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Question 1
Incorrect
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A 30-year-old primigravida gives birth to her male infant at 40+1 weeks via ventouse-assisted vaginal delivery. The estimated blood loss is 650ml and her uterus is well contracted. An episiotomy was performed during delivery, and a tear involving perineal skin and muscle with less than 50% damage to the external anal sphincter is found on postpartum vaginal examination. What is the best course of action for this patient?
Your Answer: Perineal tear healing by secondary intent
Correct Answer: Perineal tear repair in theatre
Explanation:Repair of third degree perineal tears should be carried out in a theatre by a clinician who has received appropriate training. This is because category 3 and 4 tears pose a risk of infection and have a significant impact on the patient’s health. Poor healing of perineal wounds can lead to faecal incontinence, which is a potential complication of grade 3 and 4 tears. It is advisable to pack the perineal wound for haemostasis before repairing the tear, as this will help achieve better haemostasis with sutures. Healing of perineal tears by secondary intent is not recommended, as it can result in poor healing, infection, and faecal incontinence. Additionally, the vascular nature of the perineum and anus increases the likelihood of ongoing haemorrhage if the wound is not healed. In cases of category 1 and 2 tears (involving the skin only or skin and perineal muscle), perineal tear repair can be performed immediately on the maternity ward if the clinician feels comfortable and there is adequate lighting.
Perineal tears are a common occurrence during childbirth, and the Royal College of Obstetricians and Gynaecologists (RCOG) has developed guidelines to classify them based on their severity. First-degree tears are superficial and do not require any repair, while second-degree tears involve the perineal muscle and require suturing by a midwife or clinician. Third-degree tears involve the anal sphincter complex and require repair in theatre by a trained clinician, with subcategories based on the extent of the tear. Fourth-degree tears involve the anal sphincter complex and rectal mucosa and also require repair in theatre by a trained clinician.
There are several risk factors for perineal tears, including being a first-time mother, having a large baby, experiencing a precipitant labour, and having a shoulder dystocia or forceps delivery. It is important for healthcare providers to be aware of these risk factors and to provide appropriate care and management during childbirth to minimize the risk of perineal tears. By following the RCOG guidelines and providing timely and effective treatment, healthcare providers can help ensure the best possible outcomes for both mother and baby.
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This question is part of the following fields:
- Obstetrics
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Question 2
Incorrect
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A 22-year-old female patient arrives at the emergency department complaining of wrist pain after falling off her bike and landing on her outstretched left hand earlier in the day. Upon examination, there is significant swelling in her left wrist, and she experiences pain when attempting to abduct her wrist. The anatomical snuffbox is the most tender area upon palpation, leading the physician to suspect a scaphoid fracture. An x-ray of the wrist is taken, but it appears normal.
What should be the next course of action in managing this patient's condition?Your Answer: Referral to orthopaedics and repeat imaging in 3-5 days
Correct Answer: Referral to orthopaedics and repeat imaging in 7-10 days
Explanation:Scaphoid fractures may not be immediately visible on X-ray in most cases. However, failing to detect them can result in non-union and subsequent avascular necrosis of the proximal segment due to the retrograde blood supply of the scaphoid from the dorsal carpal branch of the radial artery. According to the NICE guidelines, if a scaphoid fracture is suspected but imaging is inconclusive, repeat imaging should be conducted after 7 days. Physiotherapy is not the appropriate immediate management as further movement may cause more damage. Instead, immobilisation with a splint is more suitable at this time.
Understanding Scaphoid Fractures
A scaphoid fracture is a type of wrist fracture that typically occurs when a person falls onto an outstretched hand or during contact sports. It is important to recognize this type of fracture due to the unusual blood supply of the scaphoid bone. Interruption of the blood supply can lead to avascular necrosis, which is a serious complication. Patients with scaphoid fractures typically present with pain along the radial aspect of the wrist and loss of grip or pinch strength. Clinical examination is highly sensitive and specific when certain signs are present, such as tenderness over the anatomical snuffbox and pain on telescoping of the thumb.
Plain film radiographs should be requested, including scaphoid views, but the sensitivity in the first week of injury is only 80%. A CT scan may be requested in the context of ongoing clinical suspicion or planning operative management, while MRI is considered the definite investigation to confirm or exclude a diagnosis. Initial management involves immobilization with a splint or backslab and referral to orthopaedics. Orthopaedic management depends on the patient and type of fracture, with undisplaced fractures of the scaphoid waist typically treated with a cast for 6-8 weeks. Displaced scaphoid waist fractures require surgical fixation, as do proximal scaphoid pole fractures. Complications of scaphoid fractures include non-union, which can lead to pain and early osteoarthritis, and avascular necrosis.
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This question is part of the following fields:
- Musculoskeletal
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Question 3
Correct
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A 50-year-old man visits his doctor with symptoms of a vasculitic rash, joint pains, and swollen ankles. He reports feeling unwell, fatigued, and experiencing weight loss. During the visit, his urine dipstick shows blood and protein, and urgent blood tests reveal worsening kidney function with elevated inflammatory markers. The doctor suspects microscopic polyangiitis and requests an autoimmune screening. What autoantibody is expected to be positive in this case?
Your Answer: p-ANCA with MPO specificity
Explanation:ANCA and its association with small vessel vasculitides
Antineutrophil cytoplasmic antibodies (ANCA) are a characteristic feature of small vessel vasculitides such as microscopic polyangiitis (MPA) and granulomatosis with polyangiitis (GPA). These antibodies can also be seen in eosinophilic granulomatosis with polyangiitis (eGPA), previously known as Churg-Strauss syndrome. ANCA has two staining patterns, cytoplasmic (c-ANCA) and perinuclear (p-ANCA), which are detected through immunofluorescence. These antibodies are directed against proteins within the cytoplasmic granules of neutrophils. In most cases, c-ANCA has specificity for proteinase 3 (PR3) and p-ANCA has specificity for myeloperoxidase (MPO).
In patients with GPA, ANCA positivity is observed in approximately 90% of cases, with 80-90% being c-ANCA positive with PR3 specificity. In contrast, in patients with MPA, approximately 60% are p-ANCA positive with MPO specificity, and around 35% have c-ANCA.
The history of the patient in question is more consistent with MPA, and therefore, the most likely test to be positive is p-ANCA with MPO specificity. ANA is usually associated with systemic lupus erythematosus, which could present with similar symptoms, but the patient’s age and sex are more in line with ANCA vasculitis.
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This question is part of the following fields:
- Nephrology
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Question 4
Incorrect
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A 25-year-old healthy male undergoes an emergency appendectomy and is administered suxamethonium. Following the removal of an inflamed appendix, the patient is taken to recovery. However, one hour later, the patient experiences a temperature of 40 ºC, a tachycardia of 120 bpm, and widespread muscular rigidity. What is the probable diagnosis?
