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  • Question 1 - Among the various chromosomal anomalies, which one has the highest incidence of systemic...

    Incorrect

    • Among the various chromosomal anomalies, which one has the highest incidence of systemic lupus erythematosus (SLE), a multisystem autoimmune disease associated with genetic defects in the immune system and triggered by environmental factors?

      Your Answer: Bloom syndrome

      Correct Answer: 47,XXY (Klinefelter’s syndrome)

      Explanation:

      Chromosomal Abnormalities and Their Association with Systemic Lupus Erythematosus (SLE)

      Individuals with Klinefelter’s syndrome have a 14-fold increased risk of developing SLE compared to those with a normal karyotype, although the exact mechanism for this is unknown. However, there is no evidence to suggest an increased risk of SLE in individuals with Down syndrome, Fragile X syndrome, or Trisomy 18 (Edwards’ syndrome). Bloom syndrome, which is associated with a short stature, skin sensitivity to sun exposure, and an increased risk of malignancies, also does not appear to increase the risk of SLE. It is important to understand the potential associations between chromosomal abnormalities and SLE to better manage and treat patients with these conditions.

    • This question is part of the following fields:

      • Genetics
      21.3
      Seconds
  • Question 2 - A 25-year-old sexually active man comes to the clinic complaining of a rash...

    Incorrect

    • A 25-year-old sexually active man comes to the clinic complaining of a rash that has been present all over his body for the past two weeks. He also reports having a painless sore on his penis a few weeks prior to the onset of the rash. Upon examination, a maculopapular rash is observed on his entire body, including the palms of his hands and soles of his feet. However, his penis appears normal. What is the most probable diagnosis?

      Your Answer: HIV seroconversion illness

      Correct Answer: Secondary syphilis

      Explanation:

      Syphilis and its Symptoms

      Syphilis is a sexually transmitted infection caused by the bacterium Treponema pallidum. The disease is transmitted through intimate contact with an infected person. The primary symptom of syphilis is a painless ulcer called a chancre, which may not be reported by the patient. The secondary stage of syphilis is characterized by a maculopapular rash that affects the entire body, including the palms and soles. This rash is known as keratoderma blennorrhagica.

      It is important to note that HIV seroconversion illness may also present with a rash, but it typically does not affect the palms and soles. Additionally, constitutional symptoms such as fever and malaise are common with HIV seroconversion illness. None of the other conditions typically present with a rash.

      Treatment for secondary syphilis involves the use of long-acting penicillin.

    • This question is part of the following fields:

      • Infectious Diseases
      18.3
      Seconds
  • Question 3 - A 24-year-old man comes to the clinic complaining of back pain that has...

    Correct

    • A 24-year-old man comes to the clinic complaining of back pain that has persisted for two weeks. The pain is situated between the shoulder blades and happens frequently throughout the day. He expresses concern that this might be a severe issue and has been avoiding physical activity as a result.
      What aspects of this patient's medical history are cause for concern?

      Your Answer: Location of pain

      Explanation:

      When a patient presents with back pain in the thoracic area, it is considered a red flag and requires further investigation to rule out potential serious underlying causes such as skeletal disorders, degenerative disc disease, vertebral fractures, vascular malformations, or metastasis. Additionally, if the patient exhibits fear-avoidance behavior and reduced activity, it may indicate psychosocial factors that could lead to chronic back pain. Patients under 20 or over 50 years old, those with a history of trauma, and those whose pain is worse at night are also considered red flags.

      Lower back pain is a common issue that is often caused by muscular strain. However, it is important to be aware of potential underlying causes that may require specific treatment. Certain red flags should be considered, such as age under 20 or over 50, a history of cancer, night pain, trauma, or systemic illness. There are also specific causes of lower back pain that should be kept in mind. Facet joint pain may be acute or chronic, worse in the morning and on standing, and typically worsens with back extension. Spinal stenosis may cause leg pain, numbness, and weakness that is worse on walking and relieved by sitting or leaning forward. Ankylosing spondylitis is more common in young men and causes stiffness that is worse in the morning and improves with activity. Peripheral arterial disease may cause pain on walking and weak foot pulses. It is important to consider these potential causes and seek appropriate diagnosis and treatment.

    • This question is part of the following fields:

      • Musculoskeletal
      33.4
      Seconds
  • Question 4 - A hairy 27-year-old woman visits the medical clinic with concerns about her missing...

    Incorrect

    • A hairy 27-year-old woman visits the medical clinic with concerns about her missing menstrual cycles. What is one of the diagnostic criteria for polycystic ovarian syndrome (PCOS)?

      Your Answer: Dysmenorrhoea

      Correct Answer: Oligomenorrhoea

      Explanation:

      Although clinical features such as infrequent or absent ovulation and hyperandrogenism can suggest PCOS, NICE CKS recommends using specific diagnostic criteria. To diagnose PCOS, at least 2 out of 3 of the following criteria should be present: infrequent or no ovulation, signs of hyperandrogenism or elevated testosterone levels, and polycystic ovaries or increased ovarian volume on ultrasonography. It is important to note that a high BMI is not part of the diagnostic criteria, but signs of insulin resistance such as acanthosis nigricans may aid in diagnosis.

      Polycystic ovary syndrome (PCOS) is a condition that affects a significant percentage of women of reproductive age. The exact cause of PCOS is not fully understood, but it is believed to involve both high levels of luteinizing hormone and hyperinsulinemia, with some overlap with the metabolic syndrome. PCOS is characterized by a range of symptoms, including subfertility and infertility, menstrual disturbances such as oligomenorrhea and amenorrhea, hirsutism, acne, obesity, and acanthosis nigricans.

      To diagnose PCOS, a range of investigations may be performed, including pelvic ultrasound to detect multiple cysts on the ovaries. Other useful baseline investigations include FSH, LH, prolactin, TSH, testosterone, and sex hormone-binding globulin (SHBG). While a raised LH:FSH ratio was once considered a classical feature of PCOS, it is no longer thought to be useful in diagnosis. Testosterone may be normal or mildly elevated, but if markedly raised, other causes should be considered. SHBG is typically normal to low in women with PCOS, and impaired glucose tolerance should also be checked.

      To formally diagnose PCOS, other conditions must first be excluded. The Rotterdam criteria state that a diagnosis of PCOS can be made if at least two of the following three criteria are present: infrequent or no ovulation, clinical and/or biochemical signs of hyperandrogenism, and polycystic ovaries on ultrasound scan. Polycystic ovaries are defined as the presence of at least 12 follicles measuring 2-9 mm in diameter in one or both ovaries, and/or an increased ovarian volume of over 10 cm³.

    • This question is part of the following fields:

      • Gynaecology
      23.4
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  • Question 5 - A 68-year-old man visits his GP with concerns about unusual symptoms in his...

    Correct

    • A 68-year-old man visits his GP with concerns about unusual symptoms in his eyes. He reports experiencing flashes of light in his eyes for a few days and has also noticed dark specks floating around in his vision. He denies any discomfort. The patient is nearsighted and wears glasses, but has no significant medical history. Upon examination, his visual acuity and fields are normal. What is the probable cause of his symptoms?

      Your Answer: Posterior vitreous detachment

      Explanation:

      The most likely cause of the patient’s flashers and floaters is posterior vitreous detachment, which is a common age-related condition that occurs when the vitreous membrane separates from the retina. This condition does not cause pain or vision loss, but highly myopic patients are at increased risk. It is important to refer the patient to an ophthalmologist within 24 hours to rule out retinal tears or detachment.

      Migraine is an unlikely cause as there is no headache described. Optic neuritis is also unlikely as there is no pain or history of previous disease. While retinal detachment may be a complication of PVD, it is not as common as PVD itself and would present with sudden visual loss and a veil covering the visual field. A retinal tear may also occur without progressing to detachment and would require intervention from an ophthalmologist.

      Understanding Posterior Vitreous Detachment

      Posterior vitreous detachment is a condition where the vitreous membrane separates from the retina due to natural changes in the vitreous fluid of the eye with ageing. This is a common condition that does not cause any pain or loss of vision. However, it is important to rule out retinal tears or detachment as they may result in permanent loss of vision. Posterior vitreous detachment occurs in over 75% of people over the age of 65 and is more common in females. Highly myopic patients are also at increased risk of developing this condition earlier in life.

      Symptoms of posterior vitreous detachment include the sudden appearance of floaters, flashes of light in vision, blurred vision, and cobweb across vision. If there is an associated retinal tear or detachment, the patient will require surgery to fix this. All patients with suspected vitreous detachment should be examined by an ophthalmologist within 24 hours to rule out retinal tears or detachment.

      The management of posterior vitreous detachment alone does not require any treatment as symptoms gradually improve over a period of around 6 months. However, it is important to monitor the condition and seek medical attention if any new symptoms arise. The appearance of a dark curtain descending down vision indicates retinal detachment and requires immediate medical attention. Overall, understanding posterior vitreous detachment and its associated risks is important for maintaining good eye health.

    • This question is part of the following fields:

      • Ophthalmology
      27.2
      Seconds
  • Question 6 - A new test for human immunodeficiency virus (HIV) infection is trialled in a...

    Incorrect

    • A new test for human immunodeficiency virus (HIV) infection is trialled in a high-prevalence HIV population. Sensitivity is found to be 90%, and specificity 94%. The test is then used in a population with a low prevalence of HIV.
      Which one of the following statements about the test is correct?

      Your Answer: The specificity of the test will be lower in the high-prevalence population

      Correct Answer: The negative predictive value will be lower in the high-prevalence population

      Explanation:

      Impact of Disease Prevalence on Test Accuracy: Explained

      The accuracy of a medical test is influenced by various factors, including disease prevalence in the population being tested. In a high-prevalence population, the negative predictive value of a test will be lower as fewer people will have a negative test result. However, the sensitivity and specificity of the test should remain similar in different populations assuming the test has been rigorously evaluated. The positive predictive value will also be lower in a high-prevalence population unless the sensitivity and specificity of the test are both 100%. Therefore, it is important to consider disease prevalence when interpreting the accuracy of a medical test.

    • This question is part of the following fields:

      • Statistics
      8.8
      Seconds
  • Question 7 - Sarah is a 33-year-old woman who presents with severe pelvic pain that is...

    Incorrect

    • Sarah is a 33-year-old woman who presents with severe pelvic pain that is unresponsive to paracetamol. The pain started four months ago and occurs four days before the onset of her menstrual cycle. The pain worsens as her period approaches and gradually improves once it ends. She also reports changing her menstrual pads every four hours.

      Sarah began menstruating at the age of 14 and has had fairly regular cycles. In the past, she only experienced mild pain that was relieved with paracetamol, and her periods were not heavy. She is sexually active but uses condoms during intercourse.

      During pelvic examination, no abnormalities were observed on speculum examination, and her abdomen examination was unremarkable.

      What is the most appropriate next step in Sarah's management?

      Your Answer: Refer for abdominal ultrasound

      Correct Answer: Prescribe ibuprofen and refer to gynaecology for further investigation

      Explanation:

      Patients with secondary dysmenorrhoea require referral to gynaecology for further investigation. This is because secondary dysmenorrhoea, which is characterized by painful cramping in the lower abdomen before or after menstruation along with new menorrhagia, suggests an underlying pathology that needs to be addressed. While mefenamic acid can help manage the pain, it is not enough to simply review the patient in two weeks without organizing referrals or investigations. The insertion of an intrauterine progesterone system may be appropriate for primary dysmenorrhoea and some cases of secondary dysmenorrhoea, but this should not be the only course of action. Additional analgesia should be considered if paracetamol is not controlling the pain. An abdominal ultrasound is not suitable for investigating pelvic organs, and a transabdominal or transvaginal pelvic ultrasound is necessary to obtain views of the uterus, ovaries, Fallopian tubes, cervix, and vagina.

      Dysmenorrhoea is a condition where women experience excessive pain during their menstrual period. There are two types of dysmenorrhoea: primary and secondary. Primary dysmenorrhoea affects up to 50% of menstruating women and is not caused by any underlying pelvic pathology. It usually appears within 1-2 years of the menarche and is thought to be partially caused by excessive endometrial prostaglandin production. Symptoms include suprapubic cramping pains that may radiate to the back or down the thigh, and pain typically starts just before or within a few hours of the period starting. NSAIDs such as mefenamic acid and ibuprofen are effective in up to 80% of women, and combined oral contraceptive pills are used second line for management.

      Secondary dysmenorrhoea, on the other hand, typically develops many years after the menarche and is caused by an underlying pathology. The pain usually starts 3-4 days before the onset of the period. Causes of secondary dysmenorrhoea include endometriosis, adenomyosis, pelvic inflammatory disease, intrauterine devices, and fibroids. Clinical Knowledge Summaries recommend referring all patients with secondary dysmenorrhoea to gynaecology for investigation. It is important to note that the intrauterine system (Mirena) may help dysmenorrhoea, but this only applies to normal copper coils.

    • This question is part of the following fields:

      • Gynaecology
      67.4
      Seconds
  • Question 8 - A 68-year-old woman has been diagnosed with breast cancer and is now taking...

    Incorrect

    • A 68-year-old woman has been diagnosed with breast cancer and is now taking anastrozole to prevent recurrence after a mastectomy. She has a medical history of hypothyroidism and depression, which are managed with levothyroxine and fluoxetine. What is the most probable complication she may encounter during her breast cancer treatment?

      Your Answer: Reduced serum HDL cholesterol levels

      Correct Answer: Osteoporotic fracture

      Explanation:

      Osteoporosis may be a potential side effect of aromatase inhibitors such as anastrozole.

      Anti-oestrogen drugs are used in the management of oestrogen receptor-positive breast cancer. Selective oEstrogen Receptor Modulators (SERM) such as Tamoxifen act as an oestrogen receptor antagonist and partial agonist. However, Tamoxifen can cause adverse effects such as menstrual disturbance, hot flashes, venous thromboembolism, and endometrial cancer. On the other hand, aromatase inhibitors like Anastrozole and Letrozole reduce peripheral oestrogen synthesis, which is important in postmenopausal women. Anastrozole is used for ER +ve breast cancer in this group. However, aromatase inhibitors can cause adverse effects such as osteoporosis, hot flashes, arthralgia, myalgia, and insomnia. NICE recommends a DEXA scan when initiating a patient on aromatase inhibitors for breast cancer.

