KFP – Men’s health

Simon Carver, aged 62, presents for review following a routine PSA blood test ordered during his 45–49 year old health check which has recently been repeated due to a gradual rise. He has no urinary symptoms and feels well. He has a family history of prostate cancer—his father died of metastatic prostate cancer at age 72. His most recent PSA result is 4.8 µg/L (NR: <4.0), having risen from 3.2 µg/L over 18 months. He is concerned as a friend was recently diagnosed with prostate cancer.

Medications: Atorvastatin 20 mg daily, no other regular medications

Allergies: Nil known

Past history: Hypertension, well controlled; no prior urological concerns

Family history: Father had prostate cancer; no other significant familial cancers

Social history: Retired teacher, lives with partner, non-smoker, drinks 2 standard drinks most nights

Examination findings: BP 128/76, PR 68, Weight 84 kg, Height 179 cm, DRE: prostate smooth, mildly enlarged, non-tender, no nodules

Investigations:
PSA trend:

What is the most appropriate next step in management? Select three (3) from the following list:

Angus Delaney, aged 22, presents to your rural practice with concerns about a painless swelling in his left testicle. He first noticed it about 3 weeks ago and feels it may be getting larger. He denies trauma, urinary symptoms, or systemic signs like fever or weight loss. He is sexually active with a single partner and uses condoms inconsistently.

Medications: Nil

Allergies: Nil known

Past history: Appendectomy as a child; no other relevant history

Family history: No family history of cancer or testicular disease

Social history: Lives locally, works as a shearer, smokes socially on weekends, drinks alcohol occasionally

Examination findings: Firm, non-tender left testicular mass approximately 2.5 cm in size; not transilluminating; right testis normal; no inguinal lymphadenopathy; no gynecomastia

Investigations: Urinalysis: normal; STI screen pending

What are the most appropriate next steps in diagnosis and management? Select four (4) from the following list:

Trevor Hunt, a 46-year-old man, presents complaining of persistent fatigue, low libido, and recent difficulty achieving erections. He reports that this has been ongoing for the past 6 months but worsening over the last 2. He denies stress or relationship issues, but says he feels more irritable and has gained weight, particularly around the abdomen. He sleeps well and wakes refreshed, does not snore, and has no night sweats or signs of depression. He and his partner are trying to conceive.

Medications: Nil

Allergies: Nil known

Past history: None relevant

Family history: Father has type 2 diabetes and had a myocardial infarction at age 58

Social history: Works in IT, non-smoker, drinks 4–6 standard drinks on weekends, exercises infrequently

Examination findings: BP 132/84 mmHg, HR 72 bpm, BMI 29.1 kg/m², mild central adiposity, testicular examination: bilaterally normal size, no masses

Investigations:
Fasting bloods:

What are the most appropriate next steps in management? Select three (3) from the following list:

Douglas Faulkner, a 55-year-old truck driver, presents with bothersome urinary symptoms, including poor urinary stream, hesitancy, post-micturition dribbling, and nocturia 2–3 times per night. These have worsened over the last year. He denies haematuria, dysuria, or systemic symptoms. He feels otherwise well and is concerned about prostate cancer.

Medications: Rosuvastatin 10 mg nocte

Allergies: Nil known

Past history: Hyperlipidaemia, GORD

Family history: Father had BPH requiring TURP in his 60s. No known family history of prostate cancer.

Social history: Smokes 10 cigarettes/day, drinks 1–2 beers nightly, sedentary lifestyle due to work. Married, no current sexual concerns.

Examination findings: BMI 31.2 kg/m², BP 134/82 mmHg, Digital rectal exam: smooth, enlarged prostate, no nodules or tenderness.

Investigations:
Urinalysis: Normal
PSA: 2.6 µg/L (NR: <4.0 for age)

What are the most appropriate next steps in management? Select three (3) from the following list:

Matthew Irvine, a 33-year-old man, presents for a pre-employment medical for a position in mining. As part of the routine sexual health screening, he mentions that he had unprotected sex with a new partner around two weeks ago. He has no symptoms currently but is anxious about sexually transmitted infections (STIs), particularly HIV. He has no past history of STIs and has never been tested for HIV.

Medications: Nil

Allergies: Nil known

Past history: Nil relevant

Family history: Non-contributory

Social history: Single, drinks socially, smokes occasionally, no recreational drug use. Heterosexual. No recent overseas travel.

Examination findings: Unremarkable, no lymphadenopathy, no oral or genital lesions noted

What are the most appropriate next steps in investigation and management? Select three (3) from the following list:

Hussein Al-Rashid, a 41-year-old man, presents for review after recently being diagnosed with type 2 diabetes mellitus. He has no current symptoms but expresses concern about erectile dysfunction, which has developed gradually over the past year. He finds it difficult to maintain an erection during intercourse, although morning erections still occur occasionally. He is in a stable relationship and says this is causing some stress. He denies depression or relationship issues.

Medications: Metformin XR 1000 mg daily

Allergies: Nil known

Past history: Type 2 diabetes diagnosed 3 months ago, hypertension (controlled)

Family history: Father had diabetes and stroke; mother has hypertension

Social history: Non-smoker, drinks socially, sedentary occupation, BMI 31.8 kg/m²

Examination findings: BP 128/78 mmHg, HR 72, normal secondary sexual characteristics, normal genital exam, no penile plaques or deformities

Investigations:
HbA1c: 7.4%
Total testosterone (8am): 14.2 nmol/L (NR: 10–35)
eGFR: 92 mL/min/1.73m²
Lipids: mildly elevated LDL

What are the most appropriate next steps in management? Select three (3) from the following list:

Gary Maclean, a 61-year-old man, presents with a 3-month history of recurrent episodes of right-sided scrotal discomfort, particularly after prolonged standing. He has also noticed a dragging sensation and a lump that seems to reduce when lying down. He denies any urinary symptoms, trauma, fevers, or systemic symptoms. He is concerned it may be cancer. He has not had previous scrotal surgery.