Your Answer: Epilepsy
Correct Answer: Malignant hyperthermia
Explanation:Patients with a genetic defect may experience malignant hyperthermia when exposed to anaesthetic agents like suxamethonium. Extrapyramidal effects, such as acute dystonic reaction, are typically associated with antipsychotics (haloperidol) and metoclopramide.
Malignant Hyperthermia: A Condition Triggered by Anaesthetic Agents
Malignant hyperthermia is a medical condition that often occurs after the administration of anaesthetic agents. It is characterized by hyperpyrexia and muscle rigidity, which is caused by the excessive release of calcium ions from the sarcoplasmic reticulum of skeletal muscle. This condition is associated with defects in a gene on chromosome 19 that encodes the ryanodine receptor, which controls calcium release from the sarcoplasmic reticulum. Susceptibility to malignant hyperthermia is inherited in an autosomal dominant fashion. It is worth noting that neuroleptic malignant syndrome may have a similar aetiology.
The causative agents of malignant hyperthermia include halothane, suxamethonium, and other drugs such as antipsychotics (which can trigger neuroleptic malignant syndrome). To diagnose this condition, doctors may perform tests such as checking for elevated levels of creatine kinase and conducting contracture tests with halothane and caffeine.
The management of malignant hyperthermia involves the use of dantrolene, which prevents the release of calcium ions from the sarcoplasmic reticulum. With prompt and appropriate treatment, patients with malignant hyperthermia can recover fully. Therefore, it is essential to be aware of the risk factors and symptoms of this condition, especially when administering anaesthetic agents.
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This question is part of the following fields:
- Surgery
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Question 5
Incorrect
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A 62-year-old man presents to your GP clinic with complaints of leg pain. He reports that he has been experiencing this pain for the past 3 months. The pain is described as achy and gradually increasing in severity, particularly when he walks his dog uphill every morning. What is the most likely contributing factor to his condition?
Your Answer: Alcohol
Correct Answer: Smoking
Explanation:Peripheral arterial disease is often caused by smoking, which is a significant risk factor. The patient is likely experiencing intermittent claudication, an early symptom of PVD. While diabetes is also a risk factor, smoking has a stronger association with the development of this condition. Pain in the calf muscles due to statin therapy typically occurs at rest, and atorvastatin therapy can rarely lead to peripheral neuropathy. Alcohol and… (the sentence is incomplete and needs further information to be rewritten properly).
Understanding Peripheral Arterial Disease: Intermittent Claudication
Peripheral arterial disease (PAD) can present in three main patterns, one of which is intermittent claudication. This condition is characterized by aching or burning in the leg muscles following walking, which is typically relieved within minutes of stopping. Patients can usually walk for a predictable distance before the symptoms start, and the pain is not present at rest.
To assess for intermittent claudication, healthcare professionals should check the femoral, popliteal, posterior tibialis, and dorsalis pedis pulses. They should also perform an ankle brachial pressure index (ABPI) test, which measures the ratio of blood pressure in the ankle to that in the arm. A normal ABPI result is 1, while a result between 0.6-0.9 indicates claudication. A result between 0.3-0.6 suggests rest pain, and a result below 0.3 indicates impending limb loss.
Duplex ultrasound is the first-line investigation for PAD, while magnetic resonance angiography (MRA) should be performed prior to any intervention. Understanding the symptoms and assessment of intermittent claudication is crucial for early detection and management of PAD.
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This question is part of the following fields:
- Surgery
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Question 6
Incorrect
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What is the preferred investigation to detect renal scarring in a pediatric patient with vesicoureteral reflux?
Your Answer: Abdominal x-ray
Correct Answer: Radionuclide scan using dimercaptosuccinic acid (DMSA)
Explanation:Understanding Vesicoureteric Reflux
Vesicoureteric reflux (VUR) is a condition where urine flows back from the bladder into the ureter and kidney. This is a common urinary tract abnormality in children and can lead to urinary tract infections (UTIs). In fact, around 30% of children who present with a UTI have VUR. It is important to investigate for VUR in children following a UTI as around 35% of children develop renal scarring.
The pathophysiology of VUR involves the ureters being displaced laterally, which causes a shortened intramural course of the ureter. This means that the vesicoureteric junction cannot function properly. VUR can present in different ways, such as hydronephrosis on ultrasound during the antenatal period, recurrent childhood UTIs, and reflux nephropathy, which is chronic pyelonephritis secondary to VUR. Renal scarring can also produce increased quantities of renin, which can cause hypertension.
To diagnose VUR, a micturating cystourethrogram is usually performed. A DMSA scan may also be done to check for renal scarring. VUR is graded based on the severity of the condition, with Grade I being the mildest and Grade V being the most severe.
Overall, understanding VUR is important in preventing complications such as UTIs and renal scarring. Early diagnosis and management can help improve outcomes for children with this condition.
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This question is part of the following fields:
- Paediatrics
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Question 7
Incorrect
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A 58-year-old woman has been scheduled for a left total knee replacement in one month’s time. She has a past medical history significant for rheumatoid arthritis (RA), for which she takes methotrexate and hydroxychloroquine.
Which of the following investigations would be most important before the patient’s operation?Your Answer: Anti-citrullinated protein antibody levels
Correct Answer: Cervical spine X-rays
Explanation:The Importance of Pre-Operative Testing for a Patient with Rheumatoid Arthritis
Patients with rheumatoid arthritis (RA) require special considerations before undergoing elective surgery. One important test to consider is a cervical spine X-ray, as RA can lead to subluxation and instability in the cervical spine. This is particularly important for patients who will be intubated during surgery, as neck manipulation can exacerbate any underlying instability.
Another important consideration for RA patients is regular eye exams to test for retinal toxicity, especially for those taking hydroxychloroquine as part of their treatment regimen. However, this is not necessarily required before elective surgery.
While rheumatoid factor levels and anti-citrullinated protein antibody levels can be elevated in RA patients, they are not the most important tests to consider before surgery. Instead, a plain film of the cervical spine should be the primary investigation for patients with a history of RA.
Overall, pre-operative testing for RA patients should be tailored to their specific needs and potential risks during surgery.
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This question is part of the following fields:
- Rheumatology
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Question 8
Incorrect
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You are asked to evaluate a 3 day-old neonate who was born 2 weeks premature after a premature rupture of membranes. The infant has not passed meconium in the first 24 hours and has started vomiting. During the examination, you observe one episode of vomiting that is green in color, indicating bile. The baby appears irritable with a visibly distended abdomen, but has normal oxygen saturation and no fever. Palpation of the abdomen causes further discomfort, but no discrete mass is detected. What is the most probable underlying condition?
