the malignant nature of this patient\u2019s symptoms are the presence of low back pain with urinary symptoms (indicating potential metastases to the lumbar vertebrae) as well as the irregular nature of the prostate gland. Bacterial prostatitis can produce these symptoms, but is more likely to be accompanied by fever and chronic pelvic pain \u2013 on examination, if the infection is acute the gland can be tender and \u201cboggy\u201d, but if chronic the gland can be normal or solid from calcification. BPH is a very common cause of lower urinary tract symptoms in older men, but the prostate gland is more likely to be smoothly enlarged. Rectal cancer would likely produce rectal bleeding and change in bowel habit. Urinary tract infection would not be likely to continue for six months, and would normally produce dysuria alongside other urinary symptoms. Learning outcome: prostate disorders (core condition), change in urinary habit (core presentation), describe common signs of disease including prostate enlargement (genitourinary system outcomes)","question_score_id":null,"lang":null,"questionAudioPath":null},{"id":420482,"quiz_id":"21312","answer_id":null,"answerType_id":"0","created_at":"2018-03-31 11:24:30","updated_at":"2018-03-31 12:01:47","questionName":"A 64 year old woman presents to her GP with a two week history of increasing shortness of breath. She reports a gradual onset of breathlessness, with no cough, wheeze or chest pain. On further questioning, she reports 8kg of weight loss in the last six months, although she does state that she has been trying to lose weight. She is an ex-smoker of 20 years with a 20 pack-year history, and consumes only occasional alcohol on weekends. She has had no recent travel. Her past medical history is significant for invasive ductal carcinoma of the right breast 15 years previously, which was successfully treated with wide local excision and radiotherapy. On examination, there is reduced chest expansion on the right, with a stony dull percussion note inferior to the right sixth intercostal space and reduced air entry in the right base. The left lung is clinically normal, and no other abnormalities are detected on examination. What is the most likely diagnosis?","questionTimeSeconds":"0","questionTimeMinutes":"3","questionImagePath":null,"position":13,"explanation":"This question stem is describing a likely malignant pleural effusion, the giveaway phrase being \u201cstony dull\u201d which is essentially the examiner telling you that an effusion is present (this description is only used for pleural effusions). The most likely explanation in this case is a recurrence of the previous breast cancer spreading to the lung\/pleura. Lung abscesses would not produce stony dullness and would produce other constitutional symptoms such as fevers with sweats. Pneumothorax would have a hyperresonant percussion note. Pulmonary TB can produce an effusion as part of its presentation, but would produce other symptoms such as night sweats and is overall less likely than a recurrence of this patient\u2019s breast cancer. Right lower lobe collapse fits with this stem except for the description of stony dullness \u2013 again remember that this descriptor will only be used for effusions in the exam! Learning outcome: lung cancer any manifestation (core condition), describe common signs of disease including pleural effusion (respiratory system outcomes), breast cancer (core condition)","question_score_id":null,"lang":null,"questionAudioPath":null},{"id":420472,"quiz_id":"21312","answer_id":null,"answerType_id":"0","created_at":"2018-03-31 11:15:13","updated_at":"2018-03-31 12:01:47","questionName":"A 68 year old woman presents to the Emergency Department after collapsing in the street. She is accompanied by her husband who informs the team that they are on holiday in Newcastle visiting friends, and that she had been complaining that she \u201chasn\u2019t felt like herself\u201d since arriving yesterday afternoon. She had several episodes of vomiting and diarrhoea this morning. Her past medical history is significant for polymyalgia rheumatica with giant cell arteritis, which was diagnosed six months ago. On examination the patient is drowsy but rousable, with HR 110bpm, BP 84\/60 and temperature 38.1\u00b0C. Respiratory and cardiovascular examinations are normal and abdominal examination is normal but limited by central obesity. A urine dipstick is normal, and a blood glucose taken in the department comes back as 2.5 mmol\/L. What is the most likely diagnosis?","questionTimeSeconds":"0","questionTimeMinutes":"3","questionImagePath":null,"position":3,"explanation":"This is a much more difficult diagnosis question compared to most Endocrinology questions in the Stage 3 exam! The main clues in this stem include her recent diagnosis with PMR\/GCA, necessitating long-term corticosteroid therapy, as well as the combination of hypotension and hypoglycaemia. A common and important cause of adrenal crisis is acute steroid withdrawal \u2013 the patient in this