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  • Question 1 - A 22-year old woman comes to see her GP, seeking medication for opioid...

    Correct

    • A 22-year old woman comes to see her GP, seeking medication for opioid withdrawal. She explains that she has been using heroin for the past six months since losing her job as a store manager. She informs the GP that she has decided to quit using heroin and has not taken any for the past three days. She reports experiencing severe withdrawal symptoms that have been affecting her daily life and asks if there is anything that can be prescribed to alleviate her symptoms.
      What are the observable indications of opioid withdrawal?

      Your Answer: Dilated pupils, yawning, rhinorrhoea, epiphora

      Explanation:

      Identifying Objective Signs of Opioid Withdrawal and Intoxication

      It is crucial to recognize objective signs of opioid withdrawal and intoxication to prevent fatal outcomes. In psychiatric settings, individuals may falsely claim withdrawal to obtain opioid medications. Objective signs of withdrawal include epiphora, rhinorrhoea, agitation, perspiration, piloerection, tachycardia, vomiting, shivering, yawning, and dilated pupils. Pinpoint pupils, yawning, and galactorrhoea are indicative of opiate intoxication. Respiratory depression is a feature of opioid intoxication, along with pinpoint pupils and bradycardia. Opioid intoxication can also cause pulmonary oedema, stupor, pallor, severe respiratory depression, and nausea. By recognizing these objective signs, healthcare professionals can accurately diagnose and treat opioid withdrawal and intoxication.

    • This question is part of the following fields:

      • Psychiatry
      19.1
      Seconds
  • Question 2 - A 26-year-old woman visits a gynaecologist to discuss her options for contraception. The...

    Incorrect

    • A 26-year-old woman visits a gynaecologist to discuss her options for contraception. The doctor suggests the insertion of a copper-bearing intrauterine device (IUD) and explains its mechanism of action and potential risks. What is the frequency of uterine perforations as a complication of IUD placement?

      Your Answer: 1 in 200

      Correct Answer: 1 in 1000

      Explanation:

      Understanding the Risks and Mechanisms of Copper-Bearing IUDs

      Copper-bearing intrauterine devices (IUDs) are a popular form of reversible contraception that work through various mechanisms, including thickening cervical mucous, inhibiting sperm mobility, and reducing the likelihood of implantation. However, there are absolute contraindications to their use, such as pregnancy or recent childbirth, irregular vaginal bleeding, and gynecological cancer. Complications can include bleeding, pain, infection, discharge, and rare occurrences of uterine perforation, pelvic infection, expulsion, and ectopic pregnancy. The risk of uterine perforation is quoted as 1 in 1000 insertions, making it a rare but important consideration for those considering copper-bearing IUDs.

    • This question is part of the following fields:

      • Sexual Health
      6.8
      Seconds
  • Question 3 - A 75-year-old woman complains of mild lower back pain and tenderness around the...

    Incorrect

    • A 75-year-old woman complains of mild lower back pain and tenderness around the L3 vertebra. Upon conducting tests, the following results were obtained: Hemoglobin levels of 80 g/L (120-160), ESR levels of 110 mm/hr (1-10), and an albumin/globulin ratio of 1:2 (2:1). What is the probable diagnosis?

      Your Answer: Waldenstrom's macroglobulinaemia

      Correct Answer: Multiple myeloma

      Explanation:

      Multiple Myeloma

      Multiple myeloma is a type of cancer that affects plasma cells found in the bone marrow. These plasma cells are derived from B lymphocytes, but when they become malignant, they start to divide uncontrollably, forming tumors in the bone marrow. These tumors interfere with normal cell production and erode the surrounding bone, causing soft spots and holes. Since the malignant cells are clones derived from a single plasma cell, they all produce the same abnormal immunoglobulin that is secreted into the blood.

      Patients with multiple myeloma may not show any symptoms for many years, but eventually, most patients develop some evidence of the disease. This can include weakened bones, which can cause bone pain and fractures, decreased numbers of red or white blood cells, which can lead to anemia, infections, bleeding, and bruising, and kidney failure, which can cause an increase in creatinine levels. Additionally, destruction of the bone can increase the level of calcium in the blood, leading to symptoms of hypercalcemia. Pieces of monoclonal antibodies, known as light chains or Bence Jones proteins, can also lodge in the kidneys and cause permanent damage. In some cases, an increase in the viscosity of the blood may lead to headaches.

    • This question is part of the following fields:

      • Surgery
      9.4
      Seconds
  • Question 4 - A 28-year-old man presents to his GP with complaints of joint pain and...

    Correct

    • A 28-year-old man presents to his GP with complaints of joint pain and swelling, feeling generally unwell. He recently returned from a hiking trip in Thailand, and one day after his return, he experienced severe watery diarrhoea and abdominal cramps that lasted for a week.

      Upon examination, the patient appears fatigued and unwell. He has large effusions of the left knee and right ankle, along with tender plantar fascia bilaterally. Additionally, he has tender metatarsophalangeal joints on both feet and a papular rash on the soles of his feet. Despite taking regular paracetamol and ibuprofen for the past week, he has experienced minimal improvement in symptoms.

      What is the most appropriate next step in managing this patient, given the most likely diagnosis?

      Your Answer: Oral prednisolone

      Explanation:

      Reactive arthritis does not usually develop acutely, but can appear up to 4 weeks after the initial infection and may have a relapsing-remitting course lasting several months. The correct treatment for this patient’s severe polyarthritis would be oral prednisolone, with dosing based on the severity of the arthritis and tapering to the lowest effective dose. TNF inhibitor therapy would not be appropriate in this case, but may be considered for patients with refractory reactive arthritis. Celecoxib is not the correct choice as the patient did not respond to regular ibuprofen, and intra-articular injections would not be effective for multiple joints and systemic symptoms.

      Understanding Reactive Arthritis: Symptoms and Features

      Reactive arthritis is a type of seronegative spondyloarthropathy that is associated with HLA-B27. It was previously known as Reiter’s syndrome, which was characterized by a triad of urethritis, conjunctivitis, and arthritis following a dysenteric illness during World War II. However, later studies revealed that patients could also develop symptoms after a sexually transmitted infection, now referred to as sexually acquired reactive arthritis (SARA).

      Reactive arthritis is defined as an arthritis that develops after an infection, but the organism cannot be recovered from the joint. The symptoms typically develop within four weeks of the initial infection and last for around 4-6 months. Approximately 25% of patients experience recurrent episodes, while 10% develop chronic disease. The arthritis is usually an asymmetrical oligoarthritis of the lower limbs, and patients may also experience dactylitis.

      Other symptoms of reactive arthritis include urethritis, conjunctivitis (seen in 10-30% of patients), and anterior uveitis. Skin symptoms may also occur, such as circinate balanitis (painless vesicles on the coronal margin of the prepuce) and keratoderma blennorrhagica (waxy yellow/brown papules on palms and soles). A helpful mnemonic to remember the symptoms of reactive arthritis is Can’t see, pee, or climb a tree.

      In conclusion, understanding the symptoms and features of reactive arthritis is crucial for early diagnosis and treatment. While the condition can be recurrent or chronic, prompt management can help alleviate symptoms and improve quality of life for affected individuals.

