KFP – Pain management

Michelle Langley, aged 67, presents to your rural general practice with ongoing right shoulder pain. She reports that the pain began after she fell onto her outstretched hand while gardening three months ago. She describes a deep ache in the lateral shoulder and difficulty lifting her arm above shoulder height, particularly when trying to hang out washing or reach into cupboards. She denies any numbness or tingling in her hand. Simple analgesics such as paracetamol have provided only limited relief.

Medications: Paracetamol 1g QID PRN

Allergies: Nil known

Past history: Hypertension, hyperlipidaemia

Family history: Nil significant

Social history: Retired schoolteacher, lives alone on a small property. Non-smoker. Drinks 2–3 standard drinks on weekends. Very active in the garden and with community volunteer work.

Examination findings: Pain is reproduced with active abduction above 90 degrees and external rotation. There is weakness noted with resisted abduction. Neer and Hawkins-Kennedy tests are positive. No swelling or erythema over the shoulder joint. Neurological and vascular examinations of the right upper limb are normal.

Investigations: Right shoulder plain x-ray: mild acromioclavicular joint osteoarthritis, no fracture or dislocation.

What is the most appropriate next step in management? Select two (2) from the following list:

Jason Brodie, aged 54, presents to your urban GP clinic complaining of worsening lower back pain. The pain started insidiously six weeks ago while moving house and has progressively worsened. He describes the pain as a constant dull ache, localised to the lower lumbar region, occasionally radiating to the left buttock. He denies any numbness, weakness, bowel or bladder dysfunction. The pain is worse with prolonged sitting and relieved by standing or walking.

Medications: Ibuprofen 400 mg TDS PRN

Allergies: Nil known

Past history: Mild depression, managed with cognitive behavioural therapy

Social history: Office worker, smokes 10 cigarettes/day, drinks 1–2 standard drinks each night. Lives with partner. No recent travel. No IV drug use.

Examination findings: Normal gait. No spinal deformity. Tenderness over the left paraspinal muscles at L4–L5 level. Straight leg raise negative bilaterally. Neurological examination of lower limbs is normal. No red flags identified.

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

Angela Ricci, aged 35, presents to your clinic complaining of recurrent severe pelvic pain. She reports the pain is cyclical, beginning one to two days before her period and continuing for the first few days of menstruation. The pain is sharp, crampy, located in the suprapubic area and occasionally radiates to her back and thighs. It is associated with heavy bleeding and fatigue. She also describes deep dyspareunia and some bloating. She has had this pain for several years but it has worsened in the past six months.

Medications: Ibuprofen 400 mg TDS PRN

Allergies: Nil known

Past history: Nulliparous. Normal cervical screening history. No known chronic conditions.

Obstetric/sexual history: Not currently using contraception. In a stable relationship. No history of STIs.

Examination findings: Pelvic examination reveals tenderness in the posterior fornix and reduced uterine mobility. No palpable masses. No cervical motion tenderness.

Investigations: Pelvic ultrasound: Retroverted uterus. No adnexal mass or fibroid. Small amount of free fluid in the pouch of Douglas.

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

Matthew O’Connell, aged 48, presents to your general practice with a six-month history of chronic right knee pain. He describes a dull ache that worsens after prolonged walking or standing and improves with rest. He reports morning stiffness lasting less than 15 minutes. There is no history of trauma. Over-the-counter NSAIDs help temporarily, but the pain recurs. He is a delivery driver and says the pain is starting to affect his work.

Medications: Ibuprofen 400 mg PRN

Allergies: Nil known

Past history: Gout 10 years ago (last attack 5 years ago), hypertension

Social history: Non-smoker. Drinks socially. BMI 32. Active job but minimal formal exercise.

Examination findings: Right knee shows mild joint line tenderness medially, crepitus on movement, and reduced range of motion. No effusion or instability. No erythema or warmth. Left knee normal.

Investigations: Knee x-ray: Mild to moderate medial joint space narrowing, osteophyte formation, subchondral sclerosis. Uric acid level normal.

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

Deborah James, aged 72, presents to your clinic with a 3-month history of burning pain in both feet. The pain is worse at night and sometimes interferes with her sleep. She describes it as a ‘tingling and burning’ sensation starting in her toes and progressing up to the mid-calf. She denies weakness, falls, or loss of balance. There is no associated back pain. She has type 2 diabetes mellitus, diagnosed 10 years ago.

Medications: Metformin 1g BD, Atorvastatin 20 mg daily, Ramipril 5 mg daily

Allergies: Nil known

Past history: Type 2 diabetes mellitus, hypertension, hyperlipidaemia

Social history: Lives alone, independent with activities of daily living. Walks daily. Non-smoker. Occasional wine.

Examination findings: Decreased pinprick and vibration sense to mid-calf bilaterally. Intact power and reflexes. Gait normal. Feet appear well perfused with no ulceration or deformity.

Investigations: HbA1c 8.2% (66 mmol/mol), renal function normal, B12 within normal limits

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

Brent Mahoney, aged 29, presents to your general practice clinic following a recent episode of renal colic. He was treated in the emergency department with intravenous analgesia and discharged once pain settled. A non-contrast CT showed a 4mm distal left ureteric stone. He has no known history of kidney stones. He describes the pain as ‘the worst of his life’, radiating from his left flank to the groin, with associated nausea but no vomiting.

