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Question 1
Incorrect
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A 35-year-old woman visits the clinic to receive the outcome of her initial blood tests after discovering she is pregnant for the first time. She moved to the UK from Ukraine two years ago and did not receive the MMR vaccine during her childhood. Her rubella IgM and IgG tests both show negative results. What guidance would you offer her?
Your Answer: To receive the MMR vaccine as soon as possible
Correct Answer: To keep away from people who might have rubella and receive the MMR vaccine in the postnatal period
Explanation:If a woman who is pregnant lacks immunity to rubella, she should receive the MMR vaccine after giving birth.
In the absence of any indication that this pregnant woman has been exposed to rubella, she should avoid contact with individuals who may have the disease and receive the MMR vaccine after giving birth, as it cannot be administered during pregnancy. There is no recommended treatment for preventing rubella after exposure based on the clinical history. To prevent complications in future pregnancies, it is important to offer her the MMR vaccine.
Rubella and Pregnancy: Risks, Features, Diagnosis, and Management
Rubella, also known as German measles, is a viral infection caused by the togavirus. Thanks to the introduction of the MMR vaccine, it is now rare. However, if contracted during pregnancy, there is a risk of congenital rubella syndrome, which can cause serious harm to the fetus. It is important to note that the incubation period is 14-21 days, and individuals are infectious from 7 days before symptoms appear to 4 days after the onset of the rash.
The risk of damage to the fetus is highest in the first 8-10 weeks of pregnancy, with a risk as high as 90%. However, damage is rare after 16 weeks. Features of congenital rubella syndrome include sensorineural deafness, congenital cataracts, congenital heart disease (e.g. patent ductus arteriosus), growth retardation, hepatosplenomegaly, purpuric skin lesions, ‘salt and pepper’ chorioretinitis, microphthalmia, and cerebral palsy.
If a suspected case of rubella in pregnancy arises, it should be discussed immediately with the local Health Protection Unit (HPU) as type/timing of investigations may vary. IgM antibodies are raised in women recently exposed to the virus. It should be noted that it is very difficult to distinguish rubella from parvovirus B19 clinically. Therefore, it is important to also check parvovirus B19 serology as there is a 30% risk of transplacental infection, with a 5-10% risk of fetal loss.
If a woman is tested at any point and no immunity is demonstrated, they should be advised to keep away from people who might have rubella. Non-immune mothers should be offered the MMR vaccination in the post-natal period. However, MMR vaccines should not be administered to women known to be pregnant or attempting to become pregnant.
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This question is part of the following fields:
- Reproductive Medicine
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Question 2
Correct
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A 58-year-old man presents to his doctor with concerns about his chest. He feels embarrassed and believes that he is developing breast tissue. Upon examination, bilateral gynaecomastia is the only abnormal finding. The patient has a medical history of hypertension, high cholesterol, type 2 diabetes, and benign prostatic hyperplasia. Which medication is the most probable cause of this condition?
Your Answer: Finasteride
Explanation:Gynaecomastia in males can have various underlying causes, some of which may be serious, such as endocrine disorders, liver failure, kidney failure, or malignancy. Additionally, medication-related causes should be considered, as in the case of this patient who was taking finasteride, which is known to cause gynaecomastia. Finasteride functions by inhibiting 5-alpha-reductase, which reduces dihydrotestosterone production and shrinks the prostate. However, it can also lead to side effects such as sexual dysfunction and gynaecomastia.
Understanding Finasteride: Its Uses and Side Effects
Finasteride is a medication that works by inhibiting the activity of 5 alpha-reductase, an enzyme responsible for converting testosterone into dihydrotestosterone. This drug is commonly used to treat benign prostatic hyperplasia and male-pattern baldness.
However, like any medication, finasteride has its own set of adverse effects. Some of the most common side effects include impotence, decreased libido, ejaculation disorders, gynaecomastia, and breast tenderness. It is important to note that finasteride can also cause decreased levels of serum prostate-specific antigen.
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This question is part of the following fields:
- Pharmacology/Therapeutics
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Question 3
Incorrect
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A 22-year-old woman presents to her GP for a follow-up appointment regarding her generalised anxiety disorder (GAD). During her previous visit, she was provided with information about GAD and referred for individual guided self-help. However, she continues to experience persistent worry throughout the day and has difficulty relaxing. Her family has also noticed that she is more irritable. The patient expresses interest in trying medication for her anxiety. What would be the most suitable medication to prescribe for her?
