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  • Question 1 - Which one of the following statements regarding macular degeneration is true? ...

    Incorrect

    • Which one of the following statements regarding macular degeneration is true?

      Your Answer: Drusen are characteristic of wet macular degeneration

      Correct Answer: Wet macular degeneration carries the worst prognosis

      Explanation:

      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.

    • This question is part of the following fields:

      • Ophthalmology
      22.8
      Seconds
  • Question 2 - A 67-year-old woman visits her GP with complaints of constipation that has been...

    Incorrect

    • A 67-year-old woman visits her GP with complaints of constipation that has been ongoing for a month. She requests medication to alleviate the symptoms. The patient reports feeling more fatigued than usual and has noticed recent weight gain. During the examination, the GP observes dry scaly skin. The patient's medical history indicates recent consultation with an endocrinologist.
      What would lead to elevated thyroid-stimulating hormone (TSH) levels and normal T4 in this case?

      Your Answer: Thyrotoxicosis

      Correct Answer: Poor compliance with thyroxine

      Explanation:

      Understanding Thyroid Disorders: Differentiating Poor Compliance with Thyroxine from Other Conditions

      Thyroid disorders can present with a variety of symptoms, making it important to differentiate between different conditions. In the case of poor compliance with thyroxine medication, a patient may present with signs of a low thyroid state, but blood results will show a high TSH and normal T4, indicating recent medication use.

      Primary hypothyroidism, on the other hand, would show a low T4 and high TSH, while thyrotoxicosis would reveal a low TSH and high T4, accompanied by symptoms such as tachycardia and tremors. Secondary hypothyroidism would present with low levels of both T4 and TSH, indicating a pituitary problem.

      Sick euthyroid syndrome, which often occurs in individuals with systemic illness, would show low levels of TSH, thyroxine, and T3, but the TSH level may still be within the normal range. Understanding these differences can help healthcare professionals make accurate diagnoses and provide appropriate treatment.

    • This question is part of the following fields:

      • Endocrinology
      83.3
      Seconds
  • Question 3 - A 40-year-old woman presents to your clinic with complaints of difficulty reading, which...

    Incorrect

    • A 40-year-old woman presents to your clinic with complaints of difficulty reading, which she has noticed over the past two weeks. She has never worn glasses and is not taking any medications.

      Upon examination, her pupils are of normal size but react sluggishly to light. Both optic discs appear sharp, without signs of haemorrhages or exudates. However, her visual acuity is significantly impaired and remains so even when using a pinhole card. Additionally, she exhibits five-beat nystagmus and double vision when looking to the left.

      What is the most likely diagnosis for this patient?

      Your Answer: Pseudotumour cerebri

      Correct Answer: Multiple sclerosis

      Explanation:

      Possible Diagnosis of Multiple Sclerosis in a Young Woman

      This young woman shows signs of retrobulbar neuritis, which is characterized by inflammation of the optic nerve behind the eye. Additionally, she exhibits some cerebellar features such as nystagmus, which is an involuntary eye movement. These symptoms suggest a possible diagnosis of Multiple sclerosis (MS), a chronic autoimmune disease that affects the central nervous system.

      Further diagnostic tests can support this diagnosis. Visual evoked responses can measure the electrical activity in the brain in response to visual stimuli, which can be abnormal in MS. Magnetic resonance imaging (MRI) can reveal demyelinating plaques, or areas of damage to the protective covering of nerve fibers in the brain and spinal cord. Finally, oligoclonal bands can be detected in the cerebrospinal fluid (CSF) of MS patients, indicating an immune response in the central nervous system.

      In summary, this young woman’s symptoms and diagnostic tests suggest a possible diagnosis of MS. Further evaluation and treatment by a healthcare professional are necessary to confirm this diagnosis and manage her symptoms.

    • This question is part of the following fields:

      • Neurology
      8.9
      Seconds
  • Question 4 - A 32-year-old woman, a mother of three, comes to see you on day...