    • This question is part of the following fields:

      • Musculoskeletal
      82.5
      Seconds
  • Question 5 - An 80-year-old man presents to the surgical assessment unit for evaluation before an...

    Incorrect

    • An 80-year-old man presents to the surgical assessment unit for evaluation before an elective Hartmann's procedure in a week due to bowel cancer. He has a medical history of hypertension, atrial fibrillation, and a previous cerebrovascular accident. The registrar requests you to assess him before his surgery next week. During your review, you observe that he is currently on warfarin, and his INR is 2.6 today. All other blood tests are normal. What is the most appropriate approach to manage his anticoagulation during the peri-operative period?

      Your Answer: Continue his warfarin at the current dose as his INR is within therapeutic range

      Correct Answer: Stop his warfarin and commence treatment dose low molecular weight heparin

      Explanation:

      Managing anticoagulation during the peri-operative period can be difficult and depends on the type of anticoagulant used and the reasons for its use. It is important to assess each patient’s risk of venous thromboembolism and bleeding. In this case, the patient has a high risk of both thromboembolic disease and bleeding due to previous CVA, known AF, and major abdominal surgery. Therefore, the best approach would be to use a shorter-acting anticoagulant such as low molecular weight heparin at a treatment dose, while withholding warfarin. The low molecular weight heparin would be stopped the night before surgery, and mechanical prophylaxis would be used.

      Venous thromboembolism (VTE) is a serious condition that can lead to severe health complications and even death. However, it is preventable. The National Institute for Health and Care Excellence (NICE) has updated its guidelines for 2018 to provide recommendations for the assessment and management of patients at risk of VTE in hospital. All patients admitted to the hospital should be assessed individually to identify risk factors for VTE development and bleeding risk. The department of health’s VTE risk assessment tool is recommended for medical and surgical patients. Patients with certain risk factors, such as reduced mobility, surgery, cancer, and comorbidities, are at increased risk of developing VTE. After assessing a patient’s VTE risk, healthcare professionals should compare it to their risk of bleeding to decide whether VTE prophylaxis should be offered. If indicated, VTE prophylaxis should be started as soon as possible.

      There are two types of VTE prophylaxis: mechanical and pharmacological. Mechanical prophylaxis includes anti-embolism stockings and intermittent pneumatic compression devices. Pharmacological prophylaxis includes fondaparinux sodium, low molecular weight heparin (LMWH), and unfractionated heparin (UFH). The choice of prophylaxis depends on the patient’s individual risk factors and bleeding risk.

      In general, medical patients deemed at risk of VTE after individual assessment are started on pharmacological VTE prophylaxis, provided that the risk of VTE outweighs the risk of bleeding and there are no contraindications. Surgical patients at low risk of VTE are treated with anti-embolism stockings, while those at high risk are treated with a combination of stockings and pharmacological prophylaxis.

      Patients undergoing certain surgical procedures, such as hip and knee replacements, are recommended to receive pharmacological VTE prophylaxis to reduce the risk of VTE developing post-surgery. For fragility fractures of the pelvis, hip, and proximal femur, LMWH or fondaparinux sodium is recommended for a month if the risk of VTE outweighs the risk of bleeding.

      Healthcare professionals should advise patients to stop taking their combined oral contraceptive pill or hormone replacement therapy four weeks before surgery and mobilize them as soon as possible after surgery. Patients should also ensure they are hydrated. By following these guidelines, healthcare professionals can help prevent VTE and improve patient outcomes.

    • This question is part of the following fields:

      • Surgery
      22.7
      Seconds
  • Question 6 - A 38-year-old woman comes to the emergency department with a complaint of unequal...

    Correct

    • A 38-year-old woman comes to the emergency department with a complaint of unequal pupil size. Upon examination, there is an anisocoria of >1mm. The anisocoria appears to be more pronounced when a light is shone on the patient's face compared to when the room is darkened. The patient's eye movements are normal, and a slit-lamp examination reveals no evidence of synechiae. What possible condition could be responsible for these findings?

      Your Answer: Adie's tonic pupil

      Explanation:

      When a patient presents with anisocoria, it is important to determine whether the issue lies with dilation or constriction. In this case, the anisocoria is exacerbated by bright light, indicating a problem with the parasympathetic innervation and the affected pupil’s inability to constrict. Adie’s tonic pupil is a likely cause, as it involves dysfunction of the ciliary ganglion. Horner syndrome and oculomotor nerve palsy are unlikely causes, as they would result in different symptoms. Physiological anisocoria and pilocarpine are also incorrect answers.

      Mydriasis, which is the enlargement of the pupil, can be caused by various factors. These include third nerve palsy, Holmes-Adie pupil, traumatic iridoplegia, pheochromocytoma, and congenital conditions. Additionally, certain drugs can also cause mydriasis, such as topical mydriatics like tropicamide and atropine, sympathomimetic drugs like amphetamines and cocaine, and anticholinergic drugs like tricyclic antidepressants. It’s important to note that anisocoria, which is when one pupil is larger than the other, can also result in the appearance of mydriasis.

    • This question is part of the following fields:

      • Ophthalmology
      15.4
      Seconds
  • Question 7 - A 12-year-old girl presents with complaints of tinnitus and ear pain, as well...

    Incorrect

    • A 12-year-old girl presents with complaints of tinnitus and ear pain, as well as a noticeable decrease in her hearing ability. An MRI scan shows that bilateral acoustic neuromas are responsible for her hearing loss. What is the mode of inheritance for this disease?

      Your Answer: Autosomal recessive

      Correct Answer: Autosomal dominant

      Explanation:

      Inheritance Patterns and Genetic Disorders

      Genetic disorders can be inherited in various ways, including autosomal dominant, mitochondrial inheritance, X-linked recessive, and autosomal recessive. Somatic mutations can also occur, but they are not inherited.

      Autosomal dominant disorders are caused by a single copy of a mutated gene and can be inherited from an affected parent or occur spontaneously. Neurofibromatosis type 2 is an example of an autosomal dominant disorder that causes benign tumors in the nervous system.

      Mitochondrial inheritance occurs when mutations in mitochondrial DNA are passed down from the mother to her offspring. Disorders inherited this way include mitochondrial myopathy and Leber’s hereditary optic neuropathy.

      X-linked recessive disorders are caused by mutations on the X chromosome and typically affect males more severely than females. Examples include haemophilia A and B and Duchenne muscular dystrophy.

      Autosomal recessive disorders require two copies of a mutated gene, one from each parent, to cause the disorder. Examples include cystic fibrosis and sickle-cell disease.

      Somatic mutations occur after conception in non-germ cells and are not inherited. They can lead to cancer and neurodevelopmental disorders.

    • This question is part of the following fields:

      • Genetics
      23.9
      Seconds
  • Question 8 - A 55-year-old woman visits the Menopause clinic seeking guidance on hormone replacement therapy...

    Incorrect

    • A 55-year-old woman visits the Menopause clinic seeking guidance on hormone replacement therapy (HRT). She is worried about her chances of developing osteoporosis, as her mother and sister experienced pelvic fractures due to osteoporosis after menopause. What is the most effective test to determine her likelihood of developing osteoporosis?