Medications: Perindopril 5 mg daily

Allergies: Nil known

Past history: Hypertension

Family history: No relevant cancers

Social history: Retired electrician, walks daily, no tobacco or alcohol use

Examination findings: Right hemiscrotum is soft, fluctuant swelling palpable above the testis, non-tender. Mass reduces when supine, and increases on coughing. Testes are of normal size and consistency. Transillumination negative.

What are the most appropriate next steps in diagnosis and management? Select two (2) from the following list:

Leonard Ho, a 68-year-old retired accountant, presents for review after recent blood tests arranged during his annual check-up. He feels generally well but has noticed some mild fatigue over the past few months. He denies any weight loss, bone pain, or recent infections. He has no history of malignancy.

Medications: Ramipril 5 mg daily, aspirin 100 mg daily

Allergies: Nil known

Past history: Hypertension, hypercholesterolaemia

Family history: Brother had bowel cancer at age 70

Social history: Non-smoker, 1–2 standard drinks on weekends, walks 30 minutes daily

Examination findings: Well-appearing, no lymphadenopathy, abdomen soft, no organomegaly, no bony tenderness

Investigations:
FBC:

UEC: Normal
LFT: Normal
PSA: 2.3 µg/L (NR: <4.0)
Iron studies: Normal
Serum protein electrophoresis: Paraprotein band detected, IgG kappa, M-protein 11 g/L

What are the most appropriate next steps in investigation and management? Select three (3) from the following list:

Brandon Kelly, a 27-year-old man, presents after noticing painless blood in his urine on two occasions over the last week. He has no dysuria, frequency or fever, and reports feeling otherwise well. He denies any trauma or vigorous exercise. He is not on anticoagulants and has no significant past medical history. He is concerned, as he has read online that blood in the urine can be cancer.

Medications: Nil

Allergies: Nil known

Past history: Nil significant

Family history: Nil urological malignancy

Social history: Works as a landscaper, non-smoker, occasional alcohol, no illicit drug use

Examination findings: Normal vital signs. Abdomen soft, non-tender. No flank tenderness or palpable masses. Testes normal bilaterally.

Investigations:
Urinalysis: Microscopic haematuria, no nitrites or leukocytes, no proteinuria
Urine MCS: No growth
eGFR: 98 mL/min/1.73m²
Creatinine: 76 µmol/L
Urine cytology: Pending

What are the most appropriate next steps in management? Select three (3) from the following list:

Patrick O’Neil, a 49-year-old male, presents for review of recent mood changes and increased alcohol intake. He reports feeling ‘flat’ and unmotivated for the past 6 months. He has reduced interest in socialising, feels more tired, and his libido has dropped significantly. He reports drinking around 6–8 standard drinks most evenings. He denies suicidal thoughts. His sleep is broken and non-restorative.

Medications: Nil

Allergies: Nil known

Past history: Nil significant

Family history: Father had alcohol use disorder; mother has hypothyroidism

Social history: Lives alone, works in construction. Has not exercised regularly in years. No recent overseas travel. Smoker (10 cigarettes/day).

Examination findings: Appears tired, BMI 32 kg/m², BP 138/86 mmHg, HR 78 bpm. Testicular and prostate examination normal. Mild hepatomegaly.

Investigations:
FBC: Mild macrocytosis (MCV 102 fL)
LFTs: GGT mildly elevated, ALT 55 U/L (NR: <45)
TSH: 3.4 mU/L (NR: 0.4–4.0)
Total testosterone (8am): 8.1 nmol/L (NR: 10–35)
SHBG: 21 nmol/L (NR: 15–50)
LH: 2.3 IU/L
FSH: 4.1 IU/L

What are the most appropriate next steps in management? Select three (3) from the following list:

Daniel Singh, a 36-year-old FIFO worker, presents for a travel consultation prior to his upcoming deployment to Papua New Guinea for three months. As part of the pre-departure assessment, he reveals that he has sex with men and is currently in a monogamous relationship. He has never been diagnosed with an STI but has not had screening in over a year. He is aware of HIV and has heard about PrEP from a friend but is unsure if it’s relevant to him.

Medications: Nil

Allergies: Nil known

Past history: Nil significant

Family history: Non-contributory

Social history: Non-smoker, drinks occasionally, exercises regularly

Examination findings: Normal general and genital examination

What are the most appropriate next steps in investigation and management? Select four (4) from the following list:

Robert Stein, a 74-year-old man, presents with his wife who is concerned about his increasing forgetfulness over the past 18 months. He repeats questions, misplaces items, and recently became lost driving to a familiar location. He remains independent with basic activities but has reduced interest in social engagements. He denies mood changes or hallucinations. He takes longer to complete tasks but is still managing his own medications and finances, albeit with occasional mistakes.

