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  • Question 1 - A 28-year-old woman who has never given birth before goes into spontaneous labour...

    Correct

    • A 28-year-old woman who has never given birth before goes into spontaneous labour and you are assisting in the vaginal delivery of a baby girl weighing 3.2 kg. To assess the newborn's health, you use the Apgar score. Can you provide the correct components of the Apgar score?

      Your Answer: Pulse, respiratory effort, colour, muscle tone, reflex irritability

      Explanation:

      To evaluate the well-being of a newborn, medical professionals use the Apgar scoring system. This system takes into account the infant’s pulse, respiratory function, skin color, muscle tone, and reflex response.

      The Apgar score is a tool used to evaluate the health of a newborn baby. It is recommended by NICE to be assessed at 1 and 5 minutes after birth, and again at 10 minutes if the initial score is low. The score is based on five factors: pulse, respiratory effort, color, muscle tone, and reflex irritability. A score of 0-3 is considered very low, 4-6 is moderate low, and 7-10 indicates that the baby is in good health. The score helps healthcare professionals quickly identify any potential issues and provide appropriate care.

    • This question is part of the following fields:

      • Paediatrics
      48.4
      Seconds
  • Question 2 - A 32-year-old postal worker with asthma visits his GP for his annual asthma...

    Correct

    • A 32-year-old postal worker with asthma visits his GP for his annual asthma review. He reports experiencing breathlessness during his morning postal round for the past few months. Despite a normal examination, the GP advises him to conduct peak flow monitoring. The results show a best PEFR of 650 L/min and an average of 439 L/min, with a predicted PEFR of 660 L/min. What is the most likely interpretation of these PEFR results?

      Your Answer: Suboptimal therapy

      Explanation:

      Differentiating Between Respiratory Conditions: A Guide

      When assessing a patient with respiratory symptoms, it is important to consider various conditions that may be causing their symptoms. One key factor to consider is the patient’s peak expiratory flow rate (PEFR), which should be above 80% of their best reading. If it falls below this level, it may indicate the need for therapy titration.

      Chronic obstructive pulmonary disease (COPD) is unlikely in a young patient without smoking history, and clinical examination is likely to be abnormal in this condition. On the other hand, variability in PEFR is a hallmark of asthma, and the reversibility of PEFR after administering a nebulized dose of salbutamol can help differentiate between asthma and COPD.

      Occupational asthma is often caused by exposure to irritants or allergens in the workplace. Monitoring PEFR for two weeks while working and two weeks away from work can help diagnose this condition.

      Interstitial lung disease may cause exertional breathlessness, but fine end inspiratory crackles and finger clubbing would be present on examination. Additionally, idiopathic pulmonary fibrosis typically presents after the age of 50, making it unlikely in a 36-year-old patient.

      Finally, an acute exacerbation of asthma would present with a shorter duration of symptoms and abnormal clinical examination findings. By considering these factors, healthcare providers can more accurately diagnose and treat respiratory conditions.

    • This question is part of the following fields:

      • Respiratory
      99.5
      Seconds
  • Question 3 - A 50-year-old male patient presents with dyspepsia of 4 weeks’ duration. Other than...

    Incorrect

    • A 50-year-old male patient presents with dyspepsia of 4 weeks’ duration. Other than a 15-pack year history of smoking, he has no other medical history and reports no prescribed or over-the-counter medications. Endoscopy reveals features of gastritis and a solitary gastric ulcer in the pyloric antrum. A rapid urease test turned red, revealing a positive result.
      What would be a suitable treatment for this patient?

      Your Answer: Omeprazole

      Correct Answer: Amoxicillin, clarithromycin and omeprazole

      Explanation:

      Diagnosis and Treatment of Helicobacter pylori Infection

      Helicobacter pylori is a Gram-negative bacillus that causes chronic gastritis and can lead to ulceration if left untreated. Diagnosis of H. pylori infection can be done through a rapid urease test, which detects the presence of the enzyme urease produced by the bacterium. Treatment for H. pylori infection involves a 7-day course of two antibiotics and a proton pump inhibitor (PPI). Fluconazole, prednisolone and azathioprine, and quinine and clindamycin are not appropriate treatments for H. pylori infection. Combination drug therapy is common to reduce the risk of resistance in chronic infections. Repeat testing should be done after treatment to ensure clearance of the infection.

    • This question is part of the following fields:

      • Gastroenterology
      27
      Seconds
  • Question 4 - A 67-year-old man comes to the clinic complaining of sudden and severe pain...

    Incorrect

    • A 67-year-old man comes to the clinic complaining of sudden and severe pain in his right knee. He has never experienced this before. Upon examination, the joint fluid is extracted and sent to the lab for analysis. The rheumatology team suspects pseudogout. What characteristics can help differentiate this condition from gout?

      Your Answer: Presence of crystals

      Correct Answer: Chondrocalcinosis

      Explanation:

      Chondrocalcinosis is a useful factor in distinguishing between pseudogout and gout. Linear calcifications of the meniscus and articular cartilage seen on a knee x-ray are indicative of pseudogout, but not particularly associated with gout. Therefore, the presence of chondrocalcinosis can be used to differentiate between the two conditions.

      Age is not a determining factor in the diagnosis of gout or pseudogout. In this case, the patient’s age of 64 years does not provide any significant information to sway the diagnosis in either direction.

      The presence of crystals is not a distinguishing factor between gout and pseudogout, as both conditions involve crystals. However, the type of crystals differs between the two. Pseudogout crystals are weakly-positively birefringent rhomboid-shaped, while gout crystals are negatively birefringent.

      Both gout and pseudogout typically respond well to colchicine for acute pain management, so this is not a useful factor in distinguishing between the two conditions.

      Increased warmth of the affected joint is not a reliable factor in distinguishing between gout and pseudogout, as it may be present in both conditions.

      Pseudogout, also known as acute calcium pyrophosphate crystal deposition disease, is a type of microcrystal synovitis that occurs when calcium pyrophosphate dihydrate crystals are deposited in the synovium. This condition is more common in older individuals, but those under 60 years of age may develop it if they have underlying risk factors such as haemochromatosis, hyperparathyroidism, low magnesium or phosphate levels, acromegaly, or Wilson’s disease. The knee, wrist, and shoulders are the most commonly affected joints, and joint aspiration may reveal weakly-positively birefringent rhomboid-shaped crystals. X-rays may show chondrocalcinosis, which appears as linear calcifications of the meniscus and articular cartilage in the knee. Treatment involves joint fluid aspiration to rule out septic arthritis, as well as the use of NSAIDs or steroids, as with gout.

    • This question is part of the following fields:

      • Musculoskeletal
      9.4
      Seconds
  • Question 5 - A 6-month-old girl is brought to the emergency department by her worried father....

    Correct

    • A 6-month-old girl is brought to the emergency department by her worried father. He reports that she has had a low-grade fever and a runny nose for the past week, and in the last few days, she has been struggling to breathe and making grunting noises. He is concerned because she is not eating well and her diapers are not as wet as usual. Upon examination, you observe chest retractions, wheezing, and bilateral inspiratory crackles.
      What is the most suitable treatment for the probable diagnosis?

      Your Answer: Admit for supportive treatment

      Explanation:

      The appropriate action for a child with bronchiolitis is to admit them for supportive treatment, as antibiotics are not necessary. This condition is typically caused by RSV and can be managed with supportive care. However, if the child is experiencing severe respiratory distress and a significant reduction in feeding, they should be admitted to the hospital for treatment. Admitting for IV antibiotics would not be appropriate unless pneumonia or another bacterial infection was suspected. Salbutamol nebulisers are not typically effective for bronchiolitis. Discharging the child home with advice or oral antibiotics would not be appropriate if they are showing signs of potentially serious illness.

