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Question 1
Incorrect
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A 25-year-old man who has received a transplant of the left kidney is exhibiting symptoms that suggest hyperacute rejection of the transplant. What is the probable time frame for this type of rejection to occur?
Your Answer: 48 hours post transplantation
Correct Answer: Within minutes of transplantation
Explanation:Understanding the Types and Timing of Transplant Rejection
Transplant rejection can occur in different types and at different times after transplantation. Hyperacute rejection is the earliest and occurs within minutes of transplantation due to pre-existing donor-specific antibodies. This reaction is complement-mediated and irreversible, requiring prompt removal of the transplanted tissue. Acute rejection can occur up to 3 months after transplantation and is cell-mediated, involving the activation of phagocytes and cytotoxic T lymphocytes. Rejection that occurs in the first few days after transplantation is known as accelerated acute rejection. Chronic rejection, which is controversial, involves antibody-mediated vascular damage and can occur months to years after transplantation. Blood group matching can minimize hyperacute rejection, while monitoring and immunosuppressive therapy can help prevent and treat other types of rejection.
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This question is part of the following fields:
- Urology
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Question 2
Incorrect
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A 35-year-old man visits his doctor seeking assistance in quitting smoking. He has been smoking 20 cigarettes daily for the past six years and has a history of epilepsy. Which smoking cessation aid is most likely to result in adverse effects for this individual?
Your Answer: E-cigarettes
Correct Answer: Bupropion
Explanation:Options for Smoking Cessation in Patients with Seizure History
Patients with a predisposition or past history of seizures should avoid bupropion due to an increased risk of seizures. The Medicines and Health products Regulatory Authority (MHRA) warns against prescribing bupropion to patients who experience seizures. However, behavioural therapy is encouraged for all patients who wish to quit smoking. E-cigarettes can be a safer alternative and may eventually help patients quit entirely, but they are not currently funded by the NHS. Nicotine replacement therapy in the form of patches or gum can also be used. Varenicline is cautioned but not contraindicated for use in patients with seizures, so it should only be used if the benefits outweigh the risk.
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This question is part of the following fields:
- Respiratory
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Question 3
Correct
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Which one of the following is not related to carpal tunnel syndrome?
Your Answer: Wasting of the hypothenar eminence
Explanation:Understanding Carpal Tunnel Syndrome
Carpal tunnel syndrome is a condition that occurs when the median nerve in the carpal tunnel is compressed. Patients with this condition typically experience pain or pins and needles in their thumb, index, and middle fingers. In some cases, the symptoms may even ascend proximally. Patients often shake their hand to obtain relief, especially at night.
During an examination, doctors may observe weakness of thumb abduction and wasting of the thenar eminence (not the hypothenar). Tapping on the affected area may cause paraesthesia, which is known as Tinel’s sign. Flexion of the wrist may also cause symptoms, which is known as Phalen’s sign.
Carpal tunnel syndrome can be caused by a variety of factors, including idiopathic reasons, pregnancy, oedema (such as heart failure), lunate fracture, and rheumatoid arthritis. Electrophysiology tests may show prolongation of the action potential in both motor and sensory nerves.
Treatment for carpal tunnel syndrome may include a 6-week trial of conservative treatments, such as corticosteroid injections and wrist splints at night. If symptoms persist or are severe, surgical decompression (flexor retinaculum division) may be necessary.
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This question is part of the following fields:
- Musculoskeletal
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Question 4
Incorrect
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What is the name of the neuron that sends signals from the peripheral nervous system to the central nervous system?
Your Answer: Efferent
Correct Answer: Afferent
Explanation:Afferent Neurones
Afferent neurones are responsible for transmitting sensory signals from the periphery, such as receptors, organs, and other neurones, to the central nervous system, which includes the brain and spinal cord. These neurones are often referred to as sensory neurones. It is important to note that afferent neurones are not the same as bipolar, efferent, interneurone, or multipolar neurones.
Bipolar neurones are simply neurones that have only two extensions, such as those found in the retina or the ganglia of the vestibulocochlear nerve. Efferent neurones, on the other hand, transmit impulses from the central nervous system to the periphery, which is the opposite action of afferent neurones. Interneurones are neurones that connect afferent and efferent neurones in neural pathways. Finally, multipolar neurones are neurones that have a large number of dendrites, usually one long axon, and are found mostly in the brain and spinal cord for the integration of multiple incoming signals.
In summary, afferent neurones are responsible for transmitting sensory signals from the periphery to the central nervous system. They are distinct from other types of neurones, such as bipolar, efferent, interneurone, and multipolar neurones.
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This question is part of the following fields:
- Neurology
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Question 5
Correct
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A twenty-five-year-old male with Crohn's disease is admitted to the gastroenterology ward. Despite infliximab therapy, the patient's symptoms persist, and he complains of abdominal pain and high output through his stoma. On examination, he appears pale and cachectic, with a heart rate of 74/minute, regular respiratory rate of 14/minute, oxygen saturations of 99%, temperature of 38.2 ºC, and blood pressure of 122/74 mmHg. The stoma bag is situated in the left iliac fossa, and the stoma site is pink and spouted without evidence of infarction or parastomal hernias. What type of stoma does this patient have?
