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Question 1
Incorrect
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A 9-month-old boy is brought to the emergency department by his father. His father reports that over the past 4 hours, his son has had episodes of shaking and is less responsive than usual.
On examination, the boy is drowsy and does not respond to voice. You note he has some bruising around his torso. You suspect that the baby may have been shaken.
Which triad of symptoms is consistent with this diagnosis?Your Answer: Retinal haemorrhages + extradural haematoma + encephalopathy
Correct Answer: Retinal haemorrhages + subdural haematoma + encephalopathy
Explanation:Understanding Shaken Baby Syndrome
Shaken baby syndrome is a condition that involves a combination of retinal haemorrhages, subdural haematoma, and encephalopathy. It occurs when a child between the ages of 0-5 years old is intentionally shaken. However, there is controversy among physicians regarding the mechanism of injury, making it difficult for courts to convict suspects of causing shaken baby syndrome to a child. This condition has made headlines due to the ongoing debate among medical professionals.
Shaken baby syndrome is a serious condition that can cause long-term damage to a child’s health. It is important to understand the signs and symptoms of this condition to ensure that children are protected from harm. While the controversy surrounding the diagnosis of shaken baby syndrome continues, it is crucial to prioritize the safety and well-being of children. By raising awareness and educating the public about this condition, we can work towards preventing it from occurring in the future.
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This question is part of the following fields:
- Paediatrics
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Question 2
Correct
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A 70-year-old male with diabetes type 2 is scheduled for an appendectomy. He is not on insulin-based medications.
What is the appropriate management for this patient?Your Answer: This patient should be first on the list
Explanation:To avoid complications arising from inadequate blood sugar management, it is recommended that patients with diabetes be given priority on the surgical schedule. Those with inadequate control or who are using insulin will require a sliding scale.
Preparation for surgery varies depending on whether the patient is undergoing an elective or emergency procedure. For elective cases, it is important to address any medical issues beforehand through a pre-admission clinic. Blood tests, urine analysis, and other diagnostic tests may be necessary depending on the proposed procedure and patient fitness. Risk factors for deep vein thrombosis should also be assessed, and a plan for thromboprophylaxis formulated. Patients are advised to fast from non-clear liquids and food for at least 6 hours before surgery, and those with diabetes require special management to avoid potential complications. Emergency cases require stabilization and resuscitation as needed, and antibiotics may be necessary. Special preparation may also be required for certain procedures, such as vocal cord checks for thyroid surgery or bowel preparation for colorectal cases.
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This question is part of the following fields:
- Surgery
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Question 3
Correct
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A 70-year-old man comes to you with complaints of painful and itchy white spots on his penis. Upon examination, you notice hyperkeratotic lesions in various locations on his foreskin and glans. He also reports dysuria and reduced sensation in the glans. Based on your assessment, you suspect Balanitis Xerotica Obliterans. What are some possible associations with this condition?
Your Answer: Phimosis
Explanation:Phimosis can be caused by Balanitis Xerotica Obliterans, which is similar to lichen sclerosis in women. This condition can lead to scarring in uncircumcised males, making it difficult to retract the foreskin beyond the glans. BXO also increases the risk of squamous cell cancer and susceptibility to infections. However, it does not cause prostate hyperplasia or basal cell carcinoma, but instead, it can lead to squamous cell carcinoma.
Balanitis is a condition where the glans penis becomes inflamed, and sometimes the inflammation extends to the underside of the foreskin, which is known as balanoposthitis. The most common causes of balanitis are infective, such as bacterial and candidal infections, but there are also autoimmune causes to consider. Proper hygiene is crucial in treating balanitis, and a tight foreskin or improper washing can worsen the condition. Balanitis can present as either acute or chronic, and it affects children and adults differently.
To diagnose balanitis, a doctor will typically rely on a clinical examination and medical history. The history will reveal the acuteness of the presentation and other important features, such as the presence of itching or discharge. The doctor will also look for other skin conditions affecting the body, such as eczema, psoriasis, or connective tissue diseases. The clinical features associated with the most common causes of balanitis, their frequency, and whether they occur in children or adults are summarized in a table.
