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Question 1
Incorrect
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What is the mechanism of action of venlafaxine for elderly patients?
Your Answer: Tricyclic antidepressant
Correct Answer: Serotonin and noradrenaline reuptake inhibitor
Explanation:The mechanism of action of venlafaxine involves inhibiting the reuptake of both serotonin and noradrenaline, making it a type of antidepressant known as a serotonin and noradrenaline reuptake inhibitor. When choosing an antidepressant, factors such as patient preference, previous sensitization, overdose risk, and cost should be considered, although SSRIs are typically the first-line treatment due to their favorable risk-to-benefit ratio.
Understanding Serotonin and Noradrenaline Reuptake Inhibitors
Serotonin and noradrenaline reuptake inhibitors (SNRIs) are a type of antidepressant medication that work by increasing the levels of serotonin and noradrenaline in the brain. These neurotransmitters are responsible for regulating mood, emotions, and anxiety levels. By inhibiting the reuptake of these chemicals, SNRIs help to maintain higher levels of serotonin and noradrenaline in the synaptic cleft, which can lead to improved mood and reduced anxiety.
Examples of SNRIs include venlafaxine and duloxetine, which are commonly used to treat major depressive disorders, generalised anxiety disorder, social anxiety disorder, panic disorder, and menopausal symptoms. These medications are relatively new and have been found to be effective in treating a range of mental health conditions. SNRIs are often preferred over other types of antidepressants because they have fewer side effects and are less likely to cause weight gain or sexual dysfunction.
Overall, SNRIs are an important class of medication that can help to improve the lives of people struggling with mental health conditions. By increasing the levels of serotonin and noradrenaline in the brain, these medications can help to regulate mood and reduce anxiety, leading to a better quality of life for those who take them.
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This question is part of the following fields:
- Psychiatry
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Question 2
Correct
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An 88-year-old man presents to the Emergency Department with diffuse abdominal pain and one episode of dark rectal bleeding. He is noticed to be in fast atrial fibrillation. He is an ex-smoker and drinks three pints of beer per week. On examination, he is not peritonitic, but his pain is generalised and only temporarily alleviated by opioid analgesia. His bloods show: white blood count 14 (4.5 to 11.0 × 109/l), c-reactive protein 23 (normal: Less than 10 mg/L) and arterial lactate 4.8 (normal 1 ± 0.5 mmol/l4). Abdominal and chest X-rays are unremarkable.
What is the most likely diagnosis?Your Answer: Bowel ischaemia
Explanation:When a patient presents with consistent abdominal pain, bowel ischaemia should be considered as a possible cause. This is especially true for elderly patients who experience crampy abdominal pain followed by dark rectal bleeding. Bowel ischaemia occurs when the bowel mucosa becomes necrotic due to a lack of blood flow. Atrial fibrillation increases the risk of mesenteric artery embolisation, which can lead to bowel ischaemia. A raised lactate level is also indicative of bowel ischaemia. Haemorrhoids, on the other hand, would not cause an acute abdomen and typically present as bright red blood on wiping stool. Ulcerative colitis is more common in younger patients and is characterised by episodes of bloody diarrhoea. It is not associated with smoking and acute exacerbations are characterised by many episodes of diarrhoea, some of which may be bloody, and fever. Bowel volvulus, which is twisting of the bowel leading to obstruction, would cause abdominal distension, pain, constipation, and bloody stool. However, this patient’s normal appearance on plain film X-rays makes bowel obstruction or volvulus unlikely. Diverticulitis, which is inflammation of outpouchings of the large bowel, usually presents with gradual onset of left iliac fossa pain, loose stools, and fever. It is associated with more episodes of loose stools and fever and can progress to shock.
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This question is part of the following fields:
- Colorectal
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Question 3
Incorrect
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A 28-year-old male patient visits his GP complaining of a painless lump in his scrotum. He admits to not regularly performing self-examinations and reports no other symptoms. Upon examination, his left testicle is enlarged. The GP orders a two-week-wait ultrasound scan of the testicles, which reveals a cystic lesion with mixed solid echoes in the affected testicle. What tumor marker is linked to this condition?
Your Answer: CA 15-3
Correct Answer: Alpha fetoprotein (AFP)
Explanation:Teratomas, a type of non-seminoma germ cell testicular tumours, are known to cause elevated levels of hCG and AFP. In a young male with a painless testicular mass, an ultrasound scan revealed a cystic lesion with echoes that suggest the presence of mucinous/sebaceous material, hair follicles, etc., pointing towards a teratoma. While CEA is a tumour marker primarily used in colorectal cancer, PSA is an enzyme produced in the prostate and CA 15-3 is a tumour marker commonly associated with breast cancer. None of these markers are typically elevated in teratomas.
Understanding Testicular Cancer
Testicular cancer is a type of cancer that commonly affects men between the ages of 20 and 30. Germ-cell tumors are the most common type of testicular cancer, accounting for around 95% of cases. These tumors can be divided into seminomas and non-seminomas, which include embryonal, yolk sac, teratoma, and choriocarcinoma. Other types of testicular cancer include Leydig cell tumors and sarcomas. Risk factors for testicular cancer include infertility, cryptorchidism, family history, Klinefelter’s syndrome, and mumps orchitis.
The most common symptom of testicular cancer is a painless lump, although some men may experience pain. Other symptoms may include hydrocele and gynaecomastia, which occurs due to an increased oestrogen:androgen ratio. Tumor markers such as hCG, AFP, and beta-hCG may be elevated in germ cell tumors. Ultrasound is the first-line diagnostic tool for testicular cancer.
Treatment for testicular cancer depends on the type and stage of the tumor. Orchidectomy, chemotherapy, and radiotherapy may be used. Prognosis for testicular cancer is generally excellent, with a 5-year survival rate of around 95% for seminomas and 85% for teratomas if caught at Stage I. It is important for men to perform regular self-examinations and seek medical attention if they notice any changes or abnormalities in their testicles.
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This question is part of the following fields:
- Surgery
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Question 4
Incorrect
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A 28-year-old woman is on day one postpartum, following a normal vaginal delivery. She has called the midwife, as she is struggling to establish breastfeeding and correct positioning of the baby to the breast. She reports pain when the baby is breastfeeding.
Which of the following is a feature of a poor latch?Your Answer: There is less areola visible below the chin than above the nipple
Correct Answer: Clicking noises are heard
Explanation:Understanding the Signs of a Good Latch for Successful Breastfeeding
Latching on the breast is crucial for successful breastfeeding, but many women struggle with it. A poor latch can lead to pain and frustration, causing some women to give up on breastfeeding altogether. However, there are clear signs of a good latch that can help mothers and babies achieve successful breastfeeding.