      Your Answer: Serum alkaline phosphatase

      Correct Answer: Dual-energy X-ray absorptiometry (DEXA) scan

      Explanation:

      Diagnostic Tests for Osteoporosis

      Osteoporosis is a common condition among postmenopausal women, with a high risk of fractures. Genetic predisposition, lack of exercise, and immobility are some of the contributing factors. To diagnose osteoporosis, several diagnostic tests are available.

      Dual-energy X-ray absorptiometry (DEXA) scan is a commonly used test to measure bone density. It compares the patient’s bone density with that of their peer group to estimate the risk of fractures. The T-score and Z-score are used to interpret the results. A T-score higher than −1 is normal, between −1 and −2.5 is osteopenia, and below −2.5 is osteoporotic. A Z-score compares the patient’s bone density with that of individuals of the same sex, age, weight, and ethnicity.

      Magnetic resonance imaging (MRI) of the pelvis may suggest osteopenia, but a DEXA scan is needed for a diagnosis. Pelvic X-ray is used to detect pelvic fractures. Serum alkaline phosphatase is normal in osteoporosis patients, while serum calcium is useful in ruling out alternative diagnoses.

      In conclusion, early diagnosis of osteoporosis is crucial to prevent fractures and improve quality of life. DEXA scan is the gold standard for measuring bone density, while other tests may be used to rule out alternative diagnoses.

    • This question is part of the following fields:

      • Orthopaedics
      13.2
      Seconds
  • Question 9 - A 36-year-old man arrives at the emergency department complaining of abdominal pain. He...

    Incorrect

    • A 36-year-old man arrives at the emergency department complaining of abdominal pain. He had been at a store that specializes in exotic pets when he was stung by a scorpion. He has no medical history to report.

      During the examination, he displays severe abdominal pain that extends to his back. There is tenderness and guarding in the epigastric region.

      What is the predictive factor for a more severe disease course in this likely diagnosis?

      Your Answer: Raised lipase

      Correct Answer: Hypocalcaemia

      Explanation:

      Hypocalcaemia is an indicator of pancreatitis severity, while hypercalcaemia can cause pancreatitis. Other factors that predict the severity of pancreatitis include abdominal pain, obstructing gallstones, alcohol, trauma, and the Glasgow pancreatitis score. Hypoglycaemia is not predictive of severity, while hyperglycaemia is. Raised amylase levels aid in the diagnosis of acute pancreatitis.

      Understanding Acute Pancreatitis

      Acute pancreatitis is a condition that is commonly caused by alcohol or gallstones. It occurs when the pancreatic enzymes start to digest the pancreatic tissue, leading to necrosis. The main symptom of acute pancreatitis is severe epigastric pain that may radiate through to the back. Vomiting is also common, and examination may reveal epigastric tenderness, ileus, and low-grade fever. In rare cases, periumbilical discolouration (Cullen’s sign) and flank discolouration (Grey-Turner’s sign) may be present.

      To diagnose acute pancreatitis, doctors typically measure the levels of serum amylase and lipase in the blood. While amylase is raised in 75% of patients, it does not correlate with disease severity. Lipase, on the other hand, is more sensitive and specific than amylase and has a longer half-life. Imaging tests, such as ultrasound and contrast-enhanced CT, may also be used to assess the aetiology of the condition.

      Scoring systems, such as the Ranson score, Glasgow score, and APACHE II, are used to identify cases of severe pancreatitis that may require intensive care management. Factors that indicate severe pancreatitis include age over 55 years, hypocalcaemia, hyperglycaemia, hypoxia, neutrophilia, and elevated LDH and AST. It is important to note that the actual amylase level is not of prognostic value.

      In summary, acute pancreatitis is a condition that can cause severe pain and discomfort. It is typically caused by alcohol or gallstones and can be diagnosed through blood tests and imaging. Scoring systems are used to identify cases of severe pancreatitis that require intensive care management.

    • This question is part of the following fields:

      • Surgery
      10.4
      Seconds
  • Question 10 - A 30-year-old man presents to the A&E with a painful shoulder injury he...

    Incorrect

    • A 30-year-old man presents to the A&E with a painful shoulder injury he sustained while playing basketball. Upon examination, you discover an anterior dislocation of his right shoulder. What pre- and post-relocation test must you perform?

      Your Answer: Examine the radial pulse in the affected arm

      Correct Answer: Examine axillary nerve function in the affected arm

      Explanation:

      Assessing Vascular and Nerve Injury in Anterior Shoulder Dislocation: Important Tests to Consider

      When examining a patient with anterior shoulder dislocation, it is crucial to assess for vascular and nerve injury in the affected arm. One way to test nerve function is by assessing sensation in the regimental patch area over the deltoid muscle. An X-ray before and after relocation is necessary to check for fractures and confirm successful reduction. If there is vascular injury, it will be evident from the examination of the limb, and urgent referral to surgeons is required. Checking the brachial pulse is acceptable to assess for vascular injury, and examining axillary nerve function before and after relocation is mandatory. Ultrasound of the affected limb may be helpful in identifying soft tissue injuries, but it is not as crucial as the other tests mentioned. Overall, a thorough assessment of vascular and nerve function is essential in managing anterior shoulder dislocation.

    • This question is part of the following fields:

      • Orthopaedics
      12.9
      Seconds
  • Question 11 - A 42-year-old man is referred to an otolaryngologist with vertigo and hearing loss....

    Incorrect

    • A 42-year-old man is referred to an otolaryngologist with vertigo and hearing loss. A magnetic resonance imaging (MRI) scan of the cranial region reveals a tumour at the cerebellopontine angle. A working diagnosis of acoustic neuroma is made. In light of the progressive symptoms, the surgeon plans to remove the tumour.
      With regard to the vestibulocochlear nerve, which of the following is correct?

      Your Answer: The vestibulocochlear nerve exits the cranium through the jugular foramen

      Correct Answer: Vestibular fibres pass to the vestibular nuclear complex, located in the floor of the fourth ventricle

      Explanation:

      Anatomy of the Vestibulocochlear Nerve

      The vestibulocochlear nerve, also known as the eighth cranial nerve, is responsible for carrying special sensory afferent fibers from the inner ear. It is composed of two portions: the vestibular nerve and the cochlear nerve. The vestibular fibers pass to the vestibular nuclear complex, located in the floor of the fourth ventricle, while the cochlear fibers pass to the cochlear nuclear complex, located across the junction between the pons and medulla.

      Acoustic neuromas, which are tumors that commonly arise from the vestibular portion of the nerve, are also known as vestibular schwannomas. The efferent nerve supply to the tensor tympani, a muscle in the middle ear, is provided by the mandibular branch of the fifth cranial nerve.

      The vestibulocochlear nerve enters the brainstem at the pontomedullary junction, lateral to the facial nerve. It then passes into the temporal bone via the internal auditory meatus, along with the facial nerve. It does not exit the cranium through the jugular foramen, which is where the ninth, tenth, and eleventh cranial nerves exit. Understanding the anatomy of the vestibulocochlear nerve is important in diagnosing and treating disorders related to hearing and balance.

    • This question is part of the following fields:

      • ENT
      8.9
      Seconds
  • Question 12 - A patient in their late 60s with end stage renal disease on haemodialysis...

