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Question 1
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A 32-year-old woman presents to the antenatal clinic at 40-weeks gestation for her first pregnancy. She reports no contractions yet. Upon examination, her abdomen is soft and a palpable uterus indicates a term pregnancy. The cervix is firm and dilated to 1 cm, with the foetal head stationed 1 cm below the ischial spines. The obstetrician performs a membrane sweep and decides to initiate treatment with vaginal prostaglandins. What is the most probable complication of this procedure?
Your Answer: Uterine hyperstimulation
Explanation:When inducing labour in a patient who is past her due date, the main complication to watch out for is uterine hyperstimulation. The recommended method for inducing labour according to NICE guidelines is vaginal prostaglandins, which can be administered as a gel, tablet or slow-release pessary. A membrane sweep may also be performed alongside this. Vaginal prostaglandins work by ripening the cervix and stimulating uterine contractions. If uterine hyperstimulation occurs, tocolytic agents can be given to relax the uterus and slow contractions. It’s important to note that a breech presentation is not a complication of induction of labour, especially in cases where the foetus is stationed in the pelvis below the ischial spines. Chorioamnionitis, which is inflammation of the foetal membranes due to bacterial infection, is a risk during prolonged labour and repeated vaginal examinations, but it is not the main complication of induction of labour. Cord prolapse is also a possible complication, but it is more common when the presenting part of the foetus is high, which is not the case in this pregnancy where the foetal head is stationed 1 cm below the ischial spine.
Induction of labour is a process where labour is artificially started and is required in about 20% of pregnancies. It is indicated in cases of prolonged pregnancy, prelabour premature rupture of the membranes, maternal medical problems, diabetic mother over 38 weeks, pre-eclampsia, obstetric cholestasis, and intrauterine fetal death. The Bishop score is used to assess whether induction of labour is necessary and includes cervical position, consistency, effacement, dilation, and fetal station. A score of less than 5 indicates that labour is unlikely to start without induction, while a score of 8 or more indicates a high chance of spontaneous labour or response to interventions made to induce labour.
Possible methods of induction include membrane sweep, vaginal prostaglandin E2, oral prostaglandin E1, maternal oxytocin infusion, amniotomy, and cervical ripening balloon. The NICE guidelines recommend vaginal prostaglandins or oral misoprostol if the Bishop score is less than or equal to 6, while amniotomy and an intravenous oxytocin infusion are recommended if the score is greater than 6.
The main complication of induction of labour is uterine hyperstimulation, which refers to prolonged and frequent uterine contractions that can interrupt blood flow to the intervillous space and result in fetal hypoxemia and acidemia. Uterine rupture is a rare but serious complication. Management includes removing vaginal prostaglandins and stopping the oxytocin infusion if one has been started, and considering tocolysis.
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This question is part of the following fields:
- Obstetrics
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Question 2
Correct
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A 25-year-old man is worried about several recent incidents related to his sleep. He reports experiencing paralysis upon waking up and occasionally when falling asleep, accompanied by what he describes as 'hallucinations' such as seeing another person in the room. These episodes are causing him increasing anxiety. What is the probable diagnosis?
Your Answer: Sleep paralysis
Explanation:Understanding Sleep Paralysis
Sleep paralysis is a condition that affects many people and is characterized by a temporary inability to move the skeletal muscles when waking up or falling asleep. It is believed to be linked to the natural paralysis that occurs during REM sleep. This phenomenon is recognized in various cultures and is often accompanied by hallucinations or vivid images.
The paralysis occurs either before falling asleep or after waking up, and it can be a frightening experience for those who are not familiar with it. However, it is a relatively harmless condition that does not require medical attention in most cases. If the symptoms are particularly bothersome, medication such as clonazepam may be prescribed to alleviate the symptoms.
In summary, sleep paralysis is a common occurrence that affects many people. It is characterized by temporary paralysis of the skeletal muscles and is often accompanied by hallucinations. While it can be a frightening experience, it is generally harmless and does not require medical attention.
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This question is part of the following fields:
- Psychiatry
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Question 3
Incorrect
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A 72-year-old man presents to his GP for a routine check-up and is found to have a systolic murmur heard loudest in the aortic region. The murmur increases in intensity with deep inspiration and does not radiate. What is the most probable abnormality in this patient?
Your Answer: Aortic stenosis
Correct Answer: Pulmonary stenosis
Explanation:Systolic Valvular Murmurs
A systolic valvular murmur can be caused by aortic/pulmonary stenosis or mitral/tricuspid regurgitation. It is important to note that the location where the murmur is heard loudest can be misleading. For instance, if it is aortic stenosis, the murmur is expected to radiate to the carotids. However, the significant factor to consider is that the murmur is heard loudest on inspiration. During inspiration, venous return to the heart increases, which exacerbates right-sided murmurs. Conversely, expiration reduces venous return and exacerbates left-sided murmurs. To remember this useful fact, the mnemonic RILE (Right on Inspiration, Left on Expiration) can be used.
If a systolic murmur is enhanced on inspiration, it must be a right-sided murmur, which could be pulmonary stenosis or tricuspid regurgitation. However, in this case, only pulmonary stenosis is an option. systolic valvular murmurs and their characteristics is crucial in making an accurate diagnosis and providing appropriate treatment.
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This question is part of the following fields:
- Cardiology
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Question 4
Correct
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A five-year-old boy is rescued with his asylum-seeking parents from a boat off the coast. The child is visibly malnourished, and his parents reveal that due to conflict in their home country, he has spent most of his life hidden indoors and in shelters.
Upon skeletal examination, the child displays bossing of the forehead, bowing of his legs, and significant kyphoscoliosis of the spine. What radiological feature is commonly associated with this condition?Your Answer: Widening of joints
Explanation:The widening of wrist joints in a child may indicate the presence of Rickets, a bone disease caused by vitamin D deficiency. This condition results in poorly mineralized bones during growth and development. Radiologically, Rickets is characterized by excess non-mineralized osteoid at the growth plate, leading to joint widening. Ballooning, osteolysis, periarticular erosions, and sclerotic rims are not associated with Rickets, but rather with other bone conditions such as rare bone malignancies, Paget’s disease, rheumatoid arthritis, and gout.
Understanding Rickets: Causes, Symptoms, and Treatment
Rickets is a condition that occurs when bones in developing and growing bodies are inadequately mineralized, resulting in soft and easily deformed bones. This condition is usually caused by a deficiency in vitamin D. In adults, a similar condition called osteomalacia can occur.