Medications: Amlodipine 5 mg daily, atorvastatin 20 mg nocte

Allergies: Nil known

Past history: Hypertension, hyperlipidaemia

Family history: Mother had dementia in her 80s

Social history: Retired schoolteacher, lives with wife, non-smoker, minimal alcohol use

Examination findings: BP 138/80 mmHg, MMSE 24/30, MoCA 21/30. Cranial nerves intact, no focal neurological signs

Investigations:
FBC, UEC, LFT, TSH, B12: All within normal range

What are the most appropriate next steps in diagnosis and management? Select three (3) from the following list:

Anthony Varga, a 58-year-old man, presents for evaluation of persistent right-sided chest discomfort. He describes it as dull and intermittent, worse at night and when lying on that side. He denies cough, dyspnoea, fever, weight loss or night sweats. He is a current smoker with a 40 pack-year history. He has not seen a GP in years and has not undergone any screening investigations recently.

Medications: Nil

Allergies: Nil known

Past history: Nil recorded

Family history: Brother had colorectal cancer at 60; no known lung cancer in family

Social history: Lives alone, works as a mechanic, smokes 20 cigarettes/day, drinks 2–3 beers most nights

Examination findings: Decreased breath sounds over right base, dullness to percussion, no lymphadenopathy. Vitals: BP 130/78 mmHg, HR 84 bpm, SpO2 96% RA

What are the most appropriate next steps in investigation and management? Select four (4) from the following list:

Jacob Nguyen, a 24-year-old university student, presents with concerns about premature ejaculation. He reports ejaculating within one minute of penetration in almost all sexual encounters since becoming sexually active. He finds it distressing and reports it is affecting his confidence and relationship. He has no erectile difficulties and no history of genitourinary symptoms or trauma.

Medications: Nil

Allergies: Nil known

Past history: Nil significant

Family history: Non-contributory

Social history: Lives with partner, non-smoker, no alcohol or drug use

Examination findings: Normal genital examination. No evidence of infection or neurological deficit

What are the most appropriate next steps in diagnosis and management? Select three (3) from the following list:

Frank Deluca, a 52-year-old man, presents with concerns about increasing abdominal girth, fatigue, and reduced libido. He mentions that he has been diagnosed with fatty liver in the past and drinks around 4–5 standard drinks most evenings. He also reports poor sleep, some difficulty concentrating at work, and low energy levels. He is not on any medications and has not had recent blood tests.

Medications: Nil

Allergies: Nil known

Past history: Elevated liver enzymes in the past, no formal diagnosis of liver disease

Family history: Father had type 2 diabetes and died from cirrhosis at age 68

Social history: Married, works as a chef, smokes 5–10 cigarettes/day, drinks daily

Examination findings: Central adiposity, BMI 33 kg/m², BP 142/86 mmHg. No spider naevi or hepatomegaly. Testes normal. No signs of ascites.

What are the most appropriate next steps in investigation and management? Select four (4) from the following list:

Steve Rankin, a 63-year-old retired firefighter, presents for review of bilateral knee pain and stiffness that has been gradually worsening over the past 2 years. He finds it particularly bothersome in the mornings and after periods of inactivity. He denies joint swelling, locking, or systemic symptoms. He enjoys bushwalking but has reduced activity due to pain. He is worried this might be ‘wear and tear’ and asks what can be done to avoid surgery.

Medications: Paracetamol PRN

Allergies: Nil known

Past history: Hypercholesterolaemia, mild hypertension

Family history: Father had osteoarthritis in his 70s

Social history: Non-smoker, moderate alcohol intake, BMI 29.8 kg/m²

Examination findings: No joint effusions. Crepitus present in both knees. Mild bony enlargement at joint margins. Range of motion preserved. No signs of inflammation.

What are the most appropriate next steps in management? Select three (3) from the following list:

Jason Todd, a 34-year-old man, presents for review after a routine medical for a new job revealed elevated blood pressure. He has no known medical conditions and is asymptomatic. He exercises 2–3 times per week and eats a ‘fairly average’ diet. He does not smoke and drinks socially. He is concerned about being placed on lifelong medication and asks if it can be managed without drugs.

Medications: Nil

Allergies: Nil known

Past history: Nil

Family history: Father diagnosed with hypertension at 40; mother has hyperlipidaemia

Social history: Works in IT, married, no children. BMI 27.2 kg/m²

Examination findings: BP: 148/92 mmHg (seated, both arms), HR 76 bpm, cardiovascular and neurological exams normal. No signs of secondary causes of hypertension.

Investigations:
Fasting glucose: 5.1 mmol/L
Total cholesterol: 5.6 mmol/L
LDL: 3.4 mmol/L
HDL: 1.2 mmol/L
Triglycerides: 1.9 mmol/L
eGFR: 98 mL/min/1.73m²
Urine ACR: Normal

What are the most appropriate next steps in management? Select three (3) from the following list:

Oliver Brennan, a 47-year-old man, presents with worsening lower back pain over the past 3 months. The pain is dull, bilateral, and worse at night and early morning. It improves with activity. He denies trauma, radiculopathy, or bowel/bladder symptoms. He has tried paracetamol with limited relief. He reports prolonged morning stiffness lasting over 45 minutes. He has no history of injury or heavy lifting.

Medications: Nil

Allergies: Nil known

Past history: Nil significant

Family history: Brother has psoriasis; no known autoimmune conditions

Social history: Office worker, married with two children. Non-smoker, drinks socially

Examination findings: Normal gait. Tenderness over sacroiliac joints bilaterally. Schober test: reduced lumbar flexion. Neurological exam normal. No skin or nail changes. No peripheral joint involvement.

What are the most appropriate next steps in investigation and management? Select three (3) from the following list:

Malcolm Fraser, a 78-year-old man, presents with unintentional weight loss of 6 kg over the past 3 months. He reports reduced appetite and early satiety but denies nausea, vomiting, dysphagia, or altered bowel habits. He feels more tired than usual but has no pain or focal neurological symptoms. His wife has also noticed that he is ‘slowing down’. He has no history of cancer and has not had recent screening investigations.