      Bronchiolitis is a condition where the bronchioles become inflamed, and it is most commonly caused by respiratory syncytial virus (RSV). This virus is responsible for 75-80% of cases, with other causes including mycoplasma and adenoviruses. Bronchiolitis is most prevalent in infants under one year old, with 90% of cases occurring in those aged 1-9 months. The condition is more serious in premature babies, those with congenital heart disease or cystic fibrosis. Symptoms include coryzal symptoms, dry cough, increasing breathlessness, and wheezing. Hospital admission is often necessary due to feeding difficulties associated with increasing dyspnoea.

      Immediate referral is recommended if the child has apnoea, looks seriously unwell, has severe respiratory distress, central cyanosis, or persistent oxygen saturation of less than 92% when breathing air. Clinicians should consider referral if the child has a respiratory rate of over 60 breaths/minute, difficulty with breastfeeding or inadequate oral fluid intake, or clinical dehydration. Immunofluorescence of nasopharyngeal secretions may show RSV, and management is largely supportive. Humidified oxygen is given via a head box if oxygen saturations are persistently low, and nasogastric feeding may be necessary if children cannot take enough fluid/feed by mouth. Suction may also be used for excessive upper airway secretions. NICE released guidelines on bronchiolitis in 2015 for more information.

    • This question is part of the following fields:

      • Paediatrics
      17.5
      Seconds
  • Question 6 - A patient with persistent sinusitis is scheduled for endoscopic surgery to address any...

    Incorrect

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

      Your Answer: Anterior ethmoidal sinus

      Correct Answer: Sphenoidal sinus

      Explanation:

      Sinus Drainage Pathways in the Nasal Cavity

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

    • This question is part of the following fields:

      • ENT
      34.5
      Seconds
  • Question 7 - A 14-year-old girl comes to see you, the practice nurse, after getting an...

    Incorrect

    • A 14-year-old girl comes to see you, the practice nurse, after getting an open wound on her right arm while playing basketball. Upon examination, you find a 5 cm wound that is dirty and contains dirt. What is the best course of action for tetanus vaccination in this patient?

      Your Answer: If he has received three doses of tetanus toxoid and the last booster was more than 10 years ago he should receive a further three dose course tetanus vaccine

      Correct Answer: If his immunisation status is uncertain he should receive tetanus immunoglobulin and vaccine

      Explanation:

      Tetanus Vaccination and Treatment for Tetanus Prone Wounds

      When it comes to tetanus vaccination, individuals who have completed the full five-course of the vaccine are not recommended to receive any further doses if they suffer a tetanus prone wound. However, there is some disagreement over whether or not to administer Tetanus Immune Globulin (TIG) to those who are known to be fully immunized. Some sources suggest giving TIG for all high-risk wounds, while others recommend it only if five years have passed since the last dose. It is important to consult with a healthcare professional to determine the best course of action in the event of a tetanus prone wound. Proper vaccination and treatment can prevent the potentially fatal effects of tetanus.

    • This question is part of the following fields:

      • General Practice
      19
      Seconds
  • Question 8 - A mother of three brings her youngest daughter, aged 15, to the general...

    Incorrect

    • A mother of three brings her youngest daughter, aged 15, to the general practitioner (GP) as she is yet to start menstruating, whereas both her sisters had menarche at the age of 12.
      The patient has developed secondary female sexual characteristics and has a normal height. She reports struggling with headaches and one episode of galactorrhoea.
      Magnetic resonance imaging (MRI) reveals an intracranial tumour measuring 11 mm in maximal diameter.
      Given the most likely diagnosis, which of the following is the first-line management option?

      Your Answer: Surgery to remove the tumour

      Correct Answer: Medical treatment with cabergoline

      Explanation:

      The patient has primary amenorrhoea due to a macroprolactinoma, which is a benign prolactin-secreting tumor of the anterior pituitary gland. Treatment in the first instance is with a dopamine receptor agonist such as bromocriptine or cabergoline. Surgery is the most appropriate management if conservative management fails or the patient presents with visual field defects. Radiotherapy is rarely used. Exclusion of pregnancy is the first step in every case of amenorrhoea. Metoclopramide is a dopamine receptor antagonist and a cause of hyperprolactinaemia, so it should not be used to treat this patient. Thyroxine is not appropriate as hyperprolactinaemia is secondary to a pituitary adenoma. Indications for surgery are failure to respond to medical therapy or presentation with acute visual field defects.

    • This question is part of the following fields:

      • Gynaecology
      27.2
      Seconds
  • Question 9 - A 57-year-old woman visits her doctor complaining of fatigue and difficulty standing up...

    Incorrect

    • A 57-year-old woman visits her doctor complaining of fatigue and difficulty standing up from her chair for the past four weeks. She reports experiencing eyelid swelling and feeling generally unwell for the past two months, and now has trouble walking and grooming herself. Upon examination, the doctor observes reduced strength in her hips and shoulders, a heliotrope rash around her eyes, and a thick red rash on her knuckles. The doctor suspects a rheumatological condition and refers her for further testing. What urgent additional investigation is required, given the probable diagnosis?

      Your Answer: Fundoscopy

      Correct Answer: Malignancy screen

      Explanation:

      Patients who are newly diagnosed with dermatomyositis require an urgent screening for malignancy. The presence of proximal muscle weakness, heliotrope rash, and Gottron’s papules are indicative of dermatomyositis. It is important to investigate for underlying cancer, with common malignancies including lung, breast, ovarian, prostate, and colorectal. A malignancy screen may involve a chest x-ray, mammography, CA-125, pelvic ultrasound (in females), prostate-specific antigen (in males), faecal occult blood testing, and potentially a CT chest/abdomen/pelvis. Basic blood tests such as serum corrected calcium and LFTs should also be done as a quick screen for bone and liver metastases. Fundoscopy is not necessary in the absence of ocular symptoms. A pregnancy test is not required for this patient due to her age. A renal biopsy is only necessary if there is rheumatological renal disease or if systemic lupus erythematosus is suspected. However, the patient’s symptoms are more consistent with dermatomyositis.

      Dermatomyositis is a condition that causes inflammation and muscle weakness, as well as distinct skin lesions. It can occur on its own or be associated with other connective tissue disorders or underlying cancers, particularly ovarian, breast, and lung cancer. Screening for cancer is often done after a diagnosis of dermatomyositis. Polymyositis is a variant of the disease that does not have prominent skin manifestations.

      The skin features of dermatomyositis include a photosensitive macular rash on the back and shoulders, a heliotrope rash around the eyes, roughened red papules on the fingers’ extensor surfaces (known as Gottron’s papules), extremely dry and scaly hands with linear cracks on the fingers’ palmar and lateral aspects (known as mechanic’s hands), and nail fold capillary dilation. Other symptoms may include proximal muscle weakness with tenderness, Raynaud’s phenomenon, respiratory muscle weakness, interstitial lung disease (such as fibrosing alveolitis or organizing pneumonia), dysphagia, and dysphonia.

      Investigations for dermatomyositis typically involve testing for ANA antibodies, which are positive in around 80% of patients. Approximately 30% of patients have antibodies to aminoacyl-tRNA synthetases, including antibodies against histidine-tRNA ligase (also called Jo-1), antibodies to signal recognition particle (SRP), and anti-Mi-2 antibodies.

    • This question is part of the following fields:

      • Musculoskeletal
      26
      Seconds
  • Question 10 - A 27-year-old woman is brought to the Emergency Department by ambulance from a...

    Incorrect

    • A 27-year-old woman is brought to the Emergency Department by ambulance from a music festival. It is a hot day and she had been standing in the crowd when she suddenly collapsed and lost consciousness. She is now fully alert and gives a history of feeling dizzy and nauseated before the collapse. She tells you that she is healthy, plays tennis for her local club and is a keen runner. She has had no previous episodes of losing consciousness. Her father has recently had a heart attack aged 60 years. Her resting electrocardiogram (ECG) shows a corrected QT interval of 400 ms and a slightly prolonged PR interval but is otherwise normal.
      What is the most likely diagnosis?