question may have forgotten to bring her medication with her on holiday, may have not absorbed it given her recent diarrhoea and vomiting, or may have forgotten to adhere to her sick day rules with her steroid medication (taking extra medication when unwell). Multiple possible triggers for her adrenal crisis are therefore hinted at in the stem. While the patient definitely has hypoglycaemia, the presence of hypotension, tachycardia and a low-grade fever is not explained by this alone. HHS produces a hyperglycaemia and often has a longer duration of onset. Myxoedema coma, an extreme presentation of hypothyroidism, would typically occur on a background of long-standing untreated hypothyroidism and would produce a hypothermia, hypotension and bradycardia. Septic shock should be considered given the infective symptoms and low BP, but does not explain the hypoglycaemia. Learning outcome: endocrine emergencies \u2013 adrenal failure (endocrine system outcomes)","question_score_id":null,"lang":null,"questionAudioPath":null},{"id":420473,"quiz_id":"21312","answer_id":null,"answerType_id":"0","created_at":"2018-03-31 11:16:27","updated_at":"2018-03-31 12:01:47","questionName":"A 48 year old woman presents to her GP complaining of recurrent episodes of central chest pain for the past six weeks. The pain is burning in nature, and is worst in bed at night. She has a history of obesity and stable angina, and finds that her GTN spray does not relieve the pain, which is of a different character from her usual angina. She has no difficulty breathing or palpitations. Her examination does not reveal any pathological signs. What is the most likely diagnosis?","questionTimeSeconds":"0","questionTimeMinutes":"3","questionImagePath":null,"position":4,"explanation":"Remember that there are plenty of non-cardiac causes of chest pain; GORD is also a particularly common history in OSCEs, with the associated concern of the patient having ischaemic heart disease. Clues towards the diagnosis of GORD in this case include the burning nature, worsening on lying down, history of obesity and lack of relief from GTN. Acute pericarditis is classically relieved by sitting forwards, and so may fit with the pain being worst in bed at night, but would normally resolve in less than six weeks. Symptomatic congestive cardiac failure would typically produce clinical signs such as bibasal inspiratory crepitations and peripheral oedema, and would be more likely to cause dyspnoea than chest pains. PE would be more likely to produce an acute presentation with dyspnoea. Unstable angina is a possibility, but is more likely to be of a similar character to her usual angina with onset at rest. Learning outcome: chest pain (core presentation), GORD or peptic ulcer (core condition)","question_score_id":null,"lang":null,"questionAudioPath":null},{"id":420478,"quiz_id":"21312","answer_id":null,"answerType_id":"0","created_at":"2018-03-31 11:21:30","updated_at":"2018-03-31 12:01:47","questionName":"A 62 year old woman presents to her GP with a two month history of increasing shortness of breath and cough productive of white sputum, particularly in bed at night. She has had no fevers, weight loss, ankle swelling or palpitations. She has a past medical history of hypertension. On examination, she has bilateral basal inspiratory crepitations and a laterally displaced apex beat. What is the most likely diagnosis?","questionTimeSeconds":"0","questionTimeMinutes":"3","questionImagePath":null,"position":9,"explanation":"Another relatively simple question \u2013 these symptoms and signs are classical of heart failure, and the main issue in this question is remembering the signs of left- versus right-sided heart failure. Left affects the lungs (L->L) while right affects the rest (R->R, e.g. causing ankle oedema). The likely cause of this patient\u2019s left-sided heart failure is chronic hypertension. COPD could produce these symptoms and signs, although the pattern of crepitations is more characteristic of pulmonary oedema. The patient has no red flag symptoms of lung cancer \u2013 e.g. haemoptysis or weight loss. Pneumothorax would produce a more acute history for an SBA, and would have hyperresonant percussion notes on examination. Learning outcome: breathlessness (core presentation), cardiac failure (core condition), describe common signs of disease including cardiac failure (cardiovascular system outcomes)","question_score_id":null,"lang":null,"questionAudioPath":null},{"id":420470,"quiz_id":"21312","answer_id":null,"answerType_id":"0","created_at":"2018-03-31 11:12:31","updated_at":"2018-03-31 12:01:47","questionName":"A 65 year old man presents to his local Emergency Department complaining of severe chest pain of 40 minutes duration. The pain is retrosternal in nature, and appeared suddenly when the patient was watching television. On examination he is sweating and pale, with HR 96 bpm, regular rhythm, and BP 138\/98mmHg. Heart sounds are normal, and the remainder of the examination is unremarkable. An ECG shows new T wave