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Question 1
Incorrect
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A 6-month-old boy is scheduled for his routine immunisations. He has received all previous immunisations according to the routine schedule and has no medical history. What vaccinations should he receive during this visit?
Your Answer: '6-1 vaccine' (diphtheria, tetanus, whooping cough, polio, Hib and hepatitis B) + PCV + Men B
Correct Answer: '6-1 vaccine' (diphtheria, tetanus, whooping cough, polio, Hib and hepatitis B) + Men B
Explanation:PCV in addition to the 6-1 vaccine (which includes protection against diphtheria, tetanus, whooping cough, polio, Hib, and hepatitis B).
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 specific intervals. At 12-13 months, the Hib/Men C, MMR, PCV, and Men B vaccines are given. 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 is also 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, while students going to university or college for the first time should contact their GP to have the vaccine before the start of the academic year.
The Men C vaccine used to be given at 3 months but has now been discontinued as there are almost no cases of Men C disease in babies or young children in the UK. 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.
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This question is part of the following fields:
- Children And Young People
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Question 2
Incorrect
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A 78-year-old man presents to you with complaints of vision problems in his right eye. He has been experiencing crooked edges on his door and occasional blurring of his vision. He has noticed that he tends to turn slightly while driving, but his peripheral vision remains unaffected. He denies any pain in his eye. Upon examination, his visual acuity is normal and his fundi appear unremarkable. However, when asked to look at a lined piece of paper, he reports seeing breaks in the lines. What is the most likely diagnosis?
Your Answer: Acute closed-angle glaucoma
Correct Answer: Age-related macular degeneration
Explanation:Understanding Eye Conditions: A Guide for General Practitioners
Ophthalmology is a crucial aspect of a general practitioner’s work, yet it is often under-taught. It is essential to be aware of diagnoses and to categorize routine and urgent eye conditions. This guide aims to provide a brief overview of some common eye conditions.
Age-related macular degeneration is a condition that can often be asymptomatic, and visual loss is usually mild. Patients may experience visual distortions, blurring of vision, and difficulty reading. There may also be a difference in size and color between both eyes.
Retinal vein occlusion causes sudden, painless unilateral visual loss. Primary closed-angle glaucoma and uveitis usually present with severe and progressive eye pain, along with blurred vision. Amaurosis fugax refers to transient retinal ischemia and symptoms include rapid onset of blindness developing over seconds, as if a curtain was drawn across the eye, and lasts seconds or minutes.
It is important for general practitioners to be familiar with these conditions and to refer patients to ophthalmologists when necessary. By understanding these eye conditions, general practitioners can provide better care for their patients and ensure that they receive appropriate treatment.
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This question is part of the following fields:
- Eyes And Vision
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Question 3
Incorrect
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A 5-year-old boy presents with recurrent balanitis. He has swelling and redness of his glans penis and foreskin, and his mother reports a foul odor and slight discharge. What is the most frequently isolated organism in cases of balanitis?
Your Answer: Group B beta-haemolytic streptococci
Correct Answer: C. albicans
Explanation:Balanitis is most commonly caused by C. albicans, with group B beta-haemolytic streptococci being a less frequent cause among bacterial infections. The other options listed may also cause balanitis, but are not as commonly isolated.
Understanding Balanitis: Causes, Assessment, and Treatment
Balanitis is a condition characterized by inflammation of the glans penis and sometimes extending to the underside of the foreskin. It can be caused by a variety of factors, including bacterial and candidal infections, autoimmune conditions, and poor hygiene. Proper assessment of balanitis involves taking a thorough history and conducting a physical examination to determine the cause and severity of the condition. In most cases, diagnosis is made clinically based on the history and examination, but in some cases, a swab or biopsy may be necessary to confirm the diagnosis.
Treatment of balanitis involves a combination of general and specific measures. General treatment includes gentle saline washes and proper hygiene practices, while specific treatment depends on the underlying cause of the condition. For example, candidiasis is treated with topical clotrimazole, while bacterial balanitis may be treated with oral antibiotics. Dermatitis and circinate balanitis are managed with mild potency topical corticosteroids, while lichen sclerosus and plasma cell balanitis of Zoon may require high potency topical steroids or circumcision.
Understanding the causes, assessment, and treatment of balanitis is important for both children and adults who may be affected by this condition. By taking proper hygiene measures and seeking appropriate medical treatment, individuals with balanitis can manage their symptoms and prevent complications.
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This question is part of the following fields:
- Dermatology
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Question 4
Incorrect
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You are seeing a 65-year-old man who has come to discuss PSA testing. He plays tennis once a week with a friend who is on medication for his 'waterworks' and has had his PSA tested. He has come as he is not sure whether he would benefit from a PSA test.
He is otherwise well with no specific urinary tract/genitourinary signs or symptoms. He has no significant past medical history or family history.
Which of the following is appropriate advice to give regarding PSA testing?Your Answer: 1 in 40 men with a normal PSA level will turn out to have prostate cancer
Correct Answer: For every 25 men identified with prostate cancer following a high PSA test result, subsequent treatment will save one life
Explanation:PSA Testing for Prostate Cancer Screening: Understanding the Limitations
PSA testing for prostate cancer screening is a topic of debate among medical professionals. While some advocate for its use, others are wary of over-treatment and patient harm. One of the main concerns is the limitations of PSA testing in terms of its sensitivity and specificity.
When counseling men about PSA testing, it is important to provide them with understandable statistics and facts. For instance, two-thirds of men with a raised PSA will not have prostate cancer, while 15 out of 100 with a negative PSA will have prostate cancer. Additionally, PSA testing cannot distinguish between slow- and fast-growing cancers, and many men may have slow-growing cancers that would not have impacted their life expectancy if left undiscovered.
