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Question 1
Correct
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A 19-year-old woman visits your GP clinic with her mother to discuss contraceptive options. She reports heavy periods and prefers non-invasive methods. She also has a history of migraine with aura. What would be the most suitable option for her?
Your Answer: Progesterone only contraceptive pill (POCP)
Explanation:There are many options available for contraception, each with their own advantages and disadvantages. It is important to discuss these options to find the best fit for the patient. In this case, the progesterone only contraceptive pill is the most appropriate option due to the patient’s history of migraine with aura and heavy menstrual cycle. The combined oral contraceptive pill is not recommended for this patient. The intrauterine system is a popular option for menorrhagia, but the patient does not want an invasive device. The contraceptive implant is also invasive and not preferred by the patient. Condoms are a good barrier method, but the POCP will also help with the patient’s heavy and irregular periods.
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This question is part of the following fields:
- Gynaecology
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Question 2
Correct
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A 7-year-old boy has been diagnosed with mumps.
Which of the following complications would be unexpected for this condition?Your Answer: Disseminated intravascular coagulation
Explanation:Clinical Manifestations and Sequelae of Mumps
Mumps is a viral infection that commonly affects the salivary glands, causing parotitis, oophoritis, and orchitis. However, it can also lead to acute pancreatitis. In addition to these clinical manifestations, mumps can result in various sequelae, including meningoencephalitis, arthritis, transverse myelitis, cerebellar ataxia, and deafness. These conditions can occur as a result of the virus spreading to other parts of the body, such as the brain, spinal cord, and joints. However, disseminated intravascular coagulation (DIC) is not typically associated with mumps.
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This question is part of the following fields:
- General Practice
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Question 3
Correct
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Linda is a 51-year-old woman who is currently perimenopausal and visits your GP clinic seeking advice on how to manage her night sweats, hot flashes, and mood swings. She has heard about hormone replacement therapy (HRT) and is interested in trying it to alleviate her symptoms. She has a medical history of hypothyroidism and experienced a deep vein thrombosis (DVT) a decade ago.
What are the HRT choices you would suggest to her?Your Answer: A transdermal combined patch would be the most appropriate option
Explanation:For women who are perimenopausal and experiencing symptoms that require management, HRT is often recommended as a first-line treatment, provided there are no contraindications. While a history of DVT is not an absolute contraindication, arterial thromboembolic disease or current/recurrent VTE would be. Transdermal HRT is generally considered a safer option for those at risk of VTE compared to oral preparations.
Hormone replacement therapy (HRT) involves a small dose of oestrogen and progesterone to alleviate menopausal symptoms. The indications for HRT have changed due to the long-term risks, and it is primarily used for vasomotor symptoms and preventing osteoporosis in younger women. HRT consists of natural oestrogens and synthetic progestogens, and can be taken orally or transdermally. Transdermal is preferred for women at risk of venous thromboembolism.
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This question is part of the following fields:
- Pharmacology
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Question 4
Correct
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A 38-year-old male librarian presents with sudden loss of hearing in both ears. There is no ear pain, history of recent upper respiratory tract infection or history of trauma. He has no past medical history of note and does not take any regular prescribed or over-the-counter medications. Tuning fork testing suggests right side sensorineural hearing loss. Examination of the auditory canals and tympanic membranes is unremarkable, as is neurological examination. He is referred to the acute ear, nose and throat (ENT) clinic. Audiometry reveals a 40 db hearing loss in the right ear at multiple frequencies.
Which of the following represents the most appropriate initial management plan?Your Answer: Arrange an urgent magnetic resonance (MR) of the brain
Explanation:Management of Sudden Sensorineural Hearing Loss
Sudden sensorineural hearing loss (SSNHL) is a medical emergency that requires urgent evaluation and management. Patients with unexplained sudden hearing loss should be referred to an ENT specialist and offered an MRI scan. A CT scan may also be indicated to rule out stroke, although it is unlikely to cause unilateral hearing loss.
Antiviral medication such as acyclovir is not recommended unless there is evidence of viral infection. Antibiotics are also not indicated unless there is evidence of bacterial infection.
The mainstay of treatment for SSNHL is oral prednisolone, which should be started as soon as possible and continued for 14 days. While the cause of SSNHL is often unknown, it is important to consider a wide range of differential diagnoses, including trauma, drugs, space-occupying lesions, autoimmune inner ear disease, and many other conditions. Prompt evaluation and treatment can improve the chances of recovery and prevent further hearing loss.
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This question is part of the following fields:
- ENT
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Question 5
Correct
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A 27-year-old female receives a cervical smear test through the UK cervical screening programme and is found to be hrHPV positive. However, her cytological examination shows no abnormalities. What is the best course of action to take?
Your Answer: Repeat the test in 12 months
Explanation:If a cervical smear test is hrHPV positive but cytologically normal, the recommended course of action is to repeat the test in 12 months. This is in contrast to negative hrHPV results, which are returned to normal recall. Abnormal cytology results require colposcopy, but normal cytology results do not. It is important to note that returning to normal recall is not appropriate in this case, as the patient’s higher risk status warrants a repeat test sooner than the standard 3-year interval. Repeating the test within 3 or 6 months is also not recommended.
The cervical cancer screening program has evolved to include HPV testing, which allows for further risk stratification. A negative hrHPV result means a return to normal recall, while a positive result requires cytological examination. Abnormal cytology results lead to colposcopy, while normal cytology results require a repeat test at 12 months. Inadequate samples require a repeat within 3 months, and two consecutive inadequate samples lead to colposcopy. Treatment for CIN typically involves LLETZ or cryotherapy. Individuals who have been treated for CIN should be invited for a test of cure repeat cervical sample 6 months after treatment.
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This question is part of the following fields:
- Gynaecology
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Question 6
Incorrect
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A man in his thirties receives a punch to the left side of his face resulting in a black eye. He reports experiencing numbness in his left cheek and upper teeth on that side.
