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  • Question 1 - A 65-year-old male is admitted to the respiratory ward for severe community-acquired pneumonia...

    Correct

    • A 65-year-old male is admitted to the respiratory ward for severe community-acquired pneumonia and is being treated with amoxicillin. He has a medical history of a heart attack 2 years ago, hypertension, and type 2 diabetes. His current medications include aspirin 75 mg, atorvastatin 40 mg, ramipril 5mg, bendroflumethiazide 5mg, and metformin 500 mg BD. On the third day of treatment, the medical team noticed that the patient's creatinine levels increased from a baseline of 67 micromol/litre to 190 micromol/litre. His eGFR is found to be 25 ml/min, and he is diagnosed with acute kidney injury. Which of the patient's current medications can he continue taking in his current condition?

      Your Answer: Aspirin

      Explanation:

      In cases of acute kidney injury (AKI), it is important to identify drugs that may worsen renal function and those that can result in toxicity. AKI is defined as a 50% or greater rise in serum creatinine within the past 7 days or a fall in urine output to less than 0.5 ml/kg/hour for more than 6 hours.

      For patients on aspirin for secondary prevention of acute coronary syndrome, the cardioprotective dose of 75 mg per day should be continued as there is strong evidence supporting its use. Aspirin is a COX-inhibitor that inhibits thromboxane synthesis via the COX-1 pathway, exhibiting antithrombotic effects.

      Drugs that should be stopped in AKI as they may worsen renal function include diuretics, aminoglycosides, ACE inhibitors/ARBs, and NSAIDs that are not at cardioprotective doses. On the other hand, drugs that do not worsen renal function but can result in toxicity include metformin, lithium, and digoxin. A helpful mnemonic to remember the drugs to stop in AKI is DAMN AKI: Diuretics, Aminoglycosides and ACE inhibitors, Metformin, and NSAIDs.

      Understanding Acute Kidney Injury: A Basic Overview

      Acute kidney injury (AKI) is a condition where the kidneys experience a reduction in function due to an insult. In the past, the kidneys were often neglected in acute medicine, resulting in slow recognition and limited action. However, around 15% of patients admitted to the hospital develop AKI. While most patients recover their renal function, some may have long-term impaired kidney function due to AKI, which can result in acute complications, including death. Identifying patients at increased risk of AKI is crucial in reducing its incidence. Risk factors for AKI include chronic kidney disease, other organ failure/chronic disease, a history of AKI, and the use of drugs with nephrotoxic potential.

      AKI has three main causes: prerenal, intrinsic, and postrenal. Prerenal causes are due to a lack of blood flow to the kidneys, while intrinsic causes relate to intrinsic damage to the kidneys themselves. Postrenal causes occur when there is an obstruction to the urine coming from the kidneys. Symptoms of AKI include reduced urine output, fluid overload, arrhythmias, and features of uraemia. Diagnosis of AKI is made through blood tests, urinalysis, and imaging.

      The management of AKI is largely supportive, with careful fluid balance and medication review being crucial. Loop diuretics and low-dose dopamine are not recommended, but hyperkalaemia needs prompt treatment to avoid life-threatening arrhythmias. Renal replacement therapy may be necessary in severe cases. Prompt review by a urologist is required for patients with suspected AKI secondary to urinary obstruction, while specialist input from a nephrologist is necessary for cases where the cause is unknown or the AKI is severe.

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  • Question 2 - A 63-year-old male was admitted to the intensive care unit 2 weeks ago...

    Correct

    • A 63-year-old male was admitted to the intensive care unit 2 weeks ago following an anterior myocardial infarction secondary to severe microcytic anaemia. Today, he appears drowsy and on assessment, bilateral basal crackles and reduced air entry are discovered. The observations and monitor values are given below:

      Oxygen saturation: 85% on 2L oxygen via nasal specs.
      Respiratory rate: 30 breaths per minute.
      Pulse rate: 105 beats per minute.
      Temperature: 36.8 Celsius.
      Blood pressure (via arterial line): 100/60 mmHg.
      Pulmonary capillary wedge pressure: 28 mmHg (2 - 15 mmHg).

      His arterial blood gas (ABG) is given below:

      pH 7.24 (7.35-7.45)
      PaO2 10.2 kPa (10 - 13 kPa)
      PaCO2 7.3 kPa (4.6 - 6.1 kPa)
      HCO3- 22 mmol/L (22 - 26 mmol/L)
      Glucose 6.8 mmol/L (4.0 - 7.8 mmol/L)

      His chest x-ray shows bilateral ill-demarcated fluffy opacification, especially around the hilar regions, with a horizontal, sharp white line in the right mid-zone.

      What is the most likely diagnosis, given the above?

      Your Answer: Cardiac pulmonary oedema

      Explanation:

      The patient’s drowsiness can be attributed to the high CO2 levels, but it is unclear whether the cause is acute respiratory distress syndrome (ARDS) or pulmonary edema related to cardiac issues. To determine the likely diagnosis, we need to consider certain factors.

      While the patient’s history of blood transfusion may suggest ARDS, this condition typically occurs within four hours of transfusion. Additionally, the patient’s symptoms have an acute onset, and radiological criteria for ARDS are met. However, the high pulmonary capillary wedge pressure indicates a backlog of blood in the veins, which is a sensitive indicator of cardiac failure. This, along with the recent myocardial infarction, makes pulmonary edema related to cardiac issues more probable than ARDS.

      Fibrosis is unlikely given the acute nature of the symptoms, and there is no mention of amiodarone use. The patient’s condition does not fit the criteria for transfusion-related acute lung injury (TRALI), which occurs within six hours of transfusion. Bilateral pneumonia is rare, and the patient’s lack of fever and chest x-ray findings support pulmonary edema (fluid in the horizontal fissure and hilar edema) rather than consolidation.

      Understanding Acute Respiratory Distress Syndrome (ARDS)

      Acute respiratory distress syndrome (ARDS) is a serious medical condition that occurs when the alveolar capillaries become more permeable, leading to the accumulation of fluid in the alveoli. This condition, also known as non-cardiogenic pulmonary edema, has a mortality rate of around 40% and can cause significant morbidity in those who survive. ARDS can be caused by various factors, including infections like sepsis and pneumonia, massive blood transfusions, trauma, smoke inhalation, acute pancreatitis, and even COVID-19.

      The clinical features of ARDS are typically severe and sudden, including dyspnea, elevated respiratory rate, bilateral lung crackles, and low oxygen saturations. To diagnose ARDS, doctors may perform a chest x-ray and arterial blood gases. The American-European Consensus Conference has established criteria for ARDS diagnosis, including an acute onset within one week of a known risk factor, bilateral infiltrates on chest x-ray, non-cardiogenic pulmonary edema, and a pO2/FiO2 ratio of less than 40 kPa (300 mmHg).

      Due to the severity of ARDS, patients are generally managed in the intensive care unit (ICU). Treatment may involve oxygenation and ventilation to address hypoxemia, general organ support like vasopressors as needed, and addressing the underlying cause of ARDS, such as antibiotics for sepsis. Certain strategies, such as prone positioning and muscle relaxation, have been shown to improve outcomes in ARDS.

