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  • Question 1 - You are working as the duty physician at a high school athletics meet...

    Incorrect

    • You are working as the duty physician at a high school athletics meet and are collecting samples to look for drugs of abuse.

      Which of the following initial tests is most useful to look for testosterone abuse?

      Your Answer: Sex hormone-binding globulin (SHBG) levels

      Correct Answer: Urinary testosterone/epitestosterone ratio

      Explanation:

      The urinary testosterone/epitestosterone ratio is the best initial test for testosterone abuse, with a ratio greater than 6:1 being confirmatory. SHBG levels are too non-specific, while LH levels may be affected by other factors. Prolactin levels are also non-specific, and urinary hCG is useful only for detecting abuse of hCG itself. False positives may occur in patients with testicular cancer.

    • This question is part of the following fields:

      • Clinical Pharmacology And Therapeutics
      34.9
      Seconds
  • Question 2 - As an expedition doctor on a climbing trip to the Andes, you are...

    Incorrect

    • As an expedition doctor on a climbing trip to the Andes, you are presented with a 37-year-old man who has been brought down rapidly from the mountain to base camp. Upon arrival at the medical tent, he is receiving 40% oxygen but his saturations remain at 90%. Upon examination, you note bilateral crepitations, indicating pulmonary edema. What is the most appropriate intervention for this patient?

      Your Answer: Intravenous (IV) furosemide

      Correct Answer: High-concentration oxygen

      Explanation:

      Treatment Options for High-Altitude Pulmonary Edema

      High-altitude pulmonary edema (HAPE) is a type of high-altitude illness that occurs due to hypobaric hypoxia, resulting in the accumulation of white and red blood cells in the lungs. This leads to the breakdown of the pulmonary blood-gas barrier and the accumulation of fluid in the alveolar spaces, causing pulmonary edema. The following are treatment options for HAPE:

      High-concentration oxygen: This is the first-line treatment for HAPE, as it helps to alleviate hypoxia and reduce the accumulation of fluid in the lungs.

      Nifedipine: If high-concentration oxygen is not available, nifedipine can be used as a second-line treatment. It reduces pulmonary hypertension and is an appropriate choice for pulmonary edema in the context of acute mountain sickness.

      Intravenous (IV) furosemide: IV furosemide is not the correct choice for HAPE, as it does not address the underlying cause of the condition.

      IV Hydrocortisone: While IV hydrocortisone may be useful in treating high-altitude cerebral edema, it is not effective in treating HAPE.

      Acetazolamide: Acetazolamide may be helpful in preventing acute mountain sickness, but the best prevention for HAPE is slow acclimatization.

    • This question is part of the following fields:

      • Cardiology
      37
      Seconds
  • Question 3 - A 25-year-old man is admitted with diabetic ketoacidosis. He is typically managed with...

    Incorrect

    • A 25-year-old man is admitted with diabetic ketoacidosis. He is typically managed with basal bolus insulin but has missed several doses due to a busy work schedule. During examination, his respiratory rate is 30/min, he appears lethargic, disoriented, and has a distinct smell of acetone.
      What arterial blood gas results would be most consistent with his presentation?

      Your Answer: Metabolic acidosis with hyperventilation and pear drop smell

      Correct Answer:

      Explanation:

      The given values for pH, pCO2, and pO2 can provide clues about the underlying condition of a patient. A pH of 7.1 with a low pCO2 and high pO2, along with the characteristic smell of pear drops, suggests diabetic ketoacidosis. On the other hand, a pH of 7.25 with an elevated pCO2 indicates respiratory acidosis. A pH of 7.4 with a low pCO2 and the smell of pear drops may also indicate diabetic ketoacidosis. An alkalosis with a low pCO2 would be respiratory in origin. Finally, a presentation with a normal pH and elevated pCO2 suggests respiratory acidosis with metabolic compensation.

    • This question is part of the following fields:

      • Endocrinology, Diabetes And Metabolic Medicine
      45.1
      Seconds
  • Question 4 - A 54-year-old woman presents to the endocrine clinic with complaints of lethargy, weight...

    Correct

    • A 54-year-old woman presents to the endocrine clinic with complaints of lethargy, weight gain, and hair loss that have been worsening over the past few months. She has a history of hypertension and is currently taking indapamide. On examination, her pulse is regular at 66 beats per minute and her blood pressure is 152/88 mmHg. Her BMI is 31 and she has noticeable thinning of her hair.

      Laboratory investigations reveal a hemoglobin level of 117 g/L (normal range: 115-160), white cell count of 7.0 ×109/L (normal range: 4-11), platelet count of 186 ×109/L (normal range: 150-400), sodium level of 136 mmol/L (normal range: 135-146), potassium level of 4.0 mmol/L (normal range: 3.5-5), and creatinine level of 100 µmol/L (normal range: 79-118). Her TSH level is 9.8 IU (normal range: 0.5-5).

      What lipid abnormality would be most expected in this patient?

      Your Answer: Increased triglycerides

      Explanation:

      Lipid Profile in Hypothyroidism

      In hypothyroidism, the predominant picture is mixed dyslipidaemia, which is characterized by an increase in triglycerides. On the other hand, increased levels of HDL are observed with exercise and modest alcohol consumption. Additionally, an increase in large buoyant LDL is seen in response to increased insulin sensitivity, which is believed to be less atherogenic than small dense LDL. However, in hypothyroidism, absolute levels of LDL are increased, and a small increase in IDL may also be observed.

      Overall, the lipid profile in hypothyroidism is characterized by an increase in triglycerides and LDL, and a possible increase in IDL. While exercise and modest alcohol consumption may increase HDL levels, the predominant picture is mixed dyslipidaemia. the lipid profile in hypothyroidism is important for managing the condition and reducing the risk of cardiovascular disease.

    • This question is part of the following fields:

      • Endocrinology, Diabetes And Metabolic Medicine
      49.8
      Seconds
  • Question 5 - A 67-year-old man presents to the respiratory clinic for a follow-up appointment regarding...

    Incorrect

    • A 67-year-old man presents to the respiratory clinic for a follow-up appointment regarding his COPD. During his last visit, his medications were increased to include regular inhaled Spiriva (tiotropium bromide), Symbicort (budesonide and formoterol), and salbutamol as needed. He reports experiencing shortness of breath at rest and during physical activity, which is limiting his daily activities. He has had two exacerbations in the past year and has been an ex-smoker for six months.

      Upon examination, the patient is tachypnoeic with oxygen saturation levels of 92% on air. Bilateral wheezing is audible during auscultation, and his heart sounds are normal. The patient's calves are soft and non-tender, with no signs of oedema.

      Arterial blood gas results are as follows:

      pH 7.35 (7.35 - 7.45)
      PaO2 8.2 kPa (11 - 13)
      PaCO2 5.1 kPa (4.7 - 6.0)
      Haemoglobin 135 g/L (135 - 180)

      FEV1 is less than 50% predicted.

      What would be the most appropriate addition to this patient's long-term management plan?

      Your Answer: Montelukast

      Correct Answer: Roflumilast

      Explanation:

      Respiratory medicine utilizes various drugs to treat respiratory conditions such as asthma and chronic obstructive pulmonary disease (COPD). Salbutamol is a short-acting inhaled bronchodilator that relaxes bronchial smooth muscle through its effects on beta 2 receptors. It is commonly used in asthma and COPD treatment. Salmeterol, a long-acting beta receptor agonist, has similar effects. Corticosteroids are anti-inflammatory drugs used as maintenance therapy in the form of inhaled corticosteroids. Oral or intravenous corticosteroids are used following an acute exacerbation of asthma or COPD.

