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  • Question 1 - A 67-year-old woman presents to her general practitioner (GP) complaining of a headache...

    Incorrect

    • A 67-year-old woman presents to her general practitioner (GP) complaining of a headache and painless loss of vision in her left eye lasting for 5 minutes. Two days later, she developed sudden-onset, right-sided weakness affecting both upper and lower limbs and lasting for 30 minutes. Her past medical history includes mild hyperlipidemia. She is a non-smoker. There are no neurological abnormalities. Her blood pressure is 150/85 mmHg and heart rate 80 bpm. There are no audible carotid bruits.
      Which of the following is the most likely diagnosis?

      Your Answer: TIA secondary to small-vessel disease

      Correct Answer: Transient ischaemic attack (TIA) secondary to carotid artery disease

      Explanation:

      Understanding Transient Ischaemic Attack (TIA) and its Possible Causes

      Transient ischaemic attack (TIA) is a medical condition that occurs when blood flow to the brain is temporarily disrupted, leading to neurological symptoms that usually last for less than an hour. One of the most common causes of TIA is carotid artery disease, which accounts for up to 90% of cases. Symptoms of TIA due to carotid artery disease include contralateral motor and sensory disturbance, ipsilateral visual disturbance, and amaurosis fugax (monocular blindness). A carotid artery bruit in the neck may also be present.

      Migraine equivalents are another possible cause of TIA, but they are characterized by absent headache and slow spread of symptoms from one body part to the next. Unlike migraines, TIA episodes are sudden-onset and resolved within an hour.

      TIA can also be caused by cardioembolism, which accounts for 5-10% of cases. However, this is unlikely in the absence of atrial fibrillation or significant cardiac disease.

      Small-vessel disease is another possible cause of TIA, but it is unlikely to account for both hemiparesis and visual loss. Giant cell arteritis (GCA) can also be associated with transient visual loss, but hemiparesis is not a feature. Prodromal symptoms such as malaise, weight loss, and characteristic temporal headache are commonly present in GCA.

      In summary, TIA is a serious medical condition that requires prompt evaluation and treatment. Understanding the possible causes of TIA can help healthcare providers make an accurate diagnosis and provide appropriate care.

    • This question is part of the following fields:

      • Ophthalmology
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  • Question 2 - A 16-year-old girl presents with heavy menstrual bleeding since her first period at...

    Incorrect

    • A 16-year-old girl presents with heavy menstrual bleeding since her first period at age 13. She has a history of frequent nosebleeds in childhood. After a normal physical exam and ultrasound, what is the most crucial next step?

      Your Answer:

      Correct Answer: Blood test for coagulation disorder

      Explanation:

      Women who have experienced heavy menstrual bleeding since their first period and have indications of a coagulation disorder in their personal or family medical history should undergo testing for such disorders, including von Willebrand’s disease. This recommendation is made by NICE CG44.

      Understanding Menorrhagia: Causes and Definition

      Menorrhagia is a condition characterized by heavy menstrual bleeding. While it was previously defined as total blood loss exceeding 80 ml per menstrual cycle, the assessment and management of the condition now focuses on the woman’s perception of excessive bleeding and its impact on her quality of life. Dysfunctional uterine bleeding, which occurs in the absence of underlying pathology, is the most common cause of menorrhagia, accounting for about half of all cases. Anovulatory cycles, uterine fibroids, hypothyroidism, pelvic inflammatory disease, and bleeding disorders such as von Willebrand disease are other potential causes of menorrhagia. It is important to note that the use of intrauterine devices, specifically copper coils, may also contribute to heavy menstrual bleeding. However, the intrauterine system (Mirena) is a treatment option for menorrhagia.

    • This question is part of the following fields:

      • Reproductive Medicine
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  • Question 3 - A 62-year-old man has been referred due to a tremor and bradykinesia, leading...

    Incorrect

    • A 62-year-old man has been referred due to a tremor and bradykinesia, leading to a diagnosis of Parkinson's disease. These symptoms are now interfering with his work as an accountant and overall quality of life. What initial treatment is he likely to receive?

      Your Answer:

      Correct Answer: Levodopa

      Explanation:

      Patients with newly diagnosed Parkinson’s who experience motor symptoms that negatively impact their quality of life should be provided with levodopa.

      Management of Parkinson’s Disease: Medications and Considerations

      Parkinson’s disease is a complex condition that requires specialized expertise in movement disorders for diagnosis and management. However, all healthcare professionals should be familiar with the medications used to treat Parkinson’s disease due to its prevalence. The National Institute for Health and Care Excellence (NICE) published guidelines in 2017 to aid in the management of Parkinson’s disease.

      For first-line treatment, levodopa is recommended if motor symptoms are affecting the patient’s quality of life. If motor symptoms are not affecting the patient’s quality of life, dopamine agonists (non-ergot derived), levodopa, or monoamine oxidase B (MAO-B) inhibitors may be used. NICE provides tables to aid in decision-making regarding the use of these medications, taking into account their effects on motor symptoms, activities of daily living, motor complications, and adverse events.

      If a patient continues to have symptoms despite optimal levodopa treatment or has developed dyskinesia, NICE recommends the addition of a dopamine agonist, MAO-B inhibitor, or catechol-O-methyl transferase (COMT) inhibitor as an adjunct. Other considerations in Parkinson’s disease management include the risk of acute akinesia or neuroleptic malignant syndrome if medication is not taken or absorbed, the potential for impulse control disorders with dopaminergic therapy, and the need to adjust medication if excessive daytime sleepiness or orthostatic hypotension develops.

      Specific medications used in Parkinson’s disease management include levodopa, dopamine receptor agonists, MAO-B inhibitors, amantadine, COMT inhibitors, and antimuscarinics. Each medication has its own set of benefits and potential adverse effects, which should be carefully considered when selecting a treatment plan. Overall, the management of Parkinson’s disease requires a comprehensive approach that takes into account the individual needs and circumstances of each patient.

    • This question is part of the following fields:

      • Neurology
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  • Question 4 - A 32-year-old woman with a history of primary generalised epilepsy visits her GP...

    Incorrect

    • A 32-year-old woman with a history of primary generalised epilepsy visits her GP as she intends to conceive. She is currently on lamotrigine as a single therapy. What guidance should be provided to prevent neural tube defects?

      Your Answer:

      Correct Answer: Folic acid 5 mg per day starting now

      Explanation:

      During pregnancy, women with epilepsy should take 5mg of folic acid. Additionally, due to the potential harm of antiepileptic drugs to the fetus, they should receive specialized medical care.

      Pregnancy and breastfeeding can be a concern for women with epilepsy. It is generally recommended that women continue taking their medication during pregnancy, as the risks of uncontrolled seizures outweigh the potential risks to the fetus. However, it is important for women to take folic acid before pregnancy to reduce the risk of neural tube defects. The use of antiepileptic medication during pregnancy can increase the risk of congenital defects, but this risk is still relatively low. It is recommended to aim for monotherapy and there is no need to monitor drug levels. Sodium valproate is associated with neural tube defects, while carbamazepine is considered the least teratogenic of the older antiepileptics. Phenytoin is associated with cleft palate, and lamotrigine may require a dose increase during pregnancy. Breastfeeding is generally safe for mothers taking antiepileptics, except for barbiturates. Pregnant women taking phenytoin should be given vitamin K in the last month of pregnancy to prevent clotting disorders in the newborn.

