-
Question 1
Incorrect
-
A 50-year-old woman started treatment for tuberculosis infection 3 months ago and now complains of a burning sensation at the base of her feet. Which medication could be responsible for this new symptom?
Your Answer: Rifampicin
Correct Answer: Isoniazid
Explanation:Isoniazid treatment may lead to a deficiency of vitamin B6, which can result in peripheral neuropathy. This is a well-known side effect of TB medications that is often tested in medical school exams. The patient’s symptoms suggest the possibility of peripheral neuropathy caused by a lack of vitamin B6 due to Isoniazid therapy. Typically, pyridoxine hydrochloride is prescribed concurrently with Isoniazid to prevent peripheral neuropathy.
The Importance of Vitamin B6 in the Body
Vitamin B6 is a type of water-soluble vitamin that belongs to the B complex group. Once it enters the body, it is converted into pyridoxal phosphate (PLP), which acts as a cofactor for various reactions such as transamination, deamination, and decarboxylation. These reactions are essential for the proper functioning of the body.
One of the primary causes of vitamin B6 deficiency is isoniazid therapy, which is a medication used to treat tuberculosis. When the body lacks vitamin B6, it can lead to peripheral neuropathy, which is a condition that affects the nerves outside the brain and spinal cord. It can also cause sideroblastic anemia, which is a type of anemia that affects the production of red blood cells.
Overall, vitamin B6 plays a crucial role in the body, and its deficiency can have severe consequences. It is essential to ensure that the body receives an adequate amount of this vitamin through a balanced diet or supplements.
-
This question is part of the following fields:
- Infectious Diseases
-
-
Question 2
Incorrect
-
A 45-year-old female patient complains of painful erythematous lesions on her shins. Which of the following is not commonly associated with this presentation?
Your Answer: Pregnancy
Correct Answer: Syphilis
Explanation:Erythema nodosum caused by syphilis is uncommon.
Understanding Erythema Nodosum
Erythema nodosum is a condition characterized by inflammation of the subcutaneous fat, resulting in tender, erythematous, nodular lesions. These lesions typically occur over the shins but may also appear on other parts of the body such as the forearms and thighs. The condition usually resolves within six weeks, and the lesions heal without scarring.
There are several possible causes of erythema nodosum, including infections such as streptococci, tuberculosis, and brucellosis. Systemic diseases like sarcoidosis, inflammatory bowel disease, and Behcet’s can also lead to the condition. In some cases, erythema nodosum may be associated with malignancy or lymphoma. Certain drugs like penicillins, sulphonamides, and the combined oral contraceptive pill, as well as pregnancy, can also trigger the condition.
Overall, understanding the causes and symptoms of erythema nodosum is important for prompt diagnosis and treatment.
-
This question is part of the following fields:
- Dermatology
-
-
Question 3
Incorrect
-
A 56-year-old construction worker comes in for evaluation. He has a history of osteoarthritis in his hands but no other significant medical history. Despite taking paracetamol regularly, he is still experiencing significant pain, particularly in the base of his thumbs. What would be the most appropriate next step in his management?
Your Answer: Add oral diclofenac + lansoprazole
Correct Answer: Add topical ibuprofen
Explanation:According to the 2008 NICE guidelines, the initial treatment for osteoarthritis should involve the administration of paracetamol and topical NSAIDs, particularly for knee and hand joints.
The Role of Glucosamine in Osteoarthritis Management
Osteoarthritis (OA) is a common condition that affects the joints, causing pain and stiffness. The National Institute for Health and Care Excellence (NICE) published guidelines in 2014 on the management of OA, which includes non-pharmacological and pharmacological treatments. Glucosamine, a normal constituent of glycosaminoglycans in cartilage and synovial fluid, has been studied for its potential benefits in OA management.
Several double-blind randomized controlled trials (RCTs) have reported significant short-term symptomatic benefits of glucosamine in knee OA, including reduced joint space narrowing and improved pain scores. However, more recent studies have produced mixed results. The 2008 NICE guidelines do not recommend the use of glucosamine, and a 2008 Drug and Therapeutics Bulletin review advised against prescribing it on the NHS due to limited evidence of cost-effectiveness.
Despite the conflicting evidence, some patients may still choose to use glucosamine as a complementary therapy for OA management. It is important for healthcare professionals to discuss the potential benefits and risks of glucosamine with their patients and to consider individual patient preferences and circumstances.
-
This question is part of the following fields:
- Musculoskeletal
-
-
Question 4
Correct
-
A 16-year-old girl comes to your clinic complaining of lower abdominal pain during her menstrual cycle for the past 6 months. The pain usually begins 1-2 hours after the start of her period and subsides after 1-2 days. She reports that her period is not abnormally heavy, and she is not sexually active at the moment. What is the best course of action for managing her symptoms?
