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Question 1
Correct
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A 12-year-old boy is admitted to the paediatric ward due to recurrent episodes of arthralgia affecting multiple sites. During physical examination, swelling and tenderness are observed in the right ankle joint, while tenderness on motion and pain are present over the bilateral wrist and left sacroiliac joints. The patient had visited his GP two months ago with symptoms of vomiting, diarrhoea, and fever, for which he received supportive treatment. Synovial fluid analysis from the aspirated ankle joint reveals a high white cell count and no organisms present in the culture. What is the most likely diagnosis?
Your Answer: Reactive arthritis
Explanation:The most likely diagnosis for this case is reactive arthritis, which is a type of arthritis that occurs after a distant infection in the gastrointestinal or urogenital area. It is characterized by joint pain, urethritis, and uveitis, and is more common in individuals who have the HLA-B27 gene. The infections that commonly trigger reactive arthritis are caused by Salmonella, Shigella, Yersinia, and Campylobacter organisms.
Other possible diagnoses were ruled out based on the absence of certain symptoms. Behcet’s disease, which presents with oral and genital ulcers and uveitis, was unlikely due to the lack of ulcers or visual symptoms. Septic arthritis, which causes joint swelling and pain, was also considered but was less likely because it typically affects only one joint and is accompanied by fever and other signs. Systemic juvenile idiopathic arthritis and systemic lupus erythematosus were also considered but were ruled out due to the absence of their characteristic symptoms.
Reactive arthritis is a type of seronegative spondyloarthropathy that is associated with HLA-B27. It was previously known as Reiter’s syndrome, which was characterized by a triad of urethritis, conjunctivitis, and arthritis following a dysenteric illness during World War II. However, further studies revealed that patients could also develop symptoms after a sexually transmitted infection, now referred to as sexually acquired reactive arthritis (SARA). Reactive arthritis is defined as arthritis that occurs after an infection where the organism cannot be found in the joint. The post-STI form is more common in men, while the post-dysenteric form has an equal incidence in both sexes. The most common organisms associated with reactive arthritis are listed in the table below.
Management of reactive arthritis is mainly symptomatic, with analgesia, NSAIDs, and intra-articular steroids being used. Sulfasalazine and methotrexate may be used for persistent disease. Symptoms usually last for less than 12 months. It is worth noting that the term Reiter’s syndrome is no longer used due to the fact that Reiter was a member of the Nazi party.
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This question is part of the following fields:
- Musculoskeletal
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Question 2
Incorrect
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A 32-year-old woman presents to rheumatology with a 3 week history of joint pain, a pink, bumpy rash on her arms, legs, and trunk, and fevers that spike in the evenings. She has bilateral cervical lymphadenopathy and a palpable spleen on examination. Blood tests reveal a significant leucocytosis (≥ 10,000/µL) and elevated serum ferritin (350 ng/mL) levels, but negative antinuclear antibody and rheumatoid factor tests. What is the most probable cause of this patient's symptoms?
Your Answer: Haemochromatosis
Correct Answer: Adult-onset Still’s disease
Explanation:To diagnose adult-onset Still’s disease, it is necessary to exclude other conditions by ensuring that rheumatoid factor and anti-nuclear antibody tests are negative. The presence of joint pain, spiking fevers, and a pink bumpy rash is a characteristic triad of symptoms associated with this disease. High serum ferritin and leucocytosis are also commonly observed. Negative results for rheumatoid factor and anti-nuclear antibody tests help to rule out rheumatoid arthritis and systemic lupus erythematosus. Spiking fevers are not typically associated with Wilson’s disease or haemochromatosis. This information is based on the Oxford Handbook of Clinical Specialties (10th Edition), page 654.
Still’s disease in adults is a condition that has a bimodal age distribution, affecting individuals between the ages of 15-25 years and 35-46 years. The disease is characterized by symptoms such as arthralgia, elevated serum ferritin, a salmon-pink maculopapular rash, pyrexia, lymphadenopathy, and a daily pattern of worsening joint symptoms and rash in the late afternoon or early evening. The disease is typically diagnosed using the Yamaguchi criteria, which has a sensitivity of 93.5% and is the most widely used criteria for diagnosis.
Managing Still’s disease in adults can be challenging, and treatment options include NSAIDs as a first-line therapy to manage fever, joint pain, and serositis. It is recommended that NSAIDs be trialed for at least a week before steroids are added. While steroids may control symptoms, they do not improve prognosis. If symptoms persist, the use of methotrexate, IL-1, or anti-TNF therapy can be considered.
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This question is part of the following fields:
- Musculoskeletal
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Question 3
Incorrect
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A study is conducted to identify the risk factors associated with the development of Alzheimer's disease before the age of 60 years. A group of 100 patients with Alzheimer's disease <60 years of age is compared to a group of 80 age- and gender-matched individuals without Alzheimer's disease. The table of odds ratios for four studied risk factors is given below:
Ratio/confidence Age Family history Educational level History of head trauma
Odds ratio 4.5 3.5 0.5 1.6
95% confidence interval 0.5-8.5 1.5-5.5 0.3-1.1 1.2-2.0
What is the most significant risk factor identified in this study?Your Answer: Age
Correct Answer: Family history
Explanation:Understanding and Interpreting Odds Ratios and Confidence Intervals in Clinical Literature
Calculation of odds ratios and confidence intervals is a common practice in clinical literature to determine risk factors associated with a disease or treatment outcome. Interpreting these values accurately is crucial. If the confidence interval includes 1.0, the odds ratio is not statistically significant. A 95% confidence interval that does not include 1.0 is considered statistically significant. In a study, family history and history of head trauma were identified as potential risk factors. The odds ratio for family history was greater than that of head trauma, making it the most important risk factor. Age and educational level did not have statistically significant odds ratios. When there is insufficient data, family history remains the most important risk factor. Understanding and interpreting odds ratios and confidence intervals is essential for clinical research.
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This question is part of the following fields:
- Statistics
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Question 4
Incorrect
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A 56-year-old diabetic female comes in with cellulitis of the left foot, spreading from an ulcer on the plantar surface of the head of the left third metatarsal that had been present for 3 weeks before the onset of cellulitis. She was given oral flucloxacillin and the cellulitis improved, but after a week of treatment, the ulcer was still discharging and there was a tender area of swelling over the ulcer on examination. What is the most probable reason for this?