In most cases, a diagnosis can be made based on the history and physical appearance of the glans penis. However, in cases where the cause is unclear, a swab can be taken for microscopy and culture, or a biopsy can be performed. The management of balanitis involves gentle saline washes, proper washing under the foreskin, and the use of 1% hydrocortisone for more severe irritation and discomfort. Specific treatment depends on the cause of the balanitis. For example, candidiasis is treated with topical clotrimazole, while bacterial balanitis can be treated with oral flucloxacillin or clarithromycin. Lichen sclerosus and plasma cell balanitis of Zoon are managed with high potency topical steroids, while circumcision can help in the case of lichen sclerosus.
Reference:
Scott, G. R. (2010). Sexually Transmitted Infections. In Davidson’s Principles and Practice of Medicine (21st ed.). Churchill Livingstone, Elsevier. -
This question is part of the following fields:
- Surgery
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Question 4
Incorrect
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A 55-year-old nulliparous woman presents to the gynaecology clinic with a 3-month history of postmenopausal bleeding. She has a medical history of type 2 diabetes mellitus and her last menstrual period was 5 years ago.
On transvaginal ultrasound, the endometrial thickness measures 7mm. The pipelle biopsy results indicate an increased gland-to-stroma ratio and some nuclear atypia.
What is the best course of action for management?Your Answer: Hysterectomy alone
Correct Answer: Hysterectomy with bilateral salpingo-oophorectomy
Explanation:For postmenopausal women with atypical endometrial hyperplasia, it is recommended to undergo a total hysterectomy with bilateral salpingo-oophorectomy to reduce the risk of malignant progression. If bilateral salpingo-oophorectomy is not performed, there is an increased risk of ovarian malignancy. Endometrial ablation is not advised due to the risk of intrauterine adhesion formation and irreversible damage to the endometrium. In premenopausal patients with atypia or those who do not respond to medical management or have persistent bleeding, hysterectomy alone may be considered. However, the royal college of obstetrics and gynaecology green-top guidelines suggest that bilateral salpingectomy should still be considered in these patients due to the risk of further ovarian malignancy. For hyperplasia without atypia, the first-line treatment is a levonorgestrel-releasing intrauterine system such as the Mirena coil.
Endometrial hyperplasia is a condition where the endometrium, the lining of the uterus, grows excessively beyond what is considered normal during the menstrual cycle. This abnormal proliferation can lead to endometrial cancer in some cases. There are four types of endometrial hyperplasia: simple, complex, simple atypical, and complex atypical. Symptoms of this condition include abnormal vaginal bleeding, such as intermenstrual bleeding.
The management of endometrial hyperplasia depends on the type and severity of the condition. For simple endometrial hyperplasia without atypia, high dose progestogens may be prescribed, and repeat sampling is recommended after 3-4 months. The levonorgestrel intra-uterine system may also be used. However, if atypia is present, hysterectomy is usually advised.
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This question is part of the following fields:
- Gynaecology
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Question 5
Incorrect
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A 55-year-old male with a six year history of type 2 diabetes has been diagnosed with ischaemic heart disease and started taking atorvastatin 80 mg daily to manage his cholesterol level of 6.2 mmol/L. However, he has returned to the clinic complaining of muscle aches and pains, and his liver function tests have shown elevated levels from his baseline. His pre-treatment ALT was 60 IU/L, and now it is 95 IU/L. He is concerned about the side effects of the statin and asks if he should stop taking it. What is the most appropriate next step to manage his hypercholesterolaemia?
Your Answer: Simvastatin 20 mg daily
Correct Answer: Atorvastatin 40 mg daily
Explanation:Managing Statin Intolerance in Patients with Ischaemic Heart Disease and Type 2 Diabetes Mellitus
Patients with ischaemic heart disease and type 2 diabetes mellitus are recommended to receive high-dose statins to manage their elevated cholesterol levels. However, some patients may experience intolerance to statins, such as myalgia and raised liver function tests. In such cases, NICE advises reducing the dose or considering an alternative statin. Fibrate and ezetimibe are generally not recommended for these patients, and referral to a specialist may be necessary if statins are completely not tolerated.
To minimize the risk of side effects, starting at a low dose and gradually titrating up can be helpful. Rosuvastatin and pravastatin may have a lower incidence of myalgia compared to other statins. However, cautious monitoring of liver function tests should be performed if starting another statin. If a patient has a history of statin-related hepatitis or rhabdomyolysis, statins should generally be avoided in the future if possible.