Another point of debate is the frequency of PSA testing. While some patients opt for annual testing, experts suggest that a normal PSA in an asymptomatic man doesn’t need to be repeated for at least two years.
When it comes to prostate cancer treatment, approximately 48 men need to undergo treatment in order to save one life. Overall, it is important to understand the limitations of PSA testing and to weigh the potential benefits and risks before making a decision about screening.
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This question is part of the following fields:
- Kidney And Urology
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Question 5
Incorrect
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What is the Gold Standards Framework (GSF) and what does it enable for people nearing the end of their lives?
Your Answer: It is unsuitable for patients in care homes
Correct Answer: It involves an anticipatory approach to care
Explanation:The Gold Standards Framework: A Framework for Anticipatory End-of-Life Care
The Gold Standards Framework (GSF) was originally designed for use in primary care, but has since been adapted for use in care homes and nursing homes. Its anticipatory approach to care has been shown to have positive effects on pain and symptom control, and improved planning has helped to prevent some hospital admissions. The GSF is not a prescriptive model, but rather a framework that can be tailored to meet local needs and resources. It can also be adapted for patients with non-cancer diagnoses who require end-of-life care. Ultimately, the GSF aims to help patients live and die well in their preferred place of care.
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This question is part of the following fields:
- End Of Life
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Question 6
Correct
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A 50-year-old woman with a history of hypothyroidism presents with fatigue and a painful tongue. Her blood tests reveal the following results:
- Hemoglobin (Hb): 10.7 g/dl
- Mean corpuscular volume (MCV): 121 fl
- Platelet count (Plt): 177 * 109/l
- White blood cell count (WBC): 5.4 * 109/l
Further investigations reveal that her vitamin B12 levels are 64 ng/l (normal range: 200-900 ng/l) and her folic acid levels are 7.2 nmol/l (normal range: > 3.0 nmol/l). Antibodies to intrinsic factor are also detected. What is the most appropriate course of action?Your Answer: 1 mg of IM hydroxocobalamin 3 times each week for 2 weeks, then once every 3 months
Explanation:Vitamin B12 is essential for the development of red blood cells and the maintenance of the nervous system. It is absorbed through the binding of intrinsic factor, which is secreted by parietal cells in the stomach, and actively absorbed in the terminal ileum. A deficiency in vitamin B12 can be caused by pernicious anaemia, post gastrectomy, a vegan or poor diet, disorders or surgery of the terminal ileum, Crohn’s disease, or metformin use.
Symptoms of vitamin B12 deficiency include macrocytic anaemia, a sore tongue and mouth, neurological symptoms, and neuropsychiatric symptoms such as mood disturbances. The dorsal column is usually affected first, leading to joint position and vibration issues before distal paraesthesia.
Management of vitamin B12 deficiency involves administering 1 mg of IM hydroxocobalamin three times a week for two weeks, followed by once every three months if there is no neurological involvement. If a patient is also deficient in folic acid, it is important to treat the B12 deficiency first to avoid subacute combined degeneration of the cord.
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This question is part of the following fields:
- Metabolic Problems And Endocrinology
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Question 7
Incorrect
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For elderly patients who fast during Ramadan, what is the correct approach to managing type 2 diabetes mellitus?
Your Answer: Sulfonylureas should be stopped during Ramadan
Correct Answer: Around 4 out of 5 patients Muslim patients with type 2 diabetes mellitus fast during Ramadan
Explanation:Managing Diabetes Mellitus During Ramadan
Type 2 diabetes mellitus is more prevalent in people of Asian ethnicity, including a significant number of Muslim patients in the UK. With Ramadan falling in the long days of summer, it is crucial to provide appropriate advice to Muslim patients to ensure they can safely observe their fast. While it is a personal decision whether to fast, it is worth noting that people with chronic conditions are exempt from fasting or may delay it to shorter days in winter. However, many Muslim patients with diabetes do not consider themselves exempt from fasting. Around 79% of Muslim patients with type 2 diabetes mellitus fast during Ramadan.
To help patients with type 2 diabetes mellitus fast safely, they should consume a meal containing long-acting carbohydrates before sunrise (Suhoor). Patients should also be given a blood glucose monitor to check their glucose levels, especially if they feel unwell. For patients taking metformin, the dose should be split one-third before sunrise (Suhoor) and two-thirds after sunset (Iftar). For those taking sulfonylureas, the expert consensus is to switch to once-daily preparations after sunset. For patients taking twice-daily preparations such as gliclazide, a larger proportion of the dose should be taken after sunset. No adjustment is necessary for patients taking pioglitazone. Diabetes UK and the Muslim Council of Britain have an excellent patient information leaflet that explores these options in more detail.
Managing diabetes mellitus during Ramadan is crucial to ensure Muslim patients with type 2 diabetes mellitus can safely observe their fast. It is important to provide appropriate advice to patients, including consuming a meal containing long-acting carbohydrates before sunrise, checking glucose levels regularly, and adjusting medication doses accordingly.
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This question is part of the following fields:
- Metabolic Problems And Endocrinology
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Question 8
Incorrect
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A 70-year-old man comes to see you after his recent prostatectomy for localised prostate cancer. He was diagnosed after presenting with minimal symptoms and as such he is worried about relapse and recurrence of his prostate cancer.
He tells you that his specialist mentioned that he would have a PSA blood test performed periodically as a means of monitoring for recurrence. How often should he have his PSA checked?Your Answer: Monthly for six months then at least six monthly thereafter
Correct Answer: At six weeks, then at least six monthly for two years, then at least annually thereafter
Explanation:Monitoring Prostate Cancer Patients
Patients who have had prostate cancer require regular monitoring to check for any signs of recurrence or progression. This is usually done through PSA blood tests, which can be done at the GP surgery. However, it is important to note that patients should be under the direction of a specialist for monitoring and follow-up appointments.