One indicator of a poor latch is clicking noises, which can be painful for the mother and indicate that the baby is chewing on the nipple. In contrast, a good latch is associated with visible and audible swallowing, a rhythmic suck, and relaxed arms and hands of the infant. The baby’s chin should touch the breast, with the nose free, and the lips should be rolled out, not turned in. The mouth should be open wide, and the tongue positioned below the nipple, with the latter touching the palate of the baby’s mouth.
Another sign of a good latch is that less areola should be visible below the chin than above the nipple. This indicates that the baby is taking in not only the nipple but also the areola, which is essential for effective milk expression and feeding. By understanding these signs of a good latch, mothers can ensure successful breastfeeding and a positive experience for both themselves and their babies.
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This question is part of the following fields:
- Obstetrics
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Question 5
Correct
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You encounter a 50-year-old man who confides in you about his personal issue. He has been experiencing difficulties with achieving and maintaining erections for the past year, and it has been progressively worsening. This patient seldom visits healthcare providers and has no prior medical conditions.
What is the predominant organic etiology for this symptom?Your Answer: Vascular causes
Explanation:Erectile dysfunction (ED) is a symptom characterized by the persistent inability to achieve and maintain an erection sufficient for satisfactory sexual performance. The causes of ED can be categorized into organic, psychogenic, and mixed, with certain medications also contributing to the condition. Organic causes of ED include vasculogenic, neurogenic, structural, and hormonal factors, while psychogenic causes can be generalized or situational. Among the organic causes, vasculogenic factors are the most common, with cardiovascular disease, hypertension, hyperlipidemia, diabetes mellitus, smoking, and major pelvic surgery being the primary culprits. As such, the risk factors for ED are similar to those for CVD, including obesity, diabetes, dyslipidemia, metabolic syndrome, hypertension, endothelial dysfunction, and lifestyle factors such as lack of exercise and smoking. Therefore, when evaluating a man with ED, it is important to screen for CVD and obtain a thorough psychosexual history.
Erectile dysfunction (ED) is a condition where a man is unable to achieve or maintain an erection that is sufficient for sexual activity. It is not a disease but a symptom that can be caused by organic, psychogenic, or mixed factors. It is important to differentiate between the causes of ED, with gradual onset of symptoms, lack of tumescence, and normal libido favoring an organic cause, while sudden onset of symptoms, decreased libido, and major life events favoring a psychogenic cause. Risk factors for ED include cardiovascular disease, alcohol use, and certain medications.
To assess for ED, it is recommended to measure lipid and fasting glucose serum levels to calculate cardiovascular risk, as well as free testosterone levels in the morning. If free testosterone is low or borderline, further assessment may be needed. PDE-5 inhibitors, such as sildenafil, are the first-line treatment for ED and should be prescribed to all patients regardless of the cause. Vacuum erection devices can be used as an alternative for those who cannot or will not take PDE-5 inhibitors.
For young men who have always had difficulty achieving an erection, referral to urology is appropriate. Additionally, people with ED who cycle for more than three hours per week should be advised to stop. Overall, ED is a common condition that can be effectively managed with appropriate treatment.
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This question is part of the following fields:
- Surgery
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Question 6
Incorrect
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A 12-year-old boy is presenting with nocturnal enuresis, poor academic performance, and easy fatigue with physical activity. A full examination, including blood pressure, is unremarkable. Laboratory results show elevated WBC count and high bicarbonate levels. The 24-hour urine test reveals high potassium levels and low sodium levels. What is the likely diagnosis?
Your Answer: Primary hyperaldosteronism (Conn's syndrome)
Correct Answer: Bartter's syndrome
Explanation:Bartter’s Syndrome: A Rare Condition with Unique Symptoms
Bartter’s syndrome is a rare condition that is usually diagnosed in childhood. It is characterized by polyuria, nocturnal enuresis, and growth retardation. Patients with this syndrome also experience hypokalaemic metabolic alkalosis with urinary potassium wasting. This is due to the hyperplasia of the juxtaglomerular apparatus.
The absence of hypertension in the patient makes it unlikely that they have Conn’s or renal artery stenosis. Bartter’s syndrome is a unique condition that presents with specific symptoms and laboratory findings. It is important for healthcare providers to be aware of this condition and consider it in the differential diagnosis of patients with similar symptoms. Early diagnosis and treatment can improve the patient’s quality of life and prevent complications.
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This question is part of the following fields:
- Endocrinology
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Question 7
Correct
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A teenage girl is brought to you by her concerned mother. The girl has an erythematosus rash on her cheeks but is feeling fine otherwise. Upon examination, she has a 'slapped cheek' appearance.
What is the most probable organism responsible for this?Your Answer: Parvovirus B19
Explanation:Common Causes of Skin Rashes and Their Symptoms
Parvovirus B19: This virus causes erythema infectiosum or ‘fifth disease’ which is a self-limited disease with mild constitutional symptoms. Symptomatic management can be provided with NSAIDs.
Staphylococcus aureus: This common bacteria can cause skin diseases like folliculitis, cellulitis, impetigo, or secondary skin infections of wounds.
Human herpesvirus 6 (HHV6): HHV6A and HHV6B can cause diarrhoea, fever, and occasionally a roseola rash in young children. Infection with this virus does not cause the characteristic ‘slapped cheek’ rash.
Beta-haemolytic Streptococcus: Group B Streptococcus can cause complications during pregnancy and can be passed on to the newborn baby.
Measles virus: Measles causes a generalised maculopapular erythematous rash, alongside symptoms of fever, cough, runny nose, and red eyes. A child with a rash who is otherwise well is unlikely to have measles.
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This question is part of the following fields:
- Infectious Diseases
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Question 8
Incorrect
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A 45-year-old woman attends for her cervical smear as per the NHS cervical screening programme. She is found to have low-grade dyskaryosis. The laboratory performed a reflex high-risk human papillomavirus (HR-HPV) test on the cytology sample. The HPV sample returned as negative.
When should the patient have a repeat cervical smear?Your Answer: Six months
Correct Answer: Five years
Explanation:Appropriate Screening Interval for Women with Low-Grade Dyskaryosis and Negative HPV Testing
Women with low-grade dyskaryosis and negative HPV testing should return to the screening program. The appropriate screening interval for a 50-year-old patient is every five years. This is because the majority of patients with HPV-negative, low-grade dyskaryosis revert to normal epithelium and do not require further investigation with colposcopy. It is important to note that the screening interval for patients between 25 and 49 years is every three years. Shorter intervals, such as three months, six months, or even one year, are not necessary and may lead to unnecessary testing and anxiety for the patient.