Your Answer: The strain of the likely causative agent is intrinsically resistant to the antibiotic
Correct Answer: The patient has a collection of pus which requires surgical drainage
Explanation:Surgical drainage is necessary for the patient’s pus collection, indicating possible osteomyelitis of the metatarsal. The patient’s diabetes history and chronic ulcer elevate the risk.
Understanding Osteomyelitis: Types, Causes, and Treatment
Osteomyelitis is a bone infection that can be classified into two types: haematogenous and non-haematogenous. Haematogenous osteomyelitis is caused by bacteria that enter the bloodstream and is usually monomicrobial. It is more common in children, with vertebral osteomyelitis being the most common form in adults. Risk factors include sickle cell anaemia, intravenous drug use, immunosuppression, and infective endocarditis. On the other hand, non-haematogenous osteomyelitis results from the spread of infection from adjacent soft tissues or direct injury to the bone. It is often polymicrobial and more common in adults, with risk factors such as diabetic foot ulcers, pressure sores, diabetes mellitus, and peripheral arterial disease.
Staphylococcus aureus is the most common cause of osteomyelitis, except in patients with sickle-cell anaemia where Salmonella species predominate. To diagnose osteomyelitis, MRI is the imaging modality of choice, with a sensitivity of 90-100%. Treatment for osteomyelitis involves a six-week course of flucloxacillin. Clindamycin is an alternative for patients who are allergic to penicillin.
In summary, osteomyelitis is a bone infection that can be caused by bacteria entering the bloodstream or spreading from adjacent soft tissues or direct injury to the bone. It is more common in children and adults with certain risk factors. Staphylococcus aureus is the most common cause, and MRI is the preferred imaging modality for diagnosis. Treatment involves a six-week course of flucloxacillin or clindamycin for penicillin-allergic patients.
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This question is part of the following fields:
- Musculoskeletal
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Question 5
Correct
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Which antibody is the most specific for diffuse cutaneous systemic sclerosis?
Your Answer: Anti-Scl-70 antibodies
Explanation:The most specific test for diffuse cutaneous systemic sclerosis among patients is the presence of anti-Scl-70 antibodies.
Understanding Systemic Sclerosis
Systemic sclerosis is a condition that affects the skin and other connective tissues, but its cause is unknown. It is more common in females, with three patterns of the disease. Limited cutaneous systemic sclerosis is characterised by Raynaud’s as the first sign, affecting the face and distal limbs, and associated with anti-centromere antibodies. CREST syndrome is a subtype of limited systemic sclerosis that includes Calcinosis, Raynaud’s phenomenon, oEsophageal dysmotility, Sclerodactyly, and Telangiectasia. Diffuse cutaneous systemic sclerosis affects the trunk and proximal limbs, associated with scl-70 antibodies, and has a poor prognosis. Respiratory involvement is the most common cause of death, with interstitial lung disease and pulmonary arterial hypertension being the primary complications. Renal disease and hypertension are also possible complications, and patients with renal disease should be started on an ACE inhibitor. Scleroderma without internal organ involvement is characterised by tightening and fibrosis of the skin, manifesting as plaques or linear. Antibodies such as ANA, RF, anti-scl-70, and anti-centromere are associated with different types of systemic sclerosis.
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This question is part of the following fields:
- Musculoskeletal
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Question 6
Correct
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A 25-year-old professional who is working long hours develops intermittent periods of abdominal pain and bloating. She also notices a change in bowel habit and finds that going to the restroom helps to relieve her abdominal pain.
Which of the following drug treatments may help in the treatment of her colic and bloating symptoms?Your Answer: Mebeverine
Explanation:Treatment Options for Irritable Bowel Syndrome (IBS)
Irritable bowel syndrome (IBS) is a common functional bowel disorder that affects mostly young adults, with women being more commonly affected than men. The diagnosis of IBS can be established using the Rome IV criteria, which includes recurrent abdominal pain or discomfort for at least one day per week in the last three months, along with two or more of the following: improvement with defecation, onset associated with a change in frequency of stool, or onset associated with a change in form (appearance) of the stool.
There are several treatment options available for IBS, depending on the predominant symptoms. Mebeverine, an antispasmodic, can be used to relieve colicky abdominal pain. Loperamide can be useful for patients with diarrhea-predominant IBS (IBS-D), while osmotic laxatives such as macrogols are preferred for constipation-predominant IBS (IBS-C). Cimetidine, a histamine H2 receptor antagonist, can help with acid reflux symptoms, but is unlikely to help with colic or bloating. Metoclopramide, a D2 dopamine receptor antagonist, is used as an antiemetic and prokinetic, but is not effective for colic and bloating symptoms.
In summary, treatment options for IBS depend on the predominant symptoms and can include antispasmodics, laxatives, and acid reflux medications. It is important to consult with a healthcare provider to determine the best course of treatment for each individual patient.
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This question is part of the following fields:
- Gastroenterology
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Question 7
Correct
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A 38-year-old woman is visited by her GP at home. She is nearing the end of her life due to metastatic cervical cancer and is currently receiving diamorphine through a syringe driver. Her family is worried because she has been experiencing increasing confusion and severe pain over the past few days. Her recent blood tests, including FBC, LFT, calcium, and CRP, are all normal. However, her renal function has significantly declined since her last blood test two weeks ago. On examination, the GP notes that she has small pupils and normal respiratory rate and oxygen saturation. The patient wishes to remain at home for her care and end-of-life, and does not want to be hospitalized under any circumstances. What would be the most appropriate management plan?
Your Answer: Stop the current syringe driver and prescribe alfentanil via syringe driver for her pain
Explanation:Different Approaches to Managing a Palliative Care Patient’s Symptoms
When managing a patient in palliative care, it is important to consider the best approach to managing their symptoms. Here are some different approaches and their potential outcomes:
1. Prescribe alfentanil via syringe driver for pain relief: This is a good option for patients with renal failure or opiate toxicity problems.
2. Advise the patient to take only paracetamol and NSAIDs for pain: This may not be effective for patients experiencing severe pain, and they may not be able to swallow safely.
3. Admit the patient to hospital: This may not be in line with the patient’s wishes to remain at home during the final stages of their life.
4. Continue the current regime and advise the family: This may not address the patient’s symptoms and could lead to unnecessary suffering.
5. Reduce the dose of diamorphine and add haloperidol to the syringe driver: This may not be effective if the patient’s symptoms are due to a reversible cause.
Overall, it is important to consider the patient’s individual needs and wishes when managing their symptoms in palliative care.