Your Answer: Respiratory distress of the newborn
Correct Answer: Cystic fibrosis
Explanation:The presented history indicates a possible case of meconium ileus, where the thickened meconium caused a blockage in the small intestine due to cystic fibrosis. The neonate is likely to have a swollen abdomen and may not pass meconium. Vomiting may contain bile, which is different from pyloric stenosis that does not have bile. Additionally, there is no indication of intussusception or pyloric stenosis mass.
Cystic Fibrosis: Symptoms and Characteristics
Cystic fibrosis is a genetic disorder that affects various organs in the body, particularly the lungs and digestive system. The symptoms of cystic fibrosis can vary from person to person, but there are some common features that are often present. In the neonatal period, around 20% of infants with cystic fibrosis may experience meconium ileus, which is a blockage in the intestine caused by thick, sticky mucous. Prolonged jaundice may also occur, but less commonly. Recurrent chest infections are a common symptom, affecting around 40% of patients. Malabsorption is another common feature, with around 30% of patients experiencing steatorrhoea (excessive fat in the stool) and failure to thrive. Liver disease may also occur in around 10% of patients.
It is important to note that while many patients are diagnosed with cystic fibrosis during newborn screening or early childhood, around 5% of patients are not diagnosed until after the age of 18. Other features of cystic fibrosis may include short stature, diabetes mellitus, delayed puberty, rectal prolapse (due to bulky stools), nasal polyps, male infertility, and female subfertility. Overall, the symptoms and characteristics of cystic fibrosis can vary widely, but early diagnosis and treatment can help manage the condition and improve quality of life.
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This question is part of the following fields:
- Paediatrics
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Question 9
Incorrect
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A 36-year-old woman of African origin presented to the Emergency Department with sudden-onset dyspnoea. She was a known case of systemic lupus erythematosus (SLE), previously treated for nephropathy and presently on mycophenolate mofetil and hydroxychloroquine sulfate. She had no fever. On examination, her respiratory rate was 45 breaths per minute, with coarse crepitations in the right lung base. After admission, blood test results revealed:
Investigation Value Normal range
Haemoglobin 100g/l 115–155 g/l
Sodium (Na+) 136 mmol/l 135–145 mmol/l
Potassium (K+) 4.7 mmol/l 3.5–5.0 mmol/l
PaO2on room air 85 mmHg 95–100 mmHg
C-reactive protein (CRP) 6.6mg/l 0-10 mg/l
C3 level 41 mg/dl 83–180 mg/dl
Which of the following is most likely to be found in this patient as the cause for her dyspnoea?Your Answer: Bronchoalveolar lavage (BAL) positive for CD4 cells
Correct Answer: High diffusing capacity of the lungs for carbon monoxide (DLCO)
Explanation:This case discusses diffuse alveolar haemorrhage (DAH), a rare but serious complication of systemic lupus erythematosus (SLE). Symptoms include sudden-onset shortness of breath, decreased haematocrit levels, and possibly coughing up blood. A chest X-ray may show diffuse infiltrates and crepitations in the lungs. It is important to rule out infections before starting treatment with methylprednisolone or cyclophosphamide. A high DLCO, indicating increased diffusion capacity across the alveoli, may be present in DAH. A pulmonary function test may not be possible due to severe dyspnoea, so diagnosis is based on clinical presentation, imaging, and bronchoscopy. Lung biopsy may show pulmonary capillaritis with neutrophilic infiltration. A high ESR is non-specific and sputum for AFB is not relevant in this acute presentation. BAL fluid in DAH is progressively haemorrhagic, and lung scan with isotopes is not typical for this condition.
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This question is part of the following fields:
- Respiratory
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Question 10
Incorrect
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Which patient has an elevated PTH level that is indicative of primary hyperparathyroidism?
Patient A:
Adjusted calcium - 2.3 mmol/L
Phosphate - 0.9 mmol/L
PTH - 8.09 pmol/L
Urea - 7.8 mmol/L
Creatinine - 132 μmol/L
Albumin - 36 g/L
Patient B:
Adjusted calcium - 2.9 mmol/L
Phosphate - 0.5 mmol/L
PTH - 7.2 pmol/L
Urea - 5 mmol/L
Creatinine - 140 μmol/L
Albumin - 38 g/L
Patient C:
Adjusted calcium - 2.0 mmol/L
Phosphate - 2.8 mmol/L
PTH - 12.53 pmol/L
Urea - 32.8 mmol/L
Creatinine - 540 μmol/L
Albumin - 28 g/L
Patient D:
Adjusted calcium - 2.5 mmol/L
Phosphate - 1.6 mmol/L
PTH - 2.05 pmol/L
Urea - 32.8 mmol/L
Creatinine - 190 μmol/L
Albumin - 40 g/L
Patient E:
Adjusted calcium - 2.2 mmol/L
Phosphate - 0.7 mmol/L
PTH - 5.88 pmol/L
Urea - 4.6 mmol/L
Creatinine - 81 μmol/L
Albumin - 18 g/LYour Answer: Patient E
Correct Answer: Patient B
Explanation:Primary Hyperparathyroidism and its Complications
Primary hyperparathyroidism is a condition where the parathyroid glands produce too much parathyroid hormone (PTH), leading to elevated calcium levels and low serum phosphate. This condition can go undiagnosed for years, with an incidental finding of elevated calcium often being the first clue. However, complications can arise from longstanding primary hyperparathyroidism, including osteoporosis, renal calculi, and renal calcification.
Osteoporosis occurs due to increased bone resorption under the influence of high levels of PTH. Renal calculi are also a common complication, as high levels of phosphate excretion and calcium availability can lead to the development of calcium phosphate renal stones. Additionally, calcium deposition in the renal parenchyma can cause renal impairment, which can develop gradually over time.
Patients with longstanding primary hyperparathyroidism are at risk of impaired renal function, which is less common in patients with chronic kidney disease of other causes. While both conditions may have elevated PTH levels, hypocalcaemia is more common in chronic kidney disease due to impaired hydroxylation of vitamin D. the complications of primary hyperparathyroidism is crucial for early diagnosis and management of this condition.
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This question is part of the following fields:
- Nephrology
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Question 11
Incorrect
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A 25-year-old lady with a history of asthma is brought to the Emergency Department with an acute asthma attack. She has previously been admitted to the intensive therapy unit (ITU) with the same problem. Treatment is commenced with high-flow oxygen and regular nebulisers.