Your Answer: Ileostomy
Explanation:An ileostomy is a type of stoma that is created to prevent the skin from being exposed to the enzymes in the small intestine. This is commonly seen in patients with Crohn’s disease, which affects the entire gastrointestinal tract. While the location of the stoma may vary, it is the structure of the stoma itself that determines whether it is an ileostomy or a colostomy. In contrast, a tracheostomy is an opening in the trachea, while a nephrostomy is an opening in the kidneys that is used to drain urine into a bag. A urostomy is another type of stoma that is used to divert urine from the urinary system into a bag, but it differs from an ileostomy in that it involves the use of an ileal conduit.
Abdominal stomas are created during various abdominal procedures to bring the lumen or contents of organs onto the skin. Typically, this involves the bowel, but other organs may also be diverted if necessary. The type and method of construction of the stoma will depend on the contents of the bowel. Small bowel stomas should be sprouted to prevent irritant contents from coming into contact with the skin, while colonic stomas do not require spouting. Proper siting of the stoma is crucial to reduce the risk of leakage and subsequent maceration of the surrounding skin. The type and location of the stoma will vary depending on the purpose, such as defunctioning the colon or providing feeding access. Overall, abdominal stomas are a necessary medical intervention that requires careful consideration and planning.
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This question is part of the following fields:
- Surgery
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Question 6
Incorrect
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A 35-year-old woman who is 32 weeks pregnant presents with a two-week history of pruritus on her hands and feet without any visible rash. The symptoms are more severe at night and she has elevated liver function tests, with a bile acid level of 106 mmol/l. The obstetrician discusses with the patient about the possibility of induction of labour (IOL) after which week of gestation?
Your Answer: 35 weeks
Correct Answer: 37 weeks
Explanation:Obstetric cholestasis, which is indicated by the symptoms and blood results in a pregnant woman in the third trimester, increases the risk of stillbirth. Therefore, it is generally recommended to induce labour at 37-38 weeks gestation to minimize this risk. However, induction of labour should only be considered if there are significantly abnormal liver function tests or bile acid levels. It is not recommended before 37 weeks gestation. Women should be informed that the need for intervention may be stronger in those with more severe biochemical abnormalities.
Intrahepatic Cholestasis of Pregnancy: Symptoms and Management
Intrahepatic cholestasis of pregnancy, also known as obstetric cholestasis, is a condition that affects approximately 1% of pregnancies in the UK. It is characterized by intense itching, particularly on the palms, soles, and abdomen, and may also result in clinically detectable jaundice in around 20% of patients. Raised bilirubin levels are seen in over 90% of cases.
The management of intrahepatic cholestasis of pregnancy typically involves induction of labor at 37-38 weeks, although this practice may not be evidence-based. Ursodeoxycholic acid is also widely used, although the evidence base for its effectiveness is not clear. Additionally, vitamin K supplementation may be recommended.
It is important to note that the recurrence rate of intrahepatic cholestasis of pregnancy in subsequent pregnancies is high, ranging from 45-90%. Therefore, close monitoring and management are necessary for women who have experienced this condition in the past.
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This question is part of the following fields:
- Obstetrics
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Question 7
Incorrect
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A 64-year-old retired accountant presents with symptoms of resting tremor and bradykinesia and is referred to the Neurology Clinic. After diagnosis of Parkinson's disease, the patient is prescribed anti-Parkinson's medication. Which of the following drugs is a catechol-O-methyltransferase (COMT) inhibitor?
Your Answer: Benzatropine
Correct Answer: Entacapone
Explanation:Medications for Parkinson’s Disease
Parkinson’s disease is a progressive neurodegenerative disorder that affects movement. The main symptoms are bradykinesia (slowness of movement), rigidity, and resting tremor. The disease is caused by a decrease in dopamine production in the basal ganglia of the brain.
There are several medications used to treat Parkinson’s disease. L-dopa is an amino acid precursor of dopamine that can cross the blood-brain barrier and replenish depleted dopamine levels. It is given with a dopa decarboxylase inhibitor to limit side effects. Entacapone is a COMT inhibitor that prolongs the duration of L-dopa and smooths out fluctuations in plasma concentration.
Selegiline is a monoamine oxidase B inhibitor that reduces dopamine metabolism in the brain and potentiates the action of L-dopa. It is effective early and late in the disease but can cause cognitive side effects due to its metabolization to amphetamine.
Benzatropine is a muscarinic antagonist that can be useful in managing resting tremor. Bromocriptine is a dopamine agonist that can be used alone or in combination with L-dopa.
Overall, these medications aim to increase dopamine levels in the brain and improve movement symptoms in Parkinson’s disease.
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This question is part of the following fields:
- Pharmacology
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Question 8
Incorrect
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A 38-year-old woman presents to the Emergency Department (ED) with chest and abdominal pain, following three days of severe vomiting secondary to gastroenteritis. She reports pain being worse on swallowing and feels short of breath. On examination, she looks unwell and has a heart rate of 105 bpm, a blood pressure of 110/90 mmHg, a respiratory rate of 22 breaths/minute and a temperature of 38 °C. Boerhaave syndrome is suspected.
What is the most appropriate initial investigation, given the suspected diagnosis?Your Answer: Endoscopy
Correct Answer: Chest X-ray
Explanation:Appropriate Investigations for Suspected Oesophageal Rupture
Suspected oesophageal rupture, also known as Boerhaave syndrome, is a medical emergency that requires rapid diagnosis and treatment. The condition is often associated with vomiting, chest pain, and subcutaneous emphysema. The following are appropriate investigations for suspected oesophageal rupture:
Chest X-ray: This is the initial investigation to look for gas within soft tissue spaces, pneumomediastinum, left pleural effusion, and left pneumothorax. If there is high clinical suspicion, further imaging with CT scanning should be arranged.