Which nerve is likely to have been affected?Your Answer: Zygomatic branch of the facial nerve
Correct Answer: Infraorbital nerve
Explanation:Nerves and their Functions in Facial Sensation and Movement
The face is innervated by several nerves that serve different functions. The infraorbital nerve supplies sensation to the upper teeth and cheek, but is vulnerable to direct trauma and pressure. The supratrochlear nerve provides sensation to the upper eyelid, conjunctiva, and lower middle forehead. The mental nerve supplies sensation to the lower lip and chin, while the zygomatic branch of the facial nerve gives motor innervation to the orbicularis oculi. Lastly, the chorda tympani is responsible for taste sensation in the anterior two-thirds of the tongue. Understanding the functions of these nerves is crucial in diagnosing and treating facial injuries and disorders.
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This question is part of the following fields:
- Trauma
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Question 7
Correct
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You see a 47-year-old woman in clinic at the General Practice surgery where you are working as a Foundation Year 2 doctor. She has a diagnosis of moderate depression and would like to try an antidepressant alongside her cognitive behavioural therapy, which is due to begin in 2 weeks. She has no significant past medical history and is not on any prescribed or over-the-counter medications.
Which of the following antidepressant medications would be most appropriate as the first-line treatment?Your Answer: Citalopram
Explanation:Commonly Prescribed Psychiatric Medications and Their Uses
Depression is a prevalent psychiatric disorder that is often managed by general practitioners with support from community mental health teams. The National Institute for Health and Care Excellence (NICE) recommends antidepressants as a first-line treatment for moderate to severe depression, alongside high-intensity psychological therapy. Selective serotonin reuptake inhibitors (SSRIs) such as citalopram are the preferred antidepressants for adults due to their better side-effect profile and lower risk of overdose. Fluoxetine is the only licensed antidepressant for children and adolescents and has the largest evidence base.
Tricyclic antidepressants like amitriptyline are an older class of antidepressants that are more toxic in overdose and commonly cause antimuscarinic effects at therapeutic doses. They are more commonly used in low doses for conditions such as neuropathic pain. Carbamazepine is commonly used in epilepsy and neuropathic pain and also plays a role as a mood stabilizer in bipolar disorder. Lithium is primarily used for treatment and prophylaxis in bipolar disorder and should be prescribed by specialists due to the need for dose titration to achieve a narrow therapeutic window. Phenelzine is a monoamine oxidase inhibitor, an older class of antidepressants with a wide range of side-effects and drug interactions. Patients on phenelzine should follow a low-tyramine diet to avoid an acute hypertensive crisis.
Understanding Common Psychiatric Medications and Their Uses
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This question is part of the following fields:
- Psychiatry
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Question 8
Incorrect
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A 63-year-old, non-smoking woman without previous cardiac history, has a total cholesterol of 9.0 mmol/l. She is overweight and has sleep apnoea. On examination you notice her skin is particularly dry and there appears to be some evidence of hair loss. Her blood pressure is 140/95 mmHg and pulse rate 60 bpm.
What would be the most appropriate next step in managing this patient?Your Answer: Measure her 24-hour urinary free cortisol
Correct Answer: Check her thyroid-stimulating hormone (TSH) and free thyroxine (T4) level
Explanation:Diagnostic and Treatment Options for a Patient with High Cholesterol
When a patient presents with symptoms such as dry skin, hair loss, obesity, sleep apnea, hypertension, and slow pulse, it is important to consider hypothyroidism as a possible cause. To confirm this diagnosis, checking the patient’s thyroid-stimulating hormone (TSH) and free thyroxine (T4) levels is recommended. Hypothyroidism can also cause dyslipidemia, which may be the underlying cause of the patient’s high cholesterol levels. Therefore, treating the hypothyroidism should be the initial step, and if cholesterol levels remain high, prescribing a statin may be appropriate.
It is also important to consider the possibility of familial hypercholesterolemia, especially if the patient’s cholesterol levels are very high (≥8 mmol/l). In this case, screening family members for raised cholesterol may be necessary if cholesterol levels do not decrease with l-thyroxine treatment.
While diabetes can increase the risk of thyroid disorders, checking the patient’s fasting blood glucose level may not be necessary initially. Additionally, measuring 24-hour urinary free cortisol is not recommended as the patient’s symptoms do not suggest Cushing syndrome as the diagnosis.
In summary, considering hypothyroidism as a possible cause of high cholesterol levels and checking TSH and T4 levels should be the initial step in diagnosis. Treating the underlying cause and prescribing a statin if necessary can help manage the patient’s cholesterol levels. Screening family members for familial hypercholesterolemia may also be necessary.
Diagnostic and Treatment Options for High Cholesterol in Patients with Suspected Hypothyroidism
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This question is part of the following fields:
- Endocrinology
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Question 9
Correct
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A 42-year-old female with a lengthy history of schizophrenia has been admitted to a psychiatric inpatient facility due to a worsening of her psychosis caused by non-adherence to medication. During an interview with the patient, the psychiatrist observes that while the patient's speech is mostly comprehensible, she occasionally employs words like flibbertigibbet and snollygoster that appear to hold significance only for the patient.
What is the most appropriate term to describe the patient's speech abnormality?Your Answer: Neologism
Explanation:Language Disturbances in Mental Health
Neologism is the term used to describe the creation of new words. This phenomenon can occur in individuals with schizophrenia or brain injury. Clanging, on the other hand, is the use of rhyming words in speech. Pressured speech is characterized by rapid speech that is difficult to interrupt and is often seen in individuals experiencing mania or hypomania. Circumstantiality refers to speech that may wander from the topic for periods of time before finally returning to answer the question that was asked. Lastly, word salad is a type of speech that is completely disorganized and not understandable, which may occur in individuals who have suffered a stroke affecting Wernicke’s area.
In summary, language disturbances are common in individuals with mental health conditions. These disturbances can range from the creation of new words to completely disorganized speech. these language disturbances can aid in the diagnosis and treatment of mental health conditions.
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This question is part of the following fields:
- Psychiatry
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Question 10
Correct
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A 25-year-old man with inflammatory bowel disease has been experiencing lower back pain, stiffness, and buttock pain for the past six months. He notices that his pain improves after playing squash on Saturdays. He has tested positive for HLA-B27 and his blood tests, including C-reactive protein and erythrocyte sedimentation rate, are normal except for a mild hypochromic microcytic anemia. What is the most likely diagnosis?