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  • Question 3 - A 32-year-old man presents to his GP with persistent symptoms three weeks after...

    Correct

    • A 32-year-old man presents to his GP with persistent symptoms three weeks after a flare of ulcerative colitis. Despite daily use of topical mesalazine, he reports passing stool with a small amount of blood up to three times daily. His vital signs are within normal limits, and blood tests reveal elevated WBC and ESR levels. What is the most appropriate next step in managing this patient?

      Your Answer: Add oral mesalazine, continue topical mesalazine

      Explanation:

      If a patient with distal ulcerative colitis experiences a mild-moderate flare that does not respond to topical aminosalicylates, oral aminosalicylates should be added as an adjunct therapy. In this case, the patient’s symptoms are typical of a mild flare according to Truelove and Witt’s criteria. As his symptoms are not improving with topical treatment, oral mesalazine should be added while continuing the topical mesalazine. Oral steroids are not currently indicated for this patient’s mild flare. It is important to continue the topical therapy alongside the oral therapy for optimal management. If symptoms do not improve within two weeks, the patient should schedule a follow-up appointment.

      Ulcerative colitis can be managed through inducing and maintaining remission. The severity of the condition is classified as mild, moderate, or severe based on the number of stools and presence of systemic upset. Treatment for mild-to-moderate cases of proctitis involves using topical aminosalicylate, while proctosigmoiditis and left-sided ulcerative colitis may require a combination of oral and topical medications. Extensive disease may require a high-dose oral aminosalicylate and topical treatment. Severe colitis should be treated in a hospital with intravenous steroids or ciclosporin. Maintaining remission can involve using a low maintenance dose of an oral aminosalicylate or oral azathioprine/mercaptopurine. Methotrexate is not recommended, but probiotics may prevent relapse in mild to moderate cases.

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  • Question 4 - Primary biliary cirrhosis is most characteristically associated with: ...

    Incorrect

    • Primary biliary cirrhosis is most characteristically associated with:

      Your Answer: Anti-neutrophil cytoplasmic antibodies

      Correct Answer: Anti-mitochondrial antibodies

      Explanation:

      The M rule for primary biliary cholangitis includes the presence of IgM and anti-Mitochondrial antibodies, specifically the M2 subtype, in middle-aged women.

      Primary Biliary Cholangitis: A Chronic Liver Disorder

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

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

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

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  • Question 5 - A 45-year-old man has been referred to the hepatology clinic by his GP...

    Correct

    • A 45-year-old man has been referred to the hepatology clinic by his GP due to concerns of developing chronic liver disease. The patient reports feeling increasingly fatigued over the past few years, which he attributes to poor sleep and low libido causing relationship problems with his partner. During examination, the hepatologist notes the presence of gynaecomastia, palmar erythema, and grey skin pigmentation. Blood tests are ordered to investigate the underlying cause.

      The following results were obtained:

      Bilirubin: 18 µmol/L (3 - 17)
      ALP: 110 u/L (30 - 100)
      ALT: 220 u/L (3 - 40)
      γGT: 90 u/L (8 - 60)
      Albumin: 37 g/L (35 - 50)
      Ferritin: 1,250 ng/mL (20 - 230)

      What is the initial treatment that should be offered to this patient?

      Your Answer: Venesection

      Explanation:

      Understanding Haemochromatosis: Investigation and Management

      Haemochromatosis is a genetic disorder that causes iron accumulation in the body due to mutations in the HFE gene on both copies of chromosome 6. The best investigation to screen for haemochromatosis is still a topic of debate. For the general population, transferrin saturation is considered the most useful marker, while genetic testing for HFE mutation is recommended for testing family members. Diagnostic tests include molecular genetic testing for the C282Y and H63D mutations and liver biopsy with Perl’s stain. A typical iron study profile in a patient with haemochromatosis includes high transferrin saturation, raised ferritin and iron, and low TIBC.

      The first-line treatment for haemochromatosis is venesection, which involves removing blood from the body to reduce iron levels. Transferrin saturation should be kept below 50%, and the serum ferritin concentration should be below 50 ug/l to monitor the adequacy of venesection. If venesection is not effective, desferrioxamine may be used as a second-line treatment. Joint x-rays may show chondrocalcinosis, which is a characteristic feature of haemochromatosis. It is important to note that there are rare cases of families with classic features of genetic haemochromatosis but no mutation in the HFE gene.

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  • Question 6 - Which type of neurone has its cell body situated in the central nervous...

    Correct

    • Which type of neurone has its cell body situated in the central nervous system and is primarily responsible for connecting other neurones?

      Your Answer: An association neurone (inter-neurone)

      Explanation:

      Association Neurones and neuroglial Cells in the Central Nervous System

      Association neurones are present in the central nervous system and their primary function is to connect afferent neurones that bring information into the central nervous system to efferent neurones that carry information away from the central nervous system. Afferent neurones are responsible for transmitting sensory information from peripheral receptors to the central nervous system, while efferent neurones transmit motor information from the central nervous system to effectors such as muscles or glands.

      In addition to neurones, the nervous system also contains neuroglial cells. These non-neuronal cells provide support and nutrition to the nervous system. neuroglial cells are essential for the proper functioning of the nervous system and play a crucial role in maintaining the health of neurones.

      the role of association neurones and neuroglial cells is essential for comprehending the functioning of the central nervous system. These cells work together to ensure that the nervous system can receive and transmit information effectively. By studying these cells, researchers can gain insights into the mechanisms underlying various neurological disorders and develop new treatments to address them.

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  • Question 7 - A 60-year-old male patient complains of chronic productive cough and difficulty breathing. He...

    Correct

    • A 60-year-old male patient complains of chronic productive cough and difficulty breathing. He has been smoking 10 cigarettes per day for the past 30 years. What is the number of pack years equivalent to his smoking history?

      Your Answer: 15

      Explanation:

      Pack Year Calculation

      Pack year calculation is a tool used to estimate the risk of tobacco exposure. It is calculated by multiplying the number of packs of cigarettes smoked per day by the number of years of smoking. One pack of cigarettes contains 20 cigarettes. For instance, if a person smoked half a pack of cigarettes per day for 30 years, their pack year history would be 15 (1/2 x 30 = 15).

      The pack year calculation is a standardized method of measuring tobacco exposure. It helps healthcare professionals to estimate the risk of developing smoking-related diseases such as lung cancer, chronic obstructive pulmonary disease (COPD), and heart disease. The higher the pack year history, the greater the risk of developing these diseases. Therefore, it is important for individuals who smoke or have a history of smoking to discuss their pack year history with their healthcare provider to determine appropriate screening and prevention measures.

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  • Question 8 - John is a 44-year-old man who presented to you a month ago with...

    Incorrect

    • John is a 44-year-old man who presented to you a month ago with a 6-week history of upper abdominal pain, heartburn, and occasional reflux. His medical history is unremarkable, and you both agreed on a plan for a 1-month trial of omeprazole 20 mg daily.