In summary, managing statin intolerance in patients with ischaemic heart disease and type 2 diabetes mellitus requires careful consideration of alternative options and cautious monitoring of side effects.
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This question is part of the following fields:
- Endocrinology
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Question 6
Correct
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A 28-year-old woman has been living with type 1 diabetes mellitus for 15 years and has been under your care for the past nine years. During this time, her HbA1c levels have fluctuated between 64 mmol/mol and 75 mmol/mol (20-42).
Today, her blood pressure reads 130/84 mmHg. She has also noticed that her blood glucose levels at home have been fluctuating more than usual over the past three months. Additionally, she reports experiencing nausea after eating and requiring less food than usual to feel full.
Upon conducting investigations, the following results were obtained:
- Urea: 8.1 mmol/L (2.5-7.5)
- Creatinine: 112 µmol/L (60-110)
- Sodium: 138 mmol/L (137-144)
- Potassium: 4.2 mmol/L (3.5-4.9)
- Bicarbonate: 24 mmol/L (20-28)
- HbA1c: 42 mmol/mol (20-42)
- Urinalysis: Protein+
What is the most likely cause of her symptoms?Your Answer: Delayed gastric emptying
Explanation:Autonomic Neuropathy and Gastric Emptying
People with a long history of diabetes may experience nausea after eating, along with a feeling of fullness and reduced appetite. These symptoms suggest reduced gastric emptying, which is often associated with autonomic neuropathy. Other symptoms that may be present include postural hypotension, gustatory sweating, diarrhea, or changes in bowel habits. To confirm the diagnosis, a barium swallow and meal may be necessary. It is important to recognize these symptoms and seek medical attention to manage the underlying condition.
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This question is part of the following fields:
- Endocrinology
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Question 7
Correct
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In an international study comparing two treatment regimens (A and B) for thyroid cancer, 100 patients were randomly assigned to group A and 100 patients to group B. The five-year overall survival rate was found to be 70% in group A and 60% in group B (p = 0.02). Upon subgroup analysis, it was discovered that males in group A had a five-year overall survival rate of 80%, while males in group B had a rate of 65% (p = 0.01). What is the correct statement regarding these findings?
Your Answer: Five year overall survival for females in group A was below 70%
Explanation:Clarifying Survival Rates and Gender Differences in Drug Regimens
In group A, the five-year overall survival rate for females was below 70%, while males had a better survival rate of 80%. This suggests that females in group A have a lower survival rate than males and the overall survival rate. However, we cannot conclude whether the overall survival rate for females is lower in group A compared to group B based on the given information.
Although it appears that males have better survival rates than females in both groups, no statistical test has been conducted to compare the survival rates of males and females. Therefore, we cannot be certain whether males truly have better survival rates under regimen A or regimen B.
To demonstrate a difference in the efficacy of drug A over drug B in males compared to females, a significant interaction effect between gender and treatment regimen must be demonstrated, rather than just a greater difference in survival rates between males and females.
Overall, it is important to consider gender differences when evaluating the effectiveness of drug regimens and to conduct appropriate statistical tests to ensure accurate conclusions.
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This question is part of the following fields:
- Clinical Sciences
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Question 8
Incorrect
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A 35-year-old female patient visits her GP complaining of 'abnormal pupils'. Upon examination, it is observed that she has anisocoria, which is more noticeable in bright light, with her left pupil appearing smaller than her right. What is the most probable anatomical site that has been affected?
Your Answer: Left ciliary ganglion
Correct Answer: Right ciliary ganglion
Explanation:When an individual’s anisocoria worsens in bright light, it suggests that there may be an issue with the dilated pupil. In this case, the most probable cause of the problem is the right ciliary ganglion. The patient’s symptoms indicate a reduction in parasympathetic innervation to the right eye. As the right pupil is more dilated than the left, it is likely to be the abnormal pupil. This is because the eye is unable to constrict in response to light, making the pupillary asymmetry more noticeable as the normal eye constricts. The sympathetic nervous system is responsible for pupil dilation, while the parasympathetic system is responsible for pupil constriction. Therefore, damage to the parasympathetic nervous system can result in unopposed sympathetic innervation to the eye, leading to pupillary dilation. The ciliary ganglion is the parasympathetic ganglion of the eye, and damage to the right ciliary ganglion can cause a mydriatic right eye. The patient is likely suffering from Adie’s-tonic pupil affecting her right eye.