Medications: Amlodipine 10 mg daily, simvastatin 20 mg nocte

Allergies: Nil known

Past history: Hypertension, hyperlipidaemia, osteoarthritis

Family history: Sister had bowel cancer at 72

Social history: Lives with wife, retired farmer, ex-smoker (quit 15 years ago), occasional alcohol

Examination findings: Thin but alert and oriented. No lymphadenopathy. Chest and abdominal exams normal. No signs of anaemia or jaundice.

Investigations:
FBC: Hb 110 g/L, MCV 87 fL
CRP: 15 mg/L (NR: <5)
eGFR: 82 mL/min
LFTs: Mildly elevated ALP (140 U/L), otherwise normal
Urinalysis: Normal

What are the most appropriate next steps in investigation and management? Select four (4) from the following list:

Declan Ford, a 29-year-old man, presents with infertility concerns. He and his partner have been trying to conceive for over 18 months without success. His partner has been assessed and found to have no fertility issues. Declan reports normal libido and no erectile dysfunction. He denies any testicular trauma, mumps, or infections. He has no significant past medical history and takes no medications.

Medications: Nil

Allergies: Nil known

Past history: Nil

Family history: Father has hypertension; no known fertility issues in the family

Social history: Works in construction, wears tight-fitting workwear, smokes 5 cigarettes/day, drinks 2–3 beers on weekends

Examination findings: Healthy appearance, BMI 26. Testes normal in size, firm consistency, no masses or varicocele. Secondary sexual characteristics normal. No gynaecomastia.

What are the most appropriate next steps in investigation and management? Select three (3) from the following list:

Paul Hanley, a 44-year-old school principal, presents with recurrent episodes of pain and swelling in his right great toe. The pain begins suddenly, often overnight, and is severe enough to wake him. The affected joint becomes red, hot, and very tender to touch. Episodes last a few days and resolve spontaneously. He drinks 2–3 glasses of wine most nights and enjoys red meat. This is his third episode in the past year.

Medications: Nil

Allergies: Nil known

Past history: Nil chronic disease diagnosed

Family history: Father had gout and chronic kidney disease

Social history: Drinks daily, non-smoker, BMI 30.1 kg/m²

Examination findings: Right first MTP joint swollen, erythematous, and very tender. No tophi or joint deformity. Cardiovascular and other systems normal.

What are the most appropriate next steps in investigation and management? Select three (3) from the following list:

Ryan Gallagher, a 39-year-old man, presents with concerns about persistent fatigue, poor concentration, and low libido over the past 9 months. He works as a shift worker in logistics and reports disrupted sleep and frequent night shifts. He has no significant past history and takes no regular medications. He does not snore and denies depression, but admits to reduced motivation. He is concerned he may have ‘low testosterone’.

Medications: Nil

Allergies: Nil known

Past history: Nil significant

Family history: Father has type 2 diabetes and sleep apnoea

Social history: Non-smoker, drinks 1–2 beers on weekends, BMI 30.4 kg/m²

Examination findings: Normal testicular size and consistency, no gynaecomastia, normal secondary sexual characteristics. BP 126/82 mmHg.

Investigations:
Testosterone (8am): 10.2 nmol/L (NR: 10–35)
SHBG: 16 nmol/L (NR: 15–50)
LH: 3.8 IU/L
FSH: 4.5 IU/L
TSH: 2.8 mU/L
HbA1c: 5.6%

What are the most appropriate next steps in management? Select three (3) from the following list:

Harrison Miles, a 56-year-old man, presents with urinary frequency, nocturia, and a sensation of incomplete bladder emptying. These symptoms have been slowly worsening over the past year. He denies dysuria or haematuria. He reports mild urgency but no incontinence. He is concerned it may be prostate cancer, as his father died of it in his 70s.

Medications: Esomeprazole 20 mg daily

Allergies: Nil known

Past history: Gastro-oesophageal reflux disease

Family history: Father had prostate cancer; no other familial malignancies

Social history: Non-smoker, drinks socially, works as a lawyer, BMI 27.5 kg/m²

Examination findings: DRE: smooth, mildly enlarged prostate without nodules. Abdomen soft, no palpable bladder. No suprapubic tenderness.

Investigations:
Urinalysis: No blood, nitrites or leukocytes
PSA: 2.9 µg/L (NR: <4.0 for age)
FBC, UEC: Normal

What are the most appropriate next steps in management? Select three (3) from the following list:

Owen Turner, a 45-year-old male, presents with complaints of persistent perianal discomfort and occasional bleeding with bowel movements over the last six months. He reports the sensation of incomplete evacuation and occasional mucus discharge. He has not had any weight loss or systemic symptoms. He denies any change in stool calibre or family history of bowel cancer. He has been self-treating with over-the-counter laxatives and haemorrhoid creams with partial relief.

Medications: Nil

Allergies: Nil known

Past history: Nil significant

Family history: Nil bowel malignancy

Social history: Non-smoker, occasional alcohol, works as a delivery driver. Diet low in fibre, minimal physical activity

Examination findings: Digital rectal exam: external haemorrhoids, no masses, mild tenderness. No fissures. PR exam reveals soft stool. No perianal abscess or fistula. Abdomen soft, non-tender, no palpable masses

What are the most appropriate next steps in management? Select three (3) from the following list:

Caleb Robertson, a 51-year-old man, presents requesting a routine health check. He has no specific complaints but is concerned about prostate cancer as his older brother was recently diagnosed at age 60. He has never had a PSA test and is unsure whether he should start screening. He reports no urinary symptoms, no weight loss, and no family history of other cancers.

