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  • Question 1 - A 25-year-old female patient presents with a persistent cough and runny nose for...

    Incorrect

    • A 25-year-old female patient presents with a persistent cough and runny nose for the past 48 hours. She seeks treatment for her symptoms, but you explain that she is likely experiencing a common cold that will resolve on its own. What is the most frequent cause of the common cold?

      Your Answer: Adenovirus

      Correct Answer: Rhinovirus

      Explanation:

      Rhinoviruses are responsible for causing the common cold, while respiratory syncytial virus is a common cause of bronchiolitis. Influenza virus is the culprit behind the flu, while Streptococcus pneumonia is the most frequent cause of community-acquired pneumonia. Parainfluenza virus is commonly associated with croup.

      Respiratory Pathogens and Their Associated Conditions

      Respiratory pathogens are microorganisms that cause infections in the respiratory system. The most common respiratory pathogens include respiratory syncytial virus, parainfluenza virus, rhinovirus, influenza virus, Streptococcus pneumoniae, Haemophilus influenzae, Staphylococcus aureus, Mycoplasma pneumoniae, Legionella pneumophilia, and Pneumocystis jiroveci. Each of these pathogens is associated with a specific respiratory condition.

      Respiratory syncytial virus is known to cause bronchiolitis, while parainfluenza virus is associated with croup. Rhinovirus is the most common cause of the common cold, while influenza virus causes the flu. Streptococcus pneumoniae is the most common cause of community-acquired pneumonia, and Haemophilus influenzae is the most common cause of bronchiectasis exacerbations and acute epiglottitis. Staphylococcus aureus is known to cause pneumonia, particularly following influenza. Mycoplasma pneumoniae causes atypical pneumonia, which is characterized by flu-like symptoms that precede a dry cough. Legionella pneumophilia is another cause of atypical pneumonia, which is typically spread by air-conditioning systems and causes a dry cough. Pneumocystis jiroveci is a common cause of pneumonia in HIV patients, and patients typically have few chest signs and develop exertional dyspnea. Mycobacterium tuberculosis causes tuberculosis, which can present in a wide range of ways, from asymptomatic to disseminated disease. Cough, night sweats, and weight loss may be seen in patients with tuberculosis.

    • This question is part of the following fields:

      • Respiratory Medicine
      18.1
      Seconds
  • Question 2 - A 30-year-old woman presents with neck pain and swelling. She reports having symptoms...

    Correct

    • A 30-year-old woman presents with neck pain and swelling. She reports having symptoms of an upper respiratory tract infection followed by neck pain and swelling for the past 2 weeks. During examination, she appears anxious, her heart rate is 98/min, and her thyroid gland is tender and diffusely swollen.
      Her blood tests reveal the following results:
      Thyroid-stimulating hormone (TSH) 0.4 mU/L (0.5-5.5)
      Free thyroxine (T4) 42 pmol/L (9.0 - 18)
      ESR 65 mm/h (1-20)
      What is the most likely diagnosis?

      Your Answer: Subacute thyroiditis (de Quervain's thyroiditis)

      Explanation:

      Subacute (De Quervain’s) thyroiditis is the likely diagnosis for this woman who presents with hyperthyroidism and a tender goitre following an upper respiratory tract infection. This condition is characterized by high ESR and painful thyroid gland. Graves’ disease, Hashimoto’s thyroiditis, and thyroid cancer are less likely causes as they do not present with these specific symptoms.

      Subacute Thyroiditis: A Self-Limiting Condition with Four Phases

      Subacute thyroiditis, also known as De Quervain’s thyroiditis or subacute granulomatous thyroiditis, is a condition that is believed to occur after a viral infection. It is characterized by hyperthyroidism, a painful goitre, and raised ESR during the first phase, which lasts for 3-6 weeks. The second phase, which lasts for 1-3 weeks, is characterized by euthyroidism. The third phase, which can last for weeks to months, is characterized by hypothyroidism. Finally, in the fourth phase, the thyroid structure and function return to normal.

      To diagnose subacute thyroiditis, thyroid scintigraphy is used to show a globally reduced uptake of iodine-131. However, most patients do not require treatment as the condition is self-limiting. Thyroid pain may respond to aspirin or other NSAIDs, but in more severe cases, steroids may be used, particularly if hypothyroidism develops.

      It is important to note that subacute thyroiditis is just one of the many causes of thyroid dysfunction. A Venn diagram can be used to show how different causes of thyroid dysfunction may manifest. It is interesting to note that many causes of hypothyroidism may have an initial thyrotoxic phase. Proper diagnosis and management of thyroid dysfunction are crucial to ensure optimal patient outcomes.

    • This question is part of the following fields:

      • Endocrinology/Metabolic Disease
      41.6
      Seconds
  • Question 3 - A 68-year-old man comes to your clinic accompanied by his daughter. He reports...

    Correct

    • A 68-year-old man comes to your clinic accompanied by his daughter. He reports having painless swelling in his fingers that has been persistent. When inquiring about his medical history, he denies any issues except for a nagging cough. During the examination of his hands, you observe an increased curvature of the nails and a loss of the angle between the nail and nail bed. Considering the potential diagnoses, what would be the most crucial step to take?

      Your Answer: Urgent chest X-ray

      Explanation:

      According to NICE guidelines for suspected lung cancers, individuals over the age of 40 with finger clubbing should undergo a chest X-ray. Given that this patient is 70 years old and has a persistent cough and finger clubbing, an urgent chest X-ray is necessary to investigate the possibility of lung cancer or mesothelioma. Pain relief medication such as oral analgesia or ibuprofen gel is not necessary as the patient is not experiencing any pain, which would be indicative of osteoarthritis. Reassurance is not appropriate in this case as finger clubbing in individuals over the age of 40 requires immediate investigation.

      Referral Guidelines for Lung Cancer

      Lung cancer is a serious condition that requires prompt diagnosis and treatment. The 2015 NICE cancer referral guidelines provide clear advice on when to refer patients for further assessment. According to these guidelines, patients should be referred using a suspected cancer pathway referral if they have chest x-ray findings that suggest lung cancer or if they are aged 40 and over with unexplained haemoptysis.

      For patients aged 40 and over who have two or more unexplained symptoms, or who have ever smoked and have one or more unexplained symptoms, an urgent chest x-ray should be offered within two weeks to assess for lung cancer. These symptoms include cough, fatigue, shortness of breath, chest pain, weight loss, and appetite loss.

      In addition, an urgent chest x-ray should be considered within two weeks for patients aged 40 and over who have persistent or recurrent chest infection, finger clubbing, supraclavicular lymphadenopathy or persistent cervical lymphadenopathy, chest signs consistent with lung cancer, or thrombocytosis.

      Overall, these guidelines provide clear and specific criteria for when to refer patients for further assessment for lung cancer. By following these guidelines, healthcare professionals can ensure that patients receive timely and appropriate care.

    • This question is part of the following fields:

      • Musculoskeletal
      35
      Seconds
  • Question 4 - What is a true statement about trigeminal neuralgia? ...

    Correct

    • What is a true statement about trigeminal neuralgia?