Your Answer: Start mefenamic acid
Explanation:The initial treatment for primary dysmenorrhoea, which this girl is experiencing, is NSAIDs like mefenamic acid. There is no need for gynaecological investigation at this point. If mefenamic acid does not work, she could consider taking the combined oral contraceptive pill, but since she is not sexually active, it may not be necessary. Tranexamic acid is helpful for menorrhagia, but it will not alleviate pain. A transvaginal ultrasound scan is not necessary for primary dysmenorrhoea.
Dysmenorrhoea is a condition where women experience excessive pain during their menstrual period. There are two types of dysmenorrhoea: primary and secondary. Primary dysmenorrhoea affects up to 50% of menstruating women and is not caused by any underlying pelvic pathology. It usually appears within 1-2 years of the menarche and is thought to be partially caused by excessive endometrial prostaglandin production. Symptoms include suprapubic cramping pains that may radiate to the back or down the thigh, and pain typically starts just before or within a few hours of the period starting. NSAIDs such as mefenamic acid and ibuprofen are effective in up to 80% of women, and combined oral contraceptive pills are used second line for management.
Secondary dysmenorrhoea, on the other hand, typically develops many years after the menarche and is caused by an underlying pathology. The pain usually starts 3-4 days before the onset of the period. Causes of secondary dysmenorrhoea include endometriosis, adenomyosis, pelvic inflammatory disease, intrauterine devices, and fibroids. Clinical Knowledge Summaries recommend referring all patients with secondary dysmenorrhoea to gynaecology for investigation. It is important to note that the intrauterine system (Mirena) may help dysmenorrhoea, but this only applies to normal copper coils.
-
This question is part of the following fields:
- Reproductive Medicine
-
-
Question 5
Correct
-
A 44 year old patient is undergoing quadruple therapy (rifampicin, isoniazid, ethambutol and pyrazinamide) for a confirmed diagnosis of pulmonary tuberculosis. During a respiratory follow up, the patient reports a decline in vision, particularly a decrease in the vibrancy of colors. What modification would you suggest for the medication?
Your Answer: Stop ethambutol
Explanation:The use of ethambutol has been linked to optic neuropathy and the onset of color blindness. If these symptoms occur, the medication should be stopped. To prevent these adverse effects, pyridoxine (vitamin B6) is often administered alongside ethambutol in medical settings.
Side-Effects and Mechanism of Action of Tuberculosis Drugs
Rifampicin is a drug that inhibits bacterial DNA dependent RNA polymerase, which prevents the transcription of DNA into mRNA. However, it is a potent liver enzyme inducer and can cause hepatitis, orange secretions, and flu-like symptoms.
Isoniazid, on the other hand, inhibits mycolic acid synthesis. It can cause peripheral neuropathy, which can be prevented with pyridoxine (Vitamin B6). It can also cause hepatitis and agranulocytosis. Additionally, it is a liver enzyme inhibitor.
Pyrazinamide is converted by pyrazinamidase into pyrazinoic acid, which in turn inhibits fatty acid synthase (FAS) I. However, it can cause hyperuricaemia, leading to gout, as well as arthralgia, myalgia, and hepatitis.
Lastly, Ethambutol inhibits the enzyme arabinosyl transferase, which polymerizes arabinose into arabinan. It can cause optic neuritis, so it is important to check visual acuity before and during treatment. Additionally, the dose needs adjusting in patients with renal impairment.
In summary, these tuberculosis drugs have different mechanisms of action and can cause various side-effects. It is important to monitor patients closely and adjust treatment accordingly to ensure the best possible outcomes.
-
This question is part of the following fields:
- Pharmacology/Therapeutics
-
-
Question 6
Correct
-
A 72-year-old male presents to the emergency department with complaints of new-onset pain in his left groin. Upon examination, a large, warm, non-reducible mass located inferolateral to the pubic tubercle is observed, accompanied by erythema of the overlying skin. The patient reports vomiting twice and passing stools with blood mixed in them once. He appears to be in pain and is sweating profusely. His medical history includes peptic ulcer disease, which is managed with omeprazole. What is the most likely diagnosis?
Your Answer: Strangulated femoral hernia
Explanation:A femoral hernia can lead to the serious complication of strangulation. In this case, the patient has a non-reducible mass located below the pubic tubercle, which is typical of a femoral hernia. However, the accompanying symptoms of vomiting, bloody stools, and a toxic appearance suggest that the hernia has become strangulated, meaning that the blood supply to the herniated tissue has been compromised and may lead to tissue death.
An incarcerated femoral hernia would also present as a non-reducible mass below the pubic tubercle, but without the symptoms of strangulation.