Your Answer: Ankylosing spondylitis
Explanation:Understanding Different Types of Arthritis: Ankylosing Spondylitis, Osteoarthritis, Prolapsed Intervertebral Disc, Reactive Arthritis, and Rheumatoid Arthritis
Ankylosing spondylitis is a type of arthritis that commonly affects the sacroiliac joints, causing pain and stiffness that improves with exercise. It may also involve inflammation of the colon or ileum, which can lead to inflammatory bowel disease in some cases. The presence of the HLA-B27 gene is often associated with ankylosing spondylitis. Osteoarthritis, on the other hand, is unlikely in younger individuals and is not linked to bowel disease. Prolapsed intervertebral disc is characterized by severe lower back pain and sciatica, but stiffness is not a typical symptom. Reactive arthritis is usually triggered by a recent GI illness or sexually transmitted infection and is associated with arthritis, a psoriatic type rash, and conjunctivitis. Finally, rheumatoid arthritis rarely affects the sacroiliac joints as the primary site. It is important to understand the differences between these types of arthritis to receive proper diagnosis and treatment.
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This question is part of the following fields:
- Rheumatology
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Question 11
Incorrect
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A 20-year-old female comes to your clinic accompanied by her mother. She expresses concern about a lump in her breast that has been increasing in size. You suggest examining her and inquire if she would like a chaperone. She declines the offer of a stranger and prefers her mother to be present. What is your next step?
Your Answer: Accept the mother as a chaperone but ensure you have documented this in the notes
Correct Answer: Explain that family members cannot be used for chaperones and reoffer the patient someone at the practice to chaperone
Explanation:According to the GMC guidelines in Good Medical Practice, it is important to offer patients the option of having an impartial observer (a chaperone) present during intimate examinations. This applies regardless of the gender of the patient or doctor. The chaperone should be a health professional who is sensitive, respectful of the patient’s dignity and confidentiality, familiar with the procedures involved, and able to stay for the entire examination. If the patient requests a relative or friend to be present, this person should not be considered an impartial observer. If either the patient or doctor is uncomfortable with the choice of chaperone, the examination can be delayed until a suitable chaperone is available, as long as this does not adversely affect the patient’s health. The patient’s clinical needs should always take precedence. It is important to document any discussions about chaperones and their outcomes in the patient’s medical record. In the case of a breast lump examination, it would be unreasonable to make the patient wait for two weeks, so offering a chaperone or rescheduling the appointment would be necessary. It is not appropriate to perform the examination without a chaperone or with the patient’s mother as the chaperone.
Benign breast lesions have different features and treatments. Fibroadenomas are firm, mobile lumps that develop from a whole lobule and usually do not increase the risk of malignancy. Breast cysts are smooth, discrete lumps that may be aspirated, but blood-stained or persistently refilling cysts should be biopsied or excised. Sclerosing adenosis, radial scars, and complex sclerosing lesions cause mammographic changes that may mimic carcinoma, but do not increase the risk of malignancy. Epithelial hyperplasia may present as general lumpiness or a discrete lump, and atypical features and family history of breast cancer increase the risk of malignancy. Fat necrosis may mimic carcinoma and requires imaging and core biopsy. Duct papillomas usually present with nipple discharge and may require microdochectomy.
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This question is part of the following fields:
- Surgery
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Question 12
Correct
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A 47-year-old man arrives at the emergency department complaining of severe abdominal pain. He is restless and describes the pain as 10/10, originating from the right side of his back and radiating to his right testicle. He has vomited once but has no other symptoms. His vital signs are stable except for a heart rate of 100 bpm. A urine dip reveals ++ blood. He is administered PR diclofenac and oramorph for pain relief. The following day, his pain is under control, and the tachycardia has subsided. A CTKUB is performed, which reveals no stones in the ureters but shows stranding of the peri-ureteric fat. There is no indication of any bowel or other abdominal organ pathology. What is the accurate diagnosis?
Your Answer: Spontaneously passed ureteric calculus
Explanation:If a ureteric calculus is not present, the presence of periureteric fat stranding may indicate recent stone passage. Most stones that are less than 5mm in the ureteric axis will pass on their own. Fat stranding can be seen beside the ureter, indicating recent stone passage, or beside the kidney, which may be a sign of pyelonephritis. Urothelial carcinoma typically presents with a chronically obstructed and hydronephrotic kidney, which may have been detected on a contrast CT scan. The patient’s symptoms and radiological findings do not suggest pyelonephritis or malingering. Ureteric rupture is rare and is usually caused by medical intervention, and a urinoma in the retroperitoneal space would be visible on a CTKUB.
Types of Renal Stones and their Appearance on X-ray
Renal stones, also known as kidney stones, are solid masses that form in the kidneys due to the accumulation of certain substances. There are different types of renal stones, each with a unique appearance on x-ray. Calcium oxalate stones are the most common, accounting for 40% of cases, and appear opaque on x-ray. Mixed calcium oxalate/phosphate stones and calcium phosphate stones also appear opaque and make up 25% and 10% of cases, respectively. Triple phosphate stones, which develop in alkaline urine and are composed of struvite, account for 10% of cases and appear opaque as well. Urate stones, which are radiolucent, make up 5-10% of cases. Cystine stones, which have a semi-opaque, ‘ground-glass’ appearance, are rare and only account for 1% of cases. Xanthine stones are the least common, accounting for less than 1% of cases, and are also radiolucent. Staghorn calculi, which involve the renal pelvis and extend into at least 2 calyces, are composed of triple phosphate and are more likely to develop in alkaline urine. Infections with Ureaplasma urealyticum and Proteus can increase the risk of their formation.
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This question is part of the following fields:
- Surgery
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Question 13
Incorrect
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A 72-year-old woman has been diagnosed with stress incontinence. Her BMI is 30 kg/m2 and she has a history of hypertension and osteoporosis. She presents to you today with worsening symptoms despite reducing her caffeine intake and starting a regular exercise routine. She has had a normal pelvic exam and has completed three months of pelvic floor exercises with only mild improvement. She is hesitant to undergo surgery due to a previous severe reaction to general anesthesia. What is the next step in managing this patient?
