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Question 1
Correct
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A GP registrar has diagnosed a urinary tract infection in a 3-year-old child.
Urine cultures and sensitivity show the organism is sensitive to amoxicillin.
The child weighs 12 kg. The dose of amoxicillin is 20 mg/kg three times daily in a pharmacological preparation which contains 125 mg/5 ml.
What is the appropriate dose to be prescribed?
Choose the correct dosing schedule:Your Answer: 4 ml twice daily
Explanation:Dosage Calculation for a 10 kg Child
When administering medication to a child, it is important to calculate the correct dosage based on their weight. For a 10 kg child, the recommended dose is 4 mg/kg twice daily. This means that the child would require 40 mg twice daily.
To determine the amount of medication needed, it is important to know the concentration of the medication. If the medication contains 50 mg per 5 ml, then the child would need 4 ml twice daily to receive the correct dosage of 40 mg. It is important to carefully measure the medication and follow the instructions provided by the healthcare provider to ensure the child receives the correct amount of medication.
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This question is part of the following fields:
- Pharmacology
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Question 2
Incorrect
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A father brings his 2-day-old son to the pediatrician for a routine check-up. During the examination, the pediatrician notices that the baby's skin has a yellowish tint. The pediatrician suspects that the baby has jaundice and investigates further.
What is a possible reason for jaundice caused by reduced bilirubin conjugation?Your Answer: Congenital bile-duct cyst
Correct Answer: Hypothyroidism
Explanation:Neonatal jaundice is a common condition that affects many newborns, with up to 50% of term and 80% of preterm babies experiencing it in their first week of life. It is characterized by yellow discoloration of the skin and occurs when the serum bilirubin level exceeds 85 micromoles/l. Jaundice can be either physiological or pathological, with the former resulting from increased destruction of fetal erythrocytes and decreased liver function due to immaturity. Pathological jaundice, on the other hand, can be caused by haemolytic or non-haemolytic factors, impaired bilirubin conjugation or excretion, and post-hepatic anatomical malformations. Risk factors for neonatal jaundice include Asian origin, having a sibling with a history of the condition, metabolic disorders, prematurity, low birthweight, and being male. Prompt detection and treatment of jaundice is crucial to prevent kernicterus and severe brain damage. Other conditions that can cause neonatal jaundice include intravascular haemolysis, polycythaemia, biliary atresia, and congenital bile duct cysts.
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This question is part of the following fields:
- Paediatrics
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Question 3
Incorrect
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A 32-year-old woman injures her left hand and seeks medical attention at the Emergency Department. During the examination, she experiences tenderness in the left anatomical snuffbox. Specialized scaphoid views (X-rays) are taken, but no abnormality is detected. However, there is still clinical suspicion of a fracture. What should be the next most suitable step?
Your Answer: Magnetic resonance imaging (MRI) wrist after 3 days
Correct Answer: Repeat scaphoid views in 10-14 days
Explanation:The Importance of Repeat Scaphoid Views in Suspected Fractures
When a scaphoid fracture is suspected but not visible on initial X-rays, it is recommended to repeat the radiographs in 10-14 days. During this time, bone resorption around the fracture occurs, making the diagnosis easier. However, proceeding without treatment is not advised due to the risk of avascular necrosis. Requesting another lateral view or a bone scan would not be appropriate. Instead, a cast is usually applied after the acute injury and remains in place until the fracture is diagnosed. MRI wrist imaging after only 3 days is not necessary in this setting. Repeat scaphoid views are crucial in ensuring proper diagnosis and treatment.
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This question is part of the following fields:
- Orthopaedics
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Question 4
Incorrect
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A 7-year-old girl has been brought to the GP with a 2-day history of fever, malaise, and sore throat. She also has some facial redness that started yesterday evening. On examination, there is flushing of the cheeks and a fine, blanching, erythematosus rash that feels like sandpaper on the anterior aspect of the neck. There is erythema of the tonsils and tongue, without exudate. The GP also notices some erythematosus, non-tender lines in the creases of the elbows. The GP decides to prescribe a 10-day course of antibiotics.
What advice should the mother be given regarding her child's return to school?Your Answer: They must wait 7 days before returning to school
Correct Answer: They can return to school 24 hours after taking the first dose of antibiotics
Explanation:If a child has scarlet fever, they can go back to school after 24 hours of taking antibiotics. The symptoms of tonsillopharyngitis (red tonsils and a tongue that looks like a strawberry) and maculopapular exanthem (a rash that feels like sandpaper and lines on the elbows) suggest that the child has scarlet fever. The GP does not need to see the child again because antibiotics should help them recover. However, the child should not go back to school right away because they may still be contagious. The antibiotics will last for 10 days, but the child only needs to wait for 1 day before returning to school. Alternatively, after 7 days, the child will no longer be contagious and can go back to school as usual.