      John returns for a follow-up appointment after completing the course of omeprazole. Unfortunately, his symptoms have only slightly improved and are still causing him distress.

      What would be the most suitable course of action to manage John's persistent symptoms?

      Your Answer: Refer for routine upper gastrointestinal endoscopy

      Correct Answer: Test for Helicobacter pylori infection in 2 weeks and treat if positive

      Explanation:

      If initial treatment for dyspepsia with either a PPI or ‘test and treat’ approach fails, the other approach should be tried next. NICE guidelines recommend prescribing a full-dose PPI for 1 month or testing for H. pylori infection and prescribing eradication therapy if positive. If symptoms persist, switch to the alternative strategy. Referral for routine upper GI endoscopy is not indicated at this stage.

      Management of Dyspepsia and Referral for Possible Cancer

      Dyspepsia is a common symptom that can be caused by various factors, including medication and lifestyle choices. However, it can also be a sign of underlying conditions such as stomach or oesophageal cancer. The 2015 NICE guidelines provide updated advice on when urgent referral for endoscopy is necessary. Patients with dysphagia or an upper abdominal mass consistent with stomach cancer should be referred urgently. Patients aged 55 years or older with weight loss and upper abdominal pain, reflux, or dyspepsia should also be referred urgently. Non-urgent referrals include patients with haematemesis or those with treatment-resistant dyspepsia, upper abdominal pain with low haemoglobin levels, or raised platelet count with other symptoms.

      For patients with undiagnosed dyspepsia, a step-wise approach is recommended. First, medications should be reviewed for possible causes. Lifestyle advice should also be given. If symptoms persist, a trial of full-dose proton pump inhibitor for one month or a ‘test and treat’ approach for H. pylori can be tried. If symptoms persist after either approach, the alternative should be attempted. Testing for H. pylori infection can be done using a carbon-13 urea breath test, stool antigen test, or laboratory-based serology. If symptoms resolve following test and treat, there is no need to check for H. pylori eradication. However, if repeat testing is required, a carbon-13 urea breath test should be used.

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  • Question 9 - A 35-year-old woman presents to the hospital after experiencing her first unprovoked seizure....

    Correct

    • A 35-year-old woman presents to the hospital after experiencing her first unprovoked seizure. She seeks guidance from the neurology clinic on whether she can continue driving as she needs to take her children to school. Although the neurologist has not yet diagnosed her with epilepsy, they plan to reassess her in 6 months. What recommendations should you provide to her?

      Your Answer: She should inform the DVLA and will have to be seizure free for 6 months before she can apply to have her license reinstated

      Explanation:

      After experiencing their first seizure, individuals must wait for a period of 6 months without any further seizures before they can apply to the DVLA to have their license reinstated. However, if they have been diagnosed with epilepsy, they must wait for a minimum of 12 months without any seizures before reapplying to the DVLA for their license to be reissued. It is crucial to understand that it is the patient’s responsibility to inform the DVLA and they should not drive until they have received permission from the DVLA. It is important to note that the medical team is not responsible for informing the DVLA. It is essential to keep in mind that the requirements may differ if the individual intends to drive a public or heavy goods vehicle.

      The DVLA has guidelines for drivers with neurological disorders. Those with epilepsy/seizures must not drive and must inform the DVLA. The length of time off driving varies depending on the type and frequency of seizures. Those with syncope may need time off driving depending on the cause and number of episodes. Those with other conditions such as stroke, craniotomy, pituitary tumor, narcolepsy/cataplexy, and chronic neurological disorders should inform the DVLA and may need time off driving.

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  • Question 10 - A 30-year-old woman is currently admitted to the antenatal ward after giving birth...

    Correct

    • A 30-year-old woman is currently admitted to the antenatal ward after giving birth 5 hours ago. She experienced antepartum haemorrhage during labour and lost approximately 1200 ml of blood. Upon arrival at the ward, she complained of feeling weak, prompting a blood test to check for anaemia. The results are as follows:

      - Hb 66 g/L (Male: 135-180, Female: 115-160)
      - Platelets 302 * 109/L (150-400)
      - WBC 9.4 * 109/L (4.0-11.0)

      The patient has no significant medical history, is not taking any regular medications, and has not received any blood transfusions in the past. Based on these results, should the patient be given a transfusion of packed red blood cells? What is the transfusion threshold for this patient?

      Your Answer: Yes - transfusion threshold is 70 g/L

      Explanation:

      According to the 2015 NICE guidance, patients without acute coronary syndrome should receive a packed red blood cell transfusion if their Hb level falls below 70 g/L. As the patient’s Hb level is 66 g/L, she should receive a transfusion. The transfusion threshold is not 50 g/L, 65 g/L, 80 g/L, or 100 g/L.

      Guidelines for Red Blood Cell Transfusion

      In 2015, NICE released guidelines for the use of blood products, specifically red blood cells. These guidelines recommend different transfusion thresholds for patients with and without acute coronary syndrome (ACS). For patients without ACS, the transfusion threshold is 70 g/L, while for those with ACS, it is 80 g/L. The target hemoglobin level after transfusion is 70-90 g/L for patients without ACS and 80-100 g/L for those with ACS. It is important to note that these thresholds should not be used for patients with ongoing major hemorrhage or those who require regular blood transfusions for chronic anemia.

      When administering red blood cells, it is crucial to store them at 4°C prior to infusion. In non-urgent scenarios, a unit of RBC is typically transfused over a period of 90-120 minutes. By following these guidelines, healthcare professionals can ensure that red blood cell transfusions are administered safely and effectively.

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  • Question 11 - An 80-year-old man is admitted to the hospital with constipation, confusion, and fatigue....

    Correct

    • An 80-year-old man is admitted to the hospital with constipation, confusion, and fatigue. He has a medical history of hypertension, hypercholesterolemia, and prostate cancer. His blood work shows a significantly elevated calcium level. What is the expected ECG result?

      Your Answer: Shortening of the QT interval

      Explanation:

      Patients with cancer have a high risk of developing hypercalcemia, which is linked to a shortened QT interval. The QT interval can also be prolonged due to electrolyte imbalances such as hypokalemia, hypomagnesemia, and hypocalcemia, as well as hypothermia, myocardial ischemia, and congenital long QT syndrome. First-degree heart block is characterized by a fixed prolonged PR interval, while hyperkalemia is indicated by tall T waves that may be followed by flattened P waves, PR prolongation, and a sine-wave appearance. S1Q3T3, which refers to an S wave in lead I, a Q wave in lead III, and an inverted T wave in lead III, is a rare finding that is often associated with pulmonary embolism (PE), but it is not a reliable indicator of this condition.

      Hypercalcaemia: Symptoms and Signs

      Hypercalcaemia is a medical condition characterized by high levels of calcium in the blood. The symptoms and signs of hypercalcaemia can be remembered by the phrase ‘bones, stones, groans and psychic moans’. This means that patients with hypercalcaemia may experience bone pain, kidney stones, constipation, and changes in mood or behavior. In addition, corneal calcification and a shortened QT interval on an electrocardiogram (ECG) may also be present. Hypertension, or high blood pressure, is another common feature of hypercalcaemia. It is important to seek medical attention if any of these symptoms are present, as hypercalcaemia can lead to serious complications if left untreated.