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This question is part of the following fields:
- Palliative Care
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Question 8
Correct
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A 65-year-old man presents to the GP with a 3-week history of generalised fatigue and weakness. He reports difficulty walking or standing for extended periods and struggles to get up from chairs. During examination, a violaceous non-oedematous rash is observed around his eyes, and his hands are extremely dry. Additionally, rough red papules are present over the extensor surfaces of his fingers. He has smoked 20 cigarettes a day for the last 45 years.
What is the most crucial next step in managing his likely diagnosis?Your Answer: Malignancy screening
Explanation:Dermatomyositis is often associated with an underlying malignancy, therefore malignancy screening is necessary. The patient’s symptoms, including proximal muscle weakness, heliotrope rash, dry hands, and Gottron’s papules, suggest a diagnosis of dermatomyositis. While an electromyogram may aid in diagnosis, it is not essential. Fundoscopy and referral to ophthalmology are not necessary as there are no eye-related symptoms. Instead, screening for malignancy through chest x-rays, CT scans, and blood tests is crucial.
Dermatomyositis is a condition that causes inflammation and muscle weakness, as well as distinct skin lesions. It can occur on its own or be associated with other connective tissue disorders or underlying cancers, particularly ovarian, breast, and lung cancer. Screening for cancer is often done after a diagnosis of dermatomyositis. Polymyositis is a variant of the disease that does not have prominent skin manifestations.
The skin features of dermatomyositis include a photosensitive macular rash on the back and shoulders, a heliotrope rash around the eyes, roughened red papules on the fingers’ extensor surfaces (known as Gottron’s papules), extremely dry and scaly hands with linear cracks on the fingers’ palmar and lateral aspects (known as mechanic’s hands), and nail fold capillary dilation. Other symptoms may include proximal muscle weakness with tenderness, Raynaud’s phenomenon, respiratory muscle weakness, interstitial lung disease (such as fibrosing alveolitis or organizing pneumonia), dysphagia, and dysphonia.
Investigations for dermatomyositis typically involve testing for ANA antibodies, which are positive in around 80% of patients. Approximately 30% of patients have antibodies to aminoacyl-tRNA synthetases, including antibodies against histidine-tRNA ligase (also called Jo-1), antibodies to signal recognition particle (SRP), and anti-Mi-2 antibodies.
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This question is part of the following fields:
- Musculoskeletal
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Question 9
Correct
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A 20-year old woman arrives at the Emergency department after a night out with her friends. According to her friends, she has been talking to herself about nonsensical things and appears agitated and restless. During the examination, it is noted that her reflexes are heightened and an electrocardiogram (ECG) reveals ventricular ectopics. What type of substance abuse is suspected in this case?
Your Answer: Ecstasy
Explanation:Ecstasy Overdose
Ecstasy, also known as MDMA, is a drug that stimulates the central nervous system. It can cause increased alertness, euphoria, extroverted behavior, and rapid speech. People who take ecstasy may also experience a lack of desire to eat or sleep, tremors, dilated pupils, tachycardia, and hypertension. However, more severe intoxication can lead to excitability, agitation, paranoid delusions, hallucinations, hypertonia, and hyperreflexia. In some cases, convulsions, rhabdomyolysis, hyperthermia, and cardiac arrhythmias may also develop.
Severe cases of MDMA poisoning can result in hyperthermia, disseminated intravascular coagulation, rhabdomyolysis, acute renal failure, hyponatremia, and even hepatic damage. In rare cases, amphetamine poisoning may lead to intracerebral and subarachnoid hemorrhage and acute cardiomyopathy, which can be fatal. Chronic amphetamine users may also experience hyperthyroxinemia.
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This question is part of the following fields:
- Emergency Medicine
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Question 10
Incorrect
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A 45-year-old patient visits her primary care physician with a complaint of net-like mottled skin on her hands, lower arms, feet, and calves that has persisted for 6 months. She reports no other symptoms. The physician orders routine blood tests, including FBC and coagulation screen, which reveal a haemoglobin level of 140 g/l, platelet count of 98 * 109/L, and white cell count of 8 * 109/L. The APTT is 45s, and the PT is 12s. An autoantibody screen is also performed, with the following significant results: positive for anti-cardiolipin antibodies and lupus anticoagulant, but negative for anti-dsDNA. What is the most appropriate treatment option for the likely diagnosis?
Your Answer: Lifelong warfarin
Correct Answer: Daily low-dose aspirin
Explanation:Patients who have been diagnosed with antiphospholipid syndrome and have not had a history of thrombosis are typically prescribed low-dose aspirin. This condition is characterized by CLOTS, which stands for clots, livedo reticularis, obstetric complications, and thrombocytopenia. Diagnosis is confirmed through blood tests that show thrombocytopenia, a prolonged APTT, and positive antiphospholipid antibodies such as anti-cardiolipin, anti-beta-2-glycoprotein-1 antibodies, and lupus anticoagulant. Treatment for Raynaud’s phenomena, which causes painful and pale fingers and toes in cold temperatures, involves daily nifedipine. Lifelong LMWH is not recommended, but lifelong warfarin is recommended for patients with antiphospholipid syndrome who have experienced a previous thrombotic event. LMWH may be an option during pregnancy.
Antiphospholipid syndrome is a condition that can be acquired and is characterized by a higher risk of both venous and arterial thrombosis, recurrent fetal loss, and thrombocytopenia. It can occur as a primary disorder or as a secondary condition to other diseases, with systemic lupus erythematosus being the most common. One important point to remember for exams is that antiphospholipid syndrome can cause a paradoxical increase in the APTT. This is due to an ex-vivo reaction of the lupus anticoagulant autoantibodies with phospholipids involved in the coagulation cascade. Other features of this condition include livedo reticularis, pre-eclampsia, and pulmonary hypertension.
Antiphospholipid syndrome can also be associated with other autoimmune disorders, lymphoproliferative disorders, and, rarely, phenothiazines. Management of this condition is based on EULAR guidelines. Primary thromboprophylaxis involves low-dose aspirin, while secondary thromboprophylaxis depends on the type of thromboembolic event. Initial venous thromboembolic events require lifelong warfarin with a target INR of 2-3, while recurrent venous thromboembolic events require lifelong warfarin and low-dose aspirin. Arterial thrombosis should be treated with lifelong warfarin with a target INR of 2-3.
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This question is part of the following fields:
- Musculoskeletal
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Question 11
Correct
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An 80-year-old man arrives at the emergency department complaining of sudden pain in his left leg that has developed over the past two hours. During examination, the leg appears pale and the patient is unable to move it. The leg is also tender to the touch. The left foot is absent of dorsalis pedis and posterior tibial pulses, while the right foot has a palpable dorsalis pedis pulse. The patient's medical history includes atrial fibrillation, and he mentions being less active in recent months. He has a family history of his father dying from a pulmonary embolus.