      Ipratropium is a short-acting inhaled bronchodilator that blocks muscarinic acetylcholine receptors, relaxing bronchial smooth muscle. It is primarily used in COPD treatment, while tiotropium has similar effects but is long-acting. Methylxanthines, such as theophylline, are non-specific inhibitors of phosphodiesterase, resulting in an increase in cAMP. They are given orally or intravenously and have a narrow therapeutic index. Monteleukast and zafirlukast block leukotriene receptors and are usually taken orally. They are useful in treating aspirin-induced asthma. Overall, these drugs play a crucial role in managing respiratory conditions and improving patients’ quality of life.

    • This question is part of the following fields:

      • Respiratory Medicine
      71.8
      Seconds
  • Question 6 - What is the most accurate way to describe a raised lesion measuring 6...

    Incorrect

    • What is the most accurate way to describe a raised lesion measuring 6 cm in diameter that appears erythematous and scaly upon skin examination of a patient with a rash?

      Your Answer: Ulcer

      Correct Answer: Plaque

      Explanation:

      Skin Lesions: Plaques, Macules, Papules, Ulcers, and Vesicles

      Plaques are skin lesions that are raised and larger than 1 cm in diameter. On the other hand, macules are areas of altered skin color, regardless of their size. Papules, on the other hand, are raised lesions that are less than 1 cm in diameter. Ulcers, meanwhile, are skin discontinuities that result in the complete loss of the epidermis, as well as portions of the dermis and subcutaneous fat. Lastly, vesicles are fluid-filled, well-circumscribed raised lesions.

    • This question is part of the following fields:

      • Dermatology
      31.1
      Seconds
  • Question 7 - A 50-year-old man arrives at the emergency department complaining of sudden and severe...

    Incorrect

    • A 50-year-old man arrives at the emergency department complaining of sudden and severe pain in his left eye, along with sensitivity to light and decreased vision. Upon examination, the left eye appears red and the pupil is smaller than the right. The patient is unable to count fingers with the left eye, but has normal vision in the right eye. Additionally, there is evidence of pus in the front part of the eye.

      What is the recommended course of treatment for this patient?

      Your Answer: Topical antibiotics

      Correct Answer: Steroid + mydriatic eye drops

      Explanation:

      The most common treatment for anterior uveitis is a combination of steroid and cycloplegic (mydriatic) drops. However, the management of this condition depends on whether it is caused by an infection or not, and therefore, it must be diagnosed and treated by an ophthalmologist in secondary care. Intravenous antibiotics may be necessary in cases of infective anterior uveitis, but topical steroids and cycloplegics are more likely to be prescribed. Carbonic anhydrase diuretics, topical antibiotics, and topical beta-blockers are not the most appropriate treatments for this condition.

      Anterior uveitis, also known as iritis, is a type of inflammation that affects the iris and ciliary body in the front part of the uvea. This condition is often associated with HLA-B27 and may be linked to other conditions such as ankylosing spondylitis, reactive arthritis, ulcerative colitis, Crohn’s disease, Behcet’s disease, and sarcoidosis. Symptoms of anterior uveitis include sudden onset of eye discomfort and pain, small and irregular pupils, intense sensitivity to light, blurred vision, redness in the eye, tearing, and a ring of redness around the cornea. In severe cases, pus and inflammatory cells may accumulate in the front chamber of the eye, leading to a visible fluid level. Treatment for anterior uveitis involves urgent evaluation by an ophthalmologist, cycloplegic agents to relieve pain and photophobia, and steroid eye drops to reduce inflammation.

    • This question is part of the following fields:

      • Medical Ophthalmology
      83.4
      Seconds
  • Question 8 - A 15-year-old female presents with a swollen knee. She reports experiencing similar episodes...

    Incorrect

    • A 15-year-old female presents with a swollen knee. She reports experiencing similar episodes in the past. Additionally, she complains of excessive bleeding after dental procedures. Her father has a history of a bleeding disorder. Upon examination, her right knee is swollen and warm to the touch. A knee aspiration reveals a bloody effusion.

      The following blood results were obtained:

      - Hemoglobin (Hb): 110 g/L
      - Platelets: 682 * 10^9/L
      - Prothrombin time (PT): 12 seconds (normal range: 10-13)
      - Activated partial thromboplastin time (aPTT): 54 seconds (normal range: 25-36)
      - Factor VIII level: 2% of normal (very low)
      - Factor IX level: Normal
      - von Willebrand Factor level: Normal

      What is the most likely disorder affecting this patient?

      Your Answer: Ehlers-Danlos syndrome

      Correct Answer: Turner's syndrome

      Explanation:

      Understanding Turner’s Syndrome

      Turner’s syndrome is a genetic condition that affects approximately 1 in 2,500 females. It is caused by the absence of one sex chromosome (X) or a deletion of the short arm of one of the X chromosomes. This condition is identified as 45,XO or 45,X.

      The features of Turner’s syndrome include short stature, a shield chest with widely spaced nipples, a webbed neck, a bicuspid aortic valve (present in 15% of cases), coarctation of the aorta (present in 5-10% of cases), primary amenorrhea, cystic hygroma (often diagnosed prenatally), a high-arched palate, a short fourth metacarpal, multiple pigmented naevi, lymphoedema in neonates (especially in the feet), and elevated gonadotrophin levels. Hypothyroidism is also more common in individuals with Turner’s syndrome, as well as an increased incidence of autoimmune diseases such as autoimmune thyroiditis and Crohn’s disease.

      In summary, Turner’s syndrome is a chromosomal disorder that affects females and is characterized by various physical features and health conditions. Early diagnosis and management can help individuals with Turner’s syndrome lead healthy and fulfilling lives.

    • This question is part of the following fields:

      • Cardiology
      49
      Seconds
  • Question 9 - A 30-year-old man is brought to the Emergency Department by a friend and...

    Incorrect

    • A 30-year-old man is brought to the Emergency Department by a friend and is generally unwell with a heart rate of 120/min, blood pressure of 139/58 mmHg, and shortness of breath with a respiratory rate of 25/min. His arterial blood gases on high-flow oxygen show a pH of 7.19, p(CO2) of 1.1 kPa, p(O2) of 29.6 kPa, HCO3– of 7.8 mmol/l, and base excess of –22.0 mmol/l. Biochemistry investigations reveal abnormal levels of sodium, creatinine, glucose, bicarbonate, chloride, and phosphate. The House Officer suspects poisoning as the cause of his symptoms. What is the most likely cause of his poisoning?

      Your Answer: Lisinopril

      Correct Answer: Methanol

      Explanation:

      Causes of High Anion Gap Metabolic Acidosis

      High anion gap metabolic acidosis is a condition where the body produces too much acid or loses too much base. In this condition, the anion gap, which is the difference between the measured cations and anions in the blood, is elevated. A normal anion gap is around 12-16 mmol/l, but in high anion gap metabolic acidosis, it can be higher.

      There are several causes of high anion gap metabolic acidosis, including methanol, metformin, and isoniazid. Methanol is a common cause of this condition and can result in severe metabolic acidosis. Metoprolol overdose, on the other hand, is associated with marked hypotension and bradycardia. Lisinopril overdose can result in marked hypotension with kidney disease, but it doesn’t result in raised anion gap metabolic acidosis. Overdose of amiodarone is associated with extreme bradycardia, heart block, hypotension, and cardiogenic shock. Acetazolamide, on the other hand, is associated with a normal anion gap metabolic acidosis.