      A warning has been issued about the use of sodium valproate during pregnancy and in women of childbearing age. New evidence suggests a significant risk of neurodevelopmental delay in children following maternal use of this medication. Therefore, it should only be used if clearly necessary and under specialist neurological or psychiatric advice. It is important for women with epilepsy to discuss their options with their healthcare provider and make informed decisions about their treatment during pregnancy and breastfeeding.

    • This question is part of the following fields:

      • Reproductive Medicine
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  • Question 5 - A 55-year-old woman has been diagnosed as having lung cancer.
    Which of the following...

    Incorrect

    • A 55-year-old woman has been diagnosed as having lung cancer.
      Which of the following statements is the most appropriate?

      Your Answer:

      Correct Answer: Hypercalcaemia may occur without bone metastasis.

      Explanation:

      Paraneoplastic syndromes are a group of disorders that can occur in patients with certain types of cancer, but are not caused by metastases, infections, metabolic disorders, chemotherapy, or coagulation disorders. These syndromes can present with a variety of symptoms affecting different body systems. Some of these syndromes are specific to certain types of cancer and may be the first sign of the disease. Therefore, if a patient presents with symptoms of a paraneoplastic syndrome, it is important to consider the possibility of an underlying malignancy. While certain paraneoplastic syndromes are associated with specific types of cancer, there can be some overlap.

    • This question is part of the following fields:

      • Respiratory Medicine
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  • Question 6 - A 38-year-old woman underwent bowel resection and 48 hours post-operation, she became breathless,...

    Incorrect

    • A 38-year-old woman underwent bowel resection and 48 hours post-operation, she became breathless, tachycardic, tachypnoeic and complained of pleuritic chest pain.
      Which of the following is the most definitive investigation to request?

      Your Answer:

      Correct Answer: CT pulmonary angiogram (CTPA)

      Explanation:

      Diagnostic Tests for Pulmonary Embolism: A Comparison

      Pulmonary embolism (PE) is a serious medical condition that requires prompt diagnosis and treatment. There are several diagnostic tests available for PE, but not all are equally effective. Here, we compare the most commonly used tests and their suitability for diagnosing PE.

      CT pulmonary angiogram (CTPA) is the gold standard diagnostic test for PE. It is highly sensitive and specific, making it the most definitive investigation for PE. Patients with a history of recent surgery and subsequent symptoms pointing towards PE should undergo a CTPA.

      Electrocardiography (ECG) is not a first-line diagnostic test for PE. Although classic ECG changes may occur in some patients with PE, they are not specific to the condition and may also occur in individuals without PE.

      Chest radiograph is less definitive than CTPA for diagnosing PE. While it may show some abnormalities, many chest radiographs are normal in PE. Therefore, it is not a reliable test for diagnosing PE.

      Echocardiogram may show right-sided heart dysfunction in very large PEs, but it is not a first-line diagnostic test for PE and is not definitive in the investigation of PE.

      Positron emission tomography (PET)/CT of the chest is not recommended for the investigation of PE. It is a radioisotope functional imaging technique used in the imaging of tumours and neuroimaging, but not for diagnosing PE.

      In conclusion, CTPA is the most definitive diagnostic test for PE and should be used in patients with a high suspicion of the condition. Other tests may be used in conjunction with CTPA or in specific cases, but they are not as reliable or definitive as CTPA.

    • This question is part of the following fields:

      • Respiratory Medicine
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  • Question 7 - A 12-year-old boy comes to the clinic with a history of headaches for...

    Incorrect

    • A 12-year-old boy comes to the clinic with a history of headaches for the past 6 months. He reports experiencing these headaches once every few weeks, with each episode lasting for a day. Prior to the onset of the headache, he sees zig-zag lines. The headaches are typically on the right side of his head, accompanied by nausea and occasional vomiting. He finds some relief by sleeping in a dark, quiet room. Apart from this, he is healthy.
      What is the initial approach to managing his condition?

      Your Answer:

      Correct Answer: Oral ibuprofen

      Explanation:

      The recommended initial treatment for paediatric migraines is ibuprofen. Sumatriptan nasal spray is only approved for use in children over the age of 12, and oral sumatriptan is not approved for those under 18. Codeine and oramorph are not recommended for treating migraines in children. Indomethacin is also not typically used for paediatric migraines.

      Understanding Headaches in Children

      Headaches are a common occurrence in children, with up to 50% of 7-year-olds and 80% of 15-year-olds experiencing at least one headache. Migraine without aura is the most common cause of primary headache in children, with a strong female preponderance after puberty. The International Headache Society has produced criteria for diagnosing pediatric migraine without aura, which includes headache attacks lasting 4-72 hours, with at least two of four specific features and accompanying symptoms such as nausea and vomiting.

      When it comes to acute management, ibuprofen is considered more effective than paracetamol for pediatric migraine. Triptans may be used in children over 12 years old, but follow-up is required, and only sumatriptan nasal spray is licensed for use in young people. However, oral triptans are not currently licensed for those under 18 years old, and side effects may include tingling, heat, and pressure sensations.

      Prophylaxis for pediatric migraine is limited, with no clear consensus guidelines. Pizotifen and propranolol are recommended as first-line preventatives, while valproate, topiramate, and amitriptyline are considered second-line preventatives. Tension-type headache is the second most common cause of headache in children, with diagnostic criteria including at least 10 previous headache episodes lasting from 30 minutes to 7 days, with specific pain characteristics and the absence of nausea or vomiting.

      In summary, headaches in children are common, and migraine without aura is the most common primary headache. Acute management includes ibuprofen and triptans, while prophylaxis is limited. Tension-type headache is also a common cause of headache in children. It is important to seek medical advice if headaches are frequent or severe, or if there are any concerning symptoms such as neurological deficits or changes in behavior.

    • This question is part of the following fields:

      • Paediatrics
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  • Question 8 - As a physician on an elderly care ward, you are tasked with conducting...

    Incorrect

    • As a physician on an elderly care ward, you are tasked with conducting a cognitive assessment of Harold, an 82-year-old man who is suspected of having dementia. After administering the Addenbrooke's Cognitive Exam-3 (ACE-3), Harold scores 68 out of 100 with a global deficit in all domains tested. Based on this information, what condition do you suspect Harold may have?

      Your Answer:

      Correct Answer: Alzheimer's dementia

      Explanation:

      The Addenbrookes Cognitive Exam (ACE-3) is a reliable tool for detecting dementia, with a score of 82 or less indicating a strong likelihood of dementia. The exam assesses five domains: Memory, Attention, Fluency, Language, and Visuospatial. Alzheimer’s dementia typically results in a global deficit across all domains, with later deficits in memory and attention due to damage in the medial temporal lobe. Frontotemporal dementia primarily affects fluency and language due to damage in the frontal lobe. Vascular dementia deficits vary depending on the location and severity of previous strokes, and there is no consistent pattern seen in ACE-3 examinations. Mild cognitive impairment (MCI) is a precursor to many forms of dementia, with an ACE-3 score of 82-88 indicating MCI. In this scenario, the patient’s score of 68 rules out MCI as a diagnosis.

      Alzheimer’s disease is a type of dementia that gradually worsens over time and is the most common form of dementia in the UK. The risk factors for Alzheimer’s disease include increasing age, family history of the disease, and certain genetic mutations. Inherited forms of the disease are caused by mutations in the amyloid precursor protein, presenilin 1, and presenilin 2 genes. Additionally, the apoprotein E allele E4 and Caucasian ethnicity are also risk factors for Alzheimer’s disease.