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.
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This question is part of the following fields:
- Ophthalmology
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Question 9
Correct
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A 35-year-old woman was brought to the Emergency Department with confusion. She has a history of manic illness. There is no evidence of alcohol or drug abuse. Upon examination, she displays mild jaundice and signs of chronic liver disease, such as spider naevi and palmar erythema. Additionally, there is a brownish ring discoloration at the limbus of the cornea.
Blood tests reveal:
Investigation Result Normal value
Bilirubin 130 μmol/l 2–17 µmol/l
Alanine aminotransferase (ALT) 85 IU/l 5–30 IU/l
Ferritin 100 μg/l 10–120 µg/l
What is the most likely diagnosis based on this clinical presentation?Your Answer: Wilson’s disease
Explanation:Differential diagnosis of a patient with liver disease and neurological symptoms
Wilson’s disease, haemochromatosis, alcohol-related cirrhosis, viral hepatitis, and primary sclerosing cholangitis are among the possible causes of liver disease. In the case of a patient with Kayser-Fleischer rings, the likelihood of Wilson’s disease increases, as this is a characteristic sign of copper overload due to defective incorporation of copper and caeruloplasmin. Neurological symptoms such as disinhibition, emotional lability, and chorea may also suggest Wilson’s disease, although they are not specific to it. Haemochromatosis, which is characterized by iron overload, can be ruled out if the ferritin level is normal. Alcohol-related cirrhosis is less likely if the patient denies alcohol or drug abuse, but this information may not always be reliable. Viral hepatitis is a common cause of liver disease, but in this case, there are no obvious risk factors in the history. Primary sclerosing cholangitis, which is a chronic inflammatory disease of the bile ducts, does not present with Kayser-Fleischer rings. Therefore, a careful evaluation of the patient’s clinical features, laboratory tests, and imaging studies is necessary to establish the correct diagnosis and guide the appropriate treatment.
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This question is part of the following fields:
- Gastroenterology
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Question 10
Correct
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A 58-year-old woman has been referred by her optician to the eye clinic. She has been experiencing vision problems and is concerned about her eye health. On examination, her external eye, including the pupil, appears normal.
Investigations:
Slit-lamp: Quiet anterior chamber
Intra-ocular pressure: 30 mmHg
Fundoscopy: Optic disc appears slightly cupped
Visual field testing: Arcuate scotoma
Which of the following diagnoses is most likely based on this clinical presentation?Your Answer: Primary open angle glaucoma
Explanation:Differentiating Ophthalmic Conditions: A Guide
Primary Open Angle Glaucoma: This condition is characterized by unnoticed visual loss, which becomes apparent only after impaired vision is demonstrated. Patients with POAG develop a visual field defect due to loss of nerve fibers at the optic disc, resulting in the appearance of ‘cupping’ of the optic disc. Increased intraocular pressures are the most common cause of optic disc fiber damage.
Retinal Detachment: Patients with retinal detachment typically present with a history of flashing lights and floaters in their vision. The three most common causes of retinal detachment are rhegmatogenous, tractional, and exudative. The history and examination findings are not typical of retinal detachment.
Acute Angle Closure Glaucoma: This is an ophthalmology emergency that presents with an acutely painful red eye, usually with associated vomiting. The pupil is fixed and mid-dilated, and there is corneal edema. This condition occurs when the angle between the lens and iris becomes blocked off, causing an acute pressure rise. The high pressure can cause permanent damage to the optic nerve if not treated quickly. Although this patient has a high intraocular pressure, the history is not suggestive of an acute painful attack.
Central Retinal Vein Occlusion: This condition causes sudden painless loss of vision due to reduced blood flow to the retina. The patient in this case gives a history of slow, progressive visual loss, which is not typical of central retinal vein occlusion. This condition is also unlikely to cause a rise in intraocular pressure.
Anterior Uveitis: A quiet anterior chamber indicates that anterior uveitis (iritis) is unlikely to be the cause of the patient’s symptoms. Cells in the anterior chamber are a sign of ocular inflammation, which is not present in this case.