      In conclusion, high anion gap metabolic acidosis is a serious condition that requires prompt medical attention. It can be caused by various factors, and identifying the underlying cause is crucial for effective treatment.

    • This question is part of the following fields:

      • Clinical Pharmacology And Therapeutics
      78.2
      Seconds
  • Question 10 - A 67-year-old man on the acute medical unit presents with sudden onset, severe...

    Correct

    • A 67-year-old man on the acute medical unit presents with sudden onset, severe abdominal pain. He is an inpatient being treated for community-acquired pneumonia and has been in persistent atrial fibrillation during this admission. He is not normally on anticoagulants. His bowels have been opening regularly and are of a normal character, and he has not vomited. He has a medical history of type 2 diabetes and gastro-oesophageal reflux disease (GORD).

      His vital signs are as follows: oxygen saturations of 95% on 2L oxygen, respiratory rate of 20/min, irregular heart rate at 103/min, blood pressure of 98/62 mmHg, temperature of 37.4ºC, and he remains alert. On abdominal examination, there is a widespread, exquisitely tender abdomen with some guarding and rebound tenderness.

      What is the most appropriate next step in managing this patient?

      Your Answer: Urgent laparotomy

      Explanation:

      In cases of sudden onset peritonitis on a background of atrial fibrillation (particularly when not on anticoagulation), acute mesenteric ischaemia should be considered as a possible diagnosis. If signs of advanced ischemia, such as peritonitis or sepsis, are present, an immediate laparotomy is usually required. In this case, the patient is peritonitic and requires urgent referral to the surgical team for a laparotomy.

      While anticoagulation may be indicated in the long term for persistent atrial fibrillation, it has no role in the acute management of acute mesenteric ischaemia and may increase the risk of intraoperative bleeding.

      Emergency gastroscopy is useful in cases of acute gastrointestinal bleeding, but it is not necessary in this case as the primary complaint is pain and the bowels are normal in character.

      Although laxatives can treat constipation, which can cause acute abdominal pain, this patient has been opening his bowels regularly and has signs of peritonism, making constipation less likely.

      While PPIs may be useful in treating gastritis, which this patient is at risk of due to his history of GORD, it is unlikely to present with signs of peritonitis and deranged observations. The pain is also more likely to be epigastric rather than generalised.

      Acute mesenteric ischaemia is a condition that is commonly caused by an embolism that blocks the artery supplying the small bowel, such as the superior mesenteric artery. Patients with this condition usually have a history of atrial fibrillation. The abdominal pain associated with acute mesenteric ischaemia is sudden, severe, and does not match the physical exam findings.

      Immediate laparotomy is typically required for patients with acute mesenteric ischaemia, especially if there are signs of advanced ischemia, such as peritonitis or sepsis. Delaying surgery can lead to a poor prognosis for the patient.

    • This question is part of the following fields:

      • Gastroenterology And Hepatology
      84.7
      Seconds
  • Question 11 - A 63-year-old woman presents to the gastroenterology clinic with a history of watery...

    Correct

    • A 63-year-old woman presents to the gastroenterology clinic with a history of watery diarrhoea for the past 6 months, with 4-6 bowel movements per day. She has a medical history of hypertension, ischaemic heart disease, Type 2 diabetes, and depression.

      Lab results show Hb 11.5 g/l, Na+ 139 mmol/l, Bilirubin 12 µmol/l, Platelets 207 * 109/l, K+ 3.9 mmol/l, ALP 95 u/l, WBC 8.9 * 109/l, Urea 7.2 mmol/l, ALT 23 u/l, Neuts 5.6 * 109/l, Creatinine 100 µmol/l, γGT 56 u/l, Lymphs 1.8 * 109/l, Albumin 38 g/l, and Eosin 0.5 * 109/l.

      During colonoscopy, mild mucosal oedema is observed, and biopsy reveals lymphocytic infiltration. Which of the following agents is most likely responsible for her colonoscopy findings?

      Your Answer: Sertraline

      Explanation:

      Selective serotonin reuptake inhibitors (SSRIs) are the first-line treatment for depression, with citalopram and fluoxetine being the preferred options. They should be used with caution in children and adolescents, and patients should be monitored for increased anxiety and agitation. Gastrointestinal symptoms are the most common side-effect, and there is an increased risk of gastrointestinal bleeding. Citalopram and escitalopram are associated with dose-dependent QT interval prolongation and should not be used in certain patients. SSRIs have a higher propensity for drug interactions, and patients should be reviewed after 2 weeks of treatment. When stopping a SSRI, the dose should be gradually reduced over a 4 week period. Use of SSRIs during pregnancy should be weighed against the risks and benefits.

    • This question is part of the following fields:

      • Clinical Pharmacology And Therapeutics
      70.1
      Seconds
  • Question 12 - A 75-year-old man visits the general medical clinic to discuss his recent blood...

    Correct

    • A 75-year-old man visits the general medical clinic to discuss his recent blood test results. During a routine check-up, he was found to have low sodium levels. He has no symptoms of hyponatraemia and is clinically euvolaemic. However, a CT scan of his chest revealed radiological evidence of small cell lung cancer, which he has declined further investigation for. The medical team suspects he may have SIADH and wants to know what further investigations are necessary to confirm this.

      Na+ 122 mmol/l
      K+ 4.3 mmol/l
      Urea 5.2 mmol/l
      Creatinine 72 µmol/l
      Serum osmolality 240 mmol/kg

      Your Answer: Urinary electrolytes and osmolality

      Explanation:

      To diagnose SIADH in a euvolaemic patient with hyponatraemia and low serum osmolality, the criteria include Na < 135, serum osmolality <271, and urinary osmolality >100. Therefore, it is important to confirm elevated urinary osmolality. While a morning cortisol test can help diagnose Addison’s disease, a random serum cortisol test is not very useful. An echocardiogram may be necessary to rule out heart failure as a cause of hyponatraemia in the presence of fluid overload, but it is unlikely to be needed if there is no peripheral oedema, raised JVP, or pulmonary oedema.

      SIADH is a condition where the body retains too much water, leading to low sodium levels in the blood. This can be caused by various factors such as malignancy (particularly small cell lung cancer), neurological conditions like stroke or meningitis, infections like tuberculosis or pneumonia, certain drugs like sulfonylureas and SSRIs, and other factors like positive end-expiratory pressure and porphyrias. Treatment involves slowly correcting the sodium levels, restricting fluid intake, and using medications like demeclocycline or ADH receptor antagonists. It is important to correct the sodium levels slowly to avoid complications like central pontine myelinolysis.

    • This question is part of the following fields:

      • Endocrinology, Diabetes And Metabolic Medicine
      81.8
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  • Question 13 - A 70-year-old man undergoes a laparotomy to correct a small bowel obstruction. He...

    Incorrect

    • A 70-year-old man undergoes a laparotomy to correct a small bowel obstruction. He has a medical history of orthotopic bladder reconstruction due to bladder cancer. After 48 hours in the High Dependency Unit, he experiences confusion and refuses to consume oral fluids. His vital signs, including pulse rate, blood pressure, and urine output, are normal. The following serum biochemistry results are obtained:

      - Na+ 147 mmol/L
      - K+ 3.1 mmol/L
      - Chloride 134 mmol/L
      - Urea 14.3 mmol/L
      - Creatinine 82 µmol/L
      - Glucose 14 mmol/L

      The patient is breathing air, and blood gas analysis reveals:

      - pH 7.26
      - PaCO2 2.57 kPa
      - PaO2 9.92 kPa
      - HCO3 16.3 mmol/L
      - Base excess −14.6 mmol/L
      - Lactate 1.6 mmol/L

      What is the most appropriate initial intervention for this patient?

