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  • Question 1 - A 67-year-old man arrives at the emergency department with haematemesis. Upon reviewing his...

    Incorrect

    • A 67-year-old man arrives at the emergency department with haematemesis. Upon reviewing his medical history, it is discovered that he has been taking dabigatran since being diagnosed with pulmonary embolism. Due to the severity of the bleeding, it is necessary to reverse the effects of the anticoagulant. What medication is used for this purpose?

      Your Answer: Prothrombin complex

      Correct Answer: Idarucizumab

      Explanation:

      Understanding Direct Oral Anticoagulants

      Direct oral anticoagulants (DOACs) are medications used for various indications such as preventing stroke in non-valvular atrial fibrillation, preventing venous thromboembolism (VTE) after hip or knee surgery, and treating deep vein thrombosis (DVT) and pulmonary embolism (PE). To be prescribed DOACs for stroke prevention in non-valvular AF, certain risk factors must be present, such as prior stroke or transient ischaemic attack, age 75 years or older, hypertension, diabetes mellitus, or heart failure.

      There are four DOACs available, namely dabigatran, rivaroxaban, apixaban, and edoxaban, which differ in their mechanism of action and excretion. Dabigatran is a direct thrombin inhibitor, while rivaroxaban, apixaban, and edoxaban are direct factor Xa inhibitors. The majority of dabigatran is excreted through the kidneys, while rivaroxaban is metabolized in the liver, and apixaban and edoxaban are excreted through the feces.

      In terms of reversal agents, idarucizumab is available for dabigatran, while andexanet alfa is available for rivaroxaban and apixaban. However, there is currently no authorized reversal agent for edoxaban, although andexanet alfa has been studied. Understanding the differences between DOACs is important for healthcare professionals to make informed decisions when prescribing these medications.

    • This question is part of the following fields:

      • Pharmacology/Therapeutics
      45.8
      Seconds
  • Question 2 - A 72-year-old man comes to the clinic complaining of a severe throbbing headache...

    Correct

    • A 72-year-old man comes to the clinic complaining of a severe throbbing headache on the left side of his head. He has been experiencing this pain for approximately 5-6 days without any apparent cause. He denies any visual disturbances or weakness in his limbs. Upon examination, there are no notable neurological findings. The left side of his head is sensitive to touch, but he cannot recall any falls. What is the crucial first step in managing this probable diagnosis?

      Your Answer: Give high-dose oral prednisolone

      Explanation:

      Understanding Temporal Arteritis

      Temporal arteritis is a type of large vessel vasculitis that often overlaps with polymyalgia rheumatica (PMR). It is characterized by changes in the affected artery that skip certain sections while damaging others. This condition typically affects individuals who are over 60 years old and has a rapid onset, usually occurring in less than a month. The most common symptoms include headache and jaw claudication, while vision testing is a crucial investigation for all patients.

      Temporal arteritis can lead to various ocular complications, with anterior ischemic optic neuropathy being the most common. This results from the occlusion of the posterior ciliary artery, leading to ischemia of the optic nerve head. Patients may experience temporary visual loss or even permanent visual loss, which is the most feared complication of this condition. Other symptoms may include diplopia, tender and palpable temporal artery, and features of PMR such as aching, morning stiffness in proximal limb muscles, lethargy, depression, low-grade fever, anorexia, and night sweats.

      To diagnose temporal arteritis, doctors may look for raised inflammatory markers such as an ESR of over 50 mm/hr or elevated CRP levels. A temporal artery biopsy may also be performed to check for skip lesions. Urgent high-dose glucocorticoids should be given as soon as the diagnosis is suspected, and an ophthalmologist should review patients with visual symptoms on the same day. Treatment may also involve bone protection with bisphosphonates and low-dose aspirin, although the evidence supporting the latter is weak.

      In summary, temporal arteritis is a serious condition that requires prompt diagnosis and treatment to prevent irreversible visual damage. Patients who experience symptoms such as headache, jaw claudication, and visual disturbances should seek medical attention immediately.

    • This question is part of the following fields:

      • Musculoskeletal
      68
      Seconds
  • Question 3 - A 25-year-old woman comes to the General Practitioner complaining of pallor, fatigue, weakness,...

    Incorrect

    • A 25-year-old woman comes to the General Practitioner complaining of pallor, fatigue, weakness, palpitations and dyspnoea on exertion. Her symptoms have developed rapidly over the past two weeks. A blood test and bone marrow biopsy reveal a diagnosis of acute myeloid leukaemia (AML).
      What is the most appropriate initial treatment for this patient's condition?

      Your Answer: Iron transfusion

      Correct Answer: Chemotherapy

      Explanation:

      Treatment Options for Acute Leukaemia

      Acute leukaemia, specifically acute myeloid leukaemia (AML), is characterized by an increase in undifferentiated blast cells in the bone marrow and blood, leading to marrow failure. The traditional treatment approach for AML involves three components: induction, consolidation, and maintenance chemotherapy. Combination chemotherapy is used to eradicate blast cells, with maintenance chemotherapy given to eliminate any remaining disease.

      Iron transfusions may be necessary to treat anaemia or platelet deficiency, but they are not a direct treatment for acute leukaemia. Patients with leukaemia are at risk of graft-versus-host disease, so they are given irradiated blood components.

      Intravenous immunoglobulins are not a treatment for acute leukaemia but may be used to prevent infection in patients with hypogammaglobulinaemia resulting from cancer treatment.

      Radiotherapy is not a first-line treatment for acute leukaemia, but it may be used to treat disease that has spread to the brain or spinal cord. Total body radiotherapy can also be used before a stem-cell transplant to reduce the risk of transplant rejection.

      Stem-cell transplants can be allogeneic (from a matched or partially matched donor) or autologous (from the patient’s own stem cells) and are used after remission induction with chemotherapy. The goal is to restore the body’s ability to produce normal blood cells and can be curative, but it is not a first-line treatment.

      Understanding Treatment Options for Acute Leukaemia

    • This question is part of the following fields:

      • Haematology/Oncology
      32.2
      Seconds
  • Question 4 - A 65-year-old man presents with gradually worsening exertional dyspnoea and a dry cough...

    Correct

    • A 65-year-old man presents with gradually worsening exertional dyspnoea and a dry cough over the past year. He quit smoking 25 cigarettes/day about 25 years ago. Upon examination, his oxygen saturation is 96% on room air, respiratory rate is 16/min, and there are fine bibasal crackles. Finger clubbing is also present. The following investigations were conducted:
      - B-type natriuretic peptide: 90 pg/ml (< 100pg/ml)
      - ECG: sinus rhythm, 68/min
      - Spirometry:
      - FEV1: 1.6 L (51% of predicted)
      - FVC: 1.7 L (40% of predicted)
      - FEV1/FVC: 95%

      What is the most likely diagnosis?

      Your Answer: Idiopathic pulmonary fibrosis

      Explanation:

      A common scenario for idiopathic pulmonary fibrosis involves a man between the ages of 50 and 70 who experiences worsening shortness of breath during physical activity. Other symptoms may include clubbing of the fingers and a restrictive pattern on spirometry testing. However, a normal B-type natriuretic peptide level suggests that heart failure is not the cause of these symptoms.

      Understanding Idiopathic Pulmonary Fibrosis

      Idiopathic pulmonary fibrosis (IPF) is a chronic lung condition that causes progressive fibrosis of the interstitium of the lungs. Unlike other causes of lung fibrosis, IPF has no underlying cause. It is typically seen in patients aged 50-70 years and is more common in men.