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This question is part of the following fields:
- Ophthalmology
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Question 11
Incorrect
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A 26-year-old male comes to the rheumatology clinic complaining of lower back pain that extends to his buttocks for the past 3 months. He experiences the most discomfort in the morning, but it gets better with physical activity. Sometimes, he wakes up in the early hours of the morning due to the pain. What is the most probable finding in this patient?
Your Answer: A failure of his symptoms to improve with naproxen
Correct Answer: Syndesmophytes on plain x-ray
Explanation:Syndesmophytes, which are ossifications of the outer fibers of the annulus fibrosus, are a common feature of ankylosing spondylitis. This patient is exhibiting symptoms of inflammatory joint pain, which is most likely caused by ankylosing spondylitis given his age, gender, and the nature of his pain. Plain x-rays can reveal the presence of ossifications within spinal ligaments or intervertebral discs’ annulus fibrosus. It is incorrect to assume that his symptoms would not improve with naproxen, as NSAIDs are commonly used to alleviate inflammatory joint pain. A bamboo spine on plain x-ray is a rare late sign that is not typically seen in clinical practice. While ankylosing spondylitis may be associated with apical lung fibrosis, this would present as a restrictive defect on spirometry, not an obstructive one.
Investigating and Managing Ankylosing Spondylitis
Ankylosing spondylitis is a type of spondyloarthropathy that is associated with HLA-B27. It is more commonly seen in males aged 20-30 years old. Inflammatory markers such as ESR and CRP are usually elevated, but normal levels do not necessarily rule out ankylosing spondylitis. HLA-B27 is not a reliable diagnostic tool as it can also be positive in normal individuals. The most effective way to diagnose ankylosing spondylitis is through a plain x-ray of the sacroiliac joints. However, if the x-ray is negative but suspicion for AS remains high, an MRI can be obtained to confirm the diagnosis.
Management of ankylosing spondylitis involves regular exercise, such as swimming, and the use of NSAIDs as the first-line treatment. Physiotherapy can also be helpful. Disease-modifying drugs used for rheumatoid arthritis, such as sulphasalazine, are only useful if there is peripheral joint involvement. Anti-TNF therapy, such as etanercept and adalimumab, should be given to patients with persistently high disease activity despite conventional treatments, according to the 2010 EULAR guidelines. Ongoing research is being conducted to determine whether anti-TNF therapies should be used earlier in the course of the disease. Spirometry may show a restrictive defect due to a combination of pulmonary fibrosis, kyphosis, and ankylosis of the costovertebral joints.
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This question is part of the following fields:
- Musculoskeletal
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Question 12
Incorrect
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A 28-year-old man and his 26-year-old wife visit their GP for a follow-up appointment regarding their difficulty in conceiving. The couple has been trying to conceive for the past year without success. The wife has a regular menstrual cycle and no previous gynaecological issues. An ovulation test measuring her progesterone level showed normal ovulation. The GP advises the couple that the husband needs to undergo tests to determine if there is any cause on his side contributing to the infertility. Both the man and the woman have no history of sexually transmitted infections. The man has been smoking one to two cigarettes a day since he was 16 years old. What is the best next investigation for this patient?
Your Answer: Testicular biopsy
Correct Answer: Semen analysis
Explanation:Investigations for Male Infertility: Semen Analysis, Testicular Biopsy, Hormone and Genetic Testing
When a couple experiences fertility problems, a semen analysis is typically the first investigation for the man. This test measures semen volume, pH, sperm concentration, total sperm number, total motility, vitality, and sperm morphology, using World Health Organization reference values for interpretation. If the semen analysis reveals azoospermia (no sperm present), a testicular biopsy may be performed to collect spermatozoa for in-vitro fertilization treatment.
If the semen analysis does not explain the infertility, follicle-stimulating hormone and testosterone levels may be measured, but these are not first-line investigations. Genetic testing may also be considered to identify genetic abnormalities, such as Klinefelter syndrome, which can cause male infertility. Overall, a combination of these investigations can help diagnose and treat male infertility.
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This question is part of the following fields:
- Urology
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Question 13
Incorrect
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A 35-year-old call centre operator with a 6-year history of sarcoidosis presents with worsening shortness of breath during his visit to Respiratory Outpatients. This is his fifth episode of this nature since his diagnosis. In the past, he has responded well to tapered doses of oral steroids. What initial test would be most useful in evaluating his current pulmonary condition before prescribing steroids?
