Bryan Anderson, aged 58 years, presents with several years of tiredness. He feels his concentration is poor and he often ‘nods off’ in meetings, which has started to affect his work. Bryan sleeps for approximately eight hours during the night, although he gets up twice most nights to pass urine. Bryan has gained 6 kg in the past seven months. His wife, Nikita, states that he snores. 

Bryan has hypertension and erectile dysfunction and takes ramipril 10 mg daily, amlodipine 10 mg daily and tadalafil 10 mg as required. 

On examination, Bryan’s heart rate is 89/min regular, blood pressure 158/96 mmHg and BMI 36 kg/m2. 

What is the MOST appropriate investigation to confirm the provisional diagnosis? 

1. CT scan brain 
2. Faecal occult blood test 
3. HbA1c 
4. Plasma metanephrines 
5. Polysomnography 
6. Prostate-specific antigen test 
7. Thyroid function test 
8. Urine for microscopy, culture and sensitivity 

Mia Oliver, aged 18 months, is brought in by her father, Derek, for her routine childhood immunisations. Mia has had a runny nose and a dry cough for the past five days. COVID-19 has been definitively excluded.

On examination, Mia’s temperature is 37.5°C, heart rate 120/min regular and respiratory rate 35/min. She has clear rhinorrhoea. Her chest is clear.

What is the MOST appropriate next step?

1. Administer all routine immunisations today
2. Administer inactivated immunisations today but delay measles–mumps–rubella–varicella immunisation for one week
3. Administer paracetamol 15 mg/kg (maximum 1 g) prior to immunisations
4. Amoxicillin 25 mg/kg (maximum 500 mg) three times daily for five days
5. Saline nose drops and review for immunisations in 48 hours

Sally Jones, aged 37 years, has experienced two months of right-sided headaches following a low-speed car accident, where she was the passenger in a rear-end collision. She has persistent pain over the back of the right side of her head with a tingling and electrical-type feeling that shoots over the right side of her head and at times causes pain around her right ear. The pain is often worst in the morning and improves as the day goes on.

On examination, Sally has a normal neck range of motion, and her pain is reproduced with palpation over the base of her right skull.

What is the MOST appropriate provisional diagnosis?

1. Cervical facet joint sprain
2. Cluster headache
3. Migraine headache
4. Occipital neuralgia
5. Subarachnoid haemorrhage
6. Subdural haematoma
7. Tension-type headache
8. Vertebral artery dissection