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  • Question 12 - An aged man with aortic stenosis is evaluated. What could potentially decrease the...

    Correct

    • An aged man with aortic stenosis is evaluated. What could potentially decrease the intensity of his ejection systolic murmur?

      Your Answer: Left ventricular systolic dysfunction

      Explanation:

      A reduction in flow-rate across the aortic valve and a murmur that is less audible are consequences of left ventricular systolic dysfunction.

      Aortic Stenosis: Symptoms, Causes, and Management

      Aortic stenosis is a condition characterized by the narrowing of the aortic valve, which can lead to various symptoms. These symptoms include chest pain, dyspnea, syncope, and a characteristic ejection systolic murmur that radiates to the carotids. Severe aortic stenosis can also cause a narrow pulse pressure, slow rising pulse, delayed ESM, soft/absent S2, S4, thrill, and left ventricular hypertrophy or failure. The most common causes of aortic stenosis are degenerative calcification in older patients and bicuspid aortic valve in younger patients.

      If a patient is asymptomatic, observation is usually recommended. However, if the patient is symptomatic or has a valvular gradient greater than 40 mmHg with features such as left ventricular systolic dysfunction, valve replacement is necessary. Surgical AVR is the preferred treatment for young, low/medium operative risk patients, while TAVR is used for those with a high operative risk. Balloon valvuloplasty may be used in children without aortic valve calcification and in adults with critical aortic stenosis who are not fit for valve replacement.

      In summary, aortic stenosis is a condition that can cause various symptoms and requires prompt management to prevent complications. The causes of aortic stenosis vary, and treatment options depend on the patient’s age, operative risk, and overall health.

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  • Question 13 - A 25-year-old man is brought to the emergency department after being submerged. Upon...

    Correct

    • A 25-year-old man is brought to the emergency department after being submerged. Upon arrival, the patient is found to be in ventricular fibrillation (VF) on ECG and has a temperature of 26 degrees centigrade. You have already administered three defibrillation shocks and initiated active and passive rewarming, but the patient remains in VF. What should be your next steps in managing this patient?

      Your Answer: Continue chest compressions but withhold shocks until patient's temperature >30 degrees

      Explanation:

      When hypothermia leads to cardiac arrest, defibrillation is not as effective and should be limited to three shocks before the patient is warmed up to 30 degrees Celsius. Pacing is also ineffective until the patient reaches normal body temperature. Medications should be held off until the patient reaches 30 degrees Celsius, and then administered at double the usual intervals until the patient achieves normal body temperature or experiences the return of spontaneous circulation (ROSC).

      Hypothermia is a condition where the core body temperature drops below normal levels, often caused by exposure to cold environments. It is most common in the winter and the elderly are particularly susceptible. Signs include shivering, cold and pale skin, slurred speech, and confusion. Treatment involves removing the patient from the cold environment, warming the body with blankets, securing the airway, and monitoring breathing. Rapid re-warming should be avoided as it can lead to peripheral vasodilation and shock. Certain actions, such as putting the person in a hot bath or giving them alcohol, should be avoided.

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  • Question 14 - A 28-year-old junior doctor presents to the Emergency department with complaints of a...

    Correct

    • A 28-year-old junior doctor presents to the Emergency department with complaints of a severe headache and neck stiffness. He reports experiencing mild diarrhoea over the past few days and some coryzal symptoms. On examination, his blood pressure is 155/82 mmHg, his pulse is 85 and regular, and his temperature is 37.8℃. He displays signs consistent with severe meningism, but there are no skin rashes or other signs of vasculitis.

      The following investigations were conducted:
      - Haemoglobin: 138 g/L (135-177)
      - White cells: 8.9 ×109/L (4-11)
      - Platelet: 183 ×109/L (150-400)
      - Sodium: 141 mmol/L (135-146)
      - Potassium: 4.4 mmol/L (3.5-5)
      - Creatinine: 92 µmol/L (79-118)
      - Lumbar puncture: lymphocytosis, slightly raised protein, normal glucose.

      What is the most likely diagnosis?

      Your Answer: Enterovirus meningitis

      Explanation:

      Enterovirus Meningitis: The Commonest Cause of Viral Meningitis in Adults

      Enterovirus meningitis is the most common cause of viral meningitis in adults. The symptoms of a mild diarrhoeal illness and a runny nose, along with the lumbar puncture findings, are consistent with this diagnosis. The management of viral meningitis is conservative, with adequate hydration and analgesia.

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  • Question 15 - A 27-year-old woman presents to the emergency department with sudden onset, pleuritic chest...

    Correct

    • 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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  • Question 16 - A 63-year-old man comes to the emergency department complaining of 'flutters in his...

    Correct

    • A 63-year-old man comes to the emergency department complaining of 'flutters in his chest' for the past 24 hours. He is aware of when his symptoms started and mentions having had 2 non-ST-elevation myocardial infarctions before. He has hypertension, which is controlled with perindopril monotherapy, and hypercholesterolaemia treated with atorvastatin. He has no other relevant medical history.

      During the examination, the patient is alert and oriented. His blood pressure is 135/90 mmHg, heart rate is 112 beats per minute, temperature is 37.3ºC, and respiratory rate is 16 breaths per minute. An ECG shows an irregularly irregular rhythm. After discussing with the patient, a management plan is suggested.

      What is the most likely management plan to be initiated for this patient based on his presentation?

      Your Answer: Begin anticoagulation, undergo immediate direct current (DC) cardioversion

      Explanation:

      When a patient presents with new-onset atrial fibrillation (AF), the management plan depends on the duration and recurrence of symptoms, as well as risk stratification. If symptoms have been present for less than 48 hours, electrical cardioversion is recommended, but anticoagulation should be started beforehand. Heparin is a good choice for rapid onset anticoagulation. However, if symptoms have been present for more than 48 hours, there is a higher risk of atrial thrombus, which may cause thromboembolic disease. In this case, a transoesophageal echocardiogram (TOE) should be obtained to exclude a thrombus before cardioversion, or anticoagulation should be started for 3 weeks prior to cardioversion. Amiodarone oral therapy is not adequate for cardioversion in acute AF. If cardioversion is not possible, a DOAC such as apixaban or rivaroxaban should be started. Discharge home is appropriate for patients with chronic AF or after cardioversion. While pharmacological cardioversion with intravenous amiodarone is an option, electrical cardioversion is preferred according to NICE guidelines, especially in patients with structural heart disease.

      Atrial Fibrillation and Cardioversion: Elective Procedure for Rhythm Control

      Cardioversion is a medical procedure used in atrial fibrillation (AF) to restore the heart’s normal rhythm. There are two scenarios where cardioversion may be used: as an emergency if the patient is haemodynamically unstable, or as an elective procedure where a rhythm control strategy is preferred. In the elective scenario, cardioversion can be performed either electrically or pharmacologically. Electrical cardioversion is synchronised to the R wave to prevent delivery of a shock during the vulnerable period of cardiac repolarisation when ventricular fibrillation can be induced.