      Your Answer: Rehydration with 0.9% sodium chloride and correction of blood glucose

      Correct Answer: Intravenous infusion of 1.26% sodium bicarbonate and potassium replacement

      Explanation:

      Metabolic Acidosis in Patients with Neobladders

      Patients who undergo neobladder formation following radical cystectomy or cystoprostatectomy may experience hyperchloraemic metabolic acidosis, which is a documented complication. This condition is usually mild and improves over time, but severe and persistent metabolic acidosis may occur when patients undergo further surgery for other reasons. Medical staff treating patients with neobladders should be aware of this complication and treat it with intravenous fluids and bicarbonate. Hypokalemia, hypocalcaemia, and hypomagnesaemia may also be present. Potassium depletion can be exacerbated by the correction of acidosis. Rehydration with 0.9% N. saline may worsen the hyperchloraemic state, and potassium supplementation alone via a central venous catheter is not sufficient treatment. Encouraging the patient to breathe into a paper bag is not appropriate in this case. Hyperglycaemia may also be present, but it is secondary to the metabolic stress response and not ketoacidosis.

    • This question is part of the following fields:

      • Endocrinology, Diabetes And Metabolic Medicine
      117.8
      Seconds
  • Question 14 - A 75-year-old woman presents to the Rheumatology Clinic with a 3-week history of...

    Incorrect

    • A 75-year-old woman presents to the Rheumatology Clinic with a 3-week history of bilateral hip pain and malaise. The pain is diffuse and affects the anterior and posterior aspects of the pelvis as well as the upper thighs. It is worse in the mornings and accompanied by stiffness that takes several hours to improve. She also reports a constant right-sided headache for the past 2 weeks and a recent episode of transient visual darkening, although she cannot recall which eye was affected. Her medical history includes hypertension and hypothyroidism, and she takes amlodipine and levothyroxine regularly. On examination, her visual acuity is 6/9 in both eyes, and her right temporal artery pulsation is difficult to feel. Blood tests show elevated CRP levels. A temporal artery biopsy is negative for giant cell arteritis. What is the best treatment approach?

      Your Answer: Explanation, reassurance and referral to physiotherapy for graded aerobic exercise

      Correct Answer: IV methylprednisolone 1 gram once daily

      Explanation:

      It is important to note that a negative temporal artery biopsy does not rule out GCA, and shorter biopsy specimens are more likely to produce falsely reassuring results. To address this, the BSR recommends that biopsy specimens should be at least 1 cm in length.

      If a patient experiences transient visual loss, it may indicate the onset of permanent blindness. In such cases, the BSR recommends administering IV methylprednisolone at a dosage of 500-1000 mg daily for 3 days.

      For patients with uncomplicated GCA or established visual loss, the recommended treatment is 60 mg prednisolone daily.

      It should be noted that prednisolone 15mg daily is only appropriate for isolated PMR and is not recommended in this case. The other treatment options listed are for fibromyalgia and are therefore not applicable.

      Temporal arteritis is a type of large vessel vasculitis that often occurs in patients over the age of 60 and is commonly associated with polymyalgia rheumatica. This condition is characterized by changes in the affected artery that skip certain sections while damaging others. Symptoms of temporal arteritis include headache, jaw claudication, and visual disturbances, with anterior ischemic optic neuropathy being the most common ocular complication. A tender, palpable temporal artery is also often present, and around 50% of patients may experience symptoms of PMR, such as muscle aches and morning stiffness.

      To diagnose temporal arteritis, doctors will typically look for elevated inflammatory markers, such as an ESR greater than 50 mm/hr or elevated CRP levels. A temporal artery biopsy may also be performed to confirm the diagnosis, with skip lesions often being present. Treatment for temporal arteritis involves urgent high-dose glucocorticoids, which should be given as soon as the diagnosis is suspected and before the temporal artery biopsy. If there is no visual loss, high-dose prednisolone is typically used, while IV methylprednisolone is usually given if there is evolving visual loss. Patients with visual symptoms should be seen by an ophthalmologist on the same day, as visual damage is often irreversible. Other treatments may include bone protection with bisphosphonates and low-dose aspirin, although the evidence supporting the latter is weak.

    • This question is part of the following fields:

      • Rheumatology
      115.5
      Seconds
  • Question 15 - A 22-year-old man is brought to the Emergency Department by the Police with...

    Incorrect

    • A 22-year-old man is brought to the Emergency Department by the Police with agitation and aggression. He is accompanied by a friend, who reports that they had been out celebrating his cousin's birthday and that the patient may have ingested something.

      The friend recalls the patient complaining of intense stomach pain for some time after he allegedly took the substance, but it soon settled and he seemed in good spirits; talking enthusiastically about seeing vivid colors and patterns. As the night went on, however, he became increasingly disturbed; shouting at other clubgoers and complaining about feeling paranoid and anxious.

      On examination, his temperature is 38.9ºC. His pulse is 120 bpm and his blood pressure is 180/95 mmHg. He is difficult to examine due to intermittent aggression, and he has lashed out on several occasions.

      In order to ensure his own safety, a decision to sedate the patient is made. The patient is successfully restrained and cannulated but suffers a tonic-clonic seizure shortly afterward. He is given 4mg IV lorazepam, but then suffers a cardiac arrest from which he cannot be resuscitated.

      Which drug is most likely to be responsible?

      Your Answer: Lysergic acid diethylamide (LSD)

      Correct Answer: Nexus (2CB)

      Explanation:

      Nexus is a designer drug belonging to the 2C family, which can cause agitation, aggression, and hallucinations. It is ingested orally or by insufflation and can lead to hypertension, tachycardia, hyperthermia, seizures, and excited delirium. Excited delirium can cause unexpected cardiac arrest and has been linked to a number of 2C-related deaths. LSD is also a hallucinogen but would not cause hypertension or hyperthermia. GHB is a CNS depressant that causes euphoria followed by coma.

      Novel psychoactive substances are new drugs that are chemically related to established recreational drugs. They are often referred to as ‘legal highs’ but have been illegal in the UK since 2016. They can be stimulants, cannabinoids, hallucinogens, depressants, or other substances such as GHB and nitrous oxide. Adverse effects are similar to the original drug class.

    • This question is part of the following fields:

      • Clinical Pharmacology And Therapeutics
      76.2
      Seconds
  • Question 16 - A middle-aged patient with a history of heavy alcohol consumption presents with a...

    Correct

    • A middle-aged patient with a history of heavy alcohol consumption presents with a persistent fever, coughing up blood, green phlegm, and a left-sided effusion. The patient reports feeling unwell with fluctuating fevers for the past week and admits to drinking a significant amount of alcohol and not maintaining a proper diet. You suspect the possibility of an empyema. What test would be most helpful in confirming your suspicion?

      Your Answer: Pleural fluid pH

      Explanation:

      Diagnostic Tests for Empyema: Importance of Pleural Fluid pH

      Empyema is a serious condition that requires prompt diagnosis and treatment. Among the various diagnostic tests available, pleural fluid pH is the most useful investigation for confirming the presence of empyema. A pH of less than 7.2 is highly suggestive of empyema and should be considered a red flag.