Your Answer: Citalopram
Correct Answer: Sertraline
Explanation:Sertraline is the recommended first-line medication for treating generalised anxiety disorder (GAD). This patient exhibits typical symptoms of GAD and has already undergone step 1 and step 2 of treatment without improvement. Therefore, she requires step 3, which involves either high-intensity psychological intervention or drug treatment. As the patient prefers drug treatment, sertraline is the appropriate choice as it is the most cost-effective SSRI for GAD according to NICE guidelines. Citalopram and fluoxetine are also SSRIs that may be used as second-line treatments if sertraline is not effective or tolerated. Diazepam, a benzodiazepine, is not recommended for GAD due to the risk of dependence, except in short-term crisis situations.
Anxiety is a common disorder that can manifest in various ways. According to NICE, the primary feature is excessive worry about multiple events associated with heightened tension. It is crucial to consider potential physical causes when diagnosing anxiety disorders, such as hyperthyroidism, cardiac disease, and medication-induced anxiety. Medications that may trigger anxiety include salbutamol, theophylline, corticosteroids, antidepressants, and caffeine.
NICE recommends a step-wise approach for managing generalised anxiety disorder (GAD). This includes education about GAD and active monitoring, low-intensity psychological interventions, high-intensity psychological interventions or drug treatment, and highly specialist input. Sertraline is the first-line SSRI for drug treatment, and if it is ineffective, an alternative SSRI or a serotonin-noradrenaline reuptake inhibitor (SNRI) such as duloxetine or venlafaxine may be offered. If the patient cannot tolerate SSRIs or SNRIs, pregabalin may be considered. For patients under 30 years old, NICE recommends warning them of the increased risk of suicidal thinking and self-harm and weekly follow-up for the first month.
The management of panic disorder also follows a stepwise approach, including recognition and diagnosis, treatment in primary care, review and consideration of alternative treatments, review and referral to specialist mental health services, and care in specialist mental health services. NICE recommends either cognitive behavioural therapy or drug treatment in primary care. SSRIs are the first-line drug treatment, and if contraindicated or no response after 12 weeks, imipramine or clomipramine should be offered.
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This question is part of the following fields:
- Psychiatry
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Question 4
Correct
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A 60-year-old man presents following a fall. During an assessment of his fall, he complained of balance problems, nausea and dizziness whenever he looked upwards, eg to change a light bulb. He denies loss of consciousness and did not injure himself during the fall. His past medical history consists of hypertension and high cholesterol.
On examination, his gait and balance and neurological examination are normal, and there are no injuries. The Hallpike test is positive.
Which of the following is the most appropriate management for this patient’s vertigo?Your Answer: Epley manoeuvre
Explanation:Management Options for Benign Paroxysmal Positional Vertigo (BPPV)
Benign paroxysmal positional vertigo (BPPV) is a common vestibular disorder that can cause dizziness and vertigo. The Epley manoeuvre is the best first-line management option for BPPV, as it can reposition the debris in the vestibular canals and provide rapid relief. If symptoms persist, investigations may be necessary to rule out more serious brain pathologies, but a brain MRI is not typically required for a BPPV diagnosis.
Medications such as betahistine or prochlorperazine may provide short-term relief of symptoms, but they do not address the underlying cause of BPPV. Vestibular retraining exercises, such as Brandt-Daroff exercises, can also be effective in reducing symptoms if they persist despite the Epley manoeuvre. Overall, a combination of these management options can help alleviate the symptoms of BPPV and improve quality of life for patients.
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This question is part of the following fields:
- ENT
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Question 5
Correct
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On presentation, what is the most frequently observed symptom of lung cancer?
Your Answer: Cough
Explanation:Symptoms of Lung Cancer: What to Look Out For
Lung cancer is a serious condition that can be difficult to detect in its early stages. However, there are certain symptoms that may indicate the presence of lung cancer. The most common symptom is a persistent cough, which is present in about 40% of patients. If you have had a cough for three weeks or more, it is recommended that you seek medical attention to evaluate the possibility of lung cancer.
In addition to coughing, chest pain is another symptom that may indicate lung cancer. About 15% of patients present with both cough and chest pain, while chest pain alone is present in up to 22% of patients.
Coughing up blood, or haemoptysis, is another symptom that may suggest the presence of lung cancer. However, only 7% of patients with lung cancer actually present with this symptom.
Less common symptoms of lung cancer include shortness of breath, hoarseness, weight loss, and malaise. If you are experiencing any of these symptoms, it is important to seek medical attention as soon as possible to determine the cause and receive appropriate treatment.
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This question is part of the following fields:
- Respiratory Medicine
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Question 6
Correct
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A 30-year-old woman with a family history of renal disease presents with gross haematuria. She reports that her sister recently underwent a kidney transplant and that her mother passed away due to renal failure. During physical examination, a significant mass is palpated in the left lumbar region, and a smaller mass is felt in the right flank. Elevated levels of blood urea and serum creatinine are observed.
