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  • Question 1 - A 28-year-old woman has been prescribed tranexamic acid to alleviate symptoms of heavy...

    Incorrect

    • A 28-year-old woman has been prescribed tranexamic acid to alleviate symptoms of heavy menstrual bleeding. Can you explain the mechanism of action of tranexamic acid?

      Your Answer: Factor X inhibitor

      Correct Answer: Inhibits fibrin degradation

      Explanation:

      Anticoagulant Medications and Their Mechanisms

      Anticoagulant medications are used to prevent and treat thromboembolic disease. Tranexamic acid is a potent inhibitor of fibrinolysis, which is the process of breaking down blood clots. It works by blocking the conversion of plasminogen to plasmin, which is necessary for the breakdown of clots. Compared to aminocaproic acid, tranexamic acid is about 10 times more effective in inhibiting fibrinolysis.

      Factor X inhibitors and vitamin K inhibitors, such as warfarin, are also used to prevent thromboembolic events. These medications work by interfering with the clotting cascade, which is a series of chemical reactions that lead to the formation of blood clots. By inhibiting the production of clotting factors, these medications can prevent the formation of new clots and reduce the risk of further events.

      Aspirin and clopidogrel are medications that inhibit platelet aggregation. Platelets are small cells in the blood that play a key role in clot formation. By inhibiting platelet aggregation, these medications can reduce the risk of clot formation and prevent thromboembolic events. Aspirin works by blocking the production of thromboxane, a chemical that promotes platelet aggregation, while clopidogrel works by blocking the activation of platelets.

    • This question is part of the following fields:

      • Pharmacology
      10.1
      Seconds
  • Question 2 - A 50-year-old Asian man with ischaemic heart disease is being treated for severe...

    Correct

    • A 50-year-old Asian man with ischaemic heart disease is being treated for severe community-acquired pneumonia with amoxicillin and clarithromycin. What is the most important medication he should stop taking while on antibiotics?

      Your Answer: Simvastatin

      Explanation:

      Interactions and Contraindications of Medications in a Patient with Pneumonia

      When treating a patient with moderate-to-high severity community-acquired pneumonia, it is important to consider potential interactions and contraindications of the medications prescribed. In this case, the patient is receiving dual antibiotic therapy with amoxicillin and clarithromycin. Clarithromycin is a potent inhibitor of the CYP3A4 enzyme, which is involved in the metabolism of medications like statins, colchicine, and carbamazepine. Therefore, concurrent use of a statin and clarithromycin is contraindicated due to the risk of elevated serum concentrations and potential side effects like rhabdomyolysis. Aspirin, bisoprolol, and clopidogrel are not known to interact significantly with either amoxicillin or clarithromycin. However, it is important to consider contraindications for each medication, such as the use of bisoprolol in asthmatics or the contraindication of clopidogrel in patients with bleeding disorders or gastric ulceration. Ramipril, an ACE inhibitor, is contraindicated in patients with a history of anaphylaxis to ACE inhibitors, severe renal disease, pregnancy, or hypotension. Overall, careful consideration of medication interactions and contraindications is crucial in the treatment of patients with pneumonia.

    • This question is part of the following fields:

      • Pharmacology
      9.8
      Seconds
  • Question 3 - A 50-year-old electrician is admitted to the Emergency Department following an electrical injury...

    Correct

    • A 50-year-old electrician is admitted to the Emergency Department following an electrical injury at work. He experienced a current-induced dysrhythmia and has been under observation for the past 24 hours. His current echocardiogram monitoring shows no abnormalities, and he is comfortable at rest with a respiratory rate of 12 breaths per minute. The patient is normovolemic. What electrolyte abnormality is he most susceptible to developing?

      Your Answer: Hyperkalaemia

      Explanation:

      Electrical Injuries and Electrolyte Imbalances

      Electrical injuries can cause various electrolyte imbalances, with hyperkalaemia being a primary concern due to rhabdomyolysis. This occurs when damaged muscles release potassium, leading to its accumulation in the body. Treatment for hyperkalaemia depends on the patient’s symptoms, ECG, and other blood changes. While hyponatraemia is common in critically ill patients, it may not be the primary concern in electrical injury cases unless the patient has sustained a severe brain injury. Hypokalaemia is unlikely as rhabdomyolysis leads to hyperkalaemia. Hypernatraemia is unlikely unless the patient has had fluid losses. Hypophosphataemia may occur in severe burns, but it is not the best answer for mild thermal injuries and a lack of severe malnutrition.

    • This question is part of the following fields:

      • Trauma
      94.2
      Seconds
  • Question 4 - A 70-year-old man is brought to the emergency department after a fall. He...

    Incorrect

    • A 70-year-old man is brought to the emergency department after a fall. He fell from standing height and is experiencing pain in his right leg. A pelvic X-Ray shows a right intertrochanteric femoral fracture. There are no fractures present on the left. He has a history of osteoporosis and osteoarthritis but generally considers himself to be active and enjoys playing golf.

      What is the most suitable course of action for management?

      Your Answer: Hemiarthroplasty

      Correct Answer: Dynamic hip screw (DHS)

      Explanation:

      The preferred surgical treatment for extracapsular proximal femoral fractures, specifically intertrochanteric fractures, is the use of dynamic hip screws (DHS). Therefore, in this case, the correct answer would be DHS. Conservative management is not recommended, as the patient is in good health and does not have any medical conditions that would prevent surgery. Hemiarthroplasty is only used for intracapsular neck of femur fractures in patients who are not fit for surgery. Intramedullary nails are used for subtrochanteric femoral fractures.

      Hip fractures are a common occurrence, particularly in elderly women with osteoporosis. The femoral head’s blood supply runs up the neck, making avascular necrosis a potential risk in displaced fractures. Symptoms of a hip fracture include pain and a shortened and externally rotated leg. Patients with non-displaced or incomplete neck of femur fractures may still be able to bear weight. Hip fractures can be classified as intracapsular or extracapsular, with the Garden system being a commonly used classification system. Blood supply disruption is most common in Types III and IV fractures.

      Intracapsular hip fractures can be treated with internal fixation or hemiarthroplasty if the patient is unfit. Displaced fractures are recommended for replacement arthroplasty, such as total hip replacement or hemiarthroplasty, according to NICE guidelines. Total hip replacement is preferred over hemiarthroplasty if the patient was able to walk independently outdoors with the use of a stick, is not cognitively impaired, and is medically fit for anesthesia and the procedure. Extracapsular hip fractures can be managed with a dynamic hip screw for stable intertrochanteric fractures or an intramedullary device for reverse oblique, transverse, or subtrochanteric fractures.

    • This question is part of the following fields:

      • Musculoskeletal
      17.6
      Seconds
  • Question 5 - A 32-year-old man presents for a general check-up. He is well in himself...

    Incorrect

    • A 32-year-old man presents for a general check-up. He is well in himself and reports no symptoms.
      On examination, he has a body mass index (BMI) of 33 kg/m2 and there are some thickened folds of skin in his axilla and the nape of his neck. His blood pressure is 140/90 mmHg. He is a non-smoker and does not drink.
      A set of blood work is ordered. He demonstrated impaired fasting glucose in addition to the results below.
      Investigation Result Normal value
      Haemoglobin (Hb) 140 g/l 135–175 g/l
      Cholesterol 5.8 mmol/l < 5.2 mmol/l
      Triglyceride 3.9 mmol/l 0–1.5 mmol/l
      Alanine aminotransferase (ALT) 60 IU/l 5–30 IU/l
      Aspartate aminotransferase (AST) 30 IU/l 10–40 IU/l
      Gamma-glutamyl transferase (GGT) 30 IU/l 5–30 IU/l
      What is the next best investigation?