      Other diagnostic tests, such as urinary and serum pneumococcal antigen tests, may be helpful but are not definitive. Pleural fluid microscopy and culture are important for tailoring antimicrobial therapy, but only 60% of cultures are positive. Pleural fluid white cell count and differential may also be elevated in empyema, but a low pH is a more reliable indicator.

      Given the patient’s history of alcohol excess, the likelihood of a Klebsiella pneumonia causing the empyema is high, rather than a pneumococcal pneumonia. Therefore, clinicians should prioritize pleural fluid pH as a diagnostic test for empyema.

    • This question is part of the following fields:

      • Respiratory Medicine
      29.4
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  • Question 17 - A 50-year-old woman presents with an incidental finding of a thyroid nodule during...

    Correct

    • A 50-year-old woman presents with an incidental finding of a thyroid nodule during a routine physical exam. She has no significant medical history and no family history of thyroid disease or malignancy. On examination, a non-tender 2 cm thyroid nodule is palpable, and there is no cervical lymphadenopathy. Blood tests, including thyroid-stimulating hormone level, are within normal limits. Fine-needle aspiration of the nodule confirms papillary carcinoma. What is the most appropriate treatment for this patient?

      Your Answer: Thyroidectomy and radioiodine-131 therapy

      Explanation:

      Treatment for Papillary Thyroid Cancer

      Papillary thyroid cancer is typically treated with a total thyroidectomy, followed by radioiodine-131 (131I) therapy. This treatment is effective in destroying any remaining normal thyroid tissue and microscopic cancerous cells. However, there is no evidence that radiation therapy prolongs life in patients with this type of cancer. In cases of anaplastic thyroid cancer, radiation therapy may be used to alleviate pressure symptoms caused by the neck mass. Adjuvant chemotherapy is not recommended for patients with differentiated thyroid cancer.

      Overall, the treatment for papillary thyroid cancer involves surgical removal of the thyroid gland followed by radioiodine therapy. While radiation therapy may be used in certain cases, it does not necessarily improve life expectancy. Chemotherapy is not typically used as part of the treatment plan.

    • This question is part of the following fields:

      • Oncology
      41.9
      Seconds
  • Question 18 - A 50-year-old man presents to the endocrinology clinic with abnormal blood test results....

    Correct

    • A 50-year-old man presents to the endocrinology clinic with abnormal blood test results. His GP had ordered thyroid function tests due to concerns about hair loss. The patient denies any other symptoms such as weight changes, temperature sensitivity, or mood changes. The GP suspected male-pattern hair loss but ordered the blood test anyway. The patient's full blood count, renal function, and iron levels were all normal, but his TSH was 12mU/l and his free T4 was 12 pmol/l. On examination, there is no evidence of goitre.

      What is the most appropriate management plan for this patient?

      Your Answer: Start levothyroxine replacement

      Explanation:

      The patient is diagnosed with subclinical hypothyroidism, which means their TSH levels are high but T4 and T3 levels are normal. Since the patient’s TSH level is above 10mU/l, they should be prescribed levothyroxine. Dismissing the elevated TSH would not be appropriate, and if the level was between 4-10mU/l, repeating the test in six months would be reasonable. Nuclear uptake scans are not necessary for distinguishing between causes of hyperthyroidism, and an ultrasound would only be necessary if a mass was suspected.

      Understanding Subclinical Hypothyroidism

      Subclinical hypothyroidism is a condition where the thyroid-stimulating hormone (TSH) is elevated, but the levels of T3 and T4 are normal, and there are no obvious symptoms. However, there is a risk of the condition progressing to overt hypothyroidism, especially in men and those with thyroid autoantibodies.

      The management of subclinical hypothyroidism depends on the TSH levels and the presence of symptoms. According to the NICE Clinical Knowledge Summaries, patients with a TSH level greater than 10mU/L and normal free thyroxine levels should be considered for levothyroxine treatment. For those with a TSH level between 5.5-10mU/L and normal free thyroxine levels, a 6-month trial of levothyroxine may be offered if the patient is under 65 years old and experiencing symptoms. However, for older patients, a ‘watch and wait’ strategy is often used, and asymptomatic patients should have their thyroid function monitored every 6 months.

      In summary, subclinical hypothyroidism is a condition that requires careful monitoring and management to prevent it from progressing to overt hypothyroidism. The decision to treat or not depends on the patient’s age, symptoms, and TSH levels.

    • This question is part of the following fields:

      • Endocrinology, Diabetes And Metabolic Medicine
      70.2
      Seconds
  • Question 19 - A 25-year-old man has presented to the Emergency Department of a local hospital...

    Correct

    • A 25-year-old man has presented to the Emergency Department of a local hospital after ingesting a bottle of antifreeze as part of a dare. Upon arrival, he appears quite ill, with blood tests indicating a significant anion gap metabolic acidosis and an elevated osmolar gap. During examination, his blood pressure is 100/60 mmHg, his pulse is regular at 95 bpm, and he is lethargic. Arterial blood gas analysis reveals a severe metabolic acidosis. While he can be admitted to the high-dependency unit, there are no available ICU beds.

      What would be the most appropriate course of treatment for this individual's antifreeze poisoning?

      Your Answer: Fomepizole

      Explanation:

      Treatment for Ethylene Glycol Poisoning

      Ethylene glycol poisoning is a common cause of high anion gap metabolic acidosis. The mnemonic ‘MUDPILES’ can be used to remember some of the causes of this condition, including methanol, uraemia, diabetic ketoacidosis, paraldehyde, iron, lactate, ethylene glycol, and salicylate. Ethylene glycol is metabolized by alcohol dehydrogenase, leading to the formation of glycolic acid, glyoxylic acid, and oxalic acid. Fomepizole is an inhibitor of alcohol dehydrogenase and is preferred over ethanol as it does not cause intoxication. Methanol has negative toxicity effects, while naloxone is a reversal agent for opiates, and methylene blue is used to treat methaemoglobinaemia. Therefore, fomepizole is the treatment of choice for ethylene glycol poisoning.

    • This question is part of the following fields:

      • Clinical Pharmacology And Therapeutics
      39.6
      Seconds
  • Question 20 - A 72-year-old man presents with swelling in his legs and frothy urine for...

    Correct

    • A 72-year-old man presents with swelling in his legs and frothy urine for the past few weeks. He has no medical history and is not taking any medications. Upon examination, he has pitting edema up to mid-thighs, an irregularly irregular pulse with an ECG showing fast atrial fibrillation, and a rising JVP with inspiration. His BP is 135/85 mm Hg, and he has weakness and sensory deficits in the right ulnar nerve and left posterior tibial nerve distribution. After receiving a loading dose of 1mg IV digoxin over 2 hours, the patient deteriorates and loses consciousness. A repeat ECG shows ventricular tachycardia, which progresses to ventricular fibrillation, and the patient does not survive resuscitation attempts. What is the most likely underlying disease?

      Your Answer: AL amyloidosis

      Explanation:

      Due to the high risk of digoxin toxicity in cardiac amyloidosis, it is not recommended to administer digoxin. This is because the drug binds strongly to amyloid fibrils. If a patient presents with Kussmaul’s sign (JVP rising on inspiration) and significantly elevated JVP, along with nephrotic syndrome and mononeuritis multiplex, it is important to consider amyloidosis. AA amyloidosis is caused by chronic inflammation, such as in rheumatoid arthritis, but there is no indication of a medical history that would predispose to this condition. Additionally, cardiac involvement is rare in AA amyloidosis, unlike in AL amyloidosis, which is caused by light chain disease and frequently affects the heart. In this case, the administration of digoxin has resulted in cardiac arrhythmia due to the drug’s increased effects on an amyloid heart.