Scarlet fever is a condition caused by erythrogenic toxins produced by Group A haemolytic streptococci, usually Streptococcus pyogenes. It is more prevalent in children aged 2-6 years, with the highest incidence at 4 years. The disease spreads through respiratory droplets or direct contact with nose and throat discharges, especially during sneezing and coughing. The incubation period is 2-4 days, and symptoms include fever, malaise, headache, nausea/vomiting, sore throat, ‘strawberry’ tongue, and a rash that appears first on the torso and spares the palms and soles. The rash has a rough ‘sandpaper’ texture and desquamination occurs later in the course of the illness, particularly around the fingers and toes.
To diagnose scarlet fever, a throat swab is usually taken, but antibiotic treatment should be initiated immediately, rather than waiting for the results. Management involves administering oral penicillin V for ten days, while patients with a penicillin allergy should be given azithromycin. Children can return to school 24 hours after commencing antibiotics, and scarlet fever is a notifiable disease. Although usually a mild illness, scarlet fever may be complicated by otitis media, rheumatic fever, acute glomerulonephritis, or rare invasive complications such as bacteraemia, meningitis, or necrotizing fasciitis, which may present acutely with life-threatening illness.
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This question is part of the following fields:
- Paediatrics
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Question 5
Incorrect
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A 55-year-old woman presents at the one-stop breast clinic for triple assessment following a suspicious lesion detected on a screening mammogram. You review recent blood tests from her GP and are asked to identify the most probable underlying cause of the abnormal result.
Hb 121 g/L Male: (135-180)
Female: (115 - 160)
Platelets 242 * 109/L (150 - 400)
WBC 10.0 * 109/L (4.0 - 11.0)
Calcium 2.6 mmol/L (2.1-2.6)
Phosphate 1.1 mmol/L (0.8-1.4)
Magnesium 0.8 mmol/L (0.7-1.0)
Thyroid stimulating hormone (TSH) 4.5 mU/L (0.5-5.5)
Free thyroxine (T4) 12 pmol/L (9.0 - 18)
Amylase 203 U/L (70 - 300)
Uric acid 0.46 mmol/L (0.18 - 0.48)
Creatine kinase 1200 U/L (35 - 250)Your Answer: Rhabdomyolysis
Correct Answer: Polymyositis
Explanation:The patient is suspected to have breast cancer based on her age and abnormal mammogram results. Additionally, her blood tests show an elevated creatinine kinase (CK) level. This combination of malignancy and raised CK suggests the possibility of polymyositis, a condition that is often associated with cancer. However, a thorough medical history should be obtained before making any definitive diagnosis. The patient may report experiencing muscle weakness and tenderness, particularly in the proximal areas such as the shoulders. It is unlikely that drug-induced factors are causing the raised CK, as there is no indication of this in the patient’s case. Myocardial infarction (MI) is another potential cause of elevated CK, but there is no evidence to suggest that this is the case here. Polymyalgia rheumatica may present with similar symptoms to polymyositis, but it does not typically cause a raised CK. Instead, it is associated with elevated inflammatory markers such as ESR and CRP. Therefore, CK levels can be a useful tool in distinguishing between polymyalgia rheumatica and polymyositis.
Polymyositis: An Inflammatory Disorder Causing Muscle Weakness
Polymyositis is an inflammatory disorder that causes symmetrical, proximal muscle weakness. It is believed to be a T-cell mediated cytotoxic process directed against muscle fibers and can be idiopathic or associated with connective tissue disorders. This condition is often associated with malignancy and typically affects middle-aged women more than men.
One variant of the disease is dermatomyositis, which is characterized by prominent skin manifestations such as a purple (heliotrope) rash on the cheeks and eyelids. Other features of polymyositis include Raynaud’s, respiratory muscle weakness, dysphagia, and dysphonia. Interstitial lung disease, such as fibrosing alveolitis or organizing pneumonia, is seen in around 20% of patients and indicates a poor prognosis.
To diagnose polymyositis, doctors may perform various tests, including an elevated creatine kinase, EMG, muscle biopsy, and anti-synthetase antibodies. Anti-Jo-1 antibodies are seen in a pattern of disease associated with lung involvement, Raynaud’s, and fever.
The management of polymyositis involves high-dose corticosteroids tapered as symptoms improve. Azathioprine may also be used as a steroid-sparing agent. Overall, polymyositis is a challenging condition that requires careful management and monitoring.
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This question is part of the following fields:
- Musculoskeletal
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Question 6
Incorrect
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A 22-year-old man was brought to the Emergency Department with a knife still in his abdomen after being stabbed in the left upper quadrant. A CT scan revealed that the tip of the knife had pierced the superior border of the greater omentum at the junction of the body and pyloric antrum of the stomach. Which direct branch of a vessel is most likely to have been severed by the knife?