      Your Answer: Long QT syndrome

      Correct Answer: Vasovagal syncope

      Explanation:

      Differential Diagnosis for a Patient with Vasovagal Syncope

      Vasovagal syncope is a common cause of transient loss of consciousness. The hallmark of this condition is the three Ps – pallor, palpitations, and sweating. In patients with a history of vasovagal syncope, the ECG is typically normal. A prolonged PR interval may be seen in young athletes, but first-degree heart block rarely causes cardiac syncope. Ischemic heart disease is not a significant factor in this condition, and a family history of myocardial infarction is not relevant.

      If there are no features suggesting a more serious cause of transient loss of consciousness or a significant personal or family cardiac history, the patient can be discharged from the Emergency Department. However, they should be advised to seek medical attention if they experience any further episodes.

      Other conditions that may cause transient loss of consciousness include complete heart block, hypertrophic cardiomyopathy, substance misuse, and long QT syndrome. However, in this case, the patient’s history and ECG are not suggestive of these conditions.

    • This question is part of the following fields:

      • Cardiology
      19.2
      Seconds
  • Question 11 - A 27-year-old woman participates in the UK cervical screening programme and receives an...

    Incorrect

    • A 27-year-old woman participates in the UK cervical screening programme and receives an 'inadequate sample' result from her cervical smear test. After a repeat test 3 months later, she still receives an 'inadequate sample' result. What should be done next?

      Your Answer: Repeat the test within 3 months

      Correct Answer: Colposcopy

      Explanation:

      In the NHS cervical screening programme, cervical cancer screening involves testing for high-risk HPV (hrHPV) first. If the initial test results in an inadequate sample, it should be repeated after 3 months. If the second test also returns as inadequate, then colposcopy should be performed. This is because without obtaining hr HPV status or performing cytology, the risk of cervical cancer cannot be assessed. It would be unsafe to return the patient to normal recall as this could result in a delayed diagnosis of cervical cancer. Repeating the test after 3, 6 or 12 months is also not recommended as it may lead to a missed diagnosis.

      The cervical cancer screening program has evolved to include HPV testing, which allows for further risk stratification. A negative hr HPV result means a return to normal recall, while a positive result requires cytological examination. Abnormal cytology results lead to colposcopy, while normal cytology results require a repeat test at 12 months. Inadequate samples require a repeat within 3 months, and two consecutive inadequate samples lead to colposcopy. Treatment for CIN typically involves LLETZ or cryotherapy. Individuals who have been treated for CIN should be invited for a test of cure repeat cervical sample 6 months after treatment.

    • This question is part of the following fields:

      • Gynaecology
      10.2
      Seconds
  • Question 12 - A 68-year-old woman presents to eye casualty with a painful, red eye and...

    Incorrect

    • A 68-year-old woman presents to eye casualty with a painful, red eye and blurred vision. She reports that the pain started suddenly this morning. On examination, there is swelling of the eyelid and a small hypopyon is present. Her vision is blurry in the affected eye and she can only see moving fingers at a distance of one meter. Fundoscopy reveals periphlebitis. The patient has no significant medical history except for cataract surgery performed 3 days ago. What is the probable diagnosis?

      Your Answer: Blepharitis

      Correct Answer: Endophthalmitis

      Explanation:

      Endophthalmitis is a rare but serious complication of cataract surgery that requires urgent treatment. This patient is experiencing a painful and red eye after undergoing cataract surgery, which is a common symptom of endophthalmitis. The condition occurs when microbial organisms are introduced into the eye during surgery, either from the patient’s normal flora or contaminated instruments. Symptoms include retinal periphlebitis, pain, redness, ocular discharge, and worsening vision. Treatment involves prompt administration of intravitreal or systemic antibiotics. Blepharitis, infective conjunctivitis, and keratitis are other ocular conditions that do not fit the symptoms presented by this patient.

      Understanding Cataracts: Causes, Symptoms, and Management

      A cataract is a common eye condition that affects the lens of the eye, causing it to become cloudy and reducing the amount of light that reaches the retina. This can lead to blurred or reduced vision, making it difficult to see clearly. Cataracts are more common in women and tend to increase in incidence with age. While the normal ageing process is the most common cause, other factors such as smoking, alcohol consumption, trauma, diabetes, and long-term corticosteroid use can also contribute to the development of cataracts.

      Symptoms of cataracts include reduced vision, faded colour vision, glare, and halos around lights. A defect in the red reflex is also a sign of cataracts. Diagnosis is typically made through ophthalmoscopy and slit-lamp examination, which can reveal the presence of a visible cataract.

      In the early stages, age-related cataracts can be managed conservatively with stronger glasses or contact lenses and brighter lighting. However, surgery is the only effective treatment for cataracts and involves removing the cloudy lens and replacing it with an artificial one. Referral for surgery should be based on the presence of visual impairment, impact on quality of life, and patient choice. Complications following surgery can include posterior capsule opacification, retinal detachment, posterior capsule rupture, and endophthalmitis.

      Overall, cataracts are a common and treatable eye condition that can significantly impact a person’s vision. Understanding the causes, symptoms, and management options can help individuals make informed decisions about their eye health.

    • This question is part of the following fields:

      • Ophthalmology
      18.5
      Seconds
  • Question 13 - A 42-year-old woman comes to the Neurology Clinic with complaints of painful unilateral...

    Incorrect

    • A 42-year-old woman comes to the Neurology Clinic with complaints of painful unilateral visual disturbance, ataxia, and sensory deficit. She is diagnosed with multiple sclerosis (MS) after undergoing magnetic resonance imaging (MRI) and is started on steroid treatment, followed by disease-modifying therapy. Her disease is stable after six months, and she can manage her daily activities without significant problems. She used to drive a car but has not done so since her diagnosis. She is now curious about her driving situation.

      What are the most appropriate steps to take regarding her driving circumstances?

      Your Answer: She must inform the DVLA and cannot drive for one year since her most recent relapse

      Correct Answer: She must inform the DVLA and may continue to drive

      Explanation:

      Driving with Multiple Sclerosis: Informing the DVLA

      Multiple Sclerosis (MS) is a chronic neurological disorder that may affect vehicle control due to impaired coordination and muscle strength. It is essential to inform the Driver and Vehicle Licensing Agency (DVLA) upon diagnosis. The official guidance states that patients with MS may continue to drive as long as safe vehicle control is maintained. However, it is necessary to update the DVLA if circumstances change. There is no arbitrary timeframe for inability to drive, and it is assessed individually based on the state of the patient’s chronic disease. It is not appropriate to base this on relapses as patients may relapse at different time periods and tend not to return to baseline function in relapsing-remitting MS. Failure to inform the DVLA can result in legal consequences. Therefore, it is crucial to inform the DVLA and follow their guidelines to ensure safe driving.

    • This question is part of the following fields:

      • Neurology
      10.2
      Seconds
  • Question 14 - A 20-year-old woman discovers she is pregnant and despite it being unplanned, she...

    Incorrect

    • A 20-year-old woman discovers she is pregnant and despite it being unplanned, she is excited to become a mother. During her initial check-up, her blood pressure is measured at 170/120 mmHg. She has a clean medical history, except for a childhood bout of Henoch-Schönlein purpura. Additionally, there is no relevant family history and she does not smoke. What could be the probable reason for her hypertension?

      Your Answer: Pre-eclampsia

      Correct Answer: Chronic renal impairment

      Explanation:

      Possible Causes of Hypertension in Pregnancy

      This patient is experiencing hypertension during pregnancy, which is commonly associated with pre-eclampsia. However, pre-eclampsia usually occurs later in pregnancy and should not be present during the initial booking visit. The patient’s medical history of Henoch-Schölein purpura suggests the possibility of chronic kidney disease as a potential cause of her hypertension.