There are several factors that can predispose individuals to rickets, including a dietary deficiency of calcium, prolonged breastfeeding, unsupplemented cow’s milk formula, and lack of sunlight. Symptoms of rickets include aching bones and joints, lower limb abnormalities such as bow legs or knock knees, swelling at the costochondral junction (known as the rickety rosary), kyphoscoliosis, and soft skull bones in early life (known as craniotabes).
To diagnose rickets, doctors may perform tests to measure vitamin D levels, serum calcium levels, and alkaline phosphatase levels. Treatment for rickets typically involves oral vitamin D supplementation.
In summary, rickets is a condition that affects bone development and can lead to soft and easily deformed bones. It is caused by a deficiency in vitamin D and can be predisposed by several factors. Symptoms include bone and joint pain, limb abnormalities, and swelling at the costochondral junction. Treatment involves oral vitamin D supplementation.
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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 32-year-old woman is admitted to hospital for a hysterectomy for treatment of fibroids.
What are the standard preventive measures for all women undergoing a complete abdominal hysterectomy?Your Answer: Oral amoxicillin 7-day oral course postoperatively
Correct Answer: Co-amoxiclav ® intravenous (iv) intraoperatively
Explanation:Hysterectomy: Antibiotic Prophylaxis and Surgical Considerations
Hysterectomy is a surgical procedure that involves the removal of the uterus and is commonly used to treat pelvic pathologies such as fibroids and adenomyosis. Antibiotic prophylaxis is crucial during the operation to prevent infection, and Co-amoxiclav ® is a broad-spectrum antibiotic that is commonly used. Complications of hysterectomy include haemorrhage, trauma to the bowel, damage to the urinary tract, infection, thromboembolic disease, and an increased risk of vaginal prolapse. Vaginal hysterectomy is preferred over abdominal hysterectomy as it reduces post-operative morbidity and has a shorter recovery time. The decision to remove ovaries during abdominal hysterectomy depends on various factors such as the patient’s age, family history of breast and ovarian cancer, and plans for hormone replacement therapy. Subtotal hysterectomy is an option for women with dysfunctional uterine bleeding who have normal cervical cytology. Intraoperative prophylactic-dose heparin is not recommended as it can cause excessive bleeding. Penicillin V and trimethoprim are not suitable for intraoperative prophylaxis as they do not provide broad-spectrum cover. Amoxicillin is inadequate for this operation as it does not provide the necessary prophylaxis during the intraoperative period.
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This question is part of the following fields:
- Gynaecology
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Question 6
Incorrect
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A 5-year-old girl is brought to the emergency department by her father. The father seems hesitant for his child to be examined, and admits he has some distrust towards modern medicine. His daughter has not received any of her routine immunisations. He explains that his daughter was slightly unwell with cold symptoms and a mild cough last week, but her condition has worsened over the past 10 days. Her cough has become so severe that she experiences uncontrollable coughing fits, which have caused her lips to turn blue and led to vomiting. Her symptoms are particularly severe at night.
What is the most appropriate class of antibiotics to prescribe for this patient, given the most likely diagnosis?Your Answer: β-lactam antibiotics
Correct Answer: Macrolide antibiotics
Explanation:Whooping cough, caused by Bordetella pertussis, can be treated with macrolide antibiotics such as azithromycin or clarithromycin. This infection typically has an incubation period of 5-10 days (maximum 21 days) before the onset of symptoms such as a mild cough, low-grade fever, and coryzal symptoms. The paroxysmal phase follows, characterized by clusters of rapid coughs, a high-pitched whoop, cyanosis, vomiting, and exhaustion. Patients are infectious from the onset of the catarrhal phase until 3 weeks after the start of the paroxysmal phase. Antibiotics are only indicated if the patient presents within 3 weeks of onset of the paroxysmal phase.
Whooping Cough: Causes, Symptoms, Diagnosis, and Management
Whooping cough, also known as pertussis, is a contagious disease caused by the bacterium Bordetella pertussis. It is commonly found in children, with around 1,000 cases reported annually in the UK. The disease is characterized by a persistent cough that can last up to 100 days, hence the name cough of 100 days.
Infants are particularly vulnerable to whooping cough, which is why routine immunization is recommended at 2, 3, 4 months, and 3-5 years. However, neither infection nor immunization provides lifelong protection, and adolescents and adults may still develop the disease.
Whooping cough has three phases: the catarrhal phase, the paroxysmal phase, and the convalescent phase. The catarrhal phase lasts around 1-2 weeks and presents symptoms similar to a viral upper respiratory tract infection. The paroxysmal phase is characterized by a severe cough that worsens at night and after feeding, and may be accompanied by vomiting and central cyanosis. The convalescent phase is when the cough subsides over weeks to months.
To diagnose whooping cough, a person must have an acute cough that has lasted for 14 days or more without another apparent cause, and have one or more of the following features: paroxysmal cough, inspiratory whoop, post-tussive vomiting, or undiagnosed apnoeic attacks in young infants. A nasal swab culture for Bordetella pertussis is used to confirm the diagnosis, although PCR and serology are increasingly used.
Infants under 6 months with suspected pertussis should be admitted, and in the UK, pertussis is a notifiable disease. An oral macrolide, such as clarithromycin, azithromycin, or erythromycin, is indicated if the onset of the cough is within the previous 21 days to eradicate the organism and reduce the spread. Household contacts should be offered antibiotic prophylaxis, although antibiotic therapy has not been shown to alter the course of the illness. School exclusion is recommended for 48 hours after commencing antibiotics or 21 days from onset of symptoms if no antibiotics are given.
Complications of whooping cough include subconjunctival haemorrhage, pneumonia, bronchiectasis, and
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This question is part of the following fields:
- Paediatrics
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Question 7
Incorrect
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A 50-year-old man presents to the Emergency Department with progressively worsening shortness of breath on exertion and has recently been waking up at night feeling short of breath. He has a pansystolic murmur found on auscultation, as well as coarse bilateral basal crackles found on auscultation. His echocardiogram reveals a reduced left ventricular ejection fraction (LVEF) and severe mitral regurgitation. Cardiologists recommend that he commences certain medications to improve both his symptoms and long-term outcomes until he has definitive treatment of his valvular pathology.
Which one of the following medications has been shown to reduce mortality in patients with the described condition?Your Answer: Furosemide
Correct Answer: Carvedilol
Explanation:Common Heart Failure Medications and Their Effects on Mortality Rates
Beta-blockers were once contraindicated in the treatment of congestive cardiac failure (CCF) due to their negative inotropic effect. However, current guidelines recommend beta-blocker treatment in patients who have been stabilized on diuretic and angiotensin-converting inhibitor (ACEI) therapy, as data show that their ability to decrease cardiac contractility and overall cardiac effort increases long-term mortality in patients with CCF.
