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  • Question 1 - A 54-year-old man visits his doctor with a complaint of erectile dysfunction. He...

    Correct

    • A 54-year-old man visits his doctor with a complaint of erectile dysfunction. He reports no recent stressors or changes in his lifestyle or diet. He has a medical history of type 2 diabetes mellitus, hypertension, gastroesophageal reflux disease (GORD), and osteoarthritis. His current medications include gliclazide, indapamide, metformin, omeprazole, and paracetamol. The doctor suspects that one of his medications is responsible for his erectile dysfunction. Which medication is the most likely culprit?

      Your Answer: Indapamide

      Explanation:

      Indapamide, a thiazide-like diuretic, is known to cause sexual dysfunction and is the most likely medication responsible for this man’s erectile dysfunction. Gliclazide, metformin, and omeprazole, on the other hand, are not associated with sexual dysfunction. Gliclazide is used to manage diabetes mellitus and can cause gastrointestinal upset and hypoglycemia. Metformin is also used to manage diabetes mellitus and can cause nausea, vomiting, constipation, and rare adverse effects such as B12 deficiency and lactic acidosis. Omeprazole is a proton-pump inhibitor used to control excess stomach acid production and can cause gastrointestinal side-effects and electrolyte disturbances such as hyponatremia and hypomagnesemia.

      Thiazide diuretics are medications that work by blocking the thiazide-sensitive Na+-Cl− symporter, which inhibits sodium reabsorption at the beginning of the distal convoluted tubule (DCT). This results in the loss of potassium as more sodium reaches the collecting ducts. While loop diuretics are better for reducing overload, thiazide diuretics have a role in the treatment of mild heart failure. Bendroflumethiazide was commonly used for managing hypertension, but recent NICE guidelines recommend other thiazide-like diuretics such as indapamide and chlorthalidone.

      Like any medication, thiazide diuretics have potential adverse effects. Common side effects include dehydration, postural hypotension, and electrolyte imbalances such as hyponatraemia, hypokalaemia, and hypercalcaemia. Gout, impaired glucose tolerance, and impotence are also possible. Rare adverse effects include thrombocytopaenia, agranulocytosis, photosensitivity rash, and pancreatitis.

      To manage hypertension, current NICE guidelines recommend using thiazide-like diuretics such as indapamide or chlorthalidone as first-line treatment. If blood pressure is not adequately controlled, a calcium channel blocker or ACE inhibitor can be added. If blood pressure remains high, a thiazide-like diuretic can be combined with a calcium channel blocker or ACE inhibitor. In some cases, a beta-blocker or aldosterone antagonist may also be added. Regular monitoring and adjustment of medication is necessary to ensure optimal blood pressure control.

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  • Question 2 - An 80-year-old man is hospitalized with community-acquired pneumonia (CAP) and develops acute kidney...

    Correct

    • An 80-year-old man is hospitalized with community-acquired pneumonia (CAP) and develops acute kidney injury (AKI) on the third day of admission. His eGFR drops from 58 to 26 ml/min/1.73 m2 and creatinine rises from 122 to 196 umol/L. Which of his usual medications should be discontinued?

      Your Answer: Ramipril

      Explanation:

      Acute kidney injury (AKI) is a condition where there is a sudden decrease in kidney function, which can be defined by a decrease in glomerular filtration rate (GFR) or a decrease in urine output. AKI can be caused by various factors such as prerenal, renal, or postrenal causes. Medications can also cause AKI, and caution should be taken when prescribing ACE inhibitors to patients with declining renal function. In the event of an AKI, certain medications such as ACE inhibitors, A2RBs, NSAIDs, diuretics, aminoglycosides, metformin, and lithium should be temporarily discontinued. Atorvastatin and bisoprolol are safe to prescribe in patients with kidney disease, while finasteride and tamsulosin can be prescribed for benign prostatic hyperplasia but should be used with caution in patients with poor renal function.

      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 3 - Sarah is a 75-year-old woman who visits her doctor complaining of a persistent...

    Incorrect

    • Sarah is a 75-year-old woman who visits her doctor complaining of a persistent cough, coughing up blood, and losing weight. She used to work in a shipyard and was exposed to a significant amount of asbestos. What is the most conclusive method to diagnose the probable condition?

      Your Answer: Bronchoscopy and endobronchial ultrasound-guided transbronchial needle aspiration

      Correct Answer: Thoracoscopy and histology

      Explanation:

      To diagnose mesothelioma, a thoracoscopy and histology are necessary. Other tests such as bronchoscopy and endobronchial ultrasound guided transbronchial needle aspiration are not appropriate as mesothelioma does not spread into the airways. While a CT scan or MRI can show evidence of a tumor, a histological examination is required to confirm the diagnosis.

      Understanding Mesothelioma: A Cancer Linked to Asbestos Exposure

      Mesothelioma is a type of cancer that affects the mesothelial layer of the pleural cavity, which is strongly associated with exposure to asbestos. Although it is rare, other mesothelial layers in the abdomen may also be affected. Symptoms of mesothelioma include dyspnoea, weight loss, and chest wall pain, as well as clubbing. About 30% of cases present as painless pleural effusion, and only 20% have pre-existing asbestosis. A history of asbestos exposure is present in 85-90% of cases, with a latent period of 30-40 years.

      To diagnose mesothelioma, suspicion is typically raised by a chest x-ray showing either pleural effusion or pleural thickening. The next step is usually a pleural CT, and if a pleural effusion is present, fluid should be sent for MC&S, biochemistry, and cytology. However, cytology is only helpful in 20-30% of cases. Local anaesthetic thoracoscopy is increasingly used to investigate cytology-negative exudative effusions as it has a high diagnostic yield of around 95%. If an area of pleural nodularity is seen on CT, then an image-guided pleural biopsy may be used.

      Management of mesothelioma is typically symptomatic, with industrial compensation available for those affected. Chemotherapy and surgery may be options if the cancer is operable. However, the prognosis for mesothelioma is poor, with a median survival of only 12 months.

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  • Question 4 - 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 5 - A 12-year-old girl is brought to the hospital with lethargy and diarrhoea during...

    Correct

    • A 12-year-old girl is brought to the hospital with lethargy and diarrhoea during a local outbreak of E coli 0157:H7. Her initial blood tests reveal acute renal failure, indicating a possible diagnosis of haemolytic uraemic syndrome. What investigation result would be anticipated in this case?

      Your Answer: Fragmented red blood cells

      Explanation:

      In haemolytic uraemic syndrome, there is a reduction in serum haptoglobins, which bind to haemoglobin, and the platelet count.

      Understanding Haemolytic Uraemic Syndrome

      Haemolytic uraemic syndrome (HUS) is a condition that primarily affects young children and is characterized by a triad of symptoms, including acute kidney injury, microangiopathic haemolytic anaemia, and thrombocytopenia. The majority of cases are secondary and caused by Shiga toxin-producing Escherichia coli (STEC) 0157:H7, also known as ‘verotoxigenic’ or ‘enterohaemorrhagic’. Other causes of HUS include pneumococcal infection, HIV, systemic lupus erythematosus, drugs, and cancer. Primary HUS, also known as ‘atypical’, is caused by complement dysregulation.

