00
Correct
00
Incorrect
00 : 00 : 00
Session Time
00 : 00
Average Question Time ( Mins)
  • Question 1 - A 2-year-old boy is admitted to the ward with difficulty breathing. His mother...

    Incorrect

    • A 2-year-old boy is admitted to the ward with difficulty breathing. His mother reports a 3-day illness with cough and cold symptoms, low-grade fever and increasing difficulty breathing this morning. He has had no similar episodes. The family are all non-smokers and there is no history of atopy. His immunisations are up-to-date and he is otherwise growing and developing normally.
      In the Emergency Department, he was given burst therapy and is now on one-hourly salbutamol inhalers. On examination, he is alert and playing. Heart rate (HR) 150 bpm, respiratory rate (RR) 40 breaths per minute, oxygen saturation 94% on air. There is mild subcostal recession, and his chest shows good air entry bilaterally, with mild wheeze throughout.
      What is the most appropriate next step in management?

      Your Answer: Add Atrovent® nebulisers

      Correct Answer: Stretch to 2-hourly salbutamol and add 10 mg soluble prednisone for 3 days

      Explanation:

      Management of Viral-Induced Wheeze in Children: Treatment Options and Considerations

      Viral-induced wheeze is a common presentation of wheeze in preschool children, typically associated with a viral infection. Inhaled b2 agonists are the first line of treatment, given hourly during acute episodes. However, for children with mild symptoms and maintaining saturations above 92%, reducing the frequency of salbutamol to 2-hourly and gradually weaning off may be appropriate. Steroid tablet therapy is recommended for use in hospital settings and early management of asthma symptoms in this age group. It is important to establish a personal and family history of atopy, as a wheeze is more likely to be induced by asthma if it occurs when the child is otherwise well. Oxygen via nasal cannulae is not necessary for mild symptoms. Prednisolone may be added for 3 days with a strong history of atopy, while montelukast is given for 5 days to settle inflammation in children without atopy. Atrovent® nebulisers are not typically used in the treatment of viral-induced wheeze but may be useful in children with atopy history where salbutamol fails to reduce symptoms.

    • This question is part of the following fields:

      • Paediatrics
      52.1
      Seconds
  • Question 2 - A 56-year-old Caucasian man presents to his General Practitioner (GP) for routine health...

    Incorrect

    • A 56-year-old Caucasian man presents to his General Practitioner (GP) for routine health screening. He has a background history of obesity (BMI 31 kg/m2), impaired glucose tolerance and he used to smoke. His blood pressure is 162/100 mmHg. It is the same in both arms. There is no renal bruit and he does not appear cushingoid. He does not take regular exercise. At his previous appointment his blood pressure was 168/98 mm/Hg and he has been testing his BP at home. Average readings are 155/95 mmHg. He does not drink alcohol. His father had a heart attack at age 58. Blood results are listed below:
      Investigation Result Normal value
      HbA1C 46 mmol/l < 53 mmol/mol (<7.0%)
      Potassium 4.1 mmol/l 3.5–5 mmol/l
      Urea 7 mmol/l 2.5–6.5 mmol/l
      Creatinine 84 µmol/l 50–120 µmol/l
      Total cholesterol 5.2 mmol/l < 5.2 mmol/l
      High-density lipoprotein (HDL) 1.1 mmol/l > 1.0 mmol/l
      Low density-lipoprotein (LDL) 3 mmol/l < 3.5 mmol/l
      Triglycerides 1.1 mmol/l 0–1.5 mmol/l
      Thyroid Stimulating Hormone (TSH) 2 µU/l 0.17–3.2 µU/l
      Free T4 16 pmol/l 11–22 pmol/l
      What is the most appropriate next step in management of this patient?

      Your Answer: Commence beta blockade

      Correct Answer: Commence ACE inhibitor

      Explanation:

      Treatment for Stage 2 Hypertension: Commencing ACE Inhibitor

      Stage 2 hypertension is a serious condition that requires prompt treatment to reduce the risk of a cardiac event. According to NICE guidelines, ACE inhibitors or ARBs are the first-line treatment for hypertension. This man, who has multiple risk factors for hypertension, including age, obesity, and physical inactivity, should commence pharmacological treatment. Lifestyle advice alone is not sufficient in this case.

      It is important to note that beta blockers are not considered first-line treatment due to their side-effect profile. Spironolactone is used as fourth-line treatment in resistant hypertension or in the setting of hyperaldosteronism. If cholesterol-lowering treatment were commenced, a statin would be first line. However, in this case, the patient’s cholesterol is normal, so a fibrate is not indicated.

      In summary, commencing an ACE inhibitor is the appropriate course of action for this patient with stage 2 hypertension.

    • This question is part of the following fields:

      • Cardiology
      13.8
      Seconds
  • Question 3 - A 7 week old baby girl is brought to the clinic by her...

    Incorrect

    • A 7 week old baby girl is brought to the clinic by her father. He is worried because although the left testis is present in the scrotum the right testis is absent. He reports that it is sometimes palpable when he bathes the child. On examination the right testis is palpable at the level of the superficial inguinal ring. What is the most suitable course of action?

      Your Answer: Laparoscopy

      Correct Answer: Re-assess in 6 months

      Explanation:

      At 3 months of age, children may have retractile testes which can be monitored without intervention.

      Cryptorchidism is a condition where a testis fails to descend into the scrotum by the age of 3 months. It is a congenital defect that affects up to 5% of male infants at birth, but the incidence decreases to 1-2% by the age of 3 months. The cause of cryptorchidism is mostly unknown, but it can be associated with other congenital defects such as abnormal epididymis, cerebral palsy, mental retardation, Wilms tumour, and abdominal wall defects. Retractile testes and intersex conditions are differential diagnoses that need to be considered.

      It is important to correct cryptorchidism to reduce the risk of infertility, allow for examination of the testes for testicular cancer, avoid testicular torsion, and improve cosmetic appearance. Males with undescended testes are at a higher risk of developing testicular cancer, particularly if the testis is intra-abdominal. Orchidopexy, which involves mobilisation of the testis and implantation into a dartos pouch, is the preferred treatment for cryptorchidism between 6-18 months of age. Intra-abdominal testes require laparoscopic evaluation and mobilisation, which may be a single or two-stage procedure depending on the location. If left untreated, the Sertoli cells will degrade after the age of 2 years, and orchidectomy may be necessary in late teenage years to avoid the risk of malignancy.

    • This question is part of the following fields:

      • Surgery
      13.1
      Seconds
  • Question 4 - A 55-year-old man comes to his GP complaining of tingling in both hands...

    Incorrect

    • A 55-year-old man comes to his GP complaining of tingling in both hands that began a month ago and has been progressively worsening. He has no significant medical history. During the examination, you observe that the man has large hands, widely spaced teeth, and a prominent brow. You suspect that he may have acromegaly.
      What is the most suitable initial investigation for acromegaly?

