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Question 1
Correct
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A 50-year-old woman presents to the ear, nose and throat clinic with a 4-month history of left-sided hearing loss. She reports occasional ringing in her left ear and feeling unsteady. She has a medical history of well-controlled type 1 diabetes and denies any recent infections.
During the examination, Rinne's test is positive in both ears, and Weber's test lateralizes to her right ear. There is no evidence of nystagmus, and her coordination is normal. Other than an absent left-sided corneal reflex, her cranial nerve examination is unremarkable.
What is the most likely diagnosis?Your Answer: Acoustic neuroma
Explanation:If a patient presents with a loss of corneal reflex, an acoustic neuroma should be considered as a possible cause. This is a benign tumor that affects the vestibulocochlear nerve and can lead to symptoms such as vertigo, tinnitus, and unilateral sensorineural hearing loss. In some cases, the tumor can also invade the trigeminal nerve, resulting in an absent corneal reflex.
Other conditions that may cause hearing loss and vertigo include cholesteatoma, labyrinthitis, and Meniere’s disease. However, in this case, the patient’s hearing tests indicate a sensorineural hearing loss, which makes cholesteatoma less likely. Labyrinthitis typically causes acute vertigo that can persist for several days, but it would not be the cause of the loss of the corneal reflex. Meniere’s disease is characterized by a triad of symptoms, including tinnitus, vertigo, and sensorineural hearing loss, but the vertigo tends to be shorter in duration and follow a relapsing and remitting course.
Understanding Vestibular Schwannoma (Acoustic Neuroma)
Vestibular schwannoma, also known as acoustic neuroma, is a type of brain tumor that accounts for 5% of intracranial tumors and 90% of cerebellopontine angle tumors. The condition is characterized by a combination of symptoms such as vertigo, hearing loss, tinnitus, and an absent corneal reflex. The affected cranial nerves can predict the features of the condition. For instance, cranial nerve VIII can cause vertigo, unilateral sensorineural hearing loss, and unilateral tinnitus. On the other hand, cranial nerve V can lead to an absent corneal reflex, while cranial nerve VII can cause facial palsy.
Bilateral vestibular schwannomas are often seen in neurofibromatosis type 2. The diagnosis of vestibular schwannoma is made through an MRI of the cerebellopontine angle, and audiometry is also important since only 5% of patients have a normal audiogram.
The management of vestibular schwannoma involves surgery, radiotherapy, or observation. The choice of treatment depends on the size and location of the tumor, the patient’s age and overall health, and the severity of symptoms. In conclusion, understanding vestibular schwannoma is crucial in managing the condition effectively.
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This question is part of the following fields:
- ENT
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Question 2
Correct
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A 7-year-old girl is brought to surgery by her father. For the past 3 months she has been complaining of pain in her shins and ankles at night-time. Her symptoms are bilateral and she is otherwise healthy. There is no significant family history. Upon clinical examination, no abnormalities are found. What is the probable diagnosis?
Your Answer: Growing pains
Explanation:Understanding Growing Pains in Children
Growing pains are a common complaint among children aged 3-12 years. These pains are often attributed to ‘benign idiopathic nocturnal limb pains of childhood’ in rheumatology, as they are not necessarily related to growth. Boys and girls are equally affected by growing pains, which are characterized by intermittent pain in the legs with no obvious cause.
One of the key features of growing pains is that they are never present at the start of the day after the child has woken up. Additionally, there is no limp or limitation of physical activity, and the child is systemically well with normal physical examination and motor milestones. Symptoms may worsen after a day of vigorous activity.
Overall, growing pains are a benign condition that can be managed with reassurance and simple measures such as massage or heat application. However, it is important to rule out other potential causes of leg pain in children, especially if there are any worrying features present.
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This question is part of the following fields:
- Paediatrics
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Question 3
Incorrect
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A 36-year-old entrepreneur arrives at Eye Casualty complaining of blurred vision in both eyes that started an hour ago. He reports seeing multiple wavy and shimmering lines in his peripheral vision that are gradually getting bigger. Upon examination with a slit lamp, the anterior chamber is clear and the fundus appears normal. What is the probable reason for his symptoms?
Your Answer: Posterior vitreous detachment
Correct Answer: Migraine with aura
Explanation:Migraine sufferers often experience visual symptoms before the onset of a headache, such as wavy or shimmering lines known as a scintillating scotoma. It is important to obtain a thorough medical history as the patient may not mention a history of headaches. A normal eye exam is crucial for proper diagnosis. The other conditions listed have associated exam findings, such as cells in the anterior chamber for uveitis, a pale disc and relative afferent pupillary defect for optic neuritis, and a Weiss ring appearance with occasional hemorrhage for posterior vitreous detachment.
Diagnostic Criteria for Migraine
Migraine is a neurological disorder that affects millions of people worldwide. The International Headache Society has established diagnostic criteria for migraine without aura, which includes at least five attacks lasting between 4-72 hours and having at least two of the following characteristics: unilateral location, pulsating quality, moderate or severe pain intensity, and aggravation by routine physical activity. During the headache, there must be at least one of the following: nausea and/or vomiting, photophobia, and phonophobia. The headache cannot be attributed to another disorder.
Migraine with aura, which is seen in around 25% of migraine patients, tends to be easier to diagnose with a typical aura being progressive in nature and may occur hours prior to the headache. Typical aura include a transient hemianopic disturbance or a spreading scintillating scotoma (‘jagged crescent’). Sensory symptoms may also occur. NICE criteria suggest that migraines may be unilateral or bilateral and give more detail about typical auras, which may occur with or without headache and are fully reversible, develop over at least 5 minutes, and last 5-60 minutes. Atypical aura symptoms such as motor weakness, double vision, visual symptoms affecting only one eye, poor balance, and decreased level of consciousness may prompt further investigation or referral.
In summary, the diagnostic criteria for migraine without aura include specific characteristics of the headache and associated symptoms, while migraine with aura is characterized by typical aura symptoms that may occur prior to the headache. It is important to accurately diagnose migraine to provide appropriate treatment and management for those who suffer from this debilitating condition.
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This question is part of the following fields:
- Ophthalmology
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Question 4
Incorrect
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A 25-year-old woman came to your GP clinic complaining of sudden onset itching, burning, and watering in both eyes. During the examination, you noticed moderate chemosis in both eyes and conjunctival follicles. You also discovered tender preauricular lymph nodes while palpating her neck. She informed you that her boyfriend had similar symptoms a week ago. What is the most probable diagnosis?
Your Answer: Chlamydial conjunctivitis
Correct Answer: Adenoviral conjunctivitis
Explanation:Adenoviral conjunctivitis is easily spread from person to person. The patient’s boyfriend had the same condition a week ago, so it’s not surprising that she has it now. This type of viral conjunctivitis is the most common.
There is no evidence of herpes simplex because there are no cold sores or dendritic ulcers visible with fluorescein uptake.
Bacterial and chlamydial conjunctivitis are unlikely because there is no pus discharge. Allergic conjunctivitis is also unlikely because there is no history of atopy or itchiness.Conjunctivitis is a common eye problem that is often seen in primary care. It is characterized by red, sore eyes with a sticky discharge. There are two types of infective conjunctivitis: bacterial and viral. Bacterial conjunctivitis is identified by a purulent discharge and eyes that may be stuck together in the morning. On the other hand, viral conjunctivitis is characterized by a serous discharge and recent upper respiratory tract infection, as well as preauricular lymph nodes.