    Incorrect

    • A patient in their late 60s with end stage renal disease on haemodialysis is admitted with sudden onset of wheezing and shortness of breath. They have swollen ankles and a raised JVP of 7 cm, with a blood pressure of 110/50 mmHg. Upon chest examination, there are widespread coarse crackles. A chest radiograph reveals complete opacification of both lung fields and blunting of the left costophrenic angle. The patient had their usual haemodialysis session the previous night. What could be the potential cause of this acute presentation?

      Your Answer: Inadequate haemodialysis

      Correct Answer: Myocardial infarction

      Explanation:

      Cardiovascular Risk in Haemodialysis Patients

      Haemodialysis patients are at a significantly higher risk of developing cardiovascular disease. Therefore, any sudden deterioration in their condition is a cause for concern. In the case of a previously stable dialysis patient presenting with low blood pressure, excess fluid intake is unlikely to be the cause. Instead, a cardiac event is the most likely explanation.

      It is improbable that inadequate haemodialysis is the cause of the patient’s symptoms, as they had a session less than 24 hours ago. Furthermore, if this were the case, the patient would likely have high blood pressure due to fluid accumulation.

      While patients on dialysis are more susceptible to infections, the presentation is consistent with acute pulmonary oedema. This condition occurs when fluid accumulates in the lungs, making it difficult to breathe. Therefore, it is essential to monitor haemodialysis patients closely for any signs of cardiovascular disease and promptly address any acute events that may arise.

    • This question is part of the following fields:

      • Nephrology
      32.9
      Seconds
  • Question 13 - As a first-year resident on a surgical rotation, which of the following procedures...

    Correct

    • As a first-year resident on a surgical rotation, which of the following procedures would necessitate the use of prophylactic antibiotics?

      Your Answer: Appendicectomy

      Explanation:

      Preventing Surgical Site Infections

      Surgical site infections (SSI) are a common complication following surgery, with up to 20% of all healthcare-associated infections being SSIs. These infections occur when there is a breach in tissue surfaces, allowing normal commensals and other pathogens to initiate infection. In many cases, the organisms causing the infection are derived from the patient’s own body. Measures that may increase the risk of SSI include shaving the wound using a razor, using a non-iodine impregnated incise drape, tissue hypoxia, and delayed administration of prophylactic antibiotics in tourniquet surgery.

      To prevent SSIs, there are several steps that can be taken before, during, and after surgery. Before surgery, it is recommended to avoid routine removal of body hair and to use electrical clippers with a single-use head if hair needs to be removed. Antibiotic prophylaxis should be considered for certain types of surgery, such as placement of a prosthesis or valve, clean-contaminated surgery, and contaminated surgery. Local formulary should be used, and a single-dose IV antibiotic should be given on anesthesia. If a tourniquet is to be used, prophylactic antibiotics should be given earlier.

      During surgery, the skin should be prepared with alcoholic chlorhexidine, which has been shown to have the lowest incidence of SSI. The surgical site should be covered with a dressing, and wound edge protectors do not appear to confer any benefit. Postoperatively, tissue viability advice should be given for the management of surgical wounds healing by secondary intention. The use of diathermy for skin incisions is not advocated in the NICE guidelines, but several randomized controlled trials have demonstrated no increase in the risk of SSI when diathermy is used.

    • This question is part of the following fields:

      • Surgery
      9.9
      Seconds
  • Question 14 - A 32-year-old woman who is 39 weeks pregnant ingests an excessive amount of...

    Correct

    • A 32-year-old woman who is 39 weeks pregnant ingests an excessive amount of lithium. After being stabilised, her baby is delivered without complications. However, during routine neonatal examinations, a pansystolic murmur is detected. Further evaluation through cardiac echocardiogram shows tricuspid incompetence with a large right atrium, a small right ventricle, and a low insertion of the tricuspid valve. What is the probable diagnosis?

      Your Answer: Ebstein's anomaly

      Explanation:

      Ebstein’s anomaly is a congenital heart defect that results in the ‘atrialisation’ of the right ventricle. This condition is characterized by a low insertion of the tricuspid valve, which causes a large right atrium and a small right ventricle, leading to tricuspid incompetence. It is important to note that Ebstein’s anomaly is not the same as Fallot’s tetralogy, coarctation of the aorta, or transposition of the great arteries.

      Understanding Ebstein’s Anomaly

      Ebstein’s anomaly is a type of congenital heart defect that is characterized by the tricuspid valve being inserted too low, resulting in a large atrium and a small ventricle. This condition is also known as the atrialization of the right ventricle. It is believed that exposure to lithium during pregnancy may cause this condition.

      Ebstein’s anomaly is often associated with a patent foramen ovale (PFO) or atrial septal defect (ASD), which causes a shunt between the right and left atria. Additionally, patients with this condition may also have Wolff-Parkinson White syndrome.

      The clinical features of Ebstein’s anomaly include cyanosis, a prominent a wave in the distended jugular venous pulse, hepatomegaly, tricuspid regurgitation, and a pansystolic murmur that is worse on inspiration. Patients may also have a right bundle branch block, which can lead to widely split S1 and S2 heart sounds.

      In summary, Ebstein’s anomaly is a congenital heart defect that affects the tricuspid valve and can cause a range of symptoms. It is often associated with other conditions such as PFO or ASD and can be diagnosed through clinical examination and imaging tests.

    • This question is part of the following fields:

      • Paediatrics
      4
      Seconds
  • Question 15 - A 50-year-old man presents to the emergency department with acute joint swelling. He...

    Incorrect

    • A 50-year-old man presents to the emergency department with acute joint swelling. He has a history of type 2 diabetes and hypercholesterolemia and takes metformin and atorvastatin. He smokes 25 cigarettes daily and drinks 20 units of alcohol per week.

      His left knee joint is erythematosus, warm, and tender. His temperature is 37.2ºC, his heart rate is 105 bpm, his respiratory rate is 18 /min, and his blood pressure is 140/80 mmHg. Joint aspiration shows needle-shaped negatively birefringent crystals.

      What is the most appropriate investigation to confirm the likely diagnosis?

      Your Answer: Measure urine urate level 2 weeks after inflammation settles

      Correct Answer: Measure serum urate 2 weeks after inflammation settles

      Explanation:

      Understanding Gout: Symptoms and Diagnosis

      Gout is a type of arthritis that causes inflammation and pain in the joints. Patients experience episodes of intense pain that can last for several days, followed by periods of no symptoms. The acute episodes usually reach their peak within 12 hours and are characterized by significant pain, swelling, and redness. The most commonly affected joint is the first metatarsophalangeal joint, but other joints such as the ankle, wrist, and knee can also be affected. If left untreated, repeated acute episodes of gout can lead to chronic joint problems.

      To diagnose gout, doctors may perform a synovial fluid analysis to look for needle-shaped, negatively birefringent monosodium urate crystals under polarized light. Uric acid levels may also be checked once the acute episode has subsided, as they can be high, normal, or low during the attack. Radiological features of gout include joint effusion, well-defined punched-out erosions with sclerotic margins in a juxta-articular distribution, and eccentric erosions. Unlike rheumatoid arthritis, there is no periarticular osteopenia, and soft tissue tophi may be visible.

    • This question is part of the following fields:

      • Musculoskeletal
      22.5
      Seconds
  • Question 16 - A general practice is auditing the prescribing of antibiotics in patients diagnosed with...