      Your Answer: Computed tomography (CT) Head

      Correct Answer: Serum IGF1 levels

      Explanation:

      Investigations for Acromegaly: Serum IGF1 Levels, CT/MRI Head, and Visual Field Testing

      Acromegaly is a condition caused by excess growth hormone (GH) production, often from a pituitary macroadenoma. To diagnose acromegaly, insulin-like growth factor 1 (IGF1) levels are measured instead of GH levels, as IGF1 has a longer half-life and is more stable in the blood. If IGF1 levels are high, a glucose tolerance test is used to confirm the diagnosis. CT scans of the head are not as sensitive as MRI scans for investigating pituitary tumors, which are a common cause of acromegaly. Visual field testing is also important to assess whether a pituitary tumor is compressing the optic chiasm, but it is not specific to acromegaly and is part of the physical exam.

    • This question is part of the following fields:

      • Endocrinology
      20.9
      Seconds
  • Question 5 - A study evaluating the effectiveness of a novel treatment for metastatic breast cancer...

    Correct

    • A study evaluating the effectiveness of a novel treatment for metastatic breast cancer in comparison to standard therapy found a decrease in the primary outcome of death from metastatic disease from 60% at five years to 45% (p=0.032). What is the relative risk reduction linked with the new treatment?

      Your Answer: 20%

      Explanation:

      Relative Risk Reduction

      When analyzing data, two terms that are commonly used are absolute risk reduction and relative risk reduction. Absolute risk reduction refers to the actual difference in risk between two groups, while relative risk reduction is the percentage reduction in risk between the two groups.

      For example, if a study found that the absolute risk reduction was 10% at five years, this means that there was a 10% difference in risk between the two groups being compared. However, if the relative risk reduction was calculated to be 20%, this means that the risk of the outcome was reduced by 20% in the group receiving the intervention compared to the group that did not receive it.

      It is important to note that even if a study does not produce a significant difference, it is still possible to compute these risks. Relative risk reduction can be a more powerful reflection of the efficacy of an intervention in cases where absolute changes may be quite small. Therefore, both absolute and relative risk reduction can provide a more comprehensive of the impact of an intervention.

    • This question is part of the following fields:

      • Clinical Sciences
      32.7
      Seconds
  • Question 6 - A premature neonate is delivered via category II emergency caesarean section at 34+3...

    Incorrect

    • A premature neonate is delivered via category II emergency caesarean section at 34+3 weeks for fetal distress. The obstetrician notes the baby is delivered with the cord wrapped around its neck and appears floppy and 'blue'. The neonatal team immediately begins resuscitation as the initial APGAR score is 3. At 10 minutes, the score is 5 due to cyanosis, heart rate of 120 bpm, minimal response to stimulation, poor tone, slow and irregular respiratory effort with a respiratory rate of 12/min. What is the most appropriate management of this premature neonate to reduce hypoxic ischemic encephalopathy (HIE)?

      Your Answer: Sedation and intubation

      Correct Answer: Therapeutic cooling

      Explanation:

      Therapeutic Cooling for Neonates with Hypoxic Brain Injury

      Therapeutic cooling, also known as therapeutic hypothermia, is a medical procedure that involves deliberately lowering a patient’s body temperature to cool the brain and prevent brain damage. This procedure has been proposed for several therapeutic uses, including neuroprotection during open-heart and neurosurgical procedures, in patients following a return of spontaneous circulation post-ventricular fibrillation arrest, in patients with trauma head injuries, in patients who have suffered acute ischemic stroke, and in neonates with moderate to severe hypoxic ischemic encephalopathy (HIE). However, the only use whose efficacy has been consistently proven in existing literature is the use of therapeutic cooling in neonates.

      The use of therapeutic cooling in carefully selected term neonates with moderate to severe HIE has been recommended as standard care by the National Institute for Health and Care Excellence (NICE). It has been shown in studies to decrease mortality and improve the neurological and neurodevelopmental outcomes of treated neonates. Hypoxic perinatal brain injury is caused by a decrease in the amount of oxygen supplied to an infant’s brain just prior to, or during the process of, labor. Neonates who survive a hypoxic brain injury can develop HIE, which occurs in an estimated 2.5/1000 term births in developed countries and 26/1000 term births in the developing world.

      Therapeutic cooling remains the only intervention shown to reduce neuronal damage caused by perinatal hypoxia. The procedure is thought to influence the extent of secondary neuronal death in a multifactorial manner, although the exact way in which it achieves this is not fully understood. The procedure involves placing the infant on a cooling blanket or mattress circulated with coolant fluid or circulating cold water in a cap fitted around the head. Temperature is continuously monitored throughout the treatment using either a rectal or nasopharyngeal thermometer. Close surveillance of infants during the cooling process is required given the risk for complications of both HIE and the process of cooling itself.

    • This question is part of the following fields:

      • Paediatrics
      24.7
      Seconds
  • Question 7 - A woman of 68 presents with four episodes of postmenopausal bleeding over the...

    Incorrect

    • A woman of 68 presents with four episodes of postmenopausal bleeding over the last 6 months. She is otherwise fit and well, although her body mass index is 38 kg/m2.
      Which of the following is the most likely diagnosis?

      Your Answer: Submucosal fibroid

      Correct Answer: Endometrial cancer

      Explanation:

      postmenopausal Bleeding: Common Causes and Investigations

      postmenopausal bleeding can be caused by various factors, including atrophic vaginitis, endometrial atrophy, cervical or endometrial polyps, and endometrial hyperplasia/cancer. Among these causes, endometrial cancer is the most likely. Therefore, investigation for patients with postmenopausal bleeding is typically done in a specialist clinic, with transvaginal ultrasound, hysteroscopy, and biopsy.

      However, submucosal fibroids become quiescent following menopause and usually calcify, and there is no evidence of increased risk of endometrial cancer in women with fibroids. On the other hand, ovarian cancer rarely, if ever, presents with postmenopausal bleeding. Cervical ectropion is a condition of young women, and vaginal cancer is very rare and usually presents with vaginal discharge.

      In summary, postmenopausal bleeding should be investigated thoroughly to rule out any underlying serious conditions, such as endometrial cancer.

    • This question is part of the following fields:

      • Gynaecology
      59
      Seconds
  • Question 8 - A 70-year-old hypertensive man has been prescribed six medications but still has uncontrolled...

    Incorrect

    • A 70-year-old hypertensive man has been prescribed six medications but still has uncontrolled hypertension. You suspect that he is not adherent to his medications.
      Which screening tool is the best to use to determine his adherence to his medications?

      Your Answer: Montreal Cognitive Assessment (MOCA)

      Correct Answer: Morisky scale

      Explanation:

      Common Medical Assessment Tools

      Various medical assessment tools are available to assist healthcare professionals in diagnosing and treating patients. These tools have been validated and proven effective in detecting specific conditions. The Morisky scale, for instance, is a medication adherence questionnaire that has been validated in hypertension and is useful in assessing adherence. The Montreal Cognitive Assessment (MOCA) is a cognitive screening test that helps detect mild cognitive impairment and Alzheimer’s disease. The Patient Health Questionnaire (PHQ-9) is a depression screening tool, while the CAGE questionnaire is used to detect alcohol dependence. The Wells score, on the other hand, is a tool that risk-stratifies patients for deep vein thrombosis (DVT). It incorporates clinical gestalt and alternative diagnosis to determine the likelihood of DVT. These assessment tools are essential in providing accurate diagnoses and effective treatment plans for patients.

