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  • Question 1 - A 42-year-old man is being evaluated for possible diabetes mellitus and undergoes an...

    Incorrect

    • A 42-year-old man is being evaluated for possible diabetes mellitus and undergoes an oral glucose tolerance test using the standard WHO protocol. The results are as follows:

      Time (hours) Blood glucose (mmol/l)
      0 5.9
      2 8.2

      What is the interpretation of these findings?

      Your Answer: Impaired glucose tolerance

      Correct Answer: Normal

      Explanation:

      Type 2 diabetes mellitus can be diagnosed through a plasma glucose or HbA1c sample. The diagnostic criteria vary depending on whether the patient is experiencing symptoms or not. If the patient is symptomatic, a fasting glucose level of 7.0 mmol/l or higher or a random glucose level of 11.1 mmol/l or higher (or after a 75g oral glucose tolerance test) indicates diabetes. If the patient is asymptomatic, the same criteria apply but must be demonstrated on two separate occasions.

      In 2011, the World Health Organization released supplementary guidance on the use of HbA1c for diagnosing diabetes. A HbA1c level of 48 mmol/mol (6.5%) or higher is diagnostic of diabetes mellitus. However, a HbA1c value of less than 48 mmol/mol (6.5%) does not exclude diabetes and may not be as sensitive as fasting samples for detecting diabetes. For patients without symptoms, the test must be repeated to confirm the diagnosis. It is important to note that increased red cell turnover can cause misleading HbA1c results.

      There are certain conditions where HbA1c cannot be used for diagnosis, such as haemoglobinopathies, haemolytic anaemia, untreated iron deficiency anaemia, suspected gestational diabetes, children, HIV, chronic kidney disease, and people taking medication that may cause hyperglycaemia (such as corticosteroids).

      Impaired fasting glucose (IFG) is defined as a fasting glucose level of 6.1 mmol/l or higher but less than 7.0 mmol/l. Impaired glucose tolerance (IGT) is defined as a fasting plasma glucose level less than 7.0 mmol/l and an OGTT 2-hour value of 7.8 mmol/l or higher but less than 11.1 mmol/l. People with IFG should be offered an oral glucose tolerance test to rule out a diagnosis of diabetes. A result below 11.1 mmol/l but above 7.8 mmol/l indicates that the person does not have diabetes but does have IGT.

    • This question is part of the following fields:

      • Endocrinology/Metabolic Disease
      8.9
      Seconds
  • Question 2 - A 25-year-old man presents to the clinic with persistent beliefs that his coworkers...

    Incorrect

    • A 25-year-old man presents to the clinic with persistent beliefs that his coworkers are plotting against him and trying to sabotage his work, despite reassurance and evidence to the contrary. He has had multiple heated arguments with his colleagues and after each one, he becomes aggressive and blames them for his outbursts. He sometimes feels like he cannot function without them, but also sometimes feels that they are out to get him. He has a history of a recent suicide attempt and has difficulties trusting his family as he feels they are part of the conspiracy. What is the most likely diagnosis?

      Your Answer: Schizotypal personality disorder

      Correct Answer: Borderline personality disorder

      Explanation:

      The young man in question is likely suffering from borderline personality disorder (BPD), also known as emotionally unstable personality disorder (EUPD). This condition is characterized by unstable relationships, alternating between idealization and devaluation of others, recurrent self-harm, unstable self-image and self-esteem, suicidal behavior, difficulty controlling anger, and efforts to avoid abandonment. All of these traits are present in this patient, making BPD the most likely diagnosis.

      Narcissistic personality disorder is not a likely diagnosis for this patient, as it is characterized by a grandiose sense of self-importance, lack of empathy, and a sense of entitlement. These traits are not present in this patient, and his periods of devaluing her partner are temporary and not pervasive.

      Dependent personality disorder is also an unlikely diagnosis, as this condition is characterized by a pervasive need for others to make decisions for the patient and constant reassurance. While the patient has felt that he cannot live without his partner in the past, his labile mood and alternating view of his partner make this diagnosis less likely.

      Paranoid personality disorder is also an unlikely diagnosis, as patients with this condition tend to be reluctant to confide in others and have an unforgiving attitude when insulted or questioned. The patient in question does not exhibit these traits, and his difficulty with trusting friends is likely due to his belief that he is undeserving of them.

      Personality disorders are a set of personality traits that are maladaptive and interfere with normal functioning in life. It is estimated that around 1 in 20 people have a personality disorder, which are typically categorized into three clusters: Cluster A, which includes Odd or Eccentric disorders such as Paranoid, Schizoid, and Schizotypal; Cluster B, which includes Dramatic, Emotional, or Erratic disorders such as Antisocial, Borderline (Emotionally Unstable), Histrionic, and Narcissistic; and Cluster C, which includes Anxious and Fearful disorders such as Obsessive-Compulsive, Avoidant, and Dependent.

      Paranoid individuals exhibit hypersensitivity and an unforgiving attitude when insulted, a reluctance to confide in others, and a preoccupation with conspirational beliefs and hidden meanings. Schizoid individuals show indifference to praise and criticism, a preference for solitary activities, and emotional coldness. Schizotypal individuals exhibit odd beliefs and magical thinking, unusual perceptual disturbances, and inappropriate affect. Antisocial individuals fail to conform to social norms, deceive others, and exhibit impulsiveness, irritability, and aggressiveness. Borderline individuals exhibit unstable interpersonal relationships, impulsivity, and affective instability. Histrionic individuals exhibit inappropriate sexual seductiveness, a need to be the center of attention, and self-dramatization. Narcissistic individuals exhibit a grandiose sense of self-importance, lack of empathy, and excessive need for admiration. Obsessive-compulsive individuals are occupied with details, rules, and organization to the point of hampering completion of tasks. Avoidant individuals avoid interpersonal contact due to fears of criticism or rejection, while dependent individuals have difficulty making decisions without excessive reassurance from others.

      Personality disorders are difficult to treat, but a number of approaches have been shown to help patients, including psychological therapies such as dialectical behavior therapy and treatment of any coexisting psychiatric conditions.

    • This question is part of the following fields:

      • Psychiatry
      21.5
      Seconds
  • Question 3 - A 15-year-old girl comes to the emergency department complaining of a maculopapular rash...

    Correct

    • A 15-year-old girl comes to the emergency department complaining of a maculopapular rash that has been present for 1 day. She had visited her family doctor 2 days ago with symptoms of a cold and a sore throat and was given a course of oral antibiotics. Upon examination, she has a mild fever of 37.8ºC and a widespread maculopapular rash on her face and torso. Her tonsils are enlarged and erythematous, and she has palpable tender posterior cervical lymphadenopathy. What is the most appropriate diagnostic test to identify the underlying condition?

      Your Answer: Monospot test

      Explanation:

      The patient in question is likely suffering from glandular fever, a viral illness caused by the Ebstein-Barr virus. Symptoms include a sore throat, fever, and general malaise, as well as palpable cervical lymphadenopathy and an erythematous throat. The illness is more common in teenagers and is often spread through respiratory droplets, earning it the nickname kissing disease. The patient was prescribed amoxicillin by their GP, which can cause a non-specific maculopapular rash in patients with glandular fever. The diagnosis is typically confirmed through a Monospot blood test, which detects the presence of heterophil antibodies produced in response to the virus.

      An anti-streptolysin O titre test can detect streptococcal infections, but it does not explain the patient’s rash following antibiotic use. A full blood count can be helpful in diagnosing glandular fever, as it often shows a lymphocytosis, but the Monospot test is more definitive. A nasopharyngeal aspirate for viral PCR can diagnose viral infections like measles, but this is less likely in a teenager in the UK due to vaccination. A sputum culture is not useful in diagnosing glandular fever, as the patient does not have a cough or sputum production.

      Understanding Infectious Mononucleosis

      Infectious mononucleosis, also known as glandular fever, is a viral infection caused by the Epstein-Barr virus (EBV) in 90% of cases. It is most commonly seen in adolescents and young adults. The classic triad of symptoms includes sore throat, pyrexia, and lymphadenopathy, which are present in around 98% of patients. Other symptoms include malaise, anorexia, headache, palatal petechiae, splenomegaly, hepatitis, lymphocytosis, haemolytic anaemia, and a maculopapular rash. The symptoms typically resolve after 2-4 weeks.