Medications: Nil

Allergies: Nil known

Past history: Nil significant

Family history: Brother diagnosed with prostate cancer at age 60

Social history: Works in IT, non-smoker, drinks 1–2 beers on weekends, exercises regularly

Examination findings: Normal vital signs. Digital rectal exam: normal prostate with no nodules or asymmetry

What are the most appropriate next steps in management? Select three (3) from the following list:

Samuel Davies, a 19-year-old university student, presents to your clinic requesting advice on anabolic steroids. He has been going to the gym regularly and is considering starting a ‘bulking cycle’ using injectable testosterone obtained online. He wants to know if it is ‘safe’ and whether you can monitor him while he’s using it. He denies any current symptoms. On further questioning, he admits to pressure from friends at the gym to gain size quickly.

Medications: Nil

Allergies: Nil known

Past history: Nil significant

Family history: Non-contributory

Social history: Lives in a share house, drinks socially, denies smoking or drug use apart from planned anabolic steroid use. Plays amateur rugby league.

Examination findings: Fit young man, BP 130/78 mmHg, HR 68 bpm, BMI 25.3 kg/m². No acne, no testicular atrophy, no gynecomastia

What are the most appropriate next steps in management? Select three (3) from the following list:

Nick Wallace, a 61-year-old man, presents with intermittent bilateral leg pain when walking. The pain is described as a cramping sensation in the calves that resolves with rest and recurs after walking around 150 metres. He has no pain at rest, no ulcers, and denies any back pain or weakness. He is concerned that this might be ‘just old age’ but wants to know if anything can be done to help. He has a 40 pack-year smoking history.

Medications: Atorvastatin 40 mg nocte

Allergies: Nil known

Past history: Hyperlipidaemia, hypertension

Family history: Father had myocardial infarction at 62

Social history: Retired carpenter, ex-smoker (quit 2 years ago), drinks 1–2 beers on weekends

Examination findings: Diminished dorsalis pedis and posterior tibial pulses bilaterally. No bruits. No trophic skin changes. No oedema. Normal neurological exam.

What are the most appropriate next steps in investigation and management? Select three (3) from the following list:

Adrian Cole, a 31-year-old man, presents with concerns about ongoing testicular discomfort and a sensation of heaviness on the left side that has been present for several months. He denies acute pain, trauma, or urinary symptoms. He reports the discomfort worsens after standing for long periods and improves when lying down. He and his partner are trying to conceive and have not been successful after 14 months.

Medications: Nil

Allergies: Nil known

Past history: Nil significant

Family history: Non-contributory

Social history: Non-smoker, drinks occasionally, works as a chef. BMI 25.2 kg/m²

Examination findings: Left-sided scrotal swelling superior to the testis with a ‘bag of worms’ appearance on standing, which reduces on lying down. Right testis normal. No tenderness or masses. No lymphadenopathy.

What are the most appropriate next steps in investigation and management? Select three (3) from the following list:

Jeremy Blake, a 67-year-old man, presents for review of chronic lower urinary tract symptoms (LUTS). He reports urinary frequency, nocturia (2–3 times/night), weak stream, and a sensation of incomplete emptying. He denies haematuria, dysuria, or urinary incontinence. He has been trialling tamsulosin for six months with some improvement, but is now experiencing postural dizziness.

Medications: Tamsulosin 400 mcg daily, amlodipine 5 mg daily

Allergies: Nil known

Past history: Hypertension, hyperlipidaemia

Family history: Brother had prostate cancer diagnosed at 70

Social history: Retired, non-smoker, drinks 1–2 glasses of wine per week

Examination findings: Normal cardiovascular exam, BP 112/70 mmHg supine, 96/64 mmHg standing. No abdominal masses or palpable bladder. DRE: enlarged, smooth, non-tender prostate.

Investigations: PSA 2.8 µg/L (NR: <4.0), urinalysis normal

What are the most appropriate next steps in management? Select three (3) from the following list:

Lucas Pereira, a 50-year-old male, presents with erectile difficulties over the past 8 months. He reports difficulty achieving and maintaining an erection sufficient for intercourse. He is in a stable relationship and describes the issue as distressing. He denies decreased libido but admits to high work stress and poor sleep. He has not had a cardiovascular assessment in over 5 years.

Medications: Nil

Allergies: Nil known

Past history: Nil significant

Family history: Father had myocardial infarction at 55, mother has type 2 diabetes

Social history: Works in finance, long hours, sedentary lifestyle, drinks 3–4 beers most nights. BMI 32.1 kg/m²

Examination findings: BP 146/92 mmHg, HR 84 bpm. No penile plaques or deformities. Testes normal bilaterally. No signs of hypogonadism or neurological deficit

What are the most appropriate next steps in management? Select three (3) from the following list:

Darren Fields, a 62-year-old man, presents for review of a scaly lesion on his left ear that has been present for several months. It occasionally bleeds when he puts on his sunglasses and has recently increased in size. He has worked outdoors most of his life as a landscaper and has a history of multiple actinic keratoses. He is concerned this could be skin cancer.

Medications: Aspirin 100 mg daily, perindopril 5 mg daily

Allergies: Nil known

Past history: Hypertension, actinic keratoses

Family history: Father had melanoma at age 70

Social history: Retired, non-smoker, drinks socially. No recent overseas travel

Examination findings: 1.2 cm scaly, erythematous nodule with a small area of crusting on the helix of the left ear. No surrounding lymphadenopathy. No tenderness or ulceration noted.