Nifedipine does not improve mortality rates in heart failure and should be avoided, as most calcium channel blockers worsen symptoms and increase mortality rates in patients with heart failure.
Furosemide is a mainstay in the treatment of both acute and long-term heart failure, effectively relieving symptoms of fluid overload. However, there is little data to prove that it improves long-term mortality in patients with chronic CCF, potentially due to its nephrotoxic effects and changes in electrolyte imbalances.
Aspirin is known to be cardioprotective for patients with coronary artery disease, but there is no conclusive evidence to suggest that it offers any reduction in mortality rates or benefit for patients with heart failure.
Digoxin does not decrease mortality in heart failure and is no longer recommended as first-line therapy. Its use is reserved for patients in atrial fibrillation and those who cannot be controlled on an ACEI, beta-blocker, and loop diuretic.
Understanding the Effects of Common Heart Failure Medications on Mortality Rates
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This question is part of the following fields:
- Pharmacology
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Question 8
Incorrect
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A 40-year-old woman from Vietnam presents with abdominal swelling. She has no history of blood transfusion or jaundice in the past and is in a stable relationship with two children. Upon admission, she was found to be icteric. During the investigation, she experienced a bout of haematemesis and was admitted to the High Dependency Unit.
What is the most probable cause of her symptoms?Your Answer: Hepatitis C infection
Correct Answer: Hepatitis B infection
Explanation:The patient is likely suffering from chronic liver disease and portal hypertension, possibly caused by a hepatitis B infection. This is common in regions such as sub-Saharan Africa and East Asia, where up to 10% of adults may be chronically infected. Acute paracetamol overdose can also cause liver failure, but it does not typically present with haematemesis. Mushroom poisoning can be deadly and cause liver damage, but it is not a cause of chronic liver disease. Hepatitis C is another cause of liver cirrhosis, but it is more common in other regions such as Egypt. Haemochromatosis is a rare autosomal recessive disease that can present with cirrhosis and other symptoms, but it is less likely in this case.
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This question is part of the following fields:
- Gastroenterology
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Question 9
Incorrect
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A 65-year-old woman comes to the Emergency Department with multiple facial lesions that appeared suddenly 24 hours ago and are painful to the touch. She experienced burning pain on her forehead a week ago. Upon examination, she has tenderness on the left side of her forehead and several 4-6mm vesicles on the left side. Hutchinson's sign is positive. What aspect of her condition necessitates an immediate evaluation by an ophthalmologist?
Your Answer: Lesions on the top eyelid
Correct Answer: Lesions on the tip of the nose
Explanation:Hutchinson’s sign is a strong indicator of ocular involvement in shingles, characterized by vesicles extending to the tip of the nose. This patient is presenting with herpes zoster ophthalmicus, which is caused by the reactivation of herpes zoster affecting the ophthalmic branch of the trigeminal nerve. Urgent ophthalmological review is necessary due to the presence of lesions on the tip of the nose. Management involves oral antivirals and, if there is secondary inflammation of the eye, topical steroids may be given. Lesions above the eyebrow can also occur if the ophthalmic branch of the trigeminal nerve is affected, but this has no association with ocular involvement. Pain over the affected area is a common symptom preceding the eruption of the vesicles, but it is not indicative of ocular involvement. Lesions on the top eyelid can also occur if the ophthalmic branch of the trigeminal nerve is affected.
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.
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This question is part of the following fields:
- Ophthalmology
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Question 10
Incorrect
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A 42-year-old man presents with a one-month history of tingling sensation in his fingers, toes and around the mouth. Initially, the symptom only affected his fingers but has since spread and gradually worsened. He had a similar symptom a couple of years ago and was diagnosed with low calcium levels. The patient reports no muscle weakness, tremors or other neurological symptoms. He is currently taking esomeprazole for reflux symptoms. His recent blood test showed a calcium level of 2.2 mmol/L (2.1-2.6). What electrolyte abnormality could be causing this patient's presenting symptoms?
Your Answer: Hypermagnesaemia
Correct Answer: Hypomagnesaemia
Explanation:Hypomagnesaemia can lead to symptoms that are similar to those of hypocalcaemia, such as paresthesia, tetany, seizures, and arrhythmias. This condition can be caused by the use of proton pump inhibitors like lansoprazole and esomeprazole.
The answer hyperkalemia is incorrect because its symptoms are often non-specific, including breathing difficulty, weakness, fatigue, palpitations, or chest pain, but not paresthesia.
Similarly, hypermagnesaemia and hypernatremia are also incorrect answers. While hypermagnesaemia can cause weakness, confusion, nausea, vomiting, and shortness of breath, it does not lead to paresthesia. Hypernatremia, on the other hand, can cause lethargy, weakness, confusion, irritability, and seizures, but not paresthesia.
Understanding Hypomagnesaemia: Causes, Symptoms, and Treatment
Hypomagnesaemia is a condition characterized by low levels of magnesium in the blood. There are several causes of this condition, including the use of certain drugs such as diuretics and proton pump inhibitors, total parenteral nutrition, and chronic or acute diarrhoea. Alcohol consumption, hypokalaemia, hypercalcaemia, and metabolic disorders like Gitelman’s and Bartter’s can also lead to hypomagnesaemia. The symptoms of this condition may be similar to those of hypocalcaemia, including paraesthesia, tetany, seizures, and arrhythmias.
When the magnesium level drops below 0.4 mmol/L or when there are symptoms of tetany, arrhythmias, or seizures, intravenous magnesium replacement is commonly given. An example regime would be 40 mmol of magnesium sulphate over 24 hours. For magnesium levels above 0.4 mmol/L, oral magnesium salts are prescribed in divided doses of 10-20 mmol per day. However, diarrhoea can occur with oral magnesium salts. It is important to note that hypomagnesaemia can exacerbate digoxin toxicity.
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This question is part of the following fields:
- Pharmacology
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Question 11
Correct
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A 30-year-old man presented to the Emergency Department, complaining of severe headache, neck stiffness and photophobia. There is no history of trauma and there has been no recent foreign travel. On examination, he has fever and a non-blanching rash on his chest. Meningococcal septicaemia is suspected and treatment is commenced. A lumbar puncture was performed.
Select the result most consistent with a diagnosis of bacterial meningitis.Your Answer: Cerebrospinal fluid (CSF) pressure raised, protein elevated, glucose low and the predominant cells are polymorphs
Explanation:Interpreting CSF Results: Understanding Meningitis
Meningitis is a serious condition that can be caused by bacterial, viral, or tuberculous infections. The diagnosis of meningitis is often made by analyzing cerebrospinal fluid (CSF) obtained through a lumbar puncture. The results of the CSF analysis can provide important clues about the underlying cause of the infection.