      Cardiac amyloidosis is a condition that affects the heart and can be detected through an electrocardiogram (ECG) and echocardiogram. The ECG usually displays low-voltage complexes and a pseudoinfarction pattern, which is characterized by poor R wave progression in the chest leads. On the other hand, the echocardiogram shows a ‘global speckled’ pattern, which is a common feature of cardiac amyloidosis. This condition can cause damage to the heart and lead to heart failure if left untreated. Therefore, early detection and proper management are crucial for patients with cardiac amyloidosis.

    • This question is part of the following fields:

      • Cardiology
      85.7
      Seconds
  • Question 21 - A 67-year-old retired man with a history of diet-controlled diabetes and mild COPD...

    Incorrect

    • A 67-year-old retired man with a history of diet-controlled diabetes and mild COPD is brought in by ambulance with 3 episodes of black stool followed by collapse. He describes a 2 day history of intermittent abdominal pain. His regular medications are Seretide inhaler and paracetamol/ibuprofen when required for knee osteoarthritis.

      On examination, he has conjunctival pallor and epigastric tenderness. Rectal examination confirms the presence of melaena.

      His observations are as follows:

      Temperature 36.4
      Respiratory 28/min
      Saturations 96% on air
      Heart rate 126 bpm
      Blood pressure 78/44 mmHg

      Hb 67 g/l Na+ 140 mmol/l Bilirubin 12 µmol/l
      Platelets 88* 109/l K+ 3.9 mmol/l ALP 100 u/l
      WBC 12.0* 109/l Urea 13.3 mmol/l ALT 28 u/l
      Neuts 6.0* 109/l Creatinine 63 µmol/l Albumin 38 g/l
      Lymphs 1.0* 109/l INR 1.2
      Eosin 0.3* 109/l APTT 26 Fibrinogen 4.0 g/l

      What urgent medical treatment should be initiated before endoscopy?

      Your Answer: Red blood cell transfusion and fresh frozen plasma

      Correct Answer: Red blood cell transfusion

      Explanation:

      Acute upper gastrointestinal bleeding is a common and significant medical issue that can be caused by various conditions, with oesophageal varices and peptic ulcer disease being the most common. The main symptoms include haematemesis (vomiting of blood), melena (passage of altered blood per rectum), and a raised urea level due to the protein meal of the blood. The diagnosis can be determined by identifying the specific features associated with a particular condition, such as stigmata of chronic liver disease for oesophageal varices or abdominal pain for peptic ulcer disease.

      The differential diagnosis for acute upper gastrointestinal bleeding includes oesophageal, gastric, and duodenal causes. Oesophageal varices may present with a large volume of fresh blood, while gastric ulcers may cause low volume bleeds that present as iron deficiency anaemia. Duodenal ulcers are usually posteriorly sited and may erode the gastroduodenal artery. Aorto-enteric fistula is a rare but important cause of major haemorrhage associated with high mortality in patients with previous abdominal aortic aneurysm surgery.

      The management of acute upper gastrointestinal bleeding involves risk assessment using the Glasgow-Blatchford score, which helps clinicians decide whether patients can be managed as outpatients or not. Resuscitation involves ABC, wide-bore intravenous access, and platelet transfusion if actively bleeding platelet count is less than 50 x 10*9/litre. Endoscopy should be offered immediately after resuscitation in patients with a severe bleed, and all patients should have endoscopy within 24 hours. Treatment options include repeat endoscopy, interventional radiology, and surgery for non-variceal bleeding, while terlipressin and prophylactic antibiotics should be given to patients with variceal bleeding. Band ligation should be used for oesophageal varices, and injections of N-butyl-2-cyanoacrylate for patients with gastric varices. Transjugular intrahepatic portosystemic shunts (TIPS) should be offered if bleeding from varices is not controlled with the above measures.

    • This question is part of the following fields:

      • Gastroenterology And Hepatology
      110.2
      Seconds
  • Question 22 - A returning traveler, aged 50, presents to the emergency department with a 10-day...

    Incorrect

    • A returning traveler, aged 50, presents to the emergency department with a 10-day history of fever, cough, and abdominal pain. He has spent the last 2 weeks in Jakarta, Indonesia. On examination, an enlarged spleen and a rose spot rash over the chest are observed. Blood culture grows salmonella typhi, and the on-call doctor diagnoses enteric fever (typhoid). What is the most critical and severe complication that can occur within the next 14 days if left untreated?

      Your Answer: Splenic infarction and rupture

      Correct Answer: Bowel perforation and haemorrhage

      Explanation:

      Typhoid can lead to serious and frequent complications such as bowel perforation and haemorrhage, which are caused by the destruction of Peyer’s patches in the small intestine by the bacteria. These complications typically occur in the second or early third week of illness. Other complications include myocarditis and endocarditis.

      While chronic bacterial carriage in the gallbladder can occur, it is not the most serious complication. However, it can make the patient chronically infective and capable of transmitting the disease. Acute liver failure is not a common occurrence, but cholecystitis or hepatitis may result in mild jaundice.

      Enteric fever, also known as typhoid or paratyphoid, is caused by Salmonella typhi and Salmonella paratyphi respectively. These bacteria are not normally found in the gut and are transmitted through contaminated food and water or the faecal-oral route. The symptoms of enteric fever include headache, fever, and joint pain, as well as abdominal pain and distension. Constipation is more common in typhoid than diarrhoea, and rose spots may appear on the trunk in 40% of patients with paratyphoid. Possible complications of enteric fever include osteomyelitis, gastrointestinal bleeding or perforation, meningitis, cholecystitis, and chronic carriage. Chronic carriage is more likely in adult females and occurs in 1% of cases.

    • This question is part of the following fields:

      • Infectious Diseases
      43.8
      Seconds
  • Question 23 - A 25-year-old man visits the GUM clinic after being referred by his GP...

    Incorrect

    • A 25-year-old man visits the GUM clinic after being referred by his GP due to dysuria and a negative urine dipstick test. The healthcare provider requests a sexual health screening, which includes HIV and syphilis serology blood tests. What type of consent is necessary for this procedure?

      Your Answer: Written consent

      Correct Answer: Verbal consent

      Explanation:

      Verbal consent is the appropriate form of consent required for testing for HIV and syphilis during an investigation. While consent is necessary, it is important to obtain specific consent for each disease as they are transmittable. Patients must be informed that they are being tested for HIV and syphilis, rather than just undergoing a routine blood test. Written consent is not necessary and may even deter patients from getting tested.

      Understanding HIV Seroconversion

      HIV seroconversion is a process that occurs in individuals who have been recently infected with the virus. It is characterized by symptoms that resemble those of glandular fever, such as sore throat, lymphadenopathy, malaise, myalgia, arthralgia, diarrhea, maculopapular rash, and mouth ulcers. In some rare cases, it can also lead to meningoencephalitis. The severity of the symptoms is associated with the long-term prognosis of the patient, with more severe symptoms indicating a poorer prognosis.