      Congenital adrenal hyperplasia is a group of related disorders that can cause abnormal development of sexual characteristics, adrenal crisis, and hypertension. This condition is often diagnosed during puberty when girls experience virilization due to the production of androgens while cortisol levels remain deficient. As a result, many patients with congenital adrenal hyperplasia may have reduced fertility compared to their peers.

      While stress can contribute to hypertension, it is less likely to explain consistently high blood pressure readings. Membranous glomerulonephritis is another potential cause of hypertension, but it is uncommon in a woman of this age. This condition can be caused by heavy metal toxicity, malignancy, or infection with hepatitis C virus.

      In summary, hypertension during pregnancy can have various underlying causes, including pre-eclampsia, chronic kidney disease, congenital adrenal hyperplasia, stress, and membranous glomerulonephritis. Further investigation and medical evaluation are necessary to determine the specific cause and appropriate treatment for this patient.

    • This question is part of the following fields:

      • Nephrology
      16
      Seconds
  • Question 15 - A three-week old boy is brought to the emergency department by ambulance after...

    Incorrect

    • A three-week old boy is brought to the emergency department by ambulance after losing consciousness. His mother reports that he often appears short of breath and has a bluish tint to his skin while feeding, which she assumed was normal. Imaging reveals the presence of right ventricular hypertrophy, a ventricular septal defect, and a displaced aorta. Additional imaging is requested. Based on the probable diagnosis, what type of murmur would be anticipated in this infant?

      Your Answer: Continuous machinery murmur

      Correct Answer: Ejection systolic murmur

      Explanation:

      The correct answer is an ejection systolic murmur. Tetralogy of Fallot is characterized by cyanosis or collapse in the first month of life, hypercyanotic spells, and an ejection systolic murmur heard at the left sternal edge due to pulmonary stenosis. The other features include right ventricular hypertrophy, a ventricular septal defect, and an overriding aorta. A continuous machinery murmur is associated with a patent ductus arteriosus, while a diastolic decrescendo murmur is heard in aortic or pulmonary regurgitation. Finally, a mid-diastolic murmur with an opening click is heard in cases of mitral stenosis.

      Understanding Tetralogy of Fallot

      Tetralogy of Fallot (TOF) is a congenital heart disease that results from the anterior malalignment of the aorticopulmonary septum. It is the most common cause of cyanotic congenital heart disease, and it typically presents at around 1-2 months, although it may not be detected until the baby is 6 months old. The condition is characterized by four features, including ventricular septal defect (VSD), right ventricular hypertrophy, right ventricular outflow tract obstruction, and overriding aorta. The severity of the right ventricular outflow tract obstruction determines the degree of cyanosis and clinical severity.

      Other features of TOF include cyanosis, which may cause episodic hypercyanotic ‘tet’ spells due to near occlusion of the right ventricular outflow tract. These spells are characterized by tachypnea and severe cyanosis that may occasionally result in loss of consciousness. They typically occur when an infant is upset, in pain, or has a fever, and they cause a right-to-left shunt. Additionally, TOF may cause an ejection systolic murmur due to pulmonary stenosis, and a right-sided aortic arch is seen in 25% of patients. Chest x-ray shows a ‘boot-shaped’ heart, while ECG shows right ventricular hypertrophy.

      The management of TOF often involves surgical repair, which is usually undertaken in two parts. Cyanotic episodes may be helped by beta-blockers to reduce infundibular spasm. However, it is important to note that at birth, transposition of the great arteries is the more common lesion as patients with TOF generally present at around 1-2 months. Understanding the features and management of TOF is crucial for healthcare professionals to provide appropriate care and treatment for affected infants.

    • This question is part of the following fields:

      • Paediatrics
      28.1
      Seconds
  • Question 16 - A 30-year-old woman undergoes a vaginal delivery and is examined on the ward...

    Incorrect

    • A 30-year-old woman undergoes a vaginal delivery and is examined on the ward after the placenta is delivered. The examination shows a minor tear on the perineum without any muscle involvement. What is the best course of action?

      Your Answer: Suture in theatre

      Correct Answer: No repair required

      Explanation:

      A first-degree perineal tear typically does not need suturing.

      In the case of this woman, she has a first-degree perineal tear that only affects the surface of the perineum and does not involve any muscles. Therefore, no repair is necessary as these types of tears usually heal on their own.

      The answer glue on the ward is incorrect because first-degree perineal tears do not require closure and should be left to heal naturally. Additionally, glue is not suitable for use in the perineal area and is only appropriate for small, straight, superficial, low-tension wounds.

      Similarly, staples in theatre is also incorrect as first-degree perineal tears do not require repair and will heal on their own. Staples are not recommended for use in the perineal region.

      The answer suture in theatre is also incorrect as first-degree perineal tears typically do not require suturing and can be left to heal on their own. If suturing is necessary for a first-degree tear, it can be done on the ward by a trained practitioner. Only third or fourth-degree tears require repair in a theatre setting under regional or general anaesthesia.

      Perineal tears are a common occurrence during childbirth, and the Royal College of Obstetricians and Gynaecologists (RCOG) has developed guidelines to classify them based on their severity. First-degree tears are superficial and do not require any repair, while second-degree tears involve the perineal muscle and require suturing by a midwife or clinician. Third-degree tears involve the anal sphincter complex and require repair in theatre by a trained clinician, with subcategories based on the extent of the tear. Fourth-degree tears involve the anal sphincter complex and rectal mucosa and also require repair in theatre by a trained clinician.

      There are several risk factors for perineal tears, including being a first-time mother, having a large baby, experiencing a precipitant labour, and having a shoulder dystocia or forceps delivery. It is important for healthcare providers to be aware of these risk factors and to provide appropriate care and management during childbirth to minimize the risk of perineal tears. By following the RCOG guidelines and providing timely and effective treatment, healthcare providers can help ensure the best possible outcomes for both mother and baby.

    • This question is part of the following fields:

      • Obstetrics
      12.7
      Seconds
  • Question 17 - A 68-year-old woman presents to the Emergency Department with acute agitation, fever, nausea...

    Incorrect

    • A 68-year-old woman presents to the Emergency Department with acute agitation, fever, nausea and vomiting. On examination, she is disorientated and agitated, with a temperature of 40 °C and heart rate of 130 bpm, irregular pulse, and congestive cardiac failure. She has a history of hyperthyroidism due to Graves’ disease, neutropenia and agranulocytosis, and cognitive impairment. She lives alone. Laboratory investigations reveal the following results:
      Test Result Normal reference range
      Free T4 > 100 pmol/l 11–22 pmol/l
      Free T3 > 30 pmol/l 3.5–5 pmol/l
      Thyroid stimulating hormone (TSH) < 0.01 µU/l 0.17–3.2 µU/l
      TSH receptor antibody > 30 U/l < 0.9 U/l

      What should be included in the management plan for this 68-year-old patient?

      Your Answer: Prednisolone, paracetamol, tri-iodothyronine

      Correct Answer: Propylthiouracil, iodine, propranolol, hydrocortisone

      Explanation:

      Treatment Options for Thyroid Storm in Graves’ Disease Patients

      Thyroid storm is a life-threatening condition that requires immediate medical attention in patients with Graves’ disease. The following are some treatment options for thyroid storm and their potential effects on the patient’s condition.

      Propylthiouracil, iodine, propranolol, hydrocortisone:
      This combination of medications can help inhibit the synthesis of new thyroid hormone, tone down the severe adrenergic response, and prevent T4 from being converted to the more potent T3. Propylthiouracil and iodine block the synthesis of new thyroid hormone, while propranolol and hydrocortisone help decrease the heart rate and blood pressure.