In most cases, infective conjunctivitis is a self-limiting condition that resolves without treatment within one to two weeks. However, topical antibiotic therapy is often offered to patients, such as Chloramphenicol drops given every two to three hours initially or Chloramphenicol ointment given four times a day initially. Alternatively, topical fusidic acid can be used, especially for pregnant women, and treatment is twice daily.
For contact lens users, topical fluoresceins should be used to identify any corneal staining, and treatment should be the same as above. During an episode of conjunctivitis, contact lenses should not be worn, and patients should be advised not to share towels. School exclusion is not necessary.
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This question is part of the following fields:
- Ophthalmology
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Question 5
Correct
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A 19-year-old man's mother visits his General Practitioner with concerns about her son's behavior. The young man has become isolated from his social circle, has developed an interest in the paranormal, and appears increasingly disheveled. He has been observed talking to himself and recently covered the TV screen with paper. His speech is erratic and jumps from one unrelated topic to another. He is not using any psychotropic drugs and has no history of health issues. What is the most probable diagnosis?
Your Answer: Schizophrenia
Explanation:Differentiating between Schizophrenia and other Mental Disorders
Schizophrenia is a mental disorder that is characterized by delusions, hallucinations, abnormal behavior, social withdrawal, blunted emotions, and breaks in thought processes. These symptoms are often accompanied by an irritable or depressed mood. When presented with a patient exhibiting these symptoms, schizophrenia is the most likely diagnosis.
Dissociative identity disorder, on the other hand, is a complex psychological disorder where the individual appears to have two or more distinct personalities that alternate and dictate their behavior. This disorder is associated with severe childhood trauma, which is not present in the case of the patient in question.
Bipolar disorder is characterized by extreme mood swings, ranging from mania to depression. While the patient exhibits some symptoms of depression, they are not displaying symptoms of mania, making bipolar disorder an unlikely diagnosis.
Delirium is a serious disturbance in mental abilities that results in confused thinking and reduced awareness of the environment. While an underlying physical cause should be excluded, the patient’s symptoms are more consistent with a psychotic illness than delirium.
Depression is characterized by continuous low mood, hopelessness, low self-esteem, tearfulness, and irritability. While patients with severe depression may suffer from psychotic episodes, the patient in question is exhibiting symptoms more consistent with schizophrenia, such as knights move thinking and responding to auditory hallucinations.
In conclusion, differentiating between schizophrenia and other mental disorders requires a thorough understanding of the symptoms and their presentation. While some disorders may share similar symptoms, a careful evaluation of the patient’s history and behavior can help determine the correct diagnosis.
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This question is part of the following fields:
- Psychiatry
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Question 6
Incorrect
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A 72-year-old man presents for follow-up. He was diagnosed with angina pectoris and is currently prescribed aspirin 75mg once daily, simvastatin 40 mg once daily, and atenolol 100 mg once daily. If his angina symptoms are not adequately managed with this regimen, what would be the most suitable course of action?
Your Answer: Add an ACE inhibitor
Correct Answer: Add a long-acting dihydropyridine calcium-channel blocker
Explanation:When beta-blockers fail to control angina, it is recommended to supplement with a dihydropyridine calcium channel blocker that has a longer duration of action.
Angina pectoris is a condition that can be managed through various methods, including lifestyle changes, medication, percutaneous coronary intervention, and surgery. In 2011, NICE released guidelines for the management of stable angina. Medication is an important aspect of treatment, and all patients should receive aspirin and a statin unless there are contraindications. Sublingual glyceryl trinitrate can be used to abort angina attacks. The first-line medication should be either a beta-blocker or a calcium channel blocker, depending on the patient’s comorbidities, contraindications, and preferences. If a calcium channel blocker is used as monotherapy, a rate-limiting one such as verapamil or diltiazem should be used. If used in combination with a beta-blocker, a longer-acting dihydropyridine calcium channel blocker should be used. Beta-blockers should not be prescribed concurrently with verapamil due to the risk of complete heart block. If the initial treatment is not effective, medication should be increased to the maximum tolerated dose. If a patient is still symptomatic after monotherapy with a beta-blocker, a calcium channel blocker can be added, and vice versa. If a patient cannot tolerate the addition of a calcium channel blocker or a beta-blocker, other drugs such as long-acting nitrates, ivabradine, nicorandil, or ranolazine can be considered. Nitrate tolerance is a common issue, and patients who take standard-release isosorbide mononitrate should use an asymmetric dosing interval to maintain a daily nitrate-free time of 10-14 hours to minimize the development of nitrate tolerance. This effect is not seen in patients who take once-daily modified-release isosorbide mononitrate. If a patient is taking both a beta-blocker and a calcium-channel blocker, a third drug should only be added while awaiting assessment for PCI or CABG.
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This question is part of the following fields:
- Cardiovascular
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Question 7
Correct
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A 26-year-old female patient visits your clinic complaining of vaginal discharge. She reports a strong odour but no itching, dysuria, dyspareunia, or post-coital bleeding. During the examination, you observe a watery discharge with an odour, but no erythema on the labia. The cervix appears healthy, and there is no cervical excitation. What is the probable diagnosis?
Your Answer: Bacterial vaginosis
Explanation:To determine the cause of the watery vaginal discharge in this patient, further information about her sexual history would be necessary. However, based on the appearance of her cervix, a diagnosis of Gonorrhoea is unlikely. Gonorrhoea typically presents with a green and purulent discharge, and is not often associated with an odour. Similarly, Chlamydia would likely cause more problems with the cervix and a more mucopurulent discharge. Herpes simplex does not typically cause vaginal discharge, but instead presents with ulcers or tingling sensations around the vulva. Thrush, or candidiasis, would likely cause more itching and have a thicker, cottage cheese-like consistency. Bacterial vaginosis is the most likely diagnosis, as it often presents with a fishy odour and a thin, watery discharge that may be green or white. It can be asymptomatic and does not typically cause irritation or soreness. Diagnosis can be confirmed with a vaginal pH > 4.5 and the presence of clue cells on microscopy. These findings are in line with BASHH guidelines.
Bacterial vaginosis (BV) is a condition where there is an overgrowth of anaerobic organisms, particularly Gardnerella vaginalis, in the vagina. This leads to a decrease in the amount of lactobacilli, which produce lactic acid, resulting in an increase in vaginal pH. BV is not a sexually transmitted infection, but it is commonly seen in sexually active women. Symptoms include a fishy-smelling vaginal discharge, although some women may not experience any symptoms at all. Diagnosis is made using Amsel’s criteria, which includes the presence of thin, white discharge, clue cells on microscopy, a vaginal pH greater than 4.5, and a positive whiff test. Treatment involves oral metronidazole for 5-7 days, with a cure rate of 70-80%. However, relapse rates are high, with over 50% of women experiencing a recurrence within 3 months. Topical metronidazole or clindamycin may be used as alternatives.