Which of the following is a feature of life-threatening asthma?Your Answer: Pulse rate 105 bpm
Correct Answer: Normal PaCO2
Explanation:Assessment of Severity in Acute Asthma Attacks
Acute asthma is a serious medical emergency that can lead to fatalities. To assess the severity of an asthma attack, several factors must be considered. Severe asthma is characterized by a peak flow of 33-50% of predicted or best, a respiratory rate of over 25 breaths per minute, a heart rate of over 110 beats per minute, and the inability to complete sentences. On the other hand, life-threatening asthma is indicated by a peak flow of less than 33% of predicted or best, a silent chest, cyanosis, and arterial blood gas showing high or normal PaCO2, which reflects reduced respiratory effort. Additionally, arterial blood gas showing hypoxia (PaO2 <8 kPa) or acidosis is also a sign of life-threatening asthma. Any life-threatening features require immediate critical care and senior medical review. A peak expiratory flow rate of less than 50% of predicted or best is a feature of an acute severe asthma attack. However, a pulse rate of 105 bpm is not a marker of severity in asthma due to its lack of specificity. Respiratory alkalosis, which is a condition characterized by low carbon dioxide levels, is actually a reassuring picture on the blood gas. In contrast, a normal carbon dioxide level would be a concern if the person is working that hard. Finally, the inability to complete full sentences is another feature of acute severe asthma.
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This question is part of the following fields:
- Respiratory
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Question 12
Incorrect
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Which of the following indicates a psychiatric illness rather than an organic brain disorder?
Your Answer: Clouding of consciousness
Correct Answer: A family history of major psychiatric illness
Explanation:Distinguishing Psychiatric Disease from Organic Brain Disease
Psychiatric diseases such as depression and schizophrenia have distinct features that differentiate them from organic brain diseases like dementia. While loss of short term memory and advanced age are more typical of organic brain disease, a family history is particularly associated with depressive illness and schizophrenia. It is important to distinguish between psychiatric and organic brain diseases in order to provide appropriate treatment and care.
According to Prof Anton Helman, a psychiatric emergency can be due to either disease or psychological illness. In order to determine the cause, a thorough differential diagnosis is necessary. Medical mimics of psychotic symptoms can often be mistaken for psychiatric disease, making it crucial to consider all possible causes.
The NHS England’s Mental Health in Older People A Practice Primer emphasizes the importance of recognizing mental health issues in older individuals. While organic brain diseases are more common in this population, psychiatric diseases can also occur and should not be overlooked. By the typical features of psychiatric disease and differentiating them from organic brain disease, healthcare professionals can provide appropriate care and improve outcomes for patients.
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This question is part of the following fields:
- Neurology
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Question 13
Correct
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What is the most optimal choice for establishing a permanent entry point for haemodialysis treatment?
Your Answer: Radiocephalic arteriovenous fistula
Explanation:Haemodialysis Access Options
Haemodialysis access is the formation of a permanent connection between an artery and a vein to allow for efficient dialysis treatment. The ideal location for this connection is in the arm, where the radial artery is joined to the cephalic vein on the non-dominant arm. If this is not possible, a brachial artery-cephalic vein connection is formed higher up the arm. Leg fistulas are used as a last resort due to complications such as infection and positional access.
In cases where a direct arteriovenous connection is not possible, a PTFE graft is used. However, this foreign material has a higher risk of infection. A tunnelled internal jugular dialysis catheter is a good option for urgent access, but it is not as efficient as fistulas in clearing waste products due to recirculation of blood.
Tenckhoff catheters are used for peritoneal dialysis. It is important to consider the pros and cons of each option when choosing the best haemodialysis access for a patient. Fistulas are the preferred option, but in some cases, other options may be necessary.
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This question is part of the following fields:
- Nephrology
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Question 14
Correct
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A female infant is presenting with dyspnea and cyanosis. The mother attempted to feed her but noticed milk coming out of her nose and difficulty breathing during feeding. Upon examination, the infant was found to be tachypneic and tachycardic with intercostal recession. A bulge was observed on the praecordium and an early systolic murmur was heard along the left sternal edge. The chest x-ray revealed cardiomegaly, a loss of the normal thymus shadow, and a right aortic notch. Blood tests were normal except for low corrected serum calcium. What is the most likely diagnosis?
Your Answer: DiGeorge syndrome
Explanation:DiGeorge Syndrome
DiGeorge syndrome is a genetic disorder caused by a deletion of chromosomal region 22q11.2. It affects around 1 in 3000 live births and is characterized by a spectrum of disorders. The poor migration of neural crest cells to the third and fourth pharyngeal pouches is thought to be the cause of the midline abnormalities found in DiGeorge syndrome. These abnormalities include cardiac defects, abnormal facies, thymic hypoplasia, and hypocalcemia.
Characteristic facies develop as the child grows and include high broad noses, low set ears, small teeth, and narrow eyes. Other systems may also be affected, and cognitive and psychiatric problems are common but variable. Around 80% of patients have an associated cardiac defect, often of a conotruncal variety. Tetralogy of Fallot is also found, as are other defects such as ventricular septal defects and atrial septal defects.
The diagnosis of DiGeorge syndrome can be difficult, but clinical features consistent with the diagnosis include abnormalities of heart sounds and features of cardiac failure or cyanosis. The chest x-ray helps with the diagnosis, and an echocardiogram and possibly high resolution contrast CT imaging would be helpful in these cases. The above example has a persistent truncus arteriosus, which is a failure to separate the aorta and the main pulmonary artery. This can lead to dyspnea, cyanosis, and cardiac failure.
In summary, DiGeorge syndrome is a complex disorder that affects multiple systems in the body. Early diagnosis and management are crucial to prevent complications and improve outcomes for affected individuals.
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This question is part of the following fields:
- Paediatrics
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Question 15
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: Accessory collateral ligament
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 16
Incorrect
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A 23-year-old female patient presents at the clinic for a check-up. She complains of irregular, heavy menstrual periods, has a BMI of 30 kg/m2, and experiences acne and excessive facial hair growth. She is not taking any medication. Her sister has been diagnosed with polycystic ovarian syndrome (PCOS), and she suspects that she may have the same condition.
During the physical examination, her blood pressure is 149/90 mmHg, and her pulse is regular at 78 bpm. She has excessive hair growth on her beard line and upper torso, and central obesity. However, the rest of her physical examination is normal.
Which blood test is the most diagnostic for PCOS?Your Answer: Oestrogen
Correct Answer: Total/free testosterone
Explanation:Diagnosis and Associated Risks of Polycystic Ovary Syndrome (PCOS)
Polycystic ovary syndrome (PCOS) is diagnosed when there is evidence of at least two out of three features, with other potential causes excluded. These features include oligoamenorrhoea, elevated levels of total/free testosterone (or clinical features suggestive of hyperandrogenism), or the presence of polycystic ovaries on ultrasound. While an extremely marked elevation in testosterone can suggest an androgen-secreting tumor, this is rare. Additionally, raised luteinising hormone (LH) with a normal follicle-stimulating hormone (FSH) can lead to an elevated LH/FSH ratio, but this is not diagnostic.
PCOS is associated with an increased risk of impaired glucose tolerance, although this may take a number of years to become apparent. Furthermore, there may be a reduction in levels of oestriol, although this is not always a consistent finding. It is important to diagnose PCOS early on to manage the associated risks and prevent potential complications.