What is the initial management that should be taken for this patient's most likely diagnosis?Your Answer: Paracetamol, codeine, IV heparin, and vascular review
Explanation:The appropriate management for acute limb ischaemia involves administering analgesia, IV heparin, and requesting a vascular review. Paracetamol and codeine should not be given as the patient’s condition requires urgent attention to prevent fatal consequences for the limb. IV heparin is necessary to prevent thrombus propagation, and the patient must be seen by the vascular team for potential definitive management, such as intra-arterial thrombolysis or surgical embolectomy. Paracetamol, iloprost, and atorvastatin are not suitable for this condition as they are used to manage Raynaud’s phenomenon. Requesting a vascular review alone is not enough as analgesia is also required to alleviate pain.
Peripheral arterial disease can present in three main ways: intermittent claudication, critical limb ischaemia, and acute limb-threatening ischaemia. The latter is characterized by one or more of the 6 P’s: pale, pulseless, painful, paralysed, paraesthetic, and perishing with cold. Initial investigations include a handheld arterial Doppler examination and an ankle-brachial pressure index (ABI) if Doppler signals are present. It is important to determine whether the ischaemia is due to a thrombus or embolus, as this will guide management. Thrombus is suggested by pre-existing claudication with sudden deterioration, reduced or absent pulses in the contralateral limb, and evidence of widespread vascular disease. Embolus is suggested by a sudden onset of painful leg (<24 hours), no history of claudication, clinically obvious source of embolus, and no evidence of peripheral vascular disease. Initial management includes an ABC approach, analgesia, intravenous unfractionated heparin, and vascular review. Definitive management options include intra-arterial thrombolysis, surgical embolectomy, angioplasty, bypass surgery, or amputation for irreversible ischaemia.
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This question is part of the following fields:
- Surgery
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Question 12
Incorrect
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A 32-year-old primigravida woman is 41 weeks pregnant and has been offered a vaginal examination and membrane sweeping at her antenatal visit. Despite these efforts, she has not gone into labor after 6 hours. Upon examination, her cervix is firm, 1 cm dilated, 1.5 cm in length, and in the middle position. The fetal head station is -3, but there have been no complications during the pregnancy. What should be the next appropriate step?
Your Answer: IV Syntocinon
Correct Answer: Vaginal prostaglandin gel
Explanation:If the Bishop score is less than or equal to 6, the recommended method for inducing labor is through vaginal PGE2 or oral misoprostol. In this case, since the Bishop score was less than 5, labor is unlikely without induction. One option could be to repeat a membrane sweep, but the most appropriate course of action would be to use a vaginal prostaglandin gel.
Induction of labour is a process where labour is artificially started and is required in about 20% of pregnancies. It is indicated in cases of prolonged pregnancy, prelabour premature rupture of the membranes, maternal medical problems, diabetic mother over 38 weeks, pre-eclampsia, obstetric cholestasis, and intrauterine fetal death. The Bishop score is used to assess whether induction of labour is necessary and includes cervical position, consistency, effacement, dilation, and fetal station. A score of less than 5 indicates that labour is unlikely to start without induction, while a score of 8 or more indicates a high chance of spontaneous labour or response to interventions made to induce labour.
Possible methods of induction include membrane sweep, vaginal prostaglandin E2, oral prostaglandin E1, maternal oxytocin infusion, amniotomy, and cervical ripening balloon. The NICE guidelines recommend vaginal prostaglandins or oral misoprostol if the Bishop score is less than or equal to 6, while amniotomy and an intravenous oxytocin infusion are recommended if the score is greater than 6.
The main complication of induction of labour is uterine hyperstimulation, which refers to prolonged and frequent uterine contractions that can interrupt blood flow to the intervillous space and result in fetal hypoxemia and acidemia. Uterine rupture is a rare but serious complication. Management includes removing vaginal prostaglandins and stopping the oxytocin infusion if one has been started, and considering tocolysis.
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This question is part of the following fields:
- Obstetrics
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Question 13
Correct
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The results of a phase 3 study on a new antihypertensive is published (n = 8,000). Compared with placebo, there is a mean reduction of 6 mmHg in favour of the treatment group when added to medication in patients who have failed to achieve blood pressure control on an angiotensin-converting enzyme inhibitor (ACEi). The 95% confidence interval for the difference in blood pressure lies between 1.9 mmHg and 10.1 mmHg.
Which of the following is most accurate regarding this medication?Your Answer: The difference in blood pressure is statistically significant at the 5% significance level
Explanation:Interpretation of Blood Pressure Reduction Data for a New Medication
Interpretation of the Data:
The data provided shows that the difference in blood pressure is statistically significant at the 5% significance level, as the 95% confidence interval does not include the value 0. However, it is unclear whether this medication offers advantages compared with other treatments, as a number of established anti-hypertensives may result in a similar magnitude of blood pressure reduction.
It is also important to note that the difference in blood pressure of 6 mmHg may be considered clinically significant in terms of leading to measurable reduction in morbidity and mortality. Therefore, it is possible that this medication could offer benefits in terms of reducing cardiovascular events such as stroke, myocardial infarction, and heart failure.
However, whether this medication should be licensed is not just a question of efficacy, but also a full evaluation of the benefit-risk profile of the product. Without information about the side-effect profile of this medication, it is difficult to make a definitive recommendation.
Overall, while the data suggests that this medication may offer benefits in terms of reducing blood pressure, further evaluation is needed to determine its overall effectiveness and safety.
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This question is part of the following fields:
- Statistics
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Question 14
Correct
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At what age would a typical toddler develop the skill to walk without any support?
Your Answer: 13-15 months
Explanation:Gross Motor Developmental Milestones
Gross motor skills refer to the ability to use large muscles in the body for activities such as crawling, walking, running, and jumping. These skills are essential for a child’s physical development and are achieved through a series of developmental milestones. The table below summarizes the major gross motor developmental milestones from 3 months to 4 years of age.
At 3 months, a baby should have little or no head lag when pulled to sit and should have good head control when lying on their abdomen. By 6 months, they should be able to lift and grasp their feet when lying on their back, pull themselves to a sitting position, and roll from front to back. At 9 months, they should be able to pull themselves to a standing position and crawl. By 12 months, they should be able to cruise and walk with one hand held. At 18 months, they should be able to walk unsupported and squat to pick up a toy. By 2 years, they should be able to run and walk up and down stairs holding onto a rail. At 3 years, they should be able to ride a tricycle using pedals and walk up stairs without holding onto a rail. By 4 years, they should be able to hop on one leg.