      The diagnosis of infectious mononucleosis is confirmed through a heterophil antibody test (Monospot test) in the second week of the illness. Management is supportive and includes rest, drinking plenty of fluids, avoiding alcohol, and taking simple analgesia for any aches or pains. It is recommended to avoid playing contact sports for 4 weeks after having glandular fever to reduce the risk of splenic rupture.

      Interestingly, there is a correlation between EBV and socioeconomic groups. Lower socioeconomic groups have high rates of EBV seropositivity, having frequently acquired EBV in early childhood when the primary infection is often subclinical. However, higher socioeconomic groups show a higher incidence of infectious mononucleosis, as acquiring EBV in adolescence or early adulthood results in symptomatic disease.

    • This question is part of the following fields:

      • Infectious Diseases
      32.2
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  • Question 4 - You assess a 29-year-old woman who is 24 weeks pregnant. Due to her...

    Incorrect

    • You assess a 29-year-old woman who is 24 weeks pregnant. Due to her BMI of 33 kg/m², she underwent a routine oral glucose tolerance test which yielded the following results:
      Time (hours) Blood glucose (mmol/l)
      0 7.8
      2 10.6
      Apart from this, there have been no other complications during her pregnancy and her anomaly scan showed no abnormalities. What would be the best course of action?

      Your Answer: Advice about diet / exercise + self-monitor glucose levels

      Correct Answer: Start insulin + advice about diet / exercise + self-monitor glucose levels

      Explanation:

      The gestational diabetes guidelines of NICE have been updated, stating that insulin treatment must commence if the fasting glucose level is equal to or greater than 7 mmol/l. Additionally, it is recommended to consider administering aspirin due to the heightened risk of pre-eclampsia.

      Gestational diabetes is a common medical disorder affecting around 4% of pregnancies. Risk factors include a high BMI, previous gestational diabetes, and family history of diabetes. Screening is done through an oral glucose tolerance test, and diagnostic thresholds have recently been updated. Management includes self-monitoring of blood glucose, diet and exercise advice, and medication if necessary. For pre-existing diabetes, weight loss and insulin are recommended, and tight glycemic control is important. Targets for self-monitoring include fasting glucose of 5.3 mmol/l and 1-2 hour post-meal glucose levels.

    • This question is part of the following fields:

      • Reproductive Medicine
      24.1
      Seconds
  • Question 5 - A 32-year-old man presents with a recent change in bowel habit and is...

    Incorrect

    • A 32-year-old man presents with a recent change in bowel habit and is scheduled for outpatient sigmoidoscopy. He reports passing 3 stools daily with some mucus but no blood. The patient is in good overall health, with stable vital signs and normal blood test results. He has no known allergies and is not taking any medications at present.

      During the sigmoidoscopy, the patient is found to have localised proctitis, with no inflammation detected further up the gastrointestinal tract. Based on these findings, the patient is diagnosed with ulcerative colitis and receives appropriate counselling.

      What would be the most effective drug management approach for this patient's current symptoms?

      Your Answer: Oral steroids

      Correct Answer: Rectal aminosalicylates

      Explanation:

      For a mild-moderate flare of distal ulcerative colitis, the recommended first-line treatment is rectal aminosalicylates. This is particularly effective if the inflammation is limited to the rectum. If rectal aminosalicylates are not effective, oral aminosalicylates may be used in combination with or instead of the topical treatment. However, if the patient has contraindications or intolerances to aminosalicylates, topical or oral steroids may be preferred. Intravenous steroids are typically reserved for severe flares of colitis with symptoms such as frequent bloody stools, systemic upset, anemia, or elevated inflammatory markers.

      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.

    • This question is part of the following fields:

      • Gastroenterology/Nutrition
      18.7
      Seconds
  • Question 6 - A 26-year-old construction worker visits his GP complaining of elbow swelling that has...

    Correct

    • A 26-year-old construction worker visits his GP complaining of elbow swelling that has been present for three weeks. He reports that it started gradually and has no known triggers. The area is painful and warm to the touch, but he has no swelling in other parts of his body and feels generally well. The patient has a history of well-managed rheumatoid arthritis and is taking methotrexate, but has no other medical conditions. During the examination, the doctor detects a tender, soft, fluctuant mass on the back of the patient's elbow. Based on these findings, what is the most probable diagnosis?

      Your Answer: Olecranon bursitis

      Explanation:

      Understanding Olecranon Bursitis

      Olecranon bursitis is a condition that occurs when the olecranon bursa, a fluid-filled sac located over the olecranon process at the proximal end of the ulna, becomes inflamed. This bursa serves to reduce friction between the elbow joint and the surrounding soft tissues. Inflammation can be caused by trauma, infection, or systemic conditions such as rheumatoid arthritis or gout. It is also commonly known as student’s elbow due to the repetitive mild trauma of leaning on a desk using the elbows. The condition can be categorized as septic or non-septic depending on whether an infection is present.

      The condition is more common in men and typically presents between the ages of 30 and 60. Causes of olecranon bursitis include repetitive trauma, direct trauma, infection, gout, rheumatoid arthritis, and idiopathic reasons. Patients with non-septic olecranon bursitis typically present with swelling over the olecranon process, while some may also experience tenderness and erythema over the bursa. Patients with septic bursitis are more likely to have pain and fever.

      Signs of olecranon bursitis include swelling over the posterior aspect of the elbow, tenderness on palpation of the swollen area, redness and warmth of the overlying skin, fever, skin abrasion overlying the bursa, effusions in other joints if associated with rheumatoid arthritis, and tophi if associated with gout. Movement at the elbow joint should be painless until the swollen bursa is compressed in full flexion.

      Investigations are not always needed if a clinical diagnosis can be made and there is no concern about septic arthritis. However, if septic bursitis is suspected, aspiration of bursal fluid for microscopy and culture is essential. Purulent fluid suggests infection, while straw-colored bursal fluid favors a non-infective cause.

    • This question is part of the following fields:

      • Musculoskeletal
      11.6
      Seconds
  • Question 7 - A 35-year-old man presents with malaise, fever, backache and joint pains of 1-week...

    Correct

    • A 35-year-old man presents with malaise, fever, backache and joint pains of 1-week duration. On examination, arthritis is present asymmetrically in the lower limbs, involving the knees and metatarsophalangeal (MTP) and toe joints. An eye examination reveals conjunctival congestion, and there is a vesicular crusting lesion on his left sole. Investigations reveal an erythrocyte sedimentation rate (ESR) of 60 mm/h (normal <20 mm/h) and C-reactive protein (CRP) of 50 u/l (normal <5 u/l). Rheumatoid factor is negative and HLA-B27 positive.
      Which of the following is the most likely diagnosis?
      Select the SINGLE most appropriate diagnosis from the list below. Select ONE option only.

      Your Answer: Reactive arthritis

      Explanation:

      Reactive arthritis is a type of joint inflammation that occurs after an infection, often caused by dysentery or a sexually transmitted infection. It is more common in men who have the HLA-B27 gene. Reactive arthritis is part of a group of diseases called spondyloarthropathies, which also includes ankylosing spondylitis, psoriatic arthritis, enteropathic arthritis, and undifferentiated arthritis. Unlike rheumatoid arthritis, reactive arthritis is not associated with rheumatoid factor. Symptoms of reactive arthritis include sudden, asymmetrical lower limb joint pain, which can occur a few days to weeks after the initial infection. Enthesitis, or inflammation where tendons and ligaments attach to bones, is also common and can cause plantar fasciitis or Achilles tendonitis. In some cases, reactive arthritis can also cause back pain and inflammation of the sacroiliac joint, as well as a sterile conjunctivitis. Treatment involves addressing the initial infection and may include medications such as sulfasalazine or methotrexate for relapsing cases. It is important to trace and treat sexual partners if necessary. Gout, rheumatoid arthritis, psoriatic arthritis, and ankylosing spondylitis are other types of joint inflammation that have different symptoms and causes.