What are the most appropriate next steps in management? Select three (3) from the following list:

Mohammed Al-Khatib, a 37-year-old man, presents with concerns about low mood, lack of motivation, and reduced interest in usual activities over the past 3 months. He reports difficulty concentrating at work and poor sleep. He denies suicidal thoughts, but says he often feels like he’s ‘going through the motions’. He attributes his mood partly to pressure at work and the recent birth of his second child. He does not drink alcohol or use drugs.

Medications: Nil

Allergies: Nil known

Past history: Nil significant

Family history: Mother has depression, father has type 2 diabetes

Social history: Works full-time in IT, married, two children under 4 years old. No smoking or alcohol use. Lives in a suburban area

Examination findings: Well-groomed, appears tired. Affect is flat but cooperative. No psychomotor agitation or retardation. Normal physical examination

What are the most appropriate next steps in investigation and management? Select three (3) from the following list:

Andre Costa, a 54-year-old man, presents with a 3-month history of right-sided testicular heaviness. He denies pain, dysuria, fevers, or trauma. He reports the testicle feels ‘different’ and notes a subtle increase in size. He is otherwise well and takes no regular medications. There is no history of sexually transmitted infections.

Medications: Nil

Allergies: Nil known

Past history: Nil significant

Family history: No known malignancy

Social history: Works as a surveyor, married with two adult children, non-smoker, drinks 2–3 beers on weekends

Examination findings: Right testis is slightly enlarged and firm compared to the left. No tenderness. No transillumination. No varicocele. Epididymis and spermatic cord normal. No inguinal lymphadenopathy.

What are the most appropriate next steps in investigation and management? Select three (3) from the following list:

Greg Whitlam, a 59-year-old man, presents with fatigue, erectile dysfunction, and darkening of the skin on his hands and face. These symptoms have developed gradually over the past year. He also reports unintentional weight loss and joint stiffness. He has no known chronic illnesses and has not seen a GP in several years. He does not drink alcohol or smoke.

Medications: Nil

Allergies: Nil known

Past history: Nil significant

Family history: Brother diagnosed with type 2 diabetes at 50

Social history: Lives with wife, works as an accountant. No recent travel or infections

Examination findings: BP 108/70 mmHg, HR 76 bpm. Skin shows diffuse hyperpigmentation over hands and face. Testicular size reduced bilaterally. No hepatosplenomegaly or lymphadenopathy

Investigations:
Fasting glucose: 6.9 mmol/L
LFTs: Mildly elevated ALT and AST
Ferritin: 1240 µg/L (NR: 30–400)
Transferrin saturation: 68% (NR: 15–45%)
HbA1c: 6.3%
FBC: Mildly reduced haemoglobin (127 g/L)

What are the most appropriate next steps in investigation and management? Select three (3) from the following list:

Edward McLeod, a 41-year-old man, presents with rectal discomfort and occasional bleeding during bowel motions. He describes the bleeding as bright red on the toilet paper and toilet bowl, occurring intermittently over the past 2 months. He reports a sensation of fullness in the rectum and occasional mucous discharge. There is no significant change in stool calibre, weight loss, or nocturnal symptoms. He has no family history of bowel cancer.

Medications: Nil

Allergies: Nil known

Past history: Nil significant

Family history: Nil colorectal malignancy

Social history: Works as a paramedic, non-smoker, drinks 1–2 beers on weekends, low-fibre diet

Examination findings: Anal inspection: external skin tags and mild erythema. Digital rectal examination: soft stool, mild tenderness, no palpable mass or blood. No perianal fistulae or abscesses. Vitals stable

What are the most appropriate next steps in investigation and management? Select three (3) from the following list:

James O’Connor, a 48-year-old man, presents with worsening fatigue, mild depression, and muscle cramps. He has also noticed some recent weight gain and cold intolerance. He reports feeling ‘flat’ and says he’s not functioning well at work. He has no significant past history and takes no medications. His wife wonders if his thyroid could be the cause.

Medications: Nil

Allergies: Nil known

Past history: Nil

Family history: Sister has hypothyroidism

Social history: Non-smoker, minimal alcohol, sedentary occupation

Examination findings: Mild periorbital puffiness, dry skin, slow speech. HR 58 bpm, BP 130/82 mmHg. No goitre or lymphadenopathy. Reflexes show delayed relaxation phase. Weight: 92 kg, Height: 178 cm (BMI 29.0)

Investigations:
TSH: 9.8 mU/L (NR: 0.4–4.0)
Free T4: 10 pmol/L (NR: 10–20)
Anti-TPO antibodies: Positive

What are the most appropriate next steps in investigation and management? Select three (3) from the following list:

Sean Matthews, a 27-year-old man, presents after finding a lump in his right breast. He noticed it two weeks ago and says it feels firm and slightly tender. There is no nipple discharge, skin changes, or weight loss. He takes protein supplements and occasionally uses over-the-counter ‘bodybuilding boosters’ bought online. He is otherwise well and has no family history of breast or testicular cancer.

Medications: Nil prescribed; occasional use of OTC muscle supplements

Allergies: Nil known

Past history: Nil significant

Family history: Nil for breast or testicular cancer

Social history: Gym instructor, non-smoker, no alcohol or drug use disclosed

Examination findings: Firm, mobile, 1.5 cm subareolar mass in the right breast. Mild tenderness. No skin dimpling or nipple retraction. No axillary lymphadenopathy. Testes normal on examination

What are the most appropriate next steps in investigation and management? Select three (3) from the following list:

Trevor Hume, a 65-year-old retired truck driver, presents with progressive shortness of breath on exertion and decreased exercise tolerance. He also reports fatigue and reduced libido over the past six months. He denies cough, chest pain or weight loss. He has a long-standing history of chronic obstructive pulmonary disease (COPD), well-managed with inhalers. He was diagnosed with hypogonadism 2 years ago but stopped testosterone injections 6 months ago due to travel and now feels worse again.