In contrast, an incarcerated inguinal hernia would present as a non-reducible mass above and towards the middle of the pubic tubercle, and would not cause symptoms of strangulation.
A perforated peptic ulcer would cause pain in the upper abdomen, syncope, and possibly vomiting blood, which is different from the patient’s symptoms.
Similarly, a strangulated inguinal hernia would cause similar symptoms, but the mass would be located above and towards the middle of the pubic tubercle, rather than below it.
Understanding Femoral Hernias
Femoral hernias occur when a part of the bowel or other abdominal organs pass through the femoral canal, which is a potential space in the anterior thigh. This can result in a lump in the groin area that is mildly painful and typically non-reducible. Femoral hernias are less common than inguinal hernias, accounting for only 5% of abdominal hernias, and are more prevalent in women, especially those who have had multiple pregnancies. Diagnosis is usually clinical, but ultrasound may be used to confirm the presence of a femoral hernia and exclude other possible causes of a lump in the groin area.
Complications of femoral hernias include incarceration, where the herniated tissue cannot be reduced, and strangulation, which is a surgical emergency. The risk of strangulation is higher with femoral hernias than with inguinal hernias and increases over time. Bowel obstruction and bowel ischaemia may also occur, leading to significant morbidity and mortality for the patient.
Surgical repair is necessary for femoral hernias, and it can be done laparoscopically or via a laparotomy. Hernia support belts or trusses should not be used for femoral hernias due to the risk of strangulation. In an emergency situation, a laparotomy may be the only option. It is essential to distinguish femoral hernias from inguinal hernias, as they have different locations and require different management approaches.
-
This question is part of the following fields:
- Gastroenterology/Nutrition
-
-
Question 7
Correct
-
A 42-year-old woman presents with a sudden onset of vision loss in her left eye. She reports experiencing pain with eye movement and a decrease in colour vision. She has no significant medical history and is not taking any medications.
During the examination, her left eye has a visual acuity of 6/6 while her right eye has a visual acuity of 6/24. A relative afferent pupillary defect is observed in her left eye, and visual field testing reveals a central scotoma in the left eye.
What is the most probable cause of her symptoms?Your Answer: Optic neuritis
Explanation:A central scotoma is a common feature of optic neuritis, along with visual loss, periocular pain, and dyschromatopsia (change in colour perception). Other classic signs on examination include a relative afferent pupillary defect. Unlike open-angle glaucoma, which typically causes painless, gradual loss of peripheral vision, optic neuritis often affects the central vision. Anterior ischaemic optic neuropathy, on the other hand, causes sudden, painless loss of vision and is more common in people over 50. Optic nerve glioma, which is rare after age 20 and may be associated with neurofibromatosis, can cause visual defects and headaches but is not typically associated with eye movement pain or colour desaturation.
Optic neuritis is a condition that can be caused by multiple sclerosis, diabetes, or syphilis. It is characterized by a decrease in visual acuity in one eye over a period of hours or days, as well as poor color discrimination and pain that worsens with eye movement. Other symptoms include a relative afferent pupillary defect and a central scotoma. The condition can be diagnosed through an MRI of the brain and orbits with gadolinium contrast. Treatment typically involves high-dose steroids, and recovery usually takes 4-6 weeks. If an MRI shows more than three white-matter lesions, the risk of developing multiple sclerosis within five years is approximately 50%.
-
This question is part of the following fields:
- Ophthalmology
-
-
Question 8
Correct
-
A 56-year-old woman presents to the emergency department with symptoms of malaise and diarrhoea. She reports feeling shivery and achy for the past 3 days and has had 4 watery stools in the past 24 hours. The patient has a history of breast cancer and is currently undergoing chemotherapy. Her last dose of doxorubicin and cyclophosphamide was administered 10 days ago. She has no known allergies and takes no other medications. On examination, her heart rate is 103/min, respiratory rate is 20/min with saturations of 100% in room air, blood pressure is 100/79 mmHg, and temperature is 39.1ÂșC.
What is the initial management approach for this patient while awaiting the results of her blood culture?Your Answer: Piperacillin with tazobactam (tazocin)
Explanation:The recommended empirical antibiotic for managing neutropenic sepsis is Piperacillin with tazobactam (Tazocin). This is because the patient is displaying symptoms such as malaise, diarrhoea, flu-like aching, mild tachycardia, and a temperature >38ÂșC, and has a history of chemotherapy within the past 7-14 days. As the patient has no allergies, Tazocin should be administered until blood cultures show a specific sensitivity. Amoxicillin is not effective in treating neutropenic sepsis as it is not broad-spectrum enough. Meropenem is only indicated in patients with previous or suspected ESBL, acute leukaemia, or allogeneic stem cell transplants, and is not recommended as first-line treatment according to NICE guidelines. Teicoplanin is recommended for patients with penicillin or beta-lactam allergies and evidence of neutropenic sepsis, but should be used in combination with another non-penicillin antibiotic as per local guidelines. Vancomycin is an alternative for penicillin-allergic patients, and should be administered with gentamicin, ciprofloxacin, or amikacin depending on local guidelines and the severity of the patient’s presentation.
