Question bank

A 28-year-old woman presents with 5 days of painless visual loss in the right eye associated with discomfort on eye movement. Visual acuity is 6/36 in the right eye (corrected 6/6 left eye). Fundoscopy shows a relative afferent pupillary defect (RAPD) on the right. There is no history of previous neurological events. MRI brain with gadolinium shows an enhancing right optic nerve lesion and three non-enhancing T2/FLAIR periventricular white matter lesions, all greater than 3 mm.

According to the 2017 McDonald criteria, which of the following statements is most accurate regarding this presentation?

A 72-year-old woman presents with a 3-week history of severe bitemporal headache, jaw claudication, and scalp tenderness when brushing her hair. Over the past 2 days she has noticed brief episodes of transient visual obscuration in the right eye lasting 30 seconds. She has no history of inflammatory arthritis. On examination, there is tenderness and nodularity of the right temporal artery with absent pulsation. Blood pressure is 138/82 mmHg. Investigations: ESR 112 mm/hour (reference <30 mm/hour), CRP 78 mg/L, Hb 104 g/L (normocytic), WBC 12.1 × 10⁹/L, platelets 468 × 10⁹/L, ALP 148 U/L.

Which of the following represents the most appropriate immediate management?

A 67-year-old man is brought to the emergency department by ambulance with sudden onset left-sided weakness and speech difficulties that began 2.5 hours ago. He has a history of hypertension and type 2 diabetes mellitus. His regular medications are perindopril 8 mg daily and metformin 1000 mg twice daily. He does not take anticoagulants. On examination, blood pressure is 184/106 mmHg, heart rate 82 bpm and regular. He has a left facial droop, left arm and leg weakness (MRC 3/5), and dysphasia. NIHSS score is 14. Non-contrast CT brain shows no haemorrhage, no established infarct, and no hyperdense MCA sign. Blood glucose is 8.4 mmol/L, INR 1.0, platelets 188 × 10⁹/L.

Which of the following represents the most appropriate immediate management?

A 63-year-old woman is referred with persistent hypercalcaemia discovered during investigations for fatigue and constipation. She has no history of malignancy, sarcoidosis, or thiazide diuretic use. She does not take calcium or vitamin D supplements. Examination is unremarkable. Investigations: corrected calcium 2.94 mmol/L (reference 2.10–2.60 mmol/L), phosphate 0.72 mmol/L (0.87–1.45 mmol/L), albumin 38 g/L, creatinine 88 µmol/L, alkaline phosphatase 112 U/L, 24-hour urinary calcium 8.2 mmol/day (<7.5 mmol/day), vitamin D (25-OH) 62 nmol/L.

Which of the following investigations is most likely to identify the underlying diagnosis?

A 22-year-old woman with known type 1 diabetes mellitus presents with a 12-hour history of vomiting, polyuria, and abdominal pain. She has been unwell with a urinary tract infection for 3 days and has not been taking her insulin. On examination, she is clinically dehydrated, respiratory rate 28/min (Kussmaul breathing), temperature 37.6°C, heart rate 108 bpm, blood pressure 104/68 mmHg, and GCS is 15. Investigations: blood glucose 28.4 mmol/L, blood ketones 5.2 mmol/L, venous blood gas pH 7.18, bicarbonate 8 mmol/L, potassium 5.6 mmol/L, sodium 132 mmol/L, chloride 98 mmol/L, creatinine 118 µmol/L, eGFR 58 mL/min/1.73m². Urine dipstick: ketones 3+, glucose 3+.

Intravenous fluid resuscitation with 0.9% NaCl has been commenced. Which of the following best describes the appropriate approach to insulin and potassium management?

A 34-year-old man presents with 2 days of severe bilateral thigh and calf pain with dark urine. He attended a high-intensity exercise boot camp 3 days ago after 3 months of inactivity. He has no relevant past medical history and takes no medications. On examination, he is alert, blood pressure 122/78 mmHg, heart rate 96 bpm, temperature 36.9°C, and both thighs are swollen and tender to palpation. Urine dipstick: blood 4+, protein 2+, no nitrites. Investigations: creatinine 312 µmol/L (baseline unknown, estimated normal), urea 14.2 mmol/L, potassium 5.8 mmol/L, bicarbonate 18 mmol/L, calcium 1.88 mmol/L, phosphate 2.1 mmol/L, CK 88,000 U/L (reference <200 U/L), LDH 920 U/L, urine myoglobin elevated. ECG: peaked T waves.

Which of the following is the most appropriate immediate management?