    Correct

    • A general practice is auditing the prescribing of antibiotics in patients diagnosed with acute otitis media.
      Regarding use of patients’ records in clinical audit in general practice, which one of the following statements is true for pediatric patients?

      Your Answer: A generic flyer posted to all the patients under the general practice is sufficient notification that their records may be used in a clinical audit

      Explanation:

      Understanding Confidentiality and Anonymity in Clinical Audits

      Clinical audits are an important part of ensuring quality healthcare, but it is crucial to maintain patient confidentiality and anonymity. The NHS Code of Practice on Confidentiality outlines the guidelines for using patient information in clinical audits.

      Patients must be made aware of how their information will be used within the practice, and generic flyers can be used for this purpose. However, patients must also be informed that they have the right to refuse their information being used. Once patients have been informed, consent does not need to be sought from each individual patient.

      Patient information must be anonymised once it is to be used outside of the GP practice, including for research being undertaken by a medical school or a healthcare trust. The six Caldicott principles should be considered when deciding whether to breach patient confidentiality.

      It is not essential to anonymise patient information if a clinical audit is being done within one practice, but patients must still be informed of how their information will be used. Overall, it is important to prioritize patient confidentiality and anonymity in all clinical audits.

    • This question is part of the following fields:

      • Ethics And Legal
      21.5
      Seconds
  • Question 17 - A 49 year old male patient with a history of type 2 diabetes...

    Correct

    • A 49 year old male patient with a history of type 2 diabetes mellitus, angina and atrial fibrillation comes for a regular check-up. He is worried about experiencing erectile dysfunction and inquires about the use of sildenafil. Which of his medications is an absolute contraindication for its use?

      Your Answer: Nicorandil

      Explanation:

      Sildenafil, a type of PDE 5 inhibitor, should not be prescribed to patients taking nitrates or nicorandil due to contraindications. Nicorandil, which has both nitrate and potassium channel agonist properties, is particularly problematic as it poses a risk when combined with sildenafil.

      Understanding Phosphodiesterase Type V Inhibitors

      Phosphodiesterase type V (PDE5) inhibitors are medications used to treat erectile dysfunction and pulmonary hypertension. These drugs work by increasing the levels of cGMP, which leads to the relaxation of smooth muscles in the blood vessels supplying the corpus cavernosum. The most well-known PDE5 inhibitor is sildenafil, also known as Viagra, which was the first drug of its kind. It is a short-acting medication that is usually taken one hour before sexual activity.

      Other PDE5 inhibitors include tadalafil (Cialis) and vardenafil (Levitra). Tadalafil is longer-acting than sildenafil and can be taken on a regular basis, while vardenafil has a similar duration of action to sildenafil. However, these drugs are not suitable for everyone. Patients taking nitrates or related drugs, those with hypotension, and those who have had a recent stroke or myocardial infarction should not take PDE5 inhibitors.

      Like all medications, PDE5 inhibitors can cause side effects. These may include visual disturbances, blue discolouration, non-arteritic anterior ischaemic neuropathy, nasal congestion, flushing, gastrointestinal side-effects, headache, and priapism. It is important to speak to a healthcare professional before taking any medication to ensure that it is safe and appropriate for you.

      Overall, PDE5 inhibitors are an effective treatment for erectile dysfunction and pulmonary hypertension. However, they should only be used under the guidance of a healthcare professional and with careful consideration of the potential risks and benefits.

    • This question is part of the following fields:

      • Pharmacology
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  • Question 18 - A 25-year-old male patient comes to the clinic with a lump in his...

    Incorrect

    • A 25-year-old male patient comes to the clinic with a lump in his testicle. Upon examination, the mass is found to be painless, irregularly surfaced, hard, and about 2 cm in size. It does not transilluminate. What is the probable cause of the testicular lump?

      Your Answer: Seminoma

      Correct Answer: Teratoma

      Explanation:

      Tumour Identification and Differentiation

      The lump’s characteristics suggest that it is a tumour, specifically due to its hard and irregular nature. However, the age of the patient is a crucial factor in determining the type of tumour. Teratomas are typically found in individuals aged 20-30, while seminomas are more common in those aged 30-50. Teratomas are a type of gonadal tumour that originates from multipotent cells present in the ovaries.

      In summary, the identification and differentiation of tumours depend on various factors, including the lump’s characteristics and the patient’s age. these factors is crucial in determining the appropriate treatment and management of the tumour.

    • This question is part of the following fields:

      • Surgery
      17.6
      Seconds
  • Question 19 - A 31-year-old woman is on day four postpartum, following an emergency Caesarean section...

    Incorrect

    • A 31-year-old woman is on day four postpartum, following an emergency Caesarean section for severe pre-eclampsia. She feels well in herself and is mobilising and breastfeeding well. Her blood pressure has not normalised yet and is 158/106 mmHg today. Urinalysis is negative for protein. Following a long discussion, you decide that she is ready for discharge and can be managed in the community.
      Which of the following is correct regarding postnatal hypertension?

      Your Answer: The blood pressure should be checked at least once every two weeks until the woman discontinues antihypertensive treatment

      Correct Answer: Women who are discharged and are still hypertensive should have their blood pressure checked every other day in the community until targets are achieved

      Explanation:

      Postnatal Hypertension Management: Guidelines for Discharge and Follow-up

      Women who experience hypertension during the postnatal period require careful management to ensure their blood pressure is controlled and any underlying causes are addressed. Here are some guidelines for managing postnatal hypertension:

      – Women who are discharged and still hypertensive should have their blood pressure checked every other day in the community until targets are achieved.
      – The GP at the 6-week postnatal check should convert all women with chronic hypertension (before pregnancy) back to their pre-pregnancy antihypertensive medication, if not contraindicated in breastfeeding.
      – If blood pressure is found to be > 150/100 mmHg in the community, the patient should be referred back to the hospital.
      – The blood pressure should be checked at least once every two weeks until the woman discontinues antihypertensive treatment.
      – The GP at the 6-week postnatal check should stop antihypertensives in all women who required medical treatment in pregnancy, provided their blood pressure is < 130/80 mmHg.
      – If a woman still has a blood pressure of ≤ 160/110 mmHg and proteinuria at the 6-week postnatal appointment, despite medical management, she will require a specialist referral to the hospital for further assessment of the underlying causes of hypertension.

      By following these guidelines, healthcare providers can ensure that women with postnatal hypertension receive appropriate care and support to manage their condition effectively.

    • This question is part of the following fields:

      • Obstetrics
      51.9
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  • Question 20 - Disease prevention measures can be categorized as primary or secondary. What is an...

    Incorrect

    • Disease prevention measures can be categorized as primary or secondary. What is an example of a secondary prevention measure?

      Your Answer: Offering smoking cessation services

      Correct Answer: Screening for breast cancer

      Explanation:

      Examples of Primary and Secondary Prevention Measures

      Primary and secondary prevention measures are important in healthcare to prevent the onset or progression of diseases. Primary prevention involves preventing a disease before it even starts, while secondary prevention involves early detection and treatment of a disease.

      Examples of primary prevention measures include annual influenzae vaccination, giving away free condoms in general practice to prevent STIs, introducing healthy school meals to prevent obesity, and offering smoking cessation services to prevent lung cancer.