Bacterial vaginosis during pregnancy can increase the risk of preterm labor, low birth weight, chorioamnionitis, and late miscarriage. It was previously recommended to avoid oral metronidazole in the first trimester and use topical clindamycin instead. However, recent guidelines suggest that oral metronidazole can be used throughout pregnancy. The British National Formulary (BNF) still advises against using high-dose metronidazole regimes. Clue cells, which are vaginal epithelial cells covered with bacteria, can be seen on microscopy in women with BV.
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This question is part of the following fields:
- Reproductive Medicine
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Question 8
Incorrect
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Which one of the following statements regarding metformin is not true?
Your Answer: Decreases hepatic gluconeogenesis
Correct Answer: Increases endogenous insulin secretion
Explanation:Sulphonylureas possess the characteristic of enhancing the secretion of insulin produced naturally within the body.
Metformin is a medication commonly used to treat type 2 diabetes mellitus. It belongs to a class of drugs called biguanides and works by activating the AMP-activated protein kinase (AMPK), which increases insulin sensitivity and reduces hepatic gluconeogenesis. Additionally, it may decrease the absorption of carbohydrates in the gastrointestinal tract. Unlike other diabetes medications, such as sulphonylureas, metformin does not cause hypoglycemia or weight gain, making it a first-line treatment option, especially for overweight patients. It is also used to treat polycystic ovarian syndrome and non-alcoholic fatty liver disease.
While metformin is generally well-tolerated, gastrointestinal side effects such as nausea, anorexia, and diarrhea are common and can be intolerable for some patients. Reduced absorption of vitamin B12 is also a potential side effect, although it rarely causes clinical problems. In rare cases, metformin can cause lactic acidosis, particularly in patients with severe liver disease or renal failure. However, it is important to note that lactic acidosis is now recognized as a rare side effect of metformin.
There are several contraindications to using metformin, including chronic kidney disease, recent myocardial infarction, sepsis, acute kidney injury, severe dehydration, and alcohol abuse. Additionally, metformin should be discontinued before and after procedures involving iodine-containing x-ray contrast media to reduce the risk of contrast nephropathy.
When starting metformin, it is important to titrate the dose slowly to reduce the incidence of gastrointestinal side effects. If patients experience intolerable side effects, modified-release metformin may be considered as an alternative.
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This question is part of the following fields:
- Pharmacology/Therapeutics
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Question 9
Correct
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What is the most appropriate statement regarding GI bleeding caused by NSAID therapy? Choose only one option from the list.
Your Answer: It is due to depletion of mucosal prostaglandin E (PGE) levels
Explanation:Misconceptions about Non-Steroidal Anti-Inflammatory Drugs (NSAIDs)
Non-steroidal anti-inflammatory drugs (NSAIDs) are commonly used to relieve pain and inflammation. However, there are several misconceptions about their side effects. Here are some clarifications:
Clarifying Misconceptions about NSAIDs
Misconception 1: NSAIDs cause gastrointestinal (GI) bleeding by depleting mucosal prostaglandin E (PGE) levels.
Clarification: While it is true that NSAIDs can irritate the GI tract and reduce the levels of protective prostaglandins, not all NSAIDs have the same risk of causing GI bleeding. High-risk NSAIDs such as piroxicam have a higher prevalence of gastric side effects, while ibuprofen and diclofenac have lower rates. Additionally, GI bleeding can occur in patients without pre-existing peptic ulcers. Therefore, NSAIDs should be used at the lowest effective dose and for the shortest period possible.
Misconception 2: NSAIDs cause GI bleeding only in patients with pre-existing gastric and/or duodenal ulcers.
Clarification: While patients with pre-existing peptic ulcer disease are at higher risk of GI bleeding, NSAIDs can also cause GI bleeding in patients without ulcers. Therefore, caution should be exercised when prescribing NSAIDs to all patients.
Misconception 3: Severe dyspepsia is the only symptom of GI bleeding caused by NSAIDs.
Clarification: While dyspepsia is a common symptom of NSAID use, endoscopic evidence of peptic ulceration can be seen in up to 20% of asymptomatic patients taking NSAIDs. Therefore, regular monitoring and endoscopic evaluation may be necessary in patients taking NSAIDs.
Misconception 4: NSAIDs increase platelet adhesiveness.
Clarification: NSAIDs actually reduce platelet aggregation and adhesiveness, except for aspirin, which irreversibly inhibits COX-1 and is indicated for inhibition of platelet aggregation. However, aspirin use increases the risk of bleeding.
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This question is part of the following fields:
- Pharmacology/Therapeutics
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Question 10
Incorrect
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A 43-year-old patient presents to the emergency department with complaints of feeling generally unwell. He reports experiencing body aches and waking up in a cold sweat at night. Upon examination, you observe injection marks on the antecubital fossa. His vital signs reveal a temperature of 38.1ºC, heart rate of 122 bpm, blood pressure of 110/90 mmHg, respiratory rate of 18/min, and oxygen saturation of 98%. You urgently order blood cultures and an echocardiogram. Based on the diagnosis, which site is most likely affected?
Your Answer: Mitral valve
Correct Answer: Tricuspid valve
Explanation:The tricuspid valve is the valve most commonly affected by infective endocarditis in intravenous drug users.
Aetiology of Infective Endocarditis
Infective endocarditis is a condition that affects patients with previously normal valves, rheumatic valve disease, prosthetic valves, congenital heart defects, intravenous drug users, and those who have recently undergone piercings. The strongest risk factor for developing infective endocarditis is a previous episode of the condition. The mitral valve is the most commonly affected valve.
The most common cause of infective endocarditis is Staphylococcus aureus, particularly in acute presentations and intravenous drug users. Historically, Streptococcus viridans was the most common cause, but this is no longer the case except in developing countries. Streptococcus mitis and Streptococcus sanguinis are the two most notable viridans streptococci, commonly found in the mouth and dental plaque. Coagulase-negative Staphylococci such as Staphylococcus epidermidis are the most common cause of endocarditis in patients following prosthetic valve surgery.
Streptococcus bovis is associated with colorectal cancer, with the subtype Streptococcus gallolyticus being most linked to the condition. Non-infective causes of endocarditis include systemic lupus erythematosus and malignancy. Culture negative causes may be due to prior antibiotic therapy or infections caused by Coxiella burnetii, Bartonella, Brucella, or HACEK organisms (Haemophilus, Actinobacillus, Cardiobacterium, Eikenella, Kingella).
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This question is part of the following fields:
- Infectious Diseases
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Question 11
Correct
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A 48-year-old woman is referred to the oncology clinic by the local general surgeon. She has undergone a mastectomy for carcinoma of the right breast.
Which of the following factors is associated with a poor prognosis in patients with breast cancer?Your Answer: Young age
Explanation:Prognostic Factors in Breast Cancer and Their Impact on Survival
Breast cancer prognosis is influenced by several factors, including axillary nodal status, tumour type and grade, lymphatic/vascular invasion/proliferation markers, ethnicity, patient age at diagnosis, oestrogen receptor and progesterone receptor status, and HER2/neu overexpression. Younger patients tend to have more aggressive tumours, which increases their risk of recurrence and mortality over their lifetimes.
Oestrogen receptor-positive tumours have a better prognosis and can be treated with tamoxifen, which increases survival rates. Progesterone receptor-positive tumours also have a good prognosis and can be targeted using HER2 receptor modulators like tamoxifen. On the other hand, oestrogen receptor-negative and progesterone receptor-negative tumours are associated with a poor prognosis.