    • This question is part of the following fields:

      • Surgery
      53.1
      Seconds
  • Question 9 - A 6-month-old infant is scheduled for routine immunisations. All recommended immunisations have been...

    Incorrect

    • A 6-month-old infant is scheduled for routine immunisations. All recommended immunisations have been administered so far. What vaccinations should be given at this point?

      Your Answer: Hib/Men C + MMR + PCV

      Correct Answer: Hib/Men C + MMR + PCV + Men B

      Explanation:

      The UK immunisation schedule recommends certain vaccines at different ages. At birth, the BCG vaccine is given if the baby is at risk of tuberculosis. At 2, 3, and 4 months, the ‘6-1 vaccine’ (diphtheria, tetanus, whooping cough, polio, Hib and hepatitis B) and oral rotavirus vaccine are given, along with Men B and PCV at certain intervals. At 12-13 months, the Hib/Men C, MMR, and PCV vaccines are given, along with Men B. At 3-4 years, the ‘4-in-1 preschool booster’ (diphtheria, tetanus, whooping cough and polio) and MMR vaccines are given. At 12-13 years, the HPV vaccination is given, and at 13-18 years, the ‘3-in-1 teenage booster’ (tetanus, diphtheria and polio) and Men ACWY vaccines are given. Additionally, the flu vaccine is recommended annually for children aged 2-8 years.

      It is important to note that the meningitis ACWY vaccine has replaced meningitis C for 13-18 year-olds due to an increased incidence of meningitis W disease in recent years. The ACWY vaccine will also be offered to new students (up to the age of 25 years) at university. GP practices will automatically send letters inviting 17-and 18-year-olds in school year 13 to have the Men ACWY vaccine. Students going to university or college for the first time as freshers, including overseas and mature students up to the age of 25, should contact their GP to have the Men ACWY vaccine, ideally before the start of the academic year.

      It is worth noting that the Men C vaccine used to be given at 3 months but has now been discontinued. This is because the success of the Men C vaccination programme means there are almost no cases of Men C disease in babies or young children in the UK any longer. All children will continue to be offered the Hib/Men C vaccine at one year of age, and the Men ACWY vaccine at 14 years of age to provide protection across all age groups.

    • This question is part of the following fields:

      • Paediatrics
      7.3
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  • Question 10 - A 67-year-old man with a past medical history of dyspepsia presents with a...

    Incorrect

    • A 67-year-old man with a past medical history of dyspepsia presents with a gastric MALT lymphoma confirmed on biopsy. What treatment options are available?

      Your Answer: Laser ablation

      Correct Answer: H. pylori eradication

      Explanation:

      To treat gastric MALT lymphoma, it is recommended to eliminate H. pylori.

      Gastric MALT Lymphoma: A Brief Overview

      Gastric MALT lymphoma is a type of lymphoma that is commonly associated with H. pylori infection, which is present in 95% of cases. The good news is that this type of lymphoma has a good prognosis, especially if it is low grade. In fact, about 80% of patients with low-grade gastric MALT lymphoma respond well to H. pylori eradication.

      One potential feature of gastric MALT lymphoma is the presence of paraproteinaemia, which is an abnormal protein in the blood. However, this is not always present and may not be a reliable indicator of the disease. Overall, gastric MALT lymphoma is a treatable form of lymphoma with a high likelihood of successful treatment.

    • This question is part of the following fields:

      • Surgery
      20.4
      Seconds
  • Question 11 - During duty surgery (urgent care), you encounter a 55-year-old woman who is experiencing...

    Correct

    • During duty surgery (urgent care), you encounter a 55-year-old woman who is experiencing excruciating pain around her right eye. She has tried over-the-counter drops from the chemist, but they have not provided any relief. Although she has no significant medical history, she has been working 12-hour night shifts as a bank nurse. Upon examination, you notice a mild vesicular rash on the conjunctiva, but the eye itself appears normal under direct vision. Her visual acuity is normal, and fundoscopy reveals no abnormalities.

      What would be the most appropriate next step?

      Your Answer: Oral acyclovir and urgent ophthalmology referral

      Explanation:

      The recommended course of action for suspected herpes zoster ophthalmicus is urgent referral to an ophthalmologist and a 7-10 day course of oral antivirals such as acyclovir. Prescribing high dose oral steroids or topical dexamethasone is not the appropriate treatment for this condition. While direct referral to the emergency department may result in eventual referral to ophthalmology and treatment, it is not the most efficient or effective approach.

      Herpes Zoster Ophthalmicus: Symptoms, Treatment, and Complications

      Herpes zoster ophthalmicus (HZO) is a condition that occurs when the varicella-zoster virus reactivates in the area supplied by the ophthalmic division of the trigeminal nerve. It is responsible for approximately 10% of shingles cases. The main symptom of HZO is a vesicular rash around the eye, which may or may not involve the eye itself. Hutchinson’s sign, a rash on the tip or side of the nose, is a strong indicator of nasociliary involvement and increases the risk of ocular involvement.

      Treatment for HZO involves oral antiviral medication for 7-10 days, ideally started within 72 hours of symptom onset. Intravenous antivirals may be necessary for severe infections or immunocompromised patients. Topical antiviral treatment is not recommended for HZO, but topical corticosteroids may be used to treat any secondary inflammation of the eye. Ocular involvement requires urgent ophthalmology review to prevent complications such as conjunctivitis, keratitis, episcleritis, anterior uveitis, ptosis, and post-herpetic neuralgia.

      In summary, HZO is a condition caused by the reactivation of the varicella-zoster virus in the ophthalmic division of the trigeminal nerve. It presents with a vesicular rash around the eye and may involve the eye itself. Treatment involves oral antiviral medication and urgent ophthalmology review is necessary for ocular involvement. Complications of HZO include various eye conditions, ptosis, and post-herpetic neuralgia.

    • This question is part of the following fields:

      • Ophthalmology
      38.6
      Seconds
  • Question 12 - A senior citizen is referred to the Emergency Department by his General Practitioner,...

    Correct

    • A senior citizen is referred to the Emergency Department by his General Practitioner, feeling generally unwell and with reduced urine output. Bloods tests show: Na+ 128 mmol/l, K+ 7.2 mmol/l, urea 42.6 mmol/l, creatinine 828 μmol/l.
      An electrocardiogram (ECG) shows widespread tenting of T-waves.
      Which of the following treatments should be given first?

      Your Answer: Calcium gluconate

      Explanation:

      Managing Hyperkalaemia: Immediate Actions and Treatment Options

      Hyperkalaemia, defined as a serum potassium level greater than 6.5 mmol/l, requires immediate attention to prevent fatal arrhythmias. The first step is to confirm the result with repeat electrolyte testing and administer calcium gluconate or chloride to stabilize cardiac membranes. ECG changes such as peaked/tented T-waves and prolonged PR interval may indicate the need for urgent intervention.

      Insulin and dextrose infusion, along with salbutamol nebulizers, can be used to lower serum potassium levels. Calcium resonium may be used for continued potassium reduction, but it is not effective in acute management.

      It is important to prioritize cardioprotection by administering calcium gluconate first, followed by insulin and dextrose and salbutamol nebulizers as needed. Intravenous saline may be useful in cases of dehydration-related acute kidney injury, but it will not have an immediate effect on significant hyperkalaemia.

      In summary, prompt recognition and management of hyperkalaemia are crucial to prevent life-threatening complications.

    • This question is part of the following fields:

      • Clinical Biochemistry
      35.8
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  • Question 13 - A 68-year-old man has complained of increased frequency of urination and urge incontinence....

    Incorrect

    • A 68-year-old man has complained of increased frequency of urination and urge incontinence. He wakes up 4 times at night to urinate. He has no other medical conditions and is in good health. On physical examination, his prostate is normal in size on digital rectal examination. What is the most suitable investigation to determine the cause of his symptoms?

      Your Answer: Transrectal prostate biopsy

      Correct Answer: Urodynamic studies

      Explanation:

      Urodynamic studies are used to measure bladder voiding and can be helpful in diagnosing overactive bladder (OAB), which is suspected in patients who cannot control their urge to urinate. The symptoms of urgency described by the patient are indicative of lower urinary tract symptoms associated with OAB. While OAB is a clinical syndrome that does not necessarily require investigation, the question specifically asks which investigation would be most useful in demonstrating this condition. Therefore, the correct answer is urodynamic studies. Other modalities such as bladder ultrasound may be useful in detecting large post-voiding volumes, but they would not reveal the underlying pathology of OAB.

      Lower urinary tract symptoms (LUTS) are a common issue in men over the age of 50, with benign prostatic hyperplasia being the most common cause. However, other causes such as prostate cancer should also be considered. These symptoms can be classified into three groups: voiding, storage, and post-micturition. To properly manage LUTS, it is important to conduct a urinalysis to check for infection and haematuria, perform a digital rectal examination to assess the size and consistency of the prostate, and possibly conduct a PSA test after proper counselling. Patients should also complete a urinary frequency-volume chart and an International Prostate Symptom Score to guide management.

      For predominantly voiding symptoms, conservative measures such as pelvic floor muscle training, bladder training, and prudent fluid intake can be helpful. If symptoms are moderate or severe, an alpha-blocker may be offered. If the prostate is enlarged and the patient is at high risk of progression, a 5-alpha reductase inhibitor should be offered. If there are mixed symptoms of voiding and storage not responding to an alpha-blocker, an antimuscarinic drug may be added. For predominantly overactive bladder symptoms, moderating fluid intake and bladder retraining should be offered, and antimuscarinic drugs may be prescribed if symptoms persist. Mirabegron may be considered if first-line drugs fail. For nocturia, moderating fluid intake at night, furosemide 40 mg in the late afternoon, and desmopressin may be helpful.

    • This question is part of the following fields:

      • Surgery
      35.4
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  • Question 14 - A 38-year-old woman has given birth to her second and final child at...

    Incorrect

    • A 38-year-old woman has given birth to her second and final child at 40 weeks gestation. She has been in the third stage of labor for 70 minutes and has lost 2900 ml of blood. Her previous baby was delivered via elective c-section. She has a history of pelvic inflammatory disease. An antenatal ultrasound was performed due to her risk factors, but the results were not seen by the delivery team until now. What is the most effective treatment for the underlying issue?

      Your Answer: Ergometrine administration

      Correct Answer: Hysterectomy

      Explanation:

      In cases where delayed placental delivery is observed in patients with placenta accreta, hysterectomy is the recommended treatment. This patient has a history of previous caesarean-section and pelvic inflammatory disease, indicating a likely placenta accreta, which was also diagnosed antenatally on ultrasound. The optimal management approach involves leaving the placenta in-situ and performing a hysterectomy to avoid potential haemorrhage from attempts to actively remove the placenta. While medical management with oxytocin and ergometrine may help manage post-partum haemorrhage, it is not a definitive treatment option. Cord traction is also unlikely to be effective as the placenta is abnormally implanted into the uterine wall. Waiting another 30 minutes is not advisable due to the risk of further bleeding.

      Understanding Placenta Accreta

      Placenta accreta is a condition where the placenta attaches to the myometrium instead of the decidua basalis, which can lead to postpartum hemorrhage. This condition is caused by a defective decidua basalis. There are three types of placenta accreta, which are categorized based on the degree of invasion. The first type is accreta, where the chorionic villi attach to the myometrium. The second type is increta, where the chorionic villi invade into the myometrium. The third type is percreta, where the chorionic villi invade through the perimetrium.

      There are certain risk factors that increase the likelihood of developing placenta accreta, such as having a previous caesarean section or placenta previa. It is important for healthcare providers to be aware of these risk factors and monitor patients closely during pregnancy and delivery. Early detection and management of placenta accreta can help prevent complications and ensure the best possible outcome for both the mother and baby.

    • This question is part of the following fields:

      • Gynaecology
      9.8
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  • Question 15 - A 35-year-old woman with a body mass index of 33 kg/m2 has a...

    Incorrect

    • A 35-year-old woman with a body mass index of 33 kg/m2 has a fasting blood sugar of 10 mmol/l and 11.7 mmol/l on two separate occasions. Her family history includes diabetes mellitus in her father and maternal uncle. Despite attempting to lose weight through diet and exercise, she has been unsuccessful in achieving a balanced diet. She is open to taking either orlistat or an anorexigenic agent. Further investigation reveals that her blood insulin level tends to be relatively high.
      What is the most likely hormonal change to be observed in this patient?

      Your Answer: Increased cortisol

      Correct Answer: Reduced adiponectin

      Explanation:

      Endocrine Factors Predisposing to Type II Diabetes Mellitus

      Type II diabetes mellitus is a metabolic disorder characterized by insulin resistance and high blood sugar levels. Several endocrine factors can predispose individuals to this condition. In obese patients with a positive family history of diabetes, adiponectin levels are reduced. Adiponectin is a hormone secreted by adipocytes that plays a role in glucose metabolism. In contrast, leptin levels are increased in these patients and usually correlate with the degree of insulin resistance. Growth hormone levels are increased in acromegaly, which can also predispose individuals to type II diabetes. Phaeochromocytoma, a rare tumor of the adrenal gland, can cause increased epinephrine levels and predispose individuals to diabetes. Similarly, Cushing syndrome, a condition characterized by increased cortisol levels, can also predispose individuals to type II diabetes. Understanding these endocrine factors can help clinicians identify individuals at risk for type II diabetes and implement appropriate preventive measures.

    • This question is part of the following fields:

      • Endocrinology
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      Seconds
  • Question 16 - A 53-year-old woman presents with haematemesis. She has vomited twice, producing large amounts...

    Correct

    • A 53-year-old woman presents with haematemesis. She has vomited twice, producing large amounts of bright red blood, although the exact volume was not measured. On examination, you discover that there is a palpable spleen tip, and spider naevi over the chest, neck and arms.
      What is the diagnosis?

      Your Answer: Bleeding oesophageal varices

      Explanation:

      Causes of Upper Gastrointestinal Bleeding and Their Differentiation

      Upper gastrointestinal (GI) bleeding can have various causes, and it is important to differentiate between them to provide appropriate management. The following are some common causes of upper GI bleeding and their distinguishing features.