      On the other hand, breast cancer screening is an example of a secondary prevention measure. Its aim is to detect early breast cancer so that it can be treated before it is too late. By implementing both primary and secondary prevention measures, healthcare providers can work towards reducing the burden of diseases and improving overall health outcomes.

    • This question is part of the following fields:

      • Statistics
      12.9
      Seconds
  • Question 21 - A 32-year-old woman with shortness of breath on exercise comes to the clinic...

    Incorrect

    • A 32-year-old woman with shortness of breath on exercise comes to the clinic some 6 months after the birth of her second child. The recent pregnancy and post-partum period were uneventful. Her general practitioner has diagnosed her with asthma and prescribed a salbutamol inhaler. On examination, she looks unwell and is slightly short of breath at rest. Her blood pressure is 150/80 mmHg and her body mass index (BMI) is 24. There is mild bilateral pitting ankle oedema. Auscultation of the chest reveals no wheeze.
      Investigations
      Investigation Result Normal value
      Haemoglobin 129 g/l 115–155 g/l
      White cell count (WCC) 5.8 × 109/l 4–11 × 109/l
      Platelets 190 × 109/l 150–400 × 109/l
      Sodium (Na+) 140 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
      Electrocardiogram (ECG) Right axis deviation,
      incomplete right bundle branch block
      Pulmonary artery systolic pressure 33 mmHg
      Which of the following is the most likely diagnosis?

      Your Answer: Hypertrophic obstructive cardiomyopathy (HOCM)

      Correct Answer: Primary pulmonary hypertension

      Explanation:

      Differential Diagnosis for Postpartum Dyspnea: A Review

      Postpartum dyspnea can be a concerning symptom for new mothers. In this case, the patient presents with dyspnea and fatigue several weeks after giving birth. The following differentials should be considered:

      1. Primary Pulmonary Hypertension: This condition can present with right ventricular strain on ECG and elevated pulmonary artery systolic pressure. It is not uncommon for symptoms to develop after childbirth.

      2. Dilated Cardiomyopathy: Patients with dilated cardiomyopathy may present with left bundle branch block and right axis deviation. Symptoms can develop weeks to months after giving birth.

      3. Multiple Pulmonary Emboli: While a possible differential, the absence of pleuritic pain and risk factors such as a raised BMI make this less likely.

      4. Hypertrophic Obstructive Cardiomyopathy (HOCM): HOCM typically presents with exertional syncope or pre-syncope and ECG changes such as left ventricular hypertrophy or asymmetrical septal hypertrophy.

      5. Hypertensive Heart Disease: This condition is characterized by elevated blood pressure during pregnancy, which is not reported in this case. The patient’s symptoms are also not typical of hypertensive heart disease.

      In conclusion, a thorough evaluation and consideration of these differentials can aid in the diagnosis and management of postpartum dyspnea.

    • This question is part of the following fields:

      • Cardiology
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  • Question 22 - A 56-year-old man visits his GP due to hip discomfort. He reports that...

    Incorrect

    • A 56-year-old man visits his GP due to hip discomfort. He reports that it has been gradually worsening for the past three months. The pain is constant throughout the day and night, but it is most severe when he puts weight on it. He denies experiencing any morning stiffness. He has attempted to alleviate the pain with paracetamol and ibuprofen, but to no avail. The patient's medical history includes active Crohn's disease, which is being treated with corticosteroids. During the examination, there is tenderness when palpating the anterior groin area, but the range of passive motion is normal. What is the most probable diagnosis?

      Your Answer: Iliotibial band syndrome

      Correct Answer: Avascular necrosis of the hip

      Explanation:

      The most likely diagnosis for the patient in the vignette is avascular necrosis of the hip, which is a significant risk for those who use steroids long-term. The patient has been experiencing worsening hip pain over a few months, which is exacerbated by use and does not have morning stiffness. The location of the pain in the anterior groin region is characteristic of avascular necrosis of the hip. Greater trochanteric pain syndrome and iliotibial band syndrome are unlikely diagnoses as they present with pain in different locations and have different exacerbating factors.

      Understanding Avascular Necrosis of the Hip

      Avascular necrosis of the hip is a condition where bone tissue dies due to a loss of blood supply, leading to bone destruction and loss of joint function. This condition typically affects the epiphysis of long bones, such as the femur. There are several causes of avascular necrosis, including long-term steroid use, chemotherapy, alcohol excess, and trauma.

      Initially, avascular necrosis may not present with any symptoms, but as the condition progresses, pain in the affected joint may occur. Plain x-ray findings may be normal in the early stages, but osteopenia and microfractures may be seen. As the condition worsens, collapse of the articular surface may result in the crescent sign.

      MRI is the preferred investigation for avascular necrosis as it is more sensitive than radionuclide bone scanning. In severe cases, joint replacement may be necessary to manage the condition. Understanding the causes, features, and management of avascular necrosis of the hip is crucial for early detection and effective treatment.

    • This question is part of the following fields:

      • Musculoskeletal
      18
      Seconds
  • Question 23 - A 42-year-old man visits his GP complaining of jaundice that has been present...

    Incorrect

    • A 42-year-old man visits his GP complaining of jaundice that has been present for 2 days. He has a medical history of Crohn's disease and type 2 diabetes mellitus. The patient takes metformin, sitagliptin, infliximab, and bisoprolol regularly. He recently completed a course of clindamycin for a lower limb cellulitis and started taking glipizide for poor glycaemic control. The patient has unconjugated hyperbilirubinaemia and recalls experiencing a similar episode of jaundice as a child after consuming fava beans. Which medication is the most likely cause of the patient's jaundice?

      Your Answer:

      Correct Answer: Glipizide

      Explanation:

      The drug that can trigger haemolysis in a patient with G6PD deficiency from the given options is glipizide. G6PD deficiency is commonly caused by the consumption of fava beans/broad beans and can lead to haemolysis. Various drug classes, including sulphonamides, sulphasalazine, and sulphonylureas, among others, are also associated with haemolysis in G6PD deficiency. Glipizide is a sulphonylurea and, therefore, the correct answer. Other examples of sulphonylureas include gliclazide and glimepiride. Bisoprolol, clindamycin, and infliximab are not associated with haemolysis in G6PD deficiency. Nitrofurantoin, sulfamethoxazole, and ciprofloxacin are antibiotics that can cause haemolysis in patients with G6PD deficiency. Bisoprolol does not cause jaundice, and infliximab may rarely cause cholestasis, leading to conjugated hyperbilirubinemia, which is not associated with G6PD deficiency.

      Understanding G6PD Deficiency

      Glucose-6-phosphate dehydrogenase (G6PD) deficiency is a common red blood cell enzyme defect that is inherited in an X-linked recessive fashion and is more prevalent in people from the Mediterranean and Africa. The deficiency can be triggered by many drugs, infections, and broad (fava) beans, leading to a crisis. G6PD is the first step in the pentose phosphate pathway, which converts glucose-6-phosphate to 6-phosphogluconolactone and results in the production of nicotinamide adenine dinucleotide phosphate (NADPH). NADPH is essential for converting oxidized glutathione back to its reduced form, which protects red blood cells from oxidative damage by oxidants such as superoxide anion (O2-) and hydrogen peroxide. Reduced G6PD activity leads to decreased reduced glutathione and increased red cell susceptibility to oxidative stress, resulting in neonatal jaundice, intravascular hemolysis, gallstones, splenomegaly, and the presence of Heinz bodies on blood films. Diagnosis is made by using a G6PD enzyme assay, and some drugs are known to cause hemolysis, while others are thought to be safe.