      To diagnose HUS, doctors may perform a full blood count to check for microangiopathic hemolytic anaemia and thrombocytopenia. A fragmented blood film may also be done to look for schistocytes and helmet cells. Additionally, a stool culture may be performed to check for evidence of STEC infection, and PCR for Shiga toxins may be done.

      Treatment for HUS is supportive and may include fluids, blood transfusion, and dialysis if required. Antibiotics are not recommended, despite the preceding diarrhoeal illness in many patients. Plasma exchange may be considered for severe cases of HUS not associated with diarrhoea, while eculizumab, a C5 inhibitor monoclonal antibody, has shown greater efficiency than plasma exchange alone in the treatment of adult atypical HUS.

      Overall, understanding the causes, symptoms, and management of HUS is crucial for healthcare professionals to provide appropriate care for patients with this condition.

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  • Question 6 - A 35-year-old man visits his GP complaining of severe headaches and excruciating pain...

    Incorrect

    • A 35-year-old man visits his GP complaining of severe headaches and excruciating pain around his left eye that has been ongoing for a week. Upon further inquiry, he describes the pain as a sharp, stabbing sensation that lasts for about an hour and is localized to the left side of his head. He also mentions experiencing a congested nose and tearing in his left eye during the onset of the pain. The patient admits to smoking 10 cigarettes daily and consuming one glass of wine each night. Based on the probable diagnosis, what is the expected duration of his symptoms?

      Your Answer: Lasting 1 - 2 weeks

      Correct Answer: Lasting 4 - 12 weeks

      Explanation:

      The man’s symptoms suggest that he is experiencing cluster headaches, which typically occur once a day and cause pain around one eye. Other common symptoms include eye-watering and nasal congestion. To prevent these headaches, the man should avoid smoking and alcohol, which are known triggers. Cluster headaches usually last between 15 minutes and 2 hours and occur in clusters that can last from 4 to 12 weeks. Duration of 1-2 weeks or up to 10 days is too short, while 3-4 months or 4-6 months is too long for cluster headaches.

      Cluster headaches are a type of headache that is known to be extremely painful. They are called cluster headaches because they tend to occur in clusters that last for several weeks, usually once a year. These headaches are more common in men and smokers, and alcohol and sleep patterns may trigger an attack. The pain typically occurs once or twice a day, lasting between 15 minutes to 2 hours. The pain is intense and sharp, usually around one eye, and is accompanied by redness, lacrimation, lid swelling, and nasal stuffiness. Some patients may also experience miosis and ptosis.

      To manage cluster headaches, 100% oxygen or subcutaneous triptan can be used for acute treatment, with response rates of 80% and 75% respectively within 15 minutes. Verapamil is the drug of choice for prophylaxis, and a tapering dose of prednisolone may also be effective. It is recommended to seek specialist advice from a neurologist if a patient develops cluster headaches, especially with respect to neuroimaging. Some neurologists use the term trigeminal autonomic cephalgia to group a number of conditions including cluster headache, paroxysmal hemicrania, and short-lived unilateral neuralgiform headache with conjunctival injection and tearing (SUNCT). Patients with these conditions should be referred for specialist assessment as specific treatment may be required, such as indomethacin for paroxysmal hemicrania.

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  • Question 7 - A 56-year-old man presents to the emergency department with dyspnea. A chest x-ray...

    Correct

    • A 56-year-old man presents to the emergency department with dyspnea. A chest x-ray is performed, and pleural fluid is aspirated for analysis. The pleural fluid results reveal:
      - Fluid Protein 58 g/L (normal range: 10-20g/L)
      - Fluid LDH 1048 IU/L (less than 50% of plasma concentration)
      - Fluid Glucose 1.2 mmol/L (normal range: 4-11 mmol/L)
      - Fluid pH 7.23 (normal range: 7.60-7.64)
      - Cell Cytology shows normal cytology with benign reactive changes

      His admission blood results are as follows:
      - Hb 145 g/L (normal range: 135-180)
      - Platelets 376 * 109/L (normal range: 150-400)
      - Total Protein 73 g/L (normal range: 60-83)
      - PT 11.2 s (normal range: 11-13.5)
      - LDH 145 IU/L (normal range: 135-225)
      - Glucose 5.8 mmol/L (normal range: 4-8)
      - pH 7.38 (normal range: 7.35-7.45)

      What is the most appropriate course of action for managing this patient?

      Your Answer: Insert a chest drain and commence antibiotic therapy

      Explanation:

      Prompt drainage alongside antibiotic therapy is necessary for the management of an empyema. Therefore, the correct course of action is to insert a chest drain and commence antibiotic therapy. The diagnosis of empyema can be confirmed using Light’s criteria, which indicates an exudative effusion with a pleural fluid protein to serum protein ratio greater than 0.5 and/or a pleural fluid LDH to serum LDH ratio greater than 0.6. A pleural fluid pH <7.3 and a very low pleural glucose concentration (<1.6 mmol/L) are also indicative of empyema. The normal cell cytology makes malignancy unlikely. The patient's platelet and PT levels are appropriate for chest drain insertion, so there is no need to refer for investigation under the oncology team or to gastroenterology to investigate for liver cirrhosis. Starting IV antibiotics alone is insufficient for managing an empyema, as prompt drainage is necessary to give antibiotics the best chance of success. A chest drain is a tube that is inserted into the pleural cavity to allow air or liquid to move out of the cavity. It is used in cases of pleural effusion, pneumothorax, empyema, haemothorax, haemopneumothorax, chylothorax, and some cases of penetrating chest wall injury in ventilated patients. However, there are relative contraindications to chest drain insertion, such as an INR greater than 1.3, a platelet count less than 75, pulmonary bullae, and pleural adhesions. The patient should be positioned in a supine position or at a 45º angle, and the area should be anaesthetised using local anaesthetic injection. The drainage tube is then inserted using a Seldinger technique and secured with either a straight stitch or an adhesive dressing. Complications that may occur include failure of insertion, bleeding, infection, penetration of the lung, and re-expansion pulmonary oedema. The chest drain should be removed when there has been no output for > 24 hours and imaging shows resolution of the fluid collection or pneumothorax. Drains inserted in cases of penetrating chest injury should be reviewed by the specialist to confirm an appropriate time for removal.

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  • Question 8 - A 70-year-old man visits his doctor with complaints of fatigue and lower back...

    Incorrect

    • A 70-year-old man visits his doctor with complaints of fatigue and lower back pain. Upon conducting a thorough examination and taking a complete medical history, the physician orders blood tests. The results are as follows:

      - Hemoglobin (Hb): 101 g/L (normal range for males: 135-180; females: 115-160)
      - Platelets: 138 * 109/L (normal range: 150-400)
      - White blood cells (WBC): 4.9 * 109/L (normal range: 4.0-11.0)
      - Sodium (Na+): 132 mmol/L (normal range: 135-145)
      - Potassium (K+): 3.7 mmol/L (normal range: 3.5-5.0)
      - Bicarbonate: 27 mmol/L (normal range: 22-29)
      - Urea: 8.4 mmol/L (normal range: 2.0-7.0)
      - Creatinine: 142 µmol/L (normal range: 55-120)
      - Calcium: 3.2 mmol/L (normal range: 2.1-2.6)
      - Phosphate: 1.4 mmol/L (normal range: 0.8-1.4)
      - Magnesium: 1.0 mmol/L (normal range: 0.7-1.0)

      What is the recommended first-line imaging for this patient?