As a GP, it is important to have an understanding of the monitoring process so that you can effectively counsel and advise patients who may have concerns about recurrence. Fear of recurrence is a common issue amongst cancer survivors, and they may feel more comfortable discussing this with their GP.
NICE has provided guidance on active surveillance and monitoring post-treatment, which can help inform your consultations with patients. By understanding the necessary monitoring, you can provide better support and care for patients who have been affected by prostate cancer.
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This question is part of the following fields:
- Kidney And Urology
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Question 9
Incorrect
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A 78-year-old woman comes to the clinic with a sudden cough that has lasted for four days and a dry throat. She feels sick but has no fever. Her lung examination is normal. Which of the following is not a reason to prescribe antibiotics immediately?
Your Answer: Diabetes
Correct Answer: Hoarseness and/or laryngitis accompanying the cough
Explanation:Factors to Consider When Prescribing Antibiotics for Respiratory Infections
When considering prescribing antibiotics for respiratory infections, it is important to take into account various risk factors that may increase the likelihood of complications. While antibiotics may be necessary in some cases, their use should be weighed against potential adverse effects and the development of antibiotic-resistance patterns.
One factor to consider is hoarseness and/or laryngitis accompanying the cough. In most cases, laryngitis is mild and self-limiting, and antibiotics may not be necessary. However, they may be considered in patients with persistent symptoms.
Another factor to consider is a history of congestive cardiac failure. For patients between 65 and 79 years, two risk factors should be present before prescribing antibiotics.
Current use of oral glucocorticoids is also a risk factor, as these patients are immunosuppressed and may be more susceptible to complications from respiratory infections.
Diabetes and hospitalization in the previous year are also risk factors for complications and should be taken into account when considering antibiotic prescriptions.
Overall, it is important to carefully evaluate each patient’s individual risk factors before deciding whether antibiotics are necessary for the treatment of respiratory infections.
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This question is part of the following fields:
- Ear, Nose And Throat, Speech And Hearing
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Question 10
Incorrect
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A 25-year-old woman is seeking advice on switching from the progesterone-only pill to combined oral contraception due to irregular bleeding. She is concerned about the risk of blood clotting adverse effects but there are no contraindications to the combined pill. What advice should be given to her regarding additional contraception when making the switch?
Your Answer:
Correct Answer: 7-days of additional barrier contraception is needed
Explanation:When switching from a traditional POP to COCP, 7 days of barrier contraception is needed. The safest option is to recommend 7 days of barrier contraception while commencing the combined oral contraceptive to prevent unwanted pregnancy. 10 or 14 days of additional barrier contraception is not required, and 3 days is too short. It is safest to recommend 7 days of additional contraception.
Special Situations for Combined Oral Contraceptive Pill
Concurrent Antibiotic Use:
In the UK, doctors have previously advised that taking antibiotics concurrently with the combined oral contraceptive pill may interfere with the enterohepatic circulation of oestrogen, making the pill ineffective. As a result, extra precautions were advised during antibiotic treatment and for seven days afterwards. However, this approach is not taken in the US or most of mainland Europe. In 2011, the Faculty of Sexual & Reproductive Healthcare updated their guidelines, abandoning the previous approach. The latest edition of the British National Formulary (BNF) has also been updated in line with this guidance. Precautions should still be taken with enzyme-inducing antibiotics such as rifampicin.Switching Combined Oral Contraceptive Pills:
The BNF and Faculty of Sexual & Reproductive Healthcare (FSRH) appear to give contradictory advice on switching combined oral contraceptive pills. The Clinical Effectiveness Unit of the FSRH has stated in the Combined Oral Contraception guidelines that the pill-free interval doesn’t need to be omitted. However, the BNF advises missing the pill-free interval if the progesterone changes. Given the uncertainty, it is best to follow the BNF. -
This question is part of the following fields:
- Gynaecology And Breast
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Question 11
Incorrect
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A 68-year-old teacher suddenly lost her memory after walking her dog. Her husband noticed that she still knew the names of close friends, but she was disorientated in time and place, and seemed perplexed. She could follow complex commands, but was unable to recall something she had been told 5 minutes before. The episode resolved after 10 hours, although she did not remember the event. She has a history of migraine, but the episode of memory loss was not associated with headache.
What is the most probable clinical diagnosis for this patient?Your Answer:
Correct Answer: Transient global amnesia
Explanation:Transient Global Amnesia: Symptoms, Causes, and Differential Diagnosis
Transient Global Amnesia (TGA) is a sudden onset condition that profoundly impairs anterograde memory. Patients are disoriented in time and place, but not in person. Retrograde memory is variably disturbed, lasting for hours to years. Patients recognize their memory deficits and repeatedly ask questions to orient themselves. Immediate and procedural memory are preserved, and patients can perform complex tasks. The attack resolves gradually, with subjective recovery occurring in two-thirds of patients within 2-12 hours. Precipitating events include strenuous exercise, intense emotion, and medical procedures. Differential diagnosis includes migraine, transient epileptic amnesia, and transient ischemic attack (TIA).
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This question is part of the following fields:
- Neurology
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Question 12
Incorrect
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A 40-year-old woman has chronic diarrhoea and is suspected to have irritable bowel syndrome. What is the most suitable test to diagnose bile acid malabsorption?