CSF pressure raised, protein elevated, glucose low and the predominant cells are polymorphs: This result is indicative of bacterial meningitis, specifically meningococcal septicaemia. Immediate antibiotic treatment is necessary to prevent serious complications.
CSF pressure raised, protein elevated, glucose raised and the predominant cells are lymphocytes: This result can be consistent with either viral or tuberculous meningitis. Further testing, such as PCR, may be necessary to determine the specific cause.
CSF pressure low, protein normal, glucose raised and the predominant cells are polymorphs: This result is less indicative of infection, as the normal protein level and raised glucose level make bacterial meningitis unlikely. However, further investigation may be necessary to determine the underlying cause.
CSF pressure normal, protein low, glucose normal and the predominant cells are polymorphs: This result suggests that infection is unlikely, as the low CSF pressure and protein level are not consistent with meningitis.
CSF pressure normal, protein elevated, glucose raised and the predominant cells are lymphocytes: This result is consistent with viral meningitis, and further testing may be necessary to confirm the diagnosis.
Understanding the results of a CSF analysis is crucial in the diagnosis and treatment of meningitis. Prompt and appropriate treatment can prevent serious complications and improve outcomes for patients.
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This question is part of the following fields:
- Neurology
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Question 12
Incorrect
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A 35-year-old male patient (undergoing chemotherapy treatment for Hodgkin’s lymphoma) complains of severe mouth pain. On examination, you see white plaques over his tongue.
Which of the following treatments is most appropriate?Your Answer: Nystatin mouthwash for 10 days
Correct Answer: Oral fluconazole for 7–14 days
Explanation:Treatment Options for Oral Candida Infection During Chemotherapy
During chemotherapy, patients may experience immunosuppression, which can lead to oral candida infection. There are several treatment options available for this condition, including oral fluconazole, nystatin mouthwash, and oral mycafungin. However, the most appropriate choice for mild to moderate oral candida infection is oral fluconazole, as it is more likely to prevent or delay recurrence than nystatin. Intravenous amphotericin B and oral voriconazole are not recommended for this condition, as they are used for systemic fungal infections and other types of fungal infections, respectively. It is important for healthcare providers to consider the patient’s individual needs and medical history when selecting a treatment option.
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This question is part of the following fields:
- Oncology
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Question 13
Correct
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A 40-year-old man presents with generalized pruritus and excoriation marks on his skin. He has visible needle track marks in his antecubital fossae and shiny nails. His sclerae appear normal and he denies any significant medical or surgical history. He works as a truck driver and has no significant exposure to industrial chemicals or organic dust. He has no family history of atopy and smokes six cigarettes a day while only drinking alcohol socially once a week. What is the most appropriate initial test to perform?
Your Answer: Blood for HIV antibody
Explanation:Investigating Pruritus in a Male Patient
Pruritus, or itching, can be a symptom of various underlying conditions. In the case of a male patient without apparent cause of pruritus, an HIV antibody test would be the most appropriate first-line investigation, along with other tests such as blood sugar, thyroid profile, and urea and electrolytes. This is because HIV infection can present with intractable pruritus before other symptoms appear. Allergen skin tests may be used in suspected allergic reactions, but they would be inappropriate in this case as there is no indication of such a reaction. The anti-M2 antibody test is used for primary biliary cirrhosis, which is a rare possibility in this case. A chest x-ray is not a useful first-line test as there is no indication of malignancy. Kidney diseases can give rise to pruritus, but there is no mention of kidney disease here. It is important to consider the patient’s medical history, including any potential risk factors such as IV drug abuse, which may be the source of infection. Further investigations may be necessary depending on the results of initial tests.
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This question is part of the following fields:
- Dermatology
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Question 14
Correct
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A 29-year-old woman who is 10 weeks pregnant presents to the early pregnancy assessment unit with vaginal bleeding and abdominal pain that started yesterday. She has a history of Von Willebrand disease. A trans-vaginal ultrasound scan confirms a missed miscarriage. The patient is currently stable without fever or hemodynamic instability. What is the most suitable initial approach to manage this patient's miscarriage?
Your Answer: Vaginal misoprostol
Explanation:The recommended medical management for a miscarriage is the administration of vaginal misoprostol, as stated in the 2018 NICE guidelines. This is particularly suitable for patients with a medical history of coagulopathy, such as Von Willebrand disease, as it is a safer option than expectant management. Oral methotrexate is not appropriate for a miscarriage, as it is used for the medical management of ectopic pregnancies. Salpingectomy is a surgical procedure used for tubular ectopic pregnancies, but not for miscarriages. Vacuum aspiration is a surgical option for miscarriages, but medical management is preferred as it is safer and allows the patient to have more control over the process.
Management Options for Miscarriage
Miscarriage can be a difficult and emotional experience for women. In the 2019 NICE guidelines, three types of management for miscarriage were discussed: expectant, medical, and surgical. Expectant management involves waiting for a spontaneous miscarriage and is considered the first-line option. However, if it is unsuccessful, medical or surgical management may be offered.
Medical management involves using tablets to expedite the miscarriage. Vaginal misoprostol, a prostaglandin analogue, is used to cause strong myometrial contractions leading to the expulsion of tissue. It is important to advise patients to contact their doctor if bleeding does not start within 24 hours. Antiemetics and pain relief should also be given.
Surgical management involves undergoing a surgical procedure under local or general anaesthetic. The two main options are vacuum aspiration (suction curettage) or surgical management in theatre. Vacuum aspiration is done under local anaesthetic as an outpatient, while surgical management is done in theatre under general anaesthetic. This was previously referred to as ‘Evacuation of retained products of conception’.
It is important to note that some situations are better managed with medical or surgical management, such as an increased risk of haemorrhage, being in the late first trimester, having coagulopathies or being unable to have a blood transfusion, previous adverse and/or traumatic experience associated with pregnancy, evidence of infection, and more. Ultimately, the management option chosen should be based on the individual patient’s needs and preferences.
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This question is part of the following fields:
- Obstetrics
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Question 15
Correct
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A 29-year-old man comes to your clinic with concerns about his fertility. He and his partner have been trying to conceive for the past 2 years, but have been unsuccessful. The patient's medical history includes frequent chest infections and ear infections, which have required multiple rounds of antibiotics. He reports that he often experiences upper respiratory tract infections. Upon examination, you note that his right testicle hangs lower than his left, but there are no other abnormalities. As part of a routine check-up, you perform a chest examination and observe that the apex beat is in the 5th intercostal space on the right midclavicular line. What is the most likely diagnosis?