Your Answer: Coeliac trunk
Correct Answer: Gastroduodenal artery
Explanation:Arteries of the Upper Abdomen: A Brief Overview
The upper abdomen is supplied by several arteries that arise from the aorta. In this context, we will discuss the gastroduodenal artery, coeliac trunk, hepatic artery proper, splenic artery, and short gastric artery.
The gastroduodenal artery is a branch of the common hepatic artery that supplies blood to the stomach and duodenum. The right gastro-omental artery, one of its terminal branches, runs along the greater curvature of the stomach and anastomoses with the left gastro-omental artery, a branch of the splenic artery.
The coeliac trunk is a short artery that arises from the aorta and supplies blood to the foregut. It gives rise to the left gastric, splenic, and common hepatic arteries and is located more medially than the knife injury in this case.
The hepatic artery proper is a branch of the common hepatic artery that courses to the liver in the free edge of the lesser omentum.
The splenic artery is a tortuous branch of the coeliac trunk that supplies blood to the spleen. The left gastro-omental artery, a branch of the splenic artery, runs along the superior border of the greater omentum and anastomoses with the right gastro-omental artery.
The short gastric artery is one of several arteries that branch off the splenic artery and supply blood to the fundus of the stomach.
In conclusion, understanding the anatomy of these arteries is crucial for diagnosing and treating injuries and diseases of the upper abdomen.
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This question is part of the following fields:
- Trauma
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Question 7
Correct
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A 45-year-old man is recovering on the surgical ward three days after a laparotomy and right hemicolectomy for cancer. You are asked to see him as he has developed a temperature of 38.5ºC and is tachycardic at 120 bpm and tachypnoeic at 25 breaths per minute. On examination his abdomen is soft and not distended but tender around his midline wound. There is some discharge seeping through the dressing. His chest is clear and he has no signs of a deep vein thrombosis.
What is the most probable cause of this man's elevated temperature?Your Answer: Wound infection
Explanation:Abdominal wound infections can lead to post-operative fevers after a few days and may be accompanied by signs of systemic infection. This is a common urgent call for junior surgeons, and the two main differentials to consider are infection and thrombosis, as they are the most serious causes of post-operative fever. Given that the operation involved the bowel and was not sterile, a wound infection is the most likely differential, especially with the presence of discharge and tenderness. While an anastomotic leak is possible, it would typically present with a painful, firm abdomen and severe sepsis. There are no indications of a chest pathology from the patient’s history or examination. A physiological cause of fever would not be associated with systemic inflammation symptoms, as seen in this case.
Post-operative pyrexia, or fever, can occur after surgery and can be caused by various factors. Early causes of post-op pyrexia, which typically occur within the first five days after surgery, include blood transfusion, cellulitis, urinary tract infection, and a physiological systemic inflammatory reaction that usually occurs within a day following the operation. Pulmonary atelectasis is also often listed as an early cause, but the evidence to support this link is limited. Late causes of post-op pyrexia, which occur more than five days after surgery, include venous thromboembolism, pneumonia, wound infection, and anastomotic leak.
To remember the possible causes of post-op pyrexia, it is helpful to use the memory aid of the 4 W’s: wind, water, wound, and what did we do? (iatrogenic). This means that the causes can be related to respiratory issues (wind), urinary tract or other fluid-related problems (water), wound infections or complications (wound), or something that was done during the surgery or post-operative care (iatrogenic). It is important to identify the cause of post-op pyrexia and treat it promptly to prevent further complications. This information is based on a peer-reviewed publication available on the National Center for Biotechnology Information website.
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This question is part of the following fields:
- Surgery
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Question 8
Incorrect
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A 38-year-old African-Caribbean woman presents to Gynaecology Outpatients with heavy periods. She has always experienced heavy periods, but over the past few years, they have become increasingly severe. She now needs to change a pad every hour and sometimes experiences leaking and clots. The bleeding can last for up to 10 days, and she often needs to take time off work. Although there is mild abdominal cramping, there is no bleeding after sex. She is feeling increasingly fatigued and unhappy, especially as she was hoping to have another child. She has one child who is 7 years old, and she had a vaginal delivery. Her periods are regular, and she is not using any contraception. On examination, she appears well, with a soft abdomen, and a vaginal examination reveals a uterus the size of 10 weeks. Her blood tests show a haemoglobin level of 9, and the results of a pelvic ultrasound scan are pending.
What is the most appropriate management option based on the clinical information and expected ultrasound results?Your Answer: Mirena® intrauterine system
Correct Answer: Myomectomy
Explanation:Treatment options for menorrhagia caused by fibroids in a patient hoping to conceive
Menorrhagia, or heavy menstrual bleeding, can be caused by fibroids in the uterus. In a patient hoping to conceive, treatment options must be carefully considered. One option is myomectomy, which involves removing the fibroids while preserving the uterus. However, this procedure can lead to heavy bleeding during surgery and may result in a hysterectomy. Endometrial ablation, which destroys the lining of the uterus, is not suitable for a patient hoping to have another child. Tranexamic acid may help reduce bleeding, but it may not be a definitive treatment if the fibroids are large or in a problematic location. Laparoscopic hysterectomy, which removes the uterus, is a definitive treatment for menorrhagia but is not suitable for a patient hoping to conceive. The Mirena® intrauterine system is an effective treatment for menorrhagia but is not suitable for a patient hoping to conceive. Ultimately, the best treatment option for this patient will depend on the size and location of the fibroids and the patient’s desire to conceive.