Neutropenic Sepsis: A Common Complication of Cancer Therapy
Neutropenic sepsis is a frequent complication of cancer therapy, particularly chemotherapy. It typically occurs within 7-14 days after chemotherapy and is characterized by a neutrophil count of less than 0.5 * 109 in patients undergoing anticancer treatment who exhibit a temperature higher than 38ÂșC or other signs or symptoms consistent with clinically significant sepsis.
To prevent neutropenic sepsis, patients who are likely to have a neutrophil count of less than 0.5 * 109 as a result of their treatment should be offered a fluoroquinolone. In the event of neutropenic sepsis, antibiotics must be initiated immediately, without waiting for the white blood cell count.
According to NICE guidelines, empirical antibiotic therapy should begin with piperacillin with tazobactam (Tazocin) immediately. While some units may add vancomycin if the patient has central venous access, NICE does not support this approach. After initial treatment, patients are typically assessed by a specialist and risk-stratified to determine if they may be able to receive outpatient treatment.
If patients remain febrile and unwell after 48 hours, an alternative antibiotic such as meropenem may be prescribed, with or without vancomycin. If patients do not respond after 4-6 days, the Christie guidelines suggest ordering investigations for fungal infections (e.g. HRCT) rather than blindly initiating antifungal therapy. In selected patients, G-CSF may be beneficial.
-
This question is part of the following fields:
- Infectious Diseases
-
-
Question 9
Correct
-
A 28-year-old man undergoes surgical resection of the terminal ileum for stricturing Crohn's disease. His gastroenterologist decides to begin azathioprine for remission maintenance after the surgery. What is the crucial enzyme level to test before starting this treatment?
Your Answer: Thiopurine S-methyltransferase (TPMT)
Explanation:Azathioprine is a medication that is broken down into mercaptopurine, which is an active compound that inhibits the production of purine. To determine if someone is at risk for azathioprine toxicity, a test for thiopurine methyltransferase (TPMT) may be necessary. Adverse effects of this medication include bone marrow depression, which can be detected through a full blood count if there are signs of infection or bleeding, as well as nausea, vomiting, pancreatitis, and an increased risk of non-melanoma skin cancer. It is important to note that there is a significant interaction between azathioprine and allopurinol, so lower doses of azathioprine should be used in conjunction with allopurinol. Despite these potential side effects, azathioprine is generally considered safe to use during pregnancy.
-
This question is part of the following fields:
- Musculoskeletal
-
-
Question 10
Correct
-
A 26-year-old woman presents to her GP with worsening lower abdominal pain over the past 48 hours. The pain is located in the suprapubic area and slightly to the left. She experienced some vaginal bleeding this morning, which she describes as light. The patient also reports shoulder pain that started after playing tennis. Her last menstrual period was seven weeks ago and was normal. She has a history of Chlamydia infection and admits to not practicing safe sex. On examination, she is tender in the left iliac fossa. Her blood pressure is 98/62 mmHg, and her pulse is 100/min. What is the most likely diagnosis?
Your Answer: Ruptured ectopic pregnancy
Explanation:Ectopic pregnancy presents with amenorrhoea, abdominal pain, vaginal bleeding, and shoulder tip pain indicating peritoneal bleeding.
Understanding Ectopic Pregnancy
Ectopic pregnancy occurs when a fertilized egg implants outside the uterus. This condition is characterized by lower abdominal pain and vaginal bleeding, typically occurring 6-8 weeks after the start of the last period. The pain is usually constant and may be felt on one side of the abdomen due to tubal spasm. Vaginal bleeding is usually less than a normal period and may be dark brown in color. Other symptoms may include shoulder tip pain, pain on defecation/urination, dizziness, fainting, or syncope. Breast tenderness may also be reported.
During examination, abdominal tenderness and cervical excitation may be observed. However, it is not recommended to examine for an adnexal mass due to the risk of rupturing the pregnancy. Instead, a pelvic examination to check for cervical excitation is recommended. In cases of pregnancy of unknown location, serum bHCG levels >1,500 may indicate an ectopic pregnancy. It is important to seek medical attention immediately if ectopic pregnancy is suspected as it can be life-threatening.
-
This question is part of the following fields:
- Reproductive Medicine
-
-
Question 11
Correct
-
A 35-year-old female patient complains of indigestion for the past three months. She denies any weight loss, anorexia, dysphagia, vomiting, or alteration in bowel habits. Her abdominal examination is normal. What factor could potentially reduce the reliability of a 13C-urea breath test?