      The pathological changes associated with Alzheimer’s disease include widespread cerebral atrophy, particularly in the cortex and hippocampus. Microscopically, cortical plaques and intraneuronal neurofibrillary tangles are present due to the deposition of type A-Beta-amyloid protein and abnormal aggregation of the tau protein. The hyperphosphorylation of the tau protein has been linked to Alzheimer’s disease. Furthermore, there is a deficit of acetylcholine due to damage to an ascending forebrain projection.

      Neurofibrillary tangles are partly made from a protein called tau, which interacts with tubulin to stabilize microtubules and promote tubulin assembly into microtubules. In Alzheimer’s disease, tau proteins are excessively phosphorylated, impairing their function.

    • This question is part of the following fields:

      • Neurology
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  • Question 9 - A 23-year-old woman visits her GP with concerns about UPSI she had four...

    Incorrect

    • A 23-year-old woman visits her GP with concerns about UPSI she had four days ago. She has a medical history of asthma and psoriasis, and is allergic to latex. She uses oral steroids for her asthma but takes no regular medication. You suggest the copper coil as a form of emergency contraception, but the patient prefers a pill and mentions that her housemate recently took the 'EllaOne emergency pill' (ulipristal acetate). Why is the same method not suitable for this patient?

      Your Answer:

      Correct Answer: Asthma controlled by oral steroids

      Explanation:

      When administering ulipristal acetate to individuals with severe asthma who are using oral steroids to control their condition, caution should be exercised due to the anti-glucocorticoid effect of the medication. The possibility of latex allergy should be considered when recommending barrier contraceptive methods or conducting a physical examination while wearing latex gloves. The failure to use regular contraception is a valid reason to offer emergency contraception following unprotected sexual intercourse. The use of ulipristal as emergency contraception may require caution in individuals with psoriasis, as this condition can be managed with oral steroids. However, it is important to note that oral steroids are only recommended for the individual’s asthma.

      Emergency contraception is available in the UK through two methods: emergency hormonal contraception and intrauterine device (IUD). Emergency hormonal contraception includes two types of pills: levonorgestrel and ulipristal. Levonorgestrel works by stopping ovulation and inhibiting implantation, while ulipristal primarily inhibits ovulation. Levonorgestrel should be taken as soon as possible after unprotected sexual intercourse, within 72 hours, and is 84% effective when used within this time frame. The dose should be doubled for those with a BMI over 26 or weight over 70kg. Ulipristal should be taken within 120 hours of intercourse and may reduce the effectiveness of hormonal contraception. The most effective method of emergency contraception is the copper IUD, which can be inserted within 5 days of unprotected intercourse or up to 5 days after the likely ovulation date. It may inhibit fertilization or implantation and is 99% effective regardless of where it is used in the cycle. Prophylactic antibiotics may be given if the patient is at high risk of sexually transmitted infection.

    • This question is part of the following fields:

      • Reproductive Medicine
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  • Question 10 - A 45-year-old woman presents to the clinic with a three-week history of heartburn....

    Incorrect

    • A 45-year-old woman presents to the clinic with a three-week history of heartburn. There is no significant weight loss, no alteration in bowel movements, no nausea, and no difficulty swallowing. Physical examination reveals no abnormalities.
      What is the most appropriate course of action?

      Your Answer:

      Correct Answer: One-month trial of full-dose PPI

      Explanation:

      Management of Dyspepsia in Primary Care: Guidelines and Recommendations

      Dyspepsia is a common complaint in primary care, encompassing a range of symptoms such as epigastric pain, heartburn, acid regurgitation, bloating, nausea, and vomiting. Here are some guidelines and recommendations for managing dyspepsia in primary care:

      One-month trial of full-dose PPI: NICE guidelines recommend offering empirical full-dose PPI therapy for 4 weeks to patients with dyspepsia. Helicobacter pylori testing should also be offered, but a 2-week washout PPI-free period is necessary before testing.

      Helicobater pylori stool test and routine referral for OGD: In young patients with no risk factors and relatively benign history and physical findings, routine referral for an endoscopy or testing for Barrett’s esophagus is not necessary.

      Long-term low-dose PPI: If symptoms recur after initial treatment, offering a PPI at the lowest dose possible to control symptoms would be appropriate. H2 receptor antagonist therapy should be considered if there is an inadequate response to a PPI.

      Refer urgently for OGD: Patients presenting with dyspepsia and significant acute GI bleeding should be referred for same-day assessment to a specialist. Other reasons for urgent referral would be the suspicion of malignancy, which in young patients with no red flag symptoms would be unwarranted.

      Triple therapy for Helicobacter pylori eradication: Testing for Helicobacter pylori should be offered to patients with dyspepsia after a 2-week washout PPI-free period. It would be inappropriate to initiate triple therapy treatment without a positive test result first.

      In summary, dyspepsia in the general population in primary care is defined broadly to include patients with recurrent epigastric pain, heartburn or acid regurgitation, with or without bloating, nausea, or vomiting. Management should follow evidence-based guidelines and recommendations to ensure appropriate and effective treatment.

    • This question is part of the following fields:

      • Gastroenterology/Nutrition
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  • Question 11 - A 32-year-old female patient complains of gradual tingling and numbness in her right...

    Incorrect

    • A 32-year-old female patient complains of gradual tingling and numbness in her right hand's 4th and 5th fingers. The symptoms were occasional at first, but now they are persistent. She observes that the discomfort intensifies when she rests her right elbow on a surface. She remembers hitting her elbow against a door a while back. What is the probable diagnosis?

      Your Answer:

      Correct Answer: Cubital tunnel syndrome

      Explanation:

      Cubital tunnel syndrome is a condition that occurs when the ulnar nerve is compressed, resulting in tingling and numbness in the fourth and fifth fingers.

      The correct answer is cubital tunnel syndrome. The ulnar nerve passes through the cubital tunnel, and when it is compressed, it can cause the symptoms described, such as tingling and numbness in the fourth and fifth fingers. Treatment for this condition may involve conservative measures, but surgery may be necessary in some cases.

      Carpal tunnel syndrome, on the other hand, is caused by compression of the median nerve at the wrist, leading to pain and tingling in the hand and wrist, rather than specific fingers.

      De Quervain’s tenosynovitis presents differently, with pain occurring during movement of the thumb and wrist, and the radial styloid may become thickened and hardened.

      Medial epicondylitis, or golfer’s elbow, causes pain in the medial elbow area, near the cubital tunnel, but it is a tendinopathy rather than nerve compression. The pain is localized to the affected area.

      Understanding Cubital Tunnel Syndrome

      Cubital tunnel syndrome is a condition that occurs when the ulnar nerve is compressed as it passes through the cubital tunnel. This can cause a range of symptoms, including tingling and numbness in the fourth and fifth fingers, which may start off intermittent but eventually become constant. Over time, patients may also experience weakness and muscle wasting. Pain is often worse when leaning on the affected elbow, and there may be a history of osteoarthritis or prior trauma to the area.

      Diagnosis of cubital tunnel syndrome is usually made based on clinical features, although nerve conduction studies may be used in selected cases. Management of the condition typically involves avoiding aggravating activities, undergoing physiotherapy, and receiving steroid injections. In cases where these measures are not effective, surgery may be necessary. By understanding the symptoms and treatment options for cubital tunnel syndrome, patients can take steps to manage their condition and improve their quality of life.