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This question is part of the following fields:
- Gynaecology
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Question 9
Incorrect
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A 35-year-old recently arrived female with several skin blisters comes in for assessment. A few of the blisters have burst, resulting in a sore, exposed region. The base of one of the erosive lesions is scraped for Tzanck test. Upon examination, acantholytic keratinocytes with significant hyperchromatic nuclei are detected under the microscope.
What is the probable diagnosis?Your Answer: Bullous pemphigoid
Correct Answer: Pemphigus vulgaris
Explanation:Distinguishing Skin Conditions on Tzanck Smear: Pemphigus Vulgaris, Cytomegalovirus, Herpes Simplex, Chickenpox, and Bullous Pemphigoid
When examining a patient’s bullous skin lesions on a Tzanck smear, it is important to distinguish between various skin conditions. In the case of acantholytic keratinocytes, the most likely diagnosis is pemphigus vulgaris. This autoimmune disorder is caused by an antibody against intraepithelial desmosomal junctions, resulting in the separation of keratinocytes and the formation of intraepithelial blisters.
Cytomegalovirus, herpes simplex, and chickenpox can also present with multinucleated giant cells on a Tzanck smear. However, these conditions are caused by viral infections rather than autoimmune disorders.
Bullous pemphigoid, on the other hand, is caused by an antibody against the dermal-epidermal junction. The associated blisters are sub-epidermal in location and do not contain acantholytic keratinocytes.
In summary, a Tzanck smear can provide valuable information in diagnosing various skin conditions, including pemphigus vulgaris, cytomegalovirus, herpes simplex, chickenpox, and bullous pemphigoid. Proper diagnosis is crucial in determining the appropriate treatment plan for the patient.
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This question is part of the following fields:
- Dermatology
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Question 10
Correct
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A 40-year-old man has been admitted after a severe paracetamol overdose. Despite medical intervention, he has developed liver failure. What is the most probable outcome of the liver failure?
Your Answer: Lactic acidosis is recognised complication
Explanation:N-acetylcysteine reduces morbidity and mortality in fulminant hepatic failure
Fulminant hepatic failure is a serious condition that can lead to severe hypoglycemia and exacerbate encephalopathy in 40% of patients. This condition can develop rapidly and recur with sepsis. Lactic acidosis is also a common complication due to decreased hepatic lactate clearance, poor peripheral perfusion, and increased lactate production. Unfortunately, the prognosis for patients with fulminant hepatic failure is poor if they have a blood pH less than 7.0, prolonged prothrombin time (more than 100s), and serum creatinine more than 300 uM. Mortality is also greater in patients over 40 years of age. However, the use of intravenous N-acetylcysteine has been shown to reduce morbidity and mortality in these patients.
Overall, it is important to closely monitor patients with fulminant hepatic failure and address any complications that arise. The use of N-acetylcysteine can be a valuable tool in improving outcomes for these patients.
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This question is part of the following fields:
- Gastroenterology
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Question 11
Correct
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A 45-year-old man from South Africa presents to the clinic with complaints of worsening vision after starting tuberculosis treatment. Which medication is most likely responsible for his decreased visual acuity?
Your Answer: Ethambutol
Explanation:Ethambutol is a frequent cause of optic neuritis in patients, while Isoniazid can also lead to optic neuritis but is not as prevalent as ethambutol.
Side-Effects and Mechanism of Action of Tuberculosis Drugs
Rifampicin is a drug that inhibits bacterial DNA dependent RNA polymerase, which prevents the transcription of DNA into mRNA. However, it is a potent liver enzyme inducer and can cause hepatitis, orange secretions, and flu-like symptoms.
Isoniazid, on the other hand, inhibits mycolic acid synthesis. It can cause peripheral neuropathy, which can be prevented with pyridoxine (Vitamin B6). It can also cause hepatitis and agranulocytosis. Additionally, it is a liver enzyme inhibitor.
Pyrazinamide is converted by pyrazinamidase into pyrazinoic acid, which in turn inhibits fatty acid synthase (FAS) I. However, it can cause hyperuricaemia, leading to gout, as well as arthralgia, myalgia, and hepatitis.
Lastly, Ethambutol inhibits the enzyme arabinosyl transferase, which polymerizes arabinose into arabinan. It can cause optic neuritis, so it is important to check visual acuity before and during treatment. Additionally, the dose needs adjusting in patients with renal impairment.