    • This question is part of the following fields:

      • Pharmacology
      9.1
      Seconds
  • Question 9 - A 40-year-old female visits her doctor with a complaint of oral ulcers that...

    Incorrect

    • A 40-year-old female visits her doctor with a complaint of oral ulcers that have been persistent for a month. She also mentions that her hands have become swollen and painful over the past two weeks. During the examination, the doctor observes a rash on her face that crosses the nasal bridge but spares the nasolabial folds. To identify the underlying condition, the doctor orders some blood tests. What is the most specific antibody test for the underlying condition?

      Your Answer: Anti-CCP

      Correct Answer: Anti-dsDNA

      Explanation:

      The presence of ANA is commonly seen in SLE patients, but it is not a specific indicator for the disease. Therefore, ANA positivity alone cannot confirm a diagnosis of SLE. Similarly, anti-CCP antibody is specific to rheumatoid arthritis and not SLE. While anti-Ro antibodies may be present in some SLE patients, it is not a reliable indicator as it is only found in 20-30% of cases.

      Systemic lupus erythematosus (SLE) can be investigated through various tests, including antibody tests. ANA testing is highly sensitive, making it useful for ruling out SLE, but it has low specificity. About 99% of SLE patients are ANA positive. Rheumatoid factor testing is positive in 20% of SLE patients. Anti-dsDNA testing is highly specific (>99%), but less sensitive (70%). Anti-Smith testing is also highly specific (>99%), but only 30% of SLE patients test positive. Other antibody tests include anti-U1 RNP, SS-A (anti-Ro), and SS-B (anti-La).

      Monitoring of SLE can be done through various markers, including inflammatory markers such as ESR. During active disease, CRP levels may be normal, but a raised CRP may indicate an underlying infection. Complement levels (C3, C4) are low during active disease due to the formation of complexes that lead to the consumption of complement. Anti-dsDNA titres can also be used for disease monitoring, but it is important to note that they are not present in all SLE patients. Proper monitoring of SLE is crucial for effective management of the disease.

    • This question is part of the following fields:

      • Musculoskeletal
      12.6
      Seconds
  • Question 10 - A 6-month-old infant is scheduled for routine immunisations. All recommended immunisations have been...

    Incorrect

    • A 6-month-old infant is scheduled for routine immunisations. All recommended immunisations have been administered so far. What vaccinations should be given at this point?

      Your Answer: Hib/Men C

      Correct Answer: Hib/Men C + MMR + PCV + Men B

      Explanation:

      The UK immunisation schedule recommends certain vaccines at different ages. At birth, the BCG vaccine is given if the baby is at risk of tuberculosis. At 2, 3, and 4 months, the ‘6-1 vaccine’ (diphtheria, tetanus, whooping cough, polio, Hib and hepatitis B) and oral rotavirus vaccine are given, along with Men B and PCV at certain intervals. At 12-13 months, the Hib/Men C, MMR, and PCV vaccines are given, along with Men B. At 3-4 years, the ‘4-in-1 preschool booster’ (diphtheria, tetanus, whooping cough and polio) and MMR vaccines are given. At 12-13 years, the HPV vaccination is given, and at 13-18 years, the ‘3-in-1 teenage booster’ (tetanus, diphtheria and polio) and Men ACWY vaccines are given. Additionally, the flu vaccine is recommended annually for children aged 2-8 years.

      It is important to note that the meningitis ACWY vaccine has replaced meningitis C for 13-18 year-olds due to an increased incidence of meningitis W disease in recent years. The ACWY vaccine will also be offered to new students (up to the age of 25 years) at university. GP practices will automatically send letters inviting 17-and 18-year-olds in school year 13 to have the Men ACWY vaccine. Students going to university or college for the first time as freshers, including overseas and mature students up to the age of 25, should contact their GP to have the Men ACWY vaccine, ideally before the start of the academic year.

      It is worth noting that the Men C vaccine used to be given at 3 months but has now been discontinued. This is because the success of the Men C vaccination programme means there are almost no cases of Men C disease in babies or young children in the UK any longer. All children will continue to be offered the Hib/Men C vaccine at one year of age, and the Men ACWY vaccine at 14 years of age to provide protection across all age groups.

    • This question is part of the following fields:

      • Paediatrics
      76.1
      Seconds
  • Question 11 - A 65-year-old female visits her doctor complaining of annular papulosquamous lesions on sun-exposed...

    Incorrect

    • A 65-year-old female visits her doctor complaining of annular papulosquamous lesions on sun-exposed areas that appeared two weeks ago. She was diagnosed with primary tuberculosis four months ago and is currently undergoing treatment with rifampicin and isoniazid. What antibodies are expected to be present in this patient?

      Your Answer: Anti-centromere antibodies

      Correct Answer: Anti-histone antibodies

      Explanation:

      The presence of anti-histone antibodies is associated with drug-induced lupus, which is the most likely cause of the symmetrical annular papulosquamous lesions on sun-exposed areas in this patient who is currently taking isoniazid. Anti-Ro antibodies are not relevant as they are commonly associated with Sjogren’s syndrome, while anti-centromere antibodies are associated with limited systemic sclerosis. Anti-double stranded DNA antibodies are associated with systemic lupus erythematosus, which is less likely in this patient given her age and clinical presentation.

      Understanding Drug-Induced Lupus

      Drug-induced lupus is a condition that shares some similarities with systemic lupus erythematosus, but not all of its typical features are present. Unlike SLE, renal and nervous system involvement is rare in drug-induced lupus. The good news is that this condition usually resolves once the drug causing it is discontinued.

      The most common symptoms of drug-induced lupus include joint pain, muscle pain, skin rashes (such as the malar rash), and pulmonary issues like pleurisy. In terms of laboratory findings, patients with drug-induced lupus typically test positive for ANA (antinuclear antibodies) but negative for dsDNA (double-stranded DNA) antibodies. Anti-histone antibodies are found in 80-90% of cases, while anti-Ro and anti-Smith antibodies are only present in around 5% of cases.

      The most common drugs that can cause drug-induced lupus are procainamide and hydralazine. Other less common culprits include isoniazid, minocycline, and phenytoin.

    • This question is part of the following fields:

      • Musculoskeletal
      28.2
      Seconds
  • Question 12 - A 32-year-old professional footballer comes to the Dermatology Clinic with a lesion on...

    Correct

    • A 32-year-old professional footballer comes to the Dermatology Clinic with a lesion on his leg. The lesion started as a small cut he got during a match, but it has progressed over the past few weeks, becoming a large, painful ulcer.
      During the examination, the doctor finds that the lesion is 50 mm × 75 mm and ulcerated with a necrotic centre. The patient has no medical history, but his general practitioner (GP) recently investigated him for a change in bowel habit, including bloody stools, and fatigue.
      The patient's anti-neutrophil cytoplasmic antibody test comes back positive, and no organisms grow from the wound swab. The doctor prescribes systemic steroids, and the patient experiences rapid improvement.
      What is the most likely diagnosis?