What is the most likely diagnosis?Your Answer: Adult polycystic kidney disease
Explanation:Common Kidney Disorders and their Clinical Presentations
Autosomal Dominant Polycystic Kidney Disease (ADPKD)
ADPKD is a progressive disorder characterized by cyst formation and enlargement in the kidney and other organs. Patients may experience pain in the abdomen, flank or back, and hypertension is a common early manifestation. Palpable, bilateral flank masses are present in advanced ADPKD.Renal Cell Carcinoma (RCC)
RCC is the most common type of kidney cancer in adults. It may remain clinically occult for most of its course, with only 10% of patients presenting with the classic triad of flank pain, haematuria, and unilateral palpable flank mass. RCC presents with hypercalcaemia manifestations in 5% of cases and with varicocele in 2% of men.Renal Calculi
Renal calculi, or nephrolithiasis, classically present with sudden onset of severe pain originating in the flank and radiating inferiorly and anteriorly. On examination, there is dramatic costovertebral angle tenderness.Prostatic Carcinoma
Most cases of prostate cancer are identified by screening in asymptomatic men. Symptoms include urinary complaints or retention, back pain, and haematuria. Findings in patients with advanced disease include bony tenderness, lower-extremity oedema or deep venous thrombosis, and an overdistended bladder due to outlet obstruction.Renal Amyloidosis
Patients with renal amyloidosis typically present with proteinuria and/or hypertension, followed by progressive renal failure. Haematuria is not a feature.Clinical Presentations of Common Kidney Disorders
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This question is part of the following fields:
- Renal Medicine/Urology
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Question 7
Correct
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A 68-year-old woman comes to the emergency department complaining of fatigue and difficulty breathing for the past 2 days. She has a medical history of hypertension, a heart attack 3 years ago, heart failure, and a recent chest infection that was successfully treated with antibiotics. During the examination, the patient has bibasal crepitations and an elevated JVP. Her temperature is 37ºC, oxygen saturation is 95% on air, heart rate is 95 beats per minute, respiratory rate is 26 breaths per minute, and blood pressure is 129/86 mmHg.
What is the most appropriate course of treatment?Your Answer: IV furosemide
Explanation:The recommended treatment for acute pulmonary oedema in this patient is IV loop diuretic, specifically furosemide. This is because the patient is experiencing acute decompensated heart failure, which causes pulmonary oedema. IV loop diuretic has a prompt diuretic effect, reducing ventricular filling pressures and improving symptoms within 30 minutes.
IV dobutamine is not necessary for this patient as they are not in shock and dobutamine is typically reserved for patients with severe left ventricular dysfunction who have potentially reversible cardiogenic shock.
IV morphine is not recommended for acute heart failure as it may increase morbidity in patients with acute pulmonary oedema.
Oral furosemide is not the preferred route of administration for this patient as IV furosemide has a faster onset of diuresis.
Heart failure requires acute management, with recommended treatments for all patients including IV loop diuretics such as furosemide or bumetanide. Oxygen may also be necessary, with guidelines suggesting oxygen saturations be kept at 94-98%. Vasodilators such as nitrates should not be routinely given to all patients, but may have a role in cases of concomitant myocardial ischaemia, severe hypertension, or regurgitant aortic or mitral valve disease. However, hypotension is a major side-effect/contraindication. Patients with respiratory failure may require CPAP, while those with hypotension or cardiogenic shock may require inotropic agents like dobutamine or vasopressor agents like norepinephrine. Mechanical circulatory assistance such as intra-aortic balloon counterpulsation or ventricular assist devices may also be necessary. Regular medication for heart failure should be continued, with beta-blockers only stopped in certain circumstances. Opiates should not be routinely offered to patients with acute heart failure due to potential increased morbidity.
In summary, acute management of heart failure involves a range of treatments depending on the patient’s specific condition. It is important to carefully consider the potential side-effects and contraindications of each treatment, and to continue regular medication for heart failure where appropriate. Opiates should be used with caution, and only in cases where they are likely to reduce dyspnoea/distress without causing harm. With appropriate management, patients with acute heart failure can receive the care they need to improve their outcomes and quality of life.
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This question is part of the following fields:
- Respiratory Medicine
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Question 8
Incorrect
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A 25-year-old individual is being examined after experiencing an anaphylactic reaction believed to be caused by a wasp sting. What is the most suitable initial test to investigate the reason for the reaction?
Your Answer: Skin prick test
Correct Answer: Radioallergosorbent test (RAST)
Explanation:Performing a skin prick test would not be appropriate due to the patient’s history of anaphylaxis.
Types of Allergy Tests
Allergy tests are used to determine if a person has an allergic reaction to a particular substance. There are several types of allergy tests available, each with its own advantages and limitations. The most commonly used test is the skin prick test, which is easy to perform and inexpensive. Drops of diluted allergen are placed on the skin, and a needle is used to pierce the skin. A wheal will typically develop if a patient has an allergy. This test is useful for food allergies and pollen.
