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Question 1
Correct
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A mother of three brings her youngest daughter, aged 15, to the general practitioner (GP) as she is yet to start menstruating, whereas both her sisters had menarche at the age of 12.
The patient has developed secondary female sexual characteristics and has a normal height. She reports struggling with headaches and one episode of galactorrhoea.
Magnetic resonance imaging (MRI) reveals an intracranial tumour measuring 11 mm in maximal diameter.
Given the most likely diagnosis, which of the following is the first-line management option?Your Answer: Medical treatment with cabergoline
Explanation:The patient has primary amenorrhoea due to a macroprolactinoma, which is a benign prolactin-secreting tumor of the anterior pituitary gland. Treatment in the first instance is with a dopamine receptor agonist such as bromocriptine or cabergoline. Surgery is the most appropriate management if conservative management fails or the patient presents with visual field defects. Radiotherapy is rarely used. Exclusion of pregnancy is the first step in every case of amenorrhoea. Metoclopramide is a dopamine receptor antagonist and a cause of hyperprolactinaemia, so it should not be used to treat this patient. Thyroxine is not appropriate as hyperprolactinaemia is secondary to a pituitary adenoma. Indications for surgery are failure to respond to medical therapy or presentation with acute visual field defects.
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This question is part of the following fields:
- Gynaecology
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Question 2
Incorrect
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A 6-year-old girl walks with a limp due to right hip pain, which is relieved by rest and made worse by walking or standing. Her vital signs are normal. The Trendelenburg sign presents when she stands on her right leg.
X-rays reveal periarticular right hip swelling in soft tissue. A bone scan reveals reduced activity in the anterolateral right capital femoral epiphysis.
What is the most likely diagnosis?Your Answer: A slipped capital femoral epiphysis
Correct Answer: Legg-Calvé-Perthes disease
Explanation:Understanding Legg-Calvé-Perthes Disease and Differential Diagnoses
Legg–Calvé–Perthes disease is a condition that occurs due to vascular compromise of the capital epiphysis of the femur. The exact cause of this self-limiting disease is unclear, but it may be related to developmental changes in the hip’s blood supply. The compromised blood flow leads to ischaemic necrosis of the epiphysis. The retinacular arteries and their branches are the primary source of blood to the head of the femur, especially between the ages of 4 and 9 when the epiphyseal plate is forming. During this time, the incidence of Legg-Calvé-Perthes disease is highest.
Differential diagnoses for this condition include a slipped capital femoral epiphysis, septic arthritis, and epiphyseal dysplasia. A slipped capital femoral epiphysis would be visible on hip radiography, which is not the case in this scenario. Septic arthritis would cause systemic inflammatory responses, which are not present in this case. Epiphyseal dysplasia is a congenital defect that would typically present when the child starts to walk.
In addition to Legg-Calvé-Perthes disease, there is radiological evidence of synovitis and hip joint effusion in this scenario. However, synovitis is a non-specific sign and not a specific diagnosis. Understanding these differential diagnoses can help healthcare professionals provide accurate diagnoses and appropriate treatment plans for patients with hip joint issues.
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This question is part of the following fields:
- Paediatrics
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Question 3
Correct
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A mother brings her 9-month-old son to the general practitioner. She is concerned, as he has had an unusually high-pitched cry and has been drawing his legs up and vomiting. His last nappy revealed some bloody, slimy stools. She has recently started to wean him.
Which is the most likely diagnosis?Your Answer: Intussusception
Explanation:Pediatric Gastrointestinal Conditions: Symptoms and Differentiation
Intussusception: A pediatric emergency condition where a bowel segment invaginates into a neighboring part of the bowel, causing obstruction. Symptoms include vomiting, abdominal pain, passing blood and mucous per rectum, lethargy, and a palpable abdominal mass. Diagnosis is via ultrasonography, and treatment can be non-operative or operative depending on the severity.
Food Intolerance: Occurs following ingestion of an allergen and presents with diarrhea, vomiting, wheezing, pruritus, and rash. Typically seen in children at the age of weaning.
Colic: Excessive, high-pitched crying in infants, typically in the evenings. Can relate to a variety of causes, including gastro-oesophageal reflux, overfeeding, incomplete burping following feeds, and food allergy.
Pyloric Stenosis: Caused by hypertrophy of the pyloric muscle leading to gastric outlet obstruction. Presents in the first weeks of life with projectile non-bilious vomiting, a palpable mass in the abdomen, and visible peristalsis.
Cystic Fibrosis: An inherited condition associated with mutations in the cystic fibrosis transmembrane conductance regulator, affecting the transmembrane transport of chloride ions and leading to thick secretions in the lungs and bowel. Symptoms include meconium ileus, constipation, abdominal distension, bilious vomiting, diarrhea, steatorrhea, failure to thrive, and rectal prolapse. Identified by heel-prick screening at birth or around the age of 6-8 months.
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This question is part of the following fields:
- Paediatrics
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Question 4
Incorrect
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Which statement about leptin is accurate?
Your Answer: Plasma concentrations correlate directly with lean body mass
Correct Answer: Produces satiety
Explanation:The Role of Leptin in Regulating Appetite and Body Weight
Leptin is a hormone that is produced by adipocytes, or fat cells, and its concentration in the bloodstream is directly related to the amount of fat in the body. When leptin levels are high, it acts on receptors in the hypothalamus to produce feelings of satiety, or fullness, which can help to reduce food intake. This makes leptin an important regulator of appetite and body weight.
However, in some cases, patients may develop leptin resistance, which means that their bodies are no longer able to respond to the hormone in the same way. This can lead to continued weight gain and difficulty in controlling food intake, even when leptin levels are high. Despite this, researchers continue to study the role of leptin in the body and explore potential treatments for obesity and other related conditions.
Overall, the physiology of leptin and its effects on appetite and body weight is an important area of research that has the potential to improve the health and well-being of millions of people around the world. By developing new treatments and interventions that target leptin and other related hormones, we may be able to help patients achieve and maintain a healthy weight and reduce their risk of developing chronic diseases such as diabetes, heart disease, and cancer.
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This question is part of the following fields:
- Endocrinology
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Question 5
Incorrect
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A 60-year-old man presents to the Accident & Emergency Department following an overdose of one of his medications. On initial triage, his blood pressure is found to be 72/48 mmHg, heart rate 34 bpm and his serum blood glucose is recorded as 1.4 mmol/l. A 12-lead electrocardiogram (ECG) shows sinus bradycardia. He has a past medical history of hypertension, atrial fibrillation, insulin-dependent type 2 diabetes and hypercholesterolaemia.