      The symptoms of IPF include progressive exertional dyspnoea, dry cough, clubbing, and bibasal fine end-inspiratory crepitations on auscultation. Diagnosis is made through spirometry, impaired gas exchange tests, and imaging such as chest x-rays and high-resolution CT scans.

      Management of IPF includes pulmonary rehabilitation, but very few medications have been shown to be effective. Some evidence suggests that pirfenidone, an antifibrotic agent, may be useful in selected patients. Many patients will eventually require supplementary oxygen and a lung transplant.

      The prognosis for IPF is poor, with an average life expectancy of around 3-4 years. CT scans can show advanced pulmonary fibrosis, including honeycombing. While there is no cure for IPF, early diagnosis and management can help improve quality of life and potentially prolong survival.

    • This question is part of the following fields:

      • Respiratory Medicine
      67.8
      Seconds
  • Question 5 - Sarah, 35, has come to her doctor complaining of weakness on the left...

    Correct

    • Sarah, 35, has come to her doctor complaining of weakness on the left side of her face, which is confirmed upon examination. Sarah also reports experiencing ear pain and an otoscopy reveals vesicles on her tympanic membrane. What is the probable diagnosis?

      Your Answer: Ramsay Hunt syndrome

      Explanation:

      The correct diagnosis for this case is Ramsay Hunt syndrome. This syndrome occurs when the Varicella Zoster virus reactivates in the geniculate ganglion, leading to the appearance of vesicles on the tympanic membrane, as well as other symptoms such as facial paralysis, taste loss, dry eyes, tinnitus, vertigo, and hearing loss. While Bell’s palsy could explain the facial weakness, the presence of tympanic vesicles and ear pain make this diagnosis less likely. Trigeminal neuralgia is unlikely to cause facial weakness, although it could explain the pain. An acoustic neuroma could explain both the facial weakness and ear pain, but the absence of tympanic vesicles makes this diagnosis less probable.

      Understanding Ramsay Hunt Syndrome

      Ramsay Hunt syndrome, also known as herpes zoster oticus, is a condition that occurs when the varicella zoster virus reactivates in the geniculate ganglion of the seventh cranial nerve. The first symptom of this condition is often auricular pain, followed by facial nerve palsy and a vesicular rash around the ear. Other symptoms may include vertigo and tinnitus.

      To manage Ramsay Hunt syndrome, doctors typically prescribe oral aciclovir and corticosteroids. These medications can help reduce the severity of symptoms and prevent complications.

    • This question is part of the following fields:

      • ENT
      109
      Seconds
  • Question 6 - A 28-year-old female complains of an itchy vulva and painful intercourse. She reports...

    Correct

    • A 28-year-old female complains of an itchy vulva and painful intercourse. She reports experiencing a green, malodorous vaginal discharge for the last 14 days. What is the probable diagnosis?

      Your Answer: Trichomonas vaginalis

      Explanation:

      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.

    • This question is part of the following fields:

      • Reproductive Medicine
      45.5
      Seconds
  • Question 7 - As a foundation year two doctor in the emergency department, you are tasked...

    Incorrect

    • As a foundation year two doctor in the emergency department, you are tasked to assess a twenty-six-year-old man who fell on his right ankle while intoxicated last night. According to the patient, he was able to bear weight after the incident and continued his night out. However, he woke up the next day with ankle swelling and pain. Upon examination, you observed minimal swelling and bruising, but there is general tenderness and good mobility. What imaging modality would you recommend for this case?

      Your Answer: X-ray ankle in department

      Correct Answer: No imaging

      Explanation:

      The Ottowa ankle rules specify that imaging is necessary after trauma if there is point tenderness over the distal 6 cm of the lateral or medial malleolus, or an inability to bear weight by at least four steps immediately after the injury and in the emergency department. X-ray is the recommended first-line imaging. As this patient does not exhibit any of these indications, an x-ray is not needed.

      Ottawa Rules for Ankle Injuries

      The Ottawa Rules provide a guideline for determining whether an ankle x-ray is necessary after an injury. These rules have a sensitivity approaching 100%, meaning they are highly accurate. An ankle x-ray is only required if there is pain in the malleolar zone and one of the following findings: bony tenderness at the lateral malleolar zone or medial malleolar zone, or inability to walk four weight-bearing steps immediately after the injury and in the emergency department.

      The lateral malleolar zone is from the tip of the lateral malleolus to include the lower 6 cm of the posterior border of the fibular, while the medial malleolar zone is from the tip of the medial malleolus to the lower 6 cm of the posterior border of the tibia. These rules help healthcare professionals determine whether an ankle x-ray is necessary, which can save time and resources. It is important to note that there are also Ottawa rules available for foot and knee injuries. By following these guidelines, healthcare professionals can provide efficient and effective care for ankle injuries.

    • This question is part of the following fields:

      • Musculoskeletal
      94
      Seconds
  • Question 8 - A 35-year-old woman who is 20 weeks pregnant attends the antenatal clinic. She...

    Incorrect

    • A 35-year-old woman who is 20 weeks pregnant attends the antenatal clinic. She had an OGTT at her booking visit due to a family history of type II diabetes mellitus.

      The results at the 14-week booking were:
      Fasting glucose 6.2 mmol/L Normal <5.6 mmol/L
      2-hour post glucose challenge 9.5 mmol/L Normal <7.8mmol/L

      A decision is made to start metformin 500mg twice daily and she is provided with information leaflets regarding diet and lifestyle modification.

      On review today at 20 weeks gestation her repeat OGTT results are as follows:
      Fasting glucose 6.1 mmol/L Normal <5.3 mmol/L
      2-hour post glucose challenge 7.5 mmol/L Normal <6.4 mmol/L

      What is the next most appropriate action for managing her blood glucose levels?

      Your Answer: Increase metformin to 1g twice daily

      Correct Answer: Add insulin

      Explanation:

      If blood glucose targets are not achieved through diet and metformin in gestational diabetes, insulin should be introduced.

      The patient in this case was diagnosed with gestational diabetes during their initial appointment. Despite attempting metformin, their fasting and two-hour post glucose challenge blood glucose levels remain elevated above the normal range. Therefore, insulin should be added to their treatment plan. Choosing to make no changes to their treatment plan is not the correct answer, as this could lead to increased risks for the fetus, such as the development of polyhydramnios or macrosomia. While referral for dietary and exercise regimens may be considered, this is likely to be a first-line intervention, and further escalation of medical therapy is necessary for the health of the fetus. Increasing the dose of metformin is not the correct answer, as the NICE guidelines recommend starting insulin when initial interventions have been unsuccessful. Waiting two weeks to repeat the results would delay necessary treatment intensification, which is required at the current clinic appointment.

      Gestational diabetes is a common medical disorder affecting around 4% of pregnancies. Risk factors include a high BMI, previous gestational diabetes, and family history of diabetes. Screening is done through an oral glucose tolerance test, and diagnostic thresholds have recently been updated. Management includes self-monitoring of blood glucose, diet and exercise advice, and medication if necessary. For pre-existing diabetes, weight loss and insulin are recommended, and tight glycemic control is important. Targets for self-monitoring include fasting glucose of 5.3 mmol/l and 1-2 hour post-meal glucose levels.

    • This question is part of the following fields:

      • Reproductive Medicine
      82.2
      Seconds
  • Question 9 - You are working in a busy emergency department. A 25-year-old male presents explaining...

