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Question 1
Incorrect
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A 30-year-old woman who was born and lives in England has received her invitation to attend for her first cervical screening test. She has read the leaflet and has some questions regarding the population targeted for cervical screening.
Which of the following statements best applies to the cervical screening programme?Your Answer: Cervical screening is offered to women aged 25–64 every five years
Correct Answer: Cervical screening is offered to women aged 50–64 every five years
Explanation:Understanding Cervical Screening: Guidelines and Options
Cervical screening, also known as a smear test, is a vital tool in detecting precancerous cell changes in the cervix and preventing cervical cancer. Here are some important guidelines and options to keep in mind:
Age and Frequency: In the UK, women aged 25-64 are invited for screening, with those aged 25-49 screened every three years and those aged 50-64 screened every five years. In Scotland, screening is recommended every five years for women aged 25-65.
Hysterectomy: Women who have had a total hysterectomy (removal of the uterus and cervix) do not require cervical screening. However, those who have had a partial hysterectomy (removal of the uterus but not the cervix) should continue to be screened according to age guidelines.
Age Limit: Women over the age of 65 may still be eligible for screening if they have had recent abnormal results or have not been screened since the age of 50.
Opting Out: While cervical screening is not obligatory, it is highly recommended. Patients can opt out by speaking to their doctor and signing an ‘opting out’ form, but this decision can be reversed at any time. It is important to understand the benefits and risks associated with screening before making a decision.
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This question is part of the following fields:
- Gynaecology
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Question 2
Incorrect
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A 68-year-old man with elevated intraocular pressure is prescribed dorzolamide eye drops. What is the mechanism of action of this medication?
Your Answer: Muscarinic receptor agonist
Correct Answer: Carbonic anhydrase inhibitor
Explanation:Dorzolamide is a type of medication that works as a carbonic anhydrase inhibitor.
Glaucoma is a condition where the optic nerve is damaged due to increased pressure in the eye. Primary open-angle glaucoma is a type where the iris is clear of the trabecular meshwork, which is responsible for draining aqueous humour from the eye. This results in increased resistance to outflow and raised intraocular pressure. The condition affects 0.5% of people over 40 years old and increases with age. Genetics also play a role, with first-degree relatives having a 16% chance of developing the disease. Symptoms are usually absent, and diagnosis is made through routine eye examinations. Investigations include visual field tests, tonometry, and slit lamp examinations. Treatment involves eye drops to lower intraocular pressure, with prostaglandin analogues being the first line of treatment. Surgery may be considered in refractory cases. Regular reassessment is necessary to monitor progression and prevent visual field loss.
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This question is part of the following fields:
- Ophthalmology
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Question 3
Incorrect
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A 72-year-old woman who has smoked her entire life presents with a complaint of drooping of the left eyelid. Upon examination, there is ptosis of the left eyelid and a small pupil that responds to light but does not dilate. The right eye appears normal.
What is the probable diagnosis?Your Answer: Left third cranial nerve palsy
Correct Answer: Left Horner syndrome
Explanation:Common Cranial Nerve Palsies and Horner Syndrome
Horner’s syndrome is a condition that affects the sympathetic trunk and causes ptosis, miosis, and anhidrosis. This syndrome is commonly associated with an apical lung lesion, especially in lifelong smokers. On the other hand, cranial nerve palsies affect the third, fifth, and seventh nerves, each with distinct symptoms.
Third nerve palsy causes ptosis and mydriasis, while trigeminal nerve palsy affects sensation and mastication but leaves the pupil unaffected. Facial nerve palsy, on the other hand, results in facial paralysis and the inability to close the affected eyelid, but it does not affect the pupil.
It is important to differentiate between these conditions as they have different underlying causes and treatments. A thorough neurological examination is necessary to determine the specific cranial nerve affected and the appropriate management plan.
In summary, understanding the differences between Horner’s syndrome and cranial nerve palsies is crucial in making an accurate diagnosis and providing optimal care for patients.
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This question is part of the following fields:
- Neurology
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Question 4
Correct
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A 39-year-old man is being evaluated on the orthopaedic ward for fever and difficulty breathing. He underwent intramedullary nail surgery to repair a fracture in his right tibia a week ago. What is the probable reason for his pyrexia that occurred more than 5 days after the operation?
Your Answer: Venous thromboembolism
Explanation:Venous thromboembolism typically manifests itself between 5 to 10 days after surgery. The presence of breathlessness increases the likelihood of a diagnosis of venous thromboembolism as opposed to cellulitis or urinary tract infection. Meanwhile, pulmonary atelectasis is more prone to occur in the earlier stages following surgery.
Post-operative pyrexia, or fever, can occur after surgery and can be caused by various factors. Early causes of post-op pyrexia, which typically occur within the first five days after surgery, include blood transfusion, cellulitis, urinary tract infection, and a physiological systemic inflammatory reaction that usually occurs within a day following the operation. Pulmonary atelectasis is also often listed as an early cause, but the evidence to support this link is limited. Late causes of post-op pyrexia, which occur more than five days after surgery, include venous thromboembolism, pneumonia, wound infection, and anastomotic leak.
To remember the possible causes of post-op pyrexia, it is helpful to use the memory aid of the 4 W’s: wind, water, wound, and what did we do? (iatrogenic). This means that the causes can be related to respiratory issues (wind), urinary tract or other fluid-related problems (water), wound infections or complications (wound), or something that was done during the surgery or post-operative care (iatrogenic). It is important to identify the cause of post-op pyrexia and treat it promptly to prevent further complications. This information is based on a peer-reviewed publication available on the National Center for Biotechnology Information website.
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This question is part of the following fields:
- Surgery
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Question 5
Incorrect
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A 35-year-old man undergoes genetic testing after he develops colorectal cancer at the age of 35. His mother also had colorectal cancer at a similar age and died from the disease. He undergoes genetic testing and is found to have classic familial adenomatous polyposis (FAP) coli. He has a 3-year-old son.