Another type of allergy test is the radioallergosorbent test (RAST), which determines the amount of IgE that reacts specifically with suspected or known allergens. Results are given in grades from 0 (negative) to 6 (strongly positive). This test is useful for food allergies, inhaled allergens (e.g. pollen), and wasp/bee venom.
Skin patch testing is useful for contact dermatitis. Around 30-40 allergens are placed on the back, and irritants may also be tested for. The patches are removed 48 hours later, and the results are read by a dermatologist after a further 48 hours. Blood tests may be used when skin prick tests are not suitable, for example if there is extensive eczema or if the patient is taking antihistamines. Overall, allergy tests are an important tool in diagnosing and managing allergies.
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This question is part of the following fields:
- Immunology/Allergy
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Question 9
Incorrect
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A 68-year-old man presents with intermittent dull abdominal pain for the past few weeks. He reports no weight loss but has had one episode of dark, foul-smelling stool in the past week. On examination, he appears well and all vital signs are within normal limits. A rectal exam is unremarkable. Laboratory tests reveal a hemoglobin level of 112 g/L (normal range for males: 135-180 g/L), a hematocrit of 0.38 L/L (normal range: 0.37-0.49 L/L), a mean cell volume of 70 fL (normal range: 80-101 fL), a mean cell hemoglobin of 28 pg (normal range: 27-34 pg), a platelet count of 165 * 109/L (normal range: 150-400 * 109/L), and a white blood cell count of 6.4 * 109/L (normal range: 4.0-11.0 * 109/L). What is the most appropriate next step in management?
Your Answer: Admit to hospital
Correct Answer: Refer on 2 week wait pathway
Explanation:Microcytic Anaemia: Causes and Considerations
Microcytic anaemia is a condition characterized by small red blood cells and low haemoglobin levels. There are several possible causes of microcytic anaemia, including iron-deficiency anaemia, thalassaemia, congenital sideroblastic anaemia, and lead poisoning. It is important to note that while anaemia of chronic disease can also present with microcytosis, it typically appears as a normocytic, normochromic picture.
In some cases, a normal haemoglobin level may be observed alongside microcytosis. This can be a red flag for polycythaemia rubra vera, which can cause iron-deficiency secondary to bleeding. Additionally, new onset microcytic anaemia in elderly patients should be investigated promptly to rule out underlying malignancy. It is worth noting that in beta-thalassaemia minor, the microcytosis may be disproportionate to the anaemia.
Overall, understanding the potential causes and considerations of microcytic anaemia is crucial for proper diagnosis and treatment.
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This question is part of the following fields:
- Gastroenterology/Nutrition
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Question 10
Correct
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A 28-year-old pregnant woman presents at 34 weeks gestation with a blood pressure reading of 175/105 mmHg and 3+ proteinuria. She is started on magnesium sulphate and labetalol. The patient reports decreased foetal movements. Upon examination, a cardiotocogram reveals late decelerations and a foetal heart rate of 90 beats/minute. What is the next course of action in managing this situation?
Your Answer: Emergency caesarian section
Explanation:Pre-eclampsia can be diagnosed based on the presence of high levels of protein in the urine and hypertension. To prevent the development of eclampsia, magnesium sulphate is administered, while labetalol is used to manage high blood pressure. If a cardiotocography (CTG) shows late decelerations and foetal bradycardia, this is a concerning sign and may necessitate an emergency caesarean section. Induction would not be recommended if the CTG is abnormal.
Cardiotocography (CTG) is a medical procedure that measures pressure changes in the uterus using either internal or external pressure transducers. It is used to monitor the fetal heart rate, which normally ranges between 100-160 beats per minute. There are several features that can be observed during a CTG, including baseline bradycardia (heart rate below 100 beats per minute), which can be caused by increased fetal vagal tone or maternal beta-blocker use. Baseline tachycardia (heart rate above 160 beats per minute) can be caused by maternal pyrexia, chorioamnionitis, hypoxia, or prematurity. Loss of baseline variability (less than 5 beats per minute) can be caused by prematurity or hypoxia. Early deceleration, which is a decrease in heart rate that starts with the onset of a contraction and returns to normal after the contraction, is usually harmless and indicates head compression. Late deceleration, on the other hand, is a decrease in heart rate that lags behind the onset of a contraction and does not return to normal until after 30 seconds following the end of the contraction. This can indicate fetal distress, such as asphyxia or placental insufficiency. Variable decelerations, which are independent of contractions, may indicate cord compression.
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This question is part of the following fields:
- Reproductive Medicine
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