Tumour grade is another important prognostic factor, with high-grade tumours being linked to a poorer prognosis. Additionally, a positive lymph node status is a poor prognostic factor, as the risk of recurrence increases with the number of affected nodes.
In summary, understanding these prognostic factors can help healthcare professionals tailor treatment plans and provide patients with more accurate information about their prognosis and survival.
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This question is part of the following fields:
- Haematology/Oncology
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Question 12
Incorrect
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A 42-year-old female patient visits the GP clinic with two circular patches on her scalp that have resulted in hair loss and scarring. She reports that she first noticed these patches 4 weeks after returning from a trip to Italy. Upon further inquiry, she also acknowledges experiencing persistent joint pain and stiffness. Could scarring alopecia be caused by any of the following?
Your Answer: Telogen effluvium
Correct Answer: Lichen planus
Explanation:Scarring alopecia can be caused by various factors such as trauma/burns, radiotherapy, discoid lupus, tinea capitis, and lichen planus. However, out of these options, lichen planus is the only cause that leads to scarring alopecia. The remaining causes, including alopecia areata, carbimazole, trichotillomania, and telogen effluvium, result in non-scarring alopecia.
Input:
Alopecia may be divided into scarring (destruction of hair follicle) and non-scarring (preservation of hair follicle). Scarring alopecia can be caused by trauma, burns, radiotherapy, lichen planus, discoid lupus, and untreated tinea capitis. Non-scarring alopecia can be caused by male-pattern baldness, drugs such as cytotoxic drugs, carbimazole, heparin, oral contraceptive pill, and colchicine, nutritional deficiencies such as iron and zinc deficiency, autoimmune conditions such as alopecia areata, telogen effluvium, hair loss following a stressful period such as surgery, and trichotillomania.Output:
– Alopecia can be categorized into scarring and non-scarring types.
– Scarring alopecia is caused by trauma, burns, radiotherapy, lichen planus, discoid lupus, and untreated tinea capitis.
– Non-scarring alopecia is caused by male-pattern baldness, drugs such as cytotoxic drugs, carbimazole, heparin, oral contraceptive pill, and colchicine, nutritional deficiencies such as iron and zinc deficiency, autoimmune conditions such as alopecia areata, telogen effluvium, hair loss following a stressful period such as surgery, and trichotillomania. -
This question is part of the following fields:
- Dermatology
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Question 13
Incorrect
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A teenage boy presents with bizarre delusions, a blunted affect and tangential thought processes.
Which one of the following characteristics would indicate an unfavourable prognosis?
Your Answer: Catatonia
Correct Answer: A prolonged premorbid history of social withdrawal
Explanation:Understanding Prognostic Factors in Schizophrenia
Schizophrenia is a complex mental illness that can have a significant impact on a person’s life. While there is no cure for schizophrenia, early diagnosis and treatment can help manage symptoms and improve outcomes. Understanding prognostic factors can also be helpful in predicting the course of the illness and developing appropriate treatment plans.
One important factor to consider is the premorbid history of the patient. A prolonged history of social withdrawal is predictive of more severe and long-lasting psychopathology. Additionally, a family history of schizophrenia in first-degree relatives can have a negative impact on prognosis, while a history in second-degree relatives has little significance.
The onset of illness is also an important factor to consider. In schizophrenia, a sudden onset of illness has a more favourable prognosis than an insidious one. However, if the patient presents with catatonic symptoms, this is actually an indicator of a relatively good prognosis.
Finally, MRI changes are associated with more severe symptoms and clinical course in people with schizophrenia. While it is not fully clear whether these changes are fixed or progress over time, they can be an important factor to consider in developing a treatment plan.
Overall, understanding these prognostic factors can help clinicians develop appropriate treatment plans and provide better support for patients with schizophrenia.
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This question is part of the following fields:
- Psychiatry
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Question 14
Incorrect
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A 65-year-old man comes to the General Practitioner with his daughter. She reports that her father’s behavior has changed over the past year. He used to be a very sociable and outgoing man but recently he has become withdrawn and uninterested in his hobbies. He has also become forgetful and has difficulty completing tasks that he used to do easily. The patient tells you that he does not think there is anything wrong with him and he is just getting older.
Which of the following is the most likely diagnosis?Your Answer: Normal-pressure hydrocephalus (NPH)
Correct Answer: Frontotemporal dementia
Explanation:Differentiating Types of Dementia: A Brief Overview
Dementia is a broad term used to describe a decline in cognitive function that interferes with daily activities. However, there are different types of dementia, each with unique characteristics. Here are some key features to help differentiate between frontotemporal dementia, Alzheimer’s disease, Huntington’s disease, normal-pressure hydrocephalus (NPH), and Parkinson’s disease.
Frontotemporal Dementia
This type of dementia is rare and typically affects individuals between the ages of 55 and 65. Early personality and behavior changes are core symptoms, while memory impairment is not typical. Other key features include a gradual progression, decline in social conduct, emotional blunting, and loss of insight.Alzheimer’s Disease
Alzheimer’s disease is the most common form of dementia, affecting individuals over the age of 65. Memory loss is a key early symptom, followed by agitation and obsessive behavior later in the disease course.Huntington’s Disease
Huntington’s disease is a neurodegenerative condition that is often inherited. Symptoms include memory impairment, depression, clumsiness, mood swings, and difficulty concentrating. However, this patient’s symptoms are more consistent with early frontotemporal dementia.Normal-Pressure Hydrocephalus (NPH)
NPH is a reversible cause of dementia characterized by gait abnormality, memory impairment, and incontinence. It may be mistaken for Parkinson’s disease, but symptoms will not improve with levodopa.Parkinson’s Disease
While dementia and hallucinations may develop during the course of Parkinson’s disease, it is primarily a movement disorder characterized by tremors, rigidity, and bradykinesia. -
This question is part of the following fields:
- Neurology
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Question 15
Incorrect
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A 68-year-old woman presents to the emergency department with acute confusion. She arrives unaccompanied and is unable to provide any information about her medical history. Upon examination, she appears overweight and has non-pitting edema in her eyes and legs. Additionally, she has dry skin and coarse hair. Her vital signs include a heart rate of 50 beats/min, blood pressure of 90/60 mmHg, respiratory rate of 10 breaths/min, temperature of 30°C, and oxygen saturation of 90% on air. What is the most probable diagnosis?
Your Answer: Thyrotoxic storm
Correct Answer: Myxoedema coma
Explanation:Understanding Myxoedema Coma
Myxoedema coma is a serious medical condition that can lead to confusion and hypothermia. It is a medical emergency that requires immediate treatment. The treatment for myxoedema coma includes IV thyroid replacement, IV fluid, IV corticosteroids (until the possibility of coexisting adrenal insufficiency has been excluded), electrolyte imbalance correction, and sometimes rewarming.
In simpler terms, myxoedema coma is a condition that can cause confusion and low body temperature. It is a medical emergency that requires urgent treatment. The treatment involves giving medications through an IV, correcting any imbalances in the body’s fluids and electrolytes, and sometimes warming the body.