Which of the following medications is most likely to be responsible for this patient’s symptoms?Your Answer: Insulin
Correct Answer: Bisoprolol
Explanation:Toxidrome Analysis: Identifying the Causative Agent in a Hypoglycaemic Patient
In cases of hypoglycaemia, it is important to consider all possible causative agents before initiating treatment. In this scenario, the patient presents with hypoglycaemia, bradycardia, and hypotension. After reviewing the patient’s medication history, the most likely agent responsible for this toxidrome is bisoprolol, a cardioselective beta-blocker commonly used in the treatment of heart failure and dysrhythmias.
While amlodipine, a dihydropyridine calcium-channel blocker, can cause hypotension in overdose, it is unlikely to cause the marked hypoglycaemia seen in this case. Digoxin, a cardiovascular agent, can lead to life-threatening dysrhythmias, but the patient’s sinus bradycardia and hypoglycaemia make it a less likely causative agent than bisoprolol. Insulin overdose results in neuroglycopenia, but it would not lead to bradycardia and hypotension. Metformin overdose rarely results in hypoglycaemia, but the major concern is lactic acidosis.
Treatment for bisoprolol overdose involves airway management, fluid resuscitation, and glucagon therapy. Additional treatment options include vasopressors and lipid emulsion therapy. It is important to consider all possible causative agents and their specific toxidromes before initiating treatment for hypoglycaemia.
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This question is part of the following fields:
- Pharmacology
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Question 6
Correct
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A 48-year-old woman comes to you for a follow-up appointment after a recent fall. She has a medical history of type 2 diabetes mellitus, bilateral knee replacements, chronic hypotension, and heart failure, which limits her mobility. Her weight is 118 kg. During her last visit, her ECG showed atrial fibrillation (AF) with a heart rate of 180 bpm, and she was started on bisoprolol. She underwent a 48-hour ECG monitoring, which revealed non-paroxysmal AF. What is the most appropriate course of action for her management?
Your Answer: Start her on digoxin
Explanation:Treatment Options for Atrial Fibrillation in a Patient with Heart Failure
When treating a patient with atrial fibrillation (AF) and heart failure, the aim should be rate control. While bisoprolol is a good choice for medication, it may not be suitable for a patient with chronic low blood pressure. In this case, digoxin would be the treatment of choice. Anticoagulation with either a novel oral anticoagulant or warfarin is also necessary. Electrical cardioversion is not appropriate for this patient. Increasing the dose of bisoprolol may be reasonable, but considering the patient’s clinical presentation and past medical history, it may not be the best option. Amlodipine will not have an effect on rate control in AF, and calcium-channel blockers should not be used in heart failure. Amiodarone should not be first-line treatment in this patient due to her heart failure. Overall, the best treatment option for AF in a patient with heart failure should be carefully considered based on the individual’s medical history and current condition.
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This question is part of the following fields:
- Cardiology
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Question 7
Incorrect
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A 25-year-old man with a known harsh ejection systolic murmur on cardiac examination collapses and passes away during a sporting event. His father and uncle also died suddenly in their forties. The reason for death is identified as an obstruction of the ventricular outflow tract caused by an abnormality in the ventricular septum.
What is the accurate diagnosis for this condition?Your Answer: Mitral stenosis
Correct Answer: Hypertrophic cardiomyopathy
Explanation:Types of Cardiomyopathy and Congenital Heart Defects
Cardiomyopathy is a group of heart diseases that affect the structure and function of the heart muscle. There are different types of cardiomyopathy, each with its own causes and symptoms. Additionally, there are congenital heart defects that can affect the heart’s structure and function from birth. Here are some of the most common types:
1. Hypertrophic cardiomyopathy: This is an inherited condition that causes the heart muscle to thicken, making it harder for the heart to pump blood. It can lead to sudden death in young athletes.
2. Restrictive cardiomyopathy: This is a rare form of cardiomyopathy that is caused by diseases that restrict the heart’s ability to fill with blood during diastole.
3. Dilated cardiomyopathy: This is the most common type of cardiomyopathy, which causes the heart chambers to enlarge and weaken, leading to heart failure.
4. Mitral stenosis: This is a narrowing of the mitral valve, which can impede blood flow between the left atrium and ventricle.
In addition to these types of cardiomyopathy, there are also congenital heart defects, such as ventricular septal defect, which is the most common congenital heart defect. This condition creates a direct connection between the right and left ventricles, affecting the heart’s ability to pump blood effectively.
Understanding the different types of cardiomyopathy and congenital heart defects is important for proper diagnosis and treatment. If you experience symptoms such as chest pain, shortness of breath, or fatigue, it is important to seek medical attention promptly.
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This question is part of the following fields:
- Cardiology
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Question 8
Incorrect
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A woman in her mid-thirties arrives at the haemodialysis clinic for her regular appointment. Before the session, a typical amount of unfractionated heparin is given. What is the drug's mechanism of action?
Your Answer: Deactivates antithrombin III
Correct Answer: Activates antithrombin III
Explanation:Unfractionated heparin works by activating antithrombin III, which then inhibits the formation of fibrin and the activation of thrombin and factors Xa, Ixa, XIa, and XIIa. This process can be reversed with protamine sulphate. Antithrombin III is the most clinically important form of antithrombin, and historically, it has been divided into I, II, III, and IV based on different stages of thrombin activity.
Understanding Heparin and its Adverse Effects
Heparin is a type of anticoagulant that comes in two forms: unfractionated or standard heparin, and low molecular weight heparin (LMWH). Both types work by activating antithrombin III, but unfractionated heparin inhibits thrombin, factors Xa, IXa, XIa, and XIIa, while LMWH only increases the action of antithrombin III on factor Xa. However, heparin can cause adverse effects such as bleeding, thrombocytopenia, osteoporosis, and hyperkalemia.
Heparin-induced thrombocytopenia (HIT) is a condition where antibodies form against complexes of platelet factor 4 (PF4) and heparin, leading to platelet activation and a prothrombotic state. HIT usually develops after 5-10 days of treatment and is characterized by a greater than 50% reduction in platelets, thrombosis, and skin allergy. To address the need for ongoing anticoagulation, direct thrombin inhibitors like argatroban and danaparoid can be used.
Standard heparin is administered intravenously and has a short duration of action, while LMWH is administered subcutaneously and has a longer duration of action. Standard heparin is useful in situations where there is a high risk of bleeding as anticoagulation can be terminated rapidly, while LMWH is now standard in the management of venous thromboembolism treatment and prophylaxis and acute coronary syndromes. Monitoring for standard heparin is done through activated partial thromboplastin time (APTT), while LMWH does not require routine monitoring. Heparin overdose may be reversed by protamine sulfate, although this only partially reverses the effect of LMWH.
