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  • Question 1 - A 54-year-old man with type 2 diabetes mellitus visits the Endocrinology clinic for...

    Incorrect

    • A 54-year-old man with type 2 diabetes mellitus visits the Endocrinology clinic for evaluation. He is currently on maximum doses of metformin and glibenclamide, but his HbA1c levels have increased from 58 mmol/mol to 67 mmol/mol over the past six months. The consultant recommends adding sitagliptin as a third antidiabetic medication. What is the mechanism of action of this new medication?

      Your Answer: Decrease blood glucose by inhibiting renal glucose re-uptake via sodium-glucose co-transporter 2( SGLT2)

      Correct Answer: Inhibit the peripheral breakdown of incretins, enhancing their ability to stimulate insulin release

      Explanation:

      Diabetes mellitus is a condition that has seen the development of several drugs in recent years. One hormone that has been the focus of much research is glucagon-like peptide-1 (GLP-1), which is released by the small intestine in response to an oral glucose load. In type 2 diabetes mellitus (T2DM), insulin resistance and insufficient B-cell compensation occur, and the incretin effect, which is largely mediated by GLP-1, is decreased. GLP-1 mimetics, such as exenatide and liraglutide, increase insulin secretion and inhibit glucagon secretion, resulting in weight loss, unlike other medications. They are sometimes used in combination with insulin in T2DM to minimize weight gain. Dipeptidyl peptidase-4 (DPP-4) inhibitors, such as vildagliptin and sitagliptin, increase levels of incretins by decreasing their peripheral breakdown, are taken orally, and do not cause weight gain. Nausea and vomiting are the major adverse effects of GLP-1 mimetics, and the Medicines and Healthcare products Regulatory Agency has issued specific warnings on the use of exenatide, reporting that it has been linked to severe pancreatitis in some patients. NICE guidelines suggest that a DPP-4 inhibitor might be preferable to a thiazolidinedione if further weight gain would cause significant problems, a thiazolidinedione is contraindicated, or the person has had a poor response to a thiazolidinedione.

    • This question is part of the following fields:

      • Endocrine System
      88.9
      Seconds
  • Question 2 - John, a 29-year-old male, presented to the emergency department after a fall where...

    Incorrect

    • John, a 29-year-old male, presented to the emergency department after a fall where he landed on his outstretched hand. He reports experiencing pain.

      During the examination, John's neurovascular status is intact, but he is tender to touch and has a dinner fork deformity. The emergency physician orders an x-ray of his right hand, wrist, and arm. The x-ray report reveals a Colles' fracture.

      What will the x-ray report show as abnormal?

      Your Answer: Fracture of proximal third of the ulna with dislocation of the proximal head of the radius

      Correct Answer: Fracture of distal radius with posterior displacement of distal fragment

      Explanation:

      Smith’s fracture is the name given to a fracture of the distal radius with anterior displacement of the distal fragment, while Colles’ fracture refers to a fracture of the distal radius with posterior displacement of the distal fragment, resulting in a dinner fork deformity. Another type of fracture involving the forearm is the Monteggia fracture, which involves a fracture of the proximal third of the ulna with dislocation of the proximal head of the radius.

      Understanding Colles’ Fracture: A Common Injury from a Fall

      Colles’ fracture is a type of injury that typically occurs when a person falls onto an outstretched hand, also known as a FOOSH. This type of fracture involves the distal radius, which is the bone located near the wrist joint. The fracture is characterized by a dorsal displacement of the bone fragments, resulting in a deformity that resembles a dinner fork.

      Classical Colles’ fractures have three distinct features. Firstly, the fracture is transverse, meaning it occurs horizontally across the bone. Secondly, the fracture is located approximately one inch proximal to the radio-carpal joint, which is the joint that connects the radius to the wrist bones. Finally, the fracture results in dorsal displacement and angulation of the bone fragments.

    • This question is part of the following fields:

      • Musculoskeletal System And Skin
      117.2
      Seconds
  • Question 3 - A 56-year-old man presents to the emergency department with profuse haematemesis. Upon admission,...

    Correct

    • A 56-year-old man presents to the emergency department with profuse haematemesis. Upon admission, his vital signs include a temperature of 36.9ºC, oxygen saturation of 94% on air, heart rate of 124 beats per minute, respiratory rate of 26 breaths per minute, and blood pressure of 82/58 mmHg. An urgent endoscopy was performed to achieve haemostasis, revealing an ulcer on the posterior wall of the duodenum. Which artery is the most likely source of the gastrointestinal bleed?