It is important to note that while the majority of children crawl on all fours before walking, some children may bottom-shuffle, which is a normal variant that runs in families. These milestones serve as a guide for parents and healthcare professionals to monitor a child’s physical development and identify any potential delays or concerns.
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This question is part of the following fields:
- Paediatrics
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Question 15
Incorrect
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Which statement about Japanese encephalitis is the most accurate?
Your Answer: Previous exposure to a flavivirus predisposes to increased risk of death on infection with Japanese encephalitis
Correct Answer: Transplacental transmission occurs
Explanation:Japanese Encephalitis: A Viral Infection Endemic in Asia
Japanese encephalitis is a type of RNA virus that is commonly found in India, East Asia, Malaysia, and the Philippines. Interestingly, previous exposure to other viruses in the Flavivirus family, such as dengue, can actually provide some protection against serious illness or death from Japanese encephalitis. This means that individuals who have been infected with dengue in the past may have a lower risk of severe symptoms if they contract Japanese encephalitis.
Despite being endemic to certain regions, Japanese encephalitis can still affect travelers who spend only short periods of time in these areas. Additionally, the virus can be transmitted from mother to fetus during pregnancy.
Fortunately, there is an immunization available for travelers who may be at risk of contracting Japanese encephalitis. It is important for individuals traveling to endemic areas to take precautions and consider getting vaccinated to protect themselves from this potentially serious viral infection.
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This question is part of the following fields:
- Infectious Diseases
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Question 16
Correct
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A 56-year-old man presents to the Emergency Department with crushing substernal chest pain that radiates to the jaw. He has a history of poorly controlled hypertension and uncontrolled type II diabetes mellitus for the past 12 years. An electrocardiogram (ECG) reveals ST elevation, and he is diagnosed with acute myocardial infarction. The patient undergoes percutaneous coronary intervention (PCI) and stenting and is discharged from the hospital. Eight weeks later, he experiences fever, leukocytosis, and chest pain that is relieved by leaning forwards. There is diffuse ST elevation in multiple ECG leads, and a pericardial friction rub is heard on auscultation. What is the most likely cause of the patient's current symptoms?
Your Answer: Dressler’s syndrome
Explanation:Complications of Transmural Myocardial Infarction
Transmural myocardial infarction can lead to various complications, including Dressler’s syndrome and ventricular aneurysm. Dressler’s syndrome typically occurs weeks to months after an infarction and is characterized by acute fibrinous pericarditis, fever, pleuritic chest pain, and leukocytosis. On the other hand, ventricular aneurysm is characterized by a systolic bulge in the precordial area and predisposes to stasis and thrombus formation. Acute fibrinous pericarditis, which manifests a few days after an infarction, is not due to an autoimmune reaction. Reinfarction is unlikely in a patient who has undergone successful treatment for STEMI. Infectious myocarditis, caused by viruses such as Coxsackie B, Epstein-Barr, adenovirus, and echovirus, is not the most likely cause of the patient’s symptoms, given his medical history.
Complications of Transmural Myocardial Infarction
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This question is part of the following fields:
- Cardiology
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Question 17
Incorrect
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A 73-year-old man comes to the Emergency department after experiencing an injury while playing tennis. He felt something snap in his forearm while hitting a forehand shot. Upon examination, there is a noticeable lump above his elbow, about the size of an orange, and he has difficulty flexing his elbow. What type of injury is he likely to have sustained?
Your Answer: Proximal triceps rupture
Correct Answer: Proximal biceps rupture
Explanation:The Biceps Brachii Muscle and Tendon Rupture
The biceps brachii muscle is located in the anterior compartment of the arm and is responsible for flexion. It has two heads, the short head attaching to the tip of the coracoid process of the scapula and the long head attaching to the supraglenoid tubercle of the scapula. The tendon of the long head crosses the head of the humerus within the glenohumeral joint and descends in the intertubercular groove of the humerus.
Rupture of the biceps tendon is usually caused by wear and tear of an inflamed tendon as it moves back and forth in the intertubercular groove of the humerus. This injury is common in older athletes, particularly baseball pitchers. The tendon is typically torn from its attachment to the supraglenoid tubercle of the scapula, resulting in a dramatic snap or pop and a ball-like bulge in the distal part of the arm.
While forceful flexion of the arm against excessive resistance can also cause biceps tendon rupture, it more commonly occurs as a result of repetitive overhead motions, such as those performed by swimmers. Conservative treatment is typically the best option, with patients becoming asymptomatic after four to six weeks. Surgical intervention is usually only necessary for cosmetic reasons or if shoulder reconstruction is required.
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This question is part of the following fields:
- Clinical Sciences
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Question 18
Correct
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A 29-year-old woman presents to her GP seeking guidance on conception, specifically regarding the use of supplements or medication. She has no significant medical or family history and has previously given birth to two healthy children in the past three years without complications. Upon examination, she appears to be in good health, with a BMI of 31 kg/m2. What is the most suitable course of action for this patient?
Your Answer: 5mg of folic acid
Explanation:Pregnant women with a BMI greater than 30 kg/m2 should be prescribed a high dose of 5mg folic acid instead of the standard 400 micrograms. Therefore, the lifestyle and dietary advice given to this patient is incorrect. Additionally, prescribing 75 mg of aspirin is not appropriate for this patient as it is typically given to women with one high-risk factor or two moderate-risk factors for pre-eclampsia, and a BMI over 35 would only qualify as a single moderate-risk factor. While 150 mg of aspirin is an alternative dose for pre-eclampsia prophylaxis, 75 mg is more commonly used in practice.
Folic Acid: Importance, Deficiency, and Prevention
Folic acid is a vital nutrient that is converted to tetrahydrofolate (THF) in the body. It is found in green, leafy vegetables and plays a crucial role in the transfer of 1-carbon units to essential substrates involved in the synthesis of DNA and RNA. However, certain factors such as phenytoin, methotrexate, pregnancy, and alcohol excess can cause a deficiency in folic acid. This deficiency can lead to macrocytic, megaloblastic anemia and neural tube defects.