      Comparing G6PD deficiency to hereditary spherocytosis, G6PD deficiency is more common in males of African and Mediterranean descent, while hereditary spherocytosis affects both males and females of Northern European descent. G6PD deficiency is characterized by neonatal jaundice, infection/drug-induced hemolysis, gallstones, and Heinz bodies on blood films, while hereditary spherocytosis is characterized by chronic symptoms, spherocytes on blood films, and the possibility of hemolytic crisis precipitated by infection. The diagnostic test for G6PD deficiency is measuring enzyme activity, while the diagnostic test for hereditary spherocytosis is EMA binding.

    • This question is part of the following fields:

      • Medicine
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  • Question 24 - A 65-year-old woman presents to the Emergency Department with chest pain that has...

    Incorrect

    • A 65-year-old woman presents to the Emergency Department with chest pain that has worsened over the past 2 days. She also reported feeling ‘a little run down’ with a sore throat a week ago. She has history of hypertension and hyperlipidaemia. She reports diffuse chest pain that feels better when she leans forward. On examination, she has a temperature of 37.94 °C and a blood pressure of 140/84 mmHg. Her heart rate is 76 bpm. A friction rub is heard on cardiac auscultation, and an electrocardiogram (ECG) demonstrates ST segment elevation in nearly every lead. Her physical examination and blood tests are otherwise within normal limits.
      Which of the following is the most likely aetiology of her chest pain?

      Your Answer:

      Correct Answer: Post-viral complication

      Explanation:

      Pericarditis as a Post-Viral Complication: Symptoms and Differential Diagnosis

      Pericarditis, inflammation of the pericardium, can occur as a post-viral complication. Patients typically experience diffuse chest pain that improves when leaning forward, and a friction rub may be heard on cardiac auscultation. Diffuse ST segment elevations on ECG can be mistaken for myocardial infarction. In this case, the patient reported recent viral symptoms and then developed acute pericardial symptoms.

      While systemic lupus erythematosus (SLE) can cause pericarditis, other symptoms such as rash, myalgia, or joint pain would be expected, along with a positive anti-nuclear antibodies test. Uraemia can also cause pericarditis, but elevated blood urea nitrogen would be present, and this patient has no history of kidney disease. Dressler syndrome, or post-myocardial infarction pericarditis, can cause diffuse ST elevations, but does not represent transmural infarction. Chest radiation can also cause pericarditis, but this patient has no history of radiation exposure.

    • This question is part of the following fields:

      • Cardiology
      0
      Seconds
  • Question 25 - A 55-year-old man presents to the general practitioner (GP) with a 6-month history...

    Incorrect

    • A 55-year-old man presents to the general practitioner (GP) with a 6-month history of increasing difficulty with swallowing solid foods. He does not have any problems with swallowing liquids. He has always been overweight but has lost 5 kg in the past few months. He attributes this eating a little less due to his swallowing difficulties. He has a past history of long-term heartburn and indigestion, which he has been self-treating with over-the-counter antacids. The GP is concerned that the patient may have oesophageal cancer.
      Which one of the following statements with regard to oesophageal cancer is correct?

      Your Answer:

      Correct Answer: Achalasia predisposes to squamous carcinoma of the oesophagus

      Explanation:

      Understanding Oesophageal Carcinoma: Risk Factors, Diagnosis, and Prognosis

      Oesophageal carcinoma is a type of cancer that affects the oesophagus, the muscular tube that connects the throat to the stomach. In this article, we will discuss the risk factors, diagnosis, and prognosis of oesophageal carcinoma.

      Risk Factors

      Achalasia, a condition that affects the ability of the oesophagus to move food down to the stomach, and alcohol consumption are associated with squamous carcinoma, which most commonly affects the upper and middle oesophagus. Barrett’s oesophagus, a pre-malignant condition that may lead to squamous carcinoma, and gastro-oesophageal reflux disease (GORD) predispose to adenocarcinoma, which occurs in the lower oesophagus.

      Diagnosis

      Barrett’s oesophagus is a recognised pre-malignant condition that requires acid-lowering therapy and frequent follow-up. Ablative and excisional therapies are available. Most cases are amenable to curative surgery at diagnosis. Dysphagia, or difficulty swallowing, is an early manifestation of the disease and is typically experienced with solid foods.

      Prognosis

      Prognosis depends on the stage and grade at diagnosis, but unfortunately, the disease frequently presents once the cancer has spread. Therefore, early detection and treatment are crucial for improving outcomes.

      Conclusion

      Oesophageal carcinoma is a serious condition that requires prompt diagnosis and treatment. Understanding the risk factors, diagnosis, and prognosis can help individuals take steps to reduce their risk and seek medical attention if symptoms arise.

    • This question is part of the following fields:

      • Gastroenterology
      0
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  • Question 26 - A 22-year-old female patient reports experiencing tingling sensations around her mouth and hands,...

    Incorrect

    • A 22-year-old female patient reports experiencing tingling sensations around her mouth and hands, as well as numbness in her feet. She has a history of anorexia nervosa and her current BMI is 15. Additionally, she has been experiencing occasional, unresolved contractions in her arms and legs. Tapping the inferior portions of her cheekbones causes facial spasms. What electrolyte abnormality is most likely responsible for these symptoms?

      Your Answer:

      Correct Answer: Hypocalcaemia

      Explanation:

      Tetany in Anorexia Nervosa Patients

      Patients with anorexia nervosa are at risk of electrolyte abnormalities, which can lead to symptoms of peripheral neuropathy such as pins and needles. However, some patients may experience tetany, which is a sign of existing nerve excitability. Tetany results from a low level of calcium extracellularly, which increases the permeability of neuronal membranes to sodium ion, causing a progressive depolarization and increasing the possibility of action potentials. This is highlighted by Chvostek’s signs, which is a sign of tetany whereby tapping the inferior portions of the cheekbones produces facial spasms.

      Hypocalcaemia is the most common cause of tetany, but low levels of magnesium can also cause it. In cases of hypocalcaemia with coexisting hypomagnesemia, magnesium should be corrected first. This is especially true in cases of hypocalcaemia refractory to treatment, whereby magnesium levels should be checked. Magnesium depletion decreases the release of PTH and causes skeletal resistance to PTH. Therefore, tetany in anorexia nervosa patients is crucial to prevent further complications and ensure proper treatment.

    • This question is part of the following fields:

      • Clinical Sciences
      0
      Seconds
  • Question 27 - An otherwise healthy 62-year-old woman with an unremarkable medical history has had increasing...

    Incorrect

    • An otherwise healthy 62-year-old woman with an unremarkable medical history has had increasing back pain and right hip pain for the last 3 years. The pain is worse at the end of the day. On physical examination, bony enlargement of the distal interphalangeal joints is noted. A radiograph of the spine reveals the presence of prominent osteophytes involving the vertebral bodies. There is sclerosis with narrowing of the joint space at the right acetabulum seen on a radiograph of the pelvis. No biochemical abnormalities were detected on blood tests.
      Which of the following conditions is most likely to be affecting this patient?