Your Answer: Course of amoxicillin stopping 3 weeks ago
Explanation:To undergo a urea breath test, one must not have taken antibiotics within the last four weeks and must not have taken any antisecretory drugs, such as PPI, within the last two weeks.
Tests for Helicobacter pylori
There are several tests available to diagnose Helicobacter pylori infection. One of the most common tests is the urea breath test, where patients consume a drink containing carbon isotope 13 (13C) enriched urea. The urea is broken down by H. pylori urease, and after 30 minutes, the patient exhales into a glass tube. Mass spectrometry analysis calculates the amount of 13C CO2, which indicates the presence of H. pylori. However, this test should not be performed within four weeks of treatment with an antibacterial or within two weeks of an antisecretory drug.
Another test is the rapid urease test, also known as the CLO test. This involves mixing a biopsy sample with urea and a pH indicator. If there is a color change, it indicates the presence of H. pylori urease activity. Serum antibody tests can also be used, but they remain positive even after eradication. Culture of gastric biopsy can provide information on antibiotic sensitivity, while histological evaluation alone can be done through gastric biopsy. Lastly, the stool antigen test has a sensitivity of 90% and specificity of 95%.
Overall, these tests have varying levels of sensitivity and specificity, and the choice of test depends on the patient’s clinical presentation and the availability of resources.
-
This question is part of the following fields:
- Gastroenterology/Nutrition
-
-
Question 12
Correct
-
A 57-year-old man with no significant medical history is hospitalized after experiencing an ischemic stroke. He arrived outside of the thrombolysis window and is given aspirin for the first few days. His blood pressure is 130/80 mmHg, fasting glucose is 5.6 mmol/l, and fasting cholesterol is 3.9 mmol/l. He makes a remarkable recovery and is discharged with almost all of his previous functions restored. According to the latest NICE guidelines, what medication should he be prescribed upon discharge (i.e. after 14 days)?
Your Answer: Clopidogrel + statin
Explanation:The Royal College of Physicians (RCP) and NICE have published guidelines on the diagnosis and management of patients following a stroke. The management of acute stroke includes maintaining normal levels of blood glucose, hydration, oxygen saturation, and temperature. Blood pressure should not be lowered in the acute phase unless there are complications. Aspirin should be given as soon as possible if a haemorrhagic stroke has been excluded. Anticoagulants should not be started until brain imaging has excluded haemorrhage. Thrombolysis with alteplase should only be given if administered within 4.5 hours of onset of stroke symptoms and haemorrhage has been definitively excluded. Mechanical thrombectomy is a new treatment option for patients with an acute ischaemic stroke. NICE recommends thrombectomy for people who have acute ischaemic stroke and confirmed occlusion of the proximal anterior circulation demonstrated by computed tomographic angiography or magnetic resonance angiography. Secondary prevention includes the use of clopidogrel and dipyridamole. Carotid artery endarterectomy should only be considered if carotid stenosis is greater than 70% according to ECST criteria or greater than 50% according to NASCET criteria.
-
This question is part of the following fields:
- Neurology
-
-
Question 13
Correct
-
An 80-year-old man visits a memory clinic accompanied by his daughter. He has a medical history of hypertension and is a former smoker. The daughter reports that he had been stable for several months before experiencing sudden declines on multiple occasions. The physical examination is normal, and his MoCA score is 18 out of 30. He denies experiencing any visual or auditory hallucinations. What is the probable underlying diagnosis?
Your Answer: Vascular dementia
Explanation:The gradual decline in cognitive function, along with hypertension and smoking as risk factors for cerebrovascular disease, suggest a diagnosis of vascular dementia. This type of dementia is caused by damage to the brain from reduced blood flow or bleeding due to cerebrovascular disease. In contrast, Alzheimer’s dementia progresses slowly over time, while frontotemporal dementia affects personality, behavior, language, and attention. Lewy body dementia is characterized by hallucinations and Parkinsonian symptoms, while Parkinson’s dementia occurs in patients with Parkinson’s disease and affects their mental function and memory, along with physical signs of PD.
Understanding Vascular Dementia: Causes, Symptoms, and Management
Vascular dementia is a type of cognitive impairment that is caused by different mechanisms resulting from cerebrovascular disease. It is the second most common form of dementia after Alzheimer’s disease. Vascular dementia is often recognized as the most severe form of the spectrum of deficits encompassed by the term vascular cognitive impairment. Early detection and an accurate diagnosis are crucial in preventing vascular dementia.