If his son has inherited classic FAP and does not undergo prophylactic surgery, what is the likelihood he will develop colon cancer?Your Answer: Approximately 50%
Correct Answer: Over 90%
Explanation:Understanding Familial Adenomatous Polyposis (FAP) and its Risk of Colon Cancer
Familial Adenomatous Polyposis (FAP) is an inherited disorder that increases the risk of colon cancer. Classic FAP can cause non-cancerous growths (polyps) in the colon as early as the teenage years, which can become cancerous if not removed. The risk of cancer in classic FAP is high, with a 7% chance by age 21 and a 93% chance by age 50. Attenuated FAP is a variant of the disorder with delayed polyp growth and a lower risk of cancer, but still presents a high lifetime risk of 70%. Juvenile polyposis syndrome carries a 40% risk of colon cancer. Inherited colon cancers in general carry a high risk, with most being over 50%. While FAP is responsible for only 1% of all colon cancers, the lifetime risk for those affected by the mutation is almost 100%.
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This question is part of the following fields:
- Genetics
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Question 6
Incorrect
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A 12-year-old boy is brought into the Emergency Department by his mother. He is known to have haemophilia B and has fallen while playing basketball. His ankle is very swollen and bruised.
Which of the following would be the best treatment option for this patient?Your Answer: Cryoprecipitate
Correct Answer: Recombinant factor IX
Explanation:Treatment Options for Haemophilia B: Recombinant Factor IX and Cryoprecipitate
Haemophilia B, also known as Christmas disease, is a rare genetic disorder caused by a deficiency in factor IX. While it shares similar inheritance patterns and clinical features with haemophilia A, its incidence is much lower. Treatment for haemophilia B involves factor IX concentrates, with recombinant factor IX being the most commonly used. Prophylactic doses may be given twice a week for patients with severe disease or a history of significant bleeding, but there is a risk of developing inhibitors against the factor.
Cryoprecipitate, on the other hand, does not contain factor IX but rather fibrinogen, von Willebrand’s factor, and factors VIII and XIII. It may be used in certain situations, but it is not a primary treatment for haemophilia B.
It is important to note that recombinant factor VIII is not indicated for haemophilia B, as it is specific to haemophilia A. Similarly, factor XI is not a treatment option for haemophilia B.
While factor IX is a vitamin K-dependent clotting factor, the deficiency in haemophilia B is not caused by a lack of vitamin K. Understanding the appropriate treatment options for haemophilia B is crucial for managing this rare disorder.
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This question is part of the following fields:
- Paediatrics
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Question 7
Correct
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What is the impact of cyclo-oxygenase inhibition on the physiological changes that occur within the first 48 hours after birth?
Your Answer: Promotes ductus arteriosus closure
Explanation:The Role of Prostaglandins in Fetal Circulation
In fetal life, the ductus arteriosus plays a crucial role in transmitting blood from the pulmonary trunk to the arch of the aorta. Prostaglandins are necessary to maintain the patency of the ductus arteriosus by vasodilating it. However, at birth, the increase in arterial oxygen tension leads to a decrease in prostaglandin production, causing the ductus arteriosus to constrict and eventually fibrose over 24-48 hours.
In cases where the ductus arteriosus needs to be closed artificially, such as in patent ductus arteriosus, cyclo-oxygenase inhibitors like indomethacin are administered to reduce prostaglandin levels. On the other hand, some congenital cardiac defects rely on the patency of the ductus arteriosus to maintain systemic circulation, and prostaglandin infusions are given to keep the duct open.
After birth, right side heart pressures decrease due to a reduction in pulmonary resistance, leading to the closure of the foramen ovale. Additionally, surfactant production is dependent on corticosteroid levels.
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This question is part of the following fields:
- Clinical Sciences
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Question 8
Incorrect
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An 80-year-old man is scheduled for a surgery to remove a cancerous growth in his large intestine. He has been noticing a gradual decrease in weight and alteration in bowel movements for the past two months. A recent colonoscopy has revealed a mass in the lower part of his descending colon. Despite his age, he appears to be in good health and is prepared to proceed with the procedure. What is the most probable surgery he will undergo?
Your Answer: Low anterior resection
Correct Answer: Left hemicolectomy
Explanation:The appropriate surgical procedure for a patient with distal transverse or descending colon cancer is a left hemicolectomy. This procedure involves removing the distal two-thirds of the transverse colon, the descending colon, and the sigmoid colon. The rectum is left intact and anastomosed with the proximal transverse colon, avoiding the need for a permanent stoma.
Other surgical options, such as Hartmann’s procedure, high anterior resection, low anterior resection, and right hemicolectomy, are not suitable for this patient’s condition. Hartmann’s procedure is reserved for emergencies, while high anterior resection and low anterior resection are used for rectal tumors. Right hemicolectomy is performed for cancers in the cecum, ascending colon, or proximal third of the transverse colon.
Colorectal cancer is typically diagnosed through CT scans and colonoscopies or CT colonography. Patients with tumors below the peritoneal reflection should also undergo MRI to evaluate their mesorectum. Once staging is complete, a treatment plan is formulated by a dedicated colorectal MDT meeting.
For colon cancer, surgery is the primary treatment option, with resectional surgery being the only cure. The procedure is tailored to the patient and tumor location, with lymphatic chains being resected based on arterial supply. Anastomosis is the preferred method of restoring continuity, but in some cases, an end stoma may be necessary. Chemotherapy is often offered to patients with risk factors for disease recurrence.
Rectal cancer management differs from colon cancer due to the rectum’s anatomical location. Tumors can be surgically resected with either an anterior resection or an abdominoperineal excision of rectum (APER). A meticulous dissection of the mesorectal fat and lymph nodes is integral to the procedure. Neoadjuvant radiotherapy is often offered to patients prior to resectional surgery, and those with obstructing rectal cancer should have a defunctioning loop colostomy.
Segmental resections based on blood supply and lymphatic drainage are the primary operations for cancer. The type of resection and anastomosis depend on the site of cancer. In emergency situations where the bowel has perforated, an end colostomy is often safer. Left-sided resections are more risky, but ileocolic anastomoses are relatively safe even in the emergency setting and do not need to be defunctioned.