      Your Answer: Pyoderma gangrenosum

      Explanation:

      Differential Diagnosis for a Painful Cutaneous Ulcer in a Patient with IBD Symptoms

      When presented with a painful cutaneous ulcer, it is important to consider the underlying cause in order to provide appropriate treatment. In this case, the patient is experiencing fatigue and change in bowel habit, which could be indicative of underlying inflammatory bowel disease (IBD). One possible diagnosis is pyoderma gangrenosum, which is commonly associated with IBD, rheumatoid arthritis, or hepatitis. This condition presents with a rapidly progressing, painful, necrolytic cutaneous ulcer that responds well to systemic steroids. Livedo reticularis, erythema nodosum, and lupus pernio are other possible diagnoses, but they do not typically present with ulceration in this pattern or are not associated with IBD. While squamous cell carcinoma should be considered, it is unlikely in this case due to the patient’s young age and the rapid deterioration of the ulcer. Overall, a thorough differential diagnosis is necessary to accurately diagnose and treat the underlying condition causing the cutaneous ulcer.

    • This question is part of the following fields:

      • Dermatology
      55.7
      Seconds
  • Question 13 - After fertilisation, which part of the spermatozoon remains in the cytoplasm of the...

    Incorrect

    • After fertilisation, which part of the spermatozoon remains in the cytoplasm of the oocyte?

      Your Answer: Acrosome

      Correct Answer: Nucleus

      Explanation:

      During fertilization, the nucleus of the sperm carries the genetic material needed to create the paternal pronucleus and subsequently the zygote. The acrosome discharges its hydrolytic enzymes to help the sperm penetrate through the corona radiata and the zona pellucida. The sperm nucleus enters the cytoplasm of the egg, along with the midpiece, mitochondria, centrosome, and kinocilium of the sperm. Fertilization triggers changes in the chemistry of the zona pellucida and the discharge of cortical granules in the egg cytoplasm, which prevent additional sperm from fertilizing the egg. The sperm nucleus decondenses to form the haploid male pronucleus, which fuses with the haploid female pronucleus to form a diploid zygote nucleus. The midpiece and kinocilium of the sperm are destroyed, while the plasma membrane covering the tail remains attached to the egg plasma membrane. Mitochondrial diseases are inherited exclusively along the maternal line because the male mitochondria are destroyed soon after fertilization.

    • This question is part of the following fields:

      • Sexual Health
      48.6
      Seconds
  • Question 14 - A 35-year-old man comes to you seeking advice. He had a splenectomy ten...

    Incorrect

    • A 35-year-old man comes to you seeking advice. He had a splenectomy ten years ago after a cycling accident and has been in good health since. However, a friend recently told him that he should be receiving treatment for his splenectomy. He is currently not taking any medication.

      What would you recommend to him?

      Your Answer: Immunoglobulins

      Correct Answer: Pneumococcal vaccination

      Explanation:

      Asplenic Patients and the Importance of Vaccination

      Asplenic patients are individuals who have had their spleen removed, leaving them at risk of overwhelming bacterial infections, particularly from pneumococcus and meningococcus. To prevent such infections, it is recommended that these patients receive the Pneumovax vaccine two weeks before surgery or immediately after emergency surgery. This vaccine should be repeated every five years. Additionally, influenzae vaccination is also recommended to prevent super added bacterial infections.

      While oral penicillin is recommended for children, its long-term use in adults is a topic of debate. However, current guidance suggests that splenectomized patients should receive both antibiotic prophylaxis and appropriate immunization. It is crucial to take these preventative measures to protect asplenic patients from potentially life-threatening infections.

    • This question is part of the following fields:

      • Haematology
      39.4
      Seconds
  • Question 15 - Mrs Johnson is a 79-year-old lady who has been admitted with a urinary...

    Incorrect

    • Mrs Johnson is a 79-year-old lady who has been admitted with a urinary tract infection. She has a past medical history of chronic obstructive pulmonary disease (COPD), for which she takes inhalers. Her abbreviated mental test score (AMTS) was 8/10 on admission. A midstream urine sample was sent for microbiology and the report indicates a pure growth of Escherichia coli sensitive to trimethoprim and co-amoxiclav. After receiving 48 hours of intravenous co-amoxiclav, she is now on appropriate oral antibiotic therapy.
      You are called to the ward at 0100 h as Mrs Johnson is increasingly agitated and confused. She now has an AMTS of 2/10 and is refusing to stay in bed. Her vital signs are normal, and respiratory, cardiovascular, abdominal and neurological examinations reveal some fine crepitations at both lung bases, but no other abnormality. Her Glasgow Coma Score (GCS) is 14.
      What is the most appropriate next management option?

      Your Answer: Arrange a full septic screen, including chest X-ray, repeat urinalysis, inflammatory markers and blood cultures

      Correct Answer: Advise nursing in a well-lit environment with frequent reassurance and reorientation

      Explanation:

      Managing Acute Delirium in Mrs Smith: Nursing in a Well-Lit Environment with Frequent Reassurance and Reorientation

      Acute delirium is a common condition that can be caused by various factors, including sepsis, metabolic problems, hypoxia, intracranial vascular insults, and toxins. When assessing a patient with acute delirium, it is crucial to exclude life-threatening or reversible causes through a thorough history, clinical examination, and appropriate investigations.

      In the case of Mrs Smith, who has new confusion with preserved consciousness, there is no evidence of acute clinical illness, and she is receiving appropriate treatment for a urinary tract infection. Therefore, the most appropriate management is to nurse her in a well-lit environment with frequent reassurance and reorientation. Sedating medication, such as lorazepam or haloperidol, should only be considered as a last resort if the patient is at risk of harm due to delirium.

      It is not necessary to arrange an urgent CT head or a full septic screen unless there are specific indications. Instead, optimizing the patient’s environment can help resolve delirium and improve outcomes. By following these guidelines, healthcare professionals can effectively manage acute delirium in patients like Mrs Smith.

    • This question is part of the following fields:

      • Acute Medicine And Intensive Care
      14.2
      Seconds
  • Question 16 - A 67-year-old woman with a history of rheumatoid arthritis complains of pain in...

    Correct

    • A 67-year-old woman with a history of rheumatoid arthritis complains of pain in her left middle finger when she tries to bend it. She also experienced it getting 'stuck' once. During examination, a palpable nodule is found at the base of the finger. What is the probable diagnosis?

      Your Answer: Trigger finger

      Explanation:

      Understanding Trigger Finger

      Trigger finger is a condition that affects the flexion of the digits, and is believed to be caused by a discrepancy in size between the tendon and pulleys through which they pass. This results in the tendon becoming stuck and unable to move smoothly through the pulley. While the majority of cases are idiopathic, trigger finger is more common in women than men and is associated with conditions such as rheumatoid arthritis and diabetes mellitus.