Your Answer: Continue pelvic floor exercises for up to another three months and then reassess symptoms
Correct Answer: Duloxetine
Explanation:Management Options for Stress Incontinence: A Case-Based Discussion
Stress incontinence is a common condition that can significantly impact a patient’s quality of life. In this scenario, a female patient has attempted lifestyle changes and pelvic floor exercises for three months with little effect. What are the next steps in management?
Duloxetine is a second-line management option for stress incontinence when conservative measures fail. It works by inhibiting the reuptake of serotonin and noradrenaline, leading to continuous stimulation of the nerves in Onuf’s nucleus and preventing involuntary urine loss. However, caution should be exercised in patients with certain medical conditions.
Continuing pelvic floor exercises for another three months is unlikely to yield significant improvements, and referral is indicated at this stage.
Intramural urethral-bulking agents can be used when conservative management has failed, but they are not as effective as other surgical options and symptoms can recur.
The use of a ring pessary is not recommended as a first-line treatment option for stress incontinence.
A retropubic mid-urethral tape procedure is a successful surgical option, but it may not be appropriate for high-risk patients who wish to avoid surgery.
In conclusion, the management of stress incontinence requires a tailored approach based on the patient’s individual circumstances and preferences.
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This question is part of the following fields:
- Gynaecology
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Question 14
Incorrect
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What is a true statement about atopic eczema?
Your Answer: Does not respond to dietary measures
Correct Answer: Usually starts in the first year of life
Explanation:Atopic Eczema
Atopic eczema is a skin condition that is more likely to occur in individuals who have a family history of asthma, hay fever, and eczema. One of the common causes of this condition is cow’s milk, and switching to a milk hydrolysate may help alleviate symptoms. The condition typically affects the face, ears, elbows, and knees.
It is important to note that topical steroids should only be used sparingly if symptoms cannot be controlled. Atopic eczema often develops in the first year of life, making it crucial for parents to be aware of the symptoms and seek medical attention if necessary. By the causes and symptoms of atopic eczema, individuals can take steps to manage the condition and improve their quality of life.
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This question is part of the following fields:
- Dermatology
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Question 15
Incorrect
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A 35-year-old woman presents to her primary care physician seeking the combined oral contraceptive pill (COCP). She has a history of pelvic inflammatory disease and had an ectopic pregnancy that was treated with methotrexate a year ago. Additionally, she is a heavy smoker, consuming 20 cigarettes per day. Her family history is significant for BRCA1 mutation in her mother and sister, but she declines genetic testing. What would be an absolute contraindication for the COCP in this patient?
Your Answer: Prior ectopic pregnancy
Correct Answer: Smoker
Explanation:The combined oral contraceptive pill (COCP) is a popular form of birth control, but it is not suitable for everyone. There are absolute contraindications, which mean that the COCP should not be used under any circumstances, and relative contraindications, which require careful consideration before prescribing.
Absolute contraindications include smoking 15 or more cigarettes a day and being over 35 years old, hypertension, major surgery with prolonged immobilization, secondary Raynaud’s disease, systemic lupus erythematosus, positive for antiphospholipid syndrome, current or history of venous thromboembolism, migraine with aura, current breast cancer, liver cirrhosis, viral hepatitis, and diabetic nephropathy/retinopathy/neuropathy.
Relative contraindications include smoking less than 15 cigarettes a day and being over 35 years old, being 6 weeks to 6 months postpartum and breastfeeding, being less than 21 days postpartum and not breastfeeding, having a body mass index of 35 or higher, having a family history of venous thromboembolism in a first-degree relative, having migraines without aura, having a history of breast cancer without recurrence for 5 years, using certain anticonvulsants, having dyslipidemia, undergoing rifampicin therapy, and having a previous use of methotrexate.
A history of pelvic inflammatory disease or prior ectopic pregnancy is not considered a contraindication to the use of the COCP. The possibility of a BRCA mutation is a controversial topic, and while there is evidence of a small increase in breast cancer risk with COCP use, it is not an absolute contraindication. It is important to consult with a healthcare provider to determine the best form of birth control for individual circumstances.
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This question is part of the following fields:
- Sexual Health
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Question 16
Incorrect
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A 14-year-old girl with cystic fibrosis complains of abdominal pain. She denies any accompanying nausea or vomiting. What is the most probable cause of her symptoms?
Your Answer: Irritable bowel syndrome
Correct Answer: Distal intestinal obstruction syndrome
Explanation:Distal Intestinal Obstruction Syndrome in Cystic Fibrosis Patients
Distal intestinal obstruction syndrome is a common complication in 10-20% of cystic fibrosis patients, with a higher incidence in adults. The condition is caused by the loss of CFTR function in the intestine, leading to the accumulation of mucous and fecal material in the terminal ileum, caecum, and ascending colon. Diagnosis is made through a plain abdominal radiograph, which shows faecal loading in the right iliac fossa, dilation of the ileum, and an empty distal colon. Ultrasound and CT scans can also be used to identify an obstruction mass and show dilated small bowel and proximal colon.
Treatment for mild and moderate episodes involves hydration, dietetic review, and regular laxatives. N-acetylcysteine can be used to loosen and soften the plugs, while severe episodes may require gastrografin or Klean-Prep. If there are signs of peritoneal irritation or complete bowel obstruction, surgical review should be obtained. Surgeons will often treat initially with intravenous fluids and a NG tube while keeping the patient nil by mouth. N-acetylcysteine can be put down the NG tube.
Overall, distal intestinal obstruction syndrome is a serious complication in cystic fibrosis patients that requires prompt diagnosis and treatment. With proper management, patients can avoid severe complications and maintain their quality of life.
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This question is part of the following fields:
- Gastroenterology
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Question 17
Incorrect
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A 23-year-old woman is admitted to the acute medical unit after intentionally overdosing on 60 paracetamol tablets over a period of 12 hours. She presents with abdominal pain and nausea and has a history of depression and anxiety. The patient is started on acetylcysteine treatment and is reviewed the following day. The blood results at 24 hours into admission show a pH of 7.29 (7.35 - 7.45), lactate of 1.9 mmol/L (0.9 - 1.6), paracetamol levels of 2 (< 3), creatinine of 155 µmol/L (55 - 120), prothrombin time of 18 secs (10-14 secs), ALT of 90 u/L (3 - 40), and bilirubin of 39 µmol/L (3 - 17). What is the next most definitive step in managing this patient?