The prevalence of vascular dementia is estimated to be around 17% of dementia cases in the UK. The incidence of vascular dementia increases with age and is often associated with a history of stroke or transient ischemic attack, atrial fibrillation, hypertension, diabetes mellitus, hyperlipidemia, smoking, obesity, coronary heart disease, and a family history of stroke or cardiovascular disease. Rarely, vascular dementia can be inherited as in the case of cerebral autosomal dominant arteriopathy with subcortical infarcts and leukoencephalopathy.
Patients with vascular dementia typically present with a sudden or stepwise deterioration of cognitive function, focal neurological abnormalities, difficulty with attention and concentration, seizures, memory disturbance, gait disturbance, speech disturbance, and emotional disturbance. Diagnosis is made based on a comprehensive history and physical examination, formal screening for cognitive impairment, medical review to exclude medication cause of cognitive decline, and MRI scan.
Treatment for vascular dementia is mainly symptomatic with the aim to address individual problems and provide support to the patient and carers. It is important to detect and address cardiovascular risk factors to slow down the progression of the disease. Non-pharmacological management is tailored to the individual and may include cognitive stimulation programs, multisensory stimulation, music and art therapy, and animal-assisted therapy. Pharmacological management is limited, and there is no specific pharmacological treatment approved for cognitive symptoms. Only consider AChE inhibitors or memantine for people with vascular dementia if they have suspected comorbid Alzheimer’s disease, Parkinson’s disease dementia, or dementia with Lewy bodies. There is no evidence that aspirin is effective in treating patients with a diagnosis of vascular dementia, and no randomized trials have evaluated statins for vascular dementia.
-
This question is part of the following fields:
- Neurology
-
-
Question 14
Incorrect
-
A 72-year-old woman presents to her General Practitioner for review, two months after being discharged from hospital. She has hypothyroidism, maintained on 75 ”g levothyroxine once a day. Following discharge, she also began taking amlodipine, amitriptyline, ferrous fumarate and ranitidine.
Investigations reveal that her thyroid-stimulating hormone (TSH) level is 9.1 mU/l (normal range: 0.25â4.0 mU/l), while her free thyroxine (T4) is 8.1 pmol/l (normal range: 12.0â22.0 pmol/l).
She is compliant with her medications and takes them all together in the morning.
Which of the following is the most likely cause of this patientâs results?
Your Answer: Ranitidine
Correct Answer: Ferrous fumarate
Explanation:Interactions with Levothyroxine: Understanding the Effects of Different Medications
Levothyroxine is a medication used to treat hypothyroidism, a condition where the thyroid gland does not produce enough thyroid hormone. However, certain medications can interact with levothyroxine and affect its absorption and effectiveness. Let’s explore the effects of different medications on levothyroxine and how they can impact thyroid function tests.
Ferrous Fumarate: Iron salts can reduce the absorption of levothyroxine, leading to inadequate replacement and hypothyroidism. It is recommended to take these medications at least four hours apart to avoid this interaction.
Amitriptyline: While thyroid hormones can enhance the effect of amitriptyline, this medication does not reduce the effect of levothyroxine and would not cause hypothyroidism.
Amlodipine: There is no interaction between amlodipine and levothyroxine, and this medication would not affect thyroid function tests.
Aspirin: Similarly, there is no interaction between aspirin and levothyroxine, and the use of this medication would not impact thyroid function tests.
Ranitidine: While antacids can reduce levothyroxine absorption, ranitidine is an H2 receptor antagonist and not classified as an antacid. Therefore, there is no interaction between ranitidine and levothyroxine.
In conclusion, it is important to be aware of potential interactions between medications and levothyroxine to ensure adequate treatment of hypothyroidism. By understanding the effects of different medications, healthcare professionals can make informed decisions and adjust medication schedules as needed.
-
This question is part of the following fields:
- Endocrinology/Metabolic Disease
-
-
Question 15
Correct
-
A 35-year-old man presents with symptoms of depression, difficulty sleeping, and a strong desire for sugary foods during the winter months. He reports that his symptoms are more severe in the winter than in the summer. He has no history of other mental health issues or physical problems. What is the most probable diagnosis?
Your Answer: Seasonal affective disorder (SAD)
Explanation:Differentiating Seasonal Affective Disorder from Other Depressive Disorders
Seasonal affective disorder (SAD) is a type of depression that occurs in a regular temporal pattern, typically beginning in autumn or winter and ending in spring or summer. Unlike classic major depression, SAD is characterized by symptoms of hyperphagia, hypersomnia, and weight gain. The cause of SAD is believed to be a malfunction of the light-sensitive hormone melatonin during winter. Treatment involves phototherapy, which exposes individuals to bright light for several hours a day.
Reactive depression, on the other hand, is a subtype of major depression that occurs as a result of an external event, such as a relationship breakdown or bereavement. There is no indication of a stressful life event in the presented vignette.