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This question is part of the following fields:
- Surgery
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Question 9
Correct
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A 16-year-old girl with short stature visits her GP due to delayed onset of menstruation. During the physical examination, the GP observes a broad neck and detects a systolic murmur in the chest. What condition is most likely causing these symptoms, and with which of the following options is it associated?
Your Answer: Coarctation of the aorta
Explanation:Aortic coarctation, a congenital cardiac abnormality characterized by the narrowing of a section of the aorta, is commonly associated with Turner’s syndrome. This condition results in an increase in afterload, which can be detected as a systolic murmur. The patient’s amenorrhea further supports a diagnosis of Turner’s syndrome over other possibilities. Mitral regurgitation, mitral stenosis, and mitral valve prolapse are unlikely to be associated with Turner’s syndrome.
Understanding Turner’s Syndrome
Turner’s syndrome is a genetic disorder that affects approximately 1 in 2,500 females. It is caused by the absence of one sex chromosome (X) or a deletion of the short arm of one of the X chromosomes. This condition is denoted as 45,XO or 45,X.
The features of Turner’s syndrome include short stature, a shield chest with widely spaced nipples, a webbed neck, a bicuspid aortic valve (15%), coarctation of the aorta (5-10%), primary amenorrhea, cystic hygroma (often diagnosed prenatally), a high-arched palate, a short fourth metacarpal, multiple pigmented naevi, lymphoedema in neonates (especially feet), and elevated gonadotrophin levels. Hypothyroidism is much more common in Turner’s syndrome, and there is also an increased incidence of autoimmune disease (especially autoimmune thyroiditis) and Crohn’s disease.
In summary, Turner’s syndrome is a chromosomal disorder that affects females and can cause a range of physical features and health issues. Early diagnosis and management can help individuals with Turner’s syndrome lead healthy and fulfilling lives.
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This question is part of the following fields:
- Paediatrics
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Question 10
Correct
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A 35-year-old woman presents with sudden chest pain and difficulty breathing. She recently returned from a trip to Italy with her family. She has no significant medical history but takes oral contraceptives. On examination, her pulse is 100 bpm, temperature is 37°C, oxygen saturation is 95%, respiratory rate is 28/min, and blood pressure is 116/76 mmHg. Chest examination is unremarkable and chest x-ray is normal. What is the most appropriate diagnostic test to confirm the diagnosis?
Your Answer: CTPA scan
Explanation:Diagnosis of Pulmonary Embolism in a Woman with Chest Pain and Dyspnoea
This woman is experiencing chest pain and difficulty breathing, with a rapid heart rate and breathing rate. However, there are no visible signs on chest examination and her chest x-ray appears normal. Despite having no fever, her oxygen levels are lower than expected for a healthy person. To rule out a pulmonary embolism, doctors must consider risk factors such as recent air travel and use of oral contraceptives.
The gold standard for diagnosing a pulmonary embolism is a CT pulmonary angiogram, as it can detect even large saddle emboli near the pulmonary arteries. While VQ scanning was previously used, it can miss these larger emboli. Additionally, doctors may perform Doppler ultrasounds of the venous system to check for deep vein thrombosis.
This presentation is not indicative of atypical pneumonia, such as Legionella, as the patient’s temperature would be expected to be high and chest signs would be present. Overall, a thorough evaluation is necessary to accurately diagnose and treat a pulmonary embolism in a patient with chest pain and dyspnoea.
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This question is part of the following fields:
- Emergency Medicine
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Question 11
Incorrect
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A 28-year-old woman has recently delivered a baby in the labour ward. Following the delivery, an evaluation is conducted to determine the amount of blood loss for recording purposes. The medical records indicate that she experienced a primary postpartum haemorrhage. Can you provide the accurate definition of primary postpartum haemorrhage (PPH)?
Your Answer: The loss of 1000 ml or more of blood from the genital tract within 24 hours of the birth of a baby
Correct Answer: The loss of 500 ml or more of blood from the genital tract within 24 hours of the birth of a baby
Explanation:Maternal mortality rates are still high globally due to obstetric haemorrhage. Postpartum haemorrhage is characterized by blood loss of 500 ml after vaginal delivery, not including the placenta. If blood loss exceeds 1000mls, it is classified as major postpartum haemorrhage. It is crucial to evaluate the severity of the bleeding and seek appropriate management (as outlined below).
Understanding Postpartum Haemorrhage
Postpartum haemorrhage (PPH) is a condition where a woman experiences blood loss of more than 500 ml after giving birth vaginally. It can be classified as primary or secondary. Primary PPH occurs within 24 hours after delivery and is caused by the 4 Ts: tone, trauma, tissue, and thrombin. The most common cause is uterine atony. Risk factors for primary PPH include previous PPH, prolonged labour, pre-eclampsia, increased maternal age, emergency Caesarean section, and placenta praevia.
In managing PPH, it is important to involve senior staff immediately and follow the ABC approach. This includes two peripheral cannulae, lying the woman flat, blood tests, and commencing a warmed crystalloid infusion. Mechanical interventions such as rubbing up the fundus and catheterisation are also done. Medical interventions include IV oxytocin, ergometrine, carboprost, and misoprostol. Surgical options such as intrauterine balloon tamponade, B-Lynch suture, ligation of uterine arteries, and hysterectomy may be considered if medical options fail to control the bleeding.
Secondary PPH occurs between 24 hours to 6 weeks after delivery and is typically due to retained placental tissue or endometritis. It is important to understand the causes and risk factors of PPH to prevent and manage this life-threatening emergency effectively.
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This question is part of the following fields:
- Obstetrics
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Question 12
Correct
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An 85-year-old man with a history of hypertension, hyperlipidemia, and smoking presents to the Emergency Department with left-sided weakness and numbness. On examination, he has a drooping left face, decreased strength in his left arm and leg (4/5), and reduced sensation on the left side of his body. His pulse is regular at 70 bpm, and his blood pressure is 180/100 mmHg. The initial diagnosis is a possible ischemic stroke.