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This question is part of the following fields:
- Pharmacology
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Question 9
Correct
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A 70-year-old hypertensive, diabetic smoker presents with sudden onset unilateral facial weakness, hemiparesis of the upper and lower limbs and sensory disturbance. All symptoms are on the same side. Global aphasia is also noted on examination. CT brain is normal. An ischaemic cerebrovascular accident (CVA) is diagnosed.
What is the most likely vascular territory involved?Your Answer: Left middle cerebral artery
Explanation:Understanding the Different Types of Stroke and Their Symptoms
Strokes can occur when there is a blockage or rupture of blood vessels in the brain, leading to a lack of oxygen and nutrients to brain cells. Different types of strokes can affect different areas of the brain, resulting in varying symptoms. Here are some examples:
– Left middle cerebral artery: This type of stroke can cause unilateral facial weakness, hemiplegia, and hemisensory loss. It can also lead to global aphasia, which is a language impairment that affects the dominant hemisphere of the brain (usually the left side). This occurs when the trunk of the left MCA is occluded, causing damage to Broca’s and Wernicke’s areas in the left perisylvian cortex.
– Right middle cerebral artery: A stroke in the right MCA can cause contralateral motor and sensory symptoms without speech disturbance.
– Basilar artery: This type of stroke can be particularly devastating, as it affects the brainstem and can lead to a locked-in state. Prognosis is poor.
– Right internal carotid artery: This is typically asymptomatic, as collateral circulation from the circle of Willis can compensate for the occlusion.
– Left vertebral artery: A stroke in the left vertebral artery can cause posterior circulation stroke, which can result in symptoms such as nausea, vomiting, gait disturbance, and vertigo.It’s important to recognize the symptoms of a stroke and seek medical attention immediately. Time is of the essence when it comes to treating strokes, as early intervention can help minimize damage to the brain.
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This question is part of the following fields:
- Neurology
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Question 10
Correct
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A 65-year-old previously healthy man with a 3-day history of feeling unwell, difficulty tolerating oral fluids and symptoms of a cold, is referred to the hospital by his primary care physician. The senior Accident and Emergency (A&E) nurse triages him and takes his vital signs, which are mostly normal except for a slightly elevated heart rate (102 bpm). She also performs a 12-lead electrocardiogram (ECG) and draws blood for testing, but the results are pending. The nurse suspects that the ECG shows some abnormalities and consults with the A&E senior resident, who confirms that the QRS complexes are widened, P-waves are absent, and T-waves are abnormally large.
What is the most appropriate initial course of action?Your Answer: 10 ml of 10% calcium gluconate
Explanation:Managing Hyperkalaemia: The Importance of Calcium Gluconate as a Cardioprotectant
Hyperkalaemia can lead to serious cardiac complications, including suppression of impulse generation and reduced conduction. Therefore, the priority in managing hyperkalaemia is to administer calcium gluconate as a cardioprotectant. This should be followed by the administration of salbutamol nebuliser and Actrapid® with 50% dextrose to shift potassium into the cells. If refractory hyperkalaemia occurs, senior support should be sought, potentially requiring bicarbonate or dialysis. It is important to prioritize the administration of calcium gluconate to prevent potential myocardial infarction. Once interventions have been administered, alerting senior support is recommended.
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This question is part of the following fields:
- Acute Medicine And Intensive Care
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Question 11
Correct
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A 33-year-old woman who has never given birth before comes for her first prenatal visit at 29 weeks gestation. She is currently taking fluoxetine and lactulose and is concerned about the potential risks to her baby. What is a possible danger of using fluoxetine during the third trimester of pregnancy?
Your Answer: Persistent pulmonary hypertension
Explanation:When considering the use of SSRIs during pregnancy, it is important to assess the potential benefits and risks. While using SSRIs during the first trimester may slightly increase the risk of congenital heart defects, using them during the third trimester can lead to persistent pulmonary hypertension of the newborn. Additionally, paroxetine has a higher risk of congenital malformations, especially during the first trimester.
Selective serotonin reuptake inhibitors (SSRIs) are commonly used as the first-line treatment for depression. Citalopram and fluoxetine are the preferred SSRIs, while sertraline is recommended for patients who have had a myocardial infarction. However, caution should be exercised when prescribing SSRIs to children and adolescents. Gastrointestinal symptoms are the most common side-effect, and patients taking SSRIs are at an increased risk of gastrointestinal bleeding. Patients should also be aware of the possibility of increased anxiety and agitation after starting a SSRI. Fluoxetine and paroxetine have a higher propensity for drug interactions.
The Medicines and Healthcare products Regulatory Agency (MHRA) has issued a warning regarding the use of citalopram due to its association with dose-dependent QT interval prolongation. As a result, citalopram and escitalopram should not be used in patients with congenital long QT syndrome, known pre-existing QT interval prolongation, or in combination with other medicines that prolong the QT interval. The maximum daily dose of citalopram is now 40 mg for adults, 20 mg for patients older than 65 years, and 20 mg for those with hepatic impairment.
When initiating antidepressant therapy, patients should be reviewed by a doctor after 2 weeks. Patients under the age of 25 years or at an increased risk of suicide should be reviewed after 1 week. If a patient responds well to antidepressant therapy, they should continue treatment for at least 6 months after remission to reduce the risk of relapse. When stopping a SSRI, the dose should be gradually reduced over a 4 week period, except for fluoxetine. Paroxetine has a higher incidence of discontinuation symptoms, including mood changes, restlessness, difficulty sleeping, unsteadiness, sweating, gastrointestinal symptoms, and paraesthesia.
When considering the use of SSRIs during pregnancy, the benefits and risks should be weighed. Use during the first trimester may increase the risk of congenital heart defects, while use during the third trimester can result in persistent pulmonary hypertension of the newborn. Paroxetine has an increased risk of congenital malformations, particularly in the first trimester.
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This question is part of the following fields:
- Psychiatry
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Question 12
Correct
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You are the medical SHO in A and E. A 25-year-old female is admitted in a distressed state and experiencing shortness of breath. She is finding it difficult to speak in complete sentences and is breathing rapidly. Upon examination, her respiratory rate is 35 breaths per minute, pulse rate is 120 beats per minute, blood pressure is 110/70 mmHg, oxygen saturation is 90%, and her peak expiratory flow rate is less than 50% of predicted. The emergency medical services have administered salbutamol 5 mg twice and provided face mask oxygen. An ABG test is pending. What is the most appropriate next step for this patient?