Bipolar affective disorder is characterized by distinct episodes of depression and mania, which is not evident in the vignette. Dysthymia is a persistent depression of mood that does not fully meet the criteria for a diagnosis of major depression and does not have a definite seasonal variation like SAD.
Finally, double depression occurs when one or more episodes of major depression occur on a background of dysthymia. It is important to differentiate SAD from other depressive disorders to provide appropriate treatment and management.
-
This question is part of the following fields:
- Psychiatry
-
-
Question 16
Correct
-
A 32-year-old man presents to the neurology clinic with primary generalised epilepsy and is currently taking sodium valproate. Despite being on a therapeutic dose, he is still experiencing seizures and has also noticed weight gain since starting the medication. He expresses a desire to discontinue the current drug and try an alternative. What would be the most suitable second-line treatment option?
Your Answer: Lamotrigine
Explanation:Before starting combination therapy, it is advisable to first try monotherapy with a different drug. When combining sodium valproate and lamotrigine, it is important to be cautious as it may lead to the development of severe skin rashes like Steven-Johnson’s syndrome.
Treatment for Epilepsy
Epilepsy is a neurological disorder that affects millions of people worldwide. The condition is characterized by recurrent seizures, which can be debilitating and life-threatening. Treatment for epilepsy typically involves the use of antiepileptic drugs (AEDs) to control seizures and improve quality of life.
According to NICE guidelines, AEDs should be started after the second epileptic seizure. However, if a patient has a neurological deficit, brain imaging shows a structural abnormality, the EEG shows unequivocal epileptic activity, or the patient or their family considers the risk of having a further seizure unacceptable, AEDs may be started after the first seizure. It is important to note that sodium valproate should not be used during pregnancy and in women of childbearing age unless clearly necessary due to the risk of neurodevelopmental delay in children.
The choice of AEDs depends on the type of epilepsy. For generalized tonic-clonic seizures, males are typically prescribed sodium valproate, while females are prescribed lamotrigine or levetiracetam. For focal seizures, lamotrigine or levetiracetam are the first-line treatments, with carbamazepine, oxcarbazepine, or zonisamide as second-line options. Ethosuximide is the first-line treatment for absence seizures, with sodium valproate or lamotrigine/levetiracetam as second-line options. For myoclonic seizures, males are prescribed sodium valproate, while females are prescribed levetiracetam. Finally, for tonic or atonic seizures, males are prescribed sodium valproate, while females are prescribed lamotrigine.
In summary, treatment for epilepsy involves the use of AEDs to control seizures and improve quality of life. The choice of AEDs depends on the type of epilepsy, and sodium valproate should be used with caution in women of childbearing age.
-
This question is part of the following fields:
- Neurology
-
-
Question 17
Correct
-
A 27-year-old woman comes to her General Practitioner complaining of urinary frequency, dysuria, suprapubic pain and back pain. Her symptoms have been getting worse over the past 48 hours. On examination, she has a normal temperature, blood pressure and heart rate. A urine dipstick test shows positive results for leukocytes and nitrites but negative for blood. She is typically healthy and not taking any medications. This is her first time experiencing symptoms of a urinary tract infection. What would be the most appropriate initial investigation to arrange for this patient? Choose the SINGLE most likely option.
Your Answer: Urinary microscopy and culture
Explanation:Appropriate Investigations for Suspected Urinary Tract Infection
When a patient presents with symptoms suggestive of a urinary tract infection or pyelonephritis, the most appropriate investigation to arrange is urinary microscopy and culture. It is important to obtain a sample before starting empirical antibiotics, as this can guide subsequent antibiotic choice if the patient does not respond to the initial course. Recurrent episodes may require further investigation or referral to secondary care. Blood tests may be useful if the patient is unwell or has evidence of sepsis. However, a computed tomography of the kidneys, ureters, and bladder (CTKUB) would not be useful in this situation. Cystoscopy may be indicated for recurrent infections or unexplained bleeding, but not for a first episode. An urgent ultrasound of the renal tract may be useful to look for obstruction or anatomical abnormalities, but is not necessary for treatment. Inflammatory markers can be helpful, but urinary microscopy and culture are more appropriate in this situation.
-
This question is part of the following fields:
- Renal Medicine/Urology
-
-
Question 18
Correct
-
A 25-year-old female complains of ankle pain after twisting it during a game of basketball. What is the least significant factor to consider when determining if an x-ray is necessary?
Your Answer: Swelling immediately after the injury and now
Explanation:Ottawa Rules for Ankle Injuries
The Ottawa Rules provide a guideline for determining whether an ankle x-ray is necessary after an injury. These rules have a sensitivity approaching 100%, meaning they are highly accurate. An ankle x-ray is only required if there is pain in the malleolar zone and one of the following findings: bony tenderness at the lateral malleolar zone or medial malleolar zone, or inability to walk four weight-bearing steps immediately after the injury and in the emergency department.