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This question is part of the following fields:
- Haematology
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Question 17
Incorrect
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A 30-year-old male visits his general practitioner (GP) complaining of swelling in his testicles. He reports a soft sensation on the top of his left testicle but denies any pain or issues with urination or erections. The GP orders an ultrasound, and the results show a mild varicocele on the left side without other abnormalities detected. What is the recommended next step in managing this patient?
Your Answer: Laparoscopic repair of the varicocoele
Correct Answer: Reassure and observe
Explanation:Common Scrotal Problems and Their Features
Epididymal cysts, hydroceles, and varicoceles are the most common scrotal problems seen in primary care. Epididymal cysts are usually found posterior to the testicle and are separate from the body of the testicle. They may be associated with conditions such as polycystic kidney disease, cystic fibrosis, and von Hippel-Lindau syndrome. Diagnosis is confirmed by ultrasound, and management is usually supportive, although surgical removal or sclerotherapy may be attempted for larger or symptomatic cysts.
Hydroceles, on the other hand, describe the accumulation of fluid within the tunica vaginalis. They may be communicating or non-communicating, and may develop secondary to conditions such as epididymo-orchitis, testicular torsion, or testicular tumors. Hydroceles are usually soft, non-tender swellings of the hemi-scrotum that transilluminate with a pen torch. Diagnosis may be clinical, but ultrasound is required if there is any doubt about the diagnosis or if the underlying testis cannot be palpated. Management depends on the severity of the presentation, with infantile hydroceles generally repaired if they do not resolve spontaneously by the age of 1-2 years.
Varicoceles, on the other hand, are abnormal enlargements of the testicular veins that are usually asymptomatic but may be associated with subfertility. They are much more common on the left side and are classically described as a bag of worms. Diagnosis is confirmed by ultrasound with Doppler studies, and management is usually conservative, although surgery may be required if the patient is troubled by pain. There is ongoing debate regarding the effectiveness of surgery to treat infertility.
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This question is part of the following fields:
- Surgery
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Question 18
Incorrect
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A 50-year-old woman visits her doctor with new symptoms of flushing, severe insomnia, and headaches. She has a medical history of asthma and a spontaneous deep vein thrombosis. These symptoms are affecting her daily routine, and she has not had her period for 12 months. After discussing the benefits and risks of hormonal replacement therapy, they decide to start treatment. What is the most suitable hormonal replacement therapy regimen for this patient?
Your Answer: Oral estradiol and levonorgestrel
Correct Answer: Transdermal estradiol and levonorgestrel
Explanation:For women at risk of venous thromboembolism, transdermal HRT is the recommended option. In the case of a patient presenting with severe menopausal symptoms such as flushing, insomnia, and headaches, hormonal replacement therapy (HRT) may be prescribed after weighing the benefits and risks.
If the patient has a uterus, oral estradiol only should not be prescribed as it can cause endometrial hyperplasia and increase the risk of malignancy. Oral estradiol and levonorgestrel are a common combination for HRT, but in the case of a patient with a history of deep vein thrombosis, transdermal delivery is a more appropriate option as it does not increase the risk of developing a new clot compared to oral options.
The levonorgestrel-releasing intrauterine system can also be prescribed as HRT, but in this case, transdermal delivery is still the preferred option due to the patient’s medical history. Oral levonorgestrel alone is not used as HRT as it does not address the lack of estrogen that causes menopausal symptoms.
Hormone replacement therapy (HRT) involves a small dose of oestrogen and progesterone to alleviate menopausal symptoms. The indications for HRT have changed due to the long-term risks, and it is primarily used for vasomotor symptoms and preventing osteoporosis in younger women. HRT consists of natural oestrogens and synthetic progestogens, and can be taken orally or transdermally. Transdermal is preferred for women at risk of venous thromboembolism.
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This question is part of the following fields:
- Pharmacology
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Question 19
Incorrect
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A 33-year-old former intravenous (iv) drug abuser presents to outpatient clinic with abnormal liver function tests (LFTs) at the recommendation of his general practitioner. Although he is not experiencing any symptoms, a physical examination reveals hepatomegaly measuring 4 cm. Further blood tests confirm that he is positive for hepatitis C, with a significantly elevated viral load of hepatitis C RNA. What would be the most crucial investigation to determine the appropriate management of his hepatitis C?
Your Answer: Ultrasound scan abdomen
Correct Answer: Hepatitis C genotype
Explanation:Hepatitis C Management and Testing
Hepatitis C is a viral infection that can be acquired through blood or sexual contact, including shared needles during intravenous drug use and contaminated blood products. While some patients may be asymptomatic, the virus can cause progressive damage to the liver and may lead to liver failure requiring transplantation if left untreated.
Before starting treatment for chronic hepatitis C, it is important to determine the patient’s hepatitis C genotype, as this guides the length and type of treatment and predicts the likelihood of response. Dual therapy with interferon α and ribavirin is traditionally the most effective treatment, but newer oral medications like sofosbuvir, boceprevir, and telaprevir are now used in combination with PEG-interferon and ribavirin for genotype 1 hepatitis C.
Screening for HIV is also important, as HIV infection often coexists with hepatitis C, but the result does not influence hepatitis C management. An ultrasound of the abdomen can determine the structure of the liver and the presence of cirrhosis, but it does not alter hepatitis C management. A chest X-ray is not necessary in this patient, and ongoing intravenous drug use does not affect hepatitis C management.
Overall, proper testing and management of hepatitis C can prevent further liver damage and improve patient outcomes.
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This question is part of the following fields:
- Gastroenterology
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Question 20
Correct
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A three-year-old child is admitted to the hospital with a high fever of 39ºC that has persisted for the past five days. The parents are worried as they have noticed redness in the child's eyes, swelling in the neck, and a new rash.
During the examination, the child is found to have a widespread maculopapular rash and bilateral conjunctivitis. Additionally, there is unilateral cervical lymphadenopathy, cracked and erythematosus lips, and a strawberry tongue.
What is the initial treatment that should be given to this three-year-old child?Your Answer: Aspirin
Explanation:Kawasaki disease is a systemic vasculitis that typically affects children under the age of 5. Symptoms include a fever lasting over 5 days, bilateral non-purulent conjunctivitis, a rash, mucosal erythema with a strawberry tongue, and unilateral cervical lymphadenopathy. In some cases, swelling of the hands and feet can occur, followed by desquamation in the second week. If left untreated, up to one-quarter of patients can develop coronary aneurysms. The main goal of treatment is to reduce the risk of cardiac complications. In the UK, the standard treatment is intravenous immunoglobulin and high dose aspirin, despite the fact that aspirin is usually contraindicated in children. Benzylpenicillin is not indicated in the treatment of Kawasaki disease. Conservative management is also not appropriate, as specific treatment is required to reduce inflammation and prevent the risk of coronary complications. Corticosteroids may be used as a second-line treatment if the patient does not respond to intravenous immunoglobulins.
