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Question 1
Correct
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A 75-year-old man is admitted to the hospital with abdominal pain and confusion that has been worsening for the past 5 days. He has also experienced a decline in vision, with reduced acuity and altered colour perception. The patient had recently suffered from vomiting and diarrhoea, which had affected many others at his nursing home. Staff report that he has produced very little urine since then. The patient has a medical history of atrial fibrillation, hypertension, hypercholesterolaemia, and depression. His blood tests reveal Hb 185 g/l, platelets 435 * 109/l, WBC 11 * 109/l, Na+ 144 mmol/l, K+ 5.3 mmol/l, urea 28 mmol/l, and creatinine 170 µmol/l. Can you identify which of his regular medications may be causing his current presentation?
Your Answer: Digoxin
Explanation:Digoxin toxicity can be triggered by impaired kidney function.
When renal function is compromised, digoxin can accumulate in the body due to its predominantly renal excretion. This can result in toxicity, particularly in elderly patients. In this case, acute kidney injury caused by dehydration from vomiting and diarrhea has led to increased serum levels of digoxin. Digoxin toxicity is characterized by visual disturbances (such as yellow vision or reduced acuity) and non-specific symptoms like confusion, nausea, vomiting, and lethargy. None of the other options listed can cause toxicity in renal failure.
Understanding Digoxin and Its Toxicity
Digoxin is a medication used for rate control in atrial fibrillation and for improving symptoms in heart failure patients. It works by decreasing conduction through the atrioventricular node and increasing the force of cardiac muscle contraction. However, it has a narrow therapeutic index and requires monitoring for toxicity.
Toxicity may occur even when the digoxin concentration is within the therapeutic range. Symptoms of toxicity include lethargy, nausea, vomiting, anorexia, confusion, yellow-green vision, arrhythmias, and gynaecomastia. Hypokalaemia is a classic precipitating factor, as it allows digoxin to more easily bind to the ATPase pump and increase its inhibitory effects. Other factors that may contribute to toxicity include increasing age, renal failure, myocardial ischaemia, electrolyte imbalances, hypoalbuminaemia, hypothermia, hypothyroidism, and certain medications such as amiodarone, quinidine, and verapamil.
Management of digoxin toxicity involves the use of Digibind, correction of arrhythmias, and monitoring of potassium levels. It is important to recognize the potential for toxicity and monitor patients accordingly to prevent adverse outcomes.
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This question is part of the following fields:
- Pharmacology
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Question 2
Correct
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Sarah is a 19-year-old woman who visits her GP complaining of myalgia and fatigue. She has no significant medical history. In the past, she had a rash on her cheeks that did not improve with anti-fungal cream.
During the examination, her vital signs are normal, and there is no joint swelling or redness. However, she experiences tenderness when her hands are squeezed. Sarah's muscle strength is 5/5 in all groups.
Sarah's maternal aunt has been diagnosed with systemic lupus erythematosus (SLE), and she is worried that she might have it too.
Which of the following blood tests, if negative, can be a useful test to rule out SLE?Your Answer: ANA
Explanation:A useful test to rule out SLE is ANA positivity, as the majority of patients with SLE are ANA positive. While CRP and ESR may rise during an acute flare of SLE, they are not specific to autoimmune conditions. ANCA is an antibody found in patients with autoimmune vasculitis.
Systemic lupus erythematosus (SLE) can be investigated through various tests, including antibody tests. ANA testing is highly sensitive, making it useful for ruling out SLE, but it has low specificity. About 99% of SLE patients are ANA positive. Rheumatoid factor testing is positive in 20% of SLE patients. Anti-dsDNA testing is highly specific (>99%), but less sensitive (70%). Anti-Smith testing is also highly specific (>99%), but only 30% of SLE patients test positive. Other antibody tests include anti-U1 RNP, SS-A (anti-Ro), and SS-B (anti-La).
Monitoring of SLE can be done through various markers, including inflammatory markers such as ESR. During active disease, CRP levels may be normal, but a raised CRP may indicate an underlying infection. Complement levels (C3, C4) are low during active disease due to the formation of complexes that lead to the consumption of complement. Anti-dsDNA titres can also be used for disease monitoring, but it is important to note that they are not present in all SLE patients. Proper monitoring of SLE is crucial for effective management of the disease.
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This question is part of the following fields:
- Musculoskeletal
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Question 3
Incorrect
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A 27-year-old man presents with a persistent cough for the past 20 days which initially started with a few days of cold symptoms. He describes it as ‘the worst cough I've ever had’. He has bouts of coughing followed by an inspiratory gasp. This is usually worse at night and can be so severe that he sometimes vomits. He is otherwise fit and well and confirms he completed all his childhood immunisations. Examination of his chest is unremarkable.
What is the most suitable initial management for this likely diagnosis?Your Answer: Start a course of oral doxycycline
Correct Answer: Start a course of oral clarithromycin
Explanation:If the onset of cough is within the previous 21 days, the recommended first-line treatment for whooping cough is a course of oral clarithromycin or azithromycin. In this case, the correct answer is to start a course of oral clarithromycin as the patient’s history is consistent with whooping cough. Starting treatment within 21 days of onset of the cough can help to reduce the risk of spread. It is incorrect to not start any treatment as the patient has presented within the appropriate timeframe. Offering an immediate booster vaccination is also not indicated in the initial management of the index case, and starting a course of oral doxycycline is not the first-line treatment for whooping cough.
Whooping Cough: Causes, Symptoms, Diagnosis, and Management
Whooping cough, also known as pertussis, is a contagious disease caused by the bacterium Bordetella pertussis. It is commonly found in children, with around 1,000 cases reported annually in the UK. The disease is characterized by a persistent cough that can last up to 100 days, hence the name cough of 100 days.
Infants are particularly vulnerable to whooping cough, which is why routine immunization is recommended at 2, 3, 4 months, and 3-5 years. However, neither infection nor immunization provides lifelong protection, and adolescents and adults may still develop the disease.
Whooping cough has three phases: the catarrhal phase, the paroxysmal phase, and the convalescent phase. The catarrhal phase lasts around 1-2 weeks and presents symptoms similar to a viral upper respiratory tract infection. The paroxysmal phase is characterized by a severe cough that worsens at night and after feeding, and may be accompanied by vomiting and central cyanosis. The convalescent phase is when the cough subsides over weeks to months.