To prevent neural tube defects during pregnancy, it is recommended that all women take 400mcg of folic acid until the 12th week of pregnancy. Women at higher risk of conceiving a child with a neural tube defect should take 5mg of folic acid from before conception until the 12th week of pregnancy. Women are considered higher risk if they or their partner has a neural tube defect, they have had a previous pregnancy affected by a neural tube defect, or they have a family history of a neural tube defect. Additionally, women with certain medical conditions such as coeliac disease, diabetes, or thalassaemia trait, or those taking antiepileptic drugs, or who are obese (BMI of 30 kg/m2 or more) are also considered higher risk.
In summary, folic acid is an essential nutrient that plays a crucial role in DNA and RNA synthesis. Deficiency in folic acid can lead to serious health consequences, including neural tube defects. However, taking folic acid supplements during pregnancy can prevent these defects and ensure a healthy pregnancy.
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This question is part of the following fields:
- Gynaecology
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Question 19
Correct
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A 26-year-old swimwear model is hesitant to start a newly prescribed medication due to concerns about potential side-effects. Specifically, she is worried about staining of the teeth, which she read about in the patient information leaflet. As a model, she is worried that this side-effect could impact her work. Which antibiotic is known to cause staining of the teeth?
Your Answer: Tetracycline
Explanation:Common Side-Effects of Antibiotics and Anticonvulsants
Antibiotics and anticonvulsants are commonly prescribed medications that can have side-effects. Here are some of the most common side-effects associated with these drugs:
Tetracycline: This antibiotic can cause staining of the teeth, pancreatitis, and benign intracranial hypertension. It should be avoided in younger patients, and patients should be warned about photosensitivity.
Phenytoin: This anticonvulsant can cause gingival hyperplasia, gingivitis, and tooth decay.
Carbimazole: The most common side-effects of this antithyroid medication are haematological, though these are rare.
Azithromycin: This macrolide antibiotic can cause nausea, vomiting, and abdominal discomfort.
Gentamicin: This antibiotic is known for its potential to cause nephrotoxicity and ototoxicity.
It is important to be aware of these potential side-effects and to discuss any concerns with your healthcare provider.
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This question is part of the following fields:
- Pharmacology
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Question 20
Correct
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As a locum GP, you have been presented with blood results for five patients you have never met before. The results are as follows:
Patient A: Adjusted calcium - 2.8 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/L.
Your task is to identify which patient is likely to have acute kidney injury (AKI). Take your time to carefully review the results and make an informed decision.Your Answer: Patient D
Explanation:Biochemical Indicators of Dehydration and Kidney Function
The biochemical indicators in a patient’s blood can provide insight into their kidney function and hydration status. In cases of dehydration leading to acute renal failure (ARF) or acute kidney injury (AKI), there may be slight elevations in calcium and phosphate levels, indicating some haemoconcentration. However, the urea level is typically significantly higher compared to a more modest increase in creatinine. A urea level of 32 mmol/L is commonly seen in AKI, whereas in stable chronic kidney disease (CKD), it would typically be associated with a much higher creatinine level.
CKD often presents with multiple biochemical abnormalities that are not typically seen in AKI. These include hypocalcaemia, increased levels of parathyroid hormone (PTH) as a compensatory response to hypocalcaemia, and anemia due to erythropoietin and iron deficiency. Patients with primary hyperparathyroidism, such as Patient A and B, may have inappropriately high PTH levels with mild hypercalcaemia. Patient C, on the other hand, has CKD with secondary hyperparathyroidism. Finally, Patient E has normal blood indicators, suggesting no significant kidney or hydration issues.
Overall, the biochemical indicators of dehydration and kidney function can aid in diagnosing and managing ARF, AKI, and CKD.
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This question is part of the following fields:
- Nephrology
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Question 21
Incorrect
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A 7-year-old girl arrives at the emergency department with severe wheezing and shortness of breath. She is struggling to speak in full sentences and her peak expiratory flow rate is 320 l/min (45% of normal). Her oxygen saturation levels are at 92%. Her pCO2 is 4.8 kPa.
What is the most concerning finding from the above information?Your Answer: Cannot complete sentences
Correct Answer: pCO2 (kPa)
Explanation:Assessing Acute Asthma Attacks in Children
When assessing the severity of asthma attacks in children, the 2016 BTS/SIGN guidelines recommend using specific criteria. These criteria can help determine whether the attack is severe or life-threatening. For a severe attack, the child may have a SpO2 level below 92%, a PEF level between 33-50% of their best or predicted, and may be too breathless to talk or feed. Additionally, their heart rate may be over 125 (for children over 5 years old) or over 140 (for children between 1-5 years old), and their respiratory rate may be over 30 breaths per minute (for children over 5 years old) or over 40 (for children between 1-5 years old). They may also be using accessory neck muscles to breathe.
For a life-threatening attack, the child may have a SpO2 level below 92%, a PEF level below 33% of their best or predicted, and may have a silent chest, poor respiratory effort, agitation, altered consciousness, or cyanosis. It is important for healthcare professionals to be aware of these criteria and to take appropriate action to manage the child’s asthma attack. By following these guidelines, healthcare professionals can help ensure that children with asthma receive the appropriate care and treatment they need during an acute attack.
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This question is part of the following fields:
- Paediatrics
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Question 22
Incorrect
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Which nerve root is associated with the ankle reflex test performed during a neurological examination of the lower limbs where the foot is held in external rotation, the knee is flexed, and the Achilles tendon is struck with a tendon hammer while observing the calf?
Your Answer: Tibial nerve L5, S1
Correct Answer: Tibial nerve S1, S2
Explanation:The Tibial Nerve and Ankle Reflex
The ankle reflex is controlled by the tibial nerve, which originates from the S1 and S2 nerve roots. This nerve is a branch of the sciatic nerve and is responsible for supplying the posterior muscles of the leg and knee joint. The tibial nerve forms in the popliteal fossa and runs downwards on the tibialis posterior.
As it travels, the tibial nerve provides sensation and motor function to the muscles in the leg and knee joint. It terminates by dividing into the medial and lateral plantar nerves. These nerves are responsible for providing sensation to the sole of the foot and controlling the muscles that move the foot and toes.
Overall, the tibial nerve plays a crucial role in the ankle reflex and the overall function of the leg and foot. Its proper functioning is essential for maintaining balance and mobility.
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This question is part of the following fields:
- Clinical Sciences
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Question 23
Correct
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You have just assisted with the normal vaginal delivery of a baby boy, during the delivery there was a large amount of meconium. On observation of the baby just after the birth, what signs would indicate the need for the neonatal team to evaluate the baby?