Your Answer: Kartagener's syndrome
Explanation:In Kartagener’s syndrome, the right testicle hangs lower than the left due to situs inversus. Normally, it is the left testicle that hangs lower. This condition can be similar to cystic fibrosis, but patients with cystic fibrosis would have additional symptoms such as diabetes, diarrhoea, and deficiencies in fat-soluble vitamins. It is important to note that there is no indication that the patient is currently taking antibiotics that could affect sperm function and motility.
Understanding Kartagener’s Syndrome
Kartagener’s syndrome, also known as primary ciliary dyskinesia, is a rare genetic disorder that was first described in 1933. It is often associated with dextrocardia, which can be detected through quiet heart sounds and small volume complexes in lateral leads during examinations. The pathogenesis of Kartagener’s syndrome is caused by a dynein arm defect, which results in immotile Ciliary.
The syndrome is characterized by several features, including dextrocardia or complete situs inversus, bronchiectasis, recurrent sinusitis, and subfertility. The immotile Ciliary in the respiratory tract lead to chronic respiratory infections and bronchiectasis, while the defective ciliary action in the fallopian tubes can cause subfertility.
In summary, Kartagener’s syndrome is a rare genetic disorder that affects the motility of Ciliary in the respiratory tract and fallopian tubes. It is often associated with dextrocardia and can lead to chronic respiratory infections, bronchiectasis, recurrent sinusitis, and subfertility. Early diagnosis and management are crucial in preventing complications and improving the quality of life for individuals with this syndrome.
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This question is part of the following fields:
- Medicine
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Question 16
Incorrect
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A 63-year-old male presents with a sudden onset of double vision that has been ongoing for eight hours. He has a medical history of hypertension, which is managed with amlodipine and atenolol, and type 2 diabetes that is controlled through diet. Upon examination, the patient displays watering of the right eye, a slight droop of the eyelid, and displacement of the eye to the right. The left eye appears to have a full range of movements, and the pupil size is the same as on the left. What is the probable cause of his symptoms?
Your Answer: Cerebral infarction
Correct Answer: Diabetes
Explanation:Causes of Painless Partial Third Nerve Palsy
A painless partial third nerve palsy with pupil sparing is most likely caused by diabetes mononeuropathy. This condition is thought to be due to a microangiopathy that leads to the occlusion of the vasa nervorum. On the other hand, an aneurysm of the posterior communicating artery is associated with a painful third nerve palsy, and pupillary dilation is typical. Cerebral infarction, on the other hand, does not usually cause pain. Hypertension, which is a common condition, would normally cause signs of CVA or TIA. Lastly, cerebral vasculitis can cause symptoms of CVA/TIA, but they usually cause more global neurological symptoms.
In summary, a painless partial third nerve palsy with pupil sparing is most likely caused by diabetes mononeuropathy. Other conditions such as aneurysm of the posterior communicating artery, cerebral infarction, hypertension, and cerebral vasculitis can also cause similar symptoms, but they have different characteristics and causes. It is important to identify the underlying cause of the condition to provide appropriate treatment and management.
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This question is part of the following fields:
- Emergency Medicine
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Question 17
Incorrect
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A 38-year-old woman arrives at the emergency department complaining of palpitations that began a few hours ago. Her heart rate is 180/min and an ECG reveals atrial fibrillation. The attending cardiologist plans to use flecainide to pharmacologically convert the patient back to sinus rhythm. What pre-treatment measure should be taken before administering flecainide?
Your Answer: Urea and electrolytes
Correct Answer: Echocardiogram
Explanation:Before using flecainide for atrial fibrillation, signs of structural heart disease should be checked.
Understanding Flecainide: A Class 1c Antiarrhythmic
Flecainide is a type of antiarrhythmic medication that belongs to the Vaughan Williams class 1c. It works by blocking the Nav1.5 sodium channels, which slows down the conduction of the action potential. This can cause the QRS complex to widen and the PR interval to prolong. Flecainide is commonly used to treat atrial fibrillation and SVT associated with accessory pathway, such as Wolff-Parkinson-White syndrome.
However, it is important to note that Flecainide is contraindicated in certain situations. For example, it should not be used in patients who have recently experienced a myocardial infarction or have structural heart disease, such as heart failure. It is also not recommended for patients with sinus node dysfunction or second-degree or greater AV block, as well as those with atrial flutter.
While Flecainide can be effective in treating certain arrhythmias, it can also have adverse effects. It may cause negative inotropic effects, which can affect the heart’s ability to contract. It can also cause bradycardia, or a slow heart rate, and may even lead to proarrhythmic effects. Some patients may also experience oral paraesthesia or visual disturbances.
In summary, Flecainide is a class 1c antiarrhythmic medication that works by blocking sodium channels. It is commonly used to treat atrial fibrillation and SVT associated with accessory pathway. However, it is contraindicated in certain situations and can have adverse effects. Patients should always consult with their healthcare provider before taking any medication.
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This question is part of the following fields:
- Pharmacology
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Question 18
Incorrect
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A 34-year-old woman is at eight weeks’ gestation in her first pregnancy, with a body mass index (BMI) of 36.5 kg/m2. She has type 2 diabetes mellitus, and her sister had pre-eclampsia in both her pregnancies. She had deep vein thrombosis (DVT), following a long-haul flight to Australia last year.
Which of the following risk factors presenting in this patient’s history is considered a high-risk factor for the development of pre-eclampsia?Your Answer: BMI of 36.5 kg/m2
Correct Answer: Type 2 diabetes mellitus
Explanation:Pre-eclampsia Risk Factors in Pregnancy
During the first prenatal visit, women are screened for their risk of developing pre-eclampsia during pregnancy. High-risk factors include a personal history of pre-eclampsia, essential hypertension, type 1 or 2 diabetes mellitus, chronic kidney disease, or autoimmune conditions. Moderate risk factors include a BMI of 35-39.9 kg/m2, family history of pre-eclampsia, age of ≥ 40, first pregnancy, multiple pregnancy, and an interpregnancy interval of > 10 years. If any high or moderate risk factor is present, it is recommended that the woman take 75 mg of aspirin daily from the 12th week of gestation until delivery. A personal history of DVT is not a risk factor for pre-eclampsia, but it is associated with an increased risk of thrombi during pregnancy and the puerperium.
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This question is part of the following fields:
- Obstetrics
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Question 19
Correct
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A 25-year-old law student presents with visual loss in the right eye, accompanied by a constant headache for the past three months. She also reports not having had her menstrual cycle for six months. Upon examination, her visual acuity in the affected eye is 6/24, with slight constriction of both temporal visual fields. However, there are no other neurological deficits present. The patient is stable, without fever or hemodynamic abnormalities. What is the likely diagnosis?