      Your Answer: The pain is commonly triggered by touching the skin

      Explanation:

      Understanding Trigeminal Neuralgia

      Trigeminal neuralgia is a type of pain syndrome that is characterized by severe pain on one side of the face. While most cases are idiopathic, some may be caused by compression of the trigeminal roots due to tumors or vascular problems. According to the International Headache Society, trigeminal neuralgia is defined as a disorder that causes brief electric shock-like pains that are limited to one or more divisions of the trigeminal nerve. The pain is often triggered by light touch, such as washing, shaving, or brushing teeth, and can occur spontaneously. Certain areas of the face, such as the nasolabial fold or chin, may be more susceptible to pain. The pain may also remit for varying periods.

      Red flag symptoms and signs that suggest a serious underlying cause include sensory changes, ear problems, a history of skin or oral lesions that could spread perineurally, pain only in the ophthalmic division of the trigeminal nerve, optic neuritis, a family history of multiple sclerosis, and onset before the age of 40.

      The first-line treatment for trigeminal neuralgia is carbamazepine. If there is a failure to respond to treatment or atypical features are present, such as onset before the age of 50, referral to neurology is recommended. Understanding the symptoms and management of trigeminal neuralgia is important for proper diagnosis and treatment.

    • This question is part of the following fields:

      • Neurology
      24.7
      Seconds
  • Question 5 - A 20-year-old woman presents with a 4-day history of cough, headache, fever and...

    Correct

    • A 20-year-old woman presents with a 4-day history of cough, headache, fever and joint pains. Blood tests show the presence of raised antibody titres and the presence of cold agglutinins. A diagnosis of Mycoplasma pneumoniae infection is made.
      Which of the following drugs would you prescribe as first-line treatment for this patient?

      Your Answer: Clarithromycin

      Explanation:

      Treatment options for Mycoplasma pneumoniae infection

      Mycoplasma pneumoniae is a bacterium that causes atypical pneumonia and is transmitted through respiratory droplets. The symptoms vary but can include fever, malaise, myalgia, headache, and a rash. Diagnosis is usually confirmed with serology, and treatment typically involves a macrolide antibiotic such as clarithromycin for at least 10-14 days. Penicillin and other beta-lactam antibiotics are ineffective as Mycoplasma pneumoniae lacks a cell wall. Tetracycline can be used but macrolides are preferred due to a better side-effect profile. Rifampicin is mostly limited to the treatment of tuberculosis and leprosy, while co-trimoxazole is not indicated for Mycoplasma pneumoniae infection. Extrapulmonary involvement is possible and may suggest the diagnosis in a patient presenting with pneumonia. A chest radiograph is non-specific and typically shows a reticulonodular or patchy consolidation pattern.

    • This question is part of the following fields:

      • Respiratory Medicine
      28.8
      Seconds
  • Question 6 - You assess a 65-year-old man who has recently been discharged from hospital in...

    Correct

    • You assess a 65-year-old man who has recently been discharged from hospital in France following a heart attack. He presents with an echocardiogram report indicating his left ventricular ejection fraction is 38%. Upon examination, his pulse is regular at 76 beats per minute, blood pressure is 126/74 mmHg, and his chest is clear. He is currently taking aspirin, simvastatin, and lisinopril. What is the most appropriate course of action regarding his medication?

      Your Answer: Add bisoprolol

      Explanation:

      The use of carvedilol and bisoprolol has been proven to decrease mortality in stable heart failure patients, while there is no evidence to support the use of other beta-blockers. NICE guidelines suggest that all individuals with heart failure should be prescribed both an ACE-inhibitor and a beta-blocker.

      Drug Management for Chronic Heart Failure: NICE Guidelines

      Chronic heart failure is a serious condition that requires proper management to improve patient outcomes. In 2018, the National Institute for Health and Care Excellence (NICE) updated their guidelines on drug management for chronic heart failure. The guidelines recommend first-line therapy with both an ACE-inhibitor and a beta-blocker, with clinical judgement used to determine which one to start first. Second-line therapy involves the use of aldosterone antagonists, which should be monitored for hyperkalaemia. SGLT-2 inhibitors are also increasingly being used to manage heart failure with a reduced ejection fraction. Third-line therapy should be initiated by a specialist and may include ivabradine, sacubitril-valsartan, hydralazine in combination with nitrate, digoxin, or cardiac resynchronisation therapy. Other treatments such as annual influenza and one-off pneumococcal vaccines are also recommended.

      Overall, the NICE guidelines provide a comprehensive approach to drug management for chronic heart failure. It is important to note that loop diuretics have not been shown to reduce mortality in the long-term, and that ACE-inhibitors and beta-blockers have no effect on mortality in heart failure with preserved ejection fraction. Healthcare professionals should carefully consider the patient’s individual needs and circumstances when determining the appropriate drug therapy for chronic heart failure.

    • This question is part of the following fields:

      • Cardiovascular
      28.8
      Seconds
  • Question 7 - A 32-year-old male patient comes in for mole removal. Which areas of the...

    Incorrect

    • A 32-year-old male patient comes in for mole removal. Which areas of the body are more prone to developing keloid scars?

      Your Answer: Scalp

      Correct Answer: Sternum

      Explanation:

      Understanding Keloid Scars

      Keloid scars are abnormal growths that develop from the connective tissue of a scar and extend beyond the boundaries of the original wound. They are more common in people with dark skin and tend to occur in young adults. Keloids are most frequently found on the sternum, shoulder, neck, face, extensor surface of limbs, and trunk.

      To prevent keloid scars, incisions should be made along relaxed skin tension lines. However, if keloids do develop, early treatment with intra-lesional steroids such as triamcinolone may be effective. In some cases, excision may be necessary, but this should be approached with caution as it can potentially lead to further keloid scarring.

      It is important to note that the historical use of Langer lines to determine optimal incision lines has been shown to produce worse cosmetic results than following skin tension lines. Understanding the predisposing factors and treatment options for keloid scars can help individuals make informed decisions about their care.

    • This question is part of the following fields:

      • Dermatology
      18.7
      Seconds
  • Question 8 - A 20-year-old female is brought to the Emergency Department by her friends after...

    Correct

    • A 20-year-old female is brought to the Emergency Department by her friends after a night out. Her friends report that she took an unknown substance while clubbing. What symptom would be most indicative of ecstasy use?

      Your Answer: Temperature of 39.5ÂşC

      Explanation:

      Understanding Ecstasy Poisoning

      Ecstasy, also known as MDMA or 3,4-Methylenedioxymethamphetamine, gained popularity in the 1990s with the rise of dance music culture. However, its use can lead to poisoning with various clinical features. Neurological symptoms such as agitation, anxiety, confusion, and ataxia are common, as well as cardiovascular symptoms like tachycardia and hypertension. Hyponatremia, hyperthermia, and rhabdomyolysis are also possible.

      When it comes to managing ecstasy poisoning, supportive measures are typically used. However, if simple measures fail, dantrolene may be used to address hyperthermia. It’s important to understand the risks associated with ecstasy use and to seek medical attention if any symptoms of poisoning arise. With proper management, individuals can recover from ecstasy poisoning and avoid long-term complications.

    • This question is part of the following fields:

      • Pharmacology/Therapeutics
      60.7
      Seconds
  • Question 9 - A 56-year-old woman visits her GP complaining of pain and limited movement in...