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This question is part of the following fields:
- Statistics
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Question 9
Incorrect
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A 27-year-old trans female patient contacts her GP for a telephone consultation to discuss contraception options. She was assigned male at birth and is currently receiving treatment from the gender identity clinic, taking oestradiol and goserelin. Although she plans to undergo surgery in the future, she has not done so yet. She is currently in a relationship with a female partner and engages in penetrative sexual intercourse. She has no significant medical history and is not taking any regular medications apart from those prescribed by the GIC. What advice should she receive regarding contraception?
Your Answer: Goserelin prevents sperm production and so contraception is not needed
Correct Answer: The patient should use condoms
Explanation:While patients assigned male at birth who are undergoing treatment with oestradiol, GNRH analogs, finasteride or cyproterone may experience a decrease or cessation in sperm production, it is not a reliable method of contraception. Therefore, it is important to advise the use of condoms as a suitable option for contraception. It is incorrect to suggest that a vasectomy is the only option, as condoms are also a viable choice. Additionally, recommending that the patient’s partner use hormonal contraception is not appropriate, as advice should be given directly to the patient.
Contraceptive and Sexual Health Guidance for Transgender and Non-Binary Individuals
The Faculty of Sexual & Reproductive Healthcare has released guidance on contraceptive choices and sexual health for transgender and non-binary individuals. The guidance emphasizes the importance of sensitive communication and offering options that consider personal preferences, co-morbidities, and current medications or therapies.
For individuals engaging in vaginal sex where there may be a risk of pregnancy and/or sexually transmitted infections, condoms and dental dams are recommended. Cervical screening and human papillomavirus vaccinations should also be offered to sexually active individuals with a uterus. Those engaging in anal sex and rimming should be advised of the risk of hepatitis A & B and offered vaccinations. Individuals at risk of HIV transmission should be advised of the availability of pre-exposure prophylaxis and post-exposure prophylaxis as required.
For patients seeking permanent contraception, a fallopian tube occlusion or a vasectomy may be the most appropriate solution and neither would be affected by hormonal therapy. Testosterone therapy does not provide protection against pregnancy, and oestrogen-containing regimes are not recommended in patients undergoing testosterone therapy. Progesterone-only contraceptives are considered safe, and the intrauterine system and injections may also suspend menstruation. Non-hormonal intrauterine devices do not interact with hormonal regimes but can exacerbate menstrual bleeding.
In patients assigned male at birth, there may be a reduction or cessation of sperm production with certain therapies, but the variability of effects means they cannot be relied upon as a method of contraception. Condoms should be recommended in those patients engaging in vaginal sex wishing to avoid the risk of pregnancy. Emergency contraception may be required in patients assigned female at birth following unprotected vaginal intercourse, and either of the available oral emergency contraceptive options may be considered. The non-hormonal intrauterine device may also be an option, but it may have unacceptable side effects in some patients.
Overall, the guidance stresses the importance of individualized care and communication in contraceptive and sexual health decisions for transgender and non-binary individuals.
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This question is part of the following fields:
- Urology
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Question 10
Incorrect
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A 50-year-old man is five days post-laparotomy for subacute intestinal obstruction secondary to underlying Crohn’s disease. He has suddenly become breathless and complains of pleuritic chest pain. On examination, the patient is confused and his chest is clear to auscultation. However, he is tachypnoeic and has a mildly raised jugular venous pressure (JVP).
Observations:
Blood pressure 97/70 mmHg
Heart rate 126 bpm
Respiratory rate 25 breaths per minute
Oxygen saturations 92% on room air
Arterial blood gas:
Investigation Result Normal value
pH 7.53 7.35–7.45
Pa(CO2) 3.1 kPa 4.6–6.0 kPa
Pa(O2) 8.3 kPa 10.5–13.5 kPa
An electrocardiogram (ECG) shows sinus tachycardia and right bundle branch block.
Computed tomography pulmonary angiogram (CTPA) confirms the diagnosis of pulmonary embolism.
Which is the most appropriate immediate management for this patient?Your Answer: Intravenous (iv) fluids, oxygen, enoxaparin (treatment dose), rivaroxaban
Correct Answer: iv fluids, oxygen, rivaroxaban
Explanation:Management of Pulmonary Embolism postoperatively
Pulmonary embolism is a serious complication that can occur after surgery and is associated with high mortality rates. The prompt diagnosis and management of this condition are crucial, and anticoagulant treatment is typically recommended. Patients can be started on apixaban or rivaroxaban at a therapeutic dose or a combination of LMWH and either dabigatran or warfarin until therapeutic levels are reached. In the case of warfarin, it is typically started concurrently with LMWH since it takes 48-72 hours for its anticoagulant properties to take effect.
In addition to anticoagulant therapy, patients with pulmonary embolism may require iv fluids and high-flow oxygen if they are hypotensive and hypoxic. Enoxaparin is typically used as a treatment dose, but unfractionated iv heparin may be used as an alternative in patients with renal impairment.
Warfarin is used for long-term anticoagulation in patients who have had pulmonary embolism, but it is not appropriate for immediate management since it is initially pro-thrombotic. Thrombolysis is indicated in patients who are haemodynamically unstable, but it is generally avoided postoperatively due to an increased risk of bleeding.
In summary, the management of pulmonary embolism postoperatively involves prompt diagnosis, anticoagulant therapy, and supportive measures such as iv fluids and oxygen. The choice of anticoagulant and duration of therapy will depend on the patient’s individual circumstances and risk factors.
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This question is part of the following fields:
- Surgery
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Question 11
Correct
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A 32-year-old woman presents to the antenatal clinic at 40-weeks gestation for her first pregnancy. She reports no contractions yet. Upon examination, her abdomen is soft and a palpable uterus indicates a term pregnancy. The cervix is firm and dilated to 1 cm, with the foetal head stationed 1 cm below the ischial spines. The obstetrician performs a membrane sweep and decides to initiate treatment with vaginal prostaglandins. What is the most probable complication of this procedure?
Your Answer: Uterine hyperstimulation
Explanation:When inducing labour in a patient who is past her due date, the main complication to watch out for is uterine hyperstimulation. The recommended method for inducing labour according to NICE guidelines is vaginal prostaglandins, which can be administered as a gel, tablet or slow-release pessary. A membrane sweep may also be performed alongside this. Vaginal prostaglandins work by ripening the cervix and stimulating uterine contractions. If uterine hyperstimulation occurs, tocolytic agents can be given to relax the uterus and slow contractions. It’s important to note that a breech presentation is not a complication of induction of labour, especially in cases where the foetus is stationed in the pelvis below the ischial spines. Chorioamnionitis, which is inflammation of the foetal membranes due to bacterial infection, is a risk during prolonged labour and repeated vaginal examinations, but it is not the main complication of induction of labour. Cord prolapse is also a possible complication, but it is more common when the presenting part of the foetus is high, which is not the case in this pregnancy where the foetal head is stationed 1 cm below the ischial spine.
Induction of labour is a process where labour is artificially started and is required in about 20% of pregnancies. It is indicated in cases of prolonged pregnancy, prelabour premature rupture of the membranes, maternal medical problems, diabetic mother over 38 weeks, pre-eclampsia, obstetric cholestasis, and intrauterine fetal death. The Bishop score is used to assess whether induction of labour is necessary and includes cervical position, consistency, effacement, dilation, and fetal station. A score of less than 5 indicates that labour is unlikely to start without induction, while a score of 8 or more indicates a high chance of spontaneous labour or response to interventions made to induce labour.
Possible methods of induction include membrane sweep, vaginal prostaglandin E2, oral prostaglandin E1, maternal oxytocin infusion, amniotomy, and cervical ripening balloon. The NICE guidelines recommend vaginal prostaglandins or oral misoprostol if the Bishop score is less than or equal to 6, while amniotomy and an intravenous oxytocin infusion are recommended if the score is greater than 6.
The main complication of induction of labour is uterine hyperstimulation, which refers to prolonged and frequent uterine contractions that can interrupt blood flow to the intervillous space and result in fetal hypoxemia and acidemia. Uterine rupture is a rare but serious complication. Management includes removing vaginal prostaglandins and stopping the oxytocin infusion if one has been started, and considering tocolysis.
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This question is part of the following fields:
- Obstetrics
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Question 12
Correct
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John is a 28-year-old man who comes to see you for a follow-up visit. You initially saw him 1 month ago for low mood and referred him for counselling. He states he is still feeling low and his feelings of anxiety are worsening. He is keen to try medication to help.
John has a 5-month-old baby and is breastfeeding.
Which of the following is the most appropriate medication for John to commence?Your Answer: Sertraline
Explanation:Breastfeeding women can safely take sertraline or paroxetine as their preferred SSRIs. These medications are known to have minimal to low levels of exposure to infants through breast milk, and are not considered harmful to them. Therefore, if a mother is diagnosed with postnatal depression and requires antidepressant treatment, she should not be advised to stop breastfeeding.
Understanding Postpartum Mental Health Problems
Postpartum mental health problems can range from mild ‘baby-blues’ to severe puerperal psychosis. To screen for depression, healthcare professionals may use the Edinburgh Postnatal Depression Scale, which is a 10-item questionnaire that indicates how the mother has felt over the previous week. A score of more than 13 indicates a ‘depressive illness of varying severity’, with sensitivity and specificity of more than 90%. The questionnaire also includes a question about self-harm.
‘Baby-blues’ is seen in around 60-70% of women and typically occurs 3-7 days following birth. It is more common in primips, and mothers are characteristically anxious, tearful, and irritable. Reassurance and support from healthcare professionals, particularly health visitors, play a key role in managing this condition. Most women with the baby blues will not require specific treatment other than reassurance.
Postnatal depression affects around 10% of women, with most cases starting within a month and typically peaking at 3 months. The features are similar to depression seen in other circumstances, and cognitive behavioural therapy may be beneficial. Certain SSRIs such as sertraline and paroxetine may be used if symptoms are severe. Although these medications are secreted in breast milk, they are not thought to be harmful to the infant.
Puerperal psychosis affects approximately 0.2% of women and requires admission to hospital, ideally in a Mother & Baby Unit. Onset usually occurs within the first 2-3 weeks following birth, and features include severe swings in mood (similar to bipolar disorder) and disordered perception (e.g. auditory hallucinations). There is around a 25-50% risk of recurrence following future pregnancies. Paroxetine is recommended by SIGN because of the low milk/plasma ratio, while fluoxetine is best avoided due to a long half-life.
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This question is part of the following fields:
- Obstetrics
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Question 13
Correct
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Which of the following characteristics is not typically associated with Marfan's syndrome?
Your Answer: Learning difficulties
Explanation:Understanding Marfan’s Syndrome
Marfan’s syndrome is a genetic disorder that affects the connective tissue in the body. It is caused by a defect in the FBN1 gene on chromosome 15, which codes for the protein fibrillin-1. This disorder is inherited in an autosomal dominant pattern, meaning that a person only needs to inherit one copy of the defective gene from one parent to develop the condition. Marfan’s syndrome affects approximately 1 in 3,000 people.
The features of Marfan’s syndrome include a tall stature with an arm span to height ratio greater than 1.05, a high-arched palate, arachnodactyly (long, slender fingers), pectus excavatum (sunken chest), pes planus (flat feet), and scoliosis (curvature of the spine). In addition, individuals with Marfan syndrome may experience cardiovascular problems such as dilation of the aortic sinuses, mitral valve prolapse, and aortic aneurysm. They may also have lung issues such as repeated pneumothoraces. Eye problems are also common, including upwards lens dislocation, blue sclera, and myopia. Finally, dural ectasia, or ballooning of the dural sac at the lumbosacral level, may also occur.
In the past, the life expectancy of individuals with Marfan syndrome was around 40-50 years. However, with regular echocardiography monitoring and the use of beta-blockers and ACE inhibitors, this has improved significantly in recent years. Despite these improvements, aortic dissection and other cardiovascular problems remain the leading cause of death in individuals with Marfan syndrome.
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This question is part of the following fields:
- Musculoskeletal
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Question 14
Correct
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A 35-year-old woman presents with an incidental finding of a blood pressure of 180/130 mmHg on three separate occasions. Her cardiovascular examination is unremarkable, but further investigation reveals a significantly smaller left kidney with a 'string of beads' appearance in the left renal artery. What is the most appropriate management option for this patient?
Your Answer: Balloon angioplasty
Explanation:Management of Renal Artery Stenosis: Fibromuscular Dysplasia
Fibromuscular dysplasia is a rare cause of renal artery stenosis, typically affecting young women and presenting with hypertension. The characteristic ‘string of beads’ appearance on CT imaging helps in diagnosis. While atherosclerotic disease is the most common cause of renal artery stenosis, a combination of antihypertensive therapy and renal artery balloon angioplasty is curative for fibromuscular dysplasia. Kidney transplantation is not usually required, but it is important to recognize the condition in donors to prevent complications in recipients. Nephrectomy is not typically necessary, and surgical reconstruction is rarely recommended. Statins are not used in the management of fibromuscular dysplasia, but may be used in atherosclerotic renal artery stenosis.
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This question is part of the following fields:
- Renal
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Question 15
Incorrect
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A 36-year-old man arrives at the emergency department after taking an unknown substance during a night out. He has a history of depression. Upon examination, his GCS is 13/15, his pupils are dilated and divergent, and he is tachycardic with a heart rate of 110/min. His blood pressure is 124/70 mmHg, and his ECG shows sinus rhythm with a prolonged QTc duration of 480 msec. He appears dehydrated. What substance is most likely responsible for his symptoms?
Your Answer: MDMA
Correct Answer: Amitriptyline
Explanation:The correct answer is Amitriptyline overdose, a tricyclic antidepressant that blocks histamine, cholinergic and alpha 1 receptors. Symptoms include dilated pupils, dry skin, confusion, urinary retention, tachycardia, and potentially prolonged QTc interval and widened QRS complex leading to ventricular arrhythmias. Serotonin syndrome is a possible effect of sertraline overdose, while cocaine toxicity produces sympathetic effects such as agitation, increased heart rate and blood pressure, but would not cause a reduced GCS or altered QRS duration on ECG.
Tricyclic overdose is a common occurrence in emergency departments, with particular danger associated with amitriptyline and dosulepin. Early symptoms include dry mouth, dilated pupils, agitation, sinus tachycardia, and blurred vision. Severe poisoning can lead to arrhythmias, seizures, metabolic acidosis, and coma. ECG changes may include sinus tachycardia, widening of QRS, and prolongation of QT interval. QRS widening over 100ms is linked to an increased risk of seizures, while QRS over 160 ms is associated with ventricular arrhythmias.
Management of tricyclic overdose involves IV bicarbonate as first-line therapy for hypotension or arrhythmias. Other drugs for arrhythmias, such as class 1a and class Ic antiarrhythmics, are contraindicated as they prolong depolarisation. Class III drugs like amiodarone should also be avoided as they prolong the QT interval. Lignocaine’s response is variable, and it should be noted that correcting acidosis is the first line of management for tricyclic-induced arrhythmias. Intravenous lipid emulsion is increasingly used to bind free drug and reduce toxicity. Dialysis is ineffective in removing tricyclics.
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This question is part of the following fields:
- Pharmacology
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Question 16
Incorrect
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A 65-year-old man comes to your clinic exhibiting typical symptoms of seborrhoeic dermatitis. He also reports experiencing eye itchiness. What is the most probable diagnosis to accompany seborrhoeic dermatitis in this case?
Your Answer: Anterior uveitis
Correct Answer: Blepharitis
Explanation:Seborrhoeic dermatitis, dry eye syndrome, and acne rosacea are conditions that may be linked to blepharitis. However, the treatment for blepharitis remains consistent, with patients advised to clean their eyelids twice daily and use a warm compress with their eyes closed for 5-10 minutes. There is no apparent reason for an elevated risk of the other conditions mentioned.
Blepharitis is a condition where the eyelid margins become inflamed. This can be caused by dysfunction of the meibomian glands (posterior blepharitis) or seborrhoeic dermatitis/staphylococcal infection (anterior blepharitis). It is more common in patients with rosacea. The meibomian glands secrete oil to prevent rapid evaporation of the tear film, so any problem affecting these glands can cause dryness and irritation of the eyes. Symptoms of blepharitis are usually bilateral and include grittiness, discomfort around the eyelid margins, sticky eyes in the morning, and redness of the eyelid margins. Styes and chalazions are also more common in patients with blepharitis, and secondary conjunctivitis may occur.
Management of blepharitis involves softening the lid margin with hot compresses twice a day and practicing lid hygiene to remove debris from the lid margins. This can be done using cotton wool buds dipped in a mixture of cooled boiled water and baby shampoo or sodium bicarbonate in cooled boiled water. Artificial tears may also be given for symptom relief in people with dry eyes or an abnormal tear film.
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This question is part of the following fields:
- Ophthalmology
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Question 17
Incorrect
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A 68-year-old retired caretaker with a well-documented history of chronic obstructive pulmonary disease (COPD) is admitted, for his fourth time this year, with shortness of breath and a cough productive of green sputum. Examination findings are: respiratory rate (RR) 32 breaths/min, temperature 37.4 °C, SpO2 86% on room air, asterixis and coarse crepitations at the left base. A chest X-ray (CXR) confirms left basal consolidation.
Which arterial blood gas (ABG) picture is likely to belong to the above patient?Your Answer: pH: 7.47, pa (O2): 9.6, pa (CO2): 3.5, HCO3–: 27.40, BE +3.0 mmol
Correct Answer: pH: 7.27, pa (O2): 7.1, pa (CO2): 8.9, HCO3–: 33.20, base excess (BE) 4.9 mmol
Explanation:Interpreting Blood Gas Results in COPD Patients
COPD is a common respiratory disease that can lead to exacerbations requiring hospitalization. In these patients, lower respiratory tract infections can quickly lead to respiratory failure and the need for respiratory support. Blood gas results can provide important information about the patient’s respiratory and metabolic status. In COPD patients, a type II respiratory failure with hypercapnia and acidosis is common, resulting in a low pH and elevated bicarbonate levels. However, blood gas results that show low carbon dioxide or metabolic acidosis are less likely to be in keeping with COPD. Understanding and interpreting blood gas results is crucial in managing COPD exacerbations and providing appropriate respiratory support.
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This question is part of the following fields:
- Respiratory
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Question 18
Incorrect
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A 16-year old boy is admitted to a hospital in Scotland with a two day history of abdominal pain. He tells you the pain is worsening and that he has been vomiting. The patient has a history of autism and after discussing the possibility of a diagnosis of appendicitis with the patient and his parents, you feel that he does not have the capacity to give consent for surgery.
In Scotland, what are the provisions for treatment of 16-year olds who lack capacity to consent to treatment and investigation?Your Answer: The parents can consent to investigations and treatments that are in the patient’s best interests
Correct Answer: Such patients are to be treated the same way as adults who lack capacity
Explanation:Treatment of Patients Over 16 Years Old Who Lack Capacity in Scotland
In Scotland, all individuals aged 16 and over are presumed to have the capacity to consent to treatment unless there is evidence to the contrary. Therefore, a 17-year old without capacity is considered an adult, and the Adults with Incapacity (Scotland) Act 2000 applies. This means that a court order is needed to decide on investigations and treatments that are in the patient’s best interests.
It is important to note that patients who lack capacity over the age of 16 in Scotland are treated as adults, and not as children. Therefore, clinicians cannot proceed with what they believe is in the patient’s best interest without a court order. Additionally, parents cannot consent on behalf of the patient as they are over 16 years old.
Understanding the Treatment of Patients Over 16 Years Old Who Lack Capacity in Scotland
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This question is part of the following fields:
- Ethics And Legal
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Question 19
Incorrect
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A 25-year-old woman is scheduled for surgery to remove her appendix. She has a history of asthma since the age of 16 and is currently taking a high dose inhaled corticosteroid and theophylline. Despite this, she experiences breathlessness and uses her reliever several times a week. She has been to the emergency department twice in the past year due to asthma attacks. Her most recent peak flow measurement was 70%. She does not smoke or drink alcohol.
As a medical assistant, you are asked by the anesthesiologist to determine the ASA grade for this patient.Your Answer: 4
Correct Answer: 3
Explanation:The American Society of Anaesthesiologists (ASA) classification is a system used to categorize patients based on their overall health status and the potential risks associated with administering anesthesia. There are six different classifications, ranging from ASA I (a normal healthy patient) to ASA VI (a declared brain-dead patient whose organs are being removed for donor purposes).
ASA II patients have mild systemic disease, but without any significant functional limitations. Examples of mild diseases include current smoking, social alcohol drinking, pregnancy, obesity, and well-controlled diabetes mellitus or hypertension. ASA III patients have severe systemic disease and substantive functional limitations, with one or more moderate to severe diseases. Examples include poorly controlled diabetes mellitus or hypertension, COPD, morbid obesity, active hepatitis, alcohol dependence or abuse, implanted pacemaker, moderate reduction of ejection fraction, End-Stage Renal Disease (ESRD) undergoing regularly scheduled dialysis, history of myocardial infarction, and cerebrovascular accidents.
ASA IV patients have severe systemic disease that poses a constant threat to life, such as recent myocardial infarction or cerebrovascular accidents, ongoing cardiac ischemia or severe valve dysfunction, severe reduction of ejection fraction, sepsis, DIC, ARD, or ESRD not undergoing regularly scheduled dialysis. ASA V patients are moribund and not expected to survive without the operation, such as ruptured abdominal or thoracic aneurysm, massive trauma, intracranial bleed with mass effect, ischaemic bowel in the face of significant cardiac pathology, or multiple organ/system dysfunction. Finally, ASA VI patients are declared brain-dead and their organs are being removed for donor purposes.
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This question is part of the following fields:
- Surgery
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Question 20
Incorrect
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A 10-year-old boy with Down's syndrome, asthma, reflux, and hyperthyroidism is brought to the GP by his mother due to concerns about his chronic snoring. What could be the potential cause of his snoring based on his medical history?
Your Answer: Asthma
Correct Answer: Down's syndrome
Explanation:Children who have Down’s syndrome are susceptible to snoring due to their low muscle tone in the upper airways, large tongue/adenoids, and increased risk of obesity. On the other hand, gastroesophageal reflux disease is not connected to snoring, but it can worsen at night and cause coughing. Tonsillectomy is a common treatment for snoring as it eliminates enlarged tonsils that can obstruct the upper airway. Hypothyroidism, not hyperthyroidism, is linked to snoring.
Snoring in Children: Possible Causes
Snoring in children can be caused by various factors. One of the common causes is obesity, which can lead to the narrowing of the airways and difficulty in breathing during sleep. Another possible cause is nasal problems such as polyps, deviated septum, and hypertrophic nasal turbinates, which can also obstruct the airways and cause snoring. Recurrent tonsillitis can also contribute to snoring, as the inflamed tonsils can block the air passages.
In some cases, snoring in children may be associated with certain medical conditions such as Down’s syndrome and hypothyroidism. These conditions can affect the structure and function of the respiratory system, leading to snoring and other breathing difficulties.
It is important to identify the underlying cause of snoring in children and seek appropriate treatment to prevent potential health complications. Parents should consult a healthcare professional if their child snores regularly or experiences other symptoms such as daytime sleepiness, difficulty concentrating, or behavioral problems.
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This question is part of the following fields:
- Paediatrics
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Question 21
Incorrect
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A 28-year-old man visits his GP with complaints of poor memory. He works in a consulting company and recently faced trouble at work after missing a flight to a client in Tokyo. He has difficulty falling asleep and wakes up feeling exhausted. Sometimes he wakes up in the middle of the night screaming. When awake, he cannot relax and appears to be constantly on edge.
The patient has a history of attention-deficit hyperactivity disorder during childhood and one major depressive episode during his university years. He has not had any mental health-related complaints since then. He drinks one bottle of wine on Saturdays with his wife and admits to occasional past cocaine use. However, he stopped using cocaine after being ambushed and stabbed while dealing with a dealer during his last vacation in Thailand two months ago. His wife has recently complained that he appears emotionally unavailable.
Upon physical examination, no abnormalities are found. However, during the mental state examination, the patient exhibits low mood and an increased startle response. What is the most likely diagnosis?Your Answer:
Correct Answer: Post-traumatic stress disorder
Explanation:The individual is displaying common symptoms of PTSD, including re-experiencing the traumatic event through nightmares, avoiding triggers associated with the event, and experiencing hyperarousal such as hypervigilance and difficulty sleeping. It has been over a month since the traumatic event occurred, ruling out acute stress disorder. There are no signs of psychosis, and the individual has been sober from cocaine for two months. While anxiety is a symptom of PTSD, there is no indication of a generalized anxiety disorder or major depressive episode.
Understanding Post-Traumatic Stress Disorder (PTSD)
Post-traumatic stress disorder (PTSD) is a mental health condition that can develop in individuals of any age following a traumatic event. This can include experiences such as natural disasters, accidents, or even childhood abuse. PTSD is characterized by a range of symptoms, including re-experiencing the traumatic event through flashbacks or nightmares, avoidance of situations or people associated with the event, hyperarousal, emotional numbing, depression, and even substance abuse.
Effective management of PTSD involves a range of interventions, depending on the severity of the symptoms. Single-session interventions are not recommended, and watchful waiting may be used for mild symptoms lasting less than four weeks. Military personnel have access to treatment provided by the armed forces, while trauma-focused cognitive behavioral therapy (CBT) or eye movement desensitization and reprocessing (EMDR) therapy may be used in more severe cases.
It is important to note that drug treatments for PTSD should not be used as a routine first-line treatment for adults. If drug treatment is used, venlafaxine or a selective serotonin reuptake inhibitor (SSRI), such as sertraline, should be tried. In severe cases, NICE recommends that risperidone may be used. Overall, understanding the symptoms and effective management of PTSD is crucial in supporting individuals who have experienced traumatic events.
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This question is part of the following fields:
- Psychiatry
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Question 22
Incorrect
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A 50-year-old man presents to the emergency department with sudden onset pain in his loin-to-groin region. He reports having experienced similar pain in the past, but never to this extent. Upon arrival, the following observations are recorded:
- Blood pressure: 110/85 mmHg
- Heart rate: 119 bpm
- Temperature: 38.6ºC
- Oxygen saturation: 98% on air
- Respiratory rate: 22/min
What is the most likely diagnosis and what is the definitive management?Your Answer:
Correct Answer: IV antibiotics and urgent renal decompression
Explanation:The patient’s symptoms and observations suggest that they are suffering from ureteric colic caused by urinary calculi, which may be accompanied by an infection leading to sepsis. In such cases, urgent renal decompression and IV antibiotics are necessary. While fluid resuscitation may help manage ureteric colic, it is not sufficient when there are signs of infection, and inpatient management is required. Although oral fluids, IV antibiotics, and analgesia may provide some relief, urgent renal decompression is the definitive treatment. While NSAIDs may be helpful in managing ureteric colic, they cannot be the sole treatment when there is an infection. Rectal diclofenac is often the preferred NSAID. An urgent nephrectomy is not necessary 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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Question 23
Incorrect
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A 67-year-old male who has been on long term chlorpromazine presents with repetitive eye blinking. He is concerned about the cause of this symptom and reports being unable to control it. He has no visual disturbance and is otherwise in good health. Upon examination, he has a normal facial and ocular appearance except for excessive rapid blinking. What is the probable reason for his symptoms?