Abdominal X-ray: This may be appropriate if there are concerns regarding the cause of vomiting, to look for signs of obstruction, but would not be useful in the diagnosis of an oesophageal rupture.
Barium swallow: This may be useful in the work-up of a suspected oesophageal rupture after a chest X-ray. However, it would not be the most appropriate initial investigation.
Blood cultures: These would be appropriate to rule out systemic bacterial infection. However, they would not help to confirm Boerhaave syndrome.
Endoscopy: While endoscopy may play a role in some cases, it should be used with caution to prevent the risk of further and/or worsening perforation.
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This question is part of the following fields:
- Gastroenterology
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Question 9
Correct
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An 80-year-old man comes to the clinic with painless, symmetrical swellings in his neck. He reports no other symptoms. Laboratory tests show a haemoglobin level of 100 g/l and a white cell count of 23 × 109/l. A blood film reveals smear cells, with more than 60% of the cells being small mature lymphocytes. What is the probable diagnosis?
Your Answer: Chronic lymphocytic leukaemia
Explanation:Differentiating Leukaemia and Lymphoma: Understanding CLL and Other Types
Leukaemia and lymphoma are two types of blood cancers that can present with similar symptoms. However, each type has distinct characteristics that can help differentiate them. Among the different types of leukaemia and lymphoma, B-cell chronic lymphocytic leukaemia (B-CLL) is the most common leukaemia in adults. It is characterized by peripheral blood lymphocytosis and uncontrolled proliferation of B cell lymphocytes in the bone marrow, lymph nodes, and splenomegaly. Patients with CLL are often asymptomatic, and the condition is often picked up incidentally.
In contrast, acute lymphoblastic leukaemia is a common leukaemia of children aged 2–5 years and is very rare in adults. Multiple myeloma, on the other hand, is the uncontrolled proliferation of plasma cells and presents with bone pain, hypercalcaemia, renal failure, and neutropenia. Chronic myeloid leukaemia tends to present with more systemic, B symptoms in a slightly younger age group, and a classic symptom is massive hepatosplenomegaly.
While lymphoma is a possibility in this age group, CLL is the most likely diagnosis as it is more common in this age group and in the western world. Further investigation would be used to confirm the diagnosis. Understanding the characteristics of each type of leukaemia and lymphoma can aid in accurate diagnosis and appropriate treatment.
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This question is part of the following fields:
- Haematology
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Question 10
Correct
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A 60-year-old woman visits her GP with a complaint of hoarseness in her voice for a few weeks. She underwent a thyroidectomy a decade ago. During the examination, the doctor observed decreased breath sounds in the left upper lobe. The patient has a smoking history of 75 pack years and quit five years ago. A chest X-ray revealed an opacity in the left upper lobe. Which cranial nerve is likely to be impacted?
Your Answer: Vagus
Explanation:Cranial Nerves and their Functions: Analysis of a Patient’s Symptoms
This patient is experiencing a hoarse voice and change in pitch, which is likely due to a compression of the vagus nerve caused by an apical lung tumor. The vagus nerve is the 10th cranial nerve and provides innervation to the laryngeal muscles. The other cranial nerves, such as the trigeminal, facial, glossopharyngeal, and hypoglossal, have different functions and would not be affected by a left upper lobe opacity. Understanding the functions of each cranial nerve can aid in diagnosing and treating patients with neurological symptoms.
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This question is part of the following fields:
- Neurology
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Question 11
Incorrect
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A 55-year-old man, who has recently started a new relationship, presented with depression. He reported a decrease in libido, which was affecting his relationship. The physician decided to initiate testosterone therapy after conducting some blood tests.
Which of the following routes should not be used to administer testosterone?Your Answer: Oral
Correct Answer: Intravenous (iv)
Explanation:Different Routes of Testosterone Administration and their Risks
Testosterone is a hormone that can be administered through various routes, each with its own risks and benefits. Intravenous administration is not recommended due to the risk of emboli formation and respiratory distress. Oral preparations are available but can be toxic to the liver, making transdermal formulations a safer option. Transdermal delivery can be achieved through gels, skin patches, or matrix patches, but absorption can vary. Intramuscular injections, such as undecanoate, release the drug slowly over a period of 2-6 weeks. Buccal tablets that adhere to the mucosa can also be used, but may cause buccal ulcers. It is important to consider the risks and benefits of each route of administration when choosing a testosterone formulation.
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This question is part of the following fields:
- Pharmacology
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Question 12
Correct
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Patients who have been taking amiodarone for a prolonged period of time may experience what issues related to thyroid function?
Your Answer: Hypothyroidism + thyrotoxicosis
Explanation:Amiodarone and Thyroid Dysfunction
Amiodarone is a medication used to treat heart rhythm disorders. However, around 1 in 6 patients taking amiodarone develop thyroid dysfunction. This can manifest as either amiodarone-induced hypothyroidism (AIH) or amiodarone-induced thyrotoxicosis (AIT).
The pathophysiology of AIH is thought to be due to the high iodine content of amiodarone causing a Wolff-Chaikoff effect. This is an autoregulatory phenomenon where thyroxine formation is inhibited due to high levels of circulating iodide. Despite this, amiodarone may be continued if desirable.
On the other hand, AIT may be divided into two types: type 1 and type 2. Type 1 is caused by excess iodine-induced thyroid hormone synthesis, while type 2 is caused by amiodarone-related destructive thyroiditis. In patients with AIT, amiodarone should be stopped if possible.