To diagnose whooping cough, a person must have an acute cough that has lasted for 14 days or more without another apparent cause, and have one or more of the following features: paroxysmal cough, inspiratory whoop, post-tussive vomiting, or undiagnosed apnoeic attacks in young infants. A nasal swab culture for Bordetella pertussis is used to confirm the diagnosis, although PCR and serology are increasingly used.
Infants under 6 months with suspected pertussis should be admitted, and in the UK, pertussis is a notifiable disease. An oral macrolide, such as clarithromycin, azithromycin, or erythromycin, is indicated if the onset of the cough is within the previous 21 days to eradicate the organism and reduce the spread. Household contacts should be offered antibiotic prophylaxis, although antibiotic therapy has not been shown to alter the course of the illness. School exclusion is recommended for 48 hours after commencing antibiotics or 21 days from onset of symptoms if no antibiotics are given.
Complications of whooping cough include subconjunctival haemorrhage, pneumonia, bronchiectasis, and
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This question is part of the following fields:
- Paediatrics
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Question 4
Correct
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A 30-year-old female without underlying medical conditions undergoes a tonsillectomy and suddenly experiences a fever spike up to 40°C. Her heart rate increases to 160 beats per minute and her systolic blood pressure is measured at 180 mmHg. Additionally, the patient displays signs of muscle rigidity in her limbs. Prior to the surgery, her pre-anesthetic evaluation was unremarkable, and there is no known family history of neuromuscular disease or complications during surgery or anesthesia. The patient was induced with propofol and suxamethonium.
What is the definitive treatment for this patient in this situation?Your Answer: Dantrolene
Explanation:Suxamethonium can cause malignant hyperthermia in susceptible individuals, which is a serious side effect that requires treatment with IV dantrolene. Malignant hyperthermia is a genetic disorder that causes a hypermetabolic crisis, including hypercapnia, tachycardia, muscle rigidity, rhabdomyolysis, hyperthermia, and arrhythmia. It is often associated with volatile inhalational anesthetics and suxamethonium. Dantrolene is the only effective treatment for malignant hyperthermia and should be given intravenously. There is no evidence to support the use of IV hydrocortisone in the treatment of malignant hyperthermia. Flumazenil is an antidote for benzodiazepine overdose, while N-acetylcysteine is an antidote for paracetamol overdose.
Understanding Neuromuscular Blocking Drugs
Neuromuscular blocking drugs are commonly used in surgical procedures as an adjunct to anaesthetic agents. These drugs are responsible for inducing muscle paralysis, which is a necessary prerequisite for mechanical ventilation. There are two types of neuromuscular blocking drugs: depolarizing and non-depolarizing.
Depolarizing neuromuscular blocking drugs bind to nicotinic acetylcholine receptors, resulting in persistent depolarization of the motor end plate. On the other hand, non-depolarizing neuromuscular blocking drugs act as competitive antagonists of nicotinic acetylcholine receptors. Examples of depolarizing neuromuscular blocking drugs include succinylcholine (also known as suxamethonium), while examples of non-depolarizing neuromuscular blocking drugs include tubcurarine, atracurium, vecuronium, and pancuronium.
While these drugs are effective in inducing muscle paralysis, they also come with potential adverse effects. Depolarizing neuromuscular blocking drugs may cause malignant hyperthermia and transient hyperkalaemia, while non-depolarizing neuromuscular blocking drugs may cause hypotension. However, these adverse effects can be reversed using acetylcholinesterase inhibitors such as neostigmine.
It is important to note that suxamethonium is contraindicated for patients with penetrating eye injuries or acute narrow angle glaucoma, as it increases intra-ocular pressure. Additionally, suxamethonium is the muscle relaxant of choice for rapid sequence induction for intubation and may cause fasciculations. Understanding the mechanism of action and potential adverse effects of neuromuscular blocking drugs is crucial in ensuring their safe and effective use in surgical procedures.
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This question is part of the following fields:
- Surgery
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Question 5
Incorrect
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A 63-year-old man presented with progressive dyspnoea and cough over two years. He was previously employed in a ceramic factory as chief supervisor.
What is the most probable radiological finding in this patient?Your Answer: Rounded nodules in upper zones with lower zone emphysema
Correct Answer: Small numerous opacities in upper lung zones with hilar lymphadenopathy
Explanation:Understanding Silicosis: Radiological Findings and Risk Factors
Silicosis is a lung disease that can develop many years after exposure to silica, which is commonly found in clay used in ceramic factories. Other toxic chemicals found in ceramic factories, such as talc, lead, chromium, sulfur dioxide, and metal fumes, can also increase the risk of developing silicosis.
Radiological findings of silicosis include small numerous opacities in the upper lung zones with hilar lymphadenopathy, which may show egg shell calcification. In later stages, rounded nodules in the upper zones with lower zone emphysema may also be present. However, progressive massive fibrosis is not a common finding in silicosis lungs.
Silicosis per se does not cause lung cavitation, but it can be complicated by tuberculosis, which may lead to the formation of cavities. In acute silicosis, lower zone alveolar opacities may be present, which can lead to acute respiratory failure.
Overall, understanding the radiological findings and risk factors of silicosis is important for early detection and prevention of this debilitating lung disease.
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This question is part of the following fields:
- Respiratory
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Question 6
Incorrect
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A 25-year-old ice hockey player was tackled by a member of the opposite team and fell on the ice, hitting the right side of his head. He was disoriented but was able to continue the game. The following evening, his roommate tried to wake him but found him unconscious in a pool of vomit.