      Your Answer: MRI thorax, abdomen and pelvis

      Correct Answer: Whole body MRI

      Explanation:

      Understanding Multiple Myeloma: Features and Investigations

      Multiple myeloma is a type of blood cancer that occurs due to genetic mutations in plasma cells. It is commonly diagnosed in individuals over the age of 70. The disease is characterized by the acronym CRABBI, which stands for Calcium, Renal, Anaemia, Bleeding, Bones, and Infection. Patients with multiple myeloma may experience hypercalcemia, renal damage, anaemia, bleeding, bone pain, and increased susceptibility to infections. Other symptoms may include amyloidosis, carpal tunnel syndrome, neuropathy, and hyperviscosity.

      To diagnose multiple myeloma, doctors may perform a variety of tests, including blood tests, protein electrophoresis, bone marrow aspiration, and imaging studies. Blood tests may reveal anaemia, elevated levels of M protein in the blood or urine, and renal failure. Protein electrophoresis can detect raised concentrations of monoclonal IgA/IgG proteins in the serum or urine. Bone marrow aspiration confirms the diagnosis if the number of plasma cells is significantly raised. Imaging studies, such as whole-body MRI or X-rays, can detect osteolytic lesions or the characteristic raindrop skull pattern.

      The diagnostic criteria for multiple myeloma require one major and one minor criteria or three minor criteria in an individual who has signs or symptoms of the disease. Major criteria include plasmacytoma, 30% plasma cells in a bone marrow sample, and elevated levels of M protein in the blood or urine. Minor criteria include 10% to 30% plasma cells in a bone marrow sample, minor elevations in the level of M protein in the blood or urine, osteolytic lesions, and low levels of antibodies not produced by the cancer cells in the blood.

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  • Question 9 - A 50-year-old male presents to the acute medical unit with severe jaundice and...

    Incorrect

    • A 50-year-old male presents to the acute medical unit with severe jaundice and gross ascites. He has a history of alcohol abuse and was diagnosed with liver cirrhosis two years ago. He has been admitted to the hospital multiple times due to confusion and altered consciousness caused by his cirrhosis. What medications should be evaluated for preventing the recurrence of the aforementioned complication?

      Your Answer: Lactulose and furosemide

      Correct Answer: Lactulose and rifaximin

      Explanation:

      Lactulose and rifaximin are the recommended medications for secondary prophylaxis of hepatic encephalopathy. This condition is characterized by confusion, altered consciousness, asterixis, and triphasic slow waves on EEG, and is caused by excess absorption of ammonia and glutamine from bacterial breakdown of proteins in the gut. Lactulose promotes the excretion of ammonia and increases its metabolism by gut bacteria, while rifaximin modulates the gut flora to decrease ammonia production. Spironolactone and furosemide are not used for hepatic encephalopathy, but rather for managing ascites and edema in patients with hypoalbuminemia due to cirrhosis. Propranolol is also not used for prophylaxis against hepatic encephalopathy, but rather to lower portal pressure and prevent variceal bleeding.

      Understanding Hepatic Encephalopathy

      Hepatic encephalopathy is a condition that can occur in individuals with liver disease, regardless of the cause. The exact cause of this condition is not fully understood, but it is believed to be related to the absorption of excess ammonia and glutamine from the breakdown of proteins by bacteria in the gut. While hepatic encephalopathy is commonly associated with acute liver failure, it can also be seen in chronic liver disease. In fact, many patients with liver cirrhosis may experience mild cognitive impairment before the more recognizable symptoms of hepatic encephalopathy appear. It is also worth noting that transjugular intrahepatic portosystemic shunting (TIPSS) can trigger encephalopathy.

      The symptoms of hepatic encephalopathy can range from irritability and confusion to incoherence and coma. The condition can be graded based on the severity of the symptoms, with Grade I being the mildest and Grade IV being the most severe. There are several factors that can precipitate hepatic encephalopathy, including infection, gastrointestinal bleeding, constipation, and certain medications.

      The management of hepatic encephalopathy involves treating any underlying causes and using medications to alleviate symptoms. Lactulose is often the first-line treatment, as it promotes the excretion of ammonia and increases its metabolism by gut bacteria. Antibiotics such as rifaximin can also be used to modulate the gut flora and reduce ammonia production. In some cases, embolization of portosystemic shunts or liver transplantation may be necessary.

      Overall, hepatic encephalopathy is a complex condition that requires careful management and monitoring. By understanding the causes, symptoms, and treatment options, healthcare providers can provide the best possible care for patients with this condition.

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  • Question 10 - A 35-year-old woman presents to the emergency department with a 24-hour history of...

    Incorrect

    • A 35-year-old woman presents to the emergency department with a 24-hour history of fever, headache, and neck stiffness. She has no significant past medical history and no allergies.

      Her vital signs are currently stable, and there are no visible rashes on examination. The patient is fully alert and oriented with a GCS of 15/15.

      After consulting with a senior physician, it is determined that a lumbar puncture is necessary. However, due to departmental constraints, it is unlikely that the procedure can be performed within the next hour.

      What is the most appropriate next step in managing this patient?

      Your Answer: IV ceftriaxone + IV amoxicillin immediately

      Correct Answer: IV ceftriaxone immediately

      Explanation:

      When patients are suspected of having viral meningitis, doctors often prescribe antibiotics as a precaution until the results of a lumbar puncture are available. This is especially true for elderly patients or those with weakened immune systems. If a young patient presents with symptoms such as fever, headache, and neck stiffness, doctors may perform tests like Kernig’s or Brudzinski’s signs to help diagnose the condition. However, because bacterial meningitis can be very dangerous, doctors may start treatment before a definitive diagnosis is made. Even if the likelihood of bacterial meningitis is low, delaying treatment could have serious consequences for the patient. Viral meningitis is more common and less severe than bacterial meningitis, but it can be difficult to distinguish between the two based on symptoms alone. Therefore, doctors may prescribe antibiotics as a precaution if a lumbar puncture cannot be performed within an hour. In this case, intravenous ceftriaxone would be the appropriate treatment. IV fluconazole is used to treat severe fungal infections, but it is unlikely to be necessary in an otherwise healthy patient. IV amoxicillin is typically reserved for patients who are immunocompromised, under 6 months old, or over 60 years old, as it can help protect against Listeria monocytogenes.

      Understanding Viral Meningitis

      Viral meningitis is a condition characterized by inflammation of the leptomeninges and cerebrospinal fluid in the subarachnoid space caused by a viral agent. It is a more common and less severe condition compared to bacterial meningitis. Although approximately 3,000 cases of confirmed viral meningitis are reported yearly, the actual number of cases is likely to be much higher as patients often do not seek medical attention.