Medications: None

Allergies: Nil known

Past history: Nil significant

Social history: Works in construction, active, non-smoker, drinks alcohol occasionally. No family history of renal stones. Normal diet, no recent travel.

Examination findings: Currently pain-free. Vitals normal. Abdominal examination unremarkable. No flank tenderness. Urinalysis shows microscopic haematuria, no nitrites or leukocytes.

Investigations: Non-contrast CT KUB: 4mm left distal ureteric stone. No hydronephrosis. Normal contralateral kidney. eGFR 90 mL/min/1.73m²

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

Emma Cartwright, aged 26, presents with a two-week history of severe unilateral facial pain. The pain is paroxysmal, sharp, and electric-shock-like in nature, affecting the right cheek, upper lip, and side of the nose. It lasts for seconds at a time but occurs repeatedly throughout the day. Pain is triggered by light touch, chewing, and brushing her teeth. She is otherwise well, with no fever, visual changes, or neurological deficits.

Medications: Nil

Allergies: Nil known

Past history: Nil significant

Social history: Works as a physiotherapist. Non-smoker. No alcohol. Lives with partner. No recent travel.

Examination findings: Neurological examination is normal, including cranial nerves. No sensory loss or motor deficits. No dental pathology on oral exam. No signs of sinusitis.

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

Linda Morrison, aged 62, presents with a six-month history of persistent left shoulder and upper arm pain following a fall. She reports that the pain has gradually worsened and is now associated with significant stiffness. She has difficulty brushing her hair or reaching behind her back. The pain is deep, poorly localised, and worse at night. She denies weakness or sensory changes.

Medications: Paracetamol 1g TDS

Allergies: Nil known

Past history: Type 2 diabetes mellitus, hypothyroidism

Social history: Retired librarian. Non-smoker. Lives with husband. No recent trauma or infections. No alcohol intake.

Examination findings: Global restriction of both active and passive range of motion in the left shoulder, especially external rotation. No localised tenderness or swelling. Strength preserved.

Investigations: Shoulder x-ray: Normal bony alignment. No osteoarthritis or calcific deposits.

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

David Kim, aged 45, presents to your clinic with a 6-month history of chronic right-sided facial and jaw pain. He reports a dull ache in the area just in front of his right ear, aggravated by chewing, yawning, and clenching his teeth. There is occasional clicking and a feeling of tightness. The pain is not associated with fever, skin changes, or dental infection.

Medications: Nil

Allergies: Nil known

Past history: Anxiety

Social history: Works in IT, high stress. Non-smoker, drinks 3–4 standard drinks on weekends. No recreational drug use.

Examination findings: No facial asymmetry or swelling. Mild tenderness over right temporomandibular joint (TMJ). Audible click with jaw opening. No locking. Normal dental hygiene. Cranial nerve exam normal. No cervical lymphadenopathy.

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

Jill Fraser, aged 33, presents with ongoing vulvar pain that has been present for the past 5 months. She describes it as a constant burning and stinging sensation around the vestibule, worse with touch or during intercourse. She denies any vaginal discharge, odour, or systemic symptoms. Multiple swabs for infection have returned negative and antifungal treatments have not helped.

Medications: Nil

Allergies: Nil known

Past history: Depression (currently in remission), eczema as a child

Social history: Lives with partner. Non-smoker. No alcohol. Works in administration. No new sexual partners.

Examination findings: Vulvar skin appears normal. Marked tenderness to light touch over the vestibule (cotton swab positive). No erythema, discharge or lesions. Normal speculum and bimanual exam. No pelvic masses.

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

Pauline Tran, aged 60, presents to your clinic with a six-month history of chronic bilateral hand and wrist pain. She reports morning stiffness lasting over an hour and difficulty with fine motor tasks such as buttoning clothes and opening jars. The pain is worse in the mornings and improves with movement throughout the day. She denies any fevers or weight loss.

Medications: Nil

Allergies: Nil known

Past history: Hypertension, osteoarthritis (knee)

Social history: Recently retired teacher. Non-smoker. No alcohol. No family history of autoimmune disease.

Examination findings: Swelling and tenderness of MCP and PIP joints bilaterally. Reduced grip strength. No deformities or nodules. Knees and other large joints not involved.

Investigations: ESR 58 mm/hr, CRP 32 mg/L. Rheumatoid factor positive. Anti-CCP positive.

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

Mark Ellis, aged 72, presents to your general practice with severe, intermittent pain in his right great toe over the past 48 hours. He woke up with pain, redness, and swelling at the base of the toe. He describes the pain as excruciating, worse with movement or even touch. He has had a similar episode a year ago which resolved spontaneously after a few days.

Medications: Ramipril 10 mg daily, Aspirin 100 mg daily

Allergies: Nil known

Past history: Hypertension, ischaemic heart disease, hyperlipidaemia

Social history: Retired builder. Occasional alcohol. Eats red meat 4–5 times per week. No recent trauma.