What proportion of strokes are ischemic rather than hemorrhagic?Your Answer: 80-85%
Explanation:Understanding the Prevalence and Causes of Ischaemic and Haemorrhagic Strokes
Ischaemic strokes are the most common type of stroke, accounting for 80-85% of all cases. They are characterized by a sudden onset of neurological deficits, such as hemiplegia, and are usually caused by thromboembolic disease secondary to atherosclerosis. Risk factors for ischaemic stroke include smoking, diabetes, hyperlipidaemia, heart disease, and previous medical history of myocardial infarction, stroke or embolism.
Haemorrhagic strokes, on the other hand, account for only 10-20% of all strokes and usually result from the rupture of a blood vessel within the brain. While they are less common than ischaemic strokes, they can be more severe and have a higher mortality rate.
It is important to understand the prevalence and causes of both types of strokes in order to prevent and treat them effectively. By addressing risk factors such as smoking and heart disease, we can reduce the incidence of ischaemic strokes. And by recognizing the symptoms of haemorrhagic strokes and seeking immediate medical attention, we can improve outcomes for those affected.
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This question is part of the following fields:
- Neurology
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Question 13
Correct
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A 70-year-old man comes to the emergency department complaining of severe headache and visual disturbance. He states that he experienced sudden onset pain while watching TV last night with the lights off. Painkillers have been ineffective, and he has vomited twice since the pain started. He has no notable medical history and wears glasses for reading.
What medication should be administered as part of the initial treatment?Your Answer: Intravenous (IV) acetazolamide
Explanation:IV acetazolamide is the appropriate initial emergency medical treatment for acute angle-closure glaucoma, in addition to eye drops. This diagnosis is suggested by the patient’s symptoms of severe headache, visual disturbance, and vomiting, as well as the presence of mydriasis and hypermetropia. Oral amitriptyline and oxybutynin should not be used in the management of acute angle-closure glaucoma as they can worsen the condition. Topical dorzolamide is typically used for primary open-angle glaucoma.
Glaucoma is a group of disorders that cause optic neuropathy due to increased intraocular pressure (IOP). However, not all patients with raised IOP have glaucoma, and vice versa. Acute angle-closure glaucoma (AACG) is a type of glaucoma where there is a rise in IOP due to impaired aqueous outflow. Factors that increase the risk of AACG include hypermetropia, pupillary dilation, and lens growth associated with age. Symptoms of AACG include severe pain, decreased visual acuity, halos around lights, and a hard, red-eye. Management of AACG is an emergency and requires urgent referral to an ophthalmologist. Emergency medical treatment is necessary to lower the IOP, followed by definitive surgical treatment once the acute attack has subsided.
There are no specific guidelines for the initial medical treatment of AACG, but a combination of eye drops may be used, including a direct parasympathomimetic, a beta-blocker, and an alpha-2 agonist. Intravenous acetazolamide may also be administered to reduce aqueous secretions. Definitive management of AACG involves laser peripheral iridotomy, which creates a small hole in the peripheral iris to allow aqueous humour to flow to the angle. It is important to seek medical attention immediately if symptoms of AACG are present to prevent permanent vision loss.
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This question is part of the following fields:
- Ophthalmology
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Question 14
Incorrect
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A 55-year-old male patient has just been diagnosed with tuberculosis and is scheduled for a review before starting drug therapy. It is crucial to check his visual acuity during this consultation as one of the medications that will be prescribed can lead to visual disturbances. What is the name of this medication that may cause such an adverse effect?
Your Answer: Pyrazinamide
Correct Answer: Ethambutol
Explanation:Before starting treatment for tuberculosis with ethambutol, it is crucial to test the patient’s visual acuity to prevent the development of optic neuritis, a serious side effect. The other options listed are associated with different adverse effects: isoniazid with hepatitis and agranulocytosis, pyrazinamide with hepatitis, arthralgia, myalgia, and gout, and clarithromycin with gastrointestinal upset and cholestatic jaundice, commonly used for mycoplasma infections such as mycoplasma pneumoniae.
Side-Effects and Mechanism of Action of Tuberculosis Drugs
Rifampicin is a drug that inhibits bacterial DNA dependent RNA polymerase, which prevents the transcription of DNA into mRNA. However, it is a potent liver enzyme inducer and can cause hepatitis, orange secretions, and flu-like symptoms.
Isoniazid, on the other hand, inhibits mycolic acid synthesis. It can cause peripheral neuropathy, which can be prevented with pyridoxine (Vitamin B6). It can also cause hepatitis and agranulocytosis. Additionally, it is a liver enzyme inhibitor.
Pyrazinamide is converted by pyrazinamidase into pyrazinoic acid, which in turn inhibits fatty acid synthase (FAS) I. However, it can cause hyperuricaemia, leading to gout, as well as arthralgia, myalgia, and hepatitis.
Lastly, Ethambutol inhibits the enzyme arabinosyl transferase, which polymerizes arabinose into arabinan. It can cause optic neuritis, so it is important to check visual acuity before and during treatment. Additionally, the dose needs adjusting in patients with renal impairment.
In summary, these tuberculosis drugs have different mechanisms of action and can cause various side-effects. It is important to monitor patients closely and adjust treatment accordingly to ensure the best possible outcomes.
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This question is part of the following fields:
- Pharmacology
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Question 15
Incorrect
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A 56-year-old man with a medical history of COPD, ulcerative colitis, hypertension, and hypothyroidism presented to your clinic for follow-up. He was recently released from the hospital after being diagnosed with pneumonia. According to the discharge summary, he had an allergic reaction to co-trimoxazole during his hospital stay, resulting in the discontinuation of one of his regular medications. He has been instructed to consult with his GP about this medication. Which medication is most likely to have been discontinued due to the drug allergy?
Your Answer: Simvastatin
Correct Answer: Sulfasalazine
Explanation:If a patient has a known allergy to a sulfa drug like co-trimoxazole, they should avoid taking sulfasalazine.