    Incorrect

    • You are working in a busy emergency department. A 25-year-old male presents explaining that a few hours ago he broke up with his girlfriend and while having an argument took 20 of his mother's tablets. He is worried and says he is experiencing muffled hearing with bouts of ringing on both sides. Vital signs were all normal apart from a respiratory rate of 28 per minute.
      An overdose of which medication is most likely?

      Your Answer: Amitriptyline

      Correct Answer: Aspirin

      Explanation:

      Tinnitus could be an early indication of an aspirin overdose, as salicylate toxicity can cause respiratory alkalosis and subsequently metabolic acidosis within a few hours. The patient’s symptoms suggest the former, and the presence of tinnitus further supports this diagnosis.

      Salicylate overdose can result in a combination of respiratory alkalosis and metabolic acidosis. The initial effect of salicylates is to stimulate the respiratory center, leading to hyperventilation and respiratory alkalosis. However, as the overdose progresses, the direct acid effects of salicylates, combined with acute renal failure, can cause metabolic acidosis. In children, metabolic acidosis tends to be more prominent. Other symptoms of salicylate overdose include tinnitus, lethargy, sweating, pyrexia, nausea/vomiting, hyperglycemia and hypoglycemia, seizures, and coma.

      The treatment for salicylate overdose involves general measures such as airway, breathing, and circulation support, as well as administering activated charcoal. Urinary alkalinization with intravenous sodium bicarbonate can help eliminate aspirin in the urine. In severe cases, hemodialysis may be necessary. Indications for hemodialysis include a serum concentration of salicylates greater than 700mg/L, metabolic acidosis that is resistant to treatment, acute renal failure, pulmonary edema, seizures, and coma.

      It is important to note that salicylates can cause the uncoupling of oxidative phosphorylation, which leads to decreased adenosine triphosphate production, increased oxygen consumption, and increased carbon dioxide and heat production. Therefore, prompt and appropriate treatment is crucial in managing salicylate overdose.

    • This question is part of the following fields:

      • Pharmacology/Therapeutics
      58.3
      Seconds
  • Question 10 - What is a not a cause of hypertension in adolescents? ...

    Incorrect

    • What is a not a cause of hypertension in adolescents?

      Your Answer: Renal vascular disease

      Correct Answer: Bartter's syndrome

      Explanation:

      Bartter’s syndrome is a genetic condition that typically follows an autosomal recessive pattern of inheritance. It results in severe hypokalaemia due to a defect in the absorption of chloride at the Na+ K+ 2Cl- cotransporter in the ascending loop of Henle. Unlike other endocrine causes of hypokalaemia such as Conn’s, Cushing’s and Liddle’s syndrome, Bartter’s syndrome is associated with normotension. The condition usually presents in childhood and is characterized by symptoms such as failure to thrive, polyuria, polydipsia, hypokalaemia, and weakness.

      Hypertension, or high blood pressure, can also affect children. To measure blood pressure in children, it is important to use a cuff size that is approximately 2/3 the length of their upper arm. The 4th Korotkoff sound is used to measure diastolic blood pressure until adolescence, when the 5th Korotkoff sound can be used. Results should be compared with a graph of normal values for their age.

      In younger children, secondary hypertension is the most common cause, with renal parenchymal disease accounting for up to 80% of cases. Other causes of hypertension in children include renal vascular disease, coarctation of the aorta, phaeochromocytoma, congenital adrenal hyperplasia, and essential or primary hypertension, which becomes more common as children get older. It is important to identify the underlying cause of hypertension in children in order to provide appropriate treatment and prevent complications.

    • This question is part of the following fields:

      • Paediatrics
      17.5
      Seconds
  • Question 11 - A 7-year-old girl visits her GP clinic with her mother who is worried...

    Correct

    • A 7-year-old girl visits her GP clinic with her mother who is worried about her continued bedwetting at night. They had visited the clinic 4 weeks ago and have seen no improvement despite following general management advice and a basic reward system. The girl is healthy otherwise and has no history of constipation or daytime incontinence. She does not complain of any issues at home or school. Physical examination reveals no abnormalities.
      What additional treatment options would you suggest for her?

      Your Answer: Enuresis alarm

      Explanation:

      When general management advice has not been effective for nocturnal enuresis, an enuresis alarm is typically the first-line recommendation. This device detects urine moisture and triggers an alarm (either through sound or vibration) to wake the child and prompt them to use the toilet. Enuresis alarms have a high success rate when used consistently, and a review is typically conducted after four weeks to assess progress. Bladder training and retention control training are not recommended by NICE guidelines due to limited evidence and concerns about promoting voiding dysfunction. Desmopressin, a vasopressin analogue that reduces urine production, may be considered if the family is not receptive to or finds an enuresis alarm ineffective. However, an enuresis alarm should be offered first. Desmopressin can provide short-term control, but it can cause hyponatremia. Desmopressin plus oxybutynin may be helpful if there are daytime symptoms or if desmopressin alone does not improve the condition. As not all anticholinergic medications have UK marketing authorization for bedwetting treatment, a healthcare professional with appropriate expertise should manage this combination, often requiring a specialist referral and further investigations.

      Nocturnal enuresis, or bedwetting, is when a child involuntarily urinates during the night. Most children achieve continence by the age of 3 or 4, so enuresis is defined as the involuntary discharge of urine in a child aged 5 or older without any underlying medical conditions. Enuresis can be primary, meaning the child has never achieved continence, or secondary, meaning the child has been dry for at least 6 months before.

      When managing bedwetting, it’s important to look for any underlying causes or triggers, such as constipation, diabetes mellitus, or recent onset UTIs. General advice includes monitoring fluid intake and encouraging regular toileting patterns, such as emptying the bladder before sleep. Reward systems, like star charts, can also be helpful, but should be given for agreed behavior rather than dry nights.

      The first-line treatment for bedwetting is an enuresis alarm, which has a high success rate. These alarms have sensor pads that detect wetness and wake the child up to use the toilet. If short-term control is needed, such as for sleepovers, or if the alarm is ineffective or not acceptable to the family, desmopressin may be prescribed. Overall, managing bedwetting involves identifying any underlying causes and implementing strategies to promote continence.

    • This question is part of the following fields:

      • Paediatrics
      66.9
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  • Question 12 - A 25-year-old is diagnosed with an ectopic pregnancy at 8 weeks gestation and...

    Incorrect

    • A 25-year-old is diagnosed with an ectopic pregnancy at 8 weeks gestation and undergoes a salpingectomy. She is also rhesus negative. What is the advice regarding anti-D?

      Your Answer: Anti-D only required if pregnancy is more than 12 weeks

      Correct Answer: Anti-D should be given

      Explanation:

      When managing an ectopic pregnancy through surgery, it is necessary to administer Anti-D immunoglobulin. However, if the ectopic pregnancy is being treated medically or if the location of the pregnancy is unknown, Anti-D is not needed. The Coombs test has two types: Direct Coombs, which is used to detect autoimmune haemolytic anaemia, and Indirect Coombs, which is used during pregnancy to identify antibodies in the mother’s blood that can cause haemolytic disease in the newborn.

      Rhesus negative pregnancies can lead to the formation of anti-D IgG antibodies in the mother if she delivers a Rh +ve child, which can cause haemolysis in future pregnancies. Prevention involves testing for D antibodies and giving anti-D prophylaxis to non-sensitised Rh -ve mothers at 28 and 34 weeks. Anti-D immunoglobulin should be given within 72 hours in various situations. Tests should be done on all babies born to Rh -ve mothers, and affected fetuses may experience various complications and require treatment such as transfusions and UV phototherapy.