      Carbimazole, iodine, tri-iodothyronine:
      Carbimazole and iodine can inhibit the synthesis of thyroid hormone, but tri-iodothyronine is very potent and would do the opposite of the therapeutic aim.

      Esmolol, thyroxine, dexamethasone:
      Esmolol and dexamethasone can tone down the severe adrenergic response and prevent T4 from being turned into T3. However, thyroxine would do the opposite of the therapeutic aim and make the situation worse.

      Lugol’s iodine, furosemide, thyroxine:
      Lugol’s iodine can be used to treat hyperthyroidism, but furosemide is not appropriate for addressing thyroid storm. Thyroxine would make the situation worse.

      Prednisolone, paracetamol, tri-iodothyronine:
      Prednisolone can prevent T4 from being converted to T3, but it is usually available in oral form and may not be efficient in addressing thyroid storm. Tri-iodothyronine would exacerbate the patient’s condition, and paracetamol is not indicated for this condition.

      In conclusion, the treatment options for thyroid storm in Graves’ disease patients depend on the patient’s condition and medical history. It is important to consult with a healthcare professional to determine the best course of action.

    • This question is part of the following fields:

      • Endocrinology
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  • Question 18 - A diabetic mother gives birth at term to a healthy infant, without complications...

    Incorrect

    • A diabetic mother gives birth at term to a healthy infant, without complications during pregnancy, nor the birth. A blood test at approximately 3 hours after birth yields the following result:
      Blood glucose 2.2 mmol/L
      On examination, the infant appears well, with expected behaviour and no abnormal findings. The mother reported no problems with the first breastfeed.
      What would be the most appropriate management plan based on these findings?

      Your Answer: Continue monitoring glucose and exclusively bottle-feed controlled amounts for the next 24 hours

      Correct Answer: Continue monitoring glucose and encourage normal feeding

      Explanation:

      If the neonate is not showing any symptoms and the blood glucose levels are not significantly low, the recommended approach for neonatal hypoglycaemia is to monitor glucose levels and encourage normal feeding. As the mother is diabetic, the neonate is at a higher risk of developing hypoglycaemia. However, administering oral glucose is not necessary at this stage. Admission to the neonatal unit and dextrose infusion would be necessary if the blood glucose levels drop significantly or if the neonate shows symptoms of hypoglycaemia. Intramuscular glucagon would only be considered if the neonate is symptomatic and unable to receive dextrose through IV access. The guidelines do not recommend exclusively bottle-feeding for the next 24 hours.

      Neonatal Hypoglycaemia: Causes, Symptoms, and Management

      Neonatal hypoglycaemia is a common condition in newborn babies, especially in the first 24 hours of life. While there is no agreed definition, a blood glucose level of less than 2.6 mmol/L is often used as a guideline. Transient hypoglycaemia is normal and usually resolves on its own, but persistent or severe hypoglycaemia may be caused by various factors such as preterm birth, maternal diabetes mellitus, IUGR, hypothermia, neonatal sepsis, inborn errors of metabolism, nesidioblastosis, or Beckwith-Wiedemann syndrome.

      Symptoms of neonatal hypoglycaemia can be autonomic, such as jitteriness, irritability, tachypnoea, and pallor, or neuroglycopenic, such as poor feeding/sucking, weak cry, drowsiness, hypotonia, and seizures. Other features may include apnoea and hypothermia. Management of neonatal hypoglycaemia depends on the severity of the condition and whether the newborn is symptomatic or not. Asymptomatic babies can be encouraged to feed normally and have their blood glucose monitored, while symptomatic or severely hypoglycaemic babies may need to be admitted to the neonatal unit and receive intravenous infusion of 10% dextrose.

    • This question is part of the following fields:

      • Paediatrics
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  • Question 19 - A 50-year-old man experiences polytrauma and necessitates a massive transfusion of packed red...

    Correct

    • A 50-year-old man experiences polytrauma and necessitates a massive transfusion of packed red cells and fresh frozen plasma. After three hours, he presents with significant hypoxia and a CVP reading of 5 mmHg. A chest x-ray reveals diffuse pulmonary infiltrates in both lungs. What is the probable diagnosis?

      Your Answer: Transfusion associated lung injury

      Explanation:

      Plasma components pose the highest risk for transfusion associated lung injury.

      When plasma components are infused, there is a possibility of transfusion lung injury. This can cause damage to the microvasculature in the lungs, resulting in diffuse infiltrates visible on imaging. Unfortunately, mortality rates are often high in such cases. It is worth noting that a normal central venous pressure (which should be between 0-6 mmHg) is not necessarily indicative of fluid overload.

      Understanding Massive Haemorrhage and its Complications

      Massive haemorrhage is defined as the loss of one blood volume within 24 hours, the loss of 50% of the circulating blood volume within three hours, or a blood loss of 150ml/minute. In adults, the blood volume is approximately 7% of the total body weight, while in children, it is between 8 and 9% of their body weight.

      Massive haemorrhage can lead to several complications, including hypothermia, hypocalcaemia, hyperkalaemia, delayed type transfusion reactions, transfusion-related lung injury, and coagulopathy. Hypothermia occurs because the blood is refrigerated, which impairs homeostasis and shifts the Bohr curve to the left. Hypocalcaemia may occur because both fresh frozen plasma (FFP) and platelets contain citrate anticoagulant, which may chelate calcium. Hyperkalaemia may also occur because the plasma of red cells stored for 4-5 weeks contains 5-10 mmol K+.

      Delayed type transfusion reactions may occur due to minor incompatibility issues, especially if urgent or non-cross-matched blood is used. Transfusion-related lung injury is the leading cause of transfusion-related deaths and poses the greatest risk with plasma components. It occurs as a result of leucocyte antibodies in transfused plasma, leading to aggregation and degranulation of leucocytes in lung tissue. Finally, coagulopathy is anticipated once the circulating blood volume is transfused. One blood volume usually drops the platelet count to 100 or less, and it will both dilute and not replace clotting factors. The fibrinogen concentration halves per 0.75 blood volume transfused.

      In summary, massive haemorrhage can lead to several complications that can be life-threatening. It is essential to understand these complications to manage them effectively and prevent adverse outcomes.

    • This question is part of the following fields:

      • Surgery
      9.5
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  • Question 20 - A 20-year-old woman has come in with acute appendicitis and is currently undergoing...

    Incorrect

    • A 20-year-old woman has come in with acute appendicitis and is currently undergoing surgery to have her appendix removed. The peritoneal cavity has been opened using the appropriate approach and the caecum is visible. What would be the most appropriate feature to follow in order to locate the appendix?

      Your Answer: Appendices epiploicae

      Correct Answer: Taeniae coli

      Explanation:

      Anatomy of the Large Bowel: Taeniae Coli, Appendices Epiploicae, Haustrations, Ileocolic Artery, and Right Colic Artery

      The large bowel is composed of various structures that play important roles in digestion and absorption. Among these structures are the taeniae coli, which are three bands of longitudinal smooth muscle found on the outside of the large bowel. These bands produce haustrations or bulges in the colon when they contract. Additionally, the appendices epiploicae, or epiploic appendages, are protrusions of subserosal fat that line the surface of the bowel. The large bowel also contains the ileocolic artery, which runs over the ileocaecal junction, and the right colic artery, which supplies the ascending colon. Understanding the anatomy of the large bowel is crucial in diagnosing and treating various gastrointestinal conditions.

    • This question is part of the following fields:

      • Colorectal
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  • Question 21 - A 42-year-old male arrives at the emergency department with recently developed symptoms. He...