    • This question is part of the following fields:

      • Musculoskeletal
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  • Question 12 - A senior patient presents with congestive heart failure.
    Which of the following drugs may...

    Incorrect

    • A senior patient presents with congestive heart failure.
      Which of the following drugs may be effective in reducing mortality?

      Your Answer:

      Correct Answer: Enalapril

      Explanation:

      Medications for Heart Failure Management

      Heart failure is a serious condition that requires proper management to improve outcomes. Two drugs that have been shown to reduce mortality in heart failure are angiotensin-converting enzyme (ACE) inhibitors and beta blockers. Aspirin, on the other hand, is used to reduce the risk of mortality and further cardiovascular events following myocardial infarction and stroke, but it has no role in heart failure alone.

      Digoxin can be used for short-term rate control for atrial fibrillation, but long-term use should be approached with caution as it may lead to increased mortality. Furosemide is useful in managing symptoms and edema in heart failure, but it has not been shown to have a mortality benefit.

      Lidocaine and other antiarrhythmic agents are only useful when there is arrhythmia associated with heart failure and should only be used with specialist support for ventricular arrhythmias in an unstable patient. Standard drugs such as digitalis and diuretics have not been shown to improve survival rates.

      Studies have shown that reducing left ventricular afterload prolongs survival rates in congestive heart failure. Vasodilators such as ACE inhibitors are effective in inhibiting the formation of angiotensin II, affecting coronary artery tone and arterial wall hyperplasia. There is also evidence for the use of beta blockers in heart failure management.

      In conclusion, proper medication management is crucial in improving outcomes for patients with heart failure. ACE inhibitors, beta blockers, and vasodilators have been shown to reduce mortality rates, while other drugs such as aspirin, digoxin, and furosemide have specific roles in managing symptoms and associated conditions.

    • This question is part of the following fields:

      • Cardiovascular
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  • Question 13 - A 76-year-old man comes to his General Practitioner with one-sided visual loss. During...

    Incorrect

    • A 76-year-old man comes to his General Practitioner with one-sided visual loss. During the examination, a relative afferent pupillary defect is observed. Fundoscopy reveals a 'cherry-red spot' with a red centre of the macula and a pale surrounding of the retina.
      What is the most suitable next step in managing this patient, considering the probable diagnosis?

      Your Answer:

      Correct Answer: Send patient to the Eye Hospital for immediate review by an Ophthalmologist

      Explanation:

      Central Retinal-Artery Occlusion: An Ocular Emergency

      Central retinal-artery occlusion (CRAO) is a serious condition that requires immediate attention from an ophthalmologist. It is diagnosed through a dilated eye examination that reveals a cherry-red spot in the center of the macula, surrounded by pale retina due to lack of blood flow. Other signs include segmentation of the blood column in the arteries and cattle-trucking.

      CRAO is an ocular emergency because the retinal damage becomes irreversible with time, and urgent management is necessary to protect the other eye and the cardiovascular and cerebrovascular systems. The primary goal of management is to re-perfuse ischaemic tissue as quickly as possible and to institute secondary prevention early.

      If giant-cell arteritis is suspected, immediate treatment is necessary, including intravenous steroids followed by oral steroids.

      Referral under the 2-week-wait rule is necessary when there is a suspicion of cancer, but no signs of a tumor from history or fundoscopy findings.

      It is crucial to refer the patient for urgent brain imaging and immediate review by an eye specialist. Starting the patient on topical antibiotics and anti-inflammatories would be inappropriate since there are no signs of an infection process.

    • This question is part of the following fields:

      • Ophthalmology
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  • Question 14 - A 48 year old man presents to the emergency department with acute abdominal...

    Incorrect

    • A 48 year old man presents to the emergency department with acute abdominal pain and feeling unwell. He is typically in good health and enjoys long distance running. His medical history includes a previous finger injury from playing cricket and gallstones that have not caused any issues. During examination, his sclera is noted to be icteric. His heart rate is 106 bpm and his blood pressure is 125/85 mmHg. He has a temperature of 38.1ÂşC. There is significant rebound tenderness and guarding in the right upper quadrant, and his bowel sounds are quiet. What is the most probable diagnosis?

      Your Answer:

      Correct Answer: Ascending cholangitis

      Explanation:

      The man in this scenario is experiencing Charcot’s triad, which includes right upper quadrant pain, fever, and jaundice. These symptoms suggest that he may have ascending cholangitis, which is caused by a bacterial infection in the biliary tree due to obstruction from biliary stasis (likely caused by his gallstones). Treatment involves resuscitation, IV antibiotics, and biliary drainage.

      Understanding Ascending Cholangitis

      Ascending cholangitis is a bacterial infection that affects the biliary tree, with E. coli being the most common culprit. This condition is often associated with gallstones, which can predispose individuals to the infection. Patients with ascending cholangitis may present with Charcot’s triad, which includes fever, right upper quadrant pain, and jaundice. However, this triad is only present in 20-50% of cases. Other common symptoms include hypotension and confusion. In severe cases, Reynolds’ pentad may be observed, which includes the additional symptoms of hypotension and confusion.

      To diagnose ascending cholangitis, ultrasound is typically used as a first-line investigation to look for bile duct dilation and stones. Raised inflammatory markers may also be observed. Treatment involves intravenous antibiotics and endoscopic retrograde cholangiopancreatography (ERCP) after 24-48 hours to relieve any obstruction.

      Overall, ascending cholangitis is a serious condition that requires prompt diagnosis and treatment. Understanding the symptoms and risk factors associated with this condition can help individuals seek medical attention early and improve their chances of a successful recovery.

    • This question is part of the following fields:

      • Gastroenterology/Nutrition
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  • Question 15 - A 27-year-old woman experiences intense vomiting within four hours of consuming lunch at...

    Incorrect

    • A 27-year-old woman experiences intense vomiting within four hours of consuming lunch at a nearby restaurant. What organism is the most probable cause of this reaction?

      Your Answer:

      Correct Answer: Staphylococcus aureus

      Explanation:

      The diagnosis can be inferred as a result of the short incubation period and intense vomiting.

      Gastroenteritis can occur either at home or while traveling, known as travelers’ diarrhea. This condition is characterized by at least three loose to watery stools in 24 hours, accompanied by abdominal cramps, fever, nausea, vomiting, or blood in the stool. The most common cause of travelers’ diarrhea is Escherichia coli. Acute food poisoning is another pattern of illness that results in sudden onset of nausea, vomiting, and diarrhea after ingesting a toxin. Staphylococcus aureus, Bacillus cereus, or Clostridium perfringens are typically responsible for acute food poisoning.

      There are several types of infections that can cause gastroenteritis, each with its own typical presentation. Escherichia coli is common among travelers and causes watery stools, abdominal cramps, and nausea. Giardiasis results in prolonged, non-bloody diarrhea, while cholera causes profuse, watery diarrhea and severe dehydration leading to weight loss. Shigella causes bloody diarrhea, vomiting, and abdominal pain, while Staphylococcus aureus results in severe vomiting with a short incubation period. Campylobacter typically starts with a flu-like prodrome and progresses to crampy abdominal pains, fever, and diarrhea, which may be bloody and mimic appendicitis. Bacillus cereus can cause two types of illness, vomiting within six hours, typically due to rice, or diarrheal illness occurring after six hours. Amoebiasis has a gradual onset of bloody diarrhea, abdominal pain, and tenderness that may last for several weeks.