Your Answer: Repeat acetylcysteine treatment
Correct Answer: Referral for liver transplant
Explanation:In cases of paracetamol overdose, liver transplantation may be necessary if certain criteria are met, such as an arterial pH below 7.3, 24 hours after ingestion. This patient has shown signs of severe hepatotoxicity and meets the criteria for referral to a liver transplant. It is not appropriate to discharge them with hepatology follow-up alone.
Metabolic acidosis is a serious indicator of paracetamol overdose and can be managed with supportive treatment such as intravenous sodium bicarbonate. However, this will not cure hepatotoxicity. Dialysis may be necessary for refractory acidosis, but it will not reverse the damage caused by the overdose. The most definitive treatment is a liver transplant.
This patient has already received acetylcysteine treatment, which replaces glutathione stores used up in the metabolism of paracetamol. However, they have not shown complete hepatocellular recovery, so repeated acetylcysteine treatment is not necessary.
Paracetamol overdose management guidelines were reviewed by the Commission on Human Medicines in 2012. The new guidelines removed the ‘high-risk’ treatment line on the normogram, meaning that all patients are treated the same regardless of their risk factors for hepatotoxicity. However, for situations outside of the normal parameters, it is recommended to consult the National Poisons Information Service/TOXBASE. Patients who present within an hour of overdose may benefit from activated charcoal to reduce drug absorption. Acetylcysteine should be given if the plasma paracetamol concentration is on or above a single treatment line joining points of 100 mg/L at 4 hours and 15 mg/L at 15 hours, regardless of risk factors of hepatotoxicity. Acetylcysteine is now infused over 1 hour to reduce adverse effects. Anaphylactoid reactions to IV acetylcysteine are generally treated by stopping the infusion, then restarting at a slower rate. The King’s College Hospital criteria for liver transplantation in paracetamol liver failure include arterial pH < 7.3, prothrombin time > 100 seconds, creatinine > 300 µmol/l, and grade III or IV encephalopathy.
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This question is part of the following fields:
- Pharmacology
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Question 18
Incorrect
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A 15-year-old boy complains of dull, throbbing pain and swelling in his left knee that is aggravated by his routine basketball practices. The boy also experiences a sensation of the left knee joint getting stuck and a painful 'click' when bending or straightening the left knee. Physical examination of the knee joint reveals a slight accumulation of fluid and a detectable loose body. Furthermore, tenderness is noticeable upon palpating the femoral condyles while the knee is flexed. What is the most appropriate diagnosis for this condition?
Your Answer: Baker's cyst
Correct Answer: Osteochondritis dissecans
Explanation:Osteochondritis dissecans is commonly seen in the knee joint and is characterized by knee pain after exercise, locking, and ‘clunking’. This condition is often caused by overuse of joints due to sports activities and can lead to secondary effects on joint cartilage, including pain, swelling, and possible formation of free bodies. Baker’s cyst, Osgood-Schlatter disease, and osteoarthritis are not the correct diagnoses as they present with different symptoms and causes.
Understanding Osteochondritis Dissecans
Osteochondritis dissecans (OCD) is a condition that affects the subchondral bone, usually in the knee joint, and can lead to secondary effects on the joint cartilage. It is most commonly seen in children and young adults and can progress to degenerative changes if left untreated. Symptoms of OCD include knee pain and swelling, catching, locking, and giving way, as well as a painful clunk when flexing or extending the knee. Signs of the condition include joint effusion and tenderness on palpation of the articular cartilage of the medial femoral condyle when the knee is flexed.
To diagnose OCD, X-rays and MRI scans are often used. X-rays may show the subchondral crescent sign or loose bodies, while MRI scans can evaluate cartilage, visualize loose bodies, stage the condition, and assess the stability of the lesion. Early diagnosis is crucial, as clinical signs may be subtle in the early stages. Therefore, there should be a low threshold for imaging and/or orthopedic opinion.
Overall, understanding OCD is important for recognizing its symptoms and seeking appropriate medical attention. With early diagnosis and management, patients can prevent the progression of the condition and maintain joint health.
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This question is part of the following fields:
- Musculoskeletal
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Question 19
Correct
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A 16-year-old girl is referred to cardiology outpatients with intermittent palpitations. She describes occasional spontaneous episodes of being abnormally aware of her heart. She says her heart rate is markedly increased during episodes. She has no significant medical or family history. She is on the oral contraceptive pill. ECG is performed. She is in sinus rhythm at 80 beats per min. PR interval is 108 ms. A slurring slow rise of the initial portion of the QRS complex is noted; QRS duration is 125 ms.
What is the correct diagnosis?Your Answer: Wolff–Parkinson–White syndrome
Explanation:Understanding Wolff-Parkinson-White Syndrome: An Abnormal Congenital Accessory Pathway with Tachyarrhythmia Episodes
Wolff-Parkinson-White (WPW) syndrome is a rare condition with an incidence of about 1.5 per 1000. It is characterized by the presence of an abnormal congenital accessory pathway that bypasses the atrioventricular node, known as the Bundle of Kent, and episodes of tachyarrhythmia. While the condition may be asymptomatic or subtle, it can increase the risk of sudden cardiac death.
The presence of a pre-excitation pathway in WPW results in specific ECG changes, including shortening of the PR interval, a Delta wave, and QRS prolongation. The ST segment and T wave may also be discordant to the major component of the QRS complex. These features may be more pronounced with increased vagal tone.
Upon diagnosis of WPW, risk stratification is performed based on a combination of history, ECG, and invasive cardiac electrophysiology studies. Treatment is only offered to those who are considered to have significant risk of sudden cardiac death. Definitive treatment involves the destruction of the abnormal electrical pathway by radiofrequency catheter ablation, which has a high success rate but is not without complication. Patients who experience regular tachyarrhythmias may be offered pharmacological treatment based on the specific arrhythmia.
Other conditions, such as first-degree heart block, pulmonary embolism, hyperthyroidism, and Wenckebach syndrome, have different ECG findings and are not associated with WPW. Understanding the specific features of WPW can aid in accurate diagnosis and appropriate management.