Understanding Kawasaki Disease
Kawasaki disease is a rare type of vasculitis that primarily affects children. It is important to identify this disease early on as it can lead to serious complications, such as coronary artery aneurysms. The disease is characterized by a high-grade fever that lasts for more than five days and is resistant to antipyretics. Other symptoms include conjunctival injection, bright red, cracked lips, strawberry tongue, cervical lymphadenopathy, and red palms and soles that later peel.
Diagnosis of Kawasaki disease is based on clinical presentation as there is no specific diagnostic test available. Management of the disease involves high-dose aspirin, which is one of the few indications for aspirin use in children. Intravenous immunoglobulin is also used as a treatment option. Echocardiogram is the initial screening test for coronary artery aneurysms, rather than angiography.
Complications of Kawasaki disease can be serious, with coronary artery aneurysm being the most common. It is important to recognize the symptoms of Kawasaki disease early on and seek medical attention promptly to prevent potential complications.
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This question is part of the following fields:
- Paediatrics
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Question 21
Incorrect
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A 50-year-old man presents to the Emergency Department with a 3-week history of tiredness, epigastric discomfort and an episode of passing black stools. His past medical history includes a 4-year history of rheumatoid arthritis for which he takes regular methotrexate, folic acid and naproxen. He recently received a course of oral corticosteroids for a flare of his rheumatoid arthritis. He denies alcohol consumption and is a non-smoker. On systemic enquiry he reports a good appetite and denies any weight loss. The examination reveals conjunctival pallor and a soft abdomen with tenderness in the epigastrium. His temperature is 36.7°C, blood pressure is 112/68 mmHg, pulse is 81 beats per minute and oxygen saturations are 96% on room air. A full blood count is taken which reveals the following:
Investigation Result Normal Value
Haemoglobin 76 g/l 135–175 g/l
Mean corpuscular volume (MCV) 68 fl 76–98 fl
White cell count (WCC) 5.2 × 109/l 4–11 × 109/l
Platelets 380 × 109/l 150–400 × 109/l
Which of the following is the most likely diagnosis?Your Answer: Gastric cancer
Correct Answer: Peptic ulcer
Explanation:Gastrointestinal Conditions: Peptic Ulcer, Atrophic Gastritis, Barrett’s Oesophagus, Gastric Cancer, and Oesophageal Varices
Peptic Ulcer:
Peptic ulceration is commonly caused by NSAID use or Helicobacter pylori infection. Symptoms include dyspepsia, upper gastrointestinal bleeding, and iron deficiency anaemia. Treatment involves admission to a gastrointestinal ward for resuscitation, proton pump inhibitor initiation, and urgent endoscopy. If caused by H. pylori, triple therapy is initiated.Atrophic Gastritis:
Atrophic gastritis is a chronic inflammatory change of the gastric mucosa, resulting in malabsorption and anaemia. However, it is unlikely to account for melaena or epigastric discomfort.Barrett’s Oesophagus:
Barrett’s oesophagus is a histological diagnosis resulting from chronic acid reflux. It is unlikely to cause the patient’s symptoms as there is no history of reflux.Gastric Cancer:
Gastric cancer is less likely due to the lack of risk factors and additional ‘red flag’ symptoms such as weight loss and appetite change. Biopsies of peptic ulcers are taken at endoscopy to check for an underlying malignant process.Oesophageal Varices:
Oesophageal varices are caused by chronic liver disease and can result in severe bleeding and haematemesis. However, this diagnosis is unlikely as there is little history to suggest chronic liver disease. -
This question is part of the following fields:
- Gastroenterology
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Question 22
Incorrect
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An 88-year-old man is brought to the Emergency Department (ED) via ambulance with central crushing chest pain. An electrocardiogram (ECG) in the ambulance shows 3 mm ST elevation in the anterior leads consistent with a STEMI. His wife says he has a history of ischaemic heart disease and congestive cardiac failure. He has a cardiac arrest in the ED secondary to ventricular fibrillation. Despite resuscitation using advanced cardiac life support, he dies. His wife asks what will happen to his body.
What is the most appropriate next step in management for this deceased patient?Your Answer: Fill in the death certificate stating that a condition that may have contributed to the death (part 2) was heart failure
Correct Answer: Refer to the coroner
Explanation:Guidelines for Filling out a Death Certificate
When filling out a death certificate, it is important to follow certain guidelines to ensure accuracy and completeness. If the death was sudden and unexpected, it should be referred to the coroner. In part 1 of the certificate, the specific disease, illness, or complication that led to death should be stated, not a mode of dying. Terms such as cardiac arrest, old age, and coma are not suitable for part 1. In part 2, any conditions that may have contributed to the death should be listed, but terms such as heart failure, liver failure, and kidney failure are not acceptable. By following these guidelines, death certificates can provide valuable information for medical research and public health purposes.
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This question is part of the following fields:
- Ethics And Legal
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Question 23
Correct
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A 65-year-old woman presents with a history of facial pain and diplopia. Clinical examination reveals CN III, CN IV and CN VI palsies, a Horner’s syndrome, and facial sensory loss in the distribution of the V1 (ophthalmic) and V2 (maxillary) divisions of the trigeminal cranial nerve.
Where is the causative abnormality located?Your Answer: Cavernous sinus
Explanation:Anatomy of Cranial Nerves and the Cavernous Sinus
The cavernous sinus is a crucial location for several cranial nerves and blood vessels. Cranial nerves III, IV, and VI, as well as the ophthalmic (V1) and maxillary (V2) divisions of the V cranial nerve, pass through the cavernous sinus with the internal carotid artery. The V2 division of the trigeminal nerve exits via the foramen rotundum, while the rest of the cranial nerves enter the orbit through the superior orbital fissure.
Damage to these nerves can result in ophthalmoplegia, facial pain, and sensory loss. Involvement of sympathetic nerves around the internal carotid artery can lead to Horner’s syndrome. Tolosa Hunt syndrome is an idiopathic inflammatory process that affects the cavernous sinus and can cause a cluster of these symptoms.
Dorello’s canal carries cranial nerve VI (abducens) from the pontine cistern to the cavernous sinus. The zygomatic branch of the maxillary division of the trigeminal nerve passes through the inferior orbital fissure. Meckel’s cave houses the trigeminal nerve ganglion.
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This question is part of the following fields:
- Neurology
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Question 24
Incorrect
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You are evaluating a 23-year-old female who is 8 weeks pregnant and experiencing severe vomiting, making it difficult for her to retain fluids. What is the best method to determine the severity of her symptoms?