Your Answer: Salbutamol 5 mg and ipratropium bromide 0.5 mg with oxygen
Explanation:Management of Life-Threatening Asthma
Patients with life-threatening asthma, characterized by saturations under 92% in air, require immediate administration of β2-agonists, preferably nebulizer with oxygen. Repeat doses should be given at 15-30 minute intervals, or continuous nebulization can be used if there is an inadequate response to bolus therapy. Nebulized ipratropium bromide should be added for patients with acute severe or life-threatening asthma, or those with a poor initial response. Oxygen should be given to maintain saturations at 94-98%, and patients with saturations less than 92% on air should have an ABG to exclude hypercapnia. Steroids should be given as soon as possible, with a dose of 40-50 mg continued for five days or until recovery. Failure to respond to these treatments may warrant the use of intravenous magnesium sulfate and aminophylline, but only after discussion with senior colleagues. Intensive care is indicated for patients with severe acute or life-threatening asthma who are failing to respond to therapy.
It is important to note that chest radiographs are not necessary unless there is a suspicion of pneumothorax or consolidation, or in cases of life-threatening asthma, a failure to respond to treatment, or a need for ventilation. Attempting intubation prior to further therapy is not recommended, especially for those inexperienced in the technique, as there are other treatments that can be tried first before this step.
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This question is part of the following fields:
- Emergency Medicine
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Question 13
Correct
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A 32-year-old woman visits a fertility clinic after trying to conceive for more than two years. She is worried that she may not be ovulating despite having a regular menstrual cycle lasting 30 days. She is not using any form of birth control and her pregnancy test is negative. What is the most effective method to detect ovulation?
Your Answer: Progesterone level
Explanation:The most reliable way to confirm ovulation is through the Day 21 progesterone test. This test measures the peak level of progesterone in the serum, which occurs 7 days after ovulation. While the length of the follicular phase can vary, the luteal phase always lasts for 14 days. Therefore, if a woman has a 35-day cycle, she can expect to ovulate on Day 21 and her progesterone level will peak on Day 28. To determine when to take the test, subtract 7 days from the expected start of the next period (Day 21 for a 28-day cycle and Day 28 for a 35-day cycle). Basal body temperature charts and cervical mucous thickness are not reliable predictors of ovulation. Gonadotropins may be used to assess ovarian function in women with irregular menstrual cycles.
Infertility is a common issue that affects approximately 1 in 7 couples. It is important to note that around 84% of couples who have regular sexual intercourse will conceive within the first year, and 92% within the first two years. The causes of infertility can vary, with male factor accounting for 30%, unexplained causes accounting for 20%, ovulation failure accounting for 20%, tubal damage accounting for 15%, and other causes accounting for the remaining 15%.
When investigating infertility, there are some basic tests that can be done. These include a semen analysis and a serum progesterone test. The serum progesterone test is done 7 days prior to the expected next period, typically on day 21 for a 28-day cycle. The interpretation of the serum progesterone level is as follows: if it is less than 16 nmol/l, it should be repeated and if it remains consistently low, referral to a specialist is necessary. If the level is between 16-30 nmol/l, it should be repeated, and if it is greater than 30 nmol/l, it indicates ovulation.
It is important to counsel patients on lifestyle factors that can impact fertility. This includes taking folic acid, maintaining a healthy BMI between 20-25, and advising regular sexual intercourse every 2 to 3 days. Additionally, patients should be advised to quit smoking and limit alcohol consumption to increase their chances of conceiving.
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This question is part of the following fields:
- Gynaecology
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Question 14
Correct
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A first-year medical student is participating in a bedside teaching session and is instructed to listen to the patient's heart. The student places the stethoscope over the patient's fourth left intercostal space just lateral to the sternum.
What heart valve's normal sounds would be best detected with the stethoscope positioned as described?Your Answer: Tricuspid
Explanation:Auscultation of Heart Valves: Locations and Sounds
The human heart has four valves that regulate blood flow. These valves can be heard through auscultation, a medical technique that involves listening to the sounds produced by the heart using a stethoscope. Here are the locations and sounds of each valve:
Tricuspid Valve: This valve is located on the right side of the heart and can be heard at the left sternal border in the fourth intercostal space. The sound produced by this valve is a low-pitched, rumbling noise.
Aortic Valve: The aortic valve is located on the left side of the heart and can be heard over the right sternal border at the second intercostal space. The sound produced by this valve is a high-pitched, clicking noise.
Pulmonary Valve: This valve is located on the right side of the heart and can be heard over the left sternal border at the second intercostal space. The sound produced by this valve is a high-pitched, clicking noise.
Thebesian Valve: The Thebesian valve is located in the coronary sinus and its closure cannot be auscultated.
Mitral Valve: This valve is located on the left side of the heart and can be heard by listening at the apex, in the left mid-clavicular line in the fifth intercostal space. The sound produced by this valve is a low-pitched, rumbling noise.
In summary, auscultation of heart valves is an important diagnostic tool that can help healthcare professionals identify potential heart problems. By knowing the locations and sounds of each valve, healthcare professionals can accurately diagnose and treat heart conditions.
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This question is part of the following fields:
- Cardiology
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Question 15
Incorrect
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What is the typical distribution of atopic eczema in a 12-month-old child?
Your Answer: Nappy area and trunk
Correct Answer: Face and trunk
Explanation:Eczema in Children: Symptoms and Management
Eczema is a common skin condition that affects around 15-20% of children and is becoming more prevalent. It usually appears before the age of 2 and clears up in around 50% of children by the age of 5 and in 75% of children by the age of 10. The symptoms of eczema include an itchy, red rash that can worsen with repeated scratching. In infants, the face and trunk are often affected, while in younger children, it typically occurs on the extensor surfaces. In older children, the rash is more commonly seen on the flexor surfaces and in the creases of the face and neck.
To manage eczema in children, it is important to avoid irritants and use simple emollients. Large quantities of emollients should be prescribed, roughly in a ratio of 10:1 with topical steroids. If a topical steroid is also being used, the emollient should be applied first, followed by waiting at least 30 minutes before applying the topical steroid. Creams are absorbed into the skin faster than ointments, and emollients can become contaminated with bacteria, so fingers should not be inserted into pots. Many brands have pump dispensers to prevent contamination.
In severe cases, wet wrapping may be used, which involves applying large amounts of emollient (and sometimes topical steroids) under wet bandages. Oral ciclosporin may also be used in severe cases. Overall, managing eczema in children involves a combination of avoiding irritants, using emollients, and potentially using topical steroids or other medications in severe cases.
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This question is part of the following fields:
- Paediatrics
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Question 16
Correct
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A 25-year-old primigravida woman at 36 weeks gestation comes in with mild irregular labor pains in the lower abdomen. Upon examination, her cervix is firm, posterior, and closed, and fetal heart tones are present. However, the pain subsides during the consultation. What would be the most suitable course of action?
Your Answer: Reassure and discharge
Explanation:False labor typically happens during the final month of pregnancy. It is characterized by contractions felt in the lower abdomen that are irregular and spaced out every 20 minutes. However, there are no progressive changes in the cervix.