      Diagnosing HIV seroconversion can be challenging, as antibodies to the virus may not be present in the early stages of infection. However, HIV PCR and p24 antigen tests can confirm the diagnosis. Understanding the process of HIV seroconversion is crucial for early detection and treatment of the virus, as well as for preventing its spread to others. By recognizing the symptoms and seeking medical attention promptly, individuals can receive the care they need to manage the virus and improve their long-term outcomes.

    • This question is part of the following fields:

      • Infectious Diseases
      39.3
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  • Question 24 - A 44-year-old man is referred to the Endocrinology clinic by his GP due...

    Correct

    • A 44-year-old man is referred to the Endocrinology clinic by his GP due to asymptomatic hypercalcaemia found on routine blood tests. He has a medical history of hypertension and is currently taking amlodipine, ramipril and chlorthalidone.

      The following investigations were conducted:

      - Na+ 141 mmol/L (135 - 145)
      - K+ 4.4 mmol/L (3.5 - 5.0)
      - Calcium 2.85 mmol/L (2.2 - 2.6)
      - Urea 6.6 mmol/L (2.0 - 7.0)
      - Creatinine 98 µmol/L (55 - 120)
      - Parathyroid hormone 5.5 pmol/L (1.6 - 6.9)

      Urinary calcium 30 mg/24h (100 - 300)

      What is the most likely cause of hypercalcaemia in this patient?

      Your Answer: Familial hypocalciuric hypercalcaemia

      Explanation:

      If a patient has hypercalcemia with low urinary calcium, it is likely that they have either familial hypocalciuric hypercalcemia or are using thiazide diuretics. The correct answer in this case is familial hypocalciuric hypercalcemia, which can be confirmed by an inappropriately normal parathyroid hormone level. This condition is caused by mutations in the CASR calcium-sensing receptor, which reduces sensitivity to calcium and prevents PTH from being suppressed at higher-than-normal serum calcium levels. This leads to hypocalciuria due to a loss of CASR-mediated negative feedback on tubular reabsorption/excretion of calcium. Other potential causes, such as chlorthalidone use, hypercalcemia of malignancy with ectopic parathyroid hormone-related protein secretion, and primary hyperparathyroidism, can be ruled out based on their characteristic effects on urinary calcium and PTH levels.

      Understanding Familial Benign Hypocalciuric Hypercalcaemia

      Familial benign hypocalciuric hypercalcaemia is a rare genetic disorder that is inherited in an autosomal dominant manner. It is characterised by asymptomatic hypercalcaemia, which means that there are high levels of calcium in the blood but no symptoms are present. This disorder is caused by a defect in the calcium-sensing receptor, which results in a decreased sensitivity to increases in extracellular calcium.

      In cases of hypercalcaemia that are not related to hyperparathyroidism, the parathyroid hormone level is usually suppressed. However, in familial benign hypocalciuric hypercalcaemia, the parathyroid hormone level is often not suppressed. This is because the calcium-sensing receptor is not functioning properly, which leads to a decreased sensitivity to increases in extracellular calcium.

      Overall, familial benign hypocalciuric hypercalcaemia is a rare genetic disorder that affects the body’s ability to regulate calcium levels. While it is usually asymptomatic, it is important to monitor calcium levels and seek medical attention if necessary.

    • This question is part of the following fields:

      • Endocrinology, Diabetes And Metabolic Medicine
      54.4
      Seconds
  • Question 25 - A pediatric patient receiving chemotherapy calls for the nurses to report pain and...

    Incorrect

    • A pediatric patient receiving chemotherapy calls for the nurses to report pain and swelling around the area where the infusion cannula was inserted. The oncology resident suspects that this may be caused by the leakage of the chemotherapeutic drug into the surrounding tissue.

      What additional steps would be required following the initial treatment of this young patient?

      Your Answer: Stop the infusion and remove the cannula

      Correct Answer: Consult with a plastic surgeon for any doxorubicin or daunorubicin extravasation injuries

      Explanation:

      Managing Extravasation Injuries During Chemotherapy Infusion

      Extravasation injuries can occur during chemotherapy infusion, particularly with drugs like doxorubicin or daunorubicin. In such cases, it is important to consult with a plastic surgeon as these injuries can cause ulceration, especially on the back of the hand. The first step is to stop the infusion and remove the cannula. However, before removing it, aspirate it to remove as much of the drug as possible. Oral corticosteroids can be administered to reduce inflammation at the cannula site. Patients should be sent home with topical corticosteroids and instructed to contact the department urgently if the extravasation site becomes red, blackened, ulcerated, and/or painful. In the case of vinca alkaloids, a cold pack should be immediately applied. IV fluids should be administered after stopping the infusion. Treatment involves topical corticosteroids, plastics referral (if required), and agent-specific antidotes, after receiving specialist advice.

    • This question is part of the following fields:

      • Oncology
      43.8
      Seconds
  • Question 26 - A 78-year-old male was brought into hospital after waking with left arm weakness...

    Incorrect

    • A 78-year-old male was brought into hospital after waking with left arm weakness predominantly affecting the hand with a left sided facial droop in an upper motor neuron pattern. His blood pressure on admission was 170/85 mmHg and his heart rate was 75 beats per minute and in sinus rhythm. His blood glucose level on admission was 7.5 mmol/L.

      His initial CT brain showed some mild bi-temporal atrophic change and some chronic small vessel ischaemia without any acute ischaemic changes and in particular, no haemorrhage.

      He was admitted with a suspected diagnosis of minor ischaemic stroke. Which of the following imaging modalities will confirm the diagnosis?

      Your Answer: CT cerebral angiogram (CTA)

      Correct Answer: Diffusion weighted imaging (DWI) MRI

      Explanation:

      Stroke Assessment and Investigations

      Whilst diagnosing a stroke may be straightforward in some cases, it can be challenging in others due to vague symptoms. The FAST screening tool, which stands for Face/Arms/Speech/Time, is a well-known tool used by the general public to identify stroke symptoms. However, medical professionals use a validated tool called the ROSIER score, recommended by the Royal College of Physicians. The ROSIER score assesses loss of consciousness or syncope, seizure activity, and new, acute onset of asymmetric facial, arm, or leg weakness, speech disturbance, or visual field defect. A score of more than zero indicates a likely stroke.

      When investigating suspected stroke, a non-contrast CT head scan is the first line radiological investigation. The key question is whether the stroke is ischaemic or haemorrhagic, as this determines the appropriate treatment. Ischaemic strokes may show areas of low density in the grey and white matter of the territory, which may take time to develop. On the other hand, haemorrhagic strokes typically show areas of hyperdense material (blood) surrounded by low density (oedema). It is crucial to determine the type of stroke promptly, given the increasing role of thrombolysis and thrombectomy in acute stroke management. In rare cases, a third pathology such as a tumour may also be detected.

    • This question is part of the following fields:

      • Neurology
      62
      Seconds
  • Question 27 - A 16-year-old female presented to her general practitioner with complaints of slight breathlessness...

    Incorrect

    • A 16-year-old female presented to her general practitioner with complaints of slight breathlessness on exertion for the past six months. During examination, a soft systolic murmur was heard at the left sternal edge. An echocardiogram was ordered and she was referred to a cardiologist for further evaluation. The results of her cardiac catheterization are as follows:

      Anatomical site Oxygen saturation (%) Pressure (mmHg) End systolic/End diastolic
      Superior vena cava 74 -
      Inferior vena cava 70 -
      Right atrium (high) 72 7 (mean)
      Right atrium (mid) 71 7 (mean)
      Right atrium (low) 82 7 (mean)
      Right ventricle 79 44/12
      Pulmonary artery 81 42/15
      Pulmonary capillary wedge pressure - 9
      Left ventricle 96 125/9
      Aorta 97 120/70

      What are the expected abnormalities on her electrocardiogram?