      The causes of viral meningitis include non-polio enteroviruses such as coxsackievirus and echovirus, mumps, herpes simplex virus (HSV), cytomegalovirus (CMV), herpes zoster viruses, HIV, and measles. Patients at the extremes of age, immunocompromised patients, and intravenous drug users are at higher risk of developing viral meningitis.

      Common symptoms of viral meningitis include headache, neck stiffness, photophobia, confusion, and fever. Focal neurological deficits on examination and seizures suggest a meningoencephalitis. A lumbar puncture is necessary to confirm the diagnosis, and cerebrospinal fluid findings in viral meningitis include lymphocyte-predominant cell differential, glucose levels of 2.8 – 4.2 mmol/L or 2/3 paired serum glucose mmol/L, and protein levels of 0.5 – 1 g/dL.

      Management of viral meningitis involves supportive treatment while awaiting the results of the lumbar puncture. If there is any suspicion of bacterial meningitis or encephalitis, broad-spectrum antibiotics with CNS penetration such as ceftriaxone and acyclovir intravenously should be administered. Generally, viral meningitis is self-limiting, and symptoms improve over the course of 7 – 14 days. acyclovir may be used if the patient is suspected of having meningitis secondary to HSV. Complications are rare in immunocompetent patients.

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  • Question 11 - A 35-year-old man with a history of chronic alcohol abuse presents to the...

    Incorrect

    • A 35-year-old man with a history of chronic alcohol abuse presents to the Emergency Department. He appears disheveled, disoriented, and experiences frequent falls. Upon examination, you observe that he has difficulty with balance and coordination, and bilateral lateral rectus palsy with nystagmus. His sensory examination reveals a polyneuropathy, and his pulse is 90 bpm. There is no agitation or tremor noted on examination.
      What is the most urgent treatment that should be administered to this patient?

      Your Answer: Vitamin B12

      Correct Answer: Pabrinex

      Explanation:

      Understanding Wernicke’s Encephalopathy

      Wernicke’s encephalopathy is a condition that affects the brain and is caused by a deficiency in thiamine. This condition is commonly seen in individuals who abuse alcohol, but it can also be caused by persistent vomiting, stomach cancer, or dietary deficiencies. The classic triad of symptoms associated with Wernicke’s encephalopathy includes oculomotor dysfunction, gait ataxia, and encephalopathy. Other symptoms may include peripheral sensory neuropathy and confusion.

      When left untreated, Wernicke’s encephalopathy can lead to the development of Korsakoff’s syndrome. This condition is characterized by antero- and retrograde amnesia and confabulation in addition to the symptoms associated with Wernicke’s encephalopathy.

      To diagnose Wernicke’s encephalopathy, doctors may perform a variety of tests, including a decreased red cell transketolase test and an MRI. Treatment for this condition involves urgent replacement of thiamine. With prompt treatment, individuals with Wernicke’s encephalopathy can recover fully.

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  • Question 12 - A 68-year-old man is 2 days post-op for a laparoscopic prostatectomy and experiences...

    Correct

    • A 68-year-old man is 2 days post-op for a laparoscopic prostatectomy and experiences difficulty breathing. He has been unable to move around since his surgery and is experiencing poorly managed pain. He has no significant medical history.
      During the examination, he is lying flat in bed and his oxygen saturation is at 95% on room air. His calves are soft and non-tender. A chest X-ray reveals basal atelectasis.
      What immediate measures should be taken to improve his breathing?

      Your Answer: Reposition the patient to an upright position

      Explanation:

      If the patient’s oxygen saturation levels remain low, administering high flow oxygen would not be appropriate as it is not an emergency situation. Instead, it would be more reasonable to begin with 1-2L of oxygen and reevaluate the need for further oxygen therapy, as weaning off oxygen could potentially prolong the patient’s hospital stay.

      Atelectasis is a frequent complication that can occur after surgery, where the collapse of the alveoli in the lower part of the lungs can cause breathing difficulties. This condition is caused by the blockage of airways due to the accumulation of bronchial secretions. Symptoms of atelectasis may include shortness of breath and low oxygen levels, which typically appear around 72 hours after surgery. To manage this condition, patients may be positioned upright and undergo chest physiotherapy, which includes breathing exercises.

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  • Question 13 - You perform a home visit for an 80-year-old man diagnosed with terminal bronchial...

    Correct

    • You perform a home visit for an 80-year-old man diagnosed with terminal bronchial carcinoma. The patient has palliative care support in place, including anticipatory medications should he develop end-of-life symptoms. He is lucid and eating well, although unfortunately has developed shortness of breath and worsening pains from his metastases. The patient is a smoker and has a background of hypertension, ischaemic heart disease, and stage 4 chronic kidney disease.

      Which medication would be the most suitable to relieve his symptoms?

      Your Answer: Oxycodone

      Explanation:

      Palliative care prescribing for pain is guided by NICE and SIGN guidelines. NICE recommends starting treatment with regular oral modified-release or immediate-release morphine, with immediate-release morphine for breakthrough pain. Laxatives should be prescribed for all patients initiating strong opioids, and antiemetics should be offered if nausea persists. Drowsiness is usually transient, but if it persists, the dose should be adjusted. SIGN advises that the breakthrough dose of morphine is one-sixth the daily dose, and all patients receiving opioids should be prescribed a laxative. Opioids should be used with caution in patients with chronic kidney disease, and oxycodone is preferred to morphine in patients with mild-moderate renal impairment. Metastatic bone pain may respond to strong opioids, bisphosphonates, or radiotherapy, and all patients should be considered for referral to a clinical oncologist for further treatment. When increasing the dose of opioids, the next dose should be increased by 30-50%. Conversion factors between opioids are also provided. Opioid side-effects are usually transient, such as nausea and drowsiness, but constipation can persist. In addition to strong opioids, bisphosphonates, and radiotherapy, denosumab may be used to treat metastatic bone pain.

      Overall, the guidelines recommend starting with regular oral morphine and adjusting the dose as needed. Laxatives should be prescribed to prevent constipation, and antiemetics may be needed for nausea. Opioids should be used with caution in patients with chronic kidney disease, and oxycodone is preferred in patients with mild-moderate renal impairment. Metastatic bone pain may respond to strong opioids, bisphosphonates, or radiotherapy, and referral to a clinical oncologist should be considered. Conversion factors between opioids are provided, and the next dose should be increased by 30-50% when adjusting the dose. Opioid side-effects are usually transient, but constipation can persist. Denosumab may also be used to treat metastatic bone pain.

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  • Question 14 - A 40-year-old woman visits her primary care physician with complaints of occasional double...

    Incorrect

    • A 40-year-old woman visits her primary care physician with complaints of occasional double vision that occurs during the day. She reports that her vision returns to normal after taking a break. The symptoms have been worsening over the past six months, and she has already consulted an optometrist who could not identify a cause. There have been no indications of muscle or peripheral nerve issues. What medication is typically attempted as a first-line treatment for the suspected diagnosis?