      Your Answer: Gastroduodenal artery

      Explanation:

      Duodenal ulcers on the posterior wall pose a risk to the gastroduodenal artery, which supplies blood to this area. The posterior wall is a common site for duodenal ulcers, and erosion of the ulcer through the duodenal wall can result in severe upper gastrointestinal bleeding. The inferior mesenteric artery, on the other hand, supplies blood to the hindgut (transverse colon, descending colon, and sigmoid colon) and does not include the duodenum. The inferior pancreaticoduodenal artery, which arises from the superior mesenteric artery, supplies the lower part of the duodenum but does not provide the majority of the blood supply to the posterior duodenal wall, which is mainly supplied by the gastroduodenal artery.

      Acute upper gastrointestinal bleeding is a common and significant medical issue that can be caused by various conditions, with oesophageal varices and peptic ulcer disease being the most common. The main symptoms include haematemesis (vomiting of blood), melena (passage of altered blood per rectum), and a raised urea level due to the protein meal of the blood. The diagnosis can be determined by identifying the specific features associated with a particular condition, such as stigmata of chronic liver disease for oesophageal varices or abdominal pain for peptic ulcer disease.

      The differential diagnosis for acute upper gastrointestinal bleeding includes oesophageal, gastric, and duodenal causes. Oesophageal varices may present with a large volume of fresh blood, while gastric ulcers may cause low volume bleeds that present as iron deficiency anaemia. Duodenal ulcers are usually posteriorly sited and may erode the gastroduodenal artery. Aorto-enteric fistula is a rare but important cause of major haemorrhage associated with high mortality in patients with previous abdominal aortic aneurysm surgery.

      The management of acute upper gastrointestinal bleeding involves risk assessment using the Glasgow-Blatchford score, which helps clinicians decide whether patients can be managed as outpatients or not. Resuscitation involves ABC, wide-bore intravenous access, and platelet transfusion if actively bleeding platelet count is less than 50 x 10*9/litre. Endoscopy should be offered immediately after resuscitation in patients with a severe bleed, and all patients should have endoscopy within 24 hours. Treatment options include repeat endoscopy, interventional radiology, and surgery for non-variceal bleeding, while terlipressin and prophylactic antibiotics should be given to patients with variceal bleeding. Band ligation should be used for oesophageal varices, and injections of N-butyl-2-cyanoacrylate for patients with gastric varices. Transjugular intrahepatic portosystemic shunts (TIPS) should be offered if bleeding from varices is not controlled with the above measures.

    • This question is part of the following fields:

      • Gastrointestinal System
      52.2
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  • Question 4 - A 75-year-old man has been discharged from the hospital after experiencing an acute...

    Incorrect

    • A 75-year-old man has been discharged from the hospital after experiencing an acute coronary syndrome and undergoing percutaneous coronary intervention. He has been prescribed aspirin, bisoprolol, ramipril, and atorvastatin. Can you explain the mechanism of action of aspirin?

      Your Answer: Inhibits uptake of adenosine into platelets

      Correct Answer: Suppresses production of prostaglandins and thromboxane A2

      Explanation:

      Aspirin inhibits the COX enzyme, which results in the suppression of prostaglandins and thromboxane A2 production. This inhibition is non-reversible and affects both COX 1 and 2.

      How Aspirin Works and its Use in Cardiovascular Disease

      Aspirin is a medication that works by blocking the action of cyclooxygenase-1 and 2, which are responsible for the synthesis of prostaglandin, prostacyclin, and thromboxane. By blocking the formation of thromboxane A2 in platelets, aspirin reduces their ability to aggregate, making it a widely used medication in cardiovascular disease. However, recent trials have cast doubt on the use of aspirin in primary prevention of cardiovascular disease, and guidelines have not yet changed to reflect this. Aspirin should not be used in children under 16 due to the risk of Reye’s syndrome, except in cases of Kawasaki disease where the benefits outweigh the risks. As for its use in ischaemic heart disease, aspirin is recommended as a first-line treatment. It can also potentiate the effects of oral hypoglycaemics, warfarin, and steroids. It is important to note that recent guidelines recommend clopidogrel as a first-line treatment for ischaemic stroke and peripheral arterial disease, while the use of aspirin in TIAs remains a topic of debate among different guidelines.

      Overall, aspirin’s mechanism of action and its use in cardiovascular disease make it a valuable medication in certain cases. However, recent studies have raised questions about its effectiveness in primary prevention, and prescribers should be aware of the potential risks and benefits when considering its use.