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This question is part of the following fields:
- Cardiology
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Question 20
Incorrect
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A 78-year-old male presents to the emergency department with severe pain in his left thigh. He has a history of recurrent UTIs and currently has a catheter in place. Upon examination, he is febrile and experiences significant tenderness in the left thigh, making it difficult to move his knee. Blood and bone cultures both come back positive, leading to a diagnosis of osteomyelitis. What organism is most likely responsible for this infection?
Your Answer: Neisseria gonorrhoeae
Correct Answer: Staphylococcus aureus
Explanation:Understanding Osteomyelitis: Types, Causes, and Treatment
Osteomyelitis is a bone infection that can be classified into two types: haematogenous and non-haematogenous. Haematogenous osteomyelitis is caused by bacteria that enter the bloodstream and is usually monomicrobial. It is more common in children, with vertebral osteomyelitis being the most common form in adults. Risk factors include sickle cell anaemia, intravenous drug use, immunosuppression, and infective endocarditis. On the other hand, non-haematogenous osteomyelitis results from the spread of infection from adjacent soft tissues or direct injury to the bone. It is often polymicrobial and more common in adults, with risk factors such as diabetic foot ulcers, pressure sores, diabetes mellitus, and peripheral arterial disease.
Staphylococcus aureus is the most common cause of osteomyelitis, except in patients with sickle-cell anaemia where Salmonella species predominate. To diagnose osteomyelitis, MRI is the imaging modality of choice, with a sensitivity of 90-100%. Treatment for osteomyelitis involves a six-week course of flucloxacillin. Clindamycin is an alternative for patients who are allergic to penicillin.
In summary, osteomyelitis is a bone infection that can be caused by bacteria entering the bloodstream or spreading from adjacent soft tissues or direct injury to the bone. It is more common in children and adults with certain risk factors. Staphylococcus aureus is the most common cause, and MRI is the preferred imaging modality for diagnosis. Treatment involves a six-week course of flucloxacillin or clindamycin for penicillin-allergic patients.
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This question is part of the following fields:
- Musculoskeletal
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Question 21
Correct
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A 50-year-old woman arrives at the Emergency Department complaining of cramp-like abdominal pain, nausea, and vomiting that started 4 hours ago. She describes the pain as intermittent and has experienced similar pain before, but not as severe as this time. The patient has a history of chronic obstructive pulmonary disease, which is well-controlled with inhalers, and has been a smoker for 25 pack years.
Her vital signs are heart rate 110/min, respiratory rate 20/min, blood pressure 130/84 mmHg, temperature 38.6ºC, and oxygen saturation of 99% on room air. Upon examination, the patient appears very ill and sweaty, with some yellowing of the eyes. Palpation of the abdomen reveals tenderness in the right upper quadrant.
What is the most likely cause of the patient's symptoms?Your Answer: Ascending cholangitis
Explanation:Cholangitis can occur even in the absence of stones, although they are commonly associated with the condition. ERCP can be used to drain the biliary tree, but surgical exploration of the common bile duct may be necessary in certain cases.
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.
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This question is part of the following fields:
- Surgery
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Question 22
Incorrect
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A 40-year-old man falls while skiing. He presents to your clinic with weakness of pincer grip and pain and laxity on valgus stress of his thumb. What is the most probable injury?
Your Answer: Scaphoid fracture
Correct Answer: Ulnar collateral ligament of the thumb injury
Explanation:There are several injuries that can affect the thumb and wrist. One common injury is a Ulnar collateral ligament (UCL) injury, also known as skier’s/gamekeeper’s thumb. This injury occurs when the thumb is forcefully abducted, causing damage to the UCL of the metacarpophalangeal joint. Symptoms include weak pincer grip, reduced range of motion, swelling, and burning pain. Treatment involves immobilization with a thumb spica, and surgery may be necessary for complete UCL rupture.
Another injury is a scaphoid fracture, which often occurs in older individuals who fall onto outstretched arms. Symptoms include pain and swelling in the anatomical snuff box, reduced range of motion, and pain with wrist and thumb movement. Fractures in the proximal one-third of the bone or displaced fractures may require surgery to prevent avascular necrosis.
Extensor pollicis longus strain is another injury that can occur from repetitive thumb and wrist extension, such as in manual labor or gardening. Symptoms include pain over the thumb and dorsal wrist, worsened with palpation and extension. Treatment involves rest, ice, and pain relief.
De Quervain’s tenosynovitis is an inflammation of the extensor pollicis brevis and abductor pollicis longus tendons, which pass through the first dorsal compartment. Symptoms include pain and swelling on the lateral aspect of the wrist, and pain is reproduced with Finkelstein’s test.
Finally, Bennett’s fracture is a less common injury that often occurs in boxing and can lead to osteoarthritis later in life. It is an intra-articular fracture of the first metacarpal bone, causing pain, bruising, swelling, and difficulty with pincer grip. Treatment may involve open reduction and fixation if there is significant displacement.
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This question is part of the following fields:
- Orthopaedics
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Question 23
Incorrect
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A 38-year-old woman visits her GP complaining of symptoms consistent with premenstrual syndrome. She reports experiencing severe pain that prevents her from working for 3-4 days before the start of her period each month. She has a regular 29-day cycle and has only recently started experiencing pain in the past year. She has never given birth and uses the progesterone-only pill for contraception. What is the best course of action for managing this patient's symptoms?
Your Answer: Trial of combined oral contraceptive pill
Correct Answer: Refer to gynaecology
Explanation:Patients experiencing secondary dysmenorrhoea should be referred to gynaecology for further investigation as it is often associated with underlying pathologies such as endometriosis, adenomyosis, fibroids, or pelvic inflammatory disease. While the combined oral contraceptive pill may provide relief, it is important to determine the root cause first. Fluoxetine is not appropriate for managing secondary dysmenorrhoea, as it is used for premenstrual dysphoric disorder. Intra-uterine devices may actually cause secondary dysmenorrhoea and should not be used. Tranexamic acid is not indicated for the management of secondary dysmenorrhoea, but rather for menorrhagia.
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.
