27.    Patient UE (female, 58 years old, weight 89 kg) presents to the walk-in centre complaining of shortness of breath and a sharp pain when breathing in, plus feeling generally ‘awful’. On examination she is pale, her oxygen saturations are 88% on air, her heart rate is 112 beats per minute, blood pressure 109/78 mmHg, temperature 37°C. She denies any recent travel, she does not smoke nor drink alcohol. Her drug history is: Elleste-Solo® tablets 1 mg daily which she takes for symptoms of the menopause. She has no other significant medical history. A two-level PE Wells score is calculated.From the information provided, what course of action would seem MOST APPROPRIATE?

2.    Patient FD (female, 35 years old, weight 66 kg) is 34 weeks pregnant. She has an allergy to prawns and begins to feel unwell immediately after eating a seafood dish, which unknown to her contained prawns. She begins to feel faint and dizzy, her chest begins to feel tight, and she becomes wheezy.What is the MOST APPROPRIATE initial action to take?

29.    Patient MH (male, 68 years old, weight 69 kg) requires a tooth extraction. He has Crohn’s disease, for which he is prescribed adalimumab 40 mg subcutaneously once every 2 weeks. Which management option is MOST APPROPRIATE for prophylaxis against infective endocarditis?

5.    Patient YP (female, 75 years old, weight 68 kg) has type 1 diabetes mellitus and mild dementia. She was discharged from hospital three days ago following treatment of a urinary tract infection. She lives alone and usually has district nurses administering insulin. Upon investigation it is revealed that they were not informed of Patient YP’s discharge and therefore have not been visiting to administer her insulin. Today she is readmitted to hospital as her son has found her to be unwell. She is drowsy, more confused than usual, vomiting and her breath has a smell of ketones.She is diagnosed as having diabetic ketoacidosis (DKA).Which treatment should be started in the FIRST instance?

33.    Patient GW (male, 65 years old, weight 71 kg) presents to his GP and describes an episode which occurred the day before. During this episode, which lasted around 45 minutes, he experienced a weakness in his right arm and leg, felt dizzy and confused, and his speech was slurred.Past medical history:•    Type 2 diabetes•    HypertensionHis blood pressure today is 148/92 mmHg. Based on this information, when should Patient GW have a transient ischaemic attack (TIA) assessment?

4.    Patient JH (male, 42 years old, weight 82 kg) presents to Accident and Emergency with swelling of his lips, face, jaw-line and cheek. This has developed over the past 24 hours. His medication history is:•    Atorvastatin 20 mg once daily – started 1 year ago•    Citalopram 20 mg daily – started 2 years ago•    Loratadine 10 mg daily – started 2 months ago•    Paracetamol 1 g four times daily when required•    Ramipril 10 mg daily – started 10 months agoHe is diagnosed with a non-allergic drug-induced angioedema.Which is the MOST LIKELY causative agent?

19.    Patient JS (male, 71 years old, weight 93 kg) has presented with a painful, swollen joint affecting the big toe on his right foot. It is hot to the touch and red.Past medical history•    Hypertension•    Hypercholesterolaemia•    Heart failure•    Chronic Kidney Disease Stage 3a (eGFR 55 ml/min/1.73m2)Medication history•    Atorvastatin 20 mg once daily•    Furosemide 80 mg in the morning, 40 mg lunchtime (increased 2 weeks ago)•    Lisinopril 20 mg once daily•    Paracetamol 1 g four times daily•    Multivitamin ONE tablet once daily (buys over the counter)•    no known drug allergies A diagnosis of an acute flare of gout is made. What is the MOST LIKELY cause of this acute flare of gout in Patient JS?

35.    Patient SK (male, 68 years old, weight 80 kg) presents to the GP with dysuria, nausea, dizziness, chills, and pain in his side. The GP carries out an examination and the observations are:•    Heart rate: 110 beats per minute•    Blood pressure: 88/55 mmHg•    Respiratory rate: 25 breaths per minute•    Temperature: 38.8°C•    Oxygen saturations: 96%The patient has no significant past medical history and is not taking any regular medication. He has an allergy to penicillin (anaphylaxis).What is the MOST APPROPRIATE treatment choice for Patient SK?

21.    Patient PO (male, 23 years old, weight 70 kg) is in hospital being treated for poisoning. They are being correctly treated according to guidelines and administered activated charcoal to enhance the elimination of the overdosed substance. Which drug is MOST LIKELY to have been ingested?

20.    After identifying the cause of the flare for Patient JS (question 19) what is the MOST APPROPRIATE acute treatment?