Examination findings: Right first MTP joint is red, hot, swollen, and extremely tender to touch. No tophi present. Afebrile. No systemic signs.

Investigations: Uric acid 0.52 mmol/L (elevated). Renal function normal. CRP mildly elevated.

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

Sandra Lopez, aged 41, presents with persistent lower abdominal and pelvic pain for the past 8 months. The pain is dull, constant, and worsens during her period and with prolonged sitting. She also experiences pain during intercourse and has frequent bloating. She has had multiple pelvic ultrasounds, all reported as normal. A diagnostic laparoscopy performed two years ago was unremarkable. She has not been sexually active recently due to pain.

Medications: Paracetamol PRN, previous trial of oral contraceptive pill (ceased due to side effects)

Allergies: Nil known

Past history: Anxiety, IBS

Social history: Works as a legal secretary. Single. Non-smoker. Drinks 2 standard drinks/week. No recent travel.

Examination findings: Mild tenderness in the suprapubic and lower abdominal region. Pelvic exam reveals hypertonic pelvic floor muscles and tenderness on palpation of levator ani. No masses or discharge. Speculum and bimanual exam otherwise unremarkable.

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

Michael Donovan, aged 57, presents with chronic left foot pain that has persisted for over a year. The pain is located over the plantar aspect of the heel and is worse on first standing in the morning and after prolonged walking. He denies any trauma, swelling, or systemic symptoms. He has tried over-the-counter insoles and paracetamol with minimal relief.

Medications: Paracetamol PRN

Allergies: Nil known

Past history: Type 2 diabetes, BMI 31

Social history: Works as a postman, on his feet most of the day. Smokes 5 cigarettes/day. Moderate alcohol use.

Examination findings: Localised tenderness at the medial calcaneal tuberosity. Pain worsens with dorsiflexion of the toes. No erythema, warmth, or swelling. Neurological exam normal. Gait mildly antalgic.

Investigations: Foot x-ray: Mild calcaneal spur. No fracture or joint pathology. HbA1c 7.5%

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

Carla Nguyen, aged 38, presents with a 4-week history of gradually worsening right-sided neck and shoulder pain. She works as a graphic designer and has been spending long hours at the computer. The pain radiates from the neck into the right shoulder and occasionally down the lateral arm. She also reports some numbness in the thumb and index finger, but no weakness.

Medications: Nil

Allergies: Nil known

Past history: Migraine, mild anxiety

Social history: Non-smoker, drinks socially, works from home

Examination findings: Reduced cervical spine range of motion with pain on extension and right lateral flexion. Spurling’s test reproduces pain and paraesthesia. No motor or reflex deficits noted. Shoulder examination is normal.

Investigations: Nil performed to date

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

Amelia Rhodes, aged 70, presents with persistent right hip and lateral thigh pain for the past 3 months. The pain worsens when lying on the right side, climbing stairs, or walking long distances. She localises the pain to the lateral aspect of the hip. She denies any back pain, weakness, or systemic symptoms. There is no history of trauma or falls.

Medications: Atorvastatin 20 mg daily, Paracetamol PRN

Allergies: Nil known

Past history: Osteoporosis, hypertension

Social history: Retired teacher, walks daily, lives alone

Examination findings: Tenderness over the greater trochanter on palpation. Pain reproduced on resisted abduction and with single-leg stance. Full range of hip motion without groin pain. Neurological exam normal. Lumbar spine non-tender.

Investigations: Pelvic x-ray: Mild osteoarthritis. No fracture or avascular necrosis. DEXA scan T-score: –2.6

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

Steven Radcliffe, aged 52, presents with a 6-month history of persistent burning and shooting pain in his right lower leg following a tibial fracture sustained in a workplace accident. The fracture healed without complication, but he reports ongoing pain that is disproportionate to the original injury. He also notes increased sensitivity to touch and temperature, as well as changes in skin colour and swelling in the affected limb. Pain is worse with light touch or even breeze exposure.

Medications: Paracetamol, ibuprofen PRN

Allergies: Nil known

Past history: Tibial shaft fracture 6 months ago, no prior chronic pain

Social history: Factory worker on leave. Smoker. Moderate alcohol. Lives with wife and two children

Examination findings: Mild swelling and temperature asymmetry in right lower leg. Allodynia (pain from light touch). Hyperalgesia. Decreased range of motion at the ankle. No signs of active infection or cellulitis.

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

Isabel Frew, aged 63, presents with a 2-month history of persistent right upper quadrant abdominal pain. She describes it as a dull ache, worse after eating, particularly fatty meals. She also reports intermittent bloating and nausea but denies vomiting, jaundice, or weight loss. She has had multiple courses of antacids with minimal relief. There is no change in bowel habits or red flag symptoms.

Medications: Esomeprazole 20 mg daily

Allergies: Nil known

Past history: Type 2 diabetes, dyslipidaemia

Social history: Retired nurse. Non-smoker. Moderate alcohol intake. No recent travel. BMI 30

Examination findings: Mild tenderness in the right upper quadrant. No guarding or rebound. No masses. No hepatosplenomegaly. Murphy’s sign mildly positive. Bowel sounds normal.