      Your Answer: Prednisolone

      Correct Answer: Pyridostigmine

      Explanation:

      Myasthenia gravis is an autoimmune disorder that results in insufficient functioning acetylcholine receptors. It is more common in women and is characterized by muscle fatigability, extraocular muscle weakness, proximal muscle weakness, ptosis, and dysphagia. Thymomas are present in 15% of cases, and autoimmune disorders are also associated with the disease. Diagnosis is made through single fibre electromyography and CT thorax to exclude thymoma. Management includes long-acting acetylcholinesterase inhibitors, immunosuppression, and thymectomy. Plasmapheresis and intravenous immunoglobulins are used to manage myasthenic crisis. Antibodies to acetylcholine receptors are seen in 85-90% of cases.

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  • Question 15 - 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 16 - An elderly woman, aged 76, visits her GP complaining of breathlessness and leg...

    Correct

    • An elderly woman, aged 76, visits her GP complaining of breathlessness and leg swelling. She has a medical history of heart failure (ejection fraction 33%), rheumatoid arthritis, and type 2 diabetes mellitus. Her current medications include 7.5mg bisoprolol once daily, 10 mg lisinopril once daily, 20 mg furosemide twice daily, 500 mg metformin three times daily, and 1g paracetamol four times daily. During the examination, the GP notes mild bibasal crackles, normal heart sounds, and bilateral pedal pitting oedema. The patient's vital signs are heart rate 72 beats per minute and regular, respiratory rate 18 breaths per minute, oxygen saturations 94% on room air, blood pressure 124/68 mmHg, and temperature 36.2oC. The patient's blood test results from two weeks ago show Na+ 140 mmol/L (135 - 145), K+ 4.2 mmol/L (3.5 - 5.0), Bicarbonate 23 mmol/L (22 - 29), Urea 6.2 mmol/L (2.0 - 7.0), and Creatinine 114 µmol/L (55 - 120). What would be the most appropriate medication to initiate?

      Your Answer: Spironolactone

      Explanation:

      For individuals with heart failure with reduced ejection fraction who are still experiencing symptoms despite being on an ACE inhibitor (or ARB) and beta-blocker, it is recommended to add a mineralocorticoid receptor antagonist such as Spironolactone. Prior to starting and increasing the dosage, it is important to monitor serum sodium, potassium, renal function, and blood pressure. Amiodarone is not a first-line treatment for heart failure and should only be prescribed after consulting with a cardiology specialist. Digoxin is recommended if heart failure worsens or becomes severe despite initial treatment, but it is important to note that a mineralocorticoid receptor antagonist should be prescribed first. Ivabradine can be used in heart failure, but it should not be prescribed if the patient’s heart rate is below 75, and it is not a first-line treatment.

      Drug Management for Chronic Heart Failure: NICE Guidelines

      Chronic heart failure is a serious condition that requires proper management to improve patient outcomes. In 2018, the National Institute for Health and Care Excellence (NICE) updated their guidelines on drug management for chronic heart failure. The guidelines recommend first-line therapy with both an ACE-inhibitor and a beta-blocker, with clinical judgement used to determine which one to start first. Second-line therapy involves the use of aldosterone antagonists, which should be monitored for hyperkalaemia. SGLT-2 inhibitors are also increasingly being used to manage heart failure with a reduced ejection fraction. Third-line therapy should be initiated by a specialist and may include ivabradine, sacubitril-valsartan, hydralazine in combination with nitrate, digoxin, or cardiac resynchronisation therapy. Other treatments such as annual influenzae and one-off pneumococcal vaccines are also recommended.

      Overall, the NICE guidelines provide a comprehensive approach to drug management for chronic heart failure. It is important to note that loop diuretics have not been shown to reduce mortality in the long-term, and that ACE-inhibitors and beta-blockers have no effect on mortality in heart failure with preserved ejection fraction. Healthcare professionals should carefully consider the patient’s individual needs and circumstances when determining the appropriate drug therapy for chronic heart failure.

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  • Question 17 - 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 18 - A 65-year-old male with non-Hodgkin lymphoma (NHL) presents to the emergency department complaining...

    Correct

    • A 65-year-old male with non-Hodgkin lymphoma (NHL) presents to the emergency department complaining of fever, chills, and feeling generally unwell. Upon examination, his temperature is 38.6ºC, pulse rate is 116 beats/min, blood pressure is 102/62 mmHg, and respiratory rate is 24 beats/min. Crackles and bronchial breathing are heard in the left upper zone of his chest. A urine dip is negative for leucocytes and blood tests reveal a neutrophil count of 0.4. He received his last cycle of chemotherapy 10 days ago. What is the most appropriate antibiotic treatment to initiate for this patient?

      Your Answer: Intravenous piperacillin with tazobactam (Tazocin)

      Explanation:

      Neutropenic sepsis is a serious condition that requires immediate treatment with antibiotics. Piperacillin with tazobactam (Tazocin) is the preferred antibiotic for this condition, even before neutropenia is confirmed on blood testing. This combination works by breaking down the cell walls of bacteria and preventing bacterial resistance to piperacillin. However, if a patient is unable to tolerate Tazocin, alternative antibiotics should be considered based on local guidelines or microbiology advice.

      Amoxicillin with clavulanic acid and gentamicin are other antibiotics that can be used for severe infections, but they are not the best choice for neutropenic sepsis. Aztreonam and vancomycin can be used in combination when Tazocin is not an option, but a third antibiotic may be necessary for additional coverage. It is important to note that gentamicin should be used with caution due to the risk of kidney damage and ototoxicity.

      Neutropenic Sepsis: A Common Complication of Cancer Therapy

      Neutropenic sepsis is a frequent complication of cancer therapy, particularly chemotherapy. It typically occurs within 7-14 days after chemotherapy and is characterized by a neutrophil count of less than 0.5 * 109 in patients undergoing anticancer treatment who exhibit a temperature higher than 38ºC or other signs or symptoms consistent with clinically significant sepsis.

      To prevent neutropenic sepsis, patients who are likely to have a neutrophil count of less than 0.5 * 109 as a result of their treatment should be offered a fluoroquinolone. In the event of neutropenic sepsis, antibiotics must be initiated immediately, without waiting for the white blood cell count.

      According to NICE guidelines, empirical antibiotic therapy should begin with piperacillin with tazobactam (Tazocin) immediately. While some units may add vancomycin if the patient has central venous access, NICE does not support this approach. After initial treatment, patients are typically assessed by a specialist and risk-stratified to determine if they may be able to receive outpatient treatment.

      If patients remain febrile and unwell after 48 hours, an alternative antibiotic such as meropenem may be prescribed, with or without vancomycin. If patients do not respond after 4-6 days, the Christie guidelines suggest ordering investigations for fungal infections (e.g. HRCT) rather than blindly initiating antifungal therapy. In selected patients, G-CSF may be beneficial.

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  • Question 19 - A 28-year-old man presents to the emergency department with vague abdominal pain, nausea,...