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This question is part of the following fields:
- Gynaecology
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Question 24
Correct
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A 27-year-old woman presents to the emergency department with sudden onset, pleuritic chest pain that worsens on inspiration. She also experiences shortness of breath. She has no significant medical history or family history. Upon examination, she appears dyspnoeic, and a positive D-dimer test leads to a diagnosis of pulmonary embolism, confirmed by a subsequent CT pulmonary angiogram. There is no clear cause for the embolism. As a result, she is started on anticoagulation therapy. How long should this treatment continue?
Your Answer: 6 months
Explanation:The typical duration of treatment for unprovoked pulmonary embolisms is 6 months, with first-line treatment now being direct oral anticoagulants. Patients are usually reviewed after 3 months, and if no cause was found, treatment is continued for a further 3 months. 3 months would be appropriate for provoked embolisms, but as there was no clear cause in this case, 6 months is more appropriate. 4 months is not a standard duration of treatment, and 12 months is not usual either, although the doctor may decide to extend treatment after review. In some cases, lifelong anticoagulation may be recommended if an underlying prothrombotic condition is found, but for this patient, 6 months is appropriate.
Management of Pulmonary Embolism: NICE Guidelines
Pulmonary embolism (PE) is a serious condition that requires prompt management. The National Institute for Health and Care Excellence (NICE) updated their guidelines on the management of venous thromboembolism (VTE) in 2020, with some key changes. One of the significant changes is the recommendation to use direct oral anticoagulants (DOACs) as the first-line treatment for most people with VTE, including those with active cancer. Another change is the increasing use of outpatient treatment for low-risk PE patients, determined by a validated risk stratification tool.
Anticoagulant therapy is the cornerstone of VTE management, and the guidelines recommend using apixaban or rivaroxaban as the first-line treatment following the diagnosis of a PE. If neither of these is suitable, LMWH followed by dabigatran or edoxaban or LMWH followed by a vitamin K antagonist (VKA) can be used. For patients with active cancer, DOACs are now recommended instead of LMWH. The length of anticoagulation is determined by whether the VTE was provoked or unprovoked, with treatment typically stopped after 3-6 months for provoked VTE and continued for up to 6 months for unprovoked VTE.
In cases of haemodynamic instability, thrombolysis is recommended as the first-line treatment for massive PE with circulatory failure. Patients who have repeat pulmonary embolisms, despite adequate anticoagulation, may be considered for inferior vena cava (IVC) filters. However, the evidence base for IVC filter use is weak.
Overall, the updated NICE guidelines provide clear recommendations for the management of PE, including the use of DOACs as first-line treatment and outpatient management for low-risk patients. The guidelines also emphasize the importance of individualized treatment based on risk stratification and balancing the risks of VTE recurrence and bleeding.
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This question is part of the following fields:
- Medicine
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Question 25
Incorrect
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A 45-year-old woman presents to the rheumatology clinic with a 4-month history of myalgia and widespread bony tenderness. She reports increased fatigue and weakness when lifting heavy objects. Her medical history includes coeliac disease.
During the examination, tenderness is noted over the shoulder girdle and arms, but there is no associated joint stiffness. The patient has a waddling gait.
Blood tests are ordered and reveal the following results:
- Calcium: 1.9 mmol/L (normal range: 2.1 - 2.6)
- Phosphate: 0.8 mmol/L (normal range: 0.8 - 1.4)
- ALP: 176 u/L (normal range: 30 - 100)
What is the most likely diagnosis?Your Answer: Polymyalgia rheumatica
Correct Answer: Osteomalacia
Explanation:The correct diagnosis for a patient presenting with bone pain, muscle tenderness, and a waddling gait due to proximal myopathy is osteomalacia. This condition is caused by a demineralization of bone, often due to a deficiency in vitamin D. Laboratory tests may reveal hypocalcemia, low vitamin D levels, normal or elevated phosphate levels, and elevated alkaline phosphatase. Myositis, myotonic dystrophy, and osteoporosis are incorrect diagnoses as they do not present with the same symptoms or laboratory findings.
Understanding Osteomalacia
Osteomalacia is a condition that occurs when the bones become soft due to low levels of vitamin D, which leads to a decrease in bone mineral content. This condition is commonly seen in adults, while in growing children, it is referred to as rickets. The causes of osteomalacia include vitamin D deficiency, malabsorption, lack of sunlight, chronic kidney disease, drug-induced factors, inherited conditions, liver disease, and coeliac disease.
The symptoms of osteomalacia include bone pain, muscle tenderness, fractures, especially in the femoral neck, and proximal myopathy, which may lead to a waddling gait. To diagnose osteomalacia, blood tests are conducted to check for low vitamin D levels, low calcium and phosphate levels, and raised alkaline phosphatase levels. X-rays may also show translucent bands known as Looser’s zones or pseudofractures.
The treatment for osteomalacia involves vitamin D supplementation, with a loading dose often needed initially. Calcium supplementation may also be necessary if dietary calcium intake is inadequate. Understanding the causes, symptoms, and treatment options for osteomalacia is crucial in managing this condition effectively.
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This question is part of the following fields:
- Musculoskeletal
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Question 26
Correct
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A 19-year-old man is brought to the Emergency Department with a swollen face and lips, accompanied by wheeze after being stung by a bee. He is experiencing breathing difficulties and has a blood pressure reading of 83/45 mmHg from a manual reading. What is the next course of action?
Your Answer: Give 1 : 1000 intramuscular (im) adrenaline and repeat after 5 min if no improvement
Explanation:Treatment for Anaphylaxis
Anaphylaxis is a severe and life-threatening medical emergency that requires immediate treatment. The following are the appropriate steps to take when dealing with anaphylaxis:
Administer 1 : 1000 intramuscular (IM) adrenaline and repeat after 5 minutes if there is no improvement. Adrenaline should not be given intravenously unless the person administering it is skilled and experienced in its use. Routine use of IV adrenaline is not recommended.
Administer IV fluids if anaphylactic shock occurs to maintain the circulatory volume. Salbutamol nebulizers may help manage associated wheezing.
Do not give IV hydrocortisone as it takes several hours to work and anaphylaxis is rapidly life-threatening.
Do not observe the person as anaphylaxis may progress quickly.
Do not give 1 : 10 000 IV adrenaline as this concentration is only given during a cardiac arrest.