Medications: Salbutamol PRN, tiotropium inhaler daily

Allergies: Nil known

Past history: COPD, previous documented low testosterone requiring TRT

Family history: Non-contributory

Social history: Quit smoking 5 years ago (60 pack-years). Drinks 1–2 beers weekly. Lives alone. No recent falls or fractures

Examination findings: BMI 26.2, BP 130/82 mmHg, HR 76 bpm. No gynaecomastia. Testes appear small bilaterally. Mild wheeze on auscultation. No peripheral oedema

Investigations:
Total Testosterone (8am): 6.3 nmol/L (NR: 10–35)
LH: 2.5 IU/L
FSH: 3.0 IU/L
Hb: 134 g/L
eGFR: 86 mL/min
DEXA scan: T-score lumbar spine –2.6

What are the most appropriate next steps in management? Select three (3) from the following list:

Anthony Li, a 23-year-old university student, presents with a 4-day history of urethral discharge and dysuria. He is sexually active with multiple male partners and uses condoms inconsistently. He has not had any genital ulcers or fevers. He is otherwise well and has no significant past medical history. He last had a sexual health screen 12 months ago.

Medications: Nil

Allergies: Nil known

Past history: Nil

Family history: Non-contributory

Social history: Lives with housemates, drinks socially, non-smoker

Examination findings: Mucopurulent urethral discharge present. No inguinal lymphadenopathy or penile ulcers. Testes non-tender. No perianal lesions

What are the most appropriate next steps in investigation and management? Select three (3) from the following list:

Ian Bradley, a 72-year-old man, presents for a routine review. He reports generally feeling well but mentions increased fatigue and occasional dizziness when standing. He has had two falls in the past 6 months, both while getting out of bed. He denies chest pain, palpitations, or neurological symptoms. He is on multiple medications for chronic conditions.

Medications: Metoprolol 50 mg BD, ramipril 10 mg daily, furosemide 40 mg daily, atorvastatin 40 mg nocte, aspirin 100 mg daily

Allergies: Nil known

Past history: Hypertension, ischaemic heart disease, heart failure with preserved ejection fraction

Family history: Non-contributory

Social history: Retired engineer, lives with wife, independent in ADLs

Examination findings: BP 134/82 mmHg supine, 98/60 mmHg standing. HR 58 bpm, regular. No murmur. Gait slightly unsteady. Normal tone and power. ECG: sinus bradycardia with PR interval 200 ms

What are the most appropriate next steps in management? Select three (3) from the following list:

Ben McKenzie, a 35-year-old male construction worker, presents with concerns about chronic groin and testicular pain for the past 6 months. The pain is dull, intermittent, and worsens with prolonged sitting or physical exertion. There is no history of trauma, infection, urinary symptoms, or recent surgery. He has had multiple normal scrotal ultrasounds and urinalyses. He has been prescribed antibiotics previously with no improvement.

Medications: Occasional ibuprofen

Allergies: Nil known

Past history: Nil significant

Family history: Non-contributory

Social history: Lives with partner, no children. Smokes 10 cigarettes/day. Drinks socially. No recreational drug use

Examination findings: Normal testicular size and consistency. Mild tenderness along the epididymis on the left but no swelling or induration. No hernia. No lymphadenopathy. Digital rectal exam normal prostate without tenderness

What are the most appropriate next steps in investigation and management? Select three (3) from the following list:

Victor Young, a 58-year-old man, presents with concerns about difficulty initiating urination, a weak stream, and post-void dribbling over the past year. He reports getting up twice per night to void. He denies haematuria, dysuria, or weight loss. He has not had any previous urological investigations.

Medications: Amlodipine 10 mg daily

Allergies: Nil known

Past history: Hypertension

Family history: Brother diagnosed with BPH at age 60

Social history: Non-smoker, drinks 2–3 beers on weekends, BMI 28.4 kg/m²

Examination findings: Abdomen soft, no palpable bladder. DRE: prostate smooth, mildly enlarged, non-tender. No nodules. No neurological deficits

What are the most appropriate next steps in investigation and management? Select three (3) from the following list:

Shane D’Souza, a 32-year-old FIFO mine worker, presents with fatigue, reduced libido, and delayed recovery after workouts over the past year. He reports a prior diagnosis of hypogonadism but stopped testosterone injections due to inconvenience. He is concerned his symptoms have returned. He does not have children but is interested in starting a family in the next 1–2 years. He denies anabolic steroid use but has used OTC supplements in the past.

Medications: Nil

Allergies: Nil known

Past history: Previously diagnosed functional hypogonadism (on prior TRT)

Family history: Father has type 2 diabetes

Social history: Smokes socially, drinks on weekends, BMI 27.6 kg/m²

Examination findings: Testes normal in size. No gynaecomastia. Secondary sexual characteristics present. Normal BP and HR

Investigations:
Total testosterone (8am): 8.2 nmol/L (NR: 10–35)
SHBG: 14 nmol/L
Free testosterone: Low
LH: 3.1 IU/L
FSH: 4.0 IU/L
Semen analysis: Normal volume, low motility

What are the most appropriate next steps in investigation and management? Select three (3) from the following list:

Douglas Nguyen, a 47-year-old man, presents with concerns about increasing abdominal girth, fatigue, and mildly elevated liver enzymes on recent routine blood tests. He reports no alcohol use and no viral hepatitis risk factors. He has gained 10 kg over the past 3 years and describes a diet high in processed foods and sugary drinks. He has no symptoms of liver disease.