    • This question is part of the following fields:

      • Reproductive Medicine
      69.9
      Seconds
  • Question 13 - A 68-year-old man presents to his GP clinic complaining of confusion and difficulty...

    Incorrect

    • A 68-year-old man presents to his GP clinic complaining of confusion and difficulty sleeping for the past 5 months. According to his wife, his confusion varies in severity from day to day, and he has been experiencing visual hallucinations of people and animals in their home. The patient is currently taking apixaban 5 mg, amlodipine 5mg, and atorvastatin 20 mg, and there is no recent history of infection. Physical examination reveals normal vital signs and no motor or speech impairment, but the patient struggles to draw a clock face and count down from 20 to 1 correctly. A urine dip test is unremarkable. What is the most likely diagnosis?

      Your Answer: Vascular dementia

      Correct Answer: Lewy body dementia

      Explanation:

      Based on the information provided, Lewy body dementia is the most probable diagnosis. Unlike other forms of dementia, it is characterized by fluctuating cognitive abilities, particularly in attention and executive functioning. The patient may also experience sleep disturbances, visual hallucinations, and parkinsonism. To confirm the diagnosis, the patient will need to undergo cognitive testing, blood tests, and a CT head scan to rule out other conditions. SPECT imaging may also be considered if there is still uncertainty, as it is highly sensitive and specific for Lewy body dementia.

      Alzheimer’s disease is less likely as memory impairment is typically the first cognitive domain affected, and confusion is not as fluctuating. Visual hallucinations are also less common than in Lewy body dementia.

      Chronic subdural hematoma is unlikely as it typically presents with reduced consciousness or neurological deficits rather than cognitive deficits alone. Given the patient’s age and anticoagulation therapy, CT imaging should be performed to rule out any intracranial hemorrhage.

      Frontotemporal dementia is unlikely as it typically presents before the age of 65 with personality changes and social conduct problems, while memory and visuospatial skills are relatively preserved.

      Understanding Lewy Body Dementia

      Lewy body dementia is a type of dementia that is becoming more recognized as a cause of cognitive impairment, accounting for up to 20% of cases. It is characterized by the presence of alpha-synuclein cytoplasmic inclusions, known as Lewy bodies, in certain areas of the brain. While there is a complicated relationship between Parkinson’s disease and Lewy body dementia, with dementia often seen in Parkinson’s disease, the two conditions are distinct. Additionally, up to 40% of patients with Alzheimer’s disease have Lewy bodies.

      The features of Lewy body dementia include progressive cognitive impairment, which typically occurs before parkinsonism, but both features usually occur within a year of each other. Unlike other forms of dementia, cognition may fluctuate, and early impairments in attention and executive function are more common than memory loss. Other features include parkinsonism, visual hallucinations, and sometimes delusions and non-visual hallucinations.

      Diagnosis of Lewy body dementia is usually clinical, but single-photon emission computed tomography (SPECT) can be used to confirm the diagnosis. Management of Lewy body dementia involves the use of acetylcholinesterase inhibitors and memantine, similar to Alzheimer’s disease. However, neuroleptics should be avoided as patients with Lewy body dementia are extremely sensitive and may develop irreversible parkinsonism. It is important to carefully consider the use of medication in these patients to avoid worsening their condition.

    • This question is part of the following fields:

      • Neurology
      69.9
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  • Question 14 - A 38-year-old homeless man presents to the emergency department after collapsing on the...

    Incorrect

    • A 38-year-old homeless man presents to the emergency department after collapsing on the street. He reports feeling increasingly lethargic over the past week and has been coughing up green sputum. He has a history of alcoholic pancreatitis.

      His vital signs are as follows:
      - Temperature: 38.4ºC
      - Heart rate: 122 bpm
      - Blood pressure: 106/54 mmHg
      - Respiratory rate: 22 breaths/min
      - Oxygen saturations: 94% on 2L nasal cannulae

      Upon examination, coarse crackles are heard in the left upper lobe. His heart sounds are normal and his abdomen is soft and nontender.

      What is the most likely causative organism?

      Your Answer: Mycoplasma pneumoniae

      Correct Answer: Klebsiella pneumoniae

      Explanation:

      Klebsiella pneumoniae is a gram-negative rod that commonly causes a cavitating pneumonia in the upper lobes, particularly in individuals with a history of diabetes and alcoholism. The presence of upper zone crackles is a sign of Klebsiella pneumoniae infection, while a history of alcoholic pancreatitis suggests chronic alcohol use.

      Legionella pneumophila causes Legionnaire’s disease, an atypical pneumonia that typically spreads through contaminated water sources, such as air conditioner vents. Symptoms include fever, cough, and myalgia, with bilateral chest symptoms being more common. Other extra-pulmonary symptoms, such as hyponatremia and hepatitis, may also be present.

      Mycoplasma pneumoniae is another cause of atypical pneumonia, with symptoms including coryza and a dry cough. This form of pneumonia is associated with extra-pulmonary symptoms such as haemolytic anaemia and erythema multiforme, which are not present in this case.

      Staphylococcus aureus is the most likely cause of pneumonia following influenza virus infection. However, since there is no history of preceding coryza and the patient has upper zone crackles and alcoholism, Staphylococcus aureus is less likely to be the cause of this patient’s pneumonia.

      Klebsiella Pneumoniae: A Gram-Negative Rod Causing Infections in Humans

      Klebsiella pneumoniae is a type of Gram-negative rod that is typically found in the gut flora of humans. Although it is a normal part of the body’s microbiome, it can also cause a variety of infections in humans, including pneumonia and urinary tract infections. This bacterium is more commonly found in individuals who have diabetes or who consume alcohol regularly. In some cases, Klebsiella pneumoniae infections can occur following aspiration.

      One of the distinctive features of Klebsiella pneumoniae infections is the presence of red-currant jelly sputum. This type of sputum is often seen in patients with pneumonia caused by this bacterium. Additionally, Klebsiella pneumoniae infections tend to affect the upper lobes of the lungs.

      Unfortunately, Klebsiella pneumoniae infections can be quite serious and even life-threatening. They commonly lead to the formation of lung abscesses and empyema, and the mortality rate for these infections is between 30-50%. It is important for healthcare providers to be aware of the potential for Klebsiella pneumoniae infections, particularly in patients who are at higher risk due to underlying health conditions.

    • This question is part of the following fields:

      • Respiratory Medicine
      303.6
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  • Question 15 - A 65-year-old woman with a recent diagnosis of heart failure with reduced ejection...

    Incorrect

    • A 65-year-old woman with a recent diagnosis of heart failure with reduced ejection fraction (on echo) has a blood pressure (BP) of 160/95 mmHg. She is currently on lisinopril (maximum doses).
      Which of the following new agents would you add in?

      Your Answer: Bendroflumethiazide

      Correct Answer: Bisoprolol

      Explanation:

      Medications for Heart Failure: Benefits and Guidelines

      Heart failure is a serious condition that requires proper management through medications. Among the drugs commonly used are bisoprolol, bendroflumethiazide, clopidogrel, spironolactone, and diltiazem.

      Bisoprolol and an angiotensin-converting enzyme (ACE) inhibitor are recommended for all heart failure patients as they have been shown to reduce mortality. Bendroflumethiazide and loop diuretics like furosemide can help alleviate symptoms but do not have a mortality benefit. Clopidogrel, on the other hand, is not indicated for heart failure but is used for vascular diseases like NSTEMI and stroke.