Your Answer: Serial creatinine levels
Correct Answer: Pregnancy-Unique Quantification of Emesis (PUQE) scoring system
Explanation:Hyperemesis gravidarum is an extreme form of nausea and vomiting of pregnancy that occurs in around 1% of pregnancies and is most common between 8 and 12 weeks. It is associated with raised beta hCG levels and can be caused by multiple pregnancies, trophoblastic disease, hyperthyroidism, nulliparity, and obesity. Referral criteria for nausea and vomiting in pregnancy include continued symptoms with ketonuria and/or weight loss, a confirmed or suspected comorbidity, and inability to keep down liquids or oral antiemetics. The diagnosis of hyperemesis gravidarum requires the presence of 5% pre-pregnancy weight loss, dehydration, and electrolyte imbalance. Management includes first-line use of antihistamines and oral cyclizine or promethazine, with second-line options of ondansetron and metoclopramide. Admission may be needed for IV hydration. Complications can include Wernicke’s encephalopathy, Mallory-Weiss tear, central pontine myelinolysis, acute tubular necrosis, and fetal growth issues.
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This question is part of the following fields:
- Obstetrics
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Question 25
Incorrect
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An 80-year-old man arrives at the emergency department with lower gastrointestinal bleeding. He has a history of alcohol abuse but no other medical issues. Upon examination, you observe abdominal distension, splenomegaly, visible veins on the abdominal wall, and bright red blood per rectum. His blood pressure is 120/64 mmHg, his pulse is 100 bpm, and his oxygen saturation is 98% on air. Blood tests reveal the following results: ALP 405 u/L (30 - 100), ALT 95 u/L (3 - 40), and Albumin 31 g/L (35 - 50). Based on these findings, what is the most likely diagnosis?
Your Answer: Rectal cancer
Correct Answer: Rectal varices
Explanation:In patients with portal hypertension and lower gastrointestinal bleeding, it is important to consider rectal varices as a possible cause. This was the case for the patient in question, who presented with typical signs of portal hypertension, including ascites, splenomegaly, and caput medusae. The most common cause of portal hypertension is cirrhosis, which was indicated by the patient’s blood test results and history of alcohol abuse. However, it is important to note that liver function tests (LFTs) can be normal in patients with cirrhosis.
Rectal varices are a likely cause of lower gastrointestinal bleeding in patients with portal hypertension, as they can cause swelling of the veins in the anorectal region. While haemorrhoids are a possibility, they are less likely in this case as the patient did not report any associated symptoms. Rectal examination would still be necessary to rule out haemorrhoids, as they can also be asymptomatic.
Rectal cancer is unlikely as the patient did not exhibit any signs or symptoms suggestive of malignancy. However, rectal examination would still be necessary to exclude this possibility, as lower GI bleeding is a red flag symptom.
The patient did not have a history of bleeding problems, and his symptoms were not suggestive of a bleeding disorder. However, it is important to note that prothrombin time (PT) can provide useful information on liver function. A high PT indicates that the liver is not producing enough blood clotting proteins, which can be a sign of liver damage or cirrhosis.
Understanding Lower Gastrointestinal Bleeding
Lower gastrointestinal bleeding, also known as colonic bleeding, is characterized by the presence of bright red or dark red blood in the rectum. Unlike upper gastrointestinal bleeding, colonic bleeding rarely presents as melaena type stool. This is because blood in the colon has a powerful laxative effect and is rarely retained long enough for transformation to occur. Additionally, the digestive enzymes present in the small bowel are not present in the colon. It is important to note that up to 15% of patients presenting with hematochezia will have an upper gastrointestinal source of haemorrhage.
Right-sided bleeds tend to present with darker coloured blood than left-sided bleeds. Haemorrhoidal bleeding, on the other hand, typically presents as bright red rectal bleeding that occurs post defecation either onto toilet paper or into the toilet pan. However, it is very unusual for haemorrhoids alone to cause any degree of haemodynamic compromise.
There are several causes of lower gastrointestinal bleeding, including colitis, diverticular disease, cancer, and angiodysplasia. The management of lower gastrointestinal bleeding involves prompt correction of any haemodynamic compromise. Unlike upper gastrointestinal bleeding, the first-line management is usually supportive. When haemorrhoidal bleeding is suspected, a proctosigmoidoscopy is reasonable as attempts at full colonoscopy are usually time-consuming and often futile. In the unstable patient, the usual procedure would be an angiogram, while in others who are more stable, a colonoscopy in the elective setting is the standard procedure. Surgery may be necessary in some cases, particularly in patients over 60 years, those with continued bleeding despite endoscopic intervention, and those with recurrent bleeding.
In summary, lower gastrointestinal bleeding is a serious condition that requires prompt attention. It is important to identify the cause of the bleeding and manage it accordingly to prevent further complications.
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This question is part of the following fields:
- Surgery
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Question 26
Correct
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A 3-day-old baby born at term is brought to the Neonatal Unit with green fluid vomiting and a swollen belly. The baby was doing fine after birth and was being breastfed. The parents mention that the baby has urinated but has not yet passed meconium. During the examination, the baby seems weak, pale, and breathing rapidly.
What could be the probable reason for the baby's deteriorating condition?Your Answer: Hirschsprung’s disease
Explanation:Differential diagnosis for a neonate with abdominal distension and failure to pass meconium
Hirschsprung’s disease, NEC, biliary atresia, GBS sepsis, and haemolytic disease of the newborn are among the possible causes of abdominal distension and failure to pass meconium in a neonate. Hirschsprung’s disease is the most likely diagnosis in a term neonate with bilious vomiting and absence of meconium, as it results from a developmental failure of the gut’s parasympathetic plexus. Surgical intervention via colostomy is necessary to relieve obstruction and prevent enterocolitis. NEC, which involves bowel necrosis, is more common in preterm neonates and may present with similar symptoms. Biliary atresia, a cause of neonatal jaundice, is less likely in this case, as the baby is pale and has not yet passed meconium. GBS sepsis is a potential diagnosis in any unwell neonate, but the history of not passing meconium within the first 48 hours and the presence of bilious vomit and distended abdomen suggest Hirschsprung’s disease as a more likely cause. Haemolytic disease of the newborn, caused by rhesus antibodies crossing the placenta, would not present with abdominal distension and failure to pass meconium. Accurate diagnosis and prompt management are crucial in ensuring the best outcome for the neonate.
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This question is part of the following fields:
- Gastroenterology
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Question 27
Correct
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A 35-year-old woman presents with a two-week history of morning sickness. She is 10 weeks pregnant. She can keep down oral fluid but has vomited twice in the previous 24 hours. There are no acid reflux symptoms, abdominal pain, vaginal bleeding or urinary symptoms.
She takes folic acid and is not on any other medications.