In summary, these tuberculosis drugs have different mechanisms of action and can cause various side-effects. It is important to monitor patients closely and adjust treatment accordingly to ensure the best possible outcomes.
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This question is part of the following fields:
- Pharmacology
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Question 12
Incorrect
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A 30-year-old runner complains of heel pain. During examination, there is widespread tenderness that is more severe on the medial side of the heel. Despite taking a break from running for the past week, the pain is exacerbated by standing on their feet all day at work. Walking on their toes intensifies the pain. What is the probable diagnosis?
Your Answer: S1 radiculopathy
Correct Answer: Plantar fasciitis
Explanation:This presentation is typical of plantar fasciitis, which is the most common cause of heel pain in adults. Walking on tip toes exacerbates the pain, unlike subcalcaneal bursitis. Achilles tendonitis typically causes pain at the calcaneal insertion of the tendon or further up the tendon, depending on the affected area. Thompson’s test can rule out tendon rupture. S1 radiculopathy may cause sensory loss along the lateral aspect of the foot and reduced dorsiflexion of the foot. Morton’s neuroma is a thickening of the tissue around the nerve, usually between the 3rd and 4th toes, and pain is typically felt on the ball of the foot.
Understanding Plantar Fasciitis
Plantar fasciitis is a prevalent condition that causes heel pain in adults. The pain is typically concentrated around the medial calcaneal tuberosity, which is the bony bump on the inside of the heel. This condition occurs when the plantar fascia, a thick band of tissue that runs along the bottom of the foot, becomes inflamed or irritated.
To manage plantar fasciitis, it is essential to rest the feet as much as possible. Wearing shoes with good arch support and cushioned heels can also help alleviate the pain. Insoles and heel pads may also be beneficial in providing additional support and cushioning. It is important to note that plantar fasciitis can take time to heal, and it is crucial to be patient and consistent with treatment. By taking these steps, individuals can effectively manage their plantar fasciitis and reduce their discomfort.
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This question is part of the following fields:
- Musculoskeletal
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Question 13
Incorrect
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A 20-year-old woman comes to the clinic 72 hours after having unprotected sex and requests emergency contraception. She had her last period 5 days ago and has no significant medical history or regular medications. Her BMI is 23 kg/m2 and her blood pressure is 118/72 mmHg. She decides to take ulipristal (Ella-One) for emergency contraception and also expresses interest in starting a combined oral contraceptive pill (COCP). She asks when she can begin taking it. What advice should be given?
Your Answer: She should start taking the COCP from 7 days after taking ulipristal
Correct Answer: She should start taking the COCP from 5 days after taking ulipristal
Explanation:Women who have taken ulipristal acetate should wait for 5 days before starting regular hormonal contraception. This is because ulipristal may reduce the effectiveness of hormonal contraception. The same advice should be given for other hormonal contraception methods such as the pill, patch, or ring. Barrier methods should be used before the effectiveness of the COCP can be assured. If the patient is starting the COCP within the first 5 days of her cycle, barrier methods may not be necessary. However, in this case, barrier methods are required. The patient can be prescribed the COCP if it is her preferred method of contraception. There is no need to wait until the start of the next cycle before taking the pill, as long as barrier methods are used for 7 days.
Emergency contraception is available in the UK through two methods: emergency hormonal contraception and intrauterine device (IUD). Emergency hormonal contraception includes two types of pills: levonorgestrel and ulipristal. Levonorgestrel works by stopping ovulation and inhibiting implantation, while ulipristal primarily inhibits ovulation. Levonorgestrel should be taken as soon as possible after unprotected sexual intercourse, within 72 hours, and is 84% effective when used within this time frame. The dose should be doubled for those with a BMI over 26 or weight over 70kg. Ulipristal should be taken within 120 hours of intercourse and may reduce the effectiveness of hormonal contraception. The most effective method of emergency contraception is the copper IUD, which can be inserted within 5 days of unprotected intercourse or up to 5 days after the likely ovulation date. It may inhibit fertilization or implantation and is 99% effective regardless of where it is used in the cycle. Prophylactic antibiotics may be given if the patient is at high risk of sexually transmitted infection.
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This question is part of the following fields:
- Gynaecology
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Question 14
Incorrect
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A 38-year-old man arrives at the Emergency Department complaining of sudden central crushing chest pain while at a social gathering. He is sweating profusely and describes his pain as severe. He has no significant medical or family history but admits to snorting a considerable amount of cocaine at the party. An ECG reveals 4 mm ST elevation in the anterior leads, indicating acute coronary syndrome (ACS). What other interventions should be considered in managing this patient, in addition to standard ACS treatment?