What is the most probable finding in a CT scan of his head?Your Answer: Unilateral crescent-shaped shadow along the lateral cortex
Correct Answer: Unilateral biconvex-shaped shadow along the lateral cortex
Explanation:Understanding CT Scans: Interpreting Brain Hematomas
Brain hematomas are a serious medical condition that require prompt diagnosis and treatment. CT scans are often used to identify the location and type of hematoma present in the brain. Here are some key points to keep in mind when interpreting CT scans of brain hematomas:
Unilateral Biconvex-Shaped Shadow Along the Lateral Cortex
This is a classic case of an extradural hematoma, which occurs when temporal skull fractures damage the middle meningeal artery. Blood accumulates under arterial pressure, causing separation of the dura from the inner surface of the skull. A lucid period of several hours without symptoms may occur, but rapid blood accumulation will increase intracranial pressure, leading to uncal or transtentorial herniation and death.Bilateral Crescent-Shaped Shadow Along the Lateral Cortex
This is an incorrect interpretation because bilateral accumulation of blood is unlikely when the patient has only injured one side of their head.Unilateral Crescent-Shaped Shadow Along the Lateral Cortex
This describes a subdural hematoma, which occurs when blood accumulates between the inner surface of the dura and the outer arachnoid layer of the leptomeninges. This type of hematoma appears as a crescent-shaped shadow on a CT scan.Unilateral Biconvex-Shaped Area Along the Anterior Cortex
This is also an incorrect interpretation because accumulation of blood occurs beside the torn artery, which is typically located along the lateral cortex.Shifting of the Brain Midline Towards the Side of the Lesion
This is an incorrect interpretation because pressure due to an accumulation of blood will tend to shift the midline of the brain to the opposite side of the lesion.In summary, understanding the different types of brain hematomas and their corresponding CT scan appearances is crucial for accurate diagnosis and treatment.
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This question is part of the following fields:
- Neurosurgery
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Question 7
Correct
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A 14-year-old boy comes to the clinic with scaly patches on his scalp. Upon examination, circular areas of hair loss with scaling and raised margins, measuring 2-5 cm in diameter, are observed. There is no scarring. What is the probable cause of this condition in the patient?
Your Answer: Tinea capitis
Explanation:Causes of Non-Scarring and Scarring Alopecia
Non-scarring alopecia is a condition where hair loss occurs without any visible scarring on the scalp. The most common causes of this type of alopecia include telogen effluvium, androgenetic alopecia, alopecia areata, tinea capitis, and traumatic alopecia. In some cases, non-scarring alopecia can also be associated with lupus erythematosus and secondary syphilis.
Tinea capitis, caused by invasion of hairs by dermatophytes, most commonly Trichophyton tonsurans, is a common cause of non-scarring alopecia. This type of alopecia is characterized by hair loss in circular patches on the scalp.
On the other hand, scarring alopecia is a condition where hair loss occurs with visible scarring on the scalp. This type of alopecia is more frequently the result of a primary cutaneous disorder such as lichen planus, folliculitis decalvans, cutaneous lupus, or linear scleroderma (morphea). Scarring alopecia can be permanent and irreversible, making early diagnosis and treatment crucial.
In conclusion, the different causes of non-scarring and scarring alopecia is important in determining the appropriate treatment plan for patients experiencing hair loss.
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This question is part of the following fields:
- Dermatology
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Question 8
Correct
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A 40-year-old asthmatic has been admitted to the hospital with a worsening wheeze that has persisted for 24 hours. You are urgently called as the patient has become acutely short of breath despite receiving three sets of salbutamol nebulisers. The patient is now hypotensive and desaturating. Upon examination, you notice reduced air entry with a resonant percussion note in the left lung field and a trachea deviated to the right. Based on these symptoms, what is the most likely diagnosis?
Your Answer: Tension pneumothorax
Explanation:Urgent Treatment for Evolving Pneumothorax
This patient is showing clinical signs of a developing pneumothorax, which requires urgent treatment. While a tension pneumothorax is typically associated with a deviated trachea and hyper-resonance, these signs may not appear until later stages. It is possible that the patient has a simple pneumothorax, but given their hypotension, urgent needle decompression is necessary to treat a potential tension pneumothorax. In such cases, chest imaging should not be prioritized over immediate intervention. The procedure involves inserting a large bore needle in the second intercostal space in the mid-clavicular line, followed by a chest drain.
Pneumonia can often trigger asthma exacerbations, which can lead to severe chest sepsis and SIRS criteria evolving into severe sepsis. In such cases, ARDS may be the predominant clinical picture with wet lung fields. While massive pulmonary embolism can also cause desaturation and hypotension, there are no other apparent risk factors in this patient’s case. It is important to note that while acute asthma exacerbations can cause anxiety, the diagnosis of panic attacks should only be made after excluding other potential causes.
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This question is part of the following fields:
- Emergency Medicine
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Question 9
Correct
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A 32-year-old woman who is 32 weeks pregnant presents with vaginal bleeding and is diagnosed with placenta accreta. What is the primary risk factor associated with this condition?
Your Answer: Previous caesarean sections
Explanation:Understanding Placenta Accreta
Placenta accreta is a condition where the placenta attaches to the myometrium instead of the decidua basalis, which can lead to postpartum hemorrhage. This condition is caused by a defective decidua basalis. There are three types of placenta accreta, which are categorized based on the degree of invasion. The first type is accreta, where the chorionic villi attach to the myometrium. The second type is increta, where the chorionic villi invade into the myometrium. The third type is percreta, where the chorionic villi invade through the perimetrium.
There are certain risk factors that increase the likelihood of developing placenta accreta, such as having a previous caesarean section or placenta previa. It is important for healthcare providers to be aware of these risk factors and monitor patients closely during pregnancy and delivery. Early detection and management of placenta accreta can help prevent complications and ensure the best possible outcome for both the mother and baby.
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This question is part of the following fields:
- Obstetrics
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Question 10
Correct
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The hypothalamus is responsible for producing which hormones?
Your Answer: Corticotrophin-releasing hormone
Explanation:Hormones of the Hypothalamus
The hypothalamus produces several hormones that regulate various bodily functions. These hormones include thyrotrophic-releasing hormone (TRH), gonadotrophin-releasing hormone (GnRH), growth hormone-releasing hormone (GHRH), corticotrophin-releasing hormone (CRH), antidiuretic hormone (also known as vasopressin), dopamine (prolactin-inhibiting hormone), somatostatin (growth hormone-inhibiting hormone), and oxytocin.
CRH is responsible for regulating the release of adrenocorticotrophic hormone (ACTH) from the anterior pituitary. Oxytocin is produced by the cells in the paraventricular nucleus and secreted from the posterior pituitary. These hormones play a crucial role in maintaining homeostasis in the body. By regulating the release of other hormones, they help to control various bodily functions such as growth, metabolism, and reproduction.
In summary, the hormones of the hypothalamus are essential for maintaining the proper functioning of the body. They work together to regulate the release of other hormones and ensure that bodily functions are kept in balance.
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This question is part of the following fields:
- Endocrinology
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Question 11
Incorrect
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A 44-year-old gardener comes to her General Practitioner complaining of pain when kneeling on her right knee for the past month. She denies any fevers and is generally in good health. During the examination of her right knee, the doctor notices a slightly tender swelling in front of the patella that feels fluctuant. Although the knee is not red, it is warm to the touch, and the patient experiences some discomfort when flexing it. What are the probable results of joint aspiration?
Your Answer: Purulent aspirate
Correct Answer: Clear/milky joint aspirate with normal microscopy and culture
Explanation:Diagnosing Prepatellar Bursitis: Understanding Joint Aspirate Results
Prepatellar bursitis, also known as housemaid’s knee, is a common condition caused by inflammation of the prepatellar bursa. This can result from repetitive microtrauma, such as prolonged kneeling. Patients typically present with localised, mildly tender swelling over the patella, which can be warm but not hot. Aspiration of the aseptic bursa will reveal a clear and/or milky aspirate that has negative Gram staining and normal microscopy.
When examining joint aspirate results, it is important to consider other potential diagnoses. Gram-positive cocci, for example, would be grown in the case of Staphylococcus aureus infection, a common cause of septic bursitis. However, in the absence of fever, erythema, and reduced range of motion, septic arthritis is unlikely. Similarly, needle-shaped crystals with strong negative birefringence on polarised light microscopy are seen in gout, but this condition typically presents with acute pain, redness, and inflammation.
Rhomboid-shaped crystals with weak positive birefringence on polarised light microscopy are seen in pseudogout, which can affect the knee. However, this condition typically affects the entire knee joint and is more common in the elderly.
In summary, a clear or milky joint aspirate with normal microscopy and culture is consistent with prepatellar bursitis. Other potential diagnoses should be considered based on the patient’s history and examination findings.
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This question is part of the following fields:
- Rheumatology
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Question 12
Correct
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A 29-year-old female presents to the early pregnancy assessment unit at 7 weeks gestation with heavy vaginal bleeding. An ultrasound confirms an intra-uterine miscarriage. After 14 days of expectant management, the patient returns for a follow-up appointment. She reports experiencing light vaginal bleeding and is still haemodynamically stable without signs of ectopic pregnancy. An ultrasound scan confirms an incomplete miscarriage. What would be the most suitable course of action?
Your Answer: Vaginal misoprostol
Explanation:When managing a miscarriage, medical treatment typically involves administering vaginal misoprostol alone. According to the NICE miscarriage Clinical Knowledge Summary, medical management is recommended if expectant management is not suitable or if a woman continues to experience symptoms after 14 days of expectant management. Misoprostol can be given orally or vaginally. If products of conception are not expelled after medical treatment or if symptoms persist after 14 days of expectant management, manual vacuum aspiration or surgical management may be considered. However, hospitalization and observation are not usually necessary unless the patient is experiencing hemodynamic instability. In most cases, women can take misoprostol and complete the miscarriage at home. Oral methotrexate is used for medical management of ectopic pregnancy.
Management Options for Miscarriage
Miscarriage can be a difficult and emotional experience for women. In the 2019 NICE guidelines, three types of management for miscarriage were discussed: expectant, medical, and surgical. Expectant management involves waiting for a spontaneous miscarriage and is considered the first-line option. However, if it is unsuccessful, medical or surgical management may be offered.
Medical management involves using tablets to expedite the miscarriage. Vaginal misoprostol, a prostaglandin analogue, is used to cause strong myometrial contractions leading to the expulsion of tissue. It is important to advise patients to contact their doctor if bleeding does not start within 24 hours. Antiemetics and pain relief should also be given.
Surgical management involves undergoing a surgical procedure under local or general anaesthetic. The two main options are vacuum aspiration (suction curettage) or surgical management in theatre. Vacuum aspiration is done under local anaesthetic as an outpatient, while surgical management is done in theatre under general anaesthetic. This was previously referred to as ‘Evacuation of retained products of conception’.
It is important to note that some situations are better managed with medical or surgical management, such as an increased risk of haemorrhage, being in the late first trimester, having coagulopathies or being unable to have a blood transfusion, previous adverse and/or traumatic experience associated with pregnancy, evidence of infection, and more. Ultimately, the management option chosen should be based on the individual patient’s needs and preferences.
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This question is part of the following fields:
- Gynaecology
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Question 13
Incorrect
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A General Practitioner refers a 6-week-old infant to the neurosurgery clinic due to observing an exponential increase in the child's head circumference. What signs would indicate that the infant is suffering from hydrocephalus?
Your Answer: Sunken fontanelles
Correct Answer: Impaired upward gaze
Explanation:Infants suffering from hydrocephalus will exhibit an enlarged head size, a protruding soft spot on the skull, and downward deviation of the eyes.
Understanding Hydrocephalus
Hydrocephalus is a medical condition characterized by an excessive amount of cerebrospinal fluid (CSF) in the ventricular system of the brain. This is caused by an imbalance between the production and absorption of CSF. Patients with hydrocephalus experience symptoms due to increased intracranial pressure, such as headaches, nausea, vomiting, and papilloedema. In severe cases, it can lead to coma. Infants with hydrocephalus have an increase in head circumference, and their anterior fontanelle bulges and becomes tense. Failure of upward gaze is also common in children with severe hydrocephalus.
Hydrocephalus can be classified into two categories: obstructive and non-obstructive. Obstructive hydrocephalus is caused by a structural pathology that blocks the flow of CSF, while non-obstructive hydrocephalus is due to an imbalance of CSF production and absorption. Normal pressure hydrocephalus is a unique form of non-obstructive hydrocephalus characterized by large ventricles but normal intracranial pressure. The classic triad of symptoms is dementia, incontinence, and disturbed gait.
To diagnose hydrocephalus, a CT head is used as a first-line imaging investigation. MRI may be used to investigate hydrocephalus in more detail, particularly if there is a suspected underlying lesion. Lumbar puncture is both diagnostic and therapeutic since it allows you to sample CSF, measure the opening pressure, and drain CSF to reduce the pressure. Treatment for hydrocephalus involves an external ventricular drain (EVD) in acute, severe cases, and a ventriculoperitoneal shunt (VPS) for long-term CSF diversion. In obstructive hydrocephalus, the treatment may involve surgically treating the obstructing pathology. It is important to note that lumbar puncture must not be used in obstructive hydrocephalus since it can cause brain herniation.