    • This question is part of the following fields:

      • Musculoskeletal
      45.5
      Seconds
  • Question 8 - A 25-year-old woman presents to her General Practitioner with a complaint of difficulty...

    Correct

    • A 25-year-old woman presents to her General Practitioner with a complaint of difficulty sleeping due to a blocked nose at night. She uses inhalers regularly for wheezing during cold weather and experiences a cough at night. What is the most common complication of her underlying diagnosis that she may be experiencing?

      Your Answer: Nasal Polyps

      Explanation:

      Understanding Nasal Polyps and Associated Conditions

      Nasal polyps are a common condition that can cause a blocked nose, interrupting sleep and wheezing upon exertion. They are often associated with asthma, which is found along the atopic spectrum of diseases. Other conditions commonly associated with nasal polyps include allergic rhinitis and sinusitis.

      Allergic fungal sinusitis is another condition that can cause nasal polyps, but it is more commonly found in warmer climates and is not the most common cause in the United Kingdom. Paracetamol sensitivity is not associated with nasal polyps, but aspirin sensitivity is and can be part of Samter’s triad if the patient also has asthma.

      Chronic obstructive pulmonary disease (COPD) is not associated with nasal polyps, and it would be rare to see in a young patient unless there was underlying alpha-1 anti-trypsin disease. COPD is most commonly seen in long-term smokers and presents with symptoms such as shortness of breath and a longstanding cough.

      Diabetes mellitus is not associated with nasal polyps and would present with other symptoms such as polyuria, polydipsia, and fatigue. Understanding the conditions associated with nasal polyps can help with diagnosis and treatment.

    • This question is part of the following fields:

      • ENT
      16.1
      Seconds
  • Question 9 - A 28-year-old woman experiences a blood loss of approximately 1,000 ml after giving...

    Incorrect

    • A 28-year-old woman experiences a blood loss of approximately 1,000 ml after giving birth vaginally. What is not considered a risk factor for primary postpartum hemorrhage?

      Your Answer: Polyhydramnios

      Correct Answer: Afro-Caribbean ethnicity

      Explanation:

      Understanding Postpartum Haemorrhage

      Postpartum haemorrhage (PPH) is a condition where a woman experiences blood loss of more than 500 ml after giving birth vaginally. It can be classified as primary or secondary. Primary PPH occurs within 24 hours after delivery and is caused by the 4 Ts: tone, trauma, tissue, and thrombin. The most common cause is uterine atony. Risk factors for primary PPH include previous PPH, prolonged labour, pre-eclampsia, increased maternal age, emergency Caesarean section, and placenta praevia.

      In managing PPH, it is important to involve senior staff immediately and follow the ABC approach. This includes two peripheral cannulae, lying the woman flat, blood tests, and commencing a warmed crystalloid infusion. Mechanical interventions such as rubbing up the fundus and catheterisation are also done. Medical interventions include IV oxytocin, ergometrine, carboprost, and misoprostol. Surgical options such as intrauterine balloon tamponade, B-Lynch suture, ligation of uterine arteries, and hysterectomy may be considered if medical options fail to control the bleeding.

      Secondary PPH occurs between 24 hours to 6 weeks after delivery and is typically due to retained placental tissue or endometritis. It is important to understand the causes and risk factors of PPH to prevent and manage this life-threatening emergency effectively.

    • This question is part of the following fields:

      • Reproductive Medicine
      9.9
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  • Question 10 - A 19-year-old college student presents with results from triple swabs for a yellow...

    Incorrect

    • A 19-year-old college student presents with results from triple swabs for a yellow vaginal discharge. Microscopy reveals the presence of 'intracellular Gram-negative diplococci'. The patient is in good health with a negative pregnancy test. What course of treatment would you recommend?

      Your Answer: Oral doxycycline

      Correct Answer: IM ceftriaxone

      Explanation:

      Gonorrhoea is best treated with intramuscular ceftriaxone.

      Understanding Gonorrhoea: Causes, Symptoms, Microbiology, and Management

      Gonorrhoea is a sexually transmitted infection caused by the Gram-negative diplococcus Neisseria gonorrhoeae. It can occur on any mucous membrane surface, including the genitourinary tract, rectum, and pharynx. The incubation period of gonorrhoea is typically 2-5 days. Symptoms in males include urethral discharge and dysuria, while females may experience cervicitis leading to vaginal discharge. Rectal and pharyngeal infections are usually asymptomatic.

      Immunisation against gonorrhoea is not possible, and reinfection is common due to antigen variation of type IV pili and Opa proteins. Local complications may develop, including urethral strictures, epididymitis, and salpingitis, which can lead to infertility. Disseminated infection may also occur, with gonococcal infection being the most common cause of septic arthritis in young adults.

      Management of gonorrhoea involves the use of antibiotics. Ciprofloxacin used to be the treatment of choice, but there is now increased resistance to it. Cephalosporins are now more widely used, with a single dose of IM ceftriaxone 1g being the new first-line treatment. If ceftriaxone is refused, oral cefixime 400mg + oral azithromycin 2g should be used. Disseminated gonococcal infection (DGI) and gonococcal arthritis may also occur, with symptoms including tenosynovitis, migratory polyarthritis, and dermatitis. Later complications include septic arthritis, endocarditis, and perihepatitis.

    • This question is part of the following fields:

      • Infectious Diseases
      13.7
      Seconds
  • Question 11 - During your FY2 rotation in General Practice, you saw a 76-year-old man in...

    Incorrect

    • During your FY2 rotation in General Practice, you saw a 76-year-old man in your GP clinic who had been experiencing blurring of vision in his right eye for the past 5 months. He finally decided to seek medical attention because he felt his vision was becoming increasingly distorted. Upon examination, there were no signs of inflammation in either eye, and both corneas were clear with no fluorescein uptake. However, on dilated fundoscopy, you noticed yellowish deposits in the center of the macula in his right eye. What is the curative treatment for this condition?

      Your Answer: Intravitreal anti-VEGF injection

      Correct Answer: None

      Explanation:

      Dry age-related macular degeneration, characterized by yellowish drusen deposits, currently has no cure. However, high doses of beta-carotene, vitamins C and E, and zinc can be administered to slow down the progression of visual loss. On the other hand, wet AMD can be treated with intravitreal anti-VEGF injections, laser photocoagulation, and photodynamic therapy.

      Age-related macular degeneration (ARMD) is a common cause of blindness in the UK, characterized by the degeneration of the central retina (macula) and the formation of drusen. It is more prevalent in females and is strongly associated with advancing age, smoking, family history, and conditions that increase the risk of ischaemic cardiovascular disease. ARMD can be classified into two forms: dry and wet. Dry ARMD is more common and is characterized by drusen, while wet ARMD is characterized by choroidal neovascularisation and carries a worse prognosis. Clinical features of ARMD include subacute onset of visual loss, difficulties in dark adaptation, and visual disturbances such as photopsia and glare.

      To diagnose ARMD, slit-lamp microscopy and color fundus photography are used to identify any pigmentary, exudative, or haemorrhagic changes affecting the retina. Fluorescein angiography and indocyanine green angiography may also be used to visualize changes in the choroidal circulation. Treatment for dry ARMD involves a combination of zinc with anti-oxidant vitamins A, C, and E, which has been shown to reduce disease progression by around one third. For wet ARMD, anti-VEGF agents such as ranibizumab, bevacizumab, and pegaptanib are used to limit disease progression and stabilize or reverse visual loss. Laser photocoagulation may also be used to slow progression, but anti-VEGF therapies are usually preferred due to the risk of acute visual loss after treatment.

      In summary, ARMD is a common cause of blindness in the UK that is strongly associated with advancing age, smoking, and family history. It can be classified into dry and wet forms, with wet ARMD carrying a worse prognosis. Diagnosis involves the use of various imaging techniques, and treatment options include a combination of zinc and anti-oxidant vitamins for dry ARMD and anti-VEGF agents or laser photocoagulation for wet ARMD.

    • This question is part of the following fields:

      • Ophthalmology
      15
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  • Question 12 - A 72-year-old man visits his general practice with symptoms of difficulty initiating urine...