Your Answer:
Correct Answer: SeHCAT (tauroselcholic [75 selenium] acid) test
Explanation:Diagnostic Tests for Bile Acid Malabsorption and Coeliac Disease
Bile acids play a crucial role in the absorption of lipids, and their malabsorption can lead to gastrointestinal symptoms such as diarrhoea, bloating, and faecal incontinence. Bile acid malabsorption can be classified into three types, with primary idiopathic malabsorption being particularly common in patients with irritable bowel syndrome. Crohn’s disease and certain surgeries or diseases can also cause bile acid malabsorption.
The SeHCAT test is a diagnostic tool that tracks the retention and loss of bile acids through the enterohepatic circulation. A capsule containing radiolabeled 75 SeHCAT is ingested, and the percentage retention of SeHCAT at seven days is calculated. A value less than 15% indicates excessive bile acid loss and suggests bile acid malabsorption.
Faecal fat estimation is a standard test for malabsorption, but it is not specific for bile acids. Anti-transglutaminase antibodies are found in coeliac disease, and higher levels of these antibodies suggest a diagnosis of that condition. Small bowel biopsy is performed to confirm a diagnosis of coeliac disease. The urea breath test is a rapid diagnostic procedure used in retesting for infections by Helicobacter pylori, which requires the triple-therapy regimen for treatment.
In summary, the SeHCAT test, faecal fat estimation, anti-transglutaminase antibodies, small bowel biopsy, and urea breath test are all diagnostic tools that can aid in the diagnosis of bile acid malabsorption and coeliac disease.
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This question is part of the following fields:
- Gastroenterology
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Question 13
Incorrect
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A 10-month old baby is brought in for a developmental review by his parents. He is able to sit without support, crawl, and pull himself up to stand. He shows a preference for using his left hand for most activities. He has a weak pincer grip and can point at objects.
However, he is unable to walk without support, even with one hand. He has not yet said mama or dada but does understand the word no. He also doesn't respond to his own name.
Which of these findings is the most concerning?Your Answer:
Correct Answer: Left-handedness
Explanation:Having a hand preference before the age of 12 months is not normal and could be a sign of cerebral palsy. The child’s left-handedness is not a concern, but their early hand preference is. By 12 months, children should be able to walk with support from one parent and respond to their name. They should only be able to walk independently between 13-15 months. While 9-month old babies can typically say mama and dada, it is too early to worry about this in the child’s case.
Common Developmental Problems and Their Causes
Developmental problems can manifest in various ways, including referral points, fine motor skill problems, gross motor problems, and speech and language problems. Referral points may include a lack of smiling at 10 weeks, inability to sit unsupported at 12 months, and inability to walk at 18 months. Fine motor skill problems may be indicated by abnormal hand preference before 12 months, which could be a sign of cerebral palsy. Gross motor problems are often caused by a variant of normal, cerebral palsy, or neuromuscular disorders like Duchenne muscular dystrophy. Speech and language problems should always be checked for hearing issues, but other causes may include environmental deprivation and general developmental delay. It is important to identify and address these developmental problems early on to ensure the best possible outcomes for the child’s future.
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This question is part of the following fields:
- Children And Young People
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Question 14
Incorrect
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A 8-month-old girl presents to her General Practitioner with her mother with a runny nose, mild fever and a barking cough. Symptoms have been present for 24 hours. An inspiratory stridor can be heard when the child is crying, but not when she is calm. On examination, there is mild intercostal recession, but air entry is normal.
Which of the following is the most appropriate management?
Your Answer:
Correct Answer: Dexamethasone
Explanation:Medications for Croup: Understanding Their Uses and Limitations
Croup is a common respiratory illness in children, characterized by a barking cough and inspiratory stridor. While it is usually caused by a viral infection, treatment with medications can help alleviate symptoms and prevent complications. Here is a breakdown of some commonly used medications for croup and their uses:
Dexamethasone: This steroid medication is recommended for all children with mild to moderate croup. It helps reduce inflammation in the airways and can improve symptoms within hours.
Amoxicillin: While croup is usually caused by a virus, bacterial infections can sometimes complicate the illness. Amoxicillin is an antibiotic that can be used to treat bacterial infections in children with croup.
Cetirizine: This antihistamine medication is not recommended for children with croup, as it is used to relieve allergy symptoms and has no effect on the underlying cause of croup.
Salbutamol: This medication is used to treat asthma and other respiratory conditions, but is not typically used for croup.
Simple linctus: This cough syrup contains citric acid and is sometimes used as a demulcent to soothe the throat. However, its effectiveness in reducing cough frequency is limited.
It is important to note that medications should only be used under the guidance of a healthcare professional, and that treatment for croup may vary depending on the severity of the illness and the individual needs of the child.
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This question is part of the following fields:
- Children And Young People
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Question 15
Incorrect
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A 30-year-old woman presents with malaise, fever, malar rash, two swollen joints and the following results: ANA positive, double-stranded DNA antibody (anti-dsDNA) positive, rheumatoid factor positive and reduced C3, C4 complement levels. What is the most probable diagnosis?
Your Answer:
Correct Answer: Systemic lupus erythematosus (SLE)
Explanation:Understanding Systemic Lupus Erythematosus: Symptoms, Diagnosis, and Screening Tests
Systemic lupus erythematosus (SLE) is a complex autoimmune disease that can affect multiple organs in the body. It is more common in women, especially those aged between 15 and 35. SLE is characterized by the presence of antinuclear antibodies (ANA) and autoantibodies, which can be detected through screening tests such as ESR, ANA, and anti-dsDNA antibodies. However, the diagnosis of SLE requires the presence of at least four out of 11 criteria specified by the American College of Rheumatology, including rash, joint swelling, ANA positivity, and autoantibodies. The course of SLE is unpredictable, with periods of illness alternating with remissions. Understanding the symptoms, diagnosis, and screening tests for SLE is crucial for early detection and management of this complex disease.