Sulfasalazine: A DMARD for Inflammatory Arthritis and Bowel Disease
Sulfasalazine is a type of disease modifying anti-rheumatic drug (DMARD) that is commonly used to manage inflammatory arthritis, particularly rheumatoid arthritis, as well as inflammatory bowel disease. This medication is a prodrug for 5-ASA, which works by reducing neutrophil chemotaxis and suppressing the proliferation of lymphocytes and pro-inflammatory cytokines.
However, caution should be exercised when using sulfasalazine in patients with G6PD deficiency or those who are allergic to aspirin or sulphonamides due to the risk of cross-sensitivity. Adverse effects of sulfasalazine may include oligospermia, Stevens-Johnson syndrome, pneumonitis/lung fibrosis, myelosuppression, Heinz body anaemia, megaloblastic anaemia, and the potential to color tears and stain contact lenses.
Despite these potential side effects, sulfasalazine is considered safe to use during pregnancy and breastfeeding, making it a viable option for women who require treatment for inflammatory arthritis or bowel disease. Overall, sulfasalazine is an effective DMARD that can help manage the symptoms of these conditions and improve patients’ quality of life.
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This question is part of the following fields:
- Musculoskeletal
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Question 16
Incorrect
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A 35-year-old woman experiences a sudden and severe headache followed by collapse. Imaging reveals a subarachnoid hemorrhage, but there are no signs of increased intracranial pressure. What medication should be given?
Your Answer: Mannitol
Correct Answer: Nimodipine
Explanation:To prevent vasospasm in aneurysmal subarachnoid haemorrhages, nimodipine is utilized. This medication is a calcium channel blocker that lessens cerebral vasospasm and enhances results. It is given to the majority of subarachnoid haemorrhage cases.
A subarachnoid haemorrhage (SAH) is a type of bleeding that occurs within the subarachnoid space of the meninges in the brain. It can be caused by head injury or occur spontaneously. Spontaneous SAH is often caused by an intracranial aneurysm, which accounts for around 85% of cases. Other causes include arteriovenous malformation, pituitary apoplexy, and mycotic aneurysms. The classic symptoms of SAH include a sudden and severe headache, nausea and vomiting, meningism, coma, seizures, and ECG changes.
The first-line investigation for SAH is a non-contrast CT head, which can detect acute blood in the basal cisterns, sulci, and ventricular system. If the CT is normal within 6 hours of symptom onset, a lumbar puncture is not recommended. However, if the CT is normal after 6 hours, a lumbar puncture should be performed at least 12 hours after symptom onset to check for xanthochromia and other CSF findings consistent with SAH. If SAH is confirmed, referral to neurosurgery is necessary to identify the underlying cause and provide urgent treatment.
Management of aneurysmal SAH involves supportive care, such as bed rest, analgesia, and venous thromboembolism prophylaxis. Vasospasm is prevented with oral nimodipine, and intracranial aneurysms require prompt intervention to prevent rebleeding. Most aneurysms are treated with a coil by interventional neuroradiologists, but some require a craniotomy and clipping by a neurosurgeon. Complications of aneurysmal SAH include re-bleeding, hydrocephalus, vasospasm, and hyponatraemia. Predictive factors for SAH include conscious level on admission, age, and amount of blood visible on CT head.
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This question is part of the following fields:
- Surgery
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Question 17
Correct
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A 40-year-old man has been admitted after a severe paracetamol overdose. Despite medical intervention, he has developed liver failure. What is the most probable outcome of the liver failure?
Your Answer: Lactic acidosis is recognised complication
Explanation:N-acetylcysteine reduces morbidity and mortality in fulminant hepatic failure
Fulminant hepatic failure is a serious condition that can lead to severe hypoglycemia and exacerbate encephalopathy in 40% of patients. This condition can develop rapidly and recur with sepsis. Lactic acidosis is also a common complication due to decreased hepatic lactate clearance, poor peripheral perfusion, and increased lactate production. Unfortunately, the prognosis for patients with fulminant hepatic failure is poor if they have a blood pH less than 7.0, prolonged prothrombin time (more than 100s), and serum creatinine more than 300 uM. Mortality is also greater in patients over 40 years of age. However, the use of intravenous N-acetylcysteine has been shown to reduce morbidity and mortality in these patients.
Overall, it is important to closely monitor patients with fulminant hepatic failure and address any complications that arise. The use of N-acetylcysteine can be a valuable tool in improving outcomes for these patients.
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This question is part of the following fields:
- Gastroenterology
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Question 18
Correct
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A 56-year-old woman who has had two Colles fractures in the past three years undergoes a DEXA scan:
T-score
L2-4 -1.4
Femoral neck -2.7
What is the interpretation of the scan results?Your Answer: Osteopaenia in vertebrae, osteoporosis in femoral neck
Explanation:Osteoporosis is a condition that affects bone density and can lead to fractures. To diagnose osteoporosis, doctors use a DEXA scan, which measures bone mass. The results are compared to a young reference population, and a T score is calculated. A T score of -1.0 or higher is considered normal, while a score between -1.0 and -2.5 indicates osteopaenia, and a score below -2.5 indicates osteoporosis. The Z score is also calculated, taking into account age, gender, and ethnicity.
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This question is part of the following fields:
- Musculoskeletal
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Question 19
Correct
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A 32-year-old man presents to the Emergency department with a three-day history of paraesthesia in his feet and hands. He has also noticed weakness in his thighs, particularly when walking down stairs, and weakness affecting his shoulders. Prior to this, he had been well, except for a mild case of gastroenteritis after eating Chinese food. On examination, he appears anxious, but cranial nerve examination and fundoscopy are normal. Upper limb examination reveals reduced tone and absent reflexes bilaterally at both wrists. Lower limb examination shows 2/5 power, absent reflexes, and reduced sensation affecting both feet. A lumbar puncture is performed, yielding the following results: opening pressure 14 cmH2O (5-18), CSF protein 0.40 g/L (0.15-0.45), CSF white cell count 4 cells per ml (<5 cells), CSF red cell count 2 cells per ml (<5 cells), and negative CSF oligoclonal bands. What is the diagnosis for this patient?