inversion and ST segment depression in leads V1-V4. A troponin T test taken 6 hours later is within normal limits. What is the most likely diagnosis?","questionTimeSeconds":"0","questionTimeMinutes":"3","questionImagePath":null,"position":1,"explanation":"This question is testing your ability to differentiate the acute coronary syndromes as well as other potential causes of chest pain. The onset of symptoms at rest and prolonged central chest pain suggest that this is an acute coronary syndrome \u2013 either an MI (STEMI\/NSTEMI) or unstable angina. To diagnose an MI, there must be biochemical evidence of myocardial necrosis (e.g. significantly elevated troponin or CK-MB) with at least one of: \u2022 Ischaemic symptoms \u2022 Ischaemic ECG changes (ST-segment elevation\/depression or new pathological Q- waves), or \u2022 Demonstration of new myocardial loss on imaging\/coronary intervention Given the normal troponin in this case, STEMI and NSTEMI can be excluded. This means that the most likely diagnosis is unstable angina, given the presence of ACS symptoms, ischaemic ECG changes without ST elevation but absence of troponin rise. Stable angina would be expected to have its onset with exertion or stress, and would classically last less than 20-30 minutes. Panic disorder, while an important differential, is unlikely given the ischaemic ECG changes. Learning outcome: ischaemic heart disease (core condition), troponins and other tests for MI (core investigation)","question_score_id":null,"lang":null,"questionAudioPath":null},{"id":420483,"quiz_id":"21312","answer_id":null,"answerType_id":"0","created_at":"2018-03-31 11:26:36","updated_at":"2018-07-03 13:00:30","questionName":"A 70 year old man attends the Emergency Department with a one week history of shortness of breath, productive cough with purulent sputum and generalised fatigue. He has no wheeze, chest pain or weight loss. On examination, there an area in the right lung base with a dull percussion note, decreased air entry, crepitations, and increased vocal resonance. He appears dehydrated with HR 90bpm, BP 104\/80mmHg and RR 24 cycles\/min. What is the most appropriate management of this patient\u2019s underlying illness? His investigations are below:","questionTimeSeconds":"0","questionTimeMinutes":"4","questionImagePath":"uploads\/focp-quiz-50-questions\/investigations1.jpg","position":14,"explanation":"This question is testing your ability to apply the CURB-65 scoring system (on next page) to a case of community-acquired pneumonia as well as antimicrobial prescribing for the condition. In this case, the patient\u2019s CURB score is 2 (scoring for age and urea). This means he should be admitted to hospital but, in the absence of other comorbidities, is not likely to need critical care input. This leaves options B and C \u2013 distinguishing between the two is difficult and in the Stage 3 exam it is unlikely that they would give two answers that are so similar, particularly given that guidelines will differ between trusts. NICE recommends dual antibiotic (amoxicillin plus macrolide) therapy for moderate-severity CAP, and so amoxicillin plus clarithromycin is the most appropriate answer in this case. This would be a very difficult pneumonia question for the Stage 3 exam, so well done if you got this correct! Learning outcome: pneumonia (core condition)","question_score_id":null,"lang":"","questionAudioPath":null},{"id":420480,"quiz_id":"21312","answer_id":null,"answerType_id":"0","created_at":"2018-03-31 11:23:09","updated_at":"2018-03-31 12:01:47","questionName":"A 19 year old man with a history of asthma presents to the Emergency Department with acute shortness of breath. His symptoms began two hours previously while out for a run, and were not relieved by his regular salbutamol. He is experiencing sharp left-sided chest pains exacerbated by deep breathing, and feels panicked and distressed. On examination, he has a heart rate of 110bpm and a respiratory rate of 30 cycles\/min. There is reduced chest expansion and a hyperresonant percussion note on the left side, with reduced breath sounds on the left compared to the right. The apex beat is palpable in the fifth intercostal space, mid-clavicular line. What is the most likely diagnosis?","questionTimeSeconds":"0","questionTimeMinutes":"3","questionImagePath":null,"position":11,"explanation":"The giveaway in this stem is the unilateral hyperresonant percussion note \u2013 the only other cause of hyperresonance to be aware of is in acute asthma attacks due to hyperexpansion of the chest, but would be bilateral. Panic disorder would not produce abnormal clinical findings. Pleural effusion produces a stony dull percussion note (classic buzzword!). PE is an important differential in this case, but again would not produce the hyperresonant percussion note. The diagnosis could be confirmed in this case by performing a CXR \u2013 but remember if there are signs of tension pneumothorax (displacement of the apex beat or trachea) then this should not be performed, and