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This question is part of the following fields:
- Musculoskeletal Health
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Question 16
Incorrect
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A 4-year-old girl is brought to the pediatrician by her father. She has been experiencing coryza and a fever of 37.8ºC for the past 3 days. This morning her father noticed a red rash with a slapped cheek appearance on both cheeks and pallor surrounding her mouth. What is the most probable organism responsible for this?
Your Answer:
Correct Answer: Parvovirus B19
Explanation:The cause of the boy’s symptoms, which include a red rash following coryza and fever, is erythema infectiosum, also known as slapped-cheek syndrome. This infection is caused by parvovirus b19, a common organism responsible for childhood infections.
The table summarizes the main characteristics of childhood infections including Chickenpox, measles, mumps, rubella, erythema infectiosum, scarlet fever, and hand, foot and mouth disease. Each infection has its own set of symptoms such as fever, rash, and lymphadenopathy. Some infections have specific identifying features such as Koplik spots in measles and a ‘slapped-cheek’ rash in erythema infectiosum. Hand, foot and mouth disease is caused by the coxsackie A16 virus and presents with vesicles in the mouth and on the palms and soles of the feet.
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This question is part of the following fields:
- Children And Young People
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Question 17
Incorrect
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A 55-year-old man is hospitalized for acute pancreatitis and has a weekly alcohol intake of 90 units. What is the timeframe for the highest occurrence of delirium tremens after ceasing alcohol consumption?
Your Answer:
Correct Answer: 72 hours
Explanation:Symptoms of alcohol withdrawal can occur within 6-12 hours, seizures may occur after 36 hours, and delirium tremens can also be a potential complication.
Alcohol withdrawal occurs when an individual who has been consuming alcohol chronically suddenly stops or reduces their intake. This is due to the fact that chronic alcohol consumption enhances GABA-mediated inhibition in the central nervous system (CNS), similar to benzodiazepines, and inhibits NMDA-type glutamate receptors. When alcohol consumption is stopped, the opposite occurs, resulting in decreased inhibitory GABA and increased NMDA glutamate transmission.
Symptoms of alcohol withdrawal typically start within 6-12 hours and include tremors, sweating, tachycardia, and anxiety. Seizures are most likely to occur at around 36 hours, while delirium tremens, which is characterized by coarse tremors, confusion, delusions, auditory and visual hallucinations, fever, and tachycardia, is most likely to occur at around 48-72 hours.
Patients with a history of complex withdrawals from alcohol, such as delirium tremens, seizures, or blackouts, should be admitted to the hospital for monitoring until their withdrawals stabilize. The first-line treatment for alcohol withdrawal is long-acting benzodiazepines, such as chlordiazepoxide or diazepam, which are typically given as part of a reducing dose protocol. Lorazepam may be preferable in patients with hepatic failure. Carbamazepine is also effective in treating alcohol withdrawal, while phenytoin is said not to be as effective in the treatment of alcohol withdrawal seizures.
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This question is part of the following fields:
- Mental Health
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Question 18
Incorrect
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A 65-year-old man presents with an acute red eye.
Of the following conditions which is the most likely cause?Your Answer:
Correct Answer: Closed angle glaucoma
Explanation:Causes of Acute Red Eye
There are several causes of acute red eye, with glaucoma being the most likely to present with this symptom. Other possible causes include anterior uveitis, corneal ulcers, conjunctivitis, scleritis and episcleritis, and subconjunctival haemorrhage. It is important to note that optic neuritis presents with a specific type of central visual loss known as a central scotoma, while retinal vein occlusion, retinal detachment, and vitreous haemorrhage typically present as visual loss or disturbance. Understanding the various causes of acute red eye can help healthcare professionals make an accurate diagnosis and provide appropriate treatment.
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This question is part of the following fields:
- Eyes And Vision
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Question 19
Incorrect
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A 16-year-old patient presents with concerns about her acne treatment. She has been using a topical gel containing benzoyl peroxide and clindamycin for the past 3 months but has not seen significant improvement.
Upon examination, she has inflammatory papules and closed comedones on her forehead and chin, as well as some on her upper back. She is interested in a stronger medication and asks if she should continue using the gel alongside it.
What advice should you give regarding her current topical treatment?Your Answer:
Correct Answer: Change to topical benzoyl peroxide alone, or topical retinoid
Explanation:To effectively treat acne, it is not recommended to use both topical and oral antibiotics together. Instead, the patient should switch to using either topical benzoyl peroxide or a topical retinoid alone. Continuing to use the current combination gel or switching to topical clindamycin or topical lymecycline alone are not recommended as they involve the use of both topical and oral antibiotics, which can lead to antibiotic resistance. According to NICE guidelines, a combination of topical benzoyl peroxide or a topical retinoid with oral antibiotics is a more effective treatment option.
Acne vulgaris is a common skin condition that usually affects teenagers and is characterized by the obstruction of hair follicles with keratin plugs, resulting in comedones, inflammation, and pustules. The severity of acne can be classified as mild, moderate, or severe, depending on the number and type of lesions present. Treatment for acne typically involves a step-up approach, starting with single topical therapy and progressing to combination therapy or oral antibiotics if necessary. Tetracyclines are commonly used but should be avoided in certain populations, and a topical retinoid or benzoyl peroxide should always be co-prescribed to reduce the risk of antibiotic resistance. Combined oral contraceptives can also be used in women, and oral isotretinoin is reserved for severe cases under specialist supervision. Dietary modification has no role in the management of acne.