    Correct

    • A 56-year-old woman visits her GP complaining of pain and limited movement in her left shoulder joint for the past 4 weeks. She denies any history of injury and reports feeling generally healthy. Her medical history includes hypertension and hypothyroidism. During the examination, the patient experiences pain with all active and passive movements of the left shoulder, and there is significant restriction in external rotation. What is the probable diagnosis?

      Your Answer: Adhesive capsulitis

      Explanation:

      The impairment of external rotation, both on active and passive movement, is a classic feature of adhesive capsulitis. This condition is the most likely diagnosis, as the patient’s symptoms of restricted active and passive external rotation have only been present for the last 4 weeks. Osteoarthritis, on the other hand, tends to present with a more chronic pain history. Adhesive capsulitis is often associated with endocrine conditions such as diabetes and thyroid disease, and has three distinct phases: painful, stiff, and recovery. Physiotherapy is the mainstay of treatment, but early intra-articular steroid injection may be considered if conservative measures are not effective. Biceps tendonitis typically presents with anterior shoulder pain and point tenderness over the biceps tendon on examination. Inflammatory arthritis is unlikely as there are no other joint involvements, morning stiffness, or systemic symptoms, and the history and examination are consistent with adhesive capsulitis. While osteoarthritis may be considered in the differential diagnosis, the duration of symptoms and classic examination findings suggest adhesive capsulitis as the most likely diagnosis.

      Understanding Adhesive Capsulitis (Frozen Shoulder)

      Adhesive capsulitis, commonly known as frozen shoulder, is a prevalent cause of shoulder pain that primarily affects middle-aged women. The exact cause of this condition is not yet fully understood. However, studies have shown that up to 20% of diabetics may experience an episode of frozen shoulder. Symptoms typically develop over several days, with external rotation being more affected than internal rotation or abduction. Both active and passive movement are affected, and patients usually experience a painful freezing phase, an adhesive phase, and a recovery phase. In some cases, the condition may affect both shoulders, which occurs in up to 20% of patients. The episode typically lasts between 6 months and 2 years.

      Diagnosis of adhesive capsulitis is usually clinical, although imaging may be necessary for atypical or persistent symptoms. Unfortunately, no single intervention has been proven to improve the outcome in the long-term. However, there are several treatment options available, including nonsteroidal anti-inflammatory drugs (NSAIDs), physiotherapy, oral corticosteroids, and intra-articular corticosteroids.

    • This question is part of the following fields:

      • Musculoskeletal
      17
      Seconds
  • Question 10 - Whilst discussing common causes of respiratory infections with a group of medical students,...

    Correct

    • Whilst discussing common causes of respiratory infections with a group of medical students, a question was raised about the age at which croup is typically diagnosed. Specifically, the student asked at what age croup is most commonly diagnosed.

      Your Answer: 6 months - 3 years

      Explanation:

      Croup affects 6 months to 3 years old and is caused by parainfluenza virus, while bronchiolitis affects 1-9 month olds and is caused by respiratory syncytial virus. Neonatal respiratory distress can occur due to prematurity.

      Understanding Croup: A Respiratory Infection in Infants and Toddlers

      Croup is a type of upper respiratory tract infection that commonly affects infants and toddlers. It is characterized by a barking cough, fever, and coryzal symptoms, and is caused by a combination of laryngeal oedema and secretions. Parainfluenza viruses are the most common cause of croup. The condition typically peaks between 6 months and 3 years of age, and is more prevalent during the autumn season.

      The severity of croup can be graded based on the presence of symptoms such as stridor, cough, and respiratory distress. Mild cases may only have occasional barking cough and no audible stridor at rest, while severe cases may have frequent barking cough, prominent inspiratory stridor at rest, and marked sternal wall retractions. Children with moderate or severe croup, those under 6 months of age, or those with known upper airway abnormalities should be admitted to the hospital.

      Diagnosis of croup is usually made based on clinical presentation, but a chest x-ray may show subglottic narrowing, commonly referred to as the steeple sign. Treatment for croup typically involves a single dose of oral dexamethasone or prednisolone, regardless of severity. In emergency situations, high-flow oxygen and nebulized adrenaline may be necessary.

      Understanding croup is important for parents and healthcare providers alike, as prompt recognition and treatment can help prevent complications and improve outcomes for affected children.

    • This question is part of the following fields:

      • Paediatrics
      39.8
      Seconds
  • Question 11 - A 42-year-old man presents for follow-up. He was prescribed paroxetine for depression six...

    Correct

    • A 42-year-old man presents for follow-up. He was prescribed paroxetine for depression six months ago, but stopped taking it five days ago due to perceived lack of efficacy. He has a history of asthma but no other significant medical history. Over the past two days, he has been experiencing heightened anxiety, sweating, headaches, and a sensation of needles in his head. During the appointment, he is restless and pacing. What is the most likely cause of his symptoms?

      Your Answer: Selective serotonin reuptake inhibitor`discontinuation syndrome

      Explanation:

      Compared to other selective serotonin reuptake inhibitors, paroxetine has a greater likelihood of causing discontinuation symptoms.

      Selective serotonin reuptake inhibitors (SSRIs) are commonly used as the first-line treatment for depression. Citalopram and fluoxetine are the preferred SSRIs, while sertraline is recommended for patients who have had a myocardial infarction. However, caution should be exercised when prescribing SSRIs to children and adolescents. Gastrointestinal symptoms are the most common side-effect, and patients taking SSRIs are at an increased risk of gastrointestinal bleeding. Patients should also be aware of the possibility of increased anxiety and agitation after starting a SSRI. Fluoxetine and paroxetine have a higher propensity for drug interactions.

      The Medicines and Healthcare products Regulatory Agency (MHRA) has issued a warning regarding the use of citalopram due to its association with dose-dependent QT interval prolongation. As a result, citalopram and escitalopram should not be used in patients with congenital long QT syndrome, known pre-existing QT interval prolongation, or in combination with other medicines that prolong the QT interval. The maximum daily dose of citalopram is now 40 mg for adults, 20 mg for patients older than 65 years, and 20 mg for those with hepatic impairment.

      When initiating antidepressant therapy, patients should be reviewed by a doctor after 2 weeks. Patients under the age of 25 years or at an increased risk of suicide should be reviewed after 1 week. If a patient responds well to antidepressant therapy, they should continue treatment for at least 6 months after remission to reduce the risk of relapse. When stopping a SSRI, the dose should be gradually reduced over a 4 week period, except for fluoxetine. Paroxetine has a higher incidence of discontinuation symptoms, including mood changes, restlessness, difficulty sleeping, unsteadiness, sweating, gastrointestinal symptoms, and paraesthesia.

      When considering the use of SSRIs during pregnancy, the benefits and risks should be weighed. Use during the first trimester may increase the risk of congenital heart defects, while use during the third trimester can result in persistent pulmonary hypertension of the newborn. Paroxetine has an increased risk of congenital malformations, particularly in the first trimester.

    • This question is part of the following fields:

      • Psychiatry
      35.3
      Seconds
  • Question 12 - What is the most frequent negative outcome encountered by females who consume the...

    Correct

    • What is the most frequent negative outcome encountered by females who consume the progestin-only pill?