Investigations: LFTs normal. FBC normal. Abdominal ultrasound: Multiple gallstones, thickened gallbladder wall, no ductal dilation, no gallbladder wall oedema, CBD 5mm

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

James Pattison, aged 47, presents with a 2-month history of ongoing lower thoracic back pain. He describes it as a constant, dull ache, worse at night and not relieved by rest or analgesia. He has also noticed unintentional weight loss of 6 kg over the past 3 months and occasional night sweats. There is no recent trauma, and he has no known history of malignancy.

Medications: Nil

Allergies: Nil known

Past history: Mild hypertension

Social history: Works as an accountant. Quit smoking 10 years ago. Drinks 2–3 standard drinks on weekends. No recent travel.

Examination findings: Localised tenderness over T10–T12 vertebrae. No neurological deficits. Normal lower limb strength, reflexes, and sensation. No spinal deformity or gait abnormality.

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

Emily Saunders, aged 24, presents with severe pain following the extraction of her lower left third molar 3 days ago. She describes the pain as deep and throbbing, radiating to the ear, and worse than the initial post-operative discomfort. She has difficulty sleeping and eating due to the intensity of the pain. She denies fever or swelling.

Medications: Paracetamol and ibuprofen alternating every 3–4 hours

Allergies: Nil known

Past history: Nil significant

Social history: University student, non-smoker, occasional alcohol

Examination findings: Extraction site shows loss of visible clot with exposed bone and halitosis. Surrounding gingivae are mildly inflamed but there is no facial swelling or lymphadenopathy. Afebrile. No trismus.

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

Tom Wallace, aged 67, presents with severe left leg pain that began suddenly 5 hours ago. The pain is located in the calf and foot and is associated with numbness and a cold sensation. He has a history of peripheral vascular disease and atrial fibrillation. He is not currently anticoagulated due to a recent fall resulting in a subdural haematoma 3 months ago. He denies trauma or similar symptoms in the past.

Medications: Aspirin 100 mg daily, Atorvastatin 40 mg daily

Allergies: Nil known

Past history: Atrial fibrillation, subdural haematoma (resolved), peripheral vascular disease, hypertension

Social history: Retired builder. Former smoker. Lives with wife. No alcohol.

Examination findings: Left foot is pale, cold to touch with delayed capillary refill. Dorsalis pedis and posterior tibial pulses absent on the left, normal on the right. Decreased sensation over the foot and ankle. Power is reduced in dorsiflexion. No signs of DVT. Right leg normal.

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

Alison Kerr, aged 58, presents with persistent left chest wall pain following a shingles outbreak 3 months ago. The rash resolved completely, but she continues to experience burning, tingling, and stabbing pain in the T5 dermatome distribution. Clothing brushing against the area exacerbates her discomfort. She reports disturbed sleep due to the pain.

Medications: Paracetamol 1g QID

Allergies: Nil known

Past history: Hypertension, asthma

Social history: Works as a florist. Non-smoker. No alcohol use.

Examination findings: No visible rash. Allodynia and hyperalgesia over the T5 dermatome. Cardiopulmonary examination unremarkable. No neurological deficits.

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

Robert Dunne, aged 76, presents with gradually worsening bilateral knee pain over the last year. The pain is described as a dull ache that worsens with walking, going up or down stairs, and prolonged standing. He has difficulty getting out of chairs and his mobility has decreased. There is no morning stiffness or systemic symptoms.

Medications: Paracetamol 1g QID, Losartan 50 mg daily

Allergies: Nil known

Past history: Hypertension, osteoarthritis (hands)

Social history: Lives alone. Walks to the shops. Ex-smoker. No alcohol.

Examination findings: Bilateral bony swelling of knees, mild varus deformity. Reduced range of motion, crepitus, and pain on movement. No effusion. No signs of inflammation. Normal neurological exam.

Investigations: Knee x-ray: Joint space narrowing, osteophyte formation, subchondral sclerosis — consistent with osteoarthritis.

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

Nasir Ali, aged 35, presents with chronic anal pain and spasm, especially after defecation. He describes the pain as sharp, lasting up to two hours after passing stool. The pain has been present for several months and is affecting his quality of life. He reports occasional bright red blood on toilet paper. He has a history of constipation but denies weight loss, fevers, or rectal masses.

Medications: Occasional laxatives

Allergies: Nil known

Past history: Functional constipation

Social history: Office worker. Sedentary lifestyle. Non-smoker. No alcohol. No recent travel.

Examination findings: Anal inspection reveals a posterior midline fissure with evidence of localised skin tag. Digital rectal exam deferred due to pain. No perianal masses or signs of abscess.

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

Yvonne Mallard, aged 82, presents with severe, generalised musculoskeletal pain, predominantly affecting her shoulders, neck, and hips. She reports profound morning stiffness lasting over 60 minutes. The symptoms began insidiously over the past few weeks and have worsened. She feels fatigued and reports low mood due to the pain. She denies jaw claudication, headache, visual symptoms, or weight loss.