      Bleeding Oesophageal Varices
      Portal hypertension due to chronic liver failure can lead to oesophageal varices, which can rupture and cause severe bleeding, manifested as haematemesis. Immediate management includes resuscitation, proton pump inhibitors, and urgent endoscopy to diagnose and treat the source of bleeding.

      Mallory-Weiss Tear
      A Mallory-Weiss tear causes upper GI bleeding due to a linear mucosal tear at the oesophagogastric junction, secondary to a sudden increase in intra-abdominal pressure. It occurs in patients after severe retching and vomiting or coughing.

      Peptic Ulcer
      Peptic ulcer is the most common cause of serious upper GI bleeding, with the majority of ulcers in the duodenum. However, sudden-onset haematemesis of a large volume of fresh blood is more suggestive of a bleed from oesophageal varices. It is important to ask about a history of indigestion or peptic ulcers. Oesophagogastroduodenoscopy (OGD) can diagnose both oesophageal varices and peptic ulcers.

      Gastric Ulcer
      Sudden-onset haematemesis of a large volume of fresh blood is more suggestive of a bleed from oesophageal varices.

      Oesophagitis
      Oesophagitis may be very painful but is unlikely to lead to a significant amount of haematemesis.

      Understanding the Causes of Upper Gastrointestinal Bleeding

    • This question is part of the following fields:

      • Gastroenterology
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  • Question 17 - A 35-year-old woman presents with a 4-year history of a progressively worsening rash...

    Correct

    • A 35-year-old woman presents with a 4-year history of a progressively worsening rash on her face, characterised by dark-coloured lesions with periodic background scaling, burning and pruritus. Physical examination reveals well-defined patches of flaky skin which is yellow and dry on the scalp. There is also flaking in the nasolabial folds, eyebrows and behind the ears. The patient’s eyelids are also red and inflamed. They report itchiness and discomfort.
      Given the likely diagnosis of this patient, what is the most appropriate treatment?

      Your Answer: Ketoconazole

      Explanation:

      Treatment Options for Seborrheic Dermatitis and Psoriasis

      Seborrheic dermatitis and psoriasis are two common skin conditions that can cause discomfort and irritation. Fortunately, there are several treatment options available to help manage symptoms and improve overall skin health.

      Ketoconazole is the preferred medication for treating seborrheic dermatitis in adults. It is available as a 2% cream and should be applied once or twice daily for at least four weeks. Antifungal shampoo can also be used on the scalp. For infants with seborrheic dermatitis, clotrimazole is a suitable option and should be applied 2-3 times a day for up to four weeks.

      Emollients are often used to relieve symptoms of psoriasis by moisturizing dry skin and reducing itching. They can be used before starting steroid treatment for psoriasis. It is important to avoid using soap and shaving creams on the face, as they can exacerbate irritation. Instead, non-greasy emollients or emollient soaps can be used as an alternative.

      Topical steroids are commonly used to treat psoriasis by reducing skin inflammation. Mild topical steroids can be used on the face or skinfolds. It is important to follow the instructions provided by your healthcare provider and to use these medications as directed.

      In summary, there are several treatment options available for managing seborrheic dermatitis and psoriasis. By working with your healthcare provider, you can find the best approach to improve your skin health and overall quality of life.

    • This question is part of the following fields:

      • Dermatology
      22.4
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  • Question 18 - A 65-year-old man presents for his regular diabetic eye screening. He had visited...

    Correct

    • A 65-year-old man presents for his regular diabetic eye screening. He had visited his GP recently and had his blood sugar levels under control. During the examination, cotton wool spots and neovascularisation are observed throughout the retina, leading to a diagnosis of proliferative retinopathy. What is the most effective treatment for this condition?

      Your Answer: Panretinal laser photocoagulation

      Explanation:

      Panretinal laser photocoagulation is the preferred treatment for proliferative retinopathy, a condition characterized by the growth of fragile new blood vessels that can cause vitreal hemorrhage. In addition to controlling blood sugar levels and using anti-VEGF injections, thermal burns are made using a laser to prevent abnormal blood vessel development. Conservative management and monitoring are not sufficient for definitive management, as neovascularization can lead to serious complications. Laser iridotomy and phacoemulsification are not indicated for this condition.

      Understanding Diabetic Retinopathy

      Diabetic retinopathy is a leading cause of blindness among adults aged 35-65 years old. The condition is caused by hyperglycemia, which leads to abnormal metabolism in the retinal vessel walls and damage to endothelial cells and pericytes. This damage causes increased vascular permeability, resulting in exudates seen on fundoscopy. Pericyte dysfunction predisposes to the formation of microaneurysms, while neovascularization is caused by the production of growth factors in response to retinal ischemia.

      Patients with diabetic retinopathy are classified into those with nonproliferative diabetic retinopathy (NPDR), proliferative retinopathy (PDR), and maculopathy. NPDR is further classified into mild, moderate, and severe, depending on the presence of microaneurysms, blot hemorrhages, hard exudates, cotton wool spots, venous beading/looping, and intraretinal microvascular abnormalities. PDR is characterized by retinal neovascularization, which may lead to vitreous hemorrhage, and fibrous tissue forming anterior to the retinal disc. Maculopathy is based on location rather than severity and is more common in Type II DM.

      Management of diabetic retinopathy involves optimizing glycaemic control, blood pressure, and hyperlipidemia, as well as regular review by ophthalmology. Treatment options include intravitreal vascular endothelial growth factor (VEGF) inhibitors for maculopathy, regular observation for nonproliferative retinopathy, and panretinal laser photocoagulation and intravitreal VEGF inhibitors for proliferative retinopathy. Vitreoretinal surgery may be necessary in cases of severe or vitreous hemorrhage.

    • This question is part of the following fields:

      • Ophthalmology
      23.7
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  • Question 19 - A 25-year-old male patient arrives at the emergency department with agitation, dry mouth,...

    Correct

    • A 25-year-old male patient arrives at the emergency department with agitation, dry mouth, and blurred vision. He has a history of major depression and admits to taking an overdose of amitriptyline two hours ago in an attempt to end his life. Upon examination, his respiratory rate is 18 breaths/min, heart rate is 110 beats/min, and temperature is 37.7°C. What is the primary investigation that should be conducted based on the patient's clinical presentation?

      Your Answer: Electrocardiogram (ECG)

      Explanation:

      If tricyclic overdose is suspected, it is important to perform an ECG to check for any abnormalities. A QRS widening of over 100ms is linked to a higher risk of seizures, while a QRS widening of over 160 ms is associated with ventricular arrhythmias. Tricyclic overdose can cause sinus tachycardia, QRS widening, and QT interval prolongation. Therefore, an ECG should be conducted on all patients who have intentionally poisoned themselves (or have an unknown cause of altered GCS) to screen for TCA overdose. While urine drug screens, serum tricyclic antidepressant levels, and arterial blood gas tests can help diagnose tricyclic overdose, they are not the most crucial initial tests. Although an electroencephalogram can detect seizure activity in the brain, it does not change the management plan for tricyclic overdose.

      Tricyclic overdose is a common occurrence in emergency departments, with particular danger associated with amitriptyline and dosulepin. Early symptoms include dry mouth, dilated pupils, agitation, sinus tachycardia, and blurred vision. Severe poisoning can lead to arrhythmias, seizures, metabolic acidosis, and coma. ECG changes may include sinus tachycardia, widening of QRS, and prolongation of QT interval. QRS widening over 100ms is linked to an increased risk of seizures, while QRS over 160 ms is associated with ventricular arrhythmias.

      Management of tricyclic overdose involves IV bicarbonate as first-line therapy for hypotension or arrhythmias. Other drugs for arrhythmias, such as class 1a and class Ic antiarrhythmics, are contraindicated as they prolong depolarisation. Class III drugs like amiodarone should also be avoided as they prolong the QT interval. Lignocaine’s response is variable, and it should be noted that correcting acidosis is the first line of management for tricyclic-induced arrhythmias. Intravenous lipid emulsion is increasingly used to bind free drug and reduce toxicity. Dialysis is ineffective in removing tricyclics.

    • This question is part of the following fields:

      • Pharmacology
      43.4
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  • Question 20 - A 59-year-old man is undergoing his routine dialysis treatment when he suddenly experiences...

    Correct

    • A 59-year-old man is undergoing his routine dialysis treatment when he suddenly experiences intense chest pain and difficulty breathing. He has been on dialysis for the past nine years and uses a fistula for the procedure. So far, there have been no issues with the dialysis machine or circuit. After the session, his blood pressure is 150/85 mmHg, and an ECG is performed. What could be the probable reason for his chest pain?

      Your Answer: Acute coronary syndrome

      Explanation:

      Acute coronary syndrome is the most common cause of chest pain and shortness of breath in dialysis patients due to their increased risk of coronary disease. Air embolism, hypotension, massive haemolysis, and pulmonary embolism are also possible causes but are less likely. Air embolism is rare but can occur in patients with central lines, while hypotension is more common in the elderly and new starters on dialysis. Massive haemolysis is rare but serious, and pulmonary embolism can occur if there is a known thrombus in the fistula.

    • This question is part of the following fields:

      • Nephrology
      70.7
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  • Question 21 - A 31-year-old man presented with weakness and fatigue. On examination, he was emaciated...

    Incorrect

    • A 31-year-old man presented with weakness and fatigue. On examination, he was emaciated with a body weight of 40 kg. Blood tests revealed abnormalities including low haemoglobin, low MCV, low MCH, high platelet count, low albumin, and low calcium. His peripheral blood showed Howell-Jolly bodies. To which department should this patient be referred?

      Your Answer: Haematology Department

      Correct Answer: Gastroenterology Department

      Explanation:

      Specialty Departments and Diagnosis of Coeliac Disease

      The patient presents with microcytic, hypochromic anaemia, Howell-Jolly bodies, and splenic dysfunction, along with low albumin and calcium suggestive of malabsorption and emaciation. The most likely diagnosis is coeliac disease, which can be confirmed by antibody tests and a duodenal biopsy in the Gastroenterology department. Haematology can investigate the abnormal blood count, but treatment is not within their scope. Chronic kidney or liver disease is less likely, and there are no neurological symptoms.

    • This question is part of the following fields:

      • Haematology
      25.8
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  • Question 22 - A 16-month-old toddler comes to your primary care clinic after experiencing a seizure....

    Incorrect

    • A 16-month-old toddler comes to your primary care clinic after experiencing a seizure. The parents are extremely worried as one of their relatives has epilepsy and they fear that their child may have it too. Upon examination, the child seems alert and has a temperature of 38.4C, which the parents say has been present for four days. They have been giving calpol, which has helped to bring it down from a high of 40.7ºC. You also notice a pink, maculopapular rash on the chest with minimal spread to the limbs, which the mother says she noticed this morning. The child has been eating but has had some diarrhea, and you can feel some enlarged glands on the back of their head. There is no rash in the mouth. Based on your observations, what do you think is the most probable underlying cause of the child's symptoms?

      Your Answer: Parvovirus B19

      Correct Answer: Herpes virus 6

      Explanation:

      Herpes virus 6 is responsible for causing Roseola infantum, which is identified by a high fever lasting for 3-5 days followed by a rash that appears on the chest and spreads to the limbs over a period of 2 days. This rash typically emerges as the fever subsides. Kaposi’s sarcoma is linked to Herpes virus 8 and is commonly observed in individuals with AIDS. ‘Slapped cheek syndrome’ is caused by Parvovirus B19, which initiates a rash that starts on the cheeks and then spreads. Group A Streptococcus is known to cause infections of the throat (also known as strep throat) and skin, including cellulitis, erysipelas, and impetigo.

      Understanding Roseola Infantum

      Roseola infantum, also known as exanthem subitum or sixth disease, is a common illness that affects infants and is caused by the human herpes virus 6 (HHV6). This disease has an incubation period of 5-15 days and is typically seen in children aged 6 months to 2 years. The most common symptoms of roseola infantum include a high fever that lasts for a few days, followed by a maculopapular rash. Other symptoms may include Nagayama spots, which are papular enanthems on the uvula and soft palate, as well as cough and diarrhea.

      In some cases, febrile convulsions may occur in around 10-15% of children with roseola infantum. While this can be concerning for parents, it is important to note that this is a common occurrence and typically resolves on its own. Additionally, HHV6 infection can lead to other possible consequences such as aseptic meningitis and hepatitis.

      It is important to note that school exclusion is not necessary for children with roseola infantum. While this illness can be uncomfortable for infants, it is typically not serious and resolves on its own within a few days.

    • This question is part of the following fields:

      • Paediatrics
      26.5
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  • Question 23 - A trial is to be set up to examine a new drug for...

    Correct

    • A trial is to be set up to examine a new drug for the maintenance of remission in all people over the age of 50 with ulcerative colitis.

      A randomised double blinded placebo controlled trial recruits patients in hospital with an exacerbation of their ulcerative colitis. A standard questionnaire is used to record the frequency of exacerbations of disease over a two year period.

      Results show that there is no difference between the drug and placebo and the results are published in a medical journal.

      To which form of bias is this study most susceptible?

      Your Answer: Selection bias

      Explanation:

      Types of Bias in Clinical Trials

      Bias in clinical trials refers to a systematic difference between the results obtained from a randomized controlled trial and the true state of affairs. There are different types of bias that can occur in clinical trials. Selection bias occurs when the study population is different from the population to whom the results will be applied. Allocation bias occurs when patients are not randomly assigned to a particular treatment. Assessment bias occurs when the observer knows which treatment the subject is taking. Observer bias is when one observer consistently under or over reports a particular variable. Recall bias applies to case-control studies when a patient is more likely to remember a particular detail of exposure if they go on to develop the disease.

      One example of selection bias is the early results of trials of hormone replacement therapy (HRT) demonstrating potentially positive results on reduction in cardiovascular risk. It has been argued that women of higher social classes who exercised more were likely to choose HRT, which could have influenced the results. It is important to identify and minimize bias in clinical trials to ensure that the results obtained are reliable and can be applied to the population of interest.

    • This question is part of the following fields:

      • Clinical Sciences
      46.2
      Seconds
  • Question 24 - A 65-year-old patient is suspected of having ingested a substance with anticholinesterase effects....

    Correct

    • A 65-year-old patient is suspected of having ingested a substance with anticholinesterase effects. What combination of signs, if present, would most likely confirm this effect?