    Incorrect

    • A 32-year-old woman, a mother of three, comes to see you on day 20 postpartum and asks for contraception. She is currently alternating between breastfeeding and bottle-feeding her newborn, struggling with sleepless nights, and wants a referral for Fallopian tube ligation as she explains that, at present, she does not want any other children. She is a smoker.
      Which of the following is the best method of contraception in this patient?

      Your Answer: Intrauterine system

      Correct Answer: Progesterone-only pill

      Explanation:

      Contraception Options for Postpartum Women: A Guide for Healthcare Providers

      Postpartum women have unique contraceptive needs and considerations. In this guide, we will discuss the various contraception options available for postpartum women and their suitability based on individual circumstances.

      Progesterone-Only Pill

      The progesterone-only pill is a safe option for women who are breastfeeding and < six weeks postpartum. It can be started immediately after delivery and is the first-line management for women who cannot take the combined oral contraceptive pill (COCP). The pill thickens mucous, preventing sperm from entering the uterus, and suppresses ovulation. However, compliance can be an issue, and long-acting progesterone contraceptives may be more appropriate. Combined Oral Contraceptive Pill (COCP) The COCP should not be used before six weeks postpartum in breastfeeding women and before 21 days in non-breastfeeding women. A risk assessment should be performed, and contraindications, such as smoking and age over 35, should be considered. Intrauterine System The intrauterine system is a highly effective long-acting reversible contraceptive that can be inserted at the time of delivery or within the first 48 hours postpartum. Delayed insertion until after four weeks postpartum is recommended to reduce the risk of uterine perforation. No Contraception Required Breastfeeding can suppress ovulation, but if a woman is not exclusively breastfeeding, contraception should be offered. The patient’s wishes should be established, and contraception should be discussed at the 6-week postpartum check. Tubal Ligation (Sterilisation) Tubal ligation is a permanent form of contraception that should not be considered until after six weeks postpartum. The patient should be counselled regarding the risks and benefits, the low success of reversibility, and the possibility of future desire for children. Male sterilisation should be considered first, and both partners should be present for the consultation. In conclusion, healthcare providers should consider individual circumstances and preferences when discussing contraception options with postpartum women. A thorough risk assessment and counselling should be performed before recommending any form of contraception.

    • This question is part of the following fields:

      • Sexual Health
      34.1
      Seconds
  • Question 5 - A 52-year-old man visits his GP with complaints of burning during urination and...

    Incorrect

    • A 52-year-old man visits his GP with complaints of burning during urination and swelling in the groin area. He also reports experiencing penile discharge and pain in the groin. He has been sexually active with his wife for the past 6 years.

      During the examination, his heart rate is 91/min, respiratory rate is 15/min, blood pressure is 129/84 mmHg, and temperature is 38.3ºC. The patient experiences pain in his right testicle, which is relieved by elevating the scrotum.

      What is the most likely organism responsible for his symptoms?

      Your Answer: Neisseria gonorrhoeae

      Correct Answer: Escherichia coli

      Explanation:

      Epididymo-orchitis in individuals with a low risk of sexually transmitted infections (such as a married male in his 50s with only one sexual partner, his wife) is most likely caused by enteric organisms, specifically Escherichia coli. This is evidenced by the patient’s symptoms of unilateral testicular pain, tenderness, and swelling, as well as dysuria and relief of pain when the testicle is raised. While Enterococcus faecalis is also a possible causative organism, E. coli is more common in older patients with low-risk sexual histories. Chlamydia trachomatis and Neisseria gonorrhoeae are less likely causes, as they are more commonly associated with epididymo-orchitis in younger patients with high-risk sexual histories.