Your Answer: Pituitary tumour
Explanation:Pituitary Lesion and Visual Pathway Involvement
This patient is presenting with symptoms of headache and amenorrhoea, which are suggestive of a pituitary lesion. The lesion could either be a prolactinoma or a non-functioning tumour. Unfortunately, the involvement of the visual pathway has led to visual loss, which has further complicated the situation.
To determine the extent of the pituitary lesion, the patient needs to undergo an urgent assessment of her pituitary function. Additionally, an MRI scan of the pituitary gland is necessary to determine the extent of the lesion. One of the most important investigations to perform would be a serum prolactin test.
It is unlikely that the patient is suffering from retrobulbar neuritis associated with MS, as the amenorrhoea would argue against this. Similarly, the peripheral visual field constriction would be unusual, as a central scotoma and fluctuating visual loss would be more typical.
In conclusion, the patient’s symptoms suggest a pituitary lesion, which has been complicated by involvement of the visual pathway. Urgent assessment and imaging are necessary to determine the extent of the lesion and appropriate treatment.
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This question is part of the following fields:
- Emergency Medicine
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Question 20
Correct
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A 35-year-old intravenous drug user has been diagnosed with osteomyelitis of the right tibia. What organism is most likely responsible for this infection?
Your Answer: Staphylococcus aureus
Explanation:Understanding Osteomyelitis: Types, Causes, and Treatment
Osteomyelitis is a bone infection that can be classified into two types: haematogenous and non-haematogenous. Haematogenous osteomyelitis is caused by bacteria that enter the bloodstream and is usually monomicrobial. It is more common in children, with vertebral osteomyelitis being the most common form in adults. Risk factors include sickle cell anaemia, intravenous drug use, immunosuppression, and infective endocarditis. On the other hand, non-haematogenous osteomyelitis results from the spread of infection from adjacent soft tissues or direct injury to the bone. It is often polymicrobial and more common in adults, with risk factors such as diabetic foot ulcers, pressure sores, diabetes mellitus, and peripheral arterial disease.
Staphylococcus aureus is the most common cause of osteomyelitis, except in patients with sickle-cell anaemia where Salmonella species predominate. To diagnose osteomyelitis, MRI is the imaging modality of choice, with a sensitivity of 90-100%. Treatment for osteomyelitis involves a six-week course of flucloxacillin. Clindamycin is an alternative for patients who are allergic to penicillin.
In summary, osteomyelitis is a bone infection that can be caused by bacteria entering the bloodstream or spreading from adjacent soft tissues or direct injury to the bone. It is more common in children and adults with certain risk factors. Staphylococcus aureus is the most common cause, and MRI is the preferred imaging modality for diagnosis. Treatment involves a six-week course of flucloxacillin or clindamycin for penicillin-allergic patients.
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This question is part of the following fields:
- Musculoskeletal
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Question 21
Correct
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A 29-year-old male with schizophrenia is being evaluated by his psychiatrist. He expresses that he no longer takes pleasure in his usual pastimes. The patient used to enjoy playing video games and going to the gym, but now finds these activities uninteresting and lacks motivation to engage in them.
Which symptom of schizophrenia is the patient exhibiting?Your Answer: Anhedonia
Explanation:Symptoms of Schizophrenia
Anhedonia, affective flattening, alogia, apathy, and delusions are all symptoms of schizophrenia. Anhedonia is the inability to experience pleasure from activities that were once enjoyable. Affective flattening is the loss of a normal range of emotional expression, making it difficult for individuals to express their emotions appropriately. Alogia is a lack of spontaneous speech, making it difficult for individuals to communicate effectively. Apathy is a sense of indifference and lack of interest in activities that were once enjoyable. Delusions are firmly held false beliefs that are not based in reality. These symptoms can significantly impact an individual’s ability to function in daily life and can lead to social isolation and difficulty maintaining relationships. It is important for individuals experiencing these symptoms to seek professional help and support.
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This question is part of the following fields:
- Psychiatry
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Question 22
Correct
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An 80-year-old man with a history of recurrent falls attends the Elderly Care Clinic with his daughter. He also has a history of mild dementia, congestive heart failure, coronary artery disease, hypertension and type 2 diabetes. He takes furosemide, lisinopril, amitriptyline, aspirin, metoprolol, olanzapine and simvastatin. He lives by himself in a house in which he has lived for 30 years and has help with all activities of daily living. On examination, he appears frail, has mild bruising over both knees from recent falls and has reduced proximal lower-extremity muscle strength.
Which of the following interventions will decrease his risk of falling in the future?Your Answer: Balance and gait training physical exercises
Explanation:The Most Appropriate Interventions to Reduce Falls in the Elderly
Balance and gait training exercises are effective interventions to reduce falls in the elderly. On the other hand, continuing olanzapine and commencing donepezil have not been proven to reduce the risk of falls. Diuretics, such as furosemide, can increase the likelihood of falls, so stopping them is recommended. Additionally, amitriptyline has anticholinergic side-effects that can lead to confusion and falls, so discontinuing it is a quick and potentially effective intervention. Overall, a multifactorial approach that includes balance and gait training, medication review, and fall risk assessment is the most appropriate strategy to reduce falls in the elderly.
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This question is part of the following fields:
- Acute Medicine And Intensive Care
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Question 23
Incorrect
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A 56-year-old woman visits her GP complaining of fatigue and a painful finger that has been bothering her for the past 3 weeks. She has also discovered a soft lump at the base of her left calf and requests that it be examined. She denies any fever, weight loss, or trauma, and has a medical history of systemic lupus erythematosus.
During the examination, the GP observes erythema and swelling in the proximal interphalangeal joint of the left index finger. The patient can move the joint independently, but pain limits her range of motion. Arthrocentesis reveals yellow fluid without crystal formation or gram stain, but a high level of leukocytes (40,000/μL) and a predominance of polymorphonuclear neutrophils in the cytology.
What is the probable diagnosis?Your Answer:
Correct Answer: Rheumatoid arthritis
Explanation:A joint aspiration is recommended for this patient who presents with new-onset monoarticular arthritis and no confirmed diagnosis of rheumatoid arthritis. In cases of rheumatoid arthritis, the synovial fluid will typically appear yellow and have increased opacity due to the quantity of leukocytes present. The leukocyte count can range from 2,000 to 50,000 per microlitre, with a predominance of polymorphonuclear neutrophils (PMNs). There will be no crystals present. Despite the patient’s atypical history of rheumatoid arthritis, the arthrocentesis findings, along with their past medical history of systemic lupus erythematosus (SLE) and the presence of constitutional symptoms and an Achilles tendon nodule, support the diagnosis of rheumatoid arthritis. Gout, osteoarthritis, and pseudogout can be ruled out based on the absence of their characteristic arthrocentesis findings.