It is important for healthcare professionals to monitor patients taking amiodarone for any signs of thyroid dysfunction and adjust treatment accordingly.
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This question is part of the following fields:
- Pharmacology
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Question 13
Incorrect
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You are summoned to assess a febrile 28-year-old female patient in the postoperative recovery area following her appendectomy. The patient denies experiencing any symptoms other than feeling unwell due to the fever. The nurse reports that her temperature is 39.1ºC and verifies that she had a urinary catheter inserted during the surgery. According to the operation notes, the appendectomy was carried out 20 hours ago.
What is the probable reason for the patient's fever?Your Answer: Pulmonary embolism
Correct Answer: Physiological systemic inflammatory reaction
Explanation:An isolated fever in a patient without any other symptoms within the first 24 hours following surgery is most likely a physiological response to the operation. The body produces pro-inflammatory cytokines after surgery, which can cause a systemic inflammatory immune response and result in fever. It is unlikely to be a new infectious disease if the fever occurs within 48 hours of surgery. Other potential causes such as cellulitis, post-operative pneumonia, venous thromboembolism, and urinary tract infection are less likely based on the absence of relevant symptoms.
Post-operative pyrexia, or fever, can occur after surgery and can be caused by various factors. Early causes of post-op pyrexia, which typically occur within the first five days after surgery, include blood transfusion, cellulitis, urinary tract infection, and a physiological systemic inflammatory reaction that usually occurs within a day following the operation. Pulmonary atelectasis is also often listed as an early cause, but the evidence to support this link is limited. Late causes of post-op pyrexia, which occur more than five days after surgery, include venous thromboembolism, pneumonia, wound infection, and anastomotic leak.
To remember the possible causes of post-op pyrexia, it is helpful to use the memory aid of the 4 W’s: wind, water, wound, and what did we do? (iatrogenic). This means that the causes can be related to respiratory issues (wind), urinary tract or other fluid-related problems (water), wound infections or complications (wound), or something that was done during the surgery or post-operative care (iatrogenic). It is important to identify the cause of post-op pyrexia and treat it promptly to prevent further complications. This information is based on a peer-reviewed publication available on the National Center for Biotechnology Information website.
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This question is part of the following fields:
- Surgery
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Question 14
Correct
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A 55-year-old man visits his GP with complaints of numbness and tingling in both hands. He experiences these symptoms more severely at night and has to shake his hands for relief. He is worried that his job, which involves a lot of typing, will be affected by his symptoms. Additionally, he is concerned that his hobby of playing tennis will also be impacted. The patient has a medical history of rheumatoid arthritis and takes methotrexate. On examination, Tinel's test is positive bilaterally, and his BMI is 18kg/m². What is the most significant risk factor in this patient's medical history for this condition?
Your Answer: Rheumatoid arthritis
Explanation:Carpal tunnel syndrome is likely the cause of the patient’s symptoms, which involve compression of the median nerve in the carpal tunnel. Tinel’s test was used to reproduce the symptoms. Bilateral carpal tunnel syndrome is often linked to conditions that narrow or put pressure on the carpal tunnel, such as obesity, pregnancy, and rheumatoid arthritis. Contrary to the suggestion of a low BMI being a risk factor, it is actually a high BMI that increases the likelihood of carpal tunnel syndrome. Additionally, females are more susceptible to this condition than males, although the reason for this is not fully understood. While playing tennis may slightly increase the risk of carpal tunnel syndrome, evidence for this is not strong. Similarly, while certain occupations involving vibrating tools are associated with carpal tunnel syndrome, there is little evidence to suggest that computer-based jobs pose a significant risk.
Understanding Carpal Tunnel Syndrome
Carpal tunnel syndrome is a condition that occurs when the median nerve in the carpal tunnel is compressed. Patients with this condition typically experience pain or pins and needles in their thumb, index, and middle fingers. In some cases, the symptoms may even ascend proximally. Patients often shake their hand to obtain relief, especially at night.
During an examination, doctors may observe weakness of thumb abduction and wasting of the thenar eminence (not the hypothenar). Tapping on the affected area may cause paraesthesia, which is known as Tinel’s sign. Flexion of the wrist may also cause symptoms, which is known as Phalen’s sign.
Carpal tunnel syndrome can be caused by a variety of factors, including idiopathic reasons, pregnancy, oedema (such as heart failure), lunate fracture, and rheumatoid arthritis. Electrophysiology tests may show prolongation of the action potential in both motor and sensory nerves.
Treatment for carpal tunnel syndrome may include a 6-week trial of conservative treatments, such as corticosteroid injections and wrist splints at night. If symptoms persist or are severe, surgical decompression (flexor retinaculum division) may be necessary.
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This question is part of the following fields:
- Musculoskeletal
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Question 15
Correct
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In a double blind, randomised, placebo controlled trial of a new medication looking at reduction in blood pressure, 200 patients were enrolled with 100 patients receiving the new medication and 100 patients receiving placebo.
In the treatment group, blood pressure decreased from a mean of 150/90 mmHg to 130/80 mmHg. In the control group, blood pressure decreased from a mean of 148/88 mmHg to 140/85 mmHg. The authors concluded that the new medication was effective in reducing blood pressure as p=0.02 (2-tailed test).
Which of the following statements is correct?Your Answer: The alternative hypothesis is that drug A is more effective or less effective than placebo
Explanation:The alternative hypothesis in a two-tailed statistical hypothesis testing is that there is a difference between the variables being tested. In the case of comparing a new diuretic to a placebo, the alternative hypothesis would be that there is a difference in their potassium reducing effect, meaning the new diuretic is either more or less effective than the placebo.