    Correct

    • A 42-year-old male arrives at the emergency department with recently developed symptoms. He has a complicated medical history, including depression, schizophrenia, asthma, and rheumatoid arthritis. He had an episode one hour ago where his left eye moved upwards and inward, and he began blinking repeatedly. The episode lasted for three minutes, and he did not lose consciousness. He is currently experiencing severe neck pain. However, he is feeling fine at the moment. Which medication is the most probable cause of his symptoms?

      Your Answer: Chlorpromazine

      Explanation:

      Acute dystonic reactions are a negative effect of antipsychotic medications, particularly first-generation ones that are known to cause extrapyramidal side effects. Chlorpromazine is a medication that can cause an oculogyric crisis, which is a type of acute dystonic reaction. The exact cause of these reactions is not fully understood, but they can be managed with the use of an anticholinergic medication like procyclidine. Fluoxetine, on the other hand, is an SSRI used to treat depression and is not known to cause acute dystonic crisis. Olanzapine is an atypical antipsychotic that was developed to reduce the risk of extrapyramidal side effects, so it is less likely to cause acute dystonic reactions compared to chlorpromazine. Prednisolone, a medication used to treat various conditions, has not been shown to cause acute dystonic reactions but can lead to other side effects like Cushing’s syndrome and osteoporosis.

      Antipsychotics are a group of drugs used to treat schizophrenia, psychosis, mania, and agitation. They are divided into two categories: typical and atypical antipsychotics. The latter were developed to address the extrapyramidal side-effects associated with the first generation of typical antipsychotics. Typical antipsychotics work by blocking dopaminergic transmission in the mesolimbic pathways through dopamine D2 receptor antagonism. They are associated with extrapyramidal side-effects and hyperprolactinaemia, which are less common with atypical antipsychotics.

      Extrapyramidal side-effects (EPSEs) are common with typical antipsychotics and include Parkinsonism, acute dystonia, sustained muscle contraction, akathisia, and tardive dyskinesia. The latter is a late onset of choreoathetoid movements that may be irreversible and occur in 40% of patients. The Medicines and Healthcare products Regulatory Agency has issued specific warnings when antipsychotics are used in elderly patients, including an increased risk of stroke and venous thromboembolism. Other side-effects include antimuscarinic effects, sedation, weight gain, raised prolactin, impaired glucose tolerance, neuroleptic malignant syndrome, reduced seizure threshold, and prolonged QT interval.

    • This question is part of the following fields:

      • Psychiatry
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  • Question 22 - A 16-year-old adolescent presents to the clinic with gross haematuria. He is currently...

    Correct

    • A 16-year-old adolescent presents to the clinic with gross haematuria. He is currently suffering from a sinus infection. Apparently he had a previous episode of haematuria some 2 years earlier which was put down by the general practitioner to a urinary tract infection. Examination of notes from a previous Casualty attendance after a football game revealed microscopic haematuria on urine testing. On examination, his blood pressure is 130/70 mmHg. Physical examination is unremarkable.
      Investigations:
      Investigation Result Normal value
      Haemoglobin 133 g/l 135–175 g/l
      White cell count (WCC) 8.2 × 109/l 4–11 × 109/l
      Platelets 240 × 109/l 150–400 × 109/l
      Sodium (Na+) 141 mmol/l 135–145 mmol/l
      Potassium (K+) 4.8 mmol/l 3.5–5.0 mmol/l
      Creatinine 110 μmol/l 50–120 µmol/l
      Urine Blood ++, protein +
      C3 Normal
      Serum IgA Slight increase
      Which of the following is the most likely diagnosis?

      Your Answer: IgA nephropathy

      Explanation:

      Differential Diagnosis for Haematuria: A Case Study

      Haematuria, or blood in the urine, can be a concerning symptom for patients. In this case study, a patient presents with haematuria and a recent history of respiratory tract infection. The following differential diagnoses are considered:

      1. IgA nephropathy: This is the most common primary glomerulonephritis in adults and is often associated with a recent respiratory tract infection. Despite haematuria, renal function is usually preserved.

      2. Post-streptococcal glomerulonephritis: This diagnosis typically presents 2-4 weeks after a respiratory or skin infection. As the patient is still experiencing respiratory symptoms, this diagnosis is less likely.

      3. Lupus nephritis: This is a serious diagnosis that presents with haematuria, oedema, joint pain, and high blood pressure. As the patient does not exhibit these additional symptoms, this diagnosis is unlikely.

      4. Henoch-Schönlein purpura: This diagnosis is characterized by a rash, which the patient does not exhibit, making it less likely.

      5. Alport syndrome: This is a genetic condition that presents with kidney disease, hearing loss, and eye abnormalities.

      In conclusion, the patient’s recent respiratory tract infection and preserved renal function suggest IgA nephropathy as the most likely diagnosis. However, further testing and evaluation may be necessary to confirm the diagnosis.

    • This question is part of the following fields:

      • Renal
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  • Question 23 - You are a member of the surgical team and are currently attending to...

    Correct

    • You are a member of the surgical team and are currently attending to a 36-year-old female patient who has been involved in a car accident. She has sustained a fractured femur and is experiencing chest pain. Her medical history reveals that she has asthma which has been poorly controlled. The patient has been admitted for surgical repair and is receiving general anesthesia, nitrous oxide, and an epidural for pain relief. However, you have noticed that her breathing is becoming more labored and she is complaining of chest pain. Upon checking her vital signs, you observe that her respiratory rate is 30 breaths per minute, blood pressure is 70/50 mmHg, heart rate is 150 beats per minute, and temperature is 37ºC. During your examination, you also notice that her left chest is hyper-resonant. What is the most likely cause of her deterioration?

      Your Answer: Nitrous oxide

      Explanation:

      Caution should be exercised when using nitrous oxide in patients with a pneumothorax. This is particularly relevant for the patient in question, who has been in a car accident and is experiencing chest pain and a hyperresonant chest, indicating the presence of a pneumothorax. Administering nitrous oxide to such a patient can lead to the development of a tension pneumothorax, as the gas may diffuse into gas-filled body compartments and increase pressure. The patient is exhibiting symptoms consistent with a tension pneumothorax, including a high respiratory rate, low blood pressure, and high heart rate, as well as increasing shortness of breath and chest pain.

      An allergy to epidural pain relief is an unlikely cause of the patient’s deterioration, as there are no indications of an allergic reaction and the examination findings point to a tension pneumothorax. Malignant hyperthermia is also an unlikely explanation, as the patient does not exhibit the typical symptoms associated with this condition. Similarly, while pregnancy is a risk factor for pulmonary embolus, the examination findings suggest a tension pneumothorax as the most likely diagnosis, particularly given the patient’s past medical history of poorly controlled asthma, which is also a risk factor for pneumothorax.

      Overview of General Anaesthetics

      General anaesthetics are drugs used to induce a state of unconsciousness in patients undergoing surgical procedures. There are two main types of general anaesthetics: inhaled and intravenous. Inhaled anaesthetics, such as isoflurane, desflurane, sevoflurane, and nitrous oxide, are administered through inhalation. These drugs work by acting on various receptors in the brain, including GABAA, glycine, NDMA, nACh, and 5-HT3 receptors. Inhaled anaesthetics can cause adverse effects such as myocardial depression, malignant hyperthermia, and hepatotoxicity.

      Intravenous anaesthetics, such as propofol, thiopental, etomidate, and ketamine, are administered through injection. These drugs work by potentiating GABAA receptors or blocking NDMA receptors. Intravenous anaesthetics can cause adverse effects such as pain on injection, hypotension, laryngospasm, myoclonus, and disorientation. However, they are often preferred over inhaled anaesthetics in cases of haemodynamic instability.

      It is important to note that the exact mechanism of action of general anaesthetics is not fully understood. Additionally, the choice of anaesthetic depends on various factors such as the patient’s medical history, the type of surgery, and the anaesthetist’s preference. Overall, general anaesthetics play a crucial role in modern medicine by allowing for safe and painless surgical procedures.