    Correct

    • A 28-year-old man presents to the emergency department with vague abdominal pain, nausea, and vomiting. He has a history of alcohol abuse and depression, and has been feeling particularly low following a recent breakup. He has not been eating much in the past few days.
      Observations: heart rate 94 beats per minute, blood pressure 110/70 mmHg, respiratory rate 18 breaths per minute, temperature 37.2ºC, oxygen saturations 99% on air.
      Initial investigations are done including a capillary glucose, capillary ketones, arterial blood gas and electrocardiogram(ECG).
      ECG: sinus tachycardia
      Capillary glucose 4.8 mmol/L (4-7)
      Capillary ketones 3.5 mmol/L (0-0.6)
      pH 7.34 (7.35-7.45)
      pO2 13 kPa (10-14)
      pCO2 4.5 kPa (4.5-6)
      Lactate 1.7 mmol/L (0-2)
      What is the most appropriate management plan at this point?

      Your Answer: IV saline 0.9% and thiamine

      Explanation:

      Alcoholic ketoacidosis is treated by administering saline and thiamine through an infusion. This condition is characterized by acidosis, elevated ketones, and normal or low blood glucose levels, and typically occurs in chronic alcoholics who have not eaten enough food. When the body becomes malnourished, it starts breaking down body fat, leading to the production of ketones and the development of ketoacidosis. The first steps in managing this condition involve rehydration with IV fluids like saline and administering thiamine to prevent the onset of Wernicke’s encephalopathy. It is important to note that simply replacing glucose without also replacing thiamine can be dangerous, as glucose promotes metabolism and thiamine acts as a co-factor. In contrast, IV insulin fixed rate infusion is used to manage diabetic ketoacidosis (DKA), which is characterized by high glucose levels. However, diabetic patients taking a sodium-glucose transport protein 2 inhibitor are at risk of developing euglycemic DKA. While chlordiazepoxide can help prevent alcohol withdrawal, preventing Wernicke’s should be the primary focus of initial management.

      Alcoholic ketoacidosis is a type of ketoacidosis that occurs in individuals who consume large amounts of alcohol regularly. This condition is not related to diabetes and is characterized by normal blood sugar levels. Alcoholics often suffer from malnutrition due to their irregular eating habits and may vomit the food they consume, leading to starvation. When the body becomes malnourished, it starts breaking down body fat, which produces ketones and leads to ketoacidosis.

      The typical symptoms of alcoholic ketoacidosis include metabolic acidosis, elevated anion gap, elevated serum ketone levels, and normal or low glucose concentration. The most effective treatment for this condition is an infusion of saline and thiamine. Thiamine is essential to prevent the development of Wernicke encephalopathy or Korsakoff psychosis. Therefore, it is crucial to provide timely and appropriate treatment to individuals suffering from alcoholic ketoacidosis to prevent further complications.

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  • Question 20 - A 16-year-old female presents to the emergency department with peri-umbilical pain. The pain...

    Incorrect

    • A 16-year-old female presents to the emergency department with peri-umbilical pain. The pain is sharp in nature, is exacerbated by coughing and came on gradually over the past 12 hours. On examination, she is unable to stand on one leg comfortably and experiences pain on hip extension. The is no rebound tenderness or guarding. A urine pregnancy test is negative, and her temperature is 37.4ºC. The following tests are done:

      Hb 135 g/L Male: (135-180)
      Female: (115 - 160)

      Platelets 300 * 109/L (150 - 400)

      WBC 14 * 109/L (4.0 - 11.0)

      Neuts 11 * 109/L (2.0 - 7.0)

      Lymphs 2 * 109/L (1.0 - 3.5)

      Mono 0.8 * 109/L (0.2 - 0.8)

      Eosin 0.2 * 109/L (0.0 - 0.4)

      Na+ 136 mmol/L (135 - 145)

      K+ 4 mmol/L (3.5 - 5.0)

      Urea 6 mmol/L (2.0 - 7.0)

      Creatinine 80 µmol/L (55 - 120)

      CRP 24 mg/L (< 5)

      What is the most likely diagnosis?

      Your Answer: Inguinal hernia

      Correct Answer: Acute appendicitis

      Explanation:

      The most probable diagnosis for individuals experiencing pain in the peri-umbilical region is acute appendicitis. Early appendicitis is characterized by this type of pain, and a positive psoas sign is also present. A neutrophil predominant leucocytosis is observed on the full blood count, indicating an infection. Ovarian torsion can cause sharp pain, but it is typically sudden and severe, not gradually worsening over 12 hours. Inguinal hernia pain is more likely to be felt in the groin area, not peri-umbilical, and there is no mention of a mass during the abdominal examination. Suprapubic pain and lower urinary tract symptoms such as dysuria are more likely to be associated with a lower urinary tract infection. In the absence of high fever and/or flank pain, an upper urinary tract infection is unlikely.

      Understanding Acute Appendicitis

      Acute appendicitis is a common condition that requires surgery and can occur at any age, but is most prevalent in young people aged 10-20 years. The pathogenesis of acute appendicitis involves lymphoid hyperplasia or a faecolith, which leads to the obstruction of the appendiceal lumen. This obstruction causes gut organisms to invade the appendix wall, leading to oedema, ischaemia, and possible perforation.

      The most common symptom of acute appendicitis is abdominal pain, which is usually peri-umbilical and radiates to the right iliac fossa due to localised peritoneal inflammation. Other symptoms include mild pyrexia, anorexia, and nausea. Examination may reveal generalised or localised peritonism, rebound and percussion tenderness, guarding, and rigidity.

      Diagnosis of acute appendicitis is typically based on raised inflammatory markers, compatible history, and examination findings. Imaging may be used in some cases, such as ultrasound in females where pelvic organ pathology is suspected. The treatment of choice for acute appendicitis is appendicectomy, which can be performed via an open or laparoscopic approach. Patients with perforated appendicitis require copious abdominal lavage, while those without peritonitis who have an appendix mass should receive broad-spectrum antibiotics and consideration given to performing an interval appendicectomy.

      In conclusion, acute appendicitis is a common condition that requires prompt diagnosis and treatment. Understanding the pathogenesis, symptoms, and management of acute appendicitis is crucial for healthcare professionals to provide appropriate care for patients.

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  • Question 21 - A 35-year-old man has visited his doctor complaining of feeling unwell. He has...

    Correct

    • A 35-year-old man has visited his doctor complaining of feeling unwell. He has been experiencing flu-like symptoms, nausea, and joint pain for the past 3 weeks. Additionally, he has noticeable yellowing of the skin. The patient recently returned from a trip to Mallorca, a Spanish island, 6 weeks ago. Although he did not engage in unprotected sex, he frequently dined at local seafood restaurants. He has no medical history. Upon examination, the doctor noted an enlargement of the liver and spleen. What is the most likely cause of this patient's hepatosplenomegaly?

      Your Answer: Viral hepatitis A

      Explanation:

      Understanding Hepatomegaly and Its Common Causes

      Hepatomegaly refers to an enlarged liver, which can be caused by various factors. One of the most common causes is cirrhosis, which can lead to a decrease in liver size in later stages. In this case, the liver is non-tender and firm. Malignancy, such as metastatic spread or primary hepatoma, can also cause hepatomegaly, with a hard and irregular liver edge. Right heart failure can result in a firm, smooth, and tender liver edge, which may be pulsatile.