      According to the 2014 NICE guidelines, rate or rhythm control should be offered if the onset of the arrhythmia is less than 48 hours, and rate control should be started if it is more than 48 hours or is uncertain. If the AF is definitely of less than 48 hours onset, patients should be heparinised and may be cardioverted using either electrical or pharmacological means. However, if the patient has been in AF for more than 48 hours, anticoagulation should be given for at least 3 weeks prior to cardioversion. An alternative strategy is to perform a transoesophageal echo (TOE) to exclude a left atrial appendage (LAA) thrombus. If excluded, patients may be heparinised and cardioverted immediately.

      NICE recommends electrical cardioversion in this scenario, rather than pharmacological. If there is a high risk of cardioversion failure, it is recommended to have at least 4 weeks of amiodarone or sotalol prior to electrical cardioversion. Following electrical cardioversion, patients should be anticoagulated for at least 4 weeks. After this time, decisions about anticoagulation should be taken on an individual basis depending on the risk of recurrence.

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  • Question 17 - A young man with asthma presented to the ED complaining of shortness of...

    Incorrect

    • A young man with asthma presented to the ED complaining of shortness of breath. He was unable to speak in complete sentences and his PEFR was 50% of predicted. His heart rate was 90/min and respiratory rate was 24/min. Despite using his regular inhaler, he did not experience any relief. The patient was given nebulised salbutamol, oral prednisolone and ipratropium bromide, and his acute treatment was discontinued 10 hours ago. Currently, his PEFR is 80% of predicted and he has been stable on discharge medication. The doctor's notes indicate that he demonstrated proper inhaler technique. What other criteria must he meet before being discharged?

      Your Answer: She needs a PEFR of above 80%

      Correct Answer: She needs to be stable on discharge medication for at least 12-24 hours before discharge

      Explanation:

      Management of Acute Asthma

      Acute asthma is classified by the British Thoracic Society (BTS) into three categories: moderate, severe, and life-threatening. Patients with any of the life-threatening features should be treated as having a life-threatening attack. A fourth category, Near-fatal asthma, is also recognized. Further assessment may include arterial blood gases for patients with oxygen saturation levels below 92%. A chest x-ray is not routinely recommended unless the patient has life-threatening asthma, suspected pneumothorax, or failure to respond to treatment.

      Admission criteria include a previous near-fatal asthma attack, pregnancy, an attack occurring despite already using oral corticosteroid, and presentation at night. All patients with life-threatening asthma should be admitted to the hospital, and patients with features of severe acute asthma should also be admitted if they fail to respond to initial treatment. Oxygen therapy should be started for hypoxaemic patients. Bronchodilation with short-acting beta₂-agonists (SABA) is recommended, and all patients should be given 40-50 mg of prednisolone orally daily. Ipratropium bromide and IV magnesium sulphate may also be considered for severe or life-threatening asthma. Patients who fail to respond require senior critical care support and should be treated in an appropriate ITU/HDU setting. Criteria for discharge include stability on discharge medication, checked and recorded inhaler technique, and PEF levels above 75% of best or predicted.

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  • Question 18 - An 80-year-old man comes to the clinic with his son. The son reports...

    Correct

    • An 80-year-old man comes to the clinic with his son. The son reports that his father's memory has been declining for the past 8 months and he has been experiencing fluctuations in attention and consciousness. The patient has also reported seeing dogs and children running around in his living room. The patient has a medical history of resting tremors, rigidity, and shuffling gait for the past 10 years. However, there is no history of mood swings or urinary or bowel incontinence. On examination, there are no postural changes in his blood pressure. What is the most likely diagnosis?

      Your Answer: Parkinson's disease dementia

      Explanation:

      Dementia with Lewy bodies (DLB) and Parkinson’s disease dementia (PDD) share similar features such as tremors, rigidity, postural instability, fluctuating cognition, and hallucinations. However, they can be differentiated based on the time of onset of dementia compared to motor symptoms. PDD is diagnosed if a patient had a Parkinson’s disease diagnosis for at least 1 year before the emergence of dementia. In contrast, DLB would have dementia occurring first followed by motor symptoms. This patient has had 8 years of preceding motor symptoms before the onset of dementia, making PDD more likely. It is important to distinguish between the two as their management varies significantly. Levodopa is the mainstay of treatment in PDD, whereas rivastigmine is the drug of choice in DLB. Treating this patient as DLB may miss out on important elements of treatment needed in patients with PDD. Frontotemporal dementia (FTD) and multiple system atrophy are not likely diagnoses in this case as they have different clinical features.

      Understanding Lewy Body Dementia

      Lewy body dementia is a type of dementia that is becoming more recognized as a cause of cognitive impairment, accounting for up to 20% of cases. It is characterized by the presence of alpha-synuclein cytoplasmic inclusions, known as Lewy bodies, in certain areas of the brain. While there is a complicated relationship between Parkinson’s disease and Lewy body dementia, with dementia often seen in Parkinson’s disease, the two conditions are distinct. Additionally, up to 40% of patients with Alzheimer’s disease have Lewy bodies.

      The features of Lewy body dementia include progressive cognitive impairment, which typically occurs before parkinsonism, but both features usually occur within a year of each other. Unlike other forms of dementia, cognition may fluctuate, and early impairments in attention and executive function are more common than memory loss. Other features include parkinsonism, visual hallucinations, and sometimes delusions and non-visual hallucinations.

      Diagnosis of Lewy body dementia is usually clinical, but single-photon emission computed tomography (SPECT) can be used to confirm the diagnosis. Management of Lewy body dementia involves the use of acetylcholinesterase inhibitors and memantine, similar to Alzheimer’s disease. However, neuroleptics should be avoided as patients with Lewy body dementia are extremely sensitive and may develop irreversible parkinsonism. It is important to carefully consider the use of medication in these patients to avoid worsening their condition.

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  • Question 19 - A 58-year-old man is discovered to have a prolonged corrected QT interval (QTc)...

    Correct

    • A 58-year-old man is discovered to have a prolonged corrected QT interval (QTc) of 480 ms on his pre-operative ECG. The anaesthetist suggests modifying one of his medications before the surgery. Which of the following drugs are recognized to cause QTc prolongation?

      Your Answer: Sotalol

      Explanation:

      Sotalol is the only beta blocker known to cause long QT syndrome. Tricyclic antidepressants, selective serotonin reuptake inhibitors, and haloperidol can also cause QTc prolongation, while benzodiazepines and short-acting beta-receptor agonists are not known to have this effect.

      Understanding Long QT Syndrome

      Long QT syndrome (LQTS) is a genetic condition that causes delayed repolarization of the ventricles, which can lead to ventricular tachycardia and sudden death. The most common types of LQTS are caused by defects in the alpha subunit of the slow delayed rectifier potassium channel. A normal corrected QT interval is less than 430 ms in males and 450 ms in females.