      The condition typically affects the thumb, middle, or ring finger, and is characterized by stiffness and snapping when extending a flexed digit. A nodule may also be felt at the base of the affected finger. Management of trigger finger often involves steroid injections, which are successful in the majority of patients. A finger splint may be applied afterwards. Surgery is typically reserved for patients who have not responded to steroid injections. While there is some suggestion of a link between trigger finger and repetitive use, evidence to support this is limited.

    • This question is part of the following fields:

      • Musculoskeletal
      48.7
      Seconds
  • Question 17 - A 68-year-old man visits his general practitioner complaining of sudden vision loss in...

    Incorrect

    • A 68-year-old man visits his general practitioner complaining of sudden vision loss in his right eye for the past two days. He has no significant medical history except for taking co-codamol for occasional headaches. Upon examination, his vital signs are normal. However, his right eye's visual acuity is 6/30, while his left eye is 6/6. A fundoscopic examination reveals a pale and swollen optic disc with blurred margins. What is the probable diagnosis?

      Your Answer: Retinal vein occlusion

      Correct Answer: Anterior ischaemic optic neuropathy

      Explanation:

      The correct diagnosis for this patient is anterior ischemic optic neuropathy, which is often associated with GCA or temporal arthritis. The fundoscopic examination typically reveals a pale and swollen optic disc with blurred margins. Age-related macular degeneration is an unlikely differential diagnosis as it presents with drusen on the retina. Amaurosis fugax, which is characterized by sudden and transient visual loss, is also an unlikely diagnosis as it does not fit with the patient’s prolonged visual impairment. Diabetic retinopathy, which is characterized by cotton wool spots and neovascularization, is also an unlikely diagnosis in this case.

      Temporal arthritis, also known as giant cell arthritis, is a condition that affects medium and large-sized arteries and is of unknown cause. It typically occurs in individuals over the age of 50, with the highest incidence in those in their 70s. Early recognition and treatment are crucial to minimize the risk of complications, such as permanent loss of vision. Therefore, when temporal arthritis is suspected, urgent referral for assessment by a specialist and prompt treatment with high-dose prednisolone is necessary.

      Temporal arthritis often overlaps with polymyalgia rheumatica, with around 50% of patients exhibiting features of both conditions. Symptoms of temporal arthritis include headache, jaw claudication, and tender, palpable temporal artery. Vision testing is a key investigation in all patients, as anterior ischemic optic neuropathy is the most common ocular complication. This results from occlusion of the posterior ciliary artery, leading to ischemia of the optic nerve head. Fundoscopy typically shows a swollen pale disc and blurred margins. Other symptoms may include aching, morning stiffness in proximal limb muscles, lethargy, depression, low-grade fever, anorexia, and night sweats.

      Investigations for temporal arthritis include raised inflammatory markers, such as an ESR greater than 50 mm/hr and elevated CRP. A temporal artery biopsy may also be performed, and skip lesions may be present. Treatment for temporal arthritis involves urgent high-dose glucocorticoids, which should be given as soon as the diagnosis is suspected and before the temporal artery biopsy. If there is no visual loss, high-dose prednisolone is used. If there is evolving visual loss, IV methylprednisolone is usually given prior to starting high-dose prednisolone. Urgent ophthalmology review is necessary, as visual damage is often irreversible. Other treatments may include bone protection with bisphosphonates and low-dose aspirin.

    • This question is part of the following fields:

      • Musculoskeletal
      1196.8
      Seconds
  • Question 18 - A 12-year-old girl comes to the paediatric outpatient departments with a height of...

    Correct

    • A 12-year-old girl comes to the paediatric outpatient departments with a height of 142 cm, which is below the 0.4th centile. Upon examination, she has an immature-appearing face and a significantly delayed bone age on wrist x-ray. Her TSH levels are normal, and she is at an appropriate Tanner stage. It is noted that her mother had her menarche at the age of 11 years. What is the probable diagnosis for this patient?

      Your Answer: Growth hormone deficiency

      Explanation:

      Growth Hormone Deficiency as a Cause of Short Stature in Pubescent Girls

      A girl who has gone through puberty but has not gained height may have growth hormone deficiency. This condition is characterized by a discrepancy between the girl’s bone age and chronological age, as well as a doll-like face that gives her an immature appearance. Growth hormone deficiency is a rare but significant cause of short stature, as it can be a symptom of an underlying disease and can be treated with replacement injections.

      In some cases, GH deficiency may be caused by intracerebral masses, particularly craniopharyngiomas in 7- to 10-year-olds. However, if a chronic illness were the cause, such as coeliac disease or Cushing syndrome, it would likely delay puberty and result in an inappropriately young Tanner stage. The girl would also be expected to exhibit features of the chronic condition.

      It is important to note that this girl is not suffering from constitutional delay, as she has already entered puberty and has appropriate Tanner staging. Constitutional delay is typically characterized by a family history and delayed menarche in the affected individual. Therefore, growth hormone deficiency should be considered as a potential cause of short stature in pubescent girls who have not gained height despite going through puberty.

    • This question is part of the following fields:

      • Paediatrics
      29.6
      Seconds
  • Question 19 - A 4-year-old girl is brought to the general practitioner (GP) by her parents....

    Incorrect

    • A 4-year-old girl is brought to the general practitioner (GP) by her parents. She has been experiencing a dry cough with coryzal symptoms. On examination, there is evidence of conjunctivitis and an erythematosus rash on her forehead and neck which is confluent. Oral examination reveals red spots with a white centre on the buccal mucosa, adjacent to the lower second molar tooth. She is currently apyrexial, though her parents state she has been feverish over the past two days. Her heart rate is 80 bpm. No one else in her family is unwell, though her sister did have chickenpox earlier in the month.
      What is the most likely cause for this presentation?

      Your Answer: Parvovirus B19

      Correct Answer: Measles

      Explanation:

      Distinguishing Between Measles and Other Viral Infections

      Measles, a highly contagious viral infection, is often mistaken for other viral illnesses such as rubella, Kawasaki disease, mumps, and parvovirus B19. However, there are distinct differences in their clinical presentations. Measles is characterized by cough, coryza, and conjunctivitis, along with the presence of Koplik spots on the buccal mucosa. Rubella, on the other hand, presents with low-grade fever, conjunctivitis, and an erythematosus rash, but without Koplik spots. Kawasaki disease is an idiopathic vasculitis that affects young children and is associated with fever, inflammation of the mouth and lips, and cervical lymphadenopathy. Mumps, caused by a paramyxovirus, typically affects the salivary glands and is not associated with a rash. Parvovirus B19, also known as fifth disease, causes an erythematosus rash on the cheeks and can also cause a morbilliform rash, but without Koplik spots. Therefore, recognizing the presence of Koplik spots is crucial in distinguishing measles from other viral infections.

    • This question is part of the following fields:

      • Infectious Diseases
      7.4
      Seconds
  • Question 20 - Which diagnostic test is most effective in identifying the initial stages of Perthes'...