      Other causes of hepatomegaly include viral hepatitis, glandular fever, malaria, abscess (pyogenic or amoebic), hydatid disease, haematological malignancies, haemochromatosis, primary biliary cirrhosis, sarcoidosis, and amyloidosis. It is important to identify the underlying cause of hepatomegaly to determine the appropriate treatment and management plan.

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  • Question 22 - A 42-year-old obese female is found to have gallstones during an abdominal ultrasound,...

    Correct

    • A 42-year-old obese female is found to have gallstones during an abdominal ultrasound, which was ordered due to recurrent urinary tract infections. Other than the UTIs, she is in good health. What is the best course of action for managing the gallstones?

      Your Answer: Observation

      Explanation:

      Gallstones: Symptoms, Diagnosis, and Treatment

      Gallstones are a common condition, with up to 24% of women and 12% of men affected. Local infection and cholecystitis may develop in up to 30% of cases, and 12% of patients undergoing surgery will have stones in the common bile duct. The majority of gallstones are of mixed composition, with pure cholesterol stones accounting for 20% of cases. Symptoms typically include colicky right upper quadrant pain that worsens after fatty meals. Diagnosis involves abdominal ultrasound and liver function tests, with magnetic resonance cholangiography or intraoperative imaging used to confirm the presence of stones in the bile duct. Treatment options include expectant management for asymptomatic gallstones, laparoscopic cholecystectomy for symptomatic gallstones, and early ERCP or surgical exploration for stones in the bile duct. Intraoperative cholangiography or laparoscopic ultrasound may be used to confirm anatomy or exclude CBD stones during surgery. ERCP carries risks such as bleeding, duodenal perforation, cholangitis, and pancreatitis.

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  • Question 23 - Which one of the following statements regarding hepatitis A is not true? ...

    Correct

    • Which one of the following statements regarding hepatitis A is not true?

      Your Answer: It is a DNA virus

      Explanation:

      Understanding Hepatitis A: Symptoms, Transmission, and Prevention

      Hepatitis A is a viral infection caused by the RNA picornavirus. It is typically spread through faecal-oral transmission, often in institutions. The incubation period is around 2-4 weeks, and symptoms include a flu-like prodrome, abdominal pain (usually in the right upper quadrant), tender hepatomegaly, jaundice, and deranged liver function tests. However, the disease is usually self-limiting and benign, with serious complications being rare.

      Unlike other forms of hepatitis, hepatitis A does not cause chronic disease or increase the risk of hepatocellular cancer. An effective vaccine is available, and it is recommended for people who are travelling to or residing in areas of high or intermediate prevalence, those with chronic liver disease, patients with haemophilia, men who have sex with men, injecting drug users, and individuals at occupational risk (such as laboratory workers, staff of large residential institutions, sewage workers, and people who work with primates). After the initial dose, a booster dose should be given 6-12 months later.

      Understanding the symptoms, transmission, and prevention of hepatitis A is important for individuals who may be at risk of contracting the virus. By taking appropriate precautions and getting vaccinated, individuals can protect themselves and others from this viral infection.

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  • Question 24 - 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 25 - What is the most prevalent form of colorectal cancer that is inherited?

    Familial...

    Correct

    • What is the most prevalent form of colorectal cancer that is inherited?

      Familial adenomatous polyposis, Li-Fraumeni syndrome, Hereditary non-polyposis colorectal carcinoma, Fanconi syndrome, and Peutz-Jeghers syndrome are all types of inherited colorectal cancer. However, which one is the most common?

      Your Answer: Hereditary non-polyposis colorectal carcinoma

      Explanation:

      Genetics and Types of Colorectal Cancer

      Colorectal cancer is a type of cancer that affects the colon and rectum. There are three main types of colorectal cancer: sporadic, hereditary non-polyposis colorectal carcinoma (HNPCC), and familial adenomatous polyposis (FAP). Sporadic colon cancer is the most common type, accounting for 95% of cases. It is believed to be caused by a series of genetic mutations, including allelic loss of the APC gene, activation of the K-ras oncogene, and deletion of p53 and DCC tumour suppressor genes.

      HNPCC, also known as Lynch syndrome, is an autosomal dominant condition that accounts for 5% of cases. It is the most common form of inherited colon cancer and is caused by mutations in genes involved in DNA mismatch repair, leading to microsatellite instability. The most commonly affected genes are MSH2 and MLH1. Patients with HNPCC are also at a higher risk of developing other cancers, such as endometrial cancer.

      FAP is a rare autosomal dominant condition that accounts for less than 1% of cases. It is caused by a mutation in the adenomatous polyposis coli gene (APC), which leads to the formation of hundreds of polyps by the age of 30-40 years. Patients with FAP inevitably develop carcinoma and are also at risk of duodenal tumors. A variant of FAP called Gardner’s syndrome can also feature osteomas of the skull and mandible, retinal pigmentation, thyroid carcinoma, and epidermoid cysts on the skin.

      In conclusion, understanding the genetics behind colorectal cancer is important for diagnosis and treatment. While sporadic colon cancer is the most common type, HNPCC and FAP are inherited conditions that require genetic testing and surveillance for early detection and prevention.

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  • Question 26 - A 54-year-old man complains of fatigue, overall weakness, and weight loss for the...

    Correct

    • A 54-year-old man complains of fatigue, overall weakness, and weight loss for the past 3 months. He also reports experiencing pain in his second and third fingers for the last month and worsening erectile dysfunction. You suspect that he may have hereditary hemochromatosis and order blood tests. Which of the following results would support your suspected diagnosis?

      Your Answer: Ferritin - high; serum iron - high; total iron binding capacity - low; transferrin saturation - high

      Explanation:

      Haemochromatosis is identified by an iron study profile that shows elevated levels of transferrin saturation and ferritin, along with a low total iron-binding capacity. This condition is inherited and leads to an excessive buildup of iron in the body. To rule out other possibilities, any options that do not show increased levels of ferritin and transferrin saturation can be eliminated during initial screening. Transferrin is a protein that transports iron in the blood, and its levels rise during iron deficiency to maximize the use of available iron. Total iron-binding capacity reflects the number of iron-binding sites on transferrin, and its levels increase during iron deficiency and decrease during iron overload.

      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 27 - A 28-year-old individual visits the neurology clinic with complaints of experiencing multiple instances...

    Correct

    • A 28-year-old individual visits the neurology clinic with complaints of experiencing multiple instances of involuntary shaking in different limbs. They have some control over which limb is affected the most but are unable to stop the shaking. The intensity of the shaking increases gradually and then subsides in a similar manner. The patient reports that the shaking is more severe when they feel anxious. What is the probable diagnosis?

      Your Answer: Pseudoseizures

      Explanation:

      Distinguishing between pseudoseizures and true seizures can be challenging as they share some similarities. However, one key difference is that pseudoseizures tend to have a gradual onset, while true seizures have a sudden onset. Pseudoseizures are often linked to psychiatric conditions and are not voluntary, but rather compulsive and unwanted movements. It is common for individuals experiencing pseudoseizures to have some control over the location of their symptoms. While dystonia may involve shaking, it typically results in rigidity rather than gradual onset and offset.