      Spironolactone is recommended for patients who remain symptomatic despite treatment with an ACE inhibitor and a b blocker. It is also beneficial for those with left ventricular systolic dysfunction (LVSD) after a myocardial infarction (MI). However, diltiazem should be avoided in heart failure patients.

      According to NICE guidelines, b blockers and ACE inhibitors should be given to all LVSD patients unless contraindicated. Spironolactone can be added if symptoms persist. Proper medication management is crucial in improving outcomes for heart failure patients.

    • This question is part of the following fields:

      • Cardiovascular
      91.3
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  • Question 16 - You perform an annual medication review of a 68-year-old man with chronic kidney...

    Incorrect

    • You perform an annual medication review of a 68-year-old man with chronic kidney disease (CKD) stage 5 (GFR <15 ml/min/1.73 m2) on dialysis.
      Which of the following is the most likely cause of death in this group of patients?

      Your Answer: Hyperkalaemia

      Correct Answer: Cardiovascular disease

      Explanation:

      Common Causes of Mortality in Dialysis Patients

      Cardiovascular disease is the leading cause of death in the dialysis population, with mortality rates 10-20 times higher than the general population. Hyperkalaemia, often resulting from missed dialysis or dietary indiscretion, is the most common cause of sudden death in end-stage renal disease patients. Hypocalcaemia is a common manifestation of CKD and should be treated with calcium supplements. While there is no known association between reduced renal function and overall cancer risk, some studies suggest an increased risk of urinary, endocrine, and digestive tract cancers among dialysis patients. Sepsis related to dialysis is rare with modern techniques, but minimizing the use of temporary catheters can further reduce the risk.

    • This question is part of the following fields:

      • Renal Medicine/Urology
      21.3
      Seconds
  • Question 17 - A 56-year-old man undergoes a routine medical check-up for his job. He shows...

    Correct

    • A 56-year-old man undergoes a routine medical check-up for his job. He shows no symptoms and his clinical examination is normal. What test result confirms a diagnosis of impaired fasting glucose?

      Your Answer: Fasting glucose 6.8 mmol/L on two occasions

      Explanation:

      An oral glucose tolerance test result of 8.4 mmol/L after 2 hours with a 75g glucose load suggests impaired glucose tolerance instead of impaired fasting glucose.

      Type 2 diabetes mellitus can be diagnosed through a plasma glucose or HbA1c sample. The diagnostic criteria vary depending on whether the patient is experiencing symptoms or not. If the patient is symptomatic, a fasting glucose level of 7.0 mmol/l or higher or a random glucose level of 11.1 mmol/l or higher (or after a 75g oral glucose tolerance test) indicates diabetes. If the patient is asymptomatic, the same criteria apply but must be demonstrated on two separate occasions.

      In 2011, the World Health Organization released supplementary guidance on the use of HbA1c for diagnosing diabetes. A HbA1c level of 48 mmol/mol (6.5%) or higher is diagnostic of diabetes mellitus. However, a HbA1c value of less than 48 mmol/mol (6.5%) does not exclude diabetes and may not be as sensitive as fasting samples for detecting diabetes. For patients without symptoms, the test must be repeated to confirm the diagnosis. It is important to note that increased red cell turnover can cause misleading HbA1c results.

      There are certain conditions where HbA1c cannot be used for diagnosis, such as haemoglobinopathies, haemolytic anaemia, untreated iron deficiency anaemia, suspected gestational diabetes, children, HIV, chronic kidney disease, and people taking medication that may cause hyperglycaemia (such as corticosteroids).

      Impaired fasting glucose (IFG) is defined as a fasting glucose level of 6.1 mmol/l or higher but less than 7.0 mmol/l. Impaired glucose tolerance (IGT) is defined as a fasting plasma glucose level less than 7.0 mmol/l and an OGTT 2-hour value of 7.8 mmol/l or higher but less than 11.1 mmol/l. People with IFG should be offered an oral glucose tolerance test to rule out a diagnosis of diabetes. A result below 11.1 mmol/l but above 7.8 mmol/l indicates that the person does not have diabetes but does have IGT.

    • This question is part of the following fields:

      • Endocrinology/Metabolic Disease
      183.7
      Seconds
  • Question 18 - A 25-year-old woman arrives at the Emergency Department accompanied by a colleague from...

    Incorrect

    • A 25-year-old woman arrives at the Emergency Department accompanied by a colleague from work. She complains of experiencing a 'fluttering' sensation in her chest for the past 30 minutes. Although she admits to feeling 'a bit faint,' she denies any chest pain or difficulty breathing. Upon conducting an ECG, the results show a regular tachycardia of 166 bpm with a QRS duration of 110 ms. Her blood pressure is 102/68 mmHg, and her oxygen saturation levels are at 99% on room air. What is the most appropriate course of action?

      Your Answer: Intravenous adenosine 6mg

      Correct Answer: Carotid sinus massage

      Explanation:

      Vagal manoeuvres, such as carotid sinus massage or the Valsalva manoeuvre, are the initial treatment for supraventricular tachycardia. Adenosine should only be administered if these manoeuvres are ineffective. According to the ALS guidelines, direct current cardioversion is not recommended for this condition.

      Understanding Supraventricular Tachycardia

      Supraventricular tachycardia (SVT) is a type of tachycardia that originates above the ventricles. It is commonly associated with paroxysmal SVT, which is characterized by sudden onset of a narrow complex tachycardia, usually an atrioventricular nodal re-entry tachycardia (AVNRT). Other causes include atrioventricular re-entry tachycardias (AVRT) and junctional tachycardias.

      When it comes to acute management, vagal maneuvers such as the Valsalva maneuver or carotid sinus massage can be used. Intravenous adenosine is also an option, with a rapid IV bolus of 6mg given initially, followed by 12mg and then 18mg if necessary. However, adenosine is contraindicated in asthmatics, and verapamil may be a better option for them. Electrical cardioversion is another option.

      To prevent episodes of SVT, beta-blockers can be used. Radio-frequency ablation is also an option. It is important to work with a healthcare provider to determine the best course of treatment for each individual case.

      Overall, understanding SVT and its management options can help individuals with this condition better manage their symptoms and improve their quality of life.

    • This question is part of the following fields:

      • Cardiovascular
      190.3
      Seconds
  • Question 19 - A 28-year-old woman visits her primary care physician complaining of a fishy-smelling watery...

    Incorrect

    • A 28-year-old woman visits her primary care physician complaining of a fishy-smelling watery discharge from her vagina, which worsens after sexual activity. What test would be the most helpful in diagnosing her condition?

      Your Answer: High vaginal swab for sexually transmitted infections

      Correct Answer: Test vaginal pH

      Explanation:

      Diagnostic Tests for Bacterial Vaginosis

      Bacterial vaginosis (BV) is a common vaginal infection caused by a shift in the vaginal flora, resulting in a change in pH. Here are some diagnostic tests that can be used to identify BV:

      1. Test vaginal pH: A vaginal pH of > 4.5 in conjunction with a fishy odour and the characteristic discharge is diagnostic of BV.

      2. Blood serology testing: BV cannot be diagnosed through blood serology testing as it is not caused by a single organism.

      3. High vaginal swab for sexually transmitted infections: BV is not a sexually transmitted infection, but the presence of other STIs can increase the prevalence of BV.