      Your Answer: Bradycardia and miosis

      Explanation:

      Acetylcholinesterase Inhibitors and Muscarinic Effects

      An acetylcholinesterase inhibitor, also known as an anticholinesterase, is a chemical that prevents the breakdown of acetylcholine (ACh) by inhibiting the cholinesterase enzyme. This leads to an increase in both the level and duration of action of ACh, a neurotransmitter that stimulates postganglionic receptors to produce various effects such as salivation, lacrimation, defecation, micturition, sweating, miosis, bradycardia, and bronchospasm. These effects are referred to as muscarinic effects, and the postganglionic receptors are called muscarinic receptors since muscarine produces these effects.

      One pathological syndrome associated with excessive stimulation of the parasympathetic nervous system is SLUD, which stands for Salivation, Lacrimation, Urination, Defecation, and emesis. SLUD is not likely to occur naturally and is usually encountered only in cases of drug overdose or exposure to nerve gases. Nerve gases irreversibly inhibit the acetylcholinesterase enzyme, leading to a chronically high level of ACh at cholinergic synapses throughout the body. This, in turn, chronically stimulates ACh receptors throughout the body, resulting in SLUD and other muscarinic effects.

    • This question is part of the following fields:

      • Pharmacology
      23.3
      Seconds
  • Question 25 - A 32-year-old man with psoriasis affecting the scalp and legs visits his General...

    Incorrect

    • A 32-year-old man with psoriasis affecting the scalp and legs visits his General Practitioner with ongoing symptoms despite using once-daily Betnovate® (potent steroid) and a vitamin D analogue for six weeks. What should be the next course of action in managing this patient?

      Your Answer: Refer to Dermatology

      Correct Answer: Stop steroid treatment and continue vitamin D analogue twice daily

      Explanation:

      Management of Psoriasis: Next Steps and Referral Considerations

      Psoriasis management follows a stepwise approach, as per NICE guidance. For a patient who has already received eight weeks of once-daily potent steroid with a vitamin D analogue, the next step is to stop the steroid and start twice-daily vitamin D analogue. Steroids should not be applied at the same site for more than eight weeks, after which patients require a 4-week ‘treatment break’. If there is still no improvement in symptoms at the end of the 4-week steroid-free break, twice-daily steroids can be trialled or a coal tar preparation can be started.

      Referral to Dermatology may be necessary if the patient is severely affected by psoriasis or struggling to manage the condition. However, starting the next stage of treatment, which is twice-daily vitamin D analogue, would be the most appropriate while awaiting secondary care review.

      Continuing steroids for a further four weeks would result in an excessively long duration of steroid treatment and risk side-effects such as skin thinning. Patients should have a minimum of four weeks steroid-free after an 8-week treatment course.

      While some patients with severe psoriasis may require an ultra-potent steroid, this patient has already received eight weeks of a potent steroid and requires a 4-week steroid-free break. Following this, it may be appropriate to trial a short course of an ultra-potent steroid or to retrial the potent steroid twice daily.

    • This question is part of the following fields:

      • Dermatology
      23.1
      Seconds
  • Question 26 - A 28-year-old woman visits her GP complaining of fever, malaise and headache. During...

    Correct

    • A 28-year-old woman visits her GP complaining of fever, malaise and headache. During the examination, the GP notices a macular rash on her trunk and limbs. The patient confirms that the rash is not causing any itching. The GP suspects that the patient may have developed secondary syphilis. If the patient had untreated chancre-associated primary syphilis, how many weeks would it take for secondary syphilis to appear?

      Your Answer: 2–8 weeks

      Explanation:

      The Timeline and Symptoms of Secondary Syphilis

      Secondary syphilis is a multisystem disease that usually develops between 2 and 8 weeks following the appearance of a chancre. In women, chancres can be found on the labia, vulva, or cervix, making it easy to miss the primary stage.

      Symptoms of secondary syphilis include mild fever, malaise, and headache. A rash on the trunk and limbs is also common, which may involve the palms and soles of the feet. If left untreated, the rash can last up to 12 weeks.

      It’s important to note that clinical manifestations of secondary syphilis will resolve without treatment, but relapse may occur within the first year.

      In summary, the timeline for secondary syphilis is between 2 and 8 weeks following the chancre, and symptoms include fever, malaise, headache, and a rash on the trunk and limbs. Early detection and treatment are crucial to prevent further complications.

    • This question is part of the following fields:

      • Sexual Health
      55.5
      Seconds
  • Question 27 - A 72-year-old man is receiving a 2 units of blood transfusion for anaemia...

    Correct

    • A 72-year-old man is receiving a 2 units of blood transfusion for anaemia of unknown cause – haemoglobin (Hb) 65 g/l (normal 135–175 g/l). During the third hour of the blood transfusion he spikes a temperature of 38.1°C (normal 36.1–37.2°C). Otherwise the patient is asymptomatic and his other observations are normal.
      Given the likely diagnosis, what should you do?

      Your Answer: Temporarily stop transfusion, repeat clerical checks. Then treat with paracetamol and repeat observations more regularly (every 15 minutes)

      Explanation:

      Treatment Options for Non-Haemolytic Febrile Transfusion Reaction

      Non-haemolytic febrile transfusion reaction is a common acute reaction to plasma proteins during blood transfusions. If a patient experiences this reaction, the transfusion should be temporarily stopped, and clerical checks should be repeated. The patient should be treated with paracetamol, and observations should be repeated more regularly (every 15 minutes).

      If the patient’s temperature is less than 38.5 degrees, and they are asymptomatic with normal observations, the transfusion can be continued with more frequent observations and paracetamol. However, if the patient experiences transfusion-associated circulatory overload, furosemide is a suitable treatment option.

      Adrenaline is not needed unless there are signs of anaphylaxis, and antihistamines are only suitable for urticaria during blood transfusions. Therefore, it is essential to identify the specific type of transfusion reaction and provide appropriate treatment accordingly.

    • This question is part of the following fields:

      • Haematology
      24.5
      Seconds
  • Question 28 - A 55-year-old man, who has recently started a new relationship, presented with depression....

    Correct

    • A 55-year-old man, who has recently started a new relationship, presented with depression. He reported a decrease in libido, which was affecting his relationship. The physician decided to initiate testosterone therapy after conducting some blood tests.
      Which of the following routes should not be used to administer testosterone?

      Your Answer: Intravenous (iv)

      Explanation:

      Different Routes of Testosterone Administration and their Risks

      Testosterone is a hormone that can be administered through various routes, each with its own risks and benefits. Intravenous administration is not recommended due to the risk of emboli formation and respiratory distress. Oral preparations are available but can be toxic to the liver, making transdermal formulations a safer option. Transdermal delivery can be achieved through gels, skin patches, or matrix patches, but absorption can vary. Intramuscular injections, such as undecanoate, release the drug slowly over a period of 2-6 weeks. Buccal tablets that adhere to the mucosa can also be used, but may cause buccal ulcers. It is important to consider the risks and benefits of each route of administration when choosing a testosterone formulation.

    • This question is part of the following fields:

      • Pharmacology
      59.2
      Seconds
  • Question 29 - A 45-year-old Afro-Caribbean man presents to the Emergency Department with acute severe chest...

    Correct

    • A 45-year-old Afro-Caribbean man presents to the Emergency Department with acute severe chest pain, fever and a cough, which he has had for five days. Examination revealed signs of jaundice and the spleen was not big enough to be palpable.
      You take some basic observations:
      Temperature: 38 °C
      Respiratory rate: 26 breaths/min
      O2 saturation: 86%
      Heart rate: 134 bpm (regular)
      Blood pressure (lying): 134/86 mmHg
      Blood pressure (standing): 132/90 mmHg
      His initial investigation findings are as follows:
      Investigation Result Normal
      White cell count (WCC) 13.8 × 109/l 4–11.0 × 109/l
      Neutrophils 7000 × 106/l 3000–5800 × 106/l
      Lymphocytes 2000 × 106/l 1500–3000 × 106/l
      Haemoglobin (Hb) 105 g/l 135–175 g/l
      Mean corpuscular volume (MCV) 110 fl 76–98 fl
      Platelets 300 × 109/l 150–400 × 109/l
      Troponin l 0.01 ng/ml < 0.1 ng/ml
      D-dimer 0.03 μg/ml < 0.05 μg/ml
      Arterial blood gas (ABG) showed type 1 respiratory failure with a normal pH. Chest X-ray showed left lower lobe consolidation.
      The patient was treated successfully and is due for discharge tomorrow.
      Upon speaking to the patient, he reveals that he has suffered two similar episodes this year.
      Given the likely diagnosis, what medication should the patient be started on to reduce the risk of further episodes?

      Your Answer: Hydroxycarbamide (hydroxyurea)

      Explanation:

      Treatment Options for a Patient with Sickle Cell Disease and Acute Chest Pain Crisis

      A patient with sickle cell disease is experiencing an acute chest pain crisis, likely due to a lower respiratory tract infection. Hydroxycarbamide is recommended as a preventative therapy to reduce the risk of future crises by increasing the amount of fetal hemoglobin and reducing the percentage of red cells with hemoglobin S. Granulocyte colony-stimulating factor (G-CSF) is not necessary as the patient has a raised white blood cell count. Inhaled beclomethasone is not appropriate as asthma or COPD are not likely diagnoses in this case. Oral prednisolone may be used as a preventative therapy for severe asthma, but is not recommended for COPD and is not appropriate for this patient’s symptoms. A tuberculosis (TB) vaccination may be considered for primary prevention, but would not be useful for someone who has already been infected.

    • This question is part of the following fields:

      • Haematology
      30.4
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  • Question 30 - A 67-year-old man has recently undergone a DEXA scan after experiencing back pain.
    The...

    Incorrect

    • A 67-year-old man has recently undergone a DEXA scan after experiencing back pain.
      The results are as follows:
      Site T score
      Lumbar spine -1.5
      Femoral neck -2.0
      What does the femoral neck bone density score indicate for this individual?

      Your Answer: Her bone density is 2.5 standard deviations below that of an average 65-year-old woman

      Correct Answer: Her bone density is 2.5 standard deviations below that of an average healthy young adult

      Explanation:

      The statement that the patient’s T score is 2.5% below that of an average 65-year-old woman is inaccurate. T scores are calculated as the number of standard deviations above or below the mean of a young reference population, not as a percentage relative to the mean. Additionally, the trabecular bone score is not a measure of bone density but rather a newer method that evaluates skeletal texture from DEXA images and may offer further insight into a patient’s risk of fractures.

      Osteoporosis is a condition that affects bone density and can lead to fractures. To diagnose osteoporosis, doctors use a DEXA scan, which measures bone mass. The results are compared to a young reference population, and a T score is calculated. A T score of -1.0 or higher is considered normal, while a score between -1.0 and -2.5 indicates osteopaenia, and a score below -2.5 indicates osteoporosis. The Z score is also calculated, taking into account age, gender, and ethnicity.

    • This question is part of the following fields:

      • Musculoskeletal
      80
      Seconds
  • Question 31 - As you approach the bedside of an elderly overweight woman, you notice that...

    Correct

    • As you approach the bedside of an elderly overweight woman, you notice that she appears to be quite drowsy. Upon calling out her name, you hear a grunting noise and quickly call for the nurse's assistance. The patient's oxygen saturations are at 82% on air.

      What would be the immediate next step in managing this patient?

      Your Answer: Head tilt, chin lift, jaw thrust

      Explanation:

      Three simple manoeuvres, namely head tilt, chin lift, and jaw thrust, can effectively relieve airway obstruction caused by poor pharyngeal muscle tone. This is a common scenario where a patient’s airway is obstructed due to drowsiness, resulting in reduced muscle tone in the pharynx. By performing the head tilt, chin lift, and jaw thrust manoeuvre, the airway can be opened, allowing for the return of airflow.

      Endotracheal intubation is the only method of securing the airway, as all other airway devices are supraglottic. It is not the first-line treatment and is typically performed by a trained professional, such as an anaesthetist, when controlled and secured ventilatory support is required, such as during surgeries or cardiac arrest.

      Therefore, the correct answer is head tilt, chin lift, and jaw thrust, as it effectively opens the airway. The laryngeal mask airway is a supraglottic airway device that is only used by trained professionals when tracheal intubation is difficult and a more definitive airway is required. It is not the first-line treatment. The nasopharyngeal airway is a bridging airway adjunct used in semi-conscious patients and may be beneficial if the patient continues to desaturate despite performing the head tilt, chin lift, jaw thrust manoeuvre and providing high flow oxygen.

      Airway Management Devices and Techniques

      Airway management is a crucial aspect of medical care, especially in emergency situations. In addition to airway adjuncts, there are simple positional manoeuvres that can be used to open the airway, such as head tilt/chin lift and jaw thrust. There are also several devices that can be used for airway management, each with its own advantages and limitations.

      The oropharyngeal airway is easy to insert and use, making it ideal for short procedures. It is often used as a temporary measure until a more definitive airway can be established. The laryngeal mask is widely used and very easy to insert. It sits in the pharynx and aligns to cover the airway, but it does not provide good control against reflux of gastric contents. The tracheostomy reduces the work of breathing and may be useful in slow weaning, but it requires humidified air and may dry secretions. The endotracheal tube provides optimal control of the airway once the cuff is inflated and can be used for long or short-term ventilation, but errors in insertion may result in oesophageal intubation.

      It is important to note that paralysis is often required for some of these devices, and higher ventilation pressures can be used with the endotracheal tube. Capnography should be monitored to ensure proper placement and ventilation. Each device has its own unique benefits and drawbacks, and the choice of device will depend on the specific needs of the patient and the situation at hand.

    • This question is part of the following fields:

      • Surgery
      18.9
      Seconds
  • Question 32 - A 14-year-old girl presents with a history of easy bruising and excessive bleeding...

    Incorrect

    • A 14-year-old girl presents with a history of easy bruising and excessive bleeding after a dental procedure. She is diagnosed with von Willebrand's disease and is scheduled for additional dental extractions. The physician prescribes DDAVP. What is the mechanism of action of DDAVP in treating von Willebrand's disease?