Your Answer: Respiratory rate 75/minute
Explanation:The Apgar score is a tool used to evaluate the health of a newborn baby. It is recommended by NICE to be assessed at 1 and 5 minutes after birth, and again at 10 minutes if the initial score is low. The score is based on five factors: pulse, respiratory effort, color, muscle tone, and reflex irritability. A score of 0-3 is considered very low, 4-6 is moderate low, and 7-10 indicates that the baby is in good health. The score helps healthcare professionals quickly identify any potential issues and provide appropriate care.
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This question is part of the following fields:
- Paediatrics
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Question 24
Incorrect
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A 25-year-old man is brought to the Emergency department by his friends after being found on the floor following a night out. There are suspicions that he may have taken drugs, although the exact substance is unknown. Upon examination, he is found to be semi-conscious with a rapid respiratory rate. A catheterisation procedure yields 25 mls of dark brown coloured urine which tests positive for haemoglobin using urinalysis.
What potential blood and electrolyte imbalances should be anticipated in this patient?Your Answer: Hyperkalaemia with alkalosis
Correct Answer: Hyperuricaemia with acidosis
Explanation:Rhabdomyolysis: Symptoms and Treatment
Rhabdomyolysis is a medical condition that occurs when there is a rapid breakdown of skeletal muscle. This condition is associated with several biochemical abnormalities, including elevated levels of creatine kinase (CK), potassium, urate, and myoglobinuria. Additionally, calcium levels may be elevated intracellularly in myocytes, but normal or low in the blood during the early stages of the disease. However, as the disease progresses, calcium levels in the blood may increase. Acidosis is also a common symptom of rhabdomyolysis.
Early and aggressive treatment is crucial in managing rhabdomyolysis. Rehydration and managing hyperkalemia can help reduce the likelihood of developing complications such as arrhythmias due to electrolyte disturbance, renal failure, disseminated intravascular coagulation, and compartment syndrome. By the symptoms and seeking prompt medical attention, individuals with rhabdomyolysis can receive the necessary treatment to manage the condition and prevent further complications.
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This question is part of the following fields:
- Nephrology
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Question 25
Incorrect
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A mother of three brings her youngest daughter, aged 15, to the general practitioner (GP) as she is yet to start menstruating, whereas both her sisters had menarche at the age of 12.
The patient has developed secondary female sexual characteristics and has a normal height. She reports struggling with headaches and one episode of galactorrhoea.
Magnetic resonance imaging (MRI) reveals an intracranial tumour measuring 11 mm in maximal diameter.
Given the most likely diagnosis, which of the following is the first-line management option?Your Answer: Surgery to remove the tumour
Correct Answer: Medical treatment with cabergoline
Explanation:The patient has primary amenorrhoea due to a macroprolactinoma, which is a benign prolactin-secreting tumor of the anterior pituitary gland. Treatment in the first instance is with a dopamine receptor agonist such as bromocriptine or cabergoline. Surgery is the most appropriate management if conservative management fails or the patient presents with visual field defects. Radiotherapy is rarely used. Exclusion of pregnancy is the first step in every case of amenorrhoea. Metoclopramide is a dopamine receptor antagonist and a cause of hyperprolactinaemia, so it should not be used to treat this patient. Thyroxine is not appropriate as hyperprolactinaemia is secondary to a pituitary adenoma. Indications for surgery are failure to respond to medical therapy or presentation with acute visual field defects.
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This question is part of the following fields:
- Gynaecology
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Question 26
Correct
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A 78-year-old man collapsed during a routine hospital visit and was quickly assessed. He presented with homonymous hemianopia, significant weakness in his right arm and leg, and a new speech impairment. A CT head scan was urgently performed and confirmed the diagnosis of an ischemic stroke. What CT head results would be indicative of this condition?
Your Answer: Hyperdense middle cerebral artery (MCA) sign
Explanation:A hyperdense middle cerebral artery (MCA) sign may be observed on CT in cases of acute ischaemic stroke, typically appearing immediately after symptom onset. This is in contrast to changes in the parenchyma, which tend to develop as the ischaemia within the tissue becomes established. An acute subdural haematoma can be identified on a CT head scan by the presence of a crescent-shaped hyperdense extra-axial collection adjacent to the frontal lobe. Raised intracranial pressure can be detected on a CT head scan by the effacement of the cerebral ventricles and loss of grey-white matter differentiation. The presence of hyperdense material in the cerebral sulci and basal cisterns is indicative of subarachnoid haemorrhage (SAH) on a CT head scan.
Assessment and Investigations for Stroke
Whilst diagnosing a stroke may be straightforward in some cases, it can be challenging when symptoms are vague. The FAST screening tool, which stands for Face/Arms/Speech/Time, is a well-known tool used by the general public to identify stroke symptoms. However, medical professionals use a validated tool called the ROSIER score, recommended by the Royal College of Physicians. The ROSIER score assesses for loss of consciousness or syncope, seizure activity, and new, acute onset of asymmetric facial, arm, or leg weakness, speech disturbance, or visual field defect. A score of greater than zero indicates a likely stroke.
When investigating suspected stroke, a non-contrast CT head scan is the first line radiological investigation. The key question to answer is whether the stroke is ischaemic or haemorrhagic, as this determines the appropriate management. Ischaemic strokes may show areas of low density in the grey and white matter of the territory, while haemorrhagic strokes typically show areas of hyperdense material surrounded by low density. It is important to identify the type of stroke promptly, as thrombolysis and thrombectomy play an increasing role in acute stroke management. In rare cases, a third pathology such as a tumour may also be detected.
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This question is part of the following fields:
- Medicine
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Question 27
Incorrect
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A 65-year-old male presents with a one day history of right-sided chest pain and dyspnoea that has worsened throughout the day. He underwent a right hip replacement and was discharged from BUPA one week ago. On examination, his temperature is 37.5°C, pulse is 96 bpm, blood pressure is 138/88 mmHg, and oxygen saturations are 90% on air. There are no specific abnormalities on chest examination, but his chest x-ray shows consolidation at the right base. The ECG is also normal. What is the most appropriate investigation for this patient?
Your Answer: Blood cultures
Correct Answer: CTPA chest
Explanation:Consider Pulmonary Embolism in Post-Surgery Patients
A patient who has recently undergone surgery and presents with chest x-ray changes and respiratory symptoms should be evaluated for pulmonary embolism (PE). While infection is a possibility, it is important to consider thromboembolic disease as it can be fatal if left untreated.