Medications: Perindopril 5 mg daily, Atorvastatin 20 mg daily

Allergies: Nil known

Past history: Hypertension, hyperlipidaemia

Social history: Lives alone. Independent with activities of daily living. No smoking or alcohol.

Examination findings: No joint swelling. Tenderness and restricted active movement in shoulders and hips. No synovitis. No temporal artery tenderness. Normal visual acuity. No cranial nerve abnormalities.

Investigations: ESR 75 mm/hr, CRP 45 mg/L. FBC: Normocytic anaemia. Rheumatoid factor and anti-CCP negative.

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

Kevin Zhao, aged 49, presents with pain and tingling in the right wrist and hand for the past 3 months. The symptoms are worse at night and often wake him from sleep. He also experiences weakness when gripping objects and occasional dropping of items. The numbness affects the thumb, index, and middle fingers but not the little finger. He works as a warehouse supervisor and frequently uses vibrating tools.

Medications: Nil

Allergies: Nil known

Past history: Type 2 diabetes mellitus

Social history: Non-smoker. Occasional alcohol. Physically active job.

Examination findings: Thenar muscle wasting on the right. Decreased sensation over palmar surface of thumb, index and middle fingers. Tinel’s and Phalen’s tests are positive. No signs of arthritis or trauma. Motor power reduced in thumb abduction.

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

Helen Browne, aged 66, presents with left-sided facial pain that has been worsening over the past month. The pain is described as a dull ache over the maxillary sinus area, with intermittent sharp, stabbing pains. She also reports new-onset left-sided temporal headache and fatigue. On further questioning, she has noted jaw discomfort when chewing and some blurring of vision in her left eye over the past week.

Medications: Paracetamol PRN, Atorvastatin 20 mg daily

Allergies: Nil known

Past history: Hyperlipidaemia, osteoarthritis

Social history: Retired. Non-smoker. Occasional wine. Lives alone.

Examination findings: Tenderness over the left temporal artery. Reduced temporal artery pulsation. Normal neurological exam. Visual acuity reduced on the left. Right eye normal.

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

Jared Singh, aged 34, presents with a 2-month history of persistent pain in the anterior right knee. He reports that the pain worsens with prolonged sitting, climbing stairs, and squatting. There is no history of trauma. He plays recreational basketball twice a week. The pain is gradually affecting his ability to train and perform at work, where he does frequent lifting and kneeling.

Medications: Nil

Allergies: Nil known

Past history: Nil significant

Social history: Warehouse worker. Active lifestyle. Non-smoker. Occasional alcohol.

Examination findings: No swelling or effusion. Tenderness over patellar tendon. Pain reproduced with resisted knee extension and squatting. Normal range of motion. No instability or locking.

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

Sophie Delaney, aged 29, presents with persistent vulvar burning and itching for the past 6 months. She reports the discomfort is worse with prolonged sitting, during sexual activity, and when wearing tight clothing. There is no abnormal discharge or odour. She has seen multiple practitioners and has tried antifungal and antibacterial treatments without improvement.

Medications: Nil

Allergies: Nil known

Past history: Anxiety

Social history: Lives with partner. Works as a graphic designer. Non-smoker. Occasional alcohol. Monogamous relationship. No recent STI exposure.

Examination findings: Vulvar skin appears normal. Cotton swab test elicits pain at the vestibule. No erythema, ulcers, or discharge. Speculum exam is normal. No pelvic masses or signs of infection.

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

Trevor Hadley, aged 62, presents with persistent burning pain in both feet for the past 6 months. The pain is worse at night and described as tingling, burning, and sometimes sharp shooting. He has difficulty falling asleep due to discomfort. He has a history of long-standing poorly controlled type 2 diabetes. No history of trauma, infection, or alcohol abuse.

Medications: Metformin 1g BD, gliclazide 60 mg daily, atorvastatin 20 mg daily

Allergies: Nil known

Past history: Type 2 diabetes, hypertension, dyslipidaemia

Social history: Retired bus driver. Lives with spouse. Smoker (10/day). No alcohol.

Examination findings: Decreased pinprick and vibration sense in both feet. Preserved motor function. No ulcers or deformities. Pedal pulses present but reduced. No signs of infection.

Investigations: HbA1c 8.9%, renal function normal

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

Angela Costa, aged 45, presents with ongoing right-sided thoracic pain that developed 3 weeks after a motor vehicle accident. She describes the pain as sharp and worsened by deep inspiration, coughing, or certain movements. She denies fever, shortness of breath, or haemoptysis. She was diagnosed with non-displaced rib fractures at the emergency department after the accident and was discharged with simple analgesia.

Medications: Paracetamol PRN, Ibuprofen PRN

Allergies: Nil known

Past history: Asthma (mild, infrequent)

Social history: Office worker, non-smoker, no alcohol. Lives with partner and two children.

Examination findings: Localised tenderness over the right lateral ribs (7th–9th). Normal breath sounds. No crepitus. No chest wall bruising. No signs of respiratory distress.

Investigations: Chest x-ray from 3 weeks ago showed minimally displaced 7th and 8th rib fractures, no pneumothorax or haemothorax.