      Your Answer: Prevents renal excretion of von Willebrand's factor

      Correct Answer: Stimulates release of von Willebrand's factor from endothelial cells

      Explanation:

      DDAVP for Increasing von Willebrand Factor

      DDAVP is a medication that can be administered to increase the amount of von Willebrand factor in the body, which is necessary for surgical or dental procedures. This medication can increase plasma von Willebrand factor and factor VIII concentrations by two to five times. The mechanism of action involves the induction of cyclic adenosine monophosphate (cAMP)-mediated vWF secretion through a direct effect on endothelial cells. Overall, DDAVP is a useful tool for increasing von Willebrand factor levels in the body, allowing for safer and more successful surgical and dental procedures.

    • This question is part of the following fields:

      • Haematology
      50.9
      Seconds
  • Question 33 - What is the probable outcome if a fetus has homozygous alpha-thalassaemia, assuming it...

    Correct

    • What is the probable outcome if a fetus has homozygous alpha-thalassaemia, assuming it is at an early stage of development?

      Your Answer: Hydrops fetalis

      Explanation:

      Understanding Alpha-Thalassaemia

      Alpha-thalassaemia is a condition that arises from a deficiency of alpha chains in haemoglobin. This occurs due to the absence or reduced production of alpha-globulin genes located on chromosome 16. The severity of the condition depends on the number of alpha globulin alleles affected. If one or two alleles are affected, the blood picture would be hypochromic and microcytic, but the haemoglobin level would typically be normal. However, if three alleles are affected, it results in a hypochromic microcytic anaemia with splenomegaly, which is known as Hb H disease. In the case where all four alpha globulin alleles are affected, which is known as homozygote, it can lead to death in utero, also known as hydrops fetalis or Bart’s hydrops. Understanding the severity of alpha-thalassaemia is crucial in managing the condition and providing appropriate treatment.

    • This question is part of the following fields:

      • Paediatrics
      82.5
      Seconds
  • Question 34 - A patient with persistent sinusitis is scheduled for endoscopic surgery to address any...

    Correct

    • A patient with persistent sinusitis is scheduled for endoscopic surgery to address any blockages in the drainage pathways and perform balloon catheter dilation of the paranasal sinus openings. During the procedure, the surgeon aims to access the middle meatus of the nasal cavity to insert a cannula into the ostia.
      Which of the paranasal sinuses empties into the sphenoethmoidal recess?

      Your Answer: Sphenoidal sinus

      Explanation:

      Sinus Drainage Pathways in the Nasal Cavity

      The nasal cavity contains several sinuses that drain into different areas of the cavity. The sphenoidal sinus drains into the sphenoethmoid recess, which is located posterior and superior to the superior concha. The anterior ethmoidal sinus drains into the middle meatus via the semilunar hiatus, as does the maxillary sinus. The frontal sinus, on the other hand, drains into the infundibulum of the middle meatus. Finally, the middle ethmoidal sinus drains to the ethmoid bulla of the middle meatus. Understanding these drainage pathways is important for diagnosing and treating sinus issues.

    • This question is part of the following fields:

      • ENT
      21
      Seconds
  • Question 35 - You are recommending hormone replacement therapy (HRT) for a 50-year-old woman who is...

    Correct

    • You are recommending hormone replacement therapy (HRT) for a 50-year-old woman who is healthy but is suffering from severe menopausal symptoms. She is curious about the advantages and disadvantages of various HRT options.
      What is the accurate response concerning the risk of cancer associated with different types of HRT preparations?

      Your Answer: Combined HRT increases the risk of breast cancer

      Explanation:

      The addition of progesterone to HRT increases the likelihood of developing breast cancer, but this risk is dependent on the duration of treatment and decreases after HRT is discontinued. However, it does not affect the risk of dying from breast cancer. HRT with only oestrogen is linked to a lower risk of coronary heart disease, while combined HRT has a minimal or no impact on CHD risk. progesterone-only HRT is not available. NICE does not provide a specific risk assessment for ovarian cancer in women taking HRT, but refers to a meta-analysis indicating an increased risk for both oestrogen-only and combined HRT preparations.

      Adverse Effects of Hormone Replacement Therapy

      Hormone replacement therapy (HRT) is a treatment that involves the use of a small dose of oestrogen, often combined with a progesterone in women with a uterus, to alleviate menopausal symptoms. While it can be effective in reducing symptoms such as hot flashes and vaginal dryness, HRT can also have adverse effects and potential complications.

      Some common side-effects of HRT include nausea, breast tenderness, fluid retention, and weight gain. However, there are also more serious potential complications associated with HRT. For example, the use of HRT has been linked to an increased risk of breast cancer, particularly when a progesterone is added. The Women’s Health Initiative study found a relative risk of 1.26 at 5 years of developing breast cancer with HRT use. The risk of breast cancer is also related to the duration of use, and it begins to decline when HRT is stopped.

      Another potential complication of HRT is an increased risk of endometrial cancer. Oestrogen by itself should not be given as HRT to women with a womb, as this can increase the risk of endometrial cancer. The addition of a progesterone can reduce this risk, but it is not eliminated completely. The British National Formulary states that the additional risk is eliminated if a progesterone is given continuously.

      HRT has also been associated with an increased risk of venous thromboembolism (VTE), particularly when a progesterone is added. However, transdermal HRT does not appear to increase the risk of VTE. Women who are at high risk for VTE should be referred to haematology before starting any treatment, even transdermal, according to the National Institute for Health and Care Excellence (NICE).

      Finally, HRT has been linked to an increased risk of stroke and ischaemic heart disease if taken more than 10 years after menopause. It is important for women considering HRT to discuss the potential risks and benefits with their healthcare provider and make an informed decision based on their individual circumstances.

    • This question is part of the following fields:

      • Gynaecology
      25.1
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  • Question 36 - A 14-year-old girl presents to her GP requesting contraception.
    In which of the following...

    Correct

    • A 14-year-old girl presents to her GP requesting contraception.
      In which of the following scenarios could contraception be legally withheld?

      Your Answer: She does not have an understanding of the implications of contraception

      Explanation:

      Legal Considerations for Prescribing Contraception to a 15-Year-Old Girl

      When considering prescribing contraception to a 15-year-old girl, there are legal criteria that must be met. The Fraser criteria state that the patient must have the ability to understand the implications of contraception for herself and her family. If this is the case, and there is no medical contraindication, the girl can request whichever form of contraception she prefers.

      The Fraser criteria also state that the girl must have made a decision to start or continue to have sexual intercourse, despite attempts at persuasion, and that prescribing contraception is in her best interests. In Scotland, the legal underpinnings are statutory, and the girl must be capable of understanding the nature and possible consequences of the procedure or treatment.

      It is important to note that the type of contraception used will not have legal implications on whether contraception should be provided. However, if the girl is frightened to say no to her boyfriend, this may be a child safeguarding issue that requires careful handling. In this case, contraception can still be legally prescribed.

      If the girl refuses to discuss matters with her parents, this is not a legal reason to withhold contraception. As long as the sustained and consistent refusal to discuss with parents criteria are met, contraception can be supplied. Similarly, if the girl’s parents are abroad, this does not affect the decision to provide contraception as long as all other criteria are met.

      In conclusion, when considering prescribing contraception to a 15-year-old girl, it is important to ensure that the legal criteria are met and that the decision is in the girl’s best interests.

    • This question is part of the following fields:

      • Ethics And Legal
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  • Question 37 - A 20-year-old female comes to the clinic complaining of secondary amenorrhoea for the...

    Incorrect

    • A 20-year-old female comes to the clinic complaining of secondary amenorrhoea for the past six months. She recently experienced moderate vaginal bleeding and abdominal pain. Additionally, she has gained around 14 pounds in weight during this time. What is the probable diagnosis?

      Your Answer: Polycystic ovarian syndrome

      Correct Answer: Pregnancy

      Explanation:

      Secondary Amenorrhea and Miscarriage: A Possible Sign of Pregnancy

      Secondary amenorrhea, or the absence of menstrual periods for at least three consecutive months in women who have previously had regular cycles, can be a sign of pregnancy. In cases where a patient with secondary amenorrhea experiences a miscarriage, it is important to consider the possibility of pregnancy. This information is highlighted in the book Williams Gynecology, 4th edition, authored by Barbara L. Hoffman, John O. Schorge, Lisa M. Halvorson, Cherine A. Hamid, Marlene M. Corton, and Joseph I. Schaffer.

      The authors emphasize the importance of considering pregnancy as a possible cause of secondary amenorrhea, especially in cases where a miscarriage has occurred. This highlights the need for healthcare providers to be vigilant in their assessment of patients with secondary amenorrhea and to consider pregnancy as a possible diagnosis. Early detection of pregnancy can help ensure appropriate prenatal care and management, which can improve outcomes for both the mother and the baby.

      In conclusion, secondary amenorrhea followed by a miscarriage should raise suspicion of pregnancy. Healthcare providers should be aware of this possibility and consider pregnancy as a potential diagnosis in patients with secondary amenorrhea. Early detection and appropriate management of pregnancy can improve outcomes for both the mother and the baby.

    • This question is part of the following fields:

      • Endocrinology
      24.1
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  • Question 38 - A 50-year-old receptionist visited her GP due to a rash on her left...

    Correct

    • A 50-year-old receptionist visited her GP due to a rash on her left nipple area. She expressed discomfort and itchiness in the areola region. Upon further inquiry, she revealed that the rash has persisted for 8 weeks and has not improved with the use of E45 cream. The patient has a history of eczema, which is usually managed with E45 cream. She also mentioned that the rash started on the nipple and has spread outwards to the areola. During examination, the rash appeared crusty and erythematosus, but it did not extend beyond the nipple-areola complex. What additional measures should be taken?

      Your Answer: Breast clinic referral to be seen urgently by breast specialist

      Explanation:

      The crucial aspect of this inquiry lies in the progression of the rash, which originated on the nipple and has since extended to encompass the areola. Despite any previous instances of eczema, it is imperative that a breast specialist is consulted immediately to eliminate the possibility of Paget’s disease.

      Paget’s disease of the nipple is a condition that affects the nipple and is associated with breast cancer. It is present in a small percentage of patients with breast cancer, typically around 1-2%. In half of these cases, there is an underlying mass lesion, and 90% of those patients will have an invasive carcinoma. Even in cases where there is no mass lesion, around 30% of patients will still have an underlying carcinoma. The remaining cases will have carcinoma in situ.

      One key difference between Paget’s disease and eczema of the nipple is that Paget’s disease primarily affects the nipple and later spreads to the areolar, whereas eczema does the opposite. Diagnosis of Paget’s disease involves a punch biopsy, mammography, and ultrasound of the breast. Treatment will depend on the underlying lesion causing the disease.

    • This question is part of the following fields:

      • Surgery
      25.9
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  • Question 39 - A 21-year-old man presents to his GP with a complaint of a lump...

    Correct

    • A 21-year-old man presents to his GP with a complaint of a lump in his scrotum that he noticed while showering. He reports feeling some discomfort in the area but denies any pain. He has been in a committed relationship with his girlfriend and had a clear sexual health screen two weeks ago.

      Upon examination, the GP notes a soft mass on the anterior aspect of the right testis that cannot be distinguished from the testis itself. The lump is not tender to touch and transilluminates.

      What is the most likely diagnosis for this patient?

      Your Answer: Hydrocoele

      Explanation:

      Hydrocoeles are distinguishable from other testicular lumps as they are not separate from the testis and can be transilluminated.

      When evaluating scrotal lumps, it is crucial to determine if the mass is solid or cystic in nature and if it is continuous or separate from the testis. A hydrocoele is a fluid collection in the tunica vaginalis that surrounds the testis, making it cystic or fluctuant and indistinguishable from the testis itself. Therefore, this is the correct answer in this situation. Although benign, hydrocoeles can often be caused by testicular tumors, which should be ruled out with an ultrasound scan.

      Testicular tumors would be continuous with the testis, but they may be distinct and irregular in shape. They would not be cystic or transilluminate, but they may also present with a secondary hydrocoele.

      Varicocoeles and epididymal cysts would be separate from the testis during examination.

      Causes and Management of Scrotal Swelling

      Scrotal swelling can be caused by various conditions, including inguinal hernia, testicular tumors, acute epididymo-orchitis, epididymal cysts, hydrocele, testicular torsion, and varicocele. Inguinal hernia is characterized by inguinoscrotal swelling that cannot be examined above it, while testicular tumors often have a discrete testicular nodule and symptoms of metastatic disease. Acute epididymo-orchitis is often accompanied by dysuria and urethral discharge, while epididymal cysts are usually painless and occur in individuals over 40 years old. Hydrocele is a non-painful, soft fluctuant swelling that can be examined above, while testicular torsion is characterized by severe, sudden onset testicular pain and requires urgent surgery. Varicocele is characterized by varicosities of the pampiniform plexus and may affect fertility.

      The management of scrotal swelling depends on the underlying condition. Testicular malignancy is treated with orchidectomy via an inguinal approach, while torsion requires prompt surgical exploration and testicular fixation. Varicoceles are usually managed conservatively, but surgery or radiological management can be considered if there are concerns about testicular function or infertility. Epididymal cysts can be excised using a scrotal approach, while hydroceles are managed differently in children and adults. In children, an inguinal approach is used to ligate the underlying pathology, while in adults, a scrotal approach is preferred to excise or plicate the hydrocele sac.

    • This question is part of the following fields:

      • Surgery
      21.6
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  • Question 40 - A 35-year-old woman who is 30 weeks pregnant presents with malaise, headaches and...

    Incorrect

    • A 35-year-old woman who is 30 weeks pregnant presents with malaise, headaches and vomiting. She is admitted to the obstetrics ward after a routine blood pressure measurement was 190/95 mmHg. Examination reveals right upper quadrant abdominal pain and brisk tendon reflexes. The following blood tests are shown:

      Hb 85 g/l
      WBC 6 * 109/l
      Platelets 89 * 109/l
      Bilirubin 2.8 µmol/l
      ALP 215 u/l
      ALT 260 u/l
      γGT 72 u/l
      LDH 846 u/I

      A peripheral blood film is also taken which shows polychromasia and schistocytes. What is the most likely diagnosis?