Your Answer: Guillain-Barré syndrome
Explanation:Differential Diagnosis for Acute Motor and Sensory Neuropathy
His symptoms and signs suggest that he may be experiencing an acute motor and sensory neuropathy, which is commonly seen in Guillain-Barré syndrome following an infection. Patients with this condition often experience paraesthesias in their hands and feet, along with weakness. However, sensory abnormalities on examination are usually mild. Brainstem lesions are unlikely due to normal eye movements, and multiple sclerosis is a central demyelinating disorder that does not affect peripheral nerves. Wernicke’s encephalopathy typically presents as acute ataxia and ophthalmoplegia, while spinal cord lesions cause lower motor signs at the level of the lesion with upper motor signs below and a sensory level and bladder involvement. Although neurological complications can occur in systemic lupus erythematosus, including a peripheral neuropathy, the absence of common features such as joint or skin lesions makes this diagnosis unlikely. It is worth noting that cerebrospinal fluid protein is often normal at the onset of symptoms in Guillain-Barré syndrome.
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This question is part of the following fields:
- Neurology
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Question 20
Incorrect
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A 23-year-old pregnant woman from Sudan visits her GP with concerns about her upcoming vaginal delivery. She is currently 30 weeks pregnant and has undergone type 3 female genital mutilation. She expresses her preference to have her vagina reinfibulated after delivery, as this is what she is accustomed to. What is the recommended course of action?
Your Answer: Advise her that reinfibulation can only be performed under exceptional circumstances and she will need to be further assessed
Correct Answer: Advise her that reinfibulation is illegal and cannot be done under any circumstances
Explanation:Performing any form of female genital cutting/modification for non-medical reasons, including reinfibulation of a woman with type 3 FGM after vaginal delivery, is illegal according to the Female Genital Mutilation Act 2003. It is strictly prohibited to carry out such procedures under any circumstances. However, discussing the topic is not illegal.
Understanding Female Genital Mutilation
Female genital mutilation (FGM) is a term used to describe any procedure that involves the partial or complete removal of the external female genitalia or any other injury to the female genital organs for non-medical reasons. The World Health Organization (WHO) has classified FGM into four types. Type 1 involves the partial or total removal of the clitoris and/or the prepuce, while type 2 involves the partial or total removal of the clitoris and the labia minora, with or without excision of the labia majora. Type 3 involves the narrowing of the vaginal orifice with the creation of a covering seal by cutting and appositioning the labia minora and/or the labia majora, with or without excision of the clitoris. Finally, type 4 includes all other harmful procedures to the female genitalia for non-medical purposes, such as pricking, piercing, incising, scraping, and cauterization. It is important to understand the different types of FGM to raise awareness and prevent this harmful practice.
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This question is part of the following fields:
- Obstetrics
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Question 21
Correct
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A 62-year-old man visits the outpatient department for a review of his osteoporosis, where he is booked in for a DEXA scan. His T-score from his scan is recorded as -2.0, indicating decreased bone mineral density. What patient factors are necessary to calculate his Z-score?
Your Answer: Age, gender, ethnicity
Explanation:When interpreting DEXA scan results, it is important to consider the patient’s age, gender, and ethnicity. The Z-score is adjusted for these factors and provides a comparison of the patient’s bone density to that of an average person of the same age, sex, and race. Meanwhile, the T-score compares the patient’s bone density to that of a healthy 30-year-old of the same sex. It is worth noting that ethnicity can impact bone mineral density, with some studies indicating that Black individuals tend to have higher BMD than White and Hispanic individuals.
Osteoporosis is a condition that affects bone density and can lead to fractures. To diagnose osteoporosis, doctors use a DEXA scan, which measures bone mass. The results are compared to a young reference population, and a T score is calculated. A T score of -1.0 or higher is considered normal, while a score between -1.0 and -2.5 indicates osteopaenia, and a score below -2.5 indicates osteoporosis. The Z score is also calculated, taking into account age, gender, and ethnicity.
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This question is part of the following fields:
- Musculoskeletal
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Question 22
Incorrect
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A 32-year-old woman is brought to the edge of a roof by a trained practitioner and then left there for as long as possible until she overcomes her phobia of heights.
What sort of behavioural therapy is this?Your Answer: Exposure response therapy
Correct Answer: Flooding
Explanation:Behavioural Therapies: Techniques for Overcoming Fears and Habits
Behavioural therapies are a set of techniques used to treat various mental health conditions. These therapies aim to modify an individual’s behaviour by exposing them to their fears or habits and gradually desensitising them to the stimuli. Here are some common behavioural therapies:
1. Flooding: This therapy involves exposing an individual directly to their worst fear to trigger desensitisation.
2. Graded Exposure: Also known as systematic desensitisation, this therapy involves exposing the patient to the feared stimulus for progressively longer amounts of time or from a ‘virtual’ to a real exposure in an attempt to overcome the fear.
3. Relaxation Training: This therapy involves activities that allow the individual to calm or relax in the exposed situation.
4. Aversion Therapy: This therapy is used in the management of habits such as alcoholism and smoking. It involves exposing the individual to the behaviour while simultaneously evoking a noxious and/or painful stimulus to develop an aversion to the behaviour.
5. Exposure Response Therapy: This therapy is often used as an effective treatment for OCD. It involves gradually increasing exposure to uncomfortable stimuli to build a tolerance and reduce anxiety that feeds obsessions and compulsions.
Overall, behavioural therapies can be effective in treating various mental health conditions and helping individuals overcome their fears and habits.
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This question is part of the following fields:
- Psychiatry
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Question 23
Incorrect
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What is the recommended course of treatment for a 16-year-old boy with Reifenstein syndrome who has hypospadias, micropenis, and small testes in the scrotum?