Labour is divided into three stages, with the first stage beginning from the onset of true labour until the cervix is fully dilated. This stage is further divided into two phases: the latent phase and the active phase. The latent phase involves dilation of the cervix from 0-3 cm and typically lasts around 6 hours. The active phase involves dilation from 3-10 cm and progresses at a rate of approximately 1 cm per hour. In primigravidas, this stage can last between 10-16 hours.
During this stage, the baby’s presentation is important to note. Approximately 90% of babies present in the vertex position, with the head entering the pelvis in an occipito-lateral position. The head typically delivers in an occipito-anterior position.
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This question is part of the following fields:
- Obstetrics
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Question 17
Correct
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A 40-year-old male patient presents to the Emergency department with signs of pneumonia. Upon examination, a right middle lobe pneumonia is detected on his chest X-ray. Where is the optimal location to auscultate breath sounds from the affected lobe?
Your Answer: Mid-axillary line, 5th intercostal space
Explanation:Anatomy of the Lungs
The lungs are divided into lobes by the pleura, with the right lung having three lobes and the left lung having two. The lobes are separated by the oblique and horizontal fissures. The oblique fissure separates the inferior and superior lobes and runs from the spine of T3 to the sixth rib. The horizontal fissure is only present in the right lung and separates the superior and middle lobes. It starts in the oblique fissure near the back of the lung and runs horizontally forward, cutting the front border at the level of the fourth costal cartilage.
Auscultation of the lungs is similar on both sides of the posterior chest wall, with the lower two-thirds corresponding to the inferior lobes and the upper third corresponding to the superior lobe. On the anterior chest wall, the area above the nipples corresponds to the superior lobes, with the apices being audible just above the clavicles. The area below the nipples corresponds to the inferior lobes. The middle lobe of the right lung is the smallest and is wedge-shaped, including the lower part of the anterior border and the anterior part of the base of the lung. It is best heard in the axilla, but can also be heard in the back or at the lateral margin of the right chest (anterior axillary line).
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This question is part of the following fields:
- Clinical Sciences
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Question 18
Correct
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A 35-year-old woman presents to the emergency department with abdominal pain and nausea. She has a medical history of gallstones and alcohol dependence. Upon examination, she has a tender right epigastrium and a temperature of 38.3ºC. Despite this, she is hemodynamically stable. Her blood results show a raised white cell count and C-reactive protein, but her liver profile and serum amylase/lipase results are normal. The sepsis protocol is initiated, and she is started on intravenous antibiotics. What is the most appropriate next step in managing this patient's likely diagnosis?
Your Answer: Laparoscopic cholecystectomy within 1 week of diagnosis
Explanation:The recommended treatment for acute cholecystitis is intravenous antibiotics followed by laparoscopic cholecystectomy within 1 week of diagnosis. Conservative management is not recommended as it may lead to chronic disease and recurrence of infection. Delaying treatment and opting for open cholecystectomy once inflammation has subsided is also not recommended as it has been associated with increased rates of sepsis, jaundice, and cancer. Laparoscopic cholecystectomy is preferred over open cholecystectomy as it is associated with lower postoperative morbidity, mortality, and reduced length of stay in the hospital.
Acute cholecystitis is a condition where the gallbladder becomes inflamed. This is usually caused by gallstones, which are present in 90% of cases. The remaining 10% of cases are known as acalculous cholecystitis and are typically seen in severely ill patients who are hospitalized. The pathophysiology of acute cholecystitis is multifactorial and can be caused by gallbladder stasis, hypoperfusion, and infection. In immunosuppressed patients, it may develop due to Cryptosporidium or cytomegalovirus. This condition is associated with high morbidity and mortality rates.
The main symptom of acute cholecystitis is right upper quadrant pain, which may radiate to the right shoulder. Patients may also experience fever and signs of systemic upset. Murphy’s sign, which is inspiratory arrest upon palpation of the right upper quadrant, may be present. Liver function tests are typically normal, but deranged LFTs may indicate Mirizzi syndrome, which is caused by a gallstone impacted in the distal cystic duct, causing extrinsic compression of the common bile duct.
Ultrasound is the first-line investigation for acute cholecystitis. If the diagnosis remains unclear, cholescintigraphy (HIDA scan) may be used. In this test, technetium-labelled HIDA is injected IV and taken up selectively by hepatocytes and excreted into bile. In acute cholecystitis, there is cystic duct obstruction, and the gallbladder will not be visualized.
The treatment for acute cholecystitis involves intravenous antibiotics and cholecystectomy. NICE now recommends early laparoscopic cholecystectomy, within 1 week of diagnosis. Previously, surgery was delayed for several weeks until the inflammation had subsided. Pregnant women should also proceed to early laparoscopic cholecystectomy to reduce the chances of maternal-fetal complications.
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This question is part of the following fields:
- Surgery
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Question 19
Incorrect
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A 50-year-old female patient visits the clinic with complaints of abdominal discomfort and bloating that have been progressively worsening over the past few months. Upon examination, her GP discovered a complex left ovarian cyst. Which blood test would be the most useful in determining if the cyst is cancerous?
Your Answer: CA19-9
Correct Answer: CA125
Explanation:Tumor Markers and Their Association with Different Cancers
Tumor markers are substances that are produced by cancer cells or by normal cells in response to cancer. These markers can be used to detect the presence of cancer, monitor the progress of treatment, and detect the recurrence of cancer. One such tumor marker is CA125, which is associated with ovarian carcinoma. However, elevations in CA125 can also be seen in uterine cancer, pancreas, stomach, and colonic tumors. In some cases, benign ovarian tumors can also cause a rise in CA125 levels. If a patient has a CA125 level of over 200U/ml and an abnormal ultrasound scan, it is highly likely that they have ovarian carcinoma.
Other tumor markers include CA19-9, which is primarily associated with pancreatic tumors, beta-HCG, which is associated with germ cell tumors, alpha-fetoprotein, which is associated with hepatocellular carcinoma, and carcinoembryonic antigen, which is associated with colonic carcinoma. While AFP and beta-HCG can rarely be secreted by ovarian tumors, it is important to check CA125 levels first, as they are much more frequently elevated. By monitoring tumor markers, doctors can detect cancer early and provide appropriate treatment.
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This question is part of the following fields:
- Haematology
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Question 20
Incorrect
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An 80-year-old man arrives at the emergency department with a sudden painless loss of vision in his left eye. He has noticed a decline in his vision over the past few months, but attributed it to his age. He has a history of smoking 30 cigarettes daily for the last 45 years and well-controlled hypertension. The left eye has a visual acuity of 6/30, while the right eye has a visual acuity of 6/12. A central scotoma is evident on visual field testing. Fundus examination is being conducted after administering mydriatic eye drops. What is the most specific finding for the underlying cause of his presentation?
Your Answer: Blurring of the optic disc margins
Correct Answer: Choroidal neovascularisation
Explanation:The patient’s acute onset painless visual loss, along with their chronic visual loss, distorted vision, age, and smoking history, suggest a diagnosis of age-related macular degeneration (AMD). Since the vision loss was sudden, wet AMD is more likely than dry AMD. Choroidal neovascularisation is a hallmark feature of wet AMD, as new blood vessels formed are weak and unstable, leading to intraretinal or subretinal fluid leakage or haemorrhage.
Blurring of the optic disc margins is not a feature of AMD, but rather papilloedema, which is associated with increased intracranial pressure and typically presents with progressive and positional headaches, nausea, and vomiting.
Cotton-wool exudates are not commonly seen in AMD, but rather in hypertensive and diabetic retinopathy. Although the patient has hypertension, it is well-controlled, and hypertensive retinopathy tends to present with slow and progressive visual loss.
Geographic atrophy may be seen in the late stages of both forms of AMD, but the presence of choroidal neovascularisation is the key differentiating feature between the two.
Age-related macular degeneration (ARMD) is a common cause of blindness in the UK, characterized by the degeneration of the central retina (macula) and the formation of drusen. It is more prevalent in females and is strongly associated with advancing age, smoking, family history, and conditions that increase the risk of ischaemic cardiovascular disease. ARMD can be classified into two forms: dry and wet. Dry ARMD is more common and is characterized by drusen, while wet ARMD is characterized by choroidal neovascularisation and carries a worse prognosis. Clinical features of ARMD include subacute onset of visual loss, difficulties in dark adaptation, and visual disturbances such as photopsia and glare.
To diagnose ARMD, slit-lamp microscopy and color fundus photography are used to identify any pigmentary, exudative, or haemorrhagic changes affecting the retina. Fluorescein angiography and indocyanine green angiography may also be used to visualize changes in the choroidal circulation. Treatment for dry ARMD involves a combination of zinc with antioxidant vitamins A, C, and E, which has been shown to reduce disease progression by around one third. For wet ARMD, anti-VEGF agents such as ranibizumab, bevacizumab, and pegaptanib are used to limit disease progression and stabilize or reverse visual loss. Laser photocoagulation may also be used to slow progression, but anti-VEGF therapies are usually preferred due to the risk of acute visual loss after treatment.
In summary, ARMD is a common cause of blindness in the UK that is strongly associated with advancing age, smoking, and family history. It can be classified into dry and wet forms, with wet ARMD carrying a worse prognosis. Diagnosis involves the use of various imaging techniques, and treatment options include a combination of zinc and antioxidant vitamins for dry ARMD and anti-VEGF agents or laser photocoagulation for wet ARMD.
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This question is part of the following fields:
- Ophthalmology
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Question 21
Incorrect
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Sarah is a 75-year-old woman who visits her doctor complaining of a persistent cough, coughing up blood, and losing weight. She used to work in a shipyard and was exposed to a significant amount of asbestos. What is the most conclusive method to diagnose the probable condition?
Your Answer: Bronchoscopy and endobronchial ultrasound-guided transbronchial needle aspiration
Correct Answer: Thoracoscopy and histology
Explanation:To diagnose mesothelioma, a thoracoscopy and histology are necessary. Other tests such as bronchoscopy and endobronchial ultrasound guided transbronchial needle aspiration are not appropriate as mesothelioma does not spread into the airways. While a CT scan or MRI can show evidence of a tumor, a histological examination is required to confirm the diagnosis.
Understanding Mesothelioma: A Cancer Linked to Asbestos Exposure
Mesothelioma is a type of cancer that affects the mesothelial layer of the pleural cavity, which is strongly associated with exposure to asbestos. Although it is rare, other mesothelial layers in the abdomen may also be affected. Symptoms of mesothelioma include dyspnoea, weight loss, and chest wall pain, as well as clubbing. About 30% of cases present as painless pleural effusion, and only 20% have pre-existing asbestosis. A history of asbestos exposure is present in 85-90% of cases, with a latent period of 30-40 years.
To diagnose mesothelioma, suspicion is typically raised by a chest x-ray showing either pleural effusion or pleural thickening. The next step is usually a pleural CT, and if a pleural effusion is present, fluid should be sent for MC&S, biochemistry, and cytology. However, cytology is only helpful in 20-30% of cases. Local anaesthetic thoracoscopy is increasingly used to investigate cytology-negative exudative effusions as it has a high diagnostic yield of around 95%. If an area of pleural nodularity is seen on CT, then an image-guided pleural biopsy may be used.
Management of mesothelioma is typically symptomatic, with industrial compensation available for those affected. Chemotherapy and surgery may be options if the cancer is operable. However, the prognosis for mesothelioma is poor, with a median survival of only 12 months.
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This question is part of the following fields:
- Medicine
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Question 22
Incorrect
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A 4-year-old child was admitted with a high fever, cervical lymph node enlargement, conjunctival congestion, redness of lips and palms, and desquamation of fingertips. Upon examination, erythema of the oral cavity was observed. Blood tests showed a hemoglobin level of 110 g/l and a platelet count of 450,000. The symptoms resolved after two weeks, but during the third week, the child unexpectedly passed away. An autopsy revealed vasculitis of the coronary arteries and aneurysm formation. What is the most likely diagnosis?
Your Answer: Scarlet fever
Correct Answer: Kawasaki’s disease
Explanation:Understanding Kawasaki’s Disease and Differential Diagnosis
Kawasaki disease, also known as mucocutaneous lymph node syndrome, is a multisystem disease that primarily affects children under the age of 5. It is characterized by fever, cervical adenitis, and changes in the skin and mucous membranes. While generally benign and self-limited, it can lead to coronary artery aneurysms in 25% of cases and has a case-fatality rate of 0.5-2.8%. Treatment with high-dose intravenous globulin and aspirin has been shown to be effective in reducing the prevalence of coronary artery abnormalities.
When considering a differential diagnosis, it is important to distinguish Kawasaki disease from other conditions with similar symptoms. Scarlet fever, rheumatic fever, diphtheria, and Marfan syndrome can all present with fever and cardiovascular involvement, but each has distinct clinical features and underlying pathophysiologic mechanisms. Careful evaluation and diagnosis are essential for appropriate treatment and management.
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This question is part of the following fields:
- Paediatrics
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Question 23
Incorrect
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A 35-year-old woman presents to her primary care physician seeking the combined oral contraceptive pill (COCP). She has a history of pelvic inflammatory disease and had an ectopic pregnancy that was treated with methotrexate a year ago. Additionally, she is a heavy smoker, consuming 20 cigarettes per day. Her family history is significant for BRCA1 mutation in her mother and sister, but she declines genetic testing. What would be an absolute contraindication for the COCP in this patient?
Your Answer: Prior ectopic pregnancy
Correct Answer: Smoker
Explanation:The combined oral contraceptive pill (COCP) is a popular form of birth control, but it is not suitable for everyone. There are absolute contraindications, which mean that the COCP should not be used under any circumstances, and relative contraindications, which require careful consideration before prescribing.
Absolute contraindications include smoking 15 or more cigarettes a day and being over 35 years old, hypertension, major surgery with prolonged immobilization, secondary Raynaud’s disease, systemic lupus erythematosus, positive for antiphospholipid syndrome, current or history of venous thromboembolism, migraine with aura, current breast cancer, liver cirrhosis, viral hepatitis, and diabetic nephropathy/retinopathy/neuropathy.
Relative contraindications include smoking less than 15 cigarettes a day and being over 35 years old, being 6 weeks to 6 months postpartum and breastfeeding, being less than 21 days postpartum and not breastfeeding, having a body mass index of 35 or higher, having a family history of venous thromboembolism in a first-degree relative, having migraines without aura, having a history of breast cancer without recurrence for 5 years, using certain anticonvulsants, having dyslipidemia, undergoing rifampicin therapy, and having a previous use of methotrexate.
A history of pelvic inflammatory disease or prior ectopic pregnancy is not considered a contraindication to the use of the COCP. The possibility of a BRCA mutation is a controversial topic, and while there is evidence of a small increase in breast cancer risk with COCP use, it is not an absolute contraindication. It is important to consult with a healthcare provider to determine the best form of birth control for individual circumstances.
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This question is part of the following fields:
- Sexual Health
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Question 24
Incorrect
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A 37-year-old man comes to the Emergency Department complaining of left-sided hearing loss and tinnitus that have been ongoing for three months. He also reports experiencing dizziness, which has now progressed to difficulty walking steadily. Audiometry confirms sensorineural hearing loss in his left ear, and a contrast magnetic resonance imaging scan indicates that he has a tumor with characteristics consistent with an acoustic neuroma. Which type of cell is linked to the excessive growth of an acoustic neuroma?
Your Answer: Astrocyte cell
Correct Answer: Schwann cell
Explanation:Understanding the Cells Involved in Neurological Tumors
Neurological tumors can arise from various cells in the central and peripheral nervous systems. It is important to understand the different types of cells involved in these tumors to accurately diagnose and treat them.
Schwann cells are responsible for the pathogenesis of acoustic neuromas, which are benign tumors of the vestibulocochlear nerve. These cells surround nerves in the peripheral nervous system. Symptoms of acoustic neuromas include unilateral sensorineural hearing loss, tinnitus, and vertigo.
Microglial cells are immune cells in the central nervous system, but they do not typically form neurological tumors.
Astrocytes are glial cells in the central nervous system and are responsible for the most common type of glioma, but this patient’s symptoms are consistent with a peripheral nervous system tumor of glial origin.
Ependymal cells form the epithelial lining of the ventricles in the brain and the central canal of the spinal cord. Although they can cause ependymomas, which are a type of brain tumor, the symptoms present are not consistent with this and ependymal cells are not responsible for acoustic neuromas.
Satellite cells are neuroglial cells of the peripheral nervous system, but they are unlikely to be responsible for acoustic neuromas. Over-proliferation of Schwann cells is the pathogenesis of this type of tumor.
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This question is part of the following fields:
- Neurosurgery
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Question 25
Correct
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A 42-year-old woman has diabetes controlled by diet. Her sugars have been running at 13 mmol/l; HbA1c is 63 mmol/mol, and she has a body mass index of 32.
Which of the following is the most appropriate management?Your Answer: Metformin
Explanation:Treatment Options for Type II Diabetes: A Guide for Healthcare Professionals
When a patient presents with an HbA1c of >48 mmol/mol, it is important to commence treatment for their type II diabetes. The first-line treatment for overweight individuals who are not adequately controlled with diet is metformin. However, dietary advice should always be given and reinforced, as it is clear that this patient’s diabetes is not being controlled with diet alone.
If the HbA1c is still high on metformin monotherapy, gliclazide or pioglitazone can be used in conjunction with metformin. Insulin would only be considered if dual therapy was found to be ineffective or if there were intolerable side-effects from oral hypoglycaemic agents. It is important to note that insulin would likely worsen this patient’s obesity.
As healthcare professionals, it is our responsibility to stay up-to-date on the latest treatment options for type II diabetes and to work with our patients to find the best course of action for their individual needs.
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This question is part of the following fields:
- Endocrinology
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Question 26
Incorrect
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A 27-year-old woman presents to the Emergency department with a suspected intentional overdose. She is unsure of the medication she has taken. Her medical history includes severe asthma, anxiety, and depression. Additionally, she is a regular cannabis smoker.
During the assessment, the patient appears agitated and confused, unable to remain still on the bed. There is significant global hypertonia and clonus, particularly in the legs. Her vital signs reveal a sinus tachycardia on ECG with a pulse of 135 bpm. Her blood pressure is 156/96 mmHg, SpO2 97% on air, respiratory rate of 32, and temperature of 40.6°C. The patient's pupils are dilated, and she is sweating.
Which medication is the patient likely to have overdosed on?Your Answer: Aminophylline
Correct Answer: Fluoxetine
Explanation:Serotonergic Toxidrome
Serotonergic toxidrome, also known as serotonin syndrome, is a condition of drug toxicity that is characterized by extreme temperature, mental agitation and confusion, hypertonia, hyperreflexia, and clonus. This condition is caused by a flooding of the central nervous system with excess serotonin, which can be triggered by various drugs, including antidepressants, opioid analgesics, and certain herbal remedies. Recreational drugs such as cocaine, ecstasy, and amphetamines can also augment serotonin pharmacodynamics and increase the risk of serotonergic toxidrome.
Deliberate overdosage is a common cause of serotonergic toxidrome, but it can also occur inadvertently, especially in patients taking multiple drugs that affect the metabolism and usage of serotonin. Life-threatening serotonergic toxidrome is a medical emergency that requires admission to the intensive care unit for haemofiltration, intubation, paralysis, and artificial cooling to control the temperature and manage the rhabdomyolysis. Serotonin antagonists such as cyproheptadine may be given, and tachycardia and hypertension can be controlled with intravenous short-acting beta-blockade.
While other drugs may display some similar features, the serotonergic toxidrome is a relatively specific presentation, typically of rapid onset. Aminophylline, cannabis, diazepam, and paracetamol overdose are unlikely to cause this picture. It is important to screen blood for paracetamol levels in any patient in whom any overdose is suspected, as it is easily treated and can be lethal if missed.
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This question is part of the following fields:
- Pharmacology
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Question 27
Incorrect
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You are faced with a 60-year-old male patient who has a history of ischaemic heart disease (taking aspirin and clopidogrel) and reflux, and requires an emergency DHS for his neck of femur fracture. Despite administering a thiopentone and suxamethonium rapid sequence induction, you are unable to intubate the patient. You have attempted to reposition him, insert a bougie, and switch to a McCoy blade, but all efforts have been unsuccessful. The patient's oxygen saturation has dropped to 88%, and you are unable to ventilate him via a face mask due to his large face and thick beard. You are losing your seal and cannot achieve any tidal volume.
What would be your next step in managing this patient?Your Answer: Use a videolaryngoscope to secure a definitive airway
Correct Answer: Insert a laryngeal mask airway (LMA) and attempt to ventilate the patient
Explanation:Managing a ‘Can’t Intubate’ Scenario in a Patient with Neck of Femur Fracture
In a ‘can’t intubate’ scenario with a patient who has a neck of femur fracture, the priority is delivering oxygen. If attempts at intubation have been difficult and the patient is desaturating, the Difficult Airway Society recommends attempting ventilation with a laryngeal mask airway (LMA) as a temporary measure. If this fails and the patient continues to desaturate, an emergency cricothyrotomy is advised for urgent oxygen delivery. Using a videolaryngoscope to secure a definitive airway is not recommended if oxygenation is a priority. Similarly, attempting a fibreoptic intubation or using a long blade for further attempts at intubation can cause damage and swelling in the airway, leading to laryngospasm. Waking the patient up is also not advisable in this emergency situation, as neck of femur fractures have a high mortality rate if left untreated.
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This question is part of the following fields:
- Anaesthetics & ITU
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Question 28
Correct
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A 55-year-old man visits his GP complaining of pain in his left knee. An x-ray reveals osteoarthritis. He has no significant medical history. What is the best course of action for managing his pain?
Your Answer: Oral paracetamol
Explanation:For the treatment of osteoarthritis, the first-line medications are paracetamol and topical NSAIDs (if the affected area is the knee or hand). Oral NSAIDs should only be used as a second-line option due to their potential adverse effects.
The Role of Glucosamine in Osteoarthritis Management
Osteoarthritis (OA) is a common condition that affects the joints, causing pain and stiffness. The National Institute for Health and Care Excellence (NICE) published guidelines in 2014 on the management of OA, which includes non-pharmacological and pharmacological treatments. Glucosamine, a normal constituent of glycosaminoglycans in cartilage and synovial fluid, has been studied for its potential benefits in OA management.
Several double-blind randomized controlled trials (RCTs) have reported significant short-term symptomatic benefits of glucosamine in knee OA, including reduced joint space narrowing and improved pain scores. However, more recent studies have produced mixed results. The 2008 NICE guidelines do not recommend the use of glucosamine, and a 2008 Drug and Therapeutics Bulletin review advised against prescribing it on the NHS due to limited evidence of cost-effectiveness.
Despite the conflicting evidence, some patients may still choose to use glucosamine as a complementary therapy for OA management. It is important for healthcare professionals to discuss the potential benefits and risks of glucosamine with their patients and to consider individual patient preferences and circumstances.
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This question is part of the following fields:
- Musculoskeletal
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Question 29
Incorrect
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A 55-year-old woman is prescribed tamoxifen for the management of an oestrogen receptor positive breast cancer. What types of cancers are linked to the use of tamoxifen?
Your Answer: Ovarian cancer
Correct Answer: Endometrial cancer
Explanation:Endometrial cancer is a type of cancer that is commonly found in women who have gone through menopause, but it can also occur in around 25% of cases before menopause. The prognosis for this type of cancer is usually good due to early detection. There are several risk factors associated with endometrial cancer, including obesity, nulliparity, early menarche, late menopause, unopposed estrogen, diabetes mellitus, tamoxifen, polycystic ovarian syndrome, and hereditary non-polyposis colorectal carcinoma. Postmenopausal bleeding is the most common symptom of endometrial cancer, which is usually slight and intermittent initially before becoming more heavy. Pain is not common and typically signifies extensive disease, while vaginal discharge is unusual.
When investigating endometrial cancer, women who are 55 years or older and present with postmenopausal bleeding should be referred using the suspected cancer pathway. The first-line investigation is trans-vaginal ultrasound, which has a high negative predictive value for a normal endometrial thickness (< 4 mm). Hysteroscopy with endometrial biopsy is also commonly used for investigation. The management of localized disease involves total abdominal hysterectomy with bilateral salpingo-oophorectomy, while patients with high-risk disease may have postoperative radiotherapy. progesterone therapy is sometimes used in frail elderly women who are not considered suitable for surgery. It is important to note that the combined oral contraceptive pill and smoking are protective against endometrial cancer.
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This question is part of the following fields:
- Gynaecology
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Question 30
Incorrect
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A 16-year-old girl takes 45 of her stepfather’s aspirin tablets, following an argument with her boyfriend. 12 hours into her admission, the following arterial blood gas (ABG) and biochemistry tests were performed.
pH 7.27, PCO2 3.0 kPa, PO2 14.3 kPa, HCO3− 16.2 mmol/l, base excess −7.4 mmol/l
Na+ 143 mmol/l, K+ 4.5 mmol/l, Cl− 107 mmol/l, urea 12.4 mmol/l, creatinine 87 μmol/l
What is the patient’s anion gap?Your Answer: 47.7 mmol/l
Correct Answer: 24.3 mmol/l
Explanation:Understanding Anion Gap and Its Significance in Metabolic Acidosis
Anion gap is a crucial parameter used to diagnose metabolic acidosis, a condition where the body produces excess acid or loses too much base. It is calculated by subtracting the main anions (bicarbonate and chloride) from the main cations (sodium and potassium) in the plasma. The normal range for anion gap is 10-20 mmol/l.
An increased anion gap indicates the presence of an exogenous acid or acids that are not usually measured in small quantities. This can be caused by drug poisoning, lactic acidosis, renal failure, or ketoacidosis. On the other hand, a low anion gap is less common and can be seen in conditions such as albuminaemia, lithium toxicity, and multiple myeloma.
Understanding anion gap is essential in determining the cause of metabolic acidosis and guiding appropriate treatment. In cases of deliberate aspirin overdose, metabolic acidosis occurs due to altered metabolism and uncoupling of normal oxidative phosphorylation. Therefore, measuring anion gap can help diagnose and manage this condition.
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This question is part of the following fields:
- Clinical Biochemistry
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