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This question is part of the following fields:
- Endocrinology/Metabolic Disease
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Question 16
Correct
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A 68-year-old man comes to the Emergency Department with severe inflammation of his first metatarsophalangeal joint. He reports swelling and tenderness of the joint and a sample of fluid is sent for microscopy. He has a medical history of hypertension and duodenal ulcers.
What is the most suitable initial medication to prescribe?
Choose ONE option from the list provided.Your Answer: Colchicine
Explanation:Managing Gout: Treatment Options and Contraindications
Gout is a type of arthritis caused by the deposition of urate crystals in the synovial fluid. Chronic hyperuricemia is the primary cause of this condition. The acute management of gout involves the use of non-steroidal anti-inflammatory drugs (NSAIDs) or colchicine as first-line treatment. However, the maximum dose of NSAIDs should be prescribed until 1-2 days after the symptoms have settled, and gastroprotection may also be necessary. Colchicine has a slower onset of action and may cause diarrhea as a side effect. Oral steroids or intra-articular steroid injections may be considered if NSAIDs and colchicine are contraindicated. Allopurinol is not recommended during the acute phase but is useful for preventing recurrent attacks of gout. Diclofenac and indomethacin are contraindicated in patients with duodenal ulcers, and colchicine is a suitable alternative for the treatment of gout. Diazepam, a benzodiazepine, is not useful in the treatment of gout as it does not have anti-inflammatory or analgesic properties.
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This question is part of the following fields:
- Pharmacology/Therapeutics
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Question 17
Incorrect
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You are urgently requested to assess a 62-year-old female patient admitted to the cardiology ward with complaints of breathing difficulty. During the examination, you observe a raised JVP and bilateral fine crackles to the mid zones. The patient's blood pressure is 100/60 mmHg, and the pulse is irregular and ranges between 140-150. An ECG confirms atrial fibrillation, and there is no prior history of the condition in the patient's notes or previous ECGs. What is the most appropriate course of action for managing this patient?
Your Answer: IV amiodarone
Correct Answer: Urgent synchronised DC cardioversion
Explanation:Urgent synchronised DC cardioversion is necessary when heart failure is observed as an adverse sign.
Management of Peri-Arrest Tachycardias
The Resuscitation Council (UK) guidelines for the management of peri-arrest tachycardias have been simplified in the 2015 update. The previous separate algorithms for broad-complex tachycardia, narrow complex tachycardia, and atrial fibrillation have been replaced by a unified treatment algorithm. After basic ABC assessment, patients are classified as stable or unstable based on the presence of adverse signs such as hypotension, pallor, sweating, confusion, or impaired consciousness. If any of these signs are present, synchronised DC shocks should be given, up to a maximum of three shocks.
The treatment following this is based on whether the QRS complex is narrow or broad and whether the rhythm is regular or irregular. For broad-complex tachycardia, a loading dose of amiodarone followed by a 24-hour infusion is given if the rhythm is regular. If the rhythm is irregular, expert help should be sought as it could be due to atrial fibrillation with bundle branch block, atrial fibrillation with ventricular pre-excitation, or torsade de pointes.
For narrow-complex tachycardia, vagal manoeuvres followed by IV adenosine are given if the rhythm is regular. If unsuccessful, atrial flutter is considered, and rate control is achieved with beta-blockers. If the rhythm is irregular, it is likely due to atrial fibrillation, and electrical or chemical cardioversion is considered if the onset is less than 48 hours. Beta-blockers are usually the first-line treatment for rate control unless contraindicated. The full treatment algorithm can be found on the Resuscitation Council website.
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This question is part of the following fields:
- Cardiovascular
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Question 18
Correct
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A 2-year-old child has been referred by the pediatrician to the clinic as they are concerned about the child's appearance. Upon examination, you observe that the child has upslanting palpebral fissures, prominent epicanthic folds, low-set ears, and a flat face. You proceed to conduct a neurological assessment.
What are the expected findings?Your Answer: Hypotonia
Explanation:Hypotonia in neonates can be caused by Down’s syndrome, but it is not the only cause. Down’s syndrome does not typically present with hyperreflexia or hypertonia, and it is not associated with spina bifida. While hyporeflexia may occur in some cases of Down’s syndrome, it is not the most common neurological presentation.
Understanding Hypotonia: Causes and Symptoms
Hypotonia, also known as floppiness, is a condition that can be caused by central nervous system disorders or nerve and muscle problems. It is characterized by a decrease in muscle tone, resulting in a lack of resistance to passive movement. In some cases, an acutely ill child may exhibit hypotonia during examination, while in others, it may be associated with encephalopathy in the newborn period, which is most likely caused by hypoxic ischaemic encephalopathy.
Central causes of hypotonia include Down’s syndrome, Prader-Willi syndrome, hypothyroidism, and cerebral palsy, which may precede the development of spasticity. On the other hand, neurological and muscular problems such as spinal muscular atrophy, spina bifida, Guillain-Barre syndrome, myasthenia gravis, muscular dystrophy, and myotonic dystrophy can also cause hypotonia.
It is important to note that hypotonia can be a symptom of an underlying condition and should be evaluated by a healthcare professional. Early diagnosis and treatment can help manage the symptoms and improve the quality of life for those affected.
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This question is part of the following fields:
- Paediatrics
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Question 19
Incorrect
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A patient in her late 60s is hospitalized with digoxin toxicity. Which of her medications is the most probable cause of this condition?
Your Answer: Atorvastatin
Correct Answer: Diltiazem
Explanation:The use of diltiazem can lead to the development of digoxin toxicity.
Understanding Digoxin and Its Toxicity
Digoxin is a medication used for rate control in atrial fibrillation and for improving symptoms in heart failure patients. It works by decreasing conduction through the atrioventricular node and increasing the force of cardiac muscle contraction. However, it has a narrow therapeutic index and requires monitoring for toxicity.
Toxicity may occur even when the digoxin concentration is within the therapeutic range. Symptoms of toxicity include lethargy, nausea, vomiting, anorexia, confusion, yellow-green vision, arrhythmias, and gynaecomastia. Hypokalaemia is a classic precipitating factor, as it allows digoxin to more easily bind to the ATPase pump and increase its inhibitory effects. Other factors that may contribute to toxicity include increasing age, renal failure, myocardial ischaemia, electrolyte imbalances, hypoalbuminaemia, hypothermia, hypothyroidism, and certain medications such as amiodarone, quinidine, and verapamil.
Management of digoxin toxicity involves the use of Digibind, correction of arrhythmias, and monitoring of potassium levels. It is important to recognize the potential for toxicity and monitor patients accordingly to prevent adverse outcomes.
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This question is part of the following fields:
- Pharmacology/Therapeutics
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Question 20
Correct
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Samantha, 74, has been diagnosed with a mid-rectal tumour. After undergoing a CT scan and other tests, it has been determined that the tumour is graded as T2N0M0 and is suitable for surgical intervention. What is the recommended surgery for Samantha?
Your Answer: Low anterior resection
Explanation:The most suitable surgical procedure for the patient in this situation would be a low anterior resection. To determine the appropriate surgery, factors such as the location of the tumor, its grade, and operability must be taken into account. Since the tumor is located in the rectum, only two of the listed surgical options are viable: abdominoperineal resection and low anterior resection.