      Your Answer: Obstetric cholestasis

      Correct Answer: HELLP syndrome

      Explanation:

      The symptoms of HELLP syndrome, a severe form of pre-eclampsia, include haemolysis (H), elevated liver enzymes (EL), and low platelets (LP). A patient with this condition may experience malaise, nausea, vomiting, and headache, as well as hypertension with proteinuria and epigastric and/or upper abdominal pain. The patient in this case meets the requirements for a diagnosis of HELLP syndrome.

      Liver Complications During Pregnancy

      During pregnancy, there are several liver complications that may arise. One of the most common is intrahepatic cholestasis of pregnancy, which occurs in about 1% of pregnancies and is typically seen in the third trimester. Symptoms include intense itching, especially in the palms and soles, as well as elevated bilirubin levels. Treatment involves the use of ursodeoxycholic acid for relief and weekly liver function tests. Women with this condition are usually induced at 37 weeks to prevent stillbirth, although maternal morbidity is not typically increased.

      Another rare complication is acute fatty liver of pregnancy, which may occur in the third trimester or immediately after delivery. Symptoms include abdominal pain, nausea and vomiting, headache, jaundice, and hypoglycemia. Severe cases may result in pre-eclampsia. ALT levels are typically elevated, and support care is the primary management until delivery can be performed once the patient is stabilized.

      Finally, conditions such as Gilbert’s and Dubin-Johnson syndrome may be exacerbated during pregnancy. Additionally, HELLP syndrome, which stands for haemolysis, elevated liver enzymes, and low platelets, is a serious complication that can occur in the third trimester and requires immediate medical attention. Overall, it is important for pregnant women to be aware of these potential liver complications and to seek medical attention if any symptoms arise.

    • This question is part of the following fields:

      • Obstetrics
      46.3
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  • Question 41 - A 70-year-old man presents to his general practitioner (GP) with complaints of difficulty...

    Correct

    • A 70-year-old man presents to his general practitioner (GP) with complaints of difficulty swallowing. He mentions that solid food like meat often gets stuck in his throat. He is also beginning to lose weight and have difficulty swallowing thick liquids like soups. There is some pain on swallowing. His past medical history is significant for hypertension and depression. His current medications include amlodipine and sertraline. He has no drug allergies. He has a 30-pack-year history of smoking and drinks approximately 3–4 pints of beer per day. He is unsure of his family medical history, as he was adopted.
      Physical examination is normal, and his observations are shown below:
      Temperature 37.1°C
      Blood pressure 145/81 mmHg
      Heart rate 71 bpm
      Respiratory rate 14 breaths/min
      Oxygen saturation (SpO2) 97% (room air)
      Which of the following is the most appropriate investigation for this patient?

      Your Answer: Upper gastrointestinal (GI) endoscopy

      Explanation:

      Diagnostic Tests for Oesophageal Pathology: Indications and Limitations

      Upper gastrointestinal (GI) endoscopy is the preferred diagnostic test for patients with progressive dysphagia and odynophagia, especially those with risk factors for oesophageal malignancy. Abdominal plain film and ultrasound are rarely diagnostic and should be used sparingly, with specific indications such as inflammatory bowel disease or bowel obstruction. Chest plain film may be useful in detecting free gas in the mediastinum, but is not necessary for stable patients. Oesophageal manometry is indicated for diffuse oesophageal spasm, which presents differently from the progressive dysphagia seen in the patient described above.

    • This question is part of the following fields:

      • Gastroenterology
      39.3
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  • Question 42 - A 7-month-old baby weighing 8.5 kg has been admitted to the hospital due...

    Correct

    • A 7-month-old baby weighing 8.5 kg has been admitted to the hospital due to a respiratory infection. The doctor has prescribed an intravenous antibiotic for the baby. The loading dose recommended is 3 mg/kg, and the maintenance dose is 0.75 mg/kg to be given every 12 hours. What is the correct dosing regimen to prescribe for this baby?

      Your Answer: Loading dose of 24 mg, maintenance dose of 6 mg 12 hourly

      Explanation:

      Importance of Body Weight and Dosing Interval in Drug Prescription

      Many drugs require prescription based on body weight, especially in paediatrics. The initial dose, known as the loading dose, is calculated based on the weight of the patient. The maintenance dose is then determined and given at regular intervals to prevent total elimination of the drug from the body. Most drugs follow first order kinetics, meaning that their clearance rate is determined by their half-life. If the half-life of a drug is short, dosing must be frequent to maintain therapeutic concentrations in the blood.

      In some cases, such as in the treatment of infections, it is crucial to achieve therapeutic concentrations of the drug as soon as possible to maximize efficacy and prevent bacterial resistance. This may require the use of a loading dose to quickly attain high concentrations of the drug. The timing of dosing intervals is also important in maintaining therapeutic concentrations. Overall, the importance of body weight and dosing intervals in drug prescription is crucial for achieving optimal treatment outcomes.

    • This question is part of the following fields:

      • Pharmacology
      74.6
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  • Question 43 - A 50-year-old man, who had surgery for a bowel tumour 4 days ago,...

    Correct

    • A 50-year-old man, who had surgery for a bowel tumour 4 days ago, is now experiencing shortness of breath.
      What is the most probable diagnosis?

      Your Answer: Pulmonary embolism

      Explanation:

      Differential diagnosis of breathlessness after major surgery

      Breathlessness is a common symptom after major surgery, and its differential diagnosis includes several potentially serious conditions. Among them, pulmonary embolism is a frequent and life-threatening complication that can be prevented with appropriate measures. These include the use of thromboembolic deterrent stockings, pneumatic calf compression, and low-molecular-weight heparin at prophylactic doses. Other risk factors for pulmonary embolism in this setting include recent surgery, immobility, and active malignancy. Computed tomography pulmonary angiogram is the preferred test to confirm a clinical suspicion of pulmonary embolism.

      Acute bronchitis is another possible cause of post-operative chest infections, but in this case, the history suggests a higher likelihood of pulmonary embolism, which should be investigated promptly. A massive pulmonary embolism is the most common preventable cause of death in hospitalized, bed-bound patients.

      Myocardial infarction is less likely to present with breathlessness as the main symptom, as chest pain is more typical. Pulmonary edema can also cause breathlessness, but in this case, the risk factors for pulmonary embolism make it a more plausible diagnosis.

      Surgical emphysema, which is the accumulation of air in the subcutaneous tissues, is an unlikely diagnosis in this case, as it usually results from penetrating trauma and does not typically cause breathlessness.

    • This question is part of the following fields:

      • Surgery
      15.9
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  • Question 44 - A 27-year-old nulliparous woman presents to the Emergency Department with severe nausea and...

    Incorrect

    • A 27-year-old nulliparous woman presents to the Emergency Department with severe nausea and vomiting, as well as a 3-hour history of spotting. Her last menstrual period was approximately ten weeks ago. She denies any abdominal pain, focal neurological deficits and headaches. She has had normal cervical screening results, denies any history of sexually transmitted infections and had her Mirena® coil removed one year ago. She has been having regular unprotected sex with a new partner for the past month. Her menstrual cycle length is normally 28 days, for which her period lasts five days, without bleeding in between periods.
      She reports being previously fit and well, without regular medication. She is a non-smoker and drinks heavily once a week.
      On examination, her heart rate is 81 bpm, blood pressure 115/80 mmHg and temperature 37.2 °C, and her fundal height was consistent with a 16-week-old pregnancy. A bimanual examination with a speculum revealed a closed cervical os. A full blood count reveals all normal results. A human chorionic gonadotrophin (hCG) level and a vaginal ultrasound scan are also carried out in the department, which reveal the following:
      Serum hCG:
      Investigation Result Impression
      hCG 100,295 iu/l Grossly elevated
      Transvaginal ultrasound:
      Comment Anteverted, enlarged uterus. No fetal parts observed. Intrauterine mass with cystic components observed
      What is the most likely diagnosis for this patient?

      Your Answer: Complete miscarriage

      Correct Answer: Hydatidiform mole

      Explanation:

      Diagnosis of Hydatidiform Mole in Early Pregnancy: Clinical Features and Treatment Options

      Hydatidiform mole is a type of gestational trophoblastic disease that occurs due to abnormal fertilization of an ovum, resulting in a non-viable pregnancy. The condition presents with clinical features such as vaginal bleeding, excessive vomiting, a large-for-dates uterus, and a very high hCG level. Pelvic ultrasound may reveal a ‘snowstorm’ appearance from the intrauterine mass and cystic components.

      The diagnosis of hydatidiform mole is crucial as it determines the treatment options. If the patient wishes to retain her fertility, dilation and evacuation are offered. However, if fertility is not desired, a hysterectomy is recommended. The former has fewer post-operative complications but carries a higher risk of post-operative gestational trophoblastic neoplasia. Antiemetics are prescribed to manage nausea and vomiting.

      Twin pregnancy and complete miscarriage are differential diagnoses, but the absence of fetal parts and the grossly elevated hCG level point towards hydatidiform mole. Pre-eclampsia cannot be diagnosed before the second trimester, and endometrial carcinoma is unlikely to cause a uterine mass or elevated hCG levels.

      In conclusion, early diagnosis of hydatidiform mole is crucial for appropriate management and prevention of complications.

    • This question is part of the following fields:

      • Gynaecology
      47.8
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  • Question 45 - A 83-year-old woman presents with urinary frequency and dysuria. She reports that her...

    Correct

    • A 83-year-old woman presents with urinary frequency and dysuria. She reports that her urine appears bubbly. Over the past year, she has been treated for UTI five times. Her medical history includes hypertension, which is managed with amlodipine. On examination, she has mild suprapubic tenderness but no other significant findings. Her vital signs are heart rate 88/min, blood pressure 128/84 mmHg, respiratory rate 22/min, temperature 37.3ºC, and saturation 93%. A urine dipstick reveals the following: Blood +, Protein +, Leucocytes ++, Nitrites ++. What is the most likely diagnosis?

      Your Answer: Enterovesical fistula

      Explanation:

      The presence of bubbly urine in a woman with recurrent UTIs may indicate an enterovesical fistula, which is a connection between the bowel and bladder. This condition is often associated with colorectal cancer, as suggested by the patient’s tissue wasting. It is important to investigate this possibility. There are no symptoms of pyelonephritis or bladder stones, which would not cause gas in the urine. While the patient’s wasting could be a sign of malignancy, there is no indication that it is endometrial cancer, which typically presents with postmenopausal bleeding. The most common organism in UTIs is E. coli, which is a facultative anaerobe and does not produce large amounts of gas.

      Fistulas are abnormal connections between two epithelial surfaces, with the majority arising from diverticular disease and Crohn’s in the abdominal cavity. They can be enterocutaneous, enteroenteric or enterocolic, enterovaginal, or enterovesicular. Conservative measures may be the best option for management, but high output fistulas may require octreotide and TPN for nutritional support. Surgeons should avoid probing perianal fistulae with acute inflammation and use setons for those secondary to Crohn’s disease. It is important to delineate the fistula anatomy using barium and CT studies for intraabdominal sources and recalling Goodsall’s rule for perianal fistulae.

    • This question is part of the following fields:

      • Surgery
      92
      Seconds
  • Question 46 - A 39-year-old male with a history of alcoholism was admitted to the hospital...

    Incorrect

    • A 39-year-old male with a history of alcoholism was admitted to the hospital with jaundice and altered consciousness. He had been previously admitted for ascites and jaundice. Upon investigation, his bilirubin levels were found to be 44 µmol/L (5.1-22), serum albumin levels were 28 g/L (40-50), and his prothrombin time was 21 seconds (13 seconds). The patient had a fluid thrill in his abdomen and exhibited asterixis. Although he was awake, he was unable to distinguish between day and night. What is the patient's Child-Pugh score (CTP)?

      Your Answer: 5

      Correct Answer: 12

      Explanation:

      The Child-Turcotte-Pugh score (CTP) is used to assess disease severity in cirrhosis of liver. It consists of five clinical measures, each scored from 1 to 3 according to severity. The minimum score is 5 and maximum score is 15. Once a score has been calculated, the patient is graded A, B, or C for severity. The CTP score is primarily used to decide the need for liver transplantation. However, some criticisms of this scoring system highlight the fact that each of the five categories is given equal weighting, which is not always appropriate. Additionally, in two specific diseases, primary sclerosing cholangitis (PSC) and primary biliary cirrhosis (PBC), the bilirubin cut-off levels in the table are markedly different.

    • This question is part of the following fields:

      • Gastroenterology
      8.2
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  • Question 47 - An 82-year-old woman is brought to the Emergency Department after experiencing a sudden...

    Incorrect

    • An 82-year-old woman is brought to the Emergency Department after experiencing a sudden loss of consciousness while shopping. Upon examination, she is fully alert and appears to be in good health.
      Her temperature is normal, and her blood glucose level is 5.8 mmol/l. Her cardiovascular system shows an irregular heart rate of 89 beats per minute with low volume, and her blood pressure is 145/120 mmHg while lying down and standing up. Her jugular venous pressure is not elevated, and her apex beat is forceful but undisplaced. Heart sounds include a soft S2 and a soft ejection systolic murmur that is loudest in the right second intercostal space, with a possible fourth heart sound heard. Her chest reveals occasional bibasal crackles that clear with coughing, and there is no peripheral edema. Based on these clinical findings, what is the most likely cause of her collapse?

      Your Answer: Mixed mitral and aortic valve disease

      Correct Answer: Aortic stenosis

      Explanation:

      Clinical Presentation of Aortic Stenosis

      Aortic stenosis is a condition that presents with symptoms of left ventricular failure, angina, and potential collapse or blackout if the stenosis is critical. A patient with significant aortic stenosis may exhibit several clinical signs, including a low-volume pulse, narrow pulse pressure, slow-rising carotid pulse, undisplaced sustained/forceful apex beat, soft or absent A2, ejection systolic murmur with a fourth heart sound, and pulmonary edema.

      It is important to note that aortic regurgitation would not cause the same examination findings as aortic stenosis. Aortic regurgitation typically presents with an early diastolic murmur and a collapsing pulse. Similarly, mixed mitral and aortic valve disease would not be evident in this clinical scenario, nor would mitral stenosis or mitral regurgitation. These conditions have distinct clinical presentations and diagnostic criteria.

    • This question is part of the following fields:

      • Cardiology
      66
      Seconds
  • Question 48 - A 30-year-old female complains of pain on the radial side of her wrist...