    Incorrect

    • A 72-year-old man visits his general practice with symptoms of difficulty initiating urine flow. He also has to wake on a number of occasions each night to visit the toilet to pass urine. His pelvic exam is normal and a urinalysis does not indicate infection.
      Which of the following treatment options is likely to bring the most rapid symptom relief?

      Your Answer: Finasteride

      Correct Answer: Alpha-blocker

      Explanation:

      Treatment Options for Benign Prostatic Hyperplasia (BPH)

      Benign prostatic hyperplasia (BPH) is a common condition in men over 40 years old, characterized by non-cancerous growth of the prostate gland. This can lead to lower urinary tract symptoms (LUTS) that affect quality of life, such as obstructive symptoms (difficulty urinating) and irritative symptoms (frequent urination). While prostate cancer can present with similar symptoms, a reassuring biopsy can rule out cancer.

      Alpha-blockers, such as tamsulosin and doxazosin, are commonly used to treat moderate to severe symptomatic BPH, regardless of prostate size. These medications work by blocking α-adrenoreceptors in the prostate, prostatic urethra, and bladder neck, leading to decreased muscle tone and reduced bladder obstruction.

      Dutasteride and finasteride are both 5-α-reductase inhibitors (5ARIs) that block the production of dihydrotestosterone and reduce prostate volume. While there is no difference in clinical efficacy between the two agents, finasteride takes longer to show its effects. Current guidelines recommend 5ARIs for men with LUTS and a prostate larger than 30 g or a PSA level >1.4 ng/ml who are at high risk of progression. However, alpha-blockers remain the first-line agents for pharmacological treatment.

      Testosterone replacement therapy is not indicated for the treatment of BPH, and beta-blockers are not effective in managing BPH/LUTS.

    • This question is part of the following fields:

      • Renal Medicine/Urology
      21.2
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  • Question 13 - A 28-year-old woman presents to her General Practitioner with a 12-day history of...

    Correct

    • A 28-year-old woman presents to her General Practitioner with a 12-day history of vaginal discharge. She describes the discharge as having a fishy smell and a white colour. There is no history of abdominal pain or urinary symptoms and she denies pregnancy. She is sexually active with one regular partner of three years and has the Mirena coil in situ.
      On examination, her observations are within normal limits. Her abdomen is soft and nontender. The bimanual examination is unremarkable with no adnexal tenderness elicited. Her vaginal pH is 5.
      What is the next best investigation to confirm the likely diagnosis?

      Select ONE option only

      Your Answer: Vaginal swab for microscopy and culture

      Explanation:

      Diagnostic Tests for Bacterial Vaginosis and Urinary Tract Infections

      Bacterial vaginosis is a common vaginal infection caused by an overgrowth of Gardnerella vaginalis. The diagnosis of bacterial vaginosis is based on Amsel’s criteria, which includes thin, white-colored vaginal discharge, vaginal pH > 4.5, positive whiff test, and clue cells on microscopy. A vaginal swab for microscopy and culture is needed to confirm the diagnosis, especially if the patient meets two of the four criteria.

      On the other hand, urine microscopy and culture are used to diagnose urinary tract infections, which share some symptoms with sexually transmitted infections. However, the presence of vaginal discharge makes a sexually transmitted infection more likely, and alternative investigations are more specific.

      Blood culture and hysteroscopy and culture are not indicated in the diagnosis of bacterial vaginosis. Blood culture is not usually necessary, while hysteroscopy and biopsy are invasive procedures used to diagnose endometrial disorders.

      Lastly, nucleic acid amplification testing is used to diagnose chlamydia, the most common sexually transmitted disease. Although chlamydia may cause symptoms similar to bacterial vaginosis, the presence of increased vaginal pH makes bacterial vaginosis more likely.

    • This question is part of the following fields:

      • Infectious Diseases
      12.8
      Seconds
  • Question 14 - A 55 year old woman presents to the Emergency Department complaining of a...

    Incorrect

    • A 55 year old woman presents to the Emergency Department complaining of a cough with green sputum and palpitations. She reports feeling very sick, feverish, and tired. Upon examination, she exhibits bronchial breathing at her right base, with a respiratory rate of 25 breaths per minute and oxygen saturation of 95% on room air. Her heart sounds are normal, but her heartbeat is irregularly irregular, with a heart rate of 120 beats per minute and blood pressure of 90/40 mmHg. An ECG reveals atrial fibrillation with a fast ventricular rate. The patient has no prior history of atrial fibrillation. What is the initial treatment that should be administered?

      Your Answer: Bisoprolol

      Correct Answer: Intravenous fluids

      Explanation:

      Patient is septic from pneumonia and has developed atrial fibrillation. Treatment should focus on resolving the sepsis with IV fluids and antibiotics, which may also resolve the AF. If AF persists, other treatment options may be considered.

      Understanding Sepsis: Classification and Management

      Sepsis is a life-threatening condition caused by a dysregulated host response to an infection. In recent years, the classification of sepsis has changed, with the old category of severe sepsis no longer in use. Instead, the Surviving Sepsis Guidelines now recognize sepsis as life-threatening organ dysfunction caused by a dysregulated host response to infection, and septic shock as a more severe form of sepsis. The term ‘systemic inflammatory response syndrome (SIRS)’ has also fallen out of favor.

      To manage sepsis, it is important to identify and treat the underlying cause of the infection and support the patient regardless of the cause or severity. However, if any red flags are present, the ‘sepsis six’ should be started immediately. This includes administering oxygen, taking blood cultures, giving broad-spectrum antibiotics, giving intravenous fluid challenges, measuring serum lactate, and measuring accurate hourly urine output.

      NICE released its own guidelines in 2016, which focus on the risk stratification and management of patients with suspected sepsis. For risk stratification, NICE recommends using red flag and amber flag criteria. If any red flags are present, the sepsis six should be started immediately. If any amber flags are present, the patient should be closely monitored and managed accordingly.

      To help identify and categorize patients, the Sequential (Sepsis-Related) Organ Failure Assessment Score (SOFA) is increasingly used. The score grades abnormality by organ system and accounts for clinical interventions. A SOFA score of 2 or more reflects an overall mortality risk of approximately 10% in a general hospital population with suspected infection. Even patients presenting with modest dysfunction can deteriorate further, emphasizing the seriousness of this condition and the need for prompt and appropriate intervention.

    • This question is part of the following fields:

      • Cardiovascular
      21.1
      Seconds
  • Question 15 - At what point in the childhood immunisation schedule is the Meningitis B vaccine...

    Correct

    • At what point in the childhood immunisation schedule is the Meningitis B vaccine administered?

      Your Answer: 2, 4, and 12 months

      Explanation:

      The most prevalent cause of meningococcal disease in children in the UK is currently Meningitis B. In 2015, the Meningitis B vaccination was added to the NHS routine childhood immunisation schedule. It is administered at 2, 4, and 12 months of age, in conjunction with other immunisations in the schedule. If given at a different time, doses must be spaced at least 2 months apart. For children over one year old, only two doses are necessary.

      Meningitis B Vaccine Now Part of Routine NHS Immunisation

      Children in the UK have been vaccinated against meningococcus serotypes A and C for many years, leaving meningococcal B as the most common cause of bacterial meningitis in the country. However, a new vaccine called Bexsero has been developed to combat this strain. Initially, the Joint Committee on Vaccination and Immunisation (JCVI) rejected the use of Bexsero due to a cost-benefit analysis. However, the decision was eventually reversed, and the vaccine has been added to the routine NHS immunisation schedule.

      The vaccine is administered in three doses at 2 months, 4 months, and 12-13 months. Additionally, Bexsero will be available on the NHS for individuals at high risk of meningococcal disease, such as those with asplenia, splenic dysfunction, or complement disorder. This new vaccine is a significant step in protecting children and vulnerable individuals from meningitis B.

    • This question is part of the following fields:

      • Paediatrics
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  • Question 16 - A 35-year-old woman has recently undergone blood monitoring for hypothyroidism. She is currently...

    Incorrect

    • A 35-year-old woman has recently undergone blood monitoring for hypothyroidism. She is currently on a 100 micrograms dose of levothyroxine and her last blood tests showed normal levels of thyroid-stimulating hormone (TSH) and free thyroxine (ft4). However, her TSH has now risen to 8mU/L with ft4 slightly below the reference range. The patient confirms that she has been taking her levothyroxine as prescribed. You decide to review her recent medications to identify any potential causes for the suboptimal hypothyroidism treatment. What new medication could be responsible for this?