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This question is part of the following fields:
- Clinical Sciences
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Question 16
Incorrect
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A 35-year-old woman who is negative for HBV surface antigens is considering having unprotected sexual intercourse with a man who is positive for HBV.
What should she do in this situation?Your Answer: Vaccine and specific hepatitis B immunoglobulin
Correct Answer: Vaccine
Explanation:Hepatitis B Vaccine in the UK
Although the risk of hepatitis B is low in the UK, certain individuals are considered to be at high risk and are offered the vaccine. These high-risk groups include individuals who inject drugs or have a partner who injects drugs, those who receive regular blood transfusions, people with chronic liver disease, close family or sexual partners of someone with hepatitis B, and individuals traveling to high-risk countries.
In the case of a patient whose partner has tested positive for the surface antigen (HBsAg), indicating that they are infected with hepatitis B, the patient may not require post-exposure treatment if they plan on having regular unprotected sexual intercourse. In this situation, the best course of action would be to receive the hepatitis B vaccine alone. It is important for individuals in high-risk groups to consider getting vaccinated to protect themselves against this potentially serious infection.
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This question is part of the following fields:
- Infectious Diseases
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Question 17
Correct
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What is the mechanism of action of statins in the management of hyperlipidaemia?
Your Answer: Reduced cholesterol synthesis through inhibition of the enzyme HMG CoA reductase
Explanation:The Mechanism of Action of Statins in Reducing Cholesterol Levels
Statins are widely used as the first line treatment for hypercholesterolaemia. They work by inhibiting the rate-controlling enzyme, HMG CoA reductase, which is responsible for endogenous cholesterol synthesis. Cholesterol is an important lipid in the human body, serving as a component of cell membranes, a precursor for the synthesis of steroid hormones, and a precursor for vitamin D synthesis. Endogenous cholesterol production determines the majority of circulating serum concentrations of cholesterol.
By reducing the production of endogenous cholesterol, statins lower cholesterol levels in the blood. This also leads to an increase in the expression of LDL receptors on the liver surface, which removes atherogenic LDL particles from the blood and further reduces LDL cholesterol concentrations. Despite potential side effects, most patients tolerate statins well with few negative consequences. The efficacy of statins is supported by a large body of evidence, demonstrating their ability to rapidly reduce serum cholesterol and, more importantly, to reduce cardiovascular death and all-cause mortality in both the short and long term.
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This question is part of the following fields:
- Pharmacology
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Question 18
Incorrect
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A 32-year-old snowboarder presents to the Emergency department complaining of pain and swelling around the first metacarpophalangeal joint (MCP joint) following a fall during practice.
Upon examination, there is significant swelling and bruising on the ulnar side of the joint.
What is the most probable injury that the patient has sustained?Your Answer: Scaphoid bone
Correct Answer: Ulnar collateral ligament
Explanation:Skier’s Thumb: A Common Injury in Winter Sports
Skier’s thumb, also known as gamekeeper’s thumb, is a common injury that occurs in winter sports. It is caused by damage or rupture of the ulnar collateral ligament, which is located at the base of the thumb. This injury can result in acute swelling and gross instability of the thumb. In severe cases where a complete tear of the ligament is suspected, an MRI may be necessary to confirm the diagnosis, and surgical repair may be required.
Once the acute swelling has subsided, treatment for skier’s thumb typically involves immobilization in a thumb spica. This is the standard therapy for cases of partial rupture.
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This question is part of the following fields:
- Surgery
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Question 19
Incorrect
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A 75-year-old widower comes to the Emergency Department following a mechanical fall at a nearby store. His orthopaedic examination is normal, but he is extremely thin and agitated, has halitosis and gingivitis, and perifollicular hemorrhages are visible.
What is the most probable diagnosis?Your Answer: Pellagra
Correct Answer: Vitamin C deficiency
Explanation:Differential diagnosis of a patient with muscle pain, fatigue, skin dots, bleeding gums, and weight loss
Scurvy, a rare condition in the general population, is a relatively common nutritional finding in the elderly and socially disadvantaged groups. It results from a deficiency of vitamin C, which is needed to make collagen. Without vitamin C, collagen cannot be replaced and tissue breaks down, leading to symptoms such as muscle and joint pain, fatigue, red dots on the skin (perifollicular haemorrhages), bleeding and inflammation of the gums (gingivitis), decreased wound healing, and easy bruising. Treatment involves vitamin C supplementation and dietary changes.
Lead poisoning, although not likely to cause the signs present in this patient, can cause abdominal pain, confusion, and headaches, and in severe cases, seizures, coma, and death. It is usually caused by exposure to lead in the environment, such as from contaminated water, soil, or paint.
Vitamin K deficiency, although rare, can cause bleeding and easy bruising, but it is much less common than vitamin C deficiency. Vitamin K is needed for blood clotting and bone health, and it is found in green leafy vegetables, liver, and eggs.
Hypothyroidism, a common endocrine disorder, is more likely to cause weight gain than weight loss, as it slows down the body’s metabolism. It can also cause dry, coarse skin, fatigue, and depression. Treatment involves thyroid hormone replacement therapy.
Pellagra, a rare condition caused by a deficiency of niacin (vitamin B3), can cause diarrhoea, dermatitis, and dementia. It may also cause aggression and red skin lesions, but it is less common than vitamin C deficiency. Treatment involves niacin supplementation and dietary changes.