    Correct

    • A 30-year-old female complains of pain on the radial side of her wrist and tenderness over the radial styloid process. During examination, she experiences pain when she abducts her thumb against resistance. Additionally, when she flexes her thumb across the palm of her hand, pain is reproduced by movement of the wrist into flexion and ulnar deviation. What condition is most likely causing these symptoms?

      Your Answer: De Quervain's tenosynovitis

      Explanation:

      The described test is the Finkelstein test, which is used to diagnose De Quervain’s tenosynovitis. This condition causes pain over the radial styloid process due to inflammation of the sheath containing the extensor pollicis brevis and abductor pollicis longus tendons. Option 1 is incorrect as the test is not Tinel’s sign, which is used to diagnose carpal tunnel syndrome. Option 3 is incorrect as polymyalgia rheumatica typically presents with pain in the shoulder and pelvic muscle girdles but with normal power. Option 4 is incorrect as rheumatoid arthritis usually presents with pain in the metacarpophalangeal joints (MCP) and the proximal interphalangeal joints (PIP). Option 5 is also incorrect.

      De Quervain’s Tenosynovitis: Symptoms, Diagnosis, and Treatment

      De Quervain’s tenosynovitis is a condition that commonly affects women between the ages of 30 and 50. It occurs when the sheath containing the extensor pollicis brevis and abductor pollicis longus tendons becomes inflamed. The condition is characterized by pain on the radial side of the wrist, tenderness over the radial styloid process, and pain when the thumb is abducted against resistance. A positive Finkelstein’s test, in which the thumb is pulled in ulnar deviation and longitudinal traction, can also indicate the presence of tenosynovitis.

      Treatment for De Quervain’s tenosynovitis typically involves analgesia, steroid injections, and immobilization with a thumb splint (spica). In some cases, surgical treatment may be necessary. With proper diagnosis and treatment, most patients are able to recover from this condition and resume their normal activities.

    • This question is part of the following fields:

      • Musculoskeletal
      6.4
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  • Question 49 - A child is born at 28 weeks gestation and is transferred to the...

    Correct

    • A child is born at 28 weeks gestation and is transferred to the neonatal unit. After a few hours, the child shows signs of nasal flaring, chest wall indrawing, and appears to have jaundice. The observations show a heart rate of 75/min, a respiratory rate of 68/min, and a temperature of 38.2ºC. What is the most common organism responsible for the probable diagnosis?

      Your Answer: Group B streptococcus

      Explanation:

      The leading cause of early-onset neonatal sepsis in the UK is infection by group B streptococcus.

      Neonatal Sepsis: Causes, Risk Factors, and Management

      Neonatal sepsis is a serious bacterial or viral infection in the blood that affects babies within the first 28 days of life. It is categorized into early-onset (EOS) and late-onset (LOS) sepsis, with each category having distinct causes and common presentations. The most common causes of neonatal sepsis are group B streptococcus (GBS) and Escherichia coli, accounting for approximately two-thirds of cases. Premature and low birth weight babies are at higher risk, as well as those born to mothers with GBS colonization or infection during pregnancy. Symptoms can vary from subtle signs of illness to clear septic shock, and diagnosis is usually established through blood culture. Treatment involves early identification and use of intravenous antibiotics, with duration depending on ongoing investigations and clinical picture. Other important management factors include maintaining adequate oxygenation and fluid and electrolyte status.

      Neonatal Sepsis: Causes, Risk Factors, and Management

      Neonatal sepsis is a serious infection that affects newborn babies within the first 28 days of life. It can be caused by a variety of bacteria and viruses, with GBS and E. coli being the most common. Premature and low birth weight babies, as well as those born to mothers with GBS colonization or infection during pregnancy, are at higher risk. Symptoms can range from subtle signs of illness to clear septic shock, and diagnosis is usually established through blood culture. Treatment involves early identification and use of intravenous antibiotics, with duration depending on ongoing investigations and clinical picture. Other important management factors include maintaining adequate oxygenation and fluid and electrolyte status.

    • This question is part of the following fields:

      • Paediatrics
      14.8
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  • Question 50 - A morbidly obese 32-year-old man presents to his General Practitioner for review. His...

    Correct

    • A morbidly obese 32-year-old man presents to his General Practitioner for review. His main reason for attendance is that his wife is concerned about his loud snoring and the fact that he stops breathing during the night for periods of up to 8–10 seconds, followed by coughing, snoring or waking. Recently he has become hypertensive and is also on treatment for impotence. His 24-hour urinary free cortisol level is normal.
      Which diagnosis best fits this picture?

      Your Answer: Obstructive sleep apnoea

      Explanation:

      Distinguishing Between Obstructive Sleep Apnoea and Other Conditions

      Obstructive sleep apnoea (OSA) is a common sleep disorder that can have significant impacts on a person’s health and well-being. Symptoms of OSA include memory impairment, daytime somnolence, disrupted sleep patterns, decreased libido, and systemic hypertension. When investigating potential causes of these symptoms, it is important to rule out other conditions that may contribute to or mimic OSA.

      For example, thyroid function testing should be conducted to rule out hypothyroidism, and the uvula and tonsils should be assessed for mechanical obstruction that may be treatable with surgery. Diagnosis of OSA is typically made using overnight oximetry. The mainstay of management for OSA is weight loss, along with the use of continuous positive airway pressure (CPAP) ventilation during sleep.

      When considering potential diagnoses for a patient with symptoms of OSA, it is important to distinguish between other conditions that may contribute to or mimic OSA. For example, Cushing’s disease can be identified through elevated 24-hour urinary free cortisol levels. Essential hypertension may contribute to OSA, but it does not fully explain the symptoms described. Simple obesity may be a contributing factor, but it does not account for the full clinical picture. Finally, simple snoring can be ruled out if apnoeic episodes are present. By carefully considering all potential diagnoses, healthcare providers can provide the most effective treatment for patients with OSA.

    • This question is part of the following fields:

      • Respiratory
      15.8
      Seconds
  • Question 51 - A 30-year-old woman who was born and lives in England has received her...

    Incorrect

    • A 30-year-old woman who was born and lives in England has received her invitation to attend for her first cervical screening test. She has read the leaflet and has some questions regarding the population targeted for cervical screening.
      Which of the following statements best applies to the cervical screening programme?

      Your Answer: Cervical screening is offered to women aged 25–64 every five years

      Correct Answer: Cervical screening is offered to women aged 50–64 every five years

      Explanation:

      Understanding Cervical Screening: Guidelines and Options

      Cervical screening, also known as a smear test, is a vital tool in detecting precancerous cell changes in the cervix and preventing cervical cancer. Here are some important guidelines and options to keep in mind:

      Age and Frequency: In the UK, women aged 25-64 are invited for screening, with those aged 25-49 screened every three years and those aged 50-64 screened every five years. In Scotland, screening is recommended every five years for women aged 25-65.

      Hysterectomy: Women who have had a total hysterectomy (removal of the uterus and cervix) do not require cervical screening. However, those who have had a partial hysterectomy (removal of the uterus but not the cervix) should continue to be screened according to age guidelines.

      Age Limit: Women over the age of 65 may still be eligible for screening if they have had recent abnormal results or have not been screened since the age of 50.

      Opting Out: While cervical screening is not obligatory, it is highly recommended. Patients can opt out by speaking to their doctor and signing an ‘opting out’ form, but this decision can be reversed at any time. It is important to understand the benefits and risks associated with screening before making a decision.

    • This question is part of the following fields:

      • Gynaecology
      26.3
      Seconds
  • Question 52 - A 76-year-old man with heart failure and depression is discovered to have a...

    Incorrect

    • A 76-year-old man with heart failure and depression is discovered to have a sodium level of 130. He is not experiencing any symptoms, and his heart failure and depression are under control. He has slight pitting pedal oedema. He is currently taking ramipril, bisoprolol, simvastatin and citalopram.
      What is the optimal approach to managing this patient?

      Your Answer: Advise him to increase his salt intake

      Correct Answer: Restrict his fluid input to 1.5 l/day and recheck in 3 days

      Explanation:

      Managing Hyponatraemia: Considerations and Options

      Hyponatraemia, a condition characterized by low serum sodium levels, requires careful management to avoid potential complications. The first step in treating hyponatraemia is to restrict fluid intake to reverse any dilution and address the underlying cause. Administering saline should only be considered if fluid restriction fails, as treating hyponatraemia too quickly can lead to central pontine myelinolysis.

      In cases where hyponatraemia is caused by medication, such as selective serotonin reuptake inhibitors (SSRIs), it may be necessary to adjust or discontinue the medication. However, abrupt discontinuation of SSRIs can cause withdrawal symptoms, so patients should be gradually weaned off over several weeks or months.

      It is also important to consider other factors that may contribute to hyponatraemia, such as heart failure or hypokalaemia. However, administering intravenous saline or increasing salt intake may not be appropriate in all cases and could worsen underlying conditions.

      Overall, managing hyponatraemia requires careful consideration of the underlying cause and potential treatment options to avoid complications and promote optimal patient outcomes.

    • This question is part of the following fields:

      • Cardiology
      91.9
      Seconds
  • Question 53 - A 78-year-old woman visits her GP with a complaint of gradual loss of...

    Incorrect

    • A 78-year-old woman visits her GP with a complaint of gradual loss of peripheral vision over the past 4 months and a decline in overall visual acuity. She reports experiencing tunnel vision. The patient has a medical history of hypertension and type 2 diabetes mellitus and wears corrective glasses for her myopia. Upon fundoscopy, the doctor observes optic disc cupping and hemorrhages. What is the probable diagnosis?

      Your Answer: Diabetic retinopathy

      Correct Answer: Primary open-angle glaucoma

      Explanation:

      The main effect of glaucoma is the development of defects in the visual field.

      Glaucoma is a condition where the optic nerve is damaged due to increased pressure in the eye. Primary open-angle glaucoma (POAG) is a type of glaucoma where the peripheral iris is clear of the trabecular meshwork, which is important in draining aqueous humour from the eye. POAG is more common in older individuals and those with a family history of the condition. It may present insidiously with symptoms such as peripheral visual field loss, decreased visual acuity, and optic disc cupping. Diagnosis is made through a series of investigations including automated perimetry, slit lamp examination, applanation tonometry, central corneal thickness measurement, and gonioscopy. It is important to assess the risk of future visual impairment based on factors such as IOP, CCT, family history, and life expectancy. Referral to an ophthalmologist is typically done through a GP.

    • This question is part of the following fields:

      • Ophthalmology
      12.1
      Seconds
  • Question 54 - A 36-year-old woman with a history of Von Willebrand disease underwent a left...

    Incorrect

    • A 36-year-old woman with a history of Von Willebrand disease underwent a left knee arthroscopy and screw removal with epidural anesthesia. The epidural space was identified at L3-L4 and local anesthetic was administered. During the operation, the patient experienced sensory block to temperature up to the T10 dermatome. After the procedure, the patient was comfortable and the block resolved completely after 2 hours. However, 2 hours later, the patient complained of severe back pain and exhibited 3/5 power in all muscle groups of the right leg, absent right patellar reflex, and reduced sensation to light touch in the right leg.

      What complication of epidural anesthesia is likely to be demonstrated in this case?

      Your Answer: Direct spinal cord injury from the procedure

      Correct Answer: Spinal epidural haematoma

      Explanation:

      One potential complication of epidural anesthesia is the development of a spinal epidural hematoma, which occurs when blood accumulates in the spinal epidural space and compresses the spinal cord. The symptoms experienced by the patient will depend on the location of the hematoma, but typically include a combination of severe back pain and neurological deficits. The patient’s coagulopathy, in this case Von-Willebrand disease, increases the risk of developing this complication.

      Local anesthetic toxicity is another potential complication, which occurs when the anesthetic is accidentally injected into a blood vessel. This can cause a range of symptoms, including numbness around the mouth, restlessness, tinnitus, shivering, muscle twitching, and convulsions. However, none of these symptoms are present in this case.

      Direct spinal cord injury would typically result in immediate symptoms during the procedure, which is not the case here.

      Guillain-Barre syndrome is an acute inflammatory demyelinating polyneuropathy that is often preceded by an infection. It typically presents with sensory symptoms that precede motor symptoms.

      While spinal epidural abscess is a possibility, symptoms usually develop over a longer period of time. Given the patient’s coagulopathy, a hematoma is the most likely explanation for their symptoms.

      Pain management can be achieved through various methods, including the use of analgesic drugs and local anesthetics. The World Health Organisation (WHO) recommends a stepwise approach to pain management, starting with peripherally acting drugs such as paracetamol or non-steroidal anti-inflammatory drugs (NSAIDs). If pain control is not achieved, weak opioid drugs such as codeine or dextropropoxyphene can be introduced, followed by strong opioids such as morphine as a final option. Local anesthetics can also be used to provide pain relief, either through infiltration of a wound or blockade of plexuses or peripheral nerves.

      For acute pain management, the World Federation of Societies of Anaesthesiologists (WFSA) recommends a similar approach, starting with strong analgesics in combination with local anesthetic blocks and peripherally acting drugs. The use of strong opioids may no longer be required once the oral route can be used to deliver analgesia, and peripherally acting agents and weak opioids can be used instead. The final step is when pain can be controlled by peripherally acting agents alone.

      Local anesthetics can be administered through infiltration of a wound with a long-acting agent such as Bupivacaine, providing several hours of pain relief. Blockade of plexuses or peripheral nerves can also provide selective analgesia, either for surgery or postoperative pain relief. Spinal and epidural anesthesia are other options, with spinal anesthesia providing excellent analgesia for lower body surgery and epidural anesthesia providing continuous infusion of analgesic agents. Transversus Abdominis Plane block (TAP) is a technique that uses ultrasound to identify the correct muscle plane and injects local anesthetic to block spinal nerves, providing a wide field of blockade without the need for indwelling devices.

      Patient Controlled Analgesia (PCA) allows patients to administer their own intravenous analgesia and titrate the dose to their own end-point of pain relief using a microprocessor-controlled pump. Opioids such as morphine and pethidine are commonly used, but caution is advised due to potential side effects and toxicity. Non-opioid analgesics such as paracetamol and NSAIDs can also be used, with NSAIDs being more useful for superficial pain and having relative contraindications for certain medical conditions.