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This question is part of the following fields:
- Dermatology
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Question 20
Incorrect
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A 50-year-old woman had a renal transplant three months ago. She presents with fatigue, fever, sweating (especially at night), aching joints and headaches. On examination, there are no focal signs.
Which is the MOST LIKELY diagnosis?Your Answer:
Correct Answer: Cytomegalovirus (CMV) infection
Explanation:Common Infections in Kidney Transplant Patients
Kidney transplant patients are at a higher risk of infections due to immunosuppression. In the first month post-transplant, infections are similar to those in non-immunosuppressed individuals. However, in the one-month to six-month period, immunomodulating viruses like Cytomegalovirus (CMV), herpes simplex viruses, Epstein–Barr virus, and human herpesvirus-6, hepatitis A, B and C viruses, and human immunodeficiency virus (HIV) are most problematic. influenza can also cause respiratory symptoms, but routine annual administration of the injectable inactivated vaccine is recommended. Herpes simplex virus can cause severe lesions and even disseminated or visceral disease. Pneumonia and urinary infections are also common, and patients should receive appropriate immunisation and prophylactic antibiotics and antiviral drugs for a few months after transplantation. A small group of patients may experience persistence of viral infections and are at risk of opportunistic infections like cryptococcus, pneumocystis, listeria, and nocardia.
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This question is part of the following fields:
- Allergy And Immunology
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Question 21
Incorrect
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A previously healthy 6-month-old baby boy is brought to the General Practitioner with a 3-day history of coughing. He has now started to go off his feeds and his mother is getting rather concerned. On examination, he is tachypnoeic, with fine crepitations heard all over his lungs, with some wheeze in both lung fields.
What is the most likely diagnosis?Your Answer:
Correct Answer: Bronchiolitis
Explanation:Differential Diagnosis for Respiratory Symptoms in Infants
Respiratory symptoms in infants can be caused by a variety of conditions, and it is important to consider the differential diagnosis to provide appropriate treatment. Here are some common conditions and their typical symptoms:
Bronchiolitis: This acute infection of the lower respiratory tract is most common in infants between two and six months old. Symptoms include difficulty feeding, low-grade fever, coryza, cough, dyspnoea, wheezing, and respiratory distress.
Croup: This inflammation of the upper airways is usually caused by a respiratory virus and affects children from three months to three years old. Symptoms include a barking cough, stridor, and wheeze.
Asthma: This condition is rarely diagnosed in infants due to the lack of a clear diagnostic test. Symptoms overlap with common childhood illnesses and include coughing, wheezing, and difficulty breathing.
Heart failure: This should be considered in infants with feeding and breathing difficulties, but typically presents with symptoms since birth.
Pneumonia: This is another possible diagnosis for respiratory symptoms in infants, but examination findings such as reduced air entry and dull percussion note would support this diagnosis.
In summary, a thorough evaluation of symptoms and examination findings is necessary to determine the appropriate diagnosis and treatment for respiratory symptoms in infants.
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This question is part of the following fields:
- Children And Young People
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Question 22
Incorrect
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A 32-year-old practice nurse accidentally stabs herself with a used needle from a patient infected with the hepatitis C virus.
Select the single most appropriate management option.Your Answer:
Correct Answer: Test for HCV RNA at 6 weeks
Explanation:Transmission and Treatment of Hepatitis C
Hepatitis C virus is not as easily transmitted through a needlestick as hepatitis B virus, with a risk of transmission estimated at only 3%. Currently, there is no post-exposure vaccine available and neither immunoglobulin nor any antiviral agent has been proven effective in preventing transmission. Studies have shown that high anti-HCV titre immunoglobulin did not prevent transmission. Healthcare workers exposed to a source known to be positive for anti-HCV or HCV RNA should have their serum tested for HCV RNA at 6 and 12 weeks and for anti-HCV at 12 and 24 weeks.
In the treatment of hepatitis C infection, peg-interferon α and ribavirin are commonly used. These treatments have been found to be particularly effective in people infected with virus of genotypes 2 and 3.
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This question is part of the following fields:
- Infectious Disease And Travel Health
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Question 23
Incorrect
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A 29-year-old man presents to the emergency department with a three-day history of foot drop and tingling to his hands. Today he has noticed difficulty rising from a chair and climbing stairs. His past medical history is unremarkable except for a recent respiratory tract infection.
Upon examination, the patient has normal limb tone, reduced strength in his legs bilaterally (distal muscles worse than proximal), and a loss of his patella and ankle reflexes. Additionally, he has reduced sensation in a glove and stocking distribution.
What is the most likely diagnosis for this individual?Your Answer:
Correct Answer: Guillain-Barré syndrome
Explanation:Guillain-Barre syndrome is suggested by a progressive peripheral polyneuropathy with hyporeflexia. This condition is characterized by symmetrical demyelination caused by an autoimmune response, often triggered by a respiratory or GI infection.
Lyme disease, on the other hand, is caused by a tick bite and typically presents with vague neurological symptoms such as headaches and joint pain.
While multiple sclerosis can cause weakness and sensory loss, these symptoms are usually asymmetrical and accompanied by hyperreflexia.
Myasthenia gravis may also cause limb-girdle weakness, but it is more commonly associated with periocular symptoms such as eyelid drooping. Additionally, myasthenia gravis causes muscle fatigue rather than a progressive polyneuropathy.