      4. Low vaginal swab: A culture of the vaginal organisms via a low vaginal swab is not a useful way to diagnose BV.

      5. Urinary microscopy, sensitivity, and culture: Urinary culture is not used to diagnose BV. Diagnosis is based on characteristic findings at examination.

      In conclusion, a combination of a high vaginal swab for STIs and a test for vaginal pH can be used to diagnose BV.

    • This question is part of the following fields:

      • Infectious Diseases
      49
      Seconds
  • Question 20 - A 63-year-old man visits your clinic for his regular asthma inhaler prescription. During...

    Correct

    • A 63-year-old man visits your clinic for his regular asthma inhaler prescription. During the consultation, he mentions experiencing difficulty in sustaining his erections and requests a prescription for sildenafil. What is the most prevalent side effect of sildenafil?

      Your Answer: Headaches

      Explanation:

      Sildenafil is frequently prescribed in primary care. Adverse effects of sildenafil consist of headaches, facial flushing, indigestion, and temporary visual disturbances with a blue-green tint.

      Understanding Phosphodiesterase Type V Inhibitors

      Phosphodiesterase type V (PDE5) inhibitors are medications used to treat erectile dysfunction and pulmonary hypertension. These drugs work by increasing the levels of cGMP, which leads to the relaxation of smooth muscles in the blood vessels supplying the corpus cavernosum. The most well-known PDE5 inhibitor is sildenafil, also known as Viagra, which was the first drug of its kind. It is a short-acting medication that is usually taken one hour before sexual activity.

      Other PDE5 inhibitors include tadalafil (Cialis) and vardenafil (Levitra). Tadalafil is longer-acting than sildenafil and can be taken on a regular basis, while vardenafil has a similar duration of action to sildenafil. However, these drugs are not suitable for everyone. Patients taking nitrates or related drugs, those with hypotension, and those who have had a recent stroke or myocardial infarction should not take PDE5 inhibitors.

      Like all medications, PDE5 inhibitors can cause side effects. These may include visual disturbances, blue discolouration, non-arteritic anterior ischaemic neuropathy, nasal congestion, flushing, gastrointestinal side-effects, headache, and priapism. It is important to speak to a healthcare professional before taking any medication to ensure that it is safe and appropriate for you.

      Overall, PDE5 inhibitors are an effective treatment for erectile dysfunction and pulmonary hypertension. However, they should only be used under the guidance of a healthcare professional and with careful consideration of the potential risks and benefits.

    • This question is part of the following fields:

      • Pharmacology/Therapeutics
      45.5
      Seconds
  • Question 21 - A 12-month-old African-Caribbean boy is brought to see his General Practitioner by his...

    Correct

    • A 12-month-old African-Caribbean boy is brought to see his General Practitioner by his mother with a 6-day history of fever, reduced feeding and increased irritability. His mother has also noticed this morning that his fingers and toes are swollen and tense and some of the skin is peeling. He is reluctant to play with toys or walk. On examination, he is pale, his lips are cracked and there are no rashes present. Ear, nose and throat (ENT) examinations reveal the presence of a red, swollen tongue he also has swollen, tender digits of his hands and feet.
      He is admitted to hospital and his full blood count (FBC) result is shown below:
      Investigation Result Normal value
      Haemoglobin (Hb) 88 g/l 100–135 g/l
      White cell count (WCC) 6.2 × 109/l 3.8–11 × 109/l
      Platelets 150 × 109/l 150–400 × 1109/l
      Mean corpuscular volume 93 fl 85–105 fl
      Reticulocytes 6% 0.2–2%
      Which of the following is the most likely diagnosis?

      Your Answer: Kawasaki disease

      Explanation:

      Kawasaki disease is a condition that causes inflammation in small and medium blood vessels, particularly in the coronary vessels. Children with this disease typically experience a high fever lasting more than five days, along with symptoms such as a strawberry tongue, dry cracked lips, rashes, peeling skin on the hands and feet, conjunctivitis, and swollen and painful hands and feet.

      Acute lymphoblastic leukaemia (ALL) is a type of cancer that can cause bone pain and swelling in children, as well as unexplained fever, lethargy, recurrent infections, headaches, petechiae or purpura, and splenomegaly. However, a high white blood cell count would be present in ALL, which would be absent in this patient. Anaemia and thrombocytopenia are also common in ALL.

      Nephrotic syndrome is a condition characterized by low levels of albumin and protein in the urine due to damage to the basement membrane of the renal glomerulus. Children with this condition typically experience swelling in the face, feet, abdomen, and genitals, but not in the fingers and toes as seen in this patient.

      Rheumatic fever is a reaction to a bacterial infection, usually caused by group A streptococcus. Symptoms may include fever, abdominal pain, carditis, Sydenham’s chorea, and a rash, but joint pain typically affects the ankles, knees, elbows, and wrists rather than the hands and feet.

      Sickle cell disease is an inherited condition that causes abnormal sickle-shaped red blood cells, leading to blockages in small blood vessels and chronic anemia. It is most common in Black African and Black Caribbean populations. Symptoms may include jaundice, anemia, and acute dactylitis, and screening is recommended for high-risk ethnic groups. A diagnosis of hemolysis is supported by a high reticulocyte count and normocytic anemia on FBC.

    • This question is part of the following fields:

      • Haematology/Oncology
      76.6
      Seconds
  • Question 22 - You are working in the sexual health clinic. A 26-year-old male presents with...

    Correct

    • You are working in the sexual health clinic. A 26-year-old male presents with dysuria and urethral discharge. He had unprotected sexual intercourse 3 weeks ago. You do a full sexual health screen. Three days later he returns to get his results; the initial test is positive for Neisseria gonorrhoea, sensitivities are not known.
      What is the most suitable course of action?

      Your Answer: Intramuscular ceftriaxone

      Explanation:

      Understanding Gonorrhoea: Causes, Symptoms, Microbiology, and Management

      Gonorrhoea is a sexually transmitted infection caused by the Gram-negative diplococcus Neisseria gonorrhoeae. It can occur on any mucous membrane surface, including the genitourinary tract, rectum, and pharynx. The incubation period of gonorrhoea is typically 2-5 days. Symptoms in males include urethral discharge and dysuria, while females may experience cervicitis leading to vaginal discharge. Rectal and pharyngeal infections are usually asymptomatic.

      Immunisation against gonorrhoea is not possible, and reinfection is common due to antigen variation of type IV pili and Opa proteins. Local complications may develop, including urethral strictures, epididymitis, and salpingitis, which can lead to infertility. Disseminated infection may also occur, with gonococcal infection being the most common cause of septic arthritis in young adults.

      Management of gonorrhoea involves the use of antibiotics. Ciprofloxacin used to be the treatment of choice, but there is now increased resistance to it. Cephalosporins are now more widely used, with a single dose of IM ceftriaxone 1g being the new first-line treatment. If ceftriaxone is refused, oral cefixime 400mg + oral azithromycin 2g should be used. Disseminated gonococcal infection (DGI) and gonococcal arthritis may also occur, with symptoms including tenosynovitis, migratory polyarthritis, and dermatitis. Later complications include septic arthritis, endocarditis, and perihepatitis.

    • This question is part of the following fields:

      • Infectious Diseases
      23.8
      Seconds
  • Question 23 - What is the initial indication of puberty in young girls? ...

    Incorrect

    • What is the initial indication of puberty in young girls?