Your Answer: High-resolution computed tomography (HRCT) of the chest
Correct Answer: Pulmonary function tests with transfer factor
Explanation:Pulmonary Function Tests with Transfer Factor in Sarcoidosis: An Overview
Sarcoidosis is a complex inflammatory disease that can affect multiple organs, with respiratory manifestations being the most common. Pulmonary function tests with transfer factor are a useful tool in assessing the severity of sarcoidosis and monitoring response to treatment. The underlying pathological process in sarcoidosis is interstitial fibrosis, leading to a restrictive pattern on pulmonary function tests with reduced transfer factor. While steroids are often effective in treating sarcoidosis, monitoring transfer factor levels can help detect exacerbations and assess response to treatment. Other diagnostic tests, such as arterial blood gas, chest X-ray, serum ACE levels, and HRCT of the chest, may also be useful in certain situations but are not always necessary as an initial test. Overall, pulmonary function tests with transfer factor play a crucial role in the management of sarcoidosis.
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This question is part of the following fields:
- Respiratory
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Question 14
Correct
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A 5-year-old boy came in with a painful left shoulder after a fall. An X-ray of his left humerus reveals no visible fracture line. Upon clinical examination, the pediatric orthopedic surgeon suggests that there may be a transverse fracture across the growth plate of his left humerus, and not involving any other structures. The prognosis is positive. What kind of fracture is this?
Your Answer: Salter Harris 1
Explanation:Paediatric Fractures and Pathological Conditions
Paediatric fractures can be classified into different types based on the injury pattern. Complete fractures occur when both sides of the cortex are breached, while greenstick fractures only have a unilateral cortical breach. Buckle or torus fractures result in incomplete cortical disruption, leading to a periosteal haematoma. Growth plate fractures are also common in paediatric practice and are classified according to the Salter-Harris system. Injuries of Types III, IV, and V usually require surgery and may be associated with disruption to growth.
Non-accidental injury is a concern in paediatric fractures, especially when there is a delay in presentation, lack of concordance between proposed and actual mechanism of injury, multiple injuries, injuries at sites not commonly exposed to trauma, or when children are on the at-risk register. Pathological fractures may also occur due to genetic conditions such as osteogenesis imperfecta, which is characterized by defective osteoid formation and failure of collagen maturation in all connective tissues. Osteopetrosis is another pathological condition where bones become harder and more dense, and radiology reveals a lack of differentiation between the cortex and the medulla, described as marble bone.
Overall, paediatric fractures and pathological conditions require careful evaluation and management to ensure optimal outcomes for the child.
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This question is part of the following fields:
- Musculoskeletal
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Question 15
Incorrect
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A 62-year-old practising solicitor attends the Neurology Clinic with his wife. She is deeply concerned regarding his worsening memory. Over the past three months, he has become increasingly forgetful, to the point where he has had to take sick leave from work. He has had two recent presentations to the Emergency Department following falls, though a computed tomography (CT) head scan did not demonstrate any abnormality. On examination, there is an ataxic gait and you notice fasciculations and involuntary jerking movements of the upper limbs. He has had no family history of neurological disease and was previously fit and well.
What is the most likely underlying cause of this presentation?Your Answer: Lewy body dementia
Correct Answer: Creutzfeldt–Jakob disease (CJD)
Explanation:Distinguishing Neurodegenerative Diseases: A Case Study
A patient presents with rapidly progressive dementia, imbalance leading to falls, and myoclonus. The most likely diagnosis is Creutzfeldt–Jakob disease (CJD), a devastating prion disease without cure. Magnetic resonance imaging (MRI) is preferred for diagnosis, as CT head is ineffective.
Vascular dementia, another common cause of cognitive impairment, typically has a slower and stepwise onset in patients with a significant vascular history. A CT head would likely identify existing small vessel disease in the brain of a patient with vascular dementia.
Huntington’s disease, characterized by abnormal movements and cognitive impairment, is not the most likely diagnosis due to the rapid progression and lack of family history.
Lewy body dementia, which features visual hallucinations and Parkinsonian symptoms, usually presents over a longer period of time.
Motor neuron disease, which includes weakness and fasciculations, is unlikely due to the absence of weakness in this presentation. Frontotemporal dementia may rarely develop in motor neuron disease, but it is a slowly progressive phenomenon, unlike the rapid deterioration in this case.