Medications: Nil

Allergies: Nil known

Past history: Borderline hypertension

Family history: Father has type 2 diabetes, mother has dyslipidaemia

Social history: Office worker, sedentary lifestyle, BMI 31.8 kg/m²

Investigations:
ALT: 72 U/L (NR: 5–40)
AST: 54 U/L (NR: 5–35)
GGT: 64 U/L (NR: 0–60)
HbA1c: 6.1%
Fasting lipids: Triglycerides 2.4 mmol/L, HDL 0.8 mmol/L
Hepatitis B and C serology: Negative
Abdominal ultrasound: Increased echogenicity of liver consistent with steatosis

What are the most appropriate next steps in investigation and management? Select three (3) from the following list:

Callum Jennings, a 25-year-old man, presents with acute onset right-sided scrotal pain that started 4 hours ago while at work. The pain is severe and associated with nausea. He denies fever, urinary symptoms, trauma, or recent sexual activity. This is the first time he has experienced scrotal pain.

Medications: Nil

Allergies: Nil known

Past history: Nil

Family history: Non-contributory

Social history: Works in retail, non-smoker, drinks socially

Examination findings: Right testis high-riding and tender, with absent cremasteric reflex on the affected side. No urethral discharge. No scrotal erythema. Left testis normal

What are the most appropriate next steps in investigation and management? Select three (3) from the following list:

Stephen Reilly, a 38-year-old man, presents with concerns about ongoing stress, poor concentration, and insomnia over the past 4 months. He reports increasing pressure at work, difficulty maintaining a healthy work-life balance, and recent conflict with his manager. He denies thoughts of self-harm but feels ‘constantly wired’ and is drinking more alcohol than usual to relax in the evenings.

Medications: Nil

Allergies: Nil known

Past history: Nil significant

Family history: Mother has generalised anxiety disorder

Social history: Lives with partner, no children. Drinks 4–5 standard drinks most nights. No smoking or recreational drug use

Examination findings: Alert, tense, speech slightly pressured. No psychomotor retardation. Affect anxious. No hallucinations or delusions. Physical exam unremarkable

What are the most appropriate next steps in investigation and management? Select three (3) from the following list:

Leonard Fry, a 74-year-old man, presents with recent onset of unsteady gait, urinary urgency, and mild cognitive decline over the past 4 months. His wife reports that he has had two minor falls and appears slower in processing information. There is no history of stroke, significant head injury, or Parkinson’s disease. He has no bowel incontinence and no known psychiatric illness.

Medications: Perindopril 5 mg daily, atorvastatin 20 mg nocte

Allergies: Nil known

Past history: Hypertension, hyperlipidaemia

Family history: Mother had vascular dementia

Social history: Lives with wife, independent in ADLs, retired engineer

Examination findings: Mildly wide-based gait, positive Romberg test. No tremor or rigidity. MMSE: 24/30. Urinary dipstick: no infection. Neurological exam otherwise normal

What are the most appropriate next steps in investigation and management? Select three (3) from the following list:

Trent Holloway, a 52-year-old man, presents with a 2-month history of persistent perineal discomfort and urinary frequency. He reports dull, aching pain that worsens after ejaculation and prolonged sitting. He denies dysuria, haematuria, fever, or systemic symptoms. He was treated twice in the past with antibiotics for ‘chronic prostatitis’ with minimal relief.

Medications: Ibuprofen as needed

Allergies: Nil known

Past history: Nil significant

Family history: Non-contributory

Social history: Office-based job, non-smoker, drinks socially. In a stable relationship

Examination findings: Abdomen soft, no bladder distension. DRE: mildly tender but smooth, non-enlarged prostate. No nodules. Neurological exam normal. No costovertebral angle tenderness

Urinalysis: Clear, negative for leucocytes, nitrites, or blood

What are the most appropriate next steps in investigation and management? Select three (3) from the following list:

George Tagliaferro, a 64-year-old man, presents with concern about reduced height, increasing back pain, and a recent wrist fracture following a low-impact fall. He has no known history of osteoporosis or previous bone density testing. He does not smoke or drink alcohol excessively. He has been less physically active over the past few years due to back discomfort.

Medications: Perindopril 5 mg daily, simvastatin 20 mg nocte

Allergies: Nil known

Past history: Hypertension, hypercholesterolaemia

Family history: Mother had a hip fracture at 72

Social history: Retired teacher, no recent travel, independent in ADLs

Examination findings: Height has decreased by 3.5 cm over 4 years. Mild kyphosis. No focal neurological signs. BMI 24.5 kg/m²

What are the most appropriate next steps in investigation and management? Select three (3) from the following list:

Michael Tran, a 29-year-old man, presents for a routine STI screen. He is asymptomatic but mentions he is in a new relationship with a male partner and has had several casual partners in the past 6 months. He has never previously tested for HIV. He is concerned about HIV, and asks whether he is eligible for preventive treatment. He uses condoms inconsistently and occasionally engages in receptive anal sex.

Medications: Nil

Allergies: Nil known

Past history: Nil significant

Family history: Non-contributory

Social history: Works in hospitality, non-smoker, drinks socially

Examination findings: Normal. No lymphadenopathy, skin changes, or genital lesions

What are the most appropriate next steps in investigation and management? Select three (3) from the following list: