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Question 1
Incorrect
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A 59 year old female visits her GP with complaints of fatigue and body aches. Upon further inquiry, the patient reports feeling increasingly tired for the past several months and experiencing joint and muscle pains. Her medical history indicates chronic heart failure, which is being treated with isosorbide dinitrate and hydralazine. As hydralazine can lead to drug-induced lupus, what investigation would be most helpful in confirming this diagnosis?
Your Answer: Alkaline phosphatase (ALP)
Correct Answer: Anti-histone antibodies
Explanation:ALP can be rewritten as alkaline phosphatase.
Understanding Drug-Induced Lupus
Drug-induced lupus is a condition that shares some similarities with systemic lupus erythematosus, but not all of its typical features are present. Unlike SLE, renal and nervous system involvement is rare in drug-induced lupus. The good news is that this condition usually resolves once the drug causing it is discontinued.
The most common symptoms of drug-induced lupus include joint pain, muscle pain, skin rashes (such as the malar rash), and pulmonary issues like pleurisy. In terms of laboratory findings, patients with drug-induced lupus typically test positive for ANA (antinuclear antibodies) but negative for dsDNA (double-stranded DNA) antibodies. Anti-histone antibodies are found in 80-90% of cases, while anti-Ro and anti-Smith antibodies are only present in around 5% of cases.
The most common drugs that can cause drug-induced lupus are procainamide and hydralazine. Other less common culprits include isoniazid, minocycline, and phenytoin.
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This question is part of the following fields:
- Musculoskeletal
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Question 2
Correct
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A 16-year-old girl presents with a 24-hour history of pain in the right iliac fossa. A pregnancy test is negative and bloods show a raised white cell count. Her parents tell you she has had a ‘cold’ for the past week. She also began to suffer from headaches two days before the pain.
The girl is taken to theatre for a laparoscopic appendicectomy. However, during the operation, the appendix is found to be completely normal.
How should the surgical team proceed?Your Answer: Remove the appendix anyway
Explanation:Mesenteric Lymphadenitis and the Role of Appendicectomy
Mesenteric lymphadenitis is a common condition in children and adolescents that causes inflammation of the lymph nodes in the mesentery. It is typically associated with a recent cold or infection, and can present with abdominal pain, fever, and a raised white cell count. While it can be difficult to diagnose, it responds well to antibiotics.
In some cases, mesenteric lymphadenitis can mimic the symptoms of acute appendicitis, making it difficult to distinguish between the two. In such cases, even if the appendix appears normal, it may be beneficial to remove it anyway. This can prevent the patient from developing acute appendicitis in the future, which can be life-threatening if it ruptures prior to hospitalization. Additionally, removing the appendix can protect the patient from certain cancers that originate in the appendix.
While a laparotomy may be necessary to explore the rest of the abdomen in some cases, a skilled surgeon can often rule out other causes of pain laparoscopically. It is important to consider the possibility of mesenteric lymphadenitis when working through the differential diagnosis of right iliac fossa pain.
In conclusion, mesenteric lymphadenitis is a common condition that can mimic the symptoms of acute appendicitis. While it can be difficult to diagnose, it responds well to antibiotics. In cases where the appendix appears normal, it may still be beneficial to remove it to prevent future complications. A skilled surgeon can often explore the abdomen laparoscopically to rule out other causes of pain.
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This question is part of the following fields:
- Colorectal
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Question 3
Correct
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A 28-year-old woman with type 1 diabetes comes in for her yearly check-up. During the examination, her urine test shows positive results for protein. Upon reviewing her medical records, it is discovered that this is the first time she has had proteinuria. What further tests should be conducted to investigate this finding?
Your Answer: ACR (albumin:creatinine ratio) and microbiology
Explanation:Investigating Proteinuria in Diabetic Patients
Proteinuria or microalbuminuria is a significant finding in diabetic patients. It indicates an increased risk of developing diabetic nephropathy in type 1 diabetes and an additional risk factor for cardiovascular disease in type 2 diabetes. When a diabetic patient presents with proteinuria, it is crucial to rule out infection, which is a common cause of increased urinary protein excretion. A urine microbiology test can identify the presence of infection, while an albumin-to-creatinine ratio (ACR) can quantify the degree of proteinuria and allow for future monitoring. Although HbA1c, serum urea/creatinine, and plasma glucose are standard tests for monitoring diabetic patients, they do not help quantify urinary protein loss or exclude infection. A high HbA1c in this situation could indicate longstanding poor glycemic control or poor glycemic control for several weeks due to infection. Therefore, ACR and urine microbiology are the most useful investigations to investigate proteinuria in diabetic patients.
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This question is part of the following fields:
- Nephrology
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Question 4
Incorrect
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A 28-year-old woman presents for guidance as she has just discovered she is expecting her first child. She has a family history of diabetes (mother, aunt, grandmother). Apart from taking folic acid, she is healthy and not on any regular medications. What screening should be recommended to her?
Your Answer: Oral glucose tolerance test (OGTT) at 16-20 weeks
Correct Answer: Oral glucose tolerance test (OGTT) at 24-28 weeks
Explanation:Gestational diabetes is a common medical disorder affecting around 4% of pregnancies. Risk factors include a high BMI, previous gestational diabetes, and family history of diabetes. Screening is done through an oral glucose tolerance test, and diagnostic thresholds have recently been updated. Management includes self-monitoring of blood glucose, diet and exercise advice, and medication if necessary. For pre-existing diabetes, weight loss and insulin are recommended, and tight glycemic control is important. Targets for self-monitoring include fasting glucose of 5.3 mmol/l and 1-2 hour post-meal glucose levels.
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This question is part of the following fields:
- Obstetrics
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Question 5
Incorrect
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A 57-year-old man comes to the emergency department complaining of sudden visual loss. He reports no eye redness, ocular trauma, or headaches. The loss of vision began from the outside and progressed inward, accompanied by flashes and floaters. He wears corrective glasses and sometimes contact lenses, but he cannot recall his prescription. What characteristic raises the likelihood of this patient developing this condition?
Your Answer: Astigmatism
Correct Answer: Myopia
Explanation:Myopia increases the likelihood of retinal detachment, which should be suspected if a patient experiences gradual vision loss starting from the periphery and moving towards the centre. This may be accompanied by the sensation of a curtain or veil descending over their vision, preceded by flashes and floaters caused by the vitreous humour tugging at the retina. Myopia elongates the eyeball, stretching the retina and making it more susceptible to tearing and detachment. Astigmatism, a refractive error caused by an irregularly shaped eyeball, does not increase the risk of RD. Contact lens use is not associated with RD but may increase the risk of infection. Hypermetropia, or farsightedness, does not increase the risk of RD but is associated with acute angle-closure glaucoma, which presents with severe ocular pain, visual blurring, a hard and red eye, and systemic symptoms such as nausea and vomiting.
Retinal detachment is a condition where the tissue at the back of the eye separates from the underlying pigment epithelium. This can cause vision loss, but if detected and treated early, it can be reversible. Risk factors for retinal detachment include diabetes, myopia, age, previous cataract surgery, and eye trauma. Symptoms may include new onset floaters or flashes, sudden painless visual field loss, and reduced peripheral and central vision. If the macula is involved, visual outcomes can be much worse. Diagnosis is made through fundoscopy, which may show retinal folds or a lost red reflex. Urgent referral to an ophthalmologist is necessary for assessment and treatment.
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This question is part of the following fields:
- Ophthalmology
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Question 6
Incorrect
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You are asked to review a 27-year-old man who has had two episodes of pancreatitis. On reviewing his notes, the surgeons noticed that he appeared to have had a serum calcium of 3.2 mmol/l when it was checked at the general practice surgery a few weeks before the latest episode. Urinary calcium excretion is markedly reduced.
Which of the following diagnoses fits best with this clinical picture?Your Answer: Pseudohypoparathyroidism
Correct Answer: Familial hypocalciuric hypercalcaemia
Explanation:Differentiating Hyper- and Hypocalcaemia Disorders
One young male patient has experienced two episodes of pancreatitis due to hypercalcaemia. However, his urinary calcium levels are reduced, which suggests that he may have familial hypocalciuric hypercalcaemia. On the other hand, pseudohypoparathyroidism would result in hypocalcaemia, while hyperparathyroidism would cause hypercalcaemia without reducing urinary calcium excretion. Hypoparathyroidism would also lead to hypocalcaemia, but the calcium levels would be raised. Finally, Paget’s disease would not affect urinary calcium excretion. Therefore, it is crucial to differentiate between these disorders to provide appropriate treatment.
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This question is part of the following fields:
- Endocrinology
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Question 7
Incorrect
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A 38-year-old woman who has a history of injecting heroin has just received a positive HIV diagnosis. During her initial visits to the HIV clinic, she is offered a cervical smear. What is the recommended follow-up for her as part of the cervical screening program?
Your Answer: 6 monthly cervical cytology
Correct Answer: Annual cervical cytology
Explanation:Due to a weakened immune response and reduced clearance of the human papillomavirus, women who are HIV positive face an elevated risk of cervical intra-epithelial neoplasia (CIN) and cervical cancer. If HIV positive women have low-grade lesions (CIN1), these lesions may not clear and could progress to high-grade CIN or cervical cancer. Even with effective antiretroviral treatment, these women still have a high risk of abnormal cytology and an increased risk of false-negative results. Therefore, it is recommended that women with HIV receive cervical cytology at the time of diagnosis and annually thereafter for screening purposes.
Understanding Cervical Cancer: Risk Factors and Mechanism of HPV
Cervical cancer is a type of cancer that affects the cervix, which is the lower part of the uterus. It is most commonly diagnosed in women under the age of 45, with the highest incidence rates occurring in those aged 25-29. The cancer can be divided into two types: squamous cell cancer and adenocarcinoma. Symptoms may include abnormal vaginal bleeding, postcoital bleeding, intermenstrual bleeding, or postmenopausal bleeding, as well as vaginal discharge.
The most important factor in the development of cervical cancer is the human papillomavirus (HPV), particularly serotypes 16, 18, and 33. Other risk factors include smoking, human immunodeficiency virus, early first intercourse, many sexual partners, high parity, and lower socioeconomic status. While the association between combined oral contraceptive pill use and cervical cancer is sometimes debated, a large study published in the Lancet confirmed the link.
The mechanism by which HPV causes cervical cancer involves the production of oncogenes E6 and E7 by HPV 16 and 18, respectively. E6 inhibits the p53 tumour suppressor gene, while E7 inhibits the RB suppressor gene. Understanding the risk factors and mechanism of HPV in the development of cervical cancer is crucial for prevention and early detection. Regular cervical cancer screening is recommended for all women.
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This question is part of the following fields:
- Gynaecology
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Question 8
Incorrect
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Some elderly individuals currently receiving medical care have collected data on the prevalence of diabetes. They sampled 500 people. The data collected are shown in the table.
True positive (has the disease) True negative (does not have the disease)
Screen positive 200 50
Screen negative 20 230
Which of the following is the best description for the calculation of positive predictive value?Your Answer: The proportion of people who have the disease in the group will test positive for the disease
Correct Answer: The proportion of people who test positive for the disease in the group who have the disease
Explanation:Understanding Diagnostic Test Metrics: Definitions and Interpretations
Diagnostic tests are used to determine the presence or absence of a disease or condition in an individual. However, the accuracy of a diagnostic test is not always perfect. To evaluate the performance of a diagnostic test, several metrics are used. Here are some definitions and interpretations of commonly used diagnostic test metrics:
Positive Predictive Value (PPV): The proportion of people who test positive for the disease in the group who have the disease. PPV can be calculated using a table with the outcome of A/(A + B).
Specificity: The proportion of people disease-free in the group who test negative for the disease. Specificity can be calculated using a table with the outcome of B/(B + D).
Sensitivity: The proportion of people who have the disease in the group who test positive for the disease. Sensitivity can be calculated using a table with the outcome of A/(A + C).
False-Positive Rate: The proportion of people disease-free in the group who test positive for the disease. False-positive rate can be calculated using a table with the outcome of B/(A + B).
False-Negative (Omission) Rate: The proportion of people who have the disease in the group who test negative for the disease. Omission rate can be calculated using a table with the outcome of C/(C + D).
Understanding these metrics is crucial in evaluating the performance of a diagnostic test and making informed decisions about patient care.
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This question is part of the following fields:
- Statistics
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Question 9
Incorrect
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As a part of a haematology rotation, a final-year medical student is asked to give a PowerPoint presentation to the team about a 20-year-old patient who presented with sickle-cell crisis.
With regard to sickle-cell disease, which of the following statements is correct?Your Answer:
Correct Answer: Aplastic crisis can be precipitated by parvovirus B19
Explanation:Understanding Aplastic Crisis and Sickle-Cell Disease
Aplastic crisis is a condition of transient bone marrow failure that can be precipitated by parvovirus B19, Epstein–Barr virus (EBV), or Streptococcus. In sickle-cell disease, aplastic crisis is usually caused by parvovirus B19 and is characterized by reticulocytopenia, symptomatic anemia, and the presence of parvovirus immunoglobulin M (IgM) antibodies. It is managed by monitoring and symptomatic relief with blood transfusion until normal erythrocyte function returns. Aplastic crisis is most common in individuals of Mediterranean descent.
Sickle-cell disease is most common in individuals of Black Afro-Caribbean descent and, to a lesser extent, in individuals of Mediterranean or Middle Eastern descent. It occurs as a result of the production of an abnormal beta (β) chain in haemoglobin, caused by a mutation that changes adenine to thymine in the sixth codon of the β chain gene. This results in the formation of HbS, which circulates in the blood and forms polymers in the deoxygenated state, causing sickling of red blood cells. The resulting blood film shows elongated, thin, sickled red blood cells, target cells, and Howell–Jolly bodies.
Splenomegaly is most usually seen in childhood, as most children with sickle-cell disease have a splenic infarction event in late childhood and develop hyposplenism. Spherocytes, on the other hand, are abnormal red blood cells with a spherical shape, seen on the blood film of spherocytosis, a form of haemolytic anaemia.
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This question is part of the following fields:
- Haematology
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Question 10
Incorrect
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A 44-year-old patient arrives at the emergency department with complaints of fever and muscle rigidity that started a few hours ago. Upon examination, the patient appears sweaty, has a temperature of 38.8ºC, and a heart rate of 103 bpm. The patient's medical history includes depression and type 2 diabetes, for which they take sertraline and metformin. The patient visited their GP earlier in the day and was diagnosed with a new medical condition and prescribed a new medication. What could have triggered this presentation?
Your Answer:
Correct Answer: Tramadol
Explanation:Understanding Serotonin Syndrome
Serotonin syndrome is a potentially life-threatening condition caused by an excess of serotonin in the body. It can be triggered by a variety of medications and substances, including monoamine oxidase inhibitors, SSRIs, St John’s Wort, tramadol, ecstasy, and amphetamines. The condition is characterized by neuromuscular excitation, hyperreflexia, myoclonus, rigidity, autonomic nervous system excitation, hyperthermia, sweating, and altered mental state, including confusion.
Management of serotonin syndrome is primarily supportive, with IV fluids and benzodiazepines used to manage symptoms. In more severe cases, serotonin antagonists such as cyproheptadine and chlorpromazine may be used. It is important to note that serotonin syndrome can be easily confused with neuroleptic malignant syndrome, which has similar symptoms but is caused by a different mechanism. Both conditions can cause a raised creatine kinase (CK), but it tends to be more associated with NMS. Understanding the causes, features, and management of serotonin syndrome is crucial for healthcare professionals to ensure prompt and effective treatment.
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This question is part of the following fields:
- Pharmacology
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Question 11
Incorrect
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What is the diagnostic indicator of coronary steal phenomenon?
Your Answer:
Correct Answer: Dipyridamole
Explanation:Dipyridamole and its Effect on Myocardial Blood Flow
Dipyridamole has been found to decrease the flow of blood to specific regions of the heart, which could potentially lead to the occurrence of coronary steal phenomenon. This phenomenon happens when blood flow is diverted from healthy areas of the heart to areas that are already compromised due to reduced blood flow.
The reduction in regional myocardial blood flow caused by dipyridamole may be due to its ability to dilate blood vessels, which can lead to a decrease in blood pressure and flow. This effect can be beneficial in certain medical conditions, such as preventing blood clots, but it can also have negative consequences in patients with pre-existing heart disease.
It is important for healthcare providers to carefully consider the potential risks and benefits of using dipyridamole in patients with heart disease, as it may exacerbate existing issues. Close monitoring of patients receiving this medication is necessary to ensure that any adverse effects are promptly identified and addressed.
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This question is part of the following fields:
- Pharmacology
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Question 12
Incorrect
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An 80-year-old man is experiencing abdominal pain, bloating, and nausea while on the ward. He underwent an emergency laparotomy for a perforated diverticulum four days ago. The patient has already vomited twice this morning and has not had a bowel movement since the surgery. Upon examination, his abdomen is significantly distended with tenderness throughout. Bowel sounds are reduced, but vital signs are normal. What is the probable cause of his symptoms?
Your Answer:
Correct Answer: Postoperative ileus
Explanation:After undergoing bowel surgery, experiencing abdominal pain, bloating, and vomiting may indicate the presence of postoperative ileus.
Postoperative ileus, also known as paralytic ileus, is a common complication that can occur after bowel surgery, particularly if the bowel has been extensively handled. This condition is characterized by a reduction in bowel peristalsis, which can lead to pseudo-obstruction. Symptoms of postoperative ileus include abdominal distention, bloating, pain, nausea, vomiting, inability to pass flatus, and difficulty tolerating an oral diet. It is important to check for deranged electrolytes, such as potassium, magnesium, and phosphate, as they can contribute to the development of postoperative ileus.
The management of postoperative ileus typically involves starting with nil-by-mouth and gradually progressing to small sips of clear fluids. If vomiting occurs, a nasogastric tube may be necessary. Intravenous fluids are administered to maintain normovolaemia, and additives may be used to correct any electrolyte disturbances. In severe or prolonged cases, total parenteral nutrition may be required. It is important to monitor the patient closely and adjust the treatment plan as necessary to ensure a successful recovery.
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This question is part of the following fields:
- Surgery
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Question 13
Incorrect
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A 32-year-old woman comes in for a routine antenatal check-up at 15 weeks of pregnancy. During the clinic visit, her blood pressure is measured at 154/94 mmHg, which is confirmed by ambulatory blood pressure monitoring. Four weeks prior, her blood pressure was recorded at 146/88 mmHg. A urine dipstick test shows no abnormalities, and there is no significant medical history to report. What is the probable diagnosis?
Your Answer:
Correct Answer: Pre-existing hypertension
Explanation:It should be noted that the woman already had hypertension before becoming pregnant. Blood pressure issues related to pregnancy, such as pre-eclampsia or pregnancy-induced hypertension, typically do not occur until after 20 weeks of gestation. The elevated blood pressure readings obtained through ambulatory monitoring rule out the possibility of white-coat hypertension. It is important to note that the term pre-existing hypertension is used instead of essential hypertension, as high blood pressure in a woman of this age is uncommon and may indicate secondary hypertension.
Hypertension during pregnancy is a common occurrence that requires careful management. In normal pregnancies, blood pressure tends to decrease in the first trimester and then gradually increase to pre-pregnancy levels by term. However, in cases of hypertension during pregnancy, the systolic blood pressure is usually above 140 mmHg or the diastolic blood pressure is above 90 mmHg. Additionally, an increase of more than 30 mmHg systolic or 15 mmHg diastolic from the initial readings may also indicate hypertension.
There are three categories of hypertension during pregnancy: pre-existing hypertension, pregnancy-induced hypertension (PIH), and pre-eclampsia. Pre-existing hypertension refers to a history of hypertension before pregnancy or elevated blood pressure before 20 weeks gestation. PIH occurs in the second half of pregnancy and resolves after birth. Pre-eclampsia is characterized by hypertension and proteinuria, and may also involve edema.
The management of hypertension during pregnancy involves the use of antihypertensive medications such as labetalol, nifedipine, and hydralazine. In cases of pre-existing hypertension, ACE inhibitors and angiotensin II receptor blockers should be stopped immediately and alternative medications should be prescribed. Women who are at high risk of developing pre-eclampsia should take aspirin from 12 weeks until the birth of the baby. It is important to carefully monitor blood pressure and proteinuria levels during pregnancy to ensure the health of both the mother and the baby.
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This question is part of the following fields:
- Obstetrics
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Question 14
Incorrect
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A lesion in which lobe can result in a change in personality of the individual?
Your Answer:
Correct Answer: Frontal
Explanation:The Four Lobes of the Brain and Their Functions
The brain is a complex organ that controls all bodily functions and processes. It is divided into four main lobes, each with its own unique functions and responsibilities. The frontal lobe is responsible for behavior, personality, reasoning, planning, movement, emotions, and problem-solving. The temporal lobe is responsible for hearing and memory, specifically the hippocampus. The parietal lobe is responsible for touch, pressure, temperature, and pain perception. Lastly, the occipital lobe is responsible for vision.
In summary, the frontal lobe controls higher-level thinking and decision-making, the temporal lobe is responsible for auditory perception and memory, the parietal lobe is responsible for sensory perception, and the occipital lobe is responsible for vision. the functions of each lobe can help us better understand how the brain works and how it affects our daily lives.
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This question is part of the following fields:
- Neurology
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Question 15
Incorrect
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At what age do children typically begin to play alongside their peers without actively engaging with them?
Your Answer:
Correct Answer: 2 years
Explanation:The table summarizes developmental milestones for social behavior, feeding, dressing, and play. Milestones include smiling at 6 weeks, using a spoon and cup at 12-15 months, and playing with other children at 4 years.
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This question is part of the following fields:
- Paediatrics
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Question 16
Incorrect
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A 35-year-old woman presents to the rheumatology clinic for evaluation of her systemic lupus erythematosus (SLE). The rheumatologist recommends initiating hydroxychloroquine therapy due to her frequent complaints of wrist and hand pain flares.
What counseling points should be emphasized to the patient?Your Answer:
Correct Answer: Risk of retinopathy
Explanation:It is important to be aware of the potential side effects of various medications, including commonly used disease-modifying anti-rheumatic drugs (DMARDs), lithium, amiodarone, and medications used to treat tuberculosis. Hydroxychloroquine, which is used to manage rheumatoid arthritis and systemic/discoid lupus erythematosus, can result in severe and permanent retinopathy. Patients taking this medication should be advised to watch for visual symptoms and have their visual acuity assessed annually. Cyclophosphamide is associated with haemorrhagic cystitis, while methotrexate, amiodarone, and nitrofurantoin can potentially cause pulmonary fibrosis. Amiodarone can also lead to thyroid dysfunction, resulting in either hypothyroidism or hyperthyroidism. Rifampicin, used to treat tuberculosis, may cause orange discolouration of urine and tears, as well as hepatitis.
Hydroxychloroquine: Uses and Adverse Effects
Hydroxychloroquine is a medication commonly used in the treatment of rheumatoid arthritis and systemic/discoid lupus erythematosus. It is similar to chloroquine, which is used to treat certain types of malaria. However, hydroxychloroquine has been found to cause bull’s eye retinopathy, which can result in severe and permanent visual loss. Recent data suggests that this adverse effect is more common than previously thought, and the most recent guidelines recommend baseline ophthalmological examination and annual screening, including colour retinal photography and spectral domain optical coherence tomography scanning of the macula. Despite this risk, hydroxychloroquine may still be used in pregnant women if needed. Patients taking this medication should be asked about visual symptoms and have their visual acuity monitored annually using a standard reading chart.
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This question is part of the following fields:
- Musculoskeletal
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Question 17
Incorrect
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A 35-year-old woman comes to the eye clinic complaining of sudden vision changes in her left eye for the past 2 days. She reports that her vision has been progressively deteriorating, as if she is looking through a cloud, and the colors around her appear less vivid. Additionally, she has been experiencing retro-orbital pain that worsens with eye movement. Her right eye is unaffected, and she has no prior history of eye problems or other medical conditions. What is the most probable finding on examination for this suspected diagnosis?
Your Answer:
Correct Answer: Relative afferent pupillary defect
Explanation:Optic neuritis is a condition that affects the anterior visual pathway and is characterized by a specific sign called relative afferent pupillary defect (RAPD). RAPD is a reliable indicator of unilateral optic nerve disease and is commonly observed in optic neuritis. However, it is not present in cases of bilateral optic neuritis. Cotton wool spots, on the other hand, are small exudates on the retina that are associated with various diseases, such as hypertension and diabetes mellitus. They are not typically associated with optic neuritis, which does not affect the retina. Visual field defects can occur in optic neuritis, with central scotoma being the most common. The optic disc is usually normal in optic neuritis, although mild swelling may be present in some cases. However, RAPD is a more common finding and is therefore a more reliable diagnostic indicator.
Optic neuritis is a condition that can be caused by multiple sclerosis, diabetes, or syphilis. It is characterized by a decrease in visual acuity in one eye over a period of hours or days, as well as poor color discrimination and pain that worsens with eye movement. Other symptoms include a relative afferent pupillary defect and a central scotoma. The condition can be diagnosed through an MRI of the brain and orbits with gadolinium contrast. Treatment typically involves high-dose steroids, and recovery usually takes 4-6 weeks. If an MRI shows more than three white-matter lesions, the risk of developing multiple sclerosis within five years is approximately 50%.
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This question is part of the following fields:
- Ophthalmology
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Question 18
Incorrect
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Does PCOS elevate the risk of certain conditions in the long run?
Your Answer:
Correct Answer: Endometrial cancer
Explanation:Polycystic ovary syndrome (PCOS) is a prevalent disorder that is often complicated by chronic anovulation and hyperandrogenism. This condition can lead to long-term complications such as subfertility, diabetes mellitus, stroke and transient ischemic attack, coronary artery disease, obstructive sleep apnea, and endometrial cancer. These complications are more likely to occur in patients who are obese. Women with oligo/amenorrhea and pre-menopausal levels of estrogen are at an increased risk of endometrial hyperplasia and carcinoma. This risk is highest in those with menstrual cycle lengths of over three months. However, it can be reduced by inducing a withdrawal bleed every one to three months using a combined contraceptive pill or cyclical medroxyprogesterone or by inserting a mirena coil. Overweight patients can regulate their menstrual cycles and reduce the risk of endometrial hyperplasia by optimizing their BMI. Unlike in other conditions, there is no increased risk of osteoporosis in PCOS because there is no estrogen deficiency. The RCOG Greentop guidelines provide more information on the long-term consequences of polycystic ovary syndrome.
Polycystic ovary syndrome (PCOS) is a condition that affects a significant percentage of women of reproductive age. The exact cause of PCOS is not fully understood, but it is believed to involve both high levels of luteinizing hormone and hyperinsulinemia, with some overlap with the metabolic syndrome. PCOS is characterized by a range of symptoms, including subfertility and infertility, menstrual disturbances such as oligomenorrhea and amenorrhea, hirsutism, acne, obesity, and acanthosis nigricans.
To diagnose PCOS, a range of investigations may be performed, including pelvic ultrasound to detect multiple cysts on the ovaries. Other useful baseline investigations include FSH, LH, prolactin, TSH, testosterone, and sex hormone-binding globulin (SHBG). While a raised LH:FSH ratio was once considered a classical feature of PCOS, it is no longer thought to be useful in diagnosis. Testosterone may be normal or mildly elevated, but if markedly raised, other causes should be considered. SHBG is typically normal to low in women with PCOS, and impaired glucose tolerance should also be checked.
To formally diagnose PCOS, other conditions must first be excluded. The Rotterdam criteria state that a diagnosis of PCOS can be made if at least two of the following three criteria are present: infrequent or no ovulation, clinical and/or biochemical signs of hyperandrogenism, and polycystic ovaries on ultrasound scan. Polycystic ovaries are defined as the presence of at least 12 follicles measuring 2-9 mm in diameter in one or both ovaries, and/or an increased ovarian volume of over 10 cm³.
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This question is part of the following fields:
- Gynaecology
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Question 19
Incorrect
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A 25-year-old male comes to the clinic for a routine check-up regarding his occasional seizures that have been occurring for the past six months. He has been diagnosed with idiopathic epilepsy by a neurologist and has been prescribed lamotrigine, which he reports has been effective in controlling his seizures for the past two months. However, he admits to driving to the clinic despite being advised by his doctor to stop driving due to his condition.
As a healthcare professional, what is the best course of action to take in this situation?Your Answer:
Correct Answer: Inform patient that you will notify the DVLA
Explanation:Driving Restrictions for Epilepsy Patients
The law is unambiguous when it comes to epilepsy and driving. If a patient is diagnosed with epilepsy, they must cease driving and notify the DVLA of their diagnosis. If the patient disregards medical advice and continues to drive, the doctor has a responsibility to society that supersedes patient confidentiality and may inform the DVLA.
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This question is part of the following fields:
- Miscellaneous
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Question 20
Incorrect
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A 35-year-old pregnant woman comes to the clinic with a complaint of a burning sensation in her legs. She reports that her legs are very sore and uncomfortable. Upon examination, there is a hard, tender, bulging of veins in both her thighs and the calf region, with hyperpigmentation and eczema of both the legs and an ulcer over the medial malleolus. What would prevent radiofrequency ablation from being performed as an initial treatment for this patient?
Your Answer:
Correct Answer: Pregnancy
Explanation:Interventional Treatment for Varicose Veins and Associated Complications
According to the National Institute for Health and Care Excellence guidelines, interventional treatment for varicose veins during pregnancy is not recommended. However, compression hosiery can be used to alleviate leg swelling symptoms.
Eczema of the lower limbs in varicose veins may indicate chronic venous insufficiency. In such cases, immediate radiofrequency ablation is necessary.
Hard, painful veins are a sign of superficial venous thrombosis, a complication of varicose veins. Immediate intervention is required if there is evidence of this condition.
Hyperpigmentation of the lower limbs in varicose veins also suggests chronic venous insufficiency. In such cases, radiofrequency ablation is indicated.
An ulcer over the medial malleolus, particularly a chronic, non-healing ulcer in varicose veins, is a strong indication of chronic venous insufficiency. If eczema, non-healing leg ulcers, or hyperpigmentation are present, immediate radiofrequency ablation is necessary.
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This question is part of the following fields:
- Vascular
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Question 21
Incorrect
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A 56-year-old man presents with a range of physical symptoms that have been ongoing for the past 7 years. Despite multiple investigations and consultations with various specialists, no organic cause has been found for his symptoms. What is the most likely diagnosis for this patient?
Your Answer:
Correct Answer: Somatisation disorder
Explanation:The appropriate diagnosis for a patient who is experiencing persistent, unexplained symptoms is somatisation disorder, as they are primarily concerned with the symptoms rather than a specific underlying diagnosis like cancer (which would be indicative of hypochondria). It is important to note that intentional production of symptoms, such as self-poisoning, would fall under the category of Munchausen’s syndrome.
Psychiatric Terms for Unexplained Symptoms
There are various psychiatric terms used to describe patients who exhibit symptoms for which no organic cause can be found. One such disorder is somatisation disorder, which involves the presence of multiple physical symptoms for at least two years, and the patient’s refusal to accept reassurance or negative test results. Another disorder is illness anxiety disorder, which is characterized by a persistent belief in the presence of an underlying serious disease, such as cancer, despite negative test results.
Conversion disorder is another condition that involves the loss of motor or sensory function, and the patient does not consciously feign the symptoms or seek material gain. Patients with this disorder may be indifferent to their apparent disorder, a phenomenon known as la belle indifference. Dissociative disorder, on the other hand, involves the process of ‘separating off’ certain memories from normal consciousness, and may manifest as amnesia, fugue, or stupor. Dissociative identity disorder (DID) is the most severe form of dissociative disorder and was previously known as multiple personality disorder.
Factitious disorder, also known as Munchausen’s syndrome, involves the intentional production of physical or psychological symptoms. Finally, malingering is the fraudulent simulation or exaggeration of symptoms with the intention of financial or other gain. Understanding these psychiatric terms can help healthcare professionals better diagnose and treat patients with unexplained symptoms.
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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 56-year-old woman is brought to the emergency department after ingesting a significant amount of prescription drugs. She was discovered at home with empty bottles of imipramine nearby. Despite appearing drowsy, she informs the doctor that she took the medications about 8 hours ago.
During the examination, the patient is found to be hypotensive, tachycardic, and drowsy. An ECG reveals a QRS width of 162ms. What treatment should be given?Your Answer:
Correct Answer: Intravenous bicarbonate
Explanation:In cases of tricyclic overdose, the presence of a widened QRS complex or arrhythmia on ECG requires immediate administration of IV bicarbonate as the first-line therapy. Activated charcoal may not be effective if the patient presents more than 2 hours after ingestion. Amiodarone should be avoided as it can worsen hypotension and conduction abnormalities. Glucagon is not indicated for tricyclic overdose, as it is used for beta-blocker overdose. Magnesium sulphate is not useful in the management of tricyclic overdose, but is used for torsades de pointes and eclampsia.
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 23
Incorrect
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As part of a learning exercise, an elderly person drew a small black square and a black circle, 4 inches horizontally apart, on a piece of white paper. The elderly person then held the paper at arm’s length and closed their left eye, while focusing on the black square, which was to the left of the black circle, with their right eye. They moved the paper slowly towards them until the black circle disappeared.
Which of the following anatomical structures is responsible for the disappearance of the black circle?Your Answer:
Correct Answer: Optic disc
Explanation:Anatomy of the Eye: Optic Disc, Macula Lutea, Fovea Centralis, Dilator Pupillae, and Sphincter Pupillae
The eye is a complex organ that allows us to see the world around us. Within the eye, there are several important structures that play a role in vision. Here are five key components of the eye and their functions:
1. Optic Disc: This is the area where the optic nerve exits the retina. It lacks photoreceptor cells, creating a blind spot in our visual field. The optic disc is lighter in color than the surrounding retina and is the point from which branches of the central retinal artery spread out to supply the retina.
2. Macula Lutea: This small, yellow-colored area is located next to the optic disc. It has a higher visual sensitivity than other areas of the retina.
3. Fovea Centralis: This is the central depression of the macula lutea and contains the largest number of densely compact cone photoreceptors. It has the highest visual sensitivity of any area of the retina.
4. Dilator Pupillae: This structure is found in the iris and is innervated by sympathetic fibers. It dilates the pupillary opening.
5. Sphincter Pupillae: Also found in the iris, this structure is innervated by parasympathetics and constricts the pupillary opening.
Understanding the anatomy of the eye and how these structures work together is essential for maintaining good vision and identifying potential problems.
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This question is part of the following fields:
- Ophthalmology
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Question 24
Incorrect
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A 21-year-old man presents to the Emergency Department 50 minutes after intentionally overdosing on aspirin. He weighs 65 kg and ingested 25 tablets, each containing 250 mg. Despite the overdose, his vital signs are currently stable. What is the recommended initial course of action?
Your Answer:
Correct Answer: Give oral activated charcoal
Explanation:Activated charcoal is the recommended treatment for an aspirin overdose within the first hour of ingestion. In this case, the patient has ingested 9 grams of aspirin, which is considered an overdose as it exceeds 125 mg/kg. Giving activated charcoal should be done alongside an A to E approach. Symptoms of aspirin overdose may include tinnitus, nausea, vomiting, sweating, confusion, drowsiness, and seizures. Haemodialysis is not the first step in management as it is too early for this option. An ECG and blood gas should be done in the Emergency Department, but they do not address the effects of the aspirin overdose. IV sodium bicarbonate is used for urinary alkalinization and may be used as treatment if the time since ingestion has passed an hour. However, activated charcoal is the first-line treatment within the first hour of ingestion.
Salicylate overdose can result in a combination of respiratory alkalosis and metabolic acidosis. The initial effect of salicylates is to stimulate the respiratory center, leading to hyperventilation and respiratory alkalosis. However, as the overdose progresses, the direct acid effects of salicylates, combined with acute renal failure, can cause metabolic acidosis. In children, metabolic acidosis tends to be more prominent. Other symptoms of salicylate overdose include tinnitus, lethargy, sweating, pyrexia, nausea/vomiting, hyperglycemia and hypoglycemia, seizures, and coma.
The treatment for salicylate overdose involves general measures such as airway, breathing, and circulation support, as well as administering activated charcoal. Urinary alkalinization with intravenous sodium bicarbonate can help eliminate aspirin in the urine. In severe cases, hemodialysis may be necessary. Indications for hemodialysis include a serum concentration of salicylates greater than 700 mg/L, metabolic acidosis that is resistant to treatment, acute renal failure, pulmonary edema, seizures, and coma.
It is important to note that salicylates can cause the uncoupling of oxidative phosphorylation, which leads to decreased adenosine triphosphate production, increased oxygen consumption, and increased carbon dioxide and heat production. Therefore, prompt and appropriate treatment is crucial in managing salicylate overdose.
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This question is part of the following fields:
- Pharmacology
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Question 25
Incorrect
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What is the most effective method for diagnosing sleep apnoea syndrome?
Your Answer:
Correct Answer: Polygraphic sleep studies
Explanation:Sleep Apnoea
Sleep apnoea is a condition where breathing stops during sleep, causing frequent interruptions in sleep and restlessness. This leads to daytime drowsiness and irritability. Snoring is often associated with this condition. To diagnose sleep apnoea, a polygraphic recording of sleep is taken, which shows periods of at least 30 instances where breathing stops for 10 or more seconds in seven hours of sleep. These periods are also associated with a decrease in arterial oxygen saturation. the symptoms and diagnosis of sleep apnoea is important for proper treatment and management of the condition.
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This question is part of the following fields:
- Respiratory
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Question 26
Incorrect
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A 45-year-old female patient complains of a painless lump in her right groin. She denies any changes in bowel habits or abdominal discomfort. Her medical history includes asthma and three previous vaginal deliveries. Upon examination, a soft swelling is palpable with a positive cough impulse. The lump is located inferolateral to the right pubic tubercle, fully reducible, and non-tender. Both femoral pulses are palpated separately and are normal. What is the best course of action for managing this patient's condition?
Your Answer:
Correct Answer: Refer to the surgical team for consideration of surgical repair
Explanation:Surgical referral for repair is necessary for femoral hernias, regardless of symptoms, due to the risk of strangulation. In this case, the patient’s history and examination suggest a hernia, potentially a femoral hernia, and surgical repair is necessary. The use of a support belt could increase the risk of strangulation, and a duplex scan, while a good idea, is not the most appropriate management for this patient. No action is unsafe, and antibiotics are not currently indicated.
Understanding Femoral Hernias
Femoral hernias occur when a part of the bowel or other abdominal organs pass through the femoral canal, which is a potential space in the anterior thigh. This can result in a lump in the groin area that is mildly painful and typically non-reducible. Femoral hernias are less common than inguinal hernias, accounting for only 5% of abdominal hernias, and are more prevalent in women, especially those who have had multiple pregnancies. Diagnosis is usually clinical, but ultrasound may be used to confirm the presence of a femoral hernia and exclude other possible causes of a lump in the groin area.
Complications of femoral hernias include incarceration, where the herniated tissue cannot be reduced, and strangulation, which is a surgical emergency. The risk of strangulation is higher with femoral hernias than with inguinal hernias and increases over time. Bowel obstruction and bowel ischaemia may also occur, leading to significant morbidity and mortality for the patient.
Surgical repair is necessary for femoral hernias, and it can be done laparoscopically or via a laparotomy. Hernia support belts or trusses should not be used for femoral hernias due to the risk of strangulation. In an emergency situation, a laparotomy may be the only option. It is essential to distinguish femoral hernias from inguinal hernias, as they have different locations and require different management approaches.
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This question is part of the following fields:
- Surgery
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Question 27
Incorrect
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A 65-year-old Asian woman presents with sudden onset paranoid thoughts and suicidal ideation. She has a medical history of hypertension, type 2 diabetes mellitus, and hypercholesterolemia. Given her age and first episode of psychosis, what crucial investigation is necessary to rule out other potential underlying causes?
Your Answer:
Correct Answer: CT head
Explanation:When elderly patients present with sudden onset psychosis, it is important to consider and rule out organic causes before attributing it to a primary psychotic disorder. In such cases, a CT head scan or even an MRI should be considered to detect any underlying organic causes such as a brain tumour, stroke or CNS infection. While HbA1c is typically used to assess diabetes control, PET scans are more commonly used to provide detailed information about metabolic processes in tissues, such as identifying active cancer cells. Chest X-rays may also be useful in certain cases.