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This question is part of the following fields:
- Infectious Diseases
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Question 16
Incorrect
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A 59-year-old postmenopausal woman with a history of chronic hypertension and diabetes mellitus presents with mild vaginal bleeding. Bimanual pelvic examination reveals a relatively large mass on the right side of the pelvis. The patient undergoes an abdominal and pelvic computed tomography scan with contrast injection. The scan shows multiple enlarged lymph nodes in the pelvis, along the iliac arteries. The para-aortic lymph nodes appear normal.
What is the most likely diagnosis?Your Answer: Ovarian cancer
Correct Answer: Cervical squamous cell carcinoma
Explanation:Diagnosing Gynaecological Malignancies: Understanding the Differences
When a postmenopausal woman presents with vaginal bleeding, pelvic mass, and pelvic lymphadenopathy, it is important to consider the different types of Gynaecological malignancies that could be causing these symptoms. The most likely diagnosis in this case is cervical squamous cell carcinoma, which typically metastasises to the pelvic lymph nodes along the iliac arteries.
While endometrial carcinoma (adenocarcinoma) is the most common Gynaecological malignancy, it would also be a possibility in this patient. Ovarian cancer, the second most common Gynaecological cancer, typically metastasises to the para-aortic lymph nodes and is not associated with vaginal bleeding.
Vulval cancers tend to metastasise to the superficial inguinal node and are unlikely to present with a pelvic mass or vaginal bleeding. Cervical adenocarcinomas are rare and derived from the endocervix, while uterine leiomyosarcoma often extends beyond the uterine serosa and occasionally metastasises to distant organs through blood vessels. However, neither of these malignancies typically present with vaginal bleeding and pelvic lymphadenopathy.
In summary, understanding the differences between the various types of Gynaecological malignancies is crucial in accurately diagnosing and treating patients with these conditions.
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This question is part of the following fields:
- Gynaecology
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Question 17
Incorrect
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A 67-year-old patient with psoriasis, hypothyroidism and psychotic depression complains of painful aphthous-like ulcers that started 3 weeks ago after beginning a new medication. Which medication is the most probable cause of their symptom?
Your Answer: Lithium
Correct Answer: Methotrexate
Explanation:Methotrexate is known to cause mucositis, while lithium can lead to thyrotoxicosis but not oral ulcers. Levothyroxine may also cause thyrotoxicosis but not mouth ulcers. Atorvastatin does not typically cause mouth ulcers, with the most common side effects being myalgia and skin flushing. It is important to note that only methotrexate has mucositis listed as a side effect in the BNF.
Methotrexate: An Antimetabolite with Potentially Life-Threatening Side Effects
Methotrexate is an antimetabolite drug that inhibits the enzyme dihydrofolate reductase, which is essential for the synthesis of purines and pyrimidines. It is commonly used to treat inflammatory arthritis, psoriasis, and some types of leukemia. However, it is considered an important drug due to its potential for life-threatening side effects. Careful prescribing and close monitoring are essential to ensure patient safety.
The adverse effects of methotrexate include mucositis, myelosuppression, pneumonitis, pulmonary fibrosis, and liver fibrosis. The most common pulmonary manifestation is pneumonitis, which typically develops within a year of starting treatment and presents with non-productive cough, dyspnea, malaise, and fever. Women should avoid pregnancy for at least 6 months after treatment has stopped, and men using methotrexate need to use effective contraception for at least 6 months after treatment.
When prescribing methotrexate, it is important to follow guidelines and monitor patients regularly. Methotrexate is taken weekly, and FBC, U&E, and LFTs need to be regularly monitored. The starting dose is 7.5 mg weekly, and folic acid 5mg once weekly should be co-prescribed, taken more than 24 hours after the methotrexate dose. Only one strength of methotrexate tablet should be prescribed, usually 2.5 mg. It is also important to avoid prescribing trimethoprim or co-trimoxazole concurrently, as it increases the risk of marrow aplasia, and high-dose aspirin increases the risk of methotrexate toxicity.
In case of methotrexate toxicity, the treatment of choice is folinic acid. Methotrexate is a drug with a high potential for patient harm, and it is crucial to be familiar with guidelines relating to its use to ensure patient safety.