      The incubation period for gastroenteritis varies depending on the type of infection. Staphylococcus aureus and Bacillus cereus have an incubation period of 1-6 hours, while Salmonella and Escherichia coli have an incubation period of 12-48 hours. Shigella and Campylobacter have an incubation period of 48-72 hours, while Giardiasis and Amoebiasis have an incubation period of more than seven days.

    • This question is part of the following fields:

      • Infectious Diseases
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  • Question 16 - Generalised myositis is a known side effect of certain drugs. Among the options...

    Incorrect

    • Generalised myositis is a known side effect of certain drugs. Among the options listed below, which drug is most likely to cause this side effect?

      Your Answer:

      Correct Answer: Simvastatin

      Explanation:

      Muscle Effects of Common Medications

      Many medications can have effects on muscles, including statins, metoclopramide, amitriptyline, cyclizine, and venlafaxine. Statins can increase the risk of muscle toxicity, especially in patients with a history of muscular disorders, high alcohol intake, renal impairment, or hypothyroidism. Metoclopramide is associated with extrapyramidal symptoms and acute dystonic reactions, but not generalised myositis. Amitriptyline and cyclizine are rarely associated with extrapyramidal symptoms and tremor, and amitriptyline may cause myalgia on drug withdrawal. Venlafaxine commonly causes hypertonia and tremor, and more rarely myoclonus, but not generalised myositis. It is important to be aware of these potential muscle effects when prescribing and monitoring these medications.

      Muscle Effects of Commonly Prescribed Medications

    • This question is part of the following fields:

      • Pharmacology/Therapeutics
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  • Question 17 - You receive a letter from an endocrinology consultant following a referral that you...

    Incorrect

    • You receive a letter from an endocrinology consultant following a referral that you made for a 25 year old gentleman who has been newly diagnosed with hyperthyroidism. The consultant requests that you start the patient on carbimazole 15mg daily with a repeat thyroid function test (TFT) in 4 weeks. What is the most crucial advice to give the patient?

      Your Answer:

      Correct Answer: Attend for urgent medical review if develops any symptoms of infection e.g. sore throat or fever

      Explanation:

      Understanding Carbimazole and Its Mechanism of Action

      Carbimazole is a medication used to manage thyrotoxicosis, a condition characterized by an overactive thyroid gland. It is typically administered in high doses for six weeks until the patient becomes euthyroid, or has a normal thyroid function. The drug works by blocking thyroid peroxidase, an enzyme responsible for coupling and iodinating the tyrosine residues on thyroglobulin, which ultimately reduces thyroid hormone production.

      In contrast to propylthiouracil, another medication used to treat thyrotoxicosis, carbimazole only has a central mechanism of action. Propylthiouracil, on the other hand, also has a peripheral action by inhibiting 5′-deiodinase, an enzyme that reduces peripheral conversion of T4 to T3.

      While carbimazole can be effective in managing thyrotoxicosis, it is not without its adverse effects. One of the most serious side effects is agranulocytosis, a condition characterized by a severe reduction in white blood cells. Additionally, carbimazole can cross the placenta, but may be used in low doses during pregnancy.

      Overall, carbimazole is a medication that can be effective in managing thyrotoxicosis, but it is important to be aware of its mechanism of action and potential adverse effects. Patients should always consult with their healthcare provider before starting any new medication.

    • This question is part of the following fields:

      • Endocrinology/Metabolic Disease
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  • Question 18 - A 65-year-old man presented to the GP surgery multiple times with a persistent...

    Incorrect

    • A 65-year-old man presented to the GP surgery multiple times with a persistent conjunctivitis in one eye. Despite being treated with chloramphenicol and steroid eye drops, the symptoms did not improve. After three weeks, he visited the eye casualty with a constantly teary, painless, and red right eye. Upon examination, it was found that he had decreased visual acuity and mild proptosis in the affected eye. What is the probable diagnosis for this patient?

      Your Answer:

      Correct Answer: Orbital lymphoma

      Explanation:

      If a patient has chronic unilateral conjunctivitis that is not responding to treatment, it could be a sign of orbital lymphoma.

      Orbital lymphoma typically has a slow onset of symptoms, which is why it is the most appropriate answer in this situation. If the red eye persists despite treatment, it is important to investigate further to rule out any serious underlying conditions. The other options listed are not applicable as they are associated with a painful red eye.

      Conjunctivitis is a common eye problem that is often seen in primary care. It is characterized by red, sore eyes with a sticky discharge. There are two types of infective conjunctivitis: bacterial and viral. Bacterial conjunctivitis is identified by a purulent discharge and eyes that may be stuck together in the morning. On the other hand, viral conjunctivitis is characterized by a serous discharge and recent upper respiratory tract infection, as well as preauricular lymph nodes.

      In most cases, infective conjunctivitis is a self-limiting condition that resolves without treatment within one to two weeks. However, topical antibiotic therapy is often offered to patients, such as Chloramphenicol drops given every two to three hours initially or Chloramphenicol ointment given four times a day initially. Alternatively, topical fusidic acid can be used, especially for pregnant women, and treatment is twice daily.

      For contact lens users, topical fluoresceins should be used to identify any corneal staining, and treatment should be the same as above. During an episode of conjunctivitis, contact lenses should not be worn, and patients should be advised not to share towels. School exclusion is not necessary.

    • This question is part of the following fields:

      • Ophthalmology
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  • Question 19 - A 47-year-old man is found to have a blood pressure of 180/110 mmHg...

    Incorrect

    • A 47-year-old man is found to have a blood pressure of 180/110 mmHg on multiple readings. He undergoes investigation for secondary hypertension. Computed tomography (CT) imaging shows a 4.3 cm right-sided adrenal lesion. Below are his blood results. He is listed for elective adrenalectomy.
      Investigation Result Normal reference range
      Plasma free metanephrines 3000 pmol/l 80-510 pmol/l
      Which of the following treatments should be started to commence preparation of this patient for surgery for removal of adrenal phaeochromocytoma?

      Your Answer:

      Correct Answer: Alpha-adrenergic receptor blockers

      Explanation:

      Management of Phaeochromocytoma: Medications and Interventions

      Phaeochromocytoma is a neuroendocrine tumor that secretes adrenaline and noradrenaline, leading to sympathetic stimulation and clinical symptoms such as tachycardia, hypertension, anxiety, diaphoresis, and weight loss. Diagnosis is made through the measurement of catecholamines and metanephrines in plasma or urine. Surgery is required, but patients are at high risk due to potential life-threatening tachycardia and hypertension. The following medications and interventions are used in the management of phaeochromocytoma:

      Alpha-adrenergic receptor blockers: Phenoxybenzamine or doxazosin are used to dampen sympathetic stimulation by blocking alpha-adrenoceptors.

      Beta-adrenergic receptor blockers: Beta-blockers are used after alpha-blockers to avoid unopposed alpha-receptor stimulation, which can cause a hypertensive crisis.

      Calcium channel blockers: These are not commonly used in phaeochromocytoma management but may be used as an antihypertensive in certain populations or as an anti-anginal drug.

      Intravenous fluids: IV fluids should be readily available for all surgeries to address potential blood loss and hypotension following surgery.