      There are various causes of a prolonged QT interval, including congenital factors, drugs, and other medical conditions. Some drugs that can prolong the QT interval include amiodarone, tricyclic antidepressants, and selective serotonin reuptake inhibitors. Electrolyte imbalances, acute myocardial infarction, and subarachnoid hemorrhage can also cause a prolonged QT interval.

      LQTS may be picked up on routine ECG or following family screening. The symptoms and events associated with LQTS can vary depending on the type of LQTS. Long QT1 is usually associated with exertional syncope, while Long QT2 is often associated with syncope following emotional stress or exercise. Long QT3 events often occur at night or at rest.

      Management of LQTS involves avoiding drugs that prolong the QT interval and other precipitants if appropriate. Beta-blockers may be used, and in high-risk cases, implantable cardioverter defibrillators may be necessary. It is important to recognize and manage LQTS to prevent sudden cardiac death.

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  • Question 20 - A 28-year-old female presents with a two-day history of right loin and supra-pubic...

    Incorrect

    • A 28-year-old female presents with a two-day history of right loin and supra-pubic pain, dysuria, and swinging fevers. She has a past medical history of urinary tract infections. Upon examination, she is febrile with a temperature of 39.2°C, her blood pressure is 100/60 mmHg, and her pulse is 94 bpm and regular. She appears unwell, and right renal angle and supra-pubic pain are confirmed. Laboratory tests show an elevated white blood cell count and a creatinine level of 125 µmol/L. What is the most appropriate imaging test for this patient?

      Your Answer: CT of the urinary tract with contrast

      Correct Answer: CT of the urinary tract without contrast

      Explanation:

      Importance of CT Scan in Evaluating Ureteric Obstruction

      A CT scan is necessary to rule out ureteric obstruction, such as a stone or abscess formation, even in cases where there is a significant elevation in creatinine. Although contrast nephropathy is a risk, the likelihood is low with a creatinine level of 125 µmol/L. It is important to note that iodinated contrast is the nephrotoxic component of a CT scan, and a non-contrast CT is both effective and poses minimal risk to the patient.

      A plain radiograph may not detect stones that are not radio-opaque, and a micturating cystourethrogram is typically used to identify anatomical or functional abnormalities affecting the lower renal tract. If a CT scan is not feasible in the acute situation, an ultrasound may be a reasonable alternative. Overall, a CT scan is crucial in evaluating ureteric obstruction and should be considered even in cases where there is a slight risk of contrast nephropathy.

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  • Question 21 - A 65-year-old man arrives at the emergency department by ambulance after experiencing speech...

    Correct

    • A 65-year-old man arrives at the emergency department by ambulance after experiencing speech difficulties four hours prior. He has a medical history of hypertension, atrial fibrillation, and high cholesterol, and takes atorvastatin and ramipril regularly. Despite having atrial fibrillation, he chose not to receive anticoagulation therapy. He smokes ten cigarettes per day, drinks alcohol occasionally, and works as a language school director.

      During the examination, the patient displays expressive dysphasia and exhibits right-sided hemiplegia, sensory loss, and homonymous hemianopia. Urgent CT head and CT angiography reveal no intracranial hemorrhage but do confirm occlusion of the proximal anterior circulation.

      What is the most appropriate course of action?

      Your Answer: Intravenous thrombolysis and mechanical thrombectomy

      Explanation:

      For a patient with a large artery acute ischaemic stroke, mechanical clot retrieval should be considered along with intravenous thrombolysis. According to recent NICE guidance, thrombectomy should be offered as soon as possible and within 6 hours of symptom onset, along with intravenous thrombolysis (if within 4.5 hours), for patients with an acute ischaemic stroke and confirmed occlusion of the proximal anterior circulation demonstrated by computed tomographic angiography (CTA) or magnetic resonance angiography (MRA). As such, this patient should be offered both thrombolysis and clot retrieval. Anticoagulation with Apixaban is not recommended for atrial fibrillation until two weeks after the onset of an ischaemic stroke. Aspirin 300mg would be a reasonable treatment if the patient presented outside the thrombolysis window and mechanical thrombectomy was not an option. However, in this scenario, the patient is within the thrombolysis window and should be offered both thrombolysis and mechanical thrombectomy due to the timing and location of their stroke.

      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.

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  • Question 22 - A 50-year-old man presents for a health check and his thyroid function tests...

    Correct

    • A 50-year-old man presents for a health check and his thyroid function tests (TFTs) from three months ago showed elevated TSH levels and normal Free T4 levels. His recent TFTs show similar results and he reports feeling more tired and cold than usual. He denies any other symptoms and has no past medical history, but his mother has a history of autoimmune thyroiditis. What is the next step in managing his condition?

      Your Answer: Prescribe levothyroxine for 6 months and repeat thyroid function tests

      Explanation:

      For patients under 65 years old with subclinical hypothyroidism and a TSH level between 5.5-10mU/L, a 6-month trial of thyroxine should be offered if they have hypothyroidism symptoms and their TSH remains elevated on two separate occasions 3 months apart. This is because subclinical hypothyroidism increases the risk of cardiovascular disease and progression to overt hypothyroidism, and treatment with levothyroxine generally resolves symptoms. Repeat thyroid autoantibody tests and thyroid function testing after 3 months are unnecessary if the patient has already had negative autoantibody results and two elevated TSH levels 3 months apart. Prescribing levothyroxine only if further symptoms develop is not recommended as it delays treatment and increases the risk of negative impacts on the patient’s quality of life.

      Understanding Subclinical Hypothyroidism

      Subclinical hypothyroidism is a condition where the thyroid-stimulating hormone (TSH) is elevated, but the levels of T3 and T4 are normal, and there are no obvious symptoms. However, there is a risk of the condition progressing to overt hypothyroidism, especially in men, with a 2-5% chance per year. This risk is further increased if thyroid autoantibodies are present.

      Not all patients with subclinical hypothyroidism require treatment, and guidelines have been produced by NICE Clinical Knowledge Summaries (CKS) to help determine when treatment is necessary. If the TSH level is above 10mU/L and the free thyroxine level is within the normal range, levothyroxine may be offered. If the TSH level is between 5.5 – 10mU/L and the free thyroxine level is within the normal range, a 6-month trial of levothyroxine may be considered if the patient is under 65 years old and experiencing symptoms of hypothyroidism. For older patients, a ‘watch and wait’ strategy is often used, and asymptomatic patients may simply have their thyroid function monitored every 6 months.

      In summary, subclinical hypothyroidism is a condition that requires careful monitoring and consideration of treatment options based on individual patient factors.

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  • Question 23 - A 38-year-old female patient visits the clinic with a persistent cough. What signs...

    Correct

    • A 38-year-old female patient visits the clinic with a persistent cough. What signs or symptoms would suggest that she may have asthma?