Your Answer:
Correct Answer: Tardive dyskinesia
Explanation:The correct term for the condition described in the stem is tardive dyskinesia. This is a late onset side effect of conventional antipsychotics, such as chlorpromazine, which causes abnormal involuntary movements. Patients may exhibit symptoms such as lip-smacking, jaw pouting, chewing, or repetitive blinking. Unfortunately, this condition is often difficult to treat, but replacing the antipsychotic or trying tetrabenazine may provide some relief.
Parkinsonism is another potential side effect of conventional antipsychotics, but it presents with symptoms similar to Parkinson’s disease, such as tremors, blank facies, bradykinesia, and muscle rigidity. Dry eyes or Sjogren’s syndrome may cause eye twitching, but they are unlikely to cause repetitive blinking. Blepharospasm is a condition characterized by involuntary twitching or contraction of the eyelid, which may be caused by stress or fatigue. However, given the patient’s use of chlorpromazine, tardive dyskinesia is the most likely diagnosis.
Antipsychotics are a group of drugs used to treat schizophrenia, psychosis, mania, and agitation. They are divided into two categories: typical and atypical antipsychotics. The latter were developed to address the extrapyramidal side-effects associated with the first generation of typical antipsychotics. Typical antipsychotics work by blocking dopaminergic transmission in the mesolimbic pathways through dopamine D2 receptor antagonism. They are associated with extrapyramidal side-effects and hyperprolactinaemia, which are less common with atypical antipsychotics.
Extrapyramidal side-effects (EPSEs) are common with typical antipsychotics and include Parkinsonism, acute dystonia, sustained muscle contraction, akathisia, and tardive dyskinesia. The latter is a late onset of choreoathetoid movements that may be irreversible and occur in 40% of patients. The Medicines and Healthcare products Regulatory Agency has issued specific warnings when antipsychotics are used in elderly patients, including an increased risk of stroke and venous thromboembolism. Other side-effects include antimuscarinic effects, sedation, weight gain, raised prolactin, impaired glucose tolerance, neuroleptic malignant syndrome, reduced seizure threshold, and prolonged QT interval.
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This question is part of the following fields:
- Psychiatry
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Question 24
Incorrect
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A 14-year-old girl is brought to the Emergency Department by her mother, who found her on the bathroom floor. She is ataxic, appears confused and her speech is slurred, however she does not smell of alcohol. She says she 'took something' because she wanted to end her life. She has vomited twice.
On the blood gas, there is a metabolic acidosis.
What is the most appropriate treatment for this situation?Your Answer:
Correct Answer: Fomepizole
Explanation:Fomepizole is an effective treatment for ethylene glycol toxicity as it inhibits alcohol dehydrogenase, slowing down the production of toxic metabolites. Ethanol can also be used if fomepizole is not available. Symptoms of ethylene glycol poisoning include ataxia, vomiting, dysarthria, and metabolic acidosis with a raised anion gap. In severe cases, convulsions and coma can occur. Atropine is used to treat organophosphate poisoning, which can cause anxiety, restlessness, headache, muscle weakness, respiratory failure, and bronchospasm with bronchial secretions. Flumazenil is used to treat benzodiazepine overdose, which can cause drowsiness, dizziness, ataxia, coma, and respiratory depression. Glucagon is used to treat beta blocker overdose, which can cause sinus bradycardia, hypotension, and coma.
Understanding Ethylene Glycol Toxicity and Its Management
Ethylene glycol is a type of alcohol commonly used as a coolant or antifreeze. Its toxicity is characterized by three stages of symptoms. The first stage is similar to alcohol intoxication, with confusion, slurred speech, and dizziness. The second stage involves metabolic acidosis with high anion gap and high osmolar gap, as well as tachycardia and hypertension. The third stage is acute kidney injury.
In the past, ethanol was the primary treatment for ethylene glycol toxicity. It works by competing with ethylene glycol for the enzyme alcohol dehydrogenase, which limits the formation of toxic metabolites responsible for the haemodynamic and metabolic features of poisoning. However, in recent times, fomepizole, an inhibitor of alcohol dehydrogenase, has become the first-line treatment preference over ethanol. Haemodialysis also has a role in refractory cases.
Overall, understanding the stages of ethylene glycol toxicity and the changing management options is crucial for healthcare professionals to provide effective treatment and prevent further harm to patients.
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This question is part of the following fields:
- Pharmacology
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Question 25
Incorrect
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A 55-year-old man visits his optometrist for a check-up. He has hyperopia and his current prescription is +3/+3.25 without any astigmatism or myopia. What is the primary eye condition that this patient is susceptible to with his present eye condition?
Your Answer:
Correct Answer: Acute angle-closure glaucoma
Explanation:Hypermetropia is linked to acute angle-closure glaucoma, while myopia is associated with primary open-angle glaucoma. This is because those with hypermetropia have smaller eyes, shallower anterior chambers, and narrower angles. The connection between myopia and primary open-angle glaucoma is not as clear, but it may be due to the optic nerve head being more vulnerable to damage from increased intraocular pressure. Cataracts are commonly linked to aging and severe short-sightedness, while central retinal artery occlusion is associated with aneurysms, arterial disease, and emboli.
Glaucoma is a condition where the optic nerve is damaged due to increased pressure in the eye. Primary open-angle glaucoma (POAG) is a type of glaucoma where the peripheral iris is clear of the trabecular meshwork, which is important in draining aqueous humour from the eye. POAG is more common in older individuals and those with a family history of the condition. It may present insidiously with symptoms such as peripheral visual field loss, decreased visual acuity, and optic disc cupping. Diagnosis is made through a series of investigations including automated perimetry, slit lamp examination, applanation tonometry, central corneal thickness measurement, and gonioscopy. It is important to assess the risk of future visual impairment based on factors such as IOP, CCT, family history, and life expectancy. Referral to an ophthalmologist is typically done through a GP.