      Low-salt diet and low fluid intake: These interventions are not typically used in phaeochromocytoma management but may be used for chronic hypertension or fluid overload.

    • This question is part of the following fields:

      • Endocrinology/Metabolic Disease
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  • Question 20 - An 80-year-old man presents to his GP with difficulty extending his ring and...

    Incorrect

    • An 80-year-old man presents to his GP with difficulty extending his ring and little finger on his left hand. Upon examination, the GP notes thickening of the palm and limited extension of the metacarpophalangeal joints, leading to a diagnosis of Dupuytren's contracture. The patient has a medical history of psoriasis, epilepsy, heart failure, and type 2 diabetes mellitus. Which medication prescribed to the patient is most commonly linked to the development of this condition?

      Your Answer:

      Correct Answer: Phenytoin

      Explanation:

      Phenytoin treatment may lead to the development of Dupuytren’s contracture as a potential adverse effect.

      Understanding Dupuytren’s Contracture

      Dupuytren’s contracture is a condition that affects about 5% of the population. It is more common in older men and those with a family history of the condition. The causes of Dupuytren’s contracture include manual labor, phenytoin treatment, alcoholic liver disease, diabetes mellitus, and trauma to the hand.

      The condition typically affects the ring finger and little finger, causing them to become bent and difficult to straighten. In severe cases, the hand may not be able to be placed flat on a table.

      Surgical treatment may be necessary when the metacarpophalangeal joints cannot be straightened.

    • This question is part of the following fields:

      • Musculoskeletal
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  • Question 21 - A 30-year-old man presents to the General Practitioner (GP) with hypertension which fails...

    Incorrect

    • A 30-year-old man presents to the General Practitioner (GP) with hypertension which fails to fall into the normal range after three successive measurements at the practice nurse. These were 155/92 mmHg, 158/96 mmHg and 154/94 mmHg. He has a past history of some urinary tract infections as a child. The GP arranges some routine blood tests.
      Investigations reveal the following:
      Investigation Result Normal value
      Haemoglobin (Hb) 139 g/l 135–175 g/l
      White cell count (WCC) 5.4 × 109/l 4.0–11.0 × 109/l
      Platelets (PLT) 201 × 109/l 150–400 × 109/l
      Sodium (Na+) 139 mmol/l 135–145 mmol/l
      Potassium (K+) 4.9 mmol/l 3.5–5.0 mmol/l
      Creatinine (Cr) 187 μmol/l 50–120 μmol/l
      Ultrasound scan (USS) Left kidney 8.4 cm and appears scarred.
      Right kidney 10.3 cm
      Which of the following is the most likely diagnosis?

      Your Answer:

      Correct Answer: Chronic reflux nephropathy

      Explanation:

      Differential Diagnosis for a 25-Year-Old Man with Renal Issues

      Upon reviewing the history and test results of a 25-year-old man with renal issues, several potential diagnoses can be considered. Chronic reflux nephropathy appears to be the most likely diagnosis, given the patient’s history of urinary tract infections as a child, ultrasound scan results, and elevated creatinine levels. Further testing, such as renal tract computed tomography and a voiding cystourethrogram, can confirm this diagnosis.

      Essential hypertension, while a risk factor for reno-vascular disease, is unlikely to be the cause of the patient’s symptoms. It would not lead to a rise in creatinine or asymmetrical kidneys in a young patient.

      IgA nephropathy is another potential diagnosis, but the patient’s lack of haematuria or history of recent illness does not support this diagnosis. The history of urinary tract infections also does not align with IgA nephropathy.

      Renal artery stenosis is relatively rare in young patients and would lead to a unilaterally reduced kidney size, which does not fit with the patient’s symptoms.

      White coat hypertension, while a possibility, would not explain the rise in creatinine or the reduced size and scarring of the left kidney. A 24-hour blood pressure monitor may be needed to differentiate between persistent hypertension and white coat hypertension.

      In conclusion, chronic reflux nephropathy is the most likely diagnosis for this patient, but further testing may be necessary to confirm the diagnosis and rule out other potential causes.

    • This question is part of the following fields:

      • Renal Medicine/Urology
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  • Question 22 - A 42-year-old woman presents with complaints of hot flashes and night sweats. Upon...

    Incorrect

    • A 42-year-old woman presents with complaints of hot flashes and night sweats. Upon investigation, her blood work reveals a significantly elevated FSH level, indicating menopause. After discussing her options, she chooses to undergo hormone replacement therapy. What is the primary risk associated with prescribing an estrogen-only treatment instead of a combination estrogen-progestogen treatment?

      Your Answer:

      Correct Answer: Increased risk of endometrial cancer

      Explanation:

      Adverse Effects of Hormone Replacement Therapy

      Hormone replacement therapy (HRT) is a treatment that involves the use of a small dose of oestrogen, often combined with a progestogen in women with a uterus, to alleviate menopausal symptoms. While it can be effective in reducing symptoms such as hot flashes and vaginal dryness, HRT can also have adverse effects and potential complications.

      Some common side-effects of HRT include nausea, breast tenderness, fluid retention, and weight gain. However, there are also more serious potential complications associated with HRT. For example, the use of HRT has been linked to an increased risk of breast cancer, particularly when a progestogen is added. The Women’s Health Initiative study found a relative risk of 1.26 at 5 years of developing breast cancer with HRT use. The risk of breast cancer is also related to the duration of use, and it begins to decline when HRT is stopped.

      Another potential complication of HRT is an increased risk of endometrial cancer. Oestrogen by itself should not be given as HRT to women with a womb, as this can increase the risk of endometrial cancer. The addition of a progestogen can reduce this risk, but it is not eliminated completely. The British National Formulary states that the additional risk is eliminated if a progestogen is given continuously.

      HRT has also been associated with an increased risk of venous thromboembolism (VTE), particularly when a progestogen is added. However, transdermal HRT does not appear to increase the risk of VTE. Women who are at high risk for VTE should be referred to haematology before starting any treatment, even transdermal, according to the National Institute for Health and Care Excellence (NICE).

      Finally, HRT has been linked to an increased risk of stroke and ischaemic heart disease if taken more than 10 years after menopause. It is important for women considering HRT to discuss the potential risks and benefits with their healthcare provider and make an informed decision based on their individual circumstances.

    • This question is part of the following fields:

      • Reproductive Medicine
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  • Question 23 - A 25-year-old male with a history of ankylosing spondylitis presents to the emergency...

    Incorrect

    • A 25-year-old male with a history of ankylosing spondylitis presents to the emergency department with a painful red eye, photophobia, lacrimation, and reduced visual acuity. On examination, an irregularly shaped pupil is noted. What is the most suitable approach to manage this patient's current condition?

      Your Answer:

      Correct Answer: Steroid and cycloplegic (mydriatic) eye drops

      Explanation:

      Anterior uveitis, also known as iritis, is a type of inflammation that affects the iris and ciliary body in the front part of the uvea. It is a common cause of red eye and is associated with HLA-B27, which may also be linked to other conditions. Symptoms of anterior uveitis include sudden onset of eye discomfort and pain, small or irregular pupils, intense sensitivity to light, blurred vision, redness, tearing, and the presence of pus and inflammatory cells in the front part of the eye. This condition may be associated with ankylosing spondylitis, reactive arthritis, ulcerative colitis, Crohn’s disease, Behcet’s disease, and sarcoidosis. Urgent review by an ophthalmologist is necessary, and treatment may involve the use of cycloplegics and steroid eye drops.