Your Answer: Psychological counselling
Correct Answer: Testosterone replacement
Explanation:Management of Reifenstein Syndrome: Hormonal and Surgical Options
Reifenstein syndrome is a rare X-linked genetic disease that results in partial androgen insensitivity. In phenotypic males with this condition, testosterone replacement therapy is recommended to increase the chances of fertility. However, if the patient had been raised as a female and chose to continue this way, oestrogen replacement therapy would be appropriate. Surgical management may be necessary if the patient has undescended testes, but in this case, orchidectomy is not indicated as the patient has small testes in the scrotum. While psychological counselling is always necessary, it is not the first line of treatment. Overall, the management of Reifenstein syndrome involves a combination of hormonal and surgical options tailored to the individual patient’s needs.
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This question is part of the following fields:
- Endocrinology
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Question 24
Incorrect
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A 22-year-old female presents to her general practitioner seeking contraception. She has a past medical history of spina bifida, for which she uses a wheelchair. She has a family history of endometrial cancer, smokes 5 cigarettes a day and regularly drinks 20 units of alcohol per week. Her observations show:
Respiratory rate 18/min
Blood pressure 95/68 mmHg
Temperature 37.1ºC
Heart rate 92 bpm
Oxygen saturation 97% on room air
What would be a contraindication for starting the combined oral contraceptive pill for this patient?Your Answer: Her family history of endometrial cancer
Correct Answer: Her wheelchair use
Explanation:The use of COCP as a first-line contraceptive should be avoided for wheelchair users due to their increased risk of developing deep vein thrombosis (DVT). The presence of oestradiol in COCP increases the risk of DVT, and immobility associated with wheelchair use further exacerbates this risk. Therefore, the risks of using COCP outweigh the benefits for wheelchair users, and it is classified as UKMEC 3.
The decision to prescribe the combined oral contraceptive pill is now based on the UK Medical Eligibility Criteria (UKMEC), which categorizes potential contraindications and cautions on a four-point scale. UKMEC 1 indicates no restrictions for use, while UKMEC 2 suggests that the benefits outweigh the risks. UKMEC 3 indicates that the disadvantages may outweigh the advantages, and UKMEC 4 represents an unacceptable health risk. Examples of UKMEC 3 conditions include controlled hypertension, a family history of thromboembolic disease in first-degree relatives under 45 years old, and current gallbladder disease. Examples of UKMEC 4 conditions include a history of thromboembolic disease or thrombogenic mutation, breast cancer, and uncontrolled hypertension. Diabetes mellitus diagnosed over 20 years ago is classified as UKMEC 3 or 4 depending on severity. In 2016, Breastfeeding between 6 weeks and 6 months postpartum was changed from UKMEC 3 to UKMEC 2.
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This question is part of the following fields:
- Gynaecology
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Question 25
Incorrect
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A 36-year-old man arrives at the emergency department after taking an unknown substance during a night out. He has a history of depression. Upon examination, his GCS is 13/15, his pupils are dilated and divergent, and he is tachycardic with a heart rate of 110/min. His blood pressure is 124/70 mmHg, and his ECG shows sinus rhythm with a prolonged QTc duration of 480 msec. He appears dehydrated. What substance is most likely responsible for his symptoms?
Your Answer: MDMA
Correct Answer: Amitriptyline
Explanation:The correct answer is Amitriptyline overdose, a tricyclic antidepressant that blocks histamine, cholinergic and alpha 1 receptors. Symptoms include dilated pupils, dry skin, confusion, urinary retention, tachycardia, and potentially prolonged QTc interval and widened QRS complex leading to ventricular arrhythmias. Serotonin syndrome is a possible effect of sertraline overdose, while cocaine toxicity produces sympathetic effects such as agitation, increased heart rate and blood pressure, but would not cause a reduced GCS or altered QRS duration on ECG.
Tricyclic overdose is a common occurrence in emergency departments, with particular danger associated with amitriptyline and dosulepin. Early symptoms include dry mouth, dilated pupils, agitation, sinus tachycardia, and blurred vision. Severe poisoning can lead to arrhythmias, seizures, metabolic acidosis, and coma. ECG changes may include sinus tachycardia, widening of QRS, and prolongation of QT interval. QRS widening over 100ms is linked to an increased risk of seizures, while QRS over 160 ms is associated with ventricular arrhythmias.
Management of tricyclic overdose involves IV bicarbonate as first-line therapy for hypotension or arrhythmias. Other drugs for arrhythmias, such as class 1a and class Ic antiarrhythmics, are contraindicated as they prolong depolarisation. Class III drugs like amiodarone should also be avoided as they prolong the QT interval. Lignocaine’s response is variable, and it should be noted that correcting acidosis is the first line of management for tricyclic-induced arrhythmias. Intravenous lipid emulsion is increasingly used to bind free drug and reduce toxicity. Dialysis is ineffective in removing tricyclics.
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This question is part of the following fields:
- Pharmacology
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Question 26
Correct
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A 30-year-old Caucasian woman who is 26 weeks pregnant with her first child presents to antenatal clinic. She had been invited to attend screening for gestational diabetes on account of her booking BMI, which was 32kg/m². Prior to her pregnancy, she had been healthy and had no personal or family history of diabetes mellitus. She takes no regular medications and has no known allergies.
During her antenatal visit, she undergoes an oral glucose tolerance test (OGTT), which reveals the following results:
- Fasting glucose 6.9mmol/L
- 2-hour glucose 7.8 mmol/L
An ultrasound scan shows no fetal abnormalities or hydramnios. She is advised on diet and exercise and undergoes a repeat OGTT two weeks later. Due to persistent impaired fasting glucose, she is started on metformin.
After taking metformin for two weeks, she undergoes another OGTT, with the following results:
- Fasting glucose 5.8 mmol/L
- 2-hour glucose 7.2mmol/L
What is the most appropriate next step in managing her glycaemic control?Your Answer: Add insulin
Explanation:If blood glucose targets are not achieved through diet and metformin in gestational diabetes, insulin should be introduced. This patient was diagnosed with gestational diabetes at 25 weeks due to a fasting glucose level above 5.6mmol/L. Despite lifestyle changes and the addition of metformin, her glycaemic control has not improved, and her fasting glucose level remains above the target range. Therefore, NICE recommends adding short-acting insulin to her current treatment. Switching to modified-release metformin may help patients who experience side effects, but it would not improve glycaemic control in this case. Insulin should be added in conjunction with metformin for persistent impaired glycaemic control, rather than replacing it. Sulfonylureas like glibenclamide should only be used for patients who cannot tolerate metformin or as an adjunct for those who refuse insulin treatment, and they are not the best option for this patient.