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

Lucy Brennan, aged 36, presents with persistent pelvic pain and deep dyspareunia. She describes the pain as a deep, dull ache worsened during menstruation and with sexual intercourse. The pain began several years ago but has worsened in the past year. She and her partner have been trying to conceive for 18 months without success.

Medications: Ibuprofen PRN

Allergies: Nil known

Past history: Nil significant

Social history: Office worker. Non-smoker. Drinks 1–2 standard drinks per week. No recent travel.

Examination findings: Normal external genitalia. Bimanual exam reveals retroverted uterus and nodularity in the posterior fornix with tenderness on uterine movement. No adnexal masses.

Investigations: Transvaginal ultrasound: normal uterus, no ovarian cysts or hydrosalpinx. CA-125 mildly elevated.

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

Daniel Foster, aged 40, presents with chronic right-sided scrotal pain for the past 4 months. The pain is dull, aching, and worsens with prolonged standing or physical activity. There is no associated fever, dysuria, or urinary frequency. He denies trauma or previous infections. The pain is beginning to interfere with his ability to work in manual labour.

Medications: Nil

Allergies: Nil known

Past history: Nil significant

Social history: Builder. Non-smoker. Drinks socially. No recent travel or high-risk sexual activity.

Examination findings: Mild right-sided scrotal tenderness. Soft, fluctuant mass superior to the testis that increases on standing and reduces on lying down. Testes normal bilaterally. No inguinal lymphadenopathy.

Investigations: Scrotal ultrasound: Right-sided varicocele. Testicular parenchyma normal. No hydrocele or mass.

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

Barbara West, aged 71, presents with a 3-month history of constant left shoulder and upper arm pain. She describes the pain as dull and aching, with occasional sharp exacerbations. It is worse at night, particularly when lying on the left side, and interferes with sleep. She denies trauma or systemic symptoms. Pain is poorly responsive to paracetamol and topical NSAIDs.

Medications: Paracetamol 1g QID, Atorvastatin 20 mg daily

Allergies: Nil known

Past history: Type 2 diabetes mellitus, hypertension, osteoarthritis (knees)

Social history: Retired. Lives alone. Non-smoker. Occasional alcohol. Active with gardening.

Examination findings: Full passive range of shoulder movement. Pain and weakness with active abduction and external rotation. Positive empty can and Hawkins-Kennedy tests. No swelling or warmth. Mild tenderness over subacromial region.

Investigations: Shoulder ultrasound: Supraspinatus tendinosis with partial thickness tear. Moderate subacromial bursitis. No full-thickness tear.

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

Nick Thomson, aged 58, presents with persistent pain in the right lateral elbow that has been worsening over the past 3 months. He describes the pain as a sharp ache, particularly when gripping objects or lifting with his arm extended. He plays tennis recreationally and works as a mechanic. There is no history of trauma or neck pain.

Medications: Paracetamol PRN

Allergies: Nil known

Past history: Mild hypertension

Social history: Non-smoker, drinks 1–2 standard drinks/week, no illicit drug use

Examination findings: Tenderness over the lateral epicondyle. Pain reproduced with resisted wrist extension and gripping. Full range of elbow motion. No swelling, warmth, or neurological signs. Shoulder and neck exams are normal.

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

Grace Middleton, aged 55, presents with persistent aching pain in the midfoot and under the arch of her right foot, progressively worsening over the last 5 months. She describes it as a dull, throbbing pain that worsens after standing or walking for prolonged periods. She works as a retail assistant and is on her feet most of the day. There was no history of trauma.

Medications: Paracetamol PRN

Allergies: Nil known

Past history: Hypertension, obesity (BMI 33)

Social history: Non-smoker, minimal alcohol. Wears flat-soled shoes daily. No regular exercise.

Examination findings: Tenderness along the medial arch and midfoot. Loss of medial longitudinal arch with mild hindfoot valgus. Pain on passive dorsiflexion of the toes. No erythema or swelling. Normal neurovascular exam.

Investigations: Foot x-ray: Pes planus with no evidence of fracture or arthritis.

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

Ian McDougall, aged 65, presents with a 2-month history of left-sided groin pain. The pain is dull and intermittent, worsens when walking uphill or standing for long periods, and is relieved by rest. He has also noticed some discomfort in his buttock and anterior thigh but denies numbness, weakness, or systemic symptoms. He is an avid bushwalker and retired electrician.

Medications: Paracetamol PRN

Allergies: Nil known

Past history: Osteoarthritis (knees), hypertension

Social history: Non-smoker. Moderate alcohol. Physically active.

Examination findings: Pain with internal rotation of the left hip. Restricted range of motion in flexion and abduction. No groin mass. Neurovascular exam normal. No tenderness over lumbar spine or sacroiliac joints.

Investigations: Pelvic x-ray: Joint space narrowing, osteophytes, and subchondral sclerosis in left hip — consistent with osteoarthritis.

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

Linda Shaw, aged 44, presents with persistent pain on the plantar aspect of her right heel, present for the past 6 months. The pain is most severe when taking the first few steps in the morning and after periods of inactivity. It improves with gentle walking but worsens again with prolonged standing or activity. She works in retail and is on her feet for most of the day.