    Incorrect

    • Which diagnostic test is most effective in identifying the initial stages of Perthes' disease?

      Your Answer: Nuclear medicine scan

      Correct Answer: MRI

      Explanation:

      Legg-Calvé-Perthes’ Disease: Diagnosis and Imaging

      Legg-Calvé-Perthes’ disease is a condition where the femoral head undergoes osteonecrosis, or bone death, without any known cause. The diagnosis of this disease can be established through plain x-rays of the hip, which are highly useful. However, in the early stages, MRI and contrast MRI can provide more detailed information about the extent of necrosis, revascularization, and healing. On the other hand, a nuclear scan can provide less detail and expose the child to radiation. Nevertheless, a technetium 99 bone scan can be helpful in identifying the extent of avascular changes before they become evident on plain radiographs.

      In summary, Legg-Calvé-Perthes’ disease is a condition that can be diagnosed through plain x-rays of the hip. However, MRI and contrast MRI can provide more detailed information in the early stages, while a technetium 99 bone scan can help identify the extent of avascular changes before they become evident on plain radiographs. It is important to consider the risks and benefits of each imaging modality when diagnosing and monitoring this disease.

    • This question is part of the following fields:

      • Paediatrics
      26.4
      Seconds
  • Question 21 - Which statement accurately describes acute compartment syndrome? ...

    Incorrect

    • Which statement accurately describes acute compartment syndrome?

      Your Answer: Only occurs following fractures

      Correct Answer: Passive stretch of affected muscles exacerbates pain

      Explanation:

      Compartment Syndrome

      Compartment syndrome is a condition that occurs when the pressure within a muscle compartment increases to a level that exceeds arterial blood pressure. This can happen even without a fracture, such as in cases of crush injuries. The earliest and most reliable symptom of compartment syndrome is pain, which can be exacerbated by passive stretching of the muscles in the affected area. As the condition progresses, loss of peripheral pulses may occur, indicating that the pressure has reached a critical level.

      Treatment for compartment syndrome involves decompression of the affected compartment(s), including the skin. It is important to recognize the symptoms of compartment syndrome early on in order to prevent further damage and potential loss of function. By the signs and symptoms of this condition, individuals can seek prompt medical attention and receive the appropriate treatment to alleviate the pressure and prevent complications.

    • This question is part of the following fields:

      • Neurology
      22.2
      Seconds
  • Question 22 - A 35-year-old man visits his General Practitioner complaining of painless rectal bleeding that...

    Incorrect

    • A 35-year-old man visits his General Practitioner complaining of painless rectal bleeding that has been occurring for the past 5 days. The patient reports experiencing bright red bleeding during bowel movements, which appears as streaks on the toilet paper and in the toilet bowl. The blood is not mixed in with the stool. This has been happening every time he has a bowel movement since the symptoms began. He does not feel any pain during these episodes, but he does experience some itching and irritation around the anal area afterwards. He is otherwise healthy, without changes in bowel habits or weight loss.
      During a rectal examination, the doctor observes a fleshy protrusion at the 7 o'clock position that appears when the patient strains but recedes into the anus when he stops straining.
      Which of the following management options would be appropriate in this case?

      Your Answer: Incision and drainage

      Correct Answer: Injection sclerotherapy

      Explanation:

      Understanding Haemorrhoids and Treatment Options

      Haemorrhoids, also known as piles, are swollen vascular mucosal cushions within the anal canal that can cause discomfort and pain. They are more common with advancing age and can be associated with pregnancy, constipation, increased intra-abdominal pressure, low-fibre diet, and obesity. Haemorrhoids can be classified by the degree of prolapse through the anus, with grade 1 being the mildest and grade 4 being the most severe.

      Patients with haemorrhoids may present with painless rectal bleeding, anal itching and irritation, rectal fullness or discomfort, and soiling. Pain is not a significant feature unless the haemorrhoid becomes strangulated or thrombosed. It is important to exclude ‘red flag’ symptoms such as change in bowel habit, weight loss, iron deficiency anaemia, or unexplained abdominal pain, especially in patients over 40.

      Conservative treatment options for haemorrhoids include lifestyle changes such as increasing fluid and fibre intake, managing constipation, anal hygiene advice, and simple analgesia. If conservative treatment fails, secondary care treatment options include rubber band ligation, injection sclerotherapy, photocoagulation, diathermy, haemorrhoidectomy, and haemorrhoid artery ligation. Referral to specialists or admission may be necessary for acutely thrombosed haemorrhoids or perianal haematoma, associated perianal sepsis, large grade 3 or 4 haemorrhoids, and persistent or worsening symptoms despite conservative management.

      Other treatment options such as mebendazole, topical lidocaine ointment, incision and drainage, and sphincterotomy are not indicated for haemorrhoids. Mebendazole is used to treat threadworms, while topical lidocaine ointment is useful for anal fissures. Incision and drainage are indicated for perianal abscesses, and sphincterotomy is used to manage chronic or recurrent anal fissures.

      In conclusion, understanding the causes, symptoms, and treatment options for haemorrhoids is essential for effective management and improved quality of life for patients.

    • This question is part of the following fields:

      • Colorectal
      11.3
      Seconds
  • Question 23 - A 28-year-old female patient presents to her GP with concerns about a lump...

    Incorrect

    • A 28-year-old female patient presents to her GP with concerns about a lump in her right breast. The patient reports that she first noticed the lump about two months ago and it has remained persistent without any noticeable increase in size. Upon examination, the GP observes a smooth, mobile 2 cm lump in the Inferolateral quadrant without skin or nipple changes. The patient denies any family history of breast cancer and has no lumps in her axilla. What is the most suitable course of action for management?

      Your Answer: Urgent breast clinic referral

      Correct Answer: Routine breast clinic referral

      Explanation:

      If a woman under 30 years old presents with an unexplained breast lump with or without pain, she may not meet the 2-week-wait referral criteria but can still be referred for further evaluation. The most likely diagnosis is a fibroadenoma, which is a common benign breast lump that often occurs in younger women. These lumps are typically firm, smooth, and highly mobile. It is important to refer the patient to a breast clinic for evaluation, but routine referral is sufficient given the low likelihood of cancer. Mammograms or ultrasounds are not necessary at this stage. Reviewing the patient in one month is also unnecessary as the lump has already persisted for two months. Urgent referral is not needed due to the patient’s age and low risk of breast cancer. NICE CKS recommends a 2-week-wait referral for those over 30 years old with an unexplained breast lump, or over 50 years old with unilateral nipple changes. Referral should also be considered for those with skin changes suggestive of breast cancer or those over 30 years old with an unexplained lump in the axilla.

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

    • This question is part of the following fields:

      • Surgery
      31.1
      Seconds
  • Question 24 - A 70-year-old man, who has been a diabetic for over 20 years, visits...