Colorectal cancer is typically diagnosed through CT scans and colonoscopies or CT colonography. Patients with tumors below the peritoneal reflection should also undergo MRI to evaluate their mesorectum. Once staging is complete, a treatment plan is formulated by a dedicated colorectal MDT meeting.
For colon cancer, surgery is the primary treatment option, with resectional surgery being the only cure. The procedure is tailored to the patient and tumor location, with lymphatic chains being resected based on arterial supply. Anastomosis is the preferred method of restoring continuity, but in some cases, an end stoma may be necessary. Chemotherapy is often offered to patients with risk factors for disease recurrence.
Rectal cancer management differs from colon cancer due to the rectum’s anatomical location. Tumors can be surgically resected with either an anterior resection or an abdomino-perineal excision of rectum (APER). A meticulous dissection of the mesorectal fat and lymph nodes is integral to the procedure. Neoadjuvant radiotherapy is often offered to patients prior to resectional surgery, and those with obstructing rectal cancer should have a defunctioning loop colostomy.
Segmental resections based on blood supply and lymphatic drainage are the primary operations for cancer. The type of resection and anastomosis depend on the site of cancer. In emergency situations where the bowel has perforated, an end colostomy is often safer. Left-sided resections are more risky, but ileo-colic anastomoses are relatively safe even in the emergency setting and do not need to be defunctioned.
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This question is part of the following fields:
- Gastroenterology/Nutrition
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Question 21
Incorrect
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A 60-year-old man with a history of high blood pressure and high cholesterol presents to the Emergency Department with occasional episodes of chest pain, lasting only for a few minutes. This occurs while at rest and is accompanied by palpitations. He is currently stable, with a blood pressure of 140/95 mmHg, oxygen saturation of 98% and a heart rate of 160 bpm. An electrocardiogram (ECG) is done which shows no P waves, with regular narrow QRS complexes interspersed along a saw-tooth baseline. Vagal manoeuvres have failed and three boluses of adenosine fail to control the arrhythmia.
Given the likely diagnosis, which of the following treatments is indicated?
Select the SINGLE best treatment option from the list below.
Your Answer: Synchronised direct-current (DC) cardioversion
Correct Answer: Bisoprolol
Explanation:Management of Atrial Flutter: Medications and Procedures
Atrial flutter is a type of arrhythmia that can be managed through various medications and procedures. The first step in treatment is to control the ventricular rate, which can be achieved through the administration of beta-blockers or rate-limiting calcium-channel blockers. For patients with diabetes mellitus, cardio-selective beta-blockers such as atenolol, bisoprolol, metoprolol, and nebivolol are preferred.
Amiodarone is not the first-line treatment for atrial flutter and is mainly used for ventricular tachycardias and chemical cardioversion in atrial fibrillation. Propranolol can be used for rate control, but cardio-selective beta-blockers are preferred for patients with diabetes mellitus.
Synchronised direct-current (DC) cardioversion is the first-line treatment for patients with haemodynamic instability caused by a tachyarrhythmia. However, if the patient exhibits no adverse signs, DC cardioversion is not indicated. Unsynchronised DC cardioversion is only given in cases of ventricular fibrillation.
All patients should be assessed for their risk of stroke and the need for thromboprophylaxis, with the choice of anticoagulant based on scoring criteria such as CHA2DS2-VASc. Overall, the management of atrial flutter involves a tailored approach based on the individual patient’s needs and medical history.
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This question is part of the following fields:
- Cardiovascular
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Question 22
Correct
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A 28-year-old female patient presents to her GP complaining of a foul-smelling vaginal discharge that has persisted for 5 days after having unprotected sex. She reports feeling generally well and denies any fever or urinary symptoms. The patient also confirms that she is not pregnant. During the examination, the doctor observes multiple punctate lesions on her cervix and a green discharge with a strong odor. What is the probable diagnosis?
Your Answer: Trichomoniasis
Explanation:The patient is likely suffering from trichomoniasis caused by Trichomonas vaginalis, a sexually transmitted disease that results in a yellow/green discharge with a foul odor, vulval itching, and dysuria. During a speculum examination, the cervix may appear as a strawberry cervix due to multiple punctate haemorrhages. Bacterial vaginosis, which is not a sexually transmitted disease and can be caused by various factors, is less likely to be the diagnosis due to the recent unprotected sexual intercourse and the presence of an offensive discharge. Chlamydia and gonorrhoea, both sexually transmitted diseases, can also cause dysuria and vaginal discharge, but the punctate cervical haemorrhages and malodorous green discharge make them less likely diagnoses. Syphilis, which presents in three stages, is unlikely due to the acute onset of symptoms and the absence of genital lesions.
Understanding Trichomonas vaginalis and its Comparison to Bacterial Vaginosis
Trichomonas vaginalis is a type of protozoan parasite that is highly motile and flagellated. It is known to cause trichomoniasis, which is a sexually transmitted infection. The infection is characterized by symptoms such as offensive, yellow/green, frothy vaginal discharge, vulvovaginitis, and strawberry cervix. The pH level is usually above 4.5, and in men, it may cause urethritis.
To diagnose trichomoniasis, a wet mount microscopy is conducted to observe the motile trophozoites. The treatment for trichomoniasis involves oral metronidazole for 5-7 days, although a one-off dose of 2g metronidazole may also be used.
When compared to bacterial vaginosis, trichomoniasis has distinct differences. Bacterial vaginosis is caused by an overgrowth of bacteria in the vagina, while trichomoniasis is caused by a protozoan parasite. The symptoms of bacterial vaginosis include a thin, grayish-white vaginal discharge with a fishy odor, and a pH level above 4.5. Unlike trichomoniasis, bacterial vaginosis is not considered a sexually transmitted infection.
In conclusion, understanding the differences between trichomoniasis and bacterial vaginosis is crucial in diagnosing and treating these conditions effectively. Proper diagnosis and treatment can help prevent complications and improve overall health and well-being.
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This question is part of the following fields:
- Reproductive Medicine
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Question 23
Correct
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After expressing discomfort in their chest, a 75-year-old patient suddenly collapses on the surgical ward with no detectable pulse. The medical team initiates cardiopulmonary resuscitation (CPR) and calls for immediate assistance.
Once the defibrillator is connected, the team pauses to check the rhythm. Although there is organised electrical activity, there is still no pulse or signs of life.
In addition to continuing CPR with a ratio of 30 compressions to 2 breaths, what other actions should the team take at this stage?Your Answer: Give intravenous adrenaline
Explanation:In the case of pulseless electrical activity, which is a non-shockable rhythm, the ALS algorithm requires the administration of adrenaline as soon as intravascular access is achieved. This should be done immediately after the rhythm check, following two more minutes of CPR. The recommended dose is 1mg IV, which should be repeated every 3-5 minutes. It is important to note that intramuscular adrenaline is not appropriate for cardiac arrest, and IV amiodarone is not indicated for non-shockable rhythms. While it is correct to avoid shocking the patient, it is incorrect to delay drug administration until the next rhythm check. The most recent Resuscitation Council Guidelines (2021) support the immediate administration of adrenaline in non-shockable rhythms.