    • This question is part of the following fields:

      • Ophthalmology
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  • Question 24 - A 32-year-old woman reports to her community midwife with complaints of failure to...

    Incorrect

    • A 32-year-old woman reports to her community midwife with complaints of failure to lactate, lethargy, dizziness upon standing, and weight loss after a difficult childbirth complicated by placental abruption. What blood test results are expected?

      Your Answer:

      Correct Answer: Decreased cortisol; normal aldosterone

      Explanation:

      Interpreting Cortisol and Aldosterone Levels in Sheehan’s Syndrome

      Sheehan’s syndrome is a condition that results in hypopituitarism, causing reduced production of adrenocorticotropic hormone (ACTH) and secondary adrenal insufficiency. This can lead to decreased cortisol levels, which can cause postural hypotension. However, aldosterone levels remain normal as they are not dependent on pituitary function.

      In rare cases of adrenal adenoma, increased levels of both cortisol and aldosterone may occur, but this does not fit the clinical picture of Sheehan’s syndrome. Similarly, decreased levels of both cortisol and aldosterone would be indicative of primary adrenal insufficiency, which is not the case here.

      An unusual result would be increased cortisol levels with decreased aldosterone levels, which does not fit the clinical picture of hypocortisolism in Sheehan’s syndrome. Conversely, decreased cortisol levels with increased aldosterone levels would also be an unusual result, as aldosterone levels are not typically affected in Sheehan’s syndrome.

      Therefore, when interpreting cortisol and aldosterone levels in a patient with suspected Sheehan’s syndrome, it is important to consider the expected pattern of decreased cortisol levels with normal aldosterone levels.

    • This question is part of the following fields:

      • Endocrinology/Metabolic Disease
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  • Question 25 - A 32-year-old woman is diagnosed with breast cancer. After undergoing a wide local...

    Incorrect

    • A 32-year-old woman is diagnosed with breast cancer. After undergoing a wide local excision, it is discovered that the tumour is oestrogen-receptor positive. To lower the risk of recurrence, she is prescribed tamoxifen as adjuvant treatment. What is the most probable adverse effect she may encounter?

      Your Answer:

      Correct Answer: Hot flushes

      Explanation:

      Hot flushes are a common side effect of tamoxifen, a medication used to treat oestrogen-receptor positive breast cancer by selectively blocking oestrogen receptors. Other side effects are similar to those experienced during menopause due to the systemic blockade of oestrogen receptors. Tamoxifen does not cause deep vein thrombosis (DVT) in itself, but patients taking it are at a higher risk of developing DVT during periods of immobility. Patients with a personal or family history of unprovoked thromboembolism should not start tamoxifen treatment. Tamoxifen increases the risk of developing endometrial cancer over time, but the risk is still lower than that of experiencing hot flushes. Hair thinning, rather than hair loss, is a possible side effect of tamoxifen. Tamoxifen may also cause headaches, including migraines, but this occurs less frequently than hot flushes.

      Tamoxifen: A SERM for Breast Cancer Management

      Tamoxifen is a medication that belongs to the class of Selective oEstrogen Receptor Modulators (SERMs). It works by acting as an antagonist to the oestrogen receptor while also partially agonizing it. This medication is commonly used in the management of breast cancer that is positive for oestrogen receptors. However, tamoxifen can cause some adverse effects such as menstrual disturbances like vaginal bleeding and amenorrhoea, hot flushes, venous thromboembolism, and endometrial cancer. Climacteric side-effects are also common, with 3% of patients stopping tamoxifen due to this reason. Typically, tamoxifen is used for five years after the removal of the tumour. For those who are at risk of endometrial cancer, raloxifene is a better option as it is a pure oestrogen receptor antagonist and carries a lower risk of endometrial cancer.

      Overall, tamoxifen is a useful medication for the management of breast cancer that is positive for oestrogen receptors. However, it is important to be aware of the potential adverse effects that it can cause. Patients who experience any of these side-effects should consult their healthcare provider. Additionally, for those who are at risk of endometrial cancer, raloxifene may be a better option to consider.

    • This question is part of the following fields:

      • Pharmacology/Therapeutics
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  • Question 26 - A mother brings in her 4-week old male baby who was born at...

    Incorrect

    • A mother brings in her 4-week old male baby who was born at 30 weeks. He was discharged from neonatal intensive care unit 2 weeks ago. She reports that for the last 4 days, he has been refusing feed. This morning she noticed that he passed some bloody stools. On examination, the baby has a distended abdomen.
      What is the probable diagnosis?

      Your Answer:

      Correct Answer: Necrotising enterocolitis

      Explanation:

      Feeding intolerance, abdominal distension, and bloody stools are among the early signs of necrotising enterocolitis, which is a high risk for preterm babies. Gastroesophageal reflux disease (GORD) does not cause abdominal distension and bloody stools, while duodenal atresia typically presents with bilious vomiting within the first day of life and does not cause bloody stools. Although hospital-acquired infection is a possibility, given the clinical picture and preterm status, ruling out necrotising enterocolitis should be the priority.

      Understanding Necrotising Enterocolitis

      Necrotising enterocolitis is a serious condition that is responsible for a significant number of premature infant deaths. The condition is characterized by symptoms such as feeding intolerance, abdominal distension, and bloody stools. If left untreated, these symptoms can quickly progress to more severe symptoms such as abdominal discolouration, perforation, and peritonitis.

      To diagnose necrotising enterocolitis, doctors often use abdominal x-rays. These x-rays can reveal a number of important indicators of the condition, including dilated bowel loops, bowel wall oedema, and intramural gas. Other signs that may be visible on an x-ray include portal venous gas, pneumoperitoneum resulting from perforation, and air both inside and outside of the bowel wall. In some cases, an x-ray may also reveal air outlining the falciform ligament, which is known as the football sign.

      Overall, understanding the symptoms and diagnostic indicators of necrotising enterocolitis is crucial for early detection and treatment of this serious condition. By working closely with healthcare professionals and following recommended screening protocols, parents and caregivers can help ensure the best possible outcomes for premature infants at risk for this condition.

    • This question is part of the following fields:

      • Paediatrics
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  • Question 27 - A 28-year-old nulliparous woman presents to the labour suite at 40+6 weeks gestation....

    Incorrect

    • A 28-year-old nulliparous woman presents to the labour suite at 40+6 weeks gestation. She has expressed her desire for a vaginal delivery throughout her pregnancy. On cervical examination, the cervix is found to be in an intermediate position with a firm consistency. Cervical effacement is estimated to be around 30%, and the cervical dilatation is less than 1cm. The fetal head is palpable at the level of the ischial spines, and her bishop score is 3/10. The midwife has already performed a membrane sweep. What is the next step in management?

      Your Answer:

      Correct Answer: Vaginal prostaglandin E2

      Explanation:

      Vaginal PGE2 is the preferred method of induction of labour, with other options such as emergency caesarean section, maternal oxytocin infusion, amniotomy, and cervical ripening balloon being considered only in certain situations. Women undergoing vaginal PGE2 should be aware of the risk of uterine hyperstimulation and may require additional analgesia. The cervix should be reassessed before considering oxytocin infusion. Amniotomy may be used in combination with oxytocin infusion in patients with a ripe cervix. Cervical ripening balloon should not be used as the primary method for induction of labour due to its potential pain, bleeding, and infection risks.