Guillain-Barre Syndrome: A Breakdown of its Features
Guillain-Barre syndrome is a condition that occurs when the immune system attacks the peripheral nervous system, resulting in demyelination. This is often triggered by an infection, with Campylobacter jejuni being a common culprit. In the initial stages of the illness, around 65% of patients experience back or leg pain. However, the characteristic feature of Guillain-Barre syndrome is progressive, symmetrical weakness of all limbs, with the legs being affected first in an ascending pattern. Reflexes are reduced or absent, and sensory symptoms tend to be mild. Other features may include a history of gastroenteritis, respiratory muscle weakness, cranial nerve involvement, diplopia, bilateral facial nerve palsy, oropharyngeal weakness, and autonomic involvement, which can lead to urinary retention and diarrhea. Less common findings may include papilloedema, which is thought to be secondary to reduced CSF resorption. To diagnose Guillain-Barre syndrome, a lumbar puncture may be performed, which can reveal a rise in protein with a normal white blood cell count (albuminocytologic dissociation) in 66% of cases. Nerve conduction studies may also be conducted, which can show decreased motor nerve conduction velocity due to demyelination, prolonged distal motor latency, and increased F wave latency.
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This question is part of the following fields:
- Neurology
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Question 24
Incorrect
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A 60-year-old woman with type II diabetes mellitus has developed persistent proteinuria. Renal function tests reveal a glomerular filtration rate [GFR] of 49 ml/minute/1.73 m2), similar levels were found four months previously. Her blood pressure today is 140/88 mmHg.
Which of the following medications is most likely to improve the patient's renal prognosis?Your Answer:
Correct Answer: Angiotensin-converting enzyme (ACE) inhibitors
Explanation:Treatment Options for Chronic Kidney Disease
Chronic kidney disease (CKD) is defined by the presence of kidney damage or decreased kidney function for three months or more. Patients with proteinuria of any cause can benefit from treatment with angiotensin-converting enzyme (ACE) inhibitors, which improve renal prognosis and reduce cardiovascular risk. Blood pressure control with medications like doxazosin can also improve renal outcomes, but blocking the renin-angiotensin aldosterone system is most effective in halting disease progression. Antiplatelet therapy with aspirin is recommended for secondary prevention of cardiovascular disease, while vitamin D supplementation is used to treat deficiency in later stages of CKD and CKD-mineral and bone disorders. Statins like atorvastatin should be offered to all CKD patients to reduce the risk of cardiovascular disease.
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This question is part of the following fields:
- Kidney And Urology
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Question 25
Incorrect
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What is the most accurate definition of informed consent?
Your Answer:
Correct Answer: Putting the best interests of the patient first
Explanation:Understanding Informed Consent
Informed consent is a crucial process in healthcare that involves informing patients about the potential benefits and risks of a particular course of action. It is a way of ensuring that patients are fully aware of what they are agreeing to and that they have given their permission to proceed. This process is essential in upholding the principle of patient autonomy, which recognizes the right of patients to make decisions about their own healthcare.
It is important to note that informed consent is not the same as putting the best interests of the patient first. While doctors are obligated to act in the best interests of their patients, informed consent is about ensuring that patients have the information they need to make their own decisions. This means that patients may choose a course of action that is not necessarily in their best interests, but that they have the right to make that choice.
Obtaining a second opinion is not always necessary for informed consent, but it can be helpful in certain situations. For example, if a patient is considering a complex or risky procedure, they may want to seek a second opinion to ensure that they have all the information they need to make an informed decision. Ultimately, the goal of informed consent is to empower patients to make decisions about their own healthcare and to ensure that those decisions are respected.
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This question is part of the following fields:
- Improving Quality, Safety And Prescribing
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Question 26
Incorrect
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A 65-year-old man presents with haematuria. Investigations confirm the presence of a bladder carcinoma.
In his occupational history, select the single substance exposure which would be a significant risk factor for his current diagnosis.Your Answer:
Correct Answer: Aromatic amines
Explanation:Occupational and Environmental Carcinogens: A Brief Overview
Exposure to certain chemicals and substances in the workplace and environment can increase the risk of developing cancer. Bladder carcinoma, for example, is linked to exposure to aromatic amines found in various industries such as dyes, paints, and textiles. Smoking is also a major contributor to bladder cancer. Asbestos, commonly found in construction materials, increases the risk of lung cancer and mesothelioma. Vinyl chloride, used in plastic production and tobacco smoke, is associated with liver cancer, brain cancer, lung cancer, lymphoma, and leukemia. Arsenic exposure predisposes individuals to skin cancer, while nickel exposure increases the risk of squamous-cell carcinomas in the lung and nasal cavity. It is important for individuals to be aware of potential carcinogens in their workplace and environment to take necessary precautions and reduce their risk of developing cancer.
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This question is part of the following fields:
- Kidney And Urology
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Question 27
Incorrect
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Which of the following statements about the use of triptan agonists for treating migraines is inaccurate?
Your Answer:
Correct Answer: Should be taken as soon as possible after the onset of an aura
Explanation:It is recommended to take triptans as soon as the headache begins, rather than waiting for the aura to start.
Understanding Triptans for Migraine Treatment
Triptans are a type of medication used to treat migraines. They work by activating specific receptors in the brain called 5-HT1B and 5-HT1D. Triptans are usually the first choice for acute migraine treatment and are often used in combination with other pain relievers like NSAIDs or paracetamol.
It is important to take triptans as soon as possible after the onset of a migraine headache, rather than waiting for the aura to begin. Triptans are available in different forms, including oral tablets, orodispersible tablets, nasal sprays, and subcutaneous injections.
While triptans are generally safe and effective, they can cause some side effects. Some people may experience what is known as triptan sensations, which can include tingling, heat, tightness in the throat or chest, heaviness, or pressure.
Triptans are not suitable for everyone. People with a history of or significant risk factors for ischaemic heart disease or cerebrovascular disease should not take triptans.