      Your Answer: Screen for hereditary haemochromatosis

      Correct Answer: Ultrasound liver

      Explanation:

      Choosing the Best Investigation: A Case Study

      In this case study, a patient presents with non-alcoholic fatty liver disease (NAFLD), raised ALT, impaired glucose regulation, acanthosis nigricans, and a high BMI. The question is, what investigation should be done next?

      Ultrasound liver is the best investigation in this case. It is quick, inexpensive, and can provide enough information to guide management at initial stages. Weight management and dietary modification can help abate symptoms.

      Screening for hereditary haemochromatosis is not appropriate in this case, as the patient does not complain of arthritis, diabetes, or changes to the skin.

      Haematinics are not necessary, as the Hb is normal.

      A CT scan of the abdomen would be useful, but it is costly and would result in the patient receiving radiation. It should not be the next best investigation.

      Serum ceruloplasmin is not necessary, as there is nothing in the history to suggest Wilson’s disease.

      In conclusion, choosing the best investigation requires careful consideration of the patient’s history and symptoms. In this case, ultrasound liver is the most appropriate next step.

    • This question is part of the following fields:

      • Gastroenterology
      39.3
      Seconds
  • Question 6 - A 50-year-old man with a history of chronic active hepatitis B presents with...

    Incorrect

    • A 50-year-old man with a history of chronic active hepatitis B presents with abdominal distension and bilateral ankle oedema, worsening over the previous 2 weeks. Three months ago, he was admitted for bleeding oesophageal varices, which was treated endoscopically. There was shifting dullness without tenderness on abdominal examination, and splenomegaly was also noted. His serum albumin concentration was diminished. Prothrombin time was elevated.
      Which one of the following diuretics will best help this patient?

      Your Answer: Bumetanide

      Correct Answer: Spironolactone

      Explanation:

      Diuretics for Ascites in Liver Cirrhosis: Mechanisms and Options

      Ascites is a common complication of liver cirrhosis, caused by both Na/water retention and portal hypertension. Spironolactone, an aldosterone antagonist, is the first-line diuretic for ascites in liver cirrhosis. It promotes natriuresis and diuresis, while also preventing hypokalaemia and subsequent hepatic encephalopathy. Furosemide, a loop diuretic, can be used as an adjunct or second-line therapy. Bumetanide and amiloride are alternatives, but less preferred. Acetazolamide and thiazide diuretics are not recommended. Common side-effects of diuretics include electrolyte imbalances and renal impairment. Careful monitoring is necessary to ensure safe and effective treatment.

    • This question is part of the following fields:

      • Gastroenterology
      17.5
      Seconds
  • Question 7 - A 29-year-old woman, who previously had a negative HPV smear, has been requested...

    Incorrect

    • A 29-year-old woman, who previously had a negative HPV smear, has been requested to visit the General Practice Surgery to discuss the outcome of her recent smear. The results letter states that she is 'human papillomavirus negative'. As per NICE guidelines, what is the most suitable course of action for managing this patient?

      Your Answer: Refer back to routine screening, repeat in five years

      Correct Answer: Refer back to routine screening, repeat in three years

      Explanation:

      Cervical Screening and Referral Guidelines

      Routine Screening and Recall

      Women between the ages of 25 and 49 are screened for cervical cancer every three years. If a smear sample is negative for high-risk (HR) human papillomavirus (HPV), the patient is referred back to routine recall according to her age group.

      Referral to Colposcopy

      If reflex HR HPV testing is positive, the patient is referred to colposcopy for further assessment within six weeks. Women with high-grade dyskaryosis or abnormalities in glandular cells are referred to colposcopy as urgent appointments to be seen within two weeks. Women with borderline or mild dyskaryosis and who are HR HPV positive are referred to colposcopy as routine appointments to be seen within six weeks.

      HPV Test of Cure

      Women who have undergone treatment for cervical disease are offered an HPV test of cure six months after treatment. If the test is negative for dyskaryosis and HR HPV, the woman is recalled in three years. If the 6-month post-treatment test is negative for dyskaryosis but positive for HR HPV, the woman is re-referred to colposcopy. If there is evidence of high-grade dyskaryosis, the woman is referred back to colposcopy for reassessment.

      Recall Frequency

      Women aged 25-49 are recalled for routine screening every three years. Women aged 50-64 are recalled every five years.

    • This question is part of the following fields:

      • Gynaecology
      121.6
      Seconds
  • Question 8 - As a locum GP, you come across a 40-year-old woman who is experiencing...

    Incorrect

    • As a locum GP, you come across a 40-year-old woman who is experiencing chills, pelvic discomfort, and painful urination. This patient has no history of diabetes. What are the possible urinalysis results that you might expect in this scenario?

      A) Haemoglobin: Negative, Urobilinogen: Negative, Bilirubin: Negative, Protein: +, Glucose: +++, Nitrites: Negative, Leucocytes: +, Ketones: Negative

      B) Haemoglobin: Negative, Urobilinogen: Negative, Bilirubin: Negative, Protein: Negative, Glucose: +, Nitrites: +++, Leucocytes: ++, Ketones: +++

      C) Haemoglobin: +++, Urobilinogen: Negative, Bilirubin: Negative, Protein: Negative, Glucose: Negative, Nitrites: +++, Leucocytes: +++, Ketones: Negative

      D) Haemoglobin: Negative, Urobilinogen: Negative, Bilirubin: Negative, Protein: Negative, Glucose: Negative, Nitrites: ++++, Leucocytes: Negative, Ketones: +++

      E) Haemoglobin: Negative, Urobilinogen: +, Bilirubin: +, Protein: Negative, Glucose: Negative, Nitrites: +++, Leucocytes: Negative, Ketones: Negative

      It is important to note that the urinalysis results may vary depending on the individual patient's condition and medical history. As a healthcare professional, it is crucial to conduct a thorough examination and analysis to determine the appropriate diagnosis and treatment plan for the patient.

      Your Answer: E

      Correct Answer: C

      Explanation:

      Urinalysis Findings in Urinary Tract Infection

      Urinary tract infection (UTI) is a common condition that can be diagnosed through urinalysis. Nitrites and leucocytes are typically present in large amounts in the urine of patients with UTI. Blood may also be present due to inflammation in the bladder or contamination from menstrual bleeding. In some cases, a small amount of glucose may be detected as the body responds to infection by releasing cortisol and adrenaline, which can increase blood glucose levels. However, the presence of protein on urinalysis is usually based on measurement of albumin only, and bacterial proteins are not typically detected using this method. Overall, urinalysis can provide valuable information for diagnosing and managing UTI.

    • This question is part of the following fields:

      • Nephrology
      52.4
      Seconds
  • Question 9 - A toddler girl is brought to the emergency room with her abdominal contents...

    Correct

    • A toddler girl is brought to the emergency room with her abdominal contents protruding from the abdominal cavity. The contents are lined by the peritoneum. Her parents did not seek any prenatal scans during pregnancy.

      What is the most probable diagnosis?

      Your Answer: Omphalocele

      Explanation:

      Common Congenital Abnormalities: An Overview

      Congenital abnormalities are defects present at birth, which can affect various parts of the body. Here are some common congenital abnormalities and their characteristics:

      Omphalocele: This condition occurs when a baby’s abdominal contents protrude outside the abdominal cavity, covered by the sac (amnion). It is associated with other anomalies and requires surgical closure.

      Gastroschisis: In this condition, organs herniate in the abdominal wall, but they are not covered by the peritoneum. It is not associated with other anomalies and has a good prognosis.

      Tracheoesophageal fistula (TOF): TOF refers to a communication between the trachea and oesophagus, usually associated with oesophageal atresia. It can cause choking, coughing, and cyanosis during feeding, and is often accompanied by other congenital anomalies.

      Myelomeningocele: This is a type of spina bifida where the spinal cord and meninges herniate through a hole in the spinal vertebra. It can cause paralysis, incontinence, and other complications, and requires surgical closure and hydrocephalus drainage.

      Meningocele: This is another type of spina bifida where the meninges and fluid herniate through an opening in the vertebral bodies with skin covering. It has a good prognosis and requires surgical closure.

      Understanding these congenital abnormalities can help parents and healthcare providers identify and manage them early on, improving outcomes for affected children.

    • This question is part of the following fields:

      • Paediatrics
      13.8
      Seconds
  • Question 10 - A 35-year-old woman is seen in the epilepsy clinic. She has been effectively...

    Correct

    • A 35-year-old woman is seen in the epilepsy clinic. She has been effectively managing her epilepsy with carbamazepine 400 mg twice daily. She is expecting a baby girl soon and is eager to breastfeed. What guidance should be provided to the patient?

      Your Answer: No changes required

      Explanation:

      There is no need to increase the dose of medication as the patient’s epilepsy is well controlled on the current regimen. Switching from carbamazepine to lamotrigine is also unnecessary and not safer.

      Pregnancy and breastfeeding can be a concern for women with epilepsy. It is generally recommended that women continue taking their medication during pregnancy, as the risks of uncontrolled seizures outweigh the potential risks to the fetus. However, it is important for women to take folic acid before pregnancy to reduce the risk of neural tube defects. The use of antiepileptic medication during pregnancy can increase the risk of congenital defects, but this risk is still relatively low. It is recommended to aim for monotherapy and there is no need to monitor drug levels. Sodium valproate is associated with neural tube defects, while carbamazepine is considered the least teratogenic of the older antiepileptics. Phenytoin is associated with cleft palate, and lamotrigine may require a dose increase during pregnancy. Breastfeeding is generally safe for mothers taking antiepileptics, except for barbiturates. Pregnant women taking phenytoin should be given vitamin K in the last month of pregnancy to prevent clotting disorders in the newborn.

      A warning has been issued about the use of sodium valproate during pregnancy and in women of childbearing age. New evidence suggests a significant risk of neurodevelopmental delay in children following maternal use of this medication. Therefore, it should only be used if clearly necessary and under specialist neurological or psychiatric advice. It is important for women with epilepsy to discuss their options with their healthcare provider and make informed decisions about their treatment during pregnancy and breastfeeding.

    • This question is part of the following fields:

      • Obstetrics
      11.5
      Seconds
  • Question 11 - A patient with rectal cancer in their 60s is seen by the colorectal...

    Incorrect

    • A patient with rectal cancer in their 60s is seen by the colorectal nurse specialist and is told about a special blood test to monitor their disease.
      Which of the following is this most likely to relate to?

      Your Answer: CA-19-9

      Correct Answer: Carcinoembryonic antigen (CEA)

      Explanation:

      Tumour Markers: Types and Uses

      Tumour markers are substances produced by cancer cells or normal cells in response to cancer. They can be used to diagnose cancer, monitor treatment response, and detect recurrence. Here are some common tumour markers and their uses:

      Carcinoembryonic antigen (CEA): This glycoprotein is found in normal mucosal cells but increases in adenocarcinoma, particularly colorectal cancer. It is used to monitor disease, rather than as a diagnostic tool.

      CA-19-9: This intracellular adhesion molecule is highly specific for pancreatic and biliary tract cancers but may also be elevated in other cancers. It has a role in predicting metastatic disease.

      Alpha fetoprotein (AFP): This tumour marker is used for hepatocellular carcinoma and non-seminomatous germ cell tumours. It can be used to screen for hepatocellular carcinomas, especially in high-risk patients.

      C-reactive protein (CRP): This marker indicates acute inflammation and is not specific to cancer.

      CA-125: This glycoprotein is a marker for ovarian cancer but can also be elevated in other intra-abdominal cancers and non-malignant conditions. It is mainly used for monitoring after treatment and if ovarian cancer is suspected.

      In conclusion, tumour markers have various uses in cancer diagnosis and management. However, they should always be interpreted in conjunction with other clinical and imaging findings.

    • This question is part of the following fields:

      • Oncology
      2.9
      Seconds
  • Question 12 - A 25-year-old patient presented with red rashes on their feet. Upon examination, they...

    Incorrect

    • A 25-year-old patient presented with red rashes on their feet. Upon examination, they were found to be pale with purpuric spots on their lower legs. Their temperature was 38.3 °C and they also complained of nausea. On the second day of admission, their fever increased and they became disoriented. New bleeding spots started appearing on their face. Blood reports revealed low hemoglobin, high white cell count, low platelets, and high creatinine levels. A peripheral blood smear showed helmet cells and anisocytosis. The CSF study was normal. What test should be done next for this patient?

      Your Answer: Bone marrow study

      Correct Answer: Urinary β-human chorionic gonadotrophin (hCG)

      Explanation:

      The patient is presenting with thrombotic thrombocytopenic purpura (TTP), which is characterized by low platelet count due to clotting and platelet sequestration in small vessels. TTP is associated with haemolytic anaemia, thrombocytopenic purpura, fever, and neurological and renal abnormalities. The patient’s risk factors for TTP include being female, obese, pregnant, and of Afro-Caribbean origin. To determine the appropriate management, a urinary β-hCG test should be performed to establish pregnancy status. The first-line treatment for TTP is plasma exchange with fresh frozen plasma. Blood cultures should also be performed to check for underlying septicaemia. Antiplatelet antibody titres can be raised in idiopathic thrombocytopenic purpura (ITP), but ITP does not cause renal failure. A bone marrow study is appropriate to rule out leukaemia. Illicit drug use should also be considered as a cause of disseminated intravascular coagulation (DIC).

    • This question is part of the following fields:

      • Haematology
      18.7
      Seconds
  • Question 13 - A 25-year-old woman with a history of glomerulonephritis is scheduled to undergo a...

    Correct

    • A 25-year-old woman with a history of glomerulonephritis is scheduled to undergo a 24-hour urinary protein collection. What is the recommended starting time for the collection?

      Your Answer: Start after the first morning void

      Explanation:

      Guidelines for Accurate 24 Hour Urine Collection

      Twenty four hour urine collections are essential for measuring urinary protein levels and diagnosing various conditions. However, the accuracy and reproducibility of the test can be limited due to the difficulty in performing it correctly. To ensure accurate results, laboratories provide guidelines to patients for the procedure of taking a 24 hour urine collection.

      The guidelines advise patients to use the correct bottle for the test and to read the leaflet about dietary requirements during the test. Some analytes can be affected by diet before and during the test, so it is important to follow the instructions carefully. Patients should also be aware that some bottles contain acid, which prevents degradation of certain analytes and prevents false negative results. If there is a small amount of liquid already in the bottle, patients should not throw it out as it is usually there as a preservative.

      To start the collection, patients should begin after the first void of the day and collect all urine for 24 hours, including the first void the following day. Although the start time does not technically matter, starting after the first void tends to be at a similar time on consecutive days, minimizing error.

      The main errors made in urine collections are overcollection and undercollection. Overcollection occurs when patients collect for more than 24 hours, leading to a falsely high urine protein result. Patients should consider overcollection if urine volumes are greater than 3-4L/day. Undercollection occurs when patients collect for less than 24 hours, leading to a falsely low result. Patients should suspect undercollection if urine volumes are less than 1 L/day. By following these guidelines, patients can ensure accurate and reliable results from their 24 hour urine collection.

    • This question is part of the following fields:

      • Nephrology
      15.7
      Seconds
  • Question 14 - A 32-year-old female with a 10 year history of asthma presents with increasing...

    Incorrect

    • A 32-year-old female with a 10 year history of asthma presents with increasing dyspnoea after returning from a trip to Australia. She has not had a period in three months. On examination, she has a fever of 37.5°C, a pulse rate of 110/min, a blood pressure of 106/74 mmHg, and saturations of 93% on room air. Her respiratory rate is 24/min and auscultation of the chest reveals vesicular breath sounds. Peak flow is 500 L/min and her ECG shows no abnormalities except for a heart rate of 110 bpm. A chest x-ray is normal. What is the most likely diagnosis?

      Your Answer: Acute asthma

      Correct Answer: Pulmonary embolism

      Explanation:

      Risk Factors and Symptoms of Pulmonary Embolism

      This patient presents with multiple risk factors for pulmonary embolism, including air travel and likely pregnancy. She is experiencing tachycardia and hypoxia, which require further explanation. However, there are no indications of a respiratory tract infection or acute asthma. It is important to note that an ECG and CXR may appear normal in cases of pulmonary embolism or may only show baseline tachycardia on the ECG. Therefore, it is crucial to consider the patient’s risk factors and symptoms when evaluating for pulmonary embolism. Proper diagnosis and treatment are essential to prevent potentially life-threatening complications.

    • This question is part of the following fields:

      • Respiratory
      17.4
      Seconds
  • Question 15 - A 29-year-old primigravida is currently in labor for ten hours and has progressed...

    Incorrect

    • A 29-year-old primigravida is currently in labor for ten hours and has progressed through the first stage without any complications. However, the midwife has observed CTG abnormalities and palpated the umbilical cord. The obstetric registrar is called and upon checking the CTG, variable decelerations are noted. What is the primary course of action for addressing the cause of these decelerations?

      Your Answer: Woods' screw manoeuvre

      Correct Answer: Place hand into vagina to elevate presenting part

      Explanation:

      The situation involves cord prolapse leading to cord compression and variable decelerations on the CTG. The RCOG has issued guidelines (Green-top Guidelines No.50) for managing cord prolapse. The guidelines recommend elevating the presenting part either manually or by filling the urinary bladder to prevent cord compression. If fetal heart rate anomalies persist despite using mechanical methods to prevent compression, tocolysis (such as terbutaline) can be considered while preparing for a caesarean section.

      Understanding Umbilical Cord Prolapse

      Umbilical cord prolapse is a rare but serious complication that can occur during delivery. It happens when the umbilical cord descends ahead of the presenting part of the fetus, which can lead to compression or spasm of the cord. This can cause fetal hypoxia and potentially irreversible damage or death. Certain factors increase the risk of cord prolapse, such as prematurity, multiparity, polyhydramnios, twin pregnancy, cephalopelvic disproportion, and abnormal presentations like breech or transverse lie.

      Around half of all cord prolapses occur when the membranes are artificially ruptured. Diagnosis is usually made when the fetal heart rate becomes abnormal and the cord is palpable vaginally or visible beyond the introitus. Cord prolapse is an obstetric emergency that requires immediate management. The presenting part of the fetus may be pushed back into the uterus to avoid compression, and the cord should be kept warm and moist to prevent vasospasm. The patient may be asked to go on all fours or assume the left lateral position until preparations for an immediate caesarian section have been carried out. Tocolytics may be used to reduce uterine contractions, and retrofilling the bladder with saline can help elevate the presenting part. Although caesarian section is the usual first-line method of delivery, an instrumental vaginal delivery may be possible if the cervix is fully dilated and the head is low.

      In conclusion, umbilical cord prolapse is a rare but serious complication that requires prompt recognition and management. Understanding the risk factors and appropriate interventions can help reduce the incidence of fetal mortality associated with this condition.

    • This question is part of the following fields:

      • Obstetrics
      18.5
      Seconds
  • Question 16 - A 26-year-old man is admitted to your psychiatric ward in a state of...

    Correct

    • A 26-year-old man is admitted to your psychiatric ward in a state of distress saying that he knows for certain that his colleagues are plotting to have him dismissed from work. He says they are spreading malicious rumours about his sexuality and, with the help of the CIA, have bugged his office. In the first week of his admission, he is observed to be responding to unseen stimuli when alone in his room. His family state that he is a lovely lad who never gets into any trouble with drink or drugs. They are very worried because in the last 3 months he has told them he can hear people talking about him to each other when he lies in bed at night. He has no significant medical history.
      Which one of the following courses of action would be most appropriate?

      Your Answer: Commence olanzapine with lorazepam and procyclidine as required

      Explanation:

      Treatment Options for Schizophrenia

      Schizophrenia is a serious mental disorder that requires prompt treatment. The following are some treatment options for schizophrenia:

      Commence Olanzapine with Lorazepam and Procyclidine as Required
      Olanzapine is an atypical anti-psychotic that carries a lower risk of extrapyramidal side-effects. However, it is appropriate to prescribe anticholinergic medication such as procyclidine to reduce the risk further. The anti-psychotic action of olanzapine may take up to 10 days to begin, so short-acting benzodiazepines such as lorazepam may be prescribed for sedation.

      Do Not Just Observe with Sedation as Required
      Observing with sedation is not a definitive treatment for schizophrenia. It is essential to commence anti-psychotic medication promptly.

      Commence Chlorpromazine
      Chlorpromazine is a typical anti-psychotic that carries a higher risk of extrapyramidal side-effects. Therefore, atypical anti-psychotics are usually preferred as first-line treatment.

      Commence Clozapine
      Clozapine is the most effective medication for treatment-resistant schizophrenia. However, it carries a small risk of serious complications such as fatal agranulocytosis, myocarditis or cardiomyopathy, and pulmonary embolus. Therefore, it is usually reserved for patients who have not responded to two anti-psychotics given at an appropriate dose for 6-8 weeks.

      Commence Chlorpromazine with Lorazepam and Procyclidine as Required
      Chlorpromazine is a typical anti-psychotic that carries a higher risk of extrapyramidal side-effects. Therefore, it is appropriate to prescribe anticholinergic medication such as procyclidine to reduce the risk. Short-acting benzodiazepines such as lorazepam may also be prescribed for sedation.

    • This question is part of the following fields:

      • Psychiatry
      27
      Seconds
  • Question 17 - A 75-year-old man is scheduled for an elective knee replacement surgery the following...

    Incorrect

    • A 75-year-old man is scheduled for an elective knee replacement surgery the following day. He has type 2 diabetes and is the first patient on the surgery list. His doctor has advised him to continue taking his once-daily dose of metformin and his new anti-diabetic medication on the day of the operation. The patient's physician recently changed his diabetes medication due to hypoglycemic episodes with his previous medication. What is the most probable new antidiabetic medication he is taking?

      Your Answer: Gliclazide

      Correct Answer: Sitagliptin

      Explanation:

      Patients undergoing surgery who are taking DPP-4 inhibitors (-gliptins) and GLP-1 analogues (-tides) can continue taking these medications as normal throughout the perioperative period. However, SGLT-2 blockers such as empagliflozin and dapagliflozin should be omitted on the day of surgery due to the increased risk of diabetic ketoacidosis during periods of dehydration and acute illness. Sulphonylureas like gliclazide should also be omitted until the patient is able to eat and drink again, as they can cause hypoglycaemia in patients who are in a fasted state. It is important to note that the patient in the case scenario may have been taking sulphonylureas in the past, but they are unlikely to be part of their current treatment regimen as they were discontinued by their GP due to side effects.

      Preparation for surgery varies depending on whether the patient is undergoing an elective or emergency procedure. For elective cases, it is important to address any medical issues beforehand through a pre-admission clinic. Blood tests, urine analysis, and other diagnostic tests may be necessary depending on the proposed procedure and patient fitness. Risk factors for deep vein thrombosis should also be assessed, and a plan for thromboprophylaxis formulated. Patients are advised to fast from non-clear liquids and food for at least 6 hours before surgery, and those with diabetes require special management to avoid potential complications. Emergency cases require stabilization and resuscitation as needed, and antibiotics may be necessary. Special preparation may also be required for certain procedures, such as vocal cord checks for thyroid surgery or bowel preparation for colorectal cases.

    • This question is part of the following fields:

      • Surgery
      6.2
      Seconds
  • Question 18 - An 82-year-old retired landscape gardener presents to clinic with his daughter, who is...

    Correct

    • An 82-year-old retired landscape gardener presents to clinic with his daughter, who is concerned about a lesion on his scalp.
      The lesion is 45 mm × 30 mm, irregular, and she feels it has changed colour to become darker over recent months. He states it has occasionally bled and is more raised than before. He has a history of travel with the armed forces in South-East Asia.
      You suspect malignant melanoma.
      Which of the following features is most likely to be associated with a poor prognosis in this patient?

      Your Answer: Depth of lesion on biopsy

      Explanation:

      Understanding Prognostic Indicators for Melanoma Diagnosis

      When it comes to diagnosing melanoma, the depth of the lesion on biopsy is the most crucial factor in determining prognosis. The American Joint Committee on Cancer (AJCC) depth is now used instead of Breslow’s thickness. A raised lesion may indicate nodular malignant melanoma, which has a poor prognosis. Bleeding may occur with malignant melanoma, but it is not a reliable prognostic indicator. While a change in color and irregular border may help identify melanoma, they are not directly linked to prognosis. The size of the lesion is also not a reliable indicator, as depth is required to assess prognosis. Understanding these prognostic indicators is essential for accurate diagnosis and treatment of melanoma.

    • This question is part of the following fields:

      • Dermatology
      8
      Seconds
  • Question 19 - A 23-year-old man presents to the Emergency Department after being involved in a...

    Incorrect

    • A 23-year-old man presents to the Emergency Department after being involved in a fight. He had been in the shower after a gym session, when someone made a derogatory comment about his body, and that started the fight. A history reveals that he has had three girlfriends in the last 3 months, but none of the relationships have lasted. He admits that he struggles to achieve an erection. On examination, the patient is of normal height with normal pubic hair. His penis is small and his breasts are enlarged. He said that he had started growing breasts from the age of 11. This often caused him embarrassment. His blood pressure is 119/73 mmHg.
      Which of the following syndromes must be ruled out?

      Your Answer: Klinefelter syndrome

      Correct Answer: Reifenstein syndrome

      Explanation:

      Comparing Different Syndromes with Similar Symptoms

      When presented with a patient who has female breast development and erectile dysfunction, it is important to consider various syndromes that could be causing these symptoms. One such syndrome is Reifenstein syndrome, which is characterized by partial androgen insensitivity. Another possibility is Turner syndrome, which presents with short stature and amenorrhea in phenotypic females. However, Kallmann syndrome, which includes anosmia as a component, can be ruled out in this case. Similarly, Klinefelter syndrome, which typically results in tall stature and infertility, does not match the patient’s normal height and erectile dysfunction. Finally, 17-α hydroxylase deficiency can be eliminated as a possibility due to the absence of hypertension, which is a common symptom of this enzyme defect. By comparing and contrasting these different syndromes, healthcare professionals can more accurately diagnose and treat patients with similar symptoms.

    • This question is part of the following fields:

      • Endocrinology
      15.4
      Seconds
  • Question 20 - A 16-year-old girl who recently returned from a trip to Italy visits her...

    Incorrect

    • A 16-year-old girl who recently returned from a trip to Italy visits her doctor with complaints of a headache and sore throat. During the examination, the doctor observes swollen tonsils and cervical lymphadenopathy. The girl also has swollen axillary lymph nodes and a palpable mass in the left hypochondriac region upon abdominal examination. What is the most probable diagnosis?

      Your Answer: Cytomegalovirus

      Correct Answer: Infectious mononucleosis

      Explanation:

      Generalised lymphadenopathy can be caused by several conditions, including CMV and Infectious mononucleosis (IM), which are mentioned in the question. However, the presence of large swollen tonsils and a palpable mass in the left hypochondriac regions, which suggests splenomegaly, together with the patient’s history, highly suggests IM. Tonsillitis, viral throat infection, and dengue fever do not typically present with generalised lymphadenopathy or splenomegaly.

      Understanding Infectious Mononucleosis

      Infectious mononucleosis, also known as glandular fever, is a viral infection caused by the Epstein-Barr virus (EBV) in 90% of cases. It is most commonly seen in adolescents and young adults. The classic triad of symptoms includes sore throat, pyrexia, and lymphadenopathy, which are present in around 98% of patients. Other symptoms include malaise, anorexia, headache, palatal petechiae, splenomegaly, hepatitis, lymphocytosis, haemolytic anaemia, and a maculopapular rash. The symptoms typically resolve after 2-4 weeks.

      The diagnosis of infectious mononucleosis is confirmed through a heterophile antibody test (Monospot test) in the second week of the illness. Management is supportive and includes rest, drinking plenty of fluids, avoiding alcohol, and taking simple analgesia for any aches or pains. It is recommended to avoid playing contact sports for 4 weeks after having glandular fever to reduce the risk of splenic rupture.

      Interestingly, there is a correlation between EBV and socioeconomic groups. Lower socioeconomic groups have high rates of EBV seropositivity, having frequently acquired EBV in early childhood when the primary infection is often subclinical. However, higher socioeconomic groups show a higher incidence of infectious mononucleosis, as acquiring EBV in adolescence or early adulthood results in symptomatic disease.

    • This question is part of the following fields:

      • Medicine
      10.4
      Seconds
  • Question 21 - A 67-year-old woman comes to her GP complaining of abdominal discomfort and bloating...

    Correct

    • A 67-year-old woman comes to her GP complaining of abdominal discomfort and bloating that has persisted for six months. The GP initially suspected bowel cancer and referred her for a colonoscopy, which came back negative. The gastroenterologist who performed the colonoscopy suggested that the patient may have irritable bowel syndrome. The patient has no prior history of digestive issues. What should the GP do next?

      Your Answer: Measure serum CA125 level

      Explanation:

      According to NICE guidelines, women over the age of 50 who experience regular symptoms such as abdominal bloating, loss of appetite, pelvic or abdominal pain, and increased urinary urgency and/or frequency should undergo serum CA125 testing. It is important to note that irritable bowel disease rarely presents for the first time in women over 50, so any symptoms suggestive of IBD should prompt appropriate tests for ovarian cancer. If serum CA125 levels are elevated, an ultrasound of the abdomen and pelvis should be arranged. If malignancy is suspected, urgent referral must be made. Physical examination may also warrant direct referral to gynaecology if ascites and/or a suspicious abdominal or pelvic mass is identified.

      Ovarian cancer is a common malignancy in women, ranking fifth in frequency. It is most commonly diagnosed in women over the age of 60 and has a poor prognosis due to late detection. The majority of ovarian cancers, around 90%, are of epithelial origin, with serous carcinomas accounting for 70-80% of cases. Interestingly, recent research suggests that many ovarian cancers may actually originate in the distal end of the fallopian tube. Risk factors for ovarian cancer include a family history of BRCA1 or BRCA2 gene mutations, early menarche, late menopause, and nulliparity.

      Clinical features of ovarian cancer are often vague and can include abdominal distension and bloating, abdominal and pelvic pain, urinary symptoms such as urgency, early satiety, and diarrhea. The initial diagnostic test recommended by NICE is a CA125 blood test, although this can also be elevated in other conditions such as endometriosis and benign ovarian cysts. If the CA125 level is raised, an urgent ultrasound scan of the abdomen and pelvis should be ordered. However, a CA125 test should not be used for screening asymptomatic women. Diagnosis of ovarian cancer is difficult and usually requires a diagnostic laparotomy.

      Management of ovarian cancer typically involves a combination of surgery and platinum-based chemotherapy. Unfortunately, 80% of women have advanced disease at the time of diagnosis, leading to a 5-year survival rate of only 46%. It was previously thought that infertility treatment increased the risk of ovarian cancer due to increased ovulation, but recent evidence suggests that this is not a significant factor. In fact, the combined oral contraceptive pill and multiple pregnancies have been shown to reduce the risk of ovarian cancer by reducing the number of ovulations.

    • This question is part of the following fields:

      • Gastroenterology
      19.7
      Seconds
  • Question 22 - A 35-year-old male was given steroids after a kidney transplant. After two years,...

    Incorrect

    • A 35-year-old male was given steroids after a kidney transplant. After two years, he experienced hip pain and difficulty walking. What is the most probable cause of his symptoms?

      Your Answer: Primary osteoarthritis

      Correct Answer: Avascular necrosis

      Explanation:

      Avascular Necrosis and Its Causes

      Avascular necrosis (AVN) is a condition that occurs when the blood supply to the bones is temporarily or permanently lost. This can be caused by various factors, including trauma or vascular disease. Some of the conditions that can lead to AVN include hypertension, sickle cell disease, caisson disease, and radiation-induced arthritis. Additionally, certain factors such as corticosteroid therapy, connective tissue disease, alcohol abuse, marrow storage disease (Gaucher’s disease), and dyslipoproteinaemia can also be associated with AVN in a more complex manner.

      Of all the cases of non-traumatic avascular necrosis, 35% are associated with systemic (oral or intravenous) corticosteroid use. It is important to understand the causes of AVN in order to prevent and manage the condition effectively. By identifying the underlying factors that contribute to AVN, healthcare professionals can develop appropriate treatment plans and help patients manage their symptoms. With proper care and management, individuals with AVN can lead healthy and fulfilling lives.

    • This question is part of the following fields:

      • Nephrology
      9.8
      Seconds
  • Question 23 - A 55-year-old woman presents to her primary care physician with complaints of lower...

    Correct

    • A 55-year-old woman presents to her primary care physician with complaints of lower abdominal pain and intermittent haematuria over the past two weeks. She has no significant medical history and is not taking any medications. An abdominal ultrasound reveals a bladder lesion, and a flexible cystoscopy is performed, which confirms the presence of carcinoma-in-situ bladder cancer. What would be an appropriate treatment plan for this patient?

      Your Answer: Transurethral resection of the superficial lesions

      Explanation:

      Carcinoma in situ (CIS) is a type of bladder cancer that is considered high-grade and superficial. Unlike papillary carcinoma, CIS is more likely to invade surrounding structures. As a result, patients with CIS undergo transurethral removal of bladder tumour (TURBT) and receive intravesicle chemotherapy to reduce the risk of recurrence. Invasive bladder cancer is typically treated with radical cystectomy. It is not recommended to use watchful waiting or active surveillance for CIS in healthy patients due to its invasive potential. Hormone-based therapies are not effective in managing bladder cancer.

      Bladder cancer is the second most common urological cancer, with males aged between 50 and 80 years being the most commonly affected. Smoking and exposure to hydrocarbons such as 2-Naphthylamine increase the risk of the disease. Chronic bladder inflammation from Schistosomiasis infection is a common cause of squamous cell carcinomas in countries where the disease is endemic. Benign tumors of the bladder, including inverted urothelial papilloma and nephrogenic adenoma, are uncommon.

      Urothelial (transitional cell) carcinoma is the most common type of bladder malignancy, accounting for over 90% of cases. Squamous cell carcinoma and adenocarcinoma are less common. Urothelial carcinomas may be solitary or multifocal, with up to 70% having a papillary growth pattern. Superficial tumors have a better prognosis, while solid growths are more prone to local invasion and may be of higher grade, resulting in a worse prognosis. TNM staging is used to determine the extent of the tumor and the presence of nodal or distant metastasis.

      Most patients with bladder cancer present with painless, macroscopic hematuria. Incidental microscopic hematuria may also indicate malignancy in up to 10% of females over 50 years old. Diagnosis is made through cystoscopy and biopsies or transurethral resection of bladder tumor (TURBT), with pelvic MRI and CT scanning used to determine locoregional spread and distant disease. Treatment options include TURBT, intravesical chemotherapy, radical cystectomy with ileal conduit, or radical radiotherapy, depending on the extent and grade of the tumor. Prognosis varies depending on the stage of the tumor, with T1 having a 90% survival rate and any T with N1-N2 having a 30% survival rate.

    • This question is part of the following fields:

      • Surgery
      10.5
      Seconds
  • Question 24 - A 25-year-old man has suffered a left-sided pneumothorax. A chest drain has been...

    Incorrect

    • A 25-year-old man has suffered a left-sided pneumothorax. A chest drain has been inserted through the left fifth intercostal space at the mid-axillary line.
      As well as the intercostal muscles, which other muscle is likely to have been pierced?

      Your Answer: Pectoralis major

      Correct Answer: Serratus anterior

      Explanation:

      Muscles and Chest Drains: Understanding the Anatomy

      The human body is a complex system of muscles, bones, and organs that work together to keep us alive and functioning. When it comes to chest drains, understanding the anatomy of the surrounding muscles is crucial for successful placement and management. Let’s take a closer look at some of the key muscles involved.

      Serratus Anterior
      The serratus anterior muscle is located on the lateral chest and plays a vital role in protracting the scapula and contributing to rotation. It is likely to be pierced with most chest drains due to its position, with its lower four segments attaching to the fifth to eighth ribs anterior to the mid-axillary line.

      Latissimus Dorsi
      The latissimus dorsi muscle is a back muscle involved in adduction, medial rotation, and extension of the shoulder. It is not pierced by a chest drain.

      External Oblique
      The external oblique muscle is located in the anterior abdomen and is not involved with a chest drain.

      Pectoralis Major
      The pectoralis major muscle is situated in the anterior chest and is not affected by a chest drain, as it does not overlie the fifth intercostal space at the mid-axillary line. It flexes, extends, medially rotates, and adducts the shoulder.

      Pectoralis Minor
      The pectoralis minor muscle lies inferior to the pectoralis major on the anterior chest. It is a small muscle and is not usually pierced with a chest drain, as it does not overlie the fifth intercostal space at the mid-clavicular line.

      In conclusion, understanding the anatomy of the muscles surrounding the chest is essential for successful chest drain placement and management. Knowing which muscles are likely to be pierced and which are not can help healthcare professionals provide the best possible care for their patients.

    • This question is part of the following fields:

      • Respiratory
      13.6
      Seconds
  • Question 25 - A 32 weeks pregnant woman, who is G2 P0, presents to the emergency...

    Incorrect

    • A 32 weeks pregnant woman, who is G2 P0, presents to the emergency department with vaginal bleeding. She had suffered from severe nausea and vomiting earlier in the pregnancy which has now resolved. She has no abdominal pain, no vaginal discharge, no headache, and no pruritus. On abdominal examination, purple striae were noted on the abdomen as well as a dark line running vertically down the middle of the abdomen. A transverse lie is noticed and there is no fetal engagement. The symphyseal-fundal height is 33cm.
      What is the best gold standard investigation to perform?

      Your Answer: Pelvic ultrasound

      Correct Answer: Transvaginal ultrasound scan

      Explanation:

      It is not advisable to conduct a digital vaginal examination in cases of suspected placenta praevia without first performing an ultrasound, as this could potentially trigger a dangerous hemorrhage.

      Understanding Placenta Praevia

      Placenta praevia is a condition where the placenta is located wholly or partially in the lower uterine segment. It is a relatively rare condition, with only 5% of women having a low-lying placenta when scanned at 16-20 weeks gestation. However, the incidence at delivery is only 0.5%, as most placentas tend to rise away from the cervix.

      There are several factors associated with placenta praevia, including multiparity, multiple pregnancy, and embryos implanting on a lower segment scar from a previous caesarean section. Clinical features of placenta praevia include shock in proportion to visible loss, no pain, a non-tender uterus, abnormal lie and presentation, and a usually normal fetal heart. Coagulation problems are rare, and small bleeds may occur before larger ones.

      Diagnosis of placenta praevia should not involve digital vaginal examination before an ultrasound, as this may provoke severe haemorrhage. The condition is often picked up on routine 20-week abdominal ultrasounds, but the Royal College of Obstetricians and Gynaecologists recommends the use of transvaginal ultrasound for improved accuracy and safety. Placenta praevia is classified into four grades, with grade IV being the most severe, where the placenta completely covers the internal os.

      In summary, placenta praevia is a rare condition that can have serious consequences if not diagnosed and managed appropriately. It is important for healthcare professionals to be aware of the associated factors and clinical features, and to use appropriate diagnostic methods for accurate grading and management.

    • This question is part of the following fields:

      • Obstetrics
      24.6
      Seconds
  • Question 26 - A 27-year-old man dressed in casual attire has been admitted to the psychiatric...

    Correct

    • A 27-year-old man dressed in casual attire has been admitted to the psychiatric intensive care unit. He is asked why he was admitted and he responds 'It all started at my workplace, everyone is so busy making money, I've been busy too. I'm investing in stocks, trying to make some extra cash, I keep a record of it in my notebook, I love writing, I write all the time because I'm trying to find a cure for Alzheimer's'. The speech is rapid and has a sense of urgency and when being asked further questions he demonstrates the same behaviour.

      What best describes this patient's behaviour?

      Your Answer: Flight of ideas

      Explanation:

      The patient’s speech pattern is most likely flight of ideas, as there are discernible links between each sentence despite conveying different messages. This is commonly seen in manic episodes. Knight’s move thinking, which involves random and illogical leaps between ideas, is not present in this case. Circumstantiality, where excessive and unnecessary detail is given before eventually answering a question, and perseveration, where a patient repeats a phrase or word despite moving on from the initial question, are also not applicable.

      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.

    • This question is part of the following fields:

      • Psychiatry
      6.1
      Seconds
  • Question 27 - A 65-year-old woman presented to the Emergency Department with complaints of a painful...

    Correct

    • A 65-year-old woman presented to the Emergency Department with complaints of a painful hand. Upon further examination, it was discovered that she had sustained a Colles' fracture. A DEXA scan was performed, revealing a T-score of -2.7 from L2-L4 and -2.8 in the right hip. The patient is currently taking omeprazole for gastro-oesophageal reflux disease.

      Na+ 140 mmol/L (135 - 145)
      K+ 3.5 mmol/L (3.5 - 5.0)
      Urea 4.5 mmol/L (2.0 - 7.0)
      Creatinine 85 µmol/L (55 - 120)
      Calcium 1.95 mmol/L (2.1 - 2.6)
      Phosphate 1.2 mmol/L (0.8 - 1.4)
      Magnesium 0.55 mmol/L (0.7 - 1.0)
      Vitamin D 115 nmol/L (50 - 250)
      Parathyroid hormone (PTH) 2.1 pmol/L (1.6 – 8.5)

      What would be the most appropriate course of action at this point?

      Your Answer: Correct calcium level then commence alendronate

      Explanation:

      Before starting bisphosphonate treatment for osteoporosis, it is important to correct any hypocalcemia or vitamin D deficiency. This is because bisphosphonates work by inhibiting bone loss through osteoclastic activity, which is also responsible for increasing calcium levels in the body. Therefore, correcting calcium and vitamin D levels prior to treatment is necessary to ensure proper calcium regulation during therapy. Serum calcium levels should also be monitored during treatment. Alendronate is the first-line treatment for osteoporosis, but it should only be started after correcting any hypocalcemia. Oral calcium tablets alone are not appropriate for this patient, as the cause of hypocalcemia should be considered first. In this case, the low magnesium level should be corrected, as magnesium is required for PTH secretion and sensitivity. Raloxifene is an alternative treatment option for osteoporosis, but it should only be considered if the patient cannot tolerate bisphosphonates. It is also important to note that proton pump inhibitors can increase the risk of osteoporosis and cause hypomagnesemia.