      Your Answer: Folic acid

      Correct Answer: Ferrous sulphate

      Explanation:

      To avoid reducing the absorption of levothyroxine, it is important to give iron/calcium carbonate tablets at least four hours apart from the medication. Ferrous sulphate is the medication that can affect the absorption of levothyroxine and should also be given four hours apart. Patients should be advised to separate doses of calcium carbonate or antacids containing aluminium and magnesium from levothyroxine by at least four hours. It is recommended to review potential drug interactions before increasing treatment doses and refer to The National Institute for Health and Care Excellence (NICE) clinical knowledge summaries for a detailed list of potential drug interactions. The other medications listed do not have a known effect on the absorption of levothyroxine.

      Managing Hypothyroidism: Dosage, Monitoring, and Side-Effects

      Hypothyroidism is a condition where the thyroid gland does not produce enough thyroid hormone. The main treatment for hypothyroidism is levothyroxine, a synthetic form of thyroid hormone. When managing hypothyroidism, it is important to consider the patient’s age, cardiac history, and initial starting dose. Elderly patients and those with ischaemic heart disease should start with a lower dose of 25mcg od, while other patients can start with 50-100mcg od. After a change in dosage, thyroid function tests should be checked after 8-12 weeks to ensure the therapeutic goal of normalising the thyroid stimulating hormone (TSH) level is achieved. The target TSH range is 0.5-2.5 mU/l.

      Women with hypothyroidism who become pregnant should have their dose increased by at least 25-50 micrograms levothyroxine due to the increased demands of pregnancy. The TSH should be monitored carefully, aiming for a low-normal value. It is important to note that there is no evidence to support combination therapy with levothyroxine and liothyronine.

      While levothyroxine is generally well-tolerated, there are some potential side-effects to be aware of. Over-treatment can lead to hyperthyroidism, while long-term use can reduce bone mineral density. In patients with cardiac disease, levothyroxine can worsen angina and lead to atrial fibrillation. It is also important to be aware of drug interactions, particularly with iron and calcium carbonate, which can reduce the absorption of levothyroxine. These medications should be given at least 4 hours apart.

      In summary, managing hypothyroidism involves careful consideration of dosage, monitoring of TSH levels, and awareness of potential side-effects and drug interactions. With appropriate management, patients with hypothyroidism can achieve normal thyroid function and improve their overall health.

    • This question is part of the following fields:

      • Endocrinology/Metabolic Disease
      13.2
      Seconds
  • Question 17 - A 50-year-old woman presented with worsening pains in the small joints of both...

    Incorrect

    • A 50-year-old woman presented with worsening pains in the small joints of both her feet with swelling and redness. She experienced stiffness which was worse in the morning. She was initially started on oral prednisolone with a proton-pump inhibitor whilst awaiting a specialist review from a rheumatologist. After seeing the specialist who performed blood tests and x-rays on her feet she was started on a new medication called hydroxychloroquine.
      What serious side effects does the specialist need to counsel the patient on when starting this new medication?

      Your Answer: Suicidal ideation

      Correct Answer: Retinopathy

      Explanation:

      Hydroxychloroquine, a drug used to prevent and treat malaria, is now commonly included in treatment guidelines for conditions such as rheumatoid arthritis, SLE, and porphyria cutanea tarda. However, it is important for patients to be aware of the potential severe and permanent retinopathy that can result from chronic use of the drug. The mechanism behind this adverse effect is uncertain, but it can lead to permanent visual loss. To prevent eye toxicity, the daily safe maximum dose of hydroxychloroquine can be estimated based on the patient’s height and weight.

      Hydroxychloroquine: Uses and Adverse Effects

      Hydroxychloroquine is a medication commonly used in the treatment of rheumatoid arthritis and systemic/discoid lupus erythematosus. It is similar to chloroquine, which is used to treat certain types of malaria. However, hydroxychloroquine has been found to cause bull’s eye retinopathy, which can result in severe and permanent visual loss. Recent data suggests that this adverse effect is more common than previously thought, and the most recent guidelines recommend baseline ophthalmological examination and annual screening, including colour retinal photography and spectral domain optical coherence tomography scanning of the macula. Despite this risk, hydroxychloroquine may still be used in pregnant women if needed. Patients taking this medication should be asked about visual symptoms and have their visual acuity monitored annually using a standard reading chart.

    • This question is part of the following fields:

      • Musculoskeletal
      16.1
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  • Question 18 - A 30-year-old male is brought to the emergency department after being found unconscious...

    Correct

    • A 30-year-old male is brought to the emergency department after being found unconscious on the street with a syringe and used pack of oxycodone and alprazolam nearby. Upon examination, he is lethargic with pinpoint pupils, reduced bowel sounds, and fresh needle marks on his right arm. His vital signs are: blood pressure 110/70 mmHg, heart rate 55/min, oxygen saturation of 95% on room air, temperature 36ºC, and respiratory rate of 5 breaths per minute. His blood glucose level is 8 mmol/L. What is the most appropriate management for this patient?

      Your Answer: Naloxone

      Explanation:

      The individual displays classic symptoms of acute opioid overdose, including slow breathing, constricted pupils, and changes in consciousness.

      The management of overdoses and poisonings involves specific treatments for each toxin. For paracetamol overdose, activated charcoal is recommended if ingested within an hour, followed by N-acetylcysteine or liver transplantation if necessary. Salicylate overdose can be managed with urinary alkalinization using IV bicarbonate or haemodialysis. Opioid/opiate overdose can be treated with naloxone, while benzodiazepine overdose can be treated with flumazenil in severe cases. Tricyclic antidepressant overdose may require IV bicarbonate to reduce the risk of seizures and arrhythmias, but class 1a and class Ic antiarrhythmics should be avoided. Lithium toxicity may respond to volume resuscitation with normal saline or haemodialysis in severe cases. Warfarin overdose can be treated with vitamin K or prothrombin complex, while heparin overdose can be treated with protamine sulphate. Beta-blocker overdose may require atropine or glucagon. Ethylene glycol poisoning can be managed with fomepizole or ethanol, while methanol poisoning can be treated with the same. Organophosphate insecticide poisoning can be treated with atropine, and digoxin overdose can be treated with digoxin-specific antibody fragments. Iron overdose can be managed with desferrioxamine, and lead poisoning can be treated with dimercaprol or calcium edetate. Carbon monoxide poisoning can be managed with 100% oxygen or hyperbaric oxygen, while cyanide poisoning can be treated with hydroxocobalamin or a combination of amyl nitrite, sodium nitrite, and sodium thiosulfate.

    • This question is part of the following fields:

      • Pharmacology/Therapeutics
      10.3
      Seconds
  • Question 19 - An 80-year-old woman arrives at the emergency department complaining of chest pain and...

    Incorrect

    • An 80-year-old woman arrives at the emergency department complaining of chest pain and shortness of breath. Her oxygen saturation is 90%. After receiving oxygen, she experiences ventricular fibrillation and has a GCS of 3. ALS is initiated. The patient has a medical history of type 2 diabetes and multiple pulmonary emboli. What additional medication should be considered for her management during ALS?

      Your Answer: Adenosine

      Correct Answer: Alteplase

      Explanation:

      During CPR, thrombolytic drugs should be considered if a pulmonary embolism (PE) is suspected. Alteplase is a suitable option for advanced life support (ALS) in such cases. This is particularly relevant for patients who present with symptoms suggestive of a PE and have a medical history of previous pulmonary emboli. Thrombolysis can be a life-saving intervention for these patients.

      Adenosine is not appropriate for this situation as it is a class 5 antiarrhythmic used mainly for supraventricular tachycardia. Apixaban is an anticoagulant that is useful for long-term treatment and prevention of pulmonary emboli, but it is not suitable for immediate use in a hemodynamically unstable patient requiring advanced life support. Clopidogrel is an antiplatelet medication that is used in peripheral arterial disease and acute coronary syndrome, but it has no role in the acute treatment of a life-threatening pulmonary embolism.