      Induction of Labour: Reasons, Methods, and Complications

      Induction of labour is a medical process that involves starting labour artificially. It is necessary in about 20% of pregnancies due to various reasons such as prolonged pregnancy, prelabour premature rupture of the membranes, diabetes, pre-eclampsia, and rhesus incompatibility. The Bishop score is used to assess whether induction of labour is required, which takes into account cervical position, consistency, effacement, dilation, and fetal station. A score of less than 5 indicates that labour is unlikely to start without induction, while a score of 8 or more indicates that the cervix is ripe and there is a high chance of spontaneous labour or response to interventions made to induce labour.

      There are several methods of induction of labour, including membrane sweep, vaginal prostaglandin E2, maternal oxytocin infusion, amniotomy, and cervical ripening balloon. Membrane sweeping involves separating the chorionic membrane from the decidua by rotating the examining finger against the wall of the uterus. Vaginal prostaglandin E2 is the preferred method of induction of labour, unless there are specific clinical reasons for not using it. Uterine hyperstimulation is the main complication of induction of labour, which refers to prolonged and frequent uterine contractions that can cause fetal hypoxemia and acidemia. In rare cases, uterine rupture may occur, which requires removing the vaginal prostaglandins and stopping the oxytocin infusion if one has been started, and tocolysis with terbutaline.

    • This question is part of the following fields:

      • Reproductive Medicine
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  • Question 28 - A 75-year-old woman with age-related macular degeneration (AMD) presented to the emergency department...

    Incorrect

    • A 75-year-old woman with age-related macular degeneration (AMD) presented to the emergency department with a painless bloodshot right eye. She was very worried about her condition. The previous day, she had received an intravitreal injection for the treatment of AMD. Upon examination, her visual acuity had not decreased further, but there was bleeding under the conjunctiva around the injection site. What is the probable diagnosis?

      Your Answer:

      Correct Answer: Subconjunctival haemorrhage

      Explanation:

      It is important to inform patients about the possibility of developing subconjunctival haemorrhage after receiving intravitreal injections, as it is a common iatrogenic complication. This condition causes a red eye but is not painful and typically resolves within a couple of weeks.

      Understanding Subconjunctival Haemorrhage

      Subconjunctival haemorrhage occurs when blood vessels bleed into the subconjunctival space, usually those that supply the conjunctiva or episclera. Trauma is the most common cause, followed by spontaneous idiopathic cases, Valsalva manoeuvres, and several systemic diseases. Although subconjunctival haemorrhages can look alarming, they are rarely an indicator of anything sinister.

      Subconjunctival haemorrhages are more common in women than in men when there has been no history of trauma. The annual incidence of non-traumatic subconjunctival haemorrhages is 0.6%, and the risk increases with age as the risk factors are more common in elderly patients. Newborns are also more susceptible. The incidence of both traumatic and non-traumatic subconjunctival haemorrhages is 2.6%.

      The most common causes of subconjunctival haemorrhages are trauma and contact lens usage, which are often the sole risk factor in younger patients. Other risk factors include idiopathic causes, Valsalva manoeuvre, hypertension, bleeding disorders, drugs such as aspirin, NSAIDs and anticoagulants, diabetes, arterial disease, and hyperlipidaemia.

      Subconjunctival haemorrhages are mostly asymptomatic, but patients may experience mild irritation. The main sign is a flat, red patch on the conjunctiva with well-defined edges and normal conjunctiva surrounding it. Traumatic haemorrhages are most common in the temporal region, with the inferior conjunctiva as the next most commonly affected area. Vision should be normal, including acuity, visual fields, and range of eye movements. On examination, the fundus should be normal.

      The diagnosis of a subconjunctival haemorrhage is a clinical one. If there is no obvious traumatic cause, check the patient’s blood pressure. If raised, refer the patient appropriately. If the patient is taking warfarin, check the INR. If raised, refer for appropriate adjustments to the dose to bring the INR back into the target range. Recurrent or spontaneous, bilateral subconjunctival haemorrhages warrant investigations for bleeding disorders or other pathology.

      Reassure the patient that subconjunctival haemorrhage is a benign condition that will resolve on its own in 2 to

    • This question is part of the following fields:

      • Ophthalmology
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  • Question 29 - A 55-year-old man presents with sudden-onset back pain radiating down to his feet....

    Incorrect

    • A 55-year-old man presents with sudden-onset back pain radiating down to his feet. He reports weakness in his legs and a tingling sensation around his scrotum. He has experienced urinary incontinence a few times today. Upon examination, he displays decreased power, tone, and sensation in both legs and absent ankle reflexes.
      What is the most probable diagnosis?

      Your Answer:

      Correct Answer: Cauda equina syndrome

      Explanation:

      Differential Diagnosis of Back Pain with Neurological Symptoms

      Back pain with neurological symptoms can be a sign of various conditions. Here are some of the differential diagnoses to consider:

      Cauda Equina Syndrome
      This condition occurs when the lumbar and sacral nerve roots are compressed, leading to bilateral sciatica, neurological deficit in the legs, urinary retention or incontinence, faecal incontinence, and saddle paraesthesia. It is an emergency that requires prompt treatment to prevent irreversible damage to the spinal nerves.

      Guillain–Barré Syndrome (GBS)
      GBS is a rare acute polyneuropathy that causes gradually worsening, ascending muscle weakness, usually starting in the legs and potentially affecting respiratory function. It rarely presents with sensory symptoms, making it an unlikely diagnosis for a patient with acute back pain and sciatica.

      Multiple Sclerosis (MS)
      MS is a chronic inflammatory condition of the central nervous system that leads to demyelination. Patients may present with various neurological symptoms, such as visual disturbance, sensory loss, limb weakness, or urinary symptoms. However, sudden onset of back pain is not a typical feature of MS.

      Subacute Combined Degeneration of the Spinal Cord
      This rare condition is caused by untreated vitamin B12 deficiency and presents with gradually developing symptoms, such as unsteadiness, leg weakness, sensory or visual disturbances, and memory problems. However, lower motor-neurone signs in the legs and acute back pain are not typical features of subacute spinal cord degeneration.

      Urinary-Tract Infection (UTI)
      An upper UTI (pyelonephritis) may cause back or loin pain, rigors, vomiting, and urinary symptoms, such as dysuria, increased urinary frequency, or incontinence. However, bilateral sciatica and lower motor-neurone signs are not typical features of a UTI.

    • This question is part of the following fields:

      • Neurology
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  • Question 30 - A 68-year-old woman comes to your clinic 10 months after a heart attack....

    Incorrect

    • A 68-year-old woman comes to your clinic 10 months after a heart attack. She complains of feeling down, having difficulty concentrating, and loss of appetite since the incident. She attempted online cognitive behavioural therapy but it did not help. She feels that life has lost its meaning and that she is a burden to her family. You decide to initiate treatment with an SSRI. Which medication would be the most suitable to begin with?

      Your Answer:

      Correct Answer: Sertraline

      Explanation:

      After a myocardial infarction, Sertraline is the preferred SSRI due to its extensive research in this patient population compared to other SSRIs. It is important to note that the patient may also be taking antiplatelets and should be cautioned about the potential for dyspepsia and gastrointestinal bleeding. Co-prescribing a proton pump inhibitor should be considered.

      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
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