A ventilation/perfusion (V/Q) scan may not be sufficient in this context, and a computed tomography pulmonary angiogram (CTPA) would provide a more definitive diagnosis. While raised FDPs/D-dimers can indicate PE, they are not specific and only provide value if they fall within a normal range. Blood cultures for chest infection are unlikely to yield significant results.
It is crucial to consider the possibility of PE in post-surgery patients to ensure prompt and appropriate treatment.
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This question is part of the following fields:
- Emergency Medicine
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Question 28
Correct
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A middle-aged woman is brought to the Emergency Department (ED), after being found unconscious in the town centre by members of the police. She is poorly kept, and a police handover reports that she has no fixed abode. She is well known to various members of ED. On arrival in ED, she is still unconscious. Her airway is patent; she is saturating at 94% on room air, with a respiratory rate of 10 breaths/min. She is haemodynamically stable, with a temperature of 35.6 °C and small, constricted pupils. There appears to be an area of minor external bleeding and a scalp haematoma on the back of her head.
What is the most appropriate initial course of action?Your Answer: Naloxone 400 μg intramuscularly (IM)
Explanation:Treatment Priorities for Opioid Overdose: A Case Vignette
In cases of suspected opioid overdose, the priority is to address respiratory compromise with the administration of naloxone. The British National Formulary recommends an initial dose of 400 μg, with subsequent doses of 800 μg at 1-minute intervals if necessary, and a final dose of 2 mg if there is still no response. Naloxone acts as a non-selective and competitive opioid receptor antagonist, and is a relatively safe drug.
In the case of an unkempt man with a low respiratory rate and pinpoint pupils, the priority is to administer naloxone. High-flow oxygen is not necessary if the patient is maintaining saturations of 94%. A CT head scan or neurosurgical referral may be necessary in cases of head injury, but in this case, the priority is to address the opioid overdose.
Flumazenil, a benzodiazepine receptor antagonist, is not the correct choice for opioid overdose. Benzodiazepine overdose presents with CNS depression, ataxia, and slurred speech, but not pupillary constriction. Naloxone is the appropriate antidote for opioid overdose.
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This question is part of the following fields:
- Acute Medicine And Intensive Care
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Question 29
Incorrect
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A 65-year-old gentleman has been under your care for an acute exacerbation of COPD. It is his second admission for his COPD in the last twelve months and has had one previous ITU admission.
So far on the ward, he has received treatment with back-to-back salbutamol and ipratropium nebulisers, oral prednisolone and intravenous theophylline. He is also receiving a course of intravenous co-amoxiclav and clarithromycin due to a suspected infectious cause.
His latest results are as follows:
Obs:
BP 140/92 mmHg
HR 90/min
RR 24/min
SaO2 80%
Temp 38.2ºC
Arterial Blood Gas:
pH 7.30
PaO2 7.8 kPa
PaCO2 9.5 kPa
HCO3- 36 mmol/L
BE +5
What is the main indicator for initiating non-invasive ventilation in this patient?Your Answer: Failure to respond to intravenous theophylline
Correct Answer:
Explanation:When a patient with an acute exacerbation of COPD shows signs of respiratory acidosis (PaCO2>6 kPa, pH <7.35 ≥7.26) that persist despite immediate maximum standard medical treatment, it is recommended to consider the use of non-invasive ventilation (NIV). This is particularly important in cases where the patient is severely ill, as in the case of this patient with an infectious exacerbation of COPD. The British Thoracic Society guidelines suggest that NIV should be considered after maximal medical therapy, which in this case includes nebulisers, steroids, and theophylline. While there are other concerning features of this patient's condition, the PaCO2 and pH levels are the key indicators for the use of NIV. Guidelines for Non-Invasive Ventilation in Acute Respiratory Failure The British Thoracic Society (BTS) and the Royal College of Physicians have published guidelines for the use of non-invasive ventilation (NIV) in acute respiratory failure. NIV can be used in patients with COPD and respiratory acidosis with a pH of 7.25-7.35. However, patients with a pH lower than 7.25 require greater monitoring and a lower threshold for intubation and ventilation. NIV is also recommended for type II respiratory failure due to chest wall deformity, neuromuscular disease, or obstructive sleep apnea, as well as for cardiogenic pulmonary edema unresponsive to continuous positive airway pressure (CPAP) and weaning from tracheal intubation. For patients with COPD, the recommended initial settings for bi-level pressure support include an expiratory positive airway pressure (EPAP) of 4-5 cm H2O, an inspiratory positive airway pressure (IPAP) of 10-15 cm H2O, a back-up rate of 15 breaths/min, and a back-up inspiration-to-expiration ratio of 1:3. These guidelines aim to improve patient outcomes and reduce the need for invasive mechanical ventilation.
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This question is part of the following fields:
- Medicine
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Question 30
Incorrect
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A 64-year-old computer programmer reported experiencing frequent headaches to his GP. Upon examination, the GP observed papilloedema and pupillary dilation and referred the patient for further radiological studies and to a neurologist. The results of the radiological studies revealed a mass causing non-communicating hydrocephalus. Where is the most likely location of the tumour?
Your Answer: Internal arcuate fibres
Correct Answer: Pineal gland
Explanation:Understanding the Possible Causes of Non-Communicating Hydrocephalus
Non-communicating hydrocephalus can be caused by various factors, including a pinealoma, which is a slow-growing tumor of the pineal gland. This type of tumor can compress the midbrain cerebral aqueduct, leading to a blockage in the flow of cerebrospinal fluid (CSF) from the lateral and third ventricles to the fourth ventricle and subarachnoid space. To address this issue, surgical placement of a shunt may be necessary.
Another possible cause of non-communicating hydrocephalus is a midbrain tumor, such as a pinealoma, which can compress the Edinger-Westphal nuclei. This can result in mydriasis or dilation of the pupil due to the lack of parasympathetic input from the Edinger-Westphal nuclei to the oculomotor muscles.
It is important to note that a cerebellar lesion is unlikely to cause non-communicating hydrocephalus, as it is associated with defects in coordination and changes in gait. Similarly, an optic nerve lesion is also unlikely to cause this condition, as afferent fibers from the retina pass through the optic nerve to the hypothalamic lateral geniculate nucleus. A lesion in the lateral geniculate nucleus is more likely to cause visual symptoms rather than non-communicating hydrocephalus.
In summary, understanding the possible causes of non-communicating hydrocephalus can help in identifying and addressing the underlying issue. A thorough evaluation and diagnosis by a medical professional is necessary for proper treatment and management of this condition.
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This question is part of the following fields:
- Neurosurgery
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