Your Answer: IV labetalol
Correct Answer: IV lorazepam
Explanation:In the treatment of acute coronary syndrome (ACS) caused by cocaine use, it is recommended to administer IV benzodiazepines along with standard ACS protocols. This is because ACS in this context is often due to coronary artery vasospasm, which can be improved by benzodiazepines’ ability to reduce CNS sympathetic outflow and mitigate the toxic effects of cocaine. However, cautious dosing is necessary to avoid benzodiazepine toxicity. In cases of beta-blocker overdose with hemodynamic instability, IV glucagon is indicated. IV labetalol may be used for blood pressure control in hypertensive emergencies or aortic dissection, although its use in cocaine overdose is still generally avoided due to concerns about unopposed alpha-adrenergic activity.
Understanding Cocaine Toxicity
Cocaine is a popular recreational stimulant derived from the coca plant. However, its widespread use has resulted in an increase in cocaine toxicity cases. The drug works by blocking the uptake of dopamine, noradrenaline, and serotonin, leading to a variety of adverse effects.
Cardiovascular effects of cocaine include coronary artery spasm, tachycardia, bradycardia, hypertension, QRS widening, QT prolongation, and aortic dissection. Neurological effects may include seizures, mydriasis, hypertonia, and hyperreflexia. Psychiatric effects such as agitation, psychosis, and hallucinations may also occur. Other complications include ischaemic colitis, hyperthermia, metabolic acidosis, and rhabdomyolysis.
Managing cocaine toxicity involves using benzodiazepines as a first-line treatment for most cocaine-related problems. For chest pain, benzodiazepines and glyceryl trinitrate may be used, and primary percutaneous coronary intervention may be necessary if myocardial infarction develops. Hypertension can be treated with benzodiazepines and sodium nitroprusside. The use of beta-blockers in cocaine-induced cardiovascular problems is controversial, with some experts warning against it due to the risk of unopposed alpha-mediated coronary vasospasm.
In summary, cocaine toxicity can lead to a range of adverse effects, and managing it requires careful consideration of the patient’s symptoms and medical history.
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This question is part of the following fields:
- Pharmacology
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Question 15
Correct
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A thirty-five-year-old man with ulcerative colitis is recovering on the ward 6 days following a proctocolectomy. During the morning ward round, he complains to the team looking after him that he has developed pain in his abdomen. The pain started in the left iliac fossa but is now diffuse. It came on suddenly, overnight, and has gradually been getting worse since. He ranks it 9/10. He has not opened his bowels or passed flatus since the procedure. He has had no analgesia for this.
On examination:
Blood pressure: 105/68 mmHg;
Heart rate: 118/minute, regular;
Respiratory rate: 12/minute;
Temperature: 38.2 ºC;
Oxygen saturations: 98%.
Abdominal exam: abdomen is distended and diffusely tender upon palpation and widespread guarding, indicating peritonism. No organomegaly or palpable abdominal aortic aneurysm. Kidneys are non-ballotable. No shifting dullness. Bowel sounds are absent.
There is 250 mL of feculent matter in the abdominal wound drain.
The registrar requests an abdominal CT which demonstrates an anastomotic leak. What is the most appropriate initial management of this patient?Your Answer: Call the consultant to come in and take the patient to theatre immediately
Explanation:In the case of a confirmed anastomotic leak, immediate surgical intervention is necessary and the patient must be taken back to the operating room without delay. Administering only paracetamol or intravenous antibiotics would not be sufficient as these measures do not address the underlying problem.
Complications can occur in all types of surgery and require vigilance in their detection. Anticipating likely complications and appropriate avoidance can minimize their occurrence. Understanding the anatomy of a surgical field will allow appreciation of local and systemic complications that may occur. Physiological and biochemical derangements may also occur, and appropriate diagnostic modalities should be utilized. Safe and timely intervention is the guiding principle for managing complications.
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This question is part of the following fields:
- Surgery
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Question 16
Correct
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A 54-year-old man visits his GP with complaints of feeling weak all over. He has been experiencing difficulty standing up from his chair and climbing stairs for the past 6 months. He also reports feeling constantly tired and down, but denies any other symptoms. He has no significant medical history and is not taking any regular medications. During a routine blood test, the following results were obtained: Hb 146 g/L (Male: 135-180), Platelets 268 * 109/L (150 - 400), WBC 7.2 * 109/L (4.0 - 11.0), TSH 4.2 mU/L (0.5-5.5), Creatine kinase 428 U/L (35 - 250), eGFR 68 ml/min (<90), and ESR 42 mm/hr <(age / 2). What is the most probable diagnosis?
Your Answer: Polymyositis
Explanation:The most likely diagnosis for a patient presenting with symmetrical proximal muscle weakness, raised creatine kinase, and no rash is polymyositis. This inflammatory disease is commonly caused by Anti-Jo-1 and is more prevalent in male patients over 40 years old. The absence of a rash is a distinguishing factor from dermatomyositis, which also causes muscle weakness but presents with a rash. Polymyalgia rheumatica is not a likely diagnosis as it does not cause muscle weakness, and rhabdomyolysis is unlikely due to the chronic nature of the patient’s symptoms and mildly elevated creatine kinase levels. Treatment for polymyositis typically involves corticosteroids and/or immunosuppressants such as methotrexate.