      Bisphosphonates: Uses and Adverse Effects

      Bisphosphonates are drugs that mimic the action of pyrophosphate, a molecule that helps prevent bone demineralization. They work by inhibiting osteoclasts, which are cells that break down bone tissue. This reduces the risk of bone fractures and can be used to treat conditions such as osteoporosis, hypercalcemia, Paget’s disease, and pain from bone metastases.

      However, bisphosphonates can have adverse effects, including oesophageal reactions such as oesophagitis and ulcers, osteonecrosis of the jaw, and an increased risk of atypical stress fractures of the proximal femoral shaft in patients taking alendronate. Patients may also experience an acute phase response, which can cause fever, myalgia, and arthralgia. Hypocalcemia, or low calcium levels, can also occur due to reduced calcium efflux from bone, but this is usually not clinically significant.

      To minimize the risk of adverse effects, patients taking oral bisphosphonates should swallow the tablets whole with plenty of water while sitting or standing. They should take the medication on an empty stomach at least 30 minutes before breakfast or other oral medications and remain upright for at least 30 minutes after taking the tablet. Hypocalcemia and vitamin D deficiency should be corrected before starting bisphosphonate treatment, and calcium supplements should only be prescribed if dietary intake is inadequate. The duration of bisphosphonate treatment varies depending on the patient’s level of risk, and some authorities recommend stopping treatment after five years for low-risk patients with a femoral neck T-score of > -2.5.

    • This question is part of the following fields:

      • Musculoskeletal
      26.5
      Seconds
  • Question 28 - A 30-year-old man comes to the dermatology clinic with several small fleshy nodules...

    Incorrect

    • A 30-year-old man comes to the dermatology clinic with several small fleshy nodules around and under his finger and toe nails. Upon further inquiry, it is revealed that the patient has a history of seizures that are hard to manage.
      What is the probable underlying condition?

      Your Answer: Neurofibromatosis I

      Correct Answer: Tuberous sclerosis

      Explanation:

      Genetic Tumor Disorders and Their Skin Manifestations

      There are several genetic disorders that predispose individuals to the formation of tumors, including those in the nervous system. These disorders can also have distinct skin manifestations that aid in their diagnosis.

      Tuberous Sclerosis: This rare multisystem genetic disease is caused by abnormalities on chromosome 9 and leads to the formation of benign tumors (hamartomas) in various organs, including the brain, eyes, skin, kidney, and heart. Skin problems associated with tuberous sclerosis include periungual fibromas, adenoma sebaceum, ‘ash leaf’ hypomelanotic macules, café-au-lait patches, subcutaneous nodules, and shagreen patches. Neurological symptoms such as seizures, developmental delay, behavioral problems, and learning difficulties can also occur.

      Neurofibromatosis I: This inherited condition causes tumors (neurofibromas) to grow within the nervous system and is characterized by café-au-lait spots on the skin.

      Von Hippel-Lindau Disease: This inherited tumor disorder is caused by a mutation in a tumor suppressor gene on chromosome 3 and is commonly associated with angiomatosis, hemangioblastomas, and pheochromocytomas.

      Neurofibromatosis II: This disorder presents with bilateral hearing loss due to the development of bilateral acoustic neuromas.

      Sturge-Weber Syndrome: This congenital disorder is identified by a port-wine stain on the forehead, scalp, or around the eye.

    • This question is part of the following fields:

      • Dermatology
      8
      Seconds
  • Question 29 - Before undergoing general anaesthesia, which regular medications need to be stopped? ...

    Incorrect

    • Before undergoing general anaesthesia, which regular medications need to be stopped?

      Your Answer: Carbamazepine

      Correct Answer: Phenelzine

      Explanation:

      Medication Management in Perioperative Period

      Phenelzine and tranylcypromine are monoamine oxidase inhibitors that need to be discontinued at least two weeks before elective surgery due to their potential life-threatening interactions with pethidine and indirect sympathomimetics. Additionally, they can prolong the action of suxamethonium by decreasing the concentration of plasma cholinesterase. Carbamazepine, an anticonvulsant, should be continued throughout the perioperative period. Gliclazide, a short-acting oral hypoglycemic, can be taken if the surgery’s anticipated duration is short.

      Lisinopril, an angiotensin-converting enzyme inhibitor (ACEi), and digoxin, a cardiac glycoside, should be continued pre-operatively. Morphine sulfate tablets should also be continued pre-operatively, and a morphine infusion (PCA) should be considered for postoperative analgesia. Pyridostigmine is used in the management of myasthenia gravis and should be continued before minor surgery. However, if perioperative muscle relaxation is required, omitting one or more doses of pyridostigmine would allow a reduction in the dose of the muscle relaxant. Proper medication management in the perioperative period is crucial to ensure patient safety and optimal surgical outcomes.

    • This question is part of the following fields:

      • Anaesthetics & ITU
      5.3
      Seconds
  • Question 30 - A 27-year-old woman has been experiencing a pattern of tumultuous endings in all...

    Correct

    • A 27-year-old woman has been experiencing a pattern of tumultuous endings in all of her relationships. She confides in you that she seems to have a knack for choosing friends and romantic partners who ultimately reveal themselves to be awful people.
      What defense mechanism is most likely at play in this patient?

      Your Answer: Splitting

      Explanation:

      Defense Mechanisms: Understanding How We Cope

      Defense mechanisms are psychological strategies that we use to protect ourselves from anxiety and emotional pain. These mechanisms are often unconscious and can be both adaptive and maladaptive. Here are some common defense mechanisms and their explanations:

      Splitting: This is a common defense mechanism in borderline personality disorder. It involves seeing people as either all good or all bad, and the inability to reconcile both good and bad traits in a person.

      Dissociation: This is an immature defense mechanism where one’s personal identity is temporarily modified to avoid distress. An extreme form is dissociative identity disorder.

      Identification: This is when someone models the behavior of a more powerful example. An example would be a victim of child abuse becoming a child abuser in adulthood.

      Sublimation: This is a mature defense mechanism where the person takes an unacceptable personality trait and uses it to drive a respectable work that does not conflict with their value system.

      Reaction formation: This is an immature defense mechanism where unacceptable emotions are repressed and replaced by their exact opposite. A classic example is a man with homoerotic desires championing anti-homosexual public policy.

      Understanding these defense mechanisms can help us recognize when we are using them and how they may be impacting our relationships and mental health.

    • This question is part of the following fields:

      • Psychiatry
      4.9
      Seconds

SESSION STATS - PERFORMANCE PER SPECIALTY

Pharmacology (1/2) 50%
Trauma (1/1) 100%
Musculoskeletal (1/2) 50%
Gastroenterology (1/3) 33%
Gynaecology (0/1) 0%
Nephrology (1/3) 33%
Paediatrics (1/1) 100%
Obstetrics (1/3) 33%
Oncology (0/1) 0%
Haematology (0/1) 0%
Respiratory (0/2) 0%
Psychiatry (3/3) 100%
Surgery (1/2) 50%
Dermatology (1/2) 50%
Endocrinology (0/1) 0%
Medicine (0/1) 0%
Anaesthetics & ITU (0/1) 0%
Passmed