The lateral malleolar zone is from the tip of the lateral malleolus to include the lower 6 cm of the posterior border of the fibular, while the medial malleolar zone is from the tip of the medial malleolus to the lower 6 cm of the posterior border of the tibia. These rules help healthcare professionals determine whether an ankle x-ray is necessary, which can save time and resources. It is important to note that there are also Ottawa rules available for foot and knee injuries. By following these guidelines, healthcare professionals can provide efficient and effective care for ankle injuries.
-
This question is part of the following fields:
- Musculoskeletal
-
-
Question 19
Incorrect
-
A 42-year-old woman presents to the Ear, Nose and Throat Clinic with a 4-month history of right-sided hearing loss. She reports occasional buzzing in her right ear and feeling unsteady. She has no significant medical history and denies any recent infections. On examination, Rinne's test is positive in both ears, with Weber's test lateralizing to her left ear. There is no evidence of nystagmus, and her coordination remains intact. Apart from an absent right-sided corneal reflex, the rest of her cranial-nerve examination is unremarkable. What is the most appropriate investigation to confirm the diagnosis?
Your Answer: CT of the internal auditory canal without contrast
Correct Answer: Magnetic resonance imaging (MRI) of the cerebellopontine angle with contrast
Explanation:Diagnostic Tests for Acoustic Tumours: Importance of MRI with Contrast
Acoustic tumours require accurate diagnosis for effective treatment. The most definitive diagnostic test is gadolinium-enhanced magnetic resonance imaging (MRI) of the cerebellopontine angle. This test can detect tumours as small as 1-2 mm in diameter, while fine-cut computed tomography (CT) scanning may miss tumours as large as 1.5 cm even with intravenous contrast enhancement.
Audiometry is also important, but only 5% of patients with acoustic tumours will have a normal audiogram. If MRI is contraindicated, air-contrast cisternography can detect relatively small intracanalicular tumours with high sensitivity.
Fine-cut CT scanning of the internal auditory canal with contrast can rule out medium to large tumours, but cannot reliably detect tumours smaller than 1-1.5 cm. CT scanning without contrast can rule out medium-sized tumours, but is not reliable for detecting smaller tumours.
It is critical to use gadolinium contrast in MRI of the cerebellopontine angle, as non-enhanced MRI may miss small tumours. Therefore, MRI with contrast is the most important diagnostic test for acoustic tumours.
-
This question is part of the following fields:
- Neurology
-
-
Question 20
Correct
-
A 32-year-old woman who is 8 weeks pregnant comes in with symptoms of 'cystitis'. She reports experiencing dysuria, suprapubic pains, and frequency for the past two days. She denies any vaginal bleeding. Upon urine dipstick testing, leucocytes and nitrites are present. Her temperature is 37.6ÂșC. What is the best course of action for management?
Your Answer: Oral nitrofurantoin
Explanation:This expectant woman displays indications that align with a urinary tract infection. According to the BNF, trimethoprim should not be used during the initial trimester as it can hinder folate. Ciprofloxacin is not recommended for use during pregnancy. Since the patient is clearly experiencing a UTI and has a fever, prompt treatment is necessary instead of waiting for the MSU.
Urinary tract infections (UTIs) are common in adults and can affect different parts of the urinary tract. The management of UTIs depends on various factors such as the patient’s age, gender, and pregnancy status. For non-pregnant women, local antibiotic guidelines should be followed if available. Trimethoprim or nitrofurantoin for three days are recommended by NICE Clinical Knowledge Summaries. However, if the patient is aged over 65 years or has visible or non-visible haematuria, a urine culture should be sent. Pregnant women with UTIs should be treated with nitrofurantoin, amoxicillin, or cefalexin for seven days. Trimethoprim should be avoided during pregnancy as it is teratogenic in the first trimester. Asymptomatic bacteriuria in pregnant women should also be treated to prevent progression to acute pyelonephritis. Men with UTIs should be offered a seven-day course of trimethoprim or nitrofurantoin unless prostatitis is suspected. A urine culture should be sent before antibiotics are started. Catheterised patients should not be treated for asymptomatic bacteria, but if symptomatic, a seven-day course of antibiotics should be given. Acute pyelonephritis requires hospital admission and treatment with a broad-spectrum cephalosporin or quinolone for 10-14 days. Referral to urology is not routinely required for men who have had one uncomplicated lower UTI.
-
This question is part of the following fields:
- Renal Medicine/Urology
-
00
Correct
00
Incorrect
00
:
00
:
0
00
Session Time
00
:
00
Average Question Time (
Mins)