Build and attempt quizzes

A 32-year-old woman presents to your suburban general practice with a 3-day history of dysuria and urinary frequency. She is afebrile, has no flank pain, and is not pregnant. Her observations are normal and abdominal examination is unremarkable.

You suspect uncomplicated cystitis and are considering your differential diagnoses before choosing management.

Which diagnosis is the most likely?

A 6-month-old infant is brought to your general practice after a fever at home and a brief episode of whole-body jerking witnessed by a parent. The episode lasted about 1 minute, resolved spontaneously, and the infant is now alert and interactive.

History and examination:

• Fever started today; current temperature in clinic is 38.3 c (axillary).
• Mild coryza and cough; no neck stiffness, persistent vomiting, bulging fontanelle, or focal neurology.
• Feeding slightly reduced but still taking fluids; wet nappies normal.
• No known allergies.
• No history of immunodeficiency, steroid use, or chronic disease.
• No previous seizures.
• No previous vaccine reactions.

Immunisation history (documented on AIR and in the Green Book):

• Birth vaccines: hepatitis B given.
• 2-month vaccines: given on time.
• 4-month vaccines: given on time.

The parent asks:

Case

A 46-year-old man presents to your GP clinic with 5 days of new neck pain after spending a weekend painting ceilings and driving long distances. The pain is worse with turning his head to the right and looking up. He describes intermittent “pins and needles” into his right thumb and index finger, and occasional aching around the right shoulder blade. Paracetamol has helped a little.

He denies fever, weight loss, night sweats, intravenous drug use, or recent infection. He has not had cancer. He reports no gait disturbance, no hand clumsiness, and no bladder or bowel dysfunction. He has no facial symptoms and no speech disturbance.

Past history: hypertension, type 2 diabetes (well controlled).
Medications: perindopril, metformin. No anticoagulants. No steroid use.
Social: office-based job with prolonged computer use. Non-smoker.

You consider several differentials including cervical radiculopathy, cervical myelopathy, and peripheral entrapment neuropathy (e.g. carpal tunnel syndrome). You want your examination to identify findings that support or refute these possibilities.

Question (KFP-style)
Select the 4 examination findings that would best help confirm (and distinguish between) your most likely diagnoses in this presentation.

Mary is a 61-year-old woman who presents to a small rural emergency department (no on-site ENT/maxillofacial service; retrieval transfer time is estimated at 2–3 hours). She has had 3 days of worsening left lower molar pain and facial swelling. She reports fever and increasing difficulty swallowing. She is allergic to penicillin (immediate reaction with urticaria and wheeze previously). Her history includes type 2 diabetes and hypertension. Current medications include metformin and perindopril.

On examination she looks unwell and anxious. Observations: T 38.60C, HR 118 bpm, BP 146/88 mmHg, RR 30/min, SpO2 93% on room air. She has muffled voice and audible inspiratory noise. There is firm swelling in the submandibular region with tenderness; her tongue appears elevated. Oral examination is limited by pain and trismus; there is floor-of-mouth swelling and pooling of saliva. Neck examination shows anterior neck fullness without urticarial rash. Over the next 10 minutes she becomes more distressed with worsening stridor.

What is the most appropriate immediate priority in management?

Anna, a 30-year-old woman, presents to your GP clinic with a 3-month history of worsening fatigue, a 5 kg weight gain, and intermittent diffuse joint aches (hands, wrists, knees) without clear swelling.

She reports feeling “slowed down” and has reduced motivation. Sleep is unrefreshing, but she does not report loud snoring or witnessed apnoeas. She denies fevers, night sweats, rash, mouth ulcers, photosensitivity, Raynaud phenomenon, pleuritic chest pain, or morning stiffness lasting >60 minutes.

She notes her periods have become less regular over the past year (now 35–50 days apart). She has noticed increased facial hair and acne. She denies galactorrhoea. She is sexually active with a male partner and uses condoms inconsistently; she is not using hormonal contraception.

She denies cold intolerance and constipation. No tremor, palpitations, or heat intolerance. No proximal muscle weakness, easy bruising, or purple striae.

Medications: none. No corticosteroid use. No alcohol or recreational drug use.

Examination: BMI 31 kg/m2, BP 128/78 mmHg, HR 72 bpm regular, afebrile. Thyroid not enlarged and no nodules palpable. Skin: mild acne and mild hirsutism. No facial plethora, striae, or bruising. Hair: no patchy alopecia. Joints: no synovitis, no joint effusions, full range of motion. No peripheral oedema.

Question (select 3): Which three of the following are the most likely differential diagnoses to prioritise at this stage?

Lisa is a 45-year-old woman presenting for preventive health advice. Her mother was diagnosed with colorectal cancer at age 60. Lisa is unsure whether any other relatives have had colorectal cancer or bowel polyps, and she has never had genetic testing.

She reports no rectal bleeding, no persistent change in bowel habit, no unexplained weight loss, and no iron deficiency symptoms. She has no personal history of inflammatory bowel disease or colorectal polyps. She is not taking regular medicines and does not routinely use aspirin or NSAIDs.

Her diet is low in fibre and she is largely sedentary. BMI is 28 kg/m2. She asks what she can do now to reduce her future bowel cancer risk.

Task: Select the 3 most appropriate risk-reduction actions now.

A 61-year-old woman presents with 6 months of gradually worsening shortness of breath. She can no longer walk to the mailbox without stopping to catch her breath. Over the past few weeks she has started waking at night with a sense of chest tightness and breathlessness that improves after she sits upright for 10–15 minutes. She reports a mild, mostly dry cough but no fevers, purulent sputum or pleuritic chest pain.

She has a history of hypercholesterolaemia. She has never been diagnosed with asthma or COPD. She is an ex-smoker (15 pack-years, quit 10 years ago). She drinks 1–2 standard drinks most nights. She reports loud snoring and daytime sleepiness but no witnessed apnoeas. No calf pain or swelling.

On examination: BMI 32 kg/m2, BP 165/97 mmHg, HR 82 bpm regular, RR 16, SpO2 97% on room air, afebrile. JVP is not elevated. Heart sounds are normal with no murmurs. There is no ankle oedema. Chest is clear with good air entry and no wheeze or crackles.

Investigations available today in general practice: ECG shows sinus rhythm with left ventricular hypertrophy and no acute ischaemic changes. Point-of-care BNP is elevated. Spirometry is normal (no obstruction and no significant bronchodilator reversibility). A same-day CXR report notes mild cardiomegaly with no focal consolidation and no hyperinflation.

What is the most likely diagnosis?