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This question is part of the following fields:
- Musculoskeletal
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Question 18
Incorrect
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A 30-year-old man is referred to a Rapid Access Neurology Service due to severe headache. He gives a history of recurrent rapid-onset severe right-sided headache and eye pain. It sometimes wakes him up at night. He claims the eye itself becomes watery and red during the periods of pain. He also claims that side of his face feels hot and painful during episodes. They normally last 60 minutes. However, he says they can be shorter or longer. There is no significant medical history. He is a smoker. He is pain-free during the consultation and examination is non-contributory.
Which of the following is most likely to be of value in relieving pain?Your Answer: Amitriptyline
Correct Answer: Oxygen
Explanation:Understanding Cluster Headaches and Treatment Options
Cluster headaches are a rare and severe form of headache with an unknown cause, although it is believed to be related to serotonin hyperreactivity in the superficial temporal artery smooth muscle and an autosomal dominant gene. They are more common in young male smokers but can affect any age group. Symptoms include sudden onset of severe unilateral headache, pain around one eye, watery and bloodshot eye, lid swelling, facial flushing, and more. Attacks can occur 1-2 times a day and last 15 minutes to 2 hours. Treatment options include high-flow 100% oxygen, subcutaneous sumatriptan, and verapamil or topiramate for prevention. Other treatments, such as amitriptyline for trigeminal neuralgia or high-dose prednisolone for giant cell arthritis, are not appropriate for cluster headaches.
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This question is part of the following fields:
- Neurology
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Question 19
Incorrect
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A 63-year-old man visits his optician for routine screening and is discovered to have elevated intraocular pressure without any symptoms. The diagnosis of primary open-angle glaucoma is confirmed. He has no significant medical history and is not taking any medications. Can you identify a potential treatment and its mode of action?
Your Answer: Topical pilocarpine - reduces aqueous production
Correct Answer: Topical timolol - reduces aqueous production
Explanation:Timolol eye drops are effective in treating primary open-angle glaucoma by reducing the production of aqueous fluid in the anterior chamber. This helps to lower the intraocular pressure and prevent further fluid buildup. Other medications, such as acetazolamide, latanoprost, brimonidine, and pilocarpine, work by different mechanisms such as reducing aqueous production or increasing uveoscleral outflow. However, timolol is specifically known for its ability to reduce aqueous production and is commonly used as a first-line treatment for primary open-angle glaucoma.
Glaucoma is a condition where the optic nerve is damaged due to increased pressure in the eye. Primary open-angle glaucoma is a type where the iris is clear of the trabecular meshwork, which is responsible for draining aqueous humour from the eye. This results in increased resistance to outflow and raised intraocular pressure. The condition affects 0.5% of people over 40 years old and increases with age. Genetics also play a role, with first-degree relatives having a 16% chance of developing the disease. Symptoms are usually absent, and diagnosis is made through routine eye examinations. Investigations include visual field tests, tonometry, and slit lamp examinations. Treatment involves eye drops to lower intraocular pressure, with prostaglandin analogues being the first line of treatment. Surgery may be considered in refractory cases. Regular reassessment is necessary to monitor progression and prevent visual field loss.
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This question is part of the following fields:
- Ophthalmology
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Question 20
Incorrect
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A 49-year-old man presents to the Emergency department with excruciating pain in his right loin that has been occurring in waves for the past 2 hours. The physician decides to prescribe analgesia to alleviate his discomfort. What would be the most suitable medication to administer at this point?
Your Answer: Dihydrocodeine 50 mg IM
Correct Answer: Diclofenac 75 mg IM
Explanation:NICE guidelines still advise the utilization of IM diclofenac as the primary treatment for acute renal colic due to its superior analgesic properties. While other analgesic options are also effective, they are not recommended as the first line of treatment for this condition.
The management of renal stones involves initial medication and investigations, including an NSAID for analgesia and a non-contrast CT KUB for imaging. Stones less than 5mm may pass spontaneously, but more intensive treatment is needed for ureteric obstruction or renal abnormalities. Treatment options include shockwave lithotripsy, ureteroscopy, and percutaneous nephrolithotomy. Prevention strategies include high fluid intake, low animal protein and salt diet, and medication such as thiazides diuretics for hypercalciuria and allopurinol for uric acid stones.
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This question is part of the following fields:
- Surgery
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