      Epididymo-orchitis is a condition where the epididymis and/or testes become infected, leading to pain and swelling. It is commonly caused by infections spreading from the genital tract or bladder, with Chlamydia trachomatis and Neisseria gonorrhoeae being the usual culprits in sexually active younger adults, while E. coli is more commonly seen in older adults with a low-risk sexual history. Symptoms include unilateral testicular pain and swelling, with urethral discharge sometimes present. Testicular torsion, which can cause ischaemia of the testicle, is an important differential diagnosis and needs to be excluded urgently, especially in younger patients with severe pain and an acute onset.

      Investigations are guided by the patient’s age, with sexually transmitted infections being assessed in younger adults and a mid-stream urine (MSU) being sent for microscopy and culture in older adults with a low-risk sexual history. Management guidelines from the British Association for Sexual Health and HIV (BASHH) recommend ceftriaxone 500 mg intramuscularly as a single dose, plus doxycycline 100 mg orally twice daily for 10-14 days if the organism causing the infection is unknown. Further investigations are recommended after treatment to rule out any underlying structural abnormalities.

    • This question is part of the following fields:

      • Surgery
      53.5
      Seconds
  • Question 6 - A 68-year-old man is seen in the Cardiology Clinic. He has been on...

    Incorrect

    • A 68-year-old man is seen in the Cardiology Clinic. He has been on a cardiac glycoside for atrial fibrillation for a while. The cardiologist is worried about the medication's toxicity and wants to switch to a different one.
      What aspect of this medication is causing the most concern for the cardiologist?

      Your Answer: High protein binding

      Correct Answer: Narrow therapeutic index

      Explanation:

      Digoxin is a medication used to treat atrial fibrillation, but it has a narrow therapeutic index, meaning that even small changes in dosage or interactions with other medications can cause harmful side effects. Other drugs with a narrow therapeutic index include lithium, gentamicin, and vancomycin. High protein binding is also important in toxicology, as medications can compete for the same binding sites, leading to increased levels of free medication in the body. Amiodarone, if used long-term, can cause pulmonary toxicity, limiting its use in younger patients who may require it for extended periods. Variable first-pass metabolism can make it difficult to determine the appropriate dosage for a desired drug concentration, as the amount of drug metabolized can vary. Propranolol is an example of a drug affected by variable first-pass metabolism. Finally, zero-order kinetics refers to a constant rate of drug metabolism that is not related to drug concentration. Drugs affected by zero-order kinetics include phenytoin and ethanol.

    • This question is part of the following fields:

      • Pharmacology
      22.5
      Seconds
  • Question 7 - A 7-year-old girl is brought to the pediatrician by her father. For the...

    Incorrect

    • A 7-year-old girl is brought to the pediatrician by her father. For the past few days, she has been experiencing pain while walking. Her father is concerned as this has never happened before and he cannot think of any reason for it.
      During the examination, the girl refuses to walk. Her vital signs are stable, except for a temperature of 38ºC. On examining her legs, there is no visible inflammation, but the left hip is tender. When attempting to move the left leg, the child screams in pain. The right leg appears to be normal. She has no medical history and is not taking any medications.
      What is the most appropriate management for the most likely diagnosis?

      Your Answer: Arrange urgent orthopaedic outpatient appointment

      Correct Answer: Advise to attend the emergency department

      Explanation:

      If a child is experiencing hip pain or a limp and has a fever, it is important to refer them for same-day assessment, even if the suspected diagnosis is transient synovitis.

      The correct course of action in this case is to advise the patient to attend the emergency department. Although the patient appears to be well, the presence of a fever raises concerns about septic arthritis, which can cause long-term complications. Further investigations cannot be performed in a general practice setting, making it necessary to seek urgent medical attention.

      Advising the patient to attend a local minor injury unit is not appropriate, as the staff there would most likely transfer the patient to an emergency department, causing unnecessary delays. Similarly, arranging an urgent orthopaedic outpatient appointment is not appropriate in this acute situation.

      Prescribing aspirin and providing a safety net is not a suitable option, as aspirin should never be given to children due to the risk of Reye’s syndrome. It is also unwise to exclude septic arthritis without further supporting evidence.

      Finally, growing pains are an unlikely diagnosis in this case, as they are typically bilateral and do not interfere with daily activities.

      Transient synovitis, also known as irritable hip, is a common cause of hip pain in children aged 3-8 years. It typically occurs following a recent viral infection and presents with symptoms such as groin or hip pain, limping or refusal to weight bear, and occasionally a low-grade fever. However, a high fever may indicate other serious conditions such as septic arthritis, which requires urgent specialist assessment. To exclude such diagnoses, NICE Clinical Knowledge Summaries recommend monitoring children in primary care with a presumptive diagnosis of transient synovitis, provided they are aged 3-9 years, well, afebrile, mobile but limping, and have had symptoms for less than 72 hours. Treatment for transient synovitis involves rest and analgesia, as the condition is self-limiting.

    • This question is part of the following fields:

      • Paediatrics
      23.4
      Seconds
  • Question 8 - A 65-year-old male who recently had cardiac surgery is experiencing symptoms of fever,...

    Correct

    • A 65-year-old male who recently had cardiac surgery is experiencing symptoms of fever, fatigue, and weight loss. After being discharged following a successful mitral valve replacement 6 months ago, an urgent echocardiogram is conducted and reveals a new valvular lesion, leading to a diagnosis of endocarditis. To confirm the diagnosis, three sets of blood cultures are collected. What is the most probable organism responsible for the patient's condition?

      Your Answer: Staphylococcus aureus

      Explanation:

      The most common cause of infective endocarditis is Staphylococcus aureus, especially in acute presentations and among intravenous drug users. However, if the patient has undergone valve replacement surgery more than 2 months ago, the spectrum of organisms causing endocarditis returns to normal, making Staphylococcus epidermidis less likely. While Streptococcus bovis can also cause endocarditis, it is not as common as Staphylococcus aureus and is associated with colon cancer. Staphylococcus epidermidis is the most common cause of endocarditis within 2 months post-valvular surgery. On the other hand, Streptococcus mitis, a viridans streptococcus found in the mouth, is associated with endocarditis following dental procedures or in patients with poor dental hygiene.

      Aetiology of Infective Endocarditis

      Infective endocarditis is a condition that affects patients with previously normal valves, rheumatic valve disease, prosthetic valves, congenital heart defects, intravenous drug users, and those who have recently undergone piercings. The strongest risk factor for developing infective endocarditis is a previous episode of the condition. The mitral valve is the most commonly affected valve.

      The most common cause of infective endocarditis is Staphylococcus aureus, particularly in acute presentations and intravenous drug users. Historically, Streptococcus viridans was the most common cause, but this is no longer the case except in developing countries. Streptococcus mitis and Streptococcus sanguinis are the two most notable viridans streptococci, commonly found in the mouth and dental plaque. Coagulase-negative Staphylococci such as Staphylococcus epidermidis are the most common cause of endocarditis in patients following prosthetic valve surgery.

      Streptococcus bovis is associated with colorectal cancer, with the subtype Streptococcus gallolyticus being most linked to the condition. Non-infective causes of endocarditis include systemic lupus erythematosus and malignancy. Culture negative causes may be due to prior antibiotic therapy or infections caused by Coxiella burnetii, Bartonella, Brucella, or HACEK organisms (Haemophilus, Actinobacillus, Cardiobacterium, Eikenella, Kingella).

    • This question is part of the following fields:

      • Medicine
      25.8
      Seconds
  • Question 9 - When do most children begin to say mama and dada? Is there a...

    Correct

    • When do most children begin to say mama and dada? Is there a typical age range for this milestone?

      Your Answer: 9-10 months

      Explanation:

      Developmental milestones for speech and hearing are important indicators of a child’s growth and development. These milestones can help parents and caregivers track a child’s progress and identify any potential issues early on. At three months, a baby should be able to quieten to their parents’ voice and turn towards sound. They may also start to squeal. By six months, they should be able to produce double syllables like adah and erleh. At nine months, they may say mama and dada and understand the word no. By 12 months, they should know and respond to their own name and understand simple commands like give it to mummy.