Gestational diabetes is a common medical disorder affecting around 4% of pregnancies. Risk factors include a high BMI, previous gestational diabetes, and family history of diabetes. Screening is done through an oral glucose tolerance test, and diagnostic thresholds have recently been updated. Management includes self-monitoring of blood glucose, diet and exercise advice, and medication if necessary. For pre-existing diabetes, weight loss and insulin are recommended, and tight glycemic control is important. Targets for self-monitoring include fasting glucose of 5.3 mmol/l and 1-2 hour post-meal glucose levels.
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This question is part of the following fields:
- Obstetrics
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Question 27
Incorrect
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A patient in their mid-40s wakes up experiencing severe pain, redness, and swelling at the base of their big toe.
What is the most suitable course of treatment for this patient?Your Answer: Aspirin
Correct Answer: Indomethacin
Explanation:NSAIDs for Gout Treatment
Non-steroidal anti-inflammatory drugs (NSAIDs) are commonly used to treat acute attacks of gout. Among the NSAIDs, indomethacin is the most frequently prescribed due to its potent anti-inflammatory properties. However, it is important to note that aspirin and aspirin-containing products should be avoided during acute gout attacks as they can actually trigger or worsen the condition. Therefore, it is crucial to consult with a healthcare provider before taking any medication for gout, especially during an acute attack. Proper use of NSAIDs can help alleviate the pain and inflammation associated with gout, improving the patient’s quality of life.
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This question is part of the following fields:
- Rheumatology
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Question 28
Correct
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A 25-year-old female patient presents at the clinic and reports taking the desogestrel oral contraceptive pill. What is the primary mechanism of action through which desogestrel achieves its contraceptive effect?
Your Answer: Preventing ovulation
Explanation:Contraceptive Methods and Their Effects on Ovulation and Fertilization
When studying the effectiveness of desogestrel as a contraceptive method, it was found that ovulation occurred in only 1% of cases within two cycles. This was determined by measuring progesterone levels, with a confidence interval of 0.02% – 5.29%. Ovulation inhibition was achieved from the first cycle of use. However, when discontinuing the use of Cerazette after two cycles, ovulation occurred on average after 17 days, with a range of 7-30 days. Additionally, the progesterone only pill thickens cervical mucous, further preventing fertilization.
Intrauterine devices are another form of contraception that reduce the chances of successful implantation of a fertilized egg. This is achieved by altering the environment of the uterus, making it less hospitable for implantation. It is important to note that prostaglandins, not progesterone, play a role in stimulating uterine contraction. Overall, these methods work to prevent ovulation and/or fertilization, ultimately leading to effective contraception.
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This question is part of the following fields:
- Pharmacology
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Question 29
Correct
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A 3-month-old girl is brought to the morning clinic by her father. Since last night she has been taking reduced feeds and has been 'not her usual self'. On examination the baby appears well but has a temperature of 38.5ºC. What is the most suitable course of action?
Your Answer: Admit to hospital
Explanation:The latest NICE guidelines classify any infant under 3 months old with a temperature exceeding 38ºC as a ‘red’ feature, necessitating immediate referral to a paediatrician. While some seasoned GPs may opt not to adhere to this recommendation, it is crucial to stay informed about recent examination guidelines.
The NICE Feverish illness in children guidelines were introduced in 2007 and updated in 2013. These guidelines use a ‘traffic light’ system to assess the risk of children under 5 years old presenting with a fever. It is important to note that these guidelines only apply until a clinical diagnosis of the underlying condition has been made. When assessing a febrile child, their temperature, heart rate, respiratory rate, and capillary refill time should be recorded. Signs of dehydration should also be looked for. Measuring temperature should be done with an electronic thermometer in the axilla if the child is under 4 weeks old or with an electronic/chemical dot thermometer in the axilla or an infrared tympanic thermometer.
The risk stratification table includes green for low risk, amber for intermediate risk, and red for high risk. The table includes categories such as color, activity, respiratory, circulation and hydration, and other symptoms. If a child is categorized as green, they can be managed at home with appropriate care advice. If they are categorized as amber, parents should be provided with a safety net or referred to a pediatric specialist for further assessment. If a child is categorized as red, they should be urgently referred to a pediatric specialist. It is important to note that oral antibiotics should not be prescribed to children with fever without an apparent source, and a chest x-ray does not need to be routinely performed if a pneumonia is suspected but the child is not going to be referred to the hospital.
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This question is part of the following fields:
- Paediatrics
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Question 30
Incorrect
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What is the significant transformation that takes place enabling children to synthesize their own vitamin K?
Your Answer: Increased portal circulation efficiency
Correct Answer: Gastrointestinal bacterial colonisation
Explanation:Vitamin K in Newborns and Adults
Most of the vitamin K in adults is produced through the metabolism of precursors by intestinal bacteria. However, newborns are vitamin K deficient for several reasons, including immature hepatic metabolism, low placental transfer, and no oral intake of vitamin K or its precursors. As a result, all newborns receive intramuscular vitamin K, often within the delivery room, to reduce the risk of vitamin K deficiency bleeding, which can lead to intracerebral bleeding and other serious complications.
The production of vitamin K in adults is influenced by the development of hepatic metabolic enzymes and the colonization of intestinal bacteria during the first year of life. Small bowel length is typically not a limiting factor in normal children, although some infants may experience a short bowel syndrome after surgical resection of major sections of bowel. Despite these differences, there is no significant change in the portal circulation, renal clearance, or breakdown of clotting factors between newborns and adults.
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This question is part of the following fields:
- Clinical Sciences
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