      Your Answer: Irregular vaginal bleeding

      Explanation:

      Pros and Cons of the Progestogen Only Pill

      The progestogen only pill, also known as the mini-pill, is a highly effective form of contraception with a failure rate of only 1 per 100 woman years. One of its advantages is that it does not interfere with sex and its contraceptive effects are reversible upon stopping. It can also be used while breastfeeding and in situations where the combined oral contraceptive pill is contraindicated, such as in smokers over 35 years of age and women with a history of venous thromboembolic disease.

      However, the progestogen only pill also has its disadvantages. One of the most common adverse effects is irregular periods, with some users not having periods while others may experience irregular or light periods. It also does not protect against sexually transmitted infections and has an increased incidence of functional ovarian cysts. Common side-effects include breast tenderness, weight gain, acne, and headaches, although these symptoms generally subside after the first few months. Despite its drawbacks, the progestogen only pill remains a popular choice for women seeking a reliable and convenient form of contraception.

    • This question is part of the following fields:

      • Reproductive Medicine
      18
      Seconds
  • Question 13 - A 20-year-old runner has approached you for advice after being diagnosed with a...

    Correct

    • A 20-year-old runner has approached you for advice after being diagnosed with a stress fracture in her left tibia. She is seeking guidance on how to reduce her risk of future stress fractures. What are the risk factors that athletic females are most susceptible to when it comes to developing stress fractures?

      Your Answer: Inadequate calorie intake, menstrual irregularities and increased or new exercise intensity

      Explanation:

      Women with low calorie intake or menstrual irregularities who increase their exercise are at risk of stress fractures due to the female athlete triad, which includes excessive exercise, reduced bone mineral density, and eating disorders or inadequate calorie intake. It is important to discuss eating habits and menstrual cycles when treating women with a history of stress fractures.

      Stress fractures are small hairline fractures that can occur due to repetitive activity and loading of normal bone. Although they can be painful, they are typically not displaced and do not cause surrounding soft tissue injury. In some cases, stress fractures may present late, and callus formation may be visible on radiographs. Treatment for stress fractures may vary depending on the severity of the injury. In cases where the injury is associated with severe pain and presents at an earlier stage, immobilization may be necessary. However, injuries that present later may not require formal immobilization and can be treated with tailored immobilization specific to the site of injury.

    • This question is part of the following fields:

      • Musculoskeletal
      91.9
      Seconds
  • Question 14 - A 32-year-old male patient visits the sexual health clinic complaining of a recent...

    Incorrect

    • A 32-year-old male patient visits the sexual health clinic complaining of a recent genital lesion. The patient reports experiencing severe pain and first noticed the lesion one week ago. He admits to engaging in unprotected sexual activity with multiple partners within the past three months. Upon examination, a deep ulcer with a ragged border is observed on the penis shaft, accompanied by tenderness and inguinal lymphadenopathy. What is the probable diagnosis?

      Your Answer: Syphilis

      Correct Answer: Chancroid

      Explanation:

      The man’s ulcer appears to be caused by chancroid, which is known for causing deep and painful genital ulcers accompanied by inguinal lymphadenopathy. Gonorrhoea is an unlikely diagnosis as it typically presents with penile discharge and no ulceration. Herpes simplex can also cause painful genital ulcers, but they are usually multiple and superficial, and inguinal lymphadenopathy is not as common as with chancroid. Lymphogranuloma venereum causes painless ulceration that heals quickly, while primary syphilis causes a painless ulcer called a chancre.

      Understanding Chancroid: A Painful Tropical Disease

      Chancroid is a disease that is commonly found in tropical regions and is caused by a bacterium called Haemophilus ducreyi. This disease is characterized by the development of painful genital ulcers that are often accompanied by painful swelling of the lymph nodes in the groin area. The ulcers themselves are typically easy to identify, as they have a distinct border that is ragged and undermined.

      Chancroid is a disease that can be quite painful and uncomfortable for those who are affected by it.

    • This question is part of the following fields:

      • Infectious Diseases
      39.8
      Seconds
  • Question 15 - In an adult patient with Marfan syndrome, what is the most frequently observed...

    Incorrect

    • In an adult patient with Marfan syndrome, what is the most frequently observed cardiovascular abnormality?

      Your Answer: Aortic dissection

      Correct Answer: Aortic root dilatation

      Explanation:

      Marfan Syndrome: A Connective Tissue Disorder with Cardiovascular Manifestations

      Marfan syndrome is an autosomal dominant connective tissue disorder that presents with a wide range of clinical manifestations. The ocular, skeletal, and cardiovascular systems are characteristically involved. Aortic root dilatation, occurring in 70-80% of cases, is the most common cardiovascular manifestation, followed by mitral valve prolapse at 60-70%. Mitral annular calcification is less common, occurring in 8-15% of cases. Aortic dissection, accounting for around 5% of all cases, is more likely in patients with Marfan syndrome, especially those with severe aortic root dilatation.

      The weakening of the aortic media leads to a fusiform ascending aortic aneurysm, which may be complicated by aortic regurgitation and aortic dissection. Mitral regurgitation can result from mitral valve prolapse, dilatation of a mitral valve annulus, or mitral annular calcification. Pregnancy is particularly hazardous for patients with Marfan syndrome. Treatment with β blockers can reduce the rate of aortic dilatation and the risk of rupture.

    • This question is part of the following fields:

      • Cardiovascular
      48.3
      Seconds
  • Question 16 - A 70-year-old man complains of back pain that occurs during walking. Upon obtaining...

    Incorrect

    • A 70-year-old man complains of back pain that occurs during walking. Upon obtaining a thorough medical history and conducting a neurological and vascular assessment, the possibility of spinal stenosis is considered. Following the prescription of pain relief medication, what is the most suitable course of action?

      Your Answer: Arrange physiotherapy

      Correct Answer: Refer for MRI

      Explanation:

      To confirm the diagnosis and rule out other potential causes, an MRI is necessary for this presentation.

      Lower back pain is a common issue that is often caused by muscular strain. However, it is important to be aware of potential underlying causes that may require specific treatment. Certain red flags should be considered, such as age under 20 or over 50, a history of cancer, night pain, trauma, or systemic illness. There are also specific causes of lower back pain that should be kept in mind. Facet joint pain may be acute or chronic, worse in the morning and on standing, and typically worsens with back extension. Spinal stenosis may cause leg pain, numbness, and weakness that is worse on walking and relieved by sitting or leaning forward. Ankylosing spondylitis is more common in young men and causes stiffness that is worse in the morning and improves with activity. Peripheral arterial disease may cause pain on walking and weak foot pulses. It is important to consider these potential causes and seek appropriate diagnosis and treatment.

    • This question is part of the following fields:

      • Musculoskeletal
      106.9
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  • Question 17 - A 25-year-old man with difficult to control epilepsy is being evaluated by a...

    Correct

    • A 25-year-old man with difficult to control epilepsy is being evaluated by a surgeon, four months after switching his antiepileptic medication. Despite being seizure-free, he has gained 5 kg in weight since his last check-up. Which antiepileptic drug is commonly linked to weight gain?

      Your Answer: Sodium valproate

      Explanation:

      Weight gain can be a side effect of taking sodium valproate.