      Between 12 and 15 months, a child may know about 2-6 words and understand more complex commands. By two years old, they should be able to combine two words and point to parts of their body. Their vocabulary should be around 200 words by 2 1/2 years old. At three years old, they should be able to talk in short sentences and ask what and who questions. They may also be able to identify colors and count to 10. By four years old, they may start asking why, when, and how questions. These milestones are important to keep in mind as a child grows and develops their speech and hearing abilities.

    • This question is part of the following fields:

      • Paediatrics
      23.8
      Seconds
  • Question 10 - A 65-year-old woman with a history of depression and non-paroxysmal atrial fibrillation is...

    Correct

    • A 65-year-old woman with a history of depression and non-paroxysmal atrial fibrillation is brought to the emergency department by her daughter after being found unconscious with an empty bottle of medication. She is disoriented and complains of feeling nauseous. Shortly after arriving at the hospital, she experiences visual hallucinations and yellowing of her vision.

      The patient denies smoking or substance abuse and leads a sedentary lifestyle. On examination, her pulse is irregular with a rate of 70 beats per minute, blood pressure is 110/70 mmHg, and respiratory rate is 18 breaths per minute. An ECG shows frequent premature ventricular contractions and ventricular bigeminy.

      What is the most likely diagnosis, and what management should be implemented for this patient?

      Your Answer: Administer digoxin-specific antibody fab fragments (Digibind) intravenously

      Explanation:

      In cases of non-paroxysmal atrial fibrillation with a sedentary lifestyle, digoxin monotherapy is recommended as the first line treatment according to NICE guidelines from 2014. However, if a patient experiences severe digoxin toxicity due to an overdose with suicidal intention, Digibind, which contains digoxin-specific antibody fab fragments, is the recognized antidote. Symptoms of digoxin toxicity include gastrointestinal issues, visual disturbances, cardiovascular problems, and central nervous system complications. N-acetylcysteine is used as an antidote for paracetamol overdose, while naloxone and diazepam are used for opioid overdose and alcohol withdrawal, respectively. Cardioversion should be avoided if possible due to the risk of asystole, and if necessary, the lowest energy possible should be used.

      Understanding Digoxin and Its Toxicity

      Digoxin is a medication used for rate control in atrial fibrillation and for improving symptoms in heart failure patients. It works by decreasing conduction through the atrioventricular node and increasing the force of cardiac muscle contraction. However, it has a narrow therapeutic index and requires monitoring for toxicity.

      Toxicity may occur even when the digoxin concentration is within the therapeutic range. Symptoms of toxicity include lethargy, nausea, vomiting, anorexia, confusion, yellow-green vision, arrhythmias, and gynaecomastia. Hypokalaemia is a classic precipitating factor, as it allows digoxin to more easily bind to the ATPase pump and increase its inhibitory effects. Other factors that may contribute to toxicity include increasing age, renal failure, myocardial ischaemia, electrolyte imbalances, hypoalbuminaemia, hypothermia, hypothyroidism, and certain medications such as amiodarone, quinidine, and verapamil.

      Management of digoxin toxicity involves the use of Digibind, correction of arrhythmias, and monitoring of potassium levels. It is important to recognize the potential for toxicity and monitor patients accordingly to prevent adverse outcomes.

    • This question is part of the following fields:

      • Pharmacology
      84.6
      Seconds

SESSION STATS - PERFORMANCE PER SPECIALTY

Ophthalmology (0/1) 0%
Endocrinology (0/1) 0%
Neurology (0/1) 0%
Sexual Health (0/1) 0%
Surgery (0/1) 0%
Pharmacology (1/2) 50%
Paediatrics (1/2) 50%
Medicine (1/1) 100%
Passmed