The 2015 Resus Council guidelines for adult advanced life support outline the steps to be taken when dealing with patients with shockable and non-shockable rhythms. For both types of patients, chest compressions are a crucial part of the process, with a ratio of 30 compressions to 2 ventilations. Defibrillation is recommended for shockable rhythms, with a single shock for VF/pulseless VT followed by 2 minutes of CPR. Adrenaline and amiodarone are the drugs of choice for non-shockable rhythms, with adrenaline given as soon as possible and amiodarone administered after 3 shocks for VF/pulseless VT. Thrombolytic drugs should be considered if a pulmonary embolus is suspected. Atropine is no longer recommended for routine use in asystole or PEA. Oxygen should be titrated to achieve saturations of 94-98% following successful resuscitation. The Hs and Ts should be considered as potential reversible causes of cardiac arrest.
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This question is part of the following fields:
- Cardiovascular
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Question 24
Correct
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A 42-year-old woman complains of urine leakage when laughing or jumping. She has no other urinary symptoms, and her urine dipstick test is negative.
What is the most appropriate initial treatment option?Your Answer: Pelvic floor exercises
Explanation:Understanding Urinary Incontinence: Types and Treatment Options
Urinary incontinence is a common problem that affects people of all ages, but is more prevalent in elderly individuals and females. It is important to classify the type of urinary incontinence to determine the underlying cause and appropriate treatment.
Functional incontinence occurs due to reasons other than lower urinary tract dysfunction, such as delirium, psychiatric disorders, urinary infection, or impaired mobility. Treatment is directed at the underlying cause.
Mixed incontinence is a combination of stress incontinence and urge incontinence, characterized by mild-to-moderate urine loss with physical activities and acute urine loss without warning, respectively. Urinary frequency, urgency, and nocturia are also present.
Overflow incontinence occurs when the bladder is overdistended and urine overflows despite the absence of detrusor contraction. Symptoms may mimic those of mixed incontinence and may suggest a cause of bladder outlet obstruction or neurological dysfunction.
Stress incontinence is triggered by increased intra-abdominal pressure and is characterized by involuntary urine loss during coughing, laughing, and sneezing. Irritative voiding symptoms are typically absent.
Urge incontinence is associated with an overactive bladder and is characterized by uncontrolled urine loss associated with a strong desire to void, which occurs suddenly and without warning. Patients are unable to hold back urine and experience urinary frequency, urgency, and nocturia.
Treatment options include pelvic floor muscle training, anticholinergic medications such as oxybutynin and solifenacin, bladder retraining, and topical estrogen for postmenopausal women with vaginal atrophy. Treatment is directed at the underlying cause of urinary incontinence.
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This question is part of the following fields:
- Reproductive Medicine
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Question 25
Incorrect
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A 65-year-old woman is referred to the general medical clinic with a history of about 10 attacks of pins and needles in her right arm and leg over a period of 4 weeks. Her GP is concerned that this patient will soon have a completed stroke despite already being on aspirin. Typical attacks lasted for about 5 min and there were no additional symptoms. On closer enquiry she said that the sensation started in her right foot and then, over a period of about 1 min, spread ‘like water running up my leg’ to involve her whole leg and arm. Each attack was identical. Her past medical history includes hypertension and diabetes, for which she already takes aspirin. There are no abnormalities on neurological examination, but her blood pressure is 180/100 mmHg.
Which of the following is the most likely diagnosis?
Your Answer: Recurrent, deep, white-matter microhaemorrhages
Correct Answer: Partial epileptic seizure affecting the right hemisphere
Explanation:Differential Diagnosis for Recurrent Neurological Symptoms
Recurrent neurological symptoms can be caused by a variety of conditions, and a thorough differential diagnosis is necessary to determine the underlying cause. In the case of a patient experiencing march-like progression of symptoms affecting the left side of the body, several possibilities must be considered.
A partial epileptic seizure affecting the right hemisphere is a likely cause, as the positive sensory symptoms and stereotyped nature of the episodes are typical of epilepsy. The rapid progression of symptoms over seconds to a minute is also characteristic of seizure activity.
Transient ischaemic attacks (TIAs) affecting the right hemisphere are less likely, as the march-like progression of symptoms and positive sensory symptoms are not typical of a vascular cause. TIAs are more likely to present with loss of sensation rather than abnormal sensations.
Recurrent, deep, white-matter microhaemorrhages are a possibility due to the patient’s risk factors, but the stereotyped nature of the attacks and positive sensory symptoms make this diagnosis less likely. Microhaemorrhages would typically present with numbness affecting the entire left side at onset.
Migraine equivalent is a rare possibility, but the rapid progression of symptoms and frequency of episodes make this diagnosis unlikely. Migraine aura without headache typically spreads over 20-30 minutes and is more common in patients with a history of previous migraine.
Cerebral venous thrombosis is also unlikely, as the absence of headache makes this diagnosis less probable. CVT typically presents with headache and other neurological symptoms.
In conclusion, the positive sensory features, stereotyped nature, and march of symptoms suggest epilepsy as the most likely cause of the patient’s recurrent neurological symptoms.
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This question is part of the following fields:
- Neurology
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Question 26
Correct
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You are conducting the eight-week baby check on a healthy infant who was born at term. As part of health promotion, you are discussing ways to minimize the risk of Sudden Infant Death Syndrome (SIDS) with the mother. She is already aware of the significance of placing the baby on its back while sleeping and does not smoke. What is the most crucial additional risk factor for SIDS?
Your Answer: Sleeping in the same bed as the baby
Explanation:Studies have indicated that bed sharing is the most prominent risk factor for SIDS, followed by prone sleeping, parental smoking, hyperthermia and head covering, and prematurity.
Understanding Sudden Infant Death Syndrome
Sudden infant death syndrome (SIDS) is the leading cause of death in infants during their first year of life, with the highest incidence occurring at three months of age. There are several major risk factors associated with SIDS, including placing the baby to sleep on their stomach, parental smoking, prematurity, bed sharing, and hyperthermia or head covering. These risk factors are additive, meaning that the more risk factors present, the higher the likelihood of SIDS. Other risk factors include male sex, multiple births, lower social classes, maternal drug use, and an increased incidence during winter.
However, there are also protective factors that can reduce the risk of SIDS. Breastfeeding, room sharing (but not bed sharing), and the use of pacifiers have been shown to be protective. In the event of a SIDS occurrence, it is important to screen siblings for potential sepsis and inborn errors of metabolism.
Overall, understanding the risk factors and protective factors associated with SIDS can help parents and caregivers take steps to reduce the likelihood of this tragic event. By following safe sleep practices and promoting healthy habits, we can work towards reducing the incidence of SIDS.
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This question is part of the following fields:
- Paediatrics
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Question 27
Incorrect
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As a side-effect, which antidepressants cause the cheese effect (a hypertensive reaction)?