      The 2015 Resus Council guidelines for adult advanced life support outline the steps to be taken when dealing with patients with shockable and non-shockable rhythms. For both types of patients, chest compressions are a crucial part of the process, with a ratio of 30 compressions to 2 ventilations. Defibrillation is recommended for shockable rhythms, with a single shock for VF/pulseless VT followed by 2 minutes of CPR. Adrenaline and amiodarone are the drugs of choice for non-shockable rhythms, with adrenaline given as soon as possible and amiodarone administered after 3 shocks for VF/pulseless VT. Thrombolytic drugs should be considered if a pulmonary embolus is suspected. Atropine is no longer recommended for routine use in asystole or PEA. Oxygen should be titrated to achieve saturations of 94-98% following successful resuscitation. The Hs and Ts should be considered as potential reversible causes of cardiac arrest.

    • This question is part of the following fields:

      • Cardiovascular
      22.2
      Seconds
  • Question 20 - A newly born infant is diagnosed with gastroschisis and has exposed bowel. The...

    Incorrect

    • A newly born infant is diagnosed with gastroschisis and has exposed bowel. The mother is concerned about potential complications besides fluid loss.

      Your Answer: Microcephaly

      Correct Answer: Heat loss

      Explanation:

      Exposed bowel in babies with gastroschisis leads to a considerable loss of fluid and heat, which can pose a serious risk to their lives. Unlike exomphalos, gastroschisis is not associated with cardiac and renal issues. Additionally, there is no correlation between gastroschisis and microcephaly or macrocephaly.

      Gastroschisis and exomphalos are both types of congenital visceral malformations. Gastroschisis refers to a defect in the anterior abdominal wall located just beside the umbilical cord. In contrast, exomphalos, also known as omphalocoele, involves the protrusion of abdominal contents through the anterior abdominal wall, which are covered by an amniotic sac formed by amniotic membrane and peritoneum.

      When it comes to managing gastroschisis, vaginal delivery may be attempted, but newborns should be taken to the operating theatre as soon as possible after delivery, ideally within four hours. As for exomphalos, a caesarean section is recommended to reduce the risk of sac rupture. In cases where primary closure is difficult due to lack of space or high intra-abdominal pressure, a staged repair may be undertaken. This involves allowing the sac to granulate and epithelialise over several weeks or months, forming a shell. As the infant grows, the sac contents will eventually fit within the abdominal cavity, at which point the shell can be removed and the abdomen closed.

      Overall, both gastroschisis and exomphalos require careful management to ensure the best possible outcome for the newborn. By understanding the differences between these two conditions and the appropriate steps to take, healthcare professionals can provide effective care and support to both the infant and their family.

    • This question is part of the following fields:

      • Paediatrics
      8
      Seconds
  • Question 21 - A 28-year-old woman comes to see her general practitioner with a lump in...

    Correct

    • A 28-year-old woman comes to see her general practitioner with a lump in her right breast. She has no significant medical or family history. During the examination, a small, firm, non-painful lump is found in the upper left quadrant of her right breast. The rest of the breast examination is normal.

      What is the best course of action for this patient?

      Your Answer: Urgent referral to breast clinic

      Explanation:

      An urgent referral to a breast clinic is necessary for women over the age of 30 who have an unexplained breast lump, using a suspected cancer pathway referral. This is in accordance with NICE guidelines, as the lump may represent cancerous pathology and should be investigated promptly. Conservative management or routine referral to breast clinic is not appropriate in this case, as the potential for cancerous pathology requires urgent attention.

      In 2015, NICE released guidelines for referring individuals suspected of having breast cancer. If a person is 30 years or older and has an unexplained breast lump with or without pain, or if they are 50 years or older and have discharge, retraction, or other concerning changes in one nipple only, they should be referred using a suspected cancer pathway referral for an appointment within two weeks. If a person has skin changes that suggest breast cancer or is 30 years or older with an unexplained lump in the axilla, a suspected cancer pathway referral should also be considered. For individuals under 30 years old with an unexplained breast lump with or without pain, non-urgent referral should be considered.

    • This question is part of the following fields:

      • Haematology/Oncology
      29.4
      Seconds
  • Question 22 - A 28-year-old woman is being seen in the asthma clinic. She is currently...

    Incorrect

    • A 28-year-old woman is being seen in the asthma clinic. She is currently on salbutamol inhaler 100mcg prn and beclometasone dipropionate inhaler 400 mcg bd, but is experiencing frequent asthma exacerbations and has recently undergone a course of prednisolone. In accordance with NICE guidelines, what would be the most suitable course of action for her management?

      Your Answer: Add tiotropium

      Correct Answer: Add a leukotriene receptor antagonist

      Explanation:

      According to NICE 2017 guidelines, if a patient with asthma is not effectively managed with a SABA + ICS, the first step should be to add a LTRA rather than a LABA.

      The management of asthma in adults has been updated by NICE in 2017, following the 2016 BTS guidelines. One of the significant changes is in ‘step 3’, where patients on a SABA + ICS whose asthma is not well controlled should be offered a leukotriene receptor antagonist instead of a LABA. NICE does not follow the stepwise approach of the previous BTS guidelines, but to make the guidelines easier to follow, we have added our own steps. The steps range from newly-diagnosed asthma to SABA +/- LTRA + one of the following options, including increasing ICS to high-dose, a trial of an additional drug, or seeking advice from a healthcare professional with expertise in asthma. Maintenance and reliever therapy (MART) is a form of combined ICS and LABA treatment that is only available for ICS and LABA combinations in which the LABA has a fast-acting component. It should be noted that NICE does not recommend changing treatment in patients who have well-controlled asthma simply to adhere to the latest guidance. The definitions of what constitutes a low, moderate, or high-dose ICS have also changed, with <= 400 micrograms budesonide or equivalent being a low dose, 400 micrograms - 800 micrograms budesonide or equivalent being a moderate dose, and > 800 micrograms budesonide or equivalent being a high dose for adults.

    • This question is part of the following fields:

      • Respiratory Medicine
      11.1
      Seconds
  • Question 23 - A 45-year-old man with hypertension complains of recurring headaches accompanied by sensitivity to...

    Incorrect

    • A 45-year-old man with hypertension complains of recurring headaches accompanied by sensitivity to light, nausea, and occasional vomiting. The headaches usually affect the right side of his head and sometimes cause temporary vision problems. They last up to 10 hours and occur approximately once every 4-6 weeks. The neurological examination and blood pressure are normal.

      What would be the most suitable initial medical treatment for acute attacks? Choose the ONE most appropriate first-line medical treatment from the options provided.

      Your Answer: Sumatriptan

      Correct Answer: Ibuprofen

      Explanation:

      Treatment Options for Migraines: A Comparison of Medications

      Migraines are a recurring type of headache that can last for several hours to a few days. They are often accompanied by symptoms such as sensitivity to light and sound, nausea, and vomiting. There are several medications available for the treatment of migraines, each with its own benefits and drawbacks.

      Ibuprofen is a simple analgesic that is recommended by the National Institute for Health and Care Excellence (NICE) for the treatment of acute migraine attacks. It is safe for patients with ischaemic heart disease, but the daily dose should not exceed 1200 mg.

      Sumatriptan is a serotonin-receptor agonist that causes intracerebral vasoconstriction. It is recommended by NICE for the treatment of acute migraines, but it is contraindicated in patients with a history of ischaemic heart disease.

      Amitriptyline is a tricyclic antidepressant that is used for long-term prophylaxis of migraines. It is recommended by NICE for this use but not for acute treatment.

      Co-codamol, an opiate medication, is not recommended by NICE for the treatment of migraines due to the risk of medication-overuse headache and worsening of nausea and vomiting symptoms.

      Ergotamine tartrate, another medication that was previously used to treat migraines, is now limited in use due to its unpleasant side effects such as nausea and vomiting. NICE advises against its use for the treatment of acute migraines.

      In conclusion, the choice of medication for the treatment of migraines should be based on the patient’s medical history and the severity of their symptoms. Patients should consult with their healthcare provider to determine the best treatment plan for their individual needs.