    • This question is part of the following fields:

      • Surgery
      36.5
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  • Question 24 - You receive a call from a 27-year-old woman who is 8-weeks pregnant with...

    Correct

    • You receive a call from a 27-year-old woman who is 8-weeks pregnant with twins. Last week she had severe nausea and vomiting despite a combination of oral cyclizine and promethazine. She continued to vomit and was admitted to the hospital briefly where she was started on metoclopramide and ondansetron which helped control her symptoms.

      Today she tells you she read a pregnancy forum article warning about the potential risks of ondansetron use in pregnancy. She is concerned and wants advice on whether she should continue taking it.

      How would you counsel this woman regarding the use of ondansetron during pregnancy?

      Your Answer: There is a small increased risk of cleft lip/palate in the newborn if used in the first trimester

      Explanation:

      The use of ondansetron during pregnancy has been associated with an increased risk of 3 oral clefts per 10,000 births, according to a study. However, this risk is not included in the RCOG guideline on nausea and vomiting of pregnancy, and there is currently no official NICE guidance on the matter. A draft of NICE antenatal care guidance, published in August 2021, acknowledges the increased risk of cleft lip or palate with ondansetron use, but notes that there is conflicting evidence regarding the drug’s potential to cause heart problems in babies. It is important to note that the risk of spontaneous miscarriage in twin pregnancies is not supported by evidence, and there is no established risk of severe congenital heart defects in newborns associated with ondansetron use.

      Hyperemesis gravidarum is an extreme form of nausea and vomiting of pregnancy that occurs in around 1% of pregnancies and is most common between 8 and 12 weeks. It is associated with raised beta hCG levels and can be caused by multiple pregnancies, trophoblastic disease, hyperthyroidism, nulliparity, and obesity. Referral criteria for nausea and vomiting in pregnancy include continued symptoms with ketonuria and/or weight loss, a confirmed or suspected comorbidity, and inability to keep down liquids or oral antiemetics. The diagnosis of hyperemesis gravidarum requires the presence of 5% pre-pregnancy weight loss, dehydration, and electrolyte imbalance. Management includes first-line use of antihistamines and oral cyclizine or promethazine, with second-line options of ondansetron and metoclopramide. Admission may be needed for IV hydration. Complications can include Wernicke’s encephalopathy, Mallory-Weiss tear, central pontine myelinolysis, acute tubular necrosis, and fetal growth issues.

    • This question is part of the following fields:

      • Obstetrics
      20
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  • Question 25 - A 32-year-old woman who has three children presents to the general practice clinic...

    Correct

    • A 32-year-old woman who has three children presents to the general practice clinic with complaints of feeling tired and overwhelmed. She had previously been prescribed citalopram for about 6 months after the birth of her first child. Her medical history includes the use of depo progesterone for contraception, which she believes is hindering her ability to lose weight. On examination, her BMI is 29 and her blood pressure is 142/72 mmHg. Laboratory tests reveal a slightly elevated TSH level of 4.5 µU/l. Based on these findings, what is the most likely diagnosis?

      Your Answer: Subclinical hypothyroidism

      Explanation:

      Understanding Thyroid Function and Sub-Clinical Hypothyroidism

      Thyroid function can be assessed through the levels of thyroid-stimulating hormone (TSH) and free T4 in the blood. Subclinical hypothyroidism is diagnosed when TSH is mildly elevated, while free T4 remains within the normal range. This indicates that the thyroid is working hard to produce even this amount of T4. Treatment with thyroxine replacement is debated and usually reserved for patients with symptoms and thyroid autoantibodies.

      Hypothyroidism is diagnosed when free T4 levels fall below the minimum range, while thyrotoxicosis is ruled out when free T4 is not raised and there are no symptoms. Depression may be a plausible diagnosis, but an elevated TSH level suggests otherwise. Sick euthyroid syndrome may occur in critically ill patients and involves abnormal levels of free T4 and T3 despite seemingly normal thyroid function.

      Overall, understanding thyroid function and sub-clinical hypothyroidism can help guide appropriate diagnosis and treatment decisions.

    • This question is part of the following fields:

      • Endocrinology
      15.3
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  • Question 26 - An 80-year-old male is admitted to the urology ward with acute urinary retention....

    Incorrect

    • An 80-year-old male is admitted to the urology ward with acute urinary retention. He is catheterised successfully with a large retention volume of 1.5 litres and therefore kept on the ward for observation. Over the next 24 hours, the patient has a urine output of 200 ml/hour and develops increasing confusion. His blood results are as follows:

      Hb 130 g/L Male: (135-180)

      Platelets 280 * 109/L (150 - 400)

      WBC 9 * 109/L (4.0 - 11.0)

      Na+ 136 mmol/L (135 - 145)

      K+ 4.5 mmol/L (3.5 - 5.0)

      Urea 8 mmol/L (2.0 - 7.0)

      Creatinine 130 µmol/L (55 - 120)

      CRP 3 mg/L (< 5)

      What could be the possible reason for the patient's confusion?

      Your Answer: Delirium

      Correct Answer: Post-obstructive diuresis

      Explanation:

      To prevent any further deterioration of AKI, the patient’s urine output was replaced with intravenous fluids. Delirium, which can present as confusion, is often caused by infection or uncontrolled pain. However, since there were no indications of infection or pain in the patient’s medical history, delirium was not considered the primary differential diagnosis. Although diabetes insipidus can cause polyuria, it is unlikely in this case as there were no known triggers such as lithium therapy.

      Acute urinary retention is a condition where a person suddenly becomes unable to pass urine voluntarily, typically over a period of hours or less. It is a common urological emergency that requires investigation to determine the underlying cause. While it is more common in men, it rarely occurs in women, with an incidence ratio of 13:1. Acute urinary retention is most frequently seen in men over 60 years of age, and the incidence increases with age. It has been estimated that around a third of men in their 80s will develop acute urinary retention over a five-year period.

      The most common cause of acute urinary retention in men is benign prostatic hyperplasia, a non-cancerous enlargement of the prostate gland that presses on the urethra, making it difficult for the bladder to empty. Other causes include urethral obstructions, such as strictures, calculi, cystocele, constipation, or masses, as well as certain medications that affect nerve signals to the bladder. In some cases, there may be a neurological cause for the condition. Acute urinary retention can also occur postoperatively and in women postpartum, typically due to a combination of risk factors.

      Patients with acute urinary retention typically experience an inability to pass urine, lower abdominal discomfort, and considerable pain or distress. Elderly patients may also present with an acute confusional state. Unlike chronic urinary retention, which is typically painless, acute urinary retention is associated with pain and discomfort. A palpable distended urinary bladder may be detected on abdominal or rectal examination, and lower abdominal tenderness may also be present. All patients should undergo a rectal and neurological examination, and women should also have a pelvic examination.

      To confirm the diagnosis of acute urinary retention, a bladder ultrasound should be performed. The bladder volume should be greater than 300 cc to confirm the diagnosis, but if the history and examination are consistent with acute urinary retention, an inconsistent bladder scan does not rule out the condition. Acute urinary retention is managed by decompressing the bladder via catheterisation. Further investigation should be targeted by the likely cause, and patients may require IV fluids to correct any temporary over-diuresis that may occur as a complication.

    • This question is part of the following fields:

      • Surgery
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  • Question 27 - A 63-year-old patient, who is four days’ post hemicolectomy for colorectal carcinoma, experiences...

    Correct

    • A 63-year-old patient, who is four days’ post hemicolectomy for colorectal carcinoma, experiences a sudden onset of breathlessness.
      On examination, the patient is tachycardic at 115 bpm and his blood pressure is 108/66 mmHg. His oxygen saturations are at 92% on high-flow oxygen – the last reading from a set of observations taken three hours ago was 99% on room air. Chest examination reveals a respiratory rate of 26, with good air entry bilaterally. A pulmonary embolus is suspected as the cause of the patient’s symptoms.