    Incorrect

    • A 70-year-old man, who has been a diabetic for over 20 years, visits his GP for a routine check-up. During the appointment, he mentions to his doctor that he has been experiencing difficulty with his vision in his right eye for the past few months. He describes it as blurry vision and seeing halos around lights at night. The man has never had any vision problems before. He is currently taking medications for his high blood pressure and cholesterol levels. Other than his vision, his physical examination is unremarkable. What is the most likely diagnosis for the man's symptoms?

      Your Answer: Diabetic retinopathy

      Correct Answer: Cataract

      Explanation:

      The patient’s symptoms and medical history strongly suggest a diagnosis of cataract. Their elderly age, long-standing diabetes mellitus, and unilateral blurry vision with halos around light sources are all classic signs of cataract. There is no indication of steroid use, which can also increase the risk of cataract development.

      While primary open-angle glaucoma is a possibility, it is less likely given the patient’s symptoms. This condition typically presents with peripheral visual field loss rather than blurry vision. Acute angle-closure glaucoma is also a possibility, but it is more commonly associated with halos than primary open-angle glaucoma.

      Uveitis is unlikely given the absence of pain and redness in the eye. Additionally, it is not typically associated with diabetes. Diabetic retinopathy is another possibility in this patient, but it is often asymptomatic or presents with hemorrhage.

      Understanding Cataracts: Causes, Symptoms, and Management

      A cataract is a common eye condition that affects the lens of the eye, causing it to become cloudy and reducing the amount of light that reaches the retina. This can lead to blurred or reduced vision, making it difficult to see clearly. Cataracts are more common in women and tend to increase in incidence with age. While the normal ageing process is the most common cause, other factors such as smoking, alcohol consumption, trauma, diabetes, and long-term corticosteroid use can also contribute to the development of cataracts.

      Symptoms of cataracts include reduced vision, faded colour vision, glare, and halos around lights. A defect in the red reflex is also a sign of cataracts. Diagnosis is typically made through ophthalmoscopy and slit-lamp examination, which can reveal the presence of a visible cataract.

      In the early stages, age-related cataracts can be managed conservatively with stronger glasses or contact lenses and brighter lighting. However, surgery is the only effective treatment for cataracts and involves removing the cloudy lens and replacing it with an artificial one. Referral for surgery should be based on the presence of visual impairment, impact on quality of life, and patient choice. Complications following surgery can include posterior capsule opacification, retinal detachment, posterior capsule rupture, and endophthalmitis.

      Overall, cataracts are a common and treatable eye condition that can significantly impact a person’s vision. Understanding the causes, symptoms, and management options can help individuals make informed decisions about their eye health.

    • This question is part of the following fields:

      • Ophthalmology
      21.1
      Seconds
  • Question 25 - A 30-year-old woman is preparing for an elective laparoscopic cholecystectomy with general anesthesia...

    Incorrect

    • A 30-year-old woman is preparing for an elective laparoscopic cholecystectomy with general anesthesia and inquires about when she should discontinue her combined oral contraceptive pill. What is the best recommendation?

      Your Answer:

      Correct Answer: 4 weeks prior

      Explanation:

      Stopping the combined oral contraceptive pill four weeks before the operation is recommended due to a higher likelihood of venous thromboembolism.

      Preparation for surgery varies depending on whether the patient is undergoing an elective or emergency procedure. For elective cases, it is important to address any medical issues beforehand through a pre-admission clinic. Blood tests, urine analysis, and other diagnostic tests may be necessary depending on the proposed procedure and patient fitness. Risk factors for deep vein thrombosis should also be assessed, and a plan for thromboprophylaxis formulated. Patients are advised to fast from non-clear liquids and food for at least 6 hours before surgery, and those with diabetes require special management to avoid potential complications. Emergency cases require stabilization and resuscitation as needed, and antibiotics may be necessary. Special preparation may also be required for certain procedures, such as vocal cord checks for thyroid surgery or bowel preparation for colorectal cases.

    • This question is part of the following fields:

      • Surgery
      0
      Seconds
  • Question 26 - A 30-year-old previously healthy man is involved in an accident at home. He...

    Incorrect

    • A 30-year-old previously healthy man is involved in an accident at home. He is brought to Accident and Emergency where he is found to have superficial abrasions to the right side of his chest and upper abdomen, together with an obvious deformity of the right humerus. Radiograph of the right arm shows a displaced midshaft humerus fracture. Neurovascular examination reveals radial nerve palsy, together with absent peripheral pulses and a cool, clammy distal arm. He was given oral paracetamol at home, while waiting for the ambulance to arrive. Pain score remains 9/10. Parameters are as follows:
      Investigation Result Normal value
      Temperature 36.9 °C 36.1–37.2 °C
      Pulse 110 bpm 60–100 bpm
      Blood pressure 140/90 mmHg < 120/80 mmHg
      Oxygen saturations 98% on room air 94–98%
      Respiratory rate 22 breaths/min 12–18 breaths/min
      Which of the following is the most appropriate form of pain relief?

      Your Answer:

      Correct Answer: IV morphine

      Explanation:

      Choosing the Right Analgesic for Acute Pain: A Case-by-Case Basis

      Analgesia is typically administered in a stepwise manner, but emergency medicine requires a more individualized approach. In cases of acute pain from long bone fractures, non-opioid analgesia may not be sufficient. The two most viable options are oral and IV morphine, with IV morphine being preferred due to its rapid onset and safe side-effect profile. However, caution must be exercised due to the risk of respiratory depression and dependency. Oral NSAIDs and morphine are contraindicated as the patient must be kept nil by mouth before urgent surgical intervention. Oxycodone prolonged release is too weak for severe pain. Choosing the right analgesic for acute pain requires careful consideration of the patient’s individual needs.

    • This question is part of the following fields:

      • Acute Medicine And Intensive Care
      0
      Seconds
  • Question 27 - A 26-year-old man has been hit on the side of his head with...

    Incorrect

    • A 26-year-old man has been hit on the side of his head with a cricket bat. Upon initial examination, he has a Glasgow Coma Score (GCS) of 12 and shows some bruising at the point of impact. There are no indications of a basal skull fracture or any neurological impairments. He has not experienced vomiting or seizures. What would be the most suitable course of action?

      Your Answer:

      Correct Answer: Perform a CT head scan within 1 hour

      Explanation:

      When it comes to detecting significant brain injuries in emergency situations, CT scans of the head are currently the preferred method of investigation. MRI scans are not typically used due to safety concerns, logistical challenges, and resource limitations. If a patient’s initial assessment in the emergency department reveals a Glasgow Coma Scale (GCS) score of less than 13, a CT head scan should be performed within one hour. The specific indications for an immediate CT head scan in this scenario can be found in the guidelines provided by NICE (2014) for the assessment and early management of head injuries.

      NICE Guidelines for Investigating Head Injuries in Adults

      Head injuries can be serious and require prompt medical attention. The National Institute for Health and Care Excellence (NICE) has provided clear guidelines for healthcare professionals to determine which adult patients need further investigation with a CT head scan. Patients who require immediate CT head scans include those with a Glasgow Coma Scale (GCS) score of less than 13 on initial assessment, suspected open or depressed skull fractures, signs of basal skull fractures, post-traumatic seizures, focal neurological deficits, and more than one episode of vomiting.