    • This question is part of the following fields:

      • General Principles
      36.3
      Seconds
  • Question 5 - A 32-year-old woman has a positive pregnancy test using a home kit that...

    Correct

    • A 32-year-old woman has a positive pregnancy test using a home kit that tests for the presence of a hormone in the urine.

      Which structure secretes this hormone?

      Your Answer: Syncytiotrophoblast

      Explanation:

      During the early stages of pregnancy, the corpus luteum is stimulated to secrete progesterone by hCG, which is produced by the syncytiotrophoblast. Pregnancy tests commonly measure hCG levels in urine. This hormone is crucial for maintaining the pregnancy until the placenta is fully developed. The trophoblast is composed of two layers: the cytotrophoblast and the syncytiotrophoblast. The hypoblast is a type of tissue that forms from the inner cell mass, while the epiblast gives rise to the three primary germ layers and extraembryonic mesoderm.

      Endocrine Changes During Pregnancy

      During pregnancy, there are several physiological changes that occur in the body, including endocrine changes. Progesterone, which is produced by the fallopian tubes during the first two weeks of pregnancy, stimulates the secretion of nutrients required by the zygote/blastocyst. At six weeks, the placenta takes over the production of progesterone, which inhibits uterine contractions by decreasing sensitivity to oxytocin and inhibiting the production of prostaglandins. Progesterone also stimulates the development of lobules and alveoli.

      Oestrogen, specifically oestriol, is another major hormone produced during pregnancy. It stimulates the growth of the myometrium and the ductal system of the breasts. Prolactin, which increases during pregnancy, initiates and maintains milk secretion of the mammary gland. It is essential for the expression of the mammotropic effects of oestrogen and progesterone. However, oestrogen and progesterone directly antagonize the stimulating effects of prolactin on milk synthesis.

      Human chorionic gonadotropin (hCG) is secreted by the syncitiotrophoblast and can be detected within nine days of pregnancy. It mimics LH, rescuing the corpus luteum from degenerating and ensuring early oestrogen and progesterone secretion. It also stimulates the production of relaxin and may inhibit contractions induced by oxytocin. Other hormones produced during pregnancy include relaxin, which suppresses myometrial contractions and relaxes the pelvic ligaments and pubic symphysis, and human placental lactogen (hPL), which has lactogenic actions and enhances protein metabolism while antagonizing insulin.

    • This question is part of the following fields:

      • Reproductive System
      8
      Seconds
  • Question 6 - A 28-year-old male is undergoing chemotherapy for testicular cancer and has been prescribed...

    Incorrect

    • A 28-year-old male is undergoing chemotherapy for testicular cancer and has been prescribed cisplatin. What is the mechanism of action of this medication?

      Your Answer: Inhibition of ribonucleotide reductase

      Correct Answer: Causes cross-linking of DNA

      Explanation:

      Cisplatin causes DNA cross-linking, leading to apoptosis in cancer cells. It is commonly used in chemotherapy for various cancers. Methotrexate inhibits dihydrofolate reductase, which is not the mechanism of cisplatin. Hydroxyurea inhibits ribonucleotide reductase and is used to treat different diseases. Docetaxel prevents microtubule depolymerization and is used for breast cancer treatment. Fluorouracil blocks thymidylate synthase during S phase, leading to cell cycle arrest and apoptosis, but it is not the mechanism of cisplatin.

      Cytotoxic agents are drugs that are used to kill cancer cells. There are several types of cytotoxic agents, each with their own mechanism of action and potential adverse effects. Alkylating agents, such as cyclophosphamide, work by causing cross-linking in DNA. However, they can also cause haemorrhagic cystitis, myelosuppression, and transitional cell carcinoma. Cytotoxic antibiotics, like bleomycin and anthracyclines, degrade preformed DNA and stabilize DNA-topoisomerase II complex, respectively. However, they can also cause lung fibrosis and cardiomyopathy. Antimetabolites, such as methotrexate and fluorouracil, inhibit dihydrofolate reductase and thymidylate synthesis, respectively. However, they can also cause myelosuppression, mucositis, and liver or lung fibrosis. Drugs that act on microtubules, like vincristine and docetaxel, inhibit the formation of microtubules and prevent microtubule depolymerisation & disassembly, respectively. However, they can also cause peripheral neuropathy, myelosuppression, and paralytic ileus. Topoisomerase inhibitors, like irinotecan, inhibit topoisomerase I, which prevents relaxation of supercoiled DNA. However, they can also cause myelosuppression. Other cytotoxic drugs, such as cisplatin and hydroxyurea, cause cross-linking in DNA and inhibit ribonucleotide reductase, respectively. However, they can also cause ototoxicity, peripheral neuropathy, hypomagnesaemia, and myelosuppression.