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This question is part of the following fields:
- Surgery
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Question 14
Correct
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A 65 year-old man, who had recently undergone a full bone marrow transplantation for acute myeloid leukaemia (AML), presented with progressive dyspnoea over the past 2 weeks. There was an associated dry cough, but no fever. Examination revealed scattered wheezes and some expiratory high-pitched sounds. C-reactive protein (CRP) level was normal. Mantoux test was negative. Spirometry revealed the following report:
FEV1 51%
FVC 88%
FEV1/FVC 58%
What is the most likely diagnosis?Your Answer: Bronchiolitis obliterans (BO)
Explanation:Respiratory Disorders: Bronchiolitis Obliterans, ARDS, Pneumocystis Pneumonia, COPD Exacerbation, and Idiopathic Pulmonary Hypertension
Bronchiolitis obliterans (BO) is a respiratory disorder that may occur after bone marrow, heart, or lung transplant. It presents with an obstructive pattern on spirometry, low DLCO, and hypoxia. CT scan shows air trapping, and chest X-ray may show interstitial infiltrates with hyperinflation. BO may also occur in connective tissue diseases, such as rheumatoid arthritis, and idiopathic variety called cryptogenic organising pneumonia (COP). In contrast, acute respiratory distress syndrome (ARDS) patients deteriorate quickly, and pneumocystis pneumonia usually presents with normal clinical findings. Infective exacerbation of chronic obstructive pulmonary disease (COPD) is associated with a productive cough and raised CRP, while idiopathic pulmonary hypertension has a restrictive pattern and inspiratory fine crepitations.
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This question is part of the following fields:
- Respiratory
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Question 15
Incorrect
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A 32-year-old man presents to the emergency department with acute confusion and disorientation over the past 2 days. His vital signs are notable for a heart rate of 122 /min, oxygen saturation of 98% on air, BP 168/88 mmHg, and temperature of 37.9ºC. Physical examination reveals sweating, upper limb rigidity, and hyperreflexia. An ECG shows sinus tachycardia. The patient has a history of depression, anxiety, schizophrenia, and lower back pain, and is currently taking sertraline. He recently started a new medication after seeing his GP. Which medication is most likely responsible for his symptoms?
Your Answer: Clozapine
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 16
Incorrect
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What is the probable diagnosis for a 24-year-old man who twisted his knee during a football match, continued to play, but now experiences increasing pain, swelling, and intermittent locking two days later?
Your Answer: Anterior cruciate ligament tear
Correct Answer: Medial meniscus tear
Explanation:Meniscus Injuries
The meniscus is a type of cartilage that serves as a cushion between the bones in the knee joint. It helps absorb shock and prevents the bones from rubbing against each other. However, it is susceptible to injury, usually caused by a collision or deep knee bends. Symptoms of a meniscus tear include pain along the joint line or throughout the knee, as well as an inability to fully extend the knee. This can cause the knee to feel like it is locking and may also result in swelling.
While some minor meniscus tears may heal on their own with rest, more serious injuries often require surgery. It is important to note that a meniscus tear may also be associated with other knee injuries, such as an anterior cruciate ligament (ACL) or medial collateral ligament injury.
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This question is part of the following fields:
- Surgery
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Question 17
Incorrect
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A 60-year-old patient has been diagnosed with chronic hepatitis B through blood tests. The doctor explains that the patient is highly contagious and at a greater risk of long-term disease. Which of the following blood results is most likely to be seen in this patient?
HbSAg Anti-HBs IgM anti-HBc IgG anti-HBc HBeAg Anti-HBe
A + - + + + -
B - + - + - +
C + - - + + -
D + - - + - +
E - + - - - -Your Answer: A
Correct Answer: C
Explanation:Hepatitis B Infection and Immunity
The presence of hepatitis B surface antigen indicates the presence of the hepatitis B virus in the host cells, whether it is a chronic or acute infection. All patients infected with hepatitis B will produce antibodies to the core antigen. IgM antibodies are markers of acute infection and disappear in chronic infection, while IgG antibodies to the core antigen remain present even after the infection has been cleared. Vaccinated individuals develop antibodies to the surface antigen, which confers natural immunity after the infection has cleared.
If HBsAg persists for more than six months, the patient is a chronic carrier. HBeAg is a marker of virus replication, and HBeAg-positive carriers are highly infectious. However, over time, the HBeAg can be lost from the blood, and anti-HBe can be detected. These carriers are much less infectious.
In summary, acute HBV infection is indicated by the presence of IgM antibodies, while cleared HBV infection is indicated by the presence of IgG antibodies. Chronic HBV infection can be high or low in infectivity, depending on the presence of HBeAg or anti-HBe. Finally, individuals who respond to the HBV vaccine develop immunity to the virus. these markers and their implications can aid in the diagnosis and management of hepatitis B infection.
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This question is part of the following fields:
- Emergency Medicine
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Question 18
Incorrect
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To which bone does Sever's disease refer, and at what age is it commonly diagnosed?
Your Answer: Talus
Correct Answer: Calcaneum
Explanation:Sever’s Disease
Sever’s disease is a condition that causes pain in one or both heels when walking or standing. It occurs due to a disturbance or interruption in the growth plates located at the back of the heel bone, also known as the calcaneus. This condition typically affects children between the ages of 8 and 13 years old.
The pain associated with Sever’s disease can occur after general activities such as running, jumping, or playing sports like netball, basketball, and football. Symptoms include extreme pain when placing the heel on the ground, which can be alleviated when the child walks on their tiptoes.
In summary, Sever’s disease is a common condition that affects children during their growth and development. It is important to recognize the symptoms and seek medical attention if necessary to ensure proper treatment and management of the condition.
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This question is part of the following fields:
- Surgery
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Question 19
Incorrect
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A 32-year-old woman is scheduled for a routine cervical smear. After the test, the practice contacts her to let her know that the laboratory has reported the sample as 'inadequate'. She is asked to come back for a repeat smear. However, the second sample is also reported as 'inadequate' by the laboratory.
What is the recommended course of action now?Your Answer: Repeat smear in 3 months
Correct Answer: Refer for colposcopy
Explanation:If two consecutive samples are deemed inadequate during cervical cancer screening, the correct course of action is to refer the patient for colposcopy. Repeating the smear in 1 or 3 months is not appropriate as two inadequate samples have already been taken. Requesting hrHPV testing from the laboratory is also not useful if the sample is inadequate. Referring the patient to gynaecology is not necessary, and instead, a referral for colposcopy should be made.