Thought disorders can manifest in various ways, including circumstantiality, tangentiality, neologisms, clang associations, word salad, Knight’s move thinking, flight of ideas, perseveration, and echolalia. Circumstantiality involves providing excessive and unnecessary detail when answering a question, but eventually returning to the original point. Tangentiality, on the other hand, refers to wandering from a topic without returning to it. Neologisms are newly formed words, often created by combining two existing words. Clang associations occur when ideas are related only by their similar sounds or rhymes. Word salad is a type of speech that is completely incoherent, with real words strung together into nonsensical sentences. Knight’s move thinking is a severe form of loosening of associations, characterized by unexpected and illogical leaps from one idea to another. Flight of ideas is a thought disorder that involves jumping from one topic to another, but with discernible links between them. Perseveration is the repetition of ideas or words despite attempts to change the topic. Finally, echolalia is the repetition of someone else’s speech, including the question that was asked.
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This question is part of the following fields:
- Psychiatry
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Question 28
Incorrect
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In a 6-year-old boy, what could be a possible association with an uncomplicated ventricular septal defect (VSD)?
Your Answer:
Correct Answer: A pansystolic murmur of grade 4/6 in intensity
Explanation:Characteristics of Congenital Heart Disease
A collapsing pulse can be a sign of aortic incompetence, while clubbing is a common feature of cyanotic congenital heart disease. A holosystolic murmur of varying intensity is also a characteristic of this condition. However, splenomegaly is not typically associated with congenital heart disease. In an uncomplicated ventricular septal defect, the S2 splits normally and P2 is normal. These are important characteristics to be aware of when diagnosing and treating congenital heart disease. Proper identification and management of these symptoms can greatly improve patient outcomes.
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This question is part of the following fields:
- Paediatrics
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Question 29
Incorrect
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A 15-year-old girl is rushed to the emergency department by ambulance after experiencing difficulty breathing during a sports event. Despite using her salbutamol inhaler, she could not catch her breath. She has a history of asthma.
Upon initial assessment, her heart rate is 110 bpm, and her respiratory rate is 28 /min. She is unable to complete full sentences, and there is a widespread wheeze on chest auscultation.
Further investigations reveal the following results:
- PEFR 52% (>75%)
- pH 7.43 (7.35-7.45)
- pO2 10.9 kPa (11-14.4)
- pCO2 4.7 kPa (4.6-6.0)
What is the classification of this patient's acute asthma episode?Your Answer:
Correct Answer: Life-threatening
Explanation:The patient’s symptoms indicate a life-threatening severity of asthma, as evidenced by their inability to complete full sentences and a PEFR measurement within the severe range. This is further supported by their normal pCO2 levels, which confirm the severity classification. The classification of moderate severity is incorrect in this case.
Management of Acute Asthma
Acute asthma is classified by the British Thoracic Society (BTS) into three categories: moderate, severe, and life-threatening. Patients with any of the life-threatening features should be treated as having a life-threatening attack. A fourth category, Near-fatal asthma, is also recognized. Further assessment may include arterial blood gases for patients with oxygen saturation levels below 92%. A chest x-ray is not routinely recommended unless the patient has life-threatening asthma, suspected pneumothorax, or failure to respond to treatment.
Admission criteria include a previous near-fatal asthma attack, pregnancy, an attack occurring despite already using oral corticosteroid, and presentation at night. All patients with life-threatening asthma should be admitted to the hospital, and patients with features of severe acute asthma should also be admitted if they fail to respond to initial treatment. Oxygen therapy should be started for hypoxaemic patients. Bronchodilation with short-acting beta₂-agonists (SABA) is recommended, and all patients should be given 40-50 mg of prednisolone orally daily. Ipratropium bromide and IV magnesium sulphate may also be considered for severe or life-threatening asthma. Patients who fail to respond require senior critical care support and should be treated in an appropriate ITU/HDU setting. Criteria for discharge include stability on discharge medication, checked and recorded inhaler technique, and PEF levels above 75% of best or predicted.
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This question is part of the following fields:
- Medicine
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Question 30
Incorrect
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A 32-year-old woman has given birth to her second child at 38 weeks gestation. She experienced a natural third stage of labor without any medication. Suddenly, 5 minutes after delivery, she had a massive blood loss of around 750 mL. Despite this, her vital signs remain stable. What is the initial management plan for her?
Your Answer:
Correct Answer: Syntometrine
Explanation:Postpartum haemorrhage caused by uterine atony can be treated with various medical options such as oxytocin, ergometrine, carboprost, and misoprostol.
The most common reason for primary postpartum haemorrhage is an atonic uterus. To prevent excessive blood loss, the patient should be advised to receive Syntometrine or oxytocin to stimulate uterine contractions. During the third stage of labour, cord traction should be performed, and the uterus should be massaged after the placenta is delivered. If these measures are ineffective, additional interventions such as blood transfusion and manual removal of the placenta may be necessary. Although breastfeeding can cause uterine contractions, it is not recommended in this case due to the severity of the bleeding.
Understanding Postpartum Haemorrhage
Postpartum haemorrhage (PPH) is a condition where a woman experiences blood loss of more than 500 ml after giving birth vaginally. It can be classified as primary or secondary. Primary PPH occurs within 24 hours after delivery and is caused by the 4 Ts: tone, trauma, tissue, and thrombin. The most common cause is uterine atony. Risk factors for primary PPH include previous PPH, prolonged labour, pre-eclampsia, increased maternal age, emergency Caesarean section, and placenta praevia.
In managing PPH, it is important to involve senior staff immediately and follow the ABC approach. This includes two peripheral cannulae, lying the woman flat, blood tests, and commencing a warmed crystalloid infusion. Mechanical interventions such as rubbing up the fundus and catheterisation are also done. Medical interventions include IV oxytocin, ergometrine, carboprost, and misoprostol. Surgical options such as intrauterine balloon tamponade, B-Lynch suture, ligation of uterine arteries, and hysterectomy may be considered if medical options fail to control the bleeding.
Secondary PPH occurs between 24 hours to 6 weeks after delivery and is typically due to retained placental tissue or endometritis. It is important to understand the causes and risk factors of PPH to prevent and manage this life-threatening emergency effectively.
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This question is part of the following fields:
- Obstetrics
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