      Your Answer: Symptoms in response to exercise

      Explanation:

      BTS/SIGN Guidelines on Asthma Diagnosis and Management

      Guidelines from BTS/SIGN provide recommendations on how to diagnose and manage asthma. Symptoms such as wheezing, breathlessness, chest tightness, or cough, especially if they worsen at night or in the early morning, after exercise, allergy exposure, or cold air, are indicative of asthma. Other factors that support the diagnosis include a family history of atopy or asthma, personal history of atopy, widespread wheezing, low FEV1 or PEFR. However, symptoms such as dizziness, light-headedness, voice disturbance, and chronic cough without wheezing do not suggest asthma. Additionally, there is no evidence that symptoms corresponding to a cold indicate an underlying diagnosis of asthma. These guidelines aim to help healthcare professionals accurately diagnose and manage asthma in patients.

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  • Question 24 - A 54-year-old woman presents to the medical admissions unit with complaints of breathlessness....

    Incorrect

    • A 54-year-old woman presents to the medical admissions unit with complaints of breathlessness. Her GP had noted reduced breath sounds and dullness to percussion at the left lung base. An urgent chest X-ray reveals a left-sided pleural effusion. To identify the cause of the effusion, an aspirate of the pleural fluid is taken, and the results show a pleural effusion fluid protein/serum protein ratio of 0.73. What is the probable reason for the pleural effusion?

      Your Answer: Heart failure

      Correct Answer: Pulmonary embolism

      Explanation:

      To determine the cause of a pleural effusion, the effusion fluid protein/serum protein ratio can be used. An effusion is considered exudative if the ratio is >0.5, indicating that there is more protein in the effusion than in the serum. In this patient’s case, the ratio is 0.73, indicating an exudative effusion. Only one of the listed options can cause an exudative effusion.

      Investigating and Managing Pleural Effusion: BTS Guidelines

      Pleural effusion is a condition where fluid accumulates in the pleural space, the area between the lungs and the chest wall. To investigate and manage this condition, the British Thoracic Society (BTS) has provided guidelines.

      Imaging is an essential part of the investigation process, and the BTS recommends performing posterior anterior (PA) chest x-rays in all patients. Ultrasound is also recommended as it increases the likelihood of successful pleural aspiration and is sensitive for detecting pleural fluid septations. Contrast CT is increasingly performed to investigate the underlying cause, particularly for exudative effusions.

      Pleural aspiration is another crucial step in the investigation process. The BTS recommends using ultrasound to reduce the complication rate. A 21G needle and 50ml syringe should be used, and fluid should be sent for pH, protein, lactate dehydrogenase (LDH), cytology, and microbiology. Light’s criteria can help distinguish between a transudate and an exudate. Other characteristic pleural fluid findings include low glucose in rheumatoid arthritis and tuberculosis, raised amylase in pancreatitis and oesophageal perforation, and heavy blood staining in mesothelioma, pulmonary embolism, and tuberculosis.

      In cases of pleural infection, diagnostic pleural fluid sampling is required for all patients with a pleural effusion in association with sepsis or a pneumonic illness. If the fluid is purulent or turbid/cloudy, a chest tube should be placed to allow drainage. If the fluid is clear but the pH is less than 7.2 in patients with suspected pleural infection, a chest tube should be placed.

      For managing recurrent pleural effusion, options include recurrent aspiration, pleurodesis, indwelling pleural catheter, and drug management to alleviate symptoms such as opioids to relieve dyspnoea. The BTS guidelines provide a comprehensive approach to investigating and managing pleural effusion.

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  • Question 25 - A 35 year old female patient visits her GP clinic complaining of recent...

    Incorrect

    • A 35 year old female patient visits her GP clinic complaining of recent paresthesia in her left leg. She was diagnosed with multiple sclerosis 4 months ago by the neurology department. The paresthesia has been ongoing for 3 days and is accompanied by increased fatigue and urinary frequency/urgency symptoms. A urine dip test shows no abnormalities. What is the most suitable treatment to initiate in this scenario?

      Your Answer: Fingolimod

      Correct Answer: Methylprednisolone

      Explanation:

      In the case of this patient, it is probable that she is experiencing an acute relapse of her multiple sclerosis. A urine dip has been conducted to rule out a urinary tract infection, which could also cause a flare in her symptoms (known as Uhthoff’s phenomenon). As her symptoms are new and have persisted for more than 24 hours, it is likely that she requires treatment with methylprednisolone (either intravenous or oral) to manage the relapse.

      While Fingolimod, Natalizumab, and Beta-interferon are all disease modifying drugs that may reduce the frequency of relapses, they are not appropriate for treating acute relapses and should only be started in secondary care with proper drug counseling.

      Amantadine may be useful in managing fatigue, but it is recommended by NICE to only be trialed for fatigue once other potential causes have been ruled out. It is unlikely to be effective in treating the patient’s other symptoms.

      Multiple sclerosis is a condition that cannot be cured, but its treatment aims to reduce the frequency and duration of relapses. In the case of an acute relapse, high-dose steroids may be administered for five days to shorten its length. However, it is important to note that steroids do not affect the degree of recovery. Disease-modifying drugs are used to reduce the risk of relapse in patients with MS. These drugs are typically indicated for patients with relapsing-remitting disease or secondary progressive disease who have had two relapses in the past two years and are able to walk a certain distance unaided. Natalizumab, ocrelizumab, fingolimod, beta-interferon, and glatiramer acetate are some of the drugs used to reduce the risk of relapse in MS.

      Fatigue is a common problem in MS patients, and amantadine is recommended by NICE after excluding other potential causes such as anaemia, thyroid problems, or depression. Mindfulness training and CBT are other options for managing fatigue. Spasticity is another issue that can be addressed with first-line drugs such as baclofen and gabapentin, as well as physiotherapy. Cannabis and botox are currently being evaluated for their effectiveness in managing spasticity. Bladder dysfunction is also a common problem in MS patients, and anticholinergics may worsen symptoms in some patients. Ultrasound is recommended to assess bladder emptying, and intermittent self-catheterisation may be necessary if there is significant residual volume. Gabapentin is the first-line treatment for oscillopsia, which is a condition where visual fields appear to oscillate.

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  • Question 26 - A 27-year-old construction worker comes to you with a puncture wound that got...

    Incorrect

    • A 27-year-old construction worker comes to you with a puncture wound that got contaminated with rusted metal while working on a construction site. You want to know if he needs protection against tetanus and find out that he received 5 doses of tetanus vaccine in the past, with the last dose being 6 years ago. What is the recommended course of action for tetanus treatment in this case?

      Your Answer: Requires both a booster vaccine and immunoglobulin

      Correct Answer: No booster vaccine or immunoglobulin required

      Explanation:

      If the patient has received all 5 doses of tetanus vaccine and the last dose was administered less than 10 years ago, they do not need a booster vaccine or immunoglobulins, regardless of the severity of the wound.

      In case the last vaccine was administered more than 10 years ago, a booster vaccine would be required for a lower risk wound.

      For a high-risk wound or if the vaccination status is unknown, both a booster vaccine and immunoglobulin would be necessary.