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This question is part of the following fields:
- Gastroenterology
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Question 20
Incorrect
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A 46-year-old man, who had been working abroad in the hard metal industry, presented with progressive dyspnoea. A chest X-ray showed diffuse interstitial fibrosis bilaterally. What is the typical cellular component found in a bronchoalveolar lavage (BAL) of this patient?
Your Answer: Haemosiderin-laden macrophages
Correct Answer: Giant cells
Explanation:Understanding Giant Cell Interstitial Pneumonia in Hard Metal Lung Disease
Hard metal lung disease is a condition that affects individuals working in the hard metal industry, particularly those exposed to cobalt dust. Prolonged exposure can lead to fibrosis and the development of giant cell interstitial pneumonia (GIP), characterized by bizarre multinucleated giant cells in the alveoli. These cannibalistic cells are formed by alveolar macrophages and type II pneumocytes and can contain ingested macrophages. While cobalt exposure can also cause other respiratory conditions, GIP is a rare but serious complication that may require lung transplantation in severe cases. Understanding the significance of different cell types found in bronchoalveolar lavage can aid in the diagnosis and management of this disease.
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This question is part of the following fields:
- Respiratory
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Question 21
Incorrect
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A 25-year-old man visits his general practitioner (GP), as he is concerned that he may have inherited a heart condition. He is fit and well and has no history of any medical conditions. However, his 28-year-old brother has recently been diagnosed with hypertrophic cardiomyopathy (HCM) after collapsing when he was playing football. The patient’s father died suddenly when he was 42, which the family now thinks might have been due to the same condition.
Which of the following signs is most likely to be found in a patient with this condition?Your Answer: Ejection systolic murmur increased by squatting
Correct Answer: Ejection systolic murmur decreased by squatting
Explanation:Understanding the Ejection Systolic Murmur in Hypertrophic Cardiomyopathy: Decreased by Squatting
Hypertrophic cardiomyopathy (HCM) is a condition characterized by asymmetrical hypertrophy of both ventricles, with the septum hypertrophying and causing an outflow obstruction of the left ventricle. This obstruction leads to an ejection systolic murmur and reduced cardiac output. However, interestingly, this murmur can be decreased by squatting, which is not typical for most heart murmurs.
Squatting affects murmurs by increasing afterload and preload, which usually makes heart murmurs louder. However, in HCM, the murmur intensity is decreased due to increased left ventricular size and reduced outflow obstruction. Other findings on examination may include a jerky pulse and a double apex beat.
While HCM is often asymptomatic, it can present with dyspnea, angina, and syncope. Patients are also at risk of sudden cardiac death, most commonly due to ventricular arrhythmias. Poor prognostic factors include syncope, family history of sudden death, onset of symptoms at a young age, ventricular tachycardia on Holter monitoring, abnormal blood pressure response during exercise, and septal thickness greater than 3 cm on echocardiogram.
In summary, understanding the ejection systolic murmur in HCM and its unique response to squatting can aid in the diagnosis and management of this condition.
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This question is part of the following fields:
- Cardiology
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Question 22
Correct
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A 20-year-old student visits the Genitourinary Medicine (GUM) Clinic with concerns about a recent sexual encounter. He had unprotected sex with a woman and has since developed a purulent urethral discharge and painful urination. Gram-negative diplococci were identified in specimens taken from him. What is the probable causative organism for this patient's symptoms?
Your Answer: Neisseria gonorrhoeae
Explanation:Diagnosing and Differentiating Sexually Transmitted Infections
Sexually transmitted infections (STIs) are a common health concern, and prompt diagnosis and treatment are crucial to prevent complications and further transmission. One such STI is gonorrhoeae, caused by the bacterium N. gonorrhoeae. Symptoms include purulent discharge, dysuria, and frequency, and if left untreated, can lead to infertility.
Herpes simplex, another STI, typically presents with ulceration, which is not seen in this patient. Candida albicans, a type of yeast, is an unlikely diagnosis in men and would present with balanitis and white discharge. Chlamydia trachomatis, while similar in presentation, does not show Gram-negative diplococci on microscopy. However, up to 50% of patients with gonorrhoeae may also have coexisting chlamydia infection, so antibiotic regimes should cover both. Ciprofloxacin is effective, but drug-resistant strains of N. gonorrhoeae are emerging, so alternative antibiotics may be necessary.
Finally, Trichomonas vaginalis, an anaerobic protozoan infection, is ruled out by the microscopy result. Accurate diagnosis and differentiation of STIs are essential for effective treatment and prevention of complications.
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This question is part of the following fields:
- Sexual Health
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Question 23
Correct
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An 80-year-old woman is suffering from gastroenteritis and requires iv replacement due to her inability to tolerate oral fluids. What is the maximum flow rate achievable through a 16G cannula?
Your Answer: 180 ml/min
Explanation:Different Flow Rates of Cannulas for Infusions
Cannulas are small tubes inserted into a vein to administer medication or fluids. Different sizes and colors of cannulas are available, each with varying flow rates. The grey 16G cannula has the highest flow rate of 180 ml/min, while the blue 22G cannula has the lowest flow rate of 33 ml/min. The pink 20G cannula is the most commonly used in adults for standard infusions, with a flow rate of 54 ml/min. The green 18G cannula has a flow rate of 80 ml/min, and the orange 14G cannula has the largest size and highest flow rate of 270 ml/min. It is important to choose the appropriate cannula size and flow rate for each patient’s needs.