Medications: Paracetamol PRN

Allergies: Nil known

Past history: None significant

Social history: Non-smoker, no alcohol, BMI 31

Examination findings: Localised tenderness over the medial calcaneal tuberosity. Pain on passive dorsiflexion of the toes. No swelling, redness, or neurological deficits. Normal foot alignment.

Investigations: Foot x-ray: Calcaneal spur present. No evidence of fracture or arthritis.

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

Alana Drew, aged 48, presents with chronic pain in the left side of her jaw and temple. The pain is dull and constant, occasionally flaring into a sharp discomfort while chewing or yawning. She describes a sensation of tightness and clicking in her jaw. The pain has been ongoing for the past 4 months and is affecting her sleep and ability to eat hard foods.

Medications: Ibuprofen PRN

Allergies: Nil known

Past history: Anxiety, migraine

Social history: Works in IT. High-stress job. Non-smoker. Drinks 1–2 standard drinks/week. No recent trauma.

Examination findings: Palpation reveals tenderness over the left temporomandibular joint (TMJ) and masseter muscle. Audible clicking on jaw opening. No joint locking. No signs of dental infection. Cranial nerve exam normal.

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

Samir Patel, aged 59, presents with a 6-month history of diffuse musculoskeletal pain, persistent fatigue, and non-restorative sleep. The pain is described as a constant dull ache affecting his neck, shoulders, back, and hips. He also reports frequent headaches, difficulty concentrating, and low mood. Blood tests ordered by a previous GP were reportedly normal.

Medications: Paracetamol PRN, multivitamins

Allergies: Nil known

Past history: Irritable bowel syndrome, generalised anxiety disorder

Social history: Works part-time in administration. No alcohol or tobacco use. Lives with spouse. No recent travel.

Examination findings: Normal joint range of motion. Tenderness in multiple soft tissue areas including trapezius, upper back, and gluteal regions. No synovitis or joint swelling. Normal neurological examination.

Investigations: Recent bloods: ESR and CRP normal, TSH normal, vitamin D adequate, FBC and LFTs within normal range.

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

Renee Franklin, aged 63, presents with severe pain in her right shoulder following a fall onto her outstretched hand yesterday. She is unable to move her arm due to pain. She describes the pain as deep, constant, and worsened by any attempted movement. There is no prior history of shoulder problems.

Medications: Perindopril 5 mg daily

Allergies: Nil known

Past history: Hypertension

Social history: Lives alone, non-smoker, occasional alcohol. Recently started volunteering at a community garden.

Examination findings: Obvious swelling and bruising around the right shoulder. Marked limitation in active and passive range of motion due to pain. No sensory or motor deficit in the hand. Radial pulse present.

Investigations: Plain x-ray shoulder: Anterior dislocation with suspected greater tuberosity avulsion fracture. No humeral head fracture. Joint space widened anteriorly.

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

Mark Ellis, aged 52, presents with persistent sharp pain in the right side of his chest that began 10 days ago after recovering from a mild viral upper respiratory tract infection. He describes the pain as sharp, stabbing, and worsened by coughing, sneezing, or deep breathing. He denies fever, shortness of breath, or recent trauma. The pain is reproducible with palpation over the right costochondral junctions.

Medications: Paracetamol PRN

Allergies: Nil known

Past history: Hypertension, seasonal allergic rhinitis

Social history: Works in IT. Non-smoker. Occasional alcohol. No recreational drugs.

Examination findings: Localised tenderness over the right 4th and 5th costochondral junctions. No swelling. Normal breath sounds. No crepitus or chest wall bruising. No signs of respiratory distress.

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

Claire Morrison, aged 39, presents with left-sided pelvic pain that began two days ago. The pain is sharp, intermittent, and associated with nausea but no vomiting. It is not related to her menstrual cycle and is unrelated to bowel or bladder function. She denies fever or vaginal discharge. Her last period was 2 weeks ago and was normal. She is not using contraception and is sexually active in a monogamous relationship.

Medications: Nil

Allergies: Nil known

Past history: Nil significant

Social history: Lives with partner. Works in childcare. Non-smoker, occasional alcohol.

Examination findings: Mild tenderness in the left lower quadrant and suprapubic region. No guarding or rebound. Bimanual exam: Left adnexal tenderness with no cervical motion tenderness. No vaginal discharge. Afebrile. Normal vitals.

Investigations: Urine beta-hCG: Negative. Pelvic ultrasound: 3.8 cm left ovarian cyst with no solid components or free fluid. Normal right ovary and uterus.

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

Jacob Reynolds, aged 46, presents with ongoing pain in his left forearm and wrist that began after he slipped and caught himself on an outstretched hand two weeks ago. He did not seek medical attention initially, believing it to be a sprain. The pain is now worse with lifting and gripping, and there is occasional numbness in the thumb and index finger. He works as a delivery driver and is concerned it is affecting his ability to work.

Medications: Paracetamol PRN

Allergies: Nil known

Past history: GORD, smoker (10/day)

Social history: Lives with partner and two children. No alcohol use. Active job with heavy manual tasks.