      Your Answer:

      Correct Answer: Osteoarthritis

      Explanation:

      Differentiating Arthritis: Understanding the Symptoms and Characteristics of Osteoarthritis, Pseudogout, Rheumatoid Arthritis, Gout, and Osteomyelitis

      Arthritis is a broad term that encompasses various conditions affecting the joints. It is important to differentiate between different types of arthritis to provide appropriate treatment. Here are some characteristics and symptoms of common types of arthritis:

      Osteoarthritis: This is a degenerative condition that affects the joints, particularly with ageing. It is characterized by erosion and loss of articular cartilage. Patients may experience deep, achy pain that worsens with use, morning stiffness, crepitus, and limitation of range of movement. Osteoarthritis is an intrinsic disease of articular cartilage, not an inflammatory disease.

      Pseudogout: Also known as calcium pyrophosphate dihydrate deposition disease, this condition is more common in elderly people. It typically affects the knee joint and can cause acute attacks with marked pain, accompanied by meniscal calcification and joint space narrowing.

      Rheumatoid arthritis: This condition typically involves small joints of the hands and feet most severely, and there is a destructive pannus that leads to marked joint deformity. It presents more with an inflammatory arthritis picture, with significant morning stiffness and pain that eases with activity.

      Gout: A gouty arthritis is more likely to be accompanied by swelling and deformity, with joint destruction. The pain is not related to usage. In >90% of presentations, only one joint is affected, and in the majority of cases, that joint is the metatarsophalangeal joint of the great toe.

      Osteomyelitis: This represents an ongoing infection that produces marked bone deformity, not just joint narrowing. Additionally, patients are usually systemically unwell with signs of infection present.

      Understanding the characteristics and symptoms of different types of arthritis can help in making an accurate diagnosis and providing appropriate treatment.

    • This question is part of the following fields:

      • Orthopaedics
      0
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  • Question 28 - A 25-year-old woman presents with a nine-week history of fever. She has been...

    Incorrect

    • A 25-year-old woman presents with a nine-week history of fever. She has been experiencing daily temperatures up to 40°C, malaise, and occasional aches in the hands and knees. She also noticed a transient pink rash on her abdomen. Her GP prescribed a one-week course of ampicillin, but it had little effect. On examination, she has a temperature of 38.9°C, a pulse of 110 per minute, and a faint systolic ejection murmur. Her spleen is palpable 3 cm below the left costal margin. Her haemoglobin level is 115 g/L, and her white cell count is 12.8 ×109/L. Her ASO titre is 250 units, and her rheumatoid factor and ANF are negative. Blood cultures have been requested but are not yet available. What is the most likely diagnosis?

      Your Answer:

      Correct Answer: Adult onset Still's disease

      Explanation:

      Adult Onset Still’s Disease

      Adult onset Still’s disease is a type of inflammatory disorder that affects young adults. Its exact cause and development are still unknown, but it is characterized by various symptoms such as fever, rash, joint pain, and organ enlargement. The disease can have systemic exacerbations and chronic arthritis, with periods of remission in between. To diagnose adult onset Still’s disease, a person must have at least five criteria, including two major criteria such as high fever lasting for a week or longer, joint pain lasting for two weeks or longer, rash, and abnormal white blood cell count. Minor criteria include sore throat, lymph node or spleen swelling, liver problems, and the absence of rheumatoid arthritis.

      It is important to note that mildly raised ASO titres may be present in inflammatory or infective conditions, but an ASO titre of at least 500-1000 is expected in active acute rheumatic fever. Additionally, an ejection systolic murmur may be caused by the hyperdynamic circulation in adult onset Still’s disease, unlike acute rheumatic fever or acute bacterial endocarditis, which cause acute valvular regurgitation and result in pan-systolic or early-diastolic murmurs. Lastly, bacterial endocarditis does not cause the pink rash associated with adult onset Still’s disease.

    • This question is part of the following fields:

      • Infectious Diseases
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  • Question 29 - A 65-year-old lady is admitted with severe pneumonia and, while on the ward,...

    Incorrect

    • A 65-year-old lady is admitted with severe pneumonia and, while on the ward, develops a warm, erythematosus, tender and oedematous left leg. A few days later, her breathing, which was improving with antibiotic treatment, suddenly deteriorated.
      Which one of the following is the best diagnostic test for this patient?

      Your Answer:

      Correct Answer: Computed tomography (CT) pulmonary angiogram

      Explanation:

      The Best Imaging Method for Dual Pathology: Resolving Pneumonia and Pulmonary Embolus

      Computed tomography (CT) pulmonary angiography is the best imaging method for a patient with dual pathology of resolving pneumonia and a pulmonary embolus secondary to a deep vein thrombosis. This method uses intravenous contrast to image the pulmonary vessels and can detect a filling defect within the bright pulmonary arteries, indicating a pulmonary embolism.

      A V/Q scan, which looks for a perfusion mismatch, may indicate a pulmonary embolism, but would not be appropriate in this case due to the underlying pneumonia making interpretation difficult.

      A D-dimer test should be performed, but it is non-specific and may be raised due to the pneumonia. It should be used together with the Wells criteria to consider imaging.

      A chest X-ray should be performed to ensure there is no worsening pneumonia or pneumothorax, but in this case, a pulmonary embolism is the most likely diagnosis and therefore CTPA is required.

      An arterial blood gas measurement can identify hypoxia and hypocapnia associated with an increased respiratory rate, but this is not specific to a pulmonary embolism and many pulmonary diseases can cause this arterial blood gas picture.

    • This question is part of the following fields:

      • Respiratory
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  • Question 30 - A 56-year-old woman is brought to the emergency department after ingesting a significant...

    Incorrect

    • A 56-year-old woman is brought to the emergency department after ingesting a significant amount of prescription drugs. She was discovered at home with empty bottles of imipramine nearby. Despite appearing drowsy, she informs the doctor that she took the medications about 8 hours ago.

      During the examination, the patient is found to be hypotensive, tachycardic, and drowsy. An ECG reveals a QRS width of 162ms. What treatment should be given?

      Your Answer:

      Correct Answer: Intravenous bicarbonate

      Explanation:

      In cases of tricyclic overdose, the presence of a widened QRS complex or arrhythmia on ECG requires immediate administration of IV bicarbonate as the first-line therapy. Activated charcoal may not be effective if the patient presents more than 2 hours after ingestion. Amiodarone should be avoided as it can worsen hypotension and conduction abnormalities. Glucagon is not indicated for tricyclic overdose, as it is used for beta-blocker overdose. Magnesium sulphate is not useful in the management of tricyclic overdose, but is used for torsades de pointes and eclampsia.

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

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

    • This question is part of the following fields:

      • Pharmacology
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SESSION STATS - PERFORMANCE PER SPECIALTY

Psychiatry (1/1) 100%
Sexual Health (0/1) 0%
Surgery (1/5) 20%
Musculoskeletal (1/3) 33%
Ophthalmology (1/1) 100%
Genetics (0/1) 0%
Orthopaedics (0/2) 0%
ENT (0/1) 0%
Nephrology (0/1) 0%
Paediatrics (1/1) 100%
Ethics And Legal (1/1) 100%
Pharmacology (1/1) 100%
Obstetrics (0/1) 0%
Statistics (0/1) 0%
Cardiology (0/1) 0%
Passmed