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This question is part of the following fields:
- Anaesthetics & ITU
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Question 24
Incorrect
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A 32-week neonate is brought to the neonatal intensive care unit. The baby was delivered via emergency Caesarean section to a 17-year-old mother who had not received adequate antenatal care. The mother had a history of significant tobacco and alcohol use. During examination, it was observed that the baby had intestinal loops protruding through a hole on the left side of the umbilicus. What is the probable diagnosis?
Your Answer: Omphalocele
Correct Answer: Gastroschisis
Explanation:Socioeconomic deprivation, maternal alcohol/tobacco use, and maternal age under 20 are all associated with gastroschisis.
While gastroschisis and omphalocele have similar presentations, gastroschisis refers to a defect located to the side of the umbilicus, while omphalocele refers to a defect in the umbilicus itself.
Foetal alcohol syndrome is characterized by a small head, flattened philtrum, and thin upper lip.
Anencephaly is a neural tube defect that results in the absence of the brain, skull, and scalp.
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.
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This question is part of the following fields:
- Paediatrics
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Question 25
Incorrect
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A 16-year-old arrives at the Emergency Department with sudden and severe pain in his groin while playing basketball. He has no significant medical history and denies any trauma to the area. During the exam, he experiences persistent pain in his right testicle when it is raised. An ultrasound with Doppler reveals reduced blood flow in the right testicle. Which artery is most likely occluded in this patient?
Your Answer: Right renal artery
Correct Answer: Directly from the aorta
Explanation:Understanding the Arteries Involved in Testicular Torsion
Testicular torsion is a condition that causes extreme pain in the groin due to the rotation of the testicle within the scrotum, which occludes flow through the testicular artery. This condition is common in male teenagers during exercise and requires immediate medical attention. In this article, we will discuss the arteries involved in testicular torsion and their functions.
The testicular artery (both left and right) arises from the aorta at the level of L2. Torsion can be diagnosed through colour Doppler ultrasound of the testicle, which shows decreased blood flow. Surgery is required within 6 hours of onset of symptoms to re-establish blood flow and prevent recurrent torsion (orchidopexy). If >6 hours elapse, there is an increased risk for permanent ischaemic damage.
The right and left renal arteries provide branches to the adrenal gland, not the testicles. Both the left and right renal arteries arise from the aorta at the level of L1/2. The internal iliac artery gives off branches to the perineum, but not the testicles. The internal iliac artery branches from the common iliac artery at the level of L5/S1. The external iliac artery gives off the inferior epigastric artery and becomes the femoral artery when it crosses deep to the inguinal ligament. The external iliac artery bifurcates from the common iliac artery at the level of L5/S1.
In conclusion, understanding the arteries involved in testicular torsion is crucial for timely diagnosis and treatment. The testicular artery arising from the aorta at the level of L2 is the primary artery involved in this condition, and surgery within 6 hours of onset of symptoms is necessary to prevent permanent damage.
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This question is part of the following fields:
- Urology
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Question 26
Correct
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A 35-year-old G1P0 woman is brought to the hospital at 39 weeks of gestation by her husband because she is experiencing strong uterine contractions. She delivers a healthy baby with an Apgar score of 8, 5 min after birth. However, she experiences significant bleeding with an estimated blood loss of six litres and is hypotensive with a BP of 60/24 mmHg despite aggressive resuscitation. The placenta appears to be adherent to the uterine wall and the surgeons are unable to separate it. It is noted that she was treated with ceftriaxone for a gonococcal infection 5 years ago, although she had lower abdominal pain for some time after.
What is the definitive treatment for this patient’s present condition?Your Answer: Hysterectomy
Explanation:The patient is suffering from placenta accreta, a pregnancy complication where the placenta attaches to the myometrium wall. This condition is often caused by past Caesarean sections, Asherman syndrome, or pelvic inflammatory disease, which the patient had due to a previous infection with Neisseria gonorrhoeae. To prevent co-transmission with Chlamydia trachomatis, doxycycline is given with a third-generation cephalosporin. The patient’s placenta accreta is likely due to scarring from pelvic inflammatory disease, and a total hysterectomy may be necessary if the patient’s condition worsens. While the patient may require a large blood transfusion, immediate transfusion is not the definitive treatment. Oxytocin may be used as a first-line treatment, but a hysterectomy is the definitive treatment if bleeding persists. Phenylephrine, a vasoconstrictor, may decrease bleeding but is not a definitive treatment for placenta accreta. Dinoprostone, a prostaglandin E2 analogue, is not indicated for placenta accreta.
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This question is part of the following fields:
- Obstetrics
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Question 27
Correct
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A 68-year-old man presents to the general practitioner (GP) with visual complaints in the right eye. He intermittently loses vision in the right eye, which he describes as a curtain vertically across his visual field. Each episode lasts about two or three minutes. He denies eye pain, eye discharge or headaches.
His past medical history is significant for poorly controlled type 2 diabetes mellitus, hypertension and hypercholesterolaemia.
On examination, his pupils are of normal size and reactive to light. There is no scalp tenderness. Blood test results are pending, and his electrocardiogram (ECG) shows normal sinus rhythm, without ischaemic changes.
A provisional diagnosis of amaurosis fugax (AG) is being considered.
Given this diagnosis, which of the following is the most appropriate treatment at this time?Your Answer: Aspirin
Explanation:Treatment Options for Transient Vision Loss: Aspirin, Prednisolone, Warfarin, High-Flow Oxygen, and Propranolol
Transient vision loss can be a symptom of various conditions, including giant-cell arthritis (temporal arthritis) and transient retinal ischaemia. The appropriate treatment depends on the underlying cause.