Your Answer: Tricyclic antidepressants (TCAs)
Correct Answer: Monoamine oxidase inhibitors (MAOIs)
Explanation:Differential Diagnosis: Jaundice and Abdominal Symptoms
Gilbert Syndrome:
Gilbert syndrome is an inherited condition that can manifest as jaundice on clinical examination. Patients may also experience non-specific symptoms such as abdominal cramps, fatigue, and malaise. Fasting, febrile illness, alcohol, or exercise can exacerbate jaundice in patients with Gilbert syndrome. Diagnosis is based on a thorough history and physical examination, as well as blood tests that show unconjugated hyperbilirubinaemia.Haemolytic Anaemia:
Haemolysis is the premature destruction of erythrocytes, which can lead to anaemia if bone marrow activity cannot compensate for erythrocyte loss. Mild haemolysis can be asymptomatic, while severe haemolysis can cause life-threatening symptoms such as angina and cardiopulmonary decompensation. Changes in lactate dehydrogenase and serum haptoglobin levels are the most sensitive general tests for haemolytic anaemia.Hepatitis A:
Hepatitis A is a viral infection that results almost exclusively from ingestion, typically through faecal-oral transmission. Symptoms include fatigue, anorexia, nausea, and vomiting. LFT abnormalities are common, and diagnosis is based on serologic testing for immunoglobulin M (IgM) antibody to HAV.Hepatitis B:
Hepatitis B is a viral infection that is transmitted haematogenously and sexually. Symptoms include fatigue, anorexia, nausea, and vomiting. LFT abnormalities are common, and diagnosis is based on serologic testing for hepatitis B surface antigen (HBsAg).Cholecystitis:
Cholecystitis is inflammation of the gall bladder that occurs most commonly because of an obstruction of the cystic duct by gallstones arising from the gall bladder. Symptoms include upper abdominal pain, nausea, vomiting, and fever. Signs of peritoneal irritation may also be present.Conclusion:
In summary, the differential diagnosis of jaundice and abdominal symptoms includes Gilbert syndrome, haemolytic anaemia, hepatitis A, hepatitis B, and cholecystitis. Diagnosis is based on a thorough history and physical examination, as well as blood tests and serologic testing as appropriate. Treatment -
This question is part of the following fields:
- Psychiatry
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Question 28
Correct
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A 42-year-old woman is found to have breast cancer. She has no significant medical history, is premenopausal, and has no family history of breast or ovarian cancer. The cancer is in its early stages and she undergoes a wide-local excision followed by whole-breast radiotherapy. The pathology report reveals that the tumour is positive for oestrogen receptors but negative for HER2. What is the most probable adjuvant treatment that she will be recommended?
Your Answer: Tamoxifen
Explanation:The use of Tamoxifen is limited to pre-menopausal women, and there is a continuing discussion regarding the duration of therapy, whether it should be for 5 years or more.
Breast cancer management varies depending on the stage of the cancer, type of tumor, and patient’s medical history. Treatment options may include surgery, radiotherapy, hormone therapy, biological therapy, and chemotherapy. Surgery is typically the first option for most patients, except for elderly patients with metastatic disease who may benefit more from hormonal therapy. Prior to surgery, an axillary ultrasound is recommended for patients without palpable axillary lymphadenopathy, while those with clinically palpable lymphadenopathy require axillary node clearance. The type of surgery offered depends on various factors, such as tumor size, location, and type. Breast reconstruction is also an option for patients who have undergone a mastectomy.
Radiotherapy is recommended after a wide-local excision to reduce the risk of recurrence, while mastectomy patients may receive radiotherapy for T3-T4 tumors or those with four or more positive axillary nodes. Hormonal therapy is offered if tumors are positive for hormone receptors, with tamoxifen being used in pre- and peri-menopausal women and aromatase inhibitors like anastrozole in post-menopausal women. Tamoxifen may increase the risk of endometrial cancer, venous thromboembolism, and menopausal symptoms. Biological therapy, such as trastuzumab, is used for HER2-positive tumors but cannot be used in patients with a history of heart disorders. Chemotherapy may be used before or after surgery, depending on the stage of the tumor and the presence of axillary node disease. FEC-D is commonly used in the latter case.
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This question is part of the following fields:
- Haematology/Oncology
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Question 29
Incorrect
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A 47-year-old man presents to the clinic with concerns about his risk of coronary heart disease after a friend recently had a heart attack. He has a history of anxiety but is not currently taking any medication. He is a smoker, consuming around 20 cigarettes a day. On examination, his cardiovascular system appears normal, with a BMI of 26 kg/m² and blood pressure of 126/82 mmHg.
As his healthcare provider, you strongly advise him to quit smoking. What would be the most appropriate next step?Your Answer: Reassure him that he has a very low risk of coronary heart disease given his age
Correct Answer: Arrange a lipid profile then calculate his QRISK2 score
Explanation:The 2014 NICE guidelines recommend using the QRISK2 tool to identify patients over 40 years old who are at high risk of CVD, with a 10-year risk of 10% or greater. A full lipid profile should be checked before starting a statin, and atorvastatin 20mg should be offered first-line. Lifestyle modifications include a cardioprotective diet, physical activity, weight management, limiting alcohol intake, and smoking cessation. Follow-up should occur at 3 months, with consideration of increasing the dose of atorvastatin up to 80 mg if necessary.
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This question is part of the following fields:
- Cardiovascular
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Question 30
Correct
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A 28-year-old woman who is 20 weeks pregnant visits the GP clinic to inquire about the whooping cough vaccine. She mentions that her friend, who also sees the same GP, received the vaccine at 32 weeks of pregnancy. She wants to know if she can get the vaccine at this stage of her pregnancy.
Your Answer: She can have the vaccine now
Explanation:Pregnant women at 16-32 weeks are given the option to receive the pertussis vaccine.
Whooping Cough: Causes, Symptoms, Diagnosis, and Management
Whooping cough, also known as pertussis, is a contagious disease caused by the bacterium Bordetella pertussis. It is commonly found in children, with around 1,000 cases reported annually in the UK. The disease is characterized by a persistent cough that can last up to 100 days, hence the name cough of 100 days.
Infants are particularly vulnerable to whooping cough, which is why routine immunization is recommended at 2, 3, 4 months, and 3-5 years. However, neither infection nor immunization provides lifelong protection, and adolescents and adults may still develop the disease.
Whooping cough has three phases: the catarrhal phase, the paroxysmal phase, and the convalescent phase. The catarrhal phase lasts around 1-2 weeks and presents symptoms similar to a viral upper respiratory tract infection. The paroxysmal phase is characterized by a severe cough that worsens at night and after feeding, and may be accompanied by vomiting and central cyanosis. The convalescent phase is when the cough subsides over weeks to months.
To diagnose whooping cough, a person must have an acute cough that has lasted for 14 days or more without another apparent cause, and have one or more of the following features: paroxysmal cough, inspiratory whoop, post-tussive vomiting, or undiagnosed apnoeic attacks in young infants. A nasal swab culture for Bordetella pertussis is used to confirm the diagnosis, although PCR and serology are increasingly used.
Infants under 6 months with suspected pertussis should be admitted, and in the UK, pertussis is a notifiable disease. An oral macrolide, such as clarithromycin, azithromycin, or erythromycin, is indicated if the onset of the cough is within the previous 21 days to eradicate the organism and reduce the spread. Household contacts should be offered antibiotic prophylaxis, although antibiotic therapy has not been shown to alter the course of the illness. School exclusion is recommended for 48 hours after commencing antibiotics or 21 days from onset of symptoms if no antibiotics are given.
Complications of whooping cough include subconjunctival haemorrhage, pneumonia, bronchiectasis, and
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This question is part of the following fields:
- Paediatrics
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