      Currently, there is no need for two consecutive booster vaccines.

      Tetanus Vaccination and Management of Wounds

      The tetanus vaccine is a purified toxin that is given as part of a combined vaccine. In the UK, it is given as part of the routine immunisation schedule at 2, 3, and 4 months, 3-5 years, and 13-18 years, providing a total of 5 doses for long-term protection against tetanus.

      When managing wounds, the first step is to classify them as clean, tetanus-prone, or high-risk tetanus-prone. Clean wounds are less than 6 hours old and have negligible tissue damage, while tetanus-prone wounds include puncture-type injuries acquired in a contaminated environment or wounds containing foreign bodies. High-risk tetanus-prone wounds include wounds or burns with systemic sepsis, certain animal bites and scratches, heavy contamination with material likely to contain tetanus spores, wounds or burns with extensive devitalised tissue, and wounds or burns that require surgical intervention.

      If the patient has had a full course of tetanus vaccines with the last dose less than 10 years ago, no vaccine or tetanus immunoglobulin is required regardless of the wound severity. If the patient has had a full course of tetanus vaccines with the last dose more than 10 years ago, a reinforcing dose of vaccine is required for tetanus-prone wounds, and a reinforcing dose of vaccine plus tetanus immunoglobulin is required for high-risk wounds. If the vaccination history is incomplete or unknown, a reinforcing dose of vaccine is required regardless of the wound severity, and a reinforcing dose of vaccine plus tetanus immunoglobulin is required for tetanus-prone and high-risk wounds.

      Overall, proper vaccination and wound management are crucial in preventing tetanus infection.

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  • Question 27 - A 39-year-old man presents to the emergency department with multiple episodes of forceful...

    Correct

    • A 39-year-old man presents to the emergency department with multiple episodes of forceful retching resulting in the expulsion of approximately 3 tablespoons of blood. He reports consuming 24 units of alcohol daily for the past week due to job loss. Although his Glasgow coma score is 15, he complains of dizziness. His vital signs include a blood pressure of 105/68 mmHg, pulse rate of 105 bpm, oxygen saturations of 98%, respiratory rate of 20 breaths per minute, and fever.
      Currently, blood tests and results are pending. What is the most crucial step in managing this patient?

      Your Answer: Upper gastrointestinal tract endoscopy within 24 hours

      Explanation:

      Pyriform cortex

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  • Question 28 - A 47-year-old woman visits her doctor with a complaint of experiencing cold hands...

    Correct

    • A 47-year-old woman visits her doctor with a complaint of experiencing cold hands and feet over the last two weeks. Her medications have been recently altered, with a new medication introduced to improve her blood pressure management. Which of the following medications is the probable cause of her symptoms?

      Your Answer: Bisoprolol

      Explanation:

      Beta-blockers are frequently prescribed for hypertension treatment, but they can lead to cold extremities as a side effect. Thiazide diuretics like bendroflumethiazide commonly cause constipation, diarrhea, dizziness, and dry mouth. Angiotensin receptor blockers such as candesartan and losartan do not typically result in cold peripheries.

      Beta-blockers are a class of drugs that are primarily used to manage cardiovascular disorders. They have a wide range of indications, including angina, post-myocardial infarction, heart failure, arrhythmias, hypertension, thyrotoxicosis, migraine prophylaxis, and anxiety. Beta-blockers were previously avoided in heart failure, but recent evidence suggests that certain beta-blockers can improve both symptoms and mortality. They have also replaced digoxin as the rate-control drug of choice in atrial fibrillation. However, their role in reducing stroke and myocardial infarction has diminished in recent years due to a lack of evidence. Examples of beta-blockers include atenolol and propranolol, which was one of the first beta-blockers to be developed and is lipid soluble, allowing it to cross the blood-brain barrier.

      Like all drugs, beta-blockers have side-effects, including bronchospasm, cold peripheries, fatigue, sleep disturbances (including nightmares), and erectile dysfunction. They are contraindicated in uncontrolled heart failure, asthma, sick sinus syndrome, and concurrent use with verapamil, which may precipitate severe bradycardia.

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  • Question 29 - A 65-year-old homeless woman is brought to the emergency department by paramedics after...

    Incorrect

    • A 65-year-old homeless woman is brought to the emergency department by paramedics after being found unconscious. An ECG reveals a broad complex polymorphic tachycardia, which is suggestive of torsades de pointes. What could be a potential cause of this arrhythmia in the patient?

      Your Answer: Hypercalcaemia

      Correct Answer: Hypothermia

      Explanation:

      Torsades de pointes can be caused by hypothermia. Other causes include hypocalcaemia, hypokalemia, and hypomagnesaemia, but not their hyper counterparts. There is no known link between hypoglycemia or hyperthyroidism and Torsades de Pointes.

      Torsades de Pointes: A Life-Threatening Condition

      Torsades de pointes is a type of ventricular tachycardia that is associated with a prolonged QT interval. This condition can lead to ventricular fibrillation, which can cause sudden death. There are several causes of a prolonged QT interval, including congenital conditions such as Jervell-Lange-Nielsen syndrome and Romano-Ward syndrome, as well as certain medications like antiarrhythmics, tricyclic antidepressants, and antipsychotics. Other causes include electrolyte imbalances, myocarditis, hypothermia, and subarachnoid hemorrhage.

      The management of torsades de pointes involves the administration of intravenous magnesium sulfate. This can help to stabilize the heart rhythm and prevent further complications.

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  • Question 30 - A 50-year-old woman comes to the doctor's office complaining of a recent experience...

    Correct

    • A 50-year-old woman comes to the doctor's office complaining of a recent experience where she suddenly smelled roses while at work. The sensation lasted for about a minute, during which her left arm twitched. Her colleagues noticed that she seemed to be daydreaming during the episode. She remembers the event clearly and did not lose consciousness. What is the probable diagnosis?

      Your Answer: Focal aware seizure

      Explanation:

      The woman experiences a sudden smell of roses while at work, but remains conscious throughout the event. This suggests that she is having a focal aware seizure, which is a type of seizure that only affects a specific area of the brain. The fact that the twitching is limited to her left arm further supports this diagnosis. It is important to note that this is different from a focal impaired awareness seizure, which would cause the patient to have reduced consciousness and confusion. Absence seizures, atonic seizures, and generalised tonic-clonic seizures are also ruled out based on the patient’s symptoms.

      Epilepsy is classified based on three key features: where seizures begin in the brain, level of awareness during a seizure, and other features of seizures. Focal seizures, previously known as partial seizures, start in a specific area on one side of the brain. The level of awareness can vary in focal seizures, and they can be further classified as focal aware, focal impaired awareness, or awareness unknown. Focal seizures can also be motor, non-motor, or have other features such as aura. Generalized seizures involve networks on both sides of the brain at the onset, and consciousness is lost immediately. They can be further subdivided into motor and non-motor types. Unknown onset is used when the origin of the seizure is unknown. Focal to bilateral seizures start on one side of the brain in a specific area before spreading to both lobes and were previously known as secondary generalized seizures.

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