      Your Answer: Left ventricular strain

      Correct Answer: Right bundle branch block

      Explanation:

      Abnormal Connection between Right and Left Sides of the Heart

      The oxygen saturation in the right atrium (RA) and superior vena cava (SVC) should be equal, but there is a rise in oxygen saturation at the low RA level. This can only occur due to the addition of oxygenated blood to the deoxygenated blood in the right heart circulation, indicating an abnormal connection between the right and left sides of the heart. The location of the rise suggests a primum atrial septal defect (ASD), which affects the function of the anterior leaflet of the mitral valve, leading to mitral regurgitation. Primum ASDs are more likely to cause high right ventricular pressures.

      In ostium primum ASDs, the atrioventricular (AV) node is displaced posteriorly and inferiorly, and atrial and/or AV nodal conduction is often delayed. This can cause prolongation of the PR interval, leading to first-degree heart block. The QRS pattern is typically an rSr’ or rsR’, resulting from dilation and hypertrophy of the right ventricular outflow tract due to volume overload of the right heart. Left axis deviation with Q waves in leads I and aVL is also observed. On the other hand, secundum ASDs cause right axis deviation and RBBB.

      Overall, an abnormal connection between the right and left sides of the heart can lead to various complications, including mitral regurgitation, high right ventricular pressures, and delayed conduction through the AV node. The location and type of ASD can also affect the QRS pattern and axis deviation.

    • This question is part of the following fields:

      • Cardiology
      71.4
      Seconds
  • Question 28 - A 23-year-old male patient, who has a history of hereditary angioneurotic oedema (HAO),...

    Correct

    • A 23-year-old male patient, who has a history of hereditary angioneurotic oedema (HAO), presents with recurring fever, arthralgia, and a rash on his upper chest and face. Despite receiving treatment for his HAO, he has been experiencing recurrent attacks and has needed adrenaline on multiple occasions. His C4 levels have consistently been low due to his HAO. What is the probable reason for his current symptoms?

      Your Answer: Systemic lupus erythematosus

      Explanation:

      Hereditary Angioedema and its Association with Low C4 Levels and SLE Risk

      Hereditary angioedema (HAO) is a condition that is caused by a deficiency of C1 esterase inhibitor. This deficiency results in the continuous activation of the classical complement pathway, which often leads to low levels of C4 due to consumption and activation. If treatment fails to restore normal C4 levels and they remain persistently low, patients with HAO are at a higher risk of developing systemic lupus erythematosus (SLE). Therefore, it is important to monitor C4 levels in patients with HAO and ensure that they are adequately treated to prevent the development of SLE.

    • This question is part of the following fields:

      • Rheumatology
      38.4
      Seconds
  • Question 29 - A 48-year-old man presented to the neurology clinic with complaints of double vision...

    Incorrect

    • A 48-year-old man presented to the neurology clinic with complaints of double vision and flu-like symptoms for the past five days. He reported difficulty closing his right eye fully and noticed a similar problem with his left eye. The patient had recently been diagnosed with type 2 diabetes mellitus and was following a diabetic diet. He had no significant medical history and did not take any regular medication. On examination, the patient had oculoparesis affecting the right lateral rectus and right superior oblique muscle, bilateral facial weakness, and bilateral Bell's phenomena. He also had arthralgia in his hands and knees. Lumbar puncture revealed elevated CSF protein and white cell count with the presence of oligoclonal bands. MRI brain scan showed punctate periventricular white matter lesions. What is the likely diagnosis?

      Your Answer: Multiple sclerosis

      Correct Answer: Neuroborreliosis

      Explanation:

      The patient has mononeuritis multiplex involving several nerves and flu-like symptoms. CSF analysis and MRI suggest a demyelinating or inflammatory disorder, possibly neuroborreliosis. Lyme disease should be suspected as the patient recently visited an endemic area. Multiple sclerosis and pontine lesions are ruled out, while Guillain-Barré syndrome is a possibility but less likely. Diagnosis is made through serological testing.

    • This question is part of the following fields:

      • Neurology
      69.6
      Seconds
  • Question 30 - A 25-year-old second generation British Pakistani presents to the Tuberculosis (TB) Specialist Nurse...

    Incorrect

    • A 25-year-old second generation British Pakistani presents to the Tuberculosis (TB) Specialist Nurse for contact tracing. Her father has recently been diagnosed with active TB after presenting to the respiratory clinic with a 2-month history of cough, fever, and night sweats.

      The patient reports feeling well and denies any respiratory symptoms. She has no significant medical history and is a non-smoker. She works full-time and lives with her family. She received all her childhood vaccinations.

      Upon examination, she is afebrile with a respiratory rate of 14/min and oxygen saturation of 98% on room air. There is no lymphadenopathy, her chest is clear, and her abdomen is soft and non-tender.

      The Mantoux test is performed and read after 72 hours, revealing a 6mm area of induration within a 15mm area of erythema. An interferon-gamma release assay (IGRA) is ordered. What does a positive IGRA result indicate?

      Your Answer: Latent TB or prior immunisation

      Correct Answer: Active or latent TB

      Explanation:

      The Mantoux test result in the vignette is positive, but only the area of induration is considered, not the surrounding erythema. The patient’s history of childhood immunization suggests the possibility of a false positive result due to the Bacille Calmette-Guérin (BCG) vaccine. However, active or latent TB cannot be ruled out. To confirm prior exposure to M. tuberculosis, an IGRA would be more reliable as it is not affected by BCG vaccination. However, it cannot differentiate between active and latent TB, which is its main drawback.

      Tuberculosis can be screened for using the Mantoux test, which involves injecting a small amount of purified protein derivative (PPD) into the skin and reading the results a few days later. A positive result indicates hypersensitivity to the tuberculin protein, which may be due to previous TB infection or BCG vaccination. False negative results can occur in certain situations, such as in very young children or individuals with certain medical conditions. The Heaf test, which was previously used in the UK, has since been discontinued.

      To diagnose active tuberculosis, a chest x-ray may reveal upper lobe cavitation or bilateral hilar lymphadenopathy. Sputum smear tests involve examining three specimens for the presence of acid-fast bacilli using the Ziehl-Neelsen stain. While this test is rapid and inexpensive, its sensitivity is between 50-80% and is decreased in individuals with HIV. Sputum culture is considered the gold standard investigation, as it is more sensitive than a smear and can assess drug sensitivities. However, it can take 1-3 weeks to obtain results. Nucleic acid amplification tests (NAAT) allow for rapid diagnosis within 24-48 hours, but are less sensitive than culture.

    • This question is part of the following fields:

      • Infectious Diseases
      45.5
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SESSION STATS - PERFORMANCE PER SPECIALTY

Clinical Pharmacology And Therapeutics (2/5) 40%
Cardiology (1/4) 25%
Endocrinology, Diabetes And Metabolic Medicine (4/6) 67%
Respiratory Medicine (1/2) 50%
Dermatology (0/1) 0%
Medical Ophthalmology (0/1) 0%
Gastroenterology And Hepatology (1/2) 50%
Rheumatology (1/2) 50%
Oncology (1/2) 50%
Infectious Diseases (0/3) 0%
Neurology (0/2) 0%
Passmed