      Understanding Psychogenic Non-Epileptic Seizures

      Psychogenic non-epileptic seizures, also known as pseudoseizures, are a type of seizure that is not caused by abnormal electrical activity in the brain. Instead, they are believed to be caused by psychological factors such as stress, trauma, or anxiety. These seizures can be difficult to diagnose as they often mimic true epileptic seizures, but there are certain factors that can help differentiate between the two.

      Factors that may indicate pseudoseizures include pelvic thrusting, a family history of epilepsy, a higher incidence in females, crying after the seizure, and the seizures not occurring when the individual is alone. On the other hand, factors that may indicate true epileptic seizures include tongue biting and a raised serum prolactin level.

      Video telemetry is a useful tool for differentiating between the two types of seizures. It involves monitoring the individual’s brain activity and behavior during a seizure, which can help determine whether it is caused by abnormal electrical activity in the brain or psychological factors.

      It is important to accurately diagnose and treat psychogenic non-epileptic seizures as they can have a significant impact on an individual’s quality of life. Treatment may involve therapy to address underlying psychological factors, as well as medication to manage any associated symptoms such as anxiety or depression.

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  • Question 28 - A 16-year-old male presents to the nephrology unit with a complaint of recurrent...

    Correct

    • A 16-year-old male presents to the nephrology unit with a complaint of recurrent visible haematuria following upper respiratory tract infections. He denies any abdominal or loin pain. The urine dipstick is unremarkable, and blood tests reveal normal electrolyte levels and kidney function. What is the probable diagnosis?

      Your Answer: IgA nephropathy

      Explanation:

      Understanding IgA Nephropathy

      IgA nephropathy, also known as Berger’s disease, is the most common cause of glomerulonephritis worldwide. It is characterized by the deposition of IgA immune complexes in the mesangium, leading to mesangial hypercellularity and positive immunofluorescence for IgA and C3. The classic presentation is recurrent episodes of macroscopic hematuria in young males following an upper respiratory tract infection. Unlike post-streptococcal glomerulonephritis, IgA nephropathy is not associated with low complement levels and typically does not present with nephrotic range proteinuria or renal failure.

      Management of IgA nephropathy depends on the severity of proteinuria and renal function. Isolated hematuria without or minimal proteinuria and normal GFR requires only follow-up to monitor renal function. Persistent proteinuria with normal or slightly reduced GFR can be treated with ACE inhibitors. If there is active disease or failure to respond to ACE inhibitors, immunosuppression with corticosteroids may be necessary. The prognosis of IgA nephropathy varies, with 25% of patients developing ESRF. Factors associated with a poor prognosis include male gender, proteinuria, hypertension, smoking, hyperlipidemia, and ACE genotype DD, while frank hematuria is a marker of good prognosis.

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      • Medicine
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  • Question 29 - Liam, a 17-year-old boy, comes in for his annual asthma review. He has...

    Incorrect

    • Liam, a 17-year-old boy, comes in for his annual asthma review. He has generally well-controlled asthma, with only one exacerbation requiring steroids this year. He takes 2 puffs of his beclomethasone inhaler twice daily, and salbutamol as needed, both via a metered-dose inhaler (MDI).

      You decide to assess his inhaler technique. He demonstrates removing the cap, shaking the inhaler, and exhaling before placing his lips over the mouthpiece, pressing down on the canister while taking a slow breath in and then holding his breath for 10 seconds. He then immediately repeats this process for the second dose.

      What suggestions could you offer to improve his technique?

      Your Answer: She should wait 15 seconds before repeating the dose

      Correct Answer: She should wait 30 seconds before repeating the dose

      Explanation:

      To ensure proper drug delivery, it is important to use the correct inhaler technique. This involves removing the cap, shaking the inhaler, and taking a slow breath in while delivering the dose. After holding the breath for 10 seconds, it is recommended to wait for approximately 30 seconds before repeating the dose. In this case, the individual should have waited for the full 30 seconds before taking a second dose.

      Proper Inhaler Technique for Metered-Dose Inhalers

      Proper inhaler technique is crucial for effective treatment of respiratory conditions such as asthma. The following guidelines are recommended by Asthma.org.uk, a resource recommended to patients by the British Thoracic Society, for using metered-dose inhalers.

      To begin, remove the cap and shake the inhaler. Breathe out gently before placing the mouthpiece in your mouth. As you begin to breathe in slowly and deeply, press down on the canister and continue to inhale steadily. Hold your breath for 10 seconds, or as long as is comfortable, before exhaling. If a second dose is needed, wait approximately 30 seconds before repeating the steps.

      It is important to note that the inhaler should only be used for the number of doses indicated on the label before starting a new inhaler. By following these guidelines, patients can ensure that they are using their inhaler correctly and receiving the full benefits of their medication.

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      • Medicine
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  • Question 30 - A 24-year-old is brought to the ICU following a severe head injury from...

    Correct

    • A 24-year-old is brought to the ICU following a severe head injury from a car crash. The patient arrives agitated and hypoxic, requiring intubation and ventilation. Upon further examination, it is discovered that the patient has an elevated intracranial pressure. How does altering the ventilation rate aid in managing this patient's condition?

      Your Answer: Hyperventilation -> reduce CO2 -> vasoconstriction of the cerebral arteries -> reduced ICP

      Explanation:

      Controlled hyperventilation can be employed for patients with elevated ICP by increasing CO2 expiration. This leads to constriction of cerebral arteries due to low blood CO2 levels. As a result, blood flow decreases, reducing the volume inside the cranium and ultimately lowering intracranial pressure. Therefore, the other options are incorrect.

      Understanding Raised Intracranial Pressure

      As the brain and ventricles are enclosed by a rigid skull, any additional volume such as haematoma, tumour, or excessive cerebrospinal fluid (CSF) can lead to a rise in intracranial pressure (ICP). In adults, the normal ICP is between 7-15 mmHg in the supine position. The net pressure gradient causing cerebral blood flow to the brain is known as cerebral perfusion pressure (CPP), which can be calculated by subtracting ICP from mean arterial pressure.

      Raised intracranial pressure can be caused by various factors such as idiopathic intracranial hypertension, traumatic head injuries, infections, meningitis, tumours, and hydrocephalus. Its symptoms include headache, vomiting, reduced levels of consciousness, papilloedema, and Cushing’s triad, which is characterized by widening pulse pressure, bradycardia, and irregular breathing.

      To investigate the underlying cause, neuroimaging such as CT or MRI is key. Invasive ICP monitoring can also be done by placing a catheter into the lateral ventricles of the brain to monitor the pressure, collect CSF samples, and drain small amounts of CSF to reduce the pressure. A cut-off of >20 mmHg is often used to determine if further treatment is needed to reduce the ICP.

      Management of raised intracranial pressure involves investigating and treating the underlying cause, head elevation to 30º, IV mannitol as an osmotic diuretic, controlled hyperventilation to reduce pCO2 and vasoconstriction of the cerebral arteries, and removal of CSF through techniques such as drain from intraventricular monitor, repeated lumbar puncture, or ventriculoperitoneal shunt for hydrocephalus.

    • This question is part of the following fields:

      • Medicine
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