The cervical cancer screening program has evolved to include HPV testing, which allows for further risk stratification. A negative hrHPV result means a return to normal recall, while a positive result requires cytological examination. Abnormal cytology results lead to colposcopy, while normal cytology results require a repeat test at 12 months. Inadequate samples require a repeat within 3 months, and two consecutive inadequate samples lead to colposcopy. Treatment for CIN typically involves LLETZ or cryotherapy. Individuals who have been treated for CIN should be invited for a test of cure repeat cervical sample 6 months after treatment.
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This question is part of the following fields:
- Gynaecology
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Question 20
Incorrect
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A 50-year-old man was diagnosed with tuberculosis (TB) six months ago. He was prescribed isoniazid, rifampicin, pyrazinamide and ethambutol. Today, during his clinic visit, he reports experiencing tingling and reduced sensation in his toes for the past 2 weeks. Upon conducting a peripheral neurological examination, it was found that he has a bilateral sensory loss in his feet up to the level of his ankle. What medication should have been prescribed in addition to his current medications to prevent the development of these symptoms?
Your Answer: Duloxetine
Correct Answer: Pyridoxine
Explanation:Prescribing pyridoxine can help lower the risk of peripheral neuropathy associated with isoniazid.
Side-Effects and Mechanism of Action of Tuberculosis Drugs
Rifampicin is a drug that inhibits bacterial DNA dependent RNA polymerase, which prevents the transcription of DNA into mRNA. However, it is a potent liver enzyme inducer and can cause hepatitis, orange secretions, and flu-like symptoms.
Isoniazid, on the other hand, inhibits mycolic acid synthesis. It can cause peripheral neuropathy, which can be prevented with pyridoxine (Vitamin B6). It can also cause hepatitis and agranulocytosis. Additionally, it is a liver enzyme inhibitor.
Pyrazinamide is converted by pyrazinamidase into pyrazinoic acid, which in turn inhibits fatty acid synthase (FAS) I. However, it can cause hyperuricaemia, leading to gout, as well as arthralgia, myalgia, and hepatitis.
Lastly, Ethambutol inhibits the enzyme arabinosyl transferase, which polymerizes arabinose into arabinan. It can cause optic neuritis, so it is important to check visual acuity before and during treatment. Additionally, the dose needs adjusting in patients with renal impairment.
In summary, these tuberculosis drugs have different mechanisms of action and can cause various side-effects. It is important to monitor patients closely and adjust treatment accordingly to ensure the best possible outcomes.
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This question is part of the following fields:
- Pharmacology
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Question 21
Incorrect
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A 4-week-old infant boy born at 37 weeks gestation by caesarian section is presented to his pediatrician for a routine check-up. The pediatrician observes that the neonate's urethral meatus is situated on the ventral aspect of the penile shaft, instead of the distal glans penis. What other congenital anomaly is this neonate more likely to have?
Your Answer: Posterior urethral valve
Correct Answer: Cryptorchidism
Explanation:Hypospadias is often accompanied by cryptorchidism in neonates, indicating a potential issue with embryological urogenital migration that may be linked to endocrine disruptions during pregnancy, such as low serum androgens. Imperforate anus, obstructive uropathy with a patent urachus, and posterior urethral valve are not associated with hypospadias and would present with different symptoms or complications.
Understanding Hypospadias: A Congenital Abnormality of the Penis
Hypospadias is a condition that affects approximately 3 out of 1,000 male infants. It is a congenital abnormality of the penis that is usually identified during the newborn baby check. However, if missed, parents may notice an abnormal urine stream. This condition is characterized by a ventral urethral meatus, a hooded prepuce, and chordee in more severe forms. The urethral meatus may open more proximally in the more severe variants, but 75% of the openings are distally located. There appears to be a significant genetic element, with further male children having a risk of around 5-15%.
Hypospadias most commonly occurs as an isolated disorder, but it can also be associated with other conditions such as cryptorchidism (present in 10%) and inguinal hernia. Once hypospadias has been identified, infants should be referred to specialist services. Corrective surgery is typically performed when the child is around 12 months of age. It is essential that the child is not circumcised prior to the surgery as the foreskin may be used in the corrective procedure. In boys with very distal disease, no treatment may be needed. Understanding hypospadias is important for parents and healthcare providers to ensure proper management and treatment of this condition.
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This question is part of the following fields:
- Paediatrics
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Question 22
Incorrect
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A 33-year-old pregnant woman arrives at the maternity department at 40 weeks gestation. The medical team decides to perform an artificial rupture of the membranes, but during an examination, they discover that the umbilical cord is palpable vaginally. What position should the woman assume in this situation?
Your Answer: Legs separated and raised in stirrups
Correct Answer: On all fours
Explanation:The recommended position for women with cord prolapse is on all fours, with their knees and elbows on the ground. It is important to avoid pushing the cord back in, but to keep it warm and moist. This position helps to prevent compression of the presenting part of the fetus. However, immediate preparations for a caesarian section should also be made. The Trendelenburg position, which involves tilting the head end of the bed downwards, is not recommended for cord prolapse. The Lloyd Davis position, which involves separating the legs, is also not recommended. The McRoberts manoeuvre, which involves hyper-flexing the legs tightly to the abdomen, is used for shoulder dystocia during vaginal delivery and is not appropriate for cord prolapse. The lithotomy position, which involves raising the legs in stirrups, is commonly used in obstetrics and gynaecology but is not recommended for cord prolapse.
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.
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This question is part of the following fields:
- Obstetrics
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Question 23
Correct
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A 32-year-old man visits the sexual health clinic following unprotected sex with a female partner. He reports experiencing coryzal symptoms and myalgia, which began four weeks ago. The patient has a history of asthma, which is managed with salbutamol. The doctor advises him to undergo HIV testing, and he consents. What is the best course of action for managing his condition?
Your Answer: Order HIV p24 antigen and HIV antibody tests
Explanation:The recommended course of action is to order a combination test for HIV p24 antigen and HIV antibody. The patient is exhibiting symptoms of HIV seroconversion and had unprotected intercourse 4 weeks ago. Combination tests are now the standard for HIV diagnosis and screening, with p24 antigen tests typically turning positive between 1 and 4 weeks post-exposure and antibody tests turning positive between 4 weeks and 3 months post-exposure. If a patient at risk tests positive, the diagnosis should be confirmed with a repeat test before starting treatment.