      Your Answer: Menstrual bleeding

      Correct Answer: Breast development

      Explanation:

      Puberty: Normal Changes in Males and Females

      Puberty is a natural process that marks the transition from childhood to adulthood. In males, the first sign of puberty is testicular growth, which typically occurs around the age of 12. A testicular volume greater than 4 ml indicates the onset of puberty. The maximum height spurt for males occurs at the age of 14.

      For females, the first sign of puberty is breast development, which typically occurs around the age of 11.5. The height spurt for females reaches its maximum early in puberty, at the age of 12, before menarche. Menarche, the onset of menstruation, typically occurs at the age of 13.

      Following menarche, there is only a small increase of about 4% in height. It is important to note that normal changes in puberty may include gynaecomastia in boys, asymmetrical breast growth in girls, and diffuse enlargement of the thyroid gland. These changes are a natural part of the process and should not cause alarm. Understanding the normal changes that occur during puberty can help individuals navigate this important stage of development with confidence.

    • This question is part of the following fields:

      • Paediatrics
      10.6
      Seconds
  • Question 24 - The parents of a 15-month-old boy visit their GP with concerns about his...

    Correct

    • The parents of a 15-month-old boy visit their GP with concerns about his eyes. They have noticed that in some photos there is no 'red eye' on the right side. Upon examination, the boy is found to have an esotropic strabismus and a loss of the red-reflex in the right eye. There is a family history of a grandparent who had an enucleation as a child.

      What is the probable diagnosis?

      Your Answer: Retinoblastoma

      Explanation:

      The absence of the red-reflex may be a symptom of a congenital cataract, but this condition is typically identified at birth or during routine infant screenings. Additionally, a congenital cataract would not account for the familial history of enucleation.

      Retinoblastoma is a prevalent type of eye cancer that is commonly found in children, with an average age of diagnosis at 18 months. It is caused by a loss of function of the retinoblastoma tumor suppressor gene on chromosome 13, which is inherited in an autosomal dominant pattern. About 10% of cases are hereditary. The most common presenting symptom is the absence of red-reflex, which is replaced by a white pupil (leukocoria). Other possible features include strabismus and visual problems.

      When it comes to managing retinoblastoma, enucleation is not the only option. Depending on how advanced the tumor is, other treatment options include external beam radiation therapy, chemotherapy, and photocoagulation. The prognosis for retinoblastoma is excellent, with over 90% of patients surviving into adulthood.

    • This question is part of the following fields:

      • Paediatrics
      31.2
      Seconds
  • Question 25 - A 65-year-old man presents to the emergency department with severe chest pain that...

    Correct

    • A 65-year-old man presents to the emergency department with severe chest pain that started an hour ago and is radiating to his left arm. He has a history of type two diabetes and has smoked 50 packs of cigarettes in his lifetime. An ECG shows ST-elevation in leads V2-4, indicating a STEMI. As the healthcare provider, you decide to initiate treatment and give the patient 300mg of aspirin orally. What is the mechanism of action of this medication?

      Your Answer: Non-reversible COX 1 and 2 inhibitor

      Explanation:

      Aspirin irreversibly inhibits both COX 1 and COX 2, preventing the conversion of arachidonic acid into prostaglandin, prostacyclin, and thromboxane. Thromboxane A2 is responsible for platelet aggregation and vasoconstriction. In cases of acute coronary syndrome, high doses of aspirin are administered to prevent the enlargement of the coronary thrombus.

      The Mechanism and Guidelines for Aspirin Use in Cardiovascular Disease

      Aspirin is a medication that works by blocking the action of cyclooxygenase-1 and 2, which are responsible for the synthesis of prostaglandin, prostacyclin, and thromboxane. By inhibiting the formation of thromboxane A2 in platelets, aspirin reduces their ability to aggregate, making it a widely used medication in cardiovascular disease. However, recent trials have cast doubt on the use of aspirin in primary prevention of cardiovascular disease, leading to changes in guidelines. Aspirin is now recommended as a first-line treatment for patients with ischaemic heart disease, but it should not be used in children under 16 due to the risk of Reye’s syndrome. The medication can also potentiate the effects of oral hypoglycaemics, warfarin, and steroids.

      The Medicines and Healthcare products Regulatory Agency (MHRA) issued a drug safety update in January 2010, reminding prescribers that aspirin is not licensed for primary prevention. NICE now recommends clopidogrel as a first-line treatment following an ischaemic stroke and for peripheral arterial disease. However, the situation is more complex for TIAs, with recent Royal College of Physician (RCP) guidelines supporting the use of clopidogrel, while older NICE guidelines still recommend aspirin + dipyridamole – a position the RCP state is ‘illogical’. Despite these changes, aspirin remains an important medication in the treatment of cardiovascular disease, and its use should be carefully considered based on individual patient needs and risk factors.

    • This question is part of the following fields:

      • Pharmacology/Therapeutics
      35.1
      Seconds
  • Question 26 - A 70-year-old man who takes bendroflumethiazide for hypertension is brought to the Emergency...

    Incorrect

    • A 70-year-old man who takes bendroflumethiazide for hypertension is brought to the Emergency Department. Upon admission, his blood work shows the following:
      Na+ 131 mmol/l
      K+ 2.2 mmol/l
      Urea 3.1 mmol/l
      Creatinine 56 µmol/l
      Glucose 4.3 mmol/l
      What ECG feature is most likely to be observed?

      Your Answer: Short QT interval

      Correct Answer: U waves

      Explanation:

      ECG Features of Hypokalaemia

      Hypokalaemia is a condition characterized by low levels of potassium in the blood. This condition can be detected through an electrocardiogram (ECG) which shows specific features. The ECG features of hypokalaemia include U waves, small or absent T waves, prolonged PR interval, ST depression, and long QT. The U waves are particularly noticeable and are accompanied by a borderline PR interval.

      To remember these features, one registered user suggests the following rhyme: In Hypokalaemia, U have no Pot and no T, but a long PR and a long QT. It is important to detect hypokalaemia early as it can lead to serious complications such as cardiac arrhythmias and even cardiac arrest. Therefore, regular monitoring of potassium levels and ECGs is crucial for individuals at risk of hypokalaemia.

    • This question is part of the following fields:

      • Cardiovascular
      35.2
      Seconds
  • Question 27 - A 55-year-old woman visits her GP seeking advice on starting hormone replacement therapy...

    Correct

    • A 55-year-old woman visits her GP seeking advice on starting hormone replacement therapy (HRT) due to distressing vasomotor symptoms. Her LMP was 10 months ago, and she has not undergone any surgeries, has no significant medical history, and is not sexually active. Despite making lifestyle changes, she has not experienced much relief. Assuming there are no contraindications, what treatment would you suggest?

      Your Answer: Cyclical combined HRT

      Explanation:

      When a woman expresses interest in starting hormone replacement therapy (HRT), it is important to gather a detailed medical history to determine her menopausal status. This includes information about her last menstrual period (LMP) and any bleeding patterns leading up to it. Based on this information, it appears that the woman in question is peri-menopausal, as she has not been without a period for a full year.

      The primary reason for starting HRT is to alleviate vasomotor symptoms, such as hot flashes. However, it may also be used to prevent osteoporosis in women who have been diagnosed with premature menopause.

      For women who still have a uterus, HRT should consist of a combination of estrogen and progesterone. The progesterone is essential for reducing the risk of endometrial cancer, which can occur when estrogen is used alone. Women who have had a hysterectomy will typically receive continuous estrogen-only therapy.