    • This question is part of the following fields:

      • Haematology And Oncology
      49.9
      Seconds
  • Question 7 - A 74-year-old woman has been brought to the emergency department by her husband...

    Incorrect

    • A 74-year-old woman has been brought to the emergency department by her husband after a fall at home. Upon assessment by the orthopaedics team, it is observed that she is holding her right arm adducted to her side and there is deformity of the proximal arm and shoulder with overlying skin ecchymosis and swelling. Neurovascular examination reveals palpable distal pulses and some paraesthesia over the deltoid region, but loss of active shoulder abduction is noted. What structure is likely to have been affected by this patient's injury?

      Your Answer: Brachial plexus

      Correct Answer: Axillary nerve

      Explanation:

      The correct nerve that is likely injured in a patient with difficulty abducting their arm following a humeral neck fracture is the axillary nerve. This nerve provides motor function to the deltoid muscle, which is responsible for arm abduction at the shoulder joint, and cutaneous sensation to the deltoid region. Proximal humerus fractures, which are common in individuals of the patient’s age and gender, can often result in injury to the axillary nerve.

      The brachial plexus is an incorrect answer as injuries to this nerve bundle are rare and would likely result in neurological dysfunction beyond the shoulder. The musculocutaneous nerve is also an incorrect answer as it provides motor function to the anterior compartment of the arm and sensation to the lateral forearm, but not to the deltoid region. The radial nerve is also an incorrect answer as it is typically injured in humeral shaft fractures and would result in wrist drop and paresthesia over the dorsal hand and wrist. The suprascapular nerve is also an incorrect answer as it provides motor innervation to different muscles and sensation to different joints than those affected in this case.

      Upper limb anatomy is a common topic in examinations, and it is important to know certain facts about the nerves and muscles involved. The musculocutaneous nerve is responsible for elbow flexion and supination, and typically only injured as part of a brachial plexus injury. The axillary nerve controls shoulder abduction and can be damaged in cases of humeral neck fracture or dislocation, resulting in a flattened deltoid. The radial nerve is responsible for extension in the forearm, wrist, fingers, and thumb, and can be damaged in cases of humeral midshaft fracture, resulting in wrist drop. The median nerve controls the LOAF muscles and can be damaged in cases of carpal tunnel syndrome or elbow injury. The ulnar nerve controls wrist flexion and can be damaged in cases of medial epicondyle fracture, resulting in a claw hand. The long thoracic nerve controls the serratus anterior and can be damaged during sports or as a complication of mastectomy, resulting in a winged scapula. The brachial plexus can also be damaged, resulting in Erb-Duchenne palsy or Klumpke injury, which can cause the arm to hang by the side and be internally rotated or associated with Horner’s syndrome, respectively.

    • This question is part of the following fields:

      • Musculoskeletal System And Skin
      63.9
      Seconds
  • Question 8 - A 25-year-old woman presents with a sudden and severe headache, which is indicative...

    Incorrect

    • A 25-year-old woman presents with a sudden and severe headache, which is indicative of a possible subarachnoid hemorrhage. Upon conducting a head CT scan, the results appear normal. As a result, a lumbar puncture is performed. What is the next structure that the spinal needle will pass through after piercing the interspinous ligament?

      Your Answer: Spinal cord

      Correct Answer: Ligamentum flavum

      Explanation:

      Lumbar Puncture Landmarks and Needle Pathway

      A lumbar puncture is a medical procedure that involves inserting a needle into the lower back to collect cerebrospinal fluid for diagnostic purposes. The landmarks for this procedure are the iliac crests, which are the bony protrusions at the top of the hip bones. The fourth lumbar vertebrae is located in line with these crests and is the target for the needle insertion. It is important to note that the spinal cord ends at the level of the first lumbar vertebrae, which is several levels above the site of the puncture.

      The needle pathway for a lumbar puncture involves passing through several layers of tissue. These layers, from most superficial to most deep, include the skin, fascia, supraspinous ligament, interspinous ligament, ligamentum flavum, areolar tissue, dura, and arachnoid mater. Each of these layers serves a different purpose in protecting the spinal cord and surrounding structures, and the needle must be carefully guided through each layer to avoid complications.

      In summary, a lumbar puncture is a procedure that requires precise placement of the needle in order to collect cerebrospinal fluid for diagnostic purposes. The landmarks for the procedure are the iliac crests and the target vertebrae is the fourth lumbar vertebrae. The needle pathway involves passing through several layers of tissue, each of which serves a different protective function.