Polymyositis: An Inflammatory Disorder Causing Muscle Weakness
Polymyositis is an inflammatory disorder that causes symmetrical, proximal muscle weakness. It is believed to be a T-cell mediated cytotoxic process directed against muscle fibers and can be idiopathic or associated with connective tissue disorders. This condition is often associated with malignancy and typically affects middle-aged women more than men.
One variant of the disease is dermatomyositis, which is characterized by prominent skin manifestations such as a purple (heliotrope) rash on the cheeks and eyelids. Other features of polymyositis include Raynaud’s, respiratory muscle weakness, dysphagia, and dysphonia. Interstitial lung disease, such as fibrosing alveolitis or organizing pneumonia, is seen in around 20% of patients and indicates a poor prognosis.
To diagnose polymyositis, doctors may perform various tests, including an elevated creatine kinase, EMG, muscle biopsy, and anti-synthetase antibodies. Anti-Jo-1 antibodies are seen in a pattern of disease associated with lung involvement, Raynaud’s, and fever.
The management of polymyositis involves high-dose corticosteroids tapered as symptoms improve. Azathioprine may also be used as a steroid-sparing agent. Overall, polymyositis is a challenging condition that requires careful management and monitoring.
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This question is part of the following fields:
- Musculoskeletal
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Question 17
Correct
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A 70-year-old man with a lengthy history of hypertension is undergoing an eye examination. He has been experiencing deteriorating headaches and reduced visual acuity over the past few weeks. Upon fundoscopy, he displays flame haemorrhages, cotton wool spots, arteriovenous nipping, and papilloedema. What level of hypertensive retinopathy does this correspond to?
Your Answer: Grade IV
Explanation:Grade IV hypertensive retinopathy is indicated by papilloedema, which is a severe manifestation that requires immediate attention due to its association with high morbidity and mortality. The various grades of hypertensive retinopathy have distinct characteristics, which are outlined below.
Understanding Hypertensive Retinopathy: Keith-Wagener Classification
Hypertensive retinopathy is a condition that affects the eyes due to high blood pressure. The Keith-Wagener classification is a system used to categorize the different stages of hypertensive retinopathy. Stage I is characterized by narrowing and twisting of the blood vessels in the eyes, as well as an increased reflection of light known as silver wiring. In stage II, the blood vessels become compressed where they cross over veins, leading to arteriovenous nipping. Stage III is marked by the appearance of cotton-wool exudates, which are white patches on the retina caused by blocked blood vessels. Additionally, there may be flame and blot hemorrhages that can collect around the fovea, resulting in a ‘macular star.’ Finally, stage IV is the most severe stage and is characterized by papilloedema, which is swelling of the optic disc at the back of the eye. Understanding the Keith-Wagener classification can help healthcare professionals diagnose and manage hypertensive retinopathy.
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This question is part of the following fields:
- Ophthalmology
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Question 18
Incorrect
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A 55-year-old woman visits her doctor with a lump in her left breast that she noticed a month ago and believes has grown in size. She had her last menstrual period two years ago. Upon examination, a painless, firm nodule is found in her left breast. She is urgently referred for triple assessment and is diagnosed with invasive ductal carcinoma. Molecular subtyping of the cancer is performed as part of the diagnostic work-up, revealing that she is ER and PR positive, but HER2 negative. What is the most likely treatment for this woman?
Your Answer: Tamoxifen
Correct Answer: Anastrozole
Explanation:Tamoxifen is a targeted therapy used in women with ER+ve breast cancer who are pre- or perimenopausal, while aromatase inhibitors are preferred in those who are postmenopausal. As this patient is postmenopausal, she is most likely to be offered an aromatase inhibitor. Imatinib is a targeted therapy used in chronic myeloid leukaemia, while nivolumab is used in malignant melanoma and renal cell carcinoma, but not breast cancer. Tamoxifen is an oestrogen receptor modulator that inhibits the oestrogen receptor in the breast, making it useful in the targeted treatment of ER+ve breast cancer. It is preferred in pre- and perimenopausal women, while aromatase inhibitors are preferred in postmenopausal women due to the predominant mechanism of oestrogen production.
Breast cancer management varies depending on the stage of the cancer, type of tumor, and patient’s medical history. Treatment options may include surgery, radiotherapy, hormone therapy, biological therapy, and chemotherapy. Surgery is typically the first option for most patients, except for elderly patients with metastatic disease who may benefit more from hormonal therapy. Prior to surgery, an axillary ultrasound is recommended for patients without palpable axillary lymphadenopathy, while those with clinically palpable lymphadenopathy require axillary node clearance. The type of surgery offered depends on various factors, such as tumor size, location, and type. Breast reconstruction is also an option for patients who have undergone a mastectomy.