    • This question is part of the following fields:

      • Neurology
      12.1
      Seconds
  • Question 24 - A patient with pyogenic meningitis has been admitted and the husband is worried...

    Incorrect

    • A patient with pyogenic meningitis has been admitted and the husband is worried about contracting the disease. What is the recommended prophylaxis in this situation? Choose ONE option from the list provided.

      Your Answer: Ceftriaxone

      Correct Answer: Ciprofloxacin

      Explanation:

      Antibiotics for Meningitis: Recommended Drugs and Dosages

      Meningitis is a serious infection that affects the membranes surrounding the brain and spinal cord. Antibiotics are the mainstay of treatment for meningitis, and prophylactic antibiotics are also recommended for close contacts of infected individuals. Here are the recommended drugs and dosages for meningitis treatment and prophylaxis:

      Ciprofloxacin: This antibiotic is now the preferred choice for prophylaxis in all age groups and in pregnancy. It is a single dose and readily available in pharmacies, and does not interact with oral contraceptives. It should be given to all close contacts of probable or confirmed meningococcal meningitis, with dosages ranging from 250 mg to 500 mg depending on age.

      Metronidazole: This drug has no role in the treatment of acute meningitis.

      Ceftriaxone: This antibiotic has good penetration into inflamed meninges and can be given via intramuscular or oral route. It can be used in monotherapy in adults under 60 years old, or in dual therapy with amoxicillin in older adults.

      Co-trimoxazole: This drug is an alternative to cefotaxime or ceftriaxone in older adults, and is also used in individuals with meningitis from Listeria monocytogenes infection.

      Vancomycin: This antibiotic is recommended in cases of penicillin resistance or suspected penicillin-resistant pneumococci, but should never be used in monotherapy due to doubts about its penetration into adult CSF.

      Chemoprophylaxis: Close contacts of infected individuals should receive prophylactic antibiotics to prevent nasopharyngeal carriage of the organism. Ciprofloxacin is the first-line choice, with dosages ranging from 10 mg/kg to 600 mg depending on age. Rifampicin can be given as an alternative for those unable to take ciprofloxacin.

      It is important to seek microbiology and public health advice if in doubt about the appropriate antibiotics and dosages for meningitis treatment and prophylaxis.

    • This question is part of the following fields:

      • Infectious Diseases
      10.2
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  • Question 25 - A 78-year-old man visits his GP complaining of a cough that has been...

    Correct

    • A 78-year-old man visits his GP complaining of a cough that has been producing green sputum and shortness of breath for the past three days. During the examination, the GP detects the presence of rhonchi. The patient's vital signs are stable. Given his medical history of type 2 diabetes, which is being managed with metformin, and heart failure, for which he is taking ramipril, bisoprolol, and furosemide, the GP suspects acute bronchitis. What is the most appropriate course of action?

      Your Answer: Oral doxycycline

      Explanation:

      Antibiotics may be prescribed for acute bronchitis if the patient has co-existing co-morbidities or is at high risk of complications. NICE guidelines advise against the use of antibiotics for those who are not systemically very unwell and not at high risk of complications. However, if the patient is very unwell or at risk of complications, antibiotics should be offered. In this case, the patient’s age, diabetes, and heart failure put him at high risk, so antibiotics should be offered in accordance with NICE guidelines. While local guidelines should be consulted, NICE recommends oral doxycycline as the first-line treatment. Inhaled bronchodilators should not be offered unless the patient has an underlying airway disease such as asthma. Oral flucloxacillin is not commonly used for respiratory tract infections, and IV co-amoxiclav is not necessary in this stable patient who can be managed without admission.

      Acute bronchitis is a chest infection that typically resolves on its own within three weeks. It occurs when the trachea and major bronchi become inflamed, leading to swollen airways and the production of sputum. The primary cause of acute bronchitis is viral infection, with most cases occurring in the autumn or winter. Symptoms include a sudden onset of cough, sore throat, runny nose, and wheezing. While most patients have a normal chest examination, some may experience a low-grade fever or wheezing. It is important to differentiate acute bronchitis from pneumonia, which presents with different symptoms and chest examination findings.

      Diagnosis of acute bronchitis is typically based on clinical presentation, but CRP testing may be used to determine if antibiotic therapy is necessary. Management involves pain relief and ensuring adequate fluid intake. Antibiotics may be considered for patients who are systemically unwell, have pre-existing health conditions, or have a CRP level between 20-100mg/L. Doxycycline is the recommended first-line treatment, but it cannot be used in children or pregnant women. Alternatives include amoxicillin.

    • This question is part of the following fields:

      • Respiratory Medicine
      27.1
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  • Question 26 - Which cytotoxic agent is commonly linked to pulmonary fibrosis? ...

    Incorrect

    • Which cytotoxic agent is commonly linked to pulmonary fibrosis?

      Your Answer: Doxorubicin

      Correct Answer: Bleomycin

      Explanation:

      Pulmonary fibrosis is a potential side effect of bleomycin, a cytotoxic antibiotic commonly prescribed for metastatic germ cell cancer, squamous cell carcinoma, and non-Hodgkin’s lymphoma. The severity of this adverse effect is directly proportional to the dosage administered.

      Cytotoxic agents are drugs that are used to kill cancer cells. There are several types of cytotoxic agents, each with their own mechanism of action and adverse effects. Alkylating agents, such as cyclophosphamide, work by causing cross-linking in DNA. However, they can also cause haemorrhagic cystitis, myelosuppression, and transitional cell carcinoma. Cytotoxic antibiotics, like bleomycin, degrade preformed DNA and can lead to lung fibrosis. Anthracyclines, such as doxorubicin, stabilize the DNA-topoisomerase II complex and inhibit DNA and RNA synthesis, but can also cause cardiomyopathy. Antimetabolites, like methotrexate, inhibit dihydrofolate reductase and thymidylate synthesis, leading to myelosuppression, mucositis, liver fibrosis, and lung fibrosis. Fluorouracil (5-FU) is a pyrimidine analogue that induces cell cycle arrest and apoptosis by blocking thymidylate synthase, but can also cause myelosuppression, mucositis, and dermatitis. Cytarabine is a pyrimidine antagonist that interferes with DNA synthesis specifically at the S-phase of the cell cycle and inhibits DNA polymerase, but can also cause myelosuppression and ataxia. Drugs that act on microtubules, like vincristine and vinblastine, inhibit the formation of microtubules and can cause peripheral neuropathy, paralytic ileus, and myelosuppression. Docetaxel prevents microtubule depolymerisation and disassembly, decreasing free tubulin, but can also cause neutropaenia. Topoisomerase inhibitors, like irinotecan, inhibit topoisomerase I which prevents relaxation of supercoiled DNA, but can also cause myelosuppression. Other cytotoxic drugs, such as cisplatin, cause cross-linking in DNA and can lead to ototoxicity, peripheral neuropathy, and hypomagnesaemia. Hydroxyurea (hydroxycarbamide) inhibits ribonucleotide reductase, decreasing DNA synthesis, but can also cause myelosuppression.

    • This question is part of the following fields:

      • Haematology/Oncology
      3.1
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  • Question 27 - A 10-year-old girl comes in for a check-up. She was diagnosed with asthma...

    Correct

    • A 10-year-old girl comes in for a check-up. She was diagnosed with asthma two years ago by her pediatrician. She is currently taking a salbutamol inhaler, using 2 puffs 3 times a day, and a low-dose beclomethasone inhaler. She also takes oral montelukast. However, she still experiences a night time cough and has to use her blue inhaler most days. Unfortunately, the addition of montelukast has not provided much relief. On examination today, her chest is clear with no wheeze and a near-normal peak flow. What should be the next step in her management?

      Your Answer: Stop montelukast and add salmeterol

      Explanation:

      For children between the ages of 5 and 16 with asthma that is not being effectively managed with a combination of a short-acting beta agonist (SABA), low-dose inhaled corticosteroids (ICS), and a leukotriene receptor antagonist, it is recommended to add a long-acting beta agonist (LABA) to the treatment plan and discontinue the use of the leukotriene receptor antagonist.