      Sodium Valproate: Uses and Adverse Effects

      Sodium valproate is a medication commonly used to manage epilepsy, particularly for generalised seizures. Its mechanism of action involves increasing the activity of GABA in the brain. However, the use of sodium valproate during pregnancy is strongly discouraged due to its teratogenic effects, which can lead to neural tube defects and neurodevelopmental delays in children. Women of childbearing age should only use this medication if it is absolutely necessary and under the guidance of a specialist neurological or psychiatric advisor.

      Aside from its teratogenic effects, sodium valproate can also inhibit P450 enzymes, leading to gastrointestinal issues such as nausea, increased appetite, and weight gain. Other adverse effects include alopecia, ataxia, tremors, hepatotoxicity, pancreatitis, thrombocytopenia, hyponatremia, and hyperammonemic encephalopathy. In cases where hyperammonemic encephalopathy develops, L-carnitine may be used as a treatment option.

      Overall, while sodium valproate can be an effective medication for managing epilepsy, its use should be carefully considered and monitored due to its potential adverse effects, particularly during pregnancy.

    • This question is part of the following fields:

      • Neurology
      31.9
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  • Question 18 - A 30-year-old man presents to you with complaints of numbness and pain in...

    Correct

    • A 30-year-old man presents to you with complaints of numbness and pain in his hands and feet since this morning. He had visited for gastroenteritis 2 weeks ago. On examination, he has a bilateral reduction in power of 3/5 in his upper and lower limbs. He has no history of any other medical conditions and is usually in good health. What is the most probable diagnosis?

      Your Answer: Guillain-Barre syndrome

      Explanation:

      Guillain-Barre syndrome is a condition where the immune system attacks the peripheral nervous system, leading to demyelination. It is often triggered by an infection and causes rapidly advancing ascending motor neuropathy. Proximal muscles are more affected than distal muscles.

      A stroke or transient ischaemic attack usually has a sudden onset and causes unilateral symptoms such as facial droop, arm weakness, and slurred speech.

      Raynaud’s disease causes numbness and pain in the fingers and toes, typically in response to cold weather or stress.

      Understanding Guillain-Barre Syndrome: Symptoms and Features

      Guillain-Barre syndrome is a condition that affects the peripheral nervous system and is caused by an immune-mediated demyelination. It is often triggered by an infection, with Campylobacter jejuni being a common culprit. The initial symptoms of the illness include back and leg pain, which is experienced by around 65% of patients. The characteristic feature of Guillain-Barre syndrome is a progressive, symmetrical weakness of all the limbs, with the weakness typically starting in the legs and ascending upwards. Reflexes are reduced or absent, and sensory symptoms tend to be mild, with very few sensory signs.

      Other features of Guillain-Barre syndrome may include a history of gastroenteritis, respiratory muscle weakness, cranial nerve involvement, diplopia, bilateral facial nerve palsy, oropharyngeal weakness, and autonomic involvement. Autonomic involvement may manifest as urinary retention or diarrhea. Less common findings may include papilloedema, which is thought to be secondary to reduced CSF resorption.

      To diagnose Guillain-Barre syndrome, a lumbar puncture may be performed, which can reveal a rise in protein with a normal white blood cell count (albuminocytologic dissociation) in 66% of cases. Nerve conduction studies may also be conducted, which can show decreased motor nerve conduction velocity due to demyelination, prolonged distal motor latency, and increased F wave latency. Understanding the symptoms and features of Guillain-Barre syndrome is crucial for prompt diagnosis and treatment.

    • This question is part of the following fields:

      • Neurology
      28.7
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  • Question 19 - A 70-year-old man with metastatic lung cancer visits the general practice clinic complaining...

    Correct

    • A 70-year-old man with metastatic lung cancer visits the general practice clinic complaining of lethargy and nausea. His full blood count, thyroid function test, calcium and liver function tests all come back normal. However, his urea and electrolytes reveal significant hyponatraemia, while the rest of the results are normal. He has a reduced plasma osmolality and increased urine osmolality. He is haemodynamically stable and euvolaemic.
      What is the most probable diagnosis from the options below?

      Your Answer: Syndrome of inappropriate antidiuretic hormone secretion (SIADH)

      Explanation:

      Differentiating Causes of Abnormal Urine Osmolality: A Brief Overview

      Abnormal urine osmolality can be indicative of various underlying conditions. Here are some of the possible causes and how to differentiate them:

      Syndrome of Inappropriate Antidiuretic Hormone Secretion (SIADH)
      SIADH is characterized by excessive secretion of ADH, leading to hyperosmolar urine and low plasma osmolality. It can be caused by central nervous system disorders, malignancies, and drugs. Treatment involves fluid restriction and addressing the underlying cause.

      Cranial Diabetes Insipidus
      This condition is caused by the hypothalamus not producing enough vasopressin, resulting in extreme thirst and polyuria. However, urine osmolality is reduced, not elevated.

      Nephrogenic Diabetes Insipidus
      Nephrogenic diabetes insipidus is caused by the kidneys becoming resistant to the effect of vasopressin/ADH, leading to large volumes of dilute urine with reduced osmolality. Causes include electrolyte imbalances, medications, and renal tubular acidosis.

      Addison’s Disease
      This condition is characterized by reduced production of glucocorticoids, mineralocorticoids, and adrenal androgens. Deficiency of mineralocorticoid leads to increased sodium excretion from the kidneys, resulting in hyponatremia associated with hyperkalemia. However, in this case, the patient has normal potassium levels.

      Primary Polydipsia
      This condition is caused by excessive water drinking despite no physiological stimulus, resulting in dilute polyuria. However, in this patient, the urine osmolality is concentrated, making this diagnosis unlikely. A fluid deprivation test can help confirm or rule out this condition.

      In summary, abnormal urine osmolality can be indicative of various underlying conditions, and a thorough evaluation is necessary to determine the correct diagnosis and treatment.

    • This question is part of the following fields:

      • Endocrinology/Metabolic Disease
      113.3
      Seconds
  • Question 20 - A 35-year-old Arabic woman visits the GP clinic complaining of vision issues. She...

    Correct

    • A 35-year-old Arabic woman visits the GP clinic complaining of vision issues. She reports experiencing increasing haziness in both eyes for the past 2 years. Upon further inquiry, she discloses a history of recurrent tetany and seizures. During fundoscopy, you observe a lack of red reflex in both eyes. Additionally, both Chvostek sign and Trousseau sign are positive. She has no significant medical history and is not taking any medications. Her blood test results are as follows:
      HbA1c 40 mmol/mol
      What is the probable cause of her visual problem?

      Your Answer: Hypocalcaemia

      Explanation:

      The positive Chvostek and Trousseau signs, along with a history of tetany and convulsions, suggest that the patient is suffering from hypocalcaemia. This condition can lead to cataracts, which may explain the patient’s vision problems. It is unlikely that the cataracts are related to age, as the patient is still young. Hypercalcaemia is not a common cause of cataracts, and the patient is not taking steroids, which can also cause cataracts. Additionally, the patient’s normal HbA1c indicates that she does not have diabetes mellitus.