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This question is part of the following fields:
- Neurology
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Question 28
Incorrect
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A patient who is an intravenous drug user has contracted hepatitis C. What percentage of such patients in their age group will develop chronic hepatitis C infection?
Your Answer:
Correct Answer: 55-85%
Explanation:Develop a persistent infection.
Hepatitis C is a virus that is expected to become a significant public health issue in the UK in the coming years, with around 200,000 people believed to be chronically infected. Those at risk include intravenous drug users and individuals who received a blood transfusion before 1991, such as haemophiliacs. The virus is an RNA flavivirus with an incubation period of 6-9 weeks. Transmission can occur through needle stick injuries, vertical transmission from mother to child, and sexual intercourse, although the risk is relatively low. There is currently no vaccine for hepatitis C.
After exposure to the virus, only around 30% of patients will develop symptoms such as a transient rise in serum aminotransferases, jaundice, fatigue, and arthralgia. HCV RNA is the preferred diagnostic test for acute infection, although patients who spontaneously clear the virus will continue to have anti-HCV antibodies. Chronic hepatitis C is defined as the persistence of HCV RNA in the blood for 6 months and can lead to complications such as rheumatological problems, cirrhosis, hepatocellular cancer, and cryoglobulinaemia.
The management of chronic hepatitis C depends on the viral genotype and aims to achieve sustained virological response (SVR), defined as undetectable serum HCV RNA six months after the end of therapy. Interferon-based treatments are no longer recommended, and a combination of protease inhibitors with or without ribavirin is currently used. However, these treatments can have side effects such as haemolytic anaemia, cough, flu-like symptoms, depression, fatigue, leukopenia, and thrombocytopenia. Women should not become pregnant within 6 months of stopping ribavirin as it is teratogenic.
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This question is part of the following fields:
- Infectious Disease And Travel Health
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Question 29
Incorrect
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A 32-year-old woman has reached out for a telephone consultation regarding her recent cervical smear results. She underwent the routine screening programme and is currently not experiencing any symptoms. Her last cervical smear was conducted 3 years ago and was reported as normal. She has not been vaccinated against human papillomavirus (HPV). The results of her recent test are as follows:
- High-risk human papillomavirus (hrHPV): POSITIVE.
- Cytology: ABNORMAL (high-grade dyskaryosis).
What would be the next course of action in managing her condition?Your Answer:
Correct Answer: Referral to colposcopy for consideration of large loop excision of the transformation zone (LLETZ)
Explanation:The appropriate technique to treat cervical intraepithelial neoplasia (CIN2 or CIN3) is urgent large loop excision of the transformation zone (LLETZ). This procedure is commonly performed in the same appointment or in a prompt subsequent appointment. Cryotherapy may also be an option to remove the abnormal cells. Offering the HPV vaccination is not a correct answer as it is only offered to girls and boys aged 12 to 13. A repeat cervical smear within 3 months is also not a correct answer, as it is only offered if the high-risk human papillomavirus (hrHPV) test result is unavailable or cytology is inadequate. Routine referral to gynaecology is also not indicated, as the patient would already be followed up by the colposcopy service.
Understanding Cervical Cancer Screening Results
The cervical cancer screening program has evolved significantly in recent years, with the introduction of HPV testing allowing for further risk stratification. The NHS now uses an HPV first system, where a sample is tested for high-risk strains of human papillomavirus (hrHPV) first, and cytological examination is only performed if this is positive.
If the hrHPV test is negative, individuals can return to normal recall, unless they fall under the test of cure pathway, untreated CIN1 pathway, or require follow-up for incompletely excised cervical glandular intraepithelial neoplasia (CGIN) / stratified mucin producing intraepithelial lesion (SMILE) or cervical cancer. If the hrHPV test is positive, samples are examined cytologically, and if the cytology is abnormal, individuals will require colposcopy.
If the cytology is normal but the hrHPV test is positive, the test is repeated at 12 months. If the repeat test is still hrHPV positive and cytology is normal, a further repeat test is done 12 months later. If the hrHPV test is negative at 24 months, individuals can return to normal recall, but if it is still positive, they will require colposcopy. If the sample is inadequate, it will need to be repeated within 3 months, and if two consecutive samples are inadequate, colposcopy will be required.
For individuals who have previously had CIN, they should be invited for a test of cure repeat cervical sample in the community 6 months after treatment. The most common treatment for cervical intraepithelial neoplasia is large loop excision of transformation zone (LLETZ), which may be done during the initial colposcopy visit or at a later date depending on the individual clinic. Cryotherapy is an alternative technique.
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This question is part of the following fields:
- Gynaecology And Breast
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Question 30
Incorrect
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A researcher is designing a crossover trial to study the efficacy of a new antiviral medication versus a placebo for treating influenza in elderly patients. The medication being studied has a very short half-life. The sample size that is available to the researcher for this trial is small but there is a long time period available for the trial to be completed. All of the elderly patients that have agreed to take part in the study are expecting to receive the active treatment.
Which of these factors may make a crossover trial unsuitable in this case?Your Answer:
Correct Answer: The natural course of the disease
Explanation:Considerations for Conducting a Crossover Trial
When considering conducting a crossover trial, there are several factors to take into account. Firstly, the natural course of the disease being studied should be considered, as crossover trials are less suited to studying self-limiting illnesses. Secondly, the expectations of the patients regarding the treatment they will receive should be taken into account, as all participants will receive both the active treatment and the placebo. Thirdly, the half-life of the medication should be considered, as drugs with a long half-life may confound the results. Fourthly, the sample size required for a crossover trial is typically smaller than for other types of trial. Finally, the time available for the trial to be completed should be considered, as crossover trials consist of two study periods and may take longer than parallel designs.
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This question is part of the following fields:
- Population Health
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