      For patients with any loss of consciousness or amnesia since the injury, a CT head scan within 8 hours is recommended for those who are 65 years or older, have a history of bleeding or clotting disorders, experienced a dangerous mechanism of injury, or have more than 30 minutes of retrograde amnesia of events immediately before the head injury. Additionally, patients on warfarin who have sustained a head injury without other indications for a CT head scan should also receive a scan within 8 hours of the injury.

      It is important for healthcare professionals to follow these guidelines to ensure that patients receive appropriate and timely care for their head injuries. By identifying those who require further investigation, healthcare professionals can provide the necessary treatment and support to prevent further complications and improve patient outcomes.

    • This question is part of the following fields:

      • Surgery
      0
      Seconds
  • Question 28 - Which condition is most likely to result in a pleural effusion that is...

    Incorrect

    • Which condition is most likely to result in a pleural effusion that is classified as a transudate with protein levels below 30 mg/L?

      Your Answer:

      Correct Answer: Nephrotic syndrome

      Explanation:

      The Glasgow coma scale (GCS) is a widely used tool for assessing critically ill patients. It helps determine the severity of a patient’s condition and has prognostic implications. The GCS score is calculated based on the patient’s eye opening, verbal response, and motor response. The score ranges from 3 to 15, with a lower score indicating a worse prognosis.

      The GCS score is determined by assigning points for each of the three categories. The highest score for eye opening is 4, for verbal response is 5, and for motor response is 6. A patient who is dead would still have a GCS score of 3. The lowest possible score is 3, which indicates no response in any of the categories.

      The GCS score is important for healthcare professionals as it helps them determine the level of care a patient needs. A lower score indicates a more severe injury or illness and may require more intensive treatment. The GCS score is also used to monitor a patient’s progress over time and to assess the effectiveness of treatment.

    • This question is part of the following fields:

      • Clinical Sciences
      0
      Seconds
  • Question 29 - You are requested to assess a 25-year-old man who has been urgently referred...

    Incorrect

    • You are requested to assess a 25-year-old man who has been urgently referred to the Community Mental Health Team. He has recently left his job to work on 'a groundbreaking project' which he believes will eradicate world poverty. He has also been neglecting his basic needs such as eating and sleeping as he 'cannot afford to waste time on such trivialities'. Upon examination, the patient appears restless and lacks awareness of their condition. The patient has a history of depression and is currently on an antidepressant medication.

      What would be the most suitable course of action in managing this patient?

      Your Answer:

      Correct Answer: Start antipsychotic and stop antidepressant

      Explanation:

      The appropriate management for a patient experiencing mania/hypomania while taking antidepressants is to discontinue the antidepressant and initiate antipsychotic therapy. This is because the patient’s symptoms, such as delusions of grandeur and hyperactivity, suggest an episode of mania, which requires the use of a rapidly acting antipsychotic or benzodiazepine. Electroconvulsive therapy (ECT) is not typically used for the treatment of mania, and lithium is not the first-line treatment for acute episodes of mania. Therefore, starting antipsychotic therapy and discontinuing antidepressants is the most appropriate course of action.

      Understanding Bipolar Disorder

      Bipolar disorder is a mental health condition that is characterized by alternating periods of mania/hypomania and depression. It typically develops in the late teen years and has a lifetime prevalence of 2%. There are two recognized types of bipolar disorder: type I, which involves mania and depression, and type II, which involves hypomania and depression.

      Mania and hypomania both refer to abnormally elevated mood or irritability, but mania is more severe and can include psychotic symptoms for 7 days or more. Hypomania, on the other hand, involves decreased or increased function for 4 days or more. The presence of psychotic symptoms suggests mania.

      Management of bipolar disorder may involve psychological interventions specifically designed for the condition, as well as medication. Lithium is the mood stabilizer of choice, but valproate can also be used. Antipsychotic therapy, such as olanzapine or haloperidol, may be used to manage mania/hypomania, while fluoxetine is the antidepressant of choice for depression. It is important to address any co-morbidities, as there is an increased risk of diabetes, cardiovascular disease, and COPD in individuals with bipolar disorder.

      If symptoms suggest hypomania, routine referral to the community mental health team (CMHT) is recommended. However, if there are features of mania or severe depression, an urgent referral to the CMHT should be made. Understanding bipolar disorder and its management is crucial for healthcare professionals to provide appropriate care and support for individuals with this condition.

    • This question is part of the following fields:

      • Psychiatry
      0
      Seconds
  • Question 30 - A 26-year-old female trainee solicitor has been experiencing difficulty concentrating on her work...

    Incorrect

    • A 26-year-old female trainee solicitor has been experiencing difficulty concentrating on her work for the past 2 months. She has been complaining that the work area is too hot. She appears nervous and has a fine tremor. Despite eating more, she has lost 4 kg in the last month. During a physical examination, her temperature is 37.8 °C, pulse is 110 bpm, respiratory rate is 18 per minute, and blood pressure is 145/85 mmHg. She has a wide, staring gaze and lid lag. What is the most likely laboratory finding in this woman?

      Your Answer:

      Correct Answer: Decreased thyroid stimulating hormone (TSH)

      Explanation:

      Understanding Thyroid Axis: Interpretation of Hormone Levels in Hyperthyroidism

      Hyperthyroidism is a condition characterized by increased production of free thyroxine (T4 and T3) leading to a decrease in thyroid stimulating hormone (TSH) production at the pituitary gland. This results in a hypermetabolic state induced by excess thyroid hormone and overactivity of the sympathetic nervous system. Ocular changes such as a wide, staring gaze and lid lag are common. However, true thyroid ophthalmopathy associated with proptosis is seen only in Graves’ disease.

      Decreased plasma insulin indicates diabetes mellitus, while increased TSH in this setting indicates secondary hyperthyroidism, a rare condition caused by pathology at the level of the pituitary. Increased adrenocorticotropic hormone (ACTH) is not related to the patient’s symptoms, and increased calcitonin is not a feature of hyperthyroidism but may indicate medullary thyroid cancers. Understanding the interpretation of hormone levels in hyperthyroidism is crucial for accurate diagnosis and management.

    • This question is part of the following fields:

      • Endocrinology
      0
      Seconds

SESSION STATS - PERFORMANCE PER SPECIALTY

Surgery (3/4) 75%
Endocrinology (2/2) 100%
Gynaecology (1/1) 100%
Pharmacology (1/1) 100%
Paediatrics (1/2) 50%
Musculoskeletal (3/3) 100%
Dermatology (0/1) 0%
Sexual Health (1/1) 100%
Haematology (1/1) 100%
Acute Medicine And Intensive Care (2/2) 100%
Infectious Diseases (1/1) 100%
Neurology (1/1) 100%
Colorectal (1/1) 100%
Ophthalmology (0/1) 0%
Clinical Sciences (1/1) 100%
Psychiatry (0/1) 0%
Passmed