In summary, the immediate administration of 1 : 1000 IM adrenaline is the most critical step in treating anaphylaxis. IV adrenaline and hydrocortisone should only be given by skilled and experienced individuals. IV fluids and salbutamol nebulizers may also be used to manage symptoms.
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This question is part of the following fields:
- Acute Medicine And Intensive Care
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Question 27
Incorrect
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A 49-year-old woman, who had undergone a right-sided mastectomy for breast carcinoma, reports difficulty reaching forward and notices that the vertebral border of her scapula is closer to the midline on the side of surgery during a follow-up visit to the Surgical Outpatient Clinic. Which nerve is likely to have been injured to cause these symptoms?
Your Answer: Axillary
Correct Answer: Long thoracic
Explanation:Common Nerve Injuries and their Effects on Upper Limb Function
The nerves of the upper limb are vulnerable to injury, particularly during surgical procedures or trauma. Understanding the effects of nerve damage on muscle function is crucial for accurate diagnosis and treatment. Here are some common nerve injuries and their effects on upper limb function:
Long Thoracic Nerve: Injury to this nerve results in denervation of the serratus anterior muscle, causing winging of the scapula on clinical examination. The patient will be unable to protract the scapula, leading to weakened arm movements.
Musculocutaneous Nerve: This nerve innervates the biceps brachii, brachialis, and coracobrachialis muscles. Damage to this nerve results in weakened arm flexion and an inability to flex the forearm.
Axillary Nerve: The teres minor and deltoid muscles are innervated by this nerve. Fractures of the surgical neck of the humerus can endanger this nerve, resulting in an inability to abduct the upper limb beyond 15-20 degrees.
Radial Nerve: The extensors of the forearm and triceps brachii muscles are innervated by this nerve. Damage to this nerve results in an inability to extend the forearm, but arm extension is only slightly weakened due to the powerful latissimus muscle.
Suprascapular Nerve: This nerve innervates the supraspinatus and infraspinatus muscles, which are important for initiating abduction and external rotation of the shoulder joint. Damage to this nerve results in an inability to initiate arm abduction.
In conclusion, understanding the effects of nerve injuries on muscle function is crucial for accurate diagnosis and treatment of upper limb injuries.
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This question is part of the following fields:
- Surgery
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Question 28
Correct
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An anaesthetist administered anaesthesia to a 35-year-old pregnant woman in labour. The anaesthetist palpated the ischial spine transvaginally and then injected a local anaesthetic.
Injection of a local anaesthetic at this location anaesthetises a nerve that contains fibres from which of the following vertebral segments?Your Answer: S2, S3, S4
Explanation:Pudendal Nerve Block for Perineal Pain Relief during Childbirth
During childbirth, perineal pain can be relieved by anaesthetising the pudendal nerve. This nerve contains fibres from the S2, S3, and S4 anterior rami. To locate the nerve, the obstetrician palpates the ischial spine transvaginally as the nerve passes close to this bony feature. It is important to note that the pudendal nerve does not receive fibres from S5 or S1. The superior and inferior gluteal nerves receive fibres from L4 to S1 and L5 to S2, respectively, but they are not the nerves being targeted in this procedure.
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This question is part of the following fields:
- Neurology
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Question 29
Incorrect
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A 20-year-old woman complains of heavy and irregular periods, postcoital bleeding, and deep dyspareunia that have been present for the past six months.
What is the probable diagnosis for her symptoms?Your Answer: Fibroids
Correct Answer: Chronic pelvic inflammatory disease
Explanation:Chronic PID: A Possible Cause of Irregular Menses, Deep Dyspareunia, and Post-Coital Bleeding in Young Females
Chronic pelvic inflammatory disease (PID) is a possible diagnosis for young females experiencing irregular menses, deep dyspareunia, and post-coital bleeding. This condition is typically caused by a Chlamydia infection. PID is a result of the inflammation of the female reproductive organs, including the uterus, fallopian tubes, and ovaries. The inflammation can cause scarring and damage to the reproductive organs, leading to long-term complications such as infertility.
Irregular menses, deep dyspareunia, and post-coital bleeding are common symptoms of chronic PID. Irregular menses refer to menstrual cycles that are shorter or longer than the usual 28-day cycle. Deep dyspareunia is a condition where a woman experiences pain during sexual intercourse, particularly in the lower abdomen. Post-coital bleeding is the occurrence of vaginal bleeding after sexual intercourse.
Early diagnosis and treatment of chronic PID can prevent long-term complications. Treatment typically involves antibiotics to clear the infection and pain management to alleviate symptoms. In severe cases, surgery may be necessary to remove damaged tissue.
In conclusion, chronic PID is a possible cause of irregular menses, deep dyspareunia, and post-coital bleeding in young females.
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This question is part of the following fields:
- Gynaecology
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Question 30
Incorrect
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A 51-year-old man is admitted at the request of his concerned family due to increased confusion. This has occurred over the past 3 months and has become steadily worse. He was living independently and had been an active local councillor. Now he is unable to identify his family members.
Examination findings: pleasantly confused, intermittent jerky movements of both upper arms.
The following investigations were performed:
CT brain: normal
Dementia screen: normal
Which one of the following diagnostic tests will assist most in diagnosis?Your Answer:
Correct Answer: Electroencephalogram
Explanation:Investigations for Rapid Cognitive Decline in a Middle-Aged Patient: A Case of Sporadic Creutzfeldt-Jakob Disease
When a patient in their 60s presents with rapid cognitive decline and myoclonic jerks, the possibility of sporadic Creutzfeldt-Jakob disease (sCJD) should be considered. Despite negative findings from other investigations, a lumbar puncture and electroencephalogram (EEG) can support the diagnosis of sCJD. The EEG will show generalised bi- or triphasic periodic sharp wave complexes, while definitive diagnosis can only be made from biopsy. Doppler ultrasound of carotids is relevant for vascular dementia, but the steady decline in this case suggests sCJD. Magnetic resonance imaging (MRI) brain is unlikely to aid diagnosis, and muscle biopsy is unnecessary as myoclonic jerks are a symptom of sCJD. Bone marrow biopsy is only useful if myelodysplastic syndrome is suspected, which is not the case here.
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This question is part of the following fields:
- Neurology
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