On examination, her temperature is 36.8ºC. Blood pressure is 100/60 mmHg and heart rate is 80/min. Her abdomen is soft and non-tender. Urine B-HCG is positive and urine dipstick shows 1+ ketone only. There is no weight loss.
What is the most appropriate management option for this patient?Your Answer: Commence on oral cyclizine
Explanation:The recommended first-line treatment for nausea and vomiting in pregnancy or hyperemesis gravidarum is antihistamines, specifically oral cyclizine. Second-line options include ondansetron and domperidone. Hospital admission may be necessary if the patient cannot tolerate oral medications or fluids, or if symptoms are not controlled with primary care management. There is no indication for oral omeprazole in this case as the patient has not reported any dyspeptic symptoms.
Hyperemesis gravidarum is an extreme form of nausea and vomiting of pregnancy that occurs in around 1% of pregnancies and is most common between 8 and 12 weeks. It is associated with raised beta hCG levels and can be caused by multiple pregnancies, trophoblastic disease, hyperthyroidism, nulliparity, and obesity. Referral criteria for nausea and vomiting in pregnancy include continued symptoms with ketonuria and/or weight loss, a confirmed or suspected comorbidity, and inability to keep down liquids or oral antiemetics. The diagnosis of hyperemesis gravidarum requires the presence of 5% pre-pregnancy weight loss, dehydration, and electrolyte imbalance. Management includes first-line use of antihistamines and oral cyclizine or promethazine, with second-line options of ondansetron and metoclopramide. Admission may be needed for IV hydration. Complications can include Wernicke’s encephalopathy, Mallory-Weiss tear, central pontine myelinolysis, acute tubular necrosis, and fetal growth issues.
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This question is part of the following fields:
- Obstetrics
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Question 28
Incorrect
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A 56-year-old man has just been admitted to the medical ward. Two days ago, he returned from a business trip and his history suggests he may have caught an atypical pneumonia. While examining the patient’s chest clinically, you try to determine whether the pneumonia is affecting one lobe in particular or is affecting the whole lung.
On the right side of the patient’s chest, which one of the following surface landmarks would be most likely to mark the boundary between the middle and lower lobes?Your Answer:
Correct Answer: Sixth rib
Explanation:Surface Landmarks for Lung Lobes and Abdominal Planes
The human body has several surface landmarks that can be used to locate important anatomical structures. In the case of the lungs, the position of the lobes can be estimated using the oblique and horizontal fissures. The sixth rib is the most likely surface landmark to mark the boundary between the right middle and lower lobes, while the fourth costal cartilage indicates the level of the horizontal fissure separating the superior from the middle lobes of the right lung.
In the abdomen, the tip of the ninth costal cartilage is a useful landmark as it marks the position of the transpyloric plane. This imaginary axial plane is important as it is where many anatomical structures, such as the pylorus of the stomach and the neck of the pancreas, are located. Additionally, the horizontal line passing through the centre of the nipple, known as the mammillary line, can also be used as a surface landmark for certain procedures.
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This question is part of the following fields:
- Respiratory
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Question 29
Incorrect
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A 28-year-old woman presents to the emergency department with a decreased level of consciousness. Upon evaluation, her blood sugar is found to be 1.2 and is treated accordingly. The paramedics report finding her next to an insulin syringe, despite her not having diabetes. This is the third occurrence of such an event, and the patient denies any suicidal ideation. What is the diagnosis for this woman's condition?
Your Answer:
Correct Answer: Munchausen's syndrome
Explanation:Deliberately inducing symptoms, such as a diabetic intentionally overdosing on insulin to experience hypoglycemia, is an instance of Munchausen’s syndrome.
Psychiatric Terms for Unexplained Symptoms
There are various psychiatric terms used to describe patients who exhibit symptoms for which no organic cause can be found. One such disorder is somatisation disorder, which involves the presence of multiple physical symptoms for at least two years, and the patient’s refusal to accept reassurance or negative test results. Another disorder is illness anxiety disorder, which is characterized by a persistent belief in the presence of an underlying serious disease, such as cancer, despite negative test results.
Conversion disorder is another condition that involves the loss of motor or sensory function, and the patient does not consciously feign the symptoms or seek material gain. Patients with this disorder may be indifferent to their apparent disorder, a phenomenon known as la belle indifference. Dissociative disorder, on the other hand, involves the process of ‘separating off’ certain memories from normal consciousness, and may manifest as amnesia, fugue, or stupor. Dissociative identity disorder (DID) is the most severe form of dissociative disorder and was previously known as multiple personality disorder.
Factitious disorder, also known as Munchausen’s syndrome, involves the intentional production of physical or psychological symptoms. Finally, malingering is the fraudulent simulation or exaggeration of symptoms with the intention of financial or other gain. Understanding these psychiatric terms can help healthcare professionals better diagnose and treat patients with unexplained symptoms.
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This question is part of the following fields:
- Psychiatry
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Question 30
Incorrect
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A 55-year-old man presents with epigastric pain which radiates to the back. He feels nauseous and has been vomiting since arriving at the Emergency Department (ED). On questioning, the man tells you that he takes no regular medication. He was last in hospital three years ago after he fell from his bicycle when cycling under the influence of alcohol. He was not admitted. He travelled to Nigeria to visit relatives three months ago.
On examination, the man’s abdomen is tender in the epigastrium. He is jaundiced. He is also tachycardic and pyrexial. Some of his investigation results are as follows:
Investigation Result Normal value
Alkaline phosphatase (ALP) 320 IU/l 30–130 IU/l
Alanine aminotransferase (ALT) 70 IU/l 5–30 IU/l
Bilirubin 45 µmol/l 2–17 µmol/l
What is the best initial treatment for this man?Your Answer:
Correct Answer: Admission, iv fluids, analgesia, keep nil by mouth and place a nasogastric tube
Explanation:Appropriate Treatment for Pancreatitis and Cholecystitis: Differentiating Symptoms and Initial Management
Pancreatitis and cholecystitis are two conditions that can present with similar symptoms, such as epigastric pain and nausea. However, the nature of the pain and other clinical indicators can help differentiate between the two and guide appropriate initial treatment.
For a patient with pancreatitis, initial treatment would involve admission, IV fluids, analgesia, and keeping them nil by mouth. A nasogastric tube may also be placed to help with vomiting and facilitate healing. Antibiotics and surgical intervention are not typically indicated unless there are complications such as necrosis or abscess.
In contrast, a patient with cholecystitis would receive broad-spectrum antibiotics and analgesia as initial management. Laparoscopic cholecystectomy would only be considered after further investigations such as abdominal ultrasound or MRCP.
It’s important to note that other factors, such as a recent history of travel, may also need to be considered in determining appropriate treatment. However, careful evaluation of symptoms and clinical indicators can help guide initial management and ensure the best possible outcomes for patients.
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This question is part of the following fields:
- Gastroenterology
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