    • This question is part of the following fields:

      • Pharmacology
      27.3
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  • Question 55 - A 33-year-old woman who is at 36 weeks gestation comes to the maternity...

    Incorrect

    • A 33-year-old woman who is at 36 weeks gestation comes to the maternity unit for a routine check-up. Her pregnancy has been without any complications so far, and her blood pressure, urine dipstick, and fundal height are all normal. During a previous examination, a vertical scar from her previous pregnancy is visible on her abdomen, as the child was delivered via a caesarean section. She wants to discuss her delivery options and is interested in having a home birth. What is the most suitable delivery method for this patient?

      Your Answer: Vaginal delivery in hospital

      Correct Answer: Planned caesarean section at 37 weeks gestation

      Explanation:

      A planned caesarean section at 37 weeks gestation is the appropriate course of action for a patient who has a classical caesarean scar. This type of scar, which is characterized by a vertical incision on the abdomen, is a contraindication for vaginal birth after caesarean due to the increased risk of uterine rupture. A vaginal delivery should not be considered in this scenario as it could be potentially fatal for both the mother and the baby. It is important to ensure that the caesarean section is performed in a hospital setting. A caesarean section at 36 weeks is not recommended, and guidelines suggest that the procedure should be performed at 37 weeks or later.

      Caesarean Section: Types, Indications, and Risks

      Caesarean section, also known as C-section, is a surgical procedure that involves delivering a baby through an incision in the mother’s abdomen and uterus. In recent years, the rate of C-section has increased significantly due to an increased fear of litigation. There are two main types of C-section: lower segment C-section, which comprises 99% of cases, and classic C-section, which involves a longitudinal incision in the upper segment of the uterus.

      C-section may be indicated for various reasons, including absolute cephalopelvic disproportion, placenta praevia grades 3/4, pre-eclampsia, post-maturity, IUGR, fetal distress in labor/prolapsed cord, failure of labor to progress, malpresentations, placental abruption, vaginal infection, and cervical cancer. The urgency of C-section may be categorized into four categories, with Category 1 being the most urgent and Category 4 being elective.

      It is important for clinicians to inform women of the serious and frequent risks associated with C-section, including emergency hysterectomy, need for further surgery, admission to intensive care unit, thromboembolic disease, bladder injury, ureteric injury, and death. C-section may also increase the risk of uterine rupture, antepartum stillbirth, placenta praevia, and placenta accreta in subsequent pregnancies. Other complications may include persistent wound and abdominal discomfort, increased risk of repeat C-section, readmission to hospital, haemorrhage, infection, and fetal lacerations.

      Vaginal birth after C-section (VBAC) may be an appropriate method of delivery for pregnant women with a single previous C-section delivery, except for those with previous uterine rupture or classical C-section scar. The success rate of VBAC is around 70-75%.

    • This question is part of the following fields:

      • Obstetrics
      21.7
      Seconds
  • Question 56 - A 45-year-old woman presents to the rheumatology clinic with a 4-month history of...

    Correct

    • A 45-year-old woman presents to the rheumatology clinic with a 4-month history of myalgia and widespread bony tenderness. She reports increased fatigue and weakness when lifting heavy objects. Her medical history includes coeliac disease.

      During the examination, tenderness is noted over the shoulder girdle and arms, but there is no associated joint stiffness. The patient has a waddling gait.

      Blood tests are ordered and reveal the following results:
      - Calcium: 1.9 mmol/L (normal range: 2.1 - 2.6)
      - Phosphate: 0.8 mmol/L (normal range: 0.8 - 1.4)
      - ALP: 176 u/L (normal range: 30 - 100)

      What is the most likely diagnosis?

      Your Answer: Osteomalacia

      Explanation:

      The correct diagnosis for a patient presenting with bone pain, muscle tenderness, and a waddling gait due to proximal myopathy is osteomalacia. This condition is caused by a demineralization of bone, often due to a deficiency in vitamin D. Laboratory tests may reveal hypocalcemia, low vitamin D levels, normal or elevated phosphate levels, and elevated alkaline phosphatase. Myositis, myotonic dystrophy, and osteoporosis are incorrect diagnoses as they do not present with the same symptoms or laboratory findings.

      Understanding Osteomalacia

      Osteomalacia is a condition that occurs when the bones become soft due to low levels of vitamin D, which leads to a decrease in bone mineral content. This condition is commonly seen in adults, while in growing children, it is referred to as rickets. The causes of osteomalacia include vitamin D deficiency, malabsorption, lack of sunlight, chronic kidney disease, drug-induced factors, inherited conditions, liver disease, and coeliac disease.

      The symptoms of osteomalacia include bone pain, muscle tenderness, fractures, especially in the femoral neck, and proximal myopathy, which may lead to a waddling gait. To diagnose osteomalacia, blood tests are conducted to check for low vitamin D levels, low calcium and phosphate levels, and raised alkaline phosphatase levels. X-rays may also show translucent bands known as Looser’s zones or pseudofractures.

      The treatment for osteomalacia involves vitamin D supplementation, with a loading dose often needed initially. Calcium supplementation may also be necessary if dietary calcium intake is inadequate. Understanding the causes, symptoms, and treatment options for osteomalacia is crucial in managing this condition effectively.

    • This question is part of the following fields:

      • Musculoskeletal
      23.5
      Seconds
  • Question 57 - A 67-year-old woman comes to her GP complaining of abdominal discomfort and bloating...

    Incorrect

    • A 67-year-old woman comes to her GP complaining of abdominal discomfort and bloating that has persisted for six months. The GP initially suspected bowel cancer and referred her for a colonoscopy, which came back negative. The gastroenterologist who performed the colonoscopy suggested that the patient may have irritable bowel syndrome. The patient has no prior history of digestive issues. What should the GP do next?

      Your Answer: Refer directly to gynaecology

      Correct Answer: Measure serum CA125 level

      Explanation:

      According to NICE guidelines, women over the age of 50 who experience regular symptoms such as abdominal bloating, loss of appetite, pelvic or abdominal pain, and increased urinary urgency and/or frequency should undergo serum CA125 testing. It is important to note that irritable bowel disease rarely presents for the first time in women over 50, so any symptoms suggestive of IBD should prompt appropriate tests for ovarian cancer. If serum CA125 levels are elevated, an ultrasound of the abdomen and pelvis should be arranged. If malignancy is suspected, urgent referral must be made. Physical examination may also warrant direct referral to gynaecology if ascites and/or a suspicious abdominal or pelvic mass is identified.

      Ovarian cancer is a common malignancy in women, ranking fifth in frequency. It is most commonly diagnosed in women over the age of 60 and has a poor prognosis due to late detection. The majority of ovarian cancers, around 90%, are of epithelial origin, with serous carcinomas accounting for 70-80% of cases. Interestingly, recent research suggests that many ovarian cancers may actually originate in the distal end of the fallopian tube. Risk factors for ovarian cancer include a family history of BRCA1 or BRCA2 gene mutations, early menarche, late menopause, and nulliparity.

      Clinical features of ovarian cancer are often vague and can include abdominal distension and bloating, abdominal and pelvic pain, urinary symptoms such as urgency, early satiety, and diarrhea. The initial diagnostic test recommended by NICE is a CA125 blood test, although this can also be elevated in other conditions such as endometriosis and benign ovarian cysts. If the CA125 level is raised, an urgent ultrasound scan of the abdomen and pelvis should be ordered. However, a CA125 test should not be used for screening asymptomatic women. Diagnosis of ovarian cancer is difficult and usually requires a diagnostic laparotomy.

      Management of ovarian cancer typically involves a combination of surgery and platinum-based chemotherapy. Unfortunately, 80% of women have advanced disease at the time of diagnosis, leading to a 5-year survival rate of only 46%. It was previously thought that infertility treatment increased the risk of ovarian cancer due to increased ovulation, but recent evidence suggests that this is not a significant factor. In fact, the combined oral contraceptive pill and multiple pregnancies have been shown to reduce the risk of ovarian cancer by reducing the number of ovulations.

    • This question is part of the following fields:

      • Gastroenterology
      52.9
      Seconds
  • Question 58 - A 38-year-old man presents with a history of poor health for several months...

    Incorrect

    • A 38-year-old man presents with a history of poor health for several months and is subsequently diagnosed with syphilis. During the physical examination, it is observed that he has small pupils on both sides that are able to accommodate but do not react to light. What is the probable diagnosis?

      Your Answer: Internuclear ophthalmoplegia

      Correct Answer: Argyll-Robertson pupil

      Explanation:

      Argyll-Robertson Pupil: A Classic Pupillary Syndrome

      The Argyll-Robertson Pupil (ARP) is a classic pupillary syndrome that is sometimes observed in neurosyphilis. It is characterized by small, irregular pupils that do not respond to light but do respond to accommodation. A useful mnemonic for remembering this syndrome is Accommodation Reflex Present (ARP) but Pupillary Reflex Absent (PRA).

      The ARP can be caused by various factors, including diabetes mellitus and syphilis. It is important to note that the presence of an ARP may indicate underlying neurological or systemic disease and should prompt further evaluation and management. Proper diagnosis and treatment of the underlying condition can help prevent further complications and improve patient outcomes.

    • This question is part of the following fields:

      • Ophthalmology
      19.1
      Seconds
  • Question 59 - A 10-week-old girl has been brought to the emergency department by her father....

    Incorrect

    • A 10-week-old girl has been brought to the emergency department by her father. He noticed this morning that she was very drowsy and not feeding very much. When he measured her temperature it was 38.5ºC. She was born at 37 weeks gestation with an uncomplicated delivery. There is no past medical history or family history and she does not require any regular medications.

      On examination she is lethargic but responds to voice by opening her eyes. She is mildly hypotonic and febrile. There is a non-blanching rash on her torso that her father says was not there this morning.

      What is the most appropriate management?

      Your Answer: IV ceftriaxone

      Correct Answer: IV amoxicillin + IV cefotaxime

      Explanation:

      Investigation and Management of Meningitis in Children

      Meningitis is a serious condition that can affect children. When investigating meningitis, it is important to note any contraindications to lumbar puncture, such as signs of raised intracranial pressure, focal neurological signs, papilloedema, significant bulging of the fontanelle, disseminated intravascular coagulation, or signs of cerebral herniation. For patients with meningococcal septicaemia, a lumbar puncture is contraindicated, and blood cultures and PCR for meningococcal should be obtained instead.

      The management of meningitis in children involves administering antibiotics, such as IV amoxicillin (or ampicillin) and IV cefotaxime for children under three months, and IV cefotaxime (or ceftriaxone) for children over three months. Steroids should be considered if the lumbar puncture reveals certain findings, such as purulent cerebrospinal fluid, a high white blood cell count, or bacteria on Gram stain. Fluids should be administered to treat shock, and cerebral monitoring should be conducted, including mechanical ventilation if necessary.

      It is also important to notify public health authorities and administer antibiotic prophylaxis to contacts. Ciprofloxacin is now preferred over rifampicin for this purpose. Overall, prompt and appropriate management of meningitis in children is crucial for ensuring the best possible outcomes.

    • This question is part of the following fields:

      • Paediatrics
      28.3
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  • Question 60 - A 60-year-old man visits his GP complaining of hand pain that worsens with...

    Correct

    • A 60-year-old man visits his GP complaining of hand pain that worsens with activity and towards the end of the day. He has a medical history of psoriasis and is not currently taking any medications. During the examination, the doctor notes tender bony swellings in three DIP joints on both hands. What is the probable diagnosis?

      Your Answer: Osteoarthritis

      Explanation:

      The presence of Heberden’s nodes, which are bony swellings at the DIP joints, is a characteristic feature of osteoarthritis in the hand. Pain that worsens with activity, rather than rest, is also more indicative of OA than inflammatory arthritis. Psoriatic arthritis can cause swelling of the DIP joints, but the swelling is typically boggy rather than bony, and the pain tends to be worse in the morning and improve with activity. Reactive arthritis is unlikely to cause a DIP predominant arthritis, as it typically presents as a large joint lower limb oligoarthritis, and there is no recent history of infection. Rheumatoid arthritis does not typically affect the DIP joints.

      Understanding Osteoarthritis of the Hand

      Osteoarthritis of the hand, also known as nodal arthritis, is a condition that occurs when the cartilage at synovial joints is lost, leading to the degeneration of underlying bone. It is more common in women, usually presenting after the age of 55, and may have a genetic component. Risk factors include previous joint trauma, obesity, hypermobility, and certain occupations. Interestingly, osteoporosis may actually reduce the risk of developing hand OA.

      Symptoms of hand OA include episodic joint pain, stiffness that worsens after periods of inactivity, and the development of painless bony swellings known as Heberden’s and Bouchard’s nodes. These nodes are the result of osteophyte formation and are typically found at the distal and proximal interphalangeal joints, respectively. In severe cases, there may be reduced grip strength and deformity of the carpometacarpal joint of the thumb, resulting in fixed adduction.

      Diagnosis is typically made through X-ray, which may show signs of osteophyte formation and joint space narrowing before symptoms develop. While hand OA may not significantly impact a patient’s daily function, it is important to manage symptoms through pain relief and joint protection strategies. Additionally, the presence of hand OA may increase the risk of future hip and knee OA, particularly for hip OA.

    • This question is part of the following fields:

      • Musculoskeletal
      16.2
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SESSION STATS - PERFORMANCE PER SPECIALTY

Genetics (0/1) 0%
Infectious Diseases (0/1) 0%
Musculoskeletal (4/5) 80%
Gynaecology (1/6) 17%
Ophthalmology (3/5) 60%
Statistics (0/1) 0%
Surgery (5/8) 63%
Paediatrics (2/5) 40%
Clinical Biochemistry (1/1) 100%
Endocrinology (0/2) 0%
Gastroenterology (2/4) 50%
Dermatology (1/2) 50%
Pharmacology (4/5) 80%
Nephrology (1/1) 100%
Haematology (2/4) 50%
Clinical Sciences (1/1) 100%
Sexual Health (1/1) 100%
ENT (1/1) 100%
Ethics And Legal (1/1) 100%
Obstetrics (0/2) 0%
Cardiology (0/2) 0%
Respiratory (1/1) 100%
Passmed