Offering post-exposure prophylaxis is not appropriate in this case, as the patient had unprotected intercourse 3 weeks ago. Two NRTIs and an NNRTI should not be prescribed as treatment, as the patient has not yet tested positive. Ordering only a p24 antigen or antibody test alone is also not recommended, as combination tests are now standard practice.
Understanding HIV Seroconversion and Diagnosis
HIV seroconversion is a process where the body develops antibodies to the HIV virus after being infected. This process is symptomatic in 60-80% of patients and usually presents as a glandular fever type illness. Symptoms may include sore throat, lymphadenopathy, malaise, myalgia, arthralgia, diarrhea, maculopapular rash, mouth ulcers, and rarely meningoencephalitis. The severity of symptoms is associated with a poorer long-term prognosis and typically occurs 3-12 weeks after infection.
Diagnosing HIV involves testing for HIV antibodies, which may not be present in early infection. However, most people develop antibodies to HIV at 4-6 weeks, and 99% do so by 3 months. The diagnosis usually consists of both a screening ELISA test and a confirmatory Western Blot Assay. Additionally, a p24 antigen test may be used to detect a viral core protein that appears early in the blood as the viral RNA levels rise. Combination tests that test for both HIV p24 antigen and HIV antibody are now standard for the diagnosis and screening of HIV. If the combined test is positive, it should be repeated to confirm the diagnosis. Testing for HIV in asymptomatic patients should be done at 4 weeks after possible exposure, and after an initial negative result, a repeat test should be offered at 12 weeks.
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This question is part of the following fields:
- Medicine
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Question 24
Correct
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Which one of the following statements regarding hepatitis A is not true?
Your Answer: It is a DNA virus
Explanation:Understanding Hepatitis A: Symptoms, Transmission, and Prevention
Hepatitis A is a viral infection caused by the RNA picornavirus. It is typically spread through faecal-oral transmission, often in institutions. The incubation period is around 2-4 weeks, and symptoms include a flu-like prodrome, abdominal pain (usually in the right upper quadrant), tender hepatomegaly, jaundice, and deranged liver function tests. However, the disease is usually self-limiting and benign, with serious complications being rare.
Unlike other forms of hepatitis, hepatitis A does not cause chronic disease or increase the risk of hepatocellular cancer. An effective vaccine is available, and it is recommended for people who are travelling to or residing in areas of high or intermediate prevalence, those with chronic liver disease, patients with haemophilia, men who have sex with men, injecting drug users, and individuals at occupational risk (such as laboratory workers, staff of large residential institutions, sewage workers, and people who work with primates). After the initial dose, a booster dose should be given 6-12 months later.
Understanding the symptoms, transmission, and prevention of hepatitis A is important for individuals who may be at risk of contracting the virus. By taking appropriate precautions and getting vaccinated, individuals can protect themselves and others from this viral infection.
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This question is part of the following fields:
- Medicine
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Question 25
Correct
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A 14-year-old girl comes to the clinic with complaints of right femur pain that has been worsening over the past 3 months. She reports that the pain is particularly severe at night and she has recently noticed a painful lump in her right thigh. Although she denies any fever or weight loss, she has been experiencing a cough. Upon examination, a radiograph reveals a characteristic blastic and destructive intramedullary lesion with periosteal reaction and a sizable soft tissue mass. What is the most suitable course of action for her treatment?
Your Answer: Order a whole-body bone scan, computed tomography (CT) chest and magnetic resonance imaging (MRI) of the entire femur
Explanation:Approach to a Patient with Suspected Osteosarcoma
Suspected osteosarcoma requires a systematic approach to establish a diagnosis and stage the disease before initiating treatment. The patient’s history and examination may suggest osteosarcoma, but staging is necessary to determine the extent of the disease and guide treatment decisions.
The next step is to stage the patient, which involves a CT chest, a bone scan, and an MRI of the involved bone. Biopsy is required to obtain tissue diagnosis and institute therapy. Treatment of osteosarcoma involves a multidisciplinary team approach and may require preoperative multi-agent chemotherapy to downstage the tumour. The aim of surgical resection is to aim for limb salvage and limb preservation.
Offering amputation of the affected limb is not appropriate before staging the disease and obtaining a tissue diagnosis. Biopsy will ultimately provide tissue diagnosis and guide subsequent treatment. Repeating radiographs in 3 months to look for progression would be inappropriate. Radiotherapy, chemotherapy, and wide excision should not be performed prior to staging the disease.
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This question is part of the following fields:
- Orthopaedics
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Question 26
Incorrect
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A father brings his 15-month-old daughter into surgery. Since yesterday she seems to be straining whilst passing stools. He describes her screaming, appearing to be in pain and pulling her knees up towards her chest. These episodes are now occurring every 15-20 minutes. This morning he noted a small amount of blood in her nappy. She is taking around 60% of her normal feeds and vomiting 'green fluid' every hour. On examination, she appears irritable and lethargic but is well hydrated and apyrexial. On examination, her abdomen seems distended but no discrete mass is found.
What is the most likely diagnosis?Your Answer: Volvulus
Correct Answer: Intussusception
Explanation:Understanding Intussusception
Intussusception is a medical condition that occurs when one part of the bowel folds into the lumen of the adjacent bowel, usually around the ileo-caecal region. This condition is most common in infants between 6-18 months old, with boys being affected twice as often as girls. The symptoms of intussusception include severe, crampy abdominal pain that comes and goes, inconsolable crying, vomiting, and blood stained stool, which is a late sign. During a paroxysm, the infant will typically draw their knees up and turn pale, and a sausage-shaped mass may be felt in the right upper quadrant.
To diagnose intussusception, ultrasound is now the preferred method of investigation, as it can show a target-like mass. Treatment for intussusception involves reducing the bowel by air insufflation under radiological control, which is now widely used as a first-line treatment instead of the traditional barium enema. If this method fails, or the child shows signs of peritonitis, surgery is performed.
In summary, intussusception is a medical condition that affects infants and involves the folding of one part of the bowel into the lumen of the adjacent bowel. It is characterized by severe abdominal pain, vomiting, and blood stained stool, among other symptoms. Ultrasound is the preferred method of diagnosis, and treatment involves reducing the bowel by air insufflation or surgery if necessary.