      The type of HRT prescribed will depend on the woman’s menopausal status. Those who have had their LMP within the past year should receive cyclical combined HRT, while those who have been without a period for at least a year or who have experienced premature menopause should receive continuous combined HRT.

      For women who are unable or unwilling to take HRT, there are several non-hormonal treatments available for vasomotor symptoms. These include certain selective serotonin and noradrenaline reuptake inhibitors, clonidine, and gabapentin. However, sertraline is not effective for treating hot flashes. It is worth noting that the National Institute for Health and Clinical Excellence (NICE) does not recommend the use of herbal or complementary therapies for managing hot flashes and night sweats.

      Hormone replacement therapy (HRT) involves a small dose of oestrogen and progestogen to alleviate menopausal symptoms. The indications for HRT have changed due to the long-term risks, and it is primarily used for vasomotor symptoms and preventing osteoporosis in younger women. HRT consists of natural oestrogens and synthetic progestogens, and can be taken orally or transdermally. Transdermal is preferred for women at risk of venous thromboembolism.

    • This question is part of the following fields:

      • Pharmacology/Therapeutics
      47.4
      Seconds
  • Question 28 - During a routine check-up, a 7 week-old baby boy is seen. His mother...

    Incorrect

    • During a routine check-up, a 7 week-old baby boy is seen. His mother has a history of asthma and used inhaled steroids while pregnant. He was delivered via planned Caesarian at 39 weeks due to breech presentation and weighed 3.1kg at birth. What condition is he at a higher risk for?

      Your Answer: Congenital cataract

      Correct Answer: Developmental dysplasia of the hip

      Explanation:

      If a baby was in a breech presentation, it is important to ensure that they have been referred for screening for developmental dysplasia of the hip (DDH) as it is a risk factor for this condition. The Department of Health recommends that all babies who were breech at any point from 36 weeks (even if not breech at birth), babies born before 36 weeks who were in a breech presentation, and all babies with a first degree relative who had a hip problem in early life, should undergo ultrasound screening for hip dysplasia. If one twin was breech, both should be screened. Some hospitals also refer babies with other conditions such as oligohydramnios, high birth weight, torticollis, congenital talipes calcaneovalgus, and metatarsus adductus for screening. For more information on screening for DDH, please refer to the link provided.

      Developmental dysplasia of the hip (DDH) is a condition that affects 1-3% of newborns and is more common in females, firstborn children, and those with a positive family history or breech presentation. It used to be called congenital dislocation of the hip (CDH). DDH is more often found in the left hip and can be bilateral in 20% of cases. Screening for DDH is recommended for infants with certain risk factors, and all infants are screened using the Barlow and Ortolani tests at the newborn and six-week baby check. Clinical examination includes testing for leg length symmetry, restricted hip abduction, and knee level when hips and knees are flexed. Ultrasound is used to confirm the diagnosis if clinically suspected, but x-ray is the first line investigation for infants over 4.5 months. Management includes the use of a Pavlik harness for children under 4-5 months and surgery for older children with unstable hips.

    • This question is part of the following fields:

      • Paediatrics
      56
      Seconds
  • Question 29 - A 67-year-old man arrives at the emergency department with a history of severe...

    Correct

    • A 67-year-old man arrives at the emergency department with a history of severe chest pain, scoring 9 out of 10, that began an hour ago. He is a smoker and is currently taking amlodipine for his hypertension. Following an ECG and troponin testing, he is diagnosed with NSTEMI. Using the GRACE score, his predicted 6-month mortality is 2%, and he is not at high risk of bleeding. However, the nearest primary percutaneous intervention unit is over an hour away. What is the appropriate management plan for this patient?

      Your Answer: Aspirin, ticagrelor and fondaparinux

      Explanation:

      Managing Acute Coronary Syndrome: A Summary of NICE Guidelines

      Acute coronary syndrome (ACS) is a common and serious medical condition that requires prompt management. The management of ACS has evolved over the years, with the development of new drugs and procedures such as percutaneous coronary intervention (PCI). The National Institute for Health and Care Excellence (NICE) has updated its guidelines on the management of ACS in 2020.

      ACS can be classified into three subtypes: ST-elevation myocardial infarction (STEMI), non ST-elevation myocardial infarction (NSTEMI), and unstable angina. The management of ACS depends on the subtype. However, there are common initial drug therapies for all patients with ACS, such as aspirin and nitrates. Oxygen should only be given if the patient has oxygen saturations below 94%, and morphine should only be given for severe pain.

      For patients with STEMI, the first step is to assess eligibility for coronary reperfusion therapy, which can be either PCI or fibrinolysis. Patients with NSTEMI/unstable angina require a risk assessment using the Global Registry of Acute Coronary Events (GRACE) tool to determine whether they need coronary angiography (with follow-on PCI if necessary) or conservative management.

      This summary provides an overview of the NICE guidelines for managing ACS. The guidelines are complex and depend on individual patient factors, so healthcare professionals should review the full guidelines for further details. Proper management of ACS can improve patient outcomes and reduce the risk of complications.

    • This question is part of the following fields:

      • Cardiovascular
      61.7
      Seconds
  • Question 30 - Among the following options, which condition is considered a restrictive lung disease/condition? ...

    Incorrect

    • Among the following options, which condition is considered a restrictive lung disease/condition?

      Your Answer: Bronchiectasis

      Correct Answer: Severe scoliosis

      Explanation:

      Different Types of Lung Diseases and their Spirometry Patterns

      Scoliosis and Lung Function
      Severe scoliosis can affect the respiratory muscles and the natural movements of the thoracic cage, leading to a restrictive pattern in pulmonary function tests. This can prevent the lungs from expanding correctly, compromising their function.

      Cystic Fibrosis and Lung Function
      In early stage cystic fibrosis, the presence of inflammation and thick secretions in the airways can cause an obstructive pattern in spirometry tests. As damage to the lung tissue occurs, a restrictive component can also develop, resulting in a combined obstructive and restrictive pattern.

      Emphysema and Lung Function
      Emphysema is a type of obstructive lung disease characterized by abnormal and irreversible enlargement of air spaces and alveolar wall destruction. This leads to airflow limitation and a spirometry pattern typical of obstructive lung disease.

      Asthma and Lung Function
      Asthma is an inflammatory disorder of the airways that causes hyperresponsiveness and constriction of the airways in response to various stimuli. This leads to airflow limitation and a spirometry pattern typical of obstructive lung disease.

      Bronchiectasis and Lung Function
      Bronchiectasis is characterized by abnormal and irreversible dilatation of the bronchial walls, leading to accumulation of secretions and recurrent inflammation of the airways. This produces an obstructive pattern in pulmonary function tests.

      In summary, different types of lung diseases can affect lung function in various ways, leading to different spirometry patterns. Understanding these patterns can help in the diagnosis and management of these conditions.

    • This question is part of the following fields:

      • Respiratory Medicine
      29
      Seconds

SESSION STATS - PERFORMANCE PER SPECIALTY

Pharmacology/Therapeutics (3/5) 60%
Musculoskeletal (1/2) 50%
Haematology/Oncology (1/2) 50%
Respiratory Medicine (1/3) 33%
ENT (1/1) 100%
Reproductive Medicine (1/3) 33%
Paediatrics (2/5) 40%
Neurology (0/1) 0%
Cardiovascular (1/4) 25%
Renal Medicine/Urology (0/1) 0%
Endocrinology/Metabolic Disease (1/1) 100%
Infectious Diseases (1/2) 50%
Passmed