For transient retinal ischaemia, which is typically caused by atherosclerosis of the ipsilateral carotid artery, antiplatelet therapy with aspirin is recommended. Patients should also be evaluated for cardiovascular risk factors and considered for ultrasound of the carotid arteries.
Prednisolone is used to treat giant-cell arthritis, which is characterised by sudden mononuclear loss of vision, jaw claudication, and scalp tenderness. However, if the patient does not have scalp tenderness or jaw claudication, oral steroids would not be indicated.
Warfarin may be considered in patients with underlying atrial fibrillation and a high risk of embolic stroke. However, it should typically be bridged with a heparin derivative to avoid pro-thrombotic effects in the first 48-72 hours of use.
High-flow oxygen is used to treat conditions like cluster headaches, which present with autonomic manifestations. If the patient does not have any autonomic features, high-flow oxygen would not be indicated.
Propranolol can be used in the prophylactic management of migraines, which can present with transient visual loss. However, given the patient’s atherosclerotic risk factors and description of visual loss, transient retinal ischaemia is a more likely diagnosis.
In summary, the appropriate treatment for transient vision loss depends on the underlying cause and should be tailored to the individual patient’s needs.
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This question is part of the following fields:
- Neurology
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Question 28
Incorrect
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What is the most suitable time to collect blood samples for therapeutic monitoring of digoxin levels in elderly patients?
Your Answer: At least 2 hours after last dose
Correct Answer: At least 6 hours after last dose
Explanation:Therapeutic Drug Monitoring: Guidelines for Monitoring Lithium, Ciclosporin, Digoxin, and Phenytoin Levels
Lithium levels should be monitored 12 hours after the last dose, with the target range being 0.4-1.0 mmol/l. Ciclosporin levels should be measured immediately before the next dose, while Digoxin levels should be checked at least 6 hours after the last dose. Phenytoin levels do not need to be monitored routinely, but trough levels should be checked before the next dose if there is a need to adjust the dose, suspected toxicity, or non-adherence to the prescribed medication.
Therapeutic drug monitoring is an essential aspect of patient care, especially for drugs with narrow therapeutic windows. The guidelines for monitoring lithium, ciclosporin, digoxin, and phenytoin levels vary depending on the drug and the patient’s condition. It is crucial to follow these guidelines to ensure that the patient receives the optimal dose of medication and to prevent adverse effects. Proper monitoring of drug levels can also help detect non-adherence to the prescribed medication, which can affect treatment outcomes. By following these guidelines, healthcare professionals can provide safe and effective treatment to their patients.
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This question is part of the following fields:
- Pharmacology
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Question 29
Correct
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A 35-year-old woman with Crohn's disease presents with severe abdominal pain. Upon investigation, a small intestinal obstruction is discovered, and during surgery, a large stricture is found in the terminal ileum. As a result, approximately 90 cm of the terminal ileum had to be resected. What is the most common complication in this scenario?
Your Answer: Vitamin B12 deficiency
Explanation:Complications of Terminal Ileum Resection
When the terminal ileum is lost due to resection, there can be various complications depending on the length of the resection. One such complication is D-lactic acidosis, which occurs after the intake of refined carbohydrates. Gallstones may also form due to interruption in the enterohepatic circulation of bile acids. Patients with a short bowel are encouraged to eat more to replenish the different vitamins and minerals. They may also be at risk of developing calcium oxalate kidney stones. However, they are not at increased risk of uric acid stones unless they have coexisting conditions such as gout. It is important to note that iron deficiency may not be affected by ileal pathology, while vitamin K and D deficiencies are not common complications of terminal ileum resection.
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This question is part of the following fields:
- Colorectal
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Question 30
Incorrect
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During a pre-anaesthetic assessment, a teenage patient informs you that her mother had a negative reaction to certain drugs during an appendicectomy procedure several years ago and had to spend some time in the ICU on a ventilator. There were no lasting complications. What is the primary concern you should have?
Your Answer: Stevens-Johnson syndrome
Correct Answer: Pseudocholinesterase deficiency
Explanation:Overview of Commonly Used IV Induction Agents
Propofol, sodium thiopentone, ketamine, and etomidate are some of the commonly used IV induction agents in anesthesia. Propofol is a GABA receptor agonist that has a rapid onset of anesthesia but may cause pain on IV injection. It is widely used for maintaining sedation on ITU, total IV anesthesia, and daycase surgery. Sodium thiopentone has an extremely rapid onset of action, making it the agent of choice for rapid sequence induction. However, it may cause marked myocardial depression and metabolites build up quickly, making it unsuitable for maintenance infusion. Ketamine, an NMDA receptor antagonist, has moderate to strong analgesic properties and produces little myocardial depression, making it a suitable agent for anesthesia in those who are hemodynamically unstable. However, it may induce a state of dissociative anesthesia resulting in nightmares. Etomidate has a favorable cardiac safety profile with very little hemodynamic instability but has no analgesic properties and is unsuitable for maintaining sedation as prolonged use may result in adrenal suppression. Postoperative vomiting is common with etomidate.
Overall, each of these IV induction agents has specific features that make them suitable for different situations. Anesthesiologists must carefully consider the patient’s medical history, current condition, and the type of surgery being performed when selecting an appropriate induction agent.
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This question is part of the following fields:
- Surgery
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