Examination findings: Swelling and tenderness over the distal radius and wrist. Reduced grip strength. Positive Tinel’s sign at the wrist. Mildly reduced sensation in median nerve distribution. No deformity. Radial pulse present. Normal elbow and shoulder examination.

Investigations: Wrist x-ray: Healed buckle fracture of the distal radius, no displacement. Mild degenerative changes at radiocarpal joint. No acute fracture.

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

David King, aged 64, presents with a 3-week history of low back pain radiating into the left buttock and down the posterior thigh to the calf. The pain is sharp, worsens with sitting and bending forward, and occasionally causes numbness in the lateral foot. He reports no history of trauma, bowel or bladder dysfunction, or systemic symptoms.

Medications: Paracetamol PRN

Allergies: Nil known

Past history: Hypercholesterolaemia

Social history: Retired truck driver. Smokes 5 cigarettes/day. Lives with wife. Walks daily.

Examination findings: Positive straight leg raise on the left at 40 degrees. Reduced sensation over the lateral left foot. Left ankle reflex diminished. Normal power. Gait slightly antalgic. No spinal tenderness or red flag signs.

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

Felicity Rowe, aged 57, presents with persistent pain and swelling in her left foot following a minor ankle sprain 10 weeks ago. The initial swelling improved, but she now has ongoing burning pain, increased sensitivity to touch, and stiffness in the ankle. She also notices that her left foot appears slightly redder and warmer than the right. The pain is disproportionate to the initial injury and worsens with even light contact or movement.

Medications: Paracetamol and ibuprofen PRN

Allergies: Nil known

Past history: Depression (stable), osteoarthritis (hands)

Social history: Office worker. Lives alone. Non-smoker. No alcohol.

Examination findings: Left foot shows mild swelling, increased warmth, shiny skin, and allodynia. Reduced range of motion in the ankle. No signs of infection. Neurological exam otherwise normal.

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

Thomas Leung, aged 69, presents with a 4-month history of progressively worsening lower back pain that is worse when standing or walking, particularly downhill. He reports that leaning forward or sitting relieves the pain. There is no history of trauma. He also describes some numbness in both legs when walking but denies bowel or bladder dysfunction.

Medications: Atorvastatin 20 mg daily, Metformin 500 mg BD

Allergies: Nil known

Past history: Type 2 diabetes, hyperlipidaemia

Social history: Retired accountant. Walks daily. Non-smoker. Occasional alcohol.

Examination findings: Normal lower limb strength, reflexes, and sensation at rest. Normal pulses. Stooped posture when walking. Pain reproduced by lumbar extension and relieved by flexion.

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

Rebecca Owens, aged 30, presents with sharp right lower abdominal and pelvic pain that began suddenly while exercising at the gym this morning. The pain is constant, localised, and worsens with movement. She is sexually active and uses a copper IUD for contraception. Her last menstrual period was 4 weeks ago. She feels nauseated but has not vomited. No urinary symptoms or fever.

Medications: Nil

Allergies: Nil known

Past history: Appendectomy (10 years ago)

Social history: Lives with partner. Non-smoker. No alcohol. No recent travel.

Examination findings: Right lower quadrant tenderness with mild guarding. No rebound. No palpable mass. Bimanual exam: right adnexal tenderness, no cervical motion tenderness. Vitals: HR 88, BP 118/74, Temp 36.9°C.

Investigations: Urine beta-hCG: negative. Transvaginal ultrasound: enlarged right ovary with peripheral follicles and decreased blood flow — suspicious for ovarian torsion.

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

Patricia Lim, aged 73, presents with persistent right-sided thoracic pain following a rib fracture sustained 10 weeks ago from a minor fall. The initial pain improved with simple analgesia, but she now reports ongoing burning pain in the same area, worsened by light touch and movement. She describes it as electric and sharp, with sensitivity to clothing over the area. There are no respiratory symptoms or systemic signs.

Medications: Paracetamol 1g QID

Allergies: Nil known

Past history: Osteoporosis, hypertension, mild COPD

Social history: Widowed, lives alone. Quit smoking 5 years ago. No alcohol use.

Examination findings: Hyperalgesia and allodynia over the right T7–T9 region. No spinal tenderness or deformity. Chest clear. Cardiovascular exam normal.

Investigations: Chest x-ray (4 weeks ago): Healing fracture of right 8th rib. No lung pathology.

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

Olivia Grant, aged 36, presents with chronic perineal pain that has been progressively worsening over the past 6 months. The pain is described as burning and deep aching, radiating to the rectum and inner thighs. It is worse with prolonged sitting and during bowel movements but improves when lying down. She denies vaginal discharge, urinary symptoms, or recent trauma. Her bowel habits are regular.

Medications: Paracetamol PRN

Allergies: Nil known

Past history: Instrumental vaginal delivery (3 years ago), mild anxiety

Social history: Office-based job. Non-smoker. No alcohol. Lives with partner and two children.

Examination findings: Tenderness on palpation of the ischial spine area internally. No masses or skin changes. Neurological examination of the lower limbs normal. Rectal exam: normal tone, no masses.

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