      Understanding Cataracts: Causes, Symptoms, and Management

      A cataract is a common eye condition that affects the lens of the eye, causing it to become cloudy and reducing the amount of light that reaches the retina. This can lead to blurred or reduced vision, making it difficult to see clearly. Cataracts are more common in women and tend to increase in incidence with age. While the normal ageing process is the most common cause, other factors such as smoking, alcohol consumption, trauma, diabetes, and long-term corticosteroid use can also contribute to the development of cataracts.

      Symptoms of cataracts include reduced vision, faded colour vision, glare, and halos around lights. A defect in the red reflex is also a sign of cataracts. Diagnosis is typically made through ophthalmoscopy and slit-lamp examination, which can reveal the presence of a visible cataract.

      In the early stages, age-related cataracts can be managed conservatively with stronger glasses or contact lenses and brighter lighting. However, surgery is the only effective treatment for cataracts and involves removing the cloudy lens and replacing it with an artificial one. Referral for surgery should be based on the presence of visual impairment, impact on quality of life, and patient choice. Complications following surgery can include posterior capsule opacification, retinal detachment, posterior capsule rupture, and endophthalmitis.

      Overall, cataracts are a common and treatable eye condition that can significantly impact a person’s vision. Understanding the causes, symptoms, and management options can help individuals make informed decisions about their eye health.

    • This question is part of the following fields:

      • Ophthalmology
      72.8
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  • Question 21 - A 27-year-old woman comes to the clinic complaining of dysuria and frequency, four...

    Incorrect

    • A 27-year-old woman comes to the clinic complaining of dysuria and frequency, four weeks after giving birth. She exclusively breastfeeds her child and had an uneventful antenatal period and delivery. On examination, her abdomen appears normal and she has no fever. A urine dipstick reveals positive results for blood, protein, leucocytes, and nitrites. What is the best course of action for management?

      Your Answer: Co-amoxiclav

      Correct Answer: Trimethoprim

      Explanation:

      Breastfeeding has some contraindications that are important to know, especially when it comes to drugs. Antibiotics like penicillins, cephalosporins, and trimethoprim are safe for breastfeeding mothers, as are endocrine drugs like glucocorticoids (in low doses) and levothyroxine. Epilepsy drugs like sodium valproate and carbamazepine, asthma drugs like salbutamol and theophyllines, and hypertension drugs like beta-blockers and hydralazine are also safe. Anticoagulants like warfarin and heparin, as well as digoxin, are also safe. However, some drugs should be avoided, such as antibiotics like ciprofloxacin, tetracycline, chloramphenicol, and sulphonamides, psychiatric drugs like lithium and benzodiazepines, aspirin, carbimazole, methotrexate, sulfonylureas, cytotoxic drugs, and amiodarone. Other contraindications include galactosaemia and viral infections, although the latter is controversial in the developing world due to the increased risk of infant mortality and morbidity associated with bottle feeding.

    • This question is part of the following fields:

      • Renal Medicine/Urology
      34.1
      Seconds
  • Question 22 - Which of the following statements best describes bladder cancer? ...

    Incorrect

    • Which of the following statements best describes bladder cancer?

      Your Answer: Bladder cancer is usually a squamous carcinoma.

      Correct Answer: Survival correlates well with TNM staging at diagnosis.

      Explanation:

      Bladder Cancer: Prognostic Factors, Staging, and Treatment Options

      Bladder cancer is a common malignancy that affects the urinary system. Survival rates are closely linked to the TNM staging at diagnosis, with non-muscle invasive bladder cancer having a good prognosis and decreasing survival rates with increasing stage. The most significant prognostic factors for bladder cancer are grade, depth of invasion, and the presence of carcinoma in situ. Chemotherapy for metastatic disease is seldom used and has limited effectiveness. Cisplatin-based chemotherapy regimens are the standard treatment for metastatic bladder cancer, with a median overall patient survival of 13-15 months and a 2-year survival rate of 15-20%. Careful follow-up is necessary for non-muscle invasive bladder cancer due to the high rate of disease recurrence and progression.

    • This question is part of the following fields:

      • Renal Medicine/Urology
      24.8
      Seconds
  • Question 23 - A 26-year-old patient comes in with lesions on their lower abdomen that have...

    Correct

    • A 26-year-old patient comes in with lesions on their lower abdomen that have been present for six weeks. At first, there was only one lesion, but more have appeared since then. During the examination, around 10 raised lesions with an umbilicated appearance, each around 1-2 mm in diameter, are observed. What is the most probable diagnosis?

      Your Answer: Molluscum contagiosum

      Explanation:

      Molluscum contagiosum is typically observed in children, but the following is a classical depiction of the condition.

      Understanding Molluscum Contagiosum

      Molluscum contagiosum is a viral skin infection that is commonly seen in children, particularly those with atopic eczema. It is caused by the molluscum contagiosum virus and can be transmitted through direct contact or contaminated surfaces. The infection presents as pinkish or pearly white papules with a central umbilication, which can appear anywhere on the body except for the palms of the hands and soles of the feet. In children, lesions are commonly seen on the trunk and in flexures, while in adults, sexual contact may lead to lesions developing on the genitalia, pubis, thighs, and lower abdomen.

      While molluscum contagiosum is a self-limiting condition that usually resolves within 18 months, it is important to avoid sharing towels, clothing, and baths with uninfected individuals to prevent transmission. Scratching the lesions should also be avoided, and treatment may be considered if the itch is problematic. However, treatment is not usually recommended, and if necessary, simple trauma or cryotherapy may be used. In some cases, referral may be necessary, such as for individuals who are HIV-positive with extensive lesions or those with eyelid-margin or ocular lesions and associated red eye.

      Overall, understanding molluscum contagiosum and taking appropriate precautions can help prevent transmission and alleviate symptoms.

    • This question is part of the following fields:

      • Dermatology
      43.1
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  • Question 24 - As a general practice registrar, you are reviewing a patient who was referred...

    Incorrect

    • As a general practice registrar, you are reviewing a patient who was referred to ENT and has a history of acoustic neuroma on the right side. The patient, who is in their mid-50s, returned 2 months ago with pulsatile tinnitus in the left ear and was diagnosed with a left-sided acoustic neuroma after undergoing an MRI scan. Surgery is scheduled for later this week. What is the probable cause of this patient's recurrent acoustic neuromas?

      Your Answer: Neurofibromatosis type 1

      Correct Answer: Neurofibromatosis type 2

      Explanation:

      Neurofibromatosis type 2 is commonly linked to bilateral acoustic neuromas (vestibular schwannomas). Additionally, individuals with this condition may also experience benign neurological tumors and lens opacities.

      Understanding Vestibular Schwannoma (Acoustic Neuroma)

      Vestibular schwannoma, also known as acoustic neuroma, is a type of brain tumor that accounts for 5% of intracranial tumors and 90% of cerebellopontine angle tumors. The condition is characterized by a combination of symptoms such as vertigo, hearing loss, tinnitus, and an absent corneal reflex. The affected cranial nerves can predict the features of the condition. For instance, cranial nerve VIII can cause vertigo, unilateral sensorineural hearing loss, and unilateral tinnitus. On the other hand, cranial nerve V can lead to an absent corneal reflex, while cranial nerve VII can cause facial palsy.

      Bilateral vestibular schwannomas are often seen in neurofibromatosis type 2. The diagnosis of vestibular schwannoma is made through an MRI of the cerebellopontine angle, and audiometry is also important since only 5% of patients have a normal audiogram.