      Managing Asthma in Children: NICE Guidelines

      Asthma management in children has been updated by NICE in 2017, following the 2016 BTS guidelines. The new guidelines for children aged 5-16 are similar to those for adults, with a stepwise approach for treatment. For newly-diagnosed asthma, short-acting beta agonist (SABA) is recommended. If symptoms persist, a combination of SABA and paediatric low-dose inhaled corticosteroid (ICS) is used. Leukotriene receptor antagonist (LTRA) is added if symptoms still persist, followed by long-acting beta agonist (LABA) if necessary. Maintenance and reliever therapy (MART) is used as a combination of ICS and LABA for daily maintenance therapy and symptom relief. For children under 5 years old, clinical judgement plays a greater role in diagnosis. The stepwise approach is similar to that for older children, with an 8-week trial of paediatric moderate-dose ICS before adding LTRA. If symptoms persist, referral to a paediatric asthma specialist is recommended.

      It should be noted that NICE does not recommend changing treatment for well-controlled asthma patients simply to adhere to the latest guidelines. The definitions of low, moderate, and high-dose ICS have also changed, with different definitions for adults and children. For children, <= 200 micrograms budesonide or equivalent is considered a paediatric low dose, 200-400 micrograms is a moderate dose, and > 400 micrograms is a high dose. Overall, the new NICE guidelines provide a clear and concise approach to managing asthma in children.

    • This question is part of the following fields:

      • Paediatrics
      15.8
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  • Question 28 - A 52-year-old male presents to his GP with a complaint of weakness in...

    Incorrect

    • A 52-year-old male presents to his GP with a complaint of weakness in his ankles, followed by his knees and hips over the past 3 days. He has no known medical history.
      What is the most probable diagnosis?

      Your Answer: Polymyositis

      Correct Answer: Guillain-Barré syndrome

      Explanation:

      The patient’s symptoms suggest Guillain-Barré syndrome, an acute inflammatory polyneuropathy that often occurs after a viral or bacterial infection. This condition is characterized by progressive, bilateral, ascending weakness that typically starts in the legs and spreads to the arms, respiratory muscles, and bulbar muscles. Areflexia is also present. Treatment may involve respiratory support, intravenous immunoglobulins, and plasma exchange. Most patients recover completely or almost completely, but the mortality rate is around 10%.

      Mononeuritis multiplex is a rare condition that affects multiple peripheral and/or cranial nerves. Symptoms are usually asymmetrical and evolve at different times and with different degrees of severity. Diabetes is a common cause, but other systemic disorders can also be implicated. The patient’s symmetrical weakness affecting both legs at the same time is more consistent with a polyneuropathy than mononeuritis multiplex.

      The patient’s symptoms do not fit with a diagnosis of multiple sclerosis, which typically presents with relapsing-remitting disease characterized by acute flairs and some improvement between flairs. MS is more common in females and onset peaks between 20 and 40 years. The patient’s symmetrical distribution of symptoms and rapid progression to affect knees and hips make MS unlikely.

      Myasthenia gravis is an autoimmune disorder associated with antibodies to acetylcholine receptors at the neuromuscular junction. Patients typically display weakness of the periocular, facial, bulbar, and girdle muscles, with symptoms worsening with prolonged use. The patient’s symmetrical distal weakness is atypical for myasthenia gravis, which tends to affect proximal muscles first.

      Polymyositis is a connective tissue disease that affects striated muscle, with symmetrical proximal muscle/limb girdle weakness being a prominent feature. Muscle tenderness and atrophy may also be present. The patient’s distal muscle weakness is not consistent with polymyositis.

    • This question is part of the following fields:

      • Neurology
      11.4
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  • Question 29 - A 62-year-old non-smoker with no significant medical history presents to their GP with...

    Incorrect

    • A 62-year-old non-smoker with no significant medical history presents to their GP with a cough producing green sputum, fatigue, and shortness of breath that has lasted for several days. During chest examination, coarse crackles are heard in the lower right zone. The patient's observations are as follows: respiratory rate of 20 breaths per minute, oxygen saturation of 97% on air, heart rate of 80 beats per minute, blood pressure of 110/75 mmHg, temperature of 38.1ºC, and an abbreviated mental test score of 10/10. The patient is not on any regular medication and has no allergies. What is the most appropriate treatment?

      Your Answer: Admit to hospital for intravenous antibiotics

      Correct Answer: Discharge with oral amoxicillin

      Explanation:

      The recommended first-line antibiotic for patients with low severity community-acquired pneumonia (CAP) is oral amoxicillin. Therefore, it is appropriate to discharge this patient with oral amoxicillin as they present with symptoms of CAP, including a new cough, temperature, purulent sputum, and focal chest signs. While a chest x-ray could confirm the diagnosis, it is not usually necessary for suspected CAP managed in primary care. The patient’s CRB-65 score is 0, indicating that they can be managed in the community. Hospitalization may be required for patients with higher scores or clinical factors that increase the risk of complications, but this is not the case for this patient. Discharge with oral clarithromycin or doxycycline is not appropriate as there is no indication that amoxicillin is unsuitable as the first-line antibiotic.

      Pneumonia is a serious respiratory infection that requires prompt assessment and management. In the primary care setting, the CRB65 criteria are used to stratify patients based on their risk of mortality. Patients with a score of 0 are considered low risk and may be treated at home, while those with a score of 3 or 4 are high risk and require urgent admission to hospital. The use of a point-of-care CRP test can help guide antibiotic therapy. In the secondary care setting, the CURB65 criteria are used, which includes an additional criterion of urea > 7 mmol/L. Chest x-rays and blood and sputum cultures are recommended for intermediate or high-risk patients. Treatment for low-severity community acquired pneumonia typically involves a 5-day course of amoxicillin, while moderate and high-severity cases may require dual antibiotic therapy for 7-10 days. Discharge criteria and advice post-discharge are also provided, including information on expected symptom resolution timeframes and the need for a repeat chest x-ray at 6 weeks.

    • This question is part of the following fields:

      • Respiratory Medicine
      14
      Seconds
  • Question 30 - What is the most frequent non-intestinal symptom of Crohn's disease? ...

    Incorrect

    • What is the most frequent non-intestinal symptom of Crohn's disease?

      Your Answer: Erythema nodosum

      Correct Answer: Arthritis

      Explanation:

      Both Crohn’s and UC have arthritis as their most common extra-intestinal feature.

      Understanding Crohn’s Disease

      Crohn’s disease is a type of inflammatory bowel disease that affects various parts of the digestive tract, from the mouth to the anus. Although the exact cause of Crohn’s disease is unknown, there is a strong genetic susceptibility. The disease is characterized by inflammation in all layers of the digestive tract, which can lead to complications such as strictures, fistulas, and adhesions. Symptoms of Crohn’s disease typically appear in late adolescence or early adulthood and may include non-specific symptoms such as weight loss and lethargy, diarrhea, abdominal pain, and perianal disease. Extra-intestinal features, such as arthritis, erythema nodosum, and osteoporosis, are also common in patients with Crohn’s disease.

      To diagnose Crohn’s disease, doctors may look for raised inflammatory markers, increased faecal calprotectin, anemia, and low levels of vitamin B12 and vitamin D. It is important to note that Crohn’s disease shares some extra-intestinal features with ulcerative colitis, another type of inflammatory bowel disease. Arthritis is the most common extra-intestinal feature in both Crohn’s disease and ulcerative colitis, while primary sclerosing cholangitis is much more common in ulcerative colitis. Understanding the symptoms and features of Crohn’s disease can help with early diagnosis and management of the disease.

    • This question is part of the following fields:

      • Gastroenterology/Nutrition
      2.9
      Seconds

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Endocrinology/Metabolic Disease (0/2) 0%
Psychiatry (0/1) 0%
Infectious Diseases (2/4) 50%
Reproductive Medicine (0/2) 0%
Gastroenterology/Nutrition (0/2) 0%
Musculoskeletal (2/3) 67%
ENT (1/1) 100%
Ophthalmology (0/1) 0%
Renal Medicine/Urology (0/1) 0%
Cardiovascular (0/2) 0%
Paediatrics (2/3) 67%
Pharmacology/Therapeutics (1/1) 100%
Haematology/Oncology (1/2) 50%
Respiratory Medicine (1/3) 33%
Neurology (0/2) 0%
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