Rheumatoid Arthritis: Symptoms and Presentations
Rheumatoid arthritis is a chronic autoimmune disease that primarily affects the joints, causing pain, swelling, and stiffness. The typical features of rheumatoid arthritis include swollen and painful joints in the hands and feet, with stiffness being worse in the morning. The condition gradually worsens over time, with larger joints becoming involved. The presentation of rheumatoid arthritis usually develops insidiously over a few months, and a positive ‘squeeze test’ may be observed, which causes discomfort on squeezing across the metacarpal or metatarsal joints.
Late features of rheumatoid arthritis include Swan neck and boutonnière deformities, which are unlikely to be present in a recently diagnosed patient. However, other presentations of rheumatoid arthritis may include an acute onset with marked systemic disturbance or relapsing/remitting monoarthritis of different large joints, known as palindromic rheumatism. It is important to recognize the symptoms and presentations of rheumatoid arthritis to ensure prompt diagnosis and treatment.
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This question is part of the following fields:
- Musculoskeletal
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Question 24
Incorrect
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A 14-year-old girl presents to the emergency department with symptoms of a cold. She has been experiencing a fever, runny nose, headache, and a dry cough for a few days. Despite taking paracetamol and ibuprofen, her temperature has not gone down, which worries her mother. The patient is alert, comfortable, and well-hydrated. During the examination, her temperature is 38.9ºC, heart rate is 110 bpm, blood pressure is 90/70 mmHg, and respiratory rate is 26 breaths per minute. Her chest is clear, throat is slightly red, and there are no signs of tonsillitis. Otoscopy shows no abnormalities, and her ears are non-tender. There are no rashes, photophobia, or neck stiffness. What is the appropriate management for this patient?
Your Answer:
Correct Answer: Initiate sepsis six protocol
Explanation:Children over the age of 12 have vital signs similar to adults. However, if a child presents with symptoms of sepsis, such as a high temperature, elevated heart rate, low blood pressure, and increased respiratory rate, it is important to initiate the sepsis six protocol and conduct further investigations to determine the source of infection. In such cases, it is not appropriate to send the child home or administer additional doses of antipyretics. Aspirin should not be given to children due to the risk of Reye’s syndrome. Broad-spectrum IV antibiotics should be administered if there is a suspected bacterial infection causing sepsis.
Age-appropriate Vital Signs for Children
Paediatric vital signs vary depending on the age of the child. The table below provides age-appropriate ranges for heart rate and respiratory rate. For children under one year old, a heart rate of 110-160 beats per minute and a respiratory rate of 30-40 breaths per minute is considered normal. For children between the ages of one and two, a heart rate of 100-150 beats per minute and a respiratory rate of 25-35 breaths per minute is normal. Children between the ages of two and five should have a heart rate of 90-140 beats per minute and a respiratory rate of 25-30 breaths per minute. For children between the ages of five and twelve, a heart rate of 80-120 beats per minute and a respiratory rate of 20-25 breaths per minute is normal. Finally, for children over the age of twelve, a heart rate of 60-100 beats per minute and a respiratory rate of 15-20 breaths per minute is considered normal. It is important for healthcare professionals to be aware of these age-appropriate vital sign ranges in order to properly assess the health of children.
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This question is part of the following fields:
- Paediatrics
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Question 25
Incorrect
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A 50-year-old man is five days post-laparotomy for subacute intestinal obstruction secondary to underlying Crohn’s disease. He has suddenly become breathless and complains of pleuritic chest pain. On examination, the patient is confused and his chest is clear to auscultation. However, he is tachypnoeic and has a mildly raised jugular venous pressure (JVP).
Observations:
Blood pressure 97/70 mmHg
Heart rate 126 bpm
Respiratory rate 25 breaths per minute
Oxygen saturations 92% on room air
Arterial blood gas:
Investigation Result Normal value
pH 7.53 7.35–7.45
Pa(CO2) 3.1 kPa 4.6–6.0 kPa
Pa(O2) 8.3 kPa 10.5–13.5 kPa
An electrocardiogram (ECG) shows sinus tachycardia and right bundle branch block.
Computed tomography pulmonary angiogram (CTPA) confirms the diagnosis of pulmonary embolism.
Which is the most appropriate immediate management for this patient?Your Answer:
Correct Answer: iv fluids, oxygen, rivaroxaban
Explanation:Management of Pulmonary Embolism postoperatively
Pulmonary embolism is a serious complication that can occur after surgery and is associated with high mortality rates. The prompt diagnosis and management of this condition are crucial, and anticoagulant treatment is typically recommended. Patients can be started on apixaban or rivaroxaban at a therapeutic dose or a combination of LMWH and either dabigatran or warfarin until therapeutic levels are reached. In the case of warfarin, it is typically started concurrently with LMWH since it takes 48-72 hours for its anticoagulant properties to take effect.
In addition to anticoagulant therapy, patients with pulmonary embolism may require iv fluids and high-flow oxygen if they are hypotensive and hypoxic. Enoxaparin is typically used as a treatment dose, but unfractionated iv heparin may be used as an alternative in patients with renal impairment.
Warfarin is used for long-term anticoagulation in patients who have had pulmonary embolism, but it is not appropriate for immediate management since it is initially pro-thrombotic. Thrombolysis is indicated in patients who are haemodynamically unstable, but it is generally avoided postoperatively due to an increased risk of bleeding.
In summary, the management of pulmonary embolism postoperatively involves prompt diagnosis, anticoagulant therapy, and supportive measures such as iv fluids and oxygen. The choice of anticoagulant and duration of therapy will depend on the patient’s individual circumstances and risk factors.
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This question is part of the following fields:
- Surgery
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Question 26
Incorrect
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A 42-year-old man comes in after being found unconscious. He smells strongly of alcohol.
When considering withdrawal from this substance, which of the following statements is correct?Your Answer:
Correct Answer: Hypophosphataemia is commonly seen
Explanation:Misconceptions about Alcohol Withdrawal: Debunked
Alcohol withdrawal is a common condition that can lead to serious complications if not managed properly. However, there are several misconceptions about alcohol withdrawal that can lead to inappropriate treatment and poor outcomes. Let’s debunk some of these misconceptions:
1. Hypophosphataemia is commonly seen: This is true. Hypophosphataemia is a common electrolyte abnormality in alcohol withdrawal due to malnutrition.
2. Visual hallucinations suggest a coexisting psychiatric disorder: This is false. Visual hallucinations in alcohol withdrawal are usually related to alcohol withdrawal and not necessarily a coexisting psychiatric disorder.
3. Flumazenil is routinely used as part of the detoxification process: This is false. Flumazenil is not routinely used in alcohol detoxification but may be useful in benzodiazepine overdose.