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This question is part of the following fields:
- Ophthalmology
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Question 26
Incorrect
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A 56-year-old man presents to the Emergency Department with chest pain. He has a medical history of angina, hypertension, high cholesterol, and is a current smoker. Upon arrival, a 12-lead electrocardiogram (ECG) is conducted, revealing ST elevation in leads II, III, and aVF. Which coronary artery is most likely responsible for this presentation?
Your Answer:
Correct Answer: Right coronary artery
Explanation:ECG Changes and Localisation of Infarct in Coronary Artery Disease
Patients with chest pain and multiple risk factors for cardiac disease require prompt evaluation to determine the underlying cause. Electrocardiogram (ECG) changes can help localise the infarct to a particular territory, which can aid in diagnosis and treatment.
Inferior infarcts are often due to lesions in the right coronary artery, as evidenced by ST elevation in leads II, III, and aVF. However, in 20% of cases, this can also be caused by an occlusion of a dominant left circumflex artery.
Lateral infarcts involve branches of the left anterior descending (LAD) and left circumflex arteries, and are characterised by ST elevation in leads I, aVL, and V5-6. It is unusual for a lateral STEMI to occur in isolation, and it usually occurs as part of a larger territory infarction.
Anterior infarcts are caused by blockage of the LAD artery, and are characterised by ST elevation in leads V1-V6.
Blockage of the right marginal artery does not have a specific pattern of ECG changes associated with it, and it is not one of the major coronary vessels.
In summary, understanding the ECG changes associated with different coronary arteries can aid in localising the infarct and guiding appropriate treatment.
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This question is part of the following fields:
- Cardiology
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Question 27
Incorrect
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A 25-year-old man presents to the Emergency Department complaining of chest pain. He admits to snorting 'a large amount' of cocaine in the past few hours. What is the most likely feature that his cocaine use will cause?
Your Answer:
Correct Answer: Hyperthermia
Explanation:Understanding Cocaine Toxicity
Cocaine is a popular recreational stimulant derived from the coca plant. However, its widespread use has resulted in an increase in cocaine toxicity cases. The drug works by blocking the uptake of dopamine, noradrenaline, and serotonin, leading to a variety of adverse effects.
Cardiovascular effects of cocaine include coronary artery spasm, tachycardia, bradycardia, hypertension, QRS widening, QT prolongation, and aortic dissection. Neurological effects may include seizures, mydriasis, hypertonia, and hyperreflexia. Psychiatric effects such as agitation, psychosis, and hallucinations may also occur. Other complications include ischaemic colitis, hyperthermia, metabolic acidosis, and rhabdomyolysis.
Managing cocaine toxicity involves using benzodiazepines as a first-line treatment for most cocaine-related problems. For chest pain, benzodiazepines and glyceryl trinitrate may be used, and primary percutaneous coronary intervention may be necessary if myocardial infarction develops. Hypertension can be treated with benzodiazepines and sodium nitroprusside. The use of beta-blockers in cocaine-induced cardiovascular problems is controversial, with some experts warning against it due to the risk of unopposed alpha-mediated coronary vasospasm.
In summary, cocaine toxicity can lead to a range of adverse effects, and managing it requires careful consideration of the patient’s symptoms and medical history.
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This question is part of the following fields:
- Pharmacology
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Question 28
Incorrect
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Which hormone is responsible for the excess in Cushing's disease?
Your Answer:
Correct Answer: Adrenocorticotrophic hormone (ACTH)
Explanation:Cushing’s Disease
Cushing’s disease is a condition characterized by excessive cortisol production due to adrenal hyperfunction caused by an overproduction of ACTH from a pituitary corticotrophin adenoma. This results in both adrenal glands producing more cortisol and cortisol precursors. It is important to differentiate between primary and secondary hypercortisolaemia, which can be done by measuring ACTH levels in the blood. If ACTH levels are not suppressed, it indicates secondary hypercortisolaemia, which is driven by either pituitary or ectopic ACTH production. the underlying cause of hypercortisolaemia is crucial in determining the appropriate treatment plan for individuals with Cushing’s disease.
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This question is part of the following fields:
- Endocrinology
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Question 29
Incorrect
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A 38-year-old office worker is becoming increasingly worried that she may be experiencing early signs of Alzheimer's disease, which her mother was diagnosed with at a young age. She reports frequently misplacing her phone and struggling to recall names of colleagues she has worked with for years. She wants to learn more about the initial clinical features of the disease to see if they align with her symptoms.
What is a typical clinical characteristic of the early stage of Alzheimer's disease?Your Answer:
Correct Answer: Retention of executive function
Explanation:Understanding Different Types of Dementia and Their Symptoms
Executive function, which involves planning, reasoning, and problem-solving, is typically retained in the early stages of Alzheimer’s disease. However, in subcortical dementias like Lewy body disease (LBD), patients often lose this cognitive skill early on. Frontotemporal dementia, on the other hand, is more commonly associated with impulsivity and disinhibition, as well as personality changes. Episodic confusion is a hallmark of LBD, where patients may have good and bad days. Finally, bradykinesia and rigidity are signs of parkinsonism, which can be seen in both LBD and Parkinson’s disease. Understanding these different symptoms can help with early diagnosis and appropriate treatment.
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This question is part of the following fields:
- Neurology
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Question 30
Incorrect
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A 40-year-old man with known human immunodeficiency virus (HIV) presents to the Emergency Department with a 3-day history of worsening shortness of breath. He also has a fever and mentions the presence of a non-productive cough which has been getting worse over the past week.
On examination, the patient is febrile with a temperature of 38.2 oC, pulse is 92 bpm and regular, and his blood pressure is 110/85 mmHg.
The patient seems breathless at rest, with an oxygen saturation of 96% in room air. However, a chest examination reveals no abnormalities. The examining doctor orders tests, including a CD4 count, arterial blood gases (ABGs), and a chest X-ray; she lists Pneumocystis jirovecii pneumonia (PJP) as one of the possible differential diagnoses.
With regard to PJP, which of the following statements is true?Your Answer:
Correct Answer: Can be successfully treated with co-trimoxazole
Explanation:Understanding Pneumocystis Jirovecii Pneumonia (PJP)
Pneumocystis jirovecii pneumonia (PJP) is a fungal infection that primarily affects individuals with weakened immune systems. It is commonly seen in HIV patients with a CD4 count of less than 200, but can also occur in other immunosuppressive states. Symptoms include fever, dry cough, and progressive shortness of breath. Diagnosis can be challenging, and a high level of suspicion is required. While an abnormal chest radiograph is present in 90% of patients, blood culture is not a reliable diagnostic tool as pneumocystis cannot be cultured. Treatment involves the use of co-trimoxazole or pentamidine. Prophylaxis against PJP is recommended when CD4 counts fall below 200 cells/µl. It is important to note that while PJP is more common in HIV patients, it can also occur in individuals with other immunocompromising conditions.
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This question is part of the following fields:
- Microbiology
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