Radiotherapy is recommended after a wide-local excision to reduce the risk of recurrence, while mastectomy patients may receive radiotherapy for T3-T4 tumors or those with four or more positive axillary nodes. Hormonal therapy is offered if tumors are positive for hormone receptors, with tamoxifen being used in pre- and perimenopausal women and aromatase inhibitors like anastrozole in postmenopausal women. Tamoxifen may increase the risk of endometrial cancer, venous thromboembolism, and menopausal symptoms. Biological therapy, such as trastuzumab, is used for HER2-positive tumors but cannot be used in patients with a history of heart disorders. Chemotherapy may be used before or after surgery, depending on the stage of the tumor and the presence of axillary node disease. FEC-D is commonly used in the latter case.
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This question is part of the following fields:
- Surgery
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Question 19
Incorrect
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A 47-year-old woman has been experiencing constipation lately and noticed blood in her stool this morning. She decided to see her GP and reported having constipation for almost two months with only one instance of blood in her stool. Her husband, who accompanied her, mentioned that she has lost a considerable amount of weight recently. The woman confirmed this and stated that she has not been intentionally trying to lose weight. The GP is alarmed and orders an urgent investigation. What is the most appropriate investigation to be ordered at this stage?
Your Answer: Abdominal ultrasound scan
Correct Answer: Colonoscopy
Explanation:This man has recently experienced constipation, weight loss, and one instance of blood in his stool. The most probable diagnosis for these symptoms is colorectal cancer (CRC), and further investigation should focus on confirming or ruling out CRC. According to NICE CG131 guidelines, patients without significant comorbidities should be offered a colonoscopy to diagnose CRC.
If the patient had upper GI symptoms such as dysphagia, dyspepsia, or epigastric pain, an upper GI endoscopy would be appropriate. A Faecal Occult Blood Test (FOBT) would have been suitable for screening purposes, as is currently done in the UK. An abdominal X-ray is not necessary as there is no evidence to suggest a likely diagnosis of bowel obstruction, infarction, or perforation that would require X-ray imaging.
Referral Guidelines for Colorectal Cancer
Colorectal cancer is a serious condition that requires prompt diagnosis and treatment. In 2015, the National Institute for Health and Care Excellence (NICE) updated their referral guidelines for patients suspected of having colorectal cancer. According to these guidelines, patients who are 40 years or older with unexplained weight loss and abdominal pain, 50 years or older with unexplained rectal bleeding, or 60 years or older with iron deficiency anemia or change in bowel habit should be referred urgently to colorectal services for investigation. Additionally, patients who test positive for occult blood in their feces should also be referred urgently.
An urgent referral should also be considered for patients who have a rectal or abdominal mass, unexplained anal mass or anal ulceration, or are under 50 years old with rectal bleeding and any of the following unexplained symptoms/findings: abdominal pain, change in bowel habit, weight loss, or iron deficiency anemia.
The NHS offers a national screening program for colorectal cancer, which involves sending eligible patients aged 60 to 74 years in England and 50 to 74 years in Scotland FIT tests through the post. FIT is a type of fecal occult blood test that uses antibodies to detect and quantify the amount of human blood in a single stool sample. Patients with abnormal results are offered a colonoscopy.
The FIT test is also recommended for patients with new symptoms who do not meet the 2-week criteria listed above. For example, patients who are 50 years or older with unexplained abdominal pain or weight loss, under 60 years old with changes in their bowel habit or iron deficiency anemia, or 60 years or older who have anemia even in the absence of iron deficiency. Early detection and treatment of colorectal cancer can significantly improve patient outcomes, making it important to follow these referral guidelines.
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This question is part of the following fields:
- Surgery
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Question 20
Correct
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A 40-year-old male patient has been referred to the hypertension clinic by his general practitioner due to hypertension that has persisted for the past 18 months. His blood pressure readings have been consistently high, measuring around 210/140 mmHg. During the examination, a large ballotable mass is detected in the right flank. The patient's blood test results reveal elevated levels of renin at 120 pmol/L (normal range: 10-60) and aldosterone at 1215 pmol/L (normal range: 100-800). Additionally, his hemoglobin levels are high at 205 g/L (normal range: 120-170). What is the most likely cause of hypertension in this case?
Your Answer: Renin secretion by a renal cell carcinoma
Explanation:The patient likely has a renal carcinoma, which can cause hypertension through obstruction of renal arteries or secretion of renin. Other symptoms may include polycythaemia, a renal mass, and elevated levels of renin and aldosterone. Renal carcinomas typically present between 40-70 years of age and have a higher incidence in men. Other symptoms may include haematuria, flank pain, weight loss, fever, and night sweats. Rarely, non-reducing varicocele and paraneoplastic syndromes may occur.
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This question is part of the following fields:
- Nephrology
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