    • This question is part of the following fields:

      • Clinical Sciences
      37.9
      Seconds
  • Question 9 - You are asked to evaluate a 4-year-old girl who has been brought to...

    Incorrect

    • You are asked to evaluate a 4-year-old girl who has been brought to the clinic by her parents due to concerns over her development. While her motor development has been normal, her speech has been persistently delayed; she is still unable to put more than 2 words together to form a sentence, and often does not respond when called. Her parents are worried that she may have autism.

      The child is referred for play audiometry, which reveals abnormalities. Upon taking a careful history, it is revealed that a drug given to the child to treat an infection in her first year of life may be responsible for her developmental delay.

      Which of the following drugs is most likely to be responsible?

      Your Answer: Doxycycline

      Correct Answer: Gentamicin

      Explanation:

      Ototoxicity is a significant negative consequence associated with the use of aminoglycosides.

      Gentamicin is a type of antibiotic known as an aminoglycoside. It is not easily dissolved in lipids, so it is typically administered through injection or topical application. It is commonly used to treat infections such as infective endocarditis and otitis externa. However, gentamicin can have adverse effects on the body, such as ototoxicity, which can cause damage to the auditory or vestibular nerves. This damage is irreversible. Gentamicin can also cause nephrotoxicity, which can lead to acute tubular necrosis. The risk of toxicity increases when gentamicin is used in conjunction with furosemide. Lower doses and more frequent monitoring are necessary to prevent these adverse effects. Gentamicin is contraindicated in patients with myasthenia gravis. To ensure safe dosing, plasma concentrations of gentamicin are monitored. Peak levels are measured one hour after administration, and trough levels are measured just before the next dose. If the trough level is high, the interval between doses should be increased. If the peak level is high, the dose should be decreased.

    • This question is part of the following fields:

      • General Principles
      41.9
      Seconds
  • Question 10 - You are working in the palliative care unit. A 67-year-old male has severe...

    Incorrect

    • You are working in the palliative care unit. A 67-year-old male has severe neuropathic pain secondary to spinal cord metastasis. It has been unresponsive to titration of opioid and neuropathic agents. Your consultant decides to use ketamine.

      What is the mechanism of action of ketamine?

      Your Answer: Sodium channel blocker

      Correct Answer: NMDA receptor antagonist

      Explanation:

      Ketamine works by blocking NMDA receptors. It can be used to treat neuropathic pain that does not respond well to opioids and other oral pain medications, especially when there is abnormal pain sensitivity such as allodynia, hyperalgesia, or hyperpathia.

      Gabapentin works by changing the way voltage-gated calcium channels function.

      Pregabalin is similar to the neurotransmitter GABA.

      Benzodiazepines activate GABA receptors.

      Local anesthetics like lidocaine block sodium channels.

      Overview of Commonly Used IV Induction Agents

      Propofol, sodium thiopentone, ketamine, and etomidate are some of the commonly used IV induction agents in anesthesia. Propofol is a GABA receptor agonist that has a rapid onset of anesthesia but may cause pain on IV injection. It is widely used for maintaining sedation on ITU, total IV anesthesia, and day case surgery. Sodium thiopentone has an extremely rapid onset of action, making it the agent of choice for rapid sequence induction. However, it may cause marked myocardial depression and metabolites build up quickly, making it unsuitable for maintenance infusion. Ketamine, an NMDA receptor antagonist, has moderate to strong analgesic properties and produces little myocardial depression, making it a suitable agent for anesthesia in those who are hemodynamically unstable. However, it may induce a state of dissociative anesthesia resulting in nightmares. Etomidate has a favorable cardiac safety profile with very little hemodynamic instability but has no analgesic properties and is unsuitable for maintaining sedation as prolonged use may result in adrenal suppression. Postoperative vomiting is common with etomidate.

      Overall, each of these IV induction agents has specific features that make them suitable for different situations. Anesthesiologists must carefully consider the patient’s medical history, current condition, and the type of surgery being performed when selecting an appropriate induction agent.

    • This question is part of the following fields:

      • General Principles
      38.7
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SESSION STATS - PERFORMANCE PER SPECIALTY

Endocrine System (0/1) 0%
Musculoskeletal System And Skin (0/2) 0%
Gastrointestinal System (1/1) 100%
General Principles (0/3) 0%
Reproductive System (1/1) 100%
Haematology And Oncology (0/1) 0%
Clinical Sciences (0/1) 0%
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