4. Seizures are rare: This is false. Seizures in alcohol withdrawal are common and can lead to serious complications if not managed properly.
5. All patients who have a seizure should be started on an antiepileptic: This is false. Withdrawal seizures generally do not require antiepileptic treatment and may even increase the risk of further seizures and other medical problems.
In summary, it is important to understand the true nature of alcohol withdrawal and its associated complications to provide appropriate and effective treatment.
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This question is part of the following fields:
- Gastroenterology
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Question 27
Incorrect
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A 68-year-old man presented to the clinic with occasional abdominal pain, for which his general practitioner could find no reason. After your assessment, you organise an ultrasound scan of the abdomen to rule out any pathology and incidentally find out that the patient has an abdominal aortic aneurysm (AAA).
Which statement best applies to an AAA?Your Answer:
Correct Answer: Surveillance is carried out with CT scanning or ultrasound
Explanation:Understanding Abdominal Aortic Aneurysms: Diagnosis, Monitoring, and Treatment
Abdominal aortic aneurysms (AAAs) are a serious medical condition that require careful monitoring and prompt treatment. Diagnosis is typically done through ultrasound screening, with men being invited for screening during their 65th year. Once an AAA is detected, monitoring is done through CT scanning or ultrasound, with the frequency of scans increasing as the aneurysm grows in size. If a leak is suspected, immediate surgical intervention is necessary, although a CT scan may be performed first to assess the extent of the leak. Surgery is typically done when the aneurysm reaches a diameter of 5.5 cm or greater, with repair options including open surgery with a synthetic graft or endovascular repair. Patients may present with central and upper abdominal pain radiating to their back, and misdiagnosis as renal colic can be fatal. Understanding the diagnosis, monitoring, and treatment of AAAs is crucial for ensuring the best possible outcomes for patients.
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This question is part of the following fields:
- Vascular
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Question 28
Incorrect
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A 25-year-old female arrives at the emergency department after overdosing on a substance. She reports experiencing tinnitus and displays signs of anxiety and sweating. Your task is to conduct an arterial blood gas (ABG) test. What are the probable ABG findings?
Your Answer:
Correct Answer: Respiratory alkalosis followed by metabolic acidosis
Explanation:Based on the symptoms of tinnitus, anxiety, and diaphoresis, it is probable that the patient has overdosed on salicylates. Salicylate overdoses usually manifest with respiratory alkalosis at first, caused by hyperventilation, and then metabolic acidosis due to the buildup of lactic acid. Therefore, although options 1 and 3 are feasible, option 4 is the most probable.
Salicylate overdose can result in a combination of respiratory alkalosis and metabolic acidosis. The initial effect of salicylates is to stimulate the respiratory center, leading to hyperventilation and respiratory alkalosis. However, as the overdose progresses, the direct acid effects of salicylates, combined with acute renal failure, can cause metabolic acidosis. In children, metabolic acidosis tends to be more prominent. Other symptoms of salicylate overdose include tinnitus, lethargy, sweating, pyrexia, nausea/vomiting, hyperglycemia and hypoglycemia, seizures, and coma.
The treatment for salicylate overdose involves general measures such as airway, breathing, and circulation support, as well as administering activated charcoal. Urinary alkalinization with intravenous sodium bicarbonate can help eliminate aspirin in the urine. In severe cases, hemodialysis may be necessary. Indications for hemodialysis include a serum concentration of salicylates greater than 700 mg/L, metabolic acidosis that is resistant to treatment, acute renal failure, pulmonary edema, seizures, and coma.
It is important to note that salicylates can cause the uncoupling of oxidative phosphorylation, which leads to decreased adenosine triphosphate production, increased oxygen consumption, and increased carbon dioxide and heat production. Therefore, prompt and appropriate treatment is crucial in managing salicylate overdose.
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This question is part of the following fields:
- Pharmacology
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Question 29
Incorrect
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You see a 92-year-old gentleman who has been admitted following a fall. He had been discovered lying on the floor of his home by a neighbour. He has a diagnosis of dementia and cannot recall how long ago he had fallen. His observations are normal and he is apyrexial. A pelvic X-ray, including both hips, shows no evidence of bony injury. A full blood count is normal.
His biochemistry results are as follows:
Investigation Result Normal value
Creatinine 210 μmol/l 50–120 µmol/l
Urea 22.0 mmol/l 2.5–6.5 mmol/l
Sodium 133 mmol/l 135–145 mmol/l
Potassium 4.9 mmol/l 3.5–5.0 mmol/l
C-reactive protein (CRP) 8 mg/l 0–10 mg/l
What is the most appropriate investigation to request next?Your Answer:
Correct Answer: Creatine kinase
Explanation:Investigating the Cause of Renal Failure: Importance of Creatine Kinase
Renal failure can have various causes, including dehydration, sepsis, and rhabdomyolysis. In this case, the patient’s normal observations and inflammatory markers suggest rhabdomyolysis as the most serious potential cause. A raised creatine kinase would confirm the diagnosis. Elderly patients are particularly at risk of rhabdomyolysis following a prolonged period of immobility. A falls screen, including routine bloods, blood glucose, resting electrocardiogram, urinalysis, and lying-standing blood pressure, would be appropriate. While a catheter urine specimen may be helpful in diagnosing sepsis, it is less likely in this case. Liver function tests and upper gastrointestinal endoscopy are unlikely to provide useful information. A plain chest X-ray is also not necessary for investigating the cause of renal failure.
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This question is part of the following fields:
- Acute Medicine And Intensive Care
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Question 30
Incorrect
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A 58-year-old man undergoes a right middle lobectomy of his lung for lung cancer. A chest drain is inserted at the time of surgery to allow full lung reinflation. Three days after the operation, you notice that air bubbles escape through the chest drain into the water seal whenever the patient coughs.
What is the most likely diagnosis?Your Answer:
Correct Answer: Air leak from the area of resected lung
Explanation:Causes of Air Leak from the Area of Resected Lung
Following a lung resection, air may escape through the chest drain due to an air leak from the edge of the resected lung. This can be worsened by talking or coughing, which increases airway pressure. If the chest drain is removed, the patient is at risk of developing a pneumothorax. Conservative management is the first-line approach, which involves leaving the existing chest drain in place and on suction. If significant air leakage occurs, a second drain may be inserted. If the air leak persists, a second operation may be necessary to repair the defect.
Other potential causes of bubbling in the chest drain when the patient coughs include a blocked chest drain, empyema with gas-forming organisms, and recurrent lung cancer. However, these conditions would present differently and have additional symptoms that are absent in cases of air leak from the area of resected lung.
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This question is part of the following fields:
- Cardiothoracic
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