      Your Answer: Generally has a worse outcome than a thrombus

      Explanation:

      Thrombus vs Embolus: Understanding the Differences

      Thrombus and embolus are two terms that are often used interchangeably, but they have distinct differences. A thrombus is an organized mass of blood constituents that forms in flowing blood, while an embolus is an abnormal mass of undissolved material that is carried in the bloodstream from one place to another.

      Ischaemia resulting from an embolus tends to be worse than that caused by thrombosis because the occlusion of the vessel is sudden. Thrombi tend to occlude the vessel lumen slowly, allowing time for the development of alternative perfusion pathways via collaterals.

      A thrombus of venous origin can embolize and lodge in the pulmonary arteries, causing a pulmonary embolus. A massive pulmonary embolus is the most common preventable cause of death in hospitalized, bed-bound patients.

      Post-mortem clots and thrombi have some similarities, but they can be distinguished by their appearance and consistency. A post-mortem clot tends to be soft and fall apart easily, while a thrombus adheres to the vessel wall, may be red, white or mixed in color, and has a typical layered appearance (Lines of Zahn).

      While about 95% of all emboli are thrombotic, other emboli can include solid material such as fat, tumor cells, atheromatous material, foreign matter, liquid material such as amniotic fluid, and gas material such as air and nitrogen bubbles.

      Understanding the differences between thrombus and embolus is crucial in diagnosing and treating conditions related to blood clots and circulation.

    • This question is part of the following fields:

      • Surgery
      31.6
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  • Question 28 - A 67-year-old man presents to the Emergency Department with a hot swollen joint....

    Incorrect

    • A 67-year-old man presents to the Emergency Department with a hot swollen joint. The physician suspects septic arthritis and decides to perform synovial fluid analysis. Can you name another type of synovial joint?

      Your Answer: Inferior tibiofibular joint

      Correct Answer: Atlantoaxial joint

      Explanation:

      Different Types of Joints in the Human Body

      Joints are the points where two or more bones meet and allow movement. There are different types of joints in the human body, each with its own unique characteristics.

      Synovial Joints: These are the most mobile joints in the body and have a joint cavity filled with synovial fluid. Examples include the Atlantoaxial joint, knee, hip, shoulder, elbow, some carpals, and the first metacarpal. Inflammation or infection of the synovial fluid can cause pain, stiffness, and limited movement.

      Fibrous Joints: These joints are immovable and are held together by fibrous tissue. The skull vault sutures are an example of this type of joint, which fuse by around the age of 20 years.

      Syndesmosis: This is a type of fibrous joint where two bones are linked by ligaments and a membrane. The inferior tibiofibular joint is an example of a syndesmosis.

      Cartilaginous Joints: These joints are held together by cartilage. The joint between the first rib and the sternum is an example of a synchondrosis, which is composed of hyaline cartilage. The pubic symphysis is an example of a secondary cartilaginous joint, made of hyaline cartilage and fibrocartilage connecting the superior rami of the left and right pubic bones at the midline.

      In conclusion, understanding the different types of joints in the human body is important for diagnosing and treating joint-related conditions.

    • This question is part of the following fields:

      • Orthopaedics
      15
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  • Question 29 - A 34-year-old female who is 28 weeks pregnant presents to the emergency department...

    Incorrect

    • A 34-year-old female who is 28 weeks pregnant presents to the emergency department with severe lower abdominal pain. She is tachycardic but is otherwise stable. On examination, her uterus is tender and hard, but fetal lie is normal. Cardiotocography shows no signs of fetal distress.

      What is the most appropriate course of action for management?

      Your Answer: Admit her and administer tocolytics

      Correct Answer: Admit her and administer steroids

      Explanation:

      When managing placental abruption in a case where the fetus is alive, less than 36 weeks old, and not displaying any signs of distress, the appropriate course of action is to admit the patient and administer steroids. Admitting the patient is necessary for monitoring and providing necessary care. Steroids are given to aid in the maturation of fetal lungs. It is recommended to deliver the baby at 37-38 weeks due to the increased risk of stillbirth. Tocolytics are not routinely given due to their controversial nature and potential for maternal cardiovascular side effects. Discharging the patient with safety netting is not appropriate as the patient is symptomatic. Activating the major haemorrhage protocol, calling 2222, and performing an emergency caesarean section are not the most suitable options as the patient is not hypotensive and there are no signs of fetal distress.

      Placental Abruption: Causes, Management, and Complications

      Placental abruption is a condition where the placenta separates from the uterine wall, leading to maternal haemorrhage. The severity of the condition depends on the extent of the separation and the gestational age of the fetus. Management of placental abruption is crucial to prevent maternal and fetal complications.

      If the fetus is alive and less than 36 weeks, immediate caesarean delivery is recommended if there is fetal distress. If there is no fetal distress, close observation, administration of steroids, and no tocolysis are recommended. The decision to deliver depends on the gestational age of the fetus. If the fetus is alive and more than 36 weeks, immediate caesarean delivery is recommended if there is fetal distress. If there is no fetal distress, vaginal delivery is recommended. If the fetus is dead, vaginal delivery should be induced.

      Placental abruption can lead to various maternal complications, including shock, disseminated intravascular coagulation (DIC), renal failure, and postpartum haemorrhage (PPH). Fetal complications include intrauterine growth restriction (IUGR), hypoxia, and death. The condition is associated with a high perinatal mortality rate and is responsible for 15% of perinatal deaths.

      In conclusion, placental abruption is a serious condition that requires prompt management to prevent maternal and fetal complications. Close monitoring and timely intervention can improve the prognosis for both the mother and the baby.

    • This question is part of the following fields:

      • Obstetrics
      18
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  • Question 30 - A 23-year-old man presents to his GP with complaints of redness and itching...

    Correct

    • A 23-year-old man presents to his GP with complaints of redness and itching on his face and hands. He has been to another GP for similar issues in the past two years and has been on sick leave from his job as a builder. He is currently receiving benefits and is in the process of making an insurance claim for loss of earnings. He mentions that there was one ointment that worked for him, but he has not been able to find it again. On examination, there are no visible skin lesions or rash. The patient appears unconcerned and requests that his GP sign his insurance claim paperwork. What is the most likely diagnosis?

      Your Answer: Malingering

      Explanation:

      Somatoform Disorders, Malingering, and Munchausen’s Syndrome

      Somatoform disorders are characterized by the unconscious drive to produce illness and the motivation to seek medical attention. On the other hand, malingering involves a conscious effort to fake or claim a disorder for personal gain, such as financial compensation. Meanwhile, Munchausen’s syndrome is a chronic condition where patients have a history of multiple hospital admissions and are willing to undergo invasive procedures.

      In somatoform disorders, patients are not intentionally faking their symptoms. Instead, their unconscious mind is producing physical symptoms as a way to cope with psychological distress. This can lead to a cycle of seeking medical attention and undergoing unnecessary tests and procedures. In contrast, malingering is a deliberate attempt to deceive medical professionals for personal gain. Patients may exaggerate or fabricate symptoms to receive compensation or avoid legal consequences.

      Munchausen’s syndrome is a rare condition where patients repeatedly seek medical attention and undergo invasive procedures despite having no actual medical condition. This behavior is driven by a desire for attention and sympathy from medical professionals. Patients with Munchausen’s syndrome may go to great lengths to maintain their deception, including intentionally harming themselves to produce symptoms.

      In summary, somatoform disorders, malingering, and Munchausen’s syndrome are all conditions that involve the production or faking of physical symptoms. However, the motivations behind these behaviors differ. these conditions can help medical professionals provide appropriate care and support for patients.

    • This question is part of the following fields:

      • Dermatology
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