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This question is part of the following fields:
- Paediatrics
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Question 27
Incorrect
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A 32-year-old woman has been experiencing fatigue, bloating, and significant weight loss over the past two months. She visits her GP, who discovers that two of her first-degree relatives died from cancer after asking further questions. During the physical examination, the GP observes an abdominal mass and distension. The GP is concerned about the symptoms and orders a CA-125 test, which returns as elevated. What gene mutation carries the greatest risk for the condition indicated by high CA-125 levels?
Your Answer: p53
Correct Answer: BRCA1
Explanation:Based on the patient’s symptoms and an elevated level of CA-125, it is likely that she has ovarian cancer. Additionally, her family history of cancer in first-degree relatives and early onset cancer suggest the possibility of an inherited cancer-related gene. One such gene is BRCA1, which increases the risk of ovarian and breast cancer in those who have inherited a mutated copy. Other tumour suppressor genes, such as WT1 for Wilm’s tumour, Rb for retinoblastoma, and c-Myc for Burkitt lymphoma, confer a higher risk for other types of cancer.
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.
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This question is part of the following fields:
- Gynaecology
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Question 28
Correct
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A patient in their 50s who was taking terfenadine for allergies experienced torsades de pointes after starting an antibiotic for an upper respiratory infection. Which antibiotic is most likely responsible for causing this arrhythmia?
Your Answer: Erythromycin
Explanation:Erythromycin and its potential risk of causing torsades de pointes
Erythromycin is a medication that can cause the QT interval to become prolonged, which can lead to the development of a potentially life-threatening heart rhythm disorder called torsades de pointes. This risk may be increased if erythromycin is taken in combination with other medications that also have the potential to prolong the QT interval, such as terfenadine. It is important for healthcare providers to be aware of this potential risk and to carefully consider the risks and benefits of prescribing erythromycin, particularly in patients who are already at increased risk for QT prolongation or who are taking other medications that can prolong the QT interval. Adequate monitoring and management of patients who are prescribed erythromycin is essential to minimize the risk of torsades de pointes and other serious adverse effects.
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This question is part of the following fields:
- Pharmacology
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Question 29
Correct
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A 4-year-old girl is brought to the pediatrician by her mother. The mother is concerned as she has noticed some hair growing in her daughter's armpits, and although she has not shown any distress or had any other noticeable symptoms, the mother is worried that something is wrong as she is too young to begin going through puberty. On examination, the child has axillary hair growth bilaterally, and her breasts are of appropriate size for her age.
Gonadotrophin assays show the following:
FSH 0.2 IU/L Age 6 months - 10 years old: (1 - 3)
LH 0.1 IU/L Age 6 months - 10 years old: (1 - 5)
What is the most likely cause of this child's axillary hair growth?Your Answer: Adrenal hyperplasia
Explanation:In cases of gonadotrophin independent precocious puberty (GIPP), both FSH and LH levels are low. This is in contrast to gonadotrophin dependent precocious puberty (GDPP), where FSH and LH levels are high and testes are larger than expected for age. GIPP is caused by increased levels of sex hormones, such as testosterone, which suppress LH and FSH. This can be due to ovarian, testicular, or adrenal causes, such as congenital adrenal hyperplasia. In boys with GIPP, testicular volume is typically normal or small. Adrenal hyperplasia is the only cause of GIPP, as all other causes would result in GDPP and increased levels of FSH and LH.
Understanding Precocious Puberty
Precocious puberty is a condition where secondary sexual characteristics develop earlier than expected, before the age of 8 in females and 9 in males. It is more common in females and can be classified into two types: gonadotrophin dependent and gonadotrophin independent. The former is caused by premature activation of the hypothalamic-pituitary-gonadal axis, resulting in raised levels of FSH and LH. The latter is caused by excess sex hormones, with low levels of FSH and LH. In males, precocious puberty is uncommon and usually has an organic cause, such as gonadotrophin release from an intracranial lesion, gonadal tumour, or adrenal cause. In females, it is usually idiopathic or familial and follows the normal sequence of puberty. Organic causes are rare and associated with rapid onset, neurological symptoms and signs, and dissonance, such as in McCune Albright syndrome. Understanding precocious puberty is important for early detection and management of the condition.
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This question is part of the following fields:
- Paediatrics
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Question 30
Incorrect
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A 6-year-old girl is brought to the pediatrician due to concerns about her posture. During the examination, the pediatrician observes a kyphotic spine and blue-grey sclera. The child has not experienced any bone fractures. To investigate further, the pediatrician orders a bone profile blood test to confirm the suspicion of osteogenesis imperfecta.
What specific results from the bone profile blood test would be indicative of this condition?Your Answer: High calcium, low PTH and P04
Correct Answer: Normal calcium, PTH and PO4
Explanation:In osteogenesis imperfecta, the levels of adjusted calcium, PTH, ALP, and PO4 are typically within the normal range. This rare genetic disorder is characterized by frequent bone fractures, blue-grey sclera, micrognathia, and kyphoscoliosis. Biochemical tests usually show normal levels of calcium, phosphate, and parathyroid hormone. If parathyroid hormone levels are elevated along with high calcium, it may indicate primary hyperparathyroidism caused by parathyroid adenoma, hyperplasia, or parathyroid cancer. On the other hand, elevated parathyroid hormone with low calcium may suggest secondary hyperparathyroidism due to kidney failure or vitamin D deficiency. Hypercalcemia without elevated parathyroid hormone may indicate primary malignancy or sarcoidosis. Hypocalcemia with low parathyroid hormone levels may suggest parathyroid dysfunction, which is commonly seen after thyroid or parathyroid surgery or as part of an autoimmune syndrome.
Osteogenesis imperfecta, also known as brittle bone disease, is a group of disorders that affect collagen metabolism, leading to bone fragility and fractures. The most common type of osteogenesis imperfecta is type 1, which is inherited in an autosomal dominant manner and is caused by a decrease in the synthesis of pro-alpha 1 or pro-alpha 2 collagen polypeptides. This condition typically presents in childhood and is characterized by fractures that occur following minor trauma, as well as blue sclera, dental imperfections, and deafness due to otosclerosis.
When investigating osteogenesis imperfecta, it is important to note that adjusted calcium, phosphate, parathyroid hormone, and ALP results are usually normal. This condition can have a significant impact on a person’s quality of life, as it can lead to frequent fractures and other complications. However, with proper management and support, individuals with osteogenesis imperfecta can lead fulfilling lives.
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This question is part of the following fields:
- Musculoskeletal
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