immediate aspiration should be performed instead. Small primary pneumothoraces (<2cm in size at the level of the hilum) can be treated with observation, but given this patient\u2019s history of asthma the likelihood of this being a secondary pneumothorax is higher, so the air should be removed through simple aspiration. Chest drains are used in the case of treatment failure, or first-line if there is a large pneumothorax in an older person (>50yrs) causing dyspnoea. Learning outcome: pneumothorax (core condition), chest pain (core presentation), breathlessness (core presentation)","question_score_id":null,"lang":null,"questionAudioPath":null},{"id":420475,"quiz_id":"21312","answer_id":null,"answerType_id":"0","created_at":"2018-03-31 11:19:09","updated_at":"2018-03-31 12:01:47","questionName":"A 79 year old woman presents to her GP complaining of light-headedness and general fatigue. She has a five-day history of feeling generally unwell, and feels particularly faint when walking around her home. Her husband passed away three months previously, and she describes feeling anxious when alone at home. Her past medical history includes mitral stenosis and alcohol dependency. On examination, the patient has a heart rate of 124bpm with an irregularly irregular rhythm. Her blood pressure is 115\/76mmHg. A mid-diastolic murmur can be heard over the apex of the heart, and mild hepatomegaly is present. The remainder of the examination is unremarkable. What is the most likely cause of her symptoms?","questionTimeSeconds":"0","questionTimeMinutes":"3","questionImagePath":null,"position":6,"explanation":"This is a tricky and fairly vague question, but the main giveaway to the answer is the irregularly irregular pulse with a fast heart rate. There are two possible triggers for this patient\u2019s AF \u2013 the murmur is consistent with mitral stenosis which is a cardiac cause of AF, while the patient\u2019s history of alcohol dependency combined with recent bereavement could be an extracardiac cause. Acute pericarditis is more likely in an SBA to cause chest pain relieved by sitting forwards. Generalised anxiety disorder could absolutely cause this patient\u2019s symptoms, but would be pursued as a possible diagnosis once the AF is under control. Silent MI should be considered in elderly patients (especially with diabetes) but would be unlikely to produce mild symptoms lasting for five days. Wolff-Parkinson-White syndrome is a supraventricular tachycardia caused by an accessory pathway linking the atria and ventricles, and can cause these symptoms, but would be expected to present in a younger person. Furthermore, as this is a Stage 4 outcome, it is not likely to be an answer in the Stage 3 exam. Learning outcome: atrial fibrillation (core condition)","question_score_id":null,"lang":null,"questionAudioPath":null},{"id":420469,"quiz_id":"21312","answer_id":null,"answerType_id":"0","created_at":"2018-03-31 11:10:06","updated_at":"2018-03-31 12:01:47","questionName":"A 65 year old man presents to his local Emergency Department complaining of severe chest pain of 40 minutes duration. The pain is retrosternal in nature, and appeared suddenly when the patient was watching television. On examination he is sweating and pale, with a heart rate of 96bpm, regular rhythm, and blood pressure of 138\/98mmHg. Heart sounds are normal, and the remainder of the examination is unremarkable. What is the most important first step in managing this patient?","questionTimeSeconds":"0","questionTimeMinutes":"3","questionImagePath":null,"position":0,"explanation":"This question stem is describing an acute coronary syndrome \u2013 the retrosternal pain, onset at rest and relatively prolonged duration are all clues towards this. An ECG is a vital investigation to do in any patient presenting with chest pain, as it allows rapid diagnosis of a range of acute cardiac conditions including STEMI. A CXR would also be performed in this case to exclude alternative diagnoses (e.g. pneumothorax) but is less important than an ECG. Coronary revascularisation would not be performed until after an ECG is performed as a diagnosis is necessary. Echocardiograms are not routinely performed for acute coronary syndromes. Antiemetics would be given if morphine is given, but this treatment is less important than reaching a diagnosis. Learning outcome: chest pain (core presentation)","question_score_id":null,"lang":null,"questionAudioPath":null}]
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A 55 year old woman presents to her GP with a one month history of intermittent chest pain. The pain is particularly troublesome when walking uphill, and she has to stop for five minutes approximately every 500 metres to let the pain subside. She finds the pain highly distressing, but does not experience any shortness of breath, palpitations or loss of consciousness. She has a 40 pack-year history of smoking, and consumes 15 units of alcohol weekly. What is the most likely diagnosis?

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