      The management of vestibular schwannoma involves surgery, radiotherapy, or observation. The choice of treatment depends on the size and location of the tumor, the patient’s age and overall health, and the severity of symptoms. In conclusion, understanding vestibular schwannoma is crucial in managing the condition effectively.

    • This question is part of the following fields:

      • ENT
      67.8
      Seconds
  • Question 25 - A 35-year-old woman presents with a 7-day history of mucopurulent anal discharge, bloody...

    Incorrect

    • A 35-year-old woman presents with a 7-day history of mucopurulent anal discharge, bloody stool and pain during defecation. She denies any recent travel and has not experienced any vomiting episodes.

      Which of the following is the most probable diagnosis?

      Your Answer: Crohn’s disease

      Correct Answer: Gonorrhoea

      Explanation:

      Sexually Transmitted Infections: Differential Diagnosis

      Sexually transmitted infections (STIs) are a common cause of morbidity worldwide. When evaluating a patient with symptoms suggestive of an STI, it is important to consider a broad differential diagnosis. Here are some common STIs and their clinical presentations:

      Gonorrhoea: This is a purulent infection of the mucous membranes caused by Neisseria gonorrhoeae. In men, symptoms include urethritis, acute epididymitis, and rectal infection. A diagnosis can be made by identifying typical Gram-negative intracellular diplococci after a Gram stain.

      Crohn’s disease: This is an inflammatory bowel disease that presents with prolonged diarrhea, abdominal pain, anorexia, and weight loss. It is not consistent with a typical STI presentation.

      Candidiasis: This is a fungal infection caused by yeasts from the genus Candida. It is associated with balanitis, presenting with penile pruritus and whitish patches on the penis.

      Salmonella infection: This is often transmitted orally via contaminated food or beverages. Symptoms include a severe non-specific febrile illness, which can be confused with typhoid fever. There is nothing in this clinical scenario to suggest Salmonella infection.

      Chancroid: This is a bacterial STI caused by Haemophilus ducreyi. It is characterised by painful necrotising genital ulcers and inguinal lymphadenopathy.

      In summary, a thorough differential diagnosis is important when evaluating patients with symptoms suggestive of an STI.

    • This question is part of the following fields:

      • Infectious Diseases
      32.7
      Seconds
  • Question 26 - A 52-year-old woman presents with lethargy and pruritus. She reports having a normal...

    Correct

    • A 52-year-old woman presents with lethargy and pruritus. She reports having a normal appetite and no weight loss. Upon examination, there is no clinical jaundice or organomegaly. The following blood test results are obtained:
      - Hb: 12.8 g/dl
      - Platelets: 188 * 109/l
      - WBC: 6.7 * 109/l
      - Na+: 140 mmol/l
      - K+: 3.9 mmol/l
      - Urea: 6.2 mmol/l
      - Creatinine: 68 µmol/l
      - Bilirubin: 30 µmol/l
      - ALP: 231 u/l
      - ALT: 38 u/l
      - ÎłGT: 367 u/l
      - Albumin: 39 g/l

      What additional test is most likely to lead to a diagnosis?

      Your Answer: Anti-mitochondrial antibodies

      Explanation:

      Primary Biliary Cholangitis: A Chronic Liver Disorder

      Primary biliary cholangitis, previously known as primary biliary cirrhosis, is a chronic liver disorder that is commonly observed in middle-aged women. The exact cause of this condition is not yet fully understood, but it is believed to be an autoimmune disease. The disease is characterized by the progressive damage of interlobular bile ducts due to chronic inflammation, leading to cholestasis and eventually cirrhosis. The most common symptom of primary biliary cholangitis is itching in middle-aged women.

      This condition is often associated with other autoimmune diseases such as Sjogren’s syndrome, rheumatoid arthritis, systemic sclerosis, and thyroid disease. Early symptoms of primary biliary cholangitis may be asymptomatic or may include fatigue, pruritus, and cholestatic jaundice. Late symptoms may progress to liver failure. Diagnosis of primary biliary cholangitis involves immunology tests such as anti-mitochondrial antibodies (AMA) M2 subtype and smooth muscle antibodies, as well as imaging tests to exclude an extrahepatic biliary obstruction.

      The first-line treatment for primary biliary cholangitis is ursodeoxycholic acid, which slows down the progression of the disease and improves symptoms. Cholestyramine is used to alleviate pruritus, and fat-soluble vitamin supplementation is recommended. In severe cases, liver transplantation may be necessary, especially if bilirubin levels exceed 100. However, recurrence in the graft can occur, but it is not usually a problem. Complications of primary biliary cholangitis include cirrhosis, portal hypertension, ascites, variceal hemorrhage, osteomalacia, osteoporosis, and an increased risk of hepatocellular carcinoma.

    • This question is part of the following fields:

      • Gastroenterology/Nutrition
      19.7
      Seconds
  • Question 27 - A 55-year-old woman presents to the Emergency Department with a sudden-onset blurring of...

    Incorrect

    • A 55-year-old woman presents to the Emergency Department with a sudden-onset blurring of vision in both eyes as well as light sensitivity. She is a known type II diabetic with blood sugars well maintained with medication.
      On examination, her temperature is 36.8 oC, while her blood pressure (BP) is 180/110 mmHg. Her pulse is 70 beats per minute. Her respiratory rate is 18 breaths per minute, and her oxygen saturations are 98% on room air.
      On dilated fundoscopy, both optic discs are swollen with widespread flame-shaped haemorrhages and cotton-wool spots.
      What is the most appropriate first-line management of this condition?

      Your Answer: Pan-retinal photocoagulation

      Correct Answer: Intravenous (IV) labetalol

      Explanation:

      Misconceptions about Treatment for Hypertensive Retinopathy

      Hypertensive retinopathy is a condition that occurs when high blood pressure damages the blood vessels in the retina. However, there are several misconceptions about the treatment for this condition.

      Firstly, in a hypertensive emergency with retinopathy, it is important to lower blood pressure slowly to avoid brain damage. Intravenous labetalol is a suitable medication for this purpose, with the aim of reducing diastolic blood pressure to 100 mmHg or reducing it by 20-25 mmHg per day, whichever is less.

      Secondly, oral calcium channel blockers like amlodipine are not useful in an acute setting of hypertensive emergency. They are not effective in treating hypertensive retinopathy.

      Thirdly, intravitreal anti-vascular endothelial growth factor (anti-VEGF) injection is not a treatment for hypertensive retinopathy. It is used to treat wet age-related macular degeneration.

      Fourthly, pan-retinal photocoagulation or any laser treatment for the eye is not a treatment for hypertensive retinopathy. It is a treatment for proliferative diabetic retinopathy.

      Lastly, sublingual glyceryl trinitrate (GTN) spray is not a suitable treatment for hypertensive retinopathy. It is typically used in patients with angina and acute coronary syndrome.

      In conclusion, it is important to understand the appropriate treatments for hypertensive retinopathy to avoid misconceptions and ensure proper care for patients.

    • This question is part of the following fields:

      • Ophthalmology
      67.8
      Seconds
  • Question 28 - You assess a patient's eye and discovered that both pupils constrict when focusing...

    Incorrect

    • You assess a patient's eye and discovered that both pupils constrict when focusing on a nearby object but fail to narrow when exposed to bright light. What is the most frequent reason for this pupillary response in the United Kingdom?

      Your Answer: Optic neuritis

      Correct Answer: Diabetes mellitus

      Explanation:

      In the UK, diabetes mellitus is now the most frequent cause of Argyll-Robertson pupil, as neurosyphilis is no longer commonly observed due to effective antibiotic treatment. This condition is not caused by sexually transmitted diseases such as chlamydia or gonorrhoea, nor is it associated with optic neuritis, which instead causes a Marcus Gunn pupil or Relative afferent pupillary defect.

      Argyll-Robertson Pupil: A Classic Pupillary Syndrome

      The Argyll-Robertson Pupil (ARP) is a classic pupillary syndrome that is sometimes observed in neurosyphilis. It is characterized by small, irregular pupils that do not respond to light but do respond to accommodation. A useful mnemonic for remembering this syndrome is Accommodation Reflex Present (ARP) but Pupillary Reflex Absent (PRA).

      The ARP can be caused by various factors, including diabetes mellitus and syphilis. It is important to note that the presence of an ARP may indicate underlying neurological or systemic disease and should prompt further evaluation and management. Proper diagnosis and treatment of the underlying condition can help prevent further complications and improve patient outcomes.

    • This question is part of the following fields:

      • Ophthalmology
      21.5
      Seconds
  • Question 29 - A 78-year-old woman visits her GP complaining of a gradual loss of vision...

    Correct

    • A 78-year-old woman visits her GP complaining of a gradual loss of vision over the past 2 years. She reports difficulty seeing objects up close, particularly at dusk and in the early morning when walking her dog. Amsler grid testing reveals distorted line perception. The patient has a history of osteoarthritis in her knees, which she treats with paracetamol as needed. What is the probable observation on fundoscopy?

      Your Answer: Drusen

      Explanation:

      The patient’s symptoms and clinical findings suggest a diagnosis of dry macular degeneration, which is characterized by the presence of drusen – small yellowish deposits of lipids under the retina. The patient is experiencing a gradual loss of central vision, difficulty seeing in the dark, and distorted line perception on Amsler grid testing.

      Hypertensive retinopathy can cause AV nicking, which is visible on fundoscopy, but it is unlikely to be the cause of this patient’s symptoms. Cotton wool spots, which are associated with hypertensive and diabetic retinopathy, are also an unlikely cause as the patient has no history of hypertension or diabetes, and these spots do not typically cause changes in vision. Cupping of the optic disc, seen in glaucoma, is also an unlikely diagnosis as the patient’s symptoms do not match those typically seen in glaucoma.

      Age-related macular degeneration (ARMD) is a common cause of blindness in the UK, characterized by the degeneration of the central retina (macula) and the formation of drusen. It is more prevalent in females and is strongly associated with advancing age, smoking, family history, and conditions that increase the risk of ischaemic cardiovascular disease. ARMD can be classified into two forms: dry and wet. Dry ARMD is more common and is characterized by drusen, while wet ARMD is characterized by choroidal neovascularisation and carries a worse prognosis. Clinical features of ARMD include subacute onset of visual loss, difficulties in dark adaptation, and visual disturbances such as photopsia and glare.

      To diagnose ARMD, slit-lamp microscopy and color fundus photography are used to identify any pigmentary, exudative, or haemorrhagic changes affecting the retina. Fluorescein angiography and indocyanine green angiography may also be used to visualize changes in the choroidal circulation. Treatment for dry ARMD involves a combination of zinc with anti-oxidant vitamins A, C, and E, which has been shown to reduce disease progression by around one third. For wet ARMD, anti-VEGF agents such as ranibizumab, bevacizumab, and pegaptanib are used to limit disease progression and stabilize or reverse visual loss. Laser photocoagulation may also be used to slow progression, but anti-VEGF therapies are usually preferred due to the risk of acute visual loss after treatment.

      In summary, ARMD is a common cause of blindness in the UK that is strongly associated with advancing age, smoking, and family history. It can be classified into dry and wet forms, with wet ARMD carrying a worse prognosis. Diagnosis involves the use of various imaging techniques, and treatment options include a combination of zinc and anti-oxidant vitamins for dry ARMD and anti-VEGF agents or laser photocoagulation for wet ARMD.

    • This question is part of the following fields:

      • Ophthalmology
      351
      Seconds
  • Question 30 - A couple from Bangladesh, parents of a 13-year-old boy, seek guidance. They have...

    Correct

    • A couple from Bangladesh, parents of a 13-year-old boy, seek guidance. They have recently moved to the UK and have been advised by immigration officials that their son should receive the BCG vaccine for tuberculosis. The boy is currently healthy and shows no symptoms. What would be the most suitable course of action?

      Your Answer: Arrange a tuberculin skin test

      Explanation:

      Before administering the vaccine, it is crucial to conduct a tuberculin skin test to rule out any previous exposure to tuberculosis.

      The BCG Vaccine: Who Should Get It and How It’s Administered

      The Bacille Calmette-Guérin (BCG) vaccine is a vaccine that provides limited protection against tuberculosis (TB). In the UK, it is given to high-risk infants and certain groups of people who are at risk of contracting TB. The vaccine contains live attenuated Mycobacterium bovis and also offers limited protection against leprosy.

      The Greenbook provides guidelines on who should receive the BCG vaccine. It is recommended for all infants living in areas of the UK where the annual incidence of TB is 40/100,000 or greater, as well as infants with a parent or grandparent who was born in a country with a high incidence of TB. The vaccine is also recommended for previously unvaccinated tuberculin-negative contacts of cases of respiratory TB, new entrants under 16 years of age who were born in or have lived for a prolonged period in a high-risk country, healthcare workers, prison staff, staff of care homes for the elderly, and those who work with homeless people.

      Before receiving the BCG vaccine, any person being considered must first be given a tuberculin skin test, except for children under 6 years old who have had no contact with tuberculosis. The vaccine is given intradermally, normally to the lateral aspect of the left upper arm. It can be given at the same time as other live vaccines, but if not administered simultaneously, there should be a 4-week interval.

      There are some contraindications for the BCG vaccine, including previous BCG vaccination, a past history of tuberculosis, HIV, pregnancy, and a positive tuberculin test (Heaf or Mantoux). It is not given to anyone over the age of 35, as there is no evidence that it works for people of this age group.

    • This question is part of the following fields:

      • Paediatrics
      52.7
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SESSION STATS - PERFORMANCE PER SPECIALTY

Respiratory Medicine (1/2) 50%
Endocrinology/Metabolic Disease (2/2) 100%
Musculoskeletal (3/4) 75%
Neurology (3/3) 100%
Cardiovascular (1/2) 50%
Dermatology (1/2) 50%
Pharmacology/Therapeutics (1/1) 100%
Paediatrics (2/2) 100%
Psychiatry (1/1) 100%
Reproductive Medicine (1/1) 100%
Infectious Diseases (0/2) 0%
Ophthalmology (2/4) 50%
Renal Medicine/Urology (0/2) 0%
ENT (0/1) 0%
Gastroenterology/Nutrition (1/1) 100%
Passmed