A 64-year-old man has had central chest pain for 2 hours. His electrocardiogram (ECG) shows ST elevation in leads V1 to V4. Primary percutaneous coronary intervention (PCI) can be delivered within 120 minutes of the time fibrinolysis could be given. What is the most appropriate reperfusion strategy?
Coronary angiography with primary PCI The National Institute for Health and Care Excellence (NICE) recommends coronary angiography with follow-on primary PCI as the preferred reperfusion strategy for an acute ST-elevation myocardial infarction (STEMI) presenting within 12 hours of onset, when primary PCI can be delivered within 120 minutes of the time fibrinolysis could have been given. He presented at 2 hours, and the timing condition is met.
A 58-year-old man arrives with haematemesis and melaena. Which risk score should you use at his first assessment?
Blatchford score NICE recommends the Blatchford score at first assessment for everyone with acute upper gastrointestinal bleeding, and the full Rockall score after endoscopy. Haematemesis and melaena point to a bleed from the upper gastrointestinal tract.
A 4-month-old baby had a runny nose for 2 days, then developed a cough, fast breathing, and wheeze and crackles heard across the chest. Which organism is the most common cause of this illness?
Respiratory syncytial virus This is bronchiolitis: cold-like symptoms followed by cough with wheeze or crackles in an infant. Respiratory syncytial virus (RSV) is its most common cause.
In adults, what is the HbA1c level at or above which type 2 diabetes can be diagnosed?
48 mmol/mol An HbA1c of 48 mmol/mol (6.5%) or more is the diagnostic threshold for type 2 diabetes. In someone without symptoms, the result needs confirming with a repeat test.
A 70-year-old has sudden weakness of the right arm and face and slurred speech, which started 90 minutes ago. Thrombolysis may be indicated. Which investigation should be done immediately?
Non-contrast CT head NICE recommends an immediate non-enhanced computed tomography (CT) scan of the head in suspected acute stroke when thrombolysis or thrombectomy may be indicated. The scan shows whether there’s bleeding before treatment is decided.
A 27-year-old has a positive pregnancy test about 7 weeks after her last period, and pain low on one side of her abdomen. She is haemodynamically stable. Which first investigation is most appropriate to find where the pregnancy is?
Transvaginal ultrasound NICE recommends a transvaginal ultrasound scan to identify the location of the pregnancy in early pregnancy assessment. With one-sided pain at about 7 weeks, that’s how an ectopic pregnancy is looked for.
In NICE guidance, what is the smallest rise in serum creatinine within 48 hours that detects acute kidney injury?
26 micromol/litre NICE detects acute kidney injury (AKI) with a rise in serum creatinine of 26 micromol/litre or more within 48 hours. A rise of 50% or more within 7 days, or a fall in urine output, can also meet the definition.
A 45-year-old man in the emergency department has a hot, swollen, painful knee, a temperature of 38.6°C, and can’t bear weight. Septic arthritis is suspected. What should you do first?
Aspirate the joint, then antibiotics In suspected septic arthritis, aspirate the joint for Gram stain, microscopy and culture, ideally before starting antibiotics. It’s an emergency, because infection can destroy the joint quickly.
A 34-year-old with generalised anxiety disorder chooses drug treatment after trying psychological therapy. Which drug does NICE suggest offering first?
Sertraline NICE recommends a selective serotonin reuptake inhibitor (SSRI) when a person with generalised anxiety disorder chooses drug treatment, and suggests considering sertraline first because it’s the most cost-effective. Benzodiazepines are only for short-term use in a crisis, and antipsychotics aren’t offered in primary care.
Under the Mental Capacity Act 2005, which statement about an adult’s capacity to make a decision is correct?
Capacity is presumed unless it’s shown to be lacking The first principle of the Mental Capacity Act 2005 is that a person must be assumed to have capacity unless it’s established that they lack it. Capacity is also decision-specific, and an unwise decision alone doesn’t show a lack of capacity.
Minutes after a wasp sting, a 30-year-old has wheeze, swollen lips and a low blood pressure. Which drug should be given first?
Intramuscular adrenaline This is anaphylaxis, and intramuscular adrenaline is the first drug to give. Antihistamines and steroids aren’t first-line treatment for the emergency itself.
A 29-year-old has bloating, loose stools and iron deficiency anaemia. She eats gluten in more than one meal every day. Which is the first-choice test for coeliac disease?
Total IgA and IgA tTG NICE recommends testing total immunoglobulin A (IgA) and IgA tissue transglutaminase (tTG) as the first choice for coeliac disease, while the person is eating gluten. A positive result leads to referral for an intestinal biopsy.
A 2-year-old has a barking cough and a hoarse voice, with stridor only when he’s upset. He is alert and has no distress at rest. What is the most appropriate treatment?
One dose of oral dexamethasone This is mild croup. NICE Clinical Knowledge Summaries advise a single dose of oral corticosteroid, such as dexamethasone, for a child with mild croup.
A 40-year-old woman with heavy periods has a low haemoglobin and a low mean cell volume. Which result best confirms iron deficiency?
A low serum ferritin Serum ferritin reflects the body’s iron stores, and a low ferritin confirms iron deficiency. With heavy periods and a low mean cell volume, iron deficiency anaemia is the likely cause.
On the weighted 7-point checklist for a pigmented skin lesion, which of these is a major feature?
Change in size The checklist’s three major features, worth 2 points each, are change in size, irregular shape and irregular colour. Inflammation, oozing, change in sensation and a largest diameter of 7 mm or more are minor features, worth 1 point each.
A 22-year-old had unprotected sex 2 days ago and asks for emergency contraception. Which method is the most effective?
Copper intrauterine device The copper intrauterine device (Cu-IUD) is the most effective method of emergency contraception, and it can be fitted up to 5 days after the first unprotected sex in a cycle. The Faculty of Sexual and Reproductive Healthcare advises offering it to everyone eligible.
A patient’s serum potassium is 7.0 mmol/L. Which ECG change is typical of hyperkalaemia?
Tall, tented T waves Tall, tented T waves are a typical early ECG sign of hyperkalaemia. As potassium rises further, the PR interval lengthens, the P waves flatten and the QRS complex widens.
Fluid aspirated from an acutely painful, swollen first metatarsophalangeal joint is examined under polarised light. Which finding confirms gout?
Negatively birefringent needle crystals Gout is confirmed by monosodium urate crystals, which are needle-shaped and negatively birefringent under polarised light. Positively birefringent rhomboid crystals point to calcium pyrophosphate deposition instead.
An 84-year-old admitted with a urinary tract infection becomes confused over a day. Her attention comes and goes, and she is worse in the evening. What is the most likely diagnosis?
Delirium An acute onset, with attention that fluctuates during the day, points to delirium. Infection is a recognised trigger in older people in hospital.
During a procedure, you make an error that causes the patient minor harm. What does GMC guidance on the professional duty of candour say you should do?
Tell the patient, apologise and explain The joint guidance from the GMC and the Nursing and Midwifery Council (NMC) says that when something goes wrong, you should tell the patient, apologise, offer support to put matters right if possible, and